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Introduction: Bilateral bifocal femur fractures occur as a result of high-velocity trauma mainly road traffic accidents with dashboard injuries or fall from height. These fractures can result in high morbidity or mortality as they are usually presented with hypovolemic shock or fatal fat embolism syndrome. Case Report: We present a 47-year-old male with a history of fall from 35 feet. He sustained a symmetrical intertrochanteric femur fracture with a diaphyseal femur fracture with a bilateral patella fracture. There was no evidence of any head injury or spinal fracture. The patient reached the emergency room in hypotension and was maintaining saturation on room air. The patient was admitted to the intensive care unit; hypotension was corrected overnight and was operated on after 24 h with bilateral intramedullary long proximal femoral nail and tension band wiring for the bilateral patella fractures. At 1-year follow-up, he was able to do his daily activities with minimal limitation. Conclusion: Bilateral bifocal femur fractures result from a high-velocity trauma. In such injuries, careful evaluation of all the systems should be performed to find out concomitant injuries. Single-staged surgical intervention decreases the morbidities of the subsequent surgeries, helps in a rehabilitation hospital stay as well as financially suitable for the patient.

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Background Although subarachnoid block (SAB) is the most popular regional anesthesia (RA) technique for fixation of femur fractures, continuous lumbar epidural (CLE) anesthesia, and lumbosacral plexus blocks (LSPB) are also employed in specific situations. The choice of RA technique depends on either the choice of the anesthesiologist or based on the underlying comorbidities. At our institute, we anesthetize elderly patients who come for fixation of femur fracture with multiple comorbidities using RA techniques as mentioned based on comorbidities and overall general condition.  Methods In a cohort of 184 elderly patients, we analyzed RA techniques employed over a period of five years in elderly patients admitted with fractures of the proximal femur, its hemodynamic implications and thus attempted to find the suitable RA technique with minimal adverse events after ethics committee approval. We also compared the length of stay in the hospital in relation to RA techniques. Results The demographic data was comparable with no significant difference in administering the three RA techniques. SAB, CLE and LSPB was implemented at 33.33%, 35.96%, and 30.7% respectively. Perioperative noradrenaline infusion was a feature in patients who received SAB (p<0/001). The higher number of CLE and LSPB patients had a length of stay of fewer than 48 hours whereas most SAB patients had a length of stay of more than 48 hrs (p<0.001). Conclusion Elderly patients with multiple comorbidities should be offered CLE instead of SAB so as to maintain stable hemodynamics. RA technique in an elderly patient with multiple comorbidities should be standardized so as to provide uneventful surgical anesthesia.

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INTRODUCTION: Segmental tibia fractures with extensive soft tissue injuries are rare and surgical intervention is challenging with no definitive treatment strategies. CASE REPORT: A 52-year-old man presented with closed right segmental tibia and fibula fracture with extensive blistering of skin caused due to road traffic accident. Distal pulses were palpable and there were no signs of compartment syndrome and other systemic injuries. In the presence of extensive blistering, a monoplanar external fixator was applied within 24 h of injury. 3 weeks later, skin condition was conducive for internal fixation, and closed intramedullary multi-locking nailing was performed using the external fixator for reduction. Fracture healed at 15 months and patient had an excellent functional outcome with full knee range of motion at 2-years follow-up without any complications. CONCLUSION: Fixator-assisted nailing is a simple, minimally invasive, and easily reproducible technique that is useful in reducing the fracture and preventing axial rotation of the intercalary segment minimizing the damage to the periosteal blood supply. Our case also highlights the importance of temporary external fixator in soft tissue healing and making the skin conducive for internal fixation.

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INTRODUCTION: Atypical femoral fractures (AFFs) have an unpredictable healing process leading to higher complication rates. The literature describes various treatment modalities of non-unions in AFF. We aimed to report a case of non-union with AFF and successful union with exchange K-nailing and augmented plating techniques. CASE REPORT: A 75-year-old lady with 5 years of bisphosphonate intake sustained an AFF at the mid-diaphyseal level after a trivial injury which was fixed with closed intramedullary nailing. Nine months after fixation, she developed refracture at the fracture site with segmental breakage of the nail suggesting non-union. This was managed by the removal of fibrous structures at the fracture site, removal of a broken nail, exchange K-nailing, augmented plating, and iliac crest bone grafting. The fracture healed at 15 months from the injury and achieved good functional outcome at a short-term follow-up of 1 year. CONCLUSION: Our case report highlights the challenges of treating diaphyseal AFF and the combined benefit of exchange nailing and augmented plating with bone grafting in treating AFFs with non-union.

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INTRODUCTION: Atypical femoral fractures(AFF) are rare. To get more knowledge, these cases are being reported at an increasing rate in recent literature. Surgical treatment in these fractures is controversial. CASE REPORT: A 73-year-old lady, known rheumatoid and osteoporotic with a history of long-term bisphosphonate intake, presented with sudden onset right thigh pain after trivial trauma. We diagnosed a complete atypical femoral fracture, treated with closed intramedullary nailing. 4 months later, she presented with dull aching left thigh pain for 2 weeks. Radiographic features suggested an incomplete atypical femoral fracture, treated with prophylactic insitu intramedullary nailing. At 1 year follow-up, lady was walking well with stick support. CONCLUSION: Our case highlights two important points. Intramedullary nailing is a minimally invasive treatment option for incomplete and complete AFF. We should have a high index of suspicion in diagnosing and recognizing warning signs of incomplete fractures such as prodromal thigh pain and isolated focal lateral cortical thickening, thereby preventing further progression and treatment with prophylactic nailing at an early stage.

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BACKGROUND: Emergency laparoscopy/laparotomy is associated with high levels of mortality. The aim of this study was to determine whether outcomes following emergency laparoscopy/laparotomy in rural and regional South Australian hospitals were comparable to those reported in the National Emergency Laparotomy Audit and Perth Emergency Laparotomy Audit. METHODS: A prospective multicentre audit of patients who undergo emergency laparoscopy/laparotomy. Participating hospitals included Mount Gambier and Districts Health Service, Whyalla Hospital and Riverland General Hospital. Inclusion and exclusion criteria were identical to the National Emergency Laparotomy Audit. A modified dataset for patients was collected if patients were up-transferred to another hospital prior to operative management. Data collected included patient demographics, operative management, adherence to processes of care and outcomes. RESULTS: Data were collected for a total of 58 cases. Fifty-one of these had emergency laparoscopy/laparotomy in a rural or regional hospital and seven were transferred in the preoperative period. The median Portsmouth-Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity predicted 30-day post-operative mortality was 3.5%. One hundred percent of patients (51 out of 51) had a consultant anaesthetist and surgeon present in the operating theatre. There were no deaths reported within the 30-day post-operative period. CONCLUSION: Outcomes following emergency laparoscopy/laparotomy in rural and regional South Australian hospitals are comparable to those reported in the National Emergency Laparotomy Audit and Perth Emergency Laparotomy Audit.

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BACKGROUND: Femoral diaphyseal non-unions present difficult scenario to manage. There are multiple options but most of them still report varying incidences of failure. We combined the principles of augmented plating and exchange nailing and aim to study the effectiveness of this technique. METHOD: A retrospective study at a tertiary trauma centre was conducted. Seventy patients (60 men, 10 women), average age 40.7±15.27 years (range 18-81 years) with diaphyseal femoral fracture non-unions treated between July 2010 and January 2015 were reviewed. The average interval between first and the last surgery was 18.07±17.65 months (range 4-96 months). Forty six patients had hypertrophic non-union and 24 patients had atrophic non-union. Twenty one patients had undergone a prior surgery for non-union, 13 dynamisation, 4 bone grafting, 1 augmented plating and 3 exchange nailing. Non-unions were treated with implant removal, freshening of bone edges and exchange K-nailing and augmented plating. Autologous bone grafting and raising of osteoperiosteal flaps was done in all cases. Outcome measures were radiographic evidence of fracture union at minimum three out of four cortices, knee range of motion as compared to opposite knee, and study of complications. RESULTS: All patients demonstrated radiographic evidence of fracture union with an average time of 16.77±2.38 weeks (range 12-26 weeks). Mean knee range of motion of unaffected limb was 126±9.76° (range 90-140°) while in operated limb it was 121.1±11.36° (range 80-140°), p>0.01. Patients with hypertrophic non-unions, prior surgery for non-union and supra- or infra-isthmal non-unions had shorter union time. Two patients had superficial infection which was managed by superficial debridement and two patients had pain at proximal nail tip site which was managed by anti-inflammatory medication. None of the patients required additional surgery for implant removal. CONCLUSION: Exchange K nailing with Bone graft and additional plating technique for non-union diaphyseal femur fracture achieved good union rates with minimal complication. In our series none of the patient required revision and the technique probably will further minimise the revision rates compared to current options for non-union femur.

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BACKGROUND: Infected non-union is complex and debilitating disorder affecting orthopaedic surgeon and patient in terms of cost and time. Many methods are described in the literature for treatment of infected non-union. Local high concentration of antibiotic and mechanical stability of antibiotic cement impregnated intramedullary nail (ACIIN) proves cost and time effective. Recently it was suggested that ACIIN can achieve both union and infection control in infected non-unions with bone gap less than 4cm. The aim of our study was to investigate this hypothesis and study the outcome of antibiotic cement impregnated intramedullary nail in term of both infection control and osseous union. MATERIALS AND METHODS: We retrospectively studied 21 patients with infected diaphyseal femoral non-union. Inclusion criteria were bone gap less than 4cm after debridement and more than 1 year follow-up of the case. ACIIN prepared using K nail was used as primary procedure after adequate debridement. Infection control and osseous union was judged on the basis of clinical, radiological and haematological parameters. All patients were followed up with an average follow-up of 20.23±3.65 months (range 14-28 months). RESULTS: Infection control was achieved in all 21 patients at end of 12 months follow-up, out of which 16 patients had osseous union and infection control without any secondary procedure. Of the remaining 5 patients: two patients had good infection control but had broken ACCIN due to non-compliance to weight bearing protocol. One patient underwent exchange nailing and plate augmentation whilst the other underwent simple exchange nailing, One more patient who had infection control but had persistent non-union had to undergo exchange nailing and augmented plating to achieve union. One other patient required debridement and implant removal and attained union and fifth patient required two additional debridements to control infection after which the fracture united. Apart from above 5 cases there were two further complications of knee stiffness. CONCLUSION: In infected non-union with bone gap less than 4cm, ACIIN can achieve both infection control and osseous union in significant number of cases. All such cases should be primarily operated with aim to achieve this outcome and use of thicker nail and ensuring proper compliance from patients regarding weight bearing will improve the outcomes.

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BACKGROUND: Posteromedial and greater trochanteric fragments are a major cause of telescoping and medialization of the femoral shaft in an unstable intertrochanteric fracture. This leads to significant limb shortening, fracture collapse in varus position and implant failure, which can be prevented by trochanteric wiring in addition to dynamic hip screw (DHS) fixation. The purpose of our study is to assess the outcomes of DHS augmented with trochanteric wiring in unstable type A2 intertrochanteric fractures. MATERIALS AND METHODS: One hundred and two retrospective cases of unstable intertrochanteric fractures treated with DHS between January 2010 and December 2015 with a minimum follow-up period of 12 months were reviewed. Out of 102 cases, 28 were treated with DHS and derotation screw alone (Group A), while in rest 74 cases trochanteric wiring was used as an augmentation to DHS and derotation screw (Group B). Patients were evaluated clinically for range of motion, Harris hip score and Oxford hip score. Radiologically, fracture reduction, change in neck shaft angle and neck length ratio in comparison to opposite hip and union status of greater trochanter were assessed. RESULTS: The mean age of the patients at the time of surgery was 72 years (range 23-94 years) with 48 males and 54 females. The mean follow-up period was 20 months (range 12-48 months). The Harris hip score, Oxford hip score, shortening, attainment of weight bearing and change in neck shaft angle was not significantly different between the two groups (all p values >0.05). Incidence of greater trochanter nonunion was greater in group A (17.85%) as compared to group B (6.75%). We found significant association between occurrence of limp with varus change in neck shaft angle, decrease in neck length ratio and greater trochanteric non-union (all p values <0.05). We had 7 complications, one superficial infection, one deep vein thrombosis, 4 screw cut out and one deep infection treated with implant removal. CONCLUSION: DHS augmented with trochanteric wiring in unstable intertrochanteric fractures gives similar result to group without no wiring, although greater trochanter non-union rate was more in the latter group. Limp can be prevented by anatomical or valgus fixation, augmentation of DHS to support posteromedial and greater trochanteric fragments and delayed weight bearing.

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BACKGROUND: Trauma is a major public health problem, particularly in India due to the country's rapid urbanization. Tibia fractures are a common and often complicated injury that is at risk of infection following surgical fixation. The primary objectives of this cohort study were to determine the incidence of infection within one year of surgery and to describe the distribution of infections by location and time of diagnosis for tibia fractures in India. METHODS: We conducted a multi-center, prospective cohort study. Patients who presented with an open or closed tibia fracture treated with internal fixation to one of the participating hospitals in India were invited to participate in the study. Participants attended follow-up visits at 3, 6, and 12 months post-surgery, where they were assessed for infections, fracture healing, and health-related quality of life as measured by the EurQol-5 Dimensions (EQ-5D). RESULTS: Seven hundred eighty-seven participants were included in the study and 768 participants completed the 12 month follow-up. The overall incidence of infection was 2.9% (23 infections). The incidence of infection was 1.6% (10 infections) in closed and 8.0% (13 infections) in open fractures. There were 7 deep and 16 superficial infections, with 5 being early, 7 being delayed, and 11 being late infections. Intra-operative antibiotics were given to 92.1% of participants and post-operative antibiotics were given to 96.8% of participants. Antibiotics were prescribed for an average of 8.3 days for closed fractures and 9.1 days for open fractures. Infected fractures took significantly longer to heal, and participants who had an infection had significantly lower EQ-5D scores. CONCLUSIONS: The incidence of infection within this cohort is similar to those seen in developed countries. The duration of prophylactic antibiotic use was longer than standard practice in North America, raising concern for the potential development of antibiotic resistant microbes within Indian orthopaedic settings. Future research should aim to identify the best practice for antibiotic use in India to ensure that antibiotic usage patterns do not lead to unnecessary overuse, while maintaining a low incidence of infection. TRIAL REGISTRATION: NCT01691599 , September 17, 2012.

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BACKGROUND: In cases with infected non-union, the primary step is eradication of the infection before attempting to achieve union. Release of antibiotics from the bone cement at a high concentration and its penetration to the surrounding tissues, including cortical and cancellous bone, prompted the use of antibiotic cement in the control of bone infection. The aim of this study is to summarize our experience with the use of antibiotic cement-impregnated intramedullary nail (ACIIN) for control of infection in cases of infected non-union with bone defect. MATERIALS AND METHODS: We prospectively studied 25 cases of infected non-union (23 femora and two tibiae). There were 24 males and one female, with the mean age being 33 years (range, 21-58 years). All patients had high-velocity road traffic accidents except one patient who had farmland injury. There were seven closed fractures, one grade I compound, two grade II compound fractures, five grade IIIA compound fractures, and 10 grade IIIB compound fractures. ACIIN was used in all cases after adequate debridement. Patients were classified according to the amount of bone defect present after debridement: group 1 with bone defect <4 cm (n=13), group 2 with bone defect >/=4-<6 cm (n=7), and group 3 with bone defect >/=6 cm (n=5). Infection control was judged on the basis of discharge through the wound and laboratory parameters. All patients were followed-up, with an average follow-up time of 29 months (range, 18-40 months). The mean duration of retention of the intramedullary rod was 8 weeks (range, 6-12 weeks). RESULTS: In group 1, all cases achieved infection control, with three patients achieving bone union without any need of secondary procedure. In group 2, all cases achieved infection control but the time taken was significantly longer than for group 1 (P value 0.0002). All the cases required a secondary procedure in the form of either interlocking intramedullary nailing with iliac crest bone graft or Ilizarov ring fixator application to achieve union. None of the cases in group 3 achieved infection control. CONCLUSION: ACIINs are useful for infection control in cases of infected non-union with bone defect <6 cm. In cases with defect >6 cm, other alternatives should be used.