Introduction:. Displaced and shortened clavicle shaft fractures can be treated operatively by intra- or extramedullary fixation. The aim of the study was to compare the effectiveness of these two treatment modalities. Methods:. Forty seven patients with acute displaced and shortened clavicle shaft fractures were randomly assigned to either an
Aim: To report the clinical and radiological outcome of
Introduction: Mid-shaft clavicular fractures that are displaced and shortened are often treated surgically. The standard technique in the past has been to use plate fixation. However, in the last five years
We undertook a prospective randomised trial to determine the outcome of locked
The reliability of the radiological assessment of the healing of tibial fractures remains undetermined. We examined the inter- and intraobserver agreement of the healing of such fractures among four orthopaedic trauma surgeons who, on two separate occasions eight weeks apart, independently assessed the radiographs of 30 patients with fractures of the tibial shaft which had been treated by
Aims. Custom-made partial pelvis replacements (PPRs) are increasingly used in the reconstruction of large acetabular defects and have mainly been designed using a triflange approach, requiring extensive soft-tissue dissection. The monoflange design, where primary
Background: Long bone fractures and intramedullary stabilisation can result in the extravasation of fat and marrow emboli into the venous circulation. The effects of these emboli can become systemic causing neurological features. Aim: To establish the cerebral microembolic load following femoral and tibial diaphyseal fractures treated by
Purpose. Plating remains the most widely employed method for the fixation of displaced diaphyseal clavicle fractures. The purpose of this study was to assess the efficacy and outcomes of diaphyseal clavicle fractures treated with
Aims. The aim of this study was to examine perioperative blood transfusion practice, and associations with clinical outcomes, in a national cohort of hip fracture patients. Methods. A retrospective cohort study was undertaken using linked data from the Scottish Hip Fracture Audit and the Scottish National Blood Transfusion Service between May 2016 and December 2020. All patients aged ≥ 50 years admitted to a Scottish hospital with a hip fracture were included. Assessment of the factors independently associated with red blood cell transfusion (RBCT) during admission was performed, alongside determination of the association between RBCT and hip fracture outcomes. Results. A total of 23,266 individual patient records from 18 hospitals were included. The overall rate of blood transfusion during admission was 28.7% (n = 6,685). There was inter-hospital variation in transfusion rate, ranging from 16.6% to 37.4%. Independent perioperative factors significantly associated with RBCT included older age (90 to 94 years, odds ratio (OR) 3.04 (95% confidence interval (CI) 2.28 to 4.04); p < 0.001),
Introduction: The majority of forearm fractures in children can be managed with a plaster cast alone and manipulation under anaesthetic as required. A small number of cases however require surgical intervention. A variety of methods are available but the use of elastic intramedullary nails is becoming the technique of choice. Method: We present a two-centre study assessing the outcome of either Elastic StabJe Intramedullary Nails (ESIN) or Kirschner wires as the method of fracture stabilisation in diaphyseal forearm fractures of the radius and ulna. Results: ESIN group: 24 children underwent ESIN fixation. There were 22 boys and 2 girls, mean age 9.4 years (1.4–15.2 years, p=O.ll). Indications for stabilisation included 21 cases for fracture instability (immediate or delayed,) 2 irreducible fractures and 1 open fracture. 14 children underwent surgery on the day they sustained their fracture. The remainder were operated on an average 6.5 days following injury (1–14 days). In the K wire group: 36 children underwent K-wires fixation with 2.5mrn wires. There were 21 boys and 15 girls, mean age 10.6 years (2.2–15.5 years). Indication for stabilisation included 22 cases for fracture instability , 6 irreducible fractures and 8 open fractures. 32 children underwent surgery on the day they sustained their fracture. The remaining 4 patients were operated on the following day. Conclusions: All fractures united with no resultant subjective disability. The complication rate following K-wires was 16% and that following nail fixation 9%. Loss of forearm rotation was documented in 4 children in the K-wire group and 3 children stabilised with nails. These results confirm an excellent outcome following
Introduction:
Bone turnover markers (BTMs) follow distinct trends after fractures and limited evidence suggests differential levels in BTMs in patients with delayed healing. The effect of vitamin D, and other factors that influence BTMs and fracture healing, is important to elucidate the use of BTMs as surrogates of fracture healing. We sought to determine whether BTMs can be used as early markers of delayed fracture healing, and the effect of vitamin D on BTM response after fracture. A total of 102 participants aged 18 to 50 years (median 28 years (interquartile range 23 to 35)), receiving an intramedullary nail for a tibial or femoral shaft fracture, were enrolled in a randomized controlled trial comparing vitamin D3 supplementation to placebo. Serum C-terminal telopeptide of type I collagen (CTX; bone resorption marker) and N-terminal propeptide of type I procollagen (P1NP; bone formation marker) were measured at baseline, six weeks, and 12 weeks post-injury. Clinical and radiological fracture healing was assessed at three months.Aims
Methods
Aim: To compare two implants, the Gamma Nail and the ACE Trochanteric Nail in the treatment of pertrochanteric femoral fractures. Patients and methods: Sixty patients were randomized on admission to two treatment groups. Thirty patients were treated with the Gamma nail implants , and thirty had
Aims and methods. To compare the mechanical stability of an intramedullary (IM) screw with two crossed interfragmentary compression screws for fixation of the 1st MTPJ in ten pairs of cadaveric feet. One foot underwent fixation with two crossed 4.0-mm cannulated cancellous screws. The contralateral foot was fixed with an IM 1.6-mm Kirschner wire and an IM 6.5-mm partially threaded cancellous lag screw. A plantar-to-dorsal load was applied to the distal end of the proximal phalanx at a rate of 1 mm/sec. Failure was defined as gross actuator displacement of 5 mm. Stiffness was defined as the slope of the force versus deformation curve between 10 and 60 N. Strength was defined as the load at failure. The differences in stiffness and strength parameters between the two fixation techniques were checked for significance (P <
0.05) with a paired t-test. Results. The
Tip-apex distance (TAD) has long been discussed as a metric for determining risk of failure in fixation of peritrochanteric hip fractures. This study seeks to investigate risk factors including TAD for hospital readmission one year after hip fixation surgery. A retrospective review of proximal hip fractures treated with single screw intramedullary devices between 2016 and 2020 was performed at a 327 bed regional medical center. Patients included had a postoperative follow-up of at least twelve months or surgery-related complications developing within that time. 44 of the 67 patients in this study met the inclusion criteria with adequate follow-up post-surgery. The average TAD in our study population was 19.57mm and the average one year readmission rate was 15.9%. 3 out of 6 patients (50%) with a TAD > 25mm were readmitted within one year due to surgery-related complications. In contrast, 3 out of 38 patients (7.9%) with a TAD < 25mm were readmitted within one year due to surgery-related complications (p=0.0254). Individual TAD measurements, averaging 22.05mm in patients readmitted within one year of surgery and 19.18mm in patients not readmitted within one year of surgery were not significantly different between the two groups (p=0.2113). Our data indicate a significant improvement in hospital readmission rates up to one year after hip fixation surgery in patients with a TAD < 25mm with a decrease in readmissions of over 40% (50% vs 7.9%). This result builds upon past investigations by extending the follow-up time to one year after surgery and utilizing hospital readmissions as a metric for surgical success. With the well-documented physical and financial costs of hospital readmission after hip surgery, our study highlights a reduction of TAD < 25mm as an effective method of improving patient outcomes and reducing financial costs to patients and medical institutions.
The use of vascularised fibula grafts is an accepted method for reconstructing the distal femur following resection of malignant childhood tumours. Limitations relate to the mismatch of the cross-sectional area of the transplanted fibula graft and thel ocal bone, instability of the construct and union difficulties. We present midterm results of a unique staged technique—an immediate defect reconstruction using a double-barrel vascularised fibula graft set in in A-frame configuration and a subsequent intramedullary femoral lengthening. We retrospectively included 10 patients (mean age 10 y)with an osteosarcoma of the distal femur, who were treated ac-cording to the above-mentioned surgical technique. All patients were evaluated with regards to consolidation of the transplanted grafts, hypertrophy at the graft-host junctions, leg length discrepancies, lengthening indices, complications as well as functional outcome.Introduction
Materials & Methods
Purpose: Many surgical techniques have been described for the treatment of pathological fractures due to aggressive unicameral bone cysts in order to varying rates of success and incomplete healing or recurrence. Many Authors suggested curettage and bone grafting as effective treatment in case of active lesion in children 8 – 12 years old, adjacent to the physis with width of the lesion exceeds that of the adjacent physis and recurrence or persistence. Due to invasive nature of operation this method non is preferred by several Authors : we preferred minimally invasive treatment consisting closed reduction and flexible with titanium rod (Nancy)intramedullary fixation for low operative morbidity whether for the fracture or for the cyst; in case of recurrence of the cyst the closed curettage of the cyst with arthroscopic technique can be applied successful. Methods: Between 2002–2004 40 aggressive unicameral cysts were observed as pathologic fractures in patients between 5–15 years old in these cases there was a significant loss of bone stock. The site of involvement was in 33 patients the metadiaphysis of humerus, in 7 the femur; radiograms reveal expanding lesion in metaphyseal-diaphyseal site with cortex tinned from its inner surface and erosion with infraction with displacement. The parents were informed about contextual presence of two lesions: the fracture and cyst. The proposed internal fixation with Nancy titanium rods heals the first and might heal the second lesion ; in case of failure this method do not exclude another possibility of treatment as arthroscopic curettage. The Nancy flexible
400 patients with a trochanteric hip fracture were randomised to fixation with either a 220mm long Targon PF (proximal femoral) nail or a Sliding Hip Screw. All surgery was undertaken or supervised by one surgeon. All patients were followed up for a minimum of one year by a blinded observer. The mean age was 82 years (range 27 to 104 years), 20% were male. Mean length of surgery was slightly increased for the nail (44 versus 49 minutes, p=0.002). Fluoroscopic screening time was increased in the nail group (0.3 versus 0.6 minutes, p<
0.0001). Intra-operative complications were more common with the nailing. There was no difference in blood transfusion requirement between groups. Postoperatively there was no difference in the occurrence of medical complications or mortality. Deep wound infection requiring removal of the implant occurred in one case in the SHS group. In addition there were two cases of cut-out, three of plate detachment from the femur and one non-union in the SHS group, requiring secondary surgery. There were only once compilations in the nailed a case of cut-out which required secondary surgery. At follow-up there was no difference in pain scores between groups but there was a tendency to improved mobility in the nailed group (p=0.004). These results suggest that with improved designs and surgical technique, the newer versions of short nails for proximal femoral fractures may not suffer from the complications of the earlier short intramedullary nails.
The Sliding Hip Screw (SHS) is currently the treatment of choice for all trochanteric hip fractures. An alternative treatment is the short femoral nail. Earlier designs of these nails were associated with an increased fracture healing complication rate in comparison to the sliding hip screw. The new designs of nails (third generation nails) may however be as good as or even superior to sliding hip screw fixation. We conducted a large randomised trial to compare the Targon Proximal Femoral Nail with the Sliding Hip Screw. Patients with trochanteric hip fractures as per the AO classification (A1–A3) were randomised to either implant. All surgery was supervised by one surgeon. All patients were followed up for a minimum of one year months by a blinded observer. The mean age was 82 years, range 27 to 104 years), 20% were male. Length of surgery was slightly increased for the nail (44 versus 49 minutes, p=0.002). Fluoroscopic screening time was increased in the nail group (0.3 versus 0.6 minutes, p<
0.0001). Intra-operative complications were more common with the nailing. There was no difference in blood transfusion requirement between groups. Postoperatively there was no difference in the occurrence of medical complications or mortality. Deep wound infection requiring removal of the implant occurred in one case in the SHS group. In addition there were two cases of cut-out, three of plate detachment from the femur and one non-union in the SHS group, requiring secondary surgery. There was only one compilation in the nailed a case of cut-out which required secondary surgery. At follow-up no difference in pain scores but there was a tendency to improved mobility in the nailed group (p=0.004). These results suggest that with improved designs and surgical technique, the newer versions of short nails for proximal femoral fractures may not suffer from the complications of the earlier short intramedullary nails.
Regardless of the method used, open ankle arthrodesis is known to have a high rate of nonunion, reported to range from 4% to 25%. Salvage of failed ankle fusion is thus a relatively common procedure. Further, in cases of bone loss after distal tibial trauma, necrosis of the talus, Charcot joints and severe deformities of the ankle, there are known to be increased incidences of delayed union and nonunion. Since 1997, 25 salvage ankle arthrodesis procedures have been performed, using a retrograde interlocking intramedullary nail as fixation. In this paper we discuss the indications, surgical techniques and results. At a mean of nine weeks postoperatively, union was achieved in all cases. Complications included one case of late sepsis, which presented four years after surgery. During the operation one tibial fracture occurred. One distal screw backed out. The fixation was removed from three patients, one for late sepsis, one for septic nonunion, and the patient in whom the tibia fractured.
Lower limb fractures in children are common. These fractures can be managed in a variety of ways, and the method chosen depends on a number of factors including: Age of the child. Site of fracture. Whether the fracture is open or closed. Associated injuries. Surgeon’s expertise and experience. Parental wishes.
We present two cases of metastatic lung cancer which occurred at the site of a previously united tibial fracture. Both patients were treated with a locked intramedullary nail. The patients presented with metastases at the site of their initial fracture approximately 16 and 13 months after injury respectively. We discuss this unusual presentation and review the relevant literature. We are unaware of any previous reports of a metastatic tumour occurring at the site of an orthopaedic implant used to stabilise a non-pathological fracture. These cases demonstrate the similar clinical presentation of infection and malignancy: a diagnosis which should always be considered in such patients.
From May 2002 to April 2003, a prospective, non-randomised, blinded study was undertaken in 30 patients with fractures of the femur and tibia, all treated with unreamed intramedullary (AO) nail fixation. There were 17 (57%) femoral shaft fractures and 13 (43%) tibial shaft fractures. Most of the patients (23) had been injured in road findings accidents, 17 of them pedestrian. No patient had any known co-morbidities. Fourteen patients (47%) were HIV positive, nine with femoral fractures and five with tibial fractures. Three patients with compound femoral fractures were HIV positive, two HIV negative. The mean age of HIV-positive patients with femoral shaft fractures, two men and seven women, was 33 years (18 to 48). The mean age of the eight HIV-negative men with femoral shaft fractures was 28 years. Five tibial fractures were compound, three in HIV-positive patients and two in HIV-negative patients. The mean age of HIV-positive patients with tibial fractures, three men and two women, was 31 years (18 to 56). The mean age of the HIV-negative patients, seven men and one woman, was 28 years. All the fractures were Gustillo-Anderson grade- II. At 12 weeks, 29 fractures had united. In one HIV-positive patient with a compound tibial fracture there were no radiological signs of union at 12 weeks, but after bone grafting the fracture united uneventfully. An HIV-positive patient, who had sustained a gunshot femur injury, developed deep wound infection four months after fixation. In all other patients, the wounds healed uneventfully. In asymptomatic HIV-positive patients, wound healing and fracture union rates are comparable with those of HIV-negative patients.
Debate still exists as to the optimum method of fixation for subtrochanteric femoral fractures. Meta-analysis of studies comparing cephalocondylic nails with extramedullary implants for extracapsular hip fractures have suggested that further investigation is required in this area. We present the outcome of the largest series to date of subtrochanteric fractures treated by both methods and with a minimum of one year follow-up. 244 patients with a subtrochanteric femur fracture were treated at one centre over a 21 year period were prospectively studied. 75 were treated with an extramedullary fixation implant and 168 with an intramedullary nail. Surviving patients were followed up till one year from injury.Introduction
Methods
A retrospective study was done on the outcome of supracondylar femoral fractures treated with retrograde or supracondylar intramedullary nails. Between January 1998 and December 2000, 69 patients were treated with Russell Taylor nails, 30 at Kalafong Hospital and 39 at Pretoria Academic Hospital. Injuries had resulted from motor vehicle accidents in 27 patients, from falls in 32 and from gunshots in 10. There were 13 open fractures and 14 patients had multiple injuries, including three head injuries and two vascular injuries. Using the AO classification, 40 fractures were graded type A and 29 type C. The mean age of the 18 female and 51 males was 45 years (17 to 90). Senior registrars performed the surgery. In all cases, the knee was opened for the procedure. Four patients died from their injuries. The mean time to union was 13 weeks. Four patients had poor range of motion. Complications included two cases of superficial sepsis and three of deep sepsis. There were two cases of delayed union and three of fixation failure. In one patient the fixation impinged on the patella. We find this a good way of treating supracondylar femoral fractures.
Revision knee prostheses are often augmented with intramedullary stems to provide stability following bone loss. However, there are concerns with the use of such stems, including loosening caused by strain-shielding, end-of-stem pain, and removal of healthy bone surrounding the medullary canal. Extracortical fixation plates may present an alternative. The aim of the study was to quantitatively evaluate and compare strain-shielding in the tibia following implantation of a knee replacement component augmented with either a conventional intramedullary stem (design1), or extracortical plates (design2) on the medial and lateral surfaces. Eight composite synthetic tibiae were implanted with one of the two designs, painted with a speckle pattern, loaded in axial compression (peak 2.5 kN) using a materials test machine, and imaged with a 5-megapixel digital image correlation (DIC) system throughout loading. Bone loss was simulated in all models by removing a volume of metaphyseal bone. For four tibiae, the tibial tray was augmented with a cemented stem (∼150 mm). The others were augmented by extracortical plates (maximum 90 mm long) along the medial and lateral surfaces (Fig. 1). Strains were computed using an ARAMIS 5M software system between loaded and unloaded states in the longitudinal direction, for the medial, posterior and lateral surfaces of the tibiae. Strains were checked locally by use of strain gauge rosettes at three levels on medial, lateral and posterior aspects. The bone strains measured on the posterior surfaces were reported in three regions; proximal (0–70 mm, where the medial extracortical plate lies), middle (70–130 mm, the stem is present but not the extracortical plates), and distal (130–200 mm, beyond the stem). Mean longitudinal strains for both implant types were comparable in the distal region, and were greater than in the other regions (Fig 2). The mean strains differed considerably in the middle region: 565–715 μstrain with stemmed components 1050–1155 μstrain with plated components. Strains followed a similar pattern in the proximal region, particularly very close (20 mm) to the tibial tray component, where the stemmed component bones (775 ± 160 μstrain) displayed less surface strain than the plated component bones (1210 ± 180 μstrain). Strain-shielding was observed for both designs. The side plates were shorter than the intramedullary rods, so the region of the bone distal to the plates was not strain-shielded, while the same region was strain-shielded when a stemmed component was implanted. It was also shown that in the region of bone just distal of the tibial tray component, design1 shielded the bone from strain 56% more on average than design2. From these results, it can be speculated that the use of extracortical plate rather than intramedullary stems may lead to improved long-term results of revision TKA, assuming the plates and screws provide adequate stability. The extramedullary fixation system preserves more bone than IM fixation, and has the advantage of allowing use of primary TKA components, cemented over the subframe. Similar components have been developed for the femur.
To assess and compare the functional, radiological and cosmetic results as well as patient satisfaction in patients treated with the IMN Device Vs Volar Locking Plate All patients who presented to our institution with extra articular distal radius fractures and met the inclusion criteria were invited to take part in the study. The patients were randomly allocated to two groups, those who underwent intramedullary (IMN) distal radius fixation using the Sanoma Wrx Distal radius nail and those who underwent fixation using a volar locking plate. The patients were then followed up at 2 weeks, 6 weeks, 3 months, 6 months and 1 year. The radiological parameters, ie radial height, inclination and tilt were compared as well as the functional outcomes by means of DASH score. The range of motion of the wrist was compared as well as the scar size. Complications were reviewed.Aims of study
Method
All fractures healed at an average time of 9.2 weeks (5–26) and for the open fractures 19 (12–26) weeks. Hardware was removed in 8 cases with no complications. In two cases re-operation was needed. In one early case the nail was fractured and replaced. In the second case the bone was circlaged due to fragmentation around the fracture site and a bigger nail was inserted few days later (wrong smaller nail was inserted previously).
Methods of treatment of femoral fractures still remain controversial in adolescent age when the patients are too young for adult-type stabilization. This study examines the possibilities for improving the mechanical parameters of the bone-nail interface in flexible intramedullary nailing. Mathematical models, which simulate different fractures, have been created by using the finite elements method. The stabilizing construction with two 4,00 mm Ender nails was performed in two versions:
standard divergent “C” configuration (3 points of pressure); divergent “S” configuration (4 points of pressure). Each version has been tested towards the deforming forces – bending in frontal and sagital plane; torsion and axial loading. Strength coefficient of the nails has been calculated as well as the stiffness of the configuration. The comparative analysis of the results found out that under the angular and torsional forces the mechanical parameters of the two types of configurations are equivalent. However, under axial loading, the divergent “S” configuration shows definitely better mechanical characteristics. The strength coefficient is 30% higher and the stiffness of the configuration is twice as strong. The specific intramedullary cohesion enables more considerable resistance towards the transverse displacement in telescoping of the fragments. Proceeding from the presented data, it could be considered that the divergent “S” configuration creates much more sufficient length control. Its implementation in axial unstable femoral fractures could enable an earlier mobilization, respectively – an earlier weight-bearing loading.
The purpose of our study was to compare the mechanical nature of nails with different cross-sections in order to optimise the elasticity-stability ratio. There is no doubt that elastic intramedullary osteosynthesis is a successful choice for treating femoral shaft fractures in children. However, misalignment is a potential problem connected with stability of the fixation. The mechanics of two types of nails with the same type of surface, but with different kind of cross sections – a circle (Ender) and an ellipse – was examined using the “finite elements” method. The standard configuration of the two nails was put under four kinds of deforming forces: bending in the frontal plane and the sagital plane, torsion, and axial compression. Strength coefficient and stiffness were calculated in each particular situation. In respect to angular stability (frontal plane) and axial compression, the mechanical characteristics of the two types of nails are similar. The stability of the elliptical nail is higher in bending in the sagital plane and in torsion. The elliptical implant has better intramedullary cohesion because the large half-axis is perpendicular to the sagital plane. Nails with an elliptical cross section provide the opportunity for redistribution of stiffness. As a result, better mechanical properties are achieved. The elliptical cross section assures better intramedullary cohesion.
Background. This is a continued assessment of the effectiveness of a locked intramedullary device in the treatment of acute clavicle shaft fractures. Results of patients treated thus far were assessed, including patients reported on previously. Description of methods. Patients admitted with midshaft clavicle fractures were assessed to determine whether operative fixation of the fracture was required. Indications for surgery were midshaft clavicle fractures with 100% displacement; more than 1.5 cm of shortening, presence of a displaced butterfly segment, bilateral clavicle fractures, ipsilateral displaced glenoid neck fractures, skin and neurovascular compromise. Patients that matched the criteria for surgery were treated operatively with an intramedullary locked device by the author. Post-operatively, patients were kept in a shoulder immobilizer for a period of 6 weeks. Patients were invited to attend a scheduled follow-up visit where the data was collected that comprised the review. All patients were assessed by the surgeon, a radiologist, a physiotherapist and an occupational therapist. Scar size and quality, Dash score, Constant Shoulder score, complications and the radiological picture were assessed. Summary of results. 50 patients (52 clavicle fractures – 2 patients sustained bilateral fractures), 28 males and 22 females with a mean age of 30 attended the schedule data collection visit and were included in the study. 48 clavicles achieved complete union with the remaining 4 fractures progressing normally to union at 10 and 12 weeks post surgery. No additional complications than those reported on previously were encountered. Conclusion. Locked
The radiographic union score for tibial (RUST) fractures was developed by Whelan et al to assess the healing of tibial fractures following intramedullary nailing. In the current study, the repeatability and reliability of the RUST score was evaluated in an independent centre (a) using the original description, (b) after further interpretation of the description of the score, and (c) with the immediate post-operative radiograph available for comparison. A total of 15 radiographs of tibial shaft fractures treated by intramedullary nailing (IM) were scored by three observers using the RUST system. Following discussion on how the criteria of the RUST system should be implemented, 45 sets (i.e. AP and lateral) of radiographs of IM nailed tibial fractures were scored by five observers. Finally, these 45 sets of radiographs were rescored with the baseline post-operative radiograph available for comparison.Objectives
Methods
Conservative treatment of the ‘boxer’s fracture’ gives acceptable functional results but often leaves the patient with a residual deformity. Using a prograde intramedullary K-wire, we treated 23 consecutive patients with a fractured neck of the fifth metacarpal. Volar angulation exceeded 40°. A 1.6-mm pre-bent K-wire was inserted via the base of the fifth metacarpal in each case. Time to regaining full function, time to union and final functional and radiological outcome were recorded. All 23 patients went on to full clinical and radiological union within six weeks. In 18 patients, the reduction was anatomical with no residual angulation. In five the residual angulation ranged from 5° to 15°, with a mean of 8°. There was a transient sensory neuropraxia in two patients. This minimally invasive technique is a simple, cost-effective and reliable method of treating a ‘boxer’s fracture’ and ensures a rapid return to full function with little or no residual deformity.
To assess the effectiveness of a novel locked intra-medullary device in the treatment of acute clavicle shaft fractures. Patients admitted with midshaft clavicle fractures were assessed for inclusion in the study. Inclusion criteria were mid shaft clavicle fractures with 100% displacement; more than 1, 5 cm of shortening or containing a displaced butterfly segment. Fractures were assessed for suitability to intra-medullary fixation (fracture distance from the medial and lateral end of the clavicle, medullary diameter and fracture type). 35 patients were treated operatively using the device by the author. Post-op, patients were kept in a master sling for a period of 6 weeks and followed up for a period of at least 3 months. Fracture reduction, fracture progression to union, scar size, Dash score, Constant Shoulder score, patient satisfaction and complications were assessed at follow-up by the surgeon, a radiologist and an occupational therapist.Purpose of study:
Description of methods:
We investigated the effect of the location and the number of distal screws in the efficiency of an intramedullary nail implementing the finite element method (FEM). The left proximal femur of a 93-year old man was scanned and two series of full 3D models were developed. The first series, consisting of five models, concerned the use of a single distal screw inserted in five different distal locations. The second series, consisting of four models, concerned the use of four different pairs of distal screws. Each model was analyzed with the (FEM) twice, first considering that the femur is fractured and then considering that the femur is healed. For nails with a single distal screw, stresses around the nail hole were reduced with proximal placement of the distal screw but the area around the nail hole where the lag screw is inserted is stressed more. Furthermore, for nails with a pair of distal screws, placing the pair of distal screws at a specific location is most beneficial for the mechanical behavior of the femur/nail assembly. The distal area of the nail generally gets less stressed when a pair of distal screws is introduced, while the presence of two distal screws far away from each other results in lower proximal femoral head displacements. The stress field at the area of fracture is not influenced significantly by the presence of a single distal screw or a pair of distal screws.
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
Introduction. The management of fracture-related infection has undergone radical progress following the development of international guidelines. However, there is limited consideration to the realities of healthcare in low-resource environments due to a lack of available evidence in the literature from these settings. Initial antimicrobial suppression to support fracture union is frequently used in low- and middle-income countries despite the lack of published clinical evidence to support its practice. This study aimed to evaluate the outcomes following initial antimicrobial suppression to support fracture union in the management of fracture-related infection. Materials & Methods. A retrospective review of consecutive patients treated with initial antimicrobial suppression to support fracture healing followed by definitive eradication surgery to manage fracture-related infections following
The burden of metastatic disease presenting with axial skeleton lesions is exponentially rising predominantly due to advances in oncological therapies. A large proportion is these lesions are located in the proximal femora, which given its unique biomechanical architecture is problematic. These patients are frequently comorbid and require prompt and concise decision making regarding their orthopaedic care in line with recent British Orthopaedic Association guidelines. We present data detailing the outcomes for patients with proximal femoral metastatic disease referred and treated over a three year period in an Regional Cancer Centre. We retrospectively reviewed a prospectively maintained database of all patients referred for discussion at MDT with axial skeletal metastatic disease. From this we isolated patients with femoral disease. Demographic data along with primary tumour and metastatic disease site were assessed. Treatment regimens were analysed and compared. Finally predicted and actual mortality data was collated. 331 patients were referred over the analysed time period, of which 99 had femoral disease. 66% of patients were managed conservatively with serial monitoring while 34% underwent operative treatment. 65% of those received an
Background. Clavicle development occurs before the age of 9 in females and 12 in males. Children below the age of 10 with displaced midshaft clavicle fractures recover well with conservative management. However adolescents are more demanding of function and satisfaction following clavicle fractures and may benefit from operative management. Study aims: 1) Perform a systematic review of the current evidence supporting
Objectives. The PROximal Fracture of the Humerus: Evaluation by Randomisation (PROFHER) trial has recently demonstrated that surgery is non-superior to non-operative treatment in the management of displaced proximal humeral fractures. The objective of this study was to assess current surgical practice in the context of the PROFHER trial in terms of patient demographics, injury characteristics and the nature of the surgical treatment. Methods. A total of ten consecutive patients undergoing surgery for the treatment of a proximal humeral fracture from each of 11 United Kingdom hospitals were retrospectively identified over a 15 month period between January 2014 and March 2015. Data gathered for the 110 patients included patient demographics, injury characteristics, mode of surgical fixation, the grade of operating surgeon and the cost of the surgical implants. Results. A majority of the patients were female (66%, 73 of 110). The mean patient age was 62 years (range 18 to 89). A majority of patients met the inclusion criteria for the PROFHER trial (75%, 83 of 110). Plate fixation was the most common mode of surgery (68%, 75 patients), followed by
Background. Fractures of the femoral neck occurring outside the capsule of the hip joint are assumed to have an intact blood supply and hence their conventional management is by fixation rather than arthroplasty. The dynamic hip screw and its variants have been used over many years to fix such fractures but have inherent vulnerabilities; they require an intact lateral femoral cortex, confer a relatively long moment arm to the redistribution of body weight and may cause a stress riser due to the plate with which they are fixed to the femur. Intramedullary devices for fixation of proximal femoral fractures have a shorter moment arm, can be distally locked with reduced perforation of the femoral cortex and are believed to be inherently more stable. For these reasons, a number of surgeons believe them to be superior to the DHS for all extracapsular fractures and their use is now widespread. In this study, we present the usage trends of both devices in extracapsular fractures over the last five years and set these results in the context of patient demographics. Methods. Our departmental electronic patient management system was used to identify all patients undergoing surgery coded as either DHS or its variants or
Introduction. While knee arthrodesis is a salvage option for recalcitrant total knee arthroplasty (TKA) periprosthetic joint infection (PJI) it is used relatively uncommonly and contemporary data are limited. We sought to determine the reliability, durability and safety of knee arthrodesis as the definitive treatment for complex, persistently infected TKA in a modern series of patients. Methods. We retrospectively identified 41 knees treated from 2002–2016 with a deliberate, two-stage knee arthrodesis protocol (TKA resection, high-dose antibiotic spacer, targeted IV antibiotics and followed by subsequent knee arthrodesis) in patients with complex TKA PJI. Mean age was 64 years & mean BMI was 39 kg/m. 2. Mean follow-up was 4 years. The extensor mechanism was deficient in 66% of knees, and flap coverage was required in 34% of knees. The majority of patients were host grade B (56%) or C (29%), and extremity grade of 3 (71%). Twenty-nine percent had poly-microbial infections, and 49% had multi-drug resistant organisms. Fixation included intramedullary nail (61%), external fixator (24%), and dual plating (15%). Results. Two patients (5%) required amputation for persistently infected non-unions; therefore, limb salvage was accomplished in 95% of patients. After initial treatment, there were non-unions in 24% and persistent infection in 17%. Non-union was significantly correlated with persistent infection, with 50% of non-unions having persistent infection compared with just 6% of united knees (p=0.006). External fixation was a significant risk factor for non-union (70%) compared to
Aims. Little is known about the effect of haemorrhagic shock and resuscitation
on fracture healing. This study used a rabbit model with a femoral
osteotomy and fixation to examine this relationship. Materials and Methods. A total of 18 male New Zealand white rabbits underwent femoral
osteotomy with
Aims. The aim of this study was to investigate whether clinical and radiological outcomes after intramedullary nailing of displaced fractures of the fifth metacarpal neck using a single thick Kirschner wire (K-wire) are noninferior to those of technically more demanding fixation with two thinner dual wires. Patients and Methods. This was a multicentre, parallel group, randomized controlled noninferiority trial conducted at 12 tertiary trauma centres in Germany. A total of 290 patients with acute displaced fractures of the fifth metacarpal neck were randomized to either intramedullary single-wire (n = 146) or dual-wire fixation (n = 144). The primary outcome was the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire six months after surgery, with a third of the minimal clinically important difference (MCID) used as the noninferiority threshold. Secondary outcomes were pain, health-related quality of life (EuroQol five-dimensional questionnaire (EQ-5D)), radiological measures, functional deficits, and complications. Results. Overall, 151/290 of patients (52%) completed the six months of follow-up, leaving 83 patients in the single-wire group and 68 patients in the dual-wire group. In the modified intention-to-treat analysis set, mean DASH scores six months after surgery were 3.8 (. sd. 7.0) and 4.4 (. sd. 9.4), respectively. With multiple imputation (n = 288), mean DASH scores were estimated at 6.3 (. sd. 8.7) and 7.0 (. sd. 10.0). Upper (1 - 2α)) confidence limits consistently remained below the noninferiority margin of 3.0 points in the DASH instrument. While there was a statistically nonsignificant trend towards a higher rate of shortening and rotational malalignment in the single wire group, no statistically significant differences were observed across groups in any secondary outcome measure. Conclusion. A single thick K-wire is sufficient for
Introduction and Objective. Hip fractures represent one of the most challenging injuries in orthopaedic practice due to the associated morbidity, mortality and the financial burden they impose on the health care systems. By many still considered as the gold standard in the management of intertrochanteric fractures, the Dynamic Hip Screw utilizes controlled collapse during weight bearing to stabilize the fracture. Despite being a highly successful device, mechanical failure rate is not uncommon. The most accepted intraoperative indicator for lag screw failure is the tip apex distance (TAD), yet lateral femoral wall thickness (LWT) is another evolving parameter for detecting the potential for lateral wall fracture with subsequent medialization and implant failure. The aim of this study is to determine the mean and cut off levels for LWT that warrant lateral wall fracture and the implications of that on implant failure, revision rates and implant choice. Materials and Methods. This prospective cohort study included 42 patients with a mean age of 70.43y with intertrochanteric hip fractures treated with DHS fixation by the same consultant surgeon from April 2019 to December 2019. The study sample was calculated based on a confidence level of 90% and margin of error of 5%. Fracture types included in the study are 31A1 and 31A2 based on the AO/OTA classification system. LWT was assessed in all patients preoperatively using Surgimap (Nemaris, NY, USA) software. Patients were divided into two groups according to the post-operative integrity of the lateral femoral wall, where group (A) sustained a lateral femoral wall fracture intraoperatively or within 12 months after the index procedure, while in group (B) the lateral femoral wall remained intact. All patients were regularly followed up radiologically and clinically per the Harris Hip Score (HHS) for a period of 12 months. Results. At 12 months five patients (12%) suffered a postoperative lateral wall fracture, while in 37 patients (88%) the lateral femoral wall remained intact. The mean preoperative LWT of patients with a postoperative lateral wall fracture was 18.04 mm (SD ± 1.58) compared to 26.22mm (SD ± 5.93) in the group without a lateral wall fracture. All patients with post-operative lateral femoral wall fracture belong to 31A2 group, while 78.4% of the patients that did not develop post-operative lateral femoral wall fracture belong to 31A1 group. Eighty percent of patients in group (A) experienced shortening, collapse, shaft medialization and varus deformity. The mean Harris hip score of group (A) was 39.60 at 3 months and 65.67 at 6 months postoperatively, while that of group (B) was 80.75 and 90.65 at 3 and 6 months respectively, denoting a statistically significant difference (P<0.001). Treatment failure meriting a revision surgery was 40 % in group (A) and 8% in group (B) denoting a statistically significant difference (p<0.001). The cut-off point of LWT below which there is a high chance of post-operative lateral wall fracture when fixed with DHS is 19.6mm. This was shown on the receiver operating curve (ROC) by plotting the sensitivity against the 100 % specificity with a set 95% confidence interval 0.721 – 0.954. When lateral wall thickness was at 19.6 mm, the sensitivity was 100% and specificity was 81.8%. The area under the curve (AUC) was 0.838, which was statistically significant (P = 0.015). Conclusions. Preoperative measurement of LWT in elderly patients with intertrochanteric hip fractures is decisive. The cut off point for postoperative lateral wall fracture according to our study is 19.6 mm; hence,
Purpose.
Introduction: Most of the bone metastases have origin in breast, lung, prostate, thyroid and kidney neoplasms. The commonest locations are the axial skeleton and the proximal region of the long bones, being the femur the most affected one. The main objectives of the surgical treatment are a quick functional recuperation and immediate pain relief. Objectives: The aim of this work was to define a strategy for the surgical treatment of the bone methastasis located in the femur. Material: The study includes 94 patients with femoral methastasis (100 metastasis) surgicaly treated in the last 10 years in our department. Methods: Retrospective descriptive study based on medical records evaluation. Results: The proximal third of the femur was involved in 80 % of the cases. Pathological fracture was identified in 72 cases and impending fracture in 28. Half of the primitive neoplasms was originated in the breast. It was identified as solitary metastatic lesion only in 33 % of the situations. The mean patient survival time was 9,2 months. They were treated with a cemented calcar-replacing prosthesis in 40 patients, 10 patients submited to conventional arthroplasty and 36 with
The “keel” is the relatively short part of the undersurface of the tibial component that extends into the medullary canal. Most knee replacement systems have the capacity to attach modular stem extensions for enhanced intra-medullary fixation for revision. Diaphyseal length, large diameter stems may also guide positioning of trial components and are ideal for accurate surgical technique, even if fully cemented stems are eventually implanted. Smaller diameter non-modular stem extensions may be used for fully cemented fixation. They do not however guide component position very accurately and do not make sense for uncemented fixation. Revision surgery is different from primary surgery and enhanced fixation with some type of