Novel technique of removal of broken intra-medullary nail from femur with secondary DCS plating

<p class="abstract">Femoral shaft fractures are one of the commonest fractures of the lower limb which are frequently operated with intramedullary nailing which enables immediate post-operative mobilization of the patient. There could be various causes of nail breakage – some of the notable being weight bearing over the non-union of the femur shaft, or a re-trauma over the operated limb causing both the implant and the nail to be broken. There are various methods of removal of the broken implant the commonest being the use of T-reamer technique. However not always can this be used due to varied intra-operative obstacles in different cases as described in this case below. We have a 35 year old male patient who was brought to us 2 hours after an alleged history of slip and fall following which he had sustained right sided subtrochanteric femur fracture with a broken implant – intramedullary interlock nail. The patient is a previously operated case of right sided femur shaft fracture with interlocking nailing done 15 years back. The patient was operated with – broken implant removal on the right side along with a secondary DCS plating with bone grafting for the subtrochanteric femur fracture. Intra operative period was met with a certain number of challenges and difficulties in view of a 15 year old implant for removal which was successfully with removed with DCS plating done. As is obvious with the above case, it would be quite imperative to say that older the implant, more difficult it becomes for its removal. </p>

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>

Rare Case of a Solitary Bone Plasmacytoma of the Proximal Femur Managed with Surgery and Adjuvant Chemotherapy: A Case Report

Introduction: Solitary plasmacytoma of the bone is a rare neoplasm characterized by proliferation of neoplastic plasma cells in the bone in the absence of systemic involvement. We present a managed case of a 64-year-old male with solitary bone plasmacytoma of the right proximal femur, who presented as a pathological subtrochanteric femur fracture. Case Report: A 64-year-old male presented to our outpatient department with pain in the right hip and restricted range of motion following a trivial trauma. The radiographs showed an osteolytic lesion in the right proximal femur with a right subtrochanteric femur fracture. A magnetic resonance imaging scan revealed a well-defined lesion in the right proximal femur. A 18F-fluorodeoxyglucose positron emission tomography did not show a lesion at any other site suggesting that the lesion was solitary. A serum protein electrophoresis study was normal and the urine was negative for myeloma protein. The patient had a score of 12 as per Mirel’s criteria and hence required operative intervention and fixation. The patient was managed with a thorough mechanical and chemical curettage of the lesion followed by fixation with a proximal femur locking plate and augmentation with fibula and iliac crest bone graft. He was then given a chemotherapy regimen consisting of nine cycles of bortezomib, lenalidomide, and dexamethasone. Conclusion: Solitary bone plasmacytoma is a rare neoplasm of the bone. Early diagnosis and intervention are required to manage it and prevent its progression to multiple myeloma, which is a more aggressive entity and lies at the other end of the spectrum of plasma cell dyscrasias. Management of this lesion requires an active participation of the hematologist and a holistic approach which includes radiotherapy or surgery with possible adjuvant chemotherapy. Keywords: Solitary bone plasmacytoma, subtrochanteric femur fracture, multiple myeloma, bortezomib, lenalidomide, dexamethasone.

Congenital Insensitivity to Pain and Anhidrosis: A painful experience by a painless child

A three-year-old boy with congenital insensitivity to pain and anhidrosis (CIPA) was first presented with transphyseal separation of distal left humerus. Surgical treatment with closed reduction and k-wiring of transphyseal separation of distal humerus resulted in devastating surgical site infection and osteomyelitis. Multiple surgical debridement and application of external fixator to eliminate infection were futile. At the age of four years, he refused to bear weight as a result of left hip dislocation. Closed reduction and spica cast was unsuccessful, resulting in recurrent left hip dislocation. He has since not been able to walk. At the age of five years, the right hip was dislocated followed by ipsilateral subtrochanteric femur fracture. Appropriate treatments such as hip spica and titanium elastic nail were not possible due to extensive bruising and skin ulceration over the right thigh. This child ended up with a functionless left upper limb, bilateral hip dislocation and malunited right femur fracture. Conservative treatment and watchful neglect might be the ideal treatment for patients with CIPA.

Subtrochanteric Femur Fracture in Monostotic Pagets Disease and its Management – A Case Report and Review of Literature

Introduction: Paget disease of bone is a chronic progressive disease of the bone of uncertain etiology, characterized initially by an increase in bone resorption, followed by a disorganized and excessive formation of bone, leading to pain, fractures, and deformities. It can manifest as a monostotic or polyostotic disease. Pathological fracture secondary to Paget’s disease requires surgical management. Case Report: A 60-year-old male patient came with complaint of pain and swelling over the left hip for 30 days. The patient had a history of a trivial fall. Radiological investigations were suggestive of pathological subtrochanteric femur fracture with Paget’s disease of the left femur. We managed with the long proximal femoral nail (PFN). Histopathological examination confirmed the diagnosis of Paget’s disease. At present 1-year follow-up, the patient is having good radiological and functional outcome with no implant failure. Conclusion: Subtrochanteric pathological femur fractures in Paget’s disease are best managed with the long PFN with good outcome and fewer complications, which help in early mobilization and weight-bearing. Long PFN spans the entire pathologic femur and prevents the secondary fractures. Keywords: Pagets disease, femur subtrochanteric fracture, long proximal femur nail.

Management of Subtrochanteric Femur Fracture Using Proximal Femoral Nail

Injuries to the femur, the longest bone in the body presents a challenging situationto the orthopedic surgeon. The proximal femoral intramedullary devices are useful for the treatmentof isolated pathological lesions in the subtrochanteric region. Biomechanically, the nail can withstandbetween 3to 5 times body weight. Hence the present study was planned to study the managementof these fractures with the proximal femoral nail. Materials and Methods: A total of 44 patientswith proximal femoral fractures of the subtrochanteric region admitted in the department wereincluded in the study. Patients age more than 25 years and diagnosed with subtrochanteric femurfracture were included in the study. Results: The age of the patients was more than 25 years. Therewere 34 males and 10 females included in the study. In the clinical evaluation as per the functionalGrading of the patient as per Kyle’s Criteria excellent and good results were considered satisfactory,whereas fair and poor results were considered unsatisfactory. In this series 92%, satisfactory resultswere obtained. Conclusion: Proximal femur nail (PFN) is an effective device in the management ofcomplex femoral fractures. The use of PFN in such fractures provides various advantages: Closedprocedure, Minimal soft tissue damage. It offers superior stabilization than other currently usedmethods of internal fixation. The use of PFN is technically demanding and needs expertise.Complications can be avoided by proper operative techniques. Early postoperative mobilization andphysiotherapy improve the results of PFN.