505 Failed Femoral Nail with Significant Operative Technical Difficulty: A Practical Solution to Achieve Metalwork Extraction Using Conical Screw Remover

Introduction There is a greater risk of delayed healing and revision surgery in atypical femoral fractures (AFFs). Although non-union in reamed intra-medullary (IM) nailing is relatively uncommon, it can lead to fracture of the nail and present a considerable challenge to the treating surgeon. Case Report We present a case of AFF treated with IM nail fixation. Metalwork failure of the nail prompted removal of distal locking screws and plating of the fracture site at 8 months. Failure of the plate-bone interface 3 months later led to further revision surgery to remove the broken metalwork. We focus on the significant operative difficulty encountered during removal of the failed IM metalwork and provide a novel practical solution to overcome this particular challenge - insertion of a conical cannulated screw remover under fluoroscopy guidance to create an interference fit with the distal segment of the broken nail. Discussion This case is an example of significant and unexpected intra-operative technical difficulty, requiring improvisation and teamwork to manage. We introduce an accessible and uncomplicated alternative to the existing techniques for removal of a broken femoral nail and in doing so hope to benefit peers and colleagues should they encounter similar difficulties in the future.

PROGRESSION OF INFLAMMATORY PROCESSES IN PATIENTS AFTER IM NAILING USING BIOINERT AND BIODEGRADABLE IMPLANTS BASED ON MC-10 MAGNESIUM ALLOY

Summary. Modern medicine widely uses artificial materials to replace damaged tissues and organs. Biodegradable implants should be gradually replaced with living tissue and stay functioning within a specified period, don’t have any negative impact on surrounding tissues and a human body in general. Clinical studies of biochemical values specifying the intensity of inflammatory response to IM nailing with biodegradable implants are of clinical and scientific interest. Task of the study: to substantiate of the use of implants made of biodegradable magnesium alloy MS-10 in the dynamic IM nailing for diaphyseal fractures of the tibia. Materials and methods. The study involved 34 patients with diaphyseal tibial fractures, which resembled surgical treatment (IM nailing). Cannulated intramedullary titanium nails served as a blocking pin. The treatment included closed reposition followed with IM nailing of a tibia. To lock the nail, a screw made of magnesium alloy MS-10 was inserted in a static (round) hole in 16 patients. In 18 patients, a screw made of titanium was inserted into a static hole. The both groups passed blood sampling for studies, before and after the surgery, 2 and 4 weeks, 2 and 4 months after surgery. Biochemical blood tests were to determine the concentration of fibrinogen-monomer complexes in the blood plasma (β-naphthol test). Results. The study of the activity of AST and ALT found it lower (19 and 29%) in patients with biodegradable screws, compared to the group of patients with IM nailing locked with bioinert screws. The situation was similar with ESR, fibrinogen B and total bilirubin in the blood of patients in both groups. Conclusions. The study convincingly proves the expediency of the use of biodegradable material (magnesium alloy MS-10) to produce implants for the IM nailing for the patients with long bones’ fractures.

Preoperative Determination of Tibia Length Using Contralateral Tibial Tubercle-Medial Malleolar Distance (TMD) in Western Part of Nepal

INTRODUCTION Intramedullary (IM) nailing is most commonly preferred for adult tibial shaft fracture. The objective of this study was to find the accuracy of predicting the tibial nail length pre-operatively from contra-lateral tibial tubeorsity to medial malleolar distance (TMD) length. MATERIAL AND METHODS After ethical clearance (UCMS/IRC/239/19) from the Institutional Review Board (IRB) of Universal College of Medical Sciences, all patients with recent fracture of tibia, who fulfilled the inclusion criteria were enrolled in the study and the informed written consent was obtained. The study was conducted on 45 patients of aged more than 15 years who attended Universal College of Medical Sciences Teaching Hospital (UCMS-TH) over a period of one year (Nov 2019 to Oct 2020). The TMD length of contra-lateral leg were measured preoperatively using a measuring tape and the ideal length of IM nail were measured intra-operatively using IM tibial nail under fluoroscopic guidance. RESULTS Analysis showed that majority of patients were males (77.78%) out of total 45 patients. The mean length of TMD length of contra-lateral leg and the ideal length of IM nail were 33.067 ±1.60 and 33.11 ±1.68 respectively. The mean difference between these two measurements was 0.04 (95% CI, -0.64 to 0.72). The significant correlation was found between these two measurements i.e r=0.88 by Pearson’s correlation (95% CI, 0.79 to 0.93), (p<0.001). Most of the TMD length were equal (37.78%) to ideal length of IM nail. CONCLUSION We recommended TMD length measurement of contralateral leg as an excellent anthropometric parameter for preoperative planning.

Intramedullary Nailing for Pathological Fractures of the Proximal Humerus caused by Multiple Myeloma: A Case Report and Literature Review

BackgroundMultiple myeloma bone disease(MMBD) is indicative of multiple myeloma (MM), and it will reduce patient life quality. In addition to oncological, antineoplastic systemic therapy, surgical therapy in patients with MM represents an essential treatment pillar within the framework of supportive therapy measures and is the task of orthopedic tumor surgery. Nevertheless, there are few reports about applying intramedullary (IM) nailing in treating MM-induced proximal humeral fracture to prevent fixation loss. This paper aims to describe a case of pathological fracture of the proximal humerus caused by multiple myeloma effectively treated with IM nailing without removal of tumors and review the current literature.Case presentationThis study reported a 64-year-old male patient complaining of serious left shoulder pain and limited movement. X-ray films showed left proximal humeral fracture accompanying with osteoporosis and bone destruction. During the preoperative examinations, tumor markers, whole-body bone imaging and bone marrow biopsy were performed. The patient was finally diagnosed with multiple myeloma (IgAλ, IIIA/II). After the treatment of pathological fracture with IM nailing, the patient's function recovered and the pain was relieved rapidly. The visual analogue scale (VAS) reduced by 7 points to 2 points postoperatively compared with that preoperatively. Histopathological examination results presented plasma cell myeloma. Next, the patient received chemotherapy in the hematology department. Humeral fracture displayed good union in the 40-month follow-up, with complete healing of fracture, and the clinical outcome was still satisfactory.ConclusionThe pathological fracture of proximal humerus caused by multiple myeloma should be treated by surgery early. IM nail can be used for this kind of fracture without removal of tumors, bone cement augmentation for bone defect or local adjuvant therapy was also employed. Under the combined treatment, the proximal humerus fracture can eventually heal.

Outcome Analysis of Intramedullary Nailing Augmented with Poller Screws for Treating Difficult Reduction Fractures of Femur and Tibia: a Retrospective Cohort Study

Purpose. Poller screws may serve as an adjunctive reduction tool and aid fracture reduction while augmented with intramedullary (IM) nailing for treating diaphyseal or metaphyseal fractures of the femur and tibia. However, there is no consistent conclusion about whether the method of using IM nailing augmented with poller screws is more advantageous than using IM nailing alone. Methods. A total of 96 patients who received IM nailing with or without supportive poller screw for treating long-bone fractures in lower limbs and who experienced difficulties in performing reduction or IM insertion during the surgical process were included in this retrospective cohort study (33 patients with poller screws in group A versus 63 patients without poller screws in group B). Patient demographics including age, gender, and body mass index; injury-related data including fracture location, classification, and injury mechanism; operation-related data including American Society of Anesthesiologists, duration of operation, poller screw time, method of anesthesia, and volume of intraoperative hemorrhage; outcomes including fracture healing time; and incidence of outcomes of nonunion, malunion, infection, and secondary surgical procedures were evaluated. Results. Fracture healing time of patients in group A was significantly shorter than that of group B ( 18.3 ± 4.8 weeks versus 24.3 ± 3.0 weeks, p = 0.023 ). Union rate was higher (100.0% versus 87.3%, p = 0.048 ), and malunion rate and secondary surgical procedure rate were lower (both are 3.0% versus 19.0%, p = 0.031 ) in group A than that of group B. Conclusion. Poller screw augmentation of IM nailing is a favourable option to shorten fracture healing time and to reduce complication rates in terms of nonunion, malunion, and secondary surgical procedure in the treatment of both diaphyseal/metaphyseal fractures of the femur or tibia while compare with those treated by IM nailing alone.

Treatment of a patient with multiple myeloma of the femur

Introduction Multiple myeloma (MM) is a malignant tumor that causes widespread bone damage. The bone is involved in 90 % of MM patients, and 60% of patients develop pathologic fractures. Material and methods We report a case of combined surgical treatment and chemotherapy of a multiple myeloma patient who sustained a pathological diaphyseal fracture of the left femur and later presented with a lytic myeloma lesion in the right femur. Closed reduction and interlocking intramedullary (IM) nailing of the left femur was performed for the patient who was diagnosed with bone destruction in the shaft of the right femur a few months later. The right femur was fixed with interlocking IM nail for prophylaxis. Results The left femur consolidated at 6 months. The patient had no pain in the right femur, and enlargement in the bone destruction was not seen in the femur. The patient could ambulate with a cane with signs of deforming arthritis in the adjacent joints of the lower limbs. Discussion Three common surgical approaches used for bone tumors being complicated or not complicated by a pathologic fracture include nailing/plating, bone replacement and joint arthroplasty. Bone tumor replacement with oncological endoprostheses can be produced in specialized oncological orthopaedic units and is not available with regular trauma and orthopaedic services for different reasons. The operating orthopedic surgeon is to choose the appropriate implant to address the tumor involvement. Conclusion Interlocking IM nailing can be the method of choice for a pathologic fracture or for prophylactic bone fixation with appropriate indications identified with the Mirels's scoring system. Intramedullary nailing offers the advantage of minimally invasive stability for the operated limb and early weight-bearing in contrast to plate fixation treatment for fractures and prophylactic plating.

Intramedullary Nailing for Pathological Fractures of the Proximal Humerus Caused by Multiple Myeloma: A Case Report and Literature Review

Background: Multiple myeloma bone disease(MMBD) is indicative of multiple myeloma (MM), and it will reduce patient life quality. In addition to oncological, antineoplastic systemic therapy, surgical therapy in patients with MM represents an essential treatment pillar within the framework of supportive therapy measures and is the task of orthopedic tumor surgery. Nevertheless, there are few reports about applying intramedullary (IM) nailing in treating MM-induced proximal humeral fracture to prevent fixation loss. This paper aims to describe a case of pathological fracture of the proximal humerus caused by multiple myeloma effectively treated with IM nailing without removal of tumors and review the current literature.Case presentation: This study reported a 64-year-old male patient complaining of serious left shoulder pain and limited movement. X-ray films showed left proximal humeral fracture accompanying with osteoporosis and bone destruction. During the preoperative examinations, tumor markers, whole-body bone imaging and bone marrow biopsy were performed. The patient was finally diagnosed with multiple myeloma (IgAλ, IIIA/II). After the treatment of pathological fracture with IM nailing, the patient's function recovered and the pain was relieved rapidly. The visual analogue scale (VAS) reduced by 7 points to 2 points postoperatively compared with that preoperatively. Histopathological examination results presented plasma cell myeloma. Next, the patient received chemotherapy in the hematology department. Humeral fracture displayed good union in the 40-month follow-up, with complete healing of fracture, and the clinical outcome was still satisfactory.Conclusion: The pathological fracture of proximal humerus caused by multiple myeloma should be treated by surgery early. IM nail can be used for this kind of fracture without removal of tumors, bone cement augmentation for bone defect or local adjuvant therapy was also employed. Under the combined treatment, the proximal humerus fracture can eventually heal.

A Novel Technique to Assess Rotational Deformities in Lower Extremities

Introduction: Rotational deformities following IM nailing of tibia has a reported incidence of as high as 20%. Common techniques to measure deformities following IM nailing of tibia are either based on clinical assessment, plain X-rays or CT-scan comparing the treated leg with the uninjured contralateral side. All these techniques are based on examiners manual calculation inherently subject to bias. Following our previous rigorous motion analysis and symmetry studies on hemi pelvises, femurs and orthopaedic implants, we aimed to introduce a novel fully digital technique to measure rotational deformities in the lower legs.Material and Methods: Following formal institutional approval from the Imperial College, CT images of 10 pairs of human lower legs were retrieved. Images were anonymized and uploaded to a research server. Three dimensional CT images of the lower legs were bilaterally reconstructed. The mirrored images of the left side were merged with the right side proximally as stationary and distally as moving objects. Discrepancies in translation and rotation were automatically calculated.Results: Our study population had a mean age of 54 ± 20 years. There were six males and four females. We observed a greater variation in translation (mm) of Centre of Mass (COM) in sagittal plane (CI: -2.959--.292) which was also presented as rotational difference alongside the antero-posterior direction or Y axis (CI: .370-1.035). In other word the right lower legs in our study were more likely to be in varus compared to the left side. However, there were no statistically significant differences in coronal or axial planes.Conclusion: Using our proposed fully digital technique we found that lower legs of the human adults were symmetrical in axial and coronal plane. We found sagittal plane differences which need further addressing in future using bigger sample size. Our novel recommended technique is fully digital and commercially available. This new technique can be useful in clinical practice addressing rotational deformities following orthopaedic surgical intervention. This new technique can substitute the previously introduced techniques.

DETERMINATION OF THE EFFICACY OF SUPRAPATELLAR APPROACH FOR INTRAMEDULLARY NAILING OF PROXIMAL TIBIAL FRACTURES

Summary. The topicality of the research is predetermined by the high frequency of adverse functional results after PTF (proximal tibial fractures) treatment, like deforming osteoarthritis, contractures, knee joint instability developing fairly often in the distant period and occurring in 5.8% to 28% of cases; disability rate up to 5.9-9.1%. The mater of a traditional approach to an intramedullary nail insertion point versus the suprapatellar one for FPRTB intramedullary nailing is still under discussion. Objective: To specify the efficacy of suprapatellar approach for IM nailing in patients with PTF. Materials and methods: prospective and retrospective analysis of the efficiency of 30 PTF patients’ treatment at the clinic of the State Institution “ITO NAMN of Ukraine” and at the traumatology department of KNMP “Globinskaya CRН” within 2016-2017, using both suprapatellar and traditional accesses. Their outcomes have been evaluated after their fractures consolidation (1 year after the start of the treatment) according to the Neer-Grantham-Shelton scale. Results. The IM nailing from the suprapatellar access has shown itself to be the most efficient method for proximal tibial fractures management. The share of excellent results reached 60%, demonstrating statistically significant difference (p ≤ 0.01) from those of patients cured from a traditional access; there were only 20% of satisfactory results. No poor results were reported. Practical importance: the study proves the expediency of suprapatellar access in IM nailing of PTF and the need for wider implementation of the method within the territory of Ukraine. Conclusions. Considering the low injury rate and ensuring potentially better bone fragments reposition, the suprapatellar access in IM nailing is the most efficient method for PTF management.

Dynamic Hip Screw with Trochanter-Stabilizing Plate Compared with Proximal Femoral Nail Antirotation as a Treatment for Unstable AO/OTA 31-A2 and 31-A3 Intertrochanteric Fractures

Background. The dynamic hip screw (DHS) with the addition of an angular stable trochanter-stabilizing plate (TSP) has been considered the ideal treatment for the unstable intertrochanteric fracture type. However, there have been few comparisons between DHS+TSP augmentation with intramedullary (IM) nailing. The aim of this retrospectively registered study was to compare the clinical outcomes of patients with the unstable type of intertrochanteric fractures treated with DHS+TSP or IM nailing (proximal femoral nail antirotation (PFNA)). Methods. From June 2013 to April 2018, 358 patients with proximal femur fracture AO/OTA type 31A2 and 31A3 treated with PFNA or DHS+TSP and followed for ≥10 months postoperatively were included. The surgical-dependent outcome evaluation included the operation time, intraoperative blood loss, postoperative decrease in hemoglobin, and blood transfusion amount. Functional status was also measured. Radiographic findings and postoperative complications were recorded and analyzed. Result. The operation time was significantly shorter in the DHS+TSP group than that in the PFNA group for both A2 and A3 fractures (A2 type: 84.0 vs.96.4 min; p<0.05; A3 type: 102.4 vs.116.1 min; p<0.05). Postoperative decrease in hemoglobin was more significant in the PFNA group than that in the DHS+TSP group for both fracture types (A2 type: −1.88 vs. −1.29 (mg/dL); p<0.05; A3 type: −1.63 vs. −1.04 (mg/dL); p<0.05). However, the patients treated with DHS+TSP had significantly more residual pain than those treated with PFNA during the final follow-up (Visual Analog Scale score, A2 type: 28.4 vs.23.2; p<0.05; A3 type: 27.5 vs.23.6; p<0.05) and complained of greater implant irritation. Conclusion. We found that DHS+TSP was associated with less operation time and less postoperative decrease in hemoglobin but more residual pain and implant irritation than those of PFNA. As a treatment for unstable intertrochanteric fracture, DHS+TSP provided ideal surgical outcomes which were not inferior to the PFNA.