Intramedullary femoral nailing through the trochanteric fossa versus greater trochanter tip: a randomized controlled study with in-depth functional outcome results

Nailing precision: a systematic review and meta-analysis of randomized controlled trials comparing piriformis and trochanteric entry points for femoral antegrade nailing

INTRODUCTION

Entry point selection, a crucial aspect of femoral antegrade nailing, can impact nail fit and consequently fracture reduction. In adults, the standard entry portals used are the piriformis fossa and the tip of the greater trochanter. Previous systematic reviews comparing the two techniques have not been limited to Randomized Controlled Trials (RCTs) and have not consistently included the same available RCTs.

MATERIALS AND METHODS

A systematic search of comparative studies regarding entry portal selection in femoral antegrade nailing was conducted on seven databases. Only Prospective RCTs comparing trochanteric and piriformis entry in the management of trochanteric or diaphyseal femur fractures were eligible for inclusion.

RESULTS

Ultimately, only 6 RCTs were found eligible for inclusion. Five of the six included studies reported on operative time. The resulting mean difference (MD) illustrated a significant decrease in operative time by approximately 21.26 min (95% CI  - 28.60 to  - 13.92, p < 0.001) using trochanteric entry. Fluoroscopy exposure was reported on by four studies, however, only two studies were included in the analysis due to different reporting methods. Trochanteric entry used significantly less fluoroscopy than piriformis entry (MD -50.33 s, 95% CI  - 84.441 to  - 16.22, p = 0. 004). No significant difference in malalignment rates, delayed union rates, nonunion rates, pain scores, or complication rates was found.

CONCLUSION

The significant differences found in operating time and fluoroscopy time align with those in other studies. While we were not able to pool the data on functional outcome scores, none of the included studies found a significant difference in scores by their last follow-up. Both approaches demonstrate comparable functional outcomes and safety profiles, indicating the choice of entry point should be at the discretion of the surgeon based on technique familiarity and fracture characteristics.

Comparison of Twin Screw Derotation Type Versus Single Helical Blade Type Cephalomedullary Nail in the Management of Unstable Intertrochanteric Fractures

BACKGROUND

The intertrochanteric fracture is a frequently occurring fracture, often attributed to osteoporosis in older populations. Recently, there has been a proposal to perform early surgical fixation on elderly patients to facilitate early rehabilitation. This approach has been shown to have a beneficial effect in lowering comorbidities. The study aims to compare the efficacy of the twin screw derotation type cephalomedullary nail with that of the single helical blade type cephalomedullary nail in the management of unstable intertrochanteric fractures.

METHODOLOGY

 The research sample included patients from the orthopedic outpatient and emergency departments of Adesh Medical College and Hospital, Ambala Cantt, India, who were scheduled for surgery for unstable intertrochanteric femur fractures. The patients were categorized into two groups according to the kind of implant they were given: either a twin screw derotation cephalomedullary nail or a single helical blade cephalomedullary nail. The functional result was evaluated by comparing the modified Harris hip score (HHS). Patients with unstable intertrochanteric fractures, including reverse oblique fractures and fractures with posteromedial comminution, as well as patients who provided consent, were included in this study.

RESULTS

 Thirteen individuals received treatment with proximal femoral nail antirotation (PFNA2), whereas 19 individuals received treatment with proximal femoral nail (PFN). The mean age in the PFNA2 group was 69.51, whereas the mean age in the PFN group was 70.804. There were three patients in the PFNA2 group and five patients in the PFN group who had a tip apex distance of more than 25 mm. According to the Cleveland index, nine patients in the PFNA2 group and eight patients in the PFN group had an implant location that was not optimum. Four patients in the PFNA2 group and seven patients in the PFN group had a neck shaft angle difference of more than 10° between their undamaged and operated sides. The mean HHS was 74.55 for the PFNA2 group and 69.88 for the PFN group. The PFNA2 group exhibited four problems, whereas the PFN group had five issues.

CONCLUSION

 The study found that both implants offer similar functional outcomes, with adherence to specific radiological parameters optimizing results. While both face similar challenges with osteoporosis, there was no notable distinction between them. Notably, the PFNA2 group showed superior outcomes in perioperative morbidity.

Unravelling variations: an examination of entry point selection in proximal femoral cephalomedullary nailing

BACKGROUND

The exact positioning of the cephalomedullary (CM) nail entry point for managing femoral fractures remains debatable, with significant implications for fracture reduction and postoperative complications. This study aimed to explore the variability in the selection of the entry point among trauma surgeons, hypothesizing potential differences and their association with surgeon experience.

METHODS

In this prospective multicenter study, 16 participants, ranging from residents to senior specialists, partook in a simulation wherein they determined the optimal entry point for the implantation of a proximal femoral nail antirotation (PFN-A; DePuy Synthes) in various femora. The inter- and intra-observer variability was calculated, along with comprehensive descriptive statistical analysis, to assess the variability in entry point selection and the impact of surgeon experience.

RESULTS

In this study, the mean distance from the selected entry points to the calculated mean entry point was 3.98 mm, with a smaller distance observed among surgeons with more than 500 implantations (ANOVA, p = 0.050). Intra-surgeon variability for identical femora averaged at 5.14 mm, showing no significant differences across various levels of surgical experience or training. Notably, 13.6% of selected entry points would not allow a proper intramedullary positioning of the implant, thereby rendering anatomical repositioning unfeasible. Among these impossible entry points, a significant skew towards anterior placement was observed (70.6% of the impossible entry points), with a smaller fraction being overly lateral (27.5%) or medial (13.7%). On a patient level, the impossibility rate varied widely from 0 to 35% among the different femora examined, with a significantly higher rate seen in younger patients (mean age 55.02 versus 60.32; t-test for independent samples, p = 0.04).

CONCLUSIONS

Significant variations exist in surgeons' selection of entry points for proximal femoral nailing, underscoring the task's complexity. Experience does not prevent the choice of unfeasible entry points, emphasizing the inadequacy of a universal approach and pointing towards the necessity for a patient-specific strategy for improved outcomes.

TRIAL REGISTRATION NUMBER

DRKS00032465.

Is gluteus medius injured in patients treated with a trochanter tip entry intramedullary nail? Clinical, electrophysiological and functional outcomes

Objectives

This study aims to assess the functional outcomes, static-dynamic postural stability of patients and evaluate electromyographic activity of gluteus medius (GMed) muscle during gait and spatiotemporal parameters of gait in patients after antegrade intramedullary nailing (IMN) of femoral shaft fractures with trochanter tip entry.

Patients and methods

Sixteen patients (15 males, 1 female; mean age 34.8±15.2 years; range, 18 to 58 years) who were treated with an antegrade trochanteric IMN between January 2009 and July 2013 and eight healthy male controls (mean age 39.3±9.8 years; range, 27 to 57 years) were included in this retrospective study. Muscle strength, static and dynamic postural stability and fall risk were evaluated. In addition, spatiotemporal parameters of gait were assessed using a validated wireless inertial sensing device and a wireless electromyography (EMG) device was used to measure electromyographic activity of GMed muscle in both groups.

Results

There were significant differences in muscle strength, functional and dynamic balance test scores between operated and intact sides (one-leg hop test score p=0.009, balance test scores p<0.001-0.033). There were significant differences in functional and quality of life physical function test scores between groups (one-leg hop test score p=0.014). However, no significant differences were found in EMG results, dynamics balance, and statics postural stability test scores between groups (p>0.05).

Conclusion

After isolated femur fracture, patients treated with antegrade trochanteric IMN demonstrated good static and dynamic stability and poor functional outcomes compared to controls. In conclusion, patients with antegrade trochanteric IMN have good balance but poor functional performance; however, further studies are needed to find out the primary reason for these results.

The Results of Unstable Intertrochanteric Femur Fracture Treated with Proximal Femoral Nail Antirotation-2 with respect to Different Greater Trochanteric Entry Points

Background

Proximal femoral nail antirotation-2 (PFNA-2) has been widely used to treat intertrochanteric fractures with varied outcomes in the previous studies. The entry point of the nail plays an important role in achieving acceptable reduction, stable fixation, and avoiding implant related complications. This study was proposed to determine the optimal greater trochanteric entry point for PFNA-2 in unstable intertrochanteric femur fractures.

Methods

We conducted an observational study on 40 patients with unstable intertrochanteric fracture treated with PFNA-2 implant in a tertiary care hospital. The patients were grouped into two based on the entry point: group L for lateral and group M for medial entry. Randomization was carried out by assigning the patients to the group by alternate allocation. The quality of reduction, tip apex distance, Cleveland index, and all the complications were noted. The final follow-up was conducted at six months. The functional outcome was evaluated using modified Harris hip score. The data analysis was performed using Student's t-test, chi square test, and Mann–Whitney test. A P value below 0.05 was considered significant.

Results

Forty patients with 20 patients treated with medial entry point were included in group M and 20 patients in group L with lateral entry point. The group L had an average tip apex distance of 20.53 and group M had 20.02 (P=0.8). The complication of screw back out was seen in 3 out of 4 patients with poor reduction in group L. As per the Cleveland index, 6 patients in each group had suboptimal position and 4 out of 6 patients in group L with suboptimal position had screw back out. The lateral cortex impingement was seen in 14 patients of group L and 6 patients in group M with significant comparison (P=0.01). Three patients in group L had varus collapse with screw back out. Also, none in group M (0.05). The average modified Harris hip score in group L at six months follow-up was 71.94 and 76.8 in group M (P=0.84).

Conclusion

Overall, to achieve good quality of fixation and reducing damage to gluteus medius entry point for PFNA-2 should be 5 mm medial to the greater trochanter tip.

Abnormal femoral antetorsion-a subtrochanteric deformity

Femoral rotational malalignment is associated with pain and functional disability and may be a contributing factor to hip impingement as well as to instability. In general, the deformity can be addressed surgically by rotational osteotomy. However, the anatomic location of the deformity is debated. The goal of the present study was to narrow down the anatomic site of deformity using the lesser trochanter (LT) as an additional landmark. One hundred and eight patients underwent computer tomography (CT)-based rotational analysis of their lower extremities. Femoral torsion (FT) and LT torsion (LTT) were measured. The combined angle (CoA) between FT and LTT was calculated. Statistical evaluation was done by multiple regression analysis. Ninety-seven extremities were examined for FT and LTT. Average age was 41 years (SD = 16.9) with a range of 18–85 years. Mean values were 20° for FT (SD = 12.2) and −16° for LTT (SD = 11.3). Mean CoA was 37.2 (SD = 8.7). Statistical analysis reveals a strong linear relationship between FT and LTT (y=31+0.74x) and a weaker relationship between FT and CoA (y=31+0.24x). This study identifies the LT as a reliable landmark and shows a strong linear relationship between the orientation of the LT and the overall torsion of the femur below and above the LT with about two-thirds of torsional changes occurring distal to it. These results provide a considerable indication for a subtrochanteric osteotomy to address correction of femoral rotational deformity at its anatomical origin.

Level of Evidence: Level III, observational study.

Damage control and intramedullary nailing for long bone fractures in polytrauma patients

The early fracture treatment in patients with multiple injuries should be focused on damage control. The fracture type and its location, local soft tissue condition as well as the patient's physiological condition shall determine the time and type of fracture treatment. Prevention of local and systemic complications must be immediately considered and included in the treatment planning. The use of external fixator (ExFix), which will be replaced by IM-implants in most cases at a later stage, provides adequate temporary fracture stabilization with less collateral damage. Good clinical results can be expected in patients with long bone fractures if the principles of damage control surgery are applied and local complications are prevented through proper reduction, firm fixation, early soft tissue reconstruction, and early rehabilitation.

Influence of different great trochanteric entry points on the outcome of intertrochanteric fractures: a retrospective cohort study

BACKGROUND

The Proximal Femoral Nail Antirotation (PFNA) system for treatment of intertrochanteric fractures is currently widely applied worldwide. However, even though the PFNA has produced good clinical outcomes, a poor introduction technique with an inappropriate entry point can cause surgical complications. Some researchers suggest improving clinical outcomes by modifying the entry point, but no research has focused on this issue. The purpose of the present study is to compare the clinical and radiological outcomes of two different trochanteric entry points for the treatment of intertrochanteric fractures using the PFNA system.

METHODS

From May 2010 to October 2015, a total of 212 elderly patients with intertrochanteric fractures who were treated with the PFNA-II system were included into this retrospective cohort study. Group LA (98 patients) was treated using a lateral anterior trochanteric entry point, and group MP (114 patients) was treated using a medial posterior trochanteric entry point. All patients underwent follow-up assessments at 1, 3, 6, and 12 months after surgery. Radiographic evaluation was based on the impingement, tip-apex distance (TAD) and the position of the helical blade within the femoral head. Clinical evaluation was based on the surgical time, fluoroscopy time, blood loss, hospital stay, visual analogue scale (VAS), thigh pain, and Harris hip score.

RESULTS

The impingement was significantly reduced (P = 0.011) in group MP. The helical blade positions were significantly lower (P = 0.001) in group MP. The TADs in group LA (22.40 ± 4.43) and group MP (23.39 ± 3.60) were not significantly different (P = 0.075). The fluoroscopy time of group LA (53.26 ± 14.44) was shorter than that of group MP (63.29 ± 11.12, P = 0.000). Five iatrogenic lateral proximal fractures and 3 helical blade cutouts occurred in group LA, but none occurred in group MP. At 1 and 3 months postoperation, the Harris hip scores were significantly higher in group MP (P = 0.001 and P = 0.000, respectively), and the VAS scores were lower (P < 0.05).

CONCLUSIONS

The medial posterior trochanteric entry point achieved excellent nail and helical blade position, reduced surgical complications, and enabled early hip function recovery but required longer fluoroscopy time than the lateral anterior trochanteric entry point.

Where is the true location of the femoral piriform fossa?

OBJECTIVE

To analyze knowledge of the anatomic location of the piriform fossa using a questionnaire with anatomic figures.

MATERIALS AND METHODS

Participants taking AO Trauma Brasil courses were requested to complete a questionnaire containing a photograph of the superior surface and a photograph of the lateral surface of the femur and answer a question asking which of four numbered points corresponded to the piriform fossa.

RESULTS

Just 4.5% of respondents correctly chose point 2 (the piriform fossa) in both images, while 75.4% of respondents chose point 4 (the trochanteric fossa) as the correct anatomic structure. The subset of 4th-year residents' answers was significantly different from those of the other subsets, with 7.5% of correct answers.

CONCLUSIONS

The low rate of correct answers indicates a tendency for the respondents to be influenced by illustrations in text books or examples in scientific publications that indicate the site of the piriform fossa incorrectly. Interest in the specialty of traumatology is possibly the reason why the subset of 4th-year residents had a better- than-average rate of correct answers.

Three-dimensional correlation between trochanteric fossa and the ideal entry point for antegrade femoral nailing

PURPOSE

To verify the practical correlation between the topographical features of the femur neck base and the ideal entry point by analyzing three-dimensional (3D) models virtually implanted with an antegrade femoral nail.

MATERIALS AND METHODS

A total of 103 cadaveric femurs (50 males and 53 females) were enrolled. Specimens underwent continuous 1.0mm slice computed tomography (CT) scans. CT images were rendered into 3D images using image-processing software (Mimics^®) to reconstruct the geometry of the cortex and medullary canal. A real cannulated femoral nail (CFN)^® was processed into a 3D image using a 3D sensor at the actual size and optimally placed in the femur model using Mimics^® for virtual implantation. The correlation between the ideal entry point in the cranial view of the proximal femur and the trochanteric fossa was assessed and overlap of trochanter overhang was verified.

RESULTS

The entry point of 68 models (66.0%) was the trochanteric fossa, while the others were placed around the anterior border of the trochanteric fossa. The proximal end of the nail overlapped in 50 models (48.1%), and among them, the central point of 23 models (22.3%) was obscured by trochanteric overhang. There was a statistically significant risk associated with female gender (6.02 times) and type IV overhang of Grenchenig's classification (4.56 times). Despite the precise positioning of the trochanteric fossa, 11 models (10.7%) had the entry point covered by trochanteric overhang.

CONCLUSION

The ideal entry point was over the trochanteric fossa in just half of the models, and could be hindered by trochanteric overhang even though the CFN was ideally positioned.

Interventions for treating femoral shaft fractures in children and adolescents

BACKGROUND

Fractures of the femoral shaft in children are relatively uncommon but serious injuries that disrupt the lives of children and their carers and can result in significant long-term disability. Treatment involves either surgical fixation, such as intramedullary nailing or external fixation, or conservative treatment involving prolonged immobilisation, often in hospital.

OBJECTIVES

To assess the effects (benefits and harms) of interventions for treating femoral shaft fractures in children and adolescents.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (accessed 16 August 2013), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2013 Issue 7), MEDLINE (1946 to August Week 1 2013), EMBASE (1980 to 2012 week 9), CINAHL (16 August 2013), clinical trials registries, conference proceedings and reference lists; and contacted trial authors and experts in the field.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials comparing conservative and surgical interventions for diaphyseal fractures of the femur in children under 18 years of age. Our primary outcomes were functional outcome measures, unacceptable malunion, and serious adverse events.

DATA COLLECTION AND ANALYSIS

Two authors independently screened and selected trials, assessed risk of bias and extracted data. We assessed the overall quality of the evidence for each outcome for each comparison using the GRADE approach. We pooled data using a fixed-effect model.

MAIN RESULTS

We included 10 trials (six randomised and four quasi-randomised) involving a total of 527 children (531 fractures). All trials were at some risk of bias, including performance bias as care provider blinding was not practical, but to a differing extent. Just one trial was at low risk of selection bias. Reflecting both the risk of bias and the imprecision of findings, we judged the quality of evidence to be 'low' for most outcomes, meaning that we are unsure about the estimates of effect. Most trials failed to report on self-assessed function or when children resumed their usual activities. The trials evaluated 10 different comparisons, belonging to three main categories. Surgical versus conservative treatment. Four trials presenting data for 264 children aged 4 to 12 years made this comparison. Low quality evidence (one trial, 101 children) showed children had very similar function assessed using the RAND health status score at two years after surgery (external fixation) compared with conservative treatment (spica cast): mean 69 versus 68. The other three trials did not report on function. There was moderate quality evidence (four trials, 264 children, aged 4 to 12 years, followed up 3 to 24 months) that surgery reduced the risk of malunion (risk ratio (RR) 0.29, 95% confidence interval (CI) 0.15 to 0.59, 4 trials). Assuming an illustrative baseline risk of 115 malunions per 1000 in children treated conservatively, these data equate to 81 fewer (95% CI 47 to 97 fewer) malunions per 1000 in surgically-treated children. Conversely, low quality evidence indicated that there were more serious adverse events such as infections after surgery (RR 2.39, 95% CI 1.10 to 5.17, 4 trials). Assuming an illustrative baseline risk of 40 serious adverse events per 1000 for conservative treatment, these data equate to 56 more (95% CI 4 to 167 more) serious adverse events per 1000 children treated surgically. There was low quality evidence (one trial, 101 children) of similar satisfaction levels in children and parents with surgery involving external fixation and plaster cast only. However, there was low quality evidence (one trial, 46 children) that more parents were satisfied with intramedullary nailing than with traction followed by a cast, and that surgery reduced the time taken off from school. Comparisons of different methods of conservative treatment. The three trials in this category made three different comparisons. We are very unsure if unacceptable malunion rates differ between immediate hip spica versus skeletal traction followed by spica in children aged 3 to 10 years followed up for six to eight weeks (RR 4.0, 95% CI 0.5 to 32.9; one trial, 42 children; very low quality evidence). Malunion rates at 5 to 10 years may not differ between traction followed by functional orthosis versus traction followed by spica cast in children aged 5 to 13 years (RR 0.98, 95% CI 0.46 to 2.12; one trial, 43 children; low quality evidence). We are very unsure (very low quality evidence) if either function or serious adverse events (zero events reported) differ between single-leg versus double-leg spica casts (one trial, 52 young children aged two to seven years). Low quality evidence on the same comparison indicates that single-leg casts are less awkward to manage by parents, more comfortable for the child and may require less time off work by the caregiver. Comparisons of different methods of surgical treatment. The three trials in this category made three different comparisons. Very low quality evidence means that we are very unsure if the rates of malunion, serious adverse events, time to return to school or parental satisfaction actually differ in children whose fractures were fixed using elastic stable intramedullary nailing or external fixation (one trial, 19 children). The same applies to the rates of serious adverse events and time to resume full weight-bearing in children treated with dynamic versus static external fixation (one trial, 52 children). Very low quality evidence (one trial, 47 children) means that we do not know if malunion, serious adverse events and time to resume weight-bearing actually differ between intramedullary nailing versus submuscular plating. However, there could be more difficulties in plate removal subsequently.

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine if long-term function differs between surgical and conservative treatment. Surgery results in lower rates of malunion in children aged 4 to 12 years, but may increase the risk of serious adverse events. Elastic stable intramedullary nailing may reduce recovery time. There is insufficient evidence from comparisons of different methods of conservative treatment or of different methods of surgical treatment to draw conclusions on the relative effects of the treatments compared in the included trials.

PLAIN LANGUAGE SUMMARY

Different methods of treating fractures of the shaft of the thigh bone in children and adolescents Although uncommon, fractures of the femoral shaft (thigh bone) in children may require prolonged treatment in hospital and sometimes surgery. This can cause significant discomfort and can disrupt the lives of the children and their familles. This review compared different methods of treating these fractures. Surgical treatment comprises different methods of fixing the broken bones, such as internally-placed nails, or pins incorporated into an external frame (external fixation). Non-surgical or conservative treatment usually involves different types of plaster casts with or without traction (where a pulling force is applied to the leg). We searched for studies in the medical literature until August 2013. The review includes 10 randomised or quasi-randomised controlled trials that recruited 527 children. Four trials compared different surgical versus non-surgical treatments; three compared different methods of non-surgical treatment and three compared different methods of surgical treatment. Generally we are unsure about the results of these trials because some were at risk of bias, some results were contradictory and usually there was too little evidence to rule out chance findings. Most trials failed to report on self-assessed function or when children resumed their usual activities. Comparing surgical versus non-surgical treatment. Low quality evidence (one trial, 101 children) showed children had similar function at two years after having surgery, involving external fixation, compared with those treated with a plaster cast. The other three trials did not report this outcome. There was moderate quality evidence (four trials, 264 children, aged 4 to 12 years, followed up for 3 to 24 months) that surgery reduced the risk of malunion (the leg is deformed) compared with non-surgical treatment. However, low quality evidence (four trials) indicated that there were more serious adverse events such as infections after surgery. There was low quality evidence (one trial, 101 children) of similar satisfaction levels in children and parents with surgery involving external fixation and plaster cast only. However, there was low quality evidence (one trial, 46 children) that more parents were satisfied with surgery involving an internal nail than with traction followed by a cast and that surgery reduced the time taken off from school. Comparing various non-surgical treatments. Very low quality evidence means that we are very unsure if the rates of malunion differ or not between children treated with immediate plaster casts versus with traction followed by plaster cast (one trial, 42 children), or between children treated with traction followed by either a functional orthosis (a brace or cast that allows some movement) or a cast (one trial, 43 children). We are very unsure if either function or serious adverse events differ between young children (aged two to seven years) immobilised in single-leg versus double-leg casts (one trial, 52 children). However, single-leg casts appear to be easier to manage by parents and more comfortable for the child. Comparing various surgical treatments Very low quality evidence means that we are very unsure if the rates of malunion, serious adverse events, time to return to school or parental satisfaction actually differ in children whose fractures were fixed using internal nails or external fixation (one trial, 19 children). (ABSTRACT TRUNCATED)

Interventions for treating femoral shaft fractures in children and adolescents

BACKGROUND

Fractures of the femoral shaft in children are relatively uncommon but serious injuries that disrupt the lives of children and their carers and can result in significant long-term disability. Treatment involves either surgical fixation, such as intramedullary nailing or external fixation, or conservative treatment involving prolonged immobilisation, often in hospital.

OBJECTIVES

To assess the effects (benefits and harms) of interventions for treating femoral shaft fractures in children and adolescents.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (accessed 16 August 2013), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2013 Issue 7), MEDLINE (1946 to August Week 1 2013), EMBASE (1980 to 2012 week 9), CINAHL (16 August 2013), clinical trials registries, conference proceedings and reference lists; and contacted trial authors and experts in the field.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials comparing conservative and surgical interventions for diaphyseal fractures of the femur in children under 18 years of age. Our primary outcomes were functional outcome measures, unacceptable malunion, and serious adverse events.

DATA COLLECTION AND ANALYSIS

Two authors independently screened and selected trials, assessed risk of bias and extracted data. We assessed the overall quality of the evidence for each outcome for each comparison using the GRADE approach. We pooled data using a fixed-effect model.

MAIN RESULTS

We included 10 trials (six randomised and four quasi-randomised) involving a total of 527 children (531 fractures). All trials were at some risk of bias, including performance bias as care provider blinding was not practical, but to a differing extent. Just one trial was at low risk of selection bias. Reflecting both the risk of bias and the imprecision of findings, we judged the quality of evidence to be 'low' for most outcomes, meaning that we are unsure about the estimates of effect. Most trials failed to report on self-assessed function or when children resumed their usual activities. The trials evaluated 10 different comparisons, belonging to three main categories. Surgical versus conservative treatment Four trials presenting data for 264 children aged 4 to 12 years made this comparison. Low quality evidence (one trial, 101 children) showed children had very similar function assessed using the RAND health status score at two years after surgery (external fixation) compared with conservative treatment (spica cast): mean 69 versus 68. The other three trials did not report on function. There was moderate quality evidence (four trials, 264 children, aged 4 to 12 years, followed up 3 to 24 months) that surgery reduced the risk of malunion (risk ratio (RR) 0.29, 95% confidence interval (CI) 0.15 to 0.59, 4 trials). Assuming an illustrative baseline risk of 115 malunions per 1000 in children treated conservatively, these data equate to 81 fewer (95% CI 47 to 97 fewer) malunions per 1000 in surgically-treated children. Conversely, low quality evidence indicated that there were more serious adverse events such as infections after surgery (RR 2.39, 95% CI 1.10 to 5.17, 4 trials). Assuming an illustrative baseline risk of 40 serious adverse events per 1000 for conservative treatment, these data equate to 56 more (95% CI 4 to 167 more) serious adverse events per 1000 children treated surgically. There was low quality evidence (one trial, 101 children) of similar satisfaction levels in children and parents with surgery involving external fixation and plaster cast only. However, there was low quality evidence (one trial, 46 children) that more parents were satisfied with intramedullary nailing than with traction followed by a cast, and that surgery reduced the time taken off from school. Comparisons of different methods of conservative treatmentThe three trials in this category made three different comparisons. We are very unsure if unacceptable malunion rates differ between immediate hip spica versus skeletal traction followed by spica in children aged 3 to 10 years followed up for six to eight weeks (RR 4.0, 95% CI 0.5 to 32.9; one trial, 42 children; very low quality evidence). Malunion rates at 5 to 10 years may not differ between traction followed by functional orthosis versus traction followed by spica cast in children aged 5 to 13 years (RR 0.98, 95% CI 0.46 to 2.12; one trial, 43 children; low quality evidence). We are very unsure (very low quality evidence) if either function or serious adverse events (zero events reported) differ between single-leg versus double-leg spica casts (one trial, 52 young children aged two to seven years). Low quality evidence on the same comparison indicates that single-leg casts are less awkward to manage by parents, more comfortable for the child and may require less time off work by the caregiver. Comparisons of different methods of surgical treatmentThe three trials in this category made three different comparisons. Very low quality evidence means that we are very unsure if the rates of malunion, serious adverse events, time to return to school or parental satisfaction actually differ in children whose fractures were fixed using elastic stable intramedullary nailing or external fixation (one trial, 19 children). The same applies to the rates of serious adverse events and time to resume full weight-bearing in children treated with dynamic versus static external fixation (one trial, 52 children). Very low quality evidence (one trial, 47 children) means that we do not know if malunion, serious adverse events and time to resume weight-bearing actually differ between intramedullary nailing versus submuscular plating. However, there could be more difficulties in plate removal subsequently.

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine if long-term function differs between surgical and conservative treatment. Surgery results in lower rates of malunion in children aged 4 to 12 years, but may increase the risk of serious adverse events. Elastic stable intramedullary nailing may reduce recovery time.There is insufficient evidence from comparisons of different methods of conservative treatment or of different methods of surgical treatment to draw conclusions on the relative effects of the treatments compared in the included trials.

Piriformis fossa - an anatomical and orthopedics consideration

INTRODUCTION

Piriformis fossa is an important anatomical landmark having significant clinical value in orthopedic surgery; but its location and anatomical relationship with surrounding structures are not clearly defined. Hence it is necessary to clearly describe it in respect to anatomical and orthopedic aspect.

MATERIALS AND METHODS

Fifty Cadaveric dry femoral bones and Dissection of the four hip specimens were used to study the Piriformis fossa in respect to location and its relationship with surrounding structures. Clinical importance of piriformis fossa was determined in reference to antegrade femoral nail insertion.

OBSERVATIONS

Piriformis muscle and so called piriformis fossa are unrelated entities. Piriformis fossa is anatomical site of insertion of obturator externus. In dry cadaveric femora; fossa was not always located in the direction of femoral shaft. It was located in the direction of femoral shaft in 24% cases only. In 68% cases femoral canal was aligned lateral and in 8% cases, it lies medial to the fossa.

CONCLUSION

Piriformis fossa should be named as Trorchanteric fossa or Obturator fossa for better anatomical description. So called Piriformis fossa does not found to be universally corresponding to femoral shaft hence selection of entry site should be based on variable proximal femur and area on femur which corresponds to femoral shaft.

Trochanteric fossa or piriform fossa of the femur: time for standardised terminology?

Piriform fossa, trochanteric fossa and greater trochanteric tip have each been described as entry points for antegrade femoral nailing. However, the terminology used for these entry points is confusing. The accuracy of the entry point nomenclature in published text and illustrations was recorded in this review study. The trochanteric fossa, a deep depression at the base of the femoral neck is indicated as 'piriform fossa' in the vast majority of the publications. Other publications indicate the insertion site of the tendon of the piriformis muscle on the greater trochanteric tip as 'piriform fossa'. As a result of recurrent terminology error and consistent reproductions of it, the recommended entry point in literature is confusing and seems to need standardisation. The piriform fossa does not appear to exist in the femoral region. The trochanteric fossa is the standard entry point which most surgeons recommend for facilitating a standard straight intramedullary nail, as is in line with the medullary canal. The greater trochanteric tip is the lateral entry point for intramedullary nails with a proximal lateral bend.