[Comparative study of minimally invasive titanium elastic nail and steel plate on the treatment of fracture of tibiofibular fracture in adults].

OBJECTIVE: To compare the clinical outcomes of using elastic intramedullary nail and plate to fix fibular fracture. METHODS: The 60 patients with tibiofibular fractures admitted from January 2015 to December 2022 were divided into two groups:intramedullary nail group and plate group, 30 cases each, intramedullary nail group was treated with elastic intramedullary nail fixation group, plate group was treated with steel plate and screw fixation group. Intramedullary nail group, there were 18 males and 12 females, aged from 22 to 75 years old with an average of (39.4±9.8) years old, including 24 cases of traffic accidents injury, 6 cases of falling injury, 23 cases of closed fractures, 7 cases of open fractures. Steel plate group, there were 15 males and 15 females, aged from 24 to 78 years old with an average of (38.6±10.2) years old. The 22 cases were injured by traffic accident, 8 cases were injured by falling. The 24 cases were closed fractures and 6 cases were open fractures. The operation time, intraoperative bleeding, American Orthopedic Foot and Ankle Society (AOFAS) ankle and hind foot scores, clinical healing time of fibula and the incidence of wound complications were compared between the two groups. RESULTS: The patients in both groups were followed up for 6 to 21 months, with an average of (14.0±2.8) months. Compared with plate group, intramedullary nail group had shorter operative time, less bleeding, shorter clinical healing time of fibula, and lower infection rate of incision, and the difference was statistically significant (P<0.05). There were 2 cases of delayed healing in intramedullary nail group, 1 case of nonunion in plate group, and 2 cases of delayed healing in plate group, and there was no statistically significant difference between the two groups (P>0.05). In the last follow-up, according to the AOFAS scoring standard, the ankle function in intramedullary nail group was excellent in 17 cases, good in 12 cases, fair in 1 case, with an average of (88.33±4.57) points, while in plate group, excellent in 16 cases, good in 10 cases, fair in 4 cases, with an average of (87.00±4.14) points;There was no statistical difference between the two groups (P>0.05). CONCLUSION: Elastic intramedullary nail has the advantages of short operation time, less intraoperative bleeding, short fracture healing time and less incision complications in the treatment of fibular fracture, which is worthy of clinical application.

Comparative Outcomes of Elastic Stable Intramedullary Nailing vs. Plate Fixation in Pediatric Femoral Shaft Fractures. A Prospective Study.

BACKGROUND: Pediatric femoral fractures are common in emergency rooms, with treatment options varying by age. This study compares elastic stable intramedullary nailing (ESIN) and plate fixation for diaphyseal femoral fractures in children aged 5-10. MATERIAL AND METHODS: Conducted at Al-Kindi Teaching Hospital, Baghdad, from December 2017 to December 2019, this prospective study included 32 children with closed transverse diaphyseal femoral fractures. Patients were divided into two groups: 16 treated with ESIN (Group 1) and 16 with plate fixation (Group 2). Criteria excluded comminuted, open, or pathological fractures. RESULTS: Group 1 had a mean age of 7.1 years and weight of 23.7 kg; Group 2 had a mean age of 7.8 years and weight of 30.9 kg. ESIN resulted in shorter operative times (58.4 minutes), earlier weight-bearing, and quicker fracture union (8.8 weeks) compared to plate fixation (76.3 minutes, 11.9 weeks). Blood loss was significantly less in Group 1 (32.8 ml) versus Group 2 (205.0 ml). No significant differences in wound healing or leg length discrepancies were observed. CONCLUSIONS: 1. Our study indicates a preference for Elastic Stable Intramedullary Nailing (ESIN) over plate fixation for pediatric femoral shaft fractures in children aged 5-10 years. 2. ESIN is associated with shorter operative times and faster commencement of weight-bearing, critical in pediatric recovery. 3. While ESIN is generally preferable, plate fixation may be better suited in certain clinical scenarios, emphasizing the importance of personalized treatment. 4. Based on our findings, ESIN is recommended for treating transverse diaphyseal femur fractures in the specified pediatric age group. 5. Recommends further studies, including randomized controlled trials, for a more comprehensive understanding of these treatments' long-term outcomes.

Is Elastic Stable Intramedullary Nailing a Viable Treatment Option for Diaphyseal Fractures of the Humerus in Adults? A 29-case Series Prospective Study.

BACKGROUND: Humerus shaft fractures are common in orthopaedic practice. The emphasis in treatment has shifted from prolonged immobilisation to early mobilisation and internal fixation when needed for a quicker return to normal function. Internal fixation methods include plate osteosynthesis and intramedullary nailing. This study specifically evaluated the effectiveness of flexible intramedullary nails in treating diaphyseal humeral fractures. MATERIAL AND METHODS: Between April 2007 and January 2010, Alexandria University Hospital treated 29 patients (21 males, 8 females) with diaphyseal humeral fractures. Treatment involved closed reduction and percutaneous fixation using two flexible nails. Patients, aged 17 to 65 with a mean age of 32, were included if they did not have pathological fractures, were above 16 years old, and were medically suitable. Causes included pedestrian vehicle accidents (17 cases) and falls or sports-related activities (12 cases). Surgical intervention occurred 1 to 8 days after the injury. RESULTS: Between April 2007 and January 2010, Alexandria University Hospital treated 29 patients (21 males, 8 females) for diaphyseal humeral fractures using closed reduction and percutaneous fixation with two flexible nails. Patients, aged 17 to 65, were monitored for an average of 18 months. Radiographic assessments showed complete union in nineteen fractures within 13 to 21 weeks. One patient experienced non-union but was successfully treated with bone grafting and plating. There were no significant intraoperative complications. Notably, four patients with preoperative radial nerve injuries recovered within 6 to 8 weeks. Evaluation using the Stewart and Hundley Scoring technique showed excellent outcomes for 60% of patients, good outcomes for 30%, fair outcomes for 5%, and poor outcomes for 5%. CONCLUSIONS: 1.The Elastic Stable Intramedullary Nailing (ESIN) technique shows promise in the treatment of humeral shaft fractures. 2. However, the success of treatment may depend on various factors, including patient age, fracture characteristics, and the presence of complications such as open fractures and radial nerve palsy. 3. Careful consideration of these factors is necessary when selecting a treatment approach for humeral shaft fractures.

Unravelling variations: an examination of entry point selection in proximal femoral cephalomedullary nailing.

BACKGROUND: The exact positioning of the cephalomedullary (CM) nail entry point for managing femoral fractures remains debatable, with significant implications for fracture reduction and postoperative complications. This study aimed to explore the variability in the selection of the entry point among trauma surgeons, hypothesizing potential differences and their association with surgeon experience. METHODS: In this prospective multicenter study, 16 participants, ranging from residents to senior specialists, partook in a simulation wherein they determined the optimal entry point for the implantation of a proximal femoral nail antirotation (PFN-A; DePuy Synthes) in various femora. The inter- and intra-observer variability was calculated, along with comprehensive descriptive statistical analysis, to assess the variability in entry point selection and the impact of surgeon experience. RESULTS: In this study, the mean distance from the selected entry points to the calculated mean entry point was 3.98 mm, with a smaller distance observed among surgeons with more than 500 implantations (ANOVA, p = 0.050). Intra-surgeon variability for identical femora averaged at 5.14 mm, showing no significant differences across various levels of surgical experience or training. Notably, 13.6% of selected entry points would not allow a proper intramedullary positioning of the implant, thereby rendering anatomical repositioning unfeasible. Among these impossible entry points, a significant skew towards anterior placement was observed (70.6% of the impossible entry points), with a smaller fraction being overly lateral (27.5%) or medial (13.7%). On a patient level, the impossibility rate varied widely from 0 to 35% among the different femora examined, with a significantly higher rate seen in younger patients (mean age 55.02 versus 60.32; t-test for independent samples, p = 0.04). CONCLUSIONS: Significant variations exist in surgeons' selection of entry points for proximal femoral nailing, underscoring the task's complexity. Experience does not prevent the choice of unfeasible entry points, emphasizing the inadequacy of a universal approach and pointing towards the necessity for a patient-specific strategy for improved outcomes. TRIAL REGISTRATION NUMBER: DRKS00032465.

Antibiotic cement-coated rigid locked nails in infected femoral and tibial nonunion. Reoperation rates of commercial versus custom-made nails.

INTRODUCTION: The objective of this study is to assess bone union, infection control, and reoperation rates in a series of patients with infected femoral or tibial nonunion treated with antibiotic-cement-coated rigid nails and to compare the results obtained with custom-made nails versus commercial nails. METHODS: We retrospectively analyzed a series of consecutive patients with infected nonunion of the femur or the tibia treated with antibiotic-cement-coated rigid nails between January 2010 and 2020. We assessed patients' distinctive characteristics, initial injury, type of nail used (custom-made nail with vancomycin or commercial nail with gentamicin), success rate (bone union + infection control), reoperation rate, and failure rate. Comparative analyses were conducted between reoperated and non-reoperated patients regarding the type of nail used. A multivariate regression analysis was performed to assess the risk variables that impacted reoperation rates. RESULTS: We included 54 patients with 22 (40.74%) infected femoral nonunions and 32 (59.25%) tibial nonunions, who were treated with 38 (70.37%) custom-made antibiotic-cement coated nails and 16 (29.62%) commercial nails. Bone union and infection control were achieved in 51 (94.44%) cases. The reoperation rate was 40.74% (n = 22), and the failure rate was 5.55% (n = 3). The use of custom-made nails was associated with a higher risk of reoperation (Odds Ratio 4.71; 95% Confidence Interval 1.10 - 20.17; p = 0.036). CONCLUSION: Antibiotic-cement-coated nails reached a 94.44% success rate. Nails manufactured in the OR coated with vancomycin cement were associated with a higher risk of reoperation than commercial nails loaded with gentamicin cement. LEVEL OF EVIDENCE: III comparative, observational, non-randomized.

Eficacia y seguridad del sistema de clavo intramedular retrógrado para artrodesis en pacientes adultos con fracturas complejas y/o deformidades de la articulación tibia-astrágalo-calcáneo / Efficacy and safety of the retrograde intramedullary nail system for arthrodesis in adult patients with complex fractures and/or deformities of the tibia-talar-calcaneus joint

ANTECEDENTES En el marco de la metodología ad hoc para evaluar solicitudes de tecnologías sanitarias, aprobada mediante Resolución del Instituto de Evaluación de Tecnologías en Salud e Investigación N° 111-IETSI-ESSALUD-2021, se ha elaborado el presente dictamen preliminar sobre la evaluación de la eficacia y seguridad del sistema de clavo intramedular retrógrado (CIR) para artrodesis en pacientes adultos con fracturas complejas y/o deformidades de la articulación tibia-astrágalo-calcáneo. Mediante la Nota N° 2761-GRPA-ESSALUD-2020, los médicos especialistas del Servicio II de Ortopedia del Hospital Guillermo Almenara Irigoyen (HNGAI), a través de la gerencia de su red prestacional, solicitan al Instituto de Evaluación de Tecnologías en Salud e Investigación (IETSI) la evaluación para incorporación del dispositivo "sistema de clavo intramedular retrógrado para artrodesis tibia-astrágalo-calcáneo". ASPECTOS GENERALES: Las patologías del tobillo' y retropié2, por lo general, pueden ser ocasionadas debido a traumatismo agudo o como secuela de alguna condición crónica (ógüt and Yontar 2017). Las fracturas y deformidades son dos de las condiciones patológicas que pueden ser identificadas con mayor frecuencia a este nivel. Se estima que aproximadamente un 70 % de las fracturas son unimaleolares3, 20 % bimaleolares4y un 10 % trimaleolares5 (Court-Brown, McBirnie, and Wilson 1998). Además, se reporta una tasa similar de fracturas según sexo; sin embargo, esto puede variar según diferentes grupos de edad (Daly et al. 1987). Por su parte, se reporta que algunas deformidades de tobillo, como la osteoartritis, están presentes en aproximadamente 13 millones de adultos mayores de 60 años en los Estados Unidos (Thomas et al. 2017). A nivel local, según información proporcionada por los especialistas del Servicio II de Ortopedia del HNGAI en los anexos de la solicitud, se presentan anualmente alrededor de 36 casos nuevos de pacientes que presentan fracturas complejas que involucran la tibia distal, el astrágalo y el calcáneo. METODOLOGÍA: Se realizó una búsqueda bibliográfica exhaustiva con el objetivo de identificar la mejor evidencia disponible sobre la eficacia y seguridad de la artrodesis con el sistema de CIR, en comparación con la artrodesis utilizando tornillos o fijación externa, en pacientes con fracturas complejas y/o deformidades de la articulación tibia-astrágalo-calcáneo. La búsqueda bibliográfica8se realizó en las bases de datos de PubMed, The Cochrane Library y LILACS. Asimismo, se realizó una búsqueda manual en Google y dentro de las páginas web pertenecientes a grupos que realizan guías de práctica clínica (GPC) y evaluaciones de tecnologías sanitarias (ETS), incluyendo, el Instituto de Evaluación de Tecnologías en Salud e Investigación (IETSI), Centro Nacional de Excelencia Tecnológica en Salud (CENETEC), National Institute for Health and Care Excellence (NICE), Agency for Healthcare Research and Quality (AHRQ), Scottish Intercollegiate Guidelines Network (SIGN), The Guidelines International Network (GIN), National Health and Medical Research Council (NHMRC), Base Regional de Informes de Evaluación de Tecnologías en Salud de las Américas (BRISA), Comissáo Nacional de IncorporaQáo de Tecnologias no Sistema Único de Saúde (CONITEC), Instituto de Evaluación Tecnológica en Salud (IETS), Instituto de Efectividad Clínica y Sanitaria (IECS), Scottish Medicines Consortium (SMC), Canadian Agency for Drugs and Technologies in Health (CADTH), Instituto de Calidad y Eficiencia en la Atención de la Salud (IQWiG, por sus siglas en alemán), y Haute Autorité de Santé (HAS). RESULTADOS: Luego de la búsqueda bibliográfica con fecha 15 de febrero de 2022, se incluyeron para evaluación dos GPC orientadas al manejo de pacientes con fracturas del pie y tobillo: CENETEC e IMSS (Centro Nacional de Excelencia Tecnológica en Salud 2011, Instituto Mexicano del Seguro Social 2010); no se identificaron GPC orientadas al manejo de deformidades de la articulación tibia-astrágalo-calcáneo, o deformidades que involucran al pie, retropié y/o tobillo. Además, se incluyó un ECA (Georgiannos, Lampridis, and Bisbinas 2017) que evaluó la eficacia y seguridad del procedimiento de artrodesis con CIR, en comparación con las artrodesis con tornillos en pacientes con fracturas de tobillo. Asimismo, se incluyó el protocolo de un ECA (ACTRN12617001588381), el cual aún no cuenta con publicación de resultados, y tiene fecha aproximada de finalización en diciembre de 2022 (Tuckett et al. 2019). No se identificaron estudios que evalúen comparativamente al dispositivo CIR, y a la fijación externa en este tipo de 4,1;"147 procedimientos. CONCLUSIÓN: Por lo expuesto, el IETSI no aprueba el uso de clavo intramedular retrógrado para artrodesis en pacientes adultos con fracturas complejas y/o deformidades de la articulación tibia-astrágalo-calcáneo. El equipo evaluador del IETSI, está a la espera de nueva evidencia proveniente de ECA sobre la eficacia y seguridad de la tecnología solicitada. Por otro lado, se recomienda a los especialistas que, de tener conocimiento sobre otras tecnologías sanitarias que puedan representar un beneficio adicional a las tecnologías de uso actual en EsSalud para procedimientos de artrodesis en la población de interés, hagan envío de sus solicitudes para ser valoradas en nuevos documentos de ETS.

Biomechanical Study of Intramedullary Versus Extramedullary Implants for Four Types of Subtrochanteric Femoral Fracture.

OBJECTIVES: To compare the biomechanical performance of proximal femoral nail anti-rotation (PFNA), the "upside-down" less invasive plating system (LISS), and proximal femoral locking plate (PFLP) in fixing different fracture models of subtrochanteric fractures. METHODS: Thirty composite femurs were divided into three equal groups (PFNA, PFLP, and reverse LISS). The implant-femur constructs were tested under axial compression load (0-1400 N) from models I to IV, which represented the Seinsheimer type I subtrochanteric fracture, type IIIa subtrochanteric fracture with the posteromedial fragment reduced; type IIIa subtrochanteric fracture with the posteromedial fragment lost; and type IV subtrochanteric fracture, respectively. Axial stiffness was analyzed for each group. Each group was then divided into two subgroups, one of which underwent torsional and axial compression failure testing, while the other subgroup underwent axial compression fatigue testing. The torsional stiffness, failure load, and cycles to failure were analyzed. RESULTS: PFNA had the highest axial stiffness (F = 761.265, p < 0.0001) and failure load (F = 48.801, p < 0.0001) in model IV. The axial stiffness and failure load of the PFLP were significantly higher than those of the LISS (p < 0.0001, p = 0.001). However, no significant difference in axial stiffness was found between models I to III (model I: F = 2.439, p = 0.106; model II: F = 2.745, p = 0.082; model III: F = 0.852, p = 0.438) or torsional stiffness in model IV (F = 1.784, p = 0.187). In fatigue testing, PFNA did not suffer from construct failure after 90,000 cycles of axial compression. PFLP and LISS were damaged within 14,000 cycles, although LISS withstood more cycles than PFLP (t = 3.328, p = 0.01). CONCLUSION: The axial stiffness of the three implants was similar in models I to III. The biomechanical properties of PFNA were the best of the three implants in terms of axial stiffness, failure load, and fatigue testing cycles in model IV. The axial stiffness and failure load of the PFLP were better than those of the reverse LISS, but PFLP had fewer cycles in the fatigue tests than the reverse LISS.

New tip-apex distance and calcar-referenced tip-apex distance cut-offs may be the best predictors for cut-out risk after intramedullary fixation of proximal femur fractures.

Cut-out is one of the most common mechanical failures in the internal fixation of trochanteric hip fractures. The tip-apex distance (TAD), and the calcar-referenced tip apex distance (CalTAD) are the radiographic parameters that most predict the risk of cut-out. The optimal CalTAD value has not yet been defined, but the optimal TAD value is reported as 25 mm or less. However, this cut-off is highly specific but poorly sensitive. The aim of this study was to determine highly specific and sensitive TAD and CalTAD values and shed light on the role of other clinical variables. A total of 604 patients were included in this retrospective cross-sectional study. For each patient the following data were recorded: number of cut-out, AO/OTA classification, quality of the reduction, type of nail, cervicodiaphyseal angle, type of distal locking, post-operative weight-bearing, TAD and CalTAD values, and the position of the screw head in the femoral head according to the Cleveland system. The incidence of cut-out across the sample was 3.1%. The median TAD in the cut-out group was 38.72, while in the no cut-out group it was 22.16. The median CalTAD in the cut-out group was 39.34, while in the no cut-out group it was 22.19. The cut-off values for TAD and CalTAD with highest value of sensitivity and specificity for the risk of cut-out were 34.8 and 35.2, respectively. The incidence of cut-out can be reduced by performing careful minimal reduction and ensuring stable fixation by avoiding TAD > 34.8 mm and CalTAD > 35.2 mm.

Intramedullary nail versus sliding hip screw for stable and unstable trochanteric and subtrochanteric fractures : 17,341 patients from the Norwegian Hip Fracture Register.

AIMS: The aim of this study was to investigate if there are differences in outcome between sliding hip screws (SHSs) and intramedullary nails (IMNs) with regard to fracture stability. METHODS: We assessed data from 17,341 patients with trochanteric or subtrochanteric fractures treated with SHS or IMN in the Norwegian Hip Fracture Register from 2013 to 2019. Primary outcome measures were reoperations for stable fractures (AO Foundation/Orthopaedic Trauma Association (AO/OTA) type A1) and unstable fractures (AO/OTA type A2, A3, and subtrochanteric fractures). Secondary outcome measures were reoperations for A2, A3, and subtrochanteric fractures individually, one-year mortality, quality of life (EuroQol five-dimension three-level index score), pain (visual analogue scale (VAS)), and satisfaction (VAS) for stable and unstable fractures. Hazard rate ratios (HRRs) for reoperation were calculated using Cox regression analysis with adjustments for age, sex, and American Society of Anesthesiologists score. RESULTS: Reoperation rate was lower after surgery with IMN for unstable fractures one year (HRR 0.82, 95% confidence interval (CI) 0.70 to 0.97; p = 0.022) and three years postoperatively (HRR 0.86, 95% CI 0.74 to 0.99; p = 0.036), compared with SHS. For individual fracture types, no clinically significant differences were found. Lower one-year mortality was found for IMN compared with SHS for stable fractures (HRR 0.87; 95% CI 0.78 to 0.96; p = 0.007), and unstable fractures (HRR 0.91, 95% CI 0.84 to 0.98; p = 0.014). CONCLUSION: This national register-based study indicates a lower reoperation rate for IMN than SHS for unstable trochanteric and subtrochanteric fractures, but not for stable fractures or individual fracture types. The choice of implant may not be decisive to the outcome of treatment for stable trochanteric fractures in terms of reoperation rate. One-year mortality rate for unstable and stable fractures was lower in patients treated with IMN. Cite this article: Bone Joint J 2022;104-B(2):274-282.

Intramedullary nail holes laser indicator, a non-invasive technique for interlocking of intramedullary nails.

Interlocking of intramedullary nails is a challenging procedure in orthopedic trauma surgery. Numerous methods have been described to facilitate this process. But they are exposed patient and surgical team to X-rays or involves trial and error. An accurate and non-invasive method has been provided to easily interlocking intramedullary nails. By transferring a safe visible light inside the nail, a drilling position appears which use to drilling bone toward the nail hole. The wavelength of this light was obtained from ex-vivo spectroscopy on biological tissues which has optimal transmission, reflectance, and absorption properties. Moreover, animal and human experiments were performed to evaluate performance of the proposed system. Ex-vivo performance experiments were performed successfully on two groups of cow and sheep samples. Output parameters were procedure time and drilling quality which there were significant differences between the two groups in procedure time (P < 0.05). But no significant differences were observed in drilling quality (P > 0.05). Moreover, an In-vivo performance experiment was performed successfully on a middle-aged man. To compare the provided method, targeting-arm, and free-hand techniques, two human experiments were performed on a middle-aged and a young man. The results indicate the advantage of the proposed technique in the procedure time (P < 0.05), while the drilling quality is equal to the free-hand technique (P = 0.05). Intramedullary nail holes laser indicator is a safe and accurate method that reduced surgical time and simplifies the process. This new technology makes it easier to interlocking the intramedullary nail which can have good clinical applications.

Comparison of Minimally Invasive Fixation of Mid-Shaft Clavicular Fractures with Threaded Elastic Intramedullary Nail (TEIN) and Elastic Locking Intramedullary Nail (ELIN).

OBJECTIVE: To compare the effectiveness of threaded elastic intramedullary nail and elastic locking intradullary nail (ELIN) for mid-shaft clavicular fractures. METHODS: The clinical data of 47 patients with middle clavicle fracture treated by TEIN and ELIN from August 2017 to March 2019 were analyzed retrospectively. Twenty-three patients received intramedullary fixation treatment with ELIN, nine males and 14 females, AO/OTA fracture classification type 2A (n = 17) and 2B (n = 6). Twenty-four patients received intramedullary fixation treatment with TEIN, including nine males and 15 females, AO/OTA classification: type 2A (n = 18) and 2B (n = 6). All patients were anesthetized with ipsilateral cervical plexus block. After internal fixation was removed, the clinical outcomes were assessed and evaluated. The Constant-Murley score and disabilities of the arm, shoulder and hand questionnaire (DASH) score were compared between the two groups to evaluate the functional status of all patients. The study was done accordingly to the guidelines provided by the ethics committee. RESULTS: All patients in the two groups completed the operation successfully and were followed up. In the ELIN group, the operation time was 20.78 ± 7.71 min, intra-operative blood loss was 13.26 ± 9.72 mL, incision length was 1.60 ± 0.92 cm, internal fixation removal time was 12.86 ± 2.24 weeks, Constant-Murley score was 99.30 ± 1.36 points and DASH score was 1.43 ± 3.00 points. In the TEIN group, the operation time, intra-operative blood loss, incision length, internal fixation removal time, Constant-Murley and DASH scores were 22.83 ± 8.17 min, 22.08 ± 11.22 mL, 2.48 ± 0.84 cm, 15.66 ± 5.58 weeks, 95.79 ± 7.38 point and 6.69 ± 11.55 point respectively. In the ELIN group, four cases developed skin irritation, and the symptoms were relieved after removal of internal fixation. In the TEIN group, one patient's internal fixation broke and had an obvious scar at the incision, but there was no fracture after replacement of internal fixation; withdrawal of TEIN occurred in four patients, the nail did not shift again until the last follow-up; skin irritation and temporary bursitis occurred in six patients, and the symptoms were relieved after internal fixation was removed. No other conditions were found in the patients, and bony healing was achieved in all patients. CONCLUSION: ELIN prevents shortening and malunion of the clavicle, reduces secondary damage to related tissues, and leads to restoration of clavicle length and faster osseous healing.

A New Technique for Placement of Blocking Screws and its Mechanical Effect on Stability of Tibia Fractures with Distal Fragments after Insertion of Small-Diameter Intramedullary Nails.

OBJECTIVE: To design a novel blocking screws (BSs) geometry and insertion method to treat distal tibia fracture with nailing and comparison of mechanical properties of novel and traditional screws. METHODS: Twenty-one synthetic left tibiae were sectioned to obtain 21 distal segments measuring 55 mm. Intramedullary (IM) 9-mm tibial nails were advanced to 6 mm from the ankle joint. Two transverse and one anterior-posterior (AP) locking screws were inserted. Both medial-lateral (ML) BSs were placed 10 mm from the topmost interlocking screw. A custom-made jig assisted in placing the novel and traditional BSs. The time spent in placing each BS was recorded. All the samples were repaired with an IM nail and without BSs, with two traditional BSs, and with two novel BSs. An initial loading from -150 to +150 N was applied to specimens in the ML direction at 185 mm from the nail end, followed by cyclic loading of the same for 10,000 cycles with failure-to-test loading of 350 N in the ML direction. The maximum displacement was measured at 80 mm from the nail end and recorded under initial loading. The damage of two kinds of BSs to the nail was recorded. RESULTS: Compared with average 5.21 min of the time of placing a traditional BS, the time spent in positioning a novel BS on the fracture model was 2.53 min. In the distal bone-implant constructs (BICs), the addition of traditional BSs decreased the maximum displacement of the BICs by 26.2%. The addition of the novel BSs decreased the displacement by 28.9%. All constructs survived 10,000 cycles without hardware deformation. The failure rate of the control group was significantly greater than that of the traditional group; however, the novel group was similar to the traditional group. The damage of the traditional BS to the nail was greater than that of the novel one. CONCLUSIONS: The novel and traditional BSs are comparably effective for increasing the primary mechanical stability of distal metaphyseal fractures after nailin. However, compared to the placement of a traditional BS, implanting a novel BS took more less time and caused less damage to the nail. Additionally, the most obvious advantage of the novel BS design and insertion technology was that the pressure and distance between it and the IM nail could be controlled by rotating the screw. These advantages of the novel BS will be beneficial for clinical application.

The radiographic relationship between the cortical overlap view (COV) and the tip of the greater trochanter.

For proximal femoral nailing, choosing the proper entry point with the aid of C-arm imaging is crucial. Therefore, obtaining accurate radiological views that facilitate sound identification of the tip of the greater trochanter (GT) is of utmost importance. The aim of this study was to define a radiological view characterised by reproducible radiographic landmarks which will allow the reliable identification of the tip of the GT in the anteroposterior view. Anatomical and radiographic features of 16 cadaveric femurs were analysed. The cortical overlap view (COV), characterised by the radiological overlap of the density line of the piriform fossa and the intertrochanteric crest, was identified. It marks the rotation of the proximal femur at which the GT can be accurately identified and used to determine the desired entry point for a proximal femoral nail. Trainees and fully qualified orthopedic trauma surgeons were asked to identify the correct COV in radiological imaging series. Mean internal rotation of the femur to achieve a COV was 17.5° (range 12.8°-21.8°). In the COV the tip of the GT is the highest visible point and the mean distance from the cortical overlap line to the tip of the GT is 4.45 mm. Intra- and inter-rater reliability was high with ICC(2,k) = 0.932 and ICC(2,k) = 0.987 respectively. Trainees achieved higher rates of correct COV identification than specialists. There was no significant correlation between the internal rotation of the femur to achieve the COV and femoral antetorsion. In conclusion, the COV is a highly reproducible radiological view that is characterised by radiographic landmarks easy to recognise. It allows for accurate identification of the tip of the GT, which can be used by the surgeon as a reference to determine the desired entry point for an intramedullary nail.

[Nailing of long bone fractures in precarious situations: focus on the Surgical Implant Generation Network (SIGN) nail]. / Enclouage des os longs en situation précaire: intérêt du clou SIGN (Surgical Implant Generation Network).

Economic development in low-income countries has led to a considerable increase in motor vehicles, in particular motorcycles. Traffic accident-related fractures are therefore increasing. The treatment of long bone fractures is, in the majority of cases, based on locked intramedullary nailing, a procedure which is rarely available in countries with poor sanitary conditions. To provide optimal treatment to these countries, the SIGN (Surgical Implant Generation Network) nail was developed in 1999 by Lewis Zirkle. It is currently used free of charge in 53 countries. In return, an international database must be completed in order to assess and develop it. In the light of our experiences in Haiti and Burundi and on the basis of a literature review, we here highlight the conceptual and technical features of SIGN nail whose implant in French-speaking countries is still limited.

Additional use of anti-rotation U-blade (RC) decreases lag screw sliding and limb length inequality in the treatment of intertrochanteric fractures.

The purpose of this study is to compare the cut-out rate and sliding distance associated with limb length inequality between operations using a standard non-sliding lag screw versus those using a non-sliding lag screw with U-blade (RC) in the Gamma3 nail. This is a retrospective review of two case series involving different lag screws for the Gamma3 nail. Propensity score matching analysis was used to adjust the confounding factors. A comparative analysis of 304 patients who treated with Gamma3 nail with either a standard non-sliding lag screw or a U-Blade (RC) lag screw was performed. Between 2014 and 2018, 152 patients were treated with U-blade (RC) lag screws, and these patients were matched with those treated with standard lag screws. There was no significant difference in cut-out rate between groups. However, additional use of anti-rotation U-blade (RC) could significantly decrease lag screw sliding, with the group treated with U-Blade (RC) lag screws exhibiting shorter sliding, especially in AO/OTA31 A2 and A3 fractures. Also, in A2 and A3 fractures, the mean lag screw sliding distance was greater than that seen in A1 fractures in both groups. These findings can help trauma surgeons choose the proper implant to reduce leg length inequality.

Should Pertrochanteric and Subtrochanteric Fractures Be Treated with a Short or Long Intramedullary Nail?: A Multicenter Cohort Study.

BACKGROUND: The purpose of the present multicenter cohort study was to compare the rates of reoperation in elderly patients with pertrochanteric and subtrochanteric fractures that had been treated with a short or long intramedullary nail. METHODS: Eleven orthopaedic departments across Denmark delivered data that had been obtained from the Danish Multidisciplinary Hip Fracture Registry (DMHFR) and a review of health-care records. With use of surgical procedure codes for pertrochanteric and subtrochanteric fractures that had been treated with an intramedullary nail, the DMRHF was searched to identify patients who had been ≥65 years of age between 2008 and 2013. The health-care records for patients who had had major reoperations, defined as any reoperation with the exclusion of simple hardware removal, were retrieved from the DMHFR, were reviewed for the type of intramedullary nail and missed reoperations, including peri-implant fractures, within 2 years of follow-up. Crude logistic regression analysis with adjustment for age, sex, and comorbidity was performed, yielding odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS: Of 2,245 pertrochanteric fractures, 1,867 were treated with a short intramedullary nail and 378 were treated with a long intramedullary nail. The rate of major reoperations was 4.0% in the short intramedullary nail group and 6.3% in the long intramedullary nail group. This yielded a crude OR of 1.61 (1.01 to 2.60) and an adjusted OR of 1.67 (1.04 to 2.70). Of 909 subtrochanteric fractures, 308 were treated with a short intramedullary nail and 601 were treated with a long intramedullary nail. The rate of major reoperations was 8.4% in the short intramedullary nail group and 4.0% in the long intramedullary nail group, yielding a crude OR of 0.45 (0.25 to 0.80) and an adjusted OR of 0.45 (0.25 to 0.81). CONCLUSIONS: This is the first study confirming the theory that, for subtrochanteric fractures, a long intramedullary nail has a lower rate of major reoperations compared with a short intramedullary nail. In contrast, a short intramedullary nail has a lower rate of major reoperations compared with a long intramedullary nail for pertrochanteric fractures but with a lower absolute risk reduction compared with the results for subtrochanteric intramedullary nailing. There is a need for validation of these results in other large studies, especially for pertrochanteric fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Use of Lesser Trochanter Profile as a Rotational Alignment Guide in Intramedullary Nailing for Femoral Shaft Fracture.

BACKGROUND: Malrotation after nailing of femoral shaft fractures occurs in about 25% of cases. It can cause substantial functional problems. The lesser trochanter (LT) profile has been used to assess rotational alignment. However, the extent to which the LT profile is symmetrical between limbs, whether the LT profile varies as a function of age or sex, and the efficacy of the LT profile technique remain unknown. The purpose of this study was to determine if there was a significant side-to-side length difference in the LT profile (LTD) according to age and sex. METHODS: We attempted to determine the amount of medial prominence of the lesser trochanter relative to the medial cortex of the femoral shaft (the LT profile) using 3-dimensional computed tomography (3D-CT) images of normal femora obtained bilaterally (366 subjects) in anatomic positions. We also compared the left and right sides to determine the amount of natural asymmetry by age and sex. In addition, we compared the side-to-side difference in the LT version with the LTD to determine whether the LTD represented the difference in femoral rotation. RESULTS: The LTD was <4 mm (meaning an LT version difference of <10°) in 83% of the subjects, but was ≥4 mm (an LT version difference of ≥10°) in 17%. Subset analysis demonstrated that the differences were greatest in women >70 years of age. The largest LTD (both sexes) was observed in individuals over 70 years of age (2.62 ± 1.37 mm, compared with <55 years: 1.55 ± 1.36 mm and 55 to 70 years: 2.27 ± 1.70 mm). There was no significant difference between sexes in the under-70 age groups. However, the LTD was significantly greater in women over 70 years than in men over 70 years (3.10 ± 1.42 versus 2.41 ± 1.30 mm). CONCLUSIONS: Since the LTD demonstrated side-to-side symmetry within 4 mm, or 10° of rotation, in 83% of all subjects, we consider the LT profile to be useful as a guide to assess rotational reduction clinically. However, surgeons should recognize that, in 17% of cases, using this technique could result in malrotation of ≥10°. The rate of malrotation may be even higher in women over 70, for whom supplemental techniques to ensure correct rotation may be appropriate.

The Effect of Integrity of Lateral Wall on the Quality of Reduction and Outcomes in Elderly Patients with Intertrochanteric Fracture: A Controlled Study.

OBJECTIVE: The study is aimed at evaluating the effect of the integrity of lateral wall on the quality of reduction and outcome in intertrochanteric fracture treated with proximal femoral nail antirotation (PFNA). METHODS: Medical record systems for elderly patients with intertrochanteric fracture treated with PFNA were included. The patients were divided into incompetent and intact lateral wall groups. Patients' baseline characteristics, quality of reduction, and Harris Hip scores (HHS) were collected. RESULTS: The study included 115 patients with intertrochanteric fractures, with 59 in the incompetent lateral wall group and 56 in the intact group. Lateral wall thickness was 16.47 ± 2.46 mm and 23.68 ± 1.59 mm in the incompetent group and intact group (t = -18.766, P < 0.001), respectively. There was no significant difference in the quality of reduction (P = 0.646) between intact and incompetent groups. Mean HHS at final follow-up were 83.02 ± 13.89 in the incompetent group and 86.04 ± 3.39 in the intact group, with no significant difference (P = 0.123). In addition, there was no significant difference in weight-bearing or clinical healing between intact and incompetent groups. The partial weight-bearing with crutches was allowed at 2.71 ± 0.93 and 2.66 ± 1.01 weeks after the operation in the incompetent and intact groups. Time to clinical healing was 5.83 ± 0.99 and 6.00 ± 0.92 months in the incompetent and intact groups, respectively. However, the operative time in the incompetent group (58.54 ± 18.14 mins) were longer than that in the intact group (51.79 ± 17.77 mins). CONCLUSIONS: In conclusion, it seems that lateral wall thickness does not affect the quality of reduction and outcome in patients with intertrochanteric fracture receiving PFNA.

Percutaneous pinning with interphalangeal joint locked in phalanx fractures: The surgical technique and the results.

BACKGROUND: The purpose of the study was to compare the operation time, the fracture healed time, the postoperative function recovery between the techniques that temporary locking of the interphalangeal joint and traditional manual reduction in the treatment of percutaneous pinning of the phalanx fractures. METHODS: Patients with phalanx fractures from January 2015 to January 2018 who were admitted to our hospital were retrospectively reviewed. Patients received surgery with traditional manual or temporary locking of the interphalangeal joint reduction. The information of patients, including age, gender, the length of the operation, the fracture healed time, the postoperative function recovery, complication, and length of postoperative hospital stay, was collected. All of the information were evaluated and compared between the 2 groups. All of the surgery were performed by 2 experienced hand surgeons of our department. The patients in the 2 groups were followed up for an average of 6 months after surgery. RESULTS: All patients completed the operation and were followed up completely. There was no significant difference in baseline data between the 2 groups (P > .05). The observation group who received surgery with the interphalangeal joint locked technique had significantly shorter in operative time than the control group (P < .05). And postoperative complications in the observation group were significantly less than those in the control group (P < .05). However, the postoperative functional recovery in both groups was no significant difference between the 2 groups (P > .05). And there were no significant differences in the fracture healed time and length of postoperative hospital stay between the 2 groups (P > .05). CONCLUSION: Both surgical techniques can enable patients to achieve good function, but the technique of interphalangeal joint locked is effective in the treatment of the phalanx fractures, as it is characterized by short operations and a quick recovery. However, this technique is only suitable for extra-articular phalanx fractures that the AO/ASIF classification of type A2.3 and less than 2 weeks, not for other phalanx fractures.