Desde el análisis biomecánico óseo de koch hasta el manejo contemporáneo de la fractura del fémur proximal / From koch's bone biomechanical analysis to contemporary proximal femur fracture management

Este artículo representa una revisión actual y completa de las fuerzas biomecánicas en el fémur proximal, tal como Koch presentó preliminarmente en su trabajo sobre la arquitectura ósea del fémur proximal. Su trabajo reflejó en la complejidad de las fracturas de fémur proximal y el manejo de las fracturas subtrocantéricas en paralelo con su clasificación y con la evolución de implantes. Existen múltiples formas de clasificar las fracturas subtrocantéricas; sin embargo, no existe un sistema de clasificación que se utilice para guiar el manejo quirúrgico. El tratamiento de las fracturas subtrocantéricas es la fijación quirúrgica, que implica el enclavado endomedular y placas de osteosíntesis. El tratamiento estándar es el enclavado endomedular con opciones de enclavado anterógrado y retrógrado. Aunque el enclavado anterógrado presenta una ventaja debido a las fuerzas deformantes, el enclavado retrógrado de las fracturas de fémur proximal ofrece menos tiempo quirúrgico y pérdida de sangre. Se han informado resultados similares entre los dos métodos. La toma de decisiones cuando se contempla el enclavado anterógrado versus retrógrado para las fracturas de fémur se basa principalmente en la constitución corporal y las lesiones asociadas, y no en la distancia de la fractura del fémur proximal a la región trocantérica

This article presents a current and comprehensive review of the biomechanical forces on the proximal femur, as preliminarily presented by Koch's cornerstone work on the bone architecture of the proximal femur. His work reflected on the complexity of proximal femur fractures and subtrochanteric fracture management in parallel with implant evolution and classification. Multiple ways of classifying subtrochanteric fractures exist, however, there is not one classification system that is used to guide operative management. The management of subtrochanteric fractures is surgical fixation which involves intramedullary nailing and plating (e.g., fixed angle and locking). The gold standard management is intramedullary nailing with antegrade and retrograde nail options. Though antegrade nailing presents an advantage due to the deforming forces, retrograde nailing of proximal femur fractures offers less operative time and blood loss. Similar outcomes have been reported between the two methods. Decision making when contemplating antegrade versus retrograde nailing for femur fractures is mostly driven by body habitus and associated injuries, and not by fracture distance of the proximal femur to the trochanteric region

Fracturas basicervicales tratadas con clavo intramedular con tornillo cefálico único. Serie de casos y revisión bibliográfica / Basicervical fractures treated with single-screw cephalomedullary nail. Case series and review of the literature

Introducción: Debido a la inestabilidad rotatoria de las fracturas basicervicales, en estudios recientes, se sugiere el uso de una hoja espiral, doble tornillo o tornillos de compresión en lugar del tornillo cefálico único. Objetivo: Analizar los resultados de las fracturas basicervicales tratadas con tornillo cefálico único en nuestro centro. Materiales y Métodos: Estudio retrospectivo de una serie de casos formada a partir de la revisión de todas las fracturas extracapsulares de fémur proximal tratadas con clavo intramedular con tornillo cefálico único entre 2016 y 2020. Se revisaron las historias clínicas y las radiografías de 269 pacientes, y solo 12 (6,4%) de ellos cumplieron los criterios de inclusión (fracturas en dos fragmentos no patológicas y con seguimiento mínimo de 9 meses). Se evaluaron diferentes factores, como distancia punta-ápex, posición del tornillo cefálico, calidad de la reducción, tiempo quirúrgico, complicaciones y reintervención, y se analizaron las posibles diferencias entre los pacientes que sufrieron complicaciones y los que no. Resultados: Cuatro de los 12 pacientes tuvieron una falla de la fijación que evolucionó a cut-out (única complicación identificada en la muestra). No hubo diferencias estadísticamente significativas entre pacientes con cut-outo sin cut-out respecto al resto de las variables analizadas. Conclusiones: La elevada proporción de pacientes que desarrollaroncut-out sugiere considerar la hipótesis de que debería evitarse fijar las fracturas basicervicales con tornillo cefálico único. Dada su alta tasa de inestabilidad rotatoria, podría ser más apropiado el uso de implantes que la contrarresten. Nivel de Evidencia: IV

Background: Given the rotational instability of basicervical fractures, recent studies suggest using a spiral blade, a second screw or compression screws instead of single-screw cephalomedullary nail fixation. Objective: The aim of our study is to analyze the outcomes of basicervical fractures treated with single-screw cephalomedullary nails. Materials and Methods: This is a retrospective study based on a case series identified from all extracapsular femoral fractures treated with single-screw cephalomedullary nails in our hospital from 2016 to 2020. Clinical records and radiographs from 269 patients were reviewed; only 12 (6.4%) subjects met inclusion criteria (two-part non-pathologic fractures with at least a 9-month follow-up). Different factors were evaluated, including: tip-apex distance, cephalic screw position, reduction quality, surgical time, complications and re-operations; differences between patients who experienced complications and those who did not were also assessed. Results: Four subjects out of the 12 included patients experienced fixation failure and implant cut-out. There were no statistically significant differences between subjects with and without cut-out regarding the analyzed variables. Conclusions: The high cut-out rate observed in our sample suggests considering the hypothesis that single-screw cephalomedullary nail fixation should not be used in basicervical fractures. Alternative fixation devices capable of controlling the high rotational instability of these fractures may be preferable. Level of Evidence: IV

A comparative analysis of distal locked and unlocked long proximal femoral nail antirotation (PFNA-II) in the fixation of stable intertrochanteric fractures / 中华创伤杂志(英文版)

PURPOSE@#Long proximal femoral nail anti-rotation (PFNA-II) is a preferred implant in recent years for fixation of pertrochanteric fractures, especially in osteoporotic patients. The purpose of this study is to prospectively investigate the effect of distal locking in long PFNA-II fixation of stable intertrochanteric fractures.@*METHODS@#A total of 58 patients with isolated stable intertrochanteric fractures and treated in our hospital during the study period of 2017-2019 by distal locked or unlocked long PFNA-II fixation were included in this study. Patients who had multiple injuries or open fractures were excluded. There were 40 female and 18 male patients, with 33 affecting the left side and 25 the right side. Of them, 31 belonged to the distal locked group (group A) and 27 to the unlocked group (group B). Surgical procedures and implants used in both groups were similar except for the distal locking of the nails. General data (age, gender, fracture side, etc.) showed no significant difference between two groups (all p > 0.05). The intraoperative parameters like operative time, radiation exposure and follow-up parameters like functional and radiological outcomes were recorded and compared. Statistical tests like the independent samples t-test Fischer's exact and Chi-square test were used to analyze association.@*RESULTS@#The distribution of the fractures according to AO/OTA classification and 31A1.2 type of intertrochanteric fractures were most common in our study. All the included fractures united and the average functional outcome in both groups were good and comparable at the end of one year. The operative time (mL, 107.1 ± 12.6 vs. 77.0 ± 12.0, p < 0.001) and radiation exposure (s, 78.6 ± 11.0 vs. 40.3 ± 9.3, p < 0.001) were significantly less among the patients in group B. Fracture consolidation, three months after the operative procedures, was seen in a significantly greater proportion of patients in group B (92.6% vs. 67.7%, p = 0.025). Hardware irritation because of distal locking bolt was exclusively seen in group A, however this was not statistically significant (p = 0.241).@*CONCLUSION@#We conclude that, in fixation of stable intertrochanteric fractures by long PFNA-II nail, distal locking not only increases the operative time and radiation exposure but also delays the fracture consolidation and increases the chances of hardware irritation, and hence is not required.

Prediction of internal fixation failure of femoral trochanteric fracture by external wall morphology / 中国骨伤

OBJECTIVE@#To investigate the relationship between the shape of the lateral wall and the early failure of internal fixation in the fracture of the femoral trochanteric region(FFT).@*METHODS@#Total 295 patients with femoral trochanteric fracture underwent internal fixation from January 2015 to January 2020 were selected. The patients were divided into two groups according to whether there was early internal fixation failure after surgery, 19 patients in the failure group and 276 patients in the normal group. Gender, affected side, age, AO classification, body mass index(BMI), preoperative hemoglobin, X-ray measurement of lower lateral wall thickness, preoperative internal diseases, intraoperative blood loss, postoperative tip apex distance(TAD), postoperative neck shaft angle, operation time and other data were compared between two groups. The shape of the lateral wall was compared between two groups, and the correlation between the shape of the lateral wall and the early internal fixation failure of femoral trochanteric fracture was analyzed.@*RESULTS@#All patients were followed up for more than 1 year. There was no significant difference between two groups in terms of intraoperative blood loss, operation time, postoperative TAD, and postoperative neck shaft angle(P>0.05). At the latest follow-up, the visual anaglue scale (VAS) of the failure group was higher than that of the normal group(P<0.01), and the Harris score of the failure group was lower than that of normal group(P<0.05). The receiver operator characteristic (ROC) curve between shape of lateral wall and failure of early internal fixation of femoral trochanteric fracture was drawn. The critical value of the midpoint lateral wall thickness was 16.5 mm, and the area under the ROC curve was 0.845;The critical value of average sidewall thickness was 16.5 mm, and the area under ROC curve was 0.838;The critical value of the axial area of the sidewall was 7.5 mm, and the area under the ROC curve was 0.826.@*CONCLUSION@#The shape of the lateral femoral wall measured by CT could be used as a predictive factor for the early failure of internal fixation of femoral trochanteric fractures. For patients at risk, more reasonable surgical plans and postoperative preventive measures should be developed.

Surgical treatment for ipsilateral femoral neck and shaft fracture / 中国骨伤

OBJECTIVE@#To retrospectively analyze efficacy of single structure internal fixation and double structure internal fixation in the treatment of ipsilateral femoral shaft and neck fracture, and analyze their indications.@*METHODS@#From June 2015 to December 2020, 21 patients with ipsilateral femoral shaft and femoral neck fracture were treated, including 14 males and 7 females, aged 23 to 69 years old with an average of(38.1±12.9) years old. According to different femoral shaft fracture sites, some patients were fixed with cephalomedullary implant for both femoral neck and the femoral shaft(single structure, InterTan or PFNA Ⅱ), some patients were fixed with cannulated screws for the femoral neck and a retrograde locking nail for the femoral shaft (dual structure), and postoperative function and complications were recorded during follow-up. In 10 cases of single-structure fixation, the femoral necks were all basicervical fractures, and the femoral shaft fractures were located in the proximal isthmus;11 cases were double-structure fixation, 9 cases in 11 were basal type of femoral neck, 2 cases in 11 were neck type, and the femoral shaft fractures were located in the isthmus and the distal isthmus.@*RESULTS@#All patients were followed up for 12 to 27 months. No femoral head necrosis, deformity, delay or nonunion occurred in the patients with single-structure fixation, and no delayed union or nonunion occurred in femoral shaft fractures;At the final follow-up, Harris score of patients with single-structure fixation was 91.8±4.1, with 8 cases were excellent and 2 cases were good. The fractures of patients with dual-structure fixation achieved good union without femoral head necrosis, except 1 case of femoral shaft fracture had delayed union;At the final follow-up, Harris score of patients with dual-structure fixation was 92.4±5.9, 7 cases were excellent, 3 cases were good, and 1 case was fair.@*CONCLUSION@#Good reduction and fixation is the key to the treatment of such fractures. Both the single-structure fixation and the dual-structure fixation are good methods, and it should be selected according to the locations of femoral shaft and femoral neck fractures. Single-structure fixation is a good choice for femoral shaft fractures located at the proximal isthmus and basal femoral neck fractures. For isthmus and distal femoral shaft fractures combined with ipsilateral femoral neck fractures, dual-structure fixation is recommended.

Outcome of buttress plate-nail construct used for reconstruction of broken lateral wall in intertrochanteric fractures / 中华创伤杂志(英文版)

PURPOSE@#Intramedullary implants are well accepted fixation of all types of intertrochanteric (IT) fractures, both stable and unstable types. Intramedullary nails have an ability to effectively support the posteromedial part, but fail to buttress the broken lateral wall requiring lateral augmentation. The aim of this study was to evaluate the outcome of proximal femoral nail augmented with trochanteric buttress plate for broken lateral wall with IT fractures, which was fixed to the femur through hip screw and anti-rotation screw nail.@*METHODS@#Of 30 patients, 20 had Jensen-Evan type III and 10 had type V fractures. Patients with IT fracture of broken lateral wall and aged more than 18 years, in whom satisfactory reduction was achieved by closed methods, were included in the study. Patients with pathologic or open fractures, polytrauma, prior hip surgery, non-ambulatory prior to surgery, and those who refused to participate were excluded. The operative time, blood loss, radiation exposure, quality of reduction, functional outcome, and union time were evaluated. All data were coded and recorded in Microsoft Excel spread sheet program. SPSS 20.0 was used for data analysis and normality of the continuous data was checked using Kolmogorv Smirnov test.@*RESULTS@#The mean age of patients in the study was 60.3 years. The mean duration of surgery (min), mean intra-operative blood loss (mL) and mean number of exposures were 91.86 ± 12.8 (range 70 - 122), 144.8 ± 3.6 (range 116 - 208), and 56.6 (range 38 - 112), respectively. The mean union time was 11.6 weeks and the mean Harris hip score was 94.1.@*CONCLUSION@#Lateral trochanteric wall in IT fractures is significantly important, and needs to be reconstructed adequately. Nail-plate construct of trochanteric buttress plate fixed with hip screw and anti-rotation screw of proximal femoral nail can be successfully used to augment, fix or buttress the lateral trochanteric wall giving excellent to good results of early union and reduction.

Clinical effect of Kirschner wire intramedullary fixation in the treatment of pediatric both-bone forearm fractures at high altitude area / 中国骨伤

OBJECTIVE@#To explore the clinical effect of Kirschner wire intramedullary fixation in the treatment of both-bone forearm fractures in children of high altitude area.@*METHODS@#From August 2020 to December 2021, 19 children were treated with Kirschner wire intramedullary fixation including 11 males and 8 females, aged from 4 to 13 years old with an average of (8.16±2.71) years old. The course of disease was 1 to 10 days, with a mean of (4.11±2.51) d. First, close reduction was performed. If the reduction was unsuccessful, limited open reduction was performed, followed by Kirschner wire intramedullary fixation of the radius and ulna. The fracture healing was evaluated by X-ray after operation, and the curative effect was evaluated by Anderson forearm function score standard.@*RESULTS@#The wound healed well after operation, 2 cases had clinical manifestations of needle tail irritation after operation, and the symptoms disappeared after removing the internal fixation. The average follow-up time was(7.68±3.50) months (3 to 14 months). X-ray showed that all fracture healing in follow-up, Anderson forearm function score showed excellent in 16 cases, good in 2 cases and fair in 1 case at the final follow-up.@*CONCLUSION@#Children with fractures in plateau areas often have delayed medical treatment, lack of medical conditions and insufficient compliance. Based on these characteristics, Kirschner wire intramedullary fixation for the treatment of children's double forearm fractures has the advantages of small injury and rapid recovery. It is a kind of operation method that can be popularized.

Conceptos actuales: ventajas del clavo endomedular para fracturas del húmero proximal / Current concepts: advantages of intramedullary nail for proximal humerus fractures

Las fracturas de húmero proximal (FHP) son una de las fracturas más frecuentes en la población anciana. La reducción abierta y fijación interna (RAFI) generalmente está indicada para pacientes con una FHP desplazada en jóvenes o pacientes mayores con alta demanda funcional y buena calidad ósea. No se ha llegado a un consenso sobre la técnica de fijación ideal. La RAFI con placas ha sido la más utilizada, pero se han reportado altas tasas de reintervenciones y complicaciones globales en la literatura. La necesidad de agregar técnicas de aumentación a la RAFI con placas bloqueadas en fracturas complejas puede resultar en un tiempo quirúrgico más largo, abordajes extensos y mayores costos. Debido a esto, se hace necesario considerar otras opciones para la osteosíntesis de FHP. Con una mayor comprensión de los mecanismos de falla de la osteosíntesis, la fijación intramedular se ha convertido en una opción de tratamiento aceptada para las FHP con ventajas biomecánicas y biológicas. La fijación intramedular para las FHP ha demostrado menor tiempo quirúrgico, sangrado intraoperatorio, tiempo hasta la unión ósea y menores tasas de infecciones, que las placas bloqueadas. La fijación intramedular es una opción válida para que las fracturas complejas se resuelvan con un implante que por sí solo puede satisfacer en gran medida todas las necesidades de aumento requeridas por una placa bloqueada

Proximal humeral fractures are one of the most frequent fractures in the elderly population. Open reduction and internal fixation (ORIF) is generally indicated for young patients and older patients with high functional demands and good bone quality. No consensus has been reached regarding the ideal fixation technique. Although ORIF with plates is the most widely used technique, high re-intervention rates and global complications with locked plate fixation have been reported in the literature. Addition of augmentation techniques to locked plate fixation in complex fractures may result in longer surgical times, extensive approaches, and higher costs. Therefore, considering other options for ORIF is necessary. With a greater understanding of the mechanisms of fixation failure, intramedullary fixation has become the accepted treatment option for proximal humeral fractures considering the specific biomechanical and biological advantages. Compared with ORIF with locked plates, intramedullary fixation for proximal humeral fractures has low surgical time, intraoperative bleeding, time to bone union, and rate of infections. Intramedullary fixation is a valid option to resolve complex fractures with an implant that may largely supply all the augmentation requirements of a locked plate.

Fracturas metafiso-diafisarias de radio distal en adolescentes: estudio comparativo entre fijación percutánea con clavijas y clavos elásticos de titanio / Closed reduction and percutaneous pinning versus dorsal-entry elastic intramedullary nailing

Objetivo: Comparar los resultados y las complicaciones entre la fijación percutánea con clavijas (FPC) y el enclavado endomedular elástico (EEE). materiales y métodos:Se evaluaron las radiografías para determinar deformidades angulares en la consolidación. Se usó el sistema de Clavien-Dindo adaptado para clasificar las complicaciones. Resultados: El grupo A (FPC) incluyó a 17 pacientes y el grupo B (EEE), a 19. La edad promedio era de 12.5 ± 1.6 años y el seguimiento promedio fue de 27.6 ± 16.6 meses. Los pacientes con EEE requirieron menos tiempo de inmovilización (2.8 ± 1.8 vs. 5.9 ± 1.3 semanas, p 0,00029). Un paciente de cada grupo tuvo una angulación >10° en la consolidación. La tasa de complicaciones fue mayor en el grupo A (18% vs. 5,3%, p 0,27). En el grupo A, hubo 2 complicaciones tipo III (pérdida de corrección) y 2 tipo II (infección y granuloma). Un paciente del grupo B presentó una complicación tipo I (prominencia del implante). Dieciséis pacientes del grupo B se sometieron a una segunda cirugía para extraer el implante. Dos del grupo A requirieron revisión de la fijación por pérdida de alineación. Conclusiones: Ambas técnicas son eficaces para estabilizar fracturas metafiso-diafisarias de radio distal en adolescentes. El EEE tiene la ventaja de una inmovilización más corta y menos complicaciones, pero es más caro y requiere otra cirugía para extraer el implante. La FPC no requiere de anestesia para extraer el implante, aunque sí una inmovilización más prolongada y la tasa de complicaciones es más alta. Nivel de Evidencia: III

Objective: To compare results and complications of closed reduction percutaneous pinning (CRPP) versus dorsal entry elastic intramedullary nails (ESIN). Materials and methods: Radiographs were evaluated to determine angular deformities at the time of radiographic union. Complications were graded with a modification of the Clavien-Dindo classification. Results: The CRPP group consisted of 17 patients (Group A) whereas the ESIN group consisted of 19 patients (Group B). The average age of the patient cohort was 12.5±1.6 years. The average follow-up was 27.6±16.6 months. The demographic data revealed no differences between groups (p> 0.05). Patients treated with ESIN required a shorter immobilization time (2.8±1.8 versus 5.9±1.3 weeks, p 0.00029). One patient in each group presented an angulation >10° at the time of consolidation. The complication rate was higher in group A (18% versus 5.3%, p 0.27). According to the Clavien-Dindo classification, group A presented 2 type II (infection and granuloma), and 2 type III complications (loss of reduction). Group B presented one type I complication (implant prominence). Sixteen patients in group B underwent a second procedure for hardware removal. Two patients (11.8%) in group A required revision due to loss of reduction. Conclusions: Both techniques are effective in stabilizing metaphyseal-diaphyseal fractures of the distal radius in the adolescent population. ESIN has the advantage of requiring a shorter immobilization time and fewer complications but needs a second surgery for implant removal. CRPP does not require anesthesia for implant removal, although it requires a longer postoperative immobilization, and has a higher complication rate. Level of Evidence: III

Estudio comparativo de la función y el dolor de la rodilla entre el abordaje suprarrotuliano y pararrotuliano medial luego del enclavado endomedular de una fractura de tibia / Comparative study of knee function and pain between the suprapatellar and medial parapatellar approaches after intramedullary nailing of a tibial fracture

Introducción: El dolor anterior de rodilla es la causa más frecuente de reoperaciones luego del enclavado endomedular de una fractura de tibia. En los últimos años, los abordajes en semiextensión han facilitado la técnica quirúrgica; sin embargo, el dolor posoperatorio sigue siendo la complicación más frecuente. El objetivo de este estudio fue comparar el abordaje pararrotuliano medial con el suprarrotuliano en cuanto al dolor de rodilla y la función posoperatoria luego del enclavado endomedular de tibia. materiales y métodos: Se conformaron retrospectivamente 2 grupos de pacientes con fracturas de tibia tratados con clavo endomedular a través del abordaje pararrotuliano medial (n = 33) y suprarrotuliano (n = 17). Se evaluaron el dolor de rodilla posoperatorio con las escalas analógica visual y de Lysholm, y la función con el SF-12, al mes 1, 3, 6 y 12. Resultados: La edad promedio era de 41.5 años (rango 29-76) para el grupo con abordaje pararrotuliano y de 40.4 años (rango 23-90) para el otro grupo. Los resultados respecto del dolor y la función de la rodilla fueron significativamente mejores en el grupo operado con el abordaje suprarrotuliano. Conclusiones: El abordaje suprarrotuliano se asocia con menor dolor de rodilla y mejor función posoperatoria luego del enclavado endomedular de una fractura de tibia. Sin embargo, estudios prospectivos deberán validar estos resultados. Nivel de Evidencia: III

Anterior knee pain is the most frequent cause of reoperation after intramedullary nailing of a tibial fracture. In recent years, semi-extension approaches have simplified the surgical technique, but postoperative pain continues to be the most frequent complica-tion. The aim of this study is to compare the medial parapatellar approach (PPM) vs the suprapatellar approach (SP) with respect to knee pain and postoperative function after intramedullary tibial nailing. materials and methods: We retrospectively formed 2 groups of patients with tibial fractures treated with intramedullary nailing through the PPM (n:33) and SP (n:17) approaches. We evaluated postoperative knee pain with the VAS and Lysholm score; and function with the SF-12. They were clinically evaluated at 1, 3, 6 and 12 months. Results: The mean age of the groups was 41.5 years (29-76) for the PPM group and 40.4 years (23-90) for the SP group. Pain and knee function were significantly better in the group of patients operated through the SP approach. Conclu-sion: The suprapatellar approach is associated with less knee pain and better postoperative function after intramedullary nailing of a tibial fracture. However, prospective studies should validate these results. Level of Evidence: III

Enclavado endomedular suprarrotuliano vs. infrarrotuliano en el tratamiento de fracturas diafisarias y distales de tibia: análisis comparativo y técnica quirúrgica / Suprapatellar vs. infrapatellar intramedullary nailing for the treatment of distal and diaphyseal tibial fractures: Comparative analysis and surgical technique

Introducción: Las fracturas diafisarias y distales de tibia son lesiones frecuentes en personas jóvenes que sufren un trauma de alta energía y en ancianos por un trauma de baja energía. El objetivo de este estudio fue comparar el tiempo quirúrgico, el uso de radioscopia, la evaluación funcional y el dolor en el tratamiento de fracturas diafisarias y distales de tibia mediante una técnica suprarrotuliana y una infrarrotuliana. Materiales y métodos: Se realizó un estudio retrospectivo entre marzo de 2018 y octubre de 2019. La información de los pacientes se obtuvo de la historia clínica electrónica. Se incluyó a pacientes con fracturas diafisarias y distales de tibia. Se estudiaron y compararon los tiempos de radioscopia y de cirugía. El dolor posoperatorio se evaluó mediante la escala analógica visual y la función, con el puntaje de Lysholm. Resultados:Ochenta pacientes cumplían con los criterios de inclusión. Sus datos sociodemográficos fueron pareados en dos grupos similares. Treinta y seis pacientes fueron tratados con la técnica infrarrotuliana y 44, con la técnica suprarrotuliana. Se obtuvieron diferencias estadísticamente significativas en el tiempo de cirugía, el tiempo de radioscopia y en el puntaje de la escala analógica visual para dolor al año. Conclusiones: Los resultados mostraron un menor tiempo de cirugía y de radioscopia, y mejores resultados en la escala analógica visual para dolor con la técnica suprarrotuliana para el tratamiento de las fracturas mediodiafisarias y distales de tibia. Nivel de Evidencia: III

Introduction: Fractures of the medial and distal tibial segment often occur in young patients with high-energy trauma and older patients with low-energy trauma. The objective of this study is to compare the time of surgery, time of use of fluoroscopy, functional outcomes, and postoperative pain in patients treated with the suprapatellar vs. infrapatellar technique for tibial nailing. materials and methods: We carried out a retrospective study between March 2018 and October 2019. All the data was collected from the electronic clinical record (ECR). We included patients with diaphyseal and distal tibial fractures. The variables analyzed were: fluoroscopy and surgery time, pain evaluation, and functional outcomes of the patients using the Lysholm score. Results: 80 patients met all the inclusion criteria. Sociodemographic data were divided into 2 similar groups. The suprapatellar approach was used in 44 patients and the infrapatellar in 36 of them. A statistical difference was obtained in the analysis for the time of surgery, use of fluoroscopy, and pain evaluation in favor of the suprapatellar technique. Conclusions: The results of our study showed shorter surgery and fluoroscopy times with the use of the suprapatellar technique compared with the infrapatellar technique. The suprapatellar technique also yielded better pain results in the visual analog scale. Level of Evidence: III

Enclavado endomedular en fracturas de tibia. ¿Existe una relación entre el punto de entrada para la inserción del clavo y su alineación final? / Intramedullary nailing of tibial fractures. Is there a relationship between the entry point and its final alignment?

Introducción: Las fracturas de tibia representan aproximadamente el 2% de las fracturas del adulto. El enclavado endomedular es hoy el procedimiento de elección para tratar fracturas diafisarias de tibia; sin embargo, esta técnica no está exenta de complicaciones, la desalineación en el plano coronal es una de las más frecuentes y temidas por los cirujanos. El objetivo de este estudio fue investigar la relación entre el punto de entrada del clavo y la desalineación en el plano coronal después de la cirugía. Materiales y Métodos: Se realizó un estudio retrospectivo, descriptivo, observacional, entre enero de 2015 y enero de 2019, de pacientes con fracturas diafisarias de tibia, tratadas con clavo endomedular. Se obtuvieron radiografías en el posquirúrgico inmediato y luego cada dos meses, se tuvo en cuenta la radiografía del octavo mes, en la que se observaban signos francos de consolidación ósea, para valorar la alineación tibial. Resultados:Cuando el punto de entrada del clavo fue central, hubo apenas un 0,021 de posibilidades (o 2,1%) de alguna desalineación significativa en el posquirúrgico inmediato y luego de 8 meses. En cambio, cuando fue medial, las posibilidades de una tendencia al valgo fueron >0,85 (u 85%) ya al tomar la primera imagen, i.e., poscirugía; y cuando fue lateral, esta posibilidad se modifica y profundiza según el tiempo transcurrido hasta la imagen lograda en el paciente. Conclusión: Se observó una relación marcada y continua entre el punto de entrada del clavo endomedular y la alineación de la tibia después de la consolidación ósea. Nivel de Evidencia: IV

Introduction: Tibial fractures represent approximately 2% of adult fractures. Today, intramedullary nailing is the procedure of choice to treat diaphyseal fractures of the tibia; however, this technique is not exempt from complications, misalignment in the coronal plane is one of the most frequent and feared by surgeons. The aim of this study was to investigate the relationship between nail entry point and misalignment in the coronal plane after surgery. Materials and Methods: We carried out a retrospective, descriptive, observational study between January 2015 and January 2019 of patients with diaphyseal fractures of the tibia, treated with intramedullary nailing. Radiographs were obtained in the immediate postoperative period and then every two months. The eighth-month radiograph, in which clear signs of bone consolidation could be observed, was taken into account to assess tibial alignment. Results: When the nail entry point was central, there was only a 0.021 chance (or 2.1%) of any significant misalignment in the immediate postoperative period and after 8 months. In contrast, when it was medial, the chances of a valgus tendency were >0.85 (or 85%) already at the first image, i.e., post-surgery; and when it was lateral, this possibility was modified and deepenedaccording to the time elapsed until the image achieved in the patient. Conclusion: A marked and continuous relationship wasobserved between the entry point of the intramedullary nail and the alignment of the tibia after bone consolidation..Level of Evidence: IV

A rare complication of pelvic perforation by an excessive medial slide of the helical blade after treatment of an intertrochanteric fracture with proximal femoral nail anti-rotation: A case report and literature review / 中华创伤杂志(英文版)

Intertrochanteric fractures have become a severe public health problem in elderly patients. Proximal femoral nail anti-rotation (PFNA) is a commonly used intramedullary fixation device for unstable intertrochanteric fractures. Pelvic perforation by cephalic screw is a rare complication. We reported an 84-year-old female who fell at home and sustained an intertrochanteric fracture. The patient underwent surgery with PFNA as the intramedullary fixation device. Routine postoperative examination revealed medial migration of the helical blade that eventually caused pelvic perforation. We performed a cemented total hip arthroplasty as the savage procedure. At the latest follow-up of 12 months after total hip arthroplasty, the patient had no pain or loosening of the prosthesis in the left hip. Pelvic perforation should be considered when choosing PFNA as the intramedullary fixation device, especially in patients with severe osteoporosis wherein the helical blade can be easily inserted during the operation. The lack of devices to avoid oversliding of the helical blade in PFNA is an unreported cause of this complication and should be considered in such cases.

Comparative study between intramedullary interlocking nailing and minimally invasive percutaneous plate osteosynthesis for distal tibia extra-articular fractures / 中华创伤杂志(英文版)

PURPOSE@#Treatment of distal tibia fractures poses significant challenge to orthopedic surgeon because of poor blood supply and paucity of soft tissue coverage. There is considerable controversy regarding the superior option of treatment for distal tibia fracture between the minimally invasive percutaneous plate osteosynthesis (MIPPO) technique and intramedullary interlocking (IMIL) nailing for extra-articular distal tibia fractures. The aim of our study is to compare the functional outcome between the two treatment methods.@*METHODS@#This was the prospective comparative study of 100 patients with distal third tibia fractures divided into two groups. The first group of patients were treated with MIPPO technique while the second group of patients were managed by IMIL nailing. Patients were followed up in outpatient department to assess the functional outcomes, malunion, delayed union, nonunion, superficial and deep infection between the two groups. Statistical analyses were performed using the SPSS software (version 16.0).@*RESULTS@#Average malunion (degrees) in the MIPPO group was 5 (3-7) ± 1.41 vs. 10.22 (8-14) ± 2.04 in the IMIL group (p = 0.001). Similarly postoperative knee pain in the IMIL group was 10% vs. 2% in the MIPPO group (p = 0.001). In terms of superficial infection and nonunion, the results were 8% vs. 4% and 2% vs. 6% for the MIPPO and IMIL group, respectively (p = 0.001).@*CONCLUSION@#Both procedures have shown the reliable method of fixation for distal extra-articular tibia fractures preserving the soft tissue, bony vascularity and fracture hematoma that provide a favourable biological environment for fracture healing. Considering the results of the study, we have slightly more preference for the MIPPO technique.

Intraoperative IPC combined with 3M warming instrument to prevent lower extremity deep venous thrombosis in patients undergoing proximal femoral anti rotation intramedullary nailing / 中国骨伤

OBJECTIVE@#To explore the effect of intermittent pneumatic compression(IPC) combined with 3M thermometer on the prevention of deep venous thrombosis(DVT) in patients with femoral intertrochanteric fracture.@*METHODS@#From March 2016 to August 2019, 127 patients with femoral intertrochanteric fractures who underwent proximal femoral nail antirotation(PFNA) were retrospectively analyzed. They were divided into two groups according to different methods of thrombus prevention and treatment. Among them, 63 patients in group A did not use IPC and 3M thermometer;64 cases in group B were treated with IPC combined with 3M thermometer. Color Doppler ultrasound was used to dynamically monitor the DVT and changes of lower limbs during perioperative period. The venous thrombosis of lower limbs was monitored at 0, 24, 72 h and > 72 h after operation(recheck every 3 days until discharge).@*RESULTS@#Occurrence of DVT of lower limbs after PFNA operation in two groups:there were 5 cases (7.8%) in group B and 20 cases (31.7%) in group A, there was significant difference between two groups (P=0.001). There was no significant difference in lower limb DVT between two groups at 0, 72 and > 72 h after operation(P>0.05), but the formation rate of group A was significantly higher than that of group B at 24 h after operation (P=0.049). There was no significant difference in DVT formation between group A and group B(P>0.05). However, the formation of DVT in group A was significantly higher than that in group B(P=0.012).@*CONCLUSION@#Intraoperative IPC combined with 3M thermostat can effectively prevent DVT of lower limbs in patients undergoing PFNA surgery.

Morphometric evaluation of second to fifth metacarpals for retrograde intramedullary headless screw fixation / Evaluación morfométrica del segundo al quinto metacarpianos para la fijación retrógrada con tornillos intramedulares sin cabeza

SUMMARY: Intramedullary headless screw fixation has come to the fore in the treatment of metacarpal fractures in recent years with its advantages. Our aim was to evaluate the metacarpal morphometry for retrograde intramedullary entrance and to determine the optimal entry point. Computed tomography images of 105 patients including 64 men and 41 women, were examined. Distal and proximal metacarpal widths, medullary cavity width, cortex thickness and the measurements of the optimal entry site in volar-dorsal and radio-ulnar directions were measured in both coronal and sagittal planes. In the sagittal plane, the second metacarpal had the widest proximal width (16.29 mm), distal width was greatest in the third metacarpal (14.34 mm) which was significantly different between the sexes (p<0.001). Third metacarpal had the widest medullary cavity width in the sagittal plane (4.12 mm). In the coronal plane, it was the second metarcarpal with the widest proximal (16.14 mm) and distal width (13.92 mm) and was also the longest (66.32 mm). Unlike the sagittal plane, the medullary cavity width in the coronal plane was at the widest (4.06 mm) in fifth metacarpal. The points determined for optimal entry were respectively (4.60 mm; 4.97 mm; 4.55 mm; 4.36 mm) in the dorsal-volar plane, close to the dorsal side. There was no significant difference between the sexes for optimal insertion point in the sagittal planes in all the measured metacarpals. Considering its three dimensional structure, metacarpal bones have irregular morphometric properties and these features differ in sagittal and coronal planes. The optimal entry site is located in the midline in the coronal plane, while it is located in the sagittal plane close to the dorsal part. Knowing these properties can reduce the complication rate by reducing entry attempts and help select the correct material.

RESUMEN: En los últimos años, debido a sus ventajas la fijación intramedular con tornillos sin cabeza ha pasado a primer plano en el tratamiento de las fracturas de los huesos metacarpianos. Nuestro objetivo fue evaluar la morfometría del hueso metacarpiano para la entrada intramedular retrógrada y determinar el punto de entrada óptimo. Se examinaron imágenes de tomografía computarizada de 105 pacientes, incluidos 64 hombres y 41 mujeres. Los anchos de los huesos metacarpianos distal y proximal, el ancho de la cavidad medular, el grosor de la cortical y las medidas del sitio de entrada óptimo en las direcciones palmar-dorsal y radioulnar se midieron en los planos coronal y sagital. En el plano sagital, el segundo hueso metacarpiano presentó el mayor ancho proximal (16,29 mm), el ancho distal fue mayor en el tercer hueso metacarpiano (14,34 mm), lo que fue significativamente diferente entre individuos de ambos sexos (p<0,001). El tercer metacarpiano tenía la cavidad medular más ancha en el plano sagital (4,12 mm). En el plano coronal, era el segundo hueso metarcarpiano con mayor ancho proximal (16,14 mm) y distal (13,92 mm) y también era el más largo (66,32 mm). A diferencia del plano sagital, el ancho de la cavidad medular en el plano coronal era más ancho (4,06 mm) en el quinto hueso metacarpiano. Los puntos determinados para la entrada óptima fueron respectivamente (4,60 mm; 4,97 mm; 4,55 mm; 4,36 mm) en el plano dorsal-volar, próximo del lado dorsal. No hubo diferencia significativa entre ambos sexos para el punto de inserción óptimo en los planos sagitales en todos los huesos metacarpianos medidos. Teniendo en consideración su estructura tridimensional, los huesos metacarpianos tienen propiedades morfométricas irregulares, y estas características difieren en los planos sagital y coronal. El sitio de entrada óptimo se encuentra en la línea mediana en el plano coronal, mientras que se ubica en el plano sagital cerca de la parte dorsal. Conocer estas propiedades puede reducir la tasa de complicaciones al disminuir los intentos de entrada y ayudar a seleccionar el material correcto.

Evaluation of Intramedullary Methods with Polymethylmethacrylate for Fixation of Bone Lesions of the Extremities / Avaliação de métodos intramedulares com polimetilmetacrilato para fixação em lesões ósseas de extremidades

Abstract Objective To evaluate the better potential and functional results in pain control in the treatment of pathological fractures and prophylactic fixation with an intramedullary nail associated with polymethylmethacrylate, compared with the utilization of an intramedullary nail in long bone tumor lesions. Methods From January 2012 to September 2017, 38 patients with 42 pathological lesions (fractures or impending fractures according to the Mirels criteria) were treated surgically. Sixteen patients allocated to the control group underwent a locked intramedullary nail fixation, and 22 patients with pathological lesions were allocated to treatment with an intramedullary nail associated with polymethylmethacrylate. Postoperatively, the patients were submitted to the Musculoskeletal Tumor Society (MSTS) rating scale, radiographic assessment, and to the assessment of events and complications related to the treatment. Results The evaluation using the MSTS questionnaire showed better functional results in the group associated with polymethylmethacrylate, in comparison with the control group, which obtained an average score of 16.375 out of a maximum of 30 points (54.6%). The group studied with association with polymethylmethacrylate obtained a mean of 22.36 points (74.5%). The procedure proved to be safe, with similar complication and severity rates, and with no statistical difference in comparison with the standard treatment. Conclusion Stabilization of tumor lesions with an internal fixation associated with the polymethylmethacrylate demonstrated early rehabilitation and improved the quality of life, allowing rapid functional recovery. The use of polymethylmethacrylate has advantages such as reduced bleeding, tumor necrosis and higher mechanical stability.

Resumo Objetivo Avaliar o potencial melhor resultado funcional e controle álgico no tratamento de fraturas patológicas e fixações profiláticas tratadas com haste intramedular associada ao polimetilmetacrilato (PMMA) em comparação com o uso de haste intramedular em lesões tumorais em ossos longos. Métodos De janeiro de 2012 a setembro de 2017, 38 pacientes com 42 lesões patológicas (fraturas ou iminência segundo os critérios de Mirels) foram tratados cirurgicamente. Dezesseis pacientes submetidos a fixação com haste intramedular bloqueada foram alocados ao grupo controle e 22 pacientes com lesões patológicas foram alocados para tratamento com haste intramedular associada ao PMMA. No pósoperatório, foi realizada a submissão dos pacientes ao escore da Musculoskeletal Tumor Society (MSTS, na sigla em inglês) e à avaliação radiográfica do tratamento realizado, assim como à avaliação de intercorrências e complicações relacionadas ao tratamento. Resultados A avaliação através do questionário MSTS demonstrou melhor resultado funcional do grupo associado com PMMA quando comparado com o grupo controle, o qual obteve uma pontuação média de 16,375 em um máximo de 30 pontos (54,6%), enquanto o grupo em estudo com associação do PMMA obteve uma média de 22,36 pontos (74,5%). O procedimento mostrou-se seguro, taxas de complicações e gravidade semelhantes e sem diferença estatística quando comparado com o tratamento padrão. Conclusão A estabilização de lesões tumorais com fixação associada ao PMMA demonstrou reabilitação precoce e melhora na qualidade de vida, permitindo rápida recuperação funcional. A utilização do PMMA apresenta vantagens como diminuição do sangramento e da necrose tumoral e maior estabilidade mecânica.

Fractura de fémur proximal (31-A3. 2) asociada al uso de tenofovir en paciente VIH+: reporte de caso / Proximal femur fracture (31-A3. 2) associated with the use of tenofovir in an HIV-positive patient: case report

Presentamos el primer reporte de caso en paciente adulto con virus de la inmunodeficiencia humana (VIH + ) con fractura por fragilidad en fémur proximal asociada al uso de terapia antirretroviral (TARV) con fumarato de disoproxilo de tenofovir (FDT) en Chile. Actualmente, los pacientes diagnosticados con VIH inician tratamiento precoz con TARV, lo que implica mayor cantidad de años de exposición a los fármacos de la terapia. El tiempo de exposición acumulado al FDT se ha asociado a disminución de la densidad mineral ósea y falla renal progresiva, pudiendo el paciente desarrollar síndrome de Fanconi adquirido y osteomalacia, con riesgo aumentado de fractura. Presentamos el caso de un hombre de 44 años, VIH+ , evaluado en urgencia tras caída a nivel que resultó en fractura patológica del fémur proximal. Los exámenes de ingreso destacaron hipocalemia, hipocalcemia, hipofosfatemia e hipovitaminosis D. Se realizó manejo multidisciplinario, con suspensión del FDT, un cambio en la TARV, y suplementación con calcio y carga de vitamina D. Se realizó reducción cerrada y fijación con clavo cefalomedular largo, que evolucionó favorablemente con rehabilitación motora precoz; el paciente recuperó su funcionalidad previa, y se observó consolidación ósea a las 12 semanas. La aparición de dolor osteomuscular en pacientes VIH+ en TARV debe levantar alta sospecha clínica de efecto adverso a medicamento; el seguimiento de estos pacientes debe incluir el control seriado de la función renal y de los niveles séricos de calcio y fósforo. La búsqueda y sospecha de estas complicaciones permitiría una intervención precoz, mejorando la condición de los pacientes y previniendo fracturas patológicas.

We present the first case report of a human immunodeficiency virus (HIV)-positive adult patient with a fragility fracture of the proximal femur associated with antiretroviral therapy (ART) with tenofovir disoproxil fumarate (TDF) in Chile. Currently, patients diagnosed with HIV start ART early, resulting in more years of exposure to these drugs. The accumulated exposure time to TDF has been associated with a decreased bone mineral density and progressive renal failure, potentially leading to acquired Fanconi syndrome, osteomalacia, and an increased risk of fracture. We present a case of a 44-year-old, HIV-positive man assessed at the emergency room after a fall from standing height which resulted in a proximal femoral pathological fracture. Laboratory findings at admission revealed hypokalemia, hypocalcemia, hypophosphatemia, and hypovitaminosis D. Multidisciplinary management was performed, with TDF discontinuation, ART change, and supplementation with calcium and vitamin D. Closed reduction and fixation with a long cephalomedullary nail was successful, with early motor rehabilitation, functional recovery, and bone consolidation at 12 weeks. Musculoskeletal pain in HIV-positive patients on ART must raise the clinical suspicion of an adverse drug effect; the follow-up of these subjects must include serial monitoring of renal function and serum calcium and phosphorus levels. Screening and suspicion of such complications would enable an early intervention, improving the patients' condition and preventing pathological fractures.

Criterios radiográficos para la reducción rotatoria en fracturas diafisarias de húmero / Radiological criteria for rotational reduction in humeral shaft fractures

Introducción: La fractura diafisaria de húmero es frecuente y, en la actualidad, se privilegia el tratamiento quirúrgico. La consolidación en mala rotación puede causar un deterioro de la función y artrosis a largo plazo. Con las técnicas mínimamente invasivas, es difícil manejar la rotación intraoperatoria al no tener una visión directa de la reducción fracturaria. Objetivo: Describir criterios radiográficos para la reducción rotatoria en las fracturas diafisarias de húmero. Materiales y métodos: Estudio retrospectivo de radiografías de húmero comparando criterios radiográficos del húmero distal entre radiografías con rotación interna (sin retroversión proximal) y rotación externa (con retroversión fisiológica). Criterios estudiados: sobreproyección del epicóndilo lateral por sobre el capitellum >50%, esclerosis del borde inferior de la fosa olecraneana, esclerosis del borde lateral de la fosa olecraneana y asimetría de la fosa olecraneana. Resultados: El 97% de las 200 radiografías estudiadas cumplió con los criterios de inclusión y exclusión. Sobreproyección del epicóndilo por sobre el capitellum: 83,3% de los casos; esclerosis del borde inferior de la fosa olecraneana: 30%, esclerosis del borde lateral de la fosa olecraneana: 86,6% y asimetría: 80% de ellas. Todos los criterios con significancia estadística (p <0,001). Al analizar los tres signos positivos en conjunto, la sensibilidad fue del 70% y la especificidad, del 98%; valor predictivo positivo 95,5% y valor predictivo negativo 84,5%. Conclusiones: La rotación humeral correcta es difícil de reproducir en las cirugías mínimamente invasivas, en pacientes con una fractura diafisaria. Describimos cuatro criterios radiográficos que permiten inferir una correcta rotación humeral. Nivel de Evidencia: III

Introduction: Humeral shaft fractures are frequent and surgical treatment is currently favored. Consolidation in malrotation is a complication that can lead to impaired function and long-term osteoarthritis. In minimally invasive techniques, it is difficult to manage intraoperative rotation as there is no direct view of the fracture reduction. Objective: To describe radiological criteria for rotational reduction in humeral shaft fractures. Materials and methods: Retrospective study of humerus radiographs comparing radiological criteria of the distal humerus between radiographs with internal rotation (without proximal retroversion) and radiographs with external rotation (with physiological retroversion). Criteria studied: Overprojection of the lateral epicondyle over the capitellum of more than 50%; sclerosis of the lower border of the olecranon fossa (OF); sclerosis of the lateral border of the OF and asymmetry of the OF. Results: 200 radiographs were studied; 97% met the inclusion and exclusion criteria. Overprojection of the epicondyle over the capitellum was found in 83.3% of the cases. Sclerosis of the inferior border of the OF in 30%, sclerosis of the lateral border of the OF in 86.6%, and asymmetry of OF in 80%. All criteria with statistically significant (p<0.001). When analyzing the 3 positive signs, we found a sensitivity of 70% and a specificity of 98%. The positive predictive value was 95.5% and the negative predictive value was 84.5%. Conclusions: Correct humeral rotation is difficult to reproduce when performing minimally invasive surgeries in patients with a diaphyseal fracture. We describe 4 radiological criteria that allow inferring a correct humeral rotation. Level of Evidence: III

Versatilidad del clavo endomedular retrógrado largo de tibia para artrodesis tibio-talo-calcánea en pacientes con lesiones asociadas en el mismo segmento / Versatility of the tibia long retrograde intramedullary nail for tibiotalocalcaneal arthrodesis in patients with associated lesions in the same segment

Introducción: La afección articular que lleva a la necesidad de una artrodesis tibio-calcánea puede estar acompañada de una segunda lesión en el mismo segmento óseo, y los clavos de diseño para artrodesis no tienen la longitud adecuada para cubrir ambas lesiones. No hallamos opciones terapéuticas para este tipo de lesiones en la bibliografía. Objetivo: Presentar una serie de casos en los que se utilizó un único clavo de tibia (de colocación anterógrada) de forma retrógrada, con el doble objetivo de efectuar una artrodesis tibio-talo-calcánea, sumada al tratamiento de una lesión asociada en un mismo tiempo quirúrgico. Materiales y métodos: Se evaluó, en forma retrospectiva, desde septiembre de 2009 hasta junio de 2019, a un grupo de 12 pacientes que requirió una artrodesis tibio-talo-calcánea sumada a la necesidad de resolver simultáneamente un defecto secundario local. La edad promedio fue de 43.7 años, y el seguimiento global fue de 43.9 meses. Resultados: Todos los pacientes lograron una artrodesis tibio-calcánea constatada en radiografías de frente y de perfil, y el 83,3% recuperó el stock óseo de manera completa. Conclusión: Ante la ausencia en el mercado de osteosíntesis para resolver las patologías asociadas en un mismo paciente, proponemos el uso del clavo endomedular largo de tibia colocado de manera retrógrada como una opción de tratamiento, porque se ha demostrado que es eficaz para lograr la artrodesis tibio-calcánea. Además, se lo pudo utilizar como guía en el alargamiento y el transporte óseo, y como estabilización para tratar lesiones simultáneas. Nivel de Evidencia: IV

background: The joint condition that leads to the need for a tibiocalcaneal arthrodesis may be accompanied by a second injury in the same bone segment, and design nails for arthrodesis are not of adequate length to cover both injuries. We have not found therapeutic options for this type of injury in the literature. Objective: To present a series of cases where a single tibia nail (antegrade placement) was used retrogradely, with the dual objective of performing a tibiotalocalcaneal arthrodesis added to the treatment of an associated injury in the same surgical stage. materials and methods: We retrospectively evaluated a group of 12 patients who required a tibiotalocalcaneal arthrodesis as well as to simultaneously resolve a local secondary defect from September 2009 to June 2019. The average age was 43.7 (27-61) years, and the global follow-up was 43. 9 months. Results: All patients achieved a tibiocalcaneal arthrodesis confirmed in antero-posterior and lateral radiographs, and 83.3% of the patients recovered their bone stock completely. Conclusion: Faced with the lack of osteosynthesis in the market to resolve associated pathologies in the same patient, we propose the use of a long tibial intramedullary nail placed in a retrograde manner as a treatment option since it has proven to be efficient in achieving tibiocalcaneal arthrodesis. In addition, it could be used as a rail for bone lengthening and transport, and as stabilization to treat simultaneous injuries. Level of Evidence: IV