Descriptive analysis of incidence and risk factors for short intramedullary nail breakage in femoral intertrochanteric fractures: a multicenter (TRON group) retrospective study

BACKGROUND

The incidence of hip fractures is increasing. Femoral intertrochanteric fractures make up 50% of hip fractures and are treated by intramedullary nails. Implant breakage is a recognized complication that can have rare and serious implications. This study aimed to investigate implant breakage rates after surgical treatment for femoral intertrochanteric fractures.

METHODS

This was a retrospective multicenter analysis. All 1854 patients who underwent surgical treatment for femoral intertrochanteric fractures were selected from 12 hospitals (TRON group) between 2016 and 2020. Exclusion criteria included implants other than those specified and follow-up periods less than three months. Demographic data, surgical details, and radiographic assessments were collected from medical records and X-ray evaluations.

RESULTS

Among the 983 study patients, consisting of 245 males (24.9%) and 738 females (75.1%), the implant breakage rate was 0.31%, with three confirmed cases. The average age was 83.9 years. The mean follow-up period was 640.9 days. Two cases were linked to ASULOCK implants, and one to an OLSII implant. Statistical analysis showed a significantly higher incidence of ASULOCK implant breakage (p < 0.001). In the two cases of ASULOCK implant breakage and one case of OLSII implant breakage, breakage in all three implants occurred at the anti-rotation screws.

CONCLUSIONS

There were no implant breakages of the main body of the implants; all breakages occurred in the additional anti-rotation screw. The necessity of the anti-rotation screw will require further discussion. These results can potentially inform clinical decisions and guide further research in preventing implant breakage.

[Medium term follow up outcomes of uncemented total hip arthroplasty for traumatic arthritis after intramedullary nail fixation of femoral intertrochanteric fracture]

OBJECTIVE

To evaluate the effect of uncemented total hip arthroplasty(THA) on treatment of traumatic arthritis caused by intramedullary nailing interfixation of intertrochanteric fractures.

METHODS

Total of 22 patients treated with THA due to traumatic arthritis caused by intramedullary nailing interfixation of intertrochanteric fractures from January 2012 to January 2017 were studied retrospectively, including 10 males and 12 females with a mean age of (72.5±9.8) years old ranging from 61 to 84 years old. Initial internal fixation method:14 patients were treated with Gamma nails and 8 patients were treated wit PFNA.The time from internal fixation surgery to THA was 10 to 68 months with an average of (32.2±21.3) months.Harris scores of the hip joint before and after surgery were compared, and the position of the prosthesis through postoperative imaging at 3, 6, 12 months and the last follow-up were evaluated.

RESULTS

One patient was died due to heart failure 1 year after operation. Two patients was died to advanced tumor 2 years after operation. The other 19 patients were followed up for 36 to 64 months with an average of (48.5±11.9) months. At final follow up, 14 patients regained the ability to walk independently, 4 patients needed support of a cane, 1 patient needed assistance of a walker. No serious complications such as joint dislocation, periprosthetic fracture and deep venous thrombosis occurred during follow-up. There were no signs of loosening and subsidence of the prosthesis at the final follow-up. Mean Harris hip score increased from (29.2±12.9) points preoperatively to (74.2±11.2) points at the final follow up(P<0.05);the score was excellent in 9 patients, good in 7 and fair in 3.

CONCLUSION

Uncemented total hip arthroplasty for traumatic arthritis after intramedullary nail fixation of femoral intertrochanteric fracture can significantly improve hip function and effectively avoid bone cement implantation syndrome. The medium-term effect is satisfactory.

[Research progress on evaluation methods for head-neck nail position in femoral intertrochanteric fractures]

Objective

To summarize the research progress on the evaluation methods of head-neck nail positions in femoral intertrochanteric fractures.

Methods

The literature about the evaluation methods of head-neck nail positions for femoral intertrochanteric fractures in recent years was extensively reviewed, and research progress in the aspects of evaluation methods, clinical applications, and limitations were summarized.

Results

The position of head-neck nails in femoral intertrochanteric fractures is closely related to postoperative complications of head-neck nail cutting. Currently, the tip-apex distance (TAD) and femoral head zoning are widely used to evaluate the position of head-neck nails. The main opinion in the literature is that the use of TAD and femoral head zoning can effectively reduce the incidence of head-neck nails cutting. Parker's ratio, as one of the evaluation methods, has been controversial in subsequent studies and has not been widely used in clinical practice. The TAD as referenced to the calcar (CalTAD), which was modified based on TAD, has been gradually accepted by the clinic, but whether it is better than the TAD has not yet been conclusively determined. In recent years, new evaluation methods have been proposed to supplement the previous evaluation methods, such as the tip-neck distance ratio (TNDR) and the standardized TAD (STAD) to avoid the limitations of the TAD and the CalTAD by the volume of the femoral head, and the axis-blade angle (ABA) to supplement the direction of the head-neck nails channel, but at present the clinical application is relatively underutilized, and the validity of the method needs to be further verified.

Conclusion

Currently, there are many methods for evaluating the position of head-neck nails in femoral intertrochanteric fractures, TAD<25 mm combined with head-neck nails placed in the middle-middle quadrant or lower-middle quadrant of the femoral head division is currently a highly recognized assessment in the literature, but the optimal assessment is still controversial, and further research needs to be studied.

A comparison of functional and radiological outcome of combine compression antegrade intertrochanteric nail (InterTan) and proximal femoral nail anti-rotation II (PFNA-II) in elderly patients with intertrochanteric fractures

Objective

To compare the functional and radiological outcome of combine compression interlocking intramedullary nail (InterTan) and proximal femoral nail anti-rotation II (PFNA-II) in the treatment of elderly patients with intertrochanteric fractures.

Methods

As a retrospective cohort study, records of 88 patients with intertrochanteric fractures treated in our hospital from January 1st, 2019 to July 31st, 2021 were retrospectively reviewed. According to treatment records, it included 45 patients treated with InterTan (Group-A) and 43 patients treated with PFNA-II (Group-B). The operation safety and functional rehabilitation of the two groups were compared and analyzed.

Results

This study included 88 patients with intertrochanteric fractures (mean [SD] age, 68.72 [0.10] years at baseline), of whom 52 (59.09%) were males and 36 (40.91%) were females. Operation time and intraoperative blood loss in Group-B were less than Group-A, while fracture healing time was shorter in Group-A. The fracture separation distance was measured four weeks after the operation. The widening rate of the fracture line in Group-A was lower than Group-B (4.4% vs.18.6%; P<0.05). The incidence of complications in Group-A was lower than Group-B (4.4% vs.18.6%; P<0.05). At three, six and twelve months after the operation, the Harris hip score of the two groups was higher than at discharge (P<0.05), with no significant difference between groups (P>0.05).

Conclusions

We found no significant difference in the functional outcome in elderly patients with intertrochanteric fractures treated with InterTan and PFNA-II. Early fracture healing and reduced complication rate however has been noted with InterTan.

Effect of proximal femoral nail antirotation on clinical outcome, inflammatory factors and myocardial injury markers in patients with femoral trochanteric fracture

OBJECTIVE

To compare the differences between proximal femoral nail antirotation (PFNA) and dynamic hip screw (DHS) in treatment of femoral trochanteric fracture and analyze the factors influencing recovery after PFNA treatment.

METHODS

Eighty-six patients with femoral trochanteric fracture admitted to Taizhou Hospital of Traditional Chinese Medicine between January 2019 and June 2021 were enrolled in the study and assigned into a PFNA group and DHS group (n=43 in each group) before undergoing these treatments. The clinical efficacy, inflammatory factors, and myocardial injury markers were compared between the two groups. The influencing factors on recovery after PFNA treatment were analyzed by univariate and multivariate analysis.

RESULTS

Compared to the DHS group, the PFNA group had shorter surgical time, length of stay in hospital, postoperative weight-bearing time, time of healing and detumescence, and less intraoperative blood loss (all P<0.001). The incidence of post-surgical complications with PFNA was lower than with DHS (P<0.05). The serum levels of interleukin-6, C-reactive protein and tumor necrosis factor-αof the PFNA group were lower than those of the DHS group (all P<0.05). Moreover, the serum levels of cardiac troponin T, creatine kinase-MB and myoglobin in the PFNA group were also lower than for the DHS (all P<0.05). At the first, third, and sixth months after surgery, the Harris scores for PFNA were higher than for DHS (all P<0.05). The univariate and multivariate analysis showed that instability of fracture, history of osteoporosis, excessive intraoperative bleeding, poor compliance with rehabilitation exercise, and long time from injury to surgery were risk factors for poor recovery following PFNA treatment for patients with femoral trochanteric fracture.

CONCLUSION

Compared to DHS, PFNA had better clinical efficacy and gave lower serum levels of inflammatory factors and myocardial injury markers. Fracture classification, history of osteoporosis, intraoperative amount of bleeding, compliance of rehabilitation exercise, and time from injury to surgery were closely associated with recovery following PFNA treatment.

Impact of sarcopenia on intertrochanteric femoral fracture in the elderly

Objective

The aim of this study was to investigate the effect of skeletal sarcopenia on the prognosis of intertrochanteric fracture in the elderly.

Methods

We collected information on 144 patients with femoral intertrochanteric fracture (FIF). The influence of sarcopenia on the chance of death was determined using binary Probit regression analysis. For additional analysis, the Chow test was utilized to select the best distinguishing node in the instrumental activities of daily living (IADL) score. We looked for characteristics that were linked to a higher probability of death and a poor IADL outcome within 1 year. The data collected above were analyzed using logistic regression analysis. The internal calibration degree and model validity were assessed by GiViTI calibration.

Results

Sarcopenia, EuroQol-5D 1 month score, age, gender, and hypertension were identified as risk factors for death in older patients with FIF within a year by logistic regression analysis. Sarcopenia, psychotropics, BMI, and length of hospital stay were all found to be risk factors for poor IADL outcomes (P < 0.1). The calibration curves indicated that the anticipated and actual probabilities of these two models were very close. The study's reliability coefficient was 0.671, showing a satisfactory level of reliability.

Conclusion

In elderly patients with FIF, sarcopenia, EuroQol-5D score, age, gender, and hypertension were risk factors for death; sarcopenia, hospital stay length, BMI were risk factors for poor quality of life.

All-cause mortality risk in aged femoral intertrochanteric fracture patients

Introduction

The 1-year mortality rate after femoral intertrochanteric fracture is higher than that of femoral neck fracture, which also belongs to hip fracture (Cui et al. in Arch Osteoporos 14(1):55, 2019). With the application of the concept of co-management model of orthopedics and geriatrics, the short-term and long-term mortality of all types of hip fractures has decreased (Van Heghe et al. in Calcif Tissue Int, 2021, https://doi.org/10.1007/s00223-021-00913-5). However, the mortality of Chinese femoral intertrochanteric fracture patients under this model has not been reported in the literatures.

Aim

This paper aims to study the risk factors of postoperative all-cause mortality in aged patients with femoral intertrochanteric fracture under the co-management model of orthopedics and geriatrics.

Materials and methods

This is a single-center prospective cohort study based on the real world, under the co-management of orthopedics and geriatrics, 363 patients aged ≥ 65 years with femoral intertrochanteric fracture were enrolled and followed up for 2–3 years; 52 patients were lost to follow up. Age, gender, body mass index (BMI), history of comorbidities, hip Bone Mineral Density (BMD), fracture history, 25(OH)D level, hemoglobin level, anti-osteoporosis treatment were risk factors to be tested. Kaplan–Meier survival curves and multivariate Cox proportional hazards models were constructed to analyze the impact of factors on all-cause mortality.

Results

(1) Most of the dead patients were older (the mean age was 83.4 years, compared with 79.8 years for surviving patients), with more complications and without anti-osteoporosis medication; gender, pre-fracture history, BMI, total hip BMD, hemoglobin, 25(OH)D had no difference between the dead and the living patients. (2) Elderly patients with Intertrochanteric fracture can benefit from the early treatment of Zoledronic Acid (within 3 days after the operation).

Conclusion

Under the co-management of orthopedics and geriatrics, to Chinese patients with Femoral Intertrochanteric fracture, Doctors should pay more attention to their age and chronic disease, and give anti-osteoporosis treatment if allowed.

[Correlation between metabolic syndrome and adverse events after internal fixation of femoral intertrochanteric fracture in the elderly]

OBJECTIVE

To explore the effect of metabolic syndrome on 15 days postoperative adverse events of femoral intertrochanteric fractures with internal fixation.

METHODS

From January 2011 to June 2019, 986 elderly patients with intertrochanteric fracture were treated with internal fixation, including 312 males and 674 females, with an average age of(77.71± 7.58) years old. And there were 97 patients with metabolic syndrome and 889 patients without metabolic syndrome. Through the electronic medical record system, the patient's age, gender, fracture type, cause of trauma, body mass index, smoking history, preoperative comorbidities, preoperative bloodtransfusion, operation timing, ASA classification, anesthesia method, internal fixation type, operation duration, and 15 days postoperative adverse events, which include surgical site infection, acute heart failure, acute respiratory failure, pulmonary infection, acute renal failure, DVT, embolism in important organs, urinary tract infection, death, and blood transfusion after surgery were collected. The differences of preoperative and intraoperative baseline datas and 15 days postoperative adverse events between the two groups were compared and analyzed by t text or univariate χ² test. Adjusted for the preoperative and intraoperative mixed factors with P<0.05, and 15 days postoperative adverse events with P<0.05 were then analyzed by multivariate unconditional Logistic regression analysis to further study the independent effects of metabolic syndrome on 15 days postoperative adverse events.

RESULTS

There were statistical differences in age, body mass index, history of cardiac insufficiency, history of COPD, history of renal insufficiency, operation timing, ASA classification, operation duration, surgical site infection, acute heart failure, DVT, urinary tract infection and blood transfusion between two groups (P<0.05). Adjusted for the preoperative and intraoperative mixed factors, multivariate unconditional logistic regression analysis showed that metabolic syndrome could increase the infection rate of the surgical site [OR=3.785, 95%CI (1.086-13.188), P= 0.037], DVT incidence rate[OR=2.265, 95%CI(1.096-4.682), P=0.027], urinary tract infection rate[OR=2.703, 95%CI (1.049-6.963), P=0.0390], and blood transfusion rate [OR=1.811, 95%CI (1.142-2.870), P=0.012].

CONCLUSION

Elderly patients with intertrochanteric fracture with metabolic syndrome had higher postoperative surgical site infection rate, DVT incidence rate, urinary tract infection rate, and postoperative blood transfusion rate. Therefore, the orthopedic treatment team should give more attentionand optimize the treatment plan during the perioperative period with the cooperation of internal physician and anesthesiologist.

[Research on the classification criteria of femoral intertrochanteric fractures based on irreducibility or not]

Objective

To formulate the classification criteria of femoral intertrochanteric fractures based on irreducibility or not in order to predict the difficulty of fracture recovery.

Methods

A clinical data of 244 patients with closed femoral intertrochanteric fractures admitted between January 2017 and March 2020 was retrospectively analyzed. There were 116 males and 128 females with an average age of 77.9 years (range, 45-100 years). The cause of injury included falling in 190 cases, traffic accident in 36 cases, smashing in 13 cases, and falling from height in 5 cases. The time from injury to operation was 1-14 days (mean, 3.6 days). According toAO/Orthopaedic Trauma Association (AO/OTA) classification, the fractures were classified as type 31-A1 in 38 cases, type 31-A2 in 160 cases, and type 31-A3 in 46 cases. According to whether the recovery difficulty occurred after intraoperative closed traction reset, the patients were divided into reducible-group and irreducible-group; combined with the literature and preoperative imaging data of two groups, the classification criteria of femoral intertrochanteric fractures was formulated based on the irreducibility or not. The 244 fractures were classified by the doctors who did not attend the operation according to the classification criteria, predicted the difficulty of fracture reduction, and compared with the actual intraoperative reduction situation.

Results

The 244 patients were divided into reducible-group ( n=164, 67.21%) and irreducible-group ( n=80, 32.79%) according to the intraoperative difficulty of reduction. Comparing the imaging data and characteristics of the two groups, and formulating the classification criteria of femoral intertrochanteric fractures based on irreducibility or not, the fractures were mainly divided into two categories of irreducibility and reducibility. The fractures of irreducibility category was divided into typesⅠ-Ⅴ, among which type Ⅲ was divided into subtypes 1-4; the fractures of reducibility category was divided into typesⅠand Ⅱ. Compared with the actual intraoperative evaluation results, the total accuracy rate of the doctors who did not attend the operation was 81.15% (198/244) based on the classification criteria of femoral intertrochanteric fractures. The accuracy rate of irreducibility category was 65.74% (71/108), and the reducibility category was 93.38% (127/136). All patients were followed up 13-25 months, with an average of 17.6 months. All fractures healed except 2 cases died of infection.

Conclusion

The classification criteria of femoral intertrochanteric fractures based on irreducibility or not can accurately predict the reducible cases preoperatively, and most of the irreducible cases can be correctly predicted in a wider way. But the classification criteria still need to be further improved and supplemented.

[Morphological analysis of coronal femoral intertrochanteric fracture and its effect on reduction and internal fixation]

Objective

To investigate the morphology of coronal femoral intertrochanteric fracture and its effect on reduction and internal fixation.

Methods

The clinical and imaging data of 46 patients with femoral intertrochanteric fracture who met the selection criteria between August 2017 and October 2018 were reviewed. There were 15 males and 31 females; the age ranged from 62 to 91 years, with an average of 72.8 years. The causes of injury included walking falls in 35 cases, falling out of bed in 4 cases, and traffic accidents in 7 cases. The AO/Orthopaedic Trauma Association classification was type 31-A1 in 11 cases and type 31-A2 in 35 cases. All patients underwent closed reduction and internal fixation with intramedullary nails. During the operation, fracture reduction and fixation were performed according to the preoperative evaluation results. According to the patients' preoperative X-ray film and CT three-dimensional reconstruction images, the direction of the coronal fracture line of the femoral intertrochanter and the morphological characteristics of the fracture block were observed; and the coronal fracture discrimination analysis was carried out for the fractures of different AO/OTA types. The percentages of coronal femoral intertrochanteric fractures diagnosed by preoperative X-ray film and CT three-dimensional reconstruction were calculated and statistically analyzed. The fracture reduction, the position of internal fixation [measurement of tip-apex distance (TAD)]. and the reliability of internal fixation were observed after operation.

Results

X-ray film was not easy to identify coronary fracture, and the coronal fracture line and the shape of the fracture piece weree clearly visible in CT three-dimensional reconstruction images. The morphological characteristics of the coronary fracture block: in AO/OTA 31-A1 type, the fracture line extended obliquely backward from the anterior tip of the large rotor, above the small rotor with or without small rotor fracture; in AO/OTA 31-A2 type, fracture line extended obliquely backward from the anterior tip of the large rotor to below the small rotor. Thirteen cases (28.3%) of coronal fractures were found on preoperative X-ray films, and 35 cases (76.1%) were found by CT three-dimensional reconstruction, showing significant difference ( χ ²=21.083, P=0.000). In AO/OTA 31-A1 type patients, the proportion of coronal fractures found by X-ray film and CT three-dimensional reconstruction was 18.2% (2/11) and 54.5% (6/11), respectively, and that in AO/OTA 31-A2 type patients was 31.4% (11/35) and 82.9% (29/35), respectively, showing significant differences ( χ ²=3.143, P=0.000; χ ²=20.902, P=0.000). Among the 35 patients with coronal fractures, 6 cases (17.1%) of AO/OTA 31-A1 type, 29 cases (82.9%) of AO/OTA 31-A2 type. The operation time of the patient was 80-112 minutes, with an average of 95 minutes; the intraoperative blood loss was 180-450 mL, with an average of 360 mL. There was no complication such as infection, falling pneumonia, and deep vein thrombosis of the lower extremities. At 3 days after operation, the internal fixators were all in the proper position. The TAD was 0.9-1.8 cm, with an average of 1.4 cm. All patients were followed up 14-18 months, with an average of 16 months. All the fractures healed osseously, and there was no complication such as nonunion and loosening of internal fixation.

Conclusion

CT three-dimensional reconstruction can better identify coronal femoral intertrochanteric fractures than X-ray films, and accurately recognize and analyze the incidence and morphological characteristics of coronal fractures, which can help formulate more effective surgical strategies to promote patient recovery.

[Reasons of the guide pin eccentricity of helical blade during proximal femoral nail anti-rotation internal fixation for femoral intertrochanteric fractures]

Objective

To analyze the reasons and the influence of internal fixation about the guide pin eccentricity of helical blade during proximal femoral nail anti-rotation (PFNA) internal fixation for femoral intertrochanteric fractures.

Methods

A retrospective analysis of the intraoperative imaging data of 175 patients with femoral intertrochanteric fractures, who underwent closed reduction and PFNA internal fixation between January 2018 and January 2020, was performed. There were 76 males and 99 females with an average age of 79.8 years (mean, 61-103 years). The internal between admission and operation was 12-141 hours (median, 32 hours). According to AO/Orthopaedic Trauma Association (AO/OTA) classification, the fractures were rated as type 31-A1 in 64 cases and type 31-A2 in 111 cases. In the intraoperative fluoroscopy image by C-arm X-ray machine, the caputcollum-diaphysis (CCD) was measured after closed reduction and internal fixation, respectively; the angles between the center line of the head nail hole and the axis of proximal nail and between the axis of guide pin and proximal nail were measured, and the difference between the two angles was evaluated; the quality of fracture reduction was evaluated according to the alignment of the medial cortex, anterior cortex of the head and neck bone block, and femoral shaft cortex; the position of the helical blade in the femoral head was evaluated according to the Cleveland method.

Results

The CCDs of proximal femur were (134.6±6.8)° after closed reduction and (134.9±4.3)° after internal fixation. There was no significant difference between pre- and post-internal fixation ( t=0.432, P=0.766). The angles between the center line of the head nail hole and the axis of proximal nail and between the axis of guide pin and proximal nail were (125.4±2.44)° and (126.3±2.3)°, respectively, showing significant difference ( t=2.809, P=0.044). The difference between the two angles was (0.8±2.2)°. The guide pin eccentricity of helical blade occurred in 47 cases. After tapping the helical blade along the eccentric guide pin, 10 cases had fracture reduction loss, and 5 cases had a poor position of the helical blade in the femoral head.

Conclusion

During PFNA internal fixation, a variety of reasons can lead to the eccentric position of the guide pin of helical blade, including unstable fracture, soft tissue inserted, severe osteoporosis, mismatched tool, and fluoroscopic imaging factors. It is possible that the fracture end would be displaced again and the helical blade position may be poor when knocking into the helical blade along the eccentric guide pin. During operation, it should be judged whether the direction of the guide pin needs to be adjusted according to the eccentric angle.

[Efficacy and safety of intravenous combined with topical administration of tranexamic acid in reducing blood loss after intramedullary fixation of intertrochanteric femoral fractures]

Objective

To investigate the efficacy and safety of intravenous combined with topical administration of tranexamic acid (TXA) in reducing blood loss after intramedullary fixation of intertrochanteric femoral fractures by a prospective controlled trial.

Methods

Patients with intertrochanteric femoral fractures, who were admitted for intramedullary fixation between June 2015 and July 2019, were selected as the study subjects, 120 of whom met the selection criteria. The patients were randomly assigned to 3 groups: intravenous administration group (group A, 41 cases), topical administration group (group B, 40 cases), and combined administrations group (group C, 39 cases). In group A, 4 patients occurred deep vein thrombosis of lower extremity before operation, 1 patient died of myocardial infarction on the 5th day after operation, and 1 patient developed severe pulmonary infection after operation. In group B, 2 patients occurred deep vein thrombosis of lower extremity before operation and 1 patient had iatrogenic fracture during operation. In group C, 3 patients occurred deep vein thrombosis of lower extremity before operation and 1 patient developed pulmonary infection before operation and gave up surgical treatment. All the above patients were excluded from the study, and the remaining 107 cases were included in the analysis, including 35, 37, and 35 cases in groups A, B, and C, respectively. There was no significant difference in gender, age, height, body mass, injury cause, fracture side and type, the interval between injury and operation, and preoperative hemoglobin (Hb), hematocrit between groups ( P>0.05). Intraoperative TXA (15 mg/kg) was injected intravenously in group A at 30 minutes before operation, and 1 g of TXA was injected into the medullary cavity in group B after the proximal femur was grooted and before the intramedullary nail implantation, respectively. TXA was given in group C before and during operation according to the administration methods and dosage of groups A and B. Total blood loss, maximum Hb decrease, blood transfusion rate, operation time, fracture healing time, and the incidence of complications were recorded and compared between groups. The hip joint function were evaluated by Harris score.

Results

There was no significant difference in operation time between groups ( P>0.05). The total blood loss, the maximum Hb decrease, and the blood transfusion rate in group B were the highest, followed by group A and group C, and the differences between groups were significant ( P<0.05). No incision infection or pulmonary embolism occurred in the 3 groups after operation. The incidence of anemia in group C was significantly lower than that in groups A and B, the difference was significant ( P<0.05). There was no significant difference in the incidence of subcutaneous hematoma, aseptic exudation, and deep vein thrombosis of lower extremity between groups ( P>0.05). All patients in the 3 groups were followed up 8-35 months, with an average of 16.2 months. The fracture healing time of groups A, B, and C was (6.12±1.78), (5.89±1.63), and (5.94±1.69) months, respectively, and there was no significant difference between groups ( P>0.05). At last follow-up, the Harris scores of the hip joints in groups A, B, and C were 83.18±7.76, 84.23±8.01, and 85.43±8.34, and the difference was not significant ( P>0.05).

Conclusion

Preoperative intravenous injection combined with intraoperative topical application of TXA can effectively reduce blood loss and blood transfusion after intramedullary fixation of femoral intertrochanteric fracture, without increasing the risk of deep vein thrombosis, and the efficacy is better than that of intravenous injection or topical administration.

[Research progress in osteonecrosis of femoral head following femoral intertrochanteric fractures in adults]

Objective

To summarize the research progress of osteonecrosis of femoral head (ONFH) following femoral intertrochanteric fractures in adults.

Methods

Relevant literature at home and abroad was extensively reviewed to summarize the pathogenesis, high-risk factors, and treatment of ONFH after femoral intertrochanteric fracture in adults.

Results

ONFH after femoral intertrochanteric fracture mostly occurs within 2 years after operation, with a lower incidence. At present, it is believed that comminuted and large displacement fractures caused by high-energy injuries, fracture line close to the base of neck, excessive external rotation deformity, improper intramedullary nail entry points, and rough intraoperative manipulating may injury the deep branch of the medial circumflex femoral artery, causing ONFH. Hip replacement is the main treatment for necrosis, which can achieve good results.

Conclusion

Addressing the above risks, excessive external rotation, overstretching, and rough manipulating should be avoided. Anatomical reduction should be performed during the operation, the nail entry point should be accurate and avoid repeated drilling and thermally bone necrosis.

[Comparison of the predictive value of tip-apex distance and calcar referenced tip-apex distance in treatment of femoral intertrochanteric fractures with Asian type proximal femoral nail fixation]

Objective

To compare the predictive value of the two concepts for complications by comparing the incidences of surgical complications associated with different tip-apex distance (TAD) and calcar referenced tip-apex distance (Cal-TAD) in the treatment of femoral intertrochanteric fractures with Asian type proximal femoral nail (APFN) fixation.

Methods

A total of 188 cases of femoral intertrochanteric fractures treated with APFN fixation between January 2014 and December 2018 were collected according to inclusion criteria. TAD and Cal-TAD were measured on the X-ray film at immediate after operation; the patients were divided into two groups according to the measurement results: <25 mm and ≥25 mm. Gender, age, and fracture side and AO type were recorded. The patients in each group were reviewed whether there was delayed fracture union or nonunion, whether the screw blade moved axially, whether the femoral neck collapsed or even screw blade cut out, whether the internal fixator became loose or broken within 12 months after operation. Then statistical analysis was performed.

Results

There were 119 patients with TAD<25 mm and 69 patients with TAD≥25 mm, and 142 patients with Cal-TAD<25 mm and 46 patients with Cal-TAD≥25 mm. There was no significant difference in gender, age, or fracture side and AO type between groups ( P>0.05). During the follow-up, 6 patients (5.04%) with TAD<25 mm, 10 patients (14.49%) with TAD≥25 mm had complications, and 1 patient (0.70%) with Cal-TAD<25 mm and 15 patients (32.61%) with Cal-TAD≥25 mm had complications. There were significant differences in the incidence of complication between the patients with different TAD, between the patients with different Cal-TAD, and between patients with TAD<25 mm and Cal-TAD<25 mm ( P<0.05).

Conclusion

In the operation of femoral intertrochanteric fracture with APFN fixation, surgical complications can be significantly reduced when TAD or Cal-TAD was controlled within 25 mm, Cal-TAD is more significant in the prediction of postoperative complications.

Procedure for Femoral Intertrochanteric Fractures using the "Three-Finger Method" Assisted by Proximal Femoral Nail Antirotation

Objective

To assess long‐term follow‐up evaluations for the treatment of femoral intertrochanteric fractures with the “three‐finger method” assisted by proximal femoral nail antirotation (PFNA).

Methods

From January 2010 to January 2017, 123 patients were selected and followed for the treatment of femoral intertrochanteric fractures with PFNA assisted by the “three‐finger method” (application of the index finger, middle finger, and ring finger in the process of surgery to assist PFNA). There were 56 male patients and 67 female patients aged 52–93 years with an average age of 75.6 years, and 88 cases were due to a fall and 35 due to a traffic accident injury. The femoral necks were fixed with PFNA assisted by the “three‐finger method” applying the following procedure: traction reduction, determining the incision, inserting the needle, and placing screw. The Harris hip score, postoperative complications, hip pain and function status were statistically analyzed to evaluate the surgical efficacy and to discuss the surgical technique of the “three‐finger method” assisted by PFNA.

Results

According to the Harris scoring criteria, patients were followed for 1, 2, 4, 6, and 8 years, and the good outcomes of patients were recorded. The excellent and good rate of 87% was the highest in the second year of follow‐up. Then, the rate decreased following the eighth year of follow‐up. The excellent and good rate of 82.7% was the lowest. The patients with incisions healed well, there were no instances of fat liquefaction or infection. There were three cases of effusion, the rate was 2.4%. The secretions were cultured, and no bacterial growth was found. After treatment of the wound, it healed, and the spiral blade used for the femoral head did not wear out. There was one case of femoral head necrosis. There was no significant correlation between hip pain and sex and age (P > 0.05), and the function of the hip joint was significantly correlated with the age of the patients (P < 0.05).

Conclusion

The “three‐finger method” in the process of surgery to assist PFNA for the treatment of patients with intertrochanteric fractures of the femur simplified the operation steps, reduced the operation difficulty, shortened the operation time, improved the operation efficiency, and reduced the incidence of postoperative complications.

Proximal femoral nail anti-rotation versus cementless bipolar hemiarthroplasty for unstable femoral intertrochanteric fracture in the elderly: a retrospective study

BACKGROUND

The treatment for unstable intertrochanteric fractures in the elderly has always been a controversial issue. The aim in this study was to compare the curative effects of proximal femoral nail anti-rotation (PFNA) and cementless bipolar hemiarthroplasty (CPH) on femoral intertrochanteric fracture in the elderly.

METHODS

From March 2008 to December 2012, 108 elderly patients with femoral intertrochanteric fractures were treated by PFNA or CPH. There were 63 males and 45 females, aged 75.3-99.1 years [(83.7 ± 5.6) years]. The patients' bone mineral density was routinely measured, and the fractures were classified according to Evans-Jensen. The patients were divided into CPH group and PFNA group. The differences in operation time, intraoperative bleeding, immobilization duration, hospitalization time, Harris scores and postoperative complications including deep venous thrombosis, lung and urinary infection were analyzed.

RESULTS

All patients were followed for 12.5-36.2 months [(28.0 ± 6.3) months)]. The operation time was (53.7 ± 15.2) min and (77.5 ± 16.8) min in PFNA group and CPH group, respectively (P < 0.05); intraoperative bleeding was (132.5 ± 33.2) mL and (286.3 ± 43.2) mL, respectively (P < 0.05); immobilization duration was (28.2 ± 3.7) days and (3.1 ± 1.2) days, respectively (P < 0.05); hospitalization time was (7.6 ± 1.8) days and (6.9 ± 2.2) days, respectively (P > 0.05); and the Harris scores after 1 year were (87.7 ± 7.9) points and (88.3 ± 9.2) points, respectively (P > 0.05). There was no significant difference in postoperative complications between the two groups (P > 0.05).

CONCLUSION

Both PFNA and CPH are safe and effective treatments for femoral intertrochanteric fracture in elderly patients. Nonetheless, CPH allows faster mobilization and recovery.

TRIAL REGISTRATION

Registration Number: ChiCTR1900022846 . Reg Date:2019-04-26 00:27:33 Retrospective registration.

Optimized clinical practice for superaged patients with hip fracture: significance of damage control and enhanced recovery program

With the advent of global aging, the incidence, mortality, and medical costs of hip fracture among aged patients are increasing annually. The number of controlled clinical studies and health economics analyses that conform to evidence-based medicine principles is growing day by day. However, unfortunately, no specific recommendations regarding the procedures for the treatment of hip fracture are available. Meanwhile, the existence of both traditional treatment systems and new treatment theories means that most doctors confront difficult choices in their daily practice. These factors make the therapeutic approach for aged patients, especially among superaged patients with hip fracture, extremely challenging. This study focuses on superaged patients (> 80 years as defined by the World Health Organization) with hip fracture and includes their preoperative pathological condition; therapeutic decision-making in terms of the benefit and risk ratio, damage control theory, and enhanced recovery after surgery were also investigated. These patients were discussed specifically by combining the current treatment strategies from several experts and the results of a meta-analysis published recently. The study presents some new ideas and approaches currently recognized in the field, such as preoperative assessment, surgical planning, safety consideration, complication intervention, and enhanced recovery implementation, and further presents some clear interpretations regarding misunderstandings in clinical practice. Finally, optimized treatment according to damage control principles and enhanced recovery after surgery during the perioperative period among superaged hip fracture patients is defined.

Femoral intertrochanteric nail (fitn): a new short version design with an anterior curvature and a geometric match study using post-operative radiographs

OBJECTIVE

Femoral intertrochanteric fractures are usually fixed with short, straight cephalomedullary nails. However, mismatches between the nail and the femur frequently occur, such as tip impingement and tail protrusion. The authors designed a new type of short femoral intertrochanteric nail (fitn) with an anterior curvature (length=19.5cm, r=120cm) and herein report the geometric match study for the first of 50 cases.

METHODS

A prospective case series of 50 geriatric patients suffering from unstable intertrochanteric fractures (AO/OTA 31 A2/3) were treated. There were 15 males and 35 females, with an average age of 82.3 years. Post-operatively, the nail entry point position in the sagittal greater trochanter (in three categories, anterior, central and posterior), the nail-tip position in the medullary canal (in 5-grade scale) and the nail-tail level to the greater trochanter (in 3-grade scale) were measured using X-ray films.

RESULTS

For the nail entry point measurement, 5 cases were anterior (10%), 38 cases were central (76%), and 7 cases were posterior (14%). For the distal nail-tip position, 32 cases (64%) were located along the central canal axis, 13 cases (26%) were located anteriorly but did not contact the anterior inner cortex, 2 cases (4%) showed less than one-third anterior cortex thickness contact, and 3 cases (6%) were located posteriorly with no contact. For the proximal nail-tail level, there were no protrusions over the greater trochanter in 15 cases (30%), protrusion of less than 5mm in 29 cases (58%), and protrusion of more than 5mm in 6 cases (12%). The fitness was very high, as 96% cases showed no tip-cortex contact, and 88% cases showed less than 5mm proximal tail protrusion.

CONCLUSION

The newly designed femoral intertrochanteric nail has a good geometric match with the femur medullary canal and the proximal length in the Chinese population.

[Efficacy comparison of different methods to treat femoral intertrochanteric fracture in aged patients]

Objective

To compare the efficacy of proximal femoral nail anti-rotation (PFNA), locking compression plate (LCP), and artificial femoral head replacement for femoral intertrochanteric fracture in aged patients so as to provide reference for clinical treatment.

Methods

A retrospective analysis was made on the clinical data of 150 aged patients with femoral intertrochanteric fracture treated between September 2009 and March 2016. PFNA was used in 51 cases (group A), LCP in 53 cases (group B), and artificial femoral head replacement in 46 cases (group C). There was no significant difference in sex, age, side, cause of injury, injury to operation time, type of fracture, and combined medical diseases between groups ( P>0.05). The incision length, operation time, intraoperative blood loss, time for full weight bearing, hip Harris score, and complications were recorded and compared between groups.

Results

The patients were followed up 12-23 months (mean, 18.6 months) in group A, 12-25 months (mean, 19.0 months) in group B, and 12-24 months (mean, 18.9 months) in group C. The incision length, operation time, and intraoperative blood loss of group A were significantly less than those of groups B and C ( P<0.05); the operation time of group C was significantly shorter than that of group B ( P<0.05), but there was no significant difference in incision length and intraoperative blood loss ( P>0.05). The time for full weight bearing was significantly shorter in group C than groups A and B, and in group A than group B ( P<0.05). Postoperative complications occurred in 11 patients of group A (21.6%), 14 patients of group B (26.4%), and 2 patients of group C (4.3%), showing significant difference between group C and group A or group B ( P<0.05), but no significant difference was found between groups A and B ( P>0.05). Hip Harris score at 12 months after operation had no significant difference between groups ( P>0.05).

Conclusion

PFNA, LCP, and artificial femoral head replacement are all effective methods to treat femoral intertrochanteric fracture in aged patients. PFNA has the advantages of small incision, short operation time, less bleeding and simple procedure, and artificial femoral head replacement has the advantages of early time for full weight bearing, less bed rest time, and less complications. For these patients, PFNA and artificial femoral head replacement are appropriate.

Comparison of Post-Operative Muscular Strength Between Gamma Nailing and Hemiarthroplasty System in Femoral Intertrochanteric Fractures

Background:

The current study focuses on the comparison of postoperative muscular strength around the hip joint of patients with femoral intertrochanteric fractures treated either by cephalo-medullary (CM) nailing or a new bipolar hip prosthesis (BHP), an especially attached device to secure displaced greater trochanteric fragment.

Methods:

Twenty patients treated with CM nailing were age- and sex- matched with a control group of 20 patients treated with BHP. Maximum isometric forces at the bilateral hip joint were measured during the follow up period. Means of 3 measurements were represented.

Results:

The mean and standard deviation values (kg) of muscle strength at the non-operative/ operative side in the CM nailing group were as follows: flexion strength 9.5±4.7/8.5±4.9 (P=0.06), extension strength 6.2±3.5/5.5±3.7 (P=0.08), abduction strength at 0 degrees 7.7±3.5/6.2±2.8 (p=0.002), abduction strength at 10 degrees 5.5±2.0/4.2±2.0 (p=0.001). In the BHP group, mean and standard deviation values of muscle strength at the non-operative/ operative side were as follows: flexion strength 6.5±2.8/6.0±3.4 (P=0.08), extension strength 4.4±0.9/4.4±0.6 (P=0.83), abduction strength at 0 degrees 5.1±1.9/5.0±1.6 (p=0.12), and that at 10 degrees 4.7±1.4/4.6±1.3 (p=0.10).

Conclusion:

Our results demonstrate that CM nailing may cause a 25-30% decrease in postoperative muscle strength around the hip joint, particularly during hip abduction. With the new BHP, greater trochanter reduction is achieved allowing early weight bearing and maintaining strength in abduction. Surgeons should consider postoperative muscular strength as one of the necessary factors for selection of the appropriate surgical procedure.

Level of Evidence:

Therapeutic Level III.

Wing-augmentation reduces femoral head cutting out of dynamic hip screw

The dynamic hip screw (DHS) is commonly used in the treatment of femoral intertrochanteric fracture with high satisfactory results. However, post-operative failure does occur and result in poor prognosis. The most common failure is femoral head varus collapse, followed by lag screw cut-out through the femoral head. In this study, a novel-designed DHS with two supplemental horizontal blades was used to improve the fixation stability. In this study, nine convention DHS and 9 Orthopaedic Device Research Center (ODRC) DHSs were tested in this study. Each implant was fixed into cellular polyurethane rigid foam as a surrogate of osteoporotic femoral head. Under biaxial rocking motion, all constructs were loaded to failure point (12mm axial displacement) or up to 20,000 cycles of 1.45kN peak magnitude were achieved, whichever occurred first. The migration kinematics was continuously monitored and recorded. The final tip-to-apex distance, rotational angle and varus deformation were also recorded. The results showed that the ODRC DHS sustained significantly more loading cycles and exhibited less axial migration in comparison to the conventional DHS. The ODRC DHS showed a significantly smaller bending strain and larger torsional strain compared to the conventional DHS. The changes in tip-to-apex distance (TAD), post-study varus angle, post-study rotational angle of the ODRC DHS were all significantly less than that of the conventional DHS (p < 0.05). We concluded that the ODRC DHS augmented with two horizontal wings would increase the bone-implant interface contact surface, dissipate the load to the screw itself, which improves the migration resistance and increases the anti-rotational implant effect. In conclusion, the proposed ODRC DHS demonstrated significantly better migration resistance and anti-rotational effect in comparison to the conventional DHS construct.

[Finite element study on calcium phosphate ceramic screw implanting after removing dynamic hip screw]

Objective

To investigate the validity of improving the femur's mechanical characteristics by implanting calcium phosphate ceramic screws after removing dynamic hip screw (DHS).

Methods

The three dimensional finite element model of the femur was built based on the CT scanning of a normal male volunteer. Then the models of the femur with and without DHS were established. According to calcium phosphate ceramic screws with porosity and apparent elastic modulus, 80% and 0.1 GPa were set as group A, 50% and 1.0 GPa as group B, and 30% and 1.5 GPa as group C. Von Mises stress distribution and maximum stress were recorded when the joint was maximally loaded in a gait cycle.

Results

The Von Mises in normal femoral shaft was uniform; no phenomena of stress concentration was observed and the maximum stress located at the joint load-bearing site of the proximal femur. The stress concentration was observed in the femur without DHS, and the maximum stress located at the distal femur around the screw hole. By comparing several different calcium phosphate ceramic screws, the stress distribution of group B was similar to normal femur model, and the maximum stress located at the joint load-bearing site. The other screws of groups A and C showed varying degrees of stress concentration.

Conclusion

Implanting calcium phosphate ceramic screw can improve the mechanical characteristics of the femur after removing dynamic hip screw, and the calcium phosphate ceramic screw with 50% porosity and 1.0 GPa apparent elastic modulus is suitable for implanting.

[IMAGING STUDY ON DESIGN AND GEOMETRIC MATCH OF A NEW TYPE OF SHORT FEMORAL INTERTROCHANTERIC NAIL WITH ANTERIOR CURVATURE]

OBJECTIVE

To design a new type of short femoral intertrochanteric nail (FITN) with anterior curvature (19.5 cm in length and 120 cm in radius) and observe the geometric match with medullary cavity of the femur.

METHODS

Between November 2015 and June 2016, 25 geriatric patients with femoral intertrochanteric fractures were treated with the newly designed FITN. There were 7 males and 18 females with an average age of 82.3 years (range, 65-94 years). According to AO/OTA fracture classification, 3 cases were rated as A1.2, 2 cases as A1.3, 5 cases as A2.1, 8 cases as A2.2, and 7 cases as A2.3. The interval between injury and operation was 3.2 days (range, 2-7 days). Postoperatively, the nail entry point position (anterior, central, and posterior) on sagittal plane, the nail tip position (6-grade scale) and the nail tail level (3-grade scale) were measured using fluoroscopy and X-ray films to evaluate the geometric match of the nail with medullary cavity of the femur.

RESULTS

One patient with Parkinson disease died of asphyxia and pulmonary infection. The other 24 patients were followed up 1-8 months (mean, 4 months). Fracture union time was 6-10 weeks (mean, 8 weeks). The mean Parker-Palmer mobility score was 5.5 (range, 4-8). No patient had hip-thigh pain. The nail entry point was positioned anterior in 2 cases (8%), central in 18 cases (72%), and posterior in 5 cases (20%). The distal nail tip located at the central canal axis (grade 0) in 15 cases (60%), at anterior without contact with the anterior inner cortex (grade 1) in 8 cases (32%), at posterior (grade -1) in 1 case (4%), and at anterior with slight nail-tip impingement with the anterior cortex (grade 2) in 1 case (4%). The proximal nail tail level did not protrude out beyond the greater trochanter (grade 0) in 13 cases (52%), protruded out less than 5 mm (grade 1) in 9 cases (36%), and more than 5 mm (grade 2) in 3 cases (12%).

CONCLUSIONS

The newly designed FITN has a good geometric match with the femur medullary canal in Chinese population, which may reduce the nail related complications.

Short versus long intramedullary nails for the treatment of intertrochanteric hip fractures in patients older than 65 years

OBJECTIVE

The purpose of this study was to compare failure rates between short and long intramedullary nails used for the treatment of intertrochanteric hip fractures in patients over 65 years of age.

METHODS

A retrospective review of 156 patients aged more than 65 years with femoral intertrochanteric fractures from December 2010 to December 2012 was performed. The patients were allocated to two groups: those treated with long nail (n=59) and short nail (n=97). Relevant patient variables and medical comorbidities were collected. Medical comorbidities were evaluated according to the American Society of Anesthesiologists classification and medical records were also reviewed for age, sex, intraoperative blood loss, operative time, length of stay, time to fracture union, hip pain, Harris Hip Score 1 year postoperatively, and failure rates. The failure rate was defined as periprosthetic fracture or reoperation requiring removal or revision of nail. Variables were statistically compared between the two groups, with statistical significance at P<0.05.

RESULTS

Patients treat with long nails and short nails were comparable for all assessed clinical variables (P>0.05). There were no statistically significant differences between these groups in intraoperative blood loss, time to fracture union and Harris Hip Score at 1 year postoperatively (P>0.05). The long nail group had significantly less failure rate (0/59) and hip pain rate (3/59) than those with short nail (3/97 and 13/97, respectively) (P < 0.05), but the operative time was significantly longer in the former (60.60 ± 11.43 minutes) than the latter (53.10 ± 8.51 minutes) group (P < 0.05).

CONCLUSIONS

Both the long and short intramedullary nails are the optional internal fixation choices for femoral intertrochanteric fracture in the aged patients older than 65 years. But the long nail could avoid the refracture of femur and reduced postoperative hip pain.