Decision Making in the Management of Extracapsular Fractures of the Proximal Femur - is the Dynamic Hip Screw the Prevailing Gold Standard?

Different surgical interventions for unstable intertrochanteric fracture of the femur: Network meta-analysis

OBJECTIVE

Although a large body of evidence has reported on surgical approaches for the treatment of unstable intertrochanteric femoral fractures, studies that comprehensively evaluate treatment outcomes are limited. The purpose of this study was to compare the effectiveness of extramedullary fixation (i.e., dynamic hip screw [DHS]), intramedullary fixation (i.e., the proximal femoral nailing [PFN]), and hemiarthroplasty (HA) for the treatment of unstable intertrochanteric femoral fractures using network meta-analysis.

METHODS

This study meets the preferred reporting items for systematic reviews and meta-analyses criteria. The Patient, Intervention, Comparison and Outcome search protocol framework was used to search the Google Scholar, PubMed, Embase, and Cochrane Library databases were searched from inception until June 2023.

RESULTS

A total of 15 randomized controlled trials, including 1282 patients were analyzed. The Harris hip score (HHS) after DHS fixation was the lowest compared with that of PFN fixation and HA. DHS fixation had a significantly longer operation time than that of PFN fixation. Compared with HA, a lower incidence of superficial wound infection was observed with PFN and DHS fixations. PFN was significantly more likely to be implant cut out compared with HA. Compared with DHS, PFN and HA showed a lower incidence of fracture healing malunion.

CONCLUSION

HA and PFN have good efficacy in improving the HHS and preventing joint deformities. However, HA showed a higher incidence of superficial infection than that observed with PFN, whereas a higher risk of screw cutout is observed with PFN than with HA.

Evolving trends in hip fracture patterns among the elderly from 2001 to 2022

INTRODUCTION

Hip fractures among the elderly exhibit diverse patterns. Differences regarding treatment and prognosis of displaced versus undisplaced intracapsular fractures are well established. Unstable extracapsular fractures are associated with considerably higher rates of complications than stable fractures, including cutout failures, non-unions, wound complications and hardware related problems. The purpose of this study was to identify trends in the distribution of various types of hip fractures and their complexity between 2001 and 2022.

METHODS

This retrospective study compared hip fractures treated in the years 2001, 2006, 2010, 2014, 2018, and 2022, excluding patients under 60 years old and those with pathological or peri‑prosthetic fractures. Radiographs were reviewed and fracture patterns were categorized as stable extracapsular, unstable extracapsular, subtrochanteric or intracapsular.

RESULTS

Out of 2646 patients admitted with proximal femoral fractures during these years, 2277 patients (69.5 % women) were available for analysis. Over the initial decade, the mean patient age gradually increased from 80 to 82, subsequently stabilizing. Gender distribution remained consistent, and the proportion of intracapsular fractures showed minimal variation (36-38 %). The most significant finding was the marked decrease in the proportion of stable-to-unstable extracapsular fractures during the first decade from 51 % to 31 %, followed by stabilization after 2010. Subgroup analysis by age revealed that while the proportion change between stable and unstable fractures remained insignificant in younger age groups (p = 0.41 for sexagenarians and 0.12 for septuagenarians), a significant change was observed in older patients (p = 0.002 for octogenarians and 0.04 for nonagenarians and older patients).

DISCUSSION

This study reveals a surge in unstable peritrochanteric fractures between 2001 and 2010, particularly pronounced in patients over 80. This trend plateaued in the following decade, aligning with the stabilization of the cohort's mean age at 82. Numerous factors, from bone morphology to systemic markers, influence hip fracture types. Evolutions in osteoporosis screening and treatment over the last three decades may have contributed to the observed shifts in fracture pattern distribution.

CONCLUSION

Understanding these trends enriches treatment strategies and underscores the need for further exploration of the interplay between demographic and anatomical factors in the etiology of specific fracture patterns.

Experimental and numerical analysis of the influence of intramedullary nail position on the cut-out phenomenon

BACKGROUND AND OBJECTIVE

Proximal femur fractures, colloquially known as hip fractures, are a common pathology with increasing incidence in the last years due to the enhanced ageing population. Regarding the extracapsular fracture, the treatment for this pathology consists of a fixation of the fragments using an osteosynthesis device, mainly the intramedullary nail. This repairing method implies several complications, which may include the failure of the fixation device, frequently occurring due to the "cut-out" mechanism. The present work focuses on the study of how the position of the cephalic screw, which should be fixed during surgery, affects the cut-out risk. Through experimental tests and numerical models some variables that can be critical for the cut-out phenomenon are analysed.

METHODS

This study has been carried out through a numerical model based on the finite element method and experimental tests. The digital image correlation technique has been used in experimental tests to measure displacements on the femoral surface with the objective of numerical model validation. Some basic daily activities with different intramedullary nail positions have been analysed through the numerical model, considering variables that can induce the cut-out complication.

RESULTS

The results show how the intramedullary nail position clearly influences the cut-out risk, showing that displacements in the upper, anterior and posterior direction increase the cut-out risk, while displacement in the lower direction endangers the intramedullary nail itself. Thus, the centred position is the one which reduces the cut-out risk.

CONCLUSIONS

This work supposes an improvement in the knowledge of the cut-out phenomenon thanks to the combination of experimental testing and validated numerical models. The effects of different intramedullary nail positions in the femoral head are studied, including a novelty variable as torque, which is critical for the structural integrity of the fixation. The main conclusion of the work is the determination of the central intramedullary nail position as the most favourable one for decreasing the cut-out risk.

Comparison of clinical outcomes with proximal femoral nail anti-rotation versus dynamic hip screw for unstable intertrochanteric femoral fractures: A meta-analysis

BACKGROUND

The aim of this meta-analysis was to evaluate the advantages and disadvantages of proximal femoral nail anti-rotation (PFNA) versus dynamic hip screw (DHS) for the treatment of unstable intertrochanteric fractures, including the available evidence drawn from the literature.

METHODS

A systematic search was conducted to identify available and relevant randomized controlled trials and retrospective comparative observational studies regarding PFNA compared against DHS in treating unstable femoral intertrochanteric fractures in Embase, PubMed, Cochrane Library, Web of Science, and Scopus Online up to February 12, 2022. Data from the included studies were extracted independently by 2 reviewers and analyzed using RevMan 5.3, and the quality of the studies was assessed.

RESULTS

Five randomized controlled trials and 12 observational studies were recruited and met the inclusion criteria, which consisted of 1332 patients with PFNA and 1271 patients with DHS. The results of the meta-analysis showed that, compared with the DHS, PFNA exhibited a beneficial role in postoperative Harris Hip Scores, operation time, intraoperative blood loss, length of hospital stay, fracture healing time and full weight-bearing time, limb shortening, cutout, reoperation, union problems, the varus collapse of the femoral head/neck, and infection; however, DHS was superior to PFNA in hidden blood loss (relative risk [RR] = 139.81, 95% confidence interval [CI] [136.18, 143.43], P < .00001), postoperation drainage (RR = -17.85, 95% CI [-30.10, -5.60], P = .004), total blood loss (RR = 50.34, 95% CI [42.99, 57.69], P < .00001), and femoral shaft fracture (RR = 4.72, 95% CI [1.15, 19.32], P = .03) treated by DHS were significantly decreased, compared with those by PFNA; however, no significant differences were observed in tip-apex distance, fixation failures, screw migration, or other complicants between the 2 surgical methods.

CONCLUSION

Analysis of a large number of relevant clinical indicators available shows that PFNA has better clinical manifestation than DHS in treating unstable femoral intertrochanteric fractures.

Comparison of clinical outcomes with proximal femoral nail anti-rotation versus InterTAN nail for intertrochanteric femoral fractures: a meta-analysis

Background

A meta-analysis to access the pros and cons of proximal femoral nail anti-rotation (PFNA) versus InterTAN nail for intertrochanteric femoral fractures including available evidence extracted from literature.

Methods

According to the Cochrane systemic analysis method, randomized control trials (RCTs) and retrospective comparative observational studies which were related to the comparison of PFNA and InterTAN nail in the treatment of the elderly with intertrochanteric fractures were retrieved. Data were independently extracted from the included studies by two reviewers and analyzed using RevMan 5.3, and the quality of the studies was assessed.

Results

Two RCTs and seven observational studies were recruited, which consisted of 681 patients with PFNA and 651 patients with InterTAN nail. The meta-analyses showed no significant differences between the two approaches on Harris Hip Score, operation time, blood loss, time to union, mean hospital stay, union problems, intraoperative complications, hematoma, infection, and other complications in both RCTs and observational studies. In terms of other outcomes, for the RCTs, results showed that there were shorter tip–apex distance and reduced pain at thigh or hip in InterTAN nail than in PFNA; however, InterTAN nail was not superior to PFNA in cutout, reoperation, and femoral shaft fracture; for observational studies, the risk of the screw migration (RR = 5.13, 95%CI [1.33,19.75], P = 0.02), cutout (RR = 3.26, 95%CI [1.64,6.47], P = 0.0008), the varus collapse of the femoral head (RR = 7.19, 95%CI [2.18,23.76], P = 0.001), femoral shaft fracture (RR = 5.73, 95%CI [2.24,14.65], P = 0.0003) treated by InterTAN nail were significantly decreased, compared with those by PFNA; however, no significant differences were observed in the aspects of tip–apex distance and pain at thigh or hip between these two groups.

Conclusion

Analysis of a large number of relevant clinical indicators available shows that InterTAN nail has better clinical manifestation than PFNA in treating unstable femoral intertrochanteric fractures.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-020-02031-8.

Management Options and Outcomes for Patients with Femoral Fractures with Post-Polio Syndrome of the Lower Extremity: A Critical Analysis Review

Post-polio syndrome is characterized by a late functional deterioration (usually after >=15 years from the initial infection) in patients with a history of paralytic poliomyelitis infection, and it is defined by the March of Dimes criteria. Patients with post-polio syndrome are at increased risk for falls and associated hip and femoral fractures as a result of lower bone mineral density, decreased lean muscle mass, and musculoskeletal deformities. Current evidence suggests that treatment modalities for femoral fractures should emphasize fixation that allows early progressive weight-bearing and ambulation to optimize functional outcomes. Good results after hip arthroplasty have been described with both cemented and uncemented implants in patients who have been treated for osteoarthritis, but there has been little evidence guiding hip fracture management. Anatomic challenges that are encountered are osteoporotic bone, a valgus neck-shaft angle, increased femoral anteversion, and a small femoral canal diameter. Intramedullary nailing of hip and femoral fractures can be challenging due to the small femoral canal diameter that frequently is encountered. Alternative methods of fixation have shown promising results. These include the use of sliding hip screws for hip fracture management and fixed-angle locking plates for hip and femoral fracture management.

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

TRIAL REGISTRATION NUMBER

ACTRN12618001431213.

Fixation of AO-OTA 31-A1 and A2 trochanteric femur fractures using a sliding hip screw system: can we trust a two-hole side plate construct? A review of the literature

Trochanteric femur fractures are frequently fixed with a four-hole side plate sliding hip screw device, but in recent decades two-hole side plates have been used in an attempt to minimize operative time, surgical dissection, blood loss and post-operative pain.The aim of this review was to determine whether two-hole sliding hip screw constructs are an acceptable option for fixation of AO-OTA 31-A1 and A2 trochanteric femur fractures.An electronic MEDLINE® database search was performed using PubMed®, and articles were included in this review if they were reporting historical, biomechanical, clinical or outcome data on trochanteric fracture fixation using a two-hole sliding hip screw device.A two-hole dynamic hip screw with a minimally invasive muscle-splitting approach is recommended for fixation of AO-OTA 31-A1 simple trochanteric fractures; this implant is biomechanically safe, and allows the use of a minimally invasive muscle-splitting approach which potentially provides better clinical outcome, such as decreased surgical trauma, shorter operative time, less blood loss, decreased analgesics use, and shorter incision length. As the majority of reviewed publications relate to the dynamic hip screw, it is not clear whether the above recommendations can be extended to any other sliding hip screw device.An intramedullary device is recommended for all other extra-capsular proximal femoral fractures. Cite this article: EFORT Open Rev 2020;5:118-125. DOI: 10.1302/2058-5241.5.190020.

[Trochanteric and subtrochanteric fractures]

Proximal femoral fractures are one of the most common fractures, particularly in older people. The most common cause is a falling event due to dizziness and gait insecurity. In most cases prompt surgical treatment is necessary to achieve early mobilization and to reduce the risk of mortality. The aim is a stable osteosynthesis and patient-centered care. A great variety of implants are available for this purpose. Furthermore, perioperative management is important to prevent further problematic events, such as delirium, reoccurrence of falling events and to diagnose and adequately treat a pre-existing osteoporosis.