Breakage of intramedullary femoral nailing or femoral plating: how to prevent implant failure

Introduction Intramedullary (IM) fixation is the dominant treatment for pertrochanteric and femoral shaft fractures. In comparison to plate osteosynthesis (PO), IM fixation offers greater biomechanical stability and reduced non-union rates. Due to the minimally invasive nature, IM fixations are less prone to approach-associated complications, such as soft-tissue damage, bleeding or postoperative infection, but they are more prone to fat embolism. A rare but serious complication, however, is implant failure. Thus, the aim of this study was to identify possible risk factors for intramedullary fixation (IMF) and plate osteosynthesis (PO) failure. Materials and methods We searched our trauma surgery database for implant failure, intramedullary and plate osteosynthesis, after proximal—pertrochanteric, subtrochanteric—or femoral shaft fractures between 2011 and 2019. Implant failures in both the IMF and PO groups were included. Demographic data, fracture type, quality of reduction, duration between initial implantation and nail or plate failure, the use of cerclages, intraoperative microbiological samples, sonication, and, if available, histology were collected. Results A total of 24 femoral implant failures were identified: 11 IMFs and 13 POs. The average age of patients in the IM group was 68.2 ± 13.5 years and in the PO group was 65.6 ± 15.0 years, with men being affected in 63.6% and 39.5% of cases, respectively. A proximal femoral nail (PFN) anti-rotation was used in 7 patients, a PFN in one and a gamma nail in two patients. A total of 6 patients required cerclage wires for additional stability. A combined plate and intramedullary fixation was chosen in one patient. Initially, all intramedullary nails were statically locked. Failures were observed 34.1 weeks after the initial surgery on average. Risk factors for implant failure included the application of cerclage wires at the level of the fracture (n = 5, 21%), infection (n = 2, 8%), and the use of an additional sliding screw alongside the femoral neck screw (n = 3, 13%). In all patients, non-union was diagnosed radiographically and clinically after 6 months (n = 24, 100%). In the event of PO failure, the placement of screws within all screw holes, and interprosthetic fixation were recognised as the major causes of failure. Conclusion Intramedullary or plate osteosynthesis remain safe and reliable procedures in the treatment of proximal femoral fractures (pertrochanteric, subtrochanteric and femoral shaft fractures). Nevertheless, the surgeon needs to be aware of several implant-related limitations causing implant breakage. These may include the application of tension band wiring which can lead to a too rigid fixation, or placement of cerclage wires at the fracture site.

Vitamin D Supplementation for Prevention of Dental Implant Failure: A Systematic Review

Background. Many factors play a significant role in osseointegration and healing after dental implant insertion and restoration. Some factors are related to dental biomaterials, such as the dental implant, prosthesis, and grafting materials. Other factors can be connected to operator skills and accumulated experience. Local and systemic patient-related factors are crucial in determining the success of the dental implant. Thorough examination and analysis of local factors using available examination tools are vital to prepare the implant candidate for such treatment. The patient’s systemic condition directly affects the healing of the dental implant. One of the most overlooked systemic factors is the patients’ vitamin D level, which influences bone formation around the implant and subsequent osseointegration. The current review examined the available literature regarding the association between vitamin D supplementation and dental implant osseointegration. Methods. Data of this review were derived from recent research available on PubMed, Google Scholar, and Scopus. Inclusion criteria were the relation between the vitamin D serum and dental implant osseointegration or failure. The Systematic Reviews and Meta-Analyses (PRISMA) checklist was followed to perform the review. The study’s outcome was the need for vitamin D supplementation to prevent implant failure. Results. Five human studies (including case reports, case series, and retrospective studies) and six animal studies. All included studies discussed the relationship between vitamin D, early dental implant failure, and bone implant contact. Three retrospective studies found no significant relationship between vitamin D supplementation and EDIFs in humans. On the other hand, one retrospective study showed a significant relationship in humans. A case report and case series claimed that the implant was successfully placed after vitamin D supplementation. A total of four animal studies showed a significant relationship between vitamin D supplementation and osseointegration of the dental implant. Two animal studies showed no significant association. Conclusion. To ensure optimal treatment outcomes, it is recommended to supplement the patient with vitamin D if the serum level is not within the normal range. Further clinical studies and case reports are needed to confirm the association between serum vitamin D levels and osseointegration.

Visibility of Transcondylar Screw Fractures in Standard and Extended Scale Computed Tomography Images

Objective Application of extended computed tomography scale (ECTS) reconstruction to diagnose metal implant failure has been described in a single case report. The purpose of this study was to compare the features and visibility of humeral transcondylar screw fractures in standard CT scale (SCTS) and ECTS images. Study Design Case series: CT images of dogs with fractured transcondylar screws were retrospectively reviewed and described in both SCTS and ECTS images. Results Five dogs with a total of six transcondylar screw failures (five right and one bilateral) were reviewed. All cases had an ongoing humeral intercondylar fissure with varying degrees of stress remodelling. The fracture was seen in all screws on ECTS images, however only in three implants on SCTS images. The measured fracture gap was larger in ECTS images in all cases (range: + 0.14 mm to + 0.28mm). The three smallest fracture gaps were not seen on SCTS images. A subtle hypoattenuating streak (artefact) was visible adjacent to the screw fracture in 5/6 of cases using SCTS images. All screw fractures occurred parallel and often slightly medial to the humeral intercondylar fissure. Conclusion Implant failure is only seen with larger fracture gaps in SCTS images, with 3/6 screw fractures not visible in SCTS compared with ECTS. A hypoattenuating streak extending perpendicular to the implant in SCTS images is suggestive of screw fracture even if this is not directly visible.

Smoking and Dental Implants: A Systematic Review and Meta-Analysis

Background and Objectives: Tobacco is today the single most preventable cause of death, being associated with countless diseases, including cancer and neurological, cardiovascular, and respiratory diseases. Smoking also brings negative consequences to oral health, potentially impairing treatment with dental implants. The present review aimed to evaluate the influence of smoking on dental implant failure rates and marginal bone loss (MBL). Materials and Methods: Electronic search was undertaken in three databases, plus a manual search of journals. Meta-analyses were performed, in addition to meta-regressions, in order to verify how the odds ratio (OR) and MBL were associated with follow-up time. Results: The review included 292 publications. Altogether, there were 35,511 and 114,597 implants placed in smokers and in non-smokers, respectively. Pairwise meta-analysis showed that implants in smokers had a higher failure risk in comparison with non-smokers (OR 2.402, p < 0.001). The difference in implant failure between the groups was statistically significant in the maxilla (OR 2.910, p < 0.001), as well as in the mandible (OR 2.866, p < 0.001). The MBL mean difference (MD) between the groups was 0.580 mm (p < 0.001). There was an estimated decrease of 0.001 in OR (p = 0.566) and increase of 0.004 mm (p = 0.279) in the MBL MD between groups for every additional month of follow-up, although without statistical significance. Therefore, there was no clear influence of the follow-up on the effect size (OR) and on MBL MD between groups. Conclusions: Implants placed in smokers present a 140.2% higher risk of failure than implants placed in non-smokers.

Influence of Timing of Postoperative Weight-Bearing on Implant Failure Rate Among Older Patients With Intertrochanteric Hip Fractures: A Propensity Score Matching Cohort Study

Introduction: The purpose of this study was to determine whether immediate weight-bearing as tolerated increased the risk of implant failure and decreased functional outcomes compared with restricted weight-bearing.Methods: From January 2010 to December 2018, 1,125 consecutive patients (≥65 years) with intertrochanteric fractures were identified. Of them, 130 patients were excluded, resulting in 995 patients in final cohort (563 receiving immediate weight-bearing and 432 receiving restricted weight-bearing). Propensity score (PS) matching yielded 403 patient pairs. Primary outcome was implant failure at 12 months. Secondary outcomes were implant failure at 3 months, functional outcomes at 12 months, and time to full weight-bearing.Results: Among 806 patients who were matched by PS, the mean age was 77.8 years (SD, 7.6), and 603 patients (74.8%) were women. After matching, there was no significant difference between immediate (10.0% [39/389]) and restricted (9.1%, [35/385]) weight-bearing for implant failure at 12 months (absolute risk difference, 0.93% [95% CI, −3.26 to 5.13%]; RR, 1.11 [95% CI, 0.69 to 1.80]; p = 0.66). Additionally, no significant difference was seen for implant failure at 3 months and functional outcomes at 12 months. Patients with immediate weight-bearing had shorter time to full weight-bearing (mean [SD], 87.6 days [7.5] vs. 121.3 days [11.0]; mean difference, −33.7 [95% CI, −35.0 to −32.3]; p &lt; 0.001).Conclusions: Among older patients with intertrochanteric fractures, receipt of immediate weight-bearing as tolerated did not increase risks of implant failure or worsen functional outcomes compared with receipt of restricted weight-bearing. However, patients receiving immediate weight-bearing had a shorter time to full weight-bearing.

Dental Implants Inserted in Fresh Extraction Sockets versus Healed Sites: A Systematic Review and Meta-Analysis

The present review aimed to evaluate the difference of dental implant failure rates and marginal bone loss (MBL) between implants inserted in fresh extraction sockets or healed sites. Electronic search was undertaken in three databases, plus manual search of journals, including studies randomized or not. Meta-analyses were performed besides meta-regressions, in order to verify how the odds ratio (OR) and MBL were associated with follow-up time. The review included 163 publications. Altogether, there were 17,278 and 38,738 implants placed in fresh extraction sockets and healed sites, respectively. Pairwise meta-analyses showed that implants in sockets had a higher failure risk in comparison to healed sites: OR 1.349, all studies included; OR 2.070, only prospective non-RCTs; OR 2.487, only RCTs (all p < 0.001). The difference in implant failure between the groups was statistically significant in the maxilla (OR 1.616, p = 0.029), but not in the mandible (OR 2.192, p = 0.075). The MBL mean difference (MD) between the groups was −0.053 mm (p = 0.089). There was an estimated decrease of 0.003 in OR (p = 0.284) and an increase of 0.006 mm (p = 0.036) in the MBL MD between groups for every additional month of follow-up. In conclusion, implants placed in fresh extraction sockets present higher risk of failure than implants placed in healed sites.

Application of Antimicrobial Peptides on Biomedical Implants: Three Ways to Pursue Peptide Coatings

Biofilm formation and inflammations are number one reasons of implant failure and cause a severe number of postoperative complications every year. To functionalize implant surfaces with antibiotic agents provides perspectives to minimize and/or prevent bacterial adhesion and proliferation. In recent years, antimicrobial peptides (AMP) have been evolved as promising alternatives to commonly used antibiotics, and have been seen as potent candidates for antimicrobial surface coatings. This review aims to summarize recent developments in this field and to highlight examples of the most common techniques used for preparing such AMP-based medical devices. We will report on three different ways to pursue peptide coatings, using either binding sequences (primary approach), linker layers (secondary approach), or loading in matrixes which offer a defined release (tertiary approach). All of them will be discussed in the light of current research in this area.