Development of a Nomogram to Predict Postoperative Transfusion in the Elderly After Intramedullary Nail Fixation of Femoral Intertrochanteric Fractures.

PURPOSE: The aim of our study was to explore the risk factors related to blood transfusion after intramedullary nail fixation of elderly femoral intertrochanteric fracture (FTF) and establish a nomogram prediction model. PATIENTS AND METHODS: We conducted a retrospective study including elderly FTF patients treated by intramedullary nail between January 2017 and December 2019. Perioperative information was obtained retrospectively, uni- and multivariate regression analyses were performed to determine risk factors for blood transfusion. A nomogram model was established to predict the risk of blood transfusion, and consistency coefficient (C-index) and correction curve were used to evaluate the prediction performance and consistency of the model. RESULTS: Of 148 patients, 119 were finally enrolled in the study and and 46 patients (38.7%) received a blood transfusion after the operation. Logistic regression analysis the female, lower preoperative Hb, ASA score >2, general anesthesia, and higher intraoperative blood loss were independently associated with the blood transfusion. The accuracy of the contour map for predicting transfusion risk was 0.910. CONCLUSION: These risk factors are shown on the nomogram and verified. Through the assessment of the risk of blood transfusion and the intervention of modifiable risk factors, we may be able to reduce the blood transfusion rate to a certain extent, so as to further guarantee the safety of the elderly patients during the perioperative period.

Risk factors for mechanical failure of intertrochanteric fractures after fixation with proximal femoral nail antirotation (PFNA II): a study in a Southeast Asian population.

INTRODUCTION: Intertrochanteric hip fractures pose a significant health problem. The proximal femur nail anti-rotation (PFNA IIDePuySynthes) is the most commonly used implant for intramedullary nailing of unstable intertrochanteric fractures at our institution. We aim to identify the risk factors predisposing to mechanical failure of intertrochanteric hip fractures fixation with PFNAII in our Southeast Asian population. MATERIALS AND METHODS: We retrospectively reviewed 295 consecutive patients who underwent PFNA fixation for intertrochanteric fractures of the proximal femur between January 2014 and June 2018 at our institution. Exclusion criteria included a follow-up period of less than 4 months and patients with polytrauma. 204 patients were eligible for analysis, of which 22 had mechanical failure of PFNAII. We compared these patients with respect to their demographics, medical co-morbidities, quality of reduction according to the Baumgartner scale, calcar restoration, blade position according to Cleveland Zones, the stability of fracture according to OTA/AO classification, neck-shaft-angle, tip-apex distance, as well as neck of femur bone mineral density T-score. Patients were followed up for a minimum of 4 months and until fracture union or complication had occurred. Logistic regression analysis was performed to determine the odds ratio for mechanical failure for selected variables. RESULTS: Good quality of reduction reduced risk of mechanical failure whilst posterior blade position in lateral hip X-ray predicted it, with odds ratios of 0.147 (95% confidence interval, 0.030-0.733; p = 0.019) and12.12 (95% confidence interval, 1.583-92.825; p = 0.016) respectively. On univariate analysis, the mechanical failure group were older, had poorer calcar restoration, more unstable fracture patterns, more varus neck-shaft angle, and trochanteric starting points that were lateral to or on the tip of the greater trochanter. However, these were not significant in multivariate analysis. Tip apex distance, the severity of osteoporosis, presence of diabetes, chronic kidney disease and serum vitamin D levels were not significant predictors of failure. CONCLUSIONS: To avoid mechanical failure, one should aim to achieve a good quality of reduction and centre blade position on lateral hip X-ray. Tip apex distance did not predict mechanical failure in our study.

Plate fixation versus intramedullary nailing of proximal humerus fractures: an ACS NSQIP-based comparative analysis over 8 years.

PURPOSE: The primary goal of this study was to compare the utilization of plate versus intramedullary nail (IMN) in the treatment of humerus fractures. Secondarily, we sought to examine whether any differences in demographics and clinical course of patients who receive a nail versus plate affect the procedure selection process. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was queried for patients surgically treated for a humeral shaft fracture from the years 2007-2015, using current procedural terminology (CPT) code. Patients with overlapping procedures, nonunion, polytrauma, and malignancy were excluded. The Charlson Comorbidity Index (CCI) was calculated to compare preoperative comorbidities. A two-sample Wilcoxon rank-sum (Mann-Whitney U) test was used to compare numerical values, whereas the Fisher exact and Chi-squared analyses were performed to compare categorical variables. A p value < 0.05 was considered significant. Preoperative variables with a p value < 0.05 and a clinical prevalence > 1%, indicating statistical and clinical significance, were included in a logistic regression for multivariate analysis to identify any independent predictors for procedure selection (IMN versus PF) based on preoperative patient characteristics. RESULTS: During the study period plate fixation increased from 7 cases per year to 272 cases per year, while IMN increased from 8 cases per year to 80 cases per year. IMNs were mostly in older patients (63.85 vs 56.19 years, p < 0.001), and patients with a higher Charlson Comorbidity Index (CCI) (4.64 vs 2.79, p < 0.001). IMN was associated with shorter operation times (104 min vs 128 min, p < 0.001) and longer lengths of hospital stay (3.43d vs 2.78d, p < 0.001). No significant differences in overall complication rates were seen between patients who received IMN versus PF. However, the postoperative mortality rate was higher in patients who received IMN compared to PF (2.19% vs 0.40%, p < 0.01). Based on the regression analysis, patient age was the only independent patient factor demonstrated to predict the utilization of IMN over PF in older patients with humeral shaft fractures p = 0.043). CONCLUSION: According to this NSQIP-based analysis, the rate of PF and IMN utilization increased in the treatment of humeral shaft fractures over a period of 8 years, but PF was performed at an overall a higher rate than IMN. Intramedullary nailing was preferred over PF in older patients with more comorbidities. The last possibly contributed to the higher 30-day mortality rate observed in patients who received IMN compared to PF. LEVEL OF EVIDENCE III: Retrospective comparative study.

Treatment and re-operation rates in one thousand and three hundred tibial fractures from the Swedish Fracture Register.

PURPOSE: Approximately, 50 persons per 100,000 per year sustain a tibial fracture. There is, however, a lack of large cohort studies that describe the treatment and re-operation frequencies of tibial fractures. The aim of this study was to describe the treatment and re-operation rates of tibial fractures in all segments of the tibia. METHODS: Data related to all patients aged 16 and above treated for tibial fractures (ICD-10 S82.10-31) at Sahlgrenska University Hospital in 2011-2015 were extracted from the Swedish Fracture Register. To make sure all re-operations were included in the study, the operation planning system was checked for all patients included in the study. RESULTS: The study comprised 1371 tibial fractures - 712 proximal, 417 diaphyseal and 242 distal tibial fractures. Among the proximal and distal tibial fractures, plate fixation was the most commonly used surgical method, whereas among tibial shaft fractures, an intramedullary nail was the most commonly used surgical method. Almost 30% (29.8%) of all surgically treated tibial fractures underwent re-operation. Among proximal tibial fractures, 24.0% underwent re-operation; tibial shaft fractures 37.0% and distal tibial fractures 26.8%. Re-operations due to infection were more or less equally common in all segments (3.9-5.4%). CONCLUSION: This study describes the treatment and re-operation rates after tibial fractures in a cohort of 1371 tibial fractures at Sahlgrenska University Hospital during a period of 5 years. The study shows an overall re-operation rate of 29.8% for fractures in all segments of the tibia.

Exploring trends in admissions and treatment for ankle fractures: a longitudinal cohort study of routinely collected hospital data in England.

BACKGROUND: Evidence on the most effective and cost-effective management of ankle fractures is sparse but evolving. A recent large RCT in older patients with unstable fractures found that management with close-contact-casting was functionally equivalent and more cost-effective than internal fixation. We describe temporal and geographic variation in ankle fracture management and estimate the potential savings if close-contact-casting was used more often in older patients. METHODS: Patients admitted to hospital in England between 2007/08 and 2016/17 with an ankle fracture were identified using routine hospital episode statistics. We tested whether the use of internal fixation, and the proportion of internal fixations using intramedullary implants, changed over time. We estimated the potential annual cost savings if patients aged 60+ years were treated with close-contact-casting rather than internal fixation, in line with emerging evidence. RESULTS: Over the 10-year period, there were 223,465 hospital admissions with a primary ankle fracture diagnosis. The incidence (per 100,000) of internal fixation was fairly consistent over time in younger (33.2 in 2007/08, 30.9 in 2016/17) and older (36.5 in 2007/08, 37.4 in 2016/17) patients. The proportion of internal fixations which used intramedullary implants increased in both age groups (17.0-19.5% < 60 years; 15.2-17.4% 60+ years). In 2016/17, the cost of inpatient hospital care for ankle fractures in England was over £63.1million. If 50% of older patients who had an internal fixation instead had close-contact-casting, we estimate that approximately £1.56million could have been saved. CONCLUSIONS: Despite emerging evidence that non-surgical and surgical management achieve equivalent functional outcomes in older patients, the rate of surgical fixation has remained relatively stable over the decade. The health service could achieve substantial savings if a higher proportion of older patients were treated with close-contact-casting, in line with recent evidence.

Super elderly patients with intertrochanteric fractures do not predict worse outcomes and higher mortality than elderly patients: a propensity score matched analysis.

We aimed to investigate whether super elderly patients aged over 90 years had significantly worse functional outcomes, perioperative complications, and survival rates. Among 3560 patients aged over 65 years presenting with intertrochanteric fractures and treated surgically between Jan 2014 and Jan 2019, 2242 patients were included, including 206 in super elderly group and 2036 in elderly group. After using propensity score matching to minimize the effects of possible confounding variables, 192 remained in each group. No significant difference was observed in functional outcomes, perioperative complications, or 30-day, 90-day, and 1-year mortality after propensity score matching and McNemar's tests (p>0.05). After an average follow-up of 37 months, the Kaplan-Meier survival curve showed no significant difference between the two groups in terms of cumulative survival rate (p=0.081, log-rank). Our data demonstrated progressive increases in mortality and poor outcomes with increasing Elixhauser comorbidity scores, which represented the severity index of patients preoperatively. Our study also found that there were weak correlations between five characteristics and the patient age. These results all suggested that it is not the advanced age itself but other concomitant factors, that appear to be responsible for the adverse functional outcomes, perioperative complications, and mortality in super elderly patients.

Outcome at 1 year in patients with femoral shaft fractures treated with intramedullary nailing or skeletal traction in a low-income country: a prospective observational study of 187 patients in Malawi.

Background and purpose - Intramedullary nailing (IMN) is underutilized in low-income countries (LICs) where skeletal traction (ST) remains the standard of care for femoral shaft fractures. This prospective study compared patient-reported quality of life and functional status after femoral shaft fractures treated with IMN or ST in Malawi. Patients and methods - Adult patients with femoral shaft fractures managed by IMN or ST were enrolled prospectively from 6 hospitals. Quality of life and functional status were assessed using EQ-5D-3L, and the Short Musculoskeletal Function Assessment (SMFA) respectively. Patients were followed up at 6 weeks, 3, 6, and 12 months post-injury. Results - Of 248 patients enrolled (85 IMN, 163 ST), 187 (75%) completed 1-year follow-up (55 IMN, 132 ST). 1 of 55 IMN cases had nonunion compared with 40 of 132 ST cases that failed treatment and converted to IMN (p < 0.001). Quality of life and SMFA Functional Index Scores were better for IMN than ST at 6 weeks, 3 and 6 months, but not at 1 year. At 6 months, 24 of 51 patients in the ST group had returned to work, compared with 26 of 37 in the IMN group (p = 0.02). Interpretation - Treatment with IMN improved early quality of life and function and allowed patients to return to work earlier compared with treatment with ST. Approximately one-third of patients treated with ST failed treatment and were converted to IMN.

Intraoperative Issues and Clinical and Radiographic Outcomes of Femur Fractures Treated With Flexible Nails: A Comparison of Cases Utilizing Skeletal Traction and a Traction Table to Cases Using Manual Traction Only.

INTRODUCTION: The use of the orthopaedic traction table (OTT) during elastic stable intramedullary nailing (ESIN) in the management of displaced diaphyseal femur fractures (DFFs) is still debated. In most centers, children with displaced DFF are treated using an OTT. In some other institutions, however, fracture reduction and stabilization by ESIN are performed on a radiolucent table without an OTT. The aim of this study was to evaluate the clinical and radiologic outcome of children with displaced DFF managed by ESIN with and without the use of an OTT. METHODS: Charts and radiographs were retrospectively reviewed for all pediatric patients sustaining DFF managed by ESIN from 2011 to 2017 at 2 different institutions. In all, 69 consecutive children with displaced DFF were recorded, of whom 35 underwent operative treatment by ESIN with the use of an OTT with skeletal traction (Group A), and 34 by ESIN without OTT (Group B). The titanium elastic nails outcome measure scale score and Beaty radiologic criteria were used to evaluate the results. RESULTS: Average patient age at time of injury was 9 years (range, 5 to 13) and 10 years (range, 4 to 15) in Groups A and B, respectively. The mean follow-up was 54 months (range, 24 to 96). Overall, complications were observed in 6 patients (8.6%). Complication rate was higher among children managed without OTT (11.8%) than among children treated with OTT (2.5%); no complication related to pin insertion for skeletal traction was recorded. However, the number of patients with a poor outcome according to the titanium elastic nails outcome score was higher in Group A (20%) than in Group B (5.8%). Beaty radiologic criteria were comparable between the 2 groups. Mean length of surgery and mean cumulative time of radiation exposure during surgery were similar between the 2 groups. CONCLUSIONS: Overall, both techniques work equally well although patients treated by ESIN with the use of an OTT and skeletal traction tended to have a lower rate of complications and radiologic outcome was worse than for patients treated without using an OTT; however, no statistically significant difference was found.Despite their limitations, the results of this study suggest that displaced DFF can be safely managed by ESIN with or without the use of intraoperative OTT and skeletal traction, according to the surgeon's preference. Further studies are now needed to consolidate these conclusions and clarify the role of the OTT. LEVEL OF EVIDENCE: Level III.

Is electromagnetic guidance system superior to a free-hand technique for distal locking in intramedullary nailing of tibial fractures? A prospective comparative study.

BACKGROUND: Intramedullary nailing (IMN) technique is the gold standard for the treatment of closed fractures of the lower extremity long bones. For orthopedic surgeons, one of the most important problems in IMN procedures is the fixation of distal locking screws (DLS). Accurate and rapid placement of DLSs with minimal radiation exposure is crucial. In this study, we aimed to compare the results of two different distal locking methods concerning surgery duration and radiation exposure in patients who underwent osteosynthesis of tibia fractures with IMN. METHODS: In this prospective study, the results of 56 patients who met the inclusion and exclusion criteria from 72 patients were evaluated. Patients were divided into two groups according to the distal screwing method. Group 1 (n=29) comprised patients who used free-hand technique (FHT) for distal locking, while Group 2 (n=27) consisted of patients who used electromagnetic guidance system (EMGS) for distal locking. Demographic and medical data of the patients, duration of surgery time, amount of bleeding, total fluoroscopy counts, the time elapsed for distal locking, the measure of radiation exposure, number of attempts for distal screw locking, incorrect screw placements, complications and follow-up time were recorded. The groups were compared concerning demographic data and clinical results. RESULTS: There was no statistically significant difference between the groups about gender and side (p=0.928 and p=0.432, respectively). The mean age in Group-1 was higher than that of Group-2, and the difference was statistically significant (p=0.012). However, there was no statistically significant difference in length of hospital stay in Group-1 (p=0.140). On the other hand, in Group-2, the number of distal shots, fluoroscopy duration, effective radiation dose and operation duration were lower compared to Group-1, although this difference was not statistically significant (p=0.057, 0.073, 0.058 and 0.056, respectively). Failure was encountered in distal locking during the first attempt in three cases in Group-1 and in two cases in Group-2. Aseptic nonunion was observed in one patient in both groups. CONCLUSION: Both the FHT distal screwing technique and the EMGS distal screwing technique are highly effective methods for distal locking. The duration of operation, the duration of the fluoroscopy and radiation exposure were similar. FHT can be preferred for distal locking in conventional intramedullary nail applications, as it is effective, easy and inexpensive.

Association of Disability Benefits and/or Litigation With Time to Return to Work After Tibia Shaft Fracture Fixation.

OBJECTIVES: We explored the association of compensation status with return to work (RTW) after tibial fracture. METHODS: Eligible patients were adults with tibial shaft fractures enrolled in the Trial to Re-evaluate Ultrasound in the Treatment of Tibial Fractures. We explored the association between disability benefits and/or litigation and RTW using multivariable discrete interval hazard analysis, adjusting for sex, age, country of residence, smoking status, body mass index, polytrauma, fracture severity, fracture gap, pain severity, and physical functioning. RESULTS: Of 330 eligible patients, 111 (34%) had not returned to full-time work 1-year after surgery. In our adjusted model, receipt of disability benefits and/or involvement in litigation was associated with delayed RTW (HR = 0.71, 95% CI 0.52-0.96). DISCUSSION: Tibial shaft fracture patients receiving disability benefits and/or involved in litigation are less likely to RTW.

Cost-Effectiveness of Titanium Elastic Nail (TEN) in the Treatment of Forearm Fractures in Children.

Background and objectives: There are various methods in the management of forearm fractures in children. Elastic stable intramedullary nailing using Titanium Elastic Nail (TEN) is nowadays employed in diaphysis fractures of children, with clear benefits over other treatment options. However, in the case of TEN versus other treatment methods of forearm fractures in children, cost is an important issue. This report will focus on the cost assessment of using TEN versus other therapeutic means in the treatment of forearm fractures in children. Materials and Methods: We performed a retrospective longitudinal study of 173 consecutive patients with forearm fractures treated in a single institution during 2017. We calculated the cost for each patient by summing up direct costs plus indirect costs, calculated at an aggregate level. Hospital income data were extracted from the Diagnosis Related Groups database. Results: A total of 173 patients with forearm fractures were treated, 44 using TEN, 86 using K-wire, and 46 using closed reduction and cast. There were 66 radius fractures, 1 ulna fracture, and 106 that were both radius and ulna fractures. Mean treatment cost were $632.76 for TEN, $499.50 for K-wire, and $451.30 for closed reduction and cast. Costs for TEN were higher than for K-wire insertion (p = 0.00) and higher than closed reduction and cast ($182.42; p = 0.00). Reimbursement per patient was higher with TEN versus K-wire patients; $497.88 vs. $364.64 /patient (p = 0.00), and higher than for patients treated with closed reduction and cast (p = 0.00). Conclusions: The treatment of upper extremity fractures using TEN was more expensive than the other methods. In Romania, because the reimbursement for TEN is higher as well, there are no differences in the financial burden when treating forearm fractures with TEN versus K-wire. Non-surgical treatment has the lowest cost but also the lowest reimbursement.

Predictors of Open Reduction in Pediatric Femur Fractures Treated With Flexible Nails.

BACKGROUND: Closed reduction (CR) is sufficient to reduce the majority of femur fractures treated with flexible intramedullary nailing (FIN). No previous study has examined factors associated with failed CR of pediatric femoral shaft fractures treated with FIN. We sought to determine preoperative factors associated with failed CR. We hypothesized that fracture, patient, and surgeon characteristics would impact the need for open reduction (OR). METHODS: A retrospective review of children treated for femur fracture between 2012 and 2017 at a tertiary pediatric hospital was performed. Comparisons were made between 2 groups: FIN with CR group and FIN that required OR group. Demographic and baseline characteristics were compared between treatment groups using either χ tests or Fisher exact tests for categorical variables and general linear models for continuous variables. Odds ratios with 95% confidence intervals were calculated using univariate logistic regression tests. RESULTS: Of 449 consecutive pediatric femur fractures treated at our center, 85 children were treated with FIN and constituted the study cohort. CR failed in 14 patients (16.5%) necessitating OR of the fracture site. Significant differences between study groups were found in fracture location (P=0.018), the mechanism (P=0.003), and displacement on the anteroposterior radiograph (P=0.027). Surgical time was found to be longer in the OR group (P=0.010). We identified 3 preoperative predictors of OR for FIN including fractures caused by high energy mechanisms (odds ratio=7.5), distal third fractures (odds ratio=15.3), and fracture displacement on the anteroposterior view (odds ratio=1.06). Surgeon years in practice, patient weight, age, and time from injury to surgery were not associated with OR. CONCLUSIONS: This study presents 3 preoperative risk factors that predict the need for OR of femur fractures treated with FIN. Surgical time was longer in cases that required OR. Our findings suggest that surgeons should avoid lengthy attempts at CR and consider a lower threshold for OR of at-risk fractures or use another technique other than flexible nails. LEVEL OF EVIDENCE: Level III-prognostic.

Congenital pseudarthrosis of the tibia: the outcome of a pathology-oriented classification system and treatment protocol.

Congenital pseudarthrosis of the tibia is defined as a non-union of a tibial fracture that develops in a dysplastic bone segment of the tibial diaphysis. Pathologically, a fibrous hamartoma surrounds the bone at the congenital pseudarthrosis of the tibia site. The cases of 25 children, who have congenital pseudarthrosis of the tibia, were included in this study. Their ages ranged from 15 months to 15 years at the time of treatment. Neurofibromatosis-1 was present in 24 children. They were managed according to our classification system and treatment protocol. The treatment for mobile pseudarthrosis (types 1 and 2) included complete excision of the pathological periosteum, insertion of autogenous iliac crest bone graft, and combined fixation using intramedullary rod and Ilizarov external fixator. For type 3 pseudarthrosis (stiff pseudarthrosis), a pre-constructed Ilizarov fixator was applied for simultaneous distraction of the pseudarthrosis and deformity correction without open surgery. Evaluation of results was mainly radiological and included achievement of union, leg length equalization, deformity correction and prevention of refracture. Consolidation of the pseudarthrosis and osteotomies was achieved in all cases (100%). Refracture occurred in one case (4%) at the site of previous pseudarthrosis. Residual limb length discrepancy more than 2.5 cm occurred in two cases (8%). Valgus deformity of the ankle was present in 12 cases (48%) and was treated by supramalleolar osteotomy. Follow-up ranged from 24 to 48 months (average 36.9 months) after fixator removal. The results of our treatment protocol, based on our classification system, have been consistently good and predictable in all cases of congenital pseudarthrosis of the tibia. Mobility of the pseudarthrosis is an important factor in choosing the type of interference.

Rates of Contralateral SCFE in the United States: Analysis of the Pediatric Health Information System.

BACKGROUND: Slipped capital femoral epiphysis (SCFE) is relatively common in pediatric patients. Subsequent contralateral SCFE is also common and rates of bilateral SCFE have been reported to range from 12% to 80% in the literature. The purpose of this study was to determine the rates of subsequent contralateral SCFE in patients who present with unilateral SCFE in the United States and determine risk factors for the development of subsequent contralateral SCFE. METHODS: The authors performed a retrospective study using data from the Pediatric Health Information System (PHIS). Patients who underwent in situ pinning of a unilateral SCFE between 2004 and 2016 were included in this study and followed prospectively to determine subsequent contralateral SCFE. They excluded patients who underwent bilateral pinning at index admission. Descriptive, univariate, and multivariate statistics were used to determine rates of subsequent contralateral SCFE and identify factors associated with contralateral SCFE. RESULTS: This study included 9755 patients who underwent in situ pinning for unilateral SCFE. The mean age at the time of index SCFE was 11.9 years (SD, 1.7) and ~62% of patients were male individuals. Subsequent contralateral SCFE occurred in 1077 (11%) patients at an average of 277 days (range, 7 to 1523 d) after the index procedure. Patients who developed a subsequent contralateral SCFE were younger at the time of index SCFE than patients who did not develop a contralateral SCFE (11.3 vs. 12 y old, P<0.01). In multivariate analysis, older children had a lower risk of subsequent contralateral SCFE (adjusted odds ratio, 0.8; 95% confidence interval, 0.77-0.83), and the odds of subsequent contralateral SCFE decreased by 20% with each increasing year in age. CONCLUSIONS: The rate of subsequent contralateral SCFE is ~11% in the United States, and younger patients are more likely to develop a contralateral SCFE than older patients. Prophylactic pinning should be considered in younger patients with unilateral SCFE, and patients should be followed until skeletal maturity to monitor for subsequent contralateral SCFE. LEVEL OF EVIDENCE: Level III.

Outcome of intramedullary nailing treatment for intertrochanteric femoral fractures.

INTRODUCTION: The OTA/AO type 31 A3 intertrochanteric fracture has a transverse or reverse oblique fracture at the lesser trochanteric level, which accentuates the varus compressive stress in the region of the fracture and the implant. Intramedullary fixation using different types of nails is commonly preferred. The purpose of this study is to evaluate intertrochanteric femoral fractures with intramedullary nail treatment in regard to surgical procedure, complications, and clinical outcomes. METHODS: From one level 1 trauma center, 216 consecutive adult intertrochanteric femoral fractures (OTA/AO type 31 A3) were retrospectively identified with intramedullary nail fixation from 2004 through 2013. Of these, 193 patients (58.5% female) met the inclusion criteria. The average age was 70 years (range 19-96 years). RESULTS: Cephalomedullary nails were utilized in 176 and reconstruction nails in 17 patients. After the index procedure, 86% healed uneventfully. Nonunion development was observed in 6% and 5% had an unscheduled reoperation due to implant or fixation failure. Active smoking was reported in 16.6%. Current smokers had an increased nonunion risk compared to those who do not currently smoke (15.6% vs. 4.3%; p = 0.016). The femoral neck angle averaged 128.0° ± 5°. Fixation failure occurred in 11.1% of patients with a neck-shaft-angle < 125° compared to 2.6% (4/155) of patients with a neck-shaft angle ≥125° (p = 0.021). Patients treated with a reconstruction nail required a second surgical intervention in 23.5%, which was no different compared to 25.0% in the cephalomedullary group (p = 0.893). In the cephalomedullary group, 4.5% developed a nonunion compared to 23.5% in the reconstruction group (p = 0.002). Painful hardware led to hardware removal in 8.8%. All of them were treated with a cephalomedullary device (p = 0.180). During the last office visit, two-thirds of the patients reported no or only mild pain but most patients had reduced hip range of motion. CONCLUSION: Intramedullary nailing is a reliable surgical technique when performed with adequate reduction. Varus reduction with a neck-shaft angle < 125° resulted in an increase in fixation failures. Patient and implant factors affected nonunion formation. Smoking increased nonunion formation. Utilization of a cephalomedullary device reduced the nonunion rate, but had higher rates of painful prominent hardware compared to reconstruction nailing.

Comparison of intraoperative radiation exposure with and without use of distal targeting device: a randomized control study.

INTRODUCTION: When locking intramedullary nails, inserting the distal interlocking screw accurately and quickly with less radiation exposure is very important. The purpose of this randomized control study was to compare radiation exposure and accuracy of distal locking screws between free-hand fluoroscopic guidance and the use of a distal targeting system (DTS). MATERIALS AND METHODS: Inclusion criteria of this study were patients older than 60 years who need an intramedullary nailing due to unstable intertrochanteric and subtrochanteric fracture. The primary outcome was the attempt numbers of image intensifier during the insertion of distal locking screws. Secondary outcomes were operative time and angles between distal locking screws and nail. RESULTS: A total of 36 patients participated in the study. Eighteen patients using free-hand fluoroscopic guidance were assigned to Group I while 18 patients using DTS were assigned to Group II. The number of attempts of image intensifier during distal screw insertion (57.3 ± 31.42 vs. 11.5 ± 7.41, p < 0.001), ratio of attempt number for distal screws to the total attempts (0.33 ± 0.21 vs. 0.12 ± 0.08, p = 0.001), the number of hand exposure to image intensifier directly (75.0 ± 29.55 vs. 13.5 ± 19.07, p < 0.001), and the time of radiation exposure during distal screws insertion (42.57 ± 2.42 s vs. 12.72 ± 8.10 s, p < 0.001) were significantly lower in Group II compared to those in Group I. And, operation time (96.3 min ± 18.94 vs. 76.1 min ± 14.10, p < 0.001) was also statistically significantly lower in Group II. Both distal locking screws were significantly closer to perpendicular direction to the nail in Group II. CONCLUSION: The attempt number of image intensifier during the insertion of two distal locking screws was significantly reduced with DTS compared with that with free hand fluoroscopic guidance. Angle between distal locking screws and nail was also more accurate using DTS.

Comparison of curettage and bone grafting combined with elastic intramedullary nailing vs curettage and bone grafting in the treatment of long bone cysts in children.

To compare the efficacy of curettage and bone grafting combined with elastic intramedullary nailing (EIN) vs curettage and bone grafting in the treatment of long bone cysts in children and to clarify the necessity of using EIN in the treatment of bone cysts.Sixty-two patients were involved in this study from Jan. 2009 to Sept. 2017 (43 males, 19 females; 27 humeri, 35 femurs); the patients were assigned to an EIN group, comprising 30 patients who underwent curettage and bone grafting combined with EIN, or to a non-elastic intramedullary nailing (NEIN) group, comprising 32 patients who underwent curettage and bone grafting alone. The prognosis of the 2 groups was assessed with reference to the standard of Capanna.No statistically significant differences in sex, age, location, activity, pathological fracture, cyst volume, operative time and intraoperative blood loss were found between the 2 groups (P > .05). The effective rate was 90.0% in the EIN group and 68.8% in the NEIN group, and the difference was statistically significant (P < .05).Compared to simple curettage and bone grafting, curettage and bone grafting combined with EIN treatment can significantly improve the prognosis of children with bone cysts. It is recommended that EIN be added to bone cyst curettage and bone grafting.

The burden of femoral shaft fractures in Tanzania.

BACKGROUND: Road traffic injuries disproportionately affect low- and middle-income countries (LMICs) and are associated with femur fractures that lead to long-term disability. Information about these injuries is crucial for appropriate healthcare resource allocation. The purpose of this study is to estimate the incidence of femoral shaft fractures in Tanzania and describe the unmet surgical burden. METHODS: Study sites included six government hospitals across Tanzania. Investigators collected data from hospital admission and procedural logbooks to estimate femoral shaft fracture incidence and their treatment methods. Semi-quantitative interviews were conducted with relevant hospital personnel to validate estimates obtained from hospital records. Investigators gathered road traffic incident (RTI) statistics from national police reports and calculated femur fracture:RTI ratios. RESULTS: Femoral shaft fracture annual incidence rate ranged from 2.1 to 18.4 per 100,000 people. Median low and high femur fracture:RTI ratio were 0.54 and 0.73, respectively. At smaller hospitals, many patients (5-25%) were treated with traction, and a majority (70-90%) are referred to other centers. Barriers to surgery at each hospital include a lack of surgical implants, equipment, and personnel. CONCLUSIONS: The incidence rate is similar to previous estimations, and it is consistent with an increased femoral shaft fracture incidence in Tanzania when compared to higher income countries. The femur fracture:RTI ratio may be a valid tool for estimating femur fracture incidence rates. There is an unmet orthopaedic surgical burden for femur fractures treatment at rural hospitals in Tanzania, and the barriers to treatment could be targets for future interventions.

The association between weight-bearing status and early complications in hip fractures.

BACKGROUND: Early mobilization and weight-bearing have been proposed to improve hip fracture outcomes. This study aimed to compare early postoperative complications and outcomes of patients who underwent weight-bearing as tolerated (WBAT) on postoperative day one (POD1) with those that did not on: (1) 30-day mortality; (2) 30-day postoperative major and minor complications; (3) length of stay (LOS); and (4) discharge disposition after hip fracture management. METHODS: The NSQIP database was used to identify 7947 hip fracture patients managed with a hemiarthroplasty and internal fixation, sliding hip screw, or cephalomedullary nail, for a total of 5845 patients were allowed to WBAT on POD1. They were compared to patients who were non-WBAT using adjusted multivariate regression models to evaluate the effect of WBAT status on the outcomes above. RESULTS: Among the cephalomedullary nail patients, WBAT on POD1 was associated with a decreased likelihood of mortality. In the cephalomedullary nail and sliding hip screw treatment groups, patients were less likely to experience major and minor complications if they were WBAT on POD1. WBAT patients had shorter LOS in the sliding hip screw and cephalomedullary nail treatment groups. Patients were less likely to be discharged to a non-home facility when WBAT on POD1 regardless of treatment. CONCLUSION: Early weight-bearing after surgical care of hip fracture seems to decrease morbidity and mortality; however, this effect is treatment dependent. These findings further support the need for early mobilization and rapid recovery programs in the care of hip fracture patients. LEVEL OF EVIDENCE: Level III.

Finite element analysis of the effect of intramedullary nail compression amount on fracture union in distal tibial diaphyseal fractures.

BACKGROUND: The objective of this study was to investigate the relationship between the stress values on the fracture surface and union periods seen in cases of different compression amounts used to manage distal tibial diaphyseal fractures treated with intramedullary nailing (IMN). METHODS: Ninety-five patients (mean age: 33.99+-10.65 years; male: n=78, female: n=17) with tibial shaft fracture were included in the study. The patients were divided into 3 groups: No compression was used in Group 1 (33 patients), and dynamic compressive fixation was performed with IMN in Group 2 (1 mm, 32 patients) and Group 3 (1.5 mm, 30 patients). A finite element study was performed for Group 2 and Group 3. RESULTS: The average time to achieve radiological union was 16.08+-2.02, 13.54+-1.52, and 12.56+-1.73 weeks in Groups 1, 2, and 3, respectively. Comparatively, the union period in the non-compression group was significantly longer (p<0.001). The functional results were evaluated as excellent in 28 (85%) patients and good-medium in 5 (15%) in Group 1, excellent in 27 (92%) and good-medium in 5 (8%) in Group 2, and excellent in 26 (92%) and good-medium in 4 (8%) in Group 3. CONCLUSION: IMN is a highly effective treatment method for tibial shaft fracture.