Sure, will add soon

Severe osteoporosis

Age of the patient?

85 years

Sure, you can mail me at [email protected] or whatsapp on +91 8178605393

So, different nails have their own mechanism to block the blades or screws from free sliding. In J&J ones, the set screw sufficiently blocks the sliding, but in some other designs there is long-tip end cap that blocks free sliding.

Thanks for your feedback. 1. Compression may still happen at medial cortex, and fracture may still unite. The issue that will persist will be varus and some shortening, which may be apparent. But wedge effect + distracted fracture and large gap medially may bring a non-union also. 2. If bone is good quality then yes K wire needs to be pulled back, but in osteoporotic, it wont affect much. Usually when we see that compression is not happening, we pull the k wire 3. Yes, TAD is important for screw, it should be within the defined limits of 2.5 cm in AP+Lat view, BUT for blade, it should be kept on higher side to avoid future cut-out, especially in poor bone quality.

Thanks for your feedback! I use tourniquet only in infected cases and follow zero tourniquet policy in other cases. It helps a lot, you achieve hemostatis during surgery and accidental injury to bleeders is simultaneously controlled and no need to wait for tourniquet deflation, and most importantly good healing as there no tissue hypoxia because of hampered blood flow. Overall wound complications become negligible.

Our standard is to start range of motion exercises from day 1 in all these patients. In case of major triceps injuries involving more than half of its circumference, we ensure that repair is done using strong no.5 fiberwire. Rest the post op rehab mainly focuses on movements only without carry any extra load. No brace, no splint. Without these patient gains more confidence.

Sure, Will add soon

I think your concern is very much valid. But, as I told in the video, this case was taken in emergency OT by a resident, who thought that it would be just another neck femur fracture as the patient had given false history to get admission. The old nature of the injury was realized only when the patient was on a fracture table under general anesthesia. Now, in that situation, you don't have any backup implant or consent for a bone graft. Ideally, as I told in the video end, I would have planned for valgus osteotomy with a fibular strut.

Thanks! Yes, a 2 hole longer plate could have been better. But main principle is that the plate length should be 2-3 times the comminuted zone and with scope of at least 3 locking screws with screw density of 50% in diaphyseal segment spanned by the screws. That ensures almost negligible stress on last screw. So when putting the top screw, if it is close to second screw, it will result in stress concentration, but if is it 1-2 hole away, it will not.

Two screw PFN should never be used in unstable trochanteric fractures (screws loosening, collapse and Z effect issues), pfna can be used with blade in suboptimal bone quality but to be avoided in severely osteoporotic bones. Nails that control rotation and some sliding of blade/screw should be preferred.

If isolated medial condyle with split then medial parapatellar approach would do. If medial condyle split with simple lateral condyle, then also medial parapatellar would do. If medial condyle and lateral condyle both split (with additional posterolateral and posteromedial apices) then dual medial+ lateral approach. This has been explained with illustrations and case examples here kzbin.info/www/bejne/Y5nUZXhroL6sgZosi=AGt-4q31Dd_YZ46z

Really sorry for this issue. If speed is the issue then you can adjust it to 0.75 around in youtube player settings. Otherwise if have any specific query I can address that in comment or will add a small video addressing the same. Thanks

@@Justorthothings Thanks

Hi, thanks for your feedback. Most patients do bear some weight despite advice against doing so. We instruct them to avoid weight bearing till we are sure that there is radiological bridging bone. So, considering the noncompliance to non-weight bearing and to avoid full weight bearing, we ask patients to use a walker and then avoid weight bearing. So, with a walker, we have at least some security that the patient will not bear full weight. Partial weight bearing, I feel, should not be an issue because the forces around the hip without weight-bearing are also high and may equate to the load-bearing forces.

@@Justorthothings thank you very much. Its verys clear now. Btw, should x ray performed every months or every 2 months enough? ANd before you apply weight bearing after 2,5 month. Is it directly weightbearing or start slowly

@@nunuros We follow every 4-6 weeks until radiological healing and consolidation are evident. After that, 3-6 months. Yes, weight bearing is gradual so that the patient develops some proprioception and muscle balance.

See, in some fractures, you are invariably going to merge the nail entry with the fracture line, even if you don't intend to do so. The main thing is to avoid the wedge effect, even if your entry merges with the fracture line. See this video; you ll get it: kzbin.info/www/bejne/qmTPlquAhbB2obs

No, once guidewire has been put, no traction should be increased. See releasing traction at the first time is to align the medial cortex levels and is thus can be controlled, the second time its for relaxing muscle tension which will be perceived as the difficulty in gaining compression. As I have shown in second example, the amount of traction release can be negligible at times when medial cortex spikes are at same level even if fracture is slightly distracted. So, you have the indicators (medial cortex levels and force for compression) for sequential release of traction at two steps and the amount will vary from case to case.

Hi, Sorry, at this stage, I won't be able to make it public due to professional commitments, but maybe later I will.

Could have thought that, but here the patient was less than 20 years old, so saving the hip is worth it!

Thanks! See, as I told in the video, once you have inserted the screw, the excess traction is of no use. You can release the traction gradually so that muscle tension is relaxed. The compression actually pulls the shaft towards the proximal fragment in a direction parallel to the direction of the screw/or blade. If your reduction is positive and medial spikes (calcar ends) are at the same horizontal level, then after placing the screw, the excess release of traction won't be an issue. Problems can occur when there is a wedge effect or when the guide wire is inserted in a distracted position.

Yes, the K wire shall be removed only after some length stable fixation is done. Either you can secure that length with some lag screws when K wire is still in place and when that is not feasible, you can put plate with a screw hole over the K wire, the lock few proximal and distal screws and then remove the k wire.

Thanku sir

Thanks! Yes, a 2 hole longer plate could have been better. But main principle is that the plate length should be 2-3 times the comminuted zone and with scope of at least 3 locking screws with screw density of 50% in diaphyseal segment spanned by the screws. That ensures almost negligible stress on last screw. So when putting the top screw, if it is close to second screw, it will result in stress concentration, but if is it 1-2 hole away, it will not.

Thanks for your feedback! 🙏

Thanks for your feedback!

Thanks for your feedback!

So CT angiography is must for this kinda cases right?

@@parkaviyanr6397 In cases with extensive diaphyseal comminution, definitely yes.