Far cortical locking constructs for fixation of distal femur fractures in an Asian population: A prospective observational study.

BACKGROUND: The stiffness of locked plates suppresses healing process, prompting the introduction of far cortical locking to address this issue. This study aimed to demonstrate the clinical efficacy of far cortical locking constructs in treating distal femoral fractures in an Asian population. METHODS: This multicenter prospective observational study was conducted at four university hospitals between February 2018 and February 2021. Demographic data, the presence of metaphyseal comminution, and surgical fixation details were recorded. Clinical outcomes, including single-leg standing, EQ-5D, and EQ-VAS scores, and radiologic outcomes, including the RUST score of each cortex, were evaluated and compared according to the presence of metaphyseal comminution. RESULTS: There were 37 patients (14 men and 23 women) with a mean age of 67.3 ± 11.8 years. Twenty-two patients had metaphyseal comminution (59%), and 15 presented simple fractures in metaphyseal areas. Four patients (13%) could stand on one leg >10s at 6 weeks, and 24 patients (92%) at 1 year. EQ-5D increased from 0.022 ± 0.388 to 0.692 ± 0.347, and the mean EQ-VAS 51.1 ± 13.1 to 74.1 ± 24.1 between discharge (n = 37) and post-operative 1 year (n = 33), respectively. RUST score presented increment for time, from 6.2 ± 1.8 at 6 week to 11.6 ± 1.1 at 1 year. Radiological healing demonstrated rapid increase from week 6 (16/28, 43%) to month 3 (27/31, 87%), with no obvious increase was observed in 6 months (23/26, 89%) or 12 months (25/28, 89%). Simple metaphyseal fractures presented significantly higher RUST scores at 6 weeks and 3 months, but there was no difference in RUST scores at 6 months or 1 year according to metaphyseal comminution. CONCLUSIONS: Plate constructs with far cortical locking screws provided safe and effective fixation for distal femoral fractures, with consistent radiological and clinical results, regardless of metaphyseal comminution.

Induced membrane technique with plate fixation has a lower complication rate than bone transport over a plate for segmental tibial defects larger than 5 cm.

INTRODUCTION: The treatment of segmental tibial bone defects remains a surgical challenge. While Bone Transport (BT) and Induced Membrane Technique (IMT) are effective strategies for regenerating bone, there are few comparative studies between them. This investigation undertakes a comparative analysis of BT and IMT for large segmental tibial defects stabilised through plate fixation. MATERIALS AND METHODS: Patients with segmental tibial defects exceeding 5 cm were prospectively enrolled from 2008 to 2021 in a single institution, with a minimum follow-up duration of two years. All patients underwent either BT or IMT with plate fixation of the tibia. Procedural success, primary union as well as bone and functional outcome scores were compared. Complications, including non-unions, joint contractures and deep infections requiring surgical intervention, were also compared. RESULTS: 41 patients were recruited in total. 28 patients underwent Bone Transport Over a Plate (BTOP), while 13 patients underwent IMT with Plate fixation (IMTP). The procedural success rate trended higher in IMTP compared to BTOP (100% vs. 85.7%). The primary union rate also trended higher in IMTP compared to BTOP (92.3% vs. 79.2%). BTOP and IMTP achieved similar rates of satisfactory bone outcome scores (78.6% vs. 84.6%) and functional outcome scores (75% vs. 76.5%). There was no statistical difference between procedural success, primary union, bone and functional outcome scores. The complication rate in BTOP was 78.6% (22 of 28), including five docking site or regenerate non-unions, eight deep infections and nine joint contractures. IMTP had a 38.5% (5 of 13) complication rate, including one non-union, two deep infections and two joint contractures. The complication rate was 2.04 times higher in BTOP compared to IMTP (p = 0.0117). CONCLUSIONS: BTOP and IMTP are both equally effective techniques for regenerating bone in large tibial bone defects. However, IMTP may be a safer procedure than BTOP, with a lower probability of requiring additional procedures to address complications.

Clinical outcome of rim-plate-augmented separate vertical wiring with supplementary fixation for the treatment of patellar fracture associated comminuted inferior pole.

Despite the variety of treatment methods, comminuted inferior pole fractures of the patella remain difficult and technically demanding to achieve stable internal fixation. The purpose of this study is to evaluate the clinical outcomes of rim plate-augmented separate vertical wiring with supplementary fixation in the management of comminuted inferior pole fractures, AO/OTA 34-A1, C2, and C3, which has the secondary horizontal fracture line on lower articular boundary. From our study, bony union was achieved in all patients at an average of 3.1 ± 1.4 months after surgery. There was no patient with loss of reduction, fixation failure, or infection during follow-up. The average final range of motion was 131.6° ± 7.2°. Lysholm knee scores gradually increased over 3, 6, 9, and 12 months postoperatively by 58.7, 74.0, 82.9, and 89.4, respectively. Isokinetic peak torque deficit of the knee extensor muscles in 3, 6, 9, and 12 months postoperatively was 59.9%, 49.7%, 35.7%, and 28.1%, respectively. The rim plate-augmented separate vertical wiring with supplementary fixation for the treatment of patellar fracture associated comminuted inferior pole is effective and can be safely applied AO/OTA 34-C2 or C3 with favorable outcomes.

The Clinical Efficacy of Contouring Periarticular Plates on a 3D Printed Bone Model.

We report our experience of preoperative plate contouring for periarticular fractures using three-dimensional printing (3DP) technology and describe its benefits. We enrolled 34 patients, including 11 with humerus midshaft fractures, 12 with tibia plateau fractures, 2 with pilon fractures, and 9 with acetabulum fractures. The entire process of plate contouring over the 3DP model was videotaped and retrospectively analyzed. The total time and number of trials for the intraoperative positioning of precontoured plates and any further intraoperative contouring events were prospectively recorded. The mismatch between the planned and postoperative plate positions was evaluated. The average plate contouring time was 9.2 min for humerus shaft, 13.8 min for tibia plateau fractures, 8.8 min for pilon fractures, and 11.6 min for acetabular fractures. Most precontoured plates (88%, 30/34) could sit on the planned position without mismatch. In addition, only one patient with humerus shaft fracture required additional intraoperative contouring. Preoperative patient specific periarticular plate contouring using a 3DP model is a simple and efficient method that may alleviate the surgical challenges involved in plate contouring and positioning.

Application of an Intraoperative Limb Positioner for Adjustable Traction in Both-Column Fractures of the Acetabulum: A Technical Note with Clinical Outcome.

Traction of the ipsilateral leg is usually required to facilitate fracture reduction while operating both-column acetabular fractures. However, it is challenging to maintain constant traction manually during the operation. Herein, we surgically treated such injuries while maintaining traction using an intraoperative limb positioner and investigated the outcomes. This study included 19 patients with both-column acetabular fractures. Surgery was performed after the patient's condition had stabilized, at an average of 10.4 days after injury. The Steinmann pin was transfixed to the distal femur and connected to a traction stirrup; subsequently, the construct was affixed to the limb positioner. A manual traction force was applied through the stirrup and maintained with the limb positioner. Using a modified Stoppa approach combined with the lateral window of the ilioinguinal approach, the fracture was reduced, and plates were applied. Primary union was achieved in all cases at an average of 17.3 weeks. The quality of reduction at the final follow-up was found to be excellent, good, and poor in 10, 8, and 1 patients, respectively. The average Merle d'Aubigné score at the final follow-up was 16.6. Surgical treatment of both-column acetabular fracture using intraoperative traction with a limb positioner yields satisfactory radiological and clinical outcomes.

Prophylactic Femoral Neck Fixation in an Osteoporosis Femur Model: A Novel Surgical Technique with Biomechanical Study.

Intramedullary nailing (IMN) is a popular treatment for elderly patients with femoral shaft fractures. Recently, prophylactic neck fixation has been increasingly used to prevent proximal femoral fractures during IMN. Therefore, this study aimed to investigate the biomechanical strength of prophylactic neck fixation in osteoporotic femoral fractures. An osteoporotic femur model was created to simulate the union of femoral shaft fractures with IMN. Two study groups comprising six specimens each were created for IMN with two standard proximal locking screws (SN group) and IMN with two reconstruction proximal locking screws (RN group). Axial loading was conducted to measure the stiffness, load-to-failure, and failure modes. There were no statistically significant differences in stiffness between the two groups. However, the load-to-failure in the RN group was significantly higher than that in the SN group (p < 0.05). Femoral neck fractures occurred in all specimens in the SN group. Five constructs in the RN group showed subtrochanteric fractures without femoral neck fractures. However, one construct was observed in both subtrochanteric and femoral neck fractures. Therefore, prophylactic neck fixation may be considered an alternative biomechanical solution to prevent proximal femoral fractures when performing IMN for osteoporotic femoral fractures.

The role of an augmentative plating in the management of femoral subtrochanteric nonunion.

INTRODUCTION: Owing to its distinct biomechanical properties, nonunion is common (7-20%) after intramedullary (IM) nailing of subtrochanteric femoral fractures. Unlike diaphyseal nonunion, it is difficult to provide sufficient stability by exchanging nailing alone in subtrochanteric nonunion. This study investigated the clinical outcomes of femoral subtrochanteric nonunion initially treated with an IM nail and subsequently managed with minimally invasive augmentative plate fixation. MATERIALS AND METHODS: Nineteen patients were enrolled retrospectively. The mechanisms of initial injury were traffic accidents in 8, falls from a height in seven, and slipping in two patients. Two patients with atypical subtrochanteric femoral fractures without a specific trauma history were further included. All patients underwent IM nailing as the index operation. Nonunion surgery was performed an average of 45.2 weeks after the initial surgery. In cases of hardware damage and/or atrophic nonunion, exchange nailing and bone grafting were performed in addition to augmentative plating, as necessary. Conversely, augmentative plating alone was performed in cases of hypertrophic nonunion without any failure of the preexisting IM nail or malalignment. A narrow locking compression plate was fixed after contouring according to the shape of the proximal femur. The mean follow-up period was 36.1 months. RESULTS: Bony union was achieved in 18/19 patients (94.7%), at an average of 19.8 weeks after nonunion surgery. In the case that did not heal even after exchange nailing, additional plating and bone grafting, further autogenous bone grafting was required after 11 months, which healed uneventfully. There were 2 cases of soft tissue irritation over the plate, but no major complications were observed. CONCLUSIONS: Additional plate augmentation over a retained IM nail yields satisfactory outcomes in terms of the bony union in subtrochanteric nonunion. Given its expected biomechanical superiority and relatively easy surgical technique, it may be a reasonable option for the management of femoral subtrochanteric nonunion.

Iatrogenic radial nerve palsy in the surgical treatment of humerus shaft fracture -anterolateral versus posterior approach: A systematic review and meta-analysis.

BACKGROUND: Although many studies have investigated iatrogenic radial nerve palsy (RNP) in humerus shaft fracture, there is inconsistent evidence on which approach leads to iatrogenic RNP. Moreover, no meta-analysis has directly compared the anterolateral and posterior approaches regarding iatrogenic RNP. METHODS: In this systematic review and meta-analysis, the MEDLINE, Embase, and Cochrane Library databases were searched systematically for studies published before March 30, 2021. We included studies that (1) assessed the RNP in the surgical treatment of humerus shaft fracture and (2) directly compared the anterolateral and posterior approaches regarding the RNP. We performed synthetic analyses of the incidence of iatrogenic RNP and the recovery rate of iatrogenic RNP in humerus shaft fracture between the anterolateral and posterior approaches. RESULTS: Our study enrolled nine studies, representing 1303 patients who underwent surgery for humerus shaft fracture. After exclusion of traumatic RNP, iatrogenic RNP was reported in 35 out of 678 patients in the anterolateral approach and in 69 out of 497 patients in the posterior approach. Pooled analysis revealed that the incidence of iatrogenic RNP was significantly higher in the posterior approach than in the anterolateral approach (OR = 2.72; 95% confidence interval (CI), 1.70-4.35; P < 0.0001, I2 = 0%), but there was no significant difference in the recovery rates of iatrogenic RNP between the two approaches (OR = 1.55; 95% CI, 0.26-9.18; P = 0.63, I2 = 0%). CONCLUSION: In this meta-analysis, the posterior approach showed a higher incidence of iatrogenic RNP than the anterolateral approach in the surgical treatment of humerus shaft fracture. With limited studies, it is difficult to anticipate if any particular approach favors the recovery of iatrogenic RNP.

Masquelet Technique for the Tibia: A Systematic Review and Meta-Analysis of Contemporary Outcomes.

OBJECTIVE: To systematically review outcomes of the Masquelet "induced membrane" technique (MT) in treatment of tibial segmental bone loss and to assess the impact of defect size on union rate when using this procedure. DATA SOURCES: PubMed, EBSCO, Cochrane, and SCOPUS were searched for English language studies from January 1, 2010, through December 31, 2019. STUDY SELECTION: Studies describing the MT procedure performed in tibiae of 5 or more adult patients were included. Pseudo-arthrosis, nonhuman, pediatric, technique, nontibial bone defect, and non-English studies were excluded, along with studies with less than 5 patients. Selection adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. DATA EXTRACTION: A total of 30 studies with 643 tibiae were included in this meta-analysis. Two reviewers systematically screened titles or abstracts, followed by full texts, to ensure quality, accuracy, and consensus among authors for inclusion or exclusion criteria of the studies. In case of disagreement, articles were read in full to assess their eligibility by the senior author. Study quality was assessed using previously reported criteria. DATA SYNTHESIS: Meta-analysis was performed with random-effects models and meta-regression. A meta-analytic estimate of union rate independent of defect size when using the MT in the tibia was 84% (95% CI, 79%-88%). There was no statistically significant association between defect size and union rate ( P = 0.11). CONCLUSIONS: The MT is an effective method for the treatment of segmental bone loss in the tibia and can be successful even for large defects. Future work is needed to better understand the patient-specific factors most strongly associated with MT success and complications. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Radiographic rotational profiles of the proximal and distal humerus: analysis of 46 computed tomography scans with 3-dimensional simulation.

BACKGROUND: To date, no study has investigated the radiographic rotational profiles (RRPs) of the proximal and distal humerus. However, malrotation after minimally invasive surgery for humeral fracture has been an unsolved problem. Therefore, we aimed to investigate the RRPs of the proximal and distal humerus that linearly correlate with rotational status and show significant differences as the rotational status changes. METHODS: Forty-six computed tomography scans of the humerus were 3-dimensionally reconstructed, and 5 rotational statuses (20° and 10° of internal rotation; neutral; and 10° and 20° of external rotation) were simulated. Seven candidate RRPs of the proximal humerus and 4 candidates of the distal humerus were measured for each rotational status. The overall differences and trends in the RRPs as the rotational status changed were evaluated, and multiple comparisons were performed between the RRPs for each of the 5 rotational statuses. Moreover, the correlations between the RRPs and rotational status with adjustment of retroversion were analyzed. Finally, interobserver and intraobserver reliabilities were evaluated. RESULTS: The following proximal and distal RRPs were linearly correlated with rotational status, differed significantly between the rotational statuses, and showed a relatively low prediction error and excellent interobserver and intraobserver reliabilities: the distance from the tip of the lesser tuberosity to the lateral margin of the proximal humerus (PL1) and the medial margin of the head (PL2), as well as the PL1 to PL2 ratio (PRL), in the proximal humerus; and the distance from the medial margin of the olecranon process to the medial epicondyle (DOP), the widest width of the overlapped olecranon fossa (DOF), and the distance from the lateral margin of the capitellum to the lateral epicondyle (DC) in the distal humerus. CONCLUSION: Our findings suggest that PL1, PL2, and PRL in the proximal humerus and DOP, DOF, and DC in the distal humerus are potentially useful and reproducible RRPs for restoring the intrinsic rotational alignment in humeral fractures.

Outcome of multi-staged induced membrane technique based on post-debridement cultures for the management of critical-sized bone defect following fracture-related infection.

The authors' institution utilizes multi-staged induced membrane technique protocol based on post-debridement culture in treating patients with critical-sized bone defect in lower extremity due to infected nonunion or post-traumatic osteomyelitis. This study aimed to evaluate the success rate of this limb reconstruction method and which risk factors are associated with recurrence of infection. 140 patients were treated with multi-staged induced membrane technique from 2013 to 2018 and followed up more than 24 months after bone grafting. The primary success rate of limb reconstruction was 75% with a mean follow-up of 45.3 months. The mean Lower Extremity Functional Scale in success group improved from 12.1 ± 8.5 to 56.6 ± 9.9 after the treatment. There were 35 cases of recurrence of infection at a mean of 18.5 months after bone grafting. Independent risk factors for recurrence of infection were infected free flap, surprise positive culture, deviation from our surgical protocol, and elevated ESR before final bone graft procedure. In conclusion, this study showed that multi-staged induced membrane technique protocol based on post-debridement culture resulted in 75% success rate and revealed a number of risk factors for recurrence of infection.

Incomplete Diaphyseal Atypical Femoral Fracture due to Increased Anterolateral Bowing: Treatment with Corrective Osteotomy and Intramedullary Nailing with Augmented Plate Fixation.

BACKGROUND: Increased anterolateral bowing of the femur is associated with atypical femoral fractures among older patients (including both those receiving and those not receiving treatment with bisphosphonates) as well as a greater likelihood of occurring in the diaphyseal versus the subtrochanteric region. Prophylactic intramedullary (IM) nailing is recommended for the treatment of incomplete atypical femoral fractures, which are radiographically evident. However, this bowing deformity is considered to be a major obstacle to IM nailing as it may be associated with postoperative complications. Corrective osteotomy combined with IM nailing straightens the exaggerated curvature of the femur. We hypothesized that this technique may lead to the safe and rapid healing of incomplete diaphyseal atypical femoral fractures, thereby reducing lateral tensile stress. METHODS: From October 2015 through March 2020, 17 female patients (20 femora) with a mean age of 76.1 years (range, 68 to 86 years) underwent a surgical procedure for the treatment of an incomplete diaphyseal atypical femoral fracture associated with anterolateral bowing. The surgical technique consisted of minimally invasive osteotomy and reconstruction with use of IM nailing, with or without an augmentation plate. Preoperative and postoperative radiographic findings (lateral and anterior bowing angles, anterolateral bowing grade, and lateral distal femoral angle [LDFA]) were compared. Primary union, time to union, and complications were evaluated as the outcomes. RESULTS: Primary bone union was achieved in 19 of the 20 femora at a mean of 24.9 weeks (range, 20 to 40 weeks). There were 2 instances of delayed union, which healed at 36 and 40 weeks. The lateral bowing angle, anterior bowing angle, and LDFA significantly improved postoperatively (from 12.0° to 3.3°, from 17.3° to 11.5°, and from 93.5° to 88.8°, respectively) (p < 0.001). There was 1 instance of nonunion, which healed after plate augmentation without a bone graft. CONCLUSIONS: Given the pathophysiology of elevated lateral tensile stress, corrective osteotomy and IM nailing may be an acceptable solution for the treatment of incomplete diaphyseal atypical femoral fractures associated with increased anterolateral bowing. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

The difference in the corridor of the antegrade posterior column screw according to the presence of pelvic dysmorphism.

INTRODUCTION: Antegrade posterior column screw (aPCS) fixation via the anterior approach has been widely used for separated the posterior columns in acetabular fracture treatment. Although the relationship between pelvic dysmorphism and sacroiliac screws has been widely studied, no studies have reported on the clinical impact of pelvic dysmorphism on acetabular fractures. This study aimed to reveal the difference in the insertion angle and entry point of aPCS between the dysmorphic and normal pelvises. METHODS: Patients diagnosed with unilateral acetabular fractures and who underwent pelvic computed tomography scans between 2013 and 2019 in two institutes were enrolled in this study. Patients were divided into the dysmorphic and control groups according to the sacral dysmorphic score, which predicts the presence of pelvic dysmorphism, and each group enrolled 130 patients. The semitransparent 3D hemipelvis model was reconstructed using a 3D reconstruction program. The sagittal and coronal angles of a virtual cylinder that fill the safe corridor of the column screw the most were measured. The surface area of the safe corridor and distance of the optimal entry point from the anterior border of the sacroiliac joint were analyzed. The measurements were compared between the dysmorphic and control groups. RESULTS: The average sacral dysmorphic score in the normal and dysmorphic pelvis groups was 56.1 and 81.0, respectively. There were no significant differences in demographic data, including age, sex, height, weight, and body mass index, between the dysmorphic and control groups. There was a significant difference in the average sagittal insertion angle of PCs, which was 38.3° in the control group and 27.2° in the dysmorphic group (P < 0.001). The coronal insertion angles were not significantly different. The dysmorphic group presented longer straight distances (25.9 vs 24.8 mm, P = 0.026) and had a smaller aPCS surface area (685 vs 757 mm2, P < 0.001) than the control group. CONCLUSION: The present study describes a difference in the corridor of aPCS between the dysmorphic and normal pelvis. Insertion of aPCS in the dysmorphic pelvis requires a more acute angular trajectory in the sagittal plane than that in the normal pelvis.

Comparison of olecranon osteotomy and paratricipital approach in distal humerus intra-articular fracture: A systematic review and meta-analysis.

BACKGROUND: Surgical outcomes of the paratricipital approach (PT) and olecranon osteotomy (OO) for the treatment of distal humerus intra-articular fracture have been reported. However, there is no consensus regarding which approach is better in terms of functional outcomes and complications. This study aimed to compare the operation time, functional outcomes, and complications of OO and PT. METHODS: The databases of MEDLINE, Embase, and Cochrane Library were systematically searched for studies published before June 1, 2021. We performed synthetic analysis of the operation time, functional outcomes, and incidence of complication after the conduct of OO group or PT group in patients with distal humerus intra-articular fractures. RESULTS: Five studies were included representing a total of 243 patients who underwent surgery for distal humerus intra-articular fractures. A pooled analysis showed that there was a longer operation time in the OO group compared with the PT group (mean difference [MD] = 13.32, 95% CI: 3.78-22.87; P = .006). There was no significant difference between the functional outcomes of the OO and PT groups (elbow flexion: MD = 2.4, 95% CI: -0.82 to 5.79, P = .14; elbow extension: MD = 0.36, 95% CI: -2.20 to 2.92, P = .78; elbow arc of motion: MD = 0.40, 95% CI: -4.05 to 4.84, P = .86; Mayo Elbow Performance score: MD = -1.37, 95% CI: -4.73 to 1.98, P = .42). The incidence of infection was significantly higher in the OO group compared with that of the PT group (odds ratio [OR] = 3.82, 95% CI: 1.03-14.16, P = .04). There was no significant difference between the 2 groups in terms of the heterotopic ossification and ulnar neuropathy (OR = 1.85, 95% CI: 0.51-6.71, P = .35 and OR = 2.74, 95% CI: 0.60-12.48, P = .19, respectively). CONCLUSIONS: Since the choice of surgical approach does not influence outcomes, surgeons can base their choice of approach on the basis of their own experience and familiarity with the procedure and the need to visualize the entire articular surface in complex intra-articular fracture patterns.

Fragility Fracture Systems: International Perspectives - Asia & Australia.

Background: The incidence and burden of fragility fractures have reached the level where comprehensive systematic care is warranted to optimize the care of these patients. Hip fractures are the most frequently lethal and independence level changing fragility fractures, responsible for 30-day mortality comparable to high-energy trauma patients with injury severity scores over 12. It is a reasonable expectation that countries have a hip fracture treating system of care in place for this high-risk population. This review explores the systems of care from the Asia-Pacific Perspective. Methods: From the International Orthopaedic Trauma Association's member societies, nations from the Asia-Pacific Region were requested to contribute with an overview of their fragility fracture management systems. The content or the review was standardized by a template of headings, which each country endeavored to cover. Results: Australia, Japan, and South Korea contributed voluntarily from the 5 member countries of the region. Each country has made considerable efforts and achievements with diverse approaches to standardize and improve the care of fragility fractures, particularly hip fractures. Beyond the individual nations' efforts there is also an existing Asia-Pacific Collaborative. The data collection and in some counties the existence of a registry is promising; funding and recognition of the problem among competing health care budget priorities are common. Conclusions: Our review covers some of the countries with strongest economy and highest health care standards. The lack of a universal robust system for hip fracture care is apparent. The data collection from registry initiations is expected to drive system development further in these countries and hopefully fast track the development in other countries within the most populous geographical region of the Earth.

Stress fracture after implant removal from the tibia reconstructed by the induced membrane technique: A case report.

Background: The induced membrane technique promotes vascularization and corticalization of the grafted bone and has become one of the mainstays in treatment of segmental bone defects. However, there are clinical concerns regarding the quality of bony consolidation using the induced membrane technique including a thin cortex formation and cortical notching after consolidation. We present the case of a tibial stress fracture in the bone reconstructed by the induced membrane technique after implant removal. Case: A 49-year-old male presented post-traumatic osteomyelitis of the right tibia and was treated with staged segmental bone resection leading to an 11 cm defect which was reconstructed using the induced membrane technique. The patient requested implant removal at 33 months after bony consolidation. Four months after implant removal, he developed acute, atraumatic leg pain due to a tibial stress fracture caused by small notching in the reconstructed tibial segment. His stress fracture treated with intramedullary nailing and later healed uneventfully. Conclusion: Caution is warranted prior to implant removal from bone reconstructed by the induced membrane technique as cortical notching may result in stress fractures.

Treatment of Critical-Sized Bone Defects Involving the Ankle Joints: Staged Tibiotalocalcaneal Arthrodesis With Induced Membrane Technique and Intramedullary Nail.

OBJECTIVES: To report the outcomes of staged tibiotalocalcaneal (TTC) arthrodesis for critical-sized bone defects involving the ankle joints. DESIGN: Retrospective review of case series. SETTING: Two academic Level 1 trauma centers. PATIENTS/PARTICIPANTS: The study included 20 patients with critical-sized (≥2 cm) segmental bone defects around the ankle joints. INTERVENTION: Staged TTC arthrodesis was performed with induced membrane technique and retrograde intramedullary nail. MAIN OUTCOME MEASUREMENTS: We investigated the radiological evaluation, including modified radiographic union scale for tibia fractures score, time to union, and leg length discrepancy, and functional outcomes using foot and ankle outcome score and American Orthopaedic Foot and Ankle Society ankle-hindfoot score. RESULTS: The average bone defect was 6.4 cm (range: 2.4-12.3). Two of the 20 (10%) patients developed recurrence of infection. Fifteen patients (75%) achieved primary healing. Three patients (15%) were treated with repeated bone grafting and additional plating. The average time to union and leg length discrepancy were 10 months (range: 5-21) and 9 mm (range: 0-31), respectively. The mean foot and ankle outcome score and American Orthopaedic Foot and Ankle Society ankle-hindfoot score were 63 (range: 52-71) and 74 (range: 64-81), respectively. CONCLUSIONS: Staged TTC arthrodesis with induced membrane technique and intramedullary nail can be an effective treatment method for critical-sized bone defects involving the ankle joints. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Poller (blocking) screw with intramedullary femoral nailing for subtrochanteric femoral non-unions: clinical outcome and review of concepts.

INTRODUCTION: Surgery to treat nonunion resulted from malalignment is challenging since correction and bone union should be achieved simultaneously. To report the clinical outcomes achieved through reconstruction of sub-trochanteric femoral fractures by femoral nailing using a poller screw and to review the current concepts. MATERIALS AND METHODS: Fourteen patients (11 men and 3 women; mean age 56.4 years) who were diagnosed with non-union of subtrochanteric femoral fractures and who underwent intramedullary nailing with blocking screws between August 2013 and March 2019, with at least 1 year follow-up, were analyzed retrospectively. The preoperative and postoperative Centrum-Collum-Diaphyseal angle and anterior angulation angle were measured. Bone union time, position and number of poller screws used, and complications were analyzed. Functional assessment was performed by evaluating the Harris hip score. The related literature was searched, and 14 clinical studies on the treatment of sub-trochanteric non-union were analyzed. RESULTS: Bone union was achieved in 12/14 cases (85.7%) at the final follow-up within a mean of 6.52 (3-12) months. Bone union was also achieved in two patients lacking bone union at the final follow-up through bone grafting and augmented plating. No cases developed complications, including infection and bone necrosis, and the varus deformity and anterior angulation significantly improved from a preoperative mean of 12.4° and 9.4° to postoperative mean 3.8° and 2.4°, respectively. The mean Harris hip score at the final follow-up was 87.07 (73-98) points. Analysis of published literature revealed high rates of bone union (78-100%) through various fixation methods. CONCLUSION: Correction with blocking screws and rigid fixation with intramedullary nailing to treat sub-trochanteric-non-union-caused malalignment can yield good clinical and radiological outcomes.

Outcomes of embedded rafting k-wire technique for intermediate articular fragment fixation in comminuted olecranon fractures.

BACKGROUND: Severely comminuted olecranon fractures are challenging injuries. Commonly used tension band wiring exerts excessive compressive forces causing olecranon shortening and joint incongruity. This study aimed to introduce the embedded rafting k-wire technique with the bridging technique for intermediate articular fragment fixation in comminuted olecranon fractures and evaluate its clinical and radiological outcomes. MATERIALS AND METHODS: A total of 34 patients with comminuted olecranon fractures were treated with rafting k-wire fixation combined with a locking plate. Time to union, the number of rafting k-wires in the intermediate articular fragment, quality of joint reduction, and secondary reduction loss were analyzed. Elbow range of motion, Mayo Elbow Performance Score (MEPS), and complications were evaluated at the final follow-up. RESULTS: Fracture union was obtained in all patients. The mean number of intermediate articular fragments was 2.4 ± 0.7, and the average number of rafting k-wires was 3.0 ± 1.2. There were mild and moderate degree early posttraumatic osteoarthritis in 6 cases (17.6%) at the mean 20.8 months of follow-up. At the final follow-up, the mean range of elbow motion was 4.6° of flexion contracture and 133.5° of further flexion. The average MEPS was 97.1 (range, 75-100). Two patients had heterotrophic ossification without functional impairment. CONCLUSION: The embedded rafting k-wire technique with bridging plates in comminuted olecranon fractures exhibited satisfactory outcomes. This method might serve as an alternative when considering the ability to restore articular congruency and stability in severely comminuted olecranon fragments. LEVEL OF EVIDENCE: Level IV, therapeutic.

Peri-implant atypical femoral fracture after nail or plate osteosynthesis.

BACKGROUND: A lack of scientific information regarding the risk factors and diagnosis of peri-implant atypical femoral fracture (PI-AFF) exists. We report a case series of developed PI-AFF with a nail or plate construct wherein prior femoral fractures were already healed after osteosynthesis. This study aimed to identify the cause and risk factors of PI-AFF and to devise a preventive method based on this. METHODS: We identified 11 PI-AFFs displaying features of AFFs. All patients were ambulant females (mean age, 74.9 years). The mean T-score of the femur measured by DEXA (Dual Energy X-ray Absorptiometry) scan was 3.5. Osteosynthesis was performed with a plate and an intramedullary nail in six and five patients, respectively. Possible risk factors were investigated, including the used implant, the medication of bisphosphonate, the characteristics of previous fracture (AFF or non-AFF), and the co-existence of AFF on the contralateral side. RESULTS: The PI-AFFs developed at an average of 6.6 years from the time of prior fracture. All fractures were located at the screw through the plate or nail. Regarding anatomic locations, seven and four fractures were at the subtrochanteric area and diaphysis, respectively. Diaphyseal PI-AFFs occurred in plating cases, all of which were associated with excessive femoral bowing. Subtrochanteric PI-AFFs included all five patients with nail fixation, which occurred near a proximal interlocking screw. Six of the 11 patients were on bisphosphonate treatment before or at the time of fracture. The duration of bisphosphonate treatment was 6 years on average. Concerning the previous femoral fractures, seven and four patients were AFF and non-AFF, respectively. Considering the pathology on the contralateral leg, eight had suffered diaphyseal AFF. Four patients were treated nonoperatively. Seven patients needed an operation; 6 of them healed after reconstruction nailing, and one needed hip arthroplasty because of the associated displaced femoral neck fracture. CONCLUSIONS: PI-AFFs may develop through the screw hole at the subtrochanteric or diaphyseal area due to femoral fragility and stress riser effect of the implant. An improved osteosynthesis strategy may be necessary to avoid PI-AFFs when fixing osteoporotic femoral fractures.