Alexios Dimitrios Iliadis

Purpose The incidence of proximal tibia extra-articular fractures is fairly common accounting for approximately 5–11% of all tibia fractures (Lang in Clin Orthop Relat Res 315:64–74, 1995; Freedman in Clin Orthop Relat Res 315:25–33, 1995). The optimal treatment method for these fractures between intramedullary nailing and proximal locking plate remains equivocal. The purpose of this meta-analysis is to assess the clinical, radiological, and functional outcomes as well as the complications in adult patients with extra-articular proximal tibia fractures treated with IMN or PLP. Materials and methods We performed a systematic literature search identifying comparative studies meeting the above criteria and published from January 2000 to May 2024 from four databases: MEDLINE, EMBASE, Google Scholar, and Cochrane Library. We performed the meta-analysis in accordance with PRISMA guidelines, and the study was prospectively registered on PROSPERO. Results Of the 761 studies identified, nine (9) met our inclusion criteria. Six hundred and sixty-two patients (320 IMN and 342 PLP) were evaluated with a minimum follow-up of 12 months. IMN demonstrated a lower union time [OR = − 2.83, 95% CI: − 4.8–0.87, p = 0.005, I² = 73%] and infection rate [OR 0.49, 95%: 0.27–0.92, p = 0.03, I² = 0%], while the PLP group had a lower incidence of anterior knee pain [5.07, 95% CI: 1.77–14.48, p = 0.002, I² = 0%]. No significant difference was noted in terms of non-union, malunion, delayed union rate, revision rate, knee ROM, malalignment, operative time, and hospital stay. Conclusion IMN demonstrated shorter union time and risk of infection, while LP fixation displayed significantly lower risk for anterior knee pain. Although successful results can be achieved with both implants, further research is required on this topic to provide definitive evidence.

Fracture Related Infection (FRI) represents one of the biggest challenges for Trauma and Orthopaedic surgery. A better understanding of the microbiological profile should assist with decision-making and optimising outcomes. Our primary aim was to report on the microbiological profile of FRI cases treated over a six-year period at one of Europe’s busiest trauma centres. Secondarily, we sought to correlate our findings with existing anti-microbiological protocols and report on diagnostic techniques employed in our practice. All adult cases of FRI treated in our institution between 2016 and 2021 were identified, retrospectively. We recorded patient demographics, diagnostic strategies, causative organisms and antibiotic susceptibilities. There were 330 infection episodes in 294 patients. A total of 463 potentially pathogenic organisms (78 different species) were identified from cultures, of which 57.2% were gram-positive and 39.7% gram-negative. Polymicrobial cultures were found in 33.6% of cases and no causative organism was found in 17.5%. The most prevalent organisms were Staphylococcus aureus (24.4%), coagulase-negative Staphylococci (14%), Pseudomonas aeruginosa (8.2%), Enterobacter species (7.8%) and Escherichia coli (6.9%). Resistant gram-positive organisms (methicillin resistant Staphylococcus aureus or vancomycin-resistant Enterococci) were implicated in 3.3% of infection episodes and resistant gram-negatives (extended-spectrum beta-lactamase, ampC or carbapenemase-producing bacteria) in 13.6%. The organisms cultured in 96.3% of infection episodes would have been covered by our empirical systemic antibiotic choice of teicoplanin and meropenem. To our knowledge, this is the largest reported single-centre cohort of FRIs from a major trauma centre. Our results demonstrate patterns in microbiological profiles that should serve to inform the decision-making process regarding antibiotic choices for both prophylaxis and treatment.

Fracture-related infection (FRI) is one of the most challenging complications following operative management of fractures. It can have profound implications for the patient, can be associated with considerable morbidity and often lead to impaired outcomes. There are significant healthcare-related costs. In recent years, there has been significant progress towards developing preventative strategies. Furthermore, diagnostic algorithms and management protocols have recently been reported. Lack of a strong evidence base has previously hindered efforts to implement these and develop established standards of care. There are multiple aspects of care that need to be considered and a multi-disciplinary approach is recommended. In this narrative review, we present the most up-to-date recommendations in the prevention, diagnosis and management of FRI.

We have encountered four cases with Taylor spatial frames (TSF) (Smith & Nephew, Memphis, TN, USA) with breakage at the half-ring junction of the distal ring. This study examines the strain produced on different locations of the distal ring during loading and the effects on the strain of altering the frame construct. We mounted two ring TSF constructs on tibia saw bone models. The proximal ring was the same in all constructs and consisted of a 2/3 180 mm ring attached with three wires. Construct 1 is reproducing the configuration of cases where failure was seen. The distal 155 mm ring is attached with three half pins. The half-ring junction is located in the midline. Construct 2 has a different half pin placement and an additional wire on the distal ring. Constructs 3 and 4 have the same half pin configuration to construct 1 but the distal ring is rotated 60° internally and externally, respectively. Strain gauges were attached to different locations and measurements recorded during loading. Statistical analysis was performed. Highest strain values were recorded at the half-ring junction of constructs 1 and 2 (>600 microstrains (με) in tension). Rotating the ring 60° internally significantly reduces the strain at the half-ring junction (<300 με) whilst external rotation by 60° further reduces the strain (<180 με). Ring strain is higher in areas close to half pin attachments. The highest strain is in the half-ring junction as the half rings are subjected to different loading modes. The thickness of the half-ring is halved and the second moment of area reduced further increasing breakage risk. Placing this junction close to the half pin–frame interface, as dictated by the anatomical safe zone further increases the strain. Rotating the distal ring 60° significantly reduces the strain at the half-ring junction. Ring breakage is a rare but significant complication. This is the first study to address this potential mode of TSF failure. Insights and technical tips from this study can help reduce this. Iliadis AD, Bebja R, Wang K, et al. Reducing the Risk of Ring Breakage in Taylor Spatial Frames: The Effect of Frame Configuration on Strain at the Half-ring Junction. Strategies Trauma Limb Reconstr 2020;15(3):146–150.

The use of intramedullary lengthening devices is becoming increasingly popular. There are limited data regarding the incidence of venous thromboembolism following intramedullary lengthening surgery and no reports or guidance for current practice on use of thromboprophylaxis. Following a case of post-operative deep vein thrombosis in our institution, we felt that it is important to assess best practice. We conducted a national survey to collect data that would describe current practice and help develop consensus for treatment. We identified surgeons across the UK that perform adult intramedullary limb lengthening through the British Limb Reconstruction Society membership and a Precise Users database. Surgeons were contacted and asked to respond to an online survey. Responses to thromboprophylaxis regimes employed in their practice and cases of venous thromboembolism were collated. 24 out of 54 surgeons identified responded with a total of 454 cases of adult intramedullary lengthening (352 femoral and 102 tibial nails) performed over a five year period (January 2015–January 2020). Only one case of deep venous thrombosis (DVT) following femoral lengthening was reported. There is wide variability in practice both in terms of thromboprophylaxis risk assessment, choice of medications and duration of treatment. The vast majority of surgeons (85%) felt that there was insufficient evidence available to guide their practice. Intramedullary lengthening is a surgical treatment growing in popularity. There are limited data available to guide decision-making regarding aspects of treatment such as thromboprophylaxis. This is reflected in the wide variation in practice reported in this study. There are both a need and a desire to gather data that will allow us to come to a consensus and to guide safe practice. Venous thromboembolism is a potential complication of lower limb lengthening surgery. We report on national incidence and current practices of thromboprophylaxis to allow for informed decision-making and help develop consensus for best practice. Iliadis AD, Timms A, Fugazzotto S, et al. Thromboprophylaxis in Intramedullary Limb Lengthening Surgery. Strategies Trauma Limb Reconstr 2020;15(3):151-156.