To evaluate the functional outcome of open humerus diaphyseal fractures treated with the Three-stitch technique of antegrade humerus nailing. This is a retrospective study conducted at the Department of Orthopaedics in D. Y. Patil University, School of Medicine, Navi Mumbai, India. The study included 25 patients who were operated on from January 2019 to April 2021 and follow-ups done till May 2022. Inclusion criteria were adult patients with open humerus diaphyseal fractures (Gustilo-Anderson Classification). All patients with closed fractures, skeletally immature patients, and patients with associated head injury were excluded from the study. All patients were operated on with a minimally invasive Three-stitch technique for antegrade humerus nailing. All patients were evaluated based on DASH score. Out of the 25 patients included in the study, all patients showed complete union. The mean age of the patients was 40.4 years (range 23–66 years). The average period for consolidation of fracture was 10.56 weeks (range 8–14 weeks). The DASH score ranged from 0 to 15.8 with an average score of 2.96. Five patients reported complications with three patients of post-operative infection and delayed wound healing and two patients with screw loosening. All complications were resolved with proper wound care and the complete union was noted. None of the patients had an iatrogenic neurovascular injury. Three-stitch antegrade nailing technique is a novel method to treat diaphyseal humerus fractures and provides excellent results. It has various advantages such as minimal invasiveness, minimal injury to the rotator cuff, fewer infection rates, minimal iatrogenic injuries, and good functional outcomes. Therefore, this treatment modality can be effectively used for open humerus diaphyseal fractures

To quantify bone-nail fit in response to varying nail placements by entry point translation in straight antegrade humeral nailing using three-dimensional (3D) computational analysis. CT scans of ten cadaveric humeri were processed in 3D Slicer to obtain 3D models of the cortical and cancellous bone. The bone was divided into individual slices each consisting of 2% humeral length (L) with the centroid of each slice determined. To represent straight antegrade humeral nail, a rod consisting of two cylinders with diameters of 9.5mm and 8.5mm and length of 0.22L mm and 0.44L mm respectively joined at one end was modelled. The humeral head apex (surgical entry point) was translated by 1mm in both anterior-posterior and medio-lateral directions to generate eight entry points. Total nail protrusion surface area, maximum nail protrusion distance into cortical shell and top, middle, bottom deviation between nail and intramedullary cavity centre were investigated. Statistical analysis between the apex and translated entry points was conducted using paired t-test. A posterior-lateral translation was considered as the optimal entry point with minimum protrusion in comparison to the anterior-medial translation experiencing twice the level of protrusion. Statistically significant differences in cortical protrusion were found in anterior-medial and posterior-lateral directions producing increased and decreased level of protrusion respectively compared to the apex. The bottom anterior-posterior deviation distance appeared to be a key predictor of cortical breach with the distal nail being more susceptible. Furthermore, nails with anterior translation generated higher anterior-posterior deviation (>4mm) compared to posterior translation (<3mm). Aside from slight posterolateral translation of the entry point from the apex, inclusion of a distal posterior-lateral bend into current straight nail design could improve nail fitting within the curved humeral bone, potentially improving distal working length within the flat and narrow medullary canal of the distal humeral shaft

Background. The approach to Intramedullary (IM) fixation of long bone fractures remains a controversial issue. Early reports demonstrated less favourable results of retrograde nailing as compared with antegrade options due to higher non-union rates. The aim of this audit was to evaluate the outcomes of practice within the Trauma and Orthopaedic department with relation to IM nail fixation of diaphyseal femur fractures. Methodology. The Trauma database between February 2010 and September 2013 was used to identify all femur IM nailing procedures. Picture Archiving and Communication System (PACS) software was used to classify the fractures according to the Muller AO classification. All 3–2 (Diaphyseal femur fractures) were included in the audit. PACS imaging together with outpatient documentation was evaluated for radiological and clinical outcome. Results. A total sample size of 23 patients was identified (13 antegrade vs. 10 retrograde approach fixations). Mean patient age was 67 years and male to female ratios were similar (11M vs. 12F). Antegrade nailing was performed in a younger population as compared to retrograde nailing (mean age 60 vs. 73 respectively). Mean time to union was somewhat more protracted in the retrograde group (7 vs. 5 months), although all fractures united. The most common complication with relation to antegrade nailing was due to distal locking screws backing out. I case of infection was reported in the retrograde nail group, which was treated successfully with antibiotic therapy. There were 2 cases of nonunion observed in the antegrade group. Conclusions. The results of our practice were comparable to those published in recent literature. Overall, union rates for the two groups of fixation were similar. Each fixation technique is associated with its own specific set of complications. As a general rule antegrade nailing was reserved for a younger population so as to prevent trauma to the native knee joint

Introduction and Objective. Trochanteric fractures are associated with increasing incidence and represent serious adverse effect of osteoporosis. Their cephalomedullary nailing in poor bone stock can be challenging and associated with insufficient implant fixation in the femoral head. Despite ongoing implant improvements, the rate of mechanical complications in the treatment of unstable trochanteric fractures is high. Recently, two novel concepts for nailing with use of a helical blade – with or without bone cement augmentation – or an interlocking screw have demonstrated advantages as compared with single screw systems regarding rotational stability and cut-out resistance. However, these two concepts have not been subjected to direct biomechanical comparison so far. The aims of this study were to investigate in a human cadaveric model with low bone density (1) the biomechanical competence of cephalomedullary nailing with use of a helical blade versus an interlocking screw, and (2) the effect of cement augmentation on the fixation strength of the helical blade. Materials and Methods. Twelve osteoporotic and osteopenic femoral pairs were assigned for pairwise implantation using either short TFN-ADVANCED Proximal Femoral Nailing System (TFNA) with a helical blade head element, offering the option for cement augmentation, or short TRIGEN INTERTAN Intertrochanteric Antegrade Nail (InterTAN) with an interlocking screw. Six osteoporotic femora, implanted with TFNA, were augmented with 3 ml cement. Four study groups were created – group 1 (TFNA) paired with group 2 (InterTAN), and group 3 (TFNA augmented) paired with group 4 (InterTAN). An unstable pertrochanteric OTA/AO 31-A2.2 fracture was simulated. All specimens were biomechanically tested until failure under progressively increasing cyclic loading featuring physiologic loading trajectory, with monitoring via motion tracking. Results. T-score in groups 3 and 4 was significantly lower compared with groups 1 and 2, p=0.03. Stiffness (N/mm) in groups 1 to 4 was 335.7+/−65.3, 326.9+/−62.2, 371.5+/−63.8 and 301.6+/−85.9, being significantly different between groups 3 and 4, p=0.03. Varus (°) and femoral head rotation around neck axis (°) after 10,000 cycles were 1.9+/−0.9 and 0.3+/−0.2 in group 1, 2.2+/−0.7 and 0.7+/−0.4 in group 2, 1.5+/−1.3 and 0.3+/−0.2 in group 3, and 3.5+/−2.8 and 0.9+/−0.6 in group 4, both with significant difference between groups 3 and 4, p<=0.04. Cycles to failure and failure load (N) at 5° varus in groups 1 to 4 were 21428+/−6020 and 1571.4+/−301.0, 20611+/−7453 and 1530.6+/−372.7,21739+/−4248 and 1587.0+/−212.4, and 18622+/−6733 and 1431.1+/−336.7, both significantly different between groups 3 and 4, p=0.04. Conclusions. From a biomechanical perspective, cephalomedullary nailing of trochanteric fractures with use of helical blades is comparable to interlocking screw fixation in femoral head fragments with low bone density. Moreover, bone cement augmentation of helical blades considerably improves their fixation strength in poor bone quality

Background. Currently about 4–6% of all femur fractures consist of distal femoral fractures. Different methods and implants have been used for the surgical treatment of distal femoral fractures, including intramedullary nails. Retrograde nail. By contrast with antegrade nails, surgical approach or retrograde nailing exposes the knee joint which may lead to tendency of infection and increased knee pain. Present study aims to compare the biomechanical behaviour of distal angular condyler femoral intramedullary nail (DACFIN), retrograde nail and plate fixation. Methods. Fifteen 4th generation Saw bones were used to evaluate the biomechanical differences between the groups (Group 1: Plate fixation, Group 2: Retrograde nailing, Group 3: DACFIN; (n=5)). Biomechanical test was performed by using an electromechanical test device Shimadzu (AG-IS 5kN, Japan). Displacement values were recorded by using a Non-contact Video Extensometer (DVE-101/201, Shimadzu, Japan) during the loading each femur with 5 cycles of 500 N at a rate of 10 N/s to determine axial stiffness. The faliure stiffness was measured by axial load to each constructat a displacement rate of 5 mm/min. Torsional loading applied to all groups in amount of 6 Nm of torque with a velocity of 18 degrees/min. Results. The mean torsion stiffness value of Group 3 (6.33 Nm/degree) was signifacantly higher than Group 1 (1.18 Nm/degree) and Group 2 (2.11Nm/degree), p<0.05). The failure stiffness, Group 3 (1725 N/mm) was significantly higher than Group 1 (1275 N/ mm) and Group 2 (1290 N/mm). However, In axial stiffness, the mean value of Group 2 (2554 N/mm) was higher than Group 3 (1822 N/mm), and signifantly higher than Group 1(468 N/mm), p<0.05). Conclusions. DACFIN is more stiffer than retrograde nail and plate fixation during torsional and failure load conditions. But in axial stiffness retrograde nail was stiffer. DACFIN provide intramedullary femur condyle fracture fixations without open knee joint. Level of evidence. Level 5. Disclosure. Authors declare that there is no conflict of interest related to the present study

Displaced proximal Humeral fractures at Inverclyde Royal Hospital prior to 2008 were previously treated with the antegrade Acumed Polaris Proximal Humeral, predominantly in 2 part fractures. The Philos plate was introduced in 2008, initially being used to treat select non unions, and then expanded to acute fractures. The aim of this study was to assess time to union and complications in the lower volume District General setting comparing to published outcomes. From February 2008 – January 2011, 20 patients were identified. Age range 49–75 (mean 61.2) years, 8 male; 12 female. Left 9, Right 11 Neers 2 part 35%; 3 35%; 4 30%. 16 (80%) were performed in acute fractures with 4 for non-unions, 3 of which were previous polaris nail fixations. 2 patients were lost to follow up after 6/52 but were progressing well. Union was confirmed radiologically and clinically in all but 2 remaining patients (10%), one of whom suffered a significant complication of plate fracture, the second treated with revision for painful non union. 2 other significant complications were observed: transient axillary nerve palsy and deep infection. Both of these patients recovered with delayed union observed in the infection case (52 weeks). Time to union range was 8–52 weeks (mean 17.1). The literature shows a high failure rate of up to 45% with intramedullary nail fixation and limited predominantly to 2 part fractures with risk of damage to the rotator cuff. This study shows a satisfactory union rate using the Philos of 90% with only 3 (15%) requiring further surgery for non-union, plate fracture and infection. 3 and 4 part fractures composed 65% of case load. Early results indicate satisfactory outcomes compared to current published literature

Objectives

We studied subchondral intraosseous pressure (IOP) in an animal model during loading, and with vascular occlusion. We explored bone compartmentalization by saline injection.

Malpositioning of the trochanteric entry point during the introduction of an intramedullary nail may cause iatrogenic fracture or malreduction. Although the optimal point of insertion in the coronal plane has been well described, positioning in the sagittal plane is poorly defined.

The paired femora from 374 cadavers were placed both in the anatomical position and in internal rotation to neutralise femoral anteversion. A marker was placed at the apparent apex of the greater trochanter, and the lateral and anterior offsets from the axis of the femoral shaft were measured on anteroposterior and lateral photographs. Greater trochanteric morphology and trochanteric overhang were graded.

The mean anterior offset of the apex of the trochanter relative to the axis of the femoral shaft was 5.1 mm (sd 4.0) and 4.6 mm (sd 4.2) for the anatomical and neutralised positions, respectively. The mean lateral offset of the apex was 7.1 mm (sd 4.6) and 6.4 mm (sd 4.6), respectively.

Placement of the entry position at the apex of the greater trochanter in the anteroposterior view does not reliably centre an intramedullary nail in the sagittal plane. Based on our findings, the site of insertion should be about 5 mm posterior to the apex of the trochanter to allow for its anterior offset.

Cite this article: Bone Joint J 2014;96-B:1274–81.

In spite of extensive accounts describing the blood supply to the femoral head, the prediction of avascular necrosis is elusive. Current opinion emphasises the contributions of the superior retinacular artery but may not explain the clinical outcome in many situations, including intramedullary nailing of the femur and resurfacing of the hip. We considered that significant additional contribution to the vascularity of the femoral head may exist. A total of 14 fresh-frozen hips were dissected and the medial circumflex femoral artery was cannulated in the femoral triangle. On the test side, this vessel was ligated, with the femoral head receiving its blood supply from the inferior vincular artery alone. Gadolinium contrast-enhanced MRI was then performed simultaneously on both control and test specimens. Polyurethane was injected, and gross dissection of the specimens was performed to confirm the extraosseous anatomy and the injection of contrast. The inferior vincular artery was found in every specimen and had a significant contribution to the vascularity of the femoral head. The head was divided into four quadrants: medial (0), superior (1), lateral (2) and inferior (3). In our study specimens the inferior vincular artery contributed a mean of 56% (25% to 90%) of blood flow in quadrant 0, 34% (14% to 80%) of quadrant 1, 37% (18% to 48%) of quadrant 2 and 68% (20% to 98%) in quadrant 3. Extensive intra-osseous anastomoses existed between the superior retinacular arteries, the inferior vincular artery and the subfoveal plexus.

The aim of this study was to validate the use of three models of fracture fixation in the assessment of technical skills. We recruited 21 subjects (six experts, seven intermediates, and eight novices) to perform three procedures: application of a dynamic compression plate on a cadaver porcine model, insertion of an unreamed tibial intramedullary nail, and application of a forearm external fixator, both on synthetic bone models. The primary outcome measures were the Objective Structural Assessment of technical skills global rating scale on video recordings of the procedures which were scored by two independent expert observers, and the hand movements of the surgeons which were analysed using the Imperial College Surgical Assessment Device.

The video scores were significantly different for the three groups in all three procedures (p < 0.05), with excellent inter-rater reliability (α = 0.88). The novice and intermediate groups specifically were significantly different in their performance with dynamic compression plate and intramedullary nails (p < 0.05). Movement analysis distinguished between the three groups in the dynamic compression plate model, but a ceiling effect was demonstrated in the intramedullary nail and external fixator procedures, where intermediates and experts performed to comparable standards (p > 0.6). A total of 85% (18 of 21) of the subjects found the dynamic compression model and 57% (12 of 21) found all the models acceptable tools of assessment.

This study has validated a low-cost, high-fidelity porcine dynamic compression plate model using video rating scores for skills assessment and movement analysis. It has also demonstrated that Synbone models for the application of and intramedullary nail and an external fixator are less sensitive and should be improved for further assessment of surgical skills in trauma. The availability of valid objective tools of assessment of surgical skills allows further studies into improving methods of training.

A rat model of lumbar root constriction with an additional sympathectomy in some animals was used to assess whether the sympathetic nerves influenced radicular pain. Behavioural tests were undertaken before and after the operation.

On the 28th post-operative day, both dorsal root ganglia and the spinal roots of L4 and L5 were removed, frozen and sectioned on a cryostat (8 μm to 10 μm). Immunostaining was then performed with antibodies to tyrosine hydroxylase (TH) according to the Avidin Biotin Complex method. In order to quantify the presence of sympathetic nerve fibres, we counted TH-immunoreactive fibres in the dorsal root ganglia using a light microscope equipped with a micrometer graticule (10 x 10 squares, 500 mm x 500 mm). We counted the squares of the graticule which contained TH-immunoreactive fibres for each of five randomly-selected sections of the dorsal root ganglia.

The root constriction group showed mechanical allodynia and thermal hyperalgesia. In this group, TH-immunoreactive fibres were abundant in the ipsilateral dorsal root ganglia at L5 and L4 compared with the opposite side. In the sympathectomy group, mechanical hypersensitivity was attenuated significantly.

We consider that the sympathetic nervous system plays an important role in the generation of radicular pain.