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Flexible intramedullary nailing and external fixation have become the main methods to surgically treat femur fractures in children. This study aimed to search the current literature and evaluate the clinical and radiographic results of surgical treatment by comparing these methods and investigating their associated complications. This systematic review was carried out following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) recommendations. Searches were carried out on the PubMed, Embase, and Web of Science databases. The search for journals in these databases was carried out from January 2023 to August 2023, retrieving 695 studies. This systematic review included 11 articles, which encompassed 718 patients who underwent surgical external fixation and flexible nailing. The most frequently observed complications referred to late or malunion, superficial and deep infections, skin irritation, angular deformity, and length discrepancy between lower limbs. Both methods of stabilization of pediatric femoral fractures can provide good clinical and radiographic results. However, the choice of treatment with flexible nails is certainly more valid and has greater acceptance than external fixation. Level of Evidence III, Systematic Review ., Competing Interests: All authors declare no potential conflict of interest related to this article.

Background: Frailty associated with aging increases the risk of falls, disability, and death. The aim of this study is to explore gender-related disparities in the survival outcomes of pathological femoral fractures in older frail patients, while analyzing potential specific prognostic factors., Methods: This study is a retrospective observational analysis conducted at a single medical center. It enrolled all patients aged 65 and above who were admitted to our emergency department between 2016 and 2020 with a diagnosis of pathological femur fracture requiring surgical intervention. The primary study endpoint was evaluating gender-related differences in survival outcomes. The secondary endpoint involves investigating gender-specific prognostic factors through the analysis of clinical and laboratory parameters., Results: The average Charlson Comorbidity Index (CCI) was slightly lower in men, but the difference was not statistically significant ( p = 0.53). The Clinical Frailty Scale (CFS) showed similar results, with men and women 5.23 (SD 1.46), also not significant ( p = 0.83). An evaluation comparing patients aged 75 years or younger to those older than 75 years found significant differences in health metrics. The average CCI was higher in the over 75 group compared to the under 75 group, with a p -value of 0.001. Similarly, the CFS average was also greater in the over 75 group than in the under 75 group, with a p -value of 0.0001. Complications were more frequent in patients over 75 and those with lower educational qualifications. The evaluation analyzed cardiac patients compared to a control group, revealing that the average age of cardiac patients was 75.22 years, while the control group was younger at 73.98 years ( p = 0.5119). The CCI for cardiac patients averaged 6.53, significantly higher than 4.43 for non-cardiac patients ( p = 0.0003)., Conclusion: Frailty assessment is therefore essential in patients with pathological fracture of the proximal femur and is an important predictor of both gender differences and hospital complications. Enhancing gender analysis in this field is crucial to gather more robust evidence and deeper comprehension of potential sex- and gender-based disparities.

Objectives: To identify the characteristics of patients and femur fractures treated with a stainless steel intramedullary nail (ESIN) in children under 15 years of age. Know the results of using the ESIN of related steel in the service., Methods: Retrospective study with review of hospital records and organization of data in spreadsheets., Result: 24 cases were identified, 17 male cases and 7 female cases. A minimum age of 4 years and a maximum of 11 years were observed (average of 7 years). The 3 most common trauma mechanisms were being run over (n:8, 33%) and falling from a height (n:8, 3%). The most common location of the fractures was in the mid-diaphyseal region (n: 20, 88%), only one case presented a bilateral femur fracture. The most common associated trauma was traumatic brain injury. The observation period observed several months between 2 and 5. With regard to complications, 3 cases were observed (12.5%) being bursitis, vicious construction and loss of reduction., Conclusion: Steel HIF shows similar good results. As the study includes the retrospective profile, the absence of a group and the small sample size. Level of Evidence IV, Case series. , Competing Interests: All authors declare no potential conflict of interest related to this article.

Introduction: Entry point selection, a crucial aspect of femoral antegrade nailing, can impact nail fit and consequently fracture reduction. In adults, the standard entry portals used are the piriformis fossa and the tip of the greater trochanter. Previous systematic reviews comparing the two techniques have not been limited to Randomized Controlled Trials (RCTs) and have not consistently included the same available RCTs., Materials and Methods: A systematic search of comparative studies regarding entry portal selection in femoral antegrade nailing was conducted on seven databases. Only Prospective RCTs comparing trochanteric and piriformis entry in the management of trochanteric or diaphyseal femur fractures were eligible for inclusion., Results: Ultimately, only 6 RCTs were found eligible for inclusion. Five of the six included studies reported on operative time. The resulting mean difference (MD) illustrated a significant decrease in operative time by approximately 21.26 min (95% CI  - 28.60 to  - 13.92, p < 0.001) using trochanteric entry. Fluoroscopy exposure was reported on by four studies, however, only two studies were included in the analysis due to different reporting methods. Trochanteric entry used significantly less fluoroscopy than piriformis entry (MD -50.33 s, 95% CI  - 84.441 to  - 16.22, p = 0. 004). No significant difference in malalignment rates, delayed union rates, nonunion rates, pain scores, or complication rates was found., Conclusion: The significant differences found in operating time and fluoroscopy time align with those in other studies. While we were not able to pool the data on functional outcome scores, none of the included studies found a significant difference in scores by their last follow-up. Both approaches demonstrate comparable functional outcomes and safety profiles, indicating the choice of entry point should be at the discretion of the surgeon based on technique familiarity and fracture characteristics., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: In literature, there have been many studies conducted to research the alternatives of standard interlocking intramedullary nailing. The expandable wedge locked nail fixation, which is thought as a new alternative to the standard interlocking nailing, has been presented in previous numerical studies. The antegrade usage of the wedge locked nail fixation has provided promising results. From this point, the aim of the study is to evaluate mechanical behavior of its retrograde usage on femur models. Additionally, another aim of the study is to investigate the effect of fracture level on mechanical properties of the fixation., Materials and Methods: The mechanical behaviors of the wedge locked nail and standard interlocking nail fixations were compared by finite element methods. Sawbones femurs having osteotomies at five different levels to simulate different fractures were fixed with wedge locked nail or interlocking nail by using retrograde approach. With respect to the fracture level, two different nail lengths were used. Axial compression load was applied to fixations. The mechanical behaviors of the fixations were evaluated with respect to stiffness of the fixations and stresses occurred on both implants and bones., Results: Any of the wedge locked nail fixation did not slip at canal. The stress and stiffness results were mostly close with each other for both nail types. The maximum stresses at locking elements or bones contacting these elements increased with decreased distance between the fracture and relevant locking elements., Discussion: The wedge locked nail fixation showed comparable results to the standard interlocking nail fixation with respect to the stiffness and stress. Under axial loading, wedge locked nail provided a secured fixation without any slippage and preserved its position inside the medullary canal. It may be thought as a safe alternative to the standard interlocking nail fixation for retrograde usage. Additionally, according to stress results, it is advised to the surgeons to avoid a close locking to the fracture line., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Intro: Distal growth core fractures of the femur are the third most common fracture in patients older than 10 years. These fractures result from high-energy trauma and have a high risk of evolving into growth disorders. The classification most used to describe these types of fractures is that described by Salter and Harris. Special clinical cases often occur in clinical practice that are not described in the classifications used. In our study, we analyzed and further focused on new fracture patterns related to pediatric epiphyseal detachments not easily described by the normal classifications currently used in the literature., Materials and Methods: From January 2020 to December 2022, we treated 2 male clinical cases with epiphyseal detachments of the distal femur that could not be classified according to the Salter and Harris classification. age of the patients was 10 and 11 years, respectively; for both patients, the traumatic mechanism was a direct trauma to the right knee at high speed using an electric scooter; Serious clinical and radiographic follow-ups were performed at month 1, month 3, month 6, month 12, and month 24 from the date of surgery., Discussion: Distal femur fractures represent a challenge for the orthopedics because they have a high incidence of complications. In our experience, there has been an increase in this type of injury caused using recently developed electric vehicles, which can reach considerable speeds. The Salter Harris classification is among the most widely used for fractures involving the growth physis. This classification proved to be rather limiting in the present case, so we decided to classify the fracture as 'Salter Harris III equivalent'., Conclusions: The fracture examined is a very rare fracture of the distal femur and is not reflected in the classifications currently in use. The patient presented an excellent clinical and radiographic result after surgery with the presence of a shortening of the affected femur in relation to the contralateral one, which suggests that the growth deficit may continue and increase over time for which reason future studies until skeletal maturity will be necessary to quantify the damage to the growth physis., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Purpose: There is high burden of long bone fractures in low- and middle-income countries (LMICs). Given a limited availability of fluoroscopy in LMICs, the Surgical Implant Generation Network (SIGN) developed two types of intramedullary nails: the SIGN standard nail and the SIGN Fin Nail. A limited number of studies have analyzed healing outcomes with the SIGN Fin Nail and the current study is the largest one to date. The purpose of this study is to compare outcomes between the SIGN standard nail and SIGN Fin Nails in adult femoral shaft fractures treated with a retrograde approach., Method: A retrospective cohort study of adults with femoral shaft fractures was performed using the Sign Online Surgical Database (SOSD). The primary outcome was achieving full painless weight bearing and the secondary outcomes assessed were radiographic healing and infection. A propensity-score adjustment was performed for potential confounders and effect modification due to fracture location was tested using a Mantel-Haenszel test for heterogeneity., Results: Of 19,928 adults with femoral shaft fractures, 2,912 (14.7%) had the required 6-month follow-up to be included. The overall propensity score weighted relative risk between the Fin and Standard Nail for achieving painless weight-bearing was 0.99, 95% CI [0.96-1.03] and for radiographical healing was 0.99, 95%CI [0.97-1.02]. The propensity score weighted relative risk for infection was 1.30, 95% [0.85-1.97]. Use of the Fin nail was also significantly associated with shorter surgery times (p < 0.005, effect size = 24 min). Sub-group analysis based on fracture location and injury cause demonstrated no change in relative risk., Conclusion: The Fin nail showed no change in relative risk in terms of achieving full painless weightbearing or radiographic healing compared to the standard nail for retrograde nailing of femoral shaft fractures in adults. The heterogeneous nature of the cohort and large sample size allow for generalizability and add to a growing base of literature supporting use of the Fin Nail for retrograde femoral nailing. However, there are limitations as we could not correct for comminution at the fracture site or measure radiographic alignment or shortening., Competing Interests: No conflicts of interest to disclose. The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Objectives: To compare mortality rates between patients treated surgically for periprosthetic fractures (PPF) after total hip arthroplasty (THA), total knee arthroplasty (TKA), peri-implant (PI), and interprosthetic (IP) fractures while identifying risk factors associated with mortality following PPF., Design: Retrospective., Setting: Single, Level II Trauma Center., Patients/participants: A retrospective review was conducted of 129 consecutive patients treated surgically for fractures around a pre-existing prosthesis or implant from 2013 to 2020. Patients were separated into 4 comparison groups: THA, TKA, PI, and IP fractures., Intervention: Revision implant or arthroplasty, open reduction and internal fixation (ORIF), intramedullary nailing (IMN), percutaneous screws, or a combination of techniques., Main Outcome Measurements: Primary outcome measures include mortality rates of different types of PPF, PI, and IP fractures at 1-month, 3-month, 6-month, 1-year, and 2-year postoperative. We analyzed risk factors associated with mortality aimed to determine whether treatment type affects mortality., Results: One hundred twenty-nine patients were included for final analysis. Average follow-up was similar between all groups. The overall 1-year mortality rate was 1 month (5%), 3 months (12%), 6 months (13%), 1 year (15%), and 2 years (22%). There were no differences in mortality rates between each group at 30 days, 90 days, 6 months, 1 year, and 2 years ( P -value = 0.86). A Kaplan-Meier survival curve demonstrated no difference in survivorship up to 2 years. Older than 65 years, history of hypothyroidism and dementia, and discharge to a skilled nursing facility (SNF) led to increased mortality. There was no survival benefit in treating patients with PPFs with either revision, ORIF, IMN, or a combination of techniques., Conclusion: The overall mortality rates observed were 1 month (5%), 3 months (12%), 6 months (13%), 1 year (15%), and 2 years (22%), and no differences were found between each group at all follow-up time points. Patients aged 65 and older with a history of hypothyroidism and/or dementia discharged to an SNF are at increased risk for mortality. From a mortality perspective, surgeons should not hesitate to choose the surgical treatment they feel most comfortable performing., Level of Evidence: Level III., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Orthopaedic Trauma Association.)

Bisphosphonates (BPs) are a time-tested drug class with multivariate use cases. They are used in pathologies ranging from osteoporosis to Paget's disease, and also help in accelerated fracture healing. They have been used to treat both benign and malignant lesions of the skeletal system since a long time. However, there have been reports of increased incidences of atypical femoral fractures (AFFs) in patients exhibiting chronic use of bisphosphonates in the past years. This has led to the widespread dissuasion of physicians and practitioners from using the drug class. By means of this review of the literature, the authors aim to investigate the relationship between BP use and its association with AFFs. The review focuses on and elucidates the basic pharmacology of BPs and goes on to illustrate the indications of BPs in various pathologies of the musculoskeletal system, further exploring the effects of BPs on the healing of various bony fractures. The authors also explore the incidences of other pathologies, such as osteonecrosis of the jaw and nephropathies associated with BP use, and elaborate on their features. Through this review, the authors have tried to educate and induce critical thinking on the part of clinicians and medical professionals in regard to prescribing BPs to patients that need them, by keeping in mind the risk-reward relationship that accompanies their use., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Bal et al.)

Purpose: To compare the intraoperative procedural efficiency of antegrade and retrograde locked intramedullary nailing of diaphyseal femur fractures without intraoperative fluoroscopy, power reaming devices and fracture tables., Methods: A secondary analysis of prospectively collected data was conducted on 238 isolated diaphyseal femur fractures fixed with SIGN Standard and Fin nails within three weeks of injury. The data included baseline patient and fracture characteristics, nail type and diameter, fracture reduction methods, operative times and outcome measures., Results: There were 84 and 154 fractures in the antegrade and retrograde groups respectively. Both groups were similar vis-a-vis baseline patient and fracture characteristics. Closed reduction of the fractures was significantly easier for retrograde than an antegrade approach. The retrograde approach more readily permitted the use of Fin nails. The mean nail diameter used for retrograde was significantly larger than that for antegrade. The time taken to achieve retrograde nailing was significantly lesser than that of antegrade. There was no statistically significant difference between the outcomes of the two groups., Conclusion: In the absence of expensive fracture-surgery gadgets, retrograde nailing offers many procedural advantages over antegrade, such as easier closed reduction and canal reaming, the greater possibility of using the Fin nail with fewer interlocking screws and shorter operative times. However, we acknowledge the lack of randomisation and the presence of an unequal number of fractures in the two groups as limitations of this study., (© 2023. The Author(s) under exclusive licence to SICOT aisbl.)

Purpose: To assess the outcome of surgically fixated femur shaft and distal femur fractures following low-velocity civilian gunshot injuries over a 4-year period., Methods: A retrospective review was conducted on all patients who sustained femur shaft and distal femur fractures from civilian low-velocity gunshot injuries that required definitive surgical fixation between January 2014 and December 2017. Patient demographics, comorbidities, injury characteristics, duration between injury and surgical fixation and presence of complications were captured., Results: A total of 122 patients (mean age, 29.1 ± 9.5 years) were included. Supracondylar femur fractures (AO 33) accounted for 49% of total injuries, followed by femoral shaft (AO 32) and intra-articular distal femur fractures (AO 33 B & C) with 40% and 11%, respectively. Intramedullary nail fixation was the choice of treatment for femur shaft fractures (49.98%) and supracondylar fractures (63%). Intra-articular injuries were predominantly treated with distal femoral locking plates (85%). Arterial and nerve injuries were the most commonly encountered associated injuries occurring in five patients (4.1%) each. Fracture-related infection was diagnosed in two patients (1.6%). No cases of non-union and compartment syndrome were recorded., Conclusion: Femur shaft and supracondylar fractures fixated with intramedullary nails are associated with low complication rates and perfect union rates. Our study suggests that intra-articular distal femur fractures fixated with locking plates and cannulated screws have a high complication rate and poorer surgical outcomes. Non-union and compartment syndrome are rare complications of gunshot femur fractures fixated with either intramedullary nails or locking plates., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Background: The mismatch between the global burden of surgical disease and global health funding for surgical illness exacerbates disparities in surgical care access worldwide. Amidst competing priorities, governments need to rationally allocate scarce resources to address local needs. To build an investment case for surgery, economic data on surgical care delivery is needed. This study focuses on femur fractures., Methods: This prospective cohort study at Soroti Regional Referral Hospital (SRRH), captured demographic, clinical, and cost data from all surgical inpatients and their caregivers at SRRH from February 2018 through July 2019. We performed descriptive and inferential analyses. We estimated the cost effectiveness of intramedullary nailing relative to traction for femur fractures by using primary data and making extrapolations using regional data., Results: Among the 546 patients, 111 (20.3%) had femur fractures and their median [IQR] length of hospitalization was 27 days [14, 36 days]. The total societal cost and Quality Adjusted Life Year (QALY) gained was USD 61,748.10 and 78.81 for femur traction and USD 23,809 and 85.47 for intramedullary nailing. Intramedullary nailing was dominant over traction of femur fractures with an Incremental Cost Effectiveness Ratio of USD 5,681.75 per QALY gained., Conclusion: Femur fractures are the most prevalent and most expensive surgical condition at SRRH. Relative to intramedullary nailing, the use of femur traction at SRRH is not cost effective. There is a need to explore and adopt more cost-effective approaches like internal fixation., (© 2023. The Author(s).)

Introduction: Intramedullary nailing has been used as a standard in the treatment of the long bone fractures with its clinical and mechanical advantages. However, using distal locking screws has been associated with longer operative times, higher radiation exposure rates, and complications like breakages of distal screw or nail at the screw hole level. Therefore, attempts to eliminate distal locking screws has been always present for intramedullary nail fixation. With a similar purpose, the present study has been carried out to compare mechanical behaviors of intramedullary nail fixations with different distal locking elements., Materials and Methods: In this study, mechanical behaviors of standard interlocking and clawed nail fixations were compared experimentally in the first part. Six fourth generation Sawbones femurs, which have a simulated subtrochanteric fracture, were divided equally and were fixed with standard interlocking and clawed nails. During axial compression tests, experimental strain measurements were taken from all fixations. After validation of numerical models with using experimental strains and stiffnesses, mechanical behaviors of standard interlocking, clawed, and wedge locked nail fixations were compared numerically under axial compression loads. In numerical comparison, the stress-strain distributions were evaluated., Results: Experimental results showed that although that there was no significant difference in stiffnesses, standard nail fixation bore two times higher loads than clawed nail fixations. Under loading, decrease in the distance between fracture surfaces was approximately seven times higher in the clawed nail fixation when compared to standard nail fixations. Numerical results showed that wedge locked nail fixation provided equivalent mechanical behavior to standard interlocking nail., Discussion: In experiments of clawed nail fixation, the high decrease in the distance between fracture surfaces was evidence of the slippage of nail in the medullary canal. For a safe fixation, claws should be deployed when they are completely in contact with the cortical bone, they should be stuck into the bone in a fair amount, and the deployment in the distal third of the femur should be avoided. According to experimentally validated numerical analyses, wedge locked nail fixation may be an alternative for standard interlocking nail fixation if experimental studies support the present results., Competing Interests: Declaration of interests The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Objectives: The Radiographic Union Score for Tibia (RUST) scoring system has been validated in multiple studies assessing the healing of tibial fractures. Our objective was to assess the interobserver and intraobserver reliability for the RUST in diaphyseal femoral fractures treated with intramedullary (IM) nailing., Patients and Methods: A total of 60 sets of anteroposterior (AP) and lateral radiographs of diaphyseal femoral fractures treated by reamed IM nailing were randomly selected from a prospectively collected database. The 60 sets of radiographs were then scored by three reviewers using the RUST system. Interobserver reliability was measured at initial scoring. The 60 sets of radiographs were scored again by the three reviewers to calculate the intraobserver reliability., Results: The RUST scores ranged from 4 to 12 with a mean score of 11.3 ± 1.3. The interobserver intraclass correlation coefficient (ICC) was 0.87 (95% CI, 0.81-0.92) and the intraobserver ICC was 0.91 (95% CI, 0.88-0.94), which indicated excellent agreement., Conclusion: This study demonstrated that the RUST system can be used reliably in the assessment of healing in diaphyseal femur fractures treated by reamed intramedullary nailing, with excellent interobserver and intraobserver reliability., (© 2021. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

The COVID-19 pandemic management has led to a significant change in orthopedic surgical activity. During the pandemic, femur fractures in patients over 65 years of age have maintained a constant incidence. Our study will focus on this fragile population, analyzing the incidence of SARS-CoV-2 infection during hospital stays and the clinical and radiographic orthopedic outcomes. We also evaluated the va\riation of COVID-19 infection after health professionals' vaccinations, and the influence of inter-hospital transfers caused by logistical and organizational aspects of the pandemic. Material and Methods: This is a descriptive and prospective study from 13 October 2020 to 15 March 2021. Participants were patients over 65 years of age with diagnoses of proximal femoral fractures with r surgical treatments indicated. We compared the SARS-CoV-2 infected patients during the stay with non-infected cases. A second evaluation was carried out dividing the patients into those who underwent inter-hospital transfers and a group without transfers. We subdivided the study period into two, according to the percentage of healthcare workers vaccinated against SARS-CoV-2. The reported clinical variables included the Parker and Palmer Score, the Nottingham Hip Fracture Score, the Harris Hip Score, mortality, the Rush Score, and evaluation of reduction in radio-lucent lines in prosthetic implants. Results : Ninety-three patients were studied. The whole positive COVID cohort (11.83%) was hospitalized during the period when less than 80% of health workers were vaccinated ( p = 0.02). The COVID cohort and the patients transferred before surgery had longer stays in the Emergency Room ( p = 0.019; p = 0.00007) and longer lengths of stay compared to the other patients ( p = 0.00001; p = 0.001). Mortality was higher both in the infected group and in the patients who underwent a transfer before the surgical procedure (18.18% vs. 1.22 %; p = 0.003. 25% vs. 6.85%; p = 0.02). In terms of orthopedic outcomes measured through the third month of follow-up, we found worse score results in functional and radiographic outcomes in the COVID positive cohort and in the transferred patients' cohort. Conclusions : The impact of the COVID-19 pandemic on patients treated for proximal femur fracture was statistically significant. Patients with Coronavirus during hospitalization obtained poor short-term radiographic and functional results and increased peri-operative mortality. The incidence of intra-hospital infection was high during the period in which health professionals were not yet covered by the anti-COVID vaccination cycle. Patients who were transferred between two hospitals due to pandemic-related management issues also achieved reduced outcomes compared to non-transferred cases, with increased mortality.

Background: Pediatric femur fractures are a major trauma in children. Different treatment algorithms have been developed but indications for surgical treatment, especially in very young patients, are still controversial. Literature recommends surgical stabilization with elastic-stable intramedullary nailing (ESIN) starting at the age of 3 and non-operative treatment in younger patients. This study sought to present the outcome of patients younger than 3 years of age treated with ESIN for femur fractures., Materials and Methods: Inclusion criteria were patients younger than 3 treated with ESIN in femur fractures. Patient demographics, fracture characteristics, mechanism of injury, outcomes and complications were recorded using charts and X-rays. Primary outcome measures were time to mobility, fracture consolidation and surgical-related complications., Results: Between 2010 and 2020, 159 patients were treated with ESIN in femur fractures in our institution. A total of 30 patients met the criteria. The mean age was 2.1 ± 0.7 years (13 months-2.9 years). Most common mechanism was fall from standing height (60%). Other mechanisms were motor vehicle accidents as a pedestrian (10%) or as a passenger (10%) as well as direct blow trauma (20%). Femoral shaft fracture was the most common injury (80%). 5 subtrochanteric and one distal metaphyseal femur fractures were found. Mean length of stay was 2.0 ± 1.3 days. Radiographic controls were performed on day 1, 14 and 6 weeks after surgery if not otherwise specified or if complications occurred. 4.6 ± 1.2 (n 2-7) X-rays were performed on average after surgery. First radiographic consolidation signs were seen after 2.4 ± 0.6 weeks. Only one child showed surgical-related complication with a leg length discrepancy of 1 cm. In 10% of the patients, shortening after surgery of 1.7 ± 1.4 mm (0.3-3.1 mm) occurred. One child initially treated with traction therapy showed skin irritations and was operated with ESIN. No non-union or ESIN-related complications were found. Mean follow-up was 5.1 ± 4.4 months (4-24 months). First independent mobilization was seen at an average of 3.4 ± 1.1 weeks (2-6 weeks) after surgery. Implant removal was performed after 3.2 ± 1.3 months (2-8 months). No refracture after implant removal occurred., Conclusion: Early results with ESIN show a reasonable and safe treatment option for femur fractures in toddlers and young children under the age of 3 with easy postoperative care, fast fracture union and early independent mobilization., (© 2022. The Author(s).)

Objectives Currently, very little literature exists regarding the "fifth vital sign" in pediatric orthopedics, pain. Multiple studies have highlighted the utility of non-narcotic pain medications in treating acute pain. The objective of this study is to determine the type and amount of pain medication(s) administered and subsequently prescribed to pediatric patients ages six months to five years old with femur fractures treated with spica casting in the ER (emergency room) and OR (operative room). We also determined the incidence of spica cast change necessary for the two groups as a secondary outcome. Methods A retrospective review was completed at a single level 1 pediatric trauma center, evaluating 82 patients who met the inclusion criteria between six months to five years of age with isolated femoral shaft fractures requiring intervention at one institution. Descriptive statistics and Wilcoxon Rank-Sum or Fisher'sFisher's Exact test were used to assess differences between OR and ER groups for either continuous or categorical variables, respectively. The electronic medical record was then queried for demographic information, location of spica cast placement, hours in the hospital, and amount and type of analgesic medications administered and prescribed. Results Overall, we noted a preponderance of femur fractures in young males (72%), with the mean age of our cohort being 2.3 years old. Our patients spent a median of 20.9 hours in the hospital and had a median worst pain score of 7/10 during their hospital stay. No difference was found between standardized amounts of morphine equivalent administration between groups in the hospital. Upon discharge from the hospital, most patients received opioid and acetaminophen prescriptions (72% and 83%), but few received an ibuprofen prescription (24.4%). More spica casts placed in the ER needed to be revised in the OR compared to spica casts placed in the OR (57% vs. 8%, p<0.01). Conclusions There are various medication regimens for patients with femoral shaft fractures treated with spica casting at one institution. Our study revealed that patients received more prescription opioids if treated in the OR. Additionally, spica casting in the ER did not significantly decrease hospital stay, and it significantly increased the risk of needing a reduction in the OR in our institution., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Williams et al.)

Aims: This observational cross-sectional study aimed to answer the following questions: 1) how has nonunion incidence developed from 2009 to 2019 in a nationwide cohort; 2) what is the age and sex distribution of nonunions for distinct anatomical nonunion localizations; and 3) how high were the costs for surgical nonunion treatment in a level 1 trauma centre in Germany?, Methods: Data consisting of annual International Classification of Diseases (ICD)-10 diagnosis codes from German medical institutions from 2009 to 2019, provided by the Federal Statistical Office of Germany (Destatis), were analyzed. Nonunion incidence was calculated for anatomical localization, sex, and age groups. Incidence rate ratios (IRRs) were determined and compared with a two-sample z-test. Diagnosis-related group (DRG)-reimbursement and length of hospital stay were retrospectively retrieved for each anatomical localization, considering 210 patients., Results: In 2019, a total of 11,840 nonunion cases (17.4/100,000 inhabitants) were treated. In comparison to 2018, the incidence of nonunion increased by 3% (IRR 1.03, 95% confidence interval (CI) 0.53 to 1.99, p = 0.935). The incidence was higher for male cases (IRR female/male: 0.79, 95% CI 0.76 to 0.82, p = 0.484). Most nonunions occurred at the pelvic and hip region (3.6/100,000 inhabitants, 95% CI 3.5 to 3.8), followed by the ankle and foot as well as the hand (2.9/100,000 inhabitants each). Mean estimated DRG reimbursement for in-hospital treatment of nonunions was highest for nonunions at the pelvic and hip region (€8,319 (SD 2,410), p < 0.001)., Conclusion: Despite attempts to improve fracture treatment in recent years, nonunions remain a problem for orthopaedic and trauma surgery, with a stable incidence throughout the last decade.Cite this article: Bone Joint Res  2022;11(8):541-547.

Background: Numerous studies have pointed out how visual impairment relates to falls in the elderly, causing dangerous consequences, such as fractures. The proximal femur fracture is one of the most frequent fracture types related to poor vision. This study investigates the link between fall-related hip fractures and visual impairment., Methods: The present is an observational monocentric case-control study. We collected the ophthalmologic anamnesis and measured the visual acuity of 88 subjects with femur neck fracture (case group), comparing it with 101 adults without fractures and a recent fall history., Results: The results showed no statistical difference between the two groups regarding visual acuity, with a p -value of 0.08 for the right eye and 0.13 for the left one. One of the major ophthalmologic morbidities found was cataracts, present in 48% of the control group and 30% of the case group., Conclusions: The data obtained suggest that visual impairment might not be crucial in determining falls in the elderly.

Background: The number of hip replacements is constantly and progressively increasing, resulting in an increase in periprosthetic fractures. The main aim of this study is to analyze costs and outcomes of surgical treatment for those fractures., Materials and Methods: A retrospective study was performed on periprosthetic proximal femur fracture presented a single-level I trauma center. Medical records were reviewed in terms of demographic data, diagnosis (according to Vancouver classification), type of surgical treatment, hospitalization length and follow-up. Patients were interviewed about number of consultations after discharge, medications and physiotherapy sessions. Clinical outcome was evaluated with WOMAC score at the last follow-up, and patient health status was evaluated with the EQ5D5L score pre-trauma and at the last follow-up. Patients were divided into two groups according to surgical treatment: reduction and internal fixation alone and revision plus fixation. A further group was also considered: patients underwent a Girdlestone procedure. Global costs for each group were calculated., Results: We initially recruited 117 patients, 17 of them were lost at follow-up. Furthermore, 19 patients (19%) died during the follow-up, and 81 of them were therefore included in the study. Mean follow-up was 26.5 months. Mean postoperative WOMAC score was 39.44, and EQ5D5L score was 9.12 for the preoperative period and 12.35 at the last follow-up. A significant worsening of clinical conditions was found comparing the period before fracture to the last follow-up (p < 0.01). Quality of life after surgery resulted to be poor or fair in 40% of the patients at a mean follow-up of 26.5 months. No significant differences between groups were found according to patients' health status. Mean global costs for mayor surgeries were 18,822 Euros; mean costs for fixation alone were 17,298 Euros while for fixation and revision were 20,966 Euros, but no statistically difference was found between these two groups. Mean cost for Girdlestone group was 12,664 Euros., Conclusions: In proximal femur periprosthetic fractures, either fixation or revision plus fixation presents high costs but patients' postoperative quality of life is poor., (© 2021. Istituto Ortopedico Rizzoli.)

Aims: Bone turnover markers (BTMs) follow distinct trends after fractures and limited evidence suggests differential levels in BTMs in patients with delayed healing. The effect of vitamin D, and other factors that influence BTMs and fracture healing, is important to elucidate the use of BTMs as surrogates of fracture healing. We sought to determine whether BTMs can be used as early markers of delayed fracture healing, and the effect of vitamin D on BTM response after fracture., Methods: A total of 102 participants aged 18 to 50 years (median 28 years (interquartile range 23 to 35)), receiving an intramedullary nail for a tibial or femoral shaft fracture, were enrolled in a randomized controlled trial comparing vitamin D 3 supplementation to placebo. Serum C-terminal telopeptide of type I collagen (CTX; bone resorption marker) and N-terminal propeptide of type I procollagen (P1NP; bone formation marker) were measured at baseline, six weeks, and 12 weeks post-injury. Clinical and radiological fracture healing was assessed at three months., Results: CTX and P1NP concentrations peaked at six weeks in all groups. Elevated six-week CTX and P1NP were associated with radiological healing at 12 weeks post-injury (odds ratio (OR) 10.5; 95% confidence interval 2.71 to 53.5, p = 0.002). We found no association between CTX or P1NP and functional healing. Baseline serum 25(OH)D showed a weak inverse relationship with P1NP (p = 0.036) and CTX (p = 0.221) at 12 weeks, but we observed no association between vitamin D supplementation and either BTM., Conclusion: Given the association between six-week BTM concentrations and three-month radiological fracture healing, CTX and P1NP appear to be potential surrogate markers of fracture healing. Cite this article: Bone Joint Res  2022;11(4):239-250.

We used Veterans Health Administration (VHA) national administrative data files to identify a cohort (fiscal years 2005-2014) of veterans with spinal cord injuries and disorders (SCID) to determine risk factors for and consequences of lower extremity fracture nonunions. Odds ratios (OR) for fracture nonunion were computed using multivariable-adjusted logistic regression models. We identified three risk factors for nonunion: (i) older age (OR = 2.29; 95% confidence interval [CI] 1.21-4.33), (ii) longer duration of SCID (OR = 1.02; 95% CI 1.00-1.04), and (iii) fracture site (distal femur), with OR (comparison distal femur) including distal tibia/fibula (OR = 0.14; 95% CI 0.09-0.24), proximal tibia/fibula (OR = 0.19; 95% CI 0.09-0.38), proximal femur (OR = 0.10; 95% CI 0.04-0.21), and hip (OR = 0.13; 95% CI 0.07-0.26). Nonunions resulted in multiple complications, with upwards of 1/3 developing a pressure injury, 13% osteomyelitis, and almost 25% requiring a subsequent amputation. Our data have identified a high-risk population for fracture nonunion of older veterans with a long duration of SCID who sustain a distal femur fracture. In view of the serious complications of these nonunions, targeted interventions in these high-risk individuals who have any signs of delayed union should be considered. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research. This article has been contributed to by US Government employees and their work is in the public domain in the USA., (© 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research. This article has been contributed to by US Government employees and their work is in the public domain in the USA.)

Introduction: There has been a great effort in preventing the disadvantages of distal locking in intramedullary nailing to date. From this scope, a novel expandable nail fixation eliminating distal locking screws has been designed. The primary aim of this numerical parametric study is to investigate mechanical behavior of expandable nail fixation on the fractured femur model under different contact parameters which are effective in maintaining the nail position and to specify the appropriate values of these contact parameters for a safe fixation. The second aim is to compare mechanical behavior of the expandable nail fixation with the standard interlocking nail fixation., Materials and Methods: The expandable nail has three wedges which are responsible for distal fixation by compressing the medullary canal in the radial direction. 4th generation Sawbones femur model was used as bone model. A transverse osteotomy with 20 mm gap was created to simulate a subtrochanteric fracture. The fixations have been examined under axial compression with 1200 N and torsion with 7 Nm. In the parametric study, the tightening torque and static friction coefficient in wedge-canal contact were selected as contact parameters. The outputs were stiffnesses of the fixations, equivalent von-Mises stress distribution on the models, and load sharing between the canal and distal locking elements., Results: The results of the parametric study showed that the model with the tightening torque of 3 Nm and friction coefficient of 0.7 was the safest. The load borne by wedges is generally prone to increase with increased tightening torque and friction coefficient. The both fixations showed close stiffness and stress values., Conclusion: The tightening torque of the wedge locking mechanism is directly effective in maintaining the nail position constant in canal, and the safety of the fixation is better ensured with increased tightening torque but stress states on bone must be carefully evaluated. The expandable nail provided comparable results to standard interlocking nails with respect to the fixation stiffness, stress, and contact forces. The expandable nailing may be evaluated as an alternative in the fractures of long bones in the case that the numerical results are supported by future experimental studies., Competing Interests: Declarations of Competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021. Published by Elsevier Ltd.)

Aims: The modified Radiological Union Scale for Tibia (mRUST) fractures score was developed in order to assess progress to union and define a numerical assessment of fracture healing of metadiaphyseal fractures. This score has been shown to be valuable in predicting radiological union; however, there is no information on the sensitivity, specificity, and accuracy of this index for various cut-off scores. The aim of this study is to evaluate sensitivity, specificity, accuracy, and cut-off points of the mRUST score for the diagnosis of metadiaphyseal fractures healing., Methods: A cohort of 146 distal femur fractures were retrospectively identified at our institution. After excluding AO/OTA type B fractures, nonunions, follow-up less than 12 weeks, and patients aged less than 16 years, 104 sets of radiographs were included for analysis. Anteroposterior and lateral femur radiographs at six weeks, 12 weeks, 24 weeks, and final follow-up were separately scored by three surgeons using the mRUST score. The sensitivity and specificity of mean mRUST score were calculated using clinical and further radiological findings as a gold standard for ultimate fracture healing. A receiver operating characteristic curve was also performed to determine the cut-off points at each time point., Results: The mean mRUST score of ten at 24 weeks revealed a 91.9% sensitivity, 100% specificity, and 92.6% accuracy of predicting ultimate fracture healing. A cut-off point of 13 points revealed 41.9% sensitivity, 100% specificity, and 46.9% accuracy at the same time point., Conclusion: The mRUST score of ten points at 24 weeks can be used as a viable screening method with the highest sensitivity, specificity, and accuracy for healing of metadiaphyseal femur fractures. However, the cut-off point of 13 increases the specificity to 100%, but decreases sensitivity. Furthermore, the mRUST score should not be used at six weeks, as results show an inability to accurately predict eventual fracture healing at this time point. Cite this article: Bone Jt Open  2021;2(10):796-805.

Objective: To explore the influencing factors of perioperative blood transfusion in the treatment of elderly femoral intertrochanteric fractures with proximal femoral nail antirotation(PFNA)., Methods: The clinical data of 109 elderly patients with intertrochanteric fractures who received PFNA treatment from July 2018 to January 2020 were retrospectively analyzed. Both pelvic hip X-rays and CT plain scans were performed before surgery. All patients were diagnosed by X-ray and CT plain scan of pelvis and hip before operation. Through the statistical analysis of the basic data of patients before and during operation, the risk factors of perioperative blood transfusion were explored., Results: Logistic regression analysis showed that age ( P =0.013), fracture type ( P <0.01), diabetes history ( P =0.031) and preoperative hemoglobin ( P <0.01) were independent risk factors for perioperative blood transfusion in the treatment of intertrochanteric fractures in elderly patients with 109 patients. Spearman correlation analysis showed that there was a positive correlation between blood transfusion and age of patients ( P = 0.017), fracture type ( P <0.01), diabetes history ( P =0.023), and negatively correlated with preoperative hemoglobin ( P <0.01). However, gender ( P =0.297), history of hypertension ( P =0.318) and operation time( P =0.325) had no significant relationship with perioperative blood transfusion., Conclusion: Age, fracture type, diabetes history, and preoperative hemoglobin are independent risk factors for perioperative blood transfusion in the treatment of elderly intertrochanteric fractures with PFNA. The older the patient, the history of diabetes, the more unstable the fracture, and the lower preoperative hemoglobin, the more likely it is to require a blood transfusion, which may provide a reference for clinical perioperative blood transfusion decisions.

Introduction: Evidence regarding recommendations for treatment of ballistic fractures remains limited. This paucity of literature has largely been attributed to gunshot wound victims being a difficult population to study secondary to loss to follow-up. The purpose of this study was to examine the epidemiology of operatively treated ballistic femur fractures at our institution, the frequency of outpatient follow-up and risk factors for loss to follow-up., Methods: Inpatient consults from 2013-2018 were queried for femoral gunshot wounds treated operatively. Cases without internal or external fixation were excluded from the study. Postoperative visits where a patient was hospitalized or had expired were excluded from the analysis. Demographic information, length of hospital stay, and operative characteristics were compared for different fixation methods and examined as risk factors for loss to follow-up., Results: A total of 194 patients met inclusion criteria. The average age was 27 years old and 94% of the patients were male. Patient's stayed a median of 5 days post-operatively with patients treated with external fixation staying longer than internal fixation (14 days vs 5 days p=0.01). 9.3% of ballistic fractures had a concomitant vascular injury necessitating repair. 70.4% of patients attended their 2-week postoperative visit, 55.7% of patients attended their 6 week follow-up visit and 31.3% attended their 3 month follow-up visit. Risk factors for loss to follow-up at 3 month visit included younger age (p=0.028), decreased hospital length of stay (p=0.025) and intramedullary fixation (p=0.00015)., Discussion and Conclusion: This study reinforces the difficulty of studying ballistic fractures secondary to loss to follow-up. Younger age, shorter hospital stays and intramedullary fixation increased the risk for loss to follow-up at 3 months., Competing Interests: Declaration of Competing interest None., (Copyright © 2021. Published by Elsevier Ltd.)

Objective: Post-operative femoral shaft fractures are often accompanied by a residual varus/valgus deformity, which can result in osteoarthritis in severe cases. The purpose of this study was to investigate the biomechanical effects of residual varus/valgus deformities after middle and lower femoral fracture on the stress distribution and contact area of knee joint., Methods: Thin-slice CT scanning of lower extremities and MRI imaging of knee joints were obtained from a healthy adult male to establish normal lower limb model (neutral position). Then, the models of 3°, 5°, and 10° of varus/valgus were established respectively by modifying middle and lower femur of normal model. To validate the modifying, a patient-specific model, whose BMI was same to former and had 10° of varus deformity of tibia, was built and simulated under the same boundary conditions., Result: The contact area and maximum stress of modified models were similar to those of patient-specific model. The contact area and maximum stress of medial tibial cartilage in normal neutral position were 244.36 mm 2 and 0.64 MPa, while those of lateral were 196.25 mm 2 and 0.76 MPa. From 10° of valgus neutral position to 10° of varus, the contact area and maximum stress of medial tibial cartilage increased, and the lateral gradually decreased. The contact area and maximum stress of medial meniscus in normal neutral position were 110.91 mm 2 and 3.24 MPa, while those of lateral were 135.83 mm 2 and 3.45 MPa. The maximum stress of medial tibia subchondral bone in normal neutral position was 1.47 MPa, while that of lateral was 0.65 MPa. The variation trend of medial/lateral meniscus and subchondral bone was consistent with that of tibial plateau cartilage in the contact area and maximum stress., Conclusion: This study suggested that varus/valgus deformity of femur had an obvious effect on the contact area and stress distribution of knee joint, providing biomechanical evidence and deepening understanding when performing orthopedic trauma surgery or surgical correction of the already existing varus/valgus deformity.

Purpose: The poor prognosis in patients with floating knee injuries is mainly contributed to articular involvement (Fraser's type Ⅱ). This study aims to evaluate and compare the functional outcomes among different Fraser's type Ⅱ floating knee injuries after surgical management., Methods: Twenty-seven patients with Fraser's type Ⅱ floating knee injuries (54 fractures) between September 2014 and December 2015 were enrolled prospectively in this study and were distributed according to Fraser's floating knee classification into three different groups as type ⅡA (ipsilateral femoral shaft and tibial intra-articular involvement, n = 11), type ⅡB (ipsilateral tibial shaft and femoral intra-articular involvement, n = 9) and type ⅡC (both femoral and tibial intra-articular involvement, n = 7). The differences among the groups were evaluated and compared. The functional outcomes of these injuries at one year were analyzed using Knee Injury and Osteoarthritis Outcome Score (KOOS) which covers 5 subscales of pain, other symptoms, activities of daily living, sports and recreation, and quality of life. The result was also compared with standardized age-sex matched healthy population using paired samples t-test., Results: All the patients were male, and the injury mechanism was solely roadside accident. The mean age was 29.8 years and injury severity score 17.9 (comparable in all the three groups). Most injuries were observed on the right side (20 cases, 74.1%). Based on paired samples t-test, the KOOS score of patients with Fraser's type ⅡA was found to be better than that of type ⅡB and type ⅡC. Compared with the reference age-sex matched control group, patients with Fraser's type ⅡB and ⅡC fractures had significantly lower mean score in all KOOS subscales (all p < 0.01). However, Fraser's type ⅡA only revealed significant difference regarding the subscales of activities of daily living (p < 0.0001), sports and recreation (p < 0.0001), and quality of life (p < 0.0001)., Conclusion: The results of this study show that patients with Fraser's type ⅡA fractures had a better functional outcome as compared to those with type ⅡB and ⅡC fractures. This might be due to the open intra-articular involvement of the distal femur of the latter two fracture types., (Copyright © 2020 Chinese Medical Association. Production and hosting by Elsevier B.V. All rights reserved.)

Objectives: To document the presentation of infected non-unions of femur in pediatric and adolescent population and evaluate the outcome of segmental bone transport with the Ilizarov method., Methods: This prospective case series study was carried out over a period of five years, from January 01, 2015 to December 31, 2019. The study included all children and adolescent patients who presented with femoral infected non unions. The study excluded patients above the age of 16 years and those who had pathological fractures secondary to bone pathologies such as cysts, tumors or metabolic bone diseases., Results: Out of 31 patients, 27(87.09%) were males and 4(12.90%) were females. The mean age was 13.48±1.98 years. The underlying mechanisms that lead to the causation of fractures included road traffic accidents (n=23;74.19%), fall from height (n=7;22.58%) and firearm injuries (n=1;3.22%). The bone gaps ranged from 3-5 cm with a mean of 4.00± 0.856 cm. Bone union was achieved among 28(90.32%) patients. Infection was eradicated among 27(87.09%) patients whereas the remaining patients continued to suffer persistent infection. The most common complications included pin tract inflammation/ infection among (n=31;100%) patients and stiffness of knee joint among (n=19;61.29%) patients., Conclusion: Majority of the patients were males, aged 9-16 years. Road traffic accidents were the commonest cause of the fractures. The Ilizarov method of segmental bone transport was effective in treating the majority of infected non-unions., Competing Interests: Conflicts of Interest: None., (Copyright: © Pakistan Journal of Medical Sciences.)

Aim: This study aims to test the accuracy and feasibility of a measurement of femoral torsion of a 3D C-arm system (Linea aspera method) in a cadaver setting., Materials and Methods: A total of 11 intact femora were used. Schanz screws were inserted in the femoral bone in a parallel manner with the help of a fixed drill sleeve. Femur bones were then fractured in a controlled manner and three different internal and external torsion angles were fixed with the help of a Goniometer. After that, a 3D scan was performed. The 3D data set was analyzed using a radiologic software (Visage 7, Visage Imaging Inc, USA). Measurements were then compared in the two methods with a dependent t test., Results: Specific measurements for different angles did not show any differences between those two utilities., Conclusion: Intraoperative estimation of femoral antetorsion using a 3D C-Arm system and the Linea aspera method seems to be an accurate and feasible method. Nevertheless, more studies with higher patient numbers, comparison to CT seems to be the next step and can be recommended.

Purpose: The Surgical Implant Generation Network (SIGN) intramedullary nail was designed for use in resource limited settings which often lack fluoroscopy, specialized fracture tables, and power reaming. A newer design iteration, the SIGN Fin nail, was developed to further simplify retrograde femoral nailing by making proximal interlocking screw placement unnecessary. Instead, the leading end of the Fin nail achieves stability through an interference fit within the proximal femoral canal. While the performance of the traditional SIGN nail has been reported previously, no large series has examined long-term clinical and radiographic outcomes of femoral shaft fractures treated with the SIGN Fin nail., Methods: The SIGN online surgical database was used to identify all adult femoral shaft fractures treated with the SIGN Fin nail since its introduction. All patients with minimum 6 month clinical and radiographic follow-up were included in the analysis. Available demographic, injury, and surgical characteristics were recorded. Fracture alignment was evaluated on final follow-up radiographs using a previously validated on-screen protractor tool. Coronal and sagittal plane alignment measurements were recorded as deviation from anatomic alignment (DFAA), with units in degrees. Fracture healing was assessed on final follow-up radiographs, with union defined as any bridging callus and/or cortical remodeling across one cortex on orthogonal views. Clinical outcomes available in the database included knee range of motion (ROM) greater than 90° and weight-bearing status at final follow-up. Clinical and radiographic outcomes were then compared between patients with united and nonunited fractures., Results: The database query identified 249 femoral shaft fractures stabilized with the Fin nail in 242 patients who had minimum 6 month clinical and radiographic follow-up. Final follow-up radiographs were performed at an average of 48 weeks postoperatively. Average coronal and sagittal plane alignment measured on final follow-up radiographs were 2.18° and 2.58°, respectively. The rate of malalignment (DFAA > 10° in either plane) at final follow-up was 6%. Two hundred twenty-nine fractures (92%) were united at final follow-up. Overall, 209 (84%) of patients achieved full weight bearing and 214 (86%) achieved knee ROM >90° at final follow-up. Compared to patients with united fractures, those with nonunion were less likely to achieve full weight bearing (20% vs 90%, P  < .001) and knee ROM >90° (30% vs 91%, P  < .001). There was no significant difference in mean DFAA between united and nonunited fractures in the coronal (2.1° vs 3.8°, P  = .298) or sagittal (2.5° vs 3.5°, P  = .528) planes., Conclusion: The SIGN Fin nail achieves satisfactory radiographic alignment and clinical outcomes at minimum 6 month follow-up. The overall union rate is comparable to that achieved with the standard SIGN nail. Ease of implantation makes the Fin nail an attractive option in resource-limited settings., Competing Interests: The authors have no other conflicts of interest to disclose., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Orthopaedic Trauma Association.)

Two cases of bone failure after fracture of the distal region of the femur treated with the Masquelet technique are presented. The first case involves acute bone loss, and the second, pseudarthrosis. The proper management of these lesions led to consolidation and a good functional result., Competing Interests: Conflito de Interesses Os autores declaram não haver conflito de interesses., (Sociedade Brasileira de Ortopedia e Traumatologia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ ).)

Background: Venous thromboembolism (VTE) is a serious complication that contributes to morbidity, mortality, and healthcare costs during the surgical care of patient with lower extremity fractures. Despite this, few recommendations on the topic exist and the literature on VTE incidence is incomplete. Therefore, this study will attempt to estimate annual incidence and trends in 30-day thrombotic events and mortality for the following fractures: (1) hip, (2) femur, (3) patella, (4) tibia and/or fibula, and (5) ankle., Methods: We identified 120,521 operative lower extremity orthopaedic trauma patients from 2008 to 2016 using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. To evaluate the relationship between the year in which surgery was performed and comorbidities and demographic information bivariate analysis was performed. Bivariate analysis was also performed for the outcomes of interest and year in which the surgery was performed to assess for change. Additionally, bimodal multivariate logistic regression models for hip, femur, and ankle fractures were built, comparing the years 2009 to 2016 using 2008 as a baseline., Results: Overall incidence for VTE over the study period was 1.7% for hip fractures, 2.4% for femur fractures, 0.9% for patella fractures, 1.1% in tibia and/or fibula fractures, and 0.6% in ankle fractures. Over the study period VTE incidence saw a significant decrease (p < 0.05) in hip and femur fractures, but not for patella, tibia and/or fibula, and ankle fractures. After adjusting for confounding factors with multivariate analysis, the change in hip and femur fractures was no longer significant, while no significant decrease was again found for ankle fractures (p > 0.05)., Conclusion: Our study demonstrates that VTE rates have remained unchanged in operative lower extremity orthopaedic trauma from 2008 to 2016. This highlights the need for higher quality evidence on this important topic in orthopaedic trauma, including a reevaluation on the necessity of thromboprophylaxis guidelines., Level of Evidence: III., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Introduction: The optimal mode of treatment among the wide variety of surgical and nonsurgical treatment options for children between 5 and 15 years of age continues to be controversial. Elastic stable intramedullary nailing of long bone fractures in the skeletally immature has gained widespread popularity because of its clinical effectiveness and low risk of complications., Methods and Methodology: From Jan 2015 to August 2016, 35 patients including 37 limbs with diaphyseal fractures of the femur in the age group 5-15 years were managed by Titanium Elastic nailing and their clinico-radiological and functional outcome was assessed at 1 year post operatively as per the Flynn's criteria. RUST score was used as a guide for post-operative rehabilitation., Results: 37 patients were managed by TENS nailing including 28 males and 9 females. The outcome in proximal, middle or distal fractures of the shaft were found to be similar and the difference was statistically insignificant. Similarly, the difference in the outcomes as per fracture patterns was also found to be statistically insignificant. Partial weight bearing was allowed after a score of 6 was achieved and full weight bearing after a score of 8., Conclusion: As per the Flynn's criteria, 75% of the patients (28 out of 37) were found to have an excellent outcome while 7 had a satisfactory outcome and two had a poor outcome. RUST score can be used as an effective guide for post op rehabilitation.

Purpose: In developing countries, long bone fractures following trauma are a significant contributor to morbidity, and operating room resources are often limited in these settings. The Surgical Implant Generation Network (SIGN) Fin nail may reduce the challenges of retrograde intramedullary nailing of femoral fractures without fluoroscopy. In contrast to the traditional SIGN nail placed in a retrograde fashion, the Fin nail does not require proximal interlocking screws. Instead, the nail achieves stability through an interference fit within the proximal femoral canal. The purpose of this study is to compare postoperative alignment in femoral shaft fractures treated with either a retrograde SIGN Fin nail or a standard retrograde SIGN nail., Method: Using the SIGN online surgical database, we identified all femoral shaft fractures treated with a retrograde SIGN Fin nail at 2 African hospitals. Two examiners independently classified fracture patterns using the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) classification system. Using an on-screen protractor tool, postoperative coronal and sagittal plane alignment were measured and recorded as deviation from anatomic alignment (DFAA), with units in degrees. Available patient demographics and surgical details were also recorded. Fin nail cases were matched in a 1:1 ratio to retrograde standard SIGN nail cases based on AO/OTA fracture type., Results: Twenty-eight retrograde Fin nail cases were identified, and 28 matched retrograde SIGN nail cases were selected. The Fin nail and retrograde SIGN nail groups were well matched in terms of demographics, AO/OTA fracture type, and surgical characteristics. There was no significant difference in postoperative coronal or sagittal plane alignment between the groups. There were no cases in either group of average postoperative malalignment >5° in any plane., Conclusion: The SIGN Fin nail appears to achieve satisfactory radiographic alignment without the need for proximal interlocking screws, making it an attractive implant for retrograde femoral shaft fracture fixation in resource-limited settings. Further research is required to validate these findings and determine long-term Fin nail clinical outcomes., (Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Orthopaedic Trauma Association.)

Background: Surgical decision-making can be challenging when treating patients with osseous metastases. Numerous factors, including expected duration of survival, must be considered to ensure optimal operative stabilization of the affected bone. However, life expectancy of patients with metastatic carcinoma is often difficult to estimate. The goal of our study was to assess the associations of various clinical and demographic factors with survival time after intramedullary nail fixation of impending or completed pathologic femur fractures., Methods: One hundred thirty-eight consecutive patients treated with intramedullary nail fixation for impending or completed pathologic femur fractures between 2005 and 2017 were included in this study. Factors related to patient survival were assessed with Cox multivariate survival analysis. For all analyses, p < 0.05 was considered significant., Results: The median overall postoperative survival time was 8.4 months. Lower hemoglobin concentration (p = 0.001), lower albumin concentration (p = 0.002), and having a group 2 primary cancer (p = 0.001) were associated with shorter survival on multivariate analysis. When considering the subgroup of 88 prophylactically stabilized patients, lower hemoglobin concentration (p = 0.005), lower albumin concentration (p = 0.015), and having a group 2 primary cancer (p = 0.037) were predictive of shorter survival., Conclusion: Several factors are associated with shorter survival after intramedullary nail fixation of pathologic femur fractures. These factors should be considered by orthopedic surgeons when educating patients and determining appropriate treatment., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Little data exists on the negative impact of orthopaedic trauma on quality of life (QOL) in low- and middle-income countries (LMICs). The goal of this study is to investigate the factors associated with lower QOL after operative fixation of femoral shaft fractures in adult patients in a low-resource setting., Methods: This prospective cohort study followed 272 factures in adults undergoing operative fixation for diaphyseal femur fractures at Tanzania. Patient demographics, injury characteristics, treatment modalities, and functional outcomes up to 1-year post-operatively were evaluated for association with 1-year post-operative EQ-5D QOL scores via univariate linear regression analysis., Results: EQ-5D values were significantly lower at 1 year than at baseline (0.941 vs 0.991, p < 0.0005)., Conclusions: Operative fixation of femoral shaft fractures in LMICs results in return to near baseline QOL. Demographic and treatment factors were not significantly associated with EQ-5D. and several markers of recovery were associated with lower 1 year QOL, including pain, knee stiffness, delayed radiographic healing, complications requiring reoperation. Efforts to reduce perioperative complications may help improve post-operative QOL., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Introduction: Management of distal femur fractures above total knee arthroplasty (TKA) remains challenging. Two common surgical options are locked lateral plating (LLP) and distal femoral arthroplasty (DFR). Unfortunately, approximately 30-50% of patients may die within one year of injury, require further surgery, or not regain prior mobility performance. We compared 87 LLP to 53 DFR patients - to our knowledge the largest comparative study - focusing on 90- and 365-day mortality, mobility maintenance, and further surgery., Methods: We performed a retrospective review of patients at least 55 years old who sustained femur fractures near a primary TKA (essentially OTA-33 or Su types 1, 2, or 3) from 2000 to 2015 assigning cohort based on treatment: LLP or DFR. We excluded patients having prior care for the injury, whose surgery was not for fracture (e.g. loosening), or having other surgical intervention (e.g. intramedullary nail)., Results: Results Cohorts were similar based on body mass index and age adjusted Charlson Comorbidity Index (aaCCI). LLP was more common than DFR for fractures above and at the level of the implant, but similar for fractures within the implant for patients with aaCCI ≥ 5. LLP and DFR had similar mortality at 90 days (9% vs 4%) and 365 days (22% vs 10%), need for additional surgery (9% vs 3%), and survivors maintaining ambulation (77% vs 81%). Patients whose surgery occurred 3 or more days after presentation had similar mortality risk to those whose surgery was before 3days. The mean age of one year survivors was 77 whereas for patients who died it was 85. Neither surgical choice nor aaCCI was associated with increased risk in time to surgery., Conclusions: Fracture location, remaining bone stock, and patient's prior mobility and current comorbidities must guide treatment. Our study suggests that 90- and 365-day mortality, final mobility, and re-operation rate are not statistically different with LLP vs DFR management., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Purpose: The cerclage passer instrument was introduced for aiding percutaneous reduction in spiral femur fractures, thereby overcoming the risk of devascularization of the fracture ends commonly associated with traditional open cerclage wiring techniques. This may, however, predispose to iatrogenic vascular injuries owing to the proximity of the vessels and several other factors. We report four cases with femoral artery (superficial and deep) injuries caused by the cerclage passer in proximal femur and distal femur shaft fractures and incidence of these injuries in our institution., Methods: Retrospective analysis of hospital records of femoral fractures from 2011 to 2015. All cases of femoral fractures and periprosthetic femoral fractures with cerclage wiring done using the standard or the Synthes ® cerclage passer were included. Cases with wiring done for trochanteric fractures and other locations were excluded., Results: Incidence of vascular injuries due to the cerclage passer in proximal femur shaft fractures was 1.59%, whereas in distal femur shaft fractures it was 7.14%. There were two patients with a deep femoral artery (DFA) system injury and two with a superficial femoral artery (SFA) injury caused by the cerclage passer (Synthes) in two proximal femur shaft and two distal femur shaft fractures, respectively. End-to-end anastomosis for the SFA and ligation for DFA system injuries were used, with an uneventful postoperative period in all patients., Conclusion: Caution and accuracy is imperative to avoid vascular injuries while using the cerclage passer in femur fractures, and strict vigilance is essential for early identification and prompt management.

Purpose: Spica casting of femoral shaft fractures is standard practice for young children. In 1983, Dr. Rang published an illustration demonstrating that radiographs can be misleading when measuring femoral fracture shortening. Today, fluoroscopy is used to determine shortening after closed reduction and spica casting. This paper aims to determine the accuracy of fluoroscopy when measuring 25 mm of shortening in a femur fracture sawbone model., Methods: Magnification, elevation and angulation were evaluated using a femur fracture sawbone model with a fixed overlap of 25 mm. Two C-arm machines used in clinical practice were studied: the OEC 9900 Elite GE C-arm and the Fluoroscan InSight mini C-arm., Results: The OEC 9900 Elite GE C-arm demonstrated a 1.75 × magnification. The Fluoroscan InSight mini C-arm demonstrated a 2.5 × magnification. An 11% and a 17% magnification with elevation of the femur to 8 cm occurred using the OEC 9900 Elite GE and the Fluoroscan InSight mini C-arm respectively. Changing the tube angulation from 0° to 60° resulted in a 36% and 16% change in measured femur fracture shortening on the OEC C-arm and Fluoroscan mini C-arm respectively., Conclusion: C-arm images are inaccurate. When measuring 25 mm of shortening of a paediatric femur fracture, each machine has a unique amount of magnification that should be determined and accounted for in clinical practice. Elevation of the femur above the C-arm receiver and angulation of the femur further increase the inaccuracies when measuring 25 mm of fracture shortening. Images perpendicular to the fracture are most accurate.

The objective of this study was to analyze if the addition of CT changed the management of femoral shaft fractures caused by gunshot wounds when compared to those managed with plain radiography alone., Methods: A multiple-choice, single-answer electronic survey was created to compare utility of advanced imaging when treating femur fractures resulting from gunshot injury. A total of ten femoral shaft fracture cause by gunshot injuries were selected for an online survey to be administered to orthopeaedic traumatologists. The survey compared the use the of fixation device and surgical planning before and after the CT scan., Results: A total of 99 surveys were initiated, of which 82 were completed. For proximal shaft fractures, 37% of experts reported that a CT scan should be ordered based on the radiograph alone, prior to reviewing the CT. After reviewing the CT, 5% of experts reported that they would have performed a "major" change, and 10% reported that they would have performed a "minor" change. 4% of surveyors would have changed their decision regarding ordering a CT. For distal femoral shaft fractures, 42% of experts selected that a CT scan would have been ordered prior to reviewing the CT. After reviewing the CT, 2% would have performed a "major" change, and 8% would have performed a "minor" change in management. 5% of surveyors would have changed their decision regarding ordering a CT., Conclusion: Our study demonstrated that CT scans are relatively unlikely to cause major changes in fracture management of gunshot-induced fractures of femoral shaft., (Published by Elsevier Ltd.)

Neck of femur fractures are the most prevalent type of injury in elderly trauma patients. Both intra and extra capsular type of fractures are equally distributed in the given population. Traditionally, Extra capsular fractures are fixed with Dynamic Hip screw or Intra medullary nailing based on the type of fracture. NICE (National Institute of Clinical Excellence) recommends fixing 31-A1 and 31-A2 fractures with DHS (Dynamic Hip Screw) whereas AO recommends fixing 31-A1 with DHS and 31-A2.1 subtype with DHS and 31-A2.2 and 31-A2.3with IMN (Intra medullary nail). In regional trauma centre 178 patients, 125 females and 53 males with extra capsular neck of femur fractures fixed were selected in a retrospective study. The data was spanning over a period of 1 year. Fractures were classified as per AO classification by two registrars. The implant selection was analysed in terms of the short term out come to find out the cost effectiveness of one over the other. The quality of reduction was assessed as per standard criteria and consideration of lateral femoral wall thickness was taken into account to assess the stability of fracture. The study found more risk of peri prosthetic fractures associated with Intra medullary nailing as compared to Dynamic Hip screw and more risk of Varus collapse was found to be associated with DHS as compared to IM Nail. Moreover, despite of Nail being costly as compared to DHS, the study did not reveal its superiority in terms of inpatient hospital stay. In appropriately selected patient DHS provides results in terms of hospital stay, revision rate and wound complications comparable to IM Nail in the short term justifying its use in the above-mentioned fracture patterns as per the standard National Institute of clinical Excellence guidelines.

Aim: The aim of the study is to contribute to a more holistic evidence based on lower limb fracture management in low-income settings, by exploring the perspectives of those actually experiencing and administering skeletal traction in Malawi., Methods: The study took place at Queen Elizabeth Central Hospital in Blantyre and Kamuzu Central Hospital in Lilongwe, the two largest public hospitals of Malawi. Qualitative data were collected by participant observation, individual interviews with eight patients, two orthopedic surgeons, one physiotherapist, and two focus group discussions with multidisciplinary teams., Results: Patients experienced physical and psychological pain from the prolonged traction treatment in bed. Anxiety, indignity and emotional distress in the ward environment were commonly observed. Patients emphasized the negative impact on their families and the significant economic consequences due to prolonged hospitalization. Health care providers identified the major obstacles for quality treatment due to the lack of staff, equipment, specialized knowledge and skills. Rehabilitation services were nearly absent, thus little effort was made to maintain function and enhance recovery during and after long-term bed confinement., Conclusion: The use of long-term skeletal traction has a devastating impact on the patients and families, and causes major frustrations to health workers involved with fracture management in a low-resource setting. Implications for Rehabilitation As stated by various health care providers, there is a need to improve trauma care, strengthen rehabilitation services and educate more rehabilitation staff so they can take up the different roles and functions required in treatment and rehabilitation after injuries and other debilitating conditions. In the current situation, sufficient pain relief for patients is required. This should go hand in hand with the empowerment of patients so as to fulfill their rights to quality health services. For health care providers, multidisciplinary teamwork, enhanced specialized education and skills, improved access to adequate equipment and developing standardized procedures appear essential in order to improve fracture management. With injuries representing a growing portion of the global burden of disease, and in the changing demographic panorama with aging populations in Africa and the world at large, injury prevention, trauma care- and rehabilitation need a stronger focus in public health globally.

Background: Each year it is estimated in the United States an approximate of 8 million fractures; 5 to 10% develop delayed union or absence of periosteal new bone. There are several factors that can cause delay in fracture healing, among the well known, is the use of prophylactic antithrombotic therapy for deep vein thrombosis (DVT). DVT appears in 40 to 60% of the patients undergoing orthopedic surgery without prophylactic antithrombotic therapy. The goal of this study was to assess whether there is a difference in time of bone healing in lower limb fractures (femur and tibia) comparing rivaroxaban to enoxaparin as the prophylactic antithrombotic management., Material and Methods: We present a retrospective observational and analytic study in a sample of cases. It is a cross-sectional study with patient data from the database of the American British Cowdray (ABC) Medical Center. We included patients with femur and tibia fractures under antithrombotic prophylactic management with rivaroxaban or enoxaparin during the period of January 2011 to December 2012. Our sample included 32 patients separated into two groups. Students t-test was used for comparing parametric variables and the Mann-Whitney U test for nonparametric variables. Linear regression model was preformed considering the variables related to the time it took the fracture to heal., Results: All fractures consolidated in a time of 13 and 14 weeks for rivaroxaban and enoxaparin respectively (p = 0.67)., Discussion: We found no difference in bone healing time for lower limb fractures in patients receiving antithrombotic prophylaxis treatment comparing rivaroxaban with enoxaparin.

Interprosthetic femoral fracture (IFF) incidence is gradually increasing as the population is progressively ageing. However, treatment remains challenging due to several contributing factors, such as poor bone quality, patient comorbidities, small interprosthetic fragment, and prostheses instability. An effective and specific classification system is essential to optimize treatment management, therefore diminishing complication rates. This study aims to validate a previously described classification system for interprosthetic femoral fractures., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Purpose: Although external fixation and flexible intramedullary nailing have been extensively used in the management of pediatric femur fractures, there are very few studies, which have compared the results. The purpose of the study was to compare the results of external fixation and flexible intramedullary nailing in pediatric femur fractures., Methods: Two groups of patients were treated by external fixator (EF) and flexible intramedullary nailing (FIN) over two different but successive time periods and results compared. The first group (EF) consisted of 45 patients, and the second group had 50 patients., Results: The age in EF group ranged from 6 to 14 years (average 9.93 years), and the age in FIN group ranged from 6 to 11 years (average 7.66 years). In the EF group, fixator was removed at an average of 12.23 weeks. In the FIN group, radiographic union was evident at an average time of 10.06 weeks. Pin-site infection was common in EF group. One patient had a re-fracture in EF group, and one patient had to be re-operated in FIN group after he developed anterior angulation of more than 30°., Conclusion: We believe that it is the discretion of the surgeon to operate on the femur fracture using either of the treatment modalities. Further randomized studies need to be conducted between these two treatment modalities.

A broken lag screw of the cephalomedullary nail is a rare condition. Removal of the retained lag screw from the femoral head is also very challenging. This article describes a surgical technique and the modified instrument that was available in the operating room for removing the broken implant by closed technique.