Evaluation of proximal femoral locking plate in unstable extracapsular proximal femoral fractures: Surgical technique & mid term follow up results

Functional and Radiological Outcomes of Unstable Proximal Femur Fractures Fixed With Anatomical Proximal Locking Compression Plate

Introduction

Peritrochanteric fractures are the most frequent fractures of the proximal femur that accounts for nearly half of all proximal femur fractures. They are a major cause of disability in the elderly. The aim is to study the functional and radiological outcome of unstable proximal femur fractures fixed with proximal femur locking compression plate (PF-LCP) and its complications. Unstable proximal femur fracture patients operated with proximal femur locking compression plate were followed up functionally by Harris Hip Score and radiologically by neck-shaft angle measure.

Materials and methods

A retrospective analysis of 30 patients with unstable peritrochanteric fractures treated with PF-LCP in the first-level trauma center was conducted between 2015 and 2019. Stable peritrochanteric, pediatric and open fractures, and polytrauma were excluded. As a mid-term follow-up, functional and radiological outcomes were assessed at six weeks, three months, six months, and 12 months. Data was analyzed using a chi-square test, and results were compared with available western literature. 

Results

Thirty patients with unstable peritrochanteric fractures operated between 2015 and 2019, complying with our inclusion criteria, were analyzed. All patients were operated by the same surgeon and were available for a mid-term follow-up (12 months). Mean radiological union time was 12.5+/-2 weeks, with 24 patients achieving union between 10-15 weeks, three patients had union little more than 15 weeks. Two patients had non-union and required re-surgery. Functional results were assessed in the 30 patients available for follow-up using Harris Hip Score. Excellent results were seen in 17, good in seven, fair in three, and poor in three patients.

Conclusions

The choice of implant used to manage unstable peritrochanteric fractures has always been a debatable subject in our orthopedic fraternity. In our study, we used the anatomic, fixed-angle plates in peritrochanteric fractures and obtained significant functional and radiological outcomes over a midterm follow-up. We recommend PF-LCP as a good, stable alternative in the treatment of peritrochanteric femoral fractures. We consider that fracture pattern and extent in the proximal femur have a definite influence in determining the implant of choice. It provides good-to-excellent bone healing with reduced complications and better biomechanical stability.

Proximal Femoral Plate, Intramedullary Nail Fixation Versus Hip Arthroplasty for Unstable Intertrochanteric Femoral Fracture in the Elderly: A Meta-analysis

INTRODUCTION

Multiple operative modalities are available for management of unstable intertrochanteric femoral fractures. This meta-analysis was conducted to find out if there is superiority of surgical fixation by proximal femoral plate or surgical fixation by intramedullary nail over hip arthroplasty for management of unstable intertrochanteric femoral fractures in the elderly.

METHODS

A search for relevant studies that published from January 2000 to November 2018 through the electronic literature database of Cochrane library, Medline, Trip Database and Wiley online library.

RESULTS

A total of 19 studies including 14 prospective RCTs, and five retrospective studies. This meta-analysis showed that nail group had shorter operative time than plate group (P < 0.0001), and less blood loss than the plate and arthroplasty groups (P < 0.0001), cut-out was higher in nail group than the plate group (P < 0.0001), mortality rate was higher in hip arthroplasty compared to other groups (P < 0.0001), Harris hip score within 6 months of the operation was higher in the arthroplasty group compared with the nail and plate groups, while within 1 year of the operation, nail group had higher Harris hip score than arthroplasty group (P < 0.0001).

CONCLUSIONS

This meta-analysis suggested that the intramedullary nail fixation method is a preferred method for management of unstable intertrochanteric femoral fractures in the elderly over hip arthroplasty and proximal femoral plate fixation.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s43465-021-00426-1.

Management of unstable pertrochanteric fractures, evaluation of forgotten treatment options

INTRODUCTION

Unstable trochanteric fractures are challenging with a high rate of implant failure and re-operation. Cephalomedullary nails proved to be a rational management choice for these injuries, yet other management options have not been well assessed. The aim of this study was to compare the use of DHS with trochanteric stabilizing plate (TSP) and proximal femoral locked plate (PFLP) in unstable pertrochanteric fractures.

METHODS

This randomized controlled trial (RCT) included 40 patients (22 males, 18 females) with unstable pertrochanteric fractures (AO/OTA 31A2.2/A2.3). The patients were randomized into group 1 managed by DHS with TSP while group 2 was managed by PFLP. All patients were followed up for 1 year. Patients were assessed radiographically and clinically using Harris hip score (HHS) at 3, 6 and 12 months. Operative time, estimated blood loss and time to union were also compared.

RESULTS

The difference of intra-operative variables, including operative time and intra-operative blood loss, between both groups was statistically insignificant. Time to bony union was faster in the first group with a statistically significant P value (p = 0.04). Functional outcome per HHS was significantly better in group 1 (p < 0.01) and implant failure in group 1 occurred statistically lesser (p < 0.01).

DISCUSSION

DHS with TSP appears to be a good option of management for unstable pertrochanteric fractures. In contrast, the use of PFLP in unstable pertrochanteric fractures in the elderly does not appear to be a good alternative.

[Comparison of proximal femoral nail anti-rotation operation in traction bed supine position and non-traction bed lateral position in treatment of intertrochanteric fracture of femur]

Objective

To compare the effectiveness of proximal femoral nail anti-rotation (PFNA) in the treatment of intertrochanteric fracture of femur in traction bed supine position and non-traction bed lateral position.

Methods

A retrospective analysis of 102 elderly patients with intertrochanteric fracture of femur who met the selection criteria between January 2013 and April 2018 was made. According to the different operative positions, the patients were divided into two groups: group A (50 cases, PFNA internal fixation in traction bed supine position) and group B (52 cases, PFNA internal fixation in non-traction bed lateral position). There was no significant difference in age, gender, fracture side, cause of injury, AO classification, complications, and time from injury to operation between the two groups ( P>0.05). The preoperative preparation time, incision length, operation time, intraoperative blood loss, intraoperative X-ray fluoroscopy times, fracture healing time, and complications were recorded and compared between the two groups, and the effectiveness was evaluated by Harris hip score at 1 year after operation.

Results

There was no significant difference in incision length between groups A and B ( t=1.116, P=0.268). In addition, the preoperative preparation time, operation time, intraoperative blood loss, and intraoperative X-ray fluoroscopy times in group A were significantly greater than those in group B ( P<0.05). Both groups were followed up 12-14 months, with an average of 13 months. There were 3 postoperative complications in group A and group B respectively. In group A, there were 2 cases of hip joint pain and 1 case of local fat liquefaction (healed after dressing change); in group B, there were 2 cases of hip joint pain and 1 case of deep vein thrombosis in lower extremity; there was no significant difference in the incidence of postoperative complications between the two groups ( P=0.642). The patients of the two groups had a good result of fracture reduction and the internal fixation quality, and there was no main nail loosening, screw fracture, spiral blade cutting, withdrawal, and the nail breakage occurred, and no nonunion of bone, coxa vara, and other complications occurred. X-ray showed that the fracture healed in both groups, and there was no significant difference in fracture healing time between the two groups ( t=1.515, P=0.133). There was no significant difference in Harris hip score between the two groups at 1 year after operation ( t=0.778, P=0.438).

Conclusion

Compared with the traction bed supine position, PFNA internal fixation for intertrochanteric fracture of femur in the non-traction bed lateral position has the advantages of short preparation time, short operation time, less intraoperative blood loss, less X-ray fluoroscopy times, and satisfactory postoperative recovery effect.

A biomechanical comparison of three fixation techniques in osteoporotic reverse oblique intertrochanteric femur fracture with fragmented lateral cortex

BACKGROUND

The treatment of the reverse oblique osteoporotic femur fractures is still problematic and can be complicated especially that are accompanied by a fragmented lateral cortex.

AIM

The aim of this study was to compare three different internal fixation methods in the osteosynthesis of osteoporotic reverse oblique intertrochanteric femur fracture models with a fragmented lateral cortex.

STUDY DESIGN

Biomechanical experiment study.

METHODS

A total of 24 osteoporotic femur models were obtained and divided into three groups [Group A: Proximal femoral nail (PFN), Group B: 95° angled blade plate (ABP), and Group C: proximal femoral anatomic locking plate (PFLP)] with each group which include eight bones. A standard fracture configuration was created as a reverse oblique intertrochanteric fracture and fixed with these implants. After fixation, all femur constructs were tested with an Instron 5800R tester (Instron, Canton, MA) in the biomechanics laboratory with axial loading and bending forces to assess axial and rotational stiffness and failure load. Displacement over 10 mm and angulation greater than 10° in the fracture line were considered as failure.

RESULTS

In all tests, ABP had statistically poorer results in comparison to the PFN and PFLP group. PFLP fixation had better biomechanical fixation results in comparison to the PFN group, although the results were not statistically significant.

CONCLUSION

Orthopaedic surgeons should keep in mind that lateral cortex comminution brings further instability to these reverse oblique intertrochanteric osteoporotic fractures and high rates of failure may be encountered due to this instability. PFLP fixation may be an alternative fixation method biomechanically for these instable fractures.

High failure rate of proximal femoral locking plates in fixation of trochanteric fractures

Background

The aim of this study was to report our previous results of treatments for trochanteric fractures with proximal femoral locking plates (PFLP) and to analyze the underlying mechanisms and possible risk factors associated with the high failure rate of this technique.

Methods

From January 2010 to October 2014, 273 consecutive patients with trochanteric femoral fractures were identified, and 95 patients (with 97 fractures) ultimately met the inclusion criteria. Clinical records regarding demographic features and intraoperative data including total incision length, operation time, blood loss, and failures detected in radiographs were documented and assessed. The collected data were analyzed with SPSS 19.0 software.

Results

The stable group (AO/OTA 31 A1 and A2.1) had less blood loss than the unstable group (AO/OTA 31 A2.2, A2.3, and A3). The ultimate failure rate was 36% in 97 fractures. The obvious complications in this study included nonunion in 7 (7.2%) fractures, implant breakage in 4 (4.1%) fractures, varus deformity in 34 (35%) fractures, and loosening of the proximal femoral screw in 21 (21.6%) fractures. Six patients received reoperations. The total failure rate in the stable group was 17% and was 50% in the unstable group. In patients greater than 60 years old in the unstable group, the failure rate was 60.5%.

Conclusions

High failure rates of PFLP were observed in patients with trochanteric fracture, especially in patients who were greater than 60 years old with unstable fracture types. PFLP was not an appropriate treatment for trochanteric fractures.

Locking plate and fibular strut-graft augmentation in the reconstruction of unicameral bone cyst of proximal femur in the paediatric population

PURPOSE

Several therapeutic strategies have been used for managing unicameral bone cyst (UBC) of the proximal femur. However, there is insufficient evidence to support one treatment over another, and the optimal treatment is controversial. This study aims at describing our experience with surgical reconstruction of paediatric UBCs of the proximal femur using a proximal locking plate and fibular strut allograft.

METHODS

In total, 14 consecutive paediatric patients with Dormans types IB (four cases) and IIB (10 cases) UBC were assessed. Mean patient age was 8.6 ± 2.3 years, and mean follow-up period was 41.7 ± 29.8 months. Six patients (42.8%) were referred with a pathologic fracture. Clinical/radiological outcome and complication rates were evaluated at the final follow-up session.

RESULTS

No cysts were Capanna's class III (recurrence) or IV (no response). Complete healing (Capanna's class I) was seen in ten cysts, while four other cysts healed with residual radiolucent areas (Capanna's class II). Mean healing period was 14.1 ± 5.1 (9-24 months). One patient had superficial infection, one heterotopic ossification, and one mild coxa vara, and mean Musculoskeletal Tumor Society (MSTS) score was 99.5%.

CONCLUSION

According to our results, locking plate and fibular strut graft in Dormans classification types IB and IIB results in a favorable outcome in managing UBC of the proximal femur in the paediatric population.

Evaluation of outcome of proximal femur locking compression plate (PFLCP) in unstable proximal femur fractures

INTRODUCTION

Pertrochanteric fractures are most frequent factures of the proximal femur, accounts for nearly 50% of all proximal femur fractures and are most devastating and also a major cause of disability in elderly. The aim and objective of this study was to evaluate the role of proximal femoral locking compression plate in unstable proximal femur fractures.

MATERIAL AND METHOD

A total of 20 cases were included in our study (M:F - 16:4), who suffered proximal femur fracture due to various modalities and all of them were operated using proximal femoral locking compression plate. This proximal femoral fractures included unstable - intertrochanteric with subtrochanteric extension and subtrochanteric with intertrochanteric extensions as well as one case with intertrochanteric, subtrochanteric and neck of femur fracture. Patients were followed up regularly and minimum follow-up period was 12 months. Patients were given physiotherapy and partial weight bearing was started after 6 weeks postoperatively or after union was achieved. The outcome was evaluated as per Harris Hip Score and radiological union.

RESULT

Among 20 cases with average age of 55.3 ± 17.9 years, treated with PF-LCP, the average time of union 18.75 ± 3.67 weeks was achieved. We got 10 excellent, 3 good, 3 fair and 4 poor result with average Harris Hip Score of 80.2 ± 28.54 with 65% good to excellent result with average Post-operative Neck Shaft Angle of 124.150 ± 17.880 and with 45% rate of complication which included four cases of superficial infection and two cases of deep infection and late complications like four cases of non-union, deformity - three cases of coxa vara and 2 cases of coxa valga, with patients having more than one complication in them.

CONCLUSION

PF-LCP is not recommended as a definitive implant but can be used as an alternative for the treatment of unstable proximal femoral fractures when there is no option available for other routinely used implants. Despite of its complications, PF-LCP is used where all implants fail.

Management of unstable pertrochanteric fractures with proximal femoral locking compression plates and affect of neck-shaft angle on functional outcomes

BACKGROUND

Management of unstable pertrochanteric fractures remains a challenge with various implant choices. Intramedullary devices are usually preferred for the management of the unstable fractures. When nailing is unsuitable for the configuration of the fracture extra medullary procedures are preferred. PFLCP is a contact limited implant that allows multiple angularly stable fixations with preserving more bone stock after implantation as an extramedullary implant. There are only a few reports in the literature about the osteosynthesis of unstable trochanteric fractures with proximal femoral locking compression plates and their results are conflicting. In the present study we aimed to evaluate the functional and radiological outcomes of proksimal femoral locking compression plates in open reduction and internal fixation of AO/OTA 31A2-2 and 3 fractures.

METHODS

Patients older than 18 years of age with a minimum follow-up time of 1 year matching the inclusion criteria retrospectively evaluated. Patients' demographics, Singh index, intra and post-operative data, mobilization and union time gathered from the patients' files. Baumgaertner modified criteria of fracture reduction was used to assess the post-operative reduction quality. Early and last follow-up radiographs were used to evaluate malunion and change in neck- shaft angle. Final clinical outcome was assessed using the Harris Hip scoring system.

RESULTS

18 male and 13 female patients with the mean age of 74 (46-88) met the inclusion criteria. Reduction quality according to Baumgaertner modified criteria was good in 25 patients and acceptable in 6. Mean union time was 21.53 ± 4.18 weeks. There was neither non-union nor malunion. The mean neck-shaft angle change was -3.1° ± 2.16°. The mean HHS was 77.90 ± 4.84 and there was no significance in HHS according to reduction quality and change in neck-shaft angle (p = 0.385, p = 0.0059). HHS was negatively correlated with age, mobilization time and, longer union time (p < 0.05). There was no correlation between Singh index and reduction quality (p = 0.865). Singh index was only correlated with the patient's age (p = 0.000, rho = -0.595). There were 2 infections and, 2 backing of the proximal screws.

CONCLUSION

Even though PFLCP is not the first choice in management of unstable pertrochanteric fractures, it must be kept in mind as an alternative to the other conventional plates and intramedullary implants with the properties of an increased stability by multiaxial screw locking and the results are satisfactory when appropriate settlement achieved.

Comparing the Intramedullary Nailing Method Versus Dynamic Hip Screw in Treatment of Unstable Intertrochanteric Fractures

INTRODUCTION

Dynamic Hip Screw fixation is currently considered as a standard treatment for pre-trochanteric fractures; however, due to the long-term hospitalization and some other complications, some researchers have proposed intramedullary nailing as the alternative surgical treatment. The aim of this study was to compare and examine the consequences of the using intramedullary nailing method versus Dynamic Hip Screw.

METHODS

In this study 114 patients with unstable Intertrochanteric fracture refer to Rasoul Akram hospital during 2011 to 2013 has been selected. After reduction, fixation surgery with PFN nail (60 patients) and Dynamic Hip Screw (54 patients) has been performed. All patients were screen during surgery and six months after surgery and some parameters like, bleeding, union, as well as complications such as collapse, varus and medialization of the distal fragment were record and patients.

RESULTS

About some parameters like cutting length, surgery duration, bleeding there were significant differences between two groups. In six months follow up period 2 patinas from nail and 8 patients from DHS group had non-union. Also from the point of radiologic and clinical parameters, like anterior thigh pain, cut out, medialization of the distal fragment, collapse of the neck, walking recovery and daily activities were significant between two groups.

CONCLUSION

Due to the reduced hospital stay in intramedullary nailing method and the necessity of doing repeated surgery and applying intramedullary nailing when the patients are not treated with external fixation, the researchers recommend intramedullary nailing as the first option in treating such patients.

Unstable Intertrochanteric Fracture Fixation - Is Proximal Femoral Locked Compression Plate Better Than Dynamic Hip Screw

BACKGROUND

Intertrochanteric fractures are one of the most common fractures encountered in our practice. Most of them need operative intervention and union is achieved. As per the literature dynamic hip screw (DHS) is the gold standard for the treatment of these fractures, however problem arises with maintenance of neck shaft angle and proper reduction in unstable intertrochanteric fractures. The situation gets more complex when "cut out" of femoral head screw occurs either alone or in combination with varus collapse when they are treated with DHS. Here we are giving results of unstable intertrochanteric fractures treated with Proximal Femoral Locked Compression Plate (PFLCP) as compared with similar patients treated with Dynamic Hip Screw (DHS).

MATERIALS AND METHODS

The study included a total of 27 patients (17 males, 10 females) with unstable intertrochanteric fractures who were subjected to PFLCP treatment from March 2011 to November 2012 in one group. Another was a similar group of 35 patients treated with DHS from March 2008 to February 2010. Results of group 1 were compared with group 2. Detailed clinical conditions of all patients, duration of surgery, blood loss, length of incision and duration of image intensifier use were recorded. Patients were revisited at 6 weeks, 3 months, 6 months and 1 year after operation. Results were evaluated clinically by Harris hip Score and radiologically for fracture union. Progress of union and complications (limb shortening, varus collapse, cut out of femoral head screw and medialization of distal fragment) were recorded.

RESULTS

Among 27 patients treated with PFLCP, one patient expired 6 week postoperatively and one patient lost to follow up, so 25 patients were evaluated for final outcome of which 23 (92%) showed union at follow up of 12 months. One patient developed bending of proximal screws and three developed varus collapse. Among the group treated with DHS, eight patients developed varus collapse, seven developed medialization and three had femoral head screw cut out. According to Harris hip Score 88% cases had good to excellent result in PFLCP group whereas only 60% cases in the DHS group had good to excellent result.

CONCLUSION

Treatment of unstable intertrochanteric fractures with proximal femoral locked plate (PFLCP) can give good healing, with a limited occurrence of complication.

Common complications in hip fracture surgery: Tips/tricks and solutions to avoid them

Surgical management of hip fractures in elderly people is challenging and complications relating to surgery could be devastating. They often lead to reoperation and revision surgery and can be associated with significantly increased morbidity and mortality. The most common surgical complications after internal fixation of hip fractures include cut-out, nonunion, Z-effect/medial migration, periimplant failure and avascular necrosis. High quality surgical fixation is of outmost importance to avoid surgical complications. This article presents the aetiology, risk factors and incidence of perioperative and post-fracture fixation complications. Technical tips and tricks for a successful fixation as well as the contemporary evidence surrounding the augmentation of osteoporotic bone fixation in internal fixation of hip fractures are discussed.