Ultrasound-guided localization of the radial nerve along the humerus: providing reference points for safer upper arm surgery.

PURPOSE: The close proximity of the radial nerve to the humerus poses a risk during upper arm surgery. Although the general course of the radial nerve is well-known, its exact position in relation to anatomical reference points remains poorly investigated. This study aimed to develop a standardized protocol for the sonographic and clinical identification of the radial nerve in the upper arm. The ultimate goal is to assist surgeons in avoiding iatrogenic radial nerve palsy. METHODS: A total of 76 measurements were performed in 38 volunteers (both sides). Ultrasound measurements were performed using a linear transducer (10 MHz) to identify the radial nerve at two key points: RD (where the radial nerve crosses the dorsal surface of the humerus) and RL (where the radial nerve crosses the lateral aspect of the humerus). Distances from specific reference points (acromion, lateral epicondyle, medial epicondyle, olecranon fossa) to RD and RL were measured, and the angle between the course of the nerve and the humeral axis was recorded. Humeral length was defined as the distance between the posterodorsal corner of the acromion and the lateral epicondyle. RESULTS: The distance from the lateral epicondyle to RD was on average 15.5 cm ± 1.3, corresponding to 50% of the humeral length. The distance from the lateral epicondyle to RL was on average 6.7 cm ± 0.8, corresponding to 21% of the humeral length. The course of the nerve between RD and RL showed an average angulation of 37° to the anatomical axis of the humerus. Gender, BMI, dominant hand, and arm thickness did not correlate with the distances to RD or RL. Measurements were consistent between the left and right side. CONCLUSION: The radial nerve can typically be identified by employing a 1/2 and 1/5 ratio on the dorsal and lateral aspects of the humerus. Due to slight variations in individual anatomy, the utilization of ultrasound-assisted visualization presents a valuable and straightforward approach to mitigate the risk of iatrogenic radial nerve palsy during upper arm surgery. This study introduces an easy and fast protocol for this purpose.

Anterior medial minimally invasive plate osteosynthesis for humeral shaft fractures shows superior early shoulder and elbow function compared to locking compression plate: A retrospective study.

INTRODUCTION: Humeral shaft fractures are a common injury of the upper limb, with the primary surgical treatment modality being the locking compression plate (LCP) technique. The advent of Anterior medial minimally invasive plate osteosynthesis (MIPO) technology has led to its gradual implementation in clinical practice. However, the efficacy and long-term outcomes of MIPO require further investigation. The objective of this study is to compare the therapeutic effects of LCP and MIPO in the management of humeral shaft fractures. METHODS: The present study conducted a retrospective review of patients diagnosed with humeral shaft fractures between June 2016 and December 2019. The patients were divided into MIPO and LCP groups based on the different surgical methods. The study analyzed the length of hospital stay, radiation exposure, operative time, and postoperative Disabilities of the Arm, Shoulder and Hand (DASH) scores using statistical methods. RESULTS: A total of 53 patients who met the inclusion criteria were included in the study. The MIPO group demonstrated a statistically significant reduction in length of hospital stay compared to the LCP group (length of hospital stay: 5.39 ± 2.23 days vs 12.00 ± 7.19 days, P < 0.001). All patients achieved callus formation after surgery. However, the MIPO group had significantly more radiation exposures than the LCP group (45.96 ± 19.49 vs 5.33 ± 2.20, P < 0.001). Additionally, there was no statistically significant difference observed in the time from admission to surgery, operative time,and healing time between the two groups (the time from admission to surgery: P = 0.593; operative time: P = 0.407; Healing time: P = 0.664). During the postoperative follow-up, the MIPO group exhibited significantly lower 6-week and 3-month DASH scores compared to the LCP group (6-week: 34.17 ± 12.16 vs 45.65 ± 22.94, P = 0.028; 3-month: 17.43 ± 11.70 vs 30.12 ± 9.80, P < 0.001). However, there was no statistically significant difference in the 6-month and 12-month DASH scores between the two groups (6-month: P = 0.787; 12-month: P = 0.058). CONCLUSION: The MIPO technique provides better short-term functional recovery of the shoulder and elbow compared to the LCP technique in the treatment of humeral shaft fractures, while ensuring equivalent surgical healing.

The outcome of nonoperative treatment for adult humeral shaft fractures using a U-shaped slab in resource-limited settings: a prospective cohort study.

BACKGROUND: Humeral shaft fractures, constituting 3-5% of musculoskeletal injuries, are commonly managed conservatively using functional braces. However, this approach may not be feasible in resource-limited settings. This study aimed to evaluate the functional outcomes of nonoperative treatment for humeral shaft fractures in adults utilizing a U-shaped slab. METHODS: This prospective study was conducted from August 2021 to August 2022 involving 16-year-old and older individuals who received nonsurgical treatment for humeral shaft fractures at public tertiary hospitals in Rwanda. The assessment focused on various functional outcomes, including alignment, union rate, range of motion, return to activities of daily living, and DASH score. RESULTS: The study included 73 participants, predominantly males (73.9%), with a median age of 33 years. The union rate was high at 89.04%, and 10.96% experienced delayed union. Radial nerve palsy occurred in 4.11% of patients, but all the patients fully recovered within three months. Despite angular deformities during healing in the majority of participants, these deformities did not significantly impact functional outcomes. According to the international classification of disabilities, 77% of participants achieved a good functional grade. CONCLUSION: The conservative U-shaped slab method was effective at managing humeral shaft fractures. However, optimal results necessitate careful participant selection and comprehensive rehabilitation education. Implementing these measures can improve the overall success of nonoperative management.

Predictors of 30-day mortality, unplanned related readmission and reoperation among isolated closed femoral shaft fractures.

Background: Isolated, closed, femoral shaft fractures are dangerous injuries that commonly occur in the setting of high energy trauma or among older patients with significant comorbidities. Despite their prevalence, relatively little data exists connecting patient independent risk factors to the time to 30-day mortality, unplanned reoperations and unplanned readmissions in these fractures. Methods: Using National Surgical Quality Improvement Program (NSQIP) database, isolated close femoral shaft fractures were identified using ICD-10 codes. Patient demographics, perioperative course and adverse events were identified. Categorical and binary variables were analyzed among procedure cohorts using Chi2 analysis. Univariate and multivariate analysis were conducted to identify independent risk factors associated with primary outcomes. Results: Between 2010 and 2019, 1346 closed isolated femoral shaft fracture patients with a mean age of 66.7 were identified, of whom 30.6% and 69.4% were male and female, respectively. Surgical procedures included: 915 (68.0%) intramedullary nail (IMN); 428 (31.8%) open reduction internal fixation (ORIF); and 3 (0.2%) external fixator (Ex-fix). Patients who underwent ORIF reported 3.19 (OR: 3.19; CI: 1.45-7.03; p = 0.004) and 2.12 (OR: 2.12; CI: 1.10-4.09; p = 0.024) increased odds of mortality and unplanned related readmission compared to patients who received IMN. Transfusion, DVT, and PE rates were 34.2%, 1.4%, and 1.1%, respectively. Furthermore, 50% of mortality cases occurred within 6 days of surgery. Patients requiring reintubation reported 61.8 (OR: 61.8; CI: 15.7-242.40; p < 0.001) increased odds of mortality compared to patients not requiring reintubation. Conclusion: Patients with femoral shaft fractures who require reintubation have increased odds of mortality than those successfully extubated. In addition to precautions prior to extubation, patients with femoral shaft fractures should also be carefully monitored for the development of DVT or PE, and they should be definitively fixed with IMN whenever possible.

Primary Radial Nerve Lesions in Humerus Shaft Fractures-Revision or Wait and See.

Background: This study investigates the surgical state-of-the-art procedure for humeral shaft fractures with primary radial nerve palsy based on its own case series in relation to the current and established literature. Methods: Retrospective review of treated cases between January 2018 and December 2022 describing radial nerve palsy after humerus shaft fractures, radiological fracture classification, intraoperative findings, surgical procedure, patient follow-up and functional outcome. Results: A total of 804 patients (463 women and 341 men) with humerus shaft fractures were identified. A total of 33 patients showed symptomatic lesions of the radial nerve (4.1%). The primary lesion was identified in 17 patients (2.1%). A broad and inhomogeneous distribution of fractures according to the AO classification was found. According to the operative reports, the distraction of the radial nerve was found eleven times, bony interposed three times and soft tissue constricted/compressed three times. In every case the radial nerve was surgically explored, there was no case of complete traumatic nerve transection. Four intramedullary nails and thirteen locking plates were used for osteosynthesis. Complete recovery of nerve function was seen in 12 cases within 1 to 36 months. Three patients still showed mild hypesthesia in the thumb area after 18 months. Two patients were lost during follow-up. Conclusions: With this study, we support the strategy of early nerve exploration and plate osteosynthesis in humeral fractures with primary radial nerve palsy when there is a clear indication for surgical fracture stabilisation. In addition, early exploration appears sensible in the case of palsies in open fractures and secondary palsy following surgery without nerve exposure as well as in the case of diagnostically recognisable nerve damage. Late nerve exploration is recommended if there are no definite signs of recovery after 6 months. An initial wait-and-see strategy with clinical observation seems reasonable for primary radial nerve palsies without indication for surgical fracture stabilisation.

Avascular Necrosis of the Femoral Head Following Intramedullary Nailing of a Femoral Shaft Fracture in a Skeletally Mature Adult: A Case Report.

Avascular necrosis (AVN) of the femoral head is a well-documented complication that occurs following femoral neck fractures in both adults and pediatrics. Incidence of AVN following intramedullary nailing (IMN) for femoral shaft fractures is relatively rare. We are reporting an exceptional case of a 28-year-old skeletally mature adult, with no risk factors, who developed stage 3 AVN following trochanteric entry-point IMN for a traumatic femur shaft fracture. Our case contributes to the existing literature by adding to the limited number of reported cases available. In addition, it emphasizes the importance of observation and anticipation for such complications and shows the need for further studies to understand the relationship between this modality of treatment and the development of AVN of the femoral head.

Intramedullary Nail vs. Plate Fixation for Pathological Humeral Shaft Fracture: An Updated Narrative Review and Meta-Analysis of Surgery-Related Factors.

(1) Background: Pathological humeral shaft fracture (PHSF) is a frequently observed clinical manifestation in the later stages of tumor metastasis. Surgical interventions are typically recommended to alleviate pain and restore functionality. Intramedullary nail fixation (INF) or plate fixation (PF) is currently recommended for the treatment of PHSF. However, there is still no standard for optimal surgical treatment. Thus, we conducted a meta-analysis comparing the clinical outcomes of INF with PF for PHSF treatment. (2) Methods: We conducted searches in databases, such as Scopus, EMBASE, and PubMed, for studies published prior to May 2023. In total, nine studies with 485 patients were reviewed. (3) Results: There were no significant differences noted in the incidence of fixation failure, local recurrence, wound complication or overall complication. However, the INF group demonstrated a significantly lower incidence of postoperative radial nerve palsy than the PF group (OR, 5.246; 95% CI, 1.548-17.774; p = 0.008). A subgroup analysis indicated that there were no statistically significant differences in fixation failure or local recurrence among subgroups categorized by the design of intramedullary nail. (4) Conclusions: Considering the short life expectancy of end-stage patients, the choice of surgical method depends on the patient's individual condition, fracture and lesion patterns, the surgeon's experience, and comprehensive discussion between the surgeon and patient.

A Retrospective Analysis of Dynamic Compression Plating Versus Intramedullary Nailing for the Management of Shaft of Humerus Fractures in an Urban Trauma Care Center.

Introduction There is constant debate regarding the best surgical technique for the fixation of shaft humerus fractures. Intramedullary nailing and dynamic compression plating are the most popular surgical options. Materials and methods In our study, we retrospectively analyze the results of 27 patients with shaft humerus fractures managed with intramedullary nailing (10) and dynamic compression plating (17) at our institute from September 2021 to October 2022. Preoperative clinical assessment sheets, postoperative follow-up sheets, operative notes, anesthesia sheets, and preoperative and follow-up radiographs were analyzed. Reamed antegrade nailing was done in all cases, while dynamic compression plating was done through a posterior approach. Results The operative time of the nailing group was 82.1 ± 7.61 mins, which was significantly lesser (P value <0.05) than that of the plating group, which was 119.59 ± 10.16 mins. The intraoperative blood loss of the patients who were managed with nailing was 71 ± 7.38 mL, which was significantly lesser (P value <0.05) than that of the plating group, which was 130.59 ± 11.44 mL. The patients in both groups had a statistically nonsignificant difference in terms of functional results, which were assessed using Rodriguez-Merchan criteria. Complications were similar in both groups with infection (17.65%), and postoperative radial nerve palsy (11.76%) was more common among the patients undergoing plating, and shoulder impingement(20%) was common among those undergoing nailing. Conclusion This study concluded that both surgical options are similar in the case of functional results. The selection of the surgical method should be as per the surgeon's surgical familiarity and personalized to individual patients.

Suprapatellar intramedullary nail combined with screw fixation has comparable surgical outcomes to minimally invasive locking plate fixation in ipsilateral tibial plateau and shaft fractures.

PURPOSE: To compare union rate, union time, alignment, and complication rate in ipsilateral tibia plateau and shaft fractures treated via suprapatellar intramedullary nailing with screw fixation and minimally invasive locking plate fixation. MATERIALS AND METHODS: A retrospective study was conducted on 48 patients who underwent minimally invasive plate fixation (n = 35) or suprapatellar intramedullary nailing with screw fixation (n = 13), for the treatment of ipsilateral tibial plateau and shaft fractures with at least 1-year follow-up. Union rate, union time, radiologic alignment, and complication rate such as malalignment, nonunion, and fracture-related infection (FRI) were investigated. RESULTS: Demographic data were not different between the two groups. Coronal plane alignment was 0.17 ± 4.23 in the plate group and -0.48 ± 4.17 in the intramedullary nail group (p = 0.637). Sagittal plane alignment was -0.13 ± 5.20 in the plate group and -1.50 ± 4.01 in the suprapatellar intramedullary nail group (p = 0.313). Coronal and sagittal malalignment recorded equal results: (p > 0.99), FRI (p = 0.602), nonunion and union times recorded (p = 0.656) and (p = 0.683, 0.829), respectively, and showed no significant difference between the two groups. CONCLUSION: Suprapatellar intramedullary nailing with screw fixation had similar surgical outcomes with minimally invasive locking plate fixation in ipsilateral tibial plateau and shaft fractures in terms of union rate, union time, alignment, and complication rate. Thus, frequent use of intramedullary nailing combined with screw fixation is anticipated in patients with ipsilateral tibial plateau and shaft fractures when the soft tissue condition is not desirable. LEVEL OF EVIDENCE: Level III.

Biomechanical Comparison of Fixation of Metacarpal Shaft Fractures With Intramedullary Threaded Nail and Dorsal Plate.

PURPOSE: The purpose of this study was to investigate the mechanical properties of metacarpal long oblique and transverse shaft fractures stabilized by threaded intramedullary nails and dorsal plates and screws. METHODS: Transverse and oblique midshaft osteotomies were created in 28 paired left and right metacarpal bones from four fresh frozen cadavers. Each matched pair was fixed with one 4.5-mm threaded intramedullary nail and one 2.0-mm dorsal stainless-steel plate and a screw construct. The bones were secured at the proximal end, by a 3-D-printed customized jig, to a tensile testing machine and were loaded through a Kevlar wire tensioned over the metacarpal head, simulating muscle/tendon loading during grip. Loading to failure was performed, and the applied force and failure mode were recorded. RESULTS: Oblique fractures fixed with nails failed at a greater force than those fixed with dorsal plates (183 ± 50 N vs 130 ± 40 N). Transverse fractures showed comparable strength between the nail (215 ± 33 N) and the plate (183 ± 64 N). Plate failure modes included three diverse types of bone fracture and yielding deformation of the plate. Intramedullary nail failure modes included yielding of the nail, bone fracture without nail yielding, and relative rotation between the two sections of the bone. CONCLUSIONS: Fixation of oblique and transverse metacarpal shaft fractures using a 4.5-mm threaded intramedullary nail in a simulated grip test model showed similar or greater strength than a 2.0-mm dorsal plate and screw construct. CLINICAL RELEVANCE: Threaded intramedullary nail fixation of metacarpal shaft fractures may be an appropriate alternative to plate fixation in these fracture patterns.

Management of Displaced Metacarpal Shaft Fractures: A Systematic Review and Meta-analysis.

Background: Affecting mainly the working population, metacarpal shaft fractures account for up to 31% of hand fractures. To manage this entity, conservative management can be equal to operative management. However, surgeons tend to favor operative management in order to reduce the rate of complications, such as shortening and malunion. This meta-analysis was conducted to compare conservative to operative management of displaced metacarpal shaft fractures. Methods: PubMed, Cochrane, and Google Scholar (pages 1-20) were searched until August 2023. The clinical outcomes consisted of postoperative shortening, Disabilities of Arm, Shoulder, and Hand (DASH) score, and mean grip strength. Results: Only three studies were included in this meta-analysis. Operative management was shown to reduce postoperative shortening (p<0.00001). However, conservative management had a better postoperative DASH score (p=0.001). Conclusion: Better DASH scores were seen in the conservative group, but there was a higher postoperative shortening. However, studies have shown that the shortening has no effect on the functional outcome. Nevertheless, more randomized controlled studies and cost-effectiveness studies are needed to confirm these findings.

Femoral Shaft Fractures in Children: Exploring Treatment Outcomes and Implications.

INTRODUCTION: Femoral shaft fractures significantly impact children and families, posing a significant challenge for pediatric patients. The prevalence of limb shortening in femur shaft fractures treated with hip spica casting in our group, however, has not been the subject of many recent investigations. AIMS: By comparing the prevalence of limb shortening to various age groups and common pediatric injury patterns, this research seeks to close this information gap. METHODS: This research, which lasted six months and was done at the Orthopedics Unit of Khyber Teaching Hospital Peshawar, Pakistan, included 129 children with closed femur shaft fractures who were between the ages of one and six. Clinical assessments, radiological examinations, and hip spica casting, all supervised by experienced orthopedic surgeons, were carried out. Senior postgraduate trainees oversaw the study's findings. RESULTS: The results unveiled key insights into the study population. Among the findings, 33% (n=43) of the children were aged one to three years, while 67% (n=86) fell within the three to six years age range. Gender distribution revealed that 72% (n= 93) were male. In terms of mechanism, 22% (n=28) of fractures were attributed to road traffic accidents, 69% (n=89) were the result of falls, and 5% (n=12) were due to other causes. Notably, 19% (n=29) of the children exhibited limb shortening. CONCLUSION: This study contributes significantly to the understanding of femur shaft fractures in children, shedding light on their complex dynamics. The study enhances our understanding of pediatric femur shaft fractures. We found that 19% of children exhibited limb shortening, underscoring the need for targeted treatment strategies. These insights can significantly improve patient care and treatment protocols for this challenging condition, benefiting both children and their families.

A systematic review and meta-analysis comparing suprapatellar versus infrapatellar approach intramedullary nailing for tibal shaft fractures.

BACKGROUND: The application of the suprapatellar (SP) approach has challenged the traditional infrapatellar (IP) approach in the surgery treatment of tibial shaft fractures, yet the advantages and disadvantages still remain controversial. We included more high-quality studies for this meta-analysis and systematic review to evaluate the clinical outcomes and prognosis of both approaches and thus to provide new ideas for surgeons. METHOD: We searched literatures from PubMed, Cochrane Library, Web of Science, and EMBASE databases from January 2000 to December 2022. We extracted general information including sample size, gender, proportion of open fracture, follow-up time, and outcome indicators including entrance accuracy, fluoroscopy time, operation time, intraoperative blood loss, Lysholm score, VAS pain score, range of motion (ROM) function score, reposition accuracy, and revision cases. Cochrane Collaboration's tool and the Newcastle-Ottawa Scale were used to evaluate literature qualities. Meta-analysis was performed using RevMan 5.4 software. RESULTS: A total of 23 studies were generated that qualified for inclusion, 17 of which were used for meta-analysis. This study found statistically significant differences in coronal plane entrance accuracy, fluoroscopy time, Lysholm score, and VAS pain score. CONCLUSION: The results of our meta-analysis showed that the SP approach was significantly better than the IP approach in angle and distance entrance accuracy of coronal plane, angle entrance accuracy of sagittal plane, fluoroscopy time, Lysholm score, and VAS pain score. There were no significant differences in sagittal angle accuracy, operative time, intraoperative blood loss, and ROM score.

Widening Access: Sterile Tourniquets for Surgery to the Distal Humerus.

Purpose of the study The use of tourniquets during surgery of the distal humerus can improve visibility and reduce surgical time. However, the available operating field can be limited due to the size and placement of the tourniquet. This proof-of-concept study aimed to determine if sterile tourniquets can provide a wider surgical field compared to non-sterile tourniquets for procedures around the distal humerus. Methods Volunteers (n = 5) were positioned to simulate access to the distal humerus. The distance from the posterior corner of the acromion to the tip of the olecranon was measured. Participants were draped according to the standard protocol for the use of a non-sterile or sterile tourniquet for distal humerus and humeral shaft fractures. Two non-sterile pneumatic tourniquets (standard and narrow) and two sterile tourniquets (pneumatic and elastic exsanguination) were tested. The surgical field was measured from the sterile drape or tourniquet proximally to the tip of the olecranon. A one-way repeated measures ANOVA was conducted to examine the effect of each tourniquet on the surgical field. Results The sterile elastic exsanguination tourniquet had the largest available field with a mean of 24.4 cm (71% of arm available for incision after application), followed by the sterile pneumatic tourniquet of 20.0 cm (58%), narrow non-sterile pneumatic of 19.2 cm (55%), and standard non-sterile pneumatic of 17.0 cm (49%). Repeated measures ANOVA determined that mean surgical field length is statistically significant between tourniquet devices (F (1.729, 6.914) = 21.783, p = .001). The surgical field length was statistically significantly increased from a non-sterile standard tourniquet to a sterile elastic tourniquet (7.4 (95% CI, 2.9-11.9) cm, p = .008) but not the other two tourniquet devices tested. Conclusion The use of certain types of sterile tourniquets can provide a wider surgical field compared to non-sterile tourniquets for procedures around the distal humerus, specifically the sterile elastic exsanguination tourniquet providing a statistically significant mean gain of 7.4 cm from the non-sterile tourniquets. These findings suggest that the use of sterile tourniquets should be considered more frequently in surgery of the distal humerus, and a sterile exsanguinating tourniquet could be considered for midshaft humeral fractures, facilitating safer exposure of the radial nerve and reduced blood loss.

Current practices in the management of closed femoral shaft fractures in children: A nationwide survey among Dutch orthopaedic surgeons.

Background: There remains a lack of high-quality evidence on the treatment of pediatric femur shaft fractures. Therefore, treatment choices may still be based on personal preference of treating surgeons. To gain insight in considerations regarding treatment options, we conducted a survey among Dutch trauma and orthopedic surgeons. Methods: This survey was conducted in 2020, regarding treatment considerations for closed femoral shaft fractures in children in different age and weight groups. Results: One hundred forty-two surgeons were included in the analysis. 31% of participating surgeons considers surgical fixation in children of 2-4 years old, compared to 83% in children of 4-6 years old. In terms of weight, 30% considers surgery in children of 10-15 kg, compared to 77% considering surgery in children weighing 15-20 kg. While most surgeons find traction and spica cast suitable options for children younger than 4 years, a minority also considers these treatment modalities for children older than 4 (traction: 81% versus 19%, spica cast 63% versus 29% respectively). 33% of surgeons considers ESIN under 4 years of age, compared to 88% in children older than 4. Conclusion: An age of 4 years and a weight of 15 kg seem to be cut off points regarding preference of non-surgical versus surgical treatment of closed femoral shaft fractures. There is a wide range of ages and sizes for which treatment options are still being considered, sometimes differing from the national guideline. This questions guideline adherence, which may be due to a lack of available high-quality evidence.

Comparison of reconstruction nails versus dual implants in the treatment of ipsilateral femoral neck and shaft fractures in adults: a meta-analysis and systematic review.

OBJECTIVE: There is no consensus on the optimal treatment for ipsilateral femoral neck and shaft fractures. This meta-analysis aims to assess the effectiveness of reconstruction nails and dual implants in treating ipsilateral femoral neck and shaft fractures to provide a basis for decision-making when selecting the optimal approach. METHODS: Relevant articles were retrieved from Pubmed, Embase, and Cochrane databases using the keywords "neck of femur", "shaft" and "fracture fixation" from inception until November 17, 2022. The screening process of the studies was conducted independently by two assessors, who assessed each study's eligibility and two assessors assessed the quality. Then compared differences in outcome measures using RevMan 5.3 software. RESULTS: A total of ten retrospective cohort studies were included. There were no significant differences in union time, union rate, union-related complications (malunion, nonunion, delayed union) of femoral neck and shaft fractures, osteonecrosis of the femoral head, and functional outcomes (Friedman-Wyman scoring system) (P > 0.05). CONCLUSION: Our pooled estimates indicated that reconstruction nails and dual implants for ipsilateral femoral neck and shaft fractures could yield satisfactory surgical results, and that there is no difference between the two treatment methods. TRIAL REGISTRATION: This meta-analysis was registered on the PROSPERO website (registration number: CRD42022379606).

Comparative Outcomes of Anterior and Posterior Plating for Distal-Third Humerus Shaft Fractures.

PURPOSE: When treating distal-third humerus shaft fractures (HSFs) surgically, the optimal approach for plating is controversial. We conducted a retrospective multicenter study to investigate and compare the clinical outcomes of anterior and posterior plating in distal-third HSFs and the incidence of complications including iatrogenic radial nerve palsy. METHODS: We identified 116 patients from our multicenter trauma database who were diagnosed as having distal-third HSFs and who underwent surgical treatment, including intramedullary nailing between 2011 and 2020. We analyzed 50 cases treated in one of two ways: open reduction internal fixation with anterior plating (group A: 20 cases) and open reduction internal fixation with posterior plating (group P: 30 cases). RESULTS: The findings were similar in terms of operation time, estimated bleeding, and clinical and radiographic outcomes between the groups. Postoperative radial nerve palsy occurred only in group P (4 cases) and never in group A. CONCLUSIONS: The results of this study suggest that the anterior approach is a safe and effective method for treating distal-third HSFs with satisfactory outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Medial minimally invasive percutaneous plate osteosynthesis for humeral shaft fractures: a case series and novel technique description.

INTRODUCTION: Minimally Invasive Percutaneous Plate Osteosynthesis (MIPPO) is increasingly favored for treating humeral shaft fractures (HSFs). However, conventional MIPPO techniques pose challenges in fixing fractures near fossa olecranon and carry a risk of iatrogenic radial nerve palsy. A novel technique using a medial MIPPO for treating humeral shaft fractures (HSFs) is described. Results of clinical follow-up are presented. MATERIALS AND METHODS: This study is a retrospective case series study. Twenty-one patients (mean age 43.9 ± 17.66 [22‒81] years) with HSFs were treated with the novel MIPPO fixation method. Clinical outcomes including time for radiographic consolidation, Disabilities of the Arm, Shoulder, and Hand (DASH) score, and complications were assessed at the last follow-up. The mean follow-up was 26 ± 17.12 (range 12-67) months. RESULTS: All patients had a bony union at a mean of 15.76 ± 6.74 (range 8-40) weeks based on X-ray with an early and aggressive range of motion. The complication rate was 0. The mean DASH score was3.29 ± 4.09 (range 0-14.17) at the time of the last follow-up. The mean screw density was 0.49 ± 0.1 (range 0.2-0.65). CONCLUSION: This novel surgical technique for HSFs is a viable alternative to previously described methods with the advantage of being less prone to nerve injury and easy to fix distal extra-articular HSFs. The learning curve is short. LEVEL OF EVIDENCE: IV.

Effect of fracture level on the residual fracture gap during tibial intramedullary nailing for tibial shaft fractures.

INTRODUCTION: The development of fracture gap during intramedullary nailing in tibial fractures is associated with poor fracture fragment contact and increased time to union and complications. This study aimed to evaluate the effect of the fracture level in the development of the fracture gap and the effect of the fracture gap on pain, radiologic and functional outcomes, and complication rate. MATERIAL AND METHOD: A total of 45 patients who underwent reamed intramedullary nailing due to closed transverse or short oblique tibial shaft fractures were divided into the proximal fracture group and the distal fracture group. The correlations between the visual analog scale (VAS) score, modified radiograph union score for tibias (RUST), and postoperative 1-year lower extremity functional scale scores, residual fracture gap, and time to union were evaluated. RESULTS: The mean fracture gap amounts in the immediate postoperative anteroposterior and lateral radiographs were 5.6 ± 1.7 and 6.0 ± 1.7 mm in proximal fractures and 0.3 ± 2.4 mm and 0.4 ± 2.3 mm in distal fractures, respectively (p < 0.001 and p < 0.001, respectively). The mean time to union was 21.9 ± 2.9 weeks in the proximal fracture group and 16.7 ± 2.4 weeks in the distal fracture group (p < 0.000). The residual fracture gap amount significantly correlated with the level of fracture (r = 0.811, p < 0.001). DISCUSSION: Tibial shaft fractures proximal to the isthmus level tend to develop significantly larger fracture gaps than distal fractures. It is associated with increased time to union and radiographic union scores as well as slightly higher complication and reoperation rates.

Comparison of mini-open reduction and autologous bone grafting with closed reduction and intramedullary device insertion for tibial shaft fractures: a retrospective study.

BACKGROUND: We compared the clinical efficacy of mini-open reduction and autologous bone grafting (GM) and closed reduction (GC) using intramedullary nailing for the treatment of tibial shaft fractures. METHODS: This retrospective study included 70 tibial shaft fractures treated with GM or GC between January 2018 and December 2021. The demographic characteristics and clinical outcomes were compared between the two treatment methods. RESULTS: This study included 70 patients who were followed-up for 12.4 months. In total, 31 and 39 patients were treated with GM and GC, respectively. The operative duration was significantly shorter for GM (95.2 ± 19.3 min) than for GC (105.5 ± 22.2 min, p = 0.0454). The number of radiation times was significantly lower for GM (14.7 ± 6.3) than for GC (22.2 ± 9.2, p < 0.005). There were no statistically significant differences between the groups in terms of the wound complication or infection rates. The malunion and nonunion rates were high after GC than after GM, but there are no significant differences between the groups. CONCLUSIONS: Closed reduction and intramedullary nailing remains the first choice for tibial shaft fractures. GM is a safe and effective treatment worth considering. Future prospective randomized controlled trials are warranted.