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

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.

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 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

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

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

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. 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

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

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

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

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

Hip fusion is an uncommon procedure. Hip fusion takedown, therefore, is equally an uncommon procedure. What is of considerable interest is that the results, which I achieved in 20 cases in a paper published in 1987 are considerably superior to the results, which I am achieving today. This suggests that no simple case is now fused. It also equally suggests that there is little sense in looking at literature more than 10 or 15 years old on fusion takedowns as the two conditions are likely completely different. Most patients do not like a hip fusion. There are long-term problems with low back pain, ipsilateral global instability and contralateral patellofemoral osteoarthritis. A stiff hip produces a poor quality of life, especially in a tall person. The main problem in doing a hip fusion takedown is the condition of the abductors muscles. If fused before growth was complete, there may be pelvic hypoplasia. If the pelvis is small, the glutei will also be small. Sometimes, the glutei may have undergone fatty degeneration. This can be assessed by means of an MRI. If the abductors were damaged during fusion, a limp may persist. Other problems are that leg lengthening is difficult to achieve any longstanding hip fusion. Lengthening of 1–2 cm is usually about all that can safely be achieved. If the hip was fused in childhood, there is likely to be femoral hypoplasia. There is also likely absence of proximal cancellous bone and the proximal femur is a thin brittle cortical tube. The greater trochanter should not be detached as it is difficult to obtain union under such circumstances. The approach, which I prefer for a fusion takedown is an anterior Smith Peterson. The glutei are slid off the pelvis sidewall and then the upper part of the fusion can be exposed, blunt Hohmans can then be passed around the femoral neck prior to transection. Obviously, if any AO cobra plate has been used for a fusion, a trochanteric osteotomy may be required to preserve any glutei left. Old hardware can be removed either concurrently or as an interval procedure. In 1986, I published the results of 20 cases with a five to 40-year fusion time (mean 19). I used a variety of implants. Flexion was achieved to 90 degrees at 12 months in about 88% of people. Seventy-five percent ceased to limp by year one, although the elderly limp when tired. One patient was dissatisfied with the procedure. One was revised for pain. I have reviewed the cases done in the last 20 years. These were 28 cases, two bilateral. Seven were spontaneous fusions. Twenty-one were formal hip fusions. One was an AO fusion with a cobra plate. There were various intra-operative complications including two calcar cracks, which were wired, three femoral shaft fractures, which necessitated the use of long stems. There was one drop foot, which recovered. At review, a limp was absent in 20%, mild in 12% and severe, i.e. Trendelenburg positive in 68%. Harris hip scores were excellent in 28%, good in 32%, fair in 16% and poor in 24%. Four patients only, however, continued to use canes. The eventual range of movement was good. In 80%, more than 90 degrees of flexion was obtained, but it took up to two years to obtain maximum flexion. In 12%, the range of motion was poor at being 50 degrees to 85 degrees. The range of motion was poor, i.e. less than 45 degrees in one bilateral case of athrogryposis. This was a stiff arthrogrypotic. Further surgery is required in several cases. An ipsilateral total knee replacement and one a supracondylar femoral osteotomy. One cup loosened and was revised at seven years and one liner was exchanged at ten years

Introduction. Varus malpositioning of femoral stems has been recognised as a poor prognostic feature with regard to loosening and failure of cemented composite beam implants, but there have been no published results of the long-term effect on taper-slip designs. Objectives. To determine the results of varus placement of a polished triple tapered femoral stem. Methods. We have prospectively analysed the results of 350 consecutive polished triple-tapered C-Stem implants performed on 322 patients between March 2000 and July 2004, using a standard posterior approach and Palacos-R cement. All patients underwent annual clinical and radiological review. Results. The average duration of follow-up in surviving patients is 140 months (120–172 months). There were 49 femoral implants in 49 patients implanted with more than 5 degrees of varus (14%) with respect to the long axis of the femur, and 14 in 14 patients in more than 5 degrees of valgus (4%). Alignment within 5 degrees of neutral was achieved in 82% of cases. The average age in the varus group was 69.2 years (41–92), which was higher than in the neutral group (67.4 years: 25–89), more patients were male (49% v 36%) but the average BMI was similar (29 v 28). The average duration of follow-up was the same. There was only one re-operation in the varus group, which was a revision for deep infection. There was one dislocation successfully treated by closed reduction and one acetabular component is currently loose. In the neutral group there have been four dislocations, one of which required application of a PLAD; five revisions for aseptic loosening of the acetabular component associated with high wear rates, with a further three currently being loose; four intra-operative, undisplaced fractures of the greater trochanter; two peri-prosthetic femoral shaft fractures treated by internal fixation and two temporary nerve palsies. There has been no aseptic loosening of the femoral components in either group. Subsidence of the femoral stem within the cement mantle was noted in 96% of the entire series. There was no significant difference between the groups with respect to the degree of subsidence. In the varus group 78% subsided less than 2mm compared to 75% in the neutral group. None of the femoral implants in either group subsided more than 4mm and none demonstrated evidence of aseptic loosening or negative bone remodelling. Conclusion. Varus implantation of the femoral component was more common in older, male patients, but there was no increased risk of subsidence or loosening at a minimum follow-up of ten years

OBJECTIVE OF THE STUDY. The objective of this study is to establish the medium-term clinical and radiological results with the cementless three-dimensional Vektor-Titan stem compared with conventional cementless stem, such as PerFix stem. The latter stem has a double-wedge design with a rounded distal portion for canal filling (Fig. 1). MATERIALS AND METHODS. From July, 2004, to May, 2010, fifty seven Vektor-Titan stems and 150 PerFix stems were implanted for the patients with osteoarthritis, avascular necrosis, femoral neck fracture, and rheumatoid arthritis in our hospital. The results were evaluated clinically using Japanese Orthopedic Association (JOA) scores and the Merle d’Aubigne and Postel (M&P) scores. Radiographs were analyzed retrospectively. The criteria used for determining loosening were migration or a total radiolucent zone between the prosthesis/bone cement and host bone, wherein the width increased progressively or change of position, i.e., migration or subsidence of the prosthesis. Migration of the socket seen on the radiograph was defined as either the presence of a ≥2-mm position change or rotation. Position changes of the stem seen on the radiograph were defined as the presence of a progressive subsidence of ≥2 mm or change of position, e.g., varus or valgus. The follow-up period was 9.2 ± 2.6 (range, 5.0–14.0) years. RESULTS. One patient had intraoperative femoral shaft fracture and healed by conservative treatment. The mean JOA and M&P scores improved from preoperative 39.3 and 6.8 points to postoperative 90.9 and 17.2 points, respectively. Thigh pain was less frequent for Vektor-Titan stems (Table 1). Radiolucent lines was far less likely to appear for Vektor-Titan stems evaluated by Gruen's zonal analyses (Table 2). On the other hand, there were radiolucent zones of more than 90% in zone 4 with cementless PerFix stems (Table 2). There was no cases of loosening or postoperative infection. Although signs of bone atrophy were found in the proximal femur and the trochanters in 66.7 % of all cases, bone structure was radiologically normal without stress shielding in most cases (Table 2). On the contrary, there was evidence of an even denser bone structure, such as trabeculae, at the tip of the stem and the lateral implant fixation within the greater trochanter in Vektor-Titan stem cases. These findings remained unchanged over observation periods. DISCUSSION AND CONCLUSIONS. The cementless Vektor-Titan stem is made of Ti6AI7Nb, has got the shape of a straight three-dimensional cone. It has a high proximal volume in the form of a three-dimensional taper with longitudinal ribs. This design achieves strong primary fixation in the proximal metaphysis. Radiologically, newly formed trabeculae toward to the stem were indicative of direct biological fixation at the bone-implant interface. Medium-term results with the cementless Vektor-Titan stem show no implant loosening with stable metaphyseal fixation and preservation of bone structure in the proximal femur and the absence of radiolucent zones around the stem compared with conventional cementless stem