The Asia proximal femoral nail antirotation versus the standard proximal femoral antirotation nail for unstable intertrochanteric fractures in elderly Chinese patients

Bipolar Hemiarthroplasty With a Calcar Stem for the Management of a Failed Proximal Femoral Nail Anti-rotation Asia (PFNA2) in a Case of Geriatric Unstable Intertrochanteric Femur Fracture

Intertrochanteric (IT) femur fractures in the elderly population comprise a major part of geriatric trauma and fractures. There are various modalities of surgical management, ranging from intramedullary fixation and extramedullary fixation to even replacing the hip joint. Apart from the surgeon's choice, other factors, such as geriatric age, bone quality and osteoporosis, medical comorbidities, life expectancy, pre-operative ambulatory status, muscle strength, type and pattern of fracture, and mental health of the patient, play vital roles in determining the ideal modality of management and the long-term outcome. The present case is a 75-year-old lady who had an IT fracture due to a domestic fall, managed surgically with a proximal femoral nail anti-rotation Asia (PFNA2) for an unstable fracture. She presented with blade back-out on the 11th day postoperatively. The patient was investigated thoroughly, and infection was ruled out. She was managed by the removal of the nail, followed by a cemented calcar-replacing bipolar hemiarthroplasty for an unstable comminuted IT fracture. The patient was ambulatory with a walker by the seventh postoperative day and without a walker by the sixth week, and she was self-sufficient in her activities of daily living. Every geriatric IT fracture must be evaluated thoroughly for contributing factors, such as osteoporosis and fracture pattern, to predict outcomes, and a tailor-made strategy of surgical management and stepwise physiotherapy must be provided to the patient for the best results.

How much of the superolateral femoral neck should be removed in intramedullary nail fixation for intertrochanteric fracture?

The objective of this study was to measure how much of the superolateral femoral neck should be removed to reduce the incidence of wedge effect. Simulating surgery: Computed Tomography images of 131 intertrochanteric fracture patients were included, three-dimensionally reconstructed, virtually reduced and implanted with Proximal Femoral Nail Antirotation blade-Ⅱ(PFNA-Ⅱ) nail. The antero-posterior length and media-lateral width of the intersection between superolateral femoral neck and PFNA-Ⅱ nail were measured. Retrospective study: The pre- and postoperative CT of 30 patients were collected. The average varus angle of the neck-shaft angle and the correlation between the angles and the difference in the actual and estimated width of the fragments removed were measured. Models of 108 patient were selected for analysis. The average antero-posterior length and media-lateral width were 14.46 mm (14.00-14.93 mm) and 9.33 mm (8.79-9.87 mm), respectively. The AO/OTA classification was not significantly associated with the outcome, but the gender was. In the retrospective study, the mean value of the varus angles was -4.58° (SE = 6.85°), and the difference of width was strongly positively correlated with the varus angle with a correlation coefficient of 0.698. Results obtained in this study can improve the understanding of this region and help surgeons to make appropriate preoperative planning to reduce the incidence of wedge effect. Retrospective study provided effective proof of the reliability of this study.

Treatment of Failed Proximal Femoral Nail Anti-rotation Asia (PFNA2) in a Severely Osteoporotic Patient With a Revision Stem

An intertrochanteric fracture is a prevalent and perilous kind of fracture that often affects older persons. A customized implant, proximal femoral nail anti-rotation Asia (PFNA2) is being used expressly in unstable intertrochanteric fractures in people with osteoporosis. In this case report, we examined a female osteoporosis patient, age 74, who underwent a failed PFNA2 procedure. Subsequently, the patient had bipolar hemiarthroplasty as a treatment. To prevent mechanical failure, it is crucial to strive for a high level of reduction quality and precise alignment of the central blade throughout hip X-ray procedures. Improved surgical proficiency and skill are crucial for managing patients with severe osteoporosis and prolonged weight-bearing requirements, hence reducing the occurrence of postoperative problems. Depending on the cause of the failure and the individual circumstances of the patient when internal fixation fails, it is recommended to either replace the joint with a prosthetic or reapply fixation. These interventions may facilitate the production of beneficial healing outcomes.

Optimizing post-operative imaging: a retrospective cohort study comparing two methods of lateral hip radiography after cephalomedullary nail surgery

BACKGROUND

Currently, there is no consensus on the most appropriate technique for obtaining lateral hip radiographs after cephalomedullary nail (CMN) surgery. The aim of this study was to investigate the distribution of two commonly used postoperative lateral hip radiographic methods (classic lateral view and modified lateral view) and try to find out which one is better suited for this situation.

METHODS

A retrospective analysis was conducted on 146 patients who underwent surgical fixation for extracapsular hip fractures between January 2018 and June 2022. The main outcome measured was the angle between the straight part of the CMN and the lag screw/blade on hip lateral X-rays (CMNA). The lateral hip radiographs were categorized into two groups based on different lateral hip radiographic methods. CMNA, patient age, gender, fracture classification based on the 2018 AO classification, nail length (short/long), surgical side (left/right), height, weight, BMI, preoperative waiting time, postoperative imaging interval were collected and compared between the two groups.

RESULTS

The distribution trend of CMNA significantly differs between two types of hip joint lateral radiographic methods. Specifically, the classic lateral method exhibits a significantly bimodal and skewed distribution with a median (p25, p75) of -21.6° (-31.2°, -8°), whereas the modified lateral method presents a normal distribution with a mean ± SD of +7.57° ± 14.4°. The difference in the Mean Rank between the classic (47.10) and the modified (102.96) lateral methods is statistically significant (P < 0.001).

CONCLUSIONS

The CMNA method is an excellent tool for studying the lateral distribution.We recommend using the modified lateral view as the preferred option for obtaining lateral hip radiographs after CMN surgery due to its superior distribution of CMNA and greater patient-friendliness.

Comparison of clinical outcomes with proximal femoral nail anti-rotation versus bipolar hemiarthroplasty for the treatment of elderly unstable comminuted intertrochanteric fractures

BACKGROUND

Although proximal femoral nail anti-rotation (PFNA) and bipolar hemiarthroplasty (BHA) are selected by most of the orthopaedic surgeons for elderly intertrochanteric fractures (ITFs) patients, there is still no consensus on the superiority of PFNA and BPH for the elderly with unstable comminuted ITFs. The study aims to compare the curative effects of PFNA and cementless BHA on unstable comminuted ITFs in the elderly.

METHODS

From January 2012 to December 2016, we retrospectively reviewed 62 ITFs patients up to the inclusion and exclusion criteria in the study. Depending on the type of surgery, the patients were divided into two groups: Group BHA (n= 30) and Group PFNA (n = 32). The ITFs were classified according to Evans-Jensen. Hospitalization time, operation time, bleeding loss, weight bearing duration, Harris hip scores, 10-m walking speed, gait and postoperative complications were compared between the two groups.

RESULTS

There was no significant difference between the groups in hospital stay (P > 0.05). The BHA group trended to have a shorter operation time and a larger volume of blood loss (P < 0.01).The weight bearing duration was shorter in the BHA group than the PFNA group (P < 0.05).The Harris hip score was higher, the 10-m walking speed was faster and the gait was better in group BHA than group PFNA at three months postoperatively (P < 0.05), but there was no significant difference between the two groups at 6 and 12 months postoperatively (P > 0.05). There was no significant difference in postoperative complications between the two groups (P > 0.05).

CONCLUSION

The BHA allows an earlier return to weight-bearing activity, but ultimately has the same effective treatments as the PFNA for the elderly with unstable comminuted ITFs.

Cementless bipolar hemiarthroplasty compared with proximal femoral nail anti-rotation of unstable intertrochanteric fractures in senile patients with osteoporosis: a retrospective study

Background

Implant design for the correction of osteoporotic unstable intertrochanteric fractures in elderly patients is a controversial issue. Our study aims to compare the efficacy of PFNA and cementless bipolar hemiarthroplasty (CBH) in treating osteoporotic unstable intertrochanteric fractures in the elderly.

Methods

We retrospectively assessed 70 elderly patients, aged > 70 years old, with intertrochanteric fractures (AO/OTA 31-A2 fractures) from 2014 to 2019. Among them, 34 patients received PFNA and 36 patients received CBH, accompanied with 2-year follow-ups. Additionally, the efficacy difference between the two implants was compared.

Results

Both groups had similar general variables like age, gender, fracture site, degree of osteoporosis, fracture classification, ASA score, basic diseases, preoperative preparation time, anesthesia mode, amount of postoperative blood loss, hospital length of stay, along with postoperative blood transfusions and postoperative complications (P > 0.05). Conversely, significant differences were observed among intraoperative variables (amount of blood loss, amount of blood transfusions, operative time, number of intraoperative fluoroscopy), postoperative variables (weight-bearing time out of bed), and Harris hip function score within 12 months of operation (P < 0.05).

Conclusions

CBH showed no obvious advantage over PFNA in the perioperative period in elderly patients with osteoporotic unstable intertrochanteric fractures. However, the joint replacement allowed for earlier ambulation after the operation and rapid recovery of the hip joint function.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05426-2.

Comparison of Wrist Motion and Grip Strength between Normal Caucasian, Southern Chinese and Japanese Populations

Background: Differences in structure and function of the hand and wrist between distinct populations affect our approach to treatment, expectations and functional outcomes. The aim of this study is to compare wrist motion and grip strength in Caucasian, Chinese and Japanese populations. Methods: A total of 424 normal wrists were evaluated that included 99 Japanese, 139 Caucasian and 186 Southern Chinese. Demographic information collected included age, gender, hand dominance and occupation. Evaluation included measurement of active motion and grip strength. Motion was measured using a goniometer. Grip strength was evaluated using a JAMAR dynamometer. Demographic information and evaluation was compared among the three cohorts using statistical tests. Multivariate mixed-effect model was further used to assess the racial impact on each evaluation controlling for demographic factors as well as two-hand measurements of everyone. Results: There was no difference in global wrist motion between the cohorts. We did find significant differences between the cohorts in all discrete measurements. Conclusions: Differences in wrist motion and grip strength between normal Japanese, Chinese and Caucasian populations may be due to bony structure rather than soft tissue properties. Knowledge of these disparities can provide references for personalised wrist examination, diagnosis, treatment and comparison of outcomes between different cohorts. Level of Evidence: Level III (Diagnostic).

Factors Affecting the Outcome of Unstable Intertrochanteric Fractures Managed With Proximal Femoral Nail Anti-Rotation 2: A Prospective Outcome Study in Elderly Indian Population

Background

The proximal femoral nail anti-rotation Asia (PFNA 2) is an implant designed for unstable osteoporotic intertrochanteric fractures in Asians as the PFNA was designed for Caucasians and had various complications when applied to the Asian population due to the femoral geometrical mismatch. This study observes the functional outcomes and complications associated with PFNA 2 in unstable intertrochanteric fractures in the elderly Indian population.

Methods

Sixty-one above 60 years old patients with an unstable intertrochanteric fracture who were operated with PFNA 2 were included in this prospective observational study. They were followed up for one year. The functional and radiographic evaluations were done at 6, 12, 20 weeks, and the functional outcome was evaluated at the end of one year. Association of age, American Society of Anaesthesiologists (ASA) grade, AO Foundation classification, osteoporosis to the functional outcome of modified Harris hip score (MHHS) was evaluated.

Results

Type A2 fractures demonstrated a statistically higher-good reduction than Type A3 (Student t-test, P < 0.05). The difference in mean surgical duration in Type A3 (45.47 minutes) and Type A2 (40.30 minutes) was statistically significant (Student t-test, P < 0.05). Mean blood loss was 110.66 ml (SD = 48.40 ml). MHHS at 6, 12, 20 weeks, and one year were 40.37, 63.93, 79.03, and 82.34, respectively. At the end of the year, 46 (82.1%) patients achieved good scores, eight (14.3%) achieved fair scores, and two (3.5%) achieved poor scores. There was one case of nonunion and medial migration of the helical blade. The mortality rate was 6.55% at the end of one year.

Conclusion

A good reduction was associated with a better functional outcome. PFNA 2 is an efficient implant in managing unstable intertrochanteric fractures in elderly Indian patients with good outcomes, low morbidity rates, and mortality. Implant mismatch was not a problem in the Indian population. However, large multi-centric studies with a larger sample size are required. Moreover, achieving a good reduction cannot be over-emphasized in unstable intertrochanteric fractures, especially in the elderly, to achieve a good functional outcome.

How to get better TAD? Relationship between anteversion angle of nail and position of femoral neck guide pin during nailing of intertrochanteric fractures

Background

To demonstrate the correlation between guide pin-shaft angle (PSA) at the anteroposterior film and anteversion angle of guide pin at the lateral film and investigate whether excellent tip–apex distance (TAD) can be obtained by changing the entry point via axial rotation of the main intramedullary nail.

Methods

Fifty patients with intertrochanteric femoral fractures (IFFs) undergoing internal fixation with intramedullary nails under 2D fluoroscopy were retrospectively enrolled. Both of the PSA at the anteroposterior film and anteversion angle at the lateral film before and after adjustment of the guide pin were collected. Pearson correlation analysis was performed to investigate their correlation. Intraoperative and postoperative outcomes were recorded. Furthermore, the software of Mimics 10.0 and Pro/E were used to establish the 3D models of the proximal femur and main intramedullary nail/guide pin, respectively. Surgery was simulated on the Pro/E software platform and solid geometry analysis was conducted to calculate the correlation between the PSA and the anteversion angle.

Results

Pearson correlation analysis indicated there was a positive correlation between PSA and anteversion angle, with the correlation coefficient of 0.902 (p < 0.01). By altering the PSA and anteversion angle, TAD was adjusted to be less than 25 mm in all patients. The mean operative time, fluoroscopy time and length of hospital stay were 65.82 ± 11.16 min, 2.03 ± 0.79 min and 6.66 ± 2.49 d. Thirty-one patients received blood transfusions (3.55 ± 1.95 U). Fracture reduction was considered to be good or acceptable in all patients. Complications occurred only in 6 patients (12.00%). At a 3-month follow-up, the mean Timed Up and Go was 31.54 ± 20.95 s and Harris Hip Score was 72.88 ± 8.79. The 3D surgery model also showed when the main intramedullary nail was externally rotated or internally rotated of 20° at the standard location, the PSA of guide pin at the anteroposterior position and anteversion angle of the guide pin at the lateral position were simultaneously increased or decreased.

Conclusion

Our findings suggest altering the PSA and anteversion angle may be beneficial for obtaining excellent TAD and achieving superior outcomes.

Outcomes of Combined Neck and Trochanter Fractures of the Femur Treated with Cephallomedullary Nail in Elderly

Purpose

Proximal femur fractures are classified into intracapsular neck fractures and extracapsular trochanteric fractures, and several related treatment recommendations in elderly patients have already been introduced. Importantly, we have observed cases of combined intra and extracapsular fractures (i.e., ipsilateral neck and trochanter fractures). The purpose of this study is to report the outcomes of combined neck and trochanter fractures of the femur treated with cephalomedullary nail (CMN) in elderly patients.

Materials and Methods

From January 2010 to December 2014, 410 patients with proximal femoral fractures were fixed using CMN; among this group, 37 patients with combined neck and trochanter fractures were identified. Two of these patients died fewer than three months after injury and another two did not return for follow-up. Thirty-three patients were included and reviewed retrospectively in this study.

Results

All patients were injured by simple fall. Bone union was obtained in 28 of 33 patients. Of the five patients who failed treatment, three experienced implant penetration through head (cut-through and cut-out), one had breakage of CMN and the last one had a loosening of internal fixation device with persistent non-union at final follow-up. The former four patients underwent hip replacement surgery and the latter refused surgery because he had low demand in daily life and many medical problems.

Conclusion

Eighty-five percent of elderly patients with combined neck and trochanter fractures of the femur treated with CMN achieved bone union; these complex fractures require more accurate reduction than usual extra-articular intertrochanteric fractures.

Proximal femoral nail anti-rotation versus cementless bipolar hemiarthroplasty for unstable femoral intertrochanteric fracture in the elderly: a retrospective study

BACKGROUND

The treatment for unstable intertrochanteric fractures in the elderly has always been a controversial issue. The aim in this study was to compare the curative effects of proximal femoral nail anti-rotation (PFNA) and cementless bipolar hemiarthroplasty (CPH) on femoral intertrochanteric fracture in the elderly.

METHODS

From March 2008 to December 2012, 108 elderly patients with femoral intertrochanteric fractures were treated by PFNA or CPH. There were 63 males and 45 females, aged 75.3-99.1 years [(83.7 ± 5.6) years]. The patients' bone mineral density was routinely measured, and the fractures were classified according to Evans-Jensen. The patients were divided into CPH group and PFNA group. The differences in operation time, intraoperative bleeding, immobilization duration, hospitalization time, Harris scores and postoperative complications including deep venous thrombosis, lung and urinary infection were analyzed.

RESULTS

All patients were followed for 12.5-36.2 months [(28.0 ± 6.3) months)]. The operation time was (53.7 ± 15.2) min and (77.5 ± 16.8) min in PFNA group and CPH group, respectively (P < 0.05); intraoperative bleeding was (132.5 ± 33.2) mL and (286.3 ± 43.2) mL, respectively (P < 0.05); immobilization duration was (28.2 ± 3.7) days and (3.1 ± 1.2) days, respectively (P < 0.05); hospitalization time was (7.6 ± 1.8) days and (6.9 ± 2.2) days, respectively (P > 0.05); and the Harris scores after 1 year were (87.7 ± 7.9) points and (88.3 ± 9.2) points, respectively (P > 0.05). There was no significant difference in postoperative complications between the two groups (P > 0.05).

CONCLUSION

Both PFNA and CPH are safe and effective treatments for femoral intertrochanteric fracture in elderly patients. Nonetheless, CPH allows faster mobilization and recovery.

TRIAL REGISTRATION

Registration Number: ChiCTR1900022846 . Reg Date:2019-04-26 00:27:33 Retrospective registration.

Effect of a synthetic osteoconductive bone graft substitute with zeta potential control (geneX®ds) in the treatment of intertrochanteric fracture: A single center experience of 115 consecutive proximal femoral nail antirotations

INTRODUCTION

Although various clinical applications of geneX^®ds have been reported, no study has reported the clinical application of geneX^®ds in osteoporotic hip fracture. The present study aimed to identify the clinical effect of the application of geneX^®ds in elderly patients with intertrochanteric fracture treated using proximal femoral nail antirotation (PFNA).

MATERIALS AND METHODS

From March 2014 to October 2017, 233 patients with intertrochanteric fracture (65 men and 168 women) were enrolled in this study. All patients received surgical treatment using PFNA. Patients were classified into two groups: those in whom geneX^®ds which is synthetic osteoconductive bone graft substitute with the unique property of Zeta Potential Control (ZPC^®), was use, and those in whom it was not. We compared the preoperative details and surgical outcomes, including radiologic outcome (postoperative reduction, tip apex distance, sliding distance of the helical blade, union, and union time) and clinical outcomes (Harris Hip Score and the walking ability at the last follow-up) between the groups.

RESULTS

In patients with unstable fracture who achieved anatomical or extramedullary type of reduction, the average sliding distance at 1, 3, and 12 months was 4.9 mm, 7.5 mmm and 8.1 mm in the geneX^®ds group and 7.5 mm, 10.8 mm, and 12.1 mm in the no geneX^®ds group, respectively. There were significant differences in the sliding distance at 1, 3, and 12 months between these two groups.

CONCLUSION

The use of this synthetic osteoconductive bone graft substitute with zeta potential control may have positive effect on the controlled sliding of the helical blade and the healing of intertrochanteric fracture.

Comparison of radiological and functional outcome of unstable intertrochanteric femur fractures treated using PFN and PFNA-2 in patients with osteoporosis

INTRODUCTION

Presently, unstable intertrochanteric femur fractures are treated commonly with intramedullary nailing devices. Various designs of intramedullary nail are introduced. The conventional Proximal Femoral Nail has given diverse outcome. Complications have also been noted with this implant. Newer designs like Proximal Femoral Nail Antirotation-2 have been introduced for Asian population. The aim of our study was to compare the radiological and functional outcome of unstable intertrochanteric femur fracture treated with conventional Proximal Femoral Nail and Proximal Femoral Nail Antirotation-2 in osteoporotic patients.

MATERIALS AND METHODS

Patients presenting with unstable intertrochanteric femur fracture (AO classification) and Singh's index ≤ 3 were included. Patients were assigned to the groups based on the implant used for treatment (PFN and PFNA2 group). Post-operative radiographs were used to assess the quality of reduction, by calculating neck shaft angle. The quality of fixation was assessed, by calculating tip apex distance and Cleveland index. The duration of surgery, blood loss, number of fluoroscopic images taken and length of hospital stay were noted. Patients were followed up for 6 months, and complications were noted. The functional outcome was compared using modified Harris hip score. The data analysis was done using Student's unpaired t test/Mann-Whitney U test and Chi-square test/Fisher's exact test. A p value less than 0.05 was considered significant.

RESULTS

Seventy-eight patients with unstable intertrochanteric fractures and Singh's index < 3 were included. Thirty-seven were treated with PFNA2 and 41 with PFN. The average age in PFNA2 group was 69.51, and PFN group was 70.804. Nine patients in PFNA2 group and 10 patients in PFN group had tip apex distance more than 25 mm. Twelve patients in PFNA2 group and 14 Patients in PFN group had sub-optimal implant position as per Cleveland index. The difference in neck shaft angle between uninjured and operated side was more than 10° in four patients of PFNA2 group and seven patients of PFN group. The average Harris hip score was 74.55 for PFNA2 group and 69.88 for PFN group. Four complications were seen in PFNA2 group and 5 in PFN group.

CONCLUSION

The functional outcome (p = 0.102) achieved with both the implants was similar. Good functional outcome can be achieved, when the radiological parameters are restored, i.e. TAD < 25 mm, Cleveland index in centre-centre position and neck shaft angle difference < 5°. The overall complications, in the set-up of osteoporosis, seen with both the implants were similar (p = 0.44). PFNA2 group showed better results in terms of perioperative morbidity.

Clinical analysis of peri-operative hidden blood loss of elderly patients with intertrochanteric fractures treated by unreamed proximal femoral nail anti-rotation

The purpose of this study was to quantify the peri-operative blood loss of elderly patients with intertrochanteric fractures treated by unreamed proximal femoral nail anti-rotation (PFNA) and analyze whether the substantial hidden blood loss was induced by initial trauma or the operation. The clinical data of 123 patients with intertrochanteric fracture treated with unreamed PFNA from Jan 2013 to Apr 2017 were analyzed retrospectively. Blood routine on admission day (ADM), pre-operative day one (PRE), post-operative days one and three (POD1 and POD3) and the visible blood loss (VBL) were obtained. The total blood loss (TBL) from ADM to POD1 and POD3 were 693.5 ± 359.6 ml and 863.8 ± 429.9 ml, of which the corresponding hidden blood loss (HBL) was 86.8% and 89.4% respectively. The mean TBL and HBL from ADM to PRE (375.5 ± 242.0 ml, 375.5 ± 242.0 ml) were higher than that from PRE to POD1 (318.0 ± 183.4 ml, 226.5 ± 163.2 ml), p < 0.001 respectively. There was no significant difference between HBL from ADM to PRE and HBL from PRE to POD3 (375.5 ± 242.0 ml, 396.7 ± 254.0 ml, p = 0.361). The majority of peri-operative HBL occurred before surgery, it was mainly associated with the initial trauma rather than the operation.

Accurate guide wire of lag screw placement in the intertrochanteric fractures: a technical note

Cephalomedullary fixations are commonly used in the treatment of intertrochanteric fractures. In clinical practice, one of the difficulties is when we exit the guide wire in a wrong position of femoral neck and insert near the hole again, the guide wire often flow into the previous track. This study develops a surgical technique to direct the guide wire to slip away the previous track and slip into a right position. When guide wire is exited to the cortex of femoral, we let the wire in and out at the cortical layer for several times to enlarge the entry hole. After that, electric drill is inverted, rubbed and entered slowly at a right angle. When guide wire encountered new resistance, the electric drill is turned back instantly. This technique can help trauma and orthopedic surgeons to obtain precision placement of the lag screw after the first try is failed.

INTERTAN nail versus proximal femoral nail antirotation-Asia for intertrochanteric femur fractures in elderly patients with primary osteoporosis

Objectives To compare the long-term functional and radiographic outcomes of the proximal femoral nail antirotation-Asia (PFNA-II) and INTERTAN nail (IT) in the management of intertrochanteric femoral fractures (IFFs) (AO/OTA Type 31A1.1-A2.3) in elderly patients with primary osteoporosis. Methods A retrospective comparative study was performed in our institution. From January 2009 to March 2012, 243 patients with osteoporosis (243 hips) with IFFs (AO/OTA Type 3.1A1.1-A2.3) underwent repair with either a PFNA-II or IT. Follow-up assessments were performed 1, 3, 6, 9, and 12 months postoperatively and every year thereafter. All implant position changes were noted. Patient-related functional outcomes were evaluated based on the Harris hip score. Results In total, 174 patients with osteoporosis (IT, n = 86; PFNA-II, n = 88) were evaluated during a mean follow-up period of 40 months (range, 38-60 months). An increased risk of femoral shaft fracture after implant removal was observed at month 9 of follow-up in 0.0% and 4.4% of the IT and PFNA-II groups, respectively. This difference remained over time with rates of 1.1% and 6.8%, respectively, at the last follow-up. Conclusion The IT nail appears to be a reliable implant in the management of IFFs (AO/OTA Type 3.1A1.1-A2.3) in elderly patients with primary osteoporosis.

The visible and hidden blood loss of Asia proximal femoral nail anti-rotation and dynamic hip screw in the treatment of intertrochanteric fractures of elderly high- risk patients: a retrospective comparative study with a minimum 3 years of follow-up

Background

The purpose of this study was to evaluate whether PFNA-II (Asia proximal femoral nail anti-rotation) and DHS (dynamic hip screw) carry substantial post-operative hidden blood loss and to compare PFNA-II with DHS in terms of post-operative hidden blood loss in elderly high-risk patients with intertrochanteric femur fractures(IFFs).

Methods

The clinical data from Jan 2005 to Apr 2015 of 186 patients with PFNA-II and 177 patients with DHS were analyzed retrospectively. Indexes including pre- and post-operative blood routine, intra- and post-operative blood loss and blood transfusion situation were analyzed. The situation of perioperative blood loss (visible and hidden) was assessed.

Results

The intra-operative blood loss in the PFNA-II group was 34.7 ± 2.5 ml, the post-operative visible blood loss was 54.7 ± 2.5 ml, and the hidden blood loss was 277.2 ± 7.6 ml. In the DHS group, the intra-operative blood loss was 102.0 ± 7.0 ml, the post-operative visible blood loss was 78.8 ± 4.7 ml, and the hidden blood loss was 139.3 ± 9.6 ml. The intra-operative blood loss and the post-operative visible blood loss in the PFNA-II group were significantly less than in the DHS group (p < 0.01). However, the post-operative hidden blood loss and the total blood loss in the PFNA-II group were larger than in the DHS group (p < 0.01).

Conclusion

This study demonstrated that with PFNA-II and DHS, much post-operative hidden blood loss exists in the treatment of intertrochanteric fractures in elderly high-risk patients and DHS is more favourable than PFNA-II in terms of post-operative hidden blood loss.

Complications following implant removal in patients with proximal femur fractures - an observational study over 16 years

BACKGROUND

Fractures of the proximal femur commonly occur but the majority of orthopaedic surgeons do not consider general hardware removal as a routine necessity. Indications and time interval for hardware removal in this special selected patient group is still controversial. Therefore we performed a retrospective study to address the following questions: 1) Is there a difference between the medically- (infection, mechanical problems, implant failure) and non-medically indicated group (patients demand, meteoro-sensitivity, foreign body sensation) in relation to complications? 2) Is there a correlation regarding time interval between implantation and removal comparing these two groups? 3) Is there a context related refracture rate? 4) Should non-medically indicated implant removal (IR) be performed due to persistent pressure from the patient?

HYPOTHESIS

We hypothesized that non-medically indicated implant removals should be avoided due to a significantly higher number of associated complications.

PATIENTS AND METHODS

A total of 371 consecutive patients with 424 hardware removal procedures following a proximal femur fracture, between 08/1992 and 11/2008, have been included. Study population was divided into two groups according to their indication for implant removal: medically indicated group (MIR) consisted of 299 patients (80.59%) and 72 patients (19.41%) were assigned to the non-medically indicated (NMIR) group.

RESULTS

In the NMIR subgroup a total of (n = 21) 28% complications occurred compared to 11.46% in the MIR subgroup; (P < 0.005), 86.51% of IR in the MIR group were performed within 1.5 years, compared to 79.17% in the NMIR group after 2 to 3.5 years (NS). In the MIR group 1 refracture occurred, compared to 4 in the NMIR group (NS).

CONCLUSION

Non-medically indicated implant removal should be avoided due to the higher complication rate of 28%. Surgeons and patients should be aware of the imminent complications and therefore implant removal should only be performed for good medical reasons.

LEVEL OF EVIDENCE

Level IV. Historical case study.