Abstract

Aims. To evaluate the results of Elastic Stable Intramedullary Nailing (ESIN) for displaced, unstable paediatric forearm diaphyseal fractures. Method. A retrospective, consecutive series study of 60 patients treated with ESIN between February 1996 and July 2005. Results. There were 43 (72%) boys and 17 (28%) girls with median age of 11.5 years (range: 2.6-15.9). 54 (90%) patients had a closed injury and 6 (10%) sustained a Grade I open injury. Seven patients had an isolated radius fracture. 49 (82%) fractures were stabilised with both bone ESIN, 10 (16%) with radial and one with isolated ulnar ESIN by standard technique under tourniquet control. All but two patients were protected with an above elbow cast. Thirty-six cases (60%) were primary procedures and 24 (40%) were performed due to re-displacement following a MUA. 36 patients (60%) required a minimal open reduction. Average hospital stay was 1.8 days (1-8 days). Average length of immobilisation was 5.4 weeks (3-9 weeks). Average time for clinical fracture union was 5.7 weeks (3-13 weeks). ESIN were removed after mean period of 33.8 weeks (approx: 7.9 months). One patient had a forearm compartment syndrome and required formal fasciotomy. One patient had ulnar delayed union and one had ulnar non-union. Five patients had transient superficial radial nerve neuropraxia. Ten had soft tissue irritation leading to early nail removal in two patients and two had superficial wound infection. Three patients sustained a re-fracture with the nail in situ following a new injury. 53 (88%) patients had full elbow and wrist movements on discharge. Seven patients had restriction of forearm rotations of less than 15°. Conclusion. Good clinical outcome, transitory and modest complications; quick and safe nail removal; and better cosmesis compared to plating makes ESIN an attractive treatment option for displaced, unstable paediatric forearm diaphyseal fractures

This randomized controlled study aimed to compare surgical duration, intra-operative blood loss, and fluoroscopy time between the suprapatellar and infrapatellar approaches for intramedullary interlocking nailing of tibia. We included 40 adult patients with tibial shaft fractures, excluding those with non-union, revision surgery, or polytrauma. Patients were divided equally into two groups using block randomization: Group A (20 patients) underwent the infrapatellar approach, and Group B (20 patients) underwent the suprapatellar approach. Blood loss was measured using gravimetric method and by changes in pre-operative and post operative haemoglobin levels. Surgical duration was estimated by calculating the time elapsed between the start and end of the procedure and fluoroscopy time was logged from the fluoroscopy machine.

In group A, blood loss averaged 154±30.98ml, slightly more than in group B (150±32.92ml), though the difference was not statistically significant (p>0.05). Group A also showed a higher difference in haemoglobin levels (2.20±1.13 gm/dl) compared to group B (1.15±0.93 gm/dl), which was statistically significant (p=0.02). Fluoroscopy time and surgery duration were slightly longer in group A compared to group B but not statistically significant(p=0.693).

The suprapatellar approach results in lesser blood loss, potentially promoting faster recovery, reduced need for blood transfusions and shorter hospital stays. It also entails shorter fluoroscopy time and surgical duration (though not statistically significant) which may reduce radiation exposure for the surgical team.

Introduction

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.

Introduction

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.

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.

Introduction

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.

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.

Introduction

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.

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 Nailing (RIMN) and finally those who advocate for Distal Femoral Replacement (DFR). The literature comparing these treatments, has been infrequent, and commonly restricted to single-center studies. The purpose of this study was to retrospectively evaluate a large series of operatively treated periprosthetic distal femur fractures from multiple centers and compare treatment strategies. Patients who were treated operatively for a periprosthetic distal femur fracture at 8 centers across North America between 2003 and 2018 were retrospectively identified. Baseline characteristics, surgical details and post-operative clinical outcomes were collected from patients meeting inclusion criteria. Inclusion criteria were patients aged 18 and older, any displaced operatively treated periprosthetic femur fracture and documented 1 year follow-up. Patients with other major lower extremity trauma or ipsilateral total hip replacement were excluded. Patients were divided into 3 groups depending on the type of fixation received: Locked Plating, Retrograde Intramedullary Nailing and Distal Femoral Replacement. Documented clinical follow-up was reviewed at 2 weeks, 3 months, 6 months and 1 year following surgery. Outcome and covariate measures were assessed using basic descriptive statistics. Categorical variables, including the rate of re-operation, were compared across the three treatment groups using Fisher Exact Test. In total, 121 patients (male: 21% / female: 79%) from 8 centers were included in our analysis. Sixty-seven patients were treated with Locked Plating, 15 with Retrograde Intramedullary Nailing, and 39 were treated with Distal Femoral Replacement. At 1 year, 64% of LP patients showed radiographic union compared to 77% in the RIMN group (p=0.747). Between the 3 groups, we did not find any significant differences in ambulation, return to work and complication rates at 6 months and 1 year (Table 1). Reoperation rates at 1 year were 27% in the LP group (17 reoperations), 16% in the DFR group (6 reoperations) and 0% in the RIMN group. These differences were not statistically significant (p=0.058). We evaluated a large multicenter series of operatively treated periprosthetic distal femur fractures in this study. We did not find any statistically significant differences at 1 year between treatment groups in this study. There was a trend towards a lower rate of reoperation in the Retrograde Intramedullary Nailing group that should be evaluated further with prospective studies. For any figures or tables, please contact the authors directly

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.

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.

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.

Aim

Determine the incidence of surgical site infections (SSI) after intramedullary nailing (IN) of femoral and tibial diaphyseal fractures and evaluate possible risk factors.

Purpose

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.

Introduction

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.

Introduction

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.

Purpose

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.

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.

Background

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.