Intramedullary nailing for humeral shaft fractures: Is distal locking necessary?

INTRODUCTION: Intramedullary (IM) nailing of humeral shaft fractures is a reliable means to achieve bone union while allowing early motion. The hypothesis was that distal locking is unnecessary due to good primary stability of the impacted nail in the distal, truncated cone portion of the medullary canal. The primary objective of this study was to confirm the success of the procedure without distal locking by identifying failure criteria. The secondary objectives were to compare the outcomes of IM nailing with and without distal locking. MATERIAL AND METHODS: This was a retrospective, single-center, non-randomized study of 128 patients with a humeral shaft fracture between 2012 and 2020 treated surgically with a long IM nail. Proximal locking was done in every case, then the rotational stability of the nail was tested. Stable nails were not locked distally (group A), while unstable nails were locked distally through an anterior approach (group B). All patients were reviewed with at least 12 months' follow-up. RESULTS: Distal locking was performed in 30 patients (mean age 63, 17-91) while the fracture in 98 patients (mean age 65, 20-93) did not require distal locking. The average time to union was 4 months (2-6). The average operative time in group B was 87min (35-185) with 90s fluoroscopy time (33-158) versus 52min (20-127) with 44 s fluoroscopy time (12-143) in group A (p<0.05). Four patients in group B suffered postoperative radial nerve palsy and two others had another fracture at the level of the distal locking screws. The union rate did not differ between groups (Group A 94.6%, group B 86.2%, p=0.217) nor did the functional recovery - SSV of 79.5 (10-100) in group A versus 76 (40-100) in group B (p=0.271) - or the range of motion (p>0.05). There were no instances of rotational malunion. DISCUSSION: Except for certain distal third fractures, distal locking is not necessary to achieve bone union when the nail is impacted into the medullary canal. This reduces the operative time, fluoroscopy time and risk of neurological damage. LEVEL OF EVIDENCE: IV.

Identification and treatment of potentially destabilizing Vancouver B-lesser trochanter periprosthetic fracture ("New B2"): A 33-case series.

INTRODUCTION: A new type of periprosthetic fracture, between Vancouver-SoFCOT types A and B, was recently described and labeled "new B2". It occurs intraoperatively or in the early postoperative period, on cementless implants, and features a posteromedial cortical fragment around the lesser trochanter. The main aim of the present study was to report clinical and radiological results in a series of 33 cases of what is better called Vancouver B-lesser trochanter (VB-LT) fracture. The secondary objective was to identify risk factors. The study hypothesis was that VB-LT fracture might occur in the late postoperative course. MATERIAL AND METHOD: A2 single-center retrospective study included all patients with postoperative periprosthetic VB-LT fracture diagnosed on standard X-ray. Treatment was operative or non-operative depending on femoral implant subsidence and the patient's general health status. RESULTS: There were 33 VB-LT fractures out of 445 periprosthetic femoral fractures (7.5%), in 27 women and 6 men; all were postoperative, at a mean 47 months (range, 1 day to 20 years). Mean subsidence of the femoral stem was 8.8mm, in 73% of cases (24 out of 33 implants). The 9 VB-LT1 fractures (without subsidence) were treated non-operatively, without secondary displacement. Thirteen of the 24 VB-LT2 fractures (with subsidence) were managed by stem exchange and cerclage; 3 other patients had isolated stem exchange, 2 had isolated internal fixation by cerclage, and 6 in poor health were managed non-operatively. At a mean 28 months' follow-up (range, 6-48 months), mean PMA score was 15.5 (range, 10-18), Harris Hip score 72.4 (range, 43-100) and Parker score 7.2 (range, 4-9). All cases showed osseointegration and implant stability; there was 1 case of non-union, without impact on stability. CONCLUSION: Postoperative Vancouver B-lesser trochanter fracture seemed specific to cementless implants and did not occur exclusively in the early postoperative period. Non-operative treatment gave good results when there was no implant subsidence (type VB-LT1). LEVEL OF EVIDENCE: IV, retrospective.

Treatment of two or more metatarsal fractures.

INTRODUCTION: Metatarsal fractures are the most common type of foot fracture. When surgical treatment is needed, pinning is typically used, either percutaneous or open. However, this fixation method has been criticized by some authors who lament residual malunion and prefer to use plate and/or screws. The primary objective of our study was to compare the outcomes of K-wire versus plate and/or screw fixation for the surgical treatment of two or more metatarsal fractures. The secondary objective was to evaluate the factors that contribute to poor outcomes and complications. We hypothesized that plate and/or screw fixation will produce better functional outcomes than K-wire fixation. MATERIALS AND METHODS: This was a prospective and retrospective multicenter study carried out between 1 January 2010 and 1 June 2018 with a minimum follow-up of 12 months. Three functional scores were determined (AOFAS, FAAM and SF12 physical and mental) preoperatively, postoperatively and at the final assessment. We evaluated the outcomes in the entire study population and in four injury type subgroups, including one with isolated metatarsal fractures to control analysis bias. RESULTS: Our analysis compiled data from 165 patients (123 men, 42 women) who had a mean age of 38 years (16-82). The mean follow-up time was 27.9months (10-120). There were no complications in 130 patients (79%). Skin necrosis occurred in 25 patients (15%). The FAAM score was significantly higher in the plate and/or screw group 70.2 (17-84) versus 60.3 (31-84) in the K-wire group (P=0.033). The 78 (19-100) AOFAS was higher, but not significantly, in the plate and/or screw group versus 70 (12-100) in the K-wire group (P=0.144). CONCLUSION: Trauma to the foot that causes a fracture in two or more metatarsals often occurs due to a crush injury (39%). The frequency of associated bone lesions means that a preoperative CT scan should be done routinely to analyze the injury pattern and determine the best treatment. The fixation method should be adapted to the local conditions; when possible, it is preferable to use rigid fixation with plates and/or screws as it yields better functional outcomes. LEVEL OF EVIDENCE: IV; study with retrospective component.

Articulated bipolar vs. non-articulated conventional spacers: A comparative study of results from two-stage treatment of chronic septic arthritis in prosthetic or native hips.

INTRODUCTION: Infection is a serious complication of 0.2-0.7% of primary total hip arthroplasties (THA) and 1-22% of prosthetic revisions. The objective of our study was to compare two types of spacers (unipolar versus bipolar) for two-stage revisions of periprosthetic hip infections. The primary hypothesis was that bipolar spacers have fewer mechanical complications than unipolar spacers. The secondary hypothesis was that bipolar spacers decrease the rate of septic revisions and promote primary prosthesis reimplantation. MATERIAL AND METHOD: This retrospective, monocentric, multi-operator study was carried out between January 2012 and July 2018, including patients operated on for septic arthritis of the native or prosthetic hip (two-stage procedure). The patients were divided into two groups: group A, including the articulated spacers and group B, including the unipolar spacers. We studied the complications of the spacers and the course of the infection over a minimum of two years. Functional status was assessed by the Postel Merle d'Aubigné (PMA) score, the Harris Hip Score (HHS) and pre- and postoperative patient satisfaction scores. RESULTS: We collected data for 39 hips from 37 patients (mean age 63, 22 men and 14 women: 16 patients in group A, 21 in group B). We found no mechanical complications in group A versus 12 (52%) in group B. At 2 years, 93.8% of patients in group A no longer had any signs indicative of an active infection, compared with 71.4% in group B. In group A, the median PMA score increased from 5.5 (4-10.5) to 13.5 (12.5-15.5) and the HHS score from 27.5 (17-41.5) to 79 (64.5-89.5), postoperatively. In the final group B, the PMA score increased from 7 (6-9) to 14 (12-16) and the HHS score from 24 (11-41) to 72 (48-82) postoperatively. CONCLUSION: The use of articulated spacers in THA or septic THA two-stage revision significantly reduces the occurrence of mechanical complications in the short term, as well as the pain between the two procedures. LEVEL OF PROOF: IV.

Prospective assessment of trochanteric fracture managed by intramedullary nailing with controlled and limited blade back-out.

INTRODUCTION: The main objective of the present prospective study was to assess mechanical complications associated with an original intramedullary nail with limited and controlled blade back-out in the treatment of trochanteric fracture. MATERIAL AND METHOD: All patients treated for trochanteric fracture in a single orthopedic/traumatologic surgery department over a 2-year period were included. Minimum follow-up was 6 months. Fracture stability was assessed on the AO criteria. The TFP® intramedullary nail has a monobloc helicoid blade. Its main feature is the controlled and limited blade back-out, optimizing fracture site compression in weight-bearing, without the drawback of excessive back-out. The main endpoint was onset of mechanical complications: cut-out, intra-articular protrusion, non-union, and pain. Baumgaertner's Tip-Apex Distance (TAD), blade centering within the femoral head and fracture reduction were also assessed. RESULTS: One hundred thirty-eight patients (mean age, 83 years) were operated on, and 118 followed up. There were 9 mechanical complications (7.6%): 4 cut-outs (3.4%), 3 intra-articular protrusions (2.5%), 1 non-union (0.8%) and 1 case of pain (0.8%). TAD length was not associated with complications rate. Poor reduction was significantly associated with more complications (p=0.02), as was blade malpositioning. Mean back-out was 3.3mm, affecting 22 nails (19%). There were no complications in case of back-out, versus a 9.4% rate in absence of back-out, although this difference was not significant (p=0.21). There were no postoperative infections. CONCLUSION: The TFP® nail is useful for fixation of trochanteric fracture, whether stable or unstable, due to its low rate of mechanical complications compared to the literature.