Safety and reliability of external fixation for basicervical and intertrochanteric fractures in high-risk elderly patients

Computer aided analysis of biomechanical performance of schanz screw with different additive manufacturing materials used in pertrochanteric fixator on an intertrochanteric femoral fracture (corrosion resistance approach)

This study examines the use of computer-aided analysis to evaluate the biomechanical performance of Schanz screws made from different additive manufacturing materials (Ti6Al4V, 316 L, Inconel 625, and Inconel 718) in a pertrochanteric fixator for the treatment of intertrochanteric femoral fractures. Intertrochanteric fractures (ITFs) are severe traumas often seen in the elderly population and can lead to serious consequences. The primary objective of ITF surgery is to provide stability and allow for early ambulation and rehabilitation. The Pertrochanteric Fixator is a surgical implant used to treat hip fractures near the greater trochanter, and is attached to the femur with screws. The procedure is performed under general anesthesia and typically takes 1-2 h. Possible complications include infection, nerve injury, and hardware failure. The aim of this study is to evaluate the biomechanical performance of Schanz screw using computer-aided analysis, comparing the effects of various additive manufacturing materials including Ti6Al4V, 316 L, Inconel 625 and Inconel 718 in a pertrochanteric fixator for intertrochanteric femoral fractures. Additionally, this study will also consider the corrosion resistance of these materials to ensure long-term durability and effectiveness in a clinical setting. The stress values mentioned for the implant materials are as follows. Ti6Al4V: 153.33 MPa, 316 L: 180.98 MPa, Inconel 625: 158.94 MPa, Inconel 718: 148.91 MPa. Higher stress values indicate a greater load transfer to the bone, which can potentially lead to stress shielding. Stress shielding occurs when an implant bears a significant portion of the load that should be transferred to the bone. This reduced stress at the fracture site can prevent the healing process, as bones require adequate stress levels for optimal remodeling and regeneration.

The application of iliac fascia space block combined with esketamine intravenous general anesthesia in PFNA surgery of the elderly: A prospective, single-center, controlled trial

To observe the effect of iliac fascia space block combined with esketamine intravenous general anesthesia in proximal femoral nail antirotation (PFNA) of the elderly. Eighty elderly patients who underwent PFNA were randomly divided into experimental group and control group. In the experimental group, iliac fascial block combined with esketamine and propofol intravenous general anesthesia was used to keep spontaneous breathing. The control group used iliac fascia block combined with remifentanil and propofol intravenous general anesthesia to maintain spontaneous breathing. Record important indexes such as heart rate (HR), mean arterial pressure (MAP), pulse oxygen saturation (SpO2), visual analogue score (VAS) scores, etc. at different moment during the operation. Trial data showed that there were significant differences in HR, MAP, and SpO2 between the two groups at the beginning of operation, and there was no significant difference in VAS scores between the two groups at each moment after surgery, and there were significant differences in the number of vasopressor applications, length of hospital stay, and QoR-15 scores between the two groups, and there were significant differences in the incidence of total adverse reactions and the incidence of hypotension. The trial indicated that patients in the experimental group have more stable hemodynamics and lower stress response, which is conducive to rapid recovery after surgery.

Use of external fixators in developing countries: a short socioeconomic analysis

The use of external fixators (EFs) dates back to 377 BC Hippocrates’ time, and it has a wide range of orthopaedic applications. External fixator has expanded its use in the management of fractures and other musculoskeletal conditions. It is widely used all over the world to manage complex musculoskeletal injuries. It has many advantages as compared to internal fixation in some trauma scenarios. However, the cost of the external fixators presents a dilemma to the healthcare system in developing countries. The goals of this review article are to explain the importance of EFs in developing countries in managing fractures, to determine the problems encountered at present during external fixation by developing countries, to identify solutions that could be used to address these issues, expand the use of external fixation into other domains of treatment, the impact of COVID-19 pandemic on fracture management based on existing literature. In conclusion, EFs are very expensive, researches have been conducted to overcome these barriers in developing countries. However, there are limitations in implementing in developing countries. It is important to have affordable and clinically acceptable EFs available in developing countries.

Treatment of intertrochanteric femur fracture with closed external fixation in high-risk geriatric patients: can it be the most reliable method that reduces mortality to minimum compared to proximal femoral nail and hemiarthroplasty?

The optimal surgical treatment of intertrochanteric femur fractures (ITF) to minimize the increased mortality in geriatric patients with high anesthetic risk was investigated by comparing closed external fixation (EF), a minimal invasive and biological osteosynthesis technique, proximal femoral nail (PFN) and hemiarthroplasty (HA) methods.Three different surgical methods were performed to 167 patients who were admitted to our clinic for ITF between 2014 and 2020 and considered at high risk (American Society of Anesthesiologists III - American Society of Anesthesiologists IV) by the Anesthesiology and Reanimation Department. Patients with multi-trauma, osteoarthritis, those with malignancies and developmental hip dysplasia were excluded from the study. Group I included patients who underwent closed reduction - external fixation (n = 46), Group II included patients who underwent partial arthroplasty (n = 77), and Group III included those who received PFN (n = 44). All fractures were classified according to the Modified Evans (Kyle) method and divided into 2 categories as type 1-2 (stable) and type 3-4 (unstable).The mean operation duration was 23 minutes and follow-up time was 14 months in Group 1, in which there was no in-hospital mortality. Five patients died due to non-operative reasons within 1 year. The mean operation duration and follow-up time in Group 2 were 40 minutes and 12 months, respectively. Six patients (7.8%) died during the operation or hospitalization, while 17 patients died due to comorbidities within 1 year. In Group 3, the mean operation duration and follow-up time were 40 minutes and 13 months, respectively. One patient died during the operation and 1 patient (n = 2, 4.5%), within 24 hours in the postoperative intensive care unit. Seven patients died due to comorbidities within 1 year. Statistical analysis revealed that the mean duration of operation, postoperative hospital stay, overall mortality and blood product transfusion amount were significantly lower in the EF group compared to other treatment methods.Closed EF is the most reliable surgical method that can minimize mortality in geriatric patients compared to other surgical options, due to the short duration of the operation, no evacuation of the fracture hematoma, early mobilization, lack of blood transfusion requirement, and early union.

Comparison of the Dynamic Hip Screw with the Dynamic Hip External Fixator for Intertrochanteric Fractures: Report of a Randomized Controlled Trial

BACKGROUND

Pelvic fracture is one of the most common fractures in the elderly, especially in the intertrochanteric region. Therefore, in the present study, an external fixator was designed specifically for intertrochanteric fractures. The present study aimed to compare the operating time, amount of bleeding, and mortality rate between the patients who received either dynamic hip external fixators (DHEF) or dynamic hip screw (DHS).

METHODS

In 2018, 46 patients with intertrochanteric fracture due to trauma and high anesthesia risk were included in the study and randomly assigned to two groups of control (n=24, patients treated with DHS) and intervention group (n=22, patients treated with the DHEF). Treatment was carried out using the DHEF which was newly designed and placed outside the patient's body under short and light anesthesia. After 3 and 12 months of follow-up, the two groups were compared for some variables, including mortality rate, pain intensity, Harris hip score (HHS), cut-off rate of the device, femoral neck angles before and after the operation, hemoglobin changes, hematocrit levels before and after the operation, the number of injected blood units, and the number of hospitalization days.

RESULTS

Mortality rate was higher in open surgery with DHS. The assessment of variables in both intervention and control groups demonstrated that duration of operation (P<0.001), hospitalization length, time to union (P=0.001), pain intensity five days after the operation, as well as changes in Hb and HCT, were significantly higher in the control group than the intervention group. The mean HHS scores of 83.5±14.3 and 78.2±11.5 were gained for the DHEF and DHS groups, respectively (P=0.22).

CONCLUSION

Considering the superior results of treatment with the external fixator in comparison with the DHS, such as lower mortality rate and fewer complications, a dynamic hip external fixator can be prescribed in patients with intertrochanteric fractures and high anesthesia risk.

Autogenous fibula graft and cannulated screw fixation to cephalic cut out after DHS fixation: a retrospective study

BACKGROUND

This study aimed to explore the effect of the treatment through autologous fibula graft and hollow needle fixation to treat femoral head cutting after dynamic hip screw (DHS) fixation.

METHODS

A total of 41 patients were admitted to the department of orthopedic trauma and received DHS fixation. Preoperative and postoperative harris score of hip function, limb shortening length and collodiaphysial angle between operation group (n = 11) and non-operation group (n = 13) were compared.

RESULTS

There was no difference between the two groups before surgery (P > 0.05). There was a difference between the preoperative and postoperative in the operation group (P < 0.05). The excellent and good rate of the hip function score in patients 6 months after the operation was 55.6%. In the operation group, the hip function score increased after surgery (P < 0.001). Except for two groups of patients before operation, there was a difference in the limb shortening length and collodiaphysial angle between the operation group and non-operation group in other time points after surgery (P < 0.001).

CONCLUSION

The application of the autogenous fibula graft and hollow nail fixation was effective in treating femoral head cutting after DHS fixation, and patients' subjective evaluation and objective indicators' outcomes of follow up were satisfactory, which was worthy of clinical application.

Reference positions for transosseous elements in femur: A cadaveric study

INTRODUCTION

During external fixator treatment, displacement of soft tissue at pin sites may cause infection and contracture. Due to surrounding soft tissue thickness, the femur is especially susceptible to severe complications. However, standard textbooks demonstrate only how major neurovascular bundles should be avoided. This study is the first cadaver study investigating which pin sites within safe zones exhibit minimal soft tissue displacement.

METHODS

To identify the clear direction of any pin, the femoral shaft was divided into eight levels, from I to VIII. The transverse sections at each level were further divided into 12 radial positions analogous to a clock face, where the anterior direction was assigned twelve o'clock, the medial three, etc. Fifteen adult cadavers were used. Twelve wires were aligned radially on the examined ring, and were dyed at each point toward the soft tissue. Each soft tissue displacement was measured by marking the surface before and after three particular joint motions, namely hip flexion (0-90°), abduction (0-45), and knee flexion (0-90). The same procedures were performed in three layers of soft tissue: skin, fascia, and muscle.

RESULTS

The average displacement was determined in 89 directions excluding the groin part, upon three joint motions. The three layers of skin, fascia, and muscle showed similar data curves. Greater displacements were seen at juxta-articular areas than at the mid-diaphyseal. The data curve exhibited a bimodal characteristic, with larger displacements at the extension and flexion directions. The amount of displacement at 6 o'clock was large at the levels near the hip joint, whereas at 12 o'clock, it was large near the knee joint.

DISCUSSION

"Reference positions" for transosseous elements were defined within zones absent neurovascular bundles, indicating 30 sites with minimal tissue displacement. Three or four directions at each level were chosen: I.9-11, II.9-11, III.8-11, IV.8-11, V.7-10, VI.3, 7-9, VII.3, 4, 8, 9, and VIII.3, 4, 8, 9. The anterolateral aspect near the hip joint and the posterolateral aspect near the knee tended to be chosen. They may prove useful in perioperative practice.

Distal femoral osteotomy: is internal fixation better than external?

BACKGROUND

Distal femoral osteotomies (DFO) can be used to correct deformities around the knee. Although osteotomies can be fixed with either internal or external fixation techniques, the advantages of one over the other are unclear.

QUESTIONS/PURPOSES

We asked whether (1) for both techniques, we could accurately correct the deformities based on our preoperative goals for mechanical axis deviation (MAD) and lateral distal femoral angle (LDFA), and (2) intraoperative times, (3) preoperative and postoperative knee ROM, and (4) complications differed.

PATIENTS AND METHODS

We identified 26 patients (34 limbs) who underwent femoral osteotomies. We compared accuracy of correction (based on correction of the MAD and the LDFA), duration of surgery, preoperative and postoperative knee ROM, and complications. The minimum followup was 20 months (mean, 29 months; range, 20-40 months).

RESULTS

We achieved the desired MAD within 10 mm of the goal in 18 of 21 limbs with the unilateral frame and in 12 of 13 limbs using fixator-assisted plating. Operative time for fixator-assisted plating was longer (122 ± 34 minutes) than when using a unilateral frame (94 ± 65 minutes). Preoperative and postoperative knee ROMs were similar for both techniques and there were no major complications.

CONCLUSIONS

We obtained accurate correction of deformities with both fixation techniques. Our experience suggests the method to be used should be left to the discretion of the surgeon and the needs and wishes of the patient after adequate explanation of the advantages and disadvantages.

LEVEL OF EVIDENCE

Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.