Compression Nailing of Long Bones

Olecranon fractures are relatively common injuries, accounting for approximately 10% of upper extremity fractures in adults [26]. These fractures may result from a direct blow to the proximal ulna, or indirectly, via the forceful contraction of the triceps against resistance (typically, during a fall onto an outstretched hand). Less commonly, the olecranon may fracture when the elbow is hyperextended, as the bone is impacted against the olecranon fossa of the distal humerus. For unstable injuries, operative fixation typically is required. Even after recovery, loss of ROM is not uncommon. This article provides an overview of olecranon fractures in adults; therefore, discussion of olecranon fractures in skeletally immature patients is beyond the scope of this article.

Intramedullary fixation is the mainstay of treatment for femur fractures in the adult trauma population. With subtrochanteric fractures, accurate reduction and stable fixation become technically challenging. Adjuvant blocking screws in the proximal fragment can effectively be used to prevent varus and apex anterior malalignment when intramedullary nails are used in these fractures. Blocking screws decrease the canal volume, thereby allowing the intramedullary device to control the proximal segment. This aids in improving alignment between the proximal and distal fragments during reduction. We review the cases of six patients with proximal femur fractures who were treated with intramedullary nailing in conjunction with the placement of blocking screws.

Greater stability in intramedullary osteosynthesis using angle-stable fixation with intramedullary nails and proximal locking screws. A novel screw-and-sleeve system (ASLS®, Synthes GmbH, Oberdorf, Switzerland) is applied using normal cannulated nails. Decisions can be made intraoperatively. This technology widens the range of indications for intramedullary nailing: The smaller and less stable the fragment requiring fixation, the greater the indication for angular stable fixation of the proximal and/or distal fragment. Femoral, tibial and humeral fractures, intramedullary osteosynthesis in osteoporotic bone and ante- and retrograde nailing. Particularly in the case of retrograde nailing, sustained prevention of nail toggling is achieved. None. Drill with the first drill bit, which has the same core diameter as the screw shaft. Drill the cortex to the external diameter of the sleeve. Place the sleeve on the tip of the screw. The screw-sleeve combination is then advanced through the larger near hole until the sleeve-covered screw tip sits in the locking hole of the intramedullary fixation nail. Advance the screw. As the screw diameter becomes larger, the sleeve expands resulting in an angular stable locking effect. The screw is then advanced until the head of the screw sits on the exposed surface of the cortex. The hole is filled with the expanded part of the screw shaft beneath the screw head. The necessary 1-3 turns are cut by the self-tapping flute on the screw. According to experience to date, this form of angle-stable fixation enables earlier and/or greater partial mobilization or earlier full mobilization. In all other respects, the guidelines for aftercare in intramedullary nailing apply. A multi-center pilot study has shown the technique to be reproducible and simple. There have been no complications using this technique to date. Biomechanical laboratory studies have demonstrated that stability with respect to axial and torsional loading is statically and dynamically higher than with conventional nailing. Device failure occurs later. Further applications as well as results of a prospective randomised study currently under way will show how great the clinical advantages ultimately prove to be.

History Subtrochanteric fractures occur in the proximal region of the femur. Anatomically speaking, the subtrochanteric region of the femur is defined as the interval between the lesser trochanter and approximately 5 cm below it, toward the isthmus of the femur [1, 13]. Subtrochanteric fractures are relatively common, accounting for approximately 10% to 30% of all hip fractures [4, 16]. The subtrochanteric region is subject to tensile and compressive stressors that are substantially greater than the patient's body weight [11] as well as rotational and bending forces that directly influence the observed fracture patterns. These fractures commonly have short proximal fragments of comminution, which are pulled into flexion by the forces of the iliopsoas attaching on the lesser trochanter [9, 10]. Additionally, the comminution can be deformed into an abducted and externally rotated position as a result of the pull on the greater trochanter by the abductor muscles. This proximal abduction deformity can be further amplified as the distal fragment is pulled into an adducted position by the adductor's attachment on the femoral shaft [1, 13]. These muscular-deforming forces make avoiding varus, flexion, or external rotation fracture malreduction more difficult and challenge the fixation construct. Given the complexity of the fracture pattern and anatomy within this region, many fracture classifications have been developed to create a treatment algorithm for surgeons. Subtrochanteric fractures were initially thought to be a subset of comminuted intertrochanteric fractures. A study performed by Boyd and Griffin [3] in 1949 analyzed 300 trochanteric fractures, allowing the authors to develop a classification system based on prognosis and the perceived difficulty of fracture reduction. They divided trochanteric fractures into four designations. The first, Type I, designates a fracture with a linear break extending along the intertrochanteric line from the greater to the lesser trochanter. Notably, with these fractures, the fracture is reduced and maintained in the most simple manner of those within this system [3]. A Type II fracture is comminuted with a fracture line in a similar orientation as Type I, but with points of comminution along the adjacent cortical bone. The reduction of these fractures rises in difficulty with the increasing degree of comminution. In the Boyd and Griffin classification, a Type III fracture is subtrochanteric and may have comminution. The authors noted that there may be elements of Type I and II fractures found within Type III fractures (intertrochanteric extension, cortical comminution, etc) and are accordingly the most difficult of the first three to reduce and fix. Finally, a Type IV fracture is comminuted and extends through the entire trochanteric region and usually into the diaphysis. Frequently there are fracture lines in at least two planes, and consequently fixation must be similarly oriented in two orientations [3]. Many years later, the Fielding classification, described by Dr Joseph William Fielding in 1973, was one of the first to describe fracture patterns within the subtrochanteric region. His classification focused predominantly on the anatomic location of the fracture with Type 1 fractures occurring at the lesser trochanter, Type 2 between 2.5 and 5 cm below the lesser trochanter, and Type 3 occurring 5 to 7.5 cm below the lesser trochanter [7, 8]. Although it was at the forefront of describing subtrochanteric fractures, the Fielding classification was limited as a result of its low reproducibility and its inability to describe more complex fracture patterns [1, 7, 8, 10]. In 1978, Dr Frank Seinsheimer III developed the Seinsheimer classification, a dedicated classification of subtrochanteric femur fractures that incorporated the number of fractured fragments as well as involvement of the medial or lateral cortex [1, 19]. At the time he noted that mechanical failure of pertrochanteric femur fracture fixation often exceeded 20%. Even so, few except Magliato and Fielding had presented a classification system of proximal femur fractures that attempted to describe morphology patterns that contributed to this higher incidence of treatment failure [19]. To have been included in his study, part of the fracture plane must lie between two horizontal lines: (1) at the level of the inferior aspect of the lesser trochanter; and (2) another line 5 cm below that. Notably, as a result of these parameters, this classification system included intertrochanteric femur fractures with distal extension as well as diaphyseal fractures with proximal extension provided that a fracture line crossed this zone. Fractures were classified based on postinjury radiographs and were divided into eight categories based on the number of major fragments, the shape of the fragments, and their location. The first, Type I fractures, are nondisplaced or had < 2 mm of displacement. Type II fractures are two-part fractures and are further subdivided into (II-A) transverse fractures; (II-B) spiral fractures with the lesser trochanter attached to the proximal segment; and (II-C) spiral fractures with the lesser trochanter attached to the distal segment. Type III fractures are three-part fractures and are subdivided into two subcategories: (IIIA) a spiral fracture with the lesser trochanter as part of a third fragment as well as an inferior spike of cortex; and (IIIB) a spiral fracture of the proximal one-third of the femur with the third fragment consisting of a butterfly fragment. Type IV fractures are comminuted fractures with four or more fragments. Finally, Type V fractures are any subtrochanteric fractures with extension through the greater trochanter. Through this work, Seinsheimer concludes that Type IIIA fractures have the highest incidence of fixation failure [19]. Although descriptive, the Seinsheimer classification offered little guidance on what treatment approach to use for a given fracture [1, 19]. In 1992, Dr Thomas Russell and Dr John Charles Taylor published their classification system to describe subtrochanteric fractures. The Russell-Taylor classification accounts for involvement of the fracture within the piriformis fossa and its extension into the lesser trochanter [1, 18]. The aim of this classification was to guide surgeons in treating the injury and to assist with implant selection, which differed from other, established subtrochanteric fracture classifications [1, 18]. By underscoring the unique anatomy of the proximal femur, particularly the extension of the fracture plane into the greater trochanter (lateral wall) or the presence of stability in the lesser trochanteric region (medial cortex), this descriptive schema identifies four different fracture morphologic patterns and was developed to provide the surgeon with direction in determining the proper modality of surgical fixation [5]. All in all, there are > 15 described classification schemas for fractures of the subtrochanteric region [1, 15]. Many classification systems were generated based on the anatomic location of fractures, number of fractured fragments, degree of comminution, or simply on the perceived stability of the fracture pattern [1]. Of these, the Russell-Taylor classification was one of the first to incorporate treatment options for surgeons and has proven useful in identifying the presence or absence of disruption of the lesser trochanter (medial calcar) and the greater trochanter (piriformis fossa). Although there is no predominantly accepted classification scheme for this fracture pattern, the system described by Russell and Taylor is used fairly often in the orthopaedic community as a result of its simplicity and emphasis on surgical planning and treatment [2, 11, 20, 23]. Because this classification system remains one of the most recognizable and routinely used for subtrochanteric fractures, the purpose of this article is to investigate and critically analyze the Russell-Taylor classification and its effectiveness and use in orthopaedic surgery today, particularly as a tool to guide the identification of stable or unstable fracture patterns and to predict the need for reoperation in the perioperative period [9, 17, 23]. Purpose The aim of this classification was to guide surgeons in determining the integrity of the proximal fragment and whether plating or intramedullary nailing would be the ideal mode of fixation [18]. First, the classification identified whether the piriformis fossa was disrupted and, second, evaluated the extent of lesser trochanter involvement (Fig. 1) [12]. This information was felt to be critical in deciding whether to use a standard locking intramedullary nail that extended from the greater to the lesser trochanter or to perform reconstruction nailing with a cephalomedullary device [11, 18, 20, 22]. One reason the integrity of the piriformis fossa was highlighted in this system was the previously held belief that fractures disrupting the piriformis fossa may benefit from plating rather than nailing; surgeons were concerned that fixation of the proximal fragment would be lost with use of a piriformis starting point in these situations [1, 11, 18]. As a result of disruption of the piriformis fossa, like in Type 2 fractures, Russell et al. suggested that hip screw implants were a superior option, rather than intramedullary devices, when the fracture pattern involved the piriformis fossa (Types 2-A and 2-B) [9, 10, 13]. However, with more advanced nailing techniques through the greater trochanter, the nail "falling out of the back" of the proximal fragment has become less problematic [11, 18] and ultimately diminished the utility of the Russell-Taylor classification system [1, 11, 18].Fig. 1: This image describes the four types of fractures described by the Russell-Taylor classification system. Type 1-A fractures describe fractures that do not involve the piriformis fossa. Type 1-B fractures do not involve the piriformis fossa but do involve the lesser trochanter. Type 2-A describes fractures through the piriformis fossa but not involving the lesser trochanter. Type 2-B are fractures involving both the lesser trochanter and piriformis fossa [14, 18]. Reprinted with permission from N. G. Lasanianos and N. K Kanakaris et al. [10].Classification Type 1: Fractures not involving the piriformis fossa of the femur. Subdivided into: Type 1-A: Fractures that extend below the lesser trochanter of the femur; and Type 1-B: Fractures that involve the lesser trochanter of the femur. Type 2: Fractures that do involve the piriformis fossa of the femur. Subdivided into: Type 2-A: Fracture patterns with a stable medial buttress; and Type 2-B: Fracture patterns with no medial femoral cortex stability. Validation There are multiple classification systems that have been developed to describe subtrochanteric fractures [1, 15]. Two studies have analyzed the inter- and intraobserver reliability of the Russell-Taylor classification system: Guyver et al. [10] and Imerci et al. [12]. Guyver et al. [10] analyzed various subtrochanteric descriptive classifications, one of which was the Russell-Taylor classification system. In this study, four observers analyzed 32 subtrochanteric fractures and compared the reliability of the classification system. The observers were asked to evaluate the same fracture patterns on two separate occasions to assess intraobserver reliability [7]. Their study concluded that the mean κ value for interobserver reliability and intraobserver reliability was κ = 0.35 (fair) and κ = 0.25 (fair), respectively. However, the study by Imerci et al. [12] had an alternative conclusion. Their study utilized 35 patients with subtrochanteric fractures that were classified 6 weeks apart by 16 observers, eight of whom were specialists and eight of whom were assistants [12]. Imerci et al. [12] concluded that there was substantial agreement regarding interobserver reliability of the specialists with κ = 0.695 and 0.754 on first and second evaluations, respectively. Similarly, there was also substantial agreement for the interobserver score of assistants with κ values of 0.695 and 0.749 on their first and second evaluations, respectively, as well. Furthermore, the intraobserver reliability scores among specialists were determined as nearly perfect at 0.955 (range, 0.75-1.00) and 0.915 (range, 0.82-0.97) and 0.855 (range, 0.75-0.96) and 0.90 (range, 0.79-0.97) for the assistants. Based on the results by Guyver et al. [10], the Russell-Taylor classification's low inter- and intraobserver reliability would indicate that this system has a high risk of miscommunication, misdiagnosis, and erroneous surgical decision-making. In contrast, Imerci et al. [12] advocated that the Russell-Taylor classification was more reliable and reproducible than other classifications for subtrochanteric fractures analyzed in their study. Imerci et al. [12] stated that, as a result of a larger volume of images analyzed and more observers participating in evaluation, their study was more reliable than the Guyver et al. [10] study. Limitations According to Guyver et al. [10], the greatest limitation of the Russell-Taylor classification is that the intra- and interobserver reliability of this system is limited, typically in the range of "fair" or worse [10]. As noted, this means that the classification should be used with great care, if at all. However, Imerci et al.'s [12] results showed almost perfect repeatability and the interobserver reliability was substantial, encouraging the overall use of this classification system among surgeons. The stark contrast between these studies indicates that additional studies should be performed to better evaluate the descriptive capacity of the Russell-Taylor classification system. Regardless of the inter- and intraobserver reliability in identifying and describing these fractures, this classification system continues to have limited value with regard to treatment approach [1, 10]. As stated, the Russell-Taylor classification was created primarily to guide surgeons with surgical treatment. When the system was developed, fracture patterns that did not extend into the piriformis fossa (mainly Russell-Taylor Type 1 fractures) were best treated with intramedullary nailing, typically using a cephalomedullary nail with a piriformis entry point [15]. However, with newer orthopaedic implant designs and expanding surgical indications, most subtrochanteric fractures now are treated with intramedullary nails regardless of their Russell-Taylor classification, further limiting the system's utility [1, 10, 11, 14]. Although the Russell-Taylor classification's reproducibility and reliability are debated among authors, the addition of trochanteric-starting intramedullary nails have diminished this system's overall clinical relevance. Starr et al. [21] performed a randomized study that found no difference in outcome regarding a trochanteric versus piriformis fossa entry portal in fixation of this fracture pattern. They suggested that the quality of the fracture reduction was more important than whether the piriformis fossa was disrupted [21]. Another limitation of this classification system is that the degree of comminution is often not fully appreciated on radiographic imaging, especially in elderly patients with osteoporotic bone [23]. As such, intraoperative findings often reveal additional complexity to the injury, further complicating surgery. Finally, the lack of well-defined parameters encompassing the subtrochanteric anatomic region adds an element of vagueness to the already complex issue at hand. Loizou et al. [15] identified 15 different classification methods for subtrochanteric fractures with only eight classification systems defining which area of the bone was the subtrochanteric region. Although generally accepted as 5 cm distal to the lesser trochanter, Loizou et al. [15] found that there was no anatomic agreement among the different classifications on the distal border of the subtrochanteric region, particularly in those fractures that crossed anatomic boundaries [15]. Conclusion An ideal classification system needs to be reliable, reproducible, and able to accurately communicate between surgeons involved in care [3]. The Russell-Taylor classification, although not perfect with regard to reliability and reproducibility, remains one of the most widely known classifications for subtrochanteric femur fractures [2, 11, 20, 23]. With advancements in reduction techniques, nailing procedures, and improved versatility of implants, there is decreased clinical utility of the Russell-Taylor classification system. Although the classification system aids in describing the fracture's pattern, at this point, this system is of limited clinical relevance. Recognizing the variability in describing these fracture patterns, as concluded by Guyver et al. [10] and Imerci et al. [12], the authors of this study recommend caution while using the Russell-Taylor classification to describe fracture patterns. Furthermore, we recommend against its use to guide treatment of patients with subtrochanteric femur fractures. With such a commonly used classification system, additional studies must be done to resolve and conclude whether the reproducibility and reliability of this classification system are consistent and efficacious to maximize the potential to treat patients safely [2, 11, 20]. Given the complex nature of this fracture pattern and the detrimental effect on quality of life after injury, one can infer that an all-inclusive and fully descriptive classification system would also be equally complex [6]. Nonetheless, because of its historic significance to the study, orthopaedic trauma, and its relative familiarity, the Russell-Taylor classification may serve a role in describing the initial fracture pattern, even as the advent of trochanteric starting intramedullary nails and advanced orthopaedic implants have limited its clinical relevance.

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Femoral fractures are bone fracture involve femur, common injuries in adults. Intramedullary femoral nailing system is the recommended solution or treatment for fractures due to its high union rates.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; In this clinical inspection 30 patients were selected with bone fracture of femur, and treated by using intramedullary femoral nailing system (universal intramedullary cannulated femoral nail, expert femoral nail, gamma nail and retrograde femoral nail) manufactured by Auxein Medical Private Limited, Sonepat, Haryana, India. There are two types of patients used in this study, one is male (n=18) and another female (n=12). Patients physical fitness was also observed through American Society of Anesthesiologist.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Outcomes record from the patients using visual analog scale. Follow up of the patients were taken on 1&lt;sup&gt;st&lt;/sup&gt; month, 6&lt;sup&gt;th&lt;/sup&gt; month, and 12 months. Post-operative outcomes were good with none of the patients showing non-union of fracture site. There were no complications noticed related to intramedullary femoral nailing system in this study and hardware related complications were not encountered in this study also.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Intramedullary nailing system provide excellent outcomes with high union and low complication rates in the management of bone fracture involve femoral in patients.&lt;/p&gt;

Introduction: Humerus shaft fractures in adults can be managed conservatively with functional braces or operatively with plate osteosynthesis or with intramedullary nailing. Conventionally humerus intramedullary nailing is done either using humerus interlocking nails or Enders nails. In this study we analyse the outcome of humerus shaft fractures (upper and middle third) managed with closed ante-grade intramedullary titanium elastic nailing in terms of union rates, union time, functional results and complications.Materials and Methods: A retrospective analysis of 25 patients treated with ante-grade intramedullary titanium elastic nailing was done during the period of August 2014 to June 2016 at our tertiary care centre. Skeletally mature patients with closed and acute fractures of the upper and middle shaft humerus of both sexes were included in the study.Results: Twenty-five (100%) fractures united with an average consolidation time of 14.98 weeks (10-32 weeks), and no fractures ended in non-union. Nail impingement was seen in two (8%), shoulder stiffness in one (4%). Functional results were excellent in 22 (88%), moderate in two (8%) and poor in one (4%). There were 17 males and eight females with an average age of 39.08 years (range: 18-65 years). The average duration of hospital stay was 3.84±2.30 days.Conclusion: Closed ante-grade intramedullary titanium elastic nailing offers a safe and reliable method of fixing fractures of upper humeral shaft in adults. This method provides early fracture union, high union rates and less complications, in addition to early rehabilitation and reduces the hospital stay.

Translated article] Arthroscopic tibiotalocalcaneal arthrodesis. Technique, indications and results

The treatment of distal third tibial fractures being challenging, we read with great interest the article by Mohammed et al. “Intramedullary tibial nailing in distal third tibial fractures: distal locking screws and fracture non-union” [1]. Modern tibial nail designs have interlocking holes that enable distal placement of screws in close proximity to the tip of the nail. Three distal interlocking holes at 5, 15 and 25 mm, respectively, from the nail tip are common in current tibial nails. Also success of at least two interlocking screws in the distal fragment after removal of the distal tip of the traditional nail has been reported [2]. Screw failure and malalignment have been common problems reported in the literature following the use of a single interlocking screw in distal tibial fractures [3, 4]. Distal locking screws have less cortical purchase in metaphyseal bone; as control of the intramedullary nail position in the distal tibial canal depends on these screws, there is increased stress on the screws to maintain fracture alignment [4]. Consequently late complications, in particular loss of reduction, are attributed to implant failure at the distal locking sites of the intramedullary nail [4]. The study [1] however reported that 52% of the cases had only one distal locking bolt, which is against accepted principles. Also Mohammed et al. reported that 5 of 12 cases with a single distal screw treated for non-union had unreamed nailing. The unreamed interlocking nail screw system cannot be equated with reamed interlocking nails. Mosheiff et al. [5] reported that 22 of 52 patients with distal tibial metaphyseal fractures treated with unreamed nailing required secondary procedures (e.g. dynamisation, autogenous bone grafting, fibulectomy) to progress to union. Thus the use of unreamed nails may have been an important variable in the non-union cases. Designed as temporary implants, the unreamed nails can only bear a certain number of load cycles, significantly less than the locking screws of reamed nails. As a consequence, screw failure occurs frequently in unreamed nailing, especially on weight-bearing [6]. In spite of 46% of the cases in the study by Mohammed et al. having unreamed nailing, they had only one (0.9%) incidence of screw breakage. It would be helpful if the authors could detail the postoperative protocol and the method of supplementary protection used, if any, during mobilisation and ambulation in the two subsets of patients as these also influence the screw breakage and healing process.

Introduction: Extra-articular proximal tibial fractures, particularly AO/OTA 41-A2 patterns, are associated with a high risk of malalignment when treated with intramedullary nailing. Deforming forces acting on the short proximal fragment, most notably from the quadriceps mechanism, frequently result in sagittal plane malalignment with procurvatum. Although suprapatellar intramedullary nailing and adjunctive reduction techniques such as Poller screws have improved outcomes, maintaining reduction in selected cases remains challenging. The role of circumferential cerclage cables as a reduction-maintaining adjunct in this setting is not well described in the literature. Case Report: We present the case of a 29-year-old male who sustained an isolated AO/OTA 41-A2 extra-articular proximal tibial fracture following a motor vehicle accident. Definitive fixation was performed using a suprapatellar intramedullary tibial nail. Intra-operatively, the proximal fragment repeatedly displaced into extension during guidewire passage and reaming despite appropriate entry point selection and standard reduction manoeuvres. To address persistent sagittal plane instability, a circumferential cerclage cable was applied around the proximal tibial metaphysis and tensioned under fluoroscopic guidance. This successfully neutralized deforming forces and maintained reduction throughout nail insertion. Final imaging confirmed satisfactory alignment in both sagittal and coronal planes. Conclusion: Circumferential cerclage cable application may serve as a useful adjunct for maintaining reduction during suprapatellar intramedullary nailing of selected AO/OTA 41-A2 proximal tibial fractures with persistent proximal fragment extension. When applied judiciously, this technique may help prevent malalignment.

Our goal was to analyze the movement of acute scaphoid waist fracture fragments and adjacent bones in a common coordinate system. Our hypothesis was that the distal scaphoid fragment flexes and pronates and the proximal fragment extends. Computed tomography (CT) scans of patients diagnosed with an acute scaphoid waist fracture were evaluated using a 3-dimensional (3D) model. The scans of 57 nondisplaced and 23 displaced fractures were compared with a control group of 27 scans showing no pathological involvement of the wrist. Three anatomical landmarks were labeled on the distal and proximal fragments of the scaphoid, the lunate, and the trapezium. Each set of labels formed a triangle representing the bone or fragment. Four landmarks were labeled on the distal radial articular surface and used to create a common coordinate system. The position of each bone or fragment was calculated in reference to these coordinates. The displaced fracture group showed significant extension, supination, and volar translation of the proximal scaphoid fragment when compared with the other groups. The lunate tended toward a supinated position, which was not statistically significant. The distal scaphoid fragment and the trapezium showed no movement. In acute displaced scaphoid fractures, it is the proximal fragment that displaces and should be reduced. The typical "humpback" deformity is actually a "proximal extension" deformity, the consequence of displacement of the proximal fragment of the scaphoid (with the lunate). Manipulating only the proximal fragment (with the lunate) may be technically easier and more effective than manipulating both fragments.

The study aims to determine the effect of fibular fixation on alignment and fracture healing of tibia, and ankle functional outcomes in the treatment of distal third tibiofibular diaphyseal fractures. Consecutive 111 patients (33 females and 78 males) with distal third tibiofibular diaphyseal fracture who met the inclusion criteria were included in the study. Patients were divided into two groups as those who underwent fibular fixation with tibia intramedullary nailing (study group) and those who did not (control group). Groups were compared in terms of demographic features, trauma and fracture characteristics, functional and radiological outcomes. No significant difference was observed between the groups in terms of demographic features, trauma characteristics, complications, and follow-up time (p > 0.05). Surgery time was significantly lower in the control group (p = 0.001). Ankle joint range of motion, AOFAS score, OMAS score, and full weight-bearing time were significantly better in the fibular fixation group (p = 0.023, p = 0.001, p = 0.001 and p = 0.039, respectively). Significantly better coronal alignment and sagittal alignment were found in the fibular fixation group (p = 0.001 and p = 0.001, respectively). Patients who underwent fibular fixation had significantly better radiological outcomes in terms of fibular rotation angle and ankle arthrosis (p = 0.000 and p = 0.022, respectively). Fibular fixation not only contributes to fracture union, early full weight-bearing, and alignment but also improves ankle functional outcomes in the distal third tibiofibular fractures treated with intramedullary nailing for tibia. Level III, retrospective study.

Pathoanatomy of pertrochanteric fractures - a postmortem study

Femoral lengthening with an intramedullary nail inserted through a retrograde approach offers the unique benefit of accurate deformity correction and distraction osteogenesis without the need for external fixation with its inherent challenges. The key to a successful deformity correction and proper nail placement is preoperative planning. Insert 2 Steinmann pins or half-pins into the proximal and distal aspects of the femur to mark any rotational deformity that is being corrected or to ensure that no rotational deformity is created. The Steinmann pins need to be ≥3 mm in diameter to prevent bending with loss of rotational reference. We prefer 5-mm or 6-mm Schanz pins for this role. These sturdy pins may be used as a "joystick" for manipulating the distal fragment to achieve a correction. This step includes the approach to and reaming of the distal fragment, which is critical to the limb alignment. Perform the percutaneous osteotomy, which allows for correction of the deformity, prior to reaming the proximal segment. While holding the distal fragment in the reduced position, prepare the proximal fragment for nail insertion. Insert the nail in a standard fashion, avoiding excessive force that could damage it or jam it into the proximal fragment. Lock the nail from the distal or proximal end first. The femoral distractor helps to keep the rotation accurate during locking and helps to serve as a handle to obtain perfect overlapping circles of the locking screw site on fluoroscopy. However, the external fixator may be obstructive for distal locking in particular. The fixator can be removed for distal locking and reattached for proximal locking. Check the anteroposterior and lateral fluoroscopic images and decide how stable the nail is in the bone. Will the fragment shift into varus, valgus, or flexion? Mark the position and orientation of the magnet in the nail on the patient's skin to indicate where to place the external magnet for lengthening. Postoperative management involves nail distraction, venous thromboembolic (VTE) prophylaxis, and adherence to a specific weight-bearing protocol. Femoral lengthening with the remote-controlled magnetic intramedullary nail has had excellent clinical efficacy3.

Category:Midfoot/ForefootIntroduction/Purpose:There is still a controversy regarding the most optimal fixation instruments and bone graft materials for midfoot joint arthrodesis. We present the results of midfoot joint arthrodesis using compression plate highly porous β-tricalcium phosphate (β-TCP) and bone marrow aspirate concentrate (BMAC).Methods:We performed a retrospective review of patients undergoing midfoot joint arthrodesis using compression plate with lag screw augmenting with highly porous β - tricalcium phosphate (β - TCP) and bone marrow aspirate concentrate (BMAC) from January 2014 to May 2019. The radiographic bony union rate was investigated. Postoperative complications and reoperations were also noted. A total of 36 patients (37 feet) including 75 joints were available in this study.Results:A high bony union rate was achieved as of 97.3% in 73 out of 75 joints. Nonunion was seen in two patients including two joints: one for 1st TMT joint and the other for medial NC joint. There was no delayed union in this study. Time to radiographic union was 10.5 +- 1.9 (range, 7-15) weeks. A total of five postoperative complications were noted. All of them were related to hardware irritation, and all five patients underwent removal of hardware procedure. There was no major complication such as infection during the follow-up period. Of the two nonunion patients, only one with medial NC joint nonunion underwent a revision arthrodesis surgery.Conclusion:Based on our results, the fixation construct of compression plate with lag screw augmenting with highly porous β - tricalcium phosphate (β - TCP) and bone marrow aspirate concentrate (BMAC) is safe and effective for midfoot joint arthrodesis with an excellent union rate and a low complication rate.

Fractured Gamma nail