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

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

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

Aims

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

Aims

The aims of this study were to assess the pre- and postoperative incidence of deep vein thrombosis (DVT) using routine duplex Doppler ultrasound (DUS), to assess the incidence of pulmonary embolism (PE) using CT angiography, and to identify the factors that predict postoperative DVT in patients with a pelvic and/or acetabular fracture.

To evaluate the efficacy of elastic stable intramedullary nailing (ESIN) for the treatment of forearm fractures in children and adolescents. Between June 2002 and August 2007, 28 patients (19 boys – 9 girls) with 28 forearm fractures were treated with ESIN in our department. The mean age was 12.88 years (range 10.9–4.82). Both forearm bones were affected in all cases. 13 patients were treated by intra-medullary splinting immediate after the accident whilst 15 children were operated after failure of conservative treatment and fracture redisplacement. The radius was nailed in a retrograde fashion in all cases. On the other hand antegrade nailing of the ulna was performed in 18 cases whilst retrograde nailing in 5 patients. In 8 cases closed reduction was possible whilst a small incision at the fracture site was necessary in 20 children. In all cases an above-elbow cast was applied for 5 – 6 weeks postoperatively. The healing process was determined on the basis of two-projection radiographs. At the latest follow-up elbow and forearm motion were also assessed. Mean follow-up was 16 months (range, 7 – 28). With the exception of one case all fractures healed within 9 weeks. No case of infection, cross-union or non-union occurred. At the latest follow-up all children presented with complete restoration of elbow movement but three of them had a deficit of pronation of 15–20 degrees. In those cases where an open reduction was required the results were the same as in other cases. Based on our results, retrograde, of both bones, nailing is recommended for the treatment of all displaced forearm fractures in children older than 7 years-old. Proper preoperative curving of the nails offers increased stability maintaining the anatomic relation of the forearm bones

Damage Control Surgery minimises ARDS in trauma. Originally adapted for abdominal trauma, Pape et al extended it for ‘borderline cases’ in Orthopaedics, categorised by narrow parameters such as (ISS) > 40. The rest of the cases are treated by Primary Total Care. ARDS developed due to two ‘hits’ – first, the extent of the trauma, second, the extent and timing of surgery. By manipulating the second hit, better outcomes are obtained. We discuss our usage of Damage Control Orthopaedics (DCO) principles in India. We reviewed 1456 patients operated between January 2002 and June 2005 (mean follow-up 29.5 months). 40 patients with polytrauma (28 male), mean age 39.9 years (range 18-77) and mean ISS 21.65 (range 13-41) satisfed our inclusion criteria (at least 2 long bones fractured or 2 systems injured presenting more than 48 hours after injury). Patients were admitted under the joint care of intensivists and surgeons, and had twice daily physiotherapy with early mobilisation. Fractures awaiting fixation were mobilised with braces and plasters temporarily. Acid-base, nutritional and electrolyte imbalances were corrected on a priority basis. An average of 3.4 procedures was performed on each patient (range 2-7) including 45 long bone nailings. Mean interval between admission and last surgery was 11.1days (range 6-19). 37 patients needed significant pre-operative resuscitation including 5 with ARDS. Post-operatively 39/40 survived and 35/40 returned to normal lives. The only post-operative ARDS died. Furthermore we describe ‘the third hit’ phenomenon which is the collective adverse impact of late presentation of trauma cases, inadequate and incompetent primary care, pre-existing medical conditions, financial, social and infrastructural constraints. Polytrauma patients, even with low ISS, can develop ARDS if they present late to a trauma centre. Appropriate medical therapy and slow but systemic approach to surgery along with aggressive physiotherapy, use of orthosis and early mobilisation saves lives

Introduction: Despite the lack of good clinical evidence post operative radiotherapy is standard practice following non radical surgical treatment of skeletal metastases in long bones There is little in the literature about the size of radiation field and whether the whole bone, the nail or just the area of the metastatic deposit should be covered. Methods: We present two cases where the metastases were treated by intramedullary nailing and were subsequently irradiated. In each case the tip of the intramedullary nail was outside the radiotherapy field. Results: Subsequent second metastasis formation occurred at the tip of the nail compounded by pathological fracture. Salvage surgery was achieved in one case with a total femoral replacement and in the other by bi-columnar plating of the humerus with cement augmentation. Discussion: Intramedullary nailing of a metastasis will seed the tumour to the tip of the nail. It is therefore essential that the tip of the nail be included in the radiotherapy field post-operatively as salvage surgery for subsequent pathological fracture is technically demanding. The aim of any surgery for skeletal metastases is that the reconstruction should outlast the patient. Communication between surgeon and radiation oncologist is essential

1. Three families with the characteristic changes of the nail-patella syndrome are reported. In addition to the well established bone and nail defects they had soft-tissue contractures, web formation around the elbows and muscular hypoplasias. The literature on soft-tissue changes is reviewed and their importance emphasised. 2. Asymmetrical joint development is considered to be a characteristic feature of the syndrome. 3. The incidence of renal disease in our families is recorded. 4. The literature on the basic defect is reviewed. The likelihood of a primary alteration in connective tissue chemistry is considered

Treatment of unicameral bone cysts ranges from injections of corticosteroids, bone marrow with allogenic demineralised bone matrix to open bone grafting procedure. These procedures have their own disadvantages in form of infection, fracture, long-term morbidity, repeat procedure and high recurrence rate. We describe here a new, technically simple and safe technique with minimal morbidity and short hospital stay. We treated 2 young children with active bone cyst (that did not heal with pathological fractures in past 18 months) by this technique and in both the cases bone cyst healed without any complications. In patient with active bone cyst at the proximal end of humerus, under image intensifier control distal humerus perforated with 3.5 mm drill and a pre bent 2.5 mm, flexible, intramedullary nail passed into the medullary canal and then to proximal end of bone cyst. Nail now rotated sequentially at 5 mm intervals to destroy the architecture of the cyst completely until no resistance is felt. Wound closed with skin sutures and steristrips. Post operatively both children were comfortable and discharged home next day. In both cases cyst healed uneventfully. Though we have small experience but technique looks very promising

Intra-medullarly nail techniques for fracture fixation has gained Universal acceptance over the past 50 years. Closed interlocking nail fixation is the procedure of choice for femoral shaft fracture specially in poly trauma. Unlocked Nail can be considered when a non comminuted fracture occurs through the narrowest part of the medullarly canal. Unlocked Nail does not resist axial and rotational deformation of the fracture. Interlocking fixation controls bending and rotational deformation but allows nearly full axial load transfer by bone. Interlocking nails can be used in almost all long bones. A total of 67 cases were stabilized by intra-medullarly interlocking nails. It was a prospective study done in SSMC & Private hospital from the period of January 2004 to February 2008. Total period of follow up was about 4 years. Both male & female were included in this series. Fresh, delayed fracture & Non Union all were included. Maximum cases were closed fracture but few were fresh but open fracture. Simple unstable fracture comminuted segmental fracture, implant failure was the selection criteria. Fracture, tibia femur and humerus were selected for this study. Both closed and open techniques were applied in this series without any support from C-arm. In maximum cases bony union was achieved in expected time. In few cases healing process was delayed due to extensive soft tissue damage during the occurrence of fracture and non-cooperation of patients during post operative period. Excellent results were achieved in fresh cases. Over all result of this series is very satisfactory. Breaking of screws was in 2 cases, bending of nail was in one case due to early weight bearing. Revision of surgery done in 2 cases. Intra Modularly interlocking nail fixation is very simple device for unstable comminuted and segmental fracture shaft of long bones. If C-arm is available in that case procedure becomes more simple and easy. But without C-arm sometimes surgery becomes very lengthy and in that case expected results may not be achieved

The majority of diaphyseal forearm fractures in children are treated by closed reduction and plaster immobilisation. There is a small subset of patients where operative treatment is indicated. Recent reports indicate that elastic intramedullary nailing (EIN) is gaining popularity over plate fixation. We report the results of EIN for diaphyseal fractures of the forearm in 44 children aged between 5 and 15 years during a three-year period. The indications were instability (26), redisplacement (14), and open fractures (4). Closed reduction and nailing was carried out in 18 cases. A single bone had to be opened in 16 cases and in 10 cases both bones were opened for achieving reduction. Out of the 39 both bone forearm fractures, 35 patients had stabilisation of both radius and ulna and in 4 cases only a single bone was nailed (Radius 3, Ulna 1). Union was achieved in all the 44 cases at an average time of 7 weeks with one delayed union. All patients regained full flexion and extension of the elbow and wrist. Pronation was restricted by an average of 20° in 30% patients. Complications were seen in 10 patients (20%). 4 patients had prominent metal work which required early removal. There was refracture in one case, which was treated by nail removal and re-fixation. Two patients developed post operative compartment syndrome requiring fasciotomy. EIN of the radius alone in a patient with fractures of both the bones of forearm, led to secondary displacement of the ulna. This resulted in ulnar malunion and a symptomatic distal radio-ulnar joint subluxation. This was successfully treated by ulnar osteotomy. Compared to forearm plating EIN involves minimal scarring, easier removal and less risk of nerve damage. We therefore recommend EIN for the treatment of unstable middle and proximal third forearm fractures

Introduction: Amputation of the fingertip with loss of the finger pulp, exposed bone and nail bed injury is a common problem, not infrequently neglected. Fingertip reconstruction requires new pulp glabrous skin coverage with sensitivity, buttressed by the nail. The aim of this study is the analysis of our experience from the use of a homodigital, island flap for the reconstruction of amputated fingertips Materials and Methods: The homodigital island flap was applied in 46 patients (57 fingers), at every level of finger amputation with special indication on fingertip coverage. For the index and the middle fingers, use of the ulnar bundle is preferred. For the thumb, ring and little finger use of the radial neurovascular bundle is preferable. The neurovascular bundle is well dissected from the flap to the base of the finger. After suturing of the flap the donor area is covered with split thickness skin graft from the hypothenar. The finger is mobilized one week after the procedure. Results: Postoperatively, ROM was normal in 45 fingers, 6 fingers had 100 loss of extension at the DIP and 6 fingers had loss of motion between 100–200 . TPD was 4mm (3–10mm). Three patients had cold intolerance for 8 months. There was no neuroma or sensitive scar formation and no need for a second operation. According to patients cosmesis was acceptable in all fingers. Conclusions: The use of homodigital island flap provides excellent functional reconstruction of the fingertips after a complex tissue loss in Allen III and IV amputations It is a straightforward operation carried out under wrist block with excellent cosmetic results

Femoral nails are thought to be load sharing devices. However, the specific load sharing characteristics and associated stress concentrations have not yet been reported in the literature. The purpose of this study was to use a validated, three dimensional finite element model of a nailed femur subjected to gait loads in order to determine the resulting stresses in the femur and the nail. The results showed that load was shared between the nail and the bone throughout the gait cycle. In addition, high stress concentrations were noted in the bone around the screw holes, and dynamization was of minimal benefit. To determine the stresses in the bone and nail in a femur with a locked, retrograde, intramedullary nail. The retrograde femoral nail is a load sharing device. High stress concentrations occur in the bone around locking screw holes. When only one locking screw is used proximally and distally, stresses in the implant are excessive and may lead to failure. Dynamization was of minimal benefit. This is the first study to use a validated three dimensional finite element model to provide a detailed biomechanical analysis of stress patterns in a retrograde nailed femur under gait loads. The results can help resolve issues of stress shielding, implant removal, number of locking screws and dynamization. In the fully locked condition, loads in the femur were significantly higher than those in the nail for most of the gait cycle. Removal of locking screws to obtain dynamization only increased axial load in the femur by 17 %. However, stresses in the locking screws increased by as much as 250% when fewer than 4 screws were used. Maximum stresses in the bone were found around screw holes. A three dimensional finite element model of the femur and nail was developed. The model was validated by comparing results to a physical saw bone model instrumented with strain gages and subjected to a simple a compressive load. Once good correlation with simple loading patterns was demonstrated, gait loading patterns obtained from literature were incorporated and simulations were run for various conditions

The October 2013 Trauma Roundup³⁶⁰ looks at: Radiological, electromagnetic or just leave it out altogether?: distal locking in intramedullary nailing; Internal fixation of radiation-induced pathological fractures of the femur has a high rate of failure; Obesity and trauma; Short and sweet?: antibiotics in open fractures; Extremity injuries more important than previously thought?; Cement nails tiptop for osteomyelitis; Oxygen measurements for compartment syndrome?

End caps are intended to prevent nail migration (push-out) in elastic stable intramedullary nailing. The aim of this study was to investigate the force at failure with and without end caps, and whether different insertion angles of nails and end caps would alter that force at failure.

Simulated oblique fractures of the diaphysis were created in 15 artificial paediatric femurs. Titanium Elastic Nails with end caps were inserted at angles of 45°, 55° and 65° in five specimens for each angle to create three study groups. Biomechanical testing was performed with axial compression until failure. An identical fracture was created in four small adult cadaveric femurs harvested from two donors (both female, aged 81 and 85 years, height 149 cm and 156 cm, respectively). All femurs were tested without and subsequently with end caps inserted at 45°.

In the artificial femurs, maximum force was not significantly different between the three groups (p = 0.613). Push-out force was significantly higher in the cadaveric specimens with the use of end caps by an up to sixfold load increase (830 N, standard deviation (SD) 280 vs 150 N, SD 120, respectively; p = 0.007).

These results indicate that the nail and end cap insertion angle can be varied within 20° without altering construct stability and that the risk of elastic stable intramedullary nailing push–out can be effectively reduced by the use of end caps.

Cite this article: Bone Joint J 2015;97-B:558–63.

The April 2013 Oncology Roundup³⁶⁰ looks at: the margin for error; new money for old risks; hindquarter amputation; custom tumour jigs; preserving the tibial epiphysis; how long is long enough?; genomics and radiation-induced bone tumours; and India ink.

We present the results of 90 consecutive children with displaced fractures of the forearm treated by elastic stable intramedullary nailing with a mean follow-up of 6.6 months (2.0 to 17.6). Eight (9%) had open fractures and 77 (86%) had sustained a fracture of both bones. The operations were performed by orthopaedic trainees in 78 patients (86%). All fractures healed at a mean of 2.9 months (1.1 to 8.7). There was one case of delayed union of an ulnar fracture. An excellent or good functional outcome was achieved in 76 patients (84%). There was no statistical difference detected when the grade of operating surgeon, age of the patient and the diaphyseal level of the fracture were correlated with the outcome. A limited open reduction was required in 40 fractures (44%).

Complications included seven cases of problematic wounds, two transient palsies of the superficial radial nerve and one case each of malunion and a post-operative compartment syndrome. At final follow-up, all children were pain-free and without limitation of sport and play activities.

Our findings indicate that the functional outcome following paediatric fractures of the forearm treated by elastic stable intramedullary nailing is good, without the need for anatomical restoration of the radial bow.