Systematic review of dynamization vs exchange nailing for delayed/non-union femoral fractures

AIM To analyze the literature on efficacy of dynamamization vs exchange nailing in treatment of delayed and nonunion femur fractures.METHODS Ultimately, 31 peer-reviewed articles with 644 exchanged nailing patients and 131 dynamization patients were identified and analyzed. The following key words were inputted in different combinations in order to search the field of publications in its entirety: "nonunion", "delayed union", "ununited", "femur fracture", "femoral fracture", "exchange nailing", "dynaiz(s)ation", "secondary nailing", "dynamic", "static", and "nail revision". The initial search yielded over 150 results, and was refined based on the inclusion criteria: Only studies reporting on humans, non-unions and delayed unions, and the usage of exchange nailing and/or dynamization as a secondary treatment after failed IM nailing. The resulting 66 articles were obtained through online journal access. The results were filtered further based on the exclusion criteria: No articles that failed to report overall union rates, differentiate between success rates of their reported techniques, or articles that analyzed less than 5 patients. RESULTS Exchange nailing lead to fracture union in 84.785% of patients compared to the 66.412% of dynamization with statistically comparable durations until union(5.193 ± 2.310 mo and 4.769 ± 1.986 mo respectively). Dynamically locking exchange nails resulted in an average union time of 5.208 ± 2.475 mo compared to 5.149 ± 2.366 mo(P = 0.8682) in statically locked exchange nails. The overall union rate of the two procedures, statically and dynamically locked exchange nailing yielded union rates of 84.259% and 82.381% respectively. Therefore, there was no significant difference between the different locking methods of exchange nailing for union rate or time to union at a significance value of P < 0.05. The analysis showed exchange nailing to be the more successful choice in the treatment of femoral non-unions in respect to its higher success rate(491/567 EN, 24/57 dynam, P < 0.0001). However, there was no significant difference between the success rates of the two procedures for delayed union fractures(25/27 EN, 45/55 dynam, P = 0.3299). Nevertheless, dynamization was more efficient in the treatment of delayed unions(at rates comparable to exchange nailing) than in the treatment of non-unions.CONCLUSION In conclusion, after examination of factors, dynamization is recommended treatment of delayed femur fractures, while exchange nailing is the treatment of choice for non-unions.

Antibiotic bone cement's effect on infection rates in primary and revision total knee arthroplasties

AIM To compare infection rates in primary and revision total knee arthroplasty(TKA) procedures using antibiotic impregnated bone cement(AIBC) to those rates in procedures not using AIBC.METHODS A systematic review and meta-analysis was conducted in search for randomized controlled trials/studies(RCTs) pertaining to the field of antibiotic AIBC vs non-AIBC groups in both primary and revision TKA procedures. The primary literature search performed was to identify all RCTs that assessed AIBC in primary and revision TKA procedures. This search was done strictly through the Pub Med database using the article "filters" setting that identified and separated all RCTs from the overall search. The original search was "Primary/revision total knee arthroplasty using AIBC". Other key terms and phrases were included in the search as well. Eligible articles that were used in the "results" of this review met the following criteria:(1) Involved primary or revision TKA procedures(for any reason);(2) included TKA outcome infection rate information;(3) analyzed an AIBC group vs a non-AIBC control group;(4) were found through the RCT filter or hand search in Pub Med; and(5) published 1985-2017. Exclusion criteria was as follows:(1) Patients that were not undergoing primary or revision TKA procedures;(2) articles that did not separate total hip arthroplasity(THA) vs TKA results if both hip and knee revisions were evaluated;(3) papers that did not follow up on clinical outcomes of the procedure;(4) extrapolation of data was not possible given published results;(5) knee revisions not done on human patients;(6) studies that were strictly done on THAs;(7) articles that were not found through the RCT filter or through hand search in Pub Med;(8) articles that did not evaluate AIBC used in a prosthesis or a spacer during revision;(9) articles that did not compare an AIBC group vs a non-AIBC control group; and(10) articles that were published before 1985.RESULTS In total, 11 articles were deemed eligible for this analysis. Nine of the 11 studies dealt with primary TKA procedures comparing AIBC to non-AIBC treatment. The other two studies dealt with revision TKA procedures that compared such groups. From these papers, 4092 TKA procedures were found. 3903 of these were primary TKAs, while 189 were revision TKAs. Of the 3903 primary TKAs, 1979 of these used some form of AIBC while 1924 were part of a non-AIBC control group. Of the 189 revision TKAs, 96 of these used some form of AIBC while 93 were part of a non-AIBC control group. Average followup times of 47.2 mo and 62.5 mo were found in primary and revision groups respectively. A two-tailed Fisher's exact test was done to check if infection rates differed significantly between the groups. In the primary TKA group, a statistically significant difference between AIBC and non-AIBC groups was not found(AIBC infection rate = 23/1979, non-AIBC infection rate = 35/1924, P = 0.1132). In the revision TKA group, a statistically significant difference between the groups was found(AIBC infection rate = 0/96, non-AIBC infection rate = 7/93, P = 0.0062). No statistically significant differences existed in Knee Society Scores, Hospital for Special Surgery Scores, or Loosening Rates.CONCLUSION AIBC did not have a significant effect on primary TKA infection rates. AIBC did have a significant effect on revision TKA infection rates.

Fracture of allograft interbody spacer resulting in post-operative radiculopathy: A case report

BACKGROUND Allograft interbody spacers are utilized during transforaminal lumbar interbody fusion(TLIF) to reestablish anterior column support and disc height. While the TLIF technique offers many improvements over previous surgical methods,instrumentation and bone graft-related complications such as spacer misplacement or migration, screw fracture or misplacement, or rod breakage continue to be reported. The objective of this manuscript is to report on a fractured allograft interbody spacer that displaced into the neural foramen and resulted in impingement on the exiting nerve root that required revision.CASE SUMMARY A 50-year-old male had two-level TLIF with immediate post-operative right L5 radiculopathy. Computed tomography scan demonstrated a fractured allograft interbody spacer that displaced into the right neural foramen and impinged on the exiting L5 nerve root. Revision surgery was performed to remove the broken allograft fragments from the right L5 foramen and the intact portion of the spacer was left in place. The right leg L5 radicular pain resolved. At the last follow up 12 mo after the index procedure, computed tomography scan confirmed sound interbody and posterolateral fusion.CONCLUSION Displacement of broken allograft interbody spacer following TLIF procedures can result in neurological sequelae that require revision. To avoid such an occurrence,the authors recommend allowing sufficient time for the reconstitution of the graft in saline prior to use to decrease brittleness, to use an impactor size that is as close as possible to the spacer size and meticulous inspection of the cortical allograft spacer for any visible imperfection prior to insertion.