Purpose: The cerclage passer instrument was introduced for aiding percutaneous reduction in spiral femur fractures, thereby overcoming the risk of devascularization of the fracture ends commonly associated with traditional open cerclage wiring techniques. This may, however, predispose to iatrogenic vascular injuries owing to the proximity of the vessels and several other factors. We report four cases with femoral artery (superficial and deep) injuries caused by the cerclage passer in proximal femur and distal femur shaft fractures and incidence of these injuries in our institution. Methods: Retrospective analysis of hospital records of femoral fractures from 2011 to 2015. All cases of femoral fractures and periprosthetic femoral fractures with cerclage wiring done using the standard or the Synthes ® cerclage passer were included. Cases with wiring done for trochanteric fractures and other locations were excluded. Results: Incidence of vascular injuries due to the cerclage passer in proximal femur shaft fractures was 1.59%, whereas in distal femur shaft fractures it was 7.14%. There were two patients with a deep femoral artery (DFA) system injury and two with a superficial femoral artery (SFA) injury caused by the cerclage passer (Synthes) in two proximal femur shaft and two distal femur shaft fractures, respectively. End-to-end anastomosis for the SFA and ligation for DFA system injuries were used, with an uneventful postoperative period in all patients. Conclusion: Caution and accuracy is imperative to avoid vascular injuries while using the cerclage passer in femur fractures, and strict vigilance is essential for early identification and prompt management.

Bilateral avascular necrosis (AVN) following postictal bilateral fracture neck of the femur is a rare occurrence. Here, we report a case of bilateral AVN of the femoral head following an asynchronous bilateral postictal fracture neck of the femur. A 16-year-old autistic boy presented with left hip pain following an episode of seizures and radiographs showed Delbet type II fracture neck of the left femur. This was treated by closed reduction and cancellous screw fixation and skeletal traction for 6 weeks. At 3 months, follow-up radiograph showed union of the fracture, but he had developed segmental AVN with collapse of the head. At 8 months, the patient presented with pain in the right hip following another episode of seizures and radiograph of the pelvis showed a fresh Delbet type II fracture neck of the right femur with established AVN of the left femoral head. He underwent closed reduction and cancellous screw fixation of the right hip and implant exit of the left hip. At the 6-month follow-up after this surgery, his radiograph of the pelvis showed AVN with collapse and extrusion of the femoral head on the right side as well. Literature review shows an increased risk of fracture neck of the femur among epileptics. The incidence of AVN is maximum in Delbet type I, followed by Delbet type II and type III in that order. Although there are no clear guidelines on the management of post-traumatic AVN of the femoral head, the majority have reported that most of them will eventually develop arthritis and will require total hip replacement at a later date. Upon extensive literature search, no case report of bilateral fracture neck of the femur with bilateral AVN was found and hence this case was reported.

Purpose: Fibrous dysplasia (FD) of the proximal femur can result in severe deformity and disability. The results of surgical management in such situations have been reported to be poor. We present a novel, five-step surgical treatment to correct proximal femoral deformity in FD. Material and methods: This study is a review of prospectively collected data of cases of proximal femur polyostotic FD managed at our institute from 2012 onward. We managed three patients with FD involving four femora (one patient had bilateral disease). Mean age at presentation was 16 years with an average follow-up of 46 months. All underwent five steps, that is, (1) curettage/excision of the lesion, (2) allograft in intramedullary region, (3) lateral closing wedge valgus osteotomy, (4) fixation with extramedullary implant, and (5) augmentation of osteotomy site with autograft. Functional outcome was assessed using Harris Hip Score preoperatively and at the final follow-up. Results: The neck shaft angle was corrected from an average of 91.7 to 152.1 , while the Harris Hip Score improved from an average of 59 to 95. There was no clinical or radiological evidence of recurrence of disease or deformity in any patient till the last follow-up. Conclusion: This five-step technique ensures good functional and radiological outcomes in the management of proximal femur FD.

Our study showed that limiting analysis to 30 day unplanned readmissions would lead to failure in identification of 34.85% of readmissions especially deep surgical site infections in TJA and trauma.