Aims. The aim of this study was to assess the safety and clinical outcome of patients with a femoral shaft fracture and a previous complex post-traumatic femoral malunion who were treated with a clamshell osteotomy and fixation with an intramedullary nail (IMN). Methods. The study involved a retrospective analysis of 23 patients. All had a previous, operatively managed, femoral shaft fracture with malunion due to hardware failure. They were treated with a clamshell osteotomy between May 2015 and March 2020. The mean age was 42.6 years (26 to 62) and 15 (65.2%) were male. The mean follow-up was 2.3 years (1 to 5). Details from their medical records were analyzed. Clinical outcomes were assessed using the quality of correction of the deformity, functional recovery, the healing time of the fracture, and complications. Results. The mean length of time between the initial injury and surgery was 4.5 years (3 to 10). The mean operating time was 2.8 hours (2.05 to 4.4)), and the mean blood loss was 850 ml (650 to 1,020). Complications occurred in five patients (21.7%): two with wound necrosis, and three with deep vein thrombosis. The mean coronal deformity was significantly corrected from 17.78° (SD 4.62°) preoperatively to 1.35° (SD 1.72°) postoperatively (p < 0.001), and the mean sagittal deformity was significantly corrected from 20.65° (SD 5.88°) preoperatively to 1.61° (SD 1.95°; p < 0.001) postoperatively. The mean leg length discrepancy was significantly corrected from 3.57 cm (SD 1.27) preoperatively to 1.13 cm (SD 0.76) postoperatively (p < 0.001). All fractures healed at a mean of seven months (4 to 12) postoperatively. The mean Lower Extremity Functional Scale score improved significantly from 45.4 (SD 9.1) preoperatively to 66.2 (SD 5.5) postoperatively (p < 0.001). Partial cortical nonunion in the deformed segment occurred in eight patients (34.8%) and healed at a mean of 2.4 years (2 to 3) postoperatively. Conclusion. A clamshell osteotomy combined with IMN fixation in the treatment of patients with a femoral shaft fracture and a previous post-traumatic femoral malunion achieved excellent outcomes. Partial cortical nonunions in the deformed segment also healed satisfactorily. Cite this article: Bone Joint J 2023;105-B(4):449–454

Patients with a femoral shaft fracture requiring intra-medullary nailing were recruited to investigate if the femoral canal could be a potential source of inflammatory cytokines, previously implicated in the pathogenesis of life-threatening inflammatory complications. Femoral and peripheral blood samples were obtained at the time of surgery from patients with a femoral shaft fracture requiring intramedullary nailing. The local femoral intramedullary and peripheral release of a group of ten Th1 and Th2 cytokines concentrations (IL-1b, IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, GM-CSF, TNF-a and IFN-g) after femoral shaft fracture and intramedullary reaming, if performed, was measured using a Human Cytokine Antibody 10-plex Bead Kit. A control group of patients(n=3) undergoing hip replacement was established to allow comparison with the normal femoral intramedullary cytokine environment. 21 patients with a femoral shaft fracture were recruited. Femoral shaft fracture caused a significant increase in the local femoral concentrations of IL-6 (median 3967pg/ml; range 128–25,689pg/ml) and IL-8 (median 238pg/ml; range 8–8,288pg/ml) compared to the femoral control group(p=0.0005 and p=0.001 respectively). No significant local femoral release of the other cytokines was demonstrated. In the patients who underwent intramedullary reaming of the femoral canal (n=6), a further significant local release of IL-6 (median post-ream 15,903pg/ml; range 1,854–44,922pg/ml) and IL-8 (median post-ream 1,443pg/ml; range 493–3,734pg/ml) was demonstrated (p=0.01 and p=0.03 respectively), thus showing that intramedullary reaming can cause a significant local inflammatory response. Femoral shaft fracture produces a local inflammatory response releasing large amounts of the cytokines IL-6 and IL-8 into the local femoral environment but not of the other Th1 and Th2 cytokines studied. Reaming, produced significant elevation in local femoral IL-6 and IL-8 concentration, suggesting a local femoral response as a result of this procedure. Possibly, local femoral environment may act as a cell-priming or stimulating zone, for circulating inflammatory cells

This study investigated the effect presence, method, and timing of fixation of femoral shaft fractures have on the morbidity and mortality of patients with pulmonary contusion. In the multiply-injured patient with femoral shaft fractures, early (< 24 hours) fracture stabilization with closed, reamed, statically-locked intramedullary nailing has been shown to decrease morbidity and mortality. Controversy exists as to whether such treatment compromises the outcome in patients that have significant co-existing pulmonary injury. This study is the first to specifically investigate the sub-group of patients that have pulmonary contusion. A retrospective review of patients presenting to a Level One trauma center from 1990 to 2002 with pulmonary contusion identified three hundred and twenty-two cases. Patient characteristics of age, sex, GCS, ISS, AIS, presence of femoral shaft fracture, method and timing of treatment of femoral shaft fracture, and presence of other pulmonary injuries were recorded, as were the outcomes of pulmonary complications (acute lung injury (ALI), ARDS, fat embolism syndrome, pulmonary embolism, and pneumonia), days on ventilatory support, days in the intensive care unit and ward, and death. There were no significant differences in the patient characteristics between groups with and without femoral shaft fracture. Except for an increased likelihood of the femoral shaft fracture group having ALI (RR 1.11), there were no significant differences in outcomes between the femur fracture/non-femur fracture groups. As well, there were no significant differences in outcomes between the groups that had fracture fixation before or after twenty-four hours or had the fracture fixed with or without intramedullary nailing. The presence, method, and timing of treatment of femoral shaft fractures do not increase the morbidity or mortality of trauma patients that have pulmonary contusion

Intramedullary locking nails have proved to be of considerable advantage when treating complex, comminuted or segmental femoral shaft fractures. We have reviewed 117 patients with 120 femoral shaft fractures treated with the Strasbourg device. These included 20 compound fractures, 13 pathological fractures and two non-unions. Rehabilitation and union rates have been very satisfactory and there have been no serious infections in the series. Comminution of the proximal femur has occurred in six patients and there have been three femoral neck fractures, but all of these have healed without further complications

Fractures of the femoral shaft are generally considered to affect young patients, but we have reviewed 24 cases in patients over 60 years who have been treated by locked nailing, usually by closed methods. Most were women with low-velocity injuries, but despite this, 14 fractures were significantly comminuted. The complication rate was 54% with a peri-operative mortality of 17%. Most complications were the general ones of operating on elderly patients. Specific complications included: fractures below an abnormal hip, proximal fracture related to the nail and poor purchase in the distal femur. In all survivors, the femoral shaft fractures united satisfactorily, and the fixation allowed early mobilisation. The locking nail appears to be an effective method of managing femoral shaft fractures in the elderly patient

The torsion of both femora was evaluated in 110 patients who had been treated by intramedullary nailing for unilateral femoral shaft fractures. The anteversion (AV) angle was measured by ultrasound, using a tilted-transducer technique. True torsional deformity, defined as an AV difference of 15 degrees or more between sides was found in 21 patients, but only eight had complaints related to the deformity. Three patients had reoperations for troublesome external torsional deformities. Of 26 patients with AV differences of 10 degrees to 14 degrees, defined as possible torsional deformity, three had complaints, but none had serious problems. AV differences of up to 29 degrees were observed in symptom-free patients, and no patients with AV differences below 10 degrees had complaints. Static and dynamic nailing showed almost equal tendencies to lead to torsional deformity. We conclude that torsional deformities are usually established during the operation. Many patients tolerate abnormal torsion, but efforts should be made to reduce and stabilise the femoral shaft fracture with an AV difference of less than 15 degrees

In two hospitals, 115 consecutive open femoral shaft fractures were treated by meticulous wound excision and early locked (97) or unlocked (18) intramedullary nailing. All the fractures united; union was delayed in four, three of which required bone grafting. The average range of knee flexion at follow-up was 134 degrees (60 to 148). Five patients had a final range of less than 120 degrees, but three of these improved after manipulation under general anaesthesia. Three patients developed staphylococcal infections and required further surgical treatment. All eventually healed

We studied 47 patients with closed, displaced, diaphyseal fractures of the femur caused by blunt trauma, to determine the incidence of associated knee injuries, particularly of the meniscus. After femoral nailing, all patients had an examination under anaesthesia and an arthroscopy. There were 12 medial meniscal injuries (5 tears) and 13 injuries of the lateral meniscus (8 tears). Ten of the 13 tears were in the posterior third of the meniscus, and two patients had tears of both menisci. Synovitis was common at the meniscal attachments. Complex and radial tears were more common than peripheral or bucket-handle tears. Examination under anaesthesia revealed ligamentous laxity in 23 patients (49%), but meniscal injuries had a similar incidence in knees with and without ligament injury. Femoral shaft fractures are often associated with injuries to the ipsilateral knee, and a high index of suspicion is necessary to identify these lesions

We describe the use of Ender nails for the internal fixation of femoral shaft fractures by a closed technique via the greater trochanter and report the treatment of 100 patients with 106 fractures, of which 88 were reviewed 12 months or more after operation. There was primary union in 85 fractures (96.6%) and significant angulation, rotation or leg length discrepancy in eight (9%). We discuss the principles of management which we have evolved

Hypothesis: In severely the injured, there has been a move away from early total care to staged physiological and anatomic reconstruction, damage control orthopaedics (DCO). This seeks to limit the magnitude of the second hit insult resulting from operative treatment after trauma, deferring complex reconstructive work until a later stage. For femoral shaft fracture, this entails initial external fixation, to provide early skeletal stabilisation, and subsequent conversion to an intramedullary nail (IMN). Materials and Methods: Patients with femoral shaft fracture, who underwent primary IMN or DCO between 1996 and 2002 were identified from our database. Those with New Injury Severity Score (NISS) < 20 were excluded. The systemic inflammatory response (SIRS) and Marshall multi-organ failure scores (MMOFS) were calculated every 12h for 4 days. These systems have been previously correlated with outcome and complications in critical care. Results: 174 patients were included. The mean SIRS score was higher at each time period post operatively in the IMN group (p < 0.01). The MMOFS was slightly higher at each point in the DCO group, (only sig. at 48h). There was a higher incidence of pneumonia and mortality (significant p < 0.02), ARDS and MOF (both n.s.) in the DCO group, this being attributable to the higher incidence of head and thoracic injury (AIS severity 2 or more). The mean peak post-operative SIRS score was significantly higher in the IMN group than in the DCO group, both at primary procedure and conversion, as was the time with SIRS score above 1. The pre-op and peak post-op SIRS score correlated with the peak post op MMOFS score (p 0.0002). The conversion pre-op SIRS score correlated with post-operative peak SIRS score and MMOFS score (p 0.0001). On average, a significant rise in the MMOFS score did not occur following the conversion procedure. Conclusion: It would appear that despite having significantly more severe injuries, patients in the DCO group had a smaller, shorter postoperative systemic inflammatory response and suffered only slightly more pronounced organ failure than the IMN group. They did suffer more complications, but this was only significant for pneumonia. DCO patients undergoing conversion whilst their SIRS score was raised suffered the most pronounced subsequent inflammatory response and rise in organ failure score

We reviewed and radiographed 30 skeletally-mature patients after isolated closed femoral shaft fractures in childhood which had been treated conservatively. When the fracture had occurred between the ages of 7 and 13 years, the limb overgrew about 1 cm regardless of sex, upper limb dominance, age, fracture site or configuration. Excessive fracture overlap at the time of injury, but not at union, increased limb overgrowth. Angulation of the fracture remodelled in children injured under 10 years of age, but in older patients this sometimes added to limb shortening. Rotational deformities were minor and gave no symptoms. Treatment of the 7- to 13-year-old patient should aim at 1 cm overlap at union, with correction of angular deformity being more important in children over 10 years of age. This management of fractures will give a maximum leg length discrepancy of 1 cm at skeletal maturity

Over 15 years (1967 to 1982) 140 uncomplicated femoral shaft fractures in children under four years of age were successfully treated using Bryant's traction. Forty of these children were treated after the introduction of the domiciliary management policy in 1976; 13 children were managed at hospital and 27 were managed at home. No significant complications occurred. The advantages to the family, and the safety and economy of domiciliary management lead us to recommend its adoption in favourable cases. Treatment at home relies on an efficient and experienced home nursing service. Possible complications of the injury and treatment with recommendations to prevent them are discussed

Background. To determine the relative contributions of bilateral versus unilateral femoral shaft fracture plus injuries in other body regions to mortality after injury. Study design. A retrospective analysis of the prospectively recorded Trauma Registry data (TARN) from 1989 to 2003. Methods. Patients were divided into groups UFi (isolated unilateral femur injury),BFi (isolated bilateral femur injury) and UFa and BFa if an associated injury was present. Data collected for each patient included age, Injury Severity Scores, Glasgow Coma Scale, mortality, physiological parameters, the timing and extent of prehospital care, the time to arrival at the hospital, initial treatments, time to and type of surgery, length of ICU and hospital stay. Logistic regression data analysis was performed to determine variables that were associated with increased mortality. Results. Patients in group BFa had a significantly higher ISS (23 vs 9),reduced GCS (12 vs 15) and increased mortality rate (31.6% vs 9.8%) than patients in group BFi. Group BFa patients had an increased number of associated injuries than group UFa. Regression analysis of variables evident on admission revealed a significant correlation between bilateral femoral fractures with associated injuries and mortality. However bilateral fracture, even in isolation significantly increased the odds of mortality by 3.07(1.36-6.92). Intramedullary nailing (IMN) was the method of fracture fixation associated with the lowest patient mortality overall. However, when assessing patient mortality in the BFa group with an ISS of more than 40, three other fracture fixation regimens were associated with a lower mortality rate than the IMN group. Conclusions. The increase in mortality with bilateral femoral fractures is more closely associated with the presence of associated injuries and poor physiological parameters than to the presence of the bilateral femoral fracture alone. However contrary to ISS scoring the latter does convey a significant additional risk of mortality. The presence of bilateral femoral fractures should alert the clinician to the very high likelihood (80%) of significant associated injuries in other body systems and their life-threatening potential

Introduction: Knee dislocations are uncommon injuries with most series reporting only few cases over a period of many years. The association of knee dislocations with femoral shaft fractures is exceedingly rare and further complicates the management of this injury. We describe four patients managed at our tertiary care trauma center and evaluate the outcome. Patients and Methods: Out of 187 femoral fractures treated in our institution over a period of 6 years (1994–1999), 4 patients with 5 femoral fractures and ipsilateral knee dislocations were identified. All four patients (2 female) were in early twenties and involved in high energy road traffic accidents. One woman had bilateral knee dislocation with fractures of both femora and tibiae. None of these four patients had head, chest or major visceral injury. No patient had neurovascular damage or compartment syndrome. All were managed by immediate relocation of the knee, angiography, locked intramedullary nailing of femur and post-operative bracing of the knee for six weeks – either by external fixator or hinged brace. Following discharge from the hospital they were followed up regularly in the fracture clinic. Secondary reconstructive procedures were planned depending on the severity of injury and patient demands. The minimum follow up was two years. Results: Four of five femoral fractures united within expected time scale. One with nonunion had exchange nailing twice and is presently under follow up. Out of the five knees, four underwent a secondary reconstructive procedure. One patient had an open dislocation of the knee with loss of quadriceps tendon, part of patella and patellar tendon, which was reconstructed with Leeds-Keio ligament strips and a free flap. One other patient required an ACL reconstruction two years after injury and finally had a stable painless knee. The lady with bilateral injury had reconstruction of both PCL 2 years after injury. At the final follow up seven years later, there was residual PCL laxity in one knee and she was mobile with one stick. At final follow up all the patients were assessed by the American knee score. Conclusion: Femur fractures with knee dislocations are orthopaedic emergencies. These injuries should be treated by immediate relocation of the knee, stabilization of the femoral fracture and ensuring normal distal circulation. In our patients, we have braced the knee initially and symptomatic instability was later on managed by appropriate ligament reconstruction procedures. Cross instability may require application of bridging external fixator to facilitate knee ligament healing. Two patients in this series had a good outcome with stable painless knees. The treatment has to be individualized in each situation to achieve an optimum result

Ninety-eight fractures of the shaft of the femur were seen in one unit over the two years 1974 and 1975, and the results have been assessed in sixty-nine. Of these, thirty-eight were treated by skeletal traction in a Thomas's splint followed by skin traction, and thirty-one by skeletal traction followed by a cast-brace. The technique of application is described in some detail. The average time for application of the cast-brace was six weeks after the injury, the time in hospital eight weeks and the time till removal fifteen weeks. The patients selected for a cast-brace were in hospital for just over half the time of the others and their fractures on average united more quickly, though with some trouble from angulation of fractures of the uppermost third of the shaft. It is concluded that when used with all the judgment and skill it demands, the cast-brace method is a great advance in conservative treatment.

The April 2024 Children’s orthopaedics Roundup. 360. looks at: Ultrasonography or radiography for suspected paediatric distal forearm fractures?; Implant density in scoliosis: an important variable?; Gait after paediatric femoral shaft fracture treated with intramedullary nail fixation: a longitudinal prospective study; The opioid dilemma: navigating pain management for children’s bone fractures; 12- to 20-year follow-up of Dega acetabuloplasty in patients with developmental dysplasia of the hip; Physeal fractures of the distal ulna: incidence and risk factors for premature growth arrest; Analysis of growth after transphyseal anterior cruciate ligament reconstruction in children; Management of lateral condyle humeral fracture associated with elbow dislocation in children: a retrospective international multicentre cohort study

The December 2023 Children’s orthopaedics Roundup. 360. looks at: A comprehensive nonoperative treatment protocol for developmental dysplasia of the hip in infants; How common are refractures in childhood?; Femoral nailing for paediatric femoral shaft fracture in children aged eight to ten years; Who benefits from allowing the physis to grow in slipped capital femoral epiphysis?; Paediatric patients with an extremity bone tumour: a secondary analysis of the PARITY trial data; Split tibial tendon transfers in cerebral palsy equinovarus foot deformities; Liposomal bupivacaine nerve block: an answer to opioid use?; Correction with distal femoral transphyseal screws in hemiepiphysiodesis for coronal-plane knee deformity

Benefits of early stabilization of femoral shaft fractures, in mitigation of pulmonary and other complications, have been recognized over the past decades. Investigation into the appropriate level of resuscitation, and other measures of readiness for definitive fixation, versus a damage control strategy have been ongoing. These principles are now being applied to fractures of the thoracolumbar spine, pelvis, and acetabulum. Systems of trauma care are evolving to encompass attention to expeditious and safe management of not only multiply injured patients with these major fractures, but also definitive care for hip and periprosthetic fractures, which pose a similar burden of patient recumbency until stabilized. Future directions regarding refinement of patient resuscitation, assessment, and treatment are anticipated, as is the potential for data sharing and registries in enhancing trauma system functionality. Cite this article: Bone Joint J 2023;105-B(4):361–364

We report the use of elastic stable intramedullary nailing (ESIN) in 123 fractures of the femoral shaft in children. Flexible rods are introduced through the distal metaphyseal area, and the aim is to develop bridging callus. Early weight-bearing is possible and is recommended. There was one case of bone infection and no delayed union. Complications were minimal, the most common being minor skin ulceration caused by the ends of the rods. A surprising feature was the low incidence of growth changes, with a mean lengthening of only 1.2 mm after an average follow-up of 22 months. Compared with conservative treatment, ESIN obviates the need for prolonged bed rest and is thus particularly advantageous for treating children.

From a series of 190 consecutive fractures of the shaft of the femur treated by closed Kuntscher nailing, 32 of the more severely comminuted have been studied to determine whether treatment by closed nailing was justified. Radiological criteria were used to divide them into 19 who were moderately comminuted and 13 grossly so. Twenty-four patients were less than 21 years of age and 19 patients had 40 significant associated injuries. Fifteen fractures were nailed on the day of injury, and complications were few. Nineteen patients had a supplementary cast-brace and all those who had been employed returned to work. Twelve patients had shortening of up to two centimetres and two had three centimetres; four had mild rotational deformities; seven had mild restriction of knee flexion; and two had delayed union. There were no infections. The advantages of this technique include a negligible risk of infection and rapid stabilisation of even grossly comminuted fractures, thus facilitating management of other injuries. The 44 per cent incidence of shortening is counterbalanced by early mobilisation and rapid return of knee function. It is concluded that when proper equipment and expertise are available then closed nailing is the treatment of choice for severely comminuted fractures of the femoral shaft.

The treatment of fractures of the femoral shaft by traction may delay union and produce stiffness of the knee. The technique of Perkins' method is described and the results reported in 50 cases. All patients had at least 120 degrees of flexion of the knee when traction was discontinued, and 47 patients were considered to have clinical and radiological union of the fracture by 12 weeks. The main complications of the method was loosening of the Denham pin or infection of the pin-track in the proximal tibia. It is suggested that Perkins' traction is an excellent form of treatment for fractures of the femoral shaft, and has several advantages over other forms of traction.

The off-loading characteristics of the cast-braces of 30 patients with fractures of the shaft of the femur have been investigated, during axial loading, using strain-gauge transducers. These were applied at the level of the fracture, where the cast was circumferentially split, and to the hinges of the brace at the knee. They measured the load transferred between the two portions of the thigh cast, and between the thigh cast as a whole and the below-knee cast; by subtraction from the total load on the limb, the skeletal force at the fracture level and at the knee could be calculated. In all patients there was an increase in the fracture load as union progressed which was thought to be due to physiological feedback mechanism from the fracture site. The load carried by the two portions of the thigh cast and by the thigh cast as a whole was proportionately high at first and stabilised at an average of 35 per cent of body weight.

Aims. Bone turnover markers (BTMs) follow distinct trends after fractures and limited evidence suggests differential levels in BTMs in patients with delayed healing. The effect of vitamin D, and other factors that influence BTMs and fracture healing, is important to elucidate the use of BTMs as surrogates of fracture healing. We sought to determine whether BTMs can be used as early markers of delayed fracture healing, and the effect of vitamin D on BTM response after fracture. Methods. A total of 102 participants aged 18 to 50 years (median 28 years (interquartile range 23 to 35)), receiving an intramedullary nail for a tibial or femoral shaft fracture, were enrolled in a randomized controlled trial comparing vitamin D. 3. supplementation to placebo. Serum C-terminal telopeptide of type I collagen (CTX; bone resorption marker) and N-terminal propeptide of type I procollagen (P1NP; bone formation marker) were measured at baseline, six weeks, and 12 weeks post-injury. Clinical and radiological fracture healing was assessed at three months. Results. CTX and P1NP concentrations peaked at six weeks in all groups. Elevated six-week CTX and P1NP were associated with radiological healing at 12 weeks post-injury (odds ratio (OR) 10.5; 95% confidence interval 2.71 to 53.5, p = 0.002). We found no association between CTX or P1NP and functional healing. Baseline serum 25(OH)D showed a weak inverse relationship with P1NP (p = 0.036) and CTX (p = 0.221) at 12 weeks, but we observed no association between vitamin D supplementation and either BTM. Conclusion. Given the association between six-week BTM concentrations and three-month radiological fracture healing, CTX and P1NP appear to be potential surrogate markers of fracture healing. Cite this article: Bone Joint Res 2022;11(4):239–250

When fixing a mid or distal periprosthetic femoral fracture with an existing hip replacement, creation of a stress-riser is a significant concern. Our aim was to identify the degree of overlap required to minimise the risk of future fracture between plate and stem.

Each fixation scenario was tested using 4th generation composite femoral Sawbones®. Each sawbone was implanted with a collarless polished cemented stem with polymethyl methacrylate bone cement and cement restrictor. 4.5mm broad Peri-loc™ plates were positioned at positions ½, 1 and 2 shaft diameters (SD) proximal and distal to the tip of the femoral stem. Uni-axial strain gauges (medial and lateral longitudinal gauges, anterior and posterior torsional gauges) measured microstrain at tip of the femoral stem with a standard load of 500N in axial, 3-point lateral and composite torsion/posterior loading using an Instron machine.

With axial loading fixation with 2SD proximal resulted in the least amount of strain, in both tension & compression, at the tip of the femoral stem. Fixation with 4 unicortical screws was significantly better than 2 alternating unicortical screws (mean microstrain difference 3.9 to 15.3, p<0.0001). With lateral 3-point loading fixation with 2SD proximal overlap and 2 alternating unicortical screws resulted in the least amount of strain, in both tension and compression, at the tip of the femoral stem (p<0.0001). With torsion & posterior displacement 2SD proximal fixation resulted in the least amount of rotational strain. There was no significant difference between 4 unicortical screws compared to 2 alternating unicortical screws (p>0.05 in 3 of 4 gauges).

Fixation of midshaft or distal femoral fractures with a well-fixed total hip arthroplasty should have at least 2 shaft diameters of proximal overlap with a 4.5mm broad plate. It is not clear if 4 unicortical screws or 2 alternating screws are optimal.

We reviewed 28 children with unilateral middle-third fractures of the femoral shaft who had an angular deformity after union of 10 degrees to 26 degrees. At an average follow-up of 45 months (20 to 66), we measured remodelling of the proximal physis, the distal physis and the femoral shaft. The average correction was 85% of the initial deformity. We found that 74% of correction occurred at the physes and only 26% at the fracture site. Neither the direction nor the magnitude of the angulation much influenced the degree of remodelling. Younger children remodelled only a little better than older children. We conclude that in children under 13 years of age, malunion of as much as 25 degrees in any plane will remodel enough to give normal alignment of the joint surfaces.

One hundred and two fractures of the femoral shaft, including eighteen pathological fractures, in 100 patients were internally fixed by closed Kuntscher nailing. Sixty-eight fractures resulted from motor vehicle accidents; ten were compound. Seventy-five patients were under the age of thirty years and thirty-four had multiple injuries. Sixty-nine fractures were nailed on the day of the accident and the operative technique is described. Complications during and after operations were few. Fifty-eight patients left hospital within four weeks and 77% of those working returned to work in less than four months. There were no wound or bone infections. The results are discussed and it is concluded that, with the correct equipment and careful attention to detail, closed nailing is a straightforward procedure with few complications. Advantages include the wide range of fractures that can be nailed, the short hospitalisation, the rapid return of function to the knee, the early return to work and the absence of infection.

Objectives

The use of two implants to manage concomitant ipsilateral femoral shaft and proximal femoral fractures has been indicated, but no studies address the relationship of dynamic hip screw (DHS) side plate screws and the intramedullary nail where failure might occur after union. This study compares different implant configurations in order to investigate bridging the gap between the distal DHS and tip of the intramedullary nail.

Delayed management of high energy femoral shaft fractures is associated with increased complication rates. It has been suggested that there is less urgency to stabilize lower energy femoral shaft fractures. The purpose of this study was to evaluate the effect of surgical delay on 30-day complications following fixation of lower energy femoral shaft fractures. Patients ≥ 18 years who underwent either plate or nail fixation of low energy (falls from standing or up to three steps' height) femoral shaft fractures from 2005 – 2016 were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) via procedural codes. Patients with pathologic fractures, fractures of the distal femur or femoral neck were excluded. Patients were categorized into early (< 2 4 hours) or delayed surgery (2–30 days) groups. Bivariate analyses were used to compare demographics and unadjusted rates of complications between groups. A multivariable logistic regression was used to compare the rate of major and minor complications between groups, while adjusting for relevant covariables. Head injury patients and polytrauma patients are not included in the NSQIP database. Of 2,716 lower energy femoral shaft fracture patients identified, 2,412 (89%) were treated within 1 day of hospital admission, while 304 (11.2%) were treated between 2 and 30 days post hospital admission. Patient age, American Society of Anesthesiologists (ASA) classification score, presence of diabetes, functional status, smoking status, and surgery type (nail vs. plate) were significantly different between groups (p After adjusting for all relevant covariables, delayed surgery significantly increased the odds of 30-day minor complications (p=0.02, OR = 1.48 95%CI 1.01–2.16), and 30-day mortality (p < 0 .001), OR = 1.31 (95%CI 1.03–2.14). The delay of surgical fixation of femoral shaft fractures appears to significantly increase patients' risk of minor adverse events as well as increase mortality. With only 89% of patients being treated in the 24 hour timeframe that constitutes best practice for treatment of femoral shaft fractures, there remains room for improvement. These results suggest that early treatment of all femoral shaft fractures, even those with a lower energy mechanism of injury, leads to improved outcomes

Timely and competent treatment of paediatric fractures is paramount to a healthy future working population. Anecdotal evidence suggests that children travel greater distances to obtain care compared to adults causing economic and geographic inequities. This study aims to qualify the informal regionalization of children's fracture care in Ontario. The results could inform future policy on resource distribution and planning of the provincial health care system. A retrospective cohort study was conducted examining two of the most common paediatric orthopaedic traumatic injuries, femoral shaft and supracondylar humerus fractures (SCH), in parallel over the last 10 years (2010-2020) using multiple linked administrative databases housed at the Institute for Clinical Evaluative Sciences (ICES) in Toronto, Ontario. We compared the distance travelled by these pediatric cohorts to clinically equivalent adult fracture patterns (distal radius fracture (DR) and femoral shaft fracture). Patient cohorts were identified based on treatment codes and distances were calculated from a centroid of patient home forward sortation area to hospital location. Demographics, hospital type, and closest hospital to patient were also recorded. For common upper extremity fracture care, 84% of children underwent surgery at specialized centers which required significant travel (44km). Conversely, 67% of adults were treated locally, travelling a mean of 23km. Similarly, two-thirds of adult femoral shaft fractures were treated locally (mean travel distance of 30km) while most children (84%) with femoral shaft fractures travelled an average of 63km to specialized centers. Children who live in rural areas travel on average 51km more than their adult rural-residing counterparts for all fracture care. Four institutions provide over 75% of the fracture care for children, whereas 22 institutions distribute the same case volume in adults.?. Adult fracture care naturally self-organizes with proportionate distribution without policy-directed systemization. There is an unplanned concentration of pediatric fracture care to specialized centers in Ontario placing undue burden on pediatric patients and inadvertently stresses the surgical resources in a small handful of hospitals. In contrast, adult fracture care naturally self-organizes with proportionate distribution without policy-directed systemization. Patient care equity and appropriate resource allocation cannot be achieved without appropriate systemization of pediatric fracture care

The purpose of this project was to evaluate North American trauma surgeon preferences regarding patient positioning for antegrade fixation of mid shaft femoral shaft fractures. This project was a cross sectional survey taken of orthopaedic fellows and staff surgeons, belonging to three organizations across North America. An estimated sample size was calculated a priori, while various online techniques were utilized to reduce non responder and fatigue bias. The survey was distributed multiple times to optimize yield. Two hundred twelve (212) participants responded in full, 134 (56%) of whom practiced in Canada. The majority of surgeons worked in level one trauma centres (74%), while 72% treated more than one femoral shaft fracture per week. The most common patient position for mid shaft fixation amongst all surgeons was lateral positioning with manual traction (68%), however community surgeons were significantly more likely to use a fracture table. The most common difficulties faced with using a fracture table were inability to achieve fracture reduction and peroneal nerve palsies. The majority (64%) of surgeons quoted a complication rate with fracture tables of greater than 1 per 100 cases. Lateral position with use of manual traction is the preferred set up for antegrade fixation of femoral shaft fracture in this large North American cohort of trauma surgeons. However, a large subset of community and non academic surgeons still prefer use of the fracture table. Amongst all respondents, a high rate of fracture table complications, including malreduction, were quoted. To date, there is no prospective data comparing these two options for patient positioning, and a randomized controlled trial may be an appropriate next step

Introduction of the National Hip fracture database, best practice tariff and NICE guidelines has brought uniformity of care to hip fracture patients & consequently improved outcomes. Low energy femoral shaft fractures of the elderly are not within these guidelines, but represent a similar though significantly smaller patient cohort. A retrospective review was performed at Huddersfield Royal Infirmary using theatre, coding & hip fracture databases. Data was filtered to include patients ≥75, excluding non-femoral injuries. Imaging & notes were then reviewed confirming femoral shaft fractures; excluding open, peri-prosthetic & high energy fractures. Between September 2008 and July 2016 24 patients were identified and split into two equal cohorts, before June 2011 NICE Guidelines and after. The groups were equal in terms of age (Mean: 85.25:84.67, P=0.) & sex (12 females Pre-NICE, 9 Post-Nice, P= 0.22). Our main outcome measures of length of stay were 31.89 days:26 days (p=0.38), time to surgery was 29.8hours: 28.4 hours (p=0.8) and 1-year survival rate conditional odds ratio of 1.48 (p=1.00). A secondary measure demonstrated a significantly higher proportion of post-NICE patients receiving surgery after midday 5/12:11/12 (P= 0.03). The infrequency of low energy femoral shaft fractures makes them difficult to study and production of an adequately powered study in a single centre impossible. The authors hope this work can inspire discussion and a coordinated multicentre approach to answer this question. These patients could easily be treated with the same level of enthusiasm as hip fractures

Femoral shaft fractures are potentially devastating injuries. Despite this, clinical studies of the biomechanics of this injury are lacking. We aimed to clinically evaluate bone behaviour under high and low energy trauma in paediatric, adult and older patients. Single-centre retrospective study identifying all diaphyseal femoral fractures between Feb 2015-Feb 2017. Peri-prosthetic and pathological fractures were excluded. Patients were subdivided into groups 1 (paediatric, <16yo), 2 (adult, 17–55yo) and 3 (older, >55yo) to reflect immature, peak bone age and osteoporotic bone respectively. Chi-Squared analysis assessed significance of bone age to degree of comminution and fracture pattern. A p-value <0.05 was significant. A total 4130 radiographs were analysed with 206 femoral shaft fractures identified. Forty-three patients were excluded with 163 remaining. Group 1, 2 and 3 included 38, 37 and 88 patients respectively. Mean age 50.8 (SD 32.8) with male-to-female ratio of 1:1.2. Groups 1 and 3 included majority simple fractures (35/38 and 62/88 respectively). Group 2 included more comminuted injuries (33/37). Bone age to degree of comminution proved significant (p<0.05) with a bimodal distribution of simple fractures noted in groups 1 and 3. Energy to fracture was significant in group 2, where a high energy injury was associated with comminution (p<0.05). This study is the first to demonstrate an association between fracture comminution and age. Simple femoral shaft fractures showed a bimodal age distribution in paediatric and older patients regardless of mechanism energy. High energy mechanism trauma was directly related to fracture comminution at peak bone age

Femoral shaft fractures are fairly common injuries in paediatric age group. The treatment protocols are clear in patients of age less than 4 years and greater than 6 years. The real dilemma lies in the age group of 4–6 years. The aim of this study is to find whether a conservative line should be followed, or a more aggressive surgical intervention can provide significantly better results in these injuries. This study was conducted in a tertiary care hospital in Bhubaneswar, India from January 2020 to March 2021. A total of 40 patients with femur shaft fractures were included and randomly divided in two treatment groups. Group A were treated with a TENS nail while group B were treated with skin traction followed by spica cast. They were regularly followed up with clinical and radiological examination to look out for signs of healing and any complications. TENS was removed at 4–9 months’ time in all Group A patients. Group A patients had a statistically significant less hospital stay, immobilisation period, time to full weight bearing and radiological union. Rotational malunions were significantly lower in Group A (p-value 0.0379) while there was no statistically significant difference in angular malunion in coronal and sagittal plane at final follow up. Complications unique to group A were skin necrosis and infection. We conclude that TENS is better modality for treatment of shaft of femur fractures in patients of 4–6 years age as they significantly reduce the hospital stay, immobilization period and rotational malalignment

Introduction Retrograde nailing of femoral shaft fractures, through the knee joint, have been increasing. The indications for retrograde nailing are presently still evolving. This paper aims to discuss the indications for retrograde nailing. Methods We had conducted a prospective trial of nailing of femoral shaft fractures, using the retrograde approach. Nails were placed and reamed, with both distal and proximal locking done. Attention was given to the appropriate entry point. A literature review is also presented. Results The set-up was easy. Operative time was a median of 70 minutes and average blood loss 200 mls. Time to union was 15 weeks with minimal complications, but dynamisation rates were high. No knee problems were found at a follow-up period of 47 months. Conclusions The indications for retrograde nailing are ipsilateral femoral and acetabular fractures, ipsilateral patellar and femoral shaft fractures, ipsilateral tibial amd femoral shaft fractures, multiple trauma, femoral fracture with previous ipsilateral hip fusion, bilateral femoral shaft fractures, the obese or pregnant patient with a unilateral/bilateral femoral shaft fractures and perhaps the elderly with a unilateral femoral shaft fracture. We feel that the retrograde nailing is a useful technique for the orthopaedic surgeon to have in his/her armamentarium. Due to the longer union time and possible knee damage, indications should be respected

Total hip arthroplasty (THA) for congenital hip dysplasia (CDH) presents a challenge. In high-grade CDH, key surgical targets include cup placement in the anatomical position and leg length equality. Lengthening of more than 4 cm is associated with sciatic nerve injury, therefore shortening osteotomies are necessary. We present our experience of different shortening osteotomies including advantages and disadvantages of each technique. 89 hips, in 61 pts (28 bilateral cases), for high CDH were performed by a single surgeon from 1997 to 2022. 67 patients were female and 22 were male. Age ranged from 38 to 68 yrs. In all patients 5–8cm of leg length discrepancy (LLD) was present, requiring shortening femoral osteotomy. 12 patients underwent sequential proximal femoral resection with trochanteric osteotomy, 46 subtrochanteric, 6 midshaft, and 25 distal femoral osteotomies with simultaneous valgus correction were performed. All acetabular prostheses were placed in the true anatomical position. We used uncemented high porosity cups. Patients were followed up for a minimum of 12 months. All osteotomies healed uneventfully except 3 non-unions of the greater trochanter in the proximal femur resection group. No femoral shaft fractures in proximally based osteotomies. No significant LLD compared to the unaffected or reconstructed side. 2 patients suffered 3 and 5 degrees malrotation of the femur in the oblique sub-trochanteric group. 3 patients suffered transient sciatic nerve palsies. Shortening femoral osteotomies in the treatment of DDH are necessary to avoid injury to the sciatic nerve. In our series, we found transverse subtrochanteric osteotomies to be the most technically efficient, versatile and predictable in their clinical outcome, due to the ability to correct rotation and preserve the metaphyseal bone integrity, allowing for better initial stem stability. Distal femoral osteotomies allowed for controllable correction of valgus knee deformity

The purpose of this study was to determine whether there have been changes in the complexity of femoral fragility fractures presenting to our Dunedin Orthopaedic Department, New Zealand, over a period of ten years. Patients over the age of 60 presenting with femoral fragility fractures to Dunedin Hospital in 2009 −10 (335 fractures) were compared with respect to demographic data, incidence rates, fracture classification and treatment details to the period 2018-19 (311 fractures). Pathological and high velocity fractures were excluded. The gender proportion and average age (83.1 vs 83.0 years) was unchanged. The overall incidence of femoral fractures in people over 60 years in our region fell by 27% (p<0.001). Intracapsular fractures (31 B1 and B2) fell by 29% (p=0.03) and stable trochanteric fractures by 56% (p<0.001). The incidence of unstable trochanteric fractures (31A2 and 31A3) increased by 84.5% from 3.5 to 6.4/10,000 over 60 years (p = 0.04). The proportion of trochanteric fractures treated with an intramedullary (IM) nail increased from 8% to 37% (p <0.001). Fewer intracapsular fractures were treated by internal fixation (p<0.001) and the rate of acute total hip joint replacements increased from 13 to 21% (p=0.07). The incidence of femoral shaft fractures did not change significantly with periprosthetic fractures comprising 70% in both cohorts. While there has been little difference in the numbers there has been a decrease in the incidence of femoral fragility fractures likely due to the increasing use of bisphosphonates. However, the incidence of unstable trochanteric fractures is increasing. This has led to the increased use of IM nails which are increasingly used for stable fractures as well. The increasing complexity of femoral fragility fractures is likely to have an impact on implant use, theatre time and cost

Aims. Osteopetrosis (OP) is a rare hereditary disease that causes reduced bone resorption and increased bone density as a result of osteoclastic function defect. Our aim is to review the difficulties, mid-term follow-up results, and literature encountered during the treatment of OP. Methods. This is a retrospective and observational study containing data from nine patients with a mean age of 14.1 years (9 to 25; three female, six male) with OP who were treated in our hospital between April 2008 and October 2018 with 20 surgical procedures due to 17 different fractures. Patient data included age, sex, operating time, length of stay, genetic type of the disease, previous surgery, fractures, complications, and comorbidity. Results. The mean follow-up period was 92.5 months (25 to 140). Bony union was observed in all of our patients. Osteomyelitis developed in two patients with femoral shaft fractures, and two patients had peri-implant stress fractures. Conclusion. Treatment of fractures in OP patients is difficult, healing is protracted, and the risk of postoperative infection is high. In children and young adults with OP who have open medullary canal and the epiphyses are not closed, fractures can be treated with surgical techniques such as intramedullary titanium elastic nail (TENS) technique or fixation with Kirschner (K)-wire. Cite this article: Bone Joint J 2020;102-B(8):1082–1087

A: - determine the incidence of intraoperative periprosthetic femoral fracture (PFF). B: - determine the incidence of, and the reoperation rate for postoperative PFF. When using either CC or PTS femoral components. Retrospective review of a consecutive series of 11,018 THAs over a ten-year period. All PFFs were identified using regional radiograph archiving and electronic care systems. Of the 11,018 THAs 4,952 were CC and 6,066 were PTS. Between groups, age, sex, and BMI did not differ. A: - 55 (0.5%) had an intraoperative PFF. 44 CC and 11 PTS (p<0.001). 3 patients in each group had a femoral shaft fracture, remaining fractures were either the calcar (20 CC and 2 group) or the greater trochanter (11 CC and 6 PTS). B: - 91(0.8%) sustained a postoperative PFF. Of those 15 were managed conservatively, 15 were revised and 61 (80.3%) had an ORIF. The CC group had both a lower overall rate of postoperative PFFs (0.7% (36/4,952) vs 0.9% (55/6,066); p = 0.341), and a lower rate of return to theatre (0.4% (22/4,952) vs 0.9% (54/6,066); p = 0.005). 1.3% of male PTS (36/2,674) had a reoperation compared to 0.3% of male CC (7/2,121) (p<0.001). With regard to stem fracture there were none in the Corail group and 5 in the Exeter group. Of these 2 were sub trunnion and 3 were basal neck. A: - There were significantly more intraoperative PFFs with CC 44 (0.8%) than PTS 11 (0.2%). However, the majority of fractures were either of the calcar or greater trochanter with no impact on early recovery or one year Oxford scores. B: - Male PTS were five times more likely to have a reoperation for postoperative PFF. Females had the same incidence of reoperation with either component type. There were 5 stem fractures in the Exeter group and none in the Corail. These results represent robust estimates, which are likely to be more accurate than revision only studies typically generated from registry data

Background: Pediatric comminuted femoral shaft fractures are not frequent but difficult in treatment due to concomitant injuries and instability. Although orthopaedic literature is rich in reports on paediatric femoral shaft fractures only few focus on comminuted ones. Purpose: The aim of the study is to present results and complications of surgical treatment in comminuted femoral shaft fractures during growing age. Material and Methods: Between 2001–2006 twenty eight children presented with 29 wedge or complex femoral shaft fractures. All children underwent clinical and radiographic examination on follow up and their medical data was retrospectively reviewed. TEN scoring criteria, time to solid union, early and late complications were of the primary interest during follow up assessment. Results: There were 18 boys (64,3%) and 10 (35,7%) girls. Their mean age during injury was 10,1 years and average follow up period was 35,7 months. In 15 children (53,6%) multiple injuries were present. Three fractures were treated conservatively, the remaining 26 underwent closed or open reduction with stabilization using EBI external fixation, intramedullary Rush or TEN rodding, multiple screws or plate osteosynthesis. On follow up there were 12 (41,4%) excellent, 14 satisfactory (48,2%), 3 poor (10,4%) results. All fractures united and a mean time to achieve solid union was 20,7 weeks. Leg length discrepancy occurred in 20 children (71,4%), and in 10 (35,7%) was greater than 10 mm. Four children required in early secondary surgical procedures to achieve better alignment or fracture stabilization. One femoral osteomyelitis required in surgical drainage and prolonged intravenous antibiotic therapy. Conclusions: Comminuted femoral shaft fractures in children heal well after surgical treatment although the risk of serious complications is high. Intramedullary rodding seems to be sufficient in most cases. Screw fixation alone should be avoided

Introduction: Femoral shaft fractures are commonly thought to be primarily associated with high energy trauma in young persons. Only limited attention has be given to low energy violence as a cause of these fractures among the elderly. National epidemiological data on characteristics of patients with femoral shaft fractures are lacking. So the purpose of this study was to analyse the incidence, admissions, causes of fracture and operations for these fractures on a nationwide basis in Sweden during 1998–2004. Patients and Methods: Data on all femoral shaft fractures were extracted from the Swedish National Hospital Discharge Registry. Sex- and age-specific fracture incidence, hospital admissions, mechanisms of injury and surgical procedures were analysed using descriptive analysis, linear-regression analysis and other methods as appropriate. Results: Over a period of 7 years, 6,409 patients with femoral shaft fractures were identified, corresponding to an annual incidence rate of 10 per 100,000 person-years. Men had a younger median age (27 years, IQR 12–68) than women (79 years, IQR 62–86) (p< 0.001). Females (54%) generated more admissions than males (46%). The incident rate ratio between men and women was 0.9 (p< 0.001). Most hospital admissions were generated among females by the 80–89 years age-group and among males < 10 years of age. 2% of the fractures were open shaft fractures. The total number of hospital admissions was stable during 1998–2004. The two major mechanisms of injury were falls on the same level (50%) and transport accidents (17%). A significant number of fractures occured among elderly patients after low-energy trauma. Osteosynthesis with femoral nail (54%) was the prefered operation, followed by osteosynthesis with plate and screws (16%), skeletal traction (14%) and external fixation (6%). Discussion: This nationwide study on femoral shaft fractures provides an update on incidence, admissions, external causes and surgical procedures. This information assists health care providers in planning hospital beds, surgical interventions and risk preventions. Moreover, these data can be used for power calculations for further clinical studies

Non-operative treatment is usually employed in the treatment of femoral fractures in young individuals. Malunion, delayed union, joint stiffness, limb length discrepancy, psychological problems and delay in functional recovery are well known complications of conservative treatment. The length of hospital stay that will be a part of non-operative treatment will add to the cost of the treatment. We report our experience with intramedullary nailing of closed femoral shaft fractures with a new femoral nail in adolescent patients with an open physis. We treated 13 patients between 1995 and 2004 aged between 8–16 years (8 males and 5 females) with a new femoral nail for closed femoral shaft fractures using the tip of the greater trochanter as the entry point. 11 of the 13 patients had removal of the femoral nail. The mechanism of injury, length of hospital stay, patient mental well-being, surgical technique, requirement of secondary surgical procedures, associated complications, post-operative mobility, return to pre-injury status, range of movement at the hip and knee are discussed. At follow up ranging from few months to 7 years, we found no leg length discrepancy, rotational deformity, limp, problems with physis and all patients had a full range of movement at the hip and knee. External fixation, elastic intramedullary nails, plate and screw fixation are other surgical options available to treat femoral shaft fractures. Children poorly tolerate external fixators and plate fixation can be associated with a high incidence of complications. Flexible intramedullary fixation of femoral shaft fractures is an attractive option, but is technically difficult and is associated with a learning curve. In our view, intramedullary nailing is a simple, safe, efficient and effective method of treatment of femoral shaft fractures in adolescent patients with open physis

Background. Leg length discrepancy (LLD) after intramedullary nailing of femoral shaft fractures is a common problem reported in up to 43% of cases. Comminuted fractures with radiographic loss of bony landmarks have an increased possibility of being fixed with unequal leg lengths. Aims. The purpose of this report is to evaluate the efficacy of routinely obtaining a CT scanogram post-operatively on patients of comminuted femoral shaft fractures treated with intramedullary nailing and immediate correction of limb length inequality if indicated. Results. Twenty one patients with comminuted femoral shaft fractures that were treated with intramedullary nailing and underwent a CT scannogram for evaluation of LLD were included in the study. There were 12 patients with Winquist III and 9 with a Winquist IV fracture pattern. Following surgery leg lengths were measured from the CT scanograms using a computerised measuring ruler. The largest leg length discrepancy noted on scannogram was 4 cm. The average limb length discrepancy was 0.67 cm. Eight patients had a discrepancy of 1cm or greater. We also measured the tibial length in all patients and found only 3 patients with exactly equal tibial lengths. A tibial length discrepancy less than 5mm was observed in 11 patients. In 7 patients it was between 5-9mm and in 3 patients it was 10mm or greater. Four patients underwent leg length correction during the same admission. Conclusion. The decision to undertake correction of the LLD is primarily dependant on the degree of discrepancy. The degree of LLD that requires correction remains undefined. In this study LLD of greater than 15mm was considered for equalisation. Immediate equalisation saves cost, morbidity, delayed sequelae and litigation. Tibial length discrepancy may contribute to the total leg length discrepancy and requires consideration. We recommend a post-operative scanogram costing $380 in patients of comminuted femoral shaft fractures treated with intramedullary nailing

Fracture risks are the most common argument against the use of Ceramic on ceramic (CoC) hip implants. Question: is ceramic material at risk in case of severe local trauma?. Over a long period, we tried to identify patients with a CoC prosthesis (Ceraver Osteal°)who did sustain a trauma. This was conducted in three different institutions. Eleven patients were found: 9 males and 2 females aged 17 to 70 years at time of index surgery. Accident occurred 6 months to 15 years after index: one car accident, five motorcycle accident, five significant trauma after a fall, including one ski board accident. Consequences of these trauma were: six fractures of the acetabulum with socket loosening in 4 that needed revision, two femoral shaft fracture, one orifed and one stem exchanged, one traumatic hip dislocation associated to loosening of the socket revised at 10 years, and one traumatic loosening of the socket. Ten had no consequence on ceramic integrity. One experienced a fracture of the patella from a dashboard trauma, a liner shipping was discovered during socket revision 2 years later. This is the only case of possible relation between trauma and ceramic fracture. In a more recent longitudinal study on 1856 CoC prosthesis performed from 2010 to 2021, 29 severe traumas were identified with no consequence on Ceramic material. From this limited case study, it can be assumed that Pure Alumina Ceramic well designed and manufactured, will not break after a significant trauma

Early fracture stabilization has been shown to reduce morbidity and mortality in the patient who is multiply injured. Controversy exists in terms of managing multiple trauma patients who sustain thoracic injuries along with femoral shaft fractures. The purpose of the present study was to determine whether the presence and treatment of femoral shaft fractures increases morbidity in patients with pulmonary contusions and to determine the effect of patient and surgical factors on outcome. Patients that suffered chest injuries between January 1987 and April 2006 were identified from the prospectively collected trauma databases at two hospitals. Patient records were reviewed to verify all data. The diagnosis of pulmonary contusion was confirmed with radiologic or post-mortem investigations. All relevant patient and surgical data was collected. Exclusion criteria included severely injured patients (head/abdomen AIS> 3), age sixty years, death twenty-four hours after injuries occurred. A total of 1190 patients with confirmed pulmonary contusions met inclusion criteria; there were 113 femoral shaft fractures (five bilateral). Patients in both the isolated pulmonary contusion and pulmonary contusion with femoral fracture had similar injury severity scores (ISS) and demographic information. Fractures were reduced with intramedullary nailing in 88% of cases. Mean age was thirty-five years. There were significantly more incidences of fat embolism syndrome and acute lung injury (ALI) in patients with femoral factures (twenty-four hours following the injury had significantly greater risk of developing ARDS (p< 0.05). The presence of femoral shaft fractures in patients with pulmonary contusions increases the duration of admittance to hospital and can lead to higher rates of fat embolism syndrome and ALI, however it does not appear to impact overall mortality or contribute to the development of other common respiratory complications. Early reduction of shaft fractures is encouraged to further decrease complications

Aim: The purpose of our study is to evaluate the results of interlocking intramedullary nailing for femoral shaft fractures giving special attention in the number of the distal bolts. Materials – methods: In a period of 3.5 years (6/1999 – 12/2002), 74 patients with femoral shaft fractures were treated with the Russell – Taylor interlocking intramedullary nailing. 46 were male and 28 female; their ages ranging from 16 to 79 years (mean 37.5years). According to the A.O. Classification 21 were type A, 25 type B and 29 type C. The Russell-Taylor Nail was used. Reaming was performed in all cases. The distal bolts were inserted using the “FREE-HAND” technique. One screw was inserted in 44 cases and two in 30 in a random manner. Results: No postoperative complications occurred. Follow-up ranged from 6 to 36 months (mean 18 months). In the cases where two distal bolts were inserted the fractures united in a period of 4 to 6 months (average 4.8 m.), while these where one screw was placed healed in a period of 4 to 10 months (average 6.5 m.). Conclusion: The Russell-Taylor interlocking itramedullary nail is an efficient method of treatment for femoral shaft fractures. The insertion of two distal screws offers additional stability, which accelerates the healing process and is advocated for all femoral shaft fractures

Background:. There is limited evidence regarding HIV infection as a risk factor for delayed union and implants sepsis in patient with fractures treated with surgical fixation. Most studies have included patient with a variety of different fractures and hence very different risks regarding delayed union and implant sepsis. We have looked at a single fracture, closed femoral shaft fractures treated with intramedullary nailing, to see if HIV infection is a risk factor with for the development of delayed union and implant sepsis. We present a prospective study of 160 patients with closed femoral shaft fractures treated with intramedullary nailing. Primary outcomes were delayed union of more than 6 months and implant sepsis in the first 12 months. Methods:. From February 2011 until November 2012 all patient with closed femoral shaft fractures treated at our hospital were included in the study. Patients were tested for HIV infection and a number of clinical parameters were documented, including: AO fracture score, duration of surgery, level of training of surgeon, comorbidities, CD4 count, high energy injury and number of operations. Results:. Forty (25%) patients were HIV positive. Seven patients had CD4 counts below 350 cells/µL and 12 patients were on ARV's. Four (3%) patients developed implants sepsis and of these 1 (25%) was HIV positive. Two (1%) patients had a delayed union of more than 6 months and both these patients were HIV negative. Conclusion:. HIV is not a risk factor for delayed union and implant sepsis in the first 12 months after surgery. Intramedullary nailing is a safe and effective in the treatment of HIV positive patients with closed femur fractures

Introduction. We have investigated the long-term (minimum follow-up period; 10 years) clinical results of the total hip arthroplasty (THA) using K-MAX HS-3 tapered stem. Materials and Methods. In K-MAX HS-3 THA (Kyocera Medical, Kyoto, Japan), cemented titanium alloy stem and all polyethylene cemented socket are used. This stem has the double tapered symmetrical stem design, allowing the rotational stability and uniform stress distribution. The features of this stem are; 1. Vanadium-free high-strength titanium alloy (Ti-15Mo-5Zr-3Al), 2. Double-tapered design, 3. Smooth surface (Ra 0.4µm), 4. Broad proximal profile, 5. Small collar. Previous type stem, which was made of the same smooth-surface titanium alloy, has the design with cylindrical stem tip, allowing the maximum filling of the femoral canal. Osteolysis at the distal end of the stem had been reported in a few cases in previous type with cylindrical stem tip, probably due to the local stress concentration. Therefore the tapered stem was designed, expecting better clinical results. 157 THAs using HS-3 taper type stem were performed at Kitano Hospital between March 2004 and March 2008. And 101 THAs, followed for more than 10 years, were investigated (follow-up rate; 64.3%). The average age of the patients followed at the operation was 61.7 years and the average follow-up period was 10.9 years. The all-polyethylene socket was fixed by bone cement, and the femoral head material was CoCr (22mm; 5 hips, 26 mm; 96 hips). Results. Two hips were revised, one was due to late infection, and the other due to breakage of the implant in trauma. Japanese orthopaedic association (JOA) score improved from 40 to 86 points. Postoperative complication was three periprosthetic fractures (one femoral shaft fracture and two greater trochanteric fractures) and femoral shaft fracture case was operated. Dislocation was not observed. Socket loosening (Hodgkinson, Type 3, 4) and stem loosening (Harris, definite and probable) were not observed radiographically. Cortical hypertrophy was observed in 7.9%. The survival rate of HS-3 tapered stem was 98% for revision due to any reason and 100% for revision due to aseptic loosening. Discussion. The long-term clinical results of K-MAX HS-3 tapered stem were excellent. The osteolysis at the stem tip was not observed in this type, which was observed in a few cases in previous type. From the X-ray finding, it was suggested that this taperd stem had more uniform stress distribution to the femoral bone than previous type. Moreover, the problems associated with titanium alloy usage were not observed. From the present investigation, good farther long-term results of the tapered titanium stem were expected

Introduction: The traditional methods for the treatment of femoral shaft fractures of children consists of closed reduction and either spica casting or fixation by external fixator. There are also reports on the treatment of such injuries by open reduction and internal fixation by plate. In the last years the method of minimal invasive fixation of such fractures with elastic nails became popular in children over 6–7 year old. The purpose of this paper is to present our experience with elastic nail fixation of femoral shaft fractures of children. Material and Methods: We present a series of 43 children aged 3–13 year old, mean age: 6.5y, follow-up 2–4 years, mean 2.5 years) with shaft fractures of the femur. 12 children were under 5 year of age. Seven of them were poly-trauma patients. There were no open fractures. Each patient was treated by closed reduction and percutaneous nail insertion under C-arm imaging intensifier control. Fixation was accomplished by a knee immobilizer alone. Early non-weight-bearing mobilization was encouraged until appearance of callus formation. Subsequently, weight-bearing was encouraged. Results: The results of all cases were excellent. All fractures were united within 7–14 weeks, with an average of 9 weeks. There were not any cases of femoral fractures through nail insertion. There was no decrease in the range of hip and knee motion. None of the patients had complications such as infection, malalignment or neurovascular injury. There was two cases of bursitis around the tip of the nail in the supracondylar region, which was resolved by early pin removal. Removal of the pins was done 6–9 months following operations. Conclusions: Closed reduction and minimal invasive fixation of femoral shaft fractures by use of Nancy Nails is safe, simple and useful in children with femoral shaft fractures, even in young children under the age of 5 years, and especially in cases of poly-trauma. This minimally invasive procedure allows for early mobilization with no loss of range of motion or associated complications

Introduction: The principles of fracture management in patients with multiple injuries continue to be of crucial importance. Early treatment of unstable patients with head, chest, abdomen or pelvic injuries with blood loss) followed by an immediate fracture fixation (“Early Total Care”) may be associated with a secondary life threatening posttraumatic systemic inflammatory response syndrome (SIRS). We present our experience experience in the treatment strategy of polytraumatized patients with femoral shaft fracture. Patients and Methods: From 1995 to 2008 there were 137 polytraumatized patients with femoral shaft fracture treated in our hospital. The outcomes of their treatment were retrospectively analyzed in this study. Patients were grouped according the treatment strategies for stabilization of the femoral shaft fracture: Group A – 99 patients treated with early total care (ETC) - intramedullary nailing (IMN) within 24 h of injury Group B- 38 patients treated with temporary external fixation as a bridge to IMN (DCO surgery starting at 2005). Results: The groups were comparable regarding age, gender distribution and mechanism of injury. ISS was higher in group B (DCO) – 32,2 compared to group A (ETC) – 22,6. The patients in DCO group required significantly more fluids (14,2 L) then those in ETC (8,2 L) and blood (2,2 vs 1,3 L) in the initial 24 hours. Thoracic, abdominal or head injuries were accounted significantly higher number of patients submitted to DCO group from 2005 (24,2%) compared to ETC group (12,4%). Mean operative time for External Fixators was 40 minutes, 110 minutes for IMN. There was a significantly higher incidence of ARDS in ETC group −18,2% compared to DCO group – 8,6%. The incidence of multiple organ failure (MOF) was significantly lower in DCO group – 7,4% than in ETC group – 12,1 %. There were 3 unexpected deaths and 2 cases with conscious worsening in patients with head injury in ETC group. No significant differences in the incidence of local complications were found. Conclusions: Based on this study it seems that a significant reduction in incidence of general systemic complications (ARDS, MOF) was found in DCO group in comparison with ETC group, Changing of the treatment protocol from ETC to DCO is not associated with increased rate of local complications (pin-tract infections, delayed unions or nonunions). There is a lower complication rate in DCO Group despite higher ISS compared with the ETC Group, DCO surgery appears to be an viable alternative for polytraumatized patients with femoral shaft fracture

Antegrade intramedullary nailing via a piriformis fossa start point is the treatment of choice for most femoral shaft fractures in adults. Recently alternate approaches for intramedullary nailing of the femur have been advocated, including retrograde nailing and trochanteric start point antegrade nailing. Reasons cited for considering altenative starting points to the piriformis fossa include a concern about the damage to the hip abductor muscles that may occur during access to the piriformis fossa. There is very little literature about long- term muscle function after standard antegrade intramedullary nailing and the conclusions of the available studies are conflicting. The purpose of this study was to document the hip abductor muscle strength following standard antegrade intramedullary nailing utilizing two different objective measures (KinCom and gait analysis). Objective evidence of hip abductor muscle strength will assist in planning new nailing techniques. Twenty-two patients with isolated femoral shaft fractures who were treated with standard antegrade reamed interlocking intramedullary nailing and who had a minimum one year follow-up were identified. The patients were examined for muscle strength, range of motion and limb length. All of the patients answered a questionnaire and completed the SF-36 and Musculoskeletal Functional Assessment outcome measures. All patients had isokinetic muscle testing of their hip abductors, hip extensors and knee extensors using the KinCom muscle testing machine. Ten of the patients also underwent formal gait lab analysis. Isokinetic muscle testing showed no significant difference from the uninjured contralateral side in hip abduction, hip extension or knee extension. The gait lab analysis failed to show any important changes in gait pattern. SF-36 scores were comparable to norms. MFA scores did not indicate any significant long term disability. Antegrade reamed interlocking intramedullary nailing of femoral shaft fractures utilizing a standard piri-formis fossa starting point is not associated with any significant long term hip abductor muscle strength deficit. Gait pattern returns to normal following femoral shaft fracture treated with this technique and functional outcomes are good

Background. Polytrauma patients are at high risk of systematic inflammatory response syndrome (SIRS) due to an exaggerated unbalanced immune response that can lead to multiple organ failure and increased mortality. This response is often heightened following acute surgical management as a result, damage-control orthopaedics (DCO) was born. This allows the patient to be stabilised using external fixation allowing physiology to improve. This systematic review aims to compare DCO against early total care (ETC) (<24hrs intramedullary nailing) in polytraumatised patients with femoral shaft fractures using a diagnosis of acute lung injury (ALI) as the primary outcome measure. Method. A systematic review of MEDLINE, EMBASE, CENTRAL and AMED was carried out to identify all English language studies comparing ETC versus DCO using ALI as the primary outcome measure. Two authors independently screened the studies and performed data extraction. Risk of bias was assessed using the Cochrane risk of bias tool and the Risk-of-Bias Assessment Tool for Non-randomised Studies. Results. Three studies were selected for final inclusion. One multicentre RCT demonstrated a significantly higher odds ratio (6.69) of ALI in the subgroup receiving ETC compared to DCO. The two other studies were retrospective case series with one reporting no significant difference and the second study reporting a significant reduction in ARDS when a DCO approach was used (7.8% vs 15.1%). Meta-analysis was not possible due to heterogeneity. Conclusions. This review supports evidence that in the more unstable patients (Injury Severity Score≥30) treated surgically for femoral shaft fractures in the first 24 hours, DCO may have a protective effect over ETC for ALI. However further studies with large sample sizes are needed to provide clarity on the subject area. Level of Evidence. 1. Ethics. No approval required given the nature of this study (systematic review)

Background. The aim of the study was to assess the outcome of internal fixation using two ordinary plates with autogenous bone grafting in the management of non-union of femoral shaft fractures over a period of eleven years. Method. A retrospective study of double plating and autogenous bone grafting for un-united femoral shaft fractures performed by the two Senior Authors between 1996 and 2007. During this period, twenty-one cases were carried out. Details of preoperative, intra-operative, and postoperative findings were assessed. Postoperative follow up was recorded over a period of minimum two years. The procedure was performed using two ordinary plates; a broad lateral and narrow anterior plates. Autogenous cancellous grafts from iliac crest were used in all of the cases, and in some, half fibulas were inserted through the medullary canal of the femur. Results. A total of twenty-one patients were included in the study. All of them received previous treatment. The primary treatment was by intramedullary nailing in thirteen patients, uni-plating in four, external fixator in three, and traction in one. The average age was 32 (range from 16 to 52). The average interval between the initial fracture and the treatment of the non-unions was 13 months (range from 6 to 28 months). All wounds, both at fracture site and the graft donor site, healed primarily except one. That was at an iliac crest graft donor site, where superficial infection occurred, and was treated with antibiotics and healed 6 weeks later. All patients achieved union on an average of 16 weeks (range from 12 to 28 weeks). There has been no failure in implants. The average lower limb shortening was 0.75 cm (range from 0.5 to 1.0 cm). No one requested shoe raise. All the patients regained the preoperative range of motion at the hip and knee joints except four, who had limited flexion to 100 degrees. Conclusion. We conclude that double plating with autogenous bone grafting is not only a convenient method to treat non-union of femoral shaft fractures as it requires minimal instrumentation and equipment, but it should also be considered as a safe and accepted treatment method as postoperatively patients can be discharged early on crutches, with a high success rate. It is less expensive, an important consideration in developing countries

Twenty one cases of ipsilateral hip and femoral shaft fractures, between January 1998 and December 2001, managed by reconstruction nail were reviewed. All patients underwent simultaneous surgery for both fractures and operative treatment was executed as early as general condition of the patient permitted. Delay in treatment was generally because of associated injuries [head, chest or abdominal]. There were 20 males and 1female patients with an average age of 34.5 years. There was delayed diagnosis of neck fracture in 2 cases and these cases were not included in the study. Our average follow-up is 30.9 months. There was one case of nonunion of a femoral neck fracture, one case of avascular necrosis and one neck fracture that united in varus. There were 4 nonunions and 6 cases of delayed union of femoral shaft fractures. Mean time for union of femoral neck fracture was 15 weeks and for shaft fracture was 22 weeks. In our results, shaft fracture determined the total union period. Though complications involving the femoral shaft fracture were greater than the femoral neck fractures, the shaft complications were more manageable compared to neck complications. This stresses the need to realize the significance and seriousness of both components of this complex injury, in evaluation, management and postoperative care. Conclusion: Though technically demanding the reconstruction nail is an optimal alternative for management of concomitant fracture of femoral neck and shaft with low rates of complications and good results

Introduction. Femoral shaft fractures in children is a serious injury that needs hospitalization, with a high prevalence in the age group 6–8 years old. Various treatment options are available and with a comparable weight of evidence. Submuscular plating provides a dependable solution, especially in length-unstable fractures and heavier kids. We present a novel technique to facilitate and control the reduction intraoperatively, which would allow for easier submuscular plate application. Materials and Methods. We have retrospectively reviewed four boys and three girls; all were operated in one centre. Polyaxial clamps and rods were applied to the sagittally-oriented bone screws, the reduction was done manually, and the clamps were tightened after achieving the proper alignment in the anteroposterior and lateral fluoroscopy views. The submuscular plate was applied as described, then clamps and bone screws were removed. Results. The mean age at surgery was 13 years (range, 9–14). The mean body weight was 43.3 kg (range, 30–66). There were five mid-shaft fractures, one proximal third and one distal third. There were Four type A fractures, two type B and one type C. Four patients had road traffic accidents while three had direct trauma. The mean preoperative haemoglobin concentration 12.5 g/dl (range 11.3–13 g/dl). No blood transfusion was needed intraoperatively or postoperatively. The operative time averaged 122 minutes, and the mean hospital stay was one (range 1–4 days). The patients reported no pain at a mean of 1.5 weeks (range, one-three weeks). All fractures united at a mean of 8.7 weeks (range 6–12 weeks). No wound healing problems nor deep infections happened. The knee joint range of motion was full in all patients at six weeks postoperatively. There was no mechanical irritation from the inserted plate. At the final follow-up, all fractures united without malalignment nor length discrepancy. Conclusions. External fixator-assisted internal fixation of pediatric femoral fractures would facilitate the accuracy and control of fracture reduction and allow minimally invasive percutaneous osteosynthesis. Our study has shown a decrease in operative time, and an accompanying reduction in length of inpatient stay, prolonged need for analgesia and post-operative rehabilitation

Introduction and Aims: Recently alternate approaches for intra-medullary femoral nailing have been advocated, including retrograde nailing and trochanteric start point antegrade nailing in an attempt to avoid damage to the hip abductor muscles that may occur during access to the piriformis fossa. The aim of this study was to document the hip abductor muscle strength following standard antegrade intra-medullary nailing utilising two different objective measures. Method: Twenty-two patients with isolated femoral shaft fractures who were treated with standard ante-grade reamed interlocking intra-medullary nailing and who had a minimum one-year follow-up were identified. The patients were examined for muscle strength, range of motion and limb length. All of the patients answered a questionnaire and completed the SF-36 and Musculoskeletal Functional Assessment outcome measures. All patients had isokinetic muscle testing of their hip abductors, hip extensors and knee extensors using the KinCom muscle testing machine. Eleven of the patients also underwent formal gait lab analysis. Results: Isokinetic muscle testing showed no significant difference from the uninjured contralateral side in hip abduction, hip extension or knee extension. The gait lab analysis failed to show any important changes in gait pattern in the time spatial and hip moment parameters. SF-36 scores were comparable to norms (mean physical component score 53 and mean mental component 51). MFA scores did not indicate any significant long-term disability. Conclusion:Antegrade reamed interlocking intra-medullary nailing of femoral shaft fractures utilising a standard piriformis fossa starting point is not associated with any significant long-term hip abductor muscle strength deficit. Gait pattern returns to normal following femoral shaft fracture treated with this technique and functional outcomes are good

From May 2002 to April 2003, a prospective, non-randomised, blinded study was undertaken in 30 patients with fractures of the femur and tibia, all treated with unreamed intramedullary (AO) nail fixation. There were 17 (57%) femoral shaft fractures and 13 (43%) tibial shaft fractures. Most of the patients (23) had been injured in road findings accidents, 17 of them pedestrian. No patient had any known co-morbidities. Fourteen patients (47%) were HIV positive, nine with femoral fractures and five with tibial fractures. Three patients with compound femoral fractures were HIV positive, two HIV negative. The mean age of HIV-positive patients with femoral shaft fractures, two men and seven women, was 33 years (18 to 48). The mean age of the eight HIV-negative men with femoral shaft fractures was 28 years. Five tibial fractures were compound, three in HIV-positive patients and two in HIV-negative patients. The mean age of HIV-positive patients with tibial fractures, three men and two women, was 31 years (18 to 56). The mean age of the HIV-negative patients, seven men and one woman, was 28 years. All the fractures were Gustillo-Anderson grade- II. At 12 weeks, 29 fractures had united. In one HIV-positive patient with a compound tibial fracture there were no radiological signs of union at 12 weeks, but after bone grafting the fracture united uneventfully. An HIV-positive patient, who had sustained a gunshot femur injury, developed deep wound infection four months after fixation. In all other patients, the wounds healed uneventfully. In asymptomatic HIV-positive patients, wound healing and fracture union rates are comparable with those of HIV-negative patients

Introduction: This study compared the accuracy of reduction of intra-medullary nailed femoral shaft fractures, comparing conventional and computer navigation techniques. Methods: Twenty femoral shaft fractures were created in human cadavers, with segmental defects ranging from 9–53mm in length. All fractures were fixed with antegrade 9mm diameter femoral nails on a radiolucent operating table. Five fractures (control) were fixed with conventional techniques. Fifteen fractures (study) were fixed with computer navigation, using fluoroscopic images of the normal femur to correct for length and rotation. The surgeon was blinded to defect size. Two landmark protocols were used in the study group referencing the piriform fossa (Group A, n=10) or proximal shaft axis (Group B, n=5). Postoperative CT scans, blindly reported by a musculoskeletal radiologist, were used to compare femoral length and rotation with the normal leg. Results were analysed using ANOVA with 95% Confidence Intervals. Results: The control and study groups were not statistically different with respect to age of cadaver or size of femoral defect. Results: The mean leg length discrepancy in the study groups were significantly less (3.6mm (95% CI 1.072 – 6.128) and 4.2mm (95% CI 0.63–7.75), compared with 9.8mm (95% CI 6.225 – 13.37) in the control group (p< 0.023). The mean torsional deformities in the study groups were 8.7 degrees (95% CI 4.282 – 13.12) and 5.6 degrees (95% CI -0.65 – 11.85), compared with 9 degrees (95% CI 2.752 – 15.25) in the control group (p=0.650). Within the navigated study group, length discrepancy was similar in subgroups 1 (3.6mm) and 2 (4.2mm). Torsion appeared more accurate in group 2 (5.6 degrees) than group 1 (8.7 degrees), although this was not statistically significant. Discussion: Computer navigation significantly improves the accuracy of femoral shaft fracture fixation with regard to length. With further modifications to improve reduction of rotational deformity, it may be a useful technique in the treatment of femoral fractures

Antegrade femoral nailing through the greater trochanter, using nails designed for piriformis entry, is associated with varus and iatrogenic comminution. Nails designed for greater trochanter insertion theoretically reduce these complications, but clinical outcomes comparing these to piriformis entry remain unknown. We compared femoral shaft fracture repair with a nail designed for trochanteric entry to an identical nail without a trochanteric bend inserted through the piriformis fossa. The trochanteric nail was easier to insert with decreased operative and fluoroscopy time. It resulted in equally high union rates, low complication rates, and functional results similar to conventional nailing through the piriformis fossa. Trochanteric antegrade nailing of the femur is thought to be advantageous over conventional antegrade nailing due to improved ease of insertion, but is unproven. This study compares results of femoral shaft fracture treatment using a nail designed specifically for trochanteric entry, Trigen TAN, to results using an identical nail without a trochanteric bend inserted through the piriformis fossa, Trigen FAN. A femoral nail specially designed for trochanteric insertion resulted in equally high union rates, equally low complication rates, and functional results similar to conventional antegrade femoral nailing through the piriformis fossa. As a result of increased ease of insertion, decreased operative time and decreased fluoroscopy time, the greater trochanter entry portal, coupled with an appropriately designed nail, represents a rational alternative for antegrade femoral nailing. Insertion of a specially designed femoral nail though the trochanter is faster, easier, and requires less fluoroscopy time than conventional antegrade nailing through the piriformis fossa. Overall, there was < 10° malalignment and no iatrogenic fracture comminution. The average operative time was 21% greater using the FAN nail than using the TAN nail, (p=.08). The average fluoroscopy time was 61% greater for the FAN group than for the TAN group, (p< .05). Trends in functional outcome (Lower Extremity Measure) were similar for both groups. One hundred and eight patients treated for a femoral shaft fracture were included in this study. Ninety-eight patients were treated with either a Trigen TAN nail (n=38) or Trigen FAN nail (n=53); seventeen patients with insufficient follow-up were excluded from analysis. Funding:Smith & Nephew, Memphis TN

Introduction and Aims: The treatment of femoral shaft fractures in skeletally immature patients has changed dramatically over the past 30 years. This is due in part to the advances in intramedullary nail outcomes pioneered in the adult orthopaedic trauma literature. We examined the results of reamed, locked nails in a pediatric population. Method: The medical records of 224 children with femoral shaft fractures treated with reamed, locked intramedullary nails (RLIMN) at our institution between 1987 and 2000 were reviewed (largest series in the literature). Patients were treated with nails placed through the greater trochanter. Of those patients, 72 patients had long-term clinical (> 24 months) and radiographic (AP pelvis and leg length CT scanogram) follow-up. Functional status and radiographic parameters (femoral neck-shaft angle, leg length, presence of osteonecrosis) were recorded. Patients lacking two-year clinical and radiographic follow-up were evaluated via telephone follow-up. Results: At our institution, over 200 skeletally immature patients have successfully undergone reamed, locked, intramedullary nailing of femur fractures. Average age at the time of treatment was 10.3 years. No case of osteonecrosis of the femoral head occurred. All fractures united after treatment with RLIMN at an average of 71 days. No patient manifested a gait abnormality after healing. Complications included delayed union in two patients, (one patient was treated with exchange IMN and one patient healed after dynamisation) superficial wound infection in one patient, (treated with oral antibiotics) and coxa valga in one patient. The patient that developed coxa valga was 7.7 years old at the time of intramedullary nailing. The only other procedures performed were removal of hardware in patients who remained skeletally immature at the time of healing. All patients returned to pre-injury activity level. The average leg length difference was 0.6cm (longer on the injured extremity). Average articulo-trochanteric distance was 0.28cm (longer on injured extremity). Conclusion: Our results demonstrate that femoral shaft fractures in skeletally immature patients can be safely treated with reamed, locked intramedullary nails placed through the greater trochanter. We recommend careful placement of the nail through the greater trochanter to avoid damage to the blood supply of the femoral head

Introduction: Nailing of the femoral shaft fractures has almost exclusively been done through the antegrade approach. This involves the use of a traction table and location of the entry point piriform fossa can be difficult especially in the obese or well-built patient. The set-up and operative time and blood loss can be considerable. We conducted a prospective study of nailing of femoral fractures, using the retrograde approach (through the knee joint) to measure the operating time, blood loss and knee function. A purpose built retrograde system was used (ART Nail ® ACE Medical Company-El Segundo, California). Materials & Methods: Seventeen patients who had a femoral shaft fracture, either as an isolated injury, or with associated with other injuries were nailed using the Art Nail, using the retrograde approach. The patients were placed on a radiolucent table, with a bolster place under the knee joint. A stienmann pin was inserted into the ipsilateral tibia 1” inferior and posterior to the tibial tubercle. This was used to apply traction manually by an assistant. The surgical approach was to split the patella tendon and the knee joint was entered. Using a light source, the nail entry point at the intercondylar notch, 7mm anterior to the PCL, is located. The rest of the operative procedure was done according to the operative manual. Blood loss was estimated by the anaesthesiologist. A drain was inserted into the knee joint after a through wash-out and continuos passive motion was started when the drain was removed on the 2nd postoperative day. Results: Fourteen had a single fracture while 3 had other associated fractures. The age range of was 28 to 67 years. Operative time was 60–100 minutes with blood loss ranging from 50–600 mls,with the median at 200mls. Post-operative drainage was 10–335 mls with median at 100mls. One patient developed distal deep vein thrombosis. Two patients were lost to follow-up. Union occurred at 12–20 weeks in fourteen patients, Two patients had to undergo dynamisation of the nail, one of which required a bone grafting to achieve union at 24 weeks. Two patients had a 1cm shortening of the limb and there were no malrotations. Two patients had < 5 degree medial–lateral angulation, on X-ray. At six months follow-up, fourteen patients had full range of motion at the knee joint, while one patient who had chondrocalcinosis had range of motion from 0 to 90 degrees. . The follow-up period is from 10–26 months. No patient complained of pain or instability of the knee joint. Conclusion: The retrograde approach is a safe and quick method of nailing femoral shaft fractures with no medium term effects on the knee joint

Purpose: The intramedullary nailing is the treatment of choice for the femoral shaft fractures, giving advantages of early mobilization and weight bearing. The purpose of this study is to present our experience with numerous reamed femoral nails and to report the results and the complications. Material and Method: From 1993 to 2004, 415 femoral shaft fractures (413 patients) were treated in our hospital. There were 312 males 101 females with mean age was 27.8 yrs (17–84 yrs). The 87 % of fractures were caused by high-energy injuries (traffic accidents). Pathologic fractures were not included. The 415 fractures according to AO classification were divided as follows: Type A: 105 (25.4%), Type B: 179 (43.1 %), Type C: 131 (31.5 %) There were 341closed fractures and 74 open. Those 74 were classified according Gustilo to 33 Grade I, 24 Grade II, 14 Grade III A, 2 Grade III B and 1 Grade III C. The fractures were treated with 308 AIM titanium nails and 107 Gross-Kempf nails. Dynamic stabilization was performed in the majority of the type A fractures, and static to those classified as B and C. We encourage our patients to walk with partial weight bearing, from the second post op day, except those with type C fractures who started their weight bearing after a month. The patients were evaluated 3,6,12,36 weeks and 1 years post surgery clinically and with standing X-Rays. Results: After a mean follow-up time of 1.5 years, our union rate was 97.8%. Type A fractures were united in an mean time of 16 weeks, type B in 20 weeks and type C in 23 weeks. Our complications were: 9 non unions (aseptic pseudarthrosis) (2.2%), 14 delayed unions (3.4 %), torsional malunion (more of 5°) in 4 patients (0.96 %). In 6 patients (1.44 %) we had limb shortening of 15 mm. Neurological complications were observed postoperatively in 30 patients, 25 with paresis of the pudendal nerve, due to traction (all recovered in a month), and 5 with paresis of peroneal nerve which were recovered in 3 months. There was found 28 broken screws but no broken nail. We had 3 pulmonary and 2 fat embolisms, but none of them was fatal. In 4 patients was observed clinically vein thrombosis below knee. Also we noticed one superficial and one deep infection, but we didn’t have a case of compartment syndrome. Patients returned to their previous activities in a mean time of 10 months. Conclusion: Our results confirmed that the antegrade intramedullary nailing technique had optimal results and high union rate regarding the treatment of the femoral shaft fractures. Some of the complications could be related with the surgeon’s skills-experience and could be avoided. We prefer the use of titanium nails because their modulus elasticity is closer to bones

The October 2014 Children’s orthopaedics Roundup. 360 . looks at: spondylolisthesis management strategies; not all cervical collars are even; quality of life with Legg-Calve-Perthe’s disease; femoral shaft fractures in children; percutaneous trigger thumb release – avoid at all costs in children; predicting repeat surgical intervention in acute osteomyelitis; and C-Arm position inconsequential in radiation exposure

Introduction. Atypical femoral fracture focused on relation of bisphosphonate use, frequently. However, the mechanism of atypical femoral fracture was not yet clarified. Atypical femoral fractures have been kept femoral shaft cortical thickness and BMD, practically. We hypothesized that atypical femoral fractures were associated with impaired bone quality and curvature of femoral shaft. Materials & Methods. We experienced four atypical femoral fractures. One was subtrochanteric and three were shaft fracture. Two cases received bisphosphonate therapy for 3–5 years. BMD, bone metabolic markers, and bone quality markers were evaluated. Histomorphometry and collagen cross-link analysis were performed. Curvature of femoral shaft and 3-D finite element analysis in one incomplete fracture case were assessed. Results. BMD values were either maintained or not severely decreased. Deterioration of bone quality were verified by the results of histomorphometry, collagen cross-link analysis, and bone quality maker. Especially, homocystine values, such as one of bone quality markers, were increased in all cases. All atypical femoral shaft fractures showed outward curvature of femoral bone. In one case of incomplete atypical femoral shaft fracture, stress was concentrated at the fracture region according 3-D finite element analysis. Conclusions. The results of this study suggest that atypical femoral fractures were estimated associated with deterioration of bone quality and curvature of femoral shaft

Purpose of the study: A retrospective series of 40 patients who underwent simultaneous intramedullary nailings for bilateral femoral shaft fractures was analyzed. The aim of our study was to verify that simultaneous nailing without reaming does not increased risk of fat embolism and to assess clinical and radiological outcome. Material and method: This series included 27 men and 13 women, mean age 27.8 years, who underwent first intention intramedullary nailing between 1986 and February 1999. Thirty-two patients had multiple fractures. Mean ISS was 23 (range 9 to 59). Among the 80 femoral shaft fractures, 15 were open fractures, 3 were associated with sciatic paralysis, and 4 were complicated by an interruption of the femoral vessels. The AO classification was: type A = 44; type B = 25; type C = 11. Mean delay to simultaneous centromedullary nailing was 3.8 days: surgery was performed on the day of arrival for 25 patients. General anesthesia was used in all cases with respiratory assistance (FIO2 = 50 to 100 p. 100). Mean nail diameter was 11.6 (range 10–14). Gurd criteria and PaO2 were followed to assess pulmonary function. Clinical and radiological outcome was assessed using the modified Thorensen criteria. Results: Preoperatively, PaO2 was < 87 mmHg in 8 patients. Four of these patients showed a discrete drop off and three improved well above the normal level. Only one patient experienced an important decrease but did not develop respiratory distress. Among the 32 patients with a normal level preoperatively, PaO2 remained in the normal range in 18, fell to a limit level but below 87 mmHg in 4, and showed a substantial drop off of 46 to 172 mmHg in 10. Two of these 10 patients developed respiratory distress due to fat embolism which was fatal in one case. One other patient died in the immediate postoperative period of an undetermined cause. All of the other patients recovered normal gas levels within a few hours or days. There were four cases of phlebitis, including one with pulmonary embolism, one case of respiratory distress by pulmonary superinfection, and one case of septicemia. Both femoral fracture sites became infected in one patient. Malunion occurred in two cases. Two vascular repairs of the femoropopliteal axis were unsuccessful, leading to above knee amputations. Thirty-four patients have been examined after a minimal 12 months follow-up (mean 30 months). Outcome was excellent for 48 femurs, good for 10 and fair for 10. Discussion: This continuous series of simultaneous bilateral femoral shaft intramedullary nailings appears to be the only such report to date. The clinical and radiological outcomes were comparable with those achieved in one-side femoral fractures. The risk of fat embolism is inevitable after long bone fractures. Many factors favoring the risk are recognized, the most important being delay to fixation. Reaming creates excessive pressure in the medullary canal and could thus contribute to the risk. The presence of an associated chest trauma is not a formal contraindication if effective hematosis is preserved as evidenced by the blood gases. Conclusion: Simultaneous nailing of bilateral femoral shaft fractures can be performed if blood gases remain acceptable and minimal reaming is used

Background:. In recent times there has been an increasing trend towards surgical intervention in paediatric femoral shaft fractures with widening indications. Titanium elastic nails and external fixation are two widely practiced procedures for such fractures. Materials & Methods:. We report a series of 48 children with 52 fractured femurs, 18 being managed by TENS and 34 in a linear external fixator. Children were aged between 3.5 to 12 years and the fractures were stabilised after an optimal closed reduction on a normal theatre table under image intensifier control. Fracture site distribution was nearly uniform in both the groups. Though most children were assigned to any of the groups at random, external fixators were applied on many younger children and those having financial constraints. Results:. The average age of children in the TENS group was 7.4 years and the average fracture healing time was 9.4 weeks. In the ex-fix group the figures were 5.6 years and 8.6 weeks respectively. Fixators were removed when good callus formation was seen on at least three cortices; average fixator time was 7.5 weeks. Fracture callus formation was slower in TENS group. Soft-tissue irritation at the nail entry points was the commonest complication for the TENS whereas pin-track infection was problem in the ex-fix group. Conclusion:. Management of paediatric femoral shaft fractures has changed to include more interventions. Flexible or elastic nailing like the TENS is a versatile and popular technique, however stabilisation in an external fixator also produce comparable results. External-fixation is an easier, cheaper and shorter procedure, and a mini ex-fix becomes a convenient external splint for smaller children who can be more conveniently nursed. Moreover ex-fix removal is an office procedure without anaesthesia

1. The combination of femoral shaft fracture with dislocation of the hip in the same limb has been recorded in eighty-one patients since 1823. 2. A further fourteen cases are reported. 3. In over half the cases the hip dislocation was diagnosed late or not at all, and this error has occurred more often in modern times. The reasons for this are outlined. 4. The diagnostic physical signs of hip dislocation in the presence of a femoral shaft fracture are described. 5. The mechanism, sequels and treatment of this combined injury are discussed

Objectives: The purpose of the study is to evaluate the effectiveness of a new diagnostic protocol in identifying femoral neck fractures associated with ipsilateral shaft fractures and to study the clinical and functional outcome of these patients treated by cephalomedullary nailing. Materials and Methods: 268 consecutive patients with presenting with 273 femoral shaft fractures were subjected to AP radiographs of the ipsilateral hip along with clinical examination for neck tenderness and aspiration of the ipsilateral hip to rule out an associated neck fracture. Computerized tomography scans through the femoral neck was taken only in case of discrepancy in the initial work up. All patients diagnosed to have an associated neck fracture underwent surgical stabilization using long cephalomedullary nails. Results: All 28 neck fractures occurring in association with 273 consecutive femoral fractures were diagnosed without delay. Computerized tomography scans were required in 8 patients. All fractures united at follow up and good functional results were obtained in 19 of the 25 patients included in the final analysis. Conclusion: Neck fractures associated with ipsilateral femoral shaft fractures can be diagnosed without the need for higher imaging modalities on a routine basis. Fixation of both fractures with a long cephalomedullary nail gives good results with minimal complications

We performed a retrospective review of all patients admitted to two large University Hospitals in the United Kingdom over a 24-month period from January 2008 to January 2010 to identify the incidence of atypical subtrochanteric and femoral shaft fractures and their relationship to bisphosphonate treatment. Of the 3515 patients with a fracture of the proximal femur, 156 fractures were in the subtrochanteric region. There were 251 femoral shaft fractures. The atypical fracture pattern was seen in 27 patients (7%) with 29 femoral shaft or subtrochanteric fractures. A total of 22 patients with 24 atypical fractures were receiving bisphosphonate treatment at the time of fracture. Prodromal pain was present in nine patients (11 fractures); 11 (50%) of the patients on bisphosphonates suffered 12 spontaneous fractures, and healing of these fractures was delayed in a number of patients. This large dual-centre review has established the incidence of atypical femoral fractures at 7% of the study population, 81% of whom had been on bisphosphonate treatment for a mean of 4.6 years (0.04 to 12.1). This study does not advocate any change in the use of bisphosphonates to prevent fragility fractures but attempts to raise awareness of this possible problem so symptomatic patients will be appropriately investigated. However, more work is required to identify the true extent of this new and possibly increasing problem

We report a femoral shaft fracture that reduced spastic muscle hypertonus of the affected lower limb of a child with cerebral palsy. The child was a five years old boy. He was borne with spastic quadriplegia (total body involvement). He could not sit, stand and walk by himself. The femoral shaft fracture occurred during physiotherapy. The injury itself was iatrogenic although the bones were accompanied by roentgenological bone atrophy. Such bone atrophy comes from disuse or low physical activity. The fracture was treated by a hip spica cast. The femoral bone was shortened at the time of immobilization. After removing the cast, the spastic muscle hypertonus was apparently reduced. This instructive case suggests osteotomy as a new effective treatment for spastic hypertonus. Osteotomies would make few scars in the muscles and tendons comparing to lengthening of multiple tendons and muscles. In this case, osteotomies are believed to be a non-invasive treatment rather than other available operative procedures

Introduction: The proximal femoral nail antirotation (PFNA) system is a cephalomedullary device originally designed to contend with the challenge of unstable tro-chanteric femoral fractures with the novel helical blade component aimed at limiting femoral head limiting cutout. We demonstrate its use in a variety of cases. Methods: This is a prospective study of 370 consecutive patients treated with short and long PFNA systems at a single center with 1-year follow-up. The device was used for unstable trochanteric femoral fractures (AO-classification 31. A.2 and A.3), prophylactic and definitive fixation of pathological fractures and high energy femoral fractures for a wide age range (19–101 years). Clinical outcome involved assessment of general mobility & function, operative and post-operative parameters & complications. Radiological outcome involved assessment of blade tip-apex distance, nail tip-femoral scar distance and distal locking configurations. Results: 17% died within the follow-up period. 72% achieved their pre-trauma mobility status and nearly all fractures healed within 6 months including those in over 85 years. Of 18 problematic cases, serious complications included deep infection, loss of proximal reduction, ipsilateral femoral shaft fracture and periprosthetic supra-condylar fracture. There were no cases of acetabular penetration or blade cut-out. Short PFNA was associated with the majority of femoral shaft fractures and the only significant finding regarding instrumentation. Discussion: This study supports long PFNA design theory demonstrating adequate purchase in the femoral head-neck zone, shown by lack of cut-out. Positive results have been demonstrated in a variety of cases making it a useful option in fractures in all ages and indications alongside unstable trochanteric configurations

Objectives. Femoral shaft fracture treatment often results in mal-alignment and the high dosage of radiation exposure. The objective of this study is to develop a Parallel Manipulator Robot (PMR) on traction table to overcome these difficulties so as achieve better alignment for the fractured femur and reduce radiation to both patients and physicians. Methods. The distal platform of PMR is attached to the central pole on standard traction table by the boot adaptor. A leg model with soft tissue made by Pacific Research Laboratory, Inc. is flexed at the knee with patella on the top. A 2/3 circular ring, with 1/3 open circle down, fixed to the fractured distal femur with one trans-wire and one self-tapping screw, acting as adaptable stirrup fixing scheme. To secure proximal femur, an adapter is assembled on the traction table and fixed on the proximal femur. The distal femur is fixed to the 2/3 circular ring platform of PMR. Surgical planning is performed by first acquiring the bi-planar images from the C-Arm X-ray machine. After simulated fracture on 3-D femoral model is made, proximal and distal segments of the model will be superimposed with background bi-planar images. Finally the pre-fractured length and mechanical axis of 3-D femoral model will be restored. Afterwards, a table of schedule for length adjustments of six struts of PMR is generated. This length adjustment schedule is used to drive the PMR for fractured femur alignment and reduction. When reduction completed, a special designed device is used to fix the reduced femur. Then the PMR is removed from the traction table and the patient can be removed from the traction table. Results. Eight femoral sawbones model were artificially broken into eight different fracture patterns. All the fracture patterns have characteristics of distal segments overlapping with proximal segments but in the different locations. The operations of reduction were all following the initial tractions. The results showed that the mean errors were 1.31+-0.45mm for axial discrepancies, 2.43+-0.49mm for lateral translations, 2.26+-0.23mm for angulations. Conclusion. Femoral Shaft Fracture Reduction with PMR on traction table has been built with femoral soft tissue model. The experiments had been made on artificially broken femoral sawbone models. The experiments had been proven that such approach is accurate enough for femoral shaft reduction. Further experiments are necessary in order for it to be used clinically

Objective. Femoral shaft fracture treatment often results in mal-alignment and the high dosage of radiation exposure. The objective of this study is to develop a Parallel Manipulator Robot (PMR) on traction table to overcome these difficulties so as achieve better alignment for the fractured femur and reduce radiation to both patients and physicians. Method. The distal platform of PMR is attached to the central pole on standard traction table by the boot adaptor. A leg model with soft tissue made by Pacific Research Laboratory, Inc. is flexed at the knee with patella on the top. A 2/3 circular ring, with 1/3 open circle down, fixed to the fractured distal femur with one trans-wire and one self-tapping screw, acting as adaptable stirrup fixing scheme. To secure proximal femur, an adapter is assembled on the traction table and fixed on the proximal femur. The distal femur is fixed to the 2/3 circular ring platform of PMR. Surgical planning is performed by first acquiring the bi-planar images from the C-Arm X-ray machine. After simulated fracture on 3-D femoral model is made, proximal and distal segments of the model will be superimposed with background bi-planar images. Finally the pre-fractured length and mechanical axis of 3-D femoral model will be restored. Afterwards, a table of schedule for length adjustments of six struts of PMR is generated. This length adjustment schedule is used to drive the PMR for fractured femur alignment and reduction. When reduction completed, a special designed device is used to fix the reduced femur. Then the PMR is removed from the traction table and the patient can be removed from the traction table. Results. Eight femoral sawbones model were artificially broken into eight different fracture patterns. All the fracture patterns have characteristics of distal segments overlapping with proximal segments but in the different locations. The operations of reduction were all following the initial tractions. The results showed that the mean errors were 1.31+−0.45mm for axial discrepancies, 2.43+−0.49mm for lateral translations, 2.26+−0.23mm for angulations. Conclusion. Femoral Shaft Fracture Reduction with PMR on traction table has been built with femoral soft tissue model. The experiments had been made on artificially broken femoral sawbone models. The experiments had been proven that such approach is accurate enough for femoral shaft reduction. Further experiments are necessary in order for it to be used clinically

Aim: The purpose of the study was to report the outcome of Flexible elastic nailing for femoral shaft fractures in children. Materials and Methods: Sixty-three femoral shaft fractures in 62 children treated with titanium flexible elastic nailing over a 10 year period (1998–2007). There were 44 boys and 18 girls aged 7.4 to 15.6 yrs (mean 11.2 yrs). Their body weight ranged from 22 to 64.80 kg (mean 40.99 kg). The right side was involved in 36 and the left in 27 children (including 1 bilateral fracture). The mechanism of injury varied from Road traffic accidents (RTA) in 42, Sports in 2 and Falls in 18 children. The proximal third shaft was involved in 3, middle third in 50 and distal third in 10 children. The fracture pattern varied from Transverse in 28, Oblique in 21, Spiral in 12 and Comminuted in 2 children. Results: All fractures united with a mean union time of 15 weeks (range 6 to 30 weeks). The average follow-up was 72 weeks (range 52–104 weeks). Outcome assessment using the Titanium Elastic Nailing (TEN) Score showed 63% excellent, 32% satisfactory and 5% poor results. The minor complications varied from transient knee stiffness in 8 children, prominent nail ends in 7 children, extensor lag in 2 children, and acceptable facture angulation in 2 children. The major complications were fracture malunion, non-union, delayed union in 1 child each and re-fracture at different level in one child. The mean leg length discrepancy after union was 8mm (range 0–13 mm). There were no cases of infection. This method of treatment provided stable fixation, early mobilization and discharge. Conclusion: We found that good surgical technique with attention to surgical details resulted in 95% excellent to satisfactory outcome

This study compared the accuracy of reduction of intra-medullary nailed femoral shaft fractures, comparing conventional and computer navigation techniques. Twenty femoral shaft fractures were created in human cadavers, with segmental defects ranging from 9–53mm in length. All fractures were fixed with antegrade 9mm diameter femoral nails on a radiolucent operating table. Five fractures (control) were fixed with conventional techniques. Fifteen fractures (study) were fixed with computer navigation, using fluoroscopic images of the normal femur to correct for length and rotation. The surgeon was blinded to defect size. Two landmark protocols were used in the study group referencing the piriform fossa (n=10) or proximal shaft axis (n=5). Postoperative CT scans, blindly reported by a musculoskeletal radiologist, were used to compare femoral length and rotation with the normal leg. Results were analysed using the Wilcoxon two-sample test. The mean leg length discrepancy in the study group was 3.8mm (range 1–9), compared with 9.8mm(range 0–17) in the control group (p=0.076). The mean torsional deformity in the study group was 7.7 degrees (range 20–2) compared with 9 degrees (range 0–22) in the control group (p=0.86). Within the navigated study group, length discrepancy was similar in subgroups A (3.6mm) and B (4.2mm). Torsion appeared more accurate in group B (5.6 degrees) than group A (8.7 degrees), although not significantly. Computer navigation appears to improve leg length discrepancy following femoral nailing. Technique modification during the study improved rotational accuracy, and with further improvement, will make this technique applicable to femoral fracture fixation

A medical and engineering study was made of 1074 car accidents involving 2520 vehicle occupants. The injuries they sustained were correlated with details of the crash and with contact points inside the cars. Where possible the forces which were generated in the crash were estimated and related to the injuries. In all, 39 car occupants suffered femoral shaft fracture, with an incidence of 1.7% and 0.8% for front and rear seat occupants respectively. Of these, 31 had associated injuries to other regions of the body; these were the cause of 13 of the 14 deaths in this group. Associated injuries were more severe in car occupants who were not wearing seat belts but the incidence of femoral fracture was not significantly different. The mean velocity change (delta-V) causing femoral fracture was 26 mph (42 km/h) and there was a higher incidence of femoral shaft fracture when delta-V was over 30 mph. Estimates of forces needed to cause fracture were higher than those found in cadaver studies. The time to union of femoral fractures did not correlate with the severity of the crash but was longer (mean 19 weeks) than the average for other femoral fractures

Elastic stable Intramedullary nailing (ESIN) is a method of treating femoral fractures in older children. The purpose of this study is to report our results over a 9 year period. Between 1998 and 2007, 62 children with femoral shaft fracture were managed at our institution with flexible titanium nailing. There were 44 boys and 18 girls with a mean age of 12.4 years (range 6 to 16 years). The mechanism of injury varied from RTA, falls and sports. The right side was involved in 41 and the left in 23. Two children had bilateral fractures. The fracture was in the proximal one third in 3, middle third in 51 and the distal third of the diaphysis in 8 children. The fracture pattern varied from transverse in 33, oblique in 15, spiral in 10 and comminuted in 4 patients. 11 children had associated injuries and 2 had mild osteogenesis imperfecta and another 3 sustained pathological fractures (fibrous dysplasia - 1 patient; simple bone cyst -1 patient; aneurismal bone cyst – 1 patient). The surgical procedure was retrograde except in one child with a mid third oblique fracture where this technique failed and hence an ante grade insertion was performed. All fractures united at an average follow-up of 18 months (range 12–24 months). The mean union time was 3.8 months (range 1.2 to 7.2 months). All patients were followed until the implant was removed and the mean insertion to removal interval was 13 months (5 to 29 months). The complications noted in our series were knee discomfort with stiffness (8 patients), pain from prominent nails (2 patients), malunion (1 patient), delayed union (1 patient), peri-prosthetic fracture (1 patient). There were no cases of infection. In conclusion, the results of our series showed that Elastic stable Intramedullary nailing gives satisfactory outcome in management of femoral shaft fractures in children

Aims: The purpose of this study is to examine the rate of pseudarthrosis and possible factors involving the healing of the fracture after interlocking nailing (ILMN) as treatment of femoral shaft fractures. We examined the type of the fractures, surgical pitfalls, complications, if the patients smoked cigarettes or tooled other medications and drugs. Methods: Between 1996–2001 we treated 165 patients who had 180 fractures of the femur shaft. In 4 out of our patients primary have treated using interlocking intramedullary nailing we occurred pseud-arthrosis. We have use AO nail in 3 patients and R-T nail in one patient. After the removal of primary nailing þxation components all patients treated with ILMN wider nail and autogenous bone grafting. The preferred method of stabilization is reamed interlocking intra-medullary nailing using AO Nail. Results: Radiological callus formation was apparent in all patients after a period of 18 to 26 weeks (average time 20w). Serious complications were not observed Stiffness of the knee joint was noted in one and pain in distal metaphysis in two cases. Conclusions: The sort-term results have been more than encouraging. We recommend the reaming technique and the dynamization of the nail for optimal outcome. Bone grafting is necessary according to our opinion. Several factors involved the healing of the femoral shaft fracture, after interlocking intramedullary nailing as primary treatment

Management of femoral shaft fractures in the transitional age group (8 to 14 years) remains controversial. The aim of this retrospective review of 50 consecutive patients was to evaluate the outcomes of various treatment methods. Fifty patients (39 boys and 11 girls) with femoral shaft fractures treated between January 1998 and March 2003 were followed-up for a mean period of 30 months (9 to 54), using clinical and radiological parameters as well as patient questionnaires. Motor vehicle accidents had caused the femoral fractures in 56%. The fractures were closed in 88% of the patients and there were associated injuries in 16%. Depending on the degree of comminution and fracture pattern, patients were treated in one of five ways: initial traction, manipulation under anaesthesia and spica immobilisation (16 patients), non-locking nail (18 patients), locking nail (10 patients), plate and screws (four patients) and external fixation (two patients). The mean time to union was 11 weeks (9 to 28). There was an 8% reoperation rate. Complications included limb length discrepancy in eight patients, malrotation in eight, angulation in 12, entry site pain in five, ectopic calcification in six, delayed union in three, knee stiffness in six and scar problems in four. The mean time away from school was 6.5 weeks (2 to 20). At the last follow-up 86% of patients were satisfied with the outcome. The use of non-locking nails is cost effective, and healing time with non-locking nails is no longer than with locking nails

Introduction and Aims: The combination of ipsilateral intertrochanteric and femoral shaft fractures is an uncommon pattern associated with high-energy trauma. This retrospective study used self-report measures to evaluate functional outcome of patients sustaining this fracture pattern and compared two common treatment methods. Method: Three patient-based outcome measures, the Short Form-36 (SF-36), Short Musculoskeletal Functional Assessment (SMFA), and Lower Extremity Functional Scale (LEFS) were used to evaluate the functional outcome of twenty-one patients (13 male, mean 46.7 +/− 16.5 years) treated with a reconstruction nail (n=11) or with a sliding hip screw and retrograde nail (n=10). Results: Mechanisms of injury included motor vehicle accidents (66.7%) and falls from height (14.3%). SF-36 physical and mental component scores were less than Canadian norms, with mean values of 35.9 (p=0.0001) and 43.7 (p=0.02), respectively. There was a trend towards better functional outcome in the group treated with the sliding hip screw with retrograde nail despite this group sustaining more severe injuries as measured by ISS (p=0.004), number of days in hospital (p=0.027), and number of days in ICU (p=0.009). Conclusion: Functional outcome following treatment of ipsilateral intertrochanteric and femoral shaft fractures was reduced compared to Canadian norms. Despite having sustained more severe injuries, the sliding hip screw with retrograde nail group showed a trend towards better outcome as compared to the group treated with the reconstruction nail

Purpose. The purpose of this study was to prospectively evaluate the rehabilitation outcome of children following operative and non-operative stabilisation of long bone fractures sustained in conjunction with an acquired brain injury (ABI). Materials and Methods. Between 1996 and 2002, children up to 16 years of age who were admitted to the Paediatric Intensive Care Unit (PICU) with an ABI and concomitant tibial or femoral shaft fractures were considered eligible for inclusion. Children who died or were unable to walk before the accident were excluded. All data relating to the sustained injuries, the duration of PICU inpatient stay, the fracture treatment and the functional outcome were collected prospectively. The severity of the injuries was assessed using the Injury Severity Score (ISS) and the Glasgow Coma Score (GCS). The duration of time was taken from admission to reaching rehabilitation milestones; the ability to sit, stand and walk was then assessed. Total duration of hospital inpatient stay and mobility on discharge were also recorded. Operative skeletal stabilisation included external or internal fixation, as well as flexible intramedullary nailing. Statistical analysis was performed using the Mann-Whitney U Test. Results. From 300 children admitted to the PICU for treatment of ABI, thirty-seven fulfilled the criteria for inclusion into the study. For both groups (operative vs nonoperative treatment) the mean age of patients was 9 years (range 1–15yrs) and the ISS, GCS scores and the mean stay in PICU were similar. There was a total of 21 femoral fractures (11 treated conservatively and 10 operatively) and 16 tibial fractures (7 conservatively and 9 operatively). Overall, the results showed a reduction in the mean time taken to reach all rehabilitation milestones following operative fracture stabilisation when compared to those treated non-operatively. The mean time to sitting was reduced from 27.1 days to 17.8. The mean time to standing was reduced from 50.1 to 35.6 and to walking, from 67.1 to 45.7 days. The Mann-Whitney U Test demonstrated a statistically significant reduced time to walk in the operatively treated group (p<0.05). Due to the small size of the sample group, significant statistical data for the other parameters measured was not evident. Conclusion. This study was specifically aimed at the short to medium term gains of operative treatment of tibial and femoral fractures in association with ABI. It has been shown that a co-ordinated rehabilitation programme plus operative stabilisation of children's tibial and femoral shaft fractures sustained in association with ABI, hastens rehabilitation, as it allowed aggressive rehabilitation programme to commence at a much earlier stage without risk of loss of fracture reduction

Aim: To quantify the gait characteristics of the children with a history of treated femoral shaft fracture, and compare the outcome of three different treatment methods (spica cast, plate fixation, and flexible intramedullary nailing) in terms of kinematic and kinetic characteristics of gait. Material and Methods: Fifteen children (9 boys, 8 girls), admitted to our hospital for unilateral (n=12) and bilateral (n=3) femoral fracture were evaluated in this study. The average age was 9.4 years (range 5–15 years). They were treated by three different methods: spica cast (n=5 ), plate fixation (n= 5), flexible intra-medullary nailing (n= 5). The cases were followed up with an average period of 23 months (6–48 months). At the end of the follow up period quantitative gait analysis was performed using Vicon 370 system with five cameras and two Bertec force plates. For each assessment, a typical walk was selected for each limb on the basis of consistency of time-distance characteristics. Kinematic and kinetic gait characteristics were compared using MANOVA, post hoc Tukey and LSD tests. Results: Gait characteristics of the patients were significantly different than normal, however, the difference between spica cast, plate fixation, and flexible intra-medullary nailing groups in terms of kinematic and kinetic characteristics of gait were not statistically significant. Older children treated by spica cast showed the best gait characteristics among the others. Conclusion: Femoral shaft fractures during childhood causes significant deviations of gait characteristics even though treated by spica cast, plate fixation, or flexible intra-medullary nailing. These children need novel treatment options to prevent gait pathologies, and further evaluation to understand the compensatory mechanisms of gait deviations

Background: Hip fractures are common among the aged population, with high mortality and morbidity rates. It ‘s annual cost in the United States is expected to double by the year 2040 to about 16 billion U.S Dollars. Of those, approximately 50% are inter-trochanteric fractures. Among them, 50 to 60% are categorized as unstable fractures. Unstable intertrochanteric fractures are defined as 1) fractures with comminution of the posteromedial buttress which exceeds a simple lesser trochanteric fragment; 2) fractures with evidence of subtrochanteric fracture lines; and 3) reverse oblique fractures of the femoral neck. Review of the literature reveals large variations in the amount of complications after surgical treatment of unstable intertrochanteric fractures, among various medial institutes. Infection rates winds from fewer than 1% and up to 15% of cases, and reports of cutout events range from % to 20%. Other complications, such as non-unioin, femoral shaft fractures, and painful hardware, are much less common. Purpose: To investigate the rate of complications after surgical treatment of unstable inter-trochanteric fractures, in our department. Method: Retrospective review of 61 patients who were admitted in our department due to unstable intertro-chanteric fractures, after simple falls, between May 2001 to August 2006, and were treated with intramedullary sliding hip screw. Most of the hardware (90%) were A.O nails (PFN, proximal femoral nail). Results: There were 4 cases of infections, which are 4.9% of cases. Three of them required removal of the hardware. One admission was due to superficial surgical wound infection. There were 3 cases of mechanical cutout of the femoral head screw, which are 6.5% of the cases. No cases of non-union, femoral shaft fractures, or painful hard are noted. Conclusions: To our experience, intramedullary sliding hip screw is a safe and effective treatment for unstable intertrochanteric fractures. Complication rates to our experience are at the lower third compared to reports from medical institutes over the world

The purpose of this study was to evaluate the role of locked intramedullary nailing without reaming for the treatment of open tibial and femoral shaft fractures that has recently been widely used all over the world, and recently evaluated. Seventy open femoral and tibial shaft fractures were treated by meticulous wound excision and early inter-locking nailing without reaming between 1996 and 1999 in our department. The average follow-up of the patients was 20.2 (12–36) months. Thirty-six were fractures of the tibia, and 34 of the femur. Ten (14.3%) were classified as Grade I., 32 (45.7%) as Grade II, and 28 (40%) as grade III according to Gustilo-Anderson. Most of the fractures were the result of high-energy trauma. In patients fixed with locked intramedullary nails due to no immobilisation, rehabilitation began just after the operation. Hip, knee and ankle functions were regained rapidly. All fractures were united in an average of 17.1 (10.1–36.6) weeks. There were six (8.6%) delayed unions and four superficial infections (5.7%). One patient developed deep infection (1.4%) and required further surgical treatment. Locking screws broke in one tibia (1.4%) and two femurs (2.8%), but the breakage did not result in loss of reduction. Although there was no nail breakage observed, two (2.9%) had between eight and twelve degrees external rotation, four (8.5%) shortening of 1.1 to 2.5 cm., and three (4.3%) valgus seven to ten degrees. Of the seventy fractures, 52 (74.2%) were classified according to Folleras as excellent, 8 (11.4%) as good, 6 (8.5%) as fair and 4 (5.7%) as poor. Early unreamed intramedullary interlocking nailing is a very effective and safe treatment method for open tibial and femoral shaft fractures

Purpose: The management of disabling knee osteoarthritis of the knee following malunion of an ipsilateral femoral shaft fracture is difficult and controversial. The purpose of this study is to analyse the results of femoral shaft osteotomy at the level of the old fracture in seven such patients. Materials and Methods: Seven patients with old malunited femoral shaft fractures presented with disabling knee osteoarthritis between 1992 and 1999. Knee symptoms and function were graded at presentation. All underwent open femoral shaft osteotomy at the apex of the deformity, with locked intramedullary nail fixation. The patients were followed up regularly until osteotomy union and reviewed clinically and radiologically with particular emphasis on knee symptoms and function. Results: There were six males and one female. The mean age at presentation was 55 years and mean time from the fracture was 28 years (range 13–35 years). The mean preoperative knee alignment angle was 5.60 varus (range O′12′). The mean time to osteotomy union was 28 months. The mean postoperative knee alignment angle was 20 valgus (range 50 valgus -50 varus). All patients reported significant improvement in knee symptoms and function. One osteotomy was followed by a serious vascular complication and the patient now has a stiff but pain free knee. One patient with very advanced osteoarthritis underwent an uncomplicated total knee replacement after osteotomy union and nail removal. Conclusion: These patients presenting with severe disability at an age which is worryingly young for total knee arthroplasty present a difficult management problem. Five out seven patients had excellent symptomatic and functional improvement following the femoral shaft osteotomy. The possible need for knee replacement was delayed by at least 5 years and the eventual arthroplasty is likely to have been made less technically difficult and more functionally satisfactory as a result of the alignment correction

Aims: The purpose of this retrospective review was to analyze our results with the use of the Marchetti-Vicenzi elastic locked nail in femoral shaft fractures. Methods: Between Jan.1994 and Dec.1997, 75 femoral fractures in 73 patients were treated in our department. There were 51 men and 22 women with a mean age of 29 years. All patients were followed to fracture union. In 67 cases (89%) the cause of injury was a R.T.A. According to Winquist and Hansen, there were 8 fractures of type 0 (no comminution), 5 of type I, 22 of type II, 29 of type III and 11 of type IV. Six fractures were open grade II and two were grade IIIa. Multiple injuries were seen in 22 patients (30%). Results: Certain intraoperative complications were encountered in 25 cases (33%). Open nailing was required in 21 fractures (28%) mainly because of the loss of reduction (absence of guide wire) or because the distal pins jammed at the fracture site. Distal locking mechanism problems (bending of protruding locking wire or breakage of safety loops) occurred in 11cases (15%). In 3 patients the distal pins protruded from the anterior cortex and in another 4 breakage of one or more pins occurred during the postoperative period. Delayed union was seen in 7 patients (9%). Five fractures (7%) progressed to non-union. All the non-united fractures were type III or IV. The remaining fractures united after a mean period of 15 weeks. Four fractures (5%) which were located in the distal third, united with signiþcant varus deformity (≥10¡). Shortening (≥2 cm) were seen in 4 patients (5%). There was one deep infection that led to nonunion. Conclusions: Because of the high complication rate in this series, we do not recommend this type of elastic nail for the treatment of femoral shaft fractures

Purpose: To evaluate the effect of osteoporosis on healing time of long bone fractures. Methods: Between January 2002 to January 2004 patients with femoral shaft fracture treated in our institution by locked reamed IM nailing were eligible for inclusion in this study. Patients were divided in two age groups; Group A, consisting of patients between 18 and 41 years of age and group B consisting of patients over 65 years old with radiological evidence of osteoporosis. Exclusion criteria were open fractures, pathological fractures, patients with head injuries and patients with systematic inflammatory diseases. In addition to the demographic details such parameters were documented as fracture classification, Injury Severity Score, mode of mobilization, time to clinical and radiological union, complications, and length of hospital stay. In all patients the Singh Index Score for osteoporosis was assigned. Following discharge from the hospital, all patients were followed up at regular intervals for clinical and radiological assessment in the trauma clinics. The minimum follow up was 12 months. Results: Out of 112 patients, 90 met the inclusion criteria. Group A consisted of 48 and group B of 42 patients. The mean age in group A was 24.5 years (18 – 41) and in group B 78.3 years (65 – 93). The mean ISS was 13.3 (9 – 32) and 9.07 (9–10) respectively, (p> 0.05). According to OTA fracture classification in group A there were 16 type 32A, 19 type 32B and 13 type 32C fractures, whereas in group B there were 25 type 32A, 15 type 32B and 2 type 32C fractures respectively. In 96% of patients in group A, a Singh score of 5 or 6 was assigned, whereas 85.5% of group B patients had a Singh score of 4 or less, indicating the presence of installed osteoporosis. Overall, the incidence of complications was similar among the studied groups. Delayed union occurred in 6 patients of group B and in 1 patient of group A (P=0.113). All fractures eventually progressed to union without further intervention. In group A the mean time to union was 15.73±0.52 weeks (7–22) and in group B 19.45±1.5 weeks (10–52) from surgery (P=0.0156). Conclusion and Significance: This study indicates that fracture healing of nailed femoral shaft fractures is significantly delayed in older osteoporotic patients. Further studies are mandatory to clarify the exact mechanism of osteoporosis in the fracture healing response and the possible future therapeutic strategies

The gamma interlocking nail, designed combining the advantages of the sliding hip screw with the intramedullary nail, was initially introduced for the management of unstable proximal femoral fractures. However the unacceptably high incidence of lateral femoral shaft fractures led to the development of the long gamma nail. This is the result of a prospective study of the use of the long gamma nail in 35 patients over a 7 year period till March 2000. The mean age of the patients was 69.9 years. There were 13 men and 22 women. All but two of the fractures had a subtrochanteric component. Ten were pathological fractures. An identical size of nail was used in all cases. Elderly patients were permitted to mobilise without restriction, whereas partial weight bearing was imposed on the younger patients till some signs of radiological healing. Patients were reviewed at a hip fracture clinic. Mean clinical follow up was 381 days and radiological follow up was 244 days. Mean hospital stay 22 days. The post operative mortality at 30 days was 20%, rising to 45% at one year. General complications that occurred were pneumonia – 3, fat embolism – 1, myocardial infarction – 1, and GI bleed – 1. Four cases had superficial wound infection, which resolved with oral antibiotics. Fracture related complications occurred in 4 cases. These were intra-operative femoral shaft fracture – 1, fracture at tip of nail – 1, nail breakage – 2. All went on to heal after exchange nailing. The long gamma nail does not appear to have reduce the post-operative incidence of femoral fractures, which is most likely related to the large size of the distal locking screws and stress concentration at the tip of the nail. The two cases of nail breakage appear to reflect metal fatigue failure in the setting of delayed union in younger patients

1. A series of 154 patients with 156 femoral shaft fractures treated during a three and a half year period is reviewed. Fifty-four fractures were treated by closed intramedullary nailing, sixty-four by open intramedullary nailing and thirty-eight by conservative methods. 2. All the patients had fresh fractures of a similar degree of severity. Seventy-eight per cent of the fractures were sustained in traffic accidents, and 21 per cent were compound. 3. The technique of closed intramedullary nailing is described in detail. The importance of a complete and faultless armamentarium and a high-quality image intensifier is emphasised. 4. All fractures united within twelve months after the accident. 5. The functional results were assessed upon the basis of walking ability and return to work. Nailed fractures did better than conservatively treated ones, and closed nailing was slightly superior to open nailing. At twelve months after the injury all patients treated by closed nailing walked without a stick, compared with 96 per cent of the cases treated by open nailing and 81 per cent of the conservatively treated patients. The same trend was noted regarding return to work. 6. The benefit of intramedullary nailing was partly dependent on the severity of the fracture and the age of the patient. The most gratifying results of nailing were obtained in patients over thirty-five years of age with severe fractures. 7. Osteitis occurred in one case treated by closed nailing, and low grade wound infections in five cases, representing an overall infection rate of 3·8 per cent. 8. Seventy-four per cent of the patients were examined one to four years after the fracture. There was less angular deformity and more rotational deformity in the nailed than in the conservatively treated fractures. The tip of the nail gave slight discomfort in the trochanteric area in one patient in three. Residual joint stiffness was infrequent in the nailed cases as compared to the conservatively treated ones. 9. The indications for closed intramedullary nailing of femoral shaft fractures are outlined

Retrograde nailing of femoral shaft fractures has been a routine trauma practice option for approximately five years and may be technically advantaged in many situations. Earlier review of our antegrade experience revealed that 30% of standard nails are recognized to frequently cause pain (30%) and/or heterotopic ossification at the hip; knee pain of unclear etiology was found frequently as well (13%). This review of our preliminary experience with retrograde nails found a 30% frequency of nonspecific knee pain complaints at a mean of thirty-four months. No ectopic ossification was seen and no nails had been removed. The purpose of this study was to review the experience of patients who have undergone retrograde femoral nailing with regard to possible knee pain complaints. Chart and imaging records were reviewed retrospectively. Patients were contacted and interviewed by telephone to determine late pain complaints. From January 2000 through February 2002, eighteen patients were treated for twenty-two femoral shaft fractures. The group included ten males and and eight females of mean age 54.5 years (range, nineteen to ninety years). Treatment was with Synthes retrograde femoral nails, reamed and statically locked, inserted under fluoroscopic control on a radiolucent table using a Tenet™ leg holder. At thirty-four months, all fractures had healed primarily with no appreciable malalignment, no infections and no nonunions. No intraarticular free bodies or ectopic ossification were seen. Eleven patients were asymptomatic with regard to the index injured extremity. Five had mild to moderate pain, generally localized anteriorly, without associated articular symptoms and not requiring any analgesia. Two had severe symptoms of diffuse knee pain with radiographic degenerative changes noted, but these were cases with associated complex tibial plateau fractures to account for it. Even eliminating these two patients, fully five of sixteen patients (30%) without associated periarticular trauma at the knee had mild to moderate nondisabling anterior knee pain complaints after retrograde femoral nailing. The frequency of anterior knee pain complaints after retrograde femoral nailing is significant. Previous authors have found knee pain complaints in 27–29% of cases. We found no evidence of articular derangement in our patients undergoing retrograde femoral nailing in the absence of associated periarticular trauma at the knee, we confirm a 30% frequency of nonspecific knee pain complaints persisting at almost three years after injury. Patients should be made aware that, at intermediate-term follow-up, mild to moderate knee pain may be a result of this fracture treatment

Purpose of study. To review the treatment and outcomes of paediatric pelvic ring injuries in the UK. Methods and results. We performed a retrospective review of all pelvic fracture admissions to an English paediatric major trauma centre (MTC) from 2012 to 2016. A total of 29 patients were admitted with pelvic ring injuries with a mean age of 11 years (4- 16yrs). Road traffic accident was the mechanism in majority (72%), followed by fall from height (24%). Femoral shaft fracture was present in 5 (17%), head injury in 5 (17%), chest injuries in 5 (17%) and bladder injury in one child. 48% patients needed surgical procedures for fractures or associated injuries. We differentiated injuries according to the classification system of Torode and Zeig. 17% were Type A, 3% Type B, 48% Type C and 31% Type D. Almost all (93%) patients were treated conservatively. 51% of patients were allowed to mobilize full weight bearing after a period of bed rest. Non-weight bearing mobilization was recommended for fractures extending into the acetabulum, sacral fractures, unstable fracture patterns or associated fractures (neck of femur, femoral shaft and tibial shaft). Surgical fixation occurred in two patients. Both of these patients had significantly displaced Type D fractures. Only 44% of patients were back to sports at six months. Conclusions. Pelvic ring injuries are rare within the paediatric population and are associated with a high incidence of concomitant injury and significant functional morbidity. Their treatment should involve a multidisciplinary approach, which includes specialist in the care of pelvic trauma

Segmental fractures of the femoral neck and shaft present a treatment challenge. A diagnostic difficulty sometimes arises because the classical signs present in an isolated fractured neck of femur are masked by the associated femoral shaft fracture. Especially where there is no preoperative pelvic radiograph, the femoral neck fracture may present as an incidental finding at the time the shaft fracture is treated. Because much of the impact at the time of injury is taken up by the femoral shaft, the fracture of the femoral neck is often undisplaced. Between January 1995 and April 2001, we treated 36 patients with ipsilateral femoral neck and shaft fractures at GaRankuwa Hospital. Within 24 to 48 hours of injury, eight patients were treated with AO screws and DCP, two with DHS and DCP, 13 with Recon nails and 13 with UFN and Miss-a-nail. In four months 28 patients went on to uneventful union. Complications included two cases of implant failure, two of avascular necrosis, two of failed reduction of femoral neck fracture, one of sepsis and one of nonunion of the femoral shaft. The complications, especially implant failure and failed reduction, occurred mainly in patients who were operated on at night and by junior members of staff

The April 2023 Children’s orthopaedics Roundup³⁶⁰ looks at: CT scan of the ipsilateral femoral neck in paediatric shaft fractures; Meniscal injuries in skeletally immature children with tibial eminence fractures: a systematic literature review; Post-maturity progression in adolescent idiopathic scoliosis curves of 40° to 50°; Prospective, randomized Ponseti treatment for clubfoot: orthopaedic surgeons versus physical therapists; FIFA 11+ Kids: challenges in implementing a prevention programme; The management of developmental dysplasia of the hip in children aged under three months: a consensus study from the British Society for Children's Orthopaedic Surgery; Early investigation and bracing in developmental dysplasia of the hip impacts maternal wellbeing and breastfeeding; Hip arthrodesis in children: a review of 26 cases with a mean of 20 years’ follow-up

There has been evidence of association between femoral shaft fractures and prolonged bisphosphonate therapy. We present a case series of bisphosphonate-associated fractures and invaluable lessons we have learnt. Over the last three years at our unit we have collected a case series of eight patients who have had atypical femoral fractures whilst on bisphosphonate therapy. We present illustrative cases, a summary of key findings, and invaluable lessons we have learnt. There was a long period of prodromal pain for two years before incomplete fractures developed. We speculate this is a warning sign of impending fracture. This may have been prevented with screening. Between incomplete fracture and complete fracture there was a short window of one month. Five patients presented with complete fracture, and three with thigh pain +/- evidence of incomplete fracture. Of the latter group all but one went on to develop complete fractures. The one patient who did not progress died six years after diagnosis. Of those five patients who presented with initial complete fracture, three patients recall thigh pain before fracture on further questioning. Despite being diaphyseal femoral fractures, there is a higher risk of neck of femur fractures in this patient cohort (both patients with initial interlocked nails subsequently developed neck of femur fractures soon after and were revised to cephalomedullary nails). Excluding one death from unrelated cause, only one patient has signs of complete fracture healing. All other patients are still receiving follow-up (mean 490 days). Three patients reported bilateral symptoms (pain). Two had had bilateral symptoms for one year. Both had visible incomplete fractures on further radiographic scrutiny; one underwent prophylactic cephalomedullary nailing, one was managed with active surveillance. We suggest that improved pain and radiographic changes of cortical healing may be misleading and should not be relied upon. Cephalomedullary nailing is the treatment of choice in these fractures due to higher risk of neck of femur fractures in this cohort. We suggest prompt prophylactic cephalomedullary nailing when radiographic incomplete fractures are identified due to a short window before progression to complete fracture, and the need to consider contralateral prophylactic nailing in patients describing bilateral symptoms. We speculate that thigh pain is a warning sign of impending fracture and fracture-progression can be prevented with appropriate screening

Periprosthetic femoral shaft fractures are a significant complication of total hip arthroplasty. Plate osteosynthesis with or without onlay strut allograft has been the mainstay of treatment around well-fixed stems. Nonunions are a rare, challenging complication of this fixation method. The number of published treatment strategies for periprosthetic femoral nonunions are limited. In this series, we report the outcomes of a novel orthogonal plating surgical technique for addressing nonunions in the setting of Vancouver B1 and C-type periprosthetic fractures that previously failed open reduction internal fixation (ORIF). A retrospective chart review of all patients from 2010 to 2014 with Vancouver B1/C total hip arthroplasty periprosthetic femoral nonunions was performed. All patients were treated primarily with ORIF. Nonunion was defined as no radiographic signs of fracture healing nine months post-operatively, with or without hardware failure. Exclusion criteria included open fractures and periprosthetic infections. The technique utilised a mechanobiologic strategy of atraumatic exposure, resection of necrotic tissue, bone grafting with adjuvant recombinant growth factor and revision open reduction internal fixation. Initially, compression was achieved using an articulated tensioning device and application of an anterior plate. This was followed by locked lateral plating. Patients remained non-weight bearing for eight weeks. Six Vancouver B1/C periprosthetic femoral nonunions were treated. Five patients were female with an average age of 80.3 years (range 72–91). The fractures occurred at a mean of 5.8 years (range 1–10) from their initial arthroplasty procedure. No patients underwent further revision surgery; there were no wound dehiscence, hardware failures, infections, or surgical complications. All patients had a minimum of nine months follow up (mean 16.6, range 9–36). All fractures achieved osseous union, defined as solid bridging callus over at least two cortices and pain free, independent ambulation, at an average of 24.4 weeks (range 6.1–39.7 weeks). To our knowledge, this is the first case series describing 90–90 locked compression plating using modern implants for periprosthetic femoral nonunions. This is a rare but challenging complication of total hip arthroplasty and we present a novel solution with satisfactory preliminary outcomes. Orthogonal locked compression plating utilising an articulated tensioning device and autograft with adjuvant osteoinductive allograft should be considered in periprosthetic femur fractures around a well-fixed stem. Further biomechanical and clinical research is needed to improve our treatment strategies in this population

The October 2023 Trauma Roundup³⁶⁰ looks at: Intramedullary nailing versus sliding hip screw in trochanteric fracture management: the INSITE randomized clinical trial; Five-year outcomes for patients with a displaced fracture of the distal tibia; Direct anterior versus anterolateral approach in hip joint hemiarthroplasty; Proximal humerus fractures: treat them all nonoperatively?; Tranexamic acid administration by prehospital personnel; Locked plating versus nailing for proximal tibia fractures: a multicentre randomized controlled trial; A retrospective review of the rate of septic knee arthritis after retrograde femoral nailing for traumatic femoral fractures at a single academic institution.

Post-traumatic avascular necrosis of the femoral head usually occurs after hip dislocation and femoral neck fracture. Recently along the development of hip arthroscopy, early stage of avascular necrosis of the femoral head can be treated rthroscopically. We hereby present two cases of post-traumatic avascular necrosis patients treated with hip arthroscopy. Case 1. Twenty one year old female patient came to the hospital because of fall from height of 3 floors. Left acetabular fracture, both superior pubic rami fractures and severely displaced left femoral neck fracture were identified at the emergency department (Fig. 1-A). She underwent surgery at the injury day. After the repair of ruptured urinary bladder, internal fixation of the femoral neck was done. Four cannulated screws with washers were inserted for displaced femoral neck fracture, consistent with garden stage IV (Fig. 1-B). Skeletal traction of ipsilateral lower extremity was applied four weeks after the surgery for acetabular fracture. She visited us for painful limitation of motion on left hip at eight months postoperatively. Plain radiograph showed collapse of femoral head and osteophyte formation which were caused by post-traumatic avascular necrosis (Fig. 1-C,D). Femoral head was perforated by a screw. She was planned to remove the screw and resect the osteophyte arthroscopically. On arthroscopic examination, severe synovitis and folded, collapsed femoral cartilage were identified (Fig. 1-E). Screws were removed and osteophyte were also resected (Fig. 1-F). We filled the cavity caused by the screws with allogenic strut graft for structural support. After the surgery, pain was relieved and she came back to her active daily living and for six months, no other complication nor further collapse were identified postoperatively. Case 2. Fourty year old male patient was admitted to the hospital for fall from height about fifteen feet from the ground. Left femoral neck fracture was identified on the emergency department. Previously he had underwent intramedullary nailing for the femoral shaft fracture about five years ago. Urgent internal fixation with four cannulated screws was done on the day of injury. The fixation was unsatisfactory because previously inserted intramedullary nail hindered the proper trajectory of screws. Furthermore, direction of cephalad interlocking holes of the nail were not consistent with the anteversion of femoral neck, we could not place the screws through the nail. Four months after the index surgery, collapse of femoral head and loosening of screws have occurred. MRI showed the collapse of femoral head and posttraumatic avascular necrosis. Prominent bony beak of femoral neck were identified and he complained difficulty and pain on his hip during abduction. We left two screws for secure fixation and resected the bony beak using arthroscopic burr. After the surgery, he felt free from the pain on abduction of hip. Discussion. Even though collapse of the femoral head is identified, early intervention by the arthroscopy could minimize pain or delay the progression of arthritic change. Authors think that it might be helpful for the young adult patients in terms of pain relief and potential delay of the total hip arthroplasty

We analysed retrospectively the risk factors leading to femoral overgrowth after flexible intramedullary nailing in 43 children (mean age 7.1 years (3.6 to 12.0)) with fractures of the shaft of the femur. We reviewed their demographic data, mechanism of injury, associated injuries, the type and location of the fractures, the nail–canal diameter (NCD) ratios and femoral overgrowth at a mean follow-up of 40.7 months (25.2 to 92.7). At that time, the children were divided into two groups, those with femoral overgrowth of < 1 cm (Group 1), and those with overgrowth of ≥ 1 cm (Group 2). The mean femoral overgrowth of all patients was 0.6 cm at final follow-up. Overgrowth of ≥ 1 cm was noted in 11 children (25.6%). The NCD ratio was significantly lower in Group 2 than in Group 1, with an odds ratio of 30.0 (p = 0.003). We believe that a low NCD ratio is an indicator of an unstable configuration with flexible intramedullary nailing, and have identified an association between a low NCD ratio and femoral overgrowth resulting in leg-length discrepancy after flexible intramedullary nailing in paediatric femoral shaft fractures. Cite this article: Bone Joint J 2013;95-B:254–8