Is open bone graft always necessary when treating aseptic subtrochanteric nonunion with a reamed intramedullary nail?

Background This study aimed to compare the radiological results between closed nailing without bone graft (BG) and open nailing with BG for aseptic subtrochanteric nonunion and to determine when an open procedure with BG should be considered. Methods In this retrospective study, we investigated patients who underwent surgical intervention for subtrochanteric nonunion between January 2008 and March 2018 in two institutions. Patients with infection, large bone defect, pathologic fracture, open fracture, previous surgery using plate, and follow-up of less than 1 year were excluded. We compared the demographic details and radiological results between patients who underwent the open procedure with BG (BG group) and the closed procedure without BG (non-BG group) as a historical control, and risk factors for the failure of revision surgery were evaluated. Results Thirty-seven patients met the criteria and were divided into the following two groups: the BG group (n=19) who underwent open nailing with BG and the non-BG group (n=18) who underwent closed reamed nailing without BG. The mean degrees of correction of varus and flexion deformity were significantly different (p=0.001, respectively), 6.2° and 2.9° in the BG group and 4.1° and 0.6° in the non-BG group, respectively. Bony union was observed in 17 cases (89.5%) in an average of 7.4 months in the BG group and in 16 cases (88.9%) in 7.6 months in the non-BG group, with no significant differences. The factors that were significantly associated with failure of revision were atypical fracture, two or more previous surgeries, and varus and sagittal anterior angulation. Conclusions The radiological results of closed reamed nailing without BG for subtrochanteric nonunion were satisfactory. In the effort of percutaneous realignment, gap reduction, and intramedullary reaming, the radiological results of closed nailing without BG were not different from those of open nailing with BG; therefore, closed procedure without BG may be an acceptable option in appropriately selected patients.

Local Platelet-rich plasma (PRP) injection for the treatment of Delayed Union after Internal Fixation in Fractures of Long Bones

Introduction: Long bone fractures are among the most common orthopaedic injuries encountered. A fracture that fails to progress to union despite appropriate fixation and absence of complications presents a treatment dilemma to the surgeon. The usual solution of re-fixation with or without bone graft constitutes repeat exposure to surgery and its risks, as well as added morbidity and cost. Recent advances in molecular biology suggest Platelet rich plasma (PRP) may have bone forming potential. This study was done to determine whether PRP has any beneficial role in patients with delayed healing of long bone fractures. Methods: A prospective interventional study was done on patients arriving at the department of orthopaedic surgery of Kathmandu Medical College with delayed union of long bone fractures after internal fixation between January 2014 and January 2017. Patients were treated with local injection of group-matched PRP directly into the fracture gap and were followed-up for six months to check for radiological signs of fracture union. Results: A total of 10 fractures were included in 10 patients that involved four humeri, three tibiae, and three femora. Eight out of the 10 fractures united at a median time of three months after the injection. Two had non-union that required revision surgery. Conclusion: Local Platelet rich plasma injection may constitute a ‘nothing to lose, everything to gain’ intermediate option before a decision for major reoperation on such patients is made.

BIOMECHANICAL EVALUATION OF RECONSTRUCTED EXTENSIVE MANDIBULAR DEFECTS BY DIFFERENT MODELS USING FINITE ELEMENT METHOD

Rehabilitation of major mandibular defects after tumor resection has become a serious challenge for surgeons. In this research, four various models were designed to repair a critical mandibular lateral defect. Biomechanical behavior of the models was assessed by Finite Element Method. These models are including Fibular-Free Flap (FFF), Customized Prosthesis (CP), Tray Implant without Bone Graft (TI-wo-BG), and Tray Implant with Bone Graft (TI-w-BG). FFF is a subset of microvascular free flap technique in which some segments of patient’s fibula bone are used to restore mandibular defects. CP is a hollow and light prosthesis which is fabricated using Additive Manufacturing technology from Ti alloy powder. TI-wo-BG is similar to a crib which is designed according to the geometry of the patient’s mandible. TI-w-BG, in fact, is a TI-wo-BG which is filled with small cortico-cancellous chips in order to benefit potential profit of bone grafting. The chewing operation and loading on the mandible was simulated considering the three mandibular muscular forces including masseter, medial pterygoid, and temporalis. The result of FEM analysis of TI-wo-BG and TI-w-BG showed that in both models, screw number 6 endured a strain of 5684 and 2852[Formula: see text][Formula: see text]m/m which exceeded pathological and mild overload risk, respectively. This may increase the probability of screw loosening and system failure. The results proved the stability of the FFF and CP models. In addition, it can be concluded that stress and strain on the screw’s interfaces can decrease by improving the plate and increasing the friction at the interface of plate, bone and screw.

Secondary osteoarthritis of the knee due to 40-year nonunion of a medial femoral condyle fracture: A case with good outcome without arthroplasty

Isolated femoral condyle fracture is an uncommon entity. It accounts for only 0.65% of all femoral fractures, with lateral condyle involvement three times more frequently than the medial condyle. In neglected cases, nonunion and malalignment may occur, which results in osteoarthritis of the knee due to uneven distribution of load across respective compartments. In treating such cases, both osteoarthritis and nonunion have to be tackled to reconstruct a stable, mobile, pain-free, and well-aligned knee joint. There are a number of surgical options, including excision of the nonunion fragment, fixation of the nonunion fragment with or without bone graft, and total knee arthroplasty with or without stem extension. In the following, we present a case of 40-year non union of the lateral condyle and our rationale of management for a relatively young lady. During the course of treatment, there was an unexpected success even though arthroplasty was not performed. A management strategy for this challenging condition was also suggested.