Does the angle between dynamic hip screw and anti-rotation screw affect the outcome of vertically oriented femoral neck fractures? A biomechanical analysis and clinical results

OBJECTIVE

To analyze the effects of the angle between dynamic hip screw (DHS) and anti-rotation screw (AS) on vertically oriented femoral neck fractures (VOFNFs) and investigate the clinical results of them.

METHODS

Eighteen synthetic femurs were simulated and divided into 3 groups. The angle between DHS and AS in anteroposterior-view was marked as α, and in lateral-view was marked as β, thus the total angle (TA) was defined as the summation of α and β. The groups were categorized as group A (TA ≤ 5°), B (5° < TA ≤ 10°), and C (TA > 10°), respectively. All samples were tested under incremental, cyclical loading, and loading to failure. In clinic, 80 consecutive VOFNFs in 78 patients were treated with DHS plus AS. The patients were divided into 2 groups, including 48 fractures in parallel group (TA ≤10°) and 32 in angular group (TA >10°).

RESULTS

Group A and B survived during incremental and cyclical loading and endured longer than group C. Axial stiffness and failure loads were not different between group A and B, and greater than group C. Fracture gaps compressive stress was highest in group A, followed by group B and C. Forty-one fractures in parallel group and 23 in angular group healed at final follow-up. Nonunion and osteonecrosis occurred in 3 and 4 of parallel group, and 4 and 5 of angular group.

CONCLUSION

The construction with TA ≤10° between DHS and AS showed superior biomechanical performance and clinical results than those with TA >10°.

Surgical management of neck of femur fractures in patients younger than sixty-five years: a comparative study of three fixation methods

PURPOSE

Several surgical implants have been used for the treatment of neck of femur fracture (NOF) in younger patients such as dynamic hip screw (DHS) and cannulated compression screw. However, the superiority of one or another osteosynthesis device remains a matter of debate. The aim of this work is to evaluate and compare three fixation modalities: Cannulated Hip Screws (CHS), DHS and DHS associated to anti-rotating screw for surgical treatment of femoral neck fracture in young adults.

METHODS

It is a retrospective comparative study of three series of NOF fractures treated surgically over a period of ten years; including young adult patients (age > 18 years and < 65 years) treated conservatively using closed or open reduction and internal fixation. All types of NOF fractures according to Garden classification were included. Pathological, basi-cervical fractures and fractures on previously operated hips were excluded. The minimum follow-up recommended was two years. Clinical evaluation was based on the Postel Merle d'Aubigné score (PMA), the visual analogue scale (VAS), the Parker score, and the Hip Disability and Osteoarthritis Outcome Score (HOOS score). Reduction quality was assessed on X-rays.

RESULTS

Our series included 72 patients that were divided in three groups: Group A: Fixation using cannulated hip screws (33 patients). Group B: Fixation using DHS only (21 patients). Group C: Fixation using DHS associated to anti-rotation screw (18 patients). The patients of group A had better PMA and VAS scores, but there was no statistically significant difference. However, a significant difference (p=0.001) was found for the HOOS score. The fractures treated with DHS associated with anti-rotating screws, had the highest loss of reduction in the vertical axis (Yp) with the highest femoral head collapse (Zp) values. Group A had the lowest loss of reduction in the horizontal axis (Xp). There was no significant difference between the three methods of osteosynthesis in terms of loss of correction though.

CONCLUSION

We found comparable results in terms of healing and complication rates and loss of reduction for the three groups with no significant difference. However, the HOOS score was significantly better in the cannulated hip screw group.

Cannulated screws versus dynamic hip screw versus hemiarthroplasty versus total hip arthroplasty in patients with displaced and non-displaced femoral neck fractures: a systematic review and frequentist network meta-analysis of 5703 patients

BACKGROUND

Our aim was to determine the best operative procedure in human participants with a displaced or non-displaced femoral neck fracture comparing cannulated screw (CS) fixation, dynamic hip screw (DHS) fixation, hemiarthroplasty (HA), and total hip arthroplasty (THA) in terms of surgical and functional outcomes, reoperation and postoperative complications.

METHODS

We searched PubMed, The Cochrane Library, Clinical trials, CINAHL, and Embase for randomized controlled trials (RCTs) or quasi-RCTs up to 31 July 2022. A frequentist network meta-analysis was performed to assess the comparative effects of the four operative procedures, using fixed-effects and random-effects models. Mean differences (MDs) with 95% confidence intervals (CIs) were estimated for continuous variables and odds ratios (ORs) with 95% CIs were estimated for binary variables.

RESULTS

A total of 33 RCTs with 5703 patients were included in our network meta-analysis. CS fixation was best in terms of operation time (CS: MD = - 57.70, 95% CI - 72.78; - 42.62; DHS: MD = - 53.56, 95% CI - 76.17; - 30.95; HA: MD = - 20.90, 95% CI - 30.65; - 11.15; THA: MD = 1.00 reference) and intraoperative blood loss (CS: MD = - 3.67, 95% CI - 4.44; - 2.90; DHS: MD = - 3.20, 95% CI - 4.97; - 1.43; HA: MD = - 1.20, 95% CI - 1.73; - 0.67; THA: MD = 1.00 reference). In life quality and functional outcome, measured at different time points with EQ-5D and the Harris Hip Score (HHS), THA ranked first and HA second (e.g. EQ-5D 2 years postoperatively: CS: MD = - 0.20, 95% CI - 0.29; - 0.11; HA: MD = - 0.09, 95% CI - 0.17; - 0.02; THA: MD = 1.00 reference; HHS 2 years postoperatively: CS: MD = - 5.50, 95% CI - 9.98; - 1.03; DHS: MD = - 8.93, 95% CI - 15.08; - 2.78; HA: MD = - 3.65, 95% CI - 6.74; - 0.57; THA: MD = 1.00 reference). CS fixation had the highest reoperation risk, followed by DHS fixation, HA, and THA (CS: OR = 9.98, 95% CI 4.60; 21.63; DHS: OR = 5.07, 95% CI 2.15; 11.96; HA: OR = 1.60, 95% CI 0.89; 2.89; THA: OR = 1.00 reference).

CONCLUSION

In our cohort of patients with displaced and non-displaced femoral neck fractures, HHS, EQ-5D, and reoperation risk showed an advantage of THA and HA compared with CS and DHS fixation. Based on these findings, we recommend that hip arthroplasty should be preferred and internal fixation of femoral neck fractures should only be considered in individual cases.

LEVEL OF EVIDENCE I

a systematic review of randomized controlled trials.

TRIAL REGISTRATION

PROSPERO on 10 August 2022 (CRD42022350293).

Does intramedullary nail have advantages over dynamic hip screw for the treatment of AO/OTA31A1-A3? A meta-analysis

BACKGROUND

Hip fractures are still unsolved problems nowadays. We evaluated the functional outcomes and complications in the treatment of hip fractures (AO/OTA31A1-A3) to find potential difference and risk between intramedullary nail (IMN) and dynamic hip screw (DHS).

METHOD

We searched PubMed, Embase, Cochrane library up to 19 June 2023 and retrieved any studies comparing IMN and DHS in treatment of Hip fractures. The main outcomes and complications were extracted from the included studies. The fixed-effect model was selected to pool the data for homogeneous studies (I² < 50%). Otherwise, the random effects model was selected (heterogeneity, I² > 50%). The analysis of sensitivity and subgroup was performed to explore the homogeneous studies among studies. The p-value of less than 0.05 was considered statistically significant.

RESULTS

30 RCT studies were included in this meta-analysis. There were significant difference of in the items of blood loss, screening time, femoral neck shortening, non-union, and femoral fractures (p < 0.05). Significant difference was found in the parameter of open reduction of fracture after sensitive analysis (p < 0.05). No significant difference was found in the parameter of Mobility Score at the last follow-up after sensitive analysis (p ≥ 0.05). There was no significant difference in the parameters of open reduction of fracture, required blood transfusion, mean surgical time, hospital stays, time to healing, mean Harris Hip Score, infection, cut out, poor reduction, breakage of implant, failure of fixation, reoperation, and systemic complications of chest infection, decubital ulcer, urinary tract infection and persistent pain in the hip (p ≥ 0.05).

CONCLUSIONS

Our meta-analysis revealed that hip fractures treated with IMN have merits with lower rate of blood loss, femoral neck shortening and non-union; shortcoming of increased risk of femoral fractures. It is suggested that special attention should be paid to the risk of femoral fracture when intramedullary nail was inserted in the intraoperative.

Conversion hip arthroplasty for failed internal fixation of ipsilateral femoral neck and shaft fractures: a case report

BACKGROUND

Ipsilateral femoral neck and hip fractures are uncommon high energy injuries. In the literature no single method of treatment has emerged as superior to the others. A recent publication has documented the successful application of the rendezvous technique using dual-implants for treating these injuries. However in some cases, this technique may fail and revision surgery is required.

CASE PRESENTATION

A 67-year old man sustained ipsilateral fractures of his femur and femoral neck in a road traffic accident. His injuries were treated by a dual construct consisting of a retrograde femoral nail and dynamic hip screw. Three months after surgery the hip screw cut out of the femoral head necessitating revision to a total hip arthroplasty. Surgery was carried out using a single stage two part procedure on a standard operating table without having to reposition or redrape the patient. There were no postoperative complications and at 1 year from surgery the patient is satisfied with the result and has returned to work.

CONCLUSION

Conversion hip arthroplasty in the presence of dual implants is a technically challenging and unpredictable procedure, with an increased risk of complications. Our surgical approach provides a framework for orthopedic surgeons to safely perform this complex procedure.

Optimizing fixation methods for stable and unstable intertrochanteric hip fractures treated with sliding hip screw or cephalomedullary nailing: A comparative biomechanical and finite element analysis study

BACKGROUND

Despite recent advances in implants and surgical techniques, catastrophic and clinical failures in the treatment of intertrochanteric fractures continue to occur, with dire consequences in an overall frail population subset. The aim of the current study is to evaluate the effect of the factors under the surgeons' control, namely fracture reduction and implant selection, on the biomechanical behavior of fracture fixation constructs.

MATERIAL-METHODS

An experimental protocol was conducted with the use of instrumented sawbones, in order to validate the finite element models. The implants used were the Gamma3®and DHS systems. Subsequently, a series of scenaria were considered, including various reduction and implant angle combinations. Data were retrieved concerning the peak cancellous bone stresses around the hip screw and the volume of cancellous bone in the femoral head stressed at critical levels, as well as implant stresses and stresses on the cortical bone of the distal fragment.

RESULTS

All stable fracture models displayed significantly decreased cancellous bone stresses and implant stresses compared to their unstable counterparts, regardless of implant used. The effect of increasing implant angle led to a decrease in implant stresses in all models studied, but had a beneficial effect on the stresses in the cancellous bone of the proximal fragment only in the subgroups of stable fractures with both implants and unstable fractures treated with a cephalomedullary nail (CMN). In unstable fractures anatomically reduced, the use of CMN led to significantly lower peak stresses in the cancellous bone and a smaller volume of bone stressed at critical levels. Increasing the reduction angle by 5 ° led to a significant decrease in both peak stresses and volume of bone stressed at critical levels, more prominent in the sliding hip screw (SHS) models. Decreasing the reduction angle into varus by 5 or 10 ° led to a significant increase in bone and implant stresses regardless of implant used.

CONCLUSIONS

In stable two-part (AO31.A2) fractures the use of the SHS appears to be biomechanically equivalent to CMN. In unstable, anatomically reduced fractures, the use of CMN leads to significantly reduced cancellous bone stresses and decreased rotation of the proximal fragment during loading. A reduction in varus should be avoided at all costs. In unstable fractures treated with SHS a reduction in slight valgus appears to be biomechanically beneficial. The highest implant angle that allows for proper screw position and trajectory in the femoral head should be used for stable fractures with both implants and unstable fractures treated with Gamma3®.

A comparison of hemiarthroplasty versus dynamic hip screw fixation for intertrochanteric femoral fractures: a systematic review

INTRODUCTION

Intertrochanteric fractures are predominantly treated by dynamic hip screw (DHS) fixation. However, recent evidence has found acceptable clinical results following hemiarthroplasty for these fractures. Thus, a systematic review was conducted to compare hemiarthroplasty with DHS fixation for intertrochanteric fractures.

METHODS

A computerised search was performed, using the databases Medline, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials, with supplementation from Google Scholar and appropriate reference lists. Studies with comparative data comparing clinical outcomes of hemiarthroplasty versus DHS fixation were included. Data were extracted and quality assessment of the papers performed by 2 reviewers.

RESULTS

320 articles were independently reviewed by the investigators. A total of 10 studies met the inclusion criteria, comprising 2 randomised controlled trials and 8 cohort designs. 7 of the studies assessed unstable fracture patterns. There was no difference in operating time (SMD -1.169 min; 95% CI, -0.657 to 0.689) or blood transfusion volume (SMD-0.110 units; 95% CI, -0.520 to 0.891) between modalities. There was also no difference in length of stay (SMD -0.778 days; 95% CI, -0.606 to 0.336), mortality (RR 0.942; 95% CI, 0.749-1.183) or major complications. Hemiarthroplasty conferred significantly better Harris Hip Scores at 12 months (SMD 12.3; 95% CI, 0.0135-2.789) and allowed earlier weight-bearing than DHS fixation.

DISCUSSION

Qualitative and quantitative compilation of the included studies demonstrates hemiarthroplasty to result in better functional scores and a quicker time to weight-bearing than DHS fixation for intertrochanteric fractures. Results are comparable for other major parameters, including operative time, length of stay and mortality. Thus, hemiarthroplasty is a suitable alternative to DHS fixation for unstable intertrochanteric fractures in elderly patients.

Accuracy of guide wire placement for femoral neck stabilization using 3D printed drill guides

BACKGROUND

The goal of stabilization of the femoral neck is to limit morbidity and mortality from fracture. Of three potential methods of fixation, (three percutaneous screws, the Synthes Femoral Neck System, and a dynamic hip screw), each requires guide wire positioning of the implant(s) in the femoral neck and head. Consistent and accurate positioning of these systems is paramount to reduce surgical times, stabilize fractures effectively, and reduce complications. To help expedite surgery and achieve ideal implant positioning in the geriatric population, we have developed and validated a surgical planning methodology using 3D modelling and printing technology.

METHODS

Using image processing software, 3D surgical models were generated placing guide wires in a virtual model of an osteoporotic proximal femur sawbone. Three unique drill guides were created to achieve the optimal position for implant placement for each of the three different implant systems, and the guides were 3D printed. Subsequently, a trauma fellowship trained orthopedic surgeon used the 3D printed guides to position 2.8 mm diameter drill bit tipped guide wires into five osteoporotic sawbones for each of the three systems (fifteen sawbones total). Computed Tomography (CT) scans were then taken of each of the sawbones with the implants in place. 3D model renderings of the CT scans were created using image processing techniques and the displacement and angular deviations at guide wire entry to the optimal sawbone model were measured.

RESULTS

Across all three percutaneous screw guide wires, the average displacement was 3.19 ± 0.12 mm and the average angular deviation was 4.10 ± 0.17^o. The Femoral Neck System guide wires had an average displacement of 1.59 ± 0.18 mm and average angular deviation of 2.81 ± 0.64^o. The Dynamic Hip Screw had an average displacement of 1.03 ± 0.19 mm and average angular deviation of 2.59 ± 0.39^o.

CONCLUSION

The use of custom 3D printed drill guides to assist with the positioning of guide wires proved to be accurate for each of the three types of surgical strategies. Guides which are used to place more than 1 guide wire may have lower positional accuracy, as the guide may shift during multiple wire insertions. We believe that personalized point of care drill guides provide an accurate intraoperative method for positioning implants into the femoral neck.

Comparative effectiveness research on proximal femoral nail versus dynamic hip screw in patients with trochanteric fractures: a systematic review and meta-analysis of randomized trials

Background

The treatments for trochanteric fractures try to regain early mobility and limit morbidity and risk of reoperations. The most currently used dynamic hip screw (DHS) and the proximal femoral nail (PFN) are both with pros and cons. We aimed to assess the comparative effectiveness of these interventions for trochanteric fractures by evaluating the surgical performance and postoperative outcomes.

Methods

PubMed, Web of Science and Cochrane Central Register were searched for RCTs comparing DHS and PFN for trochanteric fractures. All selected studies and the risk of bias were assessed. Clinical data including operative time, intraoperative blood loss, intraoperative fluoroscopy time, successful closed reduction and complications like nonunion, implant failure and reoperation were recorded. Random-effects models were used in Review Manager software, and GRADE was applied for the interpretation of the evidence.

Results

From 286 identified trials, twelve RCTs including 1889 patients were eligible for inclusion; six RCTs directly comparing DHS with PFN, while other six compared DHS with proximal femoral nail antirotation (PFNA). Compared to DHS, PFN had shorter operative time and led to less intraoperative blood loss. However, DHS need less intraoperative fluoroscopy time than PFN. No difference was seen for the achievement of closed reduction. For risk of postoperative complications, no difference was seen between PFN and DHS for non-union, risk of implant failure and revision surgery.

Conclusions

PFN(A) resulted in a shorter operative time and less intraoperative blood loss compared to DHS. However, no difference was seen for postoperative complications.

Trial registration PROSPERO: CRD42021239974.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-022-03189-z.

Comparison of femoral neck system to multiple cancellous screws and dynamic hip screws in the treatment of femoral neck fractures

OBJECTIVE

To compare the short-term outcomes of the femoral neck system (FNS) with multiple cancellous screws (MCS) and dynamic hip screws (DHS) in the treatment of femoral neck fractures.

METHODS

A retrospective analysis was performed on 157 patients with fresh femoral neck fractures treated with FNS (from September 2019 to October 2020), MCS, and DHS (from January 2018 to October 2020). According to internal fixation methods, all patients were divided into the FNS group (54 cases), MCS group (51 cases), and DHS group (52 cases). Demographic data were also collected, recorded, and compared, including the follow-up time, days of hospitalization, operation time, blood loss, intraoperative fluoroscopy times (IFT), weight-bearing time (WBT), length of femoral neck shortening (LFNS), Harris hip score, and complications (such as internal fixation failure, bone nonunion, and avascular necrosis of the femoral head) between the three groups.

RESULTS

Overall, 157 patients with a mean age of 61.8 (range, 18-89) years were analyzed. In the FNS group, IFT (median 10.5) was significantly lower than that in the MCS group (median 21) and DHS group (median 20.5) (P<0.05), and WBT was significantly earlier than that of the MCS group (P<0.05). In the FNS group, the median hospitalization time, operation time, and blood loss were 2 (2, 4) days, 45 (40-59) min, and 30 (20, 50) ml, respectively. They were all significantly less than 3.5 (3, 6) days, 72 (55-88.75) min, and 50 (30, 50) ml in the DHS group, respectively (P < 0.05). There was no statistical difference in LFNS, quality of reduction, internal fixation failure rate, and Harris hip score at the latest follow-up (P>0.05). No surgical complications such as incision infection, deep infection, pulmonary embolism, or femoral head necrosis were found in any of the three groups.

CONCLUSION

FNS, MCS, and DHS are all effective for femoral neck fractures. However, a lower IFT of FNS shortens the operation time. Compared to MCS, FNS has the advantages of being a simple operation, with early WBT; compared to DHS, a minimally invasive operation is the main advantage of FNS.

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.

Outcomes of minimally invasive osteosynthesis of intertrochanteric fractures with dynamic hip screw: A prospective case series

BACKGROUND

Intertrochanteric fractures are a public health concern, especially in geriatric patients. Early surgical management is crucial to allow early mobilization, which helps reduce the disability and increase patients' survival. In this article, we report the outcomes of minimally invasive osteosynthesis of intertrochanteric fractures with dynamic hip screw (DHS).

METHODS

The present study was a prospective case series of patients who had intertrochanteric fractures treated with minimally invasive DHS technique. Postoperative patient satisfaction rate was evaluated using the visual analog scale (VAS) of pain. Functional outcomes were evaluated using the Harris hip score (HHS) and the Merle-d'Aubigne-Postel (MDP) scoring system at 12 months of follow-up. Satisfactory results were considered with HHS of ≥80 points and MDP scores of ≥15. Postoperative complications were noted.

RESULTS

In this study, 70 patients were included, 41 (58.6%) males and 29 (41.4%) females, with an average age of 69.3 ± 8.3 years. The mean length of hospital stay was 2.1 ± 0.9 days. The average follow-up period was 23.9 ± 7.1 months. The mean time to radiological union was 16.8 ± 1.9 weeks. The mean postoperative VAS score for pain was 2.5 ± 1.1. The mean HHS was 87.1 ± 4.7 points and the mean MDP score was 15.6 ± 2.3 at 12 months follow-up. An average of 10.6 ± 2.9 weeks was required for full weight bearing.

CONCLUSION

The minimally invasive DHS technique effectively treats intertrochanteric fractures with minimal incision, less bleeding, shorter operative time, early discharge from hospital, faster rehabilitation, and favorable functional outcomes.

Association between lateral femoral wall thickness and BMD with the occurrence of lateral wall fracture in DHS fixation

BACKGROUND

Nearly 50% of all hip fractures are intertrochanteric fractures (ITF) and are linked to osteopenia and advancing age. For secure ITF repair, the dynamic hip screw (DHS) fixation is regarded gold standard surgery. However, controversy exists regarding the use of DHS in the treatment of unstable ITF especially in patients with pre-operative lateral femoral wall fracture (LWF). The purpose of this study is to find if there's a link between lateral femoral wall thickness, bone mineral density and the risk of LWF in DHS fixation.

PATIENT AND METHODS

A prospective, observational cohort analysis of 70 consecutive patients with ITF was undertaken in a tertiary care government hospital. All patients were treated with a 135° DHS fixation under regional anaesthesia and fluoroscopic guidance. Lateral femoral wall thickness was assessed pre-operatively on radiographs and during surgery. Mean T score as a measure of bone mineral density was recorded in all patients.

RESULT

Postoperative LWFs occurred in 11 individuals. In 11 patients who had a postoperative LWF, the mean lateral femoral wall thickness was 19.545 mm, while the remaining 54 patients had a mean lateral femoral wall thickness of 29.285 mm (P < 0.001) With 81.5% sensitivity, the lateral femoral wall thickness threshold that could predict LWF was determined to be less than 25 mm. The mean T score of the contralateral hip in LWF patients was -2.255 standard deviation, whereas it was -2.428 standard deviation in patients without LWF, the difference of which was statistically not significant.

CONCLUSION

DHS fixation alone should be avoided in ITF patients with lateral femoral wall thickness <25 mm and other implant choices should be explored for management of these patients.

Fracture fixation versus hemiarthroplasty for unstable intertrochanteric fractures in elderly patients: A systematic review and network meta-analysis of randomized controlled trials

INTRODUCTION

There are three common types of operative options for unstable intertrochanteric fracture (ITF), i.e. dynamic hip screw (DHS), proximal femoral nail (PFN), and bipolar hemiarthroplasty (BHA). Results of these operations are still inconclusive. This systematic review and network meta-analysis was therefore conducted to compare the efficacy among those operative strategies.

HYPOTHESIS

These three operative techniques (i.e., DHS, PFN, and BHA) were not different in operative failure, reoperation, and Harris Hip Score (HHS) for unstable ITF.

MATERIAL AND METHODS

Randomized controlled trials (RCTs) comparing outcomes among DHS, PFN, and BHA in patients with unstable ITFs were searched from Medline and Scopus databases. Primary outcomes included operative failure, reoperation, and HHS. Direct meta-analysis (DMA) and network meta-analysis (NMA) were performed to compare among three operative techniques. Qualitative and quantitative evidences of all included studies were tested for heterogeneity, transitivity, and consistency in NMA. The surface under the cumulative ranking curve (SUCRA) was used to estimate the probability of being the best in lowering poor clinical outcomes, but high HHS.

RESULTS

Seven RCTs (n=528) were eligible. DMA showed that DHS and PFN were significantly higher risk of operative failure compared with BHA with risk ratio (RR) and 95% confidence interval of 7.98 (1.35, 47.06) and 3.08 (1.00, 9.51), respectively. Compared with BHA, PFN was 4.47 (1.04, 21.60) times significantly higher risk of reoperation, and lower HHS at 3-6months [mean difference (MD)=-5.41 (-15.91, 5.10)], but higher HHS at>6-12months [MD 11.67 (2.98, 20.36)], although these HHSs were not significant. NMA and SUCRA demonstrated the highest ranks for operative failure and reoperation were DHS and PFN, whereas the highest HHS was BHA.

DISCUSSION

In specific group of unstable ITF, BHA might be the best operative technique in term of lower operative failure and reoperation, and highest HHS during short to intermediate period comparing with PFN and DHS. However, PFN had higher long-term HHS than BHA.

LEVEL OF EVIDENCE

I, meta-analysis of RCTs.

Comparison of the Dynamic Hip Screw with the Dynamic Hip External Fixator for Intertrochanteric Fractures: Report of a Randomized Controlled Trial

BACKGROUND

Pelvic fracture is one of the most common fractures in the elderly, especially in the intertrochanteric region. Therefore, in the present study, an external fixator was designed specifically for intertrochanteric fractures. The present study aimed to compare the operating time, amount of bleeding, and mortality rate between the patients who received either dynamic hip external fixators (DHEF) or dynamic hip screw (DHS).

METHODS

In 2018, 46 patients with intertrochanteric fracture due to trauma and high anesthesia risk were included in the study and randomly assigned to two groups of control (n=24, patients treated with DHS) and intervention group (n=22, patients treated with the DHEF). Treatment was carried out using the DHEF which was newly designed and placed outside the patient's body under short and light anesthesia. After 3 and 12 months of follow-up, the two groups were compared for some variables, including mortality rate, pain intensity, Harris hip score (HHS), cut-off rate of the device, femoral neck angles before and after the operation, hemoglobin changes, hematocrit levels before and after the operation, the number of injected blood units, and the number of hospitalization days.

RESULTS

Mortality rate was higher in open surgery with DHS. The assessment of variables in both intervention and control groups demonstrated that duration of operation (P<0.001), hospitalization length, time to union (P=0.001), pain intensity five days after the operation, as well as changes in Hb and HCT, were significantly higher in the control group than the intervention group. The mean HHS scores of 83.5±14.3 and 78.2±11.5 were gained for the DHEF and DHS groups, respectively (P=0.22).

CONCLUSION

Considering the superior results of treatment with the external fixator in comparison with the DHS, such as lower mortality rate and fewer complications, a dynamic hip external fixator can be prescribed in patients with intertrochanteric fractures and high anesthesia risk.

Osteosynthesis of non-displaced femoral neck fractures in the elderly population using the femoral neck system (FNS): short-term clinical and radiological outcomes

Background

Femoral neck fractures (FNF) are frequent in the elderly population, and surgical management is indicated in the vast majority of cases. Osteosynthesis is an alternative to arthroplasty for non-displaced FNF. Triple screw construct (TS) and the dynamic hip screw system (DHS) are considered gold standards for osteosynthesis. The newly available femoral neck system (FNS) currently lacks evidence as to whether it is a valid alternative to TS and DHS. The purpose of this study was to evaluate the short-term clinical and radiological outcomes after non-displaced (Garden I and II) FNF osteosynthesis using TS, DHS, and FNS.

Methods

All the patients of the author’s institution aged ≥ 75 years with a non-displaced (Garden I and II) FNF eligible for osteosynthesis between November 2015 and December 2019 were included in this single-center retrospective non-randomized study. Patients were treated with either TS, DHS, or FNS depending on the surgeon’s preference. Clinical data (age, gender, ASA score, duration of surgery, need for blood transfusion and number of packed red blood cells transfused, surgical site complications, length of stay, discharge location, postoperative medical complications and readmission within 30 days, and mortality within 3 months) were extracted from the patients’ charts. The radiological analysis assessed the fracture classification, fracture impaction, and proximal femur shortening at 3 and 6 months using the institutional imaging software.

Results

Baseline characteristics in the TS (n = 32), DHS (n = 16), and FNS (n = 15) groups were similar with respect to age (mean 85 years), gender (female to male ratio 4:1), and ASA score. There were no significant differences across the groups for the need for blood transfusion, surgical site complications, length of stay, postoperative medical complications and readmission within 30 days, discharge location, and mortality within 3 months. The duration of surgery was significantly lower in the FNS group (43.3 vs 68.8 min; p < 0.001). The radiological assessment found similar impaction (5.2 mm ± 4.8) and shortening (8.6 mm ± 8.2) in all groups that did not seem to progress after 3 months.

Conclusion

The FNS appears to be a valid alternative implant for FNF osteosynthesis and is associated with a shorter operative time than TS and DHS. Short-term clinical and radiological outcomes of FNS are similar to TS and DHS implants. Further long-term multicenter randomized studies are however necessary to confirm these first results.

Profunda femoris pseudoaneurysm rupture post dynamic hip screw fixation after physiotherapy

This case discusses an elderly female who presented acutely with compromised profunda femoris pseudoaneurysm and massive haematoma five weeks after dynamic hip screw insertion for a left neck of femur fracture. The only precipitating factor leading to this presentation was ongoing physiotherapy. She was referred from a rehabilitation hospital to the nearest vascular surgical unit for acute and definitive surgical intervention. Post-operatively, she fared incredibly well, regaining her baseline level of functioning. History taking is complex in a patient with dementia. Clinical examination should follow with a focused approach to the site of recent operation and also where complications are likely to manifest when an alteration from baseline cognitive function is noted. This is of course in addition to the complete work up required from a holistic perspective with any acute deterioration. Imaging should be arranged and prompt referral made if a treatable acute cause is identified. It is imperative to involve family and/or next of kin if possible, but this should not impede prompt decision-making in the patient's best interests by the clinical team if delays are likely to occur.

Further understanding on osteopetrotic femoral fractures: a case report and literature review

BACKGROUND

Osteopetrosis is a genetic disease characterized by defects in osteoclast formation and function. There were a few cases of subtrochanteric femur fractures treated with dynamic hip screw (DHS) in patients with osteopetrosis, but unfortunately the healing outcome was rather poor.

CASE PRESENTATION

We present our experience for treating a patient with intermediate autosomal recessive osteopetrosis (IRO) suffering from subtrochanteric femur fracture. In this case, we successfully used dynamic hip screw (DHS) internal fixation through meticulous preoperative planning and postoperative care, as well as application of surgical techniques. The patient displayed stable internal fixation with no limitation of activities during follow-up for 15 months. In addition to this case, a review of previous case reports showed an increasing number of case reports demonstrating that surgical treatment-related complications could be avoided preoperatively, intraoperatively, and postoperatively.

CONCLUSION

DHS for this patient, who suffered from subtrochanteric fractures with osteopetrosis, was successfully implemented. In the light of a comprehensive literature review, preoperative planning, surgical techniques, and postoperative rehabilitation care can significantly reduce the complications.

Cephalo-medullary nailing versus dynamic hip screw with trochanteric stabilisation plate for the treatment of unstable per-trochanteric hip fractures: a meta-analysis

Background

The use of cephalo-medullary nails (CMN) is a widely accepted management option for the treatment of unstable per-trochanteric hip fractures. A growing body of literature has reported good functional and radiological outcomes in patients managed with a dynamic hip screw supplemented with a trochanteric stabilisation plate (DHS w/ TSP). However, a robust meta-analysis does not exist in the current literature comparing the two fixation methods.

Purposes

Management of these kinds of injuries is very challenging in orthopaedic practice, yet no strong evidence is in place to delineate which implant gives the best results. This meta-analysis is the first to determine the efficacy of CMN versus DHS w/ TSP.

Methods

An up-to-date literature search was performed using a predetermined search strategy and eligibility criteria. All suitable literature was appraised for methodological quality using the Cochrane’s collaboration tool. Hospital stay, operative time, intra-operative complication rate, mechanical failure rate, infection rates, revision rates and functional outcomes were all considered.

Results

A total of five studies were included in the meta-analysis. The results of this analysis suggest that CMN is only associated with lower revision rates when compared to DHS w/ TSP; however, no significant difference was found in terms of hospital stay, operative time, blood transfusion, complications rate and functional outcome.

Conclusion

Both CMN and DHS w/TSP proved to be reliable in the management of unstable per-trochanteric fractures; however, more extensive datasets are required to draw robust conclusions.

Comparison of the clinical effect of DHS and PFNA on senile osteoporotic fracture and their significance of changes in BALP expression level

OBJECTIVE

To investigate the clinical effects of dynamic hip screw (DHS) and proximal femoral nail anti-rotation (PFNA) on senile osteoporosis patients and their effects on the expression level of bone-specific alkaline phosphatase (BALP).

METHODS

116 elderly patients with osteoporotic fracture were divided into DHS group (n=67) and PFNA group (n=49). BALP values were measured by ELISA before operation and 30 days after operation.

RESULTS

The operation time, the bleeding volume, and the weight-bearing time of PFNA group was shorter than DHS group (p<0.05); the dominant blood loss and occult blood loss in PFNA group were less than those in DHS group (p<0.05); the healing time and detumescence time, the complications of PFNA group was fewer than the DHS group (p<0.05). The ten-meter walking speed and the five sitting tests in PFNA group were shorter than that in DHS group (p<0.05); the excellent and good rate and Harris score in PFNA group were higher than those in DHS group (p<0.05). The expression of BALP in PFNA group was lower than that in DHS group (p<0.05).

CONCLUSION

PFNA surgery has less trauma, fewer complications, more optimistic postoperative healing and recovery degree, and is more conducive to the reduction of BALP expression level.

Lag screw with DHS (LSD) for vertical angle femoral neck fractures in young adults

Vertical Pauwels Type III fractures of the neck of femur in young patients are difficult fractures to treat. These are usually as a result of high energy trauma which are associated with a significant degree of fracture comminution in the neck of femur. This makes the fracture reduction and fixation difficult. Many fixation methods and implants have been described for use in these fractures but are not without reported complications such as non-union and varus collapse. In this article, we highlight the incidence of fracture comminution in both the anterior and posterior cortices of the femoral neck, better visualised with axial computed tomography scanning and describe a simple technique utilizing lag screws and a DHS implant to adequately address these fractures.

Dynamic hip screws versus cannulated screws for femoral neck fractures: a systematic review and meta-analysis

OBJECTIVE

Dynamic hip screw (DHS) and cannulated screws (CS) are widely used for femoral neck fractures. However, there is no definite result as to which surgical method bring less complications. We performed this study to compare the complication (mortality, non-union, avascular necrosis (AVN), and revision) of DHS and CS for the treatment of femoral neck fractures patients.

METHODS

We searched Pubmed, Ovid, Cochrane Central Register of Controlled Trials, and other relevant studies related the comparison of DHS versus CS for femoral neck fractures from inception to Jan 7, 2020. The quality of the included randomized controlled trials (RCTs) and retrospective studies were assessed using the Cochrane Collaboration tool and Newcastle-Ottawa (NOS), respectively. The meta-analysis was performed by the RevMan 5.2 software.

RESULTS

Nine RCTs and seven retrospective cohort studies were included for meta-analysis. CS was found to be superior to DHS with respect to AVN rate (OR 1.47; 95% CI 1.08-1.99; p = 0.01, I² = 0%). There were no significant between-group differences with respect to mortality, non-union, and revision (p > 0.05).

CONCLUSION

DHS and CS have similar complication including mortality, revision rate, and non-union, but CS has superior to DHS on ANV. However, further studies are required to provide more robust evidence owing to some limitations.

Study protocol for the DEFENDD trial: an RCT on the Dynamic Locking Blade Plate (DLBP) versus the Dynamic Hip Screw (DHS) for displaced femoral neck fractures in patients 65 years and younger

Background

The Dynamic Locking Blade Plate (DLBP) was recently introduced for fixation of displaced femoral neck fractures (FNF) and has been well received. Although the results of this implant in young patients are promising, the DLBP has not yet been compared to a standard device such as the Dynamic Hip Screw (DHS). The aim of this study is to compare the clinical outcome and costs of displaced FNF treated with internal fixation by means of either the DLBP or the DHS in patients up to 65 years of age. We hypothesize that the DLBP is superior compared to the DHS in terms of revision surgery rate, union rate, incidence of avascular necrosis and implant related failure.

Methods

The DEFENDD (DisplacEd Femoral Neck fractures Dlbp versus Dhs) trial is a multicentre randomized controlled trial that will include 266 patients of 18–65 years with a displaced FNF. Patients will be randomized to receive either a DLBP or a DHS with a 1:1 allocation using a random block size, stratified for centre. Clinical follow up will last 1 year and questionnaires will be obtained up to 2 years. The main outcome parameter is the incidence of revision surgery within 1 year, due to either non-union, avascular necrosis (AVN) or cut out of the implant. Secondary study parameters are the incidence of avascular necrosis, non-union, (implant related) complications, functional outcome, elective removal of the implant and health-related quality of life and costs.

Discussion

The outcome of the DEFENDD trial will provide high-level evidence of which implant is favourable for the treatment of femoral neck fractures in young patients (≤65 years).

Trial registration

Netherlands Trial Register, NL7300 Registration date 25-09-2018.

Traditional and bionic dynamic hip screw fixation for the treatment of intertrochanteric fracture: a finite element analysis

PURPOSE

The dynamic hip screw (DHS) is widely used for fixing intertrochanteric femur fractures. A porous bionic DHS was developed recently to avoid the stress concentration and risk of post-operative complications associated with titanium alloy DHSs. The purpose of this study was to compare the effects of traditional titanium alloy, bionic titanium alloy, and bionic magnesium alloy DHS fixation for treatment of intertrochanteric fractures using finite element analysis.

METHODS

A three-dimensional model of the proximal femur was established by human computed tomography images. An intertrochanteric fracture was created on the model, which was fixed using traditional and porous bionic DHS, respectively. The von Mises stress, maximum principal stress, and minimum principal stress were calculated to evaluate the effect of bone ingrowth on stress distribution of the proximal femur after fixation.

RESULTS

Stress concentration of the bionic DHS model was lower compared with traditional DHS fixation models. The von Mises stress, maximum principal stress, and minimum principal stress distributions of bionic magnesium alloy DHS models improved, along with simulation of the bone healing process and magnesium alloy degeneration, assumed to biodegrade completely 12 months post-operatively. The distribution of maximum principal stress in the secondary tension zone of the bionic DHS model was close to the intact bone. In the minimum principal stress, the region of minimum stress value less than - 10 MPa was significantly improved compared with traditional DHS models.

CONCLUSION

The bionic magnesium alloy DHS implant can improve the stress distribution of fractured bone close to that of intact bone while reducing the risk of post-operative complications associated with traditional internal fixations.

Two-hole versus four-hole plate dynamic hip screw: a systematic review of current evidence

BACKGROUND

The dynamic hip screw (DHS) is a common device used in the fixation of hip fractures. Traditionally, this involves the use of a four-hole side plate. Reducing the length of the side plate would theoretically reduce the amount of surgical exposure required, decrease surgery duration, and decrease perioperative morbidity and mortality. Our study aims to review the current evidence regarding the use of two-hole side plates, their use and potential complications.

METHODS

Using PRISMA guidelines, two independent reviewers performed a search to collate the available literature from medical databases PubMed, EMBASE, Web of Science, and the Cochrane library. Only clinical and biochemical studies were included. The reference lists of articles included for full text review were searched for any additional primary or review publications.

RESULTS

Four online libraries were searched, with a combined total of 5344 titles reviewed. Following title, abstract, and full text review, 8 articles were considered suitable for inclusion in qualitative analysis. There was a trend towards equal efficiency between two- and four-hole plates when used in stable fractures in terms of blood loss, failure/revision rates, operative and hospital stay durations, collapse loading testing, maximum stress, and fragment migration.

CONCLUSION

The results of this study show that DHS constructs with two- or four-hole side plates have comparable outcomes when used in patients with stable fracture patterns. However, the majority of the clinical data regarding the use of two-hole DHS plates come from retrospective case series; further prospective, randomised control trials would be of significant benefit.

LEVEL OF EVIDENCE

Level II; systematic review of all levels of evidence.

The early failure of the gamma nail and the dynamic hip screw in femurs with a wide medullary canal. A biomechanical study of intertrochanteric fractures

BACKGROUND

Intertrochanteric fractures may occur in a bone with a wide medullary canal that may lead to significant mobility of a intramedullary nail, contrary to an extramedullary device. This study evaluates the Dynamic Hip Screw and the gamma nail in AO 31.A2.1 fractures in these circumstances.

METHODS

Synthetic femora with canals drilled to 18 mm were used. Five fixation types were examined: a 2 - hole and a 4 - hole Dynamic Hip Screw with a 2 - hole plate, a standard gamma nail with dynamic and static distal locking and a long gamma nail. The specimens were tested with cyclic axial loading, from 500 N increasing of 50 N increments in each cycle. Force at failure, overall stiffness, stiffness at the fracture site, location and mode of failure were recorded.

FINDINGS

The short gamma nails dislocated into varus under preload because the nail migrated laterally. The Dynamic Hip Screw was initially stable, but some specimens rotated around the lag screw. The gamma nail was rotationally stable. Both implants failed through femur fracture. The long gamma nailed failed by screw cut - out at forces lower than the ultimate force of the short gamma nail.

INTERPRETATION

This study shows that the gamma nail is unstable in a large medullary canal but offers better rotational stability of the proximal fragment. A modification of the nail design or the operative technique may be considered.

Bisphosphonate associated femoral stress fracture distal to an orthopaedic implant: They are predictable!

Stress fractures are uncommon and often occur in young athletes with high intensity physical activity. These stress fractures occur in weight bearing long bones. Recent literature suggests association of thigh pain, tension side cortical thickening of femoral shaft or a femoral subtrochanteric atypical stress fractures in patients on long term bisphosphonate therapy. The reports of peri-implant bisphosphonate associated atypical stress fractures are very rare. We describe a series of three cases of femoral shaft stress phenomenon around orthopaedic implants who presented with similar prodromal thigh pain and tension side cortical thickening. Two patients sustained fractures as the condition was not recognised despite presenting with prodromal symptoms and one patient with a stress riser who was treated prophylactically. Thus this series aims to highlight the importance of identifying the stress phenomenon around orthopaedic implants, be it intra or extra-medullary implants. The location of these fractures is just distal to the implants and are classically transverse fractures. The treatment of peri-implant stress fractures needs a personalised approach in every case with appropriate choice of implants.

Biomechanical investigation of dynamic hip screw and wire fixation on an unstable intertrochanteric fracture

Background

Although use of a dynamic hip screw (DHS) for stable intertrochanteric hip fracture fixation has been successfully applied in fracture healing for more than 20 years, DHS fixation on unstable intertrochanteric fractures still has a high failure rate, especially in patients with osteoporosis. Although the wire fixation is usually incorporated with orthopedic device to treat fracture, the wiring techniques are developed through experiences. Thus, this study is objective to investigate the biomechanical property of different wire fixation methods incorporated with DHS system to provide the lesser trochanter fragment stable fixation on osteoporotic TypeA2.1 fracture for enhancing stability after bone reduction.

Results

Sawbone testing results demonstrated higher maximum load, stiffness, and energy in a DHS with wire fixation compared with DHS fixation only. In static biomechanical testing of a cadaver femur, we compared the stiffness of five fixation models and then tested a fatigue failure model in cycle loading with DHS fixation only. Wiring fixation can enhance stability and the cut-out failure model in the fatigue test was identical to the clinical failure model.

Conclusions

Lesser trochanteric fragment fixation is a crucial concern in the stability of an A2.1 unstable fracture, and the combination of a wiring technique with a DHS seems beneficial for achieving better stability. The addition of an antirotational greater trochanter is likely to enhance stability through wiring of the greater trochanter.

Clinical outcomes of dynamic hip screw fixation of intertrochanteric fractures: comparison with additional anti-rotation screw use

BACKGROUND

Hip screw cutout is among the most common causes of intertrochanteric fracture fixation failure using dynamic hip screws (DHS). This study aimed to evaluate the effect of using an additional anti-rotation screw on hip screw migration or cutout in intertrochanteric fracture fixation.

MATERIALS AND METHODS

We screened 488 patients with unilateral fragile intertrochanteric fractures treated with DHS between January 2001 and March 2016. The inclusion criteria were as follows: (1) age ≥ 50 years; (2) low-energy injury; (3) follow-up of at least 6 months; and (4) short barrel plate used in the operation. The exclusion criteria were as follows: (1) combination with other fracture; or (2) pathological fracture. Subsequently, 166 patients were enrolled; of them, 128 underwent surgery using DHS with an additional screw (Group 1) and 38 patients underwent surgery without an additional screw (Group 2). We compared the postoperative results and clinical outcomes while focusing on screw migration and cutout. Furthermore, we investigated the risk factors for lag screw migration.

RESULTS

Bone union was achieved in 160 patients (96.4%) without secondary intervention. Two patients (1.6%) in Group 1 and 1 (2.6%) in Group 2 developed screw cutout, while 18 (14.1%) in Group 1 and 12 (31.6%) in Group 2 developed screw migration. Thus, Group 2 demonstrated a higher screw migration rate. Multiple logistic regression analysis revealed that the additional anti-rotation screw was the most important factor in preventing screw migration (P = 0.019).

CONCLUSION

The additional anti-rotation screw reduced the lag screw migration rate following DHS surgery for intertrochanteric fractures.

LEVEL OF EVIDENCE

Level IV, retrospective series.

Risk of extrapelvine vascular injuries in osteosynthesis with gliding hip screws

BACKGROUND

Dynamic hip screw (DHS) osteosynthesis represents one of the most frequently performed fixation methods in orthopedic practice. The purpose of this study was to determine the potential risk of vascular damage by DHS side-plate screws (PS) and plunging instruments for individual femoral vessels and screw positions.

METHODS

In ten hemipelvic/leg specimens mounted with a large femur distractor, a DHS system with a four-hole side-plate was inserted. PS were inserted in 3 consecutive courses with different inclinations in the frontal plane of 0° (group 1), - 30° posterior (group 2) and + 30° anterior (group 3) in relation to the side-plate's surface, resulting in 120 PS positions. After screw tightening, the soft tissues on the medial side of the femur were dissected and investigated for vascular compromise; in each course, the effect of overshot instruments within a range of 50 mm beyond the side-plate's surface was also tested.

RESULTS

Totally, 37/120 screw positions (31%) revealed potential vascular compromise which comprised of 15/120 (13%) direct hits by screw tips and 22/120 (18%) potential impacts by plunging instruments. The deep femoral artery system (DFA) was significantly (p = 0.007) most often affected but no significant differences for individual vascular structures were seen. Direct vascular impacts occurred significantly more often (p = 0.0047) in screws with 0° inclination compared to + 30° inclination (p = 0.017). Significant differences among individual screw positions were only found in group - 30° with direct vessel contacts (p = 0.038).

CONCLUSIONS

The DFA system is significantly more at risk while significant preference of a certain vessel is missing. Our data indicate that more than 30% of 120 screw positions in DHS osteosynthesis revealed a potential danger of vascular compromise, when surgical principles are denied in hip fracture fixation.

CLINICAL RELEVANCE

Though vascular complications are infrequently encountered in DHS osteosynthesis they have to be considered as a potential complication when surgical principles are not followed in this anatomic area.

Comparison of Intra- and Extramedullary Implants in Treatment of Unstable Intertrochanteric Fractures

INTRODUCTION

Comparison was made of the clinical and radiological results of the surgical treatments of proximal femoral nail (PFN), dynamic hip screw (DHS) or proximal femoral locking compression plate (PF-LCP) in patients with AO 31A2.2/2.3 unstable intertrochanteric femoral fracture(ITF).

METHODS

Evaluation was made of a total of 91 patients in respect of age, gender, time from fracture to surgery, operating time, amount of blood replacement, total hospitalisation, follow-up period, time to full weight-bearing, time to union, complications and Harris hip scores(HHS).

RESULTS

A statistically significant difference was determined between the groups in respect of perioperative operating time, blood replacement and hospitalisation period with the values of the PFN group seen to be superior to those of the other two groups (p < 0.001). No significant difference was determined beween the DHS and PFN groups in respect of time to union and in the long-term HHS, both groups were seen to be superior to the PF-LCP group (p < 0.001). Full weight-bearing was statistically significantly earlier in the PFN group (p < 0.001). The numbers of implant failures was statistically significantly higher in the PF-LCP group (p < 0.001).

CONCLUSION

The new generation intra-medullar nails are easy to apply and have more successful clinical results compared to extra-medullar implants in the treatment of A2 unstable ITF. Due to the high rates of implant failure, PF-LCP should not be preferred in these fractures.

[Comparative study of proximal femoral nail anti-rotation and dynamic hip screw in the unstable intertrochanteric fractures in the elderly]

Objective: To compare the effect of proximal femoral nail anti-rotation and dynamic hip screw in treating the femoral intertrochanteric fractures in elderly patients. Methods: From June 2011 to June 2014, totally 158 elderly patients of femoral intertrochanteric fracture were treated by surgery, among whom 68 cases were treated with dynamic hip screws (DHS), and 90 patients were treated with proximal femoral nail anti-rotation (PFNA). The operative time, hospitalization time, weight-bearing time, fracture-healing time, blood loss and the hip function score after the operation were compared between the two groups by using the t test; and the incidence of the postoperative complication was compared between the two groups by using the Chi square test. Results: All the patients were followed-up for 6 to 18 months (12. 6 months on average). There was no statistic differences in the gender, age, the surgical time after injury and the fracture type between the two groups (χ(2)=0.025, t=1.461, 1.329, χ(2)=2.070, all P>0.05). While, the operative time, blood loss, hospitalization time and the weight-bearing time in the PFNA group were all significantly lower than those in the DHS group[(47±14) vs (114±20) min, (121±26) vs (281±44) ml, (10.2±3.3) vs (13.5±2.8) d, (29±8) vs (53±10) d, t=8.376, 6.669, 2.176, 2.664, all P<0.05]; and the Harris hip score of 6 months post operation in PFNA group was significantly higher than that in the DHS group (90±17 vs 87±15, t=2.337, P<0.05). However, no significant difference in fracture healing time was found between the two groups[(11.8±2.3) vs (12.2±2.7) weeks, t=1.114, P>0.05]. Moreover, the incidence of complications in the DHS group was 16.2% while it was 7.8% in the PFNA group, the latter was obviously lower (χ(2)=4.801, P<0.05). Conclusions: DHS is suitable for the patients with good physical condition or for the patients with stable fracture types. While, PFNA has the advantages of firmly fixation, less tissue damage, lower complications and wide indications. So, it is superior in the femoral intertrochanteric fractures.

Biomechanical comparison between standard and inclined screw orientation in dynamic hip screw side-plate fixation: The lift-off phenomenon

Background

Common failure modes of dynamic hip screw are cut-out and lift-off. To minimize the latter, distal screws can be inserted in different orientations. However, the effectiveness remains controversial. The aim of this study was to biomechanically investigate the influence of distal screw orientation on construct stability.

Methods

Thirty artificial generic long bones were assigned to three groups (n = 10) and fixed with two-hole dynamic hip screw–plates, inserting distal cortical screws with neutral parallel screw orientation (A), divergent screw orientation (B) or convergent screw orientation (C). Starting at 60 N, cyclic loading was applied to the implant tip perpendicular to the lag screw axis with progressive peak load increase at a rate of 0.002 N/cycle until failure. Parameters of interest were construct stiffness and machine actuator displacement after 250, 1000 and 5000 cycles, as well as cycles to failure.

Results

Displacement after 250, 1000 and 5000 cycles was significantly higher in Group C than in Groups A and B, p < 0.01, whereas no significant differences were observed between Groups A and B, p = 0.20. Specimens in Group C failed after 11,584 [standard deviation (SD), 5924] cycles, significantly earlier than those in Groups A and B [A: 27,351 (SD, 12,509); B: 28,793 (SD, 14,764)], p ≤ 0.02. Cycles to failure were not significantly different between Groups A and B, p > 0.99.

The translational potential of this article

Parallel or divergent distal screw insertion provides similar construct stability in terms of resistance to plate lift-off. In contrast, converging screw insertion leads to inferior stability and is not advisable from a biomechanical point of view.

Conjoint Removal of Hip Screw-Femur Head during Hip Replacement after Previous Dynamic Hip Screw Fixation

The purpose of this study was to demonstrate the reduced chances of iatrogenic femoral neck fracture while removing the Richard's screw using the dynamic hip screw-femur head conjoint removal technique. This retrospective cohort study analyzed 16 hips operated on with total hip arthroplasty from March 2010 to February 2015. All cases were previously treated with dynamic hip screws (DHS) for proximal femur fractures. The age of the patients ranged from 20 to 75 years. We used uncemented sockets in 15 patients and cemented sockets in 1 patient. We used conical fluted straight stems in 9 cases, ML (Mediolateral) tapered stems in 5 patients and CLS (Cementless Spotorno) stems in 2 patients. The head of the femur was removed together with the attached Richard's screw after taking a neck cut during hip replacement after previous dynamic hip screw fixation. At 2-year follow-up, there was a statistically significant improvement in the Harris hip score: from a mean preoperative score of 35 ± 7.975 to a mean postoperative score of 89.38 ± 4.870 (P < 0.001). Stem sinking and Type A_L (Vancouver classification for periprosthetic fracture) periprosthetic fracture in 1 patient with a tapered stem was noted. Good acetabular inclination was achieved in all cases. At 2-year follow-up, all patients were able to carry out their daily activities. This is a novel technique with the advantage of avoiding iatrogenic femoral neck fracture in an osteoporotic bone.

The Effect of Positive Medial Cortical Support in Reduction of Pertrochanteric Fractures with Posteromedial Wall Defect Using a Dynamic Hip Screw

Background

We evaluated the radiological and clinical results of reduction using a dynamic hip screw according to the grade of medial cortical support in patients with AO Foundation and Orthopaedic Trauma Association (AO/OTA) classification type 31-A2 pertrochanteric fractures.

Methods

We enrolled 100 patients with AO/OTA type 31-A2 fractures with displaced lesser trochanter fragments (length of the cortical area longer than 20 mm on the pelvis anteroposterior view). Patients with positive medial cortical support were assigned to group 1 (n = 28); neutral medial cortical support, group 2 (n = 42); and negative medial cortical support, group 3 (n = 30). Radiological evaluation was done by measuring the change in the femoral neck-shaft angle and sliding distance of the lag screw. Clinical outcomes of each group were compared by means of the walking ability score proposed by Ceder.

Results

Group 1 showed significantly less changes in the femoral neck-shaft angle and shorter sliding distance than groups 2 and 3. Group 2 showed significantly less changes in the femoral neck-shaft angle and shorter sliding distance than group 3. Group 1 showed significantly higher walking ability scores than group 3 (p = 0.00). The use of trochanter stabilizing plates or fixation using wires for posteromedial wall defect resulted in no significant changes in terms of the femoral neck-shaft angle or sliding distance.

Conclusions

In the treatment of pertrochanteric fractures accompanied by posteromedial wall defect using a dynamic hip screw, reduction with negative cortical support should be avoided.

A case series of patients change in mobility following a hip fracture

INTRODUCTION

Hip fractures are common in the elderly population. It is currently believed that patients can expect to lose a level of mobility following a hip fracture. The aim of this study was to compare the pre- and post-treatment mobility of patients treated in our institution who had suffered a fracture neck of femur and identify the factors that could predict pre-operatively those patients who would suffer a deterioration in mobility after treatment.

METHODS

Patients admitted to a large UK teaching hospital with a surgically treated neck of femur fracture were included between 2 April 2011 and 31 March 2014. Patient's mobility was assessed on admission and at 1 year following surgery.

RESULTS

There were a total of 615 patients alive at 1 year. There were 142 males and 473 females with a mean age of 82.1 (range 47-100). On admission, 338 (55.0%) mobilised independently 52.2% had no change in their pre-fracture mobility at 1 year following their treatment. Age, a lower AMTS, a higher ASA and living in residential care were significant risk factors for not regaining their pre-fracture mobility. Sex and type of fracture were not associated with change in mobility.

CONCLUSION

It is commonly stated that patients lose one level of mobility following a hip fracture. This case series demonstrates that over 50% of patients can expect to have the same level of mobility at 1 year post-surgery as they did previously.

Incredible position of broken sliding dynamic hip screw implant in the medial of thigh

We report a case with implant failure after nailing of an unstable pertrochanteric fracture with dynamic hip screw. The patient presented with a medial sided thigh pain at 5 years after the surgery. Plain radiographs showed nonunion of the fracture with distant migration of assembled hip screw and side plate to the subcutaneous area of the inner thigh.

Intraoperative lateral wall fractures during Dynamic Hip Screw fixation for intertrochanteric fractures-Incidence, causative factors and clinical outcome

INTRODUCTION

The intact lateral wall plays a key role in stabilization of trochanteric fracture. Hence extreme precaution should be taken to prevent lateral wall damage during DHS fixation. Present study is aimed at evaluating the determinants of lateral wall fracture and its effect on outcome in intertrochanteric fracture femur treated with DHS.

MATERIAL AND METHODS

This is a prospective study involving intertrochanteric fractures treated with DHS fixation from July 2013 to June 2014. Out of 135 patients 49(36.3%) had stable fractures and 86(63.7%) unstable fractures. Cortical thickness index (CTI) was measured to evaluate osteoporosis. Lateral wall thickness in anteroposterior radiograph was also measured.All patients underwent 135° DHS fixation.Postoperative x-rays are assessed for implant position, intactness of the lateral wall, tip apex distance (TAD) and medialization. Functional outcome was measured at the end of fracture union by modified Harris hip score and Parkers mobility score. Clinical information including age, gender, fracture classification, TAD, lateral wall thickness and functional outcome of the patients were subjected to statistical analysis.

RESULTS

34 (19.5%) patients had lateral wall fractures. Medialization was found in 22 out of these 34 (64.7%) patients. The mean preoperative lateral wall thickness of these patients is 19.2mm, compared with 26.8mm in patients with intact lateral wall (p<0.001). The mean values of CTI and TAD are comparable in both the groups. In patients with intact lateral wall, mean Harris hip score is 73.1 compared to 65.5 in lateral wall fracture group (p<0.001). Preinjury mobility status was achieved in 70.2% of intact lateral wall patients, whereas only 32.3% (11) achieved that in lateral wall fracture group. Threshold for lateral wall thickness that could predict lateral wall fracture was found to be 21mm with 95% sensitivity and 88.2% specificity.

CONCLUSION

Lateral wall fractures during DHS fixation are not uncommon and osteoporosis has no bearing on its occurrence. It alone can lead to poor radiological and functional outcome independent of TAD. Lateral wall thickness is a reliable predictor of intra operative lateral wall fracture during DHS fixation and nailing is a good option especially when lateral wall thickness is <21mm.

Tips and Tricks in Extracapsular Hip Fracture Fixation

Aside from the decision-making in how to fix an extracapsular hip fracture, surgeons must be conversant with systems, implants and how to maximize their potential in the shortest operative time. We present a series of steps used in our unit when performing both DHS and intramedullary nail surgery to avoid the commonest problems and maximize our patients' recovery potential.

Decision Making in the Management of Extracapsular Fractures of the Proximal Femur - is the Dynamic Hip Screw the Prevailing Gold Standard?

Currently, approximately half of all hip fractures are extracapsular, with an incidence as high as 50 in 100,000 in some countries. The common classification systems fail to explain the logistics of fracture classification and whether they all behave in the same manner. The Muller AO classification system is a useful platform to delineate stable and unstable fractures. The Dynamic hip screw (DHS) however, has remained the 'gold standard' implant of choice for application in all extracapsular fractures. The DHS relies on the integrity and strength of the lateral femoral wall as well as the postero-medial fragment. An analysis of several studies indicates significant improvements in design and techniques to ensure a better outcome with intramedullary nails. This article reviews the historical trends that helped to evolve the DHS implant as well as discussing if the surgeon should remain content with this implant. We suggest that the gold standard surgical management of extracapsular fractures can, and should, evolve.

Blood loss in trochanteric fractures: multivariate analysis comparing dynamic hip screw and Gamma nail

INTRODUCTION

Anaemia in patients with trochanteric fracture is associated with increased morbidity and mortality and it is an independent risk factor for functional mobility of patients. Several authors have reported the blood loss following operative treatment comparing different fixation systems but few authors have evaluated many associated variables that could influence the perioperative blood loss.

PURPOSE

To evaluate the blood loss in patients that had their trochanteric fracture stabilized with dynamic hip screw (DHS) or Gamma nail. Multivariate analysis of different variables that can influence blood loss was carried out (type of fracture, antiaggregant or anticoagulant therapy, time to surgery). The hypothesis was that there is no difference in terms of blood loss in patients with trochanteric fracture treated with DHS or Gamma nail considering all these variables.

MATERIALS & METHODS

Perioperative blood loss was evaluated in 417 consecutive patients treated for trochanteric fracture with DHS or Gamma nail between January 2010 and March 2013. The perioperative blood loss was calculated using the Lisander formula modified by Foss-Kehlet based on pre- and post-operative haemoglobin values and transfusion rates. Univariate and multivariate analysis were performed integrating the following variables: type of fracture (A1 vs A2), antiaggregant/anticoagulant therapy vs no therapy, time to surgery (<24 vs >24 hours from trauma), type of implant (DHS vs Gamma nail).

RESULTS

A significant blood loss (p <0.05) was observed between A1 and A2 fracture types (1247ml vs 1796.7ml), antiaggregant/anticoagulant therapy and no therapy (1592.7ml vs 1470.2ml), time-to-surgery <24 and >24 hours from trauma (1584.4ml vs 1323.9ml), DHS and Gamma nail (894.7ml vs 1720.6ml). At multivariate analysis, in the A1 fracture groups the DHS showed a significant lower blood loss compared to Gamma nail (p < 0.05).

CONCLUSIONS

According to the perioperative blood loss, DHS should be used in A1 fractures while Gamma nail can be taking in account for the unstable A2 fractures.

Comparison and analysis of reoperations in two different treatment protocols for trochanteric hip fractures - postoperative technical complications with dynamic hip screw, intramedullary nail and Medoff sliding plate

Background

In treatment of unstable trochanteric fractures dynamic hip screw and Medoff sliding plate devices are designed to allow secondary fracture impaction, whereas intramedullary nails aim to maintain fracture alignment. Different treatment protocols are used by two similar Swedish regional emergency care hospitals. Dynamic hip screw is used for fractures considered as stable within the respective treatment protocol, whereas one treatment protocol (Medoff sliding plate/dynamic hip screw) uses biaxial Medoff sliding plate for unstable pertrochanteric fractures and uniaxial Medoff sliding plate for subtrochanteric fractures, the second (intramedullary nail/dynamic hip screw) uses intramedullary nail for subtrochanteric fractures and for pertrochanteric fractures with intertrochanteric comminution or subtrochanteric extension. All orthopedic surgeries are registered in a regional database.

Methods

All consecutive trochanteric fracture operations during 2011–2012 (n = 856) and subsequent technical reoperations (n = 40) were derived from the database. Reoperations were analysed and classified into the categories adjustment (percutaneous removal of the locking screw of the Medoff sliding plate or the intramedullary nail, followed by fracture healing) or minor, intermediate (reosteosynthesis) or major (hip joint replacement, Girdlestone or persistent nonunion) technical complications.

Results

The relative risk of intermediate or major technical complications was 4.2 (1.2–14) times higher in unstable pertrochanteric fractures and 4.6 (1.1–19) times higher in subtrochanteric fractures with treatment protocol: intramedullary nail/dynamic hip screw, compared to treatment protocol: Medoff sliding plate/dynamic hip screw. Overall rates of intermediate and major technical complications in unstable pertrochanteric and subtrochanteric fractures were with biaxial Medoff sliding plate 0.68%, with uniaxial Medoff sliding plate 1.4%, with dynamic hip screw 3.4% and with intramedullary nail 7.2%.

Conclusions

The treatment protocol based on use of biaxial Medoff sliding plate for unstable pertrochanteric and uniaxial Medoff sliding plate for subtrochanteric fractures reduced the risk of severe technical complications compared to using the treatment protocol based on dynamic hip screw and intramedullary nail.

Outcomes of dynamic hip screw augmented with trochanteric wiring for treatment of unstable type A2 intertrochanteric femur fractures

BACKGROUND

Posteromedial and greater trochanteric fragments are a major cause of telescoping and medialization of the femoral shaft in an unstable intertrochanteric fracture. This leads to significant limb shortening, fracture collapse in varus position and implant failure, which can be prevented by trochanteric wiring in addition to dynamic hip screw (DHS) fixation. The purpose of our study is to assess the outcomes of DHS augmented with trochanteric wiring in unstable type A2 intertrochanteric fractures.

MATERIALS AND METHODS

One hundred and two retrospective cases of unstable intertrochanteric fractures treated with DHS between January 2010 and December 2015 with a minimum follow-up period of 12 months were reviewed. Out of 102 cases, 28 were treated with DHS and derotation screw alone (Group A), while in rest 74 cases trochanteric wiring was used as an augmentation to DHS and derotation screw (Group B). Patients were evaluated clinically for range of motion, Harris hip score and Oxford hip score. Radiologically, fracture reduction, change in neck shaft angle and neck length ratio in comparison to opposite hip and union status of greater trochanter were assessed.

RESULTS

The mean age of the patients at the time of surgery was 72 years (range 23-94 years) with 48 males and 54 females. The mean follow-up period was 20 months (range 12-48 months). The Harris hip score, Oxford hip score, shortening, attainment of weight bearing and change in neck shaft angle was not significantly different between the two groups (all p values >0.05). Incidence of greater trochanter nonunion was greater in group A (17.85%) as compared to group B (6.75%). We found significant association between occurrence of limp with varus change in neck shaft angle, decrease in neck length ratio and greater trochanteric non-union (all p values <0.05). We had 7 complications, one superficial infection, one deep vein thrombosis, 4 screw cut out and one deep infection treated with implant removal.

CONCLUSION

DHS augmented with trochanteric wiring in unstable intertrochanteric fractures gives similar result to group without no wiring, although greater trochanter non-union rate was more in the latter group. Limp can be prevented by anatomical or valgus fixation, augmentation of DHS to support posteromedial and greater trochanteric fragments and delayed weight bearing.

A sliding hip screw augmented with 2 screws is biomechanically similar to an inverted triad of cannulated screws in repair of a Pauwels type-III fracture

OBJECTIVE

Pauwels III femoral neck fractures are highly unstable. These fractures are commonly treated with three cannulated screws or sliding hip screw (SHS) implants, however high rates of non-union persist. A hybrid SHS construct has recently been proposed. The objective of the study was to compare this construct to the familiar inverted triad of cannulated screws and to a single SHS.

METHODS

Fourth generation biomechanical femur analogs were used to create a highly repeatable injury model. The hybrid SHS construct contained a SHS with two superior cannulated screws in an inverted triangle configuration. Eight samples for each construct were biomechanically evaluated and the results compared using ANOVA (p<0.05).

RESULTS

The cannulated triad and hybrid SHS provided similar stiffness and fracture gap motion. The single SHS exhibited significantly lower stiffness and larger fracture plane diastasis than either the inverted triangle of cannulated screws or hybrid SHS (p<0.05). None of the constructs exhibited catastrophic failure during cyclic loading nor under loading up to 2.5 times body weight.

CONCLUSIONS

The single SHS provided the least stable fracture fixation, while the inverted triad and hybrid SHS constructs were mechanically similar. The fracture repair simulated here illustrates how these repairs have the potential to return near pre-fracture strength in ideal conditions with young, healthy bone. However; in clinical situations where comminution impairs load transfer through the cortices the hybrid SHS may be the most favorable option.

Modified dynamic hip screw loaded with autologous bone graft for treating Pauwels type-3 vertical femoral neck fractures

INTRODUCTION

Management of Pauwels type-3 vertical femoral neck fractures has been a challenging clinical problem as they experience high shear forces and thus a greater risk of treatment failure. There is no apparent consensus on the optimal implant type for these injuries. We developed a modified dynamic hip screw (DHS), which was designed to a cage in the lag screw, loaded with autologous bone graft for the treatment of Pauwels type-3 vertical femoral neck fractures.

METHODS

Between February 2010 and January 2012, 17 consecutive patients with Pauwels type-3 vertical femoral neck fractures were treated with the modified DHS loaded with autologous bone graft. All patients were followed up for a minimum of 24 months (range, 24-36 months). Surgical details, operative and postoperative complications, the rates of nonunion and osteonecrosis and the Harris hip score were evaluated.

RESULTS

There were thirteen men and four women with a mean age of 37.2 years (range, 27-52 years). There were no intraoperative complications related to this technology. All fractures healed within 14.1 weeks (range, 12 to 20 weeks). One patient required total hip replacement because of avascular necrosis of the femoral head at 27 months after surgery. According to the Harris hip score, eleven patients (64.7%) had excellent results, four (23.5%) had good results, one (5.9%) had moderate and one (5.9%) had poor result.

CONCLUSIONS

The modified DHS loaded with autologous bone graft appears to be a reliable implant for the treatment of Pauwels type-3 vertical femoral neck fractures with fewer complications.

Factors influencing radiation exposure during internal fixation of hip fractures

The use of fluoroscopy is of great importance for operative fixation of fractures. Previous studies have shown an increased fluoroscopy time for intramedullary nails and with junior surgeons in comparison with more experienced surgeons. We examined the impact of operation length on fluoroscopy dose, cumulative fluoroscopy time between consultant and registrar surgeons and cumulative fluoroscopy time between dynamic hip screw and intramedullary nailing. We performed a retrospective cohort study of all patients admitted to our centre over the period of 1 year. Patients who underwent dynamic hip screw (DHS) or intramedullary (IM) nailing were identified from our in-hospital hip fracture database. Intraoperative fluoroscopy images were then accessed through our hospital's medical imaging software. A total of 137 patients were identified. Fluoroscopy reports were not available for 49 patients, resulting in a final total of 88 patients. Patients whose operation lasted longer than 1 h received a statistically significant higher dose of radiation (183.83 cGYM2 vs. 368.22 cGYM2; p value 0.0002). Operations performed by a consultant resulted in less cumulative fluoroscopy time in comparison with those performed by a registrar or specialist registrar although this was not statistically significant (00:00:53 vs. 00:00:45; p vaue 0.38). Cumulative fluoroscopy time was less in dynamic hip screw compared to long intramedullary nails (00:00:39 vs. 00:01:29; p value <0.001) and short intramedullary nails (00:00:39 vs. 00:01:52; p value 0.387). Studies, which had a cumulative fluoroscopy time exceeding 50 secs, delivered a higher radiation dose (434.34cGYM2 vs. 150.51cGYM2; p value <0.001). We concluded that there is no significant impact in cumulative fluoroscopy time in operations performed by either a registrar or consultant. Dynamic hip screws have a lower fluoroscopy time in comparison with long intramedullary nails.

Wing-augmentation reduces femoral head cutting out of dynamic hip screw

The dynamic hip screw (DHS) is commonly used in the treatment of femoral intertrochanteric fracture with high satisfactory results. However, post-operative failure does occur and result in poor prognosis. The most common failure is femoral head varus collapse, followed by lag screw cut-out through the femoral head. In this study, a novel-designed DHS with two supplemental horizontal blades was used to improve the fixation stability. In this study, nine convention DHS and 9 Orthopaedic Device Research Center (ODRC) DHSs were tested in this study. Each implant was fixed into cellular polyurethane rigid foam as a surrogate of osteoporotic femoral head. Under biaxial rocking motion, all constructs were loaded to failure point (12mm axial displacement) or up to 20,000 cycles of 1.45kN peak magnitude were achieved, whichever occurred first. The migration kinematics was continuously monitored and recorded. The final tip-to-apex distance, rotational angle and varus deformation were also recorded. The results showed that the ODRC DHS sustained significantly more loading cycles and exhibited less axial migration in comparison to the conventional DHS. The ODRC DHS showed a significantly smaller bending strain and larger torsional strain compared to the conventional DHS. The changes in tip-to-apex distance (TAD), post-study varus angle, post-study rotational angle of the ODRC DHS were all significantly less than that of the conventional DHS (p < 0.05). We concluded that the ODRC DHS augmented with two horizontal wings would increase the bone-implant interface contact surface, dissipate the load to the screw itself, which improves the migration resistance and increases the anti-rotational implant effect. In conclusion, the proposed ODRC DHS demonstrated significantly better migration resistance and anti-rotational effect in comparison to the conventional DHS construct.

Dynamic hip screw versus proximal femur locking compression plate in intertrochanteric femur fractures (AO 31A1 and 31A2): A prospective randomized study

INTRODUCTION

Intertrochanteric fractures are common in elderly population and pose a significant financial burden to the society. Anatomically contoured proximal femur locking compression plate (PFLCP) is the latest addition in the surgeons' armamentarium to deal with these fractures. It creates an angular stable construct, which will theoretically lessen the risk of failure by screw cut-out and varus collapse, the common mode of DHS failure. We compared DHS with PFLCP in AO type 31A1 and 31A2 intertrochanteric fractures.

MATERIALS AND METHODS

A randomized prospective study was carried out between June 2011 and June 2013. 26 cases each of DHS and PFLCP were included.

RESULTS

Functional and radiological outcome was similar in both groups.

CONCLUSION

Both DHS and PFLCP are good choices for stable intertrochanteric fractures, and both lead to excellent functional outcomes, but non-union might be more common with PFLCP.

The effect of surgical experience on the amount of radiation exposure from fluoroscopy during dynamic hip screw fixation

INTRODUCTION Dynamic hip screw (DHS) fixation for proximal femur fractures is one of the most common procedures in trauma that requires the use of fluoroscopy. Emphasis is often placed on producing the 'perfect picture', which may lead to excessive use of fluoroscopy, without added patient benefit. This study, the largest of its kind, aimed to determine the effect of surgical experience on the amount of radiation exposure from fluoroscopy during DHS fixation. METHODS All hospital admissions for extracapsular proximal femur fractures to our institution between 2007 and 2012 were analysed. Patient demographics, fracture configuration, grade of surgeon and the total radiation dose after fixation were recorded. Analysis of variance was performed to assess differences in radiation levels between different grades of surgeon. RESULTS A total of 1,203 patients with a mean age of 81.3 years (range: 21-105 years) were included in the study. The majority of the fractures were three-part (33.3%), followed by two-part (32.2%), four-part (25.7%) and basicervical (8.9%). Registrars (ST3-ST8) used a significantly higher radiation dose than consultants for all fracture types (p=0.009). When analysed separately by trainee group, the most junior registrars (ST3-ST4) and the most senior registrars (ST7-ST8) were found to use significantly higher radiation levels than consultants (p=0.037 and p<0.001 respectively). CONCLUSIONS The level of surgical experience does influence the amount of radiation exposure from fluoroscopy during DHS fixation. Surgical trainees should not ignore the potential harmful effects of radiation and should be equipped with the knowledge of how to keep the radiation exposure as low as possible.

Conversion to total hip arthroplasty after failed proximal femoral nail antirotations or dynamic hip screw fixations for stable intertrochanteric femur fractures: a retrospective study with a minimum follow-up of 3 years

Background

Conversion to total hip arthroplasty (CTHA) is a relatively common procedure after a failed dynamic hip screw (DHS) or proximal femoral nail anti-rotation (PFNA) fixation of intertrochanteric fractures, but there have been far fewer reports specifically describing the long-term results of CTHA after failed treatments of stable intertrochanteric fractures with DHS or PFNA. The aim of the present study was to compare the clinical and radiological outcomes of CTHA after failed PFNA or DHS fixations of stable intertrochanteric fractures after a minimum follow-up of 3 years.

Methods

Between January 2005 and April 2014, we retrospectively reviewed 142 active elderly patients treated at our institution (a single institution study). A total of 72 patients (72 hips; 41 women, 31 men; mean age 76.9 years old; range 60–92 years old) who underwent conversion of a failed PFNA to a THA were compared with 70 patients (70 hips; 36 women, 34 men; mean age 75.0 years old; range 60–90 years old) who underwent CTHA after a failed DHS fixation. The mean follow-up periods were 48 (range 43–52) and 48 (range 44–52) months for the DHS and PFNA groups, respectively. Clinical and radiologic evaluations were performed on all patients. The primary outcome was the Harris Hip Score (HHS). The secondary outcomes were the complication rates.

Results

The Harris Hip Score (HHS) improved from 50.61 ± 3.23 preoperatively to 85.28 ± 4.45 at the last follow-up in the PFNA group and from 51.46 ± 3.90 to 84.50 ± 4.34 in the DHS group, with no significant differences noted between the groups at each follow-up (P > 0.05). However, the complication rate in the converted DHS patients was significantly higher (42.9%) than that in the converted PFNA patients (20.8%; P = 0.003). Thirty-seven PFFs (2.4%) occurred during a mean follow-up of 44.4 months. The incidence of periprosthetic fractures was found to be significantly higher (P = 0.021) for the DHS group (15.7%) than for the PFNA group (4.2%).

Conclusions

CTHA after failed DHS fixations of stable intertrochanteric fractures might be associated with a significantly higher complication rate than CTHA after failed PFNA fixations. Therefore, PFNA patients with stable intertrochanteric fractures may be more suitable for CTHA.