Extracapsular Femoral Fractures Research Articles

Fractures of the proximal femur and hip osteoarthrosis - coincidence or coherence?

The current study aimed to investigate the correlation between the grade of radiographic hip osteoarthritis (OA) and the fracture pattern observed in fragility fractures of the proximal femur. The information may help in cases of occult hip fractures. In this retrospective study all 448 patients treated with fragility fractures of the proximal femur in the years 2014-2018 were included. Patients were allocated into two groups: Group I) intracapsular (femoral neck) fractures and Group II) extracapsular (pertrochanteric and subtrochanteric) femoral fractures. The radiographic grade of OA was determined according to Kellgren and Lawrence's classification. One single observer examined all radiographs. Patients' age ranged between 52 and 104years with a mean of 80.0years. There was a significant difference in mean age between the two groups (76.9years intracapsular vs. 83.1years extracapsular fractures). A total of 250 (55.8%) fractures were intracapsular (femoral neck) and 198 (44.2%) were located extracapsular (pertrochanteric, subtrochanteric). A significant correlation between the degree of OA to fracture pattern was observed: Higher degrees of OA were related to extracapsular fractures and lower degrees of OA to intracapsular fractures. The results of this study support the hypothesis that hip osteoarthritis affects the fracture pattern in proximal femur fractures. More severe hip OA is associated with extracapsular fractures that can be treated surgically with lower complication rates compared to intracapsular fractures.

Blood-Transfusion Risk Factors after Intramedullary Nailing for Extracapsular Femoral Neck Fracture in Elderly Patients

Extracapsular femoral neck fractures (eFNF) are the third most common type of fracture in traumatology. Intramedullary nailing (IMN) is one of the most frequently used ortho-pedic treatments for eFNF. Blood loss is one of the main complications of this treatment. This study aimed to identify and evaluate the perioperative risk factors that lead to blood transfusion in frail patients with eFNF who undergo IMN. From July 2020 to December 2020, 170 eFNF-affected patients who were treated with IMN were enrolled and divided into two groups according to blood transfusion: NBT (71 patients who did not need a blood transfusion), and BT (72 patients who needed blood transfusion). Gender, age, BMI, pre-operative hemoglobin levels, in-ternational normalized ratio (INR) level, number of blood units transfused, length of hospital stay, surgery duration, type of anesthesia, pre-operative ASA score, Charlson Comorbidity Index, and mortality rate were assessed. Cohorts differed only for pre-operatively Hb and surgery time (p < 0.05). Patients who have a lower preoperative Hb level and longer surgery time have a high blood-transfusion risk and should be closely followed peri-operatively.

Extracapsular femoral neck fractures treated with total hip arthroplasty: identification of a population with better outcomes.

Femoral neck fractures (FNF) are associated to patient's disability, reduced quality of life and mortality. None of the fixation devices commonly used for extracapsular (EC) FNF (i.e., dynamic hip screws (DHS) and intramedullary nails (IN)) is clearly superior to the other, especially in case of unstable fractures (31.A2 and 31.A3 according to AO/OTA classification). The aim of our study was to identify a sub-population of patients with EC fractures in which better outcomes could be obtainable using total hip arthroplasty (THA). All patients with EC unstable fractures treated with THA were included in the present study. Demographic data, American Society of Anesthesiologists (ASA) score, hospitalization length, transfusion rate, implant-related complications and mortality rate were collected. Clinical outcomes were evaluated using the Oxford Hip Score (OHS), while patients' general health status through the 12 Item Short Form questionnaires (SF-12). 30 patients (7 male; 23 female) with a mean age of 78.8 years were included. The 1-year mortality rate was 13.3%. The mean OHS was 27.5, while the mean SF-12 were 45.84 for the mental item and 41.6 for the physical one. Age was the only factor associated with the OHS and patients older than 75 years presented a 12- fold higher risk of developing bad outcomes. THA seems to be a viable option for unstable EC fractures, with good clinical outcomes, especially in patients younger than 75 years of age. The mortality rate associated with THA in EC fractures is low and anyway comparable with IN.

Fixation and Implant Retention of Extracapsular Femoral Neck Periprosthetic Fractures Around Hip Resurfacing Arthroplasty - A Case Series.

Background:Extracapsular femoral neck fractures in the presence of a resurfacing hip arthroplasty (RHA) appear to be independent of suboptimal technique during the initial implantation of the RHA and present with a similar etiology as native hip fractures – that is, a fragility fracture related to pathological or age-related osteoporosis, as a consequence of trauma. In the presence of a well-fixed and previously well-functioning RHA, the options for management include revision arthroplasty or open reduction and internal fixation (ORIF). In the absence of loosening through mechanisms of wear, infection, metallosis, or suboptimal prosthesis positioning, many authors have advocated ORIF with implant retention. However, there is often debate regarding the use of total hip arthroplasty in these casesCase Series:The authors conducted a thorough assessment of the literature followed by a retrospective review of outcomes for three patients treated by ORIF with implant retention for extracapsular femoral neck fractures around a RHA, using a standardized technique. All patients were independently mobile and active with well-fixed and well-functioning RHAs before the date of injury. All patients suffered low-energy trauma resulting in the fracture. There were no intraoperative or perioperative complications. All patients achieved full weight-bearing status and independent mobility. Two patients achieved radiographic union and returned to full range of movement and independent mobilization comparable to their preoperative state. One patient was lost to follow-up.Conclusion:The authors believe that fixation of extracapsular proximal femoral fractures distal to a well-fixed, well-functioning RHA is a good management option in an independent and active patient. A higher level of evidence is needed to investigate the surgical management options of these injuries comparing osteosynthesis with revision arthroplasty.

Key factors influencing clinical and functional outcomes in extracapsular proximal femur fractures: the role of early weight-bearing - one-year follow-up cohort of 495 patients.

Aim To establish a correlation between immediate post-surgical weight bearing in extracapsular hip fractures and final functional outcome as well as to study the correlation between immediate post-surgical weight bearing and morbidity and mortality during the first year. Methods Retrospective observational cohort study including 495 consecutive patients ≥75 years old operated of extracapsular proximal femur fracture. Medical records were reviewed and information of demographic data, radiological evolution, time to weight-bearing, mortality rate, medical and surgical complications and final ambulation status were recorded. Results Patients' mean age was 87 years; 378 (76.4%) were females. One-year mortality rate was 21.2%. Immediate weight bearing was associated with: decreased hospital stays (7.5 days vs. 9.2 days; p=0.001) and decreased medical complications (78.3% vs. 82.3 %; p=0.02). Surgical complications prevalence was comparable (4.4% vs. 7.8 %; p=0.43) within the groups. Despite mortality rate was lower in patients with immediate weight bearing (21%) compared with delayed weight bearing (21.4%), the difference was not statistically significant (p=0.9). Conclusion Immediate weight bearing was associated with shorter hospital stay and fewer medical complications, improving functional outcome. Also, no correlation was found between immediate weight bearing and increased surgical complications or mortality rate during first year after surgery.

Short term results of modular bipolar hemiarthroplasty for the treatment of neglected trochanteric femur fracture in the elderly

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; In rural India because of native practitioner culture people tend to neglect orthopaedic injuries and often present late to the hospitals. Bipolar hemiarthroplasty for neglected intertrochanteric fractures of the femur in the elderly yields good clinical results in terms of early postoperative ambulation. This will have a direct effect on the general condition and postoperative rehabilitation.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; Sixteen patients with proximal extracapsular femoral fractures presented average 10.4 weeks late from the day of injury, were treated with modular bipolar hemiarthroplasty. There were 11 men and 5 women, with mean age of 72.8 years (range: 65–83 years). Primary cemented bipolar hemiarthroplasty was performed using the Hardinge lateral approach in a lateral decubitus position. Harris hip score was used for the clinical evaluation of the patients.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Clinically, the Harris hip score at the last follow-up ranged from 92 to 59, with a mean value of 81.7. Postoperative radiographs showed a good position in all patients. 1 patient developed complication during cementing and 1 case came with dislocation. No case of infection, acetabular erosion, periprostheic fracture or implant loosening was reported in this study.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Primary cemented bipolar hemiarthroplasty is a good choice in elderly patients with neglected intertrochanteric fractures of the femur.&lt;/p&gt;

Functional Aspects and Physiotherapy Education in Home Between Intra- and Extra-Capsular Femoral Fractures of Hospitalized Elderly

Objective: To verify the intra- and extra-capsular femoral fracture, the degree of dysfunction that the elderly patient presents in the postoperative period, and the care they receive at hospital discharge. Design/Setting: This was a prospective cross-sectional study conducted elderly patients hospitalized for proximal femoral fractures who received clinical and surgical care in a public hospital. Participants: Twenty-five elderly patients with femoral fractures: intra capsular (GFI; n=11) and extra-capsular (GFE; n=14). Main Outcome Measures: Questionnaire to the postoperative clinical aspects was performed. The angle joint of the lower limbs was determined by goniometer and the foot functionality by Foot Function Index (FFI) questionnaire. The pain was evaluated using the visual analogue pain scale (VAS) and muscle strength by the force scale. Results: A greater female predominance was observed for GFI group. Regarding home guidelines, both groups of fractures did not present reports by the health professionals involved. The range of motion remained reduced for hip adduction and ankle dorsiflexion in GFE group. The GFI group reduced flexion and extension knee and the functionality of the feet. Conclusions: It can be concluded that proximal femoral fractures intra- and extra-capsular, differ according to gender, with a female predominance of intra-capsular fractures. As well, regarding the range of joint motion, the extra-capsular fractures resulted in reductions in hip adduction and ankle dorsiflexion compared to intra-capsular fractures, which presented reductions in knee flexion and extension. Regardless of the type of fracture, there was no home guidance after the surgical procedure.

A Study of Functional Outcome of Patients with Extra Capsular Femoral (Pertrochanteric) Fractures Managed by Proximal Femoral Locking Compression Plate

A Study of Functional Outcome of Patients with Extra Capsular Femoral (Pertrochanteric) Fractures Managed by Proximal Femoral Locking Compression Plate

Fractures of the femur and blood transfusions

BackgroundBlood loss estimation after trauma (i.e. physical injury) and early identification of potential sources of bleeding are important for planning of investigation and management of trauma. Long bone fractures have been reported to be associated with substantial volumes of blood loss requiring blood transfusion. The aim of this study was to assess rates and amounts of blood transfusion in the setting of isolated extra capsular femur fractures and to determine variables associated with the need for transfusion within the first 48 h of admission. MethodsA retrospective cohort study was conducted of patients in The Alfred Trauma Registry with isolated extra capsular femur fractures over a 7-year period. We compared patients with a femoral shaft fracture (FSF) to patients with either distal femur or proximal femur fractures (i.e. extremity fracture). We collected data potentially associated with blood transfusion within 48 h as well as operation details and patient outcomes. ResultsThere were 293 patients included, of which 121 had FSF and 172 extremity fracture. 105 (36%) patients received a blood transfusion during their admission. Admission haemoglobin (AOR 0.92; 95%CI 0.89–0.94, p < 0.01) was the only independently associated variable with blood transfusion within the first 48 h of hospital admission. ConclusionVolume of blood transfused to patients with extra-capsular femoral fractures was low and usually in the post-operative period. FSF, compared to femoral extremity fractures, were not more likely to receive blood transfusion within the first 48 h of admission, and did not receive a higher volume of blood overall. In the setting of major trauma with haemorrhagic shock, alternate sources of bleeding should be sought.

Intra-operative fluoroscopic radiation exposure in orthopaedic trauma theatre

IntroductionRadiation exposure from intra-operative fluoroscopy in orthopaedic trauma surgery is a common occupational hazard. References for fluoroscopy use in the operating room for commonly performed operations have not been reported adequately. This study aimed to report appropriate intra-operative fluoroscopy use in orthopaedic trauma and compare the effect of surgery type and surgeon grade on radiation exposure.MethodsData on 849 cases over an 18-month period were analysed retrospectively. Median and 75th centile values for dose area product (DAP), screening time (ST), and number of fluoroscopy images were calculated for procedures where n > 9 (n = 808).ResultsMedian DAP for dynamic hip screws for extracapsular femoral neck fractures was 668 mGy/cm2 (ST 36 s), 1040 mGy/cm2 (ST 49 s) for short proximal femoral nail, 1720 mGy/cm2 (ST 2 m 36 s) for long femoral nail for diaphyseal fractures, 25 mGy/cm2 (ST 25 s) for manipulation and Kirschner wire fixation in distal radius fractures, and 27 mGy/cm2 (ST 23 s) for volar locking plate fixation in distal radius fractures. These represented the five commonest procedures performed in the trauma operating room in our hospital. Experienced surgeons utilized less radiation in the operating room than junior surgeons (DAP 90.55 vs. 366.5 mGy/cm2, p = 0.001) and took fewer fluoroscopic images (49 vs. 66, p = 0.008) overall.ConclusionsThis study reports reference values for common trauma operations. These can be utilized by surgeons in the operating room to raise awareness and perform clinical audits of appropriate fluoroscopy use for orthopaedic trauma, using this study as guidance for standards. We demonstrated a significant reduction in fluoroscopy usage with increasing surgeon experience.

Bipolar hemiarthroplasty for the treatment of unstable trochanteric fracture femur in the elderly

Background Hemiarthroplasty using bipolar prostheses for unstable intertrochanteric fractures of the femur in the elderly yields good clinical results in terms of early postoperative ambulation. This will have a direct effect on the general condition and postoperative rehabilitation. Patients and methods Thirty patients with unstable proximal extracapsular femoral fractures were treated with bipolar hemiarthroplasty. There were 22 men and eight women, with mean age of 60 years (range: 55–70 years). Primary cemented bipolar hemiarthroplasty was performed using the Hardinge lateral approach in a lateral decubitus position. Harris hip score was used for the clinical evaluation of the patients. Results Clinically, the Harris hip score at the last follow-up ranged from 93 to 54, with a mean value of 79.5. Postoperative radiographs showed a good position in all patients. According to the Gruen scoring for cementation, 15 (50%) cases scored A, eight (26.66%) cases scored B, three (10%) cases scored C1, two (6.66%) cases scored C2, and two (6.66%) cases scored D. Four cases developed complications in this study: infection (two patients), loosening (one patient), and acetabular wear (one patient). Revision was performed in one patient because of loosening. Conclusion Primary cemented bipolar hemiarthroplasty is a good choice in elderly patients with unstable intertrochanteric fractures of the femur, and it saves time as well as cost, with little significant complications.

Étude comparative des plaques verrouillées à compression de fémur proximal avec les vis plaques dynamiques de hanche (DHS) dans le traitement des fractures fémorales proximales extracapsulaires

IntroductionThe potential value of proximal femoral locking compression plate (PFLCP) for extracapsular femoral fractures has been discussed in several case reports; however, clinical control studies are lacking. Therefore, we performed a case control study to assess: 1) If PFLCP offers better functional results and fewer complications than dynamic hip screws (DHS)? 2) Which kind of extracapsular femoral fractures would benefit from PFLCP fixation? HypothesisThe PFLCP fixation offers better functional results and fewer complications than the DHS for the treatment of extracapsular fractures. Patients and methodsA total of 83 patients with extracapsular femoral fractures were recruited. Forty-one patients underwent PFLCP fixation, and 42 patients underwent DHS fixation. Patient information, operative time, blood loss, functional level (as assessed by Sanders’ traumatic hip rating scale), bone union, and implant complications were compared for the two treatment groups. ResultsPatients with stable intertrochanteric fractures who underwent PFLCP fixation demonstrated shorter bone union time than the DHS fixation group (3.3±0.2 vs. 4.3±0.1 month; P<0.0001); however, both groups had 100% bone union and good to excellent scores on Sanders’ traumatic hip rating scale (P=1.000). Patients with unstable intertrochanteric fractures who underwent PFLCP fixation experienced greater blood loss (619.0±23.9 vs. 474.1±19.8ml; P<0.0001), which was mainly due to the need for open reduction (64.3% vs. 12.5%; P=0.003), compared to the DHS fixation group. No differences were identified with respect to bony union, functional level, or complications. Patients with subtrochanteric fractures who underwent PFLCP fixation demonstrated significantly shorter operative times (82.1±4.3 vs 102.2±2.2min; P<0.0001), less blood loss (751.8±25.4 vs. 987.6±32.0ml; P<0.0001), shorter bone union times (5.2±0.4 vs. 8.8±1.0 month; P=0.006), more good to excellent Sanders’ traumatic hip rating scale scores (92.9% vs. 55.5%; P=0.009), and fewer complications (14.2% vs. 66.6%; P=0.005) than the DHS fixation group. ConclusionPFLCP fixation offers better functional outcomes and fewer complications for subtrochanteric femoral fractures but not for intertrochanteric femoral fractures. Levels of evidenceCase control study, level III.

A comparison of proximal femoral locking compression plates with dynamic hip screws in extracapsular femoral fractures

IntroductionThe potential value of proximal femoral locking compression plate (PFLCP) for extracapsular femoral fractures has been discussed in several case reports; however, clinical control studies are lacking. Therefore, we performed a case control study to assess: (1) If PFLCP offers better functional results and fewer complications than dynamic hip screws (DHS)? (2) Which kind of extracapsular femoral fractures would benefit from PFLCP fixation? HypothesisThe PFLCP fixation offers better functional results and fewer complications than the DHS for the treatment of extracapsular fractures. Patients and methodsA total of 83 patients with extracapsular femoral fractures were recruited. Forty-one patients underwent PFLCP fixation, and 42 patients underwent DHS fixation. Patient information, operative time, blood loss, functional level (as assessed by Sanders’ traumatic hip rating scale), bone union, and implant complications were compared for the two treatment groups. ResultsPatients with stable intertrochanteric fractures who underwent PFLCP fixation demonstrated shorter bone union time than the DHS fixation group (3.3±0.2 vs. 4.3±0.1 month; P<0.0001); however, both groups had 100% bone union and good to excellent scores on Sanders’ traumatic hip rating scale (P=1.000). Patients with unstable intertrochanteric fractures who underwent PFLCP fixation experienced greater blood loss (619.0±23.9 vs. 474.1±19.8ml; P<0.0001), which was mainly due to the need for open reduction (64.3% vs. 12.5%; P=0.003), compared to the DHS fixation group. No differences were identified with respect to bony union, functional level, or complications. Patients with subtrochanteric fractures who underwent PFLCP fixation demonstrated significantly shorter operative times (82.1±4.3 vs. 102.2±2.2minutes; P<0.0001), less blood loss (751.8±25.4 vs. 987.6±32.0ml; P<0.0001), shorter bone union times (5.2±0.4 vs. 8.8±1.0 month; P=0.006), more good to excellent Sanders’ traumatic hip rating scale scores (92.9% vs. 55.5%; P=0.009), and fewer complications (14.2% vs. 66.6%; P=0.005) than the DHS fixation group. ConclusionPFLCP fixation offers better functional outcomes and fewer complications for subtrochanteric femoral fractures but not for intertrochanteric femoral fractures. Levels of evidenceCase control study, level III.

The Treatment of Intertrochanteric Fractures of the Femur with Endovis Nail

BACKGROUND The incidence of fractures in the trochanteric area has risen with the increasing numbers of elderly persons with osteoporosis. The imperative goals of treatment are early mobilization by means of stable fixation using as minimally invasive a procedure as possible. Nowadays, there is an increasing interest in intramedullary nailing, especially for unstable intertrochanteric fractures. The aim of the present paper is to assess the efficacy of closed intramedullary osteosynthesis with the Endovis® proximal femoral nail in the treatment of peritrochanteric fractures to solve the problems associated with the use of intramedullary fixation devices. MATERIAL AND METHODS The authors describe their experience with 87 stable and unstable proximal extra-capsular femoral fractures treated with the Endovis femoral nail from July 2007 to March 2009. The results were evaluated clinically, functionally and radiographically during the 1st, 3th, 6th and 12th months post-op. Pre-injury activity and functional levels were recorded using the modified Harris hip score and V.A.S. score. RESULTS Postoperative radiographs showed a near-anatomical fracture reduction in 85% of patients. Three were the cases of cut-out, one case of valgus and two cases of shortening of the operated leg (<1 cm). The Harris Hip Score increased between the thirtieth and ninetieth postoperative day, accompanied by a significant decrease in pain symptoms and functional limitation. CONCLUSION 1. The application of an intramedullary nail provides primary stability of the fracture. 2. The Endovis nail constitutes a powerful synthesis for stable and unstable fractures of the trochanteric region, in which is difficult to reconstruct appropriate continuity between the medial and posterior cortical layers. 3.The good mechanical stability of the nail allows rapid mobilization and early functional recovery. 4. The presence of an additional anti-rotational screw and the free sliding mechanism of the lag screw may increase rotational stability of cervico-cephalic fragments and decrease overload on the femoral head.

Clinical and functional outcomes of internal fixation with intertrochanteric antegrade nail in older patients with proximal extracapsular femoral fractures.

The intertrochanteric Trigen Intertan(®) nail (Smith & Nephew, Memphis, TN) is a popular fixation device for proximal extracapsular femoral fractures (PEFFs). We evaluated clinical and functional outcomes in patients with PEFFs treated with Trigen Intertan(®) nail. In a single-site, prospective observational study, clinical and functional parameters were recorded for all patients admitted to the Emergency Department with PEFFs from June 2008 through June 2011. Patients with severe cognitive impairment, severe disability, neoplastic pathological fractures, or suffering from terminal illnesses were not eligible for the study. Fractures were classified according to the AO/OTA classification system. Preoperative physical fitness was assessed via the American Association of Anaesthetists (ASA) score. The Barthel index was used to quantify the level of physical function before fracture and at follow-up. One-hundred thirty-five patients with PEFFs were eligible for inclusion during the 3-year survey (mean age 83.2±9.5years; 82% females). Fracture type distribution was as follows: A1.1=18%, A1.2=7%, A1.3=5%, A2.1=44%, A2.2=21%, A2.3=5%. All patients were treated with Trigen Intertan(®) nail. Two patients experienced a fracture of the femoral shaft during the insertion of a long nail for an A2.3 fracture. Weight-bearing was allowed between the third and tenth postoperative day depending on pain tolerance and general conditions. No loss of reduction, collapse of the femoral neck, nonunion or fixation failure were observed. Two patients died within 10days postoperatively, and nine within 6months after surgery. Functional status 1month after surgery was lower than pre-fractural levels, and improved over follow-up. At 6months, functional status was comparable to the pre-fractural level. Trigen Intertan(®) produces highly satisfactory clinical and functional results in older patients with PEFFs. Complete functional recovery is obtained on average 6months after surgery.

Radiation Exposure During Internal Fixation of Extracapsular Femoral Neck Fractures by Today's Trainees

The use of intraoperative fluoroscopy screening is often crucial to the success of fracture fixation in orthopaedic trauma surgery. Given the possible link to carcinogenesis as well as other complications, limited exposure to and protection from radiation is mandated both for staff and patients. Governing bodies in several countries, including the UK, dictate that exposures be kept as low as reasonably practicable.

L-F4.1 Clinical and functional outcomes of internal fixation with intertrochanteric antegrade nail in older patients with proximal extracapsular femoral fractures: a case series

L-F4.1 Clinical and functional outcomes of internal fixation with intertrochanteric antegrade nail in older patients with proximal extracapsular femoral fractures: a case series

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.

The treatment of intertrochanteric fractures of the femur with Endovis nail

The incidence of fractures in the trochanteric area has risen with the increasing numbers of elderly persons with osteoporosis. The imperative goals of treatment are early mobilization by means of stable fixation using as minimally invasive a procedure as possible. Nowadays, there is an increasing interest in intramedullary nailing, especially for unstable intertrochanteric fractures. The aim of the present paper is to assess the efficacy of closed intramedullary osteosynthesis with the Endovis® proximal femoral nail in the treatment of peritrochanteric fractures to solve the problems associated with the use of intramedullary fixation devices. The authors describe their experience with 87 stable and unstable proximal extra-capsular femoral fractures treated with the Endovis femoral nail from July 2007 to March 2009. The results were evaluated clinically, functionally and radiographically during the 1st, 3th, 6th and 12th months post-op. Pre-injury activity and functional levels were recorded using the modified Harris hip score and V.A.S. score. Postoperative radiographs showed a near-anatomical fracture reduction in 85% of patients. Three were the cases of cut-out, one case of valgus and two cases of shortening of the operated leg (<1 cm). The Harris Hip Score increased between the thirtieth and ninetieth postoperative day, accompanied by a significant decrease in pain symptoms and functional limitation. 1. The application of an intramedullary nail provides primary stability of the fracture. 2. The Endovis nail constitutes a powerful synthesis for stable and unstable fractures of the trochanteric region, in which is difficult to reconstruct appropriate continuity between the medial and posterior cortical layers. 3.The good mechanical stability of the nail allows rapid mobilization and early functional recovery. 4. The presence of an additional anti-rotational screw and the free sliding mechanism of the lag screw may increase rotational stability of cervico-cephalic fragments and decrease overload on the femoral head.

Radiation exposure during internal fixation of extracapsular femoral neck fractures by trainees

Radiation exposure during internal fixation of extracapsular femoral neck fractures by trainees