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

Outcomes of cement augmentation in fragility trochanteric hip fractures - A multicenter randomized controlled trial follow-up

PURPOSE

Cement augmentation is considered to improve the bone-implant construct stability in hip fragility fractures, additionally biomechanical studies show that cement augmentation improves the pull-out strength and increases resistance to failure. Thus far, the advantage of these technique used in a clinical scenario is yet to be determined METHODS: a randomized, multicenter, single-blinded clinical trial was conducted in patients aged 65 years or older who were admitted to two level I trauma centers with a fragility intertrochanteric hip fracture during September 2015 and December 2017. Patients were stratified into 2 groups: patients between 65 and 85 years and older than 85 years. A balanced block randomization was performed using blocks of 6 patients: 3 patients assigned to the control group (no augmentation) and 3 patients to the intervention group. Follow-up visits were done at 1, 3, 6 and 12 postoperative months documenting the tip-apex distance (TAD) as well as followed up after 5 to 7 years of surgical procedure documenting EQ5D, Parker Mobility Score and mortality rates at these different time points.

RESULTS

A total of 90 patients were included but only 53 patients completed a one-year follow up. The mean immediate postoperative and one-year follow up TAD measurement from the whole cohort (20.99 mm vs 21.3 mm, respectively) showed no statistical significance (P = 0.18). For patients in the control group, the difference of TAD measurements from the immediate postoperative and one-year follow-up was -0.25 mm (P = 0.441). For patients included in the intervention group, the difference of TAD measurement from the immediate postoperative and 1-year follow up was -0.48 mm (P = 0.383). No statistical difference was found when stratified by age (p = 0.78). One patient from the control group had an implant failure after 1-month postoperative. Readmission after 30 days showed no statistical difference between both groups (7 vs. 7 patients, p = 0.754). Augmentation did not show a difference in most of the functional outcomes nor quality of life after 5 to 7 years of surgical procedure.

CONCLUSIONS

The use of augmentation can be considered a safe procedure for the fixation of fragility hip fractures.

Finite-Element Analysis of a Novel Cephalomedullary Nail for Restricted Sliding to Reduce Risk of Implant Failure in Unstable Intertrochanteric Fractures

Objective

How to restrict sliding of cephalomedullary nail and rigid reconstruct medial support for unstable intertrochanteric fractures remains a challenge. This study aims to explore the feasibility of a novel cephalomedullary nail for restriction sliding and reconstruction of medial femoral support to prevent failure in unstable trochanteric fractures through finite element analysis.

Methods

The DICOM files of a unilateral femur spiral computed tomography (CT) scans from a elderly female were converted into STL files, and the most common clinical trochanteric fracture model with the absence of medial support, AO/OTA 31‐A2.3 was simulated by removing the posterior medial femur. The model of a novel medial sustain nail (MSN‐II) and a widely used nail (proximal femoral nail anti‐rotation PFNA‐II) were modeled according to the manufacturer‐provided engineering drawing. Different loads were applied to the femoral head to simulate the postoperative weight bearing gait. The sliding distance of helical blade in femoral neck, maximum stress of femur and nail, displacement of proximal fragment were analyzed to revealing the mechanical stability of unstable trochanteric fracture stabilized by different implant.

Results

The sliding distance of helical blade in the femoral neck, the maximum stress on the femur and nail, the displacement of proximal fragment in MSN‐II under 2100N axial load were 0.65 mm, 689 MPa, 1271 MPa, 16.84 mm respectively, while that were 1.43 mm, 720.8 MPa, 1444 MPa, 18.18 mm, respectively in PFNA‐II. The difference between the two groups was statistically significant (P < 0.05) and the stress was mainly distributed in medial distal side of nail but helical blade and the proximal aperture for the nail in MSN‐II. Compared to PFNA‐II, MSN‐II demonstrates biomechanical merit against femur medialization, cut‐out and coax varus.

Conclusion

The sliding distance of helical blade in femoral neck, the maximum stress on the femur and nail, and the displacement of proximal fragment of MSN‐II were less than those of PFNA‐II in the treatment of unstable intertrochanteric fractures. Therefore MSN‐II has better stability than PFNA‐II and it may have the potential to avoid femur medialization and cut out. It might be an option in unstable trochanteric fracture because of its superiority in restricted sliding and medial support reconstruction.

Effectiveness of Cement Augmentation on Early Postoperative Mobility in Patients Treated for Trochanteric Fractures with Cephalomedullary Nailing: A Prospective Cohort Study

Fixation using cephalomedullary nails (CMNs) with additional cement augmentation (CA) was developed as a novel treatment option for the osteosynthesis of osteoporotic trochanteric fractures, though the effectiveness of CA on early postoperative mobility remains uncertain. This multicenter prospective cohort study aimed to estimate the effectiveness of CA on early postoperative mobility in patients with trochanteric fractures. We enrolled patients with femoral trochanteric fractures aged >60 years who were able to walk independently before the injury. The primary outcome was the postoperative 3-day cumulated ambulation score (CAS); the secondary outcome was the visual analog scale (VAS) pain score at rest and during movement on postoperative days 1−3. The outcomes of the patients treated using CMNs with or without CA were compared. Sixty-three eligible patients were categorized into CA (n = 32) and control (n = 31) groups. In univariate analysis, the CA group had significantly higher CAS values, lower VAS scores at rest on day 1 postoperatively, and lower VAS scores during movement on day 3. In multivariable linear regression analyses, the CA group had significantly higher CAS values (beta, 2.1; 95% confidence interval, 0.5 to 3.6; p = 0.01). The CA group had a negative adjusted beta value in their VAS scores during movement. This study indicated that CA was associated with a high CAS value in patients with geriatric trochanteric fractures. However, CA was not associated with pain reduction at rest and during movement during the initial postoperative days.