Incidence of Varus Malalignment Post Interlocking Nail in Proximal Femur Shaft Fractures Comparing Two Types of Entry Points

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Optimal entry point for antegrade and retrograde femoral intramedullary nails

Surgical management of femoral shaft fractures with intramedullary nails has become the standard of care, with multiple options for entry point described, including piriformis entry, trochanter entry and retrograde femoral nails. Our present review describes the surgical anatomy of the proximal and distal femur and its relation to different entry points for intramedullary femoral nails. In addition, we reviewed relative indications for each technique, difficulties associated and possible complications.

Changes in the femoral osteotomy level coefficient and neck shaft angle during limb lengthening with an intramedullary magnetic nail

BACKGROUND

The intramedullary magnetic IM nail enables bone graduated distraction. Proximal femur osteotomies for ante grade IM lengthening nails have a tendency towards varus-procurvatum malalignment. We examined the effect of the level of the osteotomy and of trochanteric versus piriformis entry points on the neck shaft angle (NSA) during lengthening with the PRECICE IM magnetic nail.

METHODS

A novel parameter, the osteotomy level coefficient (OLC), was introduced as a guide to determine the level of an osteotomy at the proximal femur. The OLC was defined as the ratio between the distances from the tip of the greater trochanter to the osteotomy divided by the full length of the femur. A retrospective review of all femoral lengthening procedures with the PRECICE ante grade IM lengthening nail between 2013 and 2018 was carried out.

RESULTS

31 femurs were lengthened in 30 patients (16 males and 14 females, mean age at surgery years 17.1. The average amount of lengthening was 4.4 cm. Trochanteric entry points were used in 24 femurs, and piriformis entry points in seven femurs. The OLC values ranged from 0.16 to 0.34 (average 0.25). The average follow-up period was 10.15 months. The distraction index average 10.5 days/cm (Range 8.6-11.9), Consolidation index 32.1 days/cm (14.3-51.9). The average post-operative NSA was significantly reduced from 133.5º to 128.5º [t (31) = 5.57, p = 0.000]. There was no correlation between the OLC and the change in the NSAs. The trochanteric entry point showed a greater tendency to reduce the NSA (Mdif = - 6, SD = 4.8) compared to the piriformis entry point (Mdif =  - 0.86, SD = 2.27) [t (31) = -3.96, p = 0.001].

CONCLUSION

Proximal femur lengthening with the PRECICE IM nail significantly reduced the NSA and might cause Varus deformity. The level of osteotomy by OLC did not influence the amount of NSA reduction. The trochanteric entry points have a greater tendency to reduce the NSA compared to the piriformis entry points.

Kinesiophobia in a Patient With Postoperative Midshaft Fracture: A Case Report of Its Impact on Rehabilitation in a 16-Year-Old Girl

Kinesiophobia is an irrational and debilitating fear of physical movement and activity resulting from a feeling of vulnerability to painful injury or re-injury. According to the concept of avoidance of fear, pain is interpreted as threatening, which can trigger pain-related fears and anxiety leading to avoidance behavior. Avoidance action involves a process/period characterized by a person stepping back from undertaking daily tasks like exercise, socializing, and work, which increases the intensity of the painful experience. In hospital settings, kinesiophobia needs to be resolved to ensure a positive result in rehabilitation interventions. The femur is the lower extremity's primary weight-bearing bone. Early fracture fixation in the shaft of the femur allows for early mobilization, thereby reducing the risk of hip and knee stiffness as well as quadriceps and hamstring wasting.

In this report, we present the case of a 16-year-old girl with an alleged history of fall who was admitted to Acharya Vinobha Bhave Rural Hospital (AVBRH), Datta Meghe Institute of Medical Sciences (DMIMS) Deemed To Be University (DU), Wardha, India, with primary complaints of pain and swelling over the left thigh. She was diagnosed with a left midshaft femur fracture. An open reduction internal fixation (ORIF) femur interlock nailing was performed to stabilize the fracture, and she was referred to physiotherapy after surgery for further management. The comprehensive rehabilitation program was helpful in alleviating the severe kinesiophobia in the patient, and she was able to resume her activities of daily living (ADLs) independently.