Augmenting locking plate with autologous bone graft for the treatment of nonunion of long bone fracture in the lower extremity with retaining of the original intramedullary nail / 中国骨伤

OBJECTIVE@#To explore clinical effect of attaching locking plate with bone grafting based on retaining the original intramedullary nail in treating non-union after intramedullary nail fixation of long shaft fractures of lower limbs.@*METHODS@#A retrospective study was conducted on 20 patients treated with non-union fractures after intramedullary nailing of long shaft fractures of lower limbs from June 2015 to June 2020. All patients were treated with the original intramedullary nailing and bone grafting from the iliac bone, and were underwent open reduction plate internal fixation and bone grafting for old fractures. Among them, 14 were males and 6 were females, aged from 35 to 56 years old with an average of (42.2±9.6) years old. Nine patients were femoral shaft fracture and 11 patients were tibial shaft fracture. According to characteristics of fracture end nonunion, 6 patients were stable/atrophic, 9 patients were unstable/large, and 5 patients were unstable/atrophic. The nonunion time ranged from 8 to 12 months with an average of(9.8±2.0) months after the initial surgery. Visual analogue scale (VAS), knee range of motion, bone healing time, complications and fracture-end healing were recorded before and at the latest follow-up.@*RESULTS@#All patients were followed up for 18 to 48 months with an average of (36.3±10.5) months. The incision of all patients were healed at stageⅠwithout complications such as infection or internal fixation ruptur. Healing time of femur and tibia was (8.5±2.6) months and (9.5±2.2) months. Knee joint motion increased from preoperative (101.05±8.98) ° to postoperative (139.35±8.78) ° at the latest follow-up (t=-12.845, P<0.001). VAS decreased from preoperative (5.15±1.72) to postoperative (0.75±0.96) at the latest follow-up (t=11.186, P<0.001).@*CONCLUSION@#On the basis of retaining the original intramedullary nail, the addition of locking plate internal fixation and autogenous iliac bone grafting have advantages of simple operation, less trauma, fewer complications and high fracture healing rate. It is one of the effective surgical schemes for the treatment of nonunion after intramedullary nail fixation of long bone fracture of lower extremity.

Medium term follow up outcomes of uncemented total hip arthroplasty for traumatic arthritis after intramedullary nail fixation of femoral intertrochanteric fracture / 中国骨伤

OBJECTIVE@#To evaluate the effect of uncemented total hip arthroplasty(THA) on treatment of traumatic arthritis caused by intramedullary nailing interfixation of intertrochanteric fractures.@*METHODS@#Total of 22 patients treated with THA due to traumatic arthritis caused by intramedullary nailing interfixation of intertrochanteric fractures from January 2012 to January 2017 were studied retrospectively, including 10 males and 12 females with a mean age of (72.5±9.8) years old ranging from 61 to 84 years old. Initial internal fixation method:14 patients were treated with Gamma nails and 8 patients were treated wit PFNA.The time from internal fixation surgery to THA was 10 to 68 months with an average of (32.2±21.3) months.Harris scores of the hip joint before and after surgery were compared, and the position of the prosthesis through postoperative imaging at 3, 6, 12 months and the last follow-up were evaluated.@*RESULTS@#One patient was died due to heart failure 1 year after operation. Two patients was died to advanced tumor 2 years after operation. The other 19 patients were followed up for 36 to 64 months with an average of (48.5±11.9) months. At final follow up, 14 patients regained the ability to walk independently, 4 patients needed support of a cane, 1 patient needed assistance of a walker. No serious complications such as joint dislocation, periprosthetic fracture and deep venous thrombosis occurred during follow-up. There were no signs of loosening and subsidence of the prosthesis at the final follow-up. Mean Harris hip score increased from (29.2±12.9) points preoperatively to (74.2±11.2) points at the final follow up(P<0.05);the score was excellent in 9 patients, good in 7 and fair in 3.@*CONCLUSION@#Uncemented total hip arthroplasty for traumatic arthritis after intramedullary nail fixation of femoral intertrochanteric fracture can significantly improve hip function and effectively avoid bone cement implantation syndrome. The medium-term effect is satisfactory.

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.

Analysis of risk factors of perioperative blood transfusion in the treatment of femoral intertrochanteric fracture with proximal femoral nail antirotation / 中国骨伤

OBJECTIVE@#To explore the influencing factors of perioperative blood transfusion in the treatment of elderly femoral intertrochanteric fractures with proximal femoral nail antirotation(PFNA).@*METHODS@#The clinical data of 109 elderly patients with intertrochanteric fractures who received PFNA treatment from July 2018 to January 2020 were retrospectively analyzed. Both pelvic hip X-rays and CT plain scans were performed before surgery. All patients were diagnosed by X-ray and CT plain scan of pelvis and hip before operation. Through the statistical analysis of the basic data of patients before and during operation, the risk factors of perioperative blood transfusion were explored.@*RESULTS@#Logistic regression analysis showed that age (@*CONCLUSION@#Age, fracture type, diabetes history, and preoperative hemoglobin are independent risk factors for perioperative blood transfusion in the treatment of elderly intertrochanteric fractures with PFNA. The older the patient, the history of diabetes, the more unstable the fracture, and the lower preoperative hemoglobin, the more likely it is to require a blood transfusion, which may provide a reference for clinical perioperative blood transfusion decisions.

Prevention and treatment of complications in the treatment of femoral shaft closed fracture with core drilling intramedullary nail / 中国骨伤

OBJECTIVE@#To summarize the complications of core drilling intramedullary nail in the treatment of femoral shaft closed fracture and explore the treatment strategy.@*METHODS@#From August 2014 to June 2018, a total of 215 patients with closed femoral shaft fractures were treated with closed reduction core drill intramedullary nail, including 129 males and 86 females, aged from 18 to 62 years, with an average of (44.2±10.6) years old. The time from injury to operation was 3 to 21 days. There were 102 cases of AO type A fracture, 82 cases of AO type B fracture and 31 cases of AO type C fracture. The time of operation, the amount of blood loss during operation, the duration of hospitalization, the time of fracture healing and the HSS score of knee joint function at the last follow-up were recorded. The observation of complications included:iatrogenic fracture, core drill broken, core drill twist, postoperative infection, and fracture nonunion.@*RESULTS@#The average operation time was (63.2± 15.6) min and intraoperative blood loss was (150.0±34.5) ml. All the incisions reached grade A healing. Patients were follow up for a mean of (18.5±3.2) months, the average hospital stay was (4.3±1.2) days, and the average fracture healing time was (5.6±2.3) months. At the final follow-up, the average HSS score of knee joint was 90.3±4.7. Related complications occurred in 37 cases (17.2%). The core drill related complications occurred in 13 cases (6.0%), including core drill broken in 5 cases (2.3%), core removal in 1 case and slotting in 4 cases;core drill twist in 8 cases (3.7%). After the core was cut, the core was removed. Similar complicationsof conventional intramedullary nail:iatrogenic fracture was performed in 12 cases (5.6%), including 10 cases of fracture end split and 2 cases of distal perimedullary fracture of intramedullary nail. The patients with cleavage at the fracture end were not treated after judging their stability, and the patients with fracture around the distal end of the intramedullary nail were fixed with auxiliary steel plate during operation;1 case(0.4%) with delayed infection after operation, debridement and external fixation was replaced and healed after bone transfer; fracture nonunion occurred in 11 cases (5.1%), of which 7 cases (3.3%) were hypertrophic nonunion and healed with additional plate. Atrophic nonunion occurred in 4 cases (1.9%), which healed after additional steel plate and bone graft.@*CONCLUSION@#Core drilling intramedullary nail is an effective method for the treatment of closed femoral shaft fracture, and the complications include core drill related complications and conventional intramedullary nail similar complications. Accurate preoperative evaluation, careful operation during operation and early postoperative symptomatic treatment can effectively reduce the occurrence of related complications.

Effect and complications of proximal femoral anti-rotation intramedullary nail in the treatment of femoral intertrochanteric fracture in the elderly / 中国骨伤

OBJECTIVE@#To study the prognosis and complications of proximal femoral nail antirotation(PFNA) in the treatment of elderly intertrochanteric fracture.@*METHODS@#From January 2016 to November 2019, 127 cases of femoral intertrochanteric fracture were treated with PFNA, including 51 males and 76 females. The average age was 81.39±8.16 (range from 60 to 98). According to Evans classification, the numbers of cases of typeⅠa, typeⅠb, typeⅠc, typeⅠd and typeⅡwere 10, 46, 48, 16 and 7, respectively. Based on the AO /OTA classification, there were 10 cases of type 31-A1.2, 84 of type 31- A1.3, 17 of type 31-A2.2, 9 of type 31-A2.3, and 7 of type 31-A3. Preoperative and the final follow up, function of hip joint of patients treatedwith the PFNA were evaluated by harris hip score, and the postoperative complications were observed.@*RESULTS@#No incision infection occurred in all patients after PFNA. In this research, 4 cases failed in internal fixation, three of them underwent artificial femoral head replacement;5 cases died within one year after operation;2 cases had multiple embolizations of pulmonary artery branches, which recovered after anticoagulation treatment. There were 48 cases complicated with pneumonia, among which 9 cases had pulmonary inflammation before operation;27 cases with pleural effusion, 3 cases with acute heart failure, 3 cases with acute renal insufficiency, except one case died of pneumonia, pleural effusion, hypoproteinemia and respiratory failure during hospitalization, the other patients recovered after treatment. All 119 patients were followed up for 6 to 36 months, with an average of (17.01±6.03) months, Harris hip score increased from 8.96±5.40 preoperation to 83.57±8.92 at the final follow-up (@*CONCLUSION@#PFNA is a recommended option for the treatment of senile patients with intertrochanteric fracture. However, there were a lot of complications when femoral intertrochanteric fractures happened in aged patients, especially prevention and treatment of pulmonary embolism, promptly corrected low hemoglobin and low albumin, and reduce complications.

Correlation between metabolic syndrome and adverse events after internal fixation of femoral intertrochanteric fracture in the elderly / 中国骨伤

OBJECTIVE@#To explore the effect of metabolic syndrome on 15 days postoperative adverse events of femoral intertrochanteric fractures with internal fixation.@*METHODS@#From January 2011 to June 2019, 986 elderly patients with intertrochanteric fracture were treated with internal fixation, including 312 males and 674 females, with an average age of(77.71± 7.58) years old. And there were 97 patients with metabolic syndrome and 889 patients without metabolic syndrome. Through the electronic medical record system, the patient's age, gender, fracture type, cause of trauma, body mass index, smoking history, preoperative comorbidities, preoperative bloodtransfusion, operation timing, ASA classification, anesthesia method, internal fixation type, operation duration, and 15 days postoperative adverse events, which include surgical site infection, acute heart failure, acute respiratory failure, pulmonary infection, acute renal failure, DVT, embolism in important organs, urinary tract infection, death, and blood transfusion after surgery were collected. The differences of preoperative and intraoperative baseline datas and 15 days postoperative adverse events between the two groups were compared and analyzed by t text or univariate @*RESULTS@#There were statistical differences in age, body mass index, history of cardiac insufficiency, history of COPD, history of renal insufficiency, operation timing, ASA classification, operation duration, surgical site infection, acute heart failure, DVT, urinary tract infection and blood transfusion between two groups (@*CONCLUSION@#Elderly patients with intertrochanteric fracture with metabolic syndrome had higher postoperative surgical site infection rate, DVT incidence rate, urinary tract infection rate, and postoperative blood transfusion rate. Therefore, the orthopedic treatment team should give more attentionand optimize the treatment plan during the perioperative period with the cooperation of internal physician and anesthesiologist.

Técnicas de extracción de clavos endomedulares retrógrados de fémur rotos. Presentación de tres casos / Retrograde femoral intramedullary nail extraction techniques. Report of three cases

Introducción: La indicación de realizar una osteosíntesis con un clavo endomedular retrógrado en las fracturas de fémur se ha incrementado en los últimos años y, con ello, la cantidad de complicaciones. Se describen tres técnicas quirúrgicas para el manejo del fragmento proximal de la osteosíntesis endomedular rota. Desde marzo de 2001 hasta enero de 2019, se realizaron 321 osteosíntesis con clavos endomedulares retrógrados de fémur en nuestra institución. La tasa de rotura del implante asociada a una seudoartrosis fue del 0,9%. Se realizaron técnicas mínimamente invasivas para la extracción del implante, preservando las partes blandas. Se logró la reosteosíntesis definitiva con la consiguiente consolidación en un tiempo medio de 140 días. Conclusiones: Las técnicas utilizadas fueron simples, seguras, mínimamente invasivas y muy reproducibles. Nivel de Evidencia: IV

background: The indication for osteosynthesis with a retrograde intramedullary nail in femur fractures has increased in recent years and with it, the number of complications. Three surgical techniques are described for the management of the proximal fragment of the broken intramedullary osteosynthesis. From March 2001 to January 2019, 321 osteosyntheses with retrograde femoral intramedullary nails were performed at our institution. The implant rupture rate associated with nonunion was 0.9%. Minimally invasive techniques were performed to remove the implant, preserving the soft tissues. Definitive reosteosynthesis was achieved with the consequent consolidation in an average time of 140 days. Conclusions: The techniques used were simple, safe, minimally invasive, and reproducible. Level of Evidence: IV

Lo que no te contaron de las fracturas de fémur / What nobody told you about femur fractures

Introducción: Se relaciona la bibliografía con la experiencia de nuestros cirujanos frente a un instrumental defectuoso en el tratamiento de fracturas de fémur con osteosíntesis endomedulares. Objetivos: 1) Enumerar inconvenientes técnicos que se presentan en las cirugías de fémur, 2) comparar diferentes Centros y problemas afrontados, 3) estimar los canales de reclamo. Materiales y Métodos: 1) Estudio retrospectivo, de observación, descriptivo sobre historias clínicas y archivo radiológico, 2) encuesta en línea enviada a traumatólogos generales, 3) consulta con la ANMAT, el IRAM, los Ministerios de Salud de la Ciudad Autónoma de Buenos Aires y de la Nación. Resultados: 1) 31 pacientes con fracturas de fémur tratados con osteosíntesis endomedulares entre enero de 2008 y agosto de 2013. Dieciocho casos de fallas o defectos del instrumental de colocación en 14 pacientes. Los problemas más frecuentes fueron las guías y las mechas, 2) 270 respuestas, 19 provincias argentinas, respuestas de Colombia, Ecuador, Italia, Australia y Bolivia. Se obtuvieron 180 respuestas de Centros privados y 90 de Centros públicos, 3) cuatro vías de reclamo: ANMAT bajo el programa de Tecnovigilancia, IRAM por el incumplimiento de las Normas ISO 9001, Ministerio de Salud por incumplimiento de la resolución 255 y la Ley Básica de Salud N.º 153, art. 12 (ítems k y l) y AAOT, en la subcomisión de Implantes. Conclusiones: Queda explícita la diferencia entre Centros públicos y privados; sin embargo, el medio laboral solo definió la prevalencia de inconvenientes técnicos, pero los inconvenientes fueron los mismos. Existen formas para denunciar y enfrentar esta problemática.

Background: This paper intends to correlate data obtained from different orthopedic surgical teams and literature on faulty instrumentation during femoral fracture treatment with intramedullary nailing. Objectives: 1) To define technical problems arising during surgical procedures to treat femoral fractures; 2) to compare different centers and problems; 3) to analyze possible ways to find a solution. Methods: 1) A retrospective, descriptive, observational study on clinical records and radiologic files was performed; 2) an on-line survey was sent to orthopedic surgeons; 3) a query was sent to ANMAT, IRAM, and Ministerios de Salud de la Ciudad Autónoma de Buenos Aires y de la Nación. Results: 1) 31 intramedullary femoral nailing procedures were performed from January 2008 to August 2013. Eighteen cases of surgical tool deficiencies in 14 patients. More frequent problems were related to drill bits and guide wires; 2) 270 forms were filled up, from 19 provinces of Argentina, and from Colombia, Ecuador, Italy, Australia and Bolivia. We received answers from 180 private institutions and 90 public hospitals; 3) there are four possible ways to reach a solution: ANMAT with its Programa de Tecnovigilancia, IRAM for non-fulfillment of ISO 9001 rules, Ministerios de Salud for nonfulfillment of resolution 255 and Ley Básica de Salud N.º 153, art. 12, items k and l, and AAOT Implants Subcommittee. Conclusions: A clear-cut difference was established between public and private centers; however, the working place only defined the prevalence of technical problems, but problems themselves were the same. There are legal and administrative tools to deal with these problems.

Shaft Fractures of Both Forearm Bones: The Outcomes of Surgical Treatment with Plating Only and Combined Plating and Intramedullary Nailing

BACKGROUND: Plate fixation is the most commonly used technique for the treatment of shaft fractures of both forearm bones (SFBFBs). However, all fractures are difficult to treat with plate fixation because of soft tissue injuries, fracture patterns, or the patient's condition. The purpose of this study is to compare the functional results of plate fixation only and combined plate and intramedullary (IM) nail fixation in SFBFBs. METHODS: Fifty-nine cases of SFBFBs that were surgically treated from June 2007 to July 2012 were retrospectively reviewed. In this study, 47 cases that were followed up for more than 12 months were included. All SFBFBs were divided into two groups according to the methods used for internal fixation: plate fixation only (group A) and combined plate and IM nail fixation (group B). The fixation methods were determined intraoperatively. Plate fixation was considered as the first option in all cases, but combined plate and IM nail fixation was selected as the second option if it was difficult to be fixed with plate only. Groups A and B comprised of 31 and 16 cases, respectively. The functional results were evaluated by the Grace and Eversmann rating system and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. RESULTS: In groups A and B, a radiologic union was achieved in 30/31 and 14/16 cases and average union time was 11.1 and 17.8 weeks, respectively. According to the Grace and Eversmann rating system, group A had excellent results in 15 cases, good in 14, acceptable in one, and unacceptable in one. Group B had excellent results in three cases, good in nine, acceptable in two, and unacceptable in two. The average DASH score was 7.1 points (range, 0 to 19.2 points) in group A and 15.1 points (range, 0 to 29.6 points) in group B. Three cases of nonunion with unacceptable results achieved a bony union by additional procedures and the functional results of these cases improved to good or excellent. CONCLUSIONS: The functional results and the average union time were superior in group A than in group B. However, we think that combined fixation is a useful method for SFBFBs that cannot be treated with plate fixation only.

Flexible intramedullary nails with traction versus plaster cast for treating femoral shaft fractures in children: comparative retrospective study / Hastes intramedulares flexíveis com tração versus aparelho gessado para o tratamento de fraturas diafisárias do fêmur em crianças: estudo comparativo retrospectivo

Femoral fractures are common in children between 2 and 12 years of age, and 75% of the lesions affect the femoral shaft. Traction followed by a plaster cast is universally accepted as conservative treatment. However, in some situations, a surgical approach is recommended. The objective here was to compare treatments for femoral shaft fractures using intramedullary nails (titanium elastic nails, TEN) versus traction and plaster casts in children. The hypothesis was that TEN might provide better treatment, with good clinical results in comparison with plaster casts.

This retrospective comparative study was conducted in a public university hospital.

Sixty children with femoral fractures were evaluated; 30 of them underwent surgical treatment with TEN and 30 were treated conservatively using plaster casts. The patients' ages ranged from 5 to 13 years (mean of 9 years).

The mean duration of hospitalization was nine days for the surgical group and 20 days for the conservative group. The incidence of overgrowth in the patients treated with TEN was 60.0% and, for those treated conservatively, 13.3%. Partial weight-bearing was allowed after 3.5 weeks in the surgical group and after 9.6 weeks in the conservative group. New hospitalization was required for 90.0% in the surgical group and 16.7% in the conservative group. Patients treated with plaster casts presented higher incidence of complications, such as loss of reduction.

The surgical method presented better results for children. .

Fraturas femorais são comuns em crianças entre 2 e 12 anos de idade, e 75% das lesões acometem a diáfise. Tração seguida de aparelho gessado (“gesso”) é universalmente aceita como tratamento conservador. Entretanto, em algumas situações o tratamento cirúrgico é recomendado. O objetivo foi comparar o tratamento de fraturas diafisárias do fêmur com hastes intramedulares (titanium elastic nails, TEN) com tração e gesso em crianças. A hipótese era de que TEN pode ser melhor tratamento, com bons resultados clínicos em comparação com o gesso.

Este estudo retrospectivo e comparativo foi conduzido num hospital público universitário.

Sessenta crianças com fraturas de fêmur foram avaliadas, 30 delas foram submetidas a tratamento cirúrgico com TEN e 30 foram tratadas de forma conservadora usando gesso. A idade dos pacientes variou de 5 a 13 anos (média de 9 anos).

O tempo médio de internação foi de 9 dias para o grupo cirúrgico e 20 dias para o grupo conservador. A incidência de crescimento excessivo nos pacientes tratados com TEN foi de 60,0% e, para aqueles tratados de forma conservadora, 13,3%. Sustentação parcial de peso foi permitida após 3,5 semanas no grupo cirúrgico e após 9,6 semanas no grupo conservador. Houve 90,0% de novas internações no grupo cirúrgico e 16,7% no grupo conservador. Pacientes tratados com gesso apresentaram maior incidência de complicações, tais como perda de redução.

Outcomes of long bone fractures treated by open intramedullary nailing at the St Ann's bay hospital, Jamaica / Resultados clínicos de las fracturas de huesos largos tratadas mediante enclavijado intramedular abierto en el hospital de Saint Ann's bay, Jamaica

Between May 2001 to August 2004, 35 patients had open nailing of long bones. There were 40 fractures fixed. Of these 40 fractures, there were 25 femoral fractures, 11 were tibial fractures and 4 were humeral fractures. There were 33 (82.5%) closed fractures and 7 (17.5%) open fractures. In the group of patients with open fractures, there were two Grade I, two Grade II and three Grade IIIB. Seven (20%) patients were lost to follow-up; all of whom had closed fractures. The final analysis as it relates to complications was done using 28 patients with 32 fractures. The majority of fractures healed without significant complication. All the patients with closed fractures went on to bony union. There was one non-union and three delayed unions. There were two infections (osteomyelitis) and this was from the open fracture cohort. This represents an infection rate of 28.6% in this cohort. Two (7.0%) patients had persistent pain and one (3.6%) patient had early removal of the nail because of failure of fixation. The mean time from injury to surgery for the fractured femur was 15.5 (range 0-49) days; fractured tibia 24.4 (range 0-40), days and fractured humerus 41.5 (20-81) days. The mean hospital stay was 18.9 (range 9-37) days for patients with fractured femur; for fractured tibia, it was 20.5 (range 3-82) days and for fractured humerus, it was 22.7 (range 3-82) days. The mean postoperative stay was 4.1 (range 1-14) days for fractured femur, 4.5 (range 1-14) days for fractured tibia and 4.0 (range 1-10) days for fractured humerus. The mean time to healing (consolidation) as defined by X-rays was 5.0 (range 3-11) months for fractured femur, 5.2 ( range 3-11) months for tibia and 7.0 (range 6- 8) months for fractured humerus.

Desde mayo de 2001 hasta agosto de 2004, 35 pacientes recibieron reducción de fracturas de huesos largos mediante enclavijado a cielo abierto. Se produjeron 40 fijaciones de fracturas. De estas 40 fracturas, 25 fracturas fueron del fémur, 11 fueron de la tibia, y 4 del húmero. Hubo 33 (82.5%) fracturas cerradas y 7 (17.5%) fracturas abiertas. En el grupo de pacientes con fracturas abiertas, hubo dos fracturas de grado I, dos de grado II y tres de grado IIIB. El análisis final en cuanto a las complicaciones, se realizó con 28 pacientes con 32 fracturas. La mayoría de las fracturas se curaron sin complicaciones significativas. Todos los pacientes con fracturas cerradas lograron finalmente la unión ósea. Hubo uno que no logró la unión y tres uniones retardadas. Se produjeron dos infecciones (osteomielitis), provenientes de la cohorte de fractura abierta. Esto representa una tasa de infección del 28.6% en dicha cohorte. Dos (7.0%) pacientes presentaban dolores persistentes, y a un (3.6%) paciente le fue retirado el clavo tempranamente debido a que la fijación falló. El tiempo promedio desde la lesión hasta la cirugía, fue de 15.5 días (rango 0-49) para la fractura del fémur; 24.4 días (rango 0-40) para la fractura de la tibia, y 41.5 días (20-81) para la fractura del húmero. La estancia promedio en el hospital fue de 18.9 días (rango 9-37) para los pacientes con el fémur fracturado; para la fractura de la tibia fue de 20.5 días (rango 3-82), y para el húmero fracturado fue 22.7 días (rango 3-82). La estadía postoperatoria promedio fue 4.1 días (rango 1-14) para el fémur fracturado, 4.5 días (rango 1-14) para la tibia fracturada, y 4.0 días (rango 1-10) días para los casos de fractura del húmero. El tiempo promedio de sanación (consolidación) tal como lo definieron los rayos X fue 5.0 meses (rango 3-11) para el fémur fracturado, 5.2 meses (rango 3-11) para la tibia y 7.0 meses (rango 6-8) para el húmero fracturado.

Lesiones producidas en la rodilla durante el enclavado endomedular retrógrado del fémur. Estudio experimental en rodillas cadavéricas / Knee injuries due to retrograde nailing in the femur. Experimental study in cadaveric knees

Introducción: El enclavado intramedular retrógrado es una alternativa en el tratamiento de las fracturas del fémur. Las probables lesiones articulares en la zona de ingreso no están del todo aclaradas. El objetivo de este trabajo es evaluar, en rodillas cadavéricas, las lesiones que se producen con este abordaje. Materiales y métodos: Se reprodujo el procedimiento quirúrgico para la colocación de un clavo endomedular retrógrado con un abordaje mínimamente invasivo en 12 rodillas cadavéricas. Luego se realizó su disección. Resultados: En cuatro rodillas (33 por ciento) se produjeron lesiones osteocondrales: tres en la zona de inserción delligamento cruzado anterior y una en el cóndilo interno. Conclusiones: Existe una alta posibilidad de producir lesiones iatrogénicas durante la colocación de un clavo retrógrado. La asistencia artroscópica podría reducir esa posibilidad.

Outcome of supracondylar fractures of the humerus in children treated by closed reduction and percutaneous pinning.

Supracondylar fractures of humerus in children are common injuries. Displaced fractures are inherently unstable. Conservative treatment results in malunion. Open reduction and internal fixation (ORIF) is more invasive and recovery is prolonged. From September 2004 to September 2005, 102 displaced supracondylar fractures of humerus, aged between one and half year to 13 years, were treated using close reduction and percutaneous Kirschner (K) wire fixation under c-arm fluoroscopy. Seventy nine patients were treated by cross K-wires and in twenty three cases lateral two K-wires were put. Above elbow plaster of paris back slab was applied in all cases for at least four weeks. Back slab, K-wires were removed after four weeks and elbow range of motion exercise was started. Results were analyzed using Flynn's criteria. All patients were followed up to 14th week postoperatively. In cross K-wire group(N=79) 70.8% had excellent, 22.7% good, 3.8% fair and 2.5% had poor results at eight weeks follow up which was improved to 91.1% excellent, 6.3 good, 1.2% fair and 1.26% poor results at 14 weeks follow up. In lateral K-wire group (N=23) 70% had excellent, 21.7% good, 4.3% fair and 4.3% had poor result at eighth week which was improved to 91.3% excellent, 4.3% good, 4.3% fair and no poor result at 14th week follow up. Eight patients got superficial pin tract infection and seven patients sustained ulnar nerve injury post operatively. We recommend this procedure for displaced supracondylar fractures in children as it is safe and cost effective procedure with acceptable complication rates.

Comparative study of the locked intramedullary nail and Ender pins in the treatment of tibial diaphyseal fractures

OBJECTIVE: To compare the locked, unreamed intramedullary nail with Ender pins in the treatment of open Gustilo grade I or II or closed tibial diaphyseal fractures of type A, B, or C2 of the AO classification. MATERIALS AND METHODS: Forty-four patients with unilateral tibial diaphyseal fractures were treated with intramedullary nails or Ender pins. Twenty patients were treated with an unreamed intramedullary nail with access via the patellar tendon with static locking. Twenty-four patients were treated with Ender pins introduced medially and laterally with respect to the tuberosity of the tibia. The main parameters analyzed were type of reduction, complications, union rate, deformities, joint mobility, pain, gait, effort capacity, presence of neurovascular disorders, and complaints related to the synthesis material. RESULTS: During 1 year of follow-up, the fractures of 90.0 percent of the patients with intramedullary nails and 95.7 percent of patients with Ender pins healed within an average of 21.5 weeks and 20.9 weeks, respectively. The significant findings were as follows: patients treated with Ender pins had less mobility of the subtalar joint; patients treated with intramedullary nails were more likely to have pain in the knee; both groups showed shortening of the tibia at the end of 1 year of treatment. CONCLUSIONS: The two methods are similar in the treatment of type A, B, and C2 tibial diaphyseal fractures.

OBJETIVO: Comparar a haste intramedular bloqueada não-fresada com os pinos de Ender no tratamento das fraturas da diáfise da tíbia tipos A, B ou C2 da classificação AO, fechadas ou expostas graus I ou II de Gustilo. MATERIAIS E MÉTODOS: 44 pacientes com fratura unilateral da diáfise da tíbia, tratados com HIB ou com pinos de Ender. Vinte pacientes foram tratados com uma haste intramedular bloqueada não fresada por acesso através do tendão patelar e com bloqueio estático; vinte e quatro pacientes com pinos de Ender introduzidos medial e lateralmente à tuberosidade da tíbia. Principais parâmetros analisados: tipo de redução, complicações, consolidação, deformidades, mobilidade articular, dor, marcha, capacidade para esforços, distúrbios neuro-vasculares e desconforto pelo material de síntese. RESULTADOS: No seguimento de um ano, 90,0 por cento das hastes intramedulares e 95,7 por cento dos pinos Ender dos pacientes apresentaram consolidação da fratura com tempo médio de 21,5 e 20,9 semanas, respectivamente. Os achados significantes foram: mobilidade da articulação subtalar menor nos pacientes tratados com pinos de Ender; dor no joelho mais freqüente nos pacientes tratados com HIB; encurtamento da tíbia nos dois grupos ao final de um ano de tratamento. CONCLUSÕES: Os dois métodos são semelhantes no tratamento das fraturas da diáfise da tíbia tipos A, B e C2.

An innovative technique to cut and extract loose bent Kuntscher nail.

Removal of a grossly deformed nail can be a serious and perplexing problem. We report an innovative technique to cut and extract a loose bent Kuntscher nail. The technique is simple and effective; can be used in peripheral hospitals where advanced gadgetries may not be present.

Análisis de la pseudoartrosis de la clavícula / An assessment of pseudoartrhosis of the clavicle

Se revisa una serie no comparativa de 12 pacientes con diagnóstico de pseudoartrosis de la clavícula, con edades que variaron de 18 a 50 años, tratados de 1994 a 1997. El tratamiento incial había sido conservador en 11 casos y sólo uno con enclavamiento. De los 12 casos, en 2 se encontró solamente un callo óseo protuberante que se trató con remodelación quirúrgica. Los 10 restantes se trataron con plastía de la pseudoartrosis y clavo intramedular bloqueado e injerto óseo. En todos los pacientes operados apareció callo primario en promedio a las 6 semanas después de la plastía de la pseudoartrosis. A pesar del número de pseudoartrosis aquí reportado, se sigue enfatizando la importancia de la indicación de tratamiento quirúrgico de las fracturas primarias de la clavícula únicamente en las tipo III de la clasificación AO, modificada en México por Inárritu

Secuelas post-traumáticas en el canal espinal de pacientes con instrumentación segmental / Sequelae of the spinal canal after segmental instrumentation in trauma patients

Reportamos las secuelas post traumáticas del canal espinal de 53 pacientes con fijación segmental de Luque. Por un lado, los hallazgos fueron secundarios al trauma y por otro lado, al método de instrumentación segmental. Basado en la cantidad y severidad de las secuelas, creemos que la técnica quirúrgica debe ser modificada.

Efectos de la osteosíntesis medular sobre la eritropoyesis / Effects of medular osteosynthesis on erithropoiesis

Una preocupación general de los ortopedistas al colocar un clavo intramedular consiste en la lesión de la médula ósea, lo que pudiera afectar la eritropoyesis. Con el propósito de revisar lo anterior, los autores efectuaron osteosíntesis con clavo Colchero intramedular con pernos en 39 pacientes con 23 fracturas (8 de fémur y 15 de tibia), 15 no uniones (3 de fémur y 12 de tibia) y una dismetría congénita de tibia. Para saber si la lesión de la médula ósea afectaba o no la eritropoyesis, se analizó en cada uno de los pacientes el comportamiento de los reticulocitos, precursores de los eritrocitos, encontrando que no sólo no hubo alteración en estas células, sino un aumento en los 15 primeros días, volviendo después a la normalidad. El estudio se dividió en tres etapas: prequirúrgica, quirúrgica y posquirúrgica, ésta última con un seguimiento de 15, 30, 60 y 90 días. Se añadió un grupo control de 60 personas no fracturadas.

Tratamiento de las fracturas diafisiarias de la tibia con clavos de Ender / Treatment of diaphyseal fractures of the tibia with Ender's nails

Se revisaron en forma retrospectiva las historias clinicas de los pacientes a los que se les practico enclavijamiento medular con Ender por fracturas de la tibia, entre febrero de 1985 y febrero de 1987 en el Hospital Universitario de la Samaritana. El trabajo consta ademas de una fase prospectiva, para la cual se ideo un protocolo en el que se incluyeron aquellos pacientes que consultaron en fecha posterior a febrero de 1987. Parte fundamental de este protocolo fue la enumeracion de indicaciones y contraindicaciones para la utilizacion de los clavos de Ender. De un numero total de 27 pacientes, 20 cumplieron los requisitos de inclusion, 14 hombres, 6 mujeres; con un promedio de edad de 33.2 anos, 5 fracturas abiertas, 15 cerradas. 6 pacientes presentaban fractura de femur, 5 ipsilaterales. La cirugia es relativamente sencilla, con las ventajas de un procedimiento "cerrado". La estabilidad obtenida fue muy adecuada. Se estandarizo un manejo postoperatorio. El tiempo de consolidacion se acelero considerablemente. (Promedio 11.2 semanas). Se trata de una excelente alternativa para el tratamiento de las fracturas de "alta energia" de la tibia.