We treated 108 patients with a pertrochanteric femoral fracture using either the dynamic hip screw or the proximal femoral nail in this prospective, randomised series. We compared walking ability before fracture, intra-operative variables and return to their residence. Patients treated with the proximal femoral nail (n = 42) had regained their pre-operative walking ability significantly (p = 0.04) more often by the four-month review than those treated with the dynamic hip screw (n = 41). Peri-operative or immediate post-operative measures of outcome did not differ between the groups, with the exception of operation time. The dynamic hip screw allowed a significantly greater compression of the fracture during the four-month follow-up, but consolidation of the fracture was comparable between the two groups. Two major losses of reduction were observed in each group, resulting in a total of four revision operations. Our results suggest that the use of the proximal femoral nail may allow a faster postoperative restoration of walking ability, when compared with the dynamic hip screw

Retrograde femoral nailing is gaining in popularity. We report a prospective, randomised comparison of antegrade and retrograde procedures in 68 patients with 69 fractures of the femoral shaft. All nails were inserted after appropriate reaming. There was no difference in operating time, blood loss, technical complications, size of nail or reamer, or transfusion requirements. There were more problems of length and rotation using a retrograde technique on a radiolucent table than with an antegrade approach on a fracture table. All fractures in both groups healed and there was no difference in the time taken to achieve union. Although retrograde nailing is a promising technique the skills required need practice. A longer period of follow-up is necessary to determine whether there are long-term problems in the knee after such surgery

We describe a simple method of inserting the distal screws in a locked femoral nail. The method requires no aiming device and no assistant. The only equipment needed is a 3 mm Kirschner wire and an air drill

We performed a randomised, prospective trial to evaluate the use of unreamed titanium nails for femoral fractures. Of 48 patients with 50 femoral fractures 45 were followed to union; 23 with an unreamed and 22 with a reamed nail. The study was stopped early because of a high rate of implant failure.

The fractures in the unreamed group were slower to unite (39.4 weeks) than those in the reamed group (28.5 weeks; p = 0.007). The time to union was over nine months in 57% of the unreamed group and in 18% of the reamed group.

In the unreamed group 14 secondary procedures were required in ten patients to enhance healing compared with three in three patients in the reamed group. Six implants (13%) failed, three in each group. Four of these six fractures showed evidence of delayed union.

To achieve quicker union and fewer implant failures we recommend the use of reamed nails of at least 12 mm in diameter for female patients and 13 mm in males.

We describe a method of closed, unlocked nailing for femoral fractures using ultrasound instead of an image intensifier. Radiography was used only to confirm that the guide wire had been passed into the intramedullary canal of both fragments. The method succeeded in 26 of 30 cases. The failures all occurred in fractures which could not be reduced within 20 minutes. The operating time in those nailed successfully with ultrasound control was not different from the time for 30 control cases using conventional methods with an image intensifier.

We investigated a new intramedullary locking nail that allows the distal interlocking screws to be locked to the nail. We compared fixation using this new implant with fixation using either a conventional nail or a locking plate in a laboratory simulation of an osteoporotic fracture of the distal femur. A total of 15 human cadaver femora were used to simulate an AO 33-A3 fracture pattern. Paired specimens compared fixation using either a locking or non-locking retrograde nail, and using either a locking retrograde nail or a locking plate. The constructs underwent cyclical loading to simulate single-leg stance up to 125 000 cycles. Axial and torsional stiffness and displacement, cycles to failure and modes of failure were recorded for each specimen. When compared with locking plate constructs, locking nail constructs had significantly longer mean fatigue life (75 800 cycles (. sd. 33 900) vs 12 800 cycles (. sd. 6100); p = 0.007) and mean axial stiffness (220 N/mm (. sd. 80) vs 70 N/mm (. sd. 18); p = 0.005), but lower mean torsional stiffness (2.5 Nm/° (. sd. 0.9) vs 5.1 Nm/° (. sd. 1.5); p = 0.008). In addition, in the nail group the mode of failure was either cut-out of the distal screws or breakage of nails, and in the locking plate group breakage of the plate was always the mode of failure. Locking nail constructs had significantly longer mean fatigue life than non-locking nail constructs (78 900 cycles (. sd. 25 600) vs 52 400 cycles (. sd. 22 500); p = 0.04). The new locking retrograde femoral nail showed better stiffness and fatigue life than locking plates, and superior fatigue life to non-locking nails, which may be advantageous in elderly patients. Cite this article: Bone Joint J 2014;96-B:114–21

Aims

Periprosthetic fractures (PPFs) around the knee are challenging injuries. This study aims to describe the characteristics of knee PPFs and the impact of patient demographics, fracture types, and management modalities on in-hospital mortality.

Aims

The aim of this study was to assess the safety and clinical outcome of patients with a femoral shaft fracture and a previous complex post-traumatic femoral malunion who were treated with a clamshell osteotomy and fixation with an intramedullary nail (IMN).

Aims. Patients undergoing femoral lengthening by external fixation tolerate treatment less well when compared to tibial lengthening. Lengthening of the femur with an intramedullary device may have advantages. Patients and Methods. We reviewed all cases of simple femoral lengthening performed at our unit from 2009 to 2014. Cases of nonunions, concurrent deformities, congenital limb deficiencies and lengthening with an unstable hip were excluded, leaving 33 cases (in 22 patients; 11 patients had bilateral procedures) for review. Healing index, implant tolerance and complications were compared. Results. In 20 cases (15 patients) the Precice lengthening nail was used and in 13 cases (seven patients) the LRS external fixator system. The desired length was achieved in all cases in the Precice group and in 12 of 13 cases in the LRS group. The mean healing index was 31.3 days/cm in the Precice and 47.1 days/cm in the LRS group (p < 0.001). This was associated with an earlier ability to bear full weight without aids in the Precice group. There were more complications with LRS lengthening, including pin site infections and regenerate deformity. Implant tolerance and the patients’ perception of the cosmetic result were better with the Precice treatment. Conclusion. Femoral lengthening with the Precice femoral nail achieved excellent functional results with fewer complications and greater patient satisfaction when compared with the LRS system in our patients. Cite this article: Bone Joint J 2016;98-B:1382–8

We have compared the sonographic findings of six femoral fractures with soft-tissue interposition which required open reduction with those of a control group of 40 other femoral fractures. Ultrasound assessment before operation showed that the fractured end of the proximal fragment had penetrated the quadriceps muscle anteriorly while the distal fragment lay beneath it. Transverse scans showed less soft-tissue thickness over the end of the proximal fragment in the problem cases. Radiographic image intensification did not provide any additional information. Ultrasound is of value in demonstrating soft-tissue interposition at the fracture site before femoral nailing

Ollier’s disease is characterised by severe deformity of the extremities and retarded growth because of multiple enchondromas. For correction of deformity, the Ilizarov method has been used although it has many complications. A 17-year-old boy with Ollier’s disease had a limb-length discrepancy of 17.4 cm, with a valgus deformity of the right knee and recurvatum of the femur of 23°. He had undergone three unsuccessful attempts to correct the deformities by using external fixators. We used a fully implantable, motorised, lengthening and correction nail (Fitbone) to achieve full correction of all the deformities without complications. We decided to carry out the procedure in three stages. First, we lengthened the femur by 3.6 cm and the tibia by 4 cm. We then exchanged the femoral nail for a longer implant and achieved a further 6 cm of length. This reduced the shortening to 3.8 cm. When the boy has finished secondary school we will adjust the remaining discrepancy

Rotational deformity following intramedullary nailing may cause symptoms and require surgical correction by osteotomy. Reamed, locked intramedullary nailing may be performed, but concern about cortical blood supply and potential pulmonary dysfunction from reaming have led many surgeons to limit this and use smaller diameter nails. Slotted nails are commonly used but are less stiff in torsion than the newer unslotted nails, particularly at the lower diameters. We report two cased of recurrent femoral rotational deformity after using statically interlocked slotted intramedullary nails to correct existing femoral rotational deformities. These patients show that small diameter statically interlocked femoral nails with diminished bone-nail contact must be stiff enough in rotation to avoid potential recurrence

The proximal femoral nail (PFN) is a recently introduced intramedullary system, designed to improve treatment of unstable trochanteric fractures of the hip. In a multicentre prospective clinical study, the intra-operative use, complications and outcome of treatment using the PFN (n = 211) were compared with those using the gamma nail (GN) (n = 213). The intra-operative blood loss was lower with the PFN (220 ml v 287 ml, p = 0.001). Post-operatively, more lateral protrusion of the hip screws of the PFN (7.6%) was documented, compared with the gamma nail (1.6%, p = 0.02). Most local complications were related to suboptimal reduction of the fracture and/or positioning of the implant. Functional outcome and consolidation were equal for both implants. Generally, the results of treatment of unstable trochanteric fractures were comparable for the PFN and GN. The pitfalls and complications were similar, and mainly surgeon- or fracture-related, rather than implant-related

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

It has been suggested that reamed intramedullary nailing of the femur should be avoided in some patients with multiple injuries. We have studied prospectively the effect of femoral reaming on the inflammatory process as implicated in the pathogenesis of acute respiratory distress syndrome (ARDS) and multiple-organ failure (MOF). We studied changes in the levels of serum interleukin-6 (IL-6) (proinflammatory cytokine), neutrophil CD11b (C3) receptor expression (activated neutrophil adhesion molecule), serum soluble intracellular adhesion molecule (s-ICAM-1), serum soluble E-selectin (the soluble products of endothelial adhesion molecules) and plasma elastase (neutrophil protease) in a series of patients with femoral fractures treated by nailing. We have also compared reamed nailing with unreamed nailing. We found that the levels of serum IL-6 and elastase rose significantly during the nailing procedure indicating a measurable ‘second hit’. There was no clear response in leukocyte activation and no difference in the release of endothelial adhesion molecule markers. There was no significant difference between groups treated by reamed and unreamed nailing. Although clinically unremarkable, the one patient who died from ARDS was shown to be hyperstimulated after injury and again after nailing, suggesting the importance of an excessive inflammatory reaction in the pathogenesis of these serious problems. Our findings have shown that there is a second hit associated with femoral nailing and suggest that the degree of the inflammatory reaction may be important in the pathogenesis of ARDS and MOF

We have reviewed our experience of four iatrogenic femoral neck fractures in 315 consecutive closed intramedullary nailings with the AO/ASIF universal femoral nail. The average neck-shaft angle in the bones that fractured was 139.3 degrees +/- 1.2 degrees SD (136 to 141); in the whole series the average neck-shaft angle was 125.3 degrees +/- 8.6 degrees and only 11 had angles of more than 135 degrees. The upper ends of the nails in the four which fractured were 17 mm, 5 mm, 3 mm, and 1 mm below the tip of the greater trochanter. In the seven patients with neck-shaft angles greater than 135 degrees but with no fracture, none of the nails had been inserted beyond the tip of the greater trochanter. We nailed six cadaver femora to simulate the forces produced by intramedullary nailing. Despite deep insertion, only one of the six sustained a neck fracture. This specimen had a radiographic neck-shaft angle of 140 degrees against an average of 127.3 degrees +/- 4.0 degrees for the other five. We believe that the medial prong of the AO insertion jig, with its medial overhang of 2 to 3 mm, may impinge on the superior aspect of a valgus femoral neck during final impaction, causing a neck fracture. This may be avoided by leaving the end of the nail above the tip of the trochanter in such cases