The ideal timing for nail dynamization in femoral shaft delayed union and non-union

A novel classification for aseptic femoral shaft nonunion after intramedullary nailing: a retrospective study

BACKGROUND

Although intramedullary nailing has been established as the gold standard for treating femoral shaft fractures, nonunion following intramedullary nailing remains a major concern for clinicians, severely affecting patients' walking ability and quality of life. Presently, there are certain controversies and deficiencies in nonunion classification and treatment. Herein, we propose a novel classification system for aseptic femoral shaft nonunion after intramedullary nailing based on X-ray-assessed nailing morphology and stability. Furthermore, we sought to explore the new classification's clinical significance and management implications.

METHODS

This retrospective study involved the analysis of clinical data collected from 82 patients with aseptic bone nonunion after intramedullary nailing of femoral shaft fractures between 2010 and 2022. The patients were classified into four groups based on intramedullary nailing stability and bone defect existence, as revealed in X-ray images. The four classifications were as follows: Type I (intramedullary nailing is stable without bone defect), Type II (intramedullary nailing is stable with bone defect), Type III (intramedullary nailing is not stable without bone defect), and Type IV (intramedullary nailing is not stable with bone defect). Based on the novel classifications, we introduced individualized treatment methods. Type I patients underwent dynamization, and Type II patients received bone grafting and plate fixation. Type III patients underwent larger intramedullary nail exchange or plate fixation, and Type IV patients received larger intramedullary nail exchange and plate fixation with bone graft or double plate fixation with bone graft. Data on relevant indicators were collected.

RESULTS

All patients recovered well with no complications. The average surgery times for Types I-IV were 0.4 ± 0.1, 0.8 ± 0.2, 1.1 ± 0.4, and 1.6 ± 0.4 h, respectively. Furthermore, the mean blood loss volumes for Types I-IV were 23.4 ± 4.8, 53.3 ± 8.4, 56.3 ± 7.9, and 125.2 ± 10.8 ml, respectively. The average bone healing time of all 82 patients was 5.1 ± 1.5 months. On the other hand, the mean bone healing times for Types I-IV were 4.6 ± 1.1, 4.7 ± 1.1, 5.1 ± 1.5, and 5.7 ± 1.8 months, respectively. Furthermore, the LEFS scores for Types I-IV were 68.7 ± 3.5, 69.8 ± 3.1, 66.8 ± 3.8, and 68.6 ± 2.9 points, respectively. The mean surgery time and bleeding volume increased gradually from Types I to IV (p < 0.05) but with no significant difference between Types II and III. Moreover, there were no statistical differences in fracture healing times, LEFS scores, age, and nonunion durations across the four classifications.

CONCLUSIONS

The proposed novel classification system could achieve accurate diagnosis and guidance for clinical management of aseptic femoral shaft nonunion after intramedullary nailing. The corresponding individualized treatment approaches could improve prognostic outcomes and healing rates and alleviate postoperative complications.

CLINICAL TRIAL NUMBER

Not applicable.

Use of controlled nail dynamization technique for femoral shaft hypertrophic nonunion

Background

Femoral nonunion after intramedullary nailing (IMN) of a diaphyseal long bone fracture is a severe complication that requires effective management. The IMN dynamization has been used to treat hypertrophic nonunions previously. However, routine nail dynamization has only a low success rate and the risk of limb shortening.

Methods

Two patients with femoral shaft fracture hypertrophic nonunion at 4 or 5 months after intramedullary nailing were treated with the therapeutic paradigm named "controlled nail dynamization". In this paradigm, the interlocking nails are removed but the dynamic hole nails are retained. At the same time, four Poller screws were used to limit the movement of the intramedullary nail in the coronal and sagittal planes. The intramedullary nail can only generate compressive stress along the axial direction of the femoral shaft, thereby promoting fracture healing. So this technique was named "controlled nail dynamization".

Results

Here, we describe two cases of delayed healing of the femoral diaphysis, which were successfully treated through controlled nail dynamization. Followed up for more than 12 months. Bone union was achieved in both patients, and there were no complications such as nonunion and internal fixation failure.

Conclusion

The controlled nail dynamization is feasible for safe and effective treatment for femoral shaft hypertrophic nonunion.

Femoral shaft fracture with a third fragment treated with an intramedullary nail: Is the displacement of the third fragment predictive of nonunion?

PURPOSE

Femoral shaft fractures with third fragments are difficult to reduce anatomically, affecting bone healing chances. The goal of this study is to determine the impact of the third fragment's radiological characteristics assessed on post-operative radiographs, as well as other factors, on the healing of type 32B femur shaft fractures treated with intramedullary nail.

METHODS

We conducted a retrospective study of 93 patients treated for femoral shaft fractures type 32 B. On post-operative X-rays, two radiologic parameters were evaluated: the third fragment size and the mean third fragment displacement. Patients had radiologic follow-up at 2, 4, 6, 9, and 12-months and were separated into 3 groups based on their fracture healing time: within 6 months (group 1), between 6 and 12 months (group 2), or nonunion after 12 months (group 3).

RESULTS

Among the 93 patients, 72 (77.4%) showed fracture healing at 6 months, 13 (14%) at 12 months, and 8 (8.6%) demonstrated nonunion at 12 months. The mean third fragment displacement was notably different between groups (p < 0.001) and was considerably greater in group 3 than in groups 1 and 2. The influence of third fragment displacement on outcomes under 6 months was determined by ROC analysis, using a cut-off value of 14 mm. Displacement under 14 mm predicted healing within 6 months with a sensitivity of 90.3% and a specificity of 61.9%. The statistical analysis demonstrated that the odds of experiencing non-union or delayed healing were approximately 15 times higher for patients with a third fragment displacement of 14 mm or greater.

CONCLUSION

The third fragment displacement is the most important factor influencing healing within twelve months in femur shaft fractures type 32B managed with an intramedullary nail. Inversely, the third fragment size had no effect on the healing of the fractures in our series.

Development and validation of predictive nomogram for postoperative non-union of closed femoral shaft fracture

Closed femoral shaft fracture is caused by high-energy injuries, and non-union exists after operation, which can significantly damage patients' body and mind. This study aimed to explore the factors influencing postoperative non-union of closed femoral shaft fractures and establish a predictive nomogram. Patients with closed femoral shaft fractures treated at Hebei Medical University Third Hospital between January 2015 and December 2021 were retrospectively enrolled. A total of 729 patients met the inclusion criteria; of them, those treated in 2015-2019 comprised the training cohort (n = 617), while those treated in 2020-2021 comprised the external validation cohort (n = 112). According to multivariate logistic regression analysis, complex fractures, bone defects, smoking, and postoperative infection were independent risk factors. Based on the factors, a predictive nomogram was constructed and validated. The C-indices in training and external validation cohorts were 0.818 and 0.781, respectively; and the C-index of internal validation via bootstrap resampling was 0.804. The Hosmer-Lemeshow test showed good fit of the nomogram (P > 0.05) consistent with the calibration plot results. The clinical effectiveness was best at a threshold probability of 0.10-0.40 in decision curve analysis. The risk prediction for patients with fractures using this nomogram may aid targeted prevention and rehabilitation programs.

Effects of dynamization timing and degree on bone healing of different fracture types

Dynamization, that is, increasing interfragmentary movement (IFM) by reducing fixation stiffness from a rigid to a more flexible state, has been successfully used in clinical practice to promote fracture healing. However, it remains unclear how dynamization timing and degree affect bone healing of different fracture types. Finite element models of tibial fractures based on the OTA/AO classification (Simple: A1-Spiral, A2-Oblique, A3-Transverse; Wedge: B2-Spiral, B3-Fragmented; Complex: C2-Segment, C3-Irregular), in combination with fuzzy logic-based mechano-regulatory tissue differentiation algorithms, were used to simulate the healing process when dynamization of varied degrees (dynamization coefficient or DC = 0-0.9; 0.9 represents 90% reduction in the fixation stiffness relative to a rigid fixation) were applied at different time points after fracture. The fuzzy logic-based algorithms have been validated with a preclinical animal model. The results showed that the healing responses of type A fractures were more sensitive to the changes in dynamization degree and timing comparing with type B or C fractures. Additionally, the optimal dynamization regime for each fracture type was different. For type A fractures, a moderate dynamization degree (e.g., DC = 0.5) applied after Week 1 promoted the recovery of biomechanical integrity. For type B and C fractures, the effective dynamization included a greater dynamization degree (DC = 0.7) applied after Week 2. Our results further demonstrated that the fracture morphology affected interfragmentary strain environments within the callus, leading to varied healing results for different fracture types. These results suggest that the effects of dynamization are highly dependent of the fracture types. Therefore, specific dynamization strategies should be chosen for different fracture types to achieve optimal healing outcomes.

Lateral cortical notching facilitates dynamization of proximal femoral nailing - A finite element analysis

INTRODUCTION

Dynamization of proximal femoral nailing by removal of distal interlocking is one of the recommended treatment options for nonunions of femur fractures. However, in certain inter-/subtrochanteric fractures, gliding of the nail along the femoral shaft is blocked by lateral femoral cortical support of the lag screw. For these cases, Biber et al. proposed lateral cortical notching (LCN), in which the supporting lateral bone is removed. This study investigates the biomechanical effect of LCN on gliding of proximal femoral nailing and stress distribution at the bone/implant interface.

MATERIALS AND METHODS

In this finite element analysis a three-dimensional model of an unstable intertrochanteric fracture with proximal femoral nailing without distal interlocking was simulated using the FebioStudio software suite. To simulate LCN, the lag screw hole was lengthened to 15.34 mm at the lateral cortex. Displacement of the nail along the femoral shaft axis and von Mises stress distribution were compared between LCN model and standard implantation model.

RESULTS

Displacement of the nail along the femoral shaft axis was higher in the LCN model than in the standard implantation model (0.48 mm vs. 0.07 mm). Highest von Mises stresses of 176-178 MPa at the implant and of 52-81 MPa at the proximal femur were detected. Maximum von Mises stresses of the implant were comparable at all sides, except for a reduced von Mises stress at the lateral inferior side in the LCN model (80 vs. 102 MPa). At the inferior lateral screw hole and the anterior/posterior lateral screw hole maximum von Mises stress was reduced in the LCN model (2 vs. 49 MPa and 52 vs. 81 MPa), whereas the maximum von Mises stress at the inferior medial screw hole was higher in the LCN model than in the standard implantation model (53 vs. 27 MPa).

CONCLUSIONS

Lateral cortical notching facilitates gliding of a distally dynamized proximal femoral nail along the femoral shaft axis in intertrochanteric fractures. Additionally, the lack of lateral cortical bone support at the lag screw reduces von Mises stress at the bone/implant interface and thus could lower the risk for implant breakage and peri‑implant fractures.

Fixators dynamization for delayed union and non-union of femur and tibial fractures: a review of techniques, timing and influence factors

The optimal balance between mechanical environment and biological factors is crucial for successful bone healing, as they synergistically affect bone development. Any imbalance between these factors can lead to impaired bone healing, resulting in delayed union or non-union. To address this bone healing disorder, clinicians have adopted a technique known as "dynamization" which involves modifying the stiffness properties of the fixator. This technique facilitates the establishment of a favorable mechanical and biological environment by changing a rigid fixator to a more flexible one that promotes bone healing. However, the dynamization of fixators is selective for certain types of non-union and can result in complications or failure to heal if applied to inappropriate non-unions. This review aims to summarize the indications for dynamization, as well as introduce a novel dynamic locking plate and various techniques for dynamization of fixators (intramedullary nails, steel plates, external fixators) in femur and tibial fractures. Additionally, Factors associated with the effectiveness of dynamization are explored in response to the variation in dynamization success rates seen in clinical studies.

Combined dynamized nailing with partial fibulectomy for aseptic diaphyseal tibial nonunion in adults

Background and aim of the study

Mechanical stability of hypertrophic nonunion remains the goal for treatment leading to bony bridging and remodeling. Partial fibulectomy or dynamization was reported with a wide range of clinical and radiological results. This study aims at assessment of combined dynamically locked nailing with partial fibulectomy technique to reach biological and mechanical stability with shorter healing time.

Patients and methods

This study included seventeen skeletally mature patients with aseptic diaphyseal hypertrophic tibial nonunion after nailing or external fixator. Patients with infected nonunion, atrophic nonunion, skeletally immature, and those with incomplete follow-up were excluded. Included patients were allocated into two groups, and final functional and radiological outcome regards healing time, union, limb alignment and rotation, knee and ankle rage of motions were reported.

Results

The mean follow-up period was 33.3 ± 6.2months. All nonunions healed successfully within 11.9 ± 1.5weeks (range: 10–16 weeks). One patient had tibial plafond injury that necessitated nail removal. The mean angle of coronal angulation was 1.4 ± 1.4°. The rotational difference between both limbs as per the thigh-foot angle was 2.5 ± 1.7°. The average functional outcome as per the Karlström-Olerud scale score was 30.9 ± 3. A significant difference was evident between the external fixator group and the nailing group in terms of functional grading scale (P=0.03).

Conclusion

The combined dynamically locked nailing with partial fibulectomy technique is a biology-preserving technique that provides mechanical stability, allows early return to functional activity with complete bone healing and no need for further surgeries.

Great debates in trauma biomechanics

At the 2021 annual meeting of the Orthopaedic Trauma Association, the Basic Science Focus Forum hosted its first ever debate-style symposium focused on biomechanics and fracture repair. The 3 subjects of debate were "Mechanics versus Biology-Which is 'More Important' to Consider?" "Locked Plate versus Forward Dynamization versus Reverse Dynamization-Which Way Should I Go?" and "Sawbones versus Cadaver Models-What Should I Believe Most?" These debates were held because fracture healing is a highly organized synergistic response between biological factors and the local mechanical environment. Multiple studies have demonstrated that both factors play roles in governing bone healing responses, and the causal relationships between the 2 remain unclear. The lack of clarity in this space has led to a spectrum of research with the common goal of helping surgeons make good decisions. Before reading further, the reader should understand that the questions posed in the debate titles are unanswerable and might represent a false choice. Instead, the reader should appreciate that the debates were held to gain a more thorough understanding of these topics based on the current state of the art of experimental and clinical studies, by using an engaging and thought-provoking format.

Which of the three different intramedullary nail designs is superior in the treatment of femoral shaft fractures?

Aim: The aim of this study a retrospective comparison was the clinical and radiological results results of patients with femoral shaft fracture made oftreated with three different types of intramedullary nail (IMN). Material and Method: The study included 54 patients operated on in our clinic because of femoral shaft fracture. The records were retrospectively examined of 18 patients applied with locked IMN (LIMN), 17 with blade expandable IMN (BEIMN), and 19 with talon distalfix IMN (TDIMN). The groups were compared statistically in respect of age, gender, BMI, affected side, operating time (mins), radiation exposure (number of shots), time to union (weeks), visual analog scale (VAS) score, soft tissue problems associated with implant irritation, amount of shortening (mm), coronal, sagittal and torsional angulation (degrees). Results: The mean VAS score of the TDIMN group was determined to be statistically significantly higher than that of the LIMN and BEIMN groups (p=0.008, p=0.045). The operating times were similar in the BEIN and TDIMN groups (p=0.768) and significantly shorter than in the LIMN group (p

Periprosthetic femoral re-fractures pathogenesis, classification, and surgical implications

Periprosthetic femoral re-fractures (PFRFs) represent an emerging challenge for orthopaedic surgeons, since their incidence is growing in the last years, but very few experiences about their management have been currently published. The present study aims to (1) introduce, for the first time, an etiologic classification for PRFRs and (2) to provide surgical and pharmacological tips for the correct management of these injuries. Periprosthetic femoral re-fractures (PFRFs) could be classified into traumatic-PFRFs (T-PFRFs) and pathological-PFRFs (P-PFRFs). T-PFRFs, i.e. the "true" periprosthetic re-fractures, present as new fracture lines occurring proximally or distally to a previous periprosthetic fracture, that has correctly healed. They are generally unpredictable injuries but, in selected cases, it is possible to predict them by analyzing the construct used in the treatment of the previous periprosthetic fracture. P-PFRFs, on the other hand, define re-fractures occurring on a previous periprosthetic non-union or delayed union: the new fracture line appears in the same district of the old one. According to the etiologic factors influencing the P-PFRFs pathogenesis, it is possible to define re-fractures caused by mechanical failures, biological failures, septic failures and multifactorial failures, i.e., a combination of the previously mentioned concerns. A successful postoperative outcome, following the surgical management of PFRFs, requires the correct identification of all the underlying causes, which should be promptly and appropriately managed.

Development of the Italian fractures registry (RIFra): A call for action to improve quality and safety

In recent years, there has been an increasing interest in the development of arthroplasty registries, therefore, in our country, the Italian Arthroplasty Registry (RIAP), was issued by the National Law No. 221/2012. In the last decade, however, some European countries -namely Sweden, Denmark, Norway, and Germany (in development)- have introduced another nationwide orthopaedic registry than arthroplasty registers: the fracture registry. The development of this new tool aims to improve quality and safety in fracture management, thus trying to provide a better postoperative quality of life in trauma patients. Based on these findings, the AO-Trauma Italy Council encouraged the development of a national fracture registry in Italy. The present study aims to (1) provide an overview of the fracture registries in Europe and (2) to develop, for the first time, a pilot Italian Fracture Registry (RIFra). Thirteen AO-Trauma Italy members, chairmen of Level-I orthopaedic and trauma centres, diffused throughout Italy, were involved in the RIFra project. The RIFra form, developed between November 2019 and March 2020, consists of 5 main sections, namely: epidemiologic data, previous surgical procedure (if any), patient and fracture features, surgical procedure, surgical implant details. This study constitutes the first step to start, in future years, the bureaucratic procedure leading to the final establishment of a RIAP-like fracture registry in Italy.

Assessment of fracture healing in orthopaedic trauma

Fracture healing is a complex physiologic process, relying on the crucial interplay between biological and mechanical factors. It is generally assessed using imaging modalities, including conventional radiology, CT, MRI and ultrasound (US), based on the fracture and patient features. Although these techniques are routinely used in orthopaedic clinical practice, unfortunately, they do not provide any information about the biomechanical status of the fracture site. Therefore, in recent years, several non-invasive techniques have been proposed to assess bone healing using ultrasonic wave propagation, changes in electrical properties of bones and callus stiffness measurement. Moreover, different research groups are currently developing smart orthopaedic implants (plates, intramedullary nails and external fixators), able to provide information about the fracture healing process. These devices could significantly improve orthopaedic and trauma clinical practice in the future and, at the same time, reduce patients' exposure to X-rays. This study aims to define the role of traditional imaging techniques and emerging technologies in the assessment of the fracture healing process.

Effect of Interlocking Mode on the Outcomes of Exchange Nailing for the Treatment of Aseptic Femoral Shaft Nonunion

Background

Exchange nailing is a standard treatment for femoral shaft nonunion after intramedullary nailing. However, substantial uncertainty and controversy remain regarding the mode of interlocking fixation. This study aimed to compare the success rate and time to union of exchange nailing based on interlocking modes.

Methods

We retrospectively analyzed all consecutive patients who underwent exchange nailing for aseptic femoral shaft nonunion between February 2000 and February 2021. Patients who underwent exchange nailing using the dynamically locked mode and statically locked mode constituted the dynamic group and static group, respectively. We compared the success rates of the index surgery and the time to union between the groups and measured the extent of interlocking screw migration on the dynamic oblong hole in the dynamic group.

Results

The dynamic group and static group comprised 17 patients and 18 patients, respectively. All patients in the dynamic group achieved bone union, whereas 5 patients in the static group did not and underwent additional intervention. The success rate of the index surgery was significantly higher in the dynamic group than in the static group (100% vs. 72.2%, p = 0.045). Four of the 5 failed unions in the static group achieved bone union after dynamization. The median time to union was significantly shorter in the dynamic group than in the static group (6.0 months [range, 4.0-6.0] vs. 12.0 months [range, 3.7-21.7], p = 0.035). In the dynamic group, 3 of 17 patients exhibited interlocking screw migration ranging from 1.1 to 4.1 mm.

Conclusions

Exchange nailing with dynamic mode yields a higher success rate and shorter time to union in aseptic femoral shaft nonunion than that with static mode, without the risk of excessive shortening.

"Fragment Width Ratio" as a Predictor of Nonunion for Femoral Shaft Fracture With Third Fragments

Previous studies have reported that large fracture fragment with displacement might cause nonunion of femoral shaft fractures. We therefore intended to delineate significant risk factors for developing a nonunion predisposed by a major fracture fragment. We analyzed 61 patients who were operated on using interlocking nails for femoral shaft fractures from 2009 to 2018. We classified patients with modified Radiographic Union Scale for Tibia fractures scores of less than 11 or needing reoperations by 1 year postoperatively as nonunion. We thereafter measured parameters of the displaced fracture fragment and fracture site to identify the significant difference between the union and non-union groups. We also applied the receiver operating characteristic curve to demonstrate a threshold value for the fragment width (FW) ratio. Among 61 patients with complete follow-up, no significant difference was found regarding length, displacement, and angulation of fragments between patients with and without union. Except for higher mean FW (P=.03) and the FW ratio (P=.01) in patients with nonunion, the logistic regression analysis demonstrated that FW ratio significantly affected union (P=.018; odds ratio, 0.21; 95% CI, 0.001-0.522). Although a fracture fragment greater than 4 cm with displacement greater than 2 cm was reported to significantly cause nonunions, our study showed that an FW ratio greater than 0.55 instead of fragment size or displacement was predictive for the occurrence of nonunion adjoining to the fracture site. Fixation of the third fracture fragment should not be ignored for preventing a nonunion. More attention should be paid to achieve a better fixation for a major fracture fragment with an FW ratio greater than 0.55 to avoid the development of non-union following the use of interlocking nail for femoral shaft fracture. [Orthopedics. 202x;xx(x):xx-xx.].

Augmented Stability in Leaving Original Internal Fixation with Multidimensional Cross Locking Plate through Mini-Open Femoral Anterior Approach for Aseptic Femoral Shaft Nonunion: A Retrospective Cohort Study

OBJECTIVE

Aseptic femoral shaft nonunion constitutes approximately 1%-10% of all femoral shaft fractures treated with intramedullary nail (IMN) fixation, possibly attributable to the lack of anti-rotational stability. Although a lateral locking plate (LP) with retainment of original IMN has shown the most success, lateral LP inflicts significant surgical trauma on patients. Therefore, the Multidimensional Cross Locking Plate (MDC-LP) was designed based on a mini-open femoral anterior approach. We aim to report and compare the technical aspects and clinical outcomes of using anterior MDC-LP or lateral LP with retention of original IMN for the treatment of aseptic femoral shaft nonunion.

METHODS

In this single center retrospective cohort study, records of 49 patients who had undergone revision of femoral shaft aseptic nonunion with anterior MDC-LP or lateral LP while retaining the original IMN from January 2015 to October 2019 were retrospectively reviewed. Information on patients' demographics, clinical data, and surgical outcomes were gathered and analyzed. X-ray and CT scans were used for bone union evaluation and the lower extremity functional scale (LEFS) was used for follow-up functional evaluation. For quantitative data, the Student's t-test was used if the data were normally distributed. The Mann-Whitney U-test was used for non-normally distributed data. For qualitative data, the Chi-square test was used for comparisons.

RESULTS

Twenty-seven patients were treated with anterior MDC-LP, and 22 patients were treated with lateral LP. There are no significant differences in age, sex, BMI, time since initial femoral shaft fracture, initial fracture type (close/open), nonunion type, or nonunion location between patients' group. Among patients treated with anterior MDC-LP, an average of 2-months advantage in time to union was observed (4.09 months vs. 6.8 months in the lateral LP group: P = 0.000), smaller incision was required for MDC-LP installment (7.7 cm vs 17.1 cm in lateral LP group: P = 0.000).

CONCLUSIONS

For the treatment of aseptic femoral shaft nonunion with retainment of original IMN, anterior MDC-LP via mini-open femoral anterior approach described in this study is a better option than lateral LP for achieving faster bone union and satisfactory functional outcome with less surgical trauma.

Concomitant intramedullary nailing and plate augmentation as a single-stage procedure in treating complicated nonunited femoral shaft fractures

Background and Purpose:

Complicated femur fracture represents a major challenge for the orthopedic surgeon, with failed internal fixation, nonunion with broken intramedullary nail (IMN), and infected nonunion among the complications. Mechanical instability, as well as the poor biological environment, is considered as a concern when treating these cases. The purpose of this study was to evaluate concomitant IMN and plate augmentation as a single-stage procedure for the management of multiply operated nonunited femoral shaft fractures.

Materials and Methods:

Between January 2015 and May 2018, nine patients (eight men) with an average age of 40.8 years (range 25–70) diagnosed as nonunion femoral fractures after an average of four previous surgeries (range 2–6). All patients were available for follow-up with an average of 22 months (range 12–36).

Results:

The average time for fracture union was 6.7 months (range 3–12); five patients needed bone grafting to compensate for the bone defect encountered during the initial procedure, and two patients required secondary bone grafting after 6 months follow-up. Two patients presented with surgical site infection which was treated by antibiotics and daily dressing. The average leg length discrepancy at last follow-up was 1 cm (range 0.5–1.5). No patient had a metalwork failure or needed removal of the implants.

Conclusion:

In treating complicated multiply operated nonunited femoral shaft fractures, we believe that this technique can provide a robust mechanical foundation as well as an improved biological environment for such nonunited fractures to heal.

Lateral collateral ulnar ligament reconstruction techniques in posterolateral rotatory instability of the elbow: A systematic review

BACKGROUND

Elbow chronic instability is a disable complication, presenting as recurrent joint subluxations or dislocations. This systematic review aims to assess (1) the clinical outcome and (2) the complication rates of the surgical techniques currently used in the management of posterolateral rotatory elbow instability.

METHODS

OVID-MEDLINE®, SCOPUS, and PubMed were searched from January 2009 to February 2019 to identify relevant studies. The search terms used were "LUCL", "Posterolateral dislocation", "Elbow Docking technique", "Elbow Jobe technique" and "Elbow single strand technique". The methodological qualities of the studies were evaluated, relevant data were extracted.

RESULTS

Three studies, published between 2012 and 2015, were included in this review. No studies concerning the single strand technique met the inclusion criteria. The included studies had a level of evidence IV and recruited 33 patients undergoing a Jobe technique reconstruction and 8 patients undergoing a Docking technique. Jobe procedure registered better clinical and functional outcome, assessed using the Mayo Clinic Elbow Performance Scale (MEPS), compared with patients managed with Docking technique. Nonetheless, this difference is not significant. There was not a significantly different complication rate (p = 0.57) between patients treated with these two different techniques.

CONCLUSION

This systematic review showed that both Jobe and Docking techniques are safe and effective in the treatment of posterolateral elbow instability. However, future studies with larger sample size and a longer follow-up interval are needed to draw stronger conclusions on the efficacy of the different LUCL surgical reconstruction techniques.

Use of the 95-degree angled blade plate with biological and mechanical augmentation to treat proximal femur non-unions: a case series

BACKGROUND

Intertrochanteric and subtrochanteric non-union are rare but challenging complications. In the present study, we investigate the use of a 95° blade, in association with biological and mechanical augmentation, in the management of intertrochanteric and subtrochanteric femoral non-unions.

METHODS

Between October 2015 and February 2021, a retrospective cohort study was conducted at our institution to investigate the use of a 95° blade, in association with biological and mechanical augmentation, in the management of intertrochanteric and subtrochanteric femoral non-unions, following the mechanical failure of the first device. All the patients underwent a clinical and radiographic follow-up at 6 weeks, 3, 6, 9, 12 and 18 months; at each follow-up, a plain radiograph of the femur was performed and patients were assessed using Harris Hip Score (HHS) and the Short Form-12 (SF-12) questionnaire.

RESULTS

From October 2015 and February 2021, 40 proximal femur non-unions were managed at our Institution. Fifteen patients out of forty (37.5%) met the inclusion criteria. The main data of the study are summarized in Table 1; patients' mean was 57 years old (range 19-83); 10 males and 5 females were included in the study. All the patients completely healed clinically and radiologically at an average of 6.1 months (range 4-13). All these patients returned to their pre-injury mobility status. During an average follow-up period of 25 months (range 8-60), the observed complications included wound dehiscence, which was treated with a superficial surgical debridement, a below-the-knee deep vein thrombosis, and a blade plate failure 3 months after the first revision surgery.

CONCLUSIONS

This study shows the treatment of inter-and sub-trochanteric non-unions with a 95° blade plate, medial strut allograft, and bone autograft obtained with RIA system, together with a varus malalignment correction, leads to a high percentage of bone healing, with a low incidence of complications and good clinical outcome.

Addition of shock wave therapy to nail dynamization increases the chance of long-bone non-union healing

Background

Long-bone non-unions after intramedullary nailing can be treated by nail dynamization or focused high-energy extracorporal shock wave therapy (fESWT). The objective of this study was to assess the effect of the combination therapy of nail dynamization and fESWT on long-bone non-unions.

Materials and methods

49 patients with long-bone non-unions (femur and tibia) after nailing were treated with nail dynamization (group D, n = 15), fESWT (group S, n = 17) or nail dynamization in addition to fESWT (group DS, n = 17). Patients were followed up for 6 months retrospectively. Furthermore, age, sex, Non-Union Scoring System (NUSS) score, time intervals from primary and last surgery until intervention and smoking status were analysed for their correlations to bone union.

Results

Union rates were 60% for group D, 64.7% for group S and 88.2% for group DS, with a significant difference between group D and DS (p = 0.024). Successful treatment was correlated with high age (OR 1.131; 95% CI 1.009–1.268; p = 0.034), female gender (OR 0.009; 95% CI 0.000–0.89; p = 0.039), low NUSS score (OR 0.839; 95% CI 0.717–0.081; p = 0.028) and negative smoking status (OR 86.018; 95% CI 3.051–2425.038; p = 0.009).

Conclusions

Data from the present study indicate that the combination therapy of nail dynamization and fESWT leads to a higher union rate than dynamization or fESWT alone.

Level of evidence

Level 3.

Internal fixation of acetabular quadrilateral plate fractures in elderly patients: Could the fracture reduction quality affect their functional recovery?

BACKGROUND

Osteoporotic acetabular fractures frequently involve the quadrilateral plate (QP), a flat and thin bone constituting the medial wall of the acetabulum. This study aims to assess the impact of the quality of osteoporotic QP fractures reduction on the patients' functional recovery, at 24 months follow-up.

METHODS

Patients referring with osteoporotic QP fractures to our Level I trauma centre were prospectively recruited.

INCLUSION CRITERIA

patients aged 60 years old or older; osteoporosis, defined as Dual-energy X-ray Absorptiometry (DXA) T-score ≤ - 2.5; acute acetabular fracture; anatomic or good fracture reduction according to Matta on postoperative CT.

EXCLUSION CRITERIA

moderate cognitive impairment (defined as Mini-Mental State Examination < 19); a history of malignant neoplasm; concomitant fractures in other sites; traumatic head injury; lower limb joint prostheses; patient not able to walk independently before trauma; poor fracture reduction, according to Matta, on postoperative CT. All the QP fractures were surgically managed. After surgery, the reduction of each QP fracture was classified as anatomical (displacement 0-1 mm), good (displacement 2-3 mm) and poor (displacement > 3 mm) on postoperative CT. Based on this classification: patients with a poor fracture reduction were excluded from this study, patients with an anatomical reduction were recruited in Group-A and patients with a good reduction in Group-B. All the patients underwent a clinical and radiographic 24-months follow-up.

RESULTS

68 patients (males 38; females 30; mean age 68.6 years old; range 60-79) were finally included in in the study. No cases of open fractures or concomitant pelvic ring fractures were observed. Based on the post-operative CT, 39 patients showed an anatomic fracture reduction (Group-A) while the remaining 29 patients revealed a good fracture reduction (Group-B). Complication rates and mean clinical scores showed no significant differences between groups, at 24-months follow-up.

CONCLUSIONS

In this study, the functional recovery at 24 months follow-up showed no significant differences in elderly patients with QP fracture undergoing anatomical reconstruction (displacement 0-1 mm) compared to patients receiving a good QP fracture reconstruction (displacement ≤ 3 mm).

The flipped third fragment in femoral shaft fractures: A reason for open reduction?

OBJECTIVES

First introduced by Kuntscher in the 1940s, closed intramedullary nailing of femoral shaft fractures has become the standard of care, with reported union rates up to 99% in some series. However, fractures with large intercalary segments, which are present in 10-34% of femoral shaft fractures, present unique challenges. In particular, how to treat flipped intercalary segments has remained controversial, with some advocating open reduction of these fractures. The purpose of this study was to evaluate the union rates of femoral shaft fractures with flipped intercalary segments treated with closed reduction and intramedullary nail fixation.

METHODS

A retrospective review of patients with femoral shaft fractures and flipped intercalary segments from January 2000 until January 2018 was performed at a single academic level one tertiary care referral center. All patients between the ages of 16-80 with minimum 6-month follow-up were included. Union rates were evaluated using the radiographic union score of the femur (RUSF). Patients with non-diaphyseal femur fractures, pathologic fractures, incomplete radiographic or clinical follow-up, or open reduction at the time of initial surgery were excluded.

RESULTS

Twenty-six patients (18 male and 8 female) with a mean age of 32 years (SD 12.8, range 19-65 years) and mean follow-up of 15.9 months (range, 6-82 months) met inclusion criteria. Seven patients had open fractures. The mean size of the flipped intercalary segments was 71.3 mm (range: 30-174 mm), with mean displacement of 6.6 mm (range: 1-37 mm). The mean radiographic union scale in femoral (RUSF) at 6 months was 9 (standard deviation: 1.35). There were two patients who went on to non-union. The overall union rate was 92% (24 patients); the non-union rate was 8% (2 patients).

CONCLUSIONS

Though uncommon, femoral shaft fractures with flipped intercalary segments present unique challenges to surgical treatment. While previous studies have found the presence of large intercalary segments to be associated with higher rates of non-union, the results of this study challenge prior evidence. In conclusion, the presence of flipped intercalary segments may not require different surgical management than the treatment of conventional femoral shaft fractures.

LEVEL OF EVIDENCE

IV.

Minimally invasive osteosynthesis technique in the treatment of transverse patellar fractures in the elderly

BACKGROUND

This prospective study aims to describe our experience in the management of transverse patellar fractures in elderly patients with minimally invasive osteosynthesis technique (MIOT), at 12-months follow-up.

METHODS

Patients older than 60, with transverse patellar fracture, type 34-C1 according to the AO/OTA classification system, referred to our trauma centre, between January 2014 and December 2017 were prospectively recruited. All the patients were managed using MIOT surgical procedure and underwent a clinical and radiological follow-up at 2 weeks, 6 weeks and at 3, 6, 12 and 15 months postoperatively. The clinical evaluation was performed using the Lysholm Knee Scoring System (LKSS) and the Visual Analogue Scale (VAS) for pain. The hardware removal was planned at 12-months follow-up. The paired t-test was performed. The test was two-tailed with a confidence level of 5%.

RESULTS

61 patients were recruited. The mean VAS was significantly lower in MIOT group until the 3-months follow-up (p = 0.001). ROM in flexion and LKSS score were significantly better in MIOT-group at all follow-ups, whereas ROM in extension showed no differences, between the two groups, starting from the 6-months follow-up. In the open surgery group, a significantly higher rate of delayed wound healing (p = 0.014), broken wires (p = 0.001) and non-cosmetic scar (p = 0.0221) was observed.

CONCLUSIONS

This prospective study shows that MIOT is a safe option for treatment of patellar transverse fractures in elderly patients, since it reduces the intra-operative blood loss, shortens the operating time, and is endowed with lower rates of postoperative complications.

The impact of lag screw in the healing time of distal tibia fractures treated with minimally invasive plate osteosynthesis: A randomized clinical trial

BACKGROUND

In recent years, Minimally Invasive Plate Osteosynthesis (MIPO) has been gaining popularity in the treatment of distal tibia fractures, because it is a minimally invasive surgical procedure, thus it limits the soft-tissues damage. This prospective randomized study aims to assess the impact of lag screw in the healing time of distal tibia fractures treated with MIPO technique, in a six-month follow-up.

METHODS

Patients between 20 and 70 years of age with distal tibial fracture, type 43-A according to AO/OTA classification system were included. All the patients were randomized into two groups, to receive MIPO without lag screw (Group-A) or MIPO with percutaneous lag screw (Group-B). Patients were followed clinically and radiographically at 3, 6, 12 and 24 weeks postoperatively. The main outcome measure was the time needed to achieve the painless full weight-bearing (FWB) after surgery. Unpaired t-test after ANOVA (analysis of variance) was performed to assess AOFAS score differences between the 2 groups at each follow-up. Pearson correlation test also was performed. The tests were two-tailed with a confidence level of 5%.

RESULTS

42 patients (24 male and 18 female, mean age 49.54 years old, range 25-80) were recruited. A significant shorter mean time until painless FWB (p = 0.016) was observed in Group-B (11.22 ± 3.06 weeks) compared with Group-A (13.48 ± 2.42 weeks) (Table 2). The mean AOFAS score was comparable in patients treated with (Group-B) and without lag screw (Group-A) at all follow-ups.

CONCLUSIONS

This prospective randomized clinical study has shown that the use of lag screw in distal tibia fractures treated with MIPO technique speeds the fracture healing, thus shortening the time needed to achieve FWB.

The biology and treatment of acute long-bones diaphyseal fractures: Overview of the current options for bone healing enhancement

Diaphyseal fractures represent a complex biological entity that could often end into impaired bone-healing, with delayed union and non-union occurring up to 10% of cases. The role of the modern orthopaedic surgeon is to optimize the fracture healing environment, recognize and eliminate possible interfering factors, and choose the best suited surgical fixation technique. The impaired reparative process after surgical intervention can be modulated with different surgical techniques, such as dynamization or exchange nailing after failed intramedullary nailing. Moreover, the mechanical stability of a nail can be improved through augmentation plating, bone grafting or external fixation techniques with satisfactory results. According to the "diamond concept", local therapies, such as osteoconductive scaffolds, bone growth factors, and osteogenic cells can be successfully applied in "polytherapy" for the enhancement of delayed union and non-union of long bones diaphyseal fractures. Moreover, systemic anti-osteoporosis anabolic drugs, such as teriparatide, have been proposed as off-label treatment for bone healing enhancement both in fresh complex shaft fractures and impaired unions, especially for fragility fractures. The article aims to review the biological and mechanical principles of failed reparative osteogenesis of diaphyseal fractures after surgical treatment. Moreover, the evidence about the modern non-surgical and pharmacological options for bone healing enhancement will discussed.

The impact of the third fragment features on the healing of femoral shaft fractures managed with intramedullary nailing: a radiological study

INTRODUCTION

Femoral shaft fractures with third fragments have a high non-union rate, which may reach 14%. This study aims to assess the impact of the radiological features of the third fragment, evaluated on post-operative X-rays, on the outcome of femoral shaft fractures type 32-B managed with intramedullary nailing, in order to obtain an algorithm which could predict the fracture healing time.

MATERIALS AND METHODS

We have retrospectively evaluated a series of 52 patients. On post-operative X-rays, four radiological parameters were evaluated: the third fragment angle, the fracture gap, the third fragment size, and the mean third fragment displacement. All the patients underwent a radiologic follow-up at one, two, three, six, nine and 12 months post-operatively, to assess the bone healing. The patients were then divided into three groups, according to the fracture healing time: within six months (group A), between six and 12 months (group B), or fracture non-union after 12 months (group C).

RESULTS

In 28 patients, out of 52 (53.85%), the fracture healing was observed at 6-month follow-up; in 18 patients, out of 52 (34.62%), the fracture healed within 12 months after trauma; and in six patients, out of 52 (11.54%), no fracture healing was observed at 12-month follow-up. The mean third fragment size was significantly different in each group (p < 0.05), while the mean third fragment displacement was significantly higher in group C, compared with group A (p = 0.0006) and group B (p = 0.0027). In group B, a positive correlation was found between the fracture healing time and the mean third fragment size (R = 0.594, p = 0.036); in group C, the fracture union time was positively related to the third fragment size (R = 0.689, p = 0.013) and the mean third fragment displacement (R = 0.7107, p = 0.006). Regression analysis showed that the third fragment size and the mean third fragment displacement are the most important features which affect the fracture healing time.

CONCLUSIONS

The third fragment size (cutoff 40 mm) is the leading parameter to influence the fracture healing within or in more than six months. The mean third fragment displacement (cutoff 12 mm); on the other hand, impacts on the fracture delayed rather than absent healing.