Treatment of FRI after intramedullary nailing of tibia fractures: assessment of nail retention and nail removal

Objectives: Fracture related infection (FRI) is a severe, potentially limb-threatening complication after fracture fixation. Dilemma exists with regard to removing or retaining implants while treating the infection. The purpose of this study was to compare primary bone union and infection clearance in patients who had an infection following intramedullary nailing of the tibia treated either by retaining the implant or by removing the implant. Methods: Patients from two level-I trauma centers were identified through billing registries and retrospectively reviewed between January 2013 and December 2020. We identified 44 patients who had a diagnosis of FRI within 90 days of their initial fixation and returned to the OR for operative treatment of the infection. The incidences of both primary union and infection clearance were calculated for both groups and multiple parameters that may be associated with success or failure were assessed. Results: Four patients did not have complete records and were excluded. Of the remaining patients, 20 (50%) achieved infection clearance. Twenty-three (59%) patients achieved primary union whereas 16 (41%) had a primary outcome of either delayed union, nonunion, or amputation (one additional patient excluded as healing status unknown). Further analysis showed no significant difference (X2 (39) = 1.13, p < .29) in infection clearance between patients treated with nail retention (64%) versus nail removal (68%). No significant difference was seen in primary bone union (X2 (39) = 3.24, p < .07) with 36% of patients treated with nail retention and 68% of patients treated with nail removal reaching primary union; however, this does trend toward an association. Fewer surgeries performed for infection and complication after initial fixation was positively associated with infection clearance (p < .04, M=4.6, SD=2.13, df=39) and primary union (p < .001, M=4, SD=2, df=38). Conclusion: Infection clearance seems similarly possible with both nail retention and nail removal strategies, with fewer number of surgeries performed for infection and complication improving the likelihood of infection clearance and bone union. This may suggest that more severe FRI’s are less likely to unite and clear infection. Nail removal may play a role in increasing primary bone union; however, a larger sample size is needed for more definitive assessment.

Application of the “telescopic rod” in a combined surgical technique for the treatment of congenital pseudarthrosis of the tibia in children

Background The current surgical treatment of choice is the combination surgical technique, involving tibial intramedullary fixation to maintain the mechanical axis and mechanical stability of tibial pseudarthrosis. In traditional combined surgery, the Williams rod is often used. Long-term intramedullary fixation of the foot and ankle will affect the ankle joint function of children. The intramedullary rod is relatively shorter due to the growth of the distal tibia. In addition, there are some complications such as epiphyseal bone bridge and high-arched foot. The use of a telescopic intramedullary rod may avoid these complications. Purposes To investigate the initial effect of the “telescopic rod” in a combined surgical technique for the treatment of congenital pseudarthrosis of the tibia in children. Methods A retrospective study including 15 patients with Crawford type IV CPT who were treated using a combined surgical technique and the telescopic rod from January 2017 to May 2018. The average age at the time of surgery was 43.3 months (16–126 months). Of the 15 patients, 7 had proximal tibia dysplasia and 12 exhibited neurofibromatosis type 1. The combined surgical technique using the telescopic rod included the excision of pseudarthrosis, intramedullary rod insertion, installation of Ilizarov’s fixator, tibia-fibular cross union, and wrapping autogenic iliac bone graft. The incidence of refracture, ankle valgus, tibial valgus, and limb length discrepancy (LLD) in patients were investigated. Results All patients achieved primary union with an average follow-up time of 37.3 months (26–42 months). The mean primary union time was 4.5 months (4.0–5.6 months). Nine cases showed LLD (60%), with an average limb length of 1.1 cm (0.5–2.0 cm). Ankle valgus, proximal tibial valgus, telescopic rod displacement, and epiphyseal plate tethering occurred in 1 case (6.6%) (18°), 3 cases (20%) (10°, 5°, and 6°, respectively), 6 cases (40%), and 2 cases (13%), respectively. There were no refractures during the follow-up periods. Conclusion Although there are complications such as intramedullary rod displacement while using the telescopic rod in a combined surgery, the primary healing rate of congenital pseudarthrosis of the tibia in children is high.

Efficacy of the “Eiffel tower” double titanium elastic nailing in combined management of congenital pseudarthrosis of the tibia: preliminary outcomes of 17 cases with review of literature

Background Difficulty in obtaining union, recurrent fractures, and residual deformities remain the problems challenging the management of congenital pseudarthrosis of the tibia (CPT). We applied the “Eiffel Tower” double titanium elastic nails (TENs) in the existing combined approach, which takes advantages of TEN’s mechanical stability with the protection against refracture, Ilizarov’s high fusion rate with alignment control and the biologic environment provided by bone grafting for bony union. The results of this procedure are presented and discussed. Methods Seventeen patients with CPT treated by combined surgery including pseudarthrosis resection, the “Eiffel Tower” double TENs technique, autogenous iliac bone grafting, and Ilizarov fixation between 2013 and 2019 were retrospectively investigated. Signs of bone union, limb length discrepancy (LLD), rate of refracture, and degree of residual deformities were reviewed. The AOFAS Ankle Hindfoot scale and measurement of ankle motion were used to evaluate ankle function. The mean follow-up time was 40.5 (11 to 91) months. Results The mean age at index surgery was 6.2 (2.5 to 15) years. Union of the pseudarthrosis was achieved in 100% of cases. Among them, 15 (88.2%) patients obtained union of the pseudarthrosis on the first attempt (primary union). The average time to primary union was 3.8 (2 to 6) months. The rest 2 cases achieved union after additional surgeries (secondary union). In terms of complications, refracture occurred in 2 patients (11.8%) and 4 patients (23.5%) developed pin infection. The mean limb length discrepancy at the final follow up was 33.4 (6–141) mm. The average AOFAS score improved from 38.2 (27 to 51) pre-operatively to 77 (63 to 87) post-operatively (p < 0.01). Conclusions The “Eiffel Tower” double TENs technique is an ideal intramedullary fixation method in the surgical treatment of CPT. The combination of TENs technique with bone grafting and Ilizarov fixation has the advantages of early bone union, less injury on metaphysis, and early functional recovery. Level of evidence Level IV.

Private Enforcement of the EU Rules on Competition – Nullity Neglected

Private enforcement of the European Union’s rules on competition (Arts. 101, 102 TFEU) has become prominent as a counterpart to their public enforcement. Mostly, it is identified with tort actions brought under EU-harmonized national law by individuals claiming compensation for the harm suffered from anticompetitive agreements or practices. However, claims for compensation represent imperfect sanctions for the infringement of the competition rules because they are brought only once the damage is done and at a time when the conditions of competition may have changed. Typically also, such private actions are no equivalent or complement to administrative enforcement, but are largely dependent on it (follow-on actions). In addition, bringing them is attractive only if the damage suffered is considerable, sufficient evidence available, and the defendant solvent enough. Therefore, this paper revisits the first line of private enforcement, which is enforcing the nullity of anticompetitive agreements as provided for directly by primary Union law in Art. 101(2) TFEU. Nullity was a much-discussed issue under the authorization regime of Reg. 17/62, the first regulation implementing the enforcement of the competition rules, but has become somewhat neglected as a sanction since Reg. 1/2003 changed the enforcement system. Yet, it is precisely under the regime of immediate and direct applicability of both Arts. 101(1) and 101(3) TFEU, which Reg. 1/2003 reestablished, that the potential of nullity as a sanction of anticompetitive agreements could be fully activated. Such active use of invalidity challenges may lead to redefining the interface between EU law and national contract law, which is the line of severability of the innocent parts of a restrictive agreement from its anti-competitive parts. It should also result in reassessing the legal fate of follow-on transactions concluded by a party to an anticompetitive agreement with third parties, and it should bring abusive contracts within the realm of the nullity sanction that dominant firms impose on third parties. The guiding principle for such general reappraisal of the nullity sanction must be to bring its purpose fully to bear, which is to facilitate exit from anticompetitive agreements or from (abusive) contract clauses with a view to reopening competition and/or to allow the renegotiating of a transaction in terms of undistorted competition. This may mean that only the party whose freedom of competition is restricted may claim nullity.

Możliwości zablokowania ustanowienia powiązania budżetu Unii Europejskiej z praworządnością

The new regime of conditionality for the protection of the rule of law, understood as the rule of law (new conditionality), appears to be contrary to the European Union Treaties, in particular because its essential provisions are incompatible with the requirement of legal certainty which underlies the rule of law. This conditionality is based on financial liability for the risk of illegality, that is, in sum, for lawful acts of a Member State which may possibly turn out to be unlawful, but after financial sanctions have already been applied. This publication deals with the identification and management of legal risks that give rise to financial risks. After characterising the basic EU budgetary instruments on the basis of the acquis of economic and legal sciences (which implies the application of the external integration method), using a dogmatic method, the author discusses the possibility of blocking by a Member State the introduction into EU law of a mechanism binding the budget with the broadly understood rule of law in connection with the signalled incompatibilities of the new conditionality mechanism with primary Union law. The aim of the paper is to answer the question of what legal possibilities an individual Member State has to counteract a Union regulation prima facie incompatible with the rule of law, apart from challenging the regulation before the Court of Justice (review of the legality of legal acts), on the assumption that the rule of law imposes an obligation to first counteract bad legislation (decent legislation as an element of the rule of law) and only as a last resort to lodge a complaint with the Court against a given act of derived Union law.

Prebent Titanium Elastic Nailing, Ilizarov Fixation and Bone Grafting for Treating Congenital Pseudarthrosis of the Tibia: Preliminary Outcomes of 15 Cases

Background: To report the preliminary outcome of treating congenital pseudarthrosis of the tibia (CPT) by using titanium elastic nails (TENs) combined with other surgical procedures including pseudarthrosis resection, autogenous iliac bone grafting and Ilizarov technique, with a mean follow-up time of 4.5 (3.3 to 6.3) years.Methods: 15 patients with CPT treated by combined surgery including pseudarthrosis resection, titanium elastic nails (TENs) technique, autogenous iliac bone grafting and Ilizarov fixation between 2013 and 2017 were retrospectively investigated. Signs of bone union, limb length discrepancy (LLD), rate of refracture and degree of residual deformities were reviewed. The AOFAS Ankle Hindfoot scale and measurement of ankle movement were used to evaluate ankle function. Results: The mean age at index surgery was 110 (24 to 285) months. 13 (86.7 %) patients obtained union of the pseudarthrosis on the first attempt (primary union). The average time to primary union was 4.8 (3 to 7) months. The rest 2 cases achieved union after additional surgeries (secondary union). In terms of complications, refracture occurred in 2 patients (13.3%) and 5 (33.3%) patients developed pin infection. The mean limb length discrepancy at the final follow up was 14.6 (4–41) mm. 3 patients (20 %) had ankle valgus deformities with a mean LDTA of 74.3° (range, 68 to 81°). The average AOFAS score improved from 40.3 (27 to 51) pre-operatively to 76.1 (63 to 87) post-operatively. For the patients who received proximal tibial lengthening, the average healing index (HI) was 65.1 (57.3 to 77.8) days/cm.Conclusions: Titanium elastic nails (TENs) technique is an ideal intramedullary fixation method in the surgical treatment of CPT. The combination of TENs technique with bone grafting and Ilizarov fixation has the advantages of early bone union, less injury on metaphyseal and early functional recovery.

Thoughts about indexing family benefits: Are authorities permitted to apply the Austrian indexation of family benefits? The primacy of EU law and the right/obligation to request a ruling from the Court of Justice of the European Union

Austria amended legislation, adjusting family benefits such as the family allowance and the deductible family allowance amount to the (lower) price level indices for consumer goods and services (indexation) of the State of residence of the child. This case is not a unique case. In the European Union, similar endeavours were envisaged in several Member States. The Austrian legislation, however, is now being challenged before the CJEU. In the authors’ opinion, this unsuitable cost-saving budget measure contradicts Union law. Consequently, the provisions concerned must remain unapplied. After all, since the Austrian legislation is obviously incompatible with primary Union law, authorities or courts are not even required to refer the matter to the CJEU.

Congenital pseudarthrosis of the tibia: biological and biomechanical considerations to achieve union and prevent refracture

Congenital pseudarthrosis of the tibia (CPT) is likely to be a primary periosteal disease and secondary bone disease. The primary goal of treatment is to obtain union, correct the diaphyseal deformity, correct any proximal fibular migration and prevent refracture. The pathobiology demonstrates increased osteoclasis by the surrounding fibrous hamartoma and reduced osteogenesis and bone morphogenic protein production by the bone. This leads to a loss of remodelling potential and gradual bowing and atrophy of the bone with eventual fracture of the tibia and or fibula. This recommends the synergistic use of bisphosphonates and bone morphogenic protein. The pathomechanics of CPT implicate the anterolateral bowing, narrow diameter of the atrophic bone ends and proximal fibular migration. These biomechanical factors can be addressed by means of straightening of the deformity, intramedullary support of both bones, stable fixation and reduction of proximal migration of the fibula. A summary of the literature on CPT shows that the mean probability of achieving primary union without refracture, by most treatments is 50% (12% to 80%). Two recent studies have shown a much higher success rate approaching 100%, by creating a cross-union between the tibia and fibula. The cross-union with intramedullary reinforcement of the bone makes refracture unlikely due to the cross-sectional area of union with its two-bar linkage. A new classification to guide such treatment is also proposed. Level of Evidence V – expert opinion