Fixation Of Trochanteric Fractures Research Articles

Nail fixation of unstable trochanteric fractures with or without cement augmentation: A cost-utility analysis in the United States: Cost-utility of cement augmentation

ObjectivesRecent clinical studies have shown favorable outcomes for cement augmentation for fixation of trochanteric fracture. We assessed the cost-utility of cement augmentation for fixation of closed unstable trochanteric fractures from the US payer's perspective. MethodsThe cost-utility model comprised a decision tree to simulate clinical events over 1 year after the index fixation surgery, and a Markov model to extrapolate clinical events over patients’ lifetime, using a cohort of 1,000 patients with demographic and clinical characteristics similar to that of a published randomized controlled trial (age ≥75 years, 83 % female). Model outputs were discounted costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (ICER) over a lifetime. Deterministic and probabilistic sensitivity analyses were performed to assess the impact of parameter uncertainty on results. ResultsFixation with augmentation reduced per-patient costs by $754.8 and had similar per-patient QALYs, compared to fixation without augmentation, resulting in an ICER of −$130,765/QALY. The ICER was most sensitive to the utility of revision surgery, mortality risk ratio after the second revision surgery, mortality risk ratio after successful index surgery, and mortality rate in the decision tree model. The probability that fixation with augmentation was cost-effective compared with no augmentation was 63.4 %, 58.2 %, and 56.4 %, given a maximum acceptable ceiling ratio of $50,000, $100,000, and $150,000 per QALY gained, respectively. ConclusionFixation with cement augmentation was the dominant strategy, driven mainly by reduced costs. These results may support surgeons in evidence-based clinical decision making and may be informative for policy makers regarding coverage and reimbursement.

Failure after intramedullary nailing for geriatric trochanteric fracture: does quality of fracture reduction on the AP and lateral planes show the same results?

This study aimed to investigate the failure of trochanteric fracture fixation according to the quality of fracture reduction on the anteroposterior (AP) and lateral views. Data from 340 female and 152 male patients ≥ 60years of age who underwent intramedullary nailing for a trochanteric fracture between 2016 and 2020 were analysed retrospectively. The quality of fracture reduction was classified as type A, type E, and type I on the AP view and type N, type A, and type P on the lateral view according to the relative position of the proximal and distal fragments. The failure rate was evaluated and compared according to the quality of fracture reduction. The risk factors of the fixation failure were investigated by comparison of variables between patients with and without failure and by regression analysis. Patients with poor reduction, type I and type P had higher failure rates. However, a statistically significant difference was found only for patients with poor reduction (type P) on the lateral view (p < 0.001). Patients with failure showed significantly higher rates of poor reduction on the lateral view and AO/OTA type A3 fractures. The regression analysis also showed that poor reduction on the lateral view (odds ratio [OR] 12.70; 95% confidence interval [CI] 4.0-40.6; p < 0.001) and AO/OTA type A3 fractures (OR 5.40; 95% CI 1.24-23.49, p = 0.025) were risk factors for failure. Poor reduction such as type P reduction was associated with failure after intramedullary nailing for trochanteric fractures. Surgeons should check the quality of fracture reduction carefully with the proper fluoroscopic view to prevent failure in geriatric patients with trochanteric fractures.

Patients with trochanteric hip fractures and pre-existing osteoarthritis can be treated with nailing osteosynthesis without significant decrease in functional status

PurposeFunctional outcome in patients after trochanteric fracture fixation with pre-existing radiographic osteoarthritis (OA) is unclear. Analyzing their function and independence, before and after fracture, could optimize their treatment and decrease the socioeconomic burden in this particular group. MethodsThe influence of pre-existing radiographic hip OA on functional outcome was retrospectively analyzed with a cohort of patients undergoing proximal femoral nailing for trochanteric fracture. OA was graded according to the Tonnis classification. Functional outcome was assessed preoperatively and 12 months after surgery by the Parker Mobility Score (PMS). We consider a meaningful reduction a difference between preoperatively PMS and 12 months after surgery ≥ 2. In order to evaluate if OA is related to PMS reduction ≥ 2, we calculate the SubHazard ratio (SHR) performing a competing risk regression model considering death as a competing risk event, adjusting by confounders. Death, reoperations, readmissions, surgical time, and fracture reduction quality in patients with and without osteoarthritis were recorded. Results375 trochanteric hip fractures treated with cephalomedullary nails were included, from which 80 (21% CI95% 17%-21%) were classified as Tonnis 2 or 3. This group of patients with pre-existing OA was significantly older (mean age of 88.6 [SD 5.65] vs 85.5 years [SD 6.95]) than the group without OA. The preoperatively PMS score was 6.28 (2.71) in non-OA patients and 5.69 (2.67) in OA patients. The mean PMS reduction 12 months after surgery was 1.3 (SD 2.05) in OA patients and 1.07 (SD 2.2) in non-OA patients (p = 0.43). Competing risks analysis, adjusted by confounders had an SHR of 1.15 (IC95% 0.77 - 1.69). Death, readmission, reoperations, surgical time, and fracture reduction quality did not differ in both groups. ConclusionsPatients with pre-existing radiographic OA treated with femoral nailing have a similar reduction in functional outcomes compared to the non-OA group at one-year follow-up. Further studies will be needed to compare the results of the functional outcome in arthroplasty with those of femoral nailing for the treatment of trochanteric femur fractures in patients with OA.

Comparison of bleeding during trochanteric fracture fixation with mini-invasive or conventional side plate fixation: A randomized controlled trial

BackgroundTrochanteric fractures are a public health issue due to the aging of the population. Treatment aims to reduce their related morbidity and mortality and to allow an early return to independence. Postoperative anemia is associated with poorer functional recovery and an increased mortality rate. The aim of this study was to assess whether minimally invasive side plate fixation (Minimal Invasive Screw System, MISS™) resulted in reduced perioperative bleeding compared with conventional fixation (Pertrochanteric Hip Screw, PHS™). HypothesisWe hypothesized that minimally invasive side plate fixation (MISS) would result in reduced perioperative bleeding compared with conventional fixation (PHS). Patients and methodsWe conducted an open randomized controlled trial with blinded assessment of the primary outcome. Inclusion criteria were patients aged over 65 years with isolated reducible trochanteric fracture. The 2 surgical implants were of the same shape, the only difference between them being the locking mode of the femoral neck screw on the plate of the MISS device, allowing a percutaneous approach. Primary outcome was perioperative bleeding evaluated with Mercuriali's formula. Secondary outcomes included operating time, scar length, length of hospital stay, radiological criteria such as quality of fracture reduction, implant positioning, bone healing, complications and functional recovery compared between the 2 groups. ResultsOne hundred and eight patients met the inclusion criteria and were randomized to receive either PHS (n=54) or MISS (n=54). Osteosynthesis with MISS significatively reduced perioperative bleeding (median 243mL, interquartile range [152–410] vs. 334mL [247–430] [p=0.0299]), operating time (65min [57–73] vs. 79min [66–89] [p=0.0002]) and scar length after 45 days (7cm [5–8] vs. 14cm [12–15] [p<0.0001]). There was no statistically significant difference between groups in postoperative complications, revision surgery or serious adverse events. ConclusionCompared with PHS, MISS reduced operating time, perioperative bleeding and scar length with no observed functional difference. Level of evidenceI.

Relative instability ratios of bone wall defects in trochanteric hip fractures: A finite element analysis.

Background: For decades, medial and lateral wall fragments of trochanteric hip fractures were considered two pivotal factors that could influence the stability of postoperative femur-implant complex. However, most studies seemed to misunderstand the concept of the posteromedial fragment and equated it with the medial wall, which overlooked vital roles of the anteromedial wall. Roles of the posterior coronal bone fragment were also highlighted in some research. However, influences of the bone walls above the trochanteric fracture instability are yet to be investigated and quantified by means of finite element analysis. Methods: Eight trochanteric fracture fixation models with different wall defects were constructed. Outcome indicators were the von Mises stress of the implant models, the maximum/minimum principal strain, the risky tensile/compressive volume and the volume ratios of the bone models, the femoral head vertex displacement, and the fracture surface gap. Based on these indicator values, the relative instability ratios were computed. Results: Outcome indicators, absolute values, and nephograms of all models showed the same upward and concentrating trends with exerted hip contact loads shifting from static walking to dynamic climbing. Similarly, these indicators also exhibited the same trends when the eight models were solved in sequence. Moreover, the relative instability ratio of the medial wall (100%), particularly the anteromedial part (78.7%), was higher than the figure for the lateral wall (36.6%). Conclusion: The anteromedial wall played relatively pivotal stabilizing roles in trochanteric hip fractures compared with the posteromedial wall and the lateral wall, which indicated that orthopedic surgeons should attach more importance to the anteromedial cortex support in an operating theatre.

Predictors of Failure Following Fixation of Trochanteric Fractures

BACKGROUND: Trochanteric fractures are frequent and mainly affect the elderly causing autonomy loss. Their incidence is increasing, and they are associated with substantial morbidity and high cost. AIM: The aim of our study was to identify epidemiological, radiological, and technical predictors of failure of trochanteric fracture fixation in the elderly. METHODS: We conducted a retrospective study including 188 patients aged over 65 years, who underwent surgery for trochanteric fractures, in the period between 2015 and 2020 at the orthopedics department of the Military Hospital of Tunis. The minimum follow-up was 12 months. RESULTS: Thirty-four patients had a mechanical failure (18.1% of cases), including 12 cases of cephalic screw migration (CSM) (6.4%), 12 cases of disassembly (6.4%), eight cases of malunion (4.3%), and four cases of non-union (2.1%). Bone fragility with a Singh index ≤III was associated with CSM, disassembly of fixation material, and malunion (respectively, p &lt; 0.001; p = 0.01 and p = 0.044). Reduction quality was associated with disassembly (p &lt; 0.001) and CSM (p = 0.004). Eccentric screw positioning on anteroposterior (p &lt; 0.001) and lateral views (p = 0.018), high tip-apex distance (TAD) (p &lt; 0.001), and calcar-referenced TAD (p &lt; 0.001) were predictive of CSM. Logistic regression analysis showed that poor reduction quality was an independent factor associated with the occurrence of mechanical complications. Functional outcomes were assessed using Parker and Postel Merle d’Aubigné scores. CONCLUSION: To minimize the risk of mechanical complications, the surgeon must pay close attention to the fracture reduction and to the correct positioning of the cervical screw.

Complications Patients Faces while Fixation, in Terms of Pain Relief, Walking, Sitting

Background: The fracture of the trochanteric area of the femur is one of the most frequent and challenging complications orthopedic surgeons deal daily. In virtually all instances, fractures develop through the highly vascular cancellous bone and heal within 8 to 12 weeks, independent of therapy. Malunion and varus angulations are prevalent. Due to the demands placed on the patient, nursing staff, and length of hospitalization, conservative therapy is no longer acceptable. Seventy percent of intertrochanteric fractures are considered unstable. During regular exercises, the proximal femoral loading has been calculated to reach up to three times the body weight. Muscle attachments apply force vectors in several directions, hence contributing to a trend for fracture displacement. This fracture is typically accompanied by severe comminution and osteopenia. Objective: The main objective of this study is to find thecomplications patients faces while fixation, in terms of pain relief, walking, witting. Materials and Methods: Descriptive study conducted at Department of Orthopedic Surgery, Chittagong Medical College Hospital, Chittagong, with the sample size of 36 patients aged above 50 years admitted to the Chittagong Medical College Hospital with closed trochanteric fracture. The aim of the study is to find out the Effectiveness of dynamic hip screw in fixation of trochanteric fractures of femur in elderly patients. Results: The patients' ages ranged from 52 to 95 years. The majority of patients were 70-79 years old (36.1 percent), followed by 80-89 years (25 percent), 60-69 years (22.2 percent), 50-59 years (11.1 percent), and 90-99 years (5.6 percent). The mean (±SD) age of the total study patients (n=36) was 72.± 1.20 years, male (n=21) was 75.05±12.62 years and female (n=15) were 68.07±7.46 years. There are considerable disparities between the age groups of 70-79 and 90-99.Males made up the majority of patients (58.3 percent), while females made up 41.7 percent. ....

Variation of implant use in A1 and A2 trochanteric hip fractures : a study from the National Hip Fracture Database of England and Wales.

Patients with A1 and A2 trochanteric hip fractures represent a substantial proportion of trauma caseload, and national guidelines recommend that sliding hip screws (SHS) should be used for these injuries. Despite this, intramedullary nails (IMNs) are routinely implanted in many hospitals, at extra cost and with unproven patient outcome benefit. We have used data from the National Hip Fracture Database (NHFD) to examine the use of SHS and IMN for A1 and A2 hip fractures at a national level, and to define the cost implications of management decisions that run counter to national guidelines. We used the NHFD to identify all operations for fixation of trochanteric fractures in England and Wales between 1 January 2021 and 31 December 2021. A uniform price band from each of three hip fracture implant manufacturers was used to set cost implications alongside variation in implant use. We identified 18,156 A1 and A2 trochanteric hip fractures in 162 centres. Of these, 13,483 (74.3%) underwent SHS fixation, 2,352 (13.0%) were managed with short IMN, and 2,321 (12.8%) were managed with long IMN. Total cost of IMN added up to £1.89 million in 2021, and the clinical justification for this is unclear since rates of IMN use varied from 0% to 97% in different centres. Most trochanteric hip fractures are managed with SHS, in keeping with national guidelines. There is considerable variance between hospitals for implant choice, despite the lack of evidence for clinical benefit and cost-effectiveness of more expensive nailing systems. This suggests either a lack of awareness of national guidelines or a choice not to follow them. We encourage provider units to reassess their practice if outwith the national norm. Funding bodies should examine implant use closely in this population to prevent resource waste at a time of considerable health austerity.Cite this article: Bone Jt Open2022;3(10):741-745.

Management of unstable intertrochanteric fracture by proximal femoral nailing with trochanteric buttress plating

Aim: The aim of the study is to evaluate the anatomical reduction and augmenting the lateral wall with trochanteric buttress plating along with PFN in an unstable IT fractures with broken lateral wall. Background: Unstable IT fractures have poor contact between fragments, loss of posteromedial support, reverse oblique type, severe comminution and has subtrochanteric extension. Unstable IT fracture with coronal split presents a great challenges to an orthopaedic surgeon. This study evaluates augmenting the lateral wall with trochanteric buttress plating along with PFN for unstable IT fractures with a broken lateral wall.Design: Prospective study.Materials and Methods: Totally 20 patients of unstable intertrochanteric fractures treated in Rajah Muthiah Medical College and Hospital were studied during the study period August 2020 to November 2022.Result: In our study the patients were followed up for 1 year. Modified Haris Hip Score was excellent in 60% of the patients with the mean value of 87.25. Mean duration of surgery 99.25 min. Mean blood loss 330ml.Mean time of union 15.15 weeks.Conclusion: Although reconstruction of calcar is a main predictor of successful trochanteric fracture fixation, augmenting the lateral wall with Trochanteric buttress plate along with PFN is also a Major factor for successful fixation of unstable IT fractures.

Hip fixation nail [HFN] /Intramedullary hip screw nail IMHSN management of trochanteric fractures with hip fixation nail- Innovative nail:A prospective pilot study in initial 43 cases

Intertrochanteric fractures can be fixed with various implants with surface implants or intramedullary implants. A study was done on Fixation of trochanteric fractures with Hip Fixation Nail/Intra Medullary Hip Screw an innovative cephalomedullary nail designed by author to determine its efficacy, union operative use and functional outcome. Trochanteric fractures of hip were classified upon number of parts, stable and unstable fractures in initial 43 cases. All Intertrochanteric fractures stable as well as unstable were fixed and stabilized by Dr Shashikant B Ganjale’s innovative Nail Hip Fixation nail (HFN) / Intra medullary hip screw Nail (IMHSN). 5 cases were fixed with Trochanteric Buttress Plate alongwith Hip fixation nail for lateral wall comminution.The results were Excellent in 31 cases, Good in 5 cases, and fair in 2 cases as seen in our study according to Kyles criteria. Five cases did not follow up. Author’s (Dr Shashikant B Ganjale) innovative Nail Hip Fixation nail /Intra medullary Hip Screw Nail (IMHSN) is very simple minimally invasive, cephalomedullary single screw fixation nail suitable for fixing all stable and unstable trochanteric fractures especially in young as well as elderly osteoporotic patients with minimal instrumentation and excellent functional outcome.

Comparison of Functional Outcome Like Range of Motion of Hip After Fixation of Trochanteric Fracture with Dynamic Hip Screw (DHS) and Proximal Femoral Locking Compression Plate (PF-LCP)

Trochanteric region of the femur is that part which connects the neck and shaft of femur. So head, neck, trochanter facilitates the movement at the hip joint causing the limbs to swing clear of the pelvis. Intertrochanteric fractures are divided into stable and unstable varieties. To assess the Comparison of functional outcome like range of motion of hip after fixation of trochanteric fracture with dynamic hip screw (DHS) and proximal femoral locking compression plate (PF-LCP) the present prospective randomized clinical trial was conducted in the Department of Orthopedic, National Institute of Traumatology and Orthopedic Rehabilitation (NITOR) between January 2009 to December 2010. A total of 20 patients with post traumatic trochanteric fractures and osteoporotic fractures within three weeks of incidence were included in the study. The age distribution of the patients was identical between the groups with mean age of the patients being 56.2 and 55.6 years in DHS and PF-LCP groups respectively (p=0.626). Males were predominant in both groups (each of 70%). In both groups fractures were primarily caused by RTA (60% in DHS and 50% in PF-LCP) (p=0.327) with all patients having closed type of injury. Sixty percent of the injuries in each group had right-sided involvement. (p = 0.675). All patients of either group required open surgical procedure. DHS required shorter operation time than that required by PF-LCP (72.5±5.4 min vs. 96.5±3.3 min. p&lt;0.001). Immediate postoperative outcome demonstrates that all of the patients in both groups had intact cut-out of lag-screw and implant failure did not occur. Thirty percent patients in DHS group needed blood transfusion, while only 10% patient needed the same in PF-LCP group (p = 0.291). At 4 weeks Follow up 30% of DHS group had infection as opposed to none in the PFL-CP group. Ninety percent of the patients in the former group had pain as opposed to none in the latter group (p&lt;0.001). Visible callus formation was ..........

Influence of Dynamization of Trochanteric Fracture Osteosynthesis on Bone Union.

Ineffectively treated trochanteric fractures lead to disability and thus constitute a significant social problem. The aim of the study was to analyze the effect of dynamization of the fixation of trochanteric fractures on bone union. We conducted a retrospective study involving 149 patients operated on for trochan-teric fractures in 2015-2017. The fractures were anastomosed with a DHS extramedullary device or a Gamma 3 intramedullary nail. Bone union was achieved at an average of 11 weeks after the surgery (8-20 weeks). In the extra-me-dullary stabilization (DHS) group, union was achieved after 12 weeks (8 to 16 weeks) (N = 47). In in-tramedullary stabilization, union was achieved after 10 weeks (8 to 20 weeks) (N = 96). The intramedullary nails were locked statically or dynamically. The time to union in static stabilization was 12.3 weeks (8 to 20 weeks) (N = 31), while in dynamic stabilization it was 9.4 weeks (8 to 16 weeks) (N = 64). 1. This study revealed a measurable biologically beneficial effect of dynamization of the fixation of trochanteric fractures on the time of bone union. 2. Conventional radiographs and CT imaging according to indications significantly facilitate the classification of fractures and selection of the method of stabilization with dynamization. 3. Due to the considerable comminution of the trochanteric massif, double dynamization (cervical-trochanteric and femoral-trochanteric) of fracture fragments is essential, ensuring reduction of fracture gaps and self-reduction of inter-fracture resorptive gaps, which is a prerequisite for optimal union. 4. Allowing early, full weight-bearing of the operated limb within the painless range is an important element of effective dynamization.

Increased failure rates after the introduction of the TFNA proximal femoral nail for trochanteric fractures: implant related or learning curve effect?

Background and purpose - Trochanteric fractures are often treated using intramedullary fixation. In our institution, the TFN-Advanced Proximal Femoral Nailing System (TFNA) was introduced as replacement for the Gamma Trochanteric Nail (GTN3) for the treatment of these fractures as a result of a hospital-driven change of trauma implant supplier. We compared trochanteric fracture fixation failure rate between these 2 intramedullary nails. Patients and methods - All trochanteric fractures treated surgically from 2011 to 2019 were retrospectively reviewed for fixation failure. From 2016 only the TFNA was used. Fixation failure was defined as implant cut-out, implant breakage, non-union, malpositioning of the screw/blade requiring reoperation, new fracture around the nail, or miscellaneous. Propensity score matching was used to balance distribution of covariates and to compare failure rates between TFNA and GTN3 groups. Learning curve analyses were performed. Results - After exclusion, 797 GTN3s (779 patients) and 542 (536 patients) TFNAs were available for analysis. A higher risk of fixation failure was found in the TFNA group (14%) compared with the GTN3 group (7.0%) (hazard ratio [HR] 2.0, 95% confidence interval [CI] 1.2-3.5). This was mainly attributed to a higher risk of cut-out (HR 2.2; CI 0.9-5.7), malpositioning (HR 4.7; CI 0.7-34), and new fracture around the nail (HR 4.0; CI 1.0-16). Learning curve analyses indicated no clear learning curve effect. Interpretation - Failure of fixation increased after a switch from the GTN3 to the TFNA proximal femoral nail for the treatment of trochanteric fractures. Cut-out and malpositioning of the calcar screw or blade appeared to be the most dominant failure mechanisms. Modifications in implant design may have played a role in this increased risk of failure of fixation. In our institution a new implant device was introduced without solid clinical evidence behind it. This study may help to underline the need for medical doctors with a critical and scientific background to be involved in implant choices.

Difficulties encountered during fixation of trochanteric fractures with proximal femoral nailing: A prospective analysis of 200 cases at a tertiary care centre in North-West India

Introduction: Proximal femoral nailing (PFN) compares favourably with dynamic hip screw in terms of surgical time, intra-operative blood loss and lag screw cut out in unstable inter-trochanteric fracture. However, data on difficulties faced during the fixation process are lacking. Therefore, the study was planned with the aim to identify difficulties encountered during fixation of trochanteric fractures with PFN in the patients. Materials and Methods: Two hundred patients with trochanteric fractures aimed for the operative procedure with PFN were included in the study. Patients with associated fracture of neck of femur, the shaft of the femur of the same side, with polytrauma, with multiple fractures, with pathological fractures and/or unwilling to participate in the study were excluded. Bone mineral density was evaluated using Singh's index. Fixation of trochanteric fractures was done using PFN. Results: More than 70% of the study participants were elderly, 53% of the participants were males, while 91% of the total participants belonged to a rural region. Hypertension was the most common comorbidity in 21% of the patients, followed by anaemia (14.5%) and diabetes (9%). 73% of the patients had grade 3 Singh's index. 53.5% of the patients had intra-trochanteric left femur while the remaining 46.5% of the patients had intra-trochanteric right femur. The reduction was the most common difficulty (26%) followed by entry point difficulty (21%) and guidewire passage (12.5%). No difficulty was observed in 29% of the patients. Conclusion: Achievement of good reduction between two main fragments without varus malalignment and placement of hip screw in a correct position are two important technical aspects that prevent most of the complications associated with these procedures.

Intraoperative fractures in cephalomedullary nailing for trochanteric fractures

IntroductionCephalomedullary nailing (CMN) is the standard treatment for internal fixation of trochanteric fractures. Complications related to CMN include intraoperative fracture (IF), which is difficult to detect using only plain radiographs. However, analyses of IFs using plain radiographs and computed tomography (CT) with a large sample size of clinical cases are lacking. Therefore, this study aimed to report the incidence of IFs diagnosed by CT, the risk factors for IFs, and a comparison of clinical outcomes between patients with and without IFs. MethodsThis multicenter retrospective cohort study included 638 patients who underwent CMN fixation for trochanteric fractures. We evaluated IF using pre-and postoperative plain radiographs and CT. The primary outcome was reoperation and the secondary outcome was the proportion of patients who regained independent mobility at 3 months postoperatively. Furthermore, we conducted multivariable logistic regression analyses to examine the association between risk factors and IFs. ResultsSeventy-five (11.8%) patients had IFs, including 53 patients with occult IFs (8.3%). The most common location of IF was at the interference with the lag screw entry (45.3%). The nail insertion procedure (17.3%) was the most common reason for IF. In the assessment of clinical outcomes, patients with IFs had no reoperations and independent mobility at postoperative 3 months was lower (69.6% vs. 79.1%). Regarding regaining independent walking in the IF group, IF distal to lag screw entry and obvious IF diagnosed with plain radiographs were poor factors. The multivariable analysis showed that only inadequate reduction on the anteroposterior view based on the plain radiograph was significantly associated with the incidence of IFs (odds ratio 3.91; 95% CI, 1.28–11.94; p = 0.017). ConclusionsThis multicenter study indicated that the incidence of IFs detected by CT in CMN treatment for trochanteric fractures was 11.8%. An inadequate reduction in the anteroposterior view based on plain radiographs was the only independent risk factor of IFs. In the assessment of clinical outcomes, patients with IF had no incidences of reoperation. However, patients with IFs tended not to regain independent mobility compared with those without IFs.

Peri-implant fracture: a rare complication after intramedullary fixation of trochanteric femoral fracture

IntroductionTrochanteric femoral fractures are among the most common operatively treated fractures. Intramedullary fixation has become the treatment of choice in many centers around the world. Nevertheless, the knowledge of rare complications of these fractures is limited. In this study, the incidence and treatment strategies for peri-implant fractures (PIF) were assessed.Materials and methodsA single-center retrospective cohort study was done on 987 consecutive operatively treated trochanteric fractures. PFNA cephalomedullary nail was used as a fixation method. All patients were followed up from patient records for peri-implant fractures. Plain radiographs as well as different salvage methods were analyzed and compared.ResultsThe total rate of peri-implant fractures was 1.4% (n = 14). The rate of PIF for patients treated with short (200 mm) nails, intermediate-length (240 mm) nails, and long nails was 2.7% (n = 2), 1.5% (n = 11), and 0.7% (n = 1), respectively (ns, p > 0.05 for difference). Treatment of choice for PIF was either ORIF with locking plate (57%, n = 8) or exchange nailing (43%, n = 6). None of the PIF patients needed additional surgeries for non-union, malunion, or delayed union.ConclusionsA PIF is a rare complication of intramedullary fixation of trochanteric fractures. It can be treated with either locking plates or exchange nailing with sufficient results. There are no grounds for favoring long nails to avoid PIFs.

Long proximal femoral nail vs Short proximal femoral nail for fixation of Trochanteric Fractures Which one is better? Results of a prospective cohort study.

Background: There is a paucity of studies comparing the functional outcome, the difference in radiological union status, and the incidence of anterior thigh pain between short and long proximal femoral nails in the management of intertrochanteric fractures. We hypothesized that short nail with nail tip touching the anterior cortex would cause thigh pain and decreased functional outcome. Materials and Methods: This was a prospective non-randomized study of 75 patients with intertrochanteric femur fracture treated at a tertiary care center with long or short proximal femoral nail over a period of two years. Functional outcome assessment at 12 months after the surgical procedure was done using the Modified Harris Hip Score. Patients were evaluated for anterior thigh pain and union status was evaluated using serial radiographs at one month, three months, six months, and 12-month post-surgery. Results: Out of 75 cases included, 52% of patients (n=39) were operated with a short nail and 48%(n=36) were operated by using a long nail. There were 38 male and 37 female patients with a mean age of 67 years (range: 38 to 86 years). The mean operative time, blood loss in the short nail group was significantly shorter than that in the long nail group. There was no statistical difference in the union rate of fracture and duration of stay between the groups. At the final follow-up, the mean modified Harris hip score for the short nail group was 79.7, and that for long nail was 82.1. Fifteen patients in the short nail group reported having anterior thigh pain at a six-month follow-up. Conclusion: Short proximal femoral nail has a significantly higher incidence of anterior thigh pain which was troublesome for the patient even at 12-month follow-up and the surgeon should consider the variable anterior bowing of the femur before using a short nail.

Intramedullary Fixation of Trochanteric Fractures Can Be Safely Performed by Senior Residents Without Immediate Consultant Supervision

To assess the safety of senior residents performing trochanteric hip fracture surgery without immediate consultant supervision DESIGN: A retrospective chart review of trochanteric hip fractures (AO-OTA 31-A) operated in a single center between years 2011 and 2016 (inclusive). Operations were divided into three groups: Group 1 - surgeon was a senior resident without any immediate supervision; Group 2 - surgeon was a consultant and Group 3 - surgeon was a senior resident supervised by a consultant. The follow-up period was a minimum of 2 years or until death. All re-operations and surgical related mortality were assessed. Helsinki University Hospital, Finland. A tertiary level trauma center. 987 consecutive trochanteric fractures on 966 patients treated by operative fixation of an intertrochanteric fracture with an intramedullary nail between 2011and 2016 (inclusive). The total number of reoperations was smaller in Group 1 where the surgeon was a senior resident without any immediate supervision compared to Group 2 where the surgeon was a consultant (5.5 % vs 8.8 %, p < 0.05). There were no significant differences in mortality or length of surgery. The total rate of mechanical complications was 2.0 %, with no significant differences between groups. The observed blade cut-out rate was low: 1.3 %, suggesting a good overall quality of surgery. Senior residents can safely perform intramedullary nailing of trochanteric fractures without immediate supervision.

Cement augmentation of internal fixation for trochanteric fracture: a systematic review and meta-analysis

This study aimed to determine the efficacy and safety of cement augmentation for internally fixed trochanteric fractures through a systematic review and meta-analysis of randomized controlled trials (RCTs). We searched the MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov databases to identify RCTs, published until July 2020 that examined the effects of cement augmentation of internal fixation of trochanteric fractures. The primary outcomes were reoperation and Parker Mobility Score, whereas the secondary outcomes were 1-year mortality rate, EuroQol 5 Dimension, fixation failures, and adverse events. We conducted meta-analyses of the outcome measures using the random-effects models. We evaluated the certainty of evidence based on the Cochrane risk-of-bias tool and the Grading of Recommendations, Assessment, Development, and Evaluation approach. We included three RCTs (326 participants). No significant effect was observed in favor of cement augmentation on all these outcomes. The certainty of evidence for fixation failures was very low and that for the other outcomes was low. The overall risk of bias for each outcome was high or of some concern in all included studies. The effect of cement augmentation of internal fixation of trochanteric fractures was uncertain for the clinical outcomes due to the low certainty of evidence. Further RCTs with a low risk of selection bias may present convincing conclusions on the efficacy and safety of cement augmentation. Level 1.

Trochanteric fractures treated by internal fixation using short intramedullary nails: Does the visual intraoperative estimation of the Tip-Apex Distance (TAD) concur with its digital postoperative measurement?

IntroductionThe tip-apex distance (TAD) is the only predictor for mechanical failure after internal fixation of trochanteric fractures. The main objective of our study was to assess whether the intraoperative visual estimation of the TAD concurred with the measurement taken on postoperative digital X-rays. We hypothesized that there was a good concordance between these 2 different methods of measurement. Materials and methodsPatients with an isolated trochanteric fracture were included in our study. A hardcopy of the intraoperative X-rays were printed, and the TAD was calculated manually. Radiological and clinical follow-ups were scheduled at 6 weeks, 3 months and 6 months during which numerical measurements of the TAD were taken. We also recorded the fracture type (AO/OTA classification), degree of osteoporosis (Singh index), surgeon experience, age and ASA score. ResultsA total of 98 patients were included in our study. Of these, 70 had a 6-month follow-up and interpretable postoperative X-rays. The mean age was 87 years, with 77.14% women and a mean ASA score of 3. The coefficient of concordance between the intra and postoperative TAD was 0.7202 (95% CI=0.4905–0.9499). The secondary displacement rate was 3.28%. The univariate analysis showed no statistically significant association between an intraoperative TAD>25mm and fracture type (p=0.7290), degree of osteoporosis (p=0.5701) and surgeon experience (p=1). Discussion/ConclusionsThere was a high degree of concordance between intraoperative visual estimation of the TAD and its measurement on postoperative digital X-rays. The treatment of unstable fractures in osteoporotic bone by junior surgeons was not a risk factor for intraoperative TAD>25mm. It is therefore important to educate young surgeons on the concept of TAD and its intraoperative visual estimation technique as it ensures that the cephalic screw is positioned properly during the fixation of trochanteric fractures. Level of EvidenceII.