Jayaramaraju Dheenadhayalan

Coronal plane fractures are increasingly identified in multifragmentary pertrochanteric (AO Foundation/Orthopaedic Trauma Association [AO/OTA] 31-A2) fractures, yet their clinical significance is under-researched. The aim of this study was to evaluate whether wire augmentation during Proximal Femur Nail Antirotation Asia (PFNA-II) fixation improves functional outcomes—regain of abductor strength and modified Harris Hip Score (mHHS)—compared with PFNA-II alone at 18-month follow-up. The secondary outcomes such as time to union, pain scores (Visual Analog Scale [VAS]), and complications were also assessed. In this single-center, randomized controlled trial, 142 patients of Asian race and Indian ethnicity aged older than 60 years with AO-OTA 31-A2 fractures were treated using PFNAII, with or without wire augmentation for coronal fragments. Preoperative computed tomography (CT) assessed coronal fragment size. Among them, 116 patients who completed 18-month follow-up were analyzed. Modified intention-to-treat analysis was performed. At 18 months, augmentation produced greater abductor strength (Δ 8.21%, 95% confidence interval, 4.4-12.83; p < 0.001) with no significant difference in mHHS (Δ 3.31 points, −1.3-7.9; p = 0.16). In fragments >50%, wire augmentation led to a clinically relevant 10% strength gain, exceeding the minimal clinically important difference (MCID) of 8.2%. However, VAS was similar between groups. Controls showed more varus collapse, likely due to a persisting posteromedial void when the fragment is not stabilized. Wire augmentation improved abductor strength recovery, especially when fragment size exceeded 50%, supporting its use in such cases. However, mHHS were similar between the groups. Level I Therapeutic. See Instructions for Authors for a complete description of levels of evidence.

Mechanical instability due to long metaphyseal comminution and medial bone gap after lateral locking plate results in varus collapse and implant failure. We believe that fixation in the form of Nail and plate combination provides better stability and prevents complications. We performed a retrospective analysis of 56 distal femur fractures with long metaphyseal comminution treated in our institution with nail and plate construct from 2017 to 2023. The mean age was 43.1 years and the mean follow up was 24 Months (4-36 months). Of these 56 patients, 16 were closed injuries underwent primary fixation, and 40 were open injuries requiring staged reconstruction. At the final follow up, patients were assessed for shortening, knee range of movements, Sander et al. functional score, radiological union and loss in alignment. The mean length of metaphyseal comminution was 10.15 cm(5-18 cm). Primary Iliac crest bone grafting was done in 25 patients. Of the 56 patients, 51 achieved primary union and the mean time to union was 6 months. Of the remaining, 3 patients united after secondary bone grafting and 2 patients had nonunion. The mean loss in aLDFA at the final follow up was 1.75° in 7 patients. Shortening of the limb was noted in 16 patients, and 4 patients had significant shortening of 2 cm. Three patients developed deep SSI, of which one patient required debridement and 2 patients required implant removal. Patients achieved an average of 0-85° flexion and 0-5° extension. Functionally, 8 patients had excellent, 25 had good, 15 had fair and 8 patients had poor score. The technique of combined intramedullary nail and plate fixation provides adequate stability and achieves good outcome in distal femur fractures with segmental metaphyseal comminution. Nail restores the anatomical alignment, and the plate provides rotational stability to the short distal fragment.

Case: A 37-year-old man presented with multiple fragility fractures and profound weakness. Evaluation revealed hypophosphatemia and an elevated serum fibroblast growth factor-23. A Ga-68 DOTANOC PET-CT localized a phosphaturic mesenchymal tumor in the sphenoid bone. Surgical resection was performed with immunohistochemistry confirming the diagnosis and leading to rapid biochemical normalization. The patient showed progressive fracture healing and made a complete functional recovery by 12 months. Conclusion: Intracranial phosphaturic mesenchymal tumors are a rare cause of tumor-induced osteomalacia. This case underscores that in patients with unexplained fractures, systematic serum phosphate testing is critical. Functional imaging is essential for tumor localization, and complete surgical excision is curative.