BACKGROUND: It\'s difficult to treat segmental tibial fractures (STFs), which are intricate injuries associated with significant soft tissue damage. The aim of this study was to compare the clinical effect of hexaxial external fixator (HEF) and intramedullary nail (IMN) in treatment of STFs.
METHODS: A total of 42 patients with STFs were finally recruited between January 2018 and June 2022. There were 25 males and 17 females with age range of 20 to 60 years. All fractures were classified as type 42C2 using the Arbeitsgemeinschaftfür Osteosythese/Orthopaedic Trauma Association (AO/OTA) classification. 22 patients were treated with HEF and 20 patients were treated with IMN. The condition of vascular and neural injuries, time of full weight bearing, bone union time and infection rate were documented and analyzed between the two groups. The mechanical medial proximal tibial angle (mMPTA), mechanical posterior proximal tibial angle (mPPTA), mechanical lateral distal tibial angle (mLDTA), mechanical anterior distal tibial angle (mADTA), hospital for special surgery (HSS) knee joint score, American Orthopaedic Foot and Ankle Society (AOFAS) ankle joint score, range of motion (ROM) of flexion of keen joint and ROM of plantar flexion and dorsal flexion of ankle joint were compared between the two groups at the last clinical visit.
RESULTS: There were no vascular and neural injuries or other severe complications in both groups. All 22 patients in HEF group underwent closed reduction but 3 patients in IMN group were treated by open reduction. The time of full weight bearing was (11.3 ± 3.2) days in HEF group and (67.8 ± 5.8) days in IMN group(P < 0.05), with bone union time for (6.9 ± 0.8) months and (7.7 ± 1.4) months, respectively(P < 0.05). There was no deep infection in both groups. In the HEF group and IMN group, mMPTA was (86.9 ± 1.5)° and (89.7 ± 1.8)°(P < 0.05), mPPTA was (80.8 ± 1.9)° and (78.6 ± 2.0)°(P < 0.05), mLDTA was (88.5 ± 1.7)° and (90.3 ± 1.7)°(P < 0.05), while mADTA was (80.8 ± 1.5)° and (78.4 ± 1.3)°(P < 0.05). No significant differences were found between the two groups at the last clinical visit concerning HSS knee joint score and AOFAS ankle joint score, ROM of flexion of keen joint and ROM of plantar flexion of ankle joint (P > 0.05). The ROM of dorsal flexion of ankle joint in IMN group was (30.4 ± 3.5)°, better than (21.6 ± 2.8)° in HEF group (P < 0.05).
CONCLUSIONS: In terms of final clinical outcomes, the use of either HEF or IMN for STFs can achieve good therapeutic effects. While HEF is superior to IMN in terms of completely closed reduction, early full weight bearing, early bone union and alignment. Nevertheless, HEF has a greater impact on the ROM of dorsal flexion of the ankle joint, and much more care and adjustment are needed for the patients than IMN.

Intramedullary spinal cord tumors are challenging to resect, and their postoperative neurological outcomes are often difficult to predict, with few studies assessing this outcome.
We reviewed the medical records of all patients surgically treated for Intramedullary spinal cord tumors at our multisite tertiary care institution (Mayo Clinic Arizona, Mayo Clinic Florida, Mayo Clinic Rochester) between June 2002 and May 2020. Variables that were significant in the univariate analyses were included in a multivariate logistic regression. \"MissForest\" operating on the Random Forest algorithm, was used for data imputation, and K-prototype was used for data clustering. Heatmaps were added to show correlations between postoperative neurological deficit and all other included variables. Shapley Additive exPlanations were implemented to understand each feature\'s importance.
Our query resulted in 315 patients, with 160 meeting the inclusion criteria. There were 53 patients with astrocytoma, 66 with ependymoma, and 41 with hemangioblastoma. The mean age (standard deviation) was 42.3 (17.5), and 48.1% of patients were women (n = 77/160). Multivariate analysis revealed that pathologic grade >3 (OR = 1.55; CI = [0.67, 3.58], P = 0.046 predicted a new neurological deficit. Random Forest algorithm (supervised machine learning) found age, use of neuromonitoring, histology of the tumor, performing a midline myelotomy, and tumor location to be the most important predictors of new postoperative neurological deficits.
Tumor grade/histology, age, use of neuromonitoring, and myelotomy type appeared to be most predictive of postoperative neurological deficits. These results can be used to better inform patients of perioperative risk.

BACKGROUND: Tibial shaft fractures are common injuries that can be treated with various methods, including interlocked intramedullary nail (IMN). However, there is limited data on the clinical outcomes of IMN for tibial shaft fractures in Yemen.
OBJECTIVE: To evaluate the clinical outcomes of primary IMN for tibial shaft fractures in Yemen.
METHODS: This was a prospective study of 134 patients who underwent primary IMN for tibial shaft fractures et al.-Thawra Modern General Hospital in Sana\'a, Yemen, between June 2016 and June 2020. The patients were between 18 and 70 years old, and the fractures were classified according to the AO classification system. The fractures were treated with IMN using a standard technique. The patients were followed up for a minimum of 2 years. The outcome measures included union time, complications, and functional scores.
RESULTS: The mean union time was 17 weeks. The overall complication rate was 18.7%. The most common complications were infection (8.2%), delayed union (6.7%), and nonunion (3.7%). The mean functional scores at the final follow-up were 91.4 for the Knee Society Score and 90.2 for the American Orthopaedic Foot and Ankle Society Score.
CONCLUSIONS: Primary IMN is an effective and reliable method for treating tibial shaft fractures in Yemen, with acceptable union time, complication rate, and functional outcomes.

UNASSIGNED: There is as yet a paucity of data on intramedullary spinal cord tumours (IMSCTs) in sub-Saharan Africa. This study aims to define the clinical profile and outcome of management of IMSCTs in a Nigerian tertiary hospital.
UNASSIGNED: This is a retrospective study of all the patients who had surgery for IMSCTs in our hospital over a 14 year period.
UNASSIGNED: There were 20 patients, 9 males, 11 females, in this study. The median age was 33 years (range = 7-78 years). The median duration of symptoms was 12 months (range = 1-120 months). Motor deficit was present in all but one (95%) of our patients. Only 25% of the patients presented in good functional status (McCormick grades I and II). The tumours were confined to the thoracic region in 10 patients (50%), while tumours in the thoracic region extending to the adjoining cervical and lumbar regions were seen in 6 patients (30%). Gross total tumour resection was achieved in 60% of the patients and subtotal resection in the remaining 40%. Astrocytoma and ependymoma were the most common tumours, each occurring in 35% of the cases. Six patients (30.0%) improved, 12 patients (60.0%) remained neurologically the same, while 2 patients (10.0%) deteriorated at the time of last follow up. The mortality rate was 15%. The preoperative functional status was a significant predictor of postoperative outcome (p = 0.03).
UNASSIGNED: Astrocytoma and ependymoma were the most common histological tumour types among our patients. Late presentation and poor pre-operative functional status were prominent features of our patients\' cohort.

OBJECTIVE: Although cerebrospinal fluid (CSF)-based liquid biopsy was proved to be practical in molecular analysis of intracranial gliomas, liquid biopsy of primary intramedullary astrocytoma was rarely reported. Given the distinct genomic profiles between primary intramedullary glioma and intracranial astrocytoma, whether the feasibility of CSF-based molecular analysis of intracranial gliomas can be replicated in primary spinal cord astrocytoma needs to be investigated. The aim of this pilot study is to evaluate the feasibility of molecular analysis of primary intramedullary astrocytoma through sequencing CSF-derived circulating tumor DNA (ctDNA).
METHODS: Two grade IV diffuse midline gliomas, 1 grade II, and 1 grade I astrocytoma were included. Intraoperative collection of peripheral blood and CSF samples was conducted, along with postoperative collection of matched tumor tissues. A panel covering the 1,021 most common driver genes of solid tumors was used for targeted DNA sequencing.
RESULTS: CSF-derived ctDNA was detected in 3 CSF samples (2 grade IV diffuse midline gliomas and 1 grade I astrocytoma), 5 mutations were found in both tumor tissues and CSF samples, while 11 mutations and 20 mutations were detected exclusively in tumor tissues and CSF samples, respectively. Importantly, hotspot genetic alterations, including H3F3A K28M, TP53, and ATRX, were identified in CSF and the average mutant allele frequency was often higher in CSF than in tumor tissues.
CONCLUSIONS: CSF-based liquid biopsy showed potential feasibility for molecular analysis of primary intramedullary astrocytoma through sequencing of ctDNA. This approach may assist in diagnosis and prognostic evaluation of this rare spinal cord tumor.

OBJECTIVE: This study evaluated the efficacy of continuous passive motion (CPM) versus conventional physical therapy (CPT) in the early postoperative period following retrograde femoral nailing (RFILN). Based on the principles of operation of CPM, we hypothesized that it would improve knee function and decrease pain after open reduction and internal fixation with a retrograde femoral interlocking nail.
METHODS: Eighty-eight patients over the age of 18 years who met the inclusion criteria got randomized into one of two groups. The experimental group had CPM, while the control group had CPT. Postoperative knee functions assessed were the degree of knee stiffness, the total arc of motion, and knee pain. Knee stiffness, defined as the range of motion ≤ 90° assessed one week, two weeks, and six weeks postoperatively, while knee pain was measured using the visual analog scale (VAS) on days one, two, three, four, five, six and seven postoperatively.
RESULTS: The CPM group had a significantly lower incidence of knee stiffness at one week, two weeks, and six weeks postoperatively than the CPT group (all p < 0.0001). The VAS scores of the CPM group on days one, two, three, four, five, six and seven were significantly lower than those of the CPT group (p < 0.006 for day one and p < 0.001 for the remaining days). Similarly, the total arc of motion gained postoperatively was significantly greater in the CPM group than in the CPT (all p < 0.001).
CONCLUSIONS: The continuous passive motion effectively reduced the number of patients with knee stiffness and knee pain. It increased the total arc of motion in the early postoperative period compared to CPT. Therefore, we recommend CPM for patients undergoing retrograde femoral nailing use in the early postoperative period.

OBJECTIVE: Reverse oblique (RO) and transverse intertrochanteric fracture patterns constitute a challenge for the operating surgeon. Currently, no gold standard fixation method exists. This study aimed to retrospectively compare proximal femoral nail (PFN) to dynamic condylar screw (DCS) plating in the treatment of RO and transverse intertrochanteric fractures.
METHODS: A total of 61 patients fixated by PFN or DCS were included. Of these, 36 were treated with PFN (21 females and 15 males; mean age: 65.52 years), and 25 were treated with DCS (12 females and 13 males; mean age: 59.36 years). The mean follow-up time was 33.8 and 42.6 months (range: 24-108). Radiological evaluation included the quality of fracture reduction, neck-shaft angle change, posteromedial support presence, and bone union time. Complications such as mechanical failure, nonunion, and infection were noted.
RESULTS: The only significant differences between the fixation methods were the superiority of DCS over PFN in earlier fracture union time (mean values: 8.9 versus 14.1 weeks) and the superiority (p=0.007) of PFN in shorter hospital stay (3.4 days versus 5.1 days). No significant difference was observed in radiological parameters. While similar mechanical complication rates were found, a significantly higher nonunion rate was detected with the DCS.
CONCLUSIONS: The most crucial disadvantage of DCS was the high rate of nonunion. Closed fracture reduction in PFN seems to be the most critical parameter to prevent severe complications. The open reduction using DCS showed no advantages over closed reduction and PFN fixation in providing a more anatomical alignment in AO/Orthopaedic Trauma Association (OTA) 31-A3 fractures. However, we recommend PFN application in this type of fracture, since nonunion is more common in DCS.

To determine the configuration of the distal fibula anatomy and the fitness of the Fibula Rod System (Acumed®, Hillsboro, Oregon) in a series of fibula models and to determine the optimal entry site of the rod.
Consecutive series of computed tomography (CT) of tibias and fibulae with no fracture or deformity were converted to stereo-lithograph format, and imported into Meshmixer software (Autodesk, San Rafael, California). A 3.6 × 180 mm fibula rod model was virtually inserted to best fit the intramedullary canal of the fibula model and to a depth of 0 mm proud at the distal fibula. The location of the entry point in relationship to the fibular tip, and the distance between the rod and the lateral fibula cortex were measured.
CT of 41 fibulae (23 male and 18 female patients) contributed to the three-dimensional fibula modeling. The entry point was 3.5 mm (SD 2.0) medial to (in mortise view) and 1.0 mm (SD 2.1) anterior to (in lateral view) the fibular tip. The fibula rod was inserted to a depth of 6.2 mm (SD 2.1) proximal to the fibula tip. The mean shortest distance of the rod to the outer cortex was 1.88 mm (SD 0.87). There was a breach of the posterolateral cortex in one patient.
The guide pin entry site of fibula rod should be medial and anterior offset with reference to the fibula tip, in contrary to the distal tip as recommended in the manual. There is a chance of breaching the posterolateral cortex with rod entry.

UNASSIGNED: Modern distal biceps reconstruction techniques generally have satisfactory outcomes, but are not without complications. Posterior interosseous nerve (PIN) palsy is a rare but potentially devastating complication of bicortical metal button fixation. Recently, a unicortical, intramedullary, repair technique utilizing a suture anchor has been described. The primary aim of this study was to compare short-term functional and patient-reported outcomes and complication rates in patients receiving unicortical intramedullary repair (UR) with suture anchor against those receiving bicortical repair (BR) with metallic button. We hypothesized that UR would have equally satisfactory outcomes without the complication profile.
UNASSIGNED: Retrospective chart review was conducted for all patients undergoing operative fixation of distal biceps tendon ruptures from 2015 to 2021 at our tertiary referral center. Twenty patients received BR, and eight patients received UR. Patient demographics and surgical complications were compared. QuickDASH scores at two-month and latest in-person and telehealth postoperative visits, as well as elbow and forearm range of motion at last clinical visit, were collected and analyzed.
UNASSIGNED: Average patient age in the BR & UR cohorts were 49.3 ± 9.3 and 42.1 ± 6.2 years, respectively, with a male predominance. There was no statistical difference in patient age, sex, hand dominance, injury laterality, injury chronicity, and follow-up duration. Range of motion was comparable and excellent in both groups. Latest follow-up was 3.0 ± 0.5 years in the BR and 1.5 ± 0.4 years in the UR cohorts. QuickDASH scores improved between the two-month and latest time points in each cohort however did not differ significantly in head-to-head comparison. Complications included a case of PIN palsy, distal biceps tendon rerupture, and lateral antebrachial cutaneous nerve (LABC) neuropraxia in the BR group and two cases of LABC neuropraxia in the UR group. The number needed to treat (NNT) for the prevention of one additional case of PIN palsy using UR is 22 patients.
UNASSIGNED: Short-term functional and patient-reported outcomes in traditional BR and newly reported UR of distal biceps tendon ruptures are comparable and excellent. UR did not have higher failure rate despite follow-up periods beyond what is typically reported for tendon reruptures. In this limited retrospective cohort study, UR also did not encounter postoperative PIN palsy and had an NNT of 22 patients. In the appropriate clinical setting, this provides early evidence supporting the utilization of unicortical intramedullary suture anchor fixation of distal biceps tendon ruptures as well as associated perioperative interventions such as preoperative nerve blocks.

BACKGROUND: This study aims to determine whether nail size or the difference between canal and nail diameter (CN difference) affects the union rate and time of femoral shaft fracture treated with an interlocking intramedullary nail (IMN).
METHODS: This was a retrospective review of 257 patients with femoral shaft fractures treated with IMN at a tertiary trauma medical center. All the IMN inserted were the same (Stryker T2 Femoral Nail). The patients were divided into groups based on nail size (10-, 11-, 12-, or 13-mm) and CN difference (< 1, 1-2, or > 2 mm), and union rate and time to union were compared.
RESULTS: The 10-, 11-, 12-, and 13-mm groups based on nail size had 113, 74, 54, and 16 patients, respectively. The overall union rate was 97% (257/265). No significant differences in union rate or time to union were observed among these 4 groups. The groups based on CN differences of < 1-, 1 to 2, and > 2 mm comprised 143, 79, and 35 patients, respectively. Again, no significant differences were noted in union rate or mean time to union among the groups.
CONCLUSIONS: Similar union rate and time to union were observed, regardless of nail size or CN difference. This finding indicates that most simple femoral shaft fractures can be treated with a standard, reamed 10-mm IMN. A larger nail insertion is unnecessary and presents more risks; comparatively, the use of a small nail with less reaming is simpler, requires shorter operative times, results in less blood loss, and is less expensive.