Intertrochanteric fractures: comparison between two different locking nails

Intramedullary Femur Nailing in Intertrochanteric Fractures: Postoperatively Do Helical Blades Migrate More Than Lag Screws? A Randomized Controlled Trial

Objectives

This was a prospective, randomized controlled trial to test functional outcomes between a single lag screw and helical blade nails in the treatment of intertrochanteric fractures.

Methods

72 patients with intertrochanteric fractures between March 2019 to November 2020 were randomized into two groups and treated with a lag screw or a helical blade nail. Intraoperative parameters such as operative time, blood loss, and radiation exposure were calculated. Postoperatively, tip apex distance, neck length, neck-shaft angle, lateral impingement of implant, union rate, and the functional outcomes were measured at the end of 6 month follow-up period.

Results

There was a significant decrease in tip apex distance (p = 0.03) and neck length(p-0.04) with significant lateral impingement of the implant (p = 0.04) in the helical blade group compared to the lag screw group. The functional outcome calculated using the modified Harris Hip score & Parker and Palmer mobility score, at the end of 6 months, had no significant difference between the two groups.

Conclusion

Both lag screw and helical blade devices can be used to successfully treat these fractures, although there is greater medial migration in the helical blade as compared to the lag screw.

Midterm Outcomes of Intramedullary Fixation of Intertrochanteric Femoral Fractures Using Compression Hip Nails: Radiologic and Clinical Results

BACKGROUND

Various implants are used to treat intertrochanteric fractures. However, the optimal implant to stabilize intertrochanteric femoral fractures is still a matter of debate. The purpose of the present study was to evaluate the midterm outcomes of patients treated using compression hip nails (CHNs).

METHODS

Between March 2013 and April 2018, 164 patients with intertrochanteric femoral fractures who were treated with internal fixation using CHNs were enrolled in this study. The mean age of the patients was 79.6 years. We retrospectively collected and estimated information such as reduction state, implant position, operation time, blood loss, hospital stay, time to achieve union, clinical scores (Harris hip score [HHS] and EuroQol five-dimensional [EQ-5D]), intraoperative complications (such as lag jamming and drill bit breakage), failure of fixation, avascular necrosis, and surgical site infection.

RESULTS

The mean follow-up period was 39.69 months. Eight percent of the patients required an open reduction. The mean operation time was 131 minutes, the mean blood loss was 221.19 mL, the mean hospital stay was 20.66 days, and the average time to union was 18 weeks. Intraoperative complications included 8 cases of breakage of the drill bit while making distal holes. The failure rate was 3.7% and revision surgery was performed in 6 cases (for cut-out in 5 and pull-out of the lag screw in 1). Asymptomatic venous thromboembolism occurred in 2 cases and hematoma requiring intervention occurred in 1 case. There were no other complications such as avascular necrosis, infection, and lateral irritation. At the 2-year follow-up, the averages of HHS and EQ-5D were 71.54 and 0.68, respectively.

CONCLUSIONS

Among the implants used to treat intertrochanteric femoral fractures, CHNs had a surgical failure of 3.7% and showed good radiologic and clinical results.

Intertrochanteric Femoral Fractures: A Comparison of Clinical and Radiographic Results with the Proximal Femoral Intramedullary Nail (PROFIN), the Anti-Rotation Proximal Femoral Nail (A-PFN), and the InterTAN Nail

Background and Objectives: The aim of this study was to evaluate retrospectively the radiological and functional outcomes of closed reduction and internal fixation for intertrochanteric femoral fractures (IFF) using three different proximal femoral nails (PFN). Materials and Methods: In total, 309 individuals (143 males and 166 females) who underwent surgery for IFF using a PFN between January 2018 and January 2021 were included in the study. Our surgical team conducted osteosynthesis using the A-PFN® (TST, Istanbul, Turkey) nail, the PROFIN® (TST, Istanbul, Turkey), and the Trigen InterTAN (Smith & Nephew, Memphis, TN, USA) nail. The PFNs were compared based on age, gender, body mass index (BMI), length of stay (LOS) in intensive care, whether to be admitted to intensive care, mortality in the first year, amount of transfusion, preoperative time to surgery, hospitalisation time, duration of surgery and fluoroscopy, fracture type and reduction quality, complication ratio, and clinical and radiological outcomes. The patients’ function was measured with the Harris Hip Score (HHS) and the Katz Index of Independence in Activities of Daily Living (ADL). Results: Pain in the hip and thigh is the most common complication, followed by the V-effect. The Z-effect was seen in 5.7% of PROFIN patients. A-PFN was shown to have longer surgical and fluoroscopy durations, lower HHS values, and much lower Katz ADL Index values compared to the other two PFNs. The V-effect occurrence was significantly higher in the A-PFN group (36.7%) than in the InterTAN group. The V-effect was seen in 33.1% of 31A2-type fractures but in none of the 31A3-type fractures. Conclusions: InterTAN nails are the best choice for IFFs because they have high clinical scores after surgery, there is no chance of Z-effect, and the rate of V-effect is low.

Proximal femoral nail antirotation versus external fixation for unstable intertrochanteric fractures in elderly patients: A randomized controlled trial

BACKGROUND

This study aimed to compare the clinical and radiographic outcomes of the proximal femoral nail antirotation (PFNA) and external fixation in the management of unstable intertrochanteric fractures in elderly patients.

METHODS

Eighty-seven of 114 patients with unstable intertrochanteric fractures were included in this study between January 2015 and June 2019, 46 were fixed with PFNA implant and 41 with external fixator. Patient baseline characteristics, functional and radiographic results, and postoperative complication were documented and compared between the 2 groups.

RESULTS

Prolonged operation duration, increased fluoroscopy time, and excess blood loss occurred in PFNA group. The functional results scores seemed higher in the PFNA than external fixation group in the first semester, and thereafter, there was no significant difference between groups. On early postoperative radiographs, better femur neck-shaft angle was acquired in the external fixators device, but the difference did not continue at final visit. The incidence rate of overall complications was 43.5% for the group PFNA and 100% for the group external fixation.

CONCLUSIONS

Fewer postoperative complications occurred in PFNA than external fixator group when unstable intertrochanteric fractures were treated. Nevertheless, there was no significant difference detected in final functional and radiographic outcome between the 2 groups.

Outcome of unstable pertrochanteric fractures in high-risk geriatric treated with external fixators

PURPOSE

To review the outcome of high-risk geriatrics with unstable pertrochanteric fractures treated with external fixator.

METHODS

Eighteen consecutive patients with pertrochanteric fractures were operated with external fixator by using closed reduction technique. AO type, accompanying diseases, operating time, transfused blood units, duration of hospitalization, complications, healing time and mortality were recorded. Patients were followed clinically and radiologically for two years at least. The Harris Hip Score was used to document hip function at each regular follow-up.

RESULTS

Fifteen patients with average age of 71.5 years were available for final evaluation. The mean operating time was 41.1 min and union was achieved in all cases with an average time of 16 weeks. The mean Harris Hip Score at one, three, six, twelve and twenty-four months post-operatively was 42.07 ± 8.55; 55.07 ± 11.62; 70.07 ± 10.32; 86.27 ± 9.06 and 89.27 ± 8.81 respectively. Complications included all the patients undergoing loss of some motion in the knee and four of them had to experience revision surgery because of knee stiffness, ten cases of pin-tract infections, seven cases of deep venous thrombosis, two cases of migration of the screws and two cases limb shortening.

CONCLUSIONS

The use of external fixator in high-risk geriatric provided a satisfactory long-term efficacy, but the short-term functional results were quite unsatisfactory owing to high complication rate. Therefore, the advantages and disadvantages should be fully weighed when using external fixators, which was especially suitable for those patients who could not tolerate prolonged operative time and open surgery.

LEVEL OF EVIDENCE IV

Therapeutic study, level 4.

Clinical and Radiological Outcomes of Trochanteric AO/OTA 31A2 Fractures: Comparison between Helical Blade and Lag Screw - A Retrospective Cohort Study

INTRODUCTION

The purpose of this study was to compare the clinical and radiological outcomes of AO/OTA type 31A2 fractures treated by the use of trochanteric nails either with a blade or a screw.

PATIENTS AND METHODS

This study was designed retrospectively. Between May 2007 and May 2014, a total of 144 patients with trochanteric fractures were admitted to the clinic, and only 65 of them met the inclusion criteria. Thirty-two of them (blade group) were treated with a helical blade and the rest of the 33 patients (screw group) were treated with a screw. The mean ages of the patients were 76.01 and 75.82, respectively (p = 0.905). The mean follow-up time was 27.6 months (blade group: 34.2 ± 19.1 months; screw group: 18.6 ± 7.9 months; p < 0.001). Between these two groups, we evaluated the differences in tip apex distances (TAD), calcar-referenced tip-apex distances (Cal-TAD), implant positions, cut-out rates, and implant failures. Functional outcomes were measured with the help of the Harris Hip Score.

RESULTS

No significant differences were seen between the blade and screw groups by means of cutting out, implant positions, and varus collapse. Cutting out was seen in a total of six patients (blade group n = 2; screw group = 4; p = 0.672) and varus collapse in nine patients (blade group n = 5, screw group n = 4; p = 0.733). Harris Hip Scores were similar between the two groups (blade group: 72.70 ± 18.43; screw group: 80.83 ± 18.75; p = 0.84).

Medial support nail and proximal femoral nail antirotation in the treatment of reverse obliquity inter-trochanteric fractures (Arbeitsgemeinschaft fur Osteosynthesfrogen/Orthopedic Trauma Association 31-A3.1): a finite-element analysis

BACKGROUND

The reverse obliquity inter-trochanteric fracture is a distinct fracture pattern that is mechanically different from most inter-trochanteric fractures and the optional treatment of it is still controversial. The purpose of this study was to compare differences in the efficacy of a novel nail (medial support nail [MSN-II]) and proximal femoral nail anti-rotation (PFNA-II) in the treatment of reverse obliquity inter-trochanteric fractures (Arbeitsgemeinschaft fur Osteosynthesfrogen/Orthopedic Trauma Association [AO/OTA] 31-A3.1) using finite-element analysis.

METHODS

Modeling software was used to establish a three-dimensional model of MSN-II and PFNA-II and an A3.1 inter-trochanteric fracture model. Abaqus software was used to implement different force loads to compare finite-element biomechanical parameters such as the maximum stress in implant and the displacement of fracture site.

RESULTS

The femoral stress, implant stress and fracture site displacement of MSN-II was less than that of PFNA-II. The results indicated that the maximal femoral stress was 581 MPa for PFNA-II and 443 MPa for the MSN-II. The maximum stress values in the PFNA-II and MSN-II models were 291 and 241 MPa, respectively. The maximal displacements of the fracture site were 1.47 and 1.16 mm in the PFNA-II and MSN-II models, respectively.

CONCLUSION

Compared with PFNA-II for inter-trochanteric fracture (AO/OTA 31-A3.1), MSN-II which was designed with a triangular stability structure can provide better biomechanical stability. The MSN-II may be a feasible option for the treatment of reverse obliquity inter-trochanteric fracture.

Bipolar hemiarthroplasty using microarc oxidation-coated cementless stem in patients with unstable intertrochanteric fracture

PURPOSE

Treatment for an unstable intertrochanteric fracture in elderly patients is challenging. Bipolar hemiarthroplasty (HA) using microarc oxidation (MAO) coating has been a treatment option alternative to internal fixation. However, the outcome of bipolar HA using MAO-coated stem in these patients is unknown.

METHODS

From July 2007 to April 2016, 234 (older than 65 years) patients (234 hips) who were diagnosed as having unstable intertrochanteric fractures were treated with bipolar HA using a fully MAO-coated standard-length rectangular cementless stem. During the arthroplasty, the greater trochanteric and the medial fracture fragments were attached to the stem and fixed with two to three 16-gauge wires. Forty-eight patients (48 hips) died within postoperative 2 years. The remaining 186 patients (186 hips) were followed up for a mean of 4.3 (range 2-10) years.

RESULTS

With the exception of 4 patients who died during hospitalization, 176 of 230 ( 76.5%) patients could ambulate independently with or without an assistive device at the time of hospital discharge. Venous thromboembolism occurred in seven patients (3.0%). One hip dislocated due to a fall 1 month after the arthroplasty. Periprosthetic femoral fracture occurred in four patients and periprosthetic acetabular fracture in one patient. One patient had periprosthetic of acute pyelonephritis. There was no focal osteolysis around the femoral stem.

CONCLUSION

The result of cementless HA using MAO-coated stem enabled early ambulation in most (76.5%) of elderly patients with unstable intertrochanteric fractures and the results were encouraging.

Anatomy-based MRI assessment of the iliopsoas muscle complex after pertrochanteric femoral fracture

OBJECTIVE

To evaluate the quality of the iliopsoas muscle complex after pertrochanteric femoral fracture, using MRI; to propose an anatomy-based evaluation of the iliopsoas muscle complex; and to determine the inter-reader reliability of two classifications of fatty muscle degeneration.

MATERIALS AND METHODS

We included adult patients with a displaced lesser trochanter following pertrochanteric femoral fracture. Muscle quality was evaluated using the Goutallier and Slabaugh classifications at three levels (L4/L5, L5/S1, and the anterior inferior iliac spine). Two radiologists independently reviewed the MRIs, and force measurement was performed on both hips. Linear mixed-effects models were used to determine the effect of fracture on muscle quality and strength, and Cohen's kappa statistic was used to assess inter-reader agreement.

RESULTS

In the 18 patients included, the iliopsoas muscle complex showed higher grades of fatty muscle degeneration on the fractured side than on the non-fractured side. The mean difference between muscle strength on the fractured vs the non-fractured side was -12 N (p > 0.05). Inter-reader agreement for the Goutallier and Slabaugh classifications was good and very good respectively (weighted K = 0.78 and 0.85 respectively).

CONCLUSION

Fatty muscle degeneration of the iliopsoas muscle complex after pertrochanteric femoral fracture was evident using both classification systems; however, fatty muscle degeneration resulted in only a minimal reduction of muscle strength. To provide a thorough assessment of iliopsoas muscle complex quality, we suggest evaluating it at different anatomical levels. Regarding inter-reader agreement, the Slabaugh classification was superior to the Goutallier classification.

An unusual case of femoral head perforation following fixation with proximal femoral nail antirotation (PFNA-II) for an unstable intertrochanteric fracture: Case report and literature review

The proximal femoral nail antirotation (PFNA-II) is designed for fixation of unstable proximal femoral fractures in Asian patients due to its superior biomechanical properties. The helical blade achieves purchase through bone compaction and requires less removal of bone than a screw. Medial migration of the helical blade with perforation into the hip joint without loss of reduction is a rare problem noted with PFNA. Past literature reporting the migration of the helical blade medially, perforating the femoral head has been addressed as a characteristic complication of the PFNA. A review of literature suggests various reasons for the same such as fresh trauma, fracture settlement and failure of lateralization of the blade. We report a case of postoperative medial migration of the helical blade perforating the femoral head due to loosening of the locking bolt of the helical blade without any signs of rotational or varus displacement of the fracture.

Comparison of effects of four treatment methods for unstable intertrochanteric fractures: A network meta-analysis

PURPOSE

The optimal internal fixation device for unstable intertrochanteric fracture remains a matter of controversy. By performing network meta-analysis, we developed a ranking of the following four surgical methods: proximal femoral nail antirotation, InterTan nail, gamma nail (GN) and sliding hip screws. We compare the complication rates in patients with unstable intertrochanteric fractures.

MATERIALS AND METHODS

After an exhaustive search of MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials for relevant studies, randomized controlled trials meeting selection criteria were entered into our network meta-analysis. Statistical analyses were conducted using Stata software, version 13.0 (Stata Corporation, College Station, Texas, USA).

RESULTS

We included 12 randomized controlled trials. Compared to Sliding hip screw, there were no substantial differences in rates of complications in unstable intertrochanteric fractures patient undergoing various treatments (all p > 0.05). Nevertheless, the surface under the cumulative ranking curve (SUCRA) for GN (80.6%) was significantly higher than those of the other three methods.

CONCLUSION

GN had the highest probability of reducing the total incidence of complications among the four interventions for treating unstable intertrochanteric fractures.

Network meta-analysis of surgical treatment for unstable femoral intertrochanteric fractures

In this network meta-analysis, we determined the optimal surgical method for treating unstable femoral intertrochanteric fractures. We searched the EMBASE, Cochrane Library and Medline databases for studies evaluating sliding hip screws (SHS), gamma nail (GN) or proximal femoral nail antirotation (PFNA) methods, and included nine randomized controlled trials that met the inclusion criteria. Our analysis showed no differences in the rates of complications between SHS and PFNA relative to GN (p > 0.05). However, the surface under the cumulative ranking curve (SUCRA) score for PFNA (77.6%) was higher than the SUCRA scores for GN (65%) and SHS (7.5%). This suggests PFNA is the better surgical method than GN or SHS for unstable femoral intertrochanteric fractures.

The Effect of C-Arm Mobility and Field of Vision on Radiation Exposure in the Treatment of Proximal Femoral Fractures: A Randomized Clinical Trial

Objectives

To examine the effect of fluoroscopy devices with different sizes of image intensifier and C-arm maneuverability on operating time, fluoroscopy time, radiation dose and reduction, and fixation quality at intertrochanteric femoral fractures.

Design

Single-center, randomized, prospective study.

Setting

Academic Level I trauma hospital.

Patients and Intervention

34 patients treated with cephalomedullary nailing for a stable, intertrochanteric proximal femur fracture (OTA A1).

Main Outcome Measurement

The total working time of the fluoroscopy device, the dose-area product (DAP), operating time, reduction quality (cortical continuity, symmetrical collodiaphyseal angle, and shortness), and fixation quality (Bosworth quadrants, the tip-apex distance, TAD).

Results

There were no cases of poor reduction; also the placement of the blade was optimal for 14 patients and suboptimal in 3 patients in each group. Superior-posterior placement of the blade or TAD > 25 mm was not seen in any patient. Total operating time was significantly shorter when using device A compared to the use of device B (20.1 ± 3.4 mins versus 25.3 ± 5.4 mins, p < 0.001). Total radiation time was significantly shorter with device A compared to the use of device B (58.1 ± 19.4 secs versus 98.9  ±  55.4 secs, p = 0.008). The measured radiation dose was lower with the use of device A compared to device B (3.5  ±  1.2 Gy·cm² versus 7.3  ±  4.5 Gy·cm², p = 0.002).

Conclusion

Physical properties of fluoroscopy devices used during the fixation of intertrochanteric fractures could yield significant differences in operating times and the radiation dose while having comparable clinical results.

A Comparison of the Clinico-Radiological Outcomes with Proximal Femoral Nail (PFN) and Proximal Femoral Nail Antirotation (PFNA) in Fixation of Unstable Intertrochanteric Fractures

INTRODUCTION

Management of unstable intertrochanteric fractures poses challenges in terms of obtaining stable fixation and good postoperative outcomes. There is a paucity of clinical data comparing the commonly used Proximal Femoral Nail (PFN) and Proximal Femoral Nail Antirotation (PFNA) implants, especially in relation to osteoporosis.

AIM

To assess comparative performance of PFN and PFNA in the setting of osteoporosis.

MATERIALS AND METHODS

Patients presenting with unstable intertrochanteric fractures (AO 31.A2 and 31.A3) were included and treated with either PFN or PFNA. Preoperative radiographs of normal side were used to grade osteoporosis by Singh's index. Grade 3 or less was considered significant. Postoperative radiographs were assessed for tip-apex distance, Cleveland index and quality of reduction. Patients were followed up for a minimum of nine months and any complications noted. Comparison of functional outcomes was done using the Harris Hip Score and Parker-Palmer mobility score at final follow up. Statistical analysis was done using the unpaired t-test/Mann-Whitney U test and Chi-square test/Fisher's-exact test. A p-value of < 0.05 was considered significant.

RESULTS

The study included 48 patients with unstable intertrochanteric fractures, of which 23 were treated with PFN and 25 with PFNA. Average age of PFN group was 60.78 years and of PFNA group was 74.12 years. In PFN group 8 patients (38.09%) and in PFNA group 13 patients (54.1%) had Singh's osteoporotic index of ≤ 3. The average Harris Hip Score was 75.37 and 78.85 in PFN and PFNA groups (p=0.54) respectively. From PFN and PFNA groups, 35% and 32% patients respectively were able to return to pre-injury mobility status as assessed by the Parker-Palmer mobility score (p=0.83). Out of eight implant related complications; seven were in patients treated with PFN (p=0.02). Among patients with Singh's grade ≤ 3, 3 (37.5%) in PFN group suffered from implant failure whereas all 13 patients in PFNA group had successful outcome (p=0.04).

CONCLUSION

Although functional outcomes achieved with both implants are similar (p=0.83), number of implant related complications were fewer with PFNA (p=0.02), even in osteoporotic group (p=0.04). We recommend use of the PFNA in unstable fractures, especially in the elderly osteoporotic population.

Comparison of Second and Third-Generation Nails in the Treatment of Intertrochanteric Fracture: Screws versus Helical Blades

OBJECTIVE

The aim of this study was to compare the radiological and functional outcomes of anti-rotation trochanteric nails (ATNs) with proximal femoral nail anti-rotation (PFNA) in the treatment of intertrochanteric femur fractures in elderly patients.

MATERIALS AND METHODS

In total, 165 intertrochanteric fractures were treated between January 2007 and January 2010. One hundred forty patients were included. The operation time, amount of blood loss, fluoroscopy screening time, and length of hospitalization were recorded. The radiological position of the implant, quality of fracture reduction, and tip-apex distance were evaluated, and the postoperative complications as well as functional condition of the patients were assessed.

RESULTS

There were no significant differences between the ATN and PFNA groups for the presence of general complications, length of hospitalization, and functional capacity. The mean operation time, blood loss amount, and fluoroscopy screening time were more in the ATN group than in the PFNA group. Reoperation was needed for nine and two patients in the ATN and PFNA groups, respectively, because of implant-related complications.

CONCLUSION

Both ATNs and PFNA were suitable for the fixation of intertrochanteric fractures, but the risk of complication occurrence and need for reoperation were found to be higher in patients who were treated with ATNs.

Wiring technique for lesser trochanter fixation in proximal IM nailing of unstable intertrochanteric fractures: A modified candy-package wiring technique

INTRODUCTION

The purpose of this study was to introduce a new surgical technique, that involves modified Candy-package wiring followed by IM nailing fixation and to determine the clinical and radiological results obtained in patients with unstable intertrochanteric fractures with a lesser trochanter fragment.

MATERIALS AND METHODS

This study included 22 patients who were undergone proximal IM nailing with lesser trochanter wiring between January 2014 to June 2015. All patients were treated with minimally invasive technique of candy-package wiring for lesser trochanter fragments. The mean age was 75.8 years (range, 53-88) and average follow-up period was 15.1 months (range, 12-24). Each patient was followed up for a minimum of 12 months and their clinical and radiological results were analyzed.

RESULTS

The mean period required for fracture union was 16.6 weeks. (range, 8-25) and union was successfully completed in all cases. The WOMAC scores at the last F/U visit (average; 45.4, range; 21-75) were not significantly different to pre-trauma status (average; 36.5, range; 19-59) (p=0.087). In comparison of ambulatory capacity prior to trauma, ambulatory aggravation was noted in four cases (18.2%), and eighteen cases (81.8%) was sustained walking ability of prior of trauma. Wiring breakage was found in two cases and heterotrophic ossification in one case. There were no functional deficeit related to the radiologic finding in these patients. With regard to postoperative complications, were no cut-outs, breakage, or pullout of screws.

CONCLUSION

When surgically repairing unstable intertrochanteric fractures with lesser trochanter comminution using proximal IM nailing method, the modified Candy-packaging wiring technique increases the fixation force at the fracture site. Thus, through this technique, both firm fixation of the lesser trochanter and more stable bony union were obtained.

Lacking evidence for performance of implants used for proximal femoral fractures - A systematic review

INTRODUCTION

Evaluation of the long-term performance of implants used in trauma surgery relies on post-marked clinical studies since no registry based implant assessment exists. The purpose of this study was to evaluate the evidence of performance of implants currently used for treating proximal femoral fractures (PFF) in Denmark.

METHOD

PubMed was searched for clinical studies on primary PFF with follow-up ≥12 months, reporting implant-related failure and evaluating one of following: DHS, CHS, HipLoc, Gamma3, IMHS, InterTan, PFN, PFNA or PTN.

LIMITS

English language and publication date after 1st of January 1990.

RESULTS

All studies were evidence level II or III. 30 publications for SHS were found: 13 of CHS, 15 of DHS and 2 of HipLoc. In total CHS was evaluated in 1110 patients (900 prospectively), DHS in 2486 (567 prospectively) and HipLoc in 251 (all prospectively). Fifty-four publications for nails were found: 13 of Gamma3, 7 of IMHS, 5 of InterTan, 10 of PFN, 24 of PFNA and 0 of PTN. In total Gamma3 was evaluated in 1088 patients (829 prospectively), IMHS in 1543 (210 prospectively), InterTan in 595 (585 prospectively), PFN in 716 (557 prospectively), PFNA in 1762 (1018 prospectively) and PTN in 0.

CONCLUSIONS

The clinical evidence behind the current implants used for proximal femoral fractures is weak considering the number of implants used worldwide. Sporadic evaluation is not sufficient to identify long term problems. A systematic post market surveillance of implants used for fracture treatment, preferable by a national register, is necessary in the future.

Variations of treatment in selected proximal femur fractures among surgeons with different surgical experience--A survey at an international AO course

INTRODUCTION

Different modalities of treatment for hip fractures have been discussed in the literature; however, practice may vary between centres. A survey was conducted on participants at an international AO course to assess the current management of pertrochanteric fractures (AO/OTA 31-A2) and displaced, non-impacted, subcapital fractures (AO/OTA 31-B3) in a 35-year-old patient and an 85-year-old patient.

METHODS

Surgeons taking part in an international orthopaedic course were invited to participate in a survey and were divided into two groups: inexperienced (one-to-three years since qualification) and experienced (four or more years). A survey was conducted to assess the management modalities used for pertrochanteric fractures (AO/OTA 31-A2) and displaced, non-impacted, subcapital fractures (AO/OTA 31-B3) in a 35-year-old patient and an 85-year-old patient.

RESULTS

Fifty-two surgeons participated: 18 were inexperienced and 34 were experienced. The method of operative fixation for the pertrochanteric fracture was gamma-nailing for 95% of the surgeons in the inexperienced group; in the experienced group, 56% opted for gamma-nailing and 38% for dynamic hip screw (DHS). For the displaced subcapital fracture in a 35-year-old, screw fixation was the dominant treatment option for both groups. For the displaced subcapital fracture in an 85-year-old, most of the surgeons in both groups preferred hemiarthroplasty: 59% in the inexperienced group chose cemented bipolar hemiarthroplasty and 12% uncemented, whereas 56% of the experienced group suggested cemented bipolar hemiarthroplasty and 25% uncemented.

DISCUSSION

This survey shows that a variety of methods are used to treat femoral neck fractures. A prospective randomised trial has shown the DHS to be the implant of choice for pertrochanteric fractures; however, this was not considered an option in the inexperienced group of surgeons and was the treatment of choice in only 13 out of 34 experienced surgeons. There is a general consensus for femoral head-conserving surgery in young patients with displaced subcapital fractures. Replacement arthroplasty was considered in the 85-year-old with a subcapital fracture. In the inexperienced group, 10 of 17 surgeons would cement the prosthesis, as would 27 of 36 in the experienced group.

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.

Complete traumatic backout of the blade of proximal femoral nail antirotation: a case report

This article presents a rare case of traumatic complete expulsion of the helical blade after successful treatment of an intertrochanteric fracture with proximal femoral nail antirotation (PFNA). A 94-year-old woman sustained an intertrochanteric fracture of the left femur. Fracture fixation was performed by using PFNA-II. At six months FU, the patient presented with pain at the proximal lateral left thigh after she had fallen. A protrusion was noted. Radiographs showed a complete expulsion of the helical blade with a healed intertrochanteric fracture. The PFNA-II was removed and a cemented bipolar hemiarthroplasty was performed. At 5 months after surgery, the patient was able to walk with a walker without pain. Traumatic complete expulsion of the blade should be considered as a possible complication of PFNA/PFNA-II.

Intramedullary nailing in pertrochanteric fractures of the proximal femur

INTRODUCTION

Pertrochanteric fractures of the proximal femur should be treated surgically, unless the medical condition of the patient does not allow it. Currently, there are two ways to fix these fractures; either with a sliding hip screw or with an intramedullary nail. However, there is much debate over which implant is the best for pertrochanteric fracture fixation. The sliding hip screw has been used over time with good clinical results. While it was true that with first generation intramedullary nails the risk of complications was higher, there is evidence supporting the superiority of intramedullary nails in these fractures when compared with sliding hip screws. This evidence is based on the good clinical results and fewer complications, due to an improvement in the design of the implants and surgical technique used by surgeons. In stable fractures, despite the method chosen for fixation, obtaining a good reduction prior to placing the implant is the most important factor that can be controlled by the surgeon. In stable fractures the surgeon experience is a strong factor to account for when choosing the type of implant. Clearly there are fracture patterns (reverse oblique and subtrochanteric extension) that benefit from the use of intramedullary devices due to the high risk of failure if plates are used.

CONCLUSION

It is very important that the surgeon identifies these fractures, so the type of fixation device which is chosen achieves the greatest stability possible. The aim of this paper is not to convince the surgeon about using intramedullary nails, but highlight the potential benefits intramedullary nailing has when compared with the use of extramedullary devices.

Prospective randomised controlled trial of an intramedullary nail versus a sliding hip screw for intertrochanteric fractures of the femur

PURPOSE

The purpose of this prospective randomised trial was to assess whether an intramedullary nail is superior to a sliding hip screw in the treatment of multifragmentary intertrochanteric fractures

METHODS

Eighty patients with a 31-A2.2 or A2.3 Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) intertrochanteric fracture were randomly allocated to fixation with either the Gamma nail or the AMBI sliding hip screw device.

RESULTS

All patients were followed up at one, three, six and 12 months postoperatively, except for nine who died. There was no statistical difference in Parker mobility score between groups. The Gamma nail group had significantly higher Barthel Index and EuroQol-5D (EQ-5D) scores than the AMBI group at 12 months. At the same time, the EQ-5D score had returned to its pre-operative values in the Gamma nail group but not in the AMBI group. There were no differences in mortality, radiation time and hospital stay. Duration of the operation, incision length and hip pain occurrence were significantly less in the Gamma nail group.

CONCLUSIONS

Few failures occur when unstable 31-A2.2 and A2.3 AO/OTA fractures are fixed with a sliding hip screw. Nevertheless, an intramedullary nail seems superior in reconstituting patients to their pre-operative state.