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Al-Dahan T, Murhekar S, Patel N. Treatment Outcomes of Dynamic Hip Screws Versus Short Intramedullary Nails for Extra-capsular Fragility Hip Fractures and Their Coding Audit. Cureus 2024; 16:e68617. [PMID: 39233732 PMCID: PMC11372849 DOI: 10.7759/cureus.68617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2024] [Indexed: 09/06/2024] Open
Abstract
Introduction In the UK, hip fractures are a common reason for presentations to the emergency departments, which places significant pressure on NHS hospitals, appropriate choice of an implant to treat the hip fracture is one among many other factors that affect patients' outcomes. This audit aims to identify and compare the outcome difference between the dynamic hip screws (DHS) and short cephalomedullary nails in the treatment of extracapsular hip fractures. Methods In a retrospective study of 52 patients admitted as a result of hip fractures in one NHS trust, data collection was done from the patients' records using the trust's online system, we studied different variables to compare the outcome difference between DHS and short intramedullary (IM) nails, two senior authors interpreted the patients' X-rays and verified the coding and classification of the neck of femur fractures. Results This retrospective study examined 52 extracapsular hip fracture cases, including 37 females and 15 males. Forty-six (88%) of the included patients were ASA 3 and 4 (American Society of Anesthesiologists), and the average days to discharge from therapies were 8.4 (SD-+ 4) days compared to 11 (SD-+ 5.2) days for short IM nails and DHS, respectively (P= 0.03), the 30-day mortality rate for short nails was 7% (n= 4/52) patients and 6% (n= 3/52) for DHS (P =0.69). The mean operating times for the different implants were 58.11 (SD-+ 15.1) minutes for DHS and 58.03 (SD-+ 23.2) minutes for the short nail (P =0.98). Compliance with the national guidelines for providing an appropriate operation to treat hip fractures initially went from 63% (n=33/52) initially to 73% (n=38/52). This means that more patients who are appropriate for nailing are being treated with IM nails. Conclusion Short IM nails are associated with faster hospital discharge; this fact may be reflecting the lower postoperative pain as a result of avoiding soft tissue dissection associated with extramedullary devices. keeping in mind that IM devices have mechanical advantages over sliding hip screws; hence, they are more commonly used for more complex fracture patterns, leading to nearly similar outcomes when compared to extramedullary devices, this can be a source of bias in retrospective studies, larger randomized trials may lead to different outcomes.
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Affiliation(s)
- Tarik Al-Dahan
- Trauma and Orthopaedics, East Kent Hospitals University NHS Foundation Trust, Canterbury, GBR
| | - Siddhartha Murhekar
- Trauma and orthopaedics, East Kent Hospitals University NHS Foundation Trust, Canterbury, GBR
| | - Nimesh Patel
- Trauma and Orthopaedics, East Kent Hospitals University NHS Foundation Trust, Margate, GBR
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Abulsoud MI, Elmarghany M, Ibrahim MAA, Elsebaey IM, Gaber U, Elsherbiny EA. The "foothill" entry for cephalomedullary nailing in unstable proximal femoral fractures: a technical note with a review of the literature. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:3365-3371. [PMID: 38922404 DOI: 10.1007/s00590-024-04014-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Accepted: 05/31/2024] [Indexed: 06/27/2024]
Abstract
Cephalomedullary nailing for unstable proximal femoral fractures is widely utilized, especially for geriatric osteoporotic fractures. There are two starting points for entry, namely trochanteric tip entry and pyriformis fossa entry, both have advantages and disadvantages, the tip of the greater trochanter seems that it is not the ideal starting point for trochanteric entry nails, the study presents the foothill entry point as a reproducible, technically feasible entry point to overcome the shortcoming of both standard starting points, and it could be easy executed with clear intraoperative fluoroscopic landmarks and lead to appropriate nail position without intraoperative complications.
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Affiliation(s)
- Mohamed I Abulsoud
- Department of Orthopedic Surgery, Faculty of Medicine, Al-Azhar University, Al Mokhayyam Al Dayem Street, Nasr City, Cairo, 11675, Egypt.
| | - Mohammed Elmarghany
- Department of Orthopedic Surgery, Faculty of Medicine, Al-Azhar University, Al Mokhayyam Al Dayem Street, Nasr City, Cairo, 11675, Egypt
| | - Mohamed A A Ibrahim
- Department of Orthopedic Surgery, Faculty of Medicine, Al-Azhar University, Al Mokhayyam Al Dayem Street, Nasr City, Cairo, 11675, Egypt
| | - Ibrahem M Elsebaey
- Department of Orthopedic Surgery, Faculty of Medicine, Al-Azhar University, Al Mokhayyam Al Dayem Street, Nasr City, Cairo, 11675, Egypt
| | - Usama Gaber
- Department of Orthopedic Surgery, Faculty of Medicine, Al-Azhar University, Al Mokhayyam Al Dayem Street, Nasr City, Cairo, 11675, Egypt
| | - Elsherbiny Ali Elsherbiny
- Department of Orthopedic Surgery, Faculty of Medicine, Al-Azhar University, Al Mokhayyam Al Dayem Street, Nasr City, Cairo, 11675, Egypt
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Nie S, Li J, Liu X, Liu J, Wu X, Tang P, Zhao Y, Li M, Zhang L. The clinical efficacy of Medial Sustain Nail(MSN) and Proximal femoral nail anti-rotation(PFNA) for fixation of medial comminuted trochanteric fractures: a prospective randomized controlled trial. INTERNATIONAL ORTHOPAEDICS 2024; 48:2189-2200. [PMID: 38772935 DOI: 10.1007/s00264-024-06220-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 04/30/2024] [Indexed: 05/23/2024]
Abstract
PURPOS To evaluate the clinical efficacy of the Medial Sustain Nail (MSN) for medial comminuted trochanteric fractures fixation in comparison to Proximal Femoral Nail Antirotation (PFNA) through a clinical study. METHODS A non-inferiority randomized controlled trial was conducted at a single centre between July 2019 and July 2020. Fifty patients diagnosed comminuted trochanteric fractures were randomly assigned to either the MSN group (n = 25) or the PFNA group (n = 25). A total of forty-three patients were included in the final study analysis. The primary outcome measure was Short Form 36 health surgery physical component summary (SF-36 PCS) score. Secondary outcomes included the Oxford Hip Scores (OHS), weight bearing, complication relate to implant and so on. This study was not blined to surgeons, but to patients and data analysts. RESULTS The MSN demonstrated significantly better functional outcomes as measured by SF-36 PCS and OHS at six months postoperative compared to PFNA (p < 0.05). Union of fractures in the MSN group reached 90.9% at three months after surgery, whereas the PFNA group achieved a union rate of 57.1% (p < 0.05). Furthermore, weight-bearing time of MSN group was earlier than PFNA group (p < 0.05). Additionally, complications related to implant usage were more prevalent in the PFNA group (33.3%) compared to the MSN group (4.5%) (p < 0.05). CONCLUSION MSN exhibited superior quality of life outcomes compared to PFNA at six months postoperative. This indicates that MSN effectively reconstructs medial femoral support in patients with comminuted trochanteric fractures, which facilitates early weight-bearing and accelerates the recovery process. TRIAL REGISTRATION Trial registration number: NCT01437176, Date of the trial registration:2011-9-1, Date of commencement of the study:2011-9, Date of enrolment/recruitment of the study subjects:2019-7.
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Affiliation(s)
- Shaobo Nie
- Department of Orthopaedics, The First Medical Centre of Chinese PLA General Hospital, Beijing, 100853, China
- National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, 100853, China
| | - Jiantao Li
- National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, 100853, China
- Senior Department of Orthopaedics, The Fourth Medical Center of Chinese, PLA General Hospital, Beijing, 100853, China
| | - Xiao Liu
- National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, 100853, China
- Senior Department of Orthopaedics, The Fourth Medical Center of Chinese, PLA General Hospital, Beijing, 100853, China
| | - Jianheng Liu
- National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, 100853, China
- Senior Department of Orthopaedics, The Fourth Medical Center of Chinese, PLA General Hospital, Beijing, 100853, China
| | - Xiaoyong Wu
- Department of Orthopaedics, The First Medical Centre of Chinese PLA General Hospital, Beijing, 100853, China
- National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, 100853, China
| | - Peifu Tang
- National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, 100853, China
- Senior Department of Orthopaedics, The Fourth Medical Center of Chinese, PLA General Hospital, Beijing, 100853, China
| | - Yanpeng Zhao
- National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, 100853, China.
- Senior Department of Orthopaedics, The Fourth Medical Center of Chinese, PLA General Hospital, Beijing, 100853, China.
| | - Ming Li
- National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, 100853, China.
- Senior Department of Orthopaedics, The Fourth Medical Center of Chinese, PLA General Hospital, Beijing, 100853, China.
| | - Licheng Zhang
- National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, 100853, China.
- Senior Department of Orthopaedics, The Fourth Medical Center of Chinese, PLA General Hospital, Beijing, 100853, China.
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Woldeyesus TA, Gjertsen JE, Dalen I, Meling T, Behzadi M, Harboe K, Djuv A. Preoperative CT improves the assessment of stability in trochanteric hip fractures. Bone Jt Open 2024; 5:524-531. [PMID: 38910526 PMCID: PMC11194626 DOI: 10.1302/2633-1462.56.bjo-2023-0177.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/25/2024] Open
Abstract
Aims To investigate if preoperative CT improves detection of unstable trochanteric hip fractures. Methods A single-centre prospective study was conducted. Patients aged 65 years or older with trochanteric hip fractures admitted to Stavanger University Hospital (Stavanger, Norway) were consecutively included from September 2020 to January 2022. Radiographs and CT images of the fractures were obtained, and surgeons made individual assessments of the fractures based on these. The assessment was conducted according to a systematic protocol including three classification systems (AO/Orthopaedic Trauma Association (OTA), Evans Jensen (EVJ), and Nakano) and questions addressing specific fracture patterns. An expert group provided a gold-standard assessment based on the CT images. Sensitivities and specificities of surgeons' assessments were estimated and compared in regression models with correlations for the same patients. Intra- and inter-rater reliability were presented as Cohen's kappa and Gwet's agreement coefficient (AC1). Results We included 120 fractures in 119 patients. Compared to radiographs, CT increased the sensitivity of detecting unstable trochanteric fractures from 63% to 70% (p = 0.028) and from 70% to 76% (p = 0.004) using AO/OTA and EVJ, respectively. Compared to radiographs alone, CT increased the sensitivity of detecting a large posterolateral trochanter major fragment or a comminuted trochanter major fragment from 63% to 76% (p = 0.002) and from 38% to 55% (p < 0.001), respectively. CT improved intra-rater reliability for stability assessment using EVJ (AC1 0.68 to 0.78; p = 0.049) and for detecting a large posterolateral trochanter major fragment (AC1 0.42 to 0.57; p = 0.031). Conclusion A preoperative CT of trochanteric fractures increased detection of unstable fractures using the AO/OTA and EVJ classification systems. Compared to radiographs, CT improved intra-rater reliability when assessing fracture stability and detecting large posterolateral trochanter major fragments.
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Affiliation(s)
- Thomas A. Woldeyesus
- Department of Orthopaedic Surgery, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Jan-Erik Gjertsen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Ingvild Dalen
- Department of Quality and Health Technology, University of Stavanger, Stavanger, Norway
- Department of Research, Stavanger University Hospital, Stavanger, Norway
| | - Terje Meling
- Department of Orthopaedic Surgery, Stavanger University Hospital, Stavanger, Norway
| | - Mehdi Behzadi
- Department of Radiology, Haukeland University Hospital, Bergen, Norway
| | - Knut Harboe
- Department of Orthopaedic Surgery, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Ane Djuv
- Department of Orthopaedic Surgery, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Ahmad A, Egeland EH, Dybvik EH, Gjertsen JE, Lie SA, Fenstad AM, Matre K, Furnes O. Equivalent mortality after operation with sliding hip screw or intramedullary nail for trochanteric AO/OTA A1 and A2 fractures reported in the Norwegian Hip Fracture Register 2008 to 2020. Bone Joint J 2024; 106-B:603-612. [PMID: 38821494 DOI: 10.1302/0301-620x.106b6.bjj-2023-1219.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/02/2024]
Abstract
Aims This study aimed to compare mortality in trochanteric AO/OTA A1 and A2 fractures treated with an intramedullary nail (IMN) or sliding hip screw (SHS). The primary endpoint was 30-day mortality, with secondary endpoints at 0 to 1, 2 to 7, 8 to 30, 90, and 365 days. Methods We analyzed data from 26,393 patients with trochanteric AO/OTA A1 and A2 fractures treated with IMNs (n = 9,095) or SHSs (n = 17,298) in the Norwegian Hip Fracture Register (January 2008 to December 2020). Exclusions were made for patients aged < 60 years, pathological fractures, pre-2008 operations, contralateral hip fractures, fractures other than trochanteric A1/A2, and treatments other than IMNs or SHSs. Kaplan-Meier and Cox regression analyses adjusted for type of fracture, age, sex, cognitive impairment, American Society of Anesthesiologists (ASA) grade, and time period were conducted, along with calculations for number needed to harm (NNH). Results In unadjusted analyses, there was no significant difference between IMN and SHS patient survival at 30 days (91.8% vs 91.1%; p = 0.083) or 90 days (85.4% vs 84.5%; p = 0.065), but higher one-year survival for IMNs (74.5% vs 73.3%; p = 0.031) compared with SHSs. After adjustments, no significant difference in 30-day mortality was found (hazard rate ratio (HRR) 0.94 (95% confidence interval (CI) 0.86 to 1.02(; p = 0.146). IMNs exhibited higher mortality at 0 to 1 days (HRR 1.63 (95% CI 1.13 to 2.34); p = 0.009) compared with SHSs, with a NNH of 556, but lower mortality at 8 to 30 days (HRR 0.89 (95% CI 0.80 to 1.00); p = 0.043). No differences were observed in mortality at 2 to 7 days (HRR 0.94 (95% CI 0.79 to 1.11); p = 0.434), 90 days (HRR 0.95 (95% CI 0.89 to 1.02); p = 0.177), or 365 days (HRR 0.97 (95% CI 0.92 to 1.02); p = 0.192). Conclusion This study found no difference in 30-day mortality between IMNs and SHSs. However, IMNs were associated with a higher mortality at 0 to 1 days and a marginally lower mortality at 8 to 30 days compared with SHSs. The observed differences in mortality were small and should probably not guide choice of treatment.
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Affiliation(s)
- Amara Ahmad
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Emma H Egeland
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Eva H Dybvik
- The Norwegian Hip Fracture Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Jan-Erik Gjertsen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- The Norwegian Hip Fracture Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Stein A Lie
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Dentistry, University of Bergen, Bergen, Norway
| | - Anne M Fenstad
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Kjell Matre
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- The Norwegian Hip Fracture Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Ove Furnes
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
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Wang C, Hou M, Zhang C, Ma T, Li Z, Lin H, Zhang K, Huang Q. Biomechanical evaluation of a modified intramedullary nail for the treatment of unstable femoral trochanteric fractures. Heliyon 2024; 10:e29671. [PMID: 38660243 PMCID: PMC11040111 DOI: 10.1016/j.heliyon.2024.e29671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 04/11/2024] [Accepted: 04/12/2024] [Indexed: 04/26/2024] Open
Abstract
Background The Proximal Femoral Nail Antirotation (PFNA) device is the most commonly used implant to fix unstable femoral trochanteric fractures (UFTFs), but it has a relatively high incidence of complications. Due to this factor, the modified intramedullary nail (MIN) was created to treat patients with UFTFs. The aim was to exhibit the MIN and make a comparison with PFNA and InterTAN using biomechanical methods. Methods An adult UFTF model was developed using Mimics software. The PFNA, InterTAN nail, and MIN models were drawn referring to the corresponding parameters and installed in the fracture models. Vertical, anteroposterior (AP) bending, and torsion loads of the femoral head were set in advance and loaded onto the fracture models. The value of maximal displacement and von Mises stress was evaluated via finite element analysis (FEA). Results The MIN model had smaller values for maximal displacement than that of the PFNA model, and the increase in displacement was less pronounced for the MIN compared to PFNA under increasing vertical loads. For the indicator of von Mises stress, the MIN model showed lower stress compared with the PFNA model in vertical loads ranging from 300 N to 2100 N. Except for the maximal stress at implants under AP bending loads, the MIN demonstrated the most superior biomechanical properties under AP bending and torsional loads. Conclusion The MIN offered obvious advantages in terms of mechanical stability and stress distribution among the three studied implants, providing a promising implant option for patients with UFTFs.
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Affiliation(s)
- ChaoFeng Wang
- Department of Orthopedics, Hong Hui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, 710054, China
| | - MingMing Hou
- Department of Orthopedics, Hong Hui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, 710054, China
| | - CongMing Zhang
- Department of Orthopedics, Hong Hui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, 710054, China
| | - Teng Ma
- Department of Orthopedics, Hong Hui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, 710054, China
| | - Zhong Li
- Department of Orthopedics, Hong Hui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, 710054, China
| | - Hua Lin
- Department of Orthopedics, Hong Hui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, 710054, China
| | - Kun Zhang
- Department of Orthopedics, Hong Hui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, 710054, China
| | - Qiang Huang
- Department of Orthopedics, Hong Hui Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, 710054, China
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Robioneck MW, Pishnamaz M, Becker N, Bolierakis E, Hildebrand F, Horst K. Development of early complications after treatment of trochanteric fractures with an intramedullary sliding hip screw in a geriatric population. Eur J Trauma Emerg Surg 2024; 50:329-337. [PMID: 38081966 DOI: 10.1007/s00068-023-02404-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 11/12/2023] [Indexed: 04/23/2024]
Abstract
PURPOSE Although trochanteric fractures (TF) are a frequent event in the geriatric population, studies reporting on complication rates associated with surgical treatment are sparse. Thus, this study investigated the relevance of fracture-, implant-, and surgery-associated complications in TF. Furthermore, the role of possible risk factors for the before mentioned complications was investigated. METHODS A consecutive series of patients with TF treated by intramedullary nailing with a sliding screw device was evaluated. Data were sampled retrospectively from the hospital patient information system and anonymized at the source. Demographic data and information regarding fracture pattern, the treatment performed, hospital stay, and evaluation of operative and follow-up radiographs were analyzed. Intraoperative problems (i.e., technical problems with the implant, intraoperative fracture) and postoperative complications were investigated. RESULTS Postoperative surgical complications were noted in 11.7%. The most frequent surgical problem was a difficult fracture reduction (13%) and intraoperative fracture dislocation (3.6%). The most frequent postoperative complication was intra-hospital mortality (3.6%), delayed/non-union (2.7%), and a cut-out of the lag screw in the femoral head (2.3%). Implant failure (1,4%) was significantly associated with morbid obesity while cut-out (2,3%) correlated with a higher tip-apex distance (TAD). A complex fracture type and a suboptimal screw position significantly increased the cut-out rate to 5% (p = 0.018). CONCLUSION Complications after TF treatment occur frequently. While patient-associated variables such as morbid obesity cannot be influenced by the surgeon, correct fracture reduction and implant positioning remain to be of highest importance.
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Affiliation(s)
| | - Miguel Pishnamaz
- Department of Orthopaedic Trauma and Reconstructive Surgery, University Hospital RWTH, Aachen, Germany
| | - Nils Becker
- Department of Orthopaedic Trauma and Reconstructive Surgery, University Hospital RWTH, Aachen, Germany
| | - Eftychios Bolierakis
- Department of Orthopaedic Trauma and Reconstructive Surgery, University Hospital RWTH, Aachen, Germany
| | - Frank Hildebrand
- Department of Orthopaedic Trauma and Reconstructive Surgery, University Hospital RWTH, Aachen, Germany
| | - Klemens Horst
- Department of Orthopaedic Trauma and Reconstructive Surgery, University Hospital RWTH, Aachen, Germany
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Gibson A, Guest M, Taylor T, Harrold F, Gwynne Jones D. The increasing complexity of femoral fragility fractures: incidence, fracture patterns and management over a 10-year period. Hip Int 2024; 34:252-259. [PMID: 37786250 DOI: 10.1177/11207000231199073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
INTRODUCTION The purpose of this study was to determine whether there have been changes in the numbers and complexity of femoral fragility fractures presenting to our department over a period of 10 years. METHODS Patients >60 years presenting with femoral fragility fractures to our institution in 2018-2019 (397 fractures) were compared with respect to demographic data, incidence rates, fracture classification and surgical management with a historical cohort from 2009-2010 (335 fractures). Pathological and high velocity fractures were excluded. RESULTS The gender proportion and average age (83.1 vs. 82.7 years) was unchanged. The number of femoral fractures increased by 19% but the overall incidence in people >60 years fell by 6% (p = 0.41). The proportion of unstable trochanteric fractures (31A2 and A3) increased from 22% to 55% (p < 0.001). The proportion of displaced intracapsular fractures increased from 53% to 72% (p < 0.001). The incidence of stable trochanteric fractures fell from 12.4 to 7.3/10,000 patients>60 years (p = 0.0006) while the incidence of unstable trochanteric fractures (31A2 and 31A3) increased from 3.5 to 8.9/10,000 patients >60 years (p < 0.0001). The proportion of trochanteric fractures treated with an intramedullary (IM) nail increased from 9% to 35% (p = 0.0001). The number of shaft and distal femoral fractures increased by 41% although the incidence did not change significantly. Periprosthetic fractures comprised 70% of femoral shaft fractures in both cohorts. CONCLUSIONS The increasing number and complexity of femoral fragility fractures, especially unstable trochanteric fractures and periprosthetic fractures, is likely to have an impact on implant use, theatre time and cost.
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Affiliation(s)
| | - Megan Guest
- Dunedin Hospital, Dunedin, Otago, New Zealand
- Dunedin School of Medicine, Orthopaedic Surgery, University of Otago, Dunedin, Otago, New Zealand
| | | | - Fraser Harrold
- Dunedin Hospital, Dunedin, Otago, New Zealand
- Dunedin School of Medicine, Orthopaedic Surgery, University of Otago, Dunedin, Otago, New Zealand
| | - David Gwynne Jones
- Dunedin Hospital, Dunedin, Otago, New Zealand
- Dunedin School of Medicine, Orthopaedic Surgery, University of Otago, Dunedin, Otago, New Zealand
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Zeelenberg ML, Plaisier AC, Nugteren LHT, Loggers SAI, Joosse P, Verhofstad MHJ, Den Hartog D, Van Lieshout EMM. Extramedullary versus intramedullary fixation of unstable trochanteric femoral fractures (AO type 31-A2): a systematic review and meta-analysis. Arch Orthop Trauma Surg 2024; 144:1189-1209. [PMID: 38175213 PMCID: PMC10896832 DOI: 10.1007/s00402-023-05138-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 11/13/2023] [Indexed: 01/05/2024]
Abstract
OBJECTIVE The aim of this systematic review was to compare extramedullary fixation and intramedullary fixation for AO type 31-A2 trochanteric fractures in the elderly, with regard to functional outcomes, complications, surgical outcomes, and costs. METHODS Embase, Medline, Web of Science, Cochrane Central Register of Controlled Trials, and Google Scholar were searched for randomized controlled trials (RCTs) and observational studies. Effect estimates were pooled across studies using random effects models. Results are presented as weighted risk ratio (RR) or weighted mean difference (MD) with corresponding 95% confidence interval (95% CI). RESULTS Fourteen RCTs (2039 patients) and 13 observational studies (22,123 patients) were included. Statistically superior results in favor of intramedullary fixation were found for Harris Hip Score (MD 4.09, 95% CI 0.91-7.26, p = 0.04), Parker mobility score (MD - 0.67 95% CI - 1.2 to - 0.17, p = 0.009), lower extremity measure (MD - 4.07 95% CI - 7.4 to - 0.8, p = 0.02), time to full weight bearing (MD 1.14 weeks CI 0.92-1.35, p < 0.001), superficial infection (RR 2.06, 95% CI 1.18-3.58, p = 0.01), nonunion (RR 3.67, 95% CI 1.03-13.10, p = 0.05), fixation failure (RR 2.26, 95% CI 1.16-4.44, p = 0.02), leg shortening (MD 2.23 mm, 95% CI 0.81-3.65, p = 0.002), time to radiological bone healing (MD 2.19 months, 95% CI 0.56-3.83, p = 0.009), surgery duration (MD 11.63 min, 95% CI 2.63-20.62, p = 0.01), operative blood loss (MD 134.5 mL, 95% CI 51-218, p = 0.002), and tip-apex distance > 25 mm (RR 1.73, 95% CI 1.10-2.74, p = 0.02). No comparable cost/costs-effectiveness data were available. CONCLUSION Current literature shows that several functional outcomes, complications, and surgical outcomes were statistically in favor of intramedullary fixation when compared with extramedullary fixation of AO/OTA 31-A2 fractures. However, as several of the differences found appear not to be clinically relevant and for many outcomes data remains sparse or heterogeneous, complete superiority of IM fixation for AO type 31-A2 fractures remains to be confirmed in a detailed cost-effectiveness analysis.
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Affiliation(s)
- Miliaan L Zeelenberg
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - A Cornelis Plaisier
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Leendert H T Nugteren
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Sverre A I Loggers
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
- Department of Surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Pieter Joosse
- Department of Surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Michiel H J Verhofstad
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Dennis Den Hartog
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Esther M M Van Lieshout
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
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Geetala R, Wakefield E, Bradshaw F, Zhang J, Krkovic M. Comparison of intra-operative outcomes following internal fixation with trochanteric stabilisation plate or intramedullary nail in intertrochanteric fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:1193-1199. [PMID: 38008823 PMCID: PMC10857956 DOI: 10.1007/s00590-023-03779-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 11/01/2023] [Indexed: 11/28/2023]
Abstract
PURPOSE Intertrochanteric fractures can be classified as stable (AO-OTA 31-A1) or unstable (AO-OTA 31-A2/3). For A3 fractures there is no recommended treatment, often fixed with either an intramedullary nail (IMN) or a dynamic hip screw and trochanteric stabilisation plate (DHS/TSP). This study retrospectively reviews peri-operative outcomes of patients treated with either fixator. METHODS Pre-operative demographics, operative information and patient outcome data from 213 patients who suffered intertrochanteric fractures and were treated with either DHS/TSP or IMN at a major trauma centre from 01/2015 to 01/2022 was collected. Unpaired T tests were performed to assess levels of significance between peri-operative outcomes. RESULTS The mean age for DHS/TSP-treated patients was 2.63 years greater than IMN-treated (P = 0.039). There were no other significant differences in pre-operative characteristics. We found a significantly shorter mean operative time in the DHS/TSP group (88.05 min, 95% CI: 82.1-94.0) compared to IMN counterparts (100.8 min, 95% CI: 92.7-109.0, P = 0.012), but no statistically significant difference in length of hospital stay or patient mortality, blood transfusion, re-operation or complication rates. When A3 fractures were analysed, a statistically significant greater proportion of IMN patients required blood transfusions (DHS/TSP: 35.90%, IMN: 65.00%, P = 0.0093). All other factors were found to have no significant differences. CONCLUSION This study provides evidence to support the national guidelines regarding A1 fractures and suggests that DHS/TSP is a valid alternative to the IMN in A3 intertrochanteric fractures, with reduced blood loss. With the flexibility to add the TSP intraoperatively to prevent femoral head medialisation, and cheaper implant costs, the DHS/TSP may become the preferred method of internal fixation.
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Affiliation(s)
- Rahul Geetala
- Clinical School of Medicine, University of Cambridge, Addenbrooke's Hospital, Hills Rd, Cambridge, CB2 0SP, UK.
- Trauma and Orthopaedics Department, Cambridge University Hospitals, Addenbrooke's Hospital, Hills Rd, Cambridge, CB2 0QQ, UK.
| | - Edward Wakefield
- Clinical School of Medicine, University of Cambridge, Addenbrooke's Hospital, Hills Rd, Cambridge, CB2 0SP, UK
- Trauma and Orthopaedics Department, Cambridge University Hospitals, Addenbrooke's Hospital, Hills Rd, Cambridge, CB2 0QQ, UK
| | - Florence Bradshaw
- Clinical School of Medicine, University of Cambridge, Addenbrooke's Hospital, Hills Rd, Cambridge, CB2 0SP, UK
- Trauma and Orthopaedics Department, Cambridge University Hospitals, Addenbrooke's Hospital, Hills Rd, Cambridge, CB2 0QQ, UK
| | - James Zhang
- Clinical School of Medicine, University of Cambridge, Addenbrooke's Hospital, Hills Rd, Cambridge, CB2 0SP, UK
- Trauma and Orthopaedics Department, Cambridge University Hospitals, Addenbrooke's Hospital, Hills Rd, Cambridge, CB2 0QQ, UK
| | - Matija Krkovic
- Trauma and Orthopaedics Department, Cambridge University Hospitals, Addenbrooke's Hospital, Hills Rd, Cambridge, CB2 0QQ, UK
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Hestehave RA, Gundtoft PH, Nielsen CL, Brink O, Rölfing JD. Poor usability of computer-assisted navigation for hip fracture surgery. Arch Orthop Trauma Surg 2024; 144:251-257. [PMID: 37878075 PMCID: PMC10774189 DOI: 10.1007/s00402-023-05096-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 09/28/2023] [Indexed: 10/26/2023]
Abstract
INTRODUCTION The STRYKER ADAPT computer-assisted navigation system provides intraoperative feedback to the surgeon regarding implant placement of the Gamma3 nail. The usability of the ADAPT system has not been evaluated. The aim of the study was to investigate the perceived usability of the ADAPT system. MATERIALS AND METHODS This was a descriptive study with prospectively collected data. ADAPT was introduced at Aarhus University Hospital in February 2021. Prior to introduction, surgeons at the department attended a general introduction to the system. ADAPT was introduced to the surgical nurses and was on display at the surgical ward at more than one occasion, where personal introduction to the system was possible. After introduction, it was mandatory to use ADAPT when using the Gamma3 nail to treat intertrochanteric femur fractures. After each procedure, primary and an eventual supervisor answered a questionnaire, which encompassed the System Usability Scale (SUS) questionnaire. The SUS is a ten-item questionnaire regarding the perceived usability of a system. SUS scores were translated to adjectives, describing user experience on a 7-point adjective scale (worst imaginable, awful, poor, ok, good, excellent, best imaginable). User acceptability, defined as "not acceptable", "marginal" or "acceptable", was also used to interpret the SUS scores. RESULTS ADAPT was used in 50 procedures by 29 different surgeons, with varying skill-level. Median SUS-score after first-time use of ADAPT for all 29 surgeons was 43 (range: 5-60), which translated to "poor" or "not acceptable". For surgeons who performed ≥ 3 ADAPT-assisted procedures, there were no statistically significant difference in their first to latest SUS-score (median difference: 4.3, p = 0.5). In free text comments ADAPT was positively described as helpful in placement of K-wire and providing educational opportunities for inexperienced surgeons and negatively as inconsistent, slow, time consuming, and causing excessive fluoroscopy. CONCLUSIONS Usability and acceptability of ADAPT was rated as "poor" or "not acceptable" by the majority of operating surgeons. ADAPT has not been used at our institution based on these findings. The System Usability Scale may be used in further research exploring usability and acceptability of novel computer-assisted navigation systems for orthopaedic surgery.
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Affiliation(s)
- Rasmus Abildtrup Hestehave
- Department of Orthopaedics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, J801, 8200, Aarhus, Denmark
| | - Per Hviid Gundtoft
- Department of Orthopaedics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, J801, 8200, Aarhus, Denmark
| | - Christian Lind Nielsen
- Department of Orthopaedics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, J801, 8200, Aarhus, Denmark
| | - Ole Brink
- Department of Orthopaedics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, J801, 8200, Aarhus, Denmark
| | - Jan Duedal Rölfing
- Department of Orthopaedics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, J801, 8200, Aarhus, Denmark.
- Corporate HR, MidtSim, Central Denmark Region, Hedeager 5, 8200, Aarhus, Denmark.
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Lai CY, Liu CH, Lai PJ, Hsu YH, Chou YC, Yu YH. Perioperative peri-implant fracture after osteosynthesis for geriatric femoral pertrochanteric fracture with the linear compression integrated screw intramedullary nail system (INTERTAN™): a retrospective study. J Orthop Surg Res 2023; 18:932. [PMID: 38057901 DOI: 10.1186/s13018-023-04441-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 12/03/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND Osteosynthesis for geriatric femoral pertrochanteric fractures using the linear compression integrated screw intramedullary nail system (INTERTAN™) has become popular. Nonetheless, cases of perioperative peri-implant fractures have been reported following this surgical technique. The factors responsible for this complication remain unclear. Therefore, we investigated perioperative peri-implant fracture risk factors and incidence, as well as overall outcomes, using the INTERTAN™ system for geriatric femoral pertrochanteric fractures. METHODS We retrospectively reviewed 98 consecutive patients with geriatric femoral pertrochanteric fractures after INTERTAN™ fixation, with at least a 12-month follow-up period between May 2020 and April 2022 at a single medical institute. The patients' demographic characteristics, fracture pattern, quality of reduction, quality of fixation, nail length, morphology of the femur, and perioperative complications were recorded and analyzed. RESULTS Among the 98 patients, 92 achieved union during follow-up. Twelve perioperative peri-implant fractures (12.2%) were recorded, all of which occurred during or within 1 month of osteosynthesis. Except for one patient who underwent re-osteosynthesis, the others underwent nonoperative treatment, and all achieved union. Multiple regression analysis revealed morphology of the femur with low-lesser trochanter width (odds ratio (OR) 0.532, 95% confidence interval (CI) 0.33-0.86, p = 0.01) to be the only factor contributing to perioperative peri-implant fractures. When the Youden index was used, the optimal cut-off value was 20.2 mm of low-lesser trochanter width. Low-lesser trochanter width < 20.2 mm was found to be a potential factor causing perioperative peri-implant fractures (OR 17.81, 95% CI 1.67-19.76, p = 0.017). CONCLUSIONS Morphology of the femur with a low-lesser trochanter width smaller than 20.2 mm was found to be the only potential contributor to perioperative peri-implant fractures when using INTERTAN™ for geriatric femoral pertrochanteric fractures. Care should be taken during osteosynthesis, focusing not only on the fracture site but also on the femoral cortex around the implant. Although perioperative peri-implant fractures were observed within one month following osteosynthesis, the majority of these cases were effectively treated without surgical intervention.
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Affiliation(s)
- Chih-Yang Lai
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital, Linkou Branch, and Chang Gung University, Taoyuan, Taiwan
| | - Chang-Heng Liu
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital, Linkou Branch, and Chang Gung University, Taoyuan, Taiwan
| | - Po-Ju Lai
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital, Linkou Branch, and Chang Gung University, Taoyuan, Taiwan
| | - Yung-Heng Hsu
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital, Linkou Branch, and Chang Gung University, Taoyuan, Taiwan
| | - Ying-Chao Chou
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital, Linkou Branch, and Chang Gung University, Taoyuan, Taiwan
| | - Yi-Hsun Yu
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital, Linkou Branch, and Chang Gung University, Taoyuan, Taiwan.
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Bai H, Liu L, Duan N, Xue H, Sun L, Li M, Li Z, Zhang K, Wang Q, Huang Q. Biomechanical evaluation of three implants for treating unstable femoral intertrochanteric fractures: finite element analysis in axial, bending and torsion loads. Front Bioeng Biotechnol 2023; 11:1279067. [PMID: 38026862 PMCID: PMC10661970 DOI: 10.3389/fbioe.2023.1279067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 10/30/2023] [Indexed: 12/01/2023] Open
Abstract
Purpose: How to effectively enhance the mechanical stability of intramedullary implants for unstable femoral intertrochanteric fractures (UFIFs) is challenging. The authors developed a new implant for managing such patients. Our aim was to enhance the whole mechanical stability of internal devices through increasing antirotation and medial support. We expected to reduce stress concentration in implants. Each implant was compared to proximal femoral nail antirotation (PFNA) via finite element method. Methods: Adult AO/OTA 31-A2.3 fracture models were constructed, and then the new intramedullary system (NIS), PFNA, InterTan nail models were assembled. We simulated three different kinds of load cases, including axial, bending, and torsion loads. For further comparison of PFNA and the NIS, finite element analysis (FEA) was repeated for five times under axial loads of 2100 N. Two types of displacement and stress distribution were assessed. Results: Findings showed that the NIS had the best mechanical stability under axial, bending, and torsion load conditions compared to PFNA and InterTan. It could be seen that the NIS displayed the best properties with respect to maximal displacement while PFNA showed the worst properties for the same parameter in axial loads of 2100 N. In terms of maximal stress, also the NIS exhibited the best properties while PFNA showed the worst properties in axial loads of 2100 N. For bending and torsion load cases, it displayed a similar trend with that of axial loads. Moreover, under axial loads of 2100 N, the difference between the PFNA group and the NIS group was statistically significant (p < 0.05). Conclusion: The new intramedullary system exhibited more uniform stress distribution and better biomechanical properties compared to the PFNA and InterTan. This might provide a new and efficacious device for managing unstable femoral intertrochanteric fractures.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Qian Wang
- Department of Orthopedics, Hong Hui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Qiang Huang
- Department of Orthopedics, Hong Hui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, China
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Carmona M, Gonzalez N, Segovia J, de Amesti M, Zamora T, Schweitzer D. Traction images heavily influence lateral wall measurement in trochanteric hip fractures. A prospective study. Injury 2023; 54 Suppl 6:110724. [PMID: 38143142 DOI: 10.1016/j.injury.2023.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 03/28/2023] [Accepted: 04/11/2023] [Indexed: 12/26/2023]
Abstract
INTRODUCTION hip fracture represents a global health problem, with a high morbidity and mortality rate and an increasing incidence. The treatment of trochanteric fractures is reduction and osteosynthesis, and implant selection depends mainly on the stability of the fracture and lateral wall competence. Lateral wall competence has gained relevance in recent years, which led to the modification of the AO/OTA classification. However, determination of lateral wall integrity is difficult from plain radiographs; the influence of images with traction on its measurement has not been evaluated. METHODS prospective concordance study, emergency and post-traction radiographs of 65 patients with trochanteric fracture were evaluated by six orthopedic surgeons independently, measuring the lateral wall, classifying the fracture according to the AO/OTA 2018 classification and selecting the implant for osteosynthesis. A comparison of incompetent to intact lateral wall proportion between each image set was made. Secondary outcomes were the inter-observer correlation of lateral wall measurement and inter-observer agreement of classification and implant choice. RESULTS the proportion of patients with an incompetent lateral wall in emergency x-ray was 37.43% (CI 95% 0.326-0.422), while the proportion in post-traction fluoroscopy was 15% (CI 95% 0.115-0.185), with a statistically significant difference (p < 0.001). 40.1% of patients with an incompetent lateral wall changed to an intact one. Inter-observer correlation for the lateral wall thickness was 0.399 (CI 95% 0.292-0.519) in emergency x-ray and 0.658 (CI 95% 0.564-0.748) in post-traction fluoroscopy, with a substantial agreement. Inter-observer agreement for the fracture classification was fair to moderate using emergency x-ray (κ 0.369 95%CI 0.330-0.408) and fair to moderate with post-traction fluoroscopy (κ 0.400, 95% CI 0.334-0.466). CONCLUSION traction images significantly change the measurement of the lateral wall in trochanteric fractures, changing from an incompetent to a competent wall in 40% of patients. The correct classification of trochanteric fractures is crucial to make the best decision when deciding which implant to use, and the measurement of the lateral wall is determinant in the actual AO/OTA classification. Therefore, traction images appear as necessary for correct decision-making.
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Affiliation(s)
- Maximiliano Carmona
- Department of Orthopedic Surgery, School of Medicine, Pontificia Universidad Catolica de Chile, Diagonal Paraguay 362, 3rd floor, Santiago 8330077, Chile.
| | - Nicolas Gonzalez
- Department of Orthopedic Surgery, School of Medicine, Pontificia Universidad Catolica de Chile, Diagonal Paraguay 362, 3rd floor, Santiago 8330077, Chile
| | - Javier Segovia
- Department of Orthopedic Surgery, School of Medicine, Pontificia Universidad Catolica de Chile, Diagonal Paraguay 362, 3rd floor, Santiago 8330077, Chile
| | - Martin de Amesti
- Department of Orthopedic Surgery, School of Medicine, Pontificia Universidad Catolica de Chile, Diagonal Paraguay 362, 3rd floor, Santiago 8330077, Chile
| | - Tomas Zamora
- Department of Orthopedic Surgery, School of Medicine, Pontificia Universidad Catolica de Chile, Diagonal Paraguay 362, 3rd floor, Santiago 8330077, Chile
| | - Daniel Schweitzer
- Department of Orthopedic Surgery, School of Medicine, Pontificia Universidad Catolica de Chile, Diagonal Paraguay 362, 3rd floor, Santiago 8330077, Chile
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Besnard M, Léger J, Babusiaux D, Marty F, Ropars M, Rosset P, Le Nail LR. Comparison of bleeding during trochanteric fracture fixation with mini-invasive or conventional side plate fixation: A randomized controlled trial. Orthop Traumatol Surg Res 2023; 109:103661. [PMID: 37474020 DOI: 10.1016/j.otsr.2023.103661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 03/04/2023] [Accepted: 06/06/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND Trochanteric fractures are a public health issue due to the aging of the population. Treatment aims to reduce their related morbidity and mortality and to allow an early return to independence. Postoperative anemia is associated with poorer functional recovery and an increased mortality rate. The aim of this study was to assess whether minimally invasive side plate fixation (Minimal Invasive Screw System, MISS™) resulted in reduced perioperative bleeding compared with conventional fixation (Pertrochanteric Hip Screw, PHS™). HYPOTHESIS We hypothesized that minimally invasive side plate fixation (MISS) would result in reduced perioperative bleeding compared with conventional fixation (PHS). PATIENTS AND METHODS We conducted an open randomized controlled trial with blinded assessment of the primary outcome. Inclusion criteria were patients aged over 65 years with isolated reducible trochanteric fracture. The 2 surgical implants were of the same shape, the only difference between them being the locking mode of the femoral neck screw on the plate of the MISS device, allowing a percutaneous approach. Primary outcome was perioperative bleeding evaluated with Mercuriali's formula. Secondary outcomes included operating time, scar length, length of hospital stay, radiological criteria such as quality of fracture reduction, implant positioning, bone healing, complications and functional recovery compared between the 2 groups. RESULTS One hundred and eight patients met the inclusion criteria and were randomized to receive either PHS (n=54) or MISS (n=54). Osteosynthesis with MISS significatively reduced perioperative bleeding (median 243mL, interquartile range [152-410] vs. 334mL [247-430] [p=0.0299]), operating time (65min [57-73] vs. 79min [66-89] [p=0.0002]) and scar length after 45 days (7cm [5-8] vs. 14cm [12-15] [p<0.0001]). There was no statistically significant difference between groups in postoperative complications, revision surgery or serious adverse events. CONCLUSION Compared with PHS, MISS reduced operating time, perioperative bleeding and scar length with no observed functional difference. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Marion Besnard
- Service de chirurgie orthopédique, centre hospitalier Robert-Debré, rue des Ursulines, 37403 Amboise cedex, France; Service de chirurgie orthopédique, hôpital Trousseau, centre hospitalier régional universitaire de Tours, 37044 Tours cedex 9, France.
| | - Julie Léger
- Centre hospitalier régional universitaire de Tours, Inserm CIC1415, 2, boulevard Tonnellé, 37044 Tours cedex 9, France
| | - Damien Babusiaux
- Service de chirurgie orthopédique, hôpital Trousseau, centre hospitalier régional universitaire de Tours, 37044 Tours cedex 9, France
| | - François Marty
- Service de chirurgie orthopédique, hôpital Trousseau, centre hospitalier régional universitaire de Tours, 37044 Tours cedex 9, France; Service d'orthopédie, centre hospitalier d'Albi, 22, boulevard du Général-Sibille, 81000 Albi, France
| | - Mickael Ropars
- Service de chirurgie orthopédique et traumatologique, centre hospitalier universitaire de Pontchaillou, 2, rue Henri-Le-Guilloux, 35033 Rennes cedex 9, France
| | - Philippe Rosset
- Service de chirurgie orthopédique, hôpital Trousseau, centre hospitalier régional universitaire de Tours, 37044 Tours cedex 9, France; Université François-Rabelais de Tours, PRES centre-Val de Loire université, 60, rue du Plat d'Étain, 37020 Tours cedex 1, France
| | - Louis-Romée Le Nail
- Service de chirurgie orthopédique, hôpital Trousseau, centre hospitalier régional universitaire de Tours, 37044 Tours cedex 9, France; Université François-Rabelais de Tours, PRES centre-Val de Loire université, 60, rue du Plat d'Étain, 37020 Tours cedex 1, France; CNRS ERL 7001 Leukemic niche & redox metabolisme (LNOX)/Niche leucémique et métabolisme oxydatif, EA 7501 GICC, université de Tours, 60, rue du Plat d'Étain, 37020 Tours cedex 1, France
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16
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Zhou X, Chen XH, Li SH, Li N, Liu F, Wang HM. Effects of surgical treatment modalities on postoperative cognitive function and delirium in elderly patients with extremely unstable hip fractures. World J Psychiatry 2023; 13:533-542. [PMID: 37701542 PMCID: PMC10494770 DOI: 10.5498/wjp.v13.i8.533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 06/15/2023] [Accepted: 07/05/2023] [Indexed: 08/17/2023] Open
Abstract
BACKGROUND As the perioperative risk of elderly patients with extremely unstable hip fractures (EUHFs) is relatively high and therapeutic effect is not satisfactory, new thera-peutic strategies need to be proposed urgently to improve the efficacy and clinical outcomes of such patients. AIM To determine the influence of two surgical treatment modalities on postoperative cognitive function (CF) and delirium in elderly patients with EUHFs. METHODS A total of 60 elderly patients consecutively diagnosed with EUHF between September 2020 and January 2022 in the Chongqing University Three Gorges Hospital were included. Of them, 30 patients received conventional treatment (control group; general consultation + fracture type-guided internal fixation), and the other 30 received novel treatment (research group; perioperative multidisciplinary treatment diagnosis and treatment + individualized surgical plan + risk prediction). Information on hip function [Harris hip score (HHS)], perioperative risk of orthopedic surgery [Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM)], CF [Montreal cognitive assessment scale (MoCA)], postoperative delirium [mini-cognitive (Mini-Cog)], adverse events (AEs; internal fixation failure, infection, nonunion, malunion, and postoperative delirium), and clinical indicators [operation time (OT), postoperative hospital length of stay (HLOS), ambulation time, and intraoperative blood loss (IBL)] were collected from both groups for comparative analyses. RESULTS The HHS scores were similar between both groups. The POSSUM score at 6 mo after surgery was significantly lower in the research group compared with the control group, and MoCA and Mini-Cog scores were statistically higher. In addition, the overall postoperative complication rate was significantly lower in the research than in the control group, including reduced OT, postoperative HLOS, ambulation time, and IBL. CONCLUSION The new treatment modality has more clinical advantages over the conventional treatment, such as less IBL, faster functional recovery, more effectively optimized perioperative quality control, improved postoperative CF, mitigated postoperative delirium, and reduced operation-related AEs.
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Affiliation(s)
- Xue Zhou
- Department of Operating Room, Chongqing University Three Gorges Hospital, Chongqing 404000, China
| | - Xiao-Hua Chen
- Department of Orthopedics, Chongqing University Three Gorges Hospital, Chongqing 404000, China
- Chongqing Municipality Clinical Research Center for Geriatric Diseases, Chongqing University Three Gorges Hospital, Chongqing 404000, China
| | - Sheng-Hua Li
- Department of Orthopedics, Chongqing University Three Gorges Hospital, Chongqing 404000, China
- Chongqing Municipality Clinical Research Center for Geriatric Diseases, Chongqing University Three Gorges Hospital, Chongqing 404000, China
| | - Nan Li
- Department of Orthopedics, Chongqing University Three Gorges Hospital, Chongqing 404000, China
| | - Feng Liu
- Department of Orthopedics, Chongqing University Three Gorges Hospital, Chongqing 404000, China
| | - Hao-Ming Wang
- Department of Orthopedics, Chongqing University Three Gorges Hospital, Chongqing 404000, China
- Chongqing Municipality Clinical Research Center for Geriatric Diseases, Chongqing University Three Gorges Hospital, Chongqing 404000, China
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Grønhaug KML, Dybvik E, Matre K, Östman B, Gjertsen JE. Comparison of Intramedullary Nails in the Treatment of Trochanteric and Subtrochanteric Fractures: An Observational Study of 13,232 Fractures in the Norwegian Hip Fracture Register. J Bone Joint Surg Am 2023; 105:1227-1236. [PMID: 37418538 DOI: 10.2106/jbjs.22.01245] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/09/2023]
Abstract
BACKGROUND Intramedullary nails are commonly used in the treatment of trochanteric and subtrochanteric fractures. We aimed to compare intramedullary nails in widespread use in Norway on the basis of reoperation risk. METHODS We assessed data from 13,232 trochanteric or subtrochanteric fractures treated with an intramedullary nail and registered in the Norwegian Hip Fracture Register between 2007 and 2019. The primary outcome measure was the risk of reoperation for various types of short and long intramedullary nails. Secondly, we compared risk of reoperation for the selected nails with respect to fracture type (AO/OTA type A1, A2, A3, and subtrochanteric fractures). Cox regression analysis adjusted for sex, age, and American Society of Anesthesiologists class was used to estimate hazard rate ratios (HRRs) for reoperation. RESULTS The mean patient age was 82.9 years, and 72.8% of the nails were used in the treatment of female patients. We included 8,283 short and 4,949 long nails. A1 fractures accounted for 29.8%, A2 for 40.6%, A3 for 7.2%, and subtrochanteric fractures for 22.4%. When comparing short nails regardless of fracture type, the TRIGEN INTERTAN had an increased risk of reoperation at 1 year (HRR, 1.31 [95% confidence interval (CI), 1.03 to 1.66]; p = 0.028) and 3 years (HRR, 1.31 [95% CI, 1.07 to 1.61]; p = 0.011) postoperatively compared with the Gamma3. For individual fracture types, we found no significant differences in reoperation risk between the various types of short nails. When comparing long nails, the TRIGEN TAN/FAN had an increased risk of reoperation at 1 year (HRR, 3.05 [95% CI, 2.10 to 4.42]; p < 0.001) and 3 years (HRR, 2.54 [95% CI, 1.82 to 3.54]; p < 0.001) postoperatively compared with the long Gamma3. CONCLUSIONS This study may indicate a slightly increased risk of reoperation for the short TRIGEN INTERTAN compared with other short nails in widespread use in Norway. In analyses of long nails, the TRIGEN TAN/FAN nail was associated with a higher risk of reoperation in the treatment of trochanteric and subtrochanteric fractures. LEVEL OF EVIDENCE Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Kirsten Marie Larsen Grønhaug
- Department of Orthopedic Surgery, Østfold Hospital Trust, Sarpsborg, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Eva Dybvik
- Norwegian Hip Fracture Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Kjell Matre
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Norwegian Hip Fracture Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Bengt Östman
- Department of Orthopedic Surgery, Østfold Hospital Trust, Sarpsborg, Norway
| | - Jan-Erik Gjertsen
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Norwegian Hip Fracture Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway
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18
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Rau Y, Amtsfeld J, Reimers N, Matrisch L, Frese J, Schulz AP. The development, incidence and treatment trends of trochanteric fractures in Germany: a cohort study. J Orthop Surg Res 2023; 18:491. [PMID: 37430277 PMCID: PMC10331963 DOI: 10.1186/s13018-023-03981-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 07/04/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND Hip fractures are a major public health problem worldwide and can lead to disability, increased mortality, and reduced quality of life. We aim to provide a nationwide epidemiological analysis of trochanteric and subtrochanteric fractures and their respective surgical treatments. METHODS Data were retrieved from the national database of the German Department of the Interior. ICD-10-GM and OPS data from the period of 2006 to 2020 were analysed and all patients with trochanteric and subtrochanteric fractures as their main diagnosis, who were treated in a German hospital, were included. Patients were grouped by age and gender and linear regression was performed where suitable to calculate statistically significant correlations between variables and incidences. RESULTS 985,104 pertrochanteric fractures and 178,810 subtrochanteric fractures were reported during the analysed period. We calculated a mean incidence of 80.08 ± 6.34 for pertrochanteric and 14.53 ± 1.50 for subtrochanteric fractures per million inhabitants. In both fracture types, a distinct dependence of incidence on age can be determined. Incidence rates equally rise in both sexes through the age groups with an increase of about 288-fold from those under the age of 60 to those over the age of 90 in pertrochanteric fractures, and about 123-fold in subtrochanteric fractures. Intramedullary nailing was the most common kind of treatment for both fracture types with augmentative cerclages on the rise throughout the whole period. Plate and dynamic compression screws were decreasing in frequency over the analysed period in both fractures. CONCLUSIONS We provided incidence data on per- and subtrochanteric fractures and their treatment. We calculated an economic impact of approximately 1.563 billion € per year in Germany. With regards to recent literature on costs of treatment and our findings regarding the implementation and utilization of different treatment methods, we conclude that the reinforcement of nationwide prevention programs is a relevant step in lessening the economic burden. We welcome the increased utilisation of intramedullary nailing as many studies show beneficiary outcomes and cost effectiveness in most of the included fracture types.
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Affiliation(s)
- Yannick Rau
- Faculty of Medicine, Universität zu Lübeck, Lübeck, Germany.
- Zentrum Klinische Forschung, BG Klinikum Hamburg, Hamburg, Germany.
| | - Jasper Amtsfeld
- Chair of Technology Management, Christian-Albrechts-Universität zu Kiel, Kiel, Germany
| | - Nils Reimers
- Stryker Trauma GmbH, Schoenkirchen, Germany
- Queensland University of Technology, Brisbane City, Australia
| | | | - Jasper Frese
- Zentrum Klinische Forschung, BG Klinikum Hamburg, Hamburg, Germany
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Klinikum Hamburg, Hamburg, Germany
| | - Arndt-Peter Schulz
- Faculty of Medicine, Universität zu Lübeck, Lübeck, Germany
- Zentrum Klinische Forschung, BG Klinikum Hamburg, Hamburg, Germany
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Klinikum Hamburg, Hamburg, Germany
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19
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Zeelenberg ML, Nugteren LHT, Plaisier AC, Loggers SAI, Joosse P, Den Hartog D, Verhofstad MHJ, van Lieshout EMM. Extramedullary versus intramedullary fixation of stable trochanteric femoral fractures: a systematic review and meta-analysis. Arch Orthop Trauma Surg 2023:10.1007/s00402-023-04902-1. [PMID: 37129692 PMCID: PMC10374813 DOI: 10.1007/s00402-023-04902-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 04/19/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVE This systematic review and meta-analysis compared extramedullary fixation and intramedullary fixation for stable two-part trochanteric femoral fractures (AO type 31-A1) with regards to functional outcomes, complications, and surgical outcomes. METHODS Embase, Medline, Web of Science, Cochrane Central Register of Controlled Trials, and Google Scholar were searched for randomized controlled trials (RCTs) and observational studies. Effect estimates were pooled across studies using random effects models. Results were presented as weighted risk ratio (RR) or weighted mean difference (MD) with corresponding 95% confidence interval (95% CI). RESULTS Five RCTs (397 patients) and 14 observational studies (21,396 patients) were included. No significant differences in functional outcomes, complications, or surgical outcomes were found between extramedullary and intramedullary fixation devices, except for a difference in duration of surgery (MD 14.1 min, CI 5.76-22.33, p < 0.001) and intra-operative blood loss (MD 92.30 mL, CI 13.49-171.12, p = 0.02), favoring intramedullary fixation. CONCLUSION Current literature shows no meaningful differences in complications, surgical, or functional outcomes between extramedullary and intramedullary fixation of stable two-part trochanteric femoral fractures. Both treatment options result in good outcomes. This study implicates that, costs should be taken into account when considering implants or comparing fixation methods in future research.
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Affiliation(s)
- Miliaan L Zeelenberg
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Leendert H T Nugteren
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - A Cornelis Plaisier
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Sverre A I Loggers
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
- Department of Surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Pieter Joosse
- Department of Surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Dennis Den Hartog
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Michael H J Verhofstad
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Esther M M van Lieshout
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
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20
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Raj S, Grover S, Bola H, Pradhan A, Fazal MA, Patel A. Dynamic hip screws versus cephalocondylic intramedullary nails for unstable extracapsular hip fractures in 2021: A systematic review and meta-analysis of randomised trials. J Orthop 2023; 36:88-98. [PMID: 36654796 PMCID: PMC9841034 DOI: 10.1016/j.jor.2022.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 12/15/2022] [Accepted: 12/29/2022] [Indexed: 01/09/2023] Open
Abstract
Background Extracapsular hip fractures comprise approximately half of all hip fractures and the incidence of hip fractures is exponentially increasing. Extramedullary fixation using a dynamic hip screw (DHS) has been the gold standard method of operative treatment for unstable extracapsular fractures, however, in recent years, intramedullary nails (IMN) have become a popular alternative. IMN versus DHS is continuously discussed and debated in literature. Therefore, the purpose of this systematic review and meta-analysis is to directly compare the peri- and post-operative outcomes of these two techniques to provide an up-to-date analysis of which method of fixation is superior. Methods The MEDLINE/PubMed, Embase and Web of Science Database were searched for eligible studies from 2008 to April 2022 that compared peri- and post-operational outcomes for patients undergoing IMN or DHS operations for fixation of unstable extracapsular hip fractures (PROSPERO registration ID:CRD42021228335). Primary outcomes included mortality rate and re-operation rate. Secondary outcomes included operation time, blood loss, transfusion requirement, complication, and failure of fixation rate. The risk of bias and quality of evidence were assessed using the Cochrane RoB 2.0 tool and GRADE analysis tool, respectively. Results Of the 6776 records identified, 22 studies involving 3151 patients were included in the final review. Our meta-analysis showed no significant differences between mortality rates (10 studies, OR 0.98; 95% CI 0.80 to 1.22, p = 0.88) or re-operation rates (10 studies, OR 1.03; 95% CI 0.64 to 1.64, p = 0.91) between the two procedures. There were also no significant differences found between complication rates (17 studies, OR 1.29; 95% CI 0.79 to 2.12, p = 0.31) and failure of fixation rates (14 studies, OR 1.32; 95% CI 0.74 to 2.38, p = 0.35). However, DHS operations had a significantly longer operation time (p < 0.0001) and blood loss (p < 0.00001) than IMN operations. Conclusion Overall, based on the outcomes assessed, this review has demonstrated that there is no significant difference in the post-operative outcomes for DHS vs IMN, however a significant difference exists in two of the intraoperative outcomes assessed in this review.
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Affiliation(s)
- Siddarth Raj
- GKT School of Medical Education, King's College London, London, UK
- University Hospital Coventry and Warwickshire, NHS Trust, Coventry, UK
| | - Sarika Grover
- GKT School of Medical Education, King's College London, London, UK
- University Hospital Coventry and Warwickshire, NHS Trust, Coventry, UK
| | - Harroop Bola
- Imperial College School of Medicine, Imperial College London, London, UK
| | | | - Muhammad Ali Fazal
- Department of Trauma and Orthopaedics, Royal Free London NHS Foundation Trust, London, UK
| | - Akash Patel
- Department of Trauma and Orthopaedics, Royal Free London NHS Foundation Trust, London, UK
- School of Medicine, University College London (UCL), London, UK
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21
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Tang L, Yi X, Yuan T, Li H, Xu C. Navigated intramedullary nailing for patients with intertrochanteric hip fractures is cost-effective at high-volume hospitals in mainland China: A markov decision analysis. Front Surg 2023; 9:1048885. [PMID: 36726954 PMCID: PMC9885142 DOI: 10.3389/fsurg.2022.1048885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 12/23/2022] [Indexed: 01/17/2023] Open
Abstract
Objective Previous studies have reported that navigation systems can improve clinical outcomes of intramedullary nailing (IMN) for patients with intertrochanteric fractures. However, information is lacking regarding the relationship between the costs of navigated systems and clinical outcomes. The present research aimed to evaluate the cost-effectiveness of navigated IMN as compared with traditional freehand IMN for patients with intertrochanteric fractures. Methods A Markov decision model with a 5-year time horizon was constructed to investigate the costs, clinical outcomes and incremental cost-effectiveness ratio (ICER) of navigated IMN for a 70-year-old patient with an intertrochanteric fracture in mainland China. The costs [Chinese Yuan (¥)], health utilities (quality-adjusted life-years, QALYs) and transition probabilities were obtained from published studies. The willingness-to-pay threshold for ICER was set at ¥1,40,000/QALY following the Chinese gross domestic product in 2020. Three institutional surgical volumes were used to determine the average navigation-related costs per patient: low volume (100 cases), medium volume (200 cases) and high volume (300 cases). Results Institutes at which 300, 200 and 100 cases of navigated IMN were performed per year showed an ICER of ¥43,149/QALY, ¥76,132.5/QALY and ¥1,75,083/QALY, respectively. Navigated IMN would achieve cost-effectiveness at institutes with an annual volume of more than 125 cases. Conclusions Our analysis demonstrated that the navigated IMN could be cost-effective for patients with inter-trochanteric fracture as compared to traditional freehand IMN. However, the cost-effectiveness was more likely to be achieved at institutes with a higher surgical volume.
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Affiliation(s)
- Liang Tang
- Department of Orthopaedics, Hengyang Central Hospital, The Affiliated Hengyang Hospital of Southern Medical University, Hengyang, China,Correspondence: Liang Tang Hua Li Cheng Xu
| | - Xiaoke Yi
- Department of Orthopaedics, Hengyang Central Hospital, The Affiliated Hengyang Hospital of Southern Medical University, Hengyang, China
| | - Ting Yuan
- Department of Orthopaedics, Hengyang Central Hospital, The Affiliated Hengyang Hospital of Southern Medical University, Hengyang, China
| | - Hua Li
- Senior Department of Orthopaedics, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, China,National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, China,Correspondence: Liang Tang Hua Li Cheng Xu
| | - Cheng Xu
- Senior Department of Orthopaedics, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, China,National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, China,Correspondence: Liang Tang Hua Li Cheng Xu
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22
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Pyrhönen HS, Lagergren J, Wolf O, Bojan A, Mukka S, Möller M, Rogmark C. No Difference in Conversion Rate to Hip Arthroplasty After Intramedullary Nail or Sliding Hip Screw for Extracapsular Hip Fractures: An Observational Cohort Study of 19,604 Individuals. J Bone Joint Surg Am 2022; 104:1703-1711. [PMID: 35880754 DOI: 10.2106/jbjs.22.00316] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The widespread use of intramedullary nails (IMNs) compared with sliding hip screws (SHSs) in extracapsular hip fractures (AO/OTA 31-A1, 31-A2, 31-A3) has been questioned because of a higher complication rate, although the outcome might have improved through more recent implant designs and the learning curve. This study aimed to investigate if there is a difference with regard to the cumulative incidence of conversion to arthroplasty or any reoperation during the first 5 years after IMN or SHS fixation of extracapsular hip fractures. METHODS In this nationwide, observational cohort study, individuals who were ≥60 years of age and were registered in the Swedish Fracture Register (SFR) from 2012 to 2018 due to extracapsular fracture and were primarily treated with an IMN or SHS were followed in the SFR and the Swedish Arthroplasty Register (SAR) for a minimum of 1 year. The primary outcome was the cumulative incidence of conversion to arthroplasty (conversion rate). The secondary outcome was the cumulative incidence of all reoperations (reoperation rate). Both were calculated in a competing risk analysis during the first 5 years. RESULTS We included 19,604 individuals (70% women), with a median age of 85 years (range, 60 to 107 years). The 31-A2 fracture was most prevalent (52%), followed by the 31-A1 fracture (28%). No significant differences were seen in the 1-year conversion rate after IMN or SHS use (1.0% compared with 0.9% in the 31-A1 fractures, 1.7% compared with 1.3% in the 31-A2 fractures, and 1.3% compared with 1.5% in the 31-A3 fractures) or in the 1-year reoperation rate (1.9% compared with 1.9% in the type-A1 fractures, 3.4% compared with 2.5% in the type-A2 fractures, and 4.0% compared with 5.2% in the type-A3 fractures). Only in 31-A2 fractures were more reoperations seen after IMN use at 2 and 5 years (p < 0.05). The crude 1-year-mortality was 26.4% (5,178 of 19,604), without significant differences between implants. CONCLUSIONS Considering conversion arthroplasty, IMNs and SHSs performed equally well in general. IMN use was associated with more reoperations than SHS use in 31-A2 fractures at 2 years. However, from a clinical perspective, the differences between the implants were small, in particular when considering the competing risk of dying. LEVEL OF EVIDENCE Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Helmi-Sisko Pyrhönen
- Department of Orthopaedics, Skåne University Hospital & Faculty of Medicine, Lund University, Malmö, Sweden
| | - Johan Lagergren
- Western Hospital Group, Region Västra Götaland & Faculty of Medicine, Lund University, Lund, Sweden
| | - Olof Wolf
- Orthopaedics, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.,Swedish Fracture Register, Gothenburg, Sweden
| | - Alicja Bojan
- Department of Orthopaedics, Sahlgrenska University Hospital Gothenburg/Mölndal & Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Sebastian Mukka
- Department of Surgical and Perioperative Sciences (Orthopedics), Umeå University, Umeå, Sweden
| | - Michael Möller
- Swedish Fracture Register, Gothenburg, Sweden.,Department of Orthopaedics, Sahlgrenska University Hospital Gothenburg/Mölndal & Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Cecilia Rogmark
- Department of Orthopaedics, Skåne University Hospital & Faculty of Medicine, Lund University, Malmö, Sweden.,Swedish Arthroplasty Register, Gothenburg, Sweden
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23
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Baldock TE, Dixon JR, Koubaesh C, Johansen A, Eardley WGP. Variation of implant use in A1 and A2 trochanteric hip fractures : a study from the National Hip Fracture Database of England and Wales. Bone Jt Open 2022; 3:741-745. [PMID: 36181320 PMCID: PMC9626874 DOI: 10.1302/2633-1462.310.bjo-2022-0104.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
AIMS Patients with A1 and A2 trochanteric hip fractures represent a substantial proportion of trauma caseload, and national guidelines recommend that sliding hip screws (SHS) should be used for these injuries. Despite this, intramedullary nails (IMNs) are routinely implanted in many hospitals, at extra cost and with unproven patient outcome benefit. We have used data from the National Hip Fracture Database (NHFD) to examine the use of SHS and IMN for A1 and A2 hip fractures at a national level, and to define the cost implications of management decisions that run counter to national guidelines. METHODS We used the NHFD to identify all operations for fixation of trochanteric fractures in England and Wales between 1 January 2021 and 31 December 2021. A uniform price band from each of three hip fracture implant manufacturers was used to set cost implications alongside variation in implant use. RESULTS We identified 18,156 A1 and A2 trochanteric hip fractures in 162 centres. Of these, 13,483 (74.3%) underwent SHS fixation, 2,352 (13.0%) were managed with short IMN, and 2,321 (12.8%) were managed with long IMN. Total cost of IMN added up to £1.89 million in 2021, and the clinical justification for this is unclear since rates of IMN use varied from 0% to 97% in different centres. CONCLUSION Most trochanteric hip fractures are managed with SHS, in keeping with national guidelines. There is considerable variance between hospitals for implant choice, despite the lack of evidence for clinical benefit and cost-effectiveness of more expensive nailing systems. This suggests either a lack of awareness of national guidelines or a choice not to follow them. We encourage provider units to reassess their practice if outwith the national norm. Funding bodies should examine implant use closely in this population to prevent resource waste at a time of considerable health austerity.Cite this article: Bone Jt Open 2022;3(10):741-745.
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Affiliation(s)
- Thomas E. Baldock
- Health Education England North East, Newcastle upon Tyne, UK,South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Jan R. Dixon
- Royal Victoria Hospital, Newcastle upon Tyne, United Kingdom
| | | | - Antony Johansen
- University Hospital of Wales, Cardiff, UK,National Falls and Fragility Fracture Audit Programme (FFFAP), Royal College of Physicians, London, UK
| | - William G. P. Eardley
- South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK,National Falls and Fragility Fracture Audit Programme (FFFAP), Royal College of Physicians, London, UK,Department of Health Sciences, University of York, York, UK,Correspondence should be sent to William G. P. Eardley. E-mail:
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24
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Nie S, Li J, Li M, Hao M, Wang K, Xiong Y, Gan X, Zhang L, Tang P. Finite-Element Analysis of a Novel Cephalomedullary Nail for Restricted Sliding to Reduce Risk of Implant Failure in Unstable Intertrochanteric Fractures. Orthop Surg 2022; 14:3009-3018. [PMID: 36120825 PMCID: PMC9627085 DOI: 10.1111/os.13497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/09/2022] [Accepted: 08/11/2022] [Indexed: 11/30/2022] Open
Abstract
Objective How to restrict sliding of cephalomedullary nail and rigid reconstruct medial support for unstable intertrochanteric fractures remains a challenge. This study aims to explore the feasibility of a novel cephalomedullary nail for restriction sliding and reconstruction of medial femoral support to prevent failure in unstable trochanteric fractures through finite element analysis. Methods The DICOM files of a unilateral femur spiral computed tomography (CT) scans from a elderly female were converted into STL files, and the most common clinical trochanteric fracture model with the absence of medial support, AO/OTA 31‐A2.3 was simulated by removing the posterior medial femur. The model of a novel medial sustain nail (MSN‐II) and a widely used nail (proximal femoral nail anti‐rotation PFNA‐II) were modeled according to the manufacturer‐provided engineering drawing. Different loads were applied to the femoral head to simulate the postoperative weight bearing gait. The sliding distance of helical blade in femoral neck, maximum stress of femur and nail, displacement of proximal fragment were analyzed to revealing the mechanical stability of unstable trochanteric fracture stabilized by different implant. Results The sliding distance of helical blade in the femoral neck, the maximum stress on the femur and nail, the displacement of proximal fragment in MSN‐II under 2100N axial load were 0.65 mm, 689 MPa, 1271 MPa, 16.84 mm respectively, while that were 1.43 mm, 720.8 MPa, 1444 MPa, 18.18 mm, respectively in PFNA‐II. The difference between the two groups was statistically significant (P < 0.05) and the stress was mainly distributed in medial distal side of nail but helical blade and the proximal aperture for the nail in MSN‐II. Compared to PFNA‐II, MSN‐II demonstrates biomechanical merit against femur medialization, cut‐out and coax varus. Conclusion The sliding distance of helical blade in femoral neck, the maximum stress on the femur and nail, and the displacement of proximal fragment of MSN‐II were less than those of PFNA‐II in the treatment of unstable intertrochanteric fractures. Therefore MSN‐II has better stability than PFNA‐II and it may have the potential to avoid femur medialization and cut out. It might be an option in unstable trochanteric fracture because of its superiority in restricted sliding and medial support reconstruction.
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Affiliation(s)
- Shaobo Nie
- Department of Orthopedics, PLA General Hospital, Beijing, China.,National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, China
| | - Jiantao Li
- Department of Orthopedics, PLA General Hospital, Beijing, China.,National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, China
| | - Ming Li
- Department of Orthopedics, PLA General Hospital, Beijing, China.,National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, China
| | - Ming Hao
- Department of Orthopedics, PLA General Hospital, Beijing, China.,National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, China
| | - Kun Wang
- Department of Orthopedics, PLA General Hospital, Beijing, China.,National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, China
| | - Ying Xiong
- Department of orthopedics, Yan'an Hospital Affiliated to Kunming Medical University, Kunming, China
| | - Xuewen Gan
- Department of orthopedics, Yan'an Hospital Affiliated to Kunming Medical University, Kunming, China
| | - Licheng Zhang
- Department of Orthopedics, PLA General Hospital, Beijing, China.,National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, China
| | - Peifu Tang
- Department of Orthopedics, PLA General Hospital, Beijing, China.,National Clinical Research Center for Orthopedics, Sports Medicine & Rehabilitation, Beijing, China
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25
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Xu H, Liu Y, Sezgin EA, Tarasevičius Š, Christensen R, Raina DB, Tägil M, Lidgren L. Comparative effectiveness research on proximal femoral nail versus dynamic hip screw in patients with trochanteric fractures: a systematic review and meta-analysis of randomized trials. J Orthop Surg Res 2022; 17:292. [PMID: 35658909 PMCID: PMC9164432 DOI: 10.1186/s13018-022-03189-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 05/18/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The treatments for trochanteric fractures try to regain early mobility and limit morbidity and risk of reoperations. The most currently used dynamic hip screw (DHS) and the proximal femoral nail (PFN) are both with pros and cons. We aimed to assess the comparative effectiveness of these interventions for trochanteric fractures by evaluating the surgical performance and postoperative outcomes. METHODS PubMed, Web of Science and Cochrane Central Register were searched for RCTs comparing DHS and PFN for trochanteric fractures. All selected studies and the risk of bias were assessed. Clinical data including operative time, intraoperative blood loss, intraoperative fluoroscopy time, successful closed reduction and complications like nonunion, implant failure and reoperation were recorded. Random-effects models were used in Review Manager software, and GRADE was applied for the interpretation of the evidence. RESULTS From 286 identified trials, twelve RCTs including 1889 patients were eligible for inclusion; six RCTs directly comparing DHS with PFN, while other six compared DHS with proximal femoral nail antirotation (PFNA). Compared to DHS, PFN had shorter operative time and led to less intraoperative blood loss. However, DHS need less intraoperative fluoroscopy time than PFN. No difference was seen for the achievement of closed reduction. For risk of postoperative complications, no difference was seen between PFN and DHS for non-union, risk of implant failure and revision surgery. CONCLUSIONS PFN(A) resulted in a shorter operative time and less intraoperative blood loss compared to DHS. However, no difference was seen for postoperative complications. Trial registration PROSPERO: CRD42021239974.
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Affiliation(s)
- Hong Xu
- Department of Orthopaedics, Xiaoshan Traditional Chinese Medical Hospital, Hangzhou, Zhejiang Province, China.
| | - Yang Liu
- Department of Clinical Sciences Lund, The Faculty of Medicine, Orthopedics, Lund University, Lund, Sweden
| | - Erdem Aras Sezgin
- Department of Orthopaedics&Traumatology, Faculty of Medicine, Aksaray University, Aksaray, Turkey
| | - Šarūnas Tarasevičius
- Department of Orthopedics, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Robin Christensen
- Section for Biostatistics and Evidence-Based Research, The Parker Institute, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
- Research Unit of Rheumatology, Department of Clinical Research, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - Deepak Bushan Raina
- Department of Clinical Sciences Lund, The Faculty of Medicine, Orthopedics, Lund University, Lund, Sweden
| | - Magnus Tägil
- Department of Clinical Sciences Lund, The Faculty of Medicine, Orthopedics, Lund University, Lund, Sweden
| | - Lars Lidgren
- Department of Clinical Sciences Lund, The Faculty of Medicine, Orthopedics, Lund University, Lund, Sweden
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