Aims

Deep surgical site infection (SSI) remains an unsolved problem after hip fracture. Debridement, antibiotic, and implant retention (DAIR) has become a mainstream treatment in elective periprosthetic joint infection; however, evidence for DAIR after infected hip hemiarthroplaty is limited.

Background

Orthopaedic surgeons are increasingly pressured to consider thromboprophylaxis for patients when little evidence exists. The aim of this study was to determine the incidence of fatal pulmonary embolism following office attendance in our outpatient fracture clinic.

Introduction

Minimally invasive plate osteosynthesis (MIPO) is a relatively new surgical technique for the management of distal tibial fractures. Conventional open technique is unfavourable to the fracture biology because of excessive soft tissue stripping and can be associated with significant devastating complications.

Statement of purpose of study: To determine how effective Flexible Intramedullary Nails are in treating tibial and femoral fractures in adolescents.

Introduction Flexible intramedullary nails (FIN) are increasingly used in the management of paediatric tibial and femoral fractures. Recently, concerns have been raised regarding the use of FIN in older children. The aim of this study was to determine how effective FIN's are in treating tibial and femoral fractures in adolescents.

Methods Hospital records were used to identify all patients aged 11 years or older under going FIN for tibial and femoral fractures between 2003 and 2009. Radiographs and case notes were reviewed to identify complications.

Results 35 consecutive adolescent patients underwent FIN for tibial (n=21) and femoral fractures (n=15) with a mean age of 12.9 years. 2 femoral and 9 tibial fractures were open. Eight patients sustained multiple injuries. Mean radiographic follow up was 29 weeks. 60% (n=9) and 38% (n=9) of femoral and tibial fractures respectively malunited. Fracture severity was associated with increased malunion for both tibial and femoral fractures (P=0.046 and P=0.044 respectively). There were no cases of non-union. 2 femoral fractures took longer than 20 weeks to unite and 7 tibial fractures took longer than 16 weeks to unite. One patient developed post operative compartment syndrome, one patient developed deep infection and two patients were treated with post operative traction for loss of fracture position.

Discussion Previous publications from multiple centres, including ours, have demonstrated excellent results of FIN for tibial and femoral fractures in the general paediatric population. However, concerns have recently been raised about the use of FIN in older, heavier children and with unstable fracture patterns. This is the first published series of adolescent patients undergoing FIN. We conclude that the higher than expected rates of malunion and delayed union suggest that other treatments should be considered when treating adolescents with unstable tibial or femoral fractures.

Background: Rates of around only 40% graft incorporation have been reported when irradiated bone allograft is used during revision hip arthroplasty. In this series we washed fat from irradiated allograft and added 40% by volume of autologous marrow from the iliac crest before impaction grafting. The aim of this study was to determine the rate of graft incorporation in a consecutive series of patients who underwent this modified technique of impaction bone grafting.

Methods: 85 consecutive patients, including 51 acetabular and 59 femoral revisions were reviewed. Evidence of graft cortication and or trabeculation was recorded by zone over the period of radiographic follow up.

Results: Using washed irradiated allograft with autologous marrow, 96% (49/51) of acetabular and 90% (53/59) of femoral grafts showed incorporation in the majority or all zones. Most of these changes were apparent within 6 months of surgery. The average subsidence of the stem at mean follow up of 45 months was 1.28 mm. Of the 8 patients whose graft failed to incorporate, 2 had grafts removed for post operative infection and 3 had early reoperation for intraoperative fractures. Only 3 out of 85 patients failed to demonstrate bone incorporation in the majority of zones with out an obvious reason why.

Conclusions: The addition of autologous marrow to irradiated bone allograft during impaction grafting is a cheap and effective way of increasing the rate of bone incorporation. This series demonstrates over 90% bone incorporation, usually occurring within 6 months after surgery.

Eight slipped upper femoral epiphyses in patients who had had radiotherapy are described. These cases involved five patients in an "at risk" population of 48. This increased incidence is highly significant.