Osteogenesis Imperfecta type 1: like mother, like daughter - Challenges in the perinatal management.

A third gravida with osteogenesis imperfecta (OI) type 1, in her 20s, was referred from the Medical Genetics department at 12+ weeks with a prenatal diagnosis of OI type 1 in this fetus for further management. She was wheelchair-bound and keen to continue this pregnancy. She had medical termination in her two previous pregnancies for OI in the fetuses. Ultrasound at 12+ weeks revealed a short-bent femur with sparing of the long bones of the upper limb. Serial ultrasound revealed progressive affliction of the long bones with falling growth profile and polyhydramnios. She was delivered at 36 weeks by caesarean for breech in labour under regional anaesthesia.A multidisciplinary approach, patient determination, and good partner support helped in the successful management of this pregnancy.The neonate had blue sclera, dentigerous imperfecta, bowing of the femur and relatively spared upper limbs. Growth was on the third centile. The mother says she brings the girl for follow-up every 3-6 months to give injection zoledronate. The mother confirms her girl can stand with support, crawl, and speak two-syllable words. Her daughter had to undergo femur corrective osteotomy rush nailing and hip spice application for a closed fracture of the left femur.

Tumour-induced osteomalacia: the long road to diagnosis and recovery.

Tumour-induced osteomalacia is caused by tumorous production of fibroblast growth factor 23 (FGF23) leading to urinary phosphate wasting, hypophosphataemia and decreased vitamin D activation. The resulting osteomalacia presents with muscle weakness and bone pain but progresses to multiple pathological fractures. Patients often remain undiagnosed for years with severe physical, psychological and economic ramifications. A young woman presented with multiple spontaneous fractures including bilateral femoral fractures. Laboratory tests revealed severe hypophosphataemia, elevated bone turnover markers and low to normal calcium and 25-hydroxy-vitamin D levels. Treatment with phosphate, alfalcalcidol, calcium and magnesium was initiated. 68Gallium-DOTATOC positron emission tomography imaging revealed a mass in the right foot and venous sampling of FGF23 from all extremities confirmed this tumour as the culprit. Biopsy and histology were consistent with a phosphaturic mesenchymal tumour, which was surgically resected. Phosphate levels quickly normalised postoperatively but a long convalescence with hungry bone syndrome, fracture healing and physical therapy followed.

External fixator versus elastic stable intramedullary nail for treatment of metaphyseal-diaphyseal junction fractures of the pediatric distal femur: a case-control study.

BACKGROUND: Several methods have been used for the treatment of pediatric distal femoral fractures, such as elastic stable intramedullary nail (ESIN), external fixator (EF) and plate osteosynthesis, but there has been no consensus about the optimal method. The purpose of this study was to compare the clinical outcome between EF and ESIN techniques used in metaphyseal-diaphyseal junction (MDJ) fractures of the pediatric distal femur. METHODS: We retrospectively analyzed operatively treated MDJ fractures of pediatric distal femur between January 2015 and January 2022. Patient charts were reviewed for demographics, injury and data of radiography. All of the patients were divided into EF and ESIN groups according to the operation techniques. Malalignment was defined as more than 5 degrees of angular deformity in either plane. Clinical outcomes were measured by Flynn scoring system. RESULTS: Thirty-eight patients were included in this study, among which, 23 were treated with EF, and 15 with ESIN. The mean follow-up time was 18 months (12-24 months). At the final follow-up, all of the fractures were healed. Although there were no statistical differences between the two groups in demographic data, length of stay, estimated blood loss (EBL), rate of open reduction, time to fracture healing and Flynn score, the EF was superior to ESIN in operative time, fluoroscopic exposure and time to partial weight-bearing. The EF group had a significantly higher rate of skin irritation, while the ESIN had a significantly higher rate of malalignment. CONCLUSION: EF and ESIN are both effective methods in the treatment of MDJ fractures of the pediatric distal femur. ESIN is associated with lower rates of skin irritation. However, EF technique has the advantages of shorter operative time, reduced fluoroscopic exposure, and shorter time to partial weight-bearing, as well as lower incidence of malalignment. LEVEL OF EVIDENCE: Level III.

Traumatic Floating Total Hip Arthroplasty: A Case Report.

CASE: A 58-year-old woman with medical history of a left total hip arthroplasty performed by the direct anterior (DA) approach 2 years prior presented with left hip pain. She was found to have sustained a transverse Vancouver C periprosthetic femur fracture and an unstable periprosthetic pelvic fracture. CONCLUSIONS: This patient's case represents a previously not reported injury about a total hip arthroplasty-with disruption distal to the femoral implant and proximal to the acetabular implant, with the implant-to-bone interface unaffected. This case may guide future treatment of similar injuries.

Management of complete intra-articular distal femur and patellar fractures in an achondroplastic young adult; small is challenging' revisited: a case-report.

BACKGROUND: People with achondroplasia exhibit distinct physical characteristics, but their cognitive abilities remain within the normal range. The challenges encountered during surgical procedures and perioperative care for achondroplastic individuals, are underrepresented in the existing literature. CASE PRESENTATION: In this report, the management of a 26-year-old North-African achondroplastic male is highlighted. The patient suffered a complete intra-articular distal femur fracture (AO/OTA 33-C1) and an ipsilateral patella fracture (AO/OTA 34-C1). The patient's unusual anatomical variations and the lack of suitable orthopedic implants posed significant surgical challenges, particularly in the context of a resource-limited developing country. Facial and spinal deformities, which are common in patients with achondroplasia, further complicated the anesthetic approach. CONCLUSIONS: The limited information on operative management of fractures in achondroplastic patients necessitated independent decision-making and diverging from the convenient approach where clear guidance is available in the literature.

Medial Hoffa Fracture: A Case Report and Literature Review of Approach and Management.

BACKGROUND Hoffa fractures are an uncommon form of coronal fracture that impact the femoral condyle. As a result, they are not very prevalent. It is necessary to perform anatomical reduction and rigorous fixation on these fractures; however, there is no consensus among medical professionals on the surgical procedure and implant that would be the most successful in treating these fractures. CASE REPORT A 50-year-old woman who had poliomyelitis in her right lower limb presented with a displaced medial Hoffa fracture of her left knee. She had fallen and was suffering from poliomyelitis. The trauma that caused this fracture had a modest energy level. Open reduction and internal fixation with 2 retrograde cannulated screws were included in her surgical procedure. An approach known as the medial parapatellar route was used for this treatment. As part of her postoperative rehabilitation, she participated in physiotherapy, exercises that did not require weight bearing, exercises that used passive and active assistance, activities that involved partial and full weight bearing, and exercises that involved complete weight bearing. At the 2-year follow-up, the patient's left knee continued to be painless and stable, and it had unrestricted range of motion across the whole extremity. It was determined via radiographs that the fracture had healed without any problems or arthritic changes developing. She was able to walk without help and carry out her daily tasks since she was able to walk with the use of a cane. CONCLUSIONS Retrograde cannulated screws can be a reliable and successful choice for treatment of medial Hoffa fractures, with positive results according to both clinical and radiographic characteristics. Further research is needed to analyze the outcomes over a longer period of time and make comparisons between this technique and others.

Proximal femur fracture detection on plain radiography via feature pyramid networks.

Hip fractures exceed 250,000 cases annually in the United States, with the worldwide incidence projected to increase by 240-310% by 2050. Hip fractures are predominantly diagnosed by radiologist review of radiographs. In this study, we developed a deep learning model by extending the VarifocalNet Feature Pyramid Network (FPN) for detection and localization of proximal femur fractures from plain radiography with clinically relevant metrics. We used a dataset of 823 hip radiographs of 150 subjects with proximal femur fractures and 362 controls to develop and evaluate the deep learning model. Our model attained 0.94 specificity and 0.95 sensitivity in fracture detection over the diverse imaging dataset. We compared the performance of our model against five benchmark FPN models, demonstrating 6-14% sensitivity and 1-9% accuracy improvement. In addition, we demonstrated that our model outperforms a state-of-the-art transformer model based on DINO network by 17% sensitivity and 5% accuracy, while taking half the time on average to process a radiograph. The developed model can aid radiologists and support on-premise integration with hospital cloud services to enable automatic, opportunistic screening for hip fractures.

Radiographic outcomes and non-union factor analysis in fragmentary segmental femoral shaft fractures (AO/OTA 32C3) treated with reamed antegrade nailing.

This study retrospectively assessed radiographic outcomes and risk factors associated with non-union in femoral shaft fragmentary segmental fractures (AO/OTA 32C3) treated with reamed antegrade intra-medullary nailing. Radiological outcomes, including union and alignment, were evaluated. The risk factors for non-union were investigated, including demographics and treatment-related characteristics, such as the number of interlocking screws, segmentation length, main third fragment length, distance of the main third fragment, width ratio and exposed nail length in one cortex from immediate post-operative radiographs. Multivariate logistic regression was used for statistical analysis. Among 2295 femoral shaft fracture patients from three level-1 trauma centers, 51 met the inclusion criteria. The radiological union was achieved in 37 patients (73%) with a mean union time of 10.7 ± 4.8 months. The acceptable axial alignment was observed in 30 patients (59%). Multiple logistic regression analysis identified only exposed nail length as a significant risk factor for non-union (odds ratio: 1.599, p = 0.003) and the cut-off value was 19.1 mm (sensitivity, 0.786; specificity, 0.811). The study revealed high rates of non-union (27%) and malalignment (41%). Therefore, patients who underwent intramedullary nailing with an exposed nail length greater than 19.1 mm or about twice the nail diameter should be cautioned of the potential non-union.

Titanium versus stainless steel alloy bridge plates for distal femur fractures: Does callus form earlier with titanium?

INTRODUCTION: Distal femur fractures account for 3-6% of all femur fractures. Internal fixation of most distal femur fractures with an anatomic lateral locking plate should permit some motion at the metaphyseal portion of the fracture when secondary bone healing is planned by the operating surgeon. While several studies have been performed evaluating union rates for distal femur fractures with stainless steel and titanium plates, the timing of callus formation between stainless steel and titanium implants used as bridge plates for distal femur fractures (AO/OTA 33-A and -C) has been investigated to a lesser extent. We hypothesize that callus will be visualized earlier with post-operative radiographs with titanium versus stainless steel bridge plates. METHODS: We retrospectively reviewed a consecutive cohort of patients over 18 years of age with acute AO/OTA 33-A and 33-C fracture patterns treated with an isolated stainless steel or titanium lateral bridge plate within 4 weeks of injury by a single fellowship-trained orthopedic trauma surgeon from 2011 to 2020 at one academic Level 1 trauma center. An independent, fellowship-trained orthopedic trauma attending surgeon reviewed anterior-posterior (AP) and lateral radiographs from every available post-operative clinic visit and graded them using the Modified Radiographic Score for Tibia (mRUST). RESULTS: Twenty-five subjects were included in the study with 10 with stainless steel and 15 with titanium plates. There were no significant differences in demographics between both groups, including age, sex, BMI, injury classification, open versus closed, mechanism, and laterality. Statistically significant increased mRUST scores, indicating increased callus formation, were seen on 12-week radiographs (8.4 vs. 11.9, p = 0.02) when titanium bridge plates were used. There were no statistically significant differences in mRUST scores at 6 or 24-weeks, but scores in the titanium group were higher in at every timepoint. DISCUSSION: In conclusion, we observed greater callus formation at 12 weeks after internal fixation of 33-A and 33-C distal femur fractures treated with titanium locked lateral distal femoral bridge plates compared to stainless steel plates. Our data suggest that titanium metallurgy may have quicker callus formation compared to stainless steel if an isolated, lateral locked bridge plate is chosen for distal femur fracture fixation.

Is intramedullary nailing of femoral diaphyseal fractures in the lateral decubitus position as safe and effective as on a traction table?

OBJECTIVES: The aim of this study was to compare the radiological and clinical results of femoral diaphyseal fractures operated in the lateral decubitus position with those operated in the supine position on a traction table and to detail the perioperative surgical technique. PATIENTS AND METHODS: Between October 2018 and January 2022, in this prospective, randomized, and single-blind comparative study, 75 patients diagnosed with adult femoral diaphyseal fractures to whom intramedullary nails were applied were operated in the lateral decubitus position without a traction table (Group 1, 37 patients) and in the supine position with a traction table (Group 2, 38 patients). Preoperative age, gender, fracture mechanism, fracture type, and surgical waiting times were determined. Perioperative anesthesia type, surgery preparation time, surgical time, number of fluoroscopy doses, amount of bleeding, and type of reduction were evaluated, and detailed observational descriptions of the surgical techniques were made. In the postoperative period, radiological evaluations were made with x-ray radiography and orthoroentgenogram, while in the clinical evaluation, hip-knee joint range of motion and rotational evaluation were made with the Craigs test. Follow-up periods were determined and complications noted. RESULTS: The average age was 32 in Group 1 and 28 in Group 2, the female/male ratio was 1:36 in Group 1 and 5:33 in Group 2, and the follow-up period was 18.2 months Group 1 and 21.7 months in Group 2. No significant difference was detected between the groups in terms of age, gender, fracture mechanism, fracture type, anesthesia type, surgical waiting time, and follow-up period (p > 0.05). Compared to Group 2, the shorter preparation time, surgical time, and number of fluoroscopy doses in Group 1 were found to be statistically significant (p < 0.05). The differences in the amount of bleeding and need for open reduction were not statistically significant between the groups (p > 0.05), and no statistical difference was found in joint range of motion and rotational evaluation in clinical evaluation in both groups (p > 0.05). There was no significant difference in terms of complications between groups. CONCLUSIONS: We found the lateral decubitus method without a traction table to be a safe and effective alternative to the supine method with a traction table in terms of the radiological and clinical results and that it also has the advantages of shortening the surgical time, reducing radiation exposure. LEVEL OF EVIDENCE: Level 1 prospective, randomized, single-blind controlled study.

Development and validation of a novel overhead method for anteroposterior radiographs of fractured rat femurs.

We aimed to establish a new method of obtaining femur anteroposterior radiographs from live rats. We used five adult male Sprague-Dawley rats and created a femoral fracture model with an 8 mm segmental fragment. After the surgery, we obtained two femoral anteroposterior radiographs, a novel overhead method, and a traditional craniocaudal view. We obtained the overhead method three times, craniocaudal view once, and anteroposterior radiograph of the isolated femoral bone after euthanasia. We compared the overhead method and craniocaudal view with an isolated femoral anteroposterior view. We used a two-sample t-test and intraclass correlation coefficient (ICC) to estimate the intra-observer reliability. The overhead method had significantly smaller differences than the craniocaudal view for nail length (1.53 ± 1.26 vs. 11.4 ± 3.45, p < 0.001, ICC 0.96) and neck shaft angle (5.82 ± 3.8 vs. 37.8 ± 5.7, p < 0.001, ICC 0.96). No significant differences existed for intertrochanteric length/femoral head diameter (0.23 ± 0.13 vs. 0.23 ± 0.13, p = 0.96, ICC 0.98) or lateral condyle/medial condyle width (0.15 ± 0.16 vs. 0.13 ± 0.08, p = 0.82, ICC 0.99). A fragment displacement was within 0.11 mm (2.4%). The overhead method was closer to the isolated femoral anteroposterior view and had higher reliability.

Sildenafil delays bone remodeling of fractured femora in aged mice by reducing the number and activity of osteoclasts within the callus tissue.

The elderly exhibit a reduced healing capacity after fracture, which is often associated with delayed or failed bone healing. This is due to a plethora of factors, such as an impaired bone vascular system and delayed angiogenesis. The phosphodiesterase-5 (PDE-5) inhibitor sildenafil exerts pro-angiogenic and pro-osteogenic effects. Hence, we herein investigated in aged mice whether sildenafil can improve fracture healing. For this purpose, 40 aged CD-1 mice (16-18 months) were daily treated with 5 mg/kg body weight sildenafil (n = 20) or vehicle (control, n = 20) by oral gavage. The callus tissue of their femora was analyzed at 2 and 5 weeks after fracture by X-ray, biomechanics, micro-computed tomography (µCT), histology, immunohistochemistry as well as Western blotting. These analyses revealed a significantly increased bone volume and higher ratio of callus to femoral bone diameter in sildenafil-treated mice at 5 weeks after fracture when compared to controls. This was associated with a reduced number and activity of osteoclasts at 2 weeks after fracture, most likely caused by an increased expression of osteoprotegerin (OPG). Taken together, these findings indicate that sildenafil does not improve fracture healing in the elderly but delays the process of bone remodeling most likely by reducing the number and activity of osteoclasts within the callus tissue.

Flexible nailing: Pushing the indications for diametaphyseal lower-extremity fractures.

Elastic stable intramedullary nailing (ESIN) has been shown to be an effective form of surgical management for lower-extremity diametaphyseal fractures in pediatric patients, but studies are limited because ESIN treatment for these fractures is relatively uncommon. We sought to determine whether ESIN can be used effectively in the most distal or proximal short-segment forms of these fractures. We queried the electronic medical record system at Johns Hopkins Hospital using Current Procedural Terminology codes for femur and tibia fractures treated with ESIN in patients under 18 years old between January 2015 and October 2022. Preoperative and postoperative radiographs were subsequently reviewed to identify patients with a proximal or distal third femoral or tibial shaft fracture treated with ESIN and to define criteria for short-segment diametaphyseal fractures. We used Beaty radiological criteria to evaluate radiographic outcomes and Flynn titanium elastic nails (TENs) outcome scale to assess clinical recovery after radiographic evidence of union. There were 43 children who met the inclusion criteria. Among them, 10 patients had short-segment diametaphyseal fractures. There were 22 (51.2%) who sustained femur fractures and 21 (48.8%) who sustained tibia fractures. Using Beaty radiologic criteria, ESIN was associated with more satisfactory outcomes in patients with distal or proximal third shaft fractures (32/33) than in patients with short-segment diametaphyseal fractures (7/10) (P = .03). Using the TENs outcome scale, 21 (63.4%) patients with distal or proximal third shaft fractures had excellent results, 11 (33.3%) had satisfactory results, and 1 (3%) had a poor result. Among patients with short-segment diametaphyseal fractures, 4 (40%) had excellent results, 5 (50%) had satisfactory results, and 1 (10%) had a poor result. There were no differences in TENs outcomes between the groups (P = .24). Patients with short-segment lower-extremity diametaphyseal fractures treated with ESIN had worse radiographic outcomes but did no worse clinically than patients with distal or proximal third shaft fractures. Consequently, ESIN should be considered a safe and effective surgical management option for pediatric patients with even the most distal or proximal forms of these fractures.

Differences in bone histomorphometry between White postmenopausal women with and without atypical femoral fracture after long-term bisphosphonate therapy.

Bone histomorphometric endpoints in transilial biopsies may be associated with an increased risk of atypical femoral fracture (AFF) in patients with osteoporosis who take antiresorptives, including bisphosphonates (BPs). One way to test this hypothesis is to evaluate bone histomorphometric endpoints in age-, gender-, and treatment time-matched patients who either had AFF or did not have AFF. In this study, we performed transiliac bone biopsies in 52 White postmenopausal women with (n = 20) and without (n = 32) AFFs, all of whom had been treated for osteoporosis continuously with alendronate for 4-17 yr. Despite the matched range of treatment duration (4-17 yr), AFF patients received alendronate for significantly longer time (10.7 yr) than non-AFF patients (8.0 yr) (P = .014). Bone histomorphometric endpoints reflecting microstructure and turnover were assessed in cancellous, intracortical, and endocortical envelopes from transilial biopsy specimens obtained from BP-treated patients 3-6 mo after AFF and from non-AFF patients with similar age-, gender-, and range of BP treatment duration. However, in both cancellous and intracortical envelopes, AFF patients had significantly lower wall thickness (W.Th) and higher osteoclast surface (Oc.S/BS) than non-AFF patients. In addition, AFF patients had significantly higher eroded surface (ES/BS) only in the intracortical envelope. None of the dynamic variables related to bone formation and turnover differed significantly between the groups. In conclusion, in the ilium of BP-treated patients with osteoporosis, AFF patients have lower thickness of superficial bone (lower W.Th) of the cancellous and cortical envelopes than non-AFF patients. AFF and non-AFF patients have a similar bone turnover rate in the ilium. Furthermore, in this population, as in previous work, AFF is more likely to occur in BP-treated patients with longer treatment duration.

Bisphosphonates (BPs) are widely used to prevent osteoporotic fracture and treat osteoporosis. However, prolonged use of BPs may increase the risk of atypical femoral fracture (AFF), and their pathogenesis remains unclear. This study compared the bone histomorphometric findings in cancellous and cortical bones between White osteoporotic women with (n = 20) and without AFF (n = 32), who had received BP treatment for a matched duration of 4­17 yr. The BP-treated patients with AFF had significantly lower wall thickness (W.Th) in both cancellous and cortical bones compared to BP-treated patients without AFF. There were no significant differences in bone formation, turnover, or mineral apposition rate between BP-treated AFF and non-AFF patients. In conclusion, our study results suggest that AFF risk is increased in BP-treated patients with smaller young and healthy superficial bone areas (indicated by lower W.Th). Surprisingly, we also discovered that patients with and without AFF have similar bone turnover rates, which contradicts previous beliefs. Our findings provide valuable insights into the potential factors contributing to AFF in BP-treated patients.

Comparative study of retrograde intramedullary nailing versus locking extramedullary plating in complete articular fractures with metaphyseal comminution of the distal femur.

INTRODUCTION: Fractures of the distal femur with metaphyseal comminution and complete intra-articular involvement (AO/OTA classifications 33C2 and 33C3) present challenges for reduction and fixation. However, an optimal fixation method remains unknown. This study aimed to compare the clinical and radiographic outcomes of locking extramedullary plating (LEP) and retrograde intramedullary nailing (RIN) for complete distal femoral intra-articular fractures with metaphyseal comminution. MATERIALS AND METHODS: Between January 2016 and May 2022, 80 patients (45 men and 35 women; average age, 56.7 years) diagnosed with AO/OTA 33C2 and 33C3 were treated with either LEP or RIN and followed up for at least one year. Post-operative evaluations included radiographic assessments of bone union rate, timing, and alignment. Clinically, the knee joint range of motion (ROM), lower extremity functional scale (LEFS), and Kellgren and Lawrence (KL) grade were analyzed. The complications were also compared. RESULTS: 36 underwent LEP and 44 underwent RIN. Bone union was observed in 69.4% and 63.6% of the patients in the LEP and RIN groups, respectively (p = 0.64). The average union time was 6.9 months for the LEP group and 6.6 months for the RIN group (p = 0.51). A tendency toward varus deformity was observed in the RIN group, although the difference was not statistically significant. No significant differences were observed in knee ROM, LEFS, or KL grade. Complications included non-union (33.8%; RIN, 11; LEP, 16), varus deformity (5%; RIN, 4; LEP, 0), infection (1.3%; RIN, 0; LEP, 1), heterotrophic ossification (1.3%; RIN, 0; LEP, 1), and wound dehiscence (2.5%; RIN, 2; LEP, 0). CONCLUSIONS: The surgical fixation methods, RIN and LEP, for complete distal femoral intra-articular fractures with metaphyseal comminution showed similar clinical and radiological outcomes. However, regardless of the type of fixation device used, there was a reduced rate of bone union owing to high energy and a less favorable prognosis.

MRI characteristics of radiographically occult femoral neck fractures in trauma patients with ipsilateral femoral shaft fractures.

PURPOSE: Ipsilateral femoral neck fractures can be seen alongside femoral shaft fractures in high-velocity trauma patients. These neck fractures are often occult on radiographs and CT, and can have a significant impact on patient outcomes if not treated promptly. Limited protocol pelvic MRI has been used to increase sensitivity for these occult fractures. Detailed characterization of these fractures on MRI is lacking. METHODS: 427 consecutive trauma patients presenting to our emergency department who had known femoral diaphyseal fractures but no ipsilateral femoral neck fracture on radiographs or CT were included in this study. These patients were scanned using a limited protocol MRI with coronal T1 and coronal STIR sequences. Presence of an ipsilateral femoral neck fracture and imaging characteristics of the fracture were obtained. RESULTS: 31 radiographically occult ipsilateral femoral neck fractures were found, representing 7% of all cases. All neck fractures were incomplete. All fractures originated along the lateral cortex of the femoral neck and extended medially towards the junction of the medial femoral neck and the lesser trochanter. 58% (18/31) were vertical in orientation. 61% (19/31) did not demonstrate any appreciate edema on STIR images. CONCLUSION: Implementation of limited protocol MRI protocol increases sensitivity for detection of femoral neck fractures in the setting of ipsilateral femoral shaft fractures not seen on radiograph or CT imaging. We describe the characteristic MR imaging features of these fractures.

Intramedullary nailing of femoral shaft fractures: an analysis of rotational malunions using 3D EOS.

PURPOSE: Rotational malalignment and leg length discrepancy after intramedullary nailing of femoral shaft are frequent. This study has three objectives: evaluate the rate of femoral rotational malalignment and leg length discrepancy using EOS imaging after antegrade intramedullary nailing of femoral shaft fracture, find a relevant clinical examination to detect malrotation and identified risk factors. METHODS: We performed a retrospective single-centre study between January 2014 and January 2022. Fifty-eight patients were clinically and radiographically assessed at a minimum of three months. RESULTS: The femoral rotation of the operated side was significantly greater by a mean of 15.4° in internal rotation compared to the healthy side. There was no statically significant difference for the femoral length (p = 0.08). CONCLUSION: When using EOS stereography following antegrade intramedullary nailing of post-traumatic diaphyseal femur fractures, a statistically significant difference of more than 15.4° in internal rotation was found for femoral rotation on the operated side compared to the healthy side.Please confirm if the author names are presented accurately and in the correct sequence (given name, middle name/initial, family name). Author 1 Given name: [B. Poirot] Last name [Seynaeve]. Also, kindly confirm the details in the metadata are correct.The last name of the first author was corrected : Given name = B. and last name = Poirot Seynaeve The details in matadata are correct LEVEL OF EVIDENCE: III.

Total femoral spanning for distal femur "fragility" fractures utilising nail-plate fixation "short-term experience of a district general hospital".

PURPOSE: Our primary objective was to investigate the time to radiological union following linked nail-plate fixation of distal femur "fragility" fractures. Secondary objectives were to evaluate all-cause reoperations, 90-day mortality, rate of blood transfusion and the impact on quality of life. METHODS: In this retrospective study of all adults (≥ 65 years) with native or periprosthetic distal femur fragility fractures, underwent a linked nail-plate fixation, data were retrieved on fracture classifications, clinical frailty score, blood transfusion, length of hospital stay, 90-day mortality, time to radiological union, overall complication rates and EuroQoL-5D. RESULTS: In total, 18 out of 23 patients completed sequential follow-up. Radiological union was observed in 14 patients (median 143 days; range 42-414). Three patients underwent reoperations. There were no implant failures or a subsequent periprosthetic fractures. Ninety-day mortality was 17.4%. Eighteen patients required blood transfusion. The QoL was significantly lower after index surgery (0.875 vs. 0.684; p < 0.01). CONCLUSION: Based on our observation, with short-term follow-up, the linked nail-plate yields optimal stability to allow immediate weight bearing, in a cohort with moderate frailty. It is reproducible, with variable radiological union rates. The concept of "total femoral spanning" reduces the risk of subsequent periprosthetic fractures. The additional intervention has increased the rates of allogenic blood transfusion. There is significant impact on overall QoL, with almost 50% being more dependent in self-care.

Characteristics of Femoral Shaft Fractures That Predict Ipsilateral Femoral Neck Fractures.

INTRODUCTION: This study aims to characterize radiographic features and fracture characteristics in femoral shaft fractures with associated femoral neck fractures, with the goal of establishing predictive indicators for the presence of ipsilateral femoral neck fractures (IFNFs). METHODS: A retrospective cohort was collected from the electronic medical record of three level I trauma centers over a 5-year period (2017 to 2022) by current procedural terminology (CPT) codes. Current CPT codes for combined femoral shaft and IFNFs were identified to generate our study group. CPT codes for isolated femur fractures were identified to generate a control group. RESULTS: One hundred forty patients comprised our IFNF cohort, and 280 comprised the control cohort. On univariate, there were significant differences in mechanism of injury (P < 0.001), Orthopedic Trauma Association (OTA)/Arbeitsgemeinshaft fur Osteosynthesefragen (AO) classification (P = 0.002), and fracture location (P < 0.001) between cohorts. On multivariate, motor vehicle crashes were more commonly associated with IFNFs compared with other mechanism of injuries. OTA/AO 32A fractures were more commonly associated with IFNFs when compared with OTA/AO 32B fractures (adjusted odds ratio = 0.36, P < 0.001). Fractures through the isthmus were significantly more commonly associated with IFNFs than fractures more proximal (adjusted odds ratio = 2.52, P = 0.011). DISCUSSION: Detecting IFNFs in femoral shaft fractures is challenging. Motor vehicle crashes and motorcycle collisions, OTA/AO type 32A fractures, and isthmus fractures are predictive of IFNFs.

Immediate weightbearing is safe after revision total hip arthroplasty for Vancouver B2/B3 periprosthetic femur fractures.

INTRODUCTION: Modular fluted, tapered stems provide a reliable treatment for Vancouver B2/B3 fractures. Historically, these patients had weightbearing restrictions postoperatively. Although full immediate postoperative weightbearing may provide benefits in this patient population, stem subsidence is a concern. QUESTIONS/PURPOSES: The objective of this study was to investigate the effect of post-operative weight-bearing status on stem subsidence in patients treated with modular tapered stems for Vancouver B2 and B3 periprosthetic fractures. We sought to answer two questions: (1) Does full immediate postoperative weightbearing after revision total hip arthroplasty for periprosthetic femur fracture lead to increased stem subsidence compared to protected weightbearing? (2) Is there a mortality difference between these two groups of patients with different weightbearing restrictions? METHODS: From 2009 to 2015 all patients who underwent revision for Vancouver B2/B3 fractures were made non-weightbearing (NWB) for six weeks postoperatively. After 2015, immediate weightbearing as tolerated (WBAT) was allowed postoperatively. We compared stem subsidence between immediate postoperative and final radiographs. Additionally, we performed a Kaplan-Meijer analysis with one-year mortality as an endpoint. RESULTS: The final cohort included forty-seven patients with an average follow-up of 254 days. The average stem subsidence was 1.0 mm (95 % CI, 0.5-1.5 mm) in the NWB cohort and 0.3 mm (95 % CI, 0-0.7 mm) in the WBAT cohort (P = 0.10). In our survivorship analysis, we noted no deaths in the WBAT cohort compared to 17 % mortality in the NWB cohort at the one-year timepoint. CONCLUSION: Allowing patients to weight bear immediately after revision does not increase stem subsidence. Further studies are needed to determine whether early weightbearing provides a mortality benefit.