Peri-implant fracture: a rare complication after intramedullary fixation of trochanteric femoral fracture

Introduction Trochanteric femoral fractures are among the most common operatively treated fractures. Intramedullary fixation has become the treatment of choice in many centers around the world. Nevertheless, the knowledge of rare complications of these fractures is limited. In this study, the incidence and treatment strategies for peri-implant fractures (PIF) were assessed. Materials and methods A single-center retrospective cohort study was done on 987 consecutive operatively treated trochanteric fractures. PFNA cephalomedullary nail was used as a fixation method. All patients were followed up from patient records for peri-implant fractures. Plain radiographs as well as different salvage methods were analyzed and compared. Results The total rate of peri-implant fractures was 1.4% (n = 14). The rate of PIF for patients treated with short (200 mm) nails, intermediate-length (240 mm) nails, and long nails was 2.7% (n = 2), 1.5% (n = 11), and 0.7% (n = 1), respectively (ns, p > 0.05 for difference). Treatment of choice for PIF was either ORIF with locking plate (57%, n = 8) or exchange nailing (43%, n = 6). None of the PIF patients needed additional surgeries for non-union, malunion, or delayed union. Conclusions A PIF is a rare complication of intramedullary fixation of trochanteric fractures. It can be treated with either locking plates or exchange nailing with sufficient results. There are no grounds for favoring long nails to avoid PIFs.

Individualized Determination of the Mechanical Fracture Environment After Tibial Exchange Nailing—A Simulation-Based Feasibility Study

Non-union rate after tibial fractures remains high. Apart from largely uncontrollable biologic, injury, and patient-specific factors, the mechanical fracture environment is a key determinant of healing. Our aim was to establish a patient-specific simulation workflow to determine the mechanical fracture environment and allow for an estimation of its healing potential. In a referred patient with failed nail-osteosynthesis after tibial-shaft fracture exchange nailing was performed. Post-operative CT-scans were used to construct a three-dimensional model of the treatment situation in an image processing and computer-aided design system. Resulting forces, computed in a simulation-driven workflow based on patient monitoring and motion capturing were used to simulate the mechanical fracture environment before and after exchange nailing. Implant stresses for the initial and revision situation, as well as interfragmentary movement, resulting hydrostatic, and octahedral shear strain were calculated and compared to the clinical course. The simulation model was able to adequately predict hardware stresses in the initial situation where mechanical implant failure occurred. Furthermore, hydrostatic and octahedral shear strain of the revision situation were calculated to be within published healing boundaries—accordingly the fracture healed uneventfully. Our workflow is able to determine the mechanical environment of a fracture fixation, calculate implant stresses, interfragmentary movement, and the resulting strain. Critical mechanical boundary conditions for fracture healing can be determined in relation to individual loading parameters. Based on this individualized treatment recommendations during the early post-operative phase in lower leg fractures are possible in order to prevent implant failure and non-union development.

A case of subtrochanteric femur fracture nonunion with failed implant in situ treated with exchange nailing using interlock nail and autologous bone grafting: a case report

<p class="abstract">Subtrochanteric femur fracture accounts for 25% of all hip fracture and may land up in non-union due to the inadequate reduction and fixation tech, local muscle pull over fragments, biomechanical stress in subtrochanteric region and soft tissue interposition etc., non-union are managed with various choices of implants like exchange nailing , angle blade plate , dynamic condylar screw, augmentation of previous hardware with plate and by providing biological environments at fracture site using bone graft. Strict adherence to principles of providing stability to fracture and providing environment for bony growth gives good clinical outcome. A 52 years old male with subtrochanteric femur fracture was operated with long PFN, later presented to us after 18 months with failure of the hardware and atrophic non-union manifesting as pain during walking and limping. Patient was operated with removal of implant and exchange nailing using femur interlock nail and autologous bone grafting from iliac crest graft. 1 year follow up showed complete bony union and abundant of callus formation. Patient is currently doing all the daily activities and have no complaints at present. At 1 year follow up there is complete union at non-union site and good clinical outcome is achieved. Exchange nailing with interlock nail and autologous bone grafting for treatment of atrophic non-union of subtrochanteric femur fractures gives good clinical outcome.</p>

A Three-part Broken Interlocking Femoral Nail: Novel Technique of Removal and Review of Literature

A segmentally broken (three part) interlocking femoral nail with broken interlocking screw can be challenging to remove. We describe a novel technique for extraction of an unusual two level broken cannulated anterograde femoral nail to treat the delayed union with exchange nailing. This is the first reported case of a three-part broken intramedullary interlocking nail with broken distal locking screws, where the broken hardware was removed without opening the facture site or the knee. This technique is simple and does not require specialized equipment. The surgical technique and review of literature is presented.

Exchange Nailing as Revision Surgery for Post-operative Non-union of Atypical Femoral Fractures: A Case Report and Treatment Strategy

Introduction: Atypical femoral fractures account for only 0.5% of femoral shaft fractures, but delayed union or non-union occurs in 50% of atypical femoral fractures accompanied by femoral lateral bowing. Such fractures are difficult to treat. Case Report: The case was an 84-year-old woman. She was diagnosed post-operative non-union of atypical femoral fracture. We planned a revision surgery for post-operative non-union of the atypical proximal femoral fracture. A two-dimensional template was used to simulate the intramedullary nail (IMN). Due to the advanced femoral lateral bowing deformity, a mismatch with the nail was noted when the unaffected femur was used to construct the template. When the opposite side nail was used as a template, the nail was aligned with the medullary canal, and the tip of the nail coincided with the center of the medullary canal; hence, the opposite side nail was chosen. Radiographical assessments of healing of the fracture confirmed callus formation and complete bone union 3 months and 1 year after the operation, respectively. Conclusion: We found that exchange nailing as revision surgery for post-operative non-union of atypical femoral fractures combined with an IMN on the opposite side was useful. Keywords: Alendronate, femoral fracture, osteoporosis, revision surgery.