PFNA2 versus 95 Degree Condylar Blade Plate in the Management of Unstable Trochanteric Fractures

Purpose: The proximal femoral nail anti-rotation (PFNA) is known to have advantages in enhancing the anchorage ability of internal fixation in elderly unstable osteoporotic intertrochanteric fracture patients. However whether it is superior to condylar blade fixation is not clear. This study aimed to determine which treatment has better clinical outcomes in older patients. Materials and Methods: A total of 86 patients over the age of 60 with unstable trochanteric fractures within the past 3 weeks, were included in this prospective study conducted from June 1, 2018, to May 31, 2021. All the intertrochanteric fractures were classified according to AO/OTA classification. Among them, 44 cases were treated with the Proximal Femoral Nail (PFNA2) with or without an augmentation screw, and 42 cases were treated with the Condylar Blade Plate. In addition, the operative time, intraoperative blood loss, intraoperative and postoperative blood transfusion, postoperative weight-bearing time, hospitalization time, Harris score of hip function, Kyle’s criteria and postoperative complications were compared between the two groups. Results: The mean duration of surgery for the PFN group was 66.8 minutes (on average), whereas for the condylar blade plate group, it was 99.30 minutes (on average). The PFNA2 group experienced less blood loss (average of 80 mL) compared to the condylar blade plate group (average of 120 mL). Union and partial weight-bearing occurred earlier in the PFNA2 group (14.1 weeks and 10.6 weeks, respectively) compared to the Condylar blade plate group (18.7 weeks and 15.8 weeks). In two patients from the PFNA2 group, screw backing out and varus collapse complications were encountered;however, these patients remained asymptomatic and did not require revision surgery. In two other patients, screw cut out and breakage of the nail at the helical screw hole leading to non-union of the proximal femur were observed during the nine-month follow-up, necessitating revision surgery with prosthetic replacement. Among the condylar blade plate group, three patients experienced complications, including blade breakage at the blade and plate junction. In two cases, the fracture united in varus, and in one case, the blade cut through, resulting in non-union of the femoral head, which required revision surgery. According to the Harris hip score and Kyle’s criteria, a good-excellent outcome was observed in 92.85% of cases in the PFNA2 group and 90.90% of cases in the condylar blade plate group. Conclusion: Both the Proximal Femoral Nail A2 and Condylar blade plate are effective implants for the treatment of unstable trochanteric fractures. The intramedullary implant promotes biological healing and allows for early ambulation with minimal complications. Similarly satisfactory restoration of anatomy and favorable radiological and functional results can be achieved with the biological fixation provided by the 95-degree condylar blade plate. However, the use of PFNA2 internal fixation technique has the advantage of less trauma in elderly patients than the 95-degree condylar blade plate.

Endosteal Fibular Strut Graft with Proximal Humeral Locking Plate in Delayed and Neglected Fractures of the Proximal Humerus

Purpose: The purpose of this study was to define a treatment protocol in which a non-vascularized endosteal fibular strut graft, a corticocancellous grafts and a locking plate construct are used for stabilization of the delayed and neglected proximal humerus fractures and to report its outcome. Patients & Methods: Eleven patients (6 females and 5 males) with delayed, neglected proximal humerus fractures were included in this study, conducted between March 2015 and December 2019. Average age of the patients was 57 years (range: 41 to 67 yrs). All patients were treated with the debridement, decortication and shingling of the bone at the site of the fracture followed by using an endosteal fibular strut graft, corticocancellous bone grafts and stabilization with locking plate. The patients were followed up for a mean time of 16.3 months (range: 13 to 40 months). The patient outcomes were evaluated using the Disabilities of the Arm, Shoulder, and Hand Questionnaire, and the modified scoring system of Constant and Murley. Results: Union at the fracture site was achieved in all patients at a mean of 8.5 months (range: 6 to 11 months). The DASH score improved from an average pre-operative score of 71.1 (range: 64 to 78) to an average post-operative score of 25.2 (range: 21 to 35) at the final follow-up. Albeit with a small sample size of n = 11, this difference was found to be statistically significant (p < 0.05). The CM score improved from an average pre-operative score of 33.2 (range: 20 to 48) to an average post-operative score of 66.8 (range: 59 to 72) at the final follow-up. This difference was also found to be statistically significant in this patient cohort (p < 0.05). The results were excellent in 3 patients, good in 6 and moderate in 2. Conclusions: An endosteal fibular strut, subperiosteally placed cortico-cancellous grafts with a locking plate fixation helps in biological healing of neglected fractures of proximal humerus.

Fracture Femur in a Case of Pyle’s Disease: A Case Report

Pyle’s disease is a rare genetic skeletal disorder also known as Metaphyseal dysplasia. A case of 36 yrs old female with fracture supracondylar femur in Pyle’s disease is presented. She had mild facial dysmorphism, dental malformation & mild genu valgum. Skeletal radiology revealed the characteristic Erlenmeyer flask sign at distal femoral and proximal tibial metaphysis. The fracture supracondylar femur was treated with interlocking nail. The fracture was united in sixteen weeks period. The patient is followed up for two years. The aim of the case report is the rarity of the condition with fracture supracondylar femur in adult female successfully treated with interlocking nail.

Results of Dynamic Interlock Nailing in Distal Tibial Fractures

A study was performed in adults to determine the efficacy of closed reduction and intramedullary nailing in dynamic mode on union, implant failure and incidence of malalignment in patients who sustained an extra-articular fracture of the distal tibia. Methods: Between January 2007 and December 2013, one hundred and twelve patients of distal tibia that involved the distal 6 cm of the tibia were treated at our hospital with reamed intramedullary nailing with use of two distal interlocking screws and one proximal screw in dynamic mode. The augmentation was done with poller screws whenever it was necessary. The nailing of fibular fractures was done in 27 cases. There were 85 males and 27 females with a mean age of 30.9 (range: 20 to 72). Eighty fractures were closed whereas 32 were grade 1 open fractures. Results: The average time to union of the closed fracture was 15.4 weeks (range: 12 – 28 weeks). The healing times for the primarily nailed compound Grade I averaged 17.8 (range: 15 - 34 weeks). After minimum follow-up of one year, rate of primary union was in 97.32%. One case of broken nail required revision surgery. There were three cases of delayed union and two cases of non union. In one case there was deep infection which required exchange nailing with antibiotic impregnated nail. There was breakage of interlocking screws in three cases but fracture had united. In twenty two cases acceptable malalignment of the tibia was observed after union. The outcome was determined at a minimum of one year in our study based on the criteria of Johner and Wruhs. Out of 112 patients, 79 patients had excellent results, 29 had good results and 4 had fair results. Conclusions: The dynamic osteosynthesis of distal tibia by interlocking nail and judicious use of poller screws is an effective alternative for the treatment of distal metaphyseal tibial fractures.

Humerus Nailing in Lateral Position (Operative Technique)

With the advent of good designs of nails, straight and angled in the arena of treatment for fractures from surgical neck of humerus to approximately 5 cm above the olecranon fossa, nailing is gaining popularity in recent literature. Many different nails are available in market with different proximal and distal locking configurations. Beach chair and supine are the main principle positions for antegrade humerus nailing. Beach chair or supine is the preferred position by many, but there is always difficulty in distal locking by free hand technique as it is difficult to locate the distal locking hole due to rounded smooth anatomy of anterior distal humerus and fear of neurovascular complications in both anteroposterior and latero-medial locking. The aim of this article is to demonstrate the utility of lateral position in ease of nailing all types of humerus fractures. The technique and illustrations below describe the positioning of patient, image intensifier and free hand postero-anterior distal locking without injury to neurovascular structures.