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The management of type 3 lateral condyle fractures (LCFs) remains controversial. The main goal of this study was to evaluate the feasibility of closed reduction and percutaneous pinning (CRPP) in patients with type 3 LCFs and to assess the outcome of such injuries according to the type of treatment, CRPP, or open reduction and internal fixation (ORIF).This is a retrospective review of prospectively enrolled children with type 3 LCF managed by CRPP or ORIF between 2018 and 2021. All patients were followed for at least 12 months. Patients were divided into two groups according to the type of treatment, CRPP or ORIF. Demographic characteristics were recorded for all patients. Standard radiographs were used to identify, evaluate, and classify each fracture and to detect the presence of other concomitant bone lesions. The clinical outcome was assessed according to the Hardacre et al. criteria.Seventy-eight children with type 3 LCF were included; 42 were treated by CRPP (53.8%) and 36 by ORIF (46.2%); the mean follow-up time was 17.7 months (range, 12.3-40.9). The baseline characteristics did not differ between the two groups of patients. Overall, successful CRPP could be achieved in 39 out of 42 patients (92.9%). The mean surgical time was 63.4 and 84.5 min in patients treated by CRPP and ORIF, respectively (p = 0.01). Fluoroscopy time was significantly shorter in patients managed by ORIF than in those treated by CRPP (12 versus 40 s, respectively; p 0.001). Clinical outcome according to the Hardacre et al. criteria was excellent in 37 out of 39 (94.4%) and in 35 out of 36 patients (97.2%) treated by CRPP and ORIF, respectively (p = 0.09).CRPP management of paediatric type 3 LCF has clinical and radiographic outcomes similar to ORIF; if satisfactory reduction cannot be achieved by CRPP, conversion to ORIF should be considered.

Purpose To compare the clinical results, complication rates, and radiographic outcome between both methods of fixation of lateral malleolar fractures: lateral neutralization plates and intramedullary fully threaded screws. Patients and methods This prospective case series study involved 73 patients with fractured lateral malleolus of type A, B according to Weber classification, to whom internal fixation was performed by either lateral plate and screws construct (Group A) or intramedullary screw (Group B). All patients were followed up for 12 months at least, with an average follow-up time of 12.7 months. Results There was no significant difference in the functional outcome score between both groups. The intramedullary screw group had a significantly shorter operative time and time to full union (P Conclusion The use of intramedullary fixation is a good alternative for plate fixation in low fibular fractures (Weber A and B). Although plate fixation provides an optimal anatomic reconstruction of the fractures, intramedullary fixation may have a lower risk of complications.

Background Pediatric femur fractures are a major trauma in children. Different treatment algorithms have been developed but indications for surgical treatment, especially in very young patients, are still controversial. Literature recommends surgical stabilization with elastic-stable intramedullary nailing (ESIN) starting at the age of 3 and non-operative treatment in younger patients. This study sought to present the outcome of patients younger than 3 years of age treated with ESIN for femur fractures. Materials and methods Inclusion criteria were patients younger than 3 treated with ESIN in femur fractures. Patient demographics, fracture characteristics, mechanism of injury, outcomes and complications were recorded using charts and X-rays. Primary outcome measures were time to mobility, fracture consolidation and surgical-related complications. Results Between 2010 and 2020, 159 patients were treated with ESIN in femur fractures in our institution. A total of 30 patients met the criteria. The mean age was 2.1 ± 0.7 years (13 months–2.9 years). Most common mechanism was fall from standing height (60%). Other mechanisms were motor vehicle accidents as a pedestrian (10%) or as a passenger (10%) as well as direct blow trauma (20%). Femoral shaft fracture was the most common injury (80%). 5 subtrochanteric and one distal metaphyseal femur fractures were found. Mean length of stay was 2.0 ± 1.3 days. Radiographic controls were performed on day 1, 14 and 6 weeks after surgery if not otherwise specified or if complications occurred. 4.6 ± 1.2 (n 2–7) X-rays were performed on average after surgery. First radiographic consolidation signs were seen after 2.4 ± 0.6 weeks. Only one child showed surgical-related complication with a leg length discrepancy of 1 cm. In 10% of the patients, shortening after surgery of 1.7 ± 1.4 mm (0.3–3.1 mm) occurred. One child initially treated with traction therapy showed skin irritations and was operated with ESIN. No non-union or ESIN-related complications were found. Mean follow-up was 5.1 ± 4.4 months (4–24 months). First independent mobilization was seen at an average of 3.4 ± 1.1 weeks (2–6 weeks) after surgery. Implant removal was performed after 3.2 ± 1.3 months (2–8 months). No refracture after implant removal occurred. Conclusion Early results with ESIN show a reasonable and safe treatment option for femur fractures in toddlers and young children under the age of 3 with easy postoperative care, fast fracture union and early independent mobilization.

Purpose Early weight bearing (EWB) is often recommended after intramedullary nailing of tibial shaft fractures, however, the risks and benefits have not been critically evaluated in a systematic review or meta-analysis. Therefore, the aims of this study were to perform a systematic review and meta-analysis comparing EWB and delayed weight-bearing (DWB) after intramedullary nailing of tibial shaft fractures and assess the relationship between weight-bearing, fracture union and healing. Method This review included studies comparing the effects of EWB, defined as weight-bearing before 6 weeks, and DWB on fracture union and healing. PubMed, Embase, CINAHL, and the Cochrane Library were searched from inception to 9 May 2021. Risk of bias was assessed using the Down’s and Black Checklist and Cochrane Risk of Bias Tool 2.0. Data were synthesised in a meta-analysis, as well as narrative and tabular synthesis. Results Eight studies were included for data extraction and meta-analysis. The analysis produced mixed results and found a significant decrease in mean union time (−2.41 weeks, 95% confidence interval: −4.77, −0.05) with EWB and a significant Odd’s Ratio (OR) for complications with DWB (OR: 2.93, 95% CI: 1.40, 6.16). There was no significant difference in rates of delayed union, non-union, re-operation and malunion. Conclusion The included studies were of moderate risk of bias and demonstrated shorter union time and fewer complications with EWB. However, current evidence is minimal and has significant limitations. The role of EWB in high-risk patients is yet to be examined. Further well-designed, randomised studies are required on the topic.

Over the last 20 years, suprapatellar (SP) intramedullary nailing has gained considerable attention for treating tibia fractures and is believed to improve fracture alignments, decrease anterior knee pain, and facilitate intraoperative fluoroscopy. However, it is associated with various concerns, including the need to make another infrapatellar (IP) incision to remove the nail.This study was aimed at developing a new technique for the removal of SP tibial nails through an SP approach using a cannulated extraction system. The efficiency of the novel SP approach was compared to that of the traditional IP approach for the removal of SP tibial nails.This was a retrospective cohort study from a prospectively collected clinical registry. The data for 69 consecutive patients who received surgery to remove a previous SP intramedullary nail using an SP approach (n = 30, SP cohort) or an IP approach (n = 39, IP cohort) were analyzed. Intra-operative evaluations included intraoperative blood loss, operation time, and changes in the surgical procedures. At six months follow-up, post-operative Lysholm knee score, visual analog scale (VAS) score, and the active range of motion (ROM) of the affected knee and complications were assessed.Patients in the SP cohort exhibited an increased post-operative Lysholm knee score (β, 2.6; 95% confidence interval [CI], 0.6 to 4.6; P = 0.012), decreased post-operative VAS score (β, - 0.7; 95% CI, - 1.1 to - 0.2; P = 0.004), and increased operation time (β, 9.8 minutes; 95% CI, 5.7 to 14.0 minutes; P 0.001) compared with those treated with the IP approach after adjustment for baseline characteristics. There were no statistically significant differences in blood loss, post-operative ROM, or complications between the two cohorts.Compared with the IP technique, the SP approach for the removal of an SP tibial nail was independently associated with an increased post-operative Lysholm knee score and decreased VAS score, although the surgery was longer in duration. The novel technique offers a reliable and minimally invasive option for the removal of an SP tibial nail.

Management of distal tibia fractures in the elderly is complex. The results of conservative treatments may be disappointing and primary ankle arthrodesis is now regularly offered as an alternative. In this study, we aimed to review the outcomes of primary ankle arthrodesis for distal tibia fracture in the elderly.We conducted a systematic review of the literature, from the Cochrane, MEDLINE, and Embase databases, on studies published in English and in French between 1950 and 2020. Only studies reporting the clinical results, the function, or the complications of primary ankle arthrodesis after ankle fracture in the elderly were included.We included nine studies. The total number of patients was 229: 21% of them (50/229) sustained open fractures and 41% (95/229) had three or more comorbidities. All the patients underwent a tibio-talo-calcaneal arthrodesis with a retrograde transplantar intramedullary nailing (TIMN): short nail in 52% (151/229) and long nail in 48% (78/229) of the cases. At a mean follow-up comprised between six and 21 months, 94.5% of patients (190/201) achieved bone union, 87% (123/140) recovered an ankle range of motion close to their pre-operative status, 19% (40/211) had a complication, and 11.3% (24/211) required a revision. The use of a short nail resulted in a higher rate of peri-implant complication (2%) as well as a higher rate of revision (12.4%).Primary ankle arthrodesis in recent fractures of the distal end of the tibia in the elderly frequently results in satisfactory results. The use of a long nail may be associated with a lower rate of implant specific complications.

There is currently no consensus regarding the need for fixation of concomitant fibula fractures in patients with surgically treated distal tibia fracture. Although studies have shown it to be beneficial for fractures involving the syndesmosis, it remains unclear for suprasyndesmotic fractures. This study evaluates what effect the fixation of such suprasyndesmotic fibula fractures had on patients who underwent fixation of distal tibia fractures.This retrospective cohort study included all consecutive adult patients who received surgical treatment for an extra-articular or simple intraarticular distal tibia fracture between 2012 and 2020 and had a concomitant fibula fracture proximal to the syndesmosis. Two groups were formed depending on whether the fibula was stabilized. The need for revision surgery, the occurrence of complications, fracture healing, rotational and angular malalignment were evaluated for both groups.This study included 120 patients, of which 40 (33.3%) had operative treatment of the fibula fracture. Of those with stabilized fibula fractures, 28 (70%) were treated with a plate and 12 (30%) with a titanium elastic nail. The group of patients with surgically treated fibula fractures had significantly more angular malalignments (10% vs 1.2%, p = 0.042), while there was no difference regarding rotational malalignment or fracture healing. Further, infections of the fibular surgical site occurred in 15% of surgically treated patients leading to significantly more revision surgeries in this group (40% vs 20%, p = 0.03). All infections occurred when a plate was used.This study was unable to show any benefit from stabilizing concomitant, suprasyndesmotic fibula fractures in surgically treated distal tibia fractures. On the contrary, infection, revision surgery and angular malalignment were more frequent when the fibula was fixed. Therefore, such concomitant fibula fractures should not routinely be fixed and if stabilization is deemed necessary, the implant should be chosen carefully.

Intramedullary nailing is the standard treatment of trochanteric fractures. Mechanical failure such as cut-out and cut-through are associated with high rates of revision surgery, functional impairment, and mortality. The aim of the study was to evaluate the rate of mechanical failure of the cement augmented screws of Trochanteric Fixation Nail-Advanced (TFNA) nails.A descriptive, retrospective, multi-operator, single-centre study was performed at our level 1 trauma centre between June 2019 and June 2020. Patients were included if they were 65 years of age, presented with a trochanteric fracture treated with an augmented TFNA nail with 6 months of follow-up. The primary outcome was fixation failure rate (cut-out or cut-through) at three and six post-operative months. Secondary endpoints were intra-operative data, clinical scores, and radiographic analysis.Forty-five patients (38 women and 7 men) were analysed. The mean age was 82.84 years (65-102, 9.50). There were no instances of mechanical failure in our series, after either three or six months of follow-up. No patient exhibited cut-out or cut-through. The mean amount of cement injected was 4.72 mL (3-6; 1.05). The mean length of surgery was 37.59 min (25-55; 6.48), and the mean intra-operative radiation exposure was 91.47 cGycmOur clinical results suggest that cement-augmented TFNA screws can be successfully used in the management of trochanteric fractures in patients 65 years of age.

Introduction Previous articles reported on the tip–apex distance, lag screw placement, fracture pattern, reduction quality, osteoporosis and other factors associated with second surgery. The current study focused on investigating the association of the matching degree between proximal femoral intramedullary nail and femoral medullary cavity on reoperation rate. Patients and methods A retrospective cohort study was conducted. It included patients with intertrochanteric fracture who were treated with proximal femoral anti-rotatory intramedullary nail (PFNA) between January 2016 and April 2021. The gap between the intramedullary nail and the femoral medullary cavity was equal to the difference in diameter between the two. According to the gap size, all patients were divided into three groups, as follows: high-matching group: gap ≤ 2 mm; middle-matching group: 2 Results A total of 203 eligible patients were recorded, including 78 males (38.4%) and 125 females (61.6%). They had a mean age of 77.8 ± 9.9 years old and an average follow-up time of 58.1 ± 24.0 weeks. Twenty-seven patients (13.3%) needed a second operation. Coxa varus combined with screw cutting was the most common reason for reoperation (11 cases). Unstable fracture pattern with poor reduction grade tended to contribute to reoperation, whose odds ratio (OR) was 6.61 (95% confidence interval [CI], 1.98–22.09; P = 0.002). The three groups had 11 cases (13.7%), 12 cases (13.8%) and 4 cases (11.1%) of reoperation, respectively, and logistic regression showed no significant association was noted between matching degree of intramedullary nail and reoperation rate. Conclusions The matching degree between proximal femoral intramedullary nail and femoral medullary cavity did not seem to be an important factor for reoperation, which offered more options of intramedullary nail size intraoperatively and reduced implants stock from inventory.

Background Femoral shaft fractures caused by high energy trauma can be very challenging due to the large variability in fracture morphology and poor functional outcomes. Displaced major fragments of femoral shaft fractures are difficult to manage after closed reduction and intramedullary nailing (IMN). The minimally invasive cerclage wiring (CW) procedure has become an optimal tool for major fragment resetting and stabilization after IMN. However, arguments continue for the potential risk of arterial injury, blood supply disruption, and delayed bone union or non-union with the CW procedure. The surgical algorithm for treating femoral shaft fractures with displaced major fragments remains controversial. Thus, emphasis is placed on whether the CW procedure can promote the bone union rate and improve functional outcomes without significant complications. Methods We performed a retrospective study on all patients of femoral shaft fractures with displaced major fragments between June 2015 and August 2019 in our trauma centre. Eligible patients were included and stratified into the CW group and IMN group. Demographics, radiological data, callus formation, union time, and functional outcomes were critically compared between the two groups. Results Thirty-seven patients were included in the present study according to our inclusion/exclusion criteria, of whom 16 (43.2%) were stratified into the CW group, and 21 (56.8%) into the IMN group. The modified radiographic union score for femorae (mRUSH) in the CW group and IMN group was significantly different (11.94 ± 1.29 vs. 7.95 ± 0.74, 6 months; 15.88 ± 0.50 vs. 10.33 ± 0.91, 12 months) (p p p p p Conclusions Minimally invasive CW is an optimal supplement for IMN in the treatment of femoral shaft fractures with displaced major fragments. As illustrated, the benefits of CW potentially include promotion of the bone union rate and improvement in functional outcomes.

Background The objective of this study was to evaluate the efficacy of locking plates versus interlocking intramedullary nails in the treatment of proximal humerus fractures to provide clinical data support and theoretical guidance. Methods Patients with proximal humerus fracture from the Third hospital of Shijiazhuang city and Third hospital of Hebei medical university and from January 2017 to June 2019 were selected, included and divided into the locking plate group and the interlocking intramedullary nail group according to the intervention received. Information pertaining to the perioperative period (operation time, hospital stay, blood loss, etc.) of patients in both groups was collected. VAS pain scores, shoulder activity Constant-Murley scores and postoperative complications were documented. The perioperative data of the two groups were compared, and P Results A total of 64 patients were enrolled, including 36 patients in the locking plate group, with a mean age of 61.3 ± 13.9 years, while the mean age of the interlocking intramedullary nail group was 65.6 ± 11.2 years. There was no statistical difference in gender, affected side, injury mechanism and Neer classification between the two groups (P > 0.05). However, the average operation time of the locking plate group was shorter than that of the interlocking nail group (84.9 ± 11.7 vs. 102.6 ± 22.1 min, P = 0.00), and the intraoperative blood loss of the locking plate group (137.4 ± 16.8 ml) was higher than that of the interlocking nail group (72.5 ± 10.5 ml, P = 0.00). There was no significant difference in the VAS score and Constant-Murley score between these two groups at the final follow-up. Conclusion Interlocking intramedullary nails are more minimally invasive than locking plates, but fracture reduction and fixation take longer. There was no significant difference in pain and shoulder function scores between the two internal fixation strategies for the treatment of proximal humerus fracture.

The aim of this study was (1) to compare clinical and radiological outcomes of 3- and 4-part proximal humeral fractures using either IMN or LP (2) and to report complications related to each technique. A prospective controlled randomized open-label two-arm study was performed. Ninety-nine consecutive adult patients with a 3- and 4-part displaced acute proximal humeral fractures were randomized to be treated with IMN (n = 49) or LP (n = 50). Constant, ASES and SST scores were recorded by the surgeon. Range of motion was evaluated. A visual analog scale (VAS) was used to assess shoulder pain. Complications and revision surgeries were reported. Eighty-five patients were analyzed, nine were lost, and five died during the follow-up period. The mean age was 73.7 years (± 13.3,, and the mean follow-up was 66 months (± 13.5). At last follow-up, VAS was lower in the IMN group (0.9 (± 1.1) vs. 1.9 (± 1.7), p = 0.001). The median Constant score was significantly higher in the IMN group (81.6 (± 10.9) points) vs. in the LP group (75.6 (± 19.5) points) (p = 0.043), and ASES score was also significantly higher in the IMN group (86.3 (± 9.5) vs. 75.2 (± 19.6), p = 0.001). There was no difference in the range of motion or SST scores between the two groups. Complications were seen higher in the LP group (9 (21%) vs. 22 (52%), p = 0.003). Revision surgery was higher in the LP group (37% vs. 21%). Satisfactory results were accomplished in both groups according to the reported clinical outcomes. Complication and revision rates were higher in LP group.

The purpose of this study is to assess the role of the lateral wall in post-operative clinical outcomes in patients with intertrochanteric fractures treated with the proximal femoral nail anti-rotation-Asia (PFNA-II). A cohort of 466 patients (OTA type 31A1 or A2) was divided into two groups: one was intact lateral wall group, and the other was fractured lateral wall group. Radiographic outcomes were measured by using the loss of neck-shaft angle (NSA), femoral neck shortening (FNS), and offset shortening (OS). Functional outcomes were assessed by using the Harris score and SF-36 Physical Component Summary (SF-36 PCS). Post-operative complications were recorded. The fractured lateral wall group had a greater loss of NSA (mean [SD], fractured group (8.7°) [2.7°] vs intact group (4.8°) [2.8°]; mean difference, 3.3° [95% CI 2.9 to 3.8]; P

Proton pump inhibitors (PPIs) are one of the most frequently used drugs worldwide. Previous research has shown that they could increase the risk of fracture and interfere with the fracture healing process. In this study, we analyzed the effect of PPIs on the risk of fracture non-union in patients with femoral and tibial shaft fractures. A case–control study was conducted at our institution, including a total of 254 patients who underwent fixation surgery for a femoral or tibial shaft fracture between January 2012 and December 2017. We defined cases as patients who experienced a delayed union (case group A; n = 44), or non-union (cases group B; n = 12). Cases were matched by age, sex, and fractured bone, to 144 controls who did not experience delayed fracture union and did not require further procedures. A conditional logistic regression analysis was performed adjusted to potential confounders, and to the proportion of days covered (PDC) with PPIs. Adjusted ORs (95% CI) for undergoing a nail dynamization following a tibial or femoral shaft fracture were 1.38 (0.70–2.65) for any use PPIs. Patients with a longer PPI treatment courses (PDC ≥ 0.5) had an adjusted OR of 1.86 (0.70–4.76) for undergoing nail dynamization when compared with controls. Contrastingly, patients with a PDC

To evaluate the effectiveness of interlocked humerus nail through a keyhole incision for the management of humeral diaphyseal fractures in terms of radiological union, shoulder function, and complications. In this prospective study of sixty-two patients with humeral diaphyseal fractures in our institute (51 men, 11 women; mean age 42 years; range 20 to 73 years), fifty-nine fractures were closed and three were grade I open fractures. Three patients had a preoperative radial nerve palsy. Key hole surgery was performed by closed technique (n = 56) and limited open technique (n = 6) with reamed humerus interlocked nail through an antegrade nailing procedure. The cases were followed up prospectively for union and function. The mean follow-up was 12.3 months (range 12 months to 18 months). The outcome of the procedure was assessed according to American Shoulder and Elbow Surgeons (ASES) score, radiological union, complications, and secondary procedures required. Fifty-eight (93.33%) fractures united with an average consolidation time of 12.75 weeks. Two patients had delayed union. Two patients had nonunion which required plating and bone grafting. No cases of infection were encountered. Neuropraxia which was detected preoperatively recovered fully in all three cases between three and six weeks. The ASES scores were excellent-to-good in fifty-six (90.32%) patients, fairly functional outcome was noted in four patients(6.5%), and two patients (3.2%) continued to have poor function at the time of final follow-up. The results of keyhole interlocked humerus nail with proximal multi-locking options were excellent-to-good for humeral diaphyseal fractures in terms of union, shoulder function, and complications. It is a safe, easy, and reliable method for the treatment of humeral diaphyseal fractures.

Purpose To evaluate the effect of COVID-19 positivity on inflammatory parameters and 30-day mortality rates in patients over 65 years of age who were operated on for intertrochanteric femur fractures (IFF). Methods Eighty-seven patients (31 males, 56 females) who had a dynamic hip screw (DHS) or proximal femur nail (PFN) for the IFF between March 2020 and November 2020 were included in the study. The patients were divided into two groups as COVID-19 confirmed and probable positive (Group 1) and COVID-19 negative (Group 2). Time to surgery, operation duration, length of hospital stay, 30-day mortality, rates of the intensive care unit (ICU) referral, and inflammatory parameters such as haemoglobin, CRP, sedimentation, PCT, D-Dimer, and ferritin were evaluated. Results No significant difference was observed in terms of demographic data such as age, gender, comorbidity, and fracture type between the groups. Thirty-day mortality, ICU referral rate, blood transfusion rate, and hospitalization period were higher in Group 1 (p = 0.016, p = 0.012, p = 0.031, and p = 0.011, respectively). The inflammatory parameters were higher in Group 1 compared to Group 2 in the preoperative and postoperative periods (p

Purpose ESIN (elastic stable intramedullary nailing) is considered the gold standard for various pediatric fractures. The aim of this study was to analyze the incidence and type of complications during or after TEN (titanium elastic nail) removal. Methods A retrospective data analysis was performed. Metal removal associated complications and preoperative extraosseous length/outlet angle of TENs as possible causes of complications were assessed. Results The complication rate in 384 TEN removals was 3.1% (n = 12). One major complication (rupture of M. extensor pollicis brevis) was documented. One refracture at the forearm occurred, however, remodeling prior TEN removal was completed. Ten minor complications were temporary or without irreversible restrictions (3 infections, 5 scaring/granuloma, 2 temporary paraesthesia). In 38 cases (16 forearms, 10 femora, 9 humeri, 3 lower legs), intra-operative fluoroscopy had to be used to locate the implants. In patients with forearm fractures, extraosseous implant length was relatively shorter than in cases without fluoroscopy (p = 0.01), but outlet angle of TENs was not significantly different in these two groups (28.5° vs 25.6°). In patients with femur fractures, extraosseous implant length and outlet angle were tendentially shorter, respectively, lower, but this did not reach statistical significance. Conclusion Removal of TENs after ESIN is a safe procedure with a low complication rate. Technically inaccurate TEN implantation makes removal more difficult and complicated. To prevent an untimely removal and patient discomfort, nail ends must be exactly positioned and cut. Intraoperative complications may be minimized with removal of TENs before signs of overgrowth. Evidence Level III, retrospective.

Background Extracapsular proximal femur metastasis could be treated by synthesis or resection and megaprosthesis. No universal accepted guidelines are present in the literature. The aim of our study is to analyze of patients with metastases in the trochanteric region of the femur treated by a single type of intramedullary nailing or hip megaprosthesis. Methods We retrospectively reviewed all patients affected by extracapsular metastases of proximal femur. Anthropometric and anamnestic data, routine blood exams and complications were collected. VAS score and MSTS score was administered before the surgery, ad 1–6-12 months after surgery. An un-paired T test and Chi-square were used. Multiple linear regression and logistic regression was performed. Significance was set for p Result Twenty patients were assigned in intramedullary Group, twenty-five in megaprostheses Group. The mean operative time is shorter in intramedullary group. Differential shows a higher anemization in megaprostheses group (2 ± 2 vs 3.6 ± 1.3; p = 0.02). The patients of intramedullary group showed malnutrition (Albumin: 30.5 ± 6.5 vs 37.6 ± 6 g/L; p = 0.03) and pro-inflammatory state (NLR: 7.1 ± 6.7 vs 3.8 ± 2.4; p = 0.05) (PLR: 312 ± 203 vs 194 ± 99; p = 0.04) greater than megaprostheses group. The patients in intramedullary groups shows a higher functional performance score than megaprostheses group at 1 month follow-up (MSTS: 16.4 ± 6.3 vs 12.2 ± 3.7; p = 0.004). A multivariate analysis confirms the role of type of surgery (p = 0.001), surgery duration (p = 0.005) and NLR (p = 0.02) in affecting the MSTS. Globally eight complications were recorded, no statistical difference was noticed between the two groups (p = 0.7), no predictor was found at logistic analysis. Conclusion Intramedullary nailing guarantees a rapid functional recovery, compared to patients undergoing hip megaprosthesis who instead improve gradually over time. The selection of patients with poor prognosis allows the correct surgical indication of nailing, while in the case of a more favorable prognosis, the intervention of hip megaprosthesis is to be preferred.

Background Hip fractures are common in elderly populations and can be life threatening. Changes in healthcare delivery and outcomes for patients with hip fracture treated with intramedullary nails are not well characterized. The objectives of our study were: 1) the characterization of patients treated with the Trochanteric Fixation Nail -Advanced™(TFNA) Proximal Femoral Nailing System or comparable nails (index) and estimate 12-month all-cause readmissions (ACR) and reoperations following index; and 2) the evaluation of 10-year healthcare utilization (HCU) trends for treatment of femoral fractures with femoral nails. Methods This is a retrospective database analysis using the Premier hospital database. All adults with femoral fracture treated with an intramedullary nail, from 2010 to Q3 2019, in the inpatient setting, were identified. Exclusion criteria included patients with bilateral hip surgery and presence of breakage at time of initial surgery. The primary outcome was ACR and reoperation, the secondary outcomes were healthcare utilization metrics. Variables included demographics, comorbidities (Elixhauser Index (EI)), surgical intervention variables and hospital characteristics. Results Forty-one thousand one hundred four patients were included in the study, of which 14,069 TFNA patients, with average age 77.9 (Standard deviation (SD): 12.0), more than 60% with 3 or more comorbidities (more than 64% for TFNA), 40% with severe or extreme disease severity and one third with severe or extreme risk for mortality. ACR reached 60.1% (95% confidence interval (CI): 59.6%-60.5%) – for TFNA: 60.0% (95%CI: 59.2%-60.8%). The reoperation rate was 4.0% (95%CI: 3.8%-4.2%) – for TFNA: 3.8% (95%CI: 3.5%-4.1%). Length of stay (LOS) averaged 5.8 days (SD: 4.8), and 12-month hip reoperation was 4.0% (3.8%-4.2%), in TFNA cohort: 3.8% (3.5%-4.1%). From 2010 to 2019: the percentage patients operated within 48 h of admission significantly increased, from 75.2% (95%CI: 74.3%-76.1%) to 84.3% (95%CI: 83.9%-84.6%); LOS significantly decreased, from 6.2 (95%CI: 6.0–6.4) to 5.6 (95%CI: 5.5–5.7) days; discharge to skilled nursing facilities (SNF) increased from 56.0% (95%CI: 54.8%-57.2%) to 61.5% (95%CI: 60.8%-62.2%); ACR rates decreased but reoperation rates remained constant. Conclusions ACR and reoperation rates were similar across device types and averaged 60.1% and 4.0%, respectively. Ten-year analyses showed reductions in hospital HCU and greater reliance on SNF.

Introduction Traditionally, operative treatment for displaced midshaft clavicle fractures in adolescents has been achieved by using a plate and screws. However, a minimally invasive trend has led surgeons to use the elastic stable intramedullary nail (ESIN) for displaced midshaft clavicle fractures. This study aims to compare the clinical outcomes of adolescent patients who were operated on with an ESIN vs. a plate. Methods All patients aged between 10 and 14 years with displaced midshaft clavicle fractures who were operated on at our institute between January 2014 and January 2018 were reviewed retrospectively. The preoperative data, including baseline information on the patients, and types of surgical procedure were collected from the hospital database. The postoperative data, including clinical outcome and complications, were collected during the follow-up visits. Clinical outcome was evaluated during outpatient visits using the American Shoulder and Elbow Surgeons (ASES) score. The scar problem was evaluated according to the Scar Cosmesis Assessment and Rating (SCAR) scale. Results A total of 73 patients were included. Patients were categorized into two groups: ESIN (n = 45; 27 males, 18 females) and plate (n = 28; 17 males, 11 females), according to surgical technique. The average age of the patients in the ESIN group was 12.2 ± 1.5 years, and that in the plate group was 12.2 ± 1.4 years. The ESIN group presented significantly less operative time (31.1 vs. 59.8 min), a shorter hospital stay (1.5 vs. 2.5 days), and a smaller incision (2.4 vs. 5.4 cm) as compared to the plate group (P P Conclusion A conservative approach remains the first choice for a pediatric clavicle fracture. Both the ESIN and the plate are safe and effective treatment methods for displaced midshaft clavicle fractures in adolescents. The ESIN is superior to the plate given its shorter operative time, shorter hospital stay, lower rate of scar concern, and easier implant removal. Level of evidence III, retrospective observational study.

Objective To investigate the effect of the degree of displacement of a femoral shaft fracture with the third fragment on fracture healing after intramedullary nailing. Methods In total, 216 patients with closed comminuted femoral fracture admitted to Lianyungang Hospital affiliated to Xuzhou Medical University from February 2010 to February 2016 were analyzed retrospectively. Among these patients, 142 were males and 74 were females, the mean age was 38 years (range 17–64 years), and 95 cases were on the right, while 121 cases were on the left. All patients were treated with a femoral interlocking intramedullary nail. Referring to the femoral shaft diameter, the degree of displacement of the third fragment was classified into four grades: grade I (displacement was less than a third of the diameter of the shaft): 121 cases; grade II (greater than a third of the diameter and less than two thirds): 52 cases; grade III (greater than two thirds of the diameter): 28 cases; and grade IV (fracture fragment turnover): 15 cases. According to the modified Radiological Union Scale for Femur (mRUSF), the fracture union rate and the mean union time of the fracture, the effect of the degree of displacement of the third fragment on fracture healing was evaluated. Results In total, 216 patients with a mean follow-up of 15.9 months (range 6–31 months) met the inclusion criteria. The best fracture healing was the grade I displacement, with a union rate of 89.2% and a mean union time of 7.7 months. The poorest fracture healing was for the grade IV displacement, with a union rate of 13.3% and a mean union time of 16.5 months. The healing was moderate in the grade II and III displacements, with a union rate of 46.2% and 28.6%, respectively, and a mean union time of 8.6 months and 13.5 months, respectively (P Conclusions The third fragment with grade I displacement requires no intervention, whereas fractures with grade IV displacement should be reduced to as near as possible to the diaphyseal bone defect to avoid nonunion. The third fragments with the grade II or III displacement should be treated with closed reduction whenever possible to achieve a displacement within the range of grade I to minimize the incidence of nonunion.

Background To investigate the predictive value of the Singh index for the risk of InterTAN intramedullary fixation failure in elderly patients with intertrochanteric fracture to guide clinical treatment. Methods A total of 360 patients were divided into the Singh (I ~ II) (n = 120), Singh (III ~ IV) (n = 120) and Singh (V ~ VI) (n = 120) groups. Visual analog scale (VAS) and Harris scores were recorded at 1, 6, 12, 18 and 24 months after the operation. The correlation between the Singh index and the T-score of the total hip and femoral neck was analyzed. Logistic regression was used to analyze the relationship between the Singh index and internal fixation failure; the types of internal fixation failure were also analyzed. Results The Harris scores of the Singh (I ~ II) group were lower than those of the Singh (III ~ IV) and Singh (V ~ VI) groups 12, 18 and 24 months after surgery (P P = 0.00, r = 0.89; P = 0.00, r = 0.83). The Singh (I ~ II) group had the lowest internal fixation survival rate within 24 months (P = 0.01). The Singh index was an independent predictor of internal fixation failure (P P = 0.00). Conclusion The Singh index is significantly correlated with the bone mineral density of the femoral neck and total hip. The Singh (I ~ II) group had lower Harris scores and a lower internal fixation survival rate than the other two groups. The Singh index is an independent predictor of internal fixation failure, especially lag screw cutting-out, after InterTAN fixation.

Intertrochanteric femur fractures (ITFF) are frequently fixed with proximal femoral nailing (PFN), and a common cause of fixation failure is cut-out of the lag screws. In the literature, many factors have been defined to determine the failure risk, including the tip–apex distance (TAD), calcar-referenced tip–apex distance (CalTAD), the Cleveland zone and Parker's ratio. In this study, a novel technique is described which favors infero-posterior placement of the lag screw and predicts failure risk for PFN. The purpose of this study was to evaluate the tip–neck distance ratio as a factor for the prediction of cut-out after PFN of ITFF. A retrospective evaluation was made of the data of 125 patients applied with PFN for ITFF between October 2016 and September 2019. The occurrence of mechanical complications was analyzed in relation to age, gender, fracture side, American Society of Anaesthesiologists classification, fracture classification, reduction quality, bone quality, Cleveland zone, Parker’s ratio, TAD, CalTAD and the TNDR. A total of 125 patients, including 16 with mechanical complications, were suitable for full analysis. In the univariate analysis, reduction quality (p = 0.003), the TAD (p = 0.048) and the TNDR (p = 0.030) were statistically associated with mechanical complications (p

Early closed reduction and locked intramedullary (IM) nailing has become the standard treatment for diaphyseal long bone fractures in high income countries. The low and middle income countries (LMICs) are still lagging behind in transiting from open surgical reduction and non-operative modalities to closed reduction due to lack of requisite equipment. However, some surgeons in LMICs are beginning to achieve closed reduction even without the equipment. A prospective descriptive study was done on a total of 251 fresh diaphyseal fractures of the humerus, femur and tibia fixed with a locked nail over a 5½-year period. The fractures were grouped into those that had open reduction, closed reduction or reduction with a finger. Closed reduction was done for 135 (53.8%) fractures belonging to 123 patients. The mean and range of the patients’ ages were 41.33 and 13–81 years, respectively. Males constituted 69.9% and mostly (48%) sustained fractures in motorcycle accident. There was a significant negative association between closed reduction and fracture-to-surgery interval (p

Postoperative radiographs are routinely used to assess fracture reduction following intramedullary nail fixation for pertrochanteric fractures, even though computed tomography (CT) is a superior modality. We aimed to determine the association between reduction quality assessed by CT and rates of reoperation and to evaluate the association of reoperation and reduction quality according to the assessment modality (plain radiographs vs. CT). A retrospective analysis of 299 consecutive patients treated with intramedullary nail fixation for pertrochanteric fractures was conducted. Fracture reduction measured by postoperative radiographs and CT was categorized as anatomical type, extramedullary type, or intramedullary type. Postoperative data for analysis included reduction status, tip-apex distance (TAD), screw position in the femoral head, sliding distance, and conditions associated with reoperation. Of the 299 patients included with a mean age of 83.1 ± 8.2 years, there were six patients who required reoperation (2.0%). According to the CT assessments, there were 42 intramedullary reductions (14.0%). Patients with a non-intramedullary reduction based on postoperative CT images were significantly more likely to have proper placement of the screw, a reduced TAD, a reduced sliding distance, and a lower reoperation rate than those with an intramedullary reduction (P

Closed reduction and fixation using a cephalomedullary nail represents the accepted management of unstable intertrochanteric fractures. Cut-through has been described as a complication associated with the treatment. Although a hip arthroplasty may be the most predictable revision method, a non-prosthetic option can lead to similar results. The objective is to describe a non-prosthetic revision procedure in cases of cut-through.We performed a retrospective analysis of our Institutional Registry for Hip Fractures in elderly patients (RIAFC) from January 2010 to June 2018 searching for cut-through as a failure after unstable intertrochanteric fracture treatment. REVISION PROCEDURE: (A) Helical blade removal, introduction of structural bone graft (autologous or allograft) as a plug to obliterate the communication to the joint and a new blade insertion. (B) Same as in A but augmenting the blade/head purchase with poly(methyl methacrylate) (PMMA). Before the cement insertion, a radio-opaque solution was instilled to assure lack of joint leakage.We evaluated 1616 patients. Sixteen of them presented a cut-through complication (1%). Ten of them were females with an average age for all of 84 years. One patient denied an implant revision and opted for a total joint replacement. In four of the patients, the procedure A was done, 2 of them had a new failure, and an joint arthroplasty was performed. In the B group, only one patient needed a revision to a total hip. The other 10 patients healed uneventfully and did not need any further intervention.Cut-through revision after fixation of unstable intertrochanteric fractures treated with cephalomedullary nail by blocking of the joint communication and augmenting the head blade purchase with PMMA is a safe and minimal invasive procedure, generates low blood loss and rate of complications and allows bone healing preserving the native joint.Nil.

The purpose of this study was to evaluate the radiological and clinical outcomes of treatment of comminuted open fractures of the metacarpal bone (MCB) with associated injuries to soft tissues, tendons, and neurovascular structures using antegrade intramedullary nailing (AIN) at least 2 years postoperatively. Between January 2008 and December 2017, a total of 27 patients who met the inclusion/exclusion criteria were included in this study. The inclusion criterion was open and comminuted fracture (with/without segmental bone defects). We evaluated simple radiograph and computed tomography (CT) findings and clinical conditions (visual analog scale [VAS] pain score and Disabilities of the Arm, Shoulder, and Hand [DASH] score), including active range of motion (ROM) at metacarpophalangeal joint (MP) and grip strength at final follow-up. The mean preoperative angulation was 29.63° ± 7.59° and the mean shortening was 9.30 ± 2.38 mm. Union was achieved at mean 12.3 weeks postoperatively, without any complications due to operative treatment. The dorsal angulation measured on the CT scans, shortening on simple radiographs was significantly improved (10.26 °± 3.19°, 0.52 ± 1.05 mm, respectively). The final VAS and DASH scores were 0.41 ± 0.64 and 3.6 ± 2.47, respectively, indicating satisfactory outcomes. The final ROM was 85.0° ± 3.67°. The mean final grip strength was 89.56 ± 5.69% relative to the normal side. A mean extension lag at the MP joint of 12° was noted in three patients; however, it was resolved by additional tenolysis. AIN is a simple method for fixation of open comminuted metacarpal fractures accompanied by soft tissue injury. The simplicity of the method is beneficial for repairing associated injured structures and healing soft tissue. Minimized additional damage around the MCB during surgery and good stability resulted in satisfactory bony union with minimal angulation, shortening, and rotation. Level IV, Retrospective case series.

The purpose of the present study was to determine clinical and radiographic outcomes in patients treated with limited-open retrograde intramedullary headless screw fixation for metacarpal neck and shaft fractures (group I) versus percutaneous antegrade and retrograde intramedullary double pinning linked by a connector (group II). We designed a retrospective comparative study, with the inclusion of two groups (20 patients each) of metacarpal unstable fractures. Both groups showed similar outcomes at the final follow-up, except for extension lag (significantly better in group II) and return to sport (significantly better in group I). Intramedullary screw fixation did not accelerate bone union and range of motion recovery in the early follow-up. In conclusion, limited-open retrograde intramedullary headless screw fixation and percutaneous connected antegrade and retrograde intramedullary double pinning are both reliable techniques of fixation for metacarpal neck and shaft fractures. LEVEL OF EVIDENCE: III.

Functional results after internal fixation of trochanteric femoral fractures may be negatively affected by healing in a non-physiological position. The aim of this study was to evaluate the occurrence and severity of femoral malrotation after nailing of trochanteric fractures. The authors conducted a prospective study focused on a CT analysis of malrotation after intramedullary nailing of trochanteric fractures (AO 31A1-3) in 101 patients. We recorded the type of fracture, method of anesthesia, scheduled surgery vs. acute surgery, and the surgeon’s experience as possible risk factors for limb malrotation after trochanteric fracture surgeries. The average extent of malrotation was 9° of internal rotation ranging from 29° of external to 48°of internal rotation. In 35% of patients, we observed a rotation greater than 15°, and in 15 patients (15%), the rotation was greater than 25°. The risk of significant internal malrotation was significantly higher than external malrotation (37 vs. 4 patients). None of the factors observed proved to be statistically significant. The effect of general anesthesia and the type of intertrochanteric fracture came closest to having a significant effect on rotational error. Improper reduction of a trochanteric fracture is a common problem that can lead to femur malrotation. In our study, a rotational error greater than 15° occurred in 35% of the patients, but none of the monitored factors represented a statistically significant risk for this complication.

Purpose Aim of this study was to investigate whether limited open auxiliary angle stable plate fixation has an effect on functional and radiologic outcomes one year after revision intramedullary nailing in aseptic trochanteric and subtrochanteric fracture nonunion. Methods In a retrospective analysis, surgically revised aseptic trochanteric and subtrochanteric nonunion was evaluated in a total of 190 consecutive patients ranging from 18 to 94 years between 12/2005 and 10/2018. Results One year after revision intramedullary nailing, nonunion healing was assessed in 129 out of 136 patients (95%) in group 1 without auxiliary plate fixation and in 51 out of 54 patients (94%) in group 2 with auxiliary plating (p = 0.23). In group 1, range of motion (ROM) was unrestricted in 88 patients and still restricted in 48 patients. In group 2, ROM was free in 34 patients and restricted in 20 patients (p = 0.25). The mean Lower Extremity Functional Scale (LEFS) was 56 points in group 1 and 55 points in group 2 (p = 0.55). Conclusion This study did not demonstrate significant differences in functional and radiologic outcomes following revision intramedullary nailing of aseptic trochanteric and subtrochanteric fracture nonunion. Limited open auxiliary plate fixation might be a reasonable option especially in cases of relevant varus axis deviation and comminuted or atypical fracture configurations, regardless of patients’ age. Retrospectively registered with the German Clinical Trials Register (01/25/2021; ID: DRKS00024112).

Intertrochanteric femur fractures (IFF) is one of the biggest health problems in elderly population and mostly treated by proximal femoral nails. Although it is done in less invasive technique this method can cause higher blood loss than expected and subsequent allogenic blood transfusions. In this study, we aimed to investigate the factors that were related to the blood loss in proximal femoral nail fixation of IFF including patients’ ongoing anticoagulant treatments. 231 consecutive patients with IFF who treated with proximal femoral nail anti-rotation between January 2017 and December 2019 were included the study. The factors that can affect the blood loss determined as patients demographics, time from injury to operation, duration of operation, the American Society of Anesthesiologists (ASA) scores, preoperative anticoagulant medications. Hematocrit and hemoglobin were obtained on admission day, postoperative day one and postoperative day 3. Total blood loss and allogenic blood transfusions assessed. Higher BMI is found related to higher blood loss. The patients who were operated in the first two days after admission had lower blood loss levels independent from anticoagulant use (p = 0.027). Preoperative Hct was higher in patients who did not need RBCs in the perioperative period (p = 0.039). According to the AO classification, A2.1 fractures had lower blood loss levels. This study demonstrated that ongoing anticoagulant treatments of intertrochanteric fracture patients did not increase the perioperative blood loss. The factors affecting blood loss in the proximal femoral nail fixation were BMI, the time to surgery, and fracture type in the elderly.

Surgery to treat nonunion resulted from malalignment is challenging since correction and bone union should be achieved simultaneously. To report the clinical outcomes achieved through reconstruction of sub-trochanteric femoral fractures by femoral nailing using a poller screw and to review the current concepts. Fourteen patients (11 men and 3 women; mean age 56.4 years) who were diagnosed with non-union of subtrochanteric femoral fractures and who underwent intramedullary nailing with blocking screws between August 2013 and March 2019, with at least 1 year follow-up, were analyzed retrospectively. The preoperative and postoperative Centrum–Collum–Diaphyseal angle and anterior angulation angle were measured. Bone union time, position and number of poller screws used, and complications were analyzed. Functional assessment was performed by evaluating the Harris hip score. The related literature was searched, and 14 clinical studies on the treatment of sub-trochanteric non-union were analyzed. Bone union was achieved in 12/14 cases (85.7%) at the final follow-up within a mean of 6.52 (3–12) months. Bone union was also achieved in two patients lacking bone union at the final follow-up through bone grafting and augmented plating. No cases developed complications, including infection and bone necrosis, and the varus deformity and anterior angulation significantly improved from a preoperative mean of 12.4° and 9.4° to postoperative mean 3.8° and 2.4°, respectively. The mean Harris hip score at the final follow-up was 87.07 (73–98) points. Analysis of published literature revealed high rates of bone union (78–100%) through various fixation methods. Correction with blocking screws and rigid fixation with intramedullary nailing to treat sub-trochanteric—non-union-caused malalignment can yield good clinical and radiological outcomes.

We aimed to 1) identify predictors of delayed and nonunion of tibial shaft fractures in patients treated with intramedullary nailing (IMN), including patient demographics and surgical factors, and 2) determine whether the nail/shaft ratio is associated with delayed and nonunion. This retrospective, multicenter study included 315 patients with tibial shaft fracture treated with IMN between 2014 and 2019 and excluded patients with insufficient follow-up for 12 months, lost data and inadequate radiographs. Finally, we analyzed 258 patients (184 males; 74 females). Main outcome measurements were delayed union at 6 and nonunion at 12 months after surgery as determined on anteroposterior and lateral radiographs. We extracted the following as risk factors of delayed and nonunion: age, sex, BMI, fracture site, fracture type, injury energy, smoking history, and nail/shaft ratio. We conducted logistic regression analysis to investigate risk factors of delayed and nonunion using these extracted items as explanatory variables. Type C fracture was independently associated with delayed union (odds ratio 2.9, 95% confidential interval: 1.04–8.09, P = 0.04). Nail/shaft ratio was not an independent factor of delayed union. No independent explanatory factors were related to nonunion. Type C fractures, which were unstable and fragmented, was associated with delayed union in tibia fractures treated with IMN, whereas nail thickness was not associated with delayed or nonunion fractures.

The unstable intertrochanteric femur fracture remains a challenge for surgeons. However, few studies have compared the clinical effectiveness of intramedullary nail in combination with a reconstruction plate and intramedullary nail alone in the treatment of patients with unstable intertrochanteric femoral fractures with lateral wall damage. This study retrospectively analyzed 16 patients with 31 A3 intertrochanteric fractures treated with the intramedullary nail in combination with reconstruction plate (the study group) and 19 patients with 31 A3 intertrochanteric fractures treated with intramedullary nail alone (the control group) between January 2012 and January 2018. The operation time, intra-operative blood loss, time of fracture healing, and complication rates of post-operative fixation failure were assessed between the two groups. At the follow-up of post-operative six and 12 months, Harris hip score (HHS) and the Parker-Palmer mobility score (PPMS) were used to evaluate the functional states and mobility levels. The distribution of all basic characteristics was similar between the two groups (P ˃ 0.05). The study group had longer operation time and more intra-operative blood loss in comparison with the control group (P < 0.001), while the study group had shorter fracture healing time (P = 0.03) and lower fixation failure rate as compared with the control group. Regarding the functional outcome, the study group had higher HHSs and PPMS than the control group (P = 0.003). Although intramedullary nails in combination with reconstruction plates had longer operation time and more intra-operative blood loss, it might be superior to intramedullary nail alone in terms of fracture healing time, fixation failure complication rate, and post-operative functional recovery.

Midshaft clavicle fractures represent about 4% of all fractures in the emergency department. Non-operative treatment of displaced midshaft clavicle fractures (DMCF) can result in a relatively high non-union rate. Several operative techniques, including intramedullary fixation (IMF) using elastic stable intramedullary nailing (ESIN), have therefore been established. IMF through the medial approach is less suitable for fractures of the lateral diaphysis. IMF of DMCF of the lateral diaphysis through a lateral approach can be an alternative approach for these fractures. The aim of this study is to describe the technique of IMF from the lateral side and to present the functional outcome and complications. A retrospective cohort study was performed. All patients with a traumatic DMCF treated with IMF using ESIN through a lateral approach between 2014 and 2019 were included. Endpoints were the functional outcome (QuickDASH, Subjective Shoulder Value (SSV)), pain (numeric rating scale (NRS)), daily impairment (activities of daily living (ADL)), complications and implant removal. Forty out of 43 patients were available for follow-up. Mean follow-up was 37 months. Mean age was 24 years (range 13–70). The median QuickDASH score was 0 (IQR 0.0–0.0) and the median SSV was 100 (95–100). The median ADL score was 1 (1–4) and the median NRS was 0 (0–0). No non-union occurred. Implant related irritation occurred in 11 patients (27.5%). Implants were removed in a total of 38 (95%) patients; in 10 cases due to irritation, in 28 cases routinely or on patient’s request. IMF of DMCF of the lateral diaphysis through a lateral approach leads to excellent functional results and seems to be a suitable option for internal fixation. However, as with IMF from the medial side, it is not without complications and implant-related irritation.

Nonunion of the radial neck poses an enormous challenge for treating surgeons. It is a very rare complication of the radial neck with limited experiences. In this current major study, the authors report of their own experiences concerning this problem. 11 patients with severe displaced radial neck fracture Metaizeau type IV with elbow dislocation and 2 ongoing fractures. 9 fractures had to be treated with open reduction, six with intramedullary nailing, two with K-wires and one with periosteal suture fixation. In two children, aged 4 and 5, the fracture was not diagnosed initially. The patients showed a successful reduction intraoperatively. All patients developed nonunion of the radial neck. 9 out of 11 children presented with pain and 5 out of 11 with valgus deformity. All children underwent surgical management of the complications. 3 children received a debridement of the elbow joint with resection of the fragmented radial head. 7 cases needed a following reduction, spongiosa-plasty and periosteal flap reconstruction and plate osteosynthesis. One patient received radial intramedullary pinning. All nonunions showed reunion. All patients with obtained radial head showed significant improvement concerning complaints and range of motion. Only one child showed a slight deterioration in range of motion. Children with resected radial head showed good range of motion but complaints and instability in loaded joint needing further surgical treatment. Treatment of radial neck nonunion in children should not be delayed until pain, deformity and limited function occurs because this goes along with severe transition of the radial head right up to bone atrophy.

Tibial shaft fractures are common occurrence in children and surgical treatment is sometimes required, particularly in unstable or open fractures, and in polytrauma. The aim of this study was to investigate the available evidence on the efficacy and safety of flexible intramedullary nailing (FIN) for both open and closed tibia fractures in children, exploring the main surgical outcomes and rate of complications. Pubmed/Medline, Scopus and Cochrane Central databases were searched following the PRISMA guideline. Studies reporting on the outcomes of FIN for paediatric tibia shaft fractures were included. Weighted means were evaluated for surgical outcomes. Meta-analysis of proportion and odd ratios were used to analyse total complication rates and differences between open and closed fractures. Twenty-eight studies (835 patients) were included; the mean age was 11.0 ± 3.0 years. The mean follow-up was 22.5 ± 13.5 months; the mean time to full weight-bearing was 7.5 ± 3.7 weeks. The total complication rate was 28.1% (minor = 20.7%, major = 6.3%); this was greater in open fractures (13.6% vs 5.1%, p = 0.007). The rate of union was 97.5%, with a mean time to union of 11.9 ± 7.2 weeks. Malunion was found in 8.5% cases, delayed union in 3.8%, non-union in 1.4%, symptomatic hardware in 5.1%, leg-length discrepancy in 5.0%, superficial infections in 2.3%, deep infections in 1.0%, compartment syndromes in 1.4%, and refracture in 0.2%. Almost all patients returned to unrestricted physical activity. FIN offers excellent outcomes for the treatment of paediatric tibia shaft fractures. Patients presenting with an open fracture have a higher but acceptable complication rate. Comparative studies are needed to clarify if other treatments have superior outcomes.

To summarize the evolution of intramedullary nailing, highlight important milestones, introduce the atmosphere of the era concerning the first uses and development of intramedullary nailing, and present the status of nailing in modern international orthopaedics and traumatology. A thorough literature search was undertaken in PubMed and Google Scholar as well as in physical books in libraries to summarize the literature on the history and evolution of intramedullary nailing. The first use of an intramedullary device was attested in ancient Egypt; however, the first use of intramedullary nailing was reported in 1524 in Mexico, and the first medical journals reported on intramedullary nailing around the mid-1800s. The evolutions of intramedullary nailing including approach, material, cross-section and shape, and reaming technique occurred in the twentieth century. During the 1960s, intramedullary nailing was abandoned in favour of plate and screws osteosynthesis; however, in the 1970s, 1980s, and 1990s, a surge of novelties including flexible reaming, interlocking, and use of image intensification and titanium nails led to the advent of the second-generation intramedullary nailing. Today, intramedullary nailing has become the standard treatment of long bone fractures with low infection rates, small scars, excellent stabilization of the fractures, and immediate mobilization of the patients. Intramedullary nailing has revolutionized the treatment of long bone fractures. However, with numerous nail designs, a lot of information on their efficacy is lacking. Considerably more work will need to be done to determine the optimal nail specifications.

A recently published article by Song H et al. investigated the risk factors for anteromedial cortical support loss in pertrochanteric fractures treated with cephalomedullary nails. In this Correspondence, we would like to raise some concerns. Specifically, calcar fracture gap and anteromedial cortical support are different concepts in evaluating reduction quality. In addition, calcar fracture gap using immediate postoperative radiographic images has measurement bias. Lastly, explanatory variables selected for multivariable analysis are inappropriate. We would like to discuss and suggest solutions for these problems.

Purpose The management of limb-length discrepancy secondary to traumatic femoral bone loss poses a unique challenge for surgeons. The Ilizarov technique is popular, but is associated with long external fixator time and many complications. This retrospective study assessed outcomes of post-traumatic femoral defects managed by monorail external fixation over an intramedullary nail. Methods Eight patients were included from October 2015 to May 2019 with post-traumatic femoral defects that underwent treatment with monorail fixator-assisted intramedullary nailing. Primary outcome was time to bone union and bone results according to ASAMI classification. Secondary outcomes were lengthening index, consolidation time and index, external fixator index (EFI), time to partial weight bearing(PWB) and full weight bearing (FWB), and complications. Patient reported outcome measures including EQ-5D-5L, SF-36, Oxford knee scores (OKS), and Oxford hip scores (OHS) were recorded after recovery. Results Mean follow-up time was 227 weeks. Average bone defect size was 9.69 cm. Average consolidation time and index were 11.35 months and 1.24 months/cm, respectively. Mean lengthening and external fixator index were 20.2 days/cm and 23.88 days/cm, respectively. On average, patients achieved FWB and bone union 56.25 weeks and 68.83 weeks after bone transport initiation, respectively. Two patients had docking site non-union, five patients had pin site infections, and two patients had osteomyelitis. EQ-5D-5L and EQ-VAS scores were compared to UK population norms (p = 0.104, p = 0.238, respectively). Average OKS was 32.17 and OHS was 34.00. Conclusion Monorail external fixation over an intramedullary nail is an effective option for post-traumatic femoral defects, reducing external fixator time and returning patients’ quality of life to a level comparable with the normal population.

Background Studies have shown that on the coronal plane, whether the direction of the distal locking screw is parallel to the tangent line of the tibiotalar joint can be used to determine whether there is varus or valgus deformity after the treatment of distal tibial fractures with intramedullary nail (IMN) fixation. However, there has been no statistical analysis of the included angle on the coronal plane, and there have been no reports on whether there is a relationship between the direction of the distal locking screw on the sagittal plane or the included angle of the tangent line of the tibiotalar joint and the postoperative alignment of distal tibial fractures treated with IMN fixation. Objective Our aim was to evaluate the relationship between the angles formed by the distal locking screw and the tibiotalar joint tangent (ADTTs) on the sagittal and coronal planes and postoperative alignment in the treatment of distal tibial fractures with IMN fixation. Methods We performed a retrospective analysis of 100 patients with distal tibial fractures treated with IMN fixation using the suprapatellar approach. On the coronal and sagittal planes, the ADTTs were arranged from small to large and divided into 4 groups, namely, groups A, B, C and D. One-way ANOVA was used to compare the lateral distal tibial angle (LDTA) and anterior distal tibial angle (ADTA) among all groups, and the chi-square test was used to compare the incidence of postoperative tibial misalignment among all groups. Univariate analysis was performed using chi-square tests to identify factors that might be associated with dislocation, including fibular open reduction and internal fixation (ORIF), limited open reduction, ADTT, IMN diameter, injury mechanism, open vs. closed fracture, comminution, and fibular fracture level. Then, the statistically significant variables in the univariate analysis were included in a multivariate logistic regression equation to evaluate the independent factors related to misalignment. Results On the coronal plane, the ADTTs of groups A, B, C and D were 2.7°, respectively. The mean LDTAs of groups B and C (0°-1.3° and 1.3°-2.7°), group A ( 2.7°) were 89.5 ± 1.6°, 92.0 ± 3.2° and 85.8 ± 3.5°, respectively (P P 11.8°, respectively. The average ADTAs of groups B and C (8.9°-10.4° and 10.4°-11.7°), group A ( 11.8°) were 80.4 ± 1.3°, 83.1 ± 3.7° and 77.9 ± 2.5°, respectively (P P P = 0.02) and limited open reduction (OR: 0.21, P Conclusion The alignment of distal tibial fractures after surgery is sensitive to the ADTT and use of limited open reduction. Controlling the ADTT between 0° and 2.7° on the coronal plane and between 8.9° and 11.7° on the sagittal plane is helpful to reduce the occurrence of misalignment after the treatment of distal tibial fractures by IMN fixation.

Background Closed reamed locked intramedullary nailing has been the treatment of choice for most of femoral shaft fractures. A high union rate with a low complication rate is generally predictable. For an aseptic femoral shaft nonunion with a prior inserted intramedullary nail, exchange nailing is one of favored surgical techniques for treatment. However, a greatly varied success rate of 72–100% has been reported. To improve the success rate of exchange femur nailing, a modified bone grafting technique was developed. The purpose of this retrospective study intended to evaluate outcomes of such a revised technique. Methods From July 2011 to March 2019, 48 consecutive adult patients (average, 38 years; range, 19–67 years) with aseptic femoral shaft nonunions after intramedullary nailing treatment were studied. All femoral shaft fractures were initially caused by traffic accidents, which were treated by a closed or open intramedullary nailing technique at various hospitals. The current revision treatment was performed after an average of 2.2 years (range 1.1–6.2 years) from initial injuries. In the surgery, the prior nail was removed and the marrow cavity was reamed widely (at least 2 mm as possible). Sufficient cancellous bone grafts harvested on the trochanteric marrow wall from the inside were placed in the marrow cavity of the junction of nonunion fragments. A new 1-mm smaller size locked intramedullary nail was inserted. Whether the dynamic or static mode of nails were used mainly depended on the nonunion level. Postoperatively, protected weight bearing with crutches was allowed for all patients. Results Forty-one patients were followed for an average of 2.8 years (85.4%; range, 1.9–4.5 years) and all fractures healed. The union rate was 100% (41/41, p p = 0.019). Conclusions The described modified bone grafting technique may effectively improve a union rate of exchange femur nailing while the surgical procedure is not complicated. It may therefore be used concomitantly in all aseptic femoral shaft nonunions when exchange nailing is performed.

Background Treatment of closed tibial shaft fractures in the 3rd trimester of pregnancy is controversial. Since there are few case reports published in literature, there is no consensus on the appropriate management of these fractures. This case report proposes intramedullary nailing throught the suprapatellar approach for the treatment of tibial shaft fracture in pregnant women, never described before in literature. Case presentation We report 2 cases of a tibial diaphyseal fracture treated by intramedullary nailing in women at the 3rd trimester of pregnancy. Conclusion Surgical treatment of tibial shaft fracture of pregnant women in the 3rd trimester of pregnancy with intramedullary nailing seems to be safe. The use of the specific suprapatellar approach helps in the intra-operative management of the pregnant patients.

Background The location of cephalic fixator tip with different eccentric distance (ED) should have different risks of cutout. This study aims to evaluate the cephalic fixator tip position by measuring ED of the cephalic fixator tip in geriatric ITF patients with single-screw cephalomedullary nail (SCMN) fixation and analyze the correlation between the cutout and the ED. Methods Firstly, we assumed all the femoral head was a regular sphere and standardized the radius of the femoral head (RFD) as “3” no matter how big the RFD was for complete match of the Cleveland zone system and convenient identification of artificial intelligence. Secondly, we measured the ED of the cephalic fixator tip by calculating the distances from the cephalic fixator tip to the geometric central axis of the femoral neck and head on both AP view and lateral view radiographs. Thirdly, we evaluated all the ED of the cephalic fixator tip in the eligible 123 geriatric ITF patients and analyzed the correlation between the cutout and the ED. Results The ED in cutout group (1.25 ± 0.43) is much bigger than that in non-cutout group (0.64 ± 0.34) with significant difference (OR = 50.01, 95% CI 8.42–297.19, p FD because “RFD = 3,” sensitivity = 73.3%, specificity = 86.1%, and AUC = 0.867, p Conclusion ED is suitable for evaluation of the cephalic fixator tip position for predicting cutout in geriatric ITF patients with SCMN fixation, and ED can potentially be used as artificial intelligence application during surgery. The smaller the ED, the lower the cutout rate. For avoiding cutout, the ED of the cephalic fixator tip should be less than one-third times of the radius of the femoral head.

Minimally invasive, sufficiently stable for movement and partial weight bearing, osteosythesis of pertrochanteric femoral fractures in children 6-8 years using elastic, stable intramedullary nailing (ESIN).Proximal, pertrochanteric femoral fractures Delbet type IV in children 6 years.Comminuted fractures, femoral neck fractures.By inserting three elastic titanium nails (TEN), prebent in the proximal third, retrograde into the femur, a stable 3‑point support stabilizes the proximal fragment. For further improvement of stability, EndCaps can be used.Partial weight bearing (sole-contact) for 4-5 weeks. X‑ray controls immediately after surgery and after 4-5 weeks. No sports for 3 months.In our patient population we have good experience with this technique for very rare pertrochanteric fractures in children younger than 6-8 years. With minimally invasive access, exercise-stable administration can be achieved without a pelvic leg cast.OPERATIONSZIEL: Minimal-invasive, übungsstabile Versorgung von pertrochantären Femurfrakturen bei Kindern 6 bis 8 Jahren mittels elastisch-stabiler intramedullärer Nagelung (ESIN).Proximale, pertrochantäre Femurfrakturen Delbet Typ IV bei Kindern 6 Jahre.Trümmerfrakturen, Schenkelhalsfrakturen.Durch Einbringen von insgesamt 3 (gelegentlich nur 2) im proximalen Drittel vorgebogenen, elastischen Titannägeln (TEN) retrograd in das Femur wird im proximalen Fragment eine stabile 3‑Punkt-Abstützung erreicht. Eine weitere Verbesserung der Stabilität kann durch die Applikation von Endcaps erreicht werden.Die Nachbehandlung erfolgt mittels Sohlenbelastung während 4 bis 5 Wochen. Röntgenkontrollen erfolgen direkt postoperativ sowie nach 4 bis 5 Wochen. Eine Sportunfähigkeit besteht für 3 Monate.In unserem Patientengut haben wir gute Erfahrungen mit dieser Technik bei den sehr seltenen pertrochantären Frakturen bei Kindern 6 bis 8 Jahren. Mit minimal-invasivem Vorgehen kann eine übungsstabile Versorgung ohne Notwendigkeit eines Becken-Bein-Gipses erreicht werden.

Reverse oblique intertrochanteric fractures are classified by the AO/OTA as 31A3 and account for 2–23% of all trochanteric fractures. The Gamma 3-Proximal Femoral Nail (GPFN) and the Expendable Proximal Femoral Nail (EPFN) are among the various devises used to treat this fracture. The aim of this study was to compare outcomes and complication rates in patients with AO/OTA 31A1-3 fractures, treated by either a GPFN or an EPFN. A total of 67 patients (40 in the GPFN group and 27 in the EPFN group, average age 78.8 years) were treated in our institution between July 2008 and February 2016. Data on postoperative radiological variables, including peg location and tip–apex distance (TAD), as well as orthopedic complications, such as union rate, surgical wound infection and cut-outs rates were also recorded, along with the incidence of non-orthopedic complications and more surgical data. Functional results were evaluated and quantified using the Modified Harris Hip Score (MHHS) and by the Short Form 12 Mental Health Composite questionnaire (SF-12 MHC) in order to assess the quality of life. The total prevalence of postoperative orthopedic complications including postoperative infection showed a significant difference with a p-value of 0.016 in favor of the EPFN group. Nonetheless, the frequency of revision did not differ between the two groups, being 0.134. The main orthopedic complication in both groups was head cut-out of the GPFN lag screw and the EPFN expendable peg, which was 20% and 7.4%, respectively, and required a revision surgery using a long nail or total hip replacement (THR). However, the average TAD did not significantly differ between groups which might be due to a relatively low cohort to reach a significant difference. Nonunion rate of 5% occurred solely in the GPFN group, with similar results of intraoperative open reduction between both groups. The EPFN group achieved better scores in both questionnaires (p = 0.027 and p = 0.046, respectively). Both the MHHS and SF-12 MCS values significantly differed between groups, with the EPFN group achieving better scores than the GPFN group in both questionnaires (p = 0.027 and p

Proximal femur fractures are associated with an increased mortality rate in the elderly. Early weight-bearing presents as a modifiable factor that may reduce negative postoperative outcomes and complications. As such, we aimed to compare non-weight-bearing, partial-weight-bearing and full weight-bearing cohorts, in terms of risk factors and postoperative outcomes and complications. We retrospectively reviewed our database to identify the three cohorts based on the postoperative weight-bearing status the day of surgery from 2003 to 20014. We collected data on numerous risk factors, including age, cerebrovascular accident (CVA), pulmonary embolism (PE), surgical fixation method and diagnosis type. We also collected data on postoperative outcomes, including the number of days of hospitalization, pain levels, and mortality rate. We performed a univariate and multivariate analysis; P

New generation cephalomedullary nails are, currently, widely used for the treatment of trochanteric proximal femoral fractures. This study aims to compare the midterm outcomes and complication rates in patients with unstable 31A2 fractures treated with two different lengths of nails. Retrospective study including 123 pertrochanteric proximal femoral fractures 31A2 treated with Gamma3 nail® between January/2017 and January/2019. 19 patients were excluded, resulting in a total of 104 patients with a minimum follow-up of 1 year. Two groups, Long Dynamic Gamma3 Nail (LGN) and Short Static Gamma3 Nail (SGN), with 52 patients each were compared. Mean age was 81 years (range 50–99), being 78% female. Preoperative variables included: age, medical comorbidities, mobility, anesthetic risk, associated fractures, hemoglobin and hematocrit values. Postoperatively, functional and radiological results, quality of life, hemoglobin and hematocrit concentration, transfusion requirements, mobility, and pain were evaluated. Additionally, perioperative complications were also analyzed, such as malunion, non-union, infection rates, cut-outs, and peri-implant fractures. A correct radiological fracture reduction was obtained in 73% of the cases (73% SGN/74% LGN). Two patients in LGN group had intraoperative complications (greater trochanter fractures). 38% of the patients with LGN presented nail tip impaction upon the distal anterior femoral cortex, associated with anterior knee pain. Blood loss and operative time was statistically different between groups. Despite the previous, no differences in clinical outcomes and quality of life were found. The present study comparing two lengths of the Gamma3 Nail in 31A2 fractures showed no overall differences in clinical and radiological outcomes, and complication rates. However, the use of LGN was associated with a statistically significant higher blood loss and operative time, and a tendency for increased need for transfusion, and anterior knee pain and reoperation rate. Therefore, we recommend the use of locked SGN in the treatment of 31A2 fractures.

The cut-out of the cephalomedullary nail is among the most common post-surgery complications for intertrochanteric fractures. As a risk predictor, a tip-apex distance (TAD) below 25 mm, observed from orthogonal fluoroscopic views, is recommended in the literature. This study aims to demonstrate that TAD

Although reconstruction nails have an advantage of single-construct fixation in ipsilateral femoral neck and shaft fractures, they have not been used widely due to the technical challenges associated with their placement. Reduction is particularly demanding in patients with displaced neck fractures after nailing of the shaft fracture, and can be resulted in nonunion, malunion, and osteonecrosis. We report a new technique of reconstruction nailing after the provisional reduction and fixation of a neck fracture to achieve successful healing of this injury. Osteosynthesis using a reconstruction nail was performed in ten consecutive patients with displaced femoral neck and shaft fracture. After closed reduction of the displaced neck fracture, the femoral neck was provisionally fixed with pins in an anterolateral-to-medial direction. While maintaining reduction of the neck fracture, a nail was inserted and passed into the medullary canal posterior to the provisionally fixed pins with indirect reduction of the shaft fracture. After two reconstruction locking screws were fixed for proximal interlocking, the provisional pins were removed once distal interlocking was achieved. The radiologic outcomes included quality of reduction, healing rate, and time to the union were appraised, and the functional outcomes were assessed with Friedman and Wyman’s criteria. This novel technique provided satisfactory reduction of both the femoral neck and shaft fractures with no malunion. All fractures achieved primary union, except for one case of nonunion of femoral shaft. Eight of ten patients experienced good results in functional outcome, whereas the remaining two patients reported moderate limitations in activities of daily living. At the latest follow-up, all patients had excellent range of motion in hip and knee joints. Provisional fixation after reduction of a femoral neck fracture may facilitate successful reconstruction nailing in the ipsilateral fractures of the femoral neck and shaft. This “Reverse Miss-a-Nail Technique” may minimize complications and maximize the radiologic and functional outcomes of patients who experience this injury.