Pertrochanteric fractures in elderly patients represent a major health issue. The available surgical options are fixation with extramedullary devices, intramedullary nailing, and arthroplasty. Intramedullary nailing for hip fractures has become more popular in recent years. Advantages of intramedullary nailing for hip fracture fixation include a more efficient load transfer due to the proximity of the implant to the medial calcar, less implant strain and shorter lever arm because of its closer positioning to the mechanical axis of the femur, significantly less soft tissue disruption and periosteal stripping of the femoral cortex, shorter operative time and hospital stay, fewer blood transfusions, better postoperative walking ability, and lower rates of leg-length discrepancy. Compromise of the posteromedial cortex and/or the lateral cortex, a subtrochanteric extension of the fracture, and a reversed obliquity fracture pattern represent signs of fracture instability, warranting the use of intramedullary nailing. However, the use of intramedullary nailing, with its unique set of clinical implications, has introduced a new set of complications. The reported complications include malalignment, cutout, infection, false drilling, wrong lag screw length and drill bit breakage during the interlocking procedure, external or internal malrotation (≥20°) of the femoral diaphysis, elongation of the femur (2 cm), impaired bone healing, periprosthetic fracture distal to the tip of the nail, fracture collapse, implant failure, lag screw intrapelvic migration, neurovascular injury, secondary varus deviation, complications after implant removal, trochanteric pain, and refracture. Many of these complications are related to technical mistakes. This article reviews intramedullary nailing for the treatment of pertrochanteric femoral fractures, with an emphasis on complications. [Orthopedics.2016; 39(1):e108–e116.]

Skeletal reconstruction of large tumor resection defects is challenging. Free vascularized fibular transfer offers the potential for rapid autograft incorporation in limbs compromised by adjuvant chemotherapy or radiation. We retrospectively reviewed 30 patients treated with free vascularized fibular graft reconstruction of large skeletal defects after tumor resections (mean defect length, 14.8 cm). The minimum followup was 2 years (mean, 4.9 years; range, 2–15 years). One patient died with liver and lung metastases at 3 years postoperatively. Loss of limb occurred in one patient. Five patients either had metastatic disease (one patient) or had metastatic disease (four patients) develop after treatment, with a mean time to metastasis of 18 months. The overall complication rate was 16 of 30 (53%), with a reoperation rate of 12 of 30 (40%). Union was attained in all 30 grafts. Primary union was attained in 23 (77%) at a mean of 6 months. Secondary union was achieved in seven (23%) after revision fixation and bone grafting; the mean subsequent time to union was 9.2 months, with an index of 1.33 additional operations per patient. Graft fracture (20%) and infection (10%) were other common complications. Despite a high complication rate, free vascularized fibular graft reconstruction offers a reliable treatment of large skeletal defects after tumor resection without increased risk of limb loss, local recurrence, or tumor metastasis. Level of Evidence: Level IV, case series. See Guidelines for Authors for a complete description of levels of evidence.

Objectives: The primary aim of this study was to assess whether local administration of tranexamic acid (TXA) reduced the need for a blood transfusion in elderly patients treated with an intramedullary (IM) nail for an intertrochanteric fracture. Design: Randomized prospective trial. Setting: Academic level 1 trauma center. Patients: Two hundred patients (200 fractures) over 65 years with an intertrochanteric fracture treated by IM nail between April 1, 2012, and March 31, 2014. Intervention: Subfascial administration of 3 g of TXA around the fracture site at the end of the surgical procedure, versus a control group without TXA. Follow-up ranged from 12 to 24 months. Main Outcome Measures: Group differences in number of transfused packed red blood cell (PRBC) units, and hematocrit, hemoglobin, and platelet count. Results: There was a 43% reduction in transfusion requirements in the TXA group (P < 0.01). Twenty-seven units of PRBC were transfused in 22/100 patients in the TXA group, whereas 48 PRBC units were transfused in 29/100 patients in control group. There was no difference between the 2 groups in terms of late complications and overall mortality rate. Conclusions: Subfascial administration of TXA around the fracture site in elderly patients undergoing IM nailing for intertrochanteric fractures is safe and cost-effective. A significant reduction in blood loss and transfused blood units, and health care cost can be achieved. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Osteosarcoma is the most frequent primary bone cancer, mainly affecting those of young ages. Although surgery combined with cytotoxic chemotherapy has significantly increased the chances of cure, recurrent and refractory disease still impose a tough therapeutic challenge. We performed a systematic literature review of the available clinical evidence, regarding treatment of recurrent and/or refractory osteosarcoma over the last two decades. Among the 72 eligible studies, there were 56 prospective clinical trials, primarily multicentric, single arm, phase I or II and non-randomized. Evaluated treatment strategies included cytotoxic chemotherapy, tyrosine kinase and mTOR inhibitors and other targeted agents, as well as immunotherapy and combinatorial approaches. Unfortunately, most treatments have failed to induce objective responses, albeit some of them may sustain disease control. No driver mutations have been recognized, to serve as effective treatment targets, and predictive biomarkers of potential treatment effectiveness are lacking. Hopefully, ongoing and future clinical and preclinical research will unlock the underlying biologic mechanisms of recurrent and refractory osteosarcoma, expanding the therapeutic choices available to pre-treated osteosarcoma patients.