Less invasive stabilization system (LISS) versus proximal femoral nail anti-rotation (PFNA) in treating proximal femoral fractures: a prospective randomized study

The postoperative prognosis of older intertrochanteric fracture patients as evaluated by the Chang reduction quality criteria

OBJECTIVE

The aim of this study was to investigate the relationship between the Chang reduction quality criteria (CRQC) and the outcome of intertrochanteric fractures in older adults according to follow-up time.

METHODS

This was a retrospective analysis of 389 older adult patients with intertrochanteric fractures treated surgically from January 2019 to June 2021, including 130 males and 259 females aged 84.6 (77.5-89.7) years. Patient survival was determined by telephone as the time between admission to hospital for fracture and death or until the study deadline (June 1, 2022). According to the CRQC, the patients were divided into the Poor, Acceptable, and Excellent groups. Univariate and multivariate Cox proportional hazard models were used to assess the association between CRQC and all-cause mortality in older adult intertrochanteric fractures at 1 year and the total follow-up time. Further subgroup analysis was performed according to different clinical and biological characteristics to improve the accuracy of the results.

RESULTS

The mortality rates were 24.7% and 15.4% at 1 year and the total follow-up time, respectively. Both at one year and the total follow-up time, the mortality of the CRQC-Excellent group was significantly lower than that of the CRQC-Acceptable group (p.adj < 0.05) and the CRQC-Poor group (p.adj < 0.05). After multifactor adjustment, CRQC grades of Acceptable and Poor were independent risk factors affecting the overall and 1-year mortality. In addition, advanced age, ≥ 1 comorbidities, ASA 3 + 4, and prolonged preoperative waiting time were independent risk factors for survival at the total follow-up time. At 1 year, only ASA 3 + 4 and prolonged preoperative waiting time were independent risk factors for survival. Subgroup analysis according to different characteristics at the total follow-up time and at one year showed that in most subgroups, a decrease in the CRQC grade was significantly associated with an increase in all-cause mortality (p for trend < 0.05).

CONCLUSIONS

This study highlights that CRQC grades of Acceptable and Poor are associated with increased all-cause mortality in older adult intertrochanteric fractures. We should attempt to achieve good reduction of these fractures.

Surgical interventions for treating extracapsular hip fractures in older adults: a network meta-analysis

BACKGROUND

Hip fractures are a major healthcare problem, presenting a challenge and burden to individuals and healthcare systems. The number of hip fractures globally is rising. The majority of extracapsular hip fractures are treated surgically.

OBJECTIVES

To assess the relative effects (benefits and harms) of all surgical treatments used in the management of extracapsular hip fractures in older adults, using a network meta-analysis of randomised trials, and to generate a hierarchy of interventions according to their outcomes.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, Web of Science and five other databases in July 2020.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs comparing different treatments for fragility extracapsular hip fractures in older adults. We included internal and external fixation, arthroplasties and non-operative treatment. We excluded studies of hip fractures with specific pathologies other than osteoporosis or resulting from high-energy trauma.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion. One review author completed data extraction which was checked by a second review author. We collected data for three outcomes at different time points: mortality and health-related quality of life (HRQoL) - both reported within 4 months, at 12 months and after 24 months of surgery, and unplanned return to theatre (at end of study follow-up). We performed a network meta-analysis (NMA) with Stata software, using frequentist methods, and calculated the differences between treatments using risk ratios (RRs) and standardised mean differences (SMDs) and their corresponding 95% confidence intervals (CIs). We also performed direct comparisons using the same codes.

MAIN RESULTS

We included 184 studies (160 RCTs and 24 quasi-RCTs) with 26,073 participants with 26,086 extracapsular hip fractures in the review. The mean age in most studies ranged from 60 to 93 years, and 69% were women. After discussion with clinical experts, we selected nine nodes that represented the best balance between clinical plausibility and efficiency of the networks: fixed angle plate (dynamic and static), cephalomedullary nail (short and long), condylocephalic nail, external fixation, hemiarthroplasty, total hip arthroplasty (THA) and non-operative treatment. Seventy-three studies (with 11,126 participants) with data for at least two of these treatments contributed to the NMA. We selected the dynamic fixed angle plate as a reference treatment against which other treatments were compared. This was a common treatment in the networks, providing a clinically appropriate comparison.  We downgraded the certainty of the evidence for serious and very serious risks of bias, and because some of the estimates included the possibility of transitivity owing to the proportion of stable and unstable fractures between treatment comparisons. We also downgraded if we noted evidence of inconsistency in direct or indirect estimates from which the network estimate was derived. Most estimates included the possibility of benefits and harms, and we downgraded the evidence for these treatments for imprecision.  Overall, 20.2% of participants who received the reference treatment had died by 12 months after surgery. We noted no evidence of any differences in mortality at this time point between the treatments compared. Effect estimates of all treatments included plausible benefits as well as harms. Short cephalomedullary nails had the narrowest confidence interval (CI), with 7 fewer deaths (26 fewer to 15 more) per 1000 participants, compared to the reference treatment (risk ratio (RR) 0.97, 95% CI 0.87 to 1.07). THA had the widest CI, with 62 fewer deaths (177 fewer to 610 more) per 1000 participants, compared to the reference treatment (RR 0.69, 95% CI 0.12 to 4.03). The certainty of the evidence for all treatments was low to very low. Although we ranked the treatments, this ranking should be interpreted cautiously because of the imprecision in all the network estimates for these treatments. Overall, 4.3% of participants who received the reference treatment had unplanned return to theatre. Compared to this treatment, we found very low-certainty evidence that 58 more participants (14 to 137 more) per 1000 participants returned to theatre if they were treated with a static fixed angle plate (RR 2.48, 95% CI 1.36 to 4.50), and 91 more participants (37 to 182 more) per 1000 participants returned to theatre if treated with a condylocephalic nail (RR 3.33, 95% CI 1.95 to 5.68). We also found that these treatments were ranked as having the highest probability of unplanned return to theatre. In the remaining treatments, we noted no evidence of any differences in unplanned return to theatre, with effect estimates including benefits as well as harms. The certainty of the evidence for these other treatments ranged from low to very low. We did not use GRADE to assess the certainty of the evidence for early mortality, but our findings were similar to those for 12-month mortality, with no evidence of any differences in treatments when compared to dynamic fixed angle plate. Very few studies reported HRQoL and we were unable to build networks from these studies and perform network meta-analysis.  AUTHORS' CONCLUSIONS: Across the networks, we found that there was considerable variability in the ranking of each treatment such that there was no one outstanding, or subset of outstanding, superior treatments. However, static implants such as condylocephalic nails and static fixed angle plates did yield a higher risk of unplanned return to theatre. We had insufficient evidence to determine the effects of any treatments on HRQoL, and this review includes data for only two outcomes. More detailed pairwise comparisons of some of the included treatments are reported in other Cochrane Reviews in this series. Short cephalomedullary nails versus dynamic fixed angle plates contributed the most evidence to each network, and our findings indicate that there may be no difference between these treatments. These data included people with both stable and unstable extracapsular fractures. At this time, there are too few studies to draw any conclusions regarding the benefits or harms of arthroplasty or external fixation for extracapsular fracture in older adults. Future research could focus on the benefits and harms of arthroplasty interventions compared with internal fixation using a dynamic implant.

Cephalomedullary nails versus extramedullary implants for extracapsular hip fractures in older adults

BACKGROUND

Hip fractures are a major healthcare problem, presenting a substantial challenge and burden to patients, healthcare systems and society. The increased proportion of older adults in the world population means that the absolute number of hip fractures is rising rapidly across the globe. Most hip fractures are treated surgically. This Cochrane Review evaluates evidence for implants used to treat extracapsular hip fractures.

OBJECTIVES

To assess the relative effects of cephalomedullary nails versus extramedullary fixation implants for treating extracapsular hip fractures in older adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, Web of Science, the Cochrane Database of Systematic Reviews, Epistemonikos, ProQuest Dissertations & Theses, and the National Technical Information Service in July 2020. We also searched clinical trials databases, conference proceedings, reference lists of retrieved articles, and conducted backward-citation searches.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs comparing cephalomedullary nails with extramedullary implants for treating fragility extracapsular hip fractures in older adults. We excluded studies in which all or most fractures were caused by a high-energy trauma or specific pathologies other than osteoporosis.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We collected data for seven critical outcomes: performance of activities of daily living (ADL), delirium, functional status, health-related quality of life, mobility, mortality (reported within four months of surgery as 'early mortality'; and reported from four months onwards, with priority given to data at 12 months, as '12 months since surgery'), and unplanned return to theatre for treating a complication resulting directly or indirectly from the primary procedure (such as deep infection or non-union). We assessed the certainty of the evidence for these outcomes using GRADE.  MAIN RESULTS: We included 76 studies (66 RCTs, 10 quasi-RCTs) with a total of 10,979 participants with 10,988 extracapsular hip fractures. The mean ages of participants in the studies ranged from 54 to 85 years; 72% were women. Seventeen studies included unstable trochanteric fractures; three included stable trochanteric fractures only; one included only subtrochanteric fractures; and other studies included a mix of fracture types. More than half of the studies were conducted before 2010. Owing to limitations in the quality of reporting, we could not easily judge whether care pathways in these older studies were comparable to current standards of care. We downgraded the certainty of the outcomes because of high or unclear risk of bias; imprecision (when data were available from insufficient numbers of participants or the confidence interval (CI) was wide); and inconsistency (when we noted substantial levels of statistical heterogeneity or differences between findings when outcomes were reported using other measurement tools). There is probably little or no difference between cephalomedullary nails and extramedullary implants in terms of mortality within four months of surgery (risk ratio (RR) 0.96, 95% CI 0.79 to 1.18; 30 studies, 4603 participants) and at 12 months (RR 0.99, 95% CI 0.90 to 1.08; 47 studies, 7618 participants); this evidence was assessed to be of moderate certainty. We found low-certainty evidence for differences in unplanned return to theatre but this was imprecise and included clinically relevant benefits and harms (RR 1.15, 95% CI 0.89 to 1.50; 50 studies, 8398 participants). The effect estimate for functional status at four months also included clinically relevant benefits and harms; this evidence was derived from only two small studies and was imprecise (standardised mean difference (SMD) 0.02, 95% CI -0.27 to 0.30; 188 participants; low-certainty evidence). Similarly, the estimate for delirium was imprecise (RR 1.22, 95% CI 0.67 to 2.22; 5 studies, 1310 participants; low-certainty evidence). Mobility at four months was reported using different measures (such as the number of people with independent mobility or scores on a mobility scale); findings were not consistent between these measures and we could not be certain of the evidence for this outcome. We were also uncertain of the findings for performance in ADL at four months; we did not pool the data from four studies because of substantial heterogeneity. We found no data for health-related quality of life at four months. Using a cephalomedullary nail in preference to an extramedullary device saves one superficial infection per 303 patients (RR 0.71, 95% CI 0.53 to 0.96; 35 studies, 5087 participants; moderate-certainty evidence) and leads to fewer non-unions (RR 0.55, 95% CI 0.32 to 0.96; 40 studies, 4959 participants; moderate-certainty evidence). However, the risk of intraoperative implant-related fractures was greater with cephalomedullary nails (RR 2.94, 95% CI 1.65 to 5.24; 35 studies, 4872 participants; moderate-certainty evidence), as was the risk of later fractures (RR 3.62, 95% CI 2.07 to 6.33; 46 studies, 7021 participants; moderate-certainty evidence). Cephalomedullary nails caused one additional implant-related fracture per 67 participants. We noted no evidence of a difference in other adverse events related or unrelated to the implant, fracture or both. Subgroup analyses provided no evidence of differences between the length of cephalomedullary nail used, the stability of the fracture, or between newer and older designs of cephalomedullary nail.

AUTHORS' CONCLUSIONS

Extramedullary devices, most commonly the sliding hip screw, yield very similar functional outcomes to cephalomedullary devices in the management of extracapsular fragility hip fractures. There is a reduced risk of infection and non-union with cephalomedullary nails, however there is an increased risk of implant-related fracture that is not attenuated with newer designs. Few studies considered patient-relevant outcomes such as performance of activities of daily living, health-related quality of life, mobility, or delirium. This emphasises the need to include the core outcome set for hip fracture in future RCTs.

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

INTRODUCTION

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Proximal Femoral Non-unions with Implant In Situ Treated by Revision Osteosynthesis: A Real Challenge

Introduction:

Proximal femur fractures non-union with implant failure creates a nightmare for both the surgeon and the patient. Meticulous surgical planning and the correct choice of the implant are essential to achieve success in the revision surgery.

Materials and Methods:

Eleven patients with ununited proximal femur fractures including both intertrochanteric and subtrochanteric fractures who had a failed previous implant were included in the study. Femoral neck nonunions and infected nonunions were excluded from the study. One patient was lost to follow-up.

Results:

One patient was lost to follow-up and out of the remaining ten patients, six were males and four were females. Mean age was 62.2 years (35–74). Union was achieved with mean union time of 10.1 months (9–14). Mean surgical time was 105 min (90–125) and mean blood loss during surgery was 600 ml (350–850). Mean time of revision surgery after the primary index surgery was 20 months (15–30). Mean duration of follow-up was 12.9 months (12-16).

Conclusion:

Revision osteosynthesis in proximal femoral nonunions with implant failure is a real test of surgeons expertise because of the many factors going against like osteoporosis, distorted proximal femur anatomy due to the already present implant resulting in poor bone stock availability. Judicious and appropriate selection of implants is an impeccable factor for fracture union and positive outcome.

Optimal surgical methods to treat intertrochanteric fracture: a Bayesian network meta-analysis based on 36 randomized controlled trials

Background

There are several surgical methods to treat intertrochanteric fracture: dynamic hip screw (DHS), compression hip screw (CHS), percutaneous compression plate (PCCP), Medoff sliding plate, less invasive stabilization system (LISS), Gamma nail, proximal femoral nail (PFN), and proximal femoral nail anti-rotating (PFNA). We therefore conducted a network meta-analysis to compare eight surgical interventions, including DHS, CHS, PCCP, Medoff sliding plate, LISS, Gamma nail, PFN, and PFNA, to provide the optimal surgical intervention for intertrochanteric fracture.

Methods

An electronic search of 4 databases (PubMed, Embase, Cochrane library, and Web of Science) from inception to July 2020. Two or more of the eight surgical interventions, including the DHS, CHS, PCCP, Medoff sliding plate, LISS, Gamma nail, PFN, and PFNA, for intertrochanteric fracture were included. The methodological quality of the included studies was assessed using the Cochrane Collaboration risk of bias (ROB) tool. Network meta-analysis was conducted by using R-3.5.1 software with the help of package “gemtc”. The odd ratios (ORs) with 95% credibility interval (CrI) were used to assess complications and standard mean difference (SMD) with 95% CrI to calculate the continuous outcomes (operative time, intraoperative blood loss, and Harris hip score). Surfaces under the cumulative ranking curves (SUCRA) were used to rank the intervention.

Results

A total of 36 RCTs were included in this study. The results of this network meta-analysis showed that, compared with the CHS and DHS group, PFNA exhibited a beneficial role in reducing the blood loss (SMD, 152.50; 95% CrI, 72.93 to 232.45; and SMD, 184.40; 95% CrI, 132.99 to 235.90, respectively). PFNA achieved the lowest value for the surface under the cumulative ranking curve (SUCRA) for the blood loss (SURCA = 0.072) and highest of Harris hip score (SURCA = 0.912). PCCP may have the lowest probability of the operative time (SURCA = 0.095). There were no significant differences among the eight surgical procedures in complications.

Conclusion

PFNA technique is the optimal treatment method for intertrochanteric fracture. Larger, longitudinal RCTs addressing current limitations, including sources of bias, inconsistency, and imprecision, are needed to provide more robust and consistent evidence.

Procedure for Femoral Intertrochanteric Fractures using the "Three-Finger Method" Assisted by Proximal Femoral Nail Antirotation

Objective

To assess long‐term follow‐up evaluations for the treatment of femoral intertrochanteric fractures with the “three‐finger method” assisted by proximal femoral nail antirotation (PFNA).

Methods

From January 2010 to January 2017, 123 patients were selected and followed for the treatment of femoral intertrochanteric fractures with PFNA assisted by the “three‐finger method” (application of the index finger, middle finger, and ring finger in the process of surgery to assist PFNA). There were 56 male patients and 67 female patients aged 52–93 years with an average age of 75.6 years, and 88 cases were due to a fall and 35 due to a traffic accident injury. The femoral necks were fixed with PFNA assisted by the “three‐finger method” applying the following procedure: traction reduction, determining the incision, inserting the needle, and placing screw. The Harris hip score, postoperative complications, hip pain and function status were statistically analyzed to evaluate the surgical efficacy and to discuss the surgical technique of the “three‐finger method” assisted by PFNA.

Results

According to the Harris scoring criteria, patients were followed for 1, 2, 4, 6, and 8 years, and the good outcomes of patients were recorded. The excellent and good rate of 87% was the highest in the second year of follow‐up. Then, the rate decreased following the eighth year of follow‐up. The excellent and good rate of 82.7% was the lowest. The patients with incisions healed well, there were no instances of fat liquefaction or infection. There were three cases of effusion, the rate was 2.4%. The secretions were cultured, and no bacterial growth was found. After treatment of the wound, it healed, and the spiral blade used for the femoral head did not wear out. There was one case of femoral head necrosis. There was no significant correlation between hip pain and sex and age (P > 0.05), and the function of the hip joint was significantly correlated with the age of the patients (P < 0.05).

Conclusion

The “three‐finger method” in the process of surgery to assist PFNA for the treatment of patients with intertrochanteric fractures of the femur simplified the operation steps, reduced the operation difficulty, shortened the operation time, improved the operation efficiency, and reduced the incidence of postoperative complications.

[Research progress of lateral wall injury of intertrochanteric fracture]

Objective

To summarize the general concept of lateral wall, the causes of lateral wall injury, and surgical strategies in order to improve the understanding of lateral wall and reduce the complications of operation.

Methods

The related literature on lateral wall was extensively reviewed, summarized, and analyzed.

Results

The superior extent of the lateral wall is vastus lateralis ridge and the inferior extent is the intersection between the lateral femoral cortex and a line drawn at a tangent to the inferior femoral neck. The integrity of the lateral wall is important to prevent the failure of fixation and reoperation of intertrochanteric fractures. The main causes of injury are that there is no suitable typing criteria as a guide, the fracture pattern shown by X-ray does not match with the actual situation of the fracture, the type of fracture is special, and the operation is improper. The main treatment is to reconstruct the lateral wall and choose different reconstruction methods according to different fracture patterns.

Conclusion

The lateral wall is very important for the treatment of intertrochanteric fracture. Lateral wall fracture should be internal fixation in order to minimize the risk of reoperation.

Controlled study on Gamma nail and proximal femoral locking plate for unstable intertrochanteric femoral fractures with broken lateral wall

The gamma nail and proximal femoral locking plate (PFLP) are both used for fractures. A controlled study was performed to determine the optimal implant. To assess and analyze the clinical effects of gamma nails and PFLPs for patients with unstable intertrochanteric femoral fractures, specifically with broken lateral walls. Thirty-six patients with unstable intertrochanteric femoral fractures and broken lateral walls were treated with gamma nails or PFLPs and retrospectively studied. The clinical data were compared. Duration of surgery and early full weight-bearing time were significantly longer in the PFLP group compared to the gamma nail group (P < 0.05). However, intraoperative fluoroscopy frequency and total blood loss in the PFLP group were significantly less than those in the gamma nail group (P < 0.05). No significant differences were found in hospitalized days, Parker Palmer mobility scores, Harris hip scores, and complications between the two groups. No difference in hip-functional recovery was found between the gamma nail group and the PFLP group, indicating that both the gamma nail and PFLP were effective for unstable intertrochanteric femoral fractures with a broken lateral wall. However, early weight bearing on the fractures was not encouraged in patients treated with PFLP.

Nail or plate fixation for A3 trochanteric hip fractures: A systematic review of randomised controlled trials

Continuing controversy exists for the choice of implant for treating A3 trochanteric hip fractures so we undertook a systematic review of randomised controlled trials from the year 2000 onwards that have compared an intramedullary nail with an extramedullary fixation implant for the treatment of these fractures. Data on the occurrence of any fracture healing complications was extracted and the results combined to calculate Peto odd ratio. Nine studies involving 370 fractures were identified. Three studies involving 105 fractures compared an intramedullary nail with a static fixation (condylar, blade or locking plate). Plate fixation was associated with a fivefold increase risk of fracture healing complications (19/52(36.6%) versus 4/53(7.5%), odds ratio 0.14, 95% Confidence intervals 0.04-0.45). Six studies involving 265 fractures compared an intramedullary nail with a sliding hip screw. No statistically significant difference was found in the occurrence of facture healing complications between implants (13/137(9.5%) versus 11/128(8.6%) odds ratio 0.28, 95% Confidence intervals 0.50-2.80). Bases on the evidence to date from randomised trials, the use of fixed nail plates for surgical fixation of this type of fracture cannot be justified. Intramedullary nail fixation and the sliding hip screw have comparable fracture healing complication rates.

Risk factors for implant failure after fixation of proximal femoral fractures with fracture of the lateral femoral wall

INTRODUCTION

To investigate potential predictors of implant failure following fixation of proximal femoral fractures with a fracture of the lateral femoral wall.

MATERIALS AND METHODS

Medical records of 99 adult patients who had operative treatment for a proximal femoral fracture with a fracture of the lateral femoral wall between May 2004 and April 2015 were retrospectively analysed to determine factors associated with implant failure. Patients underwent routine surgical procedures for implantation of extramedullary or intramedullary devices. Potential predictors were age, gender, body mass index, comorbidities, type of fracture, reduction method, status of greater and lesser trochanters, course of the lateral fracture line, and presence/absence of a free bone fragment at the junction of the greater trochanter and lateral femoral wall.

RESULTS

Ten (10%) implant failures were identified. Univariate analysis identified a free bone fragment at the junction of the greater trochanter and lateral femoral wall (odds ratio [OR], 21.25; 95% confidence interval [CI], 4.31-104.67; p < 0.001) and a transverse fracture line across the lateral femoral wall (primary or iatrogenic) (OR, 5.36; 95% CI, 1.29-22.30; p = 0.021) as factors associated with implant failure. Using a multivariate model, only a free bone fragment at the junction of the greater trochanter and lateral femoral wall (OR, 16.05; 95% CI, 3.06-84.23; p = 0.001) was a risk factor for implant failure.

CONCLUSIONS

A free bone fragment at the junction of the greater trochanter and lateral femoral wall and a transverse fracture line across the lateral femoral wall are predictors of implant failure in proximal femoral fractures with a fracture of the lateral femoral wall. Integrity of the lateral femoral wall correlates with prognosis of proximal femoral fracture. Lateral femoral wall reconstruction may be required for effective treatment of proximal femoral fractures with a fracture of the lateral femoral wall.

Reverse polyaxial less invasive stabilization systems for treatment of femoral intertrochanteric fractures of the distal femur

INTRODUCTION

The reverse less invasive stabilization system (LISS) for the distal femur remains generally regarded as a safe and satisfactory option for the treatment of unstable proximal femoral fractures. The polyaxial LISS provides a reverse plating technique that leverages the advantages of proximal screws by allowing the adjustable locking screw to be better positioned and providing more reliable fixation on the proximal femur compared with the standard axial LISS. To assess this fixation method, a detailed evaluation of institutional outcomes of femoral intertrochanteric fractures treated with reverse polyaxial LISS was performed.

MATERIALS AND METHODS

A total of 29 patients presenting with femoral intertrochanteric fractures were treated with the reverse polyaxial LISS system between January 2010 and March 2011. Patients were classified into stable and unstable fracture groups according to the Orthopaedic Trauma Association's (OTA) classification. Clinical data, including operative time, blood loss, radiological records and complications, Harris Hip scores and Parker scores, were collected and analyzed.

RESULTS

There were no significant between-group differences in age, sex, or American Society of Anesthesiologists score. Operative time and blood loss were significantly higher in the unstable fracture group compared with the stable fracture group. Four cases of fixation failure, consisting of one case of A2.3, one case of A3.2 and two cases of A3.3, occurred 4-7 m postoperatively.

CONCLUSIONS

Treatment of femoral intertrochanteric fractures with unstable pattern using polyaxial reverse LISS results in high failure rates; therefore, it should not be recommended as a routine alternative method for the treatment of femoral intertrochanteric fractures with unstable pattern.

Proximal Femoral Nail Antirotation Versus Reverse Less Invasive Stabilization System-distal Femur for Treating Proximal Femoral Fractures: A Meta-analysis

The aim of this study was to compare the effectiveness and safety of 2 surgical techniques that are used to treat proximal femoral fractures.A systematic literature search (up to December 2014) was conducted in Medline, Embase, PubMed, and The Cochrane Central Register of Controlled Trials to screen for studies comparing proximal femoral nail antirotation (PFNA) with less invasive stabilization system-distal femur (LISS-DF) for proximal femoral fractures. Two authors independently assessed the methodological quality of the included studies and extracted data. Surgical information and postoperative outcomes were analyzed.A total of 7 studies with 361 patients who satisfied the eligibility criteria included 3 randomized controlled trials and 4 case-controlled trials associated with PFNA versus LISS in treating proximal femoral fractures. Our results demonstrated that there was a significant reduction in hospital stay and time to weight-bearing ambulation and bone healing for PFNA compared with LISS (odds ratio [OR] -1.48, 95% confidence interval [CI] -2.92 to -0.05; OR -7.08, 95% CI -8.32 to -5.84; OR -2.71, 95% CI -4.76 to 0.67). No statistically significant difference was observed between the 2 groups for operative time, blood loss volume, Harris hip score, and incidence of complications.Based on the results of this analysis, we inferred that PFNA is safer and more effective than reverse LISS-DF in patients undergoing osteosynthesis for proximal femoral fractures, and that PFNA is associated with reduced hospital stays and reduced time to weight-bearing ambulation and bone healing. Nonetheless, in certain cases in which PFNA is not suitable due to abnormal structure of the proximal femur or particularly unstable fractures, the LISS plate technique could be a useful alternative.

Lacking evidence for performance of implants used for proximal femoral fractures - A systematic review

INTRODUCTION

Evaluation of the long-term performance of implants used in trauma surgery relies on post-marked clinical studies since no registry based implant assessment exists. The purpose of this study was to evaluate the evidence of performance of implants currently used for treating proximal femoral fractures (PFF) in Denmark.

METHOD

PubMed was searched for clinical studies on primary PFF with follow-up ≥12 months, reporting implant-related failure and evaluating one of following: DHS, CHS, HipLoc, Gamma3, IMHS, InterTan, PFN, PFNA or PTN.

LIMITS

English language and publication date after 1st of January 1990.

RESULTS

All studies were evidence level II or III. 30 publications for SHS were found: 13 of CHS, 15 of DHS and 2 of HipLoc. In total CHS was evaluated in 1110 patients (900 prospectively), DHS in 2486 (567 prospectively) and HipLoc in 251 (all prospectively). Fifty-four publications for nails were found: 13 of Gamma3, 7 of IMHS, 5 of InterTan, 10 of PFN, 24 of PFNA and 0 of PTN. In total Gamma3 was evaluated in 1088 patients (829 prospectively), IMHS in 1543 (210 prospectively), InterTan in 595 (585 prospectively), PFN in 716 (557 prospectively), PFNA in 1762 (1018 prospectively) and PTN in 0.

CONCLUSIONS

The clinical evidence behind the current implants used for proximal femoral fractures is weak considering the number of implants used worldwide. Sporadic evaluation is not sufficient to identify long term problems. A systematic post market surveillance of implants used for fracture treatment, preferable by a national register, is necessary in the future.

Comparison of the Sliding and Femoral Head Rotation among Three Different Femoral Head Fixation Devices for Trochanteric Fractures

Background

Recently, various femoral head fixation devices (HFDs) for trochanteric fractures have become available. However, there are some cases in which femoral head rotation with excessive sliding of the HFD is observed and it is often followed by cutout. The purpose of this study is to compare the ability of the three types of HFDs to prevent femoral head rotation.

Methods

Between July 2005 and December 2009, 206 patients aged over 60 years with trochanteric fractures who had undergone surgical treatment using a short femoral nail in our institution were enrolled into the study. We used the gamma 3 nail (GMN) as the screw-type HFD in 66 cases, the gliding nail (GLN) as a non-cylindrical blade in 76 cases, and the proximal femoral nail antirotation (PFNA) as a cylindrical blade in 64 cases. The sliding length of HFDs and the occurrence of femoral head rotation were evaluated by assessing radiographs as the main outcome, and the results were compared among these devices.

Results

A comparison of the degree of sliding in the GMN group showed that femoral head rotation was observed significantly more frequently in cases with rotation. Further, it appeared that femoral head rotation occurred more frequently in comminuted fractures. However, no significant differences between the sliding lengths of the different HFDs were observed among three groups. Femoral head rotation was observed in 15 cases of GMN (22.7%), 0 case of GLN, and 5 case of PFNA (7.8%). Significant differences with regard to the occurrence of femoral head rotation were observed among the three groups. Furthermore, significant differences were also observed between GLN and PFNA with respect to the occurrence of femoral head rotation.

Conclusions

The ability to stabilize femoral head appears to be greater with blade-type materials than with screw-type materials. Furthermore, we believe that a non-cylindrical blade is preferable to a cylindrical blade for the surgical treatment of comminuted, unstable trochanteric fractures in order to prevent femoral head rotation and cut-out.

Combination of modified free vascularized fibular grafting and reverse Less Invasive Stabilization System (LISS) for the management of femoral neck nonunion in patients thirty years of age or younger

Femoral neck nonunion (FNN) is a potential complication in patients with displaced femoral neck fractures, occurring in 33%. This may lead to early hip dysfunction or arthroplasty. Combination of modified free vascularized fibular grafting (FVFG) and a reverse LISS may provide a reasonable means to salvage a painless, functional and native hip. Between August 2010 and August 2012, sixteen patients with femoral neck nonunion were treated with a combined procedure involving modified free vascularized fibular grafting and a reverse LISS. The average age of them is 20.3 years (range 12.0-28.0 years). After removing old implants, the nonunion site was debrided, reduced and fixed with a LISS. The fibular grafts were compacted into a trough in the femoral neck. The Harris Hip score system was used to assess hip function and anteroposterior and frog-lateral hip roentgenograms were used to evaluate bone healing. All femoral neck nonunion healed without severe complications. The mean follow-up time was 32.9 months (range 23.0-47.0 months) and the average union time was 7.6 months (range 5.0-10.0 months). All coxa vara deformities and retroversions of the femoral head were corrected. The Harris hip scores (HHS) were improved 36.6 points on average (59.6 points preoperatively to 96.2 points postoperatively). No incidences of osteonecrosis of the femoral head were observed. The combined modified FVFG and reverse LISS plating is a suitable procedure for the management of femoral neck nonunion in patients younger than 30 years, especially for those patients with a revision history.

Accurate and Easy Measurement of Sliding Distance of Intramedullary Nail in Trochanteric Fracture

Background

In daily clinical practice, it is essential to properly evaluate the postoperative sliding distance of various femoral head fixation devices (HFD) for trochanteric fractures. Although it is necessary to develop an accurate and reproducible method that is unaffected by inconsistent postoperative limb position on radiography, few studies have examined which method is optimal. Therefore, the purpose of this study is to prospectively compare the accuracy and reproducibility of our four original methods in the measurement of sliding distance of the HFD.

Methods

Radiographs of plastic simulated bone implanted with Japanese proximal femoral nail antirotation were taken in five limb postures: neutral, flexion, minute internal rotation, greater external rotation, and flexion with external rotation. Orthopedic surgeons performed five measurements of the sliding distance of the HFD in each of the flowing four methods: nail axis reference (NAR), modified NAR, inner edge reference, and nail tip reference. We also assessed two clinical cases by using these methods and evaluated the intraclass correlation coefficients.

Results

The measured values were consistent in the NAR method regardless of limb posture, with an even smaller error when using the modified NAR method. The standard deviation (SD) was high in the nail tip reference method and extremely low in the modified NAR method. In the two clinical cases, the SD was the lowest in the modified NAR method, similar to the results using plastic simulated bone. The intraclass correlation coefficients showed the highest value in the modified NAR method.

Conclusions

We conclude that the modified NAR method should be the most recommended based on its accuracy, reproducibility, and usefulness.

Proximal femoral nails compared with reverse distal femoral locking plates in intertrochanteric fractures with a compromised lateral wall; a randomised controlled trial

PURPOSE

There is no consensus about the best option of internal fixation for unstable intertrochanteric fractures. The aim of the present study was to compare proximal femoral nail (PFN) with contralateral reverse distal femoral locking compression plate (reverse-DFLCP) in the management of unstable intertrochanteric fractures with compromised lateral wall.

METHOD

In a randomized controlled study, from November 2011 to October 2012, 40 patients with unstable intertrochanteric fractures with compromised lateral wall (AO 31A 2.2 to 3.3) had osteosynthesis by PFN (n = 20) or reverse-DFLCP (n = 20). Intra-operative variables compared were duration of surgery, blood loss during surgery, fluoroscopy time and surgeons perception of the surgery. Patients were followed up clinically for a minimum of one year. Functional outcome was assessed by Parker Palmer mobility score (PPMS), Harris hip score (HHS), and Short Form-12. Failure was defined as any condition which would necessitate revision surgery with change of implant.

RESULTS

Duration of surgery (p = 0.022), blood loss during surgery (p = 0.008) and fluoroscopy time (p = 0.0001) were significantly less in the PFN group than in the reverse-DFLCP group. No significant difference was found in type of reduction, difficulty in reduction and surgeon's perception of surgery. The PFN group had better functional outcome than the reverse-DFLCP group. HHS for the PFN group was 81.53 ± 13.21 and for the reverse-DFLCP group it was 68.43 ± 14.36 (p = 0.018). SF-12 physical (p = 0.002) and mental component (p = 0.007) scores in the PFN group was significantly better than in the reverse-DFLCP group. There was one failure in the PFN group as compared to six in the reverse-DFLCP group (p = 0.036).

CONCLUSION

Due to favourable intra-operative variables, better functional outcome and lower failure rates, we conclude that PFN is a better implant than reverse-DFLCP for intertrochanteric fractures with compromised lateral wall.

Internal fixation of intertrochanteric hip fractures: a clinical comparison of two implant designs

Objective. To compare two internal fixation devices clinically in stabilisation of intertrochanteric femur fractures. Methods. Eighty-seven patients were randomised upon their admission to the hospital using a sealed envelope method. Forty-five were treated with proximal femur nail antirotation (PFNA) and 42 with reverse less invasive stabilisation system (LISS). The perioperative data were recorded and compared in relation to fracture type. Results. In each type of fractures, no significant differences were found with respect to the blood loss, the quality of reduction, the time to bony healing, and the Harris hip score between the 2 groups. The mean duration of surgery was significantly longer in reverse LISS group than in PFNA group. Conclusion. Both the PFNA and the reversed LISS are effective in the treatment of different types of intertrochanteric femur fractures. PFNA is superior to reverse LISS in terms of surgical time, weight-bearing, and perhaps fluoroscopy time.

Biological fixation of comminuted subtrochanteric fractures with proximal femur locking compression plate

INTRODUCTION

Subtrochanteric fractures are difficult fractures associated with high incidence of complications and various implants, both intramedullary and extramedullary, are available for their fixation. Traditional extramedullary implants are associated with higher rate of implant failure and varus collapse while the biomechanically better intramedullary nails are technically demanding and are associated with higher re-operation rates. This study was done to evaluate the outcome following biological (indirect) fixation of unstable comminuted subtrochanteric fractures with proximal femur-locking compression plate (PF-LCP).

METHODS

Thirty-five consecutive patients with comminuted subtrochanteric fractures were operated upon with PF-LCP by using an indirect reduction technique. Seinsheimer types 3-5 fractures were included in the study. Operating time, blood loss and any technical difficulty with the implant were recorded. Patients were followed clinically and radiologically for union at fracture site and implant-related complications. The Harris Hip Score was used to document hip function at final follow-up.

RESULTS

Thirty-two patients with average age of 44.7 years were available for final evaluation. The mean operating time was 79.5min and total blood loss averaged 233.13ml. Union was achieved in all cases with an average time of 15.62 weeks. Complications included two cases of delayed union and two cases of infection. Two cases had a shortening of 1cm and one case had malunion with external rotation. No instances of implant failure or nonunion were recorded.

CONCLUSION

Biological fixation of comminuted subtrochanteric fractures with PF-LCP provides stable fixation with high union rate and fewer complications.

Percutaneous compression plate versus proximal femoral nail anti-rotation in treating elderly patients with intertrochanteric fractures: a prospective randomized study

BACKGROUND

The treatment and management of hip fracture poses a great challenge for clinicians in osteology and surgery. The aim of this study is to compare the clinical effectiveness of the percutaneous compression plate (PCCP) versus proximal femoral nail anti-rotation (PFNA) in the treatment of intertrochanteric fractures in elderly patients.

METHODS

A prospective randomized study was carried out from January 2008 to October 2011 involving 90 elderly patients with intertrochanteric fractures (90 hips) who underwent minimally invasive surgery using the PCCP or PFNA. Evaluation variables, including operation time, intra- and perioperative blood loss, duration of hospital stay, incidence of postoperative complications, and final clinical outcomes by the end of follow-up, were used to compare the benefits of these two implants.

RESULTS

Among 90 subjects, 45 received PCCPs and 45 received PFNAs. The baseline characteristics of the two groups were comparable. The median follow-up time was 16.9 months (12-24 months). In the PCCP group, the mean operative time was 53 min (40-75 min), and the mean intra- and perioperative blood losses were 100.7 ml (60-150 ml) and 916 ml (433-1339 ml), respectively, which were significantly lower than those in the PFNA group. Nevertheless, there was no statistical difference in the incidence of postoperative complications and final clinical outcomes including pain complaints, range of motion of the hip, postoperative hip function at 12 months, and the recovery of walking ability to pre-injury status between these two implants.

CONCLUSIONS

Overall, the PCCP and PFNA appear to have similar clinical effects in treating elderly patients with intertrochanteric fractures, although the PCCP provided shorter operation times and less blood loss than PFNA. Both implants discussed were demonstrated to be ideal for the treatment of femoral intertrochanteric fractures in elderly patients.

Advances and future directions for management of trauma patients with musculoskeletal injuries

Musculoskeletal injuries are the most common reason for operative procedures in severely injured patients and are major determinants of functional outcomes. In this paper, we summarise advances and future directions for management of multiply injured patients with major musculoskeletal trauma. Improved understanding of fracture healing has created new possibilities for management of particularly challenging problems, such as delayed union and non union of fractures and large bone defects. Optimum timing of major orthopaedic interventions is guided by increased knowledge about the immune response after injury. Individual treatment should be guided by trading off the benefits of early definitive skeletal stabilisation, and the potentially life-threatening risks of systemic complications such as fat embolism, acute lung injury, and multiple organ failure. New methods for measurement of fracture healing and function and quality of life outcomes pave the way for landmark trials that will guide the future management of musculoskeletal injuries.