Effectiveness of distally slotted proximal femoral nails on prevention of femur fractures during and after intertrochanteric femur fracture surgery

Impingement and perforation of the anterior femoral cortex in cephalomedullary nailing: Systematic review and surgical techniques

BACKGROUND

Anterior femoral cortical impingement and perforation are known risks of cephalomedullary nailing. The incidence of and risk factors for these findings have not been fully established in the literature. The purpose of this review was to answer: (1) What is the incidence of anterior femoral cortical impingement and perforation associated with cephalomedullary nailing of proximal femur fractures? (2) How does incidence vary by nail radius of curvature (ROC)? (3) What populations are at increased risk of impingement and perforation? (4) What surgical techniques prevent their occurrence?

HYPOTHESIS

Our hypothesis was that impingement would be a relatively common finding following cephalomedullary nailing, and perforation would be much less frequent but still an appreciable risk. Secondarily, nails with a larger ROC would have a higher rate of impingement.

PATIENTS AND METHODS

In this systematic review, PubMed, MEDLINE, and Cochrane databases were searched for articles from 1990-2020 written in English using the terms "cephalomedullary nail" or "femoral nail" and "perforation" or "impingement", and similar words. Inclusion criteria were studies discussing the complication of anterior femoral cortical impingement or perforation associated with the use of a cephalomedullary nail. Fourteen studies met inclusion criteria. Rates of anterior femoral cortical impingement or perforation, patient demographics, nail type, and ROC were extracted. Surgical techniques to prevent perforation were qualitatively reviewed.

RESULTS

The rate of anterior cortical impingement with long cephalomedullary nails was 17.2% (192/1117 patients) and with short nails was 29.2% (176/602). The rate of anterior cortical perforation with long nails was 1.0% (11/1116) and with short nails was 0% (0/234). Long nails with ROC>150cm showed an impingement rate of 10.9% (62/567) and perforation rate of 1.1% (7/617 patients). Nails with ROC 150cm or 100cm had an impingement rate of 1.1% (1/93) and perforation rate of 0% (0/93).

DISCUSSION

Impingement and perforation of the anterior femoral cortex during cephalomedullary nailing are appreciable risks that surgeons should anticipate and avoid, especially in certain populations and with nails with larger ROC. Surgeons may consider use of long nails with ROC 150cm and below, given a nearly 10-fold lower incidence of impingement and no reported perforations.

LEVEL OF EVIDENCE

Therapeutic, level IV.

Intertrochanteric Femoral Fractures: A Comparison of Clinical and Radiographic Results with the Proximal Femoral Intramedullary Nail (PROFIN), the Anti-Rotation Proximal Femoral Nail (A-PFN), and the InterTAN Nail

Background and Objectives: The aim of this study was to evaluate retrospectively the radiological and functional outcomes of closed reduction and internal fixation for intertrochanteric femoral fractures (IFF) using three different proximal femoral nails (PFN). Materials and Methods: In total, 309 individuals (143 males and 166 females) who underwent surgery for IFF using a PFN between January 2018 and January 2021 were included in the study. Our surgical team conducted osteosynthesis using the A-PFN® (TST, Istanbul, Turkey) nail, the PROFIN® (TST, Istanbul, Turkey), and the Trigen InterTAN (Smith & Nephew, Memphis, TN, USA) nail. The PFNs were compared based on age, gender, body mass index (BMI), length of stay (LOS) in intensive care, whether to be admitted to intensive care, mortality in the first year, amount of transfusion, preoperative time to surgery, hospitalisation time, duration of surgery and fluoroscopy, fracture type and reduction quality, complication ratio, and clinical and radiological outcomes. The patients’ function was measured with the Harris Hip Score (HHS) and the Katz Index of Independence in Activities of Daily Living (ADL). Results: Pain in the hip and thigh is the most common complication, followed by the V-effect. The Z-effect was seen in 5.7% of PROFIN patients. A-PFN was shown to have longer surgical and fluoroscopy durations, lower HHS values, and much lower Katz ADL Index values compared to the other two PFNs. The V-effect occurrence was significantly higher in the A-PFN group (36.7%) than in the InterTAN group. The V-effect was seen in 33.1% of 31A2-type fractures but in none of the 31A3-type fractures. Conclusions: InterTAN nails are the best choice for IFFs because they have high clinical scores after surgery, there is no chance of Z-effect, and the rate of V-effect is low.

Traction-bed-assisted reduction and double-plate fixation for treatment of comminuted femoral intertrochanteric fractures with coronal split

Background

A coronal comminuted femoral intertrochanteric fracture is a special type of fracture that easily leads to internal fixation failure, and the current internal fixation techniques remain controversial. This study aims to evaluate the effect of traction-bed-assisted reduction and double-plate internal fixation in the treatment of comminuted and coronally split intertrochanteric femoral fracture.

Method

Retrospective analyses of the clinical data of 83 patients diagnosed with, and treated for, comminuted and coronally split intertrochanteric femoral fracture from December 2017 to November 2019 were conducted. Among the total number of 83 patients, 40 patients received traction-bed-assisted reduction and PFNA fixation (the control group), whereas 43 patients received traction-bed-assisted reduction and double-plate internal fixation (the experimental group). The major indicators for the research analysis such as the general information of patients, perioperative data, and follow-up data of both groups were collected, sorted out, and meticulously analyzed.

Results

The time taken for traction-bed-assisted reduction and double-plate intern fixation in the experimental group was significantly shorter than that in the control group (P < .05). The post-operative Harris Hip Score (HHS) at 3 months and at the final follow-up after the surgery was significantly better in the experimental group compared with that in the control group, both of which were statistically significant (P < .05). However, there were statistically no significant differences between the two groups in terms of preoperative hemoglobin (Hb) level, amount of intraoperative total blood loss, immediate post-operative Hb level, incidence of wound infection within 14 days post-operatively, time taken to step up on the ground after surgery, HHS 2 weeks after surgery, time taken for fracture healing, and the incidence of complications (P > .05).

Conclusion

The use of a traction bed to achieve adequate reduction, followed by internal fixation using double plates, comparatively takes less time for both reduction and operation in the treatment of comminuted and coronally split intertrochanteric femoral fractures, which also restores proper hip joint movements relatively early and hence provides better hip joint functions in the long run.

Effects of alendronate sodium combined with InterTan on osteoporotic femoral intertrochanteric fractures and fracture recurrence

BACKGROUND

Osteoporosis is a global disease affecting 6.6% of the total population. Osteoporosis complications include fractures, increased bone fragility, and reduced bone strength. The most commonly affected parts are the vertebral body, hip, and wrist.

AIM

To examine the effect of alendronate sodium combined with InterTan for osteoporotic femoral intertrochanteric fractures on bone and fracture recurrence

METHODS

In total, 126 cases of osteoporotic femoral intertrochanteric fractures were selected and divided into two groups according to the 1:1 principle by the simple random method. They were admitted to the Department of Orthopedics, First Affiliated Hospital of Xingtai Medical College, from January 2018 to September 2020. The control group was treated with InterTan fixation combined with placebo, and the observation group with alendronate sodium based on InterTan fixation. Operation-related indicators, complications, and recurrent fractures were compared between the groups. Changes in bone metabolism markers, t value for hip bone mineral density, and Harris Hip Score were observed.

RESULTS

Operation time, intraoperative blood loss, postoperative ambulation time, and complications were compared between the groups, and no significant difference was found. The fracture healing time was significantly shorter in the observation group than in the control group. β-Collagen-specific sequence (β-CTX) and total aminoterminal propeptide of type I procollagen (T-PINP) in the control group at 3 mo after operation were compared with those before operation, and the difference was not significant. Six months after the operation, the β-CTX level decreased and T-PINP level increased. β-CTX level at 3 and 6 mo in the observation group after operation was lower, and T-PINP level was higher, than that before operation. Compared with the control group, T-PINP level of the observation group was significantly higher and β-CTX level was significantly lower at 3 and 6 mo after operation. The t value of hip bone mineral density was compared in the control group before and 1 mo after operation, and significant difference was not found. Compared with the control group, the t value of hip bone mineral density in the observation group was significantly higher at 1, 3, 6, and 12 mo after operation. Compared with the control group, the Harris score of the observation group was significantly higher at 1, 3, 6, and 12 mo after operation. The recurrence rate of fractures in the observation group within 12 mo was 0.00%, which was significantly lower than 6.35% in the control group.

CONCLUSION

Alendronate sodium combined with InterTan in the treatment of osteoporotic femoral intertrochanteric fractures can increase bone mineral density, improve hip joint function, promote fracture healing, and reduce fracture recurrence.