Dynamic hip screw blade fixation for intertrochanteric hip fractures

Mean Tip Apex Distance in Patients undergoing Dynamic Hip Screw Fixation for Pertrochanteric Fractures without using Traction Table: A Descriptive Cross-sectional Study

Introduction

Dynamic Hip Screw fixation has shown to be equally effective compared to cephalomedullary nailing. The effectiveness of dynamic hip screw fixation for pertrochanteric fractures without using traction table is not well investigated. This study aimed to find out the mean tip apex distance in patients undergoing dynamic hip screw fixation for pertrochanteric fractures without using traction table.

Methods

A descriptive cross-sectional study was conducted among patients undergoing dynamic hip screw fixation for pertrochanteric fractures without using traction table between 1 September 2021 and 30 June 2022, after getting approval from institutional review committee (Reference number: IRC-2021-08-23-02). All patients undergoing dynamic hip screw fixation for pertrochanteric fractures without using traction table were included in the study. Patients with pre-existing ipsilateral or contralateral hip deformity, contra-lateral hip prosthesis, bilateral hip fractures, and history of prior ipsilateral hip surgeries were excluded. Point estimate and 95% confidence interval were calculated.

Results

Among 45 patients, the mean tip apex distance was 20.45±6.13 mm (18.66-22.24 mm, 95% Confidence Interval). Among 45 patients, 24 (53.33%) were males and 21 (46.66%) were females. The average age of the participants was 67.75±21.33 years.

Conclusions

The mean tip apex distance in patients undergoing dynamic hip Screw fixation for pertrochanteric fractures without using traction table was similar to that reported in other international studies.

Keywords

fracture fixation; hip fractures; operating tables.

The effects of bone-substitute augmentation on treatment of osteoporotic intertrochanteric fractures

Background

Methods

Results

Conclusions

Level of evidence

Two-hole versus four-hole plate dynamic hip screw: a systematic review of current evidence

BACKGROUND

The dynamic hip screw (DHS) is a common device used in the fixation of hip fractures. Traditionally, this involves the use of a four-hole side plate. Reducing the length of the side plate would theoretically reduce the amount of surgical exposure required, decrease surgery duration, and decrease perioperative morbidity and mortality. Our study aims to review the current evidence regarding the use of two-hole side plates, their use and potential complications.

METHODS

Using PRISMA guidelines, two independent reviewers performed a search to collate the available literature from medical databases PubMed, EMBASE, Web of Science, and the Cochrane library. Only clinical and biochemical studies were included. The reference lists of articles included for full text review were searched for any additional primary or review publications.

RESULTS

Four online libraries were searched, with a combined total of 5344 titles reviewed. Following title, abstract, and full text review, 8 articles were considered suitable for inclusion in qualitative analysis. There was a trend towards equal efficiency between two- and four-hole plates when used in stable fractures in terms of blood loss, failure/revision rates, operative and hospital stay durations, collapse loading testing, maximum stress, and fragment migration.

CONCLUSION

The results of this study show that DHS constructs with two- or four-hole side plates have comparable outcomes when used in patients with stable fracture patterns. However, the majority of the clinical data regarding the use of two-hole DHS plates come from retrospective case series; further prospective, randomised control trials would be of significant benefit.

LEVEL OF EVIDENCE

Level II; systematic review of all levels of evidence.

Autogenous fibula graft and cannulated screw fixation to cephalic cut out after DHS fixation: a retrospective study

BACKGROUND

This study aimed to explore the effect of the treatment through autologous fibula graft and hollow needle fixation to treat femoral head cutting after dynamic hip screw (DHS) fixation.

METHODS

A total of 41 patients were admitted to the department of orthopedic trauma and received DHS fixation. Preoperative and postoperative harris score of hip function, limb shortening length and collodiaphysial angle between operation group (n = 11) and non-operation group (n = 13) were compared.

RESULTS

There was no difference between the two groups before surgery (P > 0.05). There was a difference between the preoperative and postoperative in the operation group (P < 0.05). The excellent and good rate of the hip function score in patients 6 months after the operation was 55.6%. In the operation group, the hip function score increased after surgery (P < 0.001). Except for two groups of patients before operation, there was a difference in the limb shortening length and collodiaphysial angle between the operation group and non-operation group in other time points after surgery (P < 0.001).

CONCLUSION

The application of the autogenous fibula graft and hollow nail fixation was effective in treating femoral head cutting after DHS fixation, and patients' subjective evaluation and objective indicators' outcomes of follow up were satisfactory, which was worthy of clinical application.

Gamma 3 U-Blade lag screws in patients with trochanteric femur fractures: are rotation control lag screws better than others?

Background

Intramedullary hip nails may be classified as blades or screws depending on the type of lag screw used. Recently, a combination of lag screw types with a U-clip insertion has also been used. The purpose of this study was to evaluate the clinical and radiological outcomes of these new screw types.

Methods

A total of 185 patients with trochanteric femoral fractures (age ≥ 65 years) who underwent surgery with intramedullary nails were selected. Surgeries with InterTrochanteric/SubTrochanteric (ITST), Proximal Femoral Nail Antirotation (PFNA), and Gamma 3 U-Blade lag screws were performed between January 2011 and June 2016. The AO/OTA classification, presence of a basicervical fracture type on 3D-CT, BMI, BMD, reduction quality, position of the lag screw, TAD (tip apex distance) of the lag screw, sliding distance of the lag screw, varus change (neck shaft angle), radiological union period, fixation failure and functional outcome as determined by walking ability were analyzed.

Results

There were 3/60 (5.0%) cases of fixation failure in the ITST group, all caused by cut-out; 4/57 (7.0%) in the PFNA II group: 3 caused by cut-through and 1 by metal fracture; 1/68 (1.5%) in the Gamma 3 U-Blade lag screw group (P = 0.301). In each group, the sliding distance of the lag screw showed a significant difference (P = 0.017), whereas significant sliding over 10 mm showed no statistically significant results.

Conclusion

There was only one (1.5%) case of fixation failure in the Gamma 3 U-Blade lag screw group. The sliding distance of the U-Blade was found to be in the middle, between the PFNA II (shorter) and ITST (longer) implants. The new rotational control lag screw seems to be comparable to other screw types.

Is PFNA-II a better implant for stable intertrochanteric fractures in elderly population ? A prospective randomized study

INTRODUCTION

Intertrochanteric fracture is one of the most common and severe fractures occurring in the elderly population. We conducted a randomized prospective study to compare the functional and radiological outcome of Proximal Femoral Nail anti-rotation-Asia(PFNA-II) and Dynamic Hip screw (DHS) used in fixation of stable (AO type 31 A1-A2.1) intertrochanteric fractures in elderly.

METHODS

60 elderly patients with stable intertrochanteric fractures treated with DHS and PFNA-II between August 2014 to Dec 2016 were enrolled in the study. Intraoperative variables-surgical time, blood loss, fluoroscopy time and post-operative variables-union rate, change in neck shaft angle(NSA), functional outcome in terms of Modified Harris Hip Score(HHS) & SF-12, complication rate and mortality at one year were studied and compared between both the groups.

RESULTS

The mean age of patients in our study was 70.96 years. We found patients treated with DHS required significantly longer surgical time and had more blood loss compared to PFNA-II group. However, there was no significant difference in both the groups in terms of intra-operative fluoroscopy time, change in neck shaft angle, union rate, complication rate and Modified Harris Hip Score & SF-12 at three months; six months and one year follow-up.

CONCLUSIONS

Both DHS and PFNA-II can be used effectively in the treatment of elderly patients with stable intertrochanteric fracture with comparable outcome. However, in high-risk elderly patients requiring shorter surgical time and less blood loss, PFNA-II can be used.

Femoral neck fractures after internal fixation of trochanteric fractures with implants in situ in adults: A systematic review

INTRODUCTION

Femoral neck fractures (FNF) after internal fixation of trochanteric fractures (AIFTF) with the implant in situ (WIIS) are uncommon. Publications of FNFAIFTFWIIS are rare. The purpose of this systematic review of the literature is to report on the frequency, risk factors, mechanisms, clinical presentation, diagnostic and therapeutic modalities, outcomes and the eventual prevention of this complication.

MATERIALS AND METHODS

A comprehensive review of the literature was undertaken using the PRISMA guidelines with no language restriction. Case reports of FNFAIFTFWIIS and series of trochanteric fractures (TF) with this complication in adults published between inception of journals to May 2018 were eligible for inclusion. Cases with fractures in pathological bone, undergoing treatment with hip replacement, or after partial or total implant removal were excluded. Relevant information was divided in two parts. Part I included the analysis of cases of FNFAIFTFWIIS, with the objective of establishing the eventual risk factors, mechanisms, diagnostic, treatment modalities, and outcomes. Part II analyzed series of TFs with implants in situ which included cases of FNFs for assessing the incidence of FNFs in this condition.

RESULTS

Overall 77 publications with 104 cases of FNFAIFTFWIIS met the inclusion criteria. The median incidence of this complication was 0,43%. The mean age was 80 years (range, 42-96).The prevalent factors for FNFAIFTFWIIS were osteoporosis, and the presence of the implant in the femoral neck and head. A short nail or screw with the tip far from the subchondral bone was of influence as a stress riser factor, but not prevalent because in two thirds of the cases the FNF occurred when the implant was introduced up to the subchondral bone. Other risk factors analysed included varus reduction or nonunion of the TF, and the breakage of the hip screw, which modify the forces exerted over the femoral neck, and may contribute to the FNF. The FNFs were spontaneous, i.e. not related to trauma or fall, in more than two thirds of the cases.

CONCLUSION

The etiology of FNFAIFTFWII should be considered multifactorial. The frequency seems low. Although a subchondral positioning of the hip screw might diminish the incidence of FNFS, a correct surgical technique does not preclude a FNFAIFTFWIIS, and in fact the incidence of this complication was higher in these correctly treated patients. FNFAIFTFWIIS is a fragility fracture and adequate management of systemic osteoporosis should be targeted as a main factor of prevention.

Intra-Pelvic Migration of Sliding Hip Screw During Osteosynthesis of Hip Fracture: A Rare Avoidable Intraoperative Complication

Introduction:

Hip fractures, which are common among old patients, are classified into two groups: intracapsular and extracapsular fractures. Extracapsular fractures can be treated with extramedullary implants [e.g. dynamic hip screw (DHS)] or intramedullary nails. Dynamic hip screw is the treatment of choice in stable pertrochanteric fractures. Intrapelvic migration of the sliding screw is a very rare complication.

Case Report:

We report a case of a 90-year old Caucasian woman who had an unusual intraoperative complication during osteosynthesis procedure for extracapsular hip fracture fixation. In fact, the sliding hip screw went deep into the pelvis during surgery. This mishap required an abdominal surgical approach by the general surgeon to remove the screw.

Conclusion:

Taking into consideration the poor quality of the bone in very old patients, we emphasize the importance of following every single step of the surgical procedure, in order to minimize the risk of this complication.

Teriparatide Improves Fracture Healing and Early Functional Recovery in Treatment of Osteoporotic Intertrochanteric Fractures

Osteoporotic intertrochanteric fractures result in serious health problems and decrease health-related quality of life (HRQoL). Faster time-to-union is important for early return to daily activities and reduction of complications. Teriparatide has been shown to accelerate fracture healing, but the literature is sparse on this topic. The aim of this study is to assess whether teriparatide accelerates fracture healing.Between 2008 and 2014, patients with osteoporotic intertrochanteric fractures who underwent surgical interventions were enrolled in this retrospective cohort study. Group 1 included patients who were not on any osteoporosis medication prior to fracture and who postoperatively received only calcium and vitamin D; patients in Group 2 were not on any osteoporosis medication prior to fracture, and received teriparatide and calcium and vitamin D postoperatively. Patients in Group 3 were those who were on alendronate prior to fracture and postfracture received teriparatide as well as calcium and vitamin D. Demographics, time-to-union, HRQoL (short-form health survey [SF]-12 physical component summary [PCS] and SF-12 mental component summary [MCS]), morbidities, mortalities, and radiographic and functional outcomes between groups were compared.A total of 189 patients were enrolled in this study. There were 83 patients in Group 1, 47 patients in Group 2, and 59 patients in Group 3. A significantly shorter time-to-union was found in the teriparatide-treated groups (mean, 13.6, 12.3, and 10.6 weeks, respectively [P = 0.002]). With regard to SF-12 PCS, the scores were significantly better in teriparatide-treated groups at 3 months (mean, 19, 28, and 29, respectively [P = 0.002]) and 6 months (mean, 28, 37, and 38, respectively [P = 0.008]). Similar inter-group differences were noted when comparing the pain scores, the ability to get around the house, the ability to get out of the house, and the ability to go shopping at 3 and 6 months. Complications and mortality were also markedly reduced in the teriparatide-treated groups.Postoperative use of teriparatide for 6 months appears to be an effective adjunct therapy in the treatment of patients with osteoporotic intertrochanteric fractures. However, because of the limited power of the study, a prospective, randomized, large-scale cohort study is still required for determining the efficacy of teriparatide.

Sliding hip screw versus sliding helical blade for intertrochanteric fractures

The spiral blade modification of the Dynamic Hip Screw (DHS) was designed for superior biomechanical fixation in the osteoporotic femoral head. Our objective was to compare clinical outcomes and in particular the incidence of loss of fixation.

In a series of 197 consecutive patients over the age of 50 years treated with DHS-blades (blades) and 242 patients treated with conventional DHS (screw) for AO/OTA 31.A1 or A2 intertrochanteric fractures were identified from a prospectively compiled database in a level 1 trauma centre. Using propensity score matching, two groups comprising 177 matched patients were compiled and radiological and clinical outcomes compared. In each group there were 66 males and 111 females. Mean age was 83.6 (54 to 100) for the conventional DHS group and 83.8 (52 to 101) for the blade group.

Loss of fixation occurred in two blades and 13 DHSs. None of the blades had observable migration while nine DHSs had gross migration within the femoral head before the fracture healed. There were two versus four implant cut-outs respectively and one side plate pull-out in the DHS group. There was no significant difference in mortality and eventual walking ability between the groups. Multiple logistic regression suggested that poor reduction (odds ratio (OR) 11.49, 95% confidence intervals (CI) 1.45 to 90.9, p = 0.021) and fixation by DHS (OR 15.85, 95%CI 2.50 to 100.3, p = 0.003) were independent predictors of loss of fixation.

The spiral blade design may decrease the risk of implant migration in the femoral head but does not reduce the incidence of cut-out and reoperation. Reduction of the fracture is of paramount importance since poor reduction was an independent predictor for loss of fixation regardless of the implant being used.

Cite this article: Bone Joint J 2015;97-B:398–404.

Effect of teriparatide on unstable pertrochanteric fractures

We retrospectively analyzed the radiographic and clinical outcomes of unstable pertrochanteric fractures (AO/OTA 31-A2) in 44 patients who underwent dynamic hip screw (DHS) fixation and compared the results with 29 patients who received teriparatide in addition to DHS fixation. A significantly shorter time for fracture healing was recorded in the teriparatide-treated group than in the control group. Rates of lag screw sliding, femoral shortening, and varus collapse were all significantly reduced in the teriparatide-treated group. There were no significant differences with regard to superficial wound infection, pneumonia, urinary tract infection, mortality, malunion, and cutting of the lag screw. The mean overall mobility scores were significantly better in the teriparatide-treated group at 3 and 6 months (P < 0.001 and P < 0.001, resp.) but not at 12 months or the last follow-up. The pain scores were also significantly better in the teriparatide-treated group at 3 and 6 months (P = 0.040 and P = 0.041, resp.) but not at 12 months or the last follow-up. Teriparatide improves radiographic outcomes and yields better clinical outcomes at 3 and 6 months postoperatively. The improvement in union time may be important for elderly populations with unstable pertrochanteric fractures to enable them to return to daily activities and reduce morbidity and mortality.

A biomechanical study comparing helical blade with screw design for sliding hip fixations of unstable intertrochanteric fractures

Dynamic hip screw (DHS) is a well-established conventional implant for treating intertrochanteric fracture. However, revision surgery sometimes still occurs due to the cutting out of implants. A helical blade instead of threaded screw (DHS blade) was designed to improve the fixation power of the osteoporotic intertrochanteric fracture. In this study, the biomechanical properties of DHS blade compared to the conventional DHS were evaluated using an unstable AO/OTA 31-A2 intertrochanteric fracture model. Fifty synthetic proximal femoral bone models with such configuration were fixed with DHS and DHS blade in five different positions: centre-centre (CC), superior-centre (SC), inferior-center (IC), centre-anterior (CA), and centre-posterior (CP). All models had undergone mechanical compression test, and the vertical and rotational displacements were recorded. The results showed that DHS blade had less vertical or rotational displacement than the conventional DHS in CC, CA, and IC positions. The greatest vertical and rotational displacements were found at CP position in both groups. Overall speaking, DHS blade was superior in resisting vertical or rotational displacement in comparison to conventional DHS, and the centre-posterior position had the poorest performance in both groups.