Closed Reduction Internal Fixation Research Articles

Comparative study between close reduction internal fixation and open reduction internal fixation in lower fibula with medial mallolus fracture

Comparative study between close reduction internal fixation and open reduction internal fixation in lower fibula with medial mallolus fracture - IJOS- Print ISSN No: - 2395-1354 Online ISSN No:- 2395-1362 Article DOI No:- 10.18231/j.ijos.2020.055, Indian Journal of Orthopaedics Surgery-Indian J Orthop Surg

A Study on the Evaluation of a Risk Score of Osteonecrosis of the Femoral Head Based on Survival Analysis

BackgroundThis study aimed at developing a risk score predicting the probability of developing an osteonecrosis of the femoral head (ONFH) in patients with femoral neck fracture within 3 years after closed reduction internal fixation and evaluating its performance, clinical utility, and internal validity. MethodsA retrospective follow-up study of 378 newly injured femoral neck fracture patients treated with 3 partially threaded parallel cannulated screws in 3 hospitals in Shanghai from March 2013 to January 2017 was performed. The patients were divided into development (n = 284) and validation (n = 94) cohorts. The risk score was constructed by Cox regression analysis in a form of nomogram. The performance and clinical utility were illustrated by box plots, calibration plots, and decision curve analysis. ResultsEighty-three of 378 patients had developed ONFH within 3 years. Garden alignment index, time to surgery, preoperative displace, impaction, and postoperative malposition were used as predictors to construct the risk score in a form of nomogram. In the development and validation cohort, the concordance index was 0.96 and 0.94, respectively; the discrimination slope was 0.51 and 0.47, respectively. In both cohorts, the calibration slopes and intercepts were 1 and 0, respectively. The risk score was clinically useful between the risk threshold of 0% and 88%. The performance and utility in the validation data illustrated good repeatability. ConclusionThe risk score had satisfactory discrimination and calibration performance and demonstrated clinical utility with good internal validity. It managed to distinguish high-risk groups for post-traumatic ONFH.

Appropriateness of fixation use in tibial plateau fractures

The appropriateness of fixation use in orthopedic surgery is a debated and constantly evolving topic, similar to the devices themselves. Devices and materials impossible even to imagine until a few years ago, are now available. Consequently, indications, timing and methods of surgical treatment are constantly changing, along with the expansion of knowledge and technological progress. This also applies to the treatment of tibial plateau fractures which, due to the specific anatomy of the knee joint and the traumatic mechanisms, represents a constant challenge for surgeons. In addition to the fracture typology, several factors must be considered, among which, undoubtedly, the degree of soft tissue injury. Age, functional demands, patient compliance, and comorbidities must be carefully evaluated before choosing suitable osteosynthesis devices, i.e., cannulated screws, synthetic bone substitutes, the assistance of arthroscopy technique (A.R.I.F.) in closed reduction internal fixation (C.R.I.F.) and in minimally invasive percutaneous plate osteosynthesis (M.I.P.P.O), support plates and locking plates in open reduction internal fixation (O.R.I.F.), temporary or permanent external fixators (T.E.F.) and, finally, primary total knee arthroplasty (P.T.K.A.), which in recent times have been proposed for treating complex fractures in the elderly with poor bone quality and severe pre-existing knee arthrosis.

Open Versus Closed Operative Treatment for Tongue-Type Calcaneal Fractures: Case Series and Literature Review

Because consensus on the optimal surgical treatment of tongue-type calcaneal fractures is lacking, this study aimed to compare outcomes and postoperative complications of open and closed surgical treatment of these fractures. For this cases series, all patients 18 years or older who underwent operative fixation of tongue-type calcaneal fractures at 2 level I trauma centers between 2004 and 2015 were considered eligible for participation. Data on explanatory and outcome variables were collected from medical records based on available follow-up. Additionally, a systematic literature review on surgical treatment of these fractures was conducted. Fifty-six patients (58 tongue-type fractures) were included. Open reduction internal fixation was performed in 33 fractures, and closed reduction internal (percutaneous) fixation was performed in 25. More wound problems and deep infections were observed with open treatment compared with the closed approach: 10 (30%) versus 3 (12%) and 4 (12%) versus 0 (0%) procedures, respectively. In contrast, revision and hardware removal predominated in patients with closed treatments: 4 (16%) versus 1 (3%) and 9 (36%) versus 8 (24%) procedures, respectively. The systematic literature review yielded 10 articles reporting on surgical treatment for tongue-type fractures, all showing relatively good outcomes and low complication rates with no definite advantage for either technique. Both open and closed techniques are suggested as accurate surgical treatment options for tongue-type calcaneal fractures. Surgical treatment should be individualized, considering both fracture and patient characteristics and the treating surgeon's expertise. We recommend attempting closed reduction internal fixation if deemed feasible, with conversion to an open procedure if satisfactory reduction or fixation is unobtainable.

Impact of Increasing Comorbidity Burden on Resource Utilization in Patients With Proximal Humerus Fractures.

Proximal humerus fractures (PHF) are a common upper extremity fracture in the elderly cohort. An aging and more comorbid cohort, along with recent trends of increased operative intervention, suggests that there could be an increase in resource utilization caring for these patients. We sought to quantify these trends and quantify the impact that comorbidity burden has on resource utilization. Data on 83,975 patients with PHFs were included from the Premier Healthcare Claims database (2006 to 2016) and stratified by Deyo-Charlson index. Multivariable models assessed associations between Deyo-Charlson comorbidities and resource utilization (length and cost of hospitalization, and opioid utilization in oral morphine equivalents [OME]) for five treatment modalities: (1) open reduction internal fixation (ORIF), (2) closed reduction internal fixation (CRIF), (3) hemiarthroplasty, (4) reverse total shoulder arthroplasty, and (5) nonsurgical treatment (NST). We report a percentage change in resource utilization associated with an increasing comorbidity burden. Overall distribution of treatment modalities was (proportion in percent/median length of stay/cost/opioid utilization): ORIF (19.1%/2 days/$11,183/210 OME), CRIF (1.1%/4 days/$11,139/220 OME), hemiarthroplasty (10.7%/3 days/$17,255/275 OME), reverse total shoulder arthroplasty (6.4%/3 days/$21,486/230 OME), and NST (62.7%/0 days/$1,269/30 OME). Patients with an increased comorbidity burden showed a pattern of (1) more pronounced relative increases in length of stay among those treated operatively (65.0% for patients with a Deyo-Charlson index >2), whereas (2) increases in cost of hospitalization (60.1%) and opioid utilization (37.0%) were more pronounced in the NST group. In patients with PHFs, increased comorbidity burden coincides with substantial increases in resource utilization in patients receiving surgical and NSTs. Combined with known increases in operative intervention, trends in increased comorbidity burden may have profound effects on the cohort level and resource utilization for those with PHFs, especially because the use of bundled payment strategies for fractures increases. Level III.

Percutaneous reduction and screw fixation for all types of intra-articular calcaneal fractures.

This study compares the outcomes of consecutive of patients with Sanders II and III and IV calcaneal fractures that were stabilized by either close reduction and internal fixation (CRIF) or open reduction and internal fixation (ORIF). Group I (N = 49) underwent close reduction internal fixation (CRIF). Group II (N = 39) underwent open reduction internal fixation (ORIF). The clinical outcomes included time to operation, operative duration, visual analog score (VAS), length of hospital stay, wound-related complications and AOFAS SF-36 score. Preoperative and postoperative radiographic measures also were compared. The duration of operation in the CRIF group was considerably shorter than in ORIF group (P = 0.0001). Postoperatively, at seventh day, the VAS in the CRIF group (4.2 ± 1.1) was meaningfully lower than those of the ORIF patients group (4.7 ± 1.2, P = 0.04). Totally, the prevalence of wound complications in CRIF group was significantly lower than in ORIF group. In final follow-up visit after one year, AOFAS scores and SF-36 scores between groups were comparable. Comparable radiographic measures were found in both groups. There was no significant difference between groups regarding preoperative radiographic measures (P > 0.05), while in postoperative imaging acceptable calcaneal fracture reduction was found in both groups. We believed that for treatment of various types of calcaneal fracture compared with ORIF the percutaneous reduction and screw fixation may lead to shorter hospital stay, decreased subtalar joint stiffness and earlier weight bearing along with much favorable patients' satisfaction.

Comparison of intracapsular fracture neck of femur treated with dynamic hip screw versus cannulated cancellous screw: A retrospective study

Objective: The aim of this study was to compare clinical outcomes of young patients with intracapsular neck of femur fractures operated with dynamic hip system (DHS) or cannulated cancellous screw. Methods: One hundred patients with femoral neck fractures were treated by closed reduction internal fixation with a DHS (n=50; 36 males and 14 females; mean age: 39.1 years) or cannulated cancellous screws (n=50; 36 males and 14 females; mean age: 33.2 years) between January 2014 and December 2018 at JLN Medical College and Hospital, Ajmer, Rajasthan. The groups were retrospectively studied till September 2019 (with minimum follow-up of 9 months) and compared by clinical and radiological outcome and modified Harris hip score. Results: The average follow-up time was 23 months (range, 9-60 months). No statistically significant differences in the rates of nonunion (2% vs. 8%) and avascular necrosis of the femoral head (4% vs. 6%) were observed in DHS and CCS groups. DHS group has significantly less (12%) complication rate than CCS group (28%). The mean modified Harris Hip score was significantly higher in DHS group (90.05) compared to CCS group (85.34) (p value 0.015) with greater range of motion in former group. Conclusion: The DHS and cannulated cancellous screws might be equally effective in terms of postoperative fracture union. However, the DHS has advantages over cannulated compression screws for lesser no. of complications, especially neck shortening, non-union and osteonecrosis, higher range of motion, more clinical and radiologically favourable outcome and a better mean modified Harris hip score.

A-prospective study of the outcome of closed intramedullary fixation of humeral shaft fractures treated with multiple K-wires in adults

Objective: To evaluate the feasibility and efficacy of management of fracture of shaft humerus in adults by closed reduction internal fixation with the help of long K-wires followed by immobilization for 3 weeks in splint and then guarded mobilization till fracture united. Methods: This was a prospective longitudinal study. The subjects with fresh diaphyseal humeral shaft fractures without injury to the same limb, transverse/oblique fractures with a large butterfly fragment, comminuted fractures/segmental fragments and long oblique or spiral fracture were included in the study. Patient was taken on the table in lateral position. The general anaesthesia was given. A midline vertical incision of about 3 cms was given on the posterior aspect of distal humerus and the soft tissue dissected. Triceps was split in line with the fibres and the bone was reached. Results: The mean age of the patients was 42.13 (±13.02) years. More than half (69.6%) of the subjects were male. The RTA was among 65.2% of the subjects. The oblique with butterfly type of injury was in 30.4% of the subjects and comminuted was in 21.7%. The middle site of fracture was in 52.2% and left site of fracture was in 52.2%. The antegrade nailing was used among 69.6% of the patients. There was significant increase in the extent of union, constant score and Mayo score from 4 week to 8 and 12 week. The shoulder stiffness was among 65.2% at 4 week which became 13% at 8 and 12 week. The elbow stiffness was in 17.4% of the subjects which decreased to 13% and 8.7% at 8 and 12 week respectively. Conclusion: The present study showed that K-wire fixation for humeral shaft fractures has distinct advantages over other conservative and over operative techniques.

Comparison of the clinical efficacy of close reduction internal fixation with intramedullary pin and cross Kirschner wires for the treatment of metacarpal neck fractures

Objective To compare the clinical efficacy of close reduction internal fixation with intramedullary pin and cross Kirschner wires in the treatment of metacarpal neck fractures. Methods From March 2013 to March 2016, 85 cases of metacarpal neck fractures were treated in our hospital. Close reduction internal fixation with intramedullary pin was conducted in 49 cases (intramedullary pin group) and with cross Kirschner wires in 36 cases (Kirschner wire group). Both groups were performed by the same surgeon. After the operation the same functional exercise instruction was given. The hand function was evaluated by the TAFS system issued by American Hand Surgery Association 10 months after the operation. Results All the patients were follow-up for 10 to 16 months with an average of 12 months. The fracture healing time was 10 weeks in one case from each of the two groups, and 6 to 8 weeks in the other 83 cases. The average healing time was (6. 2 +2. 4) weeks from the intramedullary pin group and (6. 3 +1. 9) weeks from the Kirschner wire group. There was no significant difference in the healing time between the two groups (P>0. 05). TAFS scores of hand function were excellent in 39 cases, good in 7 cases, fair in 3 cases with the excellent and good rate being 93. 9% from the intramedullary pin group; while they were excellent in 16 cases, good in 14 cases, fair in 6 cases with the excellent and good rate being 83. 3% from the Kirschner wire group 10 months after the operation. The results from the intramedullary pin group were better than those from the Kirschner wire group. The difference was statistically significant (P<0. 05). Conclusion The close reduction internal fixation with intramedullary pin for the treatment of metacarpal neck fractures is a simple method with small trauma. It has little effect on hand function exercise after the operation. The score of hand function recovery is better than that of Kirschner wire group. Key words: Metacarpal bones; Fractures,bone; Fracture fixation, internal; Intramedullary pin; Cross Kirschner wires

Safety of urgent hip fracture surgery protocol under influence of direct oral anticoagulation medications

IntroductionDirect oral anticoagulation agents (DOACs) are increasingly prescribed to older adults. Concerns for perioperative blood loss dictate cessation of anticoagulation treatment and postponement of surgery until the coagulation system returns to normal state. The goal of this study is to compare the estimates of perioperative blood loss and mortality between patients using DOACs and patients receiving no anticoagultaion, in order to challenge the existing policy and question the need for surgery deferral. Materials and methodsThis is a retrospective cohort of patients (age > 65) with proximal hip fractures treated with either closed reduction internal fixation (CRIF, n = 1143; DOAC use n = 60) or hemiarthroplasty (HA, n = 571; DOAC use n = 29). Baseline patient characteristics included age, gender, ASA score, socioeconomic level, type of surgica#1: In general a l treatment, duration of surgery and time from admission to surgery. The effect of anticoagulant prescription on percentage of hemoglobin change, odds of receiving blood transfusions and one-month and one-year mortality was evaluated separately for CRIF and HA patients. ResultsPatients receiving DOACs had similar perioperative hemoglobin change, transfusion rates and mortality, compared to subjects without anticoagulants in both CRIF and HA cohorts. DOAC patients undergoing CRIF had a longer delay to surgery (40.2 ± 26.9 vs 31.2 ± 22.2, p = 0.003) and higher mortality rates at one year postoperatively (26.7% vs 16.1%, p = 0.015). ConclusionsDOAC use was not associated with an increased perioperative blood loss or mortality compared to controls. However, they had to wait longer for surgery, which itself was an independent predictor of mortality. It may be safe to shorten waiting time for surgery in patients using anticoagulation, with the goal to minimize surgery delay.

Outcome analysis of hybrid fixation technique (radius nailing and ulna plating) in closed proximal radius and ulna fractures in adults

Background: The aim of the study was to evaluate results of hybrid fixation technique (radius nailing and ulna plating) in closed proximal radius and ulna fractures in adults. The hypothesis behind hybrid fixation is to provide rigid fixation and restoration of forearm length, by ulna plating and large diameter square nail in radius gives rotational stability without any posterior interosseous nerve palsy in proximal radius and ulna fractures. Closed nailing of proximal radius avoid posterior interosseous nerve palsy which has high probability in open surgical approach.Materials and method: We prospectively evaluated 25 patients with closed proximal radius and ulna fractures. 20 males and 5 females with mean age of 30.7 years underwent closed reduction and intramedullary nail fixation in radius and open reduction internal fixation in ulna with plating. The fractures were classified according to the AO/OTA system. The average follow up was 1 year (range 6 months – 18 months). Results: The average time to union was 12.77 weeks (10-14 weeks). Union was achieved in all 25 patients in both radius and ulna. Using the Grace and Eversmann rating system7 patients were excellent, 16 good, 1 acceptable and 1 unacceptable results. Using Andersons scale 23 patients had an excellent, 2 unsatisfactory, 0 failure. None of the patients had intraoperative as well as postoperative complications and no posterior interosseous nerve palsy occurred in any of case. Conclusion: Closed reduction internal fixation with use of Hybrid fixation modality in closed proximal radius and ulna fractures has good results. Rigid fixation by ulna plating and rotational stability in radius by large diameter square nail provides almost the same construct as with dual plating with minimal invasive approach. Complication rates are lower as compared to plate osteosynthesis especially with similar union rates in terms of posterior interosseous nerve palsy.

A comparative study of management of Colles fracture by closed reduction with cast versus closed reduction with internal fixation (K-wires/4 mm CC screws)

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Distal radius fracture is extremely common and represents 16% of fractures treated by orthopaedic surgeons. Near anatomical reduction with restoration of radial length, radial tilt and ulnar variances are important for good functional results. A variety of treatment options have been proposed for distal radius fracture closed reduction and immbolization in cast has been the main stay of treatment, but because it invariably results in malunion, poor functional outcome and cosmetic outcome, other modality of treatment were brought into practice like percutaneous intrafocal pinning, transulnar percutaneous pinning, external fixation, plating etc. This comparative study was to compare the clinical outcomes of closed reduction with cast and closed reduction with Percutaneous Kirschner wiring (PKW)/canullated cancellous screws (CC screws 4 mm)for the management of Colles fractures in patients between 20 and 70 years old. In this study we did an prospective study in 40 patients with extra articular distal radius fracture treated by both closed reduction with cast and closed reduction internal fixation (PKW/CC screws).&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; There were 20 patients with Colles fractures treated by closed reduction with cast and 20 patients treated with closed reduction internal fixation (PKW/CC screws). We compared both the managements together. All patients were followed up in the orthopaedic department prospectively for at least 12 months between June 2015-June 2016 The functional outcomes and radiological results were compared between the two groups.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; The study included 40 patients, aged between 20 to 69 yrs. Average follow up was 12 months. Using the demerit scoring system of Gartland and Werley we had excellent to good results of 60% in closed reduction internal fixation compared to closed reduction with casting excellent to good was 10%.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; The percutaneous pinning/cc screws and immobilization in neutral position for 3 weeks followed by physiotherapy proved to be better and simple procedure for extra articular non comminuted distal radius fractures. &lt;/p&gt;

Operative Treatment of 2-Part Surgical Neck Fracture of the Humerus: Intramedullary Nail Versus Locking Compression Plate With Technical Consideration

To compare the outcomes of patients who underwent either open reduction internal fixation with a locking plate and screws or closed reduction internal fixation with an antegrade intramedullary nail (IMN) for displaced surgical neck fracture of the humerus. Retrospective comparative study. Single institute, Level-I academic trauma center. Sixty-nine patients with 2-part surgical neck fracture of the humerus underwent either an IMN (38 patients group A) or a locked plate fixation (31 patients group B). Pain on a visual analog scale, University of California Los Angeles (UCLA) Shoulder Score, American Shoulder and Elbow Surgeons (ASES) score, and active range of motion (ROM). At the 2-year follow-up, there were no significant differences in the visual analog scale pain score (1.3 in group A; 0.9 in group B), ASES score (90.2 in group A; 91.9 in group B), and UCLA Shoulder Score (30.7 in group A; 31.8 in group B) between groups. Active ROM did not differ significantly between groups. There were 3 complications in the IMN group, 1 nonunion requiring autogenous iliac crest bone graft, and 2 cases of screw loosening. For displaced surgical neck fractures of the humerus, both IM nailing and locked plate fixation in patients yielded satisfactory outcomes at the 2-year follow-up with no significant differences in pain or ROM between groups. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Dynamic hip system blade versus cannulated compression screw for the treatment of femoral neck fractures: A retrospective study

ObjectiveThe aim of this study was to compare clinical outcomes of patients with femoral neck fractures treated with the dynamic hip system blade (DHS-BLADE) or cannulated compression screws. MethodsEighty-six patients with femoral neck fractures were treated by closed reduction internal fixation with a DHS-BLADE (n = 42; 18 males and 24 females; mean age: 56.3 years (37–87)) or cannulated compression screws (n = 44; 20 males and 24 females; mean age: 53.8 years (26–83)) between March 2011 and August 2013. The groups were compared with Harris hip score, operation time, surgical blood loss, incision size, hospital stay, and related complications. ResultsThe average follow-up time was 27 months (range, 24–36 months). There was no significant difference for the operation time, incision size, hospital stay, and Harris hip score between the groups. Also, no statistically significant differences in the rates of nonunion (4.5% vs. 0) and avascular necrosis of the femoral head (9.1% vs. 7.1%) were observed. However, the screw group experienced significantly less surgical blood loss (32.4 ± 24.7 ml) than the blade group (87.2 ± 46.6 ml; P = 0.041). The incidence of femoral neck shortening above 10 mm in the screw group was significantly higher than that in the blade group (15.9% vs. 2.4%, P = 0.031). The blade group had a significantly lower incidence of screw migration than the screw group (4.8% vs. 22.7%, P = 0.016). ConclusionThe DHS-BLADE and cannulated compression screws might be equally effective in terms of postoperative fracture union. However, the DHS-BLADE has advantages over cannulated compression screws for preventing femoral neck shortening, screw migration, and cut-out. Level of evidenceLevel III, Therapeutic study.

Cost analysis of percutaneous fixation of hand fractures in the main operating room versus the ambulatory setting

To date, there have been no studies identifying the cost differential for performing closed reduction internal fixation (CRIF) of hand fractures in the operating room (OR) versus an ambulatory setting. Our goal was to analyse the cost and efficiency of performing CRIF in these two settings and to investigate current practice trends in Canada. A detailed analysis of the costs involved both directly and indirectly in the CRIF of a hand fracture was conducted. Hospital records were used to calculate efficiency. A survey was distributed to practicing plastic surgeons across Canada regarding their current practice of managing hand fractures. In an eight-hour surgical block we are able to perform five CRIF in the OR versus eight in an ambulatory setting. The costs of performing a CRIF in the OR under local anaesthetic, not including surgeon compensation, is $461.27 Canadian (CAD) compared to $115.59 CAD in the ambulatory setting, a 299% increase. The use of a regional block increases the cost to $665.49 CAD, a 476% increase. The main barrier to performing CRIFs in an outpatient setting is the absence of equipment necessary to perform these cases effectively, based on survey results. The use of the OR for CRIF of hand fractures is associated with a significant increase in cost and hospital resources with decreased efficiency. For appropriately selected hand fractures, CRIF in an ambulatory setting is less costly and more efficient compared to the OR and resources should be allocated to facilitate CRIF in this setting.

National trends in proximal humerus fracture treatment patterns.

The treatment of proximal humerus fractures (PHF) is largely surgeon dependent with no clear guidelines for selecting the optimal method of treatment. The aim of this study was to evaluate trends and variations in treatment methods of PHF in the United States from 2004 to 2012 and to determine the regional differences in treatment. The National Inpatient Sample was used to identify all patient discharges with diagnosis codes for PHF and the data were classified based on ICD-9 procedure codes. Patient and hospital demographics were also analyzed. Simple linear regression analyses were performed for each treatment modality to evaluate current treatment trends and to extrapolate the future trends of PHF treatment over the next 20years. A national estimate of 550,116 PHF discharges was identified over the time period. Significant correlations between change over time and treatment modality were found for reverse shoulder arthroplasty (RSA) (r = 0.903, p < 0.001), open reduction internal fixation (r = 0.876, p = 0.002), and closed reduction internal fixation (r = -0.922, p < 0.001). The RSA regression model showed that by the year 2032, PHF treated with RSA will increase 100% from 2012. There were significant changes in treatment modalities for PHF from 2004 to 2012; The projected number of RSA used to treat PHF will be about 9115 in 2032, compared to 340 in 2004. Overall, there was a growth in proximal humerus fractures treated in an inpatient setting in the United States. RSA had the greatest proportional increase over time, but only accounted for less than 2% of total interventions.

Treatment of pediatric closed femoral shaft fractures: A decline in use of external fixators over the last decade

Background: Femoral fractures represent 2% of all fractures in children. While external fixation was popular for managing pediatric closed femoral shaft fractures, other methods have recently increased in popularity. The purpose of this study was to analyze trends in the treatment of closed femoral shaft fractures over the past decade and quantify the change in usage of external fixators compared to other treatment methods in the pediatric population. Methods: The Healthcare Cost and Utilization Project Kids' Inpatient Database (KID) was utilized to generate the prevalence of closed femoral shaft fractures and treatment (open reduction internal fixation, closed reduction, closed reduction internal fixation, open reduction, and external fixation) from 2000 to 2012. Results: The total number of reported pediatric femoral fractures declined from 10,504 in 2000 to 7,798 in 2012. Male-to-female ratios and mean ages were comparable between years. Overall, treatment with external fixation for closed femoral shaft fractures decreased from 2000 to 2012. There was a decrease in external fixation in each year recorded compared to previously reported years. There were no significant differences in treatment by region or hospital size. However, over the 12-year period, the rate of external fixation declined more rapidly in pediatric hospitals compared to nonpediatric hospitals. Conclusions: Treatment of pediatric closed femoral fractures with external fixation has declined in favor of internal fixation over the past decade across all geographic regions and in both teaching and nonteaching hospitals in the United States. This decline in external fixation occurred more rapidly in pediatric hospitals compared to nonpediatric hospitals. The clinical and financial impact of this change in practice needs further investigation. Level of Evidence: Level III.

Delayed treatment of femoral neck fractures in 58 children: open reduction internal fixation versus closed reduction internal fixation

The best treatment plan for femoral neck fractures in children in whom treatment is delayed by more than 24 h is unclear because of the limited number of such cases reported. This study compares the outcomes of closed and open reduction performed 24 h after the injury was sustained. We retrospectively reviewed 58 cases (40 males, 18 females) of femoral neck fractures reset after more than a 24-h delay at our hospital (May 2005 to May 2014). According to Delbet's classification, there were 30 type II fractures (51.7%), 21 type III fractures (36.2%), and seven type IV fractures (12.1%). A total of 21 patients underwent closed reduction and internal fixation; the remaining patients underwent open reduction and internal fixation. The follow-up period was 17-61 months (average, 35.1 months). The results were classified according to Ratliff's criteria. With the exception of one case of bone nonunion (closed reduction group), the fracture was healed in the remaining cases. The average healing time was 10.82 weeks (9-13 weeks). The incidence of avascular necrosis was significantly lower in the open reduction group. Further, the percentage of results classified as 'fine' according to Ratliff's criteria was significantly higher in the open reduction group than in the closed reduction group. Coxa vara occurred in three patients in the closed reduction group, but it did not occur in any of the patients in the open reduction group. The incidence of avascular necrosis was significantly lower in the patients who achieved anatomical reduction than in the patients who only achieved acceptable reduction. Finally, the results in the anatomical reduction group were obviously better than those in the acceptable reduction group. Open reduction with internal fixation yielded better outcomes than closed reduction in this group of children with displaced femoral neck fractures who were treated more than 24 h after the injury. This may be related to the better reduction quality in the open reduction group. Therapeutic studies: investigating the results of treatment, Level III.

Treatment of femoral intertrochanteric fracture by early non general anesthesia and proximal femoral nail antirotation in patients over 90 years old

Objective To study the efficacy of early non general anesthesia and proximal femoral nail anti-rotation (PFNA) in the treatment of femoral intertrochanteric fracture in senile patients over 90 years old. Methods From June 2009 to June 2015, 37 senile patients with femoral intertrochanteric fracture were treated by early non general anesthesia and PFNA internal fixation. They were 14 men and 23 women, from 90 to 107 years of age (average, 93 years). By the AO classification, 11 cases were type 31-A1, 14 ones type 31-A2, and 12 ones type 31-A3. The time from injury to surgery ranged from 8 hours to 4 days (average, 3 days). All the patients underwent closed reduction and PFNA internal fixation in non general anesthesia. Results The operation time in this group ranged from 30 to 70 minutes (average, 40 minutes). Their intraoperative bleeding ranged from 50 to 150 mL (average, 100 mL). They were followed up for an average time of 12 months (range, from 6 to 16 months). All the fractures healed after an average time of 12.5 weeks (range, from 10 to 16 weeks). Incision exudates occurred in one case postoperation. No postoperative complications such as deep vein thrombosis of lower limb, bedsore, urological infection, hip varus deformity, implants loosening and breakage, and delayed union were observed during follow-ups. According to the Harris scores at the final follow-ups, the hip function was rated as excellent in 11 cases, good in 19, medium 6, and poor in one, yielding a good to excellent rate of fine rate of 81.1%. Conclusions PFNA in early non general anesthesia is a successful treatment of femoral intertrochanteric fracture for elderly patients. Advantages of the remedy include simple manipulation, limited trauma, shorter operation time, less bleeding, early ambulation, and reduced postoperative complications. Key words: Hip fractures; Fracture fixation, intramedullary; Bone nails; Aged, 80 and over

Impact of nutritional status on perioperative hidden blood loss in elderly patients with intertrochanteric fracture treated with proximal femoral nail antirotation

Objective To observe the effect of nutritional status variation on hidden blood loss in elderly patients with intertrochanteric fracture treated with proximal femoral nail antirotation (PFNA). Methods Ninety-six elderly patients with femoral intertrochanteric fracture aged 72-94 years [mean, (78.7±9.5)years] were submitted to closed reduction and PFNA internal fixation. According to the mini nutritional assessment (MNA) score, the patients were randomized into normal-nourishment group (n=26), potentially malnourishment group (n=32) and malnourishment group (n=38). Correlation between MNA score and serological examination was analyzed. Total blood loss and hidden blood loss were calculated depending on height, weight, intra-operative blood loss, post-operative blood loss, pre-and post-operative Hct, and blood transfused. According to the mean hidden blood loss, patients were divided into low (n=51) and high (n= 45) hidden blood loss groups. Relationship among high hidden blood loss, MNA score, and serological examination was evaluated. Results Preoperative MNA score showed strong correlation with nutritional evaluation results assessed by serological examination, and the detection effectiveness of malnutrition by albumin (ALB), prealbumin (PA), transferrin (TRA), and T lymphocyte percentage (TLP) was better than that by total protein (TP), total lymphocyte count (TLC) and hemoglobin (Hb). Nutritional status was further deteriorated after PFNA in patients with malnutrition. Forty-five patients were found to have high hidden blood loss. Incidence of high hidden blood loss revealed significant difference among groups (P<0. 05). Preoperative incidence of hidden blood loss assessed by ALB, PA, TRA, TLP and Hb in high hidden blood loss group was obviously higher than that in low hidden blood loss group. Postoperative incidence of hidden blood loss assessed by the serological examination in high hidden blood loss group was evidently higher than that in low hidden blood loss group as well as higher than the preoperative results. Preoperative MNA score, ALB, PA, TRA, TLP and Hb showed strong correlations with high hidden blood loss (r =0.495, 0.480, 0.471, 0.502, 0.367 and 0.309, respectively, P<0.05). Conclusions Total blood loss, hidden blood loss and incidence of high hidden blood loss are gradually increased with the deterioration of nutritional status. MNA score and serological examination (ALB, PA, TRA, TLP and Hb) have significant values in predicting the risk of high hidden blood loss. Key words: Hip fractures; Nutritional status; Blood loss, surgical; Perioperative