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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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Objective: Assess complications and risks in staged femoral shaft fracture treatment using external fixation and intramedullary nailing (DCO). Methods: Analysis involved 37 patients with 40 fractures, mostly male (87.5%), average age 32.9 years. Data included ASA score, AO/OTA and Gustilo classifications, Glasgow Coma Score, Injury Severity Score, times to external fixation and conversion, ICU duration, nail type, and reaming status. Complications tracked were mortality, deep infection, and non-union. Results: Predominant fracture type was AO/OTA A (45%), with 40% open (Gustilo A, 93.8%). Average ISS was 21; GCS was 12.7. Median ICU stay was 3 days; average time to conversion was 10.2 days. Retrograde nails were used in 50% of cases, with reaming in 67.5%. Complications included deep infections in 5% and non-union in 2.5%. Conclusion: DCO strategy resulted in low infection and non-union rates, associated with lower GCS and longer ICU stays. Level of Evidence III; Retrospective Cohort Study.

Objetivo: Analisar taxa de complicações e riscos no tratamento estagiado de fraturas diafisárias do fêmur com fixador externo e conversão para haste intramedular (DCO). Métodos: Estudo com 37 pacientes, 35 masculinos, idade média de 32,9 anos, abordando escores ASA, classificação AO/OTA, Gustilo, Glasgow e ISS, tempo até a fixação externa, na UTI e tipo de haste. Complicações como mortalidade, infecção profunda e não união foram registradas. Resultados: Fraturas tipo AO/OTA A foram as mais comuns (45%), com 40% expostas (Gustilo A, 93,8%). ISS médio de 21 e ECG de 12,7. Média de 3 dias na UTI e 10,2 dias até a conversão. Uso de haste retrógrada em 50% dos casos e fresagem em 67,5%. As complicações incluíram infecção profunda em 5% e não união em 2,5%. A não união correlacionou-se com baixo ECG e tempo prolongado na UTI. Conclusão: A estratégia de DCO mostrou-se eficaz com baixas taxas de infecção e não união, associada a baixo ECG e tempo na UTI. Nível de Evidência III; Estudo de Coorte Retrospectivo.

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Objective: The objective of the study is to evaluate the safety and efficacy of three different treatment methods for pediatric ulnar and radial double fractures. Methods: 120 children with ulnar and radial double fractures were included in the study. According to the different treatment plans, children were divided into three groups: manual reduction, splint external fixation, double elastic intramedullary fixation, and double plate fixation. Surgical indicators, radiological results, clinical efficacy, and complications were evaluated and compared among the groups. Results: The average hospital stay and operation time were significantly longer in the double plate internal fixation group compared to the other two groups. The double elastic intramedullary nailing group showed a higher fracture healing rate at 3 months compared to the other groups. There were no significant differences in clinical efficacy among the three groups. Complications were observed in all groups but did not show significant statistical differences. Conclusion: Double elastic intramedullary nailing fixation demonstrated favorable outcomes in terms of surgical indicators and fracture healing rates for pediatric ulnar and radial double fractures.

Objetivo: Evaluar la seguridad y eficacia de tres métodos de tratamiento diferentes para las fracturas dobles cubital y radial pediátricas. Métodos: Se incluyeron en el estudio 120 niños con fracturas dobles de cúbito y radio. Según los diferentes planes de tratamiento, los niños se dividieron en tres grupos: reducción manual, fijación externa con férula, fijación intramedular doble elástica y fijación con doble placa. Se evaluaron y compararon entre los grupos indicadores quirúrgicos, resultados radiológicos, eficacia clínica y complicaciones. Resultados: La estancia hospitalaria promedio y el tiempo de operación fueron significativamente más prolongados en el grupo de fijación interna con doble placa en comparación con los otros dos grupos. El grupo de clavo intramedular elástico doble mostró una mayor tasa de curación de la fractura a los 3 meses en comparación con los otros grupos. No hubo diferencias significativas en la eficacia clínica entre los tres grupos. Se observaron complicaciones en todos los grupos pero no mostraron diferencias estadísticas significativas. Conclusión: La fijación con clavo intramedular elástico doble demostró resultados favorables en términos de indicadores quirúrgicos y tasas de curación de fracturas pediátricas dobles cubital y radial.

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Ankle arthrodesis is the gold standard for treatment of end-stage arthritis. The goal of ankle arthrodesis is to obtain bony union between the tibia and the talus. Retrograde intramedullary nailing is typically reserved for ankle and subtalar joints arthrodesis. The purpose of this study is to evaluate the effect of two different materials, two locking pin configurations and two nail designs of a retrograde locked intramedullary nail used for ankle arthrodesis. Using the finite element analysis, a numerical study of ankle arthrodesis was developed to evaluate the effect of materials: TI-6Al-4V and stainless steel AISI 316 LVM; two locking pin configurations: five and six pins, on two intramedullary nails: Ø10 × 180 mm and Ø11 × 200 mm. A model of a healthy foot was created from tomographic scans. It was found that the mechanical stimulus required to achieve bone fusion were higher for Ø10 × 180 nails (6.868 ± 0.047) than the Ø11 × 200 nails (5.918 ± 0.047; p < 0.001; mean ± SEM). We also found that six-pin configuration had a higher mechanical stimulus (6.470 ± 0.047) than the five-pin configuration (6.316 ± 0.046; p = 0.020). Similarly, it was higher for titanium (6.802 ± 0.047) than those for stainless steel (5.984 ± 0.046; p < 0.001). Finally, the subtalar zone presented higher values (7.132 ± 0.043) than the tibiotalar zone (5.653 ± 0.050; p < 0.001). The highest mechanical stimulus around the vicinity of tibiotalar and subtalar joint was obtained by Ø10 × 180 nails, made of titanium alloy, with 6P.

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ABSTRACT Objective: Assess complications and risks in staged femoral shaft fracture treatment using external fixation and intramedullary nailing (DCO). Methods: Analysis involved 37 patients with 40 fractures, mostly male (87.5%), average age 32.9 years. Data included ASA score, AO/OTA and Gustilo classifications, Glasgow Coma Score, Injury Severity Score, times to external fixation and conversion, ICU duration, nail type, and reaming status. Complications tracked were mortality, deep infection, and non-union. Results: Predominant fracture type was AO/OTA A (45%), with 40% open (Gustilo A, 93.8%). Average ISS was 21; GCS was 12.7. Median ICU stay was 3 days; average time to conversion was 10.2 days. Retrograde nails were used in 50% of cases, with reaming in 67.5%. Complications included deep infections in 5% and non-union in 2.5%. Conclusion: DCO strategy resulted in low infection and non-union rates, associated with lower GCS and longer ICU stays. Level of Evidence III; Retrospective Cohort Study.

RESUMO Objetivo: Analisar taxa de complicações e riscos no tratamento estagiado de fraturas diafisárias do fêmur com fixador externo e conversão para haste intramedular (DCO). Métodos: Estudo com 37 pacientes, 35 masculinos, idade média de 32,9 anos, abordando escores ASA, classificação AO/OTA, Gustilo, Glasgow e ISS, tempo até a fixação externa, na UTI e tipo de haste. Complicações como mortalidade, infecção profunda e não união foram registradas. Resultados: Fraturas tipo AO/OTA A foram as mais comuns (45%), com 40% expostas (Gustilo A, 93,8%). ISS médio de 21 e ECG de 12,7. Média de 3 dias na UTI e 10,2 dias até a conversão. Uso de haste retrógrada em 50% dos casos e fresagem em 67,5%. As complicações incluíram infecção profunda em 5% e não união em 2,5%. A não união correlacionou-se com baixo ECG e tempo prolongado na UTI. Conclusão: A estratégia de DCO mostrou-se eficaz com baixas taxas de infecção e não união, associada a baixo ECG e tempo na UTI. Nível de Evidência III; Estudo de Coorte Retrospectivo.

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Background: Straight antegrade humeral nailing (SAHN) is associated with excellent clinical results in proximal humerus fractures. The optimal entry point is the top of the humeral head. However, the anatomy is variable, and the entry point can affect supraspinatus tendon footprint (SSP-F) or fracture reduction. The aim of this study was to analyze the relationship between the SSP-F and SAHN entry point by analyzing magnetic resonance imaging (MRI) studies of the humerus. Methods: In total 58 MRI studies of entire humerus were reviewed. The mean age was 51.6 ± 12.4 years, with 40 female patients. The distance between the SSP-F and the SAHN insertion point (critical distance: CD), the width of the footprint, and the neck-shaft angle (NSA) were measured. Univariate and multivariate analysis were performed. Results: The mean CD was 7.51 mm ± 2.81 (0-12.9 mm) with 51.7% of proximal humerus "critical type" (CD <8 mm). The CD was found to be lower in females, with no difference found with varying age (62.5% "critical type"). CD correlated with NSA (linear regression). "Critical type" correlated with female gender and NSA (logistic regression). Discussion: More than half of the humerus are "critical types" as to SAHN and may, therefore, be at risk for procedure-related complications.

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Introduction: Tibial shaft fracture is the most common long-bone fracture, and the standard treatment is intramedullary (IM) nail fixation. Regardless of the development of this technique pseudoarthrosis remains prevalent. Objectives: Evaluate the correlation between wedge fragment size and displacement, displacement of the main fragments of the 42B2 type, and pseudoarthrosis incidence. Methods: We retrospectively assessed all patients with 42B2 type fracture treated with IM nailing between January, 2015 and December, 2019. Six radiographic parameters were defined for preoperative radiographs in the anteroposterior (AP) and lateral views. Another six parameters were defined for postoperative radiographs at three, six, and 12 months. The Radiographic Union Score for Tibial Fractures score was used to assess bone healing. Results: Of 355 patients with tibial shaft fractures, 51 were included in the study. There were 41 (82.0%) male patients, with a mean age of 36.7 years, 37 (72.5%) had open fractures, and 28 (54.9%) had associated injuries. After statistical analysis, the factors that correlated significantly with nonunion were wedge height > 18 mm, preoperative translational displacement of the fracture in the AP view > 18 mm, and final distance of the wedge in relation to its original anatomical position after IM nailing > 5 mm. Conclusion: Risk factors for nonunion related to the wedge and42B2 fracture are wedge height > 18 mm, initial translation in the AP view of the fracture > 18 mm, and distance > 5 mm of the wedge from its anatomical position after IM nailing. Evidence level III; Retrospective comparative study .

Introdução: A fratura da diáfise da tíbia é a fratura mais comum dentre os ossos longos, sendo o tratamento padrão a fixação com haste intramedular (HIM). Independentemente do desenvolvimento da técnica cirúrgica, a pseudoartrose continua prevalente. Objetivo: Avaliar a associação entre o tamanho e o desvio da cunha, os desvios dos fragmentos principais do tipo 42B2 e a incidência de pseudoartrose. Métodos: Avaliamos, retrospectivamente, todos os pacientes com fraturas tipo 42B2 tratados com hastes intramedulares entre janeiro de 2015 e dezembro de 2019. Seis parâmetros radiográficos foram definidos para as radiografias pré-operatórias nas incidências anteroposterior (AP) e perfil. Outros seis parâmetros foram definidos para as radiografias pós-operatórias em 3, 6 e 12 meses de acompanhamento pós-operatório. O Escore Radiográfico de União para as Fraturas da Tíbia (RUST) foi o instrumento usado para avaliar a consolidação óssea. Resultados: Dos 355 pacientes com fraturas da diáfise da tíbia, 51 foram incluídos no estudo. Os pacientes incluídos foram 41 (82,0%) do sexo masculino, com idade média de 36,7 anos, 37 (72,5%) com fraturas expostas e 28 (54,9%) com lesões associadas. Após análise estatística, os fatores que se correlacionaram significativamente com a não consolidação foram a altura da cunha > 18 mm, o deslocamento translacional pré-operatório da fratura na incidência AP > 18 mm e a distância final da cunha em relação à sua posição anatômica original após a cravação do MI > 5 mm. Conclusão: Os fatores de risco para a pseudartrose relacionada com a fratura em cunha e42B2 são a altura da cunha > 18 mm, a translação inicial na vista AP da fratura > 18 mm e a distância > 5 mm da cunha em relação à sua posição anatómica após a fixação IM. Nível de evidência III; estudo comparativo retrospectivo. Nível de evidência III; Estudo retrospectivo comparativo .

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Intramedullary reaming has been proven to be a safe and effective method for enhancing the union rates of long bone fractures. However, there is a risk of equipment failure, which can lead to severe complications. We present two cases of reamer failure during femoral nailing which illustrate the rare occurrence of intraoperative instrument failure. Our report also underscores the importance of routinely inspecting reaming equipment and provides technical insights to reduce the risk of failure.

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Objective: Present the preliminary results of a case series using the surgical ankle arthrodesis technique with an intramedullary retrograde nail for bone tumors. Methods: We present the preliminary data of 4 patients, 3 males and 1 female, with a mean age of 46,2 (range 32 to 58) years, with histology proven Giant Cell Tumour of bone in 3 and osteosarcoma in 1. The mean resection length of distal tibia was 11,75 (range 9 to 16) cm, and all the patients underwent reconstruction with a tibiotalocalcaneal arthrodesis with an intercalary allograft fixed by a retrograde intramedullary nail. Results: Oncological follow-up evolved without evidence of local recurrence or disease progression in all patients. After a mean time of 69.5 (range 32 to 98 months), patients had a mean MSTS12 functional score of 82.5% (range 75 to 90). All tibial arthrodesis and diaphyseal osteotomy sites were fused within 6 months with a return to activities without complications related to coverage skin or infection. Conclusion: No complications were recorded; all arthrodesis and diaphysial tibial osteotomy sites fused by 6 months, and the mean follow-up of those patients was 69,5 (range 32 to 988) months, with a mean functional MSTS score of 82,5% (range 75-90). Level of Evidence: IV; Retrospective Case Series.

Objetivo: Apresentar os resultados preliminares de uma série de casos utilizando a técnica cirúrgica de artrodese do tornozelo com haste intramedular retrógada para tumores ósseos. Métodos: Apresentamos os dados preliminares de quatro pacientes, três homens e uma mulher, com idade média de 46,2 (variação de 32 a 58) anos, com histologia comprovada de tumor de células gigantes em três e osteossarcoma em um. O comprimento médio de ressecção da tíbia distal foi de 11,75 (variação de 9 a 16) cm, e todos os pacientes foram submetidos à reconstrução com uma artrodese tibiotalocalcaneana com um aloenxerto intercalar fixado por uma haste intramedular retrógrada. Resultados: O acompanhamento oncológico evoluiu sem evidências de recidiva local ou progressão da doença, em todos os pacientes. Após um tempo médio de 69,5 (variação de 32 a 98 meses), os pacientes tiveram uma pontuação média funcional MSTS12 de 82,5% (variação de 75 a 90). Todos os locais de artrodese e osteotomia diafisária tibiais foram fundidos em 6 meses com retorno às atividades de vida diária sem complicações relacionadas à cobertura ou infecção. Conclusão: Não foram registradas complicações; todos os locais de artrodese e osteotomia diafisária da tíbia fundiram-se em 6 meses, e o acompanhamento médio desses pacientes foi de 69,5 (variação de 32 a 988) meses, com uma pontuação média funcional MSTS de 82,5% (variação de 75-90). Nível de Evidência IV; Série de Casos Retrospectivos.

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INTRODUCTION: The objective of this retrospective study was to assess the effect of the nail to canal ratio and the number and configuration of distal locking screws in bone healing in tibial shaft fractures. METHODS: We analyzed 223 consecutive tibial shaft fractures treated with reamed intramedullary nailing between January 2014 and December 2020. We recorded and evaluated the nail to canal ratio (NCR) and the number and configuration of distal locking screws. Median NCR was 0.87 (IQR 0.82-0.94). Ten (4.48%) fractures were treated with one distal locking screw, 173 (77.57%) with two, and 40 (17.93%) with three. Uniplanar fixation was used in 63 (28.25%), biplanar in 150 (67.26%), and triplanar in 10 (4.48%) cases. Uni-, bi-, and multivariate analyses were performed to compare patients who achieved bone union with those who did not. RESULTS: Bone union was achieved in 195 (87.44%) patients. Uni- and bivariate analyses showed that bone union increased significantly with larger NCR (p = 0.0001) and a greater number of locking planes (p = 0.001) and distal screws (p = 0.046). NCR > 0.78 (OR 48.77 CI 95% 15.39-154.56; p = < 0.0001) and distal locking screw configuration (OR 2.91 CI 95% 1.12-9.91; p = 0.046) were identified as independent variables for union. CONCLUSION: Our findings suggest that in tibial shaft fractures treated with intramedullary nailing, NCR should be equal to or greater than 0.79. Additionally, distal locking screws should be used with a biplanar or triplanar configuration.

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ABSTRACT Objective Present the preliminary results of a case series using the surgical ankle arthrodesis technique with an intramedullary retrograde nail for bone tumors. Methods We present the preliminary data of 4 patients, 3 males and 1 female, with a mean age of 46,2 (range 32 to 58) years, with histology proven Giant Cell Tumour of bone in 3 and osteosarcoma in 1. The mean resection length of distal tibia was 11,75 (range 9 to 16) cm, and all the patients underwent reconstruction with a tibiotalocalcaneal arthrodesis with an intercalary allograft fixed by a retrograde intramedullary nail. Results Oncological follow-up evolved without evidence of local recurrence or disease progression in all patients. After a mean time of 69.5 (range 32 to 98 months), patients had a mean MSTS12 functional score of 82.5% (range 75 to 90). All tibial arthrodesis and diaphyseal osteotomy sites were fused within 6 months with a return to activities without complications related to coverage skin or infection. Conclusion No complications were recorded; all arthrodesis and diaphysial tibial osteotomy sites fused by 6 months, and the mean follow-up of those patients was 69,5 (range 32 to 988) months, with a mean functional MSTS score of 82,5% (range 75-90). Level of Evidence: IV; Retrospective Case Series.

RESUMO Objetivo Apresentar os resultados preliminares de uma série de casos utilizando a técnica cirúrgica de artrodese do tornozelo com haste intramedular retrógada para tumores ósseos. Métodos Apresentamos os dados preliminares de quatro pacientes, três homens e uma mulher, com idade média de 46,2 (variação de 32 a 58) anos, com histologia comprovada de tumor de células gigantes em três e osteossarcoma em um. O comprimento médio de ressecção da tíbia distal foi de 11,75 (variação de 9 a 16) cm, e todos os pacientes foram submetidos à reconstrução com uma artrodese tibiotalocalcaneana com um aloenxerto intercalar fixado por uma haste intramedular retrógrada. Resultados O acompanhamento oncológico evoluiu sem evidências de recidiva local ou progressão da doença, em todos os pacientes. Após um tempo médio de 69,5 (variação de 32 a 98 meses), os pacientes tiveram uma pontuação média funcional MSTS12 de 82,5% (variação de 75 a 90). Todos os locais de artrodese e osteotomia diafisária tibiais foram fundidos em 6 meses com retorno às atividades de vida diária sem complicações relacionadas à cobertura ou infecção. Conclusão Não foram registradas complicações; todos os locais de artrodese e osteotomia diafisária da tíbia fundiram-se em 6 meses, e o acompanhamento médio desses pacientes foi de 69,5 (variação de 32 a 988) meses, com uma pontuação média funcional MSTS de 82,5% (variação de 75-90). Nível de Evidência IV; Série de Casos Retrospectivos.

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ABSTRACT Introduction: Tibial shaft fracture is the most common long-bone fracture, and the standard treatment is intramedullary (IM) nail fixation. Regardless of the development of this technique pseudoarthrosis remains prevalent. Objectives: Evaluate the correlation between wedge fragment size and displacement, displacement of the main fragments of the 42B2 type, and pseudoarthrosis incidence. Methods: We retrospectively assessed all patients with 42B2 type fracture treated with IM nailing between January, 2015 and December, 2019. Six radiographic parameters were defined for preoperative radiographs in the anteroposterior (AP) and lateral views. Another six parameters were defined for postoperative radiographs at three, six, and 12 months. The Radiographic Union Score for Tibial Fractures score was used to assess bone healing. Results: Of 355 patients with tibial shaft fractures, 51 were included in the study. There were 41 (82.0%) male patients, with a mean age of 36.7 years, 37 (72.5%) had open fractures, and 28 (54.9%) had associated injuries. After statistical analysis, the factors that correlated significantly with nonunion were wedge height > 18 mm, preoperative translational displacement of the fracture in the AP view > 18 mm, and final distance of the wedge in relation to its original anatomical position after IM nailing > 5 mm. Conclusion: Risk factors for nonunion related to the wedge and42B2 fracture are wedge height > 18 mm, initial translation in the AP view of the fracture > 18 mm, and distance > 5 mm of the wedge from its anatomical position after IM nailing. Evidence level III; Retrospective comparative study .

RESUMO Introdução: A fratura da diáfise da tíbia é a fratura mais comum dentre os ossos longos, sendo o tratamento padrão a fixação com haste intramedular (HIM). Independentemente do desenvolvimento da técnica cirúrgica, a pseudoartrose continua prevalente. Objetivo: Avaliar a associação entre o tamanho e o desvio da cunha, os desvios dos fragmentos principais do tipo 42B2 e a incidência de pseudoartrose. Métodos: Avaliamos, retrospectivamente, todos os pacientes com fraturas tipo 42B2 tratados com hastes intramedulares entre janeiro de 2015 e dezembro de 2019. Seis parâmetros radiográficos foram definidos para as radiografias pré-operatórias nas incidências anteroposterior (AP) e perfil. Outros seis parâmetros foram definidos para as radiografias pós-operatórias em 3, 6 e 12 meses de acompanhamento pós-operatório. O Escore Radiográfico de União para as Fraturas da Tíbia (RUST) foi o instrumento usado para avaliar a consolidação óssea. Resultados: Dos 355 pacientes com fraturas da diáfise da tíbia, 51 foram incluídos no estudo. Os pacientes incluídos foram 41 (82,0%) do sexo masculino, com idade média de 36,7 anos, 37 (72,5%) com fraturas expostas e 28 (54,9%) com lesões associadas. Após análise estatística, os fatores que se correlacionaram significativamente com a não consolidação foram a altura da cunha > 18 mm, o deslocamento translacional pré-operatório da fratura na incidência AP > 18 mm e a distância final da cunha em relação à sua posição anatômica original após a cravação do MI > 5 mm. Conclusão: Os fatores de risco para a pseudartrose relacionada com a fratura em cunha e42B2 são a altura da cunha > 18 mm, a translação inicial na vista AP da fratura > 18 mm e a distância > 5 mm da cunha em relação à sua posição anatómica após a fixação IM. Nível de evidência III; estudo comparativo retrospectivo. Nível de evidência III; Estudo retrospectivo comparativo .

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OBJECTIVE: Dynamization has already been described as a secondary intervention for delay unions of tibial shaft fractures treated with intramedullary nailing. Although it's a common procedure, it is not widely supported in the literature. The purpose of this study was to determine the union rate of nail dynamization in cases of delayed union of diaphyseal tibial fractures, and assess the effect of fracture morphology on union rates. MATERIALS AND METHODS: We retrospectively analyzed a series of 199 consecutive tibial shaft fractures. We recorded the dynamization rate, period from nailing to dynamization, nailing to the union, the fracture pattern (according to AO/ASIF and whether it was closed or open), the callus diameter before dynamization (fracture healing index; FHI) and union/failure rates. RESULTS: Out of a total of 199 fractures treated during the study period, 41 (20.6%) were dynamized. After applying inclusion and exclusion criteria, 39 patients with 39 fractures were included in the study. The mean time from nailing to dynamization was 18.4 ± 7.2 weeks. The union rate was 92.3% (n = 36) over a mean time of 14.1 ± 5.6 weeks as from dynamization. The overall failure rate was 6.7% (n = 3). There was no significant association between failure and AO/ASIF classification (p > 0.05) or fracture exposure (X 2 = 0.19; p = 0.66). The pre-dynamization FHI of ≥ 1.17 was significantly associated with consolidation (p < 0.05). CONCLUSION: In cases of delayed union of tibial fractures, dynamization offered a high union rate associated with pre-dynamization FHI, while fracture morphology did not affect the failure rate.

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

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BACKGROUND: The purpose of this study was to compare shoulder outcomes and function after humeral shaft fractures treated with plates and screws vs. antegrade nailing. METHODS: A group of 27 patients treated with plates and a group of 30 patients (previously published) who had undergone antegrade locked intramedullary nailing, all with acute humeral shaft fractures, were retrospectively compared. Final shoulder range of motion (ROM), full shoulder ROM recovery rate, functional outcomes, residual pain, complications, and elbow flexion-extension range were also analyzed. RESULTS: There were a total of 57 patients: 27 cases in the plate (P) group and 30 in the nail (N) group (average age, 41.9 years).There were 66.7% men in group N and 63.0% in group P. The average age was 38 years (interquartile range [IQR] 28) in group N and 37 years (IQR 55) in group P. There were no differences in follow-up between groups, which averaged 28 months (IQR 7) in group P and 30 months (IQR 2) in group N (P = .385). There was no difference in both groups in elbow flexion-extension. Group P had a full shoulder ROM (66.6% vs. 40.0%; P = .02) and excellent Rodríguez-Merchán scoring (66% vs. 40.0%; P < .01), which was significantly higher than in group N. In group P, the Constant score was 95 (IQR 9). CONCLUSIONS: Treatment with plates in this comparative study led to a better ROM in the shoulder and fewer complications. Loss of shoulder motion may be expected after humeral shaft osteosynthesis. However, the functional scores and the healing index can be good and excellent with both techniques.

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INTRODUCTION: Ideal Nail Length (INL) provides better outcomes after Intramedullary Nailing (IMN) of Tibia Shaft Fractures (TSF). Intraoperative methods do not allow for preoperative planning. Changing the nail may cause complications. X-rays are commonly used, but displacement or magnification errors may occur. Forearm measurements may be benefical in bilateral TSF. We aim to examine correlations of anthropometric measurements (AMs) and INL and use them to obtain formulae. MATERIALS AND METHODS: Tuberositas Tibia-Medial Malleolus (TM), Tuberositas Tibia-Ankle joint (TA), knee-ankle joint (JJ), and olecranon tip-5th Metacarpal head (OM) distances were evaluated in 76 IMN patients. Correlation analyses were performed and the results used to create formulae. RESULTS: The correlations between INL and TM-left, TM-right, TA-left, TA-right, OM-left, OM-right, JJ-left, JJ-right were 0.81, 0.83, 0.77, 0.77, 0.82, 0.80, 0.90, 0.91 respectively for males; and 0.93, 0.89, 0.88, 0.86, 0.80, 0.82, 0.90, 0.89 respectively for females. AMs show excellent correlation in both sexes (p<0.0001). Regression analysis was statistically significant in all formulae. The most compatible correlations in males were JJ-right and JJ-left; and in females, TM-left, TM-right, and JJ-right. CONCLUSION: The most compatible correlations wth INL were JJ in males, and TM and JJ in females. OM can be used in the presence of bilateral TSF, edema, wounds and obesity. AMs are useful preoperatively. The formulae can be used to ensure INL and reduce errors, time and radiation. Level of Evidence: Level I, Testing of previously developed diagnostic criteria on consecutive patients (with the universally applied reference gold standard).

INTRODUÇÃO: O comprimento ideal da haste (CIH) proporciona desfechos melhores depois da colocação de haste intramedular (HIM) em fraturas da diáfise da tíbia (FDT). Os métodos dessa cirurgia não permitem o planejamento pré-operatório. A troca da haste pode causar complicações. Em geral, são usadas radiografias, mas podem ocorrer erros de deslocamento ou de tamanho. As medições do antebraço podem ser benéficas nas FDTs bilaterais. Nosso objetivo é examinar as correlações das medidas antropométricas (MAs) e CIH e usá-las para obter fórmulas. MATERIAIS E MÉTODOS: As distâncias entre Tuberosidade da tíbia-Maléolo medial (TM), Tuberosidade da tíbia-Articulação do tornozelo (TT), Articulações do joelho e do tornozelo (JT) e extremidade do olécrano-cabeça do 5o metacarpal (OM) foram avaliadas em 76 pacientes com HIM. Foram realizadas análises de correlação e os resultados foram usados para criar fórmulas. RESULTADOS: As correlações entre CIH e TM-esquerda, TM-direita, TT-esquerda, TT-direita, OM-esquerda, OM-direita, JT-esquerda, JT-direito foram 0,81, 0,83, 0,77, 0,77, 0,82, 0,80, 0,90, 0,91 para homens e 0,93, 0,89, 0,88, 0,86, 0,80, 0,82, 0,90, 0,89 para mulheres. As MAs tiveram excelente correlação em ambos os sexos (p < 0,0001). A análise de regressão foi estatisticamente significativa em todas as fórmulas. As correlações mais compatíveis em homens foram JT-direita e JT-esquerda; nas mulheres, foram TM-esquerda, TM-direita, e JT-direita. CONCLUSÃO: As correlações mais compatíveis com CIH foram JT em homens e TM e JT em mulheres. A OM pode ser usada em FDT bilateral, edema, feridas e obesidade. As MAs são úteis no pré-operatório. As fórmulas podem ser usadas para garantir o CIH e reduzir erros, tempo e radiação. Nível de evidência: Nível I, Desenvolvimento de critérios diagnósticos em pacientes consecutivos (com padrão de referência "ouro" aplicado).

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ABSTRACT Introduction: Ideal Nail Length (INL) provides better outcomes after Intramedullary Nailing (IMN) of Tibia Shaft Fractures (TSF). Intraoperative methods do not allow for preoperative planning. Changing the nail may cause complications. X-rays are commonly used, but displacement or magnification errors may occur. Forearm measurements may be benefical in bilateral TSF. We aim to examine correlations of anthropometric measurements (AMs) and INL and use them to obtain formulae. Materials and methods: Tuberositas Tibia-Medial Malleolus (TM), Tuberositas Tibia-Ankle joint (TA), knee-ankle joint (JJ), and olecranon tip-5th Metacarpal head (OM) distances were evaluated in 76 IMN patients. Correlation analyses were performed and the results used to create formulae. Results: The correlations between INL and TM-left, TM-right, TA-left, TA-right, OM-left, OM-right, JJ-left, JJ-right were 0.81, 0.83, 0.77, 0.77, 0.82, 0.80, 0.90, 0.91 respectively for males; and 0.93, 0.89, 0.88, 0.86, 0.80, 0.82, 0.90, 0.89 respectively for females. AMs show excellent correlation in both sexes (p<0.0001). Regression analysis was statistically significant in all formulae. The most compatible correlations in males were JJ-right and JJ-left; and in females, TM-left, TM-right, and JJ-right. Conclusion: The most compatible correlations wth INL were JJ in males, and TM and JJ in females. OM can be used in the presence of bilateral TSF, edema, wounds and obesity. AMs are useful preoperatively. The formulae can be used to ensure INL and reduce errors, time and radiation. Level of Evidence: Level I, Testing of previously developed diagnostic criteria on consecutive patients (with the universally applied reference gold standard).

RESUMO Introdução: O comprimento ideal da haste (CIH) proporciona desfechos melhores depois da colocação de haste intramedular (HIM) em fraturas da diáfise da tíbia (FDT). Os métodos dessa cirurgia não permitem o planejamento pré-operatório. A troca da haste pode causar complicações. Em geral, são usadas radiografias, mas podem ocorrer erros de deslocamento ou de tamanho. As medições do antebraço podem ser benéficas nas FDTs bilaterais. Nosso objetivo é examinar as correlações das medidas antropométricas (MAs) e CIH e usá-las para obter fórmulas. Materiais e métodos: As distâncias entre Tuberosidade da tíbia-Maléolo medial (TM), Tuberosidade da tíbia-Articulação do tornozelo (TT), Articulações do joelho e do tornozelo (JT) e extremidade do olécrano-cabeça do 5o metacarpal (OM) foram avaliadas em 76 pacientes com HIM. Foram realizadas análises de correlação e os resultados foram usados para criar fórmulas. Resultados: As correlações entre CIH e TM-esquerda, TM-direita, TT-esquerda, TT-direita, OM-esquerda, OM-direita, JT-esquerda, JT-direito foram 0,81, 0,83, 0,77, 0,77, 0,82, 0,80, 0,90, 0,91 para homens e 0,93, 0,89, 0,88, 0,86, 0,80, 0,82, 0,90, 0,89 para mulheres. As MAs tiveram excelente correlação em ambos os sexos (p < 0,0001). A análise de regressão foi estatisticamente significativa em todas as fórmulas. As correlações mais compatíveis em homens foram JT-direita e JT-esquerda; nas mulheres, foram TM-esquerda, TM-direita, e JT-direita. Conclusão: As correlações mais compatíveis com CIH foram JT em homens e TM e JT em mulheres. A OM pode ser usada em FDT bilateral, edema, feridas e obesidade. As MAs são úteis no pré-operatório. As fórmulas podem ser usadas para garantir o CIH e reduzir erros, tempo e radiação. Nível de evidência: Nível I, Desenvolvimento de critérios diagnósticos em pacientes consecutivos (com padrão de referência "ouro" aplicado).

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PURPOSE: In recent years, plate augmentation over a retained intramedullary (IM) nail has been shown to be an effective option for managing femur fracture nonunions because it improves the biomechanical environment of the fracture site without causing additional biological damage. In the current study, we present outcome data from 22 consecutive patients treated with plate augmentation for femoral shaft nonunion leaving the nail in situ. PATIENTS AND METHODS: Between 2015 and 2018, 22 consecutive patients with femoral shaft aseptic nonunion after IM nailing were treated with plate augmentation over a retained nail at four different institutions. Nonunion was categorized based on its anatomical location and was classified according to the Weber and Cech classification. Cortical defects greater than 1.0 cm, the type of nailing procedure, and the number of previous interventions were recorded. Patients were assessed clinically and radiographically to measure the healing of nonunion sites. The time to fracture union and complications were recorded. Descriptive statistics were used when applicable. RESULTS: One site location was supra-isthmic, 12 were isthmic, and 9 were infra-isthmic. There were 10 cases of vascular nonunion and 12 cases of avascular nonunion. A cortical defect greater than 1.0 cm was observed in three patients. Antegrade nailing was performed in 11 patients, and retrograde nailing was performed in 11 patients. Reaming was performed in 12 patients. In eight patients, the fracture was openly reduced during the IM nailing index procedure. The average number of previous interventions before augmentation plating was 1.6 (1-4). Bone union was achieved in 19 patients after augmentation plating with an average follow-up of 23.5 months (12-51 months). Excellent and good clinical results were observed in all patients. There was no plate or screw breakage, and no patient developed infection. CONCLUSION: Augmentation plating leaving the nail in situ is an excellent option for treating femoral shaft nonunion after IM nailing, with a high union rate and few complications. We believe the technique should gradually replace exchange nailing as the standard of care for the majority of femoral shaft nonunions that occur after IM nailing.

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PURPOSE: Despite the fact that open reduction and internal fixation with a plate, either non-locked or locked, is the standard of care for managing lateral malleolus fractures, intramedullary (IM) fixation of the fibula has been recently introduced as an alternative, mainly for some potential complicated situations. We hypothesized that almost all patterns of distal fibula fracture can be safely fixed with an IM device, with the potential benefit of providing biomechanical efficiency, but using a soft-tissue friendly implant. Here, we present a multicenter case series based on a proposed algorithm. PATIENTS AND METHODS: Sixty-nine consecutive patients were managed with fibular IM fixation for closed malleolar fractures. Twenty patients were managed by IM screw fixation and 49 by fibular nailing. Outcome was measured both according to the American Orthopaedic Foot and Ankle Society (AOFAS) score for ankle and hindfoot, and the time to bone union. RESULTS: The mean AOFAS for Group I was 99.35 ± 1.95 points and that for Group II was 89.30 ± 16.98 points. There were no significant differences between the fracture pattern, according to the Lauge-Hansen classification, and post-operative levels of pain and functional activity among patients in both groups (p > 0.05). All fractures healed uneventfully in both groups. The mean time to union for Group I was 8.15 weeks and for Group II was 8.25 weeks (p > 0.05). CONCLUSION: In this multicenter case series, intramedullary fixation for the lateral malleolus fracture presented itself as a viable and safe option for the treatment of almost all patterns of fibula fracture in adults. Overall, we were able to demonstrate the potential indications of the proposed algorithm for the choice of IM implant for the lateral malleolus fracture in terms of the Lauge-Hansen staged classification.

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Introducción El estándar de manejo para las fracturas del peroné distal es la reducción abierta más fijación interna con placa y tornillos (bloqueados o no), sin embargo, existen complicaciones asociadas a este tipo de intervención. En pacientes ancianos con mala calidad de tejidos blandos o en quienes presentan traumas de alta energía como etiología de las fracturas en el tobillo, la tasa de complicaciones previamente mencionadas aumenta, por lo que el manejo de las fracturas de peroné distal con tornillos percutáneos representa una alternativa con menor riesgo de complicaciones y con desenlaces similares al manejo convencional. Materiales y métodos Se realiza una serie de casos de pacientes con fractura de peroné manejados de forma percutánea. Se obtuvo una muestra de 17 pacientes por un año, a quienes se les realizó seguimiento sobre tasa de consolidación, funcionalidad y complicaciones postoperatorias. Resultados Diez (62,5%) fueron hombres, con una media de edad de 59 años (rango entre 24 y 90). El 100% fueron secundarios a traumas de alta energía, 10 (62,5%) fueron izquierdas, 14 (87,5%) se clasificaron como Weber B y 7 casos (56,25%) se presentaron concomitantemente con fracturas abiertas. Conclusiones Con el fin de evitar complicaciones, se debe considerar este abordaje en pacientes con comorbilidades, de edad avanzada o con tejidos blandos lesionados severamente o de mala calidad

Background The standard management for distal fibula fractures is open reduction plus internal fixation with plate and screws (blocked or not), however, there are complications associated with this type of intervention. In elderly patients with poor soft tissue quality or in those with high-energy trauma as the etiology of ankle fractures, the rate of previously mentioned complications increases, so that the management of distal fibula fractures with percutaneous screws represents a alternative with lower risk of complications and similar outcomes to conventional management. Methods A series of cases of patients with fibula fracture managed percutaneously was carried out. A sample of 17 patients was obtained for one year, who were followed up on consolidation rate, functionality, and postoperative complications. Results 10 (62.5%) were men, with a mean age of 59 years (range between 24 and 90). 100% were secondary to high-energy trauma, 10 (62.5%) were left, 14 (87.5%) were classified as Weber B and 7 cases (56.25%) presented concomitantly with open fractures. Discussion In order to avoid complications, this approach should be considered in patients with comorbidities, the elderly, or those with severely injured or poor-quality soft tissues.

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