Fixation Of Intertrochanteric Fractures Research Articles

A novel load-sensing sliding hip screw to aid in the assessment of intertrochanteric fracture healing.

Bone healing after sliding hip screw internal fixation of intertrochanteric hip fractures is difficult to monitor with radiography. In this study, we describe and evaluate a device to non-invasively determine the loading on the screw implant as a possible qualitative indicator of bone healing. A novel load-sensing sliding hip screw (LS-SHS) was fabricated containing a radio-dense tungsten indicator rod that moves and can be measured within the screw cannulation when the screw bends under load via plain radiography. Screw bending was assessed in intact femurs and unstable A1 intertrochanteric fractures using experimental axial loading of femoral composite Sawbones® and femoral human cadaveric specimens. Sensor readings were visually tracked using plain radiographs at each load state. The sensor exhibited linear response to implant strain in the unstable fracture indicating that the implant supported the major component of the applied load. This was consistently measurable using radiography throughout loading cycles across the mechanical and cadaveric fracture models. Sensor readings indicated that the implant was mostly unloaded in the intact models. The slope of the curve was approximately equal in the composite and cadaveric models (1.0µm/N and 0.08µm/N, respectively). Sensor noise levels were sufficient to detect 10% of the applied load of 80kg, which has the potential to qualitatively assist clinicians in tracking fracture healing progression. Clinicians must carefully monitor their patients for signs of SHS implant failure after surgery. This device quantitively measures implant loading which could qualitatively assist clinicians in the assessment of fracture healing.

Immediate weight bearing as tolerated versus delayed weight bearing following intramedullary fixation for geriatric intertrochanteric fractures: a post hoc analysis

BackgroundEarly weight bearing is crucial for fracture healing after osteosynthesis for intertrochanteric fractures (ITFs). The optimal period to start weight bearing after surgery is still under debate. The aim of this study was to compare immediate weight bearing (IWB) as tolerated with delayed weight bearing (DWB) following intramedullary fixationin elderly ITF patients.MethodsThis post hoc analysis included patients aged ≥ 65 years with X-ray-confirmed ITFs who were admitted within 21 days after injury and who underwent intramedullary fixation surgery. The primary outcome was the EQ-5D score at 120 days after surgery. The secondary outcomes included the EQ-5D score at 30 days and 365 days after surgery, the complication rate and the mortality rate.ResultsAmong 410 patients (190 IWB, 220 DWB), those in the IWB group had higher EQ-5D scores at 30 (P < 0.001) and 120 days (P = 0.002) but lower scores at 365 days (P = 0.012) than did those in the DWB group. There were no significant differences in the complication rates, reoperation rates, or one-year mortality rates between the groups.ConclusionsCompared with delayed weight bearing, immediate weight bearing improves early functional outcomes without increasing the complication or mortality rates in elderly ITF patients.

Key Decision-Making in Post-Failed Internal Fixation of Intertrochanteric Fractures Hip Arthroplasty: A Multicenter Retrospective Study onFractureHealing'sImpact on Femoral Component Selection.

Following failed internal fixation of intertrochanteric fractures (FIF-ITF), the decision to use a long-stem or standard-stem femoral implant in hip arthroplasty is still debated. This study aimed to explore how the healing status of fractures after FIF-ITF failure affects the choice of femoral stem and clinical outcomes. Our retrospective cohort study reviewed 105 cases of patients with FIF-ITF who underwent hip arthroplasty at three tertiary Grade A hospitals between December 2012 and December 2022. We compared the clinical outcomes between patients with healed and unhealed fractures, focusing on the selection of femoral stems in relation to proximal medial support and the healing status of the greater trochanter. The primary outcomes measured were functional results, operative time, blood loss, and incidence of complications. A subgroup analysis was conducted to further evaluate the influence of the proximal medial buttress and greater trochanteric healing on femoral stem selection. Statistical analysis included binary and ordinal logistic regression to identify factors influencing the choice of femoral stems. Additionally, a decision tree model was developed to visually represent and explore the relationship between fracture healing status and the selection of femoral components. The study included 38 patients with healed fractures and 67 patients with unhealed fractures. Patients in the healed group predominantly chose standard stems and experienced better functional outcomes (p < 0.001, p = 0.002). In contrast, the unhealed group preferred long stems, resulting in longer surgical durations and increased blood loss (p = 0.008, p < 0.001). Binary logistic regression analysis revealed that nonunion of the proximal femoral medial buttress was an independent risk factor for long stems (p < 0.0001, OR = 10.402). The selection of femoral prostheses following FIF-ITF is influenced by the fracture healing status, particularly the presence of proximal femoral medial buttress. The decision tree model suggested that long-stem prostheses are more appropriate when there is inadequate fracture healing and the proximal femoral medial buttress is absent.

Trends in Medicare Utilization and Reimbursement for Intertrochanteric Femur Fractures: A 21-Year Review.

Sliding hip screw (SHS) and intramedullary (IMN) constructs are commonly utilized treatments for intertrochanteric (IT) femur fractures. The aim of this study was to assess the economic and utilization trends in the management of IT fractures among the Medicare population over the last 21years. A review of the publicly available Medicare Part B National Summary Data File for years 2000-2021 was performed. Collected data included true physician reimbursement and utilization numbers for all CPT codes pertaining to fixation of IT fractures with either SHS or IMN. A total of 1,361,112 IMN implants and 739,032 SHS implants were billed to Medicare for intertrochanteric femur fractures during the studied timeline. In this 21-year span, utilization of IMN increased 695% (9648-76,667), while utilization of SHS decreased by 96% (94,223-4224). After adjusting for inflation, the average physician reimbursement for SHS decreased by 34%, while IMN decreased by 41%. Absolute physician reimbursement was found to be $943.36 for SHS and $999.88 for IMN constructs. Intramedullary implants are being increasingly utilized while sliding hip screw, and intramedullary construct reimbursement continues to decrease for intertrochanteric femur fracture fixation. These trends suggest that opting for a sliding hip screw may be more cost-effective when the fracture pattern allows for either construct.

Fixing of intertrochanteric fractures with proximal femoral nail antirotation 2 by a double incision technique: a retrospective analysis

Background: The incidence of hip fractures is projected to rise from 1.66 million in 1990 to 6.26 million by 2050. Internal fixation is the most prevalent surgical intervention for intertrochanteric fractures. Hip fractures represent a significant healthcare issue amongst the elderly. The aim of this study is to evaluate a double incision technique in comparison to the conventional incision for fixing intertrochanteric fractures using the standard proximal femoral nail antirotation (PFNA2). Methods: This study took place at Dr. D. Y. Patil hospital in Navi Mumbai, India, from May 2023 to May 2024 employing an open-label, retrospective, randomized, and comparative methodology. A total of 100 patients with proven radiographic intertrochanteric fracture having undergone fixation with PFNA2 were analysed, with 50 undergoing the double incision and 50 serving as the stand control group. Results: The minimally invasive technique with a modified incision using the standard proximal femoral nail A2 can reduce bleeding, enhance precision for the entry point of the guidewire, shorten the time required for the entry, decrease soft tissue injuries, and provide better aesthetic outcomes. Conclusions: The current study delineates a minimally invasive surgical technique employing a double incision for the fixation of intertrochanteric fractures using the proximal femoral nail A2, underscoring its benefits.

Outcomes of sliding hip screw fixation in stable versus unstable intertrochanteric hip fractures

Purpose: Unstable intertrochanteric (IT) fractures are common orthopedic injuries in the elderly people with high morbidity. The treatment of unstable IT fractures with sliding hip screw (SHS) is still controversial. The purpose of our study is to assess the outcomes of conventional SHS in unstable IT fractures in comparison to stable ones. Methods: A total of 35 stable and 23 unstable IT fracture cases were treated with SHS between January 2017 and December 2018. Patients were evaluated for infection, revision rate, screw cut-out, development of post-traumatic arthritis or heterotopic ossification, and mortality. Results: The mean age of the patients at the time of surgery was 69.8 and 73.9 years for stable and unstable IT fractures, respectively, with 38 males (25 stable vs. 13 unstable) and 20 females (10 in each group). The mean follow-up was 42.2 and 49.4 weeks in stable and unstable IT fractures, respectively. We found a significant association between the occurrence of screw cut-out in unstable fractures compared to stable ones (17.4% vs. 0%, respectively, p = 0.01). There was an obvious trend for nonunion and higher revision rates in unstable IT fractures (17.4% vs. 2.9%, p = 0.056). Logistic regression analysis did not reveal any statistically significant confounder that might affect the rates of fracture union or revision rates. Post-traumatic arthritis and heterotopic ossification occurred in one case of unstable IT fracture. There were no reported cases of infection. Conclusion: There are higher risks of screw cut-out, nonunion, and the need for revision when the SHS is used to treat unstable IT fractures.

Predictors for 1-year mortality in geriatric patients following fragile intertrochanteric fracture surgery

ObjectiveTo investigate the risk factors influencing 1-year mortality after intramedullary nail fixation for fragile intertrochanteric fracture in elderly individuals.MethodsThe medical records of 622 consecutive elderly patients (aged ≥ 65 years) with fragile intertrochanteric fractures treated with proximal femoral nail anti-rotation (PFNA) and followed-up were retrospectively analyzed. The patients were divided into death and survival groups according to their survival status within 1 year after surgery, and the differences in age, sex, region of residence, tobacco use, alcohol use, body mass index (BMI), comorbidities (hypertension, diabetes mellitus, coronary heart disease, stroke, dementia, chronic obstructive pulmonary disease, pneumonia), preoperative hemoglobin, preoperative albumin, deep vein thrombosis, fracture type (AO classification), injury-to-surgery time, American Society of Anesthesiologists (ASA) score, anesthesia modality, duration of surgery, intraoperative blood loss, and blood transfusion were compared. The Kaplan–Meier method was used for univariate analysis to screen for statistically significant differences between the two groups, and the data were entered into the Cox proportional hazards model for multivariate analysis to determine independent risk factors affecting 1-year postoperative mortality. For subgroup analysis, we explored the varying effects of hypoproteinemia and being underweight in patients of different genders, as well as the effects of different age ranges, different injury-to-surgery times, and different blood transfusion volumes on 1-year postoperative mortality.ResultsThe mortality rates at 1, 3, and 6 months, and 1 year after surgery were 3.9%, 7.2%, 10.1%, and 15.3%, respectively. Univariate analysis showed that advanced age, male sex, tobacco use, underweight (BMI < 18.5), coronary heart disease, stroke, dementia, pneumonia, number of comorbidities ≥ 3, hypoproteinemia and injury-to-surgery time ≤ 2 days were associated with the 1-year postoperative survival status (P < 0.1). Multivariate analysis revealed that advanced age, male sex, dementia, number of comorbidities ≥ 3, hypoalbuminemia, and being underweight were independent risk factors for 1-year postoperative mortality. Subgroup analysis showed that being underweight was associated with 1-year postoperative mortality only in male patients but not in female patients, whereas hypoproteinemia was associated with 1-year postoperative mortality in both male and female patients. Furthermore, an injury-to-surgery time of less than 2 days improved patient survival, and patients more than 80 years old showed an elevated risk of postoperative mortality.ConclusionsPreoperative health status is a critical predictor of postoperative outcomes in elderly patients with fragile intertrochanteric fractures. Priority care should be given to the patients who are elderly, male, have dementia, have comorbidities, or are malnourished. Prompt nutritional reinforcement should be provided to patients with intertrochanteric fractures with comorbid hypoproteinemia and underweight. Furthermore, surgery should be performed as early as possible in patients with fewer comorbidities.

A study of functional outcome of intertrochanteric fractures operated with intraheal proximal hip stabilizing nail-multicentric study

Background: Modalities of fixation in intertrochanteric fractures have been a topic of debate since times immemorial. Our special aims at comparing the functional outcome of Intraheal™ proximal hip stabilizing nail (PHSN, GPC Medical Limited) fixation in 200 patients of intertrochanteric fractures. Methods: 200 patients of intertrochanteric fracture fulfilling the inclusion criteria were included in our study. Preoperative AP and Lateral views of hip joint were taken for all patients. In post-operative period, the patients were reviewed at 2 weeks, 1 month, 3 months, 6 months, and 12 months by the operating surgeon. Functional assessment, radiological assessment of bony union and complications were evaluated in follow up period. Results: 200 patients underwent Intraheal™ proximal hip stabilizing nail fixation. They were followed-up the patients at 2 weeks, 1, 3, 6 and at 12 months postoperatively AP and lateral pelvic X-rays were obtained at each follow-up, and implant position changes, all complications, and fixation failures were recorded. We included a total of 200 patients meeting the criteria in this study and follow up was done till 12 months postoperatively. Intra-operative complications, time of hospital stay, Varus fixation and fracture displacement were assessed. Conclusion: Advantages noted with PHSN fixation were excellent Harris hip score, lesser screw cutout, early union rate. However, PHSN had greater incidence of anterior thigh pain at all intervals of follow-up. There were no significant local wound complications or duration of hospital stay.

Functional evaluation of unstable intertrochanteric fractures treated with proximal femoral nailing

In this study the functional outcome of proximal femoral nailing (PFN) in patients with unstable intertrochanteric fractures is studied and outcome is assessed with Modified Harris Hip Score. A post-operative analysis of unstable intertrochanteric fractures treated with PFN is done for its functional assessment. Various national &amp; international studies are taken into consideration and our institutional study is compared with them. Between September 2020 to March 2022, 20 patients with unstable intertrochanteric fractures of the hip joint who were operated with PFN were functionally and clinically evaluated as per the Modified Harris Hip Score. Patients who satisfied the inclusion criteria were included in the study and follow-up was done up to 9 months. Fracture pattern, operative details and post-operative complications were documented. This study of 20 patients of unstable intertrochanteric fractures fixed with PFN showed excellent results in 9 patients (45 %), good functional outcome in 6 patients (30 %) and fair functional outcome in 3 patients (15 %). 2 patients showed a poor outcome accounting for 10%. The study showed that PFN is a reliable and effective device for the treatment of unstable intertrochanteric fractures. It provides a satisfactory fixation, but success is dependent mainly on fracture type, bony architecture, operative technique, postoperative care and rehabilitation. In view of the fewer post-operative complications, early union of fracture, early weight bearing and early return to work, we concluded the PFN to be a versatile, stable and acceptable implant in fixation of unstable intertrochanteric fractures which leads to a better functional outcome.

Beyond 25 millimetres makes the difference: a prospective study on tip apex distance in dynamic hip screw treatment of intertrochanteric fractures

Background: The tip apex distance (TAD) is a key indicator of screw cut-out risk in dynamic hip screw (DHS) treatment for intertrochanteric fractures. This study sought to assess the prognostic significance of TAD in intertrochanteric fractures managed with DHS. Methods: This prospective observational study encompassed 50 patients with intertrochanteric fractures who had DHS fixing treatment. TAD was measured on postoperative radiographs. Patients were followed clinically and radiologically for a minimum of 3 months. The primary outcome was screw cut-out. Results: The mean TAD was 25.5 mm, with a range of 10 to 47 mm. Four screw cut-outs were seen, all in patients with TAD exceeding 35 mm. The mean TAD was 24.18 mm for successfully treated fractures, in contrast to 40.89 mm for those who experienced cut-out. No cut-outs were seen with TAD &lt;25 mm. The inferior-central region of the femoral head was the predominant site for screw placement, occurring in 30% of cases. Conclusions: TAD is a dependable predictor of screw cut-out risk in DHS fixation of intertrochanteric fractures. Maintaining a TAD &lt;25 mm and screw position in the inferior-central zone of the femoral head may help minimize cut-out risk. Surgeons should aim for proper screw placement and consider TAD when treating these fractures.

Hip arthroplasty following failure of internal fixation in intertrochanteric femoral fractures: classification decision-making for femoral stem selection and clinical validation

AimsFollowing Failed Internal Fixation of Intertrochanteric Fractures (FIF-ITF), the choice of treatment remains a clinical challenge. This study introduces a novel classification system to guide the selection of femoral prostheses in hip arthroplasty (HA) and validates its clinical efficacy.MethodsRetrospectively, we analyzed 108 cases from three university-affiliated hospitals between December 2012 and February 2023 involving patients who underwent hip arthroplasty due to Failed Internal Fixation of Intertrochanteric Fractures (FIF-ITF). Patients were classified into three categories based on fracture healing, proximal femoral support, and the severity of femoral cortical defects, with subtypes identified. Surgical outcomes and complication rates were compared between the Classification-based Decision Group and the Non-classification Decision Group.ResultsThe Classification-based Decision Group did not differ significantly from the Non-classification Decision Group in operation time, blood loss, or the use of cemented stems. However, the classification system markedly reduced the risk of periprosthetic fractures intraoperatively from 22.5 to 4.4% and postoperatively from 10 to 1.4%. The Classification-based Decision Group also demonstrated higher postoperative Harris Hip Score (HHS) and Visual Analog Scale (VAS) scores.ConclusionThe proposed classification system serves as an innovative clinical tool for femoral prosthesis selection in hip arthroplasty post-FIF-ITF, effectively reducing complications and enhancing hip function in the Classification-based Decision Group, underscoring its significant clinical utility.

Conversion hip arthroplasty for failed nailing of intertrochanteric fracture: Reflections on some important aspects.

In this editorial, I present my comments on the article by Solarino et al. Conversion hip arthroplasty, which is an optional salvage procedure performed following unsuccessful fixation of intertrochanteric femur fractures in elderly patients, entails more complex processes and higher rates of operative complications than primary arthroplasty. Hence, it is important to consider the appropriateness of the primary treatment choice, as well as the adequacy of nailing fixation for intertrochanteric fractures. This article briefly analyzes the possible factors contributing to the nailing failure of intertrochanteric fractures and attempts to find corresponding countermeasures to prevent fixation failures. It also analyzes the choice of treatment between nailing fixation and primary arthroplasty for intertrochanteric fractures.

Comparative Study between Dynamic Hip Screw (DHS) with Lateral Stabilizing Plate versus Proximal Femoral Nail (PFN) in Fixation of Unstable Intertrochanteric Fractures. A Systematic Review &amp; Meta-Analysis

Abstract Background Intertrochanteric fractures are one of the elementary orthopaedic clinical problems accounting for 7% of osteoporotic fracture. These kind of fractures usually caused by low-energy trauma such as a fall from standing height with several risk factors including; increasing age, female gender, osteoporosis, a history of falls, and gait abnormalities. Usually intertrochanteric fracture is classified according to its stability. Fracture stability is dependent on the status of the posteromedial cortex. Stable fractures are commonly simple fractures which are less affected by vertical stress during one-leg standing. Unstable intertrochanteric fracture has decreased ability to resist stress due to affection of Posteromedial or Lateral femoral cortex. Patients and Methods Asystematic review &amp; Meta analysis was design with a careful consideration of the Cochrane Handbook for Systematic Reviews of Interventions. We also will follow The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines during the design of our study. Population: Patients with unstable Intertrochanteric fractures, intervention: Dynamic hip screws (DHS) with lateral stabilizing plate(TSP), comparator: Proximal Femur Nail, outcome parameters: Functional and radiological, study design: Clinical trials whether randomized or nonrandomized prospective or retrospective cohort, case control studies. Results Use of TSP with DHS can give good results in unstable inter trochanteric fractures. As compared to DHS with TSP, PFN is technically more demanding surgery and in our meta analysis and systematic review study we found complication rate of PFN to be higher as compared to DHS with TSP. Addition of TSP to DHS gives good lateral wall buttress which prevent excessive medialization of shaft and gives comparable result to PFN which is considered as better implant in unstable fractures. Conclusion The current systematic review indicated that there is no statistically significant difference between patients operated with Dynamic Hip Screw with Trochanteric lateral Stabilization Plate and Proximal Femoral Nail.

Proximal Femoral Nail vs Arthroplasty for Unstable Intertrochanteric Fracture in Elderly (Systematic Review &amp; Meta Analysis)

Abstract Background Hip fractures impose a considerable economic burden on healthcare, with intertrochanteric fractures contributing to increasing morbidity. The global incidence of hip fractures is expected to rise to 4.5 million by 2050, primarily due to aging and osteoporosis. Osteoporosis weakens bones, making them susceptible to fractures even from minor traumas, with femoral intertrochanteric fractures being prone to comminution. Aim of the Work To compare between proximal femoral nail and arthroplasty for Unstable intertrochanteric fracture in elderly. The objective is to perform a systematic review to better management procedure. Patients and Methods This systematic review and meta-analysis aimed to compare arthroplasty and proximal femoral nail (PFN) fixation for unstable intertrochanteric fractures in elderly patients. The study included 24 studies with 2699 patients, analyzing factors such as surgery duration, peri-operative blood loss, blood transfusion, complications, Harris hip score (HHS), and mortality. Results PFN had a significantly shorter surgery duration compared to arthroplasty, with the latter exhibiting higher blood loss. Arthroplasty also required more blood transfusion, attributed to its invasive nature. While complications did not significantly differ between groups, arthroplasty showed a higher rate of thromboembolic complications. Mortality rates were significantly higher in the arthroplasty group, emphasizing the importance of early mobilization for patient outcomes. Conclusion Underscores the significant superiority of PFN over hemiarthroplasty in treating elderly patients with intertrochanteric fractures. The PFN group had a statistically shorter operative time, less blood loss, lower mortality compared to the arthroplasty group. However, no significant differences in functional outcomes using HHS were observed between the two compared groups. In addition, no significant differences were found concerning complications between the PFN and arthroplasty groups.

Functional Outcomes of PFN Fixation and Hemiarthroplasty of Unstable Intertrochanteric Fractures in Elderly A Comparative Study

Abstract Background Unstable Intertrochanteric Fracture of femur in elderly forms a great challenge to orthopedic surgeons, the aim of the management is early ambulation and good functional outcome also avoiding complications as the elderly patients often have several comorbidities. Aim of the Work To compare Functional hip outcome between active elderly patient who receive either a bipolar hemiarthroplasty or fixation via proximal femoral nail, after an unstable intertrochanteric femoral fractures through HHS. Patients and Methods prospective Cohort study was conducted at Ain Shams university hospitals recruiting 48 active patients aged from 60 and above with unstable intertrochanteric fracture femur starting from November 2022 till January 2024. We excluded patients with pathological fractures, revision cases and patients unfit for surgery. Patients were in 2 groups each group 24 patients, one group for PFN fixation and the other for Bipolar Hemiarthroplasty (BHA). The mean follow-up period was 1 year. Results In this study, we found that there is statistically significant difference between PFN and BHA regarding the functional outcomes towards the PFN Conclusion For the healthy elderly with Unstable intertrochanteric Femoral Fractures. Fixation with PFN appeared to be superior with respect to HHs as indicator to Functional outcomes.

Comparison of three methods of greater trochanter fixation in intertrochanteric femur fractures (AO type 31/A2) treated with cementless bipolar hemiarthroplasty

Aim: The aim of this study was to compare the three most commonly used fixation methods for the fractured trochanter major fragment in patients undergoing uncemented bipolar hemiarthroplasty for unstable intertrochanteric fractures. Methods: The medical records of 231 acute hip fracture cases aged 65 years and older with AO classification 31/A2.2 and 31/A2.3 who underwent unilateral primary cementless bipolar hemiarthroplasty at Adana Şehir Training and Research Hospital between January 2021 and January 2023 were retrospectively analyzed. The files were classified into three groups based on the fixation technique used in the operation. Results: There were 231 files, with a mean age of 82.3±7.9. The majority (55.8%) were classified as ASA III. The analysis resulted in no significant differences between the groups in terms of age, number of days between the day of the injury and the day of the surgery, fixation failure, nonunion, number of revision surgeries, hospitalization duration, and HHS recorded at the third and sixth-month follow-up visits. Among the 73 males and 158 females, the ratio of the side in which the fracture occurred showed no difference (p=0.854). The female rate was significantly higher in group 3 compared to other groups (p=0.003). Regarding union success, cases in group 1 had significantly lower trochanter major union rates (p

Fixation of Intertrochanteric Fractures with Proximal Femoral Nail (PFN) versus Dynamic Hip Screw (DHS) - A Comparative Study

Hip fractures, particularly intertrochanteric fractures, pose significant challenges due to their association with disability, mortality, and economic burden, especially among the elderly population. Trochanteric fractures primarily occur due to low-energy falls, which are more frequent in elder individuals with age-related impairments in vision, hearing, and reflexes.This prospective study aimed to compare the outcomes of Proximal Femoral Nail (PFN) versus Dynamic Hip Screw (DHS) fixation in unstable intertrochanteric fractures.

Standard radiographic images in cephalomedullary nailing fixation for intertrochanteric femoral fractures

To review and summarize the projections of radiographic images during cephalomedullary nailing fixation for intertrochanteric femoral fractures, and to propose a set of three projections as standard requirement in immediate postoperative fluoroscopy. Papers on intertrochanteric femoral fractures treated with cephalomedullary nailing fixation that published in a three-year period of 2021-2023 in four leading English orthopedic trauma journals were searched in PubMed. The presented radiographic pictures were identified and scrutinized as whether they were in standard anteroposterior and/or lateral projections of the implanted nails. The nonstandard presence percentage was calculated. Combined with clinical experience, the standard anteroposterior and lateral perspective images of femoral neck, the current situation of radiographic imaging in the operation of cephalomedullary nails, the literature analysis of nonstandard images, the impact of limb rotation on image interpretation, and the characteristics of anteromedial 30° oblique perspective were summarized and analyzed. The presence of nonstandard radiographic pictures is 32.1% in anteroposterior view and 69.2% in lateral view in leading orthopedic trauma journals. In cephalomedullary nailing fixation operation of intertrochanteric femoral fractures, it is reasonable to use the radiographic images of the implanted nails to represent the fractured head-neck, as the head-neck implant (lag screw or helical blade) is aimed to put into centrally in femoral head in lateral projection. Limb rotation or nonstandard projections produced distortion of images, which interfers the surgeons' judgement of fracture reduction quality and the measurement of implant position parameters in femoral head (such as neck-shaft angle and tip-apex distance), and finally lead to a meaningless comparison with the accurate normal value. The 30° anteromedial oblique view from the true lateral (set as 0°) is a tangential projection of the cortices at the anteromedial inferior corner, which gives a clear profile for the determination of cortical apposition status and mechanical support. It is essential to get firstly the true standard lateral fluoroscopy of the nail (shown as a line), then rotate the C-arm to 90° and 30° to get anteroposterior and anteromedial oblique views, and use these three immediate postoperative radiographies as the baseline for evaluation of operative quality and follow-up comparisons. As for real-time monitoring of surgical steps, intraoperative fluoroscopy follows the "Enough is Good" principle, but as for immediate postoperative data storage and basis for operative quality evaluation and baseline for follow-up comparison, it is recommended to obtain a set of three standard radiographic pictures in anteroposterior, true lateral, and 30° anteromedial oblique fluoroscopic projections.

Finite element analysis of fixation stability according to reduction position for internal fixation of intertrochanteric fractures

In recent years, finite element analysis (FEA) has been instrumental in comparing the biomechanical stability of various implants for femur fracture treatment and in studying the advantages and disadvantages of different surgical techniques. This analysis has proven helpful for enhancing clinical treatment outcomes. Therefore, this study aimed to numerically analyze fixed stability according to location using FEA. In this study, a virtual finite element model was created based on a clinically anatomically reduced patient. It incorporated positive and negative support derived from intramedullary and extramedullary reduction from the anteroposterior (AP) view and neutral support from the lateral view. The generated model was analyzed to understand the biomechanical behavior occurring in each region under applied physiological loads. The simulation results of this study showed that the average von Mises stress (AVMS) of the nail when performing intramedullary reduction for femoral fixation was 187% of the anatomical reduction and 171% of the extramedullary reduction, and individually up to 2.5 times higher. In other words, intramedullary reduction had a very high possibility of fixation failure compared to other reduction methods. This risk is amplified significantly, especially in situations where bone strength is compromised due to factors such as old age or osteoporosis, which substantially affects the stability of fixation. Extramedullary reduction, when appropriately positioned, demonstrates greater stability than anatomical reduction. It exhibits stable fixation even in scenarios with diminished bone strength. In instances in which the bone density was low in the support position, as observed in the lateral view, the AVMS on the nail appeared to be relatively low, particularly in cases of positive support. Additionally, the femur experienced lower equivalent stress only in the extramedullary reduction-negative position. Moreover, by comparing different reduction methods and bone stiffness values using the same femoral shape, this study offers insights into the selection of appropriate reduction methods. These insights could significantly inform decision making regarding surgical strategies for intertrochanteric fractures.

Functional Outcomes of Bipolar Hemiarthroplasty in Unstable Intertrochanteric Femur Fractures in the Elderly: A Prospective Study.

Background Intertrochanteric femur fractures are relatively common injuries among elderly individuals. Treatment options include fixation of intertrochanteric fractures using proximal femoral nails (PFNs), dynamic hip screws (DHSs), and unipolar and bipolar hemiarthroplasty. Unstable types of intertrochanteric fractures (Arbeitsgemeinschaft für Osteosynthesefragen (AO) types 31-A2 and A3) are more common in elderly osteoporotic people. Intertrochanteric femur fractures having a subtrochanteric extension, comminution at the posteromedial cortex, and reverse obliquity are considered to be unstable. The purpose of the study is to evaluate the functional outcomes of an unstable intertrochanteric femur fracture treated with bipolar hemiarthroplasty as the primary treatment option. Aims and objectives This study aims to assess the functional outcomes of bipolar hemiarthroplasty in unstable intertrochanteric fractures in the elderly using the Harris Hip Score (HHS) and the Merle d'Aubigné and Postel Criteria. The time point of assessment was from August 2016 to August 2018. Material and methods Fifteen elderly patients with unstable intertrochanteric fractures of the femur were treated with cemented bipolar hemiarthroplasty. Patients with unstable femur fractures or with osteoporosis and age above 65 years were included in the study. Harris Hip Score and the Merle d'Aubigné and Postel Criteria were used to measure functional outcomes. Patients were followed up at the first, third, and sixth months and subsequently at the end of one year. Results The mean age of the patients was 78.73 years. The majority (11) of the patients were female (73%). The average operative time was 119 minutes, the average blood loss was 380 ml, the mean postoperative hospital stay was 12 days, and the average time taken for mobilization was four days. An average of 15 elderly patients with unstable intertrochanteric fractures of the femur were treated with cemented bipolar hemiarthroplasty. The HHS on the first follow-up was 42.44 (SD of 6.52), followed by a score of 64.43 (SD of 8.11) on the second follow-up, 82.32 (SD of 2.81) on the third follow-up, and 84.23 (SD of 3.15) on the fourth follow-up. Eleven patients had good results, and two had fair results at the one-year follow-up, according to the HHS. According to the Merle d'Aubigné and Postel Criteria, 11 patients had very good results, and two had moderate results at the one-year follow-up. The average Merle d'Aubigné score was 14.6 on the final follow-up after one year. Conclusion Bipolar hemiarthroplasty in an unstable intertrochanteric femur fracture in the elderly results in better functional outcomes, as it helps in early full weight-bearing mobilization, which significantly decreases complications of prolonged immobilization and can be safely considered in the treatment of unstable intertrochanteric fractures in elderly patients.