Fracture reduction with positive medial cortical support: a key element in stability reconstruction for the unstable pertrochanteric hip fractures

Anteromedial Cortical Support in Reduction of Trochanteric Hip Fractures: From Definition to Application

➤ The concept of anteromedial cortical support (AMCS) serves as valuable guidance for the intraoperative reduction of trochanteric hip fractures.➤ Positive medial cortical support (MCS) and positive or neutral anterior cortical support (ACS) are desirable. Some evidence has suggested that positive MCS is potentially superior to neutral MCS.➤ Experimental studies underscore the vital importance of the anteromedial wall and reveal why positive MCS potentially outperforms neutral MCS.➤ Incorporating the AMCS concept, the Chang reduction quality criteria (CRQC) are a reliable alternative approach to evaluate the reduction quality of trochanteric hip fractures.

High Rate of Undetected Infections in Failed Osteosynthesis of Pertrochanteric Fractures

OBJECTIVE

The objective of this study was to assess the incidence of infection in patients with cutout after proximal femur fracture (PFF) osteosynthesis.

METHODS

DESIGN

Retrospective cohort study.

SETTING

Third-level trauma center.

PATIENT SELECTION CRITERIA

Patients presenting with a cutout following PFF (OTA/AO 31A) osteosynthesis, between January 2007 and December 2020.

OUTCOME MEASUREMENTS AND COMPARISONS

The primary outcome was infection according to the European Bone and Joint Infection Society criteria.

RESULTS

Sixty-seven patients presenting with a cutout were included, with mean age of 83.3 years (range 63-96), and 51 (76.1%) were women. Of all cases, 16 (24.7%) presented a concomitant infection. The presence of concomitant infection was suspected preoperatively in only 3 of the cases. A subgroup analysis was performed between the cases with infection and those without infection, the groups being comparable in terms of demographic data and postoperative radiological criteria. Patients with underlying infection had a higher rate of surgical wound complication (56.3% vs. 22%, P = 0.014) and higher rates of leukocytosis (11.560 vs. 7.890, P = 0.023).

CONCLUSION

Faced with a cutout after osteosynthesis of a PFF, underlying infection should be considered as a possible etiological factor.

LEVEL OF EVIDENCE

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

The use of intramedullary reduction techniques in the treatment of irreducible intertrochanteric femoral fractures with negative medial cortical support

Objective

To explore the clinical efficacy of intramedullary reduction techniques for irreducible intertrochanteric femoral fractures with negative medial cortical support.

Methods

A retrospective analysis was conducted on 69 patients with irreducible intertrochanteric femoral fractures with negative medial cortical support treated in the Department of Orthopedics at Jiangsu Province Hospital (The First Affiliated Hospital of Nanjing Medical University) from July 2019 to December 2021. Patients were divided into Group A and Group B. Group A (experimental group) consisted of 36 cases with an average age of 76.2 ± 5.9 years, while Group B (control group) comprised 33 cases with an average age of 76.6 ± 6.3 years. Group A received treatment using intramedullary reduction techniques, while Group B received treatment using traditional extramedullary reduction techniques. Both groups achieved anatomic reduction of the medial cortex or slight positive support. Surgical duration, intraoperative fracture reduction time, intraoperative bleeding, intraoperative fluoroscopy time, fracture reduction quality, fracture healing, postoperative neck-shaft angle loss, femoral neck shortening, and hip joint functional recovery score (FRS) were compared between the two groups.

Results

All patients were followed up for an average of 13.8 months. Group A showed superior outcomes compared to Group B in surgical duration, intraoperative fracture reduction time, intraoperative bleeding, intraoperative fluoroscopy time, fracture reduction quality, fracture healing, postoperative neck-shaft angle loss, and femoral neck shortening (P < 0.05). Hip joint function assessed by functional recovery score was better in Group A than Group B at 1 and 3 months postoperatively (P < 0.05), with no significant statistical difference at other time points (P > 0.05).

Conclusion

For irreducible intertrochanteric femoral fractures with negative medial cortical support, intramedullary reduction techniques used during surgery demonstrated simplicity, significant reduction in surgical duration, decreased intraoperative bleeding, fewer amounts of intraoperative fluoroscopy, improved fracture reduction quality, and reduced surgical complexity. Further clinical research and application are warranted.

[Influence of anterior fracture line on anterior cortical reduction loss after cephalomedullary nail fixation in intertrochanteric fractures]

Objective

To investigate the position of the anterior fracture line in AO/Orthopaedic Trauma Association (AO/OTA) type A2 unstable intertrochanteric fractures and its impact on the incidence of anterior cortical reduction loss after cephalomedullary nail fixation.

Methods

A clinical data of 95 patients with intertrochanteric fractures who met the selection criteria between April 2020 and February 2023 was retrospectively analyzed. All patients were treated with cephalomedullary nail fixation, and the intra- and post-operative imaging data were complete. Among them, there were 37 males and 58 females. The age ranged from 61 to 97 years, with an average of 79.6 years. The time from injury to operation ranged from 7 hours to 11 days, with an average of 2.8 days. According to the 2018-AO/OTA classification standard, there were 39 cases of type 31-A2.2 and 56 cases of type 31-A2.3. Intraoperative fluoroscopy was used to record the number of patients with satisfactory fracture alignment. The preoperative CT data were imported into Mimics17.0 software to simulate the fracture reduction and measure the distance between the anterior fracture line and the intertrochanteric line bony ridge. The fractures were classified as transcapsular fractures, extra-capsular fractures, and intra-capsular fractures according to the distance. CT three-dimensional reconstruction was performed within 2 weeks after operation to observe the number of patients with anterior cortical reduction loss. The postoperative anterior cortical reduction loss incidence in patients with satisfactory fracture alignment, and the relationship between postoperative anterior cortical reduction loss and the position of the anterior fracture line were observed.

Results

There were 52 cases (54.7%) of transcapsular fractures, 24 cases (25.3%) of extra-capsular fractures, and 19 cases (20.0%) of intra-capsular fractures. Among them, 41 of the 52 transcapsular fractures had satisfactory fracture alignment, and 4 (9.8%) of them experienced anterior cortical reduction loss after operation; 19 of the 24 extra-capsular fractures had satisfactory fracture alignment, and no anterior cortical reduction loss occurred; 16 of the 19 intra-capsular fractures had satisfactory fracture alignment, and 7 (43.8%) of them experienced anterior cortical reduction loss after operation. There was a significant difference in the incidence of anterior cortical reduction loss between groups ( χ 2=8.538， P=0.003). All patients were followed up 3-26 months (mean, 9 months). Among them, 91 cases had fracture healing, and 4 cases had nonunion.

Conclusion

In AO/OTA type A2 unstable intertrochanteric fractures, where the anterior fracture line is located within the joint capsule, there is a high risk of anterior cortical reduction loss after operation.

Sagittal support rather than medial cortical support matters in geriatric intertrochanteric fracture: A finite element analysis study

Hip fracture, increasing exponentially with age, is osteoporosis's most severe clinical consequence. Intertrochanteric fracture, one of the main types of hip fracture, is associated with higher mortality and morbidity. The current research hotspots lay in improving the treatment effect and optimizing the secondary stability after intertrochanteric fracture surgery. Cortex buttress reduction is a widely accepted method for treating intertrochanteric fracture by allowing the head-neck fragment to slide and rigidly contact the femoral shaft's cortex. Medial cortical support is considered a more effective option in treating young patients. However, osteo-degenerations features, including bone weakness and cortical thickness thinning, affect the performance of cortex support in geriatric intertrochanteric fracture treatment. Literature focusing on the age-specific difference in cortex performance in the fractured hip is scarce. We hypothesized that this osteo-19 degenerative feature affects the performance of cortex support in treating intertrochanteric fractures between the young and the elderly. We established twenty models for the old and the young with intertrochanteric fractures and performed static and dynamic simulations under one-legged stance and walking cycle conditions. The von Mises stress and displacement on the femur, proximal femoral nail anti-rotation (PFNA) implant, fracture plane, and the cutting volume of cancellous bone of the femur were compared. It was observed that defects in the anterior and posterior cortical bone walls significantly increase the stress on the PFNA implant, the displacement of the fracture surface, and cause a greater volume of cancellous bone to be resected. We concluded that ensuring the integrity and alignment of the anterior and posterior cortical bones is essential for elderly patients, and sagittal support is recommended. This finding suggests that the treatment method for intertrochanteric fracture may differ, considering the patient's age difference.

Factors associated with increased radiation exposure in the fixation of proximal femoral fractures

INTRODUCTION

When using radiation intraoperatively, a surgeon should aim to keep the radiation dose as low as is reasonably achievable to obtain the therapeutic goal. We aimed to investigate factors associated with increased radiation exposure in fixation of proximal femur fractures.

METHODS

We assessed 369 neck of femur fractures over a 1-year period in a district general hospital. All hip fracture subtypes that had undergone surgical fixation were included. We assessed the relationship between type of fracture, implants used and surgeon level of experience with the dose-area product (DAP; cGy/cm2) and screening time (dS). We also looked at the quality of reduction and fixation and its effect on the radiation exposure.

RESULTS

A total of 184 patients were included in our analysis; 185 patients who were treated with hip arthroplasty were excluded. There was a significant association between higher DAP and fracture subtype (p = 0.001), fracture complexity (p < 0.001), if an additional implant was used (p = 0.001), if fixation was satisfactory (p = 0.002) and operative time (p < 0.001). DAP was higher with a proximal femoral nail than with a dynamic hip screw, especially when a long nail was used. There was some evidence of an association between the surgeon's level of experience and DAP exposure, although this was not statistically significant (p = 0.069).

CONCLUSIONS

Increased radiation in proximal femur fractures is seen in the fixation of complex fractures, some subtypes, with certain types of implants used and if an additional implant was required. Surgeon seniority did not result in less radiation exposure, which is in contrast to other published studies.

Comparison of patient positions without traction table for proximal femoral nailing: Supine, semilithotomy and lateral decubitus positions

BACKGROUND

Femur intertrochanteric fractures are performed commonly in a supine position with a traction table. There is a challenge in obtaining traction tables, especially in low- and middle-income countries. However, there is still a debate on which position should be preferred if the traction table cannot be obtained.

METHODS

A total of 123 patients who were treated for femur intertrochanteric fracture (AO/OTA A1 or A2) using cephalomedullary nail (CN) were retrospectively analyzed. All three positions without traction table (supine:25 patients, semilithotomy:36 patients and lateral decubitus:62 patients) were compared according to preparation time, surgical time, Tip-Apex distance (TAD), zones of lag screw placement, collodiaphyseal angle (CDA), CDA difference (∆ CDA), postoperative posterior sag, medial cortical support and Baumgardner reduction quality criteria.

RESULTS

The preparation time was longer in the semilithotomy group, and surgery time was longer in the supine position group. There was no difference according to total time, surgical time, TAD, CDA difference (∆ CDA), postoperative posterior sag, medial cortical support and Baumgardner reduction quality criteria. Target lag screw placement is superior in supine and semilithotomy group than lateral decubitus.

CONCLUSION

This study concluded that there was a difference in preparation time, surgery time and optimal lag screw placement in the lateral plane between groups. The surgeon may prefer all three methods according to patient benefit and surgeon familiarity.

Role of Anteromedial Cortical Support for Unstable Intertrochanteric Fractures Being Treated With Cephalomedullary Nails

INTRODUCTION

Reduction quality is of paramount importance for an optimal outcome in unstable pertrochanteric fractures. The non-anatomical functional anteromedial buttress is proposed to prevent impending mechanical complications. We aimed to evaluate the role of anteromedial cortical support in preventing mechanical complications following fixation with the cephalomedullary nail.

MATERIALS AND METHODS

A prospective, single-arm interventional study was conducted in the Orthopaedics Department of a Combined Military Hospital (CMH) in Rawalpindi. The duration of the study was 24 months. Patients were recruited by the purposive sampling technique as per inclusion/exclusion criteria. Preoperatively, the reduction was categorized as per Baumgartner's and Chang's criteria. Post-operatively, weight bearing as tolerated was advised. Radiographs prior to discharge for loss of reduction were evaluated. Follow-up radiographic measurements of neck length, neck shaft angle, and their loss as per protocol were done at three and six months.

RESULTS

A total of 202 patients were operated on from October 21 until August 23. Mortality at six months in 39 patients (19.3%) and loss to follow-up in 31 patients (15.3%) resulted in 132 patients with complete follow-up and having developed complications in 12 patients (9.09%). The mean age was 76.3 ± 7.98 years; males were 105 (79.5%), and females were 27 (20.5%). Closed reduction was 58 (43.9%), and additional manoeuvres were required in 74 (56.1%). The mean tip apex distance (TAD) was 24.56 ± 2.76, and the Calcar gap was 5.16 ± 1.27. Cleveland zone centre-centre in 54 (40.9%), inferior-centre in 65 (49.2%), and inferior-posterior (9.9%) were statistically significant for mechanical complications (p≤0.001). There was a significant association between the grading of Chang's and Baumgartner's poor groups for the development of mechanical complications (p≤0.001). The mean time to full weight bearing without support was 21 ± 1.22 weeks. The mean Hip Harris score at six months was 69.27 ± 7.68.

CONCLUSION

Results suggest that anteromedial cortical support can lead to fewer potential mechanical complications at six months. A higher Chang's grade drives surgeons to engage in additional manoeuvres. Anteromedial cortical support is worth consideration for unstable pertrochanteric fractures.

Anterior Malreduction is Associated With Lag Screw Cutout After Internal Fixation of Intertrochanteric Fractures

BACKGROUND

Lag screw cutout is a devastating complication after internal fixation of an intertrochanteric fracture. Although the tip-apex distance (TAD) is known to be associated with this complication, another factor we thought was potentially important-fracture reduction on an oblique lateral view-has not, to our knowledge, been explored.

QUESTIONS/PURPOSES

(1) Is a well-reduced fracture position on an oblique lateral view after internal fixation of intertrochanteric fracture associated with a lower odds of postoperative cutout, independently of the TAD? (2) Is postoperative sliding of the lag screw after fixation associated with postoperative cutout?

METHODS

Patients with intertrochanteric fractures who were at least 65 years old and who had been treated with internal fixation in one of six facilities between July 2011 and December 2017 were included. All patients in the study group had lag screw cutout, and controls were selected by risk-set sampling of age-matched and sex-matched patients using a ratio of 4:1 for patients from each hospital. Of the 2327 intertrochanteric fractures, there were 36 patients (0.02 per person-year), with a mean age of 85 years; 89% (32) were women. In the control group, there were 135 controls. There was no difference in age or sex between the two groups. Sagittal reduction was evaluated using an immediate postoperative oblique lateral radiograph (anterior malreduction versus anatomic reduction or posterior malreduction). The association between anterior malreduction and the odds of cutout was estimated by conditional logistic regression analysis with the TAD and interaction between the TAD and the reduced position as covariates. As a sensitivity analysis, we estimated whether sliding within 2 weeks postoperatively was associated with cutout.

RESULTS

After controlling for the potentially confounding variables of age and sex, we found that anterior malreduction was independently associated with a higher odds of cutout compared with anatomic reduction or posterior malreduction (adjusted OR 4.2 [95% CI 1.5 to 12]; p = 0.006). There was also an independent association between cutout and larger TAD (≥ 20 mm) (adjusted OR 4.4 [95% CI 1.4 to 14]; p = 0.01). However, the association between cutout and reduction was not modified by the TAD (adjusted OR of interaction term 0.6 [95% CI 0.08 to 4]; p = 0.54). Postoperative sliding ≥ 6 mm within 2 weeks was associated with higher odds of cutout after adjusting for age and sex (adjusted OR 11 [95% CI 3 to 40]; p < 0.001).

CONCLUSION

In patients older than 65 years with intertrochanteric fractures, anterior malreduction on a lateral oblique view was associated with much greater odds of postoperative cutout than anatomic reduction or posterior malreduction. Because anterior malreduction is within the surgeon's control, our findings may help surgeons focus on intraoperative reduction on an oblique lateral view to prevent cutouts. Although this factor is a reliable indicator, the results should be applied to cephalomedullary nails, because there was only one patient with cutout among those with sliding hip screws. Because this study was conducted in a homogenous Japanese population, future studies should focus on the association between anterior malreduction and cutout in people of different ethnicities, adjusting for confounding factors such as implant type and surgeon level.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Failure after intramedullary nailing for geriatric trochanteric fracture: does quality of fracture reduction on the AP and lateral planes show the same results?

PURPOSE

This study aimed to investigate the failure of trochanteric fracture fixation according to the quality of fracture reduction on the anteroposterior (AP) and lateral views.

METHODS

Data from 340 female and 152 male patients ≥ 60 years of age who underwent intramedullary nailing for a trochanteric fracture between 2016 and 2020 were analysed retrospectively. The quality of fracture reduction was classified as type A, type E, and type I on the AP view and type N, type A, and type P on the lateral view according to the relative position of the proximal and distal fragments. The failure rate was evaluated and compared according to the quality of fracture reduction. The risk factors of the fixation failure were investigated by comparison of variables between patients with and without failure and by regression analysis.

RESULTS

Patients with poor reduction, type I and type P had higher failure rates. However, a statistically significant difference was found only for patients with poor reduction (type P) on the lateral view (p < 0.001). Patients with failure showed significantly higher rates of poor reduction on the lateral view and AO/OTA type A3 fractures. The regression analysis also showed that poor reduction on the lateral view (odds ratio [OR] 12.70; 95% confidence interval [CI] 4.0-40.6; p < 0.001) and AO/OTA type A3 fractures (OR 5.40; 95% CI 1.24-23.49, p = 0.025) were risk factors for failure.

CONCLUSION

Poor reduction such as type P reduction was associated with failure after intramedullary nailing for trochanteric fractures. Surgeons should check the quality of fracture reduction carefully with the proper fluoroscopic view to prevent failure in geriatric patients with trochanteric fractures.

Should the diameter of the proximal femoral nail be large enough to fill the canal in the treatment of intertrochanteric femoral fracture in patients over fifty?

PURPOSE

Many studies have been conducted to evaluate the effects of nail shape, design, or length on the treatment of intertrochanteric fractures. However, the clinical implications of the nail diameter remain unclear.

METHODS

This study was conducted with 191 patients aged ≥ 50 years with unilateral intertrochanteric fractures treated with the same type of short cephalomedullary nail and followed for at least one year. We recorded the reduction type, tip-apex distance, cortical contact of the nail, and nail/canal diameter ratio (NCR) just distal to the locking screw. The effects of nail diameter on the clinical results were evaluated.

RESULTS

The average NCR was 68.7. The average union time was 4.78 months. Delayed union or nonunion was seen in 17 patients. Eight patients underwent additional surgery. The mean change in the modified Koval activity score was -0.84. The NCR did not significantly affect the clinical results. Comparisons of cases with NCRs above and below the average and the average - 1 standard deviation revealed no significant difference. The clinical outcome was not related to any variable associated with the nail diameter.

CONCLUSION

With this specific proximal femoral nail, a small diameter relative to that of the femoral canal had no adverse effect on the union of osteoporotic intertrochanteric fractures, even in patients with unstable fractures and those who had unsatisfactory reductions.

Correlation between cephalic screw positioning of Standard Gamma 3 Nail for intertrochanteric fractures and cut-out incidence

INTRODUCTION

Lateral fractures of proximal femur are the most frequent fractures in elderly people. Internal fixation using medullary nails is the gold standard of treatment (Gamma 3 nail is the most implanted device) due to reduced incidence of complications than other devices. We report our experience in treating this kind of fractures with Gamma 3 nail, between January 2015 and December 2021.

METHODS

We performed a retrospective cohort study of patients treated in our orthopaedic department; level of clinical care is III: 559 patients (431 females and 128 males, with an average age of 85.3 years) with lateral femoral neck fracture. All patients were surgically treated with Gamma 3 standard nail (SGN). We evaluated preliminary X-rays to classify fractures, according to AO-OTA classification and post-operative X-ray to verify cephalic screw position site, according to areas described by Cleveland in 1959: we measured tip-to-apex distance (TAD) and tip-to-apex calcar referred distance (CalTAD). Finally Chang reduction quality criteria (CRQC) for fracture reduction of trochanteric fractures were determined using preoperative or postoperative Antero-Posterior (AP) and lateral radiographs in a Picture Archiving and Communication System (PACS). Incidence of cut-out was evaluated in relation with these parameters. Patients were divided into 2 groups: first group had cephalic screw in optimal positions (5-8-9), the other group had cephalic screw in other positions.

RESULTS

In 328 patients (58.7%) screw was in positions 5-8-9, in 231 patients (41.2%) screw was in not-optimal position. Median TAD was 19.1 ± 7.0 mm (range = 0.0-50.5); in 463 patients (82.8%) TAD was ≤ 25 mm. Median CalTAD was 21.4 ± 4.7 mm (range = 5.7-39.2); in 105 patients (79.4%) CalTAD was ≤ 25 mm. Cut-out was observed in 8 cases (1.43%). Multivariate analysis showed a significant correlation (p < 0,05) between incidence of cut-out and fracture type 31A2 and with TAD values >25 mm. Cephalic screw position did not influence incidence of cut-out.

DISCUSSION

In order to obtain fracture healing with a low risk of failure, in particular cut-out, it is necessary to obtain good reduction of fracture and optimal lag screw position in order to achieve a TAD inferior to 25 mm.

Lateral wall thickness is not associated with revision risk of medially stable intertrochanteric fractures fixed with a sliding hip screw

Aims

This study aimed to determine whether lateral femoral wall thickness (LWT) < 20.5 mm was associated with increased revision risk of intertrochanteric fracture (ITF) of the hip following sliding hip screw (SHS) fixation when the medial calcar was intact. Additionally, the study assessed the association between LWT and patient mortality.

Methods

This retrospective study included ITF patients aged 50 years and over treated with SHS fixation between 2019 and 2021 at a major trauma centre. Demographic information, fracture type, delirium status, American Society of Anesthesiologists grade, and length of stay were collected. LWT and tip apex distance were measured. Revision surgery and mortality were recorded at a mean follow-up of 19.5 months (1.6 to 48). Cox regression was performed to evaluate independent risk factors associated with revision surgery and mortality.

Results

The cohort consisted of 890 patients with a mean age of 82 years (SD 10.2). Mean LWT was 27.0 mm (SD 8.6), and there were 213 patients (23.9%) with LWT < 20.5 mm. Overall, 20 patients (2.2%) underwent a revision surgery following SHS fixation. Adjusting for covariates, LWT < 20.5 mm was not independently associated with an increased revision or mortality risk. However, factors that were significantly more prevalent in LWT < 20.5 mm group, which included residence in care home (hazard ratio (HR) 1.84; p < 0.001) or hospital (HR 1.65; p = 0.005), and delirium (HR 1.32; p = 0.026), were independently associated with an increased mortality risk. The only independent factor associated with increased risk of revision was older age (HR 1.07; p = 0.030).

Conclusion

LWT was not associated with risk of revision surgery in patients with an ITF fixed with a SHS when the calcar was intact, after adjusting for the independent effect of age. Although LWT < 20.5 mm was not an independent risk factor for mortality, patients with LWT < 20.5 mm were more likely to be from care home or hospital and have delirium on admission, which were associated with a higher mortality rate.

The Effect of Cerclage Banding Distally to a Clamshell Fracture Pattern in Total Hip Arthroplasty-A Biomechanical Study

OBJECTIVES

As currently there is no existing biomechanical work on the topic of interest, the aim of the current study was to investigate the effect of cerclage banding distally to an intraoperatively occurring proximal periprosthetic femoral clamshell fracture versus a non-fractured femur after total hip arthroplasty.

METHODS

A diaphyseal anchoring stem was implanted in twenty paired human cadaveric femora, assigned to a treatment and a control group. In the treatment group, each specimen was fitted with a cerclage band placed 3 mm distally to a clamshell fracture, created with an extent of 40% of the anchoring length of the stem. The resulting fragment was not treated further. The contralateral specimens were left with the stems without further fracture creation or treatment. All constructs were tested under progressively increasing cyclic axial loading until failure. Relative bone-implant movements were monitored by motion tracking.

RESULTS

Number of cycles and the corresponding load at stem loosening, defined as 1 mm displacement of the stem along the shaft axis, were 31,417 ± 8870 and 3641.7 ± 887 N in the control group, and 26,944 ± 11,706 and 3194.4 ± 1170.6 N in the treatment group, respectively, with no significant differences between them, p = 0.106.

CONCLUSION

From a biomechanical perspective, cerclage banding distally to an intraoperative clamshell fracture with an extent of 40% of the anchoring length of the stem demonstrated comparable resistance against hip stem loosening versus a non-fractured femur. It may therefore represent a valid treatment option to restore the full axial stability of a diaphyseal anchoring stem. In addition, it may be considered to keep the medial wall fragment unfixed, thus saving operative time and minimizing associated risks.

Perioperative peri-implant fracture after osteosynthesis for geriatric femoral pertrochanteric fracture with the linear compression integrated screw intramedullary nail system (INTERTAN™): a retrospective study

BACKGROUND

Osteosynthesis for geriatric femoral pertrochanteric fractures using the linear compression integrated screw intramedullary nail system (INTERTAN™) has become popular. Nonetheless, cases of perioperative peri-implant fractures have been reported following this surgical technique. The factors responsible for this complication remain unclear. Therefore, we investigated perioperative peri-implant fracture risk factors and incidence, as well as overall outcomes, using the INTERTAN™ system for geriatric femoral pertrochanteric fractures.

METHODS

We retrospectively reviewed 98 consecutive patients with geriatric femoral pertrochanteric fractures after INTERTAN™ fixation, with at least a 12-month follow-up period between May 2020 and April 2022 at a single medical institute. The patients' demographic characteristics, fracture pattern, quality of reduction, quality of fixation, nail length, morphology of the femur, and perioperative complications were recorded and analyzed.

RESULTS

Among the 98 patients, 92 achieved union during follow-up. Twelve perioperative peri-implant fractures (12.2%) were recorded, all of which occurred during or within 1 month of osteosynthesis. Except for one patient who underwent re-osteosynthesis, the others underwent nonoperative treatment, and all achieved union. Multiple regression analysis revealed morphology of the femur with low-lesser trochanter width (odds ratio (OR) 0.532, 95% confidence interval (CI) 0.33-0.86, p = 0.01) to be the only factor contributing to perioperative peri-implant fractures. When the Youden index was used, the optimal cut-off value was 20.2 mm of low-lesser trochanter width. Low-lesser trochanter width < 20.2 mm was found to be a potential factor causing perioperative peri-implant fractures (OR 17.81, 95% CI 1.67-19.76, p = 0.017).

CONCLUSIONS

Morphology of the femur with a low-lesser trochanter width smaller than 20.2 mm was found to be the only potential contributor to perioperative peri-implant fractures when using INTERTAN™ for geriatric femoral pertrochanteric fractures. Care should be taken during osteosynthesis, focusing not only on the fracture site but also on the femoral cortex around the implant. Although perioperative peri-implant fractures were observed within one month following osteosynthesis, the majority of these cases were effectively treated without surgical intervention.

The remnant axial cortical length of the proximal femur in pertrochanteric fractures: a three-dimensional computed tomography study and its clinical implications

BACKGROUND

Cortical buttress are important factors for postoperative stable reconstruction of per/inter-trochanteric fractures. The study aimed to measure the remnant axial cortical length (RACL) of the proximal circumference of the femur, and to determine which part of the RACL can be used reliably to postoperatively sustain the head-neck fragment as a cortical support pattern.

METHODS

Eighty patients with trochanteric hip fractures admitted from January 2015 to January 2016 were included in a retrospective study. Their pre-operative computed tomography (CT) images were used to form 3D-CT reconstructions via Mimics software. After simulated rotation and movement for fracture reduction, the RACL, its three component parts-namely, the remnant anterior cortex (RAC), remnant lateral cortex (RLC), and remnant posterior cortex (RPC) -the γ angle between the anterior and posterior cortex, and the Hsu's lateral wall thickness (LWT) were evaluated.

RESULTS

Patients with an A1 fracture (21/80) had a longer RACL (88.8 ± 15.8 mm) than those with an A2 fracture (60.0 ± 11.9 mm; P < 0.01). The RAC, RLC, and RPC of the RACL in A1 fractures were also significantly longer than those in A2 fractures (P < 0.001). However, the most significant difference among the three components of the RACL was in the RPC, which was 27.3 ± 7.8 mm in A1 fractures and 9.2 ± 6.6 mm in A2 fractures. In addition, the coefficient of variation of the RAC was only 20.0%, while that of the RPC was 75.5%. The average γ angle in A1 fractures was 16.2 ± 13.1°, which was significantly smaller than that in A2 fractures, which was 40.3 ± 14.5° (P < 0.001). There was a significant statistical difference in the LWT between A1 and A2 fractures (P < 0.001). There were significant differences in the RACL, RAC, RLC, RPC, γ angle, and LWT among the five subtypes (P < 0.001).

CONCLUSIONS

The RAC is relatively stable in pertrochanteric fractures. Fracture reduction through a RAC buttress may help to enhance the postoperative stable reconstruction of per/inter-trochanteric fractures and make possible good mechanical support for fracture healing.

Trochanteric fractures: Tip-Apex distance, Calcar Tip-Apex distance, and Chang criteria-a multiple variable analysis

Failure of osteosynthesis is a common complication of the nailing of trochanteric fractures which typically occurs through form of cut-out. Tip-Apex distance (TAD), Calcar Tip-Apex distance (CalTAD), and Chang criteria are validated variables to predict failure of cephalomedullary nailing. This is a retrospective study which analyzes treatment of trochanteric fractures from 2018 to 2020 (n = 296) evaluating postoperative radiographs and factors of mechanical failure. Our objective was to assess correlation among these variables and their influence on mechanical failure, either individually or creating a new score. Our results support the CalTAD and Chang's criteria as valid predictors of mechanical failure. Furthermore, they empathize the importance of fracture reduction and proper placement of cervical screw. To our knowledge, this is the first study performing multivariate analysis including these 3 variables.

Postoperative Rotation Deformity of Head-Neck Fragments in Unstable Intertrochanteric Fractures Fixed with Intramedullary Nails

BACKGROUND

Our purpose was to quantify the postoperative rotation deformity (RD) after osteosynthesis of unstable intertrochanteric fractures (ITFx) using 3D-CT / image processing software, and to clarify the clinical meaning of RD.

METHODS

Forty-six consecutive patients with unstable intertrochanteric fractures were enrolled in this study. All were fixed with Gamma 3 Trochanteric nail and RC Lag Screw® (Stryker). We performed 3D-CT evaluations for the rotational deformity of head-neck fragments, the medial cortex support (MCS) between main fragments and bone healing at 3 months postoperatively.

RESULTS

The RD was significantly larger in the patients without the MCS (5.1 ± 4.0°, N = 9) than those with the MCS (2.4 ± 2.6°, N = 37) (P = 0.006*). Delayed healing (N=3) was observed in patients without the MCS, and the association between RD and delayed healing was significant (P = 0.003*, cut-off value 6.4°, sensitivity 100% and specificity 90.7%, AUC 0.91).

CONCLUSIONS

This study proposed a novel method of measuring postoperative RD. Lack of MCS may lead to RD and consequent delayed healing in unstable ITFx fixed with intramedullary nails.

GS Hip Nail versus Affixus Hip Fracture Nail for the Intramedullary Nailing of Intertrochanteric Fractures

BACKGROUND

Intertrochanteric fractures are a global health concern, especially in aging populations like the Republic of Korea. Surgical treatments like intramedullary nailing are preferred for their benefit. Various hip nails are used worldwide, each with unique features and challenges. This study aims to compare the GS hip nail with the Affixus hip fracture nail for the treatment of intertrochanteric fractures.

MATERIAL AND METHODS

This retrospective study, conducted at a single center, included 179 patients who underwent intramedullary nailing for intertrochanteric fractures using the GS hip nail or the Affixus hip fracture nail. Excluding specific cases, 43 patients in the GS group and 46 in the Affixus group met the minimum 6-month follow-up criteria.

RESULT

The GS group exhibited a significantly shorter mean operation time (43.26 min) compared to the Affixus group (51.11 min). Radiographically, both groups showed no significant differences in their reduction quality, tip, and apex distance (TAD), or Cleveland index in the immediate postoperative window. However, the GS group achieved a greater valgus reduction based on the contralateral femoral neck shaft angle (NSA). At 6 months post-operation, there were no significant differences in TAD or advancement and sliding distances. Complication rates were similar between the two groups, with no implant breakages. Clinical outcomes, as measured via mHHS and EQ-5D-5L, showed no significant differences. Despite a slightly higher implant cost, the GS group had a lower total hospital cost than the Affixus group, but this was not statistically significant.

CONCLUSIONS

This study highlights the efficiency of the GS hip nail in reducing the operation time compared to the Affixus hip fracture nail with comparable radiologic and clinical outcomes. Further research with long-term follow-up and larger patient studies are needed to fully assess its effectiveness in improving patient outcomes in hip fracture treatment.

Reduction quality in lateral view of X-ray and hypoalbuminemia are associated with postoperative mortality in elderly pertrochanteric fracture patients

Background

Pertrochanteric fracture is one of the most prevalent public health issues across the world for the elderly population. The purpose of this study was to investigate the association between surgical factors and postoperative mortality in patients with intramedullary nail-treated pertrochanteric fractures.

Methods

A retrospective cohort study was designed to evaluate the pertrochanteric fracture patients treated with intramedullary nail between January 2016 to February 2021. The surgical factors included the Dorr morphology, Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association (AO/OTA) classification of fractures, the tip-apex distance (TAD), location of the cephalic screw, reduction quality in anterior-posterior (AP) and lateral views, the integrity of the lateral wall, and the design of cephalic screws. Using univariate and multivariate Cox proportional hazard models, the association between these risk factors and postoperative mortality in patients with this type of fractures was evaluated.

Results

A total of 169 pertrochanteric fracture patients treated with intramedullary nails were included in our study, with the average age of 82.68±5.93 years. The mortality rates at 3 months, 1 year, and the end of follow-up were 4.14%, 11.24%, and 26.04%, respectively. According to the univariate Cox analysis, age, gender, preoperative levels of hemoglobin (Hb) and albumin (Alb) were associated with a poor overall survival (OS) (P<0.05). After multivariate adjustment, the pre-operative level of Alb (P<0.001) and the reduction in lateral view (P<0.001) were shown to be independent risk factors for poor OS.

Conclusions

The preoperative hypoalbuminemia and reduction quality in lateral view were associated with postoperative mortality in our study. Therefore, optimizing both parameters could improve the prognosis in elderly pertrochanteric fracture patients.

The Impact of Banana-Shaped Fragments on Trochanteric Hip Fractures Treated by PFNA

Background

Regarding trochanteric hip fractures, one type of posterior coronal fragments was described as the "banana-shaped fragment", while the impact of the banana-shaped fragment on mechanical stability has not been further studied. The current study investigated the association between the banana-shaped fragment and mechanical complications after surgery.

Methods

This retrospective cohort study included 273 patients treated by proximal femoral nail antirotation (PFNA) in the full analysis. The age, the sex, the fracture side, the follow-up time, the American Society of Anesthesiologists classification, the operators, the fracture classification, the tip-apex distance, the blade positions, the reduction quality and the bone mineral density were analyzed in relation to mechanical complications, through univariate and multivariate approaches.

Results

Mechanical complications happened in 33 patients. The banana-shaped fragment (adjusted odds ratio 5.240, 95% CI 2.172 to 12.641; p < 0.001), the tip-apex distance and the reduction quality showed significant association with mechanical complications in both univariate and multivariate analysis. Moreover, for 118 patients with the banana-shaped fragment, we found that the use of wire cerclage couldn't significantly lower the rates of mechanical complications (p = 0.648).

Conclusions

The banana-shaped fragment had a negative impact on mechanical stability of trochanteric hip fractures treated by PFNA. In the perioperative period, the BSF should be carefully evaluated, and its specific handling deserves further study.

Inverse relationship between femoral lateralization and neck-shaft angle is a joint event after intramedullary nailing of per trochanteric fractures

This study explored the relationship between femoral lateralization and femoral neck-shaft angle after intramedullary nail (IM) fixation for per trochanteric fractures. 70 patients (AO/OTA 31A1-2) were investigated. Anteroposterior (AP) and lateral X-ray views pre- and post-operation were recorded. Patients were classified into three groups according to the position of the medial cortex of the head-neck fragment to that of the femoral shaft: being slightly superomedial (positive medial cortex support, PMCS), being smoothly contacted (neutral position, NP) or being displaced laterally (negative medial cortex support, NMCS). Patient demographics, femoral lateralization, and neck-shaft angle were measured and statistically analyzed pre- and post-operation. Functional recovery was evaluated by Harris score 3- and 6- months post-operation. All cases ultimately demonstrated radiographic fracture union. There was a tendency to have an increased neck-shaft angle (valgus alignment) in the PMCS group and increased femoral lateralization in the NP group (p < 0.05). Among those three groups, the change in femoral lateralization and neck-shaft angle was statistically different (p < 0.05). An inverse relationship between femoral lateralization and femoral neck-shaft angle was observed. Femoral lateralization increased correspondingly when the neck-shaft angle continuously decreased from the PMCS group to the NP group and then to the NMCS group, and patients in the PMCS group had better functional recovery than the other two groups (p < 0.05). Femoral lateralization was commonly produced after IM fixation for per trochanteric fractures. The fracture fixed in PMCS mode possesses the slightest change in femoral lateralization while maintaining valgus alignment of the femoral neck-shaft angle and good functional outcome, which is superior to NP or NMCS mode.

Positive medial cortical support versus anatomical reduction for trochanteric hip fractures: Finite element analysis and biomechanical testing

BACKGROUND AND OBJECTIVES

The anatomical reduction (AR) is usually considered the best option for fractures. Nevertheless, in unstable trochanteric hip fractures (UTHF), previous clinical reports found that the positive medial cortical support (PMCS, an over-reduction technique) attained higher mechanical stability, but this challenging clinical finding still needs experimental validation.

METHODS

This study constructed in-silico and biomechanical PMCS and AR models, with the use of the most clinically-representative geometry design of fracture models, the multi-directional design in FE analysis, and the subject-specific (osteoporotic) bone material properties, to make the models better mimic the actual condition in clinical settings. Then multiple performance variables (von-Mises stress, strain, integral axial stiffness, displacement, structural changes, etc.) were assessed to uncover details of integral and regional stability.

RESULTS

Among in-silico comparison, PMCS models showed significantly lower maximum displacement than AR models, and the maximum von Mises stress of implants (MVMS-I) was significantly lower in PMCS models than in AR models (highest MVMS-I in -30°-A3-AR of 1055.80 ± 93.37 MPa). Besides, PMCS models had significantly lower maximum von Mises stress along fracture surfaces (MVMS-F) (highest MVMS-F in 30°-A2-AR of 416.40 ± 38.01 MPa). Among biomechanical testing comparison, PMCS models showed significantly lower axial displacement. Significantly lower change of neck-shaft angle (CNSA) was observed in A2-PMCS models. A fair amount of AR models converted into the obvious negative medial cortical support (NMCS) condition, whereas all PMCS models kept the PMCS condition. The results were also validated through comparison to previous clinical data.

CONCLUSIONS

The PMCS is superior to the AR in the UTHF surgery. The current study opens up the second thought of the role of over-reduction technique in bone surgery.

Optimizing post-operative imaging: a retrospective cohort study comparing two methods of lateral hip radiography after cephalomedullary nail surgery

BACKGROUND

Currently, there is no consensus on the most appropriate technique for obtaining lateral hip radiographs after cephalomedullary nail (CMN) surgery. The aim of this study was to investigate the distribution of two commonly used postoperative lateral hip radiographic methods (classic lateral view and modified lateral view) and try to find out which one is better suited for this situation.

METHODS

A retrospective analysis was conducted on 146 patients who underwent surgical fixation for extracapsular hip fractures between January 2018 and June 2022. The main outcome measured was the angle between the straight part of the CMN and the lag screw/blade on hip lateral X-rays (CMNA). The lateral hip radiographs were categorized into two groups based on different lateral hip radiographic methods. CMNA, patient age, gender, fracture classification based on the 2018 AO classification, nail length (short/long), surgical side (left/right), height, weight, BMI, preoperative waiting time, postoperative imaging interval were collected and compared between the two groups.

RESULTS

The distribution trend of CMNA significantly differs between two types of hip joint lateral radiographic methods. Specifically, the classic lateral method exhibits a significantly bimodal and skewed distribution with a median (p25, p75) of -21.6° (-31.2°, -8°), whereas the modified lateral method presents a normal distribution with a mean ± SD of +7.57° ± 14.4°. The difference in the Mean Rank between the classic (47.10) and the modified (102.96) lateral methods is statistically significant (P < 0.001).

CONCLUSIONS

The CMNA method is an excellent tool for studying the lateral distribution.We recommend using the modified lateral view as the preferred option for obtaining lateral hip radiographs after CMN surgery due to its superior distribution of CMNA and greater patient-friendliness.

Residual lateral wall width predicts a high risk of mechanical complications in cephalomedullary nail fixation of intertrochanteric fractures: a retrospective cohort study with propensity score matching

PURPOSE

The purpose of this study is to determine whether the integrity of the entry portal of head-neck implant is related to postoperative mechanical complications.

METHODS

We retrospectively reviewed consecutive patients with pertrochanteric fractures in our hospital treated from January 1, 2018, to September 1, 2021. Based on the integrity of the entry portal for head-neck implants on the femoral lateral wall, patients were divided into two groups, including the ruptured entry portal (REP) group and the intact entry portal (IEP) group. After 4:1 propensity score-matched analyses were used to balance the baseline of the two groups, a total of 55 patients were extracted from the original participants, including 11 patients in the REP group and 44 matched patients in the IEP group. The anterior to posterior cortex width on the mid-level of the lesser trochanter was measured and defined as the residual lateral wall width (RLWW).

RESULTS

Compared with the IEP group, the REP group was correlated with postoperative mechanical complications (OR = 12.00, 95% CI 1.837-78.369, P = 0.002) and hip-thigh pain (OR = 26.67, 95% CI 4.98-142.86). RLWW ≤ 18.55 mm indicated a high likelihood (tau-y = 0.583, P = 0.000) of becoming the REP type postoperatively and being more likely to suffer from mechanical complications (OR = 30.67, 95% CI 3.91-240.70, P = 0.000) and hip-thigh pain (OR = 14.64, 95% CI 2.36-90.85, P = 0.001).

CONCLUSION

Rupture of entry portal is a high-risk factor for mechanical complications in intertrochanteric fractures. RLWW ≤ 18.55 mm is a reliable predictor of the postoperative REP type.

Outcome of buttress plate-nail construct used for reconstruction of broken lateral wall in intertrochanteric fractures

PURPOSE

Intramedullary implants are well accepted fixation of all types of intertrochanteric (IT) fractures, both stable and unstable types. Intramedullary nails have an ability to effectively support the posteromedial part, but fail to buttress the broken lateral wall requiring lateral augmentation. The aim of this study was to evaluate the outcome of proximal femoral nail augmented with trochanteric buttress plate for broken lateral wall with IT fractures, which was fixed to the femur through hip screw and anti-rotation screw nail.

METHODS

Of 30 patients, 20 had Jensen-Evan type III and 10 had type V fractures. Patients with IT fracture of broken lateral wall and aged more than 18 years, in whom satisfactory reduction was achieved by closed methods, were included in the study. Patients with pathologic or open fractures, polytrauma, prior hip surgery, non-ambulatory prior to surgery, and those who refused to participate were excluded from the study. The operative time, blood loss, radiation exposure, quality of reduction, functional outcome and union time were evaluated. All data were coded and recorded in Microsoft Excel spread sheet program. SPSS 20.0 was used for data analysis and normality of the continuous data was checked using Kolmogorv Smirnov test.

RESULTS

The mean age of patients in the study was 60.3 years. The mean duration of surgery (min), mean intra-operative blood loss (mL) and mean number of exposures were 91.86 ± 12.8 (range 70 - 122), 144.8 ± 3.6 (range 116 - 208), and 56.6 (range 38 - 112), respectively. The mean union time was 11.6 weeks and the mean Harris hip score was 94.1.

CONCLUSION

Lateral trochanteric wall in IT fractures is significantly important, and needs to be reconstructed adequately. Nail-plate construct of trochanteric buttress plate fixed with hip screw and anti-rotation screw of proximal femoral nail can be successfully used to augment, fix or buttress the lateral trochanteric wall giving excellent to good results of early union and reduction.

Cementless femoral stem revision in total hip arthroplasty: The periprosthetic clamshell fracture. A biomechanical investigation

To biomechanically evaluate the stability of a diaphyseal anchored, cementless stem in presence of a proximal periprosthetic femoral medial wall defect compared to the stability of the same stem in an intact femur. Twenty-two paired human cadaveric femora were pairwise assigned either to a fracture group, featuring a proximal medial wall defect involving 40% of the stems medial anchorage distance, or a control group with native specimens. The specimens were tested under a monotonically increasing cyclic axial loading protocol. Load, cycles, and multiples of the respective body weight at implant loosening was measured. Mean initial stiffness was 2243.9 ± 467.9 N/mm for the intact group and 2190.1 ± 474.8 N/mm for the fracture group. Mean load to loosening in the intact group was 3210.5 ± 1073.2 N and 2543.6 ± 576.4 N in the fracture group, with statistical significance. Mean cycles to loosening in the intact group were 27104.9 ± 10731.7 and 20431.5 ± 5763.7 in the fracture group, with statistical significance. Mean multiples of the resulting body weight at loosening in the intact group was 548.3 ± 158.5% and 441.4 ± 104% in the fracture group, with statistical significance. A medial wall defect involving 40% of the medial anchorage distance significantly decreases the axial stability of a diaphyseal anchored stem. However, mechanical failure occurred beyond physiological stress. At loosening rates of about 4 multiples of the body weight in the fracture group, a "safe zone" remains of a 0.5-fold body weight for maximum loads and twofold body weights for average loads.

Insufficient proximal medullary filling of cephalomedullary nails in intertrochanteric femur fractures predicts excessive postoperative sliding: a case-control study

OBJECTIVE

Excessive postoperative sliding is a common complication of intramedullary nails in the treatment of intertrochanteric femur fractures. The aim of this study was to identify risk factors for excessive postoperative sliding in the intertrochanteric fractures treated with an intramedullary nail.

METHODS

A retrospective analysis of 369 patients with femoral intertrochanteric fractures treated with short intramedullary nails between February 2017 and September 2020 was performed. Patients were classified into an excessive sliding group (ES group) and a control group according to the sliding distance after 6 months of follow-up. The proximal medullary filling degree (MFD), fracture reduction patterns in the anteroposterior (AP) view and lateral view, and tip-apex distance (TAD) were evaluated and compared in each group.

RESULTS

Thirty-three cases were included in the ES group, and 336 cases were included in the control group. No significant differences in age, sex, fracture side, AO Foundation and Orthopaedic Trauma Association (AO/OTA) classification, Dorr classification, Singh Osteoporosis Index (SOI), American Society of Anesthesiologists classification (ASA), TAD or fracture reduction patterns in the AP view were noted between the two groups. The negative reduction pattern can strongly predict excessive postoperative sliding (OR 4.286, 95% CI 1.637-11.216, P = 0.003). The incidence of excessive postoperative sliding increased by 8.713-fold when the MFD decreased by 10% (OR 8.713, 95% CI 1.925-39.437, P = 0.005).

CONCLUSIONS

A low medullary filling degree and negative fracture reduction pattern in the lateral view were both independent risk factors for excessive postoperative sliding.

Trochanteric and subtrochanteric fractures irreducible by closed reduction: a retrospective study

AIM

To explore the preoperative radiographic features and reduction methods of irreducible trochanteric and subtrochanteric fractures of the femur and to compare the perioperative characteristics and prognoses of irreducible and reducible fractures.

METHODS

The data of 1235 patients with femoral trochanteric fractures surgically treated in our hospital between January 2010 and January 2021 were retrospectively analyzed. According to the inclusion criteria and exclusion criteria, 1163 cases of femoral trochanteric and subtrochanteric fractures were included in this study. Fractures in which good or acceptable reduction could not be reached by closed manipulation were defined as irreducible fractures. The preoperative radiographic features, fracture displacement patterns after closed manipulation and intraoperative reduction methods used to treat irreducible fractures were analyzed, and the perioperative characteristics and prognoses of irreducible fractures and reducible fractures were compared.

RESULTS

There were 224 patients in the irreducible group and 939 patients in the reducible group. According to the radiographic features of fractures, irreducible fractures could be divided into four types: those with interlocking of the fracture, sagging of the femoral shaft, splitting of the lateral wall or medial wall, and comminution of the subtrochanteric area. Various kinds of reduction techniques were needed for different types.

CONCLUSIONS

The incidence of irreducible trochanteric fractures was 15.4%, while the incidence of irreducible subtrochanteric fractures was 84.6%. According to the radiographic features of fractures, they can be divided into four types. It is important to identify irreducible fractures preoperatively and make comprehensive plans to the greatest extent possible to shorten the operation time, reduce intraoperative blood loss, and reduce the incidence of complications.

Coronal shear fractures of the femoral neck: a comparison with basicervical fractures

PURPOSE

We propose coronal shear fracture of the femoral neck (CSFF) as a new type of fracture that differs from a basicervical fracture. This study aimed to present the incidence of CSFF and compare its clinical characteristics and outcomes with those of basicervical fractures.

METHODS

In this multicenter retrospective cohort study, 2207 patients with hip fractures were identified using computed tomography (CT), 17 and 27 patients were diagnosed with CSFF (CSFF group) and basicervical fractures (basicervical fracture group), respectively. The primary outcome was reoperation, while the secondary outcomes were postoperative radiographic findings, ambulatory ability, and 1-year mortality rate. These outcomes were compared between the two groups. We also conducted diagnostic reliability tests for these fractures using the Cohen's kappa coefficient.

RESULTS

The incidence of CSFF and basicervical fractures in the 2207 patients were 0.77% and 1.22%, respectively. The inter-and intra-observer agreements for the diagnosis were almost perfect. The comorbidity score was significantly higher in the CSFF group than in the basicervical fracture group. No reoperations occurred in both groups. There were no significant intergroup differences in the postoperative radiographic findings. The 1-year mortality rate was higher in the CSFF group than in the basicervical fracture group (38.5% vs. 5.3%; odds ratio: 11.9, 95% CI: 1.2-118.5; p = 0.025).

CONCLUSION

This study presents the definition and incidence of CSFF with a high diagnostic reliability. Patients with CSFF had similar reoperation rate postoperative radiographic outcomes to basicervical fractures, while 1-year mortality rate was high.

Risk of shortening in operatively treated proximal femur fractures with cephalomedullary nails with dynamically versus statistically locked helical blades

INTRODUCTION

Cephalomedullary nails (CMN) have proven to be effective for the fixation of unstable pertrochanteric hip fractures, but limited data exists regarding the degree of shortening that occurs with nailing systems that offer "dynamically" versus "statistically" locked helical blades. This study aimed to determine the incidence, timing, and amount of postoperative fracture shortening in patients with pertrochanteric hip fractures treated with "dynamically" versus "statistically" locked helical blades.

METHODS

A retrospective review was performed on patients requiring operative fixation of pertrochanteric fractures. Inclusion criteria were patients aged 55 or older, low energy mechanism of injury, primary surgical open reduction and internal fixation of the injury, surgery performed by a fellowship-trained orthopaedic traumatologist, and radiographic follow up until healing or failure (minimum of 3 months). Quantification of fracture shortening was determined using the lateral screw protuberance method. Fracture shortening measurements were calculated from immediate post-operative films and subsequent radiographs at each follow-up visit.

RESULTS

222 patients met inclusion criteria (123 using Depuy Synthes Trochanteric Fixation Nail proximal femoral nailing system (TFN) with static locking; 65 TFN with dynamic locking; 23 using Depuy Synthes Trochanteric Fixation Nail-Advanced proximal nailing system (TFNA) with static locking; and 11 TFNA with dynamic locking). When comparing the final screw protuberance, the TFN dynamic (10.31 mm), TFNA static (9.52 mm), and TFNA dynamic (7.02 mm) groups were found to be significantly less compared to the TFN static cohort (11.67 mm; p < 0.001). The distribution of fracture shortening was found to be significant (p < 0.01). Interval measurements of fracture shortening by repeated measures of ANOVA within groups showed statistically significant increases in screw protuberance for the TFN static (p < 0.001), TFN dynamic (p < 0.001), and TFNA static (p < 0.01) cohorts within the first 60 days postoperatively. The TFNA with dynamic locking group was found to have statistically significant increases until the first 100 days post-operatively (p < 0.02).

DISCUSSION

The incidence of fracture shortening remains high even with the use of cephalomedullary nails, regardless of dynamization status. Current pertrochanteric fixation constructs continue to favor fracture healing at the direct expense of fracture shortening.

Biomechanical comparison of screw vs. cerclage refixation in orthogeriatric lesser trochanteric fractures: a cadaveric study

PURPOSE

Osteoporosis-related proximal femur fractures continue to increase significantly due to demographic change. This study was designed to evaluate the biomechanical stability of two different fixation methods (cerclage vs. screw) for refixation of a trochanter minor fragment in the pertrochanteric fractures in cadaveric bones.

METHODS

Artificial bones (n = 14) and human bones (n = 16) were treated with a DHS and the trochanter minor fragment was reduced by cerclage wiring or direct screw fixation. After preloading the simulated iliopsoas with 10 N, a tensile test was performed, ending with either a 70% loss of strength or avulsion of the fragment. The mean values of the avulsion force and the surface strain were recorded.

RESULTS

All tensile tests showed no significant differences between refixation using a direct screw or wire cerclage, for both artificial bones and human specimens. Absolute values showed higher avulsion forces after direct screw fixation than refixation with a wire cerclage. The surface tension of specimens treated with direct screw fixation was lower than that of specimens treated with wire cerclage. An opposite effect was seen in artificial bones. Both effects were not statistically significant.

CONCLUSION

Based on the equal stability after lag screw placement compared to cerclage wiring, we promote the placement of a lag screw into the lesser trochanter fragment in pertrochanteric femur fractures when using a dynamic hip screw.

LEVEL OF EVIDENCE

Level III.

AP3×ML3 reduction quality classification for femoral trochanteric fractures: validation for reliability focusing on positive medial cortical support

INTRODUCTION

This study evaluated the validity of the AP3 × ML3 reduction quality classification, which applies the concept of positive medial cortical support.

METHODS

A total of 120 trochanteric fractures classified as AO Foundation/Orthopedic Trauma Association 31A1 and A2 were retrospectively analyzed. The validity of the AP3 × ML3 classification was evaluated by comparison with the Baumgaertner reduction quality criteria. When using the AP3 × ML3 classification, reduction quality was divided into three classes based on the degree of anterior cortical contact between the proximal and distal fragments. Reduction quality was also divided into three classes when using the Baumgaertner criteria. The frequency of mechanical complications, including cut-out, delayed union, and excessive migration of the lag screw, was retrospectively assessed. Intra-observer and inter-observer reliability was assessed using the intraclass correlation coefficient (ICC).

RESULTS

Mechanical complications included 4 cases of cutout (3.3%) and 1 of delayed union (0.8%). Mechanical complications occurred for all levels of reduction quality in both classifications, except for the acceptable of the Baumgaertner criteria. When reduction quality was rated as good, acceptable, and poor the incidence of mechanical complications was 2.5%, 5.7%, and 16%, respectively, under the AP3 × ML3 classification and 3.3%, 0%, and 15.0%, respectively, under the Baumgaertner criteria. The ICC was 0.80 for intra-observer reliability and 0.57 for inter-observer reliability when using the AP3 × ML3 classification and 0.85 and 0.34, respectively, when using the Baumgaertner criteria.

CONCLUSION

The AP3 × ML3 classification was reliable and easy to use compared with the widely used Baumgaertner reduction quality criteria. Level of evidence 4.

Two-Part Intertrochanteric Femur Fractures with Bisection of the Lesser Trochanter: An Irreducible Fracture Pattern

Objective

To introduce the clinical features of and surgical techniques for a rare type of irreducible pertrochanteric femur fracture pattern with bisection of the lesser trochanter.

Methods

From January 2017 to December 2019, 357 patients with per/intertrochanteric femur fractures underwent surgery by closed reduction and internal fixation, of whom 12 patients were identified with rare preoperative imaging features, the lesser trochanter was almost equally bisected. The main fracture pathoanatomy of these cases included: The anterior fracture line passed along the intertrochanteric line to the medial lesser trochanter and bisected it into 2 equal parts from mid-level of the lesser trochanteric protrusion. The proximal part of the lesser trochanter connected to the head-neck fragment and attached by the psoas major tendon, while the distal part of the lesser trochanter connected to the femoral shaft and attached by the tendon of the iliac muscle. These fractures were irreducible by a closed maneuver and were reduced with limited assistance by some devices, and short intramedullary nails were used for fixation of these fractures.

Results

All patients were followed up for an average of 14.2 ± 2.1 months. Clinical fracture union occurred at an average of 10.8 ± 1.5 weeks, while radiographic union occurred at an average of 12.7 ± 1.2 weeks. No cut out of the helical blade was visible on radiographs. The average Parker-Palmer score was 6.9 ± 1.3 (range, 5-9) at the last follow up, including 8 cases rated as excellent, 2 as good and 2 as fair.

Conclusion

Two-part pertrochanteric femur fractures with bisection of the lesser trochanter have an irreducible fracture pattern with cortical locking and soft tissue incarceration. Soft tissue release and short cephalomedullary nail fixation for this fracture pattern provide stable fixation and allow early exercise. This treatment appears to have excellent outcomes in the short and medium terms.

A novel computed tomography-based three-column MLP classification of intertrochanteric fracture

OBJECTIVES

The aim of the present study was to introduce a novel three-dimensional computed tomography (3DCT)-based three-column classification (named "MLP classification system") of intertrochanteric fractures and evaluate its reproducibility and reliability.

METHODS

From September 2020 to September 2022, a total of 258 consecutive patients (60 male, 198 female;mean age 81.3 years) with intertrochanteric fractures were included in this study. The fracture in each case was assessed using a novel three-dimensional computed tomography-based three-column classification. Two examiners tested the intra and inter-observer reliability of this new classification system using kappa variance.

RESULTS

The intertrochanteric region was divided into the medial column, lateral column, and posterior column. Intertrochanteric fractures were documented as M0/1/2L0/1/2/3P0/1/2/3. All fractures were classifiable into the new classification system. The intra-observer kappa values were 0.91 and 0.89, while the inter-observer kappa value was 0.82, both indicating almost perfect reliability.

CONCLUSION

This novel 3DCT-based MLP classification system for intertrochanteric fractures is comprehensive, and reproducible with good agreement. It is based on proximal femur biomechanic characteristics and traumatic mechanism, contributing to formulating more reasonable treatment protocols involving various late-model internal fixation devices. J. Med. Invest. 70 : 524-529, August, 2023.

Proposal and validation of a new classification for trochanteric fractures based on medial buttress and lateral cortical integrity

Background

Trochanteric fractures usually require surgical treatment. The currently used classification system, such as AO classification, cannot cover all variant types, and is poor in reliability, causing confusion in surgical decision making. This study describes a simple, well-covered, re-liable, accurate, and clinically useful classification.

Methods

We retrospectively reviewed the records of 907 patients with trochanteric fractures treated by us from 1,999 to 2019 and proposed a new classification according to radiographs. Then, 50 records randomly selected in proportion were examined by 10 observers (5 experienced and 5 inexperienced) independently according to AO and the new classification. After a 2-week interval, repeat evaluation was completed. The Kappa coefficient was used to investigate the intra-observer reliability, inter-observer reliability and the agreement between the observers and the "reference standard".

Results

The new classification system includes 12 types composed of 3 medial groups and 4 lateral groups. According to the medial buttress, the fractures are divided into group I (intact lesser trochanter, adequate but-tress), group II (incomplete lesser trochanter, effective cortical buttress after reduction) and group III (huge defect of the medial cortex). According to the penetration region of the lateral fracture line, the fractures are divided into group A (intact lateral cortex), group B (incomplete lateral cortex), group C (subtrochanteric fractures) and group D (multiple lateral fracture lines). All of the included cases can be classified according to the new classification, of which 34 (3.75%) cases are unclassifiable by the AO classification. Intra-observer: The experienced achieved substantial agreement using both AO [k = 0.61 (95% confidence interval 0.46-0.76)] and new classification [k = 0.65 (0.55-0.76)]. The inexperienced reached moderate agreement using both AO [k = 0.48 (0.33-0.62)] and new classification [k = 0.60 (0.50-0.71)]. Inter-observer: The overall reliabilities for AO [k = 0.51 (0.49-0.53)] and for new classification [k = 0.57 (0.55-0.58)] were both moderate. The agreement between the experienced and the reference standard according to AO [k = 0.61 (0.49-0.74)] and new classification [k = 0.63 (0.54-0.72)] were both substantial. The agreement between the inexperienced and the reference standard according to AO [k = 0.48 (0.45-0.50)] and the new classification [k = 0.48 (0.41-0.54)] were both moderate.

Conclusion

Compared with AO classification, our new classification is better in coverage, reliability and accuracy, and has the feasibility of clinical verification and promotion.

The postoperative prognosis of older intertrochanteric fracture patients as evaluated by the Chang reduction quality criteria

OBJECTIVE

The aim of this study was to investigate the relationship between the Chang reduction quality criteria (CRQC) and the outcome of intertrochanteric fractures in older adults according to follow-up time.

METHODS

This was a retrospective analysis of 389 older adult patients with intertrochanteric fractures treated surgically from January 2019 to June 2021, including 130 males and 259 females aged 84.6 (77.5-89.7) years. Patient survival was determined by telephone as the time between admission to hospital for fracture and death or until the study deadline (June 1, 2022). According to the CRQC, the patients were divided into the Poor, Acceptable, and Excellent groups. Univariate and multivariate Cox proportional hazard models were used to assess the association between CRQC and all-cause mortality in older adult intertrochanteric fractures at 1 year and the total follow-up time. Further subgroup analysis was performed according to different clinical and biological characteristics to improve the accuracy of the results.

RESULTS

The mortality rates were 24.7% and 15.4% at 1 year and the total follow-up time, respectively. Both at one year and the total follow-up time, the mortality of the CRQC-Excellent group was significantly lower than that of the CRQC-Acceptable group (p.adj < 0.05) and the CRQC-Poor group (p.adj < 0.05). After multifactor adjustment, CRQC grades of Acceptable and Poor were independent risk factors affecting the overall and 1-year mortality. In addition, advanced age, ≥ 1 comorbidities, ASA 3 + 4, and prolonged preoperative waiting time were independent risk factors for survival at the total follow-up time. At 1 year, only ASA 3 + 4 and prolonged preoperative waiting time were independent risk factors for survival. Subgroup analysis according to different characteristics at the total follow-up time and at one year showed that in most subgroups, a decrease in the CRQC grade was significantly associated with an increase in all-cause mortality (p for trend < 0.05).

CONCLUSIONS

This study highlights that CRQC grades of Acceptable and Poor are associated with increased all-cause mortality in older adult intertrochanteric fractures. We should attempt to achieve good reduction of these fractures.

Predictors of and predictive nomogram for cut-out of proximal femur nail anti-rotation device in intertrochanteric fractures

PURPOSE

This study determined independent predictors and developed a predictive nomogram for failed correction of intertrochanteric fractures due to cut-out of the proximal femur nail anti-rotation (PFNA) device.

METHODS

Demographic and radiological data of 592 adult patients with intertrochanteric fractures (AO 31A) treated by PFNA were collected retrospectively. Independent predictors of cut-out were obtained through univariate and multivariate analyses, and a predictive nomogram was established. The discrimination, calibration, and clinical utility of the nomogram were based on receiver operating characteristic curve (AUC), concordance index (C-index), calibration curve, and decision curve analysis, respectively.

RESULTS

Overall, 18 (3.04%) cases of cut-out occurred. Independent predictors according to the multivariate analysis were body mass index (BMI), poor-to-acceptable quality of reduction, PFNA blade position, and tip-apex distance (TAD). AUC of the nomogram was 0.849, and C-index was 0.849 (95% CI [0.844-0.854]). Bootstrapping yielded a corrected C-index of 0.849. The calibration and decision curves indicated good agreement and clinical benefit of the nomogram.

CONCLUSION

A reliable predictive nomogram was developed for cut-out of the PFNA in intertrochanteric fractures, based on BMI, quality of reduction, blade position, and TAD.

Does augmentation of intramedullary nails by a buttress plate effectively restore lateral wall integrity in intertrochanteric fractures

BACKGROUND

Recent studies have proved the importance of intact lateral trochanteric wall, thus buttressing/fixing the broken lateral trochanteric wall irrespective of the implant, is likely to improve the alignment and outcome. We compared the outcome of lateral wall buttressing by trochanteric buttress plate (TBP) supplemented to proximal femoral nailing versus proximal femoral nailing alone in patients of broken lateral wall intertrochanteric fractures.

MATERIAL AND METHOD

Sixty patients of intertrochanteric factures (IT) of femur with broken lateral wall were randomized into group A or B and were treated with either proximal femoral nail (PFN) alone or proximal femoral nail augmented with trochanteric buttress plate (PFN + TBP), respectively. The TBP plate used was primarily fixed to proximal femur via 8 mm hip screw and 6.4 mm antirotation screw of the PFN. Operative time, blood loss, radiation exposure, quality of reduction, functional outcome, union time, and complications were compared.

RESULT

The mean age was 60.03 + 7.60 (range 42 to 70 years), with male to female ratio of 4:1 and left to right ratio of approximately 1:1. The mean follow up in the series was 16.2 months (range 13 to 36 months). Mean duration of surgery, mean intra-operative blood loss, and mean number of exposures in group A (PFN alone) were 64.88 + 12.24 min (48 to 88), 93 + 1.18 ml (60 to 120), and 32.13 (24 to 46) and in group B (PFN with TBP plate) were 91.86 + 12.78 min (70 to 122 min), 144.8 + 3.6 ml (116 to 208 ml), and 56.6 (38 to 112), respectively. Twenty-five patients and 28 patients in groups A and B respectively achieved score of 4 Chang quality reduction. Mean union time was 13.4 weeks in group A whereas in group B was 11.6 weeks. Mean HHS score in group A was 87.86 with 90% patients in comparison to 94.13 and 97% cases having excellent to good results in group B. In group A, 24 patients, while 29 patients in group B, had excellent to good results. Four patients had hip pain, four had impingement of screws, two had screw migration, three had Z/reverse effect, and four patients had shortening of more than 1 cm in group A. In group B, only one patient had impingement and none of the patient had hip pain, infection, implant failure, Z effect, or shortening.

CONCLUSION

The lateral trochanteric wall in IT fractures is significantly important, and when the lateral wall is broken, it can lead to poor results. TBP plate which is applied laterally on femur along with nail and fixing the plate with hip screw and antirotational screw provides faster union, early weight bearing, better reduction, and so better hip functions. TBP can be used successfully to augment, fix, or buttress the lateral trochanteric wall giving excellent to good results but at the cost of surgical time, blood loss, and radiation exposure.

[Proposal of a novel comprehensive classification for femoral intertrochanteric fractures]

OBJECTIVE

To introduce a novel comprehensive classification for femoral intertrochanteric fractures, and to accommodate the clinical requirement for the world-wide outbreak of geriatric hip fractures and surgical operations.

METHODS

On the basis of reviewing the history of classification of femoral intertrochanteric fractures and analyzing the advantages and disadvantages of AO/Orthopaedic Trauma Association (AO/OTA) classification in different periods, combined with the current situation of extensive preoperative CT scan and three-dimensional reconstruction and widespread use of intramedullary nail fixation in China, the "Elderly Hip Fracture" Research Group of the Reparative and Reconstructive Surgery Committee of the Chinese Rehabilitation Medical Association proposed a novel comprehensive classification for femoral intertrochanteric fractures, focusing on the structure of fracture stability reconstruction during internal fixation.

RESULTS

The novel comprehensive classification of femoral intertrochanteric fractures incorporates multiple indicators of fracture classification, including the orientation of the fracture line, the degree of fracture fragmentation, the lesser trochanteric bone fragment and its distal extension length (>2 cm), the posterior coronal bone fragment and its anterior extension width (involving the lateral cortex of the head and neck implant entry point), transverse fracture of the lateral and anterior wall and its relationship with the implant entry point in the head and neck, and whether the cortex of the anteromedial inferior corner can be directly reduced to contact, etc. The femoral intertrochanteric fractures are divided into 4 types (type A1 is simple two-part fractures, type A2 is characterized by lesser trochanter fragment and posterior coronal fractures, type A3 is reverse obliquity and transverse fractures, type A4 is medial comminution which lacks anteromedial cortex transmission of compression force), each of which is subdivided into 4 subtypes and further subdivide into finer subgroups. In a review of 550 trochanteric hip fracture cases by three-dimensional CT, type A1 accounted for 20.0%, type A2 for 62.5%, type A3 for 15.5%, and type A4 for 2.0%, respectively. For subtypes, A2.2 is with a "banana-like" posterior coronal fragment, A2.4 is with distal cortex extension >2 cm of the lesser trochanter and anterior cortical expansion of the posterior coronal fragment to the entry portal of head-neck implants, A3.4 is a primary pantrochanteric fracture, and A4.4 is a concomitant ipsilateral segmental fracture of the neck and trochanter region.

CONCLUSION

The novel comprehensive classification of femoral intertrochanteric fractures can describe the morphological characteristics of fractures in more detail, include more rare and complex types, provide more personalized subtype selection, and adapt to the clinical needs of both fractures and surgeries.

A sophisticated fracture classification system of the proximal femur trochanteric region (AO/OTA-31A) based on 3D-CT images

Objective

Fracture classification evolves dynamically with new and enhanced imaging modalities. This paper aims to introduce a novel hypothesis of a sophisticated fracture classification system for the proximal femur trochanteric region (AO/OTA-31A) based on 3D-CT images and accommodate the clinical requirement of the worldwide outbreak of geriatric hip fractures with large amounts of surgical operations.

Methods

In the current practice of widely preoperative 3D-CT application and cephalomedullary nailing, we attempt to propose a new comprehensive classification system to describe the fracture characteristics in a more detailed and sophisticated architecture, and pay the most important concern to the parameters that contribute to fracture stability reconstruction in osteosynthesis.

Results

The new four-by-four comprehensive classification system, followed the structure of the AO/OTA system, incorporates many fracture characteristics as dividing indexes into multiple grade levels, such as fracture line direction, the number of fragments, the lesser trochanter fragment and its distal extension (>2 cm), the posterior coronal fragment and its anterior expansion (to the entry portal of head–neck implant at the lateral cortex), the lateral wall and anterior cortex fracture, and the anteromedial inferior corner comminution. From a panoramic perspective, there are four types and each type has four subtypes. A1 is simple two-part fractures (20%), A2 is characterized by lesser trochanter fragment and posterior coronal fractures (62.5%), A3 is reverse obliquity and transverse fractures with complete lateral wall broken (15.5%), and A4 is medial wall comminution which further lacks anteromedial cortex transmission of compression force (2%). For subtypes, A2.2 is with a banana-like posterior coronal fragment, A2.4 is with distal cortex extension >2 cm of the lesser trochanter and anterior expansion of the posterior coronal fragment(s) to the entry portal of head–neck implants, A3.4 is a primary pantrochanteric fracture, and A4.4 is a concomitant ipsilateral segmental fracture of the neck and trochanter region.

Conclusion

Classification represents diversity under consistency. The four-by-four sophisticated classification system delineates fracture characteristics in more detail. It is applicable in the time of rapid outbreak of trochanteric fractures in the older population, the large amounts of surgical operations, and incorporates various rare and/or more complicated subtypes which is unclassifiable before.

Effectiveness of Cement Augmentation on Early Postoperative Mobility in Patients Treated for Trochanteric Fractures with Cephalomedullary Nailing: A Prospective Cohort Study

Fixation using cephalomedullary nails (CMNs) with additional cement augmentation (CA) was developed as a novel treatment option for the osteosynthesis of osteoporotic trochanteric fractures, though the effectiveness of CA on early postoperative mobility remains uncertain. This multicenter prospective cohort study aimed to estimate the effectiveness of CA on early postoperative mobility in patients with trochanteric fractures. We enrolled patients with femoral trochanteric fractures aged >60 years who were able to walk independently before the injury. The primary outcome was the postoperative 3-day cumulated ambulation score (CAS); the secondary outcome was the visual analog scale (VAS) pain score at rest and during movement on postoperative days 1−3. The outcomes of the patients treated using CMNs with or without CA were compared. Sixty-three eligible patients were categorized into CA (n = 32) and control (n = 31) groups. In univariate analysis, the CA group had significantly higher CAS values, lower VAS scores at rest on day 1 postoperatively, and lower VAS scores during movement on day 3. In multivariable linear regression analyses, the CA group had significantly higher CAS values (beta, 2.1; 95% confidence interval, 0.5 to 3.6; p = 0.01). The CA group had a negative adjusted beta value in their VAS scores during movement. This study indicated that CA was associated with a high CAS value in patients with geriatric trochanteric fractures. However, CA was not associated with pain reduction at rest and during movement during the initial postoperative days.

Association between Immediate Postoperative Radiographic Findings and Failed Internal Fixation for Trochanteric Fractures: Systematic Review and Meta-Analysis

Failed internal fixations for trochanteric fractures have a strong negative impact owing to increased postoperative mortality and high medical costs. However, evidence on the prognostic value of postoperative radiographic findings for failed internal fixations is limited. We aimed to clarify the association between comprehensive immediate postoperative radiographic findings and failed internal fixation using relative and absolute risk measures. We followed the meta-analysis of observational studies in epidemiology guidelines and the Cochrane handbook. We searched specific databases in November 2021. The outcomes of interest were failed internal fixation and cut-out. We pooled the odds ratios and 95% confidence intervals using a random-effects model and calculated the number needed to harm for each outcome. Thirty-six studies involving 8938 patients were included. The certainty of evidence in the association between postoperative radiographic findings and failed internal fixation or cut-out was mainly low or very low except for the association between intramedullary malreduction on the anteromedial cortex and failed internal fixation. Moderate certainty of evidence supported that intramedullary malreduction on the anteromedial cortex was associated with failed internal fixation. Most postoperative radiographic findings on immediate postoperative radiographs for trochanteric fractures were uncertain as prognostic factors for failed internal fixations.

The predictive value of the Singh index for the risk of InterTAN intramedullary fixation failure in elderly patients with intertrochanteric fractures

Background

To investigate the predictive value of the Singh index for the risk of InterTAN intramedullary fixation failure in elderly patients with intertrochanteric fracture to guide clinical treatment.

Methods

A total of 360 patients were divided into the Singh (I ~ II) (n = 120), Singh (III ~ IV) (n = 120) and Singh (V ~ VI) (n = 120) groups. Visual analog scale (VAS) and Harris scores were recorded at 1, 6, 12, 18 and 24 months after the operation. The correlation between the Singh index and the T-score of the total hip and femoral neck was analyzed. Logistic regression was used to analyze the relationship between the Singh index and internal fixation failure; the types of internal fixation failure were also analyzed.

Results

The Harris scores of the Singh (I ~ II) group were lower than those of the Singh (III ~ IV) and Singh (V ~ VI) groups 12, 18 and 24 months after surgery (P < 0.05). The Singh index was significantly correlated with the T-score of the total hip and femoral neck (P = 0.00, r = 0.89; P = 0.00, r = 0.83). The Singh (I ~ II) group had the lowest internal fixation survival rate within 24 months (P = 0.01). The Singh index was an independent predictor of internal fixation failure (P < 0.05). Lag screw cutting-out was the main type of internal fixation failure in the three groups (P = 0.00).

Conclusion

The Singh index is significantly correlated with the bone mineral density of the femoral neck and total hip. The Singh (I ~ II) group had lower Harris scores and a lower internal fixation survival rate than the other two groups. The Singh index is an independent predictor of internal fixation failure, especially lag screw cutting-out, after InterTAN fixation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05741-8.

Letter to the editor: Calcar fracture gapping: a reliable predictor of anteromedial cortical support failure after cephalomedullary nailing for pertrochanteric femur fractures

A recently published article by Song H et al. investigated the risk factors for anteromedial cortical support loss in pertrochanteric fractures treated with cephalomedullary nails. In this Correspondence, we would like to raise some concerns. Specifically, calcar fracture gap and anteromedial cortical support are different concepts in evaluating reduction quality. In addition, calcar fracture gap using immediate postoperative radiographic images has measurement bias. Lastly, explanatory variables selected for multivariable analysis are inappropriate. We would like to discuss and suggest solutions for these problems.

Risk factors for cut-outs in geriatric intertrochanteric fractures with cephalomedullary nailing after obtaining acceptable reduction: a case-control study

BACKGROUND

It is irresponsible if we disregard reduction quality to talk about cut-outs in intertrochanteric fractures (ITF) with internal fixation. The aim of this study is to analyze the risk-factors for cut-outs in geriatric ITF with cephalomedullary nailing after obtaining acceptable reduction.

METHODS

In order to investigate the risk-factors for cut-outs in geriatric ITF after obtaining acceptable reduction, we retrospectively reviewed 367 patients who underwent cephalomedullary nail for ITF in our department between September 2016 and December 2021. Potential variables including demographic data and radiological parameters (namely the fracture type, Singh index, lateral wall fracture, cephalic nail position, Parker's ratio index, tip-apex-distance (TAD), and calcar-referenced TAD (CalTAD)) were collected. Logistic regression analysis was performed to identify the significant risk factors for cut-outs.

RESULTS

One hundred twenty-one patients were suitable for this study. Of the 121 cases, nine cases (7.4%) were observed with cut-out or pending cut-out. We found that Age (adjusted odds ratio (OR) 1.158, 95% confidence interval (CI) 1.016 to 1.318, p = 0.028), lateral wall fracture (adjusted OR 11.07, 95%CI 1.790 to 68.380, p = 0.01), and CalTAD (adjusted OR 1.277, 95%CI 1.005 to 1.622, p = 0.045) were independent risk-factors for cut-outs.

CONCLUSIONS

Age, lateral wall fracture and CalTAD are independent risk-factors for cut-outs in geriatric ITF with cephalomedullary nailing after obtaining acceptable reduction. In order to avoid cut-outs, an optimal CalTAD is necessary even obtaining acceptable reduction, especially in the over-aged patients with lateral wall fracture.

Risk factors for over-telescoping in reverse oblique intertrochanteric fractures

PURPOSE

Postoperative over-telescoping (OT) with lag screws is often observed in reverse oblique intertrochanteric fractures. This study aimed to clarify the risk factors of OT in patients with reverse oblique intertrochanteric fractures.

METHODS

Electronic medical records of patients diagnosed with reverse oblique intertrochanteric fractures using plain radiography who underwent operative fixation with an intramedullary nail between August 2013 and December 2019 were reviewed. Patients were classified into two groups according to the Futamura classification: lateral wall pattern (LW) and reverse oblique pattern (RO). The incidence of OT in the LW and RO groups was compared. Also, we compared the incidence of OT for each reduction type in the LW group.

RESULTS

Twenty patients had LW, and nine had RO. OT was observed in eight fractures (42.1%) in the LW group but not in the RO group. The incidence of OT was significantly higher in the LW group than in the RO group (P = 0.0261). Among the 19 fractures with LW, OT was observed in 7 of 10 and 1 of 9 fractures with postoperative reduction in the intramedullary and extramedullary or anatomical types, respectively. In the LW group, the incidence of OT was significantly higher in fractures with postoperative reduction in the intramedullary type than in those of the extramedullary or anatomical type (P = 0.0198).

CONCLUSION

Our study showed that the incidence of OT was significantly higher in LW than in RO and that postoperative reduction in the intramedullary type in LW was a risk factor for OT.