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Yeramosu T, Taitsman LA, Kates SL. Trends and Complications of Hip Fracture Fixation Among Early Career Orthopaedic Surgeons: An Analysis of the American Board of Orthopaedic Surgery Part II Oral Examination Database. Geriatr Orthop Surg Rehabil 2025; 16:21514593241291792. [PMID: 40103706 PMCID: PMC11915309 DOI: 10.1177/21514593241291792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Revised: 08/19/2024] [Accepted: 09/23/2024] [Indexed: 03/20/2025] Open
Abstract
Background Hip fractures are a major public health concern with a high mortality rate. Numerous risk factors for hip fracture have been identified, and efforts made to reduce complications and improve outcomes. This study aimed to assess recent trends in postoperative complications amongst early-career orthopaedic surgeons. Methods This retrospective study analyzed surgical cases submitted to the American Board of Orthopaedic Surgery (ABOS) for the Part II Oral Examination from 2013 to 2022. The database includes patient demographics and medical and surgical complications. Current Procedural Terminology codes reflecting operative fixation for hip fracture were selected. Data was split into two cohorts: 2013-2016 and 2017-2020. Univariate and multivariable logistic regression analyses were used to identify significant differences between cohorts. Results 49,418 cases were analyzed. Compared to 2013-2016, 2017-2020 had a reduction in the overall medical complication rate (-1.49%, P = 0.0005), saw slight increases in congestive heart failure (+0.18%, P = 0.049), renal failure (+0.37%, P = 0.004), hypotension (+0.41%, P = 0.0007), and hypoxia (+0.41%, P = 0.0016). Minor decreases in myocardial infarction (-0.18%, P = 0.047) and pneumonia (-0.34%, P = 0.021) were noted. No differences occurred in confusion/delirium, deep vein thrombosis/pulmonary embolism, and mortality. There were no significant differences in overall surgical complications. The 90-day readmission rate increased with time (+1.17%, P < 0.0001). Multivariable logistic regression identified a decrease in the likelihood of overall medical complications (Odds Ratio (OR): 0.92 [0.89, 0.96]; P < 0.0001). Decreases were noted for the likelihood of myocardial infarction (OR: 0.81 [0.68, 0.98]; P = 0.031), pneumonia (OR: 0.87 [0.78, 0.97]; P = 0.013), fracture (OR: 0.80 [0.69, 0.92]; P = 0.002), and recurrent/persistent/uncontrolled pain (OR: 0.72 [0.56, 0.92]; P = 0.008). The likelihood of renal failure (OR: 1.18 [1.04, 1.34]; P = 0.009) and readmission increased (OR: 1.14 [1.07, 1.20]; P < 0.0001). Conclusion This study found little change in postoperative complication patterns over the past decade. These findings suggest that more efforts are needed to improve hip fracture care and outcomes.
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Affiliation(s)
- Teja Yeramosu
- Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Lisa A Taitsman
- Department of Orthopaedics and Sports Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Stephen L Kates
- Department of Orthopaedic Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
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Merrell LA, Kadiyala ML, Gibbons K, Ganta A, Konda SR, Egol KA. Cephalomedullary Nails for Isolated Subtrochanteric Femur Fractures: Age-Related Variations in Fracture Pattern and Perioperative Factors Do Not Affect Clinical and Radiographic Outcomes. Indian J Orthop 2025; 59:84-91. [PMID: 39735872 PMCID: PMC11680529 DOI: 10.1007/s43465-024-01285-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Accepted: 10/16/2024] [Indexed: 12/31/2024]
Abstract
Introduction There is scarce data in literature on the demographics, treatment, and outcomes of subtrochanteric femur fracture patients. This study evaluated the effect of age on injury details, perioperative and hospital parameters, and outcomes following subtrochanteric fracture fixation. Methods An IRB-approved review of a consecutive series of subtrochanteric femoral fractures was performed. Patient charts and radiographs were examined to confirm patients were operatively treated for an AO/OTA Type 32A, B or C subtrochanteric femur fracture, as well as for demographics, injury information, perioperative details, radiographic parameters, hospital quality measures, and outcomes. Patients were divided into younger (Y) (< 65 years old) and older (O) (≥ 65 years old) cohorts. Comparative analyses were conducted between cohorts. Results Of 205 patients, 161 (78.5%) comprised the O cohort and 44 (21.5%) the Y cohort. The O cohort represented a sicker (higher CCI and ASA), less ambulatory population. Patients in the Y cohort sustained more high-energy injuries (p < 0.001). The most common fracture pattern was type 32A in both cohorts (p = 0.003). Older patients were treated more frequently with a 1-screw nail design (p = 0.005). The Y cohort had a shorter time to surgery (p = 0.002) and were more likely to be discharged home (p < 0.001). There were no differences in post-op complications, readmission or mortality rates, nonunion, fixation failure, or radiographic time to healing between cohorts. Conclusion Younger patients present with different subtrochanteric fracture patterns and discharge profiles than older patients and are treated with different implants. However, despite these differences, younger and older patients have similar radiographic and clinical outcomes. Level of Evidence III.
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Affiliation(s)
- Lauren A. Merrell
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, 301 E 17th Street, New York, NY 10003 USA
| | - Manasa L. Kadiyala
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, 301 E 17th Street, New York, NY 10003 USA
| | - Kester Gibbons
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, 301 E 17th Street, New York, NY 10003 USA
| | - Abhishek Ganta
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, 301 E 17th Street, New York, NY 10003 USA
- Department of Orthopedic Surgery, Jamaica Hospital Medical Center, Queens, New York, NY USA
| | - Sanjit R. Konda
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, 301 E 17th Street, New York, NY 10003 USA
- Department of Orthopedic Surgery, Jamaica Hospital Medical Center, Queens, New York, NY USA
| | - Kenneth A. Egol
- Division of Orthopedic Trauma Surgery, Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, 301 E 17th Street, New York, NY 10003 USA
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Obey MR, Achor TS, Warner SJ. Use of medialized trochanteric-entry intramedullary nail to improve alignment in proximal femur nonunions. INTERNATIONAL ORTHOPAEDICS 2025; 49:75-82. [PMID: 39480561 DOI: 10.1007/s00264-024-06357-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2024] [Accepted: 10/16/2024] [Indexed: 11/02/2024]
Abstract
PURPOSE Proximal femur shaft nonunion is a challenging problem, often occurring after malreduction that results in postoperative malalignment and decreased healing potential. Correction of malalignment is critical to achieving osseous union. Here we present a novel technique for treating proximal femur nonunions with varus malalignment using an intramedullary nail inserted through a medialized trochanteric entry point. METHODS Patients who underwent a proximal femur shaft (subtrochanteric or proximal third shaft) nonunion operation at a single level 1 academic referral centre by two attending surgeons between 1/1/2014 and 1/1/2022 were identified. Radiographic imaging was reviewed to determine initial fracture classification and calculation of coronal plane alignment (CPA), which was measured on preoperative, immediate postoperative, and final follow-up radiographs. Postoperative complications, reoperations, infections, and osseous union were also collected. RESULTS Twenty-one patients with a mean age of 49.9 years (66% male) were identified. Mean preoperative CPA was 125.6 degrees, immediate postoperative mean CPA was 132.6 degrees, and mean final follow-up CPA was 131.5 degrees. Mean change in CPA from immediate postoperative films to final follow-up was a decrease of 0.4 degrees. 17 patients had follow up for a minimum of 12 months or until osseous union, and all achieved union without any major complications. CONCLUSION Exchange nailing with an antegrade trochanteric entry nail through a medialized trochanteric starting point is a safe and effective technique in the treatment of proximal femur nonunions. This technique results in improved postoperative alignment that is sustained throughout the postoperative course, and may lead to increased rates of osseous union.
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Affiliation(s)
- Mitchel R Obey
- Department of Orthopaedic Surgery, Orthopaedic Trauma Service, Washington University in St. Louis, 660 S. Euclid Campus, Box 8233, St. Louis, MO, 63110, USA.
| | - Timothy S Achor
- Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Stephen J Warner
- Department of Orthopaedic Surgery, University of Texas Health Science Center at Houston, Houston, TX, USA
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Khanna A, MacInnis BR, Cross WW, Andrew Sems S, Tangtiphaiboontana J, Hidden KA, Yuan BJ. Salvage of failed subtrochanteric fracture fixation in the elderly: revision internal fixation or hip arthroplasty? EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:3097-3101. [PMID: 39186097 DOI: 10.1007/s00590-024-04035-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 06/24/2024] [Indexed: 08/27/2024]
Abstract
PURPOSE This study aimed to compare reoperation rate and clinical outcomes between revision open reduction and internal fixation and hip arthroplasty following failed subtrochanteric fracture fixation. METHODS A retrospective review was conducted of patients > 50 years old treated for failed fixation of subtrochanteric fractures with revision ORIF or hip arthroplasty from 2003 to 2023. Primary outcomes included rate of fracture union and reoperations after initial salvage therapy. Secondary outcomes included complications (infection, dislocation, bursitis, implant prominence, implant failure, nonunion), pain, and gait-aid requirements by final follow-up. RESULTS Forty-four patients were identified: 34 treated with revision ORIF and 10 with hip arthroplasty. The arthroplasty cohort was older (75.4 vs. 66.0 years, p = 0.016) but did not differ from the ORIF cohort in sex, type of initial fixation, or reason for fixation failure. Patients treated with revision ORIF and patients treated with arthroplasty had similar rates of fracture union (85.3% vs. 80.0%, p = 0.772) and reoperation (35.3% vs. 30.0%, p = 0.710). There was no significant difference in rate of additional complications not requiring reoperation (0.0% vs. 40.0%, p = 0.071). The arthroplasty cohort achieved full weightbearing in significantly shorter time than the revision ORIF cohort (3.8 vs. 6.8 weeks, p = 0.005). CONCLUSION Both revision ORIF and hip arthroplasty are acceptable options for salvage of failed subtrochanteric fracture fixation in patients greater than 50 years old, but patients should be counseled that although the rate of fracture union is high whether revision ORIF or hip arthroplasty is selected, the rate of reoperation can exceed 1-in-4 patients. LEVEL OF EVIDENCE : Level III, Retrospective Comparative Study.
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Affiliation(s)
- Ankur Khanna
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA.
| | - Bailey R MacInnis
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA
| | - William W Cross
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA
| | - S Andrew Sems
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA
| | | | - Krystin A Hidden
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA
| | - Brandon J Yuan
- Department of Orthopedic Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN, 55905, USA
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SanJosé-Pardo I, Valle-Cruz JA, Donadeu-Sánchez S, Aguado HJ, País-Ortega S, Montoya-Adarraga J, Díez-Rodríguez Á, Alonso Del Olmo JA, Mingo-Robinet J. Is immediate weight bearing safe for subtrochanteric femur fractures in elderly patients treated by cephalomedullary nailing? A multicentric study in one hundred eighty-two patients. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:2595-2603. [PMID: 38703201 DOI: 10.1007/s00590-024-03897-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 02/01/2024] [Indexed: 05/06/2024]
Abstract
PURPOSE Biomechanical superiority of intramedullary nails over extramedullary implants has been proved for subtrochanteric fractures. Nevertheless, postoperative management of these patients has not changed, with high rates of protected weight-bearing after intramedullary nailing. The purpose of this study is to determine the mechanical complications of immediate postoperative full weigh-bearing for subtrochanteric femur fractures in elderly patients treated with a cephalomedullary nail. METHODS We performed a retrospective case series study from patients treated with a cephalomedullary nail for subtrochanteric fractures (AO/OTA 31A.3 and 32A-32C) over a nine-year period. Patients in the immediate full weight-bearing (IFWB) group received orders for immediate full weight bear as tolerated on postoperative 48 h. Patients in the non- or limited- weight-bearing (NLWB) group received orders not to full weight bear in the immediate postoperative. RESULTS There were five (2.7%) cases of implant failure including four cutouts and one nail breakage that needed a reoperation. Of them, one (2.2%) followed the NLWB protocol and four (2.9%) followed the IFWB protocol. Mean length of stay was 7.9 days (median 8, range 3-21) in the NLWB group and 10.7 days (median 8, range 2-60) in the IWBAT group. The NLWB group observed a 2.8-day shorter postoperative length of stay when compared to the IFWB, but the median remained equal. CONCLUSION This study suggests that geriatric patients with subtrochanteric fractures treated by intramedullary nailing and in which a good fracture reduction was achieved, may be able to tolerate immediate postoperative full weight-bearing, not increasing reoperation rates due to implant failure.
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Affiliation(s)
- Iñigo SanJosé-Pardo
- Orthopedic and Traumatology Department, Complejo Asistencial Universitario de Palencia, Avenida Donantes de sangre S/N, 34005, Palencia, Spain.
| | - José Antonio Valle-Cruz
- Orthopedic and Traumatology Department, Hospital Clínico San Carlos, Calle Profesor Martín Lagos, 2, 28040, Madrid, Spain
| | - Susana Donadeu-Sánchez
- Orthopedic and Traumatology Department, Hospital Clínico San Carlos, Calle Profesor Martín Lagos, 2, 28040, Madrid, Spain
| | - Héctor J Aguado
- Orthopedic and Traumatology Department, Hospital Clínico Universitario de Valladolid, Av. Ramón y Cajal 3, 47003, Valladolid, Spain
| | - Sergio País-Ortega
- Orthopedic and Traumatology Department, Hospital Clínico Universitario de Valladolid, Av. Ramón y Cajal 3, 47003, Valladolid, Spain
| | - Javier Montoya-Adarraga
- Orthopedic and Traumatology Department, Hospital Universitario Infanta Leonor, Avenida Gran Vía del Este 80, 28031, Madrid, Spain
| | - Ángel Díez-Rodríguez
- Orthopedic and Traumatology Department, Hospital Universitario Infanta Leonor, Avenida Gran Vía del Este 80, 28031, Madrid, Spain
| | - Juan Antonio Alonso Del Olmo
- Orthopedic and Traumatology Department, Hospital Clínico Universitario de Valladolid, Av. Ramón y Cajal 3, 47003, Valladolid, Spain
| | - Juan Mingo-Robinet
- Orthopedic and Traumatology Department, Complejo Asistencial Universitario de Palencia, Avenida Donantes de sangre S/N, 34005, Palencia, Spain
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Brewer J, Fuster F, Mosle S, Heng M. Principles of Minimally Invasive Reduction and Nail Fixation for Subtrochanteric Femur Fractures. J Am Acad Orthop Surg 2024; 32:e514-e522. [PMID: 38626351 DOI: 10.5435/jaaos-d-23-00904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 02/20/2024] [Indexed: 04/18/2024] Open
Abstract
Subtrochanteric femur fractures have a reputation as difficult orthopaedic injuries to treat. Strong deforming forces, including the hip musculature and high physiologic forces, must be counteracted to obtain and maintain reduction. Adding to the complexity is a wide variety of fracture morphologies that must be recognized to execute an appropriate surgical plan. The challenging nature of this injury is demonstrated by nonunion rates of 4% to 5%, but some series have reports of up to 15% and malunion rates of 10% to 15%. Improved outcomes have been shown to be dependent on appropriate reduction and stable fixation, which can be achieved with less surgical insult. The treating surgeon must have a thorough understanding of the injury characteristics and reduction techniques to appropriately execute minimally invasive techniques for these difficult fractures.
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Affiliation(s)
- Jeffrey Brewer
- From the Department of Orthopaedics, University of Miami Miller School of Medicine, Miami, FL
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Xiong M, Feng Y, Luo C, Guo J, Zeng J, Deng L, Xiao Q. Teriparatide: an innovative and promising strategy for protecting the blood-spinal cord barrier following spinal cord injury. Front Pharmacol 2024; 15:1386565. [PMID: 38770002 PMCID: PMC11103009 DOI: 10.3389/fphar.2024.1386565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 04/22/2024] [Indexed: 05/22/2024] Open
Abstract
The blood-spinal cord barrier (BSCB) is disrupted within minutes of spinal cord injury, leading to increased permeability and secondary spinal cord injury, resulting in more severe neurological damage. The preservation of blood-spinal cord barrier following spinal cord injury plays a crucial role in determining the prognosis. Teriparatide, widely used in clinical treatment for osteoporosis and promoting fracture healing, has been found in our previous study to have the effect of inhibiting the expression of MMP9 and alleviating blood-brain barrier disruption after ischemic stroke, thereby improving neurological damage symptoms. However, there are limited research on whether it has the potential to improve the prognosis of spinal cord injury. This article summarizes the main pathological mechanisms of blood-spinal cord barrier disruption after spinal cord injury and its relationship with Teriparatide, and explores the therapeutic potential of Teriparatide in improving the prognosis of spinal cord injury by reducing blood-spinal cord barrier disruption.
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Affiliation(s)
| | | | | | | | | | | | - Qiang Xiao
- Department of Orthopedics, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, China
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Markowitz MI, Al-Hardan W, Constantinescu DS, Pretell-Mazzini J, Conway SA. Subtrochanteric nonunion after intramedullary nailing due to pathological fracture: proximal femoral replacement as a salvage approach. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:167-173. [PMID: 37386190 DOI: 10.1007/s00590-023-03627-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 06/17/2023] [Indexed: 07/01/2023]
Abstract
PURPOSE To assess proximal femoral replacement as a treatment solution for nonunion of pathologic subtrochanteric fractures after cephalomedullary nailing in patients with pathological fracture and previously irradiated bone. METHODS Retrospective review of five patients with pathological subtrochanteric femoral fractures that were treated with cephalomedullary nailing and developed a nonunion, which was revised with conversion to a proximal endoprosthetic replacement. RESULTS All five patients had previously been treated with radiation. One patient had the latest follow-up at 2 months postoperatively. At that time, the patient was walking with a walker for assistance, with no evidence of hardware failure or loosening on imaging. The remaining four patients had the latest follow-up ranging from 9 to 20 months after surgery. At their latest follow-up, three of the four patients were ambulatory with no pain, using only a cane for assistance with longer distances. The other patient demonstrated pain in his affected thigh, utilizing a walker for assistance with ambulation at latest follow-up, but not requiring further surgical interventions. There were no hardware failures or implant loosening through the follow-up period. None of the patients required revision, and there were no postoperative complications observed at their last follow-up. CONCLUSIONS In patients with pathological fractures in the subtrochanteric region that is treated with cephalomedullary nailing and developed a nonunion, treatment with conversion to a proximal femoral replacement with a mega prosthesis is a valuable treatment with good functional results and low risk for complications. LEVEL OF EVIDENCE Therapeutic level IV.
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Affiliation(s)
- Moses I Markowitz
- University of Miami Miller School of Medicine, 1120 NW 14th St, Miami, FL, 33136, USA.
| | - Waleed Al-Hardan
- Department of Orthopaedic Surgery, University of Miami Miller School of Medicine, 1611 NW 12th Ave #303, Miami, FL, 33136, USA
| | - David S Constantinescu
- Department of Orthopaedic Surgery, University of Miami Miller School of Medicine, 1611 NW 12th Ave #303, Miami, FL, 33136, USA
| | - Juan Pretell-Mazzini
- Department of Orthopaedic Surgery, University of Miami Miller School of Medicine, 1611 NW 12th Ave #303, Miami, FL, 33136, USA
| | - Sheila A Conway
- Department of Orthopaedic Surgery, University of Miami Miller School of Medicine, 1611 NW 12th Ave #303, Miami, FL, 33136, USA
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Hinz N, Stacenko K, Lutz C, Schulz AP, Wendlandt R. Lateral cortical notching facilitates dynamization of proximal femoral nailing - A finite element analysis. Injury 2023; 54:111009. [PMID: 37643944 DOI: 10.1016/j.injury.2023.111009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 07/30/2023] [Accepted: 08/21/2023] [Indexed: 08/31/2023]
Abstract
INTRODUCTION Dynamization of proximal femoral nailing by removal of distal interlocking is one of the recommended treatment options for nonunions of femur fractures. However, in certain inter-/subtrochanteric fractures, gliding of the nail along the femoral shaft is blocked by lateral femoral cortical support of the lag screw. For these cases, Biber et al. proposed lateral cortical notching (LCN), in which the supporting lateral bone is removed. This study investigates the biomechanical effect of LCN on gliding of proximal femoral nailing and stress distribution at the bone/implant interface. MATERIALS AND METHODS In this finite element analysis a three-dimensional model of an unstable intertrochanteric fracture with proximal femoral nailing without distal interlocking was simulated using the FebioStudio software suite. To simulate LCN, the lag screw hole was lengthened to 15.34 mm at the lateral cortex. Displacement of the nail along the femoral shaft axis and von Mises stress distribution were compared between LCN model and standard implantation model. RESULTS Displacement of the nail along the femoral shaft axis was higher in the LCN model than in the standard implantation model (0.48 mm vs. 0.07 mm). Highest von Mises stresses of 176-178 MPa at the implant and of 52-81 MPa at the proximal femur were detected. Maximum von Mises stresses of the implant were comparable at all sides, except for a reduced von Mises stress at the lateral inferior side in the LCN model (80 vs. 102 MPa). At the inferior lateral screw hole and the anterior/posterior lateral screw hole maximum von Mises stress was reduced in the LCN model (2 vs. 49 MPa and 52 vs. 81 MPa), whereas the maximum von Mises stress at the inferior medial screw hole was higher in the LCN model than in the standard implantation model (53 vs. 27 MPa). CONCLUSIONS Lateral cortical notching facilitates gliding of a distally dynamized proximal femoral nail along the femoral shaft axis in intertrochanteric fractures. Additionally, the lack of lateral cortical bone support at the lag screw reduces von Mises stress at the bone/implant interface and thus could lower the risk for implant breakage and peri‑implant fractures.
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Affiliation(s)
- Nico Hinz
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Trauma Hospital Hamburg, Bergedorfer Strasse 10, Hamburg 21033, Germany.
| | - Katrin Stacenko
- Swemac Innovation (Germany) GmbH, Faulmannweg 5, Kiel 24148, Germany
| | - Christian Lutz
- Swemac Innovation (Germany) GmbH, Faulmannweg 5, Kiel 24148, Germany
| | - Arndt-Peter Schulz
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Trauma Hospital Hamburg, Bergedorfer Strasse 10, Hamburg 21033, Germany; Medical Faculty, Universität zu Lübeck, Ratzeburger Allee 160, Lübeck 23562, Germany
| | - Robert Wendlandt
- Medical Faculty, Universität zu Lübeck, Ratzeburger Allee 160, Lübeck 23562, Germany; Clinic for Orthopedics and Trauma Surgery, Laboratory for Biomechanics, University Medical Center Schleswig-Holstein, Ratzeburger Allee 160, Lübeck 23538, Germany
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Abstract
SUMMARY Pertrochanteric nonunion management is a technically challenging problem. When repair is undertaken rather than conversion arthroplasty, successful treatment revolves around accurate deformity correction, preservation of vascularity, and stable durable fixation. The decision to use an extramedullary or intramedullary implant should be influenced by nonunion-specific characteristics and patient-related conditions. Failure to understand these nuances when selecting an implant strategy often results in treatment failure. The primary purpose of this article was to discuss these variables and delineate when an intramedullary implant should be considered for treatment of a pertrochanteric nonunion. The secondary purpose was to describe the author's preferred surgical technique for implant-driven deformity correction and compression when choosing an intramedullary nail.
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Affiliation(s)
- Michael Githens
- Department of Orthopaedic Surgery, Harborview Medical Center, University of Washington, Seattle, WA
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11
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Walcher MG, Day RE, Gesslein M, Bail HJ, Kuster MS. Augmentative Plating versus Exchange Intramedullary Nailing for the Treatment of Aseptic Non-Unions of the Femoral Shaft-A Biomechanical Study in a Sawbone TM Model. J Pers Med 2023; 13:jpm13040650. [PMID: 37109036 PMCID: PMC10142865 DOI: 10.3390/jpm13040650] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/06/2023] [Accepted: 04/08/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Non-unions after intramedullary nailing of femoral shaft fractures are a significant problem. Treatment options such as augmenting with plates or exchange nailing have been proposed. The ideal treatment remains controversial. METHODS Augmentative plating using a 4.5 mm LCP or a 3.2 mm LCP leaving the nail in situ was tested biomechanically and compared to exchange intramedullary nailing in a SawboneTM model of a femoral shaft non-union. RESULTS The difference of fracture gap motion in axial testing was small. In rotational testing, the exchange nail allowed for the largest amount of motion. The 4.5 mm augmentative plate was the most stable construct in all loading conditions. CONCLUSIONS Augmentative plating using a 4.5 mm LCP plate while leaving the nail in situ is biomechanically superior to exchange intramedullary nailing. A small fragment 3.2 mm LCP is undersized and does not reduce fracture motion sufficiently in a femoral shaft non-union.
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Affiliation(s)
- Matthias Georg Walcher
- OC Würzburg, Oeggstr. 3, 97070 Würzburg, Germany
- Department of Orthopedics and Traumatology, Paracelsus Medical University, Breslauer Straße 201, 90471 Nuremberg, Germany
| | - Robert E Day
- Health Technology Management Unit, Royal Perth Hospital, University of Western Australia, 197 Wellington Street, Perth 6000, Australia
| | - Markus Gesslein
- Department of Orthopedics and Traumatology, Paracelsus Medical University, Breslauer Straße 201, 90471 Nuremberg, Germany
| | - Hermann Josef Bail
- Department of Orthopedics and Traumatology, Paracelsus Medical University, Breslauer Straße 201, 90471 Nuremberg, Germany
| | - Markus S Kuster
- Perth Orthopaedic Sports Medicine Centre, The University of Western Australia, 31 Outram Street, Perth 6005, Australia
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The effect of cerclage wiring with intramedullary nail surgery in proximal femoral fracture: a systematic review and meta-analysis. Eur J Trauma Emerg Surg 2022; 48:4761-4774. [PMID: 35618854 DOI: 10.1007/s00068-022-02003-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 05/07/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE The aim of this study was to evaluate the utility of cerclage wiring with intramedullary nail surgery in the treatment of proximal femoral fractures. METHODS MEDLINE, Embase, and Cochrane Library were systematically searched for studies that evaluated the impact of cerclage wiring on proximal femoral fractures published up to September 20, 2021. Pooled analysis identified differences in the (1) fracture healing profile, (2) perioperative variables, (3) complications, and (4) clinical outcome score between cerclage wiring and non-cerclage wiring. RESULTS Fourteen studies involving 1,718 patients with proximal femoral fractures who underwent cephalomedullary nailing surgeries were included. The pooled analysis revealed a longer fracture union time in the non-cerclage wiring group than in the cerclage wiring group (mean difference [MD] = - 1.03 months; 95% confidence interval [CI]: - 1.47 to - 0.59; P < 0.001), and there was no difference in the nonunion rate. The operation time was longer in the cerclage wiring group (MD = 14.32 min; 95% CI: 6.42-22.22; P < 0.001), but there were no differences in blood loss and the rate of poor quality of reduction. Superficial and deep infection rates showed no difference between the groups, and the readmission rate also showed no difference. The cerclage wiring group had a higher Harris hip score than the non-cerclage wiring group (MD = 2.13; 95% CI: 0.77-3.49; P = 0.002). CONCLUSIONS Intramedullary nailing with cerclage wiring is considered a useful treatment method for proximal femoral fractures. It enables anatomic reduction and stable fixation, thereby reducing union time and facilitating rapid functional recovery.
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LaMonica JN, Rhee B, Milligan K, Leslie M, Tommasini SM, Wiznia DH. Finite Element Evaluation of the Femoral Neck System as Prophylactic Fixation to Prevent Contralateral Hip Fractures. Geriatr Orthop Surg Rehabil 2022; 13:21514593221135117. [DOI: 10.1177/21514593221135117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 10/07/2022] [Accepted: 10/10/2022] [Indexed: 11/12/2022] Open
Abstract
Introduction Hip fractures cause significant morbidity and mortality for geriatric patients, and incidence is increasing as the population ages. Following a primary hip fracture, up to 20% may suffer a contralateral hip fracture within 5 years despite fracture risk reduction measures, including fall prevention and osteoporosis pharmacologic treatment. The aim of this study is to assess whether insertion of the Femoral Neck System (Depuy Synthes, West Chester, PA) into the contralateral proximal femur may strengthen the bone and decrease the incidence of contralateral hip fractures. Materials and Methods ScanIP, an image processing software was used to produce 3-dimensional models of a cadaver femur with the implanted device. Models were meshed and exported to Abaqus for finite element analysis to evaluate the device’s ability to reduce stress in the proximal femur. Results were analyzed for element-wise volume and von-Mises stresses. Results The implant reduced peak stress and bone failure at all levels of bone quality. Specifically in osteoporotic bone, the implant decreased peak stress by 27%, proximal femur trabecular bone failure by 5% and cortical bone failure by 100% in the femoral neck. Conclusions Our results from computer generated finite element analyses indicate that the Femoral Neck System may strengthen an osteoporotic proximal femur in the event of a lateral fall. Further investigation with expanded finite element analysis and cadaveric biomechanical studies are needed to validate these results.
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Affiliation(s)
- Julia N. LaMonica
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
- Quinnipiac University, Frank H. Netter M.D. School of Medicine, North Haven, CT, USA
| | - Brian Rhee
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Kenneth Milligan
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Michael Leslie
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Steven M. Tommasini
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
| | - Daniel H. Wiznia
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, USA
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Richardson P, Panteli M, Giannoudis PV. Exchange nailing and medial wall reconstruction following implant failure in a subtrochanteric femoral fracture. Trauma Case Rep 2021; 36:100555. [PMID: 34841032 PMCID: PMC8605424 DOI: 10.1016/j.tcr.2021.100555] [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] [Accepted: 10/25/2021] [Indexed: 10/29/2022] Open
Abstract
Failure of fixation of subtrochanteric fractures has been reported in as high as 20% of cases. Several associations have been suggested to contribute to failed fixation. Discontinuity of the medial wall/column is considered to be one of the most significant risk factors for non-union and subsequent implant failure, especially if this defect is not addressed during the revision surgery. We present a case of failed fixation of a subtrochanteric fracture in an 86-year-old female where revision surgery paid special attention to restoring the medial wall continuity via bone grafting resulting in satisfactory union of the fracture. We advocate the necessity of reconstructing the medial column in similar cases in order to enhance healing and restore the biomechanical support of the subtrochanteric region.
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Affiliation(s)
- Philippa Richardson
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Leeds, United Kingdom
| | - Michalis Panteli
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Leeds, United Kingdom
| | - Peter V. Giannoudis
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Leeds, United Kingdom
- NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, Leeds, United Kingdom
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Results of revision intramedullary nailing with and without auxillary plate in aseptic trochanteric and subtrochanteric nonunion. Eur J Trauma Emerg Surg 2021; 48:1905-1911. [PMID: 33861371 PMCID: PMC9192482 DOI: 10.1007/s00068-021-01664-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 03/30/2021] [Indexed: 11/03/2022]
Abstract
PURPOSE Aim of this study was to investigate whether limited open auxiliary angle stable plate fixation has an effect on functional and radiologic outcomes one year after revision intramedullary nailing in aseptic trochanteric and subtrochanteric fracture nonunion. METHODS In a retrospective analysis, surgically revised aseptic trochanteric and subtrochanteric nonunion was evaluated in a total of 190 consecutive patients ranging from 18 to 94 years between 12/2005 and 10/2018. RESULTS One year after revision intramedullary nailing, nonunion healing was assessed in 129 out of 136 patients (95%) in group 1 without auxiliary plate fixation and in 51 out of 54 patients (94%) in group 2 with auxiliary plating (p = 0.23). In group 1, range of motion (ROM) was unrestricted in 88 patients and still restricted in 48 patients. In group 2, ROM was free in 34 patients and restricted in 20 patients (p = 0.25). The mean Lower Extremity Functional Scale (LEFS) was 56 points in group 1 and 55 points in group 2 (p = 0.55). CONCLUSION This study did not demonstrate significant differences in functional and radiologic outcomes following revision intramedullary nailing of aseptic trochanteric and subtrochanteric fracture nonunion. Limited open auxiliary plate fixation might be a reasonable option especially in cases of relevant varus axis deviation and comminuted or atypical fracture configurations, regardless of patients' age. Retrospectively registered with the German Clinical Trials Register (01/25/2021; ID: DRKS00024112).
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