Muscle function and functional outcome following standard antegrade reamed intramedullary nailing of isolated femoral shaft fractures.

OBJECTIVE: To evaluate the functional outcomes and long-term effects on muscle strength of femoral shaft fractures treated with intramedullary (IM) antegrade nailing using a standard piriformis start point. DESIGN: Retrospective Outcome Study. SETTING: Tertiary Level Teaching Hospital and Referral Centre for the Province of British Columbia. PATIENTS/PARTICIPANTS: Twenty-one patients (7 female, 14 male; mean age 34.5 years, range 16-56 years) with isolated femoral shaft fractures who were treated with standard antegrade reamed interlocking IM nailing and who had a minimum 1-year follow-up were identified through the Orthopaedic Trauma Database. All patients had isokinetic muscle testing of their hip abductors, hip extensors, and knee extensors using the KinCom muscle testing machine. Of the patients, 10 underwent formal gait lab analysis. All of the patients answered a questionnaire and completed the Short Form (SF)-36 and Musculoskeletal Functional Assessment outcome measures. INTERVENTION: Antegrade reamed interlocking IM nailing of femoral shaft fractures using a standard trochanteric fossa (also referred to as piriformis fossa) starting point. MAIN OUTCOME MEASUREMENTS: Examination of muscle strength, using 2 different objective measures (KinCom and gait analysis). The KinCom muscle testing machine was used for isokinetic muscle testing of hip abductors, hip extensors, and knee extensors. Outcome questionnaires were used to evaluate function (Musculoskeletal Functional Assessment) and general health (SF-36). RESULTS: Isokinetic muscle testing showed a statistically significant lower peak torque generation by the hip abductors (P=0.003) and hip extensors (P=0.046) from the uninjured contralateral side. The gait lab analysis did not show important changes in gait pattern. Scores for the SF-36 were 51.77+/-7.55 and 53.73+/-8.70. Scores for the Short Musculoskeletal Functional Assessment (S-MFA) were 7.74 and 8.66. Both scores did not indicate any significant disability. CONCLUSIONS: Antegrade reamed interlocking IM nailing of femoral shaft fractures using a standard trochanteric fossa starting point is associated with a mild hip abductor muscle-strength deficit. Gait pattern returns to normal following femoral shaft fracture treated with this technique, and functional outcomes are good.

Trochanteric osteotomies in revision total hip arthroplasty: contemporary techniques and results.

Revision total hip arthroplasty (THA) presents several challenges to the orthopaedic surgeon and typically requires the use of a more extensile surgical approach. Osteotomy of the greater trochanter can be considered as the ultimate extensile exposure in revision THA. The methods of trochanteric osteotomy can be categorized into three types: the standard trochanteric osteotomy, the trochanteric slide, and the extended trochanteric osteotomy. Although the standard osteotomy and trochanteric slide osteotomy provide excellent acetabular exposure, in the revision setting they are frequently associated with an unacceptably high rate of nonunion and proximal migration of the trochanteric fragment. The extended trochanteric osteotomy (ETO) has increased in popularity as the number and complexity of revision THAs continue to increase. Two commonly used techniques are the ETO via a posterolateral approach or via a modified direct lateral approach. Both techniques provide wide exposure of the acetabulum, facilitate femoral component exposure and removal, aid in canal preparation and femoral reconstruction, and allow for correction of proximal femoral deformity. The osteotomy fragment is easily secured and may be advanced distally to achieve proper tensioning of the abductors. Recent literature demonstrates that the ETO has a relatively low rate of nonunion and is associated with fewer intraoperative femoral fractures or cortical perforations, as well as decreased surgical time.

Open fractures of the femur in children: analysis of various treatment methods.

PURPOSE: To describe the demographic and clinical characteristics of children who presented with open femur fractures. METHODS: A retrospective chart review of all children treated for open femur fractures at the McGill University Health Center between 1980 and 2009 was conducted. Thirty-seven patients (28 males and 9 females) were identified. Union was determined clinically by the absence of pain, tenderness to palpation and crepitus with motion. Complications were reported. RESULTS: The mean age of the patients was 11.5 years (range 2.8-18.1 years). The mechanism of injury involved motor vehicle-related injuries in 70% of cases. There were 13 Grade I, 15 Grade II and 9 Grade III fractures. The treatment involved traction and hip spica in 11 patients, external fixator in nine patients, intramedullary nailing in seven patients, open reduction and internal fixation in six patients, and traction and an ischial weight bearing brace in four patients. Average time to union was 5.1 months (range 1.5-14.4 months). Infections occurred in ten patients, nine had delayed unions, two developed malunions, four had a refracture and four patients developed a limb length discrepancy >2 cm. CONCLUSIONS: Open fractures of the femur are often accompanied by associated injuries, indicating the importance of early and comprehensive treatment. Treatment may include hip spica application in school-age children and solid intramedullary nails in adolescents. In children with multiple injuries, specifically those with higher fracture grades, treatment with an external fixator provides immediate stability of the fracture and allows early mobilization and ease of management of associated injuries.

Accuracy of cut-off acetabular reamers for minimally invasive THA.

Cut-off reamers have been introduced for minimally invasive hip replacement to make reamer insertion through the small incision easier. However, the accuracy of cut-off reamers in comparison to traditional hemispherical reamers has not been documented. We reamed four human cadaveric hips using a cut-off reamer and three hips using a standard reamer. We started with smallest size reamer to remove subchondral bone, and the size was progressively increased until breaching the acetabular floor. We performed computed tomography scans for each reamer size to digitally determine the true dimensions and sphericity of the reamed acetabula. The cut-off reamers breached the acetabulum at a smaller size than with a standard reamer in two specimens, and at the same size as the standard reamer in one specimen. The accuracy of each reamer size was determined by quantifying the percentage of the reamed acetabular surface that was within 0.5 mm of the hemispherical reamer size. The average accuracy of the cut-off reamers was 70% compared with 81% for the standard reamers. The cut-off acetabular reamers showed a trend toward decreased accuracy that may be attributable to a tendency of the reamer to wobble in use.