With the increasingly accepted method of suprapatellar tibial nailing for tibial shaft fractures, we aimed to compare intraoperative and postoperative outcomes of infrapatellar (IP) vs suprapatellar (SP) tibial nails. A retrospective cohort analysis of 58 patients. 34 SP tibial nails over 3 years versus 24 IP tibial nails over a similar time frame. We compared; radiation exposure, patient positioning time (PPT), non-union rate and follow-up time. Knee pain in the SP group was evaluated, utilising the Hospital for Special Surgery (HSS) Knee injury and Osteoarthritis outcome score (KOOS).Abstract
Background
Methods
Aims. To evaluate the results of Elastic Stable Intramedullary
The management of fracture-related infection has undergone radical progress following the development of international guidelines. However, there is limited consideration to the realities of healthcare in low-resource environments due to a lack of available evidence in the literature from these settings. Initial antimicrobial suppression to support fracture union is frequently used in low- and middle-income countries despite the lack of published clinical evidence to support its practice. This study aimed to evaluate the outcomes following initial antimicrobial suppression to support fracture union in the management of fracture-related infection. A retrospective review of consecutive patients treated with initial antimicrobial suppression to support fracture healing followed by definitive eradication surgery to manage fracture-related infections following intramedullary fixation was performed. Indications for this approach were; a soft tissue envelope not requiring reconstructive surgery, radiographic evidence of stable fixation with adequate alignment, and progression towards fracture union.Introduction
Materials & Methods
Metabolic bone disease encompasses disorders of bone mineralization, abnormal matrix formation or deposition and alteration in osteoblastic and osteoclastic activity. In the paediatric cohort, patients with metabolic bone disease present with pain, fractures and deformities. The aim was to evaluate the use of lateral entry rigid intramedullary nailing in lower limbs in children and adolescents. Retrospective review was performed for an 11-year period. Lower limb rigid intramedullary nailing was performed in 27 patients with a total of 63 segments (57 femora, 6 tibiae). Majority of patients had underlying diagnoses of osteogenesis imperfecta or fibrous dysplasia (including McCune Albright disease). Mean age at surgery was 14 years. Indications for surgery included acute fractures, prophylactic stabilisation, previous nonunion and malunion, deformity correction and lengthening via distraction osteogenesis.Introduction
Materials and Methods
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.
Ankle fractures in the elderly have been increasing with an ageing but active population and bring with them specific challenges. Medical co-morbidities, a poor soft tissue envelope and a requirement for early mobilisation to prevent morbidity and mortality, all create potential pitfalls to successful treatment. As a result, different techniques have been employed to try and improve outcomes. Total contact casting, both standard and enhanced open reduction internal fixation, external fixation and most recently tibiotalocalcaneal (TTC) nailing have all been proposed as suitable treatment modalities. Over the past five years popular literature has begun to herald TTC nailing as an appropriate and contemporary solution to the complex problem of high-risk ankle fragility fractures. We sought to assess whether, within our patient cohort, the outcomes seen supported the statement that TTC has equal outcomes to more traditional open reduction internal fixation (ORIF) when used to treat the high-risk ankle fragility fracture. Results of ORIF versus TTC nailing without joint preparation for treatment of fragility ankle fractures were evaluated via retrospective cohort study of 64 patients with high-risk fragility ankle fractures without our trauma centre. We aimed to assess whether results within our unit were equal to those seen within other published studies. Patients were matched 1:1 based on gender, age, Charlson Comorbidity Index (CCI) and ASA score. Patient demographics, AO/OTA fracture classification, intra-operative and post-operative complications, discharge destination, union rates, FADI scores and patient mobility were recorded.Introduction
Materials & Methods
Malalignment is a common complication following tibial surgery, occurring in 10% of fractures. This is associated with prolonged healing time and non-union. It occurs due to inability to maintain a satisfactory reduction. A reduction device, such as the Staffordshire Orthopaedic Reduction Machine (STORM), permits the surgeon to manipulate the fracture and hold it reduced. A retrospective parallel case series was undertaken of all patients undergoing tibial nails over a six-year period from 2014 to 2021. Patient demographics were obtained from medical records. Operative times obtained from the theatre IT system and included the time patient entered theatre and surgical start and finish times for each case. Anteroposterior and lateral long leg post-operative radiographs were reviewed. Angulation was measured in both coronal and sagittal planes, by two separate orthopaedic surgeons. A reduction was classified to be ‘mal-aligned’ if the angle measured was greater than 5 degrees. One tailed unpaired t-test was used to compare alignment in each plane. Bony union was assessed on subsequent radiographs and was determined according to the Radiographic Union Score for Tibial Fractures 31 patients underwent tibial nail during the time period. 8 patients were lost to follow up and were excluded. Of the remaining 23 patients, the STORM device was utilised in 11. The overall mean alignment was acceptable across all groups at 2.17° in the coronal plane and 2.56° in the saggital plane. Analysing each group individually demonstrated an improved alignment when STORM was utilised: 1.7° (1°–3°) vs 2.54° (0°–5°) for the coronal plane and 1.6° (0°–3°) vs 3.31° (0°–9°) in the saggital plane. This difference was significant in saggital alignment (p=0.03) and showed a positive trend in coronal alignment, although was not significant (p=0.08) The time in theatre was shorter in the control group with a mean of 113 minutes (65 to 219) in comparison to STORM with a mean of 140 minutes (105 to 180), an increased theatre time of 27 minutes (p=0.04). This study demonstrates that STORM can be used in the surgical treatment of tibial fractures resulting in improved fracture alignment with a modest increase in theatre time.
Intramedullary nailing is gaining popularity for treatment of distal tibial fractures due to short operative time and minimum surgical trauma to soft tissues. Distal tibial fractures are commonly associated with concurrent fibular fractures at, above or below the level of tibial fractures. So far there is no consensus for fixation of fibular fractures. Fractures of fibula at or below the level of fracture of tibia were taken into consideration. Fractures of fibula above the tibial level were excluded because they do not add to stability of fracture fixation. Retrospective study was done and distal tibia-fibula fractures were separated into 2 groups based on whether fibula was fixed or not. Measures of angulation were obtained from radiographs taken immediately after the surgery, a second time 3 months later, and at 6-month follow-up.Introduction
Materials and Methods
The management of periprosthetic distal femur fractures is an issue of increasing importance for orthopaedic surgeons. Because of the expanding indications for total knee arthroplasty (TKA) and an aging population with increasingly active lifestyles there has been a corresponding increase in the prevalence of these injuries. The management of these fractures is often complex because of issues with obtaining fixation around implants and dealing with osteopenic bone or compromised bone stock. In addition, these injuries frequently occur in frail, elderly patients, and the early restoration of function and ambulation is critical in these patients. There remains substantial controversy with respect to the optimal treatment of periprosthetic distal femur fractures, with some advocating for Locked Plating (LP), others Retrograde Intramedullary
In the polytrauma patient, intraoperative patient positioning is one factor thought to influence pulmonary complications associated with intramedullary (IM) nailing of the femur. With regards to lateral femoral nailing, it is currently unknown as to whether the position of the injured lung contributes to changes in pulmonary function. It has been proposed that, similar to prone positioning in the ICU for acute respiratory distress syndrome management, having the injured lung in a dependent position during lateral femoral nailing would prevent barotrauma from hyperinflation and promote gas exchange in the non-dependent healthy lung. This study aims to assess the association between the position of the injured lung during lateral femoral nailing and pulmonary complications as determined by ICU LOS. This retrospective cohort study was conducted at a single level 1 trauma centre. All patients treated with IM nailing for femur fracture between 2006 and 2014 were screened for inclusion. Only patients who 1) underwent lateral femoral nailing and 2) had a significant chest injury, defined by chest Abbreviated Injury Scale (AIS) of three or greater, were included. Patients with bilateral femur fractures or symmetric bilateral thoracic injuries were excluded. Intraoperative position of the lung injury was described depending on whether the injured lung was down, or in the dependent position, during lateral femoral nailing, versus the healthy lung down. The primary outcome was ICU LOS in all study patients. Secondary analysis was performed on the subgroup of patients who were admitted to ICU prior to femoral nailing. Data analysis assessing for differences in ICU LOS between groups was performed through Wilcoxan testing. One hundred and thirteen femur fractures were included in the study. During lateral femoral nailing, 53 patients had the injured lung down and 60 patients had the healthy lung down. No differences between age, ICU admission rate, injury severity score, chest AIS or head AIS were detected between the groups. There were no detectable differences in the rate of ICU admission between patients with the injured lung down (47.2%) and patients with the healthy lung down (46.7%) (P=0.96). We were unable to detect a difference in average ICU LOS between patients who had the injured lung down (4.9 days, 95% CI 2.8 – 7) compared to patients with the healthy lung down (6 days, 95% CI 3.7 – 8.4) during lateral femoral nailing (P=0.73). When looking only at patients who were admitted to ICU prior to femoral nailing, the LOS was 10.3 days (95% CI 7 – 13.7) in injured lung down patients compared to 12.9 days (9.2 – 16.6) in healthy lung down patients (P= 0.25). In patients with chest AIS greater than three, the position of the injured lung during lateral femoral IM nailing does not appear to affect ICU LOS.
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. 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.Aim
Method
The aim of this study is to discuss the results of intramedullary devices in the management of paediatric radial neck fractures and to suggest methods to avoid the pitfalls of the technique. 30 patients with isolated Judet III and IV fractures were included in this retrospective study. The method of reduction was reviewed. The final results were graded using the Metaizeau functional scoring system and Oxford Elbow score. Intramedullary K wires were used in 10 patients and blunt tipped TENS nails in 20 patients. The complications seen were radiocapitellar joint penetration-6 cases at mean 4.87 weeks, redisplacement − 6, radial epiphyseal sclerosis − 5 and heterotopic ossification − 1 case. The functional result was good to excellent in 24 of 30 cases(80%). The mean Oxford Elbow score was 44.32. The mean follow-up was 40.11 months. Intramedullary K wires may result in radiocapitellar joint penetration. Blunt tipped devices should not be used as purely fixation devices as they may not prevent redisplacement. Minimal redisplacement does not affect the functional outcome. Regular follow-up until atleast 6 weeks is essential. Patients who have a Judet IV fracture and need open reduction should be closely followed up and given a guarded prognosis.
Determine the incidence of surgical site infections (SSI) after intramedullary nailing (IN) of femoral and tibial diaphyseal fractures and evaluate possible risk factors. Prospective observational cohort study. SSI was defined according to CDC-NHSN criteria and surveillance period for the occurrence of infection was 12 months instead of the 90 days currently recommended. Incidence was calculated as the ratio between the number of patients with SSI and total number of patients. Analysis of potential risk factors included patients-related factors (age, gender, body mass index, active foci of infection, immunosuppressive conditions, ASA score, alcohol or illicit drug abuse, smoking, polytrauma, etiology of fracture, type of fracture if closed or open, classification of fracture according to Müller AO, Tcherne classification for closed fractures, Gustilo-Anderson classification and duration of bone exposure for open fractures, previous stay in other healthcare services, use of external fixator, previous surgical manipulation at same topography of fracture, use of blood products); environmental and surgical-related factors (surgical wound classification, duration of surgery, hair removal, intraoperative contamination, antimicrobial use, presence of drains, hypothermia or hypoxia in the perioperative period, type of IN used, reaming, need for muscle or skin flap repair, use of negative pressure therapy) and microbiota-related factors (presence of preoperative colonization by Aim
Method
The aim of this study was to investigate whether growth factors essential for fracture healing are released in the immediate aftermath following fracture and whether reaming of IM cavity causes increased liberation of these autocoids. Consecutive adult patients with femoral shaft fractures forming two groups (a group who received unreamed nail (n=10) and a second group who received reamed nail (n=10) were recruited for this study. Peripheral blood samples and samples from the femoral canal before and after reaming and before and after the solid nail insertion were collected. Serum was extracted and using Elisa colorimetric assays the concentration of Platelet Derived Growth Factor (PDGF), Vascular Endothelial Growth Factor (VEGF), Insulin-like Growth Factor I (IGF-I) Transforming Growth Factor beta 1 (TGF-21) and BMP-2 levels was measured.Purpose
Methods
A comprehensive met-analysis of anterior knee pain post intramedullary nailing of the tibia was performed by Katsoulis et al in 2006. The principle findings were that 47.4% of patients had anterior knee pain at 2 years post tibial nailing. Worse results were found following a patella tendon splitting approach when compared with a medial para-patellar tendon approach. These conclusions were drawn from 20 studies including 1460 patients. Currently both approaches to the proximal tibia for nailing are used at JCMH Blanchardstown. A retrospective study was performed to compare the results of tendon splitting and tendon sparing approaches to tibial nails and to compare the results of JCMH with those stated in literature. Patients who underwent tibial nailing in 2007 and 2008 were identified using the hospital coding system. Those patients who were treated under the care of Mr Kenny had a medial para-tendinous approach and those treated the care of Mr O'Flanagan and Mr Keogh had a tendon splitting approach. Apart from the approach the nailing technique using the Trigen Knee Nail and the post operative physiotherapy protocol were identical. Follow up included questions regarding knee pain and return to previous function. Specifically: Knee pain that affects daily life, Knee pain on kneeling, Knee pain on ascending or descending stairs, Return to work and Return to sports or active hobbies.Introduction
Method
The reverse obliquity fractures of the proximal femur are anatomically and mechanically different from most intertrochanteric fractures. These fractures are complex and very difficult to treat. To evaluate the results of the treatment of reverse obliquity intertrochanteric fractures with cephalomedullary nails. Between 2005 and 2009, 1179 extracapsular fractures of the proximal femur were treated at our institution. Retrospective review of these x-rays identified 59 patients with reverse obliquity fracture pattern. We analysed our results of cephalomedullary nailing of these complex fractures and evaluated factors responsible for failure of fixation.Introduction
Materials and Methods
Malrotation of the femur has been documented in as few as 0% and as many as 28% of fractures treated with an intramedullary(IM) nail. Patients with more than 15 degrees of malrotation sometimes require derotation osteotomy. Recognizing malrotation intraoperatively is the most efficient way to avoid corrective surgery. The purpose of this paper is to inform orthopaedic surgeons of the best estimate of incidence of femoral malrotation after IM nailing. This may lead to increased attention toward intraoperative control of malrotation. A literature search was performed by a library sciences professional. Two authors excluded papers not relevant to the study in two stages with clearly outlined criteria and adjudication. Inter-observer agreement was measured with the kappa statistic. Data extraction was performed by the same two authors with measure of agreement and adjudication from a third author. Data extraction included: incidence of malrotation, method used for measurement of malrotation and use of intraoperative techniques to minimize malrotation.Purpose
Method
Septic complications of long bone fracture are still a significant clinical problem. Although inflammatory process after intramedullary nailing is a rare complication, its treatment is complex. The aim of this study is to analyze the effectiveness of the treatment of septic complications of the long bone union with use of Reamer–Irrigator–Aspirator (RIA) technique and intramedullary antibiotic-coated PMMA nailing. An analysis of the effectiveness of treatment of 49 patients with septic non-union of long bones (12 femur, 37 tibia), in which the RIA method was applied with antibiotic cement impregnated intramedullary nailing. Treatment consisted of reaming of long bone canal using the RIA technique and the intramedullary cement coated nail with the targeted antibiotic. Treatment required second stage with nail exchange and PMMA removal after 6 weeks to prevent the resitant strains selection. In a group of patients treated with use of above-mentioned method the remission of inflammatory process was achieved in all cases. 32 (67%) patients developed bone union, 24 patients with tibial and 8 patients with femoral septic bone union disorders. The average duration of bone union obtainment with intramedullary nailing was 37 weeks. The most common inconveniences that occurred during treatment was prolonged wound discharge and pain.
Inflammatory complications of fractures in our material involved extensive injuries, usually high-energetic. Stabilization with intramedullary locked nail coated with antibiotic cement after debridement with RIA method is a convincing treatment. An essential element of biological bone union is to provide a good cover of the bone tissue with a soft tissue envelope and sequestrectomy. The success of the treatment of infected pseudoarthrosis may be obtained under condition of: radical removal of inflammation tissue, convincing biomechanical dynamized stabilization and antibiotic therapy.
Leg length discrepancy (LLD) after intramedullary nailing of femoral shaft fractures is a common problem reported in up to 43% of cases. Comminuted fractures with radiographic loss of bony landmarks have an increased possibility of being fixed with unequal leg lengths. The purpose of this report is to evaluate the efficacy of routinely obtaining a CT scanogram post-operatively on patients of comminuted femoral shaft fractures treated with intramedullary nailing and immediate correction of limb length inequality if indicated.Background
Aims
The goal of this paper is to compare the results and complication namely infection rates, of the techniques of Standard Ilizarov lengthening, lengthening over nail (LON) and lengthening then nailing (LTN) utilizing a standard nail (STD) and a special nail with a core of cement releasing antibiotics (SAFE). In a first study done between 1993 and 2008, we have compared 25 patients treated with lengthening with a Ilizarov frame (LIF) with 26 patients where a standard nail was used to do a lengthening over nail technique (LON). From 2009 and 2012 we have utilized the SAFE nail in 17 patients to perform lengthening over nail (SAFE-LON) and lengthening then nailing (SAFE-LTN) techniques. 7 patients had a pseudarthrosis, 5 a malconsolidation with shortening and or axial deviation and 5 a bone loss after infection of total knee replacements. We used a lengthening over nail in 4 cases, a lengthening and axial correction then nailing in three, acute compression and proximal lengthening then nailing in five patients and knee arthrodesis and femoral or tibial lengthening then nailing in another 5 cases. We have used a Ilizarov frame in all cases. We found that with LON technique, the external fixation time was 3 times lower, promoting the recovery of full range of knee mobility in half the time, comparatively with LIF technique, with statistically very significant differences. We found a rate of 30% of intercurrences on the LON group and 24% in the Ilizarov, difference that was not statistically significant. 3 patients got bone infection after LON technique, a rate of 11.5%. Late consolidation and fracture of regenerate appeared only in the Ilizarov technique group, whereas in the LON technique we had 3 cases of premature consolidation of the regenerate. In the SAFE-LON and SAFE-LTN techniques utilizing the SAFE nail with antibiotics, we found a decrease of the overall intercurrence rate from 30% to 12% and namely, bone infection was cured or didn't appeared after nailing with this new device in all cases. LON and LTN techniques are somehow more demanding, but much more comfortable for the patient, which need to carry the frame for less time, It permits an earlier return to activity, about half the time, it controls better delayed regenerate and its fracture does not increase complication rate and costs of treatment and prevents infection when converting from external to internal fixation.
