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Purpose The aim of this study was to compare the effectiveness of retrograde and antegrade intramedullary tibial nails (RTN and ATN) in managing extra-articular distal tibial fractures, addressing current controversies in surgical approaches. Patients and methods A retrospective analysis included 56 patients treated between December 2019 and August 2022 with either RTN ( n  = 23) or ATN ( n  = 33). Data on baseline characteristics, operative specifics, fluoroscopy usage, hospitalization duration, fracture healing times, time to full weight-bearing, distal tibial alignment, American Orthopedic Foot and Ankle Society (AOFAS) scores at final follow-up, and complications were evaluated and compared. Results Baseline characteristics were generally comparable and no significant differences except for fracture line lengths (RTN: 6.1 ± 1.9 cm vs. ATN: 7.8 ± 1.6 cm) were observed. Follow-up ranged from 12 to 20 months. No significant differences were observed in operative duration, hospital stays, coronal angulation of the distal tibial joint surface, or AOFAS scores at final follow-up. Intraoperative fluoroscopy was more frequent in the ATN group (9.5 ± 1.5) compared to RTN (8.3 ± 1.1) ( P  = 0.001). RTN showed shorter healing times (9.6 ± 1.2 weeks) and quicker return to full weight-bearing (12.9 ± 1.3 weeks) than ATN (10.6 ± 1.2 weeks and 13.9 ± 1.7 weeks, respectively). RTN complications included one delayed union, one superficial infection, and two ankle pain, while ATN complications comprised one delayed union, one superficial infection, seven anterior knee pain, and one malalignment. Despite higher complication rates with ATN, the differences were not statistically significant. Conclusion For the treatment of extra-articular distal tibial fractures, both RTN and ATN are effective approaches. RTN may offer benefits such as reduced fluoroscopy use, accelerated healing, and earlier return to full weight-bearing compared to ATN.

Background Fracture of the femur is one of the most common fractures that, if not stabilized and treated properly, may lead to severe disability, impairment of the individual’s efficiency, and numerous complications. This study aimed to evaluate the treatment results of femoral shaft fracture with two methods intramedullary nail (IMN) and Plate. Materials and methods In this cross-sectional study, 60 patients with femoral bone fractures were admitted to Imam Khomeini Hospital in Jiroft in 2020 and were treated for at least one year after discharge. They were divided into two treatment groups - Plate fracture fixation ( n  = 30) and IMN fracture fixation ( n  = 30). Data were collected using a researcher-made checklist including patient demographics and treatment outcomes. The collected data were analyzed using SPSS-v 26 statistical software and descriptive and inferential statistical tests at a significance level of p  < 0.05. Results Patients in the Plate treatment group were generally older (50–60 years) compared to the IMN treatment group (30–40 years), and there were more men than women in both groups. Only 10% of patients in each group developed superficial infections after surgery. There were more cases of deep infections in the Plate group, but it was not statistically significant. The IMN group had fewer cases of malignancy and claudication compared to the Plate group. Patients in the IMN group also returned to functional activities faster than those in the Plate group, which was a statistically significant difference. Conclusion Considering that deep infection, non-union, malunion, claudication, and ability to return to functional activities in the group using nails treated was less than the group treated with plates, the treatment method of femoral fracture using IMN is the preferred treatment method.

Purpose Knee arthrodesis is an established procedure for limb salvage in cases of recurrent infection, total knee arthroplasty soft tissue defect, poor bone stock or a deficient extensor mechanism. Surgical options include compression plate, external fixator and arthrodesis nail. Different types of nail exist: long fusion nail, short modular nail and bridging nail. This study presents the results on knee arthrodesis using different types of intramedullary nails. The aim is to assess if a specific type of nail has a better fusion rate, clinical outcome and lower complication rate. Methods A mono-centric retrospective study of 48 knees arthrodesis was performed between 2000 and 2018. 15 T2 ™ Arthrodesis Nail, 6 OsteoBridge ® Knee Arthrodesis and 27 Wichita ® fusion nail were used. The mean clinic and radiological follow-up was 9.8 ± 3.8 years (2.6–18 years). Results Fusion rate was 89.6%. Time to fusion was 6.9 months. Mean Parker score was 6.9/9 points. Visual Analogic Scale was 1.9. The Wichita ® fusion nail showed better results in terms of fusion, time to fusion and clinical outcome measured by Parker score and VAS but without statistical significance. The early revision rate was 10.4% and 20.8% presented a late complication requiring a surgery, due to nonunion or infection. 93.3% of infection was cured. Two patients live with a fistula (4.2%) and 1 was amputated (2.1%). Conclusion Although burdened by a big complication rate, knee arthrodesis with an intramedullary nail provides satisfactory results and is a good alternative to above-knee-amputation. The Wichita ® fusion nail shows a tendency to better results compared to the two other nails. Level of evidence Case series, level IV

Objective This study evaluated, in humeral diaphyseal fractures, how the InSafeLOCK intramedullary nail (IMN) compares with limited-contact dynamic compression plating (LC-DCP) in terms of radiologic and functional outcomes. The InSafeLOCK incorporates an internal, unicortical distal-locking feature intended to streamline distal fixation and potentially reduce neurovascular risk; however, its clinical performance has not previously been directly compared with conventional plating. Methods We retrospectively reviewed 93 adults who underwent surgery for humeral diaphyseal fractures between January 2016 and January 2023. Patients were treated with LC-DCP ( n  = 58; median age 43.5 years [IQR 29.3–69.8]) or the InSafeLOCK IMN ( n  = 35; median age 53.0 years [IQR 37.0–68.0]). Radiographic union, complications, and functional outcomes (DASH, ASES, Constant, and VAS) were assessed at 24 months; total follow-up duration beyond 24 months was recorded descriptively. Results Median union time among fractures that achieved union was 13 weeks (IQR 11–15) after LC-DCP and 12 weeks (IQR 11–15) after IMN ( p  = 0.401). Nonunion occurred in 3/58 patients (5.2%) after LC-DCP and 1/35 (2.9%) after IMN (risk ratio 1.81; 95% CI 0.20–16.73; Fisher’s exact p  = 1.00). Two transient iatrogenic radial nerve palsies occurred after plating (2/58, 3.4%) and none after IMN (0/35, 0.0%); the absolute risk difference was 3.4% (95% CI − 8.9 to 11.7) (Fisher’s exact p  = 0.53). At 24 months, DASH, ASES, Constant, and VAS scores were similar between groups (all p  > 0.05). Conclusion In this retrospective cohort, InSafeLOCK IMN and LC-DCP plating were associated with comparable radiographic and 24-month functional outcomes. Because complication events were infrequent and treatment allocation was nonrandomized, comparative safety conclusions should be interpreted cautiously. Larger prospective studies are needed to better define the role of internal distal locking systems.

In unstable pertrochanteric fractures, there are still debates regarding the complications and long-term benefits after internal fixation using short or long cephalomedullary nails. Therefore, a study was developed regarding this idea. From May 2017 to April 2020, 61 patients with unstable (AO 31-A2) and intertrochanteric fractures (AO 31-A3) were surgically operated on. During follow-up, 8 patients were excluded (lost or deceased). A total of 26 patients received internal short nail system fixation and 27 received a long nail system. All cases followed the standard 6-week rehabilitation protocol. Follow-up was at 3, 6 weeks, 3, 6 and 12 months, and clinical and functional assessment were determined by a different surgeon using the Visual Analogue Scale (VAS), Harris Hip Score (HHS) and Functional Ambulation Categories (FAC). A total of 42 (79.2%) had a 31.A2 fracture (21 in the long nail group and 21 in the short nail group) and 11 (20.8%) had a 31.A3 fracture (6 in long nail group and 5 in the short nail group). Surgical time was significantly longer (P<0.05) in the long nail group (an average of 81.38±12.01 min), compared with the short nail group (53.11±8.36 min). Blood loss was significantly higher (P<0.05) in the long nail group (210±12.1 ml) compared to the short nail group (75.4±14.8 ml). No statistical differences were noted regarding tip-apex distance (TAD) and VAS score. At 6 months, HHS was better for the short nail group (84.76±3.68) (P<0.05). Regarding the FAC scale, no significant statistical differences were identified. Cut-out occurred in 2 cases in the short nail group and 1 case from the long nail group. Only 1 peri-implant fracture occurred in a patient with a long cephalomedullary nail. In conclusion, the long cephalomedullary nail requires a longer surgical time and is associated with an increase in intraoperative blood loss without improving the functional outcome after 12 months postoperatively. A larger sample of cases is required to thoroughly analyze the postoperative complications.

Purpose This meta-analysis was designed to compare clinical outcomes, including knee scale score and nonunion rate, of patients with periprosthetic supracondylar fractures of the distal femur after total knee arthroplasty (TKA) who were treated using locking compression plates and retrograde intramedullary nails. Methods Studies were included in this meta-analysis if they compared clinical outcomes, including operation time, Knee Society Score (KSS), time to union, nonunion rate, and revision rate due to nonunion, in patients who underwent locking compression plate or retrograde intramedullary nail for periprosthetic distal femur fractures following TKA. Results Eight studies were included in this meta-analysis. Mean operation time was 11 min shorter (95 % CI −9.56 to 31.33 min; n.s.) and KSS one point higher (95 % CI −8.88 to 11.10; n.s.) with retrograde intramedullary nail than with locking compression plate, but these differences were not statistically significant. The two groups were also similar in mean time to union (0.46 weeks 95 % CI −1.17 to 2.08 weeks; n.s.), the proportion of subjects with nonunion (OR 0.83, 95 % CI 0.26–2.60; n.s.) and the proportion that underwent revision surgery (OR 0.88, 95 % CI 0.32–2.40; n.s.). Conclusions Clinical outcomes, including nonunion and revision rates, were similar in patients who underwent locking compression plate and retrograde intramedullary nail fixation for periprosthetic supracondylar femoral fracture following TKA. Orthopaedic surgeons must train to master both the retrograde intramedullary nail and locking compression plate techniques because both approaches can be considered for periprosthetic distal femur fracture after TKA as they have similar clinicoradiologic outcomes. Level of evidence II.

Objective: To compare peri and early post-operative complications in long versus short proximal femoral nails for unstable proximal femoral fractures. Study Design: Quasi-experimental study. Place and Duration of Study: Orthopaedic Department, Combined Military Hospital, Lahore Pakistan, Jan to Sep 2021. Methodology: We included all the patients who suffered from unstable proximal femur fractures diagnosed by a consultant orthopedic surgeon based on clinical and radiological findings. They were randomly divided into two groups. Group-A was managed by a long proximal femoral nail, while Group-B was managed by a short proximal femoral nail. Both groups were compared for peri- and early post-operative complications. Results: The final analysis included 110 patients. The mean age of the study participants was 63.66±8.553 years. 79(71.8%) were male, while 31(28.2%) were female. Peri- and early post-operative complications were not statistically different in both groups except for the duration of surgery. Patients undergoing long proximal femoral nail fixation had more chances of having surgery lasting more than 40 minutes than patients undergoing short femoral nail fixation (p-value-0.004). Conclusion: The peri- and early post-operative complications rate was almost similar in both groups. Patients undergoing long proximal femoral nail fixation had more chances of having prolonged surgery than patients undergoing short femoral nail fixation.

Objective This study aimed to evaluate the performance of five machine learning algorithms in predicting tibial intramedullary nail length using patient demographic data (gender, height, age, and weight), with the goal of developing a clinically relevant and accurate predictive model. Methods Retrospective data from 155 patients who underwent tibial intramedullary nailing at the Affiliated Jiangyin Hospital of Nantong University were analyzed. After data cleaning, outlier handling, and gender encoding, the dataset was divided into an 80% training set and 20% testing set. Models were trained and evaluated using root mean squared error (RMSE), mean absolute error (MAE), coefficient of determination (R 2 ), and correlation analysis. Key variables included height (cm), weight (kg), age (years), and gender. Results The XGBoost model demonstrated superior clinical precision, achieving the lowest testing RMSE (9.15 mm) and MAE (7.56 mm), with an R 2 of 0.871, explaining 87.1% of variance in nail length. While the random forest model had the highest R 2 (0.874) and correlation coefficient ( r  = 0.935), XGBoost outperformed all models in error metrics, critical for minimizing surgical complications. Variable importance analysis identified height as the most influential factor, followed by weight and age. All models achieved acceptable accuracy (≥ 86.21%) within a ± 15 mm error margin, compatible with intraoperative adjustments. Conclusions Machine learning, particularly XGBoost, significantly improves preoperative prediction of tibial intramedullary nail length compared with traditional methods. Level of evidence IV.

This study evaluates the mechanical behavior of bone-implant assemblies used in treating complex proximal humerus fractures, a clinical challenge due to the anisotropic nature of bone and variability in patient-specific conditions. The aim of this study was to compare the stability and stress distribution of three fixation methods: polyaxial locking plates, monoaxial locking plates, and intramedullary nails. Using 4th-generation composite humerus models, a four-part fracture (Neer IV) was simulated. The assemblies underwent axial compression testing using a universal testing machine, complemented by finite element analysis (FEA) and stereomicroscopy. The results indicate that while both plate types exhibited similar mechanical behavior-with stiffness values around 113-115 N/mm and failure initiated by plastic deformation of the implant-the intramedullary nail configuration demonstrated higher stiffness values under the tested experimental conditions (1084 N/mm), approximately 9.5 times higher than that of the plates. However, the nail assembly failed through brittle fracture of the bone rather than implant deformation. We conclude that while the intramedullary nail configuration demonstrated higher stiffness under the tested experimental conditions, its performance is heavily dependent on bone quality. In contrast, locking plates may provide a more gradual load-transfer behavior by transferring a greater proportion of the mechanical load to the implant, potentially making them more suitable for osteoporotic bone conditions, where reducing excessive stress concentration within the bone tissue may be beneficial.

Objective Although mini‐plate fixation is an attractive treatment option for distal radius metaphyseal diaphysis junction (DRMDJ) fractures in children, the benefits of minimally invasive fixation (MIF) with pre‐bent elastic stable intramedullary nails (MIF) remain underexplored. Therefore, this study aimed to evaluate the clinical efficacy of MIF administration in children with DRMDJ fractures. Methods This retrospective study enrolled 40 patients with DRMDJ fractures who underwent MIF or mini‐plate fixation from January 2016 to January 2021. Radiographic parameters, such as palmar inclination and ulnar deflection angle, were examined postoperatively to assess the anatomical reduction of the wrist joint. Clinical outcomes, including the range of wrist flexion and back extension, were examined to analyze the recovery of the wrist range of motion. Additionally, the Gartland–Werley scoring system was used to assess the recovery status of wrist function and healing condition. The student t‐test and χ2 test were used to compare differences among groups. Results All included patients successfully underwent the operation and were followed up for 12–24 months. Patients in the MIF group had a smaller surgical incision length (0.49 ± 0.06 cm) compared to those in the mini‐plate fixation group (4.41 ± 0.73 cm) (t = 22.438, p = 0.000). Palmar inclination and ulnar deflection were within the normal range in patients of both groups, and the fractures were successfully anatomically reduced. Moreover, wrist flexion and back extension in the MIF group and mini‐plate group were (72.50° ± 0.64° vs. 70.18° ± 0.56°) and (59.55° ± 1.75° vs. 60.04° ± 1.37°), and differences were statistically significant (t = 2.708, p = 0.010 and t = 0.885, p = 0.382, respectively). Furthermore, MIF treatment resulted in a higher proportion of excellent Gartland–Werley scores (94.44%) than mini‐plate fixation (86.36%) (p = 0.390). In addition, one case in the mini‐plate fixation group experienced re‐fracture following the removal of the internal fixation, and the fracture healed after reduction and cast fixation. All patients achieved satisfactory bone healing without other complications. Conclusion Compared with mini‐plate fixation, MIF has the advantages of small incision length, superior range of motion of thr wrist joint, and better maintenance of the physiological radian, providing a promising approach for clinical and surgical treatment of DRMDJ fractures. Compared with mini‐plates fixation, minimally invasive fixation combined with pre‐bent elastic stable intramedullary nails have the advantages of small scars, improve wrist joint range of motion, maintain the physiological radian and good curative effect, which provides a reference basis for clinical surgical treatment of DRMDJ fractures.