Role of Anteromedial Cortical Support for Unstable Intertrochanteric Fractures Being Treated With Cephalomedullary Nails

INTRODUCTION

Reduction quality is of paramount importance for an optimal outcome in unstable pertrochanteric fractures. The non-anatomical functional anteromedial buttress is proposed to prevent impending mechanical complications. We aimed to evaluate the role of anteromedial cortical support in preventing mechanical complications following fixation with the cephalomedullary nail.

MATERIALS AND METHODS

A prospective, single-arm interventional study was conducted in the Orthopaedics Department of a Combined Military Hospital (CMH) in Rawalpindi. The duration of the study was 24 months. Patients were recruited by the purposive sampling technique as per inclusion/exclusion criteria. Preoperatively, the reduction was categorized as per Baumgartner's and Chang's criteria. Post-operatively, weight bearing as tolerated was advised. Radiographs prior to discharge for loss of reduction were evaluated. Follow-up radiographic measurements of neck length, neck shaft angle, and their loss as per protocol were done at three and six months.

RESULTS

A total of 202 patients were operated on from October 21 until August 23. Mortality at six months in 39 patients (19.3%) and loss to follow-up in 31 patients (15.3%) resulted in 132 patients with complete follow-up and having developed complications in 12 patients (9.09%). The mean age was 76.3 ± 7.98 years; males were 105 (79.5%), and females were 27 (20.5%). Closed reduction was 58 (43.9%), and additional manoeuvres were required in 74 (56.1%). The mean tip apex distance (TAD) was 24.56 ± 2.76, and the Calcar gap was 5.16 ± 1.27. Cleveland zone centre-centre in 54 (40.9%), inferior-centre in 65 (49.2%), and inferior-posterior (9.9%) were statistically significant for mechanical complications (p≤0.001). There was a significant association between the grading of Chang's and Baumgartner's poor groups for the development of mechanical complications (p≤0.001). The mean time to full weight bearing without support was 21 ± 1.22 weeks. The mean Hip Harris score at six months was 69.27 ± 7.68.

CONCLUSION

Results suggest that anteromedial cortical support can lead to fewer potential mechanical complications at six months. A higher Chang's grade drives surgeons to engage in additional manoeuvres. Anteromedial cortical support is worth consideration for unstable pertrochanteric fractures.

[Research progress on distal interlocking screws of cephalomedullary nails in intertrochanteric fractures]

Objective

To summarize the new research progress in distal interlocking screws of cephalomedullary nails for the treatment of intertrochanteric fractures.

Methods

Relevant domestic and foreign literature was extensively reviewed to summarize the static/dynamic types of distal interlocking screw holes, biomechanical studies, clinical studies and application principles, effects on toggling in the cavity, and related complications of distal interlocking screws.

Results

The mode of the distal interlocking screw holes can be divided into static and dynamic. Distal interlocking screws play the role of anti-rotation, maintaining femur length, resisting compression stress, increasing torque stiffness, resisting varus stress, etc. The number of the screws directly affects the toggling of the main nail in the cavity. At present, regardless of whether long or short nails are used, distal interlocking screws are routinely inserted in clinical practice. However, using distal interlocking screws can significantly increase the duration of anesthesia and operation, increase fluoroscopy exposure time, surgical blood loss, and incision length. There is a trend of trying not to use distal interlocking screws in recent years. No significant difference is found in some studies between the effectiveness of dynamic and static interlocking for AO/Orthopaedic Trauma Association (AO/OTA) 31-A1/2 fractures. At present, the selection of the number and mode of distal interlocking screws is still controversial. When inserting distal interlocking screws, orthopedists should endeavor to minimize the occurrence of complications concerning miss shot, vascular injuries, local stress stimulation, and peri-implant fractures.

Conclusion

Distal interlocking screws are mainly used to prevent rotation. For stable fractures with intact lateral walls, long cephalomedullary nails can be used without distal interlocking screws. For any type of intertrochanteric fractures, distal interlocking screws are required when using short cephalomedullary nails for fixation. Different interlocking modes, the number of interlocking screws, and the application prospects of absorbable interlocking screws may be future research directions.

Case Report of Femoral Neck Stress Fracture in X-linked Hypophosphatemic Rachitis Patient Treated with Mechanical Axis Correction and a Literature Review

Introduction

X-linked hypophosphatemic rachitis (XLHR) is the most common cause of hereditary rickets that can lead to long bone deformities requiring multiple surgical correction procedures. In addition, high rates of fractures are reported in adult XLHR patients. This study aimed to report a case of femoral neck stress fracture in XLHR patient treated with mechanical axis correction. No previous studies demonstrating a combined valgus correction and cephalomedullary nail fixation were identified in the literature.

Case Report

A 47-year-old male patient with XLHR attended the outpatient clinic with severe left hip pain. X-rays revealed a left proximal femoral varus deformity and a femoral neck stress fracture. After 1 month without improvement of pain, and no radiographic sign of healing, correction of the proximal femoral varus deformity and fixation of the cervical neck fracture was achieved by a cephalomedullary nail. At 8 months follow-up, hip pain relief was achieved with radiographic healing of the femoral neck stress fracture and the proximal femoral osteotomy.

Conclusion

A review of the literature was performed to identify any case report of femoral neck fractures fixation due to coxa vara in an adult. Both coxa vara and XLHR can cause femoral neck stress fracture. This study presented the surgical technique for treating a rare case of femoral neck stress fracture in a XLHR patient with coxa vara. Pain relief and bone healing were achieved by combined deformity correction and fracture fixation with a femoral cephalomedullary nail. The technique for deformity correction and cephalomedullary nail insertion in the patient with coxa vara is shown.

A Cautionary Tale of a Complex Peri-Trochanteric Fracture in a Very Important Person (VIP) Patient at a Community-Based Hospital: A Case Report

Peri-trochanteric fractures with an extension into the femoral neck are relatively rare. Due to the lack of a defined treatment in the literature, these fractures pose a challenge to orthopedic surgeons. This case report highlights the value of timing to surgical intervention, choosing the appropriate operative course, not treating very important person (VIP) patients differently than standard patients, and decreasing unnecessary costs for the patient and the US healthcare system. An 85-year-old male VIP patient presented to the emergency department (ED) with a left peri-trochanteric fracture with an extension into the ipsilateral femoral neck. The initial plan was to perform arthroplasty with diaphyseal fixation. However, the community-based hospital would have to wait two to three days for the proper implants, and the patient insisted on being treated at this hospital. Due to concerns about increased mortality with delayed treatment, the patient underwent short cephalomedullary nail (CMN) fixation the next day. On postoperative day (POD) 49, a pop was heard and felt while ambulating, and radiographs revealed substantial lateral cutout of the CMN and subsidence of the femoral head. On POD 54, the patient underwent a successful left total hip arthroplasty using a modular diaphyseal press-fit femoral component, which resulted in an uneventful recovery. This case illustrates a cautionary tale in choosing the appropriate operative course for a VIP patient with a peri-trochanteric fracture extending into the femoral neck (a relatively rare fracture type that has no clearly defined treatment option). This is imperative to reduce pain and length of stay for the patient, postoperative complications, and cost. Based on the results from the second procedure and weighing the risk of prolonged treatment, the authors believe that this patient would likely have benefited from a primary arthroplasty procedure given his body habitus and complex fracture pattern.

What Is the Best Treatment Choice for Concomitant Ipsilateral Femoral Neck and Intertrochanteric Fracture? A Retrospective Comparative Analysis of 115 Consecutive Patients

PURPOSE

Although a concomitant ipsilateral femoral neck and intertrochanteric fracture has been considered to be a rare type of injury, its incidence has been increasing, especially among elderly hip fracture patients. However, there is limited evidence on the optimal treatment option. This study surveys surgical outcomes of different implants in order to assist in selecting the best possible implant for a combined femoral neck and intertrochanteric fracture.

METHODS

The postoperative complications after the treatment of a concomitant ipsilateral femoral neck and intertrochanteric fracture via cephalomedullary nail (CMN), dynamic hip screw (DHS), and hip arthroplasty groups were analyzed by retrospectively reviewing the electronic medical records of 115 consecutive patients.

RESULTS

The patient demographics and perioperative details showed no significant discrepancies amongst different surgical groups, except for the operative time; a CMN had the shortest mean operative time (standard deviation) of 85.6 min (31.1), followed by 94.7 min (22.3) during a DHS, and 107.3 min (37.2) during an HR (p = 0.021). Of the 84 osteosynthesis patients, 77 (91.7%) achieved a fracture union. Only one (3.2%) of the 31 HR cases had a dislocation. The sub-analysis of the different osteosynthesis methods showed a higher incidence of excessive sliding and the nonunion of the fracture fragment in the DHS group than that in the CMN group (p = 0.004 and p = 0.022, respectively). The different surgical methods did not significantly vary in other outcome variables, such as the re-operation rate, mortality, and hip function.

CONCLUSIONS

For the surgical treatment of combined femoral neck and trochanteric fractures, osteosynthesis did not differ significantly from an HR in terms of the overall postoperative complications, reoperation and mortality rate, and hip function, however, the risk of nonunion and more mechanical complications should be considered when choosing a DHS. Our suggestion for the treatment of a femoral neck and ipsilateral trochanteric fracture is that a surgeon should choose wisely between an HR and a CMN depending on the patient's age, the displacement of the femoral neck, and one's expertise.

What is the importance of distal nail diameter in the treatment of intertrochanteric femur fractures?

OBJECTIVES

The aim of this study was to investigate the effect of distal nail diameter in the treatment of geriatric intertrochanteric femur fractures (ITFFs).

PATIENTS AND METHODS

Between January 2017 and January 2021, a total of 91 patients (34 males, 57 females; mean age: 80.6±7.8 years; range, 65 to 96 years) who had osteosynthesis due to an ITFF with a short cephalomedullary nail (CMN) were retrospectively analyzed. The patients were divided into two groups: Group 1 (n=18) included patients with a distal nail diameter of ≤10 mm and Group 2 (n=73) included patients with a distal nail diameter of >10 mm. Patients' age, sex, fracture type according to AO classification, intramedullary femoral canal diameter, canal fit ratio, operation duration, reduction quality, the distal diameter of the CMN, and complications were evaluated.

RESULTS

There was no statistically significant difference between Group 1 and Group 2 in terms of the mean age, sex, fracture type, mean intramedullary canal diameter, reduction quality, and implant failure (p>0.05). The mean operation duration was significantly shorter in Group 2 (112.9±39.9 min) compared to Group 1 (128.8±36.4 min) (p=0.048). A total of three intraoperative peri-implant fractures occurred which included one 9 mm nail, one 12 mm nail, and one 14 mm nail.

CONCLUSION

Our study results suggest that there is no advantage of using a >10-mm CMN in the treatment of geriatric ITFFs in terms of reducing the implant failure rate. However, the utility of a >10-mm CMN can reduce the operation duration.

Functional and radiological comparison of three cephalomedullary nails with different designs used in the treatment of unstable intertrochanteric femur fractures of elderly

BACKGROUND

The aim of this study to compare three cephalomedullary nails (CMNs) with different designs in terms of complica-tion, reoperation, implant failure, mortality rates, and functional outcomes in the treatment of unstable intertrochanteric fractures (UIFs).

METHODS

This retrospective study included patients with UIFs (AO/OTA type 31-A2 and 31-A3) who were treated with one of these CMNs (74 patients with Talon-PFN, 70 patients with PFN-III, and 69 patients with Intertan) between October 2014 and October 2018.

RESULTS

A total of 213 patients (122 females and 91 males) with a mean age of 81.0±9.3 years have participated in this study. The mean follow-up time was 26.1±6.3 months. Malfixation was the most common complication and the most common reason of reop-eration for each type of CMN. Complication and reoperation rates, post-operative functional status, mean union times, and overall mortality rates were similar between groups. Mean operation/fluoroscopy time and mean blood loss were low in the Talon-PFN group, whereas the highest means of these parameters were in the PFN-III group. There were six (8.2%) implant failures in the Talon-PFN group and one (1.5%) in PFN-III group. No implant failure was seen in the Intertan group. The highest rate (58.6%) of anatomic reduc-tion was detected in PFN-III group.

CONCLUSION

Our study results showed that each implant type had its own advantages and disadvantages in the treatment of UIFs with similar functional and reoperation outcomes. Intertan was advantageous with its absence of implant failures. Talon-PFN decreased the operation/fluoroscopy time and intraoperative blood loss but had the highest implant failure rate. There was a need for more anatomic reduction to centralize two separate parallel lag screws in the femoral neck in PFN-III group, and that costs operation/fluo-roscopy time and blood loss. Malfixation, which was the most common cause of complications and reoperations, should be avoided.

Hip fractures following intramedullary nailing fixation for femoral fractures

INTRODUCTION

Proximal peri-implant femoral fractures occur following intramedullary nailing (IMN) fixation for trochanteric, femoral shaft, and distal femoral fractures. However, analyses of secondary hip fractures (SHFs) using large clinical samples are lacking. Therefore, we aimed to report the incidence and clinical outcomes of SHF after nailing fixation (IMN or cephalomedullary nailing [CMN]) for overall femoral fractures. In addition, we focused on IMN for femoral shaft fractures and investigated the risk factors for SHF.

METHODS

This multicenter, retrospective, cohort study included 2,293 patients aged > 60 years who underwent nailing fixation for femoral fractures. The primary outcome was the incidence of SHF. In the assessment of clinical outcomes, we evaluated reoperation and the regaining of walking ability following SHF management. In addition, we conducted multivariable logistic regression analyses to examine the association between risk factors and SHF.

RESULTS

Seventeen (0.7%) patients had SHFs, including 12 femoral neck fractures and 5 trochanteric fractures. Antegrade IMN was the most common type of nailing fixation. Multivariable analysis demonstrated that the absence of femoral head fixation was significantly associated with the incidence of SHF following IMN for femoral shaft fractures (odds ratio, 17.0; 95% confidence interval, 1.9-2265.7; p=0.006). In the assessment of clinical outcomes, there were two reoperations (16.7%) in the secondary femoral neck fracture group. Patients with secondary trochanteric fractures tended to have a lower probability of regaining walking ability than those with secondary femoral neck fractures (20% vs. 50%).

CONCLUSIONS

In this multicenter study, the incidence of SHF after nail fixation for femoral fractures was 0.7%. The absence of femoral head fixation was significantly associated with SHF, and the clinical outcomes were poor. Therefore, femoral head fixation at the initial IMN fixation for femoral fractures may be a fixation option for surgeons to consider as an SHF prevention measure.

Outcomes of Ipsilateral Femoral Neck and Shaft Fractures Treated With Proximal Femoral Nail Antirotation 2

Ipsilateral femoral neck and shaft fractures are relatively rare fractures, which most commonly occur in young adults following high-energy trauma. In most cases of such fractures, neck fracture is undisplaced and often of basicervical type. Many treatment methods have been described, but there is still no generalized consensus on the same. Cephalomedullary nails are one of the preferred modalities of treatment. A cephalomedullary nail-like proximal femoral nail antirotation 2 (PFNA 2) of recent design is being widely used currently. In this study, we present 13 cases of ipsilateral femoral neck and shaft fractures treated with PFNA 2 implants. The advantages of the PFNA 2 system include reduced blood loss, reduced operative time, and fewer fluoroscopy shots. PFNA 2 is a biomechanically better implant than many cephalomedullary implants. It provides satisfactory results in ipsilateral femoral neck and shaft fractures, especially where neck fracture is of a basicervical type. Some aspects have to be taken care of when employing PFNA 2, such as anatomical reduction, and length, angulation, and rotation of both neck and shaft.

CT scans better assess lateral wall morphology of "stable appearing" intertrochanteric (IT) femur fractures and predict early failure of sliding hip screw (SHS) fixation

To compare the efficacy of plain x-ray images and computed tomography (CT) to assess the morphology of the lateral wall (LW) component of intertrochanteric (IT) femur fractures and determine predictors of early fixation failure.

Clinicoradiological Outcome of Concomitant Fractures of Proximal Femur and Femoral Shaft Treated With Second-Generation Cephalomedullary Nailing

Background The ideal modality of treatment of concomitant fractures of the hip (intertrochanteric/femoral neck) and the femoral shaft is still evolving. The aim of our retrospective study was to assess the clinicoradiological outcome of such fractures managed by closed second-generation cephalomedullary nailing. Methodology The study was conducted among skeletally mature patients presenting within one week of injury who underwent closed second-generation cephalomedullary nailing (proximal femoral nail). Those presenting beyond one week or those who had pathological fractures, incomplete follow-ups, or other modes of fixation were excluded. Functional results were evaluated according to Friedman and Wyman's clinical assessment system. Time required for fracture healing and the presence of any complications were also noted. Results A total of 10 patients with the ipsilateral hip (five intertrochanteric and five femoral neck) and femoral shaft fractures were included in the study. Associated injuries found included fractures of the ipsilateral tibia/fibula at varying levels in three patients; hand and wrist injuries in two patients; and contralateral femoral shaft fracture, ipsilateral patella, bilateral crush injury of the foot, and head and chest injury with brachial plexus injury in one patient each. Four patients were diagnosed with intra-articular knee injuries (ligamentous and meniscal injuries) postoperatively. At the final follow-up, the functional outcome results were good in four, fair in one, and poor in five patients. All femoral neck fractures united at a mean of 15.2 weeks (range: 12.0-18.0 weeks) and intertrochanteric fractures at a mean of 14.0 weeks (range: 12.0-22.0 weeks). However, there was residual varus malunion in two intertrochanteric fractures. Eight femoral shaft fractures were infra-isthmic; of these, four resulted in nonunion (two of hypertrophic and two of atrophic type) and two were found to be in the delayed union, which eventually united by 24 weeks. Conclusions Second-generation cephalomedullary nail is an acceptable, cost-effective, and minimally invasive alternative for the management of concomitant ipsilateral fractures of the hip and supra-isthmic or isthmic femoral shaft fractures. For infra-isthmic fractures, retrograde femoral nail or distal femoral plate along with a separate implant for addressing the hip fracture (either cannulated cancellous screw or dynamic hip screw, preferably in a rendezvous/overlapping manner) are better options.

The Pre-Loaded Set-Screw in InterTAN Nail: Should It Be Tightened or Not Tightened in Pertrochanteric Hip Fractures

Background:

InterTAN is a specific type of cephalomedullary nail with a twin interlocking de-rotation and compression screw, which has inherent ability of anti-rotation. Whether to tighten or not to tighten the preloaded setscrew to allow or not allow secondary sliding in InterTan nail is controversial in clinical practice.

Methods:

We retrospectively collected 4 nonunion cases of unstable pertrochanteric femur fractures (AO/OTA-31A2), all were treated with InterTan nail and the preloaded setscrew was tightened in order to prevent further secondary sliding and femoral neck shortening.

Results:

After 6 months to 2 years follow-up, the fractures showed nonunion in radiography and the patients complained slight to middle degrees of pain, and had to use walking stick assistant in activities of daily life. Tightening the pre-loaded setscrew to prevent postoperative secondary sliding as static constructs might keep the femoral neck length, but lose the opportunity of telescoping for fracture impaction, and take the risk of healing complications, such as fracture nonunion, femoral head cutout or nail breakage.

Conclusions:

As the harm outweighs benefit, we advocate the preloaded setscrew in InterTan nail should not be tightened in standard-obliquity pertrochanteric hip fractures (AO/OTA-31A1 and A2).

Cyclic Damage Accumulation in the Femoral Constructs Made With Cephalomedullary Nails

Background: The purpose of this study was to evaluate the risk of peri-prosthetic fracture of constructs made with cephalomedullary (CM) long and short nails. The nails were made with titanium alloy (Ti-6Al-4V) and stainless steel (SS 316L).

Methods: Biomechanical evaluation of CM nail constructs was carried out with regard to post-primary healing to determine the risk of peri-implant/peri-prosthetic fractures. Therefore, this research comprised of, non-fractured, twenty-eight pairs of cadaveric femora that were randomized and implanted with four types of fixation CM nails resulting in four groups. These constructs were cyclically tested in bi-axial mode for up to 30,000 cycles. All the samples were then loaded to failure to measure failure loads. Three frameworks were carried out through this investigation, Michaelis–Menten, phenomenological, and probabilistic Monte Carlo simulation to model and predict damage accumulation.

Findings: Damage accumulation resulting from bi-axial cyclic loading in terms of construct stiffness was represented by Michaelis–Menten equation, and the statistical analysis demonstrated that one model can explain the damage accumulation during cyclic load for all four groups of constructs (P > 0.05). A two-stage stiffness drop was observed. The short stainless steel had a significantly higher average damage (0.94) than the short titanium nails (0.90, P < 0.05). Long titanium nail group did not differ substantially from the short stainless steel nails (P > 0.05). Results showed gender had a significant effect on load to failure in both torsional and bending tests (P < 0.05 and P < 0.001, respectively).

Interpretation: Kaplan–Meier survival analysis supports the use of short titanium CM nail. We recommend that clinical decisions should take age and gender into consideration in the selection of implants.

Management of Lateral Thigh Pain following Cephalomedullary Nail: A Technical Note

Peritrochanteric hip fractures are most commonly treated with proximal femoral fixation devices, such as a cephalomedullary nail or sliding hip screw. As usage rates increase for these fixation devices, complications from their insertion are becoming more prevalent. Lateral hip pain from proximal locking device insertion and prominence continues to be one of the most frequent complaints regarding hardware irritation following this surgical procedure. Conservative treatment options for this complaint include local corticosteroid injection and physical therapy, although once these treatments have been exhausted, surgical intervention may be recommended. This has generally been managed previously with implant removal, although studies have shown associated femoral neck fractures after removal even with the prescribed protected postoperative weight bearing. Additionally, in certain situations (e.g., when the nail is placed for prophylactic treatment), its removal is contraindicated. The purpose of this manuscript is to describe an alternative treatment option that would limit morbidity, and the need for proximal locking device or implant removal by excising the portion of the iliotibial band causing hip irritation at the level of the proximal locking device, while leaving the retained implant in place. This surgical option would allow most patients to return to their pre-operative weight-bearing status immediately following surgery without the need for additional postoperative precautions.

Radiologic predictor of intraoperative lateral wall fractures in treatment of pertrochanteric fractures with cephalomedullary nailing

Objective

This study was performed to investigate the reliability of the height of pertrochanteric fractures as a predictor of lateral wall fractures after cephalomedullary nailing and provide a simple way to determine the threshold value.

Methods

We performed a prospective randomized clinical study of 50 consecutive patients who underwent measurement of the height of the pertrochanteric fracture and the tangent line to the superior margin of the contralateral femoral neck. The preoperative and postoperative integrity of the lateral wall was evaluated by computed tomography.

Results

The pertrochanteric fracture height was significantly lower in patients with than without intraoperative lateral wall fractures (15.6 vs. 28.5 mm, respectively). The threshold value of the fracture height was 20.445 mm, which was not significantly different from the mean height of the tangent line of the superior margin of the contralateral femoral neck (19.4 mm).

Conclusions

Pertrochanteric fractures with the proximal starting point lower than the mirror position of the tangent line to the superior margin of the contralateral femoral neck have a higher risk of intraoperative lateral wall fractures during cephalomedullary nailing.

Impact of tip-apex distance and femoral head lag screw position on treatment outcomes of unstable intertrochanteric fractures using cephalomedullary nails

Background

Cephalomedullary nails are frequently used in unstable intertrochanteric fractures. The implant position is an important factor for surgical success. Thus, in the present study, finite element analysis methods were used to investigate the biomechanical behavior of five different cephalomedullary nail positions in unstable intertrochanteric fractures.

Methods

Five different cephalomedullary nail implant positions were investigated. The observed indicators were the maximum displacement of the lag screw, the stress on the intertrochanteric fracture with involvement of the posteromedial cortex, and the tip–apex distance.

Results

The smallest lag screw displacement was achieved when the implant was closer to the inferior femoral head. Lower stress was placed on the posteromedial cortex when the implant was positioned closer to the inferior femoral head. However, the tip–apex distance increased when the lag screw was positioned more inferiorly.

Conclusions

The results of this study suggest that positioning the lag screw closer to the inferior aspect of the femoral head can reduce stress on the posteromedial cortex and deformation of the implant in unstable intertrochanteric fractures. These findings provide a biomechanical basis for selection of the cephalomedullary nail implantation site.

Level of evidence

III.

Decreased postoperative gluteus medius muscle cross-sectional area measured by computed tomography scan in patients with intertrochanteric fractures nailing

BACKGROUND

In patients with femoral intertrochanteric fractures treated by cephalomedullary (CM) nailing, abduction force reportedly decreased by 25-30% during the postoperative follow-up period. The purpose of the current study is to evaluate the cross-sectional area (CSA) and adipose tissue ratio (ATR) of the gluteus medius muscle on the postoperative computed tomography (CT) view, expecting this graphic study will support clinical results.

MATERIALS AND METHODS

A total of 27 patients with femoral intertrochanteric fractures treated by CM femoral nail implants completed the study. The mean age at osteosynthesis was 83 years (range: 72-94 years). The mean postoperative follow-up period was 23 months. The three CT axial slice views were defined as slices A, B, and C corresponding to proximal, midway, and distal part of gluteus medius, respectively. The CSA and ATR were assessed bilaterally.

RESULTS

The mean and standard deviation of CSA values (mm²) between the nonoperated/ operated side were as follows: slice A: 2225.8 ± 621.2/1984.5 ± 425.8; slice B: 2145.1 ± 538.3/1854.9 ± 383.9; and slice C: 1711.0 ± 459.0/1434.5 ± 396.9 ( p < 0.01 in slices A, B, and C). The mean and standard deviation of ATR values (%) from the nonoperative/ operative side were as follows: slice A: 2.8 ± 1.7/5.2 ± 3.5; slice B: 2.7 ± 1.9/4.6 ± 3.2; and slice C: 3.6 ± 3.0/4.8 ± 3.2 ( p < 0.01 in slices A and B and p < 0.05 in slice C).

CONCLUSION

Our image findings documented that gluteus medius is significantly changed in CSA and ATR. The damage possibly triggers decrease in muscular strength of hip abduction in the postoperative follow-up period. This measurement is objective, and needed no patient's endurance and cooperation.

Treatment With Helical Blade Cephalomedullary Nail for Two-Part Basicervical Proximal Femoral Fracture in Elderly Patients: A Retrospective Observational Study

BACKGROUND

Basicervical proximal femoral fracture is a known subtype of extracapsular fracture and is mechanically unstable, especially for the rotational direction, which may lead to implant failure. A cephalomedullary nail (CMN) is widely used for the fixation of unstable extracapsular fracture; however, its application for basicervical fracture remains controversial. Helical blade CMN is proven to have more rotational stability than traditional lag screw implants and potentially advantageous in the treatment of basicervical fracture. The aim of this study is to assess the effectiveness of helical blade CMN for basicervical fracture in elderly patients.

METHODS

We conducted a retrospective review of 500 consecutive extracapsular fracture patients treated surgically between January 2005 and February 2015. Patients who had trochanteric extension or multifragment fracture were excluded. Sixteen cases of 2-part basicervical proximal femoral fracture were identified. All patients were treated with the same single helical blade CMN system (DePuy Synthes PFNA-II). Implant-related complications were recorded.

RESULTS

Two patients dropped out during follow-up and 14 patients were included in the analysis. The average follow-up period was 21.9 months. No major complication was observed. The patients were subcategorized into 2 groups: nondisplaced (displacement <2 mm at any point of the fracture line) or displaced. Excessive telescoping was observed in 2 patients, both of whom were in the displaced fracture group. The overall implant-related complication rate was 14.2% (2/16).

CONCLUSION

Internal fixation with the helical blade CMN system can be considered as a treatment option for 2-part basicervical proximal femoral fracture in elderly patients.

Embedding the lateral end of the lag screw within the lateral wall in the repair of reverse obliquity intertrochanteric femur fracture

Objective

The management of reverse oblique intertrochanteric femoral fractures is difficult because such fractures have unique biomechanical characteristics. This study was performed to review the results of treating reverse oblique intertrochanteric femoral fractures with a long cephalomedullary nail by embedding the lateral end of the lag screw to secure axial compression.

Methods

We herein report the surgical outcomes in seven patients with reverse oblique intertrochanteric fractures treated with our procedure. Patients whose hip screws obviously had no contact with the distal fragment and whose follow-up time was too short were excluded. The lateral end of the lag screw was embedded within the lateral cortex, and the screws were locked to the nail. All nails were long, and a distal locking screw was inserted in the dynamized position.

Results

No reoperation, definite leg length discrepancy, or malunion occurred in this study.

Conclusions

These data suggest that early complications do not seem to increase when the lateral end of the lag screw is embedded and the screw is locked to the nail in the treatment of reverse oblique intertrochanteric fracture at this stage.

Fracture reduction with positive medial cortical support: a key element in stability reconstruction for the unstable pertrochanteric hip fractures

PURPOSE

To introduce the concept of fracture reduction with positive medial cortical support and its clinical and radiological correlation in geriatric unstable pertrochanteric fractures.

METHODS

A retrospective analysis of 127 patients (32 men and 95 women, with mean age 78.7 years) with AO/OTA 31A2.2 and 2.3 hip fractures treated with cephalomedullary nail (PFNA-II or Gamma-3) between July 2010 and June 2013 was performed. They were classified into three groups according the grade of medial cortical support in postoperative fracture reduction (positive, neutral, and negative). The positive cortex support was defined that the medial cortex of the head-neck fragment displaced and located a little bit superomedially to the medial cortex of the shaft. If the neck cortex is located laterally to the shaft, it is negative with no cortical buttress, and if the two cortices contact smoothly, it is in neutral position. The demographic baseline, postoperative radiographic femoral neck-shaft angle and neck length, rehabilitation progress and functional recovery scores of each group were recorded and compared.

RESULTS

There were 89 cases (70 %) in positive, 26 in neutral, and 12 in negative support. No statistical differences were found between the three groups among patient age, sex ratio, prefracture score of activity of daily living, walking ability score, ASA physical risk score, number of medical comorbidities, osteoporosis Singh index, fracture reduction quality (Garden alignments), and the position of lag screw or helical blade in femoral head (TAD). In follow-up, patients in positive medial cortical support reduction group had the least loss in neck-shaft angle and neck length, and got ground-walking much earlier than negative reduction group, with good functional outcomes and less hip-thigh pain presence.

CONCLUSION

Fracture reduction with nonanatomic positive medial cortical support allows limited sliding of the head-neck fragment to contact with the femur shaft and achieve secondary stability, providing a good mechanical environment for fracture healing.

Increased complication rate following conversion total hip arthroplasty after cephalomedullary fixation for intertrochanteric hip fractures: a multi-center study

Cephalomedullary devices (CMN) have become an increasingly popular for treatment of intertrochanteric hip fractures compared to sliding hip screw and side plate (SHS) devices. Failed fixation is often treated with conversion total hip arthroplasty (THA). We performed a multi-institutional study in which 60 patients with SHS devices and 31 patients with CMN devices were converted to THA. Harris Hip Score improved from 41.6 preoperatively to 83.6 at final follow-up in the SHS group and from 41.6 to 78.6 in the CMN group, with no significant difference between the groups (P=0.23). However, the complication rate in converted CMN patients was significantly higher at 41.9% compared with 11.7% (P=0.001) in converted SHS patients. Prior fixation with CMN may be associated with significantly higher complication rates during conversion.