Search Results (25)

Background/Objectives: Trochanteric femoral fractures pose significant surgical challenges, particularly in elderly patients. Intramedullary nailing (IMN) and plate fixation (PF) are the primary operative strategies, yet their comparative efficacy and safety remain debated. This meta-analysis synthesizes randomized controlled trials (RCTs) to evaluate clinical, functional, perioperative, and biomechanical outcomes of IMN versus PF specifically in trochanteric fractures. Methods: A systematic search of six databases was conducted up to 20 May 2024, to identify RCTs comparing IMN and PF in adult patients with trochanteric femoral fractures. Data extraction followed PRISMA guidelines, and outcomes were pooled using random-effects models. Subgroup analyses examined the influence of fracture stability, implant type, and patient age. Risk of bias was assessed using the Cochrane RoB 2.0 tool. Results: Fourteen RCTs (n = 4603 patients) were included. No significant differences were found in reoperation rates, union time, implant cut-out, or mortality. IMN was associated with significantly reduced operative time (MD = −5.18 min), fluoroscopy time (MD = −32.92 s), and perioperative blood loss (MD = −111.68 mL). It also had a lower risk of deep infection. Functional outcomes and anatomical results were comparable. Subgroup analyses revealed fracture stability and nail type significantly modified operative time, and compression screws were associated with higher reoperation rates than IMN. Conclusions: For trochanteric femoral fractures, IMN and PF yield comparable results for most clinical outcomes, with IMN offering some advantages in surgical efficiency and perioperative morbidity, though functional outcomes were comparable. Implant selection and fracture stability influence outcomes, supporting individualized surgical decision making. Full article

Intramedullary nailing (IMN) is the gold standard for fixing mid-shaft fractures of long bones, but distal locking remains a challenging procedure. This study aims to develop and evaluate a novel mixed reality (MR)-based surgical navigation system for distal locking of IMN through phantom experiments. Twelve bone models closely replicating the mechanical properties, anatomy, and density of human tibial bone were utilized. Six orthopedic surgeons participated in the phantom experiments using both MR and traditional electromagnetic (EM) navigation systems. Effectiveness was evaluated using postoperative fluoroscopic imaging and the time taken for distal locking. Compared to the EM navigation system, the MR system significantly reduced distal locking time (81.54 ± 6.06 vs. 132.67 ± 6.45 s per screw) and achieved a higher success rate (23/24 vs. 21/24 screws accurately placed), but the difference in terms of success rate is not statistically significant. The MR-based navigation system for distal locking of IMN is time-efficient, accurate, and shows high potential for enhancing surgical precision in orthopedic procedures. Full article

Intramedullary nails (IMNs) are the most frequent surgical fixation method for femur fractures. Although IMNs provide good healing outcomes and low complication rates, concerns persist regarding potential complications such as malunion, nonunion, and infections. This multicenter retrospective study aims to assess the epidemiology and outcomes of IMNs for diaphyseal femoral fractures. Data from 91 patients who underwent IMN fixation at two Brazilian hospitals between 2020 and 2024 were analyzed, with a mean age of 33.3 years (SD ± 12.7) and 76.9%% of male patients. Traffic accidents were the most common mechanism of trauma (84.61%). The bone healing rate was 96.7% within six months, and 98.9% within one year, with a complication rate of 3.26%, including two cases of pseudoarthrosis, one case of pseudoarthrosis and infection, and two reoperations. There was a significant association between previous external fixation and fracture type (open/closed) (χ²(1) = 17.5, p_Fischer < 0.001). Previous external fixation was also associated with lower consolidation rates six months post-surgery (χ²(1) = 9.83, p_Fischer = 0.031), but not after one year (χ²(1) = 8.19, p_Fischer = 0.11). The retrograde approach was associated with a lower consolidation rate after six months (χ²(1) = 6.98, p_Fischer = 0.027), but no significant association was found after one year (χ²(1) = 2.27, p_Fischer = 0.308). Only one patient with pseudoarthrosis did not consolidate after one year. The outcomes support the efficacy of IMNs in achieving bone consolidation with low complication rates. Full article

This retrospective study compares the clinical outcomes of the Minimally Invasive Reduction and Osteosynthesis System (MIROS) and intramedullary nailing (IMN) in treating isolated surgical neck fractures of the humerus. A total of 42 patients were included, with 18 treated using MIROS and 24 with IMN. The primary outcomes assessed were the complication rates, functional recovery (DASH score), pain levels (VAS), and radiological healing. The MIROS group exhibited a higher complication rate (22.2% vs. 8.8%), with K-wire migration and superficial infections being the most frequent. Patients treated with MIROS reported lower postoperative pain (VAS 45 ± 25.7) compared to the IMN group (VAS 58.1 ± 12.5). Both groups demonstrated radiological healing within three months, but one MIROS patient required reoperation due to hardware failure. No significant differences were observed in the DASH scores between the groups. Our findings suggest that IMN is a preferable treatment option for younger patients with good bone quality, while MIROS may still be beneficial for elderly patients with significant comorbidities, albeit with a higher risk of complications. Future prospective studies are recommended to confirm these findings. Full article

Background: Aseptic nonunion of femoral shafts after intramedullary nailing (IMN) can be a challenging condition that may lead to long-term disability and the need for multiple surgical procedures. This study compared the clinical and radiological outcomes between exchange nailing and augmentative plating with bone grafting. Methods: In this multicenter, prospective, single-blind, randomized controlled trial, patients with aseptic nonunion of the femoral shaft after IMN were randomly assigned to receive exchange nailing or augmentative plating. The primary outcomes measured were the time to bone union and union rate 12 months after revision surgery. The secondary outcomes included operative time, blood loss, hospitalization duration, pain level using the visual analog scale (VAS), knee range of motion (ROM), and complication rates. Results: The augmentative plating group had a significantly shorter mean time to union (5.39 ± 1.29 months) compared with the exchange nailing group (7.38 ± 1.97 months; p < 0.001). The union rates at 12 months were 100% in the augmentative plating group and 89.65% in the exchange nail group. Augmentative plating resulted in a shorter operation time (99.46 ± 11.08 min vs. 106.45 ± 12.22 min; p = 0.025) and reduced blood loss (514.79 ± 45.87 mL vs. 547.72 ± 54.35 mL; p = 0.016). Significant pain reduction was observed in the augmentative plating group, with preoperative VAS scores decreasing from 6.04 ± 2.28 to 2.64 ± 1.50, compared with a decrease from 5.66 ± 2.21 to 3.66 ± 2.19 in the exchange nailing group (p = 0.047). Knee ROM improved significantly in the augmentative plating group (p = 0.0176). The complication rate was lower in the augmentative plating group (3.57%) than in the exchange nail group (17.24%). Conclusions: Augmentative plating with autologous bone grafting is superior to exchange nailing for treating aseptic nonunion of femoral shafts. It is associated with faster healing, higher union rates, better clinical and functional outcomes, and fewer complications. We recommend this technique as the preferred treatment option for such complex cases. Full article

The treatment for humeral shaft fractures (HSFs) is still controversial, consisting of a wide variety of orthopedic osteosynthesis materials that imply different grades of invasiveness. The aim of this study is to investigate the correlation between inflammatory blood-derived markers and the magnitude of the surgical procedure in young and middle-aged patients who sustained these fractures. Observational, retrospective research was conducted between January 2018 and December 2023. It followed patients diagnosed with recent HFSs (AO/OTA 12−A and B) and followed operative treatment. They were split in two groups, depending on the surgical protocol: group A, operated by closed reduction and internal fixation (CRIF) with intramedullary nails (IMNs), and group B, operated by open reduction and internal fixation (ORIF) with dynamic compression plates (DCPs). Statistically significant differences (p < 0.05) between the two groups could be observed in injury on the basis of surgery durations, surgical times, pre- and postoperative neutrophil-per-lymphocyte ratio (NLR), postoperative platelet-per-lymphocyte ratio (PLR), monocyte-per-lymphocyte ratio (MLR), systemic inflammatory index (SII), systemic inflammatory response index (SIRI) and aggregate inflammatory systemic index (AISI). The multivariate regression model proposed revealed that NLR > 7.99 (p = 0.007), AISI > 1668.58 (p = 0.008), and the surgical times (p < 0.0001) are strongly correlated to the magnitude of the surgical protocol followed. Using receiver operating characteristic (ROC) curve analysis, a balanced reliability was determined for both postoperative NLR > 7.99 (sensitivity 75.0% and specificity 75.6) and AISI > 1668.58 (sensitivity 70.6% and specificity 82.2%). Postoperative NLR and AISI as inflammatory markers are highly associated with the magnitude of surgical trauma sustained during humeral shaft fracture osteosynthesis in a younger population. Full article

The aim of this systematic review was to investigate the outcomes of knee arthrodesis (KA) after periprosthetic joint infection (PJI) of the knee. Differences in clinical outcomes and complication rates among the intramedullary nailing (IMN), external fixation (EF), and compression plating (CP) procedures were compared. A total of 23 studies were included. Demographics, microbiological data, types of implants, surgical techniques with complications, reoperations, fusion, and amputation rates were reported. A total of 787 patients were evaluated, of whom 601 (76.4%), 166 (21%), and 19 (2.4%) underwent IMN, EF, and CP, respectively. The most common causative pathogen was coagulase-negative Staphylococcus (CNS). Fusion occurred in 71.9%, 78.8%, and 92.3% of the patients after IMN, EF, and CP, respectively, and no statistically significant difference was found. Reinfection rates were 14.6%, 15.1%, and 10.5% after IMN, EF, and CP, respectively, and no statistically significant difference was found. Conversion to amputation occurred in 4.3%, 5%, and 15.8% of patients after IMN, EF, and CP, respectively; there was a higher rate after CP than after EF. The IMN technique is the most common option used for managing PJI with KA. No differences in terms of fusion, reinfection, or conversion-to-amputation rates were reported between IMN and EF. CP is rarely used, and the high amputation rate represents an important limitation of this technique. Full article

Background: The external fixation (EF) Ilizarov method, shown to offer efficacy and relative safety, has unique biomechanical properties. Intramedullary nail fixation (IMN) is an advantageous alternative, offering biomechanical stability and a minimally invasive procedure. The aim of this study was to assess outcomes in patients undergoing tibia fracture fixation, comparing the Ilizarov EF and IMN methods in an early phase of IMN implementation in Serbia. Methods: This was a retrospective study including patients with radiologically confirmed closed and open (Gustilo and Anderson type I) tibial diaphysis fractures treated at the Institute for Orthopedic Surgery “Banjica’’ from January 2013 to June 2017. The following demographic and clinical data were retrieved: age, sex, chronic disease diagnoses, length of hospital stay, surgical wait times, surgery length, type of anesthesia used, fracture, prophylaxis, mechanism of injury, postsurgical complications, time to recovery, and pain reduction. Pain intensity was measured by the Visual Analog Scale (VAS), a self-reported scale ranging from 0 to 100 mm. Results: A total of 58 IMN patients were compared to 74 patients who underwent Ilizarov EF. Study groups differed in time to recovery (p < 0.001), length of hospitalization (p = 0.007), pain intensity at the fracture site (p < 0.001), and frequency of general anesthesia in favor of intramedullary fixation (p < 0.001). A shorter surgery time (p < 0.001) and less antibiotic use (p < 0.001) were observed when EF was used. Additionally, we identified that the intramedullary fixation was a significant predictor of pain intensity. Conclusions: The IMN method offers faster recovery and reduced pain intensity in comparison to EF, while the length of surgery predicted the occurrence of any complication. Full article

Intertrochanteric femoral fractures are commonly treated with intramedullary nails (IMNs). A tip–apex distance (TAD) of more than 20–25 mm is associated with an increased risk of cut-out. The Stryker Adaptive Positioning System (ADAPT) is a computer-assisted navigation system designed to reduce TADs. We aim to assess if the ADAPT reduces the number of outliers with a TAD > 20 mm. All patients with intertrochanteric fractures treated with an IMN between 1 September 2020 and 12 March 2022 were included. Patients were included in three periods: a pre-ADAPT period (55 patients); an ADAPT period (50 patients), where it was compulsory to use the system; and a post-ADAPT period after the discontinuation of the system (59 patients). The TADs and lag screw protrusions beyond the lateral cortex were measured. The median TADs in the three periods were 17.0 mm (8–31 mm), 15.5 mm (9–30 mm), and 18.0 mm (11–32 mm), respectively. The absolute number of outliers with a TAD > 20 mm decreased from 15/55 patients in the pre-ADAPT period to 11/50 patients during the ADAPT period. This observation was not statistically significant, but this is likely due to the lack of power of the present study to show changes of this magnitude. However, our expectation that the ADAPT would diminish outliers markedly or close to zero outliers was not met, as we observed 11/50 = 22% outliers with a TAD > 20 mm when using computer-assisted surgery, i.e., ADAPT and Gamma3 for intertrochanteric fractures. Based on these findings, the use of the ADAPT was discontinued at our level 1 trauma center. Full article

Tibial shaft fractures are a commonly seen injury in orthopedic trauma patients. Fractures commonly occur following high energy mechanisms, such as motor vehicle collisions. There are multiple ways to stabilize tibial shaft fractures. Knowledge of the indications, contraindications, techniques, and complications associated with each technique allows the orthopedic surgeon to make the appropriate decision for each patient by providing both fracture and patient characteristics. This review discusses the indications, techniques, outcomes, and complications associated with intramedullary nailing, minimally invasive percutaneous plate osteosynthesis, and external fixation of tibial shaft fractures. Full article

Although intramedullary nail (IMN) fixation is the standard of care for most impending and/or complete pathologic fractures of the femur, the optimal timing/sequence of the IMN in cases of synchronous bilateral femoral disease in advanced cancer is not well established. Thus, we compared the outcomes of single-stage (SS) vs. two-stage (TS) IMN of the bilateral femur with a systematic review of the literature on this topic. Bilateral SS and TS IMN cases were identified from 14 studies extracted from four databases according to PRISMA guidelines. Safety (complications, reoperations, mortality, survival, blood loss, and transfusion) and efficacy (length of stay [LOS], time to start rehabilitation and adjuvant therapy, functional scores, and cost) were compared between the groups. A total of 156 IMNs in 78 patients (36 SS and 42 TS) were analyzed. There were one surgical (infection in TS requiring reoperation; p = 0.860) and fifteen medical complications (five in SS, ten in TS; p = 0.045), with SS being associated with lower rates of total and medical complications. Survival, intraoperative mortality, and postoperative same-admission mortality were similar. No cases of implant failure were reported. Data on LOS, rehabilitation, and adjuvant therapy were scarcely reported, although one study favored SS over TS. No study compared cost or functional scores. Our study is the largest and most comprehensive of its kind in supporting the safety and efficacy of a SS bilateral femur IMN approach in these select patients. Further investigations with higher levels of evidence are warranted to optimize treatment protocols for this clinical scenario. Full article

Background: The purpose of this study was to collect all available randomized controlled trials (RCT) on the treatment of open tibial fractures with an external fixator (EF) and intramedullary nailing (IMN) for meta-analysis to provide reliable evidence-based data for clinical decision-making. Material and methods: The systematic review was undertaken in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and AMSTAR (Assessing the Methodological Quality of Systematic Review). An electronic search of PubMed, Cochrane Library, and Web of Science was performed until 1 March 2023 to identify RCTs which compared either IMN or EF to fix the open tibial fracture. Outcome measures were: postoperative superficial and deep infection, time to union, delayed union, malunion, nonunion and hardware failure. In addition, pain and health-related quality of life were evaluated after 3 and 12 months of follow-up. Results: Sixteen publications comprising 1011 patients were included in the meta-analysis. The pooled results suggested that the IMN technique had a lower postoperative superficial infection and malunion rate (RR = 3.56, 95%CI = 2.56–4.95 and RR = 1.96, 95%CI = 1.12–3.44, respectively), but higher hardware failure occurrence in contrast to EF (RR = 0.30; 95%CI = 0.13–0.69). No significant differences were found in the union time, delayed union or nonunion rate, and postoperative deep infection rate between the treatments. Lower levels of pain were found in the EF group (RR = 0.05, 95%CI = 0.02–0.17, p < 0.001). A difference in quality of life favoring IMN after 3 months was found (RR = −0.04, 95%CI = −0.05–0.03, p < 0.001), however, no statistical difference was found after 12 months (RR = 0.03, 95%CI = −0.05–0.11, p = 0.44). Conclusions: Meta-analysis presented reduced incidence rates of superficial infection, malunion, and health-related quality of life 3 months after treatment in IMN. However, EF led to a significant reduction in pain and incidence rate of hardware failure. Postoperative deep infection, delayed union, nonunion and health-related quality of life 12 months following therapy were similar between groups. More high-quality RCTs should be conducted to provide reliable evidence-based data for clinical decision-making. Full article

Although intramedullary nailing (IMN) is considered the standard of care for the surgical management of most femur metastatic diseases, the optimal treatment of metastatic humeral impending and/or pathologic fractures is still debatable. Moreover, the use of cemented humeral nails has not been thoroughly studied, and only a few small series have compared their results with uncemented nails. The purpose of this study was to compare the (1) survivorship, (2) functional outcomes, and (3) perioperative complications in patients receiving cemented versus uncemented humerus IMN for impending or complete pathologic fractures resulting from metastatic disease or multiple myeloma. We retrospectively reviewed 100 IMNs in 82 patients, of which 53 were cemented and 47 were uncemented. With a mean survival of 10 months (Cemented: 8.3 months vs. Uncemented: 11.6 months, p = 0.34), the mean Musculoskeletal Tumor Society (MSTS) scores increased from 42.4% preoperatively (Cemented: 40.2% vs. Uncemented: 66.7%, p = 0.01) to 89.2% at 3 months postoperatively (Cemented: 89.8% vs. Uncemented: 90.9%, p = 0.72) for the overall group (p < 0.001). Both cohorts yielded comparable complication rates (overall [22.6% vs. 19.1%)], surgical ([11.3% vs. 4.3%], and medical [13.2% vs. 14.9%], all p > 0.05), but estimated blood loss was significantly higher in the cemented group (203 mL vs. 126 mL, p = 0.003). Thus, intramedullary nailing, with and without cement augmentation in select patients, is a relatively safe and effective therapeutic modality for metastatic humeral disease with similar clinical outcomes and acceptable complication rates. While controlling for possible selection bias, larger-scale, higher-level studies are warranted to validate our results. Full article

Background: Femur shaft factures (FSF) are common injuries following high-energy mechanisms mainly involving motor vehicle crashes (MVC). We evaluated the timings of nailing management and analyzed the pattern of fracture union and outcome in a level 1 trauma center. Methods: This was a retrospective observational study of all the admitted trauma patients who sustained femoral fractures between January 2016 and September 2020. Data were analyzed and compared based on time to Intramedullary Nailing (IMN) (<12 h, 12–24 h and >24 h) and outcomes of FSF (union, delayed union and nonunion). Results: A total of 668 eligible patients were included in the study, of which the majority were males (90.9%) with a mean age of 34.5 ± 15.8, and 54% of the injuries were due to MVCs. The chest (35.8%) was the most commonly associated injured body region, followed by the pelvis (25.9%) and spine (25.4%). Most of femur fractures (93.3%) were unilateral, and 84.4% were closed fractures. The complete union of fractures was observed in 76.8% of cases, whereas only 4.2% and 3.3% cases had delayed union and nonunion, respectively, on the clinical follow-up. Patients in the delayed IMN (>24 h) were severely injured, had bilateral femur fracture (p = 0.001) and had higher rate of external fixation, blood transfusion, pulmonary complications and prolonged hospitalization. Non-union proportion was greater in those who had IMN <24 h, whereas a delayed union was greater in IMN done after 24 h (p = 0.5). Those with a nonunion femur fracture were more likely to have bilateral fracture (p = 0.003), frequently had retrograde nailing (p = 0.01), and high-grade femur fracture (AO type C; p = 0.04). Conclusion: This study showed that femur fracture is not uncommon (8.9%), which is manifested with the variety of clinical characteristics, depending on the mechanism, management and outcome in our center. Bilateral fracture, retrograde nailing and AO classification type C were the significant risk factors of non-union in patients with diaphyseal fractures. The timing of IMN has an impact on the fracture union; however, it is not a statistically significant difference. Therefore, the treating physicians should consider the potential risk factors for a better outcome by careful selection of treatment in sub-groups of patients. Full article

Background and Objectives: Intramedullary nailing (IMN) and angularly stable plating (ASP) are the most popular techniques for the stabilization of comminuted fractures of the proximal humerus, without either one being obviously superior. The aim of the study was to validate the functional outcomes of both stabilization techniques in the COVID-19 pandemic by comparing them with data obtained just before the pandemic, because the limitations of the COVID-19 pandemic are affecting several aspects of social and medical life—being afraid of the transmission of the infection, patients reduce their exposure to healthcare to absolutely essential emergencies. Moreover, working conditions in the operating theater have also become more restrictive. Materials and Methods: Investigations were performed on 112 adult patients with Neer’s three- and four-fragment fractures stabilized with IMN (64) and ASP (48). Treatment effects were validated six months after surgery based on radiographs for evidence of bone union, humeral neck–shaft angle (NSA) and implant placement. Limb function was assessed with the QuickDash and Constant–Murley scores. Data obtained from patients treated in the COVID-19 pandemic were compared with those obtained before the pandemic. Results: The healing of all fractures was satisfactory, but complications developed in six cases. Three patients required secondary interventions due to inadequate repositioning: one after IMN and two after ASP. Additionally, one ASP was complicated by the secondary destabilization of a primarily properly stabilized major tubercle, and in two cases by conflict of the protruding implant with the acromion. ASP was noted to provide better functional results during the COVID-19 pandemic according to the Constant–Murley score (p = 0.0048; Student’s t-test). No significant differences were observed in the pre-COVID-19 pandemic. Conclusions: Our results suggest that ASP is more beneficial for the stabilization of comminuted fractures of the proximal humerus during the COVID-19 pandemic. Full article