Comparison of Intra- and Extramedullary Implants in Treatment of Unstable Intertrochanteric Fractures

Extramedullary versus intramedullary fixation of unstable trochanteric femoral fractures (AO type 31-A2): a systematic review and meta-analysis

OBJECTIVE

The aim of this systematic review was to compare extramedullary fixation and intramedullary fixation for AO type 31-A2 trochanteric fractures in the elderly, with regard to functional outcomes, complications, surgical outcomes, and costs.

METHODS

Embase, Medline, Web of Science, Cochrane Central Register of Controlled Trials, and Google Scholar were searched for randomized controlled trials (RCTs) and observational studies. Effect estimates were pooled across studies using random effects models. Results are presented as weighted risk ratio (RR) or weighted mean difference (MD) with corresponding 95% confidence interval (95% CI).

RESULTS

Fourteen RCTs (2039 patients) and 13 observational studies (22,123 patients) were included. Statistically superior results in favor of intramedullary fixation were found for Harris Hip Score (MD 4.09, 95% CI 0.91-7.26, p = 0.04), Parker mobility score (MD - 0.67 95% CI - 1.2 to - 0.17, p = 0.009), lower extremity measure (MD - 4.07 95% CI - 7.4 to - 0.8, p = 0.02), time to full weight bearing (MD 1.14 weeks CI 0.92-1.35, p < 0.001), superficial infection (RR 2.06, 95% CI 1.18-3.58, p = 0.01), nonunion (RR 3.67, 95% CI 1.03-13.10, p = 0.05), fixation failure (RR 2.26, 95% CI 1.16-4.44, p = 0.02), leg shortening (MD 2.23 mm, 95% CI 0.81-3.65, p = 0.002), time to radiological bone healing (MD 2.19 months, 95% CI 0.56-3.83, p = 0.009), surgery duration (MD 11.63 min, 95% CI 2.63-20.62, p = 0.01), operative blood loss (MD 134.5 mL, 95% CI 51-218, p = 0.002), and tip-apex distance > 25 mm (RR 1.73, 95% CI 1.10-2.74, p = 0.02). No comparable cost/costs-effectiveness data were available.

CONCLUSION

Current literature shows that several functional outcomes, complications, and surgical outcomes were statistically in favor of intramedullary fixation when compared with extramedullary fixation of AO/OTA 31-A2 fractures. However, as several of the differences found appear not to be clinically relevant and for many outcomes data remains sparse or heterogeneous, complete superiority of IM fixation for AO type 31-A2 fractures remains to be confirmed in a detailed cost-effectiveness analysis.

Proximal femoral nail anti-rotation vs dynamic hip screws decrease the incidence of surgical site infections in patients with intertrochanteric fractures: A meta-analysis

In this study, a meta-analysis was conducted to comprehensively analyse the effectiveness of using proximal femoral nail anti-rotation (PFNA) and dynamic hip screws (DHS) to treat intertrochanteric fractures on postoperative surgical site infections (SSI). PubMed, EMBASE, Cochrane Library, China National Knowledge Infrastructure (CNKI), and Wanfang databases were searched from their inception until December 2022 to identify studies that compared PFNA and DHS in the treatment of intertrochanteric fractures. Two investigators independently screened the retrieved studies to assess their quality and verify their eligibility for inclusion. Meta-analyses were performed with RevMan 5.4 software. Thirty studies, including 3158 patients, met the inclusion criteria. These studies included 1574 patients treated with PFNA, and 1584 were treated with DHS. The findings of the meta-analysis revealed a significant reduction in the incidence of SSI in patients treated with PFNA compared with those treated with DHS (2.64% vs 6.76%, odds ratio [OR]: 0.40, 95% confidence intervals [CIs]: 0.28-0.57, P < .001), superficial SSI (2.58% vs 5.01%, OR: 0.53, 95% CIs: 0.33-0.85, P = .008) and deep SSI (1.26% vs 3.43%, OR: 0.41, 95% CIs: 0.19-0.92, P = .03). PFNA was more effective than DHS in reducing the incidence of SSI. Even so, significant variations in sample sizes among the included studies meant that the methodology for some studies had qualitative deficiencies. Therefore, additional studies with large sample sizes are needed to validate these results.

Barriers and facilitators of weight bearing after hip fracture surgery among older adults. A scoping review

PURPOSE

This scoping review aimed to synthesise the available evidence on barriers and facilitators of weight bearing after hip fracture surgery in older adults.

METHODS

Published (Cochrane Central, MEDLINE, EMBASE, CINAHL, and PEDro) and unpublished (Global Health, EThOS, WorldCat dissertation and thesis, ClinicalTrials.gov , OpenAIRE, DART-Europe) evidence was electronically searched from database inception to 29 March 2022. Barriers and facilitators of weight bearing were extracted and synthesised into patient, process (non-surgical), process (surgical), and structure-related barriers/facilitators using a narrative review approach.

RESULTS

In total, 5594 were identified from the primary search strategy, 1314 duplicates were removed, 3769 were excluded on title and abstract screening, and 442 were excluded on full-text screening. In total, 69 studies (all from published literature sources) detailing 47 barriers and/or facilitators of weight bearing were included. Of barriers/facilitators identified, 27 were patient-, 8 non-surgical process-, 8 surgical process-, and 4 structure-related. Patient facilitators included anticoagulant, home discharge, and aid at discharge. Barriers included preoperative dementia and delirium, postoperative delirium, pressure sores, indoor falls, ventilator dependence, haematocrit < 36%, systemic sepsis, and acute renal failure. Non-surgical process facilitators included early surgery, early mobilisation, complete medical co-management, in-hospital rehabilitation, and patient-recorded nurses' notes. Barriers included increased operative time and standardised hip fracture care. Surgical process facilitators favoured intramedullary fixations and arthroplasty over extramedullary fixation. Structure facilitators favoured more recent years and different healthcare systems. Barriers included pre-holiday surgery and admissions in the first quarter of the year.

CONCLUSION

Most patient/surgery-related barriers/facilitators may inform future risk stratification. Future research should examine additional process/structure barriers and facilitators amenable to intervention. Furthermore, patient barriers/facilitators need to be investigated by replicating the studies identified and augmenting them with more specific details on weight bearing outcomes.

Morbidity and Mortality Analysis in the Treatment of Intertrochanteric Hip Fracture with Two Fixation Systems: Dynamic Hip Screw (DHS) or Trochanteric Fixation Nail Advance (TFNA)

BACKGROUND

The aim of this study was to compare the clinical outcomes, complications, and mortality of patients with intertrochanteric hip fracture treated with dynamic hip screw (DHS) vs. trochanteric fixation nail advance (TFNA).

METHODS

We evaluated 152 patients with intertrochanteric fractures concerning age, sex, comorbidity, Charlson Index, preoperative gait, OTA/AO classification, time from fracture to surgery, blood loss, amount of blood replacement, changes in gait, full weight-bearing at hospital discharge, complications, and mortality. The final indicators encompassed the adverse effects linked to implants, postoperative complications, clinical healing or bone healing duration, and functional score.

RESULTS

The study included a total of 152 patients, out of which 78 (51%) received DHS treatment and 74 (49%) received TFNA treatment. The results of this study show that the TFNA group demonstrated superiority (p < 0.001). However, it should be noted that the TFNA group had a higher frequency of the most unstable fractures (AO 31 A3, p < 0.005). Full weight-bearing at discharge also decreased in patients with more unstable fractures (p = 0.005) and severe dementia (p = 0.027). Mortality was higher in the DHS group; however, a longer time from diagnosis to surgery was also observed in this group (p < 0.005).

CONCLUSIONS

The TFNA group has shown a higher success rate in achieving full weight-bearing at hospital discharge when treating trochanteric hip fractures. This makes it the preferred choice for treating unstable fractures in this region of the hip. Additionally, it is important to note that a longer time to surgery is associated with increased mortality in patients with hip fractures.

Comparative Study of Different Entry Spots on Postoperative Gluteus Medius Muscle Cross-Sectional Area in Patients With Intertrochanteric Fractures Nailing

Introduction In a preliminary study of cephalo-medullary (CM) nailing in patients with femoral intertrochanteric fractures, the authors of this study found a 25% to 30% decrease in muscle strength, especially abduction force, during the postoperative follow-up period. This decline was partially attributed to the entry point for the nail insertion causing damage to the gluteus medius tendon at the junction of the greater trochanter after reaming. Therefore, we assumed that changing the position of nail insertion to a "bald spot (BS)" could mitigate postoperative functional impairment. Automated computed tomography (CT) imaging of skeletal muscle cross-sectional area (CSA) and adipose tissue ratio (ATR) can show pathological changes on the operated side compared with the non-operated side. In this study, the authors quantified the difference in postoperative CSA and ATR of the gluteus medius muscle after bald spot nailing versus nail insertion through the conventional tip of the greater trochanter. It was hypothesized that bald spot nailing could avoid significant injury to the gluteus medius muscle. Materials and methods Patients with femoral intertrochanteric fractures were grouped according to the site of cephalo-medullary nailing: greater trochanteric tip (TIP) in 27 patients (8 men and 19 women, mean age 84.9±5.1 years) and BS in 16 patients (3 men and 13 women, mean age 86.9±6.2 years). The CSA and ATR of the gluteus medius muscles were assessed in three slices (A, B, and C from proximal to distal). Each slice was manually traced and automatically calculated based on its contour. Adipose tissue (-100 to -50 in Hounsfield units) in the designated area was distinguished by a bimodal image histogram resulting from the distribution of CT numbers of adipose tissue and muscle. The body mass index (BMI) was used to correct the CSA in each patient. Results In the TIP group, the mean CSA values (mm²) from the non-operated/operated sides were as follows: slice A, 2180.2 ± 616.5/1976.3 ± 421.2; slice B, 2112.3 ± 535.7/1857.7 ± 386.7; and slice C: 1671.8 ± 460.0/1404.1 ± 404.3 (p<0.01 in slices A, B, and C). In the BS group, slice A was 2044.1 ± 473.0/2016.9 ± 388.4; slice B was 2073.2 ± 540.7/1848.3 ± 411.1; and slice C was 1659.1 ± 477.2/1468.5 ± 341.7 (p=0.34 in slice A, and p<0.05 in slices B and C, respectively). The mean CSA values (mm²) of the non-operated minus operated side between the TIP/BS groups were as follows: slice A, 241.3 ± 424.3/-11.8 ± 285.6; slice B, 290.3 ± 313.0/211.8 ± 333.2; and slice C, 276.4 ± 270.4/162.8 ± 319.3 (p < 0.05 in slice A, 0.45, 0.24 in slices B, C, respectively). The mean adjusted CSA per BMI values (mm²) of the non-operated minus the operated side between the TIP/BS groups were slice A, 10.6 ± 19.7/-0.4 ± 14.8; slice B, 13.3 ± 15.0/10.1 ± 16.3; and slice C, 13.1 ± 13.4/ 8.7 ± 15.3 (p < 0.05 in slice A and 0.54 and 0.36 in slices B and C, respectively). Conclusion Nail insertion at the bald spot resulted in a significantly smaller decrease in the CSA of the gluteus medius muscle compared with the conventional tip entry. In addition, an examination of BMI-adjusted CSA showed that CSA was maintained in some image slices. These results suggest that nailing from the BS of the greater trochanter can reduce damage to the gluteus medius muscle and highlight the importance of imaging beyond the usual assessment of skeletal changes.

Comparison of Extramedullary and Intramedullary Implants for Stable Intertrochanteric Fractures: Have We Swung the Pendulum Too Far the Other Way?

INTRODUCTION

Although intramedullary implants are commonly used to treat stable intertrochanteric (IT) fractures, there is a lack of evidence to demonstrate their superiority over extramedullary implants in treating these fractures. The purpose of this study was to compare short-term outcomes (<30 days) between intramedullary and extramedullary implants in patients with closed nondisplaced stable IT fractures.

METHODS

Patients with closed nondisplaced stable IT fractures were identified from the American College of Surgeons National Surgical Quality Improvement Program database between 2016 and 2019. Patients who either underwent extramedullary implant or intramedullary implant fixation were selected for this analysis. Postoperative outcomes included transfusion, surgical complications (stroke, myocardial infarction, venous thromboembolism, pneumonia, renal failure/insufficiency, surgical site infection, urinary tract infections, and sepsis), weight-bearing on postoperative day 1, discharge destination, place of residence at 30 days after the operation, days from operation to discharge, readmission related to the index procedure, any readmission, revision surgery, and mortality.

RESULTS

Of the 3,244 cases identified for the study, 2,521 (77.7%) underwent intramedullary nailing (IMN). Based on adjusted multivariable analysis, surgical complications between the two intervention groups were not statistically significantly (odds ratio [OR] 1.142; confidence interval [CI], 0.838 to 1.558; P = 0.4). However, patients who underwent IMN were associated with higher rates of blood transfusions (OR, 1.35, CI, 1.042 to 1.748, P = 0.023), more likely discharged to a place other than home (OR, 1.372, CI, 1.106 to 1.700, P = 0.004), and more likely to get readmitted (OR, 1.783, CI, 1.157 to 2.75, P = 0.009). Patients treated with IMN were associated with lower postoperative length of stay (OR 0.982, CI 0.967 to 0.998, P = 0.030).

DISCUSSION

Our study found that extramedullary implants were associated with lower transfusions rates, lower readmissions, and better patient disposition. We recommend surgeons to consider extramedullary implants when treating stable IT fractures, especially if the patient is anemic or at high risk for hospital readmission.

LEVEL OF EVIDENCE

Level III. Retrospective cohort study.

Sliding hip screw vs intramedullary nail for AO/OTA31A1-A3: a systematic review and meta-analysis

OBJECTIVE

to conduct a systematic review with consequent meta-analysis evaluating the best treatment for Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) 31A1-A3 trochanteric fractures when comparing the sliding hip screw (SHS) to the intramedullary nail (IMN). The outcomes used for comparison are major complications (in total, as well as nonunion and infection specifically), mortality rates, functional outcomes and patient-reported outcome measures (PROM).

MATERIALS AND METHODS

Search strings for the Cochrane Library, CINAHL, Medline and Embase databases were developed with the help of a scientific librarian. Two authors screened the studies from the search string independently using Covidence.org and data extraction was performed similarly. Quality assessment was performed using the Cochrane Risk of Bias tool for randomised trials (ROB2) for RCT studies, and Cochrane Risk of Bias in Non-Randomised Studies - of Interventions (ROBINS-I) for non-RCT studies. Meta-analyses were performed using Log Risk Ratio as the primary effect estimate.

RESULTS

Of the 2,051 studies screened by the two authors, six RCTs and six non-RCTs were included in this meta-analysis, with a total of 10,402 patients. The results indicated no significant differences in total major complications, nonunion, infection or mortality between SHS and IMN treatments for AO/OTA 31A1, 31A2 and 31A3 trochanteric fractures. Due to a lack of compatible data, we were unable to perform a meta-analysis on function scores and PROM. However, there are trends that favour IMN for 31A1 and 31A2 fractures.

CONCLUSION

No significant difference between SHS and IMN was found in the meta-analysis in any of the examined AO/OTA fracture subtypes in terms of primary and secondary outcomes. When assessing function scores and PROM, we found trends favouring IMN for 31A1 and 31A2 fractures that should be explored further.

"Screw First" Technique to Get Past Nail-Jig Mismatch in Proximal Femoral Nailing

Proximal femoral nailing is the gold standard of surgical treatment for unstable intertrochanteric hip fractures. One of the intraoperative complications encountered in this procedure is the nail-jig mismatch due to causes such as manufacturing errors and fatigue deformation of sleeves or jig. Nail-jig mismatch leads to eccentric placement of guidewire within the screw slots of PFN and subsequent difficulty in reaming and screw insertion. The potential complications of this include guide wire deformation, breakage, nail damage and screw malposition. We propose a simple and effective technique to tackle this complication, called as "Screw first" technique. The principle of this technique is to utilize screws as guide wire sleeves to effectively centralize the guidewire position within nail slots. On identifying a mismatch by the eccentric position of guidewire, a long screw is first inserted partially till its shaft engages into the screw slot allowing subsequent insertion of a guidewire which assumes a centralized position, thus bypassing the mismatch of jig. Following this, the usual steps of reaming and final screw insertion are undertaken. This method is effective, simple, quick and requires no special instrumentation.

Relationship between Charlson comorbidity index, early recovery and 2-year mortality in elderly patients undergoing surgical treatment of inter-trochanteric fractures: a retrospective analysis

The aim of this study was to evaluate how the Charlson Comorbidity Index (CCI) scores contribute to early recovery and 2-year mortality in elderly patients undergoing surgical treatment of inter-trochanteric fractures. 60 cases with unilateral intertrochanteric fracture were retrospectively analyzed and divided into Low-CCI group (CCI: 1–4) or high-CCI groups (CCI: 5–6). All the patients’ electronic hospital records were reviewed. The preoperative situations (demographic data, comorbidities and fracture conditions), perioperative situations (wait time, operation time, implant choice, blood loss, transfusion or not) and postoperative situations (complications, first time out of bed, function about 1-/2- week and 2-year mortality) were recorded. 51.67% were in low-CCI group and 48.33% in high-CCI group. The survival rates in low- and high-CCI group were 93.5% and 86.2% respectively. According to the functional results of 1- or 2- week after operation, no significant difference was found (P = 0.955, 0.140). Log-rank analysis showed that the main prognostic factors were blood loss, first time out of bed and complication (P < 0.05). Multivariate analysis confirmed that complication and first time out of bed were significant factor on survival rate (P = 0.029, 0.010). Charlson comorbidity index maybe not the indicator of 2-year mortality in older patients with intertrochanteric fractures. In order to improve the prognosis, more attentions should be paid to reduce the complications and encourage postoperative earlier excise out of bed.

Dynamic Hip Screw with Trochanter-Stabilizing Plate Compared with Proximal Femoral Nail Antirotation as a Treatment for Unstable AO/OTA 31-A2 and 31-A3 Intertrochanteric Fractures

Background

The dynamic hip screw (DHS) with the addition of an angular stable trochanter-stabilizing plate (TSP) has been considered the ideal treatment for the unstable intertrochanteric fracture type. However, there have been few comparisons between DHS+TSP augmentation with intramedullary (IM) nailing. The aim of this retrospectively registered study was to compare the clinical outcomes of patients with the unstable type of intertrochanteric fractures treated with DHS+TSP or IM nailing (proximal femoral nail antirotation (PFNA)).

Methods

From June 2013 to April 2018, 358 patients with proximal femur fracture AO/OTA type 31A2 and 31A3 treated with PFNA or DHS+TSP and followed for ≥10 months postoperatively were included. The surgical-dependent outcome evaluation included the operation time, intraoperative blood loss, postoperative decrease in hemoglobin, and blood transfusion amount. Functional status was also measured. Radiographic findings and postoperative complications were recorded and analyzed.

Result

The operation time was significantly shorter in the DHS+TSP group than that in the PFNA group for both A2 and A3 fractures (A2 type: 84.0 vs.96.4 min; p < 0.05; A3 type: 102.4 vs.116.1 min; p < 0.05). Postoperative decrease in hemoglobin was more significant in the PFNA group than that in the DHS+TSP group for both fracture types (A2 type: −1.88 vs. −1.29 (mg/dL); p < 0.05; A3 type: −1.63 vs. −1.04 (mg/dL); p < 0.05). However, the patients treated with DHS+TSP had significantly more residual pain than those treated with PFNA during the final follow-up (Visual Analog Scale score, A2 type: 28.4 vs.23.2; p < 0.05; A3 type: 27.5 vs.23.6; p < 0.05) and complained of greater implant irritation.

Conclusion

We found that DHS+TSP was associated with less operation time and less postoperative decrease in hemoglobin but more residual pain and implant irritation than those of PFNA. As a treatment for unstable intertrochanteric fracture, DHS+TSP provided ideal surgical outcomes which were not inferior to the PFNA.