Optimizing stability in AO/OTA 31-A2 intertrochanteric fracture fixation in older patients with osteoporosis

Proximal femoral nail antirotation versus InterTan nail for the treatment of intertrochanteric fractures: A systematic review and meta-analysis

PURPOSE

This meta-analysis compared the efficacy and safety of Proximal Femoral Nail Antirotation (PFNA) and InterTan Nail in the treatment of intertrochanteric fractures. Given the high incidence of femoral intertrochanteric fractures in the elderly population and its impact on quality of life, choosing the most effective and safest surgical option is crucial. PFNA and InterTan are currently two commonly used techniques, but there is a lack of systematic evaluation comparing their safety and effectiveness. This study aims to fill this knowledge gap through Meta-analysis, providing clinicians with evidence-based treatment recommendations.

MATERIALS AND METHODS

A computer search was used to search for published literature on PFNA and InterTan in the treatment of intertrochanteric fractures in PubMed (Medline), Web of Science, Embase, Cochrane Library (CENTRAL), Cinahl, CBM, and CNKI.A total of 853 related literatures were retrieved, and 15 literatures were finally included. Newcastle-Ottawa-Scale and Cochrane systematic review methodologies were used to assess the quality of the literature. Meta-analysis was performed using Review Manager 5.4 software, following data extraction.

RESULTS

The comparison found that during the surgical treatment of intertrochanteric fractures, the operation time, fluoroscopy time, and blood loss in the PFNA group were significantly shorter than those in the InterTan group, and the difference was statistically significant. In terms of postoperative complication rates, the InterTan group had a significant advantage over the PFNA group. Shaft fracture, varus collapse, cut out, screw migration, and pain of hip and thigh were the most likely to occur in the PFNA group, and the differences were all statistically significant. In terms of postoperative efficacy, the results of the PFNA group and the InterTan group were comparable, and there was no significant differences.

CONCLUSIONS

When selecting surgical techniques for the treatment of femoral intertrochanteric fractures, it is necessary to conduct individualized assessments based on the patient's overall health status, surgical tolerance, and post-operative recovery needs. For patients who cannot tolerate long-term surgery or are in poor physical condition, PFNA may be more appropriate. While for patients who can tolerate long-term surgery or have more complex conditions, InterTan may be more suitable.

Mechanical effect of changed femoral neck ante-version angles on the stability of an intertrochanteric fracture fixed with PFNA: A finite element analysis

Objective

Change of femoral neck ante-version angle postoperatively due to inadequate reduction could result in unsatisfying treatment outcome of intertrochanteric fracture. However, the influence of increased or decreased femoral neck ante-version on the biomechanical stability of the bone-implant complex has rarely been studied.

Methods

A finite element model of a complete normal human femur with normal femoral neck ante-version as 13° was established accurately by scanning a 64 year old female femur. The models of 31-A1.1 intertrochanteric fractures with different femoral neck ante-version angles of 3°, 5.5°, 8°, 10.5°, 13°, 15.5°, 18°, 20.5°, 23° were created. They were assembled with a proximal femoral nail anti-rotation (PFNA) device. The biomechanical differences with varying femoral neck ante-version angles were compared using finite element analysis method.

Results

As the femoral neck ante-version angle gradually increased from 13° to 23°with a gradient of 2.5°, the peak von Mises stress was gradually increased from 137.82 MPa to 276.02 MPa. Similarly, the peak von Mises stress was gradually increased from 137.82 MPa to 360.12 MPa with the femoral neck ante-version angle decreased from 13° to 3°. When decreased ante-version angle of 7.5° and increased ante-version angle of 10° will exceed the yield strength of femoral (240.32 MPa), the risk of femoral fracture will increase significantly. The maximum displacement of the femur was significantly reduced for increased ante-version models than for decreased ante-version models, whether the changes of ante-version angles were 2.5°, 5°, 7.5° or 10°. The maximum stress of PFNA was found in the intersection of main nail and helical blade, and became greater gradually as the ante-version angle increased or decreased with a gradient of 2.5°. The maximum stress of PFNA was presented in the model 5.5° with the maximum stress of 724.42 MPa (near to the yield strength of titanium alloy of 700-1000 MPa), producing the breakage risk of PFNA. The maximum displacement of the PFNA was significantly reduced for increased ante-version models than for decreased ante-version models, whether the changes of ante-version angles were 2.5°, 5°, 7.5° or 10°.

Conclusion

Based on the results of present study, it was demonstrated that the anatomical reduction of femoral neck ante-version was vital to secure the optimal stability. Abnormal femoral ante-version could increase the potential risk of failure for intertrochanteric fracture after PFNA. The stability of increased femoral ante-version (less than 10°) was superior to the stability of decreased ante-version (less than 5°) for the cases of difficulty to acquire anatomical reduction. The clinical implication of the finding was that increased femoral neck ante-version had an advantage of mechanical stability towards the decreased femoral neck ante-version for the cases of comminuted intertrochanteric fracture and failure of anatomical reduction.

Comparing short vs. intermediate and long nails in elderly patients with unstable multifragmental femoral trochanteric fractures (AO type A2): Multicenter (TRON group) retrospective study

BACKGROUND

Unstable femoral trochanteric fractures (FTFs), especially Arbeitsgemeinschaft für Osteosynthesefragen/ the Orthopedic Trauma Association (AO/OTA) 31-A2 fractures, which are multifragment fractures, occur in elderly individuals with osteoporosis and are associated with high mortality and complication rates due to prolonged immobilization. Longer nails (LNs) were developed to obtain superior fracture site stabilization in unstable FTFs. We hypothesized that the postoperative outcomes of elderly patients with unstable FTFs treated with LNs would be superior to those of patients treated with short nails (SNs), with fewer complications.

METHODS

This multicenter retrospective study aimed to compare the outcomes of SNs versus LNs in elderly patients with unstable FTFs. From the Trauma Research Group of our university (TRON) database, 1854 trochanteric fractures treated between January 2016 and December 2020 were extracted. A total of 174 patients>65 years of age with AO/OTA 31-A2 fractures were included in the present study. They were divided into the SN group and the LN group and matched for age and sex. Parameters such as operative time, blood loss, survival rate, Parker Mobility Score (PMS), and numerical rating scale (NRS) for pain, complications, and radiographic findings were analyzed.

RESULTS

Both groups included 67 patients with an average age of 87.32 years. The LN group had a longer operative time (76.52 min vs. 51.61 min, P < 0.001) and more blood loss (106.79 mL vs. 49.98 mL, P = 0.014) in comparison to the SN group. However, the 1-year survival rate, PMS, and NRS for pain did not differ to a statistically significant extent between the groups. The rates of complications, including screw cutout, nonunion, implant breakage, osteonecrosis of the femoral head, and surgical site infections, were comparable. The radiographic findings, including the nail/canal ratio, progression of varus, and sliding distance, were also similar.

CONCLUSION

Although LNs are associated with longer operative times and increased blood loss, the overall outcomes and complication rates are comparable to those of SNs in elderly patients with AO/OTA 31-A2 type unstable FTFs. The use of LNs did not confer any distinct advantages for this specific type of fracture.

Dual-screw versus single-screw cephalomedullary nails for intertrochanteric femoral fractures: a systematic review and meta-analysis

BACKGROUND

Internal fixation with cephalomedullary nails has been widely used in the treatment of intertrochanteric femoral fractures (IFF). Yet, the difference in efficacy and safety between the commonly used integrated dual-screw cephalomedullary nail (InterTAN) and single-screw cephalomedullary nail remains inconclusive. Thus we performed the present systematic review and meta-analysis.

METHODS

Randomized controlled trials (RCTs) or observational studies comparing InterTAN with proximal femoral nail anti-rotation (PFNA), the Asian PFNA (PFNA-II), or the Gamma3 nail in treating IFF were searched on PubMed, EMBASE, Web of Science and Cochrane Library from inception to April 30, 2023. The differences in perioperative parameters and clinical and radiological outcomes were evaluated by mean difference (MD) with 95% confidence interval (95%CI). The risks of various complications and mortality were assessed by risk ratio (RR) with 95%CI.

RESULTS

Twenty-three studies comprising 3566 patients were included. Compared with single-screw cephalomedullary nails (PFNA/PFNA-II, Gamma3), InterTAN conferred significantly reduced risk of implant failures (RR = 0.37, 95%CI 0.26 to 0.51, P < 0.001), hip and thigh pain (RR = 0.70, 95%CI 0.55 to 0.90, P = 0.006) and all-cause revision/reoperation (RR = 0.38, 95%CI 0.26 to 0.57, P < 0.001). Moreover, patients treated with InterTAN had significantly higher 1-year Harris Hip Score (MD = 0.82, 95%CI 0.20-1.44, P = 0.010) and shorter time to union/healing (MD = - 0.66 days, 95%CI  - 1.16 to  - 0.16, P = 0.009). Femoral neck shortening, time to full bearing, and incidences of non-union, infection, deep venous thrombosis, and mortality were comparable between both groups.

CONCLUSIONS

The integrated dual-screw InterTAN construct has superior performance in reducing risks of complications and improving clinical and functional outcomes in the treatment of IFF. More well-designed, high-quality RCTs are warranted to confirm these findings.

Treatment of Trochanteric Hip Fractures with Cephalomedullary Nails: Single Head Screw vs. Dual Integrated Compression Screw Systems

Extracapsular hip fractures are very common in the elderly. They are mainly treated surgically with an intramedullary nail. Nowadays, both endomedullary hip nails with single cephalic screw systems and interlocking double screw systems are available on the market. The latter are supposed to increase rotational stability and therefore decrease the risk of collapse and cut-out. A retrospective cohort study was carried out, in which 387 patients with extracapsular hip fracture undergoing internal fixation with an intramedullary nail were included to study the occurrence of complications and reoperations. Of the 387 patients, 69% received a single head screw nail and 31% received a dual integrated compression screw nail. The median follow-up was 1.1 years, and in that time, a total of 17 reoperations were performed (4.2%; 2.1% for single head screw nails vs. 8.7% for double head screws). According to the multivariate logistic regression model adjusted for age, sex and basicervical fracture, the adjusted hazard risk of reoperation required was 3.6 times greater when using double interlocking screw systems (p = 0.017). A propensity scores analysis confirmed this finding. In conclusion, despite the potential benefits of using two interlocking head screw systems and the increased risk of reoperation in our single center, we encourage to other researchers to explore this question in a wider multicenter study.

Intertrochanteric Femoral Fractures: A Comparison of Clinical and Radiographic Results with the Proximal Femoral Intramedullary Nail (PROFIN), the Anti-Rotation Proximal Femoral Nail (A-PFN), and the InterTAN Nail

Background and Objectives: The aim of this study was to evaluate retrospectively the radiological and functional outcomes of closed reduction and internal fixation for intertrochanteric femoral fractures (IFF) using three different proximal femoral nails (PFN). Materials and Methods: In total, 309 individuals (143 males and 166 females) who underwent surgery for IFF using a PFN between January 2018 and January 2021 were included in the study. Our surgical team conducted osteosynthesis using the A-PFN® (TST, Istanbul, Turkey) nail, the PROFIN® (TST, Istanbul, Turkey), and the Trigen InterTAN (Smith & Nephew, Memphis, TN, USA) nail. The PFNs were compared based on age, gender, body mass index (BMI), length of stay (LOS) in intensive care, whether to be admitted to intensive care, mortality in the first year, amount of transfusion, preoperative time to surgery, hospitalisation time, duration of surgery and fluoroscopy, fracture type and reduction quality, complication ratio, and clinical and radiological outcomes. The patients’ function was measured with the Harris Hip Score (HHS) and the Katz Index of Independence in Activities of Daily Living (ADL). Results: Pain in the hip and thigh is the most common complication, followed by the V-effect. The Z-effect was seen in 5.7% of PROFIN patients. A-PFN was shown to have longer surgical and fluoroscopy durations, lower HHS values, and much lower Katz ADL Index values compared to the other two PFNs. The V-effect occurrence was significantly higher in the A-PFN group (36.7%) than in the InterTAN group. The V-effect was seen in 33.1% of 31A2-type fractures but in none of the 31A3-type fractures. Conclusions: InterTAN nails are the best choice for IFFs because they have high clinical scores after surgery, there is no chance of Z-effect, and the rate of V-effect is low.

Meta-analysis of InterTan, PFNA and PFNA-II internal fixation for the treatment of unstable intertrochanteric fractures in elderly individuals

Elderly individuals are often affected by osteoporosis and have poor stability after fracture reduction. Moreover, there is still controversy regarding the clinical effects of the treatment for unstable intertrochanteric fractures in the elderly. The Cochrane, Embase, PubMed, and other databases were searched, and a meta-analysis of the literature on the treatment of unstable intertrochanteric fractures of the elderly with InterTan, PFNA, and PFNA-II was conducted. Seven studies were screened, with a total of 1236 patients. Our meta-analysis results show that InterTan is not significantly different from PFNA in terms of operation and fluoroscopy times, but it takes longer than PFNA-II. In terms of postoperative screw cut, pain, femoral shaft fracture, and secondary operations, InterTan is superior to PFNA and PFNA-II. Conversely, in terms of intraoperative blood loss, hospital stay, and postoperative Harris score, there is no significant difference between InterTan and PFNA and PFNA-II. Compared to PFNA and PFNA-II, InterTan internal fixation has advantages in the treatment of unstable intertrochanteric fractures in elderly individuals in terms of screw cutting, femoral shaft fractures, and secondary operations. However, InterTan operation and fluoroscopy times take longer than PFNA and PFNA-II.

Integrated dual lag screws versus single lag screw cephalomedullary nail constructs: a meta-analysis and systematic review

BACKGROUND/AIM

This study aims to determine the safety and efficacy of integrated dual lag screw (IDL) cephalomedullary nails (CMN) when compared with single lag screw (SL) constructs, in the internal fixation of intertrochanteric femoral fractures.

METHODS

The Smith & Nephew InterTan IDL was compared with SL CMN group consisting of the Stryker Gamma-3 (G3) and Synthes Proximal Femoral Nail Antirotation (PFNA) CMN. A multi-database search was performed according to PRISMA guidelines. Data from studies assessing the clinical and radiological outcomes, complications and perioperative parameters of InterTan versus G3 or PFNA CMN in patients with intertrochanteric femoral fractures were extracted and analysed.

RESULTS

15 studies were included in this meta-analysis, consisting of 2643 patients. InterTan was associated with lower complication rates in terms of all-cause revisions (OR 0.34; 95% CI, 0.22-0.51; p < 0.001), cut-outs (OR 0.30; 95% CI, 0.17-0.51; p < 0.001), medial or lateral screw migration (OR 0.19; 95% CI, 0.06-0.65; p = 0.008) as well as persistent hip and thigh pain (OR 0.65; 95% CI, 0.47-0.90; p = 0.008). In terms of perioperative parameters, InterTan is associated with longer operative times (MD 5.57 minutes; 95% CI, 0.37-10.78 minutes, p = 0.04) and fluoroscopy times (MD 38.89 seconds, 95% CI, 15.88-61.91 seconds; p < 0.001). There was no statistically significant difference in terms of clinical Harris Hip Score and radiological outcomes, non-union, haematoma, femoral fractures, varus collapse, length of stay and mean intraoperative blood loss between the 2 groups.

CONCLUSIONS

Integrated dual lag screw cephalomedullary nails are associated with fewer revisions and complications. However, there is insufficient data to suggest that either nail construct is associated with better functional outcomes.

Stabilisation of AO OTA 31-A unstable proximal femoral fractures: Does the choice of intramedullary nail affect the incidence of post-operative complications? A systematic literature review and meta-analysis

OBJECTIVE

To determine if there was a difference in the risk of post-operative complications associated with the use of different intramedullary (IM) devices in the treatment of unstable AO OTA 31-A trochanteric fractures.

DESIGN

Systematic literature review and meta-analysis.

METHODS

A systematic literature review was carried out in January 2022 in the Embase, MEDLINE and Cochrane databases. Studies comparing INTERTAN™ to other intramedullary nails for the treatment of AO OTA 31-A trochanteric fractures were selected for inclusion. After data extraction, meta-analyses were carried out on postoperative outcomes, with specific focus placed on unstable fracture patterns.

RESULTS

Twenty-three studies were suitable for inclusion, of which seventeen reported on outcomes in unstable fractures. INTERTAN reduced the risk of revision/reoperation by 64% (RR 0.36, 95% CI 0.25 to 0.54, p <0.0001), implant failures by 62% (RR 0.38, 95% CI 0.25 to 0.57, p<0.0001) and hip and thigh pain by 50% (RR 0.50, 95% CI 0.35 to 0.71, p=0.0001) in unstable fractures. No differences were noted between IM nail designs for infection rates, healing time, non-union rates, femoral shortening, or Harris Hip Score.

CONCLUSIONS

The INTERTAN IM nail may reduce incidence of implant-related complications, hip and thigh pain, and the need for revision/reoperation without compromising clinical and functional outcomes.

Benefit of lag screw placement by a single- or two-screw nailing system in elderly patients with AO/OTA 31-A2 trochanteric fractures

Objective

To retrospectively analyze the clinical outcomes of two intramedullary fixation devices, the INTERTAN nail and Gamma3 nail, for treatment of AO/OTA 31-A2 trochanteric fractures in elderly patients.

Methods

In total, 165 elderly patients underwent treatment for AO/OTA 31-A2 trochanteric fractures in our hospital from June 2017 to June 2018 (INTERTAN group, n = 79; Gamma3 group, n = 86). All patients underwent radiological and clinical investigations and were followed up for an average of 12 months. Age, sex, fracture type, surgical time, intraoperative blood loss, fracture healing time, and complications were compared between the two groups.

Results

The surgical time was significantly shorter and the intraoperative blood loss volume was significantly lower in the Gamma3 than INTERTAN group (58.2 ± 2.5 vs. 81.7 ± 14.2 minutes and 170 ± 29 vs. 220 ± 16 mL, respectively). However, there were no significant differences in the reduction quality, hospital stay, fracture healing time, Harris hip score, postoperative complications, or 1-year postoperative mortality.

Conclusion

Both INTERTAN and Gamma3 nails may be effective for surgical treatment of AO/OTA 31-A2 trochanteric fractures in elderly patients. However, the Gamma3 nail was superior to the INTERTAN nail in terms of surgical time and intraoperative blood loss.

Effect of lesser trochanter posteromedial wall defect on the stability of femoral intertrochanteric fracture using 3D simulation

BACKGROUND

This study investigated the effects of posteromedial fracture fragments on the postoperative stability of intertrochanteric fractures of the femur by analyzing the quantity and range of fragments in CT 3D reconstruction.

MATERIALS AND METHODS

Patients diagnosed with femoral lesser trochanter fractures were collected from September 2015 to February 2018. CT 3D reconstruction was applied to evaluate the quantity and extension of posteromedial fragments and the presence of isolated medial fragments. The stability of postoperative fracture was evaluated by comparing the changes of "neck-shaft angle" and "telescoping" from 1 week to 1 year after operation.

RESULTS

A total of 143 patients were finally confirmed, in which 63 patients contained isolated fragments on the medial side, and the average number of fragments in the posteromedial side was 1.93 ± 0.34, which accounted for an average of about 86.11% ± 8.20% in the whole posteromedial wall. When the number of posteromedial fragments was > 2 and the range of posteromedial fragments was > 75%, then the changes in the neck-shaft angle and "telescoping" showed statistical significance (12.27 ± 4.18 mm and 10.13 ± 6.17°, respectively), and when there were isolated medial isolated fragments, then the change in the neck-shaft angle was 10.66 ± 4.27°, showing statistical significance.

CONCLUSIONS

These findings revealed a certain correlation between the quantity and the range of posteromedial fragments and the postoperative "shortening" and "collapse" of femoral intertrochanteric fractures.

Proximal Femoral Nail Unlocked versus Locked (ProFNUL): a protocol for a multicentre, parallel-armed randomised controlled trial for the effect of femoral nail mode of lag screw locking and screw configuration in the treatment of intertrochanteric femur fractures

INTRODUCTION

Intertrochanteric fractures are common fragility injuries in the elderly. Surgical fixation using intramedullary devices are one of the widely used management options. To date, evidence demonstrating the effects of lag screw configuration and the mode of lag screw locking in these devices is lacking. The purpose of this study is to investigate whether the lag screw configuration (single vs integrated dual interlocking screw) and the mode of lag screw locking (static vs dynamic) of a femoral nail device result in differences in clinical and functional outcomes.

METHODS AND ANALYSIS

A multicentre, pragmatic, single-blinded randomised controlled trial (RCT) with a three-arm parallel group design is proposed. Nine-hundred patients with intertrochanteric fractures (A1 and A2 AO/OTA) will be randomised to fracture treatment using a Gamma3 nail (Stryker; proximally dynamic) or a Trigen Intertan nail (Smith & Nephew) in a dynamic or static lag screw configuration. The primary outcome measure consists of radiological evidence of construct failure within 6 months following surgery, with failure being defined as breakage of the femoral nail or distal locking screw, a change in tip-apex distance of more than 10 mm or lag screw cut-out through the femoral head. Secondary outcomes include surgical data (operation time, fluoroscopy time), complications (surgical site infection, reoperation, patient death), return to mobility and home circumstances, functional independence, function and pain. Patients who are able to walk independently with or without a mobility aid and are able to answer simple questions and follow instructions will be asked to participate in three dimensional gait analysis at 6 weeks and 6 months to assess hip biomechanics from this cohort. Additional secondary measures of gait speed, hip range of motion, joint contact and muscle forces and gross activity monitoring patterns will be obtained in this subgroup.

ETHICS AND DISSEMINATION

The Central Adelaide Local Health Network Human Research Ethics Committee has approved the protocol for this RCT (HREC/17/RAH/433). The results will be disseminated via peer-reviewed publications and presentations at relevant conferences.

TRIAL REGISTRATION NUMBER

ACTRN12618001431213.