Infected non-unions of proximal femoral fractures are difficult to treat. If debridement and revision fixation is unsuccessful, staged revision arthroplasty may be required. Non-viable tissue must be resected, coupled with the introduction of an antibiotic-eluting temporary spacer prior to definitive reconstruction. Definitive tissue microbiological diagnosis and targeted antibiotic therapy are required. In cases of significant proximal femoral bone loss, spacing options are limited.

We present a case of a bisphosphonate-induced subtrochanteric fracture that progressed to infected non-union. Despite multiple washouts and two revision fixations, the infection remained active with an unfavourable antibiogram. The patient required staged revision arthroplasty including a proximal femoral resection. To enable better function by maintaining leg length and offset, a custom-made antibiotic-eluting articulating temporary spacer, the Cement-a-TAN, was fabricated. Using a trochanteric entry cephalocondylar nail as a scaffold, bone cement was moulded in order to fashion an anatomical, patient-specific, proximal femoral spacer. Following resolution of the infection, the Cement-a-TAN was removed and a proximal femoral arthroplasty was successfully performed.

Cement-a-TAN is an excellent temporary spacing technique in staged proximal femoral replacement for infected non-union of the proximal femur where there has been significant bone loss. It preserves mobility and maintains leg length, offset and periarticular soft-tissue tension.

Various operative treatments have been proposed for proximal humeral fractures. The purpose of our study was to compare complications of plate versus nail for these proximal humeral fractures and to determine whether it is the implant or fracture and surgeon related factors which result in complications. We had 74 patients operated from March 2006 till June 2008 for displaced 3 (49pts) or 4 (25pts) part proximal humeral fractures. 43 had plating (PHILOS) and 31 had a humeral nail inserted. 57 patients were over 60 years at presentation while 17 were younger than 60. All patients were followed regularly radiologically. The functional outcomes were assessed by Quick DASH score and were comparable in both groups at 1 year postoperatively.18 of the 43 patients in the Plating group had a radiological complication with 9 cases of screw cut-out, 5 fractures maluniting and 1 nonunion. There was no case of osteonecrosis. In the nailing group, 13 patients had radiological complications, with 8 patients having varus malunion, 3 having proximal screw loosening and 1 having osteonecrosis apart from the clinical complications of impingement and rotator cuff problems. Given the similar complication rate and similar functional outcome achieved by both these techniques it is hard to determine if any one in particular is better than the other. The key determining factors for a proximal humeral fracture might actually be patient and surgeon related. It is important to achieve medial continuity and good initial reduction in these fractures to prevent them from collapsing into varus, especially with the nails. Also, patient age, osteoporosis and functional demand are factors determining success of surgery in these patients. We did not find the severity of the fracture to be a determining factor, maybe this was because the relative proportion of type 4 fractures in our series was less

Statement of purpose of study: To determine how effective Flexible Intramedullary Nails are in treating tibial and femoral fractures in adolescents. Summary of Methods used: Retrospective review of consecutive adolescent patients treated over a seven year period with Flexible Intramedullary Nails for tibial and femoral fractures. Statement of Conclusion: We conclude that the higher than expected rates of malunion and delayed union suggest that other treatments should be considered when treating adolescents with unstable tibial or femoral fractures. Introduction Flexible intramedullary nails (FIN) are increasingly used in the management of paediatric tibial and femoral fractures. Recently, concerns have been raised regarding the use of FIN in older children. The aim of this study was to determine how effective FIN's are in treating tibial and femoral fractures in adolescents. Methods Hospital records were used to identify all patients aged 11 years or older under going FIN for tibial and femoral fractures between 2003 and 2009. Radiographs and case notes were reviewed to identify complications. Results 35 consecutive adolescent patients underwent FIN for tibial (n=21) and femoral fractures (n=15) with a mean age of 12.9 years. 2 femoral and 9 tibial fractures were open. Eight patients sustained multiple injuries. Mean radiographic follow up was 29 weeks. 60% (n=9) and 38% (n=9) of femoral and tibial fractures respectively malunited. Fracture severity was associated with increased malunion for both tibial and femoral fractures (P=0.046 and P=0.044 respectively). There were no cases of non-union. 2 femoral fractures took longer than 20 weeks to unite and 7 tibial fractures took longer than 16 weeks to unite. One patient developed post operative compartment syndrome, one patient developed deep infection and two patients were treated with post operative traction for loss of fracture position. Discussion Previous publications from multiple centres, including ours, have demonstrated excellent results of FIN for tibial and femoral fractures in the general paediatric population. However, concerns have recently been raised about the use of FIN in older, heavier children and with unstable fracture patterns. This is the first published series of adolescent patients undergoing FIN. We conclude that the higher than expected rates of malunion and delayed union suggest that other treatments should be considered when treating adolescents with unstable tibial or femoral fractures

Aim: Evaluation of intermediate clinical and radiographic results of displaced intra-articular fractures of the calcaneus treated with ORIF. Materials- Methods: From 1994 to 2002, 167 displaced intra-articular fractures of the calcaneus were treated with ORIF. There were 145 male and 12 female patients. Mean age 34 years. Standard x-rays, Broden views and CT-scan images in coronal and transverse plane were obtained pre and post operatively. Fractures were classified as type III, IV, V according to Sanders. All fractures were approached through an extended lateral L-type approach. AO calcaneal plate was used. Average follow-up was 5 years. Results: In 143 Sanders type III and IV fractures KITA-OKA score was 91. Reduction failure rate was 5.5%(8 pts). 24 patients had Sanders type V fractures and KITAOKA score was 84 and reduction failure rate was 25% (6 pts). 29/167 patients complained of peroneal tendons tenderness which subsided after hardware removal. 79/167 patients had restriction of subtalar joint movements but no complains (SF_36) There were two superficial wound infections and five patients with delayed wound closure. In a group of 45 patients with similar fracture patterns who were treated conservatively, KITA-OKA score was 71, 41 fractures were malunited, 40 patients had moderate to severe pain and early OA sings. Conclutions: Displaced intra-articular fractures of the calcaneus should be treated as any other displaced intra-articular fracture, with open reduction and stable internal fixation