Is distal locking with short intramedullary nails necessary in stable pertrochanteric fractures? A prospective, multicentre, randomised study

Advantages of Distal Unlocked Proximal Femoral Nails in the Treatment of Stable Intertrochanteric Fractures in Geriatric Patients: A Single-Center Comparative Randomized Study

Background

This study aimed to investigate the effect of omitting a distal locking screw in intramedullary nailing of stable intertrochanteric femur fractures on clinical outcomes.

Methods

Ninety-six patients over 65 years old with stable pertrochanteric fractures (AO/OTA 31-A1 and A2) treated with short/intermediate proximal femoral nails (PFNA-II) were randomly assigned into two groups: Group 1 (distal locked) and Group 2 (distal unlocked). Comparative analyses were conducted on operative time, total fluoroscopy time, blood loss, incision length, complications, and functional outcomes.

Results

The mean operative time was significantly shorter in Group 2 (35.73 ± 7.62 minutes) compared to Group 1 (47.40 ± 9.96 minutes) (P < 0.001). Fluoroscopy time was also shorter in Group 2 (45.92 ± 6.08 seconds) compared to Group 1 (54.02 ± 5.94 seconds) (P < 0.001). Incision length was reduced in Group 2 (9.21 ± 1.41 centimeters) compared to Group 1 (12.96 ± 1.68 centimeters) (P < 0.001). Blood loss was lower in Group 2 (187.50 ± 32.00 milliliters) than in Group 1 (208.65 ± 49.12 milliliters) (P < 0.05). There were no significant differences between the groups in fracture union time, hospital stay, fracture union weeks, or postoperative blood transfusion rates.

Conclusions

Proximal femoral nailing without distal locking offers shorter operative times, reduced fluoroscopy exposure, and lower blood loss and complications, making it a viable option for treating stable intertrochanteric fractures.

Nailing intertrochanteric fractures in geriatric population: Do we know it all?

INTRODUCTION AND OBJECTIVES

Pertrochanteric fractures constitute an important part of the daily activity of the orthopedic surgeon. The aim of this study was to carry out an analysis of pre-, intra- and post-operative radiographic parameters and to analyze the results of stable and unstable intertrochanteric fractures treated with short nails with dynamic distal locking.

MATERIALS AND METHODS

Retrospective study in our center, between the years 2017-2021 of patients over 65 years of age with pertrochanteric fracture. We included 272 patients treated with Gamma3 Nail (Stryker®) with dynamic distal locking. As variables, we recorded: age, medical comorbidities, fracture pattern according to AO/OTA, osteopenia according to Singh's classification, pre-operative (such as diaphyseal extension), intra-operative (such as tip-to-the-apex or medial cortical support) and post-operative radiographic parameters (such as time to consolidation or loss of reduction), pre- and post-operative Barthel, quality of life and complications and reinterventions, such as non-union or cut-out.

RESULTS

The mean age was 83.28 years (65-102). Two hundred four cases were women (75%). The average follow-up was 18.2 months (12-24). The distribution according to AO/OTA classification was 85.7% 31.A1; 12.5% 31.A2; 1.9% 31.A3. Radiographic consolidation was obtained in 97.4% of cases. Tip to apex distance was less than 25mm in 95.6% of cases. Medial cortical support was positive or neutral in 88.6% of cases. Sixty cases (22.1%) of screw back-out were recorded. Eight reinterventions (2.9%) were performed, corresponding to three cut-outs (1.1%), three non-unions (1.1%), one avascular necrosis (0.4%) and one secondary hip osteoarthritis (0.4%).

CONCLUSIONS

Short nail with dynamic distal locking offers good clinical, radiological and functional results in all types of AO/OTA patterns, without increasing the complication rate, as long as there is an appropriate tip-to-the-apex distance and good medial cortical support.

Nailing intertrochanteric fractures in geriatric population: Do we know it all?

INTRODUCTION AND OBJECTIVES

Pertrochanteric fractures constitute an important part of the daily activity of the orthopedic surgeon. The aim of this study was to carry out an analysis of pre-, intra- and post-operative radiographic parameters and to analyze the results of stable and unstable intertrochanteric fractures treated with short nails with dynamic distal locking.

MATERIALS AND METHODS

Retrospective study in our center, between the years 2017-2021 of patients over 65years of age with pertrochanteric fracture. We included 272 patients treated with Gamma3 Nail (Stryker®) with dynamic distal locking. As variables, we recorded: age, medical comorbidities, fracture pattern according to AO/OTA, osteopenia according to Singh's classification, pre-operative (such as diaphyseal extension), intra-operative (such as tip-to-the-apex or medial cortical support) and post-operative radiographic parameters (such as time to consolidation or loss of reduction), pre- and post-operative Barthel, quality of life and complications and reinterventions, such as non-union or cut-out.

RESULTS

The mean age was 83.28years (65-102). Two hundred four cases were women (75%). The average follow-up was 18.2months (12-24). The distribution according to AO/OTA classification was 85.7% 31.A1; 12.5% 31.A2; 1.9% 31.A3. Radiographic consolidation was obtained in 97.4% of cases. Tip to apex distance was less than 25mm in 95.6% of cases. Medial cortical support was positive or neutral in 88.6% of cases. Sixty cases (22.1%) of screw back-out were recorded. Eight reinterventions (2.9%) were performed, corresponding to three cut-outs (1.1%), three non-unions (1.1%), one avascular necrosis (0.4%) and one secondary hip osteoarthritis (0.4%).

CONCLUSIONS

Short nail with dynamic distal locking offers good clinical, radiological and functional results in all types of AO/OTA patterns, without increasing the complication rate, as long as there is an appropriate tip-to-the-apex distance and good medial cortical support.

The effect of distal locking mode on postoperative mechanical complications in intertrochanteric fractures: a retrospective cohort study of five hundred and seven patients

PURPOSE

The optimal choice of distal locking modes remains a subject due to limited available data, and therefore, this study aims to investigate the relationship between distal locking mode and postoperative mechanical complications in an intertrochanteric fracture (ITF) population who underwent closed reduction and intramedullary fixation with a PFNA-II.

METHODS

Patients aged 65 years or older who underwent surgery with PFNA-II fixation in a university teaching hospital between January 2020 and December 2021 were potentially eligible. Based on the distal locking mode, patients were classified into static, dynamic, and limited dynamic groups, among which the differences were tested using univariate analysis. Multivariate logistic regression was used to examine whether the distal locking mode was independently associated with the risk of postoperative one year mechanical complications, adjusting for covariates and potential confounders. Subgroup analyses were performed to evaluate the robustness of the findings.

RESULT

Among 507 eligible patients, 33 (6.5%) developed postoperative mechanical complications. In the univariate analysis, sex (P = 0.007), fracture type (P = 0.020), LAT Parker ratio (P = 0.023), and lateral femoral (P = 0.003) wall showed that the differences were significant. Compared to the static group, the limited dynamic group and the dynamic group showed higher odds of postoperative mechanical complications (OR = 3.314, 95% CI: 1.215-9.041; and OR = 3.652, 95% CI: 1.451-9.191, respectively). These associations were robust across a series of analyses, including adjusting for confounders and subgroup analyses.

CONCLUSION

Using a distal non-static locking mode significantly increases the risk of postoperative mechanical complications, and static locking could be a preferable option when treating an intertrochanteric fracture.

Tip-apex distance as a risk factor for cut-out in cephalic double-screw nailing of intertrochanteric femur fractures

Aims

Proximal femur fractures treatment can involve anterograde nailing with a single or double cephalic screw. An undesirable failure for this fixation is screw cut-out. In a single-screw nail, a tip-apex distance (TAD) greater than 25 mm has been associated with an increased risk of cut-out. The aim of the study was to examine the role of TAD as a risk factor in a cephalic double-screw nail.

Methods

A retrospective study was conducted on 112 patients treated for intertrochanteric femur fracture with a double proximal screw nail (Endovis BA2; EBA2) from January to September 2021. The analyzed variables were age, sex, BMI, comorbidities, fracture type, side, time of surgery, quality of reduction, pre-existing therapy with bisphosphonate for osteoporosis, screw placement in two different views, and TAD. The last follow-up was at 12 months. Logistic regression was used to study the potential factors of screw cut-out, and receiver operating characteristic curve to identify the threshold value.

Results

A total of 98 of the 112 patients met the inclusion criteria. Overall, 65 patients were female (66.3%), the mean age was 83.23 years (SD 7.07), and the mean follow-up was 378 days (SD 36). Cut-out was observed in five patients (5.10%). The variables identified by univariate analysis with p < 0.05 were included in the multivariate logistic regression model were screw placement and TAD. The TAD was significant with an odds ratio (OR) 5.03 (p = 0.012) as the screw placement with an OR 4.35 (p = 0.043) in the anteroposterior view, and OR 10.61 (p = 0.037) in the lateral view. The TAD threshold value identified was 29.50 mm.

Conclusion

Our study confirmed the risk factors for cut-out in the double-screw nail are comparable to those in the single screw. We found a TAD value of 29.50 mm to be associated with a risk of cut-out in double-screw nails, when good fracture reduction is granted. This value is higher than the one reported with single-screw nails. Therefore, we suggest the role of TAD should be reconsidered in well-reduced fractures treated with double-screw intramedullary nail.

Lateral cortical notching facilitates dynamization of proximal femoral nailing - A finite element analysis

INTRODUCTION

Dynamization of proximal femoral nailing by removal of distal interlocking is one of the recommended treatment options for nonunions of femur fractures. However, in certain inter-/subtrochanteric fractures, gliding of the nail along the femoral shaft is blocked by lateral femoral cortical support of the lag screw. For these cases, Biber et al. proposed lateral cortical notching (LCN), in which the supporting lateral bone is removed. This study investigates the biomechanical effect of LCN on gliding of proximal femoral nailing and stress distribution at the bone/implant interface.

MATERIALS AND METHODS

In this finite element analysis a three-dimensional model of an unstable intertrochanteric fracture with proximal femoral nailing without distal interlocking was simulated using the FebioStudio software suite. To simulate LCN, the lag screw hole was lengthened to 15.34 mm at the lateral cortex. Displacement of the nail along the femoral shaft axis and von Mises stress distribution were compared between LCN model and standard implantation model.

RESULTS

Displacement of the nail along the femoral shaft axis was higher in the LCN model than in the standard implantation model (0.48 mm vs. 0.07 mm). Highest von Mises stresses of 176-178 MPa at the implant and of 52-81 MPa at the proximal femur were detected. Maximum von Mises stresses of the implant were comparable at all sides, except for a reduced von Mises stress at the lateral inferior side in the LCN model (80 vs. 102 MPa). At the inferior lateral screw hole and the anterior/posterior lateral screw hole maximum von Mises stress was reduced in the LCN model (2 vs. 49 MPa and 52 vs. 81 MPa), whereas the maximum von Mises stress at the inferior medial screw hole was higher in the LCN model than in the standard implantation model (53 vs. 27 MPa).

CONCLUSIONS

Lateral cortical notching facilitates gliding of a distally dynamized proximal femoral nail along the femoral shaft axis in intertrochanteric fractures. Additionally, the lack of lateral cortical bone support at the lag screw reduces von Mises stress at the bone/implant interface and thus could lower the risk for implant breakage and peri‑implant fractures.

Development of the Italian fractures registry (RIFra): A call for action to improve quality and safety

In recent years, there has been an increasing interest in the development of arthroplasty registries, therefore, in our country, the Italian Arthroplasty Registry (RIAP), was issued by the National Law No. 221/2012. In the last decade, however, some European countries -namely Sweden, Denmark, Norway, and Germany (in development)- have introduced another nationwide orthopaedic registry than arthroplasty registers: the fracture registry. The development of this new tool aims to improve quality and safety in fracture management, thus trying to provide a better postoperative quality of life in trauma patients. Based on these findings, the AO-Trauma Italy Council encouraged the development of a national fracture registry in Italy. The present study aims to (1) provide an overview of the fracture registries in Europe and (2) to develop, for the first time, a pilot Italian Fracture Registry (RIFra). Thirteen AO-Trauma Italy members, chairmen of Level-I orthopaedic and trauma centres, diffused throughout Italy, were involved in the RIFra project. The RIFra form, developed between November 2019 and March 2020, consists of 5 main sections, namely: epidemiologic data, previous surgical procedure (if any), patient and fracture features, surgical procedure, surgical implant details. This study constitutes the first step to start, in future years, the bureaucratic procedure leading to the final establishment of a RIAP-like fracture registry in Italy.

A comparative analysis of distal locked and unlocked long proximal femoral nail antirotation (PFNA-II) in the fixation of stable intertrochanteric fractures

PURPOSE

Long proximal femoral nail anti-rotation (PFNA-II) is a preferred implant in recent years for fixation of pertrochanteric fractures, especially in osteoporotic patients. The purpose of this study is to prospectively investigate the effect of distal locking in long PFNA-II fixation of stable intertrochanteric fractures.

METHODS

A total of 58 patients with isolated stable intertrochanteric fractures and treated in our hospital during the study period of 2017-2019 by distal locked or unlocked long PFNA-II fixation were included in this study. Patients who had multiple injuries or open fractures were excluded. There were 40 female and 18 male patients, with 33 affecting the left side and 25 the right side. Of them, 31 belonged to the distal locked group (group A) and 27 to the unlocked group (group B). Surgical procedures and implants used in both groups were similar except for the distal locking of the nails. General data (age, gender, fracture side, etc.) showed no significant difference between two groups (all p > 0.05). The intraoperative parameters like operative time, radiation exposure and follow-up parameters like functional and radiological outcomes were recorded and compared. Statistical tests like the independent samples t-test Fischer's exact and Chi-square test were used to analyze association.

RESULTS

The distribution of the fractures according to AO/OTA classification and 31A1.2 type of intertrochanteric fractures were most common in our study. All the included fractures united and the average functional outcome in both groups were good and comparable at the end of one year. The operative time (mL, 107.1 ± 12.6 vs. 77.0 ± 12.0, p < 0.001) and radiation exposure (s, 78.6 ± 11.0 vs. 40.3 ± 9.3, p < 0.001) were significantly less among the patients in group B. Fracture consolidation, three months after the operative procedures, was seen in a significantly greater proportion of patients in group B (92.6% vs. 67.7%, p = 0.025). Hardware irritation because of distal locking bolt was exclusively seen in group A, however this was not statistically significant (p = 0.241).

CONCLUSION

We conclude that, in fixation of stable intertrochanteric fractures by long PFNA-II nail, distal locking not only increases the operative time and radiation exposure but also delays the fracture consolidation and increases the chances of hardware irritation, and hence is not required.

Reoperation rates after proximal femur fracture fixation with single and dual screw femoral nails: a systematic review and meta-analysis

Purpose

Methods

Results

Conclusion

Use of the 95-degree angled blade plate with biological and mechanical augmentation to treat proximal femur non-unions: a case series

BACKGROUND

Intertrochanteric and subtrochanteric non-union are rare but challenging complications. In the present study, we investigate the use of a 95° blade, in association with biological and mechanical augmentation, in the management of intertrochanteric and subtrochanteric femoral non-unions.

METHODS

Between October 2015 and February 2021, a retrospective cohort study was conducted at our institution to investigate the use of a 95° blade, in association with biological and mechanical augmentation, in the management of intertrochanteric and subtrochanteric femoral non-unions, following the mechanical failure of the first device. All the patients underwent a clinical and radiographic follow-up at 6 weeks, 3, 6, 9, 12 and 18 months; at each follow-up, a plain radiograph of the femur was performed and patients were assessed using Harris Hip Score (HHS) and the Short Form-12 (SF-12) questionnaire.

RESULTS

From October 2015 and February 2021, 40 proximal femur non-unions were managed at our Institution. Fifteen patients out of forty (37.5%) met the inclusion criteria. The main data of the study are summarized in Table 1; patients' mean was 57 years old (range 19-83); 10 males and 5 females were included in the study. All the patients completely healed clinically and radiologically at an average of 6.1 months (range 4-13). All these patients returned to their pre-injury mobility status. During an average follow-up period of 25 months (range 8-60), the observed complications included wound dehiscence, which was treated with a superficial surgical debridement, a below-the-knee deep vein thrombosis, and a blade plate failure 3 months after the first revision surgery.

CONCLUSIONS

This study shows the treatment of inter-and sub-trochanteric non-unions with a 95° blade plate, medial strut allograft, and bone autograft obtained with RIA system, together with a varus malalignment correction, leads to a high percentage of bone healing, with a low incidence of complications and good clinical outcome.

Surgical interventions for treating extracapsular hip fractures in older adults: a network meta-analysis

BACKGROUND

Hip fractures are a major healthcare problem, presenting a challenge and burden to individuals and healthcare systems. The number of hip fractures globally is rising. The majority of extracapsular hip fractures are treated surgically.

OBJECTIVES

To assess the relative effects (benefits and harms) of all surgical treatments used in the management of extracapsular hip fractures in older adults, using a network meta-analysis of randomised trials, and to generate a hierarchy of interventions according to their outcomes.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, Web of Science and five other databases in July 2020.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs comparing different treatments for fragility extracapsular hip fractures in older adults. We included internal and external fixation, arthroplasties and non-operative treatment. We excluded studies of hip fractures with specific pathologies other than osteoporosis or resulting from high-energy trauma.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion. One review author completed data extraction which was checked by a second review author. We collected data for three outcomes at different time points: mortality and health-related quality of life (HRQoL) - both reported within 4 months, at 12 months and after 24 months of surgery, and unplanned return to theatre (at end of study follow-up). We performed a network meta-analysis (NMA) with Stata software, using frequentist methods, and calculated the differences between treatments using risk ratios (RRs) and standardised mean differences (SMDs) and their corresponding 95% confidence intervals (CIs). We also performed direct comparisons using the same codes.

MAIN RESULTS

We included 184 studies (160 RCTs and 24 quasi-RCTs) with 26,073 participants with 26,086 extracapsular hip fractures in the review. The mean age in most studies ranged from 60 to 93 years, and 69% were women. After discussion with clinical experts, we selected nine nodes that represented the best balance between clinical plausibility and efficiency of the networks: fixed angle plate (dynamic and static), cephalomedullary nail (short and long), condylocephalic nail, external fixation, hemiarthroplasty, total hip arthroplasty (THA) and non-operative treatment. Seventy-three studies (with 11,126 participants) with data for at least two of these treatments contributed to the NMA. We selected the dynamic fixed angle plate as a reference treatment against which other treatments were compared. This was a common treatment in the networks, providing a clinically appropriate comparison.  We downgraded the certainty of the evidence for serious and very serious risks of bias, and because some of the estimates included the possibility of transitivity owing to the proportion of stable and unstable fractures between treatment comparisons. We also downgraded if we noted evidence of inconsistency in direct or indirect estimates from which the network estimate was derived. Most estimates included the possibility of benefits and harms, and we downgraded the evidence for these treatments for imprecision.  Overall, 20.2% of participants who received the reference treatment had died by 12 months after surgery. We noted no evidence of any differences in mortality at this time point between the treatments compared. Effect estimates of all treatments included plausible benefits as well as harms. Short cephalomedullary nails had the narrowest confidence interval (CI), with 7 fewer deaths (26 fewer to 15 more) per 1000 participants, compared to the reference treatment (risk ratio (RR) 0.97, 95% CI 0.87 to 1.07). THA had the widest CI, with 62 fewer deaths (177 fewer to 610 more) per 1000 participants, compared to the reference treatment (RR 0.69, 95% CI 0.12 to 4.03). The certainty of the evidence for all treatments was low to very low. Although we ranked the treatments, this ranking should be interpreted cautiously because of the imprecision in all the network estimates for these treatments. Overall, 4.3% of participants who received the reference treatment had unplanned return to theatre. Compared to this treatment, we found very low-certainty evidence that 58 more participants (14 to 137 more) per 1000 participants returned to theatre if they were treated with a static fixed angle plate (RR 2.48, 95% CI 1.36 to 4.50), and 91 more participants (37 to 182 more) per 1000 participants returned to theatre if treated with a condylocephalic nail (RR 3.33, 95% CI 1.95 to 5.68). We also found that these treatments were ranked as having the highest probability of unplanned return to theatre. In the remaining treatments, we noted no evidence of any differences in unplanned return to theatre, with effect estimates including benefits as well as harms. The certainty of the evidence for these other treatments ranged from low to very low. We did not use GRADE to assess the certainty of the evidence for early mortality, but our findings were similar to those for 12-month mortality, with no evidence of any differences in treatments when compared to dynamic fixed angle plate. Very few studies reported HRQoL and we were unable to build networks from these studies and perform network meta-analysis.  AUTHORS' CONCLUSIONS: Across the networks, we found that there was considerable variability in the ranking of each treatment such that there was no one outstanding, or subset of outstanding, superior treatments. However, static implants such as condylocephalic nails and static fixed angle plates did yield a higher risk of unplanned return to theatre. We had insufficient evidence to determine the effects of any treatments on HRQoL, and this review includes data for only two outcomes. More detailed pairwise comparisons of some of the included treatments are reported in other Cochrane Reviews in this series. Short cephalomedullary nails versus dynamic fixed angle plates contributed the most evidence to each network, and our findings indicate that there may be no difference between these treatments. These data included people with both stable and unstable extracapsular fractures. At this time, there are too few studies to draw any conclusions regarding the benefits or harms of arthroplasty or external fixation for extracapsular fracture in older adults. Future research could focus on the benefits and harms of arthroplasty interventions compared with internal fixation using a dynamic implant.

Long-term outcomes of distal locking in extracapsular fractures treated with trochanteric Gamma3 nails

BACKGROUND

Few publications have assessed long-term results of distal locking of short endomedullary nails for extracapsular hip fracture. Virtually all of them focus on immediate differences. Criteria for the use of static or dynamic locking are unclear in most nailing systems, and use is advised in unstable fracture patterns or with risk of bell-clapper effect, but often influenced by the "orthopaedic school".

MATERIALS AND METHODS

This is a historical cohort study on patients diagnosed and operated in 2014 and followed up until endpoint, considered as consolidation or major complication, plus evaluation of overall long-term survival. They were categorised as static distal locking (ST) or dynamic distal locking (DN). Both are comparable, except for all stable pre-operative classifications, Fracture Mobility Score (FMS) at discharge, and immediate post-operative loading, all of which were in favour of DN.

RESULTS

Consolidation took place in > 95% of patients, with a non-statistically significant delay trend in ST. Less than 6% in both ST and DN had major complications, with no differences. Most cases suffered early cut-out. Significant fracture collapse was the most frequent minor complication. There were more statistically significant minor and total complications in ST. Infection, without differences, can precede cut-out. Lateral thigh pain was similar and could be related to back-out. In DN, 21.1% of cases were truly dynamised. We did not find differences in mobility or in long-term survival.

CONCLUSIONS

Any type of distal locking seems to be safe for consolidation, despite a slightly longer consolidation time in static locking. Early cut-out was the main complication, while others were very infrequent, which is an advantage over helical blade devices. There was a higher rate of minor and overall mechanical complications in ST, but infection and lateral thigh pain were similar. Most non-traumatic mechanical complications occurred around 5-6 weeks. About one in five of the DN truly dynamised, with all cases occurring before 8 weeks. Mobility until endpoint and overall long-term survival were not influenced by the locking mode used.

LEVEL OF EVIDENCE

Therapeutic study, level 2b.

Distal locking of short cephalomedullary nails decreases varus collapse in unstable intertrochanteric fractures - a biomechanical analysis

INTRODUCTION

Peritrochanteric fractures are a growing problem and complications relating to operative fixation of these fracture, including varus collapse and screw cutout, are common in elderly osteoporotic patients. We hypothesize that unlocked nails will demonstrate increased varus collapse and inferior construct stiffness in specimens with increased diaphyseal medullary diameter.

MATERIALS AND METHODS

Sixteen non-cadaveric osteoporotic biomechanical femur specimens were utilized in this study, with eight specimens having an artificially large femoral canal to represent Dorr C femurs. All femurs were instrumented with a short cephalomedullary nail with and without distal cross-lock screw fixation and had an unstable intertrochanteric fracture created in a repeatable pattern. Specimens underwent cyclic compression to a maximal load of 1000N with segmental motion quantified through the use of visual tracking markers. Statistical comparisons were performed using one-way ANOVA with Tukey post-hoc analysis to determine differences between specific groups. Significance was defined as p<0.05.

RESULTS

Unlocked short cephalomedullary nails showed increased varus collapse due to motion of the nail within the femoral canal in capacious femoral canals compared with narrow femoral canals and distally cross-locked nails. The coronal deformation of the wide canal unlocked group (17.9 ^o±2.6^o) was significantly greater in the varus direction than any other fixation under compressive load of 1000N. There was no significant difference in varus angulation between the wide canal or narrow canal locked groups (11.1^o±8.7^o vs. 8.2^o±1.7^o respectively, p=0.267). The narrow canal unlocked group (13.7^o±2.4^o) showed significantly greater varus angulation than the narrow canal locked (p=0.015). The wide canal unlocked group showed significantly greater varus angulation than the wide canal locked group (p=0.003). Motion between the femoral shaft and the cephalomedullary nail (toggling of the nail within the shaft) was significantly greater in narrow or wide canal unlocked specimens, 7.94^o±2.13^o and 10.2^o±1.7^o respectively, than in the narrow or wide canal locked specimens, 2.4^o±0.2^o and 4.2^o±0.5^o respectively (p<0.05) CONCLUSION: Unlocked short intramedullary fixation for unstable peritrochanteric fractures results in increased varus collapse under axial compression. This study supports the use of distal cross-locking of short intramedullary fixation for unstable peritrochanteric fractures in patients with capacious femoral canals secondary to osteoporosis who might otherwise be as risk for varus collapse, device failure, and malunion.

Distal interlocking for short trochanteric nails: static, dynamic or no locking? Review of the literature and decision algorithm

Pertrochanteric hip fractures are among the most common and the use of short cephalomedullary nails as the treatment of choice is increasing.

A systematic review regarding distal locking options for short cephalomedullary nails was undertaken using Medline/PubMed®, Embase® and Cochrane Library® in order to evaluate current indications, associated complications and to provide treatment recommendations.

The results seem to support the use of distal static locking for unstable fractures, dynamic locking for length stable/rotational unstable fractures and no locking for stable fractures.

Complications associated with distal locking include iatrogenic fractures, thigh pain, delayed union and nonunion, implant failure, screw loosening and breaking, drill bit breaking, soft tissue irritation, femoral artery branch injury, intramuscular haematoma and compartment syndrome. It is also associated with longer operative time and radiation exposure.

In unlocked constructs, dorsomedial comminution and nail/medullary canal mismatch contribute to peri-implant fractures. Anterior cortical impingement is associated with cut-out and nonunion.

Most studies comparing distally locked and unlocked nails report a short follow-up.

Distal locking mode should be based on the fracture’s stability.

Cite this article: EFORT Open Rev 2020;5:421-429. DOI: 10.1302/2058-5241.5.190045

The impact of lag screw in the healing time of distal tibia fractures treated with minimally invasive plate osteosynthesis: A randomized clinical trial

BACKGROUND

In recent years, Minimally Invasive Plate Osteosynthesis (MIPO) has been gaining popularity in the treatment of distal tibia fractures, because it is a minimally invasive surgical procedure, thus it limits the soft-tissues damage. This prospective randomized study aims to assess the impact of lag screw in the healing time of distal tibia fractures treated with MIPO technique, in a six-month follow-up.

METHODS

Patients between 20 and 70 years of age with distal tibial fracture, type 43-A according to AO/OTA classification system were included. All the patients were randomized into two groups, to receive MIPO without lag screw (Group-A) or MIPO with percutaneous lag screw (Group-B). Patients were followed clinically and radiographically at 3, 6, 12 and 24 weeks postoperatively. The main outcome measure was the time needed to achieve the painless full weight-bearing (FWB) after surgery. Unpaired t-test after ANOVA (analysis of variance) was performed to assess AOFAS score differences between the 2 groups at each follow-up. Pearson correlation test also was performed. The tests were two-tailed with a confidence level of 5%.

RESULTS

42 patients (24 male and 18 female, mean age 49.54 years old, range 25-80) were recruited. A significant shorter mean time until painless FWB (p = 0.016) was observed in Group-B (11.22 ± 3.06 weeks) compared with Group-A (13.48 ± 2.42 weeks) (Table 2). The mean AOFAS score was comparable in patients treated with (Group-B) and without lag screw (Group-A) at all follow-ups.

CONCLUSIONS

This prospective randomized clinical study has shown that the use of lag screw in distal tibia fractures treated with MIPO technique speeds the fracture healing, thus shortening the time needed to achieve FWB.

Distal locked versus unlocked intramedullary nailing for stable intertrochanteric fractures, a systematic review and meta-analysis

BACKGROUND

Intramedullary nails have become the main treatment for intertrochanteric fractures. However, a distal locking procedure during nailing gradually raised controversy. In this study, a systematic review and meta-analysis of clinical trials was performed to summarize existing evidence, aiming to determine the safety and efficacy of distal locking or unlocking in the nailing of stable intertrochanteric fractures.

METHODS

Appropriate articles were identified using the most common public databases, such as PubMed, Embase, the Cochrane Library, and Google Scholar from the inception of each database to April 2019, without restriction of language, publication date, and considering ongoing trials. Eligible studies were represented by randomized controlled trials or retrospective cohort studies, comparing distal locking and unlocking for the treatment of acute stable intertrochanteric fractures in adult patients. Information regarding methodological quality, patient demographics, and clinical outcomes were extracted independently by two reviewers. Subsequently, patients were divided into a locking and unlocking group.

RESULTS

This study included 9 articles, comprising a total of 1978 patients with a similar baseline. The results showed that the unlocking group had a shorter operation time, less intraoperative bleeding, lower transfusion rate, and less thigh pain after the treatment of femoral intertrochanteric fracture when compared with the distal locking group. No significant differences were observed in safety-related outcomes, including mortality, infection rate, cutting out, loss of reduction, backing out of lag screws, cephalic screw breakage, nail breakage, and peri-implant fractures between the two groups. In addition, efficacy-related outcomes including nonunion, delayed healing rates, and the Harris functional score were not significantly different between the two groups.

CONCLUSIONS

Our pooled analysis demonstrated that distal unlocking of stable intertrochanteric fractures can shorten the operation time, reduce intraoperative bleeding, and reduce the blood transfusion rate. The use of locked or unlocked intramedullary nailing does not affect long-term outcomes regarding complications and function.

Distal Locked versus Unlocked Intramedullary Nailing in Intertrochanteric Fracture; A Systematic Review and Meta-Analysis of Randomized and Non-Randomized Trials

Objective:

To compare the outcome of distal locked and unlocked intramedullary nailing in patients with intertrochanteric fractures through systematic review and meta-analysis of randomized and non-randomized clinical trials.

Methods:

Randomized or non-randomized controlled studies comparing the effects of unlocked and locked nails for treatment of intertrochanteric fractures were searched using the search strategy of Cochrane collaboration up to April 2019. Four eligible studies involving 691 patients were included. Their methodological quality was assessed, and data were extracted independently for meta-analysis.

Results:

The results showed that the unlocked group has significantly less operative time (MD: -8.08; 95%CI -11.36 to -4.79; P< 0.00001), fluoroscopy time (MD: -7.09, 95%CI -7.09 to -4.79; p<0.00001), length of incision (MD: -2.50, 95%CI 2.85 to -2.14; p< 0.00001) than the locked group. The complication rate was significantly higher in the locking group (OR: 0.55, 95%CI 0.26 to 1.15; p=0.03). No significant differences were found in the Harris hip score between the two groups (MD: 0.68, 95% CI -0.83 to 2.19, p<0.08).

Conclusion:

The present meta-analysis suggests that intramedullary nailing without distal locking is reliable and acceptable option for treating intertrochanteric fracture. The advantages are reduced operative time, decreased fluoroscopy time, smaller size of incision and decreased complication rate. However, owing to the low-quality evidence currently available, additional high quality Randomized controlled trials are needed to confirm these findings.

Radiologic predictor of intraoperative lateral wall fractures in treatment of pertrochanteric fractures with cephalomedullary nailing

Objective

This study was performed to investigate the reliability of the height of pertrochanteric fractures as a predictor of lateral wall fractures after cephalomedullary nailing and provide a simple way to determine the threshold value.

Methods

We performed a prospective randomized clinical study of 50 consecutive patients who underwent measurement of the height of the pertrochanteric fracture and the tangent line to the superior margin of the contralateral femoral neck. The preoperative and postoperative integrity of the lateral wall was evaluated by computed tomography.

Results

The pertrochanteric fracture height was significantly lower in patients with than without intraoperative lateral wall fractures (15.6 vs. 28.5 mm, respectively). The threshold value of the fracture height was 20.445 mm, which was not significantly different from the mean height of the tangent line of the superior margin of the contralateral femoral neck (19.4 mm).

Conclusions

Pertrochanteric fractures with the proximal starting point lower than the mirror position of the tangent line to the superior margin of the contralateral femoral neck have a higher risk of intraoperative lateral wall fractures during cephalomedullary nailing.

Parametric Finite Element Analysis of Intramedullary Nail Fixation of Proximal Femur Fractures

Proximal femur fracture fixation with intramedullary nailing relies on stability at the fracture site and integrity of the fixation construct to achieve union. The biomechanics that dictate fracture site stability and implant stress depend on fracture type as well as implant features such as nail length, nail diameter, presence of distal fixation screws, and material composition of the implant. When deciding how to fix a fracture, surgeons have choices in these implant-related design variables. This study models all combinations of a range of implant variables for nine standard AO/OTA proximal femur fractures using finite element analysis. Under simulated maximum load during gait, the maximum stress in the implant and screws as well as interfragmentary motions at the fracture site in the axial and shear directions were computed. The results were separated by fracture type to show the influence of each design variable on measured biomechanical outcomes. Filling the reamed canal with the largest fitting nail diameter reduced axial and shear interfragmentary motion for all fracture types. Nail length was less predictive of shear interfragmentary motion for most simulated fracture types than other construct variables. Furthermore, gapping at the fracture site predisposed the construct to higher implant stresses and larger interfragmentary motions. Clinical significance: Biomechanical outcomes from this computational study can aid in surgical decision-making for optimizing hip fracture fixation with IM nailing. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2358-2366, 2019.

Distal locked or unlocked nailing for stable intertrochanteric fractures? A meta-analysis

BACKGROUND

To date, there are just several studies comparing distal locked nails with distal unlocked nails in treating intertrochanteric fractures. We report the first meta-analysis about this issue.

METHODS

Systematic search was conducted for studies in PubMed, Embase and Cochrane Library. Meta-analyses were performed regarding intra operative outcomes, complications and functional outcomes.

RESULTS

Pooled results showed insignificant difference between distal locking group and distal unlocking group in hip pain (relative risk (RR) 1.14, 95% confidence interval (CI) 0.59-2.19), distal tip fracture (RR 1.08, 95% CI 0.37-3.11), lag screw cut-out (RR 1.60, 95% CI 0.54-4.78), delayed or nonunion (RR 1.32, 95% CI 0.25-7.06), deep vein thrombosis (RR 1.06, 95% CI 0.23-4.84), wound infection (RR 0.58, 95% CI 0.28-1.22), Harris hip score (standard mean deviation (SMD) 0.03, 95% CI -0.15 to 0.21) and walking ability. However, significant difference was detected in operation time (SMD 0.77, 95% CI 0.36-1.17), fluoroscopy exposure time (SMD 1.02, 95% CI 0.52-1.52), blood loss (SMD 0.80, 95% CI 0.62-0.99) and total incision length (SMD 1.16, 95% CI 0.86-1.47). Result of trial sequential analysis indicated conclusive evidence.

CONCLUSION

Current evidence indicates that the distal locked intramedullary nails should not be recommended as routine choice for stable intertrochanteric fractures.

Unlocked versus dynamic and static distal locked femoral nails in stable and unstable intertrochanteric fractures. A prospective study

INTRODUCTION

Few clinical studies have analyzed the utility of distal interlocking screws in stable and unstable intertrochanteric fractures treated with intramedullary devices. We performed a prospective analysis comparing short unlocked versus short dynamic and short static distal locked intramedullary nails.

MATERIALS AND METHODS

Nine level-II trauma centres were involved in the study. 240 patients over the age of 65 with a stable (AO/OTA 31-A1) or unstable intertrochanteric fracture (AO/OTA 31-A2) were prospectively investigated. The same type of nail was used in every patient. Patients were randomly divided into 3 groups according to the type of distal locking used. Intra-operative variables were examined and patients were followed clinically and radiographically at 1, 3, 6, 12 months postoperatively. All complications were recorded.

RESULTS

A total of 212 patients completed 1 year of follow-up visits. In the Unlocking Group (UG) the operation time, blood loss, fluoroscopy time, total length of incision were significantly decreased compared to both the Dynamic Group (DG) and the Static Group (SG) (p < 0.05). Conversely, no reliable differences in intraoperative variables were noted between the Dynamic Group and the Static Group (p > 0.05). In terms of time of fracture union we found no differences among the three Groups (p > 0.05). Moreover, no cases of limb shortening >1 cm or varus collapse were detected in any group. The 3 Groups were similar in terms of HHS, SF-12 and Barthel index results at 1-year follow-up (p > 0.05). Finally, no significant differences were demonstrated across the three Groups in terms of major complications.

CONCLUSIONS

This clinical study further confirms the hypothesis that short intramedullary nails do not need to be locked for stable and unstable intertrochanteric fractures.

The fake unlocked femoral nail: A configuration to avoid in stable pertrochanteric femur fractures

BACKGROUND

Intramedullary unlocked nailing is a safe and used treatment for stable pertrocantheric fractures. Due to the femoral anterior bow of the shaft or a wrong entry point, the distal tip of the nail can be impinging the anterior cortex. This type of situation can compromise the function of the nail, leading to nonunion of the fracture, and cut-out. The aim of this study was to assess the relationship between nail impingement of the anterior cortex of the femur and cut-out and nonunion incidence in patients with pertrochanteric stable fracture treated with an IM nail in an unlocked configuration.

MATERIAL AND METHODS

A retrospective study based on medical records and imaging from the archives of our Level I academic medical center was conducted. The study included patients with proximal femoral fractures treated with short cephalomedullary nails between January 2012 and May 2015. The data collected were analyzed to a possible correlation with the healing time and occurrence of nonunion and cut-out.

RESULTS

The study population counted 429 cases. Applying the inclusion criteria the final series was composed of 169 patients: 112 females (66.73%) and 57 males (33.27%), with a mean age of 81.23 years (range: 67-93 years). Distal tip impingement was observed in 22 cases (13.02%). In total 16 (9.47%) postoperative complications were recorded: 8 non-union and 7 cut-outs. Consolidation was registered in 153 cases and the fracture healing time averaged 14.4 ± 3.8 weeks (range, 11-24 weeks). The cortical impingement was correlated with nonunion and cut-out (p < 0.001) Logistic regression analysis revealed jamming sign significantly affected the fracture healing time (p < 0.001).

CONCLUSION

The occurrence of cut-out and nonunion after cephalomedullary nailing of stable pertrochanteric fractures appear to be correlated to the presence of the cortical impingement. For this reason, the fake unlocked femoral nail with the cortical impingement is a configuration to avoid in stable pertrochanteric femur fractures.

Implant-Related Complications and Mortality After Use of Short or Long Gamma Nail for Intertrochanteric and Subtrochanteric Fractures: A Prospective Study with Minimum 13-Year Follow-up

Background:

The purpose of this study was to evaluate the rates of implant-related complications and mortality after treatment of an intertrochanteric or subtrochanteric fracture with a short or long Gamma nail.

Methods:

Between September 1998 and August 2003, 644 patients at 2 centers treated with a long or short Gamma nail for a hip fracture were prospectively enrolled in this study. These patients were followed until they reached 1 of the study end points, which included death, a reoperation directly related to the Gamma nail, or the end date of the study.

Results:

The average age (and standard deviation) of the patients included in the study was 81.3 ± 8.6 years at the time of the operation, and 28.3% of the patients were male. The rate of implant-related complications was 9.9%. The most common complications included peri-implant fracture (4.2%), proximal lateral thigh discomfort requiring extraction of the implant (2.0%), and lag-screw cutout (1.1%). Interestingly, more than half (56%) of the 27 peri-implant fractures occurred >1.5 years after the index operation. The median time from the operation to death was 2.9 years (range, 0 to 17.1 years). The 30-day mortality rate after treatment was 9.5%. Patients with American Society of Anesthesiologists (ASA) class-3 or 4 physical status had a significantly higher risk of mortality than ASA class-1 patients.

Conclusions:

Gamma nails are effective in the treatment of intertrochanteric and subtrochanteric fractures. However, 9.8% of patients had complications requiring additional surgery. The most common serious complications include peri-implant fracture and lag-screw cutout. Several peri-implant fractures occurred long after the index procedure. Patients had a high rate of mortality (27%) after 1 year, and higher preoperative ASA class was found to be a predictor of increased risk of mortality. Therefore, clinicians must carefully consider patients’ preoperative comorbidities when counselling patients on the risks of surgery.

Level of Evidence:

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Unstable trochanteric fractures: Issues and avoiding pitfalls

The incidence of trochanteric fractures is rising because of increasing number of senior citizens with osteoporosis. There are various modalities for reduction and internal fixation. However, the incidence of complications remains high. In the herein article we discuss issues that influence the fixation and outcomes of unstable trochanteric fractures. Moreover, the results of a prospective, randomised, cohort, time bound, hospital based, comparative study is presented.