Prospective Randomised Control trial of 300 patients over a period of 3 years, 1 year post op follow up. Local ethic approval was attained for the study.

Inclusion criteria: Age > 60, Consented to Participate in the study, Unstable Inter trochanteric fracture a) Sub trochanteric b) Medial Comminution c) Reverse Obliquity D)Severe Osteoporosis. Patients selected were randomized to Intra medullary Nail vs Hips screw. Variety of markers have been assessed: Pre OP: - Mechanism of injury, Mobility status, Pre OP ASA, Pre Op haemoglobin, living Conditions. Intra OP:- I.I Time, Time taken, Surgeon experience, Intra OP complications. Post OP:- Haemoglobin, mobility, radiographic analysis-Fracture stability and Tip Apex Distance, Thrombo embolic Complications. Follow up: - 6 weeks, 3,6,12 month follow up.

There is considerable debate in literature regarding superiority of Compression Hip screw over Intra medullary nail for fixation of stable per trochanteric fractures of the femur. Biomechanical studies have shown superiority of Intra medullary device over a Compression Hip screw.

Tenser et all showed an advantage over combined bending and compression failure. Mohammad et al found unstable subtrochanteric fractures with a gamma nail were stiffer. Kerush-Brinker showed that gamma nail had significantly greater fatigue strength and fatigue life. In unstable fractures Baumgartner et al found less intra op complications and less fluoroscopic time for a compression hip screw compared to a short intra medullary nail. There have been significant reports of fracture at the Tip of a short intra medullary nail. We think this complication can be avoided by using a long intra medullary device.

Both in Australia and abroad the choice of which device to use depends largely on the preference of the surgeon.

To develop a novel modification of an existing technique¹ and to determine if it gives a precise and practical assessment of rotational alignment of the femur during the management of fractures with intramedullary nailing. It is hoped that this will help surgeons to avoid rotational malalignment which is reported to occur in 20–30% of femoral fractures managed with intramedullary nails².

Using trigonometry a procedure for accurately measuring the rotational alignment of the proximal femur was devised. This technique was performed on the fracture table with standard image intensification views and required a series of simple calculations. With the knowledge of the proximal rotational geometry of the femur the fractures were fixed according to normative data of femoral neck anteversion.

The clinical correlation was then assessed.

The development of the technique was successful. It was clinically practical and was associated with accurate rotational alignment in patients after intramedullary nailing of femoral fractures. This method was seen to be a useful adjunct to current nailing techniques with both educational and clinical benefits.

The described technique has clinical application and may help surgeons avoid rotation al malalignment when undertaking intramedullary nailing of fractures of the femur.

Bone transport/limb lengthening with circular external fixation has been associated with a prolonged period of time in the frame and a significant major complication rate following frame removal. We examined the results of bone transport in fifty-one limbs using the “monorail” technique and found a dramatically improved lengthening index (24.5 days/cm. – time in frame /cm. of length gained) and an absence of refracture or angulatory deformity following fixator removal. This technique is our treatment of choice for limb lengthening/bone transport.

We sought to determine patient oriented outcome and complication rates following b one transport using an external fixator placed over an intramedullary nail (the “monorail” technique).

Bone transport using the monorail technique is associated with a dramatically improved lengthening index and a lower major complication rate than traditional ring fixator methods. Patient satisfaction with the procedure was high.

Our study confirms the significant advantages of the monorail technique for bone transport/limb lengthening. The time in the fixator is dramatically reduced, and complications associated with earlier techniques such as angulatory deformity or refracture were not seen.

We identified forty-nine patients (fifty-one limbs) who had undergone bone transport using the monorail technique (external fixator placed over an intramedullary nail). There were thirty-five men and fourteen women with a mean age of thirty-five years (range 17–50). Pre-operative diagnoses included post traumatic length discrepancy/bone defect (forty-one), congenital short stature (six) and other (four). All patients had a unilateral fixator placed over an implanted intramedullary nail. Once length correction was achieved, the fixator was removed and the nail “locked”. The mean amount of lengthening was 5.5 cm. (range 2 – 18 cm.). The lengthening index was 24.5 days /cm. (duration of external fixation/cm. bone length gained), with a range from ten to fifty days /cm. There were nineteen complications (thirty-seven percent): nine premature consolidations, four infected pin sites, two hardware failures, two osteomyelitis, one DVT, one nonunion. There were no refractures, angulatory deformities or cases of intramedullary sepsis.

There are a variety of surgical approaches available for open reduction and internal fixation of acetabular fractures. Some centres have avoided the use of the triradiate approach in the belief that it may result in a significantly higher rate of heterotopic ossification. This has not been our experience. In contrast to many centres, acetabular fractures are treated in an emergent manner, with surgery usually undertaken within the first few days post injury. It is the investigators’ belief that this may in part result in a lower rate of heterotopic ossification.

The triradiate approach has fallen out of favour in the treatment of acetabular fractures due to concerns with both wound healing and heterotopic ossification. This approach however has been utilised frequently at the Vancouver General Hospital (VGH) in the treatment of acetabular fractures. The purpose of this study was to review the results and complications of this approach experienced in the large series at VGH.

We concluded that the results of this approach are acceptable with the exposure allowing anatomical fracture reduction in the vast majority of cases. The complication rate was low, as was the rate of heterotopic ossification.

The significance of this study is to highlight that this approach remains extremely useful in the treatment of acetabular fractures, due to its ability to give excellent exposure while still having an acceptably low complication rate. We believe that the ability of our unit to operate on these injuries in an emergent manner may impart the low rate of heterotopic ossification that we have observed.

There were a total of one hundred and sixty-one acetabular fractures that were treated operatively with the triradiate approach over the period 1989 to 2001. Of these, the majority were two column injuries (79 or 49%), T type fractures (34 or 21%) and transverse fractures (17 or 11%). The average age of the patients was thirty-seven years and the average time to surgery was three days. Our early complications included five cases of failure of fixation or loss of reduction of the fracture, two cases of neurovascular injury, two cases of superficial wound infection, one case of deep wound infection and one case of wound breakdown.

The study involved examining patient hospital records and radiographs and included fracture types, patient ages, delay to surgery, post-operative complications and degree of fracture reduction and healing. Grading of heterotopic ossification was performed by reviewing the anteroposterior radiographs and using Gruen’s classification system.

Introduction and Aims: The use of the triradiate approach has been associated with high rates of wound dehiscence, wound infection and significant heterotopic ossification. This approach has been the favoured extensile exposure at the Vancouver General Hospital for many years. We will review the outcomes of the use of this approach in the treatment of acetabular fractures.

Method: Patients were identified from the database at Vancouver General Hospital who had their acetabular fractures treated through a triradiate approach from the period January 1989 through to December 2001. Patients with a delay of greater than three weeks from injury were excluded. A retrospective review of the hospital and out-patient records and all available radiographs was performed. Patients were contacted to determine if they required any further surgery and to assess their current functional status with appropriate outcome scores. Patients were also invited to undergo repeat radiographic assessment.

Results: Of a total of 407 acetabular fractures treated surgically, 152 open reductions were performed through the triradiate approach. The average age of these patients was 38 years and 114 (75%) of these were male. Patients referred from other hospitals totalled 128 (84%). Wound outcomes were known in 138 cases. Wound complications included five cases of wound dehiscence, of which four resolved with no undue effects. There were three cases of superficial wound infection and five cases of deep wound infection. Two of the patients with deep wound infection had sustained compound acetabular injuries and a further two had significant risk factors for infection (septicaemia from chest infection and significant soft tissue necrosis). Trochanteric osteotomy was performed in 139 (91%) cases. There were only two cases of trochanteric non-union in this series, however 21 cases required removal of painful trochanteric screws. With respect to heterotopic ossification, there was a 15% Broker III/IV incidence. In this group, the injury severity scores were higher, there was a greater delay to surgery and there was a greater need for mechanical ventilation due to multiple injuries. In the group, 24 hip reconstructions were required over the period.

Conclusion: In our centre, we found a low rate of wound dehiscence and deep wound infection associated with the triradiate approach in the treatment of acetabular fractures. Both open acetabular fractures developed deep infection. Trochanteric irritation was a problem in a number of the patients. The rate of significant hetero-topic ossification was low.