BACKGROUND: A persistent fracture gap following femoral nailing increases the risk of delayed and nonunion development. A forward-striking technique for reducing the gap in femoral nailing has been described, but its efficacy and therapeutic consequences have not been investigated in comparative studies. We provide the results of a comparative study that investigated the forward-striking technique\'s efficacy in terms of remaining fracture gaps and surgical outcomes.
METHODS: Between 2017 and 2022, a retrospective cohort study was undertaken on 193 skeletal mature patients obtaining reamed femoral nailing for closed femoral shaft fractures. Comparisons of residual fracture gaps, timing to union, complications and re-operation rates were made between 80 patients (41.45%) undergoing femoral nailing with the forward striking procedure and 113 patients (58.55%) undergoing traditional nailing, accompanied by minimal 1-year follow-ups. In addition, the potential difference between fracture gaps before and after applying the forward striking procedure was compared.
RESULTS: Both groups had similar age, sex, presence of diabetes, smoking status, body mass index and time to surgery. However, the forward-striking group demonstrated significantly lower rates of postoperative complications, including delayed, nonunion, and the need for re-operation. Conversely, no significant differences were found in time to union (p = 0.222). The forward-striking procedure can significantly reduce residual fracture gaps from 3.99 to 1.66 mm (p < 0.001). No major complications in the forward-striking group including nonunion were observed.
CONCLUSIONS: This study suggests that the forward-striking technique effectively reduces residual fracture gap during femoral nailing. The technique not only could be easily performed but is also reproducible. In addition, it can lower the risk of delayed union, nonunion and obviates the necessity for re-operation.
METHODS: Level III, retrospective cohort study.

BACKGROUND: Decreased estimated glomerular filtration rate (eGFR) is associated with acute kidney injury (AKI) following hip fracture surgery. Delaying surgery for preoperative treatment of comorbidities is controversial in this patient population. The purpose of this study was 1) to assess differences in demographics and comorbidities between AKI and non-AKI groups, 2) to analyze equations used in calculating eGFR, and 3) to identify the equation which best predicts the development of AKI following hip fracture surgery. We hypothesize that one of the equations used to calculate eGFR will be superior to the others.
METHODS: 124,002 cases of hip fracture surgery were performed from 2012 to 2019, based upon a query of the National Surgical Quality Improvement Program (NSQIP). Preoperative eGFR was calculated using the following: Modification of Diet in Renal Disease (MDRD) II, re-expressed MDRD II, Chronic Kidney Disease Epidemiology Collaboration, Mayo quadratic, and Cockcroft-Gault equations. Independent associations between preoperative eGFR and postoperative renal failure were evaluated using multivariate regression analysis. The predictive ability of each equation was determined using the Akaike information criterion (AIC).
RESULTS: AKI was diagnosed in 584 (0.71%) out of the 82,326 patients following hip fracture surgery. The AKI and no AKI cohorts differed significantly by patient sex (p = <0.001), race (p = <0.001), BMI (p = < 0.001), preoperative hematocrit (p = <0.001), preoperative albumin (p = <0.001), diabetes mellitus (p = <0.001), hypertension (p = <0.001), and congestive heart failure (p = <0.001). The Mayo equation (84.0 ± 23.7) was the equation with the highest calculated mean eGFR, followed by the CKD-EPI equation (83.6 ± 20.0), MDRD II equation (83.0 ± 38.9), CG equation (74.7 ± 35.5), and finally the re-expressed MDRD II equation (68.5 ± 36.0) which had the lowest calculated mean eGFR.. All five equations detected that a decrease in preoperative eGFR was associated with an increased risk of postoperative AKI. Lower preoperative eGFR, as calculated by each of the five equations, was significantly associated with an increased risk of AKI following surgical fixation of hip fracture. The AIC was the lowest in the Mayo equation, demonstrating the best fit of the equations to predict postoperative AKI CONCLUSIONS: We propose that using the equation that best identifies those at risk of developing postoperative AKI may help with perioperative decision making and treatment to improve outcomes, which we found to be the Mayo equation. The risk of postoperative AKI was independently associated with decreased preoperative eGFR. The results of this study may warrant further investigation utilizing prospective studies.
METHODS: III; retrospective cohort study.

The chronic and incapacitating condition of infected non-union of the long bones continues to be a challenging issue for surgeons in terms of efficient and economical treatment. A number of variables, such as open fractures, soft tissue or bone loss, infection following internal fixation, persistent osteomyelitis with pathologic fractures, and surgical debridement of infected bone, can result in infected non-unions. An infected non-union is typically treated in two stages. To transform an infected non-union into an aseptic non-union, the initial step involves debridement, either with or without the insertion of antibiotic cement beads and systemic antibiotics. In order to ensure stability, external or internal fixation - with or without bone grafting - is carried out in the second stage. There is a wealth of literature supporting the use of antibiotic-impregnated cement-coated intramedullary (IM) nailing for infected non-union of tibia and femur fractures. In contrast to cement beads, the cement nail offers stability throughout the fracture site, and osseous stability is crucial for the treatment of an infected non-union. When using antibiotics for this purpose, they should possess unique qualities, including low allergenicity, heat stability, and a broad spectrum of activity. The most commonly utilised medication has been gentamicin, which is followed by vancomycin. Furthermore, it has been discovered that solid nails are more resistant to local infection than cannulated IM nails. In this case study, the patient was treated with a solid IM nail that had a specially designed slot on its exterior surface for the application of cement impregnated with antibiotics. In conclusion, an easy, affordable, and successful treatment for infected non-union of the tibia is antibiotic cement-impregnated nailing. It has strong patient compliance and removes the problems associated with external fixators, which makes it superior to them. A few benefits of this approach are early weight-bearing, stabilisation of the fracture, local antibiotic treatment, and the potential for accelerated rehabilitation. Additionally, lowering the requirement for continuous antibiotic medication may lessen the chance that antibiotic resistance may arise.

OBJECTIVE: To compare early outcomes of proximal femoral bionic nail (PFBN), Inter-TAN, proximal femoral nail antirotation (PFNA) for intertrochanteric fractures in elderly patients.
METHODS: Eighty-two elderly patients with intertrochanteric femoral fractures treated at Xiangyang No. 1 People\'s Hospital affiliated with Hubei University of Medicine from December 2021 to 2022 were retrospectively analyzed. They were categorized into three surgical groups: PFBN (22 cases), Inter-TAN (20 cases), and PFNA (40 cases). Preoperative demographics and fracture characteristics were compared, alongside intraoperative and postoperative metrics like operative time and complication rates.
RESULTS: In the PFBN group, operative time, fluoroscopy use, blood loss, and transfusion were higher, but postoperative weight-bearing, healing, and hospital stay were shorter compared to the Inter-TAN and PFNA groups (P<0.05). Inter-TAN had a significantly shorter postoperative weight-bearing time than PFNA (P<0.001). Other compared factors showed no significant differences between groups (P>0.05), including complication rates and scores at 6-month follow-up.
CONCLUSIONS: PFBN, a novel surgical approach for intertrochanteric fractures in elderly patients, outperforms Inter-TAN and PFNA by accelerating early weight-bearing and hastening fracture recovery.

BACKGROUND: This study\'s purpose was to evaluate the biomechanical performance of plate-nail and dual-plate fixation for the treatment of AO/OTA 41-C2 tibial plateau fractures.
METHODS: Twenty synthetic tibias were selected and randomly divided into a plate-nail group (n = 10) and a dual-plate group (n = 10). After the artificial tibias were osteotomized to simulate AO/OTA 41-C2 tibial plateau fractures in both groups, the plate-nail and the dual-plate methods, respectively, were used for fixation, and then axial compression loading, three-point bending, torsion, and axial failure tests were carried out. The data of each group were recorded and statistically analyzed.
RESULTS: In the axial compression test, the average stiffness of the plate-nail group was higher than that of the dual-plate group (p < 0.05). The displacement generated in the plate-nail group was significantly smaller than that in the dual-plate group (p < 0.05). In the resisting varus test, the stress of the plate-nail group was significantly higher than that of the dual-plate group (p < 0.05). In the resisting valgus test, the stress of the plate-nail group was slightly higher than that of the dual-plate group, but the difference was not statistically significant (p > 0.05). In the static torsion test, the load applied to the plate-nail group was smaller than that of the dual-plate group when rotated to 5° (p < 0.05). In the axial compression failure test, the average ultimate load of the plate-nail group was significantly higher than that of the dual-plate group (p < 0.05).
CONCLUSIONS: The treatment of AO/OTA 41-C2 tibial plateau fractures with plate-nail fixation is superior to that with dual-plate fixation in resisting axial stress and preventing tibial varus deformity, while dual-plate fixation has better resisting torsional ability.

BACKGROUND: Anterior knee pain (AKP) is a common complaint following intramedullary nail (IMN) insertion for tibial shaft fractures. There is a lack of long-term patient reported outcome data following tibial IMN, with conflicting evidence of the role of nail protrusion on AKP. In this study, we assess the long-term patient reported outcome measures and kneeling function in patients with tibial IMNs and compare the results with IMN protrusion, measured radiologically.
METHODS: A retrospective cohort of 128 patients, from a single UK centre, were invited to participate in the study, to complete a Kujala score, KOOS, EQ-5D-5L and a four-posture kneeling assessment. We report the outcomes of 45 patients at an average follow-up of 6.9 years.
RESULTS: The mean Kujala score was 80.7. The mean KOOS score was 83.2, 83.9, 85.8, 70.7 and 72.8 for symptoms, pain, daily living, sport and quality of life, respectively. We found 20.5% of patients experienced daily AKP. Pain and fear of pain were the most common limiting factors in the kneeling assessment. No significant correlation was found between the KOOS or Kujala score and nail-plateau distance, nail-anterior cortex distance, or the overall nail prominence.
CONCLUSIONS: AKP affects a subset of patients more than five years post-tibial IMN, limiting their ability to kneel and other functions of daily living. Tibial IMN prominence does not seem to be associated with AKP.

UNASSIGNED: Outcomes of patients with opioid use disorder undergoing elective procedures have been well studied, but research is lacking in the orthopaedic trauma population.
UNASSIGNED: The aim was to compare perioperative pain and morphine equivalents required by patients with versus without opioid use disorder following intramedullary nail fixation of femoral or tibial fractures.
UNASSIGNED: We conducted a retrospective review of all patients with isolated femoral or tibial diaphyseal fractures treated with intramedullary nail fixation. Outcomes were compared between patients with diagnosed opioid use disorder and controls without, including daily morphine equivalents and patient-reported pain scores.
UNASSIGNED: Patients with opioid use disorder (n = 42) required greater morphine equivalents and reported higher pain than controls (n = 42) at all time points but did not differ in change of morphine equivalents over the perioperative period.
UNASSIGNED: This highlights the challenge of perioperative pain control in this population and need for improved specific pain management protocols.

BACKGROUND: In recent years, intramedullary nails with medial support screws for proximal humeral fractures have become available. Although these devices have a potential risk of iatrogenic axillary nerve injury, no studies have investigated the anatomical relationship between the medial support screws in the modern intramedullary nail and the axillary nerve. This study aimed to clarify the anatomical relationship between the medial support screws in the intramedullary nail and the axillary nerve.
METHODS: In total, 29 cadaveric shoulders (mean age: 82.6 years old (range: 61-105); 15 males and 14 females) were included in this study. Shoulders within whole-body cadavers were used in all cases. A single proximal humeral nail with medial support screws (ARISTO Proximal Humeral Nail; MDM, Tokyo, Japan) was used. The distance of each medial support screw from the axillary nerve and its branches was measured.
RESULTS: In two (6.90%) of 29 shoulders, the axillary nerves came into contact with the medial support screws. In the remaining 27 of 29 shoulders (93.1%), the nerves were located proximal to the medial support screws.
CONCLUSIONS: Medial support screws in proximal humeral fracture nails had the potential to injure the axillary nerve and its branches.

OBJECTIVE: Offering the benefits of rigid fixation while minimizing soft tissue dissection, intramedullary implants have become a popular choice among hand surgeons. Their placement often requires traversing or passing in proximity to joint surfaces. This study aimed to assess the damage to the articular cartilage of the base of the proximal phalanx resulting from antegrade placement of threaded headless intramedullary nails.
METHODS: A cadaveric study comparing two techniques for antegrade placement of threaded headless intramedullary nails was conducted in 56 digits. The first entailed a single 2.1 mm intramedullary nail placed via the dorsal base of the proximal phalanx, whereas the second used two 1.8 mm intramedullary nails inserted via the collateral recesses of the phalangeal base. All specimens were analyzed for articular surface damage with the cartilage defect measured as a percentage of total joint surface area. Damage to the extensor tendons was also assessed in a subset of specimens.
RESULTS: No significant difference in the percentage of articular surface damage was observed, with an average 3.21% ± 2.34% defect in the single 2.1 mm nail group and a 2.71% ± 3.42% mean defect in the two 1.8 mm nails group. There was no articular surface injury in 18% of digits in each group. Damage to extensor tendons was seen in three (9.4%) specimens and in all cases involved either the extensor indicis proprius or extensor digiti minimi.
CONCLUSIONS: Hardware insertion using either the dorsal base of the proximal phalanx or the collateral recesses of the phalangeal base both demonstrated minimal articular cartilage damage and infrequent injury to the extensor tendons.
CONCLUSIONS: With proper technique for antegrade insertion into the proximal phalanx, the cartilage defect observed often encompasses only a small percentage of the overall joint surface area.

Vertical osteotomy is a procedure occasionally used for the removal of intramedullary nails when the nail has become jammed, either due to expansion after initial fixation or the formation of a new bone around the nail. Implant removal of any type is usually performed when it is either recommended by the doctor or in response to the complaints of the patients, like sensations of pain, disorder, and infection associated with the potential complications of the given implant. There are different types of cases, which range from a simple procedure of K-wire removal or more complex procedures like intramedullary nail or plate removal. During the removal of implants, certain unforeseen complications can occur such as excessive bleeding, neurovascular deficit, and some other issues related to implants like breakage of screws or implants while removing it, which might lead to its inability to be removed. We present here a technique of vertical osteotomy that was used for the removal of implants in cases of long-term implant retention, which leads to difficulty in removing it.