Search Results (12)

Background: Despite stable fixation, aseptic tibial shaft nonunion represents a severe orthopedic complication. Teriparatide and adipose-derived stem-cell augmentation have been proposed as biological supports, but comparative clinical evidence remains limited. This study explored whether adding adjuvant therapies to reamed intramedullary nailing was associated with faster healing than nailing alone. Methods: We retrospectively reviewed 43 adults with aseptic tibial shaft nonunion treated at three level I trauma centers between 2017 and 2020. Patients underwent reamed intramedullary nailing alone (n = 15), nailing plus teriparatide (n = 15), or nailing plus adipose-derived stem-cell augmentation (n = 13). Group allocation was nonrandom and based on contraindications and patient acceptance; results were therefore interpreted as exploratory. Outcomes included time to tricortical radiographic healing, pain, radiographic healing scores over time, complications, ASAMI classification, and SF-12. Results: Baseline demographic and fracture characteristics were comparable across groups. Time to tricortical radiographic healing was shorter in the teriparatide group (87.46 ± 6.34 days) and the adipose-derived stem-cell group (86.41 ± 5.67 days) than in the nailing-alone group (99.71 ± 4.29 days; p = 0.034). Pain, complication rates, ASAMI outcomes, and quality-of-life recovery did not differ significantly among groups at final follow-up. Conclusions: In this exploratory multicenter retrospective cohort, teriparatide and adipose-derived stem-cell augmentation were associated with shorter radiographic healing time after reamed intramedullary nailing for aseptic tibial shaft nonunion, but not with superior long-term functional outcomes. Because no comparator group treated with standard graft-based biological augmentation was included, the findings should be interpreted cautiously. Larger prospective studies or randomized controlled trials comparing these strategies with established graft-based approaches are needed to validate the present data. Full article

Background: Tibial shaft fractures are frequently treated with intramedullary nailing; however, malalignment remains a concern, particularly in proximal metaphyseal fractures. The surgical approach influenced the nail entry point; however, the three-dimensional (3D) geometric characteristics of the entry point among different approaches remain unclear. Methods: This single-center retrospective study included 68 patients with acute tibial shaft fractures (AO/OTA type 42) treated with reamed and locked intramedullary nails from January 2014 to June 2024. The surgical techniques employed included lateral parapatellar (LPA, n = 31), infrapatellar (IPA, n = 27), and suprapatellar (SPA, n = 10) approaches. Postoperative computed tomography (CT) data were reconstructed into standardized 3D images. The mediolateral insertion ratio was calculated as the percentage distance from the lateral tibial plateau edge to the nail entry point relative to the plateau’s width in the coronal plane. The shortest distance from the tibial articular surface to the nail (r) was measured in the sagittal plane. The Kruskal–Wallis test and Dunn’s post hoc comparisons were used to analyze group differences. Results: Baseline patient and fracture characteristics did not significantly differ among the groups. The mediolateral insertion ratio significantly differed (p < 0.0001), with a more lateral entry for the LPA (44.0% [43.0–47.0]) than for the IPA (51.0% [49.0–53.0], post hoc p < 0.0001) and SPA (49.0% [47.0–51.3], post hoc p = 0.0034). Further, the sagittal distance r significantly differed (p < 0.0001), with a more distal entry for the LPA (14.8 [12.8–20.1] mm) than for the IPA (9.7 [7.0–11.8] mm, post hoc p < 0.0001) and SPA (10.5 [5.5–12.9] mm, post hoc p = 0.0008). No statistically significant difference was observed between the IPA and SPA. Conclusions: The LPA generates a significantly more lateral and distal tibial nail entry point than the IPA and SPA. No statistically significant differences were detected between the IPA and SPA in either plane. These 3D-CT findings may warrant attention during approach selection and guidewire placement, particularly for fractures extending into the proximal metaphysis. Full article

Fractures of the posterior malleolus are key determinants of ankle stability and long-term functional outcome in complex ankle injuries. The posterolateral rim fragment represents a bony avulsion of the posterior syndesmotic complex. Anatomical reduction of this fragment restores the fibular incisura, posterior tibiotalar stability, and syndesmotic integrity. Based on a geriatric case of a trimalleolar ankle fracture with a Bartoníček type 2 posterior malleolar component, this review describes a modified minimally invasive inside-out fixation technique performed under intraoperative three-dimensional imaging. The posterior malleolar fragment was stabilized using a posterior-to-anterior headless double-threaded compression screw. The medial malleolus was fixed with two parallel partially threaded cannulated cancellous screws, and the distal fibular fracture was stabilized using a reamed intramedullary locking nail. The surgical technique, potential complications, and postoperative management are described in detail. This approach combines the biomechanical advantages of direct posterior malleolar fixation with minimal soft-tissue disruption, providing a stable and reliable construct for the treatment of complex ankle fractures, particularly in geriatric patients and in those with compromised soft-tissue conditions. Full article

Background/Objectives: Surgical treatment of chronic osteomyelitis of the proximal tibia is challenging due to limited soft tissue coverage, poor blood supply, and the weight-bearing function of the bone. Moreover, structural instability following curettage may necessitate fixation with metallic implants, which carries a risk of biofilm formation and often requires multi-stage surgeries. Methods: To address these challenges, we developed a new surgical technique combining an anterior approach with establishment of bone marrow communication via intramedullary reaming. The anterior approach provides central access to the infection site, minimizing cortical and cancellous bone loss and eliminating the need for internal fixation. Intramedullary reaming connects the infection site to the systemic circulation, enhancing local blood supply, facilitating intravenous antibiotic delivery, and promoting host immunity. Results: Fourteen patients with proximal tibia osteomyelitis were analyzed. The new surgical technique enabled precise targeting of the infection site, substantially reduced unnecessary bone loss, and eliminated the need for internal fixation. Excluding five cases with Cierny–Mader (C-M) classification IV that required fixation due to inherent structural instability, all nine cases with C-M classification III were treated without internal fixation. Two out of three patients with severe post-traumatic osteomyelitis following Gustilo–Anderson type III open fractures were successfully cured. At a mean follow-up of 53.7 months (range: 2.6–104.9 months), 11 of 14 patients were completely cured with a single surgical intervention, corresponding to a 78.6% cure rate. Conclusions: This new surgical approach enables one-step surgery, avoids the risks of biofilm formation associated with additional fixation, and enhances treatment efficacy through enhancing host immunity, representing an effective strategy for managing proximal tibia osteomyelitis. Full article

Introduction: Osteogenesis imperfecta (OI) presents significant surgical challenges due to bone fragility, narrow medullary canals, and complex deformities. While telescoping rods like the Fassier–Duval (FD) system are commonly used in growing patients, they are unsuitable when the canal diameter is too small or when patients approach skeletal maturity. The Simple Locking Intramedullary (SLIM) nail offers a solid, non-telescoping alternative in these cases. Methods: We describe the surgical technique for SLIM nail implantation and highlight key technical pearls developed through institutional experience, focusing on preoperative planning, intraoperative strategies, and the management of unique anatomical challenges in OI patients. Results: Three cases illustrate the application of these techniques: the first case demonstrates SLIM nail insertion in a 3-year-old child with a narrow IM canal to correct significant bowing; reaming was performed retrograde from the osteotomy site for the proximal segment and antegrade for the distal segment. The second case is a 15-year-old OI patient with a disengaged FD rod and narrow IM canal showing insertion of SLIM rod, and the third case is a 16-year-old patient with femoral deformity and telescoping rod who needed revision with SLIM nail and supplemental plate fixation. Conclusions: The SLIM nail is a viable option for select OI patients. Full article

Background: Insertion of medial column intramedullary fixation during Charcot reconstruction relies on proper guidewire placement in preparation for reaming to optimize endosteal purchase. Although fluoroscopy and jigs assist with wire placement, no anatomical relationship between the center of the intramedullary canal and metatarsal head or base has been described, which this cadaver study aimed to identify. Methods: The first metatarsals from ten fresh-frozen cadavers were dissected. The height and width of the first metatarsal head and base as well as length were measured with digital calipers. Each metatarsal was placed in a three-dimensional printed gantry, where radiographs were taken. Image analysis software was used to identify the relationship between the metatarsal head and base and the center of the intramedullary canal. Results: Metatarsals fromsix male and four female cadavers with an age of 68.6 ± 15.14 years were assessed. Metatarsal length was 62.71 ± 5.54 mm. The center point was 51.12 ± 3.51% and 66.8565.09%the height of themetatarsal head and base, respectively, with the inferior cortex as reference.Moreover, the center point was 53.40 ± 6.26%and 52.63 ± 2.90% the width of themetatarsal head and base, respectively, with the lateral cortex as reference. Longer metatarsals correlated withmore superior base starting positions (r = 0.74; P = .02). Conclusions: Guidewire entry should be slightly superior and medial to the center of the first metatarsal head and directed proximally toward the superior third of the metatarsal base. These findings may assist with surgical technique and instrument design. (J Am Podiatr Med Assoc 115(4), 2025; doi:10.7547/24-059) Full article

Intramedullary nailing insertion from the proximal-to-distal femur is frequently performed for impending and complete pathological femur fractures due to osteolytic metastases. After nailing through cancer-laden bone, residual chemotherapy- and/or radiation-resistant tumor may progress. Progression of osteolysis risks future nail failure or pathological fractures. This study assesses the incidence of cancer progression following intramedullary nailing in a femur-only cohort and describes a percutaneous rod-retaining salvage technique. A single-institution, retrospective study was conducted to identify adult patients who underwent intramedullary nailing for femoral osteolytic lesions for complete or impending nail failure from 2016 to 2023. Progression was defined as enlargement of the pre-existing lesion and/or appearance of new lesions on radiographs. Surgical outcomes were assessed with a combined pain and functional score. A total of 113 patients (median age 66.8 years (IQR = 16.4); median follow-up 6.0 months (IQR = 14.5)) underwent intramedullary nailing. Sixteen patients (14.2%) exhibited post-nailing cancer progression. Pre- and postoperative radiation and chemotherapy did not decrease the odds of cancer progression. Three patients underwent initial open surgical salvage consisting of proximal femur replacement arthroplasty, and six patients did not receive salvage due to poor surgical candidacy or patient choice. Seven patients (median follow-up 10.7 months (IQR = 12.9)) received percutaneous salvage. In this group, pain and functional scores improved by 4.0 points (p = 0.0078) at two-week postoperative follow-up and 2.0 points (p = 0.0312) at the most recent follow-up (mean follow-up 13.0 ± 9.4 months). All three nonambulatory patients became ambulatory, and six patients were able to ambulate independently without walking aids. No major complications were reported 30 days postoperatively. Progression of femoral osteolytic metastases may occur following intramedullary nailing. Continued monitoring of the entire femur is needed to maintain improved functional status and to prevent catastrophic progression of pre-existing lesions or appearance of new lesions. In patients with more proximal metastases only, the customary practice of bringing a long nail from the proximal femur to distal metaphysis should be reconsidered. Furthermore, there is concern of mechanical transport of cancer cells during guide wire insertion, reaming, and rod insertion through cancer laden bone to cancer free distal bone. Full article

Background/Objectives: Tibial diaphysis fractures are common injuries resulting from high-to-low-energy traumas in patients of all age groups, but few reports currently provide complementary parameters for the assessment of bone healing processes in the postoperative period. Serum alkaline phosphatase (ALP) and the scores from the Radiographic Union Scale for Tibial Fractures (RUST) can promote new horizons in this context. Therefore, the aim of this study was to assess the behavior of ALP and RUST through within-subject comparisons from immediately post-surgery to 49 days after tibial diaphysis fracture repair. Methods: This article included four case studies where patients underwent the same procedures. Adults of both sexes aged 18 to 60 years with tibial fractures requiring surgery were included. After surgical intervention (T1), the patients were followed for 49 days after surgery, returning for follow-up appointments on the 21st (T2) and 49th (T3) days. At the follow-up appointments, new X-ray images were obtained, and blood samples were collected for ALP measurement. Results: Serum ALP levels increased by T2 following tibial reamed intramedullary nailing surgery. While this increase persisted into T3 for two patients, a decline was observed during the same period for the other two patients. Both events are indicative of the bone consolidation process, and RUST scores at the T3 corroborate this perspective for all patients included in this study. Considering that delta ALP (T3-T1 value) was lower in patients who exhibited the highest RUST score, we suggest that a synchronized analysis between ALP and RUST allows medics to diagnose bone consolidation. Conclusions: Therefore, it can be concluded that the analysis of ALP alongside RUST may be complementary for evaluating bone consolidation following tibial reamed intramedullary nailing surgery, but future studies are needed to confirm this assertion. Full article

Background: The aim of this study was to evaluate detection rates and risk factors for unsuspected proof of bacteria, as well as clinical and radiologic outcomes following femoral shaft nonunion without clinical signs of infection treated by a single-stage surgical revision procedure including reamed intramedullary exchange nailing. Methods: A retrospective cohort study was performed in a European level I trauma center between January 2015 and December 2022. Fifty-eight patients were included who underwent reamed intramedullary exchange nailing as a single-step procedure for surgical revision of posttraumatic diaphyseal femoral nonunion without any indications of infection in medical history and without clinical signs of local infection. Clinical details of the patients were analyzed and functional and radiologic long-term outcomes were determined. Results: In all patients, with and without proof of bacteria osseous, healing could be observed. The physical component summary of the SF-12 demonstrated significantly better results at least one year after the final surgical revision in case of a negative bacterial culture during exchange nailing. Conclusions: Clinical long-term outcomes demonstrated a trend towards better results following femoral shaft nonunion revision if there was no evidence for the presence of low-grade infected nonunion. In this case, a single-stage surgical procedure may be recommended. Full article

Fracture healing and nonunion development are influenced by a range of biological factors. Adequate amino acid concentrations, especially arginine, are known to be important during normal bone healing. We hypothesize that bone arginine availability in autologous bone marrow grafting, when using the reamer-irrigator-aspirator (RIA) procedure, is a marker of bone healing capacity in patients treated for nonunion. Seventeen patients treated for atrophic long bone nonunion by autologous bone grafting by the RIA procedure were included and divided into two groups, successful treatment of nonunion and unsuccessful, and were compared with control patients after normal fracture healing. Reamed bone marrow aspirate from a site distant to the nonunion was obtained and the amino acids and enzymes relevant to arginine metabolism were measured. Arginine and ornithine concentrations were higher in patients with successful bone healing after RIA in comparison with unsuccessful healing. Ornithine concentrations and arginase-1 expression were lower in all nonunion patients compared to control patients, while citrulline concentrations were increased. Nitric oxide synthase 2 (Nos2) expression was significantly increased in all RIA-treated patients, and higher in patients with a successful outcome when compared with an unsuccessful outcome. The results indicate an influence of the arginine–nitric oxide metabolism in collected bone marrow, on the outcome of nonunion treatment, with indications for a prolonged inflammatory response in patients with unsuccessful bone grafting therapy. The determination of arginine concentrations and Nos2 expression could be used as a predictor for the successful treatment of autologous bone grafting in nonunion treatment. 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

The biology of mesenchymal stem cells (MSCs) in humans is incompletely understood and a possible role of systemically circulating cells in health and autoimmune disease remains controversial. Physiological movement of bone marrow MSCs to sites of injury would support the rationale for intravenous administration for relocation to damaged organs. We hypothesized that biophysical skeletal trauma rather than molecular cues may explain reported MSC circulation phenomena. Deep-femoral vein (FV) and matched peripheral vein blood samples (PVBs) were collected from patients undergoing lower-limb orthopaedic procedures during surgery (tibia using conventional sequential reaming, n = 9, femur using reamer/irrigator/aspirator (RIA), n = 15). PVBs were also taken from early (n = 15) and established (n = 12) rheumatoid arthritis (RA) patients and healthy donors (n = 12). Colony-forming unit-fibroblasts (CFU-Fs) were found in 17/36 FVBs but only 7/74 PVBs (mostly from femoral RIA); highly proliferative clonogenic cells were not generated. Only one colony was found in control/RA samples (n = 28). The rare CFU-Fs’ MSC nature was confirmed by phenotypic: CD105⁺/CD73⁺/CD90⁺ and CD19⁻/CD31⁻/CD33⁻/CD34⁻/CD45⁻/CD61⁻, and molecular profiles with 39/80 genes (including osteo-, chondro-, adipo-genic and immaturity markers) similar across multiple MSC tissue controls, but not dermal fibroblasts. Analysis of FVB-MSCs suggested that their likely origin was bone marrow as only two differences were observed between FVB-MSCs and IC-BM-MSCs (ACVR2A, p = 0.032 and MSX1, p = 0.003). Stromal cells with the phenotype and molecular profile of MSCs were scarcely found in the circulation, supporting the hypothesis that their very rare presence is likely linked to biophysical micro-damage caused by skeletal trauma (here orthopaedic manipulation) rather than specific molecular cues to a circulatory pool of MSCs capable of repair of remote organs or tissues. These findings support the use of organ resident cells or MSCs placed in situ to repair tissues rather than systemic administration. Full article