Management of Non-Prosthetic Peri-Implant Fracture in a Case of Broken Intramedullary Locking Nail - A Rare Case Report and Review of Literature

A non-prosthetic peri-implant fracture (NPPIF) can be defined as a fracture in a bone with an existing non-prosthetic implant such as an extramedullary plate and screws or an intramedullary nail, NPPIFs are mostly reported together with peri-prosthetic fractures (PPFs) that occur around joint replacement implants, but they represent a separate clinical entity with different conceptual and practical considerations1. Our case is a 72-year male with a broken humerus intramedullary Nail in right upper limb who was managed with implant removal and bridge plating with locking plate. The favourable outcome in our case sheds a light in a grey region of non-prosthetic peri implant fractures of upper limbs where no definite management protocol is available. Our patient had very good outcome which was noted by 0/100 on dash scores and complete pain-free range of movement elbow and shoulder. Our case stands as a manifest for NPPIFs of humerus, which can be managed with similar protocol which was used in our case.

Outcomes of Mini-Invasive Arthroscopic Arthrolysis Combined with Locking Screw and/or Intramedullary Nail Extraction after Osteosynthesis of the Proximal Humerus Fracture

Data on the effectiveness of arthroscopic arthrolysis and extraction of osteosynthetic material after osteosynthesis of the proximal humerus in patients with persisting problems are rare and insufficient. In this study, we performed arthroscopic arthrolysis and extraction of fixation screws, and, where protruding, extraction of the nail in 34 patients with problems persisting 12 months after osteosynthesis of the proximal humerus using an intramedullary nail. The effectiveness of the treatment was assessed using the Constant–Murley shoulder score and forward flexion difference between the treated arm and the contralateral one. A median increase of 16 points in CMS score and 30 degrees reduction in the arm forward flexion difference was recorded 12 months after the arthroscopy. The improvement was significantly higher in the patient group with intramedullary nail extraction (however, this group had worse pre-operative values and the screw was only extracted where likely to cause problems). The median time to heal was 11 weeks; no serious peri- or post-procedural complications occurred. Mini-invasive arthroscopic arthrolysis combined with extraction of osteosynthetic material proved to be a safe and effective method for treatment of patients after osteosynthesis of the proximal humerus using an intramedullary nail with persisting pain and/or mobility limitation.

A Novel Mouse Model to Study Fracture Healing of Tibia

Background Delayed union of most tibial fractures due to their special anatomical structures.So an effective animal model is very important to study the mechanism and method of fracture healing.However, due to the small tibia of mice, the operation is difficult, and the surgical model requires high surgical skills. The construction of the fixation model of intramedullary nail for this fracture has improved and simplified the traditional fixation model of intramedullary nail, which not only achieves the purpose of constructing the fracture model, but also makes it more simple and effective.Therefore, the aim of the current study was to develop a new mouse model to study fracture healing of tibia. Methods We chose a combination between an open osteotomy and intramedullary stabilization. The 22G needle was inserted into the fracture end in a closed manner by using an open approach for osteotomy at the middle and lower 1/3 level of the tibia.Fractured tibia were analyzed using microcomputed tomography and histology at days 7,14,21and 28after surgery. All animals displayed normal limb loading and a physio-logical gait pattern within the first three days after fracture. No animals were lost due to surgery or anesthesia. Results X-ray confirmed that the fracture types obtained by the fracture modeling method were transverse fractures. X-ray, Micro-CT, immunohistochemistry, histological staining and Real-time PCR showed that the fracture healing of mice was typical endochondral ossification, with high repeatability. Conclusion The mouse tibial fracture model established by intramedullary nailing is safe, rapid and simple. Its fracture healing is a typical intrachondral ossification with high repeatability, which can be better used for the study of molecular mechanism and clinical transformation of fracture healing and bone metabolism.

Fracture of pubic rami during hip fracture fixation: a rare case of traction table–related injury

We present a case of an elderly and comorbid patient who was scheduled to undergo a hip fracture fixation using an intramedullary nail. Unfortunately, this was delayed by 3 weeks as the patient was unfit to undergo this procedure. She was placed onto the traction table and intraoperatively sustained a superior and inferior pubic rami fracture while attempting reduction on the traction table. Closed-reduction techniques using traction tables and perineal posts are not without morbidity. Risk factors such as osteoporosis and delayed-fixation should be accounted for when managing this complex and often frail group of patients.

Acetabular Migration of Lag Screw of Intramedullary Nail Used as Treatment for Intertrochanteric Fracture. Case Study

Most trochanteric fractures of the femur are classified as low-energy fractures as they are seen in people with decreased mechanical properties of bone tissue. The treatment is assumed to provide biomechanical fixation with the possibility of dynamization between bony fragments to stimulate the biological processes of bone union. The aim of the study was to analyze a complication presenting as migration of the cervical screw of an intra­medullary nail towards the hip joint acetabulum and present the therapeutic management of this complication. The case report concerned a 74-year-old patient with an AO/OTA type 31 A2.2 fracture of the trochanteric massif of the right femur treated with the Gamma3 intramedullary nail. An assessment of changes over time of the radiological appearances on A-P images after the surgery showed migration of the cervical screw towards the acetabulum and displacement of the major trochanter fracture. Extensive destruction of the acetabular fossa made biologic restorative treatment impossible. A total hip joint prosthesis with a modular stem and MDM articulation was implan­ted and the trochanter was fixed with a "hook" plate with a "cable system". The postoperative course was uneventful. Failure to perform axial radiographs in the preoperative and postoperative period made it impossible to objectively determine the type of fracture and the quality of screw insertion into the femoral neck, and assessment limited to A-P images turned out to be deceptive. The wandering of the screw towards the acetabulum led to extensive destruction of the acetabular fossa. The decision to stop biological treatment, which, if properly performed, stimulates bone union, and perform the mechanical procedure of endoprosthesoplasty was fully prognostically justified. The early and late postoperative course was not complicated.

EARLY OUTCOMES OF FLEXIBLE INTRAMEDULLARY NAILING IN PEDIATRIC SHAFT OF FEMUR FRACTURES

Objective: To study the early outcomes and complications of fixation of pediatric shaft of femur fractures using flexible intramedullary nail. Study Design: Prospective observational study. Place and Duration of Study: Orthopedic Department, Bahawal Victoria Hospital Bahawalpur, from Jan to Jun 2021. Methodology: Children between the ages of 5-11 years with shaft of femur fractures were included in the study. Fixation of fracture was done using elastic intramedullary nail. Final outcomes of fixation were observed using Flynn and Schwend Scoring System. Six-month follow-up was done in all cases. Data was analyzed using SPSS-20. Results: Total 70 cases having shaft of femur fracture were included in the study. Age range of cases was 5-11 years with mean age of 7.75 ± 1.66 years and mean weight of 24.44 ± 4.77 kilograms. Mean diameter of femur medullary canal was 7.48 ± 0.63 millimeters and mean diameter of flexible nail was 3.03 ± 0.26 millimeters. Mean post-operative period of radiological union of fracture was 8.57 ± 1.05 weeks. Per-operatively, fracture site was approached in 4 (5.7%) cases. Migration of nail was not seen in any case. Final outcomes according to Flynn and Shwend Score were excellent in 62 (88.5%), satisfactory in 7 (10%) and poor in 1 (1.4%) case. Conclusion: Fixation of shaft of femur fracture using flexible intramedullary nailing technique is safe and reliable with good outcomes among children between 5-11 years of age.