Treatment outcomes in humeral fractures of different location (review)

The choice of treatment (open reduction and internal fixation) for a humeral fracture with a plate versus an intramedullary nail is highly debated. We compared outcomes (fracture union, reoperation, and adverse events) of intramedullary nailing and plate fixation in patients with proximal humeral, humeral shaft, and distal humeral fractures. No significant differences were found between intramedullary nailing and plate fixation for fracture union, reoperation, or adverse events in patients with proximal humeral or humeral shaft fractures. There is a scarcity of evidence comparing intramedullary nailing and plating for distal humeral fractures. No recommendations can be given from current evidence. Surgeons may have to continue to use discretion based on their personal preference, experience as well as patient’s characteristics and fracture features before more high-quality evidence is available.

RETROGRADE INTRAMEDULLARY SUPRACONDYLAR NAILING AND DISTAL FEMORAL LOCKING COMPRESSION PLATE IN THE MANAGEMENT OF DISTAL FEMUR FRACTURES – A COMPARATIVE STUDY

Objectives: The objective of the study is to assess the efficacy of retrograde intramedullary interlocking supracondylar nailing and distal femoral locking compression plate in the management of distal femur fractures. Methods: The present prospective study consists of a total of 36 cases with extra-articular supracondylar fractures of the femur between the age group of 21–70 years. Participants were randomly allocated to group 1 treated with distal femoral locking compression plate fixation and group 2 treated with retrograde intramedullary interlocking supracondylar nailing technique. Post-operatively, all the cases were followed up in regular intervals to assess the functional outcome using the American Knee Society score. Results: Road traffic accidents (80.56%) were the most common cause of injury. The average surgical duration (108 min and 90.14 min), duration of fracture union (12.48 weeks and 11.08 weeks), and blood loss (339.8 ml and 236.6 ml) was better in the nailing group than the plating group, respectively. The overall outcome was comparable between the two study groups. Conclusion: The supracondylar nailing technique has better functional outcomes in terms of less fracture union time, less operative duration, and minimal operative blood loss. Supracondylar nailing technique was effective and better in soft tissue damage control.

Radiological Assessment of Hip Fracture Union RUSH and Modified RUSH

Objective：Intertrochanteric fracture is a common senile disease, which is mainly treated by surgery. The evaluation of postoperative healing of such fractures has always been based on qualitative evaluation of clinical and radiological indicators. Currently, there are no quantitative evaluations of hip fracture union other than the Radiographic Union Score or Hip (RUSH) score. The aim of this study was to evaluate fracture healing of intertrochanteric fractures treated with intramedullary nailing and plates using RUSH and the modified RUSH score we developed. Methods：We collected a total of 96 patients with surgically treated intertrochanteric fractures, including 46 with lateral plate fixation and 50 with intramedullary nailing. Six orthopedic surgeons assessed the overall impression of fracture union on more than 200 postoperative X-rays without knowing any information, followed by the use of RUSH and modified RUSH to evaluate the x-rays separately to see if the two methods improved the consistency of intertrochanteric fracture union. Results：the consistency of overall fracture healing impression was moderate（ICC=0.487）, RUSH and modified RUSH improved the consistency to substantial（ICC=0.80）and basically perfect（ICC=0.81）, respectively. In addition, for the evaluation of union of all intertrochanteric fractures, the overall score of plate was always higher than that of intramedullary nail. When the lateral plate and intramedullary nail were separately scored, the RUSH score of plate was basically the same as modified RUSH, while the modified RUSH of intramedullary nail was higher than modified RUSH. Ultimately,the medial (r=0.54 and R =0.53) and anterior (r=0.55 and R =0.54) and the global score (R =0.68 and R =0.68) in the single cortex showed a high correlation with the overall fracture healing impression in both RUSH and modified RUSH scores. Ultimately,medial (r=0.54 and r =0.53) and anterior (r=0.55 and r=0.54) in individual cortices and overall scores (r=0.68 and r =0.68) showed a high correlation with overall fracture healing impressions in both RUSH and modified RUSH scores. Conclusions：we developed a new hip fracture score comparable to the RUSH score that significantly improves the consistency of radiographic assessment of intertrochanteric fracture union. Most importantly, modified RUSH filled the callus formation gap in RUSH scores between cortical bridging and no cortical bridging. Therefore, we recommend the use of RUSH or a modified RUSH score to improve orthopedic surgeons' assessment of intertrochanteric fracture union.

Addition of Bone Marrow Aspirate Concentrate Resulted in High Rate of Healing and Good Functional Outcomes in the Treatment of Clavicle Fracture Nonunion: A Retrospective Case Series

Bone marrow aspirate concentrate (BMAC) is an autologous cell composition that is obtained through a needle aspiration from the iliac crest. The purpose of this study was to evaluate the outcomes of patients treated with open reduction and internal fixation with BMAC supplementation for clavicle fracture nonunion. This was a retrospective case series of 21 consecutive patients with clavicle fracture nonunion that were treated with ORIF and BMAC supplementation between 2013 and 2020. Patients were evaluated for fracture union, time to union, complications related to surgical and donor site, and functional outcome using the Quick Disability of the Arm Shoulder and Hand (QDASH), subjective shoulder value (SSV), and pain. The mean age was 41.8 years. The mean follow-up was 36 months. Twenty (95.2%) patients demonstrated fracture union, with a mean time to union of 4.5 months. Good functional scores were achieved: SSV, 74.3; QDASH, 23.3; pain level, 3.1. There were no complications or pain related to the iliac crest donor site. Supplementary BMAC to ORIF in the treatment of clavicle fracture nonunion is a safe method, resulting in high rates of fracture union and good functional outcomes with minimal complications and pain.

A Case of Femoral Neck Insufficiency Fracture due to Tumor-Induced Osteomalacia

Tumor-induced osteomalacia (TIO) is a rare skeletal disease caused by hypersecretion of fibroblast growth factor 23 (FGF-23) from neoplasms of mesenchymal origin; patients with TIO present with insufficiency fractures, progressive bone pain, and delayed fracture unions. Herein, we report the case of a 48-year-old man with an insufficiency fracture in his left femoral neck associated with TIO. The causative tumor located in the patient’s maxillary sinus had been resected; however, complete resection was impossible due to the location of the tumor. Therefore, the patient’s osteomalacia persisted, and he experienced a left femoral neck fracture in the absence of severe trauma. Because delayed fracture union was anticipated in this patient, we performed an internal fixation using an implant with a lateral plate for angular stability and multiple screws for rotational stability. Although fracture union took 15 months, the patient’s postoperative course was uneventful, and he could walk without any symptoms or assistance at his most recent follow-up 30 months after surgery. In TIO, hypersecretion of FGF-23 leads to increased renal excretion of phosphorus, increased bone resorption of calcium and phosphorus, decreased osteoblastic bone mineralization, and decreased gastrointestinal absorption of calcium and phosphorus, leading to insufficiency fractures and delayed fracture unions. Diagnosis of TIO is often delayed due to its rarity and vague symptoms. Total resection of the causative tumor is the optimal treatment; however, in cases wherein complete tumor resection is impossible, drug therapy may be insufficient, and the underlying TIO pathology, including bone fragility, may persist. Early diagnosis of TIO is important for preventing insufficiency fractures; however, when fractures are unavoidable, the surgical treatment of femoral neck fractures in patients with osteomalacia should account for a longer time frame for complete fracture union and therefore utilize implants with sufficient stability.

Effects of vitamin D supplementation on the functional outcome in patients with osteoporotic vertebral compression fracture and vitamin D deficiency

Background In osteoporotic vertebral compression fractures, supplementation using vitamin D preparations and maintenance of blood vitamin D level within the normal range are necessary for proper fracture union, enhancement of muscle strength, and maintenance of body balance. The purpose of this study is to investigate the effects of vitamin D supplementation on blood vitamin D level, pain relief, union time, and functional outcome in patients with osteoporotic vertebral compression fracture and vitamin D deficiency. Methods One hundred thirty patients who were deficient in blood vitamin D level and had osteoporotic vertebral compression fracture were divided into supplementation group and non-supplementation group. Initially, 3 months, 6 months, and 12 months after the injury, radiographs were taken to assess fracture union, and questionnaires were evaluated to evaluate the functional outcome and quality of life. Results The mean age of the 130 patients (36 males and 94 females) was 74.75 ± 7.25 years. There were no statistically significant differences in initial severity of low back pain, functional outcome, and quality of life between the insufficient group and the deficient group (all p values were > 0.05). There was no significant time-by-group interaction between the supplementation group and the non-supplementation group (p = 0.194). In terms of SF-36 physical component score, there was no significant time-by-group interaction between the supplementation group and the non-supplementation group (p = 0.934). Conclusions Fracture union was achieved in all patients regardless of serum vitamin D level, and there were significant improvements in severity of low back pain, functional outcome, and quality of life over 12 months in patients with osteoporotic vertebral compression fracture. Short-term vitamin D supplementation of patients with osteoporotic vertebral compression fracture and deficiency of vitamin D did not result in significant differences in fracture union status, functional outcome, and quality of life between the supplementation groups and the non-supplementation groups of patients.

Intra-medullary antibiotics perfusion (iMAP) for the control of fracture-related infection early after osteosynthesis

Purpose In our hospital, cases of bone and soft tissue infections have been treated with continuous local antibiotics perfusion that allows for continuous circulation of antibiotics throughout the infected lesion. We termed this treatment “intramedullary antibiotics perfusion (iMAP)” for bone infection such as fracture-related infection (FRI) and “intrasoft tissue antibiotics perfusion” for soft tissue infection. Many cases are treated with both modalities. To introduce iMAP, this study focused on the patients with FRI treated with iMAP and reviewed their treatment outcomes. Methods We included 10 patients with FRI treated with iMAP between 2004 and 2017. The iMAP needles were inserted near the infected lesion, and an aminoglycoside antimicrobial was continuously administered. Patient characteristics, pathogenic bacteria, administered antibiotics, duration of administration, concentrations of antibiotics in blood and leachate fluid, fracture union rate, implant retention rate, and complications were studied. Results The mean age of patients was 59.9 years, and the mean follow-up period was 2.5 years. Affected bones were the tibia ( n = 8), humerus ( n = 1), and fibula ( n = 1). Deep infections developed on average 29.9 days after osteosynthesis. Pathogenic bacteria were methicillin-susceptible Staphylococcus aureus ( n = 6), methicillin-resistant S. aureus ( n = 2), and unknown ( n = 2). Average iMAP duration was 17.1 days. In all patients, infection was eradicated while preserving the implants, and fracture union was achieved without complications. Conclusion iMAP is a novel local drug delivery system allowing high concentrations of antibiotics to be administered without complications and is useful in the treatment of FRI.

A PROSPECTIVE FOLLOW UP STUDY OF EVALUATION OF SHOULDER FUNCTION AFTER ANTEGRADE INTERLOCKING NAILING IN HUMERUS SHAFT FRACTURES IN ADULTS

INTRODUCTION: This study was conducted to assess the shoulder function after antegrade interlocking humerus nailing in humerus shaft fractures, duration of union, complications (immediate and late) of this xation. METHODS: In this prospective study 40 cases with humerus shaft fractures were treated with antegrade interlocking humerus nailing and followed up for functional outcomes and complications. RESULTS: The age of patients ranged from 18 to 57 years. The assessment of shoulder function was made according to CONSTANT score. Out of 40 patients shoulder function was excellent in 35 cases (87.5%), very good in 3 cases (7.5%) and fair in 1 case (2.5%). Period of fracture union ranged from 12 to 18 weeks, average period being 13.7 weeks. None had iatrogenic radial nerve injury and/or infection. CONCLUSION: We concluded that Locked intramedullary nailing is a novel treatment option for diaphyseal fractures of the humerus. By making correct entry, repairing rotator cuff, placing the nail inside proximal end and proper physiotherapy; shoulder function outcome can be improved to excellent in cases of humerus diaphyseal fractures treated with antegrade interlocking humerus nailing.

Meta-Analysis of 3D Printing Applications in Traumatic Fractures

Background: Traumatic fracture is a common orthopaedic disease, and application of 3D printing technology in fracture treatment, which entails utilisation of pre-operative printed anatomic fracture model, is increasingly gaining popularity. However, effectiveness of 3D printing-assisted surgery lacks evidence-based findings to support its application.Materials and Methods: Embase, PubMed and Cochrane Library databases were systematically searched until October, 2020 to identify relevant studies. All randomised controlled trials (RCTs) comparing efficacy of 3D printing-assisted surgery vs. conventional surgery for traumatic fractures were reviewed. RevMan V.5.3 software was used to conduct meta-analysis.Results: A total of 12 RCTs involving 641 patients were included. Pooled findings showed that 3D printing-assisted surgery had shorter operation duration [standardised mean difference (SMD) = −1.52, 95% confidence interval (CI) – 1.70 ~ −1.34, P < 0.00001], less intraoperative blood loss (SMD = 1.34, 95% CI 1.74 ~ 0.94, P < 0.00001), fewer intraoperative fluoroscopies (SMD = 1.25, 95% CI 1.64 ~ 0.87, P < 0.00001), shorter fracture union time (SMD = −0.15, 95% CI −0.25 ~ −0.05, P = 0.003), and higher rate of excellent outcomes (OR = 2.40, 95% CI 1.07 ~ 5.37, P = 0.03) compared with conventional surgery. No significant differences in complication rates were observed between the two types of surgery (OR = 0.69, 95% CI 0.69 ~ 1.42, P = 0.32).Conclusions: Indicators including operation duration, intraoperative blood loss, number of intraoperative fluoroscopies, fracture union time, and rates of excellent outcomes showed that 3D printing-assisted surgery is a superior alternative in treatment of traumatic fractures compared with conventional surgery. Moreover, the current study did not report significant differences in incidence of complications between the two approaches.Systematic Review Registration: CRD42021239507.