The long and short of cephalomedullary nails in the treatment of osteoporotic pertrochanteric fracture

<p><b>INTRODUCTION</b>Pertrochanteric fractures after low-energy trauma are common among osteoporotic patients. Although the use of intramedullary devices to treat such fractures is becoming increasingly popular, there is a paucity of data comparing the outcomes of the use of short cephalomedullary nails (SCN) with the use of long cephalomedullary nails (LCN). This study aimed to compare the outcomes of treatment using LCN with treatment using SCN for patients with osteoporotic pertrochanteric fractures.</p><p><b>METHODS</b>A retrospective review of 64 patients with osteoporotic pertrochanteric fractures who were treated with either LCN or SCN and had a minimum follow-up of one year was performed. Primary outcome measures include complications, revision surgeries and union rates. Secondary outcome measures include duration of surgery, estimated blood loss, length of hospital stay, and ambulatory and mortality status at one year.</p><p><b>RESULTS</b>There was no significant difference in the clinical and functional outcomes of the patients who were treated with LCN and those who were treated with SCN. However, there was a higher incidence of heterotopic ossification in the latter group, and a slightly greater average estimated blood loss and duration of surgery in the former group. Patients treated with LCN tended to be more osteoporotic.</p><p><b>CONCLUSION</b>Our study found no significant difference in terms of complications, revision surgeries, union rates and ambulatory status between the patients who were treated with LCN and those who were treated with SCN. Both LCN and SCN provided safe and reliable outcomes in the treatment of osteoporotic pertrochanteric fractures.</p>

Intramedullary compression device for proximal ulna fracture

Proximal ulna fractures account for 20% of all proximal forearm fractures. Many treatment options are available for such fractures, such as cast immobilisation, plate and screw fixation, tension band wiring and intramedullary screw fixation, depending on the fracture pattern. Due to the subcutaneous nature of the proximal forearm, it is vulnerable to open injuries over the dorsal aspect of the proximal ulna. This may in turn prove challenging, as it is critical to obtain adequate soft tissue coverage to reduce the risk of implant exposure and bony infections. We herein describe a patient with a Gustillo III-B open fracture of the proximal ulna, treated with minimally invasive intramedullary screw fixation using a 6.0-mm cannulated headless titanium compression screw (FusiFIX, Péronnas, France).

Evolving trends in surgically managed patients with proximal humerus fracture: are we different after ten years?

<p><b>INTRODUCTION</b>New knowledge, and improved surgical hardware and fixation techniques have changed surgical management. We review the evolving trends of surgically managed proximal humerus fractures.</p><p><b>METHODS</b>Patients who underwent surgery for proximal humerus fractures from 1 January 2001 to 31 December 2010 were identified from the hospital's electronic diagnosis and operative coding database. Data extracted from the database included patient demographics, comorbidities, clinical and radiological findings, operative techniques, and complications.</p><p><b>RESULTS</b>In total, 95 patients with 97 surgically managed proximal humerus fractures were identified. The median age of the patients was 50 (range 12-85) years, and the male to female ratio was 1.2:1.0. Male patients tended to present at a younger age than female patients (peak age 30-39 years vs. 70-79 years, p < 0.001). Two-part surgical neck fracture was the most common type of fracture (n = 33, 34.0%). Plate osteosynthesis was predominantly used for two- and three-part surgical neck fractures involving the greater tuberosity (p = 0.03, p = 0.0002, respectively). Hemiarthroplasty was commonly performed for four-part fractures (p < 0.001). Wound infections, implant failure, avascular necrosis of the humeral head and nonunion were seen in 8 (8.3%) cases. Minimally invasive plate osteosynthesis (MIPO) had been in use since 2007 (p < 0.001).</p><p><b>CONCLUSION</b>Surgically managed proximal humerus fractures predominantly involved young men following high velocity injury and elderly women following osteoporotic fractures. Open plating was most commonly used for two- and three-part fractures, and hemiarthroplasty for four-part fractures. MIPO techniques have been practised in our institution since 2007.</p>

An Unusual Case of “Locking” of the Knee Four Years Post Fixation of an Open Supracondylar Femur Fracture

The introduction of locking plate devices have increased the number of viable options for fracture fixation. An understanding of the indications and contraindications and technique limitations are important to minimise associated adverse events. We report the case of a patient who presented with a single broken screw head four years following fixation of a supracondylar femur fracture, resulting in symptoms of migratory knee pain and locking. He underwent implant and foreign body removal and made an unremarkable recovery postoperatively. With the increasing use of locking plate devices, we are likely to see more such complications.

Epidemiological analysis of outcomes in 323 open tibial diaphyseal fractures: a nine-year experience

<p><b>INTRODUCTION</b>Open fractures of the tibia pose a challenge to orthopaedic and plastic surgeons. A retrospective observational review was conducted to evaluate the epidemiological factors and fracture outcomes in the Singapore context.</p><p><b>METHODS</b>A nine-year period of open tibial shaft fractures presenting to our institution was reviewed. Demographic and management data were recorded. Statistical analysis was performed on the outcomes of length of hospital stay, number of operations, time to union and infection rates.</p><p><b>RESULTS</b>323 fractures met our inclusion criteria (Gustilo [G] 1=53, G2=100, G3=170). Mean age of patients was 36.5 years, 91.3% were male and 40.9% were non-Singaporeans. 69.3% of fractures occurred from road traffic accidents and 21.7% from industrial accidents. Mean length of hospital stay was 28.7 days and number of operations was 4.29. Time to union was 10.7 months and overall infection rate was 20.7%. Infection rates were significantly higher in G3b/G3c compared to G3a (45.7% vs. 21.1%) patients. There was no significant reduction in infection rates when open tibial fractures were operated on within six hours of admission. Multiple injured patients required a longer time to union and hospital stay. There was an exponential cost increase with greater severity of fracture.</p><p><b>CONCLUSION</b>High Gustilo and AO classification injuries positively correlate with high non-union and infection rates, requiring multiple operations and long hospital stay. There is no benefit in performing surgery on open tibial fractures within six hours of presentation. A significant proportion of these patients would be polytraumatised, indirectly affecting fracture union.</p>