Hip fractures frequently occur in elderly patients with osteoporosis and are rapidly increasing in prevalence owing to an increase in the elderly population and social activities. We experienced several recent presentations of TFNA nails failed through proximal locking aperture which requires significant revision surgery in often highly co-morbid patient population. The study was done by retrospective data collection from 2013 to 2023 of all the hip fractures which had been fixed with Cephalomedullary nails to review and compare Gamma (2013–2017) and TFNA (2017–2023) failure rates and the timing of the failures. Infected and Elective revision to Arthroplasty cases were excluded. The results are 1034 cases had been included, 784 fixed with TFNA and 250 cases fixed Gamma nails. Out of the 784 patients fixed with TFNA, 19 fixation failed (2.45%). Out of the 250 cases fixed with Gamma nails, 15 fixation failed (6%). Mean days for fixation failure were 323 and 244 days in TFNA and Gamma nails respectively. We conclude that TFNA showed remarkable less failure rates if compared to Gamma nails. At point of launch, testing was limited and no proof of superiority of TFNA over Gamma nail. Several failures identified with proximal locking aperture in TFNA which can be related to the new design which had Substantial reduction in lateral thickness at compression screw aperture

A number of techniques have been developed to improve the immediate mechanical anchorage of implants for enhancing implant longevity. This issue becomes even more relevant in patients with osteoporosis who have fragile bone. We have previously shown that a dynamic hip screw (DHS) can be augmented with a calcium sulphate/hydroxyapatite (CaS/HA) based injectable biomaterial to increase the immediate mechanical anchorage of the DHS system to saw bones with a 400% increase in peak extraction force compared to un-augmented DHS. The results were also at par with bone cement (PMMA). The aim of this study was to investigate the effect of CaS/HA augmentation on the integration of a different fracture fixation device (gamma nail lag-screw) with osteoporotic saw bones. Osteoporotic saw bones (bone volume fraction = 15%) were instrumented with a gamma nail without augmentation (n=8) or augmented (n=8) with a CaS/HA biomaterial (Cerament BVF, Bonesupport AB, Sweden) using a newly developed augmentation method described earlier. The lag-screws from both groups were then pulled out at a displacement rate of 0.5 mm/s until failure. Peak extraction force was recorded for each specimen along with photographs of the screws post-extraction. A non-parametric t-test was used to compare the two groups. CaS/HA augmentation of the lag-screw led to a 650% increase in the peak extraction force compared with the controls (p<0.01). Photographs of the augmented samples shows failure of the saw-bones further away from the implant-bone interface indicating a protective effect of the CaS/HA material. We present a novel method to enhance the immediate mechanical anchorage of a lag-screw to osteoporotic bone and it is also envisaged that CaS/HA augmentation combined with systemic bisphosphonate treatment can lead to new bone formation and aid in the reduction of implant failures and re-operations

Aims

The primary aim of this study was to compare the migration of the femoral and tibial components of the cementless rotating platform Attune and Low Contact Stress (LCS) total knee arthroplasty (TKA) designs, two years postoperatively, using radiostereometric analysis (RSA) in order to assess the risk of the development of aseptic loosening. A secondary aim was to compare clinical and patient-reported outcome measures (PROMs) between the designs.

Aims

There are concerns regarding nail/medullary canal mismatch and initial stability after cephalomedullary nailing in unstable pertrochanteric fractures. This study aimed to investigate the effect of an additional anteroposterior blocking screw on fixation stability in unstable pertrochanteric fracture models with a nail/medullary canal mismatch after short cephalomedullary nail (CMN) fixation.

Aims

A lack of supporting clinical studies have been published to determine the ideal length of intramedullary nail in fixation of trochanteric fractures of the hip. Nevertheless, there has been a trend to use shorter intramedullary nails for the internal fixation of trochanteric hip fractures. Our aim was to determine if the length of nail affected the outcome.

Objectives

The paradoxical migration of the femoral neck element (FNE) superomedially against gravity, with respect to the intramedullary component of the cephalomedullary device, is a poorly understood phenomenon increasingly seen in the management of pertrochanteric hip fractures with the intramedullary nail. The aim of this study was to investigate the role of bidirectional loading on the medial migration phenomenon, based on unique wear patterns seen on scanning electron microscopy of retrieved implants suggestive of FNE toggling.

Aims

The aim of this study was to evaluate the outcomes of a salvage procedure using a 95° angled blade plate for failed osteosynthesis of atypical subtrochanteric femoral fractures associated with the long-term use of bisphosphonates. These were compared with those for failed osteosynthesis of subtrochanteric fractures not associated with bisphosphonate treatment.

Objectives

The monitoring of fracture healing is a complex process. Typically, successive radiographs are performed and an emerging calcification of the fracture area is evaluated. The aim of this study was to investigate whether different bone healing patterns can be distinguished using a telemetric instrumented femoral internal plate fixator.

Infected nonunion of the femur or tibia diaphysis requires resection of infected bone, stabilization of bone and reconstruction of bone defect. External fixation of the femur is poorly tolerated by patients. In 2004 authors introduced in therapy for infected nonunions of tibia and femur diaphysis coating of IMN with a layer of antibiotic loaded acrylic cement (ALAC) containing 5% of culture specific antibiotic. Seven patients with infected nonunion of the diaphysis of femur (2) and tibia (2) were treated, aged 20–63 years, followed for 2–9 years (average 5,5 years). All have been infected with S. aureus (MSSA: 2 and MRSA: 4) or Staph. epidermidis (1) and in one case with MRSA and Pseudomonas aeruginosa. All patients underwent 3 to 6 operations before authors IMN application. Custom-made IMN coated with acrylic cement (Palamed) loaded fabrically with gentamycin with admixture of 5% of culture-specific antibiotic: vancomycin (7 cases) and meropeneme (1 case) was used for bone stabilization. Static interlocking of IMN was applied in 4 cases and dynamic in 2 cases. In 1 case the femur was stabilized with IMN without interlocking screws. In 2 cases IMN was used for fixation of nonunion at docking site after bone transport. In 3 cases ALAC was used as temporary defect filling and dead space management. In one case after removal of IMN coated with ALAC, a new custom made Gamma nail and tubular bone allograft ranging 11 cm was used for defect reconstruction. Infection healing was achieved in all 7 cases, bone union was achieved in 4 from 7 cases. In 1 case of segmental diaphyseal defect ranging over 12 cm infection was healed, but bone defect was not reconstructed. This patient is waiting for total femoral replacement. In another case of segmental defect of 11 cm infection is healed, but allograft substitution and remodeling by host bone is poor. In the 3rd case of lacking bone healing, the 63 year old patients was noncooperative and not willing to walk in walker with weight bearing. This patient refused further treatment. Custom-made intramedullary nail coated with a layer of acrylic cement loaded with 5% of culture specific antibiotic can provide local infection control, offer comfortable bone stabilization, and replace standard IM nail in therapy for difficult to treat infected diaphyseal nonunion of femur or tibia

The aim of this study was to quantify the stability of fracture-implant complex in fractures after fixation. A total of 15 patients with an undisplaced fracture of the femoral neck, treated with either a dynamic hip screw or three cannulated hip screws, and 16 patients with an AO31-A2 trochanteric fracture treated with a dynamic hip screw or a Gamma Nail, were included. Radiostereometric analysis was used at six weeks, four months and 12 months post-operatively to evaluate shortening and rotation. Migration could be assessed in ten patients with a fracture of the femoral neck and seven with a trochanteric fracture. By four months post-operatively, a mean shortening of 5.4 mm (-0.04 to 16.1) had occurred in the fracture of the femoral neck group and 5.0 mm (-0.13 to 12.9) in the trochanteric fracture group. A wide range of rotation occurred in both types of fracture. Right-sided trochanteric fractures seem more rotationally stable than left-sided fractures. This prospective study shows that migration at the fracture site occurs continuously during the first four post-operative months, after which stabilisation occurs. This information may allow the early recognition of patients at risk of failure of fixation. Cite this article: Bone Joint J 2015;97-B:391–7

Malpositioning of the trochanteric entry point during the introduction of an intramedullary nail may cause iatrogenic fracture or malreduction. Although the optimal point of insertion in the coronal plane has been well described, positioning in the sagittal plane is poorly defined.

The paired femora from 374 cadavers were placed both in the anatomical position and in internal rotation to neutralise femoral anteversion. A marker was placed at the apparent apex of the greater trochanter, and the lateral and anterior offsets from the axis of the femoral shaft were measured on anteroposterior and lateral photographs. Greater trochanteric morphology and trochanteric overhang were graded.

The mean anterior offset of the apex of the trochanter relative to the axis of the femoral shaft was 5.1 mm (sd 4.0) and 4.6 mm (sd 4.2) for the anatomical and neutralised positions, respectively. The mean lateral offset of the apex was 7.1 mm (sd 4.6) and 6.4 mm (sd 4.6), respectively.

Placement of the entry position at the apex of the greater trochanter in the anteroposterior view does not reliably centre an intramedullary nail in the sagittal plane. Based on our findings, the site of insertion should be about 5 mm posterior to the apex of the trochanter to allow for its anterior offset.

Cite this article: Bone Joint J 2014;96-B:1274–81.

The April 2014 Oncology Roundup³⁶⁰ looks at: Eyeball as good as microscope for tumour margins; when is best to stabilise femoral metastases?; fluorine does not cause bone tumours; whether giant cell tumour of the proximal femur ever successfully managed; extraskeletal osteosarcoma; modular lower limb tumour reconstruction; and observational studies the basis for most bone tumour treatment.

The February 2014 Hip & Pelvis Roundup³⁶⁰ looks at: length of stay; cementless metaphyseal fixation; mortality trends in over 400,000 total hip replacements; antibiotics in hip fracture surgery; blood supply to the femoral head after dislocation; resurfacing and THR in metal-on-metal replacement; diabetes and hip replacement; bone remodelling over two decades following hip replacement; and whether bisphosphonates affect acetabular fixation.

The Gamma nail is frequently used in unstable peri-trochanteric hip fractures. We hypothesised that mechanical failure of the Gamma nail was associated with inadequate proximal three-point fixation. We identified a consecutive series of 299 Gamma nails implanted in 299 patients over a five-year period, 223 of whom fulfilled our inclusion criteria for investigation. The series included 61 men and 162 women with a mean age of 81 years (20 to 101). Their fractures were classified according to the Modified Evans’ classification and the quality of fracture reduction was graded. The technical adequacy of three points of proximal fixation was recorded from intra-operative fluoroscopic images, and technical inadequacy for each point was defined. All patients were followed to final follow-up and mechanical failures were identified. A multivariate statistical analysis was performed, adjusting for confounders. A total of 16 failures (7.2%) were identified. The position of the lag screw relative to the lateral cortex was the most important point of proximal fixation, and when inadequate the failure rate was 25.8% (eight of 31: odds ratio 7.5 (95% confidence interval 2.5 to 22.7), p < 0.001). Mechanical failure of the Gamma nail in peri-trochanteric femoral fractures is rare (< 1%) when three-point proximal fixation is achieved. However, when proximal fixation is inadequate, failure rates increase. The strongest predictor of failure is positioning the lateral end of the lag screw short of the lateral cortex. Adherence to simple technical points minimises the risk of fixation failure in this vulnerable patient group. Cite this article: Bone Joint J 2013;95-B:825–30

Objectives

Because of the contradictory body of evidence related to the potential benefits of helical blades in trochanteric fracture fixation, we studied the effect of bone compaction resulting from the insertion of a proximal femoral nail anti-rotation (PFNA).