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Chen B, Li S, Zeng F, Duan H, Lu M. The effect of two surgical modalities for the treatment of subtrochanteric fractures of the femur on postoperative wound complications in patients: A meta-analysis. Int Wound J 2023; 21:e14421. [PMID: 37931601 PMCID: PMC10895200 DOI: 10.1111/iwj.14421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 09/16/2023] [Accepted: 09/19/2023] [Indexed: 11/08/2023] Open
Abstract
Currently, there are two methods of treating subtrochanteric femur fractures: intramedullary nailing and extramedullary plate fixation. However, it remains to be seen whether internal or external fixation is the primary treatment for subrotator femur fractures in adults. In this meta-analysis, we reviewed the effects of internal and external fixation on the treatment of subrotator and subrotator fractures. Until July 2023, the researchers have been researching the Cochrane Library, Embase, Web of Science and PubMed, with English as their only language. The aims of the study are as follows: (1) to assess the efficacy of internal and external fixation for the treatment of postoperative wound infections in adult patients with subrotator femur fractures; (2) to assess the efficacy of various types of internal fixation for the treatment of adult patients with subrotator femur fractures, including postoperative complications, infections, and operative time. Meta-analysis showed that there was no significant difference in the treatment of subrotator fracture with internal versus external fixation in terms of wound infections, intra-operative bleeding, length of incision, and operative time were not significantly different. Therefore, more research is needed to support these findings with a number of large, high-quality randomized studies.
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Affiliation(s)
- Baiyi Chen
- Department of Orthopaedics, The First Hospital of Hunan University of Chinese Medicine, Changsha, China
| | - Songlian Li
- Surgery of Traditional Chinese Medicine, The Second Hospital of Hunan University of Chinese Medicine, Changsha, China
| | - Fan Zeng
- Hunan University of Chinese Medicine, Changsha, China
| | - Hang Duan
- Hunan University of Chinese Medicine, Changsha, China
| | - Min Lu
- Department of Orthopaedics, The First Hospital of Hunan University of Chinese Medicine, Changsha, China
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Wang J, Jia H, Ma X, Ma J, Lu B, Bai H, Wang Y. Biomechanical Study of Intramedullary Versus Extramedullary Implants for Four Types of Subtrochanteric Femoral Fracture. Orthop Surg 2022; 14:1884-1891. [PMID: 35706129 PMCID: PMC9363741 DOI: 10.1111/os.13364] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 05/13/2022] [Accepted: 05/20/2022] [Indexed: 11/30/2022] Open
Abstract
Objectives To compare the biomechanical performance of proximal femoral nail anti‐rotation (PFNA), the “upside‐down” less invasive plating system (LISS), and proximal femoral locking plate (PFLP) in fixing different fracture models of subtrochanteric fractures. Methods Thirty composite femurs were divided into three equal groups (PFNA, PFLP, and reverse LISS). The implant‐femur constructs were tested under axial compression load (0–1400 N) from models I to IV, which represented the Seinsheimer type I subtrochanteric fracture, type IIIa subtrochanteric fracture with the posteromedial fragment reduced; type IIIa subtrochanteric fracture with the posteromedial fragment lost; and type IV subtrochanteric fracture, respectively. Axial stiffness was analyzed for each group. Each group was then divided into two subgroups, one of which underwent torsional and axial compression failure testing, while the other subgroup underwent axial compression fatigue testing. The torsional stiffness, failure load, and cycles to failure were analyzed. Results PFNA had the highest axial stiffness (F = 761.265, p < 0.0001) and failure load (F = 48.801, p < 0.0001) in model IV. The axial stiffness and failure load of the PFLP were significantly higher than those of the LISS (p < 0.0001, p = 0.001). However, no significant difference in axial stiffness was found between models I to III (model I: F = 2.439, p = 0.106; model II: F = 2.745, p = 0.082; model III: F = 0.852, p = 0.438) or torsional stiffness in model IV (F = 1.784, p = 0.187). In fatigue testing, PFNA did not suffer from construct failure after 90,000 cycles of axial compression. PFLP and LISS were damaged within 14,000 cycles, although LISS withstood more cycles than PFLP (t = 3.328, p = 0.01). Conclusion The axial stiffness of the three implants was similar in models I to III. The biomechanical properties of PFNA were the best of the three implants in terms of axial stiffness, failure load, and fatigue testing cycles in model IV. The axial stiffness and failure load of the PFLP were better than those of the reverse LISS, but PFLP had fewer cycles in the fatigue tests than the reverse LISS.
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Affiliation(s)
- Jie Wang
- Department of Orthopaedics, Tianjin Hospital, Tianjin, China
| | - Haobo Jia
- Department of Orthopaedics, Tianjin Hospital, Tianjin, China
| | - Xinlong Ma
- Department of Orthopaedics, Tianjin Hospital, Tianjin, China.,Department of Orthopaedics Institute, Tianjin Hospital, Tianjin, China
| | - Jianxiong Ma
- Department of Orthopaedics Institute, Tianjin Hospital, Tianjin, China
| | - Bin Lu
- Department of Orthopaedics Institute, Tianjin Hospital, Tianjin, China
| | - Haohao Bai
- Department of Orthopaedics Institute, Tianjin Hospital, Tianjin, China
| | - Ying Wang
- Department of Orthopaedics Institute, Tianjin Hospital, Tianjin, China
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Lewis SR, Macey R, Lewis J, Stokes J, Gill JR, Cook JA, Eardley WG, Parker MJ, Griffin XL. Surgical interventions for treating extracapsular hip fractures in older adults: a network meta-analysis. Cochrane Database Syst Rev 2022; 2:CD013405. [PMID: 35142366 PMCID: PMC8830342 DOI: 10.1002/14651858.cd013405.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Hip fractures are a major healthcare problem, presenting a challenge and burden to individuals and healthcare systems. The number of hip fractures globally is rising. The majority of extracapsular hip fractures are treated surgically. OBJECTIVES To assess the relative effects (benefits and harms) of all surgical treatments used in the management of extracapsular hip fractures in older adults, using a network meta-analysis of randomised trials, and to generate a hierarchy of interventions according to their outcomes. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, Web of Science and five other databases in July 2020. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs comparing different treatments for fragility extracapsular hip fractures in older adults. We included internal and external fixation, arthroplasties and non-operative treatment. We excluded studies of hip fractures with specific pathologies other than osteoporosis or resulting from high-energy trauma. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion. One review author completed data extraction which was checked by a second review author. We collected data for three outcomes at different time points: mortality and health-related quality of life (HRQoL) - both reported within 4 months, at 12 months and after 24 months of surgery, and unplanned return to theatre (at end of study follow-up). We performed a network meta-analysis (NMA) with Stata software, using frequentist methods, and calculated the differences between treatments using risk ratios (RRs) and standardised mean differences (SMDs) and their corresponding 95% confidence intervals (CIs). We also performed direct comparisons using the same codes. MAIN RESULTS We included 184 studies (160 RCTs and 24 quasi-RCTs) with 26,073 participants with 26,086 extracapsular hip fractures in the review. The mean age in most studies ranged from 60 to 93 years, and 69% were women. After discussion with clinical experts, we selected nine nodes that represented the best balance between clinical plausibility and efficiency of the networks: fixed angle plate (dynamic and static), cephalomedullary nail (short and long), condylocephalic nail, external fixation, hemiarthroplasty, total hip arthroplasty (THA) and non-operative treatment. Seventy-three studies (with 11,126 participants) with data for at least two of these treatments contributed to the NMA. We selected the dynamic fixed angle plate as a reference treatment against which other treatments were compared. This was a common treatment in the networks, providing a clinically appropriate comparison. We downgraded the certainty of the evidence for serious and very serious risks of bias, and because some of the estimates included the possibility of transitivity owing to the proportion of stable and unstable fractures between treatment comparisons. We also downgraded if we noted evidence of inconsistency in direct or indirect estimates from which the network estimate was derived. Most estimates included the possibility of benefits and harms, and we downgraded the evidence for these treatments for imprecision. Overall, 20.2% of participants who received the reference treatment had died by 12 months after surgery. We noted no evidence of any differences in mortality at this time point between the treatments compared. Effect estimates of all treatments included plausible benefits as well as harms. Short cephalomedullary nails had the narrowest confidence interval (CI), with 7 fewer deaths (26 fewer to 15 more) per 1000 participants, compared to the reference treatment (risk ratio (RR) 0.97, 95% CI 0.87 to 1.07). THA had the widest CI, with 62 fewer deaths (177 fewer to 610 more) per 1000 participants, compared to the reference treatment (RR 0.69, 95% CI 0.12 to 4.03). The certainty of the evidence for all treatments was low to very low. Although we ranked the treatments, this ranking should be interpreted cautiously because of the imprecision in all the network estimates for these treatments. Overall, 4.3% of participants who received the reference treatment had unplanned return to theatre. Compared to this treatment, we found very low-certainty evidence that 58 more participants (14 to 137 more) per 1000 participants returned to theatre if they were treated with a static fixed angle plate (RR 2.48, 95% CI 1.36 to 4.50), and 91 more participants (37 to 182 more) per 1000 participants returned to theatre if treated with a condylocephalic nail (RR 3.33, 95% CI 1.95 to 5.68). We also found that these treatments were ranked as having the highest probability of unplanned return to theatre. In the remaining treatments, we noted no evidence of any differences in unplanned return to theatre, with effect estimates including benefits as well as harms. The certainty of the evidence for these other treatments ranged from low to very low. We did not use GRADE to assess the certainty of the evidence for early mortality, but our findings were similar to those for 12-month mortality, with no evidence of any differences in treatments when compared to dynamic fixed angle plate. Very few studies reported HRQoL and we were unable to build networks from these studies and perform network meta-analysis. AUTHORS' CONCLUSIONS: Across the networks, we found that there was considerable variability in the ranking of each treatment such that there was no one outstanding, or subset of outstanding, superior treatments. However, static implants such as condylocephalic nails and static fixed angle plates did yield a higher risk of unplanned return to theatre. We had insufficient evidence to determine the effects of any treatments on HRQoL, and this review includes data for only two outcomes. More detailed pairwise comparisons of some of the included treatments are reported in other Cochrane Reviews in this series. Short cephalomedullary nails versus dynamic fixed angle plates contributed the most evidence to each network, and our findings indicate that there may be no difference between these treatments. These data included people with both stable and unstable extracapsular fractures. At this time, there are too few studies to draw any conclusions regarding the benefits or harms of arthroplasty or external fixation for extracapsular fracture in older adults. Future research could focus on the benefits and harms of arthroplasty interventions compared with internal fixation using a dynamic implant.
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Affiliation(s)
- Sharon R Lewis
- Bone and Joint Health, Blizard Institute, Queen Mary University of London, London, UK
| | - Richard Macey
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - Joseph Lewis
- c/o Bone and Joint Health, Blizard Institute, Queen Mary University of London, London, UK
| | - Jamie Stokes
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - James R Gill
- Department of Trauma and Orthopaedics, Cambridge University Hospitals, Cambridge, UK
| | - Jonathan A Cook
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - William Gp Eardley
- Department of Trauma and Orthopaedics, The James Cook University Hospital, Middlesbrough, UK
| | - Martyn J Parker
- Department of Orthopaedics, Peterborough and Stamford Hospitals NHS Foundation Trust, Peterborough, UK
| | - Xavier L Griffin
- Bone and Joint Health, Blizard Institute, Queen Mary University of London, London, UK
- Barts Health NHS Trust, London, UK
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Lewis SR, Macey R, Gill JR, Parker MJ, Griffin XL. Cephalomedullary nails versus extramedullary implants for extracapsular hip fractures in older adults. Cochrane Database Syst Rev 2022; 1:CD000093. [PMID: 35080771 PMCID: PMC8791231 DOI: 10.1002/14651858.cd000093.pub6] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Hip fractures are a major healthcare problem, presenting a substantial challenge and burden to patients, healthcare systems and society. The increased proportion of older adults in the world population means that the absolute number of hip fractures is rising rapidly across the globe. Most hip fractures are treated surgically. This Cochrane Review evaluates evidence for implants used to treat extracapsular hip fractures. OBJECTIVES To assess the relative effects of cephalomedullary nails versus extramedullary fixation implants for treating extracapsular hip fractures in older adults. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, Web of Science, the Cochrane Database of Systematic Reviews, Epistemonikos, ProQuest Dissertations & Theses, and the National Technical Information Service in July 2020. We also searched clinical trials databases, conference proceedings, reference lists of retrieved articles, and conducted backward-citation searches. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs comparing cephalomedullary nails with extramedullary implants for treating fragility extracapsular hip fractures in older adults. We excluded studies in which all or most fractures were caused by a high-energy trauma or specific pathologies other than osteoporosis. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. We collected data for seven critical outcomes: performance of activities of daily living (ADL), delirium, functional status, health-related quality of life, mobility, mortality (reported within four months of surgery as 'early mortality'; and reported from four months onwards, with priority given to data at 12 months, as '12 months since surgery'), and unplanned return to theatre for treating a complication resulting directly or indirectly from the primary procedure (such as deep infection or non-union). We assessed the certainty of the evidence for these outcomes using GRADE. MAIN RESULTS: We included 76 studies (66 RCTs, 10 quasi-RCTs) with a total of 10,979 participants with 10,988 extracapsular hip fractures. The mean ages of participants in the studies ranged from 54 to 85 years; 72% were women. Seventeen studies included unstable trochanteric fractures; three included stable trochanteric fractures only; one included only subtrochanteric fractures; and other studies included a mix of fracture types. More than half of the studies were conducted before 2010. Owing to limitations in the quality of reporting, we could not easily judge whether care pathways in these older studies were comparable to current standards of care. We downgraded the certainty of the outcomes because of high or unclear risk of bias; imprecision (when data were available from insufficient numbers of participants or the confidence interval (CI) was wide); and inconsistency (when we noted substantial levels of statistical heterogeneity or differences between findings when outcomes were reported using other measurement tools). There is probably little or no difference between cephalomedullary nails and extramedullary implants in terms of mortality within four months of surgery (risk ratio (RR) 0.96, 95% CI 0.79 to 1.18; 30 studies, 4603 participants) and at 12 months (RR 0.99, 95% CI 0.90 to 1.08; 47 studies, 7618 participants); this evidence was assessed to be of moderate certainty. We found low-certainty evidence for differences in unplanned return to theatre but this was imprecise and included clinically relevant benefits and harms (RR 1.15, 95% CI 0.89 to 1.50; 50 studies, 8398 participants). The effect estimate for functional status at four months also included clinically relevant benefits and harms; this evidence was derived from only two small studies and was imprecise (standardised mean difference (SMD) 0.02, 95% CI -0.27 to 0.30; 188 participants; low-certainty evidence). Similarly, the estimate for delirium was imprecise (RR 1.22, 95% CI 0.67 to 2.22; 5 studies, 1310 participants; low-certainty evidence). Mobility at four months was reported using different measures (such as the number of people with independent mobility or scores on a mobility scale); findings were not consistent between these measures and we could not be certain of the evidence for this outcome. We were also uncertain of the findings for performance in ADL at four months; we did not pool the data from four studies because of substantial heterogeneity. We found no data for health-related quality of life at four months. Using a cephalomedullary nail in preference to an extramedullary device saves one superficial infection per 303 patients (RR 0.71, 95% CI 0.53 to 0.96; 35 studies, 5087 participants; moderate-certainty evidence) and leads to fewer non-unions (RR 0.55, 95% CI 0.32 to 0.96; 40 studies, 4959 participants; moderate-certainty evidence). However, the risk of intraoperative implant-related fractures was greater with cephalomedullary nails (RR 2.94, 95% CI 1.65 to 5.24; 35 studies, 4872 participants; moderate-certainty evidence), as was the risk of later fractures (RR 3.62, 95% CI 2.07 to 6.33; 46 studies, 7021 participants; moderate-certainty evidence). Cephalomedullary nails caused one additional implant-related fracture per 67 participants. We noted no evidence of a difference in other adverse events related or unrelated to the implant, fracture or both. Subgroup analyses provided no evidence of differences between the length of cephalomedullary nail used, the stability of the fracture, or between newer and older designs of cephalomedullary nail. AUTHORS' CONCLUSIONS Extramedullary devices, most commonly the sliding hip screw, yield very similar functional outcomes to cephalomedullary devices in the management of extracapsular fragility hip fractures. There is a reduced risk of infection and non-union with cephalomedullary nails, however there is an increased risk of implant-related fracture that is not attenuated with newer designs. Few studies considered patient-relevant outcomes such as performance of activities of daily living, health-related quality of life, mobility, or delirium. This emphasises the need to include the core outcome set for hip fracture in future RCTs.
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Affiliation(s)
- Sharon R Lewis
- Bone and Joint Health, Blizard Institute, Queen Mary University of London, London, UK
| | - Richard Macey
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - James R Gill
- Department of Trauma and Orthopaedics, Cambridge University Hospitals, Cambridge, UK
| | - Martyn J Parker
- Department of Orthopaedics, Peterborough and Stamford Hospitals NHS Foundation Trust, Peterborough, UK
| | - Xavier L Griffin
- Bone and Joint Health, Blizard Institute, Queen Mary University of London, London, UK
- Barts Health NHS Trust, London, UK
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Patel I, Amin T, Kachhad K, Patel K, Senta A, Modi D, Kodiyatar A. Results of proximal femoral nailing in subtrochanteric fracture of femur in adults. JOURNAL OF ORTHOPAEDIC DISEASES AND TRAUMATOLOGY 2022. [DOI: 10.4103/jodp.jodp_4_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Trend and Economic Implications of Implant Selection in the Treatment of Intertrochanteric Hip Fractures: A Review of the American Board of Orthopaedic Surgery Database From 2007 to 2017. J Am Acad Orthop Surg 2021; 29:789-795. [PMID: 33999883 DOI: 10.5435/jaaos-d-20-00470] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 04/21/2021] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Intertrochanteric (IT) fractures are estimated to burden the healthcare system six billion dollars annually. Previous studies have documented a trend of early-career orthopaedic surgeons favoring intramedullary nails (IMNs) for these fractures, despite multiple randomized controlled trials demonstrating no evidence for improved patient outcomes when compared with sliding hip screws (SHSs). The purpose of this study was to report the trend of implant utilization for IT fracture fixation from 2007 to 2017. METHODS The American Board of Orthopaedic Surgery (ABOS) Part II (oral) database was used to identify IT fractures (International Classification of Diseases, 9th revision, code 820.21 or 820.31, and 10th revision, code S72.14) over a 10-year period (2007 to 2017). The cases were categorized by IMN or SHS fixation by surgeon-reported Current Procedural Terminology codes. Utilization of the devices was analyzed according to year, and the implants were compared for outcomes, complications, and cost. RESULTS As of 2017, 92.4% of IT fractures were being fixed through IMN, representing a 49.1% increase in the number of IMN devices used during the course of this study. SHS had significantly lower medical complication rate (21.3%) and readmittance rate (4.0%) compared with the IMN (medical complication: 26.9%; P < 0.01) (readmittance rate: 5.4%; P = 0.02). SHS also had significantly lower rates of anemia (5.2%) and patient expiration (4.8%) compared with IMN (anemia: 10.2%; P < 0.01) (patient expiration: 6.1%; P = 0.01). Overall surgical complication rates, reoperative rates, and anesthetic complications did not differ between constructs. A cost differential of $671,812 was found from the 2007-projected distribution, which rose to $3,911,211.00 across the entire 11-year duration of the study for the population. DISCUSSION Early-career orthopaedic surgeons continue to use a more expensive implant for IT fractures despite limited evidence for improved outcomes. LEVEL OF EVIDENCE Level III; Retrospective Cohort Study.
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Jitprapaikulsarn S, Gromprasit A, Sukha K, Patamamongkonchai C, Kritsaneephaiboon A. The utility of reverse distal femur locking compression plate in minimally invasive osteosynthesis for type C subtrochanteric fractures of the femur: technical description and a clinical series of 50 cases. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:1423-1433. [PMID: 34491445 DOI: 10.1007/s00590-021-03116-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 09/02/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Establishing fracture consolidation and avoiding postoperative complications of comminuted subtrochanteric fractures of the femur are technically challenging. The authors delineated a technical description of minimally invasive plate osteosynthesis (MIPO) by using a reverse distal femur locking compression plate (LCP-DF) and retrospectively reviewed the outcomes of these particular fractures. METHODS Fifty patients with 51 type C subtrochanteric fractures of the femur were operated on by MIPO and reverse LCP-DF fixation. The collected data included postoperative complications, union times, and clinical outcomes. RESULTS All fractures were united with a mean union time of 19.4 weeks (range 16-22). Regarding postoperative complications, asymptomatic valgus angulation occurred in five patients and trochanteric pain in six. According to Harris hip score, nine patients were determined to be excellent, 36 to be good and five to be fair. CONCLUSION MIPO by reverse LCP-DF is reliable and effective for type C subtrochanteric fractures of the femur particularly in situations where intramedullary nailing is not feasible.
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Affiliation(s)
- Surasak Jitprapaikulsarn
- Department of Orthopedics, Buddhachinaraj Hospital, 90 Srithamtraipidok Road, Phitsanulok, 65000, Thailand.
| | - Arthit Gromprasit
- Department of Orthopedics, Buddhachinaraj Hospital, 90 Srithamtraipidok Road, Phitsanulok, 65000, Thailand
| | - Kritsada Sukha
- Department of Orthopedics, Buddhachinaraj Hospital, 90 Srithamtraipidok Road, Phitsanulok, 65000, Thailand
| | - Chawanan Patamamongkonchai
- Department of Orthopedics, Buddhachinaraj Hospital, 90 Srithamtraipidok Road, Phitsanulok, 65000, Thailand
| | - Apipop Kritsaneephaiboon
- Department of Orthopedic Surgery and Physical Medicine, Prince of Songkla University, Songkla, Thailand
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Kang SJ, Bao FL, Huang DS, Jiang T, Hu YM, Li JM, Liu T. Percutaneous Cerclage Wiring Combined with Cephalomedullary Nailing for Irreducible Subtrochanteric Fractures. Orthop Surg 2021; 13:1899-1911. [PMID: 34435729 PMCID: PMC8523774 DOI: 10.1111/os.13144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 08/03/2021] [Accepted: 08/03/2021] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To explore the surgical method, operation essentials and the clinical effect of the treatment of irreducible subtrochanteric femoral fractures by percutaneous cerclage wiring and Cephalomedullary nail. METHOD From February 2016 to October 2019, 17 cases of irreducible subtrochanteric femoral fractures (SFFs) treated via a minimally invasive wire system and intramedullary nail fixation were reviewed retrospectively. Ten male and seven female patients were involved. The average age was 59.88 ± 16.13 years, ranging from 41 to 94 years. Among the patients, seven were injured in traffic accidents, five fell from a standing height, and five injured themselves from falling. The cases were classified based on the Seinsheimer classification. Specifically, five cases were type IIIA, five cases were type IIIB, one case was type IV, and six cases were type V. According to the AO/OTA classification, 10 cases were 32B3, and seven cases were 32C3. During surgery, the patients were placed on a traction bed andattempted closed reduction. For those patients whose closed reduction failed confirmed by fluoroscopy, we performed a small anterolateral incision through which a self-made minimally invasive percutaneous wire introducer (passer; patent Z: 2016 2 1002800.8) was employed for temporary fixation with a wire. A double-stranded steel wire was introduced into a self-made wire traction and lifting device (patent ZL 2020 2 0205658.7), the wire was pulled vertically and firmly fixed. Then an long InterTan nail was used for the fixation. The following information was recorded: (i) length of the invasive incision, (ii) blood loss on the third day after surgery, (iii) operation time; and (iv) maximum displacement and angulation of the fracture ends of the x-rayed front and side fractures before and after surgery and the maximum displacement and formation of the three-dimensional CT-scanned fracture ends in the coronal plane, sagittal plane, and cross section before and after surgery. RESULT A total of 15 of the 17 patients were followed for 12 to 24 months. The 15 patients recovered, but one died from pulmonary infection 1 year after surgery. In the postoperative X-ray and three-dimensional CT observation reduction treatment, fracture displacement was less than 5 mm, each plane angle was less than 10 degrees, and postoperative fracture healing time was 3 to 14 months, with an average of 4.19 ± 4.04 months. The postoperative Harris hip function score ranged from 66 to 95 points, with an average of 80.81 ± 9.67 points. In terms of clinical outcomes, 11 cases were excellent, four cases were satisfactory, and one case was fair. CONCLUSION For refractory subtrochanteric fractures, percutaneous wiring combined with Cephalomedullary nail fixation is a minimally invasive, rapid, and effective method, which can achieve satisfactory results in clinical practice and is worth promoting.
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Affiliation(s)
- Shi-Jie Kang
- Department of Orthopedic Surgery, Qilu Hospital of Shandong University, Qingdao, China
| | - Fei-Long Bao
- Department of Orthopedic Surgery, Qilu Hospital of Shandong University, Qingdao, China
| | - Dong-Sheng Huang
- Department of Orthopedic Surgery, Qilu Hospital of Shandong University, Qingdao, China
| | - Tao Jiang
- Department of Orthopedic Surgery, Qilu Hospital of Shandong University, Qingdao, China
| | - Yi-Ming Hu
- Department of Orthopedic Surgery, Qilu Hospital of Shandong University, Qingdao, China
| | - Jian-Min Li
- Department of Orthopedics, Qilu Hospital of Shandong University, Jinan, China
| | - Tao Liu
- Department of Orthopedic Surgery, Qilu Hospital of Shandong University, Qingdao, China
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9
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Müller-Mai CM, Deitert D, Hörter S, Schulze Raestrup US, Zwillich C, Smektala R. [Subtrochanteric femur fractures-epidemiology, surgical procedures, influence of time to surgery and comorbidities on complications : A risk-adjusted regression analysis of routine data from 2124 cases]. Chirurg 2021; 92:248-263. [PMID: 32564107 DOI: 10.1007/s00104-020-01221-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND There are approximately 12,000 subtrochanteric femur fractures in Germany per year with a rising trend but studies about the epidemiology and the surgical outcome are rare. Furthermore, there are no guidelines from expert societies and there is no adequate quality assurance. OBJECTIVE Presentation of the epidemiology and the current treatment situation with respect to the patient collective, comorbidities, time to surgery and surgical procedures used as well as the identification of modifiable risk factors with respect to complications. MATERIAL AND METHODS Analysis of routine data based on an established data model in 2124 cases. The descriptive statistics contain data on basic patient characteristics, such as age, comorbidities, surgical procedure, time to surgery and mortality. In the analytical statistics the impact of risk factors (surgical procedure, time to surgery etc.) on the endpoints mortality, complications and decubitus was investigated by logistical regression analyses. RESULTS Of the patients 55% were operated on within the first 24h. Intramedullary osteosynthesis (89%) is the most frequently used surgical method (prostheses 2%, extramedullary procedures 5%). Within the first postoperative year 37% of the patients received a higher level of care, where the care was moved from outpatient to inpatient treatment. The mortality in the first postoperative year was 26%, while early complications were observed in 6%. A delay in surgical treatment was associated with an increased mortality and intrinsic factors, which were difficult to influence. Intramedullary osteosynthesis had the lowest mortality and revision rates. CONCLUSION Concerning the epidemiological data, the patient collectives of subtrochanteric fractures and femoral neck or pertrochanteric fractures were very similar. Major delays in the time to surgery of subtrochanteric fractures can be associated with increased complication rates and mortality. Therefore, programs to prevent older patients from falling have a high priority.
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Affiliation(s)
- C M Müller-Mai
- Klinik für Unfallchirurgie, Orthopädie und Sportmedizin, Katholisches Klinikum Lünen, Altstadtstr. 23, 44534, Lünen, Deutschland.
- Klinik für Unfallchirurgie und Orthopädie, Versorgungsforschung, Universitätsklinikum Knappschaftskrankenhaus Bochum, Ruhr-Universität Bochum, Bochum, Deutschland.
| | - D Deitert
- Klinik Für Orthopädie und Unfallchirurgie, St. Vincenz-Krankenhaus Datteln, Datteln, Deutschland
| | - S Hörter
- Krankenversicherung Knappschaft-Bahn-See, Bochum, Deutschland
| | | | - C Zwillich
- Ärztekammer Westfalen-Lippe, Münster, Deutschland
| | - R Smektala
- Klinik für Unfallchirurgie und Orthopädie, Versorgungsforschung, Universitätsklinikum Knappschaftskrankenhaus Bochum, Ruhr-Universität Bochum, Bochum, Deutschland
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Arshad Z, Thahir A, Rawal J, Hull PD, Carrothers AD, Krkovic M, Chou DTS. Dynamic hip screw fixation of subtrochanteric femoral fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 31:1435-1441. [PMID: 33590318 PMCID: PMC8448703 DOI: 10.1007/s00590-021-02895-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 01/29/2021] [Indexed: 11/29/2022]
Abstract
Introduction A subtrochanteric proximal femur fracture occurs in the 5 cm of bone immediately distal to the lesser trochanter. UK national guidelines advise that adults with subtrochanteric fractures should be treated with an intramedullary nail (IMN). This study aims to compare peri-operative outcome measures of patients with subtrochanteric fractures treated with either an IMN or a dynamic hip screw (DHS) construct. Materials and Methods We retrospectively reviewed subtrochanteric fractures presenting at our institution over 4.5 years (October 2014–May 2019), classifying them into two treatment groups; IMN and DHS. These groups were compared on outcome measures including surgical time, blood loss, radiation dose area product (DAP), length of stay, re-operation rate and mortality. Results During the time period studied, 86 patients presented with a subtrochanteric fracture of the femur; with 74 patients (86%) receiving an IMN and 12 (14%) receiving a DHS. The comparative outcome measures reaching statistical significance were blood loss and radiation DAP. The DHS group showed a significantly lower mean blood loss of 776 ml compared to 1029 ml in the IMN group. Also, the DHS group showed a significantly lower mean DAP of 150.30 mGy cm2 compared to 288.86 mGy cm2 in the IMN group. Conclusion Although UK national guidelines recommend treating all subtrochanteric fractures with an IMN; the outcome measures assessed in our study did not show use of an IMN to be superior to a DHS. The DHS group showed a lower estimated blood loss and a reduced DAP. This, along with the reduced financial cost associated with a DHS, may support the use of DHS over IMN for certain subtrochanteric fractures of the femur. There may not be a single favourable implant for the treatment of subtrochanteric fractures as a whole; instead different subtypes of fracture may be amenable to a number of fixation devices. Choice of implant should be determined locally and based on existing and future clinical and health economic research.
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Affiliation(s)
- Zaki Arshad
- University of Cambridge School of Clinical Medicine, Box 111 Cambridge Biomedical Campus, Cambridge, CB2 0SP, UK.
| | - Azeem Thahir
- Cambridge Orthopaedic Trauma Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Jaikirty Rawal
- Cambridge Orthopaedic Trauma Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Peter D Hull
- Cambridge Orthopaedic Trauma Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Andrew D Carrothers
- Cambridge Orthopaedic Trauma Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Matija Krkovic
- Cambridge Orthopaedic Trauma Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
| | - Daud T S Chou
- Cambridge Orthopaedic Trauma Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK
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Cephalo-medullary nailing versus dynamic hip screw with trochanteric stabilisation plate for the treatment of unstable per-trochanteric hip fractures: a meta-analysis. J Orthop Surg Res 2021; 16:47. [PMID: 33430910 PMCID: PMC7802196 DOI: 10.1186/s13018-020-02193-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 12/28/2020] [Indexed: 01/01/2023] Open
Abstract
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.
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Wang J, Li H, Jia H, Ma X. Intramedullary versus extramedullary fixation in the treatment of subtrochanteric femur fractures: A comprehensive systematic review and meta-analysis. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2020; 54:639-646. [PMID: 33423999 DOI: 10.5152/j.aott.2020.19216] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This meta-analysis aimed to compare the clinical outcomes of intramedullary fixation with the extramedullary fixation in the surgical management of subtrochanteric fractures by analyzing relevant randomized controlled trials (RCTs) and retrospective cohort studies (RCSs). METHODS The PubMed, Embase, Cochrane Library, Wanfang database, and Chinese National Knowledge Infrastructure (CNKI) were searched from their inception till June 29, 2020. Two reviewers extracted the data, including operation time, intraoperative blood loss, fluoroscopy time, length of stay, union time, nonunion rate, infection rate, implant failure rate, reoperation rate, Harris hip score, and mortality rate. The Cochrane risk-of-bias tool and the Newcastle-Ottawa quality assessment scale were used to evaluate the methodological quality of RCTs and RCSs, respectively. Statistical heterogeneity was quantitatively evaluated with the I2 statistic. RESULTS There were no significant differences in operation time, intraoperative blood loss, average length of stay in hospital, infection rate, implant failure rate, Harris hip scores, and mortality rate. Intramedullary nail could achieve shorter union time (MD=-1.77, 95% CI -3.40~-0.14, p=0.03), lower nonunion rate (RR=0.36, 95%CI 0.14~0.97, p=0.04), and reoperation rate (RR=0.46, 95% CI 0.24~0.89, p=0.02) than extramedullary fixations. The subgroup analysis indicated that intramedullary nail was superior than extramedullary fixations in operation time, reoperation rate, and Harris hip scores in the ≥60-year subgroup. However, the intraoperative blood loss in intramedullary nail group was significantly higher than that of extramedullary fixation group in the <60-year subgroup. CONCLUSION The results of this study have revealed that intramedullary fixation can confer shorter union time, lower nonunion, and reoperation rates compared with extramedullary fixations. Therefore, intramedullary fixation should be considered as the first selection for the treatment of patients with subtrochanteric fractures. LEVEL OF EVIDENCE Level II, Therapeutic study.
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Affiliation(s)
- Jie Wang
- Department of Orthopaedics, Tianjin Hospital, Tianjin, China
| | - Haomin Li
- Department of Orthopaedics, Tianjin Hospital, Tianjin, China
| | - Haobo Jia
- Department of Orthopaedics, Tianjin Hospital, Tianjin, China
| | - Xinlong Ma
- Department of Orthopaedics, Tianjin Hospital, Tianjin, China
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13
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Xie H, Xie L, Wang J, Chen C, Zhang C, Zheng W. Intramedullary versus extramedullary fixation for the treatment of subtrochanteric fracture: A systematic review and meta-analysis. Int J Surg 2019; 63:43-57. [PMID: 30735845 DOI: 10.1016/j.ijsu.2019.01.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 01/20/2019] [Accepted: 01/31/2019] [Indexed: 11/27/2022]
Abstract
PURPOSE This meta-analysis was performed to investigate the outcomes of intramedullary fixation versus extramedullary fixation in the treatment of subtrochanteric fracture from the current literature. METHODS The electronic literature database of PubMed, Embase, Cochrane library, CNKI and Wanfang were searched in December 2018. The data operation time, intraoperative blood loss, length of incision, length of stay, union time, rate of infection, rate of fixation failure, rate of refracture, rate of reoperation, rate of nonunion and rate of excellent and good results were extracted. Stata 14.0 software was used for our meta-analysis. RESULTS A total of 11 studies including 8 RCTs and 3 cohort studies met our inclusion criteria. This meta-analysis showed that intramedullary fixation could achieve significantly shorter operation time (P = 0.000), less intraoperative blood loss (P = 0.000), shorter length of incision (P = 0.000) and length of stay (P = 0.001) with evidently lower rate of fixation failure (P = 0.001), rate of reoperation (P = 0.003) and higher rate of excellent and good functional results (P = 0.003) than extramedullary fixation for subtrochanteric fractures. However, no significant difference was found regarding union time (P = 0.17), rate of infection (P = 0.99), rate of refracture (P = 0.98) and rate of nonunion (P = 0.42) between the two groups. CONCLUSION Our meta-analysis suggested that intramedullary fixation for subtrochanteric fracture might be superior to extramedullary fixation in term of shorter operation time, less intraoperative blood loss, shorter length of incision, length of stay and better functional outcomes. Meanwhile, intramedullary fixation had lower rate of fixation failure and reoperation. Therefore, we recommend intramedullary fixation as the treatment of subtrochanteric fracture. More large multi-center and high-quality RCTs are required for further research.
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Affiliation(s)
- Huanguang Xie
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzho, 325000, China
| | - Linzhen Xie
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzho, 325000, China
| | - Jinwu Wang
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzho, 325000, China
| | - Chunhui Chen
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzho, 325000, China
| | - Chuanxu Zhang
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzho, 325000, China
| | - Wenhao Zheng
- Department of Orthopaedic Surgery, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzho, 325000, China.
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14
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Subtrochanteric fractures: two case reports of non-union treatment. Injury 2018; 49 Suppl 4:S9-S15. [PMID: 30526952 DOI: 10.1016/j.injury.2018.11.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 11/20/2018] [Accepted: 11/23/2018] [Indexed: 02/02/2023]
Abstract
Proximal femoral fractures are a very common disease which affect elderly patients after low energy trauma, but can also affect the young population as a consequence of high energy trauma. Classification of sub trochanteric fractures has not yet been clearly defined representing a major issue in comparing different treatment techniques among the scientific literature.These fractures are well known by orthopaedic surgeons for intraoperative difficulties in reduction and post-operative high rate of non-unions and malunions.We present two clinical cases, one treated with an intramedullary device and one with an extramedullary device, both failed and revised with open surgery using a condylar angled bladeplate, following AO principles of anatomical reduction and stable fixation.
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Sun Q, Li G, Ge W, Lu G, Cai M, Li S. [Effectiveness analysis of surgical treatment of ipsilateral femoral neck fracture and subtrochanteric fracture]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2018; 31:1043-1048. [PMID: 29798559 DOI: 10.7507/1002-1892.201702069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To discuss the effectiveness of intramedullary nail fixation with selective cable wiring in the treatment of ipsilateral femoral neck fracture and subtrochanteric fracture. Methods Between June 2012 and December 2015, a total of 19 patients with ipsilateral femoral neck fracture and subtrochanteric fracture underwent closed reduction of femoral neck fracture and intramedullary nail fixation combined with selective cable wiring. There were 5 males and 14 females with a median age of 52 years (range, 35-77 years). The cause of injury included traffic accident injury in 17 cases and falling injury in 2 cases. According to Garden classification for femoral neck fractures, 7 cases were rated as type Ⅱ, 8 as type Ⅲ, and 4 as type Ⅳ. Femoral subtrochanteric fractures were classified by Seinsheimer classification, with 9 cases as type Ⅱ, 5 as type Ⅲ, 3 as type Ⅳ, and 2 as type V. The interval from injury to operation ranged from 2 to 7 days with an average of 3.7 days. Results The operation time was 58-125 minutes (mean, 82.4 minutes) and the intraoperative blood loss was 225-725 mL (mean, 289.5 mL). All incisions achieved healing by first intention and no early complication such as infection was observed. All patients were followed up 12-18 months (mean, 13.9 months). At 1 month after operation, the tip apex distance was 9-23 mm (mean, 15.2 mm). All patients achieved bone union with the healing time of 18-42 weeks (mean, 27.4 weeks). One case of hip varus and femoral neck re-displacement (femoral neck shaft angle was 122°) occurred at 3 months after operation, which achieved bone union at 42 weeks after operation. Five patients complained of postoperative pain with the visual analogue scale (VAS) score of 1-3 (mean, 1.8), which did not influence normal life. A total of 16 patients recovered preoperative hip function. During follow-up, no fracture nonunion, femoral head necrosis, implant failure, screw cut-out, and loosening of cable wiring was observed. The Harris hip score (HSS) was 72-92 (mean, 82.8) at last follow-up and 15 patients (78.9%) achieved good hip function. Conclusion Intramedullary nail fixation combined with selective cable wiring was effective in the treatment of ipsilateral femoral neck fracture and subtrochanteric fracture.
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Affiliation(s)
- Qi Sun
- Department of Orthopedics, Shanghai Tenth People's Hospital, Tongji University, School of Medicine, Shanghai, 200072, P.R.China
| | - Gen Li
- Department of Orthopedics, Shanghai Tenth People's Hospital, Tongji University, School of Medicine, Shanghai, 200072, P.R.China
| | - Wei Ge
- Department of Orthopedics, Shanghai Tenth People's Hospital, Tongji University, School of Medicine, Shanghai, 200072, P.R.China
| | - Guanghua Lu
- Department of Orthopedics, Shanghai Tenth People's Hospital, Tongji University, School of Medicine, Shanghai, 200072, P.R.China
| | - Ming Cai
- Department of Orthopedics, Shanghai Tenth People's Hospital, Tongji University, School of Medicine, Shanghai, 200072,
| | - Shaohua Li
- Department of Orthopedics, Shanghai Tenth People's Hospital, Tongji University, School of Medicine, Shanghai, 200072,
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Provisional Plating of Subtrochanteric Femur Fractures Before Intramedullary Nailing in the Lateral Decubitus Position. J Orthop Trauma 2018; 32:e151-e156. [PMID: 29065038 DOI: 10.1097/bot.0000000000001044] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Subtrochanteric femur fractures remain a challenge for surgeons to obtain and maintain adequate reduction and stable fixation. For this reason, multiple techniques have been described, but we are unaware of a detailed contemporary description of the combination of provisional plating before intramedullary fixation in the lateral decubitus position. We present our technique as it was used from 2011 to 2015 to treat 22 fractures and how it compared clinically to the other 48 subtrochanteric femur fractures treated during that period. The clinical and radiographic outcomes for all fractures were evaluated. The operative time was shorter when no open reduction was used but open cases showed no significant difference when using a provisional plate. Those patients treated with provisional plating were shown to have higher blood loss values and longer operative times, but when looking at the outcomes, the rate of malunion, which was defined as >5 degrees of angulation on postoperative radiographs, was significantly lower at 0% in the provision plating in the lateral decubitus position subset compared with the remaining subtrochanteric fractures, 27.7% (P = 0.013). As the quality of reduction and stability of fixation are the most significant factors in determining outcomes of subtrochanteric femur fractures, this study shows that this technique is a valuable tool in an orthopaedist's armamentarium and present it as such.
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Intramedullary Fixation With Minimally Invasive Clamp-Assisted Reduction for the Treatment of Ipsilateral Femoral Neck and Subtrochanteric Fractures: A Technical Trick. J Orthop Trauma 2017. [PMID: 28650943 DOI: 10.1097/bot.0000000000000933] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The purpose of this study is to describe a surgical technique for intramedullary fixation and minimally invasive clamp-assisted reduction with selective cerclage wiring for the management of combined ipsilateral femoral neck and subtrochanteric fractures and to present the clinical outcomes in 17 patients after treatment using this technique.
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Shin WC, Moon NH, Jang JH, Lee HJ, Suh KT. Comparative study between biologic plating and intramedullary nailing for the treatment of subtrochanteric fractures: Is biologic plating using LCP-DF superior to intramedullary nailing? Injury 2017; 48:2207-2213. [PMID: 28847590 DOI: 10.1016/j.injury.2017.08.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 07/12/2017] [Accepted: 08/13/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND The objective of this study is to evaluate the outcome measures of subtrochanteric fractures between biologic plating and intramedullary nailing and determine if biologic plating is superior to intramedullary nailing. METHODS Between March 2009 and December 2015, 81 patients with subtrochanteric fractures were enrolled (52 males and 29 females; 31 treated with biologic plating and 50 with intramedullary nailing). Biologic plating was conducted consecutively between May 2011 and March 2013 and intramedullary nailing was performed for the rest of period. Perioperative outcomes including operation time and blood loss during the operation; postoperative radiologic outcomes including union, time to union, coronal alignment, and shortening of the femur; and clinical outcomes including walking ability and pain were evaluated. The biologic plating group was compared with the intramedullary nailing group as a historical control. RESULTS No significant differences were identified for bony union and time to union between the two different fixation methods Coronal alignment was significantly better in the biologic plating group than in the intramedullary nailing group (p<0.016). Postoperative coronal alignment was the only risk factor associated with the nonunion of subtrochanteric fractures (unadjusted OR: 1.915, 95% CI: 0.190 - 19.273; adjusted OR: 0.042, 95% CI: 0.000 - 21.517; p=0.320). CONCLUSION Surgical outcomes using LCP-DF are comparable to those using intramedullary nailing. Further clinical studies with a larger sample size are required to show the advantage of biologic plating for the treatment of subtrochanteric fractures.
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Affiliation(s)
- Won Chul Shin
- Department of Orthopaedic Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Nam Hoon Moon
- Department of Orthopaedic Surgery, (Bio)Medical Research Institute, Pusan National University Hospital, Busan, Korea.
| | - Jae Hoon Jang
- Department of Orthopaedic Surgery, (Bio)Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Hee Jin Lee
- Department of Orthopaedic Surgery, (Bio)Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Kuen Tak Suh
- Department of Orthopaedic Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
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Hodel S, Beeres FJP, Babst R, Link BC. Complications following proximal femoral locking compression plating in unstable proximal femur fractures: medium-term follow-up. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2017; 27:1117-1124. [DOI: 10.1007/s00590-017-1981-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 05/16/2017] [Indexed: 11/28/2022]
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Wang J, Ma JX, Jia HB, Chen Y, Yang Y, Ma XL. Biomechanical Evaluation of Four Methods for Internal Fixation of Comminuted Subtrochanteric Fractures. Medicine (Baltimore) 2016; 95:e3382. [PMID: 27175636 PMCID: PMC4902478 DOI: 10.1097/md.0000000000003382] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Subtrochanteric fractures are common and result in significant morbidity and mortality. Various kinds of implants have been used to fix it. The aim of this study was to compare the biomechanical performance of PFN, DHS, DCS, and the PFLP in the treatment of subtrochanteric comminuted fractures.A total of 32 antiseptic human femurs from 16 donors were randomly allocated to 4 groups for fixation with PFN, DHS, DCS, and PFLP. A 2-cm cylindrical bone fragment was removed 1 cm below the lesser trochanter to simulate OTA/AO 32-C3.2 post instrumentation fracture. All specimens in single-leg stance situation were preloaded 5 times at 100 N in the axial direction to eliminate the time effect of relaxation and settling, followed by cyclic testing at a rate of 1 Hz with stepwise increasing load. Keeping the valley load at a constant level of 100 N during the entire cyclic test, the peak load, starting at 200 N, was increased by 100 N at 300-cycle steps until a maximum of 1500 cycles or until failure of the bone-implant construct occurred. Each specimen was kept unloaded under 100 N compression for 30 minutes between the 300-cycle steps.Femoral head displacement after 1500 cycles was 1.09 mm ± 0.13 for PFN, 1.78 mm ± 0.25 for DHS, 2.63 mm ± 0.46 for DCS, and 2.26 mm ± 0.16 for PFLP, with significant difference between any 2 implants (P < 0.01). The required load to reach 1-mm femoral head displacement was 563.04 N ± 158.34 for PFN, 485.73 N ± 147.27 for DHS, 258.44 N ± 97.23 for DCS, and 332.68 N ± 100.34 for PFLP. Significant differences were detected between any 2 implants (P < 0.001), except between DCS and PFLP and between DHS and PFN. The number of cycles until 1-mm femoral head displacement was 1458 ± 277 for PFN, 908 ± 184 for DHS, 369 ± 116 for DCS, and 603 ± 162 for PFLP. Significant differences were detected between any 2 implants (P < 0.01), except between DCS and PFLP.From biomechanical point of view, comminuted subtrochanteric fractures OTA/AO 32-C3.2 revealed in the current test setup highest fixation strength with PFN, followed by DHS, PFLP, and DCS.
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Affiliation(s)
- Jie Wang
- From the Biomechanics Laboratory of Orthopaedics Institute, Tianjin Hospital, Hexi District, Tianjin, China
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A study of 44 patients with subtrochanteric fractures treated using long nail and cerclage cables. Musculoskelet Surg 2015; 99:225-30. [PMID: 26514142 DOI: 10.1007/s12306-015-0385-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 10/09/2015] [Indexed: 02/05/2023]
Abstract
OBJECTIVE This study aims to demonstrate that the use of long cephalomedullary nail and cerclage cables represents a good strategy in order to reduce the high risk of nonunion of the most displaced subtrochanteric fractures. METHODS This retrospective study examines 44 patients with average follow-up of 23 months, with subtrochanteric fracture type SH IIB, IIC, IIIA, IIIB treated by the same operator and with the same nail and cerclage cables. The clinical results which are derived from THRS have been reported. RESULTS Clinical and radiological consolidation occurred in all 44 cases, without re-intervention. The average evaluation derived from the THRS was 48 which corresponds to good, according to the scale. CONCLUSIONS Considering the anatomic reduction achieved in all patients and the clinical results, we can define the use of long cephalomedullary nail and cerclage cables as the most useful technique in the armamentarium of a trauma surgeon for the treatment of the subtrochanteric fractures.
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Schneider K, Oh JK, Zderic I, Stoffel K, Richards RG, Wolf S, Gueorguiev B, Nork SE. What is the underlying mechanism for the failure mode observed in the proximal femoral locking compression plate? A biomechanical study. Injury 2015; 46:1483-90. [PMID: 26113034 DOI: 10.1016/j.injury.2015.05.034] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Revised: 04/05/2015] [Accepted: 05/12/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE Recently, several cases of clinical failure have been reported for the Proximal Femoral Locking Compression Plate (PF-LCP). The current study was designed to explore biomechanically the underlying mechanism and to determine whether the observed failure was due to technical error on insertion or to implant design. METHODS A foam block model simulating an unstable intertrochanteric fracture was created for 3 study groups with 6 specimens each. Group C was correctly instrumented according to the manufacturer's guidelines. In Group P and Group A, the first or second proximal screw was placed with a posterior or anterior off-axis orientation by 2° measured in the transversal plane, respectively. Each construct was cyclically tested until failure using a test setup and protocol simulating complex axial and torsional loading. Radiographs were taken prior to and after the tests. Force, number of cycles to failure and failure mode were compared. RESULTS A screw deviation of 2° from the nominal axis led to significantly earlier construct failure in Group P and Group A in comparison to Group C. The failure mode was characterised by loosening of the off-axis screw due to disengagement with the plate, resulting in loss of construct stiffness and varus collapse of the fracture. CONCLUSIONS In our biomechanical test setup, the clinical failure modes observed with the PF-LCP were reproducible. A screw deviation of 2° from the nominal axis consistently led to the failure. This highlights how crucial is the accurate placement of locking screws in the proximal femur.
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Affiliation(s)
- Kerstin Schneider
- AO Research Institute Davos, Davos, Switzerland; Schulthess Clinic Zurich, Zurich, Switzerland
| | - Jong-Keon Oh
- Guro Hospital, Korea University College of Medicine, Department of Orthopaedic Surgery, Seoul, Republic of Korea.
| | - Ivan Zderic
- AO Research Institute Davos, Davos, Switzerland
| | - Karl Stoffel
- Cantonal Hospital Baselland, Liestal, Switzerland; University of Basel, Basel, Switzerland
| | | | | | | | - Sean E Nork
- Harborview Medical Center, Department of Orthopaedic Surgery, Seattle, WA, USA
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Liu P, Wu X, Shi H, Liu R, Shu H, Gong J, Yang Y, Sun Q, Wu J, Nie X, Cai M. Intramedullary versus extramedullary fixation in the management of subtrochanteric femur fractures: a meta-analysis. Clin Interv Aging 2015; 10:803-11. [PMID: 25960644 PMCID: PMC4423507 DOI: 10.2147/cia.s82119] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background Intramedullary and extramedullary fixation methods are used in the management of subtrochanteric femur fractures. However, whether intramedullary or extramedullary fixation is the primary treatment for subtrochanteric femur fractures in adults remains debatable. Level of evidence Meta-analyses of prospective studies, level I. Materials and methods The Cochrane library, Embase, Google Scholar, and PubMed databases were searched separately for all relevant studies published before January 1, 2015. No language restriction was applied. Prospective randomized controlled trials that compared intramedullary or extramedullary internal fixation to repair subtrochanteric femur fractures in adults were included. We determined intraoperative data, postoperative complications, fracture fixation complications, wound infection, hospital stay days, and final outcome measures to assess the relative effects of different internal fixation methods for the treatment of subtrochanteric femur fractures in adults. Results Six studies were included in our meta-analysis. The relative risks (RRs) of revision rate was 83% lower (RR, 0.17, 95% confidence interval [CI], 0.05 to 0.60; P=0.006), fixation failure rate was 64% lower (RR, 0.36, 95% CI, 0.12 to 1.08; P=0.07), non-union rate was 77% lower (RR, 0.23, 95% CI, 0.07 to 0.81; P=0.02) in the intramedullary group compared with the extramedullary group. No significant differences were found between the intramedullary group and extramedullary group for intraoperative data, postoperative complications, wound infection, hospital stay days or final outcome measures. Conclusion In conclusion, our meta-analysis suggests that there was no significant difference in intraoperative data, postoperative complications, wound infection, hospital stay days or final outcome measures between intramedullary and extramedullary internal fixation. However, a significant decrease occurred in the rate of fracture fixation complications for patients treated with intramedullary internal fixation, especially in elderly patients. Some differences were not significant, but the treatment of elderly subtrochanteric femur fractures using intramedullary internal fixation is recommended.
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Affiliation(s)
- Pengcheng Liu
- Department of Orthopedics, Shanghai Tenth People's Hospital, Tongji University, School of Medicine, Shanghai, People's Republic of China ; First Clinical Medical College, Nanjing Medical University, Nanjing, People's Republic of China
| | - Xing Wu
- Department of Orthopedics, Shanghai Tenth People's Hospital, Tongji University, School of Medicine, Shanghai, People's Republic of China
| | - Hui Shi
- Department of Orthopedics, Shanghai Tenth People's Hospital, Tongji University, School of Medicine, Shanghai, People's Republic of China ; First Clinical Medical College, Nanjing Medical University, Nanjing, People's Republic of China
| | - Run Liu
- Department of Orthopedics, Shanghai Tenth People's Hospital, Tongji University, School of Medicine, Shanghai, People's Republic of China
| | - Hexi Shu
- Department of Orthopedics, Shanghai Tenth People's Hospital, Tongji University, School of Medicine, Shanghai, People's Republic of China
| | - JinPeng Gong
- Department of Orthopedics, Shanghai Tenth People's Hospital, Tongji University, School of Medicine, Shanghai, People's Republic of China
| | - Yong Yang
- Department of Orthopedics, Shanghai Tenth People's Hospital, Tongji University, School of Medicine, Shanghai, People's Republic of China
| | - Qi Sun
- Department of Orthopedics, Shanghai Tenth People's Hospital, Tongji University, School of Medicine, Shanghai, People's Republic of China
| | - Jiezhou Wu
- Department of Orthopedics, Shanghai Tenth People's Hospital, Tongji University, School of Medicine, Shanghai, People's Republic of China ; First Clinical Medical College, Nanjing Medical University, Nanjing, People's Republic of China
| | - Xiaoyang Nie
- Department of Orthopedics, Shanghai Tenth People's Hospital, Tongji University, School of Medicine, Shanghai, People's Republic of China
| | - Ming Cai
- Department of Orthopedics, Shanghai Tenth People's Hospital, Tongji University, School of Medicine, Shanghai, People's Republic of China
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Lee KJ, Min BW, Jung JH, Kang MK, Kim MJ. Expert tibia nail for subtrochanteric femoral fracture to prevent thermal injury. Int J Surg Case Rep 2015; 10:158-61. [PMID: 25839435 PMCID: PMC4430179 DOI: 10.1016/j.ijscr.2015.03.048] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Revised: 03/20/2015] [Accepted: 03/21/2015] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Subtrochanteric femoral fractures are relatively uncommon, accounting for 7-15% of all hip fractures and treatment of these fractures are considered challenge for orthopaedic surgeons. Although several treatment options are reported with up to 90% of satisfactory results, the choice of the appropriate implant is still a matter of debate. Some authors reported thermal injury after reaming for intramedullary nail fixation in patients with narrow medullary canal. PRESENTATION OF CASE A 21-year-old female patient was admitted to our hospital because of right subtrochanteric femoral fracture. The narrowest diameter of medullary canal of her femur was about 7mm but she refused open reduction and internal fixation with plate due to large scar formation. We used expert tibia nail instead of femoral intramedullary nail to prevent thermal injury. DISCUSSION Subtrochanteric femoral fractures are difficult to treat because of their biomechanical and anatomical characteristics. Although several implants are reported for the surgical treatment of these fractures, intramedullary nails have been advocated due to their biological and biomechanical advantages. However, under certain circumstances with associated injury or anatomic difference we might consider another treatment options. CONCLUSION Expert tibia nail may be considered one of the treatment options for subtrochanteric femoral fracture with narrow medullary canal. We also emphasize the importance of preoperative evaluation of the medullary canal size for these risky fractures.
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Affiliation(s)
- Kyung-Jae Lee
- Department of Orthopaedic Surgery, School of Medicine, Keimyung University, Daegu, Republic of Korea; Pain Research Center, School of Medicine, Keimyung University, Daegu, Republic of Korea.
| | - Byung-Woo Min
- Department of Orthopaedic Surgery, School of Medicine, Keimyung University, Daegu, Republic of Korea
| | - Jae-Hoon Jung
- Department of Orthopaedic Surgery, School of Medicine, Keimyung University, Daegu, Republic of Korea
| | - Mi-Kyung Kang
- Department of Orthopaedic Surgery, School of Medicine, Keimyung University, Daegu, Republic of Korea
| | - Min-Ji Kim
- Department of Orthopaedic Surgery, School of Medicine, Keimyung University, Daegu, Republic of Korea
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Joglekar SB, Lindvall EM, Martirosian A. Contemporary management of subtrochanteric fractures. Orthop Clin North Am 2015; 46:21-35. [PMID: 25435032 DOI: 10.1016/j.ocl.2014.09.001] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Cephalomedullary interlocking nails that allow for trochanteric entry and minimally invasive fixation have revolutionized the contemporary management of subtrochanteric fractures with improved union rates and decreased incidence of fixation failure. The most successful alternative to intramedullary fixation remains the angled blade plate. Despite biomechanical superiority of contemporary intramedullary implants to previous intramedullary devices, the importance of achieving and maintaining satisfactory fracture reduction prior to and during hardware insertion cannot be overemphasized. In comminuted and more challenging fractures, additional techniques, such as limited open reduction with clamps and/or cables, can allow for canal restoration and more anatomic reductions prior to and/or during nail insertion.
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Affiliation(s)
- Siddharth B Joglekar
- VAMC Fresno, 2615 East Clinton Avenue, Fresno, CA 93730, USA; UCSF Fresno, 2823 Fresno Street, Fresno, CA 93721, USA.
| | - Eric M Lindvall
- UCSF Fresno, 2823 Fresno Street, Fresno, CA 93721, USA; Department of Orthopedic Surgery, CRMC Fresno, 2823 Fresno Street, Fresno, CA 93721, USA
| | - Armen Martirosian
- UCSF Fresno, 2823 Fresno Street, Fresno, CA 93721, USA; Department of Orthopedic Surgery, CRMC Fresno, 2823 Fresno Street, Fresno, CA 93721, USA
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Abstract
OBJECTIVES The proximal femoral locking compression plate is a fixed angled anatomically contoured stainless steel plate used to treat pertrochanteric fractures of the proximal femur. Recent reports quote a high failure rate associated with this implant. We aimed to identify the common methods of failure and determine the elements of surgical techniques that could be altered to potentially improve outcomes should this implant be used for the treatment of unstable pertrochanteric fractures. DESIGN Retrospective chart analysis. SETTING Three separate centers. PATIENTS Twenty-nine patients with 29 fractures. INTERVENTION All patients were treated for pertrochanteric fractures using the proximal femoral locking compression plate. OUTCOME MEASURES The patient demographics, fracture classification, implant details, and complications. RESULTS Twelve of 29 fractures (41.4%) suffered a complication associated with the implant, and 83% of these occurred in elderly women. Complications included bending, backing-out, fracture, or cut-out of the proximal screws and plate fracture. Common technical errors included the following: (1) leaving the plate proud proximally, (2) malposition of the proximal screws within the femoral neck/head, (3) inappropriate use of the hook plate, (4) creating too ridged a construct when used as a bridging plate. CONCLUSIONS Our experience with the use of this implant suggests an unacceptably high failure rate (41.4%). A knowledge of the common pitfalls encountered when using this device is critical in an effort to reduce failure rates. Based on our data, we would urge caution when considering this device for unstable pertrochanteric fractures, especially in the elderly female. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Subtrochanteric Fractures: Comparison of Proximal Femur Locking Plate and Intramedullary Locking Nail Fixation Outcome. Indian J Surg 2013; 77:795-8. [PMID: 27011459 DOI: 10.1007/s12262-013-1004-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Accepted: 10/27/2013] [Indexed: 10/26/2022] Open
Abstract
Fixation of subtrochanteric fracture, even for experienced surgeons, is a challenge. This fracture is most difficult to treat, and the incidence of complications in this type of fracture is higher. This study compared surgical results of two methods, proximal femur locking compression plate and intramedullary locking nail. This is an analytic study, performed on all patients with subtrochanteric fracture who were referred to the hospital during 3 years. They were treated with proximal femur locking plate or intramedullary locking nail. The postoperative complications were evaluated and recorded. Finally, the data were analyzed by SPSS software. Complications were studied in both groups. Neither treatment has statistically significant difference in complications, onset of complications incidence, and time of full-weight bearing. Although the Harris Hip Score among patients improved in both methods of treatment, there is no significant difference between the two groups. The results of subtrochanteric fracture fixation by intramedullary or locking plate were similar and had the same outcome.
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28
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Wirtz C, Abbassi F, Evangelopoulos DS, Kohl S, Siebenrock KA, Krüger A. High failure rate of trochanteric fracture osteosynthesis with proximal femoral locking compression plate. Injury 2013; 44:751-6. [PMID: 23522837 DOI: 10.1016/j.injury.2013.02.020] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Revised: 01/06/2013] [Accepted: 02/14/2013] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Stable reconstruction of proximal femoral (PF) fractures is especially challenging due to the peculiarity of the injury patterns and the high load-bearing requirement. Since its introduction in 2007, the PF-locking compression plate (LCP) 4.5/5.0 has improved osteosynthesis for intertrochanteric and subtrochanteric fractures of the femur. This study reports our early results with this implant. METHODS Between January 2008 and June 2010, 19 of 52 patients (12 males, 7 females; mean age 59 years, range 19-96 years) presenting with fractures of the trochanteric region were treated at the authors' level 1 trauma centre with open reduction and internal fixation using PF-LCP. Postoperatively, partial weight bearing was allowed for all 19 patients. Follow-up included a thorough clinical and radiological evaluation at 1.5, 3, 6, 12, 24, 36 and 48 months. Failure analysis was based on conventional radiological and clinical assessment regarding the type of fracture, postoperative repositioning, secondary fracture dislocation in relation to the fracture constellation and postoperative clinical function (Merle d'Aubigné score). RESULTS In 18 patients surgery achieved adequate reduction and stable fixation without intra-operative complications. In one patient an ad latus displacement was observed on postoperative X-rays. At the third month follow-up four patients presented with secondary varus collapse and at the sixth month follow-up two patients had 'cut-outs' of the proximal fragment, with one patient having implant failure due to a broken proximal screw. Revision surgeries were performed in eight patients, one patient receiving a change of one screw, three patients undergoing reosteosynthesis with implantation of a condylar plate and one patient undergoing hardware removal with secondary implantation of a total hip prosthesis. Eight patients suffered from persistent trochanteric pain and three patients underwent hardware removal. CONCLUSIONS Early results for PF-LCP osteosynthesis show major complications in 7 of 19 patients requiring reosteosynthesis or prosthesis implantation due to secondary loss of reduction or hardware removal. Further studies are required to evaluate the limitations of this device.
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Affiliation(s)
- C Wirtz
- Department of Orthopaedic Surgery, Inselspital, University of Bern, Bern, Switzerland
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29
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Sliding hip screw versus IM nail in reverse oblique trochanteric and subtrochanteric fractures. A study of 2716 patients in the Norwegian Hip Fracture Register. Injury 2013; 44:735-42. [PMID: 23305689 DOI: 10.1016/j.injury.2012.12.010] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2012] [Revised: 11/21/2012] [Accepted: 12/07/2012] [Indexed: 02/02/2023]
Abstract
BACKGROUND Intramedullary nailing is commonly recommended as the treatment of choice for transverse/reverse oblique trochanteric (AO/OTA type A3=intertrochanteric) and subtrochanteric fractures. However, only to a limited extent is this approach supported by superior results in well designed clinical trials, and the sliding hip screw (SHS) is still a frequently used implant for these fractures. The aim of the present study was to compare IM nails and SHS in the treatment of transverse/reverse oblique trochanteric and subtrochanteric fractures using data from the Norwegian Hip Fracture Register (NHFR). METHODS Data on 2716 operations for acute transverse/reverse oblique trochanteric or subtrochanteric fractures were collected from the NHFR from 2005 to 2010. Surgeons reported patient characteristics and details from initial surgery and reoperations, and patients answered questionnaires about pain, satisfaction, and quality of life (EQ-5D) 4, 12, and 36 months postoperatively. Reoperation rates were calculated using Kaplan-Meier analyses. Primary outcome measures were pain (Visual Analogue Scale (VAS)), satisfaction (VAS), quality of life (EQ-5D), and reoperation rates at one year. RESULTS The treatment groups were similar regarding age, gender, ASA-class, cognitive impairment, and preoperative EQ-5Dindex score. At one year reoperation rates were 6.4% and 3.8% for SHS and IM nails, respectively (p=0.011). Patients treated with SHS also had slightly more pain (VAS 30 vs. 27, p=0.037) and were less satisfied (VAS 31 vs. 36, p=0.003) compared to patients treated with IM nail. There was no statistically significant difference in the EQ-5Dindex score, but the mobility was significantly better for the IM nail group. CONCLUSION 12 months postoperatively patients with transverse/reverse oblique trochanteric and subtrochanteric fractures operated with a SHS had a higher reoperation rate compared to those operated with an IM nail. Small differences regarding pain, satisfaction, quality of life, and mobility were also in favour of IM nailing. Consequently, a change in our treatment strategy for these fractures could be considered.
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Matre K, Vinje T, Havelin LI, Gjertsen JE, Furnes O, Espehaug B, Kjellevold SH, Fevang JM. TRIGEN INTERTAN intramedullary nail versus sliding hip screw: a prospective, randomized multicenter study on pain, function, and complications in 684 patients with an intertrochanteric or subtrochanteric fracture and one year of follow-up. J Bone Joint Surg Am 2013; 95:200-8. [PMID: 23389782 DOI: 10.2106/jbjs.k.01497] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Both intramedullary nails and sliding hip screws are used with good results in the treatment of intertrochanteric and subtrochanteric fractures. The aim of our study was to assess whether use of the TRIGEN INTERTAN nail, as compared with a sliding hip screw, resulted in less postoperative pain, improved functional mobility, and reduced surgical complication rates for patients with an intertrochanteric or subtrochanteric fracture. METHODS In a prospective, randomized multicenter study, 684 elderly patients were treated with the INTERTAN nail or with a sliding hip screw with or without a trochanteric stabilizing plate. The patients were assessed during their hospital stay and at three and twelve months postoperatively. A visual analogue scale (VAS) pain score was recorded at all time points, and functional mobility was assessed with use of the timed Up & Go test. The Harris hip score (HHS) was used to assess hip function more specifically. Quality of life was measured with the EuroQol-5D (EQ-5D). Radiographic findings as well as intraoperative and postoperative complications were recorded and analyzed. RESULTS Patients treated with an INTERTAN nail had slightly less pain at the time of early postoperative mobilization (VAS score, 48 versus 52; p = 0.042), although this did not influence the length of the hospital stay and there was no difference at three or twelve months. Regardless of the fracture and implant type, functional mobility, hip function, patient satisfaction, and quality-of-life assessments were comparable between the groups at three and twelve months. The numbers of patients with surgical complications were similar for the two groups (twenty-nine in the sliding-hip-screw group and thirty-two in the INTERTAN group, p = 0.67). CONCLUSIONS INTERTAN nails and sliding hip screws are similar in terms of pain, function, and reoperation rates twelve months after treatment of intertrochanteric and subtrochanteric fractures.
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Affiliation(s)
- Kjell Matre
- Department of Orthopaedic Surgery, Haukeland University Hospital, Jonas Lies vei 65, N-5021 Bergen, Norway.
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Saini P, Kumar R, Shekhawat V, Joshi N, Bansal M, Kumar S. Biological fixation of comminuted subtrochanteric fractures with proximal femur locking compression plate. Injury 2013. [PMID: 23200761 DOI: 10.1016/j.injury.2012.10.037] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Subtrochanteric fractures are difficult fractures associated with high incidence of complications and various implants, both intramedullary and extramedullary, are available for their fixation. Traditional extramedullary implants are associated with higher rate of implant failure and varus collapse while the biomechanically better intramedullary nails are technically demanding and are associated with higher re-operation rates. This study was done to evaluate the outcome following biological (indirect) fixation of unstable comminuted subtrochanteric fractures with proximal femur-locking compression plate (PF-LCP). METHODS Thirty-five consecutive patients with comminuted subtrochanteric fractures were operated upon with PF-LCP by using an indirect reduction technique. Seinsheimer types 3-5 fractures were included in the study. Operating time, blood loss and any technical difficulty with the implant were recorded. Patients were followed clinically and radiologically for union at fracture site and implant-related complications. The Harris Hip Score was used to document hip function at final follow-up. RESULTS Thirty-two patients with average age of 44.7 years were available for final evaluation. The mean operating time was 79.5min and total blood loss averaged 233.13ml. Union was achieved in all cases with an average time of 15.62 weeks. Complications included two cases of delayed union and two cases of infection. Two cases had a shortening of 1cm and one case had malunion with external rotation. No instances of implant failure or nonunion were recorded. CONCLUSION Biological fixation of comminuted subtrochanteric fractures with PF-LCP provides stable fixation with high union rate and fewer complications.
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Affiliation(s)
- Pramod Saini
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi 110029, India.
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Palmer JS, Huber CP. Operative management of hip fractures: a review of the NICE guidelines. Br J Hosp Med (Lond) 2013; 73:C141-4. [PMID: 23124369 DOI: 10.12968/hmed.2012.73.sup9.c141] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- J S Palmer
- Orthopaedic Department, Whipps Cross University Hospital, London, UK.
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Amin NH, Katsman A, Chakravarty R, Harding S, Cerynik DL. Use of blocking screws in intramedullary fixation of subtrochanteric fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2012; 22:703-7. [PMID: 27526073 DOI: 10.1007/s00590-011-0898-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2011] [Accepted: 10/11/2011] [Indexed: 10/16/2022]
Abstract
Intramedullary fixation is the mainstay of treatment for femur fractures in the adult trauma population. With subtrochanteric fractures, accurate reduction and stable fixation become technically challenging. Adjuvant blocking screws in the proximal fragment can effectively be used to prevent varus and apex anterior malalignment when intramedullary nails are used in these fractures. Blocking screws decrease the canal volume, thereby allowing the intramedullary device to control the proximal segment. This aids in improving alignment between the proximal and distal fragments during reduction. We review the cases of six patients with proximal femur fractures who were treated with intramedullary nailing in conjunction with the placement of blocking screws.
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Affiliation(s)
- Nirav H Amin
- Department of Orthopaedic Surgery, Drexel University College of Medicine, Philadelphia, PA, 19102, USA
| | - Anna Katsman
- Department of Orthopaedic Surgery, Drexel University College of Medicine, Philadelphia, PA, 19102, USA
| | - Rajit Chakravarty
- Department of Orthopaedic Surgery, Drexel University College of Medicine, Philadelphia, PA, 19102, USA
| | - Susan Harding
- Department of Orthopaedic Surgery, Drexel University College of Medicine, Philadelphia, PA, 19102, USA
| | - Douglas L Cerynik
- Department of Orthopaedic Surgery, Drexel University College of Medicine, Philadelphia, PA, 19102, USA.
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Tzioupis C, Panteliadis P, Gamie Z, Tsiridis E. Revision of a nonunited subtrochanteric femoral fracture around a failed intramedullary nail with the use of RIA products, BMP-7 and hydroxyapatite: a case report. J Med Case Rep 2011; 5:87. [PMID: 21362192 PMCID: PMC3055835 DOI: 10.1186/1752-1947-5-87] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2010] [Accepted: 03/01/2011] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Femoral subtrochanteric fractures are commonly treated using intramedullary devices. Failure of the implant and subsequent nonunion is still an issue, however, and limited evidence exists regarding the most appropriate treatment. CASE PRESENTATION We report the case of an 80-year-old Caucasian woman with a subtrochanteric fracture originally treated using a trochanteric gamma nail which failed, resulting in a nonunion and fracture of its proximal end. The nonunion was revised with the removal of the broken trochanteric gamma nail, application of a condylar blade plate, ipsilateral Reamer/Irrigator/Aspirator autografting, recombinant human bone morphogenetic protein-7 and injectable hydroxyapatite cement. The fracture united fully at ten months following revision surgery, with no signs of femoral head avascular necrosis at 18-month follow-up. CONCLUSION The essential requirements for success when revising a nonunited fracture are to provide anatomical reduction, mechanical stability, bone defect augmentation and biological stimulation to achieve healing. Current advances in molecular biology, such as recombinant human bone morphogenetic protein-7, and biotechnology such as the Reamer/Irrigator/Aspirator system and hydroxyapatite injectable cement can improve patient outcomes over the use of our traditional revision techniques.
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Affiliation(s)
- Christopher Tzioupis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Clarendon Wing A, Great George Street, Leeds, LS1 3EX, UK
| | - Pavlos Panteliadis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Clarendon Wing A, Great George Street, Leeds, LS1 3EX, UK
| | - Zakareya Gamie
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Clarendon Wing A, Great George Street, Leeds, LS1 3EX, UK
| | - Eleftherios Tsiridis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Clarendon Wing A, Great George Street, Leeds, LS1 3EX, UK
- Academic Orthopaedic Unit, Faculty of Medicine, Aristotle University of Thessaloniki 541 24, Greece
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35
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Wieser K, Babst R. Fixation failure of the LCP proximal femoral plate 4.5/5.0 in patients with missing posteromedial support in unstable per-, inter-, and subtrochanteric fractures of the proximal femur. Arch Orthop Trauma Surg 2010; 130:1281-7. [PMID: 20191276 DOI: 10.1007/s00402-010-1074-7] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2010] [Indexed: 02/09/2023]
Abstract
The LCP proximal femoral plate 4.5/5.0 (PF-LCP) represents a new generation of extramedullary fixation devices for stable and unstable trochanteric and/or subtrochanteric fractures. We report four cases of secondary varus collapse of the fracture with hardware failure of the implant.
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Affiliation(s)
- Karl Wieser
- Department of Trauma Surgery, Cantonal Hospital Lucerne, Lucerne 13, Switzerland.
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Parker MJ, Handoll HH. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults. Cochrane Database Syst Rev 2010:CD000093. [PMID: 20824825 DOI: 10.1002/14651858.cd000093.pub5] [Citation(s) in RCA: 146] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Two types of implants used for the surgical fixation of extracapsular hip fractures are cephalocondylic intramedullary nails, which are inserted into the femoral canal proximally to distally across the fracture, and extramedullary implants (e.g. the sliding hip screw). OBJECTIVES To compare cephalocondylic intramedullary nails with extramedullary implants for extracapsular hip fractures in adults. SEARCH STRATEGY We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (April 2010), The Cochrane Central Register of Controlled Trials (The Cochrane Library 2010, Issue 1), MEDLINE (1950 to March 2010), EMBASE (1980 to 2010 Week 13), and other sources. SELECTION CRITERIA All randomised and quasi-randomised controlled trials comparing cephalocondylic nails with extramedullary implants for extracapsular hip fractures. DATA COLLECTION AND ANALYSIS Both authors independently assessed trial quality and extracted data. Wherever appropriate, results were pooled. MAIN RESULTS We included 43 trials containing predominantly older people with mainly trochanteric fractures. Twenty-two trials (3749 participants) compared the Gamma nail with the sliding hip screw (SHS). The Gamma nail was associated with increased risk of operative and later fracture of the femur and increased reoperation rate. There were no major differences between implants in wound infection, mortality or medical complications.Five trials (623 participants) compared the intramedullary hip screw (IMHS) with the SHS. Fracture fixation complications were more common in the IMHS group. Results for post-operative complications, mortality and functional outcomes were similar in both groups.Three trials (394 participants) showed no difference in fracture fixation complications, reoperation, wound infection and length of hospital stay for proximal femoral nail (PFN) versus the SHS.None of the 10 trials (1491 participants) of other nail versus extramedullary implant comparisons for trochanteric fractures provided sufficient evidence to establish definite differences between the implants under test.Two trials (65 participants) found intramedullary nails were associated with fewer fracture fixation complications than fixed nail plates for unstable fractures at the level of the lesser trochanter.Two trials (124 participants) found a tendency to less fracture healing complications with the intramedullary nails compared with fixed nail plates for subtrochanteric fractures. AUTHORS' CONCLUSIONS With its lower complication rate in comparison with intramedullary nails, and absence of functional outcome data to the contrary, the SHS appears superior for trochanteric fractures. Further studies are required to confirm whether more recently developed designs of intramedullary nail avoid the complications of previous nails. Intramedullary nails may have advantages over fixed angle plates for subtrochanteric and some unstable trochanteric fractures, but further studies are required.
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Affiliation(s)
- Martyn J Parker
- Department of Trauma & Orthopaedics, Peterborough and Stamford Hospitals NHS Foundation Trust, Peterborough District Hospital, Thorpe Road, Peterborough, Cambridgeshire, UK, PE3 6DA
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Oestern HJ, Gänsslen A. [The use of blade plate and dynamic screw plate osteosynthesis]. DER ORTHOPADE 2010; 39:160-70. [PMID: 20119667 DOI: 10.1007/s00132-009-1521-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Osteosynthesis in fracture treatment and in some reconstructive procedures with blade plates or dynamic screw systems was the standard procedure for several decades. In this review, the current options and concepts using blade plate osteosynthesis, stabilization of proximal and distal femur fractures and reconstructive procedures with the dynamic hip screw or the dynamic condylar blade are discussed. On the basis of a literature review, the present indications, results and region-specific complications are reported and discussed.Blade plates are used mainly in the context of reconstructive procedures, as well as in the treatment of pseudoarthroses. The Pauwel procedure in femoral neck non-unions is one of the best known indications. In contrast, the dynamic hip screw is the gold standard for stabilization of femoral neck and most pertrochanteric fractures, whereas the dynamic condylar screw is still an alternative to internal fixators for proximal and distal femoral fracture fixations.
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Affiliation(s)
- H J Oestern
- Klinik für Unfallchirurgie, Orthopädie und Neurotraumatologie, Allgemeines Krankenhaus Celle, Siemensplatz 4, 29223, Celle, Deutschland.
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Biomechanical comparison of proximal locking plates and blade plates for the treatment of comminuted subtrochanteric femoral fractures. J Orthop Trauma 2009; 23:628-33. [PMID: 19897983 DOI: 10.1097/bot.0b013e3181b04835] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The 95 degrees angled blade plate is an accepted standard for plating subtrochanteric femoral fractures but can be technically demanding and often requires extensive soft tissue exposure. Proximal femoral locking plates (PFLPs) have been developed for subtrochanteric and pertrochanteric fractures and are potentially easier to apply with less soft tissue dissection. Clinical experience has raised concerns regarding the strength of the PFLP. The purpose of our study was to compare the relative stability of two designs of PFLP with the 95 degrees angled blade plate under loads simulating the first 3 months of progressive weight bearing after fracture fixation. METHODS A comminuted subtrochanteric femoral fracture model was created with a 2-cm gap below the lesser trochanter in 15 synthetic femora. Fracture fixation of three plates (95 degrees angled blade plate [blade plate], the original version of the PFLP [O-PFLP], and the newest version of the PFLP [N-PFLP]), all manufactured by Synthes, Inc., Paoli, PA, was tested under progressive cyclic loading to reproduce progressive weight bearing during 3 months after fracture fixation. The force and number of cycles to reach 5 mm of displacement of the femoral head or failure of the implant were compared for each implant. RESULTS N-PFLPs were significantly stiffer than blade plates and O-PFLPs (P = 0.01) and had a trend toward withstanding more cycles before failure (P = 0.06). All five O-PFLPs demonstrated catastrophic fatigue failure before completion of the protocol. One each of the blade plates and the N-PFLPs failed to complete the protocol (P = 0.04). CONCLUSIONS In the model studied, N-PFLPs were shown to have biomechanical properties that were at least equivalent to those of the blade plate. The fatigue failures of O-PFLPs mirrored our clinical experience. Use of the N-PFLP might be a viable alternative fixation method for comminuted subtrochanteric femoral fractures that currently are treated with blade plates.
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Nikolaou VS, Papathanasopoulos A, Giannoudis PV. What's new in the management of proximal femoral fractures? Injury 2008; 39:1309-18. [PMID: 19036361 DOI: 10.1016/j.injury.2008.09.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2008] [Accepted: 09/03/2008] [Indexed: 02/02/2023]
Abstract
The incidence of proximal femoral fractures has increased significantly in recent years, and is expected to continue to rise with increasing life expectancy. However, the optimal method of treatment of these fractures is still debated. This article summarises current evidence concerning the most controversial issues in the treatment of intracapsular and extracapsular proximal femoral fractures. Despite initial enthusiasm, many new treatment options have been proved inferior to older, traditional methods, and physicians should be cautious when it comes to managing these fractures. It seems that meticulous surgical technique and implant selection according to fracture pattern and the characteristics of the individual patient offer the best route to optimal final outcome.
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Indirect Reduction and Submuscular Plating of Subtrochanteric Femur Fracture. Tech Orthop 2008. [DOI: 10.1097/bto.0b013e31817bf2f9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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