Aims. Due to their radiolucency and favourable mechanical properties, carbon fibre nails may be a preferable alternative to titanium nails for oncology patients. We aim to compare the surgical characteristics and short-term results of patients who underwent intramedullary fixation with either a titanium or carbon fibre nail for pathological long-bone fracture. Methods. This single tertiary-institutional, retrospectively matched case-control study included 72 patients who underwent prophylactic or therapeutic fixation for pathological fracture of the humerus, femur, or tibia with either a titanium (control group, n = 36) or carbon fibre (case group, n = 36) intramedullary nail between 2016 to 2020. Patients were excluded if intramedullary fixation was combined with any other surgical procedure/fixation method. Outcomes included operating time, blood loss, fluoroscopic time, and complications. Fisher’s exact test and Mann-Whitney U test were used for categorical and continuous outcomes, respectively. Results. Patients receiving carbon nails as compared to those receiving titanium nails had higher blood loss (median 150 ml (interquartile range (IQR) 100 to 250) vs 100 ml (IQR 50 to 150); p = 0.042) and longer fluoroscopic time (median 150 seconds (IQR 114 to 182) vs 94 seconds (IQR 58 to 124); p = 0.001). Implant complications occurred in seven patients (19%) in the titanium group versus one patient (3%) in the carbon fibre group (p = 0.055). There were no notable differences between groups with regard to operating time, surgical wound infection, or survival. Conclusion. This pilot study demonstrates a non-inferior surgical and short-term clinical profile supporting further consideration of carbon fibre nails for pathological fracture fixation in orthopaedic oncology patients. Given enhanced accommodation of imaging methods important for oncological surveillance and radiation therapy planning, as well as high tolerances to fatigue stress, carbon fibre implants possess important oncological advantages over titanium implants that merit further prospective investigation. Level of evidence: III, Retrospective study. Cite this article: Bone Jt Open 2022;3(8):648–655

We reviewed eleven diaphyseal humerus fractures treated over an 18 month period, March 2004 to October 2005, using a single intramedullary Titanium Elastic Nail (TEN). The mean age of 6 boys and 5 girls was 7.6 years. The longest follow up was twelve months. The mean period of implant insertion was 6 months. Diaphyseal fractures were most commonly the result of a fall (45%), and 3 (27%) were the result of motor vehicle accidents (MVA) with other associated injuries. Two (18%) were pathological fractures. All were closed fractures. Nine of the eleven (81%) were treated by a closed reduction and a single retrograde TEN inserted percutaneously. Two required open reduction. There were no pre-operative or post-operative neurovascular complications. At mean follow up (6 months), there were ten satisfactory results (91%), with one complication of implant sepsis. The use of TENs for diaphyseal humerus fractures in children has not been widely described in the literature as compared to their use for diaphyseal femoral fractures. Traditional teaching advocates conservative treatment for these fractures. We believe that in 4–12 year old patients, a single TEN is a viable option in the treatment of these fractures in that it gives over-all good results with minimal morbidity. It is easy, quick, allows early return to activities, and avoids some of the complications of conservative treatment such as those associated with prolonged immobilization and malunion

Background:. In recent times there has been an increasing trend towards surgical intervention in paediatric femoral shaft fractures with widening indications. Titanium elastic nails and external fixation are two widely practiced procedures for such fractures. Materials & Methods:. We report a series of 48 children with 52 fractured femurs, 18 being managed by TENS and 34 in a linear external fixator. Children were aged between 3.5 to 12 years and the fractures were stabilised after an optimal closed reduction on a normal theatre table under image intensifier control. Fracture site distribution was nearly uniform in both the groups. Though most children were assigned to any of the groups at random, external fixators were applied on many younger children and those having financial constraints. Results:. The average age of children in the TENS group was 7.4 years and the average fracture healing time was 9.4 weeks. In the ex-fix group the figures were 5.6 years and 8.6 weeks respectively. Fixators were removed when good callus formation was seen on at least three cortices; average fixator time was 7.5 weeks. Fracture callus formation was slower in TENS group. Soft-tissue irritation at the nail entry points was the commonest complication for the TENS whereas pin-track infection was problem in the ex-fix group. Conclusion:. Management of paediatric femoral shaft fractures has changed to include more interventions. Flexible or elastic nailing like the TENS is a versatile and popular technique, however stabilisation in an external fixator also produce comparable results. External-fixation is an easier, cheaper and shorter procedure, and a mini ex-fix becomes a convenient external splint for smaller children who can be more conveniently nursed. Moreover ex-fix removal is an office procedure without anaesthesia

Introduction: It is well known that the using of Internal – External fixation for knee fusion has a high rate of failure. Aim: This announcement has to do with a new technique for knee fusion which promises low rate of failure and a safe knee arthrodesis. The whole technique has to do with a new type of modular Titanium intramedular nail. Materials and Methods: Between 2000 and 2002, two knee fusions have been done using this technique at two different patients. In both cases the main problem was the loosening of the components due to previous local infection in the first case and serious instability with suspicions of infection in the second one. The material is a modular device and it is consisted of two stems (femoral – tibial) just like the ones for THR which are connected together with a central part at the level of knee joint. The placement of the two stems is independent for each one and has to do with cement-less technique (press fit) starting from the joint level and then follows the reduction with the central part. In our both cases, bone allografts have been used. Results: Knee fusion has been achieved in first place in both cases at 3 and 4 months respectively. The mobility of both patients is excellent and the grade of satisfaction high, after 2 years and 10 months of follow up respectively. Conclusions: This technique has the advantages of intra-medular nailing, it is simple and safe, you can control the amount of shortening, and due to small surface of the device it can promises low rate of infection

We report early major complications encountered following TEN fixation of femoral fractures in children.

A case series of four children aged 8– 16 years who had primary TEN fixation of isolated femoral diaphyseal fractures.

Three of the four patients had major complications. These were: significant knee stiffness requiring manipulation, haemarthrosis requiring washout and nail removal, loss of position and refracture. Two required revision to locked intramedullary nails without early complication.

In the skeletally immature child TEN fixation of femoral fractures has a significant major complication rate. This needs to be recognised when comparing TEN fixation with other treatment options.

In order to define the operative indications, we compared the post-operative complications, time of consolidation, incidence of compartment syndrome, and fat embolism in centro medullary nails made from two different metals. This study includes approximately 234 centro medullary nails (TARGON System) used for treatment of diaphysal fractures of the leg or femur after a skiing injury. Steel nails were used before 1998 and titanium nails after 1998. The time of consolidation was the same for steel nails and titanium reamed nails. We remain faithful to limited reaming which avoids destruction of bone, and cortical and exothermic damage, but enables easier insertion of the titanium nail for leg fractures and bone grafts in sitù. The incidence of compartment syndrome with use of a titanium nail is reduced threefold. Regarding femoral fracture, the insertion of the nail without wire is more complicated and the operative stage is extended by 25%. The time of consolidation is the same for titanium or steel nails, and there were no failures with either type. However, we advise using titanium reamed nails for leg fractures and steel reamed nails for femoral fractures. If there is a suspicion of fat embolism, it is better to use femoral titanium nails

Aim: To compare the biomechanical properties of paired flexible steel and titanium nails in simulated transverse fractures of synthetic composite bones. Methods: Steel and titanium nails (3mm diameter) were individually used in pairs of divergent configuration to study torsion, cantilever bending (anteroposterior and lateral), and axial loading properties of adolescent synthetic composite tibiae model (10mm diameter). Properties of the intact bone, simulated fresh fracture with nails and simulated healing fracture with nails were studied. Instron 4303 universal testing machine was used to study axial loading. Applying fibreglass layers around the fracture with epoxy resin simulated fracture healing with callus formation. Results: Steel and titanium nails maintained good alignment of fracture fragments. Both the nails demonstrated very poor stability of fresh fractures in torsion loading. Steel nail/bone construct was 57% stronger than Titanium nail/bone construct under similar testing conditions during fracture healing (p< 0.05) but still < 50% stiffness of intact bone. In bending tests, both types of nails showed < 10% of the stiffness of intact bone in fresh fractures (p< 0.05). Mediolateral stiffness was better than anteroposterior stiffness. In fracture healing, the bending stiffness of both types of nail/bone constructs was > 50% that of intact bone. Axial stiffness of both nails was more than bending or torsion stiffness implying that fracture fragments play a significant role in the stability of the fracture. Although both types of nail/bone constructs demonstrated similar stiffness results in fresh and healing fractures, steel nails performance was statistically better than Titanium nails in all loading tests (p< 0.05). Conclusion: Fractures fixed with either type of flexible nails should be supplemented with splints or plaster for a short duration until callus formation. Flexible nails should be used with caution in comminuted fractures, over weight patients since they may not provide adequate stability or allow early mobilization. Additional research with cadaver bones may provide further insight into the performance of the flexible nails

Introduction. Locking nail have considerably improved the treatment of long weight bearing bones. However, distal locking needs experience and may expose to radiations. Many methods have been proposed to facilitate distal locking and improve safety. Recently, an external distal targeting device adapted to the ancillary of the Long Gamma Nail has been proposed. We report our experience with this device through a comparative series of distal lockings. Aim of this work was to assess feasibility and advantages brought about with this targeting device when considering time or dose of irradiation. Material and methods. Two prospective series of 50 distal locking performed by an experienced surgeon have been compared. Two methods were compared: the classical freehand technique using a Steinmann rod with the image of rounded holes, and the external distal targeting device. The following datas were collected: technical difficulties with either technique, locking mistakes and duration of exposure to radiations. Results. Two locking errors were observed using the targeting device, in pathological fractures with the use of a titanium nail. These cases belonged to the five earliest cases. External targeting device requires a learning curve that is reasonnably short with little difficulties encountered. Ther is a fundamental difference between the two series concerning exposure to radiations. In the freehand technique mean exposure was 25,8s (6–38) and it was 8,6s (6–18) with the dital targeting device. Discussion. A short learning curve confirms the ease of use of the distal targerting device. Diminution of exposure to radiation is effectively obtained. Some factors may increase the risk of error: the use of very long nails and the use of titanium nails as this may increase motion at distal end. Conclusion. The external visor is an efficient device as it facilitates distal locking and alllows for a diminution of irradiation time

The need for operative fixation of paediatric femoral fractures is increasingly being recognised in the present decade. The conventional traction and casting method for management of paediatric femoral fractures is giving way for the operative stabilisation of the fracture. We conducted a prospective study on 25 pediatric patients age group 6–14 years with diaphyseal femoral fractures, stabilised with two titanium nails of same size. Titanium nails were inserted through distal metaphyseal area 1 inch above the physis in a retrograde manner. Patients were followed up clinically and radiologically for one year.No patient was lost in the followup. Overall good results were reported with the use of TENs with minimal complications. Hospital time averaged 4.26 days in the series. All the fractures healed with an average time to union of 2.96 weeks. Return to school was early with an average of 7.8 weeks. Shortening was reported in two cases due to angulation at the fracture site. There were no delayed union or infection. The soft tissue discomfort near the knee produced by the nails ends was the most common problem encountered and thence cutting the nail ends closer to the bone is important. 5 nails had to be removed ssssubsequently after the bony union due to this problem. With proper operative technique and aftercare TENs may prove to be an ideal implant for pediatric femoral fracture fixation in the coming times

Purpose: The intramedullary nailing is the treatment of choice for the femoral shaft fractures, giving advantages of early mobilization and weight bearing. The purpose of this study is to present our experience with numerous reamed femoral nails and to report the results and the complications. Material and Method: From 1993 to 2004, 415 femoral shaft fractures (413 patients) were treated in our hospital. There were 312 males 101 females with mean age was 27.8 yrs (17–84 yrs). The 87 % of fractures were caused by high-energy injuries (traffic accidents). Pathologic fractures were not included. The 415 fractures according to AO classification were divided as follows: Type A: 105 (25.4%), Type B: 179 (43.1 %), Type C: 131 (31.5 %) There were 341closed fractures and 74 open. Those 74 were classified according Gustilo to 33 Grade I, 24 Grade II, 14 Grade III A, 2 Grade III B and 1 Grade III C. The fractures were treated with 308 AIM titanium nails and 107 Gross-Kempf nails. Dynamic stabilization was performed in the majority of the type A fractures, and static to those classified as B and C. We encourage our patients to walk with partial weight bearing, from the second post op day, except those with type C fractures who started their weight bearing after a month. The patients were evaluated 3,6,12,36 weeks and 1 years post surgery clinically and with standing X-Rays. Results: After a mean follow-up time of 1.5 years, our union rate was 97.8%. Type A fractures were united in an mean time of 16 weeks, type B in 20 weeks and type C in 23 weeks. Our complications were: 9 non unions (aseptic pseudarthrosis) (2.2%), 14 delayed unions (3.4 %), torsional malunion (more of 5°) in 4 patients (0.96 %). In 6 patients (1.44 %) we had limb shortening of 15 mm. Neurological complications were observed postoperatively in 30 patients, 25 with paresis of the pudendal nerve, due to traction (all recovered in a month), and 5 with paresis of peroneal nerve which were recovered in 3 months. There was found 28 broken screws but no broken nail. We had 3 pulmonary and 2 fat embolisms, but none of them was fatal. In 4 patients was observed clinically vein thrombosis below knee. Also we noticed one superficial and one deep infection, but we didn’t have a case of compartment syndrome. Patients returned to their previous activities in a mean time of 10 months. Conclusion: Our results confirmed that the antegrade intramedullary nailing technique had optimal results and high union rate regarding the treatment of the femoral shaft fractures. Some of the complications could be related with the surgeon’s skills-experience and could be avoided. We prefer the use of titanium nails because their modulus elasticity is closer to bones

The results of three years of treatment of children’s forearm fractures with flexible titanium nails was compared with the results from three original papers (Lascombes 1998, Richter 1998, Cullen 1998). 37 cases were identified using our trauma database and the main theatre database. 25 sets of case notes and x-rays were reviewed (age 4-16). The indication for fixation was fracture instability, either primarily or after initial conservative management. 6 cases were compound fractures. The fractures were reduced under general anaesthetic and then fixed using the ‘AO titanium elastic nail instrument and implant set’ (Synthes). 9 out of the 19 closed fractures needed to be opened for satisfactory reduction. Average theatre time was 104 minutes (25–165). Average hospital stay was two days (1–4). 22 of the patients were immobilised in plaster of Paris for an average of 5 weeks. Nails were removed on average 4 months after insertion (1–10 months). 16% had minor complications which included transient nerve impairment, superficial infection and refracture. All patients were considered to be fully recovered when discharged. Use of flexible nails in our district general hospital is comparable to previously published series in terms of case mix and complication rates

Between 1999 and 2002 14 children with femoral shaft fractures were treated with closed, locked intramedullary nailing. There were 11 male and 3 female patients, aged 11–16 years (mean 14.4 years). All fractures were closed. There were 9 transverse, 1 pathologic, 1 bipolar, 1 malunited and 2 spiral fractures. The fractures occurred following MVA or falls from height. All fractures were reduced and closed locked intramedullary nailing was performed using small diameter titanium nails without reaming. The entrance of point of the nail was created at the tip of the greater trochanter and no traction was used intraoperatively. The mean hospital stay was 2 days and immediate partial weight-bearing was permitted. All fractures united according to clinical and radiological criteria within 9 weeks. The maximum patient follow-up was 24 months (mean 17 months). Hip and knee mobility was full and no case of femoral head osteonecrosis, infection or malunion was ascertained. Closed, locked intramedullary nailing in adolescent patients provides immediate fracture immobilization combining safety and limited morbidity. Meticulous adherence to the surgical technique is necessary respecting the developing upper part of the femur

Objectives: The purpose of this biomechanical study was to compare the mechanical properties of locked nails and screws made from either stainless steel or titanium alloy. Methods: The specially designed locked nails and screws with the same structures were made from either stainless steel or titanium alloy. The structural factors investigated included inner diameter and root radius for locking screws and outer diameter and nail hole size for locked nails. The mechanical properties investigated included bending stiffness, strength, and fatigue life. Finite element models were used to simulate the mechanical tests and compute the stress concentration factors. Results: Increasing the root radius and the inner diameter could effectively increase the fatigue strength of the locking screws. Fatigue strength increased more in titanium than in stainless steel screws, especially when the inner diameter was increased. In contrast, the titanium locked nails were much weaker than their stainless steel counterparts. Finite element models could closely predict the results of the biomechanical tests with a correlation coefficient that ranged from −0.58 to −0.84 for screws and was −0.98 for nails. The stress concentration factors ranged from 1 to 1.81 for screws and from 3.06 to 4.17 for nails. Conclusions: With larger root radius and inner diameter, titanium locking screws could provide much stronger fatigue strength than stainless steel counterparts. However, titanium locked nails might lose their advantages of superior mechanical strength because of high notch sensitivity and this limitation should be a critical concern clinically. Finite element analyses could be reliably used in research and development of locked nails and locking screws

Purpose: Accurate prediction of re-operation following tibial nailing may facilitate optimal patient care. We recently completed the SPRINT trial, a large, multi-centre trial of reamed versus non-reamed intramedullary nails in 1226 patients with tibial shaft fractures. Using the SPRINT data, we conducted an investigation of baseline and surgical patient characteristics to determine if they are associated with increased risk of re-operation within one year. Method: Using multivariable logistic regression analysis, we investigated 15 characteristics for association with increased risk of re-operations. Because the primary SPRINT analysis found that reamed nailing reduced events in patients with closed but not open fractures, we considered both open and closed as well as treatment status in our model. Results: We found an increased risk of re-operation in patients with a high energy mechanism of injury (odds ratio, OR=1.57, 95% CI 1.05 to 2.35), stainless steel versus titanium nail (OR=1.52, 95% CI 1.10 to 2.13), fracture gap (OR=2.40, 95% CI 1.47 to 3.94) and post-operative weightbearing (OR=1.63, 95% 1.003 to 2.64). Open fractures increased the risk of re-operation in patients who received a reamed nail (OR=3.26, 95% CI 2.01 to 5.28) but not in patients who received a non-reamed nail (OR=1.50, 95% CI 0.92 to 2.47). Patients with open fractures who had either wound management without any additional procedures, or delayed primary closure, had a decreased risk of re-operation when compared to patients who required subsequent reconstruction (respectively, OR=0.18, 95% CI 0.09 to 0.35; OR=0.29 95% CI 0.14 to 0.62). Conclusion: To ensure optimal patient care surgeons should consider the characteristics identified in our analysis to reduce risk of re-operation

Elastic stable Intramedullary nailing (ESIN) is a method of treating femoral fractures in older children. The purpose of this study is to report our results over a 9 year period. Between 1998 and 2007, 62 children with femoral shaft fracture were managed at our institution with flexible titanium nailing. There were 44 boys and 18 girls with a mean age of 12.4 years (range 6 to 16 years). The mechanism of injury varied from RTA, falls and sports. The right side was involved in 41 and the left in 23. Two children had bilateral fractures. The fracture was in the proximal one third in 3, middle third in 51 and the distal third of the diaphysis in 8 children. The fracture pattern varied from transverse in 33, oblique in 15, spiral in 10 and comminuted in 4 patients. 11 children had associated injuries and 2 had mild osteogenesis imperfecta and another 3 sustained pathological fractures (fibrous dysplasia - 1 patient; simple bone cyst -1 patient; aneurismal bone cyst – 1 patient). The surgical procedure was retrograde except in one child with a mid third oblique fracture where this technique failed and hence an ante grade insertion was performed. All fractures united at an average follow-up of 18 months (range 12–24 months). The mean union time was 3.8 months (range 1.2 to 7.2 months). All patients were followed until the implant was removed and the mean insertion to removal interval was 13 months (5 to 29 months). The complications noted in our series were knee discomfort with stiffness (8 patients), pain from prominent nails (2 patients), malunion (1 patient), delayed union (1 patient), peri-prosthetic fracture (1 patient). There were no cases of infection. In conclusion, the results of our series showed that Elastic stable Intramedullary nailing gives satisfactory outcome in management of femoral shaft fractures in children

The new S.I.C.O. (Italian Society for Surgery of Osteoporosis) is trying to establish a register for osteoporotic complications, namely for Hip fractures, in fact at the moment only limited epidemiological data are available about the incidence of hip fractures in Italy. These data vary widely across the Italian Regions. In the last five years E.S.O.P.O. study allowed us to have epidemiological data about osteoporosis in Italy, and from then a group of Orthopedic Units, distributed along all the country, are collecting data to better understand the epidemiological relevance of Hip Fractures. 84.188 Hip fractures were registered in 2001 from the Italian Ministry of health, which meant 1.48 fracture every 1.000 citizen, 25% of which were males. From some areas through relating fractures and age was possible to establish that there were 3.7 fractures every 1.000 people over 50 years of age, 4.5 fractures every 1.000 females over 50 years of age, 1.9 every 1.000 males over 50. From the Units working at the project few significant data were obtained: mean time between hospital arrival and surgery was 3.9 days, considered very high, the mean time of Hospital stay was 9.5 days for all patients, but 14.5 days for patients that underwent to an operation. 55% were lateral fractures for which a new “Italian” undersized titanium nail was introduced in February 2003, which rapidly was adopted in many hospital for its simplicity and low cost. Controversial among Orthopedic surgeons arose because some of them are treating lateral fractures with total or partial hip replacement. Because of different health organization between Regions of North, Center and South of Italy the patients are discharged to rehabilitation Unit mainly in North of Italy, less in Southern part where for a lack of Rehabilitation Units, most of the patients go back home, supported from public health operators at their family place

In our cadaver study plating the fibula in addition to nailing the tibia decreased the mean rotation across the tibial osteotomy site compared to nailing the tibia alone. Although this is statistically significant (p=0.0034) it may not be clinically relevant as the mean values for ROM were 19.10 and 17.96 degrees respectively. Plating the fibula resulted in no statistically significant difference in the mean vertical displacement, angulation or neutral zone. Therefore, we may conclude that plating the fibula in a combined distal third tibia and fibula fracture does not enhance the stability of tibial IM nailing. The purpose of this study was to determine if combined distal third tibia and fibula fractures are more stable when fibular fixation is added to the standard tibial IM rodding. In combined distal third tibia and fibula fractures, plating the fibula does not enhance stability of intramedullary tibial nailing. No additional incision or soft tissue stripping is required for plating of the fractured fibula. The average range of motion in rotation was 19.1° for tibial and fibular fixation combined, and 18.0 ° for tibial fixation alone with a difference of 1.1°, which was clinically significant ( p=0.0034). The mean differences in vertical displacement, angulation, and neutral zone were not statistically significant. Five matched pairs of embalmed cadaveric lower limbs were dissected and stripped of soft tissue. Each tibia received a 9mm solid titanium nail that was locked proximally and distally. Fibular fixation consisted of a seven- hole LCDCP. A 1.5 cm section of tibia and a 1.0 cm section of fibula were removed. Testing was accomplished with an MTS machine. Vertical displacement was tested with an axial load to 500 N, rotation was tested with an internal and external torque of 5 Nm, and angulation was calculated from the vertical displacement data. All displacement data was measured across the osteotomy site. The mean range of motion in rotation was the only statistically significant finding. However, considering the average range of motion with and without fibular plating of 17.96° and 19.10° respectively, this finding is likely not clinically relevant. Funding: Tibial nails, bolts, fibular plates and screws provided by Synthes (Paoli, PA, USA)

Purpose: Centromedullary nailing with reaming is a recognised treatment for open leg fractures with a well-measured risk of postoperative infection. The development nailing procedures without reaming might reduce this risk. Material and methods: We performed a Medline search using the following key words: nailing, tibia, open fracture, infection. To be retained for analysis, articles had to evaluate infectious risk of nailing with or without reaming, in clinical trials or experimental studies, with precise diagnostic criteria. Clinical articles retained were classed in three categories by decreasing value of their methodology: prospective randomised comparative studies, case-control studies, comparative observation studies, simple observation studies. Only comparative experimental and prospective comparative randomised studies were considered to be pertinent. Results: Five articles met the predefined quality inclusion criteria and were retained for analysis: three experimental studies and two clinical trials. The experimental studies by Melcher (1995 and 1996) demonstrated a significant increase in infection rate and bacterial counts after nailing with reaming; there were two confounding factors however, steel or titanium nail and full or hollow nail which also had a significant effect on the rate of infection. The experimental work by Curtis (1995) did not find any difference in incidence and severity of infection between nailings with and without reaming. The two prospective comparative randomised clinical trials by Keating (1007) and Finkemeier (2000) included a total of 132 cases. the risk of infection was 8% after nailing with reaming and 7% after nailing without reaming (NS). The relative risk of infection after nailing with reaming was 1.02-fol greater than that without reaming (NS). Discussion, conclusion: There is experimental evidence that would tend to prove that the risk of infection is lower after nailing with reaming, but it is insufficient to explain the mechanism of this lower rate. Inversely, although the clinical observation series tend to confirm these results, the two methodologically valid prospective comparative randomised studies did not find any difference. To date, there is no objective evidence ruling out the usefulness of nailing with reaming because of higher infection risk in open leg fractures

Introduction: There is an increasing tendency for internal fixation of proximal metaphyseal fractures. Intra-medullary nailing only recently has been considered to be a valuable option in these cases. Through the development of new reliable implant types, nailing finds increasing acceptance. Questions: Is intramedually nailing with a new angle stable titanium nail a safe procedure in the treatment of proximal humeral fractures and is it combined with a good outcome?. Material and methods: A prospective international mul-ticenter study with standardized study control focused on the “Proximal Humeral Nail (PHN–Synthes Inc.), possible complications and clinical outcome. 151 fractures had been treated in 11 hospitals, where 72 were A-type, 67 B-type and 12 C-type (AO). There were 37 male, 114 female patients, median age 66 years ranging from 16 to 97 years. The outcome had been measured through Constant-Morley scores and DASH scores. 108 patients could be followed up until 1 year postoperatively. Results: Important complications were perforation of the articular surface by screw or spiral blade (n=8), pain due to the implant (n=10), dislocation of fragments (n=2), non union (n=2), humeral head necrosis (n=3) and wound infection (n=1). The Constant-Morley score shows in total mean values one year postoperatively 75.3 in the injured and 89.9 in the non-injured side. The DASH score pre-operatively was in total 5.9 and 9.3 one year postoperatively, where the best results could achieve 0 points, the worst 100 points. Discussion: Analyzing the complications, perforation of the articular surface by screw or spiral blade and pain due to the implant or impingement at the nail base are clearly related the technical failure in performing nailing. Here or the nail has not been introduced profoundly enough or the length for the spiral blade was not determined exactly and probably not controlled intraoperatively. This is due to the individual accuracy of the surgeon. The development of non-union (2/108) shows a ratio equal or even better to what is reported in conservative treatment or plate osteosynthesis. Dislocation of fragments n the other side, show the limit of this procedure, where in multifragmentary fracture type one spiral blade will not be able to fix a fragments. Using additional hardware is possible, but might reduce the effect of an initially low invasive approach. Constant score and Dash-score results perform similar to plate osteosynthesis, where clearly C-type-fractures present the worst prognosis. Conclusion: Proximal humeral nailing seems to be beneficial in A-type metaphyseal fractures. Even in many B-type fractures it is still a good alternative with limited incision to the plate osteosynthesis. In C-type fractures it is not advisable as a standard routine, only for experienced surgeons it might be a possible solution in selected cases

Introduction: The main features of osteogenesis imperfecta (OI) are excessive fragility and deformability of the long bones owing to poor bone quality and reduced bone mass, what leads to frequent fractures and residual deformity. Fractures in patients with OI usually heal rapidly, and conservative treatment is mostly successful. However, in displaced and unstable fractures surgical treatment is the only option. Aim: To present our experience in surgical treatment of fractures and deformities as a consequence of OI. Patients and methods: There are 41 individuals with OI in Croatian OI Register. We retrospectively analyzed 18 patients (12 males, 6 females) who were surgically treated from 1979 to June 2004 due to fractures and deformities of the long bones. At the time of the first surgical procedure in our Department, the youngest patient was 23 months old, and the oldest patient was 34 years old (average: 9.6 years). In two patients birth fractures were noticed, and in four patients fractures occurred in the first three months of their lives. In 9 patients severe form of OI was observed. There were 63 operative procedures in 18 patients, with the range from one to seven procedures per patient. We performed 36 reoperations mostly due to fractures of overgrown bone on solid intramedullary nail. Results: Different intramedullary rods were used on 34 occasions. We used solid intramedullary nails (Kuntchner’s nail, Rush’s nail) in 14 operations, Kirschner wires in 12 operations, and expandable intramedullary rod (Sheffield) in five operations. Elastic titanium nail (Nancy) was used in three operations. Other modes of fixation i.e. plates and screws, ASIF external fixator, and Ilizarov system (one patient) were used in total 29 operative procedures. None of the patients had infection related to operative procedure. Operations were mostly performed on femur (43 operations, 68%) and tibia (13 operations, 21%). There were 7 procedures (11%) on the upper extremities. We observed delayed union in three patients who were treated with bisphosphonates, and in two patients on proximal ulna. At the last follow-up ten patients were outdoor walkers, with or without one hand aid. Conclusion: Using correct indication, surgical technique and appropriate fixation device, surgical treatment can be safely performed in patients with OI. Surgery, rehabilitation, and medical treatment may significantly improve mobility and function in OI patients. The rarity of the disease, leading to small numbers of operations performed in a year, and the variable surgical findings, support centralization of surgery in OI patients with complex limb fractures and/or deformities