Distal Femoral Stress Fractures Has High Operation Rates in Adolescent and Young Adult Athletes

BACKGROUND

Although stress fractures of the distal femur are rare, symptoms can overlap with other peri-articular knee pathology, delaying diagnosis. Untreated stress fractures have the potential to progress into completed fractures with a higher likelihood for requiring surgery and longer recovery times in otherwise healthy adolescents and young adults. This case series represents the largest cohort of adolescent athletes with distal femoral stress fractures who presented with activity-related knee pain.

METHODS

Patients treated nonoperatively and operatively for metaphyseal distal femur stress fractures at a tertiary referral center over a four-year period were retrospectively identified from the medical record.

RESULTS

Eight patients (mean age 16.8 y; range 14 to 22 y; 87.5% male; mean body mass index [BMI] 20.9) with a total of 10 distal femur stress fractures were identified. All patients were involved in competitive sports or military training. There was an average of 3.8 encounters with a medical provider between presentation with activity-related knee pain and diagnosis with distal femur stress fracture. All except 1 patient (87.5%) were initially incorrectly diagnosed with another type of peri-articular knee pathology. Six stress fractures (60%) were treated conservatively with protected weight bearing, activity modification, and gradual return to activity. Four completed stress fractures (40%) required operative fixation-3 healed uneventfully, while 1 had an asymptomatic delayed union. Vitamin D insufficiency (<30 ng/mL) was identified in 7 of 8 patients (87.5%) and 3 patients (37.5%) had an underweight BMI (<18.5). The mean clinical follow-up was 13.1 weeks (range, 2.8 to 32.0 wk).

CONCLUSIONS

High clinical suspicion for distal femoral stress fractures is needed to avoid misdiagnosis or delayed diagnosis in young, active individuals with activity-related knee pain refractory to conservative management. In this patient population, activity-related knee pain recalcitrant to activity modification, rest, and physical therapy warrants further workup with magnetic resonance imaging and orthopaedic evaluation. Though rare, misdiagnosis can result in catastrophic fractures with prolonged rehabilitation needs. An open line of communication and streamlined access for referral between primary care providers and orthopaedic surgeons is critical in preventing misdiagnosis and delayed treatment. Furthermore, the treatment of concomitant metabolic disorders and nutritional deficiency should not be neglected when treating distal femoral stress fractures.

LEVEL OF EVIDENCE

Level-IV (case series).

Deep-Learning Automation of Preoperative Radiographic Parameters Associated With Early Periprosthetic Femur Fracture After Total Hip Arthroplasty

BACKGROUND

The radiographic assessment of bone morphology impacts implant selection and fixation type in total hip arthroplasty (THA) and is important to minimize the risk of periprosthetic femur fracture (PFF). We utilized a deep-learning algorithm to automate femoral radiographic parameters and determined which automated parameters were associated with early PFF.

METHODS

Radiographs from a publicly available database and from patients undergoing primary cementless THA at a high-volume institution (2016 to 2020) were obtained. A U-Net algorithm was trained to segment femoral landmarks for bone morphology parameter automation. Automated parameters were compared against that of a fellowship-trained surgeon and compared in an independent cohort of 100 patients who underwent THA (50 with early PFF and 50 controls matched by femoral component, age, sex, body mass index, and surgical approach).

RESULTS

On the independent cohort, the algorithm generated 1,710 unique measurements for 95 images (5% lesser trochanter identification failure) in 22 minutes. Medullary canal width, femoral cortex width, canal flare index, morphological cortical index, canal bone ratio, and canal calcar ratio had good-to-excellent correlation with surgeon measurements (Pearson's correlation coefficient: 0.76 to 0.96). Canal calcar ratios (0.43 ± 0.08 versus 0.40 ± 0.07) and canal bone ratios (0.39 ± 0.06 versus 0.36 ± 0.06) were higher (P < .05) in the PFF cohort when comparing the automated parameters.

CONCLUSIONS

Deep-learning automated parameters demonstrated differences in patients who had and did not have early PFF after cementless primary THA. This algorithm has the potential to complement and improve patient-specific PFF risk-prediction tools.

Radiographic outcomes and non-union factor analysis in fragmentary segmental femoral shaft fractures (AO/OTA 32C3) treated with reamed antegrade nailing

This study retrospectively assessed radiographic outcomes and risk factors associated with non-union in femoral shaft fragmentary segmental fractures (AO/OTA 32C3) treated with reamed antegrade intra-medullary nailing. Radiological outcomes, including union and alignment, were evaluated. The risk factors for non-union were investigated, including demographics and treatment-related characteristics, such as the number of interlocking screws, segmentation length, main third fragment length, distance of the main third fragment, width ratio and exposed nail length in one cortex from immediate post-operative radiographs. Multivariate logistic regression was used for statistical analysis. Among 2295 femoral shaft fracture patients from three level-1 trauma centers, 51 met the inclusion criteria. The radiological union was achieved in 37 patients (73%) with a mean union time of 10.7 ± 4.8 months. The acceptable axial alignment was observed in 30 patients (59%). Multiple logistic regression analysis identified only exposed nail length as a significant risk factor for non-union (odds ratio: 1.599, p = 0.003) and the cut-off value was 19.1 mm (sensitivity, 0.786; specificity, 0.811). The study revealed high rates of non-union (27%) and malalignment (41%). Therefore, patients who underwent intramedullary nailing with an exposed nail length greater than 19.1 mm or about twice the nail diameter should be cautioned of the potential non-union.

Forces required to dynamize sliding screws in gamma nail and selfdynamizable internal fixator

BACKGROUND

Single limb support phase of the gait-cycle in patients who are treated for a pertrochanteric fracture is characterized by transversal loads acting on the lag screw, tending to block its dynamization. If the simultaneous axial force overcomes transversal loads of the sliding screw, the dynamization can still occur.

METHODS

Biomechanical investigation was performed for three types of dynamic implants: Gamma Nail, and two types of Selfdynamizable Internal Fixators (SIF) - SIF-7 (containing two 7 mm non-cannulated sliding screws), and SIF-10 (containing one 10 mm cannulated sliding screw). Contact surface between the stem and the sliding screws is larger in SIF implants than in Gamma Nail, as the stem of Gamma Nail is hollow. A special testing device was designed for this study to provide simultaneous application of a controlled sliding screws bending moment and a controlled transversal load on sliding screws (Qt) without using of weights. Using each of the implants, axial forces required to initiate sliding screws dynamization (Qa) were applied and measured using a tensile testing machine, for several values of sliding screws bending moment. Standard least-squares method was used to present the results through the linear regression model.

RESULTS

Positive correlation between Qt and Qa was confirmed (p < 0.05). While performing higher bending moments in all the tested implants, Qa was higher than it could be provided by the body weight. It was the highest in Gamma Nail, and the lowest in SIF-10.

CONCLUSIONS

A larger contact surface between a sliding screw and stem results in lower forces required to initiate dynamization of a sliding screw. Patients treated for a pertrochanteric fracture by a sliding screw internal fixation who have longer femoral neck or higher body weight could have different programme of early postoperative rehabilitation than lighter patients or patients with shorter femoral neck.

Optimising the Orthopaedic Trauma Society Open Fracture Classification system: a proposal for modification in the context of high civilian gunshot fractures

OBJECTIVES

Uniformly classifying long bone open fractures is challenging. The purpose of this study was to propose a modified Orthopaedic Trauma Society (OTS) Open Fracture Classification System, developed in a setting with a high incidence of civilian gunshot fractures.

METHODS

From our prospectively collected database, we identified all patients with open tibia and femur fractures treated with intramedullary nailing over a 4 year period. All open fractures were retrospectively reclassified from the Gustilo-Anderson Classification system to the OTS Open Fracture Classification System.

RESULTS

One hundred and thirty-seven cases were identified. Ninety per cent of subjects were males. Their mean age was 34 years. The most common mechanism of injury was low-velocity civilian gunshot wounds (GSW) in 54.7% of cases. Soft tissue management was primary closure in 23.4% and soft tissue reconstruction in 24.1%. In 52.6% of cases (these all being secondary to civilian GSW), soft tissue management was healing via secondary intention. This is not included as a soft tissue management option in the OTS classification system. Fracture reclassification using the OTS Open Fracture Classification System was only possible in 47.5% of cases (Simple in 23.4%, Complex B in 24.1%).

CONCLUSION

We conclude that the OTS Open Fracture Classification System is not inclusive of all open tibia and femur fractures as it does not cater for gunshot fractures. We propose a modification as follows: alter 'wound debridement' to 'appropriate wound care' and to subcategorise 'Simple' into type A and B: healing via secondary intention and primary closure, respectively.

Early Periprosthetic Femur Fractures After Primary Cementless Total Hip Arthroplasty: High Risk of Periprosthetic Joint Infection and Subsequent Reoperation

BACKGROUND

Periprosthetic femur fracture (PFF) following total hip arthroplasty (THA) is a leading cause of early reoperation. The objective of this study was to compare rates of periprosthetic joint infection (PJI) and reoperation following PFFs occurring early postoperatively to those that occurred late.

METHODS

We retrospectively identified 173 consecutive surgically managed PFFs following primary THA. Cases were categorized as "early" if they occurred within 90 days of THA (n = 117) or "late" if they occurred following the initial 90 days (n = 56). Mean age at time of PFF was 68 years (range, 26 to 96) and 60% were women. Mean body mass index was 29 (range, 16 to 52). Mean follow-up was 2 years (range, 0 to 13). Kaplan-Meier survival analysis estimated cumulative incidences of PJI and reoperation.

RESULTS

Early PFFs had higher 2-year cumulative incidence of PJI (11% versus 0%, P < .001) and reoperation (24% versus 13%, P = .110). Following early PFF, 27 patients required reoperation (ie, 13 for PJI, 5 for instability, 2 for re-fracture, 2 for painful hardware, 2 for non-union, 1 for adverse local tissue reaction, 1 for aseptic loosening, and 1 for leg-length discrepancy). Following late PFF, 5 patients required reoperation (ie, 3 for instability, 1 for re-fracture, and 1 for non-union).

CONCLUSIONS

There are greater incidences of PJIs and overall reoperations following early PFFs compared to late PFFs after THA. In addition to focusing efforts on prevention of early PFFs, surgeons should consider antiseptic interventions to mitigate the increased risk of PJI after treatment of early PFF.

Posterior Cruciate Ligament Injury After Retrograde Nailing of Periprosthetic Distal Femur Fractures: A Report of 2 Cases

CASE

A 51-year-old man and 64-year-old woman with bilateral cruciate-retaining total knee arthroplasties (CR-TKAs) who sustained unilateral periprosthetic distal femur fractures above their CR-TKA and experienced knee instability secondary to an iatrogenic posterior-cruciate-ligament (posterior cruciate ligament [PCL]) injury from retrograde intramedullary nailing. Both patients recovered knee stability after undergoing revision surgery.

CONCLUSION

Many CR-TKA designs have sufficient medial-lateral intercondylar distance to place a retrograde nail, femoral components with a relatively posterior transition from the trochlear groove to the intercondylar box will necessitate a nail starting point closer to the PCL origin. This may contribute to iatrogenic postoperative knee instability for patients with CR-TKA designs.

Analysis of complications in 97 periprosthetic Vancouver B2 fractures treated either by internal fixation or revision arthroplasty

INTRODUCTION

The treatment of Vancouver B2 periprosthetic fractures after hip arthroplasty is still a matter of debate. Revision Arthroplasty (RA) was long thought to be the treatment of choice, however several recent papers suggested that Open Reduction and Internal Fixation (ORIF) is a viable option for selected B2 fractures. Complication rates of 14-26% have been reported following surgical treatment of B2 fractures. No significant difference between RA and ORIF in the complication rates nor in the functional outcome was observed.

METHOD

We conducted a retrospective analysis of 97 consecutive Vancouver B2 fractures treated according to the algorithm at our institution from 2007 to 2020 and recorded complications and patient specific data.

RESULT

From the 97 patient, 45 fractures were treated with RA while 52 fractures were treated with ORIF. Thirteen patients in the RA group had a complication that needed revision (28%) and 11 patients in the ORIF group needed revision (21%). There was no significant difference between complication rates. The reason for failure in the 13 RA patients were infection (n = 4), stem subsidence (n = 1), refracture after a new fall (n = 3), secondary dislocation of the greater trochanter (n = 1) and dislocation (n = 4). The reason for failure in the 11 ORIF patients that were revised were infection (n = 5), persistent symptomatic stem loosening (n = 3) and refracture (n = 3) after a new fall.

CONCLUSION

ORIF can be used to revise cemented and non-cemented shafts in more than half of Vancouver B2 fractures with no difference in complication rates when compared to RA. A periprosthetic fracture around the hip has a 21-28% risk of a re-operation after revision surgery with infection and re-fracture after a new fall being the most frequent cause of re-operation.

Should recommended laboratory-test cut-offs allowing surgery be followed for proximal femoral fractures in patients on direct oral anticoagulant therapy?

BACKGROUND

Proximal femoral fractures (PFFs) in elderly patients must receive prompt surgical treatment. Optimal PFF-surgery timing in patients on direct oral anticoagulant (DOA) therapy is a specific but common clinical issue. Recommendations exist about the anti-Xa or anti-IIa levels and creatinine clearance values required to allow surgery. The objectives of this study in patients older than 75 years who required PFF surgery were to evaluate bleeding when the recommendations were versus were not applied and to assess concordance between DOA-activity-assay results and creatinine clearance used to help determine the wait to surgery.

HYPOTHESIS

Peri-operative bleeding is more marked when surgery is performed while the DOA is still active.

PATIENTS AND METHODS

This single-centre, retrospective, comparative, observational study included 87 patients older than 75 years who required arthroplasty or intra-medullary nailing for PFF and were taking DOA therapy. Surgery was performed after versus before the laboratory-test results fell below the recommended cut-offs in 68 patients (Rec+ group) versus 19 patients (Rec- group), respectively. The study outcomes were blood loss estimated using the Mercuriali's formula and the proportion of patients requiring post-operative blood transfusions.

RESULTS

Mean blood loss was 287.1mL in the Rec+ group and 411.7mL in the Rec- group (p=0.12). Blood transfusions were required by a post-operative haemoglobin level below 0.8g/dL in 11 (16.2%) Rec+ patients and 6 (31.6%) Rec- patients (p=0.2). Concordance was poor between DOA activity and creatinine clearance (Cohen's κ, 0.16; p=0.146).

DISCUSSION

Peri-operative bleeding was not significantly more severe when PFF surgery was performed while DOA therapy was still active. These data suggest that PFF surgery within 48h may be appropriate in patients older than 75 years on DOA therapy.

LEVEL OF EVIDENCE

IV; retrospective single-centre study.

Retrograde intramedullary nailing with supplemental plate and lag screws allows early weight bearing following distal end-segment femur fractures (AO/OTA 33) in a low-resource setting

PURPOSE

To underline the feasibility of achieving early weight bearing in patients with distal end-segment femur fractures (AO/OTA 33) treated with retrograde intramedullary nailing and supplemental plate or lag screws in the absence of C-arm.

METHODS

41 distal end-segment femur fractures (DFFs) included in the study were treated with SIGN nails with or without a side plate in a center that lacked intraoperative fluoroscopy and fracture table. A medial or lateral para-patellar incision was used for fracture reduction, nail insertion and side plate placement. Follow-ups were done at six weeks, 12 weeks, and six months post-operatively.

RESULTS

Distal end-segment fractures constituted 13.2% of all femur fractures treated. The patients' mean age and range were 49.6 and 23-83 years respectively. They were mostly injured in road traffic accidents. 27 were daily-income earners. By the 12th week post-operatively, 82.1% of them could flex their knee beyond 90°, all of them could bear weight fully, and 71.8% could squat & smile.

CONCLUSION

The study highlighted the procedure for retrograde nailing of DFFs in a setting without the requisite facilities for minimally-invasive surgeries. The findings demonstrated the feasibility of achieving an expedited weight bearing for the predominantly daily-income-earning victims to ensure early return to work and poverty reduction. While the small sample size is a limitation, the study does provide information that could serve as a basis for future randomized controlled trials in low-resource settings.

What Are the Mortality, Infection, and Nonunion Rates After Periprosthetic Femoral Fractures in the United States?

BACKGROUND

Periprosthetic femoral fractures are a serious complication that put a high burden on patients. However, comprehensive analyses of their incidence, mortality, and complication rates based on large-registry data are scarce.

QUESTIONS/PURPOSES

In this large-database study, we asked: (1) What is the incidence of periprosthetic femoral fractures in patients 65 years and older in the United States? (2) What are the rates of mortality, infection, and nonunion, and what factors are associated with these outcomes?

METHODS

In this retrospective, comparative, large-database study, periprosthetic femoral fractures occurring between January 1, 2010, and December 31, 2019, were identified from Medicare physician service records encompassing services rendered in medical offices, clinics, hospitals, emergency departments, skilled nursing facilities, and other healthcare institutions from approximately 2.5 million enrollees. These were grouped into proximal, distal, and shaft fractures after TKA and THA. We calculated the incidence of periprosthetic femur fractures by year. Incidence rate ratios (IRR) were calculated by dividing the incidence in 2019 by the incidence in 2010. The Kaplan-Meier method with Fine and Gray subdistribution adaptation was used to calculate the cumulative incidence rates of mortality, infection, and nonunion. Semiparametric Cox regression was applied with 23 measures as covariates to determine factors associated with these outcomes.

RESULTS

From 2010 to 2019, the incidence of periprosthetic femoral fractures increased steeply (TKA for distal fractures: IRR 3.3 [95% CI 1 to 9]; p = 0.02; THA for proximal fractures: IRR 2.3 [95% CI 1 to 4]; p = 0.01). One-year mortality rates were 23% (95% CI 18% to 28%) for distal fractures treated with THA, 21% (95% CI 19% to 24%) for proximal fractures treated with THA, 22% (95% CI 19% to 26%) for shaft fractures treated with THA, 21% (95% CI 18% to 25%) for distal fractures treated with TKA , 22% (95% CI 17% to 28%) for proximal fractures treated with TKA, and 24% (95% CI 19% to 29%) for shaft fractures treated with TKA. The 5-year mortality rate was 63% (95% CI 54% to 70%) for distal fractures treated with THA, 57% (95% CI 54% to 62%) for proximal fractures treated with THA, 58% (95% CI 52% to 63%) for shaft fractures treated with THA, 57% (95% CI 52% to 62%) for distal fractures treated with TKA , 57% (95% CI 49% to 65%) for proximal fractures treated with TKA, and 57% (95% CI 49% to 64%) for shaft fractures treated with TKA. Age older than 75 years, male sex, chronic obstructive pulmonary disease (HR 1.48 [95% CI 1.32 to 1.67] after THA and HR 1.45 [95% CI 1.20 to 1.74] after TKA), cerebrovascular disease after THA, chronic kidney disease (HR 1.28 [95% CI 1.12 to 1.46] after THA and HR 1.50 [95% CI 1.24 to 1.82] after TKA), diabetes mellitus, morbid obesity, osteoporosis, and rheumatoid arthritis were clinical risk factors for an increased risk of mortality. Within the first 2 years, fracture-related infections occurred in 5% (95% CI 4% to 7%) of patients who had distal fractures treated with THA, 5% [95% CI 5% to 6%]) of patients who had proximal fractures treated with THA, 6% (95% CI 5% to 7%) of patients who had shaft fractures treated with THA, 6% (95% CI 5% to 7%) of patients who had distal fractures treated with TKA , 7% (95% CI 5% to 9%) of patients who had proximal fractures treated with TKA, and 6% (95% CI 4% to 8%) of patients who had shaft fractures treated with TKA. Nonunion or malunion occurred in 3% (95% CI 2% to 4%) of patients with distal fractures treated with THA, 1% (95% CI 1% to 2%) of patients who had proximal fractures treated with THA, 2% (95% CI 1% to 3%) of patients who had shaft fractures treated with THA, 4% (95% CI 3% to 5%) of those who had distal fractures treated with TKA, , 2% (95% CI 1% to 4%) of those who had proximal fractures treated with TKA, and 3% (95% CI 2% to 4%) of those who had shaft fractures treated with TKA.

CONCLUSION

An increasing number of periprosthetic fractures were observed during the investigated period. At 1 and 5 years after periprosthetic femur fracture, there was a substantial death rate in patients with Medicare. Conditions including cerebrovascular illness, chronic kidney disease, diabetes mellitus, morbid obesity, osteoporosis, and rheumatoid arthritis are among the risk factors for increased mortality. After the surgical care of periprosthetic femur fractures, the rates of fracture-related infection and nonunion were high, resulting in a serious risk to affected patients. Patient well-being can be enhanced by an interdisciplinary team in geriatric traumatology and should be improved to lower the risk of postoperative death. Additionally, it is important to ensure that surgical measures to prevent fracture-related infections are followed diligently. Furthermore, there is a need to continue improving implants and surgical techniques to avoid often-fatal complications such as fracture-associated infections and nonunion, which should be addressed in further studies.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Management of Isolated Greater Trochanter Fractures Associated With Total Hip Arthroplasty

Periprosthetic hip fractures are recognized complications associated with total hip arthroplasty. Over the past decade, there has been a 2.5-fold increase in the incidence of periprosthetic fractures which is expected to grow exponentially in the future. Most of these fractures require surgical fixation or revision arthroplasty. Fractures of the greater trochanter represent a subset of periprosthetic fractures for which there is currently no consensus in the literature regarding the optimal management. The purpose of this review was to outline the management strategies available to address these fractures, with formulation of recommendations for fractures sustained intraoperatively, postoperatively, and in the setting of primary and revision total hip arthroplasty.

Interimplant femoral fracture: analysis of risk factors

Interimplant fractures present a significant challenge for orthopedic surgeons. Despite a noticeable rise in these cases in recent years, our understanding of this specific fracture type remains limited. This study aims to analyze and identify the primary risk factors associated with interimplant femoral fractures. We conducted a retrospective analysis involving 20 patients with interimplant femoral fracture (case group) and 18 patients who had both proximal and distal femoral implants but did not experience interimplant fractures (control group). Our analysis focused on demographic factors (age, sex, BMI) and radiographic parameters (implant types, gap between implants, cortical thickness, femoral canal area) to identify potential risk factors. In the case group, all patients were females, whereas in the control group, 16 patients were female and 2 were males. The mean age in the case group was 88 [Formula: see text] 9 years and in the control group was 87 [Formula: see text] 12 years. None of the demographic differences reached statistical significance. The mean cortical thickness in the case group was 6 [Formula: see text] 2.25 mm, whereas in the control group, it was 9 [Formula: see text] 1.75 mm (p-value < 0.001). The median gap between the proximal and distal tips of the implants measured 194 [Formula: see text] 126 mm in the case group and 66 [Formula: see text] 78 mm in the control group (p-value < 0.001). Additionally, the mean femoral canal area was 284 [Formula: see text] 102 mm2 in the case group and 227 [Formula: see text] 26 mm2 in the control group (p-value < 0.010). Our data indicate that a small cortical thickness, a wide femoral canal area, and having a hip arthroplasty despite a gap between the implants exceeding 110 mm are factors that elevate the risk of interimplant femoral fracture. Notably, osteoporosis therapy emerges as a protective factor against these fractures.

Comparing outcomes of plate augmentation, nail exchange, and nail exchange with plate augmentation in the treatment of atrophic femoral shaft nonunion after intramedullary nailing: a multicenter retrospective study

INTRODUCTION

Intramedullary (IM) nailing is the treatment of choice for femoral shaft fractures, but nonunion rates have been reported to be as high as 12%. Surgical interventions for nonunion involve exchange nailing or plate augmentation. Recently, a combined treatment of exchange nailing and plate augmentation has demonstrated good results, but its comparative effectiveness remains unclear. This study aimed to compare the clinical and radiographic outcomes of three different surgical interventions for atrophic femoral shaft nonunion, and investigate the factors that affect bone healing after reoperation.

MATERIALS AND METHODS

A retrospective study was conducted at five university hospitals involving 149 patients with aseptic atrophic nonunion after IM nailing. These patients underwent reoperation with plate augmentation, exchange nailing, or combined treatment. Clinical and radiographic outcomes were assessed and compared according to reoperation procedure. Logistic regression analysis was performed to identify factors affecting persistent nonunion after reoperation.

RESULTS

Of the cohort, 57 patients underwent plate augmentation, 64 underwent exchange nailing, and 28 received combined treatment. There were no significant differences in patient demographics among the groups. Exchange nailing produced a significantly lower union rate than did the combined treatment (82.8% vs. 100%, p = 0.016), whereas no significant difference was observed in the union rate and time to the union between plate augmentation and the combined treatment. Combined treatment showed the longest operative time and the greatest transfusion requirements. The risk factors for persistent nonunion included age, absence of autogenous bone grafts, and use of an exchange nailing technique.

CONCLUSIONS

Exchange nailing as a treatment for atrophic femoral shaft nonunion after IM nailing resulted in a lower union rate. The efficacy of the combined treatment requires further study, and persistent nonunion may be influenced by age, bone grafting, and surgical techniques. A comprehensive approach targeting both biological environment and mechanical stability is crucial in the treatment of atrophic femoral shaft nonunion.

Low rate of periprosthetic femoral fracture with the Hueter anterior approach using stems cemented according to the 'French paradox'

Aims

The aim of this retrospective study was to assess the incidence of early periprosthetic femoral fracture (PFF) associated with Charnley-Kerboull (CK) femoral components cemented according to the 'French paradox' principles through the Hueter anterior approach (HAA) in patients older than 70 years.

Methods

From a prospectively collected database, all short CK femoral components implanted consecutively from January 2018 to May 2022 through the HAA in patients older than 70 years were included. Exclusion criteria were age below 70 years, use of cementless femoral component, and approaches other than the HAA. A total of 416 short CK prostheses used by 25 surgeons with various levels of experience were included. All patients had a minimum of one-year follow-up, with a mean of 2.6 years (SD 1.1). The mean age was 77.4 years (70 to 95) and the mean BMI was 25.3 kg/m2 (18.4 to 43). Femoral anatomy was classified according to Dorr. The measured parameters included canal flare index, morphological cortical index, canal-calcar ratio, ilium-ischial ratio, and anterior superior iliac spine to greater trochanter (GT) distance.

Results

Among the 416 THAs, two PFFs (0.48% (95% confidence interval 0.13 to 1.74)) were observed, including one Vancouver type B2 fracture 24 days postoperatively and one intraoperative Vancouver type B1 fracture. Valgus malalignment and higher canal bone ratio were found to be associated with PFF.

Conclusion

This study demonstrated that short CK femoral components cemented according to the French paradox were associated with a low rate of early PFF (0.48%) in patients aged over 70 years. Longer follow-up is warranted to further evaluate the rate of fracture that may occur during the bone remodelling process and with time.

Results of a simple treatment protocol for aseptic femoral shaft nonunion in 330 patients

INTRODUCTION

Our primary aim of the study was to assess the results of a treatment protocol for aseptic femoral shaft nonunion treated by three techniques - Exchange Nailing (EN), Plate Augmentation (PA), and Exchange Nailing combined with Plate augmentation (NP). The secondary objective was to assess the radiological outcome, duration of surgery (DOS) and need for blood transfusion (BT) in all the three groups.

MATERIALS AND METHODS

We analyzed 330 patients treated for AFNU between Jan 2007 and Dec 2019. Using a simple treatment algorithm, EN, PA and NP were performed in 24,183 and 123 patients respectively. Patients in all the three groups were assessed for radiological-union (union rate and time to union), DOS and BT.

RESULTS

Of these 330 patients, 327 (99 %) patients achieved radiological union at a mean duration of 6.07 months. Union rate is highest with NP followed by PA and EN. The union rate in patients with NP, PA and EN were 100 %, 99.5 % and 91.7 % respectively (p < 0.01). Time to union was lowest for NP followed by PA and EN (p < 0.001).The mean time to union for NP, PA and EN were 3.76, 7.2and 9.21 months respectively (p < 0.001). The mean DOS in minutes for NP, EN and PA was 107, 94 and 82 respectively (p < 0.01). The mean need for BT in the form of packed red blood cells for NP, PA and EN were 1.95, 1.87 and 1.38 units respectively (p < 0.01).

CONCLUSION

Following a simple algorithm to decide treatment protocol on a case-to case basis helps to achieve good results in an optimal time period. When compared with EN and PA, NP is associated with 100 % union rate with least time to union making NP a reasonably effective procedure with a very high success rate.

LEVEL OF EVIDENCE

IV.

Geriatric distal femoral fractures: post-operative complications and nine-year mortality-a retrospective analysis of two tertiary trauma centres

PURPOSE

This study aimed to estimate the mortality at various post-operative intervals and explore influential variables for these outcomes in elderly patients with distal femur fractures (DFF).

METHODS

A retrospective observational study was conducted across two tertiary care institutions, between 2014 and 2020. The primary outcomes were mortality rates at 30-day, six month, and one year post-surgery. Secondary outcomes included 1-year readmission and reintervention rates along with their correlated complications.

RESULTS

A total of 37 DFF in 35 patients was analyzed; average age was 83.6 years (range, 65-98 years). The overall mortality rate at a maximum follow-up of 8.8 years was 74% (26/35 patients). The median survival time was 3.2 years and the survival probability at five years was 27% (95% confidence interval [CI], 13 to 43%). Mortality rates at 30 days, six months, and one year after surgery were 8.6% (3 patients), 23% (8 patients), and 34% (12 patients), respectively. Overall mortality rate was 64% (15/24 patients) for native distal femur fractures, and 92% (13/14 patients) for periprosthetic fractures (p = 0.109). Patients older than 85 years and male gender were identified as risk factors for mortality within the first year post-operatively.

CONCLUSION

Elderly fractures have a high mortality at eight years of follow-up. Mortality at one year was much higher than in other studies of the same nature. We did not find statistically significant differences when comparing native bone fractures with periprosthetic fractures. Factors that impact mortality were being a man, advanced age, elevated index comorbidity, and dementia. There is no relationship between the time to be taken to the surgical procedure and mortality results.

Immediate weightbearing is safe after revision total hip arthroplasty for Vancouver B2/B3 periprosthetic femur fractures

INTRODUCTION

Modular fluted, tapered stems provide a reliable treatment for Vancouver B2/B3 fractures. Historically, these patients had weightbearing restrictions postoperatively. Although full immediate postoperative weightbearing may provide benefits in this patient population, stem subsidence is a concern.

QUESTIONS/PURPOSES

The objective of this study was to investigate the effect of post-operative weight-bearing status on stem subsidence in patients treated with modular tapered stems for Vancouver B2 and B3 periprosthetic fractures. We sought to answer two questions: (1) Does full immediate postoperative weightbearing after revision total hip arthroplasty for periprosthetic femur fracture lead to increased stem subsidence compared to protected weightbearing? (2) Is there a mortality difference between these two groups of patients with different weightbearing restrictions?

METHODS

From 2009 to 2015 all patients who underwent revision for Vancouver B2/B3 fractures were made non-weightbearing (NWB) for six weeks postoperatively. After 2015, immediate weightbearing as tolerated (WBAT) was allowed postoperatively. We compared stem subsidence between immediate postoperative and final radiographs. Additionally, we performed a Kaplan-Meijer analysis with one-year mortality as an endpoint.

RESULTS

The final cohort included forty-seven patients with an average follow-up of 254 days. The average stem subsidence was 1.0 mm (95 % CI, 0.5-1.5 mm) in the NWB cohort and 0.3 mm (95 % CI, 0-0.7 mm) in the WBAT cohort (P = 0.10). In our survivorship analysis, we noted no deaths in the WBAT cohort compared to 17 % mortality in the NWB cohort at the one-year timepoint.

CONCLUSION

Allowing patients to weight bear immediately after revision does not increase stem subsidence. Further studies are needed to determine whether early weightbearing provides a mortality benefit.

Fewer native and periprosthetic femoral fracture patients receive an orthogeriatric review and expedited surgery compared to hip fracture patients

INTRODUCTION

Disproportionate emphasis has been attributed to hip fracture over other femoral fractures through implementation of Best Practice Tariff (BPT).This retrospective comparative observational cohort study aimed to evaluate the epidemiology of native and periprosthetic femoral fractures and establish any disparities in their management relative to hip fractures.

METHODS

All patients ⩾60 years admitted with a native or periprosthetic femoral fracture during July 2016-June 2018 were identified using our hospital database. Results were compared to National Hip Fracture Database data over the same period.

RESULTS

58 native femoral, 87 periprosthetic and 1032 hip fractures were identified. (46/58) 79% and 76/87 (89%) of native and periprosthetic femoral fractures were managed operatively. Surgery was performed <36 hours for 34/46 (74%) of native femoral and 33/76 (43%) of periprosthetic fractures compared to 826/1032 (80%) for hips. Median time to surgery was longer in periprosthetic femoral than hip fracture patients (44.7 vs. 21.6 hours; p < 0.0001). Orthogeriatrician review occurred in 24/58 (41%) and 48/87 (55%) of native and periprosthetic fractures compared to 1017/1032 (99%) for hips (p < 0.0001). One year mortality was 35%, 20% and 26% for native femoral, periprosthetic and hip fracture patients. Cox proportional hazard ratio was higher for native femoral than hip fracture patients (1.75; 95% CI, 1.12-2.73).

CONCLUSIONS

This study demonstrates large disparities in management of other femoral and periprosthetic fractures compared to hip fractures, specifically time to surgery and orthogeriatrician review. This may have resulted in the comparatively higher mortality rate of native femoral fracture patients. Expansion of the BPT to include the whole femur is likely to improve outcomes.

Changing practice to a new-generation triple-taper collared femoral component reduces periprosthetic fracture rates after primary total hip arthroplasty

Aims

Periprosthetic femoral fracture (PPF) is a major complication following total hip arthroplasty (THA). Uncemented femoral components are widely preferred in primary THA, but are associated with higher PPF risk than cemented components. Collared components have reduced PPF rates following uncemented primary THA compared to collarless components, while maintaining similar prosthetic designs. The purpose of this study was to analyze PPF rate between collarless and collared component designs in a consecutive cohort of posterior approach THAs performed by two high-volume surgeons.

Methods

This retrospective series included 1,888 uncemented primary THAs using the posterior approach performed by two surgeons (PKS, JMV) from January 2016 to December 2022. Both surgeons switched from collarless to collared components in mid-2020, which was the only change in surgical practice. Data related to component design, PPF rate, and requirement for revision surgery were collected. A total of 1,123 patients (59.5%) received a collarless femoral component and 765 (40.5%) received a collared component. PPFs were identified using medical records and radiological imaging. Fracture rates between collared and collarless components were analyzed. Power analysis confirmed 80% power of the sample to detect a significant difference in PPF rates, and a Fisher's exact test was performed to determine an association between collared and collarless component use on PPF rates.

Results

Overall, 17 PPFs occurred (0.9%). There were 16 fractures out of 1,123 collarless femoral components (1.42%) and one fracture out of 765 collared components (0.13%; p = 0.002). The majority of fractures (n = 14; 82.4%) occurred within 90 days of primary THA. There were ten reoperations for PPF with collarless components (0.89%) and one reoperation with a collared component (0.13%; p = 0.034).

Conclusion

Collared femoral components were associated with significant decreases in PPF rate and reoperation rate for PPF compared to collarless components in uncemented primary THA. Future studies should investigate whether new-generation collared components reduce PPF rates with longer-term follow-up.

Comparison of radiological and functional results in osteoporotic distal femur fractures operated with single plating, lateral incision, and double plating, anterior paramedial incision: A retrospective study

Treatment of osteoporotic distal femur fractures is often complicated by a high rate of nonunion and varus collapse. For such fractures, lateral plating with lateral incision and double plating with anterior paramedial incision have shown promising results in the recent literature. The hypothesis of this study was that bilateral plating of comminuted distal femur fractures in osteoporotic patients would result in higher union rates and lower revision rates compared to an isolated lateral locking plate. The study included 56 patients (23 males, 33 females) with supracondylar femur fracture. According to the OA/OTA classification, 9 were type A3, 8 were A2, 13 were C1, 16 were C2, and 10 were C3. The mean follow-up period was 12 months, with 29 patients treated using lateral mini-incision, lateral locking plate, and 27 patients treated with anterior paramedial incision, dual plating. The clinical and radiological results were evaluated. The mean duration of radiological union in the studied population was 15 ± 2.1 months (range, 11-21 months) in the single plate group (Group A), and 13.5 ± 2.6 months (range, 9-19 months) in the double plate group (Group B). Mean ROM was 112.3° and flexion contracture 4° in Group A, and ROM 108.3° and flexion contracture 6.7° in Group B. (P = .15). The average Western Ontario and McMaster Universities Arthritis Index (WOMAC) score was 85.6 points in Group A and 83.5 points in Group B (P = .2278). The postoperative anteversion measurement in the operated extremity ranged from -15 to 19 in Group A, and from 5 to 18 in Group B. When the anteversion degrees were compared between the injured and uninjured extremities in the postoperative period, a significant difference was observed within Group A (P = .0018), but no significant difference was observed in Group B (P = .2492). Dual plate fixation using the anterior paramedial approach is an effective operative method for osteoporotic distal femur fractures. This has many advantages such as precise exposure, easy manipulation, anatomic reduction, and stable fixation. However, for surgical indications and medial bone defects > 1 cm, grafting should be performed.

Periprosthetic femoral fractures

The incidence of periprosthetic femoral fractures is rising in the UK, because of an ageing population and an increasing number of hip arthroplasty operations being performed. They can occur intra- or postoperatively, and usually follow low energy trauma. They present with pain, swelling over the thigh, and an inability to weight bear. Periprosthetic femoral fractures are usually classified as per the unified classification system. Their management usually is dependent on their classification, with type A (fracture at level of greater or lesser trochanter) managed non-operatively with protected weight bearing, type B (fracture adjacent to implant) managed with either open reduction internal fixation or revision surgery, and type C (fracture distal to implant) managed with open reduction internal fixation. Owing to their complexity, these patients must be adequately optimised before surgery and appropriately rehabilitated.

Comparing pediatric femoral shaft fracture repair patient outcomes between pediatric and non-pediatric orthopedic surgeons

INTRODUCTION

While pediatric femoral shaft fractures account for less than 2% of all fractures in children, they are the most common pediatric fracture requiring hospitalization. Management of pediatric femoral shaft fractures is challenging, with various treatment options relating to severity and patient age. The last few decades have seen an increased supply of pediatric orthopedic surgeons (POS) along with increased referral rates. However, there continues to be a maldistribution of POS throughout the country. This study sought to determine outcomes following femoral shaft fracture repair by POS compared to non-pediatric trained orthopedic surgeons.

METHODS

The National Surgical Quality Improvement Program-Pediatric database was queried to identify pediatric patients who underwent open treatment of femoral shaft fracture from 2012 to 2019. Differences in patient demographics, comorbidities, and postoperative complications were assessed and compared between patients who were treated by pediatric subspecialty-trained orthopedic surgeons and those treated by non-pediatric orthopedic surgeons. Bivariate and multivariable regression analyses were utilized.

RESULTS

Of the 5862 pediatric patients who underwent femoral shaft fracture treatment, 4875 (83.2%) had their surgeries performed by a POS whereas 987 (16.8%) were operated on by a non-pediatric surgeon. POS were more likely to operate on patients with a higher American Society of Anesthesiologists classification (p < 0.001) and those with medical comorbidities, including gastrointestinal (p = 0.022) and neurological (p < 0.001). After controlling for baseline patient characteristics on multivariable regression analysis, patients treated by non-pediatric orthopaedic surgeons are at an increased risk of prolonged hospital stay (OR 2.595; p < 0.001) when compared to patients operated on by POS.

CONCLUSION

The results indicated that patients undergoing surgical treatment for a femoral shaft fracture by a non-pediatric trained orthopedic surgeon were at increased risk of a prolonged hospital stay compared to those being treated by POS. Additionally, POS were more likely to operate on more difficult patients with increased comorbidities.

Perioperative periprosthetic femur fracture associated with direct anterior total hip arthroplasty using metaphyseal fit and fill stem

INTRODUCTION

This study aims to identify radiographic and clinical risk factors of perioperative periprosthetic femur fracture associated with the direct anterior approach (DAA) using a metaphyseal fit and fill stem. We hypothesize stem malalignment with this femoral implant places increased stress on the medial calcar region, which leads to an increased risk of periprosthetic fracture.

METHODS

We compared patients with periprosthetic femur fractures following DAA total hip arthroplasty (THA) utilizing the Echo Bi-Metric Microplasty Stem (Zimmer Biomet, Warsaw, IN) to a cohort of patients who did not sustain a periprosthetic fracture from five orthopedic surgeons over four years. Postoperative radiographs were evaluated for stem alignment, neck cut level, Dorr classification, and the presence of radiographic pannus. Univariate and logistic regression analyses were performed. Demographic and categorical variables were also analyzed.

RESULTS

Fourteen hips sustained femur fractures, including nine Vancouver B2 and five AG fractures. Valgus stem malalignment, proud stems, extended offset, and patients with enlarged radiographic pannus reached statistical significance for increased fracture risk. Low femoral neck cut showed a trend toward statistical significance.

CONCLUSION

Patients undergoing DAA THA using a metaphyseal fit and fill stem may be at increased risk of perioperative periprosthetic fracture when the femoral stem sits proudly in valgus malalignment with extended offset and when an enlarged pannus is seen radiographically. This study identifies a specific pattern in the Vancouver B2 fracture cohort with regard to injury mechanism, time of injury, and fracture pattern, which may be attributed to coronal malalignment of the implant.

Incidences and Outcomes of Operatively Treated Interprosthetic Femoral Fractures Compared to Vancouver Type C and Rorabeck Type II Fractures

BACKGROUND

This case-control study evaluated the incidences and outcomes of interprosthetic femoral fracture (IPFF) (Group I) and performed comparisons with Vancouver type C (Group II) and Rorabeck type II (Group III) periprosthetic femoral fractures (PPFF) occurring at similar anatomic sites.

METHODS

A retrospective analysis was performed for all patients who had a previously implanted total hip arthroplasty (THA) and total knee arthroplasty (TKA), who lived in the hospital district and had undergone surgery due to PPFF. A total of 153 PPFFs [Group I (n = 31), Group II (n = 21), and Group III (n = 108)] were included. The annual incidences of PPFFs were summarized per 100,000 individuals. The risks of complications, reoperations, and mortalities were evaluated for all groups.

RESULTS

The mean population-based annual incidence was 0.9 per 100,000 person years for Group I, 0.7 per 100,000 person years for Group II, and 3.1 per 100,000 person years for Group III. A total of 25 of 153 (16%) major complications were found and 23 of 153 (13%) cases resulted in a revision surgery. The cumulative incidence of death in Group I was 50.4% at 10 years, in Group II it was 63.8% at 10 years, and in Group III it was 74.9% at 10 years.

CONCLUSION

The annual incidence of the IPFF almost doubled while the incidence of Vancouver type C stayed stable and Rorabeck type II incidence increased 5-fold. Most of the major complications occurred in IPFF group, while Rorabeck type II patients had the worst survival.

Characteristics of Femoral Shaft Fractures That Predict Ipsilateral Femoral Neck Fractures

INTRODUCTION

This study aims to characterize radiographic features and fracture characteristics in femoral shaft fractures with associated femoral neck fractures, with the goal of establishing predictive indicators for the presence of ipsilateral femoral neck fractures (IFNFs).

METHODS

A retrospective cohort was collected from the electronic medical record of three level I trauma centers over a 5-year period (2017 to 2022) by current procedural terminology (CPT) codes. Current CPT codes for combined femoral shaft and IFNFs were identified to generate our study group. CPT codes for isolated femur fractures were identified to generate a control group.

RESULTS

One hundred forty patients comprised our IFNF cohort, and 280 comprised the control cohort. On univariate, there were significant differences in mechanism of injury (P < 0.001), Orthopedic Trauma Association (OTA)/Arbeitsgemeinshaft fur Osteosynthesefragen (AO) classification (P = 0.002), and fracture location (P < 0.001) between cohorts. On multivariate, motor vehicle crashes were more commonly associated with IFNFs compared with other mechanism of injuries. OTA/AO 32A fractures were more commonly associated with IFNFs when compared with OTA/AO 32B fractures (adjusted odds ratio = 0.36, P < 0.001). Fractures through the isthmus were significantly more commonly associated with IFNFs than fractures more proximal (adjusted odds ratio = 2.52, P = 0.011).

DISCUSSION

Detecting IFNFs in femoral shaft fractures is challenging. Motor vehicle crashes and motorcycle collisions, OTA/AO type 32A fractures, and isthmus fractures are predictive of IFNFs.

Intramedullary Nailing of Intertrochanteric Femoral Fractures in a Level I Trauma Center in Finland: What Complications Can be Expected?

BACKGROUND

Intertrochanteric hip fractures are one of the most common fractures in older people, and the number is estimated to increase. These fractures are often treated with intramedullary nailing; however, various complications have been reported. It is important to identify the potential complications and investigate whether the choice of implant and patient-related factors are associated with the risk of complications to develop better strategies for preventing them.

QUESTIONS/PURPOSES

(1) In the treatment of intertrochanteric fractures with intramedullary nailing, what are the risks of major complications and 30-day mortality? (2) Which implant types are associated with greater odds of major complications? (3) Which patient-related factors are associated with increased odds of major complications?

METHODS

In this retrospective, comparative study, we reviewed the health records of 2397 patients with a femoral fracture treated at one Level I trauma center between January 2014 and November 2020. Of those, we considered patients who were treated with intramedullary nailing for an intertrochanteric fracture after sustaining a low-energy injury as potentially eligible. Based on this criterion, 53% (1279) were eligible; a further 47% (1118) were excluded because the fixation method was other than intramedullary nailing, the fracture pattern was other than intertrochanteric fracture, or the fracture was caused by a high-energy injury mechanism. Another 4% (97) were excluded because they had incomplete datasets because of follow-up less than 12 months, leaving 49% (1182) for analysis. During the study period, intramedullary nails were generally used to treat nearly all intertrochanteric fractures at our hospital. The risk of complications was then assessed by chart review. Acute myocardial ischemia, cutout, nail breakage, pulmonary embolism, sepsis, stroke, and wound infection were defined as major complications. Cutout, nail breakage, and wound infection were defined as major complications leading to reoperation. To examine the association of implant type and major complications, a logistic regression analysis was performed. Additionally, the risks of major complications leading to reoperation were compared between implants. Finally, a univariable logistic regression analysis was performed to examine the association between patient-related factors and major complications.

RESULTS

The overall proportion of patients experiencing complications was 16% (183 of 1182), and the crude percentage of 30-day mortality was 9% (107 of 1182) based on the hospital`s medical records. After controlling for patient-related factors such as disease, age, and smoking, we found that nail type was not associated with odds of major complications leading to reoperation (Gamma3: OR 0.86 [95% CI 0.44 to 1.67]; p = 0.67; Trochanteric Fixation Nail: OR 0.61 [95% CI 0.2 to 1.53]; p = 0.33; Proximal Femoral Nail Antirotation: OR 0.55 [95% CI 0.16 to 1.49]; p = 0.29) compared with the Trochanteric Fixation Nail Advanced. Anticoagulation (OR 1.70 [95% CI 1.11 to 2.59]; p = 0.01), congestive heart failure (OR 1.91 [95% CI 1.13 to 3.11]; p = 0.01), and hypertension (OR 1.67 [95% CI 1.08 to 2.63]; p = 0.02) were associated with a major complication. Liver disease (OR 5.19 [95% CI 0.78 to 20.8]; p = 0.04) was associated with a major complication leading to reoperation.

CONCLUSION

This study provides a better understanding of the occurrence of surgical and medical complications after intramedullary nailing of intertrochanteric fractures. The new-generation nail types are comparable options based on the risk of reoperation. Anticoagulation, congestive heart failure, and hypertension were associated with major complications, highlighting the need for careful management and monitoring of these comorbidities during intramedullary nailing procedures.Level of Evidence Level III, therapeutic study.

Dynamic hip screw in proximal femoral fractures followed by "single-stage" hip arthroplasty-retrospective analysis

The aim of this study is to present the results of single-stage total hip arthroplasty (THA) after Dynamic Hip Screw (DHS) failure, or secondary posttraumatic osteoarthrosis. From 2003 to 2020, 15 THAs were performed in group of 15 patients for the treatment of DHS failure, or for late complications following femoral neck and pertrochanteric fractures. The mean follow-up period after arthroplasty was 46.9 months (range 7-139). The patients were evaluated retrospectively-both clinically and radiographically, focussing on the demography, infection rate and other complications (revision surgery), during the year 2023. 9 males and 6 females were included in the study, with a mean age of 56.5 years (range 29-93) at the time of primary osteosynthesis. Each of them had proximal femoral fracture treated primarily with a DHS and then late one-stage revision surgery, with hardware removal and THA implantation. The median time between DHS osteosynthesis and THA was 41.2 months (range 4-114). Four patients (26.6%) had complications after THA, with the need for revision in two cases (13.3%). Dislocation rate was 6.6% (one case), with the need for repeated-revision of THA. The infection rate was 6.6% (one patient) with the need for revision of THA. Peroperative periprosthetic femoral fracture was observed in 13.3% (two patients) without any other problems. Six patients (40%) died during the follow-up period. Single-stage total hip arthroplasty with concomitant hardware removal bears a high- mortality rate, with a higher incidence of postoperative complications compared to elective THA.

Retrograde Intramedullary Nailing Versus Locked Plating for Extreme Distal Periprosthetic Femur Fractures: A Multicenter Retrospective Cohort Study

OBJECTIVES

To compare clinical and radiographic outcomes after retrograde intramedullary nailing (rIMN) versus locked plating (LP) of "extreme distal" periprosthetic femur fractures, defined as those that contact or extend distal to the anterior flange.

METHODS

DESIGN

Retrospective review.

SETTING

Eight academic level I trauma centers.

PATIENT SELECTION CRITERIA

Adult patients with periprosthetic distal femur fractures at or distal to the anterior flange (OTA/AO 33B-C[VB1]) treated with rIMN or LP.

OUTCOME MEASURES AND COMPARISONS

The primary outcome was reoperation to promote healing or to treat infection (reoperation for elective removal of symptomatic hardware was excluded from this analysis). Secondary outcomes included nonunion, delayed union, fixation failure, infection, overall reoperation rate, distal femoral alignment, and ambulatory status at final follow-up. Outcomes were compared between patients treated with rIMN or LP.

RESULTS

Seventy-one patients treated with rIMN and 224 patients treated with LP were included. The rIMN group had fewer points of fixation in the distal segment (rIMN: 3.5 ± 1.1 vs. LP: 6.0 ± 1.1, P < 0.001) and more patients who were allowed to weight-bear as tolerated immediately postoperatively (rIMN: 45%; LP: 9%, P < 0.01). Reoperation to promote union and/or treat infection was 8% in the rIMN group and 16% in the LP group ( P = 0.122). There were no significant differences in nonunion ( P > 0.999), delayed union ( P = 0.079), fixation failure ( P > 0.999), infection ( P = 0.084), or overall reoperation rate ( P > 0.999). Significantly more patients in the rIMN group were ambulatory without assistive devices at final follow-up (rIMN: 35%, LP: 18%, P = 0.008).

CONCLUSIONS

rIMN of extreme distal periprosthetic femur fractures has similar complication rates compared with LP, with a possible advantage of earlier return to weight-bearing. Surgeons can consider this treatment strategy in all fractures with stable implants and amenable prosthesis geometry, even extreme distal fractures.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Femoral Shaft Fracture Developed Late-Onset Infection in 27 Years after Intramedullary Nailing: A Case Report

Postoperative late-onset infections more than 1 year after intramedullary nail surgery for femoral shaft fractures are very rare. We show an extremely rare case of developed late-onset infection 27 years after surgery, report on risk factors for late-onset infection, and infer why the infection occurred.

Adequate bone healing after supplementary fixation of periprosthetic total knee arthroplasty fractures using Luque cerclage wiring: a retrospective case series

PURPOSE

Cerclage wiring is a well-known supplemental fixation technique that can be used in many types of fractures. With the tendency toward minimally invasive approaches in the management of periprosthetic total knee arthroplasty (TKA) fractures, and with absence of a dedicated study that reports the results of cerclage wiring in TKA fractures in particular, the aim of this retrospective study is to report the outcomes of supplementary cerclage wiring using simple Luque wires in fractures of distal femur associated with TKA.

METHOD

Eighteen cases, with a mean age of 77.2 years had complete follow-up data and had their radiographs and clinical data assessed for this study. Patients received cerclage wiring along with plates, retrograde nailing or around cracked femoral shaft overlying revision TKA femoral stem during the surgical management of periprosthetic TKA distal femur fractures.

RESULTS

Fracture healing with adequate callus formation occurred in all 18 cases at a mean of 11.4 weeks postoperatively. None of the cases had any vascular injury, and after a mean clinical follow-up of 51 weeks, none of the cases had nonunion or hardware complications. One case had postoperative periprosthetic infection that developed 8 months after full fracture healing and had a two-stage revision using revision stemmed TKA and protective cerclage wiring with successful eradication of infection.

CONCLUSION

Supplementary cerclage wiring in distal femur TKA fractures can aid in enhanced bone healing with minimal complications, provided that adequate reduction and rigid fixation were achieved. This study reflects the level of evidence IV.

Fixation Strategies for Periprosthetic Fractures With Stable Implants

The fixation of periprosthetic fractures remains challenging and controversial. It is important to achieve consensus opinions regarding the management of stable periprosthetic fractures with internal fixation. Key strategies to optimize surgical decision making and fixation and manage complications following these difficult injuries are addressed.

Technical Factors Contributing to Nonunion in Supracondylar Distal Femur Fractures Treated With Lateral Locked Plating: A Risk-Stratified Analysis

OBJECTIVE

To identify technical factors associated with nonunion after operative treatment with lateral locked plating.

METHODS

DESIGN

Retrospective cohort study.

SETTING

Ten Level I trauma centers.

PATIENT SELECTION CRITERIA

Adult patients with supracondylar distal femur fractures (OTA/AO type 33A or C) treated with lateral locked plating from 2010 through 2019.

OUTCOME MEASURES AND COMPARISONS

Surgery for nonunion stratified by risk for nonunion.

RESULTS

The cohort included 615 patients with supracondylar distal femur fractures. The median patient age was 61 years old (interquartile range: 46 -72years) and 375 (61%) were female. Observed were nonunion rates of 2% in a low risk of nonunion group (n = 129), 4% in a medium-risk group (n = 333), and 14% in a high-risk group (n = 153). Varus malreduction with an anatomic lateral distal femoral angle greater than 84 degrees, was associated with double the odds of nonunion compared to those without such varus [odds ratio, 2.1; 95% confidence interval (CI), 1.1-4.2; P = 0.03]. Malreduction by medial translation of the articular block increased the odds of nonunion, with 30% increased odds per 4 mm of medial translation (95% CI, 1.0-1.6; P = 0.03). Working length increased the odds of nonunion in the medium risk group, with an 18% increase in nonunion per 10-mm increase in working length (95% CI, 1.0-1.4; P = 0.01). Increased proximal screw density was protective against nonunion (odds ratio, 0.71; 95% CI, 0.53-0.92; P = 0.02) but yielded lower mRUST scores with each 0.1 increase in screw density associated with a 0.4-point lower mRUST (95% CI, -0.55 to -0.15; P < 0.001). Lateral plate length and type of plate material were not associated with nonunion. ( P > 0.05).

CONCLUSIONS

Malreduction is a surgeon-controlled variable associated with nonunion after lateral locked plating of supracondylar distal femur fractures. Longer working lengths were associated with nonunion, suggesting that bridge plating may be less likely to succeed for longer fractures.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Unfavorable cortical hypertrophy potentially predisposes to periprosthetic "axe splitter" fracture in a collarless polished curved triple-tapered cemented stem: The time-dependent radiographic change in five SC-stem cases

BACKGROUND

The periprosthetic fracture of cemented polished tapered stems is occasionally called a "unique" or "axe splitter" fracture. However, there has been insufficient evidence regarding the association between the radiographic findings prior to incidence and this cumbersome fracture. To determine if there are any radiographic interpretations associated with this fracture pattern, we report the five SC-stem cases with total hip arthroplasty.

METHODS

We investigate the patient characteristics and serial radiographs of five fracture cases and evaluate the time-dependent specific radiographical changes around the stem between pre-arthroplasty and fracture.

RESULTS

Fractures developed at 3.5-6.4 years after surgery with low-grade injury or with no particular incentive. Femoral cortical hypertrophy at the distal medial side around the stem was observed in all cases before the development of fractures, at 2-6 years after primary surgery. The duration between cortical hypertrophy appearance to the development of fracture was 0.4-3.1 years.

CONCLUSIONS

The appearance of this zone-specific cortical hypertrophy might play a key role in the occurrence of periprosthetic fractures. Further studies with larger sample sizes should be conducted to elucidate this eccentric periprosthetic fracture.

Locking plate for periprosthetic femoral fractures according to Vancouver C: Outcome and radiological subanalysis of 40 patients

PURPOSE

Periprosthetic femoral fractures (PFF) according to type Vancouver C are less common and outcome is limited reported. Therefore, we conducted this retrospective single center study.

METHODS

We performed analysis of patients who underwent open reduction and internal fixation (ORIF) with locking plates for PPF occurring distally of a primary standard hip stem. Data on demographics, revisions, fracture patterns, and mortality were evaluated. At least two years after operation, we examined outcome using the Parker and Palmer mobility score. Primary aim of this study was revision, outcome and mortality. Secondary aim was evaluation of fracture subtypes within type Vancouver C fractures.

RESULTS

Between 2008 and 2020, 383 patients with periprosthetic femoral fracture after hip replacement were surgically treated according to our database. Among them, 40 patients (10.4%) with type Vancouver C fractures were enrolled for this study. The mean patient age was 81.5 years (59-94) at the time of fracture. Thirty-three patients were women, and 22 fractures were on the left side. Without exception, locking plates were used. The 1-year mortality rate for the sample was 27.5% (n = 11). Three revisions (7.5%) were performed for plate breakage. Rate of infection and non-union was zero. Three different fracture patterns were assessed: (1) transverse or oblique fractures below the tip of the stem (n = 9); (2) spiral-shaped fractures within the diaphysis (n = 19); and (3) burst fractures at the supracondylar region (n = 12). Demographic or outcome effects between fracture patterns were not found. On average of 4.2 years (2.0-10.4) after treatment, the mean reported Parker score was 5.5 (1-9).

CONCLUSION

ORIF with a single lateral locking plate is safe for type Vancouver C fractures with a well-fixed hip stem. Therefore, we do not recommend routinely revision arthroplasty or orthogonal double plating. Three subtypes of fractures within Vancouver C demonstrated no significant differences in baseline data and outcome.

A high risk of postoperative periprosthetic femoral fracture in Dorr type C femurs: a retrospective cohort study with 10-year follow-up data and a preliminary monochromatic image analysis

BACKGROUND

The authors applied Anatomique Benoist Girard II (ABG II) stems for total hip arthroplasty in some Dorr type C femurs as early attempts. Here, the authors compared the long-term follow-up results between ABG II stems and the 'well-performing' Corail stems and their monochromatic images.

METHODS

Among 3214 primary total hip arthroplasty records, 43 short ABG II stems and 67 standard-length Corail stems implanted in Dorr type C femurs were eligible and enrolled in this retrospective cohort study, with a mean follow-up of 10.3 years. Revision rates, Harris hip scores, and radiologic signs were compared. Spectral CT scans from a representative sample were obtained, and monochromatic images were reconstructed. A quantitative method was developed to measure the volume of the gap around stems. Patient-specific finite element analysis was conducted to investigate the strains.

RESULTS

The revision rate of ABG II stems was significantly higher than that of Corail stems (21 vs. 3%, P <0.05). In the monochromatic images, fewer spot-weld signs (2.2 vs. 3.4, P <0.05) and wider gaps around stems (1.64 cm 3 vs. 0.13 cm 3 , P <0.05) were observed on average in the ABG II group. The mean maximum principal strains of the proximal femurs in the ABG II group were close to the yield strains and significantly larger than those in the Corail group (0.0052 vs. 0.0011, P <0.05).

CONCLUSIONS

There was a high risk of postoperative periprosthetic femoral fracture for ABG II stems in Dorr type C femurs. Monochromatic images provided some insight into the failure mechanism.

LEVEL OF EVIDENCE

III.

Dual Plate Fixation of Periprosthetic Distal Femur Fractures

OBJECTIVES

Dual implants for distal femur periprosthetic fractures is a growing area of interest for these challenging fractures with dual plating (DP) emerging as a viable construct for these injuries. In the current study, an experience with DP constructs is described.

METHODS

DESIGN

Retrospective case series with comparison group.

SETTING

Level 1 academic trauma center.

PATIENT SELECTION CRITERIA

Adults >50 years old sustaining comminuted OTA/AO 33-A2 or 33-A3 DFPF treated with either DP or a single distal femur locking plating (DFLP). Patients with simple 33-A1 fractures were excluded. Prior to 2018, patients underwent DFLP after which the treatment of choice became DP.

OUTCOME MEASURES AND COMPARISONS

Reoperation rate, alignment, and complications.

RESULTS

34 patients treated with DFLP and 38 with DP met inclusion and follow up criteria. Average follow up was 18.2 ± 13.8 months in the DFLP group and 19.8 ± 16.1 months in the DP group ( P = 0.339). The average patient age in the DFLP group was 74.8 ± 7.3 years compared to 75.9 ± 11.3 years in the DP group. There were no statistical differences in demographics, fracture morphology, loss of reduction, or reoperation for any cause ( P >.05). DP patients were more likely to be weight bearing in the twelve-week postoperative period ( P <0.001) and return to their baseline ambulatory status ( P = 0.004) compared to DFLP patients.

CONCLUSIONS

Dual plating of distal femoral periprosthetic fractures maintained coronal alignment with a low reoperation rate even with immediate weight bearing and these patients regained baseline level of ambulation more reliably as compared to patients treated with a single distal femoral locking plate.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Systematic Review and Meta-Analysis of Studies Comparing the Rate of Post-operative Periprosthetic Fracture Following Hip Arthroplasty With a Polished Taper Slip versus Composite Beam Stem

BACKGROUND

We compared the incidence of postoperative periprosthetic femoral fractures (POPFF) following hip arthroplasty with either a cemented polished taper slip (PTS) stem or a cemented composite beam (CB) stem in comparative studies.

METHODS

A systematic review of comparative studies, written in English and published in peer-reviewed journals since the year 2000, was conducted. Study quality was assessed using the Newcastle-Ottawa scale.The overall study qualities were good. There were 913,021 patients from 18 cohorts included in the meta-analysis. There were 294,540 patients who received a CB stem and 618,481 received a PTS stem. Cohorts were classified as high- or low-risk for POPFF based on patient risk factors. A metanalysis was performed using a random effects model, and the relative incidence with 95% confidence intervals (CIs) was reported.

RESULTS

The patients at low risk of POPFF had an incidence rate ratio of 3.14 (CI: 2.48, 3.98) for the PTS group versus the CB group. Whereas, the patients at high risk of POPFF had an incidence rate ratio of 9.87 (CI: 3.63, 26.80) for the PTS group versus the CB group.

CONCLUSIONS

The risk of POPFF is lower when hip arthroplasty was performed using a CB stem versus a PTS stem. This protective effect was greatest in patients who had a higher risk of POPFF. Surgeons should consider the effect of cemented stem choice on the risk of subsequent periprosthetic femur fracture, particularly in frail or elderly patients who are at a higher risk of postoperative periprosthetic femoral fracture.

High revision rates and mortality after distal femoral replacement for periprosthetic distal femoral fractures: analysis from the German Arthroplasty Registry (EPRD)

PURPOSE

This study was initiated to analyze the outcome after distal femoral replacement (DFR) for periprosthetic distal femoral fractures (PDFF).

METHODS

Data from the German Arthroplasty Registry (EPRD) were analyzed. A total of 626 patients could be identified with a DFR for PDFF. Mean age was 78.8 years, and 84.2% were female. Revisions and mortality were analyzed and compared with patient groups with a similar procedure (revision total knee arthroplasty) or similar general condition (fracture total hip arthroplasty, hip hemiarthroplasty). Matched-pair-analyses were performed.

RESULTS

Within one year after surgery, 13.2% of the patients had died and further 9.4% were revised. Within four years, 32.7% had died and 19.7% were revised. Revisions were nearly twice as high as in the comparison groups. Periprosthetic infection (PJI) was the most frequent cause for revision, resulting in a PJI rate of 12.8%, which was lower in the comparison groups. Mortality after DFR was as similar high as after fracture hip arthroplasty.

CONCLUSION

PDFF are a serious injury, and the necessary surgical treatment has a high risk of complications. Every third patient after DFR for PDFF had died and every fifth patient needed revision within 4 years after surgery. Efforts should be undertaken to provide optimal treatment to these high-risk patients to reduce unfavorable outcomes.

LEVEL OF EVIDENCE

III.

REGISTRATION OF CLINICAL TRIALS

As this is a registry-derived study of data of the German Arthroplasty Registry (EPRD), no registration was performed.

Subtrochanteric nonunion after intramedullary nailing due to pathological fracture: proximal femoral replacement as a salvage approach

PURPOSE

To assess proximal femoral replacement as a treatment solution for nonunion of pathologic subtrochanteric fractures after cephalomedullary nailing in patients with pathological fracture and previously irradiated bone.

METHODS

Retrospective review of five patients with pathological subtrochanteric femoral fractures that were treated with cephalomedullary nailing and developed a nonunion, which was revised with conversion to a proximal endoprosthetic replacement.

RESULTS

All five patients had previously been treated with radiation. One patient had the latest follow-up at 2 months postoperatively. At that time, the patient was walking with a walker for assistance, with no evidence of hardware failure or loosening on imaging. The remaining four patients had the latest follow-up ranging from 9 to 20 months after surgery. At their latest follow-up, three of the four patients were ambulatory with no pain, using only a cane for assistance with longer distances. The other patient demonstrated pain in his affected thigh, utilizing a walker for assistance with ambulation at latest follow-up, but not requiring further surgical interventions. There were no hardware failures or implant loosening through the follow-up period. None of the patients required revision, and there were no postoperative complications observed at their last follow-up.

CONCLUSIONS

In patients with pathological fractures in the subtrochanteric region that is treated with cephalomedullary nailing and developed a nonunion, treatment with conversion to a proximal femoral replacement with a mega prosthesis is a valuable treatment with good functional results and low risk for complications.

LEVEL OF EVIDENCE

Therapeutic level IV.

Predictive factors for one-year mortality after surgery for periprosthetic femoral fracture: A retrospective multicenter (TRON group) study

BACKGROUND

Periprosthetic femoral fracture (PFF) after total hip arthroplasty (THA) or bipolar hip arthroplasty (BHA) represents a challenging situation and the treatment is associated with high rates of complications and mortality. The aims of this multicenter retrospective study were to determine 1-year mortality and to identify predictors associated with mortality, including patient characteristics and surgical factors, in patients undergoing surgery for PFF after THA or BHA.

METHODS

We collected 249 cases of PPF after THA or BHA that were treated in our 11 hospitals (named the TRON group) between January 2010 and December 2019. We excluded patients who were conservatively treated, cases in which the 1-year postoperative outcome was unknown, and Vancouver type A cases. Finally, we analyzed 161 patients. Univariate and multivariate Cox regression analyses were performed to identify factors affecting 1-year mortality. Patient-side factors such as age, BMI, fracture type, and preoperative mobility, and surgical factors such as surgical procedure, time to surgery, and operation time were analyzed respectively.

RESULTS

Eighteen of 161 patients (11.2%) died one year after surgery. The multivariate Cox regression analysis identified older age, wheelchair status before injury, and operation time as independent predictors of 1-year mortality (older age: hazard ratio [HR] 1.07, 95% CI 1.01-1.15, P = 0.048; wheelchair status: HR 5.82, 95% CI 1.01-33.47, P = 0.049; operation time: [HR] 1.01, 95% CI 1.00-1.01, P = 0.00929). Meanwhile, fracture type according to the Vancouver classification, body mass index, presence of previous fragility fractures, type of fixation, blood loss during operation, and time to surgery were not independent predictors of 1-year mortality in this analysis. ConclusionThe 1-year mortality rate after surgery for PPFs patients was 11.2%. Factors associated with older and poor activity of daily living (ADL) performance (e.g., wheelchair status before injury), and longer operative time were associated with 1-year mortality after surgery for PPF. Surgeons should carefully plan treatment according to each patient's condition.

Cemented femoral stem design and postoperative periprosthetic fracture risk following total hip arthroplasty

Polished taper-slip (PTS) cemented stems have an excellent clinical track record and are the most common stem type used in primary total hip arthroplasty (THA) in the UK. Due to low rates of aseptic loosening, they have largely replaced more traditional composite beam (CB) cemented stems. However, there is now emerging evidence from multiple joint registries that PTS stems are associated with higher rates of postoperative periprosthetic femoral fracture (PFF) compared to their CB stem counterparts. The risk of both intraoperative and postoperative PFF remains greater with uncemented stems compared to either of these cemented stem subtypes. PFF continues to be a devastating complication following primary THA and is associated with high complication and mortality rates. Recent efforts have focused on identifying implant-related risk factors for PFF in order to guide preventative strategies, and therefore the purpose of this article is to present the current evidence on the effect of cemented femoral stem design on the risk of PFF.

Higher Annual Total Hip Arthroplasty Volume Decreases the Risk of Intraoperative Periprosthetic Femur Fractures

BACKGROUND

Periprosthetic femur fracture (PFF) is a complication of total hip arthroplasty (THA). These occur intraoperatively or postoperatively, and documented risk factors of PFFs include women, age greater than 65 years, cementless stems, and inflammatory arthropathies. The aim of this retrospective cohort study was to assess the relationship of years of surgical experience and surgeon annual THA volume on intraoperative and postoperative PFFs.

METHODS

Data were collected from a database query, and PFFs were identified as either intraoperative or postoperative. Intraoperative and postoperative PFFs were both compared to a control group of non-PFF patients. Years of surgical experience at the time of surgery and annual THA volume for the primary surgeon were calculated for all cases. Logistic regression analyses were used to calculate odds ratios for each of the surgeon variables when adjusted for patient demographics.

RESULTS

Thirty-seven intraoperative and 108 postoperative PFFs were identified and compared to 7,629 controls. From regression analyses, high-volume surgeons (≥50 THA/year) had lower odds of intraoperative PFF (adjusted odds ratio (aOR) = 0.40, P = .020) but not postoperative PFF (aOR = 1.02, P = .921). Surgeon experience (≥15 years since board certification at the time of surgery), was not significantly related to either PFF outcomes. For patient factors, age ≥65 years (aOR = 2.30, P < .001) and women (aOR = 2.69, P < .001) were both significant predictors of postoperative PFFs only.

CONCLUSION

Surgeons who performed 50 or more THAs per year had significantly fewer intraoperative PFFs than surgeons who did less than 50 THAs per year. Surgeon experience was not significantly related to PFFs.

Retrograde intramedullary nailing or locked plating for stabilisation of distal femoral fractures? A comparative study of 193 patients

PURPOSE

The aim of this study was to evaluate the results of distal femoral fracture fixation of two different methods, lateral locking plate (LP) or an Intra-medullary nail (IMN), in patients managed in our institution. More specifically, to assess: (a) if there was a difference in functional outcomes between the LP and IMN groups; (b) whether the rate of complications was different between the two groups.

METHODS

Between January 2009 and December 2018 adult patients with distal femoral fractures managed in our unit with either LP or IMN for extra and intra-articular fractures were eligible to participate. Demographic details, fracture type, procedures performed, time to union, complications and functional scores (Oxford Knee Score) were recorded and analysed. The mean follow up was 4 years (12-120 months).

RESULTS

Out of 193 patients who met the inclusion criteria, 93 received an IMN whereas 100 patients were treated with LP. Mean age was 64.2 (18-99) and 70.1 (18-100) for the IMN and LP groups respectively. Overall, the two groups had similar demographics and there was no significant difference in the type of fractures sustained (p > 0.05). The Oxford Knee Score was highest for patients fixed with LP, mean 37.3 (6-48, SD 7.3) versus 28.4 (3-48, SD 14.4), (p =  < 0.02) compared to the IMN group. In terms of complications, the rate of non-union was higher in the LP group 8.6% versus 4% in those patients treated with an IMN, p value < 0.01.

CONCLUSION

While the rate of non-union was higher in the LP group and the functional results were superior in the plating group.

[Periprosthetic fractures-Diagnostics, classification and treatment]

BACKGROUND

Due to the increase in hip and knee prosthetic as a result of the demographic changes, with raised levels of activity among older persons with geriatric comorbidities, a continuous increase in periprosthetic fractures can be observed.

OBJECTIVE

The incidence and causes of periprosthetic fractures, presentation of diagnostic pathways and derivation of a recommendation according to generally accepted classifications.

MATERIAL AND METHOD

Literature search of basic scientific work, recommendations of experts as well as evaluation of own patient collective.

CONCLUSION

With a growing number of prosthetic interventions in combination with increasing patient age, an increase in periprosthetic fractures is to be expected. The treatment of periprosthetic fractures is complex and requires detailed analysis of the location of the fracture and its morphology as well as the recognition of possibly loosened prosthetic material. Based on this information, the correct surgical treatment can be determined and scheduled in an appropriate center of care. In geriatric patients with corresponding comorbidities, an individual holistic treatment plan should be developed.

Intramedullary nailing versus plate compound osteosynthesis in subtrochanteric and diaphyseal pathologic femoral fractures: a retrospective cohort study

PURPOSE

Pathologic fractures of the extremities due to carcinoma metastases require individual and patient prognosis-related stabilization procedures. Quick remobilization of the patient to restore the quality of life is of high importance, especially in the case of subtrochanteric and diaphyseal femoral fractures. In our retrospective cohort study, we evaluated intraoperative blood loss, length of operation, complication rate, and regain of lower extremity function in plate compound osteosynthesis (PCO) versus intramedullary nailing (IM) for subtrochanteric and diaphyseal pathologic fractures of the femur.

METHODS

Between January 2010 and July 2021, we retrospectively reviewed 49 patients who were treated at our institution for pathologic fractures of the subtrochanteric and diaphyseal femurs for group differences in terms of blood loss, length of operation, implant survival, and Musculoskeletal Tumor Society (MSTS) score.

RESULTS

We included 49 stabilization procedures of the lower extremity due to pathologic fractures of the proximal or diaphyseal femur, with a mean follow-up of 17.7 months. IM (n = 29) had a significantly shorter operation time than PCO (n = 20) (112.4 ± 9.4 and 163.3 ± 15.96 min, respectively). We did not detect any significant differences in terms of blood loss, complication rate, implant survival, or MSTS score.

CONCLUSION

Based on our data, pathologic subtrochanteric and diaphyseal fractures of the femur can be stabilized with IM, which has a shorter operation time than PCO, but the complication rate, implant survival, and blood loss remain unaffected.