Purpose of the study: Percutaneous compression plating (PCCP) is a new method for minimally invasive fixation of intratrochanteric fractures. Fixation is achieved with two neck screws and a 3-hole plate. This prospective study of a non-randomized series was designed to compare results in a monocentric cohort of patients treated by PCCP or dynamic hip screw (DHS). Material and methods: From September 2003 to December 2004, all patients presenting an A1 (75.8%) or A1 (24.2%) (AO classification) intratrochanteric fracture were treated with PCCP (n=37) or DHS (n=20). Female gender predominated (86.5%) in this elderly population, mean age 83.2 years. The following variables were studied: operative time, radiation time, blood loss, hemoglobin level, blood transfusion, bone healing, complications, quality of the reduction. Results: Mean follow-up was 8.3 months. The two groups were similar regarding bone healing, functional outcome and mortality. Intraoperative blood loss was less with PCCP (63 ml) than with DHS (120 ml). Mean fall in hemoglobin level was 2 after PCCP and 3 after DHS. The transfusion rate was 28% for PCCP and 40% for DHS. Mean operative time was 50 for PCCP and 30 minutes for DHS. Men radiation exposure was 4 minutes for PCCP and 1 minute for DHS. The positions of the screw (DHS) and the two PCCP screws were considered good for 68% of the PCCP and 75% of the DHS, acceptable for 29% PCCP and 20% DHS, and poor for 3% PCCP and 5% DHS. Complications were similar (one disassembly in each group). Discussion: Although this was a preliminary study, PCCP was found to provide an attractive alternative for the treatment of intratrochanteric fractures. Results are similar to those obtained with the DHS but with a less aggressive method (limited approach, less blood loss). A learning curve (at least 10 implantations) appears indispensable to achieve maximum skill. The main drawback is the duration of the radiation. This implant would not be acceptable for subtrochanteric fractures which would require another type of implant

Introduction: Since the introduction of periarticular locking plates (PLP) open reduction and internal fixation of periarticular fractures has gained popularity. Although initial trials have shown encouraging results, no studies to date has focused on its use for metaphyseal fractures. The purpose of this study is to report on the performance of PLP for fixation of periarticular fractures.

Material and Methods: 49 with at least one year follow up were included in this prospective review. All fractures involved the metaphyseal area and 39 had an intraarticular extension as well. Fixation was performed by a combined locking-regular screws technique. The parameters included in the analysis were fracture displacement, type of callus formation, healing of the fracture, screw pull-out, screw breakage, plate breakage, stress rising and stress shielding with subsequent bone loss.

Results: At one year follow up the results showed that: 1 fracture had lost reduction in the early post op; 2 locking screws had backed up despite being initially locked to the plate; 1 screw broke, 1 plate broke. There were no problems with stress rising or stress fractures at the end of the plate. The most impressive finding was the high rate of stress shielding with subsequent bone loss within the range delimited by the locking screws (27 %). Callus formation: 18 % had no visible callus on plain radiographs despite being clinically healed. 62% had very little callus. 15 % had moderate callus and 5% had robust callus formation.

Discussion and conclusion: The use of PLP appears to have some unique characteristics, different than conventional plating.: 80 % of the fractures healed with no or very little callus. The use of locking screws in the shaft portion of the fixation may have been the cause for the high rate of stress shielding, which typically occurred within the locking screws in our series. Since the review of our data we are no longer using locking screws in the shaft portion of the fixation.

New concepts in plate fixation have led to an evolution in plate design for olecranon fractures. The purpose of this study was

to compare the stiffness and strength of a contoured Locking Compression Plate (LCP) with a conventional plating method (one-third tubular plate) in a cadaveric comminuted olecranon fracture model with standardized osteotomy, and

In the biomechanical study, five matched pairs of cadaveric elbows were randomly assigned for fixation by either LCP or a conventional plating method. Specimens were mounted to a custom-made testing bench and subjected to cyclic loading until failure occurred while measuring gapping at the osteotomy site. In the clinical study, twenty-one patients treated with LCP for complex olecranon fractures had a mean follow up of 20 months (3–39 months) and functional and patient rated outcome were evaluated.

In the biomechanical study, there was no significant difference in fixation stiffness and strength between one third tubular plating and LCP (p > 0.05). In the clinical study, the mean time to union of the fracture was 6 months (2–28 months). According to the Mayo Elbow Performance Index (MEPI) most patients had a good or excellent outcome. No patients reported difficulty with activities of daily living. Physical capacity showed minimal loss of stability and strength. Six patients had their hardware removed.

Technical ease of application and advantageous features of the LCP -such as unicortical screw fixation and improved holding power in osteopenic bone- make it a good alternative implant for comminuted olecranon fractures.

Purpose: 151 patients with intertrochanteric (IT) fracture of femur were treated in our department, between July 2002 and December 2003. We used this system as the only system of fixation for intertrochanteric fractures, no other system of fixation was even considered. We wish to evaluate our results and report the findings.

Materials and Methods: A total of 151 patients with an IT fracture were treated, all of them underwent surgery. 152 surgeries were performed in the 151 patients, one of the patients underwent a bilateral surgery. The follow up period was 9 months to a maximum of 12 months. 34 male and 117 female patients were operated. 75 of the fractures were right and 77 left sided. One of four surgeons was involved in all the surgeries.

Results: Time of surgery varied between 25 min to 1 hrs and 15 min, the vast majority of the surgeries took around 30 min. The time of surgery depended on the experience of the surgical team i.e. surgeon, nursing staff and fluoroscopic technician, ease and quality of reduction and its stability. All surgical wounds healed well. No wound infection was encountered, there was no immediate post operative mortality,. 151 out of 152 fractures had no significant loss of fixation and one patient broke all the 3 shaft screws with loss of fixation but the screws in the head continued to hold and had to be revised to a nailing. Almost every patient received a unit of blood to maintain a minimum of 9.0gm % of Hemoglobin level. Blood loss during surgery was estimated to be between 50 –150 ml as per surgical team estimates. Post surgical wound drainage varied between 25 ml to 75 ml.

Conclusions: The PCCP is a reliable and quick system of internal fixation for IT fractures, gives excellent results by all standards, with early and successful return to function.

Aims. The aims of this network meta-analysis (NMA) were to examine nonunion rates and functional outcomes following various operative and nonoperative treatments for displaced mid-shaft clavicle fractures. Methods. Initial search strategy incorporated MEDLINE, PubMed, Embase, and the Cochrane Library for relevant randomized controlled trials (RCTs). Four treatment arms were created: nonoperative (NO); intramedullary nailing (IMN); reconstruction plating (RP); and compression/pre-contoured plating (CP). A Bayesian NMA was conducted to compare all treatment options for outcomes of nonunion, malunion, and function using the Disabilities of the Arm Shoulder and Hand (DASH) and Constant-Murley Shoulder Outcome scores. Results. In all, 19 RCTs consisting of 1,783 clavicle fractures were included in the NMA. All surgical options demonstrated a significantly lower odds ratio (OR) of nonunion in comparison to nonoperative management: CP versus NO (OR 0.08; 95% confidence interval (CI) 0.04 to 0.17); IMN versus NO (OR 0.07; 95% CI 0.02 to 0.19); RP versus NO (OR 0.07; 95% CI: 0.01 to 0.24). Compression plating was the only treatment to demonstrate significantly lower DASH scores relative to NO at six weeks (mean difference -10.97; 95% CI -20.69 to 1.47). Conclusion. Surgical fixation demonstrated a lower risk of nonunion compared to nonoperative management. Compression plating resulted in significantly less disability early after surgery compared to nonoperative management. These results demonstrate possible early improved functional outcomes with compression plating compared to nonoperative treatment. Surgical fixation of mid-shaft clavicle fractures with compression plating may result in quicker return to activity by rendering patients less disabled early after surgery. Cite this article: Bone Jt Open 2021;2(8):646–654

Periprosthetic femoral shaft fractures are a significant complication of total hip arthroplasty. Plate osteosynthesis with or without onlay strut allograft has been the mainstay of treatment around well-fixed stems. Nonunions are a rare, challenging complication of this fixation method. The number of published treatment strategies for periprosthetic femoral nonunions are limited. In this series, we report the outcomes of a novel orthogonal plating surgical technique for addressing nonunions in the setting of Vancouver B1 and C-type periprosthetic fractures that previously failed open reduction internal fixation (ORIF). A retrospective chart review of all patients from 2010 to 2014 with Vancouver B1/C total hip arthroplasty periprosthetic femoral nonunions was performed. All patients were treated primarily with ORIF. Nonunion was defined as no radiographic signs of fracture healing nine months post-operatively, with or without hardware failure. Exclusion criteria included open fractures and periprosthetic infections. The technique utilised a mechanobiologic strategy of atraumatic exposure, resection of necrotic tissue, bone grafting with adjuvant recombinant growth factor and revision open reduction internal fixation. Initially, compression was achieved using an articulated tensioning device and application of an anterior plate. This was followed by locked lateral plating. Patients remained non-weight bearing for eight weeks. Six Vancouver B1/C periprosthetic femoral nonunions were treated. Five patients were female with an average age of 80.3 years (range 72–91). The fractures occurred at a mean of 5.8 years (range 1–10) from their initial arthroplasty procedure. No patients underwent further revision surgery; there were no wound dehiscence, hardware failures, infections, or surgical complications. All patients had a minimum of nine months follow up (mean 16.6, range 9–36). All fractures achieved osseous union, defined as solid bridging callus over at least two cortices and pain free, independent ambulation, at an average of 24.4 weeks (range 6.1–39.7 weeks). To our knowledge, this is the first case series describing 90–90 locked compression plating using modern implants for periprosthetic femoral nonunions. This is a rare but challenging complication of total hip arthroplasty and we present a novel solution with satisfactory preliminary outcomes. Orthogonal locked compression plating utilising an articulated tensioning device and autograft with adjuvant osteoinductive allograft should be considered in periprosthetic femur fractures around a well-fixed stem. Further biomechanical and clinical research is needed to improve our treatment strategies in this population

Biological reconstruction techniques after diaphyseal tumour resection have increased in popularity in recent years. High complication and failure rates have been reported with intercalary allografts, with recent studies questioning their role in limb-salvage surgery. We developed a technique in which large segment allografts are augmented with intramedullary cement and fixed using compression plating. The goal of this study was to evaluate the survivorship, complications and functional outcomes of these intercalary reconstructions. Forty-two patients who had reconstruction with an intercalary allograft following tumour resection between 1989 and 2010 were identified from our prospectively collected database. Allograft survival, local recurrence-free, disease-free and overall survival were assessed using the Kaplan-Meier method. Patient function was assessed using the Musculoskeletal Tumour Society (MSTS) scoring system and the Toronto Extremity Salvage Score (TESS). The 23 women and 19 men had a mean age of 33 years (14–77). The most common diagnoses were osteosarcoma (n=16) and chondrosarcoma (n=9). There were 9 humerus, 18 femur and 15 tibia reconstructions. At a mean follow-up of 95 months (5–288), 31 patients were alive without disease, 10 were dead of disease and 1 was deceased of other causes. There were 4 local recurrences and 11 patients developed metastatic disease. 5-year local recurrence free survival was 92%, 5-year disease-free survival was 70% and overall survival was 75%. Fourteen of 42 patients (33%) experienced complications: 5 wound healing complications, 4 infections, 2 non-unions, 2 fractures and 1 nerve palsy. Four allografts (9.5%) were revised for complications and 2 (5%) for local recurrence. Mean allograft survival was 85 months (4–288). Mean time to union was 8.2 (3–36) months for the proximal osteotomy site and 8.1 (3–23) months for the distal osteotomy site. The mean score for MSTS 87 was 29.4 (+/− 4.4), MSTS 93 was 83.7 (+/−14.8) and TESS was 81.6 (+/−16.9). An intercalary allograft augmented with intramedullary cement and compression plate fixation provides a reliable and durable method of reconstruction after tumour resection. Complication rates are comparable to the literature and are associated with high levels of patient function and satisfaction

Background:. Closed femoral shortening (CFS) is a recognised procedure for managing leg length discrepancy (LLD). Method:. We report twenty-nine consecutive patients with LLD who underwent CFS using an intramedullary saw and nail. Mean age was 29.2 years (16.1–65.8). The primary outcome was accuracy of correction. Secondary outcomes were complications, union, ASAMI score and re-operation, alongside Patient Reported Outcome Measures (PROMs), using EQ5D-5L and GROC. Results:. Mean pre-operative limb length discrepancy was 3.4 cm (1.5–6.5). Mean planned and achieved shortening was 2.9 cm (1.7–5.0). Mean follow-up was 2.0 years (0.2–8.4). Minimal access surgery was possible in all cases but careful technique is essential. All patients achieved a correction within 5mm of the planned shortening (range 0–5mm). 28 patients (97%) achieved uncomplicated union. One patient had a non-union requiring exchange nailing and subsequent compression plating. 13 patients had nail removal at a mean of 1.7 years and 3 had locking screw removal. Patients had an overall positive experience with 81% reporting high PROM scores. Discussion:. This technique offered accurate limb length correction with few complications. Patients rehabilitated well with good functional outcomes. Conclusion;. CFS with an intramedullary saw is a well-tolerated and effective technique when managing LLD up to 5cm

Fractures of humeral shaft are commonly seen in orthopaedic practice accounting for approximately 3% of all fractures. Treatment of these injuries continue to evolve as advances are made in both nonoperative and operative management. We performed a prospective study in the management of fractures of diaphysis of humerus by interlocking nail fixation and dynamic compression plating (DCP) was undertaken over a period of 3 years. Forty five patients with humerus fracture were treated with either interlocking nailing or plating. Rodriguez-Merchan et al criteria was used to compare results of both groups postoperatively. Fractures with unacceptable alignment was the most common indication for operative intervention (53%). While only 50% of the interlocking group had healed by 16 weeks, 75% of the plating group had united by this time. Overall results (Rodriguez-Merchan) show 65% excellent and good results in interlocking group and 93% similar results in the plating group. Postoperative radial nerve palsy was not seen in the interlocking group but was noted in 6.25% of the plating group. All of them recovered uneventfully with time. Plating is generally considered gold standard and to have predictable results in treatment of humerus shaft fractures. We have noted earlier union and better overall results in the plating group. Interlocking nailing is particularly preferable in communited, segmental and pathological fractures

Purpose: To compare the reoperation rates of three commonly used forms of fixation for distal femur fractures. Method: 89 patients treated between 2002 and 2006 were retrospectively reviewed (mean follow up 28 months).. 40 fractures were treated with an intramedullary nail (IMN), 34 with the LISS internal fixator and 16 with a DCS construct. Patients were reviewed clinically and radiographically. The primary treatment outcome was the rate of secondary surgical intervention; secondary outcomes included radiographic alignment and clinical outcome measures (LEM and SF-36). Results: Reoperation: Reoperation rate for the DCS group was 12.5%, compared to 17.5 % in the IMN group and 44 % in the LISS group. Failure rates were the same when only AO type C fractures were considered. Most concerning in the LISS group was the rate of failure in distal short oblique type A fractures, in which catastrophic failure was observed in 4 of 9 patients. Alignment was similar comparing all three groups; the average radiographic distal femoral articular angle (DFAA) of was 10 degrees valgus in the DCS group, compared to 8 degrees in the IMN group and the LISS patients. Conclusion: Reoperation rate was highest in this study when the LISS fixator was used for distal short oblique fractures of the femur. These fractures may benefit from fixation which achieves direct interfragmentary compression, such as an intramedullary device or compression plating

Successful treatment of bone fractures requires a balance between stability, to restore functional anatomy and allow early mobilisation (and thus avoid dystrophy). The healing occurs through complex interactions of inducing, enabling and inhibitory factors. The mechanical environment (e.g. stress and strain) in/around the fracture site regulates tissue changes throughout the healing process, including the formation of a fibro-cartilaginous callus and its progressive replacement by bone. The mechanical and biological environment is controlled substantially by the selection of the fracture stabilisation method achieving either absolute stability (mostly achieved with compression plating technique) or relative stability allowing a limited amount of dynamic fracture displacement across the fracture gap. A number of treatments may be used to accomplish these conditions, ranging from splinting with a plaster cast, external fixator or an intramedullary nail to rigid internal fixation using plates affixed to the bone fragments. Fixation methods are presently selected on the basis of general guidelines, but nevertheless the optimal stability/instability remains unclear and relies heavily on the surgeon’s experience. With the recently more and more widely used locking plates the question of the optimal fixation technique and applied stability to the fracture zone especially in simple fractures have raised again. To fill this knowledge gap, an interdisciplinary approach with in vitro and in vivo experiments seems to be essential. Analysing clinical situations and the healing course with mathematical modelling and computational simulations can further aid to understand the healing conditions in respect to stability. This presentation will give an overview on the role of the mechanical environment in fracture healing, and demonstrating clinical examples that highlight the relevance of this research

Fractures repair by two mechanisms; direct fracture healing and indirect fracture healing via callus formation. Research concerning the effects of bisphosphonate on fracture repair has solely assessed indirect fracture healing. Patients with osteoporosis on bisphosphonates continue to sustain fragility fractures. A proportion of osteoporotic fractures require plate fixation. Bisphosphonates impair osteoclast activity and therefore, may adversely affect direct fracture healing that predominates with plate fixation. Five skeletally mature Sprague-Dawley rats received daily subcutaneous injections of 1mg/kg Ibandronate (IBAN). Similarly, five control rats received saline (CONTROL). Three weeks following commencement of injections a tibial osteotomy was rigidly fixed with compression plating similar to that seen in routine clinical practice. Fracture healing was monitored with radiographs. Six weeks post plate fixation, animals were sacrificed. Radiographs were performed of the extricated tibiae following plate removal. The visibility of the osteotomy site was scored as totally visible, partially visible or absent as previously described. Mechanical testing was conducted on the healing osteotomies via 4-point bending. Fractures healed without visible external callus. In the IBAN group three animals had totally visible osteotomy lines and two had partially visible osteotomy lines. The CONTROL group had three animals with absent osteotomy lines and two with partially visible osteotomy lines. The mean (±SD) stress at failure for the healing tibial osteotomies at 6 weeks was 28.8 (±23.97)MPa in the IBAN group and 37.4(±29.20) MPa in the CONTROL group (p=0.62). Our results indicate that Ibandronate adversely affected direct fracture repair as demonstrated by the radiographic density of the fracture line. The strength of the repair was reduced but this did not reach statistical significance. Our results suggest that a sample size of 220 animals is required to detect a 15% difference (alpha 0.05, beta 0.2) which suggests the effect of bisphosphonates on direct fracture repair may be small

Background: Percutaneous compression plating (PCCP) is used for the fixation of intertrochanteric hip fractures by a minimally invasive technique. While offering several advantages compared to classic open reduction and internal fixation, the technique does not allow direct hemostasis. We aimed to assess the effect of regular aspirin use on blood loss, transfusion requirements and wound complications in patients undergoing urgent fixation using this technique. Methods: The study involved 326 patients who presented to our hospital with an intertrochanteric fracture. Parameters recorded included time to surgery, blood loss (assessed by pre and post operative hemoglobin concentrations), and transfusion requirements. The status of wound healing was evaluated, with specific reference to hematoma formation. The influence of regular pre-operative aspirin use was analyzed with respect to these outcome measures. Results: 32% of patients were regular aspirin users, and were comparable to the non aspirin group. There was no significant difference between the aspirin and non aspirin groups in terms of preoperative hemoglobin concentrations, perioperative changes in hemoglobin levels, and transfusion requirements. The severity of wound hematoma and the number of drainage procedures was not significantly different between the two groups. In a multivariate logistic regression analysis (composite complications. *. versus no complications as the dependent variable. R. 2. =0.108, P< 0.001), only delay to surgery was associated with a higher complication rate. *. Composite complications defined as transfusion ≥3 units, abnormal wound hematoma and length of stay ≥ 10 days. Conclusion: Regular aspirin use pre-operatively is not associated with increased blood loss, transfusion requirements and wound complications in patients treated with this percutaneous fixation technique. Rather, it is the delay to surgery that is associated with a composite bad outcome. Our data suggest that patients on aspirin can safely undergo urgent non-delayed fracture fixation using the PCCP

Aims. Compression and absolute stability are important in intra-articular fractures such as transverse olecranon fractures. This biomechanical study aims to compare tension band wiring (TBW) with plate fixation by measuring compression within the fracture. Methods. A cross-over design and synthetic ulna models were used to reduce variation between samples. Identical transverse fractures were created using a 0.5mm saw blade and cutting jig. A Tekscan(tm) force transducer was calibrated and placed within the fracture gap. Twenty TBW or Acumed(tm) plate fixations were performed according to the recommended technique. Compression was measured while the constructs were static and during simulated elbow range of movement exercises. Dynamic testing was performed using a custom jig reproducing cyclical triceps contraction of 20N and reciprocal brachialis contraction of 10N. Both fixation methods were tested on each sample. Half were randomly allocated to TBW first and half to plating first. Data was recorded using F-scan (v 5.72) and analysed using SPSS(tm) (v 16). Paired T-tests compared overall compression and compression at the articular side of the fracture. Results. The mean overall compression for plating was 819N (+/− 602N 95%CI), TBW overall compression: 77N (+/−19N 95%CI) (P=0.039). Articular side compression for plating: 343N (+/− 276N 95%CI), TBW: 1N (+/− 2N 95%CI). (P=0.038). During simulated movements, overall compression reduced in both groups: TBW -14N (+/−7N) Plating -173N (+/−32N) and no increase in articular side compression was detected in the TBW group. Conclusion. Precontoured plates such as the Acumed(tm) olecranon system can provide significantly greater compression, compared to TBW in transverse olecranon fractures. This was significant for compression over the whole fracture surface and specifically at the articular side of the fracture. Also, in TBW, overall compression reduced and articular side compression remained negligible during simulated triceps contraction, challenging the tension band principle

Aims: Published series of traditional plate þxation of the femur note rates of up to 69% primary bone grafting, 13% infection, 15% nonunion, 68% late complications, and 25% secondary surgical procedures. A shift from traditional plating to submuscular plating has thus ensued. This series entails an all-inclusive review of the plate þxation experience by two orthopaedic trauma surgeons in a þve-year period at a university trauma center. Methods: Between June 1996 and May 2001, 40 acute diaphyseal femoral fractures in 37 patients were managed utilizing dynamic compression plating via traditional Ç biological È plating with a formal lateral incision (n = 19), or submuscular plate þxation utilizing only a proximal and distal incision (n = 21). A comparison of reduction quality, union rates, and infection rates between traditional plate þxation and submuscular þxation was performed. Results: Thirty-nine of forty femoral shaft fractures healed without need of a secondary procedure. One nonunion occurred in the ORIF group. There was one infection in each group. Two patients treated by submuscular þxation developed signiþcant heterotopic ossiþcation around the femoral shaft which signiþcantly impaired knee motion. There were 6 cases of malreduction in the submuscular group, and none in the ORIF Group. Conclusions: Although the theoretical advantages of submuscular plating are well established, its utilization in the femoral shaft did not have a clear clinical advantage. In addition, its use appears to be more technically challenging, and is associated with a high rate of sub-optimal reductions

We analysed the functional outcome of 27 humeral shaft fractures treated non-operatively in our unit between 1999 and 2000. The mean age of the 20 men and seven women was 37.9 years (20 to 65). Ten fractures occurred in motor vehicle accidents, eight in falls and three in assaults. The remaining six were gunshot injuries. There were 18 closed fractures and nine grade-I compound fractures. Nine fractures were oblique, eight transverse, eight comminuted and two spiral. There was radial nerve palsy in 12 patients, and one poly-trauma patient had a concomitant brachial artery injury. All patients were treated initially by closed reduction and U-slab immobilisation. Radiological union was achieved in 12 patients (44.4%) at a mean of 11 weeks. Fixation by compression plating was necessary in 51.9%, treating delayed union in eight patients, radial nerve palsy in three, nonunion in one, a brachial plexus injury in one and polytrauma in one. One patient (3,7%) developed a pseudarthrosis and refused surgery. We assessed pain, range of movement of adjacent joints, ability to perform activities of daily living and work. In patients treated by U-slab immobilisation, the mean time to full functional recovery was 18 weeks. Those who underwent surgery achieved full functional recovery a mean of eight weeks later. Transverse and short oblique fractures are prone to delayed union and we recommend they be treated by primary internal fixation

Thirty-eight patients with nonunion of the humeral shaft underwent a comprehensive assessment including completion of three patient-based functional outcome surveys as well as the determination of the Constant shoulder and Mayo elbow scores. Treatment consisted of compression plating with or without bone grafting. Smokers were found to have significantly longer time to union as compared to nonsmokers (25.1 weeks vs. 16.2 weeks, p< 0.001). Our results also demonstrated that increased time to union had a significant negative effect on the patient-reported functional outcome scores. To evaluate the functional outcome and identify prognostic factors that influence the healing time of surgically treated humeral shaft nonunions. Time to consolidation of operatively treated humeral shaft nonunions was significantly longer in smokers versus non-smokers. Time to union was negatively associated with the patient-reported functional outcome scores. The long-term functional outcome following surgical treatment of humeral shaft nonunions is dependent upon the time to consolidation. Smoking is a significant remediable risk factor for delayed union following surgical repair of humeral shaft nonunion. We identified thirty-eight patients (mean age fifty-five years) treated surgically for nonunion of the humeral shaft at a mean follow-up of sixty months. All patients underwent a comprehensive assessment including the completion of the SF-36, the DASH, the SMFA and the determination of the Constant shoulder and Mayo elbow scores. Seventeen (44.7%) patients were classified as ‘smokers’ and twenty-one (55.3%) were ‘non-smokers’. All nonunions united with a mean time of 16.2 weeks for non-smokers and 25.1 weeks for smokers (p< 0.001). Time to union was negatively associated with the Physical Function portion of the SF-36 (p=0.01), the DASH (p=0.01), and the Arm and Hand Function part of the SMFA (p=0.005). The only other factor that had a significant negative effect on the functional outcome scores was the presence of one or more comorbid factors (SF-36, p< 0.001; DASH, p< 0.001; SMFA, p< 0.001). Patient-oriented and surgeon based scores were found to correlate well (range r=0.545 to r=0.916, p< 0.001 for all combinations)

The Halder Nail was introduced into the UK in 1994 and the inventor has recently reported his results (Halder et al, 2001. 1. ). Our unit has used the Halder humeral nail since 1997 for the management of traumatic and pathological fractures of the proximal humerus. Methods: We conducted a retrospective cohort study of all patients undergoing Halder nailing from March 1997 to February 2001. 50 patients were included with a follow up of 3 months to 4 years. Fractures were classified into trauma related and pathological. Trauma related fractures were subdivided into 2-, 3- and 4-part fractures of the surgical neck, and humeral shaft fractures. Post-operative Constant scores were obtained for 34 patients. Results: Thirty-two female and 18 male patients were included with a mean age of 69 years. There were 6 humeral shaft fractures; 13 2-part; 7 3-part and 9 4-part humeral neck fractures. There were 15 cases of nailing in pathological bone. Trauma Cases: Of the 35 trauma related fractures there were 15 cases of non-union, and 12 cases of delayed union (time to union > 3 months). Postoperative radiographs demonstrated good reduction in 27of these 35 cases. The nail was removed in 16 cases due to impingement problems at the shoulder. Four patients subsequently required a hemiarthroplasty or dynamic compression plating following nail removal. In addition there were 6 cases of trio wire protrusion and 2 cases of broken wires. Of the 28 patients on whom post-op Constant scores had been obtained 8 scored 60% or above, 11 scored 40–59% and 9 scored 39% or less. Pathological Cases: There were 8 cases of established pathological fractures and 7 cases of prophylactic nailing in pathological bone. Good postoperative reduction was demonstrated in 14 of the 15 patients. There were 2 cases of wound infection and 2 cases of nail impingement. 13 of the 15 patients reported good pain relief following fixation. Conclusion: Despite good radiographic reduction following Halder nailing, non-union, delayed union and nail impingement were common in the trauma group. However the Halder nail did provide reliable and immediate pain relief and stability of the bone to allow healing in patients with pathological humeral fractures

Aims

The primary aim was to estimate the cost-effectiveness of routine operative fixation for all patients with humeral shaft fractures. The secondary aim was to estimate the health economic implications of using a Radiographic Union Score for HUmeral fractures (RUSHU) of < 8 to facilitate selective fixation for patients at risk of nonunion.

The traditional treatment method of pediatric femoral shaft fracture has been traction and spica casting.This method is safe but prolonged immobilization, frequent X-ray , pin tract infections are some of the disadvantages. Internal fixation has become an alternative treatment in especially children between 6-10 years. Surgical treatment has been advocated for children who have multiple injuries or severe head injury. Compression plate fixation provides rigid and stable fixation but requires extensive dissection. Fixation of the fractures with flex-ible intramedullary nailing is another alternative treatment method and is safe and effective especially in simple transverse and short oblique fractures.In the current study we tried to evaluate the results of flexible intramedullary nailing and compare them with compression plate fixation. Thirty four patients with 36 femoral segments were included to the study. Clinical and radiological records of the patients were evaluated retrospectively. Patient’s demographic data, mechanism of injury, type of treatment , duration of the operation ,age ,side were obtained from the files. 19 femoral segments were treated with compression plating .There were 13 male and 5 female patients in this group. The mean age was 7.7 (6-10).The mean operation time was 100 minutes.(75-160 minutes- time between entering and leaving the operation room )Average time to healing was calculated as 7.7 (4-10 ) months.In this group, four femoral segment non-unions and implant failures occured in 6-10 months time .These patients were managed with titanium elastic nail.17 femoral segments were treated with titanium elastic nail ( TEN ).There were 10 male and 6 female patients in this group.The mean age of the patients were 7.9 years ( 7-10 ) .There were four patients managed with plate fixation previously . Revision surgery was done with implant removal and open reduction.The remaining 12 patients were operated with closed reduction and nailing. The mean operation time for this group was 86 ( 45-135) minutes . No immobilization method was used and partial weigth bearing permitted after the surgery.The mean healing time was 4 ( 3-7 ) months for this group. As we compare the both groups , the results were similiar. Average operation time was shorter in the nailing group but there were no statistically significant difference between the two groups. ( p> 0.05) . Average healing time was statistically significantly shorter in the nailing group. ( p= 0.038). It is generally accepted that plating is a traditionally safe and effective method; this study demonstrates that flexible intramedullary nailing maintains shorter operation time and shorter time to healing . The lack of need of post-operative immobilization , and small incisions for the insertion of the nail which is cosmetically more acceptable are the other advantages of this method. Conclusion: Internal fixation with flexible intramedul-lary nailing of the femoral fractures in pediatric age group is an advocatable solution