Extra- and intramedullary implants for the treatment of pertrochanteric fractures -- results from a Finnish National Database Study of 14,915 patients

Maternal Eating Disorders, Body Mass Index, and Offspring Psychiatric Diagnoses

Importance

Maternal nutrition is essential in fetal development; thus, disordered eating may influence this process and contribute to the development of offspring psychiatric disorders.

Objective

To investigate the association of maternal eating disorders and prepregnancy body mass index (BMI) with offspring psychiatric diagnoses.

Design, Setting, and Participants

This population-based cohort study used Finnish national registers to assess all live births from January 1, 2004, through December 31, 2014, with follow-up until December 31, 2021. The data analyses were conducted from September 1, 2023, to September 30, 2024.

Exposures

Maternal eating disorder and prepregnancy BMI.

Main Outcomes and Measures

Primary outcomes were 9 neurodevelopmental and psychiatric offspring diagnoses. Cox proportional hazards modeling adjusted for potential risk factors in the development of the outcome disorders was applied in 2 models. Secondary analyses were stratified for adverse birth outcomes (prematurity, small size for gestational age, and low Apgar score) or comorbid offspring eating disorders. Categories of BMI (calculated as weight in kilograms divided by height in meters squared) included underweight (BMI <18.5), normal weight (18.5-24.9), overweight (25.0-29.9), obesity (30.0-34.9), and severe obesity (≥35.0).

Results

The mean (SD) age of 392 098 included mothers was 30.15 (5.38) years, 42 590 mothers (10.86%) were born outside of Finland, 6273 mothers (1.60%) had a history of an eating disorder, 23 114 mothers (5.89%) had prepregnancy underweight, and 208 335 (53.13%) mothers had overweight or obesity. Among 649 956 included offspring, 332 359 (51.14%) were male, and 106 777 (16.43%) had received a neurodevelopmental or psychiatric diagnosis. Maternal eating disorders, prepregnancy underweight, and overweight or obesity were associated with most of the studied mental diagnoses in offspring, even after adjusting for potential covariates. The largest effect sizes were observed for maternal eating disorders not otherwise specified in association with offspring sleep disorders (hazard ratio [HR], 3.34 [95% CI, 2.39-4.67]) and social functioning and tic disorders (HR, 2.79 [95% CI, 2.21-3.52]), while for maternal severe prepregnancy obesity, offspring intellectual disabilities (HR, 2.04 [95% CI, 1.83-2.28]) had the largest effect size. Adverse birth outcomes further increased the risk of offspring having other feeding disturbances of childhood and infancy (eg, HR, 4.53 [95% CI, 2.97-6.89] for maternal eating disorders) and attention-deficit/hyperactivity disorder and conduct disorder (eg, HR, 2.27 [95% CI, 1.74-2.96] for maternal anorexia nervosa).

Conclusions and Relevance

In this population-based cohort study including 392 098 mothers and 649 956 offspring, offspring from mothers with an eating disorder history or prepregnancy BMI outside normal weight were at higher risk of psychiatric disorders. The results differed somewhat between the 2 exposures with regard to which offspring diagnoses had associations, and effect sizes were typically larger for maternal eating disorders vs BMI. These findings suggest a need to consider these 2 exposures clinically to help prevent offspring mental illness.

The effect of valgus reduction on resistant subtrochanteric femoral non-unions: a single-centre report of twenty six cases

PURPOSE

Re-revision of subtrochanteric non-unions is technically challenging and lacks robust evidence. The results of managing subtrochanteric fractures after multiple failed procedures have rarely been reported in the literature. This study aims to evaluate the effect of valgus reduction on non-united subtrochanteric fractures with single or multiple failed revision surgeries.

METHODS

Twenty-six patients with aseptic subtrochanteric fracture non-union underwent failed single or multiple revision procedures after index fracture fixation surgery between 2011 and 2019. The exclusion criteria were as follows: septic non-union, peri-prosthetic, and pathological fractures. Lateral-based wedge valgus reduction and compression at the non-union site using a valgus-contoured DCS together with decortication, debridement, and bone grafting were used. The main outcome measurement was radiological union, pain, LLD, HHS, and restoration of pre-fracture activities.

RESULTS

The mean follow-up was 4.5 years (range 3 to 7); prior revision surgeries range from two to five and union at 6.5 months (range 3 to 10) and the delayed union in one case and an infected non-union in one case. The mean LLD was 4 cm (range 3 to 5), which improved to 1.5 cm (range 1 to 4) (P-value < 0.001). The mean VAS was 7 (range 6 to 8), and 24 patients achieved painless ambulation without a walking aid after the union. The mean HHS was 40 (range 25 to 65), which improved to 85 (range 55 to 95) (P-value < 001), achieving 15 excellent, ten good, and one poor results.

CONCLUSION

Mechanical optimisation by lateral closing wedge and stable fixation with pre-contoured DCS with biological enhancement resulted in a successful outcome in recalcitrant subtrochanteric non-unions.

Comparison of bleeding during trochanteric fracture fixation with mini-invasive or conventional side plate fixation: A randomized controlled trial

BACKGROUND

Trochanteric fractures are a public health issue due to the aging of the population. Treatment aims to reduce their related morbidity and mortality and to allow an early return to independence. Postoperative anemia is associated with poorer functional recovery and an increased mortality rate. The aim of this study was to assess whether minimally invasive side plate fixation (Minimal Invasive Screw System, MISS™) resulted in reduced perioperative bleeding compared with conventional fixation (Pertrochanteric Hip Screw, PHS™).

HYPOTHESIS

We hypothesized that minimally invasive side plate fixation (MISS) would result in reduced perioperative bleeding compared with conventional fixation (PHS).

PATIENTS AND METHODS

We conducted an open randomized controlled trial with blinded assessment of the primary outcome. Inclusion criteria were patients aged over 65 years with isolated reducible trochanteric fracture. The 2 surgical implants were of the same shape, the only difference between them being the locking mode of the femoral neck screw on the plate of the MISS device, allowing a percutaneous approach. Primary outcome was perioperative bleeding evaluated with Mercuriali's formula. Secondary outcomes included operating time, scar length, length of hospital stay, radiological criteria such as quality of fracture reduction, implant positioning, bone healing, complications and functional recovery compared between the 2 groups.

RESULTS

One hundred and eight patients met the inclusion criteria and were randomized to receive either PHS (n=54) or MISS (n=54). Osteosynthesis with MISS significatively reduced perioperative bleeding (median 243mL, interquartile range [152-410] vs. 334mL [247-430] [p=0.0299]), operating time (65min [57-73] vs. 79min [66-89] [p=0.0002]) and scar length after 45 days (7cm [5-8] vs. 14cm [12-15] [p<0.0001]). There was no statistically significant difference between groups in postoperative complications, revision surgery or serious adverse events.

CONCLUSION

Compared with PHS, MISS reduced operating time, perioperative bleeding and scar length with no observed functional difference.

LEVEL OF EVIDENCE

I.

Nail breakage in patients with hypertrophic pseudoarthrosis after subtrochanteric femur fracture: treatment with exchanging nail and decortication

In this study, we aimed to show the results of exchange nail and decortication in patients whose subtrochanteric femur fractures were treated with intramedullary nails and subsequently developed fracture nonunion and nail breakage com- plications. This study consisted of patients presenting with subtrochanteric femur fractures between January 2013 and April 2019 who underwent surgery and later experienced nail breakage due to hypertrophic nonunion. There were a total of 10 patients aged 26-62 years (Avg 40,30, SD: 9,989). Nine patients were smokers, and 1 patient had diabetes and hypertension. Three patients were admitted to the trauma center due to a car accident and 7 patients were admitted because of a fall. The infection parameters of all patients were normal. All patients had pathological movement complications and pain at the fracture site. Preoperatively, medulla diameter was measured with standard radiography in all patients. The diameters of the old nails applied to the patients ranged from 10 to 12 mm, and the diameters of the newly applied nails ranged from 14 to 16 mm. The fracture lines of all patients were opened to remove the broken nails, and decortication was performed. No additional autograft or allograft was applied to any patient. Union was achieved in all patients. We conclude that the use of larger diameter nails in conjunction with decortication will prevent nail breakage, improve healing and provide early union in patients with subtrochanteric femur fractures with hypertrophic pseudoarthrosis.

Medium-Term Outcomes of a Forward-Striking Technique to Reduce Fracture Gaps during Long Cephalomedullary Nailing in Subtrochanteric Femoral Fractures

INTRODUCTION

A residual fracture gap after intramedullary nailing is a known risk factor for delayed union and non-union. This study aimed to report the outcomes of a forward-striking technique to reduce fracture gaps during long cephalomedullary nailing in subtrochanteric femoral fractures (SFFs).

METHODS

A retrospective cohort study was conducted on patients with SFFs treated in a single institution between February 2013 and October 2018. A total of 58 patients treated via long cephalomedullary nailing with a forward-striking technique were included. The width of the fracture gap, location of the cephalic screw, tip-apex distance (TAD), and time to bone union were evaluated using intraoperative and postoperative radiographs. Complication rates, including fixation failure, non-union, implant breakage, and infection, were assessed. The mean follow-up duration was 4 (range, 2‒8) years.

RESULTS

Of the 58 patients (mean age, 67.9 years), 38 (65.5%) were female. Thirty-two cases (55.2%) were classified as atypical femoral fractures. The mean fracture gap reduced from 5.1 mm to 1.6 mm by forward striking (P<0.001). The reduced fracture gap was significantly greater in atypical SFFs (mean, 4.9 mm vs. 1.7 mm; P<0.001). The lag screw was located in the center-center or center-inferior zones of the femoral head in 54 patients (93.1%). The mean TAD was 14.2 mm and was under 25 mm in 55 patients (94.8%). Bone union was achieved in all cases without reoperation at a mean of 5.4 months. One incident of lag screw breakage was noted at 5 months, but bone union was achieved at 7 months.

CONCLUSIONS

The forward-striking technique with a long cephalomedullary nail demonstrated a 100% bone union rate in a consecutive series of 58 SFFs. This technique is effective in reducing the fracture gap as well as placing the cephalic screw into the optimal position. The forward-striking technique was particularly effective in reducing atypical SFFs with a transverse or short oblique configuration.

Subsequent ipsi- and contralateral femoral fractures after intramedullary nailing of a trochanteric or subtrochanteric fracture: a cohort study on 2012 patients

BACKGROUND

The literature is inconclusive as to whether an intramedullary nail changes the distribution of a subsequent ipsi- or contralateral fracture of the femur. We have compared the incidence, localisation, and fracture pattern of subsequent femoral fractures after intramedullary nailing of trochanteric or subtrochanteric fractures in patients without previous implants in either femur at the time of surgery.

METHODS

Retrospective analysis was performed of a two-centre cohort of 2012 patients treated with a short or long intramedullary nail for the management of trochanteric or subtrochanteric fracture between January 2005 and December 2018. Subsequent presentations with ipsi- and contralateral femoral fractures were documented. Only patients with no previous femoral surgery performed, other than the index nailing were followed. Odds ratios (ORs) for subsequent femoral fracture were calculated using robust variance estimates in logistic regression.

RESULTS

The mean age of the cohort was 82.4 years and 72.1% were female. The total number of patients presenting with subsequent femoral fractures was 299 (14.9%). The number of patients presenting with subsequent ipsilateral and contralateral femoral fractures was 51 (2.5%) and 248 (12.3%) respectively (OR 5.0; CI 3.7-6.9). Twenty-six (8.7%) of all subsequent femoral fractures occured in the ipsilateral shaft, 14 (4.7%) in the ipsilateral metaphyseal area, one (0.33%) in the contralateral shaft, and three (1.0%) in the contralateral metaphysis (OR 10; CI 3.6-29).

CONCLUSION

An intramedullary nail significantly changes the fracture pattern in the event of a second low-energy trauma, reducing the risk of subsequent proximal ipsilateral femoral fractures and increasing the risk of subsequent ipsilateral femoral fractures in the shaft and distal metaphyseal area compared with the native contralateral femur.

Use of an Angled Blade Plate for 31A3 Intertrochanteric Fractures

BACKGROUND

A subgroup of pertrochanteric fractures-namely, the AO/OTA 31A3 fracture-continues to be a difficult problem to treat, even with cephalomedullary nails. We present the results for 26 patients with a 31A3 fracture treated with the angled blade plate.

METHODS

The records of 26 consecutive patients with a 31A3 fracture that was treated operatively with the angled blade plate device between 2007 and 2012 at our center were reviewed, and the patients were contacted for follow-up. The functional outcome (traumatic hip rating score) and radiographic outcome (the neck-shaft angle at the time of fixation and final follow-up) were obtained for 20 of the 26 patients at a minimum follow-up of 1 year.

RESULTS

All 26 patients had primary surgery. At final review, 2 patients had died and 4 had been lost to follow-up. Of the 4 patients lost to follow-up, 2 had revision of the fixation with the angled blade plate. Of the 20 patients with follow-up, 1 had malreduction and implant failure but eventually had healing after revision of the fixation with the angled blade plate. The mean traumatic hip rating score at the time of follow-up was 50.0 with 4, 14, and 2 patients having excellent, good, and failed outcomes, respectively. The mean neck-shaft angle at the time of final union was 126.16°, which was an average of 4° less than that on the unaffected side. However, this did not correlate with functional outcome. There was no significant difference between the immediate postoperative and final neck-shaft angles.

CONCLUSIONS

This study demonstrated that blade plate fixation for 31A3 fractures is associated with low rates of failure (15%), revision surgery (15%), and infection (15%), which are comparable with the results of nail fixation (range, 5% to 12%) and superior to those of sliding hip screw fixation. This large series demonstrates that the angled blade plate can be utilized for these complex fractures and should be part of the armamentarium for these injuries.

LEVEL OF EVIDENCE

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

[Subtrochanteric femur fractures-epidemiology, surgical procedures, influence of time to surgery and comorbidities on complications : A risk-adjusted regression analysis of routine data from 2124 cases]

BACKGROUND

There are approximately 12,000 subtrochanteric femur fractures in Germany per year with a rising trend but studies about the epidemiology and the surgical outcome are rare. Furthermore, there are no guidelines from expert societies and there is no adequate quality assurance.

OBJECTIVE

Presentation of the epidemiology and the current treatment situation with respect to the patient collective, comorbidities, time to surgery and surgical procedures used as well as the identification of modifiable risk factors with respect to complications.

MATERIAL AND METHODS

Analysis of routine data based on an established data model in 2124 cases. The descriptive statistics contain data on basic patient characteristics, such as age, comorbidities, surgical procedure, time to surgery and mortality. In the analytical statistics the impact of risk factors (surgical procedure, time to surgery etc.) on the endpoints mortality, complications and decubitus was investigated by logistical regression analyses.

RESULTS

Of the patients 55% were operated on within the first 24h. Intramedullary osteosynthesis (89%) is the most frequently used surgical method (prostheses 2%, extramedullary procedures 5%). Within the first postoperative year 37% of the patients received a higher level of care, where the care was moved from outpatient to inpatient treatment. The mortality in the first postoperative year was 26%, while early complications were observed in 6%. A delay in surgical treatment was associated with an increased mortality and intrinsic factors, which were difficult to influence. Intramedullary osteosynthesis had the lowest mortality and revision rates.

CONCLUSION

Concerning the epidemiological data, the patient collectives of subtrochanteric fractures and femoral neck or pertrochanteric fractures were very similar. Major delays in the time to surgery of subtrochanteric fractures can be associated with increased complication rates and mortality. Therefore, programs to prevent older patients from falling have a high priority.

Fractures of the trochanteric region in children and young adolescents-a treatment algorithm for a rare injury

For femoral fractures of the trochanteric region in children and adolescents, only two mechanisms have been identified to cause a fracture of the proximal femur: high-energy trauma or predisposing bone pathologies with inadequate trauma (e.g., simple fall, movement). We identified 20 patients between 1993 and 2018 with a trochanteric fracture under the age of 18 (12 males; 8 females; mean age, 12 years; range, 4-17 years) who were treated operatively at our department. The mean follow-up of all patients was 50.06 months. All 20 patients were treated operatively. Complications occurred after a mean time of 6.27 months (range, 0.47 to 12.07 months) in two patients. Harris Hip Score was evaluated in all patients with a mean score of 94.16 (range 11 to 100). Eighty-five percent of the patients reached an excellent clinical outcome after treatment. Trochanteric femoral fractures in children and adolescents are very rare accounting for only 1% of all trochanteric fractures. Excellent long-term results can be achieved with an adequate fracture reduction.Conclusion: Physicians treating pediatric trauma have to be aware of other predisponding diseases when low-energy trauma leads to a trochanteric fracture as in this study, 50% of the trochanteric fractures were associated with bone pathologies. What is Known: • Trochanteric femoral fractures in children and adolescents are very rare • In all patients with trochanteric femoral fractures, malignancies have to be ruled out What is New: • Awareness of an underlying bone pathology in a high number of cases • Awareness for necessity of a good fracture reduction leading to highly satisfactory results.

Reoperations in intramedullary fixation of pertrochanteric hip fractures

Objective: This study evaluated the frequency of reoperation within 1 year of initial intramedullary fixation for patients with pertrochanteric hip fracture and compared 1-year healthcare resource utilization and cost burden for patients with and without reoperation. Methods: This is a retrospective evaluation of medical claims from the US Centers for Medicare and Medicaid Standard Analytic File. Patients aged ≥65 years who underwent fixation with an intramedullary implant for a pertrochanteric fracture between 2013 and 2015 were included. Healthcare resources that were evaluated included skilled nursing facility (SNF), inpatient rehabilitation facility (IRF), readmissions, and outpatient hospital visits. All-cause payments for these services comprised overall cost burden. Generalized Linear Models were used to evaluate healthcare resources and cost burden over 1-year post-surgery and to adjust for confounding between patients with and without a reoperation. Results: A total of 6,423 Medicare patients were included in the analysis. Mean (SD) age was 82.4 (7.8) years, 76.0% were female, and 93.3% were white. A second hip surgery within 1 year after the index fixation procedure was performed in 414 patients (6.4%): 121 (29.2%) contralateral, 115 (27.8%) ipsilateral, and 178 (43.0%) without specified laterality. After adjusting for confounding factors, Medicare patients with ipsilateral reoperations had statistically significantly higher readmissions (100% vs 32.5%, p < 0.0001), outpatient hospital visits (96.4% vs 88.8%, p = 0.018), admissions to a SNF (88.5% vs 80.4%, p = 0.024), and admissions to an IRF (38.8% vs 22.0%, p < 0.0001) compared to patients without reoperations. The adjusted mean total all-cause payments ($90,162 vs $55,131, p < 0.0001) during the 1-year follow-up were statistically significantly higher among patients with reoperations as compared to patients without reoperations. Conclusions: Patients who require a second hip surgery after initial fixation with an intramedullary implant for pertrochanteric hip fractures have significantly higher 1-year healthcare resource utilization and 63.5% higher costs than patients without reoperation.

Fratura pantrocantérica: incidência da complicação em pacientes com fratura trocantérica tratados com parafuso dinâmico de quadril em um hospital do Sul do Brasil

Objective

The aim of the present study was to investigate the incidence of pantrochanteric fractures in cases of trochanteric fractures treated with dynamic hip screw in our service.

Methods

A sample of 54 patients with trochanteric fractures treated with dynamic hip screws was included in this retrospective study. Preoperative radiographs were evaluated for fracture classification using the Arbeitsgemeinschaft für Osteosynthesefragen (Association for the Study of Internal Fixation, in German)/Orthopedic Trauma Association (AO/OTA) system for the identification of radiographic osteoporosis and for the measurement of the lateral femoral wall thickness. In the immediate postoperative images, the presence of pantrochanteric fracture was evaluated.

Results

The final sample presented an incidence of 16.7% of pantrochanteric fractures. The thickness of the lateral wall was significantly lower in the group with the complication ( p  < 0.001). Although fractures classified as 31-A2 were more numerous in the group with pantrochanteric fracture, the difference was not statistically significant ( p  = 0.456).

Conclusion

The percentage of pantrochanteric fractures in this service is in accordance with previous studies. There was an association between lateral femoral wall thickness and the occurrence of iatrogenic fracture of the lateral cortex. There was no significant difference between fracture classification and pantrochanteric fracture, possibly due to sample size.

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Therapeutic Level IV-case series.

Fatigue failure of the cephalomedullary nail: revision options, outcomes and review of the literature

Cephalomedullary nail (CMN) failure is a rare entity following hip fracture treatment. However, it poses significant challenges for revision surgery, both mechanically and biologically. Nail failure rates have been reported at < 2%; however, no published studies have reported revision surgery procedures and their respective outcomes. We present a regional experience, with outcomes, of the revision options. We identified 20 fatigued CMNs that underwent four different revision procedures. Mean age was 73 ± 15.24 years, with a 3:1 female preponderance, and a median ASA grade of 3. Post-operative CMN radiographs demonstrated a significant number of fractures were fixed in varus, with reductions in neck-shaft angles post-operatively. A "poor" quality of reduction resulted in significantly earlier nail failure, compared to "adequate" and "good" (p = 0.027). Tip-Apex Distance (TAD) mean was 23.2 ± 8.3 mm, and an adequate TAD with three-point fixation was seen in only 35% of cases. Mean time to failure was 401.0 ± 237.2 days, with mean age at failure of 74.0 ± 14.8 years. Options after failure included revision CMN nail, proximal femoral locking plate (PFLP), long-stem or restoration arthroplasty, or femoral endoprosthesis. Barthel Functional Index scores showed no significant difference at 3 and 12 months post-operatively, nor any difference between treatment groups. Mean 12-month mortality was 30%, akin to a primary hip fracture mortality risk according to NICE guidelines. Mortality rates were lowest in revision nails. Subsequent revision rates were higher in the PFLP group. There is no reported evidence on the best surgical technique for managing the failed CMN, with no clear functional benefit in the options above. Good surgical technique at the time of primary CMN surgery is critical in minimising fatigue failure. After revision, overall mortality rates were equivalent to reported primary hip fracture mortality rates. Further multicentre evaluations are required to assess which technique convey the best functional outcomes without compromising 12-month mortality rates.

Is there any place for the variable angle proximal femoral plate? A case matched cohort study against the Dynamic Hip Screw system

INTRODUCTION

The Variable angle Martin Plate (MP) is designed to offer patient-specific adaption for the treatment of intertrochanteric hip fractures. Its proposed benefits include optimization of lag screw placement, plate shaft congruence and reduced risk of failure. Often its use has been criticized as representing a poor reduction of the fracture. The purpose of this study was to assess for a poorer quality of reduction, and compare functional outcomes and mortality, using a MP to that of a fixed angle Dynamic Hip Screw (DHS) in a matched cohort of patients.

METHODS

A retrospective review of a prospective fracture database system was undertaken between 1st January 2004 to 31st December 2013. MP patients were matched to a cohort of DHS patients. Outcomes measure were a quality of procedure score(QPS), 1-year mortality rates, reoperation rates, and Barthel Index functional outcome. Minimum follow up was 12 months.

RESULTS

A total of 77 Martin Plate patients were identified and case matched. The mean pre- and post-op Neck Shaft Angle (NSA) in the MPs was significantly different (132.97±7.78 Vs 126±8.62; p<0.0001). Conversely, the mean pre op DHS NSA and the mean post op NSA was not (p=0.397). Mean Tip-Apex Distance (TAD) was significantly different between groups; MP mean 26.51±9.09mm vs DHS 23.50±8.14mm (p=0.023). The QPS consisted of 4 variables. A significant inverse relationship between QPS and the incidence of construct related complications exists. TAD>25mm, and a change in AP NSA of >5°conveyed the greatest risk of complications. No difference occurred in complications, nor 12-month mortality.

CONCLUSIONS

No statistical difference was found in the quality of reduction between MP and DHS in this group of matched patients. QPS demonstrated a significant inverse correlation with implant-related complications. No significant difference was noted in the incidence of complications, Barthel Index functional scores, or 12-month mortality between implants. A rationale exists regarding the use of MPs, particularly in patients with varus NSA. However, planning and adequate reduction are essential regardless of implant choice.

Intertrochanteric fracture non-unions with implant failure of the gamma nail

Failure of internal fixation of intertrochanteric fracture is associated with delayed union or malunion resulting in persistent pain and diminished function. We report a rare case of implant failure of the gamma nail with intertrochanteric fracture non union treated by DCS plate screw and bone graft.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Extra- vs. intramedullary treatment of pertrochanteric fractures: a biomechanical in vitro study comparing dynamic hip screw and intramedullary nail

INTRODUCTION

Due to the demographic trend, pertrochanteric fractures of the femur will gain increasing importance in the future. Both extra- and intramedullary implants are used with good results in the treatment of these fractures. New, angular stable extramedullary implants promise increased postoperative stability even with unstable fractures. Additional trochanteric plates are intended to prevent secondary impaction, varisation and shortening of the fracture, as well as medialisation of the femoral shaft. The aim of this study was to perform a biomechanical comparison of both procedures regarding their postoperative stability and failure mechanisms.

MATERIALS AND METHODS

Twelve fresh-frozen human femurs were randomized into two groups based on the volumetric bone mineral density (vBMD). Standardized pertrochanteric fractures (AO31-A2.3) were generated and treated either with an angular stable dynamic hip screw (DHS) or an intramedullary nail (nail). Correct implant position and the tip-apex distance (TAD) were controlled postoperatively using X-ray. Specimens were mounted in a servohydraulic testing machine and an axial loading was applied according to a single-leg stance model. Both groups were biomechanically compared with regard to native and postoperative stiffness, survival during cyclic testing, load to failure, and failure mechanisms.

RESULTS

TAD, vBMD, and native stiffness were similar for both groups. The stiffness decreased significantly from native to postoperative state in all specimens (p < 0.001). The postoperative stiffness of both groups varied non-significantly (p = 0.275). The failure loads for specimens treated with the nail were significantly higher than for those treated with the DHS (8480.8 ± 1238.9 N vs. 2778.2 ± 196.8 N; p = 0.008).

CONCLUSIONS

Extra- and intramedullary osteosynthesis showed comparable results as regards postoperative stiffness and survival during cyclic testing. Since the failure load of the nail was significantly higher in the tested AO31-A2.3 fracture model, we conclude that intramedullary implants should be preferred in these, unstable, fractures.

Intramedullary nailing for treatment of pathologic femoral fractures due to metastases

Pathologic fractures of the femur because of bone metastases seriously affect the quality of life of cancer patients. Different surgical options are indicated to achieve a durable and solid fixation, depending on several clinical, prognostic and mechanical factors. Locked intramedullary nailing is currently used to treat pathologic femoral fractures in patients with multiple metastases when the trochanteric region or shaft is mainly involved. This study evaluates intramedullary nailing for treatment of patients with pathologic femoral fractures, focussing on complications, clinical and functional outcomes and survival rates. The series included 80 pathologic fractures treated with a titanium alloy Proximal Nail (Standard or Antirotation) or Lateral Anterograde Femoral Nail (PFN, PFNA or LAFN, Synthes) inserted in a locked static mode. Acrylic cement was used to fill the bone cavity after nail insertion in eight patients; percutaneous cementoplasty was simultaneously performed in 11 cases of severe ipsilateral acetabular osteolysis. Postoperative outcomes focussed on pain relief, postoperative mobility and quality of life and they were analysed retrospectively using QOL-ACD and ECOG. Eleven patients (13.75%) suffered from non-fatal DVT post-surgery, with no pulmonary embolism. Six patients (7.5%) developed superficial wound infections and two patients (2.5%) developed pnaeumonia. There was no loss of reduction, breakage, screw pull out, or hardware or implant failure that required component substitution or revision. Lung histotype and the contemporary presence of cerebral and visceral metastases appeared to be predisposing factors in reducing survival time. All patients attained satisfactory pain relief, early deambulation and a marked clinical improvement during the first 6-10 postoperative months, with gradual worsening thereafter from deterioration of their general condition due to cancer progression. The patients' survival rate was 40% at 1 year, 25% at 2 years and 15% at 3 years. Results confirm that multiple factors related to patients and primary cancer may affect survival rate after femoral fracture. Intramedullary nailing should be indicated for pathologic fractures at femoral diaphysis and metaphysis when cancer is in an advanced stage. This procedure offers good and durable stability, and enables pain relief, early postoperative mobilisation and weight-bearing, thus improving the quality of life of cancer patients.

Fracture near press-on interlocking enhances callus mineralisation in a sheep midshaft tibia osteotomy model

INTRODUCTION

Factors which impair fracture healing after intramedullary (IM) nailing of long bone fractures range from surgical and biological factors to mechanical parameters. Mechanical parameters known to prolong bony consolidation are share forces at the site of the fracture. Fracture near press-on interlocking reduces share forces directly at the fracture site and is hypothesised to enhance callus mineralisation. A sheep model of midshaft tibia osteotomies evaluates the technique.

MATERIALS AND METHODS

Fracture near interlocking was achieved by surfacing a custom made nail with special hutches that enable firm screw seating on top of the nail ("golf ball" structure). Virtual (fine element analysis (FEA)) and biomechanical pilot tests were completed before in vivo application in 12 adult female German black sheep. Midshaft tibia osteotomy was performed creating a subcritical 7 mm gap for delay in union. One group (n=6) was treated with reamed IM nailing employing the custom made nail and in addition to proximal and distal standard interlocking a fracture near press on interlocking was employed. A second group of six sheep without additional press on interlocking served as control. 10 weeks after operation the quality of fracture healing was determined by micro-CT.

RESULTS

The FEA showed that axial loading up to 4000N did not lead to implant fatigue. Fracture near press on interlocking led to significantly more callus mineralisation compared to the conventional interlocking procedure (0.567 g/cm(3) ± 0.106 g/cm(3) versus 0.434 g/cm(3) ± 0.0836 g/cm(3), p=0.043).

CONCLUSIONS

Fracture near press on interlocking increases callus mineralisation in a subcritical osteotomy model in sheep. The results indicate that the reduction of share forces at the fracture site after nailing procedures may be effective in reducing the time until bony consolidation.

Angular stable multiple screw fixation (Targon FN) versus standard SHS for the fixation of femoral neck fractures

OBJECTIVE

Head-preserving fracture care especially for the elderly may be complicated by acetabular screw penetration, cut out, delayed union or femoral head necrosis. The following comparative study analyses whether a new angular stable device may overcome these shortcomings.

MATERIAL AND METHODS

The Targon FN plate (BBraun/Aesculap, Germany) employs up to four angular stable telescoping screws for the fixation of the head fragment. In a prospective study patients with displaced and undisplaced intracapsular femoral neck fractures where treated by closed reduction and fracture fixation using either the Targon FN implant or a standard sliding hip screw (SHS). Patients were followed up clinically, radiographically and via telephone at a mean of follow-up time of 15.5 months.

RESULTS

Fifty-two patients (mean age: 67 years) with femoral neck fractures were treated with either Targon FN (27 patients) or SHS (25 patients). Time for surgery did not differ within the two groups (56 min Targon FN vs. 55 min SHS). Eight patients with SHS (32%) and four patients (15%) with Targon FN experienced cut out of the lag screw and received hip replacement (p<0.05). Implant failure occurred after a mean of 1.8 months after SHS and 6.0 months after Targon FN implantation. Final radiographs revealed substantial subsidence in both groups (5.0mm Targon FN; 9.8mm SHS, p=0.055) with a clear trend to less subsidence for the Targon FN group. Furthermore, asymmetrical telescoping of the lag screws occurred in 30% (n=8), complete depletion of telescoping distance in 11% (n=3) in the Targon FN group. Functional assessment using the HHS assessment tool, however, presented with slightly better results for the SHS treatment (87.7 ± 13.9) when compared to Targon FN fixation (69.5 ± 14.5).

CONCLUSIONS

The study revealed less subsidence of the head fragment, lower cut out rate and a lower rate of conversion to hemiarthroplasty after Targon FN fixation in comparison to a standard SHS fixation in a small number of patients with hip fractures. However, this was not accompanied by functional limitations in the SHS group.

Complications and fixation techniques of trochanteric fractures with the TARGON(®) PF

The purpose of this study was to analyse clinical results of elderly patients with trochanteric fractures that were treated with use of TARGON(®) PF nail. Overall, 494 patients (113 males) were available for this study. On the basis of Jensen classification, there were 76 cases in type I, 164 cases in type II, 70 in type III, 129 in type IV and 55 in type V. (1) Sliding amount of lag screw in relation to the Jensen classification, (2) sliding amount of lag screw according to the Ikuta's classification that categorises the reduction in lateral view in three, Subtype A, Subtype N and Subtype P, (3) sliding amount of lag screw in correlation between Jensen classification and Ikuta's classification and (4) postoperative complications (9 cases; 1.7%) were assessed. Cut-out and back-out cases were seen in 6 cases (1.1%), and these severe complications were evaluated in details. In correlation between Jensen classification and Ikuta's classification, the excessive sliding of lag screw was prominent with the Subtype P, which was preoperatively in Jensen type III or V. Cut-out or back-out cases were caused either from (1) Subtype P that were preoperatively Jensen types III or V, or from (2) the fracture where there was bony defect anteriorly. Therefore, special care must be taken for these types.

An 8-year follow-up study of 221 consecutive hip fracture patients in Finland: analysis of reoperations and their direct medical costs

BACKGROUND

Some hip fracture patients need one or more reoperations because of complications following initial operative treatment.

AIMS

The aim of this study was to identify all further surgical interventions in a cohort of patients with hip fractures over a period of 8 years after index fracture. Immediate direct costs of these reoperations were also calculated.

MATERIAL AND METHODS

This retrospective study investigated 221 consecutive patients with hip fractures operated on at two different hospitals in southeastern Finland. The study period in hospital A was from 1 February 2003 to 31 January 2004, and in hospital B from 1 February 2003 to 30 April 2004. About 50% were femoral neck fractures, 41% trochanteric fractures, and 9% subtrochanteric fractures. Patients' medical records were checked from the hospital records and confirmed manually. Short- and long-term complications were recorded. Survival analysis was performed using a life-table method. The actual costs for reoperations and other further procedures for each patient were calculated using diagnosis-related groups-based costs for both hospitals in 2012.

RESULTS

A total of 20 patients (9%) needed reoperations. Overall, 10 patients (8.9%) with a femoral neck fracture (n = 112), 8 patients (8.7%) with trochanteric fracture (n = 92), and 2 patients (10.5%) with subtrochanteric fracture (n = 19) were reoperated on. The median interval between the primary operation of the acute hip fracture (n = 20) and the first reoperation was about 300 days (range: 2 weeks to 82 months). Among the women reoperated on, the excess mortality was lower than among those undergoing a single operation. The median costs of treatment per patient with one or more reoperations were €13,422 in hospital A (range: €1616-€61,755), €11,076 in hospital B (range: €1540-€17,866), and €12,850 in the total study group (p = 0.43). In the case of infections (3 patients), the mean costs per patient were €28,751 (range: €11,076-€61,755).

CONCLUSIONS

Almost 10% of hip fracture patients required reoperations, and these reoperations caused significant direct costs to health care. However, direct costs account for only approximately 25% of the first year's total costs. These costs should be taken into account when evaluating the economics of hip fractures and the burden of health care.

Intraoperative measurement of bone electrical potential: a piece in the puzzle of understanding fracture healing

INTRODUCTION

Bone electrical potentials change with the force applied. Also, fracture alters the bone electrical potential, so it becomes more electronegative. These potentials have an important role in fracture healing, bone growth and remodelling. Literature data on the influence of fracture operative treatment on bone electrical potentials, and possible consequences of this influence, are sparse. The objective of this study was to establish a method of intraoperative bone potential measurement, and to try to find a correlation between electrical potential and fracture type, osteosynthesis method and prognosis.

PATIENTS AND METHODS

52 patients with a pertrochanteric fracture were included in the study. Bone electrical potentials were measured intraoperatively using a thin Kirschner wire introduced through bone cortex at the selected point and pointed to opposite cortex, not penetrating it. Kirschner wires were connected using clamps to multimeter (YF-78 Multimeter) device. Neutral electrode (inductive rubber) was placed behind ipsilateral gluteus.

RESULTS

Near the fracture site potentials of -199 up to -267 mV were recorded. Mean measured potential of bone plate after fixation was -240 mV. Bone potentials correlated with the subtype of fracture and early mobilisation of patients.

CONCLUSIONS

Bone potentials, caused by fracture, can be measured intraoperatively; the operative procedure appears to influence their generation. Measured potentials depend on the fracture type, and could be correlated with prognosis.

Subtrochanteric fracture non-unions with implant failure managed with the "Diamond" concept

BACKGROUND

Subtrochanteric femoral non-unions in the setting of failed metalwork pose a challenging clinical problem. This study assessed the clinical outcome of patients treated according to the principles of the "Diamond" concept.

METHODS

Between 2007 and 2011 all patients presented with a subtrochanteric atrophic aseptic non-union in the setting of metalwork failure (broken cephalomedullary reconstruction nail), and treated in a single tertiary referral unit were included to this study. The hypertrophic and the non-unions of pathologic fractures were excluded. The revision strategy was based on the "Diamond concept"; optimisation of the mechanical and the biological environment (implantation of growth factor (rhBMP-7), scaffold (RIA bone graft from contralateral femur) and concentrated mesenchymal stem cells (MSCs) harvested from the iliac crest). The minimum follow up was 26 months (16-48).

RESULTS

Fourteen patients met the inclusion criteria. A specific sequence of metalwork failure was noted with initial breakage of the distal locking screws followed by nail breakage at the lag screw level. The intraoperative examination of the removed nails revealed no gross structural damage indicative of inappropriate drilling at the time of the initial intramedullary nailing. Varus mal-alignment was present in the majority of the cases, with an average of 5.2 degrees (0-11). The average time to distal locking screw failure was 4.4 months (2-8.5) and nail failure was 6.5 months (4-10). The time to union after the revision surgery was 6.8 months (5-12). Complications included two deaths in elderly patients (due to unrelated causes), one pulmonary embolism, one myocardial infarction, one below the knee deep vein thrombosis and one blade plate failure that required further revision with double plating and grafting.

CONCLUSION

Varus mal-alignment must be avoided in the initial stabilisation of subtrochanteric fractures. Distal locking screw failure is predictive of future fracture non-union and nail breakage. In the absence of sepsis, a single stage procedure based on the "Diamond concept" that simultaneously optimizes the mechanical and biological environment is a successful method for managing complex subtrochanteric atrophic non-unions with failed metalwork.