Reporting on quality of reduction and fixation of intertrochanteric fractures-A systematic review

Role of Anteromedial Cortical Support for Unstable Intertrochanteric Fractures Being Treated With Cephalomedullary Nails

INTRODUCTION

Reduction quality is of paramount importance for an optimal outcome in unstable pertrochanteric fractures. The non-anatomical functional anteromedial buttress is proposed to prevent impending mechanical complications. We aimed to evaluate the role of anteromedial cortical support in preventing mechanical complications following fixation with the cephalomedullary nail.

MATERIALS AND METHODS

A prospective, single-arm interventional study was conducted in the Orthopaedics Department of a Combined Military Hospital (CMH) in Rawalpindi. The duration of the study was 24 months. Patients were recruited by the purposive sampling technique as per inclusion/exclusion criteria. Preoperatively, the reduction was categorized as per Baumgartner's and Chang's criteria. Post-operatively, weight bearing as tolerated was advised. Radiographs prior to discharge for loss of reduction were evaluated. Follow-up radiographic measurements of neck length, neck shaft angle, and their loss as per protocol were done at three and six months.

RESULTS

A total of 202 patients were operated on from October 21 until August 23. Mortality at six months in 39 patients (19.3%) and loss to follow-up in 31 patients (15.3%) resulted in 132 patients with complete follow-up and having developed complications in 12 patients (9.09%). The mean age was 76.3 ± 7.98 years; males were 105 (79.5%), and females were 27 (20.5%). Closed reduction was 58 (43.9%), and additional manoeuvres were required in 74 (56.1%). The mean tip apex distance (TAD) was 24.56 ± 2.76, and the Calcar gap was 5.16 ± 1.27. Cleveland zone centre-centre in 54 (40.9%), inferior-centre in 65 (49.2%), and inferior-posterior (9.9%) were statistically significant for mechanical complications (p≤0.001). There was a significant association between the grading of Chang's and Baumgartner's poor groups for the development of mechanical complications (p≤0.001). The mean time to full weight bearing without support was 21 ± 1.22 weeks. The mean Hip Harris score at six months was 69.27 ± 7.68.

CONCLUSION

Results suggest that anteromedial cortical support can lead to fewer potential mechanical complications at six months. A higher Chang's grade drives surgeons to engage in additional manoeuvres. Anteromedial cortical support is worth consideration for unstable pertrochanteric fractures.

Meta-analysis of the clinical efficacy of the Gamma3 nail vs Gamma3U-blade system in the treatment of intertrochanteric fractures

BACKGROUND

The traditional Gamma3 nail is a mainstream treatment for femoral intertrochanteric fractures. Literature reports that the Gamma3U-blade system can increase the stability of the Gamma3 nail and reduce complication incidence. However, comparative studies between the Gamma3U-blade and Gamma3 systems are limited; hence, this meta-analysis was performed to explore the clinical efficacy of these two surgical methods.

AIM

To investigate the clinical efficacy of Gamma3 and Gamma3 U-blade for intertrochanteric fractures.

METHODS

A computerized search for Chinese and English literature published from 2010 to 2022 was conducted in PubMed, Cochrane, CNKI, Wanfang, and VIP databases. The search keywords were gamma 3, gamma 3 U blade, and intertrochanteric fracture. Additionally, literature tracking was performed on the references of published literature. The data were analyzed using Revman 5.3 software. Two individuals checked the inputs for accuracy. Continuous variables were described using mean difference and standard deviation, and outcome effect sizes were expressed using ratio OR and 95% confidence interval (CI). High heterogeneity was considered at (P < 0.05, I2 > 50%), moderate heterogeneity at I2 from 25% to 50%, and low heterogeneity at (P ≥ 0.05, I2 < 50%).

RESULTS

Following a comprehensive literature search, review, and analysis, six articles were selected for inclusion in this study. This selection comprised five articles in English and one in Chinese, with publication years spanning from 2016 to 2022. The study with the largest sample size, conducted by Seungbae in 2021, included a total of 304 cases. Statistical analysis: A total of 1063 patients were included in this meta-analysis. The main outcome indicators were: Surgical time: The Gamma3U blade system had a longer surgical time compared to Gamma3 nails (P = 0.006, I2 = 76%). Tip-apex distance: No statistical significance or heterogeneity was observed (P = 0.65, I2 = 0%). Harris Hip score: No statistical significance was found, and low heterogeneity was detected (P = 0.26, I2 = 22%). Union time: No statistical significance was found, and high heterogeneity was detected (P = 0.05, I2 = 75%).

CONCLUSION

Our study indicated that the Gamma3 system reduces operative time compared to the Gamma3 U-blade system in treating intertrochanteric fractures. Both surgical methods proved to be safe and effective for this patient group. These findings may offer valuable insights and guidance for future surgical protocols in hip fracture patients.

Finite element analysis of the effect of residual lateral wall volume on postoperative stability in intertrochanteric fractures

BACKGROUND

Lateral wall fractures represent crucial risk factors for postoperative internal fixation failure in intertrochanteric femoral fractures. However, no consensus exists on the type of lateral wall fracture requiring interventional management. This study aimed to investigate the effect of residual lateral wall volume on the postoperative stability of intertrochanteric femur fractures with associated lateral wall fractures, providing valuable reference for the clinical management of the lateral wall.

METHODS

Eleven bone defect models of intertrochanteric femur fractures with varying residual lateral wall volumes were constructed using finite element analysis. These models were fixed with proximal femoral nail antirotation (PFNA). Simulations of von Mises stress and displacement distribution of the PFNA and femur during normal walking were conducted. Statistical analysis was performed to assess the correlation between volume and the maximum von Mises stresses and displacements of the PFNA and femur.

RESULTS

In all 11 models, the maximum von Mises stress and displacement of the helical blade, intramedullary nail, and femur occurred at the same locations. As residual lateral wall volume increased, the maximum von Mises stress and displacement of the helical blade, intramedullary nail, and maximum femoral displacement gradually decreased. However, the overall trend of the maximum femoral von Mises stress gradually decreased. At 70% retention of the residual lateral wall volume, there was a more pronounced change in the value of the maximum stress change of the helical blade and the intramedullary nail. Statistical analysis, including the Shapiro-Wilk test and Pearson correlation analysis, demonstrated a significant negative correlation between volume and the maximum von Mises stress and displacement of the helical blade, intramedullary nail, and femur. Linear regression analysis further confirmed this significant negative correlation.

CONCLUSION

Finite element analysis of the residual lateral wall revealed a significant correlation between volume and the postoperative stability of intertrochanteric femur fractures. A volume of 70% may serve as the threshold for stabilizing the residual lateral wall. Volume emerges as a novel index for evaluating the strength of the residual lateral walls.

A Retrospective analysis of peri-implant fractures: insights from a large volume clinical Study

PURPOSE

Peri-implant fractures (PIFs) are a concept in evolution for which different diagnostic criteria have been proposed and modified over time. They have not been extensively reported. PIFs are usually located in the distal part of previous osteosynthesis, where fragile bone is in contact with the rigid implant and are a significant complication after orthopaedic surgery, which requires careful management and treatment. This clinical study presents findings from a retrospective analysis of PIF's, providing description of characteristics and outcomes. They provide information about the associated risk factors and description of the effectiveness of various treatments.

MATERIALS AND METHODS

A retrospective analysis was performed in a clinical study involving patients with PIFs. Data from medical records, radiographic images, and surgical reports were collected and analyzed. The study included patients with refracture of pre-existing osteosynthesis admitted to the hospital between 2015 and 2022. Demographic information, fracture characteristics, surgical interventions, and post-operative outcomes were assessed. Each case was followed for a minimum of one year after surgery, and a critical analysis was performed by senior surgeons. Furthermore, the PIFs were classified according to the type of initial implant and the position of the new fracture in relation to the original implant.

RESULTS

Between 2015 and 2022, out of 18,813 fractures treated at a Level 1 traumatology hospital, a total of 85 patients with PIF's were identified. Fracture characteristics varied, including location, fracture pattern, and implant type. Most of the PIFs, 71 cases (83.53%), occurred in the femur. Additionally, there were seven cases (8.24%) involving the humerus, four cases (4.71%) affecting the tibia/fibula, two cases (2.35%) in the radius, and one case (1.18%) involving the clavicle. Surgical management was the primary attitude in treatment. Various techniques were used, including the use of longer and stronger implants to achieve high-quality fixation, facilitating early rehabilitation and return to previous activities. Postoperative complications after surgery for PIFs were observed in 16 cases (18.8%).

CONCLUSIONS

Peri-implant fractures (PIF) are a distinct topic and a challenging condition with a high rate of postoperative complications. Complications after the second surgery may be severe and life threatening in older patients. A classification can be useful to make decisions about the optimal treatment in different anatomic areas and type of implant used for primary osteosynthesis. Currently there are no standardized protocols for management, therefore each case should be carefully discussed and planned before surgery.

Stability of Intertrochanteric Femur Fractures

SUMMARY

The stability of intertrochanteric fractures depends upon multiple factors including the fracture displacement, location and pattern, the type of fixation used for stabilization, and the loading that the fracture undergoes postfixation. Traditional classification systems are of limited utility because they typically stratify intertrochanteric fractures as stable or unstable based purely on the fracture pattern without consideration of the stability after fixation. Biomechanical studies evaluating the stability of various fixation constructs should include physiologic loading, including rotation around the axis of the femoral neck, and reproduce clinical failure modes to be clinically relevant. A growing body of evidence indicates that the type of fixation substantially affects postoperative stability of intertrochanteric fractures.

Fellowship-Trained Orthopaedic Trauma Surgeons Achieve Better Postoperative Radiographic Parameters After Intramedullary Nailing of Intertrochanteric Femur Fractures when Compared With Non-trauma-Trained Surgeons

INTRODUCTION

Intertrochanteric femoral fractures are common orthopaedic injuries accounting for nearly 30% of all fracture-related hospitalizations. Because many factors predictive of failure are related to technical aspects of the surgery, the purpose of this study was to compare radiographic parameters after fixation, comparing fellowship-trained orthopaedic trauma surgeons with surgeons who did not complete an orthopaedic trauma fellowship.

METHODS

We initiated a search for CPT code 27245 across our hospital network to identify 100 consecutive patients treated by five fellowship-trained orthopaedic traumatologists and 100 consecutive patients treated by community surgeons. Patients were then stratified based on their surgeon's subspecialty training (trauma vs community). Primary outcome variables were neck-shaft angle (NSA), a comparison of the repaired NSA with the uninjured side, tip-apex distance, and reduction quality.

RESULTS

One hundred patients were included in each group. The mean age in the community group was 77 years compared with 79 years in the trauma group. The mean tip-apex distance for the trauma group was 10 mm compared with 21 mm for the community group ( P < 0.001). The mean postoperative NSA for the trauma group was 133° compared with 127° for the community group ( P < 0.001). The mean difference of the NSA of the repaired side compared with the uninjured side was 2.5° of valgus in the trauma group compared with 5° of varus for the community group ( P < 0.001). There were 93 good reductions in the trauma group compared with 19 in the community group ( P < 0.001). There were 0 poor reductions in the trauma group and 49 in the community group ( P < 0.001).

DISCUSSION

Overall, we have shown that fellowship-trained orthopaedic trauma surgeons achieve better reductions when treating intertrochanteric femur fractures with intramedullary nails. Orthopaedic residency training should emphasize teaching proper techniques and acceptable parameters for reduction and implant placement when treating geriatric intertrochanteric femur fractures.

Post hip fracture orthogeriatric care-a Canadian position paper addressing challenges in care and strategies to meet quality indicators

INTRODUCTION

Osteoporosis is a major disease state associated with significant morbidity, mortality, and health care costs. Less than half of the individuals sustaining a low energy hip fracture are diagnosed and treated for the underlying osteoporosis.

OBJECTIVE

A multidisciplinary Canadian hip fracture working group has developed practical recommendations to meet Canadian quality indicators in post hip fracture care.

METHODS

A comprehensive narrative review was conducted to identify and synthesize key articles on post hip fracture orthogeriatric care for each of the individual sections and develop recommendations. These recommendations are based on the best evidence available today.

CONCLUSION

Recommendations are anticipated to reduce recurrent fractures, improve mobility and healthcare outcomes post hip fracture, and reduce healthcare costs. Key messages to enhance postoperative care are also provided.

Predictors of and predictive nomogram for cut-out of proximal femur nail anti-rotation device in intertrochanteric fractures

PURPOSE

This study determined independent predictors and developed a predictive nomogram for failed correction of intertrochanteric fractures due to cut-out of the proximal femur nail anti-rotation (PFNA) device.

METHODS

Demographic and radiological data of 592 adult patients with intertrochanteric fractures (AO 31A) treated by PFNA were collected retrospectively. Independent predictors of cut-out were obtained through univariate and multivariate analyses, and a predictive nomogram was established. The discrimination, calibration, and clinical utility of the nomogram were based on receiver operating characteristic curve (AUC), concordance index (C-index), calibration curve, and decision curve analysis, respectively.

RESULTS

Overall, 18 (3.04%) cases of cut-out occurred. Independent predictors according to the multivariate analysis were body mass index (BMI), poor-to-acceptable quality of reduction, PFNA blade position, and tip-apex distance (TAD). AUC of the nomogram was 0.849, and C-index was 0.849 (95% CI [0.844-0.854]). Bootstrapping yielded a corrected C-index of 0.849. The calibration and decision curves indicated good agreement and clinical benefit of the nomogram.

CONCLUSION

A reliable predictive nomogram was developed for cut-out of the PFNA in intertrochanteric fractures, based on BMI, quality of reduction, blade position, and TAD.

Therapeutic Effects of the Proximal Femoral Nail for the Treatment of Unstable Intertrochanteric Fractures

Objective

The aim of this study was to analyze the clinical effect of the proximal femoral nail on elderly patients with unstable intertrochanteric fracture and the effect of the proximal femoral nail on serum levels of matrix metalloproteinases (MMPs) and osteoprotegerin (OPG).

Methods

The elderly patients with unstable intertrochanteric fracture of the femur admitted to our hospital from January 2017 to January 2021 were studied. 100 patients were randomly divided into two groups: the control group (n = 50) and the observation group (n = 50). The patients in the control group were treated with a proximal femoral locking compression plate. The patients in the observation group were treated with the proximal femoral antirotation intramedullary nail. The clinical therapeutic effects of the two groups and the changes in serum MMPs and OPG levels before and after treatment were analyzed.

Results

Compared with the control group, the operation time, postoperative landing time, and fracture healing time of the observation group were significantly shortened, and intraoperative blood loss was significantly reduced (P < 0.05). Compared with the control group, the total effective rate of patients in the observation group was significantly higher (P < 0.05). After treatment, the levels of CRP, IL1β, IL2, MMP-2, MMP-6, TIMP-1, and RANKL decreased significantly in both groups (P < 0.05), while the levels of OPG increased significantly (P < 0.05). Compared with the control group, the changes in the above indexes were more obvious in the observation group (P < 0.05).

Conclusion

The proximal femoral antirotation intramedullary nail has a better therapeutic effect on elderly patients with unstable intertrochanteric fracture, and the level of MMPs and OPG may be related to the treatment process.

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.