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Fernandez M, Du Bourg VM, David Y, Dubrana F, Letissier H, Di Francia R. Augmented versus non-augmented Trochanteric Fixation Nail-Advanced (TFNA) nails for treating trochanteric fractures in patients over sixty-five years of age. Int Orthop 2024; 48:831-840. [PMID: 38159137 DOI: 10.1007/s00264-023-06073-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 12/15/2023] [Indexed: 01/03/2024]
Abstract
PURPOSE Intramedullary nailing is a common treatment for pertrochanteric fractures. However, implant-related mechanical failures, such as cut-out and cut-through, lead to higher rates of revision surgery, loss of autonomy, and mortality. Cemented augmentation enhances the bone-implant interface. This study compared the frequency of mechanical failures between augmented and non-augmented Trochanteric Fixation Nail-Advanced (TFNA) nails. METHODS This descriptive, retrospective study at a level 1 trauma centre included patients aged > 65 years with pertrochanteric fractures treated by a short augmented or non-augmented TFNA nail. The primary outcome was the comparison of cut-out or cut-through rates between groups at three and six months postoperatively. RESULTS Of the 181 patients analysed, 103 had augmented TFNA nails and 78 had non-augmented TFNA nails. There were no statistically significant differences between groups in terms of demographic characteristics, AO/OTA classification, or quality of reduction. The failure rate was significantly lower in the augmented group than in the non-augmented group: 1 (0.97%) versus 9 (11.54%) (p = 0.005). At six months postoperatively, there was no significant difference between the two groups concerning functional recovery, as measured by the Parker and EuroQoL 5-Dimensions scores. CONCLUSIONS For patients aged over 65 years, the use of the augmented TFNA nail may reduce the risk of fixation failures such as cut-out.
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Affiliation(s)
- Marie Fernandez
- Service d'Orthopédie Et de Traumatologie, CHRU Brest Cavale Blanche, Boulevard Tanguy Prigent, 29200, Brest, France
| | - Valentin Merle Du Bourg
- Service d'Orthopédie Et de Traumatologie, CHU Grenoble Alpes - Hôpital Sud, Avenue de Kimberley, 38130, Echirolles, France
| | - Yoann David
- Service d'Orthopédie Et de Traumatologie, CHRU Brest Cavale Blanche, Boulevard Tanguy Prigent, 29200, Brest, France
| | - Frédéric Dubrana
- Service d'Orthopédie Et de Traumatologie, CHRU Brest Cavale Blanche, Boulevard Tanguy Prigent, 29200, Brest, France
| | - Hoel Letissier
- Service d'Orthopédie Et de Traumatologie, CHRU Brest Cavale Blanche, Boulevard Tanguy Prigent, 29200, Brest, France
| | - Rémi Di Francia
- Service d'Orthopédie Et de Traumatologie, CHRU Brest Cavale Blanche, Boulevard Tanguy Prigent, 29200, Brest, France.
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Mayor J, Birgel V, Clausen JD, Aktas G, Sehmisch S, Einfeldt AK, Giannoudis V, Abdelaal AHK, Liodakis E. Lessons learned from biomechanical studies on cephalomedullary nails for the management of intertrochanteric fractures. A scoping review. Injury 2024; 55:111180. [PMID: 37972488 DOI: 10.1016/j.injury.2023.111180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 10/29/2023] [Accepted: 10/31/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION The increasing socioeconomic need for optimal treatment of hip fractures in combination with the high diversity of available implants has raised numerous biomechanical questions. This study aims to provide a comprehensive overview of biomechanical research on the treatment of intertrochanteric fractures using cephalomedullary devices. METHODS Following the PRISMA-P guidelines, a systematic literature search was performed on 31.12.2022. The databases PubMed/MEDLINE and Web of Science were searched. Scientific papers published between 01.01.2000 - 31.12.2022 were included when they reported data on implant properties related to the biomechanical stability for intertrochanteric fractures. Data extraction was undertaken using a synthesis approach, gathering data on criteria of implants, sample size, fracture type, bone material, and study results. RESULTS The initial search identified a total of 1459 research papers, out of which forty-three papers were considered for final analysis. Due to the heterogeneous methods and parameters used in the included studies, meta-analysis was not feasible. A comprehensive assessment of implant characteristics and outcome parameters was conducted through biomechanical analysis. Various factors such as proximal and distal locking, nail diameter and length, fracture model, and bone material were thoroughly evaluated. CONCLUSION This scoping review highlights the need for standardization in biomechanical studies on intertrochanteric fractures to ensure reliable and comparable results. Strategies such as avoiding varus, maintaining a sufficient tip-apex-distance, cement augmentation, and optimizing lesser trochanteric osteosynthesis enhance construct stability. Synthetic alternatives may offer advantages over cadaveric bone. Further research and meta-analyses are required to establish standardized protocols and enhance reliability.
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Affiliation(s)
- Jorge Mayor
- Department of Trauma Surgery, Hannover Medical School, Carl-Neuberg Str. 1, Hannover D-30625, Germany.
| | - Vera Birgel
- Hannover Medical School, Institute for Epidemiology, Social Medicine and Health Systems Research, Hannover, Germany
| | - Jan-Dierk Clausen
- Department of Trauma Surgery, Hannover Medical School, Carl-Neuberg Str. 1, Hannover D-30625, Germany
| | - Gökmen Aktas
- Department of Trauma Surgery, Hannover Medical School, Carl-Neuberg Str. 1, Hannover D-30625, Germany
| | - Stephan Sehmisch
- Department of Trauma Surgery, Hannover Medical School, Carl-Neuberg Str. 1, Hannover D-30625, Germany
| | - Ann-Kathrin Einfeldt
- Laboratory for Biomechanics and Biomaterials, Department of Orthopedic Surgery, Hannover Medical School, Anna-von-Borries-Str. 1-7, Hannover 30625, Germany
| | - Vasilis Giannoudis
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Leeds General Infirmary, Leeds, United Kingdom
| | - Ahmed H K Abdelaal
- Department of Orthopedic Surgery, Faculty of Medicine, Sohag University, Sohag 82524, Egypt
| | - Emmanouil Liodakis
- Department of Trauma Surgery, Hannover Medical School, Carl-Neuberg Str. 1, Hannover D-30625, Germany
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Lee H, Lee SH, Lim W, Jo S, Jo S. Comparison of Helical Blade Systems for Osteoporotic Intertrochanteric Fractures Using Biomechanical Analysis and Clinical Assessments. Medicina (Kaunas) 2022; 58. [PMID: 36556901 DOI: 10.3390/medicina58121699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 11/02/2022] [Accepted: 11/21/2022] [Indexed: 11/24/2022]
Abstract
Background and Objectives: This study aimed to compare the biomechanical properties and outcomes of osteoporotic intertrochanteric fractures treated with two different helical blade systems, the trochanteric fixation nail-advanced (TFNA) and proximal femoral nail antirotation II (PFNA), to evaluate the efficacy and safety of the newly introduced TFNA system. Materials and Methods: A biomechanical comparison of the two helical blades was performed using uniaxial compression tests on polyurethane foam blocks of different densities. The peak resistance (PR) and accumulated resistance (AR) were measured during the 20 mm advancement through the test block. For clinical comparison, 63 osteoporotic intertrochanteric fractures treated with TFNA were identified and compared with the same number of fractures treated with PFNA using propensity score matching. Ambulatory status, medial migration, lateral sliding, fixation failure, and patient-reported outcomes were compared between the two groups over a minimum of 1 year's follow up. Results: The uniaxial compression test showed that a slightly, but significantly lower resistance was required to advance the TFNA through the test block compared with the PFNA (20 PCF, p = 0.017 and p = 0.026; 30 PCF, p = 0.007 and p = 0.001 for PR and AR, respectively). Clinically, the two groups showed no significant differences in post-operative ambulatory status and patient-reported outcomes. However, in TFNA groups, significantly more medial migration (TFNA, 0.75 mm; PFNA, 0.40 mm; p = 0.0028) and also, lateral sliding was noted (TFNA, 3.99 mm; PFNA, 1.80 mm; p = 0.004). Surgical failure occurred in four and two fractures treated with the TFNA and PFNA, respectively. Conclusions: The results of our study suggest that the newly introduced TFNA provides clinical outcomes comparable with those of the PFNA. However, inferior resistance to medial migration in the TFNA raises concerns regarding potential fixation failures.
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Joeris A, Kabiri M, Galvain T, Vanderkarr M, Holy CE, Plaza JQ, Tien S, Schneller J, Kammerlander C. Cost-Effectiveness of Cement Augmentation Versus No Augmentation for the Fixation of Unstable Trochanteric Fractures. J Bone Joint Surg Am 2022; 104:2026-2034. [PMID: 36053020 DOI: 10.2106/jbjs.21.01516] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND A previous randomized controlled trial (RCT) demonstrated a trend toward a reduced risk of implant-related revision surgery following fixation with use of a Proximal Femoral Nail Antirotation (PFNA) with TRAUMACEM V+ Injectable Bone Cement augmentation versus no augmentation in patients with unstable trochanteric fractures. To determine whether this reduced risk may result in long-term cost savings, the present study assessed the cost-effectiveness of TRAUMACEM V+ cement augmentation versus no augmentation for the fixation of unstable trochanteric fractures from the German health-care payer's perspective. METHODS The cost-effectiveness model comprised 2 stages: a decision tree simulating clinical events, costs, and utilities during the first year after the index procedure and a Markov model extrapolating clinical events, costs, and utilities over the patient's lifetime. Sources of model parameters included the previous RCT, current literature, and administrative claims data. Outcome measures were incremental costs (in 2020 Euros), incremental quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). Model uncertainty was assessed with deterministic and probabilistic sensitivity analyses. RESULTS The base-case analysis showed that fixation with cement augmentation was the dominant strategy as it was associated with cost savings (€50.3/patient) and QALY gains (0.01 QALY/patient). Major influential parameters for the ICER were the utility of revision, rates of revision surgery within the first year after fixation surgery, and the costs of augmentation and revision surgery. Probabilistic sensitivity analyses demonstrated that estimates of cost savings were more robust than those of increased QALYs (66.4% versus 52.7% of the simulations). For a range of willingness-to-pay thresholds from €0 to €50,000, the probability of fixation with cement augmentation being cost-effective versus no augmentation remained above 50%. CONCLUSIONS Fixation with use of cement augmentation dominated fixation with no augmentation for unstable trochanteric fractures, resulting in cost savings and QALY gains. Given the input parameter uncertainties, future analyses are warranted when long-term costs and effectiveness data for cement augmentation are available. LEVEL OF EVIDENCE Economic and Decision Analysis Level II . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Alexander Joeris
- AO Innovation Translation Center, Clinical Science, AO Foundation, Davos, Switzerland
| | - Mina Kabiri
- Global Provider and Payer Value Demonstration, Global Health Economics, Johnson & Johnson Medical Devices, New Brunswick, New Jersey
| | - Thibaut Galvain
- Global Provider and Payer Value Demonstration, Global Health Economics, Johnson & Johnson Medical Devices, New Brunswick, New Jersey
| | | | - Chantal E Holy
- Medical Device Epidemiology, Johnson & Johnson, New Brunswick, New Jersey
| | | | - Stephanie Tien
- Global Provider and Payer Value Demonstration, Global Health Economics, Johnson & Johnson Medical Devices, New Brunswick, New Jersey
| | - Julia Schneller
- Department of Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany
| | - Christian Kammerlander
- Department of Orthopedics and Trauma Surgery, Musculoskeletal University Center Munich (MUM), University Hospital, LMU Munich, Munich, Germany.,AUVA Trauma Hospital Styria, Graz, Austria.,AUVA Trauma Hospital Styria, Kalwang, Austria
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Pastor T, Zderic I, Schopper C, Haefeli PC, Kastner P, Souleiman F, Gueorguiev B, Knobe M. Impact of Anterior Malposition and Bone Cement Augmentation on the Fixation Strength of Cephalic Intramedullary Nail Head Elements. Medicina (Kaunas) 2022; 58:1636. [PMID: 36422175 PMCID: PMC9696484 DOI: 10.3390/medicina58111636] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/04/2022] [Accepted: 11/09/2022] [Indexed: 11/26/2023]
Abstract
Background and Objectives: Intramedullary nailing of trochanteric fractures can be challenging and sometimes the clinical situation does not allow perfect implant positioning. The aim of this study was (1) to compare in human cadaveric femoral heads the biomechanical competence of two recently launched cephalic implants inserted in either an ideal (centre-centre) or less-ideal anterior off-centre position, and (2) to investigate the effect of bone cement augmentation on their fixation strength in the less-ideal position. Materials and Methods: Fourty-two paired human cadaveric femoral heads were assigned for pairwise implantation using either a TFNA helical blade or a TFNA screw as head element, implanted in either centre-centre or 7 mm anterior off-centre position. Next, seven paired specimens implanted in the off-centre position were augmented with bone cement. As a result, six study groups were created as follows: group 1 with a centre-centre positioned helical blade, paired with group 2 featuring a centre-centre screw, group 3 with an off-centre positioned helical blade, paired with group 4 featuring an off-centre screw, and group 5 with an off-centre positioned augmented helical blade, paired with group 6 featuring an off-centre augmented screw. All specimens were tested until failure under progressively increasing cyclic loading. Results: Stiffness was not significantly different among the study groups (p = 0.388). Varus deformation was significantly higher in group 4 versus group 6 (p = 0.026). Femoral head rotation was significantly higher in group 4 versus group 3 (p = 0.034), significantly lower in group 2 versus group 4 (p = 0.005), and significantly higher in group 4 versus group 6 (p = 0.007). Cycles to clinically relevant failure were 14,919 ± 4763 in group 1, 10,824 ± 5396 in group 2, 10,900 ± 3285 in group 3, 1382 ± 2701 in group 4, 25,811 ± 19,107 in group 5 and 17,817 ± 11,924 in group 6. Significantly higher number of cycles to failure were indicated for group 1 versus group 2 (p = 0.021), group 3 versus group 4 (p = 0.007), and in group 6 versus group 4 (p = 0.010). Conclusions: From a biomechanical perspective, proper centre-centre implant positioning in the femoral head is of utmost importance. In cases when this is not achievable in a clinical setting, a helical blade is more forgiving in the less ideal (anterior) malposition when compared to a screw, the latter revealing unacceptable low resistance to femoral head rotation and early failure. Cement augmentation of both off-centre implanted helical blade and screw head elements increases their resistance against failure; however, this effect might be redundant for helical blades and is highly unpredictable for screws.
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Affiliation(s)
- Torsten Pastor
- AO Research Institute Davos, 7270 Davos, Switzerland
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, 6000 Lucerne, Switzerland
| | - Ivan Zderic
- AO Research Institute Davos, 7270 Davos, Switzerland
| | - Clemens Schopper
- Department for Orthopaedics and Traumatology, Kepler University Hospital GmbH, Johannes Kepler University Linz, 4020 Linz, Austria
| | - Pascal C. Haefeli
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, 6000 Lucerne, Switzerland
| | - Philipp Kastner
- AO Research Institute Davos, 7270 Davos, Switzerland
- Department for Orthopaedics and Traumatology, Kepler University Hospital GmbH, Johannes Kepler University Linz, 4020 Linz, Austria
| | - Firas Souleiman
- AO Research Institute Davos, 7270 Davos, Switzerland
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, 04103 Leipzig, Germany
| | | | - Matthias Knobe
- Department of Orthopaedic and Trauma Surgery, Lucerne Cantonal Hospital, 6000 Lucerne, Switzerland
- Medical Faculty, University of Zurich, 8091 Zurich, Switzerland
- Medical Faculty, RWTH Aachen University Hospital, 52074 Aachen, Germany
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Bi W, Xu J, Dong Z, Wang Z, Li J, Shang Y, Wu J. Clinical Analysis of Surgical Treatment of Senile Intertrochanteric Fracture Based on Intelligent Knowledge of Health Care. Contrast Media Mol Imaging 2022; 2022:3556330. [PMID: 35854781 PMCID: PMC9279043 DOI: 10.1155/2022/3556330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 06/06/2022] [Accepted: 06/16/2022] [Indexed: 11/29/2022]
Abstract
In order to explore the clinical application value of intelligent health care knowledge combined with closed reduction intramedullary nail fixation in elderly patients with intertrochanteric fracture of the femur, a retrospective analysis is performed on 80 elderly patients who received intertrochanteric surgery from January 2019 to January 2021. All patients were divided into study group and control group based on intelligent medical knowledge received or not. During the phase of treatment, both the two groups were treated with closed reduction and intramedullary nailing. The control group received conventional knowledge training and rehabilitation before and after the surgery, and the research group received additional intelligent medical knowledge health care. Observations of patients after bed and ground time are compared and the VAS score is used to evaluate the pain degree at 12 h, 24 h, and 48 h after surgery. Besides, the incidence of postoperative complications in the two groups is observed. From the clinical follow-up results, it is clearly evident that intramedullary nail fixation based on medical care knowledge can effectively improve the hip function and quality of life in patients, reduce postoperative pain, and improve the prognosis of elderly patients with femoral trochanteric fracture.
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Affiliation(s)
- Weidong Bi
- The Second Department of Orthopedics, Shijiazhuang People's Hospital, Shijiazhuang 050000, China
| | - Jianjie Xu
- The Second Department of Orthopedics, Shijiazhuang People's Hospital, Shijiazhuang 050000, China
| | - Zhihui Dong
- The Second Department of Orthopedics, Shijiazhuang People's Hospital, Shijiazhuang 050000, China
| | - Zhaona Wang
- The Second Department of Orthopedics, Shijiazhuang People's Hospital, Shijiazhuang 050000, China
| | - Jiebing Li
- The Second Department of Orthopedics, Shijiazhuang People's Hospital, Shijiazhuang 050000, China
| | - Yongwei Shang
- The Second Department of Orthopedics, Shijiazhuang People's Hospital, Shijiazhuang 050000, China
| | - Jianzhong Wu
- The Second Department of Orthopedics, Shijiazhuang People's Hospital, Shijiazhuang 050000, China
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van Veelen NM, Beeres FJ, Link BC, Babst R. [Augmentation in the treatment of proximal humeral and femoral fractures]. Unfallchirurg 2022; 125:436-442. [PMID: 35416480 DOI: 10.1007/s00113-022-01172-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/09/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Proximal humeral and trochanteric femoral fractures in older patients are typically caused by low-energy trauma and are therefore often associated with osteoporosis. The treatment of such fragility fractures can be difficult as implant purchase is reduced in osteoporotic bone. By augmenting the fixation with cement the contact surface between implant and bone can be increased, which improves the stability of the osteosynthesis. OBJECTIVE This article describes the operative technique for the augmentation of trochanteric femoral fractures treated with the Trochanteric Fixation Nail-Advanced (TFNA, DePuy Synthes, Oberdorf BL, Switzerland) and proximal humeral fractures stabilized with a PHILOS plate (DePuy Synthes). Furthermore, the evidence for the augmentation of these two fracture types is elucidated. RESULTS Biomechanical studies could show an improved stability of the osteosynthesis after successful augmentation for both fracture types. The current evidence also indicates a clinical reduction of fixation failure. Whether the augmentation has an influence on the functional result could so far not yet clearly be proven. CONCLUSION Augmentation seems to be a safe and valuable addition to available treatment options especially for patients with fragility fractures.
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Affiliation(s)
- Nicole M van Veelen
- Klinik für Orthopädie und Unfallchirurgie, Luzerner Kantonsspital, Spitalstraße, 6000, Luzern 16, Schweiz
| | - Frank Jp Beeres
- Klinik für Orthopädie und Unfallchirurgie, Luzerner Kantonsspital, Spitalstraße, 6000, Luzern 16, Schweiz
| | - Björn-Christian Link
- Klinik für Orthopädie und Unfallchirurgie, Luzerner Kantonsspital, Spitalstraße, 6000, Luzern 16, Schweiz
| | - Reto Babst
- Klinik für Orthopädie und Unfallchirurgie, Luzerner Kantonsspital, Spitalstraße, 6000, Luzern 16, Schweiz. .,Departement Gesundheitswissenschaften und Medizin, Universität Luzern, Frohburgstraße 3, 6002, Luzern, Schweiz.
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