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Konstantinou P, Kostretzis L, Fragkiadakis G, Touchtidou P, Mavrovouniotis A, Davitis V, Ditsiou AZ, Gigis I, Nikolaides AP, Niakas D, Papadopoulos P, Ditsios K. Exploring Quality of Life and Mortality in Pertrochanteric Fragility Hip Fractures in Northern Greece: A Single Tertiary Center Study. J Clin Med 2024; 13:2478. [PMID: 38731006 PMCID: PMC11084555 DOI: 10.3390/jcm13092478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 04/11/2024] [Accepted: 04/19/2024] [Indexed: 05/13/2024] Open
Abstract
Background: Fragility-related pertrochanteric fractures have become a significant public health concern, with a rising incidence attributed to the expanding elderly demographic. Assessing patient-reported health-related quality of life (HRQoL), mortality, and factors correlated with them serves as a crucial metric in evaluating the effectiveness of hip fracture surgery. Methods: In a single-center retrospective study, 259 patients underwent surgical treatment with a cephalomedullary nail, with a mean follow-up of 21.7 months. Health-related quality of life (HRQoL) was assessed using SF-12 (12-item Short Form) and EQ-5D (EuroQoL-5 Dimensions) questionnaires. Mobility status was measured by the Crude Mobility Index (CMI). Surveys were administered during hospitalization and six months postoperatively. Statistical analysis involved descriptive statistics, non-parametric controls (Kendall, Mann-Whitney, and Wilcoxon), and Spearman correlation and logistic regression analysis, which were conducted using IBM SPSS version 28. Results: A statistically significant decrease was observed in the mean EQ-5D and SF-12 scores at 6 months post-op compared to the pre-fracture status. The ASA (American Society of Anaesthesiologists) score showed a significant correlation with the decrease in HRQoL measured by the SF-12 questionnaire. The 30-day post-operative mortality rate was 9.3%, increasing to 32.4% at 1 year. Notably, the 30-day mortality significantly rose during the pandemic era (5.0% vs. 12.0%; p = 0.003). Conclusions: Pertrochanteric hip fractures cause a lasting decline in quality of life. Annual mortality is high, and further investigations are needed to formulate policies that prevent hip fractures and reduce mortality rates.
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Affiliation(s)
- Panagiotis Konstantinou
- 2nd Orthopaedic Department, Aristotle University of Thessaloniki, “G. Gennimatas” Hospital, Eth. Aminis 41, 546 35 Thessaloniki, Greece; (L.K.); (P.T.); (A.M.); (V.D.); (I.G.); (P.P.); (K.D.)
- University Hospitals Birmingham NHS Foundation Trust, Birmingham B7 5TE, UK;
| | - Lazaros Kostretzis
- 2nd Orthopaedic Department, Aristotle University of Thessaloniki, “G. Gennimatas” Hospital, Eth. Aminis 41, 546 35 Thessaloniki, Greece; (L.K.); (P.T.); (A.M.); (V.D.); (I.G.); (P.P.); (K.D.)
| | - Georgios Fragkiadakis
- Healthcare Management, School of Social Science, Hellenic Open University, 263 35 Patra, Greece; (G.F.); (D.N.)
| | - Panagiota Touchtidou
- 2nd Orthopaedic Department, Aristotle University of Thessaloniki, “G. Gennimatas” Hospital, Eth. Aminis 41, 546 35 Thessaloniki, Greece; (L.K.); (P.T.); (A.M.); (V.D.); (I.G.); (P.P.); (K.D.)
| | - Argyrios Mavrovouniotis
- 2nd Orthopaedic Department, Aristotle University of Thessaloniki, “G. Gennimatas” Hospital, Eth. Aminis 41, 546 35 Thessaloniki, Greece; (L.K.); (P.T.); (A.M.); (V.D.); (I.G.); (P.P.); (K.D.)
| | - Vasileios Davitis
- 2nd Orthopaedic Department, Aristotle University of Thessaloniki, “G. Gennimatas” Hospital, Eth. Aminis 41, 546 35 Thessaloniki, Greece; (L.K.); (P.T.); (A.M.); (V.D.); (I.G.); (P.P.); (K.D.)
| | - Athina Zacharoula Ditsiou
- School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, 541 24 Thessaloniki, Greece;
| | - Ioannis Gigis
- 2nd Orthopaedic Department, Aristotle University of Thessaloniki, “G. Gennimatas” Hospital, Eth. Aminis 41, 546 35 Thessaloniki, Greece; (L.K.); (P.T.); (A.M.); (V.D.); (I.G.); (P.P.); (K.D.)
| | | | - Dimitris Niakas
- Healthcare Management, School of Social Science, Hellenic Open University, 263 35 Patra, Greece; (G.F.); (D.N.)
| | - Pericles Papadopoulos
- 2nd Orthopaedic Department, Aristotle University of Thessaloniki, “G. Gennimatas” Hospital, Eth. Aminis 41, 546 35 Thessaloniki, Greece; (L.K.); (P.T.); (A.M.); (V.D.); (I.G.); (P.P.); (K.D.)
| | - Konstantinos Ditsios
- 2nd Orthopaedic Department, Aristotle University of Thessaloniki, “G. Gennimatas” Hospital, Eth. Aminis 41, 546 35 Thessaloniki, Greece; (L.K.); (P.T.); (A.M.); (V.D.); (I.G.); (P.P.); (K.D.)
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Panteli M, Vun JSH, West RM, Howard A, Pountos I, Giannoudis PV. Subtrochanteric femoral fractures and intramedullary nailing complications: a comparison of two implants. J Orthop Traumatol 2022; 23:27. [PMID: 35764711 PMCID: PMC9240121 DOI: 10.1186/s10195-022-00645-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 05/21/2022] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Intramedullary (IM) nails are considered the 'gold' standard treatment for subtrochanteric femoral fractures. The incidence and risk factors for re-operation in subtrochanteric fractures remain unclear. Furthermore, no studies have compared the outcomes of different nailing systems used to treat subtrochanteric fractures in the same study population. AIMS/OBJECTIVES Our study aimed to (i) investigate the cumulative incidence and factors associated with an increased risk of re-operation in subtrochanteric fractures treated with a long intramedullary (IM) nail, (ii) compare the outcomes of subtrochanteric fractures treated with long Affixus and Gamma nails, and (iii) establish whether the addition of a proximal anti-rotation screw in the Affixus nail confers any clinical benefit. METHODS A retrospective review of all adult patients admitted to a level 1 trauma centre with a subtrochanteric femur fracture treated with a long cephalomedullary IM nail over an 8-year period was conducted. Exclusion criteria were primary surgery performed at another institution, prophylactic nailing because of tumours, incomplete fractures, and patients who were lost to follow-up or died before fracture healing. Data variables were assessed for normality prior to determining the use of either parametric or non-parametric tests. Logistic regression analysis was performed to identify potential factors associated with re-operation. For the comparison between the two nail types, patients were matched into two groups of 119 each by age (10-year intervals), gender and mechanism of injury (low energy, high energy and pathological fractures). A p-value < 0.05 was considered significant. The Kaplan-Meier nail survival curve was used to demonstrate the survival of each nail. Data were analysed using the statistical package R (R version 3.6.0). RESULTS A total of 309 subtrochanteric fractures were treated with a distally locked long IM nail (re-operation rate: 22.33%) over an 8-year period. Logistic regression identified six factors associated with an increased risk of re-operation, including age < 75 years old, use of a long Gamma nail, pre-injury coxa-vara femoral neck shaft angles, an immediate post-operative reduction angle of > 10° varus, deep wound infection and non-union. Following matching, we compared the two long cephalomedullary nailing systems used (Gamma versus Affixus nail). The only differences identified from the unadjusted analysis were a higher overall incidence of nail failure in Gamma nails due to any cause, re-operation, and impingement of the nail tip distally against the anterior femoral cortex. When we corrected for covariates, no significant differences remained evident between the two nails. From the Kaplan-Meier nail survival curves, however, the Affixus nail demonstrated better survivorship up to 5 years post-implantation in terms of nail failure and re-operation for all causes. Finally, the addition of a proximal anti-rotation screw in the Affixus nail did not seem to confer any benefit. CONCLUSION We reported a 22.3% re-operation rate in our cohort of subtrochanteric fractures treated with a long IM nail. We have identified six risk factors associated with re-operation: age < 75 years old, pre-injury femoral neck shaft angle, choice of nail, varus reduction angle, fracture-related infection and non-union. The addition of a proximal anti-rotation screw in the Affixus nail did not confer any benefit.
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Affiliation(s)
- Michalis Panteli
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Clarendon Wing, Level D, Great George Street, Leeds, LS1 3EX, West Yorkshire, UK. .,Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK. .,Leeds Orthopaedic & Trauma Sciences, Leeds General Infirmary, University of Leeds, Leeds, UK.
| | - James S H Vun
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Clarendon Wing, Level D, Great George Street, Leeds, LS1 3EX, West Yorkshire, UK.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,Leeds Orthopaedic & Trauma Sciences, Leeds General Infirmary, University of Leeds, Leeds, UK
| | - Robert M West
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Anthony Howard
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Clarendon Wing, Level D, Great George Street, Leeds, LS1 3EX, West Yorkshire, UK.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,Leeds Orthopaedic & Trauma Sciences, Leeds General Infirmary, University of Leeds, Leeds, UK
| | - Ippokratis Pountos
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Clarendon Wing, Level D, Great George Street, Leeds, LS1 3EX, West Yorkshire, UK.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Peter V Giannoudis
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Clarendon Wing, Level D, Great George Street, Leeds, LS1 3EX, West Yorkshire, UK.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,Leeds Orthopaedic & Trauma Sciences, Leeds General Infirmary, University of Leeds, Leeds, UK.,NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, Leeds, UK
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Zhao F, Guo L, Wang X, Zhang Y. Benefit of lag screw placement by a single- or two-screw nailing system in elderly patients with AO/OTA 31-A2 trochanteric fractures. J Int Med Res 2021; 49:3000605211003766. [PMID: 33787370 PMCID: PMC8020241 DOI: 10.1177/03000605211003766] [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] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective To retrospectively analyze the clinical outcomes of two intramedullary
fixation devices, the INTERTAN nail and Gamma3 nail, for treatment of AO/OTA
31-A2 trochanteric fractures in elderly patients. Methods In total, 165 elderly patients underwent treatment for AO/OTA 31-A2
trochanteric fractures in our hospital from June 2017 to June 2018 (INTERTAN
group, n = 79; Gamma3 group, n = 86). All patients underwent radiological
and clinical investigations and were followed up for an average of 12
months. Age, sex, fracture type, surgical time, intraoperative blood loss,
fracture healing time, and complications were compared between the two
groups. Results The surgical time was significantly shorter and the intraoperative blood loss
volume was significantly lower in the Gamma3 than INTERTAN group (58.2 ± 2.5
vs. 81.7 ± 14.2 minutes and 170 ± 29 vs. 220 ± 16 mL, respectively).
However, there were no significant differences in the reduction quality,
hospital stay, fracture healing time, Harris hip score, postoperative
complications, or 1-year postoperative mortality. Conclusion Both INTERTAN and Gamma3 nails may be effective for surgical treatment of
AO/OTA 31-A2 trochanteric fractures in elderly patients. However, the Gamma3
nail was superior to the INTERTAN nail in terms of surgical time and
intraoperative blood loss.
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Affiliation(s)
- Fulong Zhao
- Department of Trauma Orthopedics, Beijing Luhe Hospital affiliated to Capital Medical University, Beijing, P.R. China
| | - Lijuan Guo
- Clinical Laboratory, Emergency General Hospital, Beijing, P.R. China
| | - Xuefei Wang
- Department of Trauma Orthopedics, Beijing Luhe Hospital affiliated to Capital Medical University, Beijing, P.R. China
| | - Yakui Zhang
- Department of Trauma Orthopedics, Beijing Luhe Hospital affiliated to Capital Medical University, Beijing, P.R. China
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Toro G, Moretti A, Ambrosio D, Pezzella R, De Cicco A, Landi G, Tammaro N, Florio P, Cecere AB, Braile A, Medici A, Siano A, Di Maggio B, Calabrò G, Gagliardo N, Di Fino C, Bruno G, Pellegrino A, Negri G, Monaco V, Gison M, Toro A, Schiavone Panni A, Tarantino U, Iolascon G. Fractures around Trochanteric Nails: The "Vergilius Classification System". Adv Orthop 2021; 2021:7532583. [PMID: 33520318 PMCID: PMC7817309 DOI: 10.1155/2021/7532583] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 12/29/2020] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION The fractures that occurred around trochanteric nails (perinail fractures, PNFs) are becoming a huge challenge for the orthopaedic surgeon. Although presenting some specific critical issues (i.e., patients' outcomes and treatment strategies), these fractures are commonly described within peri-implant ones and their treatment was based on periprosthetic fracture recommendations. The knowledge gap about PNFs leads us to convene a research group with the aim to propose a specific classification system to guide the orthopaedic surgeon in the management of these fractures. MATERIALS AND METHODS A steering committee, identified by two Italian associations of orthopaedic surgeons, conducted a comprehensive literature review on PNFs to identify the unmet needs about this topic. Subsequently, a panel of experts was involved in a consensus meeting proposing a specific classification system and formulated treatment statements for PNFs. Results and Discussion. The research group considered four PNF main characteristics for the classification proposal: (1) fracture localization, (2) fracture morphology, (3) fracture fragmentation, and (3) healing status of the previous fracture. An alphanumeric code was included to identify each characteristic, allowing to describe up to 54 categories of PNFs, using a 3- to 4-digit code. The proposal of the consensus-based classification reporting the most relevant aspects for PNF treatment might be a useful tool to guide the orthopaedic surgeon in the appropriate management of these fractures.
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Affiliation(s)
- Giuseppe Toro
- 1Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
- 2Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Antimo Moretti
- 1Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Daniele Ambrosio
- 3Unit of Orthopaedics and Traumatology, Evangelical Hospital Betania, Naples, Italy
| | - Raffaele Pezzella
- 4Department of Life Health & Environmental Sciences, University of L'Aquila, Unit of Orthopaedics and Traumatology, L'Aquila, Italy
| | - Annalisa De Cicco
- 1Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Giovanni Landi
- 1Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Nicola Tammaro
- 1Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Pasquale Florio
- 3Unit of Orthopaedics and Traumatology, Evangelical Hospital Betania, Naples, Italy
| | - Antonio Benedetto Cecere
- 1Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Adriano Braile
- 1Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Antonio Medici
- 5Unit of Orthopaedics and Traumatology, AORN S. Giuseppe Moscati, Avellino, Italy
| | - Antonio Siano
- 6Unit of Orthopaedics and Traumatology, Santa Maria Della Speranza Hospital, Battipaglia, Italy
| | - Bruno Di Maggio
- 7Unit of Orthopaedics and Traumatology, “Ave Gratia Plena” Civil Hospital, Piedimonte Matese, Italy
| | - Giampiero Calabrò
- 8Unit of Orthopaedics and Traumatology, San Francesco D'Assisi Hospital, Oliveto Citra, Italy
| | - Nicola Gagliardo
- 9Unit of Orthopaedics and Traumatology, San Giuliano Hospital, Giugliano, Italy
| | - Ciro Di Fino
- 10Unit of Orthopaedics and Traumatology, AOR San Carlo, Potenza, Italy
| | - Gaetano Bruno
- 11Unit of Orthopaedics and Traumatology, AORN Sant'Anna e San Sebastiano, Caserta, Italy
| | - Achille Pellegrino
- 12Unit of Orthopaedics and Traumatology, San Giuseppe Moscati Hospital, Aversa, Italy
| | - Giacomo Negri
- 3Unit of Orthopaedics and Traumatology, Evangelical Hospital Betania, Naples, Italy
| | - Vincenzo Monaco
- 13Unit of Orthopaedics and Traumatology, Santa Maria Incoronata Dell'Olmo Hospital, Cava de' Tirreni, Italy
| | - Michele Gison
- 14Unit of Orthopaedics and Traumatology, Villa Malta Hospital, Sarno, Italy
| | - Antonio Toro
- 14Unit of Orthopaedics and Traumatology, Villa Malta Hospital, Sarno, Italy
| | - Alfredo Schiavone Panni
- 1Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - Umberto Tarantino
- 2Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Giovanni Iolascon
- 1Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, Naples, Italy
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Wu K, Xu Y, Zhang L, Zhang Y, Xu W, Chu J, Bao N, Ma Q, Yang H, Guo JJ. Which implant is better for beginners to learn to treat geriatric intertrochanteric femur fractures: A randomised controlled trial of surgeons, metalwork, and patients. J Orthop Translat 2019; 21:18-23. [PMID: 32071871 PMCID: PMC7013097 DOI: 10.1016/j.jot.2019.11.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 10/28/2019] [Accepted: 11/21/2019] [Indexed: 11/30/2022] Open
Abstract
Background We wondered whether the third-generation gamma nail-3 (GN-3) was better for junior surgeons to learn to treat geriatric intertrochanteric femur fractures than proximal femoral nail antirotation-II (PFNA-II). Methods This is a prospective randomised study of 350 patients who underwent GN-3 fixation and PFNA-II carried out by junior orthopaedic trauma surgeons from January 2011 February 2017. We compared nail positioning, complication rates, operative and fluoroscopy time, blood transfused, time to mobilisation, hospital stay, fracture union, mismatch, mortality and postoperative outcomes. The minimum follow-up was 12 months (mean, 27.2 months; range, 12–42 months). Results The recovery rate of the GN-3 group was higher than that of the PFNA-II group significantly. Compared with the PFNA-II group, the GN-3 group was superior in fracture gap, while operative time, fluoroscopy time, blood transfused, time to mobilisation, hospital stay, Harris Hip Score, reoperation, mortality and so on had no significant difference between two groups. There were five cases with cutout through the femoral neck in the GN-3 group, whereas in the PFNA-II group, we only had two cases with significant difference. The area of match in the GN-3 group conformed to that of the femur of Asian population better than that in the PFNA-II group. Conclusions PFNA-II and GN-3 internal fixation are both effective methods for junior orthopaedic trauma surgeons to treat femoral intertrochanteric fracture. But our study reveals better results of the GN-3 group over the PFNA-II group on recovery rate. There is a high rate of cutout in patients treated with the GN-3, especially for those with bone defect or serious osteoporosis. The translational potential of this article The results of this work have the potential to improve the cognition of geriatric intertrochanteric femur fractures for junior surgeons, supplying the theoretical basis for the selection and comparison of Intramedullary nail. Such a guidance will allow better healing, fewer complications, and ultimately improved outcomes.
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Affiliation(s)
- Kailun Wu
- Department of Orthopedics, Suzhou Dushuhu Public Hospital (The First Affiliated Hospital of Soochow University, Dushuhu Branch), Suzhou, China
| | - Yingjie Xu
- Department of Orthopedics, Suzhou Dushuhu Public Hospital (The First Affiliated Hospital of Soochow University, Dushuhu Branch), Suzhou, China.,Department of Orthopedics, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Lei Zhang
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yong Zhang
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Wu Xu
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jiaobao Chu
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Nirong Bao
- Department of Orthopaedics, Jinling Hospital, School of Medicine, Nanjing University, Nanjing 210002, Jiangsu, PR China
| | - Qianli Ma
- Department of Orthopedics, Fuzhou Second Hospital Affiliated to Xiamen University, Fuzhou, China
| | - Huilin Yang
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jiong Jiong Guo
- Department of Orthopedics, The First Affiliated Hospital of Soochow University, Suzhou, China
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Intramedullary nailing for pertrochanteric fractures of proximal femur: a consecutive series of 323 patients treated with two devices. J Orthop Surg Res 2019; 14:449. [PMID: 31852485 PMCID: PMC6921538 DOI: 10.1186/s13018-019-1506-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 12/03/2019] [Indexed: 11/10/2022] Open
Abstract
Introduction Pertrochanteric fractures (PFs) frequently affect the lower limb of osteoporotic patients and represent an important cause of morbidity and mortality in the elderly. In this prospective randomized controlled trial, we have compared functional and radiological results and complications of patients affected by PFs treated with two intramedullary proximal femoral nails. Materials We enrolled 323 subjects with PFs, classified according to AO/OTA system as 31.A1 (pertrochanteric simple) and 31.A2 (pertrochanteric multifragmentary). Patients were divided into two groups according to the osteosynthesis devices: group A, Elos-Intrauma® nail (155 cases) and group B, Gamma 3-Stryker® nail (168 cases). Pre-operatively, the baseline characteristics of each patient (gender, age, weight and BMI) were collected. Intraoperative blood loss, subjective pain by visual analogue scale (VAS), esthetic satisfaction, functional scores of the hip by Harris Hip Score (HHS), and Western Ontario and McMaster Universities Arthritis Index (WOMAC) were noted. The post-operative degree of fracture reduction was assessed. Each patient had a minimum follow-up of 12 months. Results The study group was composed of 106 male and 217 female with an average age of 85.4 (range, 65–90, standard deviation (SD) 5.95) years. No statistical differences about sex and age distribution were noted between the two groups. Group A reported lower intraoperative blood loss, 45 ml vs 51 ml, respectively (p < 0.001). There was not any statistical difference about operative time. Group A had a better reduction of fracture (p = 0.0347). The greatest difference was detectable comparing subgroups 31.A2 (p = 0.032). There were no statistical differences about complication frequency and the overall rate was 25% (80 cases). Finally, there was no difference in terms of VAS, HHS, and WOMAC score between the two groups on each follow-up. Patients of group A showed a higher subjective satisfaction index at 1 post-operative year, 7.42 (SD 1.19) vs 6.45 (SD 1.35) of group B (p < 0.001). Conclusion Elos® nail is a reliable device on a short-term follow-up and represents an alternative choice to the Gamma 3® nail, a well-known and appreciated system for over 25 years.
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7
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Persiani P, Ranaldi FM, Gurzì M, Formica A, Graci J, De Cristo C, Grasso R, Villani C. Choice of three different intramedullary nails in the treatment of trochanteric fractures: Outcome, analysis and consideration in midterm. Injury 2019; 50 Suppl 4:S6-S10. [PMID: 30691924 DOI: 10.1016/j.injury.2019.01.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 01/12/2019] [Indexed: 02/02/2023]
Abstract
The purpose of this study is to compare the results obtained using three different systems of osteosynthesis, developed for the surgical treatment of fractures of the trochanteric region of the femur, based on the principle intramedullary nailing: the Gamma nail, the Affixus nail and the ZNN nail. This is a retrospective study: 72 trochanteric fractures treated with the Gamma nail, 68 treated with the Affixus nail and 69 treated with the ZNN nail, between the years 2012 and 2014, with the prerequisite of a minimum follow-up of 18 months. The fractures were classified according to the AO system; the most commonly reported subtype was the A2 fracture. Clinical and radiographic examinations were performed, both at hospital admission and post-operatively, at 1, 3, 6, 12 and 18 months. Of the 209 patients, 171 were women and 38 were men. The average age was 83.12 years old. All three systems guaranteed an early mobilization and ambulation in most of the patients. There were no significant differences in the use of the three nails in terms of recovery of previous functional capacity, or in terms of the time required for the fracture to heal. There were no advantages encountered with the use of one intramedullary nail over another and, in particular, when observing the complications and patient outcome, there were no statistically significant differences detected.
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Affiliation(s)
- Pietro Persiani
- Department of Anatomical, Histological, Forensic Medicine and Orthopedic Science, Sapienza University of Rome, Italy
| | - Filippo Maria Ranaldi
- Department of Anatomical, Histological, Forensic Medicine and Orthopedic Science, Sapienza University of Rome, Italy.
| | - Michele Gurzì
- Department of Anatomical, Histological, Forensic Medicine and Orthopedic Science, Sapienza University of Rome, Italy
| | | | - Jole Graci
- Department of Anatomical, Histological, Forensic Medicine and Orthopedic Science, Sapienza University of Rome, Italy
| | - Claudia De Cristo
- Department of Anatomical, Histological, Forensic Medicine and Orthopedic Science, Sapienza University of Rome, Italy
| | - Raffaele Grasso
- Department of Anatomical, Histological, Forensic Medicine and Orthopedic Science, Sapienza University of Rome, Italy
| | - Ciro Villani
- Department of Anatomical, Histological, Forensic Medicine and Orthopedic Science, Sapienza University of Rome, Italy
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8
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Hirschfeld C, Jung J, Wicher A, Mousavi M. [Surgical revision for complications after gamma3-nailing osteosynthesis of proximal humeral fractures : Follow-up series of 1500 patients]. Unfallchirurg 2019; 122:950-957. [PMID: 30680414 DOI: 10.1007/s00113-019-0607-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The γ‑nailing system is a widespread intramedullary therapeutic option that has been used for intertrochanteric and subtrochanteric fractures since the late 1980s; however, some reports from the 1990s describing femoral shaft fractures questioned the indications for this system in simple fracture types. Due to increasing numbers of patients treated with this system, the complication rate is continuously falling as confirmed by many recent studies. OBJECTIVE Between 2008 and 2013 a total of 1500 operations using the γ‑nailing system were performed at this traumatology department. The standard 200 mm nail was used in 1290 cases and the extended system available from 340 to 440 mm in 210 cases. The aim of this study was to record the excellent results using the standard γ‑nailing system and to confirm the indications of the long intramedullary nailing system (Gamma3®) also for use in complex intertrochanteric and subtrochanteric fractures. MATERIAL AND METHODS All 1500 patients were retrospectively analyzed. Information on epidemiological data, intraoperative and postoperative complications and patient outcome was retrieved from the digital patient medical history. All available radiographs were assessed by a single traumatologist. RESULTS The results showed a low complication rate of 5% for surgical complications, mainly caused by cutting out in 34.66%, followed by hematomas in 21.33% and fractures of the nail in 16%. A comparison of the standard and long nailing systems could be carried out, showing a complication rate of 3.64% for the standard system compared to 13.33% for the long γ‑nail system. CONCLUSION The γ‑nailing system is a safe treatment option for trochanteric femoral fractures and failure of the implant is associated with high biomechanical forces in unstable fractures. A low complication rate is linked to a thorough surgical technique under consideration of a correct positioning of the implant.
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Affiliation(s)
- C Hirschfeld
- Abteilung für Unfallchirurgie und Sporttraumatologie, Donauspital Wien, Langobardenstraße 122, 1220, Wien, Österreich.
| | - J Jung
- Abteilung für Unfallchirurgie und Sporttraumatologie, Donauspital Wien, Langobardenstraße 122, 1220, Wien, Österreich
| | - A Wicher
- Medizinische Universität Wien, Spitalgasse 23, 1090, Wien, Österreich
| | - M Mousavi
- Abteilung für Unfallchirurgie und Sporttraumatologie, Donauspital Wien, Langobardenstraße 122, 1220, Wien, Österreich
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9
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Mattisson L, Bojan A, Enocson A. Epidemiology, treatment and mortality of trochanteric and subtrochanteric hip fractures: data from the Swedish fracture register. BMC Musculoskelet Disord 2018; 19:369. [PMID: 30314495 PMCID: PMC6186067 DOI: 10.1186/s12891-018-2276-3] [Citation(s) in RCA: 143] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 09/24/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hip fractures are a major worldwide public health problem and includes two main types of fractures: the intracapsular (cervical) and the extracapsular (trochanteric and subtrochanteric) fractures. The aim of this study on patients with trochanteric and subtrochanteric hip fractures was to describe the epidemiology, treatment and outcome in terms of mortality within the context of a large register study. METHODS A descriptive epidemiological register study including patients registered in the national Swedish Fracture Register from January 2014 to December 2016. Inclusion criteria were all primary surgically treated traumatic non-pathological trochanteric and subtrochanteric femoral fractures in patients aged 18 years and above. Individual patient data (age, gender, injury location, injury cause, fracture type, treatment and timing of surgery) were retrieved from the register database. Mortality data was obtained via linkage to the Swedish Death Register. RESULTS A total of 10,548 consecutive patients were identified and included in the study. The mean (±SD) age for all patients was 82 ± 11 years and the majority of the patients were females (69%). Most of the fractures were caused by a fall at the same level (83%) at the patients' accommodation (75%). Fractures were classified using the AO/OTA classification as 31-A1 in 29%, as 31-A2 in 49% and as 31-A3 in 22% of the cases. The most commonly used implant was a short antegrade intramedullary nail (42%), followed by a plate with sliding hip screw (37%). With increasing fracture complexity, the proportion of intramedullary nails was increasing, and also the use of long versus short nails. The majority of the patients were operated within 36 h (90%). There was a higher mortality at 30 days and 1 year for males, and for all those who were delayed to surgery > 36 h. CONCLUSION Safety measures to prevent fall at elderly patient's accommodation might be a way to reduce the number of trochanteric and subtrochanteric hip fractures. Surgery as soon as possible without delay should be considered to reduce the mortality rate. The selection of surgical methods depends on the fracture complexity.
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Affiliation(s)
- Leif Mattisson
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet. Department of Orthopaedics, Stockholm South General Hospital, 11883 Stockholm, Sweden
| | - Alicja Bojan
- Department of Orthopaedics, Sahlgrenska University Hospital Gothenburg/Mölndal, 431 80 Mölndal, Sweden
| | - Anders Enocson
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet. Department of Orthopaedics, Stockholm South General Hospital, 11883 Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska University Hospital, Karolinska Institutet, 17176 Stockholm, Sweden
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10
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Ax M, Reito A, Koskimaa M, Uutela A, Paloneva J. Scheduled Emergency Trauma Operation: The Green Line Orthopedic Trauma Surgery Process Of Care. Scand J Surg 2018; 108:250-257. [PMID: 30278834 DOI: 10.1177/1457496918803015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND AIMS Traditionally, patients requiring an orthopedic emergency operation were admitted to an inpatient ward to await surgery. This often led to congestion of wards and operation rooms while, for less urgent traumas, the time spent waiting for the operation often became unacceptably long. The purpose of this study was to evaluate the flow of patients coded green in a traffic light-based coding process aimed at decreasing the burden on wards and enabling a scheduled emergency operation in Central Finland Hospital. MATERIALS AND METHODS Operation urgency was divided into three categories: green (>48 h), yellow (8-48 h), and red (<8 h). Patients, who had sustained an orthopedic trauma requiring surgery, but not inpatient care (green), were assigned an operation via green line process. They were discharged until the operation, which was scheduled to take place during office hours. RESULTS Between January 2010 and April 2015, 1830 green line process operations and 5838 inpatient emergency operations were performed. The most common green line process diagnoses were distal radial fracture (15.4% of green line process), (postoperative) complications (7.7%), and finger fractures (4.9%). The most common inpatient emergency operation diagnosis was hip fracture (24.3%). Green line process and inpatient emergency operation patients differed in age, physical status, diagnoses, and surgical procedures. CONCLUSION The system was found to be a safe and effective method of implementing orthopedic trauma care. It has the potential to release operation room time for more urgent surgery, shorten the time spent in hospital, and reduce the need to operate outside normal office hours.
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Affiliation(s)
- M Ax
- 1 Central Finland Hospital, Jyväskylä, Finland
| | - A Reito
- 1 Central Finland Hospital, Jyväskylä, Finland
| | - M Koskimaa
- 1 Central Finland Hospital, Jyväskylä, Finland
| | - A Uutela
- 2 Helsinki University Hospital, Helsinki, Finland
| | - J Paloneva
- 1 Central Finland Hospital, Jyväskylä, Finland
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11
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Noda M, Saegusa Y, Takahashi M, Noguchi C, Yoshikawa C, Mikami H, Gotouda A. Comparison of Post-Operative Muscular Strength Between Gamma Nailing and Hemiarthroplasty System in Femoral Intertrochanteric Fractures. Open Orthop J 2017; 11:255-262. [PMID: 28567153 PMCID: PMC5420168 DOI: 10.2174/1874325001711010255] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 02/25/2017] [Accepted: 02/27/2017] [Indexed: 11/22/2022] Open
Abstract
Background: The current study focuses on the comparison of postoperative muscular strength around the hip joint of patients with femoral intertrochanteric fractures treated either by cephalo-medullary (CM) nailing or a new bipolar hip prosthesis (BHP), an especially attached device to secure displaced greater trochanteric fragment. Methods: Twenty patients treated with CM nailing were age- and sex- matched with a control group of 20 patients treated with BHP. Maximum isometric forces at the bilateral hip joint were measured during the follow up period. Means of 3 measurements were represented. Results: The mean and standard deviation values (kg) of muscle strength at the non-operative/ operative side in the CM nailing group were as follows: flexion strength 9.5±4.7/8.5±4.9 (P=0.06), extension strength 6.2±3.5/5.5±3.7 (P=0.08), abduction strength at 0 degrees 7.7±3.5/6.2±2.8 (p=0.002), abduction strength at 10 degrees 5.5±2.0/4.2±2.0 (p=0.001). In the BHP group, mean and standard deviation values of muscle strength at the non-operative/ operative side were as follows: flexion strength 6.5±2.8/6.0±3.4 (P=0.08), extension strength 4.4±0.9/4.4±0.6 (P=0.83), abduction strength at 0 degrees 5.1±1.9/5.0±1.6 (p=0.12), and that at 10 degrees 4.7±1.4/4.6±1.3 (p=0.10). Conclusion: Our results demonstrate that CM nailing may cause a 25-30% decrease in postoperative muscle strength around the hip joint, particularly during hip abduction. With the new BHP, greater trochanter reduction is achieved allowing early weight bearing and maintaining strength in abduction. Surgeons should consider postoperative muscular strength as one of the necessary factors for selection of the appropriate surgical procedure. Level of Evidence: Therapeutic Level III.
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Affiliation(s)
- Mitsuaki Noda
- Konan Hospital, Department of Orthopedics, Kobe, Japan
| | | | | | - Chisa Noguchi
- Konan Hospital, Department of Orthopedics, Kobe, Japan
| | | | - Hiroshi Mikami
- Yoshinogawa Medical Center, Department of Rehabilitation, Yoshinogawa city, Japan
| | - Akira Gotouda
- Yoshinogawa Medical Center, Department of Rehabilitation, Yoshinogawa city, Japan
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Roßbach BP, Faymonville C, Müller LP, Stützer H, Isenberg J. [Quality of life and job performance resulting from operatively treated tibial plateau fractures]. Unfallchirurg 2017; 119:27-35. [PMID: 25037262 DOI: 10.1007/s00113-014-2618-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The aim of this article is to present the functional results and the effect on quality of life of surgically treated tibial plateau fractures in physically active and working patients with multiple and serious injuries. In addition, the relationships between functional and radiological outcome were evaluated and compared with activity in daily and professional life. PATIENTS AND METHODS In all, 41 injured patients were followed up a mean of 47 months after surgical treatment and examined with radiological, functional, as well as quality of life score. RESULTS In the radiological scoring, a mean value of 72 points (max 100 points) was achieved. In the activity score, there was an average of 63.5 points (max 100 points). When evaluating the health-related quality of life, an average score of 69.6 points was achieved. There was a significant relationship between radiological and activity scores and the radiological and life quality scores. Furthermore, the relationship between activity and quality of life scores was considered significant. Surgeon's influence on the functional outcome could be confirmed. CONCLUSION The functional and the radiological results were moderate. Quality of life was permanently affected by the consequences of tibial plateau fracture in 12 patients; 11 patients were not re-employed. However, the quality of life was assessed as good or very good and 28 patients had returned to work. The quality of life was firmly linked to the radiological and functional parameters, which tended to be influenced by the quality of the primary surgical treatment when looking at the overall population.
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Affiliation(s)
- B P Roßbach
- Klinik und Poliklinik für Orthopädie, Physikalische Medizin und Rehabilitation, Klinikum der Universität München (LMU), Campus Großhadern, Marchioninistr. 15, 81377, München, Deutschland.
| | - C Faymonville
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinik Köln, Köln, Deutschland
| | - L P Müller
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinik Köln, Köln, Deutschland
| | - H Stützer
- Institut für Medizinische Statistik, Informatik und Epidemiologie, Universität zu Köln, Köln, Deutschland
| | - J Isenberg
- Klinik für Unfallchirurgie und Orthopädie - Klinikum Nordstadt, Klinikum Region Hannover, Hannover, Deutschland
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Cephalomedullary nail versus sliding hip screw for fixation of AO 31 A1/2 intertrochanteric femoral fracture: a 12-year comparison of failure, complications, and mortality. CURRENT ORTHOPAEDIC PRACTICE 2016; 27:604-613. [PMID: 28348717 DOI: 10.1097/bco.0000000000000424] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND In the United States intertrochanteric and pertrochanteric fractures occur at a rate of more than 150,000 cases annually. Current standard of care for these fractures includes fixation with either a cephalomedullary nail (CMN) or a sliding hip screw (SHS). The purpose of this study was to compare failure and medical complications of intertrochanteric femoral fractures repaired by CMN or SHS. METHODS This study is a retrospective cohort study that included 249 patients with AO/OTA 31 A1.1-3, 31 A2.1-3 nonpathological fractures of the femur, of which 137 received CMN and 112 received SHS. Analysis was stratified by fracture type as stable (AO 31A1.1-2.1) or unstable (AO 31A2.2-3). RESULTS The tip-apex distance in stable fractures fixed with CMN was 17.3 ± 5.9 compared to 26.2 ± 7.9 in the stable SHS group (p<0.001) while it was 19.0 ± 5.3 in the unstable CMN group compared to 24.0 ± 6.7 in the unstable SHS patients (P = 0.004). Among patients with stable fracture patterns there was no difference in collapse, complications, failure, or mortality (all P > 0.05). Among patients with unstable fractures CMN had significantly less collapse (P < 0.001) and failure (P = 0.046) but no difference in complications (P = 0.126) or mortality (P = 0.586). CONCLUSIONS There were no significant differences in failure or complication rates when comparing the CMN to the SHS in stable intertrochanteric fractures. CMN demonstrated significantly reduced failure and collapse rates in unstable intertrochanteric fractures when compared to SHS; however, this study had a relatively small sample size of unstable fractures and all results must be interpreted within this context.
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14
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Peña OR, Gómez Gélvez A, Espinosa KA. Clinical implications of impingement of the anterior femoral cortex after cephalomedullary nailing. Injury 2016; 47:2300-2306. [PMID: 27381328 DOI: 10.1016/j.injury.2016.06.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 06/10/2016] [Accepted: 06/20/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND Cortical impingement is a common complication after cephalomedullary nailing, but the evidence about its consequences is very limited. The aim of this study was to assess the clinical implications of cortical impingement on patients treated with cephalomedullary nails. METHODS A cohort study was carried out at a Level I academic Institution with consecutive patients treated with cephalomedullary nails during 2010 and 2013. Demographic and nail variables were recorded as well as cortical impingement was determined on the radiographs. Clinical outcomes such as pain, femoral fractures, and delayed or nonunion of the fracture were detected during the follow-up. The follow-up was divided into short- (6-12 months), medium- (12.1-36 months), and long-term follow-up (≥36.1months). Descriptive statistics were used, and Chi-square or Fisher's exact tests measured the association between categorical variables. The Mann-Whitney U test was performed to evaluate differences between cortical impingement in terms of pain, and pain and the follow-up categories. RESULTS A total of 119 patients were analyzed with a mean age of 74.8 years±17.1, and a mean follow-up of 23.5 months±12.1. Overall the pain was present in 61 (51.2%) cases, and it was observed in 28/59 (47.4%) and 33/60 (55%) of the patients with presence or absence of cortical impingement respectively. There was not a statistically significant association between cortical impingement and pain (p=0.20), neither differences were detected between pain and the follow-up groups (p=0.48). Out of 59 cases with cortical impingement, femoral fractures were observed in two patients (3.3%), and delayed union of the fractures was seen in two patients who did not present impingement. Since patients with delayed union received treatment as soon as it was diagnosed, no cases of nonunion of fractures were identified. CONCLUSIONS Cortical impingement of the anterior cortex of the femur was not associated with the presence of pain, so that other causes should be assessed to explain the pain after 6 months of being treated with a cephalomedullary nail. Femoral fractures, and delayed union or nonunion of the fracture may occur theoretically in patients with cortical impingement.
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Affiliation(s)
- Omar R Peña
- Department of Orthopaedics & Traumatology, Hospital Universitario de La Samaritana, Bogotá, Colombia
| | - Amparo Gómez Gélvez
- Department of Orthopaedics & Traumatology, Hospital Universitario de La Samaritana, Bogotá, Colombia
| | - Kristian A Espinosa
- Department of Orthopaedics & Traumatology, Hospital Universitario de La Samaritana, Bogotá, Colombia.
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15
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Díaz VJ, Cañizares ACP, Martín IA, Peinado MA, Doussoux PC. Predictive variables of open reduction in intertrochanteric fracture nailing: a report of 210 cases. Injury 2016; 47 Suppl 3:S51-S55. [PMID: 27692107 DOI: 10.1016/s0020-1383(16)30606-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Factors that impede closed reduction in intertrochanteric fractures remain unknown. This study was designed with the aim of establishing radiological variables that can predict an open reduction when nailing those type of fractures. MATERIALS AND METHODS Observational prospective study carried out between March 2013 and March 2015. Patients of both gender who suffered an intertrochanteric fracture, and who were surgically treated by intramedullary nailing (PFN-A), were included. Patients were evaluated by means of a questionnaire designed in 12 de Octubre Trauma department. Radiological parameters assessed preoperatively, after fracture reduction in the traction table, and after fixation were: calcar, lateral wall and posterior buttress integrity or disruption; lesser trochanter location, varus or valgus deformities, and flexion or extension of the proximal fragment. RESULTS Association between open reduction and the following types of fractures was statistically significant (p<0.001): subtypes A2.3, A3.2 and A3.3 of AO classification and subtypes IV and V of Evans classification. There were four radiological parameters associated with the need for open reduction: disruption of lateral wall (p<0.0000), posterior wall fracture (p<0.001), calcar (p<0.004) and malalignment in the axial view (p<0.001). CONCLUSIONS Open reduction seems to be necessary for complex fracture patterns such as A2.3, A3.2 and A3.3 types of AO/OTA classification, as well as types IV and V of Evans classification. There are four major radiological parameters that can predict the need of approaching the fracture site: posterior buttress, calcar disruption, lateral wall disruption and proximal fragment flexion. The development of high quality evidence regarding this topic is necessary due to the vast impact that open reduction can have on elderly patients.
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Affiliation(s)
- Verónica Jiménez Díaz
- Department of Orthopaedic and Trauma Surgery, Hospital Universitario 12 de Octubre, Madrid, Spain.
| | | | - Ismael Auñón Martín
- Department of Orthopaedic and Trauma Surgery, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Miguel Aroca Peinado
- Department of Orthopaedic and Trauma Surgery, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Pedro Caba Doussoux
- Department of Orthopaedic and Trauma Surgery, Hospital Universitario 12 de Octubre, Madrid, Spain
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16
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Schupfner R, Käsmann LT, Wagner W, Schulz AP. Complications in Treatment of 31-A Fractures with Trochanteric Gamma Nail (TGN) Versus Gamma3 Nail (G3N) - A Review of 217 Cases. Open Orthop J 2016; 10:389-395. [PMID: 28523080 PMCID: PMC5436381 DOI: 10.2174/1874325001610010389] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 05/11/2016] [Accepted: 06/19/2016] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION The aim of this study was to clinically evaluate two generations of intramedullary gamma-nail used in the treatment of 31-A femur fractures. MATERIALS AND METHODS In two consecutive series, 117 trochanteric gamma nails (TGN) and 100 Gamma3 nails (G3N) were implanted for the treatment of inter- and subtrochanteric fractures between 2009 and 2011. Clinical and radiological follow-up examinations were assessed. An analysis of surgical time, hemoglobin drop and complications were performed. RESULTS Average surgical time, fluoroscopy time, haemoglobin drop and length-of-stay (LOS) were similar in both groups. No significant differences were found in surgery-related complications like wound hematomas (p=0,59), abscesses (p=0,38), wound infections (p=0,69) and Cut-outs (p=0,69) between the two groups. The cumulative surgery-related complication rate was higher in the TGN group compared to the G3N group (13,68% vs. 8%) but this did not reach statistical significance (p=0,2). CONCLUSION Our findings suggest that both TGN and G3N allow adequate treatment of trochanteric fractures with an acceptable complication rate.
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Affiliation(s)
- R Schupfner
- Department of Traumatology, Orthopaedics & Reconstructive Surgery, Clinic Bayreuth, Germany
| | - L T Käsmann
- Department of Orthopaedics & Traumatology, University of Lübeck, Germany
| | - W Wagner
- Department of Traumatology, Orthopaedics & Reconstructive Surgery, Clinic Bayreuth, Germany
| | - A P Schulz
- Department of Orthopaedics & Traumatology, University of Lübeck, Germany
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Sambandam SN, Chandrasekharan J, Mounasamy V, Mauffrey C. Intertrochanteric fractures: a review of fixation methods. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2016; 26:339-53. [PMID: 27028746 DOI: 10.1007/s00590-016-1757-z] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 02/25/2016] [Indexed: 11/26/2022]
Affiliation(s)
- Senthil Nathan Sambandam
- Department of Orthopaedics, K.G. Hospital and Postgraduate Medical Institute, Arts College Road, Coimbatore, Tamil Nadu, 641018, India
| | - Jayadev Chandrasekharan
- Department of Orthopaedics, K.G. Hospital and Postgraduate Medical Institute, Arts College Road, Coimbatore, Tamil Nadu, 641018, India
| | - Varatharaj Mounasamy
- VCU Medical Center, Ambulatory Care Center, 417 North 11th Street, Richmond, VA, USA.
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Nyholm AM, Palm H, Malchau H, Troelsen A, Gromov K. Lacking evidence for performance of implants used for proximal femoral fractures - A systematic review. Injury 2016; 47:586-94. [PMID: 26803696 DOI: 10.1016/j.injury.2016.01.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Revised: 01/04/2016] [Accepted: 01/06/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Evaluation of the long-term performance of implants used in trauma surgery relies on post-marked clinical studies since no registry based implant assessment exists. The purpose of this study was to evaluate the evidence of performance of implants currently used for treating proximal femoral fractures (PFF) in Denmark. METHOD PubMed was searched for clinical studies on primary PFF with follow-up ≥12 months, reporting implant-related failure and evaluating one of following: DHS, CHS, HipLoc, Gamma3, IMHS, InterTan, PFN, PFNA or PTN. LIMITS English language and publication date after 1st of January 1990. RESULTS All studies were evidence level II or III. 30 publications for SHS were found: 13 of CHS, 15 of DHS and 2 of HipLoc. In total CHS was evaluated in 1110 patients (900 prospectively), DHS in 2486 (567 prospectively) and HipLoc in 251 (all prospectively). Fifty-four publications for nails were found: 13 of Gamma3, 7 of IMHS, 5 of InterTan, 10 of PFN, 24 of PFNA and 0 of PTN. In total Gamma3 was evaluated in 1088 patients (829 prospectively), IMHS in 1543 (210 prospectively), InterTan in 595 (585 prospectively), PFN in 716 (557 prospectively), PFNA in 1762 (1018 prospectively) and PTN in 0. CONCLUSIONS The clinical evidence behind the current implants used for proximal femoral fractures is weak considering the number of implants used worldwide. Sporadic evaluation is not sufficient to identify long term problems. A systematic post market surveillance of implants used for fracture treatment, preferable by a national register, is necessary in the future.
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Affiliation(s)
- Anne Marie Nyholm
- Clinical Orthopaedic Research Hvidovre, Department of Orthopaedics, Copenhagen University Hospital Hvidovre, Kettegaard Alle 30, DK-2650 Hvidovre, Denmark.
| | - Henrik Palm
- Clinical Orthopaedic Research Hvidovre, Department of Orthopaedics, Copenhagen University Hospital Hvidovre, Kettegaard Alle 30, DK-2650 Hvidovre, Denmark
| | - Henrik Malchau
- Orthopedic Department, Massachusetts General Hospital, 55 Fruit Street, GRJ 1126, Boston, MA, United States
| | - Anders Troelsen
- Clinical Orthopaedic Research Hvidovre, Department of Orthopaedics, Copenhagen University Hospital Hvidovre, Kettegaard Alle 30, DK-2650 Hvidovre, Denmark
| | - Kirill Gromov
- Clinical Orthopaedic Research Hvidovre, Department of Orthopaedics, Copenhagen University Hospital Hvidovre, Kettegaard Alle 30, DK-2650 Hvidovre, Denmark
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19
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Weihrauch S, Gradl G, Beck M, Rotter R, Mittlmeier T, Gierer P. [Biaxial reconstruction nail for pertrochanteric femoral fractures. Osteosynthesis]. Unfallchirurg 2016; 118:245-50. [PMID: 24599028 DOI: 10.1007/s00113-013-2498-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND The steady rise in life expectancy of our population leads to an exponential increase in proximal femoral fractures. The growing increase of comorbidities in these patients requires continuous development of modern implant systems for internal fixation of proximal femoral fractures. MATERIALS AND METHODS In this study we enrolled 116 patients with pertrochanteric femoral fractures who were treated with a proximal femoral nail (Targon PF, Aesculap) over a period of 1 year. The indications for this implant system were set at unstable fracture types. Data of the operative and postoperative course were collected prospectively. RESULTS The average age of the 116 predominantly female subjects was 77±14 years and the most commonly observed fracture subtype was 31-A1.2. The follow-up rate was 55 %. We observed a decrease in the postoperative modified Harris hip score of 22.7 %. The 1-year mortality was 21.6 %. CONCLUSIONS The results of this study showed a low rate of perioperative complications and implant loss anda decline in patient mobility was typically observed within 1 year.
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Affiliation(s)
- S Weihrauch
- Abteilung für Unfall- und Wiederherstellungschirurgie, Universität Rostock, Schillingallee 35, 18055, Rostock, Deutschland,
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How evolution of the nailing system improves results and reduces orthopedic complications: more than 2000 cases of trochanteric fractures treated with the Gamma Nail System. Musculoskelet Surg 2015; 100:1-8. [PMID: 26667625 DOI: 10.1007/s12306-015-0391-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Accepted: 11/21/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE The incidence of trochanteric fractures has increased significantly during the last few decades, especially in elderly patients with osteoporosis. The dynamic/sliding hip screw and the cephalomedullary nail are the most commonly used fixation methods to treat trochanteric fractures. The improvements in the Gamma Nail System (GNS) associated with a correct surgical technique reduced the postoperative orthopedic complications. The purpose of this study was to compare the results of the different Gamma Nails. METHODS The present study is a retrospective analysis of 2144 patients treated with GNS between January 1997 and December 2011 for trochanteric fractures, classified according to AO classification method. The patients were divided into three groups according to the nailing system: 525 were treated with Standard Gamma Nail (SGN), 422 with Trochanteric Gamma Nail (TGN) and 1197 with Gamma3 Nail. RESULTS The overall incidence of intra-operative complications was 1.21 %; the incidence of intra-operative complications for each group was 1.71 % for SGN group, 0.47 % for TGN group and 1.25 % for Gamma3 Nail group. The overall incidence of postoperative complications was 5.48 %, and the incidence for each group was 10.73 % for SGN group, 9.92 % for TGN group and 2.92 % for Gamma3 Nail group. CONCLUSION The GNS is a safe device with a low rate of intra-operative complications. The evolution of this nail system reduces postoperative complications, thus improving the results at follow-up and confirming that the Gamma3 Nail is a safe and predictable device to fix trochanteric fracture.
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Kanakaris NK, Noviello C, Saeed Z, Mitrogiannis L, Tosounidis TH, Tartaglia N. Preliminary results of the treatment of proximal femoral fractures with the AFFIXUS nail. Injury 2015; 46 Suppl 5:S12-7. [PMID: 26384659 DOI: 10.1016/j.injury.2015.08.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Contemporary fixation of the proximal femur is performed utilising a number of implants adopting different concepts and techniques. Cephalomedullary nails in particular represent one of two main options, the other being dynamic hip screw (DHS). The aim of this cohort study is to present the early experience of two large units from different countries of the use of the AFFIXUS nail for stabilisation of proximal femoral fractures. Over a period of almost three years, data from 476 proximal femoral fractures were collected and analysed using a specific research protocol, assessing data relevant to basic demographic details, in-hospital stay, surgical technique and post discharge outcomes with a minimum follow up of 6 months. Both the short and long versions of the nail were used in both centres, however, with some statistically significant differences as far as the type of fractures stabilised with the nail, which also translated to differences in the combination or not of 2 lag screws, and the static or dynamic mode of the proximal fixation construct. Other areas of difference amongst the 2 units, were the length of hospital stay and return of patients to their pre-injury residence, most likely reflecting the different social circumstances between the 2 countries. Overall mortality at a median follow up period of 17 months (range 6 to 35) was limited to 6.3%, nonunion and cut out rates 2.7%, whilst revision surgery occurred in just 2.5%. Over the first 6 months of follow up 63.6% returned to their pre-injury ambulatory status and 90.5% to their pre-injury residence. Further studies and higher level of scientific evidence is needed to verify the findings of this retrospective cohort study as to the effectiveness and safety of this new cephalomedullary nail.
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Affiliation(s)
- Nikolaos K Kanakaris
- Academic Department of Trauma and Orthopaedics, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom.
| | - Chiara Noviello
- Department of Trauma and Orthopaedics, Ospedale Regionale F. Miulli Bari, Italy.
| | - Zumbair Saeed
- Academic Department of Trauma and Orthopaedics, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom.
| | - Leonidas Mitrogiannis
- Academic Department of Trauma and Orthopaedics, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom.
| | - Theodoros H Tosounidis
- Academic Department of Trauma and Orthopaedics, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom.
| | - Nicola Tartaglia
- Department of Trauma and Orthopaedics, Ospedale Regionale F. Miulli Bari, Italy.
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Peña OR, Gómez Gélvez A, Espinosa KA, Cardona JR. Cephalomedullary nails: factors associated with impingement of the anterior cortex of the femur in a Hispanic population. Arch Orthop Trauma Surg 2015; 135:1533-40. [PMID: 26303280 DOI: 10.1007/s00402-015-2313-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Impingement and penetration of the anterior cortex of the femur have been reported as complications after cephalomedullary nailing. The purpose of this study was to determine factors related to nail impingement in our population of Hispanic patients. MATERIALS AND METHODS A non-matched case-control study was carried out and 156 patients who underwent cephalomedullary nailing from 2010 and 2013 were included; 78 cases with anterior cortical impingement and 78 control cases without impingement were documented. Demographic variables and specifications of the nails such as manufacture and radius of curvature were recorded. The presence of impingement, angle of incidence on radiographs--indirect measurement of the femoral bow on the sagittal plane--and nail entry site were determined. Bivariate and multivariate logistic regression analyses were performed to identify the factors associated with cortical impingement. RESULTS The distribution by sex corresponded to 87 females (56%) and 69 males (44%) with a mean age of 75 years [SD 18.2]. Cortical impingement was presented in 78 cases (50%) and 6 (3.8%) patients evidenced penetration of the anterior cortex of the femur. On the bivariate analysis the posterior nail start site is highlighted, which showed a positive association with impingement (OR 4.3; 95% CI 1.1-36 and p = 0.04). After the multivariate analysis, the factors associated with anterior cortical impingement included female gender (OR 2.2; 95 % CI 1.1-4.6 and p ≤ 0.038), straight nails-short nails-(OR 4.9; 95% CI 2.2-10 and p ≤ 0.001) and angle of incidence ≥7° (OR 4.9; 95% CI 2.2-10 and p ≤ 0.001), the latter showing a likelihood of 57 % for impingement, increasing to 90% with an angle of incidence of 11°. CONCLUSIONS Posterior entry site should be avoided and an anterior site should be used. Female gender, straight nails and greater angle of incidence of the femur were associated with cortical impingement. A specific intramedullary nail design is needed for the Hispanic population due to high impingement and anterior cortical penetration rates seen with conventional nails. Short curved nails and long nails with a lower radius of curvature are required.
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Affiliation(s)
- Omar R Peña
- Department of Orthopaedics and Traumatology, Hospital Universitario de La Samaritana, Carrera 8 No. 0-55 Sur, Third Floor, Bogotá, Colombia
| | - Amparo Gómez Gélvez
- Department of Orthopaedics and Traumatology, Hospital Universitario de La Samaritana, Carrera 8 No. 0-55 Sur, Third Floor, Bogotá, Colombia
| | - Kristian A Espinosa
- Department of Orthopaedics and Traumatology, Hospital Universitario de La Samaritana, Carrera 8 No. 0-55 Sur, Third Floor, Bogotá, Colombia.
| | - José R Cardona
- Department of Orthopaedics and Traumatology, Hospital Universitario de La Samaritana, Carrera 8 No. 0-55 Sur, Third Floor, Bogotá, Colombia
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A C U, E W, B K, C J, A P S. Treatment of trochanteric fractures with the gamma3 nail - methodology and early results of a prospective consecutive monitored clinical case series. Open Orthop J 2015; 8:466-73. [PMID: 25621082 PMCID: PMC4300511 DOI: 10.2174/1874325001408010466] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Revised: 11/18/2014] [Accepted: 11/23/2014] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES There is only sparse data on clinical results and complications of the third-generation Gamma nailing system (Gamma3, Stryker). Therefore, we started a large multi-centre case series in 2008. The aim of this paper is to present the study design and early results of a single arm of a prospective, consecutive, monitored, post-market follow-up evaluation of Gamma3 nails. METHODS From September 2009 to January 2012, 154 consecutive patients with an average age of 80 ± 1.43 years (50-99 years) and a trochanteric femoral fracture were included in the local arm of the trial. All patients that fulfilled the inclusion criteria were treated with a Gamma3 nail. Preoperative variables included age, gender, fracture classification, walking ability (Merle d'Aubigné score), daily activity level (retrospective Zuckerman score), ASA rating of operative risk, waiting time for operation, use of walker or crutches and body mass index (BMI). Skin-to-skin time, fluoroscopy time, blood loss, intraoperative complications and device information were recorded for each patient. Follow-up postoperative assessment was undertaken at 4, 12 and 24 months. Hip range of motion, pain around the hip and the tight, walking ability (Merle d'Aubigné score, Sahlgrenska mobility score) and management of daily life (Zuckerman score) were used to evaluate the outcome. RESULTS The descriptive data of age, gender, BMI, ASA classification, fracture type and skin-to-skin time is similar to other studies. Median fluoroscopy time was 62 seconds (range: 4-225 seconds) and significantly shorter in closed reductions. No intraoperative implant-related complication was recorded. A cut-out of the leg-screw during assessment period occurred in 2.6% patients (n = 4). At the 12-month assessment two (1.8%) non-unions were identified and two patients (1.8%) had broken the femoral shaft below the 180 mm nail after a fall. Analysis of the scores showed significantly declined mobility and activity in daily life four months after operation which increased significantly from four to 12 months and increased slightly between 12 and 24 months after fracture. CONCLUSION A low implant-associated complication rate was achieved in geriatric patients with trochanteric femoral fractures using the Gamma3 nail. A better outcome concerning mobility, activity in daily life and complications compared to the Gamma2 nail could not be found in comparison to historic data.
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Affiliation(s)
- Unger A C
- University Hospital SH, Campus Luebeck, Department of Trauma and Orthopaedics, Germany
| | - Wilde E
- University Hospital SH, Campus Luebeck, Department of Trauma and Orthopaedics, Germany
| | | | - Jürgens C
- University Hospital SH, Campus Luebeck, Department of Trauma and Orthopaedics, Germany ; BG Trauma Hospital Hamburg, Germany
| | - Schulz A P
- University Hospital SH, Campus Luebeck, Department of Trauma and Orthopaedics, Germany ; BG Trauma Hospital Hamburg, Germany
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Wu D, Ren G, Peng C, Zheng X, Mao F, Zhang Y. InterTan nail versus Gamma3 nail for intramedullary nailing of unstable trochanteric fractures. Diagn Pathol 2014; 9:191. [PMID: 25269555 PMCID: PMC4193997 DOI: 10.1186/s13000-014-0191-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2014] [Accepted: 09/20/2014] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Trochanteric fractures (TF) have become a major source of morbidity and mortality in elderly. We conducted this study to compare the outcomes of unstable trochanteric fractures treated with the InterTan nail and Gamma3 nail. METHODS Between January 2008 and May 2013, patients aged 60 years or older with a diagnosis of unstable TF treated with InterTan nail or Gamma3 nail were included. Patients treated with InterTan nail were pair-matched to patients treated with Gamma3 nail in a 1:2 ratio. Radiographs were obtained at 1, 3, 6, and 12 months follow-up, and all implant position changes, complications, fixation failures and functional scores were recorded. RESULTS Eighty-seven patients were included in the InterTan nail group, and 174 pair-matched patients were included in the Gamma3 nail group. Preoperative scores were similar between the 2 groups. There are significant improvements postoperatively in both groups. The incidence of cut-out and femoral shaft fracture were significantly higher in the Gamma3 nail group than the InterTan nail group (P=0.024 and P=0.044, respectively). Patients treated with the InterTan nail experienced longer fluoroscopy and operative times. CONCLUSIONS The InterTan nail may have a tendency in better outcomes for patients with unstable TF. However, the limited period of follow-up and inherent defects of nonrandomized trials indicate that better-designed randomized controlled trials will be required. VIRTUAL SLIDES The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/13000_2014_191.
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Affiliation(s)
- Dankai Wu
- Department of Orthopedics, Orthopeadic Hospital, Jilin University School of Second Hospital, 218 Ziqiang Road, Nanguan district, Changchun, Jilin 130041 China
| | - Guangkai Ren
- Department of Orthopedics, Orthopeadic Hospital, Jilin University School of Second Hospital, 218 Ziqiang Road, Nanguan district, Changchun, Jilin 130041 China
| | - Chuangang Peng
- Department of Orthopedics, Orthopeadic Hospital, Jilin University School of Second Hospital, 218 Ziqiang Road, Nanguan district, Changchun, Jilin 130041 China
| | - Xuanlin Zheng
- Department of Orthopedics, Orthopeadic Hospital, Jilin University School of Second Hospital, 218 Ziqiang Road, Nanguan district, Changchun, Jilin 130041 China
| | - Fengmin Mao
- Department of Orthopedics, Orthopeadic Hospital, Jilin University School of Second Hospital, 218 Ziqiang Road, Nanguan district, Changchun, Jilin 130041 China
| | - Yueyang Zhang
- Department of Orthopedics, Orthopeadic Hospital, Jilin University School of Second Hospital, 218 Ziqiang Road, Nanguan district, Changchun, Jilin 130041 China
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Malpositioning of the lag screws by 1- or 2-screw nailing systems for pertrochanteric femoral fractures: a biomechanical comparison of gamma 3 and intertan. J Orthop Trauma 2014; 28:276-82. [PMID: 24751606 DOI: 10.1097/bot.0000000000000008] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The aim of this investigation was to perform a biomechanical comparison between 1- and 2-screw systems used for the treatment of intertrochanteric fractures for centralized and decentralized placement of femoral neck screws of failure loads, stiffness, survival rates, tip apex distance (TAD), and failure mode. METHODS As fracture model, an AO 31A2.3 fracture was used. Twelve pairs of human cadaver femora were tested. Femoral neck screws were implanted in the femoral head in center/center, posterior/central, and anterior/superior position in axial/frontal plane. A single-screw system (Gamma 3 Locking Nail; Stryker GmbH & Co. KG) and a 2-screw system (Trigen-Intertan; Smith & Nephew GmbH) were used. To simulate the load in situ, a cyclic load was carried for 10,000 cycles in a material testing machine. If no cyclic failure occurred, femora were loaded until the failure. The systems were compared according to the stiffness, survivability through 10 k cycles, TAD, and load to failure. RESULTS None of the tested bones failed at center/center location in the decentralized positions 3 Gamma Nail and 2 Intertan specimens failed during cyclic testing. The 2-screw system resisted higher forces in all positions (Gamma: 5370N ± 1924, Intertan: 7650N ± 2043; P = 0.014). CONCLUSIONS Based on these data, it is clear that both the nail systems showed a higher biomechanical stability with a lower TAD. The 2 specimens that failed with the Intertan in the cyclic tests had a TAD ≥49 mm. The cutout failures that we detected during cyclic testing in the Gamma system had a TAD ≥30 mm. Thus, it is clear that the TAD affects failure independent of the implant used. With a less than ideal lag screw placement, however, the Intertan system with 2 integrated screws was able to withstand higher loads in this study.
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