[Experimental examination for optimized stabilisation of trochanteric femur fractures, intra- or extramedullary implant localisation and influence of femur neck component profile on cut-out risk]

Intramedullary Nail or Primary Arthroplasty? A System Review and Meta-Analysis on the Prognosis of Intertrochanteric Femoral Fractures Based on Randomized Controlled Trials

Introduction

There is no consensus regarding the superiority between intramedullary nailing and primary arthroplasty in the management of intertrochanteric femoral fractures. This systematic review was performed to investigate and compare the clinical efficacy of intertrochanteric femoral fractures treated with these 2 methods.

Materials and methods

We systematically searched PubMed, Embase, Cochrane, Web of science core collection and ClinicalTrials.gov for randomized controlled trials which compared the clinical outcomes of intertrochanteric fractures treated with either intramedullary nails or primary arthroplasty. Relevant data of the postoperative complications, reoperations, mortality and functional assessment, were pooled and presented graphically.

Results

A total of 6 trials with 427 participants were identified and included in the analyses. The pooled estimates suggested these 2 techniques have comparable risks in terms of overall complications (pooled risk ratio [RR] .80; 95% confidence interval [CI] .43 to 1.43; I² = 79.94%), the rate of patients with orthopedic complications (RR .71, 95% CI .40 to 1.27; I² = .00%), reoperations (RR 1.33, 95% CI .48 to 3.71; I² = .00%), the overall mortality (RR .52; 95%CI .26 to 1.02; I² = 31.35%) and 1-year mortality (RR .67; 95%CI .38 to 1.19; I² = .00%). Primary arthroplasty associated with higher HHS at 3 months postoperatively (MD -21.95, 95% CI -28.29 to −15.60; I² = 70.44%). While the difference was not significant at 6 months (MD 2.32, 95% CI -1.55 to 6.18; I² = .00%), and even reversed at 12 months postoperatively (MD 13.02, 95% CI 8.14 to 17.90; I² = 73.42%).

Conclusions

Meta-analytic pooling of current evidences demonstrated that primary arthroplasty is related to a better early functional recovery at the early stage postoperatively, but the long-term result tends to favor to intramedullary nailing. The differences in overall complications, the rate of patients with orthopedic complications, reoperations, overall and 1-year mortality did not reach a significant level.

Cementless bipolar hemiarthroplasty compared with proximal femoral nail anti-rotation of unstable intertrochanteric fractures in senile patients with osteoporosis: a retrospective study

Background

Implant design for the correction of osteoporotic unstable intertrochanteric fractures in elderly patients is a controversial issue. Our study aims to compare the efficacy of PFNA and cementless bipolar hemiarthroplasty (CBH) in treating osteoporotic unstable intertrochanteric fractures in the elderly.

Methods

We retrospectively assessed 70 elderly patients, aged > 70 years old, with intertrochanteric fractures (AO/OTA 31-A2 fractures) from 2014 to 2019. Among them, 34 patients received PFNA and 36 patients received CBH, accompanied with 2-year follow-ups. Additionally, the efficacy difference between the two implants was compared.

Results

Both groups had similar general variables like age, gender, fracture site, degree of osteoporosis, fracture classification, ASA score, basic diseases, preoperative preparation time, anesthesia mode, amount of postoperative blood loss, hospital length of stay, along with postoperative blood transfusions and postoperative complications (P > 0.05). Conversely, significant differences were observed among intraoperative variables (amount of blood loss, amount of blood transfusions, operative time, number of intraoperative fluoroscopy), postoperative variables (weight-bearing time out of bed), and Harris hip function score within 12 months of operation (P < 0.05).

Conclusions

CBH showed no obvious advantage over PFNA in the perioperative period in elderly patients with osteoporotic unstable intertrochanteric fractures. However, the joint replacement allowed for earlier ambulation after the operation and rapid recovery of the hip joint function.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05426-2.

Trochanteric stabilizing plate in the treatment of trochanteric fractures: a scoping review

Background and purpose - The trochanteric stabilizing plate (TSP) may be used as an adjunct to a sliding hip screw (SHS) in the treatment of trochanteric fractures to increase construct stability. We performed a scoping review of the literature to clarify when and how the TSP may be useful.Methods - A systematic search was performed in 5 databases and followed by a backwards-and-forwards citation search of the identified papers. 24 studies were included.Results - 6 biomechanical studies and 18 clinical studies were included in the review. The studies presented mainly low-level evidence. All studies were on unstable trochanteric fractures or fracture models. Due to the heterogeneity of methods and reporting, we were not able to perform a meta-analysis. In the biomechanical trials, the TSP appeared to increase stability compared with SHS alone, up to a level comparable with intramedullary nails (IMNs). We identified 1,091 clinical cases in the literature where a TSP had been used. There were 82 (8%) reoperations. The rate of complications and reoperations for SHS plus TSP was similar to previous reports on SHS alone and IMN. It was not possible to conclude whether the TSP gave better clinical results, when compared with either SHS alone or with IMN.Interpretation - The heterogeneity of methods and reporting precluded any clear recommendations on when to use the TSP, or if it should be used at all.

Long-term results after over 17 years - Intramedullary gliding nail as treatment for traumatic femoral neck fractures

Background

For the treatment of femoral neck fracture there are many different implants present on the market. Postoperative complications still exist.

Patients and methods

The aim of this retrospective study was to evaluate the Gliding Nail in patients with medial femoral neck fractures and their long-term complications.

Results

In a collective of 113 patients we had all together 21 major complications in 2018.12/113 minor complications in 2008 and all together 13/78 in 2018 has been detected.

Conclusions

The Gliding Nail as an intramedullary implant shows a high load-bearing capacity with a high rotational stability and a low cut-out rate.

Treatment of Traumatic Femoral Neck Fractures with an Intramedullary Nail in Osteoporotic Bones

PURPOSE

Sufficient anchoring of intramedullary osteosynthesis in the femoral head in a femoral neck fracture is a challenge with increasing age of the patients and decreasing bone quality. For older patients with inferior bone quality, it has not been investigated whether the application of an intramedullary force carrier, as a minimally invasive and rapid intervention, can provide a considerable benefit and reduce the postoperative complication and lethality rate. This retrospective study aimed to investigate the stability and functionality after the acute treatment of a femoral neck fracture in osteoporotic bone using an intramedullary force carrier even with higher grade fracture types.

MATERIAL AND METHODS

The retrospective analysis was based on a collective of 82 patients over 60 years of age with a femoral neck fracture treated with a gliding nail in our centre between 1999 and 2006.

RESULTS

The average time to follow-up was 69.05 months (median 71.0; minimum 27.0-maximum 108.0). Female patients made up more than two-thirds of the patient collective at 63 of the 82 patients (76.83%). The average age of the patients was 77.76 years (median 78.00; range 60.00-93.00).In 66 patients (80.49%), the implantation showed good results and no complications or further treatments. 24/82 patients of our collective had died in our re-evaluation. In no case, a pseudarthrosis or severe impaction with neck shortening occurred (loss of offset).11/82 patients had femoral head necrosis which led to total hip replacement in 8 cases, a hemiarthroplasty in 2 cases and in 1 case a remaining Girdlestone situation because of a deep infection. Another five patients also had to undergo a total hip replacement because of a central perforation of the blade in one case, breakout of the blade after another fall in another two cases and a lateral dislocation of the blade in two cases.

CONCLUSION

The use of an intramedullary force carrier in the osteoporotic bone can mean distinct advantages for the selected patient as a minimally invasive and rapid surgical method compared to extensive surgery, even in the case of severe injuries. However, the advantages and disadvantages for the patient should be considered critically.

Outcomes of U-Blade Lag Screw for Cephalomedullary Fixation of Unstable Trochanteric Femur Fractures: A Case Control Study

Background:

Unstable trochanteric femur fractures in elderly patients with osteoporosis are still challenging. Gamma3 nail with the U-blade lag screw (U-blade gamma nail) has been developed to improve mechanical stability of proximal femoral fragment. This study aimed to compare the clinical and radiologic outcomes of U-blade gamma nail to proximal femoral nail antirotation (PFNA), and standard Gamma3 nail (gamma nail) for unstable trochanteric femur fractures.

Methods:

A retrospective matched-pair case study was performed with U-blade gamma nail, PFNA, and gamma nail. During 2012-2018, 970 patients with unstable trochanteric femur fractures were reviewed. Matching criteria were set as follows: 1) sex; 2) age (± 3 years); 3) body mass index (± 2 kg/m²); 4) bone mineral density (± 1 T-score in femur neck). Finally, a total of 159 patients were enrolled. We assessed the tip-apex distance (TAD), neck shaft angle, and hip screw sliding distance using plain radiographs. Also, we evaluated the clinical outcomes with Koval’s grade and fixation failure during 2 years.

Results:

The mean postoperative TAD was not significantly different among the 3 groups (p = 0.519). However, the change in the TAD at 1 year (p = 0.027) and 2 years (p = 0.008) after surgery was significantly smaller in U-blade gamma nail group compared with PFNA and gamma nail group. The hip screw sliding distance at 1 year (p = 0.004) and 2 years (p = 0.001) after surgery was significantly smaller in U-blade gamma nail group compared with PFNA and gamma nail group. However, there was no significant difference of Koval’s grade and fixation failure among the 3 groups (p = 0.535).

Conclusion:

U-blade gamma nail showed favorable radiologic results in terms of the change in the hip screw position. However, U-blade gamma nail was not superior to PFNA and gamma nail in clinical outcomes.

Complications and imaging artifacts related to MRI in patients with intramedullary osteosynthesis after proximal femur fracture

BACKGROUND

Fractures of the proximal femur is one of the most frequent human injuries, and most of the patients are treated with osteosynthesis, such as intramedullary nails. These patients often require magnetic resonance imaging (MRI) scans in their further lives due to various reasons. This raises the question of whether complications with implanted osteosynthesis material such as implant loosening, burning, dislocation, or other complications are to be expected or whether an MRI examination is even suitable with regard to imaging artifacts.

METHODS

The aim of this retrospective study was to investigate the rate and type of complications after MRI examinations in patients with inserted intramedullary osteosynthesis device. Furthermore, artifacts in MRI caused by this device were assessed.

RESULTS

MRI scans of the head (20 of 62), spine (20 of 62), pelvis (10 of 62), and lower extremity (6/62) were performed. Three of the 62 patients received an MRI of the abdomen, and 2 of the 62 patients received an MRI of the thorax and the upper extremity. Of the 62 patients, noneexperienced complications during the immediate examination. Similarly, none of the patients showed early complications within the first 2 weeks after MRI. In our long-term follow-up examination, no long-term complication after MRI was observed in the recorded 15 patients. Artifacts were found in 14 patients: in MRI scans of the pelvis (10/10), of the abdomen (2/3), and of the lower extremity (2/6).

CONCLUSION

There were no complications during the MRI scan, in the first 2 weeks after MRI, or in the recorded long-term results. MRI with an enclosed intramedullary nail provided good image quality unless the immediate implant site was imaged. MRI diagnosis is thus possible in patients with an inserted intramedullary nail. The inserted intramedullary nail should therefore not be an exclusion criterion when sectional imaging with MRI is required.

A multicenter intertrochanteric fracture study in the elderly: Hemiarthroplasty versus proximal femoral nailing

Objectives

This study aims to compare the clinical and functional results of intertrochanteric femoral fractures treated with bipolar hemiarthroplasty (BHA) or proximal femoral nailing (PFN) in elderly patients.

Patients and methods

This multicenter, prospectively followed-up, retrospectively compared cohort-type study included 308 patients (81 males, 227 females; mean age 78.4±7.2 years; range, 65 to 95 years) who were treated with BHA or PFN for intertrochanteric fractures by five orthopedic surgeons in four provinces and seven clinics between January 2014 and May 2018. Clinical follow-up was performed at third week, third and sixth months, and at the end of the first and second years. The American Society of Anesthesiologists for preoperative status, Singh index for bone quality, and Harris Hip Score (HHS) for functional outcomes were evaluated.

Results

While 156 patients (38 males, 118 females; mean age 77.7±5.9) were treated with BHA, 152 patients (43 males, 109 females; mean age 79±6.1) were treated with PFN. While there was no significant difference between the two groups in terms of total HHS, a significant difference was found in the sub-parameters (p<0.001). Good and excellent results were found in 78.2% of BHA and 86.2% of PFN patients. Mortality rates were similar at the end of two years (14% and 13.6%, respectively).

Conclusion

In general, clinical and functional outcomes of BHA and PFN are similar. The rates of pulmonary embolism and deep vein thrombosis are significantly higher in BHA. However, BHA is advantageous in terms of operation time and early weight bearing compared to PFN.

A Comparison of U-blade Gamma3 and Gamma3 Nails Used for the Treatment of Intertrochanteric Fractures

Purpose

To compare outcomes (i.e., clinical and radiological findings, postoperative complication) in the fixation of intertrochanteric fractures with U-blade Gamma3 and Gamma3 nails.

Materials and Methods

A review of 162 patients (both male and female) treated for intertrochanteric fractures between December 2012 and December 2018 was conducted. All patients were older than 65 years of age and treated with U-blade Gamma3 (n=90) or Gamma3 (n=72) nails. Evaluations included: (i) screw-head position, (ii) fracture-reduction status, (iii) time to union, (iv) cases of cut-out, (v) tip-apex distance, and (vi) lag screw sliding distance. Differences in pre- and postoperative ambulatory ability was also investigated.

Results

There were no significant differences in baseline demographics between the two groups. While the lag-screw sliding distance was significantly shorter in U-blade Gamma3 nail group (4.7 mm vs. 3.6 mm; P=0.025), the mean time to union was similar between the groups (P=0.053). Three and six cases of cut-out were noted in the U-blade Gamma3 and Gamma3 nail groups, respectively (P=0.18), however no other postoperative complications were noted in either group. Lastly, there was no difference between the change from pre- to postoperative activity level between the groups (P=0.753).

Conclusion

Of all the clinical and radiological outcomes assessed, the only significant improvement between those treated with U-Blade Gamma and Gamma3 nails was a shorter lag-screw sliding distance. These findings should benefit clinicians when deciding between the use of U-Blade Gamma or Gamma3 nails.

Influence of reduced tip-apex distance on helical blade fixation-a biomechanical study

Migration profile of helical blades differs from conventional screw design. Tip-apex distance (TAD) greater than 25 mm is associated with early failure in hip screws. This study investigates the effect of a reduced TAD on helical blade fixation. Six pairs of human femoral heads were used. Bone mineral density (BMD) was determined by pQCT. Local bone quality was evaluated by breakaway torque. Helical blades were implanted with TAD of 20 mm (normal) and 6 mm (reduced). Specimens were cyclically tested under progressively increasing physiologic loading at 2 Hz with starting peak force of 1'000N, increasing by 0.1N/cycle. Implant migration was monitored by radiographs every 250 cycles. Paired Student's t-test and Spearman rank correlation coefficient were used for statistical evaluation (p < 0.05). Mean BMD was 246.7 mgHA/cm³ SD48.7 (normal), 244.3 mgHA/cm³ SD47.6 (reduced); p = 0.93. Mean breakaway torque was 3.59 Nm SD2.11 (normal), 3.72 Nm SD1.83 (reduced); p = 0.91. Number of cycles to failure (1 mm vertical migration) was 16'416 SD7972 (normal), 20'000 SD5232 (reduced); p = 0.38. They correlated significantly with BMD (p = 0.01;R²  = 0.91) and breakaway torque (p < 0.049; R²  = 0.814) (normal). Breakaway torque correlated significantly with BMD (p = 0.02; R²  = 0.898) (normal). In reduced TAD these parameters did not correlate significantly. Normal TAD resulted in failure in varus collapse (n = 6), whereas reduced TAD showed blade perforation (n = 3), rotation (n = 2), varus collapse (n = 1). Fixation stability of helical blades correlates with bone quality when implants are fixed in cancellous bone. Near cortical blade fixation might increase the risk of intraarticular blade perforation. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 9999:1-6, 2019.

Nail or plate fixation for A3 trochanteric hip fractures: A systematic review of randomised controlled trials

Continuing controversy exists for the choice of implant for treating A3 trochanteric hip fractures so we undertook a systematic review of randomised controlled trials from the year 2000 onwards that have compared an intramedullary nail with an extramedullary fixation implant for the treatment of these fractures. Data on the occurrence of any fracture healing complications was extracted and the results combined to calculate Peto odd ratio. Nine studies involving 370 fractures were identified. Three studies involving 105 fractures compared an intramedullary nail with a static fixation (condylar, blade or locking plate). Plate fixation was associated with a fivefold increase risk of fracture healing complications (19/52(36.6%) versus 4/53(7.5%), odds ratio 0.14, 95% Confidence intervals 0.04-0.45). Six studies involving 265 fractures compared an intramedullary nail with a sliding hip screw. No statistically significant difference was found in the occurrence of facture healing complications between implants (13/137(9.5%) versus 11/128(8.6%) odds ratio 0.28, 95% Confidence intervals 0.50-2.80). Bases on the evidence to date from randomised trials, the use of fixed nail plates for surgical fixation of this type of fracture cannot be justified. Intramedullary nail fixation and the sliding hip screw have comparable fracture healing complication rates.

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.

Intramedullary Nailing Combined with Bone Grafting for Benign Lesions of the Proximal Femur

OBJECTIVE

To evaluate the effectiveness of intramedullary nailing for benign lesions of the proximal femur.

METHOD

A retrospective analysis was carried out on 68 cases of benign lesions in the proximal femur at our hospital from April 2002 to April 2013 (38 men and 30 women). Mean age at surgery was 35.5 years (range, 22-56 years). The cases were divided into two groups: curettage of the lesion with bone grafting only as the grafting group (32 cases) and internal fixation after removal of the lesion as the fixation group (36 cases). For the grafting group, lesions were scraped out, deactivated and washed thoroughly with normal saline, then the allogeneic bone was implanted. For the fixation group, after the lesions were scraped, the intramedullary nails were implanted, and allogeneic bone was implanted into the scraped cavity with compaction.

RESULTS

Pathological examination showed that 24 out of 68 cases (35.3%) had simple bone cysts (suffered from pathological fracture in 2 cases); 21 (30.9%) fibrous dysplasia; 18 (26.5%) aneurysmal bone cysts; 3 (4.4%) chondroblastoma, 2 (2.9%) out of which were combined with aneurysmal bone cysts. All patients were followed up for 12-96 months (56 months for mean). In the grafting group, 4 patients had postoperative complications (1 pathological bone fractures and 3 deep vein thrombosis), but only 1 patient of the fixation group (deep vein thrombosis) (P < 0.05). The average bedridden time after surgery was 11.4 ± 7.6 days for the grafting group, and for the other group was 7.5 ± 5.4 days ( P < 0.05).

CONCLUSION

Both treatments are effective for benign lesions in the proximal femur, but the fixation group facilitated the functional recovery of patients and reduced postoperative complications.

Comparison of the Sliding and Femoral Head Rotation among Three Different Femoral Head Fixation Devices for Trochanteric Fractures

Background

Recently, various femoral head fixation devices (HFDs) for trochanteric fractures have become available. However, there are some cases in which femoral head rotation with excessive sliding of the HFD is observed and it is often followed by cutout. The purpose of this study is to compare the ability of the three types of HFDs to prevent femoral head rotation.

Methods

Between July 2005 and December 2009, 206 patients aged over 60 years with trochanteric fractures who had undergone surgical treatment using a short femoral nail in our institution were enrolled into the study. We used the gamma 3 nail (GMN) as the screw-type HFD in 66 cases, the gliding nail (GLN) as a non-cylindrical blade in 76 cases, and the proximal femoral nail antirotation (PFNA) as a cylindrical blade in 64 cases. The sliding length of HFDs and the occurrence of femoral head rotation were evaluated by assessing radiographs as the main outcome, and the results were compared among these devices.

Results

A comparison of the degree of sliding in the GMN group showed that femoral head rotation was observed significantly more frequently in cases with rotation. Further, it appeared that femoral head rotation occurred more frequently in comminuted fractures. However, no significant differences between the sliding lengths of the different HFDs were observed among three groups. Femoral head rotation was observed in 15 cases of GMN (22.7%), 0 case of GLN, and 5 case of PFNA (7.8%). Significant differences with regard to the occurrence of femoral head rotation were observed among the three groups. Furthermore, significant differences were also observed between GLN and PFNA with respect to the occurrence of femoral head rotation.

Conclusions

The ability to stabilize femoral head appears to be greater with blade-type materials than with screw-type materials. Furthermore, we believe that a non-cylindrical blade is preferable to a cylindrical blade for the surgical treatment of comminuted, unstable trochanteric fractures in order to prevent femoral head rotation and cut-out.

Intertrochanteric femur fractures in the elderly treated with either proximal femur nailing or hemiarthroplasty: A prospective randomised clinical study

INTRODUCTION

The purpose of this prospective randomised study is to compare in the elderly the functional results of intertrochanteric femur fractures treated either with closed reduction and internal fixation with proximal femoral nailing or cemented hemiarthroplasty.

MATERIALS AND METHODS

The study included patients above the age of 75 who were diagnosed with intertrochanteric femur fracture and admitted to the Department of Orthopaedics and Traumatology, Ege University Hospital between October 2006 and December 2012. After informed consent was obtained from the patients, they were randomised via sealed opaque envelops into two groups. Patients in Group 1 were internally fixated utilizing proximal femoral nail, whilst the patients in Group 2 were treated with a cemented hemiarthroplasty. Complications were recorded and functional results were evaluated using the Harris Hip score. The mean time of follow up was 31.72 months (min. 18-max. 47, std. dev. ±10.68).

RESULTS

A total of 54 patients were included in the study. 21 of them (38.9%) received a proximal femoral nail whilst 33 (61.1%) were treated with hemiarthroplasty. Average age of the patients was 82.24 (min. 75-max. 97). Average age in Group 1 was 79.57 (min. 75-max. 91), whilst it was 83.94 in Group 2 (min. 75-max. 97). Harris Hip score analysis revealed that the difference between the patients treated with hemiarthroplasty and proximal femoral nailing was statistically significant in favour of the hemiarthroplasty group within the first 3 months. However, this difference diminished at the 6th month time point, and even reversed as of the 12th month postoperatively.

DISCUSSION AND CONCLUSIONS

Although cases with hemiarthroplasty achieved a better level of activity in the beginning, cases with proximal femoral nailing reached a comparable level of activity within a short period of time, faster than those treated with hemiarthroplasty, displaying a better level of activity in the end.

Static load test of the modified sliding hip screw: the DHS-AF®

OBJECTIVE:

To analyze the in vitro mechanical strength of the DHS-AF^®.

METHODS:

We evaluated the in vitro resistance of a sliding bolt modified by the addition of a connector system, DHS-AF^®.

RESULTS:

The changes performed by the authors allow the exchange by the surgeon of the sliding bolt without the need to remove the plate and disassemble the entire device to reposition it properly. We conducted a static bending test to evaluate maximum strength, stiffness and ductility of the system. DHS-AF^® showed satisfactory mechanical properties when compared to other conventional devices which use the same principle.

CONCLUSION:

Based on these results, the authors propose the use of this new implant in further in vivo studies. Level of Evidence III, Analytical Study.

In vitro comparison of resistance to implant failure in unstable trochanteric fractures fixed with intramedullary single screw versus double screw device

BACKGROUND

The purpose of this study was to compare the resistance of intramedullary single screw device (Gamma nail) and double screw device proximal femoral nail (PFN) in unstable trochanteric fractures in terms of the number of cycles sustained, subsidence and implant failure in an axial loading test in cadaveric femora.

MATERIALS AND METHODS

The study was conducted on 18 dry cadaveric femoral specimens, 9 of these were implanted with a Gamma nail and 9 with PFN. There was no significant difference found in average dual energy X-ray absorptiometry value between both groups. The construct was made unstable (AO type 31A3.3) by removing a standard sized posteromedial wedge. These were tested on a cyclic physiological loading machine at 1 cycle/s with a load of 200 kg. The test was observed for 50,000 loading cycles or until implant failure, whichever occurred earlier. Peak displacements were measured and analysis was done to determine construct stiffness and gap micromotion in axial loading.

RESULT

It was observed that there was statistically significant difference in terms of displacement at the fracture gap and overall construct stiffness of specimens of both groups. PFN construct group showed a mean subsidence of 1.02 mm and Gamma nail construct group showed mean subsidence of 2.36 mm after cycling. The average stiffness of Gamma nail group was 62.8 ± 8.4 N/mm which was significantly lower than average stiffness of the PFN group (80.4 ± 5.9 N/mm) (P = 0.03). In fatigue testing, 1 out of 9 PFN bone construct failed, while 5 of 9 Gamma nail bone construct failed.

CONCLUSION

When considering micromotion (subsidence) and incidence of implant/screw failure, double screw device (PFN) had statistically significant lower micromotion across the fracture gap with axial compression and lower incidence of implant failure. Hence, double screw device (PFN) construct had higher stability compared to single screw device (GN) in an unstable trochanteric fracture femur model.

Use of the Gamma3™ nail in a teaching hospital for trochanteric fractures: mechanical complications, functional outcomes, and quality of life

BACKGROUND

Trochanteric fractures are common fractures in the elderly. Due to characteristic demographic changes, the incidence of these injuries is rapidly increasing. Treatment of these fractures is associated with high rates of complications. In addition, the long-term results remain poor, with high morbidity, declines in function, and high mortality. Therefore, in this study, complication rates and patients' outcomes were evaluated after fixation of geriatric trochanteric fractures using the Gamma3™ nail.

METHODS

Patients aged 60 years old or older, with pertrochanteric and subtrochanteric femoral fractures, were included. Patients with polytrauma or pathological fractures were excluded. Age, sex, and fracture type were collected on admission. In addition, data were recorded concerning the surgeon (resident vs. consultant), time of operation, and local or systemic perioperative complications. Complications were also collected at the 6- and 12-month follow-ups after trauma. Barthel Index, IADL, and EQ-5D measurements were evaluated retrospectively on admission, as well as at discharge and during the follow-up.

RESULTS

Ninety patients were prospectively included between April 2009 and September 2010. The patients' average age was 81 years old, and their average ASA score was 3. The incision/suture time was 53 min (95% CI 46-60 min). Hospital mortality was 4%, and overall mortality was 22% at the 12-month follow-up. Eight local complications occurred (4 haematomas, 1 deep infection, 1 cutting out, 1 irritation of the iliotibial tract, 1 periosteosynthetic fracture). The incidence of relevant systemic complications was 6%. Forty-two percent of the patients were operated on by residents in training, without significant differences in duration of surgery, complication rate, or mortality rate. The Barthel Index (82 to 71, p < .001), IADL (4.5 to 4.3, p = .0195) and EQ-5-D (0.75 to 0.66, p = .068) values did not reach pre-fracture levels during the follow-up period of 12 months.

CONCLUSION

The results showed a relatively low complication rate using the Gamma3™ nail, even if the nailing was performed by residents in training. The high mortality, declines in function, and low quality of life could probably be attributed to pre-existing conditions, such as physical status.In summary, the Gamma3™ nail seems to be a useful implant for the nailing of trochanteric fractures, although further studies are necessary comparing different currently available devices.

Does PFNA II avoid lateral cortex impingement for unstable peritrochanteric fractures?

BACKGROUND

Proximal femoral nail antirotation devices (PFNAs) are considered biomechanically superior to dynamic hip screws for treating unstable peritrochanteric fractures and reportedly have a lower complication rate. The PFNA II was introduced to eliminate lateral cortex impingement encountered with the PFNA. However, it is unclear whether the new design in fact avoids lateral cortex impingement without compromising stability of fixation and fracture healing.

QUESTIONS/PURPOSES

We therefore asked whether the PFNA II: (1) eliminates the lateral cortex impingement and fracture displacement experienced with PFNA; and (2) provides stable fracture fixation with a low major complication rate for unstable fractures in European patients.

METHODS

We retrospectively reviewed 108 patients with an unstable peritrochanteric fracture, 58 treated with PFNA and 50 with PFNA II. We compared nail positioning, major and minor complication rates, operative and fluoroscopy time, blood transfused, time to mobilization, hospital stay, fracture union, and Harris hip score. The minimum followup was 12 months (mean, 13 months; range, 12-18 months).

RESULTS

In the PFNA II group we encountered no impingement on the lateral cortex and no patients with lateral fragment or loss of reduction at insertion, whereas with the PFNA group, we had 10 and five cases, respectively. Fracture union occurred in all patients treated with PFNA II without mechanical failures. PFNA II cases were associated with a slightly shorter surgical time than PFNA cases (23 minutes versus 27 minutes, respectively).

CONCLUSION

PFNA II avoided lateral cortex impingement experienced with PFNA, providing fast and stable fixation of the unstable peritrochanteric fractures.

LEVEL OF EVIDENCE

Level III, retrospective comparative study. See Guidelines for Authors for a complete description of levels of evidence.

Evaluation of a new computer-assisted surgical planning and navigation system based on two-dimensional fluoroscopy for insertion of a proximal femoral nail: an experimental study

Pertrochanteric femoral fractures are common and intramedullary nailing is an accepted method for their surgical treatment. Accurate placement of the implant is essential to ensure fixation. The conventional technique can require multiple guide wire passes, and relies heavily on fluoroscopy. A computer-assisted planning and navigation system based on two-dimensional fluoroscopy for guide wire placement in the femoral neck has been developed, in order to perform intramedullary pertrochanteric fracture fixation using the proximal femoral nail (PFNA). The planning process was supported by a 'zero-dose C-arm navigation' system. The PFNA was inserted into 12, intact, femoral sawbones guided by the computer-based navigation, and into 12, intact, femoral sawbones using a conventional fluoroscopic-assisted technique. Guide wire and subsequent blade placement in the femoral neck was evaluated. The computer-assisted technique achieved a significant decrease in the number of required fluoroscopic images and in the number of guide wire passes. The obtained average blade placement accuracy in the femoral neck was equivalent to the conventional technique. The operation time was significantly longer in the navigation-assisted group. The addition of computer-assisted planning and surgical guidance to the intramedullary nailing of pertrochanteric femoral fractures offers a number of clinical benefits based on the results of this sawbone study. Further studies including fractured sawbones and cadaver models with extension of the navigation process to all steps of PFNA introduction and with the goal of reducing operation time are indispensable before integration of this navigation system into clinical practice.

The dynamics of proximal femoral nails: a clinical comparison between PFNA and Targon PF

The objective of this study comparing the proximal femoral nails Targon PF (Aesculap, Tuttlingen, Germany) and Proximal Femoral Nail Antirotation (PFNA; Synthes. Oberdorf, Switzerland) was to observe the complications and postoperative results following pertrochanteric femoral fracture fixation, with special attention devoted to the dynamic properties of both implants under physiological load in vivo. The survey was designed as a randomized, prospective study of 80 patients who had sustained a pertrochanteric femoral fracture (AO type 31.A2). Postoperative radiological and clinical examinations were conducted over a period of 12 months on 40 respective patients treated with a PFNA or a Targon PF nail. Average operative time was 66.2 minutes and average fluoroscopy time was 103.6 seconds in the PFNA group, which was significantly lower than in the Targon PF group (84.7 minutes and 164.5 seconds, respectively). No significant difference was found between the 2 groups in terms of range of motion (P=.26) or Harris Hip Score (P=.83). The femoral neck components of the Targon PF showed a significantly higher sliding ability (14.5 mm; P=.04) than the PFNA (11.1 mm).Both implants are suited to treat pertrochanteric femoral fractures and display comparable clinical results. The Targon PF demonstrates better dynamic properties than the PFNA under physiological load in vivo. A disadvantage of the Targon PF, however, is the more complicated surgical technique and the longer operative time.

Investigation on the distal screw of a trochanteric intramedullary implant (Fi-nail) using a simplified finite element model

Numerous studies have been published concerning the characteristics and the behaviour of the intramedullary devices in the treatment of the intertrochanteric hip fractures. However, there is still room for further exploration and exploitation concerning the implant behaviour with respect to the parts of the implant assembly (nail, lag screw and distal screw). Towards this direction, the present paper aimed at revealing the effect of the position of the distal screw on the mechanical behaviour of the fixation device. For this purpose, a simplified model was developed and analysed with the finite element method. In total, five different locations for the distal screw were examined. In all cases, the bone was fixed at its distal end while the external load was applied at the tip of the lag screw towards the hip and in the form of orthonormal force components applied individually. The results of the FE analyses were illustrated in appropriately formed plots revealing the sensitivity of the behaviour of the implant with respect to the location of the distal screw. The main conclusion derived from the present investigation was that moving the distal screw apically decreases the stresses on the distal screw but increases the stresses on the lag screw. In turn, this indicates the existence of a location for the distal screw that compromises these two effects in an optimum way.

Medial migration of lag screw with intrapelvic dislocation in gamma nailing--a unique problem? A report of 2 cases

Within the last decade, intramedullary nailing systems have gained popularity in the treatment of unstable fractures of the trochanteric region with good clinical results. However, these implants are not free of complications. Commonly reported treatment failures include implant cutout through the femoral neck, stress-derived femur fractures at the distal end of the nail, and secondary rotational displacement and varus deformity of the femoral neck and head. Only few reports exist on primary medial migration of the lag screw after treatment with intramedullary implants. We report on a rarely described complication in 2 patients who underwent osteosynthesis with a Gamma 3 nail (Stryker, Mahwah, NJ). Both patients presented with implant failures due to primary medial migration of the lag screw. Complete separation of the implant occurred, and the lag screw penetrated through the acetabulum into the pelvis. The patient's histories and course of treatment are reported. The literature on this topic is discussed.

[Treatment results of pertrochanteric and subtrochanteric femoral fractures: a retrospective comparison of PFN and PFNA]

BACKGROUND

Can the helical blade in proximal femur nailing antirotation (PFNA) reach a better bony fixation than proximal femur nailing (PFN), thereby decreasing complication rates and improving clinical outcomes especially in osteoporotic bone?

MATERIALS AND METHODS

In a retrospective study complications and clinical treatment results of pertrochanteric and subtrochanteric femoral fractures were analyzed. For this purpose a group of patients stabilized with PFN (n=65) were compared to a patient group treated with PFNA (n=66). Objective and subjective parameters were acquired and analyzed by clinical follow-up studies using the Merle d'Aubigné score and X-ray evaluation. Individual bone quality was analyzed radiologically by determining the Singh index. The mean follow-up time was 7 months in each group.

RESULTS

The PFNA showed a decrease in postoperative implant-associated complications especially in osteoporotic bone and unstable fracture types.

CONCLUSION

The philosophy of the PFNA blade with better fixation through an increased implant-bone-interface and smaller cross-section, compaction of cancellous bone as well as an antirotational fixation, seems to show advantages compared to the double screw system of the PFN.

Comparison of migration behavior between single and dual lag screw implants for intertrochanteric fracture fixation

BACKGROUND

Lag screw cut-out failure following fixation of unstable intertrochanteric fractures in osteoporotic bone remains an unsolved challenge. This study tested if resistance to cut-out failure can be improved by using a dual lag screw implant in place of a single lag screw implant. Migration behavior and cut-out resistance of a single and a dual lag screw implant were comparatively evaluated in surrogate specimens using an established laboratory model of hip screw cut-out failure.

METHODS

Five dual lag screw implants (Endovis, Citieffe) and five single lag screw implants (DHS, Synthes) were tested in the Hip Implant Performance Simulator (HIPS) of the Legacy Biomechanics Laboratory. This model simulated osteoporotic bone, an unstable fracture, and biaxial rocking motion representative of hip loading during normal gait. All constructs were loaded up to 20,000 cycles of 1.45 kN peak magnitude under biaxial rocking motion. The migration kinematics was continuously monitored with 6-degrees of freedom motion tracking system and the number of cycles to implant cut-out was recorded.

RESULTS

The dual lag screw implant exhibited significantly less migration and sustained more loading cycles in comparison to the DHS single lag screw. All DHS constructs failed before 20,000 cycles, on average at 6,638 +/- 2,837 cycles either by cut-out or permanent screw bending. At failure, DHS constructs exhibited 10.8 +/- 2.3 degrees varus collapse and 15.5 +/- 9.5 degrees rotation around the lag screw axis. Four out of five dual screws constructs sustained 20,000 loading cycles. One dual screw specimens sustained cut-out by medial migration of the distal screw after 10,054 cycles. At test end, varus collapse and neck rotation in dual screws implants advanced to 3.7 +/- 1.7 degrees and 1.6 +/- 1.0 degrees , respectively.

CONCLUSION

The single and double lag screw implants demonstrated a significantly different migration resistance in surrogate specimens under gait loading simulation with the HIPS model. In this model, the double screw construct provided significantly greater resistance against varus collapse and neck rotation in comparison to a standard DHS lag screw implant.

The AO/ASIF proximal femoral nail antirotation (PFNA): a new design for the treatment of unstable proximal femoral fractures

INTRODUCTION

PFNA design compacts the cancellous bone to provide increased stability and has been bio-mechanically proven to retard rotation and varus collapse.

METHODS

Between 2006 and 2007, 62 consecutive patients with unstable proximal femoral fractures were treated with the PFNA.

RESULTS

Twenty males and 42 females with a mean age of 78 years (44-94) were reviewed. In 48 patients, the fracture resulted from a low energy injury. The majority of the fractures belonged to AO/ASIF types 31A2.3 (22) and 31A3.2 (29). Twelve patients required open reduction. The PFNA blade position was central in 52 patients with a mean tip-apex distance (TAD) of 12 mm (range 4-34 mm). Post-operatively, five patients died within 3 months and two patients were lost to follow-up. Forty-nine fractures united between 3 and 4 months. Four patients had delayed union. The PFNA blade cut out rate was 3.6%.

CONCLUSIONS

Unstable proximal femoral fractures were treated successfully with the PFNA. The PFNA blade appears to provide additional anchoring in osteoporotic bone. No results have been published on this new design.

The PFNA proximal femur nail in treatment of unstable proximal femur fractures--3 cases of postoperative perforation of the helical blade into the hip joint

The proximal femur nail antirotation represents a new generation of intramedullary nailing devices for fixation of stable and unstable trochanteric fractures of the proximal femur. We report 3 cases of postoperative perforation of the helical blade through the femoral head into the hip joint without any signs of rotational or varus displacement of the fracture.

A prospective trial comparing the Holland nail with the dynamic hip screw in the treatment of intertrochanteric fractures of the hip

We compared the outcome of patients treated for an intertrochanteric fracture of the femoral neck with a locked, long intramedullary nail with those treated with a dynamic hip screw (DHS) in a prospective randomised study. Each patient who presented with an extra-capsular hip fracture was randomised to operative stabilisation with either a long intramedullary Holland nail or a DHS. We treated 92 patients with a Holland nail and 98 with a DHS. Pre-operative variables included the Mini Mental test score, patient mobility, fracture pattern and American Society of Anesthesiologists grading. Peri-operative variables were anaesthetic time, operating time, radiation time and blood loss. Post-operative variables were time to mobilising with a frame, wound infection, time to discharge, time to fracture union, and mortality. We found no significant difference in the pre-operative variables. The mean anaesthetic and operation times were shorter in the DHS group than in the Holland nail group (29.7 vs 40.4 minutes, p < 0.001; and 40.3 vs 54 minutes, p < 0.001, respectively). There was an increased mean blood loss within the DHS group versus the Holland nail group (160 ml vs 78 ml, respectively, p < 0.001). The mean time to mobilisation with a frame was shorter in the Holland nail group (DHS 4.3 days, Holland nail 3.6 days, p = 0.012). More patients needed a post-operative blood transfusion in the DHS group (23 vs seven, p = 0.003) and the mean radiation time was shorter in this group (DHS 0.9 minutes vs Holland nail 1.56 minutes, p < 0.001). The screw of the DHS cut out in two patients, one of whom underwent revision to a Holland nail. There were no revisions in the Holland nail group. All fractures in both groups were united when followed up after one year. We conclude that the DHS can be implanted more quickly and with less exposure to radiation than the Holland nail. However, the resultant blood loss and need for transfusion is greater. The Holland nail allows patients to mobilise faster and to a greater extent. We have therefore adopted the Holland nail as our preferred method of treating intertrochanteric fractures of the hip.

Intramedullary osteosynthesis of complex proximal femoral fractures with the Targon PF nail

We evaluated the performance of the Targon PF nailing system in the treatment of complex proximal femoral fractures with a retrospective analysis of prospectively collected data for 94 patients with a complex proximal femoral fracture (subtrochanteric fracture or fracture with reversed fracture line pattern) treated with a Targon PF nail. There were no intra-operative femoral fractures. Late complications requiring reoperation were one femoral fracture and one fracture around the nail secondary to tumour. Seven nails had to be dynamised and a further six 'self-dynamised' at the site of the distal locking screw. One patient required revision of the distal locking. Only one other patient required secondary surgery for a wound haematoma. There were no cases of implant cut-out or non-union. The Targon PF nail represents a progressive development in the design of intramedullary nails for proximal femoral fractures and the results compare favourably with other intramedullary systems used to treat complex proximal femoral fractures.

One and two femoral neck screws with intramedullary nails for unstable trochanteric fractures of femur in the elderly--randomised clinical trial

Intramedullary nailing has been the gold standard in the management of lower limb fractures by virtue of advantage of early joint mobilisation and weight bearing. They are being increasingly used in the peri-trochanteric fractures of femur. Biomechanical studies have proved the supremacy of single femoral neck screw construct over two femoral neck screws along with the intramedullary nails in osteoporotic bones due to lower incidence of complications. This randomised clinical trial was conducted to study the clinico-radiological outcome of single and two-femoral neck screw construct in the management of unstable trochanteric fractures in the elderly osteoporotic bones. Although there was no significant difference in the clinical outcome in the two groups, less sliding of the femoral neck screws was noted with two-femoral neck screw configuration. The tip-apex distance was also significantly lower in the two-screw construct compared to that of the single screw construct. This study to our knowledge is the first randomised control clinical trial evaluating the effectiveness of one and two femoral neck screw configuration of intra-medullary nails in the management of unstable trochanteric fractures.

„Cutting out“ bei pertrochantären Frakturen – ein Problem der Osteoporose?

BACKGROUND

Despite the use of intramedullary fixation devices for the stabilisation of intertrochanteric fractures, the rate of complications is still high. One of the main reasons for burdensome reinterventions in 9-15% of cases is the cutting out of the fixation device through both the spongious bone and the cortical bone at the apex of the femoral head. This phenomenon is strongly connected to the reduction of the fractures achieved, the technical performance of the operation with optimal implant positioning and the resistance of the trabecular bone in the femoral head against deformation by the fixation device. The latter is very low in cases of severe osteoporosis. To prevent the complication of cutting out, it seems sensible to find the limits of load-bearing capacity of individual osteoporosis-associated features (i.e. bone mineral density) at which special additional measures or other techniques for the treatment of these patients are desired.

METHODS

In a first step a new biomechanical standard test for implants stabilizing unstable trochanteric fractures was developed, which would provide predictable results depending on bone mineral density. In a second step a cut-off limit was sought for the bone density in the proximal femur that would afford stable fixation as measured by QCT (quantitative computed tomography) and DEXA (dual-energy X-ray absorptiometry).

RESULTS

The developed test is realistic; it can be used to study typical cutting out phenomena on cadaver femora. In an unstable fracture model (type A 2.3 of the AO classification), the implants DHS with TSP, PFN and TGN showed a stable long-term load-bearing capacity at a bone mineral density of >0.6 g/cm3. In 5 of 32 specimens a cutting out phenomenon could be demonstrated, in 4 cases if the bone mineral density of the proximal femur was below 0.6 g/cm3 as measured by DEXA, and in one case poor performance of the implant (short screw in the femoral head) was evident.

CONCLUSIONS

In cases of bone density of >0.6 g/cm3 in the proximal femur (DEXA), the standard implants for the fixation of unstable trochanteric fractures could guarantee fixation without cutting out. The critical value of sufficient bone density in our few cases seems to be around 0.6 g/cm3 as measured by DEXA. Further investigation is needed to define the limits of bone mineral density for a successful osteosynthesis. An appropriate augmentation of the trabecular bone of the femoral head or a new design of the central loading device could increase the load-bearing capacity and thus help to reduce the cutting out phenomenon. Another alternative could be the primary implantation of an endoprosthesis in the treatment of these patients.

[Treatment results and complications after PFN osteosynthesis]

Intramedullary implants, such as the proximal femur nails (PFN), are inserted for the treatment of per-, inter- and subtrochanteric fractures. The initial experiences with these PFN, carried out by AO/ASIF in 1996, have been published.

PATIENTS AND METHODS

This study makes a systematic examination of the complications and clinical treatment results from 133 patients treated at our clinic from December 1997-2001 with 139 PFN in per-, inter- and subtrochanteric femur fractures. The mean age at the time of surgery was 78.4 years. All fractures were classified according to the AO system. The most frequent injuries were 31 A2.3 fractures (61.2%). All intraoperative image-converter images and all radiographs from the total period of treatment were evaluated retrospectively in accordance with 28 criteria. The degree of osteoporosis was estimated using the Singh classification.

RESULTS

A total of 44 (31.7%) complications arose in 31 (23.3%) patients. On 11 occasions, hip screw cut-out was observed. Of these, two cases involved a Z-effect and one an inverted Z-effect. Two patients suffered a femoral neck fracture following removal of the hip screws. There were 38 (27.3%) reoperations required with 13 changes in procedure. In autumn 2002, clinical follow-up examinations were carried out on 65 (48.9%) patients who were assessed according to the Merle d'Aubigné score. A total of 51 (38.3%) patients had died at the time of follow-up. Normal ambulation was achieved by 33.8% of patients, while 64.6% were free of pain.

CONCLUSIONS

The PFN is an appropriate implant in cases of per-, inter- and subtrochanteric femur fractures. Anatomical resetting and correct implant positioning are the keys to successful osteosynthesis. The risk of implant failure is highest in the case of multi-fragmentary per- and intertrochanteric fractures in which medial strengthening has been degraded in patients aged over 80 years. The clinical results in elderly patients are unsatisfactory.

Unstable trochanteric femoral fractures: extramedullary or intramedullary fixation. Review of literature

For operative treatment of unstable trochanteric fractures two options exist: extramedullary or intramedullary stabilisation. A review of 18 international papers that compared two different treatment methods for trochanteric fractures, in prospective randomised clinical trials, is presented. In view of the overall results, routine use of intramedullary fixation devices is not to be recommended for stable trochanteric fractures. For these fractures one of the sliding hip screw systems provides a safe and simple alternative. For unstable fractures intramedullary implants are (biomechanically) superior. The review shows that clinical advantages of both treatment methods are suggested and advocated, but still remain to be demonstrated on evidence base.