Spinal diseases such as unstable fractures, infections, primary or secondary tumors or deformities require surgical stabilization with implants. The long-term success of this treatment is only ensured by a solid bony fusion. The size of the bony defect, the often poor bone quality and metabolic diseases increase the risk of non-union and make the case a great burden for the patient and a challenge for the surgeon. The goal of spinal fusion can only be achieved if the implants used offer sufficient mechanical stability and the local biological regeneration potential is large enough to form sufficient bone. The lecture will present challenging clinical cases. In addition, implant materials and new surgical techniques are discussed. Local therapeutic effects are achieved through the release of osteopromotive or anti-resorbtive drugs, growth factors and antibiotics. By influencing biological pathways, basic orthopedic research has strong potential to further positively change future spinal surgery

The lateral wall thickness (LWT) in trochanteric femoral fractures is a known predictive factor for postoperative fracture stability. Currently, the AO/OTA classification uses a patient non-specific measure to assess the absolute LWT (aLWT) and distinguish stable A1.3 from unstable A2.1 fractures based on a threshold of 20.5 mm. This approach potentially results in interpatient deviations due to different bone morphologies and consequently variations in fracture stability. Therefore, the aim of this study was to explore whether a patient-specific measure for assessment of the relative LWT (rLWT) results in a more precise threshold for prediction of unstable fractures. Part 1 of the study evaluated 146 pelvic radiographs to assess left-right symmetry with regard to caput-collum-angle (CCD) and total trochanteric thickness (TTT), and used the results to establish the rLWT measurement technique. Part 2 reevaluated 202 patients from a previous study cohort to analyze their rLWT versus aLWT for optimization purposes. Findings in Part 1 demonstrated a bilateral symmetry of the femur regarding both CCD and TTT (p ≥ 0.827) allowing to mirror bone's morphology and geometry from the contralateral intact to the fractured femur. Outcomes in Part 2 resulted in an increased accuracy for the new determined rLWT threshold (50.5%) versus the standard 20.5 mm aLWT threshold, with sensitivity of 83.7% versus 82.7% and specificity 81.3% versus 77.8%, respectively. The novel patient-specific rLWT measure can be based on the contralateral femur anatomy and is a more accurate predictor of a secondary lateral wall fracture in comparison to the conventional aLWT. This study established the threshold of 50.5% rLWT as a reference value for prediction of fracture stability and selection of an appropriate implant for fixation of trochanteric femoral fractures

Introduction and Objective. Ankle fractures are common and affect young adults as well as the elderly. An unstable ankle fracture treatment typically involves surgical fixation, immobilisation, and modified weight-bearing for six weeks. Non-weight bearing (NWB) cast immobilisation periods were used to protect the soft tissue envelope and osteosynthesis. This can have implications on patient function and may reduce independence, mobility and return to work. Newer trends in earlier mobilisation compete with traditional NWB doctrine, and weak consensus exists as to the best postoperative strategy. The purpose of this trial is to investigate the safety and efficacy of immediate weight-bearing (IWB) and range of motion (ROM) exercise regimes following ORIF of unstable ankle fractures with a particular focus on functional outcomes and complication rates. Materials and Methods. A pragmatic randomised controlled multicentre trial, comparing IWB in a walking boot and ROM within 24 hours versus non-weight-bearing (NWB) and immobilisation in a cast for six weeks, following ORIF of all types of unstable adult ankle fractures (lateral malleolar, bimalleolar, trimalleolar with or without syndesmotic injury). The exclusion criteria are skeletal immaturity and tibial plafond fractures. The primary outcome measure is the functional Olerud-Molander Ankle Score (OMAS). Secondary outcomes include wound infection (deep and superficial), displacement of osteosynthesis, the full arc of ankle motion (plantar flexion and dorsal flection), RAND-36 Item Short Form Survey (SF-36) scoring, time to return to work and postoperative hospital length of stay. Results. We recruited 160 patients with an unstable ankle fracture. Participants’ ages ranged from 15 to 94 years (M = 45.5, SD = 17.2), with 54% identified as female. The mean time from injury to surgical fixation was 1.3 days (0 to 17 days). Patients in the immediate weight-bearing group had a 9.5-point higher mean OMAS at six weeks postoperatively (95% CI 1.48, 17.52) P = 0.021. The complications rate was similar in both groups. The rate of surgical site infection was 4.3%. One patient had DVT, and another patient had a pulmonary embolism; both were randomised to NWB. Length of hospital stay (LOS) was 1 ± 1.5 (0, 12) for the IWB group vs 1.5 ± 2.5 (0, 19) for the NWB group. Conclusions. There is a paucity of quality evidence supporting the postoperative management regimes used most commonly in clinical practice. To our knowledge, immediate weight-bearing (IWB) following ORIF of all types of unstable ankle fractures has not been investigated in a controlled prospective manner in recent decades. In this large multicentre, randomised controlled trial, we investigated immediate weight-bearing following ORIF of all ankle fracture patterns in the usual care condition using standard fixation methods. Our result suggests that IWB following ankle fracture fixation is safe and resulted in a better functional outcome. Once anatomical reduction and stable internal fixation is achieved, we recommend IWB in all types of ankle fractures in a compliant patient

Recently, a new generation of superior clavicle plates was developed featuring the variable-angle locking technology for enhanced screw positioning and optimized plate-to-bone fit design. On the other hand, mini-fragment plates used in dual plating mode have demonstrated promising clinical results. However, these two bone-implant constructs have not been investigated biomechanically in a human cadaveric model. Therefore, the aim of the current study was to compare the biomechanical competence of single superior plating using the new generation plate versus dual plating with low-profile mini-fragment plates. Sixteen paired human cadaveric clavicles were assigned pairwise to two groups for instrumentation with either a 2.7 mm Variable Angle Locking Compression Plate placed superiorly (Group 1), or with one 2.5 mm anterior plate combined with one 2.0 mm superior matrix mandible plate (Group 2). An unstable clavicle shaft fracture AO/OTA15.2C was simulated by means of a 5 mm osteotomy gap. All specimens were cyclically tested to failure under craniocaudal cantilever bending, superimposed with bidirectional torsion around the shaft axis and monitored via motion tracking. Initial stiffness was significantly higher in Group 2 (9.28±4.40 N/mm) compared to Group 1 (3.68±1.08 N/mm), p=0.003. The amplitudes of interfragmentary motions in terms of craniocaudal and shear displacement, fracture gap opening and torsion were significantly bigger over the course of 12500 cycles in Group 1 compared to Group 2; p≤0.038. Cycles to 2 mm shear displacement were significantly lower in Group 1 (22792±4346) compared to Group 2 (27437±1877), p=0.047. From a biomechanical perspective, low-profile 2.5/2.0 dual plates demonstrated significantly higher initial stiffness, less interfragmentary movements, and higher resistance to failure compared to 2.7 single superior variable-angle locking plates and can therefore be considered as a useful alternative for diaphyseal clavicle fracture fixation especially in unstable fracture configurations

Abstract. Objectives. Ankle fractures have an incidence of around 90,000 per year in the United Kingdom. They affect younger patients following high energy trauma and, in the elderly, following low energy falls. Younger patients with pre-existing comorbidities including raised BMI or poor bone quality are also at risk of these injuries which impact the bony architecture of the joint and the soft tissues leading to a highly unstable fracture pattern, resulting in dislocation. At present, there is no literature exploring what effect ankle fracture-dislocations have on patients’ quality of life and activities of daily living, with only ankle fractures being explored. Methods. Relevant question formatting was utilised to generate a focused search. This was limited to studies specifically mentioning ankle injuries with a focus on ankle fracture-dislocations. The number of patients, fracture-dislocation type, length of follow up, prognostic factors, complications and outcome measures were recorded. Results. 939 fractures were included within the studies. Eight studies looked at previously validated foot and ankle scores, two primarily focused on the American Orthopaedic Foot and Ankle Society score (AOFAS), three on the Foot and Ankle Outcome Score (FAOS), and one study on the Olerud–Molander Score (OMAS). Patient, injury, and management factors were identified as being associated with poorer clinical outcomes. Conclusions. Not only are age and BMI a risk factor for posttraumatic osteoarthritis but they were also identified as prognostic indicators for functional outcome in this review. Patients sustaining a concurrent fracture-dislocation were found to have poorer clinical outcomes, and the timing and success of reduction further influenced outcomes. This review found that the quality of reduction was directly related to the patients’ functional outcomes post-follow up, and the risk of developing posttraumatic osteoarthritis, which was more frequent in patients sustaining Bosworth fractures, posterior malleolar fractures, and in patients over 35 years old

Abstract. Objectives. The purpose of this trial is to investigate the safety and efficacy of immediate weight-bearing (IWB) and range of motion exercise regimes following ORIF of unstable ankle fractures with a particular focus on functional outcomes and complication rates. Methods. A pragmatic randomised controlled multicentre trial, comparing IWB in a walking boot and ROM within 24 hours versus NWB and immobilisation in a cast for six weeks, following ORIF of all types of unstable adult ankle fractures. The exclusion criteria are skeletal immaturity and tibial plafond fractures. The primary outcome measure is the functional Olerud-Molander Ankle Score (OMAS). Secondary outcomes include wound infection, displacement of osteosynthesis, the full arc of ankle motion, RAND-36 Item Short Form Survey (SF-36) scoring, time to return to work and postoperative hospital length of stay. Results. We recruited 160 patients with an unstable ankle fracture. Participants’ ages ranged from 15 to 94 years (M = 45.5, SD = 17.2), with 54% identified as female. The mean time from injury to surgical fixation was 1.3 days (0 to 17 days). Patients in the IWB group had a 9.5-point higher mean OMAS at six weeks postoperatively (95% CI 1.48, 17.52) P = 0.021 with a similar result at three months. The complications rate was similar in both groups. The rate of surgical site infection was 4.3%. One patient had DVT, and another patient had a PE, both were randomised to NWB. Length of hospital stay was 1 ± 1.5 (0, 12) for the IWB group vs 1.5 ± 2.5 (0, 19) for the NWB group. Conclusion. In this large multicentre RCT, we investigated WB following ORIF of all ankle fracture patterns in the usual care condition using standard fixation methods. Our result suggests that IWB following ankle fracture fixation is safe and resulted in a better functional outcome

A number of classification systems exist for posterior malleolus fractures of the ankle. The reliability of these classification systems remains unclear. The primary aim of this study was to evaluate the reliability of three commonly utilised fracture classification systems of the posterior malleolus. 60 patients across 2 hospitals sustaining an unstable ankle fracture with a posterior malleolus fragment were identified. All patients underwent radiographs and computed tomography of their injured ankle. 9 surgeons including pre-ST3 level, ST3-8 level, and consultant level applied the Haraguchi, Rammelt, and Mason & Molloy classifications to these patients, at two timepoints, at least 4 weeks apart. The order was randomised between assessments. Inter-rater reliability was assessed using Fleiss’ kappa and 95% confidence intervals (CI). Intra-rater reliability was assessed using Cohen's Kappa and standard error (SE). Inter-rater reliability (Fleiss’ Kappa) was calculated for the Haraguchi classification as 0.522 (95% CI 0.490 – 0.553), for the Rammelt classification as 0.626 (95% CI 0.600 – 0.652), and the Mason & Molloy classification as 0.541 (95% CI 0.514 – 0.569). Intra-rater reliability (Cohen's Kappa) was 0.764 (SE 0.034) for the Haraguchi, 0.763 (SE 0.031) for the Rammelt, 0.688 (SE 0.035) for the Mason & Molloy classification. This study reports the inter-rater and intra-rater reliability for three classification systems for posterior malleolus fractures. Based on definitions by Landis & Koch (1977), inter-rater reliability was rated as ‘moderate’ for the Haraguchi and Mason & Molloy classifications; and ‘substantial’ for the Rammelt classification. Similarly, the intra-rater reliability was rated as ‘substantial’ for all three classifications

Despite past advances of implant technologies, complication rates of fixations remain high at challenging sites such as the proximal humerus [1]. These may not only be owed to the implant itself but also to dissatisfactory surgical execution of fracture reduction and implant positioning. Therefore, the aim of this study was to quantify the instrumentation accuracy of a highly standardised and guided procedure and its influence on the biomechanical outcome and predicted failure risk. Preoperative planning of osteotomies creating an unstable 3-part fracture and fixation with a locking plate was performed based on CT scans of eight pairs of low-density proximal humerus samples from elderly female donors (85.2±5.4 years). 3D-printed subject-specific guides were used to osteotomise and instrument the samples according to the pre-OP plan. Instrumentation accuracies in terms of screw lengths and orientations were evaluated by comparing post-OP CT scans with the pre-OP plan. The fixation constructs were biomechanically tested until cyclic cut-out failure [2]. Failure risks of the planned and the post-OP configurations were predicted using a validated sample-specific finite element (FE) simulation approach [2] and correlated with the experimental outcomes. Small deviations were found for the instrumented screw trajectories compared to the planned configuration in the proximal-distal (0.3±1.3º) and anterior-posterior directions (-1.7±1.8º), and for screw tip to joint distances (-0.3±1.1 mm). Significantly higher failure risk was predicted for the post-OP compared to the planned configurations (p<0.01) via FE. When incorporating the instrumentation inaccuracies, the biomechanical results could be predicted well with FE (R. 2. =0.70). Despite the high instrumentation accuracy achieved using sophisticated subject-specific 3D-printed guides, even minor deviations from the pre-OP plan significantly increased the FE-predicted risk of failure. This underlines the importance of intraoperative guiding technology [3] in tandem with careful pre-OP planning to assist surgeons to achieve optimal outcomes. Acknowledgements. This study was performed with the assistance of the AO Foundation via the AOTRAUMA Network

Background. Cephalomedullary nails are widely used for fixation of unstable pertrochanteric fractures. In 2018, the Depuy Synthes Trochanteric Fixation Nail - Advanced (TFNA) implant was introduced at a level I academic trauma center. Thereafter, the TFNA swiftly replaced the older implant models used at the time. Subsequently, clinical concerns were raised about the use of the TFNA due to reports of nail breakage. The purpose of this study was to investigate whether the concerns raised about the performance of the TFNA were valid and to assess long-term outcomes. Methods. The data consisted of 2397 patients who had undergone a proximal femoral hip fracture procedure between 2014 and 2020. Data were handpicked from patient records. TFNA was compared with TFN, PFNA, Gamma3, and Intertan regarding nail breakage, breakage time and long-term outcomes. Results. After exclusion a total of 23/1667 (1.4%) nails broke during the follow-up period. The TFNA broke the most often with 15 cases (2.0%), followed by the Gamma3 with five cases (1.1 %) and the PFNA with three cases (1.3%). Overall, the mean (SD) nail breakage time was 233 (147.8) days. However, for the TFNA, PFNA, and Gamma3, the mean breakage times were 176.8 days (109.9), 419 days (108.6), and 291.8 (153.4), respectively. In cox regression analysis we observed significant reduction in nail breakage when using PFNA with adjusted hazard risk of 0.081 [95% Ci, 0.011-0.576, p=0.011]. Conclusions. In our data, the TFNA had a slightly higher risk for nail breakage when compared to the PFNA and the Gamma3, with a risk difference of 0.7% and 0.9%, respectively. On average, the TFNA broke nearly four months earlier than the Gamma3 and more than eight months earlier than the PFNA. It should be noted, however, that implant breakage is a relatively infrequent complication

Introduction. Cephalomedullary nailing (CMN) is commonly used for unstable pertrochanteric fracture. CMN is relatively safe method although various complications can potentially occur needing revision surgery. Commonly used salvage procedures such as renailing, hemiarthroplasty, conservative treatment or total hip arthroplasty (THA) are viable alternatives. The aim was to investigate the rate of THA after CMN and evaluate the performance on conversion total hip arthroplasty (cTHA) after failure of CMN. Method. Collected data included patients from two orthopedic centers. Data consisted of all cTHAs after CMN between 2014-2020 and primary cementless THA operations between 2013-2023. Primary THA operations were treated as a control group where Oxford Hip Score (OHS) was the main compared variable. Result. From 2398 proximal femoral hip procedures 1667 CMN procedures were included. Altogether 46/1667 (2.8%) CMNs later received THA. Indications for THA after CMN failure were 13 (28.3%) cut-outs, nine (19.6%) cut-throughs, eight (17.4%) nail breakages, seven (15.2%) post traumatic arthrosis, seven (15.2%) nonunions, one (2.2%) malunion and one (2.2%) collum screw withdrawal. Mean (SD) time to complication after CMN operation is 5.9 (6.8) months. Mean (SD) time from nail procedure to THA was 10.4 (12.0) months. Total complication rate for cTHA after CMN was 17.4%. Reported complications were infection with seven (15.2%) cases and one (2.2%) nerve damage. Mean (SD) time to cTHA complication was 3.6 (6.1) months. One-sample T-test showed OHS to be significantly better (P<.001) for primary cementless THA compared to cTHA after one year. Conclusion. Altogether 2.8% of CMN were converted to THA. Nearly half (47.8%) of the cTHA procedures were due to CMN cut-out or cut-through. OHS was significantly better in primary cementless THA compared to cTHA. Prosthetic joint infection was the most frequent complication related to cTHA

Is Non-Weight-Bearing Necessary? (INWN) is a pragmatic multicentre randomised controlled trial comparing immediate protected weight-bearing (IWB) with non-weight-bearing cast immobilisation (NWB) following ankle fracture fixation (ORIF). This trial compares; functional outcomes, complication rates and performs an economic analysis to estimate cost-utility. IWB within 24hrs was compared to NWB, following ORIF of all types of unstable ankle fractures. Skeletally immature patients and tibial plafond fractures were excluded. Functional outcomes were assessed by the Olerud-Molander Ankle Score (OMAS) and RAND-36 Item Short Form Survey (SF-36) taken at regular follow-up intervals up to one year. A cost-utility analysis via decision tree modelling was performed to derive an incremental cost effectiveness ratio (ICER). A standard gamble health state valuation model utilising SF-36 scores was used to calculate Quality Adjusted Life Years (QALYs) for each arm. We recruited 160 patients (80 per arm), aged 15 to 94 years (M = 45.5), 54% female. Complication rates were similar in both groups. IWB demonstrated a consistently higher OMAS score, with significant values at 6 weeks (MD=10.4, p=0.005) and 3 months (MD 12.0, p=0.003). Standard gamble utility values demonstrated consistently higher values (a score of 1 equals perfect health) with IWB, significant at 3 months (Ẋ = 0.75 [IWB] / 0.69 [NWB], p=0.018). Cost-utility analysis demonstrated NWB is €798.02 more expensive and results in 0.04 fewer QALYs over 1 year. This results in an ICER of −€21,682.42/QALY. This negative ICER indicates cost savings of €21,682.42 for every QALY (25 patients = 1 QALY gain) gained implementing an IWB regime. IWB demonstrates a superior functional outcome, greater cost savings and similar complication rates, compared to NWB following ankle fracture fixation

Abstract. Objective. Spinal cord surgery is a technically challenging endeavour with potentially devastating complications for patients and surgeons. Intra-operative neurophysiological monitoring(IONM), or spinal cord monitoring (SCM), is one method of preventing and identifying damage to the spinal cord. At present, indications for its use are based more on individual surgeon preference and for medico legal purposes. Our study aimed to determine IONM's utility as a clinical tool. Methods. This is a retrospective case series of 169 patients who underwent spinal surgery with IONM at two institutions between 2013 and 2018. Signal changes detected were recorded as well as the surgeon's response to these changes. Patients were followed up to one-year post-surgery using our institution's EVOLVE system. The main outcome measure in this study was new post-operative neurological signs and/or symptoms and what effect, if any, IONM and subsequent surgeon intervention had on these complications. Result. Indications for IONM included cervical stenosis, cervical disc prolapse, unstable fractures and bony metastases. Signal changes were observed in 33% (n=55) of cases. 24 of these patients responded to re-positioning. There were 7 total complications with full resolution by 12 months. False negative rate was 2.4% (n=4). There was one true positive. The largest cohort of patients included those who experienced no signal changes and subsequently no post-operative deficits (n=124). Conclusion. IONM is a non-invasive clinical tool that may be utilised for medicolegal reasons. Its use as a clinical tool is questionable given its relatively high false negative rate and low false positive rate. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Background. A large proportion of the expense incurred due to hip fractures arises due to secondary factors such as duration of hospital stay and additional theatre time due to surgical complications. Studies have shown that the use of intramedullary (IM) nail fixation presents a statistically higher risk of re-fracture than plating, which has been attributed to the stress riser at the end of the nail. It is not clear, however, if this situation also applies to unstable fractures, for which plating has a higher fixation failure rate. Moreover, biomechanical studies to date have not considered newer designs of IM nails which have been specifically designed to better distribute weight-bearing loads. This aim of this experimental study was to evaluate the re-fracture risk produced by a newer type of nailing system compared to an equivalent plate. Methods. Experimental testing was conducted using fourth generation Sawbones composite femurs and X-Bolt IM hip nail (n=4) and fracture plate (n=4) implants. An unstable pertrochanteric fracture pattern was used (AO classification: 31-A1 / 31-A2). Loading was applied along the peak loading vector experienced during walking, up to a maximum load of 500N. The risk of re-fracture was evaluated from equivalent strains measured using four rosette strain gauges on the surface of the bone at known stress riser locations. Results. Strain gauge readings determined that the equivalent strains in the femoral diaphysis were approximately 25% larger for the nail than the plate (p < 0.005). The strain levels at the location coinciding with the end of the plate were also larger for the nail, but not significantly (p > 0.26). Conclusions. Although the risk of re-fracture for displaced tronchantaric fractures was found to be larger for nailing than plating, measured strains were substantially lower than the failure strain of cortical bone (even when scaled for full weight-bearing loads of 1800N). This indicates that fracture risk is not present in either implant for bone of healthy quality, but may still become problematic in highly osteoporotic patients. Level of Evidence. IIb - Evidence from at least one well designed experimental trial

The management of bone defects and impaired fracture healing remains one of the most challenging clinical problems. Several treatments exist to aid in the healing of large bone defects, including biologics such as recombinant human bone morphogenetic protein-2 (BMP-2), yet all have met with limited success. Regeneration of bone requires a coordinated network of molecular signals where the local mechanical environment plays a major role in the success of the healing process. The mechanical environment itself is determined by the stiffness of the implant used to stabilize the fracture and weight-bearing, and if fixation is either too flexible or too rigid the healing might fail. The hypothesis is that the healing of large-segmental bone defects and fractures can be accelerated by the imposition of an appropriate mechanical environment. An overview of the progress made in this research area on how the amount of rhBMP-2 could be reduced and its effectiveness increased by providing an optimized mechanical environment to achieve bone union will be presented. Additionally, the latest findings of improved fracture healing through the manipulation of fixation stability introducing a potential clinical strategy to improve the healing outcome of unstable fractures, particularly for non-unions through increased stabilization, will be discussed

Three Cannulated Screws (3CS), Dynamic Hip Screw (DHS) with antirotation screw (DHS–Screw) or with a Blade (DHS–Blade) are the gold standards for fixation of unstable femoral neck fractures. Compared to 3CS, both DHS systems require larger skin incision with more extensive soft tissue dissection while providing the benefit of superior stability. The newly designed Femoral Neck System (FNS) for dynamic fixation combines the advantages of angular stability with a less invasive surgical technique. The aim of this study is to evaluate the biomechanical performance of FNS in comparison to established methods for fixation of the femoral neck in a human cadaveric model. Twenty pairs of fresh–frozen human cadaveric femora were instrumented with either DHS–Screw, DHS–Blade, 3CS or FNS. A reduced unstable femoral neck fracture 70° Pauwels III, AO/OTA31–B2.3 was simulated with 30° distal and 15° posterior wedges. Cyclic axial loading was applied in 16° adduction, starting at 500N and with progressive peak force increase of 0.1N/cycle until construct failure. Relative interfragmentary movements were evaluated with motion tracking. Highest axial stiffness was observed for FNS (748.9 ± 66.8 N/mm), followed by DHS–Screw (688.8 ± 44.2 N/mm), DHS–Blade (629.1 ± 31.4 N/mm) and 3CS (584.1 ± 47.2 N/mm) with no statistical significances between the implant constructs. Cycles until 15 mm leg shortening were comparable for DHS–Screw (20542 ± 2488), DHS–Blade (19161 ± 1264) and FNS (17372 ± 947), and significantly higher than 3CS (7293 ± 850), p<0.001. Similarly, cycles until 15 mm femoral neck shortening were comparable between DHS–Screw (20846 ± 2446), DHS–Blade (18974 ± 1344) and FNS (18171 ± 818), and significantly higher than 3CS (8039 ± 838), p<0.001. From a biomechanical point of view, the Femoral Neck System is a valid alternative to treat unstable femoral neck fractures, representing the advantages of a minimal invasive angle–stable implant for dynamic fixation with comparable stability to the two DHS systems with blade or screw, and superior to Three Cannulated Screws

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

Introduction and Objective. Postoperative management regimes vary following open reduction and internal fixation of unstable ankle fractures. There is an evolving understanding that poorer outcomes could be associated with non-weight bearing protocols and immobilisation. Traditional non-weight bearing cast immobilisation may prevent loss of fixation, and this practice continues in many centres. The aim of this systematic review and meta-analysis is to compare the complication rate and functional outcomes of early weight-bearing (EWB) versus late weight-bearing (LWB) following open reduction and internal fixation of ankle fractures. Materials and Methods. We performed a systematic review with a meta-analysis of controlled trials and comparative cohort studies. MEDLINE (via PubMed), Embase and the Cochrane Library electronic databases were searched inclusive of all date up to the search time. We included all studies that investigated the effect of weight-bearing following adults ankle fracture fixation by any means. All ankle fracture types, including isolated lateral malleolus fractures, isolated medial malleolus fractures, bi-malleolar fractures, tri-malleolar fractures and Syndesmosis injuries, were included. All weight-bearing protocols were considered in this review, i.e. immediate weight-bearing (IMW) within 24 hours of surgery, early weight-bearing (EWB) within three weeks of surgery, non-weight-bearing for 4 to 6 weeks from the surgery date (or late weight-bearing LWB). Studies that investigated mobilisation but not weight-bearing, non-English language publications and tibial Plafond fractures were excluded from this systematic review. We assessed the risk of bias using ROB 2 tools for randomised controlled trials and ROBINS-1 for cohort studies. Data extraction was performed using Covidence online software and meta-analysis by using RevMan 5.3. Results. After full-text review, fourteen studies (871 patients with a mean age ranged from 35 to 57 years) were deemed eligible for this systematic review; ten randomised controlled trials and four comparative cohort studies. Most of the included studies were rated as having some concern with regard to the risk of bias. There is no important difference in the infection rate between protected EWB and LWB groups (696 patients in 12 studies). The risk ratio (RR) is 1.30, [95% CI 0.74 to 2.30], I. 2. = 0%, P = 0.36). Other complications were rare. The Olerud-Molander Ankle Score (OMAS) was the widely used patient-reported outcome measure after ankle fracture fixation among the studies. The result of the six weeks OMAS analysis (three RCTs) was markedly in favour of the early weight-bearing group (MD = 10.08 [95% CI 5.13 to 15.02], I. 2. = 0%P = <0.0001). Conclusions. The risk of postoperative complications is an essential factor when considering EWB. We found that the overall incidence of surgical site infection was 6%. When comparing the two groups, the incidence was 5.2% and 6.8% for the LWB and EWB groups. This difference is not clinically important. On the other hand, significantly better early functional outcome scores were detected in the EWB group. These results are not without limitations. Protected early weight-bearing following open reduction and internal fixation of ankle fractures is potentially safe and improve short-term functional outcome. Further good-quality randomised controlled trials would be needed before we could draw a more precise conclusion

Introduction. Being challenging, multifragmentary proximal tibial fractures in patients with severe soft tissue injuries and/or short stature can be treated using externalized locked plating. A recent finite element study, investigating the fixation stability of plated unstable tibial fractures with 2-mm, 22-mm and 32-mm plate elevation under partial and full weight-bearing, reported that from a virtual biomechanical point of view, externalized plating seems to provide appropriate relative stability for secondary bone healing under partial weight-bearing during the early postoperative phase. The aim of the current study was to evaluate the clinical outcomes of using a LISS plate as a definitive external fixator for the treatment of multifragmentary proximal tibial fractures. Methods. Following appropriate indirect reduction, externalized locked plating was performed and followed up in 12 patients with multifragmentary proximal tibial fractures with simple intraarticular involvement and injured soft tissue envelope. Results. Among all patients, the average follow up period was 22 months (range14–48 months), revealing uneventful healing in all of them. Time to fracture union was 21.8 weeks on average (range 16–28weeks). The mean HSS knee score was 87 (range 72–98) at 4 weeks postoperatively and 97 (range 88–100) at the final follow up. The average AOFAS score was 92 (range 84–100) at 4 weeks postoperatively and 98 (range 94–100) at the final follow up. Conclusions. Externalized locked plating seems to be a successful surgical alternative treatment in selected cases with unstable proximal tibial fractures and severe soft tissue injury, following appropriate indirect fracture reduction

This study aims to investigate that a single dose of tranexamic acid (TXA) will reduce blood loss and transfusion rates in elderly patients, undergoing intertrochanteric (IT) or femoral neck fractures surgery. Consecutive elderly patients receiving hip fracture surgery for stable or unstable IT fracture, treated with short intramedullary nail (IMN) insertion as well as cemented hemiarthroplasty for acute femoral neck (subcapital) hip fracture, were screened for inclusion in this single-centre randomized trial. Patients were randomly allocated to a study group by sealed envelope. One TXA dose of 15 mg/kg i.v. diluted in 100 ml N/S or one placebo dose i.v. in 100 ml N/S were administered 5 mins before the skin cut. Haemoglobin (Hb) concentration was measured at admission time and prior to surgery. Post-operatively it was measured on a daily basis until day 4, giving a total of four Hb measurements (days 1 to 4). The transfusion trigger point was determined in accordance with the French guidelines for erythrocyte blood transfusion. The transfusion trigger was 10 g/dl for patients at risk, while in all other cases, it was 9 g/dl. Information regarding the transfusions number was assessed directly by the hospital blood bank database. Blood loss was calculated by the Hb dilution method. Nadler's formula was used to calculate patients' blood volume. For calculation of total blood loss (TBL) expressed to total Hb loss and total Volume loss, the number of transfusions (55 grams of Hb per transfusion), the Hb concentration on preoperatively (Hgbi) and the Hb concentration on the last measure (Hgbe) were used. (Hb balance method). The primary efficacy outcome was the number of transfusions of allogeneic RBC from surgery up to day 4. The secondary ones were the total blood loss from surgery to day 4 as it was calculated by Hb-balance method. After randomization, 35 patients with femoral neck fracture and 30 patients with IT fracture received TXA prior to surgery. Respectively, 30 patients with femoral neck fracture and 55 with IT fracture didn't receive TXA. The groups did not differ significantly in their basic demographics (age, gender, BMI, injury mechanism, ASA score, co-morbidities). Results showed that patients undergoing hemiarthroplasty after receiving TXA, were transfused with less allogeneic RBC and had less total blood loss than patients that didn't receive TXA, but without statistical significance. While patients treated with IMN in the TXA group received a significantly lower number of RBC units than the control group (1.28 ± 1.049 vs 2.075 ± 1.685), (P = 0.0396), had a significantly lower loss of Hb (98.59 ± 55.24 vs 161.6 ± 141.7), (P = 0.0195) and a lower total blood volume loss (951.3 ± 598.9 ml vs 1513 ± 1247 ml), (P = 0.023). This trial confirmed TXA administration efficacy in reducing blood loss and transfusion rate in elderly patients undergoing hip fracture surgery. A TXA single dose may be a safer option, taking into account these patients' physiological status and co-morbidities