Cases reported "Femoral Fractures"

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1/8. Femoral bone regeneration subsequent to impaction grafting during hip revision: histologic analysis of a human biopsy specimen.

    Cemented revision with impaction grafting shows encouraging early clinical results; postoperative biopsy specimens taken from the proximal femur in humans have demonstrated viable trabecular and cortical bone. Human radiographic studies also illustrate density changes within the proximal femur, consistent with remodeling of bone-graft. In an animal experiment, bone incorporation was shown in the proximal femur, but graft lysis was reported around the distal portion of the implant. We report on a patient who sustained a traumatic femoral fracture at the level of the tip of the femoral component 27 months after revision with impaction grafting and a collarless polished taper stem. At the time of open reduction and internal fixation of the fracture, we obtained circumferential biopsy specimens from the fracture site. Three distinct zones could be identified histologically: i) an inner zone consisting of bone-cement, fibrous tissue, and partially necrotic trabeculae with evidence of bone remodeling; ii) a middle zone consisting of viable trabecular bone and probable neocortex formation with fewer particles of bone-cement; and iii) an outer zone with viable cortex. Fibrous tissue was present around some of the incorporating bone-graft fragments, but no continuous fibrous membrane was present. Cement particles were identified, but no polyethylene debris was found by light microscopy. biopsy specimens from the distal aspect of the prosthesis may not reflect changes seen proximally, but based on the available tissue, this case illustrated histological evidence of bone-graft remodeling after impaction grafting. These results are consistent with our expectations based on radiographic findings and clinical results.
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2/8. osteoporotic fractures and vitamin d deficiency.

    Case study: A caucasian woman aged 79 years, with a history of hypertension, hyperlipidaemia, and osteoarthritis, was referred for assessment of osteoporosis and generalised musculoskeletal pain after surgery for a right midshaft femoral fracture. Further history revealed she had suffered nonspecific musculoskeletal pain, particularly of the pelvic girdle, and unsteady gait for many weeks, but denied suffering any falls. She had limited mobility due to osteoarthritis of both knees. She had been mostly housebound and was on an animal product restricted diet in view of her history of hypercholesterolaemia. Initial x-rays confirmed an incomplete fracture of the midshaft of the right femur. She had an orthopaedic review, and subsequent bone scan and x-rays (Figure 1) revealed incomplete fractures of the midshaft of both femurs and the seventh rib. She was managed conservatively (alendronate 70 mg per week) and progress was closely monitored. Three weeks later, she presented to the emergency department with worsening right thigh pain and difficulty in weightbearing. x-rays revealed an extension of the right femoral fracture traversing the entire cortex that required surgery. physical examination revealed a mild thoracic kyphosis. There was no muscle or bone tenderness, proximal muscle weakness, or other significant abnormality. The plasma biochemistry revealed: mild hypocalcaemia (1.98 mmol/L), hypophoshataemia (0.7 mmol/L), raised alkaline phosphatase (ALP) (216 iu/L), low 25-hydroxyvitamin D (250HD) (22 nmol/L), and a mildly raised parathyroid hormone (PTH) level (8 pmol/L). Thyroid, renal, and liver functions were normal. The patient was treated with nine capsules of Ostelin 1000 per day, which was tapered over 8 weeks to one capsule. The repeat plasma 25OHD after 6 weeks was 56 nmol/L, and her musculoskeletal symptoms were completely resolved. There was normalisation of biochemical abnormalities and x-rays demonstrated healing of both femoral fractures. A bone biopsy taken at the time of surgery revealed an increased amount of osteoid. However, undecalcified bone sections were not examined, nor was quantitative histomorphometry performed. Dual energy X-ray absortiometry (DEXA) scan revealed a T-score of -3.32 at the hip and -1.38 at the lumbar spine. Corresponding Z-scores were -1.05 and -0.7.
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3/8. Intramedullary reaming and nailing: its early effects on cortical bone vascularization.

    The early effect of reaming the medullary cavity prior to intramedullary nailing using Kuntscher's method, on human cortical bone vascularization in the femur is discussed. In sections of the femur where the medullary tissue had been totally reamed, the inner two-thirds of the cortical bone tube was completely avascularized one week after the reaming. In the outer third of the cortex the vascularization was only moderately decreased. In the parts of the femur where the medullary tissue was not totally destroyed there was a marginal effect on the amount of intact cortical vessels. The observation is thus in accordance with corresponding results from experimental studies on animals. Microcracks, and cracks in the cortical wall, caused by the reaming and procedure are also described in the article.
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4/8. brucella osteomyelitis of a closed femur fracture.

    A 19-year-old man incurred a closed femoral fracture complicated by hematogenous dissemination of brucella osteomyelitis. Repeated limited incision and drainage were ineffective in eradicating infection. Wide debridement, delayed wound closure, and vigorous antimicrobial therapy with streptomycin and tetracycline, along with cephalosporin for secondary staphylococcal infection, were necessary measures before the infection was eradicated. A constant awareness of brucella musculoskeletal infection is advisable when caring for patients frequently exposed to all kinds of livestock, including domesticated and wild animals.
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5/8. Bacterial adherence and the glycocalyx and their role in musculoskeletal infection.

    bacteria produce a virulence-related polysaccharide exocellular slime (the glycocalyx), which preferentially adheres to the surfaces of biomaterials and compromised tissues. This biofilm resists antibiotic penetration and provides a degree of protection from antibodies and macrophages. Similar adhesive cell-to-substrate phenomena have been noted in natural environments and in bacterial-animal cell disease states. The adherent glycocalyx is one of the fundamental reasons for increased susceptibility to infection in the presence of biomaterials and compromised tissues and a significant factor in the persistence of such infection until the removal of the prosthetic device.
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6/8. Late postoperative infection caused by pasteurella multocida.

    pasteurella multocida is often found in local infections after animal bites. Septic conditions however are rare. A case of late infection by P. multocida at the site of the osteosynthesis 1 year after a primarily healed pertrochanteric fracture is described. The patient had a cat. After extraction of the plate and screws and treatment with penicillin the infection healed uneventfully.
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7/8. Accidental injuries from captive-bolt guns (slaughterer's gun).

    Captive bolt guns or 'slaughterer's guns' are weapons used in slaughtering animals. Lesions caused by these weapons are likely to have a more serious character than is to be expected from the size of the entrance wound. The wounds are primarily contaminated and it is imperative to explore the wound thoroughly as foreign bodies are often deeply embedded. Three cases are reported of accidental injuries to personnel working with such weapons.
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8/8. Open femur fracture secondary to hippopotamus bite.

    The surgical treatment of a patient who sustained a grade IIIC open femur fracture as a result of a hippopotamus bite is described. We review the available literature on large wild animal attacks to humans. A standard protocol for management of open fractures was followed in this patient, and eventually led to a good result.
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