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Background The study purpose is to evaluate the working length, proximal screw density, and diaphyseal fixation mode and the correlation to fracture union after locking plate osteosynthesis of distal femoral fractures using bridge-plating technique. Methods A four-year retrospective review was performed to identify patients undergoing operative fixation of distal femur fractures with a distal femoral locking plate using bridge-plating technique for the metadiaphyseal region. Primary variables included fracture union, secondary surgery for union, plate working length, and diaphyseal screw technique and configuration. Multiple secondary variables including plate metallurgy and coronal plane fracture alignment were also collected. Results Ninety-six patients with distal femur fractures with a mean age 60 years met inclusion criteria. None of the clinical parameters were statistically significant indicators of union. Likewise, none of the following surgical technique parameters were associated with fracture union: plate metallurgy, the mean working length, screw density and number of proximal screws and screw cortices. However, diaphyseal screw technique did show statistical significance. Hybrid technique had a statistically significant higher chance of union when compared to locking (p = 0.02). All proximal locking screw constructs were 2.9 times more likely to lead to nonunion. Conclusions Plating constructs with all locking screws used in the diaphysis when bridge-plating distal femur locking plates were 2.9 times more likely to incur a nonunion. However, other factors associated with more flexible fixation constructs such as increased working length, decreased proximal screw number, and decreased proximal screw density were not significantly associated with union in this study.

Intertrochanteric femoral fractures are common, but the nonunion of intertrochanteric fractures is not. The purpose of this study was to divide intertrochanteric fracture nonunion into different types and give corresponding treatment strategies.We retrospectively evaluated 23 patients with intertrochanteric fracture nonunion. The patients were divided into five groups and each group was treated with a different strategy. All patients had staged clinical and radiographic follow-ups and the mean follow-up was 16.0±4.6months.Except for the patients treated with total hip arthroplasty, all patients achieved fracture union. The mean union time was 4.7±1.2months. The Harris hip function score differed significantly from preoperative (28.9±6.8) to postoperative (83.8±6.3; p0.05). For the three patients who were classified as type III, the femoral neck shaft angle was corrected to a significant degree, from 97.3±6.4 to 127.3±2.5 (p0.05). For the four patients who were classified as type V, the mean time from debridement to re-internal fixation was 3.7±1.5months.There are several factors associated with the failure of intertrochanteric fracture treatments. We need to analyze the causes of fracture treatment failure carefully. Based on our five classifications and corresponding treatment strategies, the radiographic and functional treatment outcomes were satisfactory. Future larger comparative studies are needed to confirm our results.

Few clinical studies have analyzed the utility of distal interlocking screws in stable and unstable intertrochanteric fractures treated with intramedullary devices. We performed a prospective analysis comparing short unlocked versus short dynamic and short static distal locked intramedullary nails.Nine level-II trauma centres were involved in the study. 240 patients over the age of 65 with a stable (AO/OTA 31-A1) or unstable intertrochanteric fracture (AO/OTA 31-A2) were prospectively investigated. The same type of nail was used in every patient. Patients were randomly divided into 3 groups according to the type of distal locking used. Intra-operative variables were examined and patients were followed clinically and radiographically at 1, 3, 6, 12 months postoperatively. All complications were recorded.A total of 212 patients completed 1 year of follow-up visits. In the Unlocking Group (UG) the operation time, blood loss, fluoroscopy time, total length of incision were significantly decreased compared to both the Dynamic Group (DG) and the Static Group (SG) (p 0.05). Conversely, no reliable differences in intraoperative variables were noted between the Dynamic Group and the Static Group (p 0.05). In terms of time of fracture union we found no differences among the three Groups (p 0.05). Moreover, no cases of limb shortening1 cm or varus collapse were detected in any group. The 3 Groups were similar in terms of HHS, SF-12 and Barthel index results at 1-year follow-up (p 0.05). Finally, no significant differences were demonstrated across the three Groups in terms of major complications.This clinical study further confirms the hypothesis that short intramedullary nails do not need to be locked for stable and unstable intertrochanteric fractures.

A prospective cohort study was undertaken to assess the incidence of late-implant sepsis after internal fixation in HIV-positive patients. A total of 91 HIV-positive patients (67 males and 24 females) who underwent 103 procedures (111 implants) were followed up for a mean period of 27 months (range 12–66 months). No occurrences of late implant sepsis were found in 100 implants (94 procedures) in 82 patients at 27 months’ follow-up (range 12–66 months). Nine patients (9 procedures, 9 implants) developed early infections within 6 weeks and were treated with antibiotics (6 patients), amputation (1 patient) or removal of metal work (2 patients). There was no evidence of subsequent late implant sepsis in any of these patients, at a mean follow-up of 25 months (range 12–52 months). This study demonstrates that it is safe to perform internal fixation in HIV-positive patients, with no observed increase risk of late implant sepsis. There is no indication to remove implants after fracture union, other than for the general clinical indications that may lead to removal of metal work in any patient.

Background The purpose of this study was to report a new surgical technique for the treatment of unstable distal clavicle fracture with modified tension band fixation (MTBF) and coracoclavicular (CC) stabilisation, and evaluate the radiologic and clinical outcome of these patients. Material and methods Thirteen patients who had a fracture of the distal clavicle (Neer classification type IIb) were treated with MTBF and CC stabilisation. After the CC stabilisation was performed with a suture anchor or flip button, internal fixation using MTBF was carried out. Each patient was followed up for a minimum of 12 months and their clinical and radiological results were analysed. Results The mean period required for fracture union was 12.6 (range, 8–24) weeks and union was successfully completed in all cases. The mean Constant score at the final follow-up was 94.7 (88–100); the modified University of California, Los Angeles (UCLA) shoulder rating scale was 31.3 points (range, 22–35). All patients returned to normal daily activities at an average of 3.7 months postoperatively (range, 3–5 months). One patient had a new fracture around drilled holes for CC stabilisation by inappropriate tunnelling. Conclusion MTBF and CC stabilisation is a useful technique for treating an unstable distal clavicle fracture. This procedure provides minimal incision and stable fixation without causing any further acromioclavicular joint injury to those with distal clavicle fractures.

Delayed bone healing and non-union occurs in approximately 10-15% of long bone fractures. Both pathologies may result in prolonged period of pain, disability and repetitive operative interventions. Despite intense investigations and progress done in understanding the pathophysiologic processes governing bone healing, the diagnostic tools have not been altered. The clinical findings and radiographic features remain the two important landmarks of diagnosing non-union and even when the diagnosis is established there is debate on the ideal timing and mode of intervention. Emerging evidence suggest that there are certain molecules and genes that can serve as predictors of potentially unsuccessful fracture union. This article summarises the current evidence on the available 'bio-markers'to predict fracture non-union.

Introduction HIV is thought to be associated with increased rates of fracture non-union. We report on a prospective cohort of 96 HIV positive patients with 107 fractures that required internal fixation. The CD4 count was measured and patients were reviewed until eventual clinical or radiological union or non-union was established. Results Four percent of fractures (4 out of 100) failed to unite. Three patients required one further procedure to induce union, and two developed avascular necrosis. The CD4 count was not related to fracture union. Conclusion Contrary to previous assumptions, this study suggests that HIV infection does not increase rates of non-union in surgically managed fractures.

Current methods of fracture care use various adjuncts aimed at decreasing time to fracture union and improving fracture union rates. Among the most commonly used modalities, low-intensity pulsed ultrasound is emerging as a safe, cost-effective and reliable treatment for both fresh fractures and fracture nonunions. Both in vivo and in vitro basic science studies have helped to elucidate potential mechanisms of ultrasound action and a number of prospective, randomised, double-blind, placebo-controlled trials exist demonstrating the clinical efficacy of low-intensity pulsed ultrasound. This article will review the evidence for the use of low-intensity pulsed ultrasound in fracture care.

Fifty-three patients underwent closed reduction and longitudinal k-wiring of displaced Colles' fractures and were reviewed after a mean of 26 months. Radiographs taken at the time of injury, after reduction and k-wiring, and at fracture union were compared for radial shortening and dorsal angulation. Manipulation significantly improved fracture position (P0.001). Dorsal angulation was successfully corrected by manipulation in 98%, and this position was maintained to fracture union in all cases. Seventy-three percentage of fractures manipulated for radial shortening2 mm were adequately reduced, but 41% of these fractures subsequently lost position to malunite. In this group of patients, the mean radial shortening between reduction and fracture union was 1.6 mm. This did not correlate with Frykman Class or radial shortening at injury. Closed reduction and k-wire stabilisation is an attractive technique because it is relatively non-invasive compared with plating or external fixation. However, a degree of radial shortening between reduction and fracture union must be anticipated. Fractures reduced inadequately to allow for this loss of radial length, are more likely to malunite. This may compromise functional outcome.

The evolution of treatment for supracondylar femoral fractures has sequentially addressed the difficulties of alignment, articular reduction, stabilization and fracture union. Adequate surgical stabilization and early motion diminished stiffness, while newer indirect techniques in handling periarticular tissues have greatly improved union rates. Indirect methods of reduction require an understanding of anatomy and deformity to avoid malalignment. The problems we currently face are fixation in osteoporotic bone or small distal articular segments.

To compare the safety and effect on tibial diaphyseal fracture bone union of two intramedullary nailing techniques: (1) dynamic locking with early, full weight bearing, and (2) static locking with delayed weight bearing until bone union.This is a retrospective case-control study of closed or type I open tibial diaphyseal fractures (types A and B according to the AO classification) treated with dynamic nailing (32 cases) or static nailing (35 cases). The type of intramedullary nail, the surgical technique and the postoperative protocol were similar for both groups, with the exception of the locking mode and the time of weight bearing. Time to union, mechanical and biological complications, and the number and type of re-operations needed until union were recorded and analysed.Mean union time was 21 weeks in the dynamic group and 26 in the static group (p = 0.051). In both groups 3 cases of nonunion were noted. In the dynamic group there was 1 case of delayed union and 1 case of malunion. In the static group, 5 cases of delayed union and 5 cases of malunion were found. Four reoperations were required in the dynamic group, whereas 10 were needed in the static group (p0.05). Initial degree of interfragmentary gaps had an impact on the mean time to union and the appearance of biological complications in both groups.Dynamic nailing assembly in intramedullary nailing in closed or type I open tibial diaphyseal fractures with limited comminution (types A and B according to the AO classification) is safe when used for these fracture types. A dynamic mode of nailing should be encouraged in these fracture patterns.

This study was based on a series of 470 patients with an intracapsular proximal femoral fracture treated by internal fixation; the characteristics of those patients with non-union were contrasted with those of patients in which union occurred, to determine which variables would predict bony union of the fracture. Radiological factors studied included measurements of fracture displacement, anatomical site and degree of osteoporosis. Patient characteristics studied were age, sex, prefracture mobility and mental state. Patient age and pre-operative fracture displacement were found to be of the greatest value in predicting non-union.

Fracture healing is an optimized biological process yet the ability to determine when a fracture is healed, or to measure the healing response can present a clinical challenge. This review will focus on the evidence for the implementation of imaging modalities as tools to assist in evaluating fracture union. This is particularly important for common fractures that have a propensity to have delayed union or non-union, where a diagnosis of non-union would alter the treatment. We also present methods, such as biochemical markers and clinical scores that are in development or have the potential to aid in the diagnosis of non-union. Ultimately, clinical exam combined with the available modalities can help the clinician judge the progression of healing with some confidence. There is still a need for continued development of new modalities and tests to improve accuracy of the diagnosis of non-union, as well as predict which fractures are at risk for non-union.

One hundred and eighty-five patients with an intracapsular femoral fracture were prospectively studied and followed up until 1 year after injury. All patients were treated by fixation with parallel Garden screws. Fracture union occurred in 82 per cent of patients. Non-union was more frequent in displaced fractures, when the reduction was inadequate and when the screws were placed superiorly or anteriorly in the femoral head. Neither age nor sex were significantly associated with non-union.

Forty-three children with displaced transcervical femoral fractures were reviewed at a mean follow-up of 7.2 years and results were assessed using Ratliff's criteria. Of 22 patients treated by internal fixation alone, 10 had good, 6 had fair and 6 had poor results. The results in 21 children treated by internal fixation along with primary transverse intertrochanteric undisplaced osteotomy were: 14 good, 5 fair and 2 poor, but none improved to a statistically significant level (P = 0.139). However, the osteotomy improved the fracture union significantly and no delayed union or non-union was noted in this group (P = 0.05). There were no complications related to the osteotomy itself.

We report two cases of double fractures of AO intramedullary femoral nails, with metallurgical analysis of one of the nails. Technical errors were noted in both cases and in these circumstances careful assessment of fracture union is required because double fracture can lead to potentially difficult revision surgery.

Union occurred unusually rapidly in 13 fractures of long bones in 11 patients who had sustained severe head injuries. Possible metabolic mechanisms for this are discussed and it is suggested that respiratory alkalosis associated with severe head injury or its treatment affects the rate of deposition of callus by modifying the pH at the fracture site. Fractures in patients with severe head injuries should be restored to an acceptable position early in order to avoid malunion.