Early mechanical complications following fixation of proximal femur fractures: From prevention to treatment

High Rate of Complications With Early Conversion Hip Arthroplasty Following Fracture Treatment

BACKGROUND

Conversion total hip arthroplasty (THA) is associated with higher rates of complications compared with primary THA, with prior surgical fixation of fractures in the ipsilateral hip shown to further increase these rates. There is a scarcity of literature on the effect of timing of conversion THA on complication rates. In this study, we evaluated early (≤6 months of index surgery) and late (>6 months of index surgery) conversion to THA following prior fixation of the proximal femur or acetabulum.

METHODS

Ninety-one patients who underwent conversion THA following prior surgical fixation of either the proximal femur or acetabulum were identified. Index surgery, fracture characteristics, time, and cause of failure were obtained. Postoperative complications evaluated following the conversion THA included infection, revision surgery rates, dislocation, and revision rates.

RESULTS

A total of 91 patients were included, of which 22 underwent early conversion to THA. In the early conversion group, 22.7% of patients had a complication versus 11.6% of patients in the late conversion group (P = 0.194). The most common complications were deep infection (18.2% vs. 5.8%), revision surgery (22.7% vs. 10.1%), and revision THA (18.2% vs. 5.8%). The early conversion group had a markedly higher rate of perioperative blood transfusion compared with the late cohort (P = 0.013).

CONCLUSION

In this study, we found a high rate of complications associated with early THA conversion. Patients should be counseled on the high risk for complications following early conversion to THA following failed fracture fixation.

[Rotationally stable screw anchor (RoSA) vs. Gamma3 Nail (G3N) in pertrochanteric femoral fractures : A functional outcome analysis]

BACKGROUND

The pertrochanteric femoral fracture (PFF) represents one of the most common fracture types throughout Germany. To enable early mobilization of patients, the primary surgical goal is load-stable osteosynthesis. Implant failure still represents the largest group of implant-related complications (>80%).

OBJECTIVE

The aim of the study was to document and analyze the influence of the implant on the functional outcome and an evaluation of the rotationally stable screw anchor (RoSA) vs. Gamma3 nail.

MATERIAL AND METHODS

In a retrospective study 43 patients with PFF (AO 31A1-A3) were included in the study. The influence of the implant on the functional outcome was assessed by 2 standardized questionnaires (SF-36, NMS (New Mobility Score)) and analyzed in a retrospective evaluation.

RESULTS

In the study no significant differences in functional outcome scores ≥ 1 year after osteosynthesis of the PFF could be shown depending on the implant used. There is an overall tendency for a better outcome in the G3N group.

DISCUSSION/CONCLUSION

In the literature the superiority of intramedullary nailing over extramedullary implants is continually discussed. Implant failure is still the most frequent complication. In intramedullary implants, such as the G3N, the primary cause is failure of the head-neck component. For conventional extramedullary implants the biomechanical properties on the femoral shaft also pose a challenge in the case of unstable PFF. The further development of the RoSA to an intramedullary implant could combine the advantages of intramedullary load carriers with the advantages of the blade-screw combination in the head-neck fragment and lead to a reduction in implant-associated complications.

Comparative study of a novel proximal femoral bionic nail and three conventional cephalomedullary nails for reverse obliquity intertrochanteric fractures: a finite element analysis

Purpose

Conventional cephalomedullary nails (CMNs) are commonly employed for internal fixation in the treatment of reverse obliquity intertrochanteric (ROI) fractures. However, the limited effectiveness of conventional CMNs in addressing ROI fractures results in significant implant-related complications. To address challenges associated with internal fixation, a novel Proximal Femoral Bionic Nail (PFBN) has been developed.

Methods

In this study, a finite element model was constructed using a normal femoral specimen, and biomechanical verification was conducted using the GOM non-contact optical strain measurement system. Four intramedullary fixation approaches-PFBN, Proximal Femoral Nail Antirotation InterTan nail (ITN), and Gamma nail (Gamma nail)-were employed to address three variations of ROI fractures (AO/OTA 31-A3). The biomechanical stability of the implant models was evaluated through the calculation of the von Mises stress contact pressure and displacement.

Results

Compared to conventional CMNs, the PFBN group demonstrated a 9.36%-59.32% reduction in the maximum VMS at the implant. The A3.3 ROI fracture (75% bone density) was the most unstable type of fracture. In comparison to conventional CMNs, PFBN demonstrated more stable data, including VMS values (implant: 506.33 MPa, proximal fracture fragment: 34.41 MPa), contact pressure (13.28 MPa), and displacement (17.59 mm).

Conclusion

Compared to the PFNA, ITN, and GN, the PFBN exhibits improvements in stress concentration, stress conduction, and overall model stability in ROI fractures. The double triangle structure aligns better with the tissue structure and biomechanical properties of the proximal femur. Consequently, the PFBN has significant potential as a new fixation strategy for the clinical treatment of ROI fractures.

Laterally Protruded Cephalomedullary Nail Lag Screws are a Source of Consistent Thigh Pain After Pertrochanteric Fracture

OBJECTIVES

To assess the correlation between the amount of proximal screw lateralization and clinical symptoms in patients treated with a cephalomedullary nail (CMN) after a pertrochanteric fracture.

METHODS

DESIGN

Retrospective study.

SETTING

Level 1 trauma center.

PATIENT SELECTION CRITERIA

Patients operated for a pertrochanteric fracture (OTA/AO A1, A2, A3) between 2019 and 2022 and treated with a CMN were included.

OUTCOME MEASURES AND COMPARISONS

Three measurements were evaluated: D1 distance between the most laterally prominent point of the lag screw and the line tangent to the greater trochanter, D2 distance between the lateral femoral cortex and the most laterally prominent point of the lag screw, and D3 distance between the point where the lag screw emerges at the lateral edge of the femur shaft and the skin's surface. Clinical scores and information regarding lateral thigh pain were obtained, and a correlation analysis was performed.

RESULTS

Mean age of the study cohort (n = 134) was 77.9 ± 12.3 years. Patients with categorical protrusion (considered present in cases where the distance between the lateral tip of the lag screw and the lateral border of the greater trochanter was ≥0.2 mm) had significantly higher rates of lateral thigh pain ( P = 0.007) and discomfort while lying on the side ( P = 0.032) compared with those without protrusion. Correlation analyses showed a positive correlation between measurements D1 and D2 and lateral thigh pain (r = 0.324 and r = 0.334, respectively, P < 0.001) and a negative correlation between D3 and lateral thigh pain (r = -0.286, P = 0.001). Regression analysis showed that higher D1 and D2 distances and shorter D3 distances are risk factors for lateral thigh pain ( P = 0.001, 0.001, and 0.002, respectively).

CONCLUSIONS

Increasing lateral protrusion of the lag screw leads to significantly greater clinical complaints and lateral hip pain in patients treated with a CMN. Patients with lower distance between the lateral femoral wall and the skin are at higher risk of lateral pain.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

[Management of the cut-out of various forms of osteosynthesis for proximal femoral fractures]

Proximal femoral fractures are a common type of injury in older people. A cut-out of the femoral neck screw after initial osteosynthetic surgery of proximal femoral fractures is a frequent and feared complication. There could be different causes for cut-outs. Osteoporosis and necrosis of the femoral head could be biological reasons for cut-outs; however, mechanical factors, such as reduction, implant position and morphological characteristics of fractures also have a major influence on the cut-out rate. The treatment of the cut-out is often complex and depends on the destruction of the femoral head and the acetabulum. If the bone quality is still good and the head is not completely destroyed, a reosteosynthesis can be performed. Conversion to an endoprosthetic replacement is often the only possibility. Endoprosthetic treatment is often complex and associated with a high morbidity.

Proximal Femur Fractures - How Decisive are Reduction and the Chosen Implant?

Proximal femoral fractures are frequent and complex injuries requiring prompt and targeted care. Numerous treatment strategies have been described, some of which have been assessed and clinically implemented clinically. The aim of surgical is always the restoration of a pain-free and stable extremity. Mostly elderly patients are affected and treatment is associated with high postoperative complications and mortality rates. With increasing numbers of patients, the topic is of great medical and economic relevance. In this work, the choice of implants for the osteosynthesis of proximal femoral fractures - as depending on the fracture type - will be examined, as based on a review of current literature. Standard care includes cannulated screws, sliding hips screws and cephalomedullary nails. In addition, the influence of implant positioning, fracture reduction and additional measures such as cement augmentation are evaluated and discussed. Careful fracture reduction and the quality of implant positioning are paramount in order to avoid complications.

Should recommended laboratory-test cut-offs allowing surgery be followed for proximal femoral fractures in patients on direct oral anticoagulant therapy?

BACKGROUND

Proximal femoral fractures (PFFs) in elderly patients must receive prompt surgical treatment. Optimal PFF-surgery timing in patients on direct oral anticoagulant (DOA) therapy is a specific but common clinical issue. Recommendations exist about the anti-Xa or anti-IIa levels and creatinine clearance values required to allow surgery. The objectives of this study in patients older than 75 years who required PFF surgery were to evaluate bleeding when the recommendations were versus were not applied and to assess concordance between DOA-activity-assay results and creatinine clearance used to help determine the wait to surgery.

HYPOTHESIS

Peri-operative bleeding is more marked when surgery is performed while the DOA is still active.

PATIENTS AND METHODS

This single-centre, retrospective, comparative, observational study included 87 patients older than 75 years who required arthroplasty or intra-medullary nailing for PFF and were taking DOA therapy. Surgery was performed after versus before the laboratory-test results fell below the recommended cut-offs in 68 patients (Rec+ group) versus 19 patients (Rec- group), respectively. The study outcomes were blood loss estimated using the Mercuriali's formula and the proportion of patients requiring post-operative blood transfusions.

RESULTS

Mean blood loss was 287.1mL in the Rec+ group and 411.7mL in the Rec- group (p=0.12). Blood transfusions were required by a post-operative haemoglobin level below 0.8g/dL in 11 (16.2%) Rec+ patients and 6 (31.6%) Rec- patients (p=0.2). Concordance was poor between DOA activity and creatinine clearance (Cohen's κ, 0.16; p=0.146).

DISCUSSION

Peri-operative bleeding was not significantly more severe when PFF surgery was performed while DOA therapy was still active. These data suggest that PFF surgery within 48h may be appropriate in patients older than 75 years on DOA therapy.

LEVEL OF EVIDENCE

IV; retrospective single-centre study.

Should trochanteric fractures in elderly patients be treated by arthroplasty or internal fixation?

Most trochanteric fractures are treated by fixation, most often intramedullary. Nevertheless, the desire to have patients walk as soon as possible and the fear of fixation failure has driven some surgeons to carry out an arthroplasty instead, especially for unstable fractures and/or in patients with severe osteoporosis, in order to avoid the difficult conversion to arthroplasty later on if the fixation fails. The aim of this review was to specify the role, technique and results of performing arthroplasty in this context. In which fractures? Unstable fractures (A2.2, A2.3 and A3), especially in osteoporotic bone, which are the most difficult to reduce and fix, and in cases with associated osteoarthritis. For which patients? Arthroplasty should not be done in patients who have ASA≤3 due to greater blood loss and longer operative time. Since the postoperative Parker score often drops, arthroplasty should not be done in patients having a Parker score<6. What are the technical problems? Arthroplasty must be done by an experienced surgeon because of the lack of anatomical landmarks, although fracture fixation has its own demands (satisfactory reduction, appropriate length and position of cervicocephalic screw). What are the results and complications? Despite several comparative studies (randomized trials, meta-analysis and prospective studies), it is difficult to draw any conclusions. These studies show worse performance of dynamic hip screws relative to intramedullary nails. The complication and revision rates were higher for nails than arthroplasty, but not in every study, while the functional outcomes with nails (with or without immediate weightbearing) were better than those of arthroplasty beyond 6 months. What is the mortality rate? It was lower after nailing in a few studies but was mainly determined by the patient's comorbidities and preoperative Parker score. The best indication for arthroplasty may be self-sufficient patients over 70 years of age who have an unstable fracture with severe osteoporosis. Nevertheless, new studies should be done to compare arthroplasty to nailing with immediate return to weightbearing in patients having the same type of fracture, defined using 3D CT scan. Level of evidence: Expert advice.

Evaluating ChatGPT responses in the context of a 53-year-old male with a femoral neck fracture: a qualitative analysis

PURPOSE

The integration of artificial intelligence (AI) tools, such as ChatGPT, in clinical medicine and medical education has gained significant attention due to their potential to support decision-making and improve patient care. However, there is a need to evaluate the benefits and limitations of these tools in specific clinical scenarios.

METHODS

This study used a case study approach within the field of orthopaedic surgery. A clinical case report featuring a 53-year-old male with a femoral neck fracture was used as the basis for evaluation. ChatGPT, a large language model, was asked to respond to clinical questions related to the case. The responses generated by ChatGPT were evaluated qualitatively, considering their relevance, justification, and alignment with the responses of real clinicians. Alternative dialogue protocols were also employed to assess the impact of additional prompts and contextual information on ChatGPT responses.

RESULTS

ChatGPT generally provided clinically appropriate responses to the questions posed in the clinical case report. However, the level of justification and explanation varied across the generated responses. Occasionally, clinically inappropriate responses and inconsistencies were observed in the generated responses across different dialogue protocols and on separate days.

CONCLUSIONS

The findings of this study highlight both the potential and limitations of using ChatGPT in clinical practice. While ChatGPT demonstrated the ability to provide relevant clinical information, the lack of consistent justification and occasional clinically inappropriate responses raise concerns about its reliability. These results underscore the importance of careful consideration and validation when using AI tools in healthcare. Further research and clinician training are necessary to effectively integrate AI tools like ChatGPT, ensuring their safe and reliable use in clinical decision-making.

Complications Following Short Femoral Nail Fixation for Intertrochanteric Hip Fractures: A Retrospective Study

The incidence of proximal femur fractures is increasing due to aging of the population. Intramedullary nails are the mainstay of treatment for intertrochanteric hip fractures mainly due to their better biomechanical properties compared to dynamic hip screw devices, shorter operative time, and less blood loss during surgery. However intramedullary nail fixation is not devoid of complications. The purpose of this study is to look at complications related to intramedullary nailing for intertrochanteric hip fractures in a major trauma center. A retrospective study was conducted including all patients having suffered an intertrochanteric femur fracture and treated with intramedullary nails from October 1, 2020, to October 1, 2022, in the Orthopaedic Surgery Clinic. The intramedullary hip systems used were the Stryker Gamma3 Nail and the VITUS PF Nail. All complications following the postoperative period were recorded in detail. Overall, 240 patients with a mean age of 82.3 years treated with hip intramedullary devices were identified. Superior cutout of the lag screw in two patients (females 90 and 87 years old) was identified 8 and 10 weeks following initial surgery. Avascular necrosis (AVN) of the femoral head was identified in one patient (male 81 years old) which occurred 12 weeks postoperatively. All three cases were revised by replacing the nail with cemented hemiarthroplasty. Periprosthetic fractures occurred in an 88-year-old male and a 73-year-old female following an injury distal to the stem and were managed by replacing the nail with a long stem device (Long Gamma3). One case of metalwork fracture was also recorded. There are many advantages in managing intertrochanteric hip fractures with intramedullary hip devices such as shorter theater time, less blood loss, and improved biomechanical properties. However, complications such as cutout of the lag screw, AVN, and periprosthetic fracture are serious and require complex revision surgery.

Can the prognostic score proposed by Elliot serve as an educational tool to shorten the time to surgery for hip fractures in geriatric patients?

INTRODUCTION

Hip fractures require surgical treatment within 48hours to decrease the risk of postoperative complications. Elliott proposed a prognostic score to identify which patients should be prioritized for surgery. This study was designed to answer the following questions: 1- Does using this score shorten the time to surgery? 2- Does shortening the time to surgery reduce mortality at 6 months and 1 year? 3- What factors delay the surgical procedure? We hypothesized that using this score as an educational tool would reduce the time to surgery in patients over 75 years of age who have a hip fracture.

MATERIAL AND METHODS

This single-center study involved two populations: 244 patients were included prospectively who had the score applied with the aim of optimizing the time to surgery; 476 patients were included from a historical cohort to serve as a reference group.

RESULTS

The mean time to surgery was 2.5 days±1.9 [95% CI: 2.41-2.77] and the median was 2 days (minimum 0, maximum 18 days) in the reference group; the mean was 1.4 days±1.0 [95% CI: 1.46-1.67] and the median was 1 day (min. 0, max 6 days) in the prospective cohort, which was a significant reduction (p<0.001). At 6 months, the mortality rate was 22.5% in the reference population and 23% in the prospective cohort. At 1 year, the mortality rate was 47% and 46%, respectively, with no significant difference. Surgical delays were attributed to lack of OR availability, management of anticoagulants, request for cardiac ultrasound and administrative reasons.

DISCUSSION/CONCLUSION

Elliot's prognostic at-risk score for hip fracture can shorten the time to surgery when used an educational tool to raise the medical staff's awareness of the benefits of rapid surgical care.

LEVEL OF EVIDENCE

IV; retrospective study without control group.

GS Hip Nail versus Affixus Hip Fracture Nail for the Intramedullary Nailing of Intertrochanteric Fractures

BACKGROUND

Intertrochanteric fractures are a global health concern, especially in aging populations like the Republic of Korea. Surgical treatments like intramedullary nailing are preferred for their benefit. Various hip nails are used worldwide, each with unique features and challenges. This study aims to compare the GS hip nail with the Affixus hip fracture nail for the treatment of intertrochanteric fractures.

MATERIAL AND METHODS

This retrospective study, conducted at a single center, included 179 patients who underwent intramedullary nailing for intertrochanteric fractures using the GS hip nail or the Affixus hip fracture nail. Excluding specific cases, 43 patients in the GS group and 46 in the Affixus group met the minimum 6-month follow-up criteria.

RESULT

The GS group exhibited a significantly shorter mean operation time (43.26 min) compared to the Affixus group (51.11 min). Radiographically, both groups showed no significant differences in their reduction quality, tip, and apex distance (TAD), or Cleveland index in the immediate postoperative window. However, the GS group achieved a greater valgus reduction based on the contralateral femoral neck shaft angle (NSA). At 6 months post-operation, there were no significant differences in TAD or advancement and sliding distances. Complication rates were similar between the two groups, with no implant breakages. Clinical outcomes, as measured via mHHS and EQ-5D-5L, showed no significant differences. Despite a slightly higher implant cost, the GS group had a lower total hospital cost than the Affixus group, but this was not statistically significant.

CONCLUSIONS

This study highlights the efficiency of the GS hip nail in reducing the operation time compared to the Affixus hip fracture nail with comparable radiologic and clinical outcomes. Further research with long-term follow-up and larger patient studies are needed to fully assess its effectiveness in improving patient outcomes in hip fracture treatment.

Proximal femoral fracture and female gender are risk factors for recurrent fracture: Cohort study of 292 patients over 75 years-old with iterative osteoporotic fractures

PURPOSE

The purpose of this study was to: 1/ describe the characteristics of a cohort of patients over 75 years of age hospitalized in perioperative geriatric units (UPOG) for iterative fractures; 2/ investigate the risks of institutionalization related to the first fracture; and 3/ search for potential risk factors for iterative fracture.

METHODS

This is a retrospective single-center study analyzing patients over 75 years old, hospitalized in UPOG.

RESULTS

Of the 3207 patients hospitalized, 292 patients had a refracture (9.1%), with a mean age of 85.4+/-5.8 years. Initial fractures were mainly intertrochanteric (43.2%) and the femoral neck (32.9%). Refractures occurred mainly in the first year (55.5%), with a median delay of 9.6 months. Refractures were mainly intertrochanteric (29.5%), peri‑implant (prosthesis, osteosynthesis) (28.8%), and femoral neck (26.7%). Dementia was the only factor for institutionalization after the first fracture episode (p = 0.0002). Proximal femoral fracture (PFF) and female gender were risk factors for iterative fracture (10.2% vs. 6.8%, p = 0.003; 10.7% vs. 6.8%, p = 0.005 respectively), but not age (85.4 vs. 85.8 years, p = 0.24). PFF were more likely to result in the same fracture type in the second episode (58.1% vs 7.1%, p<0.0001). The time to refracture was shorter in case of peri‑implant fracture (p = 0.0002), or discharge directly to home (p = 0.04).

CONCLUSION

PFF and female gender are risk factors for recurrent fracture, which is even more likely to occur early in case of home discharge or peri‑implant fracture.

Diagnostic value of full-length femur radiographs in patients with neck of femur fracture and co-existing malignancy

PURPOSE

In the UK, it is common practice to obtain full-length femur radiographs in patients admitted with neck of femur fractures (NOF) and co-existing malignancy. Limited literature exists studying this topic. Our aim was to identify whether full-length femur radiographs are of diagnostic and therapeutic value in this demographic.

METHODS

A retrospective observational analysis of the patients admitted with a neck of femur fracture over a 5-year period (2015-2020) using the National Hip Fracture Database was performed at a major trauma centre. Electronic patient records were accessed to screen the NOF patients who had co-existing malignancy and subsequently underwent a full-length femur radiograph. In addition to patient demographics, we also identified the plan and whether it was affected by findings of the full-length radiograph, the operation performed, any additional investigations undertaken for malignancy, the type of cancer, complications and 1-year mortality.

RESULTS

Of the 2416 patients screened, 18% had a co-existing malignancy (n = 431). Of the 431 with underlying malignancy, 424 patients underwent a full-length femur radiograph while only seven of these radiographs identified lesions. From the seven patients with findings of metastatic deposits on full-length radiographs, none required an alternative operation to that which they normally would undergo. Furthermore, no patients required a longer stem arthroplasty or longer internal fixation. One in four fractures was associated with co-existing breast malignancy (26.5%, n = 114), followed by prostate cancer (14.8%, n = 64). Colorectal, lung, bladder and skin (squamous cell carcinoma) contributed 6-10% (n = 44, 40, 33, 29, respectively). Other malignancies contributed to the rest of the 25%.

CONCLUSION

To conclude, full-length radiographs had no diagnostic or therapeutic value in our cohort of patients regardless of the full-length femur findings.

Augmented osteosynthesis in fragility fracture

Due to poor bone quality and complexity, some fractures are difficult to treat, with high risk of failure. Moreover, general health is often poor in elderly patients with multiple comorbidity and poor compliance, necessitating perfect first-line management to avoid re-operation. The armamentarium comprises specific internal fixation implants and also complementary methods such as autologous, homologous or heterologous bone graft or bone substitutes with varying mechanical and biological characteristics. Associating these options is what is mean by "augmented fixation". The present review of augmented osteosynthesis addresses the following questions: What are the characteristics of fragility fractures? Fragility fracture is caused by low-energy trauma on bone with poor structural quality and low mineral density. Treatment aims to enable early mobilization and weight-bearing while avoiding mechanical failure of fixation. Prolonged bedrest, loss of mobility and surgical revision are aggravating and sometimes fatal factors in these fragile patients. What are the biological techniques of fixation augmentation in fragility fracture? Autologous or homologous bone graft are the most widely used biological augmentation techniques. They fill spaces and promote osteoconduction and consolidation. Some bone-like phosphocalcic structures are opening up promising lines of research. What are the non-biological techniques of fixation augmentation in fragility fracture? Hydroxyapatite, phosphocalcic cement and acrylic cement are the most widely used synthetic materials. Biological and mechanical effects are variable according to composition, requiring specific implementation. What are the mechanical techniques of fixation augmentation in fragility fracture? There is at present no consensus as to the augmentation techniques to be applied in fragility fracture. Cerclage or complementary plating, or external fixation associated to internal fixation are possibilities. However, the literature consists only of small series reporting surgical techniques specific to a given surgeon or team. When and how should osteosynthesis for fragility fracture be augmented? The choice of augmentation depends on fracture location, comminution, available material and local experience. The more severe the fracture, the more complex the fixation. The approach needs to be adapted to the preoperative planning and the associated mechanical means (plate, complementary cerclage) and prosthetic replacement should be considered in certain joint fractures or fractures close to load-bearing surfaces. LEVEL OF EVIDENCE: V; expert opinion.

New Prognostic Factors in Operated Extracapsular Hip Fractures: Infection and GammaTScore

There is no universal postoperative classification of extracapsular hip fractures (ECFs). We wondered if infection (according to infection after fracture fixation criteria (IAFF)), immediate partial weight bearing (PWB) and/or the new GammaTScore tool could predict early cut-out. We also examined the correlation between GammaTScore and time to consolidation and studied long-term survival. This was a retrospective cohort study of low-energy complete ECFs operated with Gamma3T nailing in 2014 and fully monitoring, in patients aged over 65. Ten not distally locked cases, one late cut-out, one cut-through, one osteonecrosis and one pseudarthrosis were discarded. Patients were classified into early cut-out (7/204; 3.55%) and no early cut-out (197/204; 96.45%). There was a lower percentage of A2 fractures according to the AO Foundation/Orthopaedic Trauma Association classification (AO/OTA, 1997) in early cut-out. IAFF and only the GammaTScore reduction parameter were different for early cut-out, in opposition to immediate PWB, tip-to-apex distance (TAD) or the Baumgaertner-Fogagnolo classification. GammaTScore inversely correlated with consolidation (p < 0.01). Long-term survival time was not statistically significantly lower in the early cut-out group. Small sample of cases may limit our results. Apart from an important role of IAFF, GammaTScore would be useful for predicting consolidation, avoiding complications and reducing costs. Further studies are needed for reliability.

Mortality and functional consequences after revision osteosynthesis for peritrochanteric fractures treated by intramedullary nail: A retrospective study of 312 patients

INTRODUCTION

Osteosynthesis of peritrochanteric fractures by intramedullary nail is associated with a 3 to 15% rate of complications requiring revision surgery. The objective of our study was to compare mortality and autonomy between patients who required revision surgery after osteosynthesis, and patients without revision surgery.

HYPOTHESES

Patients who underwent revision surgery after osteosynthesis of a peritrochanteric fracture by intramedullary nail did not exhibit excess mortality or loss of autonomy compared to those who did not undergo revision surgery.

METHODS

Between January 2017 and October 2019, 312 consecutive patients were operated on for a peritrochanteric fracture by intramedullary nail. Among them, 23 patients (7.4%) required revision surgery (change, nail removal, total hip arthroplasty). Mortality at 90 days and at one year was evaluated and compared between the group of "revision" patients and "no revision" patients. The level of autonomy was assessed by the Parker and Palmer score, one year postoperatively and compared between the 2 groups.

RESULTS

The patients requiring revision surgery were younger: 73 years old vs. 86 years old (p<0.011). The overall mortality was 7.25% at 90 days after surgery and 15% at one year. Mortality was zero at 90 days, and at 1 year, postoperatively for patients requiring revision surgery. There was no significant difference for the mortality at 90 days (p=0.39) between the 2 groups, however at 1 year, it was significantly less for the revision patients (0% vs. 17%, p=0.032). There was no significant difference for the Parker score between the "revision" group; 5 (4-9) and the "no revision" group; 4 (3-7), at one year postoperatively (p=0.24).

CONCLUSION

This study did not show any excess mortality, nor loss of autonomy at 1 year postoperatively, for patients who required osteosynthesis for a trochanteric fracture, and who presented with a complication requiring revision surgery.

LEVEL OF EVIDENCE

III, comparative retrospective study.

When to Reduce and Fix Displaced Lesser Trochanter in Treatment of Trochanteric Fracture: A Systematic Review

Purpose

To systematically evaluate the benefits of reducing and fixing displaced lesser trochanter (LT) of trochanteric fractures and when this procedure is worth the effect.

Methods

From database establishment through March 2021, four online databases (PubMed, Cochrane, Embase, and Web of Science) were searched for relevant literature that investigated reduction and fixation for displaced LT of trochanteric fractures. The papers were then screened by two reviewers independently and in duplicate according to prior inclusion and exclusion criteria. Demographic data as well as data on fracture types, surgical protocols, and surgical outcomes were recorded, analyzed, and interpreted.

Results

Total 10 clinical studies with 928 patients were included, in which 48 cases had intact LT and 880 cases involved the displaced LT, of which 196 (22.27%) cases underwent reduction and fixation for LT while the rest of 684 (77.73%) cases not. In these studies, complications were evaluated as a more applicable predictive parameter for operation than postoperative hip function.

Conclusion

It was beneficial to reduce and fix the displaced LT when one of the conditions below occurred: displacement distance of LT ≥2 cm, quantity of comminuted LT fragments ≥2, and range of LT fragments in medial wall ≥75%; the fracture line of LT fragments reaching or exceeding the midline of the posterior wall.

Interimplant femoral fractures

The number of hip or knee arthroplasties, and internal fixations of the proximal and distal femur, is increasing in proportion to the growing and ageing population, whose life expectancy is lengthening. Thus, fractures of the femur between proximal and distal implants, although rare, are becoming more frequent. Women over the age of 70, with fragile bones and whose ends of the two implants are close to each other ("kissing implants") are particularly vulnerable to them. Reliable and reproducible fracture classifications exist when it comes to 2 prostheses, but they are less well established in the presence of one, or even two, non-prosthetic implants. Their treatment is difficult and must consider the possibility of fracture consolidation while ensuring or restoring the stability and role of the implants. Whether it is the main element of treatment or a complement to prosthesis revision, locked plating forms the basis of the treatment but it must be rigorous, considering that failures are mainly the result of technical errors. Other more invasive treatments (total femoral arthroplasty, cortical sleeves) are offered more rarely if consolidation appears compromised.

Comparative study of total hip arthroplasties with dual mobility cups versus hemiarthroplasties in management of femoral neck fractures: Survival and dislocation rate at 5 years of follow-up?

BACKGROUND

Instability after hip arthroplasty, whether it is a total (THA) or intermediate (HA), poses a major risk, however arthroplasty is the standard treatment for displaced intracapsular fractures of the femoral neck of the elderly. Three types of arthroplasties can be proposed: total prostheses with or without a dual mobility cup (DM THA) reducing the risk of dislocation, and hemiarthroplasties. In the absence of clear recommendations regarding the type of implant to be used and the scarcity of studies comparing HA and DM THA, we conducted a monocentric comparative retrospective study using the propensity score method to compare DM THA versus HA on recently displaced femoral neck fractures: (1) survival and risk of dislocation, (2) functional results, (3) mortality.

HYPOTHESIS

The rate of dislocation of THA fitted with a DM cup is lower than that of HA.

PATIENTS AND METHODS

We retrospectively identified 112 patients in the HA group and 153 patients in the DM THA group who underwent an emergency arthroplasty for a displaced cervical fracture between 2010 and 2013. The minimum follow-up was 5 years (range, 5-9 years). The mean age at surgery was 81 years (range, 55-101 years). Elective surgery patients (n=2), hardware fractures (n=10), pathological fractures of the femoral neck (n=6), associated fractures (n=3), and revision surgeries (n=5) were excluded. The primary outcome measure was instability. Clinical follow-up was performed by the WOMAC score and the risk of mortality was determined after adjusting for confounding factors using the propensity score method.

RESULTS

After adjustment by the propensity score, the dislocation rate at 2-years was 2.2% (n=3/153) in the dual mobility THA group and 6.3% (n=7/112) in the HA group (OR=0.34 [95% CI: 0.06-1.96] (p=0.23)). After adjustment by the propensity score, the mean WOMAC score was 8.20 (±6.56) in the THA group, compared to 10.78±3.92 on average in the HA group (p=0.031). After adjustment by the propensity score, we did not find any significant difference in the reoperation rate without changing implants and revisions, and postoperative complications. After adjustment by the propensity score, mortality was significantly higher in the HA group 45.5% (n=69/152) versus 91.5% (n=102/112) in the HA group (OR=0.50 [95% CI: 0.25-0.98] (p=0.042)).

DISCUSSION

Few studies have compared these two types of implant in the context of trauma. Although the results of our study are not significant regarding the risk of dislocation, the use of a dual mobility cup seems to be a very satisfactory solution in this trauma context.

LEVEL OF EVIDENCE

III; comparative retrospective cohort.

Variables influencing radiological fracture healing in children with femoral neck fractures treated surgically: A review of 177 cases

PURPOSE

This study aimed: (1) to determine the probability of and the amount of time needed to achieve fracture healing in children with displaced femoral neck fractures (FNFs) treated surgically; and (2) to determine which factors can affect both the probability of and the amount of time needed to achieve radiological fracture healing in those patients.

HYPOTHESIS

Pediatric FNFs require longer time to achieve union than previously reported.

METHODS

We retrospectively reviewed the data of 177 children (mean age 10.5±3.9 years) with FNFs treated surgically. Risk factors, including age, sex, laterality, the mechanism of injury, the initial displacement severity, the type of fracture, the time to reduction, the reduction method, the fixation method and the reduction quality, were recorded. Furthermore, the presence of a comminuted medial or posterior cortex on anteroposterior (AP) or lateral radiographs was also recorded.

RESULTS

A total of 172 hips (97.2%) achieved radiological fracture healing during the follow-up period. Severe initial displacement, a comminuted cortex on the AP or lateral radiographs and poor reduction quality significantly increased the time needed to achieve radiological fracture healing (p<0.05). Cox regression analysis indicated that the cumulative probability of achieving fracture healing increased linearly during the first 6 months and then plateaued, with a monthly increase of less than 5%. The severity of initial displacement, presence/absence of comminution on the medial or posterior cortex, and reduction quality were factors influencing the probability of achieving fracture healing within the first 6 months after injury (p<0.05).

CONCLUSIONS

Radiological union of displaced pediatric FNFs treated surgically increases linearly during the first six month after surgery and then it tends to plateau. Risk factors for nonunion are severe initial displacement, poor reduction quality and the presence of comminuted medial or posterior cortex on AP or lateral radiographs; the same factors are associated with a longer time to achieve fracture healing.

LEVEL OF EVIDENCE

III.

Mechanical effects of surgical variations in the femoral neck system on Pauwels type III femoral neck fracture : a finite element analysis

AIMS

In this study, we aimed to explore surgical variations in the Femoral Neck System (FNS) used for stable fixation of Pauwels type III femoral neck fractures.

METHODS

Finite element models were established with surgical variations in the distance between the implant tip and subchondral bone, the gap between the plate and lateral femoral cortex, and inferior implant positioning. The models were subjected to physiological load.

RESULTS

Under a load of single-leg stance, Pauwels type III femoral neck fractures fixed with 10 mm shorter bolts revealed a 7% increase of the interfragmentary gap. The interfragmentary sliding, compressive, and shear stress remained similar to models with bolt tips positioned close to the subchondral bone. Inferior positioning of FNS provided a similar interfragmentary distance, but with 6% increase of the interfragmentary sliding distance compared to central positioning of bolts. Inferior positioning resulted in a one-third increase in interfragmentary compressive and shear stress. A 5 mm gap placed between the diaphysis and plate provided stability comparable to standard fixation, with a 7% decrease of interfragmentary gap and sliding distance, but similar compressive and shear stress.

CONCLUSION

Finite element analysis with FNS on Pauwels type III femoral neck fractures revealed that placement of the bolt tip close to subchondral bone provides increased stability. Inferior positioning of FNS bolt increased interfragmentary sliding distance, compressive, and shear stress. The comparable stability of the fixation model with the standard model suggests that a 5 mm gap placed between the plate and diaphysis could viably adjust the depth of the bolt. Cite this article: Bone Joint Res 2022;11(2):102-111.

Long-term outcomes of distal locking in extracapsular fractures treated with trochanteric Gamma3 nails

BACKGROUND

Few publications have assessed long-term results of distal locking of short endomedullary nails for extracapsular hip fracture. Virtually all of them focus on immediate differences. Criteria for the use of static or dynamic locking are unclear in most nailing systems, and use is advised in unstable fracture patterns or with risk of bell-clapper effect, but often influenced by the "orthopaedic school".

MATERIALS AND METHODS

This is a historical cohort study on patients diagnosed and operated in 2014 and followed up until endpoint, considered as consolidation or major complication, plus evaluation of overall long-term survival. They were categorised as static distal locking (ST) or dynamic distal locking (DN). Both are comparable, except for all stable pre-operative classifications, Fracture Mobility Score (FMS) at discharge, and immediate post-operative loading, all of which were in favour of DN.

RESULTS

Consolidation took place in > 95% of patients, with a non-statistically significant delay trend in ST. Less than 6% in both ST and DN had major complications, with no differences. Most cases suffered early cut-out. Significant fracture collapse was the most frequent minor complication. There were more statistically significant minor and total complications in ST. Infection, without differences, can precede cut-out. Lateral thigh pain was similar and could be related to back-out. In DN, 21.1% of cases were truly dynamised. We did not find differences in mobility or in long-term survival.

CONCLUSIONS

Any type of distal locking seems to be safe for consolidation, despite a slightly longer consolidation time in static locking. Early cut-out was the main complication, while others were very infrequent, which is an advantage over helical blade devices. There was a higher rate of minor and overall mechanical complications in ST, but infection and lateral thigh pain were similar. Most non-traumatic mechanical complications occurred around 5-6 weeks. About one in five of the DN truly dynamised, with all cases occurring before 8 weeks. Mobility until endpoint and overall long-term survival were not influenced by the locking mode used.

LEVEL OF EVIDENCE

Therapeutic study, level 2b.

Parallel and non-parallel cannulated screw fixation complications in femoral neck fractures: A systematic review and meta-analysis

BACKGROUND

Since its introduction in the early 1960s, the multiple cannulated screw fixation method has been developed for use in femoral neck fractures (FNFs); however, the parallelism of screws remains controversial.

MATERIALS AND METHODS

MEDLINE, Embase, and the Cochrane Library were systematically searched for studies published before June 2, 2020, that compared the use of parallel and non-parallel screw fixation for the treatment of FNF. The pooled analysis was designed to identify differences between the two groups and focused on postoperative complications, including fracture nonunion and osteonecrosis of the femoral head (ONFH).

RESULTS

Over four studies, we enrolled 445 patients, including 195 patients with fixed FNF with parallel trajectory screws and 250 patients with fixed FNF with non-parallel screws. The pooled analysis showed no difference in the nonunion rates (odds ratio (OR)=0.91; 95% confidence interval (CI), 0.24-3.44; p=0.89) and no significant difference in the incidence of ONFH between parallel and non-parallel screw fixation (OR=0.74; 95% CI: 0.21-2.63; p=0.64).

CONCLUSIONS

The results of this meta-analysis reveal that screw parallelism in multiple cannulated screw fixation of FNF has no relationship with either the fracture nonunion rate or the incidence of postoperative ONFH.

LEVEL OF EVIDENCE

III; meta-analysis.

Cerclage cable augmentation does not increase stability of the fixation of intertrochanteric fractures. A biomechanical study

BACKGROUND

Intertrochanteric fractures with a posteromedial intermediate fragment are unstable because of the loss of medial support. Additional fixation with a cerclage is used in subtrochanteric fractures, but not in intertrochanteric fractures. The aim of this biomechanical study is to evaluate whether cerclage fixation improves stability of intertrochanteric fractures.

HYPOTHESIS

Our hypothesis is that the cerclage fixation of the intermediate fragment increases fixation stability of intertrochanteric fractures.

MATERIALS AND METHODS

Synthetic femora with intertrochanteric fractures (AO 31.A1.3) with a posteromedial fragment were fixed with a long gamma nail. The intermediate fragment was fixed with a cerclage cable. Four groups were compared: 1: no cable fixation; 2: anatomic reduction and cable fixation; 3: anatomic reduction and fixation of a fragment where its proximal part was removed simulating comminution; 4: non-anatomic reduction and cable fixation. The specimens were loaded axially in a testing machine. The preload was 100N, followed by ten conditioning cycles from 100N to 500N. The test phase consisted of the cyclic loading between 100N and the maximum force that increased at a rate of 50N at each cycle until failure. The stiffness was calculated from the load/displacement curve of the last three conditioning cycles.

RESULTS

There were no statistically significant differences between force to failure (group 1: 681N; group 2: 846N; group 3: 699N; group 4: 806N; ANOVA p=0.23) and stiffness (group 1: 769N/mm; group 2: 819N/mm; group 3: 815N/mm; group 4: 810N/mm; ANOVA p=0.84) between groups. There were significant differences in the widening of the lag screw canal (group 1: 2.16mm; group 2: 4.5mm; group 3: 3mm; group 4: 2.5mm; ANOVA p=0.017). In individual comparison, the differences were significant only between the anatomical reduction group and the non-anatomical reduction (p=0.04) and the no cable group (p=0.02).

DISCUSSION

There is a controversy in clinical literature whether cable fixation improves treatment outcome of proximal femoral fractures. This study suggests that medial wall reconstruction with a cerclage cable does not improve axial stability of the fixation.

LEVEL OF EVIDENCE

Not applicable; a biomechanical study.

Improved control over implant anchorage under the use of the femoral neck system for fixation of femoral neck fractures: a technical note

Background

The depth of bolt in Femoral neck system (FNS, DePuy Synthes, Oberdorf, Switzerland) is difficult to finely control as the length of the bolt is in units of 5 mm. Thus, this study introduces a method to control the depth of FNS bolt in analogue scale in patients with femoral neck fracture.

Methods

By the technique of control of reaming and retraction of bolt, the tip of implant could be positioned close to subchondral bone without harming it. The position of implant tip in four cases in which the introduced technique was applied was compared to that of eight cases where the standard technique was performed.

Results

The average tip-apex distance measured in the cases that underwent surgery using the suggested technique in this study was statistically significantly shorter than that measured in the cases that underwent surgery under manufacturer guidelines.

Conclusion

Even though the bolt of FNS is manufactured in the unit of 5 mm, the technique proposed in this study helps surgeons to adjust the depth of bolt for the fixation of femoral neck fracture using FNS.

Design and biomechanical study of slide-poking external fixator for hip fracture

Background

Femoral head collapse and coxa vara lead to internal fixator failure in elderly patients with hip fracture. External fixator application is an optimal choice; however, the existing methods have many disadvantages.

Methods

Type 31-A1.3 hip fracture models were developed in nine pairs of 1-year-old fresh bovine corpse femur specimens. Each left femur specimen was fixed by a dynamic hip screw (control group), and each right femur specimen was fixed by the slide-poking external fixator (experimental group). Vertical loading and torsion tests were then performed in both groups.

Results

In the vertical loading experiment, a 1000-N load was implemented. The mean vertical downward displacement of the femoral head in the experimental and control groups was 1.49322 ± 0.116280 and 2.13656 ± 0.166374 mm, respectively. In the torsion experiment, when the torsion was increased to 10.0 Nm, the mean torsion angle in the experimental and control groups was 7.9733° ± 1.65704° and 15.4889° ± 0.73228°, respectively. The slide-poking external fixator was significantly more resistant to compression and rotation than the dynamic hip screw.

Conclusion

The slide-poking external fixator for hip fractures that was designed and developed in this study can provide sufficient stability to resist compression and rotation in hip fractures.

The V-effect in fixation of intertrochanteric fractures with proximal femoral nails

INTRODUCTION

Although one of the optimal treatment methods for fixing intertrochanteric femur fractures (ITFF) is the proximal femoral nail (PFN) that still has some complications, during implantation of PFN, there might be a V-effect on the trochanteric fracture line, which leads to hinging from the inferior of the femoral neck of the fracture and consequently, fixation of the hip in a varus position. The aim of this study was to identify the causes of the V-effect, and possible preventative solutions.

HYPOTHESIS

The V-effect is seen at a considerable rate and is an important iatrogenic complication with a high re-operation rate.

MATERIAL AND METHODS

A retrospective review of ITFFs treated with PFN was conducted. Fractures were classified from the injury films using the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association (AO/OTA) classification, and quality of reduction, rate of complication and re-operation, and the V-effect was evaluated on the initial postoperative films.

RESULTS

A total of 667 patients met the inclusion criteria. The overall rate of complications was 19.8% and re-operation was 5.1%. According to the AO/OTA fracture classification, 393 (58.9%) fractures were stable, and 274 (41.1%) were unstable. The reduction was good in 538 patients (80.7%), acceptable in 14 (2.1%) and poor in 115 (17.2%) patients. The V-effect was detected in 9.4% (n=63) of all patients, and re-operation was required in 19.1% (n=12) of these.

DISCUSSION

The V-effect is an iatrogenic complication during fixation of ITFF with PFN. To avoid complications of the V-effect, either constant anatomic reduction should be provided during and before implantation of PFN, or a more suitable instrument should be selected.

LEVEL OF EVIDENCE

III; retrospective study.

The effect of medullary fill on varus collapse in AO 31A3 intertrochanteric (reverse obliquity) fracture treated with cephalomedullary nails

OBJECTIVE

Cephalomedullary nails are tools commonly used for surgical fixation in proximal femoral fractures. The most common complications in their use are varus collapse and screw cutout of the femoral head. The objective of this study is to examine the effects of intramedullary nail movement on varus collapse and screw cutout.

MATERIALS AND METHODS

The study was conducted on 70 composite femur models treated with PFNA. We divided the femurs into 4 groups based on the differences in nail diameter, fracture type and filling of the distal intramedullary area. All femurs were exposed to axial cyclic loading. Each femur was examined in terms of intramedullary nail movement and amount of erosions in femoral medulla [amount of erosion in femoral head (FT distance), amount of erosion in femoral neck (FB distance), amount of erosion in trochanteric major (TB distance) and expansion of trochanter tip (TT distance)].

RESULTS

We found that degree of nail movement in the intramedullary region was inversely correlated with nail diameter and directly correlated with instability of fracture. One of the parameters used to evaluate varus development, FB distance, was affected by the degree of intramedullary nail movement and fracture type. TB distance was affected by nail diameter.

CONCLUSIONS

Nail diameter and fracture type are effective in intramedullary nail movement. Varus collapse progress is accelerated by the increase in nail movement in the intramedullary region. Thus, we conclude that it is important to strengthen diaphyseal adherence, which decreases intramedullary movement of the nail.

LEVEL OF EVIDENCE

III; well-design case control study.

Titania-Containing Bone Cement Shows Excellent Osteoconductivity in a Synovial Fluid Environment and Bone-Bonding Strength in Osteoporosis

Titania bone cement (TBC) reportedly has excellent in vivo bioactivity, yet its osteoconductivity in synovial fluid environments and bone-bonding ability in osteoporosis have not previously been investigated. We aimed to compare the osteoconductivity of two types of cement in a synovial fluid environment and determine their bone-bonding ability in osteoporosis. We implanted TBC and commercial polymethylmethacrylate bone cement (PBC) into rabbit femoral condyles and exposed them to synovial fluid pressure. Rabbits were then euthanized at 6, 12, and 26 weeks, and affinity indices were measured to evaluate osteoconductivity. We generated a rabbit model of osteoporosis through bilateral ovariectomy (OVX) and an 8-week treatment with methylprednisolone sodium succinate (PSL). Pre-hardened TBC and PBC were implanted into the femoral diaphysis of the rabbits in the sham control and OVX + PSL groups. Affinity indices were significantly higher for TBC than for PBC at 12 weeks (40.9 ± 16.8% versus 24.5 ± 9.02%) and 26 weeks (40.2 ± 12.7% versus 21.2 ± 14.2%). The interfacial shear strength was significantly higher for TBC than for PBC at 6 weeks (3.69 ± 1.89 N/mm² versus 1.71 ± 1.23 N/mm²) in the OVX + PSL group. These results indicate that TBC is a promising bioactive bone cement for prosthesis fixation in total knee arthroplasty, especially for osteoporosis patients.

MODERN ASPECTS OF THE PROBLEM OF FRACTURES OF THE PROXIMAL FEMULAR

The purpose of the study is to study the current global clinical and epidemiological features of proximal hip fractures and the risks of their development and spread. The paper identifies the main aspects of the spread and treatment of fractures of the proximal femur; main world modern epidemiological characteristics of hip fractures and levels of risks of their development and spread. The relationship between comorbidities in patients with proximal hip fractures and the risk of various treatment complications is shown. The main types of treatment tactics are identified, the groups of the most common comorbidities in such patients are given. As a result of the work it was established: the percentage of fractures of the proximal thigh is 9.00–45.00 % among all skeletal fractures in the older age group and among all age categories – 17.00–24.00 %; global annual morbidity is 1.7 million people, and mortality – 11.00–23.00 % in 6 months and 22.00–29.00 % in a year; increase in the frequency of these fractures with age with doubling after 50 years every ten years; average age of patients – 75–79 years; predominance of women over men in 2-3 times; the lowest annual age-standardized cases among women are in Nigeria, South Africa, Tunisia and Ecuador, and the highest are in Denmark, Norway, Sweden and Austria, which is also typical for men; significant economic burden of treatment and high levels of fractures with osteoporosis, cardiovascular disease, diabetes, chronic obstructive pulmonary disease and more; the advantage of surgical treatment over conservative.