Aims

This study describes the use of the Masquelet technique to treat segmental tibial bone loss in 12 patients.

Antegrade nailing of proximal humeral fractures using a straight nail can damage the bony insertion of the supraspinatus tendon and may lead to varus failure of the construct. In order to establish the ideal anatomical landmarks for insertion of the nail and their clinical relevance we analysed CT scans of bilateral proximal humeri in 200 patients (mean age 45.1 years (sd 19.6; 18 to 97) without humeral fractures. The entry point of the nail was defined by the point of intersection of the anteroposterior and lateral vertical axes with the cortex of the humeral head. The critical point was defined as the intersection of the sagittal axis with the medial limit of the insertion of the supraspinatus tendon on the greater tuberosity. The region of interest, i.e. the biggest entry hole that would not encroach on the insertion of the supraspinatus tendon, was calculated setting a 3 mm minimal distance from the critical point. This identified that 38.5% of the humeral heads were categorised as ‘critical types’, due to morphology in which the predicted offset of the entry point would encroach on the insertion of the supraspinatus tendon that may damage the tendon and reduce the stability of fixation.

We therefore emphasise the need for ‘fastidious’ pre-operative planning to minimise this risk.

Cite this article: Bone Joint J 2014;96-B:249–53.

This study compares outcomes of fixation of subtrochanteric femoral fractures using a single lag screw (Gamma3 nail, GN) with a dual lag screw device (InterTAN nail, IN). The primary outcome was mechanical failure, defined as lag screw cut-out, back-out, nail breakage or peri-implant fracture. Technical factors associated with mechanical failure were also identified.

All adult patients (>18yrs) with a subtrochanteric femoral fracture treated in a single centre were retrospectively identified using electronic records. Included patients underwent surgical fixation using either a long GN (2010–2017) or IN (2017–2022). Cox regression analysis was used to determine the risk of mechanical failure and technical predictors of failure.

The study included 587 patients, 336 in the GN group (median age 82yrs, 73% female) and 251 in the IN group (median age 82yrs, 71% female). The IN group exhibited a higher prevalence of osteoporosis (p=0.002) and CKD□3 (p=0.007). There were no other baseline differences between groups. The risk of any mechanical failure was increased two-fold in the GN group (HR 2.51, p=0.020). Mechanical failure comprising screw cut-out (p=0.040), back-out (p=0.040) and nail breakage (p=0.51) was only observed in the GN group. The risk of peri-implant fracture was similar between the groups (HR 1.10, p=0.84). Technical predictors of mechanical included varus >5° for cut-out (HR 15.61, p=0.016), TAD>25mm for back-out (HR 9.41, p=0.020) and shortening >1cm for peri-implant fracture (HR 6.50, p=<0.001).

Dual lag screw designs may reduce the risk of mechanical complications for patients with subtrochanteric femoral fractures.

Background

The optimal treatment of segmental tibial fractures (STF) is controversial. Intramedullary nailing (IMN) and external fixation (EF) have unique benefits and complications.

Purpose

Surgical correction of upper limb deformities in severe osteogenesis imperfecta (OI) is technically difficult and less absolving, hence we aimed to analyse the surgical complications of rodding the humeri in severe OI.

The aim of our study was to compare the incidence of post-operative anterior knee discomfort after anterograde tibial nailing by suprapatellar and infrapatellar approaches.

95 subjects presenting with a tibial fracture requiring an intramedullary nail were randomised to treatment using a suprapatellar (SP) or infrapatellar (IP) approach. Anterior knee discomfort was assessed at 4 months, 6 months and 1 year post operatively using the Aberdeen Weightbearing Test-Knee (AWT-K), knee specific patient reported outcome measures and the VAS pain score. The AWT-K is an objective measure which uses weight transmitted through the knee when kneeling as a surrogate for anterior knee discomfort.

53 patients were randomised to an SP approach and 42 to an IP approach. AWT-K results showed a greater mean proportion of weight transmitted through the injured leg compared to the uninjured leg when kneeling in the SP group compared to the IP group at all time points at all follow-up visits. This reached significance at 4 months for all time points except 30 seconds. It also reached significance at 6 months at 0 seconds and 1 year at 60 seconds.

We conclude that the SP approach for anterograde tibial nailing reduces anterior knee discomfort post operatively compared to the IP approach.

Aim

The aim of this study was to determine whether the absence of periosteal reaction on plain radiographs was predictive of exchange nail failure in lower limb diaphyseal fracture non-unions.

Introduction

Fractures of the distal tibia can be challenging to manage. Numerous surgical techniques have been utilised in managing these however there remains debate as to the optimum method of fixation. This study aims to assess the surgical outcomes and PROMs of patients with distal tibial fractures managed with intramedullary-nails or ring fixation.

The aim of this study was to identify risk factors for failure of exchange nailing for femoral diaphyseal fracture non-unions. The study cohort comprised 40 patients with femoral diaphyseal non-unions treated by exchange nailing. The main outcome measures were union, number of secondary fixation procedures required to achieve union and time to union. Univariate analysis and multiple regression were used to identify risk factors for failure to achieve union.

The mean age of the patients at exchange nail surgery was 37 years. The median time to exchange nailing from primary fixation was 8.4 months. Multiple causes for non-union were found in 14 (35.0%) cases, with infection present in 12 (30.0%) patients. Further exchange procedures were required in nine (22.5%) cases, one patient (2.5%) required the use of another fixation modality, to achieve union. Union was ultimately achieved in 35 (94.5%) patients. The median time to union was 9.4 months after the exchange nail procedure. Univariate analysis confirmed that cigarette smoking and infection were predictive of failure (p<0.05). Multi-regression analysis found that Gustilo-Anderson grade, presence of dead bone or a gap and infection were predictive of exchange nail failure (p <0.05).

Exchange nailing is an effective treatment for aseptic femoral diaphyseal fracture non-union. Patients with infection required more than one procedure. Smoking, infection and the presence of dead-bone or a gap at the fracture site were associated with an increased risk of further fixation surgery.

Open reduction and internal fixation of proximal humerus fractures with angular stable plates is, beside antegrade nailing of the humerus, a standard procedure. A retrograde nail has been developed to avoid penetrating the rotator cuff and to avoid opening the fracture side during osteosynthesis.

The aim of our biomechanical study was to evaluate if retrograde nailing of proximal humerus fractures is as stable as locking plate osteosynthesis.

The biomechanical properties of 2 implants were tested in 11 human fresh frozen cadaveric humeri pairs. The Retron Nail® and the Philos® plate were implanted after osteotomy. All specimens were suspected to axial and torque load for 1000 cycles in a servo pneumatic testing apparatus.

The Philos® plate had greater torsion stiffness than the Retron® nail, but we found no significance. The Retron® nail had greater axial stiffness but our findings were not statistically significant.

Our study showed, that there are no significant differences between a retrograde nail and locking plate osteosynthesis for proximal humerus fractures concerning axial and torsion deformities. Therefore the retrograde nail is a suitable alternative for fixation of proximal humerus fracture.

Background

In a systematic review of 1125 distal tibia fractures treated with an intramedullary nail, the reported incidence of malalignment was 14%. The purpose of our study is to assess whether the addition of blocking screws during intramedullary nailing of a distal tibia fracture improved radiological outcomes. As a secondary outcome, the time to radiographic union was compared to see if a more rigid bone-implant construct had an effect on healing.

The aim of this study was to identify risk factors for failure of exchange nailing in tibial diaphyseal fracture non-unions. The cohort comprised 99 tibial diaphyseal fracture non-unions treated by exchange nailing. The mean age of the patients at exchange nail surgery was 36 years. The median time from primary fixation to exchange nailing was 6.4 months. The main outcome measures were union, number of secondary fixation procedures required to achieve union and time to union. Univariate analysis and multiple regression were used to identify risk factors for failure to achieve union.

Multiple causes for non-union were found in 31.3% cases, with infection present in 32.3%. Further exchange procedures were required in 35.4%, 7.1% required the use of other fixation modalities. Union was ultimately achieved in 97.8%. The median time to union was 8.7 months. Univariate analysis revealed that cigarette smoking, an atrophic pattern of non-union and infection were predictive for failure of exchange nailing (p<0.05). Multi-regression analysis found that only infection was statistically significantly predictive (p<0.05) of exchange nail failure.

Exchange nailing is an effective treatment for tibial diaphyseal non-unions even in the presence of infection. Smoking, atrophic pattern of non-union and infection are associated with an increased risk of further fixation surgery.

AIM

SIGN-nail system was elaborated to reduce the need in image intensifier during IM-nailing and to allow use of this method in poor countries with restricted medical facilities. The aim of this study was to evaluate efficacy of SIGN-nailing in tibia fractures treatment.

We have reviewed retrospectively 80 patients who were treated for traumatic fractures of the femur with a Grosse-Kempf nail to assess the incidence and causes of persisting pain in the proximal thigh.

At a mean of 21 months after operation 33 patients had residual pain severe enough to interfere with their lifestyle or mobility. This was in the region of the scar on the greater trochanter in three-quarters of the patients. Only four showed no radiological abnormality. There was nonunion of the fracture in two, Paget’s disease in one, breakage of the nail in two and prominence of the proximal locking screw in five, although we found no correlation between prominence of the nail and pain.

There was a strong relationship between pain and heterotopic ossification at the proximal end of the implant; this was present in 64% of the patients with pain as compared with those without pain (p < 0.001, Mann-Whitney U test). Of the 80 patients, 27 had the implant removed after 18 months, 17 of them because of pain. In six of these 17, the pain was not relieved. Prominence of the nail proximally was not associated with pain, but protuberance of laterally-based proximal locking screws caused problems. We found a strong association between heterotopic bone formation and pain, but it is uncertain whether this is the true cause or merely an indication of some other factor such as traumatic damage to the glutei during insertion of the nail. Removal of the implant does not always cure such pain.

We performed a prospective, randomised study on 50 patients with Tscherne C1 tibial diaphyseal fractures comparing treatment with reamed and unreamed intramedullary nails. Our results show that reamed nailing is associated with a significantly lower time to union and a reduced requirement for a further operation. Unreamed nailing should not be used in the treatment of the common Tscherne C1 tibial fracture.

Introduction

In elderly patients, the incidence of a second fracture in the contralateral hip within 2 years of a femoral neck fracture (FNF), ranges from 7 to 12%.

We reviewed our results and complications of using a pre-bent 1.6mm Kirschner wire (K-wire) for extra-articular metacarpal fractures. The surgical procedure was indicated for angulation at the fracture site in a true lateral radiograph of at least 30 degrees and/or in the presence of a rotatory deformity.

A single K-wire is pre-bent in a lazy-S fashion with a sharp bend at approximately 5 millimetres and a longer smooth curve bent in the opposite direction. An initial entry point is made at the base of the metacarpal using a 2.5mm drill by hand. The K-wire is inserted blunt end first in an antegrade manner and the fracture reduced as the wire is passed across the fracture site. With the wire acting as three-point fixation, early mobilisation is commenced at the metacarpo-phalangeal joint in a Futuro hand splint.

The wire is usually removed with pliers post-operatively at four weeks in the fracture clinic.

We studied internal fixation of 18 little finger and 2 ring finger metacarpal fractures from November 2007 to August 2009. The average age of the cohort was 25 years with 3 women and 17 men. The predominant mechanism was a punch injury with 5 diaphyseal and 15 metacarpal neck fractures. The time to surgical intervention was a mean 13 days (range 4 to 28 days). All fractures proceeded to bony union. The wire was extracted at an average of 4.4 weeks (range three to six weeks). At an average follow up of 8 weeks, one fracture had to be revised for failed fixation and three superficial wound infections needed antibiotic treatment.

With this simple and minimally invasive technique performed as day-case surgery, all patients were able to start mobilisation immediately.

The general outcome was good hand function with few complications.

The purpose of this study was to evaluate the subjective and objective functional outcome after osteosynthesis of the forearm bone fractures with plates and screws (ORIF) or elastic nailing (CRIF).

We evaluated 55 patients (45 men and 10 women) who underwent internal fixation of both forearm bones with CRIF or ORIF, concerning the range of motion of the forearm, wrist and elbow (pronation, supination, flexion and extension), grip strength and a validated outcome measure (DASH score). The mean duration of follow-up was 3 years, and standardized radiographs of the forearm were evaluated. The mean age was 41.6.

We used the Student's t test to compare means and chi-square test to compare proportions.

The mean (confidence interval 95%) of the DASH scale was 29.6 (22.6 to 36.5), significantly higher (p<0.001) than the normative value in the U.S. (10.1). There was a statistically significant reduction of forearm supination (86.4 vs. 64.6, p<0.001) and grip strength (0.63 vs. 0.48, p<0.001) in relation to the opposite member; grip strength decrease correlated with worse subjective outcome (p<0.02). There were no significant differences between groups undergoing ORIF or CRIF. The risk of nonunion and reintervention was not different between groups (p=0214).

Forearm bones fractures are associated with high rates of consolidation and satisfactory mobility of the forearm since we obtain an anatomic reduction of the fracture, as is most easily achieved by plate fixation. However, elastic nailing is a less invasive technique that allows restoring function more quickly with less pain and no increased risk of complications. Given the scant scientific evidence currently available we will require a more comprehensive study to compare the anatomical and functional outcome after ORIF and CRIF.

We performed a prospective, randomised trial in 39 patients with open tibial fractures treated initially by external fixation to compare cast immobilisation (group A) and intramedullary nailing (group B) as a sequential protocol planned from the onset of treatment.

The results showed that group B achieved faster union (p < 0.05) than group A with less malunion or shortening and a greater range of movement. Patients treated by intramedullary nailing required fewer radiographs and outpatient visits (p = 0.0015) and had a more predictable and rapid return to full function.

We feel that these severe fractures are better treated by delayed intramedullary nailing and that this has an acceptable rate of complications.

Hypothesis

The proximal geometry and design of trochanteric nails affects initial construct stiffness, fatigue survival, and preservation of biomechanical stability over time.