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

Gunshot-induced fractures of the proximal femur typically present with severe comminution and bone loss. These fractures may also be associated with local damage to soft tissue, neurovascular structures and injuries to abdominal organs. The aim was to evaluate the outcomes of civilian gunshot injuries to the proximal femur at a major trauma center in South Africa. A retrospective review of all patients who sustained gunshot-induced proximal femur fractures between January 2014 and December 2017 was performed. Patients with gunshot injuries involving the hip joint, neck of femur or pertrochanteric fractures were included. Patient demographics, clinical- treatment and outcome data were collected. Results are reported as appropriate given the distribution of continuous data or as frequencies and counts. Our study included 78 patients who sustained 79 gunshot-induced proximal femur fractures. The mean age of patients was 31 ± 112, and the majority of patients were male (93.6%). Pertrochantenteric fractures were the most common injuries encountered (73.4%). Treatment included cephalomedullary nail (60.8%), arthrotomy and internal fixation (16.4%) and interfragmentary fixation with cannulated screws (6%). One case of complete neck of femur fracture had fixation failure, which required conversion to total hip arthroplasty. The overall union rate was 69.6%, and 6.3% of patients developed a fracture-related infection in cases who completed follow-up. The study shows an acceptable union rate when managing these fractures and a low risk of infection. As challenging as they are, individual approaches for each fracture and managing each fracture according to their merits yield acceptable outcomes

Long femoral nails for neck of femur fractures and prophylactic fixation have a risk of anterior cortex perforation. Previous studies have demonstrated the radius of curvature (ROC) of a femoral nail influencing the finishing point of a nail and the risk of anterior cortex perforation. This study aims to calculate a patients femoral ROC using preoperative XR and CT and therefore nail finishing position. We conducted a retrospective study review of patients with long femoral cephalomedullary nailing for proximal femur fractures (OTA/AO 31(A) and OTA/AO 32) or impending pathological fractures at a level 1 trauma centre between January 1, 2015 and December 31, 2020 with both full length lateral X-ray and CT imaging. Femoral ROC was calculated on both imaging modalities. Outcomes measured including nail finishing position, anterior cortex encroachment and impingement. The mean femoral ROC was 1026mm on CT and 1244mm on XR. CT femoral ROC strongly correlated with nail finishing point with a spearmans coefficient of 0.77. Additionally, femurs with a ROC <1000mm were associated with a higher risk of anterior encroachment (OR 6.12) and femurs with a ROC <900mm were associated with a higher risk of anterior cortex impingement (OR 6.47). To our knowledge this is the first study to compare a measured femoral ROC to nail finishing position. The use of CT to measure femoral ROC and to a lesser extent XR was able to predict both nail finishing position and risk of anterior cortex encroachment. Preoperative XRs and CTs were able to identify patients with a small femoral ROC. This predicted patients at risk of anterior cortex impingement, anterior cortex encroachment and nail finishing position. We may be able to select femoral nails that resemble the native femoral ROC and mitigate the risk of anterior cortex perforation

Introduction. The reverse obliquity fractures of the proximal femur are anatomically and mechanically different from most intertrochanteric fractures. These fractures are complex and very difficult to treat. To evaluate the results of the treatment of reverse obliquity intertrochanteric fractures with cephalomedullary nails. Materials and Methods. Between 2005 and 2009, 1179 extracapsular fractures of the proximal femur were treated at our institution. Retrospective review of these x-rays identified 59 patients with reverse obliquity fracture pattern. We analysed our results of cephalomedullary nailing of these complex fractures and evaluated factors responsible for failure of fixation. Results. Of the 59 patients with reverse oblique fracture pattern, one patient was treated with DHS, and two other patients didn't have post-operative x-rays and therefore were excluded from the study. Of the remaining 56 patients treated with cephalomedullary nails, forty eight were treated with gamma nails, five with PFNA and three with ATN. There were 40 females and 16 males with median age of 81.3 years (17–103 years). Six of the fifty six (10.7%) failed to heal or had failure of fixation. The failure rate was four of forty eight for the gamma nails, one of five of the PFNA and one of three of ATN. One of thirty seven (2.7%) of anatomically reduced fractures and five of nineteen (26.3%) of non-anatomically reduced fractures had failure of treatment (p = 0.01). Three of thirteen (23.1%) with femoral medialisation and three of forty three (6.9%) without femoral medialisation had failure of treatment (p = 0.13). Four of forty four (9.1%) with avulsed lesser trochanter and two of twelve (16.6%) without avulsion had failure of treatment (p = 0.59). Three of thirty seven (8.1%) with tip apex distance (TAD) of less than twenty and three of nineteen (15.7%) with TAD more than twenty had failure of treatment (p = 0.65). Conclusion. Inspite of the recent advances in the methods of internal fixation available to surgeons, reverse obliquity intertrochanteric fractures continue to be a challenge for orthopaedic surgeons. In our study, although poor fracture reduction was observed to be the only significant factor associated with a high failure rate, femoral medialisation and tip apex distance of more than 20 had a high association with poor outcome

Background. During cephalomedullary nail stabilisation of subtrochanteric femoral fractures, damage to the distal anterior femoral cortex by the nail is a recognised cause of periprosthetic fracture. Currently available cephalomedullary devices vary widely in anteroposterior curvature, though all are less curved than the mean anatomic human femur. This study tests the hypothesis that a cephalomedullary device with greater anteroposterior curvature will achieve a more favourable position in the distal femur, with greater distance of the nail tip from the anterior cortex, and therefore lower risk of cortical damage. Methods. Retrospective analysis of postoperative radiographs from patients undergoing subtrochanteric femoral fracture stabilisation with either a)Stryker Long Gamma Nail (radius of curvature 2.0m, 19 patients) or Synthes long PFNα (1.5m, 19 patients) was performed. Distance from the anterior femoral cortex to the anterior part of the distal nail was measured, using the known diameter of the nail as a radiographic size marker. Results. The mean distance from nail to anterior cortex was significantly higher for the PFNα group than the Long Gamma Nail Group (7.31mm vs 4.73mm, unpaired t-test p=0.003). Conclusion. Using a cephalomedullary device with a tighter anteroposterior curvature resulted in a distal nail position better-centred in the sagittal plane, thus decreasing the risk of anterior femoral cortex damage and periprosthetic fracture. We strongly recommend consideration of anteroposterior curvature when choosing a cephalomedullary nailing system

Background. Despite studies into patient consent and their understanding of the potential risks of trauma surgery, no study has looked at the patient's understanding of the procedure involved with neck of femur fracture surgery. Method. Prospective analysis of 150 patients who had operative fixation of neck of femur fractures in a district general hospital. Patients were asked on the third post-operative day to select which procedure they had undergone from a diagram of four different neck of femur surgeries (cannulated screws, cephalomedullary nail, dynamic hip screw and hemiarthroplasty). Exclusion criteria for patient selection - mini mental score of < 20 and confusion secondary to delirium. Results. All patients had signed consent form 1 which was matched to the procedure. All patients were consented by an FP2, CT1 or other SHO. The mean age of patients was 83years. 5% had cannulated screw fixation, 45% had a hemiarthroplasty, 42% had a dynamic hip screw and 8% had a cephalomedullary nail. 47% of patients could correctly identify the procedure they had undergone on the 3. rd. post-operative day. Conclusions. This study shows that there are questions about the effectiveness of informed consent and patient understanding of the procedure before and after hip fracture surgery. We suggest that further detailed studies may highlight the need for alternative ways of communicating procedures to the patients or that more specialised training is required for those explaining hip fracture surgery to patients. Improvements in these areas might help ensure the true informed consent required

Although there is strong evidence that bisphosphonates prevent certain types of osteoporotic fractures, there are concerns that they may be associated with rare atypical femoral fractures. 1480 patients of proximal femur and shaft fractures over a period of 2 years from Jan 2014 to Jan 2016 were retrospectively reviewed in Gloucestershire Hospitals NHS trust. Hospital trauma database was used.195 patients had fractures in subtrochancteric and femoral shaft area. 11 patients had atypical femur fractures as defined by American society for bone and mineral research (ASBMR) task force 2013, revised criteria. Ten were female, one was male. Patients were aged from 68 to 97. In 6 patients, fractures were in the shaft, 5 in subtrochancteric area and 4 patients out of these had bilateral fractures. 10 out of 11 patients were on bisphosphonates. 4 patients had delayed diagnosis. 5 out of 11 patients did not have contralateral femoral x-rays. Treatment, 9 patients had intramedullary nail, one blade plate, and one treated conservatively. One patient in the IM group, had bilateral nailing. Average follow up was 7.6 months (range 1 to 16 months). At the end of the study, only 4 had united, 6 had not united and one not followed up. 4 out of 7 had low Vitamin D levels, 3 out of 7 had their bisphosphonate treatment stopped and 2 had histology which showed necrotic bone with trabeculae surrounded by fibrosis. Increasing number of patients are on bisphosphonates for osteoporosis. Atypical femur fractures from bisphosphonates are often occult, often bilateral, with delayed healing. Patients on bisphosphonatetreatment should be advised to report any thigh or groin pain. Painful incomplete fractures need treatment with cephalomedullary nailing. Bone biology needs correcting by stopping bisphosphonatesand administering calcium & vitamin D supplements. Implications: We need to raise awareness amongst treating clinicians and have national guidelines

Treatment of trochanteric fractures is associated a high complication rate. This prospective multicenter study evaluates the new Zimmer Cephalomedullary Nail (CMN). Patients over 50 years sustaining a pertrochanteric or subtrochanteric femoral fracture were prospectively enrolled and patients with multiple injuries, pathological fractures or severe dementia were excluded. 101 patients (70% female, 30% male) from 5 different hospitals were prospectively recruited between January 2011 and August 2012. Mean age was 78 (51–98) years and mean Charlson Score was 2.6 (1–6). 65% of the trochanteric fractures were unstable, 35% were stable. There were 4 (5%) minor (3 superficial infections and 1 pain over distal locking screw) and 3 (4%) major (2 lag screw cut out, 1 nail breakage) complications Fracture healing was completed in 27 of 31 patients (87%) after 12 month (3 month: 14/42 (33%); 6 month: 27/39(69%)). The Barthel Index (85, SD 19) and EQ-5-D (0.61, SD 0.30) values reached prefracture level after 6 month. The study population and fracture type were comparable to other studies and complication and early union rates were also comparable. Technical complications were low and early functional results encouraging. Final results of this trial at one year follow up are awaited

Introduction. Rivaroxaban, an oral factor Xa inhibitor, has been approved by USFDA for prophylaxis of deep vein thrombosis (DVT) and pulmonary embolism (PE) in hip and knee arthroplasties. Its indication in hip fracture surgery has been recently recommended in Asian venous thromboembolism (VTE) guidelines. Phase II dose-ranging study demonstrated that 5 mg rivaroxaban is as effective as enoxaparin for VTE prophylaxis with lower incidence of bleeding complication than the recommended 10 mg dose. Rivaroxaban is recommended to be given 6–8 hours after operation. However, many surgeons are hesitated to follow this guideline since it might increase post-operative blood loss and wound complication. Elderly patients, such as hip fracture patients, are generally at more risk of bleeding and wound complications. These patients may benefit from using the delayed and reduced-dose regimen. Methods. Since July 2011, all eligible hip fracture patients treated by single group of surgeons were given 5mg daily dose of rivaroxaban for VTE prophylaxis. Initial dose of rivaroxaban was given after drain had been removed (24–36 hours post-operatively) and continued for 14 days. Inclusion criteria are femoral neck fracture or intertrochanteric fracture in patients age 60 and over. Exclusion criteria are pathologic fracture, reoperation for failed fixation, chronic anticoagulant therapy, and allergy to rivaroxaban. Criteria by Aniwan and Rojnackarin were used for clinical diagnosis of DVT and PE. Suspected case of DVT and PE were sent for confirmation with Doppler U/S and Pulmonary Artery CT scan, respectively. All bleeding and wound complications were recorded. Numbers of blood transfusion were also recorded. Patients were followed for at least 6 weeks, all complications were recorded. Results. There were 79 hip fracture patients matching our criteria. They were composed of 54 femoral neck fractures and 25 intertrochanteric fractures. Mean age of patients was 76.3 years. All femoral neck fractures were treated with bipolar hemiarthroplasty and intertrochanteric fractures were treated with short cephalomedullary nail. Two patients (2.6%) were compatible with clinical criteria of DVT. However, Doppler ultrasound examinations do not demonstrate thrombus or intraluminal filling defect. There was no suspected case of PE. There was no major hemorrhagic wound complication requiring reoperation. Minor wound complications include 7 (8.9%) cases of prolong serous oozing and 1 (1.3%) superficial wound infection. Extrasurgical site bleeding includes 1 (1.3%) upper GI bleeding and 2 (2.5%) hematuria. None of the patients received more than 2 units of blood transfusion. Discussion and Conclusion. Delayed and reduced-dose regimen of rivaroxaban is effective for VTE prophylaxis in hip fracture patients. There is no major hemorrhagic wound complication. Nonetheless, extrasurgical site bleeding is frequent. Further randomized comparative study with larger number of patients should be performed to demonstrate whether the benefits of the modified regimen existed or not

Aims

The use of fluoroscopy in orthopaedic surgery creates risk of radiation exposure to surgeons. Appropriate personal protective equipment (PPE) can help mitigate this. The primary aim of this study was to assess if current radiation protection in orthopaedic trauma is safe. The secondary aims were to describe normative data of radiation exposure during common orthopaedic procedures, evaluate ways to improve any deficits in protection, and validate the use of electronic personal dosimeters (EPDs) in assessing radiation dose in orthopaedic surgery.

Introduction. Total knee arthroplasty is effective for the management of osteoarthritis of the knee. Conventional techniques utilizing manual instrumentation (MI) make use of intramedullary femoral guides and either extramedullary or intramedullary tibial guides. While MI techniques can achieve excellent results in the majority of patients, those with ipsilateral hardware, post-traumatic deformity or abnormal anatomy may be technically more challenging, resulting in poorer outcomes. Computer-assisted navigation (CAN) is an alternative that utilizes fixed trackers and anatomic registration points, foregoing the need for intramedullary guides. This technique has been shown to yield excellent results including superior alignment outcomes compared to MI with fewer outliers. However, studies report a high learning curve, increased expenses and increased operative times. As a result, few surgeons are trained and comfortable utilizing CAN. Patient-specific instrumentation is an alternative innovation for total knee arthroplasty. Custom guide blocks are fabricated based on a patient's unique anatomy, allowing for the benefits of CAN but without the increased operative times or the high learning curve. In this study we sought to evaluate the accuracy of PSI techniques in patients with previous ipsilateral hardware of the femur. Methods. After reviewing our database of 300 PSI total knee arthroplasty patients, 16 were identified (10 male, 6 female) using the Zimmer NexGen Patient Specific Instrumentation System. Fourteen patients included in the study had a preexisting total hip arthroplasty on the ipsilateral side [Figure 1], 1 had a sliding hip screw, and 1 patient had a cephalomedullary nail. Postoperative mechanical axis alignment measurements were performed using plain long-standing radiographs [Figure 2]. The American Knee Society Score was used to evaluate clinical outcomes postoperatively. Results. Sixteen total knee arthroplasties were performed using PSI, all in the setting of previous ipsilateral hardware placement. The average age at the time of surgery was 72, with patients ranging from 56 to 85 years of age [Table 1]. 11 of the included knees had a preoperative varus alignment and 5 had valgus alignment. The average value of a deformity identified via the preoperative planning software was 7.9°(1.5°–15.7°). The average value of a deformity identified via preoperative radiographs was 10.1°(2.2°–14.7°). Average postoperative mechanical axis was 3.1° (1°–5.3°) measured from plain radiographs. Average angle between the FMA and femoral component was 90.0° (85.3°–94.1°). The average angle between the TMA and tibial component was 90.6°(87.6°–92.9°). The average difference between the femoral mechanical and anatomic axes was 5.9°(3.4°–7.0°). The average discrepancy between medial and lateral joint space on an anterior-posterior standing radiograph was 0.4mm(0.0mm–1.1mm). At an average of 4.5 months follow-up, American Knee Society knee scores show an aggregate average score of 82.94. Conclusions. Patient specific instrumentation (PSI) is an innovative technology in TKA that replaces the use of intramedullary femoral guides and either extramedullary or intramedullary tibial guides. This study demonstrates that PSI is capable of producing favorable radiographic and clinical outcomes despite preexisting ipsilateral hardware, which may otherwise preclude the use of customary manual instrumentation. We believe PSI is an accurate and effective tool for use in patients with preexisting ipsilateral hardware

Introduction:. Total knee arthroplasty (TKA) is an effective operation for the management of osteoarthritis of the knee. Conventional technique utilizing manual instrumentation (MI) allows for reproducible and accurate execution of the procedure. The most common techniques make use of intramedullary femoral guides and either extrameduallary or intrameduallary tibial guides. While these methods can achieve excellent results in the majority of patients, those with ipsilateral hardware, post-traumatic deformity or abnormal anatomy may preclude the accurate use of these techniques. Patient-specific instrumentation (PSI) is an alternative innovation for total knee arthroplasty. Utilizing magnetic resonance imaging (MRI) or computed tomography (CT), custom guide blocks are fabricated based on a patient's unique anatomy. This allows for the benefits of computer assisted navigation (CAN) but without the increased operative times or the high learning curve associated with it. Furthermore it allows the use of familiar cutting blocks and guides to check the accuracy of the PSI guide blocks. In this study we sought to evaluate the accuracy of PSI techniques in patients with previous ipsilateral hardware, which would make the use of MI technically challenging and possibly subject to inaccuracy. Methods:. After reviewing our database of 300 PSI total knee arthroplasty patients, 16 patients were identified (10 male, 6 female) using the Zimmer NexGen Patient Specific Instrumentation System. Fourteen patients included in the study had a preexisting total hip arthroplasty on the ipsilateral side, 1 had a preexisting sliding hip screw, and 1 patient had a preexisting cephalomedullary nail. Postoperative mechanical axis alignment measurements were performed using plain long-standing radiographs. The American Knee Society Score was used to evaluate clinical outcomes postoperatively. Results:. Sixteen total knee arthroplasties were performed using PSI, all in the setting of previous ipsilateral hardware placement. The average age at the time of surgery was 72, with patients ranging from 56 to 85 years of age. Eleven of the included knees had a preoperative varus alignment and 5 had valgus alignment. The average value of a deformity identified via the preoperative planning software was 7.85°. The average value of a deformity identified via preoperative radiographs was 10.1°. Average postoperative mechanical axis was 3.1° measured from plain radiographs. Average angle between the femoral mechanical axis and femoral component was 90.0°. The average angle between the tibial mechanical axis and tibial component was 90.6°. The average difference between the femoral mechanical and anatomic axes was 5.9°. The average discrepancy between medial and lateral joint space on an anterior-posterior standing radiograph was 0.4 mm. At an average of 4.5 months follow-up, American Knee Society knee scores show an aggregate average score of 82.94. Conclusion:. Patient specific instrumentation is an innovative technology in TKA that replaces the use of intramedullary femoral guides and either extramedullary or intramedullary tibial guides. This study demonstrates that PSI is capable of producing favorable radiographic and clinical outcomes despite preexisting ipsilateral hardware, which may preclude the use of customary manual instrumentation. We believe PSI is an accurate and effective tool for use in patients with preexisting ipsilateral hardware

In patients requiring two-stage procedures, stabilization of large skeletal defects after radical debridement must be attained in order to successfully treat the infection. With the use of standard rod plus antibiotic impregnated PMMA spacers limb salvage may be attempted with satisfactory results. Between 1992 and 2014, 23 patients were treated for hip, knee, or shoulder musculoskeletal infections resulting in an average skeletal defect of 22 cm. There were 13 males and 10 females. Twelve patients had infected tumor prostheses, seven patients had an infected total joint arthroplasty, and four patients had a primary infection involving a large skeletal defect. The mean time from the index procedure until infection was 22 months. Following debridement, the defect was stabilized with Tobramycin and Vancomycin impregnated PMMA and intramedullary nails. Patients were treated with IV and oral antibiotics for six weeks each. In 18 patients who had resection about the knee stabilization was achieved with a single femoral or tibial nail in nine patients and with two nails joined by a screw or cerclage wire in the other nine. In four patients a cephalomedullary femoral nail was used for stabilization after resection of the proximal or total femur. One patient had a custom total humeral prostalac using threaded Steinmann pins and 16-gauge wire. The organisms cultured were gram positive in 19 cases, mixed gram positive and fungal in one, mixed gram negative and mycobacterium in one, and two patients had no growth on cultures but histologic evidence of acute infection. Of the 23 patients, 16 were successfully reimplanted following the initial procedure (70%) and seven had recurrent infections. Three patients with recurrent infections were successfully reimplanted after an additional one-stage procedure and four patients were not reimplanted. Two of these four had amputations and the other two had a second two-stage procedure and have retained their spacers. There were seven complications including a broken spacer, three periprosthetic fractures, two contractures, and one case of aseptic loosening. Successful limb salvage with infection control was 19/23 (83%). One patient required an amputation for local recurrence of their tumor. The overall limb salvage rate was 18/23 (78%). Stable temporary antibiotic laden cement spacers, made in conjunction with standard intramedullary nails, can provide the necessary limb stability to treat musculoskeletal infections and allow for reimplanation of tumor prostheses for limb salvage

Aims

Elective surgery has been severely curtailed as a result of the COVID-19 pandemic. There is little evidence to guide surgeons in assessing what processes should be put in place to restart elective surgery safely in a time of endemic COVID-19 in the community.