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Introduction. Proximal humerus fractures, resulting from direct or indirect trauma, pose a significant clinical challenge. The choice of surgical intervention is influenced by various factors including patient age, comorbidities, bone quality, activity level, fracture characteristics, and the surgeon’s expertise. This study aims to assess the frequency and nature of complications arising from the surgical treatment of proximal humerus fractures. Material and Methods. In this retrospective analysis, 51 patients were included, with 22 males and 29 females. Two surgical techniques were employed: osteosynthesis using locking plates in 27 patients (average age 54.6 years) and intramedullary nailing in 24 patients (average age 58.4 years). The assessment of outcomes was conducted using the Constant Shoulder Score, and statistical analysis was performed using the Student’s T-test. Results. Complications were observed in 12 patients (23.5%), comprising 7 males and 5 females. In the locking plate group, where 8 complications occurred, the mean Constant score was 77.44, while the intramedullary nail group, with 4 complications noted, had a mean Constant score of 70.25. No statistically significant difference was found in the incidence of complications based on gender or the type of surgical technique used. Conclusion. The study found a higher incidence of complications in male patients and those treated with locking plates, though these differences were not statistically significant. These findings emphasize the need for personalized surgical planning and highlight the complexity of managing proximal humerus fractures. [ABSTRACT FROM AUTHOR]

ObjectiveTo compare the clinical efficacy and application value of a novel operative approach of anterograde elastic intramedullary needling versus traditional Kirschmann wiring for junction fractures of radius trunk and metaphyseal in children. MethodsRetrospective analysis was performed for 50 children with fractures at junction of distal radial diaphysis and metaphysis from January 2019 to January 2022.They were assigned into two groups of anterograde elastic intramedullary acupuncture (n=17) and Kirschmann acupuncture (n=33) according to different surgical approaches.The relevant clinical data included gender, age, concurrent distal ulnar fracture, operative duration, fracture angulation and alignment status at Week 2 post-operation.Duration of external fixation, wrist motion, good/excellent rate of wrist function, good/excellent rate of elbow function and complications were recorded at Month 3 post-operation. ResultsOperative duration was longer in anterograde elastic intramedullary acupuncture group than that in Kirschner's needle group[(81.8±38.4) vs.(59.4±26.1) min]and the difference was not statistically significant (P>0.05). The mean contraction of fractures was higher in anterograde elastic intramedullary acupuncture anterograde elastic intramedullary acupuncture group than that in anterograde elastic intramedullary acupuncture Kirschner's needle group (92% vs.88%) and the difference was not statistically significant (P>0.05). The removal time of external plaster fixation was shorter in anterograde elastic intramedullary acupuncture anterograde elastic intramedullary acupuncture anterograde elastic intramedullary acupuncture group than that in anterograde elastic intramedullary acupuncture anterograde elastic intramedullary acupuncture Kirschner's needle group[(31.5±5.1) vs.(39.0±9.2) day]and the difference was statistically significant (P<0.05). The wrist range of motion was higher in anterograde elastic intramedullary acupuncture anterograde elastic intramedullary acupuncture group than that in anterograde elastic intramedullary acupuncture Kirschner's needle anterograde elastic intramedullary acupuncture groupt Month 3 post-operation and the difference was statistically significant (P<0.05). The recovery rate of wrist joint was higher in anterograde elastic intramedullary acupuncture anterograde elastic intramedullary acupuncture group than that in anterograde elastic intramedullary acupuncture Kirschner's needle group (94.12% vs.66.67%) and the difference was statistically significant (P<0.05). The good/excellent recovery rate of elbow joint was lower in anterograde elastic intramedullary acupuncture anterograde elastic intramedullary acupuncture group than that in anterograde elastic intramedullary acupuncture Kirschner's needle group (82.35% vs.87.88%) and the difference was not statistically significant (P>0.05). ConclusionCompared with traditional Kirscher wiring, anterograde elastic intramedullary needling can effectively shorten the time of postoperative removal of plaster external fixation and facilitate the postoperative recovery of wrist joint activity.It is ideal for children with distal radial diaphyseal junction fractures and worth wider clinical promotions. [ABSTRACT FROM AUTHOR]

Objective To explore the causes and outcomes of delayed fracture union after elastic stable intramedullary nailing (ESIN) for pediatric long bone fractures of extremities to minimize the occurrence of this complication and provide clinical rationales for managing delayed fracture union. Methods From July 2015 to April 2020, clinical data were retrospectively reviewed for 233 children with long bone fractures of extremities after ESIN.Nine cases of delayed fracture union were found during follow-ups.Age, injury mechanism, fracture site, surgical approach, post-discharge management and subsequent rehabilitation were recorded.For various causes of delayed fracture union, the corresponding treatment was offered. Results Two cases of delayed fracture union of double fracture of radius and ulna healed after prolonged plaster fixation and immobilization.Two cases of delayed tibial fracture union received proper weight bearing under brace protection.One case of delayed fracture union of femoral fracture healed after external fixation of hip with heriform plaster and removal of elastic intramedullary nail.One case of delayed fracture union of tibia (n=1), humerus (n=1) and femur (n=1) healed after anti-infection and immobilization of affected limb.One case of delayed tibial union underwent autologous bone grafting and plaster fixation. Conclusion Treatments of delayed bone union vary for different and different types of fractures.In this cohort, strengthened fixation, greater stress stimulation at broken end, anti-infection, bone graft reconstruction and other means have been adopted for attaining bone union.Removing the influencing factors of delayed healing and re-stabilizing fracture end are vital for successful treatments. [ABSTRACT FROM AUTHOR]

ABSTRACT Introduction: Metacarpal fractures are common and can be treated surgically using Kirschner wires (K-wires) or intramedullary fixation with compression screws (IMCS). Objectives: Analyze the postsurgical results from treating the metacarpal extra-articular fractures through the retrograde Kirschner wire technique, and compare it with the intramedullary compression screw fixation. Methods: Retrospective and quantitative studies were to analyze patients’ medical records, and a postsurgical evaluation questionnaire was given to the patients, who were divided into K-wire and IMCS. Results: The period of immobilization with a splint took six weeks for the K-wire group and four weeks for the IMCS group. The average time for consolidation took, respectively, fifty-seven days and forty-seven days. The first group could restart their activities twenty-two days after the other, and the average force value of the treated hand, when compared with its contralateral, was 93.9% and 95.4%, respectively. Between the operated hand and its contralateral, there was a difference of 16° in the total measures of the metacarpophalangeal and interphalangeal joint's range of movement among the K-wire group and 5° among the IMCS group. Conclusion: The patients who participated in this study showed excellent results after surgery, and both treatments were proven to be safe and reliable. Evidence level III; Retrospective comparative study .

ABSTRACT Objective Evaluate the stability provided by two flexible intramedullary nails (FINs) in a simulation of fractures at the proximal levels in pediatric femur models. Methods Two FINs were inserted in 18 synthetic models of pediatric femurs. Fractures were simulated at one of three levels, and the models were divided into the following groups (n=6): diaphysis (control), subtrochanteric and trochanteric. Flex-compression tests were performed with force up to 85 N. Relative stiffness and the average deformation was obtained. Torsion tests were performed by rotating the proximal fragment until 20°, to obtain the average torque. Results At flex-compression, the set’s average relative stiffness and average deformations were: 54.360x103 N/m and 1.645 mm in the control group, respectively. In the subtrochanteric group, the relative stiffness was 31.415x103 N/m (-42.2%) and the deformation was 2.424 mm (+47.3%) (p

Objective To explore the clinical efficacy of elastic stable intramedullary nailing (ESIN) for long spiral tibial shaft fractures in school-age children. Methods From October 2014 to October 2019, retrospective analysis of tibial shaft fractures was conducted for 7-12-year-old school-age children using elastic intramedullary nails.According to fracture type, they were divided into two groups of long spiral fracture (n=37) and horizontal/short oblique fracture (n=76). Basic profiles, intraoperative findings, hospitalization length, treatment outcomes and postoperative complications of two groups were compared. Results No significant inter-group differences existed in gender, age, sideness, injury cause, fracture site, fibula fracture or not, operative duration, intraoperative blood loss, hospitalization length or medical expenditure (P>0.05). No significant inter-group difference existed in Flynn efficacy evaluation of ESIN (P>0.05). There was no significant inter-group difference in fracture healing time, complete weight bearing time or intramedullary nail removal time (P>0.05). Complication rate was 2.70% in long spiral fracture group and 3.94% in transverse/short oblique fracture group.There was no statistically significant inter-group difference (P>0.05). Conclusion ESIN has an excellent therapeutic efficacy for school-age children with long spiral tibial shaft fractures.With minimal invasiveness, there is a low risk of postoperative complications.It is worthy of widespread clinical applications. [ABSTRACT FROM AUTHOR]

• Elbow to thumb + 3.5 cm can be used to predict nail length for greater trochanteric entry. • Elbow to thumb + 1.4 can be used to predict nail length for piriform fossa entry. • Surgeons can be confident that the appropriate nail will be selected from a range of three, including that predicted by the "rule of thumb" and one increment to either side. Intramedullary femoral nails are measured intraoperatively using fluoroscopy. This study aims to investigate whether distance from the olecranon to fingertips can be used to estimate nail length preoperatively by evaluating agreement of the two measurements. Such preoperative measurements may provide a likely range of nails needed for theatre and serve as an adjunct to intraoperative measurements. In 70 patients, long leg radiographs were used to make linear measurements from the piriformis fossa and greater trochanter to the distal physeal scar of the femur. These were compared to measurements from the olecranon to the tip of each digit and Bland-Altman agreement analysis was performed. Train and Trial groups were formed to develop models for estimation and to then test their accuracy. Bland-Altman analysis revealed a fixed bias, indicative of average difference between measurements, of 1.4 cm when comparing the elbow-thumb length to maximum femoral nail length for piriformis fossa entry and 3.5 cm using greater trochanter entry, informing the "rule of thumb". Elbow-thumb length plus 1.4 cm or 3.5 cm predicts nail length to a range of ± one nail increment. The rule can be used to preoperatively predict a range of three nails from which there is a 94–97% likelihood the appropriate intramedullary nail would be selected. The "rule of thumb" may serve as a simple to use tool for preoperative planning and a technical check to assess the "reasonableness" of intraoperative measurements before implantation of the device. It has the potential to reduce operating time and nail wastage. [ABSTRACT FROM AUTHOR]

Background: Retrograde intramedullary nailing is commonly performed to stabilize distal femoral shaft fractures which may lead to iatrogenic injuries of the knee articular cartilage. The limited regenerative capability of cartilage may further be hindered by intake of non-steroidal anti-inflammatory drugs (NSAIDs) which are usually advised for injuries of the musculoskeletal system. The current study was designed to evaluate the histological changes in the femoral articular cartilage of knee joint after retrograde femoral nailing of rats., Methods: Retrograde intramedullary nailing was performed in 36 adult male Wistar rats, divided into three groups of 12 each. Groups 1 and 2 were given nonselective and selective COX 2 inhibitors, respectively, while the third group was taken as control. Half of the animals from each group were sacrificed at the second week, and remainder on the seventh week, and samples of the femoral articular cartilage were assessed for cartilage regeneration according to the modified Mankin scoring on histology while BMP-2 expression was evaluated on immunohistochemistry., Results: Mean modified Mankin scores for cartilage degradation were increased in animals taking NSAIDs at the second and seventh weeks of healing (P = 0.02, P < 0.001 respectively). There was a significant decrease in chondrocytes at the second week (P = 0.001), along with the loss of proteoglycan content in these animals at both time points (P = 0.001). The BMP-2 expression was significantly enhanced in the control group at the second (P = 0.001) and seventh weeks (P = 0.001)., Conclusion: The results reveal that intake of NSAIDs hinders the process of cartilage healing by reducing the number of chondrocytes and loss of proteoglycan content and decreased expression of BMP-2., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Objective: Fat embolism syndrome and cerebral fat emboli are rare yet serious conditions arising from systemic distribution of bone marrow emboli. Emboli are known to produce high-intensity transient signals (HITS) in a Doppler signal. We hypothesized that both intramedullary nailing in pigs and median sternotomy in human infants cause bone marrow release, that some of these cause cerebral emboli, and that these were detectable by a new cerebral doppler ultrasound monitoring system (NeoDoppler). We also aimed to describe the intensity of HITS generated during these procedures., Methods: Specific pathogen-free Norwegian landrace pigs were allocated to either bilateral femoral nailing or injection of autologous bone marrow (positive controls). Testing was carried out under continuous Doppler monitoring. Presence of cerebral emboli was confirmed with histology. NeoDoppler data from infants undergoing sternotomy prior to cardiac surgery were investigated for comparison., Results: Eleven of twelve pigs were monitored with cerebral Doppler ultrasound during femoral surgery. HITS were seen in five (45%). Brain biopsies demonstrated bone marrow emboli in 11 of the 12 (92%). Four positive control pigs received intraarterial injections of bone marrow, saline, or contrast, and strong HITS were detected in all pigs (100%). Median sternotomy in eight human infants was associated with a significant increase in embolic burden; the HITS intensity was lower than HITS in pigs., Conclusion: High-frequency cerebral Doppler ultrasound is a valuable tool for perioperative monitoring that can detect emboli in real-time, but sensitivity and specificity for bone marrow emboli may be limited and size-dependent., Competing Interests: Conflict of interest NTNU and St. Olavs Hospital, Trondheim University Hospital may benefit financially from a commercialization of NeoDoppler used for cerebral Doppler monitoring in infants through future possible intellectual properties. H.T. and S.A.N are coinventors of NeoDoppler. S.A.N. is a board member of CIMON Medical. H.T. and S.A.N. have part-time positions and are among shareholders in CIMON Medical, the company responsible for commercialization of NeoDoppler. A.H.J., S.K., M.L.–O., C.V., I.N., and E.W.N. declare no conflicts of interest., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: To investigate the effects of remimazolam and surgery on cognitive function and neuropathology., Methods: We performed intramedullary pin fixation of tibial fractures in wild-type male (12-13-week-old) C57BL/6J mice under intraperitoneal anesthesia with remimazolam. Age-matched wild-type control mice received either saline or remimazolam without surgery. Training was performed 1 h before surgery, and the open field test was performed on the third postoperative day, in addition to trace fear conditioning on the third versus the seventh day and the Y maze test on the fourth versus the eighth day. Phosphorylated tau (P-TAU) protein levels in hippocampal tissue, microglial activation, dendritic spine density in neuronal cells, and interleukin-6 (IL-6) levels were determined., Results: We detected no significant differences in locomotor ability among the three groups in the open field test on the third postoperative day; however, on the conditioned fear test or in the Y-maze, the cognitive related performance of the mice in the surgery group was significantly worse than that of the control group and the remimazolam group. However, there were no differences among the three groups in the behavioural experiments on the seventh and eighth days. In addition, mice in the surgery group had higher levels of P-TAU in their hippocampal tissue, more microglial activation, more significant changes in neuronal dendritic spine density, and higher levels of IL-6 in their hippocampal tissue compared with mice in the other two groups., Conclusions: The cognitive dysfunction and neuropathological changes produced by remimazolam-based surgery are mainly of surgical origin and are not related to the use of remimazolam, a general anesthetic agent., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Introduction: Traumatic obturator-type anterior dislocation of the hip with an ipsilateral subtrochanteric fracture is rarely encountered in clinical practice. This case presentation described a trauma patient with such a rare scenario., Case Report: This paper reports a case of a 20-year-old Amhara ethnic male patient who had a traumatic anterior dislocation of the hip associated with an ipsilateral subtrochanteric femur fracture after a truck rolled over. There was diffuse swelling of the proximal thigh, and the lower limb was externally rotated. Radiographic examination shows right femur subtrochanteric fracture with ipsilateral obturator-type anterior hip dislocation. Emergency open reduction of the hip dislocation and antegrade intramedullary nailing of the subtrochanteric fracture performed. Subsequent clinical and radiologic follow-up demonstrated good outcomes., Conclusion: The main peculiarity of the presented case is the association of obturator hip dislocation with ipsilateral femur shaft fracture. Early and stable reduction of the dislocation and firm internal fixation of the fracture as soon as possible will allow early rehabilitation and prevent late complications. At the 4th week of operation, he started non-weight-bearing mobilization., Competing Interests: Declarations. Ethics approval and consent to participate: Ethical protocol used for this study was approved by institutional review board of Bahir-dar University ethical committee. Written consent was obtained from the patient, and data handling was done in accordance with the Helsinki Declaration. Consent for publication: Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Competing interests: The authors declare that they have no competing interests., (© 2024. The Author(s).)

Introduction: Distal femur fractures (DFFs) are associated with high complication and mortality rates in the elderly. Using the National Inpatient Sample and Medicare data, we describe trends in the incidence of DFFs by fixation type and associated healthcare costs., Methods: Annual population rates and volume of inpatient DFFs were estimated using Poisson regression with the US Census as a denominator. We used Current Procedural Terminology codes in Medicare patients to determine episode-of-care cost by treatment, classified as intramedullary nail, open reduction and internal fixation, and distal femur arthroplasty (DFR)., Results: The annual incidence of DFFs in the United States is approximately 27.4 per 100,000. Admission for DFFs increased from 2002 to 2020, with the highest volume and rate in those aged 85 years and older. DFF incidence increased (1.95×) from 142 per 1 million (95% CI: 140 to 144) in 2006 to 281 per 1 million (95% CI: 278-284) in 2019. From 2012 to 2019, the percentage of DFFs treated by intramedullary nail increased from 6.8% to 8.4%, open reduction and internal fixation decreased from 89.9% to 76.6%, and DFR increased from 3.3% to 14.9%. DFR cost was significantly greater than other treatment choices across all years for initial inpatient admission costs and 90-day episode-of-care costs (all P < 0.0001)., Conclusion: DFF volume has increased in the past 20 years, predominantly in elderly patients. Greater than 4.5× increase was observed in the proportion of geriatric DFFs treated with DFR during this study period. The total cost of DFR treatment was consistently greater than other surgical treatments., (Copyright © 2024 by the American Academy of Orthopaedic Surgeons.)

Case: A 14-year-old adolescent boy sustained a Gustilo-Anderson Type 3A tibia fracture treated with medullary nailing. He developed an atrophic nonunion with a 10.5-cm defect after debridement. An automated hexapod system was adapted to perform trifocal tandem cable transport. Transport proceeded at 0.75 mm/day per focus, segmented into 16 increments. Docking and conversion to a nail occurred 103 days after frame application for an external fixation index of 9.8 days/cm., Conclusion: Automated balanced cable transport is a viable option for segmental bone defects. This is the first reported automated balanced cable transport., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C503)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Prolonged glucocorticoid overexposure leads to Cushing's syndrome (CS). It is characterised by diverse metabolic, cardiovascular and bone mineral manifestations. A middle-aged woman presented for a preoperative evaluation of a pathological fracture of the left neck of the femur. She had a history of a hip fracture on the opposite side 3 years back. She exhibited several features specific to CS and was subsequently diagnosed with Cushing's disease. She underwent transsphenoidal adenoma resection and achieved remission. Glucocorticoids primarily affect the trabecular bone compared with cortical bones, and vertebral fractures are common in CS. The femoral neck consists of both trabecular and cortical bone and can be involved in CS. Our patient was not diagnosed as CS at the first pathological fracture and was subsequently diagnosed only after the second fracture. This case report underscores the importance of a diligent search for a possible endocrinological aetiology in any case of pathological fractures., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Chronic obstructive pulmonary disease (COPD)-induced osteoporosis, myasthenia, and disequilibrium are important risk factors for hip fracture, and decreased respiratory function after hip fracture surgery can decelerate recovery of activities of daily living (ADL) in elderly patients., Case Presentation: A 90-year-old male patient underwent an open reduction and intramedullary pinning surgery for right femoral intertrochanteric fracture. After surgery, he remained confined to bed with pain and swelling in the right lower extremity. Due to his history of COPD, he had a postoperative pulmonary infection and respiratory insufficiency., Intervention: This patient received routine rehabilitation after surgery. However, severe respiratory symptoms prevented him from completing the rehabilitation procedure. Therefore, comprehensive pulmonary rehabilitation including airway clearance techniques, inspiratory resistance training, aerobic training, respiratory muscle training, and intermittent low-flow oxygen inhalation was carried out to enhance the recovery process., Outcomes: After 4 weeks of treatment, the patient improved from continuous oxygen inhalation to being able to complete bed resistance training without supplemental oxygen. After 8 weeks, ADL reached independence, while lower limb muscle strength, pulmonary function parameters, fatigue index, and cough efficiency were improved as compared to test values obtained before treatment., Conclusion: Compared with the 6-month recovery time reported in the literature for patients with hip fractures to achieve independence with basic ADLs, the recovery time of this patient was shortened to 2 months with the application of comprehensive pulmonary rehabilitation. It is feasible to carry out pulmonary rehabilitation for elderly patients after fracture surgery, but prospective clinical trials are needed to verify its efficacy.

An 80-year-old fit and active gentleman presented with left hip pain and a new central scotoma in his right eye after falling from an electric bicycle. He was able to mobilise independently and presented to ophthalmic services where cotton wool spots were found in both eyes and a presumptive diagnosis of Purtscher's retinopathy (PuR) was made. The patient was referred to the emergency department for assessment of a potential fracture. The subcapital femoral neck fracture was subtle on X-ray and only detected the following day with radiological and orthopaedic review. Two screws were placed to stabilise the fracture with a good outcome for his hip and for his vision. PuR can be seen following trauma to the head, neck or chest, following long bone fracture and in renal failure or pancreatitis. Our case highlights how the non-specific finding of cotton wool spots becomes a highly specific diagnosis in the context of trauma and should lead to careful evaluation for fractures., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Femoral shaft nonunion negatively affects patient quality of life. Although multiple risk factors have been identified for femoral shaft nonunion after intramedullary nail (IMN) fixation, there is no quantitative model for predicting nonunion., Study Description: The study is a retrospective cohort study of patients with femoral shaft fractures treated at two level one trauma centers who were followed to fracture union or nonunion. Patient, injury, and surgical characteristics were analyzed to create a quantitative model for nonunion risk after intramedullary nailing., Methods: Eight hundred one patients aged 18 years and older with femoral shaft fractures treated with reamed, locked IMNs were identified. Risk factors including demographics, comorbidities, surgical variables, and injury-related characteristics were evaluated. Multivariate analysis was conducted, and several variables were included in a scoring system to predict nonunion risk., Results: The overall nonunion rate was 7.62% (61/801). Multivariate analysis showed significant association among pulmonary injury (odds ratio [OR] = 2.19, P = 0.022), open fracture (OR=2.36, P = 0.02), current smoking (OR=3.05, P < 0.001), postoperative infection (OR=12.1, P = 0.007), AO/OTA fracture pattern type A or B (OR=0.43, P = 0.014), and percent cortical contact obtained intraoperatively ≥25% (OR=0.41, P = 0.021) and nonunion. The scoring system created to quantitatively stratify nonunion risk showed that a score of 3 or more yielded an OR of 6.38 for nonunion (c-statistic = 0.693, P < 0.0001)., Conclusions: Femoral shaft nonunion risk is quantifiable based on several independent injury, patient, and surgical factors. This scoring system is an additional tool for clinical decision making when caring for patients with femoral shaft fractures treated with IMNs., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

The objective of this retrospective study was to investigate the impact of tourniquet use during intramedullary tibial nailing on clinical outcomes at a regional Level I Trauma Center. One hundred ninety-four patients with intramedullary tibial fixation over a 5-year period at a single institution were studied following Institutional Review Board (IRB) approval. Patients were stratified into 81 polytrauma patients and 113 patients with isolated tibial shaft injuries. Patients were then stratified within these two groups according to whether or not a tourniquet was used intraoperatively (including during reaming). Postoperative narcotic use, length of stay, operating room (OR) time, tourniquet time, estimated blood loss, units of blood utilized, infection rate, and age were the outcome variables. No significant differences were found for any outcome measure (p ≥ 0.05), including age, narcotic use, OR time, postoperative inpatient days, estimated blood loss, and units of blood used between tourniquet and nontourniquet patients. Statistically significant differences were found between isolated and nonisolated fracture patients for postanesthesia care unit (PACU) morphine dose equivalents (MDEs), with isolated tibia fracture patients requiring more MDEs (13.80 vs. 9.92 units; p = 0.025). Nonisolated tibia patients had more inpatient days (14.88 vs. 3.16 days; p = 0.001), greater estimated blood loss (252.44 vs. 128.07 mL; p = 0.001), and more units of blood (5.07 vs. 2.29 units; p = 0.017). Thermal necrosis of the tibia was not seen in any patient within any group. Tourniquet use did not significantly affect clinical outcomes. This provides surgeons with updated data on the impact of tourniquet use on clinical outcomes given the modernization of techniques for tibial intramedullary nailing. There were statistically significant differences between isolated tibia fractures and polytrauma patients for postoperative length of stay, estimated blood loss, and units of blood; however, this was unrelated to tourniquet use and would be expected for polytraumatic patients who commonly have a longer postoperative recovery. (Journal of Surgical Orthopaedic Advances 33(3):181-183, 2024).

Case: A 48-year-old man presented to a Level 1 trauma center after a motor vehicle crash with a right irreducible posterior hip dislocation and ipsilateral fractures of the femoral head and segmental femur shaft. This injury was managed with open reduction and internal fixation and antegrade intramedullary nailing., Conclusion: This is the first report of a combined irreducible femoral head fracture-dislocation and a segmental femur fracture, a rare injury that requires a stepwise approach to operative management of each injury. Surgeons must recognize the clinical and radiographic findings associated with irreducible hip dislocations in the setting of ipsilateral fractures to the femoral head and shaft., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/C390)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Forearm fractures involving both bones are prevalent among pediatric patients. Elastic stable intramedullary nailing (ESIN) is an excellent option for forearm fractures that require surgical stabilization in children and adolescents. Proximal third fractures can be particularly challenging to reduce using closed techniques, and multiple unsuccessful attempts at nail insertion can increase the risk of compartment syndrome. In this article, we present a novel technique called Shanz-assisted closed reduction (SACR), which involves using a 4-mm Shanz to facilitate alignment and nail insertion while avoiding complications associated with longer operative times and open reduction., Competing Interests: Conflito de Interesses O autor não tem conflito de interesses a declarar., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution 4.0 International License, permitting copying and reproduction so long as the original work is given appropriate credit ( https://creativecommons.org/licenses/by/4.0/ ).)

Background: We examined the treatment outcomes following intramedullary nailing in patients with metastatic femoral tumors, excluding those from hematological malignancies., Methods: We retrospectively evaluated treatment outcomes following intramedullary nailing between patients who underwent preventative surgery compared with those who had surgery following pathological fracture. Patients who underwent preventative surgery (Mirels' score ≥8) were allocated to the impending fracture group (n = 11) and those who underwent surgery after pathological fracture were allocated to the completed fracture group (n = 20)., Results: Duration of surgery was significantly shorter in the impending fracture group than in the completed fracture group. Median blood loss was significantly less, and the median duration of hospital stay was significantly shorter in the impending fracture group than in the completed fracture group. Among patients who died following surgery, the median postoperative survival duration was significantly longer in the impending fracture group than in the completed fracture group. Significantly more patients regained walking function in the impending fracture group than in the completed fracture group. Regarding complications, infection occurred in one patient in the completed fracture group. No implant damage was observed in either group., Conclusions: Patients with metastatic femoral tumors who underwent intramedullary nailing in the impending fracture group had better postoperative survival and gait function, less blood loss, and shorter durations of surgery and hospital stay than those in the completed fracture group. These findings indicate the importance of early diagnosis and treatment and value of treatment prior to fracture occurrence., Competing Interests: Declaration of competing interest The authors declare that they have no conflicts of interest., (Copyright © 2023 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

Background: Arterial injury caused by heterotopic ossification (HO) following fractures is rarely reported, yet it can have catastrophic consequences. This case report presents a unique instance of femoral artery injury and hematoma organization, occurring a decade after intramedullary nail fixation for a femoral shaft fracture complicated by HO., Case Presentation: A 56-year-old male presented with right femoral artery injury and organized hematoma, a decade after suffering bilateral femoral shaft fractures with mild head injury in a traffic accident. He had received intramedullary nailing for the right femoral shaft fracture and plate fixation for the left side in a local hospital. Physical examination revealed two firm, palpable masses with clear boundaries, limited mobility, and no tenderness. Peripheral arterial pulses were intact. Radiography demonstrated satisfactory fracture healing, while a continuous high-density shadow was evident along the inner and posterior aspect of the right thigh. Computed tomography angiography identified a large mixed-density mass (16.8 × 14.8 × 20.7 cm) on the right thigh's medial side, featuring central calcification and multiple internal calcifications. The right deep femoral artery coursed within this mass, with a smaller lesion noted on the posterior thigh. Surgical consultation with a vascular surgeon led to planned intervention. The smaller mass was completely excised, but the larger one partially, as it encased the femoral artery. The inability to remove all HO was due to excessive bleeding. Postoperatively, the patient experienced no complications, and one-year follow-up revealed a favorable recovery with restoration of full right lower limb mobility., Conclusion: This case underscores the potential gravity of vascular injury associated with heterotopic ossification. Surgeons should remain vigilant regarding the risk of vascular injury during HO excision., (© 2024. The Author(s).)

Objective: To evaluate the clinical and radiographic results of suprasyndesmotic ankle fracture fixation with a minimally invasive technique. Methods: Retrospective study of 11 patients with suprasyndesmotic fractures of the lateral malleolus who underwent surgery between 2016 and 2018. Retrospective analysis of medical records considered the following: radiographic assessments (preoperative, immediate postoperative, six weeks postoperative), clinical evaluation, and strength scale and movement test results. Results: Of the 18 patients qualified for inclusion, 7 failed to appear at the follow-up appointment and were excluded. The patients’ age varied from 20 to 53 years, and 72.7% were male. The trauma mechanisms included torsion (46% of the cases), automobile accidents (36.4%) and direct trauma (17.6%). The mean time between trauma and definitive surgery was 3.27 days. The mean talocrural angle in the preoperative period was 83.13º, ranging from 80.63º in the immediate postoperative period to 81.27º at 6 months postoperatively. Approximately 90% of the patients did not lose strength. Regarding the range of motion, the mean dorsiflexion and plantar flexion 6 months postoperatively were 10.72º and 34.4º, respectively. Conclusion: The minimally invasive technique had excellent technical results in patients treated surgically for ankle fractures and required smaller incisions than conventional surgery. Osteolysis or fatigue of the osteosynthesis material is a possibility with this technique, which generally occurred between three and four months postoperatively. Level of Evidence IV; Therapeutic Studies; Case series.

Objective: To report our experience with intramedullary fixation and osteosynthesis of the tibia with suprapatellar approach and semiextended positioning. Methods: This study retrospectively assessed 6 patients with tibial fracture treated with suprapatellar intramedullary nail fixation and osteosynthesis from September 2015 to September 2018. Results: There was acceptable bone fixation. Mean healing time was 6 months (range: 4-10 months). Postoperative pain was assessed using a visual analog scale, and the knee was divided into 9 quadrants to help locate the specific site of pain; all participants reported that pain was located at distal quadrants. Knee function was completely restored. Conclusion: Suprapatellar approach with the knee in the semiextended position is a good surgical technique for extra-articular proximal tibial fractures or those associated with soft tissue involvement at the conventional infrapatellar entry site. Thus, this analysis led us to believe that the technique should also be applicable to middle diaphyseal fractures or fractures in general, regardless of their location. Level of Evidence IV, Therapeutic Studies; Case Series.

Objective: The purpose of the study was to evaluate early clinical and radiological results with a novel minimally invasive surgery (MIS) technique for Lapidus arthrodesis using intramedullary nail. Methods: Retrospective review of patients with hallux valgus surgery during an 18-month period. Patients with a procedure other than MIS Lapidus nail fixation were excluded. We describe surgical technique with a percutaneous joint preparation and fixation with an intramedullary nail through a MIS approach. Demographic variables, early complications and radiographic parameters were measured. Results: Ten feet in 8 patients with severe HV underwent a Lapidus procedure performed with a minimal invasive technique using intramedullary nail for fixation. No soft tissue complications and 1 patient required screw removal after bone healing. Mean HVA decreased from 31,4 degrees (range 17 to 47) SD (±9,3) to 10,3 degrees (range, -8,8 to 31,5) SD (±8,4), mean IMA decreased from 17,91 degrees (range, -17 to 20) SD (±0,9) to 5,46 degrees (range, –7,3 to 15.3) SD (±2,9) and mean DMAA decreased from 20,36 (range, 10-40) SD (±8,4) to 7,67 (range, -5 to 30) SD (±8,0). Conclusion: Intramedullary nail for Lapidus arthrodesis with minimally invasive technique showed satisfactory radiographic correction and minimal complications, but further follow up is needed to analyze clinical-radiographic results. Level of Evidence IV; Therapeutic Study; Case Series.

Purpose: To evaluate the role of immediate and definitive management of Gustilo type III A/B tibia fractures with intramedullary nailing and fasciocutaneous flap. Methods: From August 2010 to July 2012, 22 patients with Gustilo Grade III A/B tibia fractures were managed with a single stage treatment of ipsilateral fasciocutaneous flap & reamed intramedullary nailing and were included in the study. The severity of the injury was calculated with Ganga Hospital injury severity score. Results: The mean age of patients was 41 years and the follow-up time ranged from six months to one year. Among the 22 patients, 73% were type III B fractures with upper leg involved in 55% of them. The time interval from injury to completion of surgery was 8–14 h. The incidence of bone infection requiring secondary procedure was 9%; the major and minor soft tissue complication rate was 9% and 14% respectively. The limb salvage rate was 100%. Conclusion: Multidisciplinary management of severe lower limb trauma is important and provides good outcomes. Intramedullary nailing and immediate flap fixation can achieve early bone union and good soft tissue coverage, leading to good outcomes in patient with Grade III A & B tibia fractures.

ABSTRACT The use of intramedullary nailing to treat proximal femoral fractures has increased in recent years. Nail breakage is a rare complication of intramedullary nailing of the femur, and generally occurs at the non-united fracture site. Removal of the distal fragment of a broken nail is a challenging problem. In this article, the authors describe the methods used to remove strongly fixed broken intramedullary nails. Level of Evidence IV; Case series.

Objective: To investigate the position of the anterior fracture line in AO/Orthopaedic Trauma Association (AO/OTA) type A2 unstable intertrochanteric fractures and its impact on the incidence of anterior cortical reduction loss after cephalomedullary nail fixation., Methods: A clinical data of 95 patients with intertrochanteric fractures who met the selection criteria between April 2020 and February 2023 was retrospectively analyzed. All patients were treated with cephalomedullary nail fixation, and the intra- and post-operative imaging data were complete. Among them, there were 37 males and 58 females. The age ranged from 61 to 97 years, with an average of 79.6 years. The time from injury to operation ranged from 7 hours to 11 days, with an average of 2.8 days. According to the 2018-AO/OTA classification standard, there were 39 cases of type 31-A2.2 and 56 cases of type 31-A2.3. Intraoperative fluoroscopy was used to record the number of patients with satisfactory fracture alignment. The preoperative CT data were imported into Mimics17.0 software to simulate the fracture reduction and measure the distance between the anterior fracture line and the intertrochanteric line bony ridge. The fractures were classified as transcapsular fractures, extra-capsular fractures, and intra-capsular fractures according to the distance. CT three-dimensional reconstruction was performed within 2 weeks after operation to observe the number of patients with anterior cortical reduction loss. The postoperative anterior cortical reduction loss incidence in patients with satisfactory fracture alignment, and the relationship between postoperative anterior cortical reduction loss and the position of the anterior fracture line were observed., Results: There were 52 cases (54.7%) of transcapsular fractures, 24 cases (25.3%) of extra-capsular fractures, and 19 cases (20.0%) of intra-capsular fractures. Among them, 41 of the 52 transcapsular fractures had satisfactory fracture alignment, and 4 (9.8%) of them experienced anterior cortical reduction loss after operation; 19 of the 24 extra-capsular fractures had satisfactory fracture alignment, and no anterior cortical reduction loss occurred; 16 of the 19 intra-capsular fractures had satisfactory fracture alignment, and 7 (43.8%) of them experienced anterior cortical reduction loss after operation. There was a significant difference in the incidence of anterior cortical reduction loss between groups ( χ 2 =8.538， P =0.003). All patients were followed up 3-26 months (mean, 9 months). Among them, 91 cases had fracture healing, and 4 cases had nonunion., Conclusion: In AO/OTA type A2 unstable intertrochanteric fractures, where the anterior fracture line is located within the joint capsule, there is a high risk of anterior cortical reduction loss after operation.

Objective: To explore the effectiveness of irreducible intertrochanteric femoral fracture in the elderly by treating with folding top technique and right-angle pliers prying and pulling under G-arm X-ray fluoroscopy., Methods: The clinical data of 74 elderly patients with irreducible intertrochanteric femoral fracture admitted between February 2016 and December 2022 and met the selection criteria were retrospectively analyzed. Among them, 38 cases were treated with folding top technique combined with right-angle pliers prying and pulling under G-arm X-ray fluoroscopy and intramedullary nailing fixation (study group), and 36 cases were treated with limited open reduction combined with other reduction methods and intramedullary nailing fixation (control group). There was no significant difference in baseline data between the two groups, such as age, gender, cause of injury, affected side and classification of fractures, complicated medical diseases, and time from injury to operation ( P >0.05). The operation time, intraoperative blood loss, hospital stay, fracture reduction time, fracture healing time, and complications of the two groups were recorded and compared. The quality of fracture reduction was evaluated by Baumgaertner et al. and Chang et al. fracture reduction standards., Results: Patients in both groups were followed up 10-14 months, with an average of 12 months. The operation time and intraoperative blood loss in the study group were significantly less than those in the control group ( P <0.05), there was no significant difference in hospital stay between the two groups ( P >0.05). At 2 days after operation, according to the fracture reduction standards of Baumgaertner et al. and CHANG Shimin et al. , the quality of fracture reduction in the study group was better than that in the control group, and the fracture reduction time in the study group was shorter than that in the control group, with significant differences ( P <0.05). After operation, the fractures of the two groups all healed, and there was no significant difference in healing time between the two groups ( P >0.05). During the follow-up, there was no complication such as incision infection, internal fixation failure, deep venous thrombosis of lower limbs, intramedullary nail breakage, spiral blade cutting, or hip varus in the two groups, except for 2 cases of coxa vara in the control group., Conclusion: For the irreducible intertrochanteric femoral fracture, using folding top technique combined with right-angle pliers prying and pulling under G-arm X-ray fluoroscopy can obviously shorten the operation time, reduce the intraoperative blood loss, and improve the quality of fracture reduction.