Surgical management of bifocal femoral fractures:a systematic review and pooled analysis of treatment with a single implant versus double implants

Introduction: Fractures of the proximal femur accompanied by a fracture of the femoral shaft are relatively rare, with a reported prevalence between 1 and 12%. Multiple surgical options are available, consisting of treatment with a single implant or with double implants. Controversy exists about the optimal management. A systematic review and pooled analysis were performed to assess the most reliable treatment for bifocal femoral fractures of the femur. Materials and methods: A literature search was conducted on July 15, 2022. Selected studies were screened on title and abstract by two researchers independently, and full texts were read by both authors. Emphasis was put on adverse events such as postoperative infection, healing complications, malalignment, and functional outcome using either a single implant or double implants. Results: For the proximal femoral fractures, no significant difference could be confirmed for avascular necrosis of the femoral neck (5.1% for single implant and 3.8% for double implants), nonunion (6.4% for single implant and 7.8% for double implants), or varus malalignment (6.6% for single implant and 10.9% for double implants). This study also suggests that the number of implants is irrelevant for complications of the femoral shaft regarding the rates of postoperative infection and healing complications. Pooled rates of bone healing complications were 1.6–2.7-fold higher when patients were treated with a single implant, but statistical significance could not be confirmed. For hardware failure, revision surgery, leg length discrepancy, and functional outcome, no difference between the two groups was found either. Conclusions: The pooled proportions of all postoperative complications had overlapping confidence intervals; thus, no inference about a statistically significant difference on the number of implants used for treating ipsilateral fractures of the femur can be made. Both treatment groups showed a similar functional outcome at the last moment of follow-up, with more than 75% of the patients reporting a good outcome.</p

From numbers to meaningful change:Minimal important change by using PROMIS in a cohort of fracture patients

Introduction: use of the Patient-Reported Outcomes measurement Information System (PROMIS®) is slowly increasing in patients with a fracture. Yet, minimal important change of PROMIS in patients with fractures has been addressed in a very limited number of studies. As the minimal important change (MIC) is important to interpret PROMIS-scores, the goal is to estimate the MIC for PROMIS physical function (PF), PROMIS pain interference (PI) and PROMIS ability to participate in social roles and activities (APSRA) in patients with a fracture. Secondly, the smallest detectable change was determined. Materials and methods: A longitudinal cohort study on patients ≥ 18 years receiving surgical or non-surgical care for fractures was conducted. Patients completed PROMIS PF V1.1, PROMIS PI V1.1 and PROMIS APSRA V2.0. For follow-up, patients completed three additional anchor questions evaluating patient-reported improvement on a seven point rating scale. The predictive modeling method was used to estimate the MIC value of all three PROMIS questionnaires. Results: Hundred patients with a mean age of 55.4 ± 12.6 years were included of which sixty (60%) were female. Seventy-two (72%) patients were recovering from a surgical procedure. PROMIS-CAT T-scores of all PROMIS measures showed significant correlations with their anchor questions. The predictive modeling method showed a MIC value of +2.4 (n = 98) for PROMIS PF, -2.9 (n = 96) for PROMIS PI and +3.2 (n = 91) for PROMIS APSRA. Conclusion: By using the anchor based predictive modeling method, PROMIS MIC-values for improvement of respectively +2.4 points on a T-score metric for PROMIS-PF, -2.9 for PROMIS-PI and +3.2 for PROMIS APSRA give the impression of being meaningful to patients. These values can be used in clinical practice for managing patient expectations; to inform on treatment results; and to assess if patients experience significant change. This in order to encourage patient centered care.</p

Trends in incidence, health care consumption, and medical and productivity costs of femoral shaft fractures in the Netherlands between 2005 and 2019

Introduction: Population-based knowledge on the occurrence of femoral shaft fractures is necessary for allocation of health care services, optimization of preventive measures, and research purposes. This nationwide study aimed to provide an overview on the incidence of femoral shaft fractures over a 15-year period and to gain insight into health care consumption and work absence with associated costs in the Dutch population. Methods: Data of patients who sustained an acute femoral shaft fracture in the years 2005–2019 were extracted from the National Medical Registration of the Dutch Hospital Database. The incidence rate, hospital length of stay (HLOS), direct medical costs, productivity costs, and years lived with disability were calculated for age- and gender specific groups. Results: A total of 15,847 patients with a femoral shaft fracture were included. The incidence rate increased with 13 % over this 15-year period (5.71/100,000 persons per year in 2005 and 6.47/100,000 in 2019). The mean HLOS per patient was 13.8 days in 2005–2009 versus 8.4 days in 2015–2019 for the entire group. Mean HLOS per patient increased with age (10.0 days for age group 0–9 and 12.7 days for age group &gt;80), but declined over time from 13.6 days in 2005–2009 to 8.8 days in 2015–2019 in males, and from 13.7 days and to 8.2 days, respectively, in females. The costs due to work absence was higher in males. Cumulative health care costs were highest in females &gt;80 years (8.4 million euros versus 1.6 million in males). Conclusion: The incidence rate of femoral shaft fractures increased over the past 15 years in the Netherlands. Mean HLOS per patient has decreased in all age groups and in both sexes. Health care costs were highest for female octogenarians.</p

3D-printed patient specific instruments for corrective osteotomies of the lower extremity

3D-printing has become a promising adjunct in orthopedic surgery over the past years. A significant drop in costs and increased availability of the required hardware and software needed for using the technique, have resulted in a relatively fast adaptation of 3D-printing techniques for various indications. In this review, the role of 3D-printing for deformity corrections of the lower extremity is described.</p

Functional and Clinical Outcomes After Plate Osteosynthesis Versus Intramedullary Nailing of a Humeral Shaft Fracture:The Results of the HUMMER Multicenter, Prospective Cohort Study

BACKGROUND: Plate osteosynthesis (referred to throughout as plating) and intramedullary nailing (referred to throughout as nailing) are the most common operative strategies for humeral shaft fractures. However, it is undecided which treatment is more effective. This study aimed to compare functional and clinical outcomes of these treatment strategies. We hypothesized that plating would result in an earlier recovery of shoulder function and fewer complications. METHODS: From October 23, 2012, to October 3, 2018, adults with a humeral shaft fracture, OTA/AO type 12A or 12B, were enrolled in a multicenter, prospective cohort study. Patients were treated with plating or nailing. Outcome measures included the Disabilities of the Arm, Shoulder and Hand (DASH) score, Constant-Murley score, ranges of motion of the shoulder and elbow, radiographic healing, and complications until 1 year. Repeated-measure analysis was done with correction for age, sex, and fracture type. RESULTS: Of the 245 included patients, 76 were treated with plating and 169 were treated with nailing. Patients in the plating group were younger, with a median age of 43 years compared with 57 years for the nailing group (p &lt; 0.001). The mean DASH score after plating improved faster over time, but did not differ significantly from the score after nailing at 12 months (11.7 points [95% confidence interval (CI), 7.6 to 15.7 points]) for plating and 11.2 points [95% CI, 8.3 to 14.0 points] for nailing). The Constant-Murley score and shoulder abduction, flexion, external rotation, and internal rotation displayed a significant treatment effect (p treatment ≤ 0.001), in favor of plating. The plating group had 2 implant-related complications, whereas the nailing group had 24, including 13 nail protrusions and 8 screw protrusions. Plating resulted in more postoperative temporary radial nerve palsy (8 patients [10.5%] compared with 1 patient [0.6%]; p &lt; 0.001) and a trend toward fewer nonunions (3 patients [5.7%] compared with 16 patients [11.9%]; p = 0.285) than nailing. CONCLUSIONS: Plating of a humeral shaft fracture in adults results in faster recovery, especially of shoulder function. Plating was associated with more temporary nerve palsies, but fewer implant-related complications and surgical reinterventions, than nailing. Despite heterogeneity in implants and surgical approach, plating seems to be the preferred treatment option for these fractures. LEVEL OF EVIDENCE: Therapeutic Level II . See Instructions for Authors for a complete description of levels of evidence.</p

Treatment options in extra-articular distal radius fractures:a systematic review and meta-analysis

PURPOSE: This systematic literature review aimed to make a detailed overview on the clinical and functional outcomes and to get insight into the possible superiority of a treatment method for extra-articular distal radius fractures. METHODS: Embase, Medline, Cochrane Library, Web of Science, and Google Scholar were searched for studies describing treatment results. Five treatment modalities were compared: plaster cast immobilization, K-wire fixation, volar plating, external fixation, and intramedullary fixation. RESULTS: Out of 7,054 screened studies, 109 were included in the analysis. Overall complication rate ranged from 9% after plaster cast treatment to 18.5% after K-wire fixation. For radiographic outcomes, only volar tilt in the plaster cast group was lower than in the other groups. Apart from better grip strength after volar plating, no clear functional differences were found across treatment groups. CONCLUSION: Current literature does not provide uniform evidence to prove superiority of a particular treatment method when looking at complications, re-interventions, and long-term functional outcomes. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s00068-021-01679-z

Activities of daily living in lower limb amputees with a bone-anchored prosthesis:a retrospective case series with 24 months’ follow-up

Background and purpose:Little is known about the activities of daily living (ADL) of patients with a bone-anchored prosthesis (BAP). We aimed to objectively measure ADL without and with BAP during standard care of follow-up. Our secondary aim was to measure mobility and walking ability. Patients and methods:Patients aged 18–99 years who underwent surgery for transfemoral or transtibial BAP between September 11, 2017, and February 11, 2021, were eligible for inclusion in this retrospective case series of patients with socket prosthesis. ADL was measured with a continuous recording activity monitor (hours [h]) before surgery, and at 6, 12, and 24 months with BAP. Mobility and walking ability were assessed by the Timed Up and Go test (TUG) (seconds [s]) and 6 Minute Walk Test (6MWT) (meters [m]), respectively. Results:48 of the 57 eligible patients provided informed consent and were included. Their age was 59 (1st quartile to 3rd quartile 51–63) years. Total daily activity before BAP was 1.6 h (0.82–2.1) and increased to 2.1 h (1.4–2.5) at 6, 2.0 h (1.5–2.7) at 12, and 2.7 h (2.0–3.3) at 24 months with BAP. Daily walking increased from 1.3 h (0.79–1.9) before BAP to 1.8 h (1.6–2.3) at 6, to 1.7 h (1.2–2.4) at 12, and 2.0 h (1.6–2.6) at 24 months. Median TUG decreased from 12 s (9.1–14) before BAP to 8.9 s (7.7–10) at 24 months. Mean 6MWT increased from 272 m (SD 92) before BAP to 348 m (SD 68) at 24 months.Conclusion:Objective measurements on ADL positively changed in patients with BAP. This effect was also seen in mobility and walking ability at 24 months.</p