Unstable Proximal Femur Fractures Treated With Proximal Femoral Locking Plates: A Retrospective, Multicenter Study of 111 Cases

Treatment of Delbet II/III Pediatric Femoral Neck Fractures With Proximal Femoral Locking Plate Versus Cannulated Screws

INTRODUCTION

Complications following operative treatment of pediatric femoral neck fractures include nonunion, coxa vara, and avascular necrosis (AVN). Proximal femoral locking plates (PFLPs) provide a fixed-angle construct that may reduce the rates of coxa vara, but their use in pediatric femoral neck fractures has not been studied. The purpose of this study was to evaluate rates of union, coxa vara, and AVN in traumatic pediatric femoral neck fractures treated with PFLP or cannulated screws (CS).

METHODS

We retrospectively reviewed all traumatic, nonpathologic Delbet II/III femoral neck fractures in patients below 18 years of age treated with PFLP or CS. All cases had ≥6 months of radiographic follow-up to evaluate for osseous union and AVN. Changes in proximal femoral alignment were determined by measuring injured and contralateral femoral neck-shaft angle and articulotrochanteric distance (ATD) between 6 and 12 months postoperatively.

RESULTS

Forty-two patients were identified with mean age at surgery of 10.7±2.9 years (range 3.3 to 16.3 years) and mean follow-up of 36±27 months. Sixteen patients (38%) underwent PFLP fixation, whereas 26 patients (62%) underwent CS fixation. When compared with the CS cohort, the PFLP cohort had a greater proportion of males (87.5% vs. 50%, P =0.02) and Delbet III fractures (68.8% vs. 15.4%, P <0.001). There was no difference between PFLP and CS cohorts with respect to rates of union (81% vs. 88%, respectively, P =0.66), AVN (25% vs. 35%, respectively, P =0.73), or secondary surgery (62% vs 62%, P =0.95). There was no significant difference in neck-shaft angle between injured and contralateral hips in those patients treated with PFLP ( P =0.93) or CS ( P =0.16). However, the ATD was significantly decreased in hips treated with CS compared with the contralateral hip (18.4±4.6 vs. 23.3±4.2 mm, P =0.001), with no significant difference in the PFLP group ( P =0.57).

CONCLUSIONS

This study suggests that the use of a PFLP in Delbet II/III femoral neck fractures does not appear to significantly increase nonunion rates or AVN and maintains anatomic ATD when compared with screw fixation.

LEVEL OF EVIDENCE

Level III-therapeutic study.

Biomechanical Behavior of Dynamic vs. Static Distal Locking Intramedullary Nails in Subtrochanteric Femur Fractures

OBJECTIVE

Hip fractures are one of the most frequent fractures presenting to the emergency department and orthopedic trauma teams. The aim of this study was to determine the best indication and therapeutic technique for subtrochanteric fractures and unifying criteria when choosing the most suitable type of nail.

MATERIALS AND METHODS

To analyze the influence of the material and the type of distal locking of intramedullary nails (static or dynamic), a femur model with a fracture in the subtrochanteric region stabilized with a long Gamma intramedullary nail was applied using finite element method (FEM) simulation.

RESULTS

The mechanical study shows that titanium nails allow for greater micromobility at the fracture site, which could act as a stimulus for the formation of callus and consolidation of the fracture. In the mechanical study, the type of distal locking mainly affects mobility at the fracture site and stress in the cortical bone around the distal screws, without in any case exceeding values that may compromise the viability of the assembly or that may result in detrimental effects (in terms of mobility at the fracture site) for the consolidation process.

CONCLUSION

Subtrochanteric fractures treated with titanium nail and static distal locking is safe and does not hinder consolidation.

Fragility Fractures of the Pelvis and Sacrum: Current Trends in Literature

Fragility fractures of the pelvis (FFP) and fragility fractures of the sacrum (FFS), which are emerging in the geriatric population, exhibit characteristics that differ from those of pelvic ring disruptions occurring in the younger population. Treatment of FFP/FFS by a multidisciplinary team can be helpful in reducing morbidity and mortality with the goal of reducing pain, regaining early mobility, and restoring independence for activities of daily living. Conservative treatment, including bed rest, pain therapy, and mobilization as tolerated, is indicated for treatment of FFP type I and type II as loss of stability is limited with these fractures. Operative treatment is indicated for FFP type II when conservative treatment has failed and for FFP type III and type IV, which are displaced fractures associated with intense pain and increased instability. Minimally invasive stabilization techniques, such as percutaneous fixation, are favored over open reduction internal fixation. There is little evidence regarding outcomes of patients with FFP/FFS and more literature is needed for determination of optimal management. The aim of this article is to provide a concise review of the current literature and a discussion of the latest recommendations for orthopedic treatment and management of FFP/FFS.

Reverse distal femoral locking compression plate (DF-LCP), does it fit and how to fit on Asian's proximal femurs? A cadaveric study

INTRODUCTION

Reverse distal femoral locking compression plates (DF-LCP) have been used as an alternative treatment in complex proximal femur fractures.

OBJECTIVE

The purpose of this study was to assess the compatibility of reverse DF-LCP with Asian proximal femurs, to determine the matching patterns and integrate information to establish guidelines for correct application.

METHODS

Twenty-eight adult cadaveric femurs were obtained from 5 males and 9 females with an average age of 69.27 years (range 59-85). A contralateral 13-hole DF-LCP was applied with MIPO technique using the vastus ridge as a landmark for Hole A. The first locking screw was inserted through Hole A under fluoroscopic guidance just above the femoral head-neck junction in AP view and centered of the neck in lateral view, followed by three proximal locking screws. The number of screws successfully inserted through the femoral neck, including any penetration of femoral neck, the gap between anterior and posterior borders between plate and bone, the anatomical parameters of proximal femur, and any mismatches between the plate and the bone were recorded.

RESULTS

Most of the screws (82.1%) in Holes A, D, E, and F were put into the femoral neck without breaking through. The average distance from the entry point at the vastus ridge to the anterior cortex of the femur was 17.3 ± 2.3 mm and from the posterior cortex was 19.46 ± 2.55 mm. The anterior gap was 4.93 ± 1.01 mm, and the posterior gap was 13.48 ± 1.44 mm. The mismatch where the distal part of the plate started to lift off from the bone > 2 mm at the 8th hole with an average distance of 2.78 ± 2.01 mm. That distance gradually increased distally to an average of 9.38 ± 6.03 mm at the 13th hole.

CONCLUSIONS

Reverse DF-LCP can fit most proximal femurs in the Asian population and can be used as an alternative implant when performed using an appropriate technique. However, as a relatively consistent mismatch was found at the distal part starting at the 8th hole, so if a plate is longer than 9 holes, the plate contouring should be considered.

Radiological findings and outcomes of anterior wall fractures in pertrochanteric fractures

BACKGROUND

Anterior wall fractures with comminution at the anterior cortex in pertrochanteric fractures are relatively rare. We aimed to investigate the prevalence and clinical findings of anterior wall fractures in this comparative cohort study.

METHODS

We reviewed 516 consecutive patients who underwent internal fixation. Anterior wall fractures were classified into three types: proximal, distal, and proximal/distal. Outcome measures included demographic data, residual anterior cortex length, fracture reduction, tip-apex distance (TAD), sliding distance, bone union, and revision surgery. We compared radiological outcomes between patients with anterior wall fractures and posterior comminuted fractures without an anterior wall fracture. The groups were matched for age and sex.

RESULTS

Anterior wall fractures were noted in 44 patients (8.5%). Residual anterior cortex length was shorter for the proximal/distal type. The distal type was the most common, was the most difficult to achieve an acceptable reduction status for, and was associated with the longest sliding distance. The proportion of unacceptable reduction status was higher for anterior wall fractures. However, there were no statistically significant differences between anterior wall fractures and posterior comminuted fractures without an anterior wall fracture in terms of TAD, sliding distance, bone union, and revision rate.

CONCLUSIONS

This study suggests that anterior wall fracture is not a significant predictor of over-sliding distance.

Subtrochanteric femur fractures: current review of management

Subtrochanteric (ST) femur fractures are proximal femur fractures, which are often difficult to manage effectively because of their deforming anatomical forces.

Operative management of ST fractures is the mainstay of treatment, with the two primary surgical implant options being intramedullary (IM) nails and extramedullary plates.

Of these, IM nails have a biologic and biomechanical superiority, and have become the gold standard for ST femur fractures.

The orthopaedic surgeon should become familiar and facile with several reduction techniques to create anatomical alignment in all unique ST fracture patterns.

This article presents a comprehensive and current review of the epidemiology, anatomy, biomechanics, clinical presentation, diagnosis, and management of subtrochanteric femur fractures.

Cite this article: EFORT Open Rev 2021;6:145-151. DOI: 10.1302/2058-5241.6.200048

Sacral Insufficiency Fractures: a Review of Risk Factors, Clinical Presentation, and Management

PURPOSE OF THE REVIEW

Sacral insufficiency fractures (SIF) are a common and often underdiagnosed source of low back pain. In patients with SIF, there is both a compromised sacroiliac joint and weakened sacrum, resulting in decreased resistance to torsional stress, leading to fracture. While conservative medical management is a safe option, minimally invasive intervention may provide improved short and long-term relief of low back pain in patients presenting with SIF. This comprehensive review is undertaken to provide an update to the current understanding of SIF with description of risk factors, clinical presentation, and management.

RECENT FINDINGS

Sacroplasty is a minimally invasive procedure in which polymethylmethacrylate (PMMA) cement is inserted into bone to improve its structural integrity and alleviate symptoms. Balloon sacroplasty (BSP) has also been successful in alleviating pain with minimal cement leakage in SIF patients. Various other interventional techniques, including navigation-assisted screw fixation have been used to address SIF and have shown improvement in pain with minimal side effects. This review included various modalities of treatments available to manage SIF. This review shows that in comparison with nonsurgical management, sacroplasty has been shown to have greater pain reduction and improved mobility.

Augmented Fixation for Fractures of the Appendicular Skeleton

Despite advances in technology such as locked plating, osteoporotic bone and bone defects remain challenging complications for orthopaedic surgeons. The concept of augmented fixation is useful in these settings. Augmented fixation can be described as improving construct strength and stability by enhancing the surrounding environment. By understanding and using the techniques of alternative fixation strategies, endosteal or medullary support, structural grafting, or the use of bone graft substitutes in combination with standard or integrated fixation, surgeons can improve the chances of success when treating difficult fractures. The purpose of this article is to introduce the reader to the concept of augmented fixation, review strategies for its application, and review applicable published results.

Ninety-Five Degree Angled Blade Plate Fixation of High-Energy Unstable Proximal Femur Fractures Results in High Rates of Union and Minimal Complications

OBJECTIVES

To describe the surgical technique and clinical outcomes of high-energy proximal femur fractures treated with a 95-degree angled blade plate.

DESIGN

Retrospective case series.

SETTING

Single academic Level I trauma center.

PATIENT/PARTICIPANTS

Forty-five consecutive patients from March 2012 to April 2017 who sustained a high-energy, unstable proximal femur fracture including (OTA/AO 31-A1, 31-A2, 31-A3, 31-B3, 32-A1a, and 32-C3i).

INTERVENTION

Open reduction internal fixation with a 95-degree angled blade plate used in conjunction with an articulated tensioning device.

MAIN OUTCOME MEASUREMENTS

Nonunion, malunion, secondary operations, and postoperative infection.

RESULTS

Twenty six patients were available for follow-up. The mean age was 43.8 (range 22-86) years, and 81% (21/26) were men. The most common fracture pattern was OTA/AO 31-A3.3. Two fractures were open. The articulated tensioner was used in 100% of cases. Average clinical follow-up was 19.2 (range 7-40) months. Twenty-four of 26 patients (92%) achieved osseous union after the index procedure. One patient underwent nonunion repair, and 2 patients had the blade plate removed as it was symptomatic laterally. No other secondary procedures were performed, and no instances of implant failure were seen. No patients had evidence of a superficial or deep infection.

CONCLUSIONS

We found that high-energy proximal femur fractures treated with a 95-degree condylar blade plate and articulated tensioning device had a high rate of union with minimal postoperative complications. Although intramedullary nailing of these fractures remains a preferred treatment modality, the angled blade plate with articulated tensioning device is an excellent option to restore anatomical alignment and obtain bony union in certain highly comminuted fracture patterns.

LEVEL OF EVIDENCE

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

A biomechanical comparison of three fixation techniques in osteoporotic reverse oblique intertrochanteric femur fracture with fragmented lateral cortex

BACKGROUND

The treatment of the reverse oblique osteoporotic femur fractures is still problematic and can be complicated especially that are accompanied by a fragmented lateral cortex.

AIM

The aim of this study was to compare three different internal fixation methods in the osteosynthesis of osteoporotic reverse oblique intertrochanteric femur fracture models with a fragmented lateral cortex.

STUDY DESIGN

Biomechanical experiment study.

METHODS

A total of 24 osteoporotic femur models were obtained and divided into three groups [Group A: Proximal femoral nail (PFN), Group B: 95° angled blade plate (ABP), and Group C: proximal femoral anatomic locking plate (PFLP)] with each group which include eight bones. A standard fracture configuration was created as a reverse oblique intertrochanteric fracture and fixed with these implants. After fixation, all femur constructs were tested with an Instron 5800R tester (Instron, Canton, MA) in the biomechanics laboratory with axial loading and bending forces to assess axial and rotational stiffness and failure load. Displacement over 10 mm and angulation greater than 10° in the fracture line were considered as failure.

RESULTS

In all tests, ABP had statistically poorer results in comparison to the PFN and PFLP group. PFLP fixation had better biomechanical fixation results in comparison to the PFN group, although the results were not statistically significant.

CONCLUSION

Orthopaedic surgeons should keep in mind that lateral cortex comminution brings further instability to these reverse oblique intertrochanteric osteoporotic fractures and high rates of failure may be encountered due to this instability. PFLP fixation may be an alternative fixation method biomechanically for these instable fractures.

Management of Subtrochanteric Proximal Femur Fractures: A Review of Recent Literature

Subtrochanteric femur fractures are an uncommon injury in orthopedics, but when they are encountered they may present difficulties in management. The purpose of this paper is to examine the recent literature on the epidemiology, classification, initial evaluation, and definitely treatment for these injuries. These will assist the physician to determine the optimal treatment strategy and avoid potential surgical complication.

High failure rate of proximal femoral locking plates in fixation of trochanteric fractures

Background

The aim of this study was to report our previous results of treatments for trochanteric fractures with proximal femoral locking plates (PFLP) and to analyze the underlying mechanisms and possible risk factors associated with the high failure rate of this technique.

Methods

From January 2010 to October 2014, 273 consecutive patients with trochanteric femoral fractures were identified, and 95 patients (with 97 fractures) ultimately met the inclusion criteria. Clinical records regarding demographic features and intraoperative data including total incision length, operation time, blood loss, and failures detected in radiographs were documented and assessed. The collected data were analyzed with SPSS 19.0 software.

Results

The stable group (AO/OTA 31 A1 and A2.1) had less blood loss than the unstable group (AO/OTA 31 A2.2, A2.3, and A3). The ultimate failure rate was 36% in 97 fractures. The obvious complications in this study included nonunion in 7 (7.2%) fractures, implant breakage in 4 (4.1%) fractures, varus deformity in 34 (35%) fractures, and loosening of the proximal femoral screw in 21 (21.6%) fractures. Six patients received reoperations. The total failure rate in the stable group was 17% and was 50% in the unstable group. In patients greater than 60 years old in the unstable group, the failure rate was 60.5%.

Conclusions

High failure rates of PFLP were observed in patients with trochanteric fracture, especially in patients who were greater than 60 years old with unstable fracture types. PFLP was not an appropriate treatment for trochanteric fractures.

Use of the 95-degree Angled Blade Plate to Treat a Proximal Femur Fracture

There are a variety of ways to treat high-energy proximal femur fractures, including intramedullary nails and laterally based plates. Although each have distinct advantages and disadvantages, fracture reduction and avoiding varus alignment are critical. For some fractures, the blade plate is a reliable, straightforward implant to treat these injuries. This article and the accompanying video describe the surgical technique of using a 95-degree angled blade plate to treat an acute high-energy proximal femur fracture.

[Effectiveness analysis of surgical treatment of ipsilateral femoral neck fracture and subtrochanteric fracture]

Objective

To discuss the effectiveness of intramedullary nail fixation with selective cable wiring in the treatment of ipsilateral femoral neck fracture and subtrochanteric fracture.

Methods

Between June 2012 and December 2015, a total of 19 patients with ipsilateral femoral neck fracture and subtrochanteric fracture underwent closed reduction of femoral neck fracture and intramedullary nail fixation combined with selective cable wiring. There were 5 males and 14 females with a median age of 52 years (range, 35-77 years). The cause of injury included traffic accident injury in 17 cases and falling injury in 2 cases. According to Garden classification for femoral neck fractures, 7 cases were rated as type Ⅱ, 8 as type Ⅲ, and 4 as type Ⅳ. Femoral subtrochanteric fractures were classified by Seinsheimer classification, with 9 cases as type Ⅱ, 5 as type Ⅲ, 3 as type Ⅳ, and 2 as type V. The interval from injury to operation ranged from 2 to 7 days with an average of 3.7 days.

Results

The operation time was 58-125 minutes (mean, 82.4 minutes) and the intraoperative blood loss was 225-725 mL (mean, 289.5 mL). All incisions achieved healing by first intention and no early complication such as infection was observed. All patients were followed up 12-18 months (mean, 13.9 months). At 1 month after operation, the tip apex distance was 9-23 mm (mean, 15.2 mm). All patients achieved bone union with the healing time of 18-42 weeks (mean, 27.4 weeks). One case of hip varus and femoral neck re-displacement (femoral neck shaft angle was 122°) occurred at 3 months after operation, which achieved bone union at 42 weeks after operation. Five patients complained of postoperative pain with the visual analogue scale (VAS) score of 1-3 (mean, 1.8), which did not influence normal life. A total of 16 patients recovered preoperative hip function. During follow-up, no fracture nonunion, femoral head necrosis, implant failure, screw cut-out, and loosening of cable wiring was observed. The Harris hip score (HSS) was 72-92 (mean, 82.8) at last follow-up and 15 patients (78.9%) achieved good hip function.

Conclusion

Intramedullary nail fixation combined with selective cable wiring was effective in the treatment of ipsilateral femoral neck fracture and subtrochanteric fracture.

Limited Dynamic Hip Screw for Treatment of Intertrochanteric Fractures: A Biomechanical Study

Background

Material/Methods

Results

Conclusions

Biomechanical Analysis of the Proximal Femoral Locking Compression Plate: Do Quality of Reduction and Screw Orientation Influence Construct Stability?

OBJECTIVES

To investigate biomechanically in a human cadaveric model the failure modes of the proximal femoral locking compression plate and explore the underlying mechanism.

METHODS

Twenty-four fresh-frozen paired human cadaveric femora with simulated unstable intertrochanteric fractures (AO/OTA 31-A3.3) were assigned to 4 groups with 6 specimens each for plating with proximal femoral locking compression plate. The groups differed in the quality of fracture reduction and plating fashion of the first and second proximal screws as follows: (1) anatomic reduction with on-axis screw placement; (2) anatomic reduction with off-axis screw placement; (3) malreduction with on-axis screw placement; (4) malreduction with off-axis screw placement. The specimens were tested until failure using a protocol with combined axial and torsional loading. Mechanical failure was defined as abrupt change in machine load-displacement data. Clinical failure was defined as 5 degrees varus tilting of the femoral head as captured with optical motion tracking.

RESULTS

Initial axial stiffness (in N/mm) in groups 1 to 4 was 213.6 ± 65.0, 209.5 ± 134.0, 128.3 ± 16.6, and 106.3 ± 47.4, respectively. Numbers of cycles to clinical and mechanical failure were 16,642 ± 10,468 and 8695 ± 1462 in group 1, 14,076 ± 3032 and 7449 ± 5663 in group 2, 8800 ± 8584 and 4497 ± 2336 in group 3, and 9709 ± 3894 and 5279 ± 4119 in group 4. Significantly higher stiffness and numbers of cycles to both clinical and mechanical failure were detected in group 1 in comparison with group 3, P ≤ 0.044.

CONCLUSIONS

Generally, malreduction led to significantly earlier construct failure. The observed failures were cut-out of the proximal screws in the femoral head, followed by either screw bending, screw loosening, or screw fracture. Proper placement of the proximal screws in anatomically reduced fractures led to significantly higher construct stability. Our data also indicate that once the screws are placed off-axis (>5 degrees), the benefit of an anatomic reduction is lost.

Management of unstable pertrochanteric fractures with proximal femoral locking compression plates and affect of neck-shaft angle on functional outcomes

BACKGROUND

Management of unstable pertrochanteric fractures remains a challenge with various implant choices. Intramedullary devices are usually preferred for the management of the unstable fractures. When nailing is unsuitable for the configuration of the fracture extra medullary procedures are preferred. PFLCP is a contact limited implant that allows multiple angularly stable fixations with preserving more bone stock after implantation as an extramedullary implant. There are only a few reports in the literature about the osteosynthesis of unstable trochanteric fractures with proximal femoral locking compression plates and their results are conflicting. In the present study we aimed to evaluate the functional and radiological outcomes of proksimal femoral locking compression plates in open reduction and internal fixation of AO/OTA 31A2-2 and 3 fractures.

METHODS

Patients older than 18 years of age with a minimum follow-up time of 1 year matching the inclusion criteria retrospectively evaluated. Patients' demographics, Singh index, intra and post-operative data, mobilization and union time gathered from the patients' files. Baumgaertner modified criteria of fracture reduction was used to assess the post-operative reduction quality. Early and last follow-up radiographs were used to evaluate malunion and change in neck- shaft angle. Final clinical outcome was assessed using the Harris Hip scoring system.

RESULTS

18 male and 13 female patients with the mean age of 74 (46-88) met the inclusion criteria. Reduction quality according to Baumgaertner modified criteria was good in 25 patients and acceptable in 6. Mean union time was 21.53 ± 4.18 weeks. There was neither non-union nor malunion. The mean neck-shaft angle change was -3.1° ± 2.16°. The mean HHS was 77.90 ± 4.84 and there was no significance in HHS according to reduction quality and change in neck-shaft angle (p = 0.385, p = 0.0059). HHS was negatively correlated with age, mobilization time and, longer union time (p < 0.05). There was no correlation between Singh index and reduction quality (p = 0.865). Singh index was only correlated with the patient's age (p = 0.000, rho = -0.595). There were 2 infections and, 2 backing of the proximal screws.

CONCLUSION

Even though PFLCP is not the first choice in management of unstable pertrochanteric fractures, it must be kept in mind as an alternative to the other conventional plates and intramedullary implants with the properties of an increased stability by multiaxial screw locking and the results are satisfactory when appropriate settlement achieved.