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Background Fractures of the humerus are one of the more common fractures in the United States and a cause of fragility fractures in the elderly population. This study aims to understand recent trends in the demographic factors correlated with humeral shaft fractures (HSF) and humeral shaft fracture nonunion (HSFN) following open reduction internal fixation (ORIF) and intramedullary nailing (IMN). Methods The TriNetX database was used to query using International Classification of Diseases-10 (ICD10) diagnosis codes for patients who sustained HSF between 2017 and 2022. Patients were then organized into cohorts based on Current Procedural Terminology (CPT) codes 24515 and 24516 for ORIF and IMN of HSFs, respectively. Subsequent nonunion after operative management was queried. Descriptive and comparative analysis was performed to examine the differences observed between patients based on age, sex, ethnicity, race, and smoking status as well as surgical management across the six-year study period. Results The incidence of HSF increased from 7,108 in 2017 to 8,450 in 2022. The rate of HSF ORIF increased from 12% to 17% while the nonunion rate following ORIF decreased from 4% to 3%. The rate of HSF IMN increased from 4% to 6% and the rate of nonunion following IMN increased from 2% to 4%. The overall rate of HSFN surgery was 1.7% with slight decreasing trend over the past year. Conclusion It is speculated that improved care and surgical indications resulted in a lower rate of nonunion despite an increase in the overall rate of HSF and its operative managements.

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Introduction: Fibrous dysplasia (FD) is a skeletal developmental abnormality commonly affecting the ribs, femur, tibia, skull, pelvis, spine, and shoulder. FD of the proximal radius is extremely rare and very few cases have been reported. In addition, monostotic lesions of FD in the upper extremity go unnoticed as they are usually asymptomatic. Symptomatic lesions warrant surgical intervention. Here, we present a rare case of FD of the proximal radius treated with curettage and non-vascularized fibular cortical strut graft with intramedullary elastic nailing. We believe that this is the first report in the literature wherein this treatment modality has been undertaken. Case Report: A 27-year-old woman presented with excruciating pain and swelling in her right elbow for 4 weeks, with no inciting event or trauma leading to the pain. Plain radiographs revealed a well-circumscribed radiolucent lesion in the proximal radius with cortical thinning at the metaphysis and a rim of epiphyseal bone. Clinically, the patient had restricted supination (50°) and limited elbow range of motion (ROM) (20-130°), mostly because of the pain but had full pronation. With these radiographic and clinical features, FD and giant cell tumor were kept as differential diagnoses and surgical treatment was planned. The lesion was excised leaving the normal epiphysis of the radius intact and samples were sent for histopathological examination. A non-vascularized fibular cortical strut graft was harvested from the same side and was fluted into the radial shaft. Final stabilization was done using a 2.5 mm intramedullary elastic nail. The arm was immobilized in an above-elbow slab. Histopathology confirmed our diagnosis of FD. The slab was removed after 6 weeks, and a gentle ROM was started in the form of active-assisted ROM. At the end of 1 year, complete union and almost full ROM were achieved and the patient was completely pain-free. Conclusion: Non-vascularized fibular strut grafting with intramedullary nailing provides a comparatively quicker, cost-effective way of treating this lesion with a minimum insult of the bony cortex and quicker rehabilitation.

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Introduction: Compartment syndrome as a complication during intramedullary nailing of closed tibia fractures was first documented as early as 1980. Case Report: We report a case of a 19-year-old young man victim of a road accident (motorcycle accident) causing an uncomplicated closed fracture of 2 bones of the left leg. The patient underwent centromedullary nailing of the tibia. The evolution was marked by the early onset of an acute and serious compartment syndrome. Conclusion: The first symptom of compartment syndrome is pain regardless of the severity of the trauma. The diagnosis is clinical and is generally confirmed by measuring the pressure in the muscle compartment. The treatment is fasciotomy.

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Introduction: There have been very few cases of intramedullary (IM) nailing for tibia shaft fracture using a humerus nail. We present to you a unique case of humerus nail used in tibia shaft fracture in a short-stature patient. Case Report: A 26-year-old female, was brought to our emergency room, she sustained trauma to her left leg while she was walking on the road hit by an automobile (pedestrian injury) with complaints of pain and swelling in her left leg. She has a family history of short stature. X-ray suggested of left tibia diaphyseal fracture with a left calcaneum fracture (undisplaced). Preoperatively, tibia length came out to be 22 cm. The shortest tibia nail available is 26 cm. Hence, the plan was to do IM humerus nailing. Closed reduction with internal fixation was done with a similar method as in tibia nailing. Titanium nail of size 8 mm × 22 cm was used. In the humerus nail, the bend is lateral, which was kept posteriorly as Herzog bends in the tibia nail. Postoperatively, patient was given below knee slab with nil weight bearing for 6 weeks. Conclusion: Use of IM humerus nailing in tibia diaphyseal fracture fixation is possible. It provides rotational stability, leg length control, early mobilization and is also available in smaller sizes. Tibial fracture fixation with humeral nails in patients with short limb lengths is one of the possible options with satisfactory outcomes.

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Introduction In the UK, hip fractures are a common reason for presentations to the emergency departments, which places significant pressure on NHS hospitals, appropriate choice of an implant to treat the hip fracture is one among many other factors that affect patients' outcomes. This audit aims to identify and compare the outcome difference between the dynamic hip screws (DHS) and short cephalomedullary nails in the treatment of extracapsular hip fractures. Methods In a retrospective study of 52 patients admitted as a result of hip fractures in one NHS trust, data collection was done from the patients' records using the trust's online system, we studied different variables to compare the outcome difference between DHS and short intramedullary (IM) nails, two senior authors interpreted the patients' X-rays and verified the coding and classification of the neck of femur fractures. Results This retrospective study examined 52 extracapsular hip fracture cases, including 37 females and 15 males. Forty-six (88%) of the included patients were ASA 3 and 4 (American Society of Anesthesiologists), and the average days to discharge from therapies were 8.4 (SD-+ 4) days compared to 11 (SD-+ 5.2) days for short IM nails and DHS, respectively (P= 0.03), the 30-day mortality rate for short nails was 7% (n= 4/52) patients and 6% (n= 3/52) for DHS (P =0.69). The mean operating times for the different implants were 58.11 (SD-+ 15.1) minutes for DHS and 58.03 (SD-+ 23.2) minutes for the short nail (P =0.98). Compliance with the national guidelines for providing an appropriate operation to treat hip fractures initially went from 63% (n=33/52) initially to 73% (n=38/52). This means that more patients who are appropriate for nailing are being treated with IM nails. Conclusion Short IM nails are associated with faster hospital discharge; this fact may be reflecting the lower postoperative pain as a result of avoiding soft tissue dissection associated with extramedullary devices. keeping in mind that IM devices have mechanical advantages over sliding hip screws; hence, they are more commonly used for more complex fracture patterns, leading to nearly similar outcomes when compared to extramedullary devices, this can be a source of bias in retrospective studies, larger randomized trials may lead to different outcomes.

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A significant amount of all paediatric fractures are forearm fractures involving the radius, ulnar shaft, or both. As surgical stabilisation lowers the likelihood of re-displacement, surgical intervention is currently recommended over conservative treatment of such fractures involving significant displacement and angulation. Open reduction and plating can better anatomically repair the majority of fractures. Bracing is necessary for the first six to eight weeks after nailing since nailing does not give a rigid fixation. External bracing is generally not necessary for plating. In our facility, paediatric diaphyseal forearm fractures are typically treated using titanium elastic nail system (TENS) nailing. However, there are occasional instances where the primary fracture site refractures after surgery, particularly in diaphyseal forearm fractures involving both bones. Our patient was a 12-year-old boy who had come to our facility with a left forearm radius shaft fracture and ulna shaft plastic deformation. The radius shaft fracture was fixed with TENS nailing, and the ulna shaft plastic deformation was corrected by the three-point bending method. Three months later, the patient came back with a refracture of the radius shaft. TENS nail removal, open reduction, and internal fixation of the radius shaft refracture were done with a plate and screws. Anatomic reduction of forearm fractures, open reduction, and the use of plate fixation enable a more thorough correction of malrotation and restoration of the radial bow, allowing for an early range of motion. Since the TENS nail is not a locking device, there is always some amount of mobility at the fracture site, causing loss of reduction, chances of implant failure, and non-union. So primary plating, especially in cases of forearm fractures, appears to be a better option compared to primary TENS nailing in juvenile patients.

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BACKGROUND: A persistent fracture gap following femoral nailing increases the risk of delayed and nonunion development. A forward-striking technique for reducing the gap in femoral nailing has been described, but its efficacy and therapeutic consequences have not been investigated in comparative studies. We provide the results of a comparative study that investigated the forward-striking technique's efficacy in terms of remaining fracture gaps and surgical outcomes. METHODS: Between 2017 and 2022, a retrospective cohort study was undertaken on 193 skeletal mature patients obtaining reamed femoral nailing for closed femoral shaft fractures. Comparisons of residual fracture gaps, timing to union, complications and re-operation rates were made between 80 patients (41.45%) undergoing femoral nailing with the forward striking procedure and 113 patients (58.55%) undergoing traditional nailing, accompanied by minimal 1-year follow-ups. In addition, the potential difference between fracture gaps before and after applying the forward striking procedure was compared. RESULTS: Both groups had similar age, sex, presence of diabetes, smoking status, body mass index and time to surgery. However, the forward-striking group demonstrated significantly lower rates of postoperative complications, including delayed, nonunion, and the need for re-operation. Conversely, no significant differences were found in time to union (p = 0.222). The forward-striking procedure can significantly reduce residual fracture gaps from 3.99 to 1.66 mm (p < 0.001). No major complications in the forward-striking group including nonunion were observed. CONCLUSION: This study suggests that the forward-striking technique effectively reduces residual fracture gap during femoral nailing. The technique not only could be easily performed but is also reproducible. In addition, it can lower the risk of delayed union, nonunion and obviates the necessity for re-operation. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

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Background: The study aimed to assess functional and radiological outcomes of the suprapatellar approach (SPA) and infrapatellar approaches (IPA) of tibial nailing in patients with closed tibia shaft fractures. Method: After Institutional Ethical Committee (IEC) and Clinical Trials Registry- India (CTRI) approval, patients with Orthopaedic Trauma Association (OTA) fracture type 42 were enrolled from August 2021 and August 2022 at a level I trauma centre and randomized to SPA and IPA with informed consent. Demographics, American Society of Anaesthesiologists (ASA) physical grading, intraoperative fluoroscopy time, operative duration, bleeding, postoperative radiographic alignment, and union were compared among both approaches. Functional parameters like Lysholm knee score, Anterior knee pain (AKP), Visual Analog Scale (VAS) Score upon kneeling, Knee Injury and Osteoarthritis outcome score (KOOS), KOOS Patellofemoral score (KOOS PF), EuroQol (EQ5D5L), Forgotten joint score (FJS), Range of motion (ROM) of knee and any complications were assessed at 3,6 and 12 months postoperatively. Results: Per protocol analysis of 50 patients (25 SPA, 25 IPA) done at the end of the study. SPA group had significantly lesser fluoroscopy time (91.28 ± 12.40s vs. 105.36 ± 9.23s, p < 0.001) and operative duration (mins) (123.80 ± 24.25 vs. 130.00 ± 18.20, p < 0.001) than IPA. No significant differences were noted in Lysholm knee score at three months (p = 0.094), six months (p = 0.406), and 12 months (p = 0.071). The SPA group showed significantly lower VAS Score upon kneeling at six months (p < 0.0001). Similarly, KOOS (p < 0.001), KOOS PF (p = 0.01), and EQ 5D5L (p = 0.03) were significantly better in the SPA group at six months postoperatively. Lower Coronal translation was found in SPA [0 (0-1.8) vs. 1.4 (0.9-1.8), p = 0.010]. Whereas, IPA had higher range of flexion at 3 months [130.0 (129.0-135.0) vs 123.1 (120.0-130.5), p = 0.047]. However, no significant differences were noted in blood loss, AKP, FJS, EQ-VAS, coronal angulation, sagittal malalignment, time to union, return to work and postoperative complications among the groups. Conclusion: SPA has lesser surgery time, more straightforward anatomic fracture reduction, better fracture alignment, lesser radiation exposure for both patients and surgeons, quicker recovery time, and promotes early kneeling activities with similar long-term functional outcomes and union rates, and can be considered in routine clinical practice than conventional IPA.

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Pediatric forearm fractures, particularly involving the shaft or diaphysis, are common injuries typically resulting from accidental trauma during various activities. Traditional treatment involves closed reduction and casting; however, surgical intervention may be necessary in certain cases. The gold standard surgical approach utilizes elastic stable intramedullary nailing (ESIN), but a newer technique uses bioabsorbable intramedullary nails made of poly(lactic-co-glycolic acid) (PLGA). This study aims to compare the outcomes of these two surgical methods in pediatric diaphyseal forearm fractures. We retrospectively reviewed 86 patients who underwent operative treatment due to the diaphyseal fractures of the forearm in the Surgical Division, Department of Pediatrics, Medical School, University of Pécs, Pécs, Hungary between 2018 and September 2022. The mean age was 9.48 (ranging from 4 to 17). A total of 41 patients underwent surgery with PLGA implants (RESIN technique), while 45 patients were treated with titanium elastic nails (ESIN technique). Various factors including patient demographics, injury mechanisms, fracture characteristics, and complications were assessed. Both groups showed similar gender distribution, with a majority of fractures occurring in boys (the male-female ratio was 31:10 in the PLGA group, while in the titanium elastic nailing (TEN) group, this ratio was 29:16, with no statistical difference between the groups (p > 0.005). The average age of the patients treated with PLGA implants (8.439 years) was lower compared to those treated with titanium nails (10.422 years). A statistically significant difference was found regarding the average age of the two groups (p = 0.0085). Left-sided injuries were more prevalent in both groups (59% of the cases in the PLGA group and 69% in the TEN group, with no statistically significant difference, p = 0.716), and fractures typically involved both the radius and ulna. This represents 93% of the cases in the PLGA group and 80% in the TEN group. Regarding the involvement of bones, we also did not find a statistically significant difference (p = 0.123). The mechanisms of injury predominantly involved indirect force, such as falls (30 cases in the PLGA group and 27 cases in the TEN group), and no statistically significant difference was found (p = 0.139) regarding the mechanism of the injury. Complication rates were lower in the PLGA group (7%) compared to the titanium group (20%). The treatment of pediatric diaphyseal forearm fractures using PLGA implants appears to be a viable alternative to traditional titanium implants. Advantages include no need for secondary surgery and associated cost savings and reduced complication rate and stress associated with anesthesia and surgery. Prospective randomized trials are warranted to further validate these findings and explore long-term outcomes.

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Intramedullary nailing insertion from the proximal-to-distal femur is frequently performed for impending and complete pathological femur fractures due to osteolytic metastases. After nailing through cancer-laden bone, residual chemotherapy- and/or radiation-resistant tumor may progress. Progression of osteolysis risks future nail failure or pathological fractures. This study assesses the incidence of cancer progression following intramedullary nailing in a femur-only cohort and describes a percutaneous rod-retaining salvage technique. A single-institution, retrospective study was conducted to identify adult patients who underwent intramedullary nailing for femoral osteolytic lesions for complete or impending nail failure from 2016 to 2023. Progression was defined as enlargement of the pre-existing lesion and/or appearance of new lesions on radiographs. Surgical outcomes were assessed with a combined pain and functional score. A total of 113 patients (median age 66.8 years (IQR = 16.4); median follow-up 6.0 months (IQR = 14.5)) underwent intramedullary nailing. Sixteen patients (14.2%) exhibited post-nailing cancer progression. Pre- and postoperative radiation and chemotherapy did not decrease the odds of cancer progression. Three patients underwent initial open surgical salvage consisting of proximal femur replacement arthroplasty, and six patients did not receive salvage due to poor surgical candidacy or patient choice. Seven patients (median follow-up 10.7 months (IQR = 12.9)) received percutaneous salvage. In this group, pain and functional scores improved by 4.0 points (p = 0.0078) at two-week postoperative follow-up and 2.0 points (p = 0.0312) at the most recent follow-up (mean follow-up 13.0 ± 9.4 months). All three nonambulatory patients became ambulatory, and six patients were able to ambulate independently without walking aids. No major complications were reported 30 days postoperatively. Progression of femoral osteolytic metastases may occur following intramedullary nailing. Continued monitoring of the entire femur is needed to maintain improved functional status and to prevent catastrophic progression of pre-existing lesions or appearance of new lesions. In patients with more proximal metastases only, the customary practice of bringing a long nail from the proximal femur to distal metaphysis should be reconsidered. Furthermore, there is concern of mechanical transport of cancer cells during guide wire insertion, reaming, and rod insertion through cancer laden bone to cancer free distal bone.

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Background: The incidence of proximal humerus fractures (PHFs) continues to increase with an aging population, and intramedullary nailing (IMN) and locking plate fixation are two commonly employed techniques for the surgical management of PHF. However, the optimal fixation method can be a source of ongoing controversy. Some influencing factors include the extent of humeral head involvement, fracture complexity, patient age, and surgeon preference. There are many studies that provide a mix of data either when comparing the two techniques or analyzing them in isolation. The aim of this review is to further elucidate the indications and technical considerations involved specifically in IMN vs. locking plate fixation for PHF to further aid orthopedic surgeons when choosing surgical management. Methods: A narrative approach was chosen for this review allowing for a comprehensive review of literature, including recent findings pertaining to the comparison of management options for PHF. A comprehensive literature search was conducted using the PubMed, Embase, and Cochrane Library databases. The inclusion criteria involved studies that discussed "proximal humerus fracture" and either "intramedullary nail" or "locking plate fixation." Results: Complications such as avascular necrosis, hardware failure, additional surgical interventions, infection, fracture redisplacement, rotator cuff rupture, and nonunion did not show significant differences between the two groups. Newer generation humeral nails have minimized early complications. As both techniques undergo further refinement and utilization when specifically indicated, functional outcomes, potential complications, and postoperative pain continue to be improved. Conclusion: The available evidence suggests that both intramedullary nails and locking plates can effectively restore shoulder function in the treatment of displaced proximal humeral fractures, with unclear superiority of either method. The choice of technique should be tailored to patient factors such as fracture type, age, bone quality, and functional expectations. Surgeon experience also plays a role. While certain presentations may exhibit trends that favor one fixation, no specific technique can be universally recommended. Both IMN and LP have shown comparable and satisfactory outcomes, and the final fixation method chosen should take into account the unique characteristics of each patient.

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INTRODUCTION: Non-operative treatment (NOT) of proximal humerus fractures (PHF) has regained significance due to recent evidence. Additionally, positive outcomes of plate osteosynthesis and fracture arthroplasty prompt a reassessment of the role of intramedullary nailing (IMN). While favorable short and medium-term results have been documented following IMN, little is known regarding functional outcomes and quality of life in the long-term. METHODS: Data from 180 patients with dislocated PHF of Neer types III, IV and V, treated at our level-I trauma center between 2004 and 2014 using IMN or NOT therapy, were scanned. Patients were re-evaluated after a minimum of 5 years to assess functional outcomes (age- and sex-adapted Constant Score, QuickDASH), quality of life (SF12), and complications or reoperations. RESULTS: Out of the initially identified 180 patients, 51 were unavailable for follow-up (FU) and 71 had deceased during the FU period. Functional outcomes and quality of life was, therefore, assessed in 58 patients (30 IMN, 28 NOT) with an average age at injury of 68 years after a mean FU time of 10.3 ± 3.4 years. Epidemiological patient characteristics did not exhibit significant differences between the two groups (p > .05). The functional outcome assessed by age- and sex-adapted Constant Score (NOT: 74 ± 28; IMN: 68 ± 24; p = .438), QuickDASH (NOT: 25 ± 27; IMN: 31 ± 23; p = .374) or quality of life using the SF12 (p > .05) revealed no significant disparities in long-term outcomes between the treatment groups. 10 of 30 patients in the IMN group underwent surgical revision to address complications, exceeding mere implant removal. Conversely, no patient in the NOT group underwent a revision surgery during the FU period. CONCLUSIONS: In the long-term, functional and quality of life-related outcomes of IMN did not diverge significantly from those of NOT, while causing a higher incidence of follow-up interventions.

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Introduction: A minority of geriatric hip fracture patients pursue non-operative treatment. Compared with surgical patients, non-operative patients have higher mortality rates. However, patient satisfaction following non-operative vs operative treatment has not been investigated extensively. The purpose of this study was to compare satisfaction among non-operatively vs operatively treated hip fracture patients. Methods: We identified patients aged 60+ years with proximal femur fractures treated over a 10-year period. Excluded were patients with isolated greater/lesser trochanteric fractures. Patients or relatives were asked to complete a 6-question survey about their treatment satisfaction. Results: Survey responses from 56 operative and 28 non-operative patients were recorded. Overall, 91.1% of operative and 82.1% of non-operative patients were satisfied with their treatment course (P = 0.260). However, only 71.4% of non-operative patients were satisfied with treatment option explanations vs 83.9% of operative patients (P = 0.014). While only 64.3% of non-operative respondents were satisfied with the ultimate treatment outcome (vs 85.7% of operative patients, P = 0.025), 89.3% of patients in each cohort would choose the same treatment plan again. Discussion: Our findings highlight the complexity of defining patient satisfaction, particularly in a geriatric hip fracture population. Unlike previous studies, we chose a direct approach to quantifying patient satisfaction by asking participants specifically about satisfaction with treatment outcome and the overall treatment course. Additional survey questions were then included to assess factors considered important in treatment satisfaction, such as health care provider treatment explanations, post-treatment mobility, and palliative care service involvement. Conclusions: We identified significant differences between non-operatively and operatively treated geriatric hip fracture patients regarding satisfaction with the explanation of treatment options, and ultimate treatment outcomes. There was no significant difference in overall satisfaction with the treatment course or likelihood of choosing the same treatment again. Further research investigating patient satisfaction following geriatric hip fracture treatment is warranted.

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INTRODUCTION: This is a retrospective cohort study designed to compare short-term postoperative complication rates between closed humeral shaft fractures treated by open reduction and internal fixation (ORIF) versus intramedullary nailing (IMN), as well as secondary independent risk factors for adverse outcomes. MATERIALS AND METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried using CPT codes to identify patients that underwent an open reduction and plate fixation or intramedullary nailing procedure for a closed humeral shaft fracture from 2010 to 2021. Cohorts were matched using propensity scores to account for demographic differences and rates of complications were compared between the two groups. RESULTS: From the database, a total of 4,222 patients were identified who met inclusion criteria, with 3,326 and 896 undergoing ORIF and IMN respectively. After propensity score matching, 866 of the nearest-neighbor matches were included in each cohort for a total of 1,732 patients in the final analysis. The rate of any adverse event (AAE) was significantly higher in the ORIF cohort (16.3%) than the IMN cohort (12.1%, p = 0.01). The ORIF group had higher rates of postoperative transfusion (p = 0.002), return to OR (p = 0.005), and surgical site infection (SSI, p = 0.03). After multivariate analysis, ASA class 4, increasing age, increasing operative time, and history of bleeding disorder were found to increase the risk of AAE in both ORIF and IMN patients. CONCLUSIONS: While prior studies have claimed higher complication rates in IMN patients, this study found a significantly higher short-term risk of AAE in ORIF patients when compared in matched cohorts. However, individual 30-day complication rates do not differ significantly between procedures, and both have been shown to be safe and effective tools in the management of humeral shaft fractures.

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OBJECTIVE: This study aims to investigate the effect of bone grafting on the bone union in exchange nailing (EN) for the treatment of femoral shaft nonunions. METHODS: A total of 26 patients (16 male) were included in this study. The mean age of the patients was 36.1±9.3. Bone grafts were used in 8 patients (bone graft group), and EN was performed without bone grafting (no bone graft group) in 18 patients. Etiology, fracture type, location, and classification of the fractures at the time of initial injury were evaluated. The reduction type (open or closed) and locking status of the nails were also noted. Nonunion types were recorded. In the bone grafting group, iliac bone autografts were used in seven patients and a synthetic bone graft was used in one patient. Following EN, the presence and duration of bone union, and the increase in the nails' diameter were analyzed for each group and compared. RESULTS: Union rates were 100% and 94.4% in bone grafting and no bone grafting groups, respectively. The mean union period was not significant between the groups (22.5 and 16.5 months, respectively). The mean increase in the nail diameter was 1.88 mm in the bone graft group and 2.00 mm in the no bone graft group (p>0.05). CONCLUSION: This study demonstrated that high union rates can be achieved with EN by means of using larger diameter nails with or without bone grafting in the management of femoral shaft nonunions, and bone grafting had no significant effect on union rates and periods.

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Introduction: Cut-out, a biomechanical complication, is one of the most common causes of internal fixation failure of trochanteric hip fractures. The tip-apex distance (TAD) and the calcar-referenced tip-apex distance (CalTAD) have been suggested as the radiographic parameters that most predict the risk of cut-out. The purpose of this study was to check whether these two factors could predict implant cut-out in a series 398 of intertrochanteric hip fractures, treated by dynamic intramedullary nailing with the Trigen Intertan short nail. Methods: We reviewed 398 consecutive intertrochanteric fractures included in a prospective study and treated in a single private hospital by the same surgeon. The radiographic parameters were obtained from anteroposterior (AP) and axial hip plain radiographs before surgery, immediately postoperatively, and every 3 weeks after surgery until 3 months postoperatively, and every month until the 6-month follow-up. The concept of medial cortex support (MCS) was also analyzed as a criterion for evaluating the quality of fracture reduction. Results: The overall cut-out rate was 2.3% (9/398). The significant parameters in the univariate analysis were AO fracture type, quality of fracture reduction (p = 0.02), TAD (p < 0.001), CalTAD (p = 0.001), and quality of reduction. No statistically significant relationships were observed between the occurrence of cut-out and sex, age, fracture side, and American Society of Anesthesiologists type. Varus collapse and cut-out were only found in cases of negative MCS (22.2% and 77.8%, respectively). Multivariate analysis showed that only TAD showed an independent significant relationship to cut-out (p < 0.001). In this study, CalTAD has no predictive value in the multivariable analysis. Conclusions: Our findings differed from those in previous reported studies suggesting that CalTAD is the best predictor of cut-out. According to our data, careful optimal reduction ensuring stable fixation with TAD >25 mm reduced the occurrence of cut-out after dynamic intramedullary nailing of intertrochanteric fractures.

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SUMMARY: The objective of this study was to compare and analyze the clinical efficacy of different approaches of intramedullary nailing with blocking screws for proximal tibial fractures. One hundred cases of proximal tibial fractures treated in the orthopedic department from April 2021 to September 2023 were included in the study and divided into control and treatment groups using a random number table. A control group (n=50) treated with infrapatellar intramedullary nailing with blocking screws, and a treatment group (n=50) treated with suprapatellar intramedullary nailing with blocking screws. We observed the excellent and good rates in both groups, compared various perioperative indicators, changes in joint range of motion (ROM), Visual Analog Scale (VAS) pain scores, Lysholm knee joint function scores, changes in inflammatory factors, and various bone markers before and after treatment, and analyzed postoperative complications. There were no significant differences in baseline data such as age, sex, body mass index, fracture site, concomitant fibular fractures, time from fracture to surgery, injury mechanism, and AO/OTA fracture classification between the two groups (P>0.05). The excellent and good rate in the treatment group after treatment was 90.00 % (45/50), significantly higher than 72.00 % (36/50) in the control group (P0.05). However, the treatment group had shorter surgical times and fewer fluoroscopy times than the control group (P<0.05). After treatment, both groups showed increased ROM and Lysholm scores, as well as decreased VAS scores. Moreover, compared to the control group, the treatment group had higher ROM and Lysholm scores and lower VAS scores (P<0.05). Inflammatory factors including interleukin-1β (IL-1β), C-reactive protein (CRP), tumor necrosis factor-α (TNF-α), osteocalcin (BGP), and calcitonin (CT) increased in both groups after treatment, while total n- terminal propeptide of type I procollagen (Total-PINP) and b-C-terminal telopeptide of type I collagen (β-CTX) decreased. Compared to the control group, the treatment group exhibited greater increases in inflammatory factors and lower levels of Total-PINP and β-CTX, but higher BGP and CT levels (P<0.05). The incidence of postoperative complications was 8.00 % (4/50) in the treatment group and 24.00 % (12/50) in the control group, with statistically significant differences (P=4.762, X2=0.029). In the treatment of proximal tibial fractures, intramedullary nailing with blocking screws using the suprapatellar approach achieves significant clinical efficacy. It reduces surgical time, minimizes radiation exposure to healthcare workers and patients, improves knee joint range of motion and function, decreases postoperative pain and complication rates, suppresses inflammatory reactions, and promotes the improvement of bone markers related to fracture healing.

El objetivo de este estudio fue comparar y analizar la eficacia clínica de diferentes abordajes de clavo intramedular con tornillos de bloqueo para las fracturas de tibia proximal. Se incluyeron en el estudio 100 casos de fracturas de tibia proximal tratados en el departamento de ortopedia desde abril de 2021 hasta septiembre de 2023 y se dividieron en grupos de control y de tratamiento mediante una tabla de números aleatorios. Un grupo control (n=50) tratado con clavo intramedular infrapatelar con tornillos de bloqueo, y un grupo tratamiento (n=50) tratado con clavo intramedular suprapatelar con tornillos de bloqueo. Observamos excelentes y buenas tasas en ambos grupos, comparamos varios indicadores perioperatorios, cambios en el rango de movimiento articular (ROM), puntuaciones de dolor en la escala visual analógica (EVA), puntuaciones de función Lysholm de la articulación de la rodilla , cambios en factores inflamatorios y varios marcadores óseos, antes y después del tratamiento, y se analizaron las complicaciones postoperatorias. No hubo diferencias significativas en los datos iniciales como edad, sexo, índice de masa corporal, sitio de fractura, fracturas de fíbula concomitantes, tiempo desde la fractura hasta la cirugía, mecanismo de lesión y clasificación de fractura AO/OTA entre los dos grupos (P>0,05). La tasa de excelente y buena en el grupo con tratamiento después del tratamiento fue del 90,00 % (45/50), significativamente mayor que el 72,00 % (36/50) en el grupo control (P0,05). Sin embargo, el grupo con tratamiento tuvo tiempos quirúrgicos más cortos y menos tiempos de fluoroscopía que el grupo control (P <0,05). Después del tratamiento, ambos grupos mostraron un aumento de las puntuaciones de ROM y Lysholm, así como una disminución de las puntuaciones de VAS. Además, en comparación con el grupo control, el grupo con tratamiento tuvo puntuaciones ROM y Lysholm más altas y puntuaciones EVA más bajas (P <0,05). Los factores inflamatorios que incluyen interleucina-1β (IL-1β), proteína C reactiva (CRP), factor de necrosis tumoral-α (TNF-α), osteocalcina (BGP) y calcitonina (CT) aumentaron en ambos grupos después del tratamiento, mientras que el total disminuyó el propéptido n-terminal del procolágeno tipo I (Total-PINP) y el telopéptido β-C-terminal del colágeno tipo I (β-CTX). En comparación con el grupo control, el grupo con tratamiento mostró mayores aumentos en los factores inflamatorios y niveles más bajos de Total-PINP y β-CTX, pero niveles más altos de BGP y CT (P <0,05). La incidencia de complicaciones postoperatorias fue del 8 % (4/50) en el grupo de tratamiento y del 24 % (12/50) en el grupo control, con diferencias estadísticamente significativas (P=4,762, X2=0,029). En el tratamiento de las fracturas de tibia proximal, el clavo intramedular con tornillos de bloqueo mediante el abordaje suprapatelar logra una eficacia clínica significativa. Reduce el tiempo quirúrgico, minimiza la exposición a la radiación de los trabajadores de la salud y los pacientes, mejora el rango de movimiento y la función de la articulación de la rodilla, disminuye el dolor postoperatorio y las tasas de complicaciones, suprime las reacciones inflamatorias y promueve la mejora de los marcadores óseos relacionados con la curación de las fracturas.

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BACKGROUND: Distal femur fractures remain treatment challenges with a considerable postoperative non-union rate. Concern remains that surgery may compromise osseous vascularity. This study aimed to determine effects of retrograde femoral intramedullary nailing (RFIN) on distal femur vascularity, and the locations of the middle genicular artery terminal branches in relation to the standard RFIN entry point. METHODS: Five lower limb cadaveric pairs were obtained (ten specimens). Experimental limbs were randomly assigned, and contralateral limbs served as controls. An 11 mm femoral nail was implanted in experimental specimens. Controls only underwent a medial parapatellar incision with capsulotomy. Quantitative pre- and post-contrast-MRI was performed to assess arterial contributions to distal femur regions. Osseous vascularity was further evaluated with contrast-CT imaging. Next, specimens were injected with latex medium, and dissection was performed to assess extraosseous vasculature. RESULTS: No statistically significant differences were found with quantitative-MRI in experimental and control groups for the entire distal femur or individual regions. The experimental group demonstrated a small mean decrease of 1.4% in distal femur arterial contributions. CT and anatomic dissection confirmed maintenance of middle genicular artery terminal branches. On average, 3.3 (±1.3) terminal branches entered along the posterior intercondylar notch. A mean distance of 15.2 mm (±6.9 mm) was found between the posterior RFIN entry point and these terminal branches. CONCLUSIONS: RFIN did not significantly alter arterial contributions to the distal femur or disrupt the middle genicular artery terminal branches. However, care must be taken to ensure nail entry point accuracy given proximity of the entry point to terminal branches.

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PURPOSE: To describe the methods and outcomes of reamed intramedullary nailing (IMN) of diaphyseal multifragmentary femur (AO/OTA C2 and C3) fractures (DMFFs) in a low-resource setting without fluoroscopy and fracture table. METHODS: The prospective study involved 35 DMFFs among 318 femur fractures treated ≤ 3 weeks post-injury with SIGN nails. The fractures were fixed without fluoroscopy, fracture table and power reaming. Closed, mini-open or open reduction was done. Anatomical length and alignment were ensured using a surgical support triangle during retrograde nailing, and by an assistant during antegrade nailing. Follow-ups were done at 6 weeks, 12 weeks and 6 months. RESULTS: DMFFs constituted 11.0% of the 318 fractures. Twenty-four (68.6%) were males. The mean age was 39.0 years (range 17-75 years). About 94.3% were injured in road traffic accidents. Fracture reduction was closed in 18, mini-open in 8 and full-open in 9. The operative times were significantly shorter for closed than open reduction (p = 0.001). Five fractures received a supplemental fixation with plate or lag screws. By the 12th post-operative week, 97.1% demonstrated continuing radiographic healing, 94.1% tolerated painless weight-bearing and 91.2% could squat & smile. There was no infection or noticeable rotational malunion. Five fractures healed with a limb-length discrepancy of < 2 cm. CONCLUSION: The study demonstrates the feasibility of reamed IMN of DMFFs without fluoroscopy. The outcomes were satisfactory. Although the small sample size and short follow-up period are limitations, the study could serve as a basis for future larger studies in low-resource settings.

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