Biomechanical evaluation of a modified intramedullary nail for the treatment of unstable femoral trochanteric fractures

Background

The Proximal Femoral Nail Antirotation (PFNA) device is the most commonly used implant to fix unstable femoral trochanteric fractures (UFTFs), but it has a relatively high incidence of complications. Due to this factor, the modified intramedullary nail (MIN) was created to treat patients with UFTFs. The aim was to exhibit the MIN and make a comparison with PFNA and InterTAN using biomechanical methods.

Methods

An adult UFTF model was developed using Mimics software. The PFNA, InterTAN nail, and MIN models were drawn referring to the corresponding parameters and installed in the fracture models. Vertical, anteroposterior (AP) bending, and torsion loads of the femoral head were set in advance and loaded onto the fracture models. The value of maximal displacement and von Mises stress was evaluated via finite element analysis (FEA).

Results

The MIN model had smaller values for maximal displacement than that of the PFNA model, and the increase in displacement was less pronounced for the MIN compared to PFNA under increasing vertical loads. For the indicator of von Mises stress, the MIN model showed lower stress compared with the PFNA model in vertical loads ranging from 300 N to 2100 N. Except for the maximal stress at implants under AP bending loads, the MIN demonstrated the most superior biomechanical properties under AP bending and torsional loads.

Conclusion

The MIN offered obvious advantages in terms of mechanical stability and stress distribution among the three studied implants, providing a promising implant option for patients with UFTFs.

Nail fixation of unstable trochanteric fractures with or without cement augmentation: A cost-utility analysis in the United States: Cost-utility of cement augmentation

OBJECTIVES

Recent clinical studies have shown favorable outcomes for cement augmentation for fixation of trochanteric fracture. We assessed the cost-utility of cement augmentation for fixation of closed unstable trochanteric fractures from the US payer's perspective.

METHODS

The cost-utility model comprised a decision tree to simulate clinical events over 1 year after the index fixation surgery, and a Markov model to extrapolate clinical events over patients' lifetime, using a cohort of 1,000 patients with demographic and clinical characteristics similar to that of a published randomized controlled trial (age ≥75 years, 83 % female). Model outputs were discounted costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (ICER) over a lifetime. Deterministic and probabilistic sensitivity analyses were performed to assess the impact of parameter uncertainty on results.

RESULTS

Fixation with augmentation reduced per-patient costs by $754.8 and had similar per-patient QALYs, compared to fixation without augmentation, resulting in an ICER of -$130,765/QALY. The ICER was most sensitive to the utility of revision surgery, mortality risk ratio after the second revision surgery, mortality risk ratio after successful index surgery, and mortality rate in the decision tree model. The probability that fixation with augmentation was cost-effective compared with no augmentation was 63.4 %, 58.2 %, and 56.4 %, given a maximum acceptable ceiling ratio of $50,000, $100,000, and $150,000 per QALY gained, respectively.

CONCLUSION

Fixation with cement augmentation was the dominant strategy, driven mainly by reduced costs. These results may support surgeons in evidence-based clinical decision making and may be informative for policy makers regarding coverage and reimbursement.

Should recommended laboratory-test cut-offs allowing surgery be followed for proximal femoral fractures in patients on direct oral anticoagulant therapy?

BACKGROUND

Proximal femoral fractures (PFFs) in elderly patients must receive prompt surgical treatment. Optimal PFF-surgery timing in patients on direct oral anticoagulant (DOA) therapy is a specific but common clinical issue. Recommendations exist about the anti-Xa or anti-IIa levels and creatinine clearance values required to allow surgery. The objectives of this study in patients older than 75 years who required PFF surgery were to evaluate bleeding when the recommendations were versus were not applied and to assess concordance between DOA-activity-assay results and creatinine clearance used to help determine the wait to surgery.

HYPOTHESIS

Peri-operative bleeding is more marked when surgery is performed while the DOA is still active.

PATIENTS AND METHODS

This single-centre, retrospective, comparative, observational study included 87 patients older than 75 years who required arthroplasty or intra-medullary nailing for PFF and were taking DOA therapy. Surgery was performed after versus before the laboratory-test results fell below the recommended cut-offs in 68 patients (Rec+ group) versus 19 patients (Rec- group), respectively. The study outcomes were blood loss estimated using the Mercuriali's formula and the proportion of patients requiring post-operative blood transfusions.

RESULTS

Mean blood loss was 287.1mL in the Rec+ group and 411.7mL in the Rec- group (p=0.12). Blood transfusions were required by a post-operative haemoglobin level below 0.8g/dL in 11 (16.2%) Rec+ patients and 6 (31.6%) Rec- patients (p=0.2). Concordance was poor between DOA activity and creatinine clearance (Cohen's κ, 0.16; p=0.146).

DISCUSSION

Peri-operative bleeding was not significantly more severe when PFF surgery was performed while DOA therapy was still active. These data suggest that PFF surgery within 48h may be appropriate in patients older than 75 years on DOA therapy.

LEVEL OF EVIDENCE

IV; retrospective single-centre study.

Augmented versus non-augmented Trochanteric Fixation Nail-Advanced (TFNA) nails for treating trochanteric fractures in patients over sixty-five years of age

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.

Failure after intramedullary nailing for geriatric trochanteric fracture: does quality of fracture reduction on the AP and lateral planes show the same results?

PURPOSE

This study aimed to investigate the failure of trochanteric fracture fixation according to the quality of fracture reduction on the anteroposterior (AP) and lateral views.

METHODS

Data from 340 female and 152 male patients ≥ 60 years of age who underwent intramedullary nailing for a trochanteric fracture between 2016 and 2020 were analysed retrospectively. The quality of fracture reduction was classified as type A, type E, and type I on the AP view and type N, type A, and type P on the lateral view according to the relative position of the proximal and distal fragments. The failure rate was evaluated and compared according to the quality of fracture reduction. The risk factors of the fixation failure were investigated by comparison of variables between patients with and without failure and by regression analysis.

RESULTS

Patients with poor reduction, type I and type P had higher failure rates. However, a statistically significant difference was found only for patients with poor reduction (type P) on the lateral view (p < 0.001). Patients with failure showed significantly higher rates of poor reduction on the lateral view and AO/OTA type A3 fractures. The regression analysis also showed that poor reduction on the lateral view (odds ratio [OR] 12.70; 95% confidence interval [CI] 4.0-40.6; p < 0.001) and AO/OTA type A3 fractures (OR 5.40; 95% CI 1.24-23.49, p = 0.025) were risk factors for failure.

CONCLUSION

Poor reduction such as type P reduction was associated with failure after intramedullary nailing for trochanteric fractures. Surgeons should check the quality of fracture reduction carefully with the proper fluoroscopic view to prevent failure in geriatric patients with trochanteric fractures.

Different types of hip fragility fractures have different values of 25-hydroxyvitamin D and parathyroid hormone

BACKGROUND

Vitamin D insufficiency/deficiency is related to fragility fracture. In most previous studies, there was no assessment of vitamin D deficiency status separately for hip fracture types. The first aim is to evaluate vitamin D and parathyroid hormone (PTH) status in patients with hip fracture. The second objective is to determine whether there are differences in vitamin D and PTH between the femoral neck fracture and the femoral metaphyseal fracture group.

METHODS

62 men and 248 women with fragility hip fractures were enrolled. 25-hydroxyviamin D [25(OH)D] and intact PTH (iPTH) values were evaluated, and femoral neck bone mineral density (BMD) was measured on the uninjured side. Vertebral fractures (VFs) were assessed using radiographs of the thoracic and lumbar spine. We examined the relationships of 25(OH)D value with the number of prevalent VFs, T-score of femoral neck, and iPTH level. These analyses were also performed, neck fracture and trochanteric fracture separately.

RESULTS

Mean age was 85 years. The mean 25(OH)D was 11.2 (range, 4.0-26.1) ng/ml, whereas the mean iPTH value was 48.9 pg/ml (range, 9-429 pg/ml). The mean number of VFs was 1.5 (range, 0-11), and the mean T-score was -3.3 (range, -5.2 to -0.5). There was a weak correlation between the 25(OH)D value and the number of VFs. There was a weak but significant correlation between 25(OH)D and iPTH values. In the patients with trochanteric fractures, 25(OH)D value was significantly lower and iPTH value was significantly higher than those with neck fractures. There was a significant correlation between the 25(OH)D value and number of the VFs, 25(OH)D, and iPTH values only in trochanteric fractures.

CONCLUSIONS

Vitamin D deficiency was severe and PTH levels were higher in the trochanteric fractures. Both vitamin D deficiency and high PTH levels were suggested to have association with bone fragility.

Risk of peri‑implant femoral fracture after cephalomedullary nailing in older patients with trochanteric fractures

INTRODUCTION

Despite the recent increase in the use of cephalomedullary nails for trochanteric hip fractures, factors that may be associated with peri‑implant femoral fracture (PIFF) after cephalomedullary nailing for trochanteric fractures remain unknown. We investigated the factors associated with PIFF after cephalomedullary nailing of trochanteric hip fractures in older patients.

METHODS

A nested case-control study was conducted using a database of patients aged ≥65 years who underwent surgery with cephalomedullary nails for trochanteric fractures caused by low-energy trauma during 2005-2021. The cases were defined as patients who developed PIFF after surgery, while controls were patients who did not develop PIFF and who were followed up for ≥3 years after surgery. Four controls were randomly matched to each case for sex and age. First, potential factors associated with PIFF were compared between cases and controls. Second, multivariable conditional logistic regression analysis was employed to assess factors possibly associated with PIFF, controlling for potential confounding factors.

RESULTS

Of 1531 patients who underwent surgery with cephalomedullary nails because of trochanteric fractures, we assessed 34 cases and 136 controls (N = 170; mean age 85.7 ± 7 years; and females, 94 %). PIFF was significantly associated with patients having undergone total knee arthroplasty (adjusted odds ratios [95 % confidence intervals], 4.41 [1.16-16.8]) and those with AO/OTA classification 31A3 fracture (A3 fracture) (2.3 [1.12-4.76]), after adjusting for potential confounding factors.

CONCLUSIONS

Our results showed that PIFF was more likely to develop among older patients with a clinical history of total knee arthroplasty and A3 fracture. These findings suggest that such patients may require careful follow-up with rigorous assessments after cephalomedullary nailing for trochanteric fractures.

Patients with trochanteric hip fractures and pre-existing osteoarthritis can be treated with nailing osteosynthesis without significant decrease in functional status

PURPOSE

Functional outcome in patients after trochanteric fracture fixation with pre-existing radiographic osteoarthritis (OA) is unclear. Analyzing their function and independence, before and after fracture, could optimize their treatment and decrease the socioeconomic burden in this particular group.

METHODS

The influence of pre-existing radiographic hip OA on functional outcome was retrospectively analyzed with a cohort of patients undergoing proximal femoral nailing for trochanteric fracture. OA was graded according to the Tonnis classification. Functional outcome was assessed preoperatively and 12 months after surgery by the Parker Mobility Score (PMS). We consider a meaningful reduction a difference between preoperatively PMS and 12 months after surgery ≥ 2. In order to evaluate if OA is related to PMS reduction ≥ 2, we calculate the SubHazard ratio (SHR) performing a competing risk regression model considering death as a competing risk event, adjusting by confounders. Death, reoperations, readmissions, surgical time, and fracture reduction quality in patients with and without osteoarthritis were recorded.

RESULTS

375 trochanteric hip fractures treated with cephalomedullary nails were included, from which 80 (21% CI95% 17%-21%) were classified as Tonnis 2 or 3. This group of patients with pre-existing OA was significantly older (mean age of 88.6 [SD 5.65] vs 85.5 years [SD 6.95]) than the group without OA. The preoperatively PMS score was 6.28 (2.71) in non-OA patients and 5.69 (2.67) in OA patients. The mean PMS reduction 12 months after surgery was 1.3 (SD 2.05) in OA patients and 1.07 (SD 2.2) in non-OA patients (p = 0.43). Competing risks analysis, adjusted by confounders had an SHR of 1.15 (IC95% 0.77 - 1.69). Death, readmission, reoperations, surgical time, and fracture reduction quality did not differ in both groups.

CONCLUSIONS

Patients with pre-existing radiographic OA treated with femoral nailing have a similar reduction in functional outcomes compared to the non-OA group at one-year follow-up. Further studies will be needed to compare the results of the functional outcome in arthroplasty with those of femoral nailing for the treatment of trochanteric femur fractures in patients with OA.

Traction images heavily influence lateral wall measurement in trochanteric hip fractures. A prospective study

INTRODUCTION

hip fracture represents a global health problem, with a high morbidity and mortality rate and an increasing incidence. The treatment of trochanteric fractures is reduction and osteosynthesis, and implant selection depends mainly on the stability of the fracture and lateral wall competence. Lateral wall competence has gained relevance in recent years, which led to the modification of the AO/OTA classification. However, determination of lateral wall integrity is difficult from plain radiographs; the influence of images with traction on its measurement has not been evaluated.

METHODS

prospective concordance study, emergency and post-traction radiographs of 65 patients with trochanteric fracture were evaluated by six orthopedic surgeons independently, measuring the lateral wall, classifying the fracture according to the AO/OTA 2018 classification and selecting the implant for osteosynthesis. A comparison of incompetent to intact lateral wall proportion between each image set was made. Secondary outcomes were the inter-observer correlation of lateral wall measurement and inter-observer agreement of classification and implant choice.

RESULTS

the proportion of patients with an incompetent lateral wall in emergency x-ray was 37.43% (CI 95% 0.326-0.422), while the proportion in post-traction fluoroscopy was 15% (CI 95% 0.115-0.185), with a statistically significant difference (p < 0.001). 40.1% of patients with an incompetent lateral wall changed to an intact one. Inter-observer correlation for the lateral wall thickness was 0.399 (CI 95% 0.292-0.519) in emergency x-ray and 0.658 (CI 95% 0.564-0.748) in post-traction fluoroscopy, with a substantial agreement. Inter-observer agreement for the fracture classification was fair to moderate using emergency x-ray (κ 0.369 95%CI 0.330-0.408) and fair to moderate with post-traction fluoroscopy (κ 0.400, 95% CI 0.334-0.466).

CONCLUSION

traction images significantly change the measurement of the lateral wall in trochanteric fractures, changing from an incompetent to a competent wall in 40% of patients. The correct classification of trochanteric fractures is crucial to make the best decision when deciding which implant to use, and the measurement of the lateral wall is determinant in the actual AO/OTA classification. Therefore, traction images appear as necessary for correct decision-making.

Comparison of bleeding during trochanteric fracture fixation with mini-invasive or conventional side plate fixation: A randomized controlled trial

BACKGROUND

Trochanteric fractures are a public health issue due to the aging of the population. Treatment aims to reduce their related morbidity and mortality and to allow an early return to independence. Postoperative anemia is associated with poorer functional recovery and an increased mortality rate. The aim of this study was to assess whether minimally invasive side plate fixation (Minimal Invasive Screw System, MISS™) resulted in reduced perioperative bleeding compared with conventional fixation (Pertrochanteric Hip Screw, PHS™).

HYPOTHESIS

We hypothesized that minimally invasive side plate fixation (MISS) would result in reduced perioperative bleeding compared with conventional fixation (PHS).

PATIENTS AND METHODS

We conducted an open randomized controlled trial with blinded assessment of the primary outcome. Inclusion criteria were patients aged over 65 years with isolated reducible trochanteric fracture. The 2 surgical implants were of the same shape, the only difference between them being the locking mode of the femoral neck screw on the plate of the MISS device, allowing a percutaneous approach. Primary outcome was perioperative bleeding evaluated with Mercuriali's formula. Secondary outcomes included operating time, scar length, length of hospital stay, radiological criteria such as quality of fracture reduction, implant positioning, bone healing, complications and functional recovery compared between the 2 groups.

RESULTS

One hundred and eight patients met the inclusion criteria and were randomized to receive either PHS (n=54) or MISS (n=54). Osteosynthesis with MISS significatively reduced perioperative bleeding (median 243mL, interquartile range [152-410] vs. 334mL [247-430] [p=0.0299]), operating time (65min [57-73] vs. 79min [66-89] [p=0.0002]) and scar length after 45 days (7cm [5-8] vs. 14cm [12-15] [p<0.0001]). There was no statistically significant difference between groups in postoperative complications, revision surgery or serious adverse events.

CONCLUSION

Compared with PHS, MISS reduced operating time, perioperative bleeding and scar length with no observed functional difference.

LEVEL OF EVIDENCE

I.

Clinical and radiological outcome of the Chimaera short nailing system in inter- and subtrochanteric fractures

BACKGROUND

cephalomedullary devices are popular treatment for femoral intertrochanteric or subtrochanteric fractures. Various complications include post-surgical lateral thigh pain and cut-out. To prevent those complications, a new concept cephalomedullary device system was designed (Chimaera, Orthofix®). This study aimed to evaluate the clinical and radiological outcomes in patients with femoral intertrochanteric or subtrochanteric fractures treated with the proximal femoral cephalomedullary device system.

METHODS

A prospective cohort study involved consecutive patients with Arbeitsgemeinschaft für Osteosynthesefragen/ Orthopaedic Trauma Association type 31-A1, 2, 3 fractures treated with the Chimaera short cephalomedullary device system from October 2016 to September 2017 at our level 1 trauma center. The Parker and Palmer mobility score and Jensen social function scores and post-surgical lateral thigh pain were assessed at 3 months post-operatively and compared to before surgery. Radiologic assessment consisted of controlling the position of the cephalic screw by using the tip-apex distance (TAD) and Cleveland zone as well as union and cut-out rates.

RESULTS

We included 99 patients (79 women; 100 hips; one bilateral fracture 3 months after a first trochanteric fracture) with a mean follow-up of 2 years. The Parker and Palmer mobility score decreased by 22% at 3 months post-operatively as compared with the pre-fracture score (42/99 patients showed a return to their pre-injury level). The Jensen social function score increased by 16.5% at 3 months post-operatively as compared with the pre-fracture score (68/99 patients showed a return to their pre-injury level). No major intra-operative complication was recorded. Nine TAD scores were > 25 mm. The mean TAD was 16.5 mm (range 5-36), and the lag screw position was well positioned in most (95%) hips according to Cleveland zones. Three patients required revision surgery (one for cut-out of the lag screw, one for hip osteoarthritis and one for gluteus medius insufficiency). All patients but the one with the cut-out showed fracture union.

CONCLUSION

The Chimaera short cephalomedullary device exhibited good mid-term functional and radiological outcomes.

Coronal shear fractures of the femoral neck: a comparison with basicervical fractures

PURPOSE

We propose coronal shear fracture of the femoral neck (CSFF) as a new type of fracture that differs from a basicervical fracture. This study aimed to present the incidence of CSFF and compare its clinical characteristics and outcomes with those of basicervical fractures.

METHODS

In this multicenter retrospective cohort study, 2207 patients with hip fractures were identified using computed tomography (CT), 17 and 27 patients were diagnosed with CSFF (CSFF group) and basicervical fractures (basicervical fracture group), respectively. The primary outcome was reoperation, while the secondary outcomes were postoperative radiographic findings, ambulatory ability, and 1-year mortality rate. These outcomes were compared between the two groups. We also conducted diagnostic reliability tests for these fractures using the Cohen's kappa coefficient.

RESULTS

The incidence of CSFF and basicervical fractures in the 2207 patients were 0.77% and 1.22%, respectively. The inter-and intra-observer agreements for the diagnosis were almost perfect. The comorbidity score was significantly higher in the CSFF group than in the basicervical fracture group. No reoperations occurred in both groups. There were no significant intergroup differences in the postoperative radiographic findings. The 1-year mortality rate was higher in the CSFF group than in the basicervical fracture group (38.5% vs. 5.3%; odds ratio: 11.9, 95% CI: 1.2-118.5; p = 0.025).

CONCLUSION

This study presents the definition and incidence of CSFF with a high diagnostic reliability. Patients with CSFF had similar reoperation rate postoperative radiographic outcomes to basicervical fractures, while 1-year mortality rate was high.

Peri-implant fracture: a rare complication after intramedullary fixation of trochanteric femoral fracture

INTRODUCTION

Trochanteric femoral fractures are among the most common operatively treated fractures. Intramedullary fixation has become the treatment of choice in many centers around the world. Nevertheless, the knowledge of rare complications of these fractures is limited. In this study, the incidence and treatment strategies for peri-implant fractures (PIF) were assessed.

MATERIALS AND METHODS

A single-center retrospective cohort study was done on 987 consecutive operatively treated trochanteric fractures. PFNA cephalomedullary nail was used as a fixation method. All patients were followed up from patient records for peri-implant fractures. Plain radiographs as well as different salvage methods were analyzed and compared.

RESULTS

The total rate of peri-implant fractures was 1.4% (n = 14). The rate of PIF for patients treated with short (200 mm) nails, intermediate-length (240 mm) nails, and long nails was 2.7% (n = 2), 1.5% (n = 11), and 0.7% (n = 1), respectively (ns, p > 0.05 for difference). Treatment of choice for PIF was either ORIF with locking plate (57%, n = 8) or exchange nailing (43%, n = 6). None of the PIF patients needed additional surgeries for non-union, malunion, or delayed union.

CONCLUSIONS

A PIF is a rare complication of intramedullary fixation of trochanteric fractures. It can be treated with either locking plates or exchange nailing with sufficient results. There are no grounds for favoring long nails to avoid PIFs.

Biomechanical analysis of recently released cephalomedullary nails for trochanteric femoral fracture fixation in a human cadaveric model

BACKGROUND

Recently, two novel concepts for intramedullary nailing of trochanteric fractures using a helical blade or interlocking dual screws have demonstrated advantages as compared to standard single-screw systems. However, these two concepts have not been subjected to a direct biomechanical comparison so far. The aims of this study were to investigate in a human cadaveric model with low bone quality (1) the biomechanical competence of nailing with the use of a helical blade versus interlocking screws, and (2) the effect of cement augmentation on the fixation strength of the helical blade.

METHODS

Twelve osteoporotic and osteopenic human cadaveric femoral pairs were assigned for pairwise implantation using either a short TFN-ADVANCED Proximal Femoral Nailing System (TFNA) with a helical blade head element or a short TRIGEN INTERTAN Intertrochanteric Antegrade Nail (InterTAN) with interlocking screws. Six osteoporotic femora, implanted with TFNA, were augmented with bone cement. Four groups were created: group 1 (TFNA) paired with group 2 (InterTAN), both consisting of osteopenic specimens, and group 3 (TFNA augmented) paired with group 4 (InterTAN), both consisting of osteoporotic specimens. An unstable trochanteric AO/OTA 31-A2.2 fracture was simulated and all specimens were tested until failure under progressively increasing cyclic loading.

RESULTS

Stiffness in group 3 was significantly higher versus group 4, p = 0.03. Varus (°) and femoral head rotation around the femoral neck axis (°) after 10,000 cycles were 1.9 ± 1.0/0.3 ± 0.2 in group 1, 2.2 ± 0.7/0.7 ± 0.4 in group 2, 1.5 ± 1.3/0.3 ± 0.2 in group 3 and 3.5 ± 2.8/0.9 ± 0.6 in group 4, being significantly different between groups 3 and 4, p = 0.04. Cycles to failure and failure load (N) at 5° varus or 10° femoral head rotation around the neck axis in groups 1-4 were 21,428 ± 6020/1571.4 ± 301.0, 20,611 ± 7453/1530.6 ± 372.7, 21,739 ± 4248/1587.0 ± 212.4 and 18,622 ± 6733/1431.1 ± 336.7, being significantly different between groups 3 and 4, p = 0.04.

CONCLUSIONS

Nailing of trochanteric femoral fractures with use of helical blades is comparable to interlocking dual screws fixation in femoral head fragments with low bone quality. Bone cement augmentation of helical blades provides significantly greater fixation strength compared to interlocking screws constructs.

Is the reconstruction of medial support important for revision following failed treatment of femoral trochanteric fractures? a retrospective comparative study

BACKGROUND

Hip-preserving revision in patients with failed treatment of femoral trochanteric fracture is still a major challenge. Whether the medial support reconstruction could benefit the patients and improve the success rate of hip-preserving revision is still controversial. Hence, the purpose of this study was to evaluate the clinical significance and prognosis of medial support reconstruction during the hip-preserving revision of failed femoral trochanteric fracture treatment.

METHODS

Patients with failed femoral trochanteric fractures treatments addressed by hip-preserving revision at our hospital from January 2014 to December 2020 were analyzed retrospectively. 31 patients were included and divided into a medial support group (n = 16) and a non-medial support group (n = 15). The fracture healing rate was the primary measurement. In addition, the differences in Oxford Hip Score (OHS), quality of life, surgical trauma, and complications were also evaluated.

RESULTS

The fracture healing rate (100%, 16/16 vs. 66.67%, 10/15), the OHS (42.06 ± 4.12 vs. 30.93 ± 11.56, M ± SD), and the mental component score of the 12-item Short-Form Survey (SF-12) (54.48 ± 5.38 vs. 47.90 ± 3.47, M ± SD), were significantly better and the incidence of complications [0(0/16) vs. 40%(6/15)] was significantly lower in the medial support group than the non-medial support group (p < 0.05). No significant differences in the physical component score of the SF-12, surgical trauma and reduction in collodiaphyseal angle of affected femur were observed between groups.

CONCLUSIONS

The reconstruction of medial support seems important for revision following failed treatment of femoral trochanteric fractures. Due to the medial augmentation and improvement of the mechanical stability for proximal femur, the patients might benefit from fracture healing prognosis and functional.

A standardized soft tissue release technique to lower the risk of greater trochanteric fractures for the anterior approach in total hip arthroplasty

INTRODUCTION

The direct anterior approach (DAA) is suggested to accelerate postoperative recovery and decrease the dislocation risk after primary total hip arthroplasty (THA). However, exposure of the femur can be challenging. Insufficient exposure increases the risk for intraoperative femoral fracture.

MATERIALS AND METHODS

Of 435 consecutive anterior THA, the first 102 consecutive THA in 94 patients were treated with an external rotator tendon "release-on-demand" (RoD). The following 311 consecutive patients (333 THA) underwent routine release of the conjoint tendon (CTR) of its bony insertion on the greater trochanter only. Retrospective analysis recorded trochanteric fractures, intraoperative calcar fractures, postoperative periprosthetic fractures, stem subsidence, ossifications, and dislocations.

RESULTS

Three (2.9%) fractures of the greater trochanter were recorded in the RoD group, but no (0.0%) fractures occurred in the CTR group (p = 0.002). There was no significant difference in the occurrence of intraoperative calcar fractures (0% (RoD) vs. 1.2% (CTR), p = 0.267), postoperative periprosthetic fractures (0% (RoD) vs. 0.3% (CTR), p = 0.560), stem subsidence (2.0% (RoD) vs. 1.2% (CTR), p = 0.565) or ossifications (2.9% (RoD) vs. 1.6% (CTR), p = 0.344) between these groups. There were no dislocations within a minimum 12 months follow-up period.

CONCLUSION

The routine release of the conjoined tendon (CTR group) decreases the shear forces on the tip of the greater trochanter during DAA THA and eliminates the risk of greater trochanter fractures. The routine release of the conjoined tendon did not increase the risk of postoperative dislocations.

Mortality and functional consequences after revision osteosynthesis for peritrochanteric fractures treated by intramedullary nail: A retrospective study of 312 patients

INTRODUCTION

Osteosynthesis of peritrochanteric fractures by intramedullary nail is associated with a 3 to 15% rate of complications requiring revision surgery. The objective of our study was to compare mortality and autonomy between patients who required revision surgery after osteosynthesis, and patients without revision surgery.

HYPOTHESES

Patients who underwent revision surgery after osteosynthesis of a peritrochanteric fracture by intramedullary nail did not exhibit excess mortality or loss of autonomy compared to those who did not undergo revision surgery.

METHODS

Between January 2017 and October 2019, 312 consecutive patients were operated on for a peritrochanteric fracture by intramedullary nail. Among them, 23 patients (7.4%) required revision surgery (change, nail removal, total hip arthroplasty). Mortality at 90 days and at one year was evaluated and compared between the group of "revision" patients and "no revision" patients. The level of autonomy was assessed by the Parker and Palmer score, one year postoperatively and compared between the 2 groups.

RESULTS

The patients requiring revision surgery were younger: 73 years old vs. 86 years old (p<0.011). The overall mortality was 7.25% at 90 days after surgery and 15% at one year. Mortality was zero at 90 days, and at 1 year, postoperatively for patients requiring revision surgery. There was no significant difference for the mortality at 90 days (p=0.39) between the 2 groups, however at 1 year, it was significantly less for the revision patients (0% vs. 17%, p=0.032). There was no significant difference for the Parker score between the "revision" group; 5 (4-9) and the "no revision" group; 4 (3-7), at one year postoperatively (p=0.24).

CONCLUSION

This study did not show any excess mortality, nor loss of autonomy at 1 year postoperatively, for patients who required osteosynthesis for a trochanteric fracture, and who presented with a complication requiring revision surgery.

LEVEL OF EVIDENCE

III, comparative retrospective study.

Locking in trochanteric fractures: a comparison of static versus dynamic locking using the Gamma3 nail

PURPOSE

The Gamma3 nail (Stryker®) is an intramedullary device consisting of a proximal lag screw and distal interlocking screw. It is still unknown whether the screw locking mode could influence clinical outcomes. The aim of this study is to compare static and dynamic screw locking regarding their influence on surgical revisions and lag screw displacement.

METHODS

A retrospective single-centre study was performed on patients ≥ 60 years admitted for a trochanteric fracture between September 2016 and January 2020. Surgical revisions and lag screw displacement were evaluated at 6 weeks and 1-year follow-up, respectively.

RESULTS

A total of 142 patients were included for analysis. Surgical revisions were needed in 13 cases (9.2%). Indications included implant breakage (n = 3), lag screw cut-out (n = 3), lateral hip pain (n = 6) and non-union (n = 1). The number of surgical revisions was not different between static and dynamic locking (OR 2.55; 95%CI 0.73-8.56; p 0.142). The median lag screw displacement was 2.5 mm, which was similar for static and dynamic locking (2.3 mm versus 2.7 mm; p 0.785).

CONCLUSION

The screw locking mode of the Gamma3 nail is not associated with a higher risk of surgical revisions. However, the design of the Gamma3 nail may not be suitable for static locking.

CT analysis of femoral malrotation after intramedullary nailing of trochanteric fractures

PURPOSE

Functional results after internal fixation of trochanteric femoral fractures may be negatively affected by healing in a non-physiological position. The aim of this study was to evaluate the occurrence and severity of femoral malrotation after nailing of trochanteric fractures.

MATERIALS AND METHODS

The authors conducted a prospective study focused on a CT analysis of malrotation after intramedullary nailing of trochanteric fractures (AO 31A1-3) in 101 patients. We recorded the type of fracture, method of anesthesia, scheduled surgery vs. acute surgery, and the surgeon's experience as possible risk factors for limb malrotation after trochanteric fracture surgeries.

RESULTS

The average extent of malrotation was 9° of internal rotation ranging from 29° of external to 48°of internal rotation. In 35% of patients, we observed a rotation greater than 15°, and in 15 patients (15%), the rotation was greater than 25°. The risk of significant internal malrotation was significantly higher than external malrotation (37 vs. 4 patients). None of the factors observed proved to be statistically significant. The effect of general anesthesia and the type of intertrochanteric fracture came closest to having a significant effect on rotational error.

CONCLUSION

Improper reduction of a trochanteric fracture is a common problem that can lead to femur malrotation. In our study, a rotational error greater than 15° occurred in 35% of the patients, but none of the monitored factors represented a statistically significant risk for this complication.

Letter to the editor: Calcar fracture gapping: a reliable predictor of anteromedial cortical support failure after cephalomedullary nailing for pertrochanteric femur fractures

A recently published article by Song H et al. investigated the risk factors for anteromedial cortical support loss in pertrochanteric fractures treated with cephalomedullary nails. In this Correspondence, we would like to raise some concerns. Specifically, calcar fracture gap and anteromedial cortical support are different concepts in evaluating reduction quality. In addition, calcar fracture gap using immediate postoperative radiographic images has measurement bias. Lastly, explanatory variables selected for multivariable analysis are inappropriate. We would like to discuss and suggest solutions for these problems.

Bilateral simultaneous asymmetric hip fracture without major trauma in an elderly patient: a case report

BACKGROUND

Simultaneous bilateral hip fractures without major trauma in the elderly are rare and usually symmetrical. To the best of our knowledge, only two cases of bilateral simultaneous asymmetric hip fracture in the elderly without major trauma have been reported.

CASE PRESENTATION

We present the case of a 90-year-old Japanese man with simultaneous bilateral asymmetric hip fractures with trochanteric fracture on the right side and greater trochanteric fracture on the left side. He complained of dyspnea at midnight and was referred to our emergency department. He was admitted to the internal medicine department for bacterial pneumonia treatment. On the 8th day of hospitalization, he was referred to our orthopedic surgery department for hip pain and was found to have fractures of both hips. Computed tomography findings showed that the left femoral neck fracture was an old fracture, while the left greater trochanteric fracture and the right trochanteric fracture were fresh fractures. He was surgically treated through open reduction and internal fixation with an intramedullary nail on the right and hemiarthroplasty on the left in supine position, performed during the same surgical sessions on the 12th day of hospitalization.

CONCLUSIONS

We report a new form of simultaneous bilateral asymmetric hip fracture in the elderly. The fracture types of the case were femoral trochanteric fracture and greater trochanteric fracture of the femur, which were different from the fracture types in the previously reported two cases. Clinicians should be aware of the possibility of simultaneous bilateral hip fractures, especially in the elderly.

Subsequent ipsi- and contralateral femoral fractures after intramedullary nailing of a trochanteric or subtrochanteric fracture: a cohort study on 2012 patients

Background

The literature is inconclusive as to whether an intramedullary nail changes the distribution of a subsequent ipsi- or contralateral fracture of the femur. We have compared the incidence, localisation, and fracture pattern of subsequent femoral fractures after intramedullary nailing of trochanteric or subtrochanteric fractures in patients without previous implants in either femur at the time of surgery.

Methods

Retrospective analysis was performed of a two-centre cohort of 2012 patients treated with a short or long intramedullary nail for the management of trochanteric or subtrochanteric fracture between January 2005 and December 2018. Subsequent presentations with ipsi- and contralateral femoral fractures were documented. Only patients with no previous femoral surgery performed, other than the index nailing were followed. Odds ratios (ORs) for subsequent femoral fracture were calculated using robust variance estimates in logistic regression.

Results

The mean age of the cohort was 82.4 years and 72.1% were female. The total number of patients presenting with subsequent femoral fractures was 299 (14.9%). The number of patients presenting with subsequent ipsilateral and contralateral femoral fractures was 51 (2.5%) and 248 (12.3%) respectively (OR 5.0; CI 3.7–6.9). Twenty-six (8.7%) of all subsequent femoral fractures occured in the ipsilateral shaft, 14 (4.7%) in the ipsilateral metaphyseal area, one (0.33%) in the contralateral shaft, and three (1.0%) in the contralateral metaphysis (OR 10; CI 3.6–29).

Conclusion

An intramedullary nail significantly changes the fracture pattern in the event of a second low-energy trauma, reducing the risk of subsequent proximal ipsilateral femoral fractures and increasing the risk of subsequent ipsilateral femoral fractures in the shaft and distal metaphyseal area compared with the native contralateral femur.

Posterior hip fracture-dislocation associated with posterior wall fracture of the acetabulum and ipsilateral comminuted trochanteric fracture of the femur: A case report

Introduction and importance

Traumatic posterior dislocation of the hip is often associated with fractures of the femoral head and posterior wall of the acetabulum. However, hip fracture-dislocation that includes the posterior wall of the acetabulum and the ipsilateral femoral trochanter is rare. There is no consensus on the bone that should be operated on first, the operative position, and the choice of implant for femoral fixation.

Case presentation

A 67-year-old man was brought to our emergency department after a 2-m fall. He was diagnosed with a hip fracture-dislocation associated with posterior wall acetabular fracture and ipsilateral femoral trochanteric fracture. Surgical reconstruction was performed with intramedullary nail (IMN) fixation of the femoral trochanteric lesion, followed by anatomically rigid acetabular fixation in the lateral decubitus position. At the 5-year follow-up after the injury, the patient showed good objective and subjective clinical outcomes.

Clinical discussion

Fixing the femur first could allow an easier reduction and traction. The lateral decubitus position was useful, because fixation of the femur and the acetabulum could be performed without changing the position. When fixing the femoral trochanteric lesion, attention was paid to reduce the anteromedial cortex of the proximal fragment extramedullarly to the distal fragment to prevent complications such as cutout and implant breakage.

Conclusion

Anatomically rigid fixation of the posterior wall of the acetabulum secondary to IMN fixation of the femur, with anteromedial cortical support in the lateral decubitus position, could achieve good objective and subjective clinical outcomes.

•

We report a case of posterior hip fracture-dislocation with fractures of posterior wall and ipsilateral femoral trochanter

•

This is a rare clinical presentation

•

For treatment, femoral intramedullary nail fixation is performed first

•

Then, acetabular posterior wall fixation is performed in lateral decubitus position

•

Anteromedial cortex of proximal fragment is reduced extramedullarly to distal fragment

Variation in treatment of hip fractures and guideline adherence amongst surgeons with different training backgrounds in the Netherlands

BACKGROUND AND PURPOSE

Two medical specialties, general surgery and orthopaedic surgery, with different training programs but matching trauma certification requirements, provide hip fracture surgery in the Netherlands. This study analyses treatment preferences and guideline adherence of Dutch surgeons with different surgical backgrounds.

PATIENTS AND METHODS

All hip fracture patients registered in the Dutch Hip Fracture Audit in 2018 and 2019 were included in this retrospective study. Four types of surgeons were distinguished: trauma-certified general surgeons (ST+), non-trauma certified general surgeons (ST-), trauma-certified orthopaedic surgeons (OT+) and non-trauma certified orthopaedic surgeons (OT-). Differences in patient characteristics, and practice variation in treatment choices and guideline adherence per fracture type were analysed using descriptive statistics.

RESULTS

28,656 patients were included; 16,367 (57.1%) treated by ST+, 1,371 (4.8%) by ST-, 4,692 (16.4%) by OT+ and 6,226 (21.7%) by OT-. Few clinically relevant differences in patient characteristics and hospital processes were found between all surgeon groups. Displaced FNF were the most commonly treated fracture type for all types of surgeons. Both OT+ and OT- operated mostly (displaced) FNFs, while the fracture types treated by ST+ and ST- were more heterogeneous. For all fracture types, the orthopaedic surgeons performed THA and HA more often than general surgeons, while general surgeons more often placed SHS and IMN for specific fracture types. Guideline adherence was on average 68.4% and differed significantly per surgeon type (68.7% by ST+, 65.2% by ST-, 74.4% by OT+ and 63.6% by OT- (p<0.01)), as well as per fracture type: >90% treatment according to the guideline for trochanteric AO-31A2 and A3 fractures, 18.8% for AO-31A1 fractures and 51.7% guideline adherence for undisplaced FNF. Guideline adherence for displaced FNF varied depending on patient characteristics.

DISCUSSION

In the Netherlands, different surgical specialists treat different types of hip fractures and have different preferences concerning implants for hip fracture surgery in comparable patients. Guideline adherence of trauma- and non-trauma certified orthopaedics and general surgeons differs significantly. Reduction of practice variation should be strived for in order to improve hip fracture care.

Quality of fracture reduction is associated with patient survival at one year, but not 30 days, following trochanteric hip fracture fixation. A retrospective cohort study

INTRODUCTION

Few studies have been performed to evaluate the association between technical surgical factors and patient outcomes following hip fracture surgery. We performed a retrospective cohort study of elderly patients who had undergone fixation of trochanteric hip fractures using a sliding hip screw (SHS), with the aim of establishing whether there was a correlation between quality of fracture reduction and mortality at 30 days and one year.

PATIENTS AND METHODS

A retrospective cohort study was designed. Inclusion criteria were trochanteric (AO 31A1 or 31A2) fractures in patients aged ≥ 65 years, presenting <3 days after injury and fixed using an SHS. Fracture reduction was classified using the Baumgaertner Reduction Quality Criteria (BRQC). A validated predictor of mortality following hip fracture was used to stratify for confounding variables that might affect mortality. Multivariate logistic regression was used to explore the association between fracture reduction and mortality.

RESULTS

329 patients were identified (mean age 86, 27% male). 57% had a good reduction, 39% had a fair reduction and 4% had a poor reduction. As reduction grade deteriorated, predicted mortality increased (good reduction: 7.3%; fair reduction: 8.4%; poor reduction: 15.5%). Without adjustment for predicted mortality, there was a significant correlation between decreasing reduction grade and mortality at both time points (30-day: odds ratio 1.95, p = 0.049; one year: odds ratio 1.86, p = 0.003). When adjusted for predicted mortality, only one year mortality remained significant (30 day: odds ratio 1.61, p = 0.173; one year: odds ratio 1.62, p = 0.037).

CONCLUSION

Some, but not all, of the association between fracture reduction and mortality can be explained by predetermined predictors of a poor outcome. There remains, however, a correlation between poor fracture reduction and mortality at one year. Every effort must be made to achieve an anatomical reduction for these injuries, and trainees must be instructed in methods to achieve this.

Topical administration of tranexamic acid in elderly patients undergoing short femoral nailing for intertrochanteric fracture: A randomised controlled trial

INTRODUCTION

Topical application of tranexamic acid (TXA) has been proposed as an alternative to intravenous administration to reduce perioperative bleeding in orthopaedic surgery. The purpose of this randomised controlled trial was to evaluate the efficacy and safety of 1 g topically applied TXA in patients undergoing fixation of intertrochanteric hip fractures by short femoral nailing.

METHODS

A total of 121 patients were enrolled between May 2018 and January 2020. Patients were randomly allocated (1:1) to receive either 10 mL (1 g) of TXA or 10 mL of normal saline (NS) injected through the subfascial drain following wound closure. Total blood loss, total drain output and blood transfusion requirements up to postoperative day 3 were recorded. Rates of thromboembolic complications and mortality up to 90 days postoperatively were also compared.

RESULTS

There was no statistically significant difference in total blood loss, total drain output or proportion of patients requiring transfusions. Median total blood loss was 1.088 L (IQR: 0.760-1.795) in the TXA group and 1.078 L (IQR: 0.797-1.722) in the NS group (P = .703). Median total drain output was 60 mL (IQR: 40-140) in the TXA group and 70 mL (IQR: 30-168) in the NS group (P = .696). Blood transfusions were administered in 29 patients (47.5%) in the TXA group and 27 patients (45.0%) in the NS group (P = .782). There was also no difference in frequency of thrombotic complications or mortality within 90 days. There were five thrombotic events in the TXA group and four in the NS group (P = .751). The 90-day mortality rate was 6.6% (4 patients) in the TXA group and 3.3% (2 patients) in the NS group (P = .680).

CONCLUSION

A 1 g dose of topically administered TXA did not produce any difference in blood loss, transfusion requirements, thromboembolic complications, or 90-day mortality. Future trials may consider the effect of larger doses in patients undergoing hip fracture fixation surgery.

Intraoperative fractures in cephalomedullary nailing for trochanteric fractures

INTRODUCTION

Cephalomedullary nailing (CMN) is the standard treatment for internal fixation of trochanteric fractures. Complications related to CMN include intraoperative fracture (IF), which is difficult to detect using only plain radiographs. However, analyses of IFs using plain radiographs and computed tomography (CT) with a large sample size of clinical cases are lacking. Therefore, this study aimed to report the incidence of IFs diagnosed by CT, the risk factors for IFs, and a comparison of clinical outcomes between patients with and without IFs.

METHODS

This multicenter retrospective cohort study included 638 patients who underwent CMN fixation for trochanteric fractures. We evaluated IF using pre-and postoperative plain radiographs and CT. The primary outcome was reoperation and the secondary outcome was the proportion of patients who regained independent mobility at 3 months postoperatively. Furthermore, we conducted multivariable logistic regression analyses to examine the association between risk factors and IFs.

RESULTS

Seventy-five (11.8%) patients had IFs, including 53 patients with occult IFs (8.3%). The most common location of IF was at the interference with the lag screw entry (45.3%). The nail insertion procedure (17.3%) was the most common reason for IF. In the assessment of clinical outcomes, patients with IFs had no reoperations and independent mobility at postoperative 3 months was lower (69.6% vs. 79.1%). Regarding regaining independent walking in the IF group, IF distal to lag screw entry and obvious IF diagnosed with plain radiographs were poor factors. The multivariable analysis showed that only inadequate reduction on the anteroposterior view based on the plain radiograph was significantly associated with the incidence of IFs (odds ratio 3.91; 95% CI, 1.28-11.94; p = 0.017).

CONCLUSIONS

This multicenter study indicated that the incidence of IFs detected by CT in CMN treatment for trochanteric fractures was 11.8%. An inadequate reduction in the anteroposterior view based on plain radiographs was the only independent risk factor of IFs. In the assessment of clinical outcomes, patients with IF had no incidences of reoperation. However, patients with IFs tended not to regain independent mobility compared with those without IFs.

Use of a Trochanteric Fixation Nail-Advanced (TFNA) with cement augmentation for treatment of trochanteric fractures in patients greater than sixty five years of age

PURPOSE

Intramedullary nailing is the standard treatment of trochanteric fractures. Mechanical failure such as cut-out and cut-through are associated with high rates of revision surgery, functional impairment, and mortality. The aim of the study was to evaluate the rate of mechanical failure of the cement augmented screws of Trochanteric Fixation Nail-Advanced (TFNA) nails.

PATIENTS AND METHODS

A descriptive, retrospective, multi-operator, single-centre study was performed at our level 1 trauma centre between June 2019 and June 2020. Patients were included if they were > 65 years of age, presented with a trochanteric fracture treated with an augmented TFNA nail with 6 months of follow-up. The primary outcome was fixation failure rate (cut-out or cut-through) at three and six post-operative months. Secondary endpoints were intra-operative data, clinical scores, and radiographic analysis.

RESULTS

Forty-five patients (38 women and 7 men) were analysed. The mean age was 82.84 years (65-102, 9.50). There were no instances of mechanical failure in our series, after either three or six months of follow-up. No patient exhibited cut-out or cut-through. The mean amount of cement injected was 4.72 mL (3-6; 1.05). The mean length of surgery was 37.59 min (25-55; 6.48), and the mean intra-operative radiation exposure was 91.47 cGycm² (25.04-201.81; 51.40) for a mean duration of 43.11 s (17-86; 16.81). The mean duration of hospitalisation was 6.38 days (2-11; 2.27).

CONCLUSIONS

Our clinical results suggest that cement-augmented TFNA screws can be successfully used in the management of trochanteric fractures in patients > 65 years of age.

Low filling ratio of the distal nail segment to the medullary canal is a risk factor for loss of anteromedial cortical support: a case control study

Background

Anteromedial cortical support apposition (positive and/or neutral cortical relations) is crucial for surgical stability reconstruction in the treatment of trochanteric femur fractures. However, the loss of fracture reduction is frequent in follow-ups after cephalomedullary nail fixation. This paper aimed to investigate the possible predictive risk factors for postoperative loss of anteromedial cortex buttress after nail fixation.

Methods

A retrospective analysis of 122 patients with AO/OTA 31A1 and A2 trochanteric femur fractures treated with cephalomedullary nails between January 2017 and December 2019 was performed. The patients were classified into two groups according to the postoperative status of the anteromedial cortical apposition in 3D CT images: Group 1 with contact “yes” (positive or anatomic) and Group 2 with contact “No” (negative, loss of contact). The fracture reduction quality score, tip-apex distance (TAD), calcar-referenced TAD (Cal-TAD), Parker ratio, neck-shaft angle (NSA), and the filling ratio of the distal nail segment to medullary canal diameter in anteroposterior (AP) and lateral fluoroscopies (taken immediately after the operation) were examined in univariate and multivariate analyses. Mechanical complications were measured and compared in follow-up radiographs.

Results

According to the postoperative 3D CT, 84 individuals (69%) were categorized into Group 1, and 38 individuals (31%) were classified as Group 2. The multivariate logistic regression analysis showed that the poor fracture reduction quality score (P < 0.001) and decreasing filling ratio in the lateral view (P < 0.001) were significant risk factors for the loss of anteromedial cortical contact. The threshold value for the distal nail filling ratio in lateral fluoroscopy predicting fracture reduction re-displacement was found to be 53%, with 89.3% sensitivity and 78.9% specificity. The mechanical complication (varus and over lateral sliding) rate was higher in Group 2.

Conclusions

The fracture reduction quality score and the decreasing filling ratio of the distal nail to the medullary canal in the lateral view (a novel parameter causing pendulum-like movement of the nail) were possible risk factors for postoperative loss of anteromedial cortical support.

Intramedullary Fixation of Trochanteric Fractures Can Be Safely Performed by Senior Residents Without Immediate Consultant Supervision

OBJECTIVE

To assess the safety of senior residents performing trochanteric hip fracture surgery without immediate consultant supervision DESIGN: A retrospective chart review of trochanteric hip fractures (AO-OTA 31-A) operated in a single center between years 2011 and 2016 (inclusive). Operations were divided into three groups: Group 1 - surgeon was a senior resident without any immediate supervision; Group 2 - surgeon was a consultant and Group 3 - surgeon was a senior resident supervised by a consultant. The follow-up period was a minimum of 2 years or until death. All re-operations and surgical related mortality were assessed.

SETTING

Helsinki University Hospital, Finland. A tertiary level trauma center.

PARTICIPANTS

987 consecutive trochanteric fractures on 966 patients treated by operative fixation of an intertrochanteric fracture with an intramedullary nail between 2011and 2016 (inclusive).

RESULTS

The total number of reoperations was smaller in Group 1 where the surgeon was a senior resident without any immediate supervision compared to Group 2 where the surgeon was a consultant (5.5 % vs 8.8 %, p < 0.05). There were no significant differences in mortality or length of surgery. The total rate of mechanical complications was 2.0 %, with no significant differences between groups. The observed blade cut-out rate was low: 1.3 %, suggesting a good overall quality of surgery.

CONCLUSIONS

Senior residents can safely perform intramedullary nailing of trochanteric fractures without immediate supervision.

Vibration therapy as an intervention for enhancing trochanteric hip fracture healing in elderly patients: a randomized double-blinded, placebo-controlled clinical trial

BACKGROUND

There are more than 300,000 hip fractures yearly in the USA with mortality rates of 20% within 1 year. The treatment of osteoporotic fractures is a major challenge as bone quality is poor, and healing is expected to delay due to the impaired healing properties with respect to bone formation, angiogenesis, and mineralization. Enhancement of osteoporotic fracture healing and function is therefore critical as a major goal in modern fracture management. Previous pre-clinical studies have shown that low-magnitude high-frequency vibration (LMHFV) accelerates osteoporotic fracture healing. The objective of this study is to investigate the effect of LMHFV on accelerating trochanteric hip fracture healing and functional recovery.

METHODS

This is a randomized, double-blinded, placebo-controlled clinical trial to evaluate the effect of LMHFV in accelerating trochanteric hip fracture healing. All fractures undergo cephalomedullary nail fixation. The primary outcome of this study is time to fracture healing by X-ray. Computed tomography (CT) and dual-energy X-ray absorptiometry (DXA) will also be performed. Blood circulation at the fracture site will be assessed by dynamic perfusion magnetic resonance (MR). Clinical results include functional recovery by muscle strength, timed up and go test (TUG), quality of life questionnaire (SF-36), balancing, falls, and mortality.

DISCUSSION

Previous animal studies have demonstrated LMHFV to improve both normal and osteoporotic fracture healing by accelerating callus formation and mineralization. The mechanical stimulation stimulates angiogenesis by significantly enhancing vascular volume and blood flow velocity. This is the first study to translate LMHFV to enhancing hip fracture healing clinically. Positive results would provide a huge impact in the recovery of hip fracture patients and save healthcare costs.

TRIAL REGISTRATION

Clinicaltrials.gov NCT04063891. Registered on August 21, 2019.

Risk factors for excessive postoperative sliding of femoral trochanteric fracture in elderly patients: A retrospective multicenter study

INTRODUCTION

The application of a load on the internal fixation of a trochanteric fracture exerts a moment along the lag screw, causing the proximal bone fragment to slide along the lag screw, allowing contact between the proximal and distal bone fragments, which promotes healing. However, excessive sliding is related to poor postoperative outcomes. We aimed to identify the risk factors for excessive sliding.

MATERIALS AND METHODS

We conducted a multicenter retrospective study including 115 trochanteric fractures sustained through low-energy trauma in 19 male and 96 female patients aged 60 years or older (mean age: 82.9 years) between September 2013 and December 2014. We measured the postoperative sliding distance after osteosynthesis using a sliding hip screw or intramedullary nailing, and classified participants with ≥8 mm of sliding into the excessive sliding group (ESG) and with <8 mm into non-ESG. Finally, we investigated the risk factors of excessive postoperative sliding.

RESULTS

Fifty participants were classified into the ESG and 65 participants into the non-ESG. Female sex (p = 0.0264), an A3 fracture type (p = 0.0003), greater tip-apex distance (p = 0.0250), and poor reduction in either the anteroposterior or lateral radiographic views (p = 0.0156) were identified as risk factors for excessive sliding by multivariate regression analysis.

CONCLUSIONS

Female sex, an unstable fracture type, a greater tip-apex distance, and a poor reduction, in either the anteroposterior or lateral views, are associated with excessive postoperative sliding. Therefore, surgery should aim to achieve good reduction and stabilization from both radiographic views.

Urban versus rural differences of hip fractures among the elderly in Kyoto, Japan: a 10-year study

Secular changes in the incidence rate of hip fractures were estimated to vary by fracture type, i.e., femoral neck or trochanteric fractures, age, and sex, in urban or rural areas in Kyoto Prefecture, Japan from 2008 to 2017.

PURPOSE

Our survey in Kyoto Prefecture from 2008 to 2017 showed that the incidence rate of femoral neck fractures is generally increasing. We investigated the differences between urban and rural areas in the changes of the incidence rate over time of femoral neck and trochanteric fractures during the same period.

METHODS

Patients aged 65 years and above who sustained hip fractures between 2008 and 2017 and were treated at one of the participating 11 hospitals were included. The ratio of sick beds for acute-term care at the investigated hospitals to total number of beds in the urban area was 16.5% (1863/11,158) and 30.6% (1863/5623) in the rural area. The change in incidence rate was estimated utilizing the population according to the national census conducted in 2010 and 2015.

RESULTS

There were 3559 and 6474 hip fractures in the urban and rural areas, respectively. Femoral neck fractures were 1936 (54.4%) and 2813 (43.5%) in each area. The increase of the population-adjusted numbers was marked by neck fractures in males, in both areas. In women, there was a significant increase in femoral neck fractures in the urban area in those aged 85 years and over. For trochanteric fractures, a significant increase was only found in women aged 65 to 74 years in the rural area.

CONCLUSION

A regional difference in the secular changes in incidence rate of hip fractures was found in women, not in men, mostly because neck fractures in women increased in the over 85 group in the urban area.

Reduction of trochanteric fractures in lateral view is significant predictor for radiological and functional result after six months

OBJECTIVES

The goal of our retrospective study was to determine which radiological parameter after fixation of trochanteric fractures type AO 31 A2 is most important for the position of the fracture after six months. The additional goal was to find how the end position influences mechanical failure and the mobility of the patients.

PATIENTS AND METHODS

We analysed 92 patients operated in one-year period for A 2 type trochanteric fractures with sliding hip screw or proximal femur intramedullary nail. They were divided in two groups according to the radiological position of the proximal fragment six months after the surgery. In group A we had 46 patients with satisfactory and in group B 46 patients with unsatisfactory position. In anteroposterior view we evaluated neck-shaft angle (NSA) and medial cortical support (MCS) and in lateral view anterior cortical support (ACS). Unsatisfactory position was recognized if NSA was in varus or ACS or MCS were negative. We compared the groups regarding basic patients characteristics (age, gender, ASA score, preinjury mobility, and degree of osteoporosis), type and quality of fixation, the position of the fracture (postoperatively and after 6 months), mechanical failure and mobility after 6 months. Statistical significance level was set to p ≤ 0.05.

RESULTS

Basic patients' characteristics as well as type and quality of fixation did not significantly differ between the groups. After the injury the difference between the groups in reduction quality was significant in lateral view (ACS; p=0.001), while after half a year there were significant differences in both views: NSA (p=0.003), ACS and MCS (both p<0.001). Proximal fragment position after six months statistically significant correlated with postoperative ACS in B group (r = 0.386, p = 0.008), but not with NCA nor with MCS. There were also significantly more fixation failures in group B (p<0.001) and less patients regain preinjury mobility (p=0.029).

CONCLUSIONS

In trochanteric fractures reduction in lateral view is the most important prognostic factor for favourable radiological result after half a year. Unsatisfactory position of the proximal fragment after six months influences mechanical failures and walking ability.

Early postoperative Barthel index score and long-term walking ability in patients with trochanteric fractures walking independently before injury: a retrospective cohort study

INTRODUCTION

Trochanteric fractures are one of the most common fragility fractures, and the number of the patients is increasing worldwide. Identifying prognostic factors is important to manage and minimize the social losses caused by postoperative walking impairment. The purpose of this retrospective study is to clarify the association between early postoperative Barthel index score and postoperative long-term walking ability among patients with trochanteric fractures who could walk independently before injury.

MATERIALS AND METHODS

Consecutive patients with trochanteric fractures aged ≥ 65 years who were walking independently before injury were included. Patients were divided into two groups according to the Barthel index score measured within 1 week after surgery; the cut-off value was set at 20 points. The prevalence of walking impairment after 1 year was compared between these two groups after adjusting for confounding factors in a complete case analysis and using the data introduced by the multiple imputation method.

RESULTS

Among the 758 eligible patients, 254 patients (34%) had their walking ability evaluated after 1 year from injury. The patients in the lower Barthel index group showed a significantly impaired walking ability in both analyses (adjusted odds ratio 5.5 and 2.4, 95% confidence intervals 2.4-13 and 1.5-3.8, respectively).

CONCLUSIONS

The present results suggested that the Barthel index score measured in the early postoperative period after trochanteric fractures was associated with the level of long-term walking impairment in patients who could walk independently before injury.

Cement augmentation of internal fixation for trochanteric fracture: a systematic review and meta-analysis

PURPOSE

This study aimed to determine the efficacy and safety of cement augmentation for internally fixed trochanteric fractures through a systematic review and meta-analysis of randomized controlled trials (RCTs).

METHODS

We searched the MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov databases to identify RCTs, published until July 2020 that examined the effects of cement augmentation of internal fixation of trochanteric fractures. The primary outcomes were reoperation and Parker Mobility Score, whereas the secondary outcomes were 1-year mortality rate, EuroQol 5 Dimension, fixation failures, and adverse events. We conducted meta-analyses of the outcome measures using the random-effects models. We evaluated the certainty of evidence based on the Cochrane risk-of-bias tool and the Grading of Recommendations, Assessment, Development, and Evaluation approach.

RESULTS

We included three RCTs (326 participants). No significant effect was observed in favor of cement augmentation on all these outcomes. The certainty of evidence for fixation failures was very low and that for the other outcomes was low. The overall risk of bias for each outcome was high or of some concern in all included studies.

CONCLUSIONS

The effect of cement augmentation of internal fixation of trochanteric fractures was uncertain for the clinical outcomes due to the low certainty of evidence. Further RCTs with a low risk of selection bias may present convincing conclusions on the efficacy and safety of cement augmentation.

LEVEL OF EVIDENCE

Level 1.

Reduction quality and nail fixation ratio as bone-implant stability factors associated with reoperation for trochanteric fractures

INTRODUCTION

Geriatric trochanteric fractures are a major global issue, and their incidence is steadily rising. Bone quality, fracture type, fracture reduction quality, implant selection, and implant placement affect bone-implant stability in osteoporotic fractures. Our aim in this study was to evaluate the association between bone-implant stability factors, including nail construct, and the rate of reoperation in a more extensive case series with comprehensive variables.

METHODS

This was a retrospective cohort study of 390 patients with trochanteric fractures aged ≥60 years and treated with intramedullary nailing. The primary outcome was the rate of reoperation due to any cause. Univariate and multivariable logistic regression analyses were used to identify factors associated with reoperation.

RESULTS

In this study, 15 patients (3.8%) required reoperation. Univariate analysis showed that the following variables were significantly different between patients who required reoperation and those who did not: T-score at the total hip and lumbar spine, cortical thickness index, fracture type, and reduction quality. Multivariable logistic regression analysis showed that the odds ratio (OR) for A3 fracture type was 2.76 (95% confidence interval [CI], 0.77-9.76; p=0.116) and that for inadequate reduction, assessed by computed tomography, was 2.94 (95% CI, 0.89-9.69; p=0.076). These were independent predictors of reoperation. There was only one case (6.7%) of reoperation among patients with a distal femoral fragment fixation ratio (FR) >0.8. Considering the intraoperative decision-making process, the combination of inadequate reduction and an FR ≤0.8 were associated with the highest reoperation at a rate of 9.3% (OR, 3.327; 95% CI, 1.091-10.142; p=0.043).

CONCLUSIONS

Risk factors on bone-implant stability for reoperation were the reduction quality and fracture type. Regarding the intraoperative decision-making process, the selection of a nail length with an FR >0.8 is a better option when the intramedullary reduction has been maintained intraoperatively.

Factors associated with one year mortality in ill patients with proximal femoral fractures treated non operatively

INTRODUCTION

Non-operative treatment is an exceptional indication for the treatment of proximal femur fracture. The aim of the study was to analyze the mortality rate in one year and associated factors in severely ill patients submitted to non-operative treatment.

METHODS

It was included 28 patients treated from August 2014 to September 2019. Eighteen (64.3%) patients were female and 10 (35.7%) were male. The mean age was 78.7 ± 11.9 years old. The main outcome evaluated was the mortality rate in one year. It was also evaluated the correlation with gender, age, personal habits, number of comorbidities and Charlson Comorbidity Index (CCI).

RESULTS

The functional result was assessed with WOMAC score via telephone call. The mortality rate in one year was 42.8% without statistical positive correlation with any of the studied parameters. Patients with three or more comorbidities didn't have a higher mortality rate comparing to survived patients (83.3% vs 81.3%). The CCI also didn't show any correlation with high mortality (6.9 vs 7.1). The functional result of the survived patients was poor (78.2 points WOMAC).

CONCLUSION

The conclusion is that the mortality rate in one year of ill patients with hip fractures treated non-operatively is 42.8% without correlation with age, gender of number of comorbidities, and the functional result of the survived patients is poor.

Clinical prediction model for postoperative ambulatory ability outcomes in patients with trochanteric fractures

INTRODUCTION

Regaining independent ambulatory ability is one of the primary goals of treatment in patients with trochanteric fractures. This study aimed to develop and evaluate the discriminative accuracy of a clinical prediction model for ambulatory ability outcomes 3 months after surgery for trochanteric fractures.

METHODS

This retrospective cohort study included 346 patients treated with intramedullary nailing for trochanteric fractures who had independent ambulatory ability before their injury. Multiple regression models with preoperative and postoperative factors were used to predict ambulatory ability outcomes at 3 months. A clinical prediction model (CPM) was created based on a decision tree developed using a chi-square automatic interaction detector technique.

RESULTS

Three months after surgery, 263 (76.0%) and 83 (24.0%) patients regained and lost independent ambulatory ability, respectively. Univariate analysis showed that the Barthel index (BI) total score at 2 weeks predicted the ambulatory ability outcome at 3 months with good discriminative accuracy (area under the receiver operating characteristic curve [AUROC]: 0.819; 95% confidence interval [CI]: [0.769, 0.868], cut-off value: 22.5; sensitivity: 69.5%; specificity: 82.3%). Multiple logistic regression analysis showed that preoperative factors (residence before injury, diagnosis of dementia, and serum albumin at admission) and postoperative factors (BI total score at 2 weeks) predicted ambulatory ability outcomes at 3 months (AUROC: 0.710; 95%CI: [0.636, 0.783]; sensitivity: 91.3%; specificity: 41.8%). The CPM with the BI total score at 2 weeks (≤10; 10<, ≤50; >50 points) and dementia status (present; absent) had a moderate discriminative accuracy (AUROC: 0.676; 95%CI: [0.600, 0.752]; sensitivity: 94.7%; specificity: 40.5%).

CONCLUSIONS

We developed a CPM with moderate accuracy to predict ambulatory ability outcomes in patients 3 months after surgery for trochanteric fractures. Our results demonstrate the importance of the BI score measured soon after surgery and dementia status for the prediction of postoperative ambulation.

Infections after intramedullary fixation of trochanteric fractures are uncommon and implant removal is not usually needed

BACKGROUND AND PURPOSE

Infections after intramedullary fixation of trochanteric femoral fractures are rare, but potentially life-threatening complications. There are limited data available to support decision making in these cases.

PATIENTS AND METHODS

A retrospective study of 995 consecutive operatively treated trochanteric fractures was made to find out different risk factors for infection and to describe the results of treatment.

RESULTS

28 patients developed a surgical site infection (2.8%) after intramedullary fixation of trochanteric fracture. 15 patients (1.5%) had a deep and 13 patients (1.3%) a superficial surgical site infection. Cigarette smoking (p<0.05) and prolonged operative time (p<0.05) were significant risk factors for an infection. 15 of 28 patients needed revision surgeries. Implant removal or exchange was needed only for 4 of 28 patients: 1 exchange of the blade, 1 removal of additional cable used to assist reduction and 2 removals of distal locking screws. None of the patients needed additional surgeries for problems with fracture healing. Mortality was not increased among patients with an infection.

INTERPRETATION

Infection after intramedullary fixation of trochanteric fractures can be successfully treated without removal or exchange of the fixation material.

The safety and accuracy of the fluoroscopic imaging during proximal femoral fixation: A computerized 3D reappraisal of the joint penetration risk

BACKGROUND

To assess the success of proximal cephalomedullary nailing operations for treating trochanteric fractures, surgeons utilize 2D fluoroscopy to observe the relative positions of the femoral head and the implant. One distance-based risk parameter, observed from the AP and Lateral projections, is the Tip-Surface Distance(TSD) that dictates how close to the outer cortex should the implant tip be residing to avoid post-surgical complications such as cut-out or joint penetration. In this study, the safety and the accuracy of the orthogonal fluoroscopic imaging were evaluated.

METHODS

A femoral head model was created and the risk zone was defined as a hemispherical shell of 5 mm thickness beneath the subchondral cortex, which should not be violated during screw insertion. The remaining hemisphere beneath the risk zone was designated as the safe zone. To assess the effect of head size, each simulation was conducted for 34, 47, and 60 mm diameter(D_femur) femoral heads. The rate of safe zone violation was calculated for all possible screw endpoints with a TSD of at least 5 mm on fluoroscopic orthogonal views (TSD_AP and TSD_Lat).

RESULTS

The minimum risk of joint penetration was achieved when the TSD_AP/TSD_Lat ratio was 1. For D_femur of 34 mm there was a risk of 91.7% of the safe zone violation when each TSD_AP and TSD_Lat were 5 mm and 0% for 9 mm. For D_femur of 47 mm, the risk was 92.2% for 5 mm and 0% for 11 mm. For D_femur of 60 mm, the risk was 92.3% for 5 mm and 0% for 13 mm. Safety maps were constructed for all possible TSD combinations for 34, 47, and 60 mm femoral heads.

CONCLUSIONS

Depending solely on the orthogonal fluoroscopic images is not a safe and accurate technique for assessing joint penetration risk during proximal femoral fixation due to the spherical geometry of the femoral head. The screw tip can lie completely outside of the femoral head even when it appears inside, in both orthogonal fluoroscopic views. Evidently, when using TSD, more stringent distance limits should be chosen, contrary to the recommended 5 mm limit. Our safety maps for TSD combinations may be used to check the security of the implantation.

Postoperative computed tomography assessment of anteromedial cortex reduction is a predictor for reoperation after intramedullary nail fixation for pertrochanteric fractures

PURPOSE

Postoperative radiographs are routinely used to assess fracture reduction following intramedullary nail fixation for pertrochanteric fractures, even though computed tomography (CT) is a superior modality. We aimed to determine the association between reduction quality assessed by CT and rates of reoperation and to evaluate the association of reoperation and reduction quality according to the assessment modality (plain radiographs vs. CT).

METHODS

A retrospective analysis of 299 consecutive patients treated with intramedullary nail fixation for pertrochanteric fractures was conducted. Fracture reduction measured by postoperative radiographs and CT was categorized as anatomical type, extramedullary type, or intramedullary type. Postoperative data for analysis included reduction status, tip-apex distance (TAD), screw position in the femoral head, sliding distance, and conditions associated with reoperation.

RESULTS

Of the 299 patients included with a mean age of 83.1 ± 8.2 years, there were six patients who required reoperation (2.0%). According to the CT assessments, there were 42 intramedullary reductions (14.0%). Patients with a non-intramedullary reduction based on postoperative CT images were significantly more likely to have proper placement of the screw, a reduced TAD, a reduced sliding distance, and a lower reoperation rate than those with an intramedullary reduction (P < 0.05). The reduction quality assessed by postoperative CT was significantly associated with reoperation (95% CI, 1.45-29.31).

CONCLUSIONS

Intramedullary reduction assessed by CT was associated with reoperation. The reduction quality based on CT findings was more predictive for reoperation than that from plain radiographs.

Reverse wedge effect following intramedullary nail fixation of trochanteric fracture, what does it imply?

Lag screw cut-out is the most common cause of fixation failure of trochanteric fractures. Intraoperative assessment of fracture reduction and fixation quality is vital to avoid fracture reduction and achieve good functional outcomes. In a recent study, Zhang et al. reported the occurrence of a reverse wedge effect after intraoperative nail insertion based on a new computed tomography(CT)-guided fracture classification system, which specifically happened to the basicervical facture type and resulted in valgus deformity with gapping at the medial inferior fracture line. Impingement between the reamer/nail and superolateral cortex of the femoral neck has been regarded as the main cause. Based on these findings, together with an extensive literature review, the practicality of the new fracture classification system, the definition of basicervical trochanteric fracture, and the mechanisms underlying the reverse wedge effect have been deeply discussed. More studies should be carried out in the future to analyse pre- and intraoperative related factors that could affect the intraoperative fragment migration effects and determine highly specific measures to address them.

Benefit of lag screw placement by a single- or two-screw nailing system in elderly patients with AO/OTA 31-A2 trochanteric fractures

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.

Results of revision intramedullary nailing with and without auxillary plate in aseptic trochanteric and subtrochanteric nonunion

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).

Application of the reversed LISS-DF technique in an elderly patient to salvage infection-related failure of trochanteric fracture fixation

Failure of cephalomedullary fixation in geriatric trochanteric fractures is a potential complication. Attempts have been made to optimize the implant fixation (e. g. cement augmentation) and several factors (e. g. malreduction, tip apex distance) have been identified as risk factors for failure. Nevertheless, if intramedullary fixation fails, it is often associated with bone defects in mostly preexisting poor bone-stock. Accordingly, conversion to total hip arthroplasty (THA) is recommended by some authors as the only valid treatment option. However, in specific situations (e. g. implant associated infection) conversion to THA might be less reasonable than an attempt to re-osteosynthesis. This article reports on the successful use of a reversed contralateral LISS-DF (LISS for the distal femur, DePuy Synthes, Zuchwil, Switzerland) application after failed cephalomedullary fixation and failed re-osteosynthesis using a blade plate in a trochanteric fracture in an elderly patient with additional implant associated infection.

Hip fractures among the elderly in Kyoto, Japan: a 10-year study

In Kyoto Prefecture, Japan, the number of hip fractures increased during 2013-2017 compared to 2008-2012. However, the estimated overall incidence rate increased only in femoral neck fractures in men aged ≥75 and women aged ≥85.

PURPOSE

The incidence rate of hip fractures in Japan has plateaued or decreased. We investigated the annual hip fracture occurrences in Kyoto Prefecture, Japan, from 2008 to 2017.

METHODS

Patients aged 65 years and above who sustained hip fractures between 2008 and 2017 and were treated at one of the participating 11 hospitals were included. The total number of beds in these institutions was 3701, accounting for 21.5% of the 17,242 acute-care beds in Kyoto Prefecture. The change in incidence rate was estimated utilizing the population according to the national census conducted in 2010 and 2015.

RESULTS

The total number of hip fractures was 10,060, with 47.5% femoral neck fractures and 52.5% trochanteric fractures. A decrease in number was seen only in trochanteric fractures in the group of 75- to 84-year-old women. The population-adjusted numbers of femoral neck fractures showed a significant increase in all age groups in men, whereas in women, there was an increase in femoral neck fractures in the ≥85 group and trochanteric fractures in the age group 65-74, and a decrease in trochanteric fractures in the age group 75-84. The estimated change in incidence rate showed an increase in femoral neck fractures in men aged ≥75 and women aged ≥85.

CONCLUSION

In Kyoto Prefecture, the number of hip fractures increased in the second half of the study period (2013-2017) compared to the first half (2008-2012). However, the incidence rate had not increased, except in femoral neck fractures in men aged ≥75 and women aged ≥85.

The functional effect of lesser trochanter involvement in hip fractures: A prospective cohort study

INTRODUCTION

Hip fractures are the most common fractures amongst frail older patients. Earlier studies have indicated an impaired hip flexion strength in patients with fractures that include detachment of the lesser trochanter. These patients may experience protracted functional impairment and longer recovery time, causing prolonged rehabilitation journeys. This study aimed to evaluate the effects of a detached lesser trochanter in trochanteric fractures on the recovery of hip function.

METHOD

A prospective observational cohort study was performed between 2016 and 2019. Community dwelling patients aged 70 years or older with AO 31A1-A3 trochanteric fractures were included. Patients followed routine care and were treated with a DHS or PFNA. The groups with and without involvement of the lesser trochanter were analysed. The primary outcome was hip function assessed at 6 weeks, 3 months and 1 year after surgery with the Harris Hip Score. Secondary outcomes included the Ludloff's test, complications, rehabilitation time, and pain-, independence-, and quality of life scores. A propensity score was used to adjust for any baseline differences between the two groups.

RESULTS

A total of 114 patients were included, 51 (44.7%) with involvement of the lesser trochanter and 63 (55.3%) without. Minor differences were observed in the baseline characteristics. No significant difference was observed for the Harris Hip Score (coefficient estimate: 3.31; 95% CI, -5.09-11.72; P = 0.43). The flexion function of the iliopsoas muscle was more often normal with the Ludloff's test in patients without involvement of the lesser trochanter (OR, 2.33; 95% CI, 1.241-4.387; P = 0.009). However, no differences were observed for any of the other secondary outcomes.

CONCLUSION

Although no differences in overall hip function were found, more hip fracture patients with involvement of the lesser trochanter showed prolonged impaired flexion of the hip. The absence of long-term, clinically relevant disadvantages however, proves fixing the lesser trochanter to be redundant.

Does auxiliary cerclage wiring provide intrinsic stability in cephalomedullary nailing of trochanteric and subtrochanteric fractures?

Purpose

The aim of this study was to assess functional and radiological results following cephalomedullary nailing with and without use of auxiliary cable cerclages in a large series of trochanteric and subtrochanteric femoral fractures.

Methods

In a retrospective study of prospectively collected data between January 2014 and March 2019, a total of 260 consecutive patients (155 women and 105 men) with the diagnosis of AO/OTA A1 to A3 fractures were included. The mean age of patients was 76.4 ± 15.6 years. According to the AO/OTA classification, 72 A1 fractures, 124 A2 fractures, and 64 A3 fractures were found. In 72 patients with auxiliary cerclage wiring three A1 fractures, 27 A2 fractures and 42 A3 fractures were assessed. In the patient group with auxiliary cerclages, fracture healing according to the Radiographic Union Score for Hip (RUSH) within one year after surgery was assessed in 68 out of 72 patients (healing rate 94%). The mean RUSH in the group with cerclages was 28.7 ± 2.2 points and was 28.5 ± 2.2 points in the group without cerclages (p = 0.72). In 91 patients available for a complete follow-up, mean functional outcome according to the Lower Extremity Functional Scale (LEFS) was 65.3 ± 17.2 points in the group with cerclages versus 58.4 ± 21 points in the group without cerclages (p = 0.04).

Conclusion

The additional use of cerclages provides intrinsic stability and enables axial alignment and medial cortical support during anatomical fracture reduction and cephalomedullary nail insertion. In the current study, this technique resulted in significantly better functional long-term outcomes than without cerclages. Therefore, it can be recommended as a useful supportive tool especially in comminuted trochanteric and subtrochanteric fractures. Trial registration number DRKS00020550, 01/30/2020, retrospectively registered.