Management of unstable pertrochanteric fractures, evaluation of forgotten treatment options

Angle-Adjustable Dynamic Hip Screw Plate for Unstable Trochanteric Fractures in Middle-Aged Patients: Mid-Term Outcomes and Return to Sport

BACKGROUND

There are conflicting results in the literature regarding the superiority of proximal femoral nails over dynamic hip screw (DHS) plates. The primary aim of this study is to evaluate mid-term post-injury patient-reported outcome measures (PROMs) and return to sport (RTS) in middle-aged patients treated with the DHS plate for unstable trochanteric fractures.

METHODS

Fifty-seven middle-aged patients (35-64 years) treated for proximal femoral fractures of type 31-A2 and 31-A3 according to the AO/OTA classification with the DMS Dynamic Martin Screw (KLS Martin Group, Jacksonville, FL, USA) between January 2017 and December 2019 were enrolled.

RESULTS

Forty-nine patients were included in this retrospective study, and the average age was 54.1 years (SD 8.4). The average follow-up duration at final follow-up was 60.5 months (SD 8.6). Post-operative complications included only one case of aseptic loosening of the implant, with a complication rate of 2%. There were no infections, peri-implant fractures, or other complications reported. Two out of the forty-nine patients (4.1%) required treatment with a total hip arthroplasty due to post-traumatic arthritis. The Harris Hip Score at final follow-up was 77.1 (SD 20.1), and the Western Ontario and McMaster Universities Osteoarthritis Index was 21.6 (SD 13.7). The overall rate of RTS was 57.7%.

CONCLUSIONS

Treatment with DHS for unstable trochanteric fractures is a safe option in middle-aged patients, ensuring a good functional recovery.

Proposal of a modified tip apex distance for prediction of lag screw cut-out in trochanteric hip fractures

INTRODUCTION

Lag screw cut-out is a serious complication of dynamic hip screw fixation of trochanteric hip fractures. The lag screw position has been acknowledged as one of the important factors affecting the lag screw cut-out. We propose a modification of the Tip Apex Distance (TAD) and hypothesise that it could improve the reliability of predicting lag screws cut-out in these injuries.

MATERIALS AND METHODS

A retrospective study was conducted for hip fracture entries in the period from Jan 2018 to July 2022. A hundred and nine patients were suitable for the final analysis. The modified TAD was measured in millimetres based on the sum of the traditional TAD in the lateral view and the net value of two distances in the AP view, the first distance is from the tip of the lag screw to the opposite point on the femoral head along the axis of the lag screw while the second distance is from that point to the femoral head apex. The first distance is a positive value, whereas the second distance is positive if the lag screw is superior and negative if inferior. A receiver operating characteristic curve was used to evaluate the reliability of the different parameters assessing the lag screw position within the femoral head.

RESULTS

Reduction quality, fracture pattern as per the AO/OTA classification, TAD, Calcar Referenced TAD, Axis Blade Angle, Parker's ration in the AP view, Cleveland Zone 1, and modified TAD were statistically associated with lag screw cut-out. Among the tested parameters, the modified TAD had 90.1% sensitivity and 90.9% specificity for lag screw cut-out at a cut-off value of 25 mm with a P-value < 0.001.

CONCLUSION

The modified TAD had the highest reliability in the prediction of lag screw cut-out. A value ≤ 25 mm could potentially protect against lag screw cut-out in trochanteric hip fractures.

Prospective Comparative Study Between Proximal Femoral Nail vs. Screw Augmented Proximal Femoral Nail in Unstable Intertrochanteric Fractures of Femur

Introduction The proximal femoral nail (PFN) is a widely accepted fixation method for the management of unstable intertrochanteric fractures. Reconstructing the lateral trochanteric wall and ensuring the stability of the trochanteric fragments are considered to be essential for enhancing the prognosis of unstable intertrochanteric fractures. The aim of this study is to evaluate and compare the results of the management of unstable intertrochanteric fracture of the femur using PFN and the screw-augmented PFN (aPFN). Methods This prospective comparative study was undertaken from January 2020 to July 2021 and included 60 patients presenting with unstable intertrochanteric fractures (AO/OTA type 31-A2.2 and 31-A2.3) at a tertiary care teaching institute in northern India. The enrolled patients were randomly divided into two groups (group 1 and group 2) and were managed with screw-augmented PFN and PFN, respectively. Functional outcome was evaluated using the Salvati and Wilson score at the 12-month follow-up. SPSS version 24.0 (IBM Corp., Armonk, NY, USA) was used for statistical analysis. A p-value less than 0.05 was regarded as significant. Results The average time to union of the fractures in group 1 was 12.66 ± 1.68 weeks, while it was 13.47 ± 1.47 weeks in group 2 (p = 0.055). At the 12-month follow-up, the average functional outcome, as evaluated by Salvati and Wilson score, was 34 ± 2.40 in group 1, whereas it was 31.58 ± 4.4 in group 2; and the difference was observed to be statistically significant (p = 0.011). Group 1 had 28 patients (93.33%) with excellent to good results, while group 2 had 25 patients (83.33%) with excellent to good results. One patient in group 1 and five patients in group 2 had poor outcomes at the 12-month follow-up. Conclusion Screw-augmented PFN has better functional outcomes as compared to PFN alone for the management of unstable intertrochanteric fractures. Hence, in our opinion, screw augmentation of PFN may be the better fixation technique for most unstable intertrochanteric femur fractures.

Early mobilisation after pain relief for conservative management for intertrochanteric fractures: a pandemic enforced innovation and its results

BACKGROUND

The COVID pandemic challenged the orthopaedic mind on several fronts. 1 of them was in the management of intertrochanteric fractures. A subset of these patients refused surgical intervention during the pandemic for related reasons. Faced with the goal of early verticalisation, the senior author used pain relief as a method to facilitate early mobilisation in 23 patients with peritrochanteric fractures.

METHODS

23 patients with stable intertrochanteric fractures received a β 6 distal sodium channel block (DSCB) and were allowed to walk from day 1 without surgery, traction or spica. The goal was to prevent complications of recumbency in this subset of patients. The basic idea of immediate mobilisation from the time of fracture was based on Sarmiento's sausage theory.

RESULTS

All the fractures united. There were no major complications. No shortening was seen in more than 50% cases and the shortening did not exceed 2 cm in any case. All patients were satisfied with the outcome and had good to excellent Harris Hip Scores.

CONCLUSIONS

The block and walk method is a surprisingly satisfactory method of treatment for stable intertrochanteric fractures. It circumvents the risks of surgery whilst allowing immediate mobilisation preventing complications associated with the other modalities of fracture management.

Functional Symmetry after Surgical Treatment of Pertrochanteric Fractures in the Elderly

Pertrochanteric fractures (PFs) in the elderly and their consequences are among the leading causes of disability; they significantly reduce the quality of life and lead to loss of independence. This article aims to determine the functional and radiological outcomes in a group of patients with PFs treated with either the Dynamic hip screw (DHS) or intramedullary Gamma nail fixation. A total of 618 patients, admitted to hospital for pertrochanteric fractures between 2015 and 2019, at a mean age of 82.40 (range 29–104) were screened. Finally, 78 patients were enrolled. Parameters related to hospital stay and surgery (length of hospital stay, surgery duration) were compared in both groups. Functional outcomes were assessed by the Harris hip score, subjective pain was measured with a visual analogue scale (VAS), and quality of life was evaluated using the EQ-5D-5L questionnaire. The obtained results were evaluated at 3- and 6-month follow-up. Radiographic parameters were measured based on the preoperative and postoperative standing anterior–posterior pelvic radiographs and axial projection of the hip at 6-month follow-up. The results showed no significant difference between groups treated either with DHS or intramedullary Gamma nail fixation within the scope of the variables under study. In conclusion, both analysed methods support the functional symmetry of the musculoskeletal system.

Trochanteric stabilizing plate in the treatment of trochanteric fractures: a scoping review

Background and purpose - The trochanteric stabilizing plate (TSP) may be used as an adjunct to a sliding hip screw (SHS) in the treatment of trochanteric fractures to increase construct stability. We performed a scoping review of the literature to clarify when and how the TSP may be useful.Methods - A systematic search was performed in 5 databases and followed by a backwards-and-forwards citation search of the identified papers. 24 studies were included.Results - 6 biomechanical studies and 18 clinical studies were included in the review. The studies presented mainly low-level evidence. All studies were on unstable trochanteric fractures or fracture models. Due to the heterogeneity of methods and reporting, we were not able to perform a meta-analysis. In the biomechanical trials, the TSP appeared to increase stability compared with SHS alone, up to a level comparable with intramedullary nails (IMNs). We identified 1,091 clinical cases in the literature where a TSP had been used. There were 82 (8%) reoperations. The rate of complications and reoperations for SHS plus TSP was similar to previous reports on SHS alone and IMN. It was not possible to conclude whether the TSP gave better clinical results, when compared with either SHS alone or with IMN.Interpretation - The heterogeneity of methods and reporting precluded any clear recommendations on when to use the TSP, or if it should be used at all.

Selection of internal fixation method for femoral intertrochanteric fractures using a finite element method

BACKGROUND

Failure to fix unstable intertrochanteric fractures impairs return to daily activities.

AIM

To simulate five different internal fixation methods for unstable proximal femoral fractures.

METHODS

A three-dimensional model of the femur was established from sectional computed tomography images, and an internal fixation model was established. Finite element analysis of the femur model was established, and three intertrochanteric fracture models, medial defect, lateral defect, and medial-lateral defects, were simulated. Displacement and stress distribution after fixation with a proximal femoral anti-rotation intramedullary nail (PFNA), integrated dual-screw fixation (ITN), PFNA + wire, PFNA + plate, and PFNA + wire + plate were compared during daily activities.

RESULTS

The maximum displacement and stress of PFNA and ITN were 3.51 mm/473 MPa and 2.80 mm/588 MPa for medial defects; 2.55 mm/288 MPa and 2.10 mm/307 MPa for lateral defects; and 3.84 mm/653 MPa and 3.44 mm/641 MPa for medial-lateral defects, respectively. For medial-lateral defects, reconstructing the medial side alone changed the maximum displacement and stress to 2.79 mm/515 MPa; reconstructing the lateral side changed them to 3.72 mm/608 MPa, when both sides were reconstructed, they changed to 2.42 mm/309 MPa.

CONCLUSION

For medial defects, intramedullary fixation would allow early low-intensity rehabilitation exercise, and ITN rather than PFNA reduces the risk of varus and cut-out; for lateral wall defects or weakness, intramedullary fixation allows higher-intensity rehabilitation exercise, and ITN reduces the risk of varus. For both medial and lateral defects, intramedullary fixation alone will not allow early functional exercise, but locating lateral or medial reconstruction will. For defects in both the inner and outer sides, if reconstruction cannot be completed, ITN is more stable.

Use of a Double Reverse Traction Repositor versus a Traction Table for the Treatment of Intertrochanteric Femur Fractures: A Comparative Study

OBJECTIVE

The aim of the present study was to compare the clinical results for unstable femoral intertrochanteric fractures treated with a double reverse traction repositor (DRTR) and those treated using a traction table with the Asia proximal femoral nail antirotation (PFNA-II).

METHODS

A retrospective study was performed including 95 patients with AO/OTA type 31-A2 and 31-A3 unstable femoral intertrochanteric fractures who underwent DRTR or traction table-facilitated PFNA-II nailing from April 2015 to December 2018 in our traumatic center. Demographics, duration of operation, blood loss, part loading time after surgery, fracture healing time, and early and late complications were assessed. Clinical and radiological outcomes were collected to compare the differences between the two groups.

RESULTS

A total of 95 unstable intertrochanteric fracture patients treated with the PFNA-II were analyzed. Of these cases, 56 patients were treated with a DRTR and the other 39 patients were treated using a traction table to achieve fracture reduction. No patients died during surgery and hospitalization. There were no significant differences in respect to demographics and fracture characteristics of cases enrolled. The total operative time was significantly longer in the traction table group than in the DRTR group (72.5 ± 6.1 min for the traction table and 63.0 ± 4.1 min for the DRTR group, P < 0.001). No significant differences were observed in intraoperative blood loss and duration of hospitalization. The periods of follow up ranged from 12 to 31 months among all patients. At the last follow up, the Harris hip score (HHS) in the DRTR group was excellent in 10 patients (17.9%), good in 36 (64.3%), fair in 8 (14.3%), and poor in 2 (3.6%). These scores were comparable to those in the traction table group, which were: excellent in 8 patients (20.5%), good in 24 (61.5%), fair in 6 (15.4%), and poor in 1 (2.6%). Regarding the radiological evaluation, excellent rates of reduction rate were achieved in 39 cases (69.6%) in the DRTR group, which was comparable to 19 cases (48.7%) in the traction table group. In addition, the mean fracture healing time after surgery was 20.6 ± 2.3 weeks in the DRTR group and 21.4 ± 3.4 weeks in the traction table group, which did not reach a significant difference (P = 0.18). During the follow up, 6 cases of thigh pain, 4 cases of deep vein thrombosis, and 1 case of fracture of the anterior superior iliac spine were reported in the DRTR group. In the traction table group, there were 2 cases of deep vein thrombosis and 3 cases of thigh pain.

CONCLUSION

When using the PFNA-II for unstable intertrochanteric fractures, the DRTR was superior to the traction table in respect to operative time and duration of patient position, despite an additional ipsilateral anterior superior iliac spine (ASIS) incision and drilling of the ASIS and the femur condyle.

Cephalo-medullary nailing versus dynamic hip screw with trochanteric stabilisation plate for the treatment of unstable per-trochanteric hip fractures: a meta-analysis

Background

The use of cephalo-medullary nails (CMN) is a widely accepted management option for the treatment of unstable per-trochanteric hip fractures. A growing body of literature has reported good functional and radiological outcomes in patients managed with a dynamic hip screw supplemented with a trochanteric stabilisation plate (DHS w/ TSP). However, a robust meta-analysis does not exist in the current literature comparing the two fixation methods.

Purposes

Management of these kinds of injuries is very challenging in orthopaedic practice, yet no strong evidence is in place to delineate which implant gives the best results. This meta-analysis is the first to determine the efficacy of CMN versus DHS w/ TSP.

Methods

An up-to-date literature search was performed using a predetermined search strategy and eligibility criteria. All suitable literature was appraised for methodological quality using the Cochrane’s collaboration tool. Hospital stay, operative time, intra-operative complication rate, mechanical failure rate, infection rates, revision rates and functional outcomes were all considered.

Results

A total of five studies were included in the meta-analysis. The results of this analysis suggest that CMN is only associated with lower revision rates when compared to DHS w/ TSP; however, no significant difference was found in terms of hospital stay, operative time, blood transfusion, complications rate and functional outcome.

Conclusion

Both CMN and DHS w/TSP proved to be reliable in the management of unstable per-trochanteric fractures; however, more extensive datasets are required to draw robust conclusions.