The delay looks radiographically as a fracture callus not very evident or absent 6 months after osteosynthesis. Patients undergo a long period of immobilization and this fact causes the increase the social cost of the disease. The technique we suggest aims to the reduce the period of immobilization and as a consequence the management costs of the disease. Our technique includes the infiltration of the delay focus with platelet rich fibrin, bone marrow concentrated and demineralized bone matrix. Outpatients and radiographic checks were carried out 3, 6 and 12 months after surgery. The treatment was considered fail in case of absence of bone callus at 3 out of 4 corticals at the rx after 6 months from surgery.Introduction
Materials and methods
A successful outcome following treatment of nonunion requires the correct identification of all of the underlying cause(s) and addressing them appropriately. The aim of this study was to assess the distribution and frequency of causative factors in a consecutive cohort of nonunion patients in order to optimise the management strategy for individual patients presenting with nonunion. Causes of the nonunion were divided into four categories: mechanical; infection; dead bone with a gap; and host. Prospective and retrospective data of 100 consecutive patients who had undergone surgery for long bone fracture nonunion were analysed.Objectives
Methods
Aims. The incidence of atypical femoral fractures (AFFs) continues to increase. However, there are currently few long-term studies on the complications of AFFs and factors affecting them. Therefore, we attempted to investigate the outcomes, complications, and risk factors for complication through mid-term follow-up of more than three years. Methods. From January 2003 to January 2016, 305 patients who underwent surgery for AFFs at six hospitals were enrolled. After exclusion, a total of 147 patients were included with a mean age of 71.6 years (48 to 89) and 146 of whom were female. We retrospectively evaluated medical records, and reviewed radiographs to investigate the fracture site, femur bowing angle, presence of delayed union or nonunion, contralateral AFFs, and peri-implant fracture. A statistical analysis was performed to identify the significance of associated factors. Results. The mean follow-up period was 70.2 months (36 to 191). There were 146 AFFs (99.3%) in female patients and the mean age was 71.6 years (48 to 89). The AFFs were located in the subtrochanter and shaft in 52 cases (35.4%) and 95 (64.6%), respectively. The preoperative mean anterior/lateral femoral bowing angles were 10.5° (SD 5.7°)/6.1° (SD 6.2°). The postoperative mean anterior/lateral bowing values were changed by 8.7° (SD 5.4°)/4.6° (SD 5.9°). Bisphosphonates had been used contemporarily in 115 AFFs (78.2%) for a mean of 52.4 months (1 to 204; SD 45.5) preoperatively. Nailing was performed in 133 AFFs (90.5%), and union was obtained at a mean of 23.6 weeks (7 to 85).
Aims. The primary aim of this study was to identify independent predictors associated with nonunion and delayed union of tibial diaphyseal fractures treated with intramedullary nailing. The secondary aim was to assess the Radiological Union Scale for Tibial fractures (RUST) score as an early predictor of tibial fracture nonunion. Methods. A consecutive series of 647 patients who underwent intramedullary nailing for tibial diaphyseal fractures were identified from a trauma database. Demographic data, comorbidities, smoking status, alcohol consumption, use of non-steroidal anti-inflammatory drugs (NSAIDs), and steroid use were documented. Details regarding mechanism of injury, fracture classification, complications, and further surgery were recorded. Nonunion was defined as the requirement for revision surgery to achieve
To analyse the management of open paediatric tibial fractures treated at a children's Major Trauma Centre (MTC), comparing fixation methods, union and complications. We retrospectively identified all patients admitted to RMCH with an open tibia fracture between 2008 – 2016. Demographics, mechanism, inpatient stay and follow-up management were reviewed. There were a total of 44 patients, with an average age = 10 years (3–15). 93% of cases were caused by road traffic accidents, commonly pedestrian versus car. Older children were more likely to sustain higher grade injuries, requiring increased length of stay. 35 patients had primary / delayed wound closure, 1 patient required fasciotomies and 4/44 needed skin grafts and/or flap. 7 patients were treated in plaster, 9 by elastic nailing, 15 had mono-lateral fixators and 12 with circular frame. The average number of surgeries = 3 (1–7) with older children having increased risk of revision surgery. Monolateral fixators were the most common primary fixation method (n=15), however 60% required revision to ring fixator due to displacement or delayed union. The main risk factor for displacement was inadequate fracture reduction in theatre, as well as those fracture patterns involving butterfly fragments. Union (defined as RUST score = 3 on >3 cortices) was achieved in all patients (ave 6 months).
Objective. To determine what factors affect fracture healing with low-intensity pulsed ultrasound (LIPUS) for delayed unions and nonunions. Patients. A consecutive cohort of 101 delayed unions and 50 nonunions after long bone fractures treated with LIPUS between May 1998 and April 2007. Main Outcome and Measurements. Radiographic determination of osseous bone union within one year after start of LIPUS therapy. Recognition of predictable factors that affect treatment results of LIPUS. Main Results. 1)
Objective. Combined metatarso-phalangeal and inter-phalangeal deformity represents about 1% of hallux valgus deformity, and its treatment remains a debated topic, because a single osteotomy does not entirely correct the deformity and double osteotomies are needed. The aim of this study is to review the results of 50 consecutive combined metatarso-phalangeal and inter-phalangeal hallux valgus treated by Akin proximal phalangeal osteotomy and SERI minimally invasive distal metatarsal osteotomy. Material and Methods. Fifty feet in 27 patients, aged between 18 and 75 years (mean 42 years) affected by symptomatic hallux valgus without arthritis were included. Two 1-cm medial incisions were performed at the metatarsal neck and at proximal phalanx. Then SERI osteotomy was performed to correct metatarso-phalangeal deformity and Akin osteotomy was performed to correct interphalangeal deformity. Both osteotomies were fixed with a single K-wire. A gauze bandage of the forefoot was applied and immediate weight-bearing on hindfoot was allowed. K-wire was removed after 4 weeks. All patients were checked at a mean 4 year follow-up. Results. All osteotomies healed.
There is a lack of published evidence relating to the rate of nonunion seen in occult scaphoid fractures, diagnosed only after MRI. This study reports the rate of delayed union and nonunion in a cohort of patients with MRI-detected acute scaphoid fractures. This multicentre cohort study at eight centres in the UK included all patients with an acute scaphoid fracture diagnosed on MRI having presented acutely following wrist trauma with normal radiographs. Data were gathered retrospectively for a minimum of 12 months at each centre. The primary outcome measures were the rate of acute surgery, delayed union, and nonunion.Aims
Methods
AIM. SIGN-nail system was elaborated to reduce the need in image intensifier during IM-nailing and to allow use of this method in poor countries with restricted medical facilities. The aim of this study was to evaluate efficacy of SIGN-nailing in tibia fractures treatment. MAT. 119 patients with 120 tibia fractures were treated with SIGN nails from 2006 to 2009. Mean age 41.4±12.9 years (17–72). Closed fractures - 106, open - 14 (Gustilo I-6, II-6, III-2 III). Interval from the injury to operation: 6.24±7.9 days (0–45); 71.7% of patients were operated within a week after the injury. Closed reposition achieved in all but 7 cases. Manual reaming was performed in most cases, power -9, no reaming -8 cases. Distal locking was performed with use of supplied jig. RES. Satisfactory reposition and fixation was achieved in most cases, axial deviations more than 5° were noticed post-operatively in 6 cases, or developed within 2 months in other 2, but were well tolerated clinically. All deviations were seen in joint-adjacent fractures (proximal 5, distal 3). Purulent complications were seen in 2 cases (1.6%). Follow-up results in terms exceeding 12 months were obtained in 106 patients (mean 13.6±6.6, range 6–36). No non-unions were seen.
Postoperative malalignment of the femur is one of the main complications in distal femur fractures. Few papers have investigated the impact of intraoperative malalignment on postoperative function and bone healing outcomes. The aim of this study was to investigate how intraoperative fracture malalignment affects postoperative bone healing and functional outcomes. In total, 140 patients were retrospectively identified from data obtained from a database of hospitals participating in a trauma research group. We divided them into two groups according to coronal plane malalignment of more than 5°: 108 had satisfactory fracture alignment (< 5°, group S), and 32 had unsatisfactory alignment (> 5°, group U). Patient characteristics and injury-related factors were recorded. We compared the rates of nonunion, implant failure, and reoperation as healing outcomes and Knee Society Score (KSS) at three, six, and 12 months as functional outcomes. We also performed a sub-analysis to assess the effect of fracture malalignment by plates and nails on postoperative outcomes.Aims
Methods
The study objective was to prospectively assess clinical outcomes for a pilot cohort of tibial shaft fractures treated with a new tibial nailing system that produces controlled axial interfragmentary micromotion. The hypothesis was that axial micromotion enhances fracture healing compared to static interlocking. Patients were treated in a single level I trauma centre over a 2.5-year period. Group allocation was not randomized; both the micromotion nail and standard-of-care static locking nails (control group) were commercially available and selected at the discretion of the treating surgeons. Injury risk levels were quantified using the Nonunion Risk Determination (NURD) score. Radiological healing was assessed until 24 weeks or clinical union. Low-dose CT scans were acquired at 12 weeks and virtual mechanical testing was performed to objectively assess structural bone healing.Aims
Methods
Following cast removal for nonoperatively treated distal radius fractures, rehabilitation facilitated by advice leaflet and advice video were compared to a course of face-to-face therapy. Adults with an isolated, nonoperatively treated distal radius fracture were included at six weeks post-cast removal. Participants were randomized to delivery of rehabilitation interventions in one of three ways: an advice leaflet; an advice video; or face-to-face therapy session(s). The primary outcome measure was the Disabilities of the Arm, Shoulder and Hand (DASH) score at six weeks post intervention and secondary outcome measures included DASH at one year, DASH work subscale, grip strength, and range of motion at six weeks and one year.Aims
Methods
The primary aim of this study was to establish the cost-effectiveness of the early fixation of displaced midshaft clavicle fractures. A cost analysis was conducted within a randomized controlled trial comparing conservative management (n = 92) Aims
Patients and Methods
In this retrospective observational cohort study,
we describe 17 patients out of 1775 treated for various fractures who
developed mycobacterium tuberculosis (MTB) infection after surgery.
The cohort comprised 15 men and two women with a mean age of 40
years (24 to 70). A total of ten fractures were open and seven were
closed. Of these, seven patients underwent intramedullary nailing
of a fracture of the long bone, seven had fractures fixed with plates,
two with Kirschner-wires and screws, and one had a hemiarthroplasty
of the hip with an Austin Moore prosthesis. All patients were followed-up
for two years. In all patients, the infection resolved, and in 14
the fractures united. Nonunion was seen in two patients one of whom
underwent two-stage total hip arthroplasty (THA) and the other patient
was treated using excision arthoplasty. Another patient was treated
using two-stage THA. With only sporadic case reports in the literature,
MTB infection is rarely clinically suspected, even in underdeveloped
and developing countries, where pulmonary and other forms of TB
are endemic. In developed countries there is also an increased incidence
among immunocompromised patients. In this paper we discuss the pathogenesis
and incidence of MTB infection after surgical management of fractures
and suggest protocols for early diagnosis and management. Cite this article:
The aim of this study was to evaluate the outcomes of a salvage procedure using a 95° angled blade plate for failed osteosynthesis of atypical subtrochanteric femoral fractures associated with the long-term use of bisphosphonates. These were compared with those for failed osteosynthesis of subtrochanteric fractures not associated with bisphosphonate treatment. Between October 2008 and July 2016, 14 patients with failed osteosynthesis of an atypical subtrochanteric femoral fracture were treated with a blade plate (atypical group). Their mean age was 67.8 years (60 to 74); all were female. During the same period, 21 patients with failed osteosynthesis of a typical subtrochanteric fracture underwent restabilization using a blade plate (typical group). Outcome variables included the time of union, postoperative complications, Harris Hip Score, and Sanders functional rating scale.Aims
Patients and Methods
The management of a significant bony defect following excision
of a diaphyseal atrophic femoral nonunion remains a challenge. We
present the outcomes using a combined technique of acute femoral
shortening, stabilized with a long retrograde intramedullary nail,
accompanied by bifocal osteotomy compression and distraction osteogenesis with
a temporary monolateral fixator. Eight men and two women underwent the ‘rail and nail’ technique
between 2008 and 2016. Proximal locking of the nail and removal
of the external fixator was undertaken once the length of the femur
had been restored and prior to full consolidation of the regenerate.Aims
Patients and Methods
External fixators are the traditional fixation method of choice for contaminated open fractures. However, patient acceptance is low due to the high profile and therefore physical burden of the constructs. An externalised locking compression plate is a low profile alternative. However, the biomechanical differences have not been assessed. The objective of this study was to evaluate the axial and torsional stiffness of the externalised titanium locking compression plate (ET-LCP), the externalised stainless steel locking compression plate (ESS-LCP) and the unilateral external fixator (UEF). A fracture gap model was created to simulate comminuted mid-shaft tibia fractures using synthetic composite bones. Fifteen constructs were stabilised with ET-LCP, ESS-LCP or UEF (five constructs each). The constructs were loaded under both axial and torsional directions to determine construct stiffness.Objectives
Methods
This study compares the outcomes of two methods
of fixation of displaced fractures of the radial neck. The 58 patients
with a mean age of 38.5 years (18 to 56), were treated in a non
randomised study with screws (n = 29) or a plate and screws (n =
29) according to the surgeon’s preference. The patients were reviewed at one year. Radiographs and functional
evaluations were carried out up to one year post-operatively, using
the Broberg and Morrey functional evaluation score, range of movement,
and assessment of complications. The mean functional scores did not differ significantly between
groups (90 (55 to 100) Cite this article:
Although it is widely accepted that grade IIIB open tibial fractures require combined specialised orthopaedic and plastic surgery, the majority of patients in the UK initially present to local hospitals without access to specialised trauma facilities. The aim of this study was to compare the outcome of patients presenting directly to a specialist centre (primary group) with that of patients initially managed at local centres (tertiary group). We reviewed 73 consecutive grade IIIB open tibial shaft fractures with a mean follow-up of 14 months (8 to 48). There were 26 fractures in the primary and 47 in the tertiary group. The initial skeletal fixation required revision in 22 (47%) of the tertiary patients. Although there was no statistically-significant relationship between flap timing and flap failure, all the failures (6 of 63; 9.5%) occurred in the tertiary group. The overall mean time to union of 28 weeks was not influenced by the type of skeletal fixation. Deep infection occurred in 8.5% of patients, but there were no persistently infected fractures. The infection rate was not increased in those patients debrided more than six hours after injury. The limb salvage rate was 93%. The mean limb functional score was 74% of that of the normal limb. At review, 67% of patients had returned to employment, with a further 10% considering a return after rehabilitation. The times to union, infection rates and Enneking limb reconstruction scores were not statistically different between the primary and tertiary groups. The increased complications and revision surgery encountered in the tertiary group suggest that severe open tibial fractures should be referred directly to specialist centres for simultaneous combined management by orthopaedic and plastic surgeons.
The ideal form of fixation for displaced, extra-articular
fractures of the distal tibia remains controversial. In the UK, open
reduction and internal fixation with locking-plates and intramedullary
nailing are the two most common forms of treatment. Both techniques
provide reliable fixation but both are associated with specific
complications. There is little information regarding the functional
recovery following either procedure. We performed a randomised pilot trial to determine the functional
outcome of 24 adult patients treated with either a locking-plate
(n = 12) or an intramedullary nailing (n = 12). At six months, there
was an adjusted difference of 13 points in the Disability Rating
Index in favour of the intramedullary nail. However, this was not
statistically significant in this pilot trial (p = 0.498). A total
of seven patients required further surgery in the locking-plate
group and one in the intramedullary nail group. This study suggests that there may be clinically relevant, functional
differences in patients treated with nail