Open Femoral Fractures Research Articles

Early Definitive Fixation of an Open Periprosthetic Femur Fracture in the Polytraumatized Patient: A Case Report and Review of the Literature.

Introduction:Periprosthetic fractures of the femur after total hip arthroplasty are increasing in frequency. In the polytraumatized patient with long-bone fracture, an ongoing debate exists regarding early definitive stabilization versus initial damage control orthopaedics, followed by delayed fixation. It remains to be seen whether this rationale applies to the polytraumatized patient with periprosthetic fracture.Case presentation:We present the case of a 73-years old Caucasian woman who sustained bilateral Gustillo-Anderson grade III open femur fractures; the fracture on the right was a Vancouver C open periprosthetic fracture after cemented total hip arthroplasty. After massive fluid resuscitation in the trauma bay she was taken to the intensive care unit in a hemodynamically unstable condition. She was subsequently operated and underwent early definitive fixation of both femurs with the rationale of potentially reducing pulmonary complications and promoting early mobilization.Conclusion:Early definitive stabilization versus delayed fixation in the polytraumatized patient with an open periprosthetic femur fracture is reviewed. Although several treatment algorithms based on fracture classification and implant stability exist, further study is required to delineate the preferred method and timeline of fixation for this growing cohort of patients.

The iTClamp in the management of prehospital haemorrhage

IntroductionBleeding remains a leading cause of death in trauma patients. The iTClamp is a temporary wound closure device designed to control external bleeding within seconds of injury. We describe our experience using this device on 10 patients in the prehospital environment. MethodsWe have implemented the iTClamp for prehospital use through our physician-staffed helicopter emergency medical service (HEMS). Indications were massive bleeding that could not be controlled with an ordinary compressive bandage or a haemostatic bandage. ResultsTen patients were treated with the iTClamp. Seven patients had a severe head injury due to various traumas, one patient had a neck injury from a disk cutter, one patient had an open chest wound and one patient had an open femur fracture. After applying the iTClamp, bleeding was controlled in 90% of these patients (n=9), with complete cessation reported in 60% (n=6), partial cessation with adequate control reported in 30% (n=3); in one patient, the bleeding could not be controlled with the iTClamp alone. It took an average of 10s to apply the iTClamp, and the average usage satisfaction score was 7.7. ConclusionWe conclude that the iTClamp is a safe, fast and useful tool for stopping or controlling external blood loss in our series of prehospital patients. Further studies of the iTClamp are needed to determine which patients might benefit from this device.

Can Normal Fracture Healing Be Achieved When the Implant Is Retained on the Basis of Infection? An Experimental Animal Model.

Infection after open fractures is a common complication. Treatment options for infections developed after intramedullary nailing surgery remain a topic of controversy. We therefore used a rat fracture model to evaluate the effects of infection on osseous union when the implant was maintained. In a rat model, (1) does infection alter callus strength; (2) does infection alter the radiographic appearance of callus; and (3) does infection alter the histological properties of callus? An open femoral fracture was created and fixed with an intramedullary Kirschner wire in 72 adult male Sprague-Dawley rats, which were divided into two study groups. In the infection group, the fracture site was contaminated with Staphylococcus aureus (36 animals), whereas in the control group, there was no bacterial contamination (36 animals). No antibiotics were used either for prophylaxis or for treatment. We performed biomechanical (maximum torque causing failure and stiffness), radiographic (Lane and Sandhu scoring for callus formation), and histologic (scoring for callus maturity) assessments at 3 and 6 weeks. The number of bacteria colonies on the femur, wire, and soft tissue inside knee were compared to validate that we successfully created an infection model. The number of bacteria colonies in the soft tissue inside the knee was higher in the infection group after 6 weeks than after the third week, demonstrating the presence of locally aggressive infection. Infection decreased callus strength at 6 weeks. Torque to failure (299.07 ± 65.53 Nmm versus 107.20 ± 88.81, mean difference with 95% confidence interval, 192 [43-340]; p = 0.007) and stiffness at 6 weeks (11.28 ± 2.67 Nmm versus 2.03 ± 1.68, mean difference with 95% confidence interval, 9 [3-16]; p = 0.004) both were greater in the control group than in the group with infection. Radiographic analysis at 6 weeks demonstrated the fracture line was less distinct (Lane and Sandhu score of 2-3) in the infection group and complete union was observed (Lane and Sandhu score of 3-4) in the control group (p = 0.001). Semiquantitative histology scores were not different between the noninfected controls and the rats with infection (score 10 versus 9). Retaining an implant in the presence of an underlying infection without antibiotic treatment leads to weaker callus and impedes callus maturation compared with noninfected controls in a rat model. Future studies might evaluate whether antibiotic treatment would modify this result. This model sets the stage for further investigations that might study the influence of different interventions on fracture healing in implant-associated osteomyelitis. Future observational studies might also evaluate the histological properties of callus in patients with osteomyelitis.

Efficacy of different irrigation solutions on the early debridement of open fracture in rats.

Contaminating bacteria are only found on wound surfaces in the initial stages of open fractures; therefore, effective debridement is critical for bacterial infection prevention and the reduction of inflammatory reactions. Various irrigation solutions are currently being used; however, a comprehensive study on their efficacy is lacking. In the present study, a comparison of the effects of normal saline, iodophor and hydrogen peroxide as the irrigation solutions for debridement of open femur fractures in rat models was conducted. It was revealed that all three solutions were comparably effective in bacterial removal while normal saline was superior in minimizing adverse wound inflammation; therefore, the use of normal saline for routine debridement is recommended in the early-stage treatment of open fractures in the trauma clinic and in relief fieldwork.

Assessment of racial and sex disparities in open femoral fractures

BackgroundOpen femoral fractures are common; however, many factors may affect treatment protocol. We aim to assess any racial/ethnic or sex disparities associated with the definitive fixation of open femoral fractures. MethodsICD-9 codes from the National Trauma Data Bank (2007 to 2010) for patients greater than or equal to 18 years with open femoral fractures who underwent operative management at level I or II trauma centers were identified and analyzed. ResultsOf the 9,406 cases, the majority were White (61%), men (73%), and aged between 25 and 44 years (41%). The odds of definitive fixation after hospital day 2 (odds ratio [OR] .96, 95% confidence interval [CI] .82 to 1.09, P = .53) or any complication (OR .96, 95% CI .79 to 1.15, P = .69) were not associated with race/ethnicity. Men were 17% less likely to have surgery after hospital day 2 (OR .83, 95% CI .78 to .96, P < .001), and 18% more likely to have a complication (OR 1.18, 95% CI 1.03 to 1.35, P = .02). ConclusionsThere are no racial/ethnic disparities associated with the timing of definitive fixation. Men are more likely to undergo fixation earlier than women; however, they are more likely to have a complication. Fixation within the first 2 hospital days may decrease complications.

Stimulation of Bone Tissue Reparative Regeneration by Implants with Bioactive Coating for Diaphyseal Fractures

The open fracture of femur has been experimentally modeled on dogs. A comparative analysis of the consolidation process under the osteosynthesis with the Ilizarov apparatus (the first group of animals) and the combination of osteosynthesis with the Ilizarov apparatus and intramedullary reinforcement with hydroxyapatite-coated wires (the second group of animals) has been carried out. Fracture consolidation in the second group has been confirmed morphologically in 2-3 weeks without signs of fibrous and cartilaginous tissue. In case of osteosynthesis with the Ilizarov apparatus only, the process of reparative regeneration was slowed down.

FEIBA™ for Patients on Direct Oral Anticoagulants Requiring Urgent Surgery

Introduction: A recent Canadian population based review showed a rapid increase in use of direct oral anticoagulants (DOACs) for prevention of systemic embolism in patients with atrial fibrillation (AF) (Xu et al.). These drugs offer advantages over traditional vitamin K antagonists (VKA) including fixed dosing regimens and elimination of laboratory monitoring. In Canada, patients receiving VKA requiring urgent surgery are reversed with prothrombin complex concentrates (PCC) with or without vitamin K. DOAC specific antidotes are under development and use of PCCs or activated PCC for the purposes of DOAC reversal for emergent procedures is controversial. We describe the use of activated PCC (FEIBA™) in patients receiving the DOACs (dabigatran, apixaban, or rivaroxaban) who required urgent surgical intervention.Methods: A retrospective review of patients receiving DOACs and requiring urgent reversal of anticoagulation effect for procedures or surgery at The Ottawa Hospital between January 2013 and June 2014 are included. Major bleeding was defined using the ISTH criteria (Schulman et al.). The primary outcome was major bleeding peri-operatively and secondary outcome was adverse embolic and thrombotic events during follow up.Results: Five patients were identified: two patients were on rivaroxaban, two were on apixaban, and one was on dabigatran. Baseline characteristics are shown in Table 1. One patient was on rivaroxaban for secondary prevention of venous thromboembolism (VTE), while the remaining patients had AF. Three patients required laparotomy for bowel obstruction; one patient required open femur fracture repair; and one patient required angiography and stent placement for ischemic bowel. A large majority of patients (80%) had received a dose of anticoagulant on the day of surgery. One patient required intra-operative blood transfusion. There were no embolic or thrombotic complications following FEIBA™ administration and all patients’ survived hospitalization.Conclusions: The use of FEIBA™ for reversal of DOAC effect for urgent surgery in this cohort of patients was effective and not associated with adverse thrombotic complications. Prospective studies evaluating use of potential benefits and harms of FEIBA™ for reversal of DOACs in patients requiring emergent surgery are needed.Abstract 4259. Table 1:Patients on DOACs Requiring Urgent ProcedurePatient (Age and Gender)Indication For DOAC [AF(CHADS2); VTE]DOAC and DosageSurgery/ ProcedureUnits of PRBCs TransfusedFEIBA™ Dose (IU)Adverse Events post-FEIBA™ administrationSurvived Hospitalization91 FemaleAF (4)Rivaroxaban 15 mg dailyFemur fracture ORIF3, intra-operatively1812--Yes50 MaleVTEApixaban 5 mg BIDLaparotomy for SBO01350--Yes50 FemaleAF (4)Apixaban 2.5 mg BIDAngiography + SMA stent for ischemic bowel03918--Yes77 MaleAF (2)Rivaroxaban 20 md dailyLaparotomy for incarcerated hernia/SBO03241Venous oozing intra-operativelyYes78 MaleAF (3)Dabigatran 110 mg BIDSBO/ Femoral hernia repair06000--YesAF = atrial fibrillation; BID = twice daily; CHADS = congestive heart failure, hypertension, age, diabetes, stroke; DOAC = direct oral anticoagulant; IU = international units; ORIF = open reduction internal fixation; PRBC = packed red blood cells; SBO = small bowel obstruction; SMA = superior mesenteric artery; VTE = venous thromboembolism

Sox11-modified mesenchymal stem cells (MSCs) accelerate bone fracture healing: Sox11 regulates differentiation and migration of MSCs.

Mesenchymal stem cells (MSCs) are a promising cell resource for tissue engineering. Sry-related high-mobility group box 11 (Sox11) plays critical roles in neural development and organogenesis. In the present study, we investigated the role of Sox11 in regulating trilineage differentiation (osteogenesis, adipogenesis, and chondrogenesis) and migration of MSCs, and explored the effect of systemically administrated Sox11-modified MSCs on bone fracture healing using the rat model of open femur fracture. Our results demonstrated that Sox11 overexpression increased the trilineage differentiation and migration of MSCs, as well as cell viability under oxidative stress. The effect of Sox11 on osteogenesis was confirmed by ectopic bone formation assay conducted in nude mice. In addition, we found that Sox11 could activate the bone morphogenetic protein (BMP)/Smad signaling pathway in MSCs. By dual-luciferase reporter assay, we also demonstrated that Sox11 could transcriptionally activate runt-related transcription factor 2 (Runx2) and CXC chemokine receptor-4 (CXCR4) expression. The activation of the BMP/Smad signaling pathway and Runx2, CXCR4 expression may have a synergic effect, which largely contributed to the effect of Sox11 on MSC fate determination and migration. Finally, using an open femur fracture model in rats, we found that a larger number of MSCs stably expressing Sox11 migrated to the fracture site and improved bone fracture healing. Taken together, our study shows that Sox11 is an important regulator of MSC differentiation and migration, and Sox11-modified MSCs may have clinical implication for accelerating bone fracture healing, which can reduce the delayed unions or nonunions.

Evacuation and care of servicemen with open femoral fractures in flanders (1914–1918)

The static trench warfare that emerged on the Flanders plain during 1914 departed from previous concepts of military confrontation owing to this terrain’s particular geology and climate. Unlike fuctuating battles in desert, the hilly and mountainous conditions, rich low-lying farm lands and frequent rainfall generated handicapping mud, churned up by thousands of soldiers, horses, military vehicles and shell-fire ( Figure 1 ).

Application of the First Expert Arthrodesis Nail to a Patient with Previous Performed Arthrodesis According to Ulrich Holz – Case Report

AIM: The aim of this paper was to present application of the first expert arthrodesis nail in our clinic to a patient with previous performed arthrodesis according to Ulrich Holz.CASE REPORT: Patients A.M. on the age of 22 (1992) have a motor vehicle injury, (fall from a motor bike) with diagnosis polytrauma, shock, supra and transcondyar open fracture of the right femur III degree, open fracture of the right tibia and fibula. We perform reposition and fixation of supra and transcondyar femoral fracture with “cobra” plate. Also we perform reposition and fixation of right cruris with external fixation. After the operation we found fistula in the place of operation of the right crural regia. During the time the infection goes worse and the patient develop osteomyelittis on the right crural regia. After 5 months with therapy the situation become calm. We remove the external fixation. The patient develops severe “pes equinus” on the right leg and he cannot walk. We try to reduce this equines situation with elongation of the Achilles tendonin the first step, and because we didn’t solve the problem we continue with complete section of the Achilles tendon and after that we perform osteotomy of the right talocrural joint simultaneous to tibia plafond and talus and resection of fibula 2sm.above the syndesmosae tibiofibularis and we fixed the talocrural joint with two screws according the technique of Ulrich Holz.CONCLUSION: So we received fixed position on of the food on 110 degrees which was steel unacceptable for normal walking. At last we remove the screws, make once again osteotomy with positioning of the food in maximal dorsiflexion and perform the Experf Hindfood arthrodesis nail so with this method we achieve correction of dorsiflexion on 95 degrees, and the patient become satisfied because he can walk without support.

Results of the treatment of the open femoral shaft fractures in children

BackgroundIntramedullary nailing has become the treatment of choice for closed femoral shaft fractures in children and adolescents. Immediate intramedullary nailing of open fractures of femur in children remains controversial, with most surgeons preferring to treat grade II or III open fractures either by debridement and traction or external fixation. The aimsThe aim of this study is to evaluate the results of intramedullary nailing of open femoral fractures in children. Methods172 children were treated for femoral shaft fracture in our department. 19 fractures were opened in 18 patients. ResultsIn children with polytrauma, multiple fractures, head injuries and other conditions which necessitate intensive nursing care, intramedullary nailing of opens femoral shaft fractures (type I, II, IIIA, IIIB) should be preferred. ConclusionSatisfactory results were obtained in all patients in terms of self evaluation of patients, radiological and clinical evaluation. The infection rate was much lower for patients who had been given a cephalosporin than for patient who had been given a penicillin or had been given no antibiotic.

Spatial cytokine distribution following traumatic injury

Temporal changes in cytokine concentrations following traumatic injuries have been extensively studied. Less is known regarding spatial differences in cytokine concentrations following traumatic injury. The primary aim of this study was to determine the spatial relationship between cytokines and the zone of injury (ZOI). Muscle and vessel tissues obtained from rats subjected to an open femoral fracture were analyzed to determine if spatial cytokine gradients exist that could potentially be used as biomarkers of the ZOI. Samples were collected at 4 time points following fracture from 3 distinct locations: at the fracture site, 1-cm away from the fracture, and from the opposite leg. The concentrations of IL-6, IL-1α, IL-1ß, IL-2, GM-CSF, TNF-α, and MIP-1α were quantified in each sample. Temporally and spatially regulated variations in cytokine concentrations were found. IL-6 showed the most promise as a ZOI biomarker with statistically different spatial concentrations that were inversely proportional to the distance from the fracture in both tissues. IL-1ß and IL-2 also showed spatial differences in concentration in both tissues, while GM-CSF, MIP-1α, and TNF-α showed spatial differences in vessel samples. These results demonstrate that spatial cytokine gradients exist following traumatic injury, representing potential biomarkers that may be used to define the ZOI.

Compartment Syndrome following Open Femoral Fracture with an Isolated Femoral Vein Injury Treated with Acute Repair.

Acute compartment syndrome is a surgical emergency and its diagnosis is more difficult in obtunded or insensate patients. We present the case of a 34-year-old woman who sustained a Gustilo-Anderson grade III open midshaft femur fracture with an isolated femoral vein injury treated with direct repair. She developed lower leg compartment syndrome at 48 hours postoperatively, necessitating fasciotomies. She was subsequently found to have a DVT in her femoral vein at the level of the repair and was started on therapeutic anticoagulation. This case highlights the importance of recognition of isolated venous injuries in a trauma setting as a risk factor for developing compartment syndrome.

Treatment of pediatric open femoral fractures with external fixator versus flexible intramedullary nails.

In children, inappropriate treatment of open femoral fractures may induce several complications. A few studies have compared the external fixator with flexible intramedullary nails in high-grade open femoral fractures of children. The present study aims at comparing results of these two treatment methods in open femoral fractures. In this descriptive analytical study, 27 patients with open femoral fractures, who were treated using either the external fixator (n=14) or TEN nails (n=13) method from 2006-2011, were studied. Some patients were treated with a combination method of TEN and pin. The results were evaluated considering infection, union, malunion, and refracture and the patients were followed up for two years. Mean time required for fracture union was 3.89 (range: 2-5.8) and 3.61 (range: 2-5.6) months for the external fixator and TEN groups, respectively. The difference was not statistically significant and there was not any significant difference between the two groups considering infection of the fractured area. Osteomyelitis was not observed in any group. There was an infection surrounding the external fixator pin in 4 cases (28.5%) and so this required changing the location of the pin. In the TEN group, one case (7.6%) of painful bursitis was observed at the entry point of TEN and so the pin was removed earlier than usual. There were two cases (14.2%) of femoral refracture in the external fixator group. Malunion requiring correction was not observed in any of the groups. There were no complications observed in five patients treated with a combined method of pin and flexible intramedullary nails. Both external fixator and intramedullary nail methods are effective ways in treating high grade open femoral fractures in children and final treatment results are similar. Combining pins and flexible intramedullary nails is effective in developing more stability and is not associated with more complications.

Thalidomide prolongs survival after experimental musculoskeletal injury, through an effect on mononuclear apoptosis

BackgroundThis study was conducted to investigate the effects of intravenous thalidomide administration in an experimental model of musculoskeletal trauma. We hypothesized that because thalidomide inhibits secretion of tumor necrosis factor alpha (TNF-α), survival of animals that received thalidomide would be significantly prolonged. Material and methodsAfter an open fracture of the right femur, 24 rabbits were randomly assigned to control and thalidomide groups. Intravenous therapy with thalidomide was started 30 min after fracture. Hemodynamic monitoring of all animals was performed for 4 h. Survival was recorded and bacterial growth in blood and organs was measured after animal death or sacrifice. Blood was sampled for TNF-α measurement and for isolation of peripheral blood mononuclear cells (PBMCs). Apoptosis of PBMCs was measured by flow cytometry. ResultsSurvival was significantly prolonged in the thalidomide group. Apoptosis of PBMCs was increased in the control group compared with the thalidomide group at 24 h. There were no differences in vital signs, blood and tissue cultures, and serum TNF-α concentration between the two groups. ConclusionsIntravenous thalidomide prolonged survival in an experimental model of severe musculoskeletal injury in rabbits. Its mechanism of action did not involve TNF-α suppression but prevention of mononuclear apoptosis. In view of these promising results, further research is needed to clarify the immunomodulatory mechanism of action of thalidomide and its potential use for the management of severe trauma.

Intraosseous Epidermoid Cyst in the Femur After an Open Fracture: A Case Report.

An intraosseous epidermoid cyst is a rare lesion usually arising from a phalanx in the hand or foot or from the skull1-5. To the best of our knowledge, only one case of an intraosseous epidermoid cyst involving the femur previously has been reported in the literature6. In this case report, we present the clinicopathological features of an intraosseous epidermoid cyst after an open fracture of the femur; we also review previous reports to discuss the etiology and treatment options for intraosseous epidermoid cysts. The patient was informed that data concerning the case would be submitted for publication, and he provided consent. A sixty-four-year-old man had sustained an open fracture of the right femur (Gustilo-Anderson grade IIIA) eleven years previously. After emergency debridement, he had been managed with intramedullary nailing and bone-grafting. After union of the fracture had been achieved, the clinical course was uneventful. Eleven years after the initial surgery for the fracture, the patient was seen at the local hospital with increasing pain in the right thigh. A radiograph showed an osteolytic lesion around the intramedullary nail in the epiphysis of the distal part of the right femur (Fig. 1). The intramedullary nail was extracted, and an open biopsy was performed. The biopsy specimen confirmed the diagnosis of an epidermoid cyst in the femur. An intralesional excision of the cyst was performed, and beta-tricalcium phosphate (β-TCP) (OSferion; Olympus, Tokyo, Japan) was implanted (Fig. 2). Fig. 1 Radiograph showing intramedullary nails and osteolysis in the epiphysis of the distal part of the femur. Fig. 2 Radiograph after the intralesional excision of the cyst and the implantation of β-TCP. Seven months after the second surgery, pain in the right thigh returned. On physical examination, diffuse swelling and heat (calor) were found in the distal aspect of the right …

Hyperbaric Hyperoxia Accelerates Fracture Healing in Mice

Increased oxygen tension influences bone metabolism. This study comprised two main experiments: one aimed to determine the bone mineral apposition and bone formation rates in vivo under hyperbaric hyperoxia (HBO), and the other aimed to evaluate the effects of exposure to HBO on fracture healing. In experiment 1, male mice were exposed to HBO [90 min/day at 90% O2 at 2 atmospheres absolute (ATA) for 5 days]. In experiment 2, an open femur fracture model was created in mice, followed by exposure to HBO 5 times/week (90 min/day at 90% O2 at 2 ATA) for 6 weeks after surgery. In experiment 1, HBO treatment significantly increased the mineral apposition and bone formation rates in the lumbar vertebra and femur and type 1 collagen alpha 1 and alkaline phosphatase mRNA expression in the lumbar vertebra. In experiment 2, at 2 weeks after fracture, the fracture callus was significantly larger in the HBO group than in the non-HBO group. Furthermore, at 4 and 6 weeks after fracture, radiographic findings showed accelerated fracture healing in the HBO group. At 6 weeks after fracture, femur stiffness and maximum load were significantly higher in the HBO group than in the non-HBO group. Urinary 8-hydroxy-2′-deoxyguanosine and plasma calcium concentrations were not significantly different between groups. These results suggest that exposure to HBO enhances bone anabolism and accelerates fracture healing without causing oxidative DNA damage or disruption of plasma calcium homeostasis.

Incidence and analysis of open fractures of the midshaft and distal femur

The purpose of this study was to determine whether different forms of stabilization for open femur fractures can be performed without influencing outcome, in particular infection and delayed unions/nonunions. Although the traditional management of these injuries is external fixation, a trend toward definitive stabilization techniques has evolved in the current literature. All open fractures of the femur shaft and the distal femur presenting to our urban Level I trauma center during a 10 year period were reviewed. A total of 40 patients (41 fractures) were initially treated at the above institution within 6 h of injury. All patients underwent emergent wound irrigation, debridement, and antibiothic theraphy. The method of fracture immobilization was left to the discretion of the attending trauma surgent. Study population consited of 12 (29 %) GI, 10 (25 %) GII, and 19 (46 %) GIII fractures. Initially, fracture management was performed with external fixation (EF) 19 (43.2 %), intramedullary nailing (IM) 18 (38.6 %), plating (PL) 3 (6.8 %), screw fixation (SF) 1 (2.3 %) and without treatment 4 (9.1 %). In all, 3 (6.8 %) fractures were complicated by infection, 7 (15.9 %) had implant failure, and 5 (11.4 %) developed delayed union. Using external fixation in acute fracture treatment for open femur fractures is a safe and effective surgical technique. Based on our results, external fixation might be superior to intramedullary nailing or plating when evaluating outcome parameters and complications.

F4.1 Intramedullary nailing of Grade II and Grade III open diaphyseal femoral and tibial fractures

between 3 and 11 cm proximal to the plafond. Eighteen patients were treated with closed IMN (Group I) and 28 patients were treated with PLP fixation (Group II). Patients with at least 1-year follow-up were included. The mean age was 40.5 (range:16–70) years; 78% of the patients were men. The rates of union, malunion, malalignment (defined as >5 degrees of angulation in any plane), infection, and removal of implants were compared according to final outcomes. The average followup period was twenty eight months. Twenty-one fractures (27%) were open. Results: The age and gender were similar in both groups. None of the patients had deep infection. Two patients (7%) had nonunion in Group II. Two patients treated with IMN, compared with three patients treatedwith PLP, had amalalignment. Significant differences were found with regard to union time between the two groups (p <0.05). The average union times were 16 weeks in Group I and 19 weeks in Group II. Conclusion: For earlier union time compared to PLP, we advise considering the use of IMN for extra-articular fractures in the distal third of the tibia.

Eighteen-year follow-up after rotationplasty for a grade IIIC open fracture of the distal femur

We report the 18-year follow-up of a patient who underwent rotationplasty for severe bone loss and infection after an grade IIIC open fracture of the distal femur. The patient is now 49years old and fully satisfied with his life. During the follow-up period, he has never had significant physical or psychological problems directly concerning the rotationplasty. The analysis of quality of life using the SF36 questionnaire revealed even higher scores than the normal healthy population in seven out of eight sub-categories. Clinical examination revealed bland soft tissues without hyperkeratosis or other signs of maladaptation. Articular and cutaneous proprioception was intact all over the left leg. The active extension/flexion of the prosthetic knee was 0°-0°-100° and 10°-0°-70° of the ankle joint. Manual testing of motor strength revealed grade five of five for dorsiflexion and plantar flexion of the ankle. Gait patterns including climbing slopes and stairs were close to normal. Examination in sports physiology showed lower maximum power of hip and knee muscles compared to the healthy side, but better muscular endurance. These findings emphasize that rotationplasty can be a good alternative to arthrodesis or amputation in trauma patients providing high satisfaction and activity levels in the long-term follow-up.