Fixation Of Proximal Femoral Fractures Research Articles

Total Hip Arthroplasty After Failed Internal Fixation of Proximal Femoral Fractures

Between February 1987 and October 2008, we performed 102 total hip arthroplasties (THAs) after failed internal fixation of a prior hip fracture. There were 39 intertrochanteric fractures and 63 femoral neck fractures. Etiology of failure included 35 cases of osteonecrosis, 32 cases of arthritis, 25 cases of early failure of fixation, and 10 cases of nonunion. There were 12 patients who had early surgical complications related to the procedure (11.8%, 12/102). These included 5 patients who had dislocations (4.9%), 4 periprosthetic fractures (3.9%), 2 hematomas (2.0%), and 1 infection (1%). Of these 102 THAs, 50 were available for at least 2 years of follow-up (mean, 3.2 years). At a minimum 2-year follow-up, THA after failed internal fixation of hip fracture in these patients was clinically successful with an elevated risk of periprosthetic fracture and dislocation.

Less Invasive Stabilization System (LISS) Versus Proximal Femoral Nail Anti-rotation (PFNA) in Treating Proximal Femoral Fractures

To evaluate the outcome and efficacy of LISS (Less Invasive Stabilization System; Synthes USA, Paoli, PA) for the treatment of proximal femoral fractures to find another appropriate minimally invasive surgery for these fractures in which intramedullary nailing may be difficult. A consecutive prospective randomized clinical study. University teaching hospital. Between May 2006 and March 2008, 64 consecutive patients who had a proximal femoral fracture were randomized to be treated with fixation with either LISS or PFNA (Proximal Femoral Nail Anti-rotation; Synthes USA). LISS or PFNA fixation of proximal femoral fractures. Intraoperative time, intraoperative blood loss, length of hospitalization, hip function (Harris score), general complications, fracture complications. Fifty-nine patients were evaluated with a mean follow-up time of 26.8 months (range, 21-36 months). No statistical differences in general complications, intraoperative blood loss, length of hospitalization, or hip function could be found between the two groups. The average operative time was longer in the LISS group (98.25 minutes) compared with the PFNA group (65.36 minutes) (P < 0.05). One PFNA case had intrapelvic penetration of the helical blade; two LISS cases had breakage of the screws. There were no major differences in outcome or complications between the treatment groups. LISS can be used effectively in treating proximal femoral fractures, especially for complex fractures patterns in which intramedullary nailing may be difficult. Therapeutic Level II. See page 128 for a complete description of levels of evidence.

Tip Apex Distance – Is It Enough To Predict Implant Failure?

The aim of this study was to establish any association between implant cut-out and a Tip Apex Distance (TAD), ≥25mm, in proximal femoral fractures, following closed reduction and stabilisation, with either a Dynamic Hip Screw (DHS) or Intramedullary Hip Screw (IMHS) device. Furthermore, we investigated whether any difference in cut-out rate was related to fracture configuration or implant type. WE conducted a retrospective review of the full clinical records and radiographs of 65 consecutive patients, who underwent either DHS or IMHS fixation of proximal femoral fractures. The TAD was measured in the standard fashion using the combined measured AP and lateral radiograph distances. Fractures were classified according to the Muller AO classification. 35 patients underwent DHS fixation and 30 patients had IMHS fixation. 5 in each group had a TAD≥25mm. There were no cut-outs in the DHS group and 3 in the IMHS group. 2 of the cut-outs had a TAD≥25mm. The 3 cut-outs in the IMHS group had a fracture classification of 31-A2, 31-A3 and 32-A3.1 respectively. In addition, the fractures were inadequately reduced and fixed into a varus position. A TAD

Proximal femoral periprosthetic fracture fixation with a hooked locking plate: a Kenyan experience

The advent and increasing use of joint replacement for various pathologies has led to a new group of fractures- the periprosthetic fractures. The hip joint is no exception to this group, a fair share of these fractures do occur around the hip joint. The management of these fractures is complex and usually needs application of basic principles to fit an individual situation rather than having a fixed set of rules. In this article we discuss the use of a hooked locking plate in the management of one such fracture.

Non-invasive traction for proximal femoral fractures in amputees

Fracture reduction for fixation of proximal femoral fractures in amputees using a Steinmann pin carries the risk of infection and delayed mobilisation. The use of an arm trap used for shoulder arthroscopy provides non-invasive traction of the limb. Rotational control can be achieved using an assistant with a steady grip if required. Apply a thin layer of wool to the stump followed by the hand trap (Allen Medical Systems, Ashby de la Zouch, LE65 1JG). Wrap with a four-inch self-adhesive bandage (3M™ Coban™, 3M Health Care Ltd, Loughborough, LE11 1EP) and secure the cord to the traction table. Prepare and drape as routine. Figure 1 Use of the hand trap

Modular endoprosthetic replacement for failed internal fixation of the proximal femur following trauma

Although originally designed for reconstruction after primary malignant bone tumour resection, modular endoprosthetic replacement (EPR) can be used in salvage surgery for complex periprosthetic fracture and failed internal fixation. The purpose of this study was to assess the functional outcome following EPR for failed internal fixation of the proximal femur. We assessed clinical and functional outcomes of using a modular tumour endoprosthesis to reconstruct the proximal femur following failed internal fixation in eight consecutive patients between 2001 and 2008. There were four men and four women, with a mean age of 67.5 (range 50-79) years and a mean follow-up of 16.5 (6-36) months. All patients had failed internal fixation for traumatic proximal femoral fractures--four 31.A2.3, two 31.A3.1, two 31.A3.3 using the Arbeitsgemeinshaft für Osteosynthesefragen (AO) fracture classification. Mean time from the first attempted internal fixation to definitive EPR was 34 (6-102) months, and the median number of previous surgical procedures was two (1-11). Histology revealed infection (two cases), uninfected nonunion (five cases) and plasmocytoma (one case). The EPR was carried out as a one-stage procedure in six cases and a two-stage procedure in two cases. Mean postoperative Harris Hip Score was 71.4 (range 64-85). There were no surgical complications. One patient died as a result of systemic complications of myeloma several years following EPR. EPR is an effective salvage procedure for failed fixation of traumatic proximal femoral fractures. Immediate weightbearing and a good functional outcome can be expected in this difficult group of patients.

Gotfried Percutaneous Compression Plating Compared with Sliding Hip Screw Fixation of Intertrochanteric Hip Fractures

The use of a Gotfried percutaneous compression plate provides a minimally invasive technique for the fixation of intertrochanteric proximal femoral fractures. The purpose of this study was to determine if the percutaneous compression plate provided advantages compared with the sliding hip screw for treatment of A1 and A2 AO/OTA intertrochanteric proximal femoral fractures. An institutional review board-approved, prospective, randomized, single-blinded study was conducted at a level-I trauma center between July 2004 and September 2007. All patients who met the study criteria and provided informed consent were randomized to treatment with a sliding hip screw or percutaneous compression plate. Of the sixty-six patients who consented to participate, thirty-three were randomized to be treated with a sliding hip screw and thirty-three, with a percutaneous compression plate. Data evaluated included surgical time, incision length, blood loss, need for blood transfusion, and postoperative functional status. Follow-up included clinical findings, radiographs until healing was confirmed, functional and pain assessment scores, and the Short Form-36. The median follow-up period for surviving patients was thirty-six months. Sixty-six patients, forty-seven women and nineteen men, with a mean age of seventy-seven years were entered into the study. The treatment groups were similar with respect to study variables (p > 0.05). Operative times (forty-eight vs. seventy-eight minutes), incision length (56 vs. 82 mm), and blood loss (41 vs. 101 mL) significantly favored the percutaneous compression plate group (p < 0.001). The groups were similar immediately postoperatively; however, by discharge, fewer patients with a percutaneous compression plate required walking aids (40% vs. 59%). This trend continued throughout the study but was not significant. Pain with activity was lower throughout the study for the percutaneous compression plate group, but the difference was significant only at the three-month interval. Previously published reports showing shorter operative times and less blood loss with the percutaneous compression plate were reaffirmed. Compared with the sliding hip screw, the percutaneous compression plate resulted in a larger percentage of patients who were able to walk independently, consistently lower levels of pain with activity, and improved quality of life according to multiple scales of the Short Form-36, but the differences were not significant. Significant differences favoring the percutaneous compression plate were found with regard to operating times, incision length, and blood loss.

Fractures of the head and neck of the femur in children: an outcome study

Fractures of the head and neck of the femur in children are very rare, occurring only after a high-velocity trauma, e.g. a fall from a height. This analysis shows the clinical course of traumatic femoral head and neck fractures in paediatric patients. Predisposing factors for poor outcome or fracture complications, such as non-union or femoral head necrosis, are described. Between 1993 and 2006, 16 paediatric patients with proximal femoral fractures were treated at the Level One Trauma Centre of the Medical University of Vienna. The minimum follow-up was two years. Inclusion criteria were age less then 16 years, intact growth plate and a proximal femoral fracture according to the classification by Delbet and Colonna. Exclusion criteria were pathological fractures or fractures of the subtrochanteric region (6/16). Ten patients met the inclusion criteria. Two patients were lost to follow-up. Therefore eight patients were included in the study. All patients except one were operated upon within 48 h after the injury ("primary") and healed without further complications. A single case was managed by "secondary" surgical treatment, two weeks after the initial trauma resulting in femoral head necrosis that healed without any subjective complaints. This case series confirms the importance of early surgical fixation of proximal femoral fractures in paediatric patients. An operative intervention later then 48 h after the initial trauma may increase the risk of complications such as femoral head necrosis, particularly in Delbet type I fractures (traumatic slipped capital femoral epiphysis).

A BIOMECHANICAL VALIDATION OF A NEW FEMORAL NECK FIXATION DYNAMIC HIP SCREW FOR PROXIMAL FEMORAL FRACTURE

High failure rates are expected in the treatment of osteoporotic proximal femoral fractures. A newly designed femoral neck locking dynamic hip screw has been developed to increase the fixation strength; a biomechanical examination was performed to prove its efficacy. Femoral surrogate specimens were used for the test. Unstable intertrochanteric fractures were created on specimens. Then these specimens were divided into two groups to test two different methods of fixation: (1) the conventional dynamic hip screw and (2) the new designed femoral neck fixation dynamic hip screw. For each specimen, the peak cyclic loading was 800 N, and a total of 20,000 cycles were applied. The vertical displacement, rotation around the long axis of lag screw, and the varus rotation around the center of femoral head between the two groups were compared at specific intervals. All the conventional dynamic hip screw constructs failed within 1000 cycles, while no gross mechanical failure was recorded for the femoral neck fixation dynamic hip construct even after 20,000 loading cycles. The mechanical test comparing the two constructs at the end of each 1000 loading cycles demonstrated that the femoral neck fixation dynamic hip screw construct is stronger than that of the conventional dynamic hip screw. For the fixation of proximal femoral fractures, the femoral neck fixation dynamic hip screw can provide a stronger support than what a conventional dynamic hip screw can do. At the same time, femoral neck can be a suitable site for the application of proximal locking screws.

A randomised controlled trial to compare the haemodynamic changes during the fixation of extracapsular proximal femoral fractures using the compression hip screw versus the intramedullary hip screw

A randomised controlled trial to compare the haemodynamic changes during the fixation of extracapsular proximal femoral fractures using the compression hip screw versus the intramedullary hip screw

Complications and outcomes of the ATN™ trochanteric nail in the fixation of proximal femoral fractures at Macclesfield District General Hospital

Complications and outcomes of the ATN™ trochanteric nail in the fixation of proximal femoral fractures at Macclesfield District General Hospital

THA for Failed Internal Fixation of Proximal Femur Fractures and Retained Hardware

Hip fracture surgery is one of the most common orthopedic procedures performed today. With an aging population and wide prevalence of osteoporosis, the incidence of hip fractures is on the rise. When fixations for hip fractures fail, a total hip replacement is the usual treatment. Total hip replacement after failed fixation for proximal femur fractures is a difficult problem with its own challenges. Depending on the previous fracture type and the type of fixation used, specific issues must be addressed and principles followed to obtain good results from the salvage total hip replacement. Long term results of salvage hip replacement surgery are not as good as primary total hip replacement and the rate of complications is high.

Randomised controlled trial of electrical stimulation of the quadriceps after proximal femoral fracture

Proximal femoral fracture is often associated with long-term residual disability. Quadriceps weakness may be a factor in poor outcome. This study aimed to determine whether training of the quadriceps using electrical stimulation (ES) increases leg extensor power and decreases disability in elderly subjects rehabilitating after fracture. A single-blind randomized controlled trial of elderly postsurgical proximal femoral fracture patients, comparing 6 weeks of supplementary electrical stimulation of the quadriceps (15 patients) to usual physiotherapy alone (11 patients). The electrical stimulation on:off duty cycle was 7:23 seconds, with 36 cycles per session, given daily as an in-patient and twice weekly after discharge. The primary outcome measure was change in leg extensor power (Nottingham Power Rig). Functional mobility (Elderly Mobility Scale), disability (Barthel Index) and health status (Nottingham Health Profile) were also measured. There was no significant difference in change in leg extensor power, or any other outcome measure, in the ES group compared to usual care controls. Fractured leg extensor power increased by 10.9 (standard error of the mean 2.1) Watts at 6 weeks in the ES group compared to 15.3 (5.5) in the controls (mean adjusted difference -3.1, 95% CI -7.8, 1.6 Watts). Only 3 (20%) of the intervention patients tolerated sufficient stimulation intensity to produce repetitive knee extension, while 11 (73%) sustained palpable or visible contractions with no leg movement. A 6-week program of electrical stimulation of the quadriceps did not increase leg extensor power, or reduce disability, in elderly patients rehabilitating after surgical fixation of proximal femoral fracture. In many patients local discomfort limited the intensity of electrical stimulation that could be delivered.

Significance of hip rotation on measurement of 'Tip Apex Distance' during fixation of extracapsular proximal femoral fractures

Significance of hip rotation on measurement of 'Tip Apex Distance' during fixation of extracapsular proximal femoral fractures

Pseudo-anévrisme de la branche interne de l’artère fémorale profonde après vissage d’une fracture proximale du fémur

Development of pseudoaneurysm is due to either initial injury or is a complication of internal fixation of the femoral fracture [1]. This is a rare, serious but preventable complication following proximal femoral fracture [7]. We present an unusual case of pseudoaneurysm of medial branch of profunda femoris artery 2 months following osteosynthesis of proximal femoral fracture. The pseudoaneurysm was treated by endovascular embolisation.

Complications after Intramedullary Stabilization of Proximal Femur Fractures: a Retrospective Analysis of 178 Patients.

Secondary dislocation, non-union, re-fracture and implant failure are generally known complications after intramedullary fixation of proximal femur fractures with the PFN(®) (Synthes GmbH, Solothurn, Switzerland). The goal of our study was to assess the impact of patient- and treatment-specific risk factors on these complications. Complex fracture type and poor bone quality were defined as patient-specific risk factors. Inadequate fracture reduction and implant position were defined as treatment-specific risk factors. One hundred and seventy-eight cases were retrospectively analyzed. All patients had at least one clinical and radiological follow-up examination 3-6 months after the operation. Fifty percent of the patients were available for one more follow-up at least 1 year after the operation. All patients without patient-specific risk factors had a good outcome, irrespective of whether treatmentspecific risk factors were present or absent. In 153 of the 178 cases, patients had a complex type of fracture and/or poor bone quality. Of these patients, 27 (15.2%) had a poor result. Twenty-four of these patients needed re-operation within 6 months. Complication rate in these patients highly depended on treatment-specific risk factors. We conclude that the PFN is a secure implant for the stabilization of simple cases. Stabilization of complex proximal femoral fractures with the PFN, however, has a relevant complication rate and should therefore be considered a challenge.

Significance of hip rotation on measurement of ‘Tip Apex Distance’ during fixation of extracapsular proximal femoral fractures

The Tip Apex Distance (TAD) is defined as the sum of the distance, in millimetres, from the tip of the lag screw to the apex of the femoral head, as measured on an antero-posterior radiograph and lateral radiograph, after correction has been made for magnification. The relationship between the degree of rotation of the hip joint and its implication on measuring TAD during fixation of a proximal femoral fracture was studied. This relationship has not been previously explored in the English literature. This study involved radiographs of a lag screw placed in a synthetic femur specimen taken in neutral and varying degrees of rotation and adduction/abduction. The lag screw was placed anteriorly in the femoral head. Measurements were taken for each radiograph after correction for magnification. Statistical analysis between measurements showed statistically significant differences (P<0.05) of TAD in AP and lateral (abduction and adduction) views. A graph to show the relationship between hip rotation and TAD was conducted and demonstrates a linear correlation. If an anteriorly placed hip screw is not seen to be breaching the articular surface on a view taken in internal rotation, the screw is definitely not in the joint. Beware of a hip screw appearing very close to the joint surface on a view taken in external rotation or abduction as it could be within the joint. The converse may apply to a posteriorly placed screw.

Intramedullary fixation of complex unstable proximal femoral fractures: A district general hospital experience

Intramedullary fixation of complex unstable proximal femoral fractures: A district general hospital experience

Incidence and risk factors for development of venous thromboembolism in Indian patients undergoing major orthopaedic surgery: results of a prospective study

Introduction: The incidence of venous thromboembolism (VTE) in Western populations undergoing major orthopaedic surgery without any thromboprophylaxis has been reported to range from 32% to 88%. There is however limited...

Femoral neck-shaft angle in extra-capsular proximal femoral fracture fixation; does it make a TAD of difference?

The effect of femoral neck-shaft angle and implant type on the accuracy of lag screw placement in extra-capsular proximal femoral fracture fixation was investigated. Radiographs of all extra-capsular proximal femoral fractures seen in one unit over 18 months were reviewed. Of 399 cases, 307 (237 female, 70 male) were included in the study as they had no contra-lateral proximal femoral metal work. Femoral neck-shaft angle (NSA) of the uninjured hip and magnification adjusted tip-apex distance (TAD) of femoral head lag screw were measured. Type of fixation implant was 135 degrees classic hip screw (CHS) (n=144) or 130 degrees intra-medullary hip screw (IMHS) (n=163). Mean contra-lateral NSA was 130.2 degrees (112.9--148 degrees ) and 64 patients (58 female, 6 male) had a NSA <125 degrees . Mean adjusted TAD was 18.7 mm (5.8--43.8mm) and 88.9% of cases had a TAD of less than 25 mm. TAD values were significantly greater using an IMHS if NSA was <125 degrees than if NSA was >125 degrees (p=0.028). This was not the case with the CHS. The use of the 130 degrees -IMHS in patients with a NSA <125 degrees leads to poorer lag screw placement than if NSA >125 degrees and caution is advocated when using this device in such cases.