No difference in flexion power despite iliopsoas fatty degeneration in healed hip fractures with large lesser trochanter displacement

Intertrochanteric femoral fracture with lateral wall fracture at the lag screw insertion site may cause postoperative anterior wall fracture and lead to deterioration in activities of daily living

BACKGROUND

Incomplete reduction and fixation of intertrochanteric femoral fractures significantly affect patients' daily activities. The lateral wall's integrity is pivotal in such fractures. This study examines instability, particularly lateral wall fractures at the lag screw insertion site and postoperative anterior wall fractures.

METHODS

Overall, 161 patients with femoral intertrochanteric fractures were included. Three-dimensional computed tomography was conducted preoperatively and 3 weeks postoperatively to determine the postoperative anterior wall fractures incidence. Patient background, operative time, intraoperative blood loss, postoperative telescoping, and daily living activities were compared.

RESULTS

The study recorded 51 cases of lateral wall fractures at the lag screw insertion site and 17 of postoperative fractures of the anterior wall. Postoperative fractures of the anterior wall were found in 3 of 110 and 14 of 51 patients in the group without and with the lag screw insertion site, respectively. The group of postoperative fractures of the anterior wall had significantly lower bone mineral density, longer operative time, and increased intraoperative blood loss. At 4 weeks postoperatively, the group of postoperative fractures of the anterior wall showed increased telescoping and decreased motor component of the functional independence measure (with postoperative fractures of the anterior wall: 28, without postoperative fractures of the anterior wall: 30), and significant reductions were observed in the transfer and locomotion items, indicating lower limb function (with postoperative fractures of the anterior wall group: 11, without postoperative fractures of the anterior wall group: 12).

CONCLUSIONS

Postoperative anterior wall fractures occurred in 27.5% cases with lateral wall fractures at the lag screw insertion site. Three-dimensional computed tomography is useful for preoperative evaluation of lateral wall fractures at the lag screw insertion site to assess instability. Postoperative fractures of the anterior wall related reduction in daily living activities needs attention.

Trochanter migrans: late complications due to displacement of the lesser trochanter in trochanteric fractures

Complications associated with secondary displacement and migration of the lesser trochanter fragment in trochanteric fractures are rare. The complaints expressed by the patient may be misunderstood and attributed to implant-associated or patient-specific problems likely to occur after surgery. This series illustrates potentially dangerous late complications caused by secondary migration of the lesser trochanter. It may help focus the surgeon's attention on possible functional impairment and severe late complications caused by displacement of the lesser trochanter in trochanteric fractures that require prompt intervention.

The impact of the union of lesser trochanter fragments after intramedullary fixation of trochanteric femoral fractures: an X-ray based study

BACKGROUND

Displacement of the lesser trochanter (LT) is not uncommon after managing intertrochanteric femoral fractures and the influence of nonunion of the LT-fragment on clinical outcomes remains controversial. This study aimed to investigate the relationship between the displacement distance and union of the LT-fragment and evaluate the influence of LT-fragment nonunion on hip function and complications.

METHODS

This retrospective study included patients with intertrochanteric fractures and displaced LT treated with intramedullary fixation at Wenzhou Hospital of Integrated Traditional Chinese and Western Medicine from June 2015 to July 2017. The patients were grouped as union and nonunion of the LT-fragment at 1 year. The LT-fragment displacement distance of LT was measured by the anterior-posterior radiographs.

RESULTS

Thirty-one and 22 patients showed union and nonunion at 1 year, respectively. The nonunion group had a higher postoperative complication rate than the union group (59% vs. 29%, P = 0.047), especially mechanical complications (45% vs. 6%, P = 0.001). There was no significant difference in hip function between the two groups (P > 0.05). The receiver operating characteristic (ROC) curve revealed an area under the curve of 0.933 of displacement ratio. Patients with a displacement ratio > 0.35 were more likely to have nonunion of the LT-fragment.

CONCLUSIONS

The displacement ratio might be a reliable predictor of LT-fragment union. The incidence of postoperative complications might increase with LT-fragment nonunion.

When to Reduce and Fix Displaced Lesser Trochanter in Treatment of Trochanteric Fracture: A Systematic Review

Purpose

To systematically evaluate the benefits of reducing and fixing displaced lesser trochanter (LT) of trochanteric fractures and when this procedure is worth the effect.

Methods

From database establishment through March 2021, four online databases (PubMed, Cochrane, Embase, and Web of Science) were searched for relevant literature that investigated reduction and fixation for displaced LT of trochanteric fractures. The papers were then screened by two reviewers independently and in duplicate according to prior inclusion and exclusion criteria. Demographic data as well as data on fracture types, surgical protocols, and surgical outcomes were recorded, analyzed, and interpreted.

Results

Total 10 clinical studies with 928 patients were included, in which 48 cases had intact LT and 880 cases involved the displaced LT, of which 196 (22.27%) cases underwent reduction and fixation for LT while the rest of 684 (77.73%) cases not. In these studies, complications were evaluated as a more applicable predictive parameter for operation than postoperative hip function.

Conclusion

It was beneficial to reduce and fix the displaced LT when one of the conditions below occurred: displacement distance of LT ≥2 cm, quantity of comminuted LT fragments ≥2, and range of LT fragments in medial wall ≥75%; the fracture line of LT fragments reaching or exceeding the midline of the posterior wall.

Inferior Outcome after Unstable Trochanteric Fracture Patterns Compared to Stable Fractures in the Elderly

BACKGROUND

Various risk factors affecting outcome of elderly patients after proximal femur fracture have been identified. The present study aims to evaluate the impact of the fracture pattern in trochanteric fractures on postoperative mobility and complications.

METHODS

Ninety-two patients with a mean age of 84 years were included. According to the revised AO/OTA classification, fractures were divided into stable (AO 31A1) and unstable (AO 31A2/3) patterns. A follow-up examination was performed 12 months after cephalomedullary fixation to assess outcome parameters for mobility/activities of daily living (Parker Mobility Score (PMS)/Barthel Index (BI)) and complications (increase in requirement of care, hospital readmission, mortality rate).

RESULTS

At follow-up, patients with unstable trochanteric fracture patterns presented with lower PMS and BI compared to stable fractures (p < 0.05). Further, higher requirement of care and higher readmission rates compared to stable patterns were observed.

CONCLUSION

Unstable trochanteric fractures presented inferior outcome compared to simple fracture patterns. This might be explained by the increasing surgical trauma in unstable fractures as well as by the mechanical impact of the lesser trochanter, which provides medial femoral support and is of functional relevance. Subsequent studies should assess if treatment strategies adapted to the specific fracture pattern (refixation of lesser trochanter) influence outcome in unstable trochanteric fractures.

The functional effect of lesser trochanter involvement in hip fractures: A prospective cohort study

INTRODUCTION

Hip fractures are the most common fractures amongst frail older patients. Earlier studies have indicated an impaired hip flexion strength in patients with fractures that include detachment of the lesser trochanter. These patients may experience protracted functional impairment and longer recovery time, causing prolonged rehabilitation journeys. This study aimed to evaluate the effects of a detached lesser trochanter in trochanteric fractures on the recovery of hip function.

METHOD

A prospective observational cohort study was performed between 2016 and 2019. Community dwelling patients aged 70 years or older with AO 31A1-A3 trochanteric fractures were included. Patients followed routine care and were treated with a DHS or PFNA. The groups with and without involvement of the lesser trochanter were analysed. The primary outcome was hip function assessed at 6 weeks, 3 months and 1 year after surgery with the Harris Hip Score. Secondary outcomes included the Ludloff's test, complications, rehabilitation time, and pain-, independence-, and quality of life scores. A propensity score was used to adjust for any baseline differences between the two groups.

RESULTS

A total of 114 patients were included, 51 (44.7%) with involvement of the lesser trochanter and 63 (55.3%) without. Minor differences were observed in the baseline characteristics. No significant difference was observed for the Harris Hip Score (coefficient estimate: 3.31; 95% CI, -5.09-11.72; P = 0.43). The flexion function of the iliopsoas muscle was more often normal with the Ludloff's test in patients without involvement of the lesser trochanter (OR, 2.33; 95% CI, 1.241-4.387; P = 0.009). However, no differences were observed for any of the other secondary outcomes.

CONCLUSION

Although no differences in overall hip function were found, more hip fracture patients with involvement of the lesser trochanter showed prolonged impaired flexion of the hip. The absence of long-term, clinically relevant disadvantages however, proves fixing the lesser trochanter to be redundant.

Anatomy-based MRI assessment of the iliopsoas muscle complex after pertrochanteric femoral fracture

OBJECTIVE

To evaluate the quality of the iliopsoas muscle complex after pertrochanteric femoral fracture, using MRI; to propose an anatomy-based evaluation of the iliopsoas muscle complex; and to determine the inter-reader reliability of two classifications of fatty muscle degeneration.

MATERIALS AND METHODS

We included adult patients with a displaced lesser trochanter following pertrochanteric femoral fracture. Muscle quality was evaluated using the Goutallier and Slabaugh classifications at three levels (L4/L5, L5/S1, and the anterior inferior iliac spine). Two radiologists independently reviewed the MRIs, and force measurement was performed on both hips. Linear mixed-effects models were used to determine the effect of fracture on muscle quality and strength, and Cohen's kappa statistic was used to assess inter-reader agreement.

RESULTS

In the 18 patients included, the iliopsoas muscle complex showed higher grades of fatty muscle degeneration on the fractured side than on the non-fractured side. The mean difference between muscle strength on the fractured vs the non-fractured side was -12 N (p > 0.05). Inter-reader agreement for the Goutallier and Slabaugh classifications was good and very good respectively (weighted K = 0.78 and 0.85 respectively).

CONCLUSION

Fatty muscle degeneration of the iliopsoas muscle complex after pertrochanteric femoral fracture was evident using both classification systems; however, fatty muscle degeneration resulted in only a minimal reduction of muscle strength. To provide a thorough assessment of iliopsoas muscle complex quality, we suggest evaluating it at different anatomical levels. Regarding inter-reader agreement, the Slabaugh classification was superior to the Goutallier classification.