Occurrence of secondary fracture around intramedullary nails used for trochanteric hip fractures: a systematic review of 13,568 patients

Previous Implant Fractures: A New Descriptive Classification System

OBJECTIVES

To propose a previous implant fractures (PIFs) classification system with good interobserver reliability.

DESIGN

Retrospective classification.

SETTING

Four academic medical centers.

PATIENTS/PARTICIPANTS

A retrospective review of PIFs treated at 4 academic medical centers over 10 years was performed. Data collected included initial implant and PIF radiographs. There were 103 PIFs in 96 patients during the study period. Seventy-three (70.9%) were about plate/screw (PS) constructs and 30 (29.1%) were about intramedullary (IM) devices.

INTERVENTION

Assignment of PIF classification.

MAIN OUTCOME MEASUREMENTS

PIFs were classified based on initial implant (PS or IM) and fracture location with respect to the initial implant (proximal or distal to the implant, at the tip of the construct, or within the construct). Reliability of this scheme was assessed among 5 observers using Fleiss' kappa tests.

RESULTS

Of PIFs about plate/screw constructs, 26.0% were proximal/distal to the implant (classification: PS1), 57.5% involved bone between the most proximal/distal screw and the same end of the plate (classification: PS2), and 16.4% involved only bone between the most proximal and distal screws (classification: PS3). Of PIFs about IM, 43.3% were distal to the device (classification: IM1), 46.7% involved bone between the most proximal/distal locking bolt and the same end of the device (classification: IM2), and 10.0% involved only bone between locking bolts (classification: IM3). Interobserver reliability for the classification system was excellent between observers, κ = 0.839, P < 0.0005.

CONCLUSIONS

The proposed system offers a simple method to classify and describe fractures that occur about a previously implanted fracture device. Development of a classification system will allow for comparison of treatment modalities between injury types.

Distal locked or unlocked nailing for stable intertrochanteric fractures? A meta-analysis

BACKGROUND

To date, there are just several studies comparing distal locked nails with distal unlocked nails in treating intertrochanteric fractures. We report the first meta-analysis about this issue.

METHODS

Systematic search was conducted for studies in PubMed, Embase and Cochrane Library. Meta-analyses were performed regarding intra operative outcomes, complications and functional outcomes.

RESULTS

Pooled results showed insignificant difference between distal locking group and distal unlocking group in hip pain (relative risk (RR) 1.14, 95% confidence interval (CI) 0.59-2.19), distal tip fracture (RR 1.08, 95% CI 0.37-3.11), lag screw cut-out (RR 1.60, 95% CI 0.54-4.78), delayed or nonunion (RR 1.32, 95% CI 0.25-7.06), deep vein thrombosis (RR 1.06, 95% CI 0.23-4.84), wound infection (RR 0.58, 95% CI 0.28-1.22), Harris hip score (standard mean deviation (SMD) 0.03, 95% CI -0.15 to 0.21) and walking ability. However, significant difference was detected in operation time (SMD 0.77, 95% CI 0.36-1.17), fluoroscopy exposure time (SMD 1.02, 95% CI 0.52-1.52), blood loss (SMD 0.80, 95% CI 0.62-0.99) and total incision length (SMD 1.16, 95% CI 0.86-1.47). Result of trial sequential analysis indicated conclusive evidence.

CONCLUSION

Current evidence indicates that the distal locked intramedullary nails should not be recommended as routine choice for stable intertrochanteric fractures.

Short Versus Long InterTAN Fixation for Geriatric Intertrochanteric Hip Fractures: A Multicentre Head-to-Head Comparison

OBJECTIVE

To determine if geriatric intertrochanteric hip fracture patients achieve equivalent postoperative functional status after management with either a short (180-200 mm) or a long (260-460 mm) InterTAN intramedullary device.

DESIGN

Retrospective review of a prospective randomized control trial.

SETTING

Four Level I Trauma Centers.

PATIENTS/PARTICIPANTS

One hundred eight patients with OTA/AO classification 31A-1 and 31A-2 intertrochanteric hip fractures were included in the study.

INTERVENTION

Internal fixation using an IT device.

MAIN OUTCOMES MEASURES

Primary outcomes included Functional Independence Measure and Timed Up and Go. Secondary outcomes included blood loss, surgical time, length of stay, adverse events, and mortality.

RESULTS

Seventy-one short and 37 long IT patients met study inclusion criteria. Demographics were similar between groups. There was no difference in Functional Independence Measure or Timed Up and Go scores between the 2 IT groups at any of the time points collected. Mean operative time was lower in the short IT group than in the long IT group (60 vs. 73 minutes; P = 0.021). A higher proportion of long IT patients had reamed constructs (95% vs. 48% short IT, P < 0.001). Postoperative blood loss was significantly higher in the long IT group without a significant influence on the number of patients requiring transfusion (P = 0.582) or average units transfused (P = 0.982). There was no significant difference in the proportion of postoperative adverse events between the 2 cohorts despite a higher number of peri-implant femur fractures in the short IT group than in the long IT group (5 vs. 1, P = 0.350).

CONCLUSIONS

Postoperative functional status was not influenced by the length of IT device in the management of geriatric intertrochanteric hip fractures.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Proposal for the classification of peri-implant femoral fractures: Retrospective cohort study

Background Peri-implant fractures occur in association with an implant used to treat a previous injury and that is still attached to the bone. Peri-implant fractures are considered to be relatively "new" fractures and they lack any classification system that is accepted in practice. Generally, the fracture classification systems currently used in our clinical practice were not developed or validated using rigorous scientific evaluation methods. Aim To provide data for a proposed classification of peri-implant femoral fractures. Methods This is an international and multicentre study (12 centres) based on a cohort of consecutive peri-implant fractures with the criterion being: a fracture in any segment of the femur in association with previously-used osteosynthesis material, whether a nail, plate or screws. A proposed system for the classification was tested, based on a topographical classification using alphanumeric coding, following a similar nomenclature to that explained in the "Vancouver-Classification-for-Total-Hip-Arthroplasty-Periprosthetic-Fractures", and classified according to whether the implant is a nail, a screw or a plate, and the location of the fracture in relation to the original implant and the affected femoral segment. The study coordinator performed the first classification exercise, which was discussed subsequently for the study coordinator group to reach a consensus. A descriptive analysis of the fractures was produced. The proportion of peri-implant femoral fractures was estimated, and 95% confidence interval (95%CI) was calculated. Results Between January 2013 and December 2016, data on a total of 143 peri-implant femoral fractures were collected. Only 5 (3.5%) fractures had to be discussed to reach a consensus. The most common peri-implant femoral fractures were located at the diaphyseal segment (#32) and associated with nails or plates: 51%, 73/143, 95%CI:43-59%; at the proximal segment (#31): 39%, 56/143, 95%CI:32-47%; and at the distal femoral segment (#33): 10%, 14/143, 95%CI:6-16%. The highest proportion of peri-implant femoral fractures corresponded to #31-AN (trochanteric and neck area) and #32-CNP (diaphysis fractures distant from the implant, often distal and spiral). Conclusion The proposed classification for peri-implant femoral fractures appears to be useful and easy to accomplish. Future studies will be necessary to validate it and demonstrate the effectiveness of its application in clinical practice.

Breakage in Two Points of a Short and Undersized "Affixus" Cephalomedullary Nail in a Very Active Elderly Female: A Case Report and Review of the Literature

Introduction

Trochanteric fractures of the femur are common in elderly individuals with osteoporosis. The use of cephalomedullary nails is increasing, and they are now the most commonly used fixation devices, especially for the treatment of unstable trochanteric fractures. The nail breakage is not the most common complication of intramedullary nailing. Many scientific papers report nail breakage in a specific location: through the lag screw hole, the nail shaft, or the distal locking hole.

Materials and Methods

We present a case of an 84-year-old patient treated with modular revision hip arthroplasty due to the breakage in two points of a cephalomedullary nail implanted 3 years earlier for a subtrochanteric fracture.

Results

After modular revision hip arthroplasty, the functional results and quality of life have been excellent.

Conclusions

As far as we could determine, this appears to be the first case of a breakage of a cephalomedullary nail in two points after nonunion in a very active elderly female.

Outcomes after unstable pertrochanteric femur fracture: intermediate versus long cephalomedullary nails

PURPOSE

Optimal cephalomedullary nail (CMN) length for unstable pertrochanteric femur fractures is controversial. Long CMNs (L-CMNs) are currently recommended; however, intermediate-length CMNs (I-CMNs) may provide stable fixation without the additional surgical steps required by L-CMNs. We analyzed outcomes after unstable pertrochanteric femur fractures treated with L-CMNs or I-CMNs to determine whether functional outcomes, perioperative measures, complications, and mortality and reoperation rates differ by CMN length.

METHODS

We retrospectively reviewed medical records at our institution for 100 patients who received surgical treatment for pertrochanteric femur fractures from June 2014 to June 2016. Data from 43 unstable pertrochanteric femur fractures treated with L-CMNs (n = 25) or I-CMNs (n = 18) were analyzed. We evaluated operative time, fluoroscopy time, intraoperative blood loss, blood transfusions, and perioperative complications; peri-implant fracture, malunion, reoperation, and death; and neck-shaft angle, tip-apex distance, and 6-month postoperative functional scores. We analyzed categorical data with Fisher exact tests and continuous data with Student t tests. P < 0.05 was considered significant.

RESULTS

The I-CMN group had shorter operative time (68 versus 92 min; P = 0.048), shorter fluoroscopy time (72 versus 110 s; P = 0.019), and less intraoperative blood loss (80 versus 168 mL; P < 0.001) than the L-CMN group. The groups were similar in rates of blood transfusion, perioperative complications, peri-implant fracture, malunion, reoperation, and death. Six-month postoperative functional scores were similar between groups (P > 0.05).

CONCLUSIONS

We found operative advantages of I-CMNs over L-CMNs with no difference in treatment outcomes.

LEVEL OF EVIDENCE

Level IV, Retrospective case series study.

Non-prosthetic peri-implant fractures: classification, management and outcomes

INTRODUCTION

Non-prosthetic peri-implant fractures (NPPIFs) are an under-reported entity. Management is challenging because of alterations in anatomy, the presence of orthopaedic implants and phenomena such as stress shielding, disuse osteopenia and fracture remodeling. The aims of this paper were to review patterns of injury, management and outcomes and to propose a classification system to aid further research.

MATERIALS AND METHODS

This study is a multi-centered retrospective case series. Patients were identified from the orthopaedic department trauma databases of public hospitals in Singapore and individual surgeon case series of members of the Singapore Orthopaedic Research Collaborative (SORCE) group.

RESULTS

We collected a series of 60 NPPIFs in 53 patients. 38 fractures involved the femur, 12 the radius/ulna, 5 humeri, 3 tibia/fibula and 1 clavicle. 39 patients had fractures around plates and screws, 12 around nails, and 3 around screws. Fractures were managed with a variety of surgical techniques. Six patients had surgical complications with refracture in four and non-union in two cases. Two patients had multiple refractures (total 12 additional fractures). All surgical complications required further surgery. Three patients had deep vein thrombosis and one patient died of post-operative pneumonia. Fractures were classified according to the initial implant (plate or nail), the position of the new fracture relative to the original implant (at the tip or distant) and the status of the original fracture (healed, not healed or failing). Surgical strategies for common subtypes were reviewed.

CONCLUSIONS

This study represents the largest series in the literature. NPPIFs are a challenging clinical problem with a high rate of post-operative complications. They are distinct from peri-prosthetic fractures and should be understood as a separate entity. We, therefore, propose a novel classification system. Further research is needed to determine the optimal treatment for the various subtypes.

LEVEL OF EVIDENCE

Therapeutic Level IV-case series.

Optimizing stability in AO/OTA 31-A2 intertrochanteric fracture fixation in older patients with osteoporosis

Objectives

To compare the functional and radiographic outcomes of InterTAN nail (IT) and proximal femoral nail anti-rotation (PFNA) for managing primary AO/OTA 31-A2 intertrochanteric hip fractures (IHFs) in older osteoporotic patients.

Methods

Patients aged 60 years or older who received surgical treatment for IHFs (AO/OTA 3.1A2.1-A2.3) with IT or PFNA were retrospectively evaluated. The primary outcome was the postoperative treatment failure rate. The secondary outcome was the Harris Hip Score (HHS).

Results

A total of 326 osteoporotic cases (326 hips: IT, n = 162; PFNA, n = 164) were assessed with a mean follow-up of 43.5 months (range, 38–48 months). For the entire cohort, the incidence of postoperative treatment failure (periprosthetic fracture and reoperation) was 29/326 (8.9%); the IT-treated cohort (7/162, 4.3%) had a significantly lower rate compared with the PFNA-treated cohort (22/165, 13.3%). The incidence of postoperative periprosthetic fractures was significantly lower in the IT-treated cohort than in the PFNA-treated cohort (2.5% vs 7.9%). The postoperative HHS at the final follow-up was not significantly different between the groups.

Conclusion

IT might show a better outcome in managing osteoporotic AO/OTA 31-A2 IHFs in terms of periprosthetic fracture and reoperation compared with PFNA.

Dual head screw hip nailing for trochanteric fractures

INTRODUCTION

There are limited information and inconclusive results for dual head screw intramedullary hip nails for trochanteric fractures. Therefore, we performed a prospective study to evaluate the healing of fractures, and survival, function, and complications of patients operated with this implant.

METHODS

We prospectively studied 79 patients (61 women and 18 men; mean age: 84.7 years; range: 65-96 years) with a low-energy trochanteric fracture, treated with a dual head screw intramedullary hip nail from 2013 to 2016. The mean follow-up was 2.1 years (range: 1-3 years); seven patients were lost to follow up. This left 72 patients for further analysis. We evaluated the healing of fractures, and survival, function, and complications of patients.

RESULTS

Fracture healing was evident in 70 patients (97.2%) at 2-3 months postoperatively. One patient experienced cut-out and z-effect phenomenon of the head screws. Another patient experienced a periprosthetic femoral diaphysis fracture at the distal tip of the nail. A third patient experienced an acute postoperative superficial skin infection that was treated successfully with wound dressing changes and a course of antibiotics. Sixteen patients (22.2%) deceased within 12 months postoperatively. In the remaining patients, the Harris Hip Score (HHS) at 12 months postoperatively was excellent in 16 (28.6%), good in 23 (41.1%), fair in 10 (17.8%), and poor in 7 patients (12.5%). The function declined after the patients' fracture. Fair and poor results were related to age > 85 years, poor pre-fracture level of function, and AO/OTA-31-A3 fracture types.

CONCLUSION

The dual head screw intramedullary hip nail is associated with high healing and low complication rates for intertrochanteric fractures. The function of the patients is good or excellent in most cases; however, it declines, especially for those patients with age > 85 years, poor pre-fracture level of function, and AO/OTA-31-A3 fracture types.

Secondary femur shaft fracture following treatment with cephalomedullary nail: a retrospective single-center experience

AIM

Secondary femur fracture subsequent to treatment of trochanteric fractures with cephalomedullary nailing (i.e., a periprosthetic fracture related to the cephalomedullary nail) is a rare but very severe complication. As such, the aim of this study was to assess the impact of revision surgery and general state of health on mortality and functional outcomes in patients suffering femur fractures following treatment with cephalomedullary nails.

MATERIALS AND METHODS

Between 2000 and 2015, 3549 patients presenting with OTA/AO 31A1-3 femur fractures were admitted to our department and subsequently treated with either a Gamma^® Nail or PFNA^®. Out of this sample population, 42 patients suffered 43 secondary femur shaft fractures (1.2%). The mean follow-up time was 26 ± 9.7 months. Fractures were classified according to the AO classification and the modified Vancouver classification. Treatment options included ORIF, removing the cephalomedullary nail and fixation with a long nail with or without cerclage wires. General health status was defined according to the ASA Score. Mortality, pre- and postoperative mobility, hospital stay and complications were assessed retrospectively.

RESULTS

A total of 14.3% patients died within 90 days following surgery. At least 16.6% patients died due to medical complications strongly related to the surgery. The average time to secondary fracture following initial surgery for trochanteric fracture was 122.7 ± 32 weeks. The most common fracture types were AO 32A1 (53.5%) and AO 32B1 (23.3), as well as Vancouver C and B1. A time-to-secondary-fracture of less than or longer than 6 months following surgery for trochanteric fracture and ASA Score all had no significant influence on mortality, complications, duration of surgery and postoperative mobility.

CONCLUSION

Femoral shaft facture subsequent to fixation of trochanteric fracture with cephalomedullary nails is a severe complication. It leads to prolonged hospital stays and delayed recovery. Postoperative hospital stay mortality rates may be as high as 16.6%.

Long and short intramedullary nails for fixation of intertrochanteric femur fractures (OTA 31-A1, A2 and A3): A systematic review and meta-analysis

Previous studies have reported conflicting findings concerning the efficacy and safety of the treatment of intertrochanteric fractures (OTA 31-A1,A2 and A3) using short intramedullary nails (SIN) and long intramedullary nails (LIN). The present meta-analysis and literature review investigated the outcomes of SIN and LIN, thereby providing guidance for the treatment of intertrochanteric femur fractures. When used to treat intertrochanteric femur fractures, LIN did not decrease the secondary femoral shaft refracture or reoperation rates. Eight electronic databases were searched for studies related to the use of SIN compared to LIN in treating intertrochanteric fractures. The modified Jadad Scale and the Newcastle-Ottawa Scale (NOS) were used to assess the methodological quality and the risk of bias of these studies. The two groups were compared based on nine indicators, including the surgical times, intraoperative blood loss, transfusion, length of hospital stay, secondary femoral shaft refracture, reoperation, 1-year mortality, Harris hip scores (1 year) and complications. A total of 2431 patients were included in the analysis, with 1498 LIN cases and 940 SIN cases (bilateral nails were used in 7 cases), and the average patient age was 74.83 years. The pooled results indicated that patients in the LIN group had longer surgical times (MD [mean difference]: 12.56; 95% CI: 8.28-16.84; P<0.00001), more intraoperative blood loss (MD: 37.44; 95% CI: 8.06-66.82, P=0.01) and a higher transfusion rate (OR [odds ratio]: 1.53; 95% CI: 1.12-2.10, P=0.008) than patients in the SIN group. However, there was no significant difference in the length of hospital stay (MD: 0.24; 95% CI: -0.58-1.06, P=0.56), occurrence of secondary femoral shaft refractures (OR: 0.72; 95% CI: 0.34-1.53, P=0.39), reoperation rate (OR: 0.95; 95% CI: 0.60-1.50, P=0.82), 1-year mortality (OR: 1.1; 95% CI: 0.67-1.8, P=0.71), Harris hip score (MD: 1.87; 95% CI: -2.8-6.54, P=0.43) or complication rate (OR: 1.29; 95% CI: 0.84-1.99, P=0.25). LIN may not be a better method or provide more effective treatment for intertrochanteric femur fractures; the LIN patients demonstrated the same prognosis as the SIN patients, particularly in terms of secondary femoral shaft refracture and reoperation rate, but they experienced greater trauma. Due to the limitations of the included studies, however, more highly powered randomized controlled trials are needed to clarify the findings. Systematic review and meta-analysis.

LEVEL OF EVIDENCE

III.

Comparison of intramedullary fixation and arthroplasty for the treatment of intertrochanteric hip fractures in the elderly: A meta-analysis

BACKGROUND

More and more studies conduct to compare intramedullary fixation (IMF) with arthroplasty in treating intertrochanteric hip fractures, but it remains controversy. The aim of this meta-analysis was to find out whether IMF or arthroplasty was more appropriate for treating intertrochanteric hip fractures in elderly patients.

METHODS

Relevant studies were searched in the electronic databases of PubMed, Embase, and The Cochrane Central Register of Controlled Trials from January 1980 to September 2016 with English language restriction. Surgical information and postoperative outcomes were analyzed using RevMan 5.3 version.

RESULTS

A total of 1239 patients from 11 studies which satisfied the eligibility criteria were included. Compared with IMF, the use of arthroplasty reduced implant-related complications (odds ratio [OR]: 2.05, P = .02) and reoperation rate (OR: 7.06, P < .001), and had similar length of hospital stay (weighted mean difference [WMD]: -0.41, P = .63). However, IMF reduced blood loss (WMD: -375.01, P = .001) and transfusion requirement (OR: 0.07, P < .001), shorter operation time (WMD: -18.92, P = .010), higher Harris hip score (WMD: 4.19, P < .001), and lower rate of 1-year mortality (OR: 0.67, P = .02) compared with arthroplasty.

CONCLUSION

The main treatment of intertrochanteric hip fractures is internal fixation using IMF. In the absence of concrete evidence, arthroplasty should be undertaken with caution in carefully selected patient and surgeon should be aware of the increased complexity of doing the arthroplasty in these elderly patients. Further high-quality randomized controlled trials (RCTs) are needed to provide robust evidence and evaluate the treatment options.

Biomechanical evaluation of the risk of secondary fracture around short versus long cephalomedullary nails

INTRODUCTION

For proximal femur fractures, long cephalomedullary nails (CMNs) are often selected to avoid a diaphyseal stress riser at the tip of a shorter nail. Secondary peri-implant fracture rates for long and short CMN have not been shown to differ clinically. This study biomechanically compares both CMN in a cadaveric model.

METHODS

Ten matched pairs of cadaveric femora with short or long CMN were axially loaded and internally rotated to failure.

RESULTS

Resulting fractures involved distal interlocking screws of the short and long CMN. Energy and rotation to failure were significantly greater for short CMN. Torque at failure trended higher for short CMN but not significantly. No statistical difference was detected in stiffness of the short and long CMN.

DISCUSSION

A greater risk of secondary fracture is not indicated for short versus long CMN under torsional stress. Short CMN may be suitable in the younger patient.

Trabecular deformations during screw pull-out: a micro-CT study of lapine bone

The mechanical fixation of endosseous implants, such as screws, in trabecular bone is challenging because of the complex porous microstructure. Development of new screw designs to improve fracture fixation, especially in high-porosity osteoporotic bone, requires a profound understanding of how the structural system implant/trabeculae interacts when it is subjected to mechanical load. In this study, pull-out tests of screw implants were performed. Screws were first inserted into the trabecular bone of rabbit femurs and then pulled out from the bone inside a computational tomography scanner. The tests were interrupted at certain load steps to acquire 3D images. The images were then analysed with a digital volume correlation technique to estimate deformation and strain fields inside the bone during the tests. The results indicate that the highest shear strains are concentrated between the inner and outer thread diameter, whereas compressive strains are found at larger distances from the screw. Tensile strains were somewhat smaller. Strain concentrations and the location of trabecular failures provide experimental information that could be used in the development of new screw designs and/or to validate numerical simulations.

Short Versus Long Cephalomedullary Nails for Pertrochanteric Hip Fracture

This study compared patients who underwent treatment with short or long cephalomedullary nails with integrated cephalocervical screws and linear compression. Patients with AO/OTA 31-A2 or A3 pertrochanteric fractures treated with either short (n=72) or long (n=97) InterTAN (Smith & Nephew, Memphis, Tennessee) cephalomedullary nails were reviewed. Information on perioperative measures (estimated blood loss, surgical time, and fluoroscopy time) and postoperative orthopedic complications (infection, implant failure, screw cutout, and periprosthetic femur fracture) was included. Estimated blood loss (short nail, 161 mL; long nail, 208 mL; P=.002) and surgical time (short nail, 64 minutes; long nail, 83 minutes; P=.001) were lower in the short nail group. There were no differences in fluoroscopy time (short nail, 90 seconds; long nail, 142 seconds; P=.071) or rates of infection (short nail, 1.4%; long nail, 3.1%; P=.637) or overall orthopedic complications (short nail, 11.1%; long nail, 9.3%; P=.798) between the 2 groups. The long nail group had a trend toward more screw cutouts (long nail, 5.2%; short nail, 0.0%; P=.134) but fewer periprosthetic femur fractures (short nail, 8.3%; long nail, 0.0%; P=.013). This study found a similar overall rate of orthopedic complications between short and long nails with integrated cephalocervical screws and linear compression. These results confirm the suspected advantages of short nails, including faster surgery and less blood loss; however, the rate of periprosthetic femur fracture remains high, despite changes to implant design. [Orthopedics. 2017; 40(2):83-88.].

Insufficiency Fracture Occurring 3 Years After Union of an Intertrochanteric Hip Fracture: A Case Report

CASE

We present a rare case of insufficiency fracture at the level of the distal interlocking screw following union of an intertrochanteric hip fracture. A 74-year-old woman reported chronic thigh pain for 1 month. She had a history of an osteoporotic stable intertrochanteric fracture that was successfully treated with a short intramedullary nail 3.5 years prior. However, after union, the neck-shaft angle of the femur changed from 125° to 117°. She had been on alendronic acid therapy to prevent a secondary osteoporotic fracture. A recent radiograph and bone scan suggested an insufficiency fracture around the level of the distal interlocking screw. Revision surgery with a long intramedullary nail was performed, and complete union was observed 1 year postoperatively.

CONCLUSION

This case suggests that subsequent insufficiency fracture can occur after complete union of an intertrochanteric hip fracture. Physicians should be aware of the possibility of a stress fracture when a patient has thigh pain after an intertrochanteric fracture has healed following repair with a short intramedullary nail.

Implant options for the treatment of intertrochanteric fractures of the hip

Aims

The aim of this paper is to review the evidence relating to the anatomy of the proximal femur, the geometry of the fracture and the characteristics of implants and methods of fixation of intertrochanteric fractures of the hip.

Materials and Methods

Relevant papers were identified from appropriate clinical databases and a narrative review was undertaken.

Results

Stable, unstable, and subtrochanteric intertrochanteric fractures vary widely in their anatomical and biomechanical characteristics, as do the implants used for their fixation. The optimal choice of implant addresses the stability of the fracture and affects the outcome.

Conclusion

The treatment of intertrochanteric fractures of the hip has evolved along with changes in the design of the implants used to fix them, but there remains conflicting evidence to guide the choice of implant. We advocate fixation of 31A1 fractures with a sliding hip screw and all others with an intramedullary device. Cite this article: Bone Joint J 2017;99-B:128–33.

A comparative study of the therapeutic effect between long and short intramedullary nails in the treatment of intertrochanteric femur fractures in the elderly

PURPOSE

To compare the clinical effects of long vs. short intramedullary nails in the treatment of intertrochanteric fractures in old patients more than 65 years old.

METHODS

A retrospective analysis of 178 cases of intertrochanteric fractures of the femur (AO type A1 and A2) in the elderly was conducted from January 2008 to December 2013. There were 85 males (47.8%) and 93 females (52.2%) with the age of 65e89 (70.2±10.8) years. The patients were treated by closed reduction and long or short intramedullary nail (Gamma 3) fixation. The length of short nail was 180 mm and that for long nail was 320e360 mm. The general data of patients, operation time, intraoperative blood loss, length of hospital stay, preoperative hemoglobin level, blood transfusion rate, postoperative periprosthetic fractures, infections, complications, etc were carefully recorded.

RESULTS

There were 76 cases (42.7%) in the long intramedullary nail group and 102 cases (57.3%) in the short nail group. All the cases were followed up for 12e48 (21.3±6.8) months, during which there were 21 deaths (11.8%), mean (13.8±6.9) months after operation. The intraoperative blood loss was (90.7±50.6) ml in short nail group, greatly less than that in long nail group (127.8±85.9) ml (p=0.004). The short nail group also had a significantly shorter operation time (43.5 min±12.3 min vs. 58.5 min±20.3 min, p=0.002) and lower rate of postoperative transfusion (42.3% vs. 56.7%, p=0.041). But the length of hospital stay showed no big differences. After operation, in each group there was 1 case of periprosthetic fracture with a total incidence of 1.1%, 1.3% in long nail group and 0.9% in short nail group. At the end of the follow-up, all patients achieved bony union. The average healing time of the long nail group was (6.5±3.1) months, and the short nail group was (6.8±3.7) months, revealing no significant differences (p=0.09). Postoperative complications showed no great differences either.

CONCLUSION

Both the intramedullary long and short nail fixation has a good clinical effect in treating intertrochanteric femur fractures in the elderly. They showed no significant difference in terms of therapeutic effect, hospital stay and postoperative complications. The incidence of periprosthetic fractures treated by either length of nails was low. But short intramedullary nailing can obviously decrease the intraoperative blood loss, operation time and postoperative blood transfusion.

Is distal locking with short intramedullary nails necessary in stable pertrochanteric fractures? A prospective, multicentre, randomised study

We investigated whether a proximal femoral nail can be implanted without a distal locking screw in AO/OTA 31-A1 and 31-A2 pertrochanteric stable femur fractures. A multicentre, randomised study was conducted in six level-two trauma centres in our area (Puglia, Italy). A total of 333 patients received their allocated intervention (162 in the locking group [LG] and 171 in the unlocking group [UG]) and 266 patients were included in the final analysis at 1year. Our data showed no statistically significant difference between the two groups at 1-year follow-up for ability to walk, SF-36 questionnaire results, residual pain (visual analogue scale [VAS] score) and level of overall satisfaction. There were also no statistically significant differences between groups for mortality and length of hospital stay. Conversely, the UG was associated with shorter operation and fluoroscopy times, shorter surgical incision length, and less blood loss and residual thigh pain. Pertrochanteric stable fractures (31-A1, 31-A2) can be treated successfully with intramedullary nails without distal locking, reducing patient and clinical personnel radiation exposure and sanitary costs (surgery time and screws costs).

Complications After Hip Nailing for Fractures

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.

Nail Length in the Management of Intertrochanteric Fracture of the Femur

Intramedullary devices are used increasingly to treat intertrochanteric femur fractures, especially those with unstable patterns. In spite of the considerable use of nails in the management of these fractures, opinions differ about the correct length of intramedullary nail. Long nails were developed to address the risk of diaphyseal fracture associated with earlier short nail designs and to extend the indications for use to include diaphyseal and subtrochanteric fractures. Several recent studies, however, have found no differences between modern short nails and long nails with regard to union and complication rates. In the absence of existing guidelines, the treating surgeon's preference and fracture characteristics continue to influence the decision of whether to use short nails or long nails. The surgeon needs to consider the fracture configuration and related factors, including whether osteoporosis is present and the cost and risk of revision surgery, when selecting the appropriate nail length.

Long versus short cephalomedullary nail for trochanteric femur fractures (OTA 31-A1, A2 and A3): a systematic review

BACKGROUND

Both long and short cephalomedullary nails (CMN) may be used to treat trochanteric femur fractures. The objective of this paper was to compare the clinical outcomes between long and short CMN in the treatment of trochanteric hip fractures.

MATERIALS AND METHODS

A literature search was performed, identifying 135 papers; 4 of which met inclusion and exclusion criteria. Papers included were those that compared cohorts of long and short nails for stable trochanteric femur fractures of level III evidence or superior. Data was pooled and analyzed, focusing on reoperation rate, secondary femoral shaft fracture rate, estimated blood loss, transfusion rate, operative time and length of stay.

RESULTS

Included in the analysis were 1276 patients, with 438 short and 838 long CMN. The average age was 82.0 years for short CMN and 79.0 years for long CMN (P = 0.0002). The average follow up was 18 months, 46 % were male, and 71 % had an ASA (American Society of Anesthesiologists score) classification ≥3. The rate of reoperation was 5.0 % and 3.8 % for short and long CMN, respectively (P = 0.31). The rate of refracture was 1.6 % and 0.95 % for short and long CMN, respectively (P = 0.41). As compared to long nails, short nails had an average blood loss of 39 mL less (P = 0.0003), an 8.8 % decrease in transfusion rate (P = 0.07), and incurred 19 min less operative time (P < 0.0001). No significant differences between short and long nails were observed for either other complications, hardware complications, non-union, or mortality.

CONCLUSIONS

For trochanteric femur fractures, short CMN have a low reoperation rate while significantly decreasing operative time and estimated blood loss with the additional benefit of being cost effective.

LEVEL OF EVIDENCE

Level 3.

A meta-analysis of percutenous compression plate versus intramedullary nail for treatment of intertrochanteric HIP fractures

INTRODUCTION

Intertrochanteric hip fracture is associated with increased morbidity. Currently, a dramatic change in practice was demonstrated, with the intramedullary fixation rate increasing, despite a lack of evidence in the literature supporting the change. As a minimally invasive technique, percutaneous compression plating (PCCP) has been advocated to reduce blood loss, relieve pain, and lead to faster rehabilitation for treatment of intertrochanteric hip fractures. The purpose of this meta-analysis was to estimate the outcomes and complications of the PCCP versus intramedullary nail (IMN) fixation for intertrochanteric fractures.

METHODS

A comprehensive search of related literature was conducted to identify all articles in Medline, Embase, Scopus, Research Gate, and the Cochrane Central Register of Controlled Trials published on or between January 1998 and January 2016. All studies that compared PCCP with IMN in treating adult patients with intertrochanteric fractures were included. Main outcomes about the two fixation method were collected and analysised using the Review Manager 5.1 provided by The Cochrane Collaboration.

RESULTS

Six trials involving 908 fractures met the inclusion criteria. Compared with IMN, PCCP had similar operation time, intraoperative blood loss, mortality, system complications, function score, function recovery, and reoperation rate (P > 0.05). But hospital stay, transfusion need, and incidence of implant-related complications significantly favored the PCCP (P < 0.05).

CONCLUSIONS

The PCCP was associated with less transfusion need, reduced hospital stay, and fewer incidence of implant-related complications compared with IMN. Although a change in practice was occurred, the patients treated with IMN seemed to face the potential for more complications. Owing to the limitations of this systematic review, more high-quality randomized controlled trials (RCTs) are still needed to confirm this conclusion.

Costs and Complications of Short Versus Long Cephalomedullary Nailing of OTA 31-A2 Proximal Femur Fractures in U.S. Veterans

OBJECTIVES

In fractures without subtrochanteric extension, the indications for the use of short versus long cephalomedullary nails (CMNs) for intertrochanteric femur fractures are unclear. We hypothesized that long nails would be associated with higher costs and similar complication rates.

DESIGN

Retrospective comparative study.

SETTING

United States Department of Veterans Affairs Medical Centers.

PARTICIPANTS

Patients receiving CMNs for OTA 31-A2 pertrochanteric fractures from 2001 to 2010.

INTERVENTIONS

Short versus long cephalomedullary nailing.

MAIN OUTCOME MEASUREMENTS

Costs, perioperative complications, readmissions, surgical failures, and mortality.

RESULTS

We identified 262 patients with OTA 31-A2 pertrochanteric fractures (125 treated with short CMNs and 137 treated with long CMNs). The 2 cohorts had similar demographic and medical characteristics. There were no significant differences in perioperative complications, readmissions within 30 days, surgical failures within one year, or death within 30 days or one year. The average cost of hospitalization was significantly higher for the cohort treated with long nails (greater than $7000 in actual costs, and greater than $3000 when statistically adjusted for differences in postoperative lengths of stay). Multivariable analyses showed no significant differences in the rates of development of at least one complication, readmission, or death.

CONCLUSIONS

In a cohort of patients with similar characteristics and fracture patterns, the use of long CMNs was associated with similar rates of complications, readmission, and reoperations, but significantly higher costs than with the use of short nails.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Short Versus Long Intramedullary Nails in the Treatment of Pertrochanteric Hip Fractures: Incidence of Ipsilateral Fractures and Costs Associated With Each Implant

OBJECTIVES

Both short intramedullary nails (SIMNs) and long intramedullary nails (LIMNs) are routinely used in the surgical treatment of pertrochanteric hip fractures. The purpose of this study was to assess the incidence of ipsilateral femur fractures after the surgical treatment of hip fractures and the overall costs associated with each implant.

DESIGN

Retrospective cohort study.

SETTING

Level I trauma center and 2 community hospitals.

PATIENTS/PARTICIPANTS

A total of 609 patients with pertrochanteric hip fractures treated with an SIMN or LIMN from 2005 to 2011.

INTERVENTION

Review of patient demographics and clinical outcomes over a 5-year follow-up period.

MAIN OUTCOME MEASUREMENTS

Ipsilateral femur refracture rates were recorded for both groups, and a cost analysis was then performed to compare SIMNs and LIMNs while accounting for their observed refracture rates and surgical/hospital costs to determine the overall cost of each implant.

RESULTS

Union rates were equivalent between groups and averaged over 97%. The incidence of ipsilateral femur fractures in both groups steadily increased with greater follow-up time to reach nearly 10% at 5 years. Although only 47% of all nails were locked distally, 15 of the 16 refractures occurred in nails that were not distally locked. Cost analysis revealed no significant difference in the use of short versus LIMNs over a 5-year period (P = 0.76).

CONCLUSIONS

The incidence of ipsilateral femur refractures steadily rose with greater follow-up in both SIMN and LIMNs. Distally locking the initial fixation seems to protect against future femur fractures and may also affect the refracture location when using LIMNs. No differences in overall costs were seen at 1, 2, or 5 years between SIMNs and LIMNs.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Proximal Femoral Nail Antirotation in Treatment of Intertrochanteric Hip Fractures: a Retrospective Study in 113 Patients

Introduction:

The best treatment for intertrochanteric fractures remains controversial. Many methods have been recommended.

Aim:

We aimed to assess the results of osteosynthesis using the Proximal Femoral Nail Antirotation (PFNA) system.

Patients and Methods:

We retrospectively analyzed 113 consecutive patients with intertrochanteric fractures treated with PFNA. Fractures were classified in accordance with the AO/OTA classification system into the groups A1, A2 and A3. The postoperative quality of fracture reduction was described as good, acceptable or poor. The location of the blade within the head was recorded as per the Cleveland method. Tip-apex distance (TAD) was used as a method for evaluating screw position. Pre-fracture and postoperative functional level were evaluated by the new mobility score (NMS).

Results:

The average age at the time of surgery was 75.9 years. The majority, 75 (66.3 %), were unstable fracture types. The reduction was good in 67 (61.4 %) cases. Of the 24 deaths, 19 patients had comorbidities (p < 0.001). The number of deaths in the first 6 months was significantly higher than in the next 6 months (p = 0.001). The mean TAD was 25.6 mm. The Cleveland zone centre-centre was the most common placement of the blade, accounting for 33 (29 %) of the cases. Reoperation was required in four patients. There were four patients with cut-out. The pre-facture mean value NMS was 8.6 (SD 1.1) and the postoperative mean value was 4.3 (SD 3.6).

Conclusion:

We concluded that PFNA offers biomechanical advantages, but the best position of the blade is still unknown.

How evolution of the nailing system improves results and reduces orthopedic complications: more than 2000 cases of trochanteric fractures treated with the Gamma Nail System

PURPOSE

The incidence of trochanteric fractures has increased significantly during the last few decades, especially in elderly patients with osteoporosis. The dynamic/sliding hip screw and the cephalomedullary nail are the most commonly used fixation methods to treat trochanteric fractures. The improvements in the Gamma Nail System (GNS) associated with a correct surgical technique reduced the postoperative orthopedic complications. The purpose of this study was to compare the results of the different Gamma Nails.

METHODS

The present study is a retrospective analysis of 2144 patients treated with GNS between January 1997 and December 2011 for trochanteric fractures, classified according to AO classification method. The patients were divided into three groups according to the nailing system: 525 were treated with Standard Gamma Nail (SGN), 422 with Trochanteric Gamma Nail (TGN) and 1197 with Gamma3 Nail.

RESULTS

The overall incidence of intra-operative complications was 1.21 %; the incidence of intra-operative complications for each group was 1.71 % for SGN group, 0.47 % for TGN group and 1.25 % for Gamma3 Nail group. The overall incidence of postoperative complications was 5.48 %, and the incidence for each group was 10.73 % for SGN group, 9.92 % for TGN group and 2.92 % for Gamma3 Nail group.

CONCLUSION

The GNS is a safe device with a low rate of intra-operative complications. The evolution of this nail system reduces postoperative complications, thus improving the results at follow-up and confirming that the Gamma3 Nail is a safe and predictable device to fix trochanteric fracture.

Internal fixation treatments for intertrochanteric fracture: a systematic review and meta-analysis of randomized evidence

The relative effects of internal fixation strategies for intertrochanteric fracture after operation remain uncertain. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to address this important issue. We searched PubMed, EMBASE and CENTRAL for RCTs that compared different internal fixation implants in patients with intertrochanteric fracture at 6-month follow-up or longer. We ultimately included 43 trials enrolling 6911 patients; most trials were small in sample sizes and events. Their risk of bias was generally unclear due to insufficient reporting. Because of these, no statistically significant differences were present from most of the comparisons across all the outcomes, and no definitive conclusions can be made. However, a number of trials compared two commonly used internal fixation strategies, gamma nail (GN) and sliding hip screw (SHS). There is good evidence suggesting that, compared to SHS, GN may increase the risk of cut out (OR = 1.87, 95% CI, 1.08 to 3.21), re-operation (OR = 1.61, 95% CI, 1.02 to 2.53), intra-operative (OR = 3.14, 95% CI, 1.34 to 7.35) and later fractures (OR = 3.67, 95% CI, 1.37 to 9.83). Future randomized trials or observational studies that are carefully designed and conducted are warranted to establish the effects of alternative internal fixation strategies for intertrochanteric fracture.

Common complications in hip fracture surgery: Tips/tricks and solutions to avoid them

Surgical management of hip fractures in elderly people is challenging and complications relating to surgery could be devastating. They often lead to reoperation and revision surgery and can be associated with significantly increased morbidity and mortality. The most common surgical complications after internal fixation of hip fractures include cut-out, nonunion, Z-effect/medial migration, periimplant failure and avascular necrosis. High quality surgical fixation is of outmost importance to avoid surgical complications. This article presents the aetiology, risk factors and incidence of perioperative and post-fracture fixation complications. Technical tips and tricks for a successful fixation as well as the contemporary evidence surrounding the augmentation of osteoporotic bone fixation in internal fixation of hip fractures are discussed.

Which Fixation Device is Preferred for Surgical Treatment of Intertrochanteric Hip Fractures in the United States? A Survey of Orthopaedic Surgeons

BACKGROUND

The best treatment for intertrochanteric hip fractures is controversial. The use of cephalomedullary nails has increased, whereas use of sliding hip screws has decreased despite the lack of evidence that cephalomedullary nails are more effective. As current orthopaedic trainees receive less exposure to sliding hip screws, this may continue to perpetuate the preferential use of cephalomedullary nails, with important implications for resident education, evidence-based best practices, and healthcare cost.

QUESTIONS/PURPOSES

We asked: (1) What are the current practice patterns in surgical treatment of intertrochanteric fractures among orthopaedic surgeons? (2) Do surgical practice patterns differ based on surgeon characteristics, practice setting, and other factors? (3) What is the rationale behind these surgical practice patterns? (4) What postoperative approaches do surgeons use for intertrochanteric fractures?

METHODS

A web-based survey containing 20 questions was distributed to active members of the American Academy of Orthopaedic Surgeons. Three thousand seven-hundred eighty-six of 10,321 invited surgeons participated in the survey (37%), with a 97% completion rate (3687 of 3784 responded to all questions in the survey). The survey elicited information regarding surgeon demographics, preferred management strategies, and decision-making rationale for intertrochanteric fractures.

RESULTS

Surgeons use cephalomedullary nails most frequently for treatment of intertrochanteric hip fractures. Sixty-eight percent primarily use cephalomedullary nails, whereas only 19% primarily use sliding hip screws, and the remaining 13% use cephalomedullary nails and sliding hip screws with equal frequency. The cephalomedullary nail was the dominant approach regardless of experience level or practice setting. Surgeons who practiced in a nonacademic setting (71% versus 58%; p < 0.001), did not supervise residents (71% versus 61%; p < 0.001), or treated more than five intertrochanteric fractures a month (78% versus 67%; p < 0.001) were more likely to use primarily cephalomedullary nails. Of the surgeons who used only cephalomedullary nails, ease of surgical technique (58%) was cited as the primary reason, whereas surgeons who used only sliding hip screws cite familiarity (44%) and improved outcomes (37%) as their primary reasons. Of those who use only short cephalomedullary nails, ease of technique (59%) was most frequently cited. Postoperatively, 67% allow the patient to bear weight as tolerated. Nearly all respondents (99.5%) use postoperative chemical thromboprophylaxis.

CONCLUSIONS

Despite that either sliding hip screw or cephalomedullary nail fixation are associated with equivalent outcomes for most intertrochanteric femur fractures, the cephalomedullary nail has emerged as the preferred construct, with the majority of surgeons believing that a cephalomedullary nail is easier to use, associated with improved outcomes, or is biomechanically superior to a sliding hip screw. The difference between what is evidence-based and what is done in clinical practice may be attributed to several factors, including financial considerations, educational experience, or inability of our current outcomes measures to reflect the experiences of surgeons. The educators, researchers, and policymakers among us must work harder to better define the roles of sliding hip screws and cephalomedullary nails and ensure that the increasing population with hip fractures receives high-quality and economically responsible care.

LEVEL OF EVIDENCE

Level V, therapeutic study.

Calcar femorale grafting in the hemiarthroplasty of the hip for unstable inter trochanteric fractures

BACKGROUND

The sliding screw-plate devices and cephalo-medullary nail devices have performed well in stable inter-trochanteric fractures in patients with reasonably good quality of bone. However, their suboptimal performance in comminuted fractures in the presence of osteoporotic bone has prompted many surgeons to consider bipolar hemiarthroplasty as the primary modality of management of comminuted inter-trochanteric fractures in elderly patients. However, long term stability of the hemiarthroplasty implant also may be compromised due to the presence of postero-medial bone loss at the area of the calcar.

MATERIALS AND METHODS

We have presented a simple and effective technique of calcar grafting by harvesting cortical bone strut from the neck of the fractured femur. A total of 34 patients with inter-trochanteric fractures of the femur were treated with calcar grafting. The mean age was 79.2 years. The graft was harvested from the calcar region of the head and neck fragment of the femur and wedged between the medial femoral cortex and medial edge of the prosthesis. The mean followup period was 54.5 months.

RESULTS

In 32 of 34 (94%) patients in our series, the calcar graft healed well without dislodgement. There was graft resorption in two patients associated with subsidence of the implant and loosening.

CONCLUSION

Calcar grafting using this technique provides stability to the implant in the presence of comminution and incorporates well in the majority of patients. Donor site morbidity of graft harvesting is also avoided.

Subtrochanteric fractures after retrograde femoral nailing

Secondary fractures around femoral nails placed for the management of hip fractures are well known. We report, two cases of a fracture of the femur at the interlocking screw site in the subtrochanteric area after retrograde femoral nailing of a femoral shaft fracture. Only a few reports in the existing literature have described these fractures. Two young men after sustaining a fall presented to us with pain, swelling and deformity in the upper thigh region. On enquiring, examining and radiographing them, peri-implant fractures of subtrochanteric nature through the distal interlocking screws were revealed in both patients who also had histories of previous falls for which retrograde intramedullary nailing was performed for their respective femora. Both patients were managed with similar surgical routines including removal of the existing hardware, open reduction and ace cephallomedullary antegrade nailing. The second case did show evidence of delayed healing and was additionally stabilized with cerclage wires. Both patients had uneventful postoperative outcomes and union was evident at the end of 6 mo postoperatively with a good range of motion at the hip and knee. Our report suggests that though seldom reported, peri-implant fractures around the subtrochanteric region can occur and pose a challenge to the treating orthopaedic surgeon. We suggest these be managed, after initial stabilization and resuscitation, by implant removal, open reduction and interlocking intramedullary antegrade nailing. Good results and progression to union can be expected in these patients by adhering to basic principles of osteosynthesis.

Wedge effect following intramedullary hip screw fixation of intertrochanteric proximal femur fracture

INTRODUCTION

The aim of the current study was to determine whether application of an intramedullary hip screw for definitive management of intertrochanteric fracture was associated with post-operative deformity. Specifically this study investigated whether nail insertion would cause a "wedge effect" of the intertrochanteric fracture manifesting as lateralization of the femoral shaft and varus malalignment.

MATERIALS AND METHODS

The trauma database at the University of Pittsburgh Medical Center was investigated to identify all intertrochanteric fractures (AO/OTA 31A) over the past 3 years treated with an IMHS. Fractures eligible for inclusion were performed under the supervision of a fellowship trained orthopedic trauma surgeon. All fractures were reduced in optimal alignment using percutaneous or mini-open strategies during the reaming process and nail insertion. The entry portal was over-reamed by at least 1.5 mm. Cases selected for review of the "wedge effect" had optimal post-operative imaging allowing for assessment of discrepancy between the operative and normal hip.

RESULTS

Forty six patients with an average age of 77 years were included for study. Fifty percent were classified as unstable patterns. Shaft lateralization following IMHS fixation of the fractured hip was found to be an average of 7 mm greater than the contralateral intact hip (p < 0.001) (range 0-30 mm). The neck-shaft angle of the operative hips was 129° as compared to 133° on the intact side (p = 0.009). The stability of the fracture pattern was not predictive for post-operative lateralization of the femoral shaft or varus angulation (p > 0.05) (Table 2). There was no difference in post-operative deformity among techniques used for maintenance of reduction during reaming and nail insertion (p > 0.05). Despite deformity, all cases demonstrated radiographic radiographic fracture union.

CONCLUSION

Despite attention to detail, the application of an intramedullary hip screw for intertrochanteric fracture has the tendency to lateralize the shaft relative to the head/neck segment (The "wedge effect").

Prevention of excessive postoperative sliding of the short femoral nail in femoral trochanteric fractures

INTRODUCTION

Lag screw cut-out is one of the major postoperative complications on femoral trochanteric fractures. However, precise analyses of excessive sliding and lag screw cut-out were limited. The purpose of this study was to investigate the factors that induce this unfavorable event.

METHODS

From April 2010 to April 2013, 226 patients were operated in our institute using a short femoral nail. Among them, 177 patients (29 males and 148 females) with a mean age of 84 years (60-97 years), who were followed up >3 months, were included in this study. The postoperative sliding distance, fracture type (AO/OTA classification), tip-apex distance (TAD), reduction pattern in the postoperative X-ray (antero-posterior and lateral views), bone quality (canal flare and cortical indices), walking ability at the time of pre-injury and final follow-up, and complications were investigated retrospectively.

RESULTS

The mean sliding distance was 3.7 mm, and one cut-out case (0.6 %) was observed. The sliding distance of the AO/OTA 31-A2 fractures was significantly longer than that of the A1 fractures (p < 0.0001). Regarding the reduction pattern, the sliding distance of the intramedullary type was longer than that of the extramedullary and anatomical types in the lateral view (p < 0.01, p < 0.001, respectively). Further, even in the medial and anatomical types, where the reduction patterns are recommended in the antero-posterior view, the sliding distance of the intramedullary type was significantly longer than that of the anatomical type in the lateral view. There was no correlation of bone quality with the sliding distance.

CONCLUSIONS

Because the sliding distance increased in the intramedullary type in the lateral view of unstable fractures, an accurate reduction in the lateral view at surgery is important, particularly in unstable fractures.

Nailing intertrochanteric hip fractures: short versus long; locked versus nonlocked

A large number of implants have been developed for intramedullary fixation of intertrochanteric fractures. This article attempts to summarize the contemporary understanding of the existing biomechanical and clinical evidence on intramedullary nailing of intertrochanteric fractures, as to whether they should be short or long nails, and the use or not of distal locking screws. Difficulties on the translation of biomechanical findings to the clinical setting, as well as the pressing demand for standardization of the indications and the use of different modes of cephalomedullary nailing, should direct orthopaedic trauma research toward focused, well-designed clinical studies.

LEVEL OF EVIDENCE

Level V-expert opinion.

Biomechanical comparison of long, short, and extended-short nail construct for femoral intertrochanteric fractures

OBJECTIVES

Short and long cephalomedullary (CM) nails are commonly used construct for fixation of intertrochanteric (IT) fractures. Each of these constructs has its advantages and its shortcomings. The extended-short (ES) CM nail offers a hybrid between long and short nail design that aims to combine their respective benefits. The goals of this study were to (1) biomechanically evaluate and compare construct stiffness for the long, short and ES constructs in the fixation of IT fractures, and to (2) investigate the nature of periprosthetic fractures of constructs implanted with these various designs.

METHODS

Eighteen synthetic femora were used to evaluate three types of fracture fixation constructs. Axial compression, bending, and torsional stiffness were reported for both stable and comminuted IT fracture models. All comminuted fracture constructs were loaded to failure in axial compression to measure failure loads and evaluate periprosthetic fracture patterns.

RESULTS

Stiffness were similar among constructs with few exceptions. Axial stiffness was significantly higher for the short nail compared to the long nail for the comminuted model (p= 0.020). ES nail constructs exhibited a significantly higher failure load than short nail constructs (p = 0.039). Periprosthetic fractures occurred around the distal interlocking screw in all constructs.

CONCLUSIONS

Nail length and position of interlocking screw did not alter the biomechanical properties of the fixation construct in the presented IT fracture model. Periprosthetic fractures generated in this study had similar patterns to those seen clinically. This study also suggests that if a periprosthetic fracture is to occur, there is an increased probability of it happening around the site of the interlocking screw, regardless of nail design.

Mid-term results after treatment of intertrochanteric femoral fractures with percutaneous compression plate (PCCP)

BACKGROUND

With the ageing of the population, intertrochanteric femoral fracture is associated with increased morbidity. There is continuing controversy over the best treatment for the injury, and the choice of internal fixation method has been a focus of dispute. The purpose of this study was to evaluate the results of these fractures being treated with the percutaneous compression plate (PCCP) technique.

METHODS

From March 2009 to May 2012, 154 patients with intertrochanteric femoral fractures were treated using the PCCP method. Forty-one patients were excluded from the study. According to the AO classification, the remaining 113 fractures were classified as 35 cases of 31A1 fractures, 59 cases of 31A2 fractures, and 19 cases of 31A3 fractures. The clinical data and imaging results were retrospectively analysed.

RESULTS

The mean operation time was 42.0 (range, 25-82) min, the mean intraoperative blood loss was 40.5 (range, 10-100) ml, and the mean hospital stay was 8.6 (range, 3-18) days. One patient died of renal failure in the perioperative period. Twelve patients died during the 12 months after surgery. The remaining 100 patients were followed-up for 12-36 months and healed their fractures except one, whose neck screw cut out from the femoral neck after 1 postoperative month and resulting in a revision to a hemiarthroplasty. The mean time to bone healing was 12.6 (range, 6-23) weeks. Sixteen patients had pain. There were 13 major device-related complications, including 5 cases of coxa vara, 4 cases of fracture collapse, 2 cases of head penetration, and 2 cases of fracture collapse combined with head penetration. At the time of the last follow-up, 81 patients had regained a pre-injury level of function. The median Harris hip score was 89 points. The median Parker-Palmer score was 7 points. Patients with poor quality of reduction and bad positioning of neck screw were more likely to suffer complications (p<0.05).

CONCLUSION

The results suggest that the PCCP is an effective and safe method in the treatment of all types of intertrochanteric femoral fractures, but good fracture reduction and ideal positioning of the neck screw are prerequisites for the success of the device.

Expandable Proximal Femoral Nails (EPFNs) in Elderly Patients

PURPOSE

The purpose was to study the performance of expandable proximal femoral nails (EPFNs) for the treatment of unstable intertrochanteric fractures in elderly patients.

PATIENTS AND METHODS

Eighty-four patients were treated with a newly designed EPFN and followed up for one year.

RESULTS

The mean operating time was 50.1 ± 3.2 min and the mean blood loss was 112.3 ± 5.3 ml. Patients were treated with EPFNs of 220 mm (n = 24), 240 mm (n = 59), and 340 mm (n = 1) length. At six months postoperatively, the Harris Hip Score was 74.5 ± 5.3. At the end of follow up, 75% of patients completely recovered their preoperative function and resumed their normal activities. Seven patients died within one year postoperatively. During the operation, one patient experienced proximal femoral diaphyseal slight crack fracture. This crack fracture was treated by using a long EPFN (340 mm). Two patient developed screw cut-outs, which were solved by reoperation. And one developed deep infection resolved favorably by the appropriate antibiotic treatment. Implant failure, deep venous thrombosis, fat embolism, secondary fracture, and nonunion were not encountered.

CONCLUSIONS

In conclusion, the results of the EPFNs were satisfactory in most elderly patients with unstable intertrochanteric fracture. However, during the inflation period, the pressure on the nail must be monitored carefully in order to prevent a crack fracture.

Avascular necrosis of the femoral head following trochanteric fractures in adults: a systematic review

INTRODUCTION

Avascular necrosis of the femoral head (ANFH) following trochanteric fractures (TFx) is infrequent. The causal relationship between ANFH and TFx remains controversial. Although several major risk factors for ANFH have been proposed, most of them remain under discussion. In this study we undertook a systematic review of the literature to investigate the incidence of AVN, risk factors and outcomes following Tfx fixation.

MATERIALS AND METHODS

A comprehensive review of the literature was undertaken using the PRISMA guidelines with no language restriction. Case reports of ANFH and series of TFx with or without cases of ANFH published between inception of journals to December 2013 were eligible for inclusion. Relevant information was divided in two sections. Part I: included the analysis of detailed case reports of ANFH, either published isolated or included in series of TFx, with the objective of establishing potential risk factors, clinical and radiological presentation, time to development, treatment and outcome of this complication. Part II: analyzed series of TFx, which included cases of ANFH with or without details of aetiology, treatment modalities and outcomes, with the objective of assessing the incidence of ANFH in TFx.

RESULTS

Overall 80 articles with 192 cases of ANFH after TFx met the inclusion criteria. The most probable developmental pathway appears to be a disruption of the extra osseous arterial blood supply to the femoral head. Suggested risk factors included high-energy trauma with fracture comminution and displacement, and an atypical course of the fracture line, more proximal, at the base of the neck. Most cases were diagnosed within the first two years after fracture. The clinical and radiological features appear to be similar to those of idiopathic avascular necrosis of the femoral head. The incidence of AVFH with a minimum of 1-year follow-up was calculated 0.95%, and with a minimum 2-year follow-up it was 1.37%. Total hip replacement was the mainstay of treatment.

CONCLUSION

The incidence of AVFH after Tfx fixation is small 1.37% within the first 2 years of injury. Risk factors for the development of this complication are related to the severity of trauma, fragment geometry and fracture displacement. Optimum surgery of these fractures cannot guarantee prevention of ANFH.

Is distal locking of long nails for intertrochanteric fractures necessary? A clinical study

BACKGROUND

Few clinical studies have examined the utility of distal interlocking nails when fixing intertrochanteric fractures with intramedullary devices. In this study we performed a retrospective analysis comparing fixation method of intertrochanteric fractures with either a long unlocked cephalomedullary nail versus a long locked cephalomedullary nail. Our hypothesis was there would be no difference in device related failures or complications in stable intertrochanteric fractures treated with long locked or long unlocked cephalomedullary nails.

METHODS

A retrospective chart review was performed of all stable intertrochanteric fractures treated with a long cephalomedullary nail between 2006 and 2012 at our institution. Clinical history as well as perioperative radiography was carefully reviewed for all subjects. AO classification, the use of locked or unlocked technique, and failure status was recorded.

RESULTS

Overall, a device related failure rate of 1.8% (2/107) was observed for stable intertrochanteric fractures treated with long cephalomedullary nails. No statistical difference in failure rate was found between locked and unlocked nails within our studied population (0% long locked (0/56) versus 3.9% long unlocked (2/51), p = 0.224).

CONCLUSION

This clinical study supports our hypothesis that long cephalomedullary nails do not need to be locked for stable intertrochanteric fractures. We found no difference in failure rates between the two approaches across 107 patients.

Fragility fractures of the ankle in the frail elderly patient

Conventional methods of treating ankle fractures in the elderly are associated with high rates of complication. We describe the results of treating these injuries in 48 frail elderly patients with a long calcaneotalotibial nail.

The mean age of the group was 82 years (61 to 96) and 41 (85%) were women. All were frail, with multiple medical comorbidities and their mean American Society of Anaesthesiologists score was 3 (3 to 4). None could walk independently before their operation. All the fractures were displaced and unstable; the majority (94%, 45 of 48) were low-energy injuries and 40% (19 of 48) were open.

The overall mortality at six months was 35%. Of the surviving patients, 90% returned to their pre-injury level of function. The mean pre- and post-operative Olerud and Molander questionnaire scores were 62 and 57 respectively. Complications included superficial infection (4%, two of 48); deep infection (2%, one of 48); a broken or loose distal locking screw (6%, three of 48); valgus malunion (4%, two of 48); and one below-knee amputation following an unsuccessful vascular operation. There were no cases of nonunion, nail breakage or peri-prosthetic fracture.

A calcaneotalotibial nail is an excellent device for treating an unstable fracture of the ankle in the frail elderly patient. It allows the patient to mobilise immediately and minimises the risk of bone or wound problems. A long nail which crosses the isthmus of the tibia avoids the risk of peri-prosthetic fracture associated with shorter devices.

Cite this article: Bone Joint J 2014; 96-B:817–22.

Short versus long intramedullary nails for treatment of intertrochanteric femur fractures (OTA 31-A1 and A2)

OBJECTIVES

The purpose of this study was to compare blood loss and operative times associated with long versus short intramedullary nails for intertrochanteric fracture fixation and rate of periprosthetic fracture.

DESIGN

A retrospective study.

SETTING

Level 1 trauma center.

PATIENTS

One hundred ninety-four patients with an intertrochanteric fracture (AO/OTA class 31-A1 and A2) and low-energy mechanism of injury treated by 1 of 4 fellowship-trained orthopaedic traumatologists.

INTERVENTION

Short versus long intramedullary nail.

METHODS

Medical records were reviewed for age, gender, estimated blood loss (EBL), transfusion rate, operative time, length of stay, and incidence of periprosthetic fracture. Variables were statistically compared between long and short intramedullary nails, with statistical significance at P < 0.05.

RESULTS

The average EBL (135.5 ± 91.9 mL) and transfusion rate (57.1%) for long nails were found to be significantly greater (P = 0.002) than the EBL (92.6 ± 47.2 mL) and transfusion rate (40.2%) for short nails. Average operative time was also found to be significantly greater (P < 0.001) for long (56.8 ± 19.4 minutes) than for short (44.0 ± 10.7 minutes) intramedullary nail procedures. The overall incidence of periprosthetic fracture was 0.5%, one patient with initial treatment of a long intramedullary nail.

CONCLUSIONS

Statistically significant lower operative time, EBL, and transfusion rate were found in this study for short intramedullary nails. There were no differences seen in length of stay or periprosthetic fracture. The incidence of periprosthetic fracture was very low in both cohorts. Further study with greater statistical power is needed.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Classification and surgical approaches to hip fractures for nonsurgeons

The location and type of hip fracture, and the patient's activity level, help to determine the method of surgical repair. Nondisplaced femoral neck fractures are treated with screw fixation. Displaced fractures are treated with arthroplasty. If the patient is very active, the treatment of choice should be total hip replacement, whereas if the patient is less active, the treatment of choice is hemiarthroplasty. Intertrochanteric fractures are classified as stable (treated with a sliding hip screw) or unstable (treated with an intramedullary hip screw). Subtrochanteric fractures are classified as typical or atypical. All subtrochanteric fractures are treated with intramedullary hip screws.

Mismatch of the short straight cephalomedullary nail (PFNA-II) with the anterior bow of the Femur in an Asian population

OBJECTIVES

The aims of this study were to evaluate the morphologic discrepancies between the short straight proximal femoral nail antirotation-Asian version (PFNA-II) and the anterior bow of the femur in Chinese patients and to propose a further design modification.

DESIGN

Retrospective study.

SETTING

Level I academic trauma center.

PATIENTS/PARTICIPANTS

A consecutive 158 cases (35 men and 123 women with mean age of 77.2 years) with unstable per/intertrochanteric fractures (AO/OTA 31 A2 and A3) treated by PFNA-II from August 2008 to December 2010 participated in this study.

INTERVENTION

Nailing of PFNA-II.

MAIN OUTCOME MEASUREMENTS

The nail tip position was classified to a 5-grade scale on postoperative lateral radiographs of the femur. The distance between the nail axis and the canal axis at the tip level was measured. The degree of the theoretical bent curvature and its corresponding radius were calculated, assuming that the anterior protrusive nail tip was placed back to the central canal axis.

RESULTS

The distal tip of PFNA-II was located anterior to the femur canal central axis in 118 cases (74.7%), of which 55 cases abutted against the anterior cortex (contact between nail and internal cortex) (34.8%). With longer nails, the abutment occurred more often and was more prominent. For nail lengths of 170, 200, and 240 mm, the theoretical distance to replace the nail tip to the central canal axis was 1.42 ± 0.18, 1.77 ± 0.39, and 2.46 ± 0.20 mm, respectively; the corresponding bent curvature angle was 2.51 ± 2.40, 2.13 ± 1.65, and 2.09 ± 0.98 degrees, respectively; and the bent curvature radius was 1483 ± 818, 2329 ± 1293, and 3710 ± 1957 mm, respectively.

CONCLUSIONS

There is a mismatch between the current short straight PFNA-II and the anterior bow of the femur in the Chinese population. In light of the documented complications and technical problems related to this mismatch, further modifications with an anterior bow are proposed.