Search Results (9)

Background: Effective postoperative pain management is essential in femoral limb lengthening surgery. Although regional nerve blocks reduce pain and opioid use, their benefit in antegrade femoral intramedullary limb lengthening is unclear. This study compares postoperative pain and opioid consumption in patients receiving general anesthesia (GA) alone versus GA with a preoperative femoral or fascia iliaca nerve block. Methods: A retrospective review included 192 patients who underwent femoral lengthening with intramedullary telescoping nails between January 2012 and October 2023 at a single center. Patients were categorized into Group A (GA alone, n = 131) and Group B (GA plus nerve block, n = 61). Primary outcomes were postoperative mean and maximum pain scores in the first 24 h, total opioid pills prescribed at discharge, and total morphine milligram equivalents (MMEs) used in the Post-Anesthesia Care Unit (PACU). Non-inferiority was defined by a margin of one standard deviation for pain scores and opioid usage. Results: Demographics were similar between groups. Maximum PACU pain scores were 3.8 for Group A and 3.3 for Group B (p > 0.05); mean pain scores were 2.1 and 1.9, respectively (p > 0.05). GA alone was non-inferior for pain control. However, total opioid pills prescribed at discharge were higher in Group A (23.2) than Group B (10) (p < 0.05). PACU MME usage was also higher in Group A (26 vs. 18.4 ± 15 mg, p < 0.05), though non-inferiority criteria were met. Conclusions: GA alone is non-inferior to GA with nerve block for postoperative pain management following antegrade femoral intramedullary limb lengthening. Although patients without a nerve block received more opioids at discharge, their pain control remained similarly effective. Given potential risks and the lack of clear pain reduction benefits, routine nerve block use may not be warranted. Decisions regarding nerve block application should be individualized, considering patient preferences, surgeon recommendations, and anesthesiologist input. Full article

Background and Clinical Significance: Non-prosthetic peri-implant fractures (NPPIFs) are rare injuries occurring around internal fixation devices, and are distinct from periprosthetic fractures. While most studies focus on the femur, humeral NPPIFs remain poorly documented. This case illustrates a complex humeral NPPIF and highlights key surgical considerations. Case Presentation: A 62-year-old woman presented with a spiral humeral shaft fracture (AO 12B2) after a fall. Following closed reduction and antegrade intramedullary nailing, an intraoperative peri-implant fracture occurred at the distal interlocking screw. CT imaging revealed a complex fracture extending from the lateral condyle to the proximal humerus. Treatment included implant removal and open reduction with dual plate fixation—lateral distal and helically contoured proximal plates—plus cerclage bands and antibiotic-loaded beads. Recovery was uneventful, with a full range of motion achieved at six months. At one year, the DASH score and MEPS were 86 and 75, respectively. Conclusions: Humeral NPPIFs are challenging and require individualized, biomechanically sound strategies. This case reinforces the importance of intraoperative assessment and careful implant selection in humeral fracture management. Full article

Background: Glucocorticoids induce osteoporosis, while bisphosphonates treat it, yet both can lead to atypical femoral fractures. Patients on both agents may face challenges in healing from such fractures due to their pathophysiology and pharmacological effects. Methods: Intramedullary nail surgery was performed on 20 limbs in 19 patients with atypical femoral fractures and autoimmune diseases, who had received bisphosphonates for GC-induced osteoporosis. The average durations of glucocorticoid and bisphosphonate use were 17 and 9 years (standard deviation: 7.59 and 4.35), respectively, and the mean follow-up period was 66 months. Fifteen and five limbs were fractured at the subtrochanter and diaphysis, respectively. The surgical techniques (type of nail) and additional procedures performed in these cases were examined. The post-operative alignment and reduction status on radiographs were examined to determine their relationship with post-operative outcomes. Results: Cephalomedullary long nails were inserted in nine limbs and antegrade intramedullary nails in 11 limbs. As an additional surgical procedure, open reduction, bone grafting and drilling were carried out on six, two, and five limbs, respectively. Regarding malalignment on radiographs, AP images showed varus in four limbs, and lateral images showed extension in two limbs. Regarding the cortical discontinuity, the distal fragment of the 11th limb shifted posteriorly in the lateral view. Gaps at the fracture sites were observed in 11 limbs. As a result, bone union was confirmed in 13 limbs. Five of the seven nonunion limbs required additional surgery. When comparing union and nonunion, open reduction and drilling were involved in nonunion limbs. Conclusion: The surgical outcomes of atypical femoral fractures in patients with autoimmune disease and on long-term glucocorticoids and bisphosphonates were poor. Although it is not possible to affirm for sure based on these results alone, management with prophylactic surgery before complete fracture is considered to be required to improve outcomes. Full article

Background: Proximal humeral fractures (PHFs) are common injuries that can lead to significant functional impairment. This retrospective cohort study aimed to evaluate the clinical outcomes and complications associated with the use of the Targon PH+ (Fa. Aesculap, Germany) intramedullary nail for the treatment of PHFs. Methods: A subgroup consisting of 70 patients with a mean follow-up of 4.91 years out of 479 patients who underwent treatment with the Targon PH+ intramedullary nail for PHFs at a single center between 2014 and 2021 were included. Patient-reported outcome measures (PROMs) and health-related quality of life (HRQoL) were assessed using validated German versions of the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, American Shoulder and Elbow Surgeons (ASES) score, Oxford Shoulder Score (OSS), and EuroQol 5-Dimension 5-Level (EQ-5D-5L). Radiographic assessment was performed using pre- and postoperative imaging. Results: Among the 70 patients of the subgroup who completed follow-up, 21.4% experienced complications, including major complications in 15.7% of cases, all of which were revised (revision rate of 15.7%). Anatomical reduction was achieved in 48,5% of cases. The mean DASH, ASES, and OSS scores were 25.4 ± 22.0, 76.2 ± 21.1, and 38.8 ± 10.3, respectively. Significant correlations were observed among the PROMs, indicating their convergent validity. Additionally, a significant correlation of all used PROMs and patient well-being (HRQoL) was observed. Severe complications and revisions were associated with significantly lower ASES scores (−11.1%, p = 0.013). There was a tendency for PROM scores to slightly decline with increasing fracture complexity, although this trend did not reach statistical significance. Our findings indicate that patients over the age of 65 years tend to exhibit lower scores in PROMs and HRQoL measures. Conclusion: The use of the Targon PH+ intramedullary nail for the treatment of PHFs resulted in satisfactory clinical outcomes and acceptable complication and revision rates. The PROMs and HRQoL measures indicated varying levels of disability and symptoms, with major complications, revision surgery, and age negatively impacting shoulder function after midterm follow-up. Full article

Leg length discrepancies (LLD) are frequently associated with coronal malalignment. Temporary hemiepiphysiodesis (HED) is a well-established procedure for the correction of limb malalignment in skeletally immature patients. For treatment of LLD > 2 cm, lengthening with intramedullary devices gains increasing popularity. However, no studies have investigated the combined application of HED and intramedullary lengthening in skeletally immature patients. This retrospective single-center study evaluated the clinical and radiological outcomes of femoral lengthening with an antegrade intramedullary lengthening nail combined with temporary HED performed in 25 patients (14 females) between 2014 and 2019. Temporary HED through the implantation of flexible staples of the distal femur and/or proximal tibia was either performed prior (n = 11), simultaneously (n = 10) or subsequently (n = 4) to femoral lengthening. The mean follow-up period was 3.7 years (±1.4). The median initial LLD was 39.0 mm (35.0–45.0). Twenty-one patients (84%) presented valgus and four (16%) showed varus malalignment. Leg length equalization was achieved in 13 of the skeletally mature patients (62%). The median LLD of the eight patients with residual LLD > 10 mm at skeletal maturity was 15.5 mm (12.8–21.8). Limb realignment was observed in nine of seventeen skeletally mature patients (53%) in the valgus group, and in one of four patients (25%) in the varus group. Combining antegrade femoral lengthening and temporary HED is a viable option to correct LLD and coronal limb malalignment in skeletally immature patients; however, achieving limb length equalization and realignment may be difficult in cases of severe LLD and angular deformity, in particular. Full article

Antegrade intramedullary (IM) nailing is the gold standard treatment for femoral shaft fractures; however, the non-union rate of infra-isthmal femoral shaft fractures is still high after antegrade IM nailing. This retrospective case–control study aimed to determine the association between perioperative radiographic factors and the non-union of infra-isthmal femoral shaft fractures after antegrade IM nailing. Univariate and multivariate analyses were used to evaluate the radiographic risk factors of non-union. Ninety-three patients were included, with thirty-one non-unions and sixty-two matched controls between 2007 and 2017. All were regularly followed up for 2 years. Receiver operating characteristic analysis revealed that a ratio of the unfixed distal segment > 32.5% was strongly predictive of postoperative non-union. The risk factors for non-union were AO/OTA type B and C (odds ratio [OR]: 2.20), a smaller ratio of the distal fragment (OR: 4.05), a greater ratio of the unfixed distal segment (OR: 7.16), a higher ratio of IM canal diameter to nail size at the level of fracture (OR: 6.23), and fewer distal locking screws (OR: 2.31). The radiographic risk factors for non-union after antegrade IM nailing for infra-isthmal femoral shaft fractures were unstable fractures, shorter distal fragments, longer unfixed distal fragments, wider IM canal, and fewer distal locking screws. Surgeons must strive to avoid non-union with longer and larger nails and apply more distal locking screws, especially for unstable, wider IM canal, and shorter distal fragment fractures. Full article

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. Full article

Intramedullary lengthening, in cases of extensive humeral shortening, offers the advantages of preventing external-fixator-associated problems. The humeral cavity, as the main parameter in nailing, however, has been neglected in recent literature. It was hypothesized that available implants might be too large and therefore increase the risk of intraoperative fractures. The aim of this cross-sectional study was to describe the humeral canal and how it might affect the choice of implant and the surgical approach. Thirty humeri (15 female, 15 male) from clinical patients and anatomical specimens were studied. Specifically, the medullary cavity width (MCW), cortical thickness (CoT), and the course of the medullary canal were examined. The smallest MCW diameters were found at the distal third of the humeral shaft with mean diameters of 10.15 ± 1.96 mm. CoTs of female humeri were significantly smaller than those of male humeri (p < 0.001). The mean angles of the pro- and recurvatum were 4.01 ± 1.68° and 10.03 ± 2.25°, and the mean valgus bending was 3.37 ± 1.58°. Before implanting a straight lengthening nail into a doubly curved humerus, X-rays and, in selected cases, CT-scans should be performed. The unique size and course of the humeral canal favors an antegrade approach in cases of intramedullary lengthening. Full article

Background and objectives: Pediatric tibial shaft fractures often have satisfactory outcomes after closed reduction and casting. However, surgical treatment may be required in unstable or open fractures. Titanium elastic nails (TENs) are a good option for the surgical treatment of pediatric tibial fractures due to their advantages such as short hospitalization periods, easy applicability, early weight bearing, and early union. In this study, we evaluated radiological and functional outcomes in pediatric patients with tibial shaft fractures that underwent fixation with TENs. Materials and methods: A total of twenty tibial shaft fractures that were treated with TENs in our clinic between 2013 and 2017 were retrospectively reviewed. The mean age at injury was 8.9 ± 2.78 (range of 3–14) years. Seven (35%) out of 20 fractures were open fractures, of which one fracture was classified as Grade I and six fractures were classified as Grade II. In each patient, antegrade nailing was performed by inserting a TEN in the medial and another TEN in the lateral side of the proximal metaphysis. Clinical outcomes including union, alignment, leg-length inequality, and complications were evaluated using modified Flynn’s criteria. Results: The mean time to union was 10.85 ± 3.39 (range of 6–20) weeks. No patient had a sagittal or coronal angulation of over 10°. One patient had a leg-length inequality of 10 mm. Among three patients with open fractures, two of them had superficial wound infections and the other patient had a deep wound infection. All the infections were successfully treated with appropriate antibiotic therapies. Four other patients had pin tract irritation that required no intervention. No significant difference was observed between patients with open and closed fractures with regard to the clinical and radiological findings although patients with open fractures had a significantly higher complication rate compared to patients with closed fractures (p < 0.05). No patient had a restricted range of motion of the ankle and knee joints. Twelve (60%) patients had an excellent outcome, and eight (40%) patients had a satisfactory outcome. Conclusions: Intramedullary fixation with TENs provides favorable outcomes and reduced complication rates in the treatment of unstable pediatric tibial shaft fractures that cannot be reduced with conservative treatment modalities or cannot be casted due to the presence of an edema or open wound. Full article