Bilateral Femoral Fractures Research Articles

Bilateral atypical femoral fractures: how much symmetry is there on imaging?

To evaluate bilateral atypical femoral fractures (AFFs) and to compare imaging features of paired fractures. Bilateral femoral imaging studies of 124 patients on bisphosphonate therapy with at least one AFF were retrospectively reviewed. Time between AFF diagnoses was determined. The following imaging features were evaluated for each AFF: fracture location, femoral angle, length of cortical thickening, medial spike location, fracture orientation, and comminution. Associations between imaging findings on pairs of bilateral AFFs were assessed with Spearman's correlation (rs) and the Kappa statistic (κ). Bilateral AFFs were present in 78/124 (62.9%) cases (3 men, 75 women; mean age 67.3 years). Average time between contralateral AFF diagnoses was 10.3 months. Contralateral AFFs were diagnosed within 12 months of the index fracture in 60/78 (76.9%) cases and within 3 years in 69/78 (88.5%) cases. There was a strong correlation between bilateral AFF locations (rs = 0.65), with 58/76 (76.3%) occurring within a distance of <5 cm and 41/76 (53.9%) within a distance of ≤2.5 cm. Bilateral AFF pairs had moderately correlated femoral angles (rs = 0.42), and weakly correlated lengths of cortical thickening (rs = 0.28). There was substantial agreement for medial spike location (κ = 0.68) and fracture orientation (κ = 0.64), and moderate agreement for lack of comminution (κ = 0.42). All findings were independent of time between AFF diagnoses. Patients with unilateral atypical femoral fractures are likely to be diagnosed with a contralateral AFF within the first year of presentation. Bilateral AFFs commonly have similar imaging features, including location along the femur.

Morbidity and Mortality of Bilateral Femur Fractures.

Bilateral femur fractures have been associated with frequent morbidity and mortality. Associated injuries and massive hemorrhage contributed to mortality rates that were as high as 27% in previous reports. The goals of this study were to determine the frequency of associated complications, including mortality, and to identify which patient and injury features are associated with increased morbidity and mortality. The authors proposed that some patients with bilateral femur fractures may undergo early definitive fixation with an acceptable rate of complications. Patients who had bilateral femur fractures during the same injury event were retrospectively reviewed. Demographic characteristics, associated injuries, and the type and timing of treatment were determined. Complications were identified. The authors identified 50 men and 22 women, with a mean age of 41.5 years, who had high-energy bilateral femur fractures. These patients accounted for 5.5% of all femur fractures treated at the authors' institution over a period of 11 years. Two patients died before fixation. In addition, 13 other patients (19%) had 21 complications, including pneumonia in 6 (8.6%) and deep venous thrombosis in 7 (10%). No patient had adult respiratory distress syndrome, but 2 died of multiple organ failure. All patients with pulmonary complications had an underlying chest injury (P=.004). The overall mortality rate was 6.9%, and mortality was associated with higher mean age and higher Injury Severity Score (ISS). Of the 60 patients who had definitive fixation within 24 hours of injury, 53 (88%) had no complications. Complication rates were similar to those reported in the literature, with a mortality rate of 6.9%, including 3 patients who died after femoral fixation. Mortality was associated with advanced age and higher ISS. Chest injuries were associated with pulmonary complications. Most patients had early definitive fixation without complications, but it is not possible to predict which patients may be safely treated on an early basis.

Bilateral Atypical Femoral Fracture in a Man on Long-Term Bisphosphonate and Glucocorticoid Therapy: A Case Report.

We present here, to our knowledge, the first case of a male patient with a sequential bilateral atypical femoral fracture associated with long-term use of bisphosphonates to treat glucocorticoid-induced osteoporosis. Given the known effectiveness of bisphosphonates, both their use and the potential complication of rare atypical femoral fractures have increased. These fractures are understood to occur when there is an alteration in the bone quality and its resistance to fatigue fracture in a subgroup of patients receiving bisphosphonates or denosumab.

Bilateral incomplete atypical femoral fracture due to long-term bisphosphonate use: A case report

Bilateral incomplete atypical femoral fracture due to long-term bisphosphonate use: A case report

Inhalative IL-10 treatment after bilateral femoral fractures affect pulmonary inflammation in mice

BackgroundMusculoskeletal injuries induce systemic inflammation which often impairs lung function contributing to morbidity. IL-10 has been shown to have a beneficial effect on immune dysfunction and organ damage after different traumatic insults. We sought to investigate the effect of inhalative IL-10 administration on the systemic and pulmonary inflammatory response in a small animal model of bilateral femoral fracture. Materials and methodsMale C57/BL6 mice (6 animals per group) were subjected to bilateral femoral fracture and intramedullary nailing followed by inhalative administration of either 50μL PBS (Fx group) or 50μg/kg recombinant mouse IL-10 dissolved in 50μL PBS (FxIL-10 group). All animals were sacrificed at 6, 24, or 72h after fracture induction. Blood samples were collected and analyzed for IL-6, IL-10, KC, and MCP-1 (CCL2) plasma concentrations by Bio-Plex Pro™ assays. Pulmonary infiltration by neutrophils was assessed by myeloperoxidase (MPO) activity (ELISA) and histological analysis of lung tissue. Pulmonary ICAM-1 expression (immunohistochemistry), and pulmonary IL-6 levels (ELISA) were determined. ResultsInhalative IL-10 administration showed a decrease in the pulmonary infiltration by neutrophils. A significant decrease in the expression of the adhesion molecule ICAM-1 after local IL-10 application was observed. In contrast, local IL-10 administration did not show a significant effect on the systemic inflammatory response. ConclusionOur findings suggest that inhalative IL-10 administration may beneficially modulate the pulmonary microenvironment, in which IL-10 effect on the local ICAM-1 expression seems to play a central role.

Bilateral Femur Fractures Associated With Short-term Bisphosphonate Use

Bisphosphonates are the most commonly prescribed drugs to treat osteoporosis because they have been proposed to prevent bone loss. Nevertheless, in up to 0.1% of patients, long-term use may cause atypical stress or insufficiency femoral fractures. Bilateral femoral shaft fractures have been reported after long-term use of bisphosphonates; however, there is limited evidence of the effect of short-term use. The current study reports a case of bilateral femoral fractures after a low-energy fall in a 56-year-old woman and provides a review of the literature on bilateral femoral shaft fractures after long-term use of bisphosphonates. Patients should be educated about the potential for stress fractures with the use of this treatment. In patients with thigh pain, a thorough history and physical examination, including the contralateral thigh, may be beneficial to detect bilateral traumatic or atypical stress fracture patterns. More studies with larger sample sizes are necessary to better identify patients who may be at risk for fracture, including histomorphometric evidence of low bone turnover in patients with unfortunate bilateral cases.

Effects of agmatine on excessive inflammatory reaction and proliferation of splenic cells in mice with trauma

To observe protective effects of agmatine (AGM) on inflammatory response and spleen immune function in mice with trauma. Forty-eight adult male C57BL/6 mice were randomly divided into three groups (n = 16 each), including control group, model group (bilateral femoral fracture and removal of 35% of the total blood volume), and AGM group (trauma/hemorrhage and AGM 200 mg/kg). Eight mice in each group were sacrificed at 3 hours and 24 hours, respectively, after modeling, and blood samples and tissue homogenate of spleen and liver were collected. The contents of tumor necrosis factor-α (TNF-α), interleukins (IL-6, IL-1β) in serum and liver tissue were determined with enzyme linked immunosorbent assay (ELISA). Serum aspartate transaminase (AST), alanine aminotransferase (ALT) and lactic dehydrogenase (LDH) were determined with automatic biochemistry analyzer. Spleen proliferation response stimulated with concanavalin A (ConA) was evaluated with methyl thiazolyl tetrazolium colourimetry (MTT). γ-interferon (IFN-γ) and IL-2 releases were determined with ELISA. Compared with control group, 3 hours after trauma/hemorrhage, the levels of serum TNF-α, IL-6, and IL-1β in model group were significantly elevated [TNF-α (ng/L): 145.38±31.50 vs. 23.06±11.14, IL-6 (ng/L): 496.94±50.76 vs. 47.13±17.47, IL-1β (ng/L): 321.31±43.02 vs. 29.25±16.24,all P < 0.01]. It was found that AGM treatment could alleviate the increase in serum pro-inflammatory mediators induced by trauma/hemorrhage, such as TNF-α (ng/L: 111.56±25.47 vs. 145.38±31.50), IL-6 (ng/L: 412.56±44.33 vs. 496.94±50.76), IL-1β (ng/L: 273.38±45.25 vs. 321.31±43.02, P < 0.05 or P < 0.01). Twenty-four hours after trauma/hemorrhage, serum pro-inflammatory mediators were recovered to the levels in control group. There was no significant difference in TNF-α and IL-6 levels at 3 hours after trauma/hemorrhage among groups. Compared with control group, the expressions of liver TNF-α and IL-6 in model group were increased at 24 hours following trauma [TNF-α (ng/mg): 32.93±4.90 vs. 26.58±2.33,IL-6 (ng/mg): 11.20±1.66 vs. 8.38±0.89,both P < 0.01]. However, AGM inhibited the level of TNF-α (ng/mg: 28.92±3.16 vs. 32.93±4.90) and IL-6 (ng/mg: 9.03±1.28 vs. 11.20±1.66) in the liver as induced by trauma/hemorrhage (P < 0.05 and P < 0.01). At 24 hours after modeling, model group and AGM group had distinctly higher serum AST, ALT, LDH levels than those of control group [AST (U/L): 405.9±31.2, 245.7±22.1 vs. 128.2±15.9; ALT (U/L): 92.1±6.3, 51.6±5.0 vs. 30.1±3.2; LDH (U/L): 606.7±36.3, 478.7±25.3 vs. 384.0±16.6, all P < 0.01]. Nevertheless,the increase in serum AST, ALT and LDH was alleviated in AGM group (all P < 0.01). Meantime, trauma/hemorrhage produced a noticeable depression of proliferation of splenic cells and IFN-γ and IL-2 release stimulated with ConA compared with control group [proliferation rate: (40.97±4.13)% vs. (89.99±7.76)%, IFN-γ (ng/L): 91.6±12.3 vs. 353.2±21.5,IL-2 (ng/L): 53.4±6.4 vs. 91.0±12.2,all P < 0.01]. In contrast, AGM notably restored the capacity of proliferation response of splenic cells [proliferation rate: (74.86±5.75)% vs. (40.97±4.13)%,P < 0.01],enhanced the release of IFN-γ and IL-2 stimulated with ConA [IFN-γ (ng/L): 327.8±23.6 vs. 91.6±12.3, IL-2 (ng/L): 74.8±10.4 vs. 53.4±6.4, both P < 0.01]. AGM can dramatically alleviate spleen immunosuppression, excessive inflammation and organ damage induced by trauma/hemorrhage.

Bilateral Venous Femoral Catheter Fracture and Migration: Case Report and Review of Literature

In developing countries like ours, patients with End Stage Renal Disease present late requiring urgent haemodialysis. The femoral vein is commonly used in this situation, as access is easier and faster with few complications. Few cases of catheter fracture and migration have been reported. We aim at reporting a case of 26-year-old woman who presented with bilateral venous femoral catheters fracture and migration. Both were successfully removed via bilateral groin exploration and venotomy. We recommend early removal in order to avert life-threatening complications.

Bilateral Femoral Neck Fractures in A Young Patient Suffering from Hypophosphatasia, Due to A First Time Epileptic Seizure.

Introduction:We report a case of an adolescent sustaining bilateral femoral neck fractures due to a first time epileptic seizure, as a result of expansion of his known syrinx.Case Report:A 19-year-old patient suffering from hypophosphatasia (HPP), Arnold-Chiari malformation, and a ventriculoperitoneal shunt sustained a trivial fall with profound pain and an inability to mobilize. Radiographs demonstrated a right-sided Garden-4 femoral neck and left-sided multi-fragmentary intracapsular/extracapsular fractures. The patient had previously suffered bilateral proximal femoral shaft fractures, treated with intramedullary unlocked nail fixation that was still in situ. Operative treatment with an exchange to Synthes Adolescent Lateral Recon nail was performed on the right with two Recon screws inserted into the femoral head. On the left, the existing Pedinail was preserved with an additional single screw inserted into the femoral head. In addition, 3 months of non-mobilization was required for adequate bone healing. After 1-year from time of injury, there is no avascular necrosis on radiographs and the patient is mobilizing pain-free.Conclusion:Patients with hypophosphatasia have delayed bone healing. We recommend surgical fixation with an intramedullary device and periods of non-mobilization until there is radiographical evidence of adequate bone healing.

The horror of wrong-site surgery continues: report of two cases in a regional trauma centre in Nigeria.

BackgroundWrong- site surgeries are iatrogenic errors encountered in the course of surgical patient management. Despite the ‘never do harm’ pledge in the ‘Hippocratic Oath’ drafted in 5th century BC, man is after all human, with this limitation manifesting in the physician’s art despite his best intention. Beyond the catastrophic consequences of wrong- site surgery on the patient and surgeon, and the opprobrium on the art of medicine, the incidents have come to be regarded as a quality-of-care indicator. Orthopaedic surgery is a specialty with a preponderance of this phenomenon and the attendant medico-legal issues relating to malpractice claims. Consequently the specialty had pioneered institutional initiatives at preventing these ‘friendly-fires’. Awareness and implementation of these initiatives however remain low in many parts of the world, hampered by a culture of denial and shame.Case presentationThis report presents two cases of wrong-site surgery following trauma from road-traffic accident. The first case was a closed reduction of the ‘wrong’ dislocated hip in the trauma/emergency unit under the care of senior residents, while the second case was attempted wrong-site surgery on the right leg in a patient with fracture of the left tibia, in conjunction with bilateral femoral fracture and right radio-ulnar fracture; by an experienced Chief Consultant Orthopaedic Surgeon operating elective list. Both are orthopaedic cases, each with some trauma to both lower extremeties. Neither of the cases was formally mentioned anywhere in clinical discourse in the hospital, much less a formal report or audit.ConclusionThere was no formal, institutionalized process to prevent wrong-site surgery in the health institution and this could have been largely responsible for these incidents. An open, mandatory process of reporting such incidents for relevant audit and awareness is necessary, as a mechanism for prevention rather than blame or punishment.

Surgical treatment of bilateral distal femoral Salter-Harris type I fractures in a juvenile southern hairy-nosed wombat

We report a case of a 13-month-old 7.5 kg male hand-raised orphaned southern hairy-nosed wombat that presented with progressive hindlimb lameness and reluctance to move. Radiographs revealed bilateral distal femoral...

Atypical Bilateral Femur Fractures in a Long-Term Bisphosphonate Therapy: A Case Report

Atypical Femur Fractures (AFF) are associated with Bisphosphonate Osteoporosis Therapy. Bisphosphonate therapy is widely used as the Gold-Standard Therapy for Osteoporosis: it increases bone density and reduce the risk of vertebral, non-vertebral and hip fractures. However, long-term alendronic acid administration can causes severely suppressed bone turnover and finally non-traumatic stress fractures. Here we present a case of Non-Traumatic stress fractures of bilateral femoral shafts in a Long-Term Alendronic Acid Therapy.

Prothrombin Complex Concentrate in Combination with Fibrinogen Plus Tranexamic Acid Is More Effective Than Mono-Therapy with Prothrombin Complex Concentrate in a Dabigatran Anticoagulation Experimental Polytrauma Model

Background: Urgent surgery or life-threatening bleeding requires prompt reversal of the anticoagulant effects of the direct thrombin inhibitor dabigatran. As no specific reversal agent in situations of life-threatening bleeding with dabigatran is currently available, this study assessed the ability of a four-factor prothrombin complex concentrate (PCC) as mono-therapy as well as PCC in combination with tranexamic acid (TX) and fibrinogen in an experimental polytrauma pig model.Methods: After ethical approval dabigatran etexilate (30 mg/kg p.o. twice daily, n=24) was administered to male pigs for 3 days. On day 4, the pigs were anesthetized and given a 90 min infusion of active dabigatran to achieve consistent, supratherapeutic plasma levels. A standardized polytrauma including bilateral femur fractures and a blunt liver injury was induced. Animals underwent hemorrhagic shock and were resuscitated using Ringer’s solution (1 L). Twelve min after polytrauma, animals received either placebo (control group, n=6); TX, 20 mg/kg plus fibrinogen (80 mg/kg; TX+F group, n=6); PCC alone (PCC group, 50 U/kg, n=6); or TX (20 mg/kg) plus fibrinogen (80 mg/kg) plus PCC (50 U/kg; TX+F+PCC group, n=6) according to randomized group allocation. Coagulation was assessed by thromboelastometry, coagulation parameters and diluted TT. Blood loss (BL) was measured over the observation period of 240 min. Data were analyzed by ANOVA (± SD).Results: Dabigatran levels were 504 ± 171 ng/mL prior to injury and plasma levels remained significantly elevated in all animals throughout the observation period. The degree of injury was similar among animals with comparable BL of 803 ± 46 mL 12 min post injury. Anticoagulation with dabigatran without intervention resulted in a total BL of 3521 ± 600 mL, with 100% mortality and mean survival time of 101 ± 34 min (range: 67 - 148 min; p<0.05 vs PCC-treated groups). In contrast, treatment with 50 U/kg PCC (1712 ± 147 mL) resulted in a significant reduction in BL (p<0.05 vs. controls, TX+F group) and 100% survival. Blood loss was further reduced by adding TX and F with PCC (TX+F+PCC group: 1234 ± 215 mL, p<0.05 vs. all groups). In contrast total BL in animals treated with only TX plus F was 3601 ± 410 mL and comparable to control animals receiving only dabigatran, mortality was 100%, although the onset of bleeding was slightly reduced. Likewise, coagulation parameters improved substantially in animals from PCC and TX+F+PCC groups. Despite a significant increase of fibrinogen after substitution (196 ± 22 mg/dL) in the TX+F group, only moderate effects were measured on coagulation parameters including clot strength and kinetics of clot formation. Clinically and macroscopically no adverse events were observed.Conclusions: This study shows that bleeding in a lethal trauma model can be reduced with mono-therapy using a four-factor PCC. Prior correction of hypofibrinogenanemia with fibrinogen concentrate and tranexamic acid further improves PCC efficacy. Although the effects of PCCs on dabigatran reversal are not well understood, one possible explanation is that by elevating thrombin concentrations through PCC administration, (i.e. PCCs contain prothrombin) this may competitively bind to dabigatran, thereby reducing its anti-thrombin anticoagulant activity. This hypothesis is supported by the lack of effect on blood loss by mono-therapy with TX plus fibrinogen in this study. DisclosuresGrottke:Boehringer Ingelheim: Consultancy, Research Funding; CSL Behring: Research Funding. Honickel:Boehringer Ingelheim: Travel support Other. Spronk:Boehringer Ingelheim: Research Funding. van Ryn:Boehringer Ingelheim Pharma: Employment. Rossaint:CSL Behring: Honoraria.

Abstract 18544: Bloods Loss in Dabigatran Anticoagulated Pigs With Polytrauma is Significantly Reduced by Early Therapy With Activated and Non-activated Prothrombin Complex Concentrates

Introduction: The reversal of the new oral anticoagulants in severely bleeding patients with prothrombin complex concentrates remains uncertain with conflicting evidence. This study assessed the ability of a four-factor PCC and activated PCC (aPCC) to reverse dabigatran anticoagulation in a porcine polytrauma model. Methods: After ethical approval, male pigs (n=30) were given dabigatran etexilate for 3 days (30 mg/kg bid PO), the sham group (n=6) received placebo. To accomplish supratherapeutic anticoagulation, dabigatran was infused for 90 min (30 min: 0.77 mg/kg/h; 60 min 0.52 mg/kg/min) prior to injury on day 4 in anaesthetized pigs. A standardized blunt liver injury and bilateral femur fractures were induced. Following hemorrhagic shock, resuscitation was started 5 min after trauma and blood loss (BL) was recorded 12 min post trauma. Randomized animals (n=6/group) received a single injection of PCC or aPCC (25 and 50 IU/kg), or vehicle (control). BL and hemodynamic variables were monitored over 5 h or until time of death. Data were analyzed by ANOVA (± SD). Results: After infusion and prior to injury dabigatran levels were 559 ± 36 ng/mL and remained elevated throughout. In contrast to sham animals (BL: 601 ± 137 mL), BL in in all anticoagulated animals was significantly elevated 12 min post injury (BL : 791 ± 54 mL). Anticoagulation with dabigatran without PCC therapy resulted in a total BL of 3774 ± 628 mL) with 100% mortality (survival time: 65-146 min; p&lt;0.05 vs PCC/aPCC 50 IU/kg treated animals). Although the onset of bleeding was reduced in animals receiving 25 IU/kg PCC or aPCC, total BL (PCC: 3679 ± 782 mL; aPCC: 3638 ± 474 mL) was similar to control animals. In contrast, application of 50 IU/kg PCC (1767 ± 135 mL) or aPCC (1647 ± 302 mL) showed a significant reduction in total BL with 100% survival. Conclusions: This porcine model demonstrates that high doses of PCC and aPCC application of PCC may be a reasonable intervention for dabigatran-treated patients with life-threatening haemorrhage, though these data need clinical confirmation.

Are bilateral tibial shaft fractures associated with an increased risk for adverse outcome?

IntroductionLong bone fractures are assumed to be an independent risk factor for systemic complications and death after trauma. Multiple studies have identified an increased risk for mortality and morbidity in patients with bilateral femoral fractures. Data about bilateral tibial shaft fractures is rare. The aim of our study was to analyze if patients with bilateral tibial shaft fractures are at higher risk for systemic complications. MethodsWe performed a retrospective analysis of the TraumaRegister DGU® from 1993 to 2008. Inclusion criteria were unilateral or bilateral tibial shaft fractures and an age ≥16. Additionally to the overall collective we analyzed different subgroups (divided into different injury severities and treatment periods). Results1899 patients with unilateral and 175 patients with bilateral tibial shaft fractures were included. Age, gender and mean ISS (25.8 vs. 26.2, p=0.51) in the two groups were comparable. Regarding the entire study population, patients with bilateral tibial shaft fractures showed no significant higher incidence of respiratory organ failure (29.5% vs. 23.1%, p=0.076) or mortality (20.0% vs. 16.3%, p=0.203). However, subgroup analysis showed a significant higher rate of pulmonary organ failure for bilateral tibial shaft fractures as compared to unilateral tibial shaft fractures in the group ISS<25 (20.7% vs. 11.7%, p=0.023). Multivariate regression analysis identified the additional tibial shaft fracture as an independent risk factor for pulmonary organ failure (OR=1.56) but not for mortality. DiscussionThe additional tibial shaft fracture is an independent risk factor for pulmonary organ failure but not for multiple organ failure or mortality. The impact of the additional tibial shaft fracture is especially pronounced in less severely injured patients (ISS<25). These findings are comparable to results of bilateral femoral fracture studies and we therefore suggest to treat patients with bilateral tibial shaft fractures with the same caution as those with bilateral femoral fractures.

Early clinical protocols for traumatic bilateral femoral shaft fracture

Objective To investigate the mechanism,injury characteristics,and early interventions of bilateral femoral shaft fracture.Methods Twenty-five cases of bilateral femoral shaft fracture treated between December 2009 and June 2012 were enrolled in the study.Eighteen patients were males and 7 were females with mean age of 31.2 years (range,17-40 years).Nineteen cases were injured due to traffic accidents and 6 due to the hit by heavy objects.There were 47 sides with closed fracture and 3 sides with open fracture.Intramedullary nailing was performed at 32 sides and plate fixation was used at 18 sides.ISS,blood routine,some blood biochemical items,blood or plasma use,and hospitalization days were measured.Results ISS was (14.6 ± 5.2) points.Preoperative readiness time and hospital stay were (10.1 ± 3.7) days and (28.9 ± 8.4) days respectively.After hospitalization,measured values were (3.0 ± 0.4) × l012/L for red blood cells,(86.0 ± 13.5) g/L for hemogIobin,(47.0 ± 10.6) g/L for total protein,(31.4 ± 6.5) g/L for albumin,(124.1 ± 95.1) U/L for aspartate aminotransferase,(114.2 ± 107.1) U/L for alanine aminotransferase,and (1 848.7 ± 1 044.8) U/L for creatine kinase with significant differences from the reference ranges (P ＜ 0.05 or 0.01).Amount of blood transfused for 23 cases was (1 444.4 t 726.5) ml and plasma transfused for 19 cases was (305.6 ± 98.3) ml before operation.Volume of intra-and post-operative blood transfusion was (2 005.7 ± 1 153.1) ml.Conclusions Stabilization of vital signs predominates the early treatment of bilateral femoral shaft fracture.After the condition is stable,intramedulary nailing or plating can be performed concurrently. Key words: Femoral fractures ; Fracture fixation, internal; Early diagnosis

English

Even though there are recent reports showing strong association between long term bisphosphonate therapy and atypical femoral shaft fractures, there are no well-defined guidelines regarding screening of these fractures and also regarding prevention of the same in a patient with bilateral sequential atypical femoral shaft fractures. We report our experience with two cases of bilateral, sequential, atypical femoral shaft fractures helpful in formulating guidelines for screening and management of these fractures. We also believe that prophylactic femoral intramedullary nailing with continuation of bisphosphonate therapy as a potential option for preventing the propagation of incomplete bilateral simultaneous/sequential atypical femoral shaft fractures into complete fracture.

Bilateral subtrochanteric femoral fractures in a previous alendronate-medicated patient: a case report

Bilateral subtrochanteric femoral fractures in a previous alendronate-medicated patient: a case report Jacob J Triplet,1 Timothy Hawkes,2 Sein Lwin2 1Nova Southeastern University, College of Osteopathic Medicine, Fort Lauderdale, FL, USA; 2Broward Health Medical Center, Orthopedic Surgery Residency Program, Fort Lauderdale, FL, USA Abstract: Bisphosphonate therapy is commonly employed in the management of osteoporosis. Several drug-associated adverse events are well established but are often not considered in patients who have discontinued therapy. Here, we present the case of a patient who sustained bilateral atypical subtrochanteric fractures 1 year after discontinuation of long-term bisphosphonate therapy. We discuss the prodromal clinical presentations and the importance of radiographic imaging to investigate impending fractures. The treatment of these fractures included the implementation of a drug holiday and the use of intramedullary nail stabilization. Keywords: bisphosphonate, femur, osteoporosis, prophylactic stabilization

Comparision of two kinds of intramedullary nail in fixing femoral fractures in goats

Objective Toestablish femoral fracture models in goats,and compare the effect of using carmulated interlocking intramedullary nail and intramedullary nail with tail wire.Methods 40 adult male goats were selected,and the bilateral posterior middle femoral fracture models were artificially established.Twenty goats were fixed with cannulated interlocking intramedullary nail (group A),and 20 with intramedullary nail with tail wire (group B).X-ray examination was done at 4th and 8th week postoperatively and the nails were removed after fractures were healed.All the operative data were recorded and analyzed statistically.Results All fractures were healed in about 8 weeks postoperatively.Implanting operative time was (37.9 ± 5.1) min,blood loss was (38.0 + 66.0) mL,intraoperative fluoroscopy time was (6.8 + 3.1) s,and removal operative time was (24.4 + 5.3) min,blood loss was (26.3 ± 7.8) mL in group B,which were significantly different from those in group A (P ＜ 0.05 for all).End cap falls in both groups had no significant differences (P ＞ 0.05).One goat in group B was died after the implanting operation.Conclusion Intramedullary nail with tail wire in fixing femoral fractures has the same effects as cannulated interlocking intramedullary nail,but it has many advantages,including shorter operative time,less blood loss and X-ray exposure,and simple steps. Key words: Goats; Femoral fracture; Intramedullary nail with tail wire; Cannulated interlocking intramedullary nail; Intramedullary nail removal operation

Dehydroepiandrosterone modulates the inflammatory response in a bilateral femoral shaft fracture model.

BackgroundDehydroepiandrosterone (DHEA) has been shown to have immunomodulatory effects after hemorrhage and sepsis. The present study analyzes whether DHEA is also involved in the mediation of inflammatory stimuli induced by bilateral femoral shaft fracture.MethodsMale C57/BL6 mice (6 per group) were subjected to closed bilateral femoral shaft fracture with intramedullary nailing followed by administration of either 25 mg/kg/24 h DHEA diluted in saline with 0.1% ethanol or saline with 0.1% ethanol. The sham group was treated by isolated intramedullary nailing without fracture. Animals were sacrificed after 6, 24, or 72 h. Serum TNFα, IL-1β, IL-6, IL-10, MCP-1, and KC concentrations were measured by Bio-Plex ProTm analysis. Acute pulmonary inflammation was assessed by histology, pulmonary myeloperoxidase (MPO) activity, and pulmonary IL-6 concentration.ResultsDHEA was associated with a decrease in the systemic inflammatory response induced by bilateral femoral fracture, especially systemic IL-6 (322.2 vs. 62.5 pg/mL; P = 0.01), IL-1β (1,422.6 vs. 754.1 pg/mL; P = 0.05), and MCP-1 (219.4 vs. 44.1 pg/mL; P >0.01) levels. No changes in pulmonary inflammation were measured.ConclusionWe conclude that DHEA may be a treatment option to reduce systemic inflammation following musculoskeletal injuries although the pulmonary inflammatory reaction was not affected.