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Mahmood A, Subbaraman K, Gadullah M, Hawkes D, Bose D, Fenton P. Circular frame versus reamed intramedullary tibial nail in the treatment of grade III open tibial diaphyseal fractures. Eur J Orthop Surg Traumatol 2024:10.1007/s00590-024-03946-2. [PMID: 38662197 DOI: 10.1007/s00590-024-03946-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 04/02/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Grade III open tibial diaphyseal fractures are challenging to treat and controversy exists on whether to treat them with an intramedullary nail (IMN) or a circular frame (CF). This study aims to compare outcomes for intramedullary nail and circular frame in the treatment of open tibial diaphyseal fractures. METHODOLOGY Retrospective study at a major trauma center of all patients admitted with a grade III open tibial diaphyseal fracture between January 2016 and January 2022. The primary outcome measures were major complications: non-union, malunion, refracture, DBI and amputation. Secondary outcome measures were time to union and reoperation rates. RESULTS Fifty-five patients were included in the study, 32 patients in CF group and 23 patients in IMN group. There were no significant differences in the baseline demographics of patients in both groups. Major complications were recorded in 13 limbs (54%) in IMN group and in 18 limbs (56%) in CF group which were not statistically significant (p = 0.797). Deep bone infection rates were noted in 4 (12.5%) in the CF group, compared to 1 (4%) in IMN group; however, the result was not statistically significant (p = 0.240). Amputation rates as a result of infected non-unions were seen in 1 limb (4%) in IMN group and 2 limbs (6%) in CF group (p = 0.99). Median time to union was significantly shorter in IMN group at 30 weeks compared to 30 weeks for CF group (p = 0.04). CONCLUSION IMN should be the treatment of choice in the treatment of grade III open tibial diaphyseal fracture, but CF should be considered for delayed treatment and in patients with bone loss.
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Affiliation(s)
- Aatif Mahmood
- Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham, B15 2GW, UK.
| | | | - Moheeb Gadullah
- Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham, B15 2GW, UK
| | - David Hawkes
- Wirral University Teaching Hospital NHS Foundation Trust, Birkenhead, UK
| | - Deepa Bose
- Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham, B15 2GW, UK
| | - Paul Fenton
- Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham, B15 2GW, UK
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Cardenas J, Pfeil AN, Fertitta DK, Comrie R, Rospigliosi D, Shumareva M, Vidal E, Hryc CF, Ihekweazu UN. Orthopedic Hardware Type Impacts Case Complexity in Conversion Total Hip Arthroplasty Surgery. Arthroplast Today 2024; 26:101317. [PMID: 38415066 PMCID: PMC10897850 DOI: 10.1016/j.artd.2024.101317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 11/15/2023] [Accepted: 01/21/2024] [Indexed: 02/29/2024] Open
Abstract
Background Conversion total hip arthroplasty (THA) includes a variety of operations and prior implants. The implant present before conversion may influence the outcome and complexity of the procedure. The group hypothesized that conversion arthroplasty for patients with intramedullary nails (IMNs) is more complex from a surgical and resource utilization perspective than for those with screw fixation. Methods THA conversion cases were reviewed retrospectively from 2012 to 2020 from 6 surgeons across 3 institutions. The included cohort had 106 patients with fixation in the proximal femur for prior traumatic events. Demographics, operative data, outcomes, and implant information were collected from the medical record. The conversion THA group was categorized by preoperative fixation type: closed reduction and percutaneous pinning/screw fixation (CRPP) or IMN. Results No age or body mass index differences were observed between the cohorts. Prior to conversion THA, IMN patients had undergone more surgeries than CRPP (P < .05). Perioperatively, the IMN cohort sustained increased blood loss (P < .001), had longer surgeries (P < .0001), had longer length of hospital stays (P < .01), necessitated trochanteric plates more often (P < .05), were readmitted more (P < .05), and required additional follow-up surgery (P < .01) than the CRPP cohort. Conclusions Conversion THA of a prior IMN implant is associated with worse perioperative outcomes than conversion of a CRPP construct. Surgeons, health systems, and payors should consider these differences when caring for these distinct groups of patients.
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Affiliation(s)
- Justin Cardenas
- Department of Orthopedic Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Allyson N Pfeil
- Fondren Orthopedic Research Institute, Fondren Orthopedic Group, Texas Orthopedic Hospital, Houston, TX, USA
| | - Davin K Fertitta
- Fondren Orthopedic Research Institute, Fondren Orthopedic Group, Texas Orthopedic Hospital, Houston, TX, USA
| | - Robert Comrie
- Fondren Orthopedic Research Institute, Fondren Orthopedic Group, Texas Orthopedic Hospital, Houston, TX, USA
| | - Delia Rospigliosi
- Department of Orthopedic Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Mariya Shumareva
- Fondren Orthopedic Research Institute, Fondren Orthopedic Group, Texas Orthopedic Hospital, Houston, TX, USA
| | - Emily Vidal
- Fondren Orthopedic Research Institute, Fondren Orthopedic Group, Texas Orthopedic Hospital, Houston, TX, USA
| | - Corey F Hryc
- Fondren Orthopedic Research Institute, Fondren Orthopedic Group, Texas Orthopedic Hospital, Houston, TX, USA
| | - Ugonna N Ihekweazu
- Fondren Orthopedic Research Institute, Fondren Orthopedic Group, Texas Orthopedic Hospital, Houston, TX, USA
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van Cruchten S, Warmerdam EC, Reijman M, Kempink DRJ, de Ridder VA. Current practices in the management of closed femoral shaft fractures in children: A nationwide survey among Dutch orthopaedic surgeons. J Orthop 2023; 45:1-5. [PMID: 37780229 PMCID: PMC10534205 DOI: 10.1016/j.jor.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 09/15/2023] [Accepted: 09/17/2023] [Indexed: 10/03/2023] Open
Abstract
Background There remains a lack of high-quality evidence on the treatment of pediatric femur shaft fractures. Therefore, treatment choices may still be based on personal preference of treating surgeons. To gain insight in considerations regarding treatment options, we conducted a survey among Dutch trauma and orthopedic surgeons. Methods This survey was conducted in 2020, regarding treatment considerations for closed femoral shaft fractures in children in different age and weight groups. Results One hundred forty-two surgeons were included in the analysis. 31% of participating surgeons considers surgical fixation in children of 2-4 years old, compared to 83% in children of 4-6 years old. In terms of weight, 30% considers surgery in children of 10-15 kg, compared to 77% considering surgery in children weighing 15-20 kg. While most surgeons find traction and spica cast suitable options for children younger than 4 years, a minority also considers these treatment modalities for children older than 4 (traction: 81% versus 19%, spica cast 63% versus 29% respectively). 33% of surgeons considers ESIN under 4 years of age, compared to 88% in children older than 4. Conclusion An age of 4 years and a weight of 15 kg seem to be cut off points regarding preference of non-surgical versus surgical treatment of closed femoral shaft fractures. There is a wide range of ages and sizes for which treatment options are still being considered, sometimes differing from the national guideline. This questions guideline adherence, which may be due to a lack of available high-quality evidence.
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Affiliation(s)
| | - Eefke C. Warmerdam
- Reinier de Graaf Gasthuis, Reinier de Graafweg 5, 2625 AD, Delft, the Netherlands
| | - Max Reijman
- Erasmus MC Sophia Children Hospital, Wytemaweg 80, 3015 CN, Rotterdam, the Netherlands
| | - Dagmar RJ. Kempink
- Erasmus MC Sophia Children Hospital, Wytemaweg 80, 3015 CN, Rotterdam, the Netherlands
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Vargas-Hernández JS, Sánchez CA, Renza S, Leal JA. Effectiveness of antibiotic-coated intramedullary nails for open tibia fracture infection prevention. A systematic review and meta-analysis. Injury 2023; 54 Suppl 6:110857. [PMID: 38143139 DOI: 10.1016/j.injury.2023.110857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/26/2023] [Accepted: 05/30/2023] [Indexed: 12/26/2023]
Abstract
INTRODUCTION Open Tibia fractures are associated with high rates of Fracture Related Infection (FRI). Given the negative outcomes and increased costs related to the latter, several prophylactic local antibiotic delivery methods have been proposed, aiming to decrease the FRI rate. Our objective with this study was to determine the effectiveness of antibiotic-coated intramedullary nails for open tibia FRI prevention. PATIENTS AND METHODS We conducted a PRISMA compliant systematic review and meta-analysis. Queries were performed on Embase, PubMed, Lilacs and Cochrane data libraries. Seventeen studies were included for qualitative analysis and 2 studies were amenable for meta-analysis. RESULTS Global infection, deep infection and non-union rates were 8.4%, 5.4% and 3.7% in the antibiotic-coated nail group and 22%, 14% and 14% in the non-antibiotic-coated nail group respectively. The meta-analysis showed a protective trend that favored the antibiotic-coated nail group although it didn't achieve statistical significance: deep infection Relative Risk (RR) (RR = 0.17 CI95% [0.02 - 1.31]); global infection RR = 0.36 CI95% [0.10 - 1.35]) and non-union (RR = 0.14 CI95% [0.02 - 1.22]), CONCLUSIONS: Our findings suggest a favorable trend towards antibiotic-coated nail, with decreased risk of global infection, deep infection and non-union as compared to non-antibiotic-coated nail in patients with open tibia fractures. Nonetheless, higher level evidence studies are required to confirm our findings.
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Affiliation(s)
| | - Carlos A Sánchez
- Department of Orthopedic Surgery, Hospital Universitario de la Samaritana, Bogotá, Colombia
| | - Stephanie Renza
- Department of Orthopedic Surgery, Hospital Universitario de la Samaritana, Bogotá, Colombia
| | - Jaime Andrés Leal
- Department of Orthopedic Surgery, Hospital Universitario de la Samaritana, Bogotá, Colombia
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Xiao C, Gao Z, Yu W, Yao K, Cao Y, Long N, Zhang S, Jiang Y. Medullary cavity application of tranexamic acid to reduce blood loss in tibial intramedullary nailing procedures-a randomized controlled trial. Int Orthop 2023; 47:2095-2102. [PMID: 37140597 PMCID: PMC10345084 DOI: 10.1007/s00264-023-05824-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 04/19/2023] [Indexed: 05/05/2023]
Abstract
PURPOSE Studies have shown an average postoperative hidden blood loss (HBL) of 473.29 ml and an average Hb loss of 16.71 g/l after intramedullary nailing. Reducing HBL has become a primary consideration for orthopaedic surgeons. METHODS Patients with only tibial stem fractures who visited the study clinic between December 2019 and February 2022 were randomized into two groups using a computer-generated form. Two grams of tranexamic acid (TXA) (20 ml) or 20 ml of saline was injected into the medullary cavity before implantation of the intramedullary nail. On the morning of the surgery, as well as on days one, three and five after surgery, routine blood tests and analyses of CRP and interleukin-6 were completed. The primary outcomes were total blood loss (TBL), HBL, and blood transfusion, in which the TBL and HBL were calculated according to the Gross equation and the Nadler equation. Three months after surgery, the incidence of wound complications and thrombotic events, including deep vein thrombosis and pulmonary embolism, was recorded. RESULTS Ninety-seven patients (47 in the TXA group and 50 in the NS group) were analyzed; the TBL (252.10 ± 10.05 ml) and HBL (202.67 ± 11.86 ml) in the TXA group were significantly lower than the TBL (417.03 ± 14.60 ml) and HBL (373.85 ± 23.70 ml) in the NS group (p < 0.05). At the three month postoperative follow-up, two patients (4.25%) in the TXA group and three patients (6.00%) in the NS group developed deep vein thrombosis, with no significant difference in the incidence of thrombotic complications (p = 0.944). No postoperative deaths or wound complications occurred in either group. CONCLUSIONS The combination of intravenous and topical TXA reduces blood loss after intramedullary nailing of tibial fractures without increasing the incidence of thrombotic events.
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Affiliation(s)
- Cong Xiao
- Department of Orthopedics, The Third Hospital of Mianyang, Sichuan Mental Health Center, No. 190 The East Jiannan Road, 621000 Mianyang, China
| | - Zhixiang Gao
- Department of Orthopedics, The Third Hospital of Mianyang, Sichuan Mental Health Center, No. 190 The East Jiannan Road, 621000 Mianyang, China
| | - Wei Yu
- Department of Orthopedics, The Third Hospital of Mianyang, Sichuan Mental Health Center, No. 190 The East Jiannan Road, 621000 Mianyang, China
| | - Kai Yao
- Department of Orthopedics, The Third Hospital of Mianyang, Sichuan Mental Health Center, No. 190 The East Jiannan Road, 621000 Mianyang, China
| | - Yang Cao
- Department of Orthopedics, The Third Hospital of Mianyang, Sichuan Mental Health Center, No. 190 The East Jiannan Road, 621000 Mianyang, China
| | - Nengji Long
- Department of Orthopedics, The Third Hospital of Mianyang, Sichuan Mental Health Center, No. 190 The East Jiannan Road, 621000 Mianyang, China
| | - Shaoyun Zhang
- Department of Orthopedics, The Third Hospital of Mianyang, Sichuan Mental Health Center, No. 190 The East Jiannan Road, 621000 Mianyang, China
| | - Yishan Jiang
- Department of Orthopedics, The Third Hospital of Mianyang, Sichuan Mental Health Center, No. 190 The East Jiannan Road, 621000 Mianyang, China
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Nester M, Borrelli J. Distal femur fractures management and evolution in the last century. Int Orthop 2023:10.1007/s00264-023-05782-1. [PMID: 37079125 DOI: 10.1007/s00264-023-05782-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 03/13/2023] [Indexed: 04/21/2023]
Abstract
PURPOSE The purpose of this historical review is to illustrate the progression and evolution of treatment for distal femur fractures. METHODS Scientific literature was searched for descriptions of treatment for distal femur fractures to provide an in-depth overview of the topic, with emphasis on the evolution of surgical constructs used to treat these fractures. RESULTS Prior to the 1950s, distal femur fractures were treated nonoperatively, resulting in considerable morbidity, limb deformity, and limited function. As principles of surgical intervention for fractures emerged in the 1950s, surgeons developed conventional straight plates to better stabilize distal femur fractures. Angle blade plates and dynamic condylar screws emerged out of this scaffolding to prevent post-treatment varus collapse. Meanwhile, intramedullary nails, and later, in the 1990s, locking screws, were introduced to minimize soft tissue disruption. Treatment failure led to the development of locking compression plates with the advantage of accommodating either locking or nonlocking screws. Despite this advancement, the rare but significant incidence of nonunion has not been eliminated, leading to the recognition of the biomechanical environment as important for prevention and the development of active plating techniques. CONCLUSION Emphasis for the surgical treatment of distal femur fractures has incrementally progressed over time, with initial focus on complete stabilization of the fracture while the biological environment surrounding the fracture was ignored. Techniques slowly evolved to minimize soft tissue disruption, allow more ease of implant placement at the fracture site, and attend to the systemic health of the patient, while simultaneously ensuring appropriate fracture fixation. Through this dynamic process, the desired results of complete fracture healing and maximization of functional outcomes have emerged.
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Affiliation(s)
- Matthew Nester
- Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Joseph Borrelli
- Department of Orthopedic and Sports Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, USA.
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Mittal S, Kabra A, Trikha T, Karpe A, Kumar A, Mukherjee K, Trikha V. Interest in curves: when the radius of curvature matters in femur fractures. A CT based morphometric study. Eur J Orthop Surg Traumatol 2022:10.1007/s00590-022-03412-x. [PMID: 36282333 DOI: 10.1007/s00590-022-03412-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 10/09/2022] [Indexed: 06/16/2023]
Abstract
PURPOSE In today's era, fractures of the femur are primarily managed with intramedullary devices. Keeping in mind the anatomical sagittal bow of the femur, intramedullary devices have been devised with an anterior bow, but this varies amongst various manufacturers - leading to complications such as anterior cortex impingement beyond the isthmus and posterior cortical opening at the fracture site. We intend to find the average radius of curvature (ROC) of the anatomical bow of the femur and the variation of the same. METHODS Radiographic data of 150 normal femur scans done in 81 patients were loaded in the Mimics 21.0 software (Materialise, Leuven, Belgium). A centerline (of the medullary cavity) was created using the software. A best-fit circle was created in the sagittal plane involving a major part of the centerline, and ROC was calculated. RESULTS We found the average ROC of our data was 1027.2, with a standard deviation of 241.55. ROC and length of the femur (an indirect measure of height) had a slight positive correlation (r = 0.36; p < 0.05); and a highly positive correlation in the ROC of the left and right femurs of the same individuals (r = 0.605; p < 0.05). CONCLUSIONS The usual ROC of intramedullary nails is commonly > 1300 mm, much higher than the average ROC we identified in our population. Thus, we conclude that implants with smaller ROC in the range of 1100 mm are needed, leading to better implant placement in the canal and avoiding complications of anterior cortex impingement and preventing fracture gap widening in our setting.
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Affiliation(s)
- Samarth Mittal
- Department of Orthopaedics, Jai Prakash Narayan Apex Trauma Centre, AIIMS, New Delhi, India
| | - Apoorva Kabra
- Department of Orthopaedics, Jai Prakash Narayan Apex Trauma Centre, AIIMS, New Delhi, India
| | - Tanya Trikha
- MGM Medical College and Hospital, Aurangabad, India
| | | | - Atin Kumar
- Department of Radiodiagnosis, AIIMS, New Delhi, India
| | - Kaushik Mukherjee
- Department of Mechanical Engineering, Indian Institute of Technology Delhi, New Delhi, India
| | - Vivek Trikha
- Department of Orthopaedics, Jai Prakash Narayan Apex Trauma Centre, AIIMS, New Delhi, India.
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van Cruchten S, Warmerdam EC, Kempink DRJ, de Ridder VA. Treatment of closed femoral shaft fractures in children aged 2-10 years: a systematic review and meta-analysis. Eur J Trauma Emerg Surg 2021; 48:3409-3427. [PMID: 34338819 PMCID: PMC9532337 DOI: 10.1007/s00068-021-01752-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 07/18/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To review current literature on treatment of closed femoral shaft fractures in children of 2-10 years old, with subgroup analysis of children aged 2-6 years, comparing intramedullary nailing (IMN) to conservative treatment modalities. METHODS We included clinical trials and observational studies that compared traction and subsequent casting (TSC), spica casting and IMN for treatment of femur shaft fractures in children of 2-10 years of age. Subgroup analysis of children aged 2-6 years was performed. RESULTS Compared to treatment with immediate spica casting, IMN led to significantly less coronal angulation (mean difference (MD): 2.03 degrees, confidence interval (CI) 1.15-2.90), less sagittal angulation (MD: 1.59 degrees, CI 0.82-2.35) and lower rates of LLD (Risk difference (RD): 0.07, CI 0.03-0.11). In terms of rehabilitation, IMN leaded to shorter time until walking with aids (MD: 31.53 days, CI 16.02-47.03), shorter time until independent ambulation (MD: 26.59 days, CI 22.07, 31.11) and shorter time until full weight bearing (MD: 27.05 days, CI 6.11, 47,99). Compared to TSC, IMN led to a lower rate of malunion (RD: 0.31, CI 0.05-0.56), shorter hospital stays (MD: 12.48 days, CI 11.57, 13.39), time until walking with aids (MD: 54.55, CI 40.05-69.04) and full weight bearing (MD: 27.05 days [6.11, 47,99]). CONCLUSION Although a lack of quality evidence, this systematic review showed a clear tendency to treatment with elastic intramedullary nails of femoral shaft fractures in children of 2-10 years of age. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Stijn van Cruchten
- UMC Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
- , Kromme Nieuwegracht 15, 3512 HC, Utrecht, The Netherlands.
| | - Eefke C Warmerdam
- Reinier Haga Orthopedisch Centrum, Toneellaan 2, 2725 NA, Zoetermeer, The Netherlands
| | - Dagmar R J Kempink
- Erasmus MC/Sophia Children's Hospital, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands
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Arshad Z, Thahir A, Rawal J, Hull PD, Carrothers AD, Krkovic M, Chou DTS. Dynamic hip screw fixation of subtrochanteric femoral fractures. Eur J Orthop Surg Traumatol 2021; 31:1435-1441. [PMID: 33590318 PMCID: PMC8448703 DOI: 10.1007/s00590-021-02895-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 01/29/2021] [Indexed: 11/29/2022]
Abstract
Introduction A subtrochanteric proximal femur fracture occurs in the 5 cm of bone immediately distal to the lesser trochanter. UK national guidelines advise that adults with subtrochanteric fractures should be treated with an intramedullary nail (IMN). This study aims to compare peri-operative outcome measures of patients with subtrochanteric fractures treated with either an IMN or a dynamic hip screw (DHS) construct. Materials and Methods We retrospectively reviewed subtrochanteric fractures presenting at our institution over 4.5 years (October 2014–May 2019), classifying them into two treatment groups; IMN and DHS. These groups were compared on outcome measures including surgical time, blood loss, radiation dose area product (DAP), length of stay, re-operation rate and mortality. Results During the time period studied, 86 patients presented with a subtrochanteric fracture of the femur; with 74 patients (86%) receiving an IMN and 12 (14%) receiving a DHS. The comparative outcome measures reaching statistical significance were blood loss and radiation DAP. The DHS group showed a significantly lower mean blood loss of 776 ml compared to 1029 ml in the IMN group. Also, the DHS group showed a significantly lower mean DAP of 150.30 mGy cm2 compared to 288.86 mGy cm2 in the IMN group. Conclusion Although UK national guidelines recommend treating all subtrochanteric fractures with an IMN; the outcome measures assessed in our study did not show use of an IMN to be superior to a DHS. The DHS group showed a lower estimated blood loss and a reduced DAP. This, along with the reduced financial cost associated with a DHS, may support the use of DHS over IMN for certain subtrochanteric fractures of the femur. There may not be a single favourable implant for the treatment of subtrochanteric fractures as a whole; instead different subtypes of fracture may be amenable to a number of fixation devices. Choice of implant should be determined locally and based on existing and future clinical and health economic research.
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Affiliation(s)
- Zaki Arshad
- University of Cambridge School of Clinical Medicine, Box 111 Cambridge Biomedical Campus, Cambridge, CB2 0SP, UK.
| | - Azeem Thahir
- Cambridge Orthopaedic Trauma Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Jaikirty Rawal
- Cambridge Orthopaedic Trauma Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Peter D Hull
- Cambridge Orthopaedic Trauma Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Andrew D Carrothers
- Cambridge Orthopaedic Trauma Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Matija Krkovic
- Cambridge Orthopaedic Trauma Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Daud T S Chou
- Cambridge Orthopaedic Trauma Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
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Li YH, Yu T, Shao W, Liu Y, Zhu D, Tan L. Distal locked versus unlocked intramedullary nailing for stable intertrochanteric fractures, a systematic review and meta-analysis. BMC Musculoskelet Disord 2020; 21:461. [PMID: 32660560 PMCID: PMC7359611 DOI: 10.1186/s12891-020-03444-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 06/22/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Intramedullary nails have become the main treatment for intertrochanteric fractures. However, a distal locking procedure during nailing gradually raised controversy. In this study, a systematic review and meta-analysis of clinical trials was performed to summarize existing evidence, aiming to determine the safety and efficacy of distal locking or unlocking in the nailing of stable intertrochanteric fractures. METHODS Appropriate articles were identified using the most common public databases, such as PubMed, Embase, the Cochrane Library, and Google Scholar from the inception of each database to April 2019, without restriction of language, publication date, and considering ongoing trials. Eligible studies were represented by randomized controlled trials or retrospective cohort studies, comparing distal locking and unlocking for the treatment of acute stable intertrochanteric fractures in adult patients. Information regarding methodological quality, patient demographics, and clinical outcomes were extracted independently by two reviewers. Subsequently, patients were divided into a locking and unlocking group. RESULTS This study included 9 articles, comprising a total of 1978 patients with a similar baseline. The results showed that the unlocking group had a shorter operation time, less intraoperative bleeding, lower transfusion rate, and less thigh pain after the treatment of femoral intertrochanteric fracture when compared with the distal locking group. No significant differences were observed in safety-related outcomes, including mortality, infection rate, cutting out, loss of reduction, backing out of lag screws, cephalic screw breakage, nail breakage, and peri-implant fractures between the two groups. In addition, efficacy-related outcomes including nonunion, delayed healing rates, and the Harris functional score were not significantly different between the two groups. CONCLUSIONS Our pooled analysis demonstrated that distal unlocking of stable intertrochanteric fractures can shorten the operation time, reduce intraoperative bleeding, and reduce the blood transfusion rate. The use of locked or unlocked intramedullary nailing does not affect long-term outcomes regarding complications and function.
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Affiliation(s)
- Yan-Hui Li
- Department of Cardiology and Echocardiography, the First Hospital of Jilin University, Changchun, 130021, China
| | - Tiecheng Yu
- Department of Orthopedic Trauma, the First Hospital of Jilin University, No. 71 Xinmin Street, Changchun, 130021, Jilin, China
| | - Wenjing Shao
- Department of Obstetrics and Gynecology, the First Hospital of Jilin University, Changchun, 130021, China
| | - Yanwei Liu
- Department of Orthopedic Trauma, the First Hospital of Jilin University, No. 71 Xinmin Street, Changchun, 130021, Jilin, China
| | - Dong Zhu
- Department of Orthopedic Trauma, the First Hospital of Jilin University, No. 71 Xinmin Street, Changchun, 130021, Jilin, China.
| | - Lei Tan
- Department of Orthopedic Trauma, the First Hospital of Jilin University, No. 71 Xinmin Street, Changchun, 130021, Jilin, China.
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Xing F, Chen W, Long C, Huang F, Wang G, Xiang Z. Postoperative outcomes of tranexamic acid use in geriatric trauma patients treated with proximal femoral intramedullary nails: A systematic review and meta-analysis. Orthop Traumatol Surg Res 2020; 106:117-126. [PMID: 31928976 DOI: 10.1016/j.otsr.2019.10.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 09/07/2019] [Accepted: 10/01/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Recently, there has been a series of clinical studies focusing on the perioperative administration of tranexamic acid (TXA) in geriatric trauma patients undergoing proximal femoral intramedullary nail surgery. However, the safety and efficacy of TXA in these patients remains controversial. Therefore, we performed a systematic review to focus on two questions: (1) would TXA reduce perioperative blood loss in geriatric trauma patients undergoing proximal femoral intramedullary nail surgery? and (2) would TXA increase the rate of perioperative complications in geriatric trauma patients undergoing proximal femoral intramedullary nail surgery? PATIENTS AND METHODS We systematically searched electronic databases (MEDLINE, EMBASE, PubMed, and Cochrane Central Register of Controlled Trials) up to April 20, 2019. The perioperative blood loss and complication data were extracted and analysed by RevMan Manager 5.3. RESULTS Finally, five randomized controlled studies, involving 539 geriatric intertrochanteric fracture patients undergoing proximal femoral intramedullary nail surgery, were enrolled in this systematic review. Compared with the control group, the TXA group had significantly lower total perioperative blood loss (WMD=-172.84; 95% CI, -241.44 to -104.24; I2=0%), intraoperative blood loss (WMD=-34.20; 95% CI, -46.04 to -22.36; I2=0%), total perioperative hidden blood loss (WMD=-139.05; 95% CI, -213.67 to -64.43; I2=0%), perioperative transfusion rates (RR =-0.16; 95% CI, -0.24 to -0.08; I2=22%), length of hospital stay (WMD=-1.18; 95% CI, -1.91 to -0.46; p=0.001; I2=12%), and postoperative wound haematoma rates (RD=-0.05; 95% CI, -0.09 to 0.00; p=0.03; I2=0%). In addition, there were no significant differences between TXA and control groups in the terms of surgical time, postoperative mortality, total thromboembolic events, wound infections, cerebrovascular accidents, respiratory infections, and renal failure. DISCUSSION TXA in geriatric trauma patients undergoing intramedullary nail surgery is effective for perioperative haemostasis without increasing the incidence of postoperative complications. LEVEL OF EVIDENCE II, Systematic review and Meta-analysis.
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Affiliation(s)
- Fei Xing
- Department of Orthopaedics, West China Hospital, Sichuan University, No. 37 Guoxue Lane, Chengdu 610041, Sichuan, People's Republic of China
| | - Wei Chen
- Department of Orthopaedics, West China Hospital, Sichuan University, No. 37 Guoxue Lane, Chengdu 610041, Sichuan, People's Republic of China
| | - Cheng Long
- Department of Orthopaedics, West China Hospital, Sichuan University, No. 37 Guoxue Lane, Chengdu 610041, Sichuan, People's Republic of China
| | - Fuguo Huang
- Department of Orthopaedics, West China Hospital, Sichuan University, No. 37 Guoxue Lane, Chengdu 610041, Sichuan, People's Republic of China
| | - Guanglin Wang
- Department of Orthopaedics, West China Hospital, Sichuan University, No. 37 Guoxue Lane, Chengdu 610041, Sichuan, People's Republic of China
| | - Zhou Xiang
- Department of Orthopaedics, West China Hospital, Sichuan University, No. 37 Guoxue Lane, Chengdu 610041, Sichuan, People's Republic of China.
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Zhang R, Wang L, Lin Y, Yang M, Guo Z, Xia W, Wei J, Yi C, Wu X, Cheng X, Gao X. A novel method for estimating nail-tract bone density for intertrochanteric fractures. J Orthop Translat 2019; 18:40-47. [PMID: 31508306 PMCID: PMC6718973 DOI: 10.1016/j.jot.2018.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 09/29/2018] [Accepted: 11/28/2018] [Indexed: 11/30/2022] Open
Abstract
Summary A novel method based on voxel-based morphometry was proposed to investigate the average volumetric bone mineral density (vBMD) of femoral head nail tract in patients treated with intramedullary nails—proximal femoral nail antirotation (PFNA) and gamma nail (GN). The results showed that there was no significant difference in average vBMD between the two groups. Background For unstable intertrochanteric fractures, poor bone quality might be one of the most important causes of cut-out complications in the femoral head during surgical treatment. Bone quality is generally regarded as an equivalent of BMD. Thus, we develop a novel voxel-based morphometry–based method to quantify vBMD of the femoral head nail tract. Methods Automatic calculation of average vBMD of nail tracts requires three main steps. First, we built a standard nail tract in a proximal femur template. Then, we mapped the proximal femur structure of each patient to the template by B-spline and Demons registration so that the anatomical positions of the proximal femur of all patients spatially corresponded to the standard template. Finally, we calculated and visualized the average vBMD distribution of the nail tract of all patients. To verify the feasibility of the method, we enrolled 75 patients (52 women and 23 men) with hip fractures to our study to compare measurements. The root mean square of the standard deviation (RMSSD) was calculated, and the coefficient of variation (CV) of the RMSSD (CV-RMSSD) was used to evaluate the reproducibility of intraoperator and interscan measurements. The Mann–Whitney U test was used to compare the average vBMD of nail tracts for the PFNA and GN. Results The CV-RMSSD of intraoperator measurements ranged from 1.0% to 2.0%, and the CV-RMSSD of interscan measurements ranged from 3.6% to 4.5%. There was no significant difference in the average vBMD between patients with PFNAs and those with GNs (p > 0.05). Conclusions The proposed method is reproducible for determining the average vBMD, which may provide a reference index for selection of appropriate intramedullary nails for individual patients. The current choice of intramedullary nail based on the experience of a surgeon may be biased. The translational potential of this article A novel method was proposed to measure the spatial average vBMD of nail tracts, which has good potential to provide a reference index for surgeons to choose appropriate implants.
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Affiliation(s)
- Rui Zhang
- Medical Imaging Department, Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, China
| | - Ling Wang
- Department of Radiology, Beijing Jishuitan Hospital, Peking University Fourth School of Clinical Medicine, Beijing, China
| | - Yanyu Lin
- Medical Imaging Department, Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, China.,College of Materials Sciences and Opto-Electronic Technology, University of Chinese Academy of Sciences, Beijing, China
| | - Minghui Yang
- Department of Traumatology and Orthopedic Surgery, Beijing Jishuitan Hospital, Peking University Fourth School of Clinical Medicine, Beijing, China
| | - Zhe Guo
- Department of Radiology, Beijing Jishuitan Hospital, Peking University Fourth School of Clinical Medicine, Beijing, China
| | - Wei Xia
- Medical Imaging Department, Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, China
| | - Jie Wei
- Department of Traumatology and Orthopedic Surgery, Beijing Jishuitan Hospital, Peking University Fourth School of Clinical Medicine, Beijing, China
| | - Chen Yi
- Department of Traumatology and Orthopedic Surgery, Beijing Jishuitan Hospital, Peking University Fourth School of Clinical Medicine, Beijing, China
| | - Xinbao Wu
- Department of Traumatology and Orthopedic Surgery, Beijing Jishuitan Hospital, Peking University Fourth School of Clinical Medicine, Beijing, China
| | - Xiaoguang Cheng
- Department of Radiology, Beijing Jishuitan Hospital, Peking University Fourth School of Clinical Medicine, Beijing, China
| | - Xin Gao
- Medical Imaging Department, Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou, China
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O’Neill CJ, Fitzgerald E, Kaar K, Murphy CG. Refracture of the Pediatric Forearm with Intramedullary Nails in situ. J Orthop Case Rep 2019; 9:15-18. [PMID: 31559218 PMCID: PMC6742864 DOI: 10.13107/jocr.2250-0685.1398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION There are few described cases in literature describing the management of refracture of both bone forearm fractures with elastic stable intramedullary nails (ESIN) in situ. We describe our experience and discuss it in the context of existing reports. CASE REPORT A 6-year-old girl presented to our unit with a refracture of her forearm with ESIN in situ following a trauma, 5 months post her index injury and ESIN procedure. She was managed with closed reduction under general anesthesia with a good outcome. DISCUSSION Treatment of this unusual injury is challenging given the paucity of evidence to inform management. Many existing case series fail to report this complication. We echo those studies that have employed similar strategies and note potential complications associated with this management including altered biomechanics of the ESIN. CONCLUSION Closed reduction of a refracture of pediatric forearm with ESIN in situ is an acceptable approach to this unusual injury. Caution must be taken intraoperatively and postoperatively to account for any biomechanical deficiencies in the ESIN resulting from the forces applied to cause the refracture and forces applied to the in situ nails to achieve correction intraoperatively.
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Affiliation(s)
- Cathleen J. O’Neill
- Department of Trauma and Orthopaedics, University Hospital Galway, Galway, Ireland,Address of Correspondence: Dr. Cathleen J. O’Neill, Department of Trauma and Orthopaedics, University Hospital Galway, Galway, Ireland. E-mail:
| | - Eammon Fitzgerald
- Department of Trauma and Orthopaedics, University Hospital Galway, Galway, Ireland
| | - Ken Kaar
- Department of Trauma and Orthopaedics, University Hospital Galway, Galway, Ireland
| | - Colin G. Murphy
- Department of Trauma and Orthopaedics, University Hospital Galway, Galway, Ireland
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Croccolo D, De Agostinis M, Fini S, Funaioli S, Olmi G, Robusto F. Experimentally validated structural finite element method analysis of a tibial intramedullary nail: Optimal choice of the contact settings. Proc Inst Mech Eng H 2018; 233:193-206. [PMID: 30565500 DOI: 10.1177/0954411918819111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This article focuses on the static structural analysis of a tibial intramedullary nail, carried out by the finite element method. The investigated subject is concerned with the issue of frictional contacts that, generating a non-linear problem, play an important role in numerical analyses. Experimental tests were also developed on tibial intramedullary nail specimens. The experimental results, in terms of force-displacement, were used to calibrate and validate the finite element analysis, by tuning the contact parameters available in the software.
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Affiliation(s)
- D Croccolo
- Department of Industrial Engineering (DIN), University of Bologna, Bologna, Italy
| | - M De Agostinis
- Department of Industrial Engineering (DIN), University of Bologna, Bologna, Italy
| | - S Fini
- Department of Industrial Engineering (DIN), University of Bologna, Bologna, Italy
| | - S Funaioli
- Department of Industrial Engineering (DIN), University of Bologna, Bologna, Italy
| | - G Olmi
- Department of Industrial Engineering (DIN), University of Bologna, Bologna, Italy
| | - F Robusto
- Department of Industrial Engineering (DIN), University of Bologna, Bologna, Italy
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Ciaffa V, Vicenti G, Mori CM, Panella A, Conserva V, Corina G, Scialpi L, Speciale M, Fraccascia A, Picca G, Carrozzo M, Leone A, Morizio A, Abate A, Petrelli L, Aloisi A, Rollo G, Filipponi M, Freda V, Pansini A, Puce A, De Gabriele S, Solarino G, Moretti B. Unlocked versus dynamic and static distal locked femoral nails in stable and unstable intertrochanteric fractures. A prospective study. Injury 2018; 49 Suppl 3:S19-25. [PMID: 30415664 DOI: 10.1016/j.injury.2018.09.063] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 09/29/2018] [Accepted: 09/30/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Few clinical studies have analyzed the utility of distal interlocking screws in stable and unstable intertrochanteric fractures treated with intramedullary devices. We performed a prospective analysis comparing short unlocked versus short dynamic and short static distal locked intramedullary nails. MATERIALS AND METHODS Nine level-II trauma centres were involved in the study. 240 patients over the age of 65 with a stable (AO/OTA 31-A1) or unstable intertrochanteric fracture (AO/OTA 31-A2) were prospectively investigated. The same type of nail was used in every patient. Patients were randomly divided into 3 groups according to the type of distal locking used. Intra-operative variables were examined and patients were followed clinically and radiographically at 1, 3, 6, 12 months postoperatively. All complications were recorded. RESULTS A total of 212 patients completed 1 year of follow-up visits. In the Unlocking Group (UG) the operation time, blood loss, fluoroscopy time, total length of incision were significantly decreased compared to both the Dynamic Group (DG) and the Static Group (SG) (p < 0.05). Conversely, no reliable differences in intraoperative variables were noted between the Dynamic Group and the Static Group (p > 0.05). In terms of time of fracture union we found no differences among the three Groups (p > 0.05). Moreover, no cases of limb shortening >1 cm or varus collapse were detected in any group. The 3 Groups were similar in terms of HHS, SF-12 and Barthel index results at 1-year follow-up (p > 0.05). Finally, no significant differences were demonstrated across the three Groups in terms of major complications. CONCLUSIONS This clinical study further confirms the hypothesis that short intramedullary nails do not need to be locked for stable and unstable intertrochanteric fractures.
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Grangeiro PM, Rezende MUD, Helito CP, Felix AM, Ocampos GP, Guarniero R. Double femoral osteotomy fixed with a Puddu plate and a retrograde intramedullary nail to treat biapical deformity of the femur. Rev Bras Ortop 2018; 53:378-383. [PMID: 29892592 PMCID: PMC5993912 DOI: 10.1016/j.rboe.2018.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 05/02/2017] [Indexed: 11/30/2022] Open
Abstract
Biapical femoral deformities are challenging to treat. In order to correct concomitant metaphyseal and diaphyseal deformities of the femur, the authors propose a double femoral controlled osteotomy with combined internal fixation, consisting of a Puddu plate and an intramedullary nail. The method was described in two patients. Results were analyzed using a visual analog scale (VAS), the Lysholm score, and SF-36. No complications were found. Complete consolidation of the osteotomies and radiographic alignment correction were achieved. Results were obtained with a minimum follow-up of 66 months. Both patients had improved for pain (VAS from 60 to 40 and from 50 to 20 at reassessment), function (Lysholm score from 78 to 93 and from 55 to 73) and quality of life (SF-36, both mental - from 40.7 to 57.1 in case one and from 24.7 to 59.7 in case two - and physical - from 27.7 to 45.6 and from 28.2 to 46.8). The authors have found that this technique is a reliable, accurate, and reproducible solution for biapical deformities of the femur.
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Affiliation(s)
- Patrícia Moreno Grangeiro
- Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HC-FM-USP), São Paulo, SP, Brazil
| | - Márcia Uchoa de Rezende
- Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HC-FM-USP), São Paulo, SP, Brazil
| | - Camilo Partezani Helito
- Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HC-FM-USP), São Paulo, SP, Brazil
| | - Alessandro Monterroso Felix
- Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HC-FM-USP), São Paulo, SP, Brazil
| | - Guilherme Pereira Ocampos
- Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HC-FM-USP), São Paulo, SP, Brazil
| | - Roberto Guarniero
- Departamento de Ortopedia e Traumatologia, Faculdade de Medicina, Universidade de São Paulo (FM-USP), São Paulo, SP, Brazil
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17
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Nherera L, Trueman P, Horner A, Watson T, Johnstone AJ. Comparison of a twin interlocking derotation and compression screw cephalomedullary nail (InterTAN) with a single screw derotation cephalomedullary nail (proximal femoral nail antirotation): a systematic review and meta-analysis for intertrochanteric fractures. J Orthop Surg Res 2018; 13:46. [PMID: 29499715 PMCID: PMC5834859 DOI: 10.1186/s13018-018-0749-6] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 02/22/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Intertrochanteric hip fractures are common and devastating injuries especially for the elderly. Surgical treatment is the optimal strategy for managing intertrochanteric fractures as it allows early rehabilitation and functional recovery. The relative effects of internal fixation strategies for intertrochanteric fracture after operation remain limited to relatively small studies which create uncertainty in attempts to establish evidence-based best practice. METHODS We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) and observational studies to assess the clinical effectiveness of two commonly used intramedullary devices: a twin screw integrated cephalomedullary nail (InterTAN) versus a single screw cephalomedullary nail (proximal femoral nail antirotation) in patients with intertrochanteric fractures. The following outcomes were considered: revisions, implant-related failures, non-unions, pain, Harris Hip Score and intraoperative outcomes. Odds ratios or mean differences with 95% confidence intervals in brackets are reported. RESULTS Six studies met the inclusion criteria, two randomised controlled trials and four observational studies enrolling 970 patients with mean age of 77 years, and 64% of patients were female. There was a statistically significant difference (p value < 0.05) for revisions OR 0.27 (0.13 to 0.56), implant-related failures OR 0.16 (0.09 to 0.27) and proportion of patients complaining of pain OR 0.50 (0.34 to 0.74). There was no difference in non-unions and Harris Hip Score (p value > 0.05). There was a significant difference in blood loss and fluoroscopy usage in favour of PFNA, whilst no difference in operating times were observed between the two devices. CONCLUSIONS Our meta-analysis suggests that a twin screw integrated cephalomedullary nail InterTAN is clinically more effective when compared to a single screw cephalomedullary nail proximal femoral nail antirotation resulting in fewer complications, fewer revisions and fewer patients complaining of pain. No difference has been established regarding non-unions and Harris Hip Score. Intraoperative outcomes favour PFNA with less blood loss and fluoroscopy usage. Further studies are warranted to explore the cost-effectiveness of these and other implants in managing patients with intertrochanteric fractures.
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Affiliation(s)
- Leo Nherera
- Smith & Nephew Advanced Wound Management, Hull, UK
| | - Paul Trueman
- Smith & Nephew Advanced Wound Management, Hull, UK
| | - Alan Horner
- Smith & Nephew Advanced Wound Management, Hull, UK
| | - Tracy Watson
- Department of Orthopaedic Surgery, Saint Louis University School of Medicine, St. Louis, Missouri USA
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Sun Q, Ge W, Li G, Wu J, Lu G, Cai M, Li S. Locking plates versus intramedullary nails in the management of displaced proximal humeral fractures: a systematic review and meta-analysis. Int Orthop 2017; 42:641-650. [PMID: 29119298 DOI: 10.1007/s00264-017-3683-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 10/27/2017] [Indexed: 01/03/2023]
Abstract
PURPOSE To compare the clinical outcome and complications of locking plates versus intramedullary nails in patients with displaced proximal humeral fractures. Our hypothesis was that there would be no difference between these two implants with regard to clinical outcome and complications. METHODS We performed a systemic review of PubMed, EMBASE, Clinical Trials Registry, Cochrane Central Register of Controlled Trials and Google Scholar to identify all relevant randomized controlled trials, prospective and retrospective comparative studies on April 26, 2017. The studies of locking plates compared to intramedullary nails in patients with displaced proximal humeral fractures were included. We conducted a meta-analysis of shoulder functional scores, range of motion, pain scores, and complications. RESULTS This meta-analysis included 13 comparative studies with 958 patients (529 in the locking plate group and 429 in the intramedullary nail group). A significantly greater external rotation (MD = 9.67; 95% CI, 4.22-15.12; P = 0.0005) and a significantly higher penetration rate (RR = 1.75; 95% CI, 1.11-2.77; P = 0.02) were observed in the locking plate group compared with the intramedullary nail group. Constant-Murley scores, DASH scores and total complication rate were comparable between the two groups. Moreover, there were no significant differences in forward elevation, VAS scores, and other complications. CONCLUSIONS Current evidence indicates that locking plates and intramedullary nails have similar performance in terms of the functional scores and total complication rate. No superior treatment was suggested between locking plates and intramedullary nails for displaced proximal humeral fractures.
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Affiliation(s)
- Qi Sun
- Department of Orthopaedics, Shanghai Tenth People's Hospital, Tongji University, School of Medicine, Shanghai, 200072, China
| | - Wei Ge
- Department of Orthopaedics, Shanghai Tenth People's Hospital, Tongji University, School of Medicine, Shanghai, 200072, China
| | - Gen Li
- Department of Orthopaedics, Shanghai Tenth People's Hospital, Tongji University, School of Medicine, Shanghai, 200072, China
| | - Jiezhou Wu
- Department of Orthopaedics, Shanghai Tenth People's Hospital, Tongji University, School of Medicine, Shanghai, 200072, China
| | - Guanghua Lu
- Department of Orthopaedics, Shanghai Tenth People's Hospital, Tongji University, School of Medicine, Shanghai, 200072, China
| | - Ming Cai
- Department of Orthopaedics, Shanghai Tenth People's Hospital, Tongji University, School of Medicine, Shanghai, 200072, China
| | - Shaohua Li
- Department of Orthopaedics, Shanghai Tenth People's Hospital, Tongji University, School of Medicine, Shanghai, 200072, China.
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Abstract
Tibiotalocalcaneal arthrodesis is a safe and viable option to treat patients with arthridities affecting ankle and subtalar joints, neuromuscular disorders, avascular necrosis of the talus, failed ankle arthrodesis, instability, and Charcot neuroarthropathy. Choice of incision and fixation is based on deformity, pathology, prior surgery and hardware, and surgeon comfort and preference. Intramedullary nails offer high primary stability, reduce sustained soft tissue damage, and may allow for earlier return to activities than traditional plate or screw constructs. Peri- and postoperative fractures, malunion, nonunion, and infections are potential complications. Postoperative recovery is a vital component for an overall successful outcome.
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Affiliation(s)
- Patrick R Burns
- Podiatric Medicine and Surgery Residency, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, 1515 Locust Street #350, Pittsburgh, PA 15219, USA.
| | - Augusta Dunse
- PGY-2, Podiatric Medicine and Surgery Residency, University of Pittsburgh Medical Center, 1400 Locust Street, Pittsburgh, PA 15217, USA
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Morawska-Chochół A, Domalik-Pyzik P, Menaszek E, Sterna J, Bielecki W, Bonecka J, Boguń M, Chłopek J. Biodegradable intramedullary nails reinforced with carbon and alginate fibers: In vitro and in vivo biocompatibility. J Appl Biomater Funct Mater 2018; 16:36-41. [PMID: 28623633 DOI: 10.5301/jabfm.5000370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Commonly, intramedullary nails are made of nondegradable materials, and hence they need to be removed once the bone fracture is healed. We propose a novel composite material consisting of poly-L-lactide matrix modified with carbon and alginate fibers to be used for biodegradable intramedullary fixation. The aim of this study was to make in vitro and in vivo biocompatibility assessments. METHODS In the in vitro conditions, biocompatibility of biomaterials was compared using normal human osteoblasts. After 3 and 7 days, cytotoxicity, viability and proliferation tests were performed, as well as cell morphology and adhesion observations. In the in vivo experiments, Californian rabbits (approx. 9 months old) were used. The composite nails and controls (Kirschner wires) were used for fixation of distal femoral osteotomy. The evaluation was made on the basis of clinical observations, radiographs taken after 2, 4, 6 and 8 weeks post implantation, and macroscopic and histological observations. RESULTS Cell tests indicated that both modifiers had a positive influence on cell viability. Biodegradable composite nails led to bony union when used for fixation of distal diaphysis osteotomy in rabbits. Histological analysis showed that the initial focal necrosis should be fully compensated for by the osteoblast proliferation and trabeculae formation. CONCLUSIONS Both in vitro and in vivo tests confirmed biocompatibility and potential applicability of novel biodegradable intramedullary nails modified with long carbon and alginate fibers for osteosynthesis of bone epiphysis.
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Schmutz B, Kmiec S Jr, Wullschleger ME, Altmann M, Schuetz M. 3D Computer graphical anatomy study of the femur: a basis for a new nail design. Arch Orthop Trauma Surg 2017; 137:321-31. [PMID: 28168640 DOI: 10.1007/s00402-016-2621-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Current intramedullary nails with a radius of curvature (ROC) of 1500-2000 mm sometimes cause distal anterior cortical encroachment. Furthermore, clinical data indicate that the proximal nail end is too long for some Asian patients. The objective of our study was to develop a comprehensive 3D measurement protocol that measures both the anatomy of the canal and the proximal region. The protocol was used to obtain measurements from Caucasian and Asian (Japanese and Thai) specimens. MATERIALS AND METHODS A total of 90 3D bone models representative of hip fracture patients were reconstructed from CT data. RapidForm 2006 was used to generate the reference geometries required for determining radius and angulation of shaft antecurvature as well as measurements of the proximal anatomy. Multiple linear regression analyses were used to determine the relative contribution of height, age, ethnicity, gender, and body side on the total variance. RESULTS The mean ROC in the natural 3D antecurvature plane was 885 mm overall, 974 mm in Caucasians and 787 mm in Asians. Height, age, ethnicity, gender, and body side significantly predicted ROC (R = 0.53, p = 0.000). The mean values of anteversion measurements for Asians (Japanese: 22.1°; Thai: 22.7°) were significantly larger than those of the Caucasians (14.5°; p = 0.001). There was virtually no difference (p = 0.186) between the measurements pertaining to the length of the proximal nail end between Caucasian and Asian samples. There was no significant difference between the mean neck-to-shaft angles (Caucasian: 126°; Japanese: 128.2°; Thai: 125.7°; p = 0.198 for Asians vs Caucasians). CONCLUSIONS The developed comprehensive anatomical 3D measurement protocol could serve as standardised approach for anthropometric studies in the future. Our data suggest that the ROC of current nail designs should be reduced from between 1500 and 2000 to 1000 mm to achieve an improved fit for the investigated population.
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Morawska-Chochół A, Domalik-Pyzik P, Chłopek J, Szaraniec B, Sterna J, Rzewuska M, Boguń M, Kucharski R, Mielczarek P. Gentamicin release from biodegradable poly-l-lactide based composites for novel intramedullary nails. Mater Sci Eng C Mater Biol Appl 2014; 45:15-20. [PMID: 25491796 DOI: 10.1016/j.msec.2014.08.059] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 07/18/2014] [Accepted: 08/29/2014] [Indexed: 11/26/2022]
Abstract
One of the major problems in orthopedic surgery is infection associated with implantation. The treatment is a very difficult and long-term process. A solution to this issue can be the use of implants which additionally constitute an antibiotic carrier preventing the development of an infection. Prototypes of biodegradable intramedullary nails made of three different composites with a poly(L-lactide) matrix were designed. The nails served as gentamicin sulfate (GS) carrier - an antibiotic commonly used in the treatment of osteomyelitis. The matrix was reinforced with carbon fibers (CF), alginate fibers (Alg) and magnesium alloy wires (Mg), as well as modified with bioactive particles of tricalcium phosphate (TCP) in various systems. In this way, novel, multi-phase and multifunctional degradable intramedullary nails were obtained. The tests demonstrated strong dependence between the type of the modifying phase introduced into the composite, and the rate of drug release. Introduction of gentamicin into the nail structure strengthened and prolonged antibacterial activity of the nails.
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Affiliation(s)
- Anna Morawska-Chochół
- AGH University of Science and Technology, Faculty of Materials Science and Ceramics, Department of Biomaterials, al. A. Mickiewicza 30, 30-059 Krakow, Poland.
| | - Patrycja Domalik-Pyzik
- AGH University of Science and Technology, Faculty of Materials Science and Ceramics, Department of Biomaterials, al. A. Mickiewicza 30, 30-059 Krakow, Poland
| | - Jan Chłopek
- AGH University of Science and Technology, Faculty of Materials Science and Ceramics, Department of Biomaterials, al. A. Mickiewicza 30, 30-059 Krakow, Poland
| | - Barbara Szaraniec
- AGH University of Science and Technology, Faculty of Materials Science and Ceramics, Department of Biomaterials, al. A. Mickiewicza 30, 30-059 Krakow, Poland
| | - Jacek Sterna
- Warsaw University of Life Sciences - SGGW, Faculty of Veterinary Medicine, Department of Small Animal Diseases with Clinic, ul. Nowoursynowska 159c, 02-776 Warszawa, Poland
| | - Magdalena Rzewuska
- Warsaw University of Life Sciences - SGGW, Faculty of Veterinary Medicine, Department of Preclinical Sciences, ul. Ciszewskiego 8, 02-786 Warszawa, Poland
| | - Maciej Boguń
- Lodz University of Technology, Faculty of Material Technologies and Textile Design, Department of Material and Commodity Sciences and Textile Metrology, ul. Żeromskiego 116, 90-924 Lodz, Poland
| | - Rafael Kucharski
- CJS Sp. z o. o., Gen. Jankego 134/1, 40-617 Katowice, Poland; IEE Group, Hannover, Germany
| | - Przemysław Mielczarek
- AGH University of Science and Technology, Faculty of Materials Science and Ceramics, Department of Biochemistry and Neurobiology, al. A. Mickiewicza 30, 30-059 Krakow, Poland
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Shahid M, Yeo M, Smibert JG. Closed reduction of radius refracture: A case report. Int J Surg Case Rep 2011; 2:275-7. [PMID: 22096752 DOI: 10.1016/j.ijscr.2011.09.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2011] [Revised: 08/23/2011] [Accepted: 09/01/2011] [Indexed: 10/17/2022] Open
Abstract
INTRODUCTION Refractures of the radius and ulna in the paediatric patient with flexible intramedullary nails in situ are known to occur. There are no formal guidelines currently in the literature to guide the management of such fractures. PRESENTATION OF CASE A 10-year-old Caucasian girl, sustained a closed refracture of the radius at the same level, with the flexible intramedullary nails in situ to treat her recent ulna and radius fractures. DISCUSSION We proposed a new non-invasive way of reducing and maintaining such fractures without removal of the bent nail completely. CONCLUSION This method does not significantly reduce the mechanical strength of the nail, as we do not advocate applying an external lateral force, which would compromise nail mechanical strength and eventually lead to breakage of the nail in situ.
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Affiliation(s)
- Mohammad Shahid
- Department of Orthopaedics and Traumatology, Yeovil District Hospital, Yeovil BA214AT, England, United Kingdom
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