Subtrochanteric fractures after retrograde femoral nailing

Secondary fractures around femoral nails placed for the management of hip fractures are well known. We report, two cases of a fracture of the femur at the interlocking screw site in the subtrochanteric area after retrograde femoral nailing of a femoral shaft fracture. Only a few reports in the existing literature have described these fractures. Two young men after sustaining a fall presented to us with pain, swelling and deformity in the upper thigh region. On enquiring, examining and radiographing them, peri-implant fractures of subtrochanteric nature through the distal interlocking screws were revealed in both patients who also had histories of previous falls for which retrograde intramedullary nailing was performed for their respective femora. Both patients were managed with similar surgical routines including removal of the existing hardware, open reduction and ace cephallomedullary antegrade nailing. The second case did show evidence of delayed healing and was additionally stabilized with cerclage wires. Both patients had uneventful postoperative outcomes and union was evident at the end of 6 mo postoperatively with a good range of motion at the hip and knee. Our report suggests that though seldom reported, peri-implant fractures around the subtrochanteric region can occur and pose a challenge to the treating orthopaedic surgeon. We suggest these be managed, after initial stabilization and resuscitation, by implant removal, open reduction and interlocking intramedullary antegrade nailing. Good results and progression to union can be expected in these patients by adhering to basic principles of osteosynthesis.

Treatment for subtrochanteric fracture and subsequent nonunion in an adult patient with osteopetrosis:A case report and review of the literature

BACKGROUND As a congenital metabolic bone disease caused by defective osteoclastic resorption of immature bone,osteopetrosis is characterized by diffused sclerosis of bones,brittle bones,easy fracturing,narrow medullary canals,and a weak fracture healing ability.At present,clear standards and principles for the treatment of fractures in patients with osteopetrosis are lacking.Non-operative treatment can prevent fracture hematoma and preserve the blood supply to the bone fragments,while being associated with frequent failures and higher mortality rates.Meanwhile,closed reduction and internal fixation with intramedullary nail(CRIF+IMN)approaches can also protect blood supply to the fracture site.However,IMN cannot be used for the vast majority of patients with osteopetrosis due to the narrowing of medullary canals.Thus,open reduction and internal fixation with plate remains the most appropriate surgical method for treating fractures in patients with osteopetrosis,but this approach is complicated by the lack of intramedullary hematopoiesis in such patients.Fracture healing primarily depends on the blood supply to the external periosteum.Open reduction can also easily destroy the periosteum and cause delayed fracture healing or even nonunion;however,CRIF may be the most practical approach.As a result,it would be prudent to solve the difficulty of drilling during the operation and the problem of postoperative nonunion.CASE SUMMARY In 2018,we treated an adult patient with osteopetrosis presenting with a subtrochanteric fracture.The fracture was fixed using a femoral locking compression plate.Because of delayed consolidation,at 12 mo postoperatively the patient was further treated with platelet-rich plasma(PRP)combined with radial extracorporeal shock wave therapy(rESWT).Antero-posterior and lateral radiographs obtained at the latest follow-up(10 mo)showed that the callus had grown at the original fracture site,and the medial fracture line almost disappeared.CONCLUSION Osteosynthesis remains the first choice of treatment approach for fractures in patients with osteopetrosis,especially peritrochanteric fractures.Preoperative preparation is necessary to avoid risks such as drill bit breakage and iatrogenic fracture during the operation.Moreover,fractures in a patient with osteopetrosis present with a high risk of delayed union and nonunion,which can be potentially cured with PRP+rESWT.

Subtrochanteric femur fracture treated by intramedullary fixation

Purpose： To discuss surgical technique, operative efficacy and clinical outcome of intramedullary fixation in the treatment of subtrochanteric femur fractures. Methods： From February 2011 to February 2013, 76 cases of subtrochanteric femur fractures were treated by intramedullary fixation in our hospital, including 53 males and 23 females, with the age range of 37 -72 years （mean 53.5 years）. According to Seinsheimer classification, there were 2 cases of type I, 7 type Ⅱ, 15 type Ⅲ, 23 type IV and 29 type V. Firstly, all patients underwent closed reduction with the guidance of C-arm fluoroscopy in a traction table. Two cases of type I and 3 cases of type Ill fractures had ideal closed reduction followed by internal fixation. The others needed additional limited open reduction. Radiographic examination was used to evaluate callus formation and fracture healing in postoperative 1, 3, 6 and 12 months follow-up. Functional recovery was evaluated by Harris Hip Scoring （HHS） system. Results： Patients were followed up for 6-12 months. All fractures were healed except one patient with delayed union. The average bone union time was 4.5 months. According to HHS system, 65 cases were considered as excellent in functional recovery, 8 good, 2 fair and 1 poor. The proportion of the patients with excellent and good recovery was 96.05%. Conclusion： Intramedullary fixation is feasible for the treatment of subtrochanteric femur fracture. The accuracy of intraoperative reduction and surgical skill are important for the clinical outcome and the patients＇ prognosis.

Two Different Total Hip Arthroplasties for Hartofilakidis Type C1 Developmental Dysplasia of Hip in Adults

Background： Total hip arthroplasty （THA） in developmental dysplasia of the hip （DDH） is more complex than the normal hip, with large replacement risks and many complications.Although nonosteotomy THA is convenient to perform, femoral osteotomy shortening can avoid blood vessel and nerve traction injuries.This study aimed to compare osteotomy THA with nonosteotomy to determine reasonable options for operative management of DDH.Methods： Data on 48 DDH patients who underwent THA were analyzed retrospectively.The patients were divided into two groups： Group A 29 cases （nonosteotomy）, and group B 19 cases （osteotomy）.Harris and Western Ontario and McMaster Universities Osteoarthritis Index （WOMAC） scores, limb length discrepancy （LLD）, radiological data on the hip, and claudication were evaluated.Data were analyzed by using paired-sample Student＆#39;s t-test, independent-sample Student＆#39;s t-test, and Pearson＆#39;s Chi-square test;the test level was α =0.05.Results： Postoperative Harris （90.7 ＆#177; 5.1） and WOMAC scores （88.0 ＆#177; 10.6） were significantly improved compared with preoperative Harris （44.8 ＆#177; 5.7） and WOMAC scores （42.0 ＆#177; 5.3） in group A （P 〈 0.05）.Postoperative Harris （90.4 ＆#177; 2.8） and WOMAC scores （88.2 ＆#177; 5.9） were significantly improved compared with preoperative Harris （44.4 ＆#177; 4.2） and WOMAC scores （43.2 ＆#177; 4.3） in group B （P 〈 0.05）.One case of dislocation occurred in group A;after closed reduction, dislocation did not recur.In group A, 2 patients developed cutaneous branch injury of the femoral nerve, which spontaneously recovered without treatment.Postoperative LLD 〉2 cm was seen in one case in group A and five cases in group B.Postoperative claudication showed no significant difference between the two groups （P 〉 0.05）.No patients developed infection;postoperative X-rays showed that the location of the prosthesis was satisfactory, and the surrounding bone was not dissolved.Conclusions： THA is effective and safe for DDH.For unilateral high dislocation DDH patients with limb lengthening ≤4 cm and good tissue conditions, THA without femoral osteotomy may be considered.