Aims. This study aimed to compare mortality in trochanteric AO/OTA A1 and A2 fractures treated with an intramedullary nail (IMN) or sliding hip screw (SHS). The primary endpoint was 30-day mortality, with secondary endpoints at 0 to 1, 2 to 7, 8 to 30, 90, and 365 days. Methods. We analyzed data from 26,393 patients with trochanteric AO/OTA A1 and A2 fractures treated with IMNs (n = 9,095) or SHSs (n = 17,298) in the Norwegian Hip Fracture Register (January 2008 to December 2020). Exclusions were made for patients aged < 60 years, pathological fractures, pre-2008 operations, contralateral hip fractures, fractures other than trochanteric A1/A2, and treatments other than IMNs or SHSs. Kaplan-Meier and Cox regression analyses adjusted for type of fracture, age, sex, cognitive impairment, American Society of Anesthesiologists (ASA) grade, and time period were conducted, along with calculations for number needed to harm (NNH). Results. In unadjusted analyses, there was no significant difference between IMN and SHS patient survival at 30 days (91.8% vs 91.1%; p = 0.083) or 90 days (85.4% vs 84.5%; p = 0.065), but higher one-year survival for IMNs (74.5% vs 73.3%; p = 0.031) compared with SHSs. After adjustments, no significant difference in 30-day mortality was found (hazard rate ratio (HRR) 0.94 (95% confidence interval (CI) 0.86 to 1.02(; p = 0.146). IMNs exhibited higher mortality at 0 to 1 days (HRR 1.63 (95% CI 1.13 to 2.34); p = 0.009) compared with SHSs, with a NNH of 556, but lower mortality at 8 to 30 days (HRR 0.89 (95% CI 0.80 to 1.00); p = 0.043). No differences were observed in mortality at 2 to 7 days (HRR 0.94 (95% CI 0.79 to 1.11); p = 0.434), 90 days (HRR 0.95 (95% CI 0.89 to 1.02); p = 0.177), or 365 days (HRR 0.97 (95% CI 0.92 to 1.02); p = 0.192). Conclusion. This study found no difference in 30-day mortality between IMNs and SHSs. However, IMNs were associated with a higher mortality at 0 to 1 days and a marginally lower mortality at 8 to 30 days compared with SHSs. The observed differences in mortality were small and should probably not guide choice of treatment. Cite this article: Bone Joint J 2024;106-B(6):603–612

Aims. Patients with A1 and A2 trochanteric hip fractures represent a substantial proportion of trauma caseload, and national guidelines recommend that sliding hip screws (SHS) should be used for these injuries. Despite this, intramedullary nails (IMNs) are routinely implanted in many hospitals, at extra cost and with unproven patient outcome benefit. We have used data from the National Hip Fracture Database (NHFD) to examine the use of SHS and IMN for A1 and A2 hip fractures at a national level, and to define the cost implications of management decisions that run counter to national guidelines. Methods. We used the NHFD to identify all operations for fixation of trochanteric fractures in England and Wales between 1 January 2021 and 31 December 2021. A uniform price band from each of three hip fracture implant manufacturers was used to set cost implications alongside variation in implant use. Results. We identified 18,156 A1 and A2 trochanteric hip fractures in 162 centres. Of these, 13,483 (74.3%) underwent SHS fixation, 2,352 (13.0%) were managed with short IMN, and 2,321 (12.8%) were managed with long IMN. Total cost of IMN added up to £1.89 million in 2021, and the clinical justification for this is unclear since rates of IMN use varied from 0% to 97% in different centres. Conclusion. Most trochanteric hip fractures are managed with SHS, in keeping with national guidelines. There is considerable variance between hospitals for implant choice, despite the lack of evidence for clinical benefit and cost-effectiveness of more expensive nailing systems. This suggests either a lack of awareness of national guidelines or a choice not to follow them. We encourage provider units to reassess their practice if outwith the national norm. Funding bodies should examine implant use closely in this population to prevent resource waste at a time of considerable health austerity. Cite this article: Bone Jt Open 2022;3(10):741–745

Aims. The aim of this study was to investigate if there are differences in outcome between sliding hip screws (SHSs) and intramedullary nails (IMNs) with regard to fracture stability. Methods. We assessed data from 17,341 patients with trochanteric or subtrochanteric fractures treated with SHS or IMN in the Norwegian Hip Fracture Register from 2013 to 2019. Primary outcome measures were reoperations for stable fractures (AO Foundation/Orthopaedic Trauma Association (AO/OTA) type A1) and unstable fractures (AO/OTA type A2, A3, and subtrochanteric fractures). Secondary outcome measures were reoperations for A2, A3, and subtrochanteric fractures individually, one-year mortality, quality of life (EuroQol five-dimension three-level index score), pain (visual analogue scale (VAS)), and satisfaction (VAS) for stable and unstable fractures. Hazard rate ratios (HRRs) for reoperation were calculated using Cox regression analysis with adjustments for age, sex, and American Society of Anesthesiologists score. Results. Reoperation rate was lower after surgery with IMN for unstable fractures one year (HRR 0.82, 95% confidence interval (CI) 0.70 to 0.97; p = 0.022) and three years postoperatively (HRR 0.86, 95% CI 0.74 to 0.99; p = 0.036), compared with SHS. For individual fracture types, no clinically significant differences were found. Lower one-year mortality was found for IMN compared with SHS for stable fractures (HRR 0.87; 95% CI 0.78 to 0.96; p = 0.007), and unstable fractures (HRR 0.91, 95% CI 0.84 to 0.98; p = 0.014). Conclusion. This national register-based study indicates a lower reoperation rate for IMN than SHS for unstable trochanteric and subtrochanteric fractures, but not for stable fractures or individual fracture types. The choice of implant may not be decisive to the outcome of treatment for stable trochanteric fractures in terms of reoperation rate. One-year mortality rate for unstable and stable fractures was lower in patients treated with IMN. Cite this article: Bone Joint J 2022;104-B(2):274–282

Aims. This study aims to describe a new method that may be used as a supplement to evaluate humeral rotational alignment during intramedullary nail (IMN) insertion using the profile of the perpendicular peak of the greater tuberosity and its relation to the transepicondylar axis. We called this angle the greater tuberosity version angle (GTVA). Methods. This study analyzed 506 cadaveric humeri of adult patients. All humeri were CT scanned using 0.625 × 0.625 × 0.625 mm cubic voxels. The images acquired were used to generate 3D surface models of the humerus. Next, 3D landmarks were automatically calculated on each 3D bone using custom-written C++ software. The anatomical landmarks analyzed were the transepicondylar axis, the humerus anatomical axis, and the peak of the perpendicular axis of the greater tuberosity. Lastly, the angle between the transepicondylar axis and the greater tuberosity axis was calculated and defined as the GTVA. Results. The value of GTVA was 20.9° (SD 4.7°) (95% CI 20.47° to 21.3°). Results of analysis of variance revealed that females had a statistically significant larger angle of 21.95° (SD 4.49°) compared to males, which were found to be 20.49° (SD 4.8°) (p = 0.001). Conclusion. This study identified a consistent relationship between palpable anatomical landmarks, enhancing IMN accuracy by utilizing 3D CT scans and replicating a 20.9° angle from the greater tuberosity to the transepicondylar axis. Using this angle as a secondary reference may help mitigate the complications associated with malrotation of the humerus following IMN. However, future trials are needed for clinical validation. Cite this article: Bone Jt Open 2024;5(10):929–936

Introduction. Ankle fractures in the elderly are an increasing problem with our aging population. Options for treatment include non-operative and operative with a range of techniques available. Failure of treatment can lead to significant complications, morbidity and poor function. We compared the outcomes of two operative techniques, intramedullary hindfoot nailing (IMN) and fibular-pro-tibia fixation (FPT). This is the largest analysis of these techniques and there are no comparative studies published. Method. We retrospectively reviewed patients over the age of 60 with ankle fractures who were treated operatively between 2012 and 2017. We identified 1417 cases, including 27 patients treated with IMN and 41 treated with FPT. Age, sex, co-morbidities and injury pattern were collected. Primary outcome was re-operation rate. Secondary outcomes included other complications, length of stay and functional status. Results. The IMN group had a higher average co-morbidity score compared with the FPT group (estimated 10-year survival, 21% vs 53%, p=0.03). Re-operation rate was higher in the IMN group compared with FPT (12 v 1, p< 0.0001). There were more complications in the IMN group compared with the FPT group (23 v 11, p< 0.0001). Length of stay was longer in the IMN group (17 v 29 days, p=0.02). Mobility tended to return to baseline in the FPT patients but decreased in the IMN patients. Conclusion. Outcomes were worse in the IMN group compared with the FPT group in terms of re-operation, complications and length of stay. However, the IMN group tended to have increased comorbidities and poorer soft tissues. We believe that both techniques have a role in the management of elderly ankle fractures, but patient selection is key. We suggest FPT should be the first-choice technique when soft tissues permit. We discuss the indications, risks and benefits of each method based on our experience and literature review

Introduction. The evaluation of treatment modalities for distal femur periprosthetic fractures (DFPF) post-total knee arthroplasty (TKA) has predominantly focused on functional and radiological outcomes in existing literature. This study aimed to comprehensively compare the functional and radiological efficacy of locking plate (LP) and retrograde intramedullary nail (IMN) treatments, while incorporating mortality rates. Method. Twenty patients (15 female, 5 male) with a minimum 24-month follow-up period, experiencing Lewis-Rorabeck type-2 DFPF after TKA were included. These patients underwent either LP (n=10) or IMN (n=10). The average follow-up duration was 48 months (range: 24–192). Treatment outcomes, including functional scores, alignment, union time, complications, and mortality rates, were assessed and compared between LP and IMN groups. Clinical examination findings pre-treatment and at final follow-up, along with two-way plain radiographs, were utilized. Statistical analyses comprised Student's t-test and Kaplan-Meier survival analysis with a 95% confidence interval. Result. At final follow-up, the LP group demonstrated a mean Knee Society score of 67.2 ± 16.1, while the IMN group exhibited a score of 72.8 ± 9.4(P = 0.58). No statistically significant differences were observed in alignment between the groups[aLDFA (anatomical lateral distal femoral angle), P = 0.31; aPDFA (anatomical posterior distal femoral angle), P = 0.73]. The mean time to union was 3.7 ± 0.8 months for LP and 3.9 ± 0.6 months for IMN (P = 0.62). Complications such as infection occurred in 1 LP patient, and non-union was observed in 2 LP patients, while no complications were noted in IMN group(P < 0.01). Mortality rates were notably lower in the IMN group compared to the LP group across various time intervals. Conclusion. Both LP and IMN treatments yielded similar functional scores, alignment, and union time for DFPF post-TKA. However, the lower incidence of complications and mortality rates associated with IMN treatment suggest its superiority in managing DFPF following TKA

Aims. This study evaluated variation in the surgical treatment of stable (A1) and unstable (A2) trochanteric hip fractures among an international group of orthopaedic surgeons, and determined the influence of patient, fracture, and surgeon characteristics on choice of implant (intramedullary nailing (IMN) versus sliding hip screw (SHS)). Methods. A total of 128 orthopaedic surgeons in the Science of Variation Group evaluated radiographs of 30 patients with Type A1 and A2 trochanteric hip fractures and indicated their preferred treatment: IMN or SHS. The management of Type A3 (reverse obliquity) trochanteric fractures was not evaluated. Agreement between surgeons was calculated using multirater kappa. Multivariate logistic regression models were used to assess whether patient, fracture, and surgeon characteristics were independently associated with choice of implant. Results. The overall agreement between surgeons on implant choice was fair (kappa = 0.27 (95% confidence interval (CI) 0.25 to 0.28)). Factors associated with preference for IMN included USA compared to Europe or the UK (Europe odds ratio (OR) 0.56 (95% CI 0.47 to 0.67); UK OR 0.16 (95% CI 0.12 to 0.22); p < 0.001); exposure to IMN only during training compared to surgeons that were exposed to both (only IMN during training OR 2.6 (95% CI 2.0 to 3.4); p < 0.001); and A2 compared to A1 fractures (Type A2 OR 10 (95% CI 8.4 to 12); p < 0.001). Conclusion. In an international cohort of orthopaedic surgeons, there was a large variation in implant preference for patients with A1 and A2 trochanteric fractures. This is due to surgeon bias (country of practice and aspects of training). The observation that surgeons favoured the more expensive implant (IMN) in the absence of convincing evidence of its superiority suggests that surgeon de-biasing strategies may be a useful focus for optimizing patient outcomes and promoting value-based healthcare. Cite this article: Bone Joint J 2021;103-B(4):775–781

Aims. The primary aim of this study was to compare surgical methods (sliding hip screw (SHS) vs intramedullary nailing (IMN)) for trochanteric hip fracture in relation to death within 120 days after surgery and return to independent living. The secondary aim was to assess whether the associations between surgical method and death or ability to return to independent living varied depending on fracture subtype or other patient characteristics. Methods. A total of 27,530 individuals from the Swedish Hip Fracture Register RIKSHÖFT (SHR) aged ≥ 70 years, admitted to hospital between 1 January 2014 and 31 December 2019 with trochanteric hip fracture, were included. Within this cohort, 12,041 individuals lived independently at baseline, had follow-up information in the SHR, and were thus investigated for return to independent living. Death within 120 days after surgery was analyzed using Cox regression with SHS as reference and adjusted for age and fracture type. Return to independent living was analyzed using logistic regression adjusted for age and fracture type. Analyses were repeated after stratification by fracture type, age, and sex. Results. Overall, 2,171 patients (18%) who were operated with SHS and 2,704 patients (18%) who were operated with IMN died within 120 days after surgery. Adjusted Cox regression revealed no difference in death within 120 days for the whole group (hazard ratio 0.97 (95% CI 0.91 to 1.03)), nor after stratification by fracture type. In total, 3,714 (66%) patients who were operated with SHS and 4,147 (64%) patients who were operated with IMN had returned to independent living at follow-up. There was no significant difference in return to independent living for the whole group (odds ratio 0.95 (95% CI 0.87 to 1.03)), nor after stratification by fracture type. Conclusion. No overall difference was observed in death within 120 days or return to independent living following surgery for trochanteric hip fracture, depending on surgical method (SHS vs IMN) in this recent Swedish cohort, but there was a suggested benefit for SHS in subgroups of patients. Cite this article: Bone Jt Open 2024;5(10):843–850

Appropriate surgical management of hip fractures has major clinical and economic consequences. Recently IMN use has increased compared to SHS constructs, despite no clear evidence demonstrating superiority of outcome. We therefore set out to provide further evidence about the clinical and economic implications of implant choice when considering hip fracture fixation strategies. A retrospective cohort study using Scottish hip fracture audit (SHFA) data was performed for the period 2016–2022. Patients ≥50 with a hip fracture and treated with IMN or SHS constructs at Scottish Hospitals were included. Comparative analyses, including adjustment for confounders, were performed utilising Multivariable logistic regression for dichotomous outcomes and Mann-Whitney-U tests for non-parametric data. A sub-group analysis was also performed focusing on AO-A1/A2 configurations which utilised additional regional data. Cost differences in Length of Stay (LOS) were calculated using defined costs from the NHS Scotland Costs book. In all analyses p<0.05 denoted significance. 13638 records were included (72% female). 9867 received a SHS (72%). No significant differences were identified in 30 or 60-day survival (Odds Ratio [OR] 1.05, 95%CI 0.90–1.23; p=0.532), (OR 1.10, 95%CI 0.97–1.24; p=0.138) between SHS and IMN's. There was however a significantly lower early mobilisation rate with IMN vs SHS (OR 0.64, 95%CI 0.59–0.70; p<0.001), and lower likelihood of discharge to domicile by day-30 post-admission (OR 0.77, 95%CI 0.71–0.84; p<0.001). Acute and overall, LOS were significantly lower for SHS vs IMN (11 vs 12 days and 20 vs 24 days respectively; p<0.001). Findings were similar across a sub-group analysis of 559 AO A1/A2 fracture configurations. Differences in LOS potentially increases costs by £1230 per-patient, irrespective of the higher costs of IMN's v SHS. Appropriate SHS use is associated with early mobilisation, reduced LOS and likely with reduced cost of treatment. Further research exploring potential reasons for the identified differences in early mobilisation are warranted

The choice of whether to perform antegrade intramedullary nailing (IMN) or plate fixation (PF) poses a conundrum for the surgeon who must strike the balance between anatomical restoration while reducing elbow and shoulder functional impairment. Most humeral middle third shaft fractures are amenable to conservative management given the considerable acceptable deformity and anatomical compensation by patients. This study is concerned with the patient reported outcomes regarding shoulder and elbow function for IMN and PF respectively. A prospective cohort study following up all the cases treated surgically for middle third humeral fractures from 2016 to 2022 at a single centre. Telephonically an analogue pain score, an American Shoulder and Elbow Society (ASES) score for shoulder function and the Oxford Elbow score (OES) for elbow function were obtained. One hundred and three patients met the inclusion criteria. Twenty four patients participated in the study, fifteen had IMN (62.5%) and nine had PF (37.5%.). The shoulder function outcomes showed no statistical difference with an average ASES score of sixty-six for the IMN group and sixty-nine for the PF group. Women and employed individuals expressed greater functional impairment. Hand dominance has no impact on the scores of elbow and shoulder function post operatively. The impairment of abduction score post antegrade nailing was higher in the antegrade nailing group than the plated group. The OES demonstrated greater variance in elbow function in the PF group with the IMN group expressing greater elbow disfunction. This study confirms that treatment of middle third humerus shaft fractures by plate fixation is marginally superior to antegrade intramedullary nailing in preserving elbow function and abduction ability

We aimed to use data from a randomized controlled trial (RCT) comparing the sliding hip screw vs. intramedullary nailing (IMN) for trochanteric fractures to examine complication rates between those managed with a short vs. long IMN. This is a secondary analysis using one arm of an RCT of patients ≥18 years with trochanteric fractures. We examined differences in fracture-related (femoral shaft fracture, implant failure, surgical site infection (SSI), nonunion, limb shortening, and pain) and medical (organ failure, respiratory distress, stroke, deep vein thrombosis [DVT] gastrointestinal upset, pneumonia, myocardial infarction, sepsis, or urinary tract infection) adverse events (AE), and readmission between short vs. long IMNs. We included 412 trochanteric fracture patients, 339 (82.2%) of whom received a short (170mm–200mm) nail, while 73 (17.7%) received a long (260mm–460 mm) nail. Patients in the long group were more likely to be admitted from home (vs. an institution), and have comorbidities, or more complex fracture types. Patients in the long group had higher rates of fracture-related AE (12.3%) vs. the short group (3.5%). Specifically, SSI (5.5% vs. 0.3%) and pain (2.7% vs. 0.0%) were significantly higher in the long group. Patients in the long group were also more likely to develop DVT (2.7% vs. 0.3%), and be readmitted to the hospital (28.8% vs. 20.7%). Following covariable adjustment, long nails remained associated with a higher odds of fracture-related AE (5.11, 1.96–13.33) compared to short nails. We found no association between the adjusted odds of readmission and nail length (1.00, 0.52–1.94). Our analyses revealed that trochanteric fracture patients managed with long IMN nails may have a higher odds of fracture-related AE compared to short nails. Future research is required to validate these findings with larger event rates, and further optimize IMN for trochanteric fracture patients

Aims. Fractures of the distal femur are an important cause of morbidity. Their optimal management remains controversial. Contemporary implants include angular-stable anatomical locking plates and locked intramedullary nails (IMNs). We compared the long-term patient-reported functional outcome of fixation of fractures of the distal femur using these two methods of treatment. Patients and Methods. A total of 297 patients were retrospectively identified from a State-wide trauma registry in Australia: 195 had been treated with a locking plate and 102 with an IMN. Baseline characteristics of the patients and their fractures were recorded. Health-related quality-of-life, functional and radiographic outcomes were compared using mixed effects regression models at six months and one year. Results. There was a clinically relevant and significant difference in quality-of-life at six months in favour of fixation with an IMN (mean difference in EuroQol-5 Dimensions Score (EQ-5D) = 0.12; 95% CI 0.02 to 0.22; p = 0.025). There was weak evidence that this trend continued to one year (mean difference EQ-5D = 0.09; 95% CI -0.01 to 0.19; p = 0.073). There was a significant although very small reduction in angular deformity using an IMN (mean difference -1.02; 95% CI -1.99 to -0.06; p = 0.073). There was no evidence that there was a difference in any other outcomes at any time point. Take home message: IMN may be a superior treatment compared with anatomical locking plates for fractures of the distal femur. These findings are concordant with other data from pilot randomised studies which favour treatment of these fractures with an IMN. This study strongly supports the need for a definitive randomised trial. Cite this article: Bone Joint J 2016;98-B:846–50

Surgeons must explain the risk of complications to prospective patients and get informed consent. If a complication that occurred was omitted in the process or given the wrong risk level, culpability of the surgeon is judged in court against what a “reasonable patient” would like to know to give or refuse consent. ObjectivesThe concept “reasonable patient” is widely used, no attempt has been made to define it objectively. We assessed insight of patients, presumed “reasonable”, about risks of certain complications after they underwent one of five orthopaedic procedures. Questionnaire was administered with procedures: femur IMN, tibia IMN, ankle ORIF, distal radius ORIF and hip arthroplasty. Four common/serious complications were chosen per procedure, and matched against life events with documented risk levels. There were 230 participants 163 males and 67 females. We found 19.1% of patients above age 40 and 33.3% with tertiary education wouldn't accept nerve injury as reported in literature. With infection risk, 18.1% above 40 and 52.9% with pre-tertiary education would not accept. All patients below 40 and 7.4% pre-tertiary education wouldn't accept the risk of death as reported. However, 37.1% above 40 and 76.9% with pre-tertiary education would accept that risk at a higher level. It is hard to predict what risk of complication a patient may accept. This study highlights that some patients will not accept risks as reported in literature, even though they need the procedure. Therefore, surgeons need to explain complications fully, so that patients knowingly accepts or refuses consent. The subset of patients who are not willing to accept any level of risk, should be the subject of another study

Aims. The aim of this study was to assess the safety and clinical outcome of patients with a femoral shaft fracture and a previous complex post-traumatic femoral malunion who were treated with a clamshell osteotomy and fixation with an intramedullary nail (IMN). Methods. The study involved a retrospective analysis of 23 patients. All had a previous, operatively managed, femoral shaft fracture with malunion due to hardware failure. They were treated with a clamshell osteotomy between May 2015 and March 2020. The mean age was 42.6 years (26 to 62) and 15 (65.2%) were male. The mean follow-up was 2.3 years (1 to 5). Details from their medical records were analyzed. Clinical outcomes were assessed using the quality of correction of the deformity, functional recovery, the healing time of the fracture, and complications. Results. The mean length of time between the initial injury and surgery was 4.5 years (3 to 10). The mean operating time was 2.8 hours (2.05 to 4.4)), and the mean blood loss was 850 ml (650 to 1,020). Complications occurred in five patients (21.7%): two with wound necrosis, and three with deep vein thrombosis. The mean coronal deformity was significantly corrected from 17.78° (SD 4.62°) preoperatively to 1.35° (SD 1.72°) postoperatively (p < 0.001), and the mean sagittal deformity was significantly corrected from 20.65° (SD 5.88°) preoperatively to 1.61° (SD 1.95°; p < 0.001) postoperatively. The mean leg length discrepancy was significantly corrected from 3.57 cm (SD 1.27) preoperatively to 1.13 cm (SD 0.76) postoperatively (p < 0.001). All fractures healed at a mean of seven months (4 to 12) postoperatively. The mean Lower Extremity Functional Scale score improved significantly from 45.4 (SD 9.1) preoperatively to 66.2 (SD 5.5) postoperatively (p < 0.001). Partial cortical nonunion in the deformed segment occurred in eight patients (34.8%) and healed at a mean of 2.4 years (2 to 3) postoperatively. Conclusion. A clamshell osteotomy combined with IMN fixation in the treatment of patients with a femoral shaft fracture and a previous post-traumatic femoral malunion achieved excellent outcomes. Partial cortical nonunions in the deformed segment also healed satisfactorily. Cite this article: Bone Joint J 2023;105-B(4):449–454

Background. The optimal treatment of segmental tibial fractures (STF) is controversial. Intramedullary nailing (IMN) and external fixation (EF) have unique benefits and complications. Aim. To compare outcomes for AO/OTA 42C2 and 42C3 fractures treated using IMN with those treated using EF in a University Teaching Hospital. Methods. Retrospective case note and radiograph review of 31 segmental tibial fractures treated between 2010 and 2017. Results. There were 17 42C2 and 14 42C3 fractures. 17 patients underwent IMN and 14 EF, and were matched for age and gender. 9 fractures in each group were open. Median time to radiological union was 7 months for IMN and 8 months for EF. Revision surgery was needed for 4 IMN patients and 3 EF patients. The mean number of unplanned procedures was 1.46 for IMN and 1.1 for EF (p=0.69). Length of stay was 15.5 days for IMN and 16.2 days for EF (p=0.9). There was one compartment syndrome in each group and 2 cases of deep infection in the IMN group. There was no significant difference in coronal and sagittal plane alignment. Conclusions. Notwithstanding the small numbers and the retrospective design, the results show that the results of IMN may be equivalent to EF. Modern techniques using suprapatellar entry and blocking screws, combined with early plastic surgical coverage in open injuries are likely to have improved outcomes. Implications. Modern IM nailing techniques have produced similar clinical and radiological outcomes to that achieved by external fixation in this series

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

Introduction. This study aimed to compare MIPO and IMNr in the treatment of supracondylar femur fracture following TKA in respect of fracture healing, complications and functional results. Materials and Methods. A retrospective analysis was made of 32 supracondylar femur fractures classified according to the Rorabeck classification, comprising 20 cases treated with MIPO and 12 with IMNr. The two techniques were compared in respect of ROM, KSS, SF-12 scores, intraoperative blood loss, surgery time, and radiological examination findings. Results. No significant difference was determined between the two groups in respect of age, gender and fracture type, or in the median time to union (MIPO 4.3 months, IMNr 4.2 mths) (p >0.05). In the MIPO group, 2 patients had delayed union, so revision surgery was applied. The mean postoperative ROM was comparable between IMNr and MIPO (86.2 °vs 86 °, p > 0.05). The mean Knee Society Score (KSS) and SF-12 score did not differ between the IMN and MIPO groups. (p>0.05). Reduction quality in the sagittal plane was better in the MIPO group and no difference was determined in coronal alignment. Greater shortening of the lower extremity was seen in the IMNr group than in the MIPO group. (20.3 vs 9.3mm, p<0.05). Perioperative blood loss was greater (2 units vs.1.2 units) and mean operating time was longerin the MIPO group. (126.5 min vs 102.2 min, p<0.05). Conclusion. In patients with good bone stock, supracondylar femur fracture following TKA can be treated successfully with IMN or MIPO. IMN has the advantage of less blood loss and a shorter operating time. Reduction quality may be improved with the MIPO technique. Both surgery techniques can be successfully used by orthopaedic surgeons taking a case-by-case approach

Infected nonunion of the femur or tibia diaphysis requires resection of infected bone, stabilization of bone and reconstruction of bone defect. External fixation of the femur is poorly tolerated by patients. In 2004 authors introduced in therapy for infected nonunions of tibia and femur diaphysis coating of IMN with a layer of antibiotic loaded acrylic cement (ALAC) containing 5% of culture specific antibiotic. Seven patients with infected nonunion of the diaphysis of femur (2) and tibia (2) were treated, aged 20–63 years, followed for 2–9 years (average 5,5 years). All have been infected with S. aureus (MSSA: 2 and MRSA: 4) or Staph. epidermidis (1) and in one case with MRSA and Pseudomonas aeruginosa. All patients underwent 3 to 6 operations before authors IMN application. Custom-made IMN coated with acrylic cement (Palamed) loaded fabrically with gentamycin with admixture of 5% of culture-specific antibiotic: vancomycin (7 cases) and meropeneme (1 case) was used for bone stabilization. Static interlocking of IMN was applied in 4 cases and dynamic in 2 cases. In 1 case the femur was stabilized with IMN without interlocking screws. In 2 cases IMN was used for fixation of nonunion at docking site after bone transport. In 3 cases ALAC was used as temporary defect filling and dead space management. In one case after removal of IMN coated with ALAC, a new custom made Gamma nail and tubular bone allograft ranging 11 cm was used for defect reconstruction. Infection healing was achieved in all 7 cases, bone union was achieved in 4 from 7 cases. In 1 case of segmental diaphyseal defect ranging over 12 cm infection was healed, but bone defect was not reconstructed. This patient is waiting for total femoral replacement. In another case of segmental defect of 11 cm infection is healed, but allograft substitution and remodeling by host bone is poor. In the 3rd case of lacking bone healing, the 63 year old patients was noncooperative and not willing to walk in walker with weight bearing. This patient refused further treatment. Custom-made intramedullary nail coated with a layer of acrylic cement loaded with 5% of culture specific antibiotic can provide local infection control, offer comfortable bone stabilization, and replace standard IM nail in therapy for difficult to treat infected diaphyseal nonunion of femur or tibia

Due to its popularity of intramedullary nails (IMN) high success rate, newer design (titanium) IMN system have been introduced to replace stainless steel system. However the stability provided by the titanium IMN. may not be adequate, there by influencing the union rate. We aimed to compare the results of both IMN systems via prospective clinical study and biomechanical testing using RSA. Biomechanical study. This study was done in an experimental set-up which consisted of a physically simulated femoral shaft fractures models fixed with a stainless steel (Russell Taylor) or Titanium (Trigen) IM nailing system. Two common fracture configurations with stimulated weight bearing conditions were used and the axis of fragment movements recorded. Clinical study. The data on two groups of patients were collected as part of a prospective cohort study. Details of the implant, such as size of nail, cross screw lengths, screw thickness, etc. was collected. Patients were followed up for a minimum of 4 months and details of clinical complications recorded. Biomechanical study. The degree of translation movement in comminuted fracture, using titanium IMN system, was 6 times more compared to stainless steel IMN system. Clinical study. The results show that there is a 5.7% of non union and 14% hardware problems with titanium based IMN system when compared to 2.2% non union in the stainless steel IMN system. Titanium based IM nailing system have a potential to inherent mechanical instability when used to treat comminuted fractures. This may explain some of the clinically observed delayed or non-union of femoral fractures

Extracapsular Hip Fractures (EHF's) are a significant health burden on healthcare services. Optimal treatment is controversial with conflicting evidence being reported. Currently treatment is undertaken with Intramedullary Nail (IMN) or Dynamic Hip Screw (DHS) constructs with a recent increase in IMN use (1). This study aims to conduct a systematic review of Randomised Control Trials published between 2020 and 2023 with particular focus on patient demographics and holistic patient outcomes. Using a unified search-protocol, RCT's published between 2020 and 2023 were collected from CENTRAL, PubMed, MEDLINE and EMBASE. Rayyan software screened duplicates. Using the CASP and Cochrane Risk of Bias Tool papers were critically examined twice, and Blood Loss, Infection and Mobility described the patient journey. Patient demographics were recorded and were contrasted with geographically diverse cohort studies to compare population differences. Parametric tests were used to determine significance levels between population demographics, namely Age and Sex. Eleven papers were included, representing 908 patients (436 Male). The mean age for patients was 64.39. There was considerable risk of bias in 7/11 studies owing to the randomization process and the recording of data. Four Cohort studies were selected for comparison representing 14314 patients. Mean age was significantly different between Cohort Studies and RCT's (Independent T-Test, df 13, t=7.8, p = <0.001, mean difference = 19.251, 95% CI = 13.888, 24.613). This was also true for sex ratios included in the studies (df 13, t = -2.268, p = 0.024, Mean Difference = -0.4884, 95% CI = -0.9702, -0.0066). To conclude, RCT's published in the post COVID-19 era are not representative of patient demographics. This has the potential to provide inaccurate information for implant selection. Additionally further research must be conducted in how to better improve RCT patient inclusion so as to be more representative of patients whilst balancing the risks of operations