PURPOSE: Ultrasonography has been used increasingly in orthopaedic practice credited to its low cost, easy accessibility, non-invasiveness, reproducibility, and safety from radiation. The purpose of this study was to test the validity and efficacy of ultrasonography as an adjunct in the assessment of fracture healing in long bones treated with intramedullary interlocking devices and its predictive value in determining the need for a secondary surgical procedure. METHODS: This was a descriptive longitudinal study of 40 skeletally mature patients from November 2016 to February 2019, who sustained long bone fractures of the tibia or femur treated using intramedullary interlocking nails. Patients with comminuted and segmental fracture patterns were excluded from the study. Each patient was evaluated at 6- and 12-week post-surgery using standard orthogonal radiographs and ultrasonography to assess fracture healing. Patients were then followed up until fracture union. Quantitative data was analyzed using frequency statistics and descriptive data with inferential statistics. RESULTS: Ultrasonography predicted 87.5% union and 12.5% delayed or non-union as early as 6 weeks after surgery, while radiographs predicted 22.5% union as late as 3 months of follow-up. The sensitivity and specificity of ultrasonography in assessing fracture healing were 100% and 97.2%, respectively, with a positive predictive value of 80.0%. Vascular resistance index was less than 0.5 in all patients who developed delayed or non-union. CONCLUSION Ultrasonography is able to predict fracture outcomes much earlier than standardized radiographs with comparable sensitivity and specificity. Vascular resistance index is an objective parameter in assessing callus quality and predicting fracture outcomes.
Humans ; Fracture Fixation, Intramedullary/methods* ; Male ; Female ; Ultrasonography/methods* ; Adult ; Fracture Healing ; Tibial Fractures/diagnostic imaging* ; Middle Aged ; Femoral Fractures/diagnostic imaging* ; Longitudinal Studies ; Bone Nails ; Young Adult ; Predictive Value of Tests ; Aged ; Treatment Outcome ; Adolescent

PURPOSE: To methodically assess the effectiveness of augmentative plating (AP) and exchange nailing (EN) in managing nonunion following intramedullary nailing for long bone fractures of the lower extremity. METHODS: PubMed, EMBASE, Web of Science, and the Cochrane Library were searched to gather clinical studies regarding the use of AP and EN techniques in the treatment of nonunion following intramedullary nailing of lower extremity long bones. The search was conducted up until May 2023. The original studies underwent an independent assessment of their quality, a process conducted utilizing the Newcastle-Ottawa scale. Data were retrieved from these studies, and meta-analysis was executed utilizing Review Manager 5.3. RESULTS: This meta-analysis included 8 studies involving 661 participants, with 305 in the AP group and 356 in the EN group. The results of the meta-analysis demonstrated that the AP group exhibited a higher rate of union (odds ratio: 8.61, 95% confidence intervals (CI): 4.12 - 17.99, p < 0.001), shorter union time (standardized mean difference (SMD): -1.08, 95% CI: -1.79 - -0.37, p = 0.003), reduced duration of the surgical procedure (SMD: -0.56, 95% CI: -0.93 - -0.19, p = 0.003), less bleeding (SMD: -1.5, 95% CI: -2.81 - -0.18, p = 0.03), and a lower incidence of complications (relative risk: -0.17, 95% CI: -0.27 - -0.06, p = 0.001). In the subgroup analysis, the time for union in the AP group in nonisthmal and isthmal nonunion of lower extremity long bones was shorter compared to the EN group (nonisthmal SMD: -1.94, 95% CI: -3.28 - -0.61, p < 0.001; isthmal SMD: -1.08, 95% CI: -1.64 - -0.52, p = 0.002). CONCLUSION In the treatment of nonunion in diaphyseal fractures of the long bones in the lower extremity, the AP approach is superior to EN, both intraoperatively (with reduced duration of the surgical procedure and diminished blood loss) and postoperatively (with an elevated union rate, shorter union time, and lower incidence of complications). Specifically, in the management of nonunion of lower extremity long bones with non-isthmal and isthmal intramedullary nails, AP demonstrated shorter union time in comparison to EN.
Humans ; Bone Nails/adverse effects* ; Bone Plates/adverse effects* ; Femoral Fractures/surgery* ; Fracture Fixation, Intramedullary/methods* ; Fractures, Ununited/surgery* ; Lower Extremity/injuries*

PURPOSE: This study aims to investigate the efficacy of novel distraction support (DS) in intramedullary nailing treatment for tibial shaft fracture. METHODS: The random controlled trial included adult patients with tibial shaft fractures who were treated with intramedullary nailing at the trauma center between July 2013 and December 2018. Participants were randomly assigned to either control group (n=43) or DS group (n=42) based on whether DS was used during the operation. All surgical procedures were conducted by a single, experienced surgeon. Parameters such as hospital stay, blood loss, operative time, infection, delayed union, and malalignment were recorded for assessment. Shapiro-Wilk test was used to assess normality, and the F test was adopted to measure variance homogeneity. Continuous variables were presented as mean±standard deviation and compared via independent samples t-tests. Categorical variables are expressed as percentages. The Pearson's Chi-squared or Fisher's exact test was used for categorical variables n (%). Two-sided p<0.05 indicated statistical significance. RESULTS: A total of 85 participants were enrolled in the study. All cases achieved acceptable reduction. The operative time was significantly shorter in the DS group than in control group ((75.3±10.5) min vs. (90.4±15.5) min, p<0.001). Additionally, the DS group showed lesser blood loss ((60.1±27.2) mL vs. (85.4±25.4) mL, p<0.001). No significant differences were observed between the 2 groups in terms of hospital stay ((9.4±2.7) days vs. (10.2±3.1) days, p=0.370), infection (3 (7.1%) vs. 2 (4.7%), p=0.978), delayed union (2 (4.8%) vs. 5 (11.6%), p=0.450), and malalignment (3 (7.1%) vs. 5 (11.6%), p=0.713). CONCLUSION The use of DS in intramedullary nailing surgery is effective. The application of this DS system may represent a valuable addition to future clinical practice.
Humans ; Fracture Fixation, Intramedullary/methods* ; Tibial Fractures/surgery* ; Male ; Female ; Adult ; Middle Aged ; Operative Time ; Length of Stay ; Young Adult ; Osteogenesis, Distraction/methods*

PURPOSE: Flexible intramedullary nails (FIN) enable minimally invasive and immediate fracture stabilisation, while facilitating early active movement in metacarpal fractures. This systematic review aims to compare locked, non-locked, single, and double FIN and their post-operative outcomes in metacarpal fractures. METHODS: A primary literature search was performed on July 15, 2024. English-language studies investigating acute metacarpal fractures, treated with FIN were included. Analyses included: the 5th metacarpal neck fractures locked vs. non-locked FIN; 5th metacarpal neck fractures non-locked single vs. dual FIN; and the 2nd-5th metacarpal fractures locked vs. non-locked FIN. The National Institute for Health tool and the JBI tool were used to assess study quality for controlled trials and case series, respectively. RESULTS: Thirteen studies (n=649 fractures) were eligible, with 12 low risks of bias. There was no difference in overall complication rates between locked and non-locked, and single and double non-locked FIN. Non-locked FIN demonstrated reduced metacarpophalangeal joint penetration (odds ratio (OR): 3.30 (95% confidence interval (CI): 1.23-8.80; p=0.017 and delayed union (OR: 6.95; 95% CI: 1.86-25.97; p=0.004), but increased tendon irritation (OR: 0.19; 95% CI: 0.05-0.83; p=0.027 vs. locked FIN. Overall operative times were lower for single vs. double non-locked nails (mean difference: 9.17; 95% CI: 6.12-12.22; p<0.001). CONCLUSIONS These findings demonstrate low complication rates and excellent functional results using FIN to fix displaced metacarpal fractures. Although complication profiles are contrasting, there is no clear benefit in using locked or double nails compared to a single non-locked FIN.
Humans ; Metacarpal Bones/surgery* ; Fracture Fixation, Intramedullary/methods* ; Fractures, Bone/surgery* ; Bone Nails

PURPOSE: Hidden blood loss (HBL) during the perioperative period significantly impacts postoperative recovery and complications, yet it is frequently disregarded. This study aimed to investigate the effects of tip-apex distance (TAD) and calcar-referenced tip-apex distance (calTAD) on HBL in the treatment of intertrochanteric fractures utilizing proximal femoral nail antirotation (PFNA). The study also seeks to evaluate the possible decrease in HBL subsequent to PFNA treatment by optimizing nail positioning. METHOD: A historical cohort study was conducted from January 2020 to December 2022. Patients diagnosed with unilateral acute closed femoral intertrochanteric fracture and who underwent PFNA internal fixation surgery met the inclusion criteria, and were grouped according to the value of calTAD and TAD. The participants were divided into low TAD group (TAD<20 mm) and high TAD group (TAD≥20 mm); low calTAD group (calTAD<7.625 mm) and high calTAD group (calTAD≥7.625 mm), respectively. The primary outcome measures were intraoperative blood loss (including HBL, overt blood loss, and total blood loss). Continuous data were analyzed using an independent sample t-test or Mann-Whitney U test, and categorical data were analyzed using the Pearson Chi-square test. Univariate analysis was used to evaluate the association between various indicators and perioperative HBL. A stepwise multiple linear regression analysis model was used to determine the independent factors affecting perioperative HBL. A p value less than 0.05 was considered statistically significant. RESULTS: A total of 131 patients were initially included, of which 80 were assigned to the calTAD group (with 61 in the high calTAD group and 19 in the low calTAD group), and 80 were assigned to the TAD group (with 34 in the high TAD group and 46 in the low TAD group). The average HBL for the low TAD group was 772.85 mL, whereas for the high TAD group it was 919.68 mL (p>0.05). The average HBL for the low calTAD group was 611.42 mL, whereas for the high calTAD group it was 904.97 mL (p<0.05). Subsequent analysis revealed that the patient's height, preoperative hemoglobin levels, changes in hemoglobin and hematocrit levels from pre- to post-surgery, and calTAD are independent risk factors influencing HBL. CONCLUSION In summary, our investigation revealed a significant correlation between the positioning of nails in PFNA and HBL during the perioperative period. By optimizing the placement of the cephalic nail, specifically by ensuring a calTAD of less than 7.625 mm, a significant decrease in HBL can be attained. Additionally, we identified that height, preoperative hemoglobin, differences in preoperative and postoperative hemoglobin and hematocrit, and the positioning of the cephalic nail were independent risk factors for HBL.
Humans ; Retrospective Studies ; Male ; Blood Loss, Surgical/prevention & control* ; Female ; Hip Fractures/surgery* ; Aged ; Fracture Fixation, Intramedullary/methods* ; Bone Nails ; Perioperative Period ; Middle Aged ; Aged, 80 and over

OBJECTIVE: To compare the short-term effectiveness between Gamma 3 intramedullary nails and Gamma 3 U-Blade system in the treatment of osteoporotic intertrochanteric fractures in the elderly. METHODS: A retrospective analysis was conducted on the clinical data of 124 elderly patients with osteoporotic intertrochanteric fractures, who were admitted between February 2020 and February 2023 and met the selection criteria. The fractures were fixed with Gamma 3 intramedullary nails in 65 patients (control group) and Gamma 3 U-Blade systems in 59 patients (UB group). The differences between the two groups were not significant in age, gender, body mass index, American Society of Anesthesiologists (ASA) classification, bone mineral density, time from injury to operation, fracture classification, and affected side ( P>0.05). The operation time, intraoperative blood loss, hospital stay, and fracture healing time were recorded; the tip-apex distance, fracture reduction quality, and lag screw position were evaluated on X-ray films at immediate after operation; the lag screw sliding distance and change value of neck-shaft angle were measured on X-ray films at last follow-up. Harris hip score at 1 year after operation and the occurrence of internal fixation-related complications were compared between the two groups. RESULTS: The operation time, intraoperative blood loss, and hospital stay in the UB group increased compared to the control group, but the differences were not significant ( P>0.05). All patients in both groups were followed up 12-24 months (mean, 17.1 months). At 12 months after operation, there was no significant difference in the Harris hip score between the two groups ( P<0.05). Radiological examination showed that there was no significant difference between the two groups ( P>0.05) in terms of tip-apex distance, fracture reduction quality, and lag screw position. Fractures healed in both groups, and there was no significant difference in healing time ( P>0.05). At last follow-up, the change value of neck-shaft angle and lag screw sliding distance in the UB group were significantly lower than those in the control group ( P<0.05). During follow-up, no related complications occurred in the UB group, while 6 cases (9.2%) in the control group experienced complications, and the difference in the incidence was significant ( P<0.05). CONCLUSION For the osteoporotic intertrochanteric fractures in the elderly, the Gamma 3 U-Blade system fixation can achieve good short-term effectiveness, with better imaging results compared to Gamma 3 intramedullary nails fixation.
Humans ; Retrospective Studies ; Hip Fractures/surgery* ; Male ; Female ; Aged ; Fracture Fixation, Intramedullary/methods* ; Osteoporotic Fractures/surgery* ; Bone Nails ; Bone Screws ; Aged, 80 and over ; Treatment Outcome ; Fracture Healing ; Operative Time ; Length of Stay

OBJECTIVE: To explore the effectiveness of proximal femoral nail antirotation (PFNA) combined with minimally invasive clamp reduction technique by Kocher pincers in the treatment of irreducible intertrochanteric femoral fracture in the elderly. METHODS: The clinical data of 35 elderly patients with irreducible intertrochanteric femoral fractures who were treated with PFNA combined with minimally invasive clamp reduction technique by Kocher pincers between January 2016 and December 2022 were retrospectively analysed. There were 16 males and 19 females, aged from 63 to 95 years (mean, 75.2 years). The causes of injury included traffic accident in 3 cases and falling in 32 cases. The time from injury to operation was 2-11 days (mean, 3.6 days). According to AO/Orthopaedic Trauma Association (AO/OTA) classification system for intertrochanteric fractures, there were 14 cases of type A1, 18 cases of type A2, and 3 cases of type A3. According to the displacement of fracture by intraoperative fluoroscopy, there were 5 cases with only coronal displacement, 17 cases with only sagittal displacement, and 13 cases with both coronal and sagittal displacement. The operation time, intraoperative blood loss, rate of hemoglobin decline at 1 day after operation, length of hospital stay, and fracture healing time were recorded. The reduction quality of fracture during operation was evaluated according to reduction quality criteria proposed by Chang et al. The Harris scoring system was used to evaluate the hip joint function at last follow-up. RESULTS: The operation time was 45-105 minutes (mean, 54.4 minutes); the intraoperative blood loss was 80-300 mL (mean, 116.3 mL). The reduction quality of fracture during operation was good in 22 cases (62.9%) and acceptable in 13 cases (37.1%). The rate of hemoglobin decline at 1 day after operation ranged from 6.2% to 18.6% (mean, 10.2%); the length of hospital stay was 5-18 days (mean, 7.2 days). One case died of respiratory failure due to pulmonary infection, 2 cases were lost to follow-up, and the remaining 32 cases were followed up 6-24 months (mean, 10.6 months). All 32 patients achieved bony union and the healing time was 3-9 months (mean, 3.6 months). There was no complication such as incision infection, internal fixation failure, or coxa varus during follow-up. At last follow-up, the Harris score of hip joint was 67-96 (mean, 88.9); among them, 19 cases were excellent, 10 cases were good, 2 cases were fair, and 1 case was poor, with an excellent and good rate of 90.6%. CONCLUSION For the elderly patients with irreducible intertrochanteric femoral fracture, the application of PFNA combined with minimally invasive clamp reduction technique by Kocher pincers can achieve high-quality fracture reduction, which has the advantages of simple reduction operation, less trauma, and can avoid the radiation exposure of operators during maintenance reduction.
Humans ; Male ; Female ; Aged ; Minimally Invasive Surgical Procedures/methods* ; Hip Fractures/diagnostic imaging* ; Bone Nails ; Aged, 80 and over ; Retrospective Studies ; Fracture Fixation, Intramedullary/instrumentation* ; Middle Aged ; Treatment Outcome ; Fracture Fixation, Internal/instrumentation* ; Fracture Healing ; Femoral Fractures/surgery*

OBJECTIVE: To investigate the surgical technique and preliminary effectiveness of closed reduction and internal fixation (CRIF) using antegrade elastic intramedullary nailing (ESIN) via a novel approach through the proximal radius for treating distal radius metaphyseal-diaphyseal junction (DRMDJ) fractures in children. METHODS: A retrospective analysis was conducted on 34 children with DRMDJ fractures who met the selection criteria and were treated between January 2020 and June 2023. There were 21 boys and 13 girls, aged 6-14 years (mean, 8.2 years). Injury causes included falls in 11 cases and sports-related trauma in 23 cases. Twenty-six cases were associated with ipsilateral distal ulnar fractures. All patients had failed initial closed reduction in the outpatient clinic. The time from injury to operation ranged from 1 to 15 days (mean, 4 days). All patients underwent CRIF using antegrade ESIN inserted via a novel approach at the proximal one-third of the radius. The operation time, intraoperative fluoroscopy frequency, fracture healing time, and complications were recorded. Fracture reduction was assessed immediately after operation on anteroposterior and lateral X-ray films for residual translation and angulation. Wrist function was evaluated using the modified Mayo wrist score. RESULTS: Surgery was successfully completed in all 34 children. CRIF with ESIN failed in 2 cases with associated ipsilateral distal ulnar fractures, requiring conversion to open reduction of the ulna. Operation time ranged from 15 to 56 minutes (mean, 21 minutes). Intraoperative fluoroscopy frequency ranged from 5 to 21 times (mean, 7 times). Immediate postoperative X-ray films showed residual translation of 0-15% on anteroposterior view and 0-10% on lateral view, and residual angulation of 0°-5° on both anteroposterior and lateral views. All children were followed up 6-18 months (mean, 12 months). There was no complication such as neurovascular injury, incision infection, or limitation of forearm rotation. Follow-up X-ray films showed no fracture displacement, implant loosening, delayed union, or nonunion. Fracture healing time ranged from 4 to 8 weeks (mean, 6 weeks). Implants were removed at 4-6 months postoperatively (mean, 5 months). At last follow-up, all fractures had achieved anatomic or near-anatomic healing. The modified Mayo wrist score ranged from 80 to 100 (mean, 94), with 27 excellent and 7 good results, yielding an excellent and good rate of 100%. CONCLUSION CRIF using antegrade ESIN via a novel approach through proximal radius is a safe and effective treatment for pediatric DRMDJ fractures, associated with few postoperative complications and excellent restoration of wrist function.
Humans ; Child ; Female ; Male ; Fracture Fixation, Intramedullary/instrumentation* ; Adolescent ; Radius Fractures/diagnostic imaging* ; Retrospective Studies ; Bone Nails ; Treatment Outcome ; Fracture Healing ; Diaphyses/surgery* ; Radius/surgery* ; Operative Time ; Closed Fracture Reduction/methods* ; Ulna Fractures/surgery*

OBJECTIVE: To explore the effectiveness of additional anti-rotation steel plate assisted intramedullary nail technology in treatment of aseptic femoral non-union patients. METHODS: A retrospective analysis was conducted on 21 patients with aseptic femoral non-union who admitted between September 2020 and October 2024 and treated with additional anti-rotation steel plate assisted intramedullary nail technology. There were 17 males and 4 females, aged 25-67 years (mean, 44 years). There were 19 cases of femoral anterograde intramedullary nail fixation, 1 case of femoral retrograde intramedullary nail fixation, and 1 case of steel plate fixation with fatigue fracture. There were 9 cases of hypertrophic non-union and 12 cases of atrophic non-union. All patients had varying degrees of fracture end atrophy/sclerosis. Among them, 20 patients who were fixed with intramedullary nails underwent removal of soft tissue and hardened bone at the fracture end, and cortical treatment resulted in the appearance of "chili sign" at the fracture end. Iliac bone grafting and anti-rotation steel plate fixation were performed. One patient with steel plate fixation was removed the steel palte and fixed with a retrograde intramedullary nail, while the hardened bone at the fracture end was removed, iliac bone grafting and anti-rotation steel plate fixation were performed. Postoperative follow-up observation included the incision healing, maximum knee flexion range of motion, bone healing, length of lower limbs, and subjective satisfaction. The lower extremity functional scale (LEFS) score was used to evaluate the lower limb function. RESULTS: All incisions healed by first intention. All patients were followed up 7-26 months (mean, 15.5 months). At last follow-up, the femoral fracture healed with the obvious callus formation at the fracture end; the maximum knee flexion range of motion was 95°-127° (mean, 112.67°). The LEFS score increased from 29.9±6.7 before operation to 75.9±3.0 at last follow-up, and the difference was significant (t=-29.622, P<0.001). Except for 1 patient who underwent intramedullary nail dynamic treatment before operation and had a lower limb shortening of about 0.9 cm, the other patients had bilateral lower limbs of equal length. All patients had no postoperative infections, mal-union of fractures, deep vein thrombosis, joint stiffness, or other complications. CONCLUSION The use of additional anti-rotation steel plate assisted intramedullary nail technology in the treatment of aseptic femoral non-union not only overcomes the drawbacks of insufficient stability at the fracture end of intramedullary nails, but also overcomes the shortcomings of biased fixation with steel plates. It has the advantages of minimal trauma, effective maintenance of fracture stability, and ideal postoperative functional recovery, making it an effective treatment for aseptic femoral non-union.
Humans ; Male ; Fracture Fixation, Intramedullary/instrumentation* ; Female ; Bone Plates ; Middle Aged ; Adult ; Femoral Fractures/surgery* ; Retrospective Studies ; Bone Nails ; Aged ; Fractures, Ununited/surgery* ; Treatment Outcome ; Bone Transplantation/methods* ; Steel ; Fracture Healing

OBJECTIVE: This review summarized the first 10-year progresses and controversies in the concept of anteromedial cortical support reduction, to provide references for further study and clinical applications. METHODS: Relevant domestic and foreign literature on cortical support reduction was extensively reviewed to summarize the definition of positive, neutral, and negative support, anteromedial cortices at the inferior corner, intraoperative technical tips for fracture reduction, radiographic assessment at different periods, comparison between positive versus neutral and medial versus anterior support, and the clinical efficacy of Chang reduction quality criteria (CRQC) and postoperative stability score. RESULTS: Anteromedial cortical support reduction was only focused on the cortex of anteromedial inferior corner, with no concern the status of lateral wall or lesser trochanter. Anteromedial cortex was seldom involved by fracture comminution, it was thicker, denser, and stronger, and was the key for mechanical buttress of the head-neck fragment to share compression load. Positive, neutral, and negative support were also called "extramedullary, anatomic, and intramedullary reduction", respectively. There was hardly seen parallel cortical apposition, but characterized by some kinds of head-neck rotation, for example 10°-15° flexed rotation for positive cortical contact and support. Due to intraoperative compression and postoperative impaction, the status of cortical support may be changed at different time of radiographic examination. The positive medial cortex support was more reliable with less reduction loss than its neutral counterpart, and the anterior cortex contact was more predictive than the medial cortex for final results. As incorporation the bearing of cortex apposition and using a 4-point score, CRQC demonstrated more efficacy and was gradually accepted and applied in the evaluation of trochanteric fracture reduction quality. Postoperative stability score (8 points) provided a assessment tool for early weight-bearing in safety to prevent mechanical failure. CONCLUSION Anteromedial cortical support reduction is a key point for stability reconstruction in the treatment of trochanteric femur fractures. Evidence has definitely shown that non-negative (positive and neutral) is superior to negative (loss of cortical support). There is a tendency that positive cortex support is superior to neutral, but high quality study with large sample size is needed for a clear conclusion.
Humans ; Femur/diagnostic imaging* ; Fracture Fixation, Internal/methods* ; Hip Fractures/diagnostic imaging* ; Treatment Outcome ; Fracture Fixation, Intramedullary/methods*