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PURPOSE: The retrograde femoral nailing advanced (RFNA) system (DePuy synthes) is a commonly used implant for the fixation of low distal femur and periprosthetic fractures. There is concern that the rate of distal interlock screw back-out may be higher for the RFNA compared to other nails (ON). The purpose of this study was to evaluate the incidence of interlock screw back-out and associated screw removal for RFNA versus ON, along with associated risk factors. METHODS: A retrospective comparative study of patients who underwent retrograde nailing for a distal femur fracture at an academic level one trauma center was performed. The incidence of distal interlock screw back-out and need for screw removal were compared for RFNA versus a propensity score matched cohort who received other nails. RESULTS: One hundred and ten patients underwent retrograde nailing with the RFNA for a distal femur fracture from 2015 to 2022 (average age: 66, BMI: 32, 52.7% smokers, 54.5% female, 61.8%). There was a significantly higher rate of interlock back-out in the RFNA group compared to the ON (27 patients, 24.5% vs 12 patients, 10.9%, p = 0.01), which occurred 6.3 weeks postoperatively. Screw removal rates for back-out were not significantly different for the RFNA group versus ON (8 patients, 7.3% vs 3 patients, 2.7%, p = 0.12). CONCLUSION: In this retrospective comparative study of distal femur fractures treated with retrograde nailing, the RFNA implant was associated with an increased risk of distal interlock screw back-out compared to other nails.

A proper and reliable fracture fixation is important for fracture healing. The proximal femoral intramedullary nail (IN), such as proximal femoral nail anti-rotation (PFNA) or Gamma nail, is widely used for intertrochanteric fracture fixation. However, it still suffers considerable stress concentrations, especially at the junction between the nail and the blade or lag screw. In this study, we propose a novel intramedullary nail design to enhance the intramedullary nail integrity by introducing a bolt screw to form a stable triangular structure composed of the nail, the lag screw, and the bolt screw (PFTN, Proximal femoral triangle nail). Systematic finite element numerical simulations were carried out to compare the biomechanical performances of PFTN and PFNA under both static and dynamic loads during the postures of ascending and descending stairs. The simulation results highlight the advantages of the proposed PFTN design with lower stresses, less stress concentration, and higher structure stability. [ABSTRACT FROM AUTHOR]

The best treatment method for reverse obliquity intertrochanteric fractures (ROIFs) is still under debate. Our team designed the modified proximal femoral nail (MPFN) specially for treating such fractures. The objective of this research was to introduce the MPFN device and compare the biomechanical properties with Proximal Femoral Nail Antirotation (PFNA) and InterTAN nail via finite element modelling. An AO/OTA 31-A3.1 ROIF model was established via Mimics software. Three implants were depicted and assembled on the ROIF models. The axial, bending, and torsion loads were simulated to test stress and displacement of three fixation models. Compared to the PFNA and InterTAN models, the MPFN model had more dispersed stress distribution under axial loads of 2,100 N. The MPFN showed lower von Mises stress on bones compared with that of PFNA and InterTAN in axial loads. In term of maximum displacement, the MPFN had a 12.6% reduction compared to the PFNA model in axial load case. In bending and torsion loads, the MPFN model also demonstrated better biomechanical properties than the PFNA and InterTAN models. The modified proximal femoral nail presented the best biomechanical performance, followed by the InterTAN nail, and the PFNA for fixing reverse obliquity intertrochanteric fractures. The MPFN has the potential to be a promising device for patients with ROIFs. [ABSTRACT FROM AUTHOR]

Purpose: Proximal femur shaft nonunion is a challenging problem, often occurring after malreduction that results in postoperative malalignment and decreased healing potential. Correction of malalignment is critical to achieving osseous union. Here we present a novel technique for treating proximal femur nonunions with varus malalignment using an intramedullary nail inserted through a medialized trochanteric entry point. Methods: Patients who underwent a proximal femur shaft (subtrochanteric or proximal third shaft) nonunion operation at a single level 1 academic referral centre by two attending surgeons between 1/1/2014 and 1/1/2022 were identified. Radiographic imaging was reviewed to determine initial fracture classification and calculation of coronal plane alignment (CPA), which was measured on preoperative, immediate postoperative, and final follow-up radiographs. Postoperative complications, reoperations, infections, and osseous union were also collected. Results: Twenty-one patients with a mean age of 49.9 years (66% male) were identified. Mean preoperative CPA was 125.6 degrees, immediate postoperative mean CPA was 132.6 degrees, and mean final follow-up CPA was 131.5 degrees. Mean change in CPA from immediate postoperative films to final follow-up was a decrease of 0.4 degrees. 17 patients had follow up for a minimum of 12 months or until osseous union, and all achieved union without any major complications. Conclusion: Exchange nailing with an antegrade trochanteric entry nail through a medialized trochanteric starting point is a safe and effective technique in the treatment of proximal femur nonunions. This technique results in improved postoperative alignment that is sustained throughout the postoperative course, and may lead to increased rates of osseous union. [ABSTRACT FROM AUTHOR]

Objectives: Distal femur fractures (DFF) are frequently treated surgically with single traditional constructs (STC), such as with a lateral plate or intramedullary nail, although nail-plate combination constructs (NPCC) are gaining attention. The purpose of this study is to compare outcomes between NPCC and STC for surgical fixation of DFF to guide surgeon decision-making. Methods: Data Sources: This study is a systematic review and meta-analysis using PubMed, CINAHL, MEDLINE, Web of Science, Science Direct, and SPORTDiscus from database inception until January 10th, 2024. Study Selection: Inclusion criteria were comparative studies that examined clinical outcomes and complications for NPCC versus STC for DFF in adult patients. Data Extraction: Data included operative time, estimated blood loss (EBL), length of stay (LOS), as well as likelihood of total complications, total unplanned reoperations, and malunion. Data Synthesis: Statistical analysis included a random-effects model using unstandardized mean difference or odds ratio (OR). Results: Five retrospective comparative studies (n = 1,368 patients; mean age: 52.3 ± 8.1 years; 134 patients in the NPCC group) were included. There was no statistically significant difference in operative time (p = 0.696), EBL (p = 0.408), or LOS (p = 0.963) between patients in the NPCC group as compared to patients in the STC group after DFF. Patients in the NPCC group had a statistically significant lower number of total complications (p = 0.009; OR: 0.31; 10.6% versus 16.0%) and total unplanned reoperations (p = 0.027; OR: 0.42; 8.2% versus 14.8%) as compared to patients in the STC group after DFF. However, there was no statistically significant difference in the number of malunion cases between groups (p = 0.130), although the NPCC group had far fewer cases than the STC group (2.9% versus 10.5%). Conclusion: Patients treated with NPCC had significantly fewer cases of total complications and total unplanned reoperations without significant differences in operative time, EBL, or LOS as compared to patients treated with STC for DFF, although these associations are limited by sample size. Level of evidence: Level IV. [ABSTRACT FROM AUTHOR]

Purpose: Although several techniques have been described for bent intramedullary nail removal, there is no universally accepted strategy. We hypothesized that a device based on the action principle of a three-point bend fixture could facilitate extraction of bent intramedullary nails; this paper describes its design and experimental testing. Methods: Five large synthetic left femurs and five steel intramedullary nails were used. The nails were bent in a manual hydraulic press and implanted into the model femurs, which had been previously sectioned as necessary. A device to correct the angular deformity imparted to the nails was designed, and a prototype fabricated from AISI 1045 steel. Specimens were secured in a vise and the device attached; manual tension was then applied to gradually correct the nail deformity. Plain radiographs were obtained, and the nails were removed. The model femurs and intramedullary nails were visually inspected for proper contact of the device tip, coronal and sagittal alignment, and points of failure. Results: Before device application, the angles of the specimens averaged 40.2° (38.27°–41.32°) in the coronal plane and 7.22° (8.5°–10.2°) in the sagittal plane. After device application, these angles averaged 15.04° (2.5°–32.3°) and 4.16° (0°–9.8°), respectively. There were no implant fractures, but in two models, peri-implant fractures (one catastrophic) occurred close to the proximal and distal locking screws. Conclusion: The proposed device for bent intramedullary nail extraction was effective, but homogeneous behavior in terms of angle correction was not observed in the tested specimens. Further development is needed. [ABSTRACT FROM AUTHOR]

Purpose: Sliding hip screw (SHS) and intramedullary (IMN) constructs are commonly utilized treatments for intertrochanteric (IT) femur fractures. The aim of this study was to assess the economic and utilization trends in the management of IT fractures among the Medicare population over the last 21 years. Methods: A review of the publicly available Medicare Part B National Summary Data File for years 2000–2021 was performed. Collected data included true physician reimbursement and utilization numbers for all CPT codes pertaining to fixation of IT fractures with either SHS or IMN. Results: A total of 1,361,112 IMN implants and 739,032 SHS implants were billed to Medicare for intertrochanteric femur fractures during the studied timeline. In this 21-year span, utilization of IMN increased 695% (9648–76,667), while utilization of SHS decreased by 96% (94,223–4224). After adjusting for inflation, the average physician reimbursement for SHS decreased by 34%, while IMN decreased by 41%. Absolute physician reimbursement was found to be $943.36 for SHS and $999.88 for IMN constructs. Conclusion: Intramedullary implants are being increasingly utilized while sliding hip screw, and intramedullary construct reimbursement continues to decrease for intertrochanteric femur fracture fixation. These trends suggest that opting for a sliding hip screw may be more cost-effective when the fracture pattern allows for either construct. [ABSTRACT FROM AUTHOR]

Purpose: Femoral shaft fractures with third fragments are difficult to reduce anatomically, affecting bone healing chances. The goal of this study is to determine the impact of the third fragment’s radiological characteristics assessed on post-operative radiographs, as well as other factors, on the healing of type 32B femur shaft fractures treated with intramedullary nail. Methods: We conducted a retrospective study of 93 patients treated for femoral shaft fractures type 32 B. On post-operative X-rays, two radiologic parameters were evaluated: the third fragment size and the mean third fragment displacement. Patients had radiologic follow-up at 2, 4, 6, 9, and 12-months and were separated into 3 groups based on their fracture healing time: within 6 months (group 1), between 6 and 12 months (group 2), or nonunion after 12 months (group 3). Results: Among the 93 patients, 72 (77.4%) showed fracture healing at 6 months, 13 (14%) at 12 months, and 8 (8.6%) demonstrated nonunion at 12 months. The mean third fragment displacement was notably different between groups (p < 0.001) and was considerably greater in group 3 than in groups 1 and 2. The influence of third fragment displacement on outcomes under 6 months was determined by ROC analysis, using a cut-off value of 14 mm. Displacement under 14 mm predicted healing within 6 months with a sensitivity of 90.3% and a specificity of 61.9%. The statistical analysis demonstrated that the odds of experiencing non-union or delayed healing were approximately 15 times higher for patients with a third fragment displacement of 14 mm or greater. Conclusion: The third fragment displacement is the most important factor influencing healing within twelve months in femur shaft fractures type 32B managed with an intramedullary nail. Inversely, the third fragment size had no effect on the healing of the fractures in our series. [ABSTRACT FROM AUTHOR]

Introduction In lengthening of limbs in children, the combination of elastic intramedullary reinforcement and external fixation has advantages over standard techniques, but requires the removal of elastic nails and does not provide the possibility of their locking, that could significantly reduce the period of external fixation. The purpose of the work was to study the features of tibial distraction regenerate formation and residual growth of the lengthened segment in lambs under the conditions of external fixation combined with a transphyseal rigid titanium rod. Materials and methods In vivo experiments were performed on lambs (n = 7) during their growth period. In the control group, the right tibia was lengthened using transosseous distraction osteosynthesis for 28 days. In the study group, the segment was additionally reinforced with an intramedullary rigid rod. The following were measured in radiographs: the height of the distraction gap between the fragments, the transverse dimensions of the distraction regenerate, the height of the bone sections of the regenerate and the growth zone, the length of the tibia; the anatomical angles of the proximal articular end of the tibia. To determine the intrinsic growth dynamics of the segment under lengthening, the size of the distraction regenerate was subtracted from the length of the tibia. Results In the main group, the transverse dimensions of the distraction regenerate were larger, and the height of the growth zone was smaller than in the control group. Consolidation of the regenerate in the main group occurred after 30 days, and in the control group 60 days after the cessation of lengthening. No slowdown in the longitudinal growth of the elongated segment was noted compared to the contralateral one, the orientation angles of the inclination of the proximal articular surfaces did not change. Discussion Transphyseal implants should be located centrally to reduce the risk of epiphysiodesis, their area should not exceed 7 % of the growth zone. These conditions were met in the study. The reduction in the time of distraction regenerate corticalization and early termination of external fixation was associated with pronounced periosteal osteogenesis and increased bone fragments stability. The location of the rod in the growth plate does not lead to epiphysiodesis and does not interfere with normal growth of the segment. Conclusion Pronounced periosteal osteogenesis and additional stabilization of the bone fragments with a transphyseal rigid titanium rod contribute to the faster bone regenerate formation and maturation. There are no signs of inhibition of spontaneous growth of the segment under lengthening and radiographic signs of epiphysiodesis at the transphyseal level. The central location of the transphyseal rod relative to the growth zone plane and its cross-sectional area of less than 5 % of the physis area can be considered conditions under which epiphysiodesis does not develop.

Objectives: (1) To describe our operative technique for femoral neck fractures using an intramedullary device with integrated compression screws. (2) Retrospective analysis of patients treated with intramedullary fixation with interlocking lag and compression screws for femoral neck fracture (3). To compare our results to published literature on more classic fixation techniques. Design: Single-center retrospective cohort. Setting: Level 1 trauma center. Patients/Participants: Thirty-eight patients with 39 femoral neck fractures were treated with internal fixation. Only patients treated with intramedullary fixation with integrated interlocking lag and compression screws were included; patients treated for femoral neck fractures with a sliding hip screw, screw fixation alone, or intramedullary devices without integrated interlocking screws were excluded. Our final cohort consisted of 19 patients (47% female) with an average age of 50 (27–82) who had 15 (79%) isolated femoral neck fractures and 4 (21%) femoral neck-shaft combined fractures. Intervention: Internal fixation with intramedullary fixation using interlocking lag and compression screws for femoral neck fracture. Outcome Measurements: Quality of reduction, radiographic healing, and radiographic assessment of nonunion/avascular necrosis (AVN). Results: Follow-up time was on average 50 months (range: 34–84), with a median of 50 months (interquartile range: 42–56). Nineteen patients (100%) had successful healing without further intervention. There were no nonunions, and 2 (10%) patients developed AVN leading to conversion to total hip arthroplasty. Conclusion: Femoral neck fractures are challenging to manage due to their intracapsular location and the tenuous blood supply to the femoral head. The use of intramedullary devices with integrated lag and compression screws is an effective method for the operative fixation of femoral neck fractures. Level of evidence: Level IV therapeutic.

Introduction: Antegrade intramedullary nail fixation for humeral shaft fractures yields satisfactory union rates. However, one of the related concerns is damage to the rotator cuff during nail insertion, which may affect long-term outcomes. The effect of a rotator cuff lesion on mid- and long-term shoulder outcomes remains unknown. This study aimed to investigate the incidence of rotator cuff tears 5 years or more after intramedullary nailing for humeral shaft fractures and to determine the impact of post-operative rotator cuff tears on mid-term outcomes. Materials and methods: We retrospectively identified 27 patients who underwent antegrade intramedullary nail fixation for traumatic humeral shaft fractures and received follow-up for at least 5 years post-operatively. The patients were divided into two groups: those without tears and those with partial or complete tears, diagnosed using ultrasonography. We compared the functional and radiological shoulder outcomes between the two groups. Results: Of the 27 patients, 10 had partial or complete supraspinatus tears with a mean follow-up of 7.5 years post-operatively. The incidence of acromial spurs was significantly higher in patients with partial or complete tears than in those without tears (P

Abstract Background Perioperative peri-implant fractures (PPIFs) pose infrequent yet significant challenges in orthopedic surgery, particularly in the context of femoral pertrochanteric fractures (FPF) treated with proximal femoral nail antirotation 2 (PFNA-2) nails. PPIFs can lead to prolonged recovery and may necessitate re-osteosynthesis in severe cases. Despite the effectiveness of PFNA-2 in the management of FPFs, our understanding of PPIFs in this specific context remains limited. This study aimed to elucidate the factors contributing to PPIFs in patients with PFNA-2-treated FPF. Methods In this retrospective analysis spanning from 2019 to 2022, patients with FPF treated with PFNA-2 nails were examined. Demographic data, fracture characteristics, and radiological parameters were collected, along with details of the PPIF management strategies and rehabilitation protocols. Radiological assessments included femoral morphology measurements and reduction and fixation quality evaluation. The area under the curve (AUC) was analyzed in this specific group. Results Among 157 patients, 3.2% experienced acute PPIFs managed conservatively with successful union without secondary surgical intervention. Younger age and increased femoral isthmus diameter (DI) emerged as significant predictors of PPIFs in the univariate regression analyses (P = 0.01). The AUCs for age (65.5 years) and DI (1.4 cm) were 0.78 and 0.79, respectively, indicating moderate accuracy. Conclusions Although PFNA-2 nails are reliable in managing FPFs, the persistence of PPIFs emphasizes their complex causes. This study highlights that younger age and increased femoral DI are crucial factors for PPIF occurrence in patients with PFNA-2-treated FPF. Conservative treatment with delayed weight-bearing ambulation may be effective in treating these fractures.

Cerclage wiring may be used to optimize the stability of intramedullary nail or plate fixations in comminuted proximal femoral fractures, periprosthetic fractures, and other selected cases. In this article, we presented a novel case of iatrogenic sciatic nerve entrapment from cerclage wiring used to supplement intramedullary nail fixation. We also illustrate and highlight the role of ultrasound in assessing the sciatic nerve to make a timely diagnosis.

Abstract Background Prompt identification of fracture healing is crucial for medical decision-making and clinical research. This study aims to assess the effectiveness of the Radiographic Union Score for Hip (RUSH) in subtrochanteric fractures and determine the optimal scoring threshold for fracture healing. Methods We obtained 94 sets of X-ray films from the postoperative follow-up of 35 patients who underwent intramedullary nail fixation for subtrochanteric fractures. Six orthopedic trauma surgeons evaluated the imaging data and determined fracture healing based on subjective judgment. They then scored the X-ray images using the RUSH form. After four weeks, the same observers re-evaluated 47 randomly selected sets of radiographs. Subsequently, the observers and study designer conducted a consensus meeting where they agreed on whether the fractures had healed. We used Fleiss kappa to evaluate agreement among observers based on subjective impressions, and the intraclass correlation coefficient assessed RUSH score consistency. Regression analysis examined the relationship between scores and fracture healing consensus using a receiver operator characteristic (ROC) curve. Results Based on overall impressions, the agreement level among orthopedic trauma surgeons for determining the healing status of subtrochanteric fractures was moderate (Kappa = 0.564, 95% CI: 0.511–0.616). However, utilizing the RUSH scoring system can improve the consistency to a substantial level of agreement (ICC = 0.748, 95% CI: 0.663–0.817). Regarding intraobserver reliability, there were significant differences among orthopedic trauma surgeons in judging fracture healing based on overall impressions. However, using the RUSH scoring form, the attending group achieved better intraobserver consistency than the resident group. Regression analysis and ROC curve analysis revealed a strong correlation between the RUSH total score, cortical bone score, cancellous bone score, and consensus on fracture healing. The AUC values are 0.769 (95% CI: 0.670–0.868), 0.779 (95% CI: 0.681–0.876), and 0.771 (95% CI: 0.674–0.867), respectively. Conclusions Our study highlights the effectiveness of the RUSH scoring system in enhancing interobserver agreement and intraobserver consistency when evaluating subtrochanteric fracture healing in orthopedic trauma surgeons. We propose setting 21 points as the threshold for the simplified RUSH scoring system to determine fracture healing. This system includes only eight items related to cortical bone, with a total score of 24 points.

Aims: This study aims to describe a new method that may be used as a supplement to evaluate humeral rotational alignment during intramedullary nail (IMN) insertion using the profile of the perpendicular peak of the greater tuberosity and its relation to the transepicondylar axis. We called this angle the greater tuberosity version angle (GTVA). Methods: This study analyzed 506 cadaveric humeri of adult patients. All humeri were CT scanned using 0.625 × 0.625 × 0.625 mm cubic voxels. The images acquired were used to generate 3D surface models of the humerus. Next, 3D landmarks were automatically calculated on each 3D bone using custom-written C++ software. The anatomical landmarks analyzed were the transepicondylar axis, the humerus anatomical axis, and the peak of the perpendicular axis of the greater tuberosity. Lastly, the angle between the transepicondylar axis and the greater tuberosity axis was calculated and defined as the GTVA. Results: The value of GTVA was 20.9° (SD 4.7°) (95% CI 20.47° to 21.3°). Results of analysis of variance revealed that females had a statistically significant larger angle of 21.95° (SD 4.49°) compared to males, which were found to be 20.49° (SD 4.8°) (p = 0.001). Conclusion: This study identified a consistent relationship between palpable anatomical landmarks, enhancing IMN accuracy by utilizing 3D CT scans and replicating a 20.9° angle from the greater tuberosity to the transepicondylar axis. Using this angle as a secondary reference may help mitigate the complications associated with malrotation of the humerus following IMN. However, future trials are needed for clinical validation. Cite this article: Bone Jt Open 2024;5(10):929–936.

Background: Humeral shaft fractures are relatively common. Complications associated with this type of fracture and its treatment include nonunion and radial nerve palsy. Plate osteosynthesis with autologous bone grafting is considered the gold standard for treating nonunion. However, bone grafts might not always be necessary in cases of hypertrophic nonunion, and treatment should be tailored to the specific type and characteristics of the nonunion. The treatment of radial nerve palsy is debated, with some favoring expectant management based on the nerve’s ability to regenerate, and others preferring early surgical exploration to prevent possible lasting nerve damage. Methods: We present the case of a 46-year-old male patient with a six-year-old humeral shaft fracture resulting in hypertrophic nonunion. We treated the nonunion with anterograde intramedullary nailing without bone grafting. Postoperatively, the patient developed severe radial nerve palsy. After repeated electrophysiological studies, a decision was made to surgically explore the nerve 10 days after the nonunion surgery. The nerve was subsequently found to be intact and treated with neurolysis. Results: Bony union was shown at six months after nonunion surgery. Four months after the nonunion surgery, the patient started to show clinical signs of nerve recovery, and at 12 months he achieved nearly full clinical recovery of radial nerve function. Conclusions: Anterograde intramedullary nailing without autologous bone grafting may be considered an option for treating hypertrophic nonunion. The management of radial nerve palsy requires effective cooperation and communication between patient and physician. Further research is necessary to be able to better predict nerve recovery.

Background: Perioperative peri-implant fractures (PPIFs) pose infrequent yet significant challenges in orthopedic surgery, particularly in the context of femoral pertrochanteric fractures (FPF) treated with proximal femoral nail antirotation 2 (PFNA-2) nails. PPIFs can lead to prolonged recovery and may necessitate re-osteosynthesis in severe cases. Despite the effectiveness of PFNA-2 in the management of FPFs, our understanding of PPIFs in this specific context remains limited. This study aimed to elucidate the factors contributing to PPIFs in patients with PFNA-2-treated FPF. Methods: In this retrospective analysis spanning from 2019 to 2022, patients with FPF treated with PFNA-2 nails were examined. Demographic data, fracture characteristics, and radiological parameters were collected, along with details of the PPIF management strategies and rehabilitation protocols. Radiological assessments included femoral morphology measurements and reduction and fixation quality evaluation. The area under the curve (AUC) was analyzed in this specific group. Results: Among 157 patients, 3.2% experienced acute PPIFs managed conservatively with successful union without secondary surgical intervention. Younger age and increased femoral isthmus diameter (DI) emerged as significant predictors of PPIFs in the univariate regression analyses (P = 0.01). The AUCs for age (65.5 years) and DI (1.4 cm) were 0.78 and 0.79, respectively, indicating moderate accuracy. Conclusions: Although PFNA-2 nails are reliable in managing FPFs, the persistence of PPIFs emphasizes their complex causes. This study highlights that younger age and increased femoral DI are crucial factors for PPIF occurrence in patients with PFNA-2-treated FPF. Conservative treatment with delayed weight-bearing ambulation may be effective in treating these fractures. [ABSTRACT FROM AUTHOR]

Purpose: To investigate whether the outcomes, including union rates, complications, reoperations, blood loss, operative time, and range of motion, differed following intramedullary nailing (IMN) or open reduction internal fixation (ORIF) of two- and three-part proximal humerus fractures with or without ipsilateral shaft fractures and head-split patterns. Methods: This was a retrospective multicenter study at three community centers and one level 1 trauma center. Inclusion criteria were two- and three-part proximal humerus fracture treated with either IMN or ORIF from 2015 to 2022 with at least three months of postoperative follow-up. Results: 228 patients. No significant differences in preoperative subject characteristics were observed. IMN was significantly more common with ipsilateral shaft fractures (p = 0.011). The number of fracture parts was significantly associated with treatment (p < 0.001). IMN had significantly less blood loss in two-part fractures (p = 0.016) and concomitant shaft fractures (p = 0.029), but operative time was not significantly less in any group. Union rates, complications, reoperation, postoperative humeral neck shaft angle, and postoperative range of motion were not significantly different. Conclusions: IMN and ORIF result in similar outcomes for proximal humerus fractures. Both treatments result in high union rates, the potential for near anatomic postoperative humeral neck shaft angles, and sufficient postoperative range of motion. IMN has lower blood loss than ORIF. IMN is a viable option for two-part proximal humerus fractures and may be effective in select three-part fractures as well. Concomitant humeral shaft fractures can be treated with either IMN or ORIF. Head-split patterns should be treated with ORIF. [ABSTRACT FROM AUTHOR]

Background: To compare the biomechanical performance of three internal fixation constructs for AO/OTA 33-A3 distal femoral fractures. Methods: Thirty AO/OTA 33-A3 synthetic distal femoral fracture models were constructed and randomly divided into three groups. Group A (dual-plate construct) was fixed with a medial locking plate combined with a less invasive stabilization system (LISS). Group B was fixed with a retrograde femoral nail (RFN) combined with an LISS (RFN + LISS construct), and Group C was fixed with a retrograde tibial nail (RTN) combined with an LISS (RTN + LISS construct). The axial displacement, axial stiffness, torsional displacement, torsional stiffness and maximum failure load of different internal fixation constructs were recorded and statistically analyzed. Results: In the axial compression test, the average stiffness of Group C was significantly higher than that of Groups A and B, and the average displacement of Group C was significantly smaller than that of Groups A and B. In the torsion test, the torsion degree of Group C was significantly lower than that of Groups A and B, and Group C had a higher torsional stiffness than Groups A and B. In the axial compression failure test, the average ultimate load (a displacement greater than 5 mm) of Group C was significantly higher than that of Groups A and B. Conclusion: The biomechanical strength of the RTN combined with a plate is higher than that of the RFN combined with plate and dual-plate constructs, which can be used as an internal fixation option for the treatment of comminuted distal femoral fractures. [ABSTRACT FROM AUTHOR]

Background: Prompt identification of fracture healing is crucial for medical decision-making and clinical research. This study aims to assess the effectiveness of the Radiographic Union Score for Hip (RUSH) in subtrochanteric fractures and determine the optimal scoring threshold for fracture healing. Methods: We obtained 94 sets of X-ray films from the postoperative follow-up of 35 patients who underwent intramedullary nail fixation for subtrochanteric fractures. Six orthopedic trauma surgeons evaluated the imaging data and determined fracture healing based on subjective judgment. They then scored the X-ray images using the RUSH form. After four weeks, the same observers re-evaluated 47 randomly selected sets of radiographs. Subsequently, the observers and study designer conducted a consensus meeting where they agreed on whether the fractures had healed. We used Fleiss kappa to evaluate agreement among observers based on subjective impressions, and the intraclass correlation coefficient assessed RUSH score consistency. Regression analysis examined the relationship between scores and fracture healing consensus using a receiver operator characteristic (ROC) curve. Results: Based on overall impressions, the agreement level among orthopedic trauma surgeons for determining the healing status of subtrochanteric fractures was moderate (Kappa = 0.564, 95% CI: 0.511–0.616). However, utilizing the RUSH scoring system can improve the consistency to a substantial level of agreement (ICC = 0.748, 95% CI: 0.663–0.817). Regarding intraobserver reliability, there were significant differences among orthopedic trauma surgeons in judging fracture healing based on overall impressions. However, using the RUSH scoring form, the attending group achieved better intraobserver consistency than the resident group. Regression analysis and ROC curve analysis revealed a strong correlation between the RUSH total score, cortical bone score, cancellous bone score, and consensus on fracture healing. The AUC values are 0.769 (95% CI: 0.670–0.868), 0.779 (95% CI: 0.681–0.876), and 0.771 (95% CI: 0.674–0.867), respectively. Conclusions: Our study highlights the effectiveness of the RUSH scoring system in enhancing interobserver agreement and intraobserver consistency when evaluating subtrochanteric fracture healing in orthopedic trauma surgeons. We propose setting 21 points as the threshold for the simplified RUSH scoring system to determine fracture healing. This system includes only eight items related to cortical bone, with a total score of 24 points. [ABSTRACT FROM AUTHOR]

Purpose: The objective of this study was to describe the use of retrograde gentamicin-coated tibial intramedullary nail (ETN PROtect™) in patients with tibial defects who required a tibiotalocalcaneal arthrodesis (TTC). Methods: Consecutive series case review of seven men treated with TTC using retrograde PROtect™ between January 2018 and December 2023. The main outcomes evaluated were fracture union, complications, and the health-related quality of life using the EuroQol five-dimension three-level questionnaire (EQ-5D-3L). Results: The mean age was 45.3 ± 8.0 years. Six patients had a clinical history of chronic osteomyelitis, and one case underwent TTC for congenital pseudoarthrosis. Fracture union was achieved in 5 of 7 patients between 4 and 11 months after surgery. Three patients developed complications; two patients had fistulas, and one had persistent pain. At the end of the follow-up, a median of 70 points (interquartile range: 60 to 90) on the EQ-5D-3L was reported. No complications directly attributed to the use of the PROtect™ were reported. Conclusion: TTC with retrograde PROtect™ is a prophylactic treatment option in patients with tibial defects treated with external fixation requiring a tibiotalar and subtalar arthrodesis. This novel use of PROtect™ allows simultaneous fixation of the tibiotalocalcaneal joint and protection of the regenerated bone, facilitating earlier rehabilitation in patients at high risk for postoperative infections. [ABSTRACT FROM AUTHOR]

Case: A 77-year-old man experienced acute failure of fixation of his humeral shaft fracture after fixation with IlluminOss photodynamic system stabilization (Photodynamic Bone Stabilization System [PBSS]). Owing to the well-fixed IlluminOss PBSS implant to the humeral intramedullary canal, complete removal was deemed not indicated. Partial implant removal and revision open reduction internal fixation with a proximal humerus plate was performed. However, this was complicated by recalcitrant deep hardware infection that failed multiple surgical debridements, requiring eventual humeral osteotomy to remove the remainder of the infected IlluminOss PBSS implant. Conclusion: This is one of the first articles highlighting the technical challenges and morbidity associated with removal of an IlluminOss PBSS. [ABSTRACT FROM AUTHOR]

Cerclage wiring may be used to optimize the stability of intramedullary nail or plate fixations in comminuted proximal femoral fractures, periprosthetic fractures, and other selected cases. In this article, we presented a novel case of iatrogenic sciatic nerve entrapment from cerclage wiring used to supplement intramedullary nail fixation. We also illustrate and highlight the role of ultrasound in assessing the sciatic nerve to make a timely diagnosis. [ABSTRACT FROM AUTHOR]

Background: Humeral shaft fractures are relatively common. Complications associated with this type of fracture and its treatment include nonunion and radial nerve palsy. Plate osteosynthesis with autologous bone grafting is considered the gold standard for treating nonunion. However, bone grafts might not always be necessary in cases of hypertrophic nonunion, and treatment should be tailored to the specific type and characteristics of the nonunion. The treatment of radial nerve palsy is debated, with some favoring expectant management based on the nerve's ability to regenerate, and others preferring early surgical exploration to prevent possible lasting nerve damage. Methods: We present the case of a 46-year-old male patient with a six-year-old humeral shaft fracture resulting in hypertrophic nonunion. We treated the nonunion with anterograde intramedullary nailing without bone grafting. Postoperatively, the patient developed severe radial nerve palsy. After repeated electrophysiological studies, a decision was made to surgically explore the nerve 10 days after the nonunion surgery. The nerve was subsequently found to be intact and treated with neurolysis. Results: Bony union was shown at six months after nonunion surgery. Four months after the nonunion surgery, the patient started to show clinical signs of nerve recovery, and at 12 months he achieved nearly full clinical recovery of radial nerve function. Conclusions: Anterograde intramedullary nailing without autologous bone grafting may be considered an option for treating hypertrophic nonunion. The management of radial nerve palsy requires effective cooperation and communication between patient and physician. Further research is necessary to be able to better predict nerve recovery. [ABSTRACT FROM AUTHOR]

Intramedullary nails (ILNs) are commonly used in orthopedic surgery for the fixation of long bone fractures and limb lengthening. Understanding the structural mechanics (i.e. nail bend) of an ILN device is crucial in determining its performance under various loading conditions. Furthermore, nail diameter was found to play a key role in an ILN's susceptibility to plastic deformity. This study aims to investigate the degree of nail bending and incidence of plastic deformity in patients receiving antegrade femoral ILNs (PRECICE, NuVasive, Inc.). Retrospectively evaluated 130 ILNs (PRECICE, NuVasive, Inc.) in 100 adult patients who underwent limb lengthening done in a single center. Patients who had concomitant osteotomies, tibial lengthening, malunion, non-union, mechanical failure, or revision surgery for any reason were excluded. All nails were inserted through the greater trochanter or piriformis. Patients' age, weight, height, and body mass index (BMI)were extracted. Radiologic assessments involved analyzing long lower limb standing X-rays before, during, and at consolidation for total distraction and nail bend. Naildiameter and patient characteristics were directly sourced from medical records. Nail bend at consolidation averaged 2.4° (SD 2.4), ranging from 0 to 9. Additionally, total femoral lengthening was assessed, with a mean value of 5.3 cm (SD 2.1). A significant positive association was observed in the nail bend and weight (weight in kg/nail diameter in mm) coefficient (P < 00.01). Bilateral limb lengthening was also correlated to increase nail bend (P < 00.05). Patient's weight to nail diameter ratio and bilateral limb lengthening were found to be significant factors affecting nail bend. These findings advance our understanding of the interrelation between the nail biomechanical profile and the patient's physical attributes, offering important implications for limb lengthening. III. [ABSTRACT FROM AUTHOR]

BACKGROUND Intertrochanteric femur fractures are typically treated with proximal femoral nails. There are two varieties of proximal femoral nails in our study: PFNA2, which has a single proximal blade, and normal PFN, which has two proximal screws. AIM Our study compares functional results and implant-related problems in individuals treated for proximal femur fracture using PFNA2 nails versus conventional PFN nails. MATERIAL AND METHODS After obtaining ethical clearance from Institutional ethical committee, this prospective study was conducted in the Department of Orthopaedics in Sri Madhusudhan Sai Institute of Medical Sciences and Research from Nov 2022 to Nov 2023. A series of 50 cases were included in the study. After obtaining prior informed and written consent from the patients. Fracture diagnosis confirmed by clinical examination and radiography. Pre-anaesthetic evaluation done as per protocols. 25 Patients underwent PFN nailing and 25 Patients underwent PFN- A2 nailing. Post operatively follow up was done until 6 months to assess various outcomes namely fracture healing, incidence of post-operative complications, rehabilitation and functional outcome. RESULTS Implant A2-PFN nails has better results than implant standard PFN nail in terms of operative time, operative blood-loss and functional outcome. CONCLUSION We concluded from the study that, in comparison to standard PFN nails, PFNA2 nails minimises surgical time, blood loss, and radiation exposure. When compared to standard PFN nail, PFNA2 nails offers substantially superior functional outcomes and a greater union rate. PFNA2-treated patients are able to bear weight quickly. PFNA2 does not cause too many implant-related issues including screw backing out and cut-through of screws in the femoral head (also known as the z-effect and reverse z-effect). Consequently, we draw the conclusion that PFNA2 nails are better than standard PFN nails. [ABSTRACT FROM AUTHOR]

Intramedullary nailing is the preferred internal fixation technique for the treatment of subtrochanteric fractures because of its biomechanical advantages. However, no definitive conclusion has been reached regarding whether combined cable cerclage is required during intramedullary nailing treatment. This study is performed to compare the clinical effects of intramedullary nailing with cerclage and non-cerclage wiring in the treatment of irreducible spiral subtrochanteric fractures. Patients with subtrochanteric fractures admitted to our center from January 2013 to December 2021 were retrospectively analyzed. The patients were enrolled in the case-control study according to the inclusion and exclusion criteria and divided into the non-cerclage group and the cerclage group. The patients' clinical data, including the operative time, intraoperative blood loss, hospital stay, reoperation rate, fracture union time, and Harris hip score, were compared between these 2 groups. Categorical variables were compared using Chi-square or Fisher's exact test. Continuous variables with normal distribution were presented as mean ± standard deviation and analyzed with Student's t -test. Non-normally distributed variables were expressed as median (Q 1 , Q 3) and assessed using the Mann-Whitney test. A p < 0.05 was considered significant. In total, 69 patients were included in the study (35 patients in the non-cerclage group and 34 patients in the cerclage group). The baseline data of the 2 groups were comparable. There were no significant difference in the length of hospital stay (z = -0.391, p = 0.696), operative time (z = -1.289, p = 0.197), or intraoperative blood loss (z = -1.321, p = 0.186). However, compared with non-cerclage group, the fracture union time was shorter (z = -5.587, p < 0.001), the rate of nonunion was lower (χ 2 = 6.030, p = 0.03), the anatomical reduction rate was higher (χ 2 = 5.449, p = 0.03), and the Harris hip score was higher (z = -2.99, p = 0.003) in the cerclage group, all with statistically significant differences. Intramedullary nailing combined with cable cerclage wiring is a safe and reliable technique for the treatment of irreducible subtrochanteric fractures. This technique can improve the reduction effect, increase the stability of fracture fixation, shorten the fracture union time, reduce the occurrence of nonunion, and contribute to the recovery of hip joint function. [ABSTRACT FROM AUTHOR]

Abstract Background Osteosynthesis using antegrade intramedullary nailing for humeral shaft fractures yields satisfactory bone union rates; however, it may adversely affect postoperative shoulder function. To date, factors affecting mid- or long-term shoulder functional outcomes following intramedullary nail fixation have not been clarified. In this study, we aimed to identify the risk factors for poor mid-term functional outcomes over 5 years postoperatively following antegrade intramedullary nail osteosynthesis for humeral shaft fractures. Methods We retrospectively identified 33 patients who underwent surgery using an antegrade intramedullary nail for acute traumatic humeral shaft fractures and were followed up for at least 5 years postoperatively. We divided the patients into clinical failure and no clinical failure groups using an age- and sex-adjusted Constant score of 55 at the final follow-up as the cutoff value. We compared preoperative, perioperative, and postoperative factors between the two groups. Results Five of the 33 patients had poor shoulder functional outcomes (adjusted Constant score

Objective To explore the effect of extended InterTAN intramedullary nail internal fixation in the treatment of elderly femoral intertrochanteric fractures and its influence on hip function and incidence rates of complications. Methods A total of 138 patients with femoral intertrochanteric fractures aged≥60 years admitted to Orthopedics Department of Anhui Medical University Affiliated Hefei Hospital from April 2019 to May 2022 were included. According to the different intramedullary nails during surgery, the patients were divided into short nail group (n=70, standard InterTAN intramedullary nail) and long nail group (n=68, extended InterTAN intramedullary nail). The perioperative conditions (intraoperative blood loss, surgical time, ambulation time, fracture healing time and the rate of internal fixation failure), complications, visual anologue scale (VAS) scores at 1 day, 3 days, 1 month and 3 months after surgery were compared between the two groups. The patients were followed up for 6 months, and Harris scores were compared between the two groups before surgery and at 3 months and 6 months after surgery. Results Compared with short nail group, intraoperative blood loss was more ［(266.15±52.73) mL vs (243.29±46.13) mL, t=2.71, P=0.01］ and surgery time was longer ［(84.21±14.54) min vs (72.57±13.08) min, t=4.95, P＜0.01］ in long nail group (P＜0.05), but the ambulation time ［(9.32±1.74)d vs (11.50±1.67) d, t=7.51, P＜0.01］ and fracture healing time ［(3.36±1.24) months vs (3.85±1.26)months, t=2.30, P=0.02］ were significantly shorter (P＜0.05). There was no statistically significant difference in internal fixation failure rate and incidence of postoperative complications between two groups (P＞0.05). VAS scores of the two groups was gradually decreased, and the difference was significant at different time points within the groups (P＜0.05). VAS scores in long nail group at 1 day, 3 days, 1 month and 3 months after surgery were significantly lower than those in short nail group (P＜0.05). The Harris scores revealed a statistical difference from the aspects of between-group, time-point and interaction (P＜0.05). The Harris scores in the two groups showed an upward trend, and there was a significant difference at various time points (P＜0.05), and the Harris scores in long nail group at 3 months and 6 months after surgery were significantly higher than those in short nail group (P＜0.05). Conclusion Both standard and extended InterTAN intramedullary nail internal fixation can effectively treat elderly femoral intertrochanteric fractures, but extended InterTAN intramedullary nail has faster healed, milder postoperative pain and better hip function recovery.

Aims: Proximal femur fractures treatment can involve anterograde nailing with a single or double cephalic screw. An undesirable failure for this fixation is screw cut-out. In a single-screw nail, a tip-apex distance (TAD) greater than 25 mm has been associated with an increased risk of cut-out. The aim of the study was to examine the role of TAD as a risk factor in a cephalic double-screw nail. Methods: A retrospective study was conducted on 112 patients treated for intertrochanteric femur fracture with a double proximal screw nail (Endovis BA2; EBA2) from January to September 2021. The analyzed variables were age, sex, BMI, comorbidities, fracture type, side, time of surgery, quality of reduction, pre-existing therapy with bisphosphonate for osteoporosis, screw placement in two different views, and TAD. The last follow-up was at 12 months. Logistic regression was used to study the potential factors of screw cut-out, and receiver operating characteristic curve to identify the threshold value. Results: A total of 98 of the 112 patients met the inclusion criteria. Overall, 65 patients were female (66.3%), the mean age was 83.23 years (SD 7.07), and the mean follow-up was 378 days (SD 36). Cut-out was observed in five patients (5.10%). The variables identified by univariate analysis with p < 0.05 were included in the multivariate logistic regression model were screw placement and TAD. The TAD was significant with an odds ratio (OR) 5.03 (p = 0.012) as the screw placement with an OR 4.35 (p = 0.043) in the anteroposterior view, and OR 10.61 (p = 0.037) in the lateral view. The TAD threshold value identified was 29.50 mm. Conclusion: Our study confirmed the risk factors for cut-out in the double-screw nail are comparable to those in the single screw. We found a TAD value of 29.50 mm to be associated with a risk of cut-out in double-screw nails, when good fracture reduction is granted. This value is higher than the one reported with single-screw nails. Therefore, we suggest the role of TAD should be reconsidered in well-reduced fractures treated with double-screw intramedullary nail. Cite this article: Bone Jt Open 2024;5(6):457–463.

Introduction: Anterior knee pain (AKP) is a common complaint following intramedullary nail (IMN) insertion for tibial shaft fractures. There is a lack of long-term patient reported outcome data following tibial IMN, with conflicting evidence of the role of nail protrusion on AKP. In this study, we assess the long-term patient reported outcome measures and kneeling function in patients with tibial IMNs and compare the results with IMN protrusion, measured radiologically. Materials and methods: A retrospective cohort of 128 patients, from a single UK centre, were invited to participate in the study, to complete a Kujala score, KOOS, EQ-5D-5L and a four-posture kneeling assessment. We report the outcomes of 45 patients at an average follow-up of 6.9 years. Results: The mean Kujala score was 80.7. The mean KOOS score was 83.2, 83.9, 85.8, 70.7 and 72.8 for symptoms, pain, daily living, sport and quality of life, respectively. We found 20.5% of patients experienced daily AKP. Pain and fear of pain were the most common limiting factors in the kneeling assessment. No significant correlation was found between the KOOS or Kujala score and nail-plateau distance, nail-anterior cortex distance, or the overall nail prominence. Conclusion: AKP affects a subset of patients more than five years post-tibial IMN, limiting their ability to kneel and other functions of daily living. Tibial IMN prominence does not seem to be associated with AKP. [ABSTRACT FROM AUTHOR]

Background Context: This study's purpose was to evaluate the biomechanical performance of plate–nail and dual-plate fixation for the treatment of AO/OTA 41-C2 tibial plateau fractures. Methods: Twenty synthetic tibias were selected and randomly divided into a plate–nail group (n = 10) and a dual-plate group (n = 10). After the artificial tibias were osteotomized to simulate AO/OTA 41-C2 tibial plateau fractures in both groups, the plate–nail and the dual-plate methods, respectively, were used for fixation, and then axial compression loading, three-point bending, torsion, and axial failure tests were carried out. The data of each group were recorded and statistically analyzed. Results: In the axial compression test, the average stiffness of the plate–nail group was higher than that of the dual-plate group (p < 0.05). The displacement generated in the plate–nail group was significantly smaller than that in the dual-plate group (p < 0.05). In the resisting varus test, the stress of the plate–nail group was significantly higher than that of the dual-plate group (p < 0.05). In the resisting valgus test, the stress of the plate–nail group was slightly higher than that of the dual-plate group, but the difference was not statistically significant (p > 0.05). In the static torsion test, the load applied to the plate–nail group was smaller than that of the dual-plate group when rotated to 5° (p < 0.05). In the axial compression failure test, the average ultimate load of the plate–nail group was significantly higher than that of the dual-plate group (p < 0.05). Conclusion: The treatment of AO/OTA 41-C2 tibial plateau fractures with plate–nail fixation is superior to that with dual-plate fixation in resisting axial stress and preventing tibial varus deformity, while dual-plate fixation has better resisting torsional ability. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study was to analyze the ratio of fracture site diameter to tibial isthmus diameter (TFI ratio) as a predictor of postoperative complications, including malunion and delayed union, after tibial intramedullary nailing for middle and lower tibial fractures. Methods: Data were collected from all adult patients older than 20 years of age who underwent tibial intramedullary nailing for middle and lower tibial fractures between January 2015 and January 2023 and were followed up for at least 1 year. Diabetes history, smoking history, fracture type, injury mechanism, surgical method, surgical approach, diameter of the medullary cavity at the fracture site, and diameter of the tibial isthmus were recorded. Logistic regression analysis was used to determine the variables affecting the occurrence of complications. The TFI ratio was used to calculate the sensitivity and specificity of the parameters, and ROC curves were generated to establish TFI ratio thresholds for predicting complications. Results: A total of 123 patients with middle and lower tibial fractures were treated with intramedullary nails. The mean age of the patients was 43.72 years (range, 21–81 years); 89 were males, and 34 were females. Univariate logistic regression analysis showed that fracture type, open reduction surgery, superior patellar approach, and TFI ratio were significantly correlated with postoperative complications after intramedullary nailing of a tibial fracture. Multivariate logistic regression analysis showed that the TFI ratio was an independent risk factor for complications (P = 0.001*). By using the TFI ratio as a predictor of complications, an ROC curve was generated to establish a threshold. The ROC curve showed that a TFI ratio ≥ 1.31 had a sensitivity of 0.89, a specificity of 0.71, and an area under the ROC curve of 0.82 for predicting complications. Conclusions: The results of this study suggest that a wider intramedullary diameter and a shorter fixed length at the fracture site are associated with a higher incidence of complications after tibial intramedullary nailing. The TFI ratio may be used as a reliable parameter for predicting complications after such surgery. In patients with a high TFI ratio (≥ 1.31), additional reduction and fixation techniques may be needed to obtain and maintain fracture reduction. [ABSTRACT FROM AUTHOR]

BACKGROUND: Intramedullary nails and locking plates are widely used in the treatment of proximal humeral fractures, but there is no consensus on the choice of internal fixation. OBJECTIVE: To compare the biomechanical stability of intramedullary nails and locking plates in the treatment of two-part and three-part proximal humeral fractures by finite element analysis. METHODS: CT data of the humerus of a volunteer were collected and imported into Minics 21.0, Geomagic Wrap, Soildwork 2017, and Abaqus 2021 to establish finite element models of two-part and three-part fractures treated with two internal fixation methods, respectively. Group A: two-part fracture fixed with intramedullary nail model; group B: two-part fracture fixed with locking plate model; group C: three-part fracture fixed with intramedullary nail model; group D: three-part fracture fixed with locking plate model. The stress distribution, displacement degree, and maximum value of the humerus and internal fixation were compared and analyzed. RESULTS AND CONCLUSION: (1) The maximum stress and maximum displacement of the humerus were the smallest in the model of group A, and the maximum stress and maximum displacement of the humerus were the largest in the model of group D. The stress of the locking plate group was mainly concentrated in the medial inferior part of the humeral head and the screw hole area, while the stress of the intramedullary nail group was mainly concentrated around the fracture line and the lateral inferior part of the surgical neck of the humerus. There is no significant difference in displacement distribution between the two. It is mainly concentrated in the distal humerus. (2) The maximum stress value of the intramedullary nail was the lowest in the model of group A, and the maximum stress value of the locking plate was the highest in the model of group D. The maximum stress of the two internal fixations was mainly concentrated in the talar screw and the connection with the internal fixation. The stress cloud distribution of the locking steel plate was concentrated, while the stress cloud distribution of the intramedullary nail was more uniform. (3) The results showed that compared with the locking plate, the intramedullary nail had more biomechanical advantages, and this advantage was more obvious in three-part fractures. [ABSTRACT FROM AUTHOR]

Objective To compare the efficacy of triangular anchor reduction forceps and towel forceps in the treatment of long oblique or spiral distal tibial fractures. Methods The data of 58 patients admitted to the Department of Traumatic Orthopaedics in Second Affiliated Hospital of Anhui Medical University from June 2019 to March 2021 were analyzed prospectively. According to the reduction methods during operation, they were divided into point reduction forceps group (n = 26) and triangle anchor reduction forceps group (n = 32) . The operation time, intraoperative fluoroscopy times, intraoperative blood loss, postoperative fracture reduction quality, hospital stay, fracture healing time, American orthopedic foot and ankle society (AOFAS) score, curative effect and complications at the last follow-up were compared between the two groups. Results All patients participated in the follow-up for more than one year. There was no significant difference in age, sex, basic diseases and injury mechanism between the two groups. The operation time and fluoroscopy times of patients in triangle anchor reduction group were significantly lower than those in point reduction forceps group (P < 0.05), while the quality of fracture reduction was higher than that in point reduction forceps group (P < 0.05), and there was no significant difference in other perioperative indexes. The fracture healing time of patients in triangle anchor reduction group was shorter, and the ankle joint function was better than that in point reduction forceps group (P < 0.05) . There was no significant difference in the incidence of various complications between the two groups, but the overall incidence of complications in the triangle anchor reduction group was significantly lower (P < 0.05) . Conclusion Triangular anchor reduction forceps can improve the quality of fracture reduction, shorten the healing time of fracture, reduce the occurrence of complications, reduce the operation time and the number of fluoroscopy during operation, and there is no obvious increase in local infection. It is an effective and reliable reduction method. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To assess the fatigue and load-to-failure mechanical characteristics of an intramedullary nail with a threaded interference design (TID) in comparison to a commercially available veterinary angle-stable nail with a Morse taper bolt design (I-Loc) of an equivalent size. METHODS: 10 single interlocking screw/bolt constructs of TID and I-Loc implants were assembled using steel pipe segments and placed through 50,000 cycles of simulated, physiologic axial or torsional loading. Entry torque, postfatigue extraction torque, and 10th, 25,000th, and 50,000th cycle torsional toggle were assessed. Each construct was then loaded to failure in the same respective direction as fatigue testing. Four complete constructs of each design were then assessed using a synthetic bone analog with a 50-mm central defect via nondestructive torsional and axial loading followed by axial load to failure. RESULTS: All constructs were angle stable at all time points and withstood fatigue loading. Median insertional torque, extraction torque-to-insertion torque ratio, and torsional yield load were 33%, 33%, and 72.5% lower, respectively, for the TID interlocking screws. No differences in torsional peak load, torsional stiffness, axial yield load, axial stiffness, or axial peak load were identified. No differences in complete construct angle stability, torsional stiffness, axial peak load, axial stiffness, or axial yield load were identified. CLINICAL RELEVANCE: The TID had an inferior torsional yield load when compared to I-Loc implants but generated angle stability and sustained simulated physiologic fatigue loading. The TID may be a suitable mechanism for generating angle stability in interlocking nails. [ABSTRACT FROM AUTHOR]

Objective: To compare the clinical efficacy of the minimally invasive locking plate technique (Philos plate) and interlocking intramedullary nailing technique (TRIGEN intramedullary nail) in the treatment of Neer two-part and three-part proximal humeral fractures. Methods and materials: The clinical data of 60 patients with Neer two-part and three-part proximal humerus fractures admitted to the hospital from April 2017 to April 2021 were retrospectively analyzed. Thirty-two patients were treated with the minimally invasive locking plate technique (minimally invasive plate group), and 28 patients were treated with the interlocking intramedullary nailing technique (intramedullary nail group). The operation time, intraoperative blood loss, incision length, fracture healing time, and postoperative complications were compared between the two groups. The ASES score and Constant–Murley score were used to evaluate the shoulder joint function of the two groups one year after surgery. Results: All 60 patients were followed up for 12 to 24 months, with an average of 16 months. There was no significant difference in operation time, intraoperative blood loss, incision length, or fracture healing time between the two groups (P > 0.05). The incidence of postoperative complications in the intramedullary nail group was significantly lower than that in the minimally invasive steel plate group, and the difference between the groups was statistically significant (P < 0.05). There was no significant difference in the ASES score or Constant–Murley score between the two groups one year after surgery (P > 0.05). Conclusion: The use of the minimally invasive locking plate technique and interlocking intramedullary nailing technique in the treatment of Neer two-part and three-part proximal humerus fractures has the advantages of a small incision, less blood loss, and a high fracture healing rate, and both can achieve satisfactory clinical effects. The internal nail technique is more convenient than the minimally invasive locking plate technique in controlling postoperative complications. [ABSTRACT FROM AUTHOR]

Purpose: We aimed to report the early results of performing acute ankle arthrodesis using a modified retrograde femoral intramedullary locking IMN concomitant with plating at the same setting for managing diabetic patients' acute ankle fractures. Methods: We prospectively included patients who presented acutely with ankle fractures, where hemoglobin A1C (HbA1C) on admission was > 7%, and the Adelaide Fracture in the Diabetic Ankle (AFDA) algorithm score was 5 or above. All patients were treated by acute ankle arthrodesis using a modified retrograde femoral IMN combined with lateral plating. Functional assessment was reported according to a modified American Orthopaedic Foot and Ankle Society ankle hindfoot scale (AOFAS), and complications were documented. Results: Six patients had an average age of 55.7 years (37–65). The average HbA1C on admission was 7.9 (7.3–9), and the average AFDA score was 7.3 (6–8). The average operative time was 79.2 min (70–90). All patients, except for one, achieved union at the arthrodesis site after an average of 10.3 weeks (8–14). After an average last follow-up of 9 months (6–12), the average modified AOFAS was 73.2 (82 to 62); four patients had an excellent score and one good. Complications developed in two, one deep infection after 2 weeks treated by metal removal and Ilizarov, and the other patient developed a stress fracture at the tibial end of the nail, which was treated by open reduction and internal fixation using a plate and screws. Conclusion: Using a modified femoral IMN combined with lateral plating is a promising technique to achieve ankle arthrodesis in diabetic patients with acute ankle fractures with acceptable outcomes; however, further studies with larger numbers are needed. Level of evidence: IV [ABSTRACT FROM AUTHOR]

Bone fractures represent a common health problem, particularly in an increasingly aging population. Bioresorbable magnesium (Mg) alloy‐based implants offer promising alternatives to traditional metallic implants for the treatment of bone fractures because they eliminate the need for implant removal after healing. The Mg‐Y‐rare‐earth (RE)‐Zr alloy WE43, designed for orthopedic implants, has received European Conformity mark approval. However, currently, WE43 is not clinically used in certain countries possibly because of concerns related to RE metals. In this study, we investigated the use of a RE‐free alloy, namely, Mg‐Zn‐Zr alloy (ZK30), as an implant for bone fractures. Hydrofluoric acid (HF) treatment was performed to improve the corrosion resistance of ZK30. HF‐treated ZK30 (HF‐ZK30) exhibited lower corrosion rate and higher biocompatibility than those of WE43 in in vitro experiments. After implanting a rod of HF‐ZK30 into the fractured femoral bones of mice, HF‐ZK30 held the bones and healed the fracture without deformation. Treatment results of HF‐ZK30 were comparable to those of WE43, indicating the potential of HF‐ZK30 as a bioresorbable and safe implant for bone repair. [ABSTRACT FROM AUTHOR]

Objectives: (1) To describe our operative technique for femoral neck fractures using an intramedullary device with integrated compression screws. (2) Retrospective analysis of patients treated with intramedullary fixation with interlocking lag and compression screws for femoral neck fracture (3). To compare our results to published literature on more classic fixation techniques. Design: Single-center retrospective cohort. Setting: Level 1 trauma center. Patients/Participants: Thirty-eight patients with 39 femoral neck fractures were treated with internal fixation. Only patients treated with intramedullary fixation with integrated interlocking lag and compression screws were included; patients treated for femoral neck fractures with a sliding hip screw, screw fixation alone, or intramedullary devices without integrated interlocking screws were excluded. Our final cohort consisted of 19 patients (47% female) with an average age of 50 (27–82) who had 15 (79%) isolated femoral neck fractures and 4 (21%) femoral neck-shaft combined fractures. Intervention: Internal fixation with intramedullary fixation using interlocking lag and compression screws for femoral neck fracture. Outcome Measurements: Quality of reduction, radiographic healing, and radiographic assessment of nonunion/avascular necrosis (AVN). Results: Follow-up time was on average 50 months (range: 34–84), with a median of 50 months (interquartile range: 42–56). Nineteen patients (100%) had successful healing without further intervention. There were no nonunions, and 2 (10%) patients developed AVN leading to conversion to total hip arthroplasty. Conclusion: Femoral neck fractures are challenging to manage due to their intracapsular location and the tenuous blood supply to the femoral head. The use of intramedullary devices with integrated lag and compression screws is an effective method for the operative fixation of femoral neck fractures. Level of evidence: Level IV therapeutic. [ABSTRACT FROM AUTHOR]