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Paulsson M, Ekholm C, Rolfson O, Tranberg R, Geijer M. Secondary Displacement was Common in Healing Distal Femur Fractures in a Cohort of Elderly Patients. Geriatr Orthop Surg Rehabil 2024; 15:21514593241280914. [PMID: 39386900 PMCID: PMC11462582 DOI: 10.1177/21514593241280914] [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: 02/07/2024] [Revised: 07/06/2024] [Accepted: 08/18/2024] [Indexed: 10/12/2024] Open
Abstract
Introduction Surgical treatment of distal femoral fractures (DFFs) in osteoporotic bone is challenging despite improvements in hardware and surgical techniques. The occurrence and degree of secondary displacement during healing after bridging plate fixation are still unknown. This study aimed to assess the occurrence and degree of secondary displacement in healing DFFs in elderly patients and correlate the secondary displacement to body mass index, bone density, and weight-bearing regimen. Patients and Methods The study involved 32 patients, 65 years or older, with a DFF of AO/OTA types 33 A2-3, B1-2, C1-2, and 32(c) A-C,1-3, including peri-prosthetic fractures with stable implants. Twenty-seven patients had at least 8 weeks of follow-up, and 21 patients had a complete 1-year follow-up. Minimally invasive surgery was performed using a distal anatomical femoral plate as a long bridge-plating construct. Secondary displacement was assessed with computed tomography of the entire femur postoperatively and at 8, 16, and 52 weeks. Femoral length, coronal angulation (varus/valgus), and subsidence as the change in distance between the distal joint surface and a specified locking screw were measured. Results There was a statistically significant mean femoral shortening at 52 weeks of 4.7 mm (SD 3.9, (95% CI 2.9-6.5), P < 0.001) mainly by subsidence of the distal fragment. Most patients experienced limited coronal angulation. There was no correlation between body mass index or bone density and secondary displacement. At the 1-year follow-up, no patient needed revision surgery for non-union or plate breakage. Restricted weight-bearing for 8 weeks did not prevent secondary displacements or adverse events such as cut-outs. Conclusion Modern dynamic plate osteosynthesis could not prevent commonly occurring fracture subsidence in DFF in an elderly cohort. Restricted weight-bearing for 8 weeks did not prevent secondary displacements or mechanical adverse events.
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Affiliation(s)
- Martin Paulsson
- Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Carl Ekholm
- Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ola Rolfson
- Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Roy Tranberg
- Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Mats Geijer
- Department of Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
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Barra AE, Barrios C. Predictive value of tip-apex distance and calcar-referenced tip-apex distance for cut-out in 398 femoral intertrochanteric fractures treated in a private practice with dynamic intramedullary nailing. Front Surg 2024; 11:1438858. [PMID: 39205795 PMCID: PMC11349698 DOI: 10.3389/fsurg.2024.1438858] [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: 05/26/2024] [Accepted: 07/22/2024] [Indexed: 09/04/2024] Open
Abstract
Introduction Cut-out, a biomechanical complication, is one of the most common causes of internal fixation failure of trochanteric hip fractures. The tip-apex distance (TAD) and the calcar-referenced tip-apex distance (CalTAD) have been suggested as the radiographic parameters that most predict the risk of cut-out. The purpose of this study was to check whether these two factors could predict implant cut-out in a series 398 of intertrochanteric hip fractures, treated by dynamic intramedullary nailing with the Trigen Intertan short nail. Methods We reviewed 398 consecutive intertrochanteric fractures included in a prospective study and treated in a single private hospital by the same surgeon. The radiographic parameters were obtained from anteroposterior (AP) and axial hip plain radiographs before surgery, immediately postoperatively, and every 3 weeks after surgery until 3 months postoperatively, and every month until the 6-month follow-up. The concept of medial cortex support (MCS) was also analyzed as a criterion for evaluating the quality of fracture reduction. Results The overall cut-out rate was 2.3% (9/398). The significant parameters in the univariate analysis were AO fracture type, quality of fracture reduction (p = 0.02), TAD (p < 0.001), CalTAD (p = 0.001), and quality of reduction. No statistically significant relationships were observed between the occurrence of cut-out and sex, age, fracture side, and American Society of Anesthesiologists type. Varus collapse and cut-out were only found in cases of negative MCS (22.2% and 77.8%, respectively). Multivariate analysis showed that only TAD showed an independent significant relationship to cut-out (p < 0.001). In this study, CalTAD has no predictive value in the multivariable analysis. Conclusions Our findings differed from those in previous reported studies suggesting that CalTAD is the best predictor of cut-out. According to our data, careful optimal reduction ensuring stable fixation with TAD >25 mm reduced the occurrence of cut-out after dynamic intramedullary nailing of intertrochanteric fractures.
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Affiliation(s)
- Amariel E. Barra
- School of Doctorate, Valencia Catholic University, Valencia, Spain
| | - Carlos Barrios
- Institute for Research on Musculoskeletal Disorders, Valencia Catholic University, Valencia, Spain
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DeBaun MR, Vanderkarr M, Holy CE, Ruppenkamp JW, Parikh A, Vanderkarr M, Coplan PM, Pean CA, McLaurin TM. Persistent racial disparities in postoperative management after tibia fracture fixation: A matched analysis of US medicaid beneficiaries. Injury 2024; 55:111696. [PMID: 38945078 DOI: 10.1016/j.injury.2024.111696] [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: 02/09/2024] [Revised: 06/10/2024] [Accepted: 06/19/2024] [Indexed: 07/02/2024]
Abstract
INTRODUCTION Racial and ethnic disparities in orthopaedic surgery are well documented. However, the extent to which these persist in fracture care is unknown. This study sought to assess racial disparities in the postoperative surgical and medical management of patients after diaphyseal tibia fracture fixation. METHODS Patients with surgically treated tibial shaft fractures from October 1, 2015, to December 31, 2020, were identified in the MarketScan® Medicaid Database. Exclusion criteria included concurrent fractures or amputation. Outcomes included 2-year postoperative complications, reoperation rates, and filled prescriptions. Surgically-treated Black and White cohorts were propensity-score matched using nearest-neighbor matching on patient demographics, comorbidities, fracture pattern and severity, and fixation type. Chi-square tests and survival analyses (Kaplan-Meier and Cox proportional hazard models) were conducted. RESULTS 5,472 patients were included, 2,209 Black and 3,263 White patients. After matching, 2,209 were retained in each cohort. No significant differences in complication rates were observed in the matched Black vs White cohorts. Rates of reoperation, however, were significantly lower in Black as compared to White patients (28.5 % vs. 35.5 % rate, risk difference = 7.0 % (95 % confidence interval (CI): 4.2 % to 9.7 %)). Implant removal was also significantly lower in Black (17.9 %) vs. White (25.1 %) patients (Risk difference = 7.2 %, (95 %CI: 4.8 % to 9.6 %)). The adjusted hazard ratio comparing the reoperation rate in Black versus White patients was 0.77 (95 %CI: 0.69-0.82, p < 0.0001). Significantly lower proportions of Black vs White patients filled at least one prescription for benzodiazepine, antidepressants, strong opiates, or antibiotics at every time point post-index. DISCUSSION Fewer resources were used in post-operative management after surgical treatment of tibial shaft fractures for Black versus White Medicaid-insured patients. These results may be reflective of the undertreatment of complications after tibia fracture surgery for Black patients and highlight the need for further interventions to address racial disparities in trauma care.
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Affiliation(s)
- Malcolm R DeBaun
- Duke University School of Medicine, Orthopedic Surgery, Durham, NC 27710, USA.
| | - Mari Vanderkarr
- Johnson & Johnson MedTech Epidemiology, New Brunswick, NJ 08901, USA
| | - Chantal E Holy
- Johnson & Johnson MedTech Epidemiology, New Brunswick, NJ 08901, USA
| | - Jill W Ruppenkamp
- Johnson & Johnson MedTech Epidemiology, New Brunswick, NJ 08901, USA
| | | | | | - Paul M Coplan
- Johnson & Johnson MedTech Epidemiology, New Brunswick, NJ 08901, USA
| | - Christian A Pean
- Duke University School of Medicine, Orthopedic Surgery, Durham, NC 27710, USA
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Coviello M, Abate A, Maccagnano G, Ippolito F, Nappi V, Abbaticchio AM, Caiaffa E, Caiaffa V. Tip-apex distance as a risk factor for cut-out in cephalic double-screw nailing of intertrochanteric femur fractures. Bone Jt Open 2024; 5:457-463. [PMID: 38823797 PMCID: PMC11144064 DOI: 10.1302/2633-1462.56.bjo-2023-0163.r1] [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] [Indexed: 06/03/2024] Open
Abstract
Aims Proximal femur fractures treatment can involve anterograde nailing with a single or double cephalic screw. An undesirable failure for this fixation is screw cut-out. In a single-screw nail, a tip-apex distance (TAD) greater than 25 mm has been associated with an increased risk of cut-out. The aim of the study was to examine the role of TAD as a risk factor in a cephalic double-screw nail. Methods A retrospective study was conducted on 112 patients treated for intertrochanteric femur fracture with a double proximal screw nail (Endovis BA2; EBA2) from January to September 2021. The analyzed variables were age, sex, BMI, comorbidities, fracture type, side, time of surgery, quality of reduction, pre-existing therapy with bisphosphonate for osteoporosis, screw placement in two different views, and TAD. The last follow-up was at 12 months. Logistic regression was used to study the potential factors of screw cut-out, and receiver operating characteristic curve to identify the threshold value. Results A total of 98 of the 112 patients met the inclusion criteria. Overall, 65 patients were female (66.3%), the mean age was 83.23 years (SD 7.07), and the mean follow-up was 378 days (SD 36). Cut-out was observed in five patients (5.10%). The variables identified by univariate analysis with p < 0.05 were included in the multivariate logistic regression model were screw placement and TAD. The TAD was significant with an odds ratio (OR) 5.03 (p = 0.012) as the screw placement with an OR 4.35 (p = 0.043) in the anteroposterior view, and OR 10.61 (p = 0.037) in the lateral view. The TAD threshold value identified was 29.50 mm. Conclusion Our study confirmed the risk factors for cut-out in the double-screw nail are comparable to those in the single screw. We found a TAD value of 29.50 mm to be associated with a risk of cut-out in double-screw nails, when good fracture reduction is granted. This value is higher than the one reported with single-screw nails. Therefore, we suggest the role of TAD should be reconsidered in well-reduced fractures treated with double-screw intramedullary nail.
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Affiliation(s)
- Michele Coviello
- Department of Clinical and Experimental Medicine, Orthopaedics Unit, Faculty of Medicine and Surgery, University of Foggia, Policlinico Riuniti di Foggia, Foggia, Italy
| | - Antonella Abate
- Orthopaedic and Traumatology Unit, "Di Venere" Hospital, Bari, Italy
| | - Giuseppe Maccagnano
- Department of Clinical and Experimental Medicine, Orthopaedics Unit, Faculty of Medicine and Surgery, University of Foggia, Policlinico Riuniti di Foggia, Foggia, Italy
| | | | - Vittorio Nappi
- Orthopaedic and Traumatology Unit, "Di Venere" Hospital, Bari, Italy
| | - Andrea M. Abbaticchio
- Department of Basic Medical Sciences, Orthopaedic and Trauma Unit, Neurscience and Sense Organs, School of Medicine, AOU Consorziale Policlinico, University of Bari “Aldo Moro”, Bari, Italy
| | - Elio Caiaffa
- Department of Basic Medical Sciences, Orthopaedic and Trauma Unit, Neurscience and Sense Organs, School of Medicine, AOU Consorziale Policlinico, University of Bari “Aldo Moro”, Bari, Italy
| | - Vincenzo Caiaffa
- Orthopaedic and Traumatology Unit, "Di Venere" Hospital, Bari, Italy
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Buijs MAS, Haidari S, IJpma FFA, Hietbrink F, Govaert GAM. What can they expect? Decreased quality of life and increased postoperative complication rate in patients with a fracture-related infection. Injury 2024; 55:111425. [PMID: 38402709 DOI: 10.1016/j.injury.2024.111425] [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: 07/22/2023] [Revised: 11/05/2023] [Accepted: 02/11/2024] [Indexed: 02/27/2024]
Abstract
BACKGROUND By gaining insight into the Quality of Life (QoL) status and occurrence of complications, critical facets in the care for patients with Fracture-Related Infection (FRI) can be mitigated and measures can be taken to improve their outcome. Therefore, the aims of this study were to 1) determine the QoL in FRI patients in comparison to non-FRI patients and 2) describe the occurrence of other complications in both FRI and non-FRI patients. METHODS An ambidirectional cohort study was conducted in a level 1 trauma centre between January 1st 2016 and November 1st 2021. All patients who underwent surgical stabilisation of an isolated long bone fracture were eligible for inclusion. To avoid confounding, only patients with an Injury Severity Score (ISS) <16 were included. Data regarding patient demographics, fracture characteristics, treatment, follow-up and complications were collected of both non-FRI and FRI patients. QoL was assessed through the use of five-level EuroQol five-dimension (EQ-5D-5L) questionnaires twelve months post-injury. RESULTS A total of 134 patients were included in this study, of whom 38 (28%) FRI patients and 96 (72%) non-FRI patients. In comparison to non-FRI patients, FRI patients scored significantly worse on the QoL assessment regarding the index value (p = 0.012) and the domains mobility (p<0.001), usual activities (p = 0.010) and pain/discomfort (p = 0.009). Other postoperative complications were more often reported (p<0.001) in FRI patients (66%, n = 25/38) compared to non-FRI patients (27%, n = 26/96). During the median follow-up of 14.5 months (interquartile range (IQR) 9.5-26.5), 25 FRI patients developed a total of 49 distinctive complications besides FRI. The complications nonunion (18%, n = 9/49), infection other than FRI (e.g. line infection, urinary tract infection, pneumonia) (18%, n = 9/49) and implant failure (14%, n = 7/49) were the most frequently described in the FRI group. CONCLUSION Patients who suffered from an FRI have a decreased QoL in comparison to those without an FRI. Moreover, patients with an FRI have a higher rate of additional complications. These findings can help in patient counselling regarding the potential physical and mental consequences of having a complicated course of recovery due to an infection.
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Affiliation(s)
- M A S Buijs
- Department of Trauma Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - S Haidari
- Department of Trauma Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - F F A IJpma
- Department of Trauma Surgery, University Medical Centre Groningen, Groningen, the Netherlands
| | - F Hietbrink
- Department of Trauma Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - G A M Govaert
- Department of Trauma Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands.
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Thusoo V, Nehru A, Kudyar S, Chakrapani AS, Saini ES, Alok KV, Narender D, Philip S. A Comparative Study of Dynamic Hip Screws and Proximal Femoral Nails in Intertrochanteric Fractures. Cureus 2024; 16:e59063. [PMID: 38800311 PMCID: PMC11128190 DOI: 10.7759/cureus.59063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Accepted: 04/26/2024] [Indexed: 05/29/2024] Open
Abstract
Background Intertrochanteric fractures, which occur in the hip of older individuals due to the weak and brittle structure of the bone caused by osteoporosis, make up over 50% of all hip fractures. There are several treatment options available for these fractures. The major objective of this study was to carry out a comparative analysis to evaluate the efficacy of dynamic hip screws (DHS) and proximal femoral nails (PFN) in treating intertrochanteric fractures. Methodology Two hundred instances of intertrochanteric hip fractures were surgically treated between July 2022 and January 2024 at a tertiary care facility. The evaluation of fractures was conducted in two groups, namely, group 1, which consisted of 140 patients, each having a fracture in one hip, treated using the DHS method. Group 2 consisted of 60 patients, each having a fracture in one hip, treated using the PFN technique. The evaluation of functional results was performed with the Harris hip score. Results In the investigation within these groups, group 1 produced excellent outcomes in 53 patients, which accounts for 37.86% of the total. In group 2, the expected results were achieved in 34 patients (56.67%). Achieved outcomes were favorable in 75 (53.57%) individuals in group 1 and 21 (35%) in group 2. Out of the individuals in group 1, eight (5.71%) saw benefits, whereas four (1.6%) did not gain significantly. In group 2, five (8.33%) individuals benefitted. None of the patients in group 2 had unfavorable outcomes. Conclusion While both PFN and DHS provide comparable outcomes in stable bone, PFN demonstrated superior results in cases of unstable bone. The use of PFN results in reduced surgical duration and a smaller surgical opening. Additionally, PFN exhibited superior specificity compared to DHS, especially in cases with stable intertrochanteric bone.
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Affiliation(s)
- Varun Thusoo
- Orthopaedic Surgery, Adesh Medical College and Hospital, Ambala, IND
| | - Ashish Nehru
- Orthopaedics and Trauma, Government Medical College and Rajindra Hospital, Patiala, IND
| | - Sachin Kudyar
- Orthopaedics, Government Medical Hospital, Jammu, IND
| | | | | | - K V Alok
- Orthopaedics and Trauma, Osmania Medical College, Hyderabad, IND
| | - D Narender
- Orthopaedics and Trauma, Government Medical College, Bhadradri, Kothagudem, IND
| | - Suraj Philip
- Orthopaedics, Pushpagiri Institute of Medical Sciences, Hyderabad, IND
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Lähdesmäki M, Ylitalo AAJ, Karjalainen L, Uimonen M, Mattila VM, Repo JP. Intramedullary Nailing of Intertrochanteric Femoral Fractures in a Level I Trauma Center in Finland: What Complications Can be Expected? Clin Orthop Relat Res 2024; 482:278-288. [PMID: 37582281 PMCID: PMC10776171 DOI: 10.1097/corr.0000000000002792] [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] [Received: 02/17/2023] [Accepted: 06/29/2023] [Indexed: 08/17/2023]
Abstract
BACKGROUND Intertrochanteric hip fractures are one of the most common fractures in older people, and the number is estimated to increase. These fractures are often treated with intramedullary nailing; however, various complications have been reported. It is important to identify the potential complications and investigate whether the choice of implant and patient-related factors are associated with the risk of complications to develop better strategies for preventing them. QUESTIONS/PURPOSES (1) In the treatment of intertrochanteric fractures with intramedullary nailing, what are the risks of major complications and 30-day mortality? (2) Which implant types are associated with greater odds of major complications? (3) Which patient-related factors are associated with increased odds of major complications? METHODS In this retrospective, comparative study, we reviewed the health records of 2397 patients with a femoral fracture treated at one Level I trauma center between January 2014 and November 2020. Of those, we considered patients who were treated with intramedullary nailing for an intertrochanteric fracture after sustaining a low-energy injury as potentially eligible. Based on this criterion, 53% (1279) were eligible; a further 47% (1118) were excluded because the fixation method was other than intramedullary nailing, the fracture pattern was other than intertrochanteric fracture, or the fracture was caused by a high-energy injury mechanism. Another 4% (97) were excluded because they had incomplete datasets because of follow-up less than 12 months, leaving 49% (1182) for analysis. During the study period, intramedullary nails were generally used to treat nearly all intertrochanteric fractures at our hospital. The risk of complications was then assessed by chart review. Acute myocardial ischemia, cutout, nail breakage, pulmonary embolism, sepsis, stroke, and wound infection were defined as major complications. Cutout, nail breakage, and wound infection were defined as major complications leading to reoperation. To examine the association of implant type and major complications, a logistic regression analysis was performed. Additionally, the risks of major complications leading to reoperation were compared between implants. Finally, a univariable logistic regression analysis was performed to examine the association between patient-related factors and major complications. RESULTS The overall proportion of patients experiencing complications was 16% (183 of 1182), and the crude percentage of 30-day mortality was 9% (107 of 1182) based on the hospital`s medical records. After controlling for patient-related factors such as disease, age, and smoking, we found that nail type was not associated with odds of major complications leading to reoperation (Gamma3: OR 0.86 [95% CI 0.44 to 1.67]; p = 0.67; Trochanteric Fixation Nail: OR 0.61 [95% CI 0.2 to 1.53]; p = 0.33; Proximal Femoral Nail Antirotation: OR 0.55 [95% CI 0.16 to 1.49]; p = 0.29) compared with the Trochanteric Fixation Nail Advanced. Anticoagulation (OR 1.70 [95% CI 1.11 to 2.59]; p = 0.01), congestive heart failure (OR 1.91 [95% CI 1.13 to 3.11]; p = 0.01), and hypertension (OR 1.67 [95% CI 1.08 to 2.63]; p = 0.02) were associated with a major complication. Liver disease (OR 5.19 [95% CI 0.78 to 20.8]; p = 0.04) was associated with a major complication leading to reoperation. CONCLUSION This study provides a better understanding of the occurrence of surgical and medical complications after intramedullary nailing of intertrochanteric fractures. The new-generation nail types are comparable options based on the risk of reoperation. Anticoagulation, congestive heart failure, and hypertension were associated with major complications, highlighting the need for careful management and monitoring of these comorbidities during intramedullary nailing procedures.Level of Evidence Level III, therapeutic study.
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Affiliation(s)
- Miika Lähdesmäki
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Antti AJ Ylitalo
- Department of Orthopaedics and Traumatology, Tampere University Hospital, Tampere, Finland
| | - Leevi Karjalainen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Mikko Uimonen
- Department of Surgery, Hospital Nova of Central Finland, Jyväskylä, Finland
| | - Ville M. Mattila
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Orthopaedics and Traumatology, Tampere University Hospital, Tampere, Finland
| | - Jussi P. Repo
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Orthopaedics and Traumatology, Tampere University Hospital, Tampere, Finland
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Mayor J, Birgel V, Clausen JD, Aktas G, Sehmisch S, Einfeldt AK, Giannoudis V, Abdelaal AHK, Liodakis E. Lessons learned from biomechanical studies on cephalomedullary nails for the management of intertrochanteric fractures. A scoping review. Injury 2024; 55:111180. [PMID: 37972488 DOI: 10.1016/j.injury.2023.111180] [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: 08/05/2023] [Revised: 10/29/2023] [Accepted: 10/31/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION The increasing socioeconomic need for optimal treatment of hip fractures in combination with the high diversity of available implants has raised numerous biomechanical questions. This study aims to provide a comprehensive overview of biomechanical research on the treatment of intertrochanteric fractures using cephalomedullary devices. METHODS Following the PRISMA-P guidelines, a systematic literature search was performed on 31.12.2022. The databases PubMed/MEDLINE and Web of Science were searched. Scientific papers published between 01.01.2000 - 31.12.2022 were included when they reported data on implant properties related to the biomechanical stability for intertrochanteric fractures. Data extraction was undertaken using a synthesis approach, gathering data on criteria of implants, sample size, fracture type, bone material, and study results. RESULTS The initial search identified a total of 1459 research papers, out of which forty-three papers were considered for final analysis. Due to the heterogeneous methods and parameters used in the included studies, meta-analysis was not feasible. A comprehensive assessment of implant characteristics and outcome parameters was conducted through biomechanical analysis. Various factors such as proximal and distal locking, nail diameter and length, fracture model, and bone material were thoroughly evaluated. CONCLUSION This scoping review highlights the need for standardization in biomechanical studies on intertrochanteric fractures to ensure reliable and comparable results. Strategies such as avoiding varus, maintaining a sufficient tip-apex-distance, cement augmentation, and optimizing lesser trochanteric osteosynthesis enhance construct stability. Synthetic alternatives may offer advantages over cadaveric bone. Further research and meta-analyses are required to establish standardized protocols and enhance reliability.
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Affiliation(s)
- Jorge Mayor
- Department of Trauma Surgery, Hannover Medical School, Carl-Neuberg Str. 1, Hannover D-30625, Germany.
| | - Vera Birgel
- Hannover Medical School, Institute for Epidemiology, Social Medicine and Health Systems Research, Hannover, Germany
| | - Jan-Dierk Clausen
- Department of Trauma Surgery, Hannover Medical School, Carl-Neuberg Str. 1, Hannover D-30625, Germany
| | - Gökmen Aktas
- Department of Trauma Surgery, Hannover Medical School, Carl-Neuberg Str. 1, Hannover D-30625, Germany
| | - Stephan Sehmisch
- Department of Trauma Surgery, Hannover Medical School, Carl-Neuberg Str. 1, Hannover D-30625, Germany
| | - Ann-Kathrin Einfeldt
- Laboratory for Biomechanics and Biomaterials, Department of Orthopedic Surgery, Hannover Medical School, Anna-von-Borries-Str. 1-7, Hannover 30625, Germany
| | - Vasilis Giannoudis
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, Leeds General Infirmary, Leeds, United Kingdom
| | - Ahmed H K Abdelaal
- Department of Orthopedic Surgery, Faculty of Medicine, Sohag University, Sohag 82524, Egypt
| | - Emmanouil Liodakis
- Department of Trauma Surgery, Hannover Medical School, Carl-Neuberg Str. 1, Hannover D-30625, Germany
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Fisher ND, Parola R, Anil U, Herbosa C, Boadi B, Ganta A, Tejwani N, Konda SR, Egol KA. A Good Tip-Apex Distance Does Not Make Up For a Poor Reduction in Intertrochanteric Hip Fractures Treated with an Cephalomedullary Nail: The Utility of the Neck-Shaft Angle in Preventing Fixation Failure. J Am Acad Orthop Surg 2024; 32:83-91. [PMID: 37748038 DOI: 10.5435/jaaos-d-22-00972] [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] [Received: 10/20/2022] [Accepted: 07/25/2023] [Indexed: 09/27/2023] Open
Abstract
PURPOSE Determine if any fracture characteristics or radiographic parameters were predictive of fixation failure [FF] within 1 year following cephalomedullary nailing for intertrochanteric fractures. METHODS A consecutive series of intertrochanteric hip fracture patients (AO/OTA 31A) treated with a cephalomedullary nail were reviewed. Pre-fixation (neck-shaft angle [NSA], distance from ischial tuberosities to greater and lesser trochanters, integrity of lesser trochanter, and fracture angulation) and post-fixation (post-fixation NSA, posteromedial cortex continuity, lag screw position, tip to apex distance [TAD], and post-fixation angulation and translation) radiographic parameters were measured by blinded independent reviewers. The FF and non-FF groups were statistically compared. Logistic regression was performed to determine radiographic parameter correlates of FF. RESULTS Of 1249 patients, 23 (1.8%) developed FF within 1 year. The FF patients were younger than their non-FF counterparts (77.2 years vs 81.0 years, p=0.048), however there were no other demographic differences. The FF cohort did not differ in frequency of TAD over 25 mm (4.3% vs 9.6%, p=0.624) and had decreased mean TAD (13.6mm vs 16.3mm, p=0.021) relative to the non-FF cohort. The FF cohort had a higher rate of a post-fixation coronal plane NSA more than 10° different from the contralateral side (delta NSA>10°, 34.8% vs 13.7%, p=0.011) with the majority fixed in relative varus. For every 1° increase in varus compared to the contralateral side the odds of FF increased 7% (OR=1.065, 95%CI[1.005-1.130], p=0.034) on univariate analysis. On univariate logistic regression, patients with an absolute post-fixation NSA of 10° or more of varus compared to contralateral were significantly more likely to have a FF (OR=3.139, 95%CI[1.067-8.332], p=0.026). CONCLUSION Despite an acceptable TAD, post-fixation NSA in relative varus as compared to the contralateral side was significantly associated with failure in intertrochanteric hip fractures fixed with a cephalomedullary nail. LEVEL OF EVIDENCE Prognostic Level III.
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Affiliation(s)
- Nina D Fisher
- From the NYU Langone Orthopedic Hospital, New York, NY (Fisher, Parola, Anil, Herbosa, Boadi, Ganta, Tejwani, Konda, and Egol), and the Jamaica Hospital Medical Center, Richmond Hill, NY (Ganta, Tejwani, Konda, and Egol)
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10
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Qi H, Li Z, Ma T, Jiang Y, Ren C, Xu Y, Huang Q, Zhang K, Lu Y, Li M. Robot Navigation System Assisted PFNA Fixation of Femoral Intertrochanteric Fractures in the Elderly: A Retrospective Clinical Study. Clin Interv Aging 2024; 19:11-19. [PMID: 38204959 PMCID: PMC10777025 DOI: 10.2147/cia.s412397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 12/01/2023] [Indexed: 01/12/2024] Open
Abstract
Objective The incidence of hip fracture in the elderly is increasing. Robot navigation technology has the advantages of minimally invasive and accurate. To explore the difference between the clinical effects of proximal femoral anti-rotation intramedullary nail (PFNA) assisted by robot navigation in the treatment of femoral intertrochanteric fracture and traditional PFNA in the treatment of femoral intertrochanteric fracture in the elderly; analyze the advantages and feasibility of PFNA assisted by robot navigation in the treatment of femoral intertrochanteric fracture in the elderly. Patients and Methods From February 2021 to October 2022, the elderly (>65 years old) with femoral intertrochanteric fracture underwent surgery in our center. Divided the patients included in the study into 2 groups based on the surgical method. The surgical method of robot group was PFNA fixation assisted by robot navigation, while the surgical method of traditional group was classic PFNA fixation, Baseline data (general condition, Evans classification, time from injury to operation, preoperative hemoglobin) and observation indicators (intraoperative bleeding, operation time, the length of incision for mail nail insertion, postoperative hemoglobin drop, blood transfusion rate and the Harris score of hip joint 1 year after operation) of the two groups were collected to compare whether there were differences between the two groups. Results There was no statistical difference in baseline data between the two groups (P>0.05). The intraoperative bleeding in the robot group was 68.17±10.66 mL, the intraoperative bleeding in the traditional group was 174±8.11mL (P<0.001). The operation time in the robot group was 68.81 ± 6.89 min, in the traditional group, the operation time was 76.94 ± 8.18 min (P<0.001). The length of incision for mail nail insertion in the robot group was 3.53 ± 0.63 cm, the length of the incision for mail nail insertion in the traditional group was 4.23 ± 0.71 cm (P<0.001). 5 patients (13.9%) in the robot group received blood transfusion treatment, and 13 patients (36.1%) in the traditional group received blood transfusion treatment (P=0.029). The hemoglobin in the robot group decreased by 14.81 ± 3.27 g/l after operation compared with that before operation, while that in the traditional group decreased by 16.69 ± 3.32 g/l (P=0.018). The Harris score of the hip joint of the affected limb in the robot group was excellent in 25 cases, good in 8 cases and poor in 3 cases one year after the operation; In the traditional group, Harris scores were excellent in 18 cases, good in 11 cases and poor in 7 cases (P=0.021). Conclusion PFNA fixation of femoral intertrochanteric fracture with robot navigation assistance has the advantages of minimally invasive and accurate, shorter operation time, less bleeding and lower blood transfusion rate than traditional surgical methods, and has certain advantages in reducing postoperative complications of elderly patients.
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Affiliation(s)
- Hongfei Qi
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi’an Jiaotong University College of Medicine, Xi’an, Shaanxi, 710000, People’s Republic of China
| | - Zhong Li
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi’an Jiaotong University College of Medicine, Xi’an, Shaanxi, 710000, People’s Republic of China
| | - Teng Ma
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi’an Jiaotong University College of Medicine, Xi’an, Shaanxi, 710000, People’s Republic of China
| | - Yangyang Jiang
- Xi’an Medical College, Xi’an, Shaanxi, 710000, People’s Republic of China
| | - Cheng Ren
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi’an Jiaotong University College of Medicine, Xi’an, Shaanxi, 710000, People’s Republic of China
| | - Yibo Xu
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi’an Jiaotong University College of Medicine, Xi’an, Shaanxi, 710000, People’s Republic of China
| | - Qiang Huang
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi’an Jiaotong University College of Medicine, Xi’an, Shaanxi, 710000, People’s Republic of China
| | - Kun Zhang
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi’an Jiaotong University College of Medicine, Xi’an, Shaanxi, 710000, People’s Republic of China
| | - Yao Lu
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi’an Jiaotong University College of Medicine, Xi’an, Shaanxi, 710000, People’s Republic of China
| | - Ming Li
- Department of Orthopaedics and Trauma, Hong Hui Hospital, Xi’an Jiaotong University College of Medicine, Xi’an, Shaanxi, 710000, People’s Republic of China
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11
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Vasilopoulou A, Trichonas A, Palaiologos K, Antonogiannakis E, Nikakis C, Angelis S, Maris SJ, Grekas C, Karadimas EJ, Apostolopoulos AP. Complications Following Short Femoral Nail Fixation for Intertrochanteric Hip Fractures: A Retrospective Study. J Long Term Eff Med Implants 2024; 34:23-32. [PMID: 38842230 DOI: 10.1615/jlongtermeffmedimplants.2023048205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
The incidence of proximal femur fractures is increasing due to aging of the population. Intramedullary nails are the mainstay of treatment for intertrochanteric hip fractures mainly due to their better biomechanical properties compared to dynamic hip screw devices, shorter operative time, and less blood loss during surgery. However intramedullary nail fixation is not devoid of complications. The purpose of this study is to look at complications related to intramedullary nailing for intertrochanteric hip fractures in a major trauma center. A retrospective study was conducted including all patients having suffered an intertrochanteric femur fracture and treated with intramedullary nails from October 1, 2020, to October 1, 2022, in the Orthopaedic Surgery Clinic. The intramedullary hip systems used were the Stryker Gamma3 Nail and the VITUS PF Nail. All complications following the postoperative period were recorded in detail. Overall, 240 patients with a mean age of 82.3 years treated with hip intramedullary devices were identified. Superior cutout of the lag screw in two patients (females 90 and 87 years old) was identified 8 and 10 weeks following initial surgery. Avascular necrosis (AVN) of the femoral head was identified in one patient (male 81 years old) which occurred 12 weeks postoperatively. All three cases were revised by replacing the nail with cemented hemiarthroplasty. Periprosthetic fractures occurred in an 88-year-old male and a 73-year-old female following an injury distal to the stem and were managed by replacing the nail with a long stem device (Long Gamma3). One case of metalwork fracture was also recorded. There are many advantages in managing intertrochanteric hip fractures with intramedullary hip devices such as shorter theater time, less blood loss, and improved biomechanical properties. However, complications such as cutout of the lag screw, AVN, and periprosthetic fracture are serious and require complex revision surgery.
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Affiliation(s)
- Anastasia Vasilopoulou
- Trauma and Orthopaedic Department, Red Cross Hospital Korgialeneio-Benakeio, Athens, Greece
| | | | | | | | - C Nikakis
- Trauma and Orthopaedic Department Red Cross Hospital, Athens, Greece
| | - Stavros Angelis
- Second Orthopedic Department, Panagiotis & Aglaia Kyriakou Children's Hospital, Athens, Greece; Trauma and Orthopedic Department, Korgialenio-Benakio Hellenic Red Cross Hospital, Athens, Greece; Department of Anatomy, School of Medicine, National and Kapodistrian University of Athens, Greece
| | - Spyridon J Maris
- Trauma and Orthopaedic Department, "Korgialenio-Benakio" Hellenic Red Cross Hospital, Athens, Greece
| | - C Grekas
- Trauma and Orthopaedic Department Red Cross Hospital, Athens, Greece
| | - Efthymios J Karadimas
- Trauma and Orthopaedic Department, "Korgialenio-Benakio" Hellenic Red Cross Hospital, Athens, Greece
| | - Alexandros P Apostolopoulos
- Trauma and Orthopaedic Department, "Korgialenio-Benakio" Hellenic Red Cross Hospital, Athens, Greece; Trauma and Orthopaedic Department, Ealing Hospital, North West University Healthcare NHS Trust, London, United Kingdom
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12
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Hoelscher-Doht S, Heilig M, von Hertzberg-Boelch SP, Jordan MC, Gbureck U, Meffert RH, Heilig P. Experimental magnesium phosphate cement paste increases torque of trochanteric fixation nail advanced™ blades in human femoral heads. Clin Biomech (Bristol, Avon) 2023; 109:106088. [PMID: 37660575 DOI: 10.1016/j.clinbiomech.2023.106088] [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: 01/23/2023] [Revised: 08/18/2023] [Accepted: 08/29/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND The use of polymethylmethacrylate cement for in-situ implant augmentation has considerable disadvantages: it is potentially cytotoxic, exothermic and non-degradable. Therefore, the primary aim of this study was to develop a magnesium phosphate cement which meets the requirements for in-situ implant augmentation as an alternative. Secondly, this experimental cement was compared to commercial bone cements in a biomechanical test set-up using augmented femoral head blades. METHODS A total of 40 human femoral heads were obtained from patients who underwent total hip arthroplasty. After bone mineral density was quantified, specimens were assigned to four treatment groups. A blade of the Trochanteric Fixation Nail Advanced™ was inserted into each specimen and augmented with either Traumacem™ V+, Paste-CPC, the experimental magnesium phosphate cement or no cement. A rotational load-to-failure-test (0° to 90°) was performed. FINDINGS A conventional two-component magnesium phosphate cement failed in-situ implant augmentation consistently due to filter pressing. Only a glycerol-based magnesium phosphate paste was suitable for the augmentation of femoral head blades. While the blades augmented with Traumacem™ V+ yielded the highest maximum torque overall (22.1 Nm), the blades augmented with Paste-CPC and the magnesium phosphate paste also showed higher maximum torque values (15.8 and 12.8 Nm) than the control group (10.8 Nm). INTERPRETATION This study shows for the first time the development of a degradable magnesium phosphate cement paste which fulfills the requirements for in-situ implant augmentation. Simultaneously, a 48% increase in stability is demonstrated for a scenario where implant anchorage is difficult in osteoporotic bone.
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Affiliation(s)
- Stefanie Hoelscher-Doht
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital of Wuerzburg, Oberdürrbacherstraße 6, 97080 Wuerzburg, Germany
| | - Maximilian Heilig
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital of Wuerzburg, Oberdürrbacherstraße 6, 97080 Wuerzburg, Germany
| | | | - Martin Cornelius Jordan
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital of Wuerzburg, Oberdürrbacherstraße 6, 97080 Wuerzburg, Germany
| | - Uwe Gbureck
- Department for Functional Materials in Medicine and Dentistry, University of Wuerzburg, Pleicherwall 2, 97070, Wuerzburg, Germany
| | - Rainer Heribert Meffert
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital of Wuerzburg, Oberdürrbacherstraße 6, 97080 Wuerzburg, Germany
| | - Philipp Heilig
- Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital of Wuerzburg, Oberdürrbacherstraße 6, 97080 Wuerzburg, Germany.
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13
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Li H, Wang D, Zhang W, Xu G, Xu C, Zhang H, Zhang L, Li J, Tang P. Does computer-assisted orthopaedics system (ADAPT system) improve outcomes of intertrochanteric hip fractures? Injury 2023; 54:1047-1054. [PMID: 36759309 DOI: 10.1016/j.injury.2023.02.011] [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: 07/03/2022] [Revised: 01/29/2023] [Accepted: 02/02/2023] [Indexed: 02/11/2023]
Abstract
INTRODUCTION Intramedullary nailing (IMN) is a general treatment for intertrochanteric hip fractures. The computer-assisted orthopaedics system (CAOS), ADAPT system (Stryker, NJ), has been developed to facilitate lag screw insertion. When compared to the conventional freehand method, the efficacy of CAOS has not been clearly clarified. Therefore, we conducted this systematic review and meta-analysis to answer: does the CAOS performed better than freehand method in IMN. MATERIALS AND METHODS Studies published up to January 2023 were searched in the PubMed, Embase, Web of Science and Cochrane Library databases with predetermined key words. Comparative clinical studies between CAOS (ADAPT system) and freehand method were included. The primary outcomes of interest were the tip-apex-distance (TAD) and positions of lag screw. Fluoroscopy use, operation duration and intraoperative/postoperative complications were also extracted. A meta-analysis was performed for pooled analysis. RESULTS There were seven studies with 326 fractures in CAOS group and 325 fractures in Freehand group. All studies included presented high qualities. The CAOS group showed a statistically smaller TAD than Freehand group (weighted mean difference = -3.24 mm; 95% confidence interval [CI] -5.10 to -1.37 mm; p = 0.0007) and a better lag screw position (83/92 [90.2%] VS 64/92 [69.6%]; RR = 1.3; 95% CI 1.12 to 1.51; p = 0.0007). The operative time and radiation use revealed no difference between two groups. CONCLUSIONS The current evidence indicated that ADAPT system could help to perform a more accurate lag screw than freehand manipulation while the operative time and radiation time was not reduced as expectations on such new technique. Long-term follow-up studies are appealed.
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Affiliation(s)
- Hua Li
- Senior Department of Orthopedics, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, 100048, China; National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, China
| | - Daofeng Wang
- Senior Department of Orthopedics, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, 100048, China; National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, China
| | - Wupeng Zhang
- Senior Department of Orthopedics, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, 100048, China; National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, China; School of Medicine, Nankai University, No.94 Weijin Road, Tianjin, 300071, China
| | - Gaoxiang Xu
- Senior Department of Orthopedics, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, 100048, China; National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, China
| | - Cheng Xu
- Senior Department of Orthopedics, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, 100048, China; National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, China
| | - Hao Zhang
- Senior Department of Orthopedics, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, 100048, China; National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, China
| | - Licheng Zhang
- Senior Department of Orthopedics, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, 100048, China; National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, China.
| | - Jiantao Li
- Senior Department of Orthopedics, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, 100048, China; National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, China.
| | - Peifu Tang
- Senior Department of Orthopedics, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, 100048, China; National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, China.
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Corró S, Óleo-Taltavull R, Teixidor-Serra J, Tomàs-Hernández J, Selga-Marsà J, García-Sánchez Y, Guerra-Farfán E, Andrés-Peiró JV. Salvage hip replacement after cut-out failure of cephalomedullary nail fixation for proximal femur fractures: a case series describing the technique and results. INTERNATIONAL ORTHOPAEDICS 2022; 46:2775-2783. [PMID: 35922520 DOI: 10.1007/s00264-022-05529-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 07/22/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Cut-out failure following proximal femoral fracture fixation is a compromising complication warranting surgical treatment. We describe 24 patients with cut-out failure after cephalomedullary nail fixation managed with salvage hip replacement. METHODS Twenty-four consecutive patients who had sustained a proximal femoral fracture from December 2009 to December 2019, were managed with cephalomedullary nail fixation and experienced a cut-out failure were reviewed retrospectively. Data on demographics, comorbidities, injury characteristics, treatment, and post-operative course were analysed. RESULTS Among 2802 proximal femoral fractures assessed, 28 fixations failed due to cut-out, with 24/28 patients subsequently undergoing salvage hip replacement. Intertrochanteric fractures (66.7%) managed with short nails predominated (79.2%). The median tip-to-apex distance (TAD) was 19 mm, but only two fractures had a good quality of reduction. Inverse correlations were identified between patient age and the time from fixation to cut-out (r = - 0.57; p = 0.02), and between the time of nailing to failure among patients with a greater TAD (r = - 0.43; p = 0.04). Most patients were managed via cemented hemiarthroplasty (66.7%). Surgical time was longer for total hip replacements (175.4 vs. 136.8 min; p < 0.01), but no bleeding or blood transfusion requirement differences were found. Two patients had orthopaedic complications, and three patients died within the first follow-up year. CONCLUSION In our series, 1% of the proximal femoral fractures managed with a cephalomedullary nail failed due to cut-out. Salvage hip replacement appeared to be a relatively safe and reliable procedure for managing this challenging complication in patients who typically are elderly and physically frail.
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Affiliation(s)
- Sebastián Corró
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Son Espases, Mallorca, Spain
| | - Rafael Óleo-Taltavull
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Jordi Teixidor-Serra
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Jordi Tomàs-Hernández
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Jordi Selga-Marsà
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Yaiza García-Sánchez
- Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Ernesto Guerra-Farfán
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, Spain.,Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - José-Vicente Andrés-Peiró
- Department of Orthopaedic Surgery and Traumatology, Hospital Universitari Vall d'Hebron, Barcelona, Spain. .,Department of Orthopaedic Surgery and Traumatology, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain.
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Matsubara T, Soma K, Yamada I, Fujita H, Yoshitani J, Oka H, Okada H, Tanaka S. Offset nail fixation for intertrochanteric fractures improves reduction and lag screw position. PLoS One 2022; 17:e0276903. [PMID: 36383515 PMCID: PMC9668128 DOI: 10.1371/journal.pone.0276903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 10/17/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Surgery for intertrochanteric fractures using intramedullary hip nails (IHNs) is among the most common surgical procedures in the orthopedic field. Although IHNs provide good overall outcomes, they sometimes cause complications, such as loss of reduction and cut-out. Here, we investigated the usefulness of IHNs with an anterior offset (Best Fit Nail® [BFN]) in maintaining fragment reduction and ensuring proper lag screw position compared with conventional non-offset nails (Proximal Femoral Nail Antirotation® [PFNA]), using postoperative computed tomography (CT). METHODS Fifty consecutive patients with intertrochanteric fractures who underwent surgery with BFNs (BFN group) and 50 patients who underwent surgery with PFNAs (PFNA group) were retrospectively analyzed. Indices evaluated by postoperative CT were displacement distance of proximal fragment relative to distal fragment, reduction status (intramedullary, anatomical, and extramedullary types), lag screw direction, and angle between lag screw and femoral neck axis (deviation angle). RESULTS Median [interquartile range] displacement distance was significantly smaller in the BFN group (0 [0, 0] mm) compared with the PFNA group (5.2 [3.6, 7.1] mm) (p<0.001). Reduction status was significantly better in the BFN group (anatomical type, 40 cases; intramedullary type, in 9 cases, and extramedullary type in 1 case) than in the PFNA group (anatomical type, 6 cases; intramedullary type, 43 cases; extramedullary type, 1 case) (p<0.001). Deviation of lag screw direction was observed in significantly fewer cases in the BFN group (20 cases; 40%) compared with the PFNA group (36 cases; 72%). Lag screw deviation angle was significantly smaller in the BFN group (-0.71°±4.0°) compared with the PFNA group (6.9°±7.1°). No adverse events related to surgery were observed in either group. CONCLUSIONS Intertrochanteric fracture surgery using offset BFNs exhibited significantly smaller displacement distance, better reduction status, and higher frequency of no deviation with central lag screw position, compared with surgery using non-offset PFNAs.
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Affiliation(s)
- Takehiro Matsubara
- Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, Bunkyo-ku, Tokyo, Japan
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | | | - Ikufumi Yamada
- Fushimi Momoyama General Hospital, Fushimi-ku, Kyoto, Japan
| | - Hiroshi Fujita
- Hip Joint Center of Rakuyo Hospital, Sakyo-ku, Kyoto, Japan
| | | | - Hiroyuki Oka
- Faculty of Medicine, Department of Medical Research and Management for Musculoskeletal Pain, 22nd Century Medical and Research Center, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Hiroyuki Okada
- Center for Disease Biology and Integrative Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Sakae Tanaka
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
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Predictors of and predictive nomogram for cut-out of proximal femur nail anti-rotation device in intertrochanteric fractures. Arch Orthop Trauma Surg 2022:10.1007/s00402-022-04676-y. [PMID: 36348087 DOI: 10.1007/s00402-022-04676-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 10/25/2022] [Indexed: 11/09/2022]
Abstract
PURPOSE This study determined independent predictors and developed a predictive nomogram for failed correction of intertrochanteric fractures due to cut-out of the proximal femur nail anti-rotation (PFNA) device. METHODS Demographic and radiological data of 592 adult patients with intertrochanteric fractures (AO 31A) treated by PFNA were collected retrospectively. Independent predictors of cut-out were obtained through univariate and multivariate analyses, and a predictive nomogram was established. The discrimination, calibration, and clinical utility of the nomogram were based on receiver operating characteristic curve (AUC), concordance index (C-index), calibration curve, and decision curve analysis, respectively. RESULTS Overall, 18 (3.04%) cases of cut-out occurred. Independent predictors according to the multivariate analysis were body mass index (BMI), poor-to-acceptable quality of reduction, PFNA blade position, and tip-apex distance (TAD). AUC of the nomogram was 0.849, and C-index was 0.849 (95% CI [0.844-0.854]). Bootstrapping yielded a corrected C-index of 0.849. The calibration and decision curves indicated good agreement and clinical benefit of the nomogram. CONCLUSION A reliable predictive nomogram was developed for cut-out of the PFNA in intertrochanteric fractures, based on BMI, quality of reduction, blade position, and TAD.
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17
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CT analysis of femoral malrotation after intramedullary nailing of trochanteric fractures. Arch Orthop Trauma Surg 2022; 142:1865-1871. [PMID: 33881592 DOI: 10.1007/s00402-021-03902-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 04/06/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Functional results after internal fixation of trochanteric femoral fractures may be negatively affected by healing in a non-physiological position. The aim of this study was to evaluate the occurrence and severity of femoral malrotation after nailing of trochanteric fractures. MATERIALS AND METHODS The authors conducted a prospective study focused on a CT analysis of malrotation after intramedullary nailing of trochanteric fractures (AO 31A1-3) in 101 patients. We recorded the type of fracture, method of anesthesia, scheduled surgery vs. acute surgery, and the surgeon's experience as possible risk factors for limb malrotation after trochanteric fracture surgeries. RESULTS The average extent of malrotation was 9° of internal rotation ranging from 29° of external to 48°of internal rotation. In 35% of patients, we observed a rotation greater than 15°, and in 15 patients (15%), the rotation was greater than 25°. The risk of significant internal malrotation was significantly higher than external malrotation (37 vs. 4 patients). None of the factors observed proved to be statistically significant. The effect of general anesthesia and the type of intertrochanteric fracture came closest to having a significant effect on rotational error. CONCLUSION Improper reduction of a trochanteric fracture is a common problem that can lead to femur malrotation. In our study, a rotational error greater than 15° occurred in 35% of the patients, but none of the monitored factors represented a statistically significant risk for this complication.
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18
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Onggo JR, Nambiar M, Onggo JD, Ambikaipalan A, Singh PJ, Babazadeh S. Integrated dual lag screws versus single lag screw cephalomedullary nail constructs: a meta-analysis and systematic review. Hip Int 2022; 32:550-557. [PMID: 33566701 DOI: 10.1177/1120700020985067] [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] [Indexed: 02/04/2023]
Abstract
BACKGROUND/AIM This study aims to determine the safety and efficacy of integrated dual lag screw (IDL) cephalomedullary nails (CMN) when compared with single lag screw (SL) constructs, in the internal fixation of intertrochanteric femoral fractures. METHODS The Smith & Nephew InterTan IDL was compared with SL CMN group consisting of the Stryker Gamma-3 (G3) and Synthes Proximal Femoral Nail Antirotation (PFNA) CMN. A multi-database search was performed according to PRISMA guidelines. Data from studies assessing the clinical and radiological outcomes, complications and perioperative parameters of InterTan versus G3 or PFNA CMN in patients with intertrochanteric femoral fractures were extracted and analysed. RESULTS 15 studies were included in this meta-analysis, consisting of 2643 patients. InterTan was associated with lower complication rates in terms of all-cause revisions (OR 0.34; 95% CI, 0.22-0.51; p < 0.001), cut-outs (OR 0.30; 95% CI, 0.17-0.51; p < 0.001), medial or lateral screw migration (OR 0.19; 95% CI, 0.06-0.65; p = 0.008) as well as persistent hip and thigh pain (OR 0.65; 95% CI, 0.47-0.90; p = 0.008). In terms of perioperative parameters, InterTan is associated with longer operative times (MD 5.57 minutes; 95% CI, 0.37-10.78 minutes, p = 0.04) and fluoroscopy times (MD 38.89 seconds, 95% CI, 15.88-61.91 seconds; p < 0.001). There was no statistically significant difference in terms of clinical Harris Hip Score and radiological outcomes, non-union, haematoma, femoral fractures, varus collapse, length of stay and mean intraoperative blood loss between the 2 groups. CONCLUSIONS Integrated dual lag screw cephalomedullary nails are associated with fewer revisions and complications. However, there is insufficient data to suggest that either nail construct is associated with better functional outcomes.
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Affiliation(s)
- James R Onggo
- Department of Orthopaedic Surgery, Maroondah Hospital, Victoria, Australia
| | - Mithun Nambiar
- Department of Orthopaedic Surgery, Maroondah Hospital, Victoria, Australia
| | - Jason D Onggo
- Department of Orthopaedic Surgery, Maroondah Hospital, Victoria, Australia
| | | | - Parminder J Singh
- Department of Orthopaedic Surgery, Maroondah Hospital, Victoria, Australia
| | - Sina Babazadeh
- Department of Orthopaedic Surgery, Maroondah Hospital, Victoria, Australia
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The effect of cerclage wiring with intramedullary nail surgery in proximal femoral fracture: a systematic review and meta-analysis. Eur J Trauma Emerg Surg 2022; 48:4761-4774. [PMID: 35618854 DOI: 10.1007/s00068-022-02003-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 05/07/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE The aim of this study was to evaluate the utility of cerclage wiring with intramedullary nail surgery in the treatment of proximal femoral fractures. METHODS MEDLINE, Embase, and Cochrane Library were systematically searched for studies that evaluated the impact of cerclage wiring on proximal femoral fractures published up to September 20, 2021. Pooled analysis identified differences in the (1) fracture healing profile, (2) perioperative variables, (3) complications, and (4) clinical outcome score between cerclage wiring and non-cerclage wiring. RESULTS Fourteen studies involving 1,718 patients with proximal femoral fractures who underwent cephalomedullary nailing surgeries were included. The pooled analysis revealed a longer fracture union time in the non-cerclage wiring group than in the cerclage wiring group (mean difference [MD] = - 1.03 months; 95% confidence interval [CI]: - 1.47 to - 0.59; P < 0.001), and there was no difference in the nonunion rate. The operation time was longer in the cerclage wiring group (MD = 14.32 min; 95% CI: 6.42-22.22; P < 0.001), but there were no differences in blood loss and the rate of poor quality of reduction. Superficial and deep infection rates showed no difference between the groups, and the readmission rate also showed no difference. The cerclage wiring group had a higher Harris hip score than the non-cerclage wiring group (MD = 2.13; 95% CI: 0.77-3.49; P = 0.002). CONCLUSIONS Intramedullary nailing with cerclage wiring is considered a useful treatment method for proximal femoral fractures. It enables anatomic reduction and stable fixation, thereby reducing union time and facilitating rapid functional recovery.
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20
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Papaioannou I, Pantazidou G, Repantis T, Mousafeiris VK, Kalyva N. Late-Onset Hematoma Due to Bleeding of a Small Branch of the Lateral Circumflex Femoral Artery Following Proximal Femur Intramedullary Nailing. Cureus 2022; 14:e23513. [PMID: 35495014 PMCID: PMC9038585 DOI: 10.7759/cureus.23513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2022] [Indexed: 11/30/2022] Open
Abstract
Intramedullary nailing of proximal femur fracture is not deprived of complications, although vascular complications are very rare and a high index of suspicion is required for timely diagnosis. This case report describes how a late-onset hematoma formation and bleeding of a small branch of the lateral circumflex femoral artery can complicate intramedullary nailing after a pertrochanteric fracture. To the best of our knowledge, this complication has never been reported and should be considered among the possible vascular complications of intramedullary nailing. Orthopedic surgeons should be aware of the vascular complications that can occur even with late-onset presentation and even from small vessels, while administration of anticoagulants is an aggravating factor. Elderly patients with proximal femur fractures are more susceptible to vascular injury due to the structure of their vessels and the vicinity of the fracture to the arterial supply of the hip.
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21
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Becker N, Hafner T, Pishnamaz M, Hildebrand F, Kobbe P. Patient-specific risk factors for adverse outcomes following geriatric proximal femur fractures. Eur J Trauma Emerg Surg 2022; 48:753-761. [PMID: 35325262 PMCID: PMC9001566 DOI: 10.1007/s00068-022-01953-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 03/11/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Proximal femur fractures (PFFs) occur frequently among geriatric patients due to diverse risk factors, such as a lower bone mineral density and the increased risk of falls. METHODS In this review, we focus on recent literature of patient-specific risk factors and their impact on common complications and outcome parameters in patients with PFF. RESULTS Patient- and treatment related factors have a significant impact on outcome and are associated with an increased risk of mortality, impairments in functional rehabilitation and complicative courses. CONCLUSION Geriatric patients at high risk for complications are nursing home inhabitants suffering from severe osteoporosis, dementia and sarcopenia. The early and ongoing assessment for these individual risk factors is crucial. Strategies including interdisciplinary approaches, addressing comorbidities and facilitating an optimal risk factor evaluation result in a beneficial outcome. The ongoing ambulant assessment and therapy of complicating factors (e.g., malnutrition, sarcopenia, frailty or osteoporosis) have to be improved.
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Affiliation(s)
- Nils Becker
- Department of Orthopedics, Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Aachen, Germany.
| | - Tobias Hafner
- Department of Orthopedics, Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Aachen, Germany
| | - Miguel Pishnamaz
- Department of Orthopedics, Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Aachen, Germany
| | - Frank Hildebrand
- Department of Orthopedics, Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Aachen, Germany
| | - Philipp Kobbe
- Department of Orthopedics, Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Aachen, Germany
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22
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Caruso G, Corradi N, Caldaria A, Bottin D, Lo Re D, Lorusso V, Morotti C, Valpiani G, Massari L. New tip-apex distance and calcar-referenced tip-apex distance cut-offs may be the best predictors for cut-out risk after intramedullary fixation of proximal femur fractures. Sci Rep 2022; 12:357. [PMID: 35013492 PMCID: PMC8748913 DOI: 10.1038/s41598-021-04252-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 12/20/2021] [Indexed: 11/30/2022] Open
Abstract
Cut-out is one of the most common mechanical failures in the internal fixation of trochanteric hip fractures. The tip-apex distance (TAD), and the calcar-referenced tip apex distance (CalTAD) are the radiographic parameters that most predict the risk of cut-out. The optimal CalTAD value has not yet been defined, but the optimal TAD value is reported as 25 mm or less. However, this cut-off is highly specific but poorly sensitive. The aim of this study was to determine highly specific and sensitive TAD and CalTAD values and shed light on the role of other clinical variables. A total of 604 patients were included in this retrospective cross-sectional study. For each patient the following data were recorded: number of cut-out, AO/OTA classification, quality of the reduction, type of nail, cervicodiaphyseal angle, type of distal locking, post-operative weight-bearing, TAD and CalTAD values, and the position of the screw head in the femoral head according to the Cleveland system. The incidence of cut-out across the sample was 3.1%. The median TAD in the cut-out group was 38.72, while in the no cut-out group it was 22.16. The median CalTAD in the cut-out group was 39.34, while in the no cut-out group it was 22.19. The cut-off values for TAD and CalTAD with highest value of sensitivity and specificity for the risk of cut-out were 34.8 and 35.2, respectively. The incidence of cut-out can be reduced by performing careful minimal reduction and ensuring stable fixation by avoiding TAD > 34.8 mm and CalTAD > 35.2 mm.
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Affiliation(s)
- Gaetano Caruso
- Department of Neurosciences and Rehabilitation, University of Ferrara, Via Aldo Moro 8, 44124, Ferrara, Italy. .,Orthopaedic and Traumatology Unit, S. Anna University Hospital of Ferrara, Ferrara, Italy.
| | - Nicola Corradi
- Department of Neurosciences and Rehabilitation, University of Ferrara, Via Aldo Moro 8, 44124, Ferrara, Italy.,Orthopaedic and Traumatology Unit, S. Anna University Hospital of Ferrara, Ferrara, Italy
| | - Antonio Caldaria
- Department of Neurosciences and Rehabilitation, University of Ferrara, Via Aldo Moro 8, 44124, Ferrara, Italy.,Orthopaedic and Traumatology Unit, S. Anna University Hospital of Ferrara, Ferrara, Italy
| | - Daniele Bottin
- Orthopaedic and Traumatology Unit, S. Anna University Hospital of Ferrara, Ferrara, Italy
| | - Dario Lo Re
- Department of Neurosciences and Rehabilitation, University of Ferrara, Via Aldo Moro 8, 44124, Ferrara, Italy.,Orthopaedic and Traumatology Unit, S. Anna University Hospital of Ferrara, Ferrara, Italy
| | - Vincenzo Lorusso
- Orthopaedic and Traumatology Unit, S. Anna University Hospital of Ferrara, Ferrara, Italy
| | - Chiara Morotti
- Research and Innovation Office, S. Anna University Hospital of Ferrara, Ferrara, Italy
| | - Giorgia Valpiani
- Research and Innovation Office, S. Anna University Hospital of Ferrara, Ferrara, Italy
| | - Leo Massari
- Department of Neurosciences and Rehabilitation, University of Ferrara, Via Aldo Moro 8, 44124, Ferrara, Italy.,Orthopaedic and Traumatology Unit, S. Anna University Hospital of Ferrara, Ferrara, Italy
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Misailidis AI, Aifantis ID, Pallis D, Mitsikostas PK, Gourtzelidis G, Tsivelekas K, Papadakis SA. Drill-guided femoral nail extraction: a novel technique. J Surg Case Rep 2021; 2021:rjab523. [PMID: 34858578 PMCID: PMC8634110 DOI: 10.1093/jscr/rjab523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 10/10/2021] [Accepted: 11/02/2021] [Indexed: 11/13/2022] Open
Abstract
Femoral nail extraction, although it is considered a challenging procedure for orthopedic surgeons, can be simplified. We present a new technique to aid the removal of a proximally (antegrade) inserted femoral nail by applying drilling consecutively in order to identify the margins and depth of the nail into the intramedyllary canal of the femur. The damage to the bone is minimal as we use k-wires or drilling and in our practice was uneventful. This technique is the first to be reported in literature. Most authors suggest techniques that enable radiolucent table and fluoroscopy techniques using C-arm. With this technique, traction table and fluoroscopy techniques seem to be less essential to accomplish the removal of a proximally (antegrade) inserted femoral nail.
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Affiliation(s)
| | - Ioannis D Aifantis
- B' Department of Orthopaedics, KAT General Hospital of Attica, Kifisia, Greece
| | - Dimitrios Pallis
- B' Department of Orthopaedics, KAT General Hospital of Attica, Kifisia, Greece
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24
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Li P, Zhang Z, Zhou F, Lv Y, Guo Y, Tian Y. Characteristics of intramedullary nail breakage in pertrochanteric femur fractures: a summary of 70 cases. J Orthop Surg Res 2021; 16:676. [PMID: 34789313 PMCID: PMC8597261 DOI: 10.1186/s13018-021-02826-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 11/01/2021] [Indexed: 11/21/2022] Open
Abstract
Objective To reveal noteworthy characteristics of intramedullary (IM) nail breakage in pertrochanteric femur fractures. Materials and methods The data from 6 patients with IM nail breakage in our hospital between August 2008 and May 2018 were reviewed retrospectively. With an additional 64 cases reported in articles in the PubMed database prior to October 2019, a total of 70 cases were reviewed and analysed; epidemiological patient data and data on the initial trauma, fracture type, nail selected for the original surgery, time from surgery to breakage, mechanism and location of breakage, status of fracture healing, salvage treatment and prognosis were assessed. Results Seventy patients with pertrochanteric fractures, including 2 stable fractures and 68 unstable fractures, experienced IM nail breakage at a mean of 9.4 months after the initial surgery. Among them, 9 (12.9%) occurred within 3 months, 23 (32.9%) between 3 and 6 months and 38 (54.3%) after 6 months. The mean age was 72.3 years, and 16 (22.9%) patients were younger than 65 years old. When nail breakage occurred, 66 fractures (94.3%) exhibited delayed union/non-union. Self-dynamisation was found in 12 cases (17.1%). The salvage procedures included 4 partial/total implant removal procedures, 17 hemi/total hip arthroplasty procedures, 3 conservative treatment procedures, and 46 revised osteosyntheses, of which 7 cases (15.2%) sustained secondary implant failure. No significant differences were found between the failure rates of IM nails and extramedullary(EM) devices (odds ratio [OR], 3.429; 95% confidence interval [CI], 0.632–18.877; p = 0.330). Conclusion IM nail breakage is a rare complication lack of time regularity and mostly occurs in unstable pertrochanteric fractures in the presence of delayed union/non-union. Osteosynthesis revision can be conduct by a new IM nail or EM device but considerable secondary failure rate is noteworthy. Self-dynamisation may be a warning sign of nail breakage.
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Affiliation(s)
- Pengfei Li
- Department of Orthopaedics, Peking University Third Hospital, No. 49 North Huayuan Road, Haidian District, Beijing, 100191, People's Republic of China.,Center of Foot and Ankle Surgery, Beijing Tongren Hospital, Capital Medical University, No. 1 Dongjiaomin Lane, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Zhishan Zhang
- Department of Orthopaedics, Peking University Third Hospital, No. 49 North Huayuan Road, Haidian District, Beijing, 100191, People's Republic of China.
| | - Fang Zhou
- Department of Orthopaedics, Peking University Third Hospital, No. 49 North Huayuan Road, Haidian District, Beijing, 100191, People's Republic of China.
| | - Yang Lv
- Department of Orthopaedics, Peking University Third Hospital, No. 49 North Huayuan Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Yan Guo
- Department of Orthopaedics, Peking University Third Hospital, No. 49 North Huayuan Road, Haidian District, Beijing, 100191, People's Republic of China
| | - Yun Tian
- Department of Orthopaedics, Peking University Third Hospital, No. 49 North Huayuan Road, Haidian District, Beijing, 100191, People's Republic of China
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25
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Burgesson BN, Coles CP. Technique for Removal of Broken InterTAN Integrated Cephalomedullary Screw. J Orthop Trauma 2021; 35:e352-e354. [PMID: 33278207 DOI: 10.1097/bot.0000000000002024] [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] [Accepted: 11/17/2020] [Indexed: 02/02/2023]
Abstract
SUMMARY Pertrochanteric femoral fractures are routinely treated with cephalomedullary nailing, with good success. In the event of nonunion, implant fatigue failure may occur. The Trigen InterTAN system (Smith & Nephew, Memphis, TN) features 2 integrated cephalomedullary screws for improved rotational stability of the proximal segment. The inferior compression screw prevents rotation of the larger, superior lag screw. In the event of inferior screw breakage, the retained portion will prevent the integrated lag screw from being rotated to permit extraction. We present a case of a broken nail as well as a broken integrated screw, and describe a technique for successful implant removal.
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Affiliation(s)
- Bernard N Burgesson
- Division of Orthopaedic Surgery, Dalhousie University, Queen Elizabeth II Health Sciences Center, Halifax, NS, Canada
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26
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Abstract
Rotational malreduction is a common yet underreported postoperative complication following intramedullary nailing of long bone fractures. In most situations, this can be prevented at the time of initial surgery with meticulous preoperative planning, careful use of intraoperative fluoroscopy, and awareness of risk factors for malrotation. However, rotational alignment remains difficult to assess by clinical examination so a high index of suspicion is always necessary. Here, the authors review the literature on this complication and report on 3 such cases of femoral and the tibial malrotation, methods for calculating femoral version and tibial torsion, and techniques for correcting these deformities.
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Affiliation(s)
- Matthew Sullivan
- SUNY Upstate, 6620 Fly Road, Suite 200, East Syracuse, NY 13057, USA
| | - Kelsey Bonilla
- Department of Orthopaedics, University of Pennsylvania, 3737 Market Street, 6th Floor, Philadelphia, PA 19104, USA
| | - Derek Donegan
- Department of Orthoapedics, Division of Orthopaedic Trauma, University of Pennsylvania, 3737 Market Street, 6th Floor, Philadelphia, PA 19104, USA.
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27
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Neglected Broken Femoral Intramedullary Nail Resulting in an Urethrocutaneous Fistula. Indian J Orthop 2021; 56:169-173. [PMID: 35070158 PMCID: PMC8748568 DOI: 10.1007/s43465-021-00442-1] [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: 02/20/2021] [Accepted: 06/08/2021] [Indexed: 02/04/2023]
Abstract
A femur fracture is one of the most commonly encountered fractures by orthopaedicians worldwide. Being one of the longest and strongest bones in the body, it is one of the principal load-bearing bones of the lower extremity. Various modalities of fixation have been tried and tested for femur fracture but the most accepted fixation modality for diaphyseal femur fracture worldwide is the interlocking intramedullary nailing. However, intramedullary nailing is not free of any complications. Complications such as infection, non-union, malunion, limb length discrepancy due to wrong size nail, screw or nail breakage, and injury to neurovascular structures while passing guidewire or drilling for the interlocking bolt are commonly reported. We report a case of a patient who presented with a neglected broken femoral nail which resulted in an urethrocutaneous fistula. As per our literature review, this complication has never been reported before.
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Zhang J, Zhu J, Liu Z, Zhang Y, Jin Y, Wang M, Zhang X, He K, Zhang Y. Predictive factors associated with the clinical outcome of intertrochanteric hip fracture in high-risk elderly patients treated with total hip arthroplasty versus percutaneous external fixation. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:740. [PMID: 34268353 PMCID: PMC8246164 DOI: 10.21037/atm-20-8037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 03/17/2021] [Indexed: 11/17/2022]
Abstract
Background Little is known regarding the survival and functional recovery of elderly intertrochanteric hip fracture (IHF) patients after total hip arthroplasty (THA) versus percutaneous external fixation (PEF). This study aims to analyze the prognostic factors of THA and PEF in elderly IHF patients. Methods A total of 155 consecutive elderly patients (mean age of 80 years) diagnosed with IHF were retrospectively reviewed from our database between January 1, 2010, and December 31, 2018. The preoperative, intraoperative and postoperative covariates were analyzed by two independent surgical cohorts: THA and PEF. The main outcomes included the hip function score, all-cause mortality within 1 year after surgery, and overall survival. Covariables and their influence on independent outcomes were analyzed using multivariate regression models. Results The median follow-up period was 5.1 years, and 6 patients were lost to follow-up. At the endpoint, 70 of 85 patients treated with THA and 37 of 70 patients treated with PEF survived, exhibiting mean Harris hip scores of 84.4 and 69.0, respectively. The Kaplan-Meier curves and log-rank tests showed no significant difference in overall survival. After adjusting for the covariates, the surgical mode was a unique prognostic factor affecting hip function recovery, and two prognostic factors (leukocyte count and D-dimer) were correlated with 1-year all-cause mortality. Age at admission, fracture classification, D-dimer level and surgical mode were identified as prognostic factors affecting overall survival. After adjusting for the former three covariates, THA reduced the risk of death by 67.20% compared with PEF (HR 0.328, 95% CI, 0.121–0.890). Conclusions Despite the nonsignificant difference in 1-year all-cause mortality, THA demonstrated superior midterm survival and hip function recovery in elderly IHF patients compared with PEF. Predictive factors, including age at admission, fracture classification, D-dimer level and surgical mode, are associated with the overall survival of IHF in high-risk elderly patients.
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Affiliation(s)
- Jun Zhang
- Joint Disease & Sport Medicine Center, Department of Orthopedics, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Jie Zhu
- Department of Neurology, Daping Hospital, Army Medical University, Chongqing, China
| | - Zaiyang Liu
- Joint Disease & Sport Medicine Center, Department of Orthopedics, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Yumei Zhang
- Joint Disease & Sport Medicine Center, Department of Orthopedics, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Yunfei Jin
- Peking University Clinical Research Institute, Peking University First Hospital, Beijing, China
| | - Min Wang
- Joint Disease & Sport Medicine Center, Department of Orthopedics, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Xia Zhang
- Joint Disease & Sport Medicine Center, Department of Orthopedics, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Kaiqi He
- Joint Disease & Sport Medicine Center, Department of Orthopedics, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Yuan Zhang
- Joint Disease & Sport Medicine Center, Department of Orthopedics, Xinqiao Hospital, Army Medical University, Chongqing, China
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Evaluation of the quadrants of femoral neck-head in the cephalomedullary fixation of intertrochanteric fractures with a helical blade: Is inferior posterior quadrant also safe? A clinical study. Jt Dis Relat Surg 2021; 32:93-100. [PMID: 33463423 PMCID: PMC8073430 DOI: 10.5606/ehc.2021.78098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 10/13/2020] [Indexed: 11/21/2022] Open
Abstract
Objectives
This study aims to investigate the positioning of the helical blade to prevent mechanical complications in surgically fixed intertrochanteric fractures (ITFs). Patients and methods
In this retrospective study, 392 patients (158 males, 234 females; mean age: 75.5±13.4; range, 20 to 101) years) with ITFs treated in lateral decubitus position with proximal femoral nail anti-rotation in a single center between January 2009 and January 2017 were evaluated. The fractures were classified according to the Orthopedic Trauma Association classification preoperatively and grouped as stable or unstable. Postoperatively, tip-apex distance (TAD), Baumgaertner reduction criteria, and obtained quadrants were evaluated. Patients with an unstable fracture, proper TAD, and acceptable or good reduction were included in the final evaluation for statistical analysis to investigate the safest quadrant to prevent cut-out complication. Results
Cut-out complications were observed in 19 (4.8%) patients. The scenario; unstable fracture, TAD <25 mm, acceptable or good reduction consisted of 111 patients in total and cut-out complication occurred in four of them (3.6%) (one in center-posterior, one in center-center, one in superior-anterior, and one in superior-center quadrants). There was no statistically significant difference between center-center, inferior-center, and inferior-posterior quadrants (p=0.49). Conclusion
Inferior-posterior placement is as safe as central-central or inferior-central placement for blade fixation in the surgical treatment of ITF.
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30
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Yam M, Kang BJ, Chawla A, Zhang W, Way LG, Xavier RPA, Park DH, Yeo NEM, Howe TS, Kwek EBK. Cephalomedullary blade cut-ins: a poorly understood phenomenon. Arch Orthop Trauma Surg 2020; 140:1939-1945. [PMID: 32266516 DOI: 10.1007/s00402-020-03439-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Proximal femoral nail antirotation (PFNA) cut-in is a unique phenomenon seen in pertrochanteric hip fractures treated with the PFNA. Cut-in refers to the superomedial migration of the proximal femoral blade into the femoral head and hip joint. We recognize that cut-in is a completely separate entity from the well-described cut-out failure. This study assesses relevant radiological and patient risks factors for cut-in. DESIGN Retrospective multicenter study looking at patients with pertrochanteric hip fractures managed with the Synthes PFNA SETTING: Four tertiary hospitals over 7 years. PATIENTS Patients with cut-ins were identified. OUTCOME MEASUREMENT The radiological appearance of this mode of failure was assessed and compared to cut-outs. Patient demographics, fracture configuration, time to implant failure (cut-in), bone mineral density, tip-apex distance, neck-shaft angle and position of the tip of the helical blade in the femoral head were collected. RESULTS There was a total of 1027 patients across 4 institutions with 23 patients with cut-in. Average neck-shaft angle was 133 degrees. 16 out of 19 patients had severe osteoporosis with BMD < - 2.5. 14 of 23 patients had poor placement of the blade. 13 of 23 had a tip-apex distance of more than 20 mm. CONCLUSION We propose a standardized nomenclature of "cut-in" for the phenomenon of superomedial migration of the proximal femoral blade. An anatomical neck-shaft reduction, accurate blade placement and increased surveillance for patients with severe osteoporosis are required to reduce the incidence and morbidity of cut-in.
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Affiliation(s)
- Michael Yam
- Tan Tock Seng Hospital, Singapore, Singapore.
| | | | | | | | - Law Gin Way
- Tan Tock Seng Hospital, Singapore, Singapore
| | | | | | - N E M Yeo
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore, Singapore
| | - T S Howe
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore, Singapore
| | - E B K Kwek
- Department of Orthopaedic Surgery, Woodlands Health Campus, Singapore, Singapore
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Aissa I, Wartiti LE, Bouhaba N, Khallikane S, Moutaoukil M, Kartite N, Elkoundi A, Benakrout A, Chlouchi A, Elbouti A, Najout H, Grine A, Touab R, Zaizi A, Youssef J, Bakkali H, Balkhi H, Bensghir M. [Combined lumbar plexus-sciatic nerve block in the emergency surgery for pertrochanteric fracture: an alternative technique in patients at high risk of anaesthetic complications]. Pan Afr Med J 2020; 37:12. [PMID: 33062115 PMCID: PMC7532854 DOI: 10.11604/pamj.2020.37.12.21392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 07/13/2020] [Indexed: 11/16/2022] Open
Abstract
Introduction l’anesthésie pour la chirurgie urgente de la fracture pertrochantérienne (FPT) chez les patients à haut risque anesthésique représente souvent un véritable challenge pour les praticiens en vue du risque periopératoire majeur. Nous rapportons notre expérience avec le bibloc ou bloc combiné lombaire et sciatique plexique (BCLS) comme technique anesthésique alternative face à ce type de situation. Méthodes une étude transversale, descriptive, monocentrique, a été menée sur une période de 3 ans, incluant les patients à haut risque anesthésique présentant une FPT récente. Les deux blocs nerveux étaient réalisés au niveau plexique selon la technique classique de neurostimulation. Un mélange de 20ml de lidocaine 2% et de bupivacaine 0,5% (50/50) a été injecté au niveau de chaque bloc. Le critère d’évaluation principal était l’efficacité du BCLS apprécié par l’incidence d’échecs de la technique anesthésique, définie par la nécessité de convertir en anesthésie générale (AG). Les critères d’évaluation secondaires étaient: 1) les données techniques de la procédure anesthésique, 2) les retentissements hémodynamiques, respiratoires et neurologiques periopératoires, et 3) les résultats et les complications éventuelles en postopératoire. Résultats trente patients ont été colligés. L’âge moyen était de 74 ± 10 ans. Le délai moyen d’admission aux urgences-intervention était de 12(5-36) heures. La durée moyenne pour la réalisation de la procédure était de 15,20 ± 3,45 minutes. Aucune conversion en AG n’a été nécessaire. Il n’y avait pas de différences statistiquement significatives entre les différentes valeurs enregistrées des paramètres hémodynamiques et respiratoires periopératoires (PAM, FC, SpO2) (p > 0,05). La durée de l’intervention était de 46 ± 5 minutes. La satisfaction des chirurgiens était de 9,7 ± 0,1. La première demande en antalgiques postopératoires était après 8(1-24) heures. Tous les patients avaient une récupération sensitivomotrice complète. Conclusion le BCLS est une alternative anesthésique pour les interventions urgentes de FPT chez les patients à haut risque anesthésique: délais opératoires réduits, efficacité anesthésique, stabilité hémodynamique et respiratoire periopératoire, absence de complications inhérentes aux autres techniques anesthésiques, passage rapide en salle de surveillance post-interventionnelle (SSPI), et analgésie postopératoire de qualité.
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Affiliation(s)
- Ismail Aissa
- Pôle d'Anesthésie-Réanimation, Hôpital Militaire d'Instruction Mohamed V, Faculté de Médecine et de Pharmacie, Université Mohamed V, Rabat, Maroc
| | - Loukman El Wartiti
- Pôle d'Anesthésie-Réanimation, Hôpital Militaire d'Instruction Mohamed V, Faculté de Médecine et de Pharmacie, Université Mohamed V, Rabat, Maroc
| | - Najib Bouhaba
- Pôle d'Anesthésie-Réanimation, Hôpital Militaire d'Instruction Mohamed V, Faculté de Médecine et de Pharmacie, Université Mohamed V, Rabat, Maroc
| | - Said Khallikane
- Pôle d'Anesthésie-Réanimation, Hôpital Militaire d'Instruction Mohamed V, Faculté de Médecine et de Pharmacie, Université Mohamed V, Rabat, Maroc
| | - Mohamed Moutaoukil
- Pôle d'Anesthésie-Réanimation, Hôpital Militaire d'Instruction Mohamed V, Faculté de Médecine et de Pharmacie, Université Mohamed V, Rabat, Maroc
| | - Noureddine Kartite
- Pôle d'Anesthésie-Réanimation, Hôpital Militaire d'Instruction Mohamed V, Faculté de Médecine et de Pharmacie, Université Mohamed V, Rabat, Maroc
| | - Abdelghafour Elkoundi
- Pôle d'Anesthésie-Réanimation, Hôpital Militaire d'Instruction Mohamed V, Faculté de Médecine et de Pharmacie, Université Mohamed V, Rabat, Maroc
| | - Aziz Benakrout
- Pôle d'Anesthésie-Réanimation, Hôpital Militaire d'Instruction Mohamed V, Faculté de Médecine et de Pharmacie, Université Mohamed V, Rabat, Maroc
| | - Abdellatif Chlouchi
- Pôle d'Anesthésie-Réanimation, Hôpital Militaire d'Instruction Mohamed V, Faculté de Médecine et de Pharmacie, Université Mohamed V, Rabat, Maroc
| | - Anas Elbouti
- Pôle d'Anesthésie-Réanimation, Hôpital Militaire d'Instruction Mohamed V, Faculté de Médecine et de Pharmacie, Université Mohamed V, Rabat, Maroc
| | - Hamza Najout
- Pôle d'Anesthésie-Réanimation, Hôpital Militaire d'Instruction Mohamed V, Faculté de Médecine et de Pharmacie, Université Mohamed V, Rabat, Maroc
| | - Ali Grine
- Pôle d'Anesthésie-Réanimation, Hôpital Militaire d'Instruction Mohamed V, Faculté de Médecine et de Pharmacie, Université Mohamed V, Rabat, Maroc
| | - Reda Touab
- Pôle d'Anesthésie-Réanimation, Hôpital Militaire d'Instruction Mohamed V, Faculté de Médecine et de Pharmacie, Université Mohamed V, Rabat, Maroc
| | - Abderrahim Zaizi
- Service de Traumatologie Orthopédie, Hôpital Militaire d'Instruction Mohamed V, Faculté de Médecine et de Pharmacie, Université Mohamed V, Rabat, Maroc
| | - Jalal Youssef
- Service de Traumatologie Orthopédie, Hôpital Militaire d'Instruction Mohamed V, Faculté de Médecine et de Pharmacie, Université Mohamed V, Rabat, Maroc
| | - Hicham Bakkali
- Pôle d'Anesthésie-Réanimation, Hôpital Militaire d'Instruction Mohamed V, Faculté de Médecine et de Pharmacie, Université Mohamed V, Rabat, Maroc
| | - Hicham Balkhi
- Pôle d'Anesthésie-Réanimation, Hôpital Militaire d'Instruction Mohamed V, Faculté de Médecine et de Pharmacie, Université Mohamed V, Rabat, Maroc
| | - Mustapha Bensghir
- Pôle d'Anesthésie-Réanimation, Hôpital Militaire d'Instruction Mohamed V, Faculté de Médecine et de Pharmacie, Université Mohamed V, Rabat, Maroc
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Chitnis A, Ray B, Sparks C, Grebenyuk Y, Vanderkarr M, Holy CE. Long bone fractures: treatment patterns and factors contributing to use of intramedullary nailing. Expert Rev Med Devices 2020; 17:731-738. [PMID: 32597254 DOI: 10.1080/17434440.2020.1779055] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND This study evaluated treatment patterns for long bone fractures and factors that contribute to use of intramedullary nails (IMN). METHODS Patients from IBM MarketScan® Research Commercial and Medicare Databases with femoral/tibial/humeral fractures during inpatient admission between January 2016-July 2019 were identified. Patients were categorized by treatment (i.e., non-surgical/internal fixation [extramedullary internal fixation/plating]/IMN/external fixation). Four-year rates of IMN were reported by fracture type. Logistic regression evaluated factors contributing to IMN use. RESULTS 14,961 femoral, 14,101 tibial, and 7,059 humeral fracture patients were identified (mean[SD] age was 45.3[18.9], 42.0[16.3], and 39.8[21.6] years and % female 50.8%, 47.7%, and 55.3%, respectively). Mean(SD) lengths of stay were 6.7(9.2), 5.9(7.0), and 5.8(10.3) days, rates of surgical treatment were 74.3%, 84.0%, and 62.7%, and rates of IMN among surgical patients were 46.6%, 27.1%, and 6.7% for femoral, tibial, and humeral fractures, respectively. IMN was the predominant treatment for femoral fractures over the past 4 years. Factors contributing to IMN use included open/closed diaphyseal fractures, pathological fractures, diagnoses of cancer or AIDS/HIV, and alcohol abuse. CONCLUSIONS IMN was the predominant treatment for femoral fractures and use slightly increased for tibial/humeral fractures. Open/closed diaphyseal fractures, pathological fractures, cancer or AIDS/HIV, and alcohol abuse contributed to IMN use.
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Affiliation(s)
- Abhishek Chitnis
- Medical Devices Epidemiology,Real World Data Sciences, Johnson & Johnson , New Brunswick, NJ, USA
| | | | - Charisse Sparks
- Medical Affairs, DePuy Orthopedics, Inc , West Chester, PA, USA
| | - Yuriy Grebenyuk
- Medical Affairs, DePuy Orthopedics, Inc , West Chester, PA, USA
| | - Mollie Vanderkarr
- Health Economics and Market Access, DePuy Synthes , West Chester, PA, USA
| | - Chantal E Holy
- Medical Devices Epidemiology,Real World Data Sciences, Johnson & Johnson , New Brunswick, NJ, USA
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Buruian A, Silva Gomes F, Roseiro T, Vale C, Carvalho A, Seiça E, Mendes A, Pereira C. Distal interlocking for short trochanteric nails: static, dynamic or no locking? Review of the literature and decision algorithm. EFORT Open Rev 2020; 5:421-429. [PMID: 32818069 PMCID: PMC7407850 DOI: 10.1302/2058-5241.5.190045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Pertrochanteric hip fractures are among the most common and the use of short cephalomedullary nails as the treatment of choice is increasing. A systematic review regarding distal locking options for short cephalomedullary nails was undertaken using Medline/PubMed®, Embase® and Cochrane Library® in order to evaluate current indications, associated complications and to provide treatment recommendations. The results seem to support the use of distal static locking for unstable fractures, dynamic locking for length stable/rotational unstable fractures and no locking for stable fractures. Complications associated with distal locking include iatrogenic fractures, thigh pain, delayed union and nonunion, implant failure, screw loosening and breaking, drill bit breaking, soft tissue irritation, femoral artery branch injury, intramuscular haematoma and compartment syndrome. It is also associated with longer operative time and radiation exposure. In unlocked constructs, dorsomedial comminution and nail/medullary canal mismatch contribute to peri-implant fractures. Anterior cortical impingement is associated with cut-out and nonunion. Most studies comparing distally locked and unlocked nails report a short follow-up. Distal locking mode should be based on the fracture’s stability.
Cite this article: EFORT Open Rev 2020;5:421-429. DOI: 10.1302/2058-5241.5.190045
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Affiliation(s)
- Alexei Buruian
- Hospital Distrital da Figueira da Foz, Figueira Da Foz, Portugal
| | | | - Tiago Roseiro
- Hospital Distrital da Figueira da Foz, Figueira Da Foz, Portugal
| | - Claudia Vale
- Hospital Distrital da Figueira da Foz, Figueira Da Foz, Portugal
| | - André Carvalho
- Hospital Distrital da Figueira da Foz, Figueira Da Foz, Portugal
| | - Emanuel Seiça
- Hospital Distrital da Figueira da Foz, Figueira Da Foz, Portugal
| | - Antonio Mendes
- Hospital Distrital da Figueira da Foz, Figueira Da Foz, Portugal
| | - Carlos Pereira
- Hospital Distrital da Figueira da Foz, Figueira Da Foz, Portugal
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Dynamic Hip Screw with Trochanter-Stabilizing Plate Compared with Proximal Femoral Nail Antirotation as a Treatment for Unstable AO/OTA 31-A2 and 31-A3 Intertrochanteric Fractures. BIOMED RESEARCH INTERNATIONAL 2020; 2020:1896935. [PMID: 32923477 PMCID: PMC7453265 DOI: 10.1155/2020/1896935] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 08/05/2020] [Indexed: 11/18/2022]
Abstract
Background The dynamic hip screw (DHS) with the addition of an angular stable trochanter-stabilizing plate (TSP) has been considered the ideal treatment for the unstable intertrochanteric fracture type. However, there have been few comparisons between DHS+TSP augmentation with intramedullary (IM) nailing. The aim of this retrospectively registered study was to compare the clinical outcomes of patients with the unstable type of intertrochanteric fractures treated with DHS+TSP or IM nailing (proximal femoral nail antirotation (PFNA)). Methods From June 2013 to April 2018, 358 patients with proximal femur fracture AO/OTA type 31A2 and 31A3 treated with PFNA or DHS+TSP and followed for ≥10 months postoperatively were included. The surgical-dependent outcome evaluation included the operation time, intraoperative blood loss, postoperative decrease in hemoglobin, and blood transfusion amount. Functional status was also measured. Radiographic findings and postoperative complications were recorded and analyzed. Result The operation time was significantly shorter in the DHS+TSP group than that in the PFNA group for both A2 and A3 fractures (A2 type: 84.0 vs.96.4 min; p < 0.05; A3 type: 102.4 vs.116.1 min; p < 0.05). Postoperative decrease in hemoglobin was more significant in the PFNA group than that in the DHS+TSP group for both fracture types (A2 type: −1.88 vs. −1.29 (mg/dL); p < 0.05; A3 type: −1.63 vs. −1.04 (mg/dL); p < 0.05). However, the patients treated with DHS+TSP had significantly more residual pain than those treated with PFNA during the final follow-up (Visual Analog Scale score, A2 type: 28.4 vs.23.2; p < 0.05; A3 type: 27.5 vs.23.6; p < 0.05) and complained of greater implant irritation. Conclusion We found that DHS+TSP was associated with less operation time and less postoperative decrease in hemoglobin but more residual pain and implant irritation than those of PFNA. As a treatment for unstable intertrochanteric fracture, DHS+TSP provided ideal surgical outcomes which were not inferior to the PFNA.
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Fernandes PX, Medeiros DM, Teixeira RC, Nunes AM, Seco AS, Caetano AC. Injury to the Superior Gluteal Artery during Intramedullary Fixation of a Proximal Femoral Fracture - A Case Report. J Orthop Case Rep 2020; 9:27-31. [PMID: 32548023 PMCID: PMC7276602 DOI: 10.13107/jocr.2019.v09.i06.1574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction Proximal femoral fractures represent a health problem of global proportions. Iatrogenic vascular lesion in the treatment of these fractures is an unusual potentially lethal complication, reported in only 0.2% of trochanteric fractures treated with intramedullary implants. Superior gluteal artery injury is extremely rare, with only two cases reported in literature. Case Report A 66-year-old Caucasian woman, with metastatic disease, was admitted with a right pertrochanteric fracture. She underwent closed reduction and long intramedullary nail fixation. Five days post-operatively, a sudden hemoglobin drop occurred. A computed tomography demonstrated an extensive hematoma. Angiography confirmed an arterial bleeding from the superior gluteal artery and subsequent selective embolization was successfully performed. Conclusion The presence of anemia and thigh hematoma that progressively worsens post-operatively should raise the diagnostic suspicion of an iatrogenic vascular injury. To the best of our knowledge, this is only the third case reported of superior gluteal artery injury after intramedullary fixation of a proximal femoral fracture. We describe the post-operative course and management strategy and hope this will contribute to the global knowledge and increase awareness of these rare injuries.
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Affiliation(s)
- Pedro Xavier Fernandes
- Department of Orthopaedic Surgery, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, Estrada do Forte do Alto do Duque, 1495-005 Lisbon, Portugal
| | - Duarte Manuel Medeiros
- Department of Vascular Surgery, Hospital de Egas Moniz,Centro Hospitalar de Lisboa Ocidental, R. da Junqueira 126, 1349-019 Lisbon, Portugal
| | - Raquel C Teixeira
- Department of Orthopaedic Surgery, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, Estrada do Forte do Alto do Duque, 1495-005 Lisbon, Portugal
| | - Andreia Mercier Nunes
- Department of Orthopaedic Surgery, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, Estrada do Forte do Alto do Duque, 1495-005 Lisbon, Portugal
| | - Antonio Sousa Seco
- Department of Orthopaedic Surgery, Hospital Lusiadas, R. Abílio Mendes 12, 1500-458 Lisbon, Portugal
| | - Afonso Cevadinha Caetano
- Department of Orthopaedic Surgery, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, Estrada do Forte do Alto do Duque, 1495-005 Lisbon, Portugal
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Li P, Lv Y, Zhou F, Tian Y, Ji H, Zhang Z, Guo Y, Yang Z, Hou G. Medial wall fragment involving large posterior cortex in pertrochanteric femur fractures: a notable preoperative risk factor for implant failure. Injury 2020; 51:683-687. [PMID: 31987607 DOI: 10.1016/j.injury.2020.01.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 01/18/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION To introduce a classification for medial wall fragments in pertrochanteric femur fractures and investigate potential preoperative predictors of implant failure following fixation. MATERIAL AND METHODS Medical records of 324 adult patients receiving routine operative treatment using intramedullary devices for pertrochanteric femur fractures with medial wall fragments between August 2008 and May 2018 were retrospectively analyzed. Potential predictors including age, gender, body mass index, comorbidities, AO/OTA classification of fractures were noted. The medial wall fractures were categorized into three types: 1) Type I: avulsion of the lesser trochanter; fracture line does not exceed the base of the lesser trochanter; 2) Type II: fragment involving the posterior cortex near the base of the lesser trochanter; fracture line does not reach the midline of the posterior wall; 3) Type III: fragment involving the large posterior cortex; fracture line reaches or exceeds the midline of the posterior wall. RESULTS The 8 (2.5%) implant failures comprised 1 in 186 Type I fractures, 1 in 76 Type II fractures and 6 in 62 Type III fractures. The failure rates of each fracture type were 0.5% in Type I, 1.3% in Type II and significantly increased to 9.7% in Type III (odds ratio [OR], 19.821; 95% confidence interval [CI], 2.337-168.135; p=0.001). CONCLUSIONS Type III fractures had a significantly increased failure rate. It is important for orthopedists to identify Type III fractures presurgically, reduction of the medial wall fragment and fixation should be considered during surgery using intramedullary nails.
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Affiliation(s)
- Pengfei Li
- Department of Orthopaedics, Peking University Third Hospital. No. 49 North Huayuan Road, Haidian District, Beijing 100191, PR China
| | - Yang Lv
- Department of Orthopaedics, Peking University Third Hospital. No. 49 North Huayuan Road, Haidian District, Beijing 100191, PR China
| | - Fang Zhou
- Department of Orthopaedics, Peking University Third Hospital. No. 49 North Huayuan Road, Haidian District, Beijing 100191, PR China.
| | - Yun Tian
- Department of Orthopaedics, Peking University Third Hospital. No. 49 North Huayuan Road, Haidian District, Beijing 100191, PR China
| | - Hongquan Ji
- Department of Orthopaedics, Peking University Third Hospital. No. 49 North Huayuan Road, Haidian District, Beijing 100191, PR China
| | - Zhishan Zhang
- Department of Orthopaedics, Peking University Third Hospital. No. 49 North Huayuan Road, Haidian District, Beijing 100191, PR China
| | - Yan Guo
- Department of Orthopaedics, Peking University Third Hospital. No. 49 North Huayuan Road, Haidian District, Beijing 100191, PR China
| | - Zhongwei Yang
- Department of Orthopaedics, Peking University Third Hospital. No. 49 North Huayuan Road, Haidian District, Beijing 100191, PR China
| | - Guojin Hou
- Department of Orthopaedics, Peking University Third Hospital. No. 49 North Huayuan Road, Haidian District, Beijing 100191, PR China
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Sivakumar A, Thewlis D, Ladurner A, Edwards S, Rickman M. 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. BMJ Open 2020; 10:e032640. [PMID: 32047013 PMCID: PMC7044810 DOI: 10.1136/bmjopen-2019-032640] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 11/13/2019] [Accepted: 12/10/2019] [Indexed: 11/03/2022] Open
Abstract
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.
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Affiliation(s)
- Arjun Sivakumar
- Centre for Orthopaedic & Trauma Research (COTR), Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - Dominic Thewlis
- Centre for Orthopaedic & Trauma Research (COTR), Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - Andreas Ladurner
- Department of Orthopaedics & Trauma, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Suzanne Edwards
- Adelaide Health Technology Assessment, The University of Adelaide, Adelaide, South Australia, Australia
| | - Mark Rickman
- Department of Orthopaedics & Trauma, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Rehabilitation protocols in unstable trochanteric fractures treated with cephalomedullary nails in elderly: current practices and outcome. Eur J Trauma Emerg Surg 2020; 46:1267-1280. [PMID: 31900496 DOI: 10.1007/s00068-019-01294-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 12/23/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Optimal rehabilitation treatment after surgery for fixation of unstable trochanteric fractures is challenging in elderly patients. PURPOSE The objective of this study is to analyse the existing literature on available rehabilitation protocols with regards to permitting or restricting early weight bearing following fixation of unstable trochanteric fractures treated by the use of cephalomedullary nails in patients at least 65 years of age. METHODS A systematic review was performed based on the checklist of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Studies published between 1948 and 2018 on elderly patients with unstable trochanteric fractures treated with cephalomedullary nails that offered information on the postoperative rehabilitation protocol have been selected. Subsequently, the results and complications have been analysed according to the protocols. RESULTS Fifteen of the 7056 initial articles have been selected for analysis. Authors who did not restrict weight bearing to their patients reported a shorter hospitalization time and a lower orthopaedic complication rate but a greater systemic complication rate, worse functional scores, and a higher reoperation and mortality rates. Those results should be taken with caution because of the heterogeneity of provided clinical information and the fact that none of the included studies considered the different rehabilitation protocols as study variables to analyse its influence on the results. CONCLUSION With evidence available to date, there is no clear agreement on the postoperative rehabilitation protocol following fixation of an unstable trochanteric fracture by cephalomedullary nail in the elderly.
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Abstract
Traumatic injuries of the hip and pelvis are commonly encountered in the emergency department. This article equips all emergency medicine practitioners with the knowledge to expertly diagnose, treat, and disposition these patients. Pelvic fractures occurring in young patients tend to be associated with high-energy mechanisms and polytrauma. Pelvic and hip fractures in the elderly are often a result of benign trauma but are associated with significant morbidity and mortality.
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Affiliation(s)
- Jason V Brown
- Emergency Medical Services, United States Air Force, 96TW/SGOE, 307 Boatner Road, Eglin AFB, FL 32542, USA.
| | - Sharleen Yuan
- Department of Emergency Medicine, University of Maryland Medical Center, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA
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Kokoroghiannis C, Vasilakos D, Zisis K, Dimitriou G, Pappa E, Evangelopoulos D. Is rotation the mode of failure in pertrochanteric fractures fixed with nails? Theoretical approach and illustrative cases. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2019; 30:199-205. [PMID: 31538272 DOI: 10.1007/s00590-019-02557-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 09/16/2019] [Indexed: 11/26/2022]
Abstract
PURPOSE The present article reviews data from biomechanical and clinical studies which indicate that rotational instability can cause failure of fixation due to the particular characteristics of the fracture, the mechanical properties of the chosen implant or flaws in surgical technique. METHODS Although radiographs give a similar impression in failure of fractures fixed with cephalomedullary nails, different mechanisms involving rotation of the femoral head may play a key role. RESULTS The incidence of failure in pertrochanteric fracture fixation is decreasing as implants continue to evolve. It is possible that currently reported low failure rates do not apply equally to all subtypes of this diverse group of fractures. Since the introduction of sliding hip screws, "cut-out" due to varus collapse of the proximal fracture fragment has been the only reported mode of failure. CONCLUSION Excessive rotation leading to eventual "cut-out" has not been adequately studied, and thus, available evidence is not sufficient to definitely prove this theoretical approach. As nailing is gradually overtaking extramedullary fixation as the treatment of choice, especially for comminuted pertrochanteric fractures which can be rotationally unstable, further research is warranted to improve our understanding of the pathogenetic mechanisms of failure.
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Affiliation(s)
- C Kokoroghiannis
- 5th Department of Orthopaedics, "KAT" General Hospital of Athens, Nikis 2 Str, Athens, Greece
| | - D Vasilakos
- 5th Department of Orthopaedics, "KAT" General Hospital of Athens, Nikis 2 Str, Athens, Greece
| | - K Zisis
- 5th Department of Orthopaedics, "KAT" General Hospital of Athens, Nikis 2 Str, Athens, Greece
| | - G Dimitriou
- 5th Department of Orthopaedics, "KAT" General Hospital of Athens, Nikis 2 Str, Athens, Greece
| | - E Pappa
- 5th Department of Orthopaedics, "KAT" General Hospital of Athens, Nikis 2 Str, Athens, Greece.
| | - D Evangelopoulos
- 5th Department of Orthopaedics, "KAT" General Hospital of Athens, Nikis 2 Str, Athens, Greece
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Law GW, Wong YR, Yew AKS, Choh ACT, Koh JSB, Howe TS. Medial migration in cephalomedullary nail fixation of pertrochanteric hip fractures: A biomechanical analysis using a novel bidirectional cyclic loading model. Bone Joint Res 2019; 8:313-322. [PMID: 31463040 PMCID: PMC6691370 DOI: 10.1302/2046-3758.87.bjr-2018-0271.r1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objectives The paradoxical migration of the femoral neck element (FNE) superomedially against gravity, with respect to the intramedullary component of the cephalomedullary device, is a poorly understood phenomenon increasingly seen in the management of pertrochanteric hip fractures with the intramedullary nail. The aim of this study was to investigate the role of bidirectional loading on the medial migration phenomenon, based on unique wear patterns seen on scanning electron microscopy of retrieved implants suggestive of FNE toggling. Methods A total of 18 synthetic femurs (Sawbones, Vashon Island, Washington) with comminuted pertrochanteric fractures were divided into three groups (n = 6 per group). Fracture fixation was performed using the Proximal Femoral Nail Antirotation (PFNA) implant (Synthes, Oberdorf, Switzerland; n = 6). Group 1 was subjected to unidirectional compression loading (600 N), with an elastomer (70A durometer) replacing loose fracture fragments to simulate surrounding soft-tissue tensioning. Group 2 was subjected to bidirectional loading (600 N compression loading, 120 N tensile loading), also with the elastomer replacing loose fracture fragments. Group 3 was subjected to bidirectional loading (600 N compression loading, 120 N tensile loading) without the elastomer. All constructs were tested at 2 Hz for 5000 cycles or until cut-out occurred. The medial migration distance (MMD) was recorded at the end of the testing cycles. Results The MMDs for Groups 1, 2, and 3 were 1.02 mm, 6.27 mm, and 5.44 mm respectively, with reliable reproduction of medial migration seen in all groups. Bidirectional loading groups showed significantly higher MMDs compared with the unidirectional loading group (p < 0.01). Conclusion Our results demonstrate significant contributions of bidirectional cyclic loading to the medial migration phenomenon in cephalomedullary nail fixation of pertrochanteric hip fractures. Cite this article: G. W. Law, Y. R. Wong, A. K-S. Yew, A. C. T. Choh, J. S. B. Koh, T. S. Howe. Medial migration in cephalomedullary nail fixation of pertrochanteric hip fractures: A biomechanical analysis using a novel bidirectional cyclic loading model. Bone Joint Res 2019;8:313–322. DOI: 10.1302/2046-3758.87.BJR-2018-0271.R1.
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Affiliation(s)
- G W Law
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore, Singapore
| | - Y R Wong
- Singapore General Hospital, Singapore, Singapore
| | - A K-S Yew
- Singapore General Hospital, Singapore, Singapore
| | - A C T Choh
- Singapore General Hospital, Singapore, Singapore
| | - J S B Koh
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore, Singapore
| | - T S Howe
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore, Singapore
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Chitnis AS, Vanderkarr M, Ruppenkamp J, Lerner J, Holy CE, Sparks C. Reoperations in intramedullary fixation of pertrochanteric hip fractures. J Med Econ 2019; 22:706-712. [PMID: 30912723 DOI: 10.1080/13696998.2019.1600526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: This study evaluated the frequency of reoperation within 1 year of initial intramedullary fixation for patients with pertrochanteric hip fracture and compared 1-year healthcare resource utilization and cost burden for patients with and without reoperation. Methods: This is a retrospective evaluation of medical claims from the US Centers for Medicare and Medicaid Standard Analytic File. Patients aged ≥65 years who underwent fixation with an intramedullary implant for a pertrochanteric fracture between 2013 and 2015 were included. Healthcare resources that were evaluated included skilled nursing facility (SNF), inpatient rehabilitation facility (IRF), readmissions, and outpatient hospital visits. All-cause payments for these services comprised overall cost burden. Generalized Linear Models were used to evaluate healthcare resources and cost burden over 1-year post-surgery and to adjust for confounding between patients with and without a reoperation. Results: A total of 6,423 Medicare patients were included in the analysis. Mean (SD) age was 82.4 (7.8) years, 76.0% were female, and 93.3% were white. A second hip surgery within 1 year after the index fixation procedure was performed in 414 patients (6.4%): 121 (29.2%) contralateral, 115 (27.8%) ipsilateral, and 178 (43.0%) without specified laterality. After adjusting for confounding factors, Medicare patients with ipsilateral reoperations had statistically significantly higher readmissions (100% vs 32.5%, p < 0.0001), outpatient hospital visits (96.4% vs 88.8%, p = 0.018), admissions to a SNF (88.5% vs 80.4%, p = 0.024), and admissions to an IRF (38.8% vs 22.0%, p < 0.0001) compared to patients without reoperations. The adjusted mean total all-cause payments ($90,162 vs $55,131, p < 0.0001) during the 1-year follow-up were statistically significantly higher among patients with reoperations as compared to patients without reoperations. Conclusions: Patients who require a second hip surgery after initial fixation with an intramedullary implant for pertrochanteric hip fractures have significantly higher 1-year healthcare resource utilization and 63.5% higher costs than patients without reoperation.
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Affiliation(s)
- Abhishek S Chitnis
- a Medical Devices Epidemiology, Real World Data Sciences , Johnson & Johnson , New Brunswick , NJ , USA
| | - Mollie Vanderkarr
- b Health Economics and Market Access , DePuy Synthes Orthopaedics , West Chester , PA , USA
| | - Jill Ruppenkamp
- a Medical Devices Epidemiology, Real World Data Sciences , Johnson & Johnson , New Brunswick , NJ , USA
| | - Jason Lerner
- c Health Economics and Market Access Analytics , Johnson & Johnson , Raynham , MA , USA
| | - Chantal E Holy
- a Medical Devices Epidemiology, Real World Data Sciences , Johnson & Johnson , New Brunswick , NJ , USA
| | - Charisse Sparks
- d Medical Affairs, DePuy Synthes Orthopaedics , West Chester , PA , USA
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Kim CH, Chang JS, Kim JW. Clinical outcomes of dynamic hip screw fixation of intertrochanteric fractures: comparison with additional anti-rotation screw use. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2019; 29:1017-1023. [PMID: 30847679 DOI: 10.1007/s00590-019-02397-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 02/08/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND Hip screw cutout is among the most common causes of intertrochanteric fracture fixation failure using dynamic hip screws (DHS). This study aimed to evaluate the effect of using an additional anti-rotation screw on hip screw migration or cutout in intertrochanteric fracture fixation. MATERIALS AND METHODS We screened 488 patients with unilateral fragile intertrochanteric fractures treated with DHS between January 2001 and March 2016. The inclusion criteria were as follows: (1) age ≥ 50 years; (2) low-energy injury; (3) follow-up of at least 6 months; and (4) short barrel plate used in the operation. The exclusion criteria were as follows: (1) combination with other fracture; or (2) pathological fracture. Subsequently, 166 patients were enrolled; of them, 128 underwent surgery using DHS with an additional screw (Group 1) and 38 patients underwent surgery without an additional screw (Group 2). We compared the postoperative results and clinical outcomes while focusing on screw migration and cutout. Furthermore, we investigated the risk factors for lag screw migration. RESULTS Bone union was achieved in 160 patients (96.4%) without secondary intervention. Two patients (1.6%) in Group 1 and 1 (2.6%) in Group 2 developed screw cutout, while 18 (14.1%) in Group 1 and 12 (31.6%) in Group 2 developed screw migration. Thus, Group 2 demonstrated a higher screw migration rate. Multiple logistic regression analysis revealed that the additional anti-rotation screw was the most important factor in preventing screw migration (P = 0.019). CONCLUSION The additional anti-rotation screw reduced the lag screw migration rate following DHS surgery for intertrochanteric fractures. LEVEL OF EVIDENCE Level IV, retrospective series.
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Affiliation(s)
- Chul-Ho Kim
- Department of Orthopedic Surgery, Asan Medical Center, Ulsan University, College of Medicine, 88, Olympic-ro 43-gil, Songpa-Gu, Seoul, Republic of Korea
| | - Jae Suk Chang
- Department of Orthopedic Surgery, Asan Medical Center, Ulsan University, College of Medicine, 88, Olympic-ro 43-gil, Songpa-Gu, Seoul, Republic of Korea
| | - Ji Wan Kim
- Department of Orthopedic Surgery, Asan Medical Center, Ulsan University, College of Medicine, 88, Olympic-ro 43-gil, Songpa-Gu, Seoul, Republic of Korea.
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Kani KK, Porrino JA, Mulcahy H, Chew FS. Fragility fractures of the proximal femur: review and update for radiologists. Skeletal Radiol 2019; 48:29-45. [PMID: 29959502 DOI: 10.1007/s00256-018-3008-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 06/10/2018] [Accepted: 06/14/2018] [Indexed: 02/02/2023]
Abstract
Proximal femoral fragility fractures are common and result in significant morbidity and mortality along with a considerable socioeconomic burden. The goals of this article are to review relevant proximal femoral anatomy together with imaging, classification, and management of proximal femoral fragility fractures, and their most common complications. Imaging plays an integral role in classification, management and follow-up of proximal femoral fragility fractures. Classification of proximal femoral fragility fractures is primarily based on anteroposterior hip radiographs. Pertinent imaging features for each category of proximal femoral fractures that would guide management are: differentiating nondisplaced from displaced femoral neck fractures, distinguishing stable from unstable intertrochanteric fractures, and determining the morphology and comminution of subtrochanteric fractures. Treatment of proximal femoral fragility fractures is primarily surgical with either arthroplasty or internal fixation. Intramedullary nailing is used in the treatment of some types of proximal femoral fragility fractures and may be associated with unique complications that become evident on postoperative follow-up radiographs.
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Affiliation(s)
- Kimia Khalatbari Kani
- Department of Radiology, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Jack A Porrino
- Department of Radiology, University of Washington, 4245 Roosevelt Way NE, Box 354755, Seattle, WA, 98105, USA
| | - Hyojeong Mulcahy
- Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, 98105, USA
| | - Felix S Chew
- Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, 98105, USA
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Roth J, Goldman B, Zirkle L, Schlechter J, Ibrahim J, Shearer D. Early clinical cxperience with the SIGN hip construct: a retrospective case series. SICOT J 2018; 4:55. [PMID: 30500327 PMCID: PMC6269155 DOI: 10.1051/sicotj/2018050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 10/28/2018] [Indexed: 01/10/2023] Open
Abstract
Background: As the population ages, the developing world industrializes, and more urban centers emerge, the burden of orthopedic trauma will steadily increase. SIGN Fracture Care International has developed a unique intramedullary device for fixation of hip fractures in low-resource settings lacking fluoroscopy. The purpose of this study is to report the safety profile and complication rate for a consecutive series of hip fracture patients managed using this implant. Methods: We conducted a retrospective analysis of the first 170 patients treated with the SIGN Hip Construct (SHC) from 2009 to 2014 using the SIGN Online Surgical Database (SOSD). Patients with follow-up greater than 12 weeks and adequate radiographs were included. Data recorded include patient demographics, time-to-surgery, union rate, AO/OTA classification, complications, neck-shaft angle, and clinical outcomes including painless weight bearing and knee flexion greater than 90°. Results: Of 170 patients, 71 met inclusion criteria with mean follow-up of 39 weeks. Mean age was 49.5 and by WHO, regions were Africa (27), Eastern Mediterranean (21), Western Pacific (17), Americas (3), and Southeast Asia (3). Fractures included intertrochanteric (55), subtrochanteric (7), femoral neck (4), and combined (5). Reduction quality was good in 35 (49%), acceptable in 19 (27%), and poor in 17 (24%). Major complications consisted of varus collapse (6), non- or delayed union (3), intra-articular screw (5), and infection (3). Average postoperative neck-shaft angle was 126° and 119.3° at final follow-up. Conclusions: This is the first comprehensive report of a novel implant for hip fractures specifically designed for low-resource settings. The early clinical data and outcomes suggest that the SHC can be safely inserted in the absence of fluoroscopy, and facilitates early mobilization while maintaining acceptable reduction until union.
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Affiliation(s)
- Justin Roth
- Department of Orthopaedic Surgery, Washington University, Campus Box 8233, One Children's Place, Saint Louis, MO 63110, USA
| | - Brian Goldman
- Largo Medical Center, 201 14th St SW, Largo, FL 33770, USA
| | - Lewis Zirkle
- SIGN Fracture Care International, 451 Hills St #B, Richland, WA 99354, USA
| | - John Schlechter
- Adult and Pediatric Orthopedic Specialists, 1310 W Stewart Dr #508, Orange, CA 92868, USA
| | - John Ibrahim
- University of California San Francisco, Orthopaedic Trauma Institute, 2550 23rd Street Building 9, 2nd Floor, San Francisco, CA 94110, USA
| | - David Shearer
- University of California San Francisco, Orthopaedic Trauma Institute, 2550 23rd Street Building 9, 2nd Floor, San Francisco, CA 94110, USA
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Hörlesberger N, Hohenberger G, Matzi V, Grechenig P. [Extensive emphysema after intramedullary nailing of a pertrochanteric fracture : Life-threatening infection or benign complication]. Unfallchirurg 2018; 122:160-164. [PMID: 30421303 DOI: 10.1007/s00113-018-0580-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The development of emphysema after intramedullary nailing can represent an easily manageable complication but in the differential diagnostics it could, however, be a life-threatening infection with Clostridium perfringens. This is a report about the case of an extensive subcutaneous and retroperitoneal emphysema, which developed after intramedullary nailing of a pertrochanteric femoral fracture and where such an infection was suspected.
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Affiliation(s)
- Nina Hörlesberger
- Universitätsklinik für Orthopädie und Traumatologie, Medizinische Universität Graz, Auenbruggerplatz 5, 8036, Graz, Österreich.
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Thamyongkit S, MacKenzie JS, Sirisreetreerux N, Shafiq B, Hasenboehler EA. Outcomes after unstable pertrochanteric femur fracture: intermediate versus long cephalomedullary nails. Eur J Trauma Emerg Surg 2018; 46:963-968. [PMID: 30143808 DOI: 10.1007/s00068-018-1002-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 08/20/2018] [Indexed: 01/10/2023]
Abstract
PURPOSE Optimal cephalomedullary nail (CMN) length for unstable pertrochanteric femur fractures is controversial. Long CMNs (L-CMNs) are currently recommended; however, intermediate-length CMNs (I-CMNs) may provide stable fixation without the additional surgical steps required by L-CMNs. We analyzed outcomes after unstable pertrochanteric femur fractures treated with L-CMNs or I-CMNs to determine whether functional outcomes, perioperative measures, complications, and mortality and reoperation rates differ by CMN length. METHODS We retrospectively reviewed medical records at our institution for 100 patients who received surgical treatment for pertrochanteric femur fractures from June 2014 to June 2016. Data from 43 unstable pertrochanteric femur fractures treated with L-CMNs (n = 25) or I-CMNs (n = 18) were analyzed. We evaluated operative time, fluoroscopy time, intraoperative blood loss, blood transfusions, and perioperative complications; peri-implant fracture, malunion, reoperation, and death; and neck-shaft angle, tip-apex distance, and 6-month postoperative functional scores. We analyzed categorical data with Fisher exact tests and continuous data with Student t tests. P < 0.05 was considered significant. RESULTS The I-CMN group had shorter operative time (68 versus 92 min; P = 0.048), shorter fluoroscopy time (72 versus 110 s; P = 0.019), and less intraoperative blood loss (80 versus 168 mL; P < 0.001) than the L-CMN group. The groups were similar in rates of blood transfusion, perioperative complications, peri-implant fracture, malunion, reoperation, and death. Six-month postoperative functional scores were similar between groups (P > 0.05). CONCLUSIONS We found operative advantages of I-CMNs over L-CMNs with no difference in treatment outcomes. LEVEL OF EVIDENCE Level IV, Retrospective case series study.
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Affiliation(s)
- Sorawut Thamyongkit
- Department of Orthopaedic Surgery, The Johns Hopkins University/Johns Hopkins Bayview Medical Center, 4940 Eastern Ave., #A667, Baltimore, MD, 21224-2780, USA.,Chakri Naruebodindra Medical Institute, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchatewi, Bangkok, 10400, Thailand
| | - James S MacKenzie
- Department of Orthopaedic Surgery, The Johns Hopkins University/Johns Hopkins Bayview Medical Center, 4940 Eastern Ave., #A667, Baltimore, MD, 21224-2780, USA
| | - Norachart Sirisreetreerux
- Department of Orthopaedic Surgery, The Johns Hopkins University/Johns Hopkins Bayview Medical Center, 4940 Eastern Ave., #A667, Baltimore, MD, 21224-2780, USA
| | - Babar Shafiq
- Department of Orthopaedic Surgery, The Johns Hopkins University/Johns Hopkins Bayview Medical Center, 4940 Eastern Ave., #A667, Baltimore, MD, 21224-2780, USA
| | - Erik A Hasenboehler
- Department of Orthopaedic Surgery, The Johns Hopkins University/Johns Hopkins Bayview Medical Center, 4940 Eastern Ave., #A667, Baltimore, MD, 21224-2780, USA.
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Abstract
OBJECTIVES To determine and test mathematical models of the relationship between hip flexion-extension, femoral rotation, and NSA. We hypothesized that hip flexion-extension and femoral rotation would result in NSA measurement error. METHODS Two mathematical models were developed to predict NSA in varying degrees of hip flexion-extension and femoral rotation. The predictions of the equations were tested in vitro using a model that varied hip flexion-extension while keeping rotation constant, and vice versa. The NSA was measured from an anterior-posterior radiograph obtained with a C-arm. Attributable measurement error based on hip positioning was calculated from the models. RESULTS The predictions of the model correlated well with the experimental data (correlation coefficient = 0.82-0.90). A wide range of patient positioning was found to result in <5-10 degrees error in the measurement of NSA. Hip flexion-extension and femoral rotation had a synergistic effect in measurement error of the NSA. Measurement error was minimized when hip flexion-extension was within 10 degrees of neutral. CONCLUSIONS This study demonstrates that hip flexion-extension and femoral rotation significantly affect the measurement of the NSA. To avoid inadvertently fixing the proximal femur in varus or valgus, the hip should be positioned within 10 degrees of neutral flexion-extension with respect to the C-arm to minimize positional measurement error.
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Galanopoulos IP, Mavrogenis AF, Megaloikonomos PD, Vottis CT, Mitsiokapa E, Koulouvaris P, Mastrokalos DS, Papagelopoulos PJ, Kontogeorgakos VA. Similar function and complications for patients with short versus long hip nailing for unstable pertrochanteric fractures. SICOT J 2018; 4:23. [PMID: 29905526 PMCID: PMC6003248 DOI: 10.1051/sicotj/2018023] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 05/04/2018] [Indexed: 11/14/2022] Open
Abstract
PURPOSE To compare short with long intramedullary hip nailing for elderly patients with unstable pertrochanteric fractures. METHODS We prospectively studied 50 patients (33 women, 17 men; mean age, 80 years; range, 74-93 years) with unstable pertrochanteric fractures admitted and treated with a short (group A) or a long (group B) intramedullary hip nail from January 2013 to 2017. The patients were randomly allocated into each group according to their order of admission. The mean follow-up was 2 years (range, 1-5 years). We evaluated operative time, function, fracture healing, varus/valgus loss of reduction, and distance between the distal line of the fracture and the distal locking screw of the nail. RESULTS Operative time was significantly shorter in group A. Function, fracture healing and varus/valgus loss of reduction was similar between the two groups. The mean distance between the distal fracture line and distal locking screw was 7.2 cm (range, 3-10 cm) in patients of group A; in all patients of group B, an appropriate nail length was chosen so that the distal locking screw was inserted at least 3 times the diameter of the bone at the distal fracture line. Complications included periprosthetic fracture (one patient of group A), and z-effect phenomenon (one patient of group B); complications rate was similar between the two groups. CONCLUSION Short intramedullary hip nailing is associated with similar function and complications, but shorter operative time compared to long intramedullary hip nails for patients with unstable pertrochanteric fractures.
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Affiliation(s)
- Ioannis P. Galanopoulos
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, ATTIKON University Hospital,
Athens Greece
| | - Andreas F. Mavrogenis
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, ATTIKON University Hospital,
Athens Greece
| | - Panayiotis D. Megaloikonomos
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, ATTIKON University Hospital,
Athens Greece
| | - Christos T. Vottis
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, ATTIKON University Hospital,
Athens Greece
| | - Evanthia Mitsiokapa
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, ATTIKON University Hospital,
Athens Greece
| | - Panayiotis Koulouvaris
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, ATTIKON University Hospital,
Athens Greece
| | - Dimitrios S. Mastrokalos
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, ATTIKON University Hospital,
Athens Greece
| | - Panayiotis J. Papagelopoulos
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, ATTIKON University Hospital,
Athens Greece
| | - Vasilios A. Kontogeorgakos
- First Department of Orthopaedics, National and Kapodistrian University of Athens, School of Medicine, ATTIKON University Hospital,
Athens Greece
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Reduction techniques for difficult subtrochanteric fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2018; 29:197-204. [PMID: 29855787 DOI: 10.1007/s00590-018-2239-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 05/24/2018] [Indexed: 01/26/2023]
Abstract
Subtrochanteric fractures can result from high-energy trauma in young patients or from a fall or minor trauma in the elderly. Intramedullary nails are currently the most commonly used implants for the stabilization of these fractures. However, the anesthetic procedure for the patients, the surgical reduction and osteosynthesis for the fractures are challenging. The anesthetic management of orthopedic trauma patients should be based upon various parameters that must be evaluated before the implementation of any anesthetic technique. Surgery- and patient-related characteristics and possible comorbidities must be considered during the pre-anesthetic evaluation. Adequate fracture reduction and proper nail entry point are critical. Understanding of the deforming forces acting on various fracture patterns and knowledge of surgical reduction techniques are essential in obtaining successful outcomes. This article discusses the intraoperative reduction techniques for subtrochanteric fractures in adults and summarizes tips and tricks that the readers may find useful and educative.
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