A Digital Health Intervention Platform (Active and Independent Management System) to Enhance the Rehabilitation Experience for Orthopedic Joint Replacement Patients: Usability Evaluation Study

BACKGROUND

Optimal rehabilitation programs for orthopedic joint replacement patients ensure faster return to function, earlier discharge from hospital, and improved patient satisfaction. Digital health interventions show promise as a supporting tool for re-enablement.

OBJECTIVE

The main goal of this mixed methods study was to examine the usability of the AIMS platform from the perspectives of both patients and clinicians. The aim of this study was to evaluate a re-enablement platform that we have developed that uses a holistic systems approach to address the de-enablement that occurs in hospitalized inpatients, with the older adult population most at risk. The Active and Independent Management System (AIMS) platform is anticipated to deliver improved patient participation in recovery and self-management through education and the ability to track rehabilitation progression in hospital and after patient discharge.

METHODS

Two well-known instruments were used to measure usability: the System Usability Scale (SUS) with 10 items and, for finer granularity, the User Experience Questionnaire (UEQ) with 26 items. In all, 26 physiotherapists and health care professionals evaluated the AIMS clinical portal; and 44 patients in hospital for total knee replacement, total hip replacement, or dynamic hip screw implant evaluated the AIMS app.

RESULTS

For the AIMS clinical portal, the mean SUS score obtained was 82.88 (SD 13.07, median 86.25), which would be considered good/excellent according to a validated adjective rating scale. For the UEQ, the means of the normalized scores (range -3 to +3) were as follows: attractiveness=2.683 (SD 0.100), perspicuity=2.775 (SD 0.150), efficiency=2.775 (SD 0.130), dependability=2.300 (SD 0.080), stimulation=1.950 (SD 0.120), and novelty=1.625 (SD 0.090). All dimensions were thus classed as excellent against the benchmarks, confirming the results from the SUS questionnaire. For the AIMS app, the mean SUS score obtained was 74.41 (SD 10.26), with a median of 77.50, which would be considered good according to the aforementioned adjective rating scale. For the UEQ, the means of the normalized scores were as follows: attractiveness=2.733 (SD 0.070), perspicuity=2.900 (SD 0.060), efficiency=2.800 (SD 0.090), dependability=2.425 (SD 0.060), stimulation=2.200 (SD 0.010), and novelty=1.450 (0.260). All dimensions were thus classed as excellent against the benchmarks (with the exception of novelty, which was classed as good), providing slightly better results than the SUS questionnaire.

CONCLUSIONS

The study has shown that both the AIMS clinical portal and the AIMS app have good to excellent usability scores, and the platform provides a solid foundation for the next phase of research, which will involve evaluating the effectiveness of the platform in improving patient outcomes after total knee replacement, total hip replacement, or dynamic hip screw.

Restoration of Hip Geometry after Femoral Neck Fracture: A Comparison of the Femoral Neck System (FNS) and the Dynamic Hip Screw (DHS)

BACKGROUND

The femoral neck system (FNS) was introduced as a minimally invasive fixation device for managing femoral neck fractures.

OBJECTIVE

To compare radiographic, clinical, and patient-reported outcome measures (PROMs) of femoral neck fracture patients following FNS compared to dynamic hip screw (DHS) implantation combined with an anti-rotational screw.

METHODS

Patients who underwent closed reduction and internal fixation of a femoral neck fracture between 2020 and 2022 were retrospectively included. We measured leg length, femoral offset, and centrum-collum-diaphyseal (CCD) angle in plain radiographs. Scar length, Harris Hip Score, short-form health survey 36-item score (SF-36), and Numeric Rating Scale (NRS) were assessed during follow-up visits.

RESULTS

We included 43 patients (22 females) with a median age of 66 (IQR 57, 75). In both groups, leg length differences between the injured and the contralateral side increased, and femoral offset and CCD angle differences were maintained over time. FNS patients had shorter scars and reported fewer emotional problems and more energy. There were no differences between groups regarding the remaining SF-36 sub-scores, Harris Hip Score, and NRS.

CONCLUSIONS

The FNS allows for a comparable leg length, femoral offset, and CCD angle reconstruction while achieving similarly high functional and global health scores to the DHS.

Proximal femoral nail anti-rotation vs dynamic hip screws decrease the incidence of surgical site infections in patients with intertrochanteric fractures: A meta-analysis

In this study, a meta-analysis was conducted to comprehensively analyse the effectiveness of using proximal femoral nail anti-rotation (PFNA) and dynamic hip screws (DHS) to treat intertrochanteric fractures on postoperative surgical site infections (SSI). PubMed, EMBASE, Cochrane Library, China National Knowledge Infrastructure (CNKI), and Wanfang databases were searched from their inception until December 2022 to identify studies that compared PFNA and DHS in the treatment of intertrochanteric fractures. Two investigators independently screened the retrieved studies to assess their quality and verify their eligibility for inclusion. Meta-analyses were performed with RevMan 5.4 software. Thirty studies, including 3158 patients, met the inclusion criteria. These studies included 1574 patients treated with PFNA, and 1584 were treated with DHS. The findings of the meta-analysis revealed a significant reduction in the incidence of SSI in patients treated with PFNA compared with those treated with DHS (2.64% vs 6.76%, odds ratio [OR]: 0.40, 95% confidence intervals [CIs]: 0.28-0.57, P < .001), superficial SSI (2.58% vs 5.01%, OR: 0.53, 95% CIs: 0.33-0.85, P = .008) and deep SSI (1.26% vs 3.43%, OR: 0.41, 95% CIs: 0.19-0.92, P = .03). PFNA was more effective than DHS in reducing the incidence of SSI. Even so, significant variations in sample sizes among the included studies meant that the methodology for some studies had qualitative deficiencies. Therefore, additional studies with large sample sizes are needed to validate these results.

Comparison of clinical outcomes with proximal femoral nail anti-rotation versus dynamic hip screw for unstable intertrochanteric femoral fractures: A meta-analysis

BACKGROUND

The aim of this meta-analysis was to evaluate the advantages and disadvantages of proximal femoral nail anti-rotation (PFNA) versus dynamic hip screw (DHS) for the treatment of unstable intertrochanteric fractures, including the available evidence drawn from the literature.

METHODS

A systematic search was conducted to identify available and relevant randomized controlled trials and retrospective comparative observational studies regarding PFNA compared against DHS in treating unstable femoral intertrochanteric fractures in Embase, PubMed, Cochrane Library, Web of Science, and Scopus Online up to February 12, 2022. Data from the included studies were extracted independently by 2 reviewers and analyzed using RevMan 5.3, and the quality of the studies was assessed.

RESULTS

Five randomized controlled trials and 12 observational studies were recruited and met the inclusion criteria, which consisted of 1332 patients with PFNA and 1271 patients with DHS. The results of the meta-analysis showed that, compared with the DHS, PFNA exhibited a beneficial role in postoperative Harris Hip Scores, operation time, intraoperative blood loss, length of hospital stay, fracture healing time and full weight-bearing time, limb shortening, cutout, reoperation, union problems, the varus collapse of the femoral head/neck, and infection; however, DHS was superior to PFNA in hidden blood loss (relative risk [RR] = 139.81, 95% confidence interval [CI] [136.18, 143.43], P < .00001), postoperation drainage (RR = -17.85, 95% CI [-30.10, -5.60], P = .004), total blood loss (RR = 50.34, 95% CI [42.99, 57.69], P < .00001), and femoral shaft fracture (RR = 4.72, 95% CI [1.15, 19.32], P = .03) treated by DHS were significantly decreased, compared with those by PFNA; however, no significant differences were observed in tip-apex distance, fixation failures, screw migration, or other complicants between the 2 surgical methods.

CONCLUSION

Analysis of a large number of relevant clinical indicators available shows that PFNA has better clinical manifestation than DHS in treating unstable femoral intertrochanteric fractures.

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.

Biomechanical comparison of the undercut thread design versus conventional buttress thread for the lag screw of the dynamic hip screw system

Objective: To compare the fixation stability of the lag screw with a undercut thread design for the dynamic hip screw (DHS) system versus the lag screw with the conventional buttress thread. Methods: The lag screws with the undercut thread (a flat crest feature, a tip-facing undercut feature) and buttress thread were both manufactured. Fixation stability was investigated using cyclic compressive biomechanical testing on custom osteoporotic femoral head sawbone. The forces required for the same vertical displacement in the two types of lag screw were collected to evaluate the resistance to migration. Varus angle was measured on X-ray images to assess the ability in preventing varus collapse. Finite element analysis (FEA) was performed to analyze the stress and strain distribution at the bone-screw interface of the two types of lag screws. Results: The biomechanical test demonstrated that the force required to achieve the same vertical displacement of the lag screw with the undercut thread was significantly larger than the lag screw with conventional buttress thread (p < 0.05). The average varus angles generated by the undercut and buttress threads were 3.38 ± 0.51° and 5.76 ± 0.38°, respectively (p < 0.05). The FEA revealed that the region of high-stress concentration in the bone surrounding the undercut thread was smaller than that surrounding the buttress thread. Conclusion: The proposed DHS system lag screw with the undercut thread had higher migration resistance and superior fixation stability than the lag screw with the conventional buttress thread.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

In Silico Finite Element Modeling of Stress Distribution in Osteosynthesis after Pertrochanteric Fractures

A stabilization method of pertrochanteric femur fractures is a contentious issue. Here, we assess the feasibility of rapid in silico 2D finite element modeling (FEM) to predict the distribution of stresses arising during the two most often used stabilization methods: gamma nail fixation (GNF) and dynamic hip screw (DHS). The modeling was based on standard pre-surgery radiographs of hip joints of 15 patients with pertrochanteric fractures of type A1, A2, and A3 according to the AO/OTA classification. The FEM showed that the stresses were similar for both GNF and DHS, with the medians ranging between 53-60 MPa and consistently lower for A1 than A3 fractures. Stresses also appeared in the fixation materials being about two-fold higher for GNF. Given similar bone stresses caused by both GNF and DHS but shorter surgery time, less extensive dissection, and faster patient mobilization, we submit that the GNF stabilization appears to be the most optimal system for pertrochanteric fractures. In silico FEM appears a viable perioperative method that helps predict the distribution of compressive stresses after osteosynthesis of pertrochanteric fractures. The promptness of modeling fits well into the rigid time framework of hip fracture surgery and may help optimize the fixation procedure for the best outcome. The study extends the use of FEM in complex orthopedic management. However, further datasets are required to firmly position the FEM in the treatment of pertrochanteric fractures.

Comparing Perioperative Outcome Measures of the Dynamic Hip Screw and the Femoral Neck System

Background and Objective: Various fixation devices and surgical techniques are available for the management of proximal femur fractures. Recently, the femoral neck system (FNS) was introduced, and was promoted on the basis of less invasiveness, shorter operating time, and less fluoroscopy time compared to previous systems. The aim of this study was to compare two systems for the internal fixation of femoral neck fractures (FNF), namely the dynamic hip screw (DHS) with an anti-rotation screw (ARS) and an FNS. The outcome measures included operating room time (ORT), dose−area product (DAP), length of stay (LOS), perioperative changes in haemoglobin concentrations, and transfusion rate. Materials and Methods: A retrospective single-centre study was conducted. Patients treated for FNF between 1 January 2020 and 30 September 2021 were included, provided that they had undergone closed reduction and internal fixation. We measured the centrum-collum-diaphyseal (CCD) and the Pauwels angle preoperatively and one week postoperatively. Results: In total, 31 patients (16 females), with a mean age of 62.81 ± 15.05 years, were included. Fracture complexity assessed by the Pauwels and Garden classification did not differ between groups preoperatively. Nonetheless, the ORT (54 ± 26.1 min vs. 91.68 ± 23.96 min, p < 0.01) and DAP (721 ± 270.6 cGycm² vs. 1604 ± 1178 cGycm², p = 0.03) were significantly lower in the FNS group. The pre- and postoperative CCD and Pauwels angles did not differ statistically between groups. Perioperative haemoglobin concentration changes (−1.77 ± 1.19 g/dl vs. −1.74 ± 1.37 g/dl) and LOS (8 ± 5.27 days vs. 7.35 ± 3.43 days) were not statistically different. Conclusions: In this cohort, the ORT and DAP were almost halved in the patient group treated with FNS. This may confer a reduction in secondary risks related to surgery.

Dynamic Hip Screw versus Cannulated Cancellous Screw in Pauwels Type II or Type III Femoral Neck Fracture: A Systematic Review and Meta-Analysis

Vertically oriented femoral neck fractures (FNFs) are known to be especially unstable FNFs, and they have a higher associated risk of failure. The dynamic hip screw (DHS) technique and the cannulated cancellous screw (CCS) technique are the two main fixation techniques used in the treatment of FNFs. However, no large clinical study has compared the DHS and CCS techniques in patients with high-shear-angle FNFs. MEDLINE, Embase, Cochrane Library, and Web of Science were systematically searched for studies that compared the DHS and CCS techniques for the treatment of Pauwels type II or type III FNF. Pooled analysis was performed to identify differences between the DHS and CCS techniques in Pauwels type II or type III FNF, with a focus on postoperative complications such as fracture nonunion and osteonecrosis of the femoral head (ONFH). We included five studies with a total of 252 patients. The DHS technique was used in 96 patients (DHS group), and the CCS technique was used in 156 patients (CCS group). The pooled analysis revealed that the nonunion rate in the CCS group was significantly higher than that in the DHS group (OR = 0.32; 95% CI, 0.11–0.96; p = 0.04, I² = 0%), but there was no difference in the incidence of ONFH between the groups (OR = 0.98; 95% CI, 0.20–4.73; p = 0.98, I² = 53%). For vertically oriented FNFs, the DHS technique is more favorable and has a lower risk of fracture nonunion than the CCS technique.

A Shepherd's Crook Deformity of Proximal Femur Treated by Valgus Osteotomy and Bone Grafting

The Shepherd’s crook deformity of the proximal femur is a characteristic radiologic feature of fibrous dysplasia. It may be limited to a single bone, which is called monostotic, or may be polyostotic involving multiple bones as seen in McCune-Albright Syndrome. We report a case of a 19-year-old male patient who presented to us with pain in the right hip for one year. He had dysmorphic facies and multiple café-au-lait spots over the back, which were suggestive of McCune-Albright Syndrome. The radiographs of the hip showed varus deformity of the proximal femur. A lateral closing wedge osteotomy was done and the defect was filled with morselised femoral head allografts and fibular strut allografts. At the 14-month follow-up, the patient remained functionally active without any symptoms. The use of morselised femoral head allograft combined with strut fibular allograft ensures both stability and improved biology at the site of the lesion without any donor site morbidity.

Biomechanical analysis of the treatment of intertrochanteric hip fracture with different lengths of dynamic hip screw side plates

BACKGROUND

Dynamic hip screw (DHS) is a common implant used to treat stable-type intertrochanteric hip fractures. There are many factors that can affect the success rate of the surgery, including the length of side plates. It is therefore important to investigate the biomechanical effect of different DHS side plates on bones.

OBJECTIVE

In order to reduce the likelihood of an implant failure, the aim of this study was to use finite element analysis (FEA) to investigate and understand the effect of side plates with different lengths in DHS.

METHODS

In this FEA study, a 3D model with cortical bone, cancellous bone, side plate, lag screw, and cortical screws to simulate the implantation of DHS with different lengths of side plate (2-hole, 4-hole, and 6-hole) for intertrochanteric hip fractures was constructed. The loading condition was used to simulate the force (400 N) on the femoral head and the stress distribution on the lag screw, side plate, cortical screws, and femur was measured.

RESULTS

The highest stress points occured around the region of contact between the screw and the cortical bones. The stress on the femur at the most distal cortical screw was the greatest. The shorter the length of the side plate, the greater the stress on the cortical screws, resulting in an increased stress on the femur surrounding the cortical screws.

CONCLUSIONS

The use of DHS with 2-hole side plate may increase the risk of side plate pull-out. The results of this study provide a biomechanical analysis for selection of DHS implant lengths that can be useful for orthopaedic surgeons.

The impact of COVID-19 on dynamic hip screw fixation and training

COVID-19 has had a profound impact on orthopaedic services and surgical training.

AIM

This study aims to identify changes in lag screw position and Tip Apex Distance (TAD) in dynamic hip screw fixation due to changes in practice during the coronavirus pandemic and determine whether the changes resulted in improved patient outcomes and enhanced training opportunities.

MATERIALS AND METHODS

Retrospective evaluation of two patient cohorts - pre-covid (n=27) and during covid (n=26) - to evaluate the TAD and lag screw position for each patient and record the grade of operating surgeon. A total of 53 patients were included.

RESULTS

A mean TAD of 19.78mm and 19.80mm was calculated for cohort 1 and 2 respectively with no significant difference identified. When considering both key risk factors for lag screw cut-out (lag screw position and TAD) the number of patients with both a "satisfactory position" of the screw and a TAD <20mm, were 8/27 (29.6%) and 11/26 (42.3%), respectively. In cohort 1 3/27 cases had a consultant documented as the primary surgeon, while no consultants were documented as being present for the remaining 24 cases. 21/26 cases in cohort 2 had a consultant present some capacity, either as primary surgeon (15/21) or assistant (6/21).

CONCLUSIONS

Changes in practice due to the pandemic have had some positive effects for both patients and trainees. This study has highlighted the importance of Consultant led trauma lists for improving training and surgical outcomes with a demonstrated improvement when considering both key factors associated with screw cut-out together. Ultimately some of the changes in practice should be continued in the post-covid era.

Design and biomechanical study of slide-poking external fixator for hip fracture

Background

Femoral head collapse and coxa vara lead to internal fixator failure in elderly patients with hip fracture. External fixator application is an optimal choice; however, the existing methods have many disadvantages.

Methods

Type 31-A1.3 hip fracture models were developed in nine pairs of 1-year-old fresh bovine corpse femur specimens. Each left femur specimen was fixed by a dynamic hip screw (control group), and each right femur specimen was fixed by the slide-poking external fixator (experimental group). Vertical loading and torsion tests were then performed in both groups.

Results

In the vertical loading experiment, a 1000-N load was implemented. The mean vertical downward displacement of the femoral head in the experimental and control groups was 1.49322 ± 0.116280 and 2.13656 ± 0.166374 mm, respectively. In the torsion experiment, when the torsion was increased to 10.0 Nm, the mean torsion angle in the experimental and control groups was 7.9733° ± 1.65704° and 15.4889° ± 0.73228°, respectively. The slide-poking external fixator was significantly more resistant to compression and rotation than the dynamic hip screw.

Conclusion

The slide-poking external fixator for hip fractures that was designed and developed in this study can provide sufficient stability to resist compression and rotation in hip fractures.

Subtrochanteric Femoral Fracture in a Patient with Osteopetrosis: Treated with Internal Fixation and Complicated by Intraoperative Femoral Neck Fracture

Objective

Osteopetrosis (OP) is a rare, heritable skeletal disorder that is caused by osteoclast dysfunction, leading to failure of bone resorption and increased bone density. The fragility of such dense bone may result in an increased incidence of fractures. Furthermore, surgery in patients with OP is associated with increased technical difficulty and a higher risk of complications.

Case Report

We report a case of a 20-year-old woman with autosomal dominant OP who developed a subtrochanteric femoral fracture. The fracture was treated by open reduction and internal fixation using a dynamic hip screw. Although technical difficulties were experienced and an intraoperative femoral neck fracture occurred, the surgical outcome was satisfactory. Union of the fractures was visible on radiographs obtained 12 months postoperatively. At 2 years postoperatively, the patient was completely free of any complications resulting from her injury and treatment.

Conclusion

Open reduction and internal fixation may be an effective option for fractures in patients with OP. Orthopedic surgeons should be aware that the increased density and stiffness of osteopetrotic bone increases the risks of intraoperative technical difficulties, iatrogenic fractures, and postoperative complications.

Thrombosis of the Superficial Femoral Artery following Fixation of Intertrochanteric Fracture of the Femur using a Dynamic Hip Screw

INTRODUCTION

Vascular injuries in orthopedic surgery are relatively rare but potentially limb and life threatening. They are most commonly encountered in knee and hip arthroplasty but also have been reported in trauma surgeries. Pertrochanteric fractures of proximal femur are among the most common fractures encountered in elderly osteoporotic patients. Positioning on fracture table, traction, and reduction maneuvers employed during fixation of these fractures, place the vessels at risk by bringing them closer to the bone. Iatrogenic vascular injuries can occur if adequate care is not taken during instrumentation for fracture fixation.

CASE REPORT

We are reporting a case of 62 years female who underwent fixation of an intertrochanteric fracture of femur using a dynamic hip screw (DHS) and subsequently started developing ischemic changes in the operated lower limb on the 3rd post-operative day. Angiography revealed thrombosis of the superficial femoral artery at the level of the third screw of the DHS and the patient ultimately landed up with an amputation.

CONCLUSION

Operating surgeon should be aware of the risk of iatrogenic vascular injury during fixation of pertrochanteric fractures. Good surgical technique and simple precautionary measures can minimize the risk of this devastating complication.

Stress Fracture of Bilateral Neck of Femur in a Healthy Non-athletic Young Adult - A Case Report With Review of Literature

Stress fractures of femoral neck are rare injuries and are usually seen in military recruits, marathon runners, and elderly with osteoporosis, renal rickets, steroid abuse, and metabolic bone diseases. Bilateral involvement of femoral neck in a healthy, non-athletic young adult is an extremely rare entity. We report one such case of a 36-year-old male who presented with bilateral groin pain for last three months. He had a history of excessive running prior to the onset of pain. The investigations confirmed bilateral stress fracture of the femoral neck, and the patient was operated with dynamic hip screw (DHS) on both sides. He returned to his routine activities in six months and at latest follow-up after two years; he is asymptomatic and has full function at both hips. This report highlights a rare cause of bilateral groin pain in a young adult, which requires early diagnosis and treatment to prevent complications.

Hybrid triad provides fracture plane stability in a computational model of a Pauwels Type III hip fracture

The study utilized finite element method to determine displacements and stresses in a set of Pauwels Type III femoral neck fractures repaired using 3 techniques (cannulated screws (Triad), sliding hip screw (SHS), and a Hybrid (SHS + cannulated screws). The research found that shear displacement doubled between the 65° and 75° fracture angles regardless of fixation construct. The SHS alone was the least stable construct, with highest construct stresses and shear displacement along the fracture plane. The stability of the Hybrid and Triad constructs were similar, but stress in the Hybrid was lower suggesting it would provide a higher load to failure than the Triad.

Length Matters: Short Base-Plate Angle Guides May Lead to Guide-Wire Mal-Positioning When Inserting a DHS. A Radiographic Modeling Study

The dynamic hip screw (DHS) consists of a barrel-plate fixed to the relatively-straight proximal femoral shaft, and a screw which slides within the barrel at a fixed angle, usually 135°. The guide-wire is inserted using a guide at the set angle. Guide design varies between manufacturers, with some new guides being particularly short. We analysed the impact of guide design on the resulting trajectory of the guidewire, and its potential to cause a surgical error. Twenty AP hip radiographs were analysed. Trauma Cad (Brainlab, Munich, Germany) software was used to template a 4-hole 135° DHS onto the intact femur with the screw positioned in the center of the head. A template of a Stryker (Michigan, USA) 135° DHS guide (37 mm long) was then overlaid at the hip screw entry point, and the set trajectory marked. The divergence between the two trajectories was measured (α angle). The distance the guide would have to be moved inferiorly to attain the correct position in the head was then noted. The median divergence (α angle) caused by the guide relative to the ideal position was 6° (range 2-12). This led to the guidewire placement being a median of 9.1 mm (range 3-23) superior in the head (β).To achieve the correct position of the wire in the head, the guide needed to be moved inferiorly a median of 8 mm (range 2-10). © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:574-577, 2020.

Fixation of AO-OTA 31-A1 and A2 trochanteric femur fractures using a sliding hip screw system: can we trust a two-hole side plate construct? A review of the literature

Trochanteric femur fractures are frequently fixed with a four-hole side plate sliding hip screw device, but in recent decades two-hole side plates have been used in an attempt to minimize operative time, surgical dissection, blood loss and post-operative pain.

The aim of this review was to determine whether two-hole sliding hip screw constructs are an acceptable option for fixation of AO-OTA 31-A1 and A2 trochanteric femur fractures.

An electronic MEDLINE® database search was performed using PubMed®, and articles were included in this review if they were reporting historical, biomechanical, clinical or outcome data on trochanteric fracture fixation using a two-hole sliding hip screw device.

A two-hole dynamic hip screw with a minimally invasive muscle-splitting approach is recommended for fixation of AO-OTA 31-A1 simple trochanteric fractures; this implant is biomechanically safe, and allows the use of a minimally invasive muscle-splitting approach which potentially provides better clinical outcome, such as decreased surgical trauma, shorter operative time, less blood loss, decreased analgesics use, and shorter incision length. As the majority of reviewed publications relate to the dynamic hip screw, it is not clear whether the above recommendations can be extended to any other sliding hip screw device.

An intramedullary device is recommended for all other extra-capsular proximal femoral fractures.

Cite this article: EFORT Open Rev 2020;5:118-125. DOI: 10.1302/2058-5241.5.190020

Salvage of failed dynamic hip screw fixation of intertrochanteric fractures

Background and aim

Failure of intertrochanteric fracture fixation can occur in patients with poor bone quality, extreme osteoporosis, or unstable fracture arrangement. Although hip replacement is a commonly successful process, it includes technical problems, such as implant removal, bone loss, low bone quality, nonunion of trochanter, and difficult surgical exposure. The goal of this study was to restore total hip replacement for failed intertrochanteric fractures to assess the outcomes.

Methods

During April 2009 to October 2015, 203 patients (203 hips) underwent total hip arthroplasty through the direct lateral approach, as salvage of failed intertrochanteric fracture management by dynamic hip screw (DHS). The restoration process was done by a direct lateral approach (Hardinge) in all hips. The operation details, such as duration, blood transfusion volume, blood loss, and duration of hospital stay, were recorded. Modified Harris hip score (MHHS) was applied for assessment of clinical outcome before and after the operation, and during the follow-up.

Results

Overall, 112 patients were male (55.17%) and 91 patients (44.8%) were female and the mean of age was 72.58±10.60 years old. Average operation time was 93.96±10.72 minutes. The mean blood loss volume during the operation was 355.86±84.11 mL. The mean preoperative MHHS score was 39.55±6.74 (range: 30–50). The MHHS score improved to 90.55±2.24, 92.34±1.26, and 94.34±1.85 during the first, second, and final follow-up, respectively (P<0.0001). Infection was found in only two patients, who had undergone one stage revision and linear of the cup was exchanged. Total rate of complications during the follow-up was 4.92%.

Conclusion

The current research was a large population study and indicated that sufficient functional outcome could be obtained by total hip replacement in geriatrics with failed intertrochanteric fractures. Therefore, well-performed hip replacement could be a suitable choice for restoring failed DHS in unsuccessfully managed intertrochanteric fractures in the elderly.

A Comparison of Dynamic Hip Screw and Two Cannulated Screws in the Treatment of Undisplaced Intracapsular Neck Fractures-Two-Year Follow-Up of 453 Patients

One of the most common fractures is that of the intracapsular femoral neck; however, the optimal implant for head-preserving treatment remains controversial. The aim of the study was to compare the outcomes of treating undisplaced intracapsular femoral neck fractures with either the dynamic hip screw (DHS) or the double cannulated screw fixation (CSFN). This retrospective cohort study analysed the data of 453 patients, with a mean age of 76.9 years, whose intracapsular fractures were treated with the DHS or CSFN between 2005 and 2013. The analysis focused on the rates of revision surgeries and complications; however, the impact of confounding exogenous factors, such as smoking and alcohol, were also considered. No significant difference was observed between the revision rates of DHS and CSFN (15.0% vs. 13.1%; p = 0.565). According to the complication rate, the advantage in favour of the CSFN was not significant (20.5% vs. 13.1%, p = 0.038). The use of the DHS was associated with a 13 min longer surgery (p < 0.0001) and a one day longer hospitalization (p = 0.242). Excessive consumption of alcohol was associated with an increased incidence of avascular necrosis (18.6% vs. 8.7%, p = 0.035). The choice of implant showed no significant impact on rates of revision surgery and complications. In terms of socioeconomic factors, the fixation with two cannulated screws was more favourable, making it the more cost-effective and less stressful method.

Functional and Radiological Outcome of Unstable Intertrochanteric Fracture Post Dynamic Hip Screw Fixation

Introduction

Intertrochanteric fractures are the most frequently operated fracture type and have the highest postoperative fatality rate. The most commonly used devices are the dynamic hip screw (DHS) with side plate assemblies and proximal femoral nail (PFN). The aim of this study was to determine the functional and radiological outcome of unstable intertrochanteric fracture post DHS fixation at a tertiary care hospital in Karachi, Pakistan.

Methods

A study was carried out in the department of orthopedics at the Jinnah Postgraduate Medical Center (JPMC), from 12th June 2016 to 8th September 2017. A total of 106 patients between 18 and 75 years of age with unstable intertrochanteric fracture were included. Those patients who had multiple injuries and open fractures, subtrochanteric fractures, intracapsular fractures neck of femur, pathological fractures and patients who were non-ambulatory prior to their injury were excluded. Functional outcomes were measured both during pain using the visual analog scale and range of motion on goniometer between 80 and 100 degrees. Satisfactory outcomes were measured after three months.

Results

A total of 106 patients with the radiological diagnosis of the unstable intertrochanteric fracture having post DHS fixation were included in this study. Out of which, 69.8% (74) were males and the mean age was 66.61 ± 7.79 years over the range of 50 to 80 years. Patients with type II diabetes were 22.6% (24) with a mean duration of 4.3 ± 8.37 years. At the end of three months, no pain was reported in 82.1% (87) patients and 85.8% (91) patients had normal function. The satisfactory radiological outcome was observed in 86.8% (92) patients. Overall, acceptable outcomes were observed in 81.1% (86) patients at the end of three months.

Conclusion

The treatment of unstable intertrochanteric fracture with dynamic hip screw (DHS) fixation results in better outcomes. In our study, we observed acceptable outcomes in a vast majority, 81.1%, of patients after three months of DHS fixation of the unstable intertrochanteric fracture.

Surgical Treatment of Type 31-A1 Two-part Intertrochanteric Femur Fractures: Is Proximal Femoral Nail Superior to Dynamic Hip Screw Fixation?

Introduction

The implant of choice for two-part intertrochanteric femur fracture is still under debate. This study was done to compare the operative parameters and functional outcome of two-part intertrochanteric fractures treated by dynamic hip screw (DHS) and proximal femur nail (PFN).

Methods

Fifty-four operated cases of two-part intertrochanteric (AO 31A1) were analysed and divided into two groups based on implant used (PFN 30, DHS 24). Operative details, which include blood loss and duration of surgery, were obtained from hospital records. All patients were followed up for six months and assessed for radiographic and functional outcome. The functional outcome was calculated with modified Harris hip score and Parker mobility score.

Results

There was no significant difference in the operative parameters (p > 0.05) between DHS and PFN. The average blood loss for DHS and PFN was 202.5 ml and 198 ml respectively while operative duration was 136 min and 126 min, respectively. All patients had good functional outcome at the end of six months with average Harris hip score of 69.7 and Parker score of 8. No difference was found between the two surgeries in terms of functional outcome as well (p > 0.05).

Conclusion

There is no conclusive evidence to show that PFN is superior to DHS in the treatment of two-part intertrochanteric (31A1) fracture. Both DHS and PFN are equally effective in treatment of such fractures.

Poor outcomes for osteoporotic patients undergoing conversion total hip arthroplasty following prior failed dynamic hip screw fixation: a nationwide retrospective cohort study

Objectives

This study was performed to compare the long-term clinical and radiological outcomes of conversion total hip arthroplasty (CTHA) following prior failed InterTan nail (IT) fixation or dynamic hip screw (DHS) fixation in Asian patients with osteoporotic intertrochanteric hip fractures (IHFs) and to clarify which implant tends to be more favourable for CTHA.

Methods

Records of consecutive Asian patients with osteoporosis who underwent conversion of failed primary unilateral IT or DHS fixation to THA from 2010 to 2013 were extracted from the comprehensive database of the China Pacific Insurance Company Ltd. All consecutive procedures were managed by high-volume surgeons. The primary endpoint was the clinical outcome. The secondary endpoint was the radiological outcome.

Results

In total, 447 Asian patients with osteoporotic IHFs (DHS, n = 223; IT, n = 224) were assessed during a median follow-up of 46 months (range, 39–53 months). The two groups showed a significant difference in the Harris hip score at final follow-up and in the orthopaedic complication rate (DHS, 20.2%; IT, 9.8%).

Conclusion

Conversion to THA following prior failed DHS fixation tends to be associated with poorer clinical and radiological outcomes in Asian patients with osteoporotic IHFs than that following prior failed IT fixation.

A Case of Fibrous Dysplasia with Bilateral Shepherd Crook Deformity Treated with Dynamic Hip Screw Fixation

Introduction:

Fibrous dysplasia is a rare benign disorder of the skeletal system characterized by fibro-osseous proliferation with intervening areas of normal or immature bone in the intramedullary region. It can either be a monostotic (involves one bone) or a polyostotic (involves more than one bone) presentation and usually occurs equally in males and females. Deformities such as scoliosis and shepherd’s crook deformity are frequently encountered in the polyostotic form. We report the management of a rare managed case of bilateral shepherd’s crook deformity of the proximal femur with impending neck of femur fracture.

Case Report:

A 22-year-old male known case of polyostotic fibrous dysplasia presented with bilateral shepherd’s crook deformity of the proximal femur. Preoperatively, neck-shaft angle was 15° on the right side and 55° on the left side. The patient had severe pain on the right side due to an impending neck of femur fracture. On the right side, we first did a valgus osteotomy in the subtrochanteric region and fixed with dynamic hip screw, and after 3 months, the left proximal femur valgus osteotomy with dynamic hip screw fixation was done. Postoperatively, we achieved a neck-shaft angle of 140° on the right side and 135° on the left side. 1-year follow-up imaging showed union at both the osteotomy sites. At present, at 12-month post-operative, the patient is walking full weight-bearing without support, no apparent shortening.

Conclusion:

Valgus osteotomy is an easy and effective method to correct the shepherd’s crook deformity and achieve correct mechanical alignment. Valgization of the shepherd crook deformity will prevent the development of a pathological neck of femur fracture.

Comparison of efficacy, complications and TGF-β2 expression between DHS and PFNA in elderly patients with osteoporotic femoral intertrochanteric fracture

The aim of the present study was to compare the efficacy and complications of two fixation techniques, namely dynamic hip screw (DHS) and proximal femoral nail antirotation (PFNA), in the treatment of osteoporotic femoral intertrochanteric fracture in elderly patients, and to detect changes in transforming growth factor β2 (TGF-β2) expression in the two groups. A total of 100 elderly patients with femoral intertrochanteric fracture were randomly divided into two groups that were treated with either DHS or PFNA. Peri-operative complications were observed in the patients and ELISA was used to detect TGF-β2 expression levels at 1, 7, 15 and 30 days after surgical treatment. The clinical efficacy and the incidence rate of complications at 3 months after the operation were compared. In comparison with the DHS group, the PFNA group had a shorter operation time, a lower bleeding volume and a shorter post-operative weight-bearing time. The contents of TGF-β2 in the two groups at 7 days after the operation were higher than those at 1 day, reached a peak at 15 days and had gradually decreased again at 30 days after the operation. The contents of TGF-β2 at 1, 7 and 15 days in the PFNA group were higher than those at the identical time-points in the DHS group (P<0.01). Regarding the clinical efficacy in the two groups at 3 months of post-surgery, the rate of excellent/good efficacy in the PFNA fixation group (90.0%) was higher than that in the DHS fixation group (74.0%). Of note, PFNA fixation had a higher clinical efficacy, a shorter operation time, less intra-operative trauma, a relatively faster fracture healing process and fewer complications in comparison with DHS fixation, and is therefore more suitable for treating osteoporotic femoral intertrochanteric fracture in the elderly. PFNA fixation is superior to DHS fixation, which may be associated with the higher level of TGF-β2 expression in comparison with that in the DHS group.

A biomechanical comparison of the two- and four-hole side-plate dynamic hip screw in an osteoporotic composite femur model

OBJECTIVES

The objectives of this study were (1) to compare the axial and torsional stiffness of a dynamic hip screw with a two- and four-hole side-plate in a synthetic model of a healed and stable intertrochanteric femur fracture and (2) to evaluate the load to failure, as well as propensity to peri-implant fracture.

METHODS

Fourth-generation synthetic composite femur models, simulating osteoporotic bone, were implanted with 135° dynamic hip screws (DHS) with either a two- or four-hole side-plate with or without a stable intertrochanteric fracture. Specimens were cyclically loaded up to a nondestructive load to determine the axial and torsional stiffness. Constructs were then loaded to failure in axial compression emulating physiologic forces. Failure load and location of the peri-implant fractures were recorded.

RESULTS

Axial and torsional stiffness did not differ significantly between the two- and four-hole constructs in either model. Likewise, there was no significant difference in the load to failure. In the intact femurs, failure occurred either at the end of the plate at the distal screw or through the lag screw hole.

CONCLUSION

The results of this study demonstrate that DHS constructs with a two- or four-hole side-plate are biomechanically comparable with regard to axial and torsional stiffness and load to failure in an osteoporotic composite femur model. In a healed intertrochanteric fracture model, a two-hole construct did not appear to be more prone to peri-implant fracture. To date, a biomechanical comparison of these two implants with regard to torsional forces has not been reported.

[Treatment of benign bone lesions of proximal femur using dynamic hip screw and intralesional curettage via Watson-Jones approach]

Objective

To explore the effectiveness of dynamic hip screw (DHS) and intralesional curettage via Watson-Jones approach in treatment of benign bone lesions of the proximal femur.

Methods

Between March 2012 and December 2016, 20 patients (21 lesions) with benign bone tumors or tumor like conditions of proximal femurs were treated with DHS and intralesional curettage via Watson-Jones approach. Their average age was 27.8 years (range, 11-51 years), including 13 males and 7 females. The pathological diagnosis were fibrous dysplasia in 11 cases, simple bone cyst in 2 cases, aneurysmal bone cyst in 2 cases, benign fibrous histocytoma in 2 cases, giant cell tumor in 2 cases, and chondroblastoma in 1 case, including 3 pathological fractures. According to the Enneking staging system, 18 patients were in stage S1, 3 patients with pathological fractures in stage S2. There was no varus deformity or valgus deformity. The operation time, intraoperative blood loss, and time of full weight-bearing were recorded. X-ray film and CT were used to observe the bone graft fusion and location of DHS. Complications were recorded. Visual analogue scale (VAS) and Musculoskeletal Tumor Society (MSTS) scoring were used to evaluate function of lower limbs.

Results

The average operation time was 177.1 minutes (range, 110-265 minutes). The average intraoperative blood loss was 828.6 mL (range, 200-2 300 mL). There was superficial incision infection in 1 case, deep incision infection in 1 case, and hip discomfort in 1 case, respectively. All patients were followed up 6-63 months (mean, 27.4 months). The time of full weight-bearing was 2 days in 2 patients with giant cell tumor and 2 to 13 weeks with an average of 7.2 weeks in the other patients. At last follow-up, VAS and MSTS were 0.19±0.51 and 29.62±0.97 respectively, showing significant differences when compared with the values before operation (3.52±2.62 and 23.71±8.77) ( t=5.565, P=0.000; t=-3.020, P=0.007 ). X-ray film showed the all bone grafts fusion with mean time of 8.2 months (range, 5-12 months). There was no pathological fracture of the femur, local tumor recurrence, chronic hip pain, dislocation, or femoral head necrosis during follow-up.

Conclusion

The treatment of benign bone lesion of the proximal femur using DHS and intralesional curettage via Watson-Jones approach is a safe and effective method.

Proximal femoral nail antirotation versus dynamic hip screw fixation for treatment of osteoporotic type 31-A1 intertrochanteric femoral fractures in elderly patients

Objective To evaluate long-term radiographic and functional outcomes between dynamic hip screw (DHS) and proximal femoral nail antirotation (PFNA) fixation for treatment of osteoporotic type 31-A1 intertrochanteric femoral fractures (IFFs) among elderly patients Methods A retrospective comparative study was carried out. Follow-up was performed at 1, 3, 6, 9, and 12 months postoperatively and yearly thereafter. The primary outcome was the radiographic outcome, and the secondary outcome was the functional outcome. Results A significant difference in radiographic complications was observed between the DHS group (n = 45, 40.2%) and PFNA group (n = 15, 13.6%). The risk of femoral shaft fracture after implant removal at the 1-year follow-up was increased by 0.9% (n = 1) and 6.3% (n = 7) in the PFNA and DHS groups, respectively. This difference persisted with rates of 3.6% (n = 4) and 12.5% (n = 14) at the final follow-up. Additionally, significant differences were present in the Harris hip score at each visit. Conclusion Our results indicate that PFNA yields better outcomes than DHS fixation among elderly patients with osteoporotic type 31-A1 IFFs.

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

Objective

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

Methods

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

Results

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

Conclusion

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

Treatment of neglected femoral neck fractures using the modified dynamic hip screw with autogenous bone and bone morphogenetic protein-2 composite materials grafting

BACKGROUND

The neglected femoral neck fracture is one where there has been a delay of more than 30 days to seek medical help from the time of the original injury. Salvage procedures, such as osteotomy and other treatment options such as vascularized and nonvascularized bone grafts have high failure rates and arthroplasty procedures are not ideal, given the patient's young age and higher levels of activity. We designed a hollow bone graft dynamic hip screw (Hb-DHS) (modified DHS, Hb-DHS) for use in neglected femoral neck fractures. This study evaluates the efficacy and safety of the modified dynamic hip screw (DHS) with autogenous bone and bone morphogenetic protein 2 (BMP-2) composite materials grafting for the treatment of the neglected femoral neck fractures.

MATERIALS AND METHODS

A prospective study was carried out in twenty patients of neglected femoral neck fractures treated with the modified DHS with autogenous bone and BMP-2 composite materials grafting between July 2007 and February 2010. There were 14 men and 6 women with a mean age of 29.6 years (range 19-42 years). The mean time from injury to surgery was 9.7 weeks (range 6-16 weeks). The operation time, intraoperative blood loss, fracture healing time, Harris scoring for hip function and complications were recorded to evaluate treatment effects.

RESULTS

The mean operation time was 75.8 min (range 55-100 min) with mean intraoperative blood loss volume of 105 mL (range 70-220 mL). The mean time to union was 17 weeks (range 12-24 weeks). One patient did not achieve union, and two patients had avascular necrosis of the femoral head. This patient with nonunion underwent intertrochanteric osteotomy. In patients with avascular necrosis one required total hip arthroplasty, the other did not require intervention at the last followup. A total of 14 patients (70%) had excellent results, 2 (10%) had good, 1 (5%) had moderate and 3 (15%) had poor results.

CONCLUSION

The modified DHS with autogenous bone and BMP-2 composite materials grafting for the treatment of neglected femoral neck fractures waseffective and had less complications.

Comparison of functional recovery in the very early period after surgery between plate and nail fixation for correction of stable femoral intertrochanteric fractures: a controlled clinical trial of 18 patients

PURPOSE

This study aimed to compare the differences in functional recovery between patients undergoing plate and nail fixation in the very early period after surgery.

METHOD

This study was designed as a controlled clinical trial that included 18 patients who were surgically treated with either dynamic hip screw as plate fixation or proximal femoral nail as nail fixation for stable intertrochanteric fractures. In particular, all patients selected for the study reported walking completely independently without the use of walking aids prior to sustaining their initial fracture. In all, 8 patients (mean age, 73.8 years; range, 65-89 years) were treated with plate fixation (group plate) and 10 patients (mean age, 79.7 years; range, 70-90 years) were treated with nail fixation (group nail). Functional evaluations were assessed every week after surgery using the Japanese Orthopaedic Association (JOA) hip functional scores and active range of motion (ROM) of the hip joint.

RESULTS

The recovery of activities of daily living (ADLs) according to JOA hip functional scores at week 4 after surgery was significantly better in group nail than in group plate (P = .03), whereas active ROM of hip flexion improved significantly in group plate than in group nail at weeks 3 and 4 after surgery (P = .04 and P = .02, respectively).

CONCLUSIONS

The results suggested that nail fixation may provide a more rapid recovery of ADLs than that of plate fixation in the very early period after surgery. However, plate fixation may provide better ROM of hip flexion than that of nail fixation.

130- versus 135-degree sliding hip screws and failure in pertrochanteric hip fractures

BACKGROUND

The fixed-angle sliding hip screw has become a popular method of fixation for pertrochanteric hip fractures. The tip-to-apex distance (TAD) concept was introduced by Baumgaertner et al. in 1995 and has subsequently become a decisive predictor of the successfulness of fixation. The 135-degree plate has become the most popular plate used for fracture fixation, although this has not been compared with lower angled plates (130 degree) in relation to TAD.

METHOD

We analysed 567 consecutive cases of dynamic hip screw (DePuy-Synthes) fixation to compare TAD in various angled plates and rate of failure.

RESULTS

The 130-degree plate has significantly lower mean TAD 19.3 mm versus 20.8 mm (P = 0.016). There were nine failures because of superior screw cut-out in the 135-degree plates and 0 failures in the 130-degree plates.

CONCLUSION

We believe the improved trajectory for lag screw placement using 130-degree angled plates leads to a lower TAD and improved fixation in pertrochanteric fractures.

Radiographic quantification of dynamic hip screw migration

PURPOSE

This study aimed to propose a technique to quantify dynamic hip screw (DHS®) migration on serial anteroposterior (AP) radiographs by accounting for femoral rotation and flexion.

METHODS

Femoral rotation and flexion were estimated using radiographic projections of the DHS® plate thickness and length, respectively. The method accuracy was evaluated using a synthetic femur fixed with a DHS® and positioned at pre-defined rotation and flexion settings. Standardised measurements of DHS® migration were trigonometrically adjusted for femoral rotation and flexion, and compared with unadjusted estimates in 34 patients.

RESULTS

The mean difference between the estimated and true femoral rotation and flexion values was 1.3° (95% CI 0.9-1.7°) and -3.0° (95% CI - 4.2° to -1.9°), respectively. Adjusted measurements of DHS® migration were significantly larger than unadjusted measurements (p = 0.045).

CONCLUSION

The presented method allows quantification of DHS® migration with adequate bias correction due to femoral rotation and flexion.

Avascular necrosis of femoral head: a rare complication of a common fracture in an octogenarian

Avascular necrosis (AVN) of the femoral head is a relatively uncommon complication following an extracapsular hip fracture. Although it can occur following fixation of unstable 3-part or 4-part intertrochanteric fractures with significant posteromedial and posterolateral comminution, it remains a rare complication. We present a case of AVN of the femoral head following fixation of a stable 2-part intertrochanteric fracture in spite of good healing at the hip fracture site. This is a rare but eminently treatable cause of persisting hip pain after hip fracture surgery, and primary or secondary care physicians should be aware of this possibility.

A review of tip apex distance in dynamic hip screw fixation of osteoporotic hip fractures

Fractured neck of femur is a common problem seen in elderly osteoporotic females, mostly in Western countries, among which are the extra-capsular fractures such as intertrochanteric and pertrochanteric fractures also known as peritrochanteric fractures, and commonly treated with dynamic hip screw (DHS) or compression hip screw (CHS). The DHS is based on tension band principle and allows the screw to slide within the barrel to enable compression of the fracture when the patient begins to bear weight. This principle only works in the presence of intact medial wall and so cannot be successful in a reverse oblique fracture of the proximal femur. However, it is important that the technique of screw placement is precise and should ideally be central in the femoral neck, on both AP and lateral radiographs. This is why the concept of tip apex distance (TAD) is critical to the outcome of fixation and can accurately predict failure or survival of the screw. A systematic review of articles published in PubMed/Medline, from 1991 to 2011 (twenty years), was carried out to critically analyse common practice with regards to DHS fixation of extra-capsular femoral neck fractures, and review the recommendations of previous authors, with regard to the effect of TAD in DHS fixation. Search words used include TAD, DHS, sliding hip screw, femoral neck fractures, peritrochanteric fractures, tension band principle, fracture collapse, screw cut-out, DHS failure, and failure of fixation. At the end of the review, recommendations and suggestions regarding the ideal techniques of placement of DHS screw into the femoral neck will be made in line with current published literature, in order to establish an evidence base for best practice. A total of forty eight (48) published articles were found relevant to the review topic. Most papers suggested that Tip Apex Distance (TAD) is the most important predictive factor for DHS failure, followed by lag screw position, fracture pattern and reduction, patient's age and presence of osteoporosis. Therefore, we recommend proper training of surgeons, as well as attention to detail while performing DHS for intertrochanteric neck of femur fractures.

Outcome of the dynamic helical hip screw system for intertrochanteric hip fractures in the elderly patients

INTRODUCTION

The dynamic helical hip system (DHHS; Synthes, Paoli, Pennsylvania) differs from the standard dynamic sliding hip screw (SHS) in that in preparing for its insertion, reaming of the femoral head is not performed, thereby preserving bone stock. It also requires less torque for insertion of the helical screw. The associated plate has locking options to allow locking screw fixation in the femoral shaft, thereby decreasing the chance of the plate pulling off. While biomechanical studies have shown improved resistance to cutout and increased rotational stability of the femoral head fragment when compared with traditional hip lag screws, there is limited information on clinical outcome of the implant available in the literature.

METHODS

We report a single surgeon series of 87 patients who were treated for their per-trochanteric hip fractures with this implant to evaluate their clinical outcome and compare it with a cohort of 344 patients who were treated with the standard SHS. All data were prospectively collected, most as part of a structured Geriatric Fracture Care Program.

RESULTS

The 2 groups were similar demographically, and medically, with similar rates of in-hospital complications and implant failure. Failure in the DHHS group was attributable to use of the implant outside its indications and repeated fall of the patient.

CONCLUSION

This limited case series showed that the DHHS outcomes are comparable with that of the SHS. Whether there is any benefit to its use will require larger, prospective randomized controlled trials.