Stabilization of Comminuted Fractures of the Proximal Humerus with Intramedullary Nails and Angularly Stable Locking Plates-Functional Results before and during the SARS-COVID-19 Pandemics.

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

Outcomes of Reamed Intramedullary Nailing for Lower Extremity Diaphyseal Fractures in COVID-Positive Patients: A Multi-institutional Observational Study.

OBJECTIVE: To determine if reamed intramedullary nailing (IMN) of tibial and femoral shaft fractures exacerbated the hypercoagulable state of COVID infection, resulting in increased thromboembolic and pulmonary complications. DESIGN: Retrospective chart review. SETTING: Eleven Level I trauma centers. PATIENTS: From January 1, 2020, to December 1, 2022, 163 patients with orthopaedic trauma and COVID positivity and 36 patients with tibial and femoral shaft fractures were included. INTERVENTION: Reamed IMN. MAIN OUTCOME MEASURES: Incidence of postoperative thromboembolic and respiratory complications. RESULTS: Thirty-six patients with a median age of 52 years (range, 18-92 years; interquartile range, 29-72 years) met criteria. There were 21 and 15 patients with femoral and tibial shaft fractures. There were 15 patients sustaining polytrauma; of which, 10 had a new injury severity score of >17. All patients underwent reamed IMN in a median of 1 day (range, 0-12 days; interquartile range = 1-2 days) after injury. Two patients developed acute respiratory distress syndrome (ARDS) and 3 pneumonia. No patients had pulmonary embolism, deep vein thrombosis, or died within 30 days. CONCLUSION: In this multi-institutional review of COVID-positive patients undergoing reamed IMN, there were no thromboembolic events. All patients developing pulmonary complications (ARDS or pneumonia) had baseline chronic obstructive pulmonary disease, were immune compromised, or sustained polytraumatic injuries with new injury severity score of >20. Given this, it seems reasonable to continue using reamed IMN for tibial and femoral shaft fractures after evaluation for COVID severity, comorbidities, and other injuries. LEVELS OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Treatment preferences of orthopedic surgeons for closed, isolated middle-third diaphyseal long bone fractures without neurovascular injury in children: A cross- sectional survey.

OBJECTIVE: This study aimed to assess the treatment trends and the factors influencing the treatment methods of Orthopaedic Surgeons in closed, isolated, middle-third diaphyseal long bone fractures without any neurovascular injury in children. METHODS: This was a cross-sectional electronic survey of Turkish Orthopaedic Surgeons who were active members of the Turkish Society of Children's Orthopaedics (TSCO) and still managing the children's fractures in their daily clinical practice. An initial e-mail including the electronic survey followed by three reminder e-mails was sent to 110 members, and then reminder telephone calls were made. RESULTS: The survey response rate was 66/110 (60%). In recent years, a definitive trend to surgical treatment was not seen 98%, 77%, 39%, and 88% of the responders in the closed humerus, forearm, femur, and tibia mid-shaft fractures, respectively. Neither the years of expertise nor the intensity of daily pediatric patients of the participants did not affect the treatment trend in any fracture scenarios. The patient's age was the most cited factor influencing the responders' decisions on whether conservative or surgical treatment would be performed in each fracture scenario. The most cited lowest age limits for surgical treatment inclosed mid-shaft fractures of the humerus, forearm, femur, and tibia, were the adolescent age group, 10-12 years, six years, and ten years, respectively. CONCLUSION: This is the first study assessing the daily clinical practice of members of TSCO in the management of closed, isolated, non- complicated middle-third diaphyseal long bone fractures in children just before the covid-19 pandemic started. A marked tendency toward surgical treatment is seen in femur mid-shaft fractures, followed by forearm mid-shaft fractures up to a certain level. The patient's age is the main determinant of the responders' decisions on the type of treatment in closed, isolated, non-complicated middle-third diaphyseal long bone fractures in children.

Sliding hip screw vs intramedullary nail for AO/OTA31A1-A3: a systematic review and meta-analysis.

OBJECTIVE: to conduct a systematic review with consequent meta-analysis evaluating the best treatment for Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) 31A1-A3 trochanteric fractures when comparing the sliding hip screw (SHS) to the intramedullary nail (IMN). The outcomes used for comparison are major complications (in total, as well as nonunion and infection specifically), mortality rates, functional outcomes and patient-reported outcome measures (PROM). MATERIALS AND METHODS: Search strings for the Cochrane Library, CINAHL, Medline and Embase databases were developed with the help of a scientific librarian. Two authors screened the studies from the search string independently using Covidence.org and data extraction was performed similarly. Quality assessment was performed using the Cochrane Risk of Bias tool for randomised trials (ROB2) for RCT studies, and Cochrane Risk of Bias in Non-Randomised Studies - of Interventions (ROBINS-I) for non-RCT studies. Meta-analyses were performed using Log Risk Ratio as the primary effect estimate. RESULTS: Of the 2,051 studies screened by the two authors, six RCTs and six non-RCTs were included in this meta-analysis, with a total of 10,402 patients. The results indicated no significant differences in total major complications, nonunion, infection or mortality between SHS and IMN treatments for AO/OTA 31A1, 31A2 and 31A3 trochanteric fractures. Due to a lack of compatible data, we were unable to perform a meta-analysis on function scores and PROM. However, there are trends that favour IMN for 31A1 and 31A2 fractures. CONCLUSION: No significant difference between SHS and IMN was found in the meta-analysis in any of the examined AO/OTA fracture subtypes in terms of primary and secondary outcomes. When assessing function scores and PROM, we found trends favouring IMN for 31A1 and 31A2 fractures that should be explored further.

A preliminary experience with a new intramedullary nail for trochanteric fractures.

BACKGROUND AND AIM OF THE WORK: The worldwide incidence of fractures of the proximal end of the femur is increasing as the average age of the population rises. The current surgical gold treatment standard is intramedullary nail fixation. The Authors present their experience with the D-Nail system for intertrochanteric femur fractures. METHODS: From January 1st to February 21st 2020 (breakout of COVID-19 pandemic) 34 patients were treated with the D-Nail system: 11 with basicervical fractures, 16 with intertrochanteric stable fractures and 7 with intertrochanteric unstable fractures. In 11 cases, a single cephalic screw was used; in 23 cases, two of them were used. Distal locking was executed in 7 patients. Follow-up time ranged from 2 to 3 months. RESULTS: None of the reported intra- or post-operative complication was linked to the fixation device or the surgical technique. Patients were monitored with clinical and radiological checkups using modified Harris Hip Score to accurately evaluate the fluctuations in the rehabilitation period. CONCLUSION: The main advantages of this synthesis device are the proximal hole's peculiar shape, which allows the possibility to position one or two cephalic screws on the same nail, and the silicon coating, which provides numerous biological advantages. Distal locking was executed in selected cases only, based on fracture type. Optimum treatment involves rapid execution of surgery, minimal trauma during surgery, maximum mechanical stability, and rapid weight-bearing. Although our case number is small and follow-up time brief, our results are encouraging.