Outcomes of Intramedullary Nailing with Cerclage Wiring in Subtrochanteric Femoral Fractures.

AIMS: The aim of this study was to compare the outcomes of closed reduction against open reduction with cerclage wires in patients with subtrochanteric fractures treated with intramedullary nailing (IMN). MATERIALS AND METHODS: We identified 141 patients who had an IMN over a 4-year period. They were classified into three groups based on fracture pattern and whether open or closed reduction was performed. Type I was a transverse fracture, type II, a spiral fracture with an intact posterior and medial wall in the proximal fragment, and a type III fracture without intact posterior or medial walls. The primary outcome measure was a revision surgery for implant failure. Secondary outcome measures were related to fracture reduction and radiological union scores of the hip (RUSH). RESULTS: There were 35 patients who had a type I fracture, 26 patients with a type II fracture, and 80 patients with a type III fracture. The mean follow-up was 7 months. Closed reduction in type III fractures was associated with a significantly increased risk of mechanical complications (p = 0.005) and unplanned returns to theatre for implant failure (p = 0.04) as compared to open reduction. Open reduction in type III fractures was associated with a significantly higher mean RUSH scores (p = 0.0006). There was no significant difference in mean operative time between open and closed reduction in type III fractures (p = 0.12). CONCLUSION: We recommend open reduction with cerclage wiring in type III subtrochanteric fractures in order to reduce the risk of implant failure, nonunion, and need for further surgery. HOW TO CITE THIS ARTICLE: Mehta NJ, Goldsmith T, Lacey A, et al. Outcomes of Intramedullary Nailing with Cerclage Wiring in Subtrochanteric Femoral Fractures. Strategies Trauma Limb Reconstr 2019;14(1):29-33.

Documentation of Focal Neurology on Patients with Suspected Cauda Equina Syndrome and the Development of an Assessment Proforma.

OBJECTIVE: Cauda equina syndrome is a relatively rare condition with a disproportionately high medico legal profile. Definitive management involves prompt surgical decompression with outcome dependent on timing of surgery. Documentation of a comprehensive clinical and neurological assessment including examination of anal tone and perianal sensation is essential in reducing litigation and identifying patients requiring urgent surgical decompression. The aim of this study was to evaluate the documentation of focal neurology in patients with suspected cauda equina syndrome and devise an assessment proforma to use in the accident and emergency departments. METHODS: A retrospective case note review was performed in all patients presenting to A&E with suspected cauda equina syndrome from January 2013 to March 2014. A full neurological examination was defined as having all modalities documented such as: MRC grade power, reflexes, sensory exam, vibration proprioception, anal tone & perianal sensation. RESULTS: Sixty-nine patients with suspected cauda equina syndrome were identified with a median age of 44 (35-55) and a male to female ratio of 1:1.6. 4 patients (6%) had confirmed cauda equina syndrome and were transferred to a tertiary neurosurgical centre for further management. Only 2 patients (3%) had a complete neurological examination documented. 11 (16%) patients did not have any documentation of perianal sensation and 8 patients (12%) did not have documentation of anal tone. CONCLUSION: Documentation of neurological was poor across our department. The introduction of an assessment proforma is proposed to increase documentation and optimise emergency department evaluation in these patients.

A Traumatic Bilateral Anterolateral Compartment Syndrome and Subsequent small Bowel Obstruction in a Patient with Schizophrenia.

INTRODUCTION: A traumatic bilateral compartment syndrome is not widely reported. There is usually a precipitating event to cause compartment syndrome for example open and closed fractures, plaster of Paris application, burns and post-ischaemia reperfusion injury. This case confirms the need for a high index of suspicion for compartment syndrome in a patient presenting with bilateral leg pain, swelling and erythema as early diagnosis and urgent decompression by fasciotomy is of vital importance to preserve limb function and avoid complications. CASE REPORT: We wish to report the case of atraumatic bilateral anterolateral compartment syndrome in a 58-year-old Caucasian man with a medical history of schizophrenia. He presented to Accident and Emergency with bilateral leg pain, swelling and erythema with no preceding history of trauma. Initially he was treated for bilateral lower leg cellulitis with a late diagnosis of compartment syndrome. CONCLUSION: This case illustrates the need for a broad differential diagnosis.

The AO/ASIF proximal femoral nail antirotation (PFNA): a new design for the treatment of unstable proximal femoral fractures.

INTRODUCTION: PFNA design compacts the cancellous bone to provide increased stability and has been bio-mechanically proven to retard rotation and varus collapse. METHODS: Between 2006 and 2007, 62 consecutive patients with unstable proximal femoral fractures were treated with the PFNA. RESULTS: Twenty males and 42 females with a mean age of 78 years (44-94) were reviewed. In 48 patients, the fracture resulted from a low energy injury. The majority of the fractures belonged to AO/ASIF types 31A2.3 (22) and 31A3.2 (29). Twelve patients required open reduction. The PFNA blade position was central in 52 patients with a mean tip-apex distance (TAD) of 12 mm (range 4-34 mm). Post-operatively, five patients died within 3 months and two patients were lost to follow-up. Forty-nine fractures united between 3 and 4 months. Four patients had delayed union. The PFNA blade cut out rate was 3.6%. CONCLUSIONS: Unstable proximal femoral fractures were treated successfully with the PFNA. The PFNA blade appears to provide additional anchoring in osteoporotic bone. No results have been published on this new design.