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Robioneck MW, Pishnamaz M, Becker N, Bolierakis E, Hildebrand F, Horst K. Development of early complications after treatment of trochanteric fractures with an intramedullary sliding hip screw in a geriatric population. Eur J Trauma Emerg Surg 2024; 50:329-337. [PMID: 38081966 DOI: 10.1007/s00068-023-02404-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 11/12/2023] [Indexed: 04/23/2024]
Abstract
PURPOSE Although trochanteric fractures (TF) are a frequent event in the geriatric population, studies reporting on complication rates associated with surgical treatment are sparse. Thus, this study investigated the relevance of fracture-, implant-, and surgery-associated complications in TF. Furthermore, the role of possible risk factors for the before mentioned complications was investigated. METHODS A consecutive series of patients with TF treated by intramedullary nailing with a sliding screw device was evaluated. Data were sampled retrospectively from the hospital patient information system and anonymized at the source. Demographic data and information regarding fracture pattern, the treatment performed, hospital stay, and evaluation of operative and follow-up radiographs were analyzed. Intraoperative problems (i.e., technical problems with the implant, intraoperative fracture) and postoperative complications were investigated. RESULTS Postoperative surgical complications were noted in 11.7%. The most frequent surgical problem was a difficult fracture reduction (13%) and intraoperative fracture dislocation (3.6%). The most frequent postoperative complication was intra-hospital mortality (3.6%), delayed/non-union (2.7%), and a cut-out of the lag screw in the femoral head (2.3%). Implant failure (1,4%) was significantly associated with morbid obesity while cut-out (2,3%) correlated with a higher tip-apex distance (TAD). A complex fracture type and a suboptimal screw position significantly increased the cut-out rate to 5% (p = 0.018). CONCLUSION Complications after TF treatment occur frequently. While patient-associated variables such as morbid obesity cannot be influenced by the surgeon, correct fracture reduction and implant positioning remain to be of highest importance.
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Affiliation(s)
| | - Miguel Pishnamaz
- Department of Orthopaedic Trauma and Reconstructive Surgery, University Hospital RWTH, Aachen, Germany
| | - Nils Becker
- Department of Orthopaedic Trauma and Reconstructive Surgery, University Hospital RWTH, Aachen, Germany
| | - Eftychios Bolierakis
- Department of Orthopaedic Trauma and Reconstructive Surgery, University Hospital RWTH, Aachen, Germany
| | - Frank Hildebrand
- Department of Orthopaedic Trauma and Reconstructive Surgery, University Hospital RWTH, Aachen, Germany
| | - Klemens Horst
- Department of Orthopaedic Trauma and Reconstructive Surgery, University Hospital RWTH, Aachen, Germany
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Zeelenberg ML, Plaisier AC, Nugteren LHT, Loggers SAI, Joosse P, Verhofstad MHJ, Den Hartog D, Van Lieshout EMM. Extramedullary versus intramedullary fixation of unstable trochanteric femoral fractures (AO type 31-A2): a systematic review and meta-analysis. Arch Orthop Trauma Surg 2024; 144:1189-1209. [PMID: 38175213 PMCID: PMC10896832 DOI: 10.1007/s00402-023-05138-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 11/13/2023] [Indexed: 01/05/2024]
Abstract
OBJECTIVE The aim of this systematic review was to compare extramedullary fixation and intramedullary fixation for AO type 31-A2 trochanteric fractures in the elderly, with regard to functional outcomes, complications, surgical outcomes, and costs. METHODS Embase, Medline, Web of Science, Cochrane Central Register of Controlled Trials, and Google Scholar were searched for randomized controlled trials (RCTs) and observational studies. Effect estimates were pooled across studies using random effects models. Results are presented as weighted risk ratio (RR) or weighted mean difference (MD) with corresponding 95% confidence interval (95% CI). RESULTS Fourteen RCTs (2039 patients) and 13 observational studies (22,123 patients) were included. Statistically superior results in favor of intramedullary fixation were found for Harris Hip Score (MD 4.09, 95% CI 0.91-7.26, p = 0.04), Parker mobility score (MD - 0.67 95% CI - 1.2 to - 0.17, p = 0.009), lower extremity measure (MD - 4.07 95% CI - 7.4 to - 0.8, p = 0.02), time to full weight bearing (MD 1.14 weeks CI 0.92-1.35, p < 0.001), superficial infection (RR 2.06, 95% CI 1.18-3.58, p = 0.01), nonunion (RR 3.67, 95% CI 1.03-13.10, p = 0.05), fixation failure (RR 2.26, 95% CI 1.16-4.44, p = 0.02), leg shortening (MD 2.23 mm, 95% CI 0.81-3.65, p = 0.002), time to radiological bone healing (MD 2.19 months, 95% CI 0.56-3.83, p = 0.009), surgery duration (MD 11.63 min, 95% CI 2.63-20.62, p = 0.01), operative blood loss (MD 134.5 mL, 95% CI 51-218, p = 0.002), and tip-apex distance > 25 mm (RR 1.73, 95% CI 1.10-2.74, p = 0.02). No comparable cost/costs-effectiveness data were available. CONCLUSION Current literature shows that several functional outcomes, complications, and surgical outcomes were statistically in favor of intramedullary fixation when compared with extramedullary fixation of AO/OTA 31-A2 fractures. However, as several of the differences found appear not to be clinically relevant and for many outcomes data remains sparse or heterogeneous, complete superiority of IM fixation for AO type 31-A2 fractures remains to be confirmed in a detailed cost-effectiveness analysis.
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Affiliation(s)
- Miliaan L Zeelenberg
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - A Cornelis Plaisier
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Leendert H T Nugteren
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Sverre A I Loggers
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
- Department of Surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Pieter Joosse
- Department of Surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Michiel H J Verhofstad
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Dennis Den Hartog
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Esther M M Van Lieshout
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
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Hestehave RA, Gundtoft PH, Nielsen CL, Brink O, Rölfing JD. Poor usability of computer-assisted navigation for hip fracture surgery. Arch Orthop Trauma Surg 2024; 144:251-257. [PMID: 37878075 PMCID: PMC10774189 DOI: 10.1007/s00402-023-05096-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 09/28/2023] [Indexed: 10/26/2023]
Abstract
INTRODUCTION The STRYKER ADAPT computer-assisted navigation system provides intraoperative feedback to the surgeon regarding implant placement of the Gamma3 nail. The usability of the ADAPT system has not been evaluated. The aim of the study was to investigate the perceived usability of the ADAPT system. MATERIALS AND METHODS This was a descriptive study with prospectively collected data. ADAPT was introduced at Aarhus University Hospital in February 2021. Prior to introduction, surgeons at the department attended a general introduction to the system. ADAPT was introduced to the surgical nurses and was on display at the surgical ward at more than one occasion, where personal introduction to the system was possible. After introduction, it was mandatory to use ADAPT when using the Gamma3 nail to treat intertrochanteric femur fractures. After each procedure, primary and an eventual supervisor answered a questionnaire, which encompassed the System Usability Scale (SUS) questionnaire. The SUS is a ten-item questionnaire regarding the perceived usability of a system. SUS scores were translated to adjectives, describing user experience on a 7-point adjective scale (worst imaginable, awful, poor, ok, good, excellent, best imaginable). User acceptability, defined as "not acceptable", "marginal" or "acceptable", was also used to interpret the SUS scores. RESULTS ADAPT was used in 50 procedures by 29 different surgeons, with varying skill-level. Median SUS-score after first-time use of ADAPT for all 29 surgeons was 43 (range: 5-60), which translated to "poor" or "not acceptable". For surgeons who performed ≥ 3 ADAPT-assisted procedures, there were no statistically significant difference in their first to latest SUS-score (median difference: 4.3, p = 0.5). In free text comments ADAPT was positively described as helpful in placement of K-wire and providing educational opportunities for inexperienced surgeons and negatively as inconsistent, slow, time consuming, and causing excessive fluoroscopy. CONCLUSIONS Usability and acceptability of ADAPT was rated as "poor" or "not acceptable" by the majority of operating surgeons. ADAPT has not been used at our institution based on these findings. The System Usability Scale may be used in further research exploring usability and acceptability of novel computer-assisted navigation systems for orthopaedic surgery.
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Affiliation(s)
- Rasmus Abildtrup Hestehave
- Department of Orthopaedics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, J801, 8200, Aarhus, Denmark
| | - Per Hviid Gundtoft
- Department of Orthopaedics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, J801, 8200, Aarhus, Denmark
| | - Christian Lind Nielsen
- Department of Orthopaedics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, J801, 8200, Aarhus, Denmark
| | - Ole Brink
- Department of Orthopaedics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, J801, 8200, Aarhus, Denmark
| | - Jan Duedal Rölfing
- Department of Orthopaedics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, J801, 8200, Aarhus, Denmark.
- Corporate HR, MidtSim, Central Denmark Region, Hedeager 5, 8200, Aarhus, Denmark.
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She Z, Yang F, Zhang S, Yang L, Wang X. A novel intramedullary nail design of intertrochanteric fracture fixation improved by proximal femoral nail antirotation. Comput Methods Biomech Biomed Engin 2023:1-11. [PMID: 38006389 DOI: 10.1080/10255842.2023.2286917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 11/18/2023] [Indexed: 11/27/2023]
Abstract
A proper and reliable fracture fixation is important for fracture healing. The proximal femoral intramedullary nail (IN), such as proximal femoral nail anti-rotation (PFNA) or Gamma nail, is widely used for intertrochanteric fracture fixation. However, it still suffers considerable stress concentrations, especially at the junction between the nail and the blade or lag screw. In this study, we propose a novel intramedullary nail design to enhance the intramedullary nail integrity by introducing a bolt screw to form a stable triangular structure composed of the nail, the lag screw, and the bolt screw (PFTN, Proximal femoral triangle nail). Systematic finite element numerical simulations were carried out to compare the biomechanical performances of PFTN and PFNA under both static and dynamic loads during the postures of ascending and descending stairs. The simulation results highlight the advantages of the proposed PFTN design with lower stresses, less stress concentration, and higher structure stability.
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Affiliation(s)
- Ze She
- School of Aerospace Engineering and Applied Mechanics, Tongji University, Shanghai, China
| | - Fan Yang
- School of Aerospace Engineering and Applied Mechanics, Tongji University, Shanghai, China
| | - Siyuan Zhang
- School of Aerospace Engineering and Applied Mechanics, Tongji University, Shanghai, China
| | - Liang Yang
- Tongji Hospital of Tongji University, Shanghai, China
- School of Medicine, Tongji University, Shanghai, China
| | - Xin Wang
- Tongji Hospital of Tongji University, Shanghai, China
- School of Medicine, Tongji University, Shanghai, China
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Carmona M, Gonzalez N, Segovia J, de Amesti M, Zamora T, Schweitzer D. Traction images heavily influence lateral wall measurement in trochanteric hip fractures. A prospective study. Injury 2023; 54 Suppl 6:110724. [PMID: 38143142 DOI: 10.1016/j.injury.2023.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/28/2023] [Accepted: 04/11/2023] [Indexed: 12/26/2023]
Abstract
INTRODUCTION hip fracture represents a global health problem, with a high morbidity and mortality rate and an increasing incidence. The treatment of trochanteric fractures is reduction and osteosynthesis, and implant selection depends mainly on the stability of the fracture and lateral wall competence. Lateral wall competence has gained relevance in recent years, which led to the modification of the AO/OTA classification. However, determination of lateral wall integrity is difficult from plain radiographs; the influence of images with traction on its measurement has not been evaluated. METHODS prospective concordance study, emergency and post-traction radiographs of 65 patients with trochanteric fracture were evaluated by six orthopedic surgeons independently, measuring the lateral wall, classifying the fracture according to the AO/OTA 2018 classification and selecting the implant for osteosynthesis. A comparison of incompetent to intact lateral wall proportion between each image set was made. Secondary outcomes were the inter-observer correlation of lateral wall measurement and inter-observer agreement of classification and implant choice. RESULTS the proportion of patients with an incompetent lateral wall in emergency x-ray was 37.43% (CI 95% 0.326-0.422), while the proportion in post-traction fluoroscopy was 15% (CI 95% 0.115-0.185), with a statistically significant difference (p < 0.001). 40.1% of patients with an incompetent lateral wall changed to an intact one. Inter-observer correlation for the lateral wall thickness was 0.399 (CI 95% 0.292-0.519) in emergency x-ray and 0.658 (CI 95% 0.564-0.748) in post-traction fluoroscopy, with a substantial agreement. Inter-observer agreement for the fracture classification was fair to moderate using emergency x-ray (κ 0.369 95%CI 0.330-0.408) and fair to moderate with post-traction fluoroscopy (κ 0.400, 95% CI 0.334-0.466). CONCLUSION traction images significantly change the measurement of the lateral wall in trochanteric fractures, changing from an incompetent to a competent wall in 40% of patients. The correct classification of trochanteric fractures is crucial to make the best decision when deciding which implant to use, and the measurement of the lateral wall is determinant in the actual AO/OTA classification. Therefore, traction images appear as necessary for correct decision-making.
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Affiliation(s)
- Maximiliano Carmona
- Department of Orthopedic Surgery, School of Medicine, Pontificia Universidad Catolica de Chile, Diagonal Paraguay 362, 3rd floor, Santiago 8330077, Chile.
| | - Nicolas Gonzalez
- Department of Orthopedic Surgery, School of Medicine, Pontificia Universidad Catolica de Chile, Diagonal Paraguay 362, 3rd floor, Santiago 8330077, Chile
| | - Javier Segovia
- Department of Orthopedic Surgery, School of Medicine, Pontificia Universidad Catolica de Chile, Diagonal Paraguay 362, 3rd floor, Santiago 8330077, Chile
| | - Martin de Amesti
- Department of Orthopedic Surgery, School of Medicine, Pontificia Universidad Catolica de Chile, Diagonal Paraguay 362, 3rd floor, Santiago 8330077, Chile
| | - Tomas Zamora
- Department of Orthopedic Surgery, School of Medicine, Pontificia Universidad Catolica de Chile, Diagonal Paraguay 362, 3rd floor, Santiago 8330077, Chile
| | - Daniel Schweitzer
- Department of Orthopedic Surgery, School of Medicine, Pontificia Universidad Catolica de Chile, Diagonal Paraguay 362, 3rd floor, Santiago 8330077, Chile
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Yu F, Tang YW, Wang J, Lin ZC, Liu YB. Does intramedullary nail have advantages over dynamic hip screw for the treatment of AO/OTA31A1-A3? A meta-analysis. BMC Musculoskelet Disord 2023; 24:588. [PMID: 37464358 DOI: 10.1186/s12891-023-06715-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 07/12/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND Hip fractures are still unsolved problems nowadays. We evaluated the functional outcomes and complications in the treatment of hip fractures (AO/OTA31A1-A3) to find potential difference and risk between intramedullary nail (IMN) and dynamic hip screw (DHS). METHOD We searched PubMed, Embase, Cochrane library up to 19 June 2023 and retrieved any studies comparing IMN and DHS in treatment of Hip fractures. The main outcomes and complications were extracted from the included studies. The fixed-effect model was selected to pool the data for homogeneous studies (I2 < 50%). Otherwise, the random effects model was selected (heterogeneity, I2 > 50%). The analysis of sensitivity and subgroup was performed to explore the homogeneous studies among studies. The p-value of less than 0.05 was considered statistically significant. RESULTS 30 RCT studies were included in this meta-analysis. There were significant difference of in the items of blood loss, screening time, femoral neck shortening, non-union, and femoral fractures (p < 0.05). Significant difference was found in the parameter of open reduction of fracture after sensitive analysis (p < 0.05). No significant difference was found in the parameter of Mobility Score at the last follow-up after sensitive analysis (p ≥ 0.05). There was no significant difference in the parameters of open reduction of fracture, required blood transfusion, mean surgical time, hospital stays, time to healing, mean Harris Hip Score, infection, cut out, poor reduction, breakage of implant, failure of fixation, reoperation, and systemic complications of chest infection, decubital ulcer, urinary tract infection and persistent pain in the hip (p ≥ 0.05). CONCLUSIONS Our meta-analysis revealed that hip fractures treated with IMN have merits with lower rate of blood loss, femoral neck shortening and non-union; shortcoming of increased risk of femoral fractures. It is suggested that special attention should be paid to the risk of femoral fracture when intramedullary nail was inserted in the intraoperative.
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Affiliation(s)
- Fei Yu
- College of Management, Guangdong Polytechnic Normal University, Guangzhou, China
| | - Yang-Wei Tang
- Department of Orthopedics, Huaiji People's Hospital, Zhaoqing, China
| | - Ju Wang
- Department of Orthopedics, Huaiji People's Hospital, Zhaoqing, China
| | - Zhi-Cheng Lin
- Orthopedics Center, Department of Orthopedics and Traumatology, Zhujiang Hospital, Southern Medical University, No.253. Gongye Middle Avenue, Haizhu District, Guangzhou, Guangdong, 510280, China
| | - Yu-Bin Liu
- Orthopedics Center, Department of Orthopedics and Traumatology, Zhujiang Hospital, Southern Medical University, No.253. Gongye Middle Avenue, Haizhu District, Guangzhou, Guangdong, 510280, China.
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Nho JH, Seo GW, Kang TW, Jang BW, Park JS, Suh YS. Bipolar Hemiarthroplasty in Unstable Intertrochanteric Fractures with an Effective Wiring Technique. Hip Pelvis 2023; 35:99-107. [PMID: 37323545 PMCID: PMC10264230 DOI: 10.5371/hp.2023.35.2.99] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 01/30/2023] [Accepted: 02/01/2023] [Indexed: 06/17/2023] Open
Abstract
Purpose Bipolar hemiarthroplasty has recently been acknowledged as an effective option for treatment of unstable intertrochanteric fracture. Trochanteric fragment nonunion can cause postoperative weakness of the abductor muscle and dislocation; therefore, reduction and fixation of the fragment is essential. The purpose of this study was to perform an evaluation and analysis of the outcomes of bipolar hemiarthroplasty using a useful wiring technique for management of unstable intertrochanteric fractures. Materials and Methods A total of 217 patients who underwent bipolar hemiarthroplasty using a cementless stem and a wiring technique for management of unstable intertrochanteric femoral fractures (AO/OTA classification 31-A2) at our hospital from January 2017 to December 2020 were included in this study. Evaluation of clinical outcomes was performed using the Harris hip score (HHS) and the ambulatory capacity reported by patients was classified according to Koval stage at six months postoperatively. Evaluation of radiologic outcomes for subsidence, breakage of wiring, and loosening was also performed using plain radiographs at six months postoperatively. Results Among 217 patients, five patients died during the follow-up period as a result of problems unrelated to the operation. The mean HHS was 75±12 and the mean Koval category before the injury was 2.5±1.8. A broken wire was detected around the greater trochanter and lesser trochanter in 25 patients (11.5%). The mean distance of stem subsidence was 2.2±1.7 mm. Conclusion Our wiring fixation technique can be regarded as an effective additional surgical option for fixation of trochanteric fracture fragments during performance of bipolar hemiarthroplasty.
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Affiliation(s)
- Jae-Hwi Nho
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Seoul, Seoul, Korea
| | - Gi-Won Seo
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Seoul, Seoul, Korea
| | - Tae Wook Kang
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Seoul, Seoul, Korea
| | - Byung-Woong Jang
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Gumi, Gumi, Korea
| | - Jong-Seok Park
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Cheonan, Cheonan, Korea
| | - You-Sung Suh
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Seoul, Seoul, Korea
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Zeelenberg ML, Nugteren LHT, Plaisier AC, Loggers SAI, Joosse P, Den Hartog D, Verhofstad MHJ, van Lieshout EMM. Extramedullary versus intramedullary fixation of stable trochanteric femoral fractures: a systematic review and meta-analysis. Arch Orthop Trauma Surg 2023:10.1007/s00402-023-04902-1. [PMID: 37129692 PMCID: PMC10374813 DOI: 10.1007/s00402-023-04902-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 04/19/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVE This systematic review and meta-analysis compared extramedullary fixation and intramedullary fixation for stable two-part trochanteric femoral fractures (AO type 31-A1) with regards to functional outcomes, complications, and surgical outcomes. METHODS Embase, Medline, Web of Science, Cochrane Central Register of Controlled Trials, and Google Scholar were searched for randomized controlled trials (RCTs) and observational studies. Effect estimates were pooled across studies using random effects models. Results were presented as weighted risk ratio (RR) or weighted mean difference (MD) with corresponding 95% confidence interval (95% CI). RESULTS Five RCTs (397 patients) and 14 observational studies (21,396 patients) were included. No significant differences in functional outcomes, complications, or surgical outcomes were found between extramedullary and intramedullary fixation devices, except for a difference in duration of surgery (MD 14.1 min, CI 5.76-22.33, p < 0.001) and intra-operative blood loss (MD 92.30 mL, CI 13.49-171.12, p = 0.02), favoring intramedullary fixation. CONCLUSION Current literature shows no meaningful differences in complications, surgical, or functional outcomes between extramedullary and intramedullary fixation of stable two-part trochanteric femoral fractures. Both treatment options result in good outcomes. This study implicates that, costs should be taken into account when considering implants or comparing fixation methods in future research.
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Affiliation(s)
- Miliaan L Zeelenberg
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Leendert H T Nugteren
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - A Cornelis Plaisier
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Sverre A I Loggers
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
- Department of Surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Pieter Joosse
- Department of Surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Dennis Den Hartog
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Michael H J Verhofstad
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Esther M M van Lieshout
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
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Raj S, Grover S, Bola H, Pradhan A, Fazal MA, Patel A. Dynamic hip screws versus cephalocondylic intramedullary nails for unstable extracapsular hip fractures in 2021: A systematic review and meta-analysis of randomised trials. J Orthop 2023; 36:88-98. [PMID: 36654796 PMCID: PMC9841034 DOI: 10.1016/j.jor.2022.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 12/15/2022] [Accepted: 12/29/2022] [Indexed: 01/09/2023] Open
Abstract
Background Extracapsular hip fractures comprise approximately half of all hip fractures and the incidence of hip fractures is exponentially increasing. Extramedullary fixation using a dynamic hip screw (DHS) has been the gold standard method of operative treatment for unstable extracapsular fractures, however, in recent years, intramedullary nails (IMN) have become a popular alternative. IMN versus DHS is continuously discussed and debated in literature. Therefore, the purpose of this systematic review and meta-analysis is to directly compare the peri- and post-operative outcomes of these two techniques to provide an up-to-date analysis of which method of fixation is superior. Methods The MEDLINE/PubMed, Embase and Web of Science Database were searched for eligible studies from 2008 to April 2022 that compared peri- and post-operational outcomes for patients undergoing IMN or DHS operations for fixation of unstable extracapsular hip fractures (PROSPERO registration ID:CRD42021228335). Primary outcomes included mortality rate and re-operation rate. Secondary outcomes included operation time, blood loss, transfusion requirement, complication, and failure of fixation rate. The risk of bias and quality of evidence were assessed using the Cochrane RoB 2.0 tool and GRADE analysis tool, respectively. Results Of the 6776 records identified, 22 studies involving 3151 patients were included in the final review. Our meta-analysis showed no significant differences between mortality rates (10 studies, OR 0.98; 95% CI 0.80 to 1.22, p = 0.88) or re-operation rates (10 studies, OR 1.03; 95% CI 0.64 to 1.64, p = 0.91) between the two procedures. There were also no significant differences found between complication rates (17 studies, OR 1.29; 95% CI 0.79 to 2.12, p = 0.31) and failure of fixation rates (14 studies, OR 1.32; 95% CI 0.74 to 2.38, p = 0.35). However, DHS operations had a significantly longer operation time (p < 0.0001) and blood loss (p < 0.00001) than IMN operations. Conclusion Overall, based on the outcomes assessed, this review has demonstrated that there is no significant difference in the post-operative outcomes for DHS vs IMN, however a significant difference exists in two of the intraoperative outcomes assessed in this review.
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Affiliation(s)
- Siddarth Raj
- GKT School of Medical Education, King's College London, London, UK
- University Hospital Coventry and Warwickshire, NHS Trust, Coventry, UK
| | - Sarika Grover
- GKT School of Medical Education, King's College London, London, UK
- University Hospital Coventry and Warwickshire, NHS Trust, Coventry, UK
| | - Harroop Bola
- Imperial College School of Medicine, Imperial College London, London, UK
| | | | - Muhammad Ali Fazal
- Department of Trauma and Orthopaedics, Royal Free London NHS Foundation Trust, London, UK
| | - Akash Patel
- Department of Trauma and Orthopaedics, Royal Free London NHS Foundation Trust, London, UK
- School of Medicine, University College London (UCL), London, UK
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Multi-stage treatment for malunion and avascular necrosis of the femoral head following reverse oblique pertrochanteric fracture: A case report and literature review. Trauma Case Rep 2022; 41:100684. [PMID: 35942319 PMCID: PMC9356153 DOI: 10.1016/j.tcr.2022.100684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2022] [Indexed: 11/21/2022] Open
Abstract
Femoral reverse oblique intertrochanteric fractures are successfully treated using intramedullary devices. Poor fracture reduction and the use of the inaproppriate implant can lead to implant failure and subsequent malunion or non-union. We present the case of a 21-year-old polytrauma female who, among other injuries, sustained a reverse oblique intertrochanteric fracture that was primarily operated on with the dynamic hip screw. After implant failure the patient developed malunion with bone defect and avascular necrosis of the femoral head. Successful salvage of the bone stock in the inter- and subtrochanteric region was achieved using the two-stage induced membrane technique. The uncemented total hip arthroplasty was performed to address the osteonecrosis of the femoral head.
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