Although intramedullary nail fixation maybe highly indicated for comminuted and segmental humeral fractures that require operative treatment, the literature lacks reviews of this content.

The aim of the present study is to prospectively evaluate the clinical and radiographic outcomes in patients with combined head and shaft fractures of the humerus who were treated by antegrade locking intramedullary nailing.

During a period of four years 21 patients (9 men & 12 women) between 36 and 82 years old, with combined fractures of the humeral head and shaft, were operated by one surgeon. Three types of nail implants were used (Polarus long, Garnavos nail, True flex nail) and ante-grade technique was performed in all cases.

The mean operating time was 105 min (50′–140′). The period of follow-up averaged 14.25 months (range, 9 to 18 months). Two patients were lost to follow up and one died before the callus formation procedure was accomplished. The functional assessment included determination of the Constant score and documentation of shoulder function as compared with the non injured extremity. Radiographic control was obtained during the follow-up intervals and at the final follow up. No neurovascular complications, deep wound infections or non-unions were recorded and all fractures were fully healed between 4 to 8 months post-operatively. In one case the nail was extracted before callus formation was achieved, because of acromion impingement.

The results are judged as very satisfying, taking into account the comminution of the fractures. Further evaluation of the results, with comparable methods of internal fixation of such fracture patterns, is needed.

Femoral head aseptic necrosis is a common complication after HSCT. In allogeneic HSCT recipients, hip tuberculosis on top of aseptic necrosis is infrequent and the mortality is high.

We present a case of hip joint tuberculosis in a 57-year-old man with acute myelomonocytic leukemia (M4) treated with HSCT. The patient developed extensive chronic graft versus host disease (cGVHD) five months after transplantation and was treated with cyclosporine and corticosteroids. Eight months after the transplantation because of low-grade fever, elevated ESR and abnormal chest CT scan findings, empirical anti-TB treatment started despite negative tuberculin skin test. Three weeks later anti-TB treatment was stopped because of hepatic enzyme elevation. One year after the transplantation he complained about bilateral hip pain. MRI revealed bilateral femoral head aseptic necrosis. One year later, the right femoral head collapsed, and suddenly, rapid hip joint destruction occurred. He was planned to have total right hip arthroplasty. During the operation an abscess was evacuated and biopsy showed tuberculosis. Necrotic tissues and bone were removed and suction drainage was applied. Diagnosis was confirmed by acid-fast stain, PCR and cultures. In BACTEC MGIT 960 culture system and on Löwenstein-Jensen Mycobacterium tuberculosis was isolated, which was sensitive to all first line anti-TB drugs. After one year of anti-TB treatment (HRZE for 2 months followed by HRE for 10 months), synovial fluid samples were negative for tuberculosis. The patient was submitted to cementless total left hip replacement. Three months later, the right hip was allografted on the acetabular side and a reinforcement ring was used in order to perform a successful total hybrid arthroplasty. Nine months postoperatively the patient is symptom free and able to walk.

Tuberculosis should be considered in the differential diagnosis when rapid joint destruction occurs. Early diagnosis improves response to anti-TB therapy and surgery.