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Gausden EB, Bedard NA, Gililland JM, Haidukewych GJ. What's New in Periprosthetic Femur Fractures? J Arthroplasty 2024:S0883-5403(24)00360-7. [PMID: 38642853 DOI: 10.1016/j.arth.2024.04.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 04/09/2024] [Accepted: 04/11/2024] [Indexed: 04/22/2024] Open
Abstract
BACKGROUND Periprosthetic femur fracture (PFF) is one of the most common indications for reoperation following total hip arthroplasty. METHODS/RESULTS This article provides a review of a symposium on PFF that was presented at the American Association of Hip and Knee Surgeons 2023 annual meeting, including an overview of the Vancouver classification and its implications on treatment and subsequent complications, an updated approach to the management of intraoperative fractures, and finally, contemporary strategies for both osteosynthesis as well as revision arthroplasty for PFFs. CONCLUSION As the incidence of PPF continues to increase, arthroplasty and trauma surgeons must be prepared to address this challenging complication with a contemporary understanding of the treatment options and their outcomes.
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Affiliation(s)
- Elizabeth B Gausden
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | | | - Jeremy M Gililland
- Department of Orthopedic Surgery, University of Utah, Salt Lake City, Utah
| | - George J Haidukewych
- Department of Orthopedic Surgery, Orlando Health Medical Group, Orlando, Florida
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Fraval A, Hegeman EM, Krueger CA. Management of Isolated Greater Trochanter Fractures Associated With Total Hip Arthroplasty. J Am Acad Orthop Surg 2024; 32:196-204. [PMID: 38147680 DOI: 10.5435/jaaos-d-23-00560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 11/08/2023] [Indexed: 12/28/2023] Open
Abstract
Periprosthetic hip fractures are recognized complications associated with total hip arthroplasty. Over the past decade, there has been a 2.5-fold increase in the incidence of periprosthetic fractures which is expected to grow exponentially in the future. Most of these fractures require surgical fixation or revision arthroplasty. Fractures of the greater trochanter represent a subset of periprosthetic fractures for which there is currently no consensus in the literature regarding the optimal management. The purpose of this review was to outline the management strategies available to address these fractures, with formulation of recommendations for fractures sustained intraoperatively, postoperatively, and in the setting of primary and revision total hip arthroplasty.
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Affiliation(s)
- Andrew Fraval
- From the Rothman Orthopedic Institute at Thomas Jefferson University (Fraval, and Krueger), and Department of Orthopaedic Surgery, San Antonio Military Medical Center (Hegeman)
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Habibi AA, Schwarzkopf R. Treatment of Intraoperative Trochanteric Fractures During Primary and Revision Total Hip Arthroplasty. Orthop Clin North Am 2024; 55:19-26. [PMID: 37980100 DOI: 10.1016/j.ocl.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2023]
Abstract
Intraoperative trochanteric fractures during primary and revision total hip arthroplasty typically occur during femoral canal preparation and component placement. Several fixation strategies, including wires, cables, cable grips, and plating, are available for fracture fixation. Surgeons should consider patient activity level preoperatively, bone mineral density, and fracture morphology when deciding on fixation strategies. Patient activity must be modified postoperatively to prevent fracture displacement and additional complications. Patients must be counseled postoperatively about the possibility of decreased clinical outcomes.
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Affiliation(s)
- Akram A Habibi
- Department of Orthopedic Surgery, NYU Langone Health, 301 East 17th Street, 15th Floor Suite 1518, New York, NY 10003, USA
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, 301 East 17th Street, 15th Floor Suite 1518, New York, NY 10003, USA.
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Hu Y, Xu Z, Qiao H, Kong K, Li H, Zhang J. Shape-memory sawtooth-arm embracing clamp used in complex femoral revision hip arthroplasty for stem stability: average 9-year follow-up study. BMC Musculoskelet Disord 2023; 24:970. [PMID: 38102625 PMCID: PMC10722768 DOI: 10.1186/s12891-023-07080-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 11/29/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Nickel-Titanium shape-memory sawtooth-arm embracing clamps (SSECs) have been used in revision total hip arthroplasties (rTHAs) to protect stem stability. This study was to introduce this technique and report its mid to long-term clinical and radiographic outcomes. METHODS We retrospectively reviewed all patients implanted with SSECs in our department from January 2008 to December 2015. 41 patients (41 hips) were finally included. Radiographs and Harris hip scores (HHS) were collected. Radiographs were blindly analyzed for evidence of loosening, subsidence and stress shielding. HHS were compared to previous records by student's t tests. The average follow-up period was 9.3 years. RESULTS All stems were stably fixed with no signs of loosening. The mean stem subsidence was 0.9 mm (range, 0 to 3 mm). Only one patient (2.4%) demonstrated the fourth degree of stress shielding, with the others none or minor bone resorption. The mean HHS at the final follow-up was 84.2 (range, 81 to 91), which was improved from 17.4 (range, 0 to 37) before surgery. No implant failures or re-revisions occurred. Dislocation occurred in 1 case during the follow-up period. CONCLUSIONS The SSEC protected stem fixation and achieved favorable clinical and radiographic outcomes in this 9-year follow-up study. It offered an additional extramedullary fixation option for surgeons to choose from in treating complex femoral revision arthroplasties.
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Affiliation(s)
- Yi Hu
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, 639# Zhizaoju Road, Shanghai, 200011, P. R. China
| | - Zhengquan Xu
- Department of Orthopaedic Surgery, Suzhou Hospital, Nanjing Medical University, 16# Baita West Road, Suzhou, Jiangsu, 215000, P. R. China
| | - Hua Qiao
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, 639# Zhizaoju Road, Shanghai, 200011, P. R. China
| | - Keyu Kong
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, 639# Zhizaoju Road, Shanghai, 200011, P. R. China
| | - Huiwu Li
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, 639# Zhizaoju Road, Shanghai, 200011, P. R. China.
| | - Jingwei Zhang
- Shanghai Key Laboratory of Orthopaedic Implants, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, 639# Zhizaoju Road, Shanghai, 200011, P. R. China.
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Acevedo D, Trapana JE, Constantinescu D, Carvajal Alba JA. Trochanteric Bolt Failure in a Modular Femoral Revision System. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202309000-00008. [PMID: 37703502 PMCID: PMC10499066 DOI: 10.5435/jaaosglobal-d-23-00066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 07/31/2023] [Accepted: 08/05/2023] [Indexed: 09/15/2023]
Abstract
With the incidence of primary total hip arthroplasty continuing to rise in the United States, the innovation behind improving current total hip arthroplasty systems inevitably grows with it-each new design potentially ushering in new flaws. We report a case of screw failure with the Arcos Modular Femoral Revision System-Trochanteric Bolt and Claw Technique in a 74-year-old male patient. The patient presented to the investigator's clinic for their 20-month follow-up evaluation of their complex right hip revision. Radiographs revealed failure of the screw attaching the claw plate to the stem resulting in dislodgement and relocation of the screw within the intra-articular cavity. The patient elected for nonsurgical management and will continue to be monitored. Consent by the patient involved in this case report was obtained.
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Affiliation(s)
- Daniel Acevedo
- From the Nova Southeastern University Dr. Kiran C. Patel College of Allopathic Medicine (NSU MD), Fort Lauderdale, FL (Acevedo), and the Department of Orthopedic Surgery, University of Miami Hospital, Miami, FL (Dr. Trapana, Dr. Constantinescu, Dr. Carvajal Alba)
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Schafer P, Sullivan TC, Lambert B, Park KJ, Clyburn TA, Incavo SJ. Greater Trochanteric Fixation Using Cable Plate Devices in Complex Primary and Revision Total Hip Arthroplasty. Arthroplast Today 2023; 20:101103. [PMID: 36844656 PMCID: PMC9945632 DOI: 10.1016/j.artd.2023.101103] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 12/19/2022] [Accepted: 01/15/2023] [Indexed: 02/12/2023] Open
Abstract
Background Successful fixation of the greater trochanter (GT) in total hip arthroplasty (THA) is a challenging task. A wide range of clinical results are reported in the literature despite advancements in fixation technology. Previous studies may have lacked adequate sample sizes to detect differences. This study evaluates nonunion and reoperation rates and determines factors influencing successful fixation of the GT using current-generation cable plate devices. Methods This retrospective cohort study included 76 patients who underwent surgery requiring fixation of their GT and had at least 1-year radiographic follow-up. Indications for a surgery were periprosthetic fracture (n = 25), revision THA requiring an extended trochanteric osteotomy (n = 30), GT fracture (n = 3), GT fracture nonunion (n = 9), and complex primary THA (n = 3). Primary outcomes were radiographic union and reoperation. Secondary objectives were patient and plate factors influencing radiographic union. Results At a mean radiographic follow-up of 2.5 years, the union rate was 76.3% with a nonunion rate of 23.7%. Twenty-eight patients underwent plate removal, reasons for removal were pain (n = 21), nonunion (n = 5), and hardware failure (n = 2). Seven patients had cable-induced bone loss. Anatomic positioning of the plate (P = .03) and number of cables used (P = .03) were associated with radiographic union. Nonunion was associated with a higher incidence (+30%) of hardware failure due to broken cable(s) (P = .005). Conclusions Greater trochanteric nonunion remains a problem in THA. Successful fixation using current-generation cable plate devices may be influenced by plate positioning and number of cables used. Plate removal may be required for pain or cable-induced bone loss.
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Affiliation(s)
| | | | | | | | | | - Stephen J. Incavo
- Corresponding author. Houston Methodist Hospital, Houston Methodist Orthopedics & Sports Medicine, 6445 Main Street, Suite 2500, Houston, TX 77030, USA. Tel.: +1 713 441 3539.
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Neitzke C, Davis E, Puri S, Chalmers BP, Sculco PK, Gausden EB. Contemporary Use of Trochanteric Plates in Periprosthetic Femur Fractures: A Displaced Trochanter Will Not Be Tamed. J Arthroplasty 2023; 38:158-164. [PMID: 35872232 DOI: 10.1016/j.arth.2022.07.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 07/13/2022] [Accepted: 07/15/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The objective of this study was to evaluate the reoperation and complication rate following trochanteric plate fixation of greater trochanter (GT) periprosthetic femur fractures associated with total hip arthroplasty and to identify risk factors for subsequent reoperation, nonunion, and hardware failure (plate/cable breakage or migration). METHODS Between 2010 and 2020, 44 patients who had 44 periprosthetic greater trochanter fractures at mean follow up of 2 years were retrospectively reviewed. Initial injury radiographs as well as immediate and final follow-up radiographs were evaluated. Subsequent reoperations, nonunion, and cases of hardware failure were identified. There were 22 (50%) Vancouver B2 fractures and 22 (50%) Vancouver A fractures. RESULTS The 2-year cumulative probability of any subsequent reoperation was 20%. There were 9 total subsequent reoperations. The trochanteric fracture went on to nonunion in 14 patients (39%), and hardware failure occurred in 10 (28%) patients. A trochanteric bolt was used in addition to the trochanteric plate in 6 patients (14%), of which 4 (67%) patients had trochanteric plate displacement and 3 (50%) patients had trochanteric nonunion. Displacement of the greater trochanter prior to fixation was a predictor of subsequent nonunion (77% versus 23%, P = .02). CONCLUSION In this large contemporary series, there was a high incidence of reoperation (20%) with in the first 2-years following plating of periprosthetic GT fractures, as well as a high rate of nonunion (39%), and hardware failure (28%). Displacement of the GT prior to plating predicted nonunion. LEVEL OF EVIDENCE Level IV, retrospective observational study.
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Affiliation(s)
- Colin Neitzke
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois
| | - Elizabeth Davis
- Department of Orthopaedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York
| | - Simarjeet Puri
- Department of Orthopaedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York
| | - Brian P Chalmers
- Department of Orthopaedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York
| | - Peter K Sculco
- Department of Orthopaedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York
| | - Elizabeth B Gausden
- Department of Orthopaedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York
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Outcomes After Abductor Reattachment to Proximal Femur Endoprosthesis After Tumor Resection. J Am Acad Orthop Surg 2023; 31:34-40. [PMID: 36548152 DOI: 10.5435/jaaos-d-22-00369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 08/02/2022] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Resection of the proximal femur raises several challenges including restoration of the abductor mechanism. Few evaluated the outcomes of different techniques of abductor fixation to the proximal femur endoprosthesis. METHODS A retrospective review of patients who underwent proximal femoral arthroplasty with a minimum follow-up of 12 months was conducted. Patients were divided into two groups: (1) those with preserved greater trochanter (GT) reattached to the implant and (2) those with direct abductor muscle reattachment. Both groups were compared for surgical and functional outcomes. Group 1 patients were subdivided into those who received GT reinsertion using grip and cables and those reattached using sutures. RESULTS Fifty-three patients were included with a mean follow-up of 49 months. There were 22 patients with reinserted GT and 31 patients with soft-tissue repair. The endoprosthesis revision rate was comparable between groups (P = 0.27); however, the incidence of dislocations was higher in group 2 (0/22 versus 6/31; P = 0.035). Trendelenburg gait (77% versus 74%), use of walking aids (68% versus 81%), and abductor muscle strength were comparable between both groups (P > 0.05). In group 1, 15 patients had GT reinsertion with grip and cables. Of those, five patients (33%) had cable rupture within 13 months of follow-up. GT displacement reached 12 mm at 12 months of follow-up in patients with grip and cables compared with 26 mm in patients with GT suture reinsertion (P < 0.05). DISCUSSION Although GT preservation did not improve functional outcomes, it was associated with a lower dislocation rate despite frequent cable failure. Less displacement was observed when GT reattachment used grip and cables.
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Zhang B, Du Y, Zhang Y, Dong Y, Zhang T, Zhou Y. Comparison of Functional and Radiographic Outcomes Between Two Fixation Methods for Extended Trochanteric Osteotomy in Revision Total Hip Arthroplasty: A Retrospective Cohort Study. J Arthroplasty 2022; 37:1844-1850. [PMID: 35436529 DOI: 10.1016/j.arth.2022.04.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 03/28/2022] [Accepted: 04/10/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND To compare the functional and radiographic outcomes between two fixation methods for extended trochanteric osteotomy (ETO) in revision total hip arthroplasty (rTHA). METHODS Included in this study were 64 patients who underwent ETO in rTHA using either claw-plate fixation (claw-plate group, n = 31) or cable-alone fixation (cable group, n = 33) in our hospital from 2008 to 2020. The functional and radiographic results and complications were compared between the groups during a mean follow-up period of 64 and 78 months. RESULTS The Harris hip score and visual analogue scale at the last follow-up improved significantly in both groups, showing no significant statistical difference between the two fixation methods. In the cable group, the mean abductor lever arm, the proximal migration, and medial migration in the affected hip were significantly decreased compared to those in the contralateral normal hip (P < .05), whereas in the claw-plate group no significant statistical differences were observed between two sides. No or slight limping occurred in 25 patients (81%) in the claw-plate group and 16 patients (48%) in the cable group (P = .007). A multiple logistic regression demonstrated that claw-plate fixation could reduce the incidence of postoperative moderate-to-severe limping. CONCLUSION Both claw-plate fixation and cable-alone fixation could improve the functional performance of rTHA with ETO, whereas claw-plate fixation could offer superior biomechanical results and gait improvement as compared with cable-alone fixation.
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Affiliation(s)
- Bohan Zhang
- Medical School of Chinese PLA, Beijing, People's Republic of China; Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, People's Republic of China; Senior Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, People's Republic of China
| | - Yinqiao Du
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, People's Republic of China; Senior Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, People's Republic of China
| | - Yanchao Zhang
- Medical School of Chinese PLA, Beijing, People's Republic of China; Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, People's Republic of China; Senior Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, People's Republic of China
| | - Yu Dong
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, People's Republic of China; Senior Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, People's Republic of China; Medical School of Nankai University, Tianjin, People's Republic of China
| | - Ti Zhang
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, People's Republic of China; Senior Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, People's Republic of China; Medical School of Nankai University, Tianjin, People's Republic of China
| | - Yonggang Zhou
- Department of Orthopedics, The First Medical Center, Chinese PLA General Hospital, Beijing, People's Republic of China; Senior Department of Orthopedics, The Fourth Medical Center, Chinese PLA General Hospital, Beijing, People's Republic of China
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Çiloğlu O, Karaali E, Kuşvuran Özkan A, Ekiz T. Distally-fixed non-modular monoblock fluted long-stem hemiarthroplasty versus proximal femoral nailing for elderly patients with an osteoporotic intertrochanteric fracture: a retrospective comparative study. Hip Int 2022; 32:124-130. [PMID: 33021123 DOI: 10.1177/1120700020963529] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The treatment of Intertrochanteric fractures in the elderly osteoporotic patient is still controversial. The aim of this study was to compare the outcomes of proximal femoral nailing (PFN) and a distally-fixed non-modular monoblock fluted long-stem hemiarthroplasty (HA) in elderly patients with an osteoporotic intertrochanteric fracture. METHODS This retrospective study included patients who had undergone surgery for an unstable intertrochanteric fracture. The patients were separated into PFN and HA groups. The demographic features of the 2 groups were compared. All patients were evaluated using the Singh index, ASA score, AO/OTA classification, Harris Hip Score (HHS), and Parker and Palmer mobility score. RESULTS The most common complications were nonunion (12.0%) and cut-out of the screw (10.7%) in the PFN group, and dislocation of the prosthesis (6.7%) and wound infection (5.7%) in the HA group. Overall, the 2-year mortality rate was 29.3%. Mortality, particularly within the first 3 months, was 2.4 times higher in the PFN Group than in the HA group (40% vs. 19.75%). Although the HHS was significantly higher in the first year for the HA group, no significant difference was seen between the 2 groups at 24 months. CONCLUSIONS Although PFN and HA have similar good outcomes at 2 years, HA allows earlier mobilisation and has fewer complications and a lower mortality rate.
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Affiliation(s)
- Osman Çiloğlu
- Department of Orthopaedics, Adana City Training and Research Hospital, Adana, Turkey
| | - Evren Karaali
- Department of Orthopaedics, Adana City Training and Research Hospital, Adana, Turkey
| | - Aslıhan Kuşvuran Özkan
- Department of Physical and Rehabilitation Medicine, Özülkü Medical Centre, Adana, Turkey
| | - Timur Ekiz
- Department of Physical and Rehabilitation Medicine, Türkmenbaşı Medical Centre, Adana, Turkey
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Mei XY, Gong YJ, Safir OA, Gross AE, Kuzyk PR. Fixation Options Following Greater Trochanteric Osteotomies and Fractures in Total Hip Arthroplasty: A Systematic Review. JBJS Rev 2019; 6:e4. [PMID: 29894341 DOI: 10.2106/jbjs.rvw.17.00164] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND The optimal system for greater trochanteric fixation following osteotomy or fracture remains unknown. This systematic review aims to synthesize the available English-language literature on 5 commonly reported trochanteric fixation methods to quantify and compare rates of complications and reoperation. METHODS A comprehensive search of MEDLINE and Embase databases from January 1946 to June 2017 was performed for articles in English describing fixation of trochanteric osteotomies and fractures using wires, cables, cable-plate devices, claw or locking plates, and trochanteric bolts. Pooled mean rates of complications and reoperation with 95% confidence intervals (CIs) were analyzed using a random-effects model. RESULTS Fifty-seven studies involving 10,956 hips were eligible for inclusion. Five studies had Level-III evidence and 52 had Level-IV evidence. The pooled mean rate of nonunion was 4.17% (95% CI, 3.21% to 5.13%; I = 79%) for wires, 5.07% (95% CI, 0.37% to 9.77%; I = 74%) for cables, 16.11% (95% CI, 10.85% to 21.37%; I = 89%) for cable-plate systems, 9.60% (95% CI, 2.23% to 16.97%; I = 59%) for claw or locking plates, and 12.42% (95% CI, 3.41% to 21.43%; I = 75%) for trochanteric bolts. Substantial heterogeneity in the data precluded formal statistical comparison of outcomes and complications between implants. CONCLUSIONS Available literature on the various trochanteric fixation implants is heterogeneous and consists primarily of retrospective case series. Based on the current literature, it is difficult to support the use of one implant over another. Despite superior mechanical properties, rates of complication and reoperation following cable-plate fixation remains suboptimal, especially in complex revision scenarios. Additional rigorous prospective randomized and cohort studies are needed to make definitive recommendations regarding the most reliable method of trochanteric fixation. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Xin Y Mei
- Division of Orthopaedic Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada
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Mei XY, Bhanot K, Tsvetkov D, Rajgopal R, Safir OA, Kuzyk PR. Current Uses of the Transtrochanteric Approach to the Hip: A Systematic Review. JBJS Rev 2018; 6:e2. [PMID: 29979233 DOI: 10.2106/jbjs.rvw.17.00180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND The indications and technique for the transtrochanteric approach to the hip have evolved greatly since its initial popularization in the 1960s. The purpose of this systematic review was to assess current uses of this approach on the basis of indications, osteotomy technique, trochanteric fixation method, complications, and functional outcome. METHODS A comprehensive search of MEDLINE and Embase databases from January 2000 to July 2017 was performed in accordance with the PRISMA guidelines. Articles were divided into 3 major categories on the basis of the type of hip surgery performed: (1) primary arthroplasty, (2) revision arthroplasty, and (3) joint-preserving procedures. Patient data were then analyzed according to these 3 categories. RESULTS Seventy-six studies (5,028 hips), mainly of Level-IV evidence, were included. Four types of osteotomy were reported for a variety of indications. Rates of nonunion were 6.0% (303 of 5,028) across all studies, 4.2% (39 of 921) for primary arthroplasty, 6.7% (114 of 1,690) for revision arthroplasty, and 4.4% (56 of 1,278) for joint-preserving procedures. Rates of dislocation were 1.5% (14 of 921) for primary arthroplasty and 4.6% (77 of 1,690) for revision arthroplasty. The rate of osteonecrosis after joint-preserving procedures was 1.1% (14 of 1,278). Rates of deep infection were 1.1% (55 of 5,028) across all studies, 0.1% (1 of 921) for primary arthroplasty, 2.1% (36 of 1,690) for revision arthroplasty, and 0.6% (8 of 1,278) for joint-preserving procedures. CONCLUSIONS The transtrochanteric approach remains useful in cases requiring extensile exposure of the acetabulum or femoral medullary canal. However, trochanteric complications continue to pose a clinical challenge. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Xin Y Mei
- Division of Orthopaedic Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada
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