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

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

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

Aim. The aim of this study was to compare the results of humerus intramedullary nail (IMN) and dynamic compression plate (DCP) for the management of diaphyseal fractures of humerus. Material & methods. 47 patients with diaphyseal fracture of shaft humerus were randomised prospectively and treated by open reduction and internal fixation with IMN or DCP. The criteria for inclusion were Grade 1.2a compound fractures; Polytrauma; Early failure of conservative treatment; Unstable fracture. Patients with pathological fracture, Grade 3 open fracture, refracture or old neglected fracture of humerus were excluded from the study. 23 patients underwent internal fixation by IMN and 24 by DCP. Reamed antegrade nailing was done in all cases. DCP was done through an anterolateral or posterior approach. Results. The outcome was assessed in terms of union time, union rate, functional outcome and incidence of complications. Functional outcome was assessed using the American Shoulder and Elbow Surgeons Score (ASES). On comparing the results by independent samples t test, there was no significant difference in ASES score between the two groups. The average union time was found to be significantly lower for IMN compared to DCP(P<.05). The union rate was found to be similar in both the groups. Complications like infection were found to be higher with DCP compared to IMN, while shortening of the arm (1.5-4cm) and restriction of shoulder movements due to impingement of the nail were found to be higher with DCP compared with IMN. However, this improved in all patients following removal of the nail once the fracture healed. Conclusion. This study proves that IMN can be considerd as a better surgical option for these fractures as it offers shorter union time and less incidence of serious complications like infection. However, there appears to be no difference between two groups in union rate and functional outcome

Aims of study. 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. Method. 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. Results. We present our early results. Currently we have included 9 patients in the IMN group and 7 patients in the volar plate group with follow-ups longer than 3 months. Results show smaller scars (2.5 vs 6.7cm), comparable flexion and extension (40 vs 40 and 45 vs 40), slight improvements in pronation and supination (80 vs 75 and 85 vs 80) in the IMN compared to the volar plate. Radial and ulnar deviation is comparable. The radiological parameters showed slight improvements in the radial height (2.5 vs 2.2 mm), inclination (3.6 vs 3.2 degrees) and tilt 13,7 vs 12 degrees) with the IMN. Dash scores will be compared at 6 months. Conclusion. Intra medullary nailing of the distal radius seems to compare to volar plating in terms of radiological parameters and rotational stability but has the added benefit of early range of motion, minimal invasive technique, less post op pain and less complications such as tendon irritation. NO DISCLOSURES

Aim. The incidence of deep infections after internal fixation of ankle and lower leg fractures is estimated 1 to 2%. Hindfoot arthrodesis by retrograde intramedullary nailing (IMN) is a potential alternative to external fixation for post-infectious ankle destruction. The aim of this study was to evaluate the clinical results, complications and effects of soft tissue management with this treatment modality. Method. This is a single-center retrospective review of routine hospital data from 21 patients (15 men, 6 women, median age 65 [range, 21 to 87] years) undergoing IMN arthrodesis of the hindfoot for post-traumatic infections between January 1st, 2012 and March 15, 2018. We observed four bimalleolar, eight trimalleolar, three pilon fractures, and six distal lower leg fractures. Six and three patients had sustained second- and third degree open fractures, respectively. Early- and late-onset surgical infections were observed in 8 and 13 cases. Four participants had diabetes mellitus, two arterial occlusive disease, and four had both. Six patients were smokers. Results. Intraoperative cultures before implanting the nail revealed staphylococcus aureus in 12, staphylococcus epidermidis in five, and enterococcus faecalis in eight cases. After a median follow-up of 21 months, infection was considered cured in 19 / 21 subjects (90%, 95% confidence interval 70 – 99%). Soft tissue comminution required coverage with a suralis flap in five patients, and with a latissimus dorsi flap in another three. Mesh graft was necessary in 8 / 21 reconstructions. Conclusions. Tibiotalocalcaneal fusion by IMN is an effective salvage procedure for post-traumatic ankle infections. Arthrodesis and definitive wound closure or plastic flap coverage can be performed as single-stage surgery. By resecting the prominent distal fibula, lateral soft tissue defects can be managed more easily. The small sample size prohibited a more detailed analysis of exposure variables, but 8 / 13 patients in this cohort had at least one known risk factor for infection and prolonged healing

Intramedullary nailing (IMN) has been frequently indicated to treat long bone open and closed fractures, but infection following internal fixation may have devastating consequences, with higher costs. Treatment of intramedullary nail-associated infections (IMNI) is challenging and based upon surgery and adequate antibiotic administration, which requires the correct identification of causative microorganisms. However, there have been difficulties for the microbial diagnosis of IMNI, as the peri-prosthetic tissue cultures may show no microbial growth, particularly in patients with previous use of antibiotics. Sonication have shown higher sensitivity and specificity for microbial identification on a variety of orthopedic implant-associated infections. Aim: To compare clinical and microbiological results and sensitivity for the pathogen identification obtained by conventional peri-implant tissue culture samples with culture of samples obtained by sonication of explanted IMN implants, among patients presenting IMNI of long bones. Methods: Longitudinal prospective cohort study performed at a tertiary public hospital, ongoing since August 2011. We analyzed all patients with indication for IMN implant removal, and orthopedic-implant associated infections was defined according to previous publications addressing osteosynthesis-associated infections (Yano 2014). Minimal of 2 samples from the peri-implant tissue were taken and sent under sterile conditions to the laboratory for culture. Statistical analysis was performed McNemar's test for related proportions. Results: We included 26 patients presenting clinical signs of IMNI, of which tissue and sonication cultures were performed for 26 (100%) and 20 (77%) patients, respectively. Among them, 88% were male, with mean age was 35.9 years (range, 19–59 yo). Causes of trauma were mainly motorcycle crashes accounting 54% of accidents; tibia and fibula were affected in 65% and 27%, respectively. Gustilo open fracture classification was grade II (35%) and IIIA (35%). First stage management with external fixation for fracture stabilization was performed in 75% of trauma patients. Sensitivity of peri-prosthetic tissue culture and sonication was 80.7% (21/26), and 95% (19/20) (p< 0.05), respectively. Only one infected patient presented negative tissue and fluid cultures. Gram-positive cocci were isolated in 75% and 79% in tissue and sonication fluid cultures, respectively. Staphylococcus aureus, coagulase-negative staphylococci, Enterococcus sp., were isolated from tissue and sonication culture in 43.5% and 36.3%, 8.7% and 22.7%, 13% and 13.7%, respectively. Polymicrobial infection was diagnosed in 3.8% (1/26) and 15.8% (3/19), patients by tissue and sonication fluid cultures (p< 0,01), respectively. Conclusion: Sonication of retrieved infected intramedullary nails has the potential for improving the microbiological diagnosis of IMNI

The availability and usage of portable image intensifiers has revolutionised routine orthopaedic practice. Many procedures have become simpler, easier, less invasive and less time-consuming. Extensive use of fluoroscopy can, however, result in significant radiation exposure to operating staff. An accumulated dose of 65 (Sv after multiple exposures has been reported to increase the risk of thyroid cancer many years later. Previous studies have shown that it is possible to exceed this dose during various orthopaedic procedures. Though thyroid shields are extensively available most orthopaedic surgeons do not use them. The present study was aimed at measuring the scattered dose to thyroid during DHS/IMHS for neck of femur fractures and IM nailing for long bone fractures and thereby emphasise the need for operating theatre personnel to wear a thyroid shield. A prospective study of 32 consecutive procedures was carried out. The EDD Unfors dosimeter was used to measure the tissue specific exposure dose to thyroid. Measurements were also obtained from the mobile C-arm fluoroscope unit, which calculated the total number of images and the total dose and duration of radiation for each procedure. Other factors including the grade of surgeon, the total number of theatre personnel wearing the lead gown and/or the thyroid shield and the duration of surgery were also recorded. In 32 procedures, the dose of 65 (Sv was exceeded 13 times; 8 times during DHS/IMHS and 5 times during IMN. The average thyroid dose was 142 (Sv during IMN and 55 (Sv during DHS. Only 9 of 223 (4%) theatre personnel were using a thyroid shield in spite of its availability. The results suggest that the thyroid is frequently exposed to potentially harmful radiation during these procedures. Strict inclusion of a thyroid shield as a part of routine radiation protection is recommended

Aims

Excision of chronic osteomyelitic bone creates a dead space which must be managed to avoid early recurrence of infection. Systemic antibiotics cannot penetrate this space in high concentrations, so local treatment has become an attractive adjunct to surgery. The aim of this study was to present the mid- to long-term results of local treatment with gentamicin in a bioabsorbable ceramic carrier.

Aims

The standard of wide tumour-like resection for chronic osteomyelitis (COM) has been challenged recently by adequate debridement. This paper reviews the evolution of surgical debridement for long bone COM, and presents the outcome of adequate debridement in a tertiary bone infection unit.

Gold standard for the management of non-union is open surgical debridement, stabilisation, and autologous bone grafting. LIPUS is becoming more popular, yet the evidence is still inconclusive. LIPUS involves the use of ultrasound at the fracture site with little risk to the patient. The purpose of this study was to assess effectiveness and cost benefit of LIPUS in the management of non-unions post sustaining an open fracture. We retrospectively reviewed 29 patients with open fractures with established non-union undergoing LIPUS since 2010 (4 females, mean age 48) range 3–27 months, mean 9 months, either post injury or last intervention. All were tertiary referrals, sustaining injuries to the following areas; Tibial 21, Femur 6, Humerus 2, Radius 1. Definitive fixation being; 9 TSF's, 11 IMN's, 9 plates. (undergoing a mean 2.4 procedures). Aside from sustaining an open fracture, 7 had risk factors for non-unions 5 smokers, 2 NSAID's. Failure of treatment was based on undertaking bone grafting. In 28 patients (1 lost to follow up) union was achieved in 71% (mean 157 days). All were screened for infection, 4 had organisms on enrichment culture. 8 (5 Gustillo Anderson Grade 3A/B) injuries did not show evidence of callus formation, LIPUS was discontinued and grafting performed. Open fractures were graded as; 7 Grade 1, 4 Grade 2, 8 Grade 3A, 10 Grade 3B being received. Of these; 20 underwent primary closure, 6 free flaps and 3 SSG. The cost of LIPUS is approx £2500, compared bone grafting using autologous iliac crest graft with no medical comorbidities of £3715. This case series further supports union rates after LIPUS. Cost and morbidity benefit of utilising LIPUS over opting for bone grafting initially is £1215 per patient. Whilst autologous bone grafting is currently the gold standard, it is not without morbidity. We achieved union rates of 71% despite a number of patients having recognised risk factors, showing that LIPUS is a useful resource in the management of non-union

Background. To determine the relative contributions of bilateral versus unilateral femoral shaft fracture plus injuries in other body regions to mortality after injury. Study design. A retrospective analysis of the prospectively recorded Trauma Registry data (TARN) from 1989 to 2003. Methods. Patients were divided into groups UFi (isolated unilateral femur injury),BFi (isolated bilateral femur injury) and UFa and BFa if an associated injury was present. Data collected for each patient included age, Injury Severity Scores, Glasgow Coma Scale, mortality, physiological parameters, the timing and extent of prehospital care, the time to arrival at the hospital, initial treatments, time to and type of surgery, length of ICU and hospital stay. Logistic regression data analysis was performed to determine variables that were associated with increased mortality. Results. Patients in group BFa had a significantly higher ISS (23 vs 9),reduced GCS (12 vs 15) and increased mortality rate (31.6% vs 9.8%) than patients in group BFi. Group BFa patients had an increased number of associated injuries than group UFa. Regression analysis of variables evident on admission revealed a significant correlation between bilateral femoral fractures with associated injuries and mortality. However bilateral fracture, even in isolation significantly increased the odds of mortality by 3.07(1.36-6.92). Intramedullary nailing (IMN) was the method of fracture fixation associated with the lowest patient mortality overall. However, when assessing patient mortality in the BFa group with an ISS of more than 40, three other fracture fixation regimens were associated with a lower mortality rate than the IMN group. Conclusions. The increase in mortality with bilateral femoral fractures is more closely associated with the presence of associated injuries and poor physiological parameters than to the presence of the bilateral femoral fracture alone. However contrary to ISS scoring the latter does convey a significant additional risk of mortality. The presence of bilateral femoral fractures should alert the clinician to the very high likelihood (80%) of significant associated injuries in other body systems and their life-threatening potential

Aims

Chronic osteomyelitis may recur if dead space management, after excision of infected bone, is inadequate. This study describes the results of a strategy for the management of deep bone infection and evaluates a new antibiotic-loaded biocomposite in the eradication of infection from bone defects.