Postoperative stability on lateral radiographs in the surgical treatment of pertrochanteric hip fractures

Incidence and Risk Factors of Osteonecrosis of the Femoral Head after Cephalomedullary Nailing for Pertrochanteric Fractures: Observational Single-Center Study

Background

The objective of this study was to investigate the incidence of osteonecrosis of the femoral head (ONFH) after cephalomedullary nailing in elderly patients with pertrochanteric fractures and to analyze the risk factors related to ONFH.

Methods

A total of 689 consecutive patients with cephalomedullary nailing for pertrochanteric fractures at our hospital were recruited. Of these, 368 patients who met the inclusion criteria were finally enrolled. ONFH after cephalomedullary nailing was identified by reviewing patients' electronic charts and serial radiographs. The ONFH group was then compared with the non-ONFH group.

Results

ONFH was identified in 9 of 368 patients (2.4%). The time to diagnosis of ONFH averaged 23.8 months (range, 5-54 months) after index surgery. The mean age, body mass index, and bone mineral density (T-score in femur neck) were 84.1 ± 7.1 years, 23.7 ± 3.6 kg/m2, and -3.1 ± 0.7 kg/m2, respectively. The times from injury to surgery, from admission to surgery, and operation time averaged 4.2 ± 2.7 days, 3.6 ± 2.6 days, and 87.2 ± 30.0 minutes, respectively. Among 9 patients, 3 underwent conversion arthroplasty. The ONFH group had advanced age (p = 0.029), more basicervical fracture components (p = 0.002), and inadequate reduction (p = 0.045) compared to the non-ONFH group. On multivariate analysis, advanced age (odds ratio [OR], 1.61;, p = 0.022), basicervical fracture components (OR, 24.58; p = 0.001), and inadequate reduction (OR, 4.11; p = 0.039) were identified as risk factors of ONFH.

Conclusions

Although ONFH is relatively rare after cephalomedullary nailing for pertrochanteric fractures in elderly patients, its risk may increase with advanced age, basicervical fracture components, and inadequate reduction. Therefore, in patients with these risk factors, meticulous and longer follow-up is needed even after bone union.

Anterior Malreduction is Associated With Lag Screw Cutout After Internal Fixation of Intertrochanteric Fractures

BACKGROUND

Lag screw cutout is a devastating complication after internal fixation of an intertrochanteric fracture. Although the tip-apex distance (TAD) is known to be associated with this complication, another factor we thought was potentially important-fracture reduction on an oblique lateral view-has not, to our knowledge, been explored.

QUESTIONS/PURPOSES

(1) Is a well-reduced fracture position on an oblique lateral view after internal fixation of intertrochanteric fracture associated with a lower odds of postoperative cutout, independently of the TAD? (2) Is postoperative sliding of the lag screw after fixation associated with postoperative cutout?

METHODS

Patients with intertrochanteric fractures who were at least 65 years old and who had been treated with internal fixation in one of six facilities between July 2011 and December 2017 were included. All patients in the study group had lag screw cutout, and controls were selected by risk-set sampling of age-matched and sex-matched patients using a ratio of 4:1 for patients from each hospital. Of the 2327 intertrochanteric fractures, there were 36 patients (0.02 per person-year), with a mean age of 85 years; 89% (32) were women. In the control group, there were 135 controls. There was no difference in age or sex between the two groups. Sagittal reduction was evaluated using an immediate postoperative oblique lateral radiograph (anterior malreduction versus anatomic reduction or posterior malreduction). The association between anterior malreduction and the odds of cutout was estimated by conditional logistic regression analysis with the TAD and interaction between the TAD and the reduced position as covariates. As a sensitivity analysis, we estimated whether sliding within 2 weeks postoperatively was associated with cutout.

RESULTS

After controlling for the potentially confounding variables of age and sex, we found that anterior malreduction was independently associated with a higher odds of cutout compared with anatomic reduction or posterior malreduction (adjusted OR 4.2 [95% CI 1.5 to 12]; p = 0.006). There was also an independent association between cutout and larger TAD (≥ 20 mm) (adjusted OR 4.4 [95% CI 1.4 to 14]; p = 0.01). However, the association between cutout and reduction was not modified by the TAD (adjusted OR of interaction term 0.6 [95% CI 0.08 to 4]; p = 0.54). Postoperative sliding ≥ 6 mm within 2 weeks was associated with higher odds of cutout after adjusting for age and sex (adjusted OR 11 [95% CI 3 to 40]; p < 0.001).

CONCLUSION

In patients older than 65 years with intertrochanteric fractures, anterior malreduction on a lateral oblique view was associated with much greater odds of postoperative cutout than anatomic reduction or posterior malreduction. Because anterior malreduction is within the surgeon's control, our findings may help surgeons focus on intraoperative reduction on an oblique lateral view to prevent cutouts. Although this factor is a reliable indicator, the results should be applied to cephalomedullary nails, because there was only one patient with cutout among those with sliding hip screws. Because this study was conducted in a homogenous Japanese population, future studies should focus on the association between anterior malreduction and cutout in people of different ethnicities, adjusting for confounding factors such as implant type and surgeon level.

LEVEL OF EVIDENCE

Level III, therapeutic study.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The role of postoperative piriformis fossa and greater trochanter tubercle distance to predict cutout failure after cephalomedullary nail fixation

BACKGROUND

This study investigated the association between postoperative piriformis fossa and greater trochanter tubercle distance (distance from the deepest point of piriformis fossa to the most lateral greater trochanter tubercle [PG]) and cutout failure after cephalomedullary nail (CMN) osteosynthesis for intertrochanter fracture (ITF). A rotating femur model was designed to analyze PG variation during femur rotation.

METHODS

From 2005 to 2010, 311 patients diagnosed of ITF (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association [AO/OTA] 31-A2 and A3) underwent CMN fixation at our institute were reviewed. Of these, 281 (90.3%) patients achieved union without complication, 21 (6.8%) had cutout failure, six (1.9%) had femoral head osteonecrosis, and three (1%) had nonunion during postoperative 2-year follow-up. The side difference of postoperative PG compared to contralateral uninjured hip (dPG) was analyzed between patients who had cutout failure and those who did not. In the rotating femur model, the PG was measured for every 2.5° increments of internal and external rotation from 0° to 50°.

RESULTS

The dPG was significantly higher in the failure group (10.2 ± 4.2 vs 6.6 ± 3.5 mm, p <0.001). The odds ratio for lag screw cutout was 6.35 (95% CI, 1.10-11.6, p =0.003) for every 1 mm dPG increment. dPG exhibited high diagnostic performance in predicting cutout failure according to receiver operating characteristic curve analysis. The area under the curve was 0.774 (95% CI, 0.711-0.837). dPG yielded the greatest sensitivity (78.4%) and specificity (78.4%) to predict lag screw cutout when cutoff value being 8.65 mm. In rotating femur model, PG change from baseline demonstrated significant ( p <0.001) positive and negative correlation with increased external and internal rotation, respectively.

CONCLUSION

Increased dPG is a risk factor of cutout failure for ITF osteosynthesis with CMN. In conjunction with tip-apex distance, fracture displacement, and reduction quality; dPG can help surgeons interpret postoperative radiograph and predict failure. However, it should be noticed that a proper and standard patient positioning is critical for accurate dPG measurement.

The remnant axial cortical length of the proximal femur in pertrochanteric fractures: a three-dimensional computed tomography study and its clinical implications

BACKGROUND

Cortical buttress are important factors for postoperative stable reconstruction of per/inter-trochanteric fractures. The study aimed to measure the remnant axial cortical length (RACL) of the proximal circumference of the femur, and to determine which part of the RACL can be used reliably to postoperatively sustain the head-neck fragment as a cortical support pattern.

METHODS

Eighty patients with trochanteric hip fractures admitted from January 2015 to January 2016 were included in a retrospective study. Their pre-operative computed tomography (CT) images were used to form 3D-CT reconstructions via Mimics software. After simulated rotation and movement for fracture reduction, the RACL, its three component parts-namely, the remnant anterior cortex (RAC), remnant lateral cortex (RLC), and remnant posterior cortex (RPC) -the γ angle between the anterior and posterior cortex, and the Hsu's lateral wall thickness (LWT) were evaluated.

RESULTS

Patients with an A1 fracture (21/80) had a longer RACL (88.8 ± 15.8 mm) than those with an A2 fracture (60.0 ± 11.9 mm; P < 0.01). The RAC, RLC, and RPC of the RACL in A1 fractures were also significantly longer than those in A2 fractures (P < 0.001). However, the most significant difference among the three components of the RACL was in the RPC, which was 27.3 ± 7.8 mm in A1 fractures and 9.2 ± 6.6 mm in A2 fractures. In addition, the coefficient of variation of the RAC was only 20.0%, while that of the RPC was 75.5%. The average γ angle in A1 fractures was 16.2 ± 13.1°, which was significantly smaller than that in A2 fractures, which was 40.3 ± 14.5° (P < 0.001). There was a significant statistical difference in the LWT between A1 and A2 fractures (P < 0.001). There were significant differences in the RACL, RAC, RLC, RPC, γ angle, and LWT among the five subtypes (P < 0.001).

CONCLUSIONS

The RAC is relatively stable in pertrochanteric fractures. Fracture reduction through a RAC buttress may help to enhance the postoperative stable reconstruction of per/inter-trochanteric fractures and make possible good mechanical support for fracture healing.

Residual lateral wall width predicts a high risk of mechanical complications in cephalomedullary nail fixation of intertrochanteric fractures: a retrospective cohort study with propensity score matching

PURPOSE

The purpose of this study is to determine whether the integrity of the entry portal of head-neck implant is related to postoperative mechanical complications.

METHODS

We retrospectively reviewed consecutive patients with pertrochanteric fractures in our hospital treated from January 1, 2018, to September 1, 2021. Based on the integrity of the entry portal for head-neck implants on the femoral lateral wall, patients were divided into two groups, including the ruptured entry portal (REP) group and the intact entry portal (IEP) group. After 4:1 propensity score-matched analyses were used to balance the baseline of the two groups, a total of 55 patients were extracted from the original participants, including 11 patients in the REP group and 44 matched patients in the IEP group. The anterior to posterior cortex width on the mid-level of the lesser trochanter was measured and defined as the residual lateral wall width (RLWW).

RESULTS

Compared with the IEP group, the REP group was correlated with postoperative mechanical complications (OR = 12.00, 95% CI 1.837-78.369, P = 0.002) and hip-thigh pain (OR = 26.67, 95% CI 4.98-142.86). RLWW ≤ 18.55 mm indicated a high likelihood (tau-y = 0.583, P = 0.000) of becoming the REP type postoperatively and being more likely to suffer from mechanical complications (OR = 30.67, 95% CI 3.91-240.70, P = 0.000) and hip-thigh pain (OR = 14.64, 95% CI 2.36-90.85, P = 0.001).

CONCLUSION

Rupture of entry portal is a high-risk factor for mechanical complications in intertrochanteric fractures. RLWW ≤ 18.55 mm is a reliable predictor of the postoperative REP type.

Insufficient proximal medullary filling of cephalomedullary nails in intertrochanteric femur fractures predicts excessive postoperative sliding: a case-control study

OBJECTIVE

Excessive postoperative sliding is a common complication of intramedullary nails in the treatment of intertrochanteric femur fractures. The aim of this study was to identify risk factors for excessive postoperative sliding in the intertrochanteric fractures treated with an intramedullary nail.

METHODS

A retrospective analysis of 369 patients with femoral intertrochanteric fractures treated with short intramedullary nails between February 2017 and September 2020 was performed. Patients were classified into an excessive sliding group (ES group) and a control group according to the sliding distance after 6 months of follow-up. The proximal medullary filling degree (MFD), fracture reduction patterns in the anteroposterior (AP) view and lateral view, and tip-apex distance (TAD) were evaluated and compared in each group.

RESULTS

Thirty-three cases were included in the ES group, and 336 cases were included in the control group. No significant differences in age, sex, fracture side, AO Foundation and Orthopaedic Trauma Association (AO/OTA) classification, Dorr classification, Singh Osteoporosis Index (SOI), American Society of Anesthesiologists classification (ASA), TAD or fracture reduction patterns in the AP view were noted between the two groups. The negative reduction pattern can strongly predict excessive postoperative sliding (OR 4.286, 95% CI 1.637-11.216, P = 0.003). The incidence of excessive postoperative sliding increased by 8.713-fold when the MFD decreased by 10% (OR 8.713, 95% CI 1.925-39.437, P = 0.005).

CONCLUSIONS

A low medullary filling degree and negative fracture reduction pattern in the lateral view were both independent risk factors for excessive postoperative sliding.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

AP3×ML3 reduction quality classification for femoral trochanteric fractures: validation for reliability focusing on positive medial cortical support

INTRODUCTION

This study evaluated the validity of the AP3 × ML3 reduction quality classification, which applies the concept of positive medial cortical support.

METHODS

A total of 120 trochanteric fractures classified as AO Foundation/Orthopedic Trauma Association 31A1 and A2 were retrospectively analyzed. The validity of the AP3 × ML3 classification was evaluated by comparison with the Baumgaertner reduction quality criteria. When using the AP3 × ML3 classification, reduction quality was divided into three classes based on the degree of anterior cortical contact between the proximal and distal fragments. Reduction quality was also divided into three classes when using the Baumgaertner criteria. The frequency of mechanical complications, including cut-out, delayed union, and excessive migration of the lag screw, was retrospectively assessed. Intra-observer and inter-observer reliability was assessed using the intraclass correlation coefficient (ICC).

RESULTS

Mechanical complications included 4 cases of cutout (3.3%) and 1 of delayed union (0.8%). Mechanical complications occurred for all levels of reduction quality in both classifications, except for the acceptable of the Baumgaertner criteria. When reduction quality was rated as good, acceptable, and poor the incidence of mechanical complications was 2.5%, 5.7%, and 16%, respectively, under the AP3 × ML3 classification and 3.3%, 0%, and 15.0%, respectively, under the Baumgaertner criteria. The ICC was 0.80 for intra-observer reliability and 0.57 for inter-observer reliability when using the AP3 × ML3 classification and 0.85 and 0.34, respectively, when using the Baumgaertner criteria.

CONCLUSION

The AP3 × ML3 classification was reliable and easy to use compared with the widely used Baumgaertner reduction quality criteria. Level of evidence 4.

The postoperative prognosis of older intertrochanteric fracture patients as evaluated by the Chang reduction quality criteria

OBJECTIVE

The aim of this study was to investigate the relationship between the Chang reduction quality criteria (CRQC) and the outcome of intertrochanteric fractures in older adults according to follow-up time.

METHODS

This was a retrospective analysis of 389 older adult patients with intertrochanteric fractures treated surgically from January 2019 to June 2021, including 130 males and 259 females aged 84.6 (77.5-89.7) years. Patient survival was determined by telephone as the time between admission to hospital for fracture and death or until the study deadline (June 1, 2022). According to the CRQC, the patients were divided into the Poor, Acceptable, and Excellent groups. Univariate and multivariate Cox proportional hazard models were used to assess the association between CRQC and all-cause mortality in older adult intertrochanteric fractures at 1 year and the total follow-up time. Further subgroup analysis was performed according to different clinical and biological characteristics to improve the accuracy of the results.

RESULTS

The mortality rates were 24.7% and 15.4% at 1 year and the total follow-up time, respectively. Both at one year and the total follow-up time, the mortality of the CRQC-Excellent group was significantly lower than that of the CRQC-Acceptable group (p.adj < 0.05) and the CRQC-Poor group (p.adj < 0.05). After multifactor adjustment, CRQC grades of Acceptable and Poor were independent risk factors affecting the overall and 1-year mortality. In addition, advanced age, ≥ 1 comorbidities, ASA 3 + 4, and prolonged preoperative waiting time were independent risk factors for survival at the total follow-up time. At 1 year, only ASA 3 + 4 and prolonged preoperative waiting time were independent risk factors for survival. Subgroup analysis according to different characteristics at the total follow-up time and at one year showed that in most subgroups, a decrease in the CRQC grade was significantly associated with an increase in all-cause mortality (p for trend < 0.05).

CONCLUSIONS

This study highlights that CRQC grades of Acceptable and Poor are associated with increased all-cause mortality in older adult intertrochanteric fractures. We should attempt to achieve good reduction of these fractures.

Offset nail fixation for intertrochanteric fractures improves reduction and lag screw position

BACKGROUND

Surgery for intertrochanteric fractures using intramedullary hip nails (IHNs) is among the most common surgical procedures in the orthopedic field. Although IHNs provide good overall outcomes, they sometimes cause complications, such as loss of reduction and cut-out. Here, we investigated the usefulness of IHNs with an anterior offset (Best Fit Nail® [BFN]) in maintaining fragment reduction and ensuring proper lag screw position compared with conventional non-offset nails (Proximal Femoral Nail Antirotation® [PFNA]), using postoperative computed tomography (CT).

METHODS

Fifty consecutive patients with intertrochanteric fractures who underwent surgery with BFNs (BFN group) and 50 patients who underwent surgery with PFNAs (PFNA group) were retrospectively analyzed. Indices evaluated by postoperative CT were displacement distance of proximal fragment relative to distal fragment, reduction status (intramedullary, anatomical, and extramedullary types), lag screw direction, and angle between lag screw and femoral neck axis (deviation angle).

RESULTS

Median [interquartile range] displacement distance was significantly smaller in the BFN group (0 [0, 0] mm) compared with the PFNA group (5.2 [3.6, 7.1] mm) (p<0.001). Reduction status was significantly better in the BFN group (anatomical type, 40 cases; intramedullary type, in 9 cases, and extramedullary type in 1 case) than in the PFNA group (anatomical type, 6 cases; intramedullary type, 43 cases; extramedullary type, 1 case) (p<0.001). Deviation of lag screw direction was observed in significantly fewer cases in the BFN group (20 cases; 40%) compared with the PFNA group (36 cases; 72%). Lag screw deviation angle was significantly smaller in the BFN group (-0.71°±4.0°) compared with the PFNA group (6.9°±7.1°). No adverse events related to surgery were observed in either group.

CONCLUSIONS

Intertrochanteric fracture surgery using offset BFNs exhibited significantly smaller displacement distance, better reduction status, and higher frequency of no deviation with central lag screw position, compared with surgery using non-offset PFNAs.

Intraoperative fractures in cephalomedullary nailing for trochanteric fractures

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The effects of bone-substitute augmentation on treatment of osteoporotic intertrochanteric fractures

Background

Methods

Results

Conclusions

Level of evidence

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Comparison of sliding distance of lag screw and nonunion rate according to anteromedial cortical support in intertrochanteric fracture fixation: A systematic review and meta-analysis

INTRODUCTION

We compared the sliding distance of the lag screw, change in neck-shaft angle (NSA), and nonunion rates according to the anteromedial cortical support on anteroposterior (AP) and lateral view radiographs post intertrochanteric fracture reduction.

MATERIAL AND METHODS

In this systematic review and meta-analysis, MEDLINE, Embase, and Cochrane Library databases were searched systematically for studies published before September 26, 2020. We performed synthetic analyses of the amount of lag screw sliding, change in NSA, and incidence of nonunion following reduction of intertrochanteric fractures by extramedullary reduction (EMR), neutral reduction (NR), and intramedullary reduction (IMR). The combined data of EMR and NR comprised the non-IMR group.

RESULTS

Our study enrolled eight studies, representing 1,363 patients who underwent surgery for intertrochanteric fractures. A pooled analysis showed a larger sliding distance in the IMR group than in the non-IMR group (standard mean difference [SMD] = 1.47, 95% confidence interval [CI]: 0.73-2.20; P < 0.0001 and SMD = 1.27, 95% CI: 0.56-1.99; P = 0.0005, respectively) in both AP and lateral views. The pooled mean difference of change in NSA in the IMR group was -3.11° and differed significantly from that of the non-IMR group (95% CI: -4.07 to -2.16; P < 0.0001). In the lateral view, the nonunion rate was significantly higher in the IMR group than in the non-IMR group (odds ratio [OR] = 11.61; 95% CI, 3.32-40.62; P = 0.0001). In the subgroup analysis, the NR group showed a larger sliding distance than that of the EMR group in the AP view (SMD = 0.40, 95% CI: 0.04-0.76; P = 0.03); however, the reverse was true in the lateral view (SMD = 0.68, 95% CI: 0.38-0.97; P < 0.00001).

CONCLUSION

In the current meta-analysis, larger sliding distances, more varus in NSA, and higher nonunion rates were observed in the IMR group than the non-IMR group, in both AP and lateral views. However, in the comparison between EMR and NR, it was difficult to conclude which of them was the ideal reduction method because of inconsistent results.

Additional Reduction Screw Fixation Technique for Pertrochanteric Hip Fractures: A Novel Method to Prevent Excessive Sliding in Cephalomedullary Nail Surgery

Extramedullary (EM) reduction, defined as the medial cortex of the head-neck fragment located outside the medullary canal of the distal shaft fragment, has been introduced to prevent excessive postoperative sliding or failure of the lag screw in pertrochanteric fracture surgeries. Favorable EM reduction results have recently been reported in several clinical and biomechanical studies. Despite these efforts, maintaining the head-neck fragment in an EM position is periodically a difficult and challenging problem. Herein, the technique for reduction and maintenance of the head-neck fragment was introduced in an EM position using a Kirschner wire and partially threaded cannulated screw fixation via screw fixation from EM to the head-neck fragment, which was positioned inferior to the lag screw on the femoral calcar, also called the reduction screw. The authors utilized this reduction screw in 34 pertrochanteric fracture surgeries using a cephalomedullary nail and fracture union was acheive in all cases by a minimum one-year follow-up period without surgical complications.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level 1.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Effect of Fracture Reduction with Different Medial Cortical Support on Stability After Cephalomedullary Nail Fixation of Unstable Pertrochanteric Fractures: A Biomechanical Analysis

BACKGROUND

This study evaluated the biomechanics of the proximal femoral nail antirotation-II (PFNA-II) in AO/OTA 31A2.2 intertrochanteric fractures based on the fracture reduction quality.

METHODS

Unstable intertrochanteric fractures were created according to the AO classification and repaired by proximal femoral nail antirotation-II (PFNA-II) using one of three medial cortical support groups. The specimens were tested using cyclic axial loading. The following parameters were recorded: force and stiffness at failure, maximum vertical and horizontal displacement, neck-shaft angle, and location and patten of failure.

RESULTS

In the cyclic loading test, the force at failure in the anatomical reduction (AR) group was greater than that of the positive medial cortical support (PMCS) group (984.22 ± 12.63 vs. 936.95 ± 16.78) N (P < 0.05) and negative medial cortical support (NMCS) group (918.04 ± 28.86) N (P < 0.05). The stiffness in the AR group was 4.77 and 31.9% higher than that in the PMCS group (P > 0.05) and NMCS group (P < 0.05). The maximum vertical displacement was the largest in the NMCS group. The maximum horizontal displacement in the NMCS group was 28.6 and 19.1% larger than that in the AR group (P > 0.05) and PMCS group (P < 0.05). The neck-shaft angle in the NMCS group was smaller than that in the anatomic reduction group (P < 0.05) and positive support group (P < 0.05).

CONCLUSION

For the unstable AO/OTA 31A2.2 intertrochanteric fracture, there were significant differences in their mechanical stability among AR, PMCS and NMCS. The NMCS is not recommended during the intraoperative reduction.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Radiological findings and outcomes of anterior wall fractures in pertrochanteric fractures

BACKGROUND

Anterior wall fractures with comminution at the anterior cortex in pertrochanteric fractures are relatively rare. We aimed to investigate the prevalence and clinical findings of anterior wall fractures in this comparative cohort study.

METHODS

We reviewed 516 consecutive patients who underwent internal fixation. Anterior wall fractures were classified into three types: proximal, distal, and proximal/distal. Outcome measures included demographic data, residual anterior cortex length, fracture reduction, tip-apex distance (TAD), sliding distance, bone union, and revision surgery. We compared radiological outcomes between patients with anterior wall fractures and posterior comminuted fractures without an anterior wall fracture. The groups were matched for age and sex.

RESULTS

Anterior wall fractures were noted in 44 patients (8.5%). Residual anterior cortex length was shorter for the proximal/distal type. The distal type was the most common, was the most difficult to achieve an acceptable reduction status for, and was associated with the longest sliding distance. The proportion of unacceptable reduction status was higher for anterior wall fractures. However, there were no statistically significant differences between anterior wall fractures and posterior comminuted fractures without an anterior wall fracture in terms of TAD, sliding distance, bone union, and revision rate.

CONCLUSIONS

This study suggests that anterior wall fracture is not a significant predictor of over-sliding distance.

Biomechanical Evaluation of Extramedullary Versus Intramedullary Reduction in Unstable Femoral Trochanteric Fractures

Introduction:

The failure rate of operations involving the cephalomedullary nail technique for unstable femoral trochanteric fractures is 3-12%. Changing the reduction strategy may improve the stability. This study aimed to confirm whether reducing the proximal fragment with the medial calcar contact, as opposed to utilizing an intramedullary reduction, would improve the stability of such fractures.

Materials and Methods:

The unstable femoral trochanteric fracture model was created with fixation by cephalomedullary nails in 22 imitation bones. The 2 reduction patterns were as follows: one was with the proximal head-neck fragment external to the distal bone in the frontal plane and anterior in the sagittal plane as “Extramedullary,” while the other was the opposite reduction position, that is, bone in the frontal plane and sagittal plane as “Intramedullary.” We evaluated the tip-apex distance, compression stiffness, change in femoral neck-shaft angle, amount of blade telescoping, and diameter of the distal screw hole after the compression test. Statistical analysis was conducted using the Mann-Whitney U test.

Results:

No significant differences were seen in compression stiffness (p = 0.804) and femoral neck-shaft angle change (p = 0.644). Although the “Extramedullary” tip-apex distance was larger than the “Intramedullary” distance (p = 0.001), it indicated clinically acceptable lengths. The amount of blade telescoping and the distal screw hole diameter were significantly larger in “Intramedullary” than in “Extramedullary” (p < 0.001, p = 0.019, respectively). Our results showed that “Intramedullary” had significantly larger blade telescoping and distal screw hole diameters than “Extramedullary,” and contrary to our hypothesis, no significant differences were seen in compression stiffness and femoral neck-shaft angle change.

Conclusions:

As opposed to the “Intramedullary” reduction pattern, the biomechanical properties of the “Extramedullary” reduction pattern improved stability during testing and decreased sliding.

Three-Dimensional Mapping of Medial Wall in Unstable Pertrochanteric Fractures

OBJECTIVE

Unstable pertrochanteric fractures are usually treated with internal fixation, and the integrity of the anteromedial cortex is an important factor for stability and healing. In this study, we described and analyzed the three-dimensional mapping technology and morphological characteristics of pertrochanteric fractures.

METHODS

Fifty-nine pertrochanteric fractures (OTA/AO 2007 types 31A2) were retrospectively reviewed. Computed tomographic (CT) images for all fractures were superimposed on a standard template. Medial wall integrity was analyzed, and three-dimensional fracture maps were created.

RESULTS

Pertrochanteric fractures always have a posterior defect in the medial cortex. The mean width of the defect, in our study, was 21.5 mm (SD: 6.1 mm, range: 10-40 mm), 56.3% (SD: 13.7%, range: 27.5-100%). Bone segments that contact by the anteromedial cortex were 16.5 mm (SD: 5.3 mm, range: 0-29 mm).

CONCLUSION

The integrity of the anteromedial cortex should be considered during internal fixation of femoral trochanteric fractures. These morphological characteristics could be used to form postoperative cortical contact and improve stability of the fixation. Three-dimensional mapping technology can help establish a typical fracture model, thereby improving doctors' understanding of fracture characteristics.

Intertrochanteric Femur Fracture Treatment in Asia: What We Know and What the World Can Learn

Hip fractures are of great interest worldwide as the geriatric population continues to increase rapidly. Currently, surgeons prefer to use cephalomedullary nail for internal fixation of pertrochanteric/intertrochanteric fractures. This article summarizes 10 concepts in hip fracture treatment over the past 20 years, including fracture line mapping, proximal lateral wall and anterior cortex, posteromedial lesser trochanter-calcar fragment, anteromedial cortex support reduction, changes of fracture reduction after sliding and secondary stability, nail entry point and wedge-open deformity, tip-apex distance and calcar-referenced tip-apex distance, femoral anterior bowing and nail modification, long nails for wide medullary canal and large posterior coronal fragment, and postoperative stability score.

Percutaneous acetabular anchoring pin-assisted cephalomedullary nailing for subtrochanteric and unstable intertrochanteric fractures

It is important to maintain acceptable reduction and make suitable entry when performing cephalomedullary nailing for subtrochanteric and unstable intertrochanteric fractures; however, this is often challenging due to deforming forces or the unstable nature of the fracture itself. Several percutaneous reduction techniques for fractures have been introduced, but, in some cases, a loss of reduction during the nailing procedure is experienced. To prevent this problem, it is important to keep the proximal fragment stable for the entire nailing procedure. The present study reports favourable outcomes for cephalomedullary nailing for subtrochanteric and unstable intertrochanteric fractures when percutaneous acetabular anchoring pin is used to maintain the proximal fragment stably in the reduced position.

Outcomes of Combined Neck and Trochanter Fractures of the Femur Treated with Cephallomedullary Nail in Elderly

Purpose

Proximal femur fractures are classified into intracapsular neck fractures and extracapsular trochanteric fractures, and several related treatment recommendations in elderly patients have already been introduced. Importantly, we have observed cases of combined intra and extracapsular fractures (i.e., ipsilateral neck and trochanter fractures). The purpose of this study is to report the outcomes of combined neck and trochanter fractures of the femur treated with cephalomedullary nail (CMN) in elderly patients.

Materials and Methods

From January 2010 to December 2014, 410 patients with proximal femoral fractures were fixed using CMN; among this group, 37 patients with combined neck and trochanter fractures were identified. Two of these patients died fewer than three months after injury and another two did not return for follow-up. Thirty-three patients were included and reviewed retrospectively in this study.

Results

All patients were injured by simple fall. Bone union was obtained in 28 of 33 patients. Of the five patients who failed treatment, three experienced implant penetration through head (cut-through and cut-out), one had breakage of CMN and the last one had a loosening of internal fixation device with persistent non-union at final follow-up. The former four patients underwent hip replacement surgery and the latter refused surgery because he had low demand in daily life and many medical problems.

Conclusion

Eighty-five percent of elderly patients with combined neck and trochanter fractures of the femur treated with CMN achieved bone union; these complex fractures require more accurate reduction than usual extra-articular intertrochanteric fractures.

Comparison of Baumgaertner and Chang reduction quality criteria for the assessment of trochanteric fractures

Objectives

Different criteria for assessing the reduction quality of trochanteric fractures have been reported. The Baumgaertner reduction quality criteria (BRQC) are relatively common and the Chang reduction quality criteria (CRQC) are relatively new. The objectives of the current study were to compare the reliability of the BRQC and CRQC in predicting mechanical complications and to investigate the clinical implications of the CRQC.

Methods

A total of 168 patients were assessed in a retrospective observational study. Clinical information including age, sex, fracture side, American Society of Anesthesiologists (ASA) classification, tip-apex distance (TAD), fracture classification, reduction quality, blade position, BRQC, CRQC, bone quality, and the occurrence of mechanical complications were used in the statistical analysis.

Results

A total of 127 patients were included in the full analysis, and mechanical complications were observed in 26 patients. The TAD, blade position, BRQC and CRQC were significantly associated with mechanical complications in the univariate analysis. Only the TAD (p = 0.025) and the CRQC (p < 0.001) showed significant results in the multivariate analysis. In the comparison of the receiver operating characteristic curves, the CRQC also performed better than the BRQC.

Conclusion

The CRQC are reliable in predicting mechanical complications and are more reliable than the BRQC. Future studies could use the CRQC to assess fracture reduction quality. Intraoperatively, the surgeon should refer to the CRQC to achieve good reduction in trochanteric fractures.

Cite this article: Bone Joint Res 2019;8:502–508.

Preoperative radiographic features of trochanteric fractures irreducible by closed reduction

INTRODUCTION

The aim of this study was to clarify the relationship between the preoperative radiographic classification of trochanteric fractures and the success/failure of closed reduction. Identification of irreducible fractures would be important to proceed promptly to direct reduction.

PATIENTS AND METHODS

Our retrospective analysis included 141 trochanteric fractures, in 122 women and 17 men, with a mean age of 85.7 years (range, 45-101 years). Evans' classification of trochanteric fractures, as modified by Jensen, and the lateral view classification were used, based on preoperative plain radiographs and computed tomography images. Features predictive of irreducible fractures were identified.

RESULTS

Among the 141 fractures, 16 (11.3%) were irreducible by closed reduction. The position of the proximal fragment, relative to the shaft on lateral view, and the fracture pattern of the lesser and greater trochanters were predictive of the feasibility of obtaining a successful closed reduction. These criteria identified success/failure of closed reduction in 99.3% of cases.

CONCLUSION

Our findings should be useful for identifying patients in whom closed reduction would be suitable and for avoiding ineffectual manipulation in unsuitable patients.

Effect of a synthetic osteoconductive bone graft substitute with zeta potential control (geneX®ds) in the treatment of intertrochanteric fracture: A single center experience of 115 consecutive proximal femoral nail antirotations

INTRODUCTION

Although various clinical applications of geneX^®ds have been reported, no study has reported the clinical application of geneX^®ds in osteoporotic hip fracture. The present study aimed to identify the clinical effect of the application of geneX^®ds in elderly patients with intertrochanteric fracture treated using proximal femoral nail antirotation (PFNA).

MATERIALS AND METHODS

From March 2014 to October 2017, 233 patients with intertrochanteric fracture (65 men and 168 women) were enrolled in this study. All patients received surgical treatment using PFNA. Patients were classified into two groups: those in whom geneX^®ds which is synthetic osteoconductive bone graft substitute with the unique property of Zeta Potential Control (ZPC^®), was use, and those in whom it was not. We compared the preoperative details and surgical outcomes, including radiologic outcome (postoperative reduction, tip apex distance, sliding distance of the helical blade, union, and union time) and clinical outcomes (Harris Hip Score and the walking ability at the last follow-up) between the groups.

RESULTS

In patients with unstable fracture who achieved anatomical or extramedullary type of reduction, the average sliding distance at 1, 3, and 12 months was 4.9 mm, 7.5 mmm and 8.1 mm in the geneX^®ds group and 7.5 mm, 10.8 mm, and 12.1 mm in the no geneX^®ds group, respectively. There were significant differences in the sliding distance at 1, 3, and 12 months between these two groups.

CONCLUSION

The use of this synthetic osteoconductive bone graft substitute with zeta potential control may have positive effect on the controlled sliding of the helical blade and the healing of intertrochanteric fracture.

A novel angle on helical blade placement in trochanteric fractures - The axis-blade angle

INTRODUCTION

For trochanteric fractures, helical blade placement is crucial to the prognosis of operations. Existing measurement methods used for blade placement include the Cleveland zone, the tip-apex distance (TAD), the calcar-referenced tip-apex distance (CalTAD), and the Parker's ratio. These methods all lack a direct view on blade direction. The current study proposed the axis-blade angle (ABA) to solve direction problem and investigated its clinical applicability.

METHODS

A retrospective study collected 156 patients between May 2014 and February 2018. The occurrence of mechanical complications was analyzed in relation to age, gender, fracture side, American Society of Anesthesiologists classification, fracture classification, reduction quality, bone quality, the Cleveland zone, the Parker's ratio, the TAD, the CalTAD, and the ABA.

RESULTS

119 patients, including 25 with mechanical complications, were suitable for full analysis. In the univariate analysis, the Cleveland zone, reduction quality, the TAD, the CalTAD and the ABA were statistically associated with mechanical complications. In the multivariate analysis, reduction quality (p = 0.008) and the ABA (p < 0.001; adjusted OR 0.86;95% CI 0.77 to 0.96) showed significant results, which indicated that reduction quality and the ABA were two independent influencing factors for mechanical complications. Calculation of the receiver operating characteristic (ROC) curve indicated that the ABA was a reliable predictor of mechanical complications at the cut-off of -10°.

CONCLUSIONS

The ABA provides instruction for the intraoperative adjustment of guide wire direction. Placing the helical blade with an ABA > -10° can effectively reduce the risk of mechanical complications.

Radiographic risk factors for predicting failure of geriatric intertrochanteric fracture treatment with a cephalomedullary nail

BACKGROUND

The cephalomedullary nail is the most common device used to treat unstable intertrochanteric fractures (ITFs) (AO/OTA 31-A2 and A3) in the geriatric population. However, there is lack of radiological parameter to evaluate the entry point; hence, this study reports a new radiological parameter to evaluate the entry point of the nail. Besides, other risk factors were also examined.

METHODS

A retrospective study on the geriatric population with unstable ITFs was conducted from July 2011 to December 2014. A total of 136 patients were enrolled in this study; they received treatment with Gamma-3 nails (Stryker, Mahwah, NJ, USA) and were followed for at least 1 year. Demographic data, radiological parameters, and side-difference of the distance from the piriformis fossa to the greater trochanteric tubercle in the anteroposterior view (dPG) were compared between the union and failure groups. Student's t test, χ test, and multiple logistic regression were used in the statistical analyses.

RESULTS

The overall failure rate was 13.23% (18 patients). Sex, tip-apex distance (TAD), and dPG were significantly different between the failure and union groups in multivariate analyses. Using a dPG > 6 mm as a reference, patients with a dPG > 6 mm had an odds ratio of 7.64 for failure relative to a dPG < 6 mm.

CONCLUSION

This study provides additional evidence demonstrating that sex and TAD have significant effects on the outcomes of unstable ITFs after nailing. Moreover, the newly reported radiological parameter, dPG, can be used to predict the failure of ITFs treated using cephalomedullary nails.

Effect of reduction quality on post-operative outcomes in 31-A2 intertrochanteric fractures following intramedullary fixation: a retrospective study based on computerised tomography findings

Purpose

To determine how the reduction of medial and anteromedial cortices using CT findings in 31-A2 intertrochanteric fractures treated with the intramedullary nail could affect the clinical outcomes and complication rates of the fractures.

Methods

We retrospectively analyzed the data of 43 patients with 31-A2 intertrochanteric fractures who underwent closed reduction and intramedullary internal fixation (CRIF) between January 2010 and December 2013. Patients were classified into two groups based on the post-operative CT scans taken from the sagittal and coronal planes, respectively. Five radiographic parameters and three clinical parameters were used to evaluate the post-operative functional states and mobilization levels in this study. Post-operative complications were also recorded.

Results

The mean loss of the femoral neck-shaft angle (FNSA) was significantly smaller in Group C1 than that in Group C2. There were significant differences in the sliding distance of the cephalic nail and the loss of femoral head height between the two groups. In terms of the reduction conditions shown on the sagittal planes, the FNSA, sliding distance of the cephalic nail, and the loss of FHH were significantly different, although differences in TCD were not significant. Patients in groups C1 (3.6%) and S1 (0.0%) had lower complication rates compared to patients in groups C2 (26.7%) and S2 (27.8%).

Conclusion

Patients with good reduction quality of the medial and anteromedial sustainable cortices had better clinical outcomes and lower complication rates. The sustainable stability and anti-rotational function of these validated reductions might play a critical role in maintaining the fragment positions and reducing the incidence of complications in patients.

Electronic supplementary material

The online version of this article (10.1007/s00264-018-4098-1) contains supplementary material, which is available to authorized users.

Optimizing intraoperative imaging during proximal femoral fracture fixation - a performance improvement program for surgeons

INTRODUCTION

Formal training for surgeons regarding intraoperative imaging is lacking. This project investigated the effect of an educational intervention focusing on obtaining and assessing a standardized lateral view of the proximal femur during intramedullary nailing of a pertrochanteric fracture.

MATERIALS AND METHODS

Anatomical landmarks of the proximal femur that can be identified using intraoperative fluoroscopy and criteria for image quality, i.e. quality of projection were defined in a consensus process, followed by the development of educational materials and a 7-item checklist. Five surgeons from 5 Trauma Centers in 4 countries participated. Each surgeon a) assessed 5 of their own retrospective cases and 5 retrospective cases from 4 colleagues from their clinic, b) viewed an educational video and poster and re-assessed the same cases, and c) assessed the intraoperative images of 5 prospectively collected consecutive cases of their own and of colleagues afterwards.

RESULTS

The percentage of positive ratings for image quality increased from 72% prior to educational intervention to 88% after intervention (p<0.001), and number of "not assessable" images decreased significantly. Percentage agreement between surgeons on the assessments increased from 75% to 87%. The proportion of best possible ratings for fracture reduction and implant position increased from 58% to 72% and from 49% to 66%, respectively. Percentage agreement between surgeons on assessment of reduction and implant position increased.

DISCUSSION AND CONCLUSIONS

A focused educational intervention can improve surgeons' ability to obtain and assess lateral view intraoperative images of the proximal femur and can improve the quality of reduction and implant positioning.

Anteromedial cortical support reduction in unstable pertrochanteric fractures: a comparison of intra-operative fluoroscopy and post-operative three dimensional computerised tomography reconstruction

PURPOSE

Anteromedial cortical support reduction is favourable for secondary stability after limited sliding in unstable pertrochanteric fractures. The aim of this study was to compare the accuracy and agreement between intra-operative fluoroscopy and post-operative 3D reconstruction.

MATERIALS AND METHODS

A retrospective analysis of 28 patients (mean 81.6 years) treated with short cephalomedullary nails was performed. All patients had full sets of intra-operative fluoroscopy and post-operative 3D CT images. Observation was focused on the position of the anteromedial cortices of the inferior corner between the head-neck fragment and femoral shaft, and their relationship was categorised into three types: positive, neutral and negative. The percentage of subsequent changes in cortical reduction quality between fluoroscopy and 3D CT was calculated and compared.

RESULTS

There were 24 positive (85.7%), four neutral and no negative positions in the anteroposterior (AP) view and one positive, 20 neutral (71.4%) and seven negative positions in the lateral view from fluoroscopy. On post-operative 3D CT images with a full range of rotation, definitive anteromedial cortical contact (positive and neutral support) was observed in 18 cases (64.3%). Ten cases lost the anteromedial cortical buttress. With the posteromedial region of the lesser trochanter detached, a positive AP cortical position combined with a positive/neutral lateral position on fluoroscopy (17 cases) was highly predictive of reliable, definitive cortical support (15 cases, 88.2%) on 3D CT. A negative lateral position on fluoroscopy (seven cases), regardless of the combination in the AP view, was likely to predict the final loss of cortical support (six cases, 85.7%) on 3D CT; a positive/neutral lateral position (21 cases) was only associated with loss of support in four cases (19.1%) (p < 0.05).

CONCLUSIONS

A lateral negative position of the anterior cortex on fluoroscopy for unstable pertrochanteric fractures may be highly predictive of post-operative final loss of the anteromedial cortical buttress, which should be avoided during operation.

Teriparatide Improves Fracture Healing and Early Functional Recovery in Treatment of Osteoporotic Intertrochanteric Fractures

Osteoporotic intertrochanteric fractures result in serious health problems and decrease health-related quality of life (HRQoL). Faster time-to-union is important for early return to daily activities and reduction of complications. Teriparatide has been shown to accelerate fracture healing, but the literature is sparse on this topic. The aim of this study is to assess whether teriparatide accelerates fracture healing.Between 2008 and 2014, patients with osteoporotic intertrochanteric fractures who underwent surgical interventions were enrolled in this retrospective cohort study. Group 1 included patients who were not on any osteoporosis medication prior to fracture and who postoperatively received only calcium and vitamin D; patients in Group 2 were not on any osteoporosis medication prior to fracture, and received teriparatide and calcium and vitamin D postoperatively. Patients in Group 3 were those who were on alendronate prior to fracture and postfracture received teriparatide as well as calcium and vitamin D. Demographics, time-to-union, HRQoL (short-form health survey [SF]-12 physical component summary [PCS] and SF-12 mental component summary [MCS]), morbidities, mortalities, and radiographic and functional outcomes between groups were compared.A total of 189 patients were enrolled in this study. There were 83 patients in Group 1, 47 patients in Group 2, and 59 patients in Group 3. A significantly shorter time-to-union was found in the teriparatide-treated groups (mean, 13.6, 12.3, and 10.6 weeks, respectively [P = 0.002]). With regard to SF-12 PCS, the scores were significantly better in teriparatide-treated groups at 3 months (mean, 19, 28, and 29, respectively [P = 0.002]) and 6 months (mean, 28, 37, and 38, respectively [P = 0.008]). Similar inter-group differences were noted when comparing the pain scores, the ability to get around the house, the ability to get out of the house, and the ability to go shopping at 3 and 6 months. Complications and mortality were also markedly reduced in the teriparatide-treated groups.Postoperative use of teriparatide for 6 months appears to be an effective adjunct therapy in the treatment of patients with osteoporotic intertrochanteric fractures. However, because of the limited power of the study, a prospective, randomized, large-scale cohort study is still required for determining the efficacy of teriparatide.

Three-Dimensional Computed Tomographic Analysis for Comminution of Pertrochanteric Femoral Fracture: Comminuted Anterior Cortex as a Predictor of Cutting Out

Background:

Fixed angle sliding hip screw devices allow controlled impaction between the head neck fragment and the femoral shaft fragment in the surgical treatment of pertrochanteric fractures. This study was performed to evaluate the frequency and pattern of comminution at the fracture site, which may prevent the intended impaction.

Materials and Methods:

Three-dimensional computed tomography was used to investigate 101 pertrochanteric fractures treated with fixed angle sliding hip screw devices, with emphasis on the comminuted cortex. A comminuted fracture was defined as a fracture that had a third fracture fragment at the main fracture line.

Results:

There were 40 fractures without comminution and 61 with comminution. All 61 comminuted fractures had a comminuted posterior cortex, and 3 of 61 fractures also had comminution at the anterior cortex. The prevalence of cutting out of the implant from the femoral head was significantly higher in cases involving comminution at both the posterior and anterior cortices than in cases involving comminution only at the posterior cortex (66.7 % and 3.4 %, p < 0.0001).

Conclusion:

The posterior cortex was comminuted in 60.4% of pertrochanteric fractures and the anterior cortex in 3.0%. Intended impaction at the fracture site could not be obtained at any cortex in cases with comminution at both the anterior and posterior cortices; comminution at the anterior cortex may be a predictor of cutting out.

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.

Accurate and Easy Measurement of Sliding Distance of Intramedullary Nail in Trochanteric Fracture

Background

In daily clinical practice, it is essential to properly evaluate the postoperative sliding distance of various femoral head fixation devices (HFD) for trochanteric fractures. Although it is necessary to develop an accurate and reproducible method that is unaffected by inconsistent postoperative limb position on radiography, few studies have examined which method is optimal. Therefore, the purpose of this study is to prospectively compare the accuracy and reproducibility of our four original methods in the measurement of sliding distance of the HFD.

Methods

Radiographs of plastic simulated bone implanted with Japanese proximal femoral nail antirotation were taken in five limb postures: neutral, flexion, minute internal rotation, greater external rotation, and flexion with external rotation. Orthopedic surgeons performed five measurements of the sliding distance of the HFD in each of the flowing four methods: nail axis reference (NAR), modified NAR, inner edge reference, and nail tip reference. We also assessed two clinical cases by using these methods and evaluated the intraclass correlation coefficients.

Results

The measured values were consistent in the NAR method regardless of limb posture, with an even smaller error when using the modified NAR method. The standard deviation (SD) was high in the nail tip reference method and extremely low in the modified NAR method. In the two clinical cases, the SD was the lowest in the modified NAR method, similar to the results using plastic simulated bone. The intraclass correlation coefficients showed the highest value in the modified NAR method.

Conclusions

We conclude that the modified NAR method should be the most recommended based on its accuracy, reproducibility, and usefulness.

Prevention of excessive postoperative sliding of the short femoral nail in femoral trochanteric fractures

INTRODUCTION

Lag screw cut-out is one of the major postoperative complications on femoral trochanteric fractures. However, precise analyses of excessive sliding and lag screw cut-out were limited. The purpose of this study was to investigate the factors that induce this unfavorable event.

METHODS

From April 2010 to April 2013, 226 patients were operated in our institute using a short femoral nail. Among them, 177 patients (29 males and 148 females) with a mean age of 84 years (60-97 years), who were followed up >3 months, were included in this study. The postoperative sliding distance, fracture type (AO/OTA classification), tip-apex distance (TAD), reduction pattern in the postoperative X-ray (antero-posterior and lateral views), bone quality (canal flare and cortical indices), walking ability at the time of pre-injury and final follow-up, and complications were investigated retrospectively.

RESULTS

The mean sliding distance was 3.7 mm, and one cut-out case (0.6 %) was observed. The sliding distance of the AO/OTA 31-A2 fractures was significantly longer than that of the A1 fractures (p < 0.0001). Regarding the reduction pattern, the sliding distance of the intramedullary type was longer than that of the extramedullary and anatomical types in the lateral view (p < 0.01, p < 0.001, respectively). Further, even in the medial and anatomical types, where the reduction patterns are recommended in the antero-posterior view, the sliding distance of the intramedullary type was significantly longer than that of the anatomical type in the lateral view. There was no correlation of bone quality with the sliding distance.

CONCLUSIONS

Because the sliding distance increased in the intramedullary type in the lateral view of unstable fractures, an accurate reduction in the lateral view at surgery is important, particularly in unstable fractures.

Fracture reduction with positive medial cortical support: a key element in stability reconstruction for the unstable pertrochanteric hip fractures

PURPOSE

To introduce the concept of fracture reduction with positive medial cortical support and its clinical and radiological correlation in geriatric unstable pertrochanteric fractures.

METHODS

A retrospective analysis of 127 patients (32 men and 95 women, with mean age 78.7 years) with AO/OTA 31A2.2 and 2.3 hip fractures treated with cephalomedullary nail (PFNA-II or Gamma-3) between July 2010 and June 2013 was performed. They were classified into three groups according the grade of medial cortical support in postoperative fracture reduction (positive, neutral, and negative). The positive cortex support was defined that the medial cortex of the head-neck fragment displaced and located a little bit superomedially to the medial cortex of the shaft. If the neck cortex is located laterally to the shaft, it is negative with no cortical buttress, and if the two cortices contact smoothly, it is in neutral position. The demographic baseline, postoperative radiographic femoral neck-shaft angle and neck length, rehabilitation progress and functional recovery scores of each group were recorded and compared.

RESULTS

There were 89 cases (70 %) in positive, 26 in neutral, and 12 in negative support. No statistical differences were found between the three groups among patient age, sex ratio, prefracture score of activity of daily living, walking ability score, ASA physical risk score, number of medical comorbidities, osteoporosis Singh index, fracture reduction quality (Garden alignments), and the position of lag screw or helical blade in femoral head (TAD). In follow-up, patients in positive medial cortical support reduction group had the least loss in neck-shaft angle and neck length, and got ground-walking much earlier than negative reduction group, with good functional outcomes and less hip-thigh pain presence.

CONCLUSION

Fracture reduction with nonanatomic positive medial cortical support allows limited sliding of the head-neck fragment to contact with the femur shaft and achieve secondary stability, providing a good mechanical environment for fracture healing.

Direct reduction may need to be considered to avoid postoperative subtype P in patients with an unstable trochanteric fracture: a retrospective study using a multivariate analysis

INTRODUCTION

It has recently been reported that the cases with an anterior femoral neck cortex posterior to the distal fragment (subtype P) in the lateral view of a postoperative radiograph have a risk of excessive sliding of lag screws compared to those located anterior to the distal fragment (subtype A) or perfectly continuous to the distal fragment (subtype N) following osteosynthesis for the treatment of a trochanteric fracture. The purpose of this study was to investigate factors that influence the postoperative subtype in the lateral view of radiographs.

PATIENTS AND METHODS

This study reviewed 136 patients who underwent osteosynthesis using an intramedullary hip nail for the treatment of a trochanteric fracture. A closed reduction was performed in 130 patients (95.6 %), while a direct reduction via a small elevator with a small skin incision was performed in the other six patients (4.4 %). The 136 patients were divided into two groups (subtype P and subtype A or N) based on postoperative radiographs taken of the lateral view. Both clinical and radiological factors were analyzed using the univariate and multivariable analyses.

RESULTS

Thirty-nine patients (29 %) were categorized as subtype P and 97 patients (71 %) were categorized as subtype A or N. A multivariate analysis demonstrated that unstable fractures were associated with a significant risk of postoperative subtype P (Odds ratio: 24.45, P = 0.0024).

CONCLUSIONS

The results of this study suggest that direct reduction via a small elevator with a small skin incision or percutaneous intrafocal pinning may be needed in these cases.