Purpose This study evaluated the clinical results and implant safety of a newly developed implant, Trochanteric Fixation Nail-Advanced (TFNA; DePuy Synthes), in the treatment of proximal femur fractures. Materials and Methods This was a retrospective cohort study of 26 patients diagnosed with proximal femur fracture and treated surgically with TFNA. The patients’ demographic data, surgical data, radiologic findings, and functional outcomes, including complications, were evaluated. Results The mean age of the patients was 71.2 years (95% confidence interval [CI], 68.2-74.2); 65.4% were female. The mean Carlson comorbidity index score was 5.4, and the mean Koval grade before fracture was 2.1. Fracture classification included four cases of AO/OTA 31.A1, nine cases of A2, six cases of A3, and seven cases of 32A including six cases of atypical femoral fractures. The mean operating time was 53.3 minutes (95% CI, 43.6-63.1). There were no early postoperative complications, such as postoperative infection, deep vein thrombosis, pulmonary embolism, or in-hospital death, except one case of pneumonia. The mean Koval score at the postoperative six-month follow-up was 2.9. EuroQol-5 Dimension (EQ-5D) increased from 0.05 to 0.54 after three months and 0.72 at six months postoperatively. Bone union was observed in all cases with a mean union time of 12.9 weeks. No implant failure occurred, and no cases required secondary revision surgery. Conclusion A new intramedullary nail system, TFNA, showed excellent outcomes and safety in the surgical treatment of proximal femur fractures.
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Clinical and Radiological Outcomes of Unstable Intertrochanteric Fractures Treated with Trochanteric Fixation Nail-Advanced and Proximal Femoral Nail Antirotation-II: Correlation between Lateral Sliding of the Helical Blade and Lateral Trochanteric Pain Sung Yoon Jung, Myoung Jin Lee, Lih Wang, Hyeon Jun Kim, Dong Hoon Sung, Jun Ha Park Journal of the Korean Orthopaedic Association.2024; 59(3): 208. CrossRef
Prospective randomized multicenter noninferiority clinical trial evaluating the use of TFN-advancedTM proximal femoral nailing system (TFNA) for the treatment of proximal femur fracture in a Chinese population Lidan Zhang, Zhijun Pan, Xiaohui Zheng, Qiugen Wang, Peifu Tang, Fang Zhou, Fan Liu, Bin Yu, Frankie K. L. Leung, Alex Wu, Suzanne Hughson, Zhuo Chen, Michael Blauth, Anthony Rosner, Charisse Sparks, Manyi Wang European Journal of Trauma and Emergency Surgery.2023; 49(3): 1561. CrossRef
Risk of shortening in operatively treated proximal femur fractures with cephalomedullary nails with dynamically versus statically locked helical blades Nathan Cherian, Lasun Oladeji, Cole Ohnoutka, Dan Touhey, Madeline Sauer, Kyle A. Schweser, Mauricio Kfuri, James L. Cook, Gregory J. Della Rocca, Brett D. Crist Injury.2023; 54(2): 669. CrossRef
GS Hip Nail versus Affixus Hip Fracture Nail for the Intramedullary Nailing of Intertrochanteric Fractures Seungcheol Kwon, Minjae Lee, Heeyeon Lee, Jihyo Hwang Journal of Clinical Medicine.2023; 12(21): 6720. CrossRef
Comparison of the Clinical and Radiological Outcomes of TFNA (Trochanteric Fixation Nail-Advanced) and PFNA-II (Proximal Femoral Nail Antirotation-II) Treatment in Elderly Patients with Intertrochanteric Fractures Min Sung Kwon, Young Bok Kim, Gyu Min Kong Journal of the Korean Fracture Society.2022; 35(4): 162. CrossRef
Analysis of Clinical and Functional Outcomes according to the Blood Sugar Control Status at the Time of Ankle Fractures Resulting from Rotational Injuries Jun Young Lee, Dong Seop Lim, Seung Hyun Lee, Seo Jin Park Journal of the Korean Fracture Society.2022; 35(4): 135. CrossRef
Conventional versus helical blade screw insertion following the removal of the femoral head screw: a biomechanical evaluation using trochanteric gamma 3 locking nail versus PFN antirotation Hong Man Cho, Kwang Min Park, Tae Gon Jung, Ji Yeon Park, Young Lee BMC Musculoskeletal Disorders.2021;[Epub] CrossRef
Clinical and Radiologic Outcome of Intertrochanteric Fracture Treatment Using TFNA (Trochanteric Fixation Nail-Advanced) Hyeon Joon Lee, Hyun Bai Choi, Ba Rom Kim, Seung Hwan Jo, Sang Hong Lee Journal of the Korean Fracture Society.2021; 34(3): 105. CrossRef
Purpose This study determined whether the sonication of explants could improve the detection of bacteria and influence the optimal antibiotics treatment. Materials and Methods This retrospective study included the patients who underwent implant removal surgery followed by sonication culture as well as tissue culture in order to diagnose implant-related infection. A total of 37 consecutive patients with 41 cases were included. The patients’ demographic data, use of preoperative antibiotics, type of implants, change of antibiotics following the culture results, and recurrence of infection were all reviewed. Results Among 41 cases, 20 cases met the diagnostic requirements for implant-related infection as defined by musculoskeletal infection society criteria, while the other 21 cases had explant sonication to exclude indolent infection or residual infection. The latter showed negative results on the both explant cultures and tissue cultures. Among the 20 cases that met the requirements for implant-related infection, 19 cases (95.0%) were identified by any cultures. Of the 19 cases with positive culture results, 2 cases (10.5%) showed positive results only on sonication cultures, and one case (5.3%) showed positive results only on tissue culture. In 1 case of culture negative implant-related infection, a drain sinus was present preoperatively, but the cultures were negative according to both methods. The culture results made postoperative antibiotics change in 12 cases among the 19 culture (+) cases. Antibiotics changes were based on the tissue culture in 2 cases, 2 cases were based on the sonication culture, and the remaining 8 cases were based on both cultures. Conclusion The sonication culture improved the diagnosis of implant-related infection combined with conventional tissue culture and helped to determine administering the proper antibiotics.
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Systematic Diagnosis and Treatment Principles for Acute Fracture-Related Infections Jeong-Seok Choi, Jun-Hyeok Kwon, Seong-Hyun Kang, Yun-Ki Ryu, Won-Seok Choi, Jong-Keon Oh, Jae-Woo Cho Journal of the Korean Fracture Society.2023; 36(4): 148. CrossRef
In the surgical treatment of acetabular fractures, the anterior approach is used widely for anterior column fractures with or without posterior column fractures. This paper reviews the anterior approach for the anatomical reduction and rigid fixation of acetabular fractures: traditional ilioinguinal approach, modified Stoppa approach, and new Pararectal approach.
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Adhesion of External Iliac Vessels Found in a Modified Stoppa Approach to Acetabular Fracture in a Patient with a History of Previous Abdominal Surgery Seong-Tae Kim, Seungyup Shin, Hohyoung Lee, Seong Man Jeon Journal of the Korean Orthopaedic Association.2022; 57(1): 68. CrossRef
PURPOSE The purpose of this study was to investigate the radiological and epidemiological characteristics, as well as the clinical course of pelvic insufficiency fractures in the elderly population. MATERIALS AND METHODS At a Haeundae Paik Hospital, we retrospectively reviewed patients with pelvic insufficiency fractures between March 2010 and May 2017. The demographic data of patients were analyzed, and bone mineral density and bone turnover markers were evaluated to estimate the metabolic status of the bone. The radiological characteristics were evaluated by comparing the simple x-ray images with the computed tomography images, and the types of fractures were classified via computed tomography images. For clinical course evaluation, we investigated comorbid complications, and compared the walking ability scale before and 6 months after the fracture. RESULTS A total of 42 patients were included, with an average age of 76.5 years. All were female except one case. In 5 cases where the initial medical examination was from another institution, the fracture was not found in 3 cases. All cases received conservative treatment. After the diagnosis of pelvic bone fracture using a simple x-ray imaging, additional fractures were found in 81.0% of the study population using a computed tomography. Initiation of gait occurred at an average of 2.8 weeks, and every case except 1 (97.6%) fully recovered their gait ability. CONCLUSION We concluded that there was a limitation with diagnosing pelvic insufficiency fracture using only a simple x-ray imaging technique. In general, cases in this study showed conservative treatment yielded favorable clinical outcome with relatively less critical complications.
In elderly acetabular fractures, central dislocation of the femoral head and impacted superior dome of the acetabulum is common. Unreduced dome impaction can lead to degenerative arthritis and results in poor results. Herein, we present a case of operative reduction and fixation performed via the modified Stoppa approach in acetabular fracture with superior dome impaction.
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Surgical outcomes of acetabular fracture of elderly patients with superomedial dome impaction Eic Ju Lim, Hyun-Chul Shon, Jae-Young Yang, Joosuk Ahn, Jung Jae Kim, Ji Wan Kim Scientific Reports.2023;[Epub] CrossRef
Anterior Approach for the Acetabular Fractures Jae Youn Yoon, Jae-Woo Cho, Ji Wan Kim Journal of the Korean Fracture Society.2019; 32(3): 157. CrossRef
With an aging population and the development of surgical techniques, there is a growing demand for bone reconstruction in areas of trauma, arthroplasty, and spinal fusion Although autogenous bone grafting may be the best method for stimulating bone repair and regeneration, there are still problems and complications, including morbidity related to bone harvesting and limitation of harvest amount. Allogeneic bone grafts have a limited supply and risk of transmission of infectious diseases. Over the past several decades, the use of bone substitutes, such as calcium phosphate, has increased; however, they have limited indications. Biomedical research has suggested a possibility of stimulating the self-healing mechanism by locally transmitting the external growth factors or stimulating local production through a gene transfer. In this review, we evaluate recent advances, including bone graft, bone substitutes, and tissue engineering.
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Calcium phosphate injection technique for treatment of distal radius fracture Dae-Geun Kim, Byung Hoon Kwack Medicine: Case Reports and Study Protocols.2021; 2(9): e0117. CrossRef
Experimental Study ofDohongsamul-tang(Taohongsiwu-tang) on Fracture Healing Hyun Ju Ha, Min-Seok Oh Journal of Korean Medicine Rehabilitation.2020; 30(2): 47. CrossRef
PURPOSE The purpose of this study was to introduce our method of stabilizing unstable intertrochanteric fractures by using the dynamic hip screw (DHS) with a beta-tricalcium phosphate (β-TCP) graft and to compare the outcomes of this procedure with those of the conventional DHS without β-TCP. MATERIALS AND METHODS Patients who underwent surgery by using DHS between March 2002 and January 2016 were retrospectively reviewed for analysis of the outcomes. The inclusion criteria were: 1) age of 60 years and older; 2) low-energy fracture resulting from a fall from no greater than the standing height; 3) multifragmentary pertrochanteric fracture (AO classification 31-A2.2, 2.3); and 4) follow-up of over 3 months. We compared 29 patients (29 hips) who underwent surgery, using DHS without β-TCP, with 29 age-sex matched patients (29 hips) who underwent surgery using DHS with grafted β-TCP granules to empty the trochanter area after reaming. We investigated the fracture union rate, union time, and length of lag screw sliding. RESULTS Bone union was achieved in all cases. The mean union time was 7.0 weeks in the β-TCP group and 8 .8 weeks in the non-β-TCP group. The length of lag screw sliding was 3.6 mm in the β-TCP group and 5 .5 mm in the non-β-TCP group. There were no implant failure cases in both groups. CONCLUSION The β-TCP graft for reinforcement DHS acquired satisfactory clinical outcomes for treating unstable intertrochanteric fractures.
PURPOSE The purpose of this study is to evaluate clinical outcomes and complications after fasciotomy in acute compartment syndrome. MATERIALS AND METHODS Seventeen cases diagnosed as compartment syndrome and underwent fasciotomy from January 2011 to February 2015 were evaluated retrospectively. We investigated the causes and regions of acute compartment syndrome, the methods of wound management, the necessity of skin graft, and the complications including amputation and infection. RESULTS According to the causes of acute compartment syndrome, there were 7 fractures, 1 traumatic hematoma, 6 reperfusion injury, and 3 rhabdomyolysis. The regions of acute compartment syndrome were 3 cases of thigh, 10 cases of leg, and 3 cases of foot. One case had acute compartment syndrome involving thigh, leg, and foot. Of 17 cases, 3 cases died due to reperfusion injury and one case with severe necrosis of soft tissues underwent amputation. Among the 13 cases excluding 4 cases with death or amputation, 3 cases underwent split thickness skin graft. Shoelace technique and/or vacuum-assisted closure (VAC) was used for 9 cases, and wound closure without skin graft was achieved in all except one case, while 2 cases required skin graft among 4 cases without shoelace technique or VAC. There were 2 cases of infection. CONCLUSION Acute compartment syndrome caused by reperfusion injury had poor outcomes. Shoelace technique and/or VAC were useful for management of wound after fasciotomy.
PURPOSE The purpose of this study is to evaluate the clinical results of modified Stoppa approach in acetabular fractures. MATERIALS AND METHODS Twelve patients who underwent surgery using the modified Stoppa approach for acetabular fractures were enrolled. There were 10 cases of isolated acetabular fracture, two cases of acetabular fracture combined with pelvic ring injury. There were two cases of anterior column fracture, nine cases of both column fracture, and one case of T-type fracture according to Letournel classification. The clinical outcomes were evaluated from Harris hip score (HHS) at postoperative one year and complications. The radiologic result was evaluated according to Matta criteria; anatomical, imperfect, and poor. RESULTS According to the radiological results, there were eight cases of anatomical, three cases of imperfect, and one case of poor reduction. The average HHS was 82.5 and 10 patients had excellent or good results. The other two patients had poor results due to lumbosacral plexopathy and poor reduction, respectively. The complication included one case of incomplete sciatic nerve palsy, which was recovered at postoperative three months. CONCLUSION Internal fixation of acetabular fractures using the modified Stoppa approach had satisfactory clinical and radiological outcomes. The modified Stoppa approach can be a useful option for acetabular fractures with appropriate indication and anatomical information.
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Adhesion of External Iliac Vessels Found in a Modified Stoppa Approach to Acetabular Fracture in a Patient with a History of Previous Abdominal Surgery Seong-Tae Kim, Seungyup Shin, Hohyoung Lee, Seong Man Jeon Journal of the Korean Orthopaedic Association.2022; 57(1): 68. CrossRef
Anterior Approach for the Acetabular Fractures Jae Youn Yoon, Jae-Woo Cho, Ji Wan Kim Journal of the Korean Fracture Society.2019; 32(3): 157. CrossRef
Reduction Technique of Dome Impaction Using the Modified Stoppa Approach: A Technical Note Ji Wan Kim, Yong Min Seo, Hyo-Seok Jang Journal of the Korean Fracture Society.2017; 30(3): 131. CrossRef
Biological fixation of pelvic ring and acetabular fractures: a pilot study with anatomical validation Abdelfattah Mohamed Fathy Saoud, Ahmed Mohamed Sallam, Ahmed Mohamed Morsey Current Orthopaedic Practice.2017; 28(3): 303. CrossRef
Cerclage Clamping Using Cerclage Passer for Reduction of Anterior and Posterior Column Fracture Ki Chul Park, Hyun Joong Cho, Hun Chul Kim, Kyung-Sik Min, Hae Won Jeong Journal of the Korean Orthopaedic Association.2016; 51(6): 486. CrossRef
PURPOSE The purpose of this study is to evaluate the incidence of ankle injury in ipsilateral tibial shaft fractures and to assess the risk factors for ankle injury associated with tibial shaft fractures. MATERIALS AND METHODS Sixty patients with tibial shaft fractures were enrolled in this retrospective study. The incidence and characteristics of ankle injury were evaluated, and fracture classification, fracture site, and fracture pattern of the tibial shaft fractures were analyzed for assessment of the risk factors for ankle injury combined with tibial shaft fractures. RESULTS Ankle injury occurred in 20 cases (33%). There were four cases of lateral malleolar fracture, four cases of posterior malleolar fracture, two cases of distal tibiofibular ligament avulsion fracture, and 10 cases of complex injury. Fourteen cases (70%) of 20 cases of ankle injury were diagnosed from x-ray films, and the other six cases were recognized in ankle computed tomography (CT). Ankle injury occurred in 45.1% of distal tibial shaft fractures and found in 41.4% of A type, but there was no statistical significance. Ankle injury was observed in 54% of cases of spiral pattern of tibial shaft fracture and the incidence was statistically higher than 19% of cases of non-spiral pattern tibial shaft fracture. CONCLUSION Ankle injury was observed in 33% of tibial shaft fractures; however, only 70% could be diagnosed by x-ray. Ankle injury occurred frequently in cases of spiral pattern of tibial shaft fracture, and evaluation of ankle injury with CT is recommended in these cases.
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Usefulness of Computed Tomography on Distal Tibia Intra-Articular Fracture Associated with Spiral Tibia Shaft Fracture Seong-Eun Byun, Sang-June Lee, Uk Kim, Young Rak Choi, Soo-Hong Han, Byong-Guk Kim Journal of the Korean Fracture Society.2016; 29(2): 114. CrossRef
PURPOSE To evaluate the incidence of neurologic injury in pelvic ring injuries and to assess the risk factors for neurologic injury related to pelvic fractures. MATERIALS AND METHODS Sixty-two patients with the pelvic ring injury were enrolled in the study from March 2010 to May 2013. When the neurologic injury was suspected clinically, the electro-diagnostic tests were performed. Combined injuries, fracture types, and longitudinal displacements were examined for correlations with the neurologic injury. RESULTS There were 7 cases of AO/OTA type A, 37 cases of type B, and 18 cases of type C. Among them, 25 patients (40%) had combined spine fractures, and the average of longitudinal displacement was 7 mm (1-50 mm). Of the 62 patients, 13 (21%) had neurologic injury related with pelvic fractures; 5 with lumbosacral plexus injury, 5 with L5 or S1 nerve injury, 2 with obturator nerve injury, and 1 case of lateral femoral cutaneous nerve injury. There were no relationships between the neurologic injuries and fracture types (p=0.192), but the longitudinal displacements of posterior ring and combined spine fractures were related to the neurologic injury within pelvic ring injury (p=0.006, p=0.048). CONCLUSION The incidence of neurologic injury in pelvis fracture was 21%. In this study, the longitudinal displacements of posterior ring and combined spine fractures were risk factors for neurological injury in pelvic ring injury.
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Surgical Outcome of Posterior Pelvic Fixation Using S1, S2 Screws in Vertically Unstable Pelvic Ring Injury Kwang Hee Yeo, Nam Hoon Moon, Jae Min Ahn, Jae Yoon Jeong, Jae Hoon Jang Journal of the Korean Fracture Society.2018; 31(1): 9. CrossRef
Primary Cementless Hip Arthroplasty in Unstable Intertrochanteric Femur Fracture in Elderlys: Short-term Results Su-Hyun Cho, Hyung Lae Cho, Hong Cho Hip & Pelvis.2014; 26(3): 157. CrossRef
PURPOSE To discriminate the characteristics between reverse obliquity fractures in the elderly and that of young adults using three-dimensional computed tomography (3D CT). MATERIALS AND METHODS Eighteen patients who had reverse obliquity intertrochanteric fractures were enrolled from January 2007 to March 2012. The fracture pattern was analyzed using the 3D CT. The area showing low density (bone defect) of trochanter and femoral neck region was measured. Patients were divided into two groups: Group I, less than 65 years old and Group 2, 65 years and over. RESULTS In all 9 cases of group 1, the proximal fragment had a 'V' shape with an average of 5.6 cm below the vastus ridge; however, the fracture of 8 cases (88.97%) in group 2 had a 'Lambda' shape of the distal fragment at the level of vastus ridge and an additional fracture line extending to the greater trochanter tip. The bone defect volume of the trochanter and femoral neck region was larger significantly in group 2 than in group 1. CONCLUSION Reverse obliquity intertrochanteric fracture in the elderly demonstrated a pattern of bursting fracture with 4 parts, which had different patterns from that of young patients. We believe that the larger volume of bone defects resulted in the difference of fracture patterns between the two groups.
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A Comparison of Internal Fixation and Bipolar Hemiarthroplasty for the Treatment of Reverse Oblique Intertrochanteric Femoral Fractures in Elderly Patients Bong-Ju Park, Hong-Man Cho, Woong-Bae Min Hip & Pelvis.2015; 27(3): 152. CrossRef
A Review of Domestic and International Clinical Research Trends on Pharmacopuncture Treatment for Fractures Hea Sun Chun Journal of Physiology & Pathology in Korean Medicine.2023; 37(6): 185. CrossRef
Comparison of Greater Trochanter Versus Piriformis Entry Nail for Treatment of Femur Shaft Fracture Jong-Hee Lee, Jong-Hoon Park, Si-Yeong Park, Seong-Cheol Park, Seung-Beom Han Journal of the Korean Fracture Society.2014; 27(4): 287. CrossRef
Heterotopic ossification around the patellar tendon is known to be extremely rare. A 42-year-old man had a transverse fracture of the left patella. Open reduction and tension band wiring were performed. At four weeks, plain radiographs showed an extensive ossification around the patellar tendon and the patient presented limitation of flexion and pain in kneeling position. We just encouraged active and passive ranges of motion exercises and performed one manipulation under anesthesia. At the final follow-up (10 months post-operatively), he was able to flex his knee by 140 degrees. We present a case of heterotopic ossification around the patellar tendon with limitation of knee flexion that was successfully treated with nonoperative treatment.
PURPOSE To acquire anatomical data for the normal pelvic bone structure using three-dimensional computed tomography (3D CT) and to propose the most appropriate angle and screw length for safe screw insertion during symphysis pubis plating. MATERIALS AND METHODS We performed 3D CT analysis in 52 patients who required plating and selected a medial and lateral insertion point between the symphysis pubis and the pubic tubercle. Using a three-dimensional medical image analysis program, we evaluated the appropriate screw length, sagittal angle, and oblique angle at each point in this cohort. RESULTS At the medial point, the sagittal angle was determined to be 49.1degrees with an average screw length of 49.4 mm. At the lateral point, we calculated an average screw length of 49.1 mm, oblique angle of 23.2degrees, and sagittal angle of 45.7degrees. The screw length was longer in men than in women (4.6 mm and 7.3 mm, respectively) at the medial and lateral point. CONCLUSION At the symphysis pubis diastasis, we can insert the screw caudally at 49degrees with a minimal length of 37 mm at the medial point. We can insert the screw caudally at 46degrees, medially at 23degrees, with a minimal 34 mm length at the lateral point.
PURPOSE To evaluate the incidence of venous thromboembolism (VTE) in trauma patients with pelvic or acetabular fracture and determine high risk factors. MATERIALS AND METHODS Twenty-three patients who had a pelvic or acetabular fracture were enrolled between March 2011 and February 2012. All patients had mechanical and chemical prophylaxis and underwent deep vein thrombosis (DVT) computed tomography around 2 weeks after injury for evaluation of VTE. The relationships between VTE and each of sex, age, body mass index, injury severity score, intensive care unit stay, transfusion, operation time, coagulopathy, and associated injury were analyzed. RESULTS A total of 8 patients developed VTE (34.8%), of which 5 had DVT, 2 had pulmonary embolism (PE), and one had both DVT and PE. The group with a VTE risk score of 14 or more had a significantly higher incidence of VTE. CONCLUSION Careful attention is needed in management of patients with pelvic or acetabular fracture.
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Abdominal injuries are common in patients with pelvic or acetabular fracture. However intestinal entrapment or perforation caused by fragments of a pelvic or acetabular fracture is rare and to date there has been no report of this occurring in Korea so far. As it is difficult to diagnose intestinal entrapment caused by fragments of pelvic or acetabular fracture, the entrapment therefore results in intestinal perforation, sepsis, and a high mortality rate in the absence of early detection. We present a case of intestinal entrapment and perforation caused by fragments of acetabular fracture as well as a literature review.
When treating femur shaft fracture in adults, undreamed nail can be an option in order to avoid systemic complications. To appropriately insert unreamed intramedullary nail, an accurate entry point and sufficient reaming of the entry portal is essential. The intramedullary canal of the proximal femur must be reamed over than the diameter of the proximal end of the nail. If the proximal reaming is not sufficient, complications such as bursting fracture of proximal femur can occur. We present two cases of bursting fracture of proximal femur following insertion of undreamed intramedullary nail as well as a literature review.
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Fixation of the Femoral Subtrochanteric Fracture with Minimally Invasive Reduction Techniques Chul-Hyun Park, Chul-Wung Ha, Sang-Jin Park, Min-Su Ko, Oog-Jin Shon Journal of the Korean Fracture Society.2013; 26(2): 112. CrossRef
The Treatment of Subtrochanteric Fracture with Cephallomedually Nail -Minimal Incision and Lowman Clamp Assisted Reduction- Jang Seok Choi, Do Hyun Moon, Young Tae Noh Journal of the Korean Fracture Society.2011; 24(4): 301. CrossRef