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Xie W, Shi L, Zhang C, Cui X, Chen X, Xie T, Zhang S, Chen H, Rui Y. Anteromedial cortical support reduction of intertrochanteric fractures-A review. Injury 2024; 55:111926. [PMID: 39388744 DOI: 10.1016/j.injury.2024.111926] [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: 07/02/2024] [Revised: 09/19/2024] [Accepted: 09/21/2024] [Indexed: 10/12/2024]
Abstract
The intertrochanteric fracture is a common fragility fracture typically resulting from low-energy falls. The functional outcome of intertrochanteric fractures is closely linked to the patient's underlying physical condition, intraoperative procedures, and postoperative complications. In terms of surgery, while timely surgery and appropriate internal fixation have demonstrated favorable outcomes, attention to intraoperative reduction is crucial. In recent years, there have been further developments in the evaluation of reduction of intertrochanteric fractures, particularly in the anteromedial cortical reduction, and these advances have been further scientifically elucidated in terms of their ability to provide stable fracture reduction and resist loss of reduction. In order to gain a comprehensive understanding of the anteromedial cortex theory, this article reviewed the anatomy, related theoretical progress, and controversies in recent years.
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Affiliation(s)
- Wenjun Xie
- Department of Orthopaedics, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, China; Trauma Center, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, China; Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, 210009, China; Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management Zhongda Hospital, School of Medicine Southeast University, Nanjing, Jiangsu, China.
| | - Liu Shi
- Department of Orthopaedics, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, China; Trauma Center, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, China; Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, 210009, China; Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management Zhongda Hospital, School of Medicine Southeast University, Nanjing, Jiangsu, China.
| | - Cheng Zhang
- Department of Orthopaedics, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, China; Trauma Center, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, China; Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, 210009, China; Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management Zhongda Hospital, School of Medicine Southeast University, Nanjing, Jiangsu, China.
| | - Xueliang Cui
- Department of Orthopaedics, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, China; Trauma Center, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, China; Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, 210009, China; Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management Zhongda Hospital, School of Medicine Southeast University, Nanjing, Jiangsu, China.
| | - Xiangxu Chen
- Department of Orthopaedics, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, China; Trauma Center, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, China; Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, 210009, China; Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management Zhongda Hospital, School of Medicine Southeast University, Nanjing, Jiangsu, China.
| | - Tian Xie
- Department of Orthopaedics, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, China; Trauma Center, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, China; Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, 210009, China; Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management Zhongda Hospital, School of Medicine Southeast University, Nanjing, Jiangsu, China.
| | - Sheng Zhang
- Department of Orthopaedics, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, China; Trauma Center, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, China; Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, 210009, China; Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management Zhongda Hospital, School of Medicine Southeast University, Nanjing, Jiangsu, China.
| | - Hui Chen
- Department of Orthopaedics, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, China; Trauma Center, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, China; Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, 210009, China; Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management Zhongda Hospital, School of Medicine Southeast University, Nanjing, Jiangsu, China.
| | - Yunfeng Rui
- Department of Orthopaedics, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, China; Trauma Center, Zhongda Hospital, Southeast University, 87 Ding Jia Qiao, Nanjing, Jiangsu, 210009, China; Orthopaedic Trauma Institute (OTI), Southeast University, Nanjing, Jiangsu, 210009, China; Multidisciplinary Team (MDT) for Geriatric Hip Fracture Management Zhongda Hospital, School of Medicine Southeast University, Nanjing, Jiangsu, China.
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Maehara T, Hayakawa T, Mukoyama S, Anraku Y, Hamada T, Suzuki H, Doi T, Shimizu T, Yorimitsu M, Teramoto H, Mae T, Okamoto Y, Hara J, Mihara K, Kanekasu K. The effect of anterior support screw (AS2) in unstable femoral trochanteric fractures: A multicenter randomized controlled trial. Injury 2024; 55:111725. [PMID: 39096804 DOI: 10.1016/j.injury.2024.111725] [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: 12/29/2023] [Revised: 07/08/2024] [Accepted: 07/09/2024] [Indexed: 08/05/2024]
Abstract
OBJECTIVES This study was conducted to verify the effectiveness of Anterior Support Screw (AS2) for unstable femoral trochanteric fractures. DESIGN A multicenter, prospective, randomized controlled trial SETTING: This study was conducted across 15 academic medical centers in Japan PATIENTS/PARTICIPANTS: We enrolled 240 cases of femoral trochanteric fractures with posterior crushing and intramedullary displacement of proximal bone fragments across 15 institutions in Japan. INTERVENTION All patients were subjected to a reduction in which the anterior cortex was brought into contact. The patients were randomly assigned to the anterior support screw group (AS2 group) and the non-screw group (control group). MAIN OUTCOME MEASUREMENTS Two computed-tomography (CT) scans were taken immediately after surgery and early postoperative period (day 14-21) to investigate the reduction loss rate of the anterior cortex and sliding distances in the early postoperative period. RESULTS The reduction loss rate was 4.5 % in the AS2 group and 16.8 % in the control group, indicating a significantly lower reduction loss rate in the AS2 group (p = 0.003). The average sliding distance was 1.8 mm in the AS2 group and 2.8 mm in the control group, indicating a significantly shorter sliding distance in the AS2 group (p < 0.0001). CONCLUSION Adding a screw in front of the intramedullary nail significantly reduces reduction loss, and maintains anterior bony contact. This study also showed that these screws suppress the sliding distance during the postoperative period. LEVEL OF EVIDENCE Therapeutic Level I.
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Affiliation(s)
- Takashi Maehara
- Department of Orthopaedic Surgery, Kagawa Rosai Hospital, Japan.
| | - Takashi Hayakawa
- Department of Joint Orthopaedic Surgery, Niigata Central Hospital, Japan
| | | | - Yoshihisa Anraku
- Department of Orthopaedic Surgery, Saiseikai Kumamoto Hospital, Japan
| | - Takahiro Hamada
- Department of Orthopaedic Surgery, Kyushu Central Hospital, Japan
| | - Hiroyuki Suzuki
- Department of Orthopaedic Surgery, Kasugai Municipal Hospital, Japan
| | - Takeshi Doi
- Department of Orthopaedic Surgery, Okayama Red Cross Hospital, Japan
| | - Tomohiko Shimizu
- Department of Orthopaedic Surgery, Fujieda Municipal General Hospital, Japan
| | | | | | - Takao Mae
- Department of Orthopaedic Surgery, Saga-ken Medical Centre Koseikan, Japan
| | - Yasunori Okamoto
- Department of Orthopaedic Surgery, Hoshigaoka Medical Center, Japan
| | - Jun Hara
- Department of Orthopaedic Surgery, Kawasaki Saiwai Hospital, Japan
| | - Kazushi Mihara
- Department of Orthopaedic Surgery, Toyooka Hospital, Japan
| | - Koichi Kanekasu
- Department of Orthopaedic Surgery, Saiseikai Takaoka Hospital, Japan
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Kasha S, Yalamanchili RK, Rohit G. Design innovation and rationale of the intramedullary implants for treating Intertrochanteric fractures: A review. J Clin Orthop Trauma 2024; 56:102525. [PMID: 39324022 PMCID: PMC11419893 DOI: 10.1016/j.jcot.2024.102525] [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: 05/27/2024] [Revised: 08/04/2024] [Accepted: 08/28/2024] [Indexed: 09/27/2024] Open
Abstract
Intertrochanteric fracture management require effective management strategies for early return to function and minimise complications. Intramedullary devices like proximal femoral nail have an biomechanical advantage, particularly in unstable intertrochanteric fractures. Such unstable injury patterns not only require precise reduction technique, but also right implant design to minimise the complications. Novel concepts of reduction like medial cortical support classification and antero-posterior reduction (Subtype classification system) refine the reduction strategies. Despite reporting of the reduction analysis, there has been continuing number of implant failures following proximal femoral nail implantation. Complications like 'Z' effect and reverse 'Z' effect are very well reported with the 2 screw Recon - Proximal femur nails. Analysis of failure and complications have constantly upgraded the designs of proximal femur nails. Design of the new generation intramedullary implants for treatment of intertrochanteric fractures like Gamma nail, PFNA-II (Proximal Femoral Nail Anterotation), Zimmer Natural Nail, Trigen Intertan nail and TFN - Advanced (Trochanteric Femoral Nail Advanced) are described in this review. While the new implant designs offer advancements, fundamental principles of reduction remains crucial for successful outcomes. Design rationale and instrumentation of each implant must be known at the time of application along with techniques of maintaining the reduction for a successful outcome.
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Affiliation(s)
- Srinivas Kasha
- Orthopaedic Surgeon, Krishna Institute of Medical Sciences, Minister Road, Secunderabad, India
| | | | - G.P.R.K. Rohit
- Orthopaedic Surgeon, Krishna Institute of Medical Sciences, Minister Road, Secunderabad, India
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Güven Ş, Naldöven ÖF, Alkan H, Erdoğan Y, Çepni Ş, Veizi E. Laterally Protruded Cephalomedullary Nail Lag Screws are a Source of Consistent Thigh Pain After Pertrochanteric Fracture. J Orthop Trauma 2024; 38:320-326. [PMID: 38470134 DOI: 10.1097/bot.0000000000002803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 03/06/2024] [Indexed: 03/13/2024]
Abstract
OBJECTIVES To assess the correlation between the amount of proximal screw lateralization and clinical symptoms in patients treated with a cephalomedullary nail (CMN) after a pertrochanteric fracture. METHODS DESIGN Retrospective study. SETTING Level 1 trauma center. PATIENT SELECTION CRITERIA Patients operated for a pertrochanteric fracture (OTA/AO A1, A2, A3) between 2019 and 2022 and treated with a CMN were included. OUTCOME MEASURES AND COMPARISONS Three measurements were evaluated: D1 distance between the most laterally prominent point of the lag screw and the line tangent to the greater trochanter, D2 distance between the lateral femoral cortex and the most laterally prominent point of the lag screw, and D3 distance between the point where the lag screw emerges at the lateral edge of the femur shaft and the skin's surface. Clinical scores and information regarding lateral thigh pain were obtained, and a correlation analysis was performed. RESULTS Mean age of the study cohort (n = 134) was 77.9 ± 12.3 years. Patients with categorical protrusion (considered present in cases where the distance between the lateral tip of the lag screw and the lateral border of the greater trochanter was ≥0.2 mm) had significantly higher rates of lateral thigh pain ( P = 0.007) and discomfort while lying on the side ( P = 0.032) compared with those without protrusion. Correlation analyses showed a positive correlation between measurements D1 and D2 and lateral thigh pain (r = 0.324 and r = 0.334, respectively, P < 0.001) and a negative correlation between D3 and lateral thigh pain (r = -0.286, P = 0.001). Regression analysis showed that higher D1 and D2 distances and shorter D3 distances are risk factors for lateral thigh pain ( P = 0.001, 0.001, and 0.002, respectively). CONCLUSIONS Increasing lateral protrusion of the lag screw leads to significantly greater clinical complaints and lateral hip pain in patients treated with a CMN. Patients with lower distance between the lateral femoral wall and the skin are at higher risk of lateral pain. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Şahan Güven
- Department of Orthopedics and Traumatology, Ankara City Hospital, Ankara, Turkey; and
| | - Ömer Faruk Naldöven
- Department of Orthopedics and Traumatology, Ankara City Hospital, Ankara, Turkey; and
| | - Hilmi Alkan
- Department of Orthopedics and Traumatology, Ankara City Hospital, Ankara, Turkey; and
| | - Yasin Erdoğan
- Department of Orthopedics and Traumatology, Ankara City Hospital, Ankara, Turkey; and
| | - Şahin Çepni
- Department of Orthopedics and Traumatology, Ankara City Hospital, Ankara, Turkey; and
| | - Enejd Veizi
- Department of Orthopedics and Traumatology, Yıldırım Beyazıt University, School of Medicine, Ankara City Hospital, Ankara, Turkey
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Lee C, Kates SL, Graves ML, Jeray KJ, Javedan H, Firoozabadi R, Schemitsch E. Geriatric trauma: there is more to it than just the implant! OTA Int 2024; 7:e327. [PMID: 38487398 PMCID: PMC10936161 DOI: 10.1097/oi9.0000000000000327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 12/30/2023] [Accepted: 01/01/2024] [Indexed: 03/17/2024]
Abstract
Geriatric trauma continues to rise, corresponding with the continuing growth of the older population. These fractures continue to expand, demonstrated by the incidence of hip fractures having grown to 1.5 million adults worldwide per year. This patient population and their associated fracture patterns present unique challenges to the surgeon, as well as having a profound economic impact on the health care system. Pharmacologic treatment has focused on prevention, with aging adults having impaired fracture healing in addition to diminished bone mineral density. Intraoperatively, novel ideas to assess fracture reduction to facilitate decreased fracture collapse have recently been explored. Postoperatively, pharmacologic avenues have focused on future fracture prevention, while shared care models between geriatrics and orthopaedics have shown promise regarding decreasing mortality and length of stay. As geriatric trauma continues to grow, it is imperative that we look to optimize all phases of care, from preoperative to postoperative.
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Affiliation(s)
- Christopher Lee
- Department of Orthopaedic Surgery, University of California Los Angeles, Los Angeles, CA
| | - Stephen L. Kates
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA
| | - Matthew L. Graves
- Department of Orthopaedic Surgery, University of Mississippi, Jackson, MI
| | - Kyle J. Jeray
- Department of Orthopaedic Surgery, Univeristy of South Carolina School of Medicine, Greenville, SC
| | | | - Reza Firoozabadi
- Department of Orthopaedic Surgery, Univeristy of Washington, Seattle, WA
| | - Emil Schemitsch
- Department of Orthopaedic Surgery, Western University, Bone and Joint Institute, London, ON, Canada
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Chan DS, Moghadamian ES. Preventing the Slide in High-Energy Intertrochanteric Fractures With Intramedullary Nails. J Orthop Trauma 2023; 37:S5-S10. [PMID: 37710369 DOI: 10.1097/bot.0000000000002667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/05/2023] [Indexed: 09/16/2023]
Abstract
LEVEL OF EVIDENCE Therapeutic Level V.
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Affiliation(s)
- Daniel S Chan
- Musculoskeletal Care Orthopaedic Trauma, AtriumHealth Navicent, Macon, GA; and
| | - Eric S Moghadamian
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, KY
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Yurek JW, Doerr NA, Tang A, Kohring AS, Liporace FA, Yoon RS. Assessing the Necessity of Extra Reduction Aides in Intramedullary Nailing of Intertrochanteric Hip Fractures. Hip Pelvis 2023; 35:183-192. [PMID: 37727297 PMCID: PMC10505845 DOI: 10.5371/hp.2023.35.3.183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 07/21/2023] [Accepted: 07/21/2023] [Indexed: 09/21/2023] Open
Abstract
Purpose This study aims to determine which intertrochanteric (IT) hip fracture and patient characteristics predict the necessity for adjunct reduction aides prior to prep and drape aiming for a more efficient surgery. Materials and Methods Institutional fracture registries from two academic medical centers from 2017-2022 were analyzed. Data on patient demographics, comorbidities, fracture patterns identified on radiographs including displacement of the lesser trochanter (LT), thin lateral wall (LW), reverse obliquity (RO), subtrochanteric extension (STE), and number of fracture parts were collected, and the need for additional aides following traction on fracture table were collected. Fractures were classified using the AO/OTA classification. Regression analyses identified significant risk factors for needing extra reduction aides. Results Of the 166 patients included, the average age was 80.84±12.7 years and BMI was 24.37±5.3 kg/m2. Univariate regression revealed increased irreducibility risk associated with RO (odds ratio [OR] 27.917, P≤0.001), LW (OR 24.882, P<0.001), and STE (OR 5.255, P=0.005). Multivariate analysis significantly correlated RO (OR 120.74, P<0.001) and thin LW (OR 131.14, P<0.001) with increased risk. However, STE (P=0.36) and LT displacement (P=0.77) weren't significant. Fracture types 2.2, 3.2, and 3.3 displayed elevated risk (P<0.001), while no other factors increased risk. Conclusion Elderly patients with IT fractures with RO and/or thin LW are at higher risk of irreducibility, necessitating adjunct reduction aides. Other parameters showed no significant association, suggesting most fracture patterns can be achieved with traction manipulation alone.
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Affiliation(s)
- John W. Yurek
- Division of Orthopaedic Trauma and Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center – RWJBarnabas Health, Jersey City, NJ, USA
| | - Nikki A. Doerr
- Division of Orthopaedic Trauma and Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center – RWJBarnabas Health, Jersey City, NJ, USA
| | - Alex Tang
- Division of Orthopaedic Trauma and Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center – RWJBarnabas Health, Jersey City, NJ, USA
| | - Adam S. Kohring
- Division of Orthopaedic Trauma and Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center – RWJBarnabas Health, Jersey City, NJ, USA
| | - Frank A. Liporace
- Division of Orthopaedic Trauma and Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center – RWJBarnabas Health, Jersey City, NJ, USA
| | - Richard S. Yoon
- Division of Orthopaedic Trauma and Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center – RWJBarnabas Health, Jersey City, NJ, USA
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Somasundaram V, Owen AR, Hidden KA, Barlow JD, Cross WW, Sems SA, Yuan BJ. Cephalomedullary Nailing of Unstable Geriatric Intertrochanteric Fractures on a Traction Table Combined With Percutaneous Reduction Techniques Is Safe and Results in a Low Rate of Cutout. J Orthop Trauma 2023; 37:323-329. [PMID: 36750432 DOI: 10.1097/bot.0000000000002577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/20/2023] [Indexed: 02/09/2023]
Abstract
OBJECTIVES To describe a reproducible technique for reduction assessment and percutaneous reduction of unstable intertrochanteric fractures treated with a cephalomedullary nail on a traction table. DESIGN Retrospective cohort study. SETTING Level-1 trauma center. PATIENTS Two-hundred 20 consecutive patients with intertrochanteric fractures. INTERVENTION Initial closed reduction performed on a traction table. Accessory incisions were used to facilitate a reduction in 77 patients (35%). All fractures were stabilized with a cephalomedullary nail. MAIN OUTCOME MEASUREMENTS Radiographic outcome including union, cutout, and fracture collapse (FC). Surgical outcomes including infection and hematoma were also reported. RESULTS Mechanical complications (nonunion, cutout, and varus collapse) occurred in 8.8% of patients at 1 year. Eleven of 13 patients who developed these complications had either suboptimal implant placement (tip-to-apex distance >25 mm) or a varus reduction. There was no difference in the incidence of reoperation, nonunion, lag screw cutout, or posttraumatic arthritis based on the use of an accessory incision for fracture reduction. There was a significant increase in FC in patients who received an accessory incision (6.8 mm vs. 5.4 mm, P = 0.04). One patient (1%) developed a hematoma in the accessory incision cohort, and 1 patient (0.7%) who did not have an accessory incision developed a postoperative infection. CONCLUSIONS The current study suggests utilization of accessory incisions assist in reduction is safe and is associated with a low rate of complications. The surgeon should prioritize fracture reduction and optimal implant placement and not hesitate to use an accessory incision to assist with fracture reduction. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | - Aaron R Owen
- Department of Orthopedic Surgery, Mayo Clinic, Rochester
| | | | | | | | - Stephen A Sems
- Department of Orthopedic Surgery, Mayo Clinic, Rochester
| | - Brandon J Yuan
- Department of Orthopedic Surgery, Mayo Clinic, Rochester
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Insufficient proximal medullary filling of cephalomedullary nails in intertrochanteric femur fractures predicts excessive postoperative sliding: a case-control study. BMC Musculoskelet Disord 2023; 24:156. [PMID: 36855090 PMCID: PMC9972673 DOI: 10.1186/s12891-023-06213-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 01/31/2023] [Indexed: 03/02/2023] Open
Abstract
OBJECTIVE Excessive postoperative sliding is a common complication of intramedullary nails in the treatment of intertrochanteric femur fractures. The aim of this study was to identify risk factors for excessive postoperative sliding in the intertrochanteric fractures treated with an intramedullary nail. METHODS A retrospective analysis of 369 patients with femoral intertrochanteric fractures treated with short intramedullary nails between February 2017 and September 2020 was performed. Patients were classified into an excessive sliding group (ES group) and a control group according to the sliding distance after 6 months of follow-up. The proximal medullary filling degree (MFD), fracture reduction patterns in the anteroposterior (AP) view and lateral view, and tip-apex distance (TAD) were evaluated and compared in each group. RESULTS Thirty-three cases were included in the ES group, and 336 cases were included in the control group. No significant differences in age, sex, fracture side, AO Foundation and Orthopaedic Trauma Association (AO/OTA) classification, Dorr classification, Singh Osteoporosis Index (SOI), American Society of Anesthesiologists classification (ASA), TAD or fracture reduction patterns in the AP view were noted between the two groups. The negative reduction pattern can strongly predict excessive postoperative sliding (OR 4.286, 95% CI 1.637-11.216, P = 0.003). The incidence of excessive postoperative sliding increased by 8.713-fold when the MFD decreased by 10% (OR 8.713, 95% CI 1.925-39.437, P = 0.005). CONCLUSIONS A low medullary filling degree and negative fracture reduction pattern in the lateral view were both independent risk factors for excessive postoperative sliding.
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Hao Y, Zhang Z, Zhou F, Ji H, Tian Y, Guo Y, Lv Y, Yang Z, Hou G. Trochanteric and subtrochanteric fractures irreducible by closed reduction: a retrospective study. J Orthop Surg Res 2023; 18:141. [PMID: 36843011 PMCID: PMC9969640 DOI: 10.1186/s13018-023-03635-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Accepted: 02/22/2023] [Indexed: 02/28/2023] Open
Abstract
AIM To explore the preoperative radiographic features and reduction methods of irreducible trochanteric and subtrochanteric fractures of the femur and to compare the perioperative characteristics and prognoses of irreducible and reducible fractures. METHODS The data of 1235 patients with femoral trochanteric fractures surgically treated in our hospital between January 2010 and January 2021 were retrospectively analyzed. According to the inclusion criteria and exclusion criteria, 1163 cases of femoral trochanteric and subtrochanteric fractures were included in this study. Fractures in which good or acceptable reduction could not be reached by closed manipulation were defined as irreducible fractures. The preoperative radiographic features, fracture displacement patterns after closed manipulation and intraoperative reduction methods used to treat irreducible fractures were analyzed, and the perioperative characteristics and prognoses of irreducible fractures and reducible fractures were compared. RESULTS There were 224 patients in the irreducible group and 939 patients in the reducible group. According to the radiographic features of fractures, irreducible fractures could be divided into four types: those with interlocking of the fracture, sagging of the femoral shaft, splitting of the lateral wall or medial wall, and comminution of the subtrochanteric area. Various kinds of reduction techniques were needed for different types. CONCLUSIONS The incidence of irreducible trochanteric fractures was 15.4%, while the incidence of irreducible subtrochanteric fractures was 84.6%. According to the radiographic features of fractures, they can be divided into four types. It is important to identify irreducible fractures preoperatively and make comprehensive plans to the greatest extent possible to shorten the operation time, reduce intraoperative blood loss, and reduce the incidence of complications.
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Affiliation(s)
- Youliang Hao
- grid.411642.40000 0004 0605 3760Department of Orthopaedics, Peking University Third Hospital, Beijing, 100191 China ,Engineering Research Center of Bone and Joint Precision Medicine, Beijing, 100191 China
| | - Zhishan Zhang
- grid.411642.40000 0004 0605 3760Department of Orthopaedics, Peking University Third Hospital, Beijing, 100191 China ,Engineering Research Center of Bone and Joint Precision Medicine, Beijing, 100191 China
| | - Fang Zhou
- Department of Orthopaedics, Peking University Third Hospital, Beijing, 100191, China. .,Engineering Research Center of Bone and Joint Precision Medicine, Beijing, 100191, China.
| | - Hongquan Ji
- grid.411642.40000 0004 0605 3760Department of Orthopaedics, Peking University Third Hospital, Beijing, 100191 China ,Engineering Research Center of Bone and Joint Precision Medicine, Beijing, 100191 China
| | - Yun Tian
- grid.411642.40000 0004 0605 3760Department of Orthopaedics, Peking University Third Hospital, Beijing, 100191 China ,Engineering Research Center of Bone and Joint Precision Medicine, Beijing, 100191 China
| | - Yan Guo
- grid.411642.40000 0004 0605 3760Department of Orthopaedics, Peking University Third Hospital, Beijing, 100191 China ,Engineering Research Center of Bone and Joint Precision Medicine, Beijing, 100191 China
| | - Yang Lv
- grid.411642.40000 0004 0605 3760Department of Orthopaedics, Peking University Third Hospital, Beijing, 100191 China ,Engineering Research Center of Bone and Joint Precision Medicine, Beijing, 100191 China
| | - Zhongwei Yang
- grid.411642.40000 0004 0605 3760Department of Orthopaedics, Peking University Third Hospital, Beijing, 100191 China ,Engineering Research Center of Bone and Joint Precision Medicine, Beijing, 100191 China
| | - Guojin Hou
- grid.411642.40000 0004 0605 3760Department of Orthopaedics, Peking University Third Hospital, Beijing, 100191 China ,Engineering Research Center of Bone and Joint Precision Medicine, Beijing, 100191 China
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11
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Strategies for Pertrochanteric Fracture Reduction and Intramedullary Nail Placement: Technical Tips and Tricks. J Am Acad Orthop Surg 2022; 30:867-878. [PMID: 36166383 DOI: 10.5435/jaaos-d-21-01007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 03/30/2022] [Indexed: 02/01/2023] Open
Abstract
The incidence of pertrochanteric hip fractures continues to rise as the aging population expands. Despite advancements in techniques and implants, failure rates remain up to 16% in the literature. The recognition of challenging fracture patterns and the use of meticulous preoperative planning can help to avoid common pitfalls. Understanding fluoroscopic views for reduction assessment and implant placement is instrumental in preventing fixation failure. In addition, adjunctive techniques including the use of a bone hook, cerclage wire, and colinear clamps can facilitate reduction efforts. It is imperative for the surgeon to recognize common pitfalls and to consider a wide array of techniques to manage these challenging and common fractures.
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12
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Tips and tricks to avoid implant failure in proximal femur fractures treated with cephalomedullary nails: a review of the literature. OTA Int 2022; 5:e191. [PMID: 35949270 PMCID: PMC9359031 DOI: 10.1097/oi9.0000000000000191] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 12/18/2021] [Indexed: 11/27/2022]
Abstract
Objective: To describe the surgical aspects potentially contributing to hardware failure of cephalomedullary nails. Data Sources: A search of the Embase, PubMed (MEDLINE), Web of Science, and the Cochrane library for reports of hardware failures after intramedullary fixation of proximal femur fractures. Issues of cut out and cut through phenomena related to technique were excluded. Expert opinion of 3 surgeons, each trained on several fixation systems at Level | trauma centers is reported. Data Extraction: Three authors extracted data using a predesigned form. Implant type, reported failure mechanism, and associated factors with implant failure were recorded as well as potential bias. Results: Of 2182 search results screened, 64 articles were deemed relevant for our research question and were included. The authors identified factors associated with implant failure: preoperative patient and fracture characteristics, intraoperative reduction, implant handling, and postoperative nonunion. Issues were identified as independent modifiable intraoperative risk factors: inadequate fracture reduction, varus position of femoral neck, direct damage of the cephalomedullary nail aperture by eccentric drilling related to guide sleeve handling, and implant design mechanism failures. Conclusions: Multiple factors associated with intraoperative handling can influence the healing of proximal femur fractures. Although many of these have been well described and are taught in fracture courses, surgeons should be aware of subtle intraoperative complications reported in the literature that can weaken implants and add to the likelihood of early failure. Level of Evidence: IV
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Song H, Chang SM, Hu SJ, Du SC. Low filling ratio of the distal nail segment to the medullary canal is a risk factor for loss of anteromedial cortical support: a case control study. J Orthop Surg Res 2022; 17:27. [PMID: 35033125 PMCID: PMC8760759 DOI: 10.1186/s13018-022-02921-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 01/06/2022] [Indexed: 11/23/2022] Open
Abstract
Background Anteromedial cortical support apposition (positive and/or neutral cortical relations) is crucial for surgical stability reconstruction in the treatment of trochanteric femur fractures. However, the loss of fracture reduction is frequent in follow-ups after cephalomedullary nail fixation. This paper aimed to investigate the possible predictive risk factors for postoperative loss of anteromedial cortex buttress after nail fixation. Methods A retrospective analysis of 122 patients with AO/OTA 31A1 and A2 trochanteric femur fractures treated with cephalomedullary nails between January 2017 and December 2019 was performed. The patients were classified into two groups according to the postoperative status of the anteromedial cortical apposition in 3D CT images: Group 1 with contact “yes” (positive or anatomic) and Group 2 with contact “No” (negative, loss of contact). The fracture reduction quality score, tip-apex distance (TAD), calcar-referenced TAD (Cal-TAD), Parker ratio, neck-shaft angle (NSA), and the filling ratio of the distal nail segment to medullary canal diameter in anteroposterior (AP) and lateral fluoroscopies (taken immediately after the operation) were examined in univariate and multivariate analyses. Mechanical complications were measured and compared in follow-up radiographs. Results According to the postoperative 3D CT, 84 individuals (69%) were categorized into Group 1, and 38 individuals (31%) were classified as Group 2. The multivariate logistic regression analysis showed that the poor fracture reduction quality score (P < 0.001) and decreasing filling ratio in the lateral view (P < 0.001) were significant risk factors for the loss of anteromedial cortical contact. The threshold value for the distal nail filling ratio in lateral fluoroscopy predicting fracture reduction re-displacement was found to be 53%, with 89.3% sensitivity and 78.9% specificity. The mechanical complication (varus and over lateral sliding) rate was higher in Group 2. Conclusions The fracture reduction quality score and the decreasing filling ratio of the distal nail to the medullary canal in the lateral view (a novel parameter causing pendulum-like movement of the nail) were possible risk factors for postoperative loss of anteromedial cortical support.
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Affiliation(s)
- Hui Song
- Department of Orthopaedic Surgery, Yangpu Hospital, School of Medicine, Tongji University, 450 Tengyue Road, Shanghai, 200090, China
| | - Shi-Min Chang
- Department of Orthopaedic Surgery, Yangpu Hospital, School of Medicine, Tongji University, 450 Tengyue Road, Shanghai, 200090, China.
| | - Sun-Jun Hu
- Department of Orthopaedic Surgery, Yangpu Hospital, School of Medicine, Tongji University, 450 Tengyue Road, Shanghai, 200090, China
| | - Shou-Chao Du
- Department of Orthopaedic Surgery, Yangpu Hospital, School of Medicine, Tongji University, 450 Tengyue Road, Shanghai, 200090, China
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Vatsya P, Mittal S, Gupta A, Trikha V. Is a double cerclage technique for lesser trochanter in fixation of hip fractures really helpful? Injury 2021; 52:3550. [PMID: 33127077 DOI: 10.1016/j.injury.2020.10.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 10/11/2020] [Indexed: 02/02/2023]
Affiliation(s)
- Pulak Vatsya
- Department of Orthopaedics, JPNATC, AIIMS, New Delhi, India
| | - Samarth Mittal
- Department of Orthopaedics, JPNATC, AIIMS, New Delhi, India.
| | - Anupam Gupta
- Department of Orthopaedics, JPNATC, AIIMS, New Delhi, India
| | - Vivek Trikha
- Department of Orthopaedics, JPNATC, AIIMS, New Delhi, India
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15
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Comparison of sliding distance of lag screw and nonunion rate according to anteromedial cortical support in intertrochanteric fracture fixation: A systematic review and meta-analysis. Injury 2021; 52:2787-2794. [PMID: 34417003 DOI: 10.1016/j.injury.2021.08.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 07/07/2021] [Accepted: 08/05/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION We compared the sliding distance of the lag screw, change in neck-shaft angle (NSA), and nonunion rates according to the anteromedial cortical support on anteroposterior (AP) and lateral view radiographs post intertrochanteric fracture reduction. MATERIAL AND METHODS In this systematic review and meta-analysis, MEDLINE, Embase, and Cochrane Library databases were searched systematically for studies published before September 26, 2020. We performed synthetic analyses of the amount of lag screw sliding, change in NSA, and incidence of nonunion following reduction of intertrochanteric fractures by extramedullary reduction (EMR), neutral reduction (NR), and intramedullary reduction (IMR). The combined data of EMR and NR comprised the non-IMR group. RESULTS Our study enrolled eight studies, representing 1,363 patients who underwent surgery for intertrochanteric fractures. A pooled analysis showed a larger sliding distance in the IMR group than in the non-IMR group (standard mean difference [SMD] = 1.47, 95% confidence interval [CI]: 0.73-2.20; P < 0.0001 and SMD = 1.27, 95% CI: 0.56-1.99; P = 0.0005, respectively) in both AP and lateral views. The pooled mean difference of change in NSA in the IMR group was -3.11° and differed significantly from that of the non-IMR group (95% CI: -4.07 to -2.16; P < 0.0001). In the lateral view, the nonunion rate was significantly higher in the IMR group than in the non-IMR group (odds ratio [OR] = 11.61; 95% CI, 3.32-40.62; P = 0.0001). In the subgroup analysis, the NR group showed a larger sliding distance than that of the EMR group in the AP view (SMD = 0.40, 95% CI: 0.04-0.76; P = 0.03); however, the reverse was true in the lateral view (SMD = 0.68, 95% CI: 0.38-0.97; P < 0.00001). CONCLUSION In the current meta-analysis, larger sliding distances, more varus in NSA, and higher nonunion rates were observed in the IMR group than the non-IMR group, in both AP and lateral views. However, in the comparison between EMR and NR, it was difficult to conclude which of them was the ideal reduction method because of inconsistent results.
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Kim CH, Kim HS, Moon DH. Additional Reduction Screw Fixation Technique for Pertrochanteric Hip Fractures: A Novel Method to Prevent Excessive Sliding in Cephalomedullary Nail Surgery. Hip Pelvis 2021; 33:162-166. [PMID: 34552894 PMCID: PMC8440134 DOI: 10.5371/hp.2021.33.3.162] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 03/31/2021] [Accepted: 04/01/2021] [Indexed: 11/24/2022] Open
Abstract
Extramedullary (EM) reduction, defined as the medial cortex of the head-neck fragment located outside the medullary canal of the distal shaft fragment, has been introduced to prevent excessive postoperative sliding or failure of the lag screw in pertrochanteric fracture surgeries. Favorable EM reduction results have recently been reported in several clinical and biomechanical studies. Despite these efforts, maintaining the head-neck fragment in an EM position is periodically a difficult and challenging problem. Herein, the technique for reduction and maintenance of the head-neck fragment was introduced in an EM position using a Kirschner wire and partially threaded cannulated screw fixation via screw fixation from EM to the head-neck fragment, which was positioned inferior to the lag screw on the femoral calcar, also called the reduction screw. The authors utilized this reduction screw in 34 pertrochanteric fracture surgeries using a cephalomedullary nail and fracture union was acheive in all cases by a minimum one-year follow-up period without surgical complications.
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Affiliation(s)
- Chul-Ho Kim
- Department of Orthopedic Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Han Soul Kim
- Department of Orthopedic Surgery, Gachon University Gil Medical Center, Incheon, Korea
| | - Dou Hyun Moon
- Department of Orthopedic Surgery, Gachon University Gil Medical Center, Incheon, Korea
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17
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Effect of Fracture Reduction with Different Medial Cortical Support on Stability After Cephalomedullary Nail Fixation of Unstable Pertrochanteric Fractures: A Biomechanical Analysis. Indian J Orthop 2021; 56:34-40. [PMID: 35070140 PMCID: PMC8748581 DOI: 10.1007/s43465-021-00443-0] [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: 02/24/2021] [Accepted: 06/11/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND This study evaluated the biomechanics of the proximal femoral nail antirotation-II (PFNA-II) in AO/OTA 31A2.2 intertrochanteric fractures based on the fracture reduction quality. METHODS Unstable intertrochanteric fractures were created according to the AO classification and repaired by proximal femoral nail antirotation-II (PFNA-II) using one of three medial cortical support groups. The specimens were tested using cyclic axial loading. The following parameters were recorded: force and stiffness at failure, maximum vertical and horizontal displacement, neck-shaft angle, and location and patten of failure. RESULTS In the cyclic loading test, the force at failure in the anatomical reduction (AR) group was greater than that of the positive medial cortical support (PMCS) group (984.22 ± 12.63 vs. 936.95 ± 16.78) N (P < 0.05) and negative medial cortical support (NMCS) group (918.04 ± 28.86) N (P < 0.05). The stiffness in the AR group was 4.77 and 31.9% higher than that in the PMCS group (P > 0.05) and NMCS group (P < 0.05). The maximum vertical displacement was the largest in the NMCS group. The maximum horizontal displacement in the NMCS group was 28.6 and 19.1% larger than that in the AR group (P > 0.05) and PMCS group (P < 0.05). The neck-shaft angle in the NMCS group was smaller than that in the anatomic reduction group (P < 0.05) and positive support group (P < 0.05). CONCLUSION For the unstable AO/OTA 31A2.2 intertrochanteric fracture, there were significant differences in their mechanical stability among AR, PMCS and NMCS. The NMCS is not recommended during the intraoperative reduction.
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Yamamoto N, Imaizumi T, Noda T, Inoue T, Kawasaki K, Ozaki T. Postoperative computed tomography assessment of anteromedial cortex reduction is a predictor for reoperation after intramedullary nail fixation for pertrochanteric fractures. Eur J Trauma Emerg Surg 2021; 48:1437-1444. [PMID: 34057554 DOI: 10.1007/s00068-021-01718-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 05/26/2021] [Indexed: 12/20/2022]
Abstract
PURPOSE Postoperative radiographs are routinely used to assess fracture reduction following intramedullary nail fixation for pertrochanteric fractures, even though computed tomography (CT) is a superior modality. We aimed to determine the association between reduction quality assessed by CT and rates of reoperation and to evaluate the association of reoperation and reduction quality according to the assessment modality (plain radiographs vs. CT). METHODS A retrospective analysis of 299 consecutive patients treated with intramedullary nail fixation for pertrochanteric fractures was conducted. Fracture reduction measured by postoperative radiographs and CT was categorized as anatomical type, extramedullary type, or intramedullary type. Postoperative data for analysis included reduction status, tip-apex distance (TAD), screw position in the femoral head, sliding distance, and conditions associated with reoperation. RESULTS Of the 299 patients included with a mean age of 83.1 ± 8.2 years, there were six patients who required reoperation (2.0%). According to the CT assessments, there were 42 intramedullary reductions (14.0%). Patients with a non-intramedullary reduction based on postoperative CT images were significantly more likely to have proper placement of the screw, a reduced TAD, a reduced sliding distance, and a lower reoperation rate than those with an intramedullary reduction (P < 0.05). The reduction quality assessed by postoperative CT was significantly associated with reoperation (95% CI, 1.45-29.31). CONCLUSIONS Intramedullary reduction assessed by CT was associated with reoperation. The reduction quality based on CT findings was more predictive for reoperation than that from plain radiographs.
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Affiliation(s)
- Norio Yamamoto
- Department of Orthopedic Surgery, Kagawa Prefectural Central Hospital, 1-2-1, Asahi-machi, Takamatsu, Kagawa, 760-8557, Japan.
| | - Takahiro Imaizumi
- Department of Orthopedic Surgery, Kagawa Prefectural Central Hospital, 1-2-1, Asahi-machi, Takamatsu, Kagawa, 760-8557, Japan
| | - Tomoyuki Noda
- Department of Orthopedic Surgery, Kagawa Prefectural Central Hospital, 1-2-1, Asahi-machi, Takamatsu, Kagawa, 760-8557, Japan
| | - Tomoo Inoue
- Department of Orthopedic Surgery, Kagawa Prefectural Central Hospital, 1-2-1, Asahi-machi, Takamatsu, Kagawa, 760-8557, Japan
| | - Keisuke Kawasaki
- Department of Orthopedic Surgery, Kagawa Prefectural Central Hospital, 1-2-1, Asahi-machi, Takamatsu, Kagawa, 760-8557, Japan
| | - Toshifumi Ozaki
- Department of Orthopedic Surgery, Kagawa Prefectural Central Hospital, 1-2-1, Asahi-machi, Takamatsu, Kagawa, 760-8557, Japan
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Marmor M, Guenthner G, Rezaei A, Saam M, Matityahu A. Reporting on quality of reduction and fixation of intertrochanteric fractures-A systematic review. Injury 2021; 52:324-329. [PMID: 33612251 DOI: 10.1016/j.injury.2021.02.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 02/04/2021] [Accepted: 02/06/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Patient outcomes after intertrochanteric fracture fixation is the subject of a large body of published and ongoing clinical research. Fracture reduction and stable fixation are a pre-requisite for achieving optimal results. However, reporting on the quality of postoperative reduction and fixation, has been inconsistent in the literature on intertrochanteric fractures. The purpose of this study was to examine the quality and consistency of reporting of immediate postoperative reduction and fixation in clinical outcome studies of intertrochanteric fracture fixation. METHODS Outcome studies of intertrochanteric fractures, published between 2001 and 2019, were identified using a PubMed. Six journals were identified as having a high impact on intertrochanteric fracture research by either having an impact factor greater than 3.0 or more than 30 published studies fulfilling inclusion criteria. Two independent reviewers reviewed each article for its reporting on immediate post-operative radiographic findings and whether an attempt was made to correlate these findings to outcomes. Quality and consistency of reduction reporting were assessed by recording the type and number of uniquely reported reduction metrics in all of the included studies. RESULTS The reviewers identified 134 papers for the study, of which 110 (82%) reported on immediate postoperative radiographic findings. Of the papers reporting these findings, 84 (76%) reported quantitative measurements. Quantitative reporting changed from 79% in papers published between 2001-2014 to 86% in papers published between 2015-2019. Sixty-one (46%) papers reported Tip-Apex Distance, 56 (42%) reported degree of varus (compared to non-injured side), 42 (31%) reported Neck-Shaft Angle restoration, 31(23%) reported leg-length discrepancy, 18 (13%) reported rotation, 15(11%) reported on the status of the lateral wall, and 6 (4%) reported on calcar (medial buttress) reduction. Sixty-eight (51%) papers that measured reduction found an association between better immediate post-operative reduction and improved outcomes. CONCLUSIONS Despite its recognized influence on outcomes of intertrochanteric fractures, leading peer-reviewed journals do not uniformly report on the immediate postoperative assessment of the quality of reduction and fixation. However, reporting has improved over the past five years. Standardized quantitative metrics will need to be reported in the future to allow meaningful comparisons between studies and accurate assessment of intertrochanteric fracture outcome.
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Affiliation(s)
- Meir Marmor
- Orthopaedic Trauma Institute (OTI), San Francisco General Hospital, University of California, San Francisco (UCSF), 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA 94110, USA.
| | - Guy Guenthner
- University of Minnesota Medical School, 420 Delaware Street Southeast, Minneapolis, MN 55455, USA
| | - Arash Rezaei
- University of Illinois-Chicago Department of Orthopaedics, 1801 West Taylor Street, Suite 2A, Chicago, IL 60612, USA
| | - Morshed Saam
- Orthopaedic Trauma Institute (OTI), San Francisco General Hospital, University of California, San Francisco (UCSF), 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA 94110, USA
| | - Amir Matityahu
- Orthopaedic Trauma Institute (OTI), San Francisco General Hospital, University of California, San Francisco (UCSF), 2550 23rd Street, Building 9, 2nd Floor, San Francisco, CA 94110, USA
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Yamamoto N, Tamura R, Inoue T, Noda T, Nagano H, Ozaki T. Radiological findings and outcomes of anterior wall fractures in pertrochanteric fractures. J Orthop Sci 2021; 26:247-253. [PMID: 32241602 DOI: 10.1016/j.jos.2020.02.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 02/18/2020] [Indexed: 10/24/2022]
Abstract
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.
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Affiliation(s)
- Norio Yamamoto
- Department of Orthopaedic Surgery, Unnan City Hospital, Shimane, Japan.
| | - Ryu Tamura
- Department of Orthopaedic Surgery, Kochi Health Sciences Center, Kochi, Japan
| | - Tomoo Inoue
- Department of Orthopaedic Surgery, Kagawa Prefectural Central Hospital, Kagawa, Japan
| | - Tomoyuki Noda
- Department of Musculoskeletal Traumatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hiroshi Nagano
- Department of Orthopaedic Surgery, Kagawa Prefectural Central Hospital, Kagawa, Japan
| | - Toshifumi Ozaki
- Department of Orthopaedic Surgery, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
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Kawamura T, Minehara H, Tazawa R, Matsuura T, Sakai R, Takaso M. Biomechanical Evaluation of Extramedullary Versus Intramedullary Reduction in Unstable Femoral Trochanteric Fractures. Geriatr Orthop Surg Rehabil 2021; 12:2151459321998611. [PMID: 33717634 PMCID: PMC7917859 DOI: 10.1177/2151459321998611] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 01/27/2021] [Accepted: 02/06/2021] [Indexed: 11/16/2022] Open
Abstract
Introduction: The failure rate of operations involving the cephalomedullary nail technique for unstable femoral trochanteric fractures is 3-12%. Changing the reduction strategy may improve the stability. This study aimed to confirm whether reducing the proximal fragment with the medial calcar contact, as opposed to utilizing an intramedullary reduction, would improve the stability of such fractures. Materials and Methods: The unstable femoral trochanteric fracture model was created with fixation by cephalomedullary nails in 22 imitation bones. The 2 reduction patterns were as follows: one was with the proximal head-neck fragment external to the distal bone in the frontal plane and anterior in the sagittal plane as “Extramedullary,” while the other was the opposite reduction position, that is, bone in the frontal plane and sagittal plane as “Intramedullary.” We evaluated the tip-apex distance, compression stiffness, change in femoral neck-shaft angle, amount of blade telescoping, and diameter of the distal screw hole after the compression test. Statistical analysis was conducted using the Mann-Whitney U test. Results: No significant differences were seen in compression stiffness (p = 0.804) and femoral neck-shaft angle change (p = 0.644). Although the “Extramedullary” tip-apex distance was larger than the “Intramedullary” distance (p = 0.001), it indicated clinically acceptable lengths. The amount of blade telescoping and the distal screw hole diameter were significantly larger in “Intramedullary” than in “Extramedullary” (p < 0.001, p = 0.019, respectively). Our results showed that “Intramedullary” had significantly larger blade telescoping and distal screw hole diameters than “Extramedullary,” and contrary to our hypothesis, no significant differences were seen in compression stiffness and femoral neck-shaft angle change. Conclusions: As opposed to the “Intramedullary” reduction pattern, the biomechanical properties of the “Extramedullary” reduction pattern improved stability during testing and decreased sliding.
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Affiliation(s)
- Tadashi Kawamura
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, Minami-ku, Sagamihara, Kanagawa, Japan
| | - Hiroaki Minehara
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, Minami-ku, Sagamihara, Kanagawa, Japan
| | - Ryo Tazawa
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, Minami-ku, Sagamihara, Kanagawa, Japan
| | - Terumasa Matsuura
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, Minami-ku, Sagamihara, Kanagawa, Japan
| | - Rina Sakai
- Department of Medical Engineering and Technology, Kitasato University, Minami-ku, Sagamihara, Kanagawa, Japan
| | - Masashi Takaso
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, Minami-ku, Sagamihara, Kanagawa, Japan
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Buruian A, Silva Gomes F, Roseiro T, Vale C, Carvalho A, Seiça E, Mendes A, Pereira C. Distal interlocking for short trochanteric nails: static, dynamic or no locking? Review of the literature and decision algorithm. EFORT Open Rev 2020; 5:421-429. [PMID: 32818069 PMCID: PMC7407850 DOI: 10.1302/2058-5241.5.190045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Pertrochanteric hip fractures are among the most common and the use of short cephalomedullary nails as the treatment of choice is increasing. A systematic review regarding distal locking options for short cephalomedullary nails was undertaken using Medline/PubMed®, Embase® and Cochrane Library® in order to evaluate current indications, associated complications and to provide treatment recommendations. The results seem to support the use of distal static locking for unstable fractures, dynamic locking for length stable/rotational unstable fractures and no locking for stable fractures. Complications associated with distal locking include iatrogenic fractures, thigh pain, delayed union and nonunion, implant failure, screw loosening and breaking, drill bit breaking, soft tissue irritation, femoral artery branch injury, intramuscular haematoma and compartment syndrome. It is also associated with longer operative time and radiation exposure. In unlocked constructs, dorsomedial comminution and nail/medullary canal mismatch contribute to peri-implant fractures. Anterior cortical impingement is associated with cut-out and nonunion. Most studies comparing distally locked and unlocked nails report a short follow-up. Distal locking mode should be based on the fracture’s stability.
Cite this article: EFORT Open Rev 2020;5:421-429. DOI: 10.1302/2058-5241.5.190045
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Affiliation(s)
- Alexei Buruian
- Hospital Distrital da Figueira da Foz, Figueira Da Foz, Portugal
| | | | - Tiago Roseiro
- Hospital Distrital da Figueira da Foz, Figueira Da Foz, Portugal
| | - Claudia Vale
- Hospital Distrital da Figueira da Foz, Figueira Da Foz, Portugal
| | - André Carvalho
- Hospital Distrital da Figueira da Foz, Figueira Da Foz, Portugal
| | - Emanuel Seiça
- Hospital Distrital da Figueira da Foz, Figueira Da Foz, Portugal
| | - Antonio Mendes
- Hospital Distrital da Figueira da Foz, Figueira Da Foz, Portugal
| | - Carlos Pereira
- Hospital Distrital da Figueira da Foz, Figueira Da Foz, Portugal
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Kim KH, Kang MS, Lim EJ, Park ML, Kim JJ. Posterior Sagging After Cephalomedullary Nailing for Intertrochanteric Femur Fracture is Associated with a Separation of the Greater Trochanter. Geriatr Orthop Surg Rehabil 2020; 11:2151459320946013. [PMID: 32821469 PMCID: PMC7412896 DOI: 10.1177/2151459320946013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 06/12/2020] [Accepted: 07/07/2020] [Indexed: 11/21/2022] Open
Abstract
Introduction: Cephalomedullary nailing presents several biomechanical benefits for treatment of intertrochanteric fractures, but posterior sagging (PS) of the proximal fragment occurs postoperatively in some patients despite intraoperative achievement of an adequate reduction. We investigated the risk factors for PS in those patients, with specific attention to posterior split fragment involving the greater trochanter (GT separation) as a possible significant risk factor. Methods: We retrospectively reviewed 50 (12 males, 38 females) patients ≥50 years old at diagnosis of an intertrochanteric fracture after low-energy trauma who underwent cephalomedullary nailing between April 2015 and February 2017 and were not lost to follow-up within 12 months postoperatively. Results: Thirteen (26%) patients experienced PS postoperatively. Average time to bone union was significantly longer in the PS (9.5 months) than in the non-PS (4.8 months) groups (P = .002). Three patients in the PS group experienced nonunion compared to none in the non-PS group (P = .015). Significant difference was found in postoperative level of ambulatory ability (Koval score) and deterioration of the score after the injury between 2 groups (4.2 vs 2.8, P = .043 and 2.5 vs 0.8, P = .005). On multivariate logistic regression analysis, GT separation (P = .010) was a significant risk factor for PS. Discussion and Conclusion: The presence of GT separation in cases of intertrochanteric fractures seems to weaken posterior stability in the proximal fragment, thus showing poor clinical outcomes.
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Affiliation(s)
- Keong-Hwan Kim
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, Republic of Korea.,Department of Orthopaedic Surgery, Kangwon National University Hospital, Chuncheon-Si, Gangwon-Do, Republic of Korea
| | - Michael Seungcheol Kang
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, Republic of Korea
| | - Eic Ju Lim
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, Republic of Korea
| | - Mi Lan Park
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, Republic of Korea
| | - Jung Jae Kim
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, Republic of Korea
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Matsumura T, Takahashi T, Nakashima M, Nibe Y, Takeshita K. Clinical Outcome of Mid-Length Proximal Femoral Nail for Patients With Trochanteric Hip Fractures: Preliminary Investigation in a Japanese Cohort of Patients More Than 70 Years Old. Geriatr Orthop Surg Rehabil 2020; 11:2151459320936444. [PMID: 32637198 PMCID: PMC7315652 DOI: 10.1177/2151459320936444] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 05/16/2020] [Accepted: 05/19/2020] [Indexed: 11/16/2022] Open
Abstract
Introduction: The TFN-ADVANCED Proximal Femoral Nailing System (TFNA) 235 mm (DePuySynthes) and Proximal Femoral Nail Antirotation (PFNA)-II 240 mm (DePuySynthes) were developed to obtain better stability for patients with trochanteric hip fractures without increasing surgical time and amount of blood loss. However, there are currently no studies concerning clinical and radiological outcomes of patients treated using these proximal femoral nails (PFNs) that have been performed in the Japanese population. The aim of this study was to retrospectively evaluate the clinical outcomes associated with 235 to 240 mm PFNs for Japanese patients >70 years old with trochanteric hip fractures who could walk independently before the injury. Materials and Methods: This study involved a retrospective analysis of data on trochanteric hip fracture patients who had undergone internal fixation from March 2016 to June 2018. The inclusion criteria were patients >70 years old with trochanteric hip fractures who could walk independently before the injury and were followed up for ≥3 months after surgery. Initially, 124 patients were identified, but 33 of these were excluded because other implants were used for internal fixation. Of the remaining 91 patients in whom PFNs were used at the time of internal fixation who were included for the perioperative evaluation, 66 patients followed up for ≥3 months were included in the clinical evaluations. Results: The average surgical time was 56.8 ± 19.6 minutes (range, 23-123 minutes). The average blood loss was 89 ± 41 mL (range, 0-245 mL). The union rate was 98%. Discussion: There were no cases of nail jamming, and all nails were successfully inserted below the end of the distal isthmus without additional reaming to dilate the canal. Conclusions: Proximal femoral nails were a useful implant in Japanese elderly patients with trochanteric hip fractures and gave comparable clinical outcomes despite the femoral length being short and occurrence of intensive bowing.
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Affiliation(s)
- Tomohiro Matsumura
- Jichi Medical University Hospital Life Saving Emergency Center, Shimotsuke, Japan
| | - Tsuneari Takahashi
- Department of Orthopedic Surgery, School of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Mitsuharu Nakashima
- Department of Orthopedic Surgery, School of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Yoshiya Nibe
- Department of Orthopedic Surgery, School of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Katsushi Takeshita
- Department of Orthopedic Surgery, School of Medicine, Jichi Medical University, Shimotsuke, Japan
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Gamma3 nail with U-Blade (RC) lag screw is effective with better surgical outcomes in trochanteric hip fractures. Sci Rep 2020; 10:6021. [PMID: 32265481 PMCID: PMC7138836 DOI: 10.1038/s41598-020-62980-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 03/19/2020] [Indexed: 11/17/2022] Open
Abstract
The objective of this retrospective study was to investigate the surgical outcomes of AO/OTA 31 A1-3 trochanteric fractures treated with the new-generation Gamma3 nail with U-Blade (RC) lag screw and to analyze the risk factors related to fixation failure. A total of 318 consecutive patients who underwent cephalomedullary nailing using Gamma3 nail with U-Blade lag screw for trochanteric hip fractures between September 2015 and June 2018 were enrolled. The average age was 80 years and most patients (69%) were women. The mean follow-up was 12.2 months with a minimum of 6 months. 309 (97.2%) showed bony union with a mean time to union of 13.5 ± 8.7 weeks. Cut-out occurred in 2 patients (0.6%) and 7 patients showed excessive collapse (≥15 mm) of the proximal fragment. These 9 patients were assigned to the failure group. The presence of a basicervical fracture component and comminution of the anterior cortex on preoperative 3-D CT showed a significant association with fixation failure, including cut-out, although comminution of the anterior cortex was the only independent risk factor for fixation failure on multivariate logistic regression analysis. Gamma3 nail with U-Blade lag screw showed favorable results for trochanteric hip fractures, with low cut-out rate (0.6%). However, more caution is required in treating trochanteric fractures with a basicervical fracture component and anterior cortex comminution even with this nail.
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Yoon YC, Oh CW, Sim JA, Oh JK. Intraoperative assessment of reduction quality during nail fixation of intertrochanteric fractures. Injury 2020; 51:400-406. [PMID: 31727398 DOI: 10.1016/j.injury.2019.10.087] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 10/23/2019] [Accepted: 10/27/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND The quality of intertrochanteric fracture reduction has traditionally been evaluated using simple radiographs. However, subjective intraoperative evaluation and efforts to achieve a perfect reduction are essential for optimal outcomes. This study aimed to establish criteria for the intraoperative assessment of the quality of intertrochanteric fracture reduction and also analyzed postoperative outcomes in terms of reduction quality. METHODS This study included 106 patients who received cephalo-medullary nailing for the treatment of intertrochanteric fractures between March 2012 and May 2016 and were followed-up for at least 1 year. An image intensifier was used intraoperatively to evaluate reduction quality by examining the restoration of anteromedial cortex continuity, and neck-shaft angle and anteversion. Based on the reduction quality, the patients were classified into optimal, acceptable, and unacceptable groups, with intervention provided for the unacceptable group. The need for revision surgery and the degree of blade sliding were assessed, and postoperative outcomes related to implant position were analyzed. RESULTS Over 50% of patients with Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) type 31A2 and A3 fractures were assigned to the unacceptable group after closed reduction (P = 0.006), and 60 cases required additional reduction. Approximately 40% of cases classified as clinically unacceptable required revision, and the rate of sliding was ≥2-fold higher in the unacceptable group than those in the optimal and acceptable groups (P = 0.015), with an average excessive sliding of 9.85 mm. Regarding implant position, cut-out or penetration were observed in cases with superiorly-located blades (P = 0.039). CONCLUSIONS Good outcomes cannot be achieved with traction alone for femoral intertrochanteric fractures. Active management is required because accurate anteromedial cortex reduction, and restoration of neck-shaft angle and anteversion are essential in femoral intertrochanteric fractures.
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Affiliation(s)
- Yong-Cheol Yoon
- Orthopedic Trauma Division, Trauma Center, Gachon University College of Medicine, Namdong-gu, Incheon, Korea
| | - Chang-Wug Oh
- Department of Orthopaedic Surgery, Kyungpook National University Hospital, Chung-gu, Daegu, Korea
| | - Jae-Ang Sim
- Department of Orthopaedic Surgery, Gachon University College of Medicine, Namdong-gu, Incheon, Korea
| | - Jong-Keon Oh
- Department of Orthopaedic Surgery, Korea University College of Medicine, Guro Hospital, Gurodong-gil, Guro-gu, Seoul, Korea.
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Ikuta Y, Nagata Y, Iwasaki Y. Preoperative radiographic features of trochanteric fractures irreducible by closed reduction. Injury 2019; 50:2014-2021. [PMID: 31327460 DOI: 10.1016/j.injury.2019.06.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 06/15/2019] [Accepted: 06/24/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The aim of this study was to clarify the relationship between the preoperative radiographic classification of trochanteric fractures and the success/failure of closed reduction. Identification of irreducible fractures would be important to proceed promptly to direct reduction. PATIENTS AND METHODS Our retrospective analysis included 141 trochanteric fractures, in 122 women and 17 men, with a mean age of 85.7 years (range, 45-101 years). Evans' classification of trochanteric fractures, as modified by Jensen, and the lateral view classification were used, based on preoperative plain radiographs and computed tomography images. Features predictive of irreducible fractures were identified. RESULTS Among the 141 fractures, 16 (11.3%) were irreducible by closed reduction. The position of the proximal fragment, relative to the shaft on lateral view, and the fracture pattern of the lesser and greater trochanters were predictive of the feasibility of obtaining a successful closed reduction. These criteria identified success/failure of closed reduction in 99.3% of cases. CONCLUSION Our findings should be useful for identifying patients in whom closed reduction would be suitable and for avoiding ineffectual manipulation in unsuitable patients.
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Affiliation(s)
- Yasunari Ikuta
- Department of Orthopaedic Surgery, Hiroshima-Nishi Medical Center, Japan; Department of Orthopaedic Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Japan.
| | - Yoshihiko Nagata
- Department of Orthopaedic Surgery, Hiroshima-Nishi Medical Center, Japan
| | - Yoichi Iwasaki
- Department of Orthopaedic Surgery, Hiroshima-Nishi Medical Center, Japan
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Zhang S, Hu S, Du S, Zhang L. [Concept evolution and research progress of stability reconstruction for intertrochanteric fracture]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2019; 33:1203-1209. [PMID: 31544426 DOI: 10.7507/1002-1892.201904148] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Objective To summarize the evolving concept and research progress on stability reconstruction in the surgical treatment of intertrochanteric fracture. Methods Related literature and author's own experience concerning the surgical treatment of intertrochanteric fracture were reviewed and analyzed in terms of fracture pathoanatomy, stable and unstable pattern, adequate and in-adequate reduction, primary and secondary stability, postoperative stability evaluation, and early weight-bearing. Results Intertrochanteric fracture occur at the translational area of cervico-trochanteric junction, which has a nature tendency to varus instability. Fracture reduction quality is the paramount factor and is evaluated by two views, the anteroposterior and lateral Garden alignment and cortex apposition between the head-neck fragment and the femoral shaft. Rather than the posteromedial lesser trochanteric frag ment, the cortical support concept (positive, neutral, negative) emphasizes the reduction of anteromedial cortex to a nonanatomic positive apposition or an "anatomic" neutral apposition in intraoperative fluoroscopy. Postoperative radiographic stability score provides a quantitative assessment for early weight-bearing standing and walking. However, some fractures may lose cortical contact and buttress (negative) during the process of postoperative telescoping and secondary stability. Further studies are needed to elucidate the risk factors such as tilting, swing or rotation of the head-neck fragment, and propose new preventive methods. Conclusion Stability reconstruction of intertrochanteric fracture requires adequate fracture reduction with Garden alignment and anteromedial cortical support apposition, and reliable sustainment by internal fixation implants. Early weight-bearing standing and walking is safe in patients with perfect postoperative stability score.
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Affiliation(s)
- Shimin Zhang
- Department of Orthopedic Surgery, Yangpu Hospital, Tongji University, Shanghai, 200090,
| | - Sunjun Hu
- Department of Orthopedic Surgery, Yangpu Hospital, Tongji University, Shanghai, 200090, P.R.China
| | - Shouchao Du
- Department of Orthopedic Surgery, Yangpu Hospital, Tongji University, Shanghai, 200090, P.R.China
| | - Lizhi Zhang
- Department of Orthopedic Surgery, Yangpu Hospital, Tongji University, Shanghai, 200090, P.R.China
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Tian K, Liu C, Yan J, Fan K, Ma W, Chen K. [Feasibility study of Kirschner wire-fixation-cortical bone technique in treatment of intertrochanteric fracture]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2019; 33:1239-1244. [PMID: 31544432 DOI: 10.7507/1002-1892.201904126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To explore the feasibility and effectiveness of maintaining the reduction of unstable intertrochanteric fractures by Kirschner wire-fixation-cortical bone technique. Methods Forty patients with intertrochanteric fracture [AO/Orthopaedic Trauma Association (AO/OTA) type 31-A2.2] admitted between May 2015 and January 2017 and requiring closed reduction and proximal femoral nail antirotation (PFNA) were randomly divided into trial group (intraoperative Kirschner wire-fixation-cortical bone technique group, 20 cases) and control group (conventional treatment group, 20 cases). There was no significant difference in general data of gender, age, side, body mass index, cause of injury, time from injury to operation between the two groups ( P>0.05). The operation time, intraoperative blood loss, and intraoperative fluoroscopy times of the two groups were recorded; the reduction quality of fracture was observed according to the corresponding relationship between medial and anterior cortex (positive, neutral, and negative support) of intraoperative fluoroscopy proposed by ZHANG Shimin, and the stability of internal fixation and fracture healing were observed; Harris score was used to evaluate the recovery of hip function at 12 months after operation. Results In the trial group, 6 cases (30%) had 2 Kirschner wires implanted less than 4 times, 7 cases (35%) had 5-8 times, and 7 cases (35%) had 9 times or more. There was no significant difference in operation time and intraoperative blood loss between the two groups ( P>0.05), but the blood transfusion volume and intraoperative fluoroscopy times in the trial group were significantly less than those in the control group ( P<0.05). Both groups were followed up 13-21 months, with an average of 17 months. There was no complications such as wound infection, deep venous thrombosis of lower extremities, refracture, and internal fixation-related complications. The quality of intraoperative reduction in the trial group was significantly better than that in the control group ( Z=-2.794, P=0.024). The Harris score of the trial group was significantly better than that of the control group at 12 months after operation ( t=2.98, P=0.01). Conclusion The use of Kirschner wire-fixation-cortical bone technique during intertrochanteric fracture closed reduction and PFNA internal fixation surgery can effectively maintain the reduction effect, reduce the number of fluoroscopy, improve the reduction quality, reduce allogeneic blood input, obtain better hip function, and do not increase the operation time and intraoperative blood loss.
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Affiliation(s)
- Kewei Tian
- No.1 Department of Hip Injury and Disease, Luoyang Orthopedic-Traumatological Hospital of Henan Province (Henan Provincial Orthopedic Hospital), Luoyang Henan, 471000, P.R.China
| | - Chao Liu
- Department of Pelvic Injury and Disease, Luoyang Orthopedic-Traumatological Hospital of Henan Province (Henan Provincial Orthopedic Hospital), Luoyang Henan, 471000, P.R.China
| | - Jiaxiang Yan
- Department of Geriatric Disease, Luoyang No.1 Hospital of Traditional Chinese Medicine, Luoyang Henan, 471000, P.R.China
| | - Kejie Fan
- No.1 Department of Hip Injury and Disease, Luoyang Orthopedic-Traumatological Hospital of Henan Province (Henan Provincial Orthopedic Hospital), Luoyang Henan, 471000, P.R.China
| | - Wenlong Ma
- No.1 Department of Hip Injury and Disease, Luoyang Orthopedic-Traumatological Hospital of Henan Province (Henan Provincial Orthopedic Hospital), Luoyang Henan, 471000, P.R.China
| | - Ke Chen
- No.1 Department of Hip Injury and Disease, Luoyang Orthopedic-Traumatological Hospital of Henan Province (Henan Provincial Orthopedic Hospital), Luoyang Henan, 471000,
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Jung EY, Oh IT, Shim SY, Yoon BH, Sung YB. The Effect of Valgus Reduction on the Position of the Blade of the Proximal Femoral Nail Antirotation in Intertrochanteric Hip Fractures. Clin Orthop Surg 2019; 11:36-42. [PMID: 30838106 PMCID: PMC6389525 DOI: 10.4055/cios.2019.11.1.36] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 10/31/2018] [Indexed: 11/06/2022] Open
Abstract
Background The purpose of this study was to evaluate the quantitative association between the degree of reduction and the position of the blade of the proximal femoral nail antirotation (PFNA) in intertrochanteric hip fractures. Methods From March 2009 to April 2015, 530 patients treated with PFNA for intertrochanteric hip fractures were retrospectively reviewed. Patients were divided into a valgus reduced group (group 1) and a non-valgus reduced group (group 2), and the "valgus reduced" was defined as valgus reduction over 5°. We compared the calcar referenced tip-apex distance (calTAD) and the area between the blade of PFNA and the medial cortex of the femoral neck between the two groups. Results The calTAD was measured as 22.5 ± 4.1 mm in group 1 and 24.8 ± 3.8 mm in group 2 (p < 0.05). The area between the blade and the medial femoral neck was measured as 135.5 ± 49.8 mm2 in group 1 and 145.1 ± 54.8 mm2 in group 2 (p = 0.074). The area corrected for the length difference in the femoral neck was 0.55 ± 0.16 in group 1 and 0.79 ± 0.19 in group 2 (p < 0.05). Conclusions Valgus reduction resulted in less calTAD and inferior position of the blade at the femoral neck in the treatment of intertrochanteric hip fractures with PFNA.
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Affiliation(s)
- Eui Yub Jung
- Department of Orthopedic Surgery, Samsung Medical Center, Seoul, Korea
| | - In Taek Oh
- Department of Orthopedic Surgery, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Sang Yeup Shim
- Department of Orthopedic Surgery, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Byung Ho Yoon
- Department of Orthopedic Surgery, Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Yerl Bo Sung
- Department of Orthopedic Surgery, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
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Kim KH, Han KY, Kim KW, Lee JH, Chung MK. Local Postoperative Complications after Surgery for Intertrochanteric Fractures Using Cephalomedullary Nails. Hip Pelvis 2018; 30:168-174. [PMID: 30202751 PMCID: PMC6123510 DOI: 10.5371/hp.2018.30.3.168] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 07/23/2018] [Accepted: 07/25/2018] [Indexed: 11/24/2022] Open
Abstract
Purpose Cephalomedullary nails (CMN) are commonly used for the surgical treatment of intertrochanteric fractures. This study aimed to evaluate overall postoperative local complications by reviewing patients who received surgical treatment using three different types of implants. Materials and Methods The study sample included 353 patients (107 males, 246 females) who underwent surgery using CMN for intertrochanteric fractures. Three different types of implants were used: i) the Gamma3® (Stryker) in 80 cases, ii) the Targon® PF (Aesculap) in 225 cases, and iii) the Compression Hip Nail® (Trademedics) in 48 cases. The mean age was 82.6 (range, 60–109) years and the average follow-up period was 15 (range, 6–80) months. Postoperative local complications and risk factors of cut-out were assessed. Results The most common complication was cut-out (n=26). Other complications included non-union (n=3), periprosthetic fracture (n=2), avascular necrosis (n=1), heterotopic ossification (n=1), and sleeve pull out (n=1). Multivariate analysis revealed that the cut-out group had a higher rate of poor reduction compared to the non-complicated group (P<0.001). Although the mean tip-apex distance (TAD) was 18.4 mm in the non-complicated group, lower than that of the cut-out group (P=0.001), multivariate analysis revealed that TAD was not a significant risk factor for cut-out (P=0.065). Conclusion Cut-out is the most common local complication associated with surgical treatment of intertrochanteric fractures using CMN. Proper reduction appears to be important in lowering the risk of cut-out. Maintaining low TAD is another critical factor in achieving sufficient fixation of lag screw to the subchondral bone of the femoral head.
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Affiliation(s)
- Keong-Hwan Kim
- Department of Orthopaedic Surgery, Kangwon National University College of Medicine, Chuncheon, Korea
| | - Kye Young Han
- Department of Orthopaedic Surgery, Kangwon National University College of Medicine, Chuncheon, Korea
| | - Keun Woo Kim
- Department of Orthopaedic Surgery, Kangwon National University College of Medicine, Chuncheon, Korea
| | - Jun Hee Lee
- Department of Orthopaedic Surgery, Kangwon National University College of Medicine, Chuncheon, Korea
| | - Myung Ki Chung
- Department of Orthopaedic Surgery, Kangwon National University College of Medicine, Chuncheon, Korea
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Cho MR, Lee JH, Kwon JB, Do JS, Chae SB, Choi WK. The Effect of Positive Medial Cortical Support in Reduction of Pertrochanteric Fractures with Posteromedial Wall Defect Using a Dynamic Hip Screw. Clin Orthop Surg 2018; 10:292-298. [PMID: 30174804 PMCID: PMC6107818 DOI: 10.4055/cios.2018.10.3.292] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Accepted: 05/17/2018] [Indexed: 12/01/2022] Open
Abstract
Background We evaluated the radiological and clinical results of reduction using a dynamic hip screw according to the grade of medial cortical support in patients with AO Foundation and Orthopaedic Trauma Association (AO/OTA) classification type 31-A2 pertrochanteric fractures. Methods We enrolled 100 patients with AO/OTA type 31-A2 fractures with displaced lesser trochanter fragments (length of the cortical area longer than 20 mm on the pelvis anteroposterior view). Patients with positive medial cortical support were assigned to group 1 (n = 28); neutral medial cortical support, group 2 (n = 42); and negative medial cortical support, group 3 (n = 30). Radiological evaluation was done by measuring the change in the femoral neck-shaft angle and sliding distance of the lag screw. Clinical outcomes of each group were compared by means of the walking ability score proposed by Ceder. Results Group 1 showed significantly less changes in the femoral neck-shaft angle and shorter sliding distance than groups 2 and 3. Group 2 showed significantly less changes in the femoral neck-shaft angle and shorter sliding distance than group 3. Group 1 showed significantly higher walking ability scores than group 3 (p = 0.00). The use of trochanter stabilizing plates or fixation using wires for posteromedial wall defect resulted in no significant changes in terms of the femoral neck-shaft angle or sliding distance. Conclusions In the treatment of pertrochanteric fractures accompanied by posteromedial wall defect using a dynamic hip screw, reduction with negative cortical support should be avoided.
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Affiliation(s)
- Myung Rae Cho
- Department of Orthopaedic Surgery, College of Medicine, Daegu Catholic University, Daegu, Korea
| | - Jae Hyuk Lee
- Department of Orthopaedic Surgery, College of Medicine, Daegu Catholic University, Daegu, Korea
| | - Jai Bum Kwon
- Department of Orthopaedic Surgery, College of Medicine, Daegu Catholic University, Daegu, Korea
| | - Jung Suk Do
- Department of Orthopaedic Surgery, College of Medicine, Daegu Catholic University, Daegu, Korea
| | - Seung Bum Chae
- Department of Orthopaedic Surgery, College of Medicine, Daegu Catholic University, Daegu, Korea
| | - Won-Kee Choi
- Department of Orthopaedic Surgery, College of Medicine, Daegu Catholic University, Daegu, Korea
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The Effects of Extramedullary Reduction in Unstable Intertrochanteric Fracture: A Biomechanical Study Using Cadaver Bone. ACTA ACUST UNITED AC 2018. [DOI: 10.12671/jkfs.2018.31.3.79] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Choo SK, Oh HK, Ko HT, Min DU, Kim Y. Effectiveness of controlled telescoping system for lateral hip pain caused by sliding of blade following intramedullary nailing of trochanteric fracture. Injury 2017; 48:2201-2206. [PMID: 28801201 DOI: 10.1016/j.injury.2017.07.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 07/14/2017] [Accepted: 07/24/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The purpose of this study was to demonstrate the effectiveness of controlled telescoping system for lateral hip pain caused by sliding of the blade following intramedullary nailing of trochanteric fractures. MATERIALS AND METHODS A retrospective cohort study was performed to compare the controlled telescoping system (Compression Hip Nail; CHN) with the conventional sliding system (Proximal Femoral Nail Antirotation; PFNA) for trochanteric fractures. 74 cases in the PFNA group and 77 cases in the CHN group were included from two university hospitals in this study. All patients had a minimum of 12-month follow up period. Lateral hip pain was evaluated and operation time and blood loss during the surgery were measured. The fracture classification was evaluated. The quality of postoperative reduction and other complications after surgery were also evaluated and tip-apex distance (TAD), telescoping and lateral protrusion of the blade and lag screw were measured. RESULTS The mean age was 78.5 years in the PFNA group and 74.7 years in the CHN group (p=0.25). The mean telescoping was 19.2mm in the PFNA group and 10.7mm in the CHN group (p<0.001). The mean length of lateral protrusion was 10.5mm in the PFNA group and 2.5mm in the CHN group (p<0.001). Twenty-eight patients in the PFNA group complained of lateral hip pain, whereas 12 patients in the CHN group did (p=0.002). These four variables showed statistically significant differences between the PFNA and CHN groups (p<0.05). The length of lateral protrusion was the only variable significantly related to lateral hip pain through multivariate logistic regression analysis (p=0.045). CONCLUSIONS The degree of lateral protrusion was mainly related to lateral hip pain. Therefore, controlled telescoping would help to decrease lateral hip pain by decreasing the lateral protrusion beyond the lateral femoral cortex.
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Affiliation(s)
- Suk Kyu Choo
- Department of Orthopaedic Surgery, Inje University Ilsan Paik Hospital, Goyang, Republic of Korea
| | - Hyoung-Keun Oh
- Department of Orthopaedic Surgery, Inje University Ilsan Paik Hospital, Goyang, Republic of Korea
| | - Hyeong Tak Ko
- Department of Orthopaedic Surgery, Inje University Ilsan Paik Hospital, Goyang, Republic of Korea
| | - Dong-Uk Min
- Department of Orthopedic Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Republic of Korea
| | - Youngwoo Kim
- Department of Orthopedic Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Republic of Korea.
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Provisional pin fixation can maintain reduction in A3 intertrochanteric fractures. Arch Orthop Trauma Surg 2016; 136:945-55. [PMID: 27245452 DOI: 10.1007/s00402-016-2476-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Indexed: 10/21/2022]
Abstract
A3 intertrochanteric fracture has a higher incidence of intraoperative re-displacement than A1 and 2. The authors have also experienced difficulty with maintenance of reduction in A3 intertrochanteric fractures, as the technique depends on manual effort and can fail easily during the procedure. It induced us to develop this surgical technique to ease the surgical procedure and improve clinical outcomes. This paper introduces a modified provisional guide pin fixation technique applicable to even AO/OTA A3 intertrochanteric fractures, and presents preliminary results of 11 patients who were treated by provisional pin fixation-assisted nailing in A3 intertrochanteric fractures. Using this technique, we have reduced the chances of intraoperative reduction loss and achieved favorable clinical outcomes.
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Tsukada S, Wakui M, Yoshizawa H, Miyao M, Honma T. Three-Dimensional Computed Tomographic Analysis for Comminution of Pertrochanteric Femoral Fracture: Comminuted Anterior Cortex as a Predictor of Cutting Out. Open Orthop J 2016; 10:62-70. [PMID: 27347234 PMCID: PMC4897036 DOI: 10.2174/1874325001610010062] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 01/06/2016] [Accepted: 02/04/2016] [Indexed: 11/30/2022] Open
Abstract
Background: Fixed angle sliding hip screw devices allow controlled impaction between the head neck fragment and the femoral shaft fragment in the surgical treatment of pertrochanteric fractures. This study was performed to evaluate the frequency and pattern of comminution at the fracture site, which may prevent the intended impaction. Materials and Methods: Three-dimensional computed tomography was used to investigate 101 pertrochanteric fractures treated with fixed angle sliding hip screw devices, with emphasis on the comminuted cortex. A comminuted fracture was defined as a fracture that had a third fracture fragment at the main fracture line. Results: There were 40 fractures without comminution and 61 with comminution. All 61 comminuted fractures had a comminuted posterior cortex, and 3 of 61 fractures also had comminution at the anterior cortex. The prevalence of cutting out of the implant from the femoral head was significantly higher in cases involving comminution at both the posterior and anterior cortices than in cases involving comminution only at the posterior cortex (66.7 % and 3.4 %, p < 0.0001). Conclusion: The posterior cortex was comminuted in 60.4% of pertrochanteric fractures and the anterior cortex in 3.0%. Intended impaction at the fracture site could not be obtained at any cortex in cases with comminution at both the anterior and posterior cortices; comminution at the anterior cortex may be a predictor of cutting out.
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Affiliation(s)
- Sachiyuki Tsukada
- Department of Orthopaedic Surgery, Nekoyama Miyao Hospital, Niigata, Japan
| | - Motohiro Wakui
- Department of Orthopaedic Surgery, Nekoyama Miyao Hospital, Niigata, Japan
| | - Hiroshi Yoshizawa
- Department of Orthopaedic Surgery, Nekoyama Miyao Hospital, Niigata, Japan
| | - Masunao Miyao
- Department of Orthopaedic Surgery, Nekoyama Miyao Hospital, Niigata, Japan
| | - Takeshi Honma
- Department of Rehabilitation, Nekoyama Miyao Hospital, Niigata, Japan
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Cho WT, Cho JW, Yoon YC, Kim Y, Oh CW, Oh JK. Provisional pin fixation: An efficient alternative to manual maintenance of reduction in nailing of intertrochanteric fractures. Arch Orthop Trauma Surg 2016; 136:55-63. [PMID: 26681185 DOI: 10.1007/s00402-015-2359-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Indexed: 11/26/2022]
Abstract
INTRODUCTION During nailing of intertrochanteric fractures, there is always a risk of reduction loss despite achieving an acceptable reduction status after a percutaneous procedure. Most surgeons usually attempted to maintain the reduction with a manual endeavor. However, we experienced varying amounts of intraoperative reduction loss and had to perform readjustments several times. These struggles motivated us to attempt provisional pin fixation as an alternative method. The purpose of this study was to analyze the factors affecting intraoperative reduction loss, especially in comparison between two methods. MATERIALS AND METHODS Sixty-eight patients with intertrochanteric fractures were included. They were divided into two groups based on the method, by retrospective analysis of the intraoperative c-arm image. In the manual maintenance group, an assistant maintained the instruments during the procedure. In the provisional pin fixation group, the reduction was temporaryily held by a 3.2mm guide pin fixation across the fracture. A displacement of more than one cortical thickness in any plane or angular deformity during any point in the procedure after acceptable reduction was judged as an intraoperative reduction loss. Multivariate logistic regression was used for statistical analysis. RESULTS The number of cases with intraoperative reduction loss was 18 (18 of 38, 46.1%) in the manual maintenance group and 6 (6 of 30, 20.0%) in the provisional pin fixation group. The odds ratio of intraoperative reduction loss in the manual maintenance group was 5.182 (95% confidence interval, 1.455-18.452) compared with the provisional pin fixation group as the reference. CONCLUSIONS As a reasonable approach for maintaining reduction, provisional pin fixation can significantly decrease intraoperative reduction loss after percutaneous reduction of intertrochanteric fractures during nailing.
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Affiliation(s)
- Won-Tae Cho
- Department of Orthopaedic Surgery, Korea University Guro Hospital, 80, Guro-Dong, Guro-Gu, Seoul, 152-703, Republic of Korea.
| | - Jae-Woo Cho
- Department of Orthopaedic Surgery, Korea University Guro Hospital, 80, Guro-Dong, Guro-Gu, Seoul, 152-703, Republic of Korea.
| | - Yong-Cheol Yoon
- Trauma Center, Gachon University Gil Hospital, 21, Namdong-daero 774 beon-gil, Namdong-gu, Incheon, 405-760, Republic of Korea.
| | - Youngwoo Kim
- Department of Orthopedic Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 271, Cheonbo-Ro, Uijeongbu-si, Gyeonggi-do, 480-717, Republic of Korea.
| | - Chang-Wug Oh
- Department of Orthopedic Surgery, Kyungpook National University Hospital, 130 Dongduk-ro, Jung-gu, Daegu, 700-721, Republic of Korea.
| | - Jong-Keon Oh
- Department of Orthopaedic Surgery, Korea University Guro Hospital, 80, Guro-Dong, Guro-Gu, Seoul, 152-703, Republic of Korea.
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Tosounidis TH, Castillo R, Kanakaris NK, Giannoudis PV. Common complications in hip fracture surgery: Tips/tricks and solutions to avoid them. Injury 2015; 46 Suppl 5:S3-11. [PMID: 26298022 DOI: 10.1016/j.injury.2015.08.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Surgical management of hip fractures in elderly people is challenging and complications relating to surgery could be devastating. They often lead to reoperation and revision surgery and can be associated with significantly increased morbidity and mortality. The most common surgical complications after internal fixation of hip fractures include cut-out, nonunion, Z-effect/medial migration, periimplant failure and avascular necrosis. High quality surgical fixation is of outmost importance to avoid surgical complications. This article presents the aetiology, risk factors and incidence of perioperative and post-fracture fixation complications. Technical tips and tricks for a successful fixation as well as the contemporary evidence surrounding the augmentation of osteoporotic bone fixation in internal fixation of hip fractures are discussed.
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Affiliation(s)
- Theodoros H Tosounidis
- Academic Department of Trauma & Orthopaedic Surgery, University of Leeds, Clarendon Wing, Floor A, Great George Street, Leeds General Infirmary, LS1 3EX Leeds, UK; NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, Leeds, West Yorkshire, Leeds LS7 4SA, UK
| | - Raul Castillo
- Academic Department of Trauma & Orthopaedic Surgery, University of Leeds, Clarendon Wing, Floor A, Great George Street, Leeds General Infirmary, LS1 3EX Leeds, UK
| | - Nikolaos K Kanakaris
- Academic Department of Trauma & Orthopaedic Surgery, University of Leeds, Clarendon Wing, Floor A, Great George Street, Leeds General Infirmary, LS1 3EX Leeds, UK
| | - Peter V Giannoudis
- Academic Department of Trauma & Orthopaedic Surgery, University of Leeds, Clarendon Wing, Floor A, Great George Street, Leeds General Infirmary, LS1 3EX Leeds, UK; NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, Leeds, West Yorkshire, Leeds LS7 4SA, UK.
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Gordon M, Berntsson PO, Sjölund E, Demir Y, Hedbeck CJ, Stark A, Sköldenberg O. Loss of offset after pertrochanteric hip fractures affects hip function one year after surgery with a short intramedullary nail. A prospective cohort study. INTERNATIONAL ORTHOPAEDICS 2015; 40:799-806. [DOI: 10.1007/s00264-015-2815-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 05/09/2015] [Indexed: 10/23/2022]
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Short or Long, Locked or Unlocked Nails for Intertrochanteric Fractures. Tech Orthop 2015. [DOI: 10.1097/bto.0000000000000129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Xu Z, Zhang M, Yin J, Ren L, Zeng Y. Redisplacement after reduction with intramedullary nails in surgery of intertrochanteric fracture: cause analysis and preventive measures. Arch Orthop Trauma Surg 2015; 135:751-8. [PMID: 25808352 DOI: 10.1007/s00402-015-2205-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Indexed: 11/26/2022]
Abstract
OBJECTIVE During the implantation of intramedullary nail in surgery of intertrochanteric fracture, the fact that the originally satisfactory reduction may incur redisplacement remains a major concern. In this article, we will analyze the reasons of redisplacement and describe some methods that can improve the quality of reduction. METHODS From January 2012 to October 2014, 67 patients with intertrochanteric fracture were treated using Gamma3 or PFNA system. All the surgical procedures were monitored by fluoroscopy on the AP and lateral views, and the X-ray films were used to evaluate all cases. RESULTS Redisplacement occurred in ten cases intraoperatively. According to the fracture type, re-occurring deformities appeared in 31-A2 and 31-A3 commonly, 6 and 3 cases. We found the redisplacement emerged usually in operative procedure and some manipulations should be taken to obtain an anatomic reduction. CONCLUSIONS When reduction is achieved in the surgery of intertrochanteric fracture, surgeons tend to overlook the occurrence of redisplacement, or not to treat it that has emerged timely. Internal fixation in nonanatomic reduction may increase the likelihood of fixation failure postoperatively. For the importance of accurate reduction of the fracture, once redisplacement occurs during the surgery, some methods or tricks are applicable to it to restore the anatomic reduction.
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Affiliation(s)
- Zhiyang Xu
- Department of Orthopaedics, Chuiyangliu Hospital of Beijing, Beijing, 100022, China,
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Ito J, Takakubo Y, Sasaki K, Sasaki J, Owashi K, Takagi M. Prevention of excessive postoperative sliding of the short femoral nail in femoral trochanteric fractures. Arch Orthop Trauma Surg 2015; 135:651-7. [PMID: 25801809 DOI: 10.1007/s00402-015-2200-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Lag screw cut-out is one of the major postoperative complications on femoral trochanteric fractures. However, precise analyses of excessive sliding and lag screw cut-out were limited. The purpose of this study was to investigate the factors that induce this unfavorable event. METHODS From April 2010 to April 2013, 226 patients were operated in our institute using a short femoral nail. Among them, 177 patients (29 males and 148 females) with a mean age of 84 years (60-97 years), who were followed up >3 months, were included in this study. The postoperative sliding distance, fracture type (AO/OTA classification), tip-apex distance (TAD), reduction pattern in the postoperative X-ray (antero-posterior and lateral views), bone quality (canal flare and cortical indices), walking ability at the time of pre-injury and final follow-up, and complications were investigated retrospectively. RESULTS The mean sliding distance was 3.7 mm, and one cut-out case (0.6 %) was observed. The sliding distance of the AO/OTA 31-A2 fractures was significantly longer than that of the A1 fractures (p < 0.0001). Regarding the reduction pattern, the sliding distance of the intramedullary type was longer than that of the extramedullary and anatomical types in the lateral view (p < 0.01, p < 0.001, respectively). Further, even in the medial and anatomical types, where the reduction patterns are recommended in the antero-posterior view, the sliding distance of the intramedullary type was significantly longer than that of the anatomical type in the lateral view. There was no correlation of bone quality with the sliding distance. CONCLUSIONS Because the sliding distance increased in the intramedullary type in the lateral view of unstable fractures, an accurate reduction in the lateral view at surgery is important, particularly in unstable fractures.
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Affiliation(s)
- Juji Ito
- Department of Orthopaedic Surgery, Nihonkai General Hospital, 30 Akihocho, Sakata, Yamagata, 998-8501, Japan,
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Sharma G, kumar G N K, Yadav S, Lakhotia D, Singh R, Gamanagatti S, Sharma V. Pertrochanteric fractures (AO/OTA 31-A1 and A2) not amenable to closed reduction: causes of irreducibility. Injury 2014; 45:1950-7. [PMID: 25458060 DOI: 10.1016/j.injury.2014.10.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Revised: 09/29/2014] [Accepted: 10/04/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To define the unique radiographic features, operative treatment, and complications of pertrochanteric fractures (AO/OTA 31-A1 and A2) which are not amenable to the usual closed reduction manoeuvres. METHODS During a 2-year period (from August 2011 until December 2013), 212 patients with pertrochanteric fractures were treated at our level I trauma centre. A retrospective review was undertaken to determine which of these fractures were not reducible via the routine closed reduction manoeuvres and required some form of open reduction. These fractures were assessed for radiographic markers of irreducibility, surgical findings, reduction techniques, and perioperative complications. RESULTS Twenty-four patients had fractures, which were not amenable to closed reduction and underwent open reduction. These fractures could be grouped into four patterns. A preoperative CT scan was available for at least two cases of each pattern, which provided further insights into the cause of irreducibility by closed means. These included a variant where the proximal fragment is locked underneath the shaft fragment (3 cases), bisected lesser trochanter with a locked proximal fragment (3 cases), irreducibility due to entrapped posteromedial fragment at the fracture site (6 cases) and a variant where the proximal fragment is flexed passively by the underlying lesser trochanter (12 cases). CONCLUSIONS Pertrochanteric fractures, which are not amenable to closed reduction, are uncommon, but are heralded by unique radiographic features. These patients warrant special consideration in terms of recognition and management. The specific radiographic markers should alert the surgeon to this injury pattern and its related difficulty encountered during closed reduction. Once reduction is achieved, however, these fractures follow an uneventful course.
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Techniques for Pertrochanteric Fracture Reduction Without a Traction Table. Tech Orthop 2014. [DOI: 10.1097/bto.0000000000000068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kim Y, Dheep K, Lee J, Yoon YC, Shon WY, Oh CW, Oh JK. Hook leverage technique for reduction of intertrochanteric fracture. Injury 2014; 45:1006-10. [PMID: 24731692 DOI: 10.1016/j.injury.2014.02.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Revised: 01/22/2014] [Accepted: 02/02/2014] [Indexed: 02/02/2023]
Affiliation(s)
- Youngwoo Kim
- Department of Orthopedic Surgery, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Kunal Dheep
- Department of Orthopedic Surgery, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Jaeheon Lee
- Department of Orthopedic Surgery, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Yong-Cheol Yoon
- Department of Orthopedic Surgery, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Won-Yong Shon
- Department of Orthopedic Surgery, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Chang-Wug Oh
- Department of Orthopedic Surgery, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Jong-Keon Oh
- Department of Orthopedic Surgery, Ajou University School of Medicine, Suwon, Republic of Korea.
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Takigawa N, Moriuchi H, Abe M, Yasui K, Eshiro H, Kinoshita M. Complications and fixation techniques of trochanteric fractures with the TARGON(®) PF. Injury 2014; 45 Suppl 1:S44-8. [PMID: 24252573 DOI: 10.1016/j.injury.2013.10.036] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The purpose of this study was to analyse clinical results of elderly patients with trochanteric fractures that were treated with use of TARGON(®) PF nail. Overall, 494 patients (113 males) were available for this study. On the basis of Jensen classification, there were 76 cases in type I, 164 cases in type II, 70 in type III, 129 in type IV and 55 in type V. (1) Sliding amount of lag screw in relation to the Jensen classification, (2) sliding amount of lag screw according to the Ikuta's classification that categorises the reduction in lateral view in three, Subtype A, Subtype N and Subtype P, (3) sliding amount of lag screw in correlation between Jensen classification and Ikuta's classification and (4) postoperative complications (9 cases; 1.7%) were assessed. Cut-out and back-out cases were seen in 6 cases (1.1%), and these severe complications were evaluated in details. In correlation between Jensen classification and Ikuta's classification, the excessive sliding of lag screw was prominent with the Subtype P, which was preoperatively in Jensen type III or V. Cut-out or back-out cases were caused either from (1) Subtype P that were preoperatively Jensen types III or V, or from (2) the fracture where there was bony defect anteriorly. Therefore, special care must be taken for these types.
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Affiliation(s)
- Naohide Takigawa
- Department of Orthopaedic Surgery, Nishinomiya Kyoritsu Neurosurgical Hospital, Japan.
| | - Hiromitsu Moriuchi
- Department of Orthopaedic Surgery, Nishinomiya Kyoritsu Neurosurgical Hospital, Japan
| | - Muneki Abe
- Department of Orthopaedic Surgery, Nishinomiya Kyoritsu Neurosurgical Hospital, Japan
| | - Kenji Yasui
- Department of Orthopaedic Surgery, Nishinomiya Kyoritsu Neurosurgical Hospital, Japan
| | - Hisako Eshiro
- Department of Orthopaedic Surgery, Nishinomiya Kyoritsu Neurosurgical Hospital, Japan
| | - Mitsuo Kinoshita
- Department of Orthopaedic Surgery, Nishinomiya Kyoritsu Neurosurgical Hospital, Japan
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Abstract
BACKGROUND Internal fixation of OTA type 31-A2 proximal femoral fractures can be performed with either a sliding hip screw and side plate (SHS-P) or a sliding hip screw and intramedullary nail (SHS-IMN). Controversy exists as to which is the best implant for these types of fractures. The primary aim of this study was to investigate the stability of 31-A2 fractures as a function of loss of medial cortical buttress. The secondary aim was to assess the influence of fracture stability on the different internal fixation constructs. METHODS Simulated simple intertrochanteric fractures were made in 12 cadaver proximal femurs. Six fractures were fixed with an SHS-P and 6 with an SHS-IMN. Both implants were instrumented with a strain gauge at the lag screw-nail/plate interface to allow assessment of implant load bearing (ILB). A primary fracture line, in accordance with the 31-A2 OTA classification, was created after which 3 subsequent horizontal osteotomies in 1-cm increments were made across the medial cortex. Compressive loading up to 1050 N was performed after each osteotomy. RESULTS ILB was presented as percentage of maximal ILB. SHS-P constructs increased their load bearing gradually. For SHS-P constructs, ILB was 8.1% ± 1.8% in the intact state, increasing to 49.6% ± 14.0% after the initial intertrochanteric osteotomy (P = 0.0002), 68.7% ± 15.9% after the first medial osteotomy (P = 0.028), and 80.0% ± 15.9% after the second medial osteotomy (P = 0.15). After the first-level medial osteotomy, SHS-IMN constructs reached a plateau in which the implant carried the entire load. CONCLUSIONS Type 31-A2 fractures become increasingly unstable with increased medial comminution (or fragment size). SHS-P constructs were more load sharing than SHS-IMN constructs. These findings may help guide the surgeon in choice of implant for a 31-A2 intertrochanteric fracture, leaning toward SHS-IMN for the more unstable fracture patterns.
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Postoperative stability on lateral radiographs in the surgical treatment of pertrochanteric hip fractures. Arch Orthop Trauma Surg 2012; 132:839-46. [PMID: 22350102 DOI: 10.1007/s00402-012-1484-9] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2011] [Indexed: 11/27/2022]
Abstract
BACKGROUND Fixed-angle sliding hip-screw devices are commonly used to treat pertrochanteric fractures. The controlled impaction between the head and neck fragment and the femoral shaft fragment is crucial. However, the poor quality of fracture reduction can intercept controlled impaction and lead to excessive sliding. We hypothesized that excessive sliding occurs when most of the impaction is placed on the fragile posterior cortex of the fracture site. METHODS This retrospective study included 128 AO/OTA type 31-A1 or 31-A2 fractures treated with fixed-angle sliding hip-screw devices. Cases involving reduced continuity of the anterior cortex at fracture site were defined as Type 1, those involving head and neck fragment anteriorly displaced relative to the femoral shaft fragment as Type 2, and those involving head and neck fragment posteriorly displaced relative to the femoral shaft fragment as Type 3. The extent of postoperative sliding distance of lag screw was measured. RESULTS There were 52 cases of Type 1, 30 of Type 2, and 46 of Type 3, with no differences in patient characteristics between types. The mean ± standard deviation extent of sliding for types 1-3 was 4.5 ± 4.9 mm, 7.8 ± 5.6 mm, and 11.1 ± 6.0 mm, respectively (p < 0.0001). Sliding was significantly greater for Type 3 cases than for Type 1 or 2 (p < 0.0001 and p = 0.044, respectively). CONCLUSIONS Excessive sliding occurs in surgical treatment for pertrochanteric fractures with posterior displacement of the head and neck fragment. In such cases, we recommend appropriate reduction prior to internal fixation.
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Yan SG, Zhao X, Li H, Zheng Q, Li JB, Pan ZJ, Wu HB. Comparison of percutaneous compression plating and short reconstruction nail for treatment of intertrochanteric fracture. Orthop Surg 2012; 3:14-21. [PMID: 22009975 DOI: 10.1111/j.1757-7861.2010.00117.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE To compare percutaneous compression plating (PCCP) with Trigen short reconstruction nail (Trigen SRN) for the treatment of intertrochanteric hip fracture. METHODS Eighty-four patients with intertrochanteric hip fracture admitted to our hospital from January 2007 to June 2008 were included in this retrospective study. Thirty-six patients were treated with PCCP and 48 with Trigen SRN. Information regarding age, surgical time, blood loss, length of follow-up, mortality, fracture impaction, time to union, complications, Harris score and visual analog scale (VAS) were all recorded. RESULTS The mean follow-up time was 16.3 ± 3.2 months (13-19 months). The mean time to achieve radiological fracture healing was 3.6 ± 0.8 and 4.1 ± 1.0 months for the PCCP and Trigen SRN groups, respectively (P= 0.020); the mean Harris hip scores were 78.1 ± 4.8 and 74.1 ± 5.2 (P= 0.001); and the mean fracture impaction was 3.6 ± 2.3 and 3.3 ± 2.6 mm (P= 0.023). There were no statistical differences between the two groups in duration of surgery (P= 0.131) and blood loss (P= 0.268). The amount of nail in the inferior-central quadrants was greater in the PCCP group than in the Trigen SRN group. CONCLUSION PCCP achieves earlier pain release and better fracture reduction than Trigen SRN.
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Affiliation(s)
- Shi-gui Yan
- Department of Orthopaedic Surgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Chun YS, Oh H, Cho YJ, Rhyu KH. Technique and early results of percutaneous reduction of sagittally unstable intertrochateric fractures. Clin Orthop Surg 2011; 3:217-24. [PMID: 21909469 PMCID: PMC3162202 DOI: 10.4055/cios.2011.3.3.217] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2010] [Accepted: 11/14/2010] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND This paper introduces a percutaneous reduction technique using one or two Steinman pin(s) to reduce sagittally unstable intertrochanteric fractures. METHODS A fracture was defined as a sagittally unstable intertrochanteric fracture when posterior sagging of a distal fragment and flexion of the proximal fragment worsens after usual maneuvers for a closed reduction. Of 119 intertrochanteric fractures treated from June 2007 to December 2008, twenty-one hips showed sagittal instability. The sagittal displacement was reduced using a Steinmann pin as a joystick, and stabilized with a nail device. Nineteen hips were followed up for more than one year. The clinical and radiological results were reviewed in 19 hips and compared with those of the remaining cases. RESULTS The demographics were similar in both groups. The mean anesthetic time did not differ. Although the pre-injury and final activity levels were significantly lower in the study group, the degree of recovery was the same. No clinical complications related to this technique were encountered. Radiologically, the reduction was good in all hips in both groups. Union was obtained in all cases without any time differences. CONCLUSIONS This less invasive reduction technique is simple and safe to use for this type of difficult fracture.
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Affiliation(s)
- Young Soo Chun
- Department of Orthopedic Surgery, Kyung Hee University Hospital at Gangdong, Seoul, Korea
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