External fixation as definitive treatment or external fixation followed by early fixation in open fractures of the tibial shaft: A descriptive study.

INTRODUCTION: Treatment options for open tibial shaft fractures include external fixation with or without early conversion to internal fixation. OBJECTIVES: The aim of this study was to describe 1) early conversion to internal fixation and definitive external fixation and 2) in case of conversion, to identify risk factors for complications. METHODS: Seventy-two external fixations of open fractures of the tibial shaft (Gustilo classification, 7 fractures (9.7 %) grade I, 25 fractures (34.7 %) grade II, 40 fractures (55.6 %) grade III (31 grade IIIA and 9 grade IIIB)) were included in a continuous non-randomised study. Thirty-three fractures without infection signs were converted to internal fixation at a mean time of 40.5 +/-15 days (IF group). External fixation was maintened in the remaining 39 fractures (EF group). RESULTS: In the "IF" group, the union rate was 69.7 % at 6.3 +/-3.6 months (3-16). All patients had complete union at 16 months, requiring 2.8 +/-0.8 reoperations. Fixation with external fixation only ("EF" group) showed a union rate of 51.3 % at 8.9 +/-4 (5-22) months and 96 % at 16 months after 3.7 +/-0.9 reoperations. Superficial infection (12.1 %; p = 0.011) and numerous surgeries (2.76; p = 0.004) were found to be risk factors for deep infection. Time to wound closure >7 days (p = 0.049), time to reoperation >28 days (p = 0.00), numerous surgeries (2.76; p = 0.004) and deep infection (6.1 %; p = 0.027) were found to be union failure factors. CONCLUSION: Early conversion of external fixation to internal fixation is an effective option to achieve bone union of open tibial fractures in selected patients.

Full weight bearing after internal fixation of isolated distal fibular fractures with anatomically contoured locking plates: Our institutional experience.

Isolated fractures of the distal fibula mainly affect young, active people. In most cases, fixation is by open reduction with or without casting for six weeks without weight bearing. The current trend is to reduce this period of non-weight-bearing in order to promote earlier functional rehabilitation. The improved mechanical stability resulting from the use of plates with locking screws has changed the postoperative management of many fractures, but there is little evidence for the ankle. Between October 2013 and August 2015, 36 patients were enrolled in a prospective study to evaluate the performance of internal fixation of isolated distal fibular fractures using a lateral anatomically contoured titanium locking plate (InitialA® plate from Newclip Technics, Haute Goulaine, France) with immediate mobilisation and full weight bearing. No patient required further surgery due to mechanical failure or non-union. The bone healing rate was 100 % at 3 months. Two patients had septic complications requiring plate removal and antibiotic treatment and were eventually cured. The use of anatomically contoured locking plates provides strong and stable fixation, allowing immediate full weight-bearing. Such a technique has the advantage of a short recovery time and an early return to work without additional complications.

Can the Reamer/Irrigator/Aspirator System replace anterior iliac crest grafting when treating long bone nonunion?

INTRODUCTION: Autologous bone graft is the gold standard for filling bone defects associated with diaphyseal nonunions. It is typically harvested from the anterior iliac crest (AIC) despite the high complication rate. The Reamer/Irrigator/Aspirator System (RIA) was developed to recover the reaming aspirate and use it as autograft. Initially described for harvesting bone from the femur, the bone volume available is similar to the AIC site; however, its use directly at nonunion sites has been studied very little. HYPOTHESES: Compared to AIC harvesting, RIA at a non-union site will result in (1) sufficient bone volume, (2) similar time to union and union rate, (3) lower morbidity. RESULTS: Two groups of patients received an autograft for aseptic nonunion of the tibia or femur for a bone defect up to 2cm: the RIA group (n=30) was followed prospectively and received an autograft by RIA while the AIC group (n=29) was reviewed retrospectively and received an autograft by AIC. We compared the time to union and union rate, operative time, intake of analgesics, duration of hospital stay and complication rate between groups. The RIA provided sufficient bone, 60cm3 on average in a reliable manner. The union rate was similar between groups: 90% (RIA) and 89.7% (CIA) (p=0.965), while the time to union was shorter in the RIA group (8.63±1.47months vs. 10.08±1.7 months) (p=0.006). The operative time (p<0.0001), analgesic intake (p=0.013), length of stay (p<0.0001) and immediate complication rate (p=0.0195) were higher in the AIC group. DISCUSSION: For the treatment of aseptic long bone nonunion, autograft harvested by the RIA from the nonunion site results in similar union rate and time to union as AIC grafts without additional complications. LEVEL OF EVIDENCE: IV, comparative retrospective study.

Long-term results of custom cementless-stem total hip arthroplasty performed in hip fusion.

INTRODUCTION: Due to complex anatomical considerations, results of cementless-stem total hip arthroplasty (THA) in hip fusion remain controversial compared with conventional THA. We therefore aimed to analyse 3D anatomy of the fused hip based on pre-operative computed tomography (CT) scans, functional outcomes based on the Harris Hip Score (HHS) and the Hip Disability and Osteoarthritis Outcome Score (HOOS), modifications of hip anatomy based on post-operative standardised radiography, and determine complication rate and long-term survival based on Kaplan-Meier analysis. METHODS: We retrospectively studied 23 hips that underwent conversion of a fused hip to THA using a 3D CT scan-based custom titanium (Ti alloy hypoxyapetite (HA)-coated stem. The mean follow-up was 15 (9-22) years. Femur anteversion ranged from -29° to 80°. RESULTS: HHS improved from 59 to 89 points and average range of motion (ROM) was 88° for flexion. Back pain decreased in 62%, and knee pain decreased in 42%. The mean post-operative leg-length discrepancy was 7.8 mm. No intra-operative complications occurred. One aseptic stem loosening for mechanical failure was observed. The Kaplan-Meier survivorship considering revision for any reasons as the end point was 95.6% [95% confidence interval (CI) 92.4-98.8] at 15 years. CONCLUSION: Custom cementless stems may be an interesting solution to address the particular anatomical features of hip fusion at the time of THA, with an excellent survival rate at 15 years.