Radiographically guided femoral neck osteosynthesis with cannulated compressive titanium screw and anti-rotational component in a Brown Howler Monkey (Alouatta guariba clamitans)

A Brown Howler Monkey presented with a femoral neck fracture was successfully treated with a cannulated compressive screw and an anti-rotational component inserted with radiographically guided technique. Complete bone consolidation and functional recovery were observed 9 weeks after the surgery, and the monkey was released to his place of origin.

Assessing Muscle Mass in the Orthopedic Clinical Setting: Application of the Ultrasound Sarcopenia Index in Elderly Subjects with a Recent Femoral Fracture

BACKGROUND

Sarcopenia poses a risk factor for falls, disability, mortality, and unfavorable postoperative outcomes. Recently, the Ultrasound Sarcopenia Index (USI) has been validated to assess muscle mass, and this study aimed to apply the USI in the clinical setting.

METHODS

This prospective observational study included 108 patients aged >65 years, hospitalized for proximal femoral traumatic fracture. Patients were divided into two groups based on anamnestic data: patients with independent walking (IW) and patients requiring walking aid (WA) before admission. All the participants received an ultrasound examination. Other parameters evaluated were handgrip strength, limb circumferences, nutrition (MNA), and activity of daily living (ADL) scores.

RESULTS

Fifty-six IW patients (83 ± 6 y; 38 females) and 52 WA patients (87 ± 7 y; 44 females) were recruited. The USI was significantly higher in the IW group compared to the WA group (p = 0.013, Cohen's d = 0.489). Significant correlations were found between the USI and other sarcopenia-associated parameters, such as handgrip strength, MNA, ADLs, other muscle ultrasound parameters, and limb circumferences.

CONCLUSION

The application of the USI in the orthopedic surgery setting is feasible and might support the diagnosis of sarcopenia when combined with other measures of strength and function.

Comparative Outcomes of Elastic Stable Intramedullary Nailing vs. Plate Fixation in Pediatric Femoral Shaft Fractures. A Prospective Study

BACKGROUND

Pediatric femoral fractures are common in emergency rooms, with treatment options varying by age. This study compares elastic stable intramedullary nailing (ESIN) and plate fixation for diaphyseal femoral fractures in children aged 5-10.

MATERIAL AND METHODS

Conducted at Al-Kindi Teaching Hospital, Baghdad, from December 2017 to December 2019, this prospective study included 32 children with closed transverse diaphyseal femoral fractures. Patients were divided into two groups: 16 treated with ESIN (Group 1) and 16 with plate fixation (Group 2). Criteria excluded comminuted, open, or pathological fractures.

RESULTS

Group 1 had a mean age of 7.1 years and weight of 23.7 kg; Group 2 had a mean age of 7.8 years and weight of 30.9 kg. ESIN resulted in shorter operative times (58.4 minutes), earlier weight-bearing, and quicker fracture union (8.8 weeks) compared to plate fixation (76.3 minutes, 11.9 weeks). Blood loss was significantly less in Group 1 (32.8 ml) versus Group 2 (205.0 ml). No significant differences in wound healing or leg length discrepancies were observed.

CONCLUSIONS

1. Our study indicates a preference for Elastic Stable Intramedullary Nailing (ESIN) over plate fixation for pediatric femoral shaft fractures in children aged 5-10 years. 2. ESIN is associated with shorter operative times and faster commencement of weight-bearing, critical in pediatric recovery. 3. While ESIN is generally preferable, plate fixation may be better suited in certain clinical scenarios, emphasizing the importance of personalized treatment. 4. Based on our findings, ESIN is recommended for treating transverse diaphyseal femur fractures in the specified pediatric age group. 5. Recommends further studies, including randomized controlled trials, for a more comprehensive understanding of these treatments' long-term outcomes.

Age-related exacerbation of lung damage after trauma is associated with increased expression of inflammasome components

Background

Trauma, a significant global cause of mortality and disability, often leads to fractures and hemorrhagic shock, initiating an exaggerated inflammatory response, which harms distant organs, particularly the lungs. Elderly individuals are more vulnerable to immune dysregulation post-trauma, leading to heightened organ damage, infections, and poor health outcomes. This study investigates the role of NF-κB and inflammasomes in lung damage among aged mice post-trauma.

Methods

Twelve male C57BL/6J mice underwent hemorrhagic shock and a femoral fracture (osteotomy) with external fixation (Fx) (trauma/hemorrhage, THFx), while another 12 underwent sham procedures. Mice from young (17-26 weeks) and aged (64-72 weeks) groups (n=6) were included. After 24h, lung injury was assessed by hematoxylin-eosin staining, prosurfactant protein C (SPC) levels, HMGB1, and Muc5ac qRT-PCR. Gene expression of Nlrp3 and Il-1β, and protein levels of IL-6 and IL-1β in lung tissue and bronchoalveolar lavage fluid were determined. Levels of lung-infiltrating polymorphonuclear leukocytes (PMNL) and activated caspase-3 expression to assess apoptosis, as well as NLRP3, ASC, and Gasdermin D (GSDMD) to assess the expression of inflammasome components were analyzed via immunostaining. To investigate the role of NF-κB signaling, protein expression of phosphorylated and non-phosphorylated p50 were determined by western blot.

Results

Muc5ac, and SPC as lung protective proteins, significantly declined in THFx versus sham. THFx-aged exhibited significantly lower SPC and higher HMGB1 levels versus THFx-young. THFx significantly increased activated caspase-3 versus both sham groups, and THFx-aged had significantly more caspase-3 positive cells versus THFx-young. IL-6 significantly increased in both sham and THFx-aged groups versus corresponding young groups. THFx significantly enhanced PMNL in both groups versus corresponding sham groups. This increase was further heightened in THFx-aged versus THFx-young. Expression of p50 and phosphorylated p50 increased in all aged groups, and THFx-induced p50 phosphorylation significantly increased in THFx-aged versus THFx-young. THFx increased the expression of inflammasome markers IL-1β, NLRP3, ASC and GSDMD versus sham, and aging further amplified these changes significantly.

Conclusion

This study's findings suggest that the aging process exacerbates the excessive inflammatory response and damage to the lung following trauma. The underlying mechanisms are associated with enhanced activation of NF-κB and increased expression of inflammasome components.

Ultrasound-guided femoral nerve block versus fascia iliaca compartment block for femoral fractures in emergency department: A randomized controlled trial

Aim

Femoral fractures are one of the most debilitating injuries presenting to the emergency departments (EDs). The pain caused by these fractures is typically managed with opioids and adjunctive regional analgesia. These approaches are often associated with adverse side effects. Thus, appropriate alternative methods should be thoroughly investigated. To evaluate ultrasound-guided femoral nerve block (FNB) with ultrasound-guided fascia iliaca compartment block (FICB) in femoral fractures, to determine which provides better analgesia and less opioid requirement.

Methods

This study was a randomized clinical trial performed on adult patients presenting to the ED within 3 h of isolated femoral fracture with initial numerical pain rating scale (NRS-0) score of more than 5. The patients were randomized to receive FNB or FICB. The outcomes were block success rates, pain at 20 (NRS-20) and 60 (NRS-60) min after the end of the procedures, as well as the number and total dose of fentanyl administration during ED stay.

Results

Eighty-seven patients were recruited (40 FNB and 47 FICB). Success rates were 82.5% in FNB and 83.0% in FICB group, with no significant difference between the groups. NRS-20, NRS-60, the number of patients who received supplemental fentanyl, and the total dose of administered fentanyl were significantly lower following FNB. However, the length of the procedure was significantly lower in the FICB group.

Conclusion

Both FNB and FICB are effective in pain reduction for fractures of femur, but FNB provides more pain relief and less need for supplemental fentanyl.

The floating hip injury: a descriptive study and case-control analysis

PURPOSE

A "floating hip" (FH) injury is a rare injury describing the simultaneous ipsilateral fracture of the femur and pelvis or acetabulum (P/A). We describe our experience with patients presenting with FH injuries and compare them to controls with similar P/A fractures but without femoral involvement.

METHODS

Medical records and radiographs of FH patients and controls presenting to our tertiary centre between 2015 and 2020 were reviewed. Follow-up data from outpatient clinical records were also extracted. The control group were extensively matched by age, sex, body mass index, fracture classification and energy of injury.

RESULTS

From 1392 recorded P/A fractures, 42 FH cases were identified (average age 39 years, 78.6% males). The most common femoral fracture was the midshaft (35.7%), followed by the neck of femur (26.2%). 90.5% of FH injuries were due to high-energy mechanisms. 64.3% of P/A fractures, and 100% of femoral fractures were managed surgically. Compared to controls, FH cases were more likely to have additional orthopaedic injuries (73.8% vs. 40.5%, p = 0.002), more total theatre admissions (mean 2.5 vs. 1.19, p < 0.001), longer hospital stays (28.3 vs. 14.9 days, p = 0.02), and a higher rates of post-op complications (53.8% vs. 20%, p = 0.025).

CONCLUSIONS

We report differences in the presentation, management, and outcomes of FH injuries versus controls, even after extensive matching for confounders. These differences may inform future treatment strategies for the FH injury.

Prediction of leg-length discrepancy in pediatric femoral shaft fracture using bone SPECT/CT: A case report

RATIONALE

Children's bones are in the process of growing in both length and width. Therefore, evaluating whether fractures affect the growth plate or not is very crucial. However, even in cases of lower limb fractures where the growth plate remains unaffected, overgrowth or shortening of the affected limb are encountered.

PATIENT CONCERNS

An 11-year-old boy was admitted to the emergency department after a passenger car accident.

DIAGNOSES

A comminuted fracture of the right femoral shaft was diagnosed by X-ray image.

INTERVENTIONS

Closed reduction and internal fixation were performed using intramedullary titanium elastic nails. Six months after the operation, bone union was achieved and the nails were removed.

OUTCOMES

Nine months after nail removal, the right leg was unexpectedly noticed 5 mm shorter than the left one. On the initial and follow-up bone single-photon emission computed tomography/computed tomography images with a 9-month interval, radioactivity of growth plate in the right proximal femur was much lower than that of the left femur, suggesting a further increasing of leg-length discrepancy (LLD) in the future. As we expected, LLD had progressively increased up to 20 mm. Epiphysiodesis was finally decided for the left distal femur. Twenty-two months after the length equalization operation, LLD decreased to 5 mm.

LESSONS

This case emphasizes that quantitative analysis of growth plate activity using bone single-photon emission computed tomography/computed tomography could predict LLD and help us decide when and which limb should be operated on for pediatric patients with lower limb fractures.

Plate fixation versus flexible intramedullary nails for management of closed femoral shaft fractures in the pediatric population: A systematic review and meta-analysis of the adverse outcomes

Purpose

Fractures of the femoral diaphysis are associated with a risk of morbidity in children. Various fixation methods have been developed, but with only limited evidence to support their use. This systematic review assesses the evidence regarding clinical outcomes of closed femoral diaphyseal fractures in children treated with plate fixation or flexible intramedullary nails.

Methods

A PROSPERO-registered, PRISMA-compliant systematic review and meta-analysis were conducted. MEDLINE, Embase, and Web of Science (WoS) databases were searched from inception to February 2023. Inclusion criteria included clinical studies reporting adverse outcomes following surgical treatment of pediatric closed femoral diaphyseal fractures using plate fixation and flexible intramedullary nails. The ROBINS-I and RoB 2 tools evaluated the risk of bias.

Results

Thirteen papers (2 prospective randomized controlled trials and 11 retrospective cohorts) reported 805 closed diaphyseal femoral fractures in 801 children (559 males, 242 females). There were 360 plate fixations and 445 flexible intramedullary nails. Two cases of osteomyelitis and one nonunion were reported. Meta-analysis showed that plate fixation had a lower risk of soft tissue infection (relative risk 0.26 (95% confidence interval 0.07-0.92)). There was no difference in the following outcomes: malunion (relative risk 0.68 (95% confidence interval 0.32-1.44)); unplanned reoperation (relative risk 0.59 (95% confidence interval 0.31-1.14)), and leg-length difference (relative risk 1.58 (95% confidence interval 0.66-3.77)). The risk of bias was high in all studies.

Conclusions

An analysis of 805 fractures with minimal differences in meta-analyses is considered high quality even when the quality of the evidence is low. The findings are limited by important flaws in the methodology in the published literature. Well-designed multicentre prospective studies using standardized core outcomes are required to advise treatment recommendations.

Level of evidence

III.

Efficacy of Different Volumes of 0.2% Ropivacaine in Suprainguinal Fascia Iliaca Compartment Block for Multimodal Analgesia in Lower Limb Surgery

Background Ultrasound-guided (USG) suprainguinal fascia iliaca (SIFI) block is being used widely for post-operative analgesia in patients undergoing hip and femur surgeries. However, the optimal volume of local anesthetic required for SIFI block is not well defined. Thus, we compared different volumes of 0.2% ropivacaine in SIFI for post-operative pain relief in lower limb surgeries. Material and methods A total of 90 patients undergoing hip and femur surgeries were randomly allocated into three groups: A, B, and C, who received USG SIFI block with 20 mL, 30 mL, and 40 mL of 0.2% ropivacaine, respectively. Intravenous tramadol was used as rescue analgesia when the numeric rating scale (NRS) score exceeded 3. Time to first request of rescue analgesic was the primary outcome. NRS scores in the first 24 hours post-operatively, total amount of tramadol consumption in 24 hours, and patient satisfaction with pain management were secondary outcomes. Results The time to first request to rescue analgesic was significantly longer in group B and group C as compared to group A. NRS scores were significantly reduced in group B and group C than group A in the 24-hour post-operative period. Median 24-hour tramadol consumption was significantly less in group C as compared to group A and group B. Patient satisfaction with pain management was better with group B and group C as compared to group A. Conclusion In comparison to 20 mL of 0.2% ropivacaine, 30 mL and 40 mL of 0.2% ropivacaine in SIFI compartment block are more efficacious in reducing post-operative pain after hip and lower limb surgeries.

A double-blind, randomised, placebo-controlled trial comparing intrathecal bupivacaine with bupivacaine plus morphine to reduce delirium in patients with hip fractures-Salmon-Mind trial study protocol

Background

Surgical treatment of proximal femur fractures is complicated by postoperative delirium in about one-third of patients. Pain and opioid consumption are modifiable factors that may influence the incidence of delirium.1 An intrathecal injection of morphine may lead to a reduction in postoperative pain and reduced systemic opioid consumption. In current practice, the addition of morphine to intrathecal anaesthesia is commonly used but depends on the anaesthesiologist's preference. Recently, a retrospective study found that intrathecal morphine was independently associated with a lower incidence of delirium. However, this has to be confirmed in a prospective, randomised study. We hypothesise that using intrathecal morphine reduces postoperative pain and opioid consumption during the first 48 h after surgery and reduces the incidence of delirium during hospital admission. We also seek additional evidence of the association between neuronal injury (delirium) and neurofilament light in serum of patients with proximal femur fractures.

Objective

The primary objective is to compare the incidence of delirium. The secondary objectives are to compare pain scores, systemic opioid consumption, and (opioid-related) side-effects. The tertiary objective is to test the association between intrathecal morphine and neurofilament light as a marker of neuronal injury.

Study design

A double-blind, randomised, placebo-controlled intervention study is proposed.

Study population

All patients with a proximal femur fracture who are scheduled for surgery under spinal anaesthesia.

Intervention

The intervention is the addition of morphine 100 μg to the intrathecal injection for spinal anaesthesia. The intervention group will receive a mixture of bupivacaine 10 mg and morphine 100 μg. The control group will receive bupivacaine 10 mg.

Clinical trial registration

EU Clinical Trials Register: EudraCT number 2020-002143-27.

Suggestion of a Novel Classification Based on the Anatomical Region and Type of Bilateral Fatigue Femoral Fractures

Purpose: Bilateral fatigue femoral fractures (BFFF) represent an extremely rare clinical entity. The present study introduces a novel classification, in order to categorize the BFFFs and provide a thorough review of all these, so far in the literature, reported cases. Methods: The BFFF were classified taking into account the anatomical region of the femoral fracture; (fh): femoral head, (sc): sub-capital, (pt): peri-trochanteric, (st): sub-trochanteric, (s): shaft, (d): distal femur and the fracture type (complete or incomplete); type I: bilateral incomplete fractures, type II: unilateral incomplete fracture, and type III: bilateral complete fractures. Type III was further subdivided into type IIIA: bilateral non-displaced fractures, type IIIB: unilateral displaced fracture, and type IIIC: bilateral displaced fractures. Furthermore, a meticulous review of the PubMed and MEDLINE databases was conducted to locate all articles reporting these injuries. Results: A total of 38 patients (86.8% males), with a mean age of 25.3 years, suffering BFFFs were identified from the literature search. The mean time interval from symptoms' onset to diagnosis was 54 days. According to the proposed classification, 2.6% of the fractures were categorized as type I (h), 36.8% as type I (sc), 2.6% as type I(st/s), 7.9% as type I (s), 2.6% as type I (d), 5.4% as type II (fh), 26.3% as type II (sc), 2.6% as type IIIA (st), 2.6% as type IIIA (d), 5.4% as type IIIB (sc), 2.6% as type IIIB (d) and 2.6% as type IIIC (sc). Surgery was performed in 52.6%, while non-operative treatment was followed in 47.4% of the population. Regarding the fracture type, 75% of type I fractures were conservatively treated, while 91.7% and 66.6% of type II and III fractures were surgically treated. For patients treated conservatively, the mean time from diagnosis to return to previous status was 260 days, while for patients treated surgically, 343 days. Conclusions: BFFFs, although rare, may pose a diagnostic and therapeutic challenge. The present classification offers valuable information and may act as a guide for the management of these patients.

Impact of age on liver damage, inflammation, and molecular signaling pathways in response to femoral fracture and hemorrhage

Background

Trauma causes disability and mortality globally, leading to fractures and hemorrhagic shock. This can trigger an irregular inflammatory response that damages remote organs, including liver. Aging increases the susceptibility to dysregulated immune responses following trauma, raising the risk of organ damage, infections, and higher morbidity and mortality in elderly patients. This study investigates how aging affects liver inflammation and damage post-trauma.

Methods

24 male C57BL/6J mice were randomly divided into four groups. Twelve young (17-26 weeks) and 12 aged (64-72 weeks) mice were included. Mice further underwent either hemorrhagic shock (trauma/hemorrhage, TH), and femoral fracture (osteotomy) with external fixation (Fx) (THFx, n=6) or sham procedures (n=6). After 24 hours, mice were sacrificed. Liver injury and apoptosis were evaluated using hematoxylin-eosin staining and activated caspase-3 immunostaining. CXCL1 and infiltrating polymorphonuclear leukocytes (PMNL) in the liver were assessed by immunostaining, and concentrations of CXCL1, TNF, IL-1β, and IL-10 in the liver tissue were determined by ELISA. Gene expression of Tnf, Cxcl1, Il-1β, and Cxcl2 in the liver tissue was determined by qRT-PCR. Finally, western blot was used to determine protein expression levels of IκBα, Akt, and their phosphorylated forms.

Results

THFx caused liver damage and increased presence of active caspase-3-positive cells compared to the corresponding sham group. THFx aged group had more severe liver injury than the young group. CXCL1 and PMNL levels were significantly higher in both aged groups, and THFx caused a greater increase in CXCL and PMNL levels in aged compared to the young group. Pro-inflammatory TNF and IL-1β levels were elevated in aged groups, further intensified by THFx. Anti-inflammatory IL-10 levels were lower in aged groups. Tnf and Cxcl1 gene expression was enhanced in the aged sham group. Phosphorylation ratio of IκBα was significantly increased in the aged sham group versus young sham group. THFx-induced IκBα phosphorylation in the young group was significantly reduced in the aged THFx group. Akt phosphorylation was significantly reduced in the THFx aged group compared to the THFx young group.

Conclusion

The findings indicate that aging may lead to increased vulnerability to liver injury and inflammation following trauma due to dysregulated immune responses.

Using a Traction Table for Fracture Reduction during Minimally Invasive Plate Osteosynthesis (MIPO) of Distal Femoral Fractures Provides Anatomical Alignment

INTRODUCTION

Fracture reduction and fixation of distal femur fractures are technically demanding. Postoperative malalignment is still commonly reported after minimally invasive plate osteosynthesis (MIPO). We evaluated the postoperative alignment after MIPO using a traction table with a dedicated femoral support.

METHODS

The study included 32 patients aged 65 years or older with distal femur fractures of all AO/OTA types 32 (c) and 33 (except 33 B3 and C3) and peri-implant fractures with stable implants. Internal fixation was achieved with MIPO using a bridge-plating construct. Bilateral computed tomography (CT) scans of the entire femur were performed postoperatively, and measurements of the uninjured contralateral side defined anatomical alignment. Due to incomplete CT scans or excessively distorted femoral anatomy, seven patients were excluded from analyses.

RESULTS

Fracture reduction and fixation on the traction table provided excellent postoperative alignment. Only one of the 25 patients had a rotational malalignment of more than 15° (18°).

CONCLUSIONS

The surgical setup for MIPO of distal femur fractures on a traction table with a dedicated femoral support facilitated reduction and fixation, resulting in a low rate of postoperative malalignment, despite a high rate of peri-implant fractures, and could be recommended for surgical treatment of distal femur fractures.

Bilateral femur fracture as the first manifestation of multiple myeloma: a case report

Abstract

The authors aimed to elaborate on an interesting clinical case of a subject that came to our attention following a low-energy traumatic event, producing a bilateral femur fracture. During the instrumental investigations, findings pointing to multiple myeloma were described, in fact later confirmed by the histological and biochemical investigations. In this specific case, unlike manifestations in most patients with MM, the classic correlated pathognomonic symptoms, such as lower back pain, weight loss, recurrent infections, asthenia, were not present. Furthermore, the inflammatory indices, the values of serum calcium, renal function and hemoglobin were completely normal, although numerous bone localizations of disease already coexisted, and these were all unknown to the patient.

Risk Factors and Preventive Strategies for Perioperative Distal Femoral Fracture in Patients Undergoing Total Knee Arthroplasty

Background and Objectives Perioperative distal femoral fracture is rare in patients undergoing total knee arthroplasty (TKA). In such rare cases, additional fixation might be required, and recovery can be delayed. Several studies have focused on perioperative distal femoral fractures in TKA, but there remains a lack of information on risk factors. The purpose of this study was to investigate risk factors for perioperative distal femoral fractures in patients undergoing TKA and suggest preventive strategies. Materials and Methods: This retrospective study included a total of 5364 TKA cases in a single institution from 2011 to 2022. Twenty-four distal femoral fractures occurred during TKA or within one month postoperatively (0.45%). Patient demographics, intraoperative findings, and postoperative progress were obtained from patient medical records and radiographs. Risk factors for fractures were analyzed using multivariate Firth logistic regression analysis. Results: Although all 24 distal femoral fractures occurred in female patients (24 of 4819 patients, 0.50%), the incidence rate of fracture between male and female patients was not significantly different (p = 0.165). The presence of osteoporosis and insertion of a polyethylene (PE) insert with knee dislocation were statistically significant risk factors (p = 0.009 and p = 0.046, respectively). However, multivariate logistic regression analysis showed that only osteoporosis with bone mineral density (BMD) < -2.8 (odds ratio (2.30), 95% CI (1.03-5.54), p = 0.043) was an independent risk factor for perioperative distal femoral fracture in TKA patients. Conclusions: Our results suggest that osteoporosis with BMD < -2.8 is a risk factor for distal femoral fractures in patients undergoing TKA. In these patients, careful bone cutting, adequate gap balancing, and especially the use of the sliding method for insertion of a PE insert are recommended as preventive strategies.

Investigation of taurine and aqueous garlic extract diet supplementation effect on the healing of rat osteoporotic fractures

BACKGROUND

We have evaluated the effects of taurine and aqueous garlic extract (AGE) as a dietary supplement on osteoporotic fracture (OPF) healing in the ovariectomized rat femur fracture model.

METHODS

In this experimental animal study,twenty-four osteoporosis-remodeled female Wistar albino rats were randomly divided into 3 groups (n: 8) according to their supplemented diet; control, taurine, and AGE groups. Unilateral femur middiaphysis mini-open osteotomy was stabilized with Kirschner wires. Six weeks after osteotomy, the rats were sacrificed before the femurs were harvested and OPF healing was evaluated with biochemical, histologic, microcomputed-tomography, and scintigraphic methods.

RESULTS

As an indicator of the antiosteoporotic effect, the calcium levels of the taurine group were significantly lower than the AGE and control groups in biochemical analyzes (p < 0.01). In histological studies, the new bone diameter and new bone volume values of the taurine group were significantly higher than the control group (p = 0.002 and p = 0.032, respectively), while higher trabecular-compact callus was observed in the taurine and AGE groups, respectively, compared to the control group. In morphological analyses, taurine and AGE groups had significantly higher bone volume/tissue volume, trabecular number, bone surface density, and lower trabecular separation than the control group (p < 0.05). The scintigraphic imaging showed a significant increase in osteoblastic activity of the taurine group compared to the control group (p = 0.005).

DISCUSSION

Taurine and AGE have positive anabolic effects, respectively, on the healing of OPFs, demonstrated by biochemical, histological, morphological, and scintigraphic methods.

Quality of Life and Post-Surgical Complications in Patients on Chronic Antiplatelet Therapy with Proximal Femur Fracture: 12-Month Follow-Up after Implementing a Strategy to Shorten the Time to Surgery

BACKGROUND

We evaluated a strategy to shorten the time from admission to surgery in patients with proximal femur fractures on chronic antiplatelet therapy. We reported a 12-month follow-up on complications and quality of life (QoL).

METHODS

Multicentre, open-label, randomized, parallel clinical trial. Patients were randomized to either early platelet function-guided surgery (experimental group) or delayed surgery (control group). Medical and surgical complications and QoL (EQ-5D-5L questionnaire) were assessed during the hospital stay, and after hospital discharge at 30 days, and 6 and 12 months.

RESULTS

From 156 randomized patients, 143 patients underwent surgery. The mean age was 85.5 (7.8) years and 68.0% were female. After hospital discharge, 5.7% of patients had surgical wound complications and 55.9% had medical complications, with 42.7% having serious adverse events. QoL improved significantly after surgery, with the best scores at the six-month follow-up. The overall mortality was 32.2%. There were no differences between early and delayed surgery groups in any assessed outcomes.

CONCLUSION

It seems safe to reduce the time of surgery under neuraxial anaesthesia in patients with hip fractures on chronic antiplatelet therapy by platelet function testing. QoL in particular improves in the first six months after surgery.

Bifidobacterium longum supplementation improves age-related delays in fracture repair

Age-related delays in bone repair remains an important clinical issue that can prolong pain and suffering. It is now well established that inflammation increases with aging and that this exacerbated inflammatory response can influence skeletal regeneration. Recently, simple dietary supplementation with beneficial probiotic bacteria has been shown to influence fracture repair in young mice. However, the contribution of the gut microbiota to age-related impairments in fracture healing remains unknown. Here, we sought to determine whether supplementation with a single beneficial probiotic species, Bifidobacterium longum (B. longum), would promote fracture repair in aged (18-month-old) female mice. We found that B. longum supplementation accelerated bony callus formation which improved mechanical properties of the fractured limb. We attribute these pro-regenerative effects of B. longum to preservation of intestinal barrier, dampened systemic inflammation, and maintenance of the microbiota community structure. Moreover, B. longum attenuated many of the fracture-induced systemic pathologies. Our study provides evidence that targeting the gut microbiota using simple dietary approaches can improve fracture healing outcomes and minimize systemic pathologies in the context of aging.

Operative challenges of intramedullary nailing for subtrochanteric blastic pathological femur fracture: a case report

Prostate adenocarcinoma metastasizes to bone and forms fragile blastic lesions, which can present as dense obstacles intraoperatively. There are limited reports on the challenges surgeons face when operating through these lesions. A 60-year-old male with a pathologic subtrochanteric femur fracture in the presence of blastic lesions was successfully treated with intramedullary (IM) fixation. Pathologic fractures from blastic bone lesions are expected to increase in prevalence as survivability improves for metastatic prostate cancer. Orthopedic surgeons, when performing IM fixation for these fractures, should be prepared to utilize accessory equipment and should adopt creative techniques for reduction and fixation.

The current issues and challenges in the management of floating knee injury: a retrospective study

Purpose

The management of floating knee injuries is still controversial and challenging for trauma specialists. This study aims to evaluate the incidence of the floating knee in lower limb trauma, analyzing the challenges in its management, and factors affecting clinical outcomes.

Methods

In this mono-center retrospective study, 36 consecutive patients were included. All individuals were diagnosed with an ipsilateral fracture of the femur and tibia, managed surgically according to their fracture pattern (Fraser classification), and the severity of the injury. The timing for each operation was determined based on the general condition of the patient and the local physiological condition of soft tissues. The patients' clinical outcomes were finally evaluated based on their Karlstrom and Olerud scores and were categorized as excellent, good, acceptable, fair, or poor.

Results

In this study, the mean follow-up period was 51.39 ± 16.02 months (11-130 months). Incidence of the floating knee was 2.32% in all lower limb traumas. From this number, 16 patients suffered from floating knee injury in the left lower extremity, and 18 in the right lower limb, while in 2 patients the condition was bilateral. The most common injury mechanism was road traffic accidents, accounting for 28 (77.78%) cases. The outcome was as follows; Excellent to good results in 22 (61.11%) cases, acceptable results in 2 (5.56%) cases, and fair to poor results in 12 (33.33%) cases according to the Karlström-Olerud scoring system. The most frequent early complications were wound infection and deep venous thrombosis in 5 (13.88%) of the cases. The most common late complication was common peroneal nerve palsy recorded in 2 (5.56%) cases.

Conclusion

The presence of important concomitant injuries to the floating knee together with poor soft tissue conditions constituted important factors influencing possible management options and may have led to poorer clinical outcomes.

Does obesity affect diaphyseal femoral fracture healing treated with intramedullary locking nail?

OBJECTIVES

This study aims to evaluate the effect of obesity on radiological fracture union in diaphyseal femoral fractures (DFFs) treated with intramedullary nailing (IMN).

PATIENTS AND METHODS

Between January 2017 and December 2018, a total of 120 patients (101 males, 19 females; mean age: 35.1±3.0 years; range, 18 to 72 years) treated with IMN for closed DFFs were retrospectively analyzed. Data including age, sex, location, weight, height, comorbidities such as diabetes mellitus, hypertension or kidney injury, date of injury, mechanism of injury, type of femoral fractures (AO classification), date of surgery, duration of surgery, IMN length and diameter used, date of radiological fracture union and complications of surgery such as nonunion, delayed union, and infections were recorded.

RESULTS

Of the patients, 63 had obesity and 57 did not have obesity. There was a statistically significant difference in fracture configuration among patients with obesity; they sustained type B (p=0.001) and type C (p=0.024), the most severe fracture configuration. The nonunion rate was 45%. Obesity had a significant relationship with fracture nonunion with patients with obesity having the highest number of nonunion rates (n=40, 74.1%) compared to those without obesity (n=14, 25.9%) (p=0.001). Fracture union was observed within the first 180 days in 78.9% of patients without obesity, while it developed in the same time interval in only 38.1% of patients with obesity (p=0.001).

CONCLUSION

Fracture union time for the patients with obesity was longer, regardless of the fracture configuration. Obesity strongly affects fracture union time in DFFs treated with an IMN. Obesity should be considered a relative risk in decision-making in the choice of fixation while treating midshaft femoral fractures.

Cellular activation status in femoral shaft fracture hematoma following different reaming techniques - A large animal model

The local inflammatory impact of different reaming protocols in intramedullary nailing has been sparsely investigated. We examined the effect of different reaming protocols on fracture hematoma (FH) immunological characteristics in pigs. To do so, a standardized midshaft femur fracture was induced in adult male pigs. Fractures were treated with conventional reamed femoral nailing (group RFN, n = 6); unreamed femoral nailing (group UFN, n = 6); reaming with a Reamer Irrigator Aspirator device (group RIA, n = 12). Animals were observed for 6 h and FH was collected. FH-cell apoptosis and neutrophil receptor expression (Mac-1/CD11b and FcγRIII/CD16) were studied by flow cytometry and local temperature changes were analyzed. The study demonstrates that apoptosis-rates of FH-immune cells were significantly lower in group RIA (3.50 ± 0.53%) when compared with non-RIA groups: (group UFN 12.50 ± 5.22%, p = 0.028 UFN vs. RIA), (group RFN 13.30 ± 3.18%, p < 0.001, RFN vs. RIA). Further, RIA-FH showed lower neutrophil CD11b/CD16 expression when compared with RFN (mean difference of 43.0% median fluorescence intensity (MFI), p = 0.02; and mean difference of 35.3% MFI, p = 0.04, respectively). Finally, RIA induced a transient local hypothermia and hypothermia negatively correlated with both FH-immune cell apoptosis and neutrophil activation. In conclusion, immunologic changes observed in FH appear to be modified by certain reaming techniques. Irrigation during reaming was associated with transient local hypothermia, decreased apoptosis, and reduced neutrophil activation. Further study is warranted to examine whether the rinsing effect of RIA, specific tissue removal by reaming, or thermal effects predominantly determine local inflammatory changes during reaming.

Preliminary Evidence on the Effectiveness of a Multidisciplinary Nutritional Support for Older People with Femur Fracture at an Orthogeriatric Unit in Spain

To describe the nutritional and functional changes that occurred in older patients with a femur fracture following a dietary intervention and oral nutritional support implemented at an orthogeriatric unit in Aragon, Spain. Open-label, prospective study. Patients were consecutively recruited and arranged into three groups based on their CONtrolling NUTritional (CONUT^®) score and nutritional needs. Nutritional status was assessed while in hospital, and at 45-, 100- and 180-days post-hospital discharge. One hundred and sixty-nine patients [mean age: 86 years (SD ± 5.48)] were recruited (July 2017 to January 2020). At admission, 53.3% were at risk of malnutrition; 26.6% were malnourished; 20.1% were well-nourished. Variable proportions of malnourished patients at admission were well-nourished 45-, 100-, and 180-days post-discharge. CONUT^® and Barthel index correlations showed that as nutritional status enhanced, patients gained functionality. Dietary interventions and nutritional support may help restoring the nutritional and functional status of older patients with a femur fracture.

Mortality in COVID-19 patients after proximal femur fracture surgery: a systematic review and meta-analysis

BACKGROUND

COVID-19 infection first emerged in December 2019 in China and has since rapidly spread to become a worldwide pandemic. Orthopaedic surgery suffered a significant decline in the volume of surgical cases, while the orthopaedic trauma services maintained or increased the activity. Emergency operations for proximal femur fractures (PFF) in the elderly population assumed levels comparable to before the pandemic, with the 1-year mortality rate ranging from 14% to 36%.

AIMS

To determine whether patients with PFF affected by COVID-19 have a higher risk of postoperative mortality through a systematic review and meta-analysis.

METHODS

PubMed, Web of Science, Scopus and BMC were searched from January 2020 to January 2021 to identify original studies reporting the mortality in COVID-19 patients after PFF surgery. Study and participants' characteristics, mortality rate and odds ratio (OR) were extracted. Risk of bias assessment was carried, and visual inspection of the funnel plot was used to assess publication bias. A random-effects model for meta-analysis was adopted.

RESULTS

Among 656 articles that came from the search query and hand-search, 10 articles were eligible after applying inclusion and exclusion criteria. Overall, the sum of the study participants was 1882, with 351 COVID-19 positive patients (18.7%) and a total number of 117 deaths, with an overall mortality rate of 33.3%. The mortality rate of COVID-19 positive patients varied from 14.8% to 60% and was higher than of those without COVID-19, with OR ranging from 2.424 to 72.00. The inverse variance method showed an OR = 3.652. All studies showed a statistically significant p-value.

CONCLUSIONS

The postoperative mortality in hip fracture patients with concomitant COVID-19 was 3.65 times higher than the mortality in non-COVID patients. The currently available literature demonstrates that COVID-19 infection represents a substantial risk factor for postoperative mortality in the already susceptible hip fracture population.

AAHKS Best Podium Presentation Research Award: Femoral Perforation During Direct Anterior Approach Total Hip Arthroplasty: Incidence, Cohort Characteristics, and Management

BACKGROUND

Cortical perforation during femoral preparation is a recognized complication of total hip arthroplasty (THA) but the incidence, patient characteristics, management, and outcome have not been described for the direct anterior approach (DAA).

METHODS

A database query of all primary and conversion DAA THAs performed by a single surgeon from 2009 to 2021 was used to identify hips that sustained a recognized intraoperative femoral perforation. Radiographs were used to assess stem subsidence, Dorr femur type, and Canal Flare Index.

RESULTS

Among 3,973 THAs, 16 patients (0.4%) sustained perforations during broaching including 8 males and 8 females with a mean age at surgery of 65.6 (range 41-81) years and a mean body mass index of 31.0 (range 19.0-44.4). Two hips were converted to longer primary cementless stems to bypass the perforation. For the remaining 14, the broach was redirected and the same primary stem was implanted. Limited weight-bearing (6 patients) or protected weight-bearing as tolerated with a walker/cane (10 patients) was advised postoperatively. At a mean follow-up of 18.7 (range 4-105) months, all stems were stable with no fractures, subsidence, or revisions. Factors associated with perforation included difficulty with exposure (body mass index >40 or a contracture), measurable osteoporosis (Canal Flare Index <3.0), and abnormal proximal femoral anatomy due to prior trauma, retained hardware, or Perthes disease.

CONCLUSION

In this case series, isolated perforation of an otherwise intact femur during DAA was successfully managed with redirection of the broach, implantation of a primary stem that achieved axial/rotational stability, and protected weight-bearing.

LEVEL OF EVIDENCE

IV, Case Series.

Concomitant post-traumatic ocular and cerebral fat embolism syndrome and thrombotic pulmonary embolism: A case report

RATIONALE

Fat embolism syndrome (FES) is composed of a triad of symptoms, including respiratory distress, neurologic deficit, and petechiae. Respiratory distress usually presents first before the other symptoms. Thrombotic pulmonary embolism (TPE) is a differential diagnosis of FES. Trauma is a risk factor for both diseases; however, co-occurrence is rare.

PATIENT CONCERNS

A 35-year-old male patient presented with altered consciousness, focal neurologic deficit, and respiratory distress after a left femoral subtrochanteric fracture and subsequent open reduction and internal fixation with an intramedullary nail.

DIAGNOSIS

Computed tomography pulmonary angiography (CTPA) revealed lower pulmonary artery filling defects and ground-glass opacities in bilateral lung, indicating TPE and FES, respectively.

INTERVENTIONS

Heparin was initially added and subsequently switched to apixaban. The symptoms improved quickly without major bleeding complications.

LESSION SUBSECTIONS

Concomitant TPE and FES after trauma are rare and require different treatment approaches. Due to clinical similarities, prompt chest CTPA was advised to detect TPE that was treated with anticoagulant therapy instead of supportive care for FES.

Acute Intoxication With Alcohol Reduces Trauma-Induced Proinflammatory Response and Barrier Breakdown in the Lung via the Wnt/β-Catenin Signaling Pathway

Background

Trauma is the third leading cause of mortality worldwide. Upon admission, up to 50% of traumatized patients are acutely intoxicated with alcohol, which might lead to aberrant immune responses. An excessive and uncontrolled inflammatory response to injury is associated with damage to trauma-distant organs. We hypothesize that, along with inflammation-induced apoptosis, the activation of the Wnt/β-catenin signaling pathway would cause breakdown of the lung barrier and the development of lung injury after trauma. It remains unclear whether ethanol intoxication (EI) prior to trauma and hemorrhagic shock will attenuate inflammation and organ injury.

Methods

In this study, 14 male C57BL/6J mice were randomly assigned to two groups and exposed either to EtOH or to NaCl as a control by an oral gavage before receiving a femur fracture (Fx) and hemorrhagic shock, followed by resuscitation (THFx). Fourteen sham animals received either EtOH or NaCl and underwent surgical procedures without THFx induction. After 24 h, oil red O staining of fatty vacuoles in the liver was performed. Histological lung injury score (LIS) was assessed to analyze the trauma-induced RLI. Gene expression of Cxcl1, Il-1β, Muc5ac, Tnf, and Tnfrsf10b as well as CXCL1, IL-1β, and TNF protein levels in the lung tissue and bronchoalveolar lavage fluid were determined by RT-qPCR, ELISA, and immunohistological analyses. Infiltrating polymorphonuclear leukocytes (PMNLs) were examined via immunostaining. Apoptosis was detected by activated caspase-3 expression in the lung tissue. To confirm active Wnt signaling after trauma, gene expression of Wnt3a and its inhibitor sclerostin (Sost) was determined. Protein expression of A20 and RIPK4 as possible modulators of the Wnt signaling pathway was analyzed via immunofluorescence.

Results

Significant fatty changes in the liver confirmed the acute EI. Histopathology and decreased Muc5ac expression revealed an increased lung barrier breakdown and concomitant lung injury after THFx versus sham. EI prior trauma decreased lung injury. THFx increased not only the gene expression of pro-inflammatory markers but also the pulmonary infiltration with PMNL and apoptosis versus sham, while EI prior to THFx reduced those changes significantly. EI increased the THFx-reduced gene expression of Sost and reduced the THFx-induced expression of Wnt3a. While A20, RIPK4, and membranous β-catenin were significantly reduced after trauma, they were enhanced upon EI.

Conclusion

These findings suggest that acute EI alleviates the uncontrolled inflammatory response and lung barrier breakdown after trauma by suppressing the Wnt/β-catenin signaling pathway.

Use of the Locking Attachment Plate for Internal Fixation of Periprosthetic Femur Fractures

Introduction

The locking attachment plate (LAP) can be added to a locking compression plate (LCP) to allow the fixation of locking screws bicortically around a femoral implant. We aimed to examine surgical and fracture characteristics associated with healing for periprosthetic femur fractures (PPFFx) treated with constructs employing LAP fixation. We hypothesize that the addition of an LAP provides stable peri-implant fixation.

Materials &Methods

We retrospectively reviewed a consecutive series of 28 PPFFx surgically treated with LCP-LAP constructs by 4 surgeons from 2015-2020. Fractures were classified and grouped using the Vancouver Classification System and included 12 B1, 2 B2, 11 C fractures, and 3 fractures around other stemmed implants. Primary outcome measures included hardware failure such as screw pullout, broken screws, and plate fracture. Clinical complications including infection, non-union, malunion, and reoperation were recorded.

Results

No LAP failures, screw pullout, or broken screws were observed. Two fractured plates (7.1%) occurred in patients with Vancouver C fracture types. Overall complication rate was 17.9% and included 3 non-unions, 1 deep infection, and 1 implant loosening with painful hardware, each requiring reoperation. Differences were observed between unions and nonunions for total number of screws (12.4 vs 14.7, P = .005) and number of locking screws used (8.04 vs 11.3, P = .03).

Conclusion

The LAP provides adequate fixation and low failure rates where fixation is required around a well-fixed stem. When failures occur, it is from plate breakage and not due to failure of fixation at the area of plate-stem overlap.

Retrospective analysis of outcomes and complications after Korus hemiarthroplasty in elderly patients with neck femur fractures

BACKGROUND

Femoral neck fractures (FNF) is one of the most common traumatic events in elderly patients: the choice of an appropriate treatment is necessary to decrease the related mortality and to achieve the best possible outcomes. Nowadays, it is still debated whether or not to cement the stem in hemiarthroplasty and above all, which stem to use to best respect the integrity of the elderly bone.

METHODS

From January 2017 to December 2019, a bi-centric study utilizing prospectively collected databases of elderly patients with FNF treated with uncemented Korus stem hemiarthroplasty was performed. Patients were preoperatively classified according to ASA score. Patients' clinical and X-ray follow-up was at 1, 3, 6, 12 months. Harris Hip Score (HHS) was used for analysed clinical improvement. On the X-rays, we analysed iatrogenic fractures, osteolysis area and radiolucent lines in the stem region during follow up.

RESULTS

233 patients were identified. Median follow-up was 12 months. Over time, 51 patients died (21.88%). Mean age was 89,56 ± 6,25. 75 patients had ASA score of 2 (32.3%), 102 patients a score of 3 (43.7%), 56 an ASA score of 4 (24,0%). The main Harris hip score was 68,66 ± 8.53 at 1 month of follow-up, 71,74 ± 9.65 after 3 months, 72,50 ± 10.66 at 6 months and 75,61 ± 9.63 at 12 months control.

CONCLUSIONS

Hydroxyapatite coated stem with an accurate design guarantee early fixation, good clinical and radiographic results, low rate of re-intervention and mortality rate and a satisfying return to pre-injury activities.

Acetabular Migration of Lag Screw of Intramedullary Nail Used as Treatment for Intertrochanteric Fracture. Case Study

Most trochanteric fractures of the femur are classified as low-energy fractures as they are seen in people with decreased mechanical properties of bone tissue. The treatment is assumed to provide biomechanical fixation with the possibility of dynamization between bony fragments to stimulate the biological processes of bone union. The aim of the study was to analyze a complication presenting as migration of the cervical screw of an intra-medullary nail towards the hip joint acetabulum and present the therapeutic management of this complication. The case report concerned a 74-year-old patient with an AO/OTA type 31 A2.2 fracture of the trochanteric massif of the right femur treated with the Gamma3 intramedullary nail. An assessment of changes over time of the radiological appearances on A-P images after the surgery showed migration of the cervical screw towards the acetabulum and displacement of the major trochanter fracture. Extensive destruction of the acetabular fossa made biologic restorative treatment impossible. A total hip joint prosthesis with a modular stem and MDM articulation was implan-ted and the trochanter was fixed with a &quot;hook&quot; plate with a &quot;cable system&quot;. The postoperative course was uneventful. Failure to perform axial radiographs in the preoperative and postoperative period made it impossible to objectively determine the type of fracture and the quality of screw insertion into the femoral neck, and assessment limited to A-P images turned out to be deceptive. The wandering of the screw towards the acetabulum led to extensive destruction of the acetabular fossa. The decision to stop biological treatment, which, if properly performed, stimulates bone union, and perform the mechanical procedure of endoprosthesoplasty was fully prognostically justified. The early and late postoperative course was not complicated.

Early Surgery with Neuraxial Anaesthesia in Patients on Chronic Antiplatelet Therapy with a Proximal Femur Fracture: Multicentric Randomised Clinical Trial

Background: Patients with proximal femur fracture on antiplatelet treatment benefit from early surgery. Our goal was to perform early surgery under neuraxial anaesthesia when indicated by the platelet function test. Methods: We conducted a multicentre randomised open-label parallel clinical trial. Patients were randomised to either early platelet function-guided surgery (experimental group) or delayed surgery (control group). Early surgery was programmed when the functional platelet count (as measured by Plateletworks) was >80 × 10⁹/L. The primary outcome was the emergency admission-to-surgery interval. Secondary outcomes were platelet function, postoperative bleeding, medical and surgical complications, and mortality. Results: A total of 156 patients were randomised, with 78 in each group, with a mean (SD) age of 85.96 (7.9) years, and 67.8% being female. The median (IQR) time to surgery was 2.3 (1.5–3.7) days for the experimental group and 4.9 (4.4–5.6) days for the control group. One-third of patients did not achieve the threshold functional platelet count on the first day of admission, requiring more than one test. There was no difference in clinical outcomes between groups. Conclusions: A strategy individualised according to the platelet function test shortens the time to proximal femur fracture surgery under neuraxial anaesthesia in patients on chronic antiplatelet treatment. Better powered randomised clinical trials are needed to further evaluate the clinical impact and safety of this strategy.

Minimally Invasive Internal Fixation of Femoral Shaft Fractures-A Biomechanical Study with a Disruptive Technique

(1) Background: In polytrauma patients, femur fractures are usually stabilised by external fixation for damage control, later being treated with definitive plate or nail osteosynthesis. Screw/rod systems established in spinal surgery might be inserted for internal fixation, providing sufficient fracture stability that subsequent intervention is unnecessary. This was to be investigated biomechanically. (2) Methods: The unilaterally applied spinal internal fixator (IF) was subjected to load and deformation analysis on artificial femurs with 32-A3 fracture according to AO classification. Distance of screws to fracture and rod to cortical bone were analysed as parameters influenced surgically as stiffness and deformation of the treated fracture. In addition, the stability of another construct with a second screw/rod system was determined. The axial load in stance phase during walking was simulated. The results were compared against an established fixed-angle plate osteosynthesis (IP). (3) Results: There were no implant failures in the form of fractures, avulsions or deformations. All unilateral IF combinations were inferior to IP in terms of stability and stiffness. The bilateral construct with two screw/rod systems achieved biomechanical properties comparable to IP. 4) Conclusion: Biomechanically, a biplanar screw/rod system is suitable for definitive fracture stabilisation of the femur, despite a damage control approach.

The Initial Economic Burden of Femur Fractures on Informal Caregivers in Dar es Salaam, Tanzania

Background

Femur fracture patients require significant in-hospital care. The burden incurred by caregivers of such patients amplifies the direct costs of these injuries and remains unquantified.

Aim

Here we aim to establish the in-hospital economic burden faced by informal caregivers of femur fracture patients.

Methods

70 unique caregivers for 46 femoral shaft fracture patients were interviewed. Incurred economic burden was determined by the Human Capital Approach, using standardized income data to quantify productivity loss (in $USD). Linear regression assessed the relationship between caregiver burden and patient time-in-hospital.

Results

The average economic burden incurred was $149, 9% of a caregiver's annual income and positively correlated with patient time in hospital (p<0.01).

Conclusion

Caregivers of patients treated operatively for femur fractures lost a large portion of their annual income, and this loss increased with patient time in hospital. These indirect costs of femur fracture treatment constitute an important component of the total injury burden.

Weight-bearing status may influence rates of radiographic healing following reamed, intramedullary fixation of diaphyseal femur fractures

Objective

To investigate the effect of weight-bearing status on radiographic healing of diaphyseal femur fractures.

Design

Retrospective 1:1 matched cohort study.

Setting

Single-level 1 trauma center.

Participants

One-hundred forty-four (N = 154) patients matched 1:1 in non-weight bearing (NWB) and weight-bearing as tolerated (WBAT) groups.

Intervention

Non-weight bearing following reamed, statically locked intramedullary fixation of diaphyseal femur fracture, generally due to concurrent lower extremity fracture.

Main Outcome Measurement

Postoperative radiographic healing using modified Radiographic Union Scale for Tibia fractures (mRUST) scores.

Results

Groups were well matched on age, sex, race, prevalence of tobacco and alcohol use, diabetes mellitus status, Injury Severity Score, fracture pattern and shaft location, vascular injury, open fracture prevalence, and operative characteristics. Radiographic follow-up was similar between groups (231 vs 228 days, P = .914). At 6 to 8 weeks status post intramedullary fixation, the median mRUST score in the NWB group (9) was lower than that of the WBAT group (10) (mean: 8.4 vs 9.7, P = .004). At 12 to 16 weeks, the median mRUST in the NWB group (10) was again lower than the WBAT group (12) (mean: 9.9 vs 11.7, P = .003). The median number of days to 3 cortices of bridging callous was 85 in the WBAT group, compared with 122 in the NWB group (P = .029). Median time to mRUST scores of 12 (111 vs 162 days, P = .008), 13 (218 vs 278 days, P = .023), and 14 (255 vs 320 days, P = .028) were all longer in the NWB group compared with the WBAT group.

Conclusions

Non-weight bearing after intramedullary fixation of diaphyseal femur fractures delays radiographic healing, with median time to 3 cortices of bridging callous increased from 85 days in WBAT groups to 122 days in NWB groups. These results provide clinicians with an understanding of the expected postoperative course, as well as further support the need to expeditiously advance weight-bearing status.Level of Evidence: IV.

Radiographic outcomes of femur fractures following SIGN Fin nailing in low- and middle-income countries

Objective:

To measure the effectiveness of the Surgical Implant Generation Network (SIGN) Fin nail for achieving satisfactory postoperative radiographic alignment following femoral shaft fractures.

Methods:

Femoral shaft fractures stabilized with the SIGN Fin nail were identified using the SIGN Online Surgical Database. A random number generator was used to identify 500 femur fractures fixed within 6 weeks of injury for which postoperative radiographs were available. Fractures were classified using OTA/AO and Winquist-Hansen classification systems. Deviation from anatomic alignment was measured on anterior-posterior and lateral radiographs using an on-screen protractor tool. Other clinical variables recorded in the SIGN Online Surgical Database were also analyzed. Simple logistic regression was used to assess for associations between subject and surgical characteristics and misalignment status. Intra- and inter-rater agreement was assessed with intraclass correlation coefficient (ICC).

Results:

The overall rate of malalignment >5° was 9.4%. Factors associated with increased incidence of malalignment include older age, increased time to surgery, distal diaphyseal location, closed (vs open) reduction, degree of comminution, and fracture classification. Intra-rater ICC was 0.70 (0.52, 0.82) in the coronal plane and 0.55 (0.32, 0.72) in the sagittal plane. Inter-rater ICC was 0.37 (0.08, 0.60) and 0.32 (0.05, 0.54), respectively.

Conclusion:

The SIGN Fin nail is an effective implant for fixation of femoral shaft fractures in resource-limited regions, achieving rates of satisfactory postoperative alignment comparable to that of the standard SIGN nail as well as femoral shaft fractures treated in North American Trauma Centers. Further research is required to investigate rotational alignment and long-term clinical outcomes for the SIGN Fin nail.

Level of evidence:

IV.

Benefit of continued noninvasive cardiac monitoring in geriatric trauma: A retrospective review of geriatric pelvis, hip, and femur fractures and analysis of cardiac events during immediate post-traumatic course

Objective

The geriatric population suffers from a predisposition to cardiac events due to physiologic changes commonly associated with aging. The majority of the trauma population seen at our facility is within the geriatric population (greater than 65 years old). Therefore, this study was aimed to determine which of those preexisting factors were associated with an increased risk for developing cardiac event. By assessing those risks, we hoped to determine a timeline for the highest risk of cardiac event occurrence, in order to identify a safe period of when cardiac monitoring was indicated.

Methods

A retrospective study performed over 6 months reviewing geriatric trauma patients with hip, pelvis, or femur fractures, n = 125. A list of predetermined risk factors including comorbidities, pathologies, laboratory values, electrocardiogram findings, and surgery was crossed with the patient's records in order to identify factors for increased risk of cardiac event. Once patients who had documented cardiac events were identified, a temporal pattern of cardiac event occurrence was analyzed in order to determine a period when noninvasive cardiac monitoring should remain in place.

Results

In 125 patients, 40 cardiac events occurred in 30 patients. The analyzed variables with statistically significant associations for having a cardiac event were comorbidities (p = 0.019), elevated body mass index (p = 0.001), abnormal initial phosphorus (p = 0.002), and an electrocardiogram finding of other than normal sinus rhythm (p = 0.020). Of the identified cardiac events, we found that by hospital day 3 68% of cardiac event had occurred, with 85% by hospital day 4, 95% by day 5, and 100% within the first 7 days of admission.

Conclusion

Patient history of cardiac comorbidities, elevated body mass index, abnormal phosphorus, and abnormal electrocardiogram findings were found to be significant risk factors for cardiac event development in geriatric trauma. All recorded events in our study occurred within 7 days of the initial trauma.

The Effect of Waterpipe Tobacco Smoking on Bone Healing Following Femoral Fractures in Male Rats

Background: Given the increasing use of waterpipe tobacco smoking in the world and its unknown effects on bone healing, this study investigated the repairing of femoral bone fractures in rats exposed to waterpipe tobacco smoking (WTS).

Main Methods: This study involved 40 male Wistar rats that were divided into two groups, including the femoral fracture (Fx) and the Fx + WTS groups. Each group was divided into two subgroups that were evaluated for bone healing 28 and 42 days after femoral fracture. After fixing the fractured femur, the healing process was evaluated by radiography, pathological indicators, and a measurement of the blood levels of vascular endothelial growth factor (VEGF), parathyroid hormone (PTH), Ca ++, transforming growth factor-beta (TGF-β), and insulin-like growth factor 1 (IGF-1). Additionally, the density of VEGF and CD34 in fracture tissue was investigated by immunohistochemistry.

Key Findings: Radiographic findings showed that factors related to the earlier stages of bone healing had higher scores in the Fx + WTS28 and 42 subgroups in comparison to the Fx groups. The density of VEGF and CD34 showed that the angiogenesis processes were different in the bone fracture area and callus tissue in the Fx +WTS subgroups. The serum levels of VEGF, TGF-β, and IGF-1 were significantly lower in the Fx +WTS42 group, and PTH in the Fx +WTS28 group was higher than that in the other groups.

Significance: The findings showed the disturbance and delay in the femoral fracture union in rats exposed to hookah smoke. This is partly due to the reduction of molecular stimuli of bone synthesis and the attenuation of quantitative angiogenesis.

Variations in Cost and Readmissions of Patients in the Bundled Payment for Care Improvement Bundle for Hip and Femur Fractures

Introduction

The Bundled Payment for Care Improvement (BPCI) for hip and femur fractures is an effort to increase care quality and coordination at a lower cost. The bundle includes all patients undergoing an operative fixation of a hip or femur fracture (diagnosis-related group codes 480-482). This study aims to investigate variance in the hospital cost and readmission rates for patients within the bundle.

Materials and Methods

The study is a retrospective analysis of patients ≥65 years old billed for a diagnosis-related groups 480-482 in 2016 in the National Readmission Database. Cost of admission and length of stay were compared between patients who were or were not readmitted. Regression analysis was used to determine the effects of the primary procedure code and anatomical location of the femur fracture on costs, length of stay, and readmission rates.

Results

Patients that were readmitted within 90 days of surgery had an increased cost on initial admission ($18,427 vs $16,844, P < .0001), and an increased length of stay (6.24 vs 5.42, P < .0001). When stratified by procedure, patients varied in readmission rates (20.7% vs 19.6% vs 21.8%), initial cost, and length of stay (LOS). Stratification by anatomical location also led to variation in readmission rates (20.7% vs 18.3% vs 20.6%), initial cost, and LOS.

Conclusion

The hip and femur fractures bundle includes a great number of procedures with variance in cost, readmission, and length of stay. This amount of variation may make standardization difficult and may put the hospital at potential financial risk.

Effect of Individual Nutrition Therapy and Exercise Regime on Gait Speed, Physical Function, Strength and Balance, Body Composition, Energy and Protein, in Injured, Vulnerable Elderly: A Multisite Randomized Controlled Trial (INTERACTIVE)

It is imperative that the surgical treatment of hip fractures is followed up with rehabilitation to enhance recovery and quality of life. This randomized controlled trial aimed to determine if an individualised, combined exercise–nutrition intervention significantly improved health outcomes in older adults, after proximal femoral fracture. We commenced the community extended therapy while in hospital, within two weeks post-surgery. The primary outcome was gait speed and secondary outcomes included physical function, strength and balance, body composition, energy and protein intake. Eighty-six and 89 participants were randomized into six months individualised exercise and nutrition intervention and attention-control groups, respectively. There were no statistically significant differences in gait speed between the groups at six and 12 months. There were no major differences between groups with respect to the secondary outcomes, except estimated energy and protein intake. This may be explained by the sample size achieved. Participants in the intervention group had greater increment in energy (235 kcal; 95% CI, 95 to 375; p = 0.01) and protein intake (9.1 g; 95% CI, 1.5 to 16.8; p = 0.02), compared with those in the control group at six months but not significant at 12 months. This study has demonstrated that providing early, combined exercise and nutrition therapy can improve dietary energy and protein intake in older adults with hip fractures.

Incidence of Fat Embolism Syndrome in Femur Fractures and Its Associated Risk Factors over Time-A Systematic Review

BACKGROUND

Fat embolism (FE) continues to be mentioned as a substantial complication following acute femur fractures. The aim of this systematic review was to test the hypotheses that the incidence of fat embolism syndrome (FES) has decreased since its description and that specific injury patterns predispose to its development.

MATERIALS AND METHODS

Data Sources: MEDLINE, Embase, PubMed, and Cochrane Central Register of Controlled Trials databases were searched for articles from 1 January 1960 to 31 December 2019.

STUDY SELECTION

Original articles that provide information on the rate of FES, associated femoral injury patterns, and therapeutic and diagnostic recommendations were included.

DATA EXTRACTION

Two authors independently extracted data using a predesigned form.

STATISTICS

Three different periods were separated based on the diagnostic and treatment changes: Group 1: 1 January 1960-12 December 1979, Group 2: 1 January 1980-1 December 1999, and Group 3: 1 January 2000-31 December 2019, chi-square test, χ² test for group comparisons of categorical variables, p-value < 0.05.

RESULTS

Fifteen articles were included (n = 3095 patients). The incidence of FES decreased over time (Group 1: 7.9%, Group 2: 4.8%, and Group 3: 1.7% (p < 0.001)). FES rate according to injury pattern: unilateral high-energy fractures (2.9%) had a significantly lower FES rate than pathological fractures (3.3%) and bilateral high-energy fractures (4.6%) (p < 0.001).

CONCLUSIONS

There has been a significant decrease in the incidence of FES over time. The injury pattern impacts the frequency of FES. The diagnostic and therapeutic approach to FES remains highly heterogenic to this day.

Patterns, Management, and Outcome of Traumatic Femur Fracture: Exploring the Experience of the Only Level 1 Trauma Center in Qatar

Background: Femur is the most fractured long bone in the body that often necessitates surgical fixation; however, data on the impact of the mechanism of injury (MOI), age, and timing of intervention are lacking in our region of the Arab Middle East. We aimed to describe the patterns, management, and outcome of traumatic femoral shaft fractures. Methods: A retrospective descriptive observational study was conducted for all trauma patients admitted with femoral shaft fractures between January 2012 and December 2015 at the only level 1 trauma center and tertiary hospital in the country. Data were analyzed and compared according to the time to intervention (intramedullary nailing; IMN), MOI, and age groups. Main outcomes included in-hospital complications and mortality. Results: A total of 605 hospitalized cases with femur fractures were reviewed. The mean age was 30.7 ± 16.2 years. The majority of fractures were unilateral (96.7%) and 91% were closed fractures. Three-fourths of fractures were treated by reamed intramedullary nailing (rIMN), antegrade in 80%. The pyriform fossa nails were used in 71.6% while trochanteric entry nails were used in 28.4%. Forty-five (8.9%) fractures were treated with an external fixator, 37 (6.1%) had conservative management. Traffic-related injuries occurred more in patients aged 14–30 years, whereas fall-related injuries were significantly higher in patients aged 31–59. Thirty-one patients (7.8%) had rIMN in less than 6 h post-injury, 106 (25.5%) had rIMN after 6–12 h and 267 (66.8%) had rIMN after more than 12 h. The implant type, duration of surgery, DVT prophylaxis, in-hospital complications, and mortality were comparable among the three treatment groups. Conclusions: In our center, the frequency of femoral fracture was 11%, and it mainly affected severely injured young males due to traffic-related collisions or falls. Further multicenter studies are needed to set a consensus for an appropriate management of femur fracture based on the MOI, location, and timing of injury.

Rare popliteal mass following retrograde nailing of ballistic femur fracture: a case report

Introduction:

Civilian ballistic injuries are commonly associated with fracture, vascular injury, and soft tissue trauma. Posttraumatic pseudoaneurysms represent an extremely rare subset of vascular injuries following ballistic fractures.

Case:

We present the rare case of a posttraumatic pseudoaneurysm that occurred after retrograde femoral nailing of a ballistic distal femur fracture. The patient presented in clinic postoperatively with a pulsatile popliteal mass. Distal pulses were intact but subsequent ultrasound and angiography revealed a pseudoaneurysm of the distal superficial femoral artery. The pseudoaneurysm was subsequently treated with a covered stent and the patient's recovery was uncomplicated.

Conclusion:

Due to the potential life and limb-threating complications from pseudoaneurysm rupture, this case report emphasizes the early recognition and expeditious management of vascular complications following ballistic fractures in the civilian population.

Segmental Defect-Bridging Intramedullary Knee Arthrodesis for Osseous Hydatidosis of the Distal Femur: A Case Report

Hydatid cyst is a condition endemic to many parts of the world and is mainly caused by Echinococcus granulosus (E. granulosus). It rarely affects the bone tissue, with the most commonly impacted sites being the vertebrae and the pelvis. Preoperative diagnosis is challenging and very rarely possible because of its similarities with other pathologies. In this report, we present the case of a 64-year-old patient with osseous hydatidosis of a pathological distal femur fracture. The fracture pattern was not recognized on the initial operation and multiple serial debridements were required to control the disease, leading to a large bone defect and a weakened extensor mechanism. A knee arthrodesis with a segmental defect-bridging intramedullary system was eventually performed, which led to satisfying outcomes.

Osseous hydatidosis very often presents itself as a pathological fracture and is difficult to diagnose preoperatively with plain radiographs. Orthopedic surgeons are advised to maintain a high index of suspicion and to test for this disease when cystic bone lesions are detected at fracture sites, especially in patients from endemic regions.

Femur Shaft Fracture in Newborns: A Report of Two Cases

Birth injuries caused by trauma during the childbirth process are very rare. They are a cause of significant neonatal morbidity despite improved obstetric and perinatal care, particularly in developing countries. Our current research, consisting of two newborns with a femur fracture, aims to shed light on their treatment strategy.

Post-Mortem Diagnosis and Autopsy Findings in SARS-CoV-2 Infection: Forensic Case Series

Towards the end of 2019, a novel coronavirus was identified as the culprit for a cluster of pneumonia cases in Wuhan, China. Since then, it has rapidly spread worldwide, affecting more than 43 million people, and in March 2020, the World Health Organization (WHO) declared it a pandemic. The purpose of the study is to present the findings of 15 forensic autopsies performed in Romania, on SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) positive subjects, and to present the case of one SARS-CoV-2 infected patient who experienced a violent death, as established during their autopsy. A total of 11 male and 4 female patients were autopsied, and SARS-CoV-2 infection was diagnosed post-mortem in two cases. The most frequent symptoms before death were dry cough, dyspnoea, and fever. Hypertension, ischemic cardiac disease, and a history of stroke were the most frequent associated diseases. The mean duration from the symptoms' debut to a RT-PCR positive SARS-CoV-2 test was 3.7 days, while the mean survival time from the RT-PCR positive test was 4.2 days. A histological examination was performed in seven cases and revealed, in most of them, hyaline membranes, and mixed inflammatory cell infiltration of the interstitium, alveoli, and perivascular areas. In addition, all of the examined cases developed small vessel thrombosis. A case of violent death was also reported, regarding a 87-year-old male subject who suffered a femur fracture (domestic fall) and was diagnosed with SARS-CoV-2 infection the following day after surgery. After transfer to a COVID-19 (coronavirus disease-19) support hospital, during an episode of behavioral disorder, the patient jumped from the first floor window. Death occurred a few days later, and the cause was established as bronchopneumonia superimposed on SARS-CoV-2 infection. In conclusion, autopsies should be conducted while providing a safe environment for professionals to perform them, because they are crucial procedures that can help gain a better understanding of the role of SARS-CoV-2 infection in thanatogenesis.

Investigation of femur fracture potential in common pediatric falls using finite element analysis

A finite element (FE) model of an 11-month-old child's femur was developed to evaluate fracture risk in short-distance feet-first falls and bed falls. Pediatric material properties were applied to the FE model. Femur loading was derived from previously conducted fall experiments using a child surrogate where fall conditions (e.g., fall height, impact surface) were varied. Fracture thresholds based on principal stress and strain were used to examine potential for fracture. Peak stress/strain were significantly greater for feet-first falls from greater heights and onto harder impact surfaces. Feet-first falls exceeded some, but not all fracture thresholds. Bed falls did not exceed any fracture thresholds.

Oral Carbohydrate Administration in Patients Undergoing Cephalomedullary Nailing for Proximal Femur Fractures: An Analysis of Clinical Outcomes and Patient Satisfaction

Purpose:

The purpose of this study was to investigate the clinical effects of oral carbohydrate intake for cephalomedullary nailing on proximal femoral fractures and patient satisfaction.

Subjects and Methods:

88 patients were admitted to our hospital with proximal femoral fracture from July 2019 to December 2019. All patients were treated with closed reduction and internal fixation (CR&IF, Cephalomedullary nailing) under spinal anesthesia. The exclusion criteria included the presence of endocrine disorders including diabetes mellitus (DM), patients treated with steroids, and cognitive impairment. Additionally, those with fasting blood glucose levels above 126 mg / dl or HbA1C> 6.5% were considered as having undiagnosed DM. After obtaining informed consent, the subjects were randomized into either the preoperative oral carbohydrate (POC) group or control group. Patients who were assembled into the control group fasted including water from midnight of the day of the surgical procedure according to the conventional method. Patients assembled into the POC group received 400 ml of oral carbohydrate solution (Nucare NONPO, DAESANG, 12.8%, 1 kcal/ml)) between 21-24 hours on the day before operation and 400 ml oral carbohydrate solution 2 hours before the administration of anesthesia. Serum glucose on the day before operation at 7 am (before breakfast, baseline), immediately before anesthesia, at skin incision, 1 hour, 4 hours, 6 hours, 24 hours after anesthesia, and 3 days after surgery (before breakfast) was measured, and insulin, cortisol, and IL-6 were measured at baseline 7 am at day before operation, immediately before anesthesia, 4 hours and 24 hours after anesthesia, and 3 days after surgery (before breakfast). The patients completed questionnaires about their satisfaction (thirst, hunger, nausea and vomiting, and anxiety) in the morning (before the surgery) on the day of the surgery. Additionally, the length of hospital stay (LOS) and preoperative opioid usage was also investigated.

Results:

The operative characteristics of the patients did not differ between the groups except for the actual fasting time. The glucose levels were higher in the control group at skin incision; however, there were no significant differences in both groups at other time points. Additionally, insulin, insulin resistance, cortisol, and IL-6 also did not differ significantly between the 2 groups at all time-points. Among the factors related to patient satisfaction, the POC group showed significantly higher scores for thirst and hunger factors and shorter LOS than the control group.

Conclusion:

The intake of oral carbohydrates in patients treated with closed reduction and internal fixation for proximal femoral fractures does not affect the improvement of post-operative insulin resistance. However, there was significant improvement in patients’ thirst and hunger before surgery and LOS.

Impact of intraoperative femoral fractures in primary hip arthroplasty: a comparative study with a mid-term follow-up

BACKGROUND

Intraoperative femoral fractures (IFF) during primary total hip arthroplasty (THA) pose a major clinical challenge, and data on mid-term implant performance, functional outcome and patient satisfaction is limited.

METHODS

50 patients who sustained IFFs during primary THA were retrospectively reviewed. A control group of patients who received a primary THA without complications was matched according to gender, age, body mass index and indication for THA. Both groups were followed-up for a minimum duration of 2 years. Average follow-up duration was 5.6 years (range 2-11.8 years) for the fracture group and 6 years (range 4.1-8.3 years) for the control group respectively. The following parameters were assessed and compared: stem revision, Harris Hip Score improvement, pain scale improvement, WOMAC, Tegner Score, UCLA, SF-36, forgotten joint score and patient satisfaction.

RESULTS

There were no stem revisions in the fracture group and 1 stem revision in the control group. Stem survival was 100% and 98.1% respectively (p = 0.447). The mean improvement in Harris hip score was 35.3 and 44.8 respectively. Significantly lower Harris Hip score improvement (p = 0.021) and patient satisfaction (p = 0.01) were observed in the fracture group. All other acquired parameters did not show significant differences.

CONCLUSION

Intraoperative fractures of the proximal femur are a relevant complication that does not lead to higher revision rates but might worsen the functional outcome and negatively impact patient satisfaction in mid-term follow-up even if treated appropriately.

Clinical and Radiological Outcomes After Surgical Treatment of Lower Limb Fractures in Patients With Spinal Cord Injury

STUDY DESIGN

Retrospective observational study.

OBJECTIVES

To analyze the clinical and radiological outcomes of lower limb fractures following surgical treatment in patients with chronic spinal cord injury (SCI).

METHODS

Between January 2003 and December 2015, 102 chronic SCI patients with a lower limb fracture were surgically treated at our hospital. A total of 58 patients met the inclusion criteria and were recruited for final analysis. Patients with 2-stage procedure or incomplete clinical records with lost-to-follow-up were excluded from the study. Patients were divided into 2 groups (group 1= internal fixation; group 2 = external fixation). Primary outcome measures were to identify the number of nonunions via Kaplan-Meier analysis and the time to bone consolidation. The diagnosis of a pseudarthrosis was made after more than 180 days of consolidation time. Considering the Kaplan-Meier analysis, pseudarthrosis was interpreted as treatment failure. Secondary outcome measure was to evaluate the complication rate with special focus on heterotopic ossification.

RESULTS

A total of 58 chronic SCI patients with closed bone fractures were included in this study. Fifty-two fractures (88%) were simple and 7 (12%) were complex (type C) fractures according to AO classification. The majority of patients (34 cases, 59%) developed femur fractures followed by 24 tibial fractures (41%). Seventeen patients received an external (29%) and 41 an internal fixation (71%). Bone consolidation was reported in 31 patients (53%) with a mean time interval of bone consolidation after 97 days (range from 45 to 160 days; SD = 30). The reported nonunion (pseudarthrosis) rate was 47%. Comparing the internal group (n = 15 patients) versus the external group (n = 14), we could not find any significant difference (P = .939) concerning the bone consolidation time. The Kaplan-Meier analysis showed a 75% cumulative survivorship at 120 days (internal group) versus 111 days (external group). Most common postoperative complications occurred in the internal fixation group with Wound infections being predominantly observed (10%), followed by heterotopic ossifications (8%).

CONCLUSIONS

Our results show that surgical treatment of lower limb fractures in chronic SCI patients is a challenging treatment with a high pseudarthrosis rate in both groups. The complication rate seems to be lower in the patients treated with external fixation. As a clinical recommendation, longer implants should be used for a stable osteosynthesis since SCI patients seem to have a higher load on the osteosynthesis material due to missing sensomotoric feedback.