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Background: Fixation of trochanteric fractures with an intramedullary nail in a non-physiological position can cause poor functional outcomes. The aim of this study is to evaluate the effect of intraoperative patient position on rotational alignment in intramedullary nail fixation of trochanteric fractures. Methods: The femoral rotational alignment of 84 trochanteric fracture patients who underwent intramedullary nailing was measured by computed tomography (CT) images. Patients were divided into two groups: the supine position on the fracture table (FT) (Group 1, n = 42) and the lateral decubitus (LD) position (Group 2, n = 42). Femoral malrotation angles were measured and divided into three subgroups: insignificant, significant, and excessive. The number of intraoperative fluoroscopy images, preparation time, surgery time, and anesthesia time in both groups were compared. Results: The malrotation degrees of patients in Group 1 ranged from 17° external rotation (ER) to 57° internal rotation (IR), with a mean of 10° IR. Of the patients in Group 1, 27 were insignificant, 5 were significant, and 10 were in the excessive subgroup. The malrotation degrees of patients in Group 2 ranged from 33° ER to 47° IR, with a mean of 11° IR. Of the patients in Group 2, 21 were insignificant, 12 were significant, and 9 were in the excessive subgroup. There was no statistically significant relationship between patient position and malrotation angle. The number of intraoperative fluoroscopy images, preparation time, and anesthesia time were statistically lower in Group 2. There was no statistically significant difference between Group 1 and Group 2 in terms of surgery time. Conclusion: Intramedullary nailing in the LD position is a reliable and practical surgical method in the treatment of femoral trochanteric fractures since there is no need for the use of a FT, the surgeon is exposed to less radiation, there is no risk of complications related to the traction of the FT, and there is a shorter operation time. [ABSTRACT FROM AUTHOR]

Improper osteotomy during total knee arthroplasty (TKA) can lead to anterior femoral notching, which increases the risk of periprosthetic fractures due to stress concentration. One potential solution is the addition of an intramedullary stem to the femoral component. However, the optimal stem length remains unclear. In this study, we aimed to determine the optimal stem length using finite element models. Finite element models of femurs were developed with unstemmed prostheses and prostheses with stem lengths of 50, 75, and 100 mm. Under squat loading conditions, the von Mises stress at the notch and stress distribution on four transversal sections of the femur were analyzed. Additionally, micromotion of the prosthesis–bone interface was evaluated to assess initial stability. The unstemmed prosthesis exhibited a von Mises stress of 191.8 MPa at the notch, which decreased to 43.1, 8.8, and 23.5 MPa for stem lengths of 50, 75, and 100 mm, respectively. The stress reduction on four selected femoral transversal sections compared with the unstemmed prosthesis was 40.0%, 84.4%, and 67.1% for stem lengths of 50, 75, and 100 mm, respectively. Micromotion analysis showed a maximum of 118.8 μm for the unstemmed prosthesis, which decreased significantly with the application of stems, particularly at the anterior flange. Intramedullary stems effectively reduced stress concentration at the femoral notch. The 50‐mm stem length provided the optimal combination of reduced notch stress, minimized stress‐shielding effect, and decreased micromotion at the anterior flange. [ABSTRACT FROM AUTHOR]

Hip fracture prevention approaches like prophylactic augmentation devices have been proposed to strengthen the femur and prevent hip fracture in a fall scenario. The aim of this study was to validate the finite element model (FEM) of specimens augmented by prophylactic intramedullary nailing in a simulated sideways fall impact against ex vivo experimental data. A dynamic inertia‐driven sideways fall simulator was used to test six cadaveric specimens (3 females, 3 males, age 63–83 years) prophylactically implanted with an intramedullary nailing system used to augment the femur. Impact force measurements, pelvic deformation, effective pelvic stiffness, and fracture outcomes were compared between the ex vivo experiments and the FEMs. The FEMs over‐predicted the effective pelvic stiffness for most specimens and showed variability in terms of under‐ and over‐predicting peak impact force and pelvis compression depending on the specimen. A significant correlation was found for time to peak impact force when comparing ex vivo and FEM data. No femoral fractures were found in the ex vivo experiments, but two specimens sustained pelvic fractures. These two pelvis fractures were correctly identified by the FEMs, but the FEMs made three additional false‐positive fracture identifications. These validation results highlight current limitations of these sideways fall impact models specific to the inclusion of an orthopaedic implant. These FEMs present a conservative strategy for fracture prediction in future applications. Further evaluation of the modelling approaches used for the bone‐implant interface is recommended for modelling augmented specimens, alongside the importance of maintaining well‐controlled experimental conditions. [ABSTRACT FROM AUTHOR]

Lapidus arthrodesis is one of the most commonly used techniques in the correction of moderate and severe hallux valgus. We analyzed the clinical and radiological outcomes after using the Phantom® Lapidus intramedullary nail to find an effective technique with low complications. We retrospectively analyzed data of 52 patients who underwent a modified Lapidus arthrodesis with an intramedullary nail at our center from November 2019 to September 2022. The mean follow-up period was 27 (range, 18–34) months. Clinical results were evaluated using the visual analog scale (VAS), the European Foot and Ankle Society score (EFAS) and the American Orthopaedic Foot and Ankle Society score (AOFAS); three different radiological measures were analyzed. The mean AOFAS score increased from 44.8 to 82 points. The mean EFAS score increased from 11.2 to 20.1 points. The mean VAS score decreased by 4.7 points. The mean EFAS Sport score was increased from 9.2 (SD 4.6) to 12.6 (SD 5.4) points. The intermetatarsal angle decreased from 15° to 6.9° and the hallux valgus angle by a mean of 17.9°. The forefoot width reduced from 93.6 to 84.7 mm. All results were statistically significant (p <.001). One case of nonunion was recorded. No implant-related complications were observed. This device was effective in correcting moderate to severe hallux valgus, with significant patient satisfaction. Its complication rate was not higher than that of other fixation devices. Correct compression of the arthrodesis, absence of extraosseous material, and multidirectional stability are important qualities of this implant for the correct treatment of this pathology. Level IV, retrospective case series [ABSTRACT FROM AUTHOR]

AbstractDistraction osteogenesis (DO) is a bone regenerative maneuver, which is conventionally done with external fixators and, more recently, with telescopic intramedullary nails. Despite the proven effectiveness, external approaches are intrusive to the patient’s life while intramedullary nailing damages the growth plates, making them unsuitable for pediatric patients. An internal DO plate fixator (IDOPF) was developed for pediatric patients to address these limitations. The objective of this study was to test the hypothesis that the IDOPF can withstand a partial weight bearing scenario and create a favorable mechanical microenvironment at the osteotomy gap for bone regeneration as the device elongates. A finite element model of a surrogated long bone diaphysis osteotomy fixation by means of the IDOPF was created and subjected to axial compression, bending and torsion. As the osteotomy gap increased from 2 mm to 20 mm, under compression, The average axial interfragmentary strains decreased from 2.33% to 0.35%. Stress increased from 179 MPa to 281 MPa at the contact interfaces of the telescopic compartments, which exceeded the endurance limit of stainless steel (270 MPa) but was below its yield limit (415 MPa). These results demonstrate, that the IDOPF can withstand a partial load bearing scenario and provide a stable biomechanical environment conductive to bone healing. However, high contact stresses at the telescopic interfaces of the device are likely to cause wear, as is frequently reported in telescopic fixators. This study is a step towards refining the IDOPF design for clinical use. [ABSTRACT FROM AUTHOR]

Objective: There is currently a lack of in-depth comparative evaluation regarding the biomechanical properties of novel intramedullary nail devices in the treatment of basal femoral neck fractures (BFNF). This study aims to utilize finite element analysis to compare the performance differences of two novel devices with traditional PFNA and InterTan nails in the fixation of BFNF. Methods: Based on a validated finite element model, this study constructed an accurate BFNF model and implanted four different intramedullary nail devices: PFNA, InterTan nail, PFBN (proximal femoral biomimetic nail), and NIS (novel intramedullary system). Under a vertical load of 2100N, the displacement and Von Mises stress (VMS) distribution of each group of models were evaluated through simulation testing. Results: Under a load of 2100N, the PFBN device exhibited the best performance in terms of displacement and peak stress, while PFNA performed poorly. The peak displacement of the NIS device was lower than that of PFNA and InterTan nails, while the peak stress of the InterTan nail was lower than that of PFNA and NIS. Conclusion: The PFBN device demonstrates stronger load-bearing and shear-resistant properties in the treatment of BFNF, and the NIS device also shows significant improvement in stability. Therefore, both the PFBN and NIS devices are reliable internal fixation techniques for the treatment of CFIFs, with potential clinical application prospects. [ABSTRACT FROM AUTHOR]

Brachial artery access for coronary diagnostic or therapeutic procedures is associated with a greater risk of vascular complications. To determine whether 3D printing of a novel elbow joint fixation device could reduce postoperative complications after percutaneous coronary diagnostic or therapeutic procedures through the brachial artery. Patients who underwent percutaneous coronary diagnostic or therapeutic procedures by brachial access were randomly assigned to receive either a 3D-printed elbow joint fixation device (brace group) or traditional compression (control group) from March 2023 to December 2023. The severity of puncture site-related discomfort at 24 h postsurgery was significantly lower in the brace group (P = 0.014). Similarly, the upper arm calibration rate at 24 h postsurgery was significantly lower in the brace group [0.024 (0.019–0.046) vs. 0.077 (0.038–0.103), P < 0.001], as was the forearm calibration rate [0.026 (0.024–0.049) vs. 0.050 (0.023–0.091), P = 0.007]. The brace group had a significantly lower area of subcutaneous hemorrhage at 24 h postsurgery [0.255 (0–1.00) vs. 1 (0.25–1.75) cm2]. In patients who underwent percutaneous coronary diagnostic or therapeutic procedures by brachial access after manual compression hemostasis, the novel elbow joint fixation device was effective at reducing puncture site-related discomfort, alleviating the degree of swelling, and minimizing the subcutaneous bleeding area. Additionally, no significant complications were observed. Trial registration: China Clinical Trial Registration on 01/03/2023 (ChiCTR2300068791). [ABSTRACT FROM AUTHOR]

Background: Proximal humerus fractures are common fractures of the elderly population which can lead to long-term compromise of a patient's shoulder function. Closed reduction and internal fixation with intramedullary nailing is a well-established surgical technique yielding good outcomes, as perceived by patients, obtained via Patient-Reported Outcome Measures, and objectified by clinical shoulder testing. Apart from conventional range-of-motion testing and clinical shoulder tests, strength testing of the shoulder is a yet-neglected but meaningful and standardizable outcome parameter. In this study, isometric shoulder strength is evaluated in relation to fracture morphology/postoperative reduction quality as well as with patient-reported outcomes. Methods: 25 patients (mean age 73.2 ± 10.5 years) underwent isometrics strength-testing of the shoulder joint in the scapular plane (abduction) as well as in the sagittal plane (flexion) as well as hand-grip strength-testing at 4.5 ± 1.88 years follow-up. Pre- and postoperative radiographs were analysed. Patients completed ASES and CMS questionnaires. Results: Patients exhibited a decrease in abduction and flexion force (−24.47% and −25.30%, respectively, p < 0.001) using the contralateral, uninjured arm as reference. Abduction force tended to be decreased in three- and four-part fractures. Patient satisfaction correlated negatively with the relatively reduced force of the affected arm. Varus-angulated humeral heads produced significantly lower abduction force output than valgus- or physiologic angulation (p = 0.014), whereas flexion force was unaffected (p = 0.468). The anatomical reduction had no influence on shoulder strength. Conclusions: Proximal humerus fractures may cause a significant reduction in shoulder function, both reported by patients and objectified by shoulder strength testing. Varus head angulation demonstrated the greatest loss of shoulder strength and should be avoided to ensure proper functioning. Further, strength testing seems a valuable outcome parameter for a thorough shoulder examination with easy obtainability. [ABSTRACT FROM AUTHOR]

BACKGROUND Intertrochanteric femur fractures are typically treated with proximal femoral nails. There are two varieties of proximal femoral nails in our study: PFNA2, which has a single proximal blade, and normal PFN, which has two proximal screws. AIM Our study compares functional results and implant-related problems in individuals treated for proximal femur fracture using PFNA2 nails versus conventional PFN nails. MATERIAL AND METHODS After obtaining ethical clearance from Institutional ethical committee, this prospective study was conducted in the Department of Orthopaedics in Sri Madhusudhan Sai Institute of Medical Sciences and Research from Nov 2022 to Nov 2023. A series of 50 cases were included in the study. After obtaining prior informed and written consent from the patients. Fracture diagnosis confirmed by clinical examination and radiography. Pre-anaesthetic evaluation done as per protocols. 25 Patients underwent PFN nailing and 25 Patients underwent PFN- A2 nailing. Post operatively follow up was done until 6 months to assess various outcomes namely fracture healing, incidence of post-operative complications, rehabilitation and functional outcome. RESULTS Implant A2-PFN nails has better results than implant standard PFN nail in terms of operative time, operative blood-loss and functional outcome. CONCLUSION We concluded from the study that, in comparison to standard PFN nails, PFNA2 nails minimises surgical time, blood loss, and radiation exposure. When compared to standard PFN nail, PFNA2 nails offers substantially superior functional outcomes and a greater union rate. PFNA2-treated patients are able to bear weight quickly. PFNA2 does not cause too many implant-related issues including screw backing out and cut-through of screws in the femoral head (also known as the z-effect and reverse z-effect). Consequently, we draw the conclusion that PFNA2 nails are better than standard PFN nails. [ABSTRACT FROM AUTHOR]

Introduction: fixation of unstable intertrochanteric fractures presents a significant challenge, especially in the context of osteoporosis. Intramedullary implants have been established as superior to plate constructs. Our aim is to compare the complications and clinical outcomes of the Proximal Femur Nail (PFN) and Proximal Femur Nail Antirotation-2 (PFNA2) in managing unstable intertrochanteric fractures. Material and methods: a total of 212 patients meeting inclusion and exclusion criteria underwent fixation of trochanteric fractures using either a standard PFN (n = 110) or PFNA2 (n = 102). Their intraoperative and postoperative clinical and radiographic data were evaluated along with the quality of fixation. Data analysis was performed using the student's t-test, χ² test, and Mann-Whitney U test. Results: PFNA2 demonstrated more favorable outcomes compared to PFN in terms of a better intraoperative profile, functional outcomes (PFNA2: PFN = 82:75), and fewer implant-related complications. Significant issues in the PFN group included screw backout, guidewire breakage, and proximal protrusion of the nail tip. In contrast, locking mechanism failure and lateral screw prominence were significant problems in the PFNA2 group. Conclusion: PFNA2 is the preferred implant for managing osteoporotic unstable intertrochanteric fractures, given the bone's weak inherent tendency to secure the implant. [ABSTRACT FROM AUTHOR]

Introduction: Minimally invasive plate osteosynthesis (MIPO) and intramedullary nails are two accepted and effective methods in the treatment of tibial fractures. This study was aimed to evaluate the surgical treatment and complications of distal tibial fractures not related to the ankle joint with MIPO and intramedullary nails in the geriatric group retrospectively. Materials and Methods: Between 2019 and 2020, 42 patients in the geriatric group with distal tibia fractures that did not extend to the ankle joint and who underwent surgical treatment were evaluated retrospectively. The patients were divided into two groups: those who underwent MIPO and those who underwent osteosynthesis with an intramedullary nail. Patients were evaluated according to JoVVhner Wrush criteria. Results: This study enrolled 42 patients. The mean age of the patients was 70±3.4 years. 22 of these patients underwent osteosynthesis with intramedullary nailing. MIPO was performed in the treatment of 20 patients. Based on the Johner Wrush criteria, the intramedullary nail group evaluated 16 patients as very good, 5 as good, and 1 as bad. The MIPO group evaluated 15 patients as excellent, 3 as good, 1 as moderate, and 1 as poor. Conclusion: In geriatric age groups, there was no significant difference in clinical outcomes or complications from surgical treatment of closed tibial distal fractures that do not extend to the ankle joint. Both surgical treatment methods can be applied effectively to geriatric patients. [ABSTRACT FROM AUTHOR]

Background and Objectives: Rotational malformation after intramedullary nailing of intertrochanteric fractures is a relatively common, possibly severe, and difficult-to-detect complication, since intraoperative radiographic imaging allows for the assessment of the quality of reduction in the frontal and sagittal planes, but not in the transverse plane. The purpose of this study is to evaluate the rotational malalignment after intramedullary nailing of intertrochanteric fractures and to investigate a possible connection with specific patients' or fractures' characteristics. Materials and Methods: 74 patients treated with intramedullary nailing due to an intertrochanteric fracture underwent a postoperative CT of the pelvis-hips and knees. The value of the anteversion was measured both in the operated-on (angle 1) and in the healthy hip (angle 2) based on the technique described by Jeanmart et al. and the difference in anteversion (D angle = angle 1 minus angle 2) was calculated. A positive D angle indicated the presence of excessive internal overcorrection of the distal fragment during fracture reduction, while a negative D angle indicated the presence of excessive external overcorrection. The absolute value of the D angle represents the postoperative difference in anteversion between the two hips. The patients were divided into three groups according to this value: group A, with D < 5° (physiological difference); group B, with 5° < D < 15° (acceptable rotational alignment); and group C, with D ≥ 15° (rotational deformity). Results: Group A constitutes 56.8%, group B 12.2%, and group C 31.1% of the study population. Overall, 79.7% of the patients presented a positive angle D, while, for group C, the percentage was even higher at 91.3%. According to the AO/OTA classification system, 37.8% of the cases were stable fractures, 47.3% were unstable fractures, and 14.9% were reverse oblique fractures. Based on our analysis, the type of fracture has a serious impact on the rotational alignment, since the statistical significance of the mean angle D for the three types of fracture is reliable (p = 0.029). Stable fractures present the lowest anteversion difference values, while reverse oblique fractures present the highest difference. Conclusions: Our study reveals that the percentage of rotational malalignment after the intramedullary nailing of intertrochanteric fractures remains high (31.1%), despite the proper use of radiographic imaging during the intraoperative fracture reduction. In most cases (91.3%), this malalignment appears to be a matter of internal overcorrection. A clear correlation between hip's rotational deformity and patients′ functional outcome has yet to be proven, and constitutes our objective in the near future. [ABSTRACT FROM AUTHOR]

This study aims to provide radiation reference levels in orthopaedic surgery. A total of 753 procedures were collected within 1 y. Categories containing several similar procedures were created based on four criteria: same anatomical area, same level of complexity, only single procedures, and at least 10 cases per category. Exposure was defined in terms of air kerma-area product, fluoroscopy time, and air kerma at the patient entrance reference point. For common procedures, median effective doses to patient were calculated using the Monte Carlo Software PCXMC. Most irradiating procedure in this study i.e. intramedullary nailing of the proximal femur was equivalent to an air kerma at the patient entrance reference point of 37.1 mGy, which is ~50 times lower than the threshold for acute deterministic effects of radiation. Optimization remains a must to reduce the dose while maintaining the image quality and reducing the likelihood of stochastic effects. [ABSTRACT FROM AUTHOR]

Introduction: Surgical management of intertrochanteric hip fractures is a common surgery with low rates of intraoperative complications. Vascular injuries are exceptionally rare when placing an intramedullary nail without open reduction. There are very few reported cases of direct arterial injury and active bleed at the level of the distal interlocking screw following closed reduction and intramedullary nailing of a hip fracture. We report one such case. Case Presentation: An 88‐year‐old female presented to the emergency department with a left intertrochanteric hip fracture. Closed reduction with a cephalomedullary nail fixation of the left hip fracture occurred as planned without any obvious intraoperative technical issues. The patient remained stable intraoperatively. No open reduction was required. Postoperatively, the patient developed hemorrhagic shock and required massive transfusion protocol. Angiography demonstrated an intramuscular hematoma at the level of the distal intramedullary nail interlocking screw with active extravasation. The patient subsequently required embolization. Nine days following surgery, she began Eliquis for DVT prophylaxis and was ambulating independently with signs of hematoma resolution. Discussion: Profunda femoris artery injury can stem from various mechanisms during surgery. Atherosclerosis places patients at a higher risk of complication due to rigid vessels. In this case, it is believed that drilling beyond the medial femoral cortex led to the arterial injury. Conclusion: Care should be taken to prevent drills from plunging beyond the medial femoral cortex during surgery. Cautious observation of patient's vitals and clinical course can allow for early detection of vascular complication. [ABSTRACT FROM AUTHOR]

Introduction: Distal locking is a challenging and time-consuming step in interlocked intramedullary nailing of long bone fractures. Current methods have limitations in terms of simplicity, universality, accuracy, speed, and safety. We propose a novel device and software for distal locking using computer vision. Methods and materials: The device consists of an universal ancillary clamp, a telescopic arm, a viewfinder clamp, and a radio-opaque cross. The software uses a camera photo from the C-arm intensifier and adjusts for geometric projection deformities. The software employs edge detection, Hough transform, perspective interpolation, and vector calculation algorithms to locate the distal hole center. The device and software were designed, manufactured, and tested using 3D CAD, FEM, DRR, and performance testing on phantom bones. Results: The device and software showed high accuracy and precision of 98.7% and 99.2% respectively in locating the distal hole center and calculating the correctional vector. The device and software also showed high success ratio in drilling the hole and inserting the screw. The device and software reduced the radiation exposure for the surgeon and the patient. The success ratio of the device and software was validated by the physical testing, which simulated the real clinical scenario of distal locking. The radiation exposure was as low as 5 s with a radiation dose of 0.2mSv, drastically reducing radiation exposure during distal locking. Discussion: Our device and software have several advantages over other distal locking methods, such as simplicity, universality, accuracy, speed, and safety. Our device and software also have some disadvantages, such as reliability and legislation. Our device and software can be compared with other distal locking methods based on these criteria. Our device and software have some limitations and challenges that need to be addressed in the future, such as clinical validation, and regulatory approval. Conclusion: The device showed promising results in terms of low-cost, reusability, low radiation exposure, high accuracy, fast distal locking, high stiffness, and adaptability. The device has several advantages over other distal locking techniques, such as free-hand technique, mechanical aiming devices, electromagnetic navigation systems, and computer-assisted systems. We believe that our device and software have the potential to revolutionize the distal locking technique and to improve the outcomes and quality of life of the patients with long bone fractures. [ABSTRACT FROM AUTHOR]

Background: Proximal humerus fractures (PHFs) are relatively common, although optimal rehabilitation is unknown. This review aims to characterize the published rehabilitation regimens utilized for PHFs. Methods: A systematic review was performed per PRISMA guidelines, utilizing PubMed/MEDLINE, Embase, and Cochrane. All studies reporting PHF rehabilitation protocols after nonoperative management, open reduction internal fixation with a plate, or intramedullary nailing were included. Results: Forty articles comprising 3507 patients (66% female, weighted mean age 63.5 years) were included. Substantial variability was present regardless of management. Rehabilitation modalities reported were: sling use in 34 cohorts, most commonly for three weeks; pendulum exercises in 21 cohorts, most commonly starting at post-intervention day 1; post-intervention passive range of motion (ROM) for 30 cohorts, most commonly starting at two days; active-ROM in eight cohorts, most commonly starting at three weeks; active-assisted ROM for 21 cohorts, most commonly starting at three weeks; unlimited ROM for 20 cohorts, most commonly at 4 or 6 weeks; non-weight-bearing for six cohorts, most commonly for six weeks; strengthening for 16 cohorts, most commonly at six weeks; removal of all restrictions for nine cohorts, most commonly starting at six weeks. Conclusions: Published rehabilitation protocols for PHFs vary considerably regardless of management. Future studies comparing methods of management need to consider the influence of postoperative rehabilitation protocol heterogeneity when aggregating data from multiple sites. Level of Evidence: IV [ABSTRACT FROM AUTHOR]

Introduction: This is a retrospective cohort study designed to compare short-term postoperative complication rates between closed humeral shaft fractures treated by open reduction and internal fixation (ORIF) versus intramedullary nailing (IMN), as well as secondary independent risk factors for adverse outcomes. Materials and methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried using CPT codes to identify patients that underwent an open reduction and plate fixation or intramedullary nailing procedure for a closed humeral shaft fracture from 2010 to 2021. Cohorts were matched using propensity scores to account for demographic differences and rates of complications were compared between the two groups. Results: From the database, a total of 4,222 patients were identified who met inclusion criteria, with 3,326 and 896 undergoing ORIF and IMN respectively. After propensity score matching, 866 of the nearest-neighbor matches were included in each cohort for a total of 1,732 patients in the final analysis. The rate of any adverse event (AAE) was significantly higher in the ORIF cohort (16.3%) than the IMN cohort (12.1%, p = 0.01). The ORIF group had higher rates of postoperative transfusion (p = 0.002), return to OR (p = 0.005), and surgical site infection (SSI, p = 0.03). After multivariate analysis, ASA class 4, increasing age, increasing operative time, and history of bleeding disorder were found to increase the risk of AAE in both ORIF and IMN patients. Conclusions: While prior studies have claimed higher complication rates in IMN patients, this study found a significantly higher short-term risk of AAE in ORIF patients when compared in matched cohorts. However, individual 30-day complication rates do not differ significantly between procedures, and both have been shown to be safe and effective tools in the management of humeral shaft fractures. [ABSTRACT FROM AUTHOR]

Introduction: Non-operative treatment (NOT) of proximal humerus fractures (PHF) has regained significance due to recent evidence. Additionally, positive outcomes of plate osteosynthesis and fracture arthroplasty prompt a reassessment of the role of intramedullary nailing (IMN). While favorable short and medium-term results have been documented following IMN, little is known regarding functional outcomes and quality of life in the long-term. Methods: Data from 180 patients with dislocated PHF of Neer types III, IV and V, treated at our level-I trauma center between 2004 and 2014 using IMN or NOT therapy, were scanned. Patients were re-evaluated after a minimum of 5 years to assess functional outcomes (age- and sex-adapted Constant Score, QuickDASH), quality of life (SF12), and complications or reoperations. Results: Out of the initially identified 180 patients, 51 were unavailable for follow-up (FU) and 71 had deceased during the FU period. Functional outcomes and quality of life was, therefore, assessed in 58 patients (30 IMN, 28 NOT) with an average age at injury of 68 years after a mean FU time of 10.3 ± 3.4 years. Epidemiological patient characteristics did not exhibit significant differences between the two groups (p >.05). The functional outcome assessed by age- and sex-adapted Constant Score (NOT: 74 ± 28; IMN: 68 ± 24; p =.438), QuickDASH (NOT: 25 ± 27; IMN: 31 ± 23; p =.374) or quality of life using the SF12 (p >.05) revealed no significant disparities in long-term outcomes between the treatment groups. 10 of 30 patients in the IMN group underwent surgical revision to address complications, exceeding mere implant removal. Conversely, no patient in the NOT group underwent a revision surgery during the FU period. Conclusions: In the long-term, functional and quality of life-related outcomes of IMN did not diverge significantly from those of NOT, while causing a higher incidence of follow-up interventions. Highlights: • Comparing intramedullary nailing to non-operative treatment of Neer type III - V proximal humerus fractures, there was no significant difference in long-term functional outcome. • Revision rates were significantly higher in the surgically treated patient group. • Irrespective of the treatment modality long-term functional outcomes were significantly worse in fractures with more than two key fragments according to the Codman Classification. [ABSTRACT FROM AUTHOR]

Purpose: Robot-assisted total knee arthroplasty (TKA) was developed to improve the precision and accuracy of implant placement in conventional TKA. However, the angular differences between referenced axes in robot-assisted TKA and conventional TKA remain unclear. The aim of this study was to investigate the angular differences in sagittal alignment between robot-assisted TKA and conventional TKA for both the femur and the tibia and to discuss their clinical implications. Methods: We conducted a retrospective analysis of data from 100 patients (97 patients) who underwent computed tomography (CT) for Mako TKA. We measured the angle between the robot femoral axis (RFA) and conventional femoral axis (CFA) in the sagittal plane and the angle between the robot tibial axis (RTA) and the conventional tibial axis (CTA). Angles were compared between the sexes. Correlation analysis was conducted between the angles and height. Results: In the sagittal plane, the mean RFA-CFA angle was 2.2° ± 1.6°, and the mean RTA-CTA angle was 2.3° ± 1.6°. There were no significant differences between the two angles among males and females (p > 0.05). There was a correlation between the RFA-CFA angle and RTA-CTA angle (p < 0.001, r = 0.33), and there was a correlation between height and the combination of the RFA-CFA angle and RTA-CTA angle (p = 0.03, r = 0.22). Conclusion: There are angular differences between the axes referenced by robot-assisted TKA and those referenced by conventional TKA, which may be influenced by patient height. Correctly understanding these differences is crucial when evaluating the implant position and surgical outcomes after robot-assisted TKA. Furthermore, caution should be taken when assessing the flexion–extension angle of the knee since the angles displayed in the Mako system are different from the angles measured with intramedullary anatomical axes. After all, sagittal alignment principles differ between robot-assisted and conventional TKA; however, further studies are required to determine which principle is more appropriate or to modify these principles. [ABSTRACT FROM AUTHOR]

Purpose: Femoral fractures are common in low and middle-income countries (LMIC), predominantly caused by high-energy trauma. The surgical implant generation network (SIGN®) program offers two different intramedullary nails in LMIC which are designed to be used without image intensifier free of charge for the patients: the SIGN standard nail (SSN®) and the SIGN Fin nail (SFN®). This study aimed to compare the results of the SSN® and the SFN® for the treatment of middle and distal shaft femoral fractures through a retrograde approach. Material and Methods: This was a retrospective, descriptive, and non-experimental study including all consecutive patients who underwent surgical management of middle or distal shaft femoral fracture between January 2017 and May 2022 in an NGO hospital located in Freetown, Sierra Leone. The duration of surgery, type of reduction, complications like screw loosening, implant migration, anterior knee pain and non-union rate at six months of follow up were evaluated. Results: A total of 122 patients were included in the study. Group A: 60 patients were managed with SSN® and Group B: 62 patients with SFN®. The mean operative time was 104 min with SSN® and 78 with SFN® (p < 0.001). Open reduction of the fracture was necessary in ten (16.7%) patients with SSN® and 12 (19.4%) patients treated with SFN® (p = 0.69). Non-union was observed in one (1.7%) patient with SSN® and two (3.2%) patients with SFN® (p = 0.57). Conclusions: Both options seem equally effective in treating midshaft and distal femoral shaft fractures. The SFN® reduces the surgical time, due to this fact, in polytraumatized patients, patients with bilateral femur fracture or patients with ipsilateral tibia fracture, it can be considered as the best option to be used. There was no statistical difference in the complications presented by the two groups. [ABSTRACT FROM AUTHOR]

Teriparatide is an anabolic drug sometimes administered to patients who have atypical femoral fracture (AFF). However, whether teriparatide has beneficial effects on bone healing remains uncertain. The present study aimed to analyze the association between teriparatide and bone healing in complete AFF. A total of 59 consecutive cases (58 patients) who underwent intramedullary nailing for complete AFF were categorized based on postoperative use of teriparatide into the non-teriparatide (non-TPTD, n = 34) and teriparatide groups (TPTD, n = 25). Time-to-bone union was evaluated and compared between the two groups. Additionally, multiple regression analysis was performed to evaluate factors affecting time-to-bone union. All participants were women, with a mean age of 77.6 years (range: 62–92). No significant difference in time-to-bone union was found between the non-TPTD and TPTD groups (5.5 months vs. 5.8 months, p = 0.359). Two patients in the non-TPTD group underwent reoperation (p = 0.503) due to failure caused by inadequate fixation, and both achieved bone healing after additional fixation with blocking screws. Multiple regression analysis revealed that the anterior gap of the fracture site postoperatively was a factor affecting time-to-bone union (p = 0.014). The beneficial effect of teriparatide on bone healing in complete AFF could not be confirmed. Additional randomized controlled trials are required. Nonetheless, appropriate techniques, including efforts to reduce the gap on the tensile side during the surgery, are important for reliable bone healing. [ABSTRACT FROM AUTHOR]

Fracture detection is one of the most commonly used and studied aspects of artificial intelligence (AI) in medicine. In this systematic review and meta-analysis, we aimed to summarize available literature and data regarding AI performance in fracture detection on plain radiographs and various factors affecting it. We systematically reviewed studies evaluating AI algorithms in detecting bone fractures in plain radiographs, combined their performance using meta-analysis (a bivariate regression approach), and compared it with that of clinicians. We also analyzed the factors potentially affecting algorithm performance using meta-regression. Our analysis included 100 studies. In 83 studies with confusion matrices, AI algorithms showed a sensitivity of 91.43% and a specificity of 92.12% (Area under the summary receiver operator curve = 0.968). After adjustment and false discovery rate correction, tibia/fibula (excluding ankle) fractures were associated with higher (7.0%, p=0.004) AI sensitivity, while more recent publications (5.5%, p=0.003) and Xception architecture (6.6%, p<0.001) were associated with higher specificity. Clinicians and AI showed similar specificity in fracture identification, although AI leaned to higher sensitivity (7.6%, p=0.07). Radiologists, on the other hand, were more specific than AI overall and in several subgroups, and more sensitive to hip fractures before FDR correction. Currently available AI aids could result in a significant improvement in care where radiologists are not readily available. Moreover, identifying factors affecting algorithm performance could guide AI development teams in their process of optimizing their products. • Studies assessing AI in fracture detection have high degrees of bias. • AI showed a pooled sensitivity and specificity of >90% in detecting fractures. • Various factors, including fracture site and architecture affect AI's performance. • Radiologists remain superior to algorithms in fracture detection on X-rays. [ABSTRACT FROM AUTHOR]

Purpose: Fractures occurring at the metaphyseal–diaphyseal junction of the distal humerus in children are not commonly documented in the literature. Until this moment, there is no gold standard technique regarding its management and most surgeons treat it as a regular supracondylar humerus fracture by conventional pinning. This systematic review explores the relevant literature to assess the efficacy of different techniques. Methods: This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Our literature search encompassed several online databases, including PUBMED/MEDLINE, Scopus, Web of Science Core Collection, and Google Scholar. Data from articles that met our general inclusion criteria were extracted and categorized into treatment method groupings. Functional and cosmetic outcomes, demographic characteristics, and complications were the main parameters used to analyze the data. Results: Ten retrospective studies met our inclusion criteria with a total of 178 participants of unilateral pediatric distal humerus metaphyseal–diaphyseal junction fractures. Most literature chose closed reduction and percutaneous pinning in seven articles, followed by elastic stable intramedullary nail technique used in three articles, then conservative treatment was chosen in two articles, while only one article used lateral miniplate and assisted K-wire and another article used combined closed reduction and percutaneous pinning and intramedullary K-wire. As regards the operation time; elastic stable intramedullary nails had the shortest time with a mean of 39.7 min (range: 37.5–41.9 min), while closed reduction and percutaneous pinning had the longest time with a mean of 75.47 min (range: 55.9–92.1 min). The shortest healing time was observed in miniplate with a mean of 7.2 weeks, while the most prolonged was in conservative management with a mean of 12 weeks and closed reduction and percutaneous pinning was a mean of 10 weeks. Regarding Flynn's criteria, all participants received excellent and good except in closed reduction and percutaneous pinning; 13 cases were fair and 2 cases were poor. Regarding complications, the most commonly observed complication after metaphyseal–diaphyseal junction fracture was cubitus varus, the highest incidence was in conservative management (33% of cases), followed by closed reduction and percutaneous pinning (10.9% of cases), the least incidence was observed in elastic stable intramedullary nails (3.77% of cases), and none of the cases treated with mini plate developed this complication. Other complications were observed only with closed reduction and percutaneous pinning; 8.5% of cases developed fixation loss, 6.2% of cases had a significantly reduced range of motion, and one case refractured. Conclusion: Pediatric distal humerus metaphyseal–diaphyseal junction fractures should be distinguished from the more prevalent supracondylar humerus fractures, as conventional pinning techniques are associated with a higher incidence of complications and increased both operative and healing times. Level of evidence: III [ABSTRACT FROM AUTHOR]

Introduction: Bone marrow embolization may complicate orthopedic surgery, potentially causing fat embolism syndrome. The inflammatory potential of bone marrow emboli is unclear. We aimed to investigate the inflammatory response to femoral intramedullary nailing, specifically the systemic inflammatory effects in plasma, and local tissue responses. Additionally, the plasma response was compared to that following intravenous injection of autologous bone marrow. Methods: Twelve pigs underwent femoral nailing (previously shown to have fat emboli in lung and heart), four received intravenous bone marrow, and four served as sham controls. Blood samples were collected hourly and tissue samples postmortem. Additionally, we incubated bone marrow and blood, separately and in combination, from six pigs in vitro. Complement activation was detected by C3a and the terminal C5b-9 complement complex (TCC), and the cytokines TNF, IL-1b, IL-6 and IL-10 as well as the thrombin-antithrombin complexes (TAT) were all measured using enzyme-immunoassays. Results: After nailing, plasma IL-6 rose 21-fold, compared to a 4-fold rise in sham (p=0.0004). No plasma differences in the rest of the inflammatory markers were noted across groups. However, nailing yielded 2-3-times higher C3a, TCC, TNF, IL-1b and IL-10 in lung tissue compared to sham (p<0.0001-0.03). Similarly, heart tissue exhibited 2-times higher TCC and IL-1b compared to sham (p<0.0001-0.03). Intravenous bone marrow yielded 8-times higher TAT than sham at 30 minutes (p<0.0001). In vitro, incubation of bone marrow for four hours resulted in 95-times higher IL-6 compared to whole blood (p=0.03). Discussion: A selective increase in plasma IL-6 was observed following femoral nailing, whereas lung and heart tissues revealed a broad local inflammatory response not reflected systemically. In vitro experiments may imply bone marrow to be the primary IL-6 source. [ABSTRACT FROM AUTHOR]

Objectives: To compare the iatrogenic radial nerve injury (iRNI) rate of different implant (plate vs. intramedullary nail) and surgical approaches during humeral shaft fracture surgery. Methods: The online PubMed database was used to search for articles describing iRNI after humeral fracture with a publication date from Jan 2000 to October 2023. The following types of articles were selected: (1) case series associating with adult humeral shaft fracture, preoperative radial nerve continuity, non-pathological fracture and non-periprosthetic fracture; (2) involving humeral shaft (OTA/AO 12) fractures. Articles where we were unable to judge surgical approach or fracture pattern (OTA/AO 12) were excluded. The data were analyzed by SPSS 27.0 and Chi-square test was performed to identify incidence of iRNI associated with different implant and surgical approaches. Results: Fifty-four articles with 5063 cases were included, with 3510 cases of the plate, 830 cases of intramedullary nail and 723 cases of uncertain internal fixation. The incidences of iRNI with plate and intramedullary nail were 5.95% (209/3510) and 2.77% (23/830) (p < 0.05). And iRNI incidences of different surgical approaches were 3.7% (3/82) for deltopectoral approach, 5.74% (76/1323) for anterolateral approach, 13.54% (26/192) for lateral approach and 6.68% (50/749) for posterior approach. The iRNI rates were 0.00% (0/33) for anteromedial MIPO, 2.67% (10/374) for anterolateral MIPO and 5.40% (2/37) for posterior MIPO (p > 0.05). The iRNI rates were 2.87% (21/732) for anterograde intramedullary nail and 2.04% (2/98) for retrograde intramedullary nail (p > 0.05). In humeral bone nonunion surgery, the rate of iRNI was 15.00% (9/60) for anterolateral approach, 16.7% (2/12) for lateral approach and 18.2% (6/33) for posterior approach (p > 0.05). Conclusion: Intramedullary nailing is the preferred method of internal fixation for humeral shaft fractures that has the lowest rate of iRNI. Compared with anterolateral and posterior approaches, the lateral surgical approach had a higher incidence of iRNI. The rate of iRNI in MIPO was lower than that in open reduction and internal fixation. Level of evidence: Level IV. [ABSTRACT FROM AUTHOR]

Background: Pediatric forearm fractures represent a substantial proportion of childhood injuries, requiring effective and minimally invasive treatments. Our study investigated the mid-term outcomes of biodegradable poly-L-lactide-co-glycolide (PLGA) intramedullary implants in managing diaphyseal forearm fractures in children. Methods: A follow-up cohort study was conducted with 38 patients treated with PLGA implants. Control examinations were performed one year post-operation, assessing bone healing through radiographic evaluations and functional outcomes using injured and uninjured limb range of motion (ROM) comparisons. Scarring was evaluated employing the Vancouver Scar Scale (VSS), and satisfaction via a questionnaire. Results: Children were predominantly female (76.4%), with a mean age of 9.71 (SD: 2.69) years. Effective fracture stabilization and bone healing were found in all patients, with a minor reduction (mean difference of −1.5°, p = 0.282) in elbow flexion on the operated side (139.3°) compared to the intact (140.8°). Elbow extension presented negligible average changes (0.2°, p = 0.098). Forearm movements were slightly reduced on the operated side (mean pronation: 80.8° vs. 83.7°, p = 0.166; average supination: 83.5° vs. 85.7°, p = 0.141). Wrist palmar flexion and dorsiflexion showed no significant differences. VSS ratings indicated minimal scarring (mean guardian and doctor scores were 1.13 and 0.55, respectively, p = 0.020), and all patients reported satisfaction with the treatment outcomes. Conclusions: Biodegradable implants are effective for pediatric forearm fractures, providing stable bone healing while preserving functional ROM with minimal scarring and high patient satisfaction. PLGA proved to be a viable alternative to traditional metal implants, eliminating secondary removal surgeries. [ABSTRACT FROM AUTHOR]

Background: To evaluate the effectiveness of a sequential internal fixation strategy and intramedullary nailing with plate augmentation (IMN/PA) for bone reconstruction in the management of infected femoral shaft defects using the Masquelet technique. Methods: We performed a retrospective descriptive cohort study of 21 patients (mean age, 36.4 years) with infected bone defects of the femoral shaft treated by the Masquelet technique with a minimum follow-up of 18 months after second stage. After aggressive debridement, temporary stabilisation (T1) was achieved by an antibiotic-loaded bone cement spacer and internal fixation with a bone cement–coated locking plate. At second stage (T2), the spacer and the locking plate were removed following re-debridement, and IMN/PA was used as definitive fixation together with bone grafting. We evaluated the following clinical outcomes: infection recurrence, bone union time, complications, and the affected limb's knee joint function. Results: The median and quartiles of bone defect length was 7 (4.75–9.5) cm. Four patients required iterative debridement for infection recurrence after T1. The median of interval between T1 and T2 was 10 (9–19) weeks. At a median follow-up of 22 (20–27.5) months, none of the patients experienced recurrence of infection. Bone union was achieved at 7 (6–8.5) months in all patients, with one patient experiencing delayed union at the distal end of bone defect due to screws loosening. At the last follow-up, the median of flexion ROM of the knee joint was 120 (105–120.0)°. Conclusions: For infected femoral shaft bone defects treated by the Masquelet technique, sequential internal fixation and IMN/PA for the reconstruction can provide excellent mechanical stability, which is beneficial for early functional exercise and bone union, and does not increase the rate of infection recurrence. [ABSTRACT FROM AUTHOR]

Background: The rotational change after using a flexible intramedullary (IM) nail for femoral shaft fractures has been a concern for many surgeons. Recently, a statistical shape model (SSM) was developed for the three-dimensional reconstruction of the femur from two-dimensional plain radiographs. In this study, we measured postoperative femoral anteversion (FAV) in patients diagnosed with femoral shaft fractures who were treated with flexible IM nails and investigated age-related changes in FAV using the SSM. Methods: This study used radiographic data collected from six regional tertiary centers specializing in pediatric trauma in South Korea. Patients diagnosed with femoral shaft fractures between September 2002 and June 2020 and patients aged < 18 years with at least two anteroposterior (AP) and lateral (LAT) femur plain radiographs obtained at least three months apart were included. A linear mixed model (LMM) was used for statistical analysis. Results: Overall, 72 patients were included in the study. The average patient age was 7.6 years and the average follow-up duration was 6.8 years. The average FAV of immediate postoperative images was 27.5 ± 11.5°. Out of 72 patients, 52 patients (72.2%) showed immediate postoperative FAV greater than 20°. The average FAV in patients with initial FAV > 20° was 32.74°, and the LMM showed that FAV decreased by 2.5° (p = 0.0001) with each 1-year increase from the time of initial trauma. Conclusions: This study explored changes in FAV after femoral shaft fracture using a newly developed technology that allows 3D reconstruction from uncalibrated 2D images. There was a pattern of change on the rotation of the femur after initial fixation, with a 2.5° decrease of FAV per year. [ABSTRACT FROM AUTHOR]

Purpose: This meta-analysis compared the efficacy and safety of Proximal Femoral Nail Antirotation (PFNA) and InterTan Nail in the treatment of intertrochanteric fractures. Given the high incidence of femoral intertrochanteric fractures in the elderly population and its impact on quality of life, choosing the most effective and safest surgical option is crucial. PFNA and InterTan are currently two commonly used techniques, but there is a lack of systematic evaluation comparing their safety and effectiveness. This study aims to fill this knowledge gap through Meta-analysis, providing clinicians with evidence-based treatment recommendations. Materials and methods: A computer search was used to search for published literature on PFNA and InterTan in the treatment of intertrochanteric fractures in PubMed (Medline), Web of Science, Embase, Cochrane Library (CENTRAL), Cinahl, CBM, and CNKI.A total of 853 related literatures were retrieved, and 15 literatures were finally included. Newcastle-Ottawa-Scale and Cochrane systematic review methodologies were used to assess the quality of the literature. Meta-analysis was performed using Review Manager 5.4 software, following data extraction. Results: The comparison found that during the surgical treatment of intertrochanteric fractures, the operation time, fluoroscopy time, and blood loss in the PFNA group were significantly shorter than those in the InterTan group, and the difference was statistically significant. In terms of postoperative complication rates, the InterTan group had a significant advantage over the PFNA group. Shaft fracture, varus collapse, cut out, screw migration, and pain of hip and thigh were the most likely to occur in the PFNA group, and the differences were all statistically significant. In terms of postoperative efficacy, the results of the PFNA group and the InterTan group were comparable, and there was no significant differences. Conclusions: When selecting surgical techniques for the treatment of femoral intertrochanteric fractures, it is necessary to conduct individualized assessments based on the patient's overall health status, surgical tolerance, and post-operative recovery needs. For patients who cannot tolerate long-term surgery or are in poor physical condition, PFNA may be more appropriate. While for patients who can tolerate long-term surgery or have more complex conditions, InterTan may be more suitable. [ABSTRACT FROM AUTHOR]

Background: For the treatment of coronoid process fractures, medial, lateral, anterior, anteromedial, and posterior approaches have been increasingly reported; however, there is no general consensus on the method of fixation of coronal fractures. Here, we present a highly-extensile minimally invasive approach to treat coronoid process fractures using a mini-plate that can achieve anatomic reduction, stable fixation, and anterior capsular repair. Further, the study aimed to determine the complication rate of the anterior minimally invasive approach and to evaluate functional and clinical patient-reported outcomes during follow-up. Methods: Thirty-one patients diagnosed with coronoid fractures accompanied with a "terrible triad" or posteromedial rotational instability between April 2012 and October 2018 were included in the analysis. Anatomical reduction and mini-plate fixation of coronoid fractures were performed using an anterior minimally invasive approach. Patient-reported outcomes were evaluated using the Mayo Elbow Performance Index (MEPI) score, range of motion (ROM), and the visual analog score (VAS). The time of fracture healing and complications were recorded. Results: The mean follow-up time was 26.7 months (range, 14–60 months). The average time to radiological union was 3.6 ± 1.3 months. During the follow-up period, the average elbow extension was 6.8 ± 2.9° while the average flexion was 129.6 ± 4.6°. According to Morrey's criteria, 26 (81%) elbows achieved a normal desired ROM. At the last follow-up, the mean MEPI score was 98 ± 3.3 points. There were no instances of elbow instability, elbow joint stiffness, subluxation or dislocation, infection, blood vessel complications, or nerve palsy. Overall, 10 elbows (31%) experienced heterotopic ossification. Conclusion: An anterior minimally invasive approach allows satisfactory fixation of coronoid fractures while reducing incision complications due to over-dissection of soft tissue injuries. In addition, this incision does not compromise the soft tissue stability of the elbow joint and allows the patient a more rapid return to rehabilitation exercises. [ABSTRACT FROM AUTHOR]

Background: Injuries to the metacarpal bones are widespread and may severely limit a person's ability to go about their everyday lives. Unstable fractures usually need surgical intervention. Objectives: This study aimed to investigate how well Kirschner wires percutaneous fixing improves the prognosis of patients with unstable metacarpal fractures. Patients and methods: Fifteen patients with unstable metacarpal fractures were included in this study. They were treated by percutaneous fixation at Sharm El Sheikh Hospital through the period from 2017 to 2019. Nine patients in group 1 had antegrade intramedullary bouquet fixation and six in group 2 had transverse pinning. The results were evaluated using the total active movements (TAM) score after clinical and radiological follow-ups. Results: The mean patient age was 33.26 years. There were no statistically significant differences between the groups when it came to the intervals of time before fixation (p=0.64) and time until union (p=0.44). Results showed that both group 1 (76.77%) and group 2 (66.66%) when evaluated using TAM scores (p=0.26), had very good results. There were also no statistically significant differences between both groups in terms of the duration of follow-up or surgical complications (p=0.39 and p=0.35 respectively). Conclusion: There were no major variations in clinical or radiological outcomes between intramedullary and transverse pinning approaches when it comes to percutaneous fixation with Kirschner wires for unstable metacarpal fractures. Both methods provided equivalent results. [ABSTRACT FROM AUTHOR]

Case: A 48-year-old man presented to a Level 1 trauma center after a motor vehicle crash with a right irreducible posterior hip dislocation and ipsilateral fractures of the femoral head and segmental femur shaft. This injury was managed with open reduction and internal fixation and antegrade intramedullary nailing. Conclusion: This is the first report of a combined irreducible femoral head fracture-dislocation and a segmental femur fracture, a rare injury that requires a stepwise approach to operative management of each injury. Surgeons must recognize the clinical and radiographic findings associated with irreducible hip dislocations in the setting of ipsilateral fractures to the femoral head and shaft. [ABSTRACT FROM AUTHOR]

Aim Open fracture of the tibia is most common in road traffic accident specially motor cycle accident. Topics of debate in the orthopaedic traumatology continue regarding the specific methods of bone stabilization and soft tissue management of open fracture of Tibia. Objectives To evaluate the results of intramedullary nailing in the open fractures of the tibia in Combined Military Hospital, Dhaka. Material and Methods A prospective study was done from January 2018 to June 2019in Combined Military Hospital, Dhaka. Total twenty cases were selected who sustained open fractures of tibia Gustilo and Anderson grades I, II and IIIA. Primary undreamed intramedullary interlocking nail fixation done after thorough debridement and wounds were closed with suture. All the patients were followed up for a minimum of one year. Results Of the total twenty cases, ten were of grade I, seven were of grade II and three were of grade IIIA injury. Dynamization was done in nine cases. The average time to union was 16.0 weeks in the grade I cases, 18.3 weeks in the grade II cases and 23.6 weeks in the grade III A cases. The mean time to union was 19.3 weeks. Infection occurred in 3 cases. Mal union was observed in one case of type IIIA. No case had any implant failure (nail / screw breakage), or deep vein thrombosis. Conclusion From our study we have concluded that the unreamed intramedullary nailing in cases of open fractures of the tibia with soft tissue closure results faster soft tissue and bony healing. Biomechanical stability, early rehabilitation and infection rates are also comparable to those which are seen with other methods. [ABSTRACT FROM AUTHOR]

The objective of this study was to compare and analyze the clinical efficacy of different approaches of intramedullary nailing with blocking screws for proximal tibial fractures. One hundred cases of proximal tibial fractures treated in the orthopedic department from April 2021 to September 2023 were included in the study and divided into control and treatment groups using a random number table. A control group (n=50) treated with infrapatellar intramedullary nailing with blocking screws, and a treatment group (n=50) treated with suprapatellar intramedullary nailing with blocking screws. We observed the excellent and good rates in both groups, compared various perioperative indicators, changes in joint range of motion (ROM), Visual Analog Scale (VAS) pain scores, Lysholm knee joint function scores, changes in inflammatory factors, and various bone markers before and after treatment, and analyzed postoperative complications. There were no significant differences in baseline data such as age, sex, body mass index, fracture site, concomitant fibular fractures, time from fracture to surgery, injury mechanism, and AO/OTA fracture classification between the two groups (P>0.05). The excellent and good rate in the treatment group after treatment was 90.00 % (45/50), significantly higher than 72.00 % (36/50) in the control group (P<0.05). There were no significant differences in intraoperative blood loss and fracture healing time between the two groups (P>0.05). However, the treatment group had shorter surgical times and fewer fluoroscopy times than the control group (P<0.05). After treatment, both groups showed increased ROM and Lysholm scores, as well as decreased VAS scores. Moreover, compared to the control group, the treatment group had higher ROM and Lysholm scores and lower VAS scores (P<0.05). Inflammatory factors including interleukin-1b (IL-1b), C-reactive protein (CRP), tumor necrosis factor-a (TNF-a), osteocalcin (BGP), and calcitonin (CT) increased in both groups after treatment, while total nterminal propeptide of type I procollagen (Total-PINP) and b-C-terminal telopeptide of type I collagen (b-CTX) decreased. Compared to the control group, the treatment group exhibited greater increases in inflammatory factors and lower levels of Total-PINP and b-CTX, but higher BGP and CT levels (P<0.05). The incidence of postoperative complications was 8.00 % (4/50) in the treatment group and 24.00 % (12/50) in the control group, with statistically significant differences (P=4.762, X2=0.029). In the treatment of proximal tibial fractures, intramedullary nailing with blocking screws using the suprapatellar approach achieves significant clinical efficacy. It reduces surgical time, minimizes radiation exposure to healthcare workers and patients, improves knee joint range of motion and function, decreases postoperative pain and complication rates, suppresses inflammatory reactions, and promotes the improvement of bone markers related to fracture healing. [ABSTRACT FROM AUTHOR]

Purpose: It is still controversial whether complete displaced mid-shaft clavicle fractures should be treated with internal fixation or conservative therapy. This retrospective study aims to compare clinical outcomes of two treatment protocols. Materials and methods: 105 patients with displaced and comminuted mid-shaft clavicle fractures were included in this study, among which 55 patients were treated conservatively and 50 patients accepted surgical fixation and were followed up for over 20 months on average. Rate of union, malunion, time taken for union, functional outcome, self-reported satisfaction and complications were compared. Results: Union rate of operative group (n=49, 98.0%) was higher than the non-operative group (n=48, 87.3%). Time taken for union in operative group (2.37±1.06 months) was shorter than the non-operative group (3.69±1.01 months). Malunion and asymmetric were only seen in the conservative group. Numbness of the shoulder was only reported in the operative group (n=23, 46.0%). Most of patients in the operative group (n=45, 90%) accepted a second operation to remove the implant. No statistically difference was found in self-reported satisfaction, Quick-DASH and Constant-Murley score. The operative group returned to work faster (1.47±0.89 to 3.34±1.37 months), regained full range of motion earlier (1.66±0.78 to 3.83±1.24 months) and regained strength faster (3.86±2.45 to 8.03±2.78 months) than the non-operative group. Conclusion: Complete displaced and comminuted mid-shaft clavicle fractures treated surgically have more reliable union and faster recovery when compared to conservatively treated fractures. [ABSTRACT FROM AUTHOR]

Purpose: The optimal choice of distal locking modes remains a subject due to limited available data, and therefore, this study aims to investigate the relationship between distal locking mode and postoperative mechanical complications in an intertrochanteric fracture (ITF) population who underwent closed reduction and intramedullary fixation with a PFNA-II. Methods: Patients aged 65 years or older who underwent surgery with PFNA-II fixation in a university teaching hospital between January 2020 and December 2021 were potentially eligible. Based on the distal locking mode, patients were classified into static, dynamic, and limited dynamic groups, among which the differences were tested using univariate analysis. Multivariate logistic regression was used to examine whether the distal locking mode was independently associated with the risk of postoperative one year mechanical complications, adjusting for covariates and potential confounders. Subgroup analyses were performed to evaluate the robustness of the findings. Result: Among 507 eligible patients, 33 (6.5%) developed postoperative mechanical complications. In the univariate analysis, sex (P = 0.007), fracture type (P = 0.020), LAT Parker ratio (P = 0.023), and lateral femoral (P = 0.003) wall showed that the differences were significant. Compared to the static group, the limited dynamic group and the dynamic group showed higher odds of postoperative mechanical complications (OR = 3.314, 95% CI: 1.215–9.041; and OR = 3.652, 95% CI: 1.451–9.191, respectively). These associations were robust across a series of analyses, including adjusting for confounders and subgroup analyses. Conclusion: Using a distal non-static locking mode significantly increases the risk of postoperative mechanical complications, and static locking could be a preferable option when treating an intertrochanteric fracture. [ABSTRACT FROM AUTHOR]

Haptic strength, durability, and angulation of the LAL may support the possibility of Yamane FISHF in the hands of an experienced surgeon. Purpose: To compare maximum tensile strength between commonly used 3-piece intraocular lens (IOL) for flanged intrascleral haptic fixation (FISHF). Setting: Willis-Knight Eye Institute, Shreveport, Louisiana. Design: Laboratory investigation. Methods: Haptic tensile strength was compared with MA60AC, CT Lucia 602, AR40E, and the light-adjustable lens (LAL). Haptic strength with a 24-diopter (D) IOL was compared across all lenses, as well as across a range of 10 to 30 D with the MA60AC. A custom device was created to hold the IOL in correct haptic orientation. The maximum tension (mean ± SD) was recorded in Newtons (N) when the haptic lost tension or broke. Results: CT Lucia was the strongest at 1.53 ± 0.11 N vs 1.00 ± 0.15 (MA60AC), 0.87 ± 0.19 (AR40E), and 0.83 ± 0.14 N (LAL) (P <.001). The LAL and AR40E were similar to a 9-0 polypropylene suture while being significantly stronger than 10-0 polypropylene suture (P <.001). No difference in haptic tension for the MA60AC from 10 to 30 D (P >.05). High magnification revealed the highest haptic fractures for MA60AC at 40% compared with LAL, AR40E, and CT Lucia at 0%. CT Lucia and AR40E had 100% of haptics disinserted from the IOL without any damage compared with 60% LAL and 60% MA60AC. CT Lucia, AR40E, and LAL have a flatter haptic angulation at 5 degrees. Conclusions: Haptic strength, durability, and angulation of the LAL may support the possibility of FISHF in the hands of experienced surgeons. However, further testing is strongly recommended to verify whether physiologic conditions or light treatments may compromise long-term haptic stability. [ABSTRACT FROM AUTHOR]

Objective: AO/OTA 31‐A3.3 intertrochanteric fracture is the most unstable type of intertrochanteric fracture, with a high rate of postoperative complications and implant failure. We have designed a new intramedullary fixation, proximal femoral totally bionic nail (PFTBN), for the treatment of A3.3 intertrochanteric fracture. To test its biomechanical performance, we adopted the method of finite element analysis and compared PFTBN with proximal femoral nail antirotation (PFNA) and proximal femoral bionic nail (PFBN, another internal fixation we previously designed for stable intertrochanteric fractures). Methods: Mimics, 3‐matic, ANSYS, and other software were used to construct a highly precise and realistic 3D digital model of the human femur. An AO/OTA 31‐A3.3 intertrochanteric fracture of the femur was constructed according to the 2018 classification of AO/OTA, and then assembled with PFNA, PFBN and PFTBN models, respectively. The stress distribution and displacement distribution of the three groups of constructs were tested under three times the body weight load and one‐foot standing configuration. Results: In terms of maximum stress and maximum displacement, the PFTBN group outperforms the PFBN group, and the PFBN group, in turn, surpasses the PFNA group. The maximum stress of PFTBN group was 408.5 Mpa, that of PFBN group was 525.4 MPa, and that of PFNA group was 764.3 Mpa. Comparatively, the maximum stress in the PFTBN group was reduced by 46.6% when contrasted with the PFNA group. Moreover, the stress dispersion within the PFTBN group was more evenly distributed than PFNA group. Regarding maximum displacement, the PFTBN group displayed the least displacement at 5.15 mm, followed by the PFBN group at 7.32 mm, and the PFNA group at 7.73 mm. Notably, the maximum displacement of the PFTBN group was 33.4% less than that observed in the PFNA group. Additionally, the relative displacement between the fragment and implant at the tip of pressure screw or helical blade was 0.22 mm in the PFTBN group, 0.34 mm in the PFBN group, and substantially higher 0.51 mm in the PFNA group. Conclusion: The "lever‐reconstruction‐balance" theory provides a new perspective for us to understand the mechanical conduction of the proximal femur. Compared with PFNA, in treating A3.3 intertrochanteric fractures PFTBN can better reconstruct the function of lateral wall, restore physiological mechanical conduction, increase postoperative stability, and finally reduce the risk of postoperative cut‐out and implant failure. It might be a better alternative for the treatment of A3.3 intertrochanteric fracture. [ABSTRACT FROM AUTHOR]

The study aimed to validate a newly developed postoperative stability score for evaluating clinical follow-up in elderly patients with low-energy hip fractures. From 1 January 2020 to 31 December 2021, we enrolled patients aged over 65 who underwent cephalomedullary nail fixation using proximal femoral nail antirotation II (PFNAII) and had at least 6 months of follow-up; excluding multiple fractures, pathological fractures, and periprosthetic fractures. We collected general patient data. Parameters such as TAD, Parker's ratio (AP and lateral), and the new postoperative stability score were recorded. A loss of reduction was defined using the decline in the Chang reduction quality criteria (CRQC) score within one month. Among the 108 enrolled patients, 23 (21.3%) experienced a loss of reduction, with a mean age of 82.1 years and a mean follow-up time of 7.4 months. Univariate analysis showed no significant association between loss of reduction and general data. However, the new postoperative stability score correlated significantly with loss of reduction (mean scores: 6.68 vs. 4.83, p = 0.045). Multivariate analysis confirmed this association (odds ratio: 0.076, 95% confidence interval: 0.022–0.263, p < 0.05). The newly developed postoperative stability score, incorporating surgical technique assessment, improves prediction accuracy for loss of reduction in elderly intertrochanteric fracture (ITF) patients. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To assess the fatigue and load-to-failure mechanical characteristics of an intramedullary nail with a threaded interference design (TID) in comparison to a commercially available veterinary angle-stable nail with a Morse taper bolt design (I-Loc) of an equivalent size. METHODS: 10 single interlocking screw/bolt constructs of TID and I-Loc implants were assembled using steel pipe segments and placed through 50,000 cycles of simulated, physiologic axial or torsional loading. Entry torque, postfatigue extraction torque, and 10th, 25,000th, and 50,000th cycle torsional toggle were assessed. Each construct was then loaded to failure in the same respective direction as fatigue testing. Four complete constructs of each design were then assessed using a synthetic bone analog with a 50-mm central defect via nondestructive torsional and axial loading followed by axial load to failure. RESULTS: All constructs were angle stable at all time points and withstood fatigue loading. Median insertional torque, extraction torque-to-insertion torque ratio, and torsional yield load were 33%, 33%, and 72.5% lower, respectively, for the TID interlocking screws. No differences in torsional peak load, torsional stiffness, axial yield load, axial stiffness, or axial peak load were identified. No differences in complete construct angle stability, torsional stiffness, axial peak load, axial stiffness, or axial yield load were identified. CLINICAL RELEVANCE: The TID had an inferior torsional yield load when compared to I-Loc implants but generated angle stability and sustained simulated physiologic fatigue loading. The TID may be a suitable mechanism for generating angle stability in interlocking nails. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Assess femorotibial features in foals with and without medial femoral condyle (MFC) subchondral radiolucencies (SR+ and SR-). METHODS: 3 independent, sequential radiographic studies were performed. Study 1 retrospectively measured femorotibial morphological parameters in repository radiographs (SR- and SR+). Study 2 qualitatively compared drawings of intercondylar notch shape in postmortem radiographs (SR-). Study 3 prospectively measured femorotibial parameters in 1-month-old foals (SR-). In studies 1 and 3, 13 morphologic parameters were measured. Limb directional asymmetry was assessed in 2 age groups (< 7 or ≥7 months). RESULTS: Study 1 (SR-group; n = 183 radiographs) showed increased femoral measurements with maturation, except the distal femoral intercondylar notch width (FINwal), which decreased. In contrast, in SR+ stifles (53 radiographs), 3 femoral parameters (MFC width [MFCwpf], MFC height, or FINwal) showed no changes. Tibial plateau width alone increased with maturation in both groups. Interobserver reliability was good to excellent. Study 2 (n = 53 radiographs) confirmed a distal FINw decrease in SR- foals. In study 1, left SR- stifles in greater than or equal to 7-monthold fillies had significantly larger femoral bicondylar width and FINw, while right SR+ stifles in fillies greater than or equal to 7 months had a significantly larger MFCw. In study 3 of 1-month-old foals (n = 94 SR- radiographs), the MFCw, femoral condyle bicondylar width, and lateral femoral condyle height were all greater on the left, whereas the intercondylar intereminence space width was larger on the right. CLINICAL RELEVANCE: In SR+ stifles, the distal femur exhibited divergent maturation, indicating a wider MFC in the right stifle in older foals. As SR lesions are more common on the right, this suggests a potential association with MFC morphology. [ABSTRACT FROM AUTHOR]

We examined the treatment outcomes following intramedullary nailing in patients with metastatic femoral tumors, excluding those from hematological malignancies. We retrospectively evaluated treatment outcomes following intramedullary nailing between patients who underwent preventative surgery compared with those who had surgery following pathological fracture. Patients who underwent preventative surgery (Mirels' score ≥8) were allocated to the impending fracture group (n = 11) and those who underwent surgery after pathological fracture were allocated to the completed fracture group (n = 20). Duration of surgery was significantly shorter in the impending fracture group than in the completed fracture group. Median blood loss was significantly less, and the median duration of hospital stay was significantly shorter in the impending fracture group than in the completed fracture group. Among patients who died following surgery, the median postoperative survival duration was significantly longer in the impending fracture group than in the completed fracture group. Significantly more patients regained walking function in the impending fracture group than in the completed fracture group. Regarding complications, infection occurred in one patient in the completed fracture group. No implant damage was observed in either group. Patients with metastatic femoral tumors who underwent intramedullary nailing in the impending fracture group had better postoperative survival and gait function, less blood loss, and shorter durations of surgery and hospital stay than those in the completed fracture group. These findings indicate the importance of early diagnosis and treatment and value of treatment prior to fracture occurrence. [ABSTRACT FROM AUTHOR]

AO/OTA 31A3 fractures (A3 fractures) have risk for postoperative complications with major impact on morbidity and mortality. For older patients, limited information is available for factors associated with postoperative complications. We aimed to assess factors associated with postoperative complications after surgery using cephalomedullary nails. A retrospective cohort study was conducted using the information on patients aged ≥65 years who underwent surgery using cephalomedullary nails for trochanteric fractures due to low-energy trauma in three hospitals. Postoperative complications were diagnosed when patients were identified as nonunion, cutout of lag screw, or nail breakage. First, we compared differences including age, sex, body mass index, American Society of Anesthesiologists physical status classification system, preoperative waking ability, fracture type, nail length, neck shaft angle, reduction method, reduction quality and tip apex distance between patients with and without postoperative complications. Second, multivariable logistic regression analysis was employed to assess factors associated with postoperative complications resulting from A3 fractures. Among 120 patients with A3 fractures, postoperative complications were identified in 12 patients (10.0%). Postoperative complications were significantly more likely to develop among patients with poor reduction quality (adjusted odds ratio [95% confidence interval], 35.0 [4.43–275.9]) and a tip-apex distance ≥25 mm (16.4 [1.92–140.3]). These findings suggest that surgeons should aim to perform appropriate postoperative reduction and to prevent postoperative complications when using a cephalomedullary nail for A3 fractures among older patients. [ABSTRACT FROM AUTHOR]

Tibial diaphysis is the most common site of fracture in the tibia and about 80% of these injuries are associated with fibular fractures. Surgically, intramedullary nail fixation remains the treatment of choice for displaced and un-displaced tibial shaft fractures in adult population. Supra-patellar nailing in the semi extended position has recently been suggested as a safe and effective surgical technique. All these patients were clinically and radiologically confirmed with proximal and distal tibial fractures, and were eligible for the study. After carrying out necessary laboratory investigations and obtaining physical fitness for surgery, the subjects were surgical managed with expert tibial nailing through suprapatellar approach. The mean VAS, 1 month after surgery was 5.03±1.10, which got significantly reduced to 1.70±0.84 and 0.43±0.50 at 3 and 6 months after surgery. The mean duration required for healing of wounds was 11.87±1.72 days. The radiological union was observed in 90.0% at 6 months and in 100.0% at 12 months, and also the suprapatellar approach was successful in significantly improving the radiological outcome in a short period of time. Delayed union was the only complication observed in 3 individuals. There was statistically significant relation only in terms of age and interval between injury and surgery, thereby suggesting that younger the age of the subjects, earlier the surgery after injury, better was the functional outcome. [ABSTRACT FROM AUTHOR]

Background and aim: Hip fractures are common in elderly and are usually managed by proximal femoral nailing (PFN) surgery. Fascia iliaca compartment block (FICB) is commonly administered to manage postoperative pain. The present study was aimed to compare duration of analgesia between suprainguinal and infrainguinal approach for FICB. Patients and methods: 80 geriatric patients undergoing elective PFN surgery under spinal anaesthesia were included in the study. At the end of surgery ultrasound guided FICB was administered. Patients were divided in to two groups, group SIFICB received FICB using suprainguinal approach and group IIFICB received FICB using infrainguinal approach. 40 ml of 0.125% levobupivacaine was injected below fascia iliaca. Postoperative pain was assessed using visual analogue scale (VAS) score at 2,4,6,8,12,16,20, and 24 hours. When VAS score was 4 or more, rescue analgesia (inj.Tramadol 1 mg/kg IV) along with inj. Ondansetron 4mg IV was administered. Postoperatively haemodynamic parameters were assessed at 2,4,6,8,12,16,20, and 24 hours. Any adverse effects such as delirium, nausea and vomiting were noted. Results: The duration of analgesia was significantly prolonged in group SIFICB when compared to group IIFICB (11.58±3.2 hrs vs 8.2±2.5 hrs, p< 0.0001). 24 hours tramadol requirement was significantly less in SIFICB group in comparison to IIFICB group (62.6±12.8 mg vs 87.4±14.6 mg, p<0.0001). VAS scores were significantly lower in SIFICB group at 12 and 16 hours postoperatively in comparison to IIFICB group (p<0.0001). Conclusion: Suprainguinal FICB is preferred to infrainguinal FICB in geriatric patients undergoing PFN surgery as it provides longer duration of analgesia, decreases postoperative tramadol requirement, and decreases postoperative VAS score. [ABSTRACT FROM AUTHOR]

OBJECTIVE: This study aims to investigate the effect of bone grafting on the bone union in exchange nailing (EN) for the treatment of femoral shaft nonunions. METHODS: A total of 26 patients (16 male) were included in this study. The mean age of the patients was 36.1±9.3. Bone grafts were used in 8 patients (bone graft group), and EN was performed without bone grafting (no bone graft group) in 18 patients. Etiology, fracture type, location, and classification of the fractures at the time of initial injury were evaluated. The reduction type (open or closed) and locking status of the nails were also noted. Nonunion types were recorded. In the bone grafting group, iliac bone autografts were used in seven patients and a synthetic bone graft was used in one patient. Following EN, the presence and duration of bone union, and the increase in the nails' diameter were analyzed for each group and compared. RESULTS: Union rates were 100% and 94.4% in bone grafting and no bone grafting groups, respectively. The mean union period was not significant between the groups (22.5 and 16.5 months, respectively). The mean increase in the nail diameter was 1.88 mm in the bone graft group and 2.00 mm in the no bone graft group (p>0.05). CONCLUSION: This study demonstrated that high union rates can be achieved with EN by means of using larger diameter nails with or without bone grafting in the management of femoral shaft nonunions, and bone grafting had no significant effect on union rates and periods. [ABSTRACT FROM AUTHOR]

PURPOSE OF THE STUDY The purpose of this study was to assess the clinical outcomes and complications associated with intramedullary and transverse K-wire fixations of 5th metacarpal neck fractures. MATERIAL AND METHODS Patients who were operated for 5th metacarpal neck fractures between 2019 and 2022 were evaluated retrospectively. Regarding the surgical treatment methods, patients were assessed by dividing them into two groups. The first group comprised patients who underwent treatment with an intramedullary K-wire. The second group comprises patients who underwent transverse K-wire fixation. RESULTS The average quick DASH score of all patients was 5.6±4.7 in the intramedullary K-wire fixation group and 5.9±5.1 in the transverse K-wire fixation group. An average 5th finger metacarpophalangeal joint extension limitation was 6.2±5.7° in the intramedullary fixation group and 6.1±5.8° in the transverse K-wire group. The mean radiological union time was 4.9±0.7 weeks in the intramedullary fixation group and 5.1±0.7 weeks in the transverse K-wire group. No statistically significant difference was found between the quick DASH scores and degrees of the MCP joint extension limitation (p=0.785). Intramedullary fixation and transverse K-wire fixations are effective surgical treatment methods for metacarpal neck fractures. DISCUSSION It has been reported that the intramedullary fixation method in metacarpal bone fractures is more effective than the fixation methods with cross and transverse K-wire. But our results revealed no difference in clinical outcomes between the two surgical fixation methods. CONCLUSIONS We observed no statistically significant difference between the two fixation techniques with regard to union, clinical outcomes, or complications. [ABSTRACT FROM AUTHOR]

Introduction: Tibial shaft fractures pose a significant challenge in orthopaedic practice, often necessitating surgical intervention for optimal recovery. The selection of the entry point for intramedullary nailing, particularly between the suprapatellar and infrapatellar approaches, remains a debated aspect in fracture management. This study aims to compare the suprapatellar and infrapatellar approaches, analyzing surgical techniques, complications, and functional outcomes to inform clinical decision-making. Methodology: A retrospective comparative analysis was conducted on patients undergoing intramedullary nailing for tibial shaft fractures, comparing outcomes between the suprapatellar and infrapatellar approaches. Result: Operative time was longer in the infrapatellar group (137.8 minutes) compared to the suprapatellar group (114.4 minutes). The mean radiation dose was higher in the infrapatellar group compared to suprapatellar group. Postoperative outcomes showed a mean Lysholm score of 74 and 90 in the infrapatellar group and suprapatellar group respectively. one case of infection and malunion were reported in the infrapatellar group, while the suprapatellar group had one infection case but no instances of non-union or malunion. Conclusion: This study provides valuable insights into the surgical and clinical outcomes of the suprapatellar and infrapatellar approaches for tibial shaft fractures. Among both techniques the suprapatellar approach may offer advantages in terms of operative efficiency and functional recovery. [ABSTRACT FROM AUTHOR]

Purpose: This study aimed to compare two different double‐level knee osteotomy (DLO) fixation techniques. The primary outcome reported the radiological coronal plane correction and its accuracy. The secondary outcomes reported the correction outliers, the clinical outcomes, the 5‐year postoperative satisfaction and the complications. Methods: A retrospective review of a single surgeon osteotomy database identified 52 cases of DLO between 2011 and 2019, of which 24 cases met the inclusion criteria. Patients were categorised into two groups: the nail‐plate (NP) group fixed with a magnetic extendable intramedullary tibial nail and femoral conventional plate, and the double‐plate (DP) group fixed with conventional plates (tibia and femur). Radiographic parameters were recorded, including the mechanical femorotibial angle (mFTA), medial proximal tibial angle (MPTA), mechanical lateral distal femoral angle (mLDFA), joint line convergence angle (JLCA) and weight‐bearing line ratio (Mikulicz %). Surgical accuracy was calculated as the difference between the achieved and the planned correction. Outliers were defined as those with a greater than 10% difference from the planned correction. Simple knee value scores and visual analogue scale for pain were recorded preoperatively and postoperatively at 2 and 5 years. Five‐year patient satisfaction was recorded. Results: A total of 24 patients were included: the NP group (n = 12) and the DP group (n = 12). Significant coronal plane corrections were achieved in the NP group for the mean mFTA (preoperative 167.9° ± 3.4° to postoperative 182.1° ± 1.4°), the mean MPTA (preoperative 83.5° ± 2.9° to postoperative 91.3° ± 2.8°) and the mean mLDFA (preoperative 89.8° ± 3.4° to postoperative 85.9° ± 4.4°). Similarly, significant coronal plane corrections were achieved in the DP group for the mean mFTA (preoperative 168.6° ± 4.4° to postoperative 182.2° ± 2°), the mean MPTA (preoperative 84.2° ± 2° to postoperative 88.3° ± 4.1°) and the mean mLDFA (preoperative 90.7° ± 2.9° to postoperative 83.9° ± 1.7°) (all p < 0.05). The mean correction accuracy was higher for the NP versus DP group at 3.4 ± 3.4% versus 7.1 ± 3.9% (intergroup p < 0.05). There were no outliers in the NP group versus two outliers (overcorrected) (16.7%) in the DP group. Significant clinical improvement was reported in both groups at 2 and 5 years postoperatively (all p < 0.05). Conclusion: Superior correction accuracy and no outliers were achieved in hybrid fixation double‐level knee osteotomy compared to the conventional double‐plating technique. The magnetic extendable nail offers the advantage of fine‐tuning the correction postoperatively and could be a potential research template for future designs of postoperative correction implants. Level of Evidence: Level III, retrospective cohort study. [ABSTRACT FROM AUTHOR]