Intertrochanteric Fractures Research Articles

Comparison of the outcome of dynamic hip screw versus proximal femoral nail for treatment of intertrochanteric femoral fractures among elderly patients.

Objective: To compare the outcome of DHS versus PFNA for treatment of intertrochanteric femoral fractures (IFFs) among elderly patients. Study Design: Randomized Clinical Trial. Setting: Sheikh Zayed Hospital, Lahore. Period: 2-03-2022 to 2-09-2022. Methods: In total 90 patients fulfilling inclusion criteria were registered after approval from the ethical review committee of the hospital. Every patient provided written informed consent. Patients were allotted to each group (Group A = PFNA, Group B = DHS) using lottery method. Patients were operated upon by a single surgical team. Data was obtained VIA questionnaires designed for pre- operative period, immediate post-operative period, 1 and 3 months follow up. Patients were interviewed and evaluated by blind researchers at each stage. Harris hip score was used to assess the functional outcomes. Results: In 90 patients (45 in each), 36.2% (n=17) were male in PFNA group and 63.8% (n=30) in DHS group and 65.1% (n=28) were female in PFNA and 34.9% (n=15) in DHS group, p=0.011. Mean age of PFNA group was calculated as 66.00± 3.41 years and mean age of DHS group was 66.80±3.71 years (p=0.714). Distribution of BMI was 28.14+6.20kg/m2 in PFNA group and 27.47+6.24kg/m2 in DHS group, p=0.612. Distribution of Harris hip score at 1 month was 31.11+4.08 in PFNA group and 30.11+4.18 in DHS group, p=0.254 and Harris hip score at 3 months was 88.68+1.23 in PFNA group and 81.68+0.95 in DHS group, p=0.000. Conclusion: We concluded that PFN is superior to DHS in treating Boyd and Griffin type II intertrochanteric fractures of femur. It’s only a matter of time that PFN becomes the new gold standard for these fractures.

Key factors for increased tip-apex distance when treating intertrochanteric fractures with InterTAN nails

Key factors for increased tip-apex distance when treating intertrochanteric fractures with InterTAN nails

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.

Five states of reduction in OTA/AO A1.3 intertrochanteric fractures of the femur a biomechanical study

ObjectiveThis study aims to analyze the differences in mechanical stability of OTA/AO 31A1.3 intertrochanteric fractures under various reduction conditions.MethodsTwenty standard synbone artificial femur test bones were selected for the OTA/AO 31A1.3 intertrochanteric fracture model. The models were divided into five groups according to their reduction state: positive support, neutral support, negative support, varus fixation, and valgus fixation, with four specimens in each group. All models were fixed using PFNA intramedullary fixation and subjected to static axial compression tests. The subsidence displacement of the proximal femur under different loads and the axial stiffness of the model were measured to verify the mechanical stability of the OTA/AO 31A1.3 intertrochanteric fracture under different reduction conditions.ResultsAfter the static axial compression test, the proximal femoral subsidence displacement in the positive support and neutral support groups was lower than that in the negative support, valgus fixation, and varus fixation groups (p < 0.001). The axial stiffness of the model was highest in the positive support group. Significant differences in subsidence displacement and axial stiffness were found between the groups (p < 0.001). The positive support group demonstrated the best mechanical stability, while the varus fixation group showed the poorest performance.ConclusionPositive support of the medial cortex can be regarded as the best reduction state for OTA/AO 31A1.3 intertrochanteric fractures, suggesting that this approach should be preferred during surgery to enhance mechanical stability and improve clinical outcomes. Conversely, varus fixation should be avoided due to its inferior stability.

Functional outcome of treatment of fracture intertrochanteric femur by using proximal femoral nail antirotation II

Background: The elderly are most frequently affected by intertrochanteric fractures, which have a major effect on the medical community and society at large. In 2003, AO introduced the proximal femoral nail anti-rotation device, which was further improved and named proximal femoral nail antirotation II (PFNA II) in 2009. Methods: This study was conducted from December 2020 to August 2022. The 60 cases of proximal femoral nail anti-rotation II-managed intertrochanteric femur fractures were assessed. Results: In the present study, 24 patients (40%) had type IV (Evan’s) fractures. Right hip was involved in 30 patients (50%). Meantime for clinic-radiological union was 20 weeks. There was complication rate of 2.08% as helical blade protrusion and non-union, 2.08% as helical blade protrusion, 2.08% as blade backout, 4.17% as superficial infection and 4.17% as lateral wall fracture. Seven patients expired postoperatively within 3 months while 5 patients lost during follow Up. After a 6-month follow-up, the Harris hip grade was used to evaluate 48 instances. Of these, 8 cases (16.67%) had an excellent score, 29 cases (60.42%) had a good score, 7 cases (14.58%) had a fair score, and 4 cases (8.33%) had a poor score. Thirty-seven of the 48 cases had reached the one-year follow-up mark. Thus, of the 37 patients assessed, 11 cases (29.73%) had excellent Harris hip grades, 19 cases (51.35%) had good scores, 4 cases (10.81%) had fair scores, and 3 cases (8.11%) had poor scores at the end of a one-year follow-up. Conclusions: Even in rural populations, PFN A-II is a better, safer implant with a low rate of complications for treating stable and unstable intertrochanteric femur fractures.

Comparison of two surgical methods for the treatment of intertrochanteric fractures of the femur in elderly patients with knee osteoarthritis

To explore the difference in the effectiveness between proximal femoral nail anti-rotation(PFNA) and proximal femoral locking compression plate(PFLCP) of intertrochanteric fracture in the elderly patients combined with knee osteoarthritis. The clinical data of 65 intertrochanteric femoral fractures combined with knee osteoarthritis between June 2015 and February 2021 were retrospectively analyze. They were divided into two groups according to the different surgical methods. PFNA group was composed of 36 patients, 12 males and 24 females, aged from 61to 88 years old with an average of (77.0±6.4)years old. There were 17 cases of left injury and 19 cases of right injury. According to modified Evans classification, there were 3 cases of typeⅡ, 19 cases of type Ⅲ, 10 cases of type Ⅳ, and 4 cases of type Ⅴ. PFLCP group was composed of 29 patients, 11 males and 18 females, aged from 60 to 92 years old with an average of (78.8±6.5) years old. There were 14 cases of left injury and 15 cases of right injury.According to modified Evans classification, there were 2 cases of typeⅡ, 18 cases of type Ⅲ, 7 cases of type Ⅳ, and 2 cases of type Ⅴ. Comparison of operation time, intraoperation blood loss, postoperative bed time, incidence of postoperative complications, Harris score at 6 months and 1 year postoperation. All 65 patients were followed up ranging from 12 to 24 months with an average of (16.9±3.6) months. In the PFNA and PFLCP groups, the operation time was respectively (57.6±6.8) min and (77.4±6.5) min, the intraoperative blood loss was (128.3±50.3) ml and (156.3±23.9) ml, postoperative bed time was (4.0±2.5) days and (8.1±2.0) days, Harris score at 6 months postoperative was (45.3±8.6) points and (36.3±7.0) points. There were significant differences between two groups(P<0.05). Incidence of postoperative complications was 19.4%(7/36)and 34.5%(10/29), Harris score at 1 year postoperative was (60.8±6.7) points and (59.0±8.1) points.There was no significant difference between the two groups(P>0.05). Compared with PFLCP, PFNA treatment of elderly patients with knee osteoarthritis between the femoral intertrochanteric fractures shorter surgical time, less intraoperative blood loss, bed rest after surgery, short-term hip function recovery better, when the affected knee joint can tolerate traction, can be used as a priority.

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.

Clinical outcomes of post-surgery osteoporosis treatment in elderly intertrochanteric fracture patients: a prospective study

Background: This study aims to evaluate the clinical and functional outcomes of administering zoledronic acid in elderly patients undergoing surgical management of hip fractures. The goal is to assess the impact on mortality, postoperative complications, and functional recovery as measured by the modified Harris hip score. Methods: A prospective study was conducted over 18 months at a tertiary care center in New Delhi, India, involving 42 patients aged 60 and above with intertrochanteric femur fractures. Patients received surgical fixation and standard postoperative care. Zoledronic acid (5 mg) was administered intravenously three months post-surgery. Data on demographics, injury-to-surgery interval, fracture type, DEXA score, and functional outcomes were collected at follow-ups of 6 weeks, 3 months, 6 months, and 12 months. Results: The mean age of participants was 72.67 years. Zoledronic acid administration was associated with a 9.5% mortality rate. Functional outcomes, measured by the modified Harris hip score, significantly improved from a mean of 42.14 at 6 weeks to 77.68 at 12 months (p&lt;0.001). Younger patients (&lt;70 years) had significantly better scores at 3 months compared to older patients (&gt;80 years). However, no significant differences were observed at 6 and 12 months. The mean modified Harris hip scores did not differ significantly between patients with osteopenia and osteoporosis at any time point. Additionally, the type of surgical fixation (intramedullary versus extramedullary) showed no significant impact on functional outcomes. Conclusions: Zoledronic acid administration in elderly hip fracture patients may reduce mortality and enhance functional recovery. The study supports its use in postoperative care to improve outcomes, although larger, randomized controlled studies are needed to confirm these findings. The results suggest that zoledronic acid can be an effective adjunct therapy in managing osteoporosis-related hip fractures in the geriatric population.

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.

Quantitative ROI differences for assessment of occult intertrochanteric extension of greater trochanteric fractures on pelvis CT.

To determine if difference in Hounsfield Units (HU) of the medullary bone between the injured and non-injured femurs in patients with greater trochanteric fractures is associated with occult intertrochanteric (IT) extension. Retrospective review was performed of 81 patients (age range 54-102, 54 females and 27 males) who underwent CT and subsequent MRI after identification of a greater trochanteric fracture without evidence of IT extension on radiography and/or CT. Hounsfield units of the injured and non-injured femurs on CT were recorded at the level of the base of the greater trochanter centrally (ROI1) and the level of the upper border of the lesser trochanter posteromedially (ROI2). The difference between the injured and non-injured femur for each ROI1 and ROI2 were calculated. Absence or presence, and if present, extent of IT extension was assessed on MRI. Analysis was performed to determine if there is correlation of difference in density with presence, and extent of occult IT fractures. 81 cases met inclusion criteria, 14 (17%) had no IT extension, 11 (14%) had less than 50% IT extension and 56 (69%) had 50% or greater IT extension. There was statistical significance between presence and absence of IT extension between the injured and non-injured femur for ROI1 (HU) no IT extension median (IQR): 18.8(4-40), ROI1 (HU) present IT extension median (IQR): 65.5(46-90) p < .0001, and for ROI2 no IT extension median (IQR): 3(-8-25.5) and ROI2 present IT extension 51(40.5-76), p < .0001. There was statistical significance of the extent of IT extension: ROI1 less than 50% IT extension median (IQR): 37.5(27.5-57), ROI1 50% or greater IT extension median (IQR): 72.3(53.5-91.3), p < .0001, and for ROI2 less than 50% IT extension median (IQR): 17.5(8-49), and ROI2 50% or greater IT extension median (IQR): 55.8(45.3-81.5), p < .0001. A threshold ROI2 difference of 50 HU resulted in specificity of 92% and sensitivity 60.7% of for IT extension 50% or greater. Patients presenting with greater trochanteric fractures, an asymmetric increased density measured by ROI differences within the medullary space of the IT region between the injured and non-injured femur is associated with occult IT extension.

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.

Risk Factors for Early Implant Failure in Geriatric Intertrochanteric Fractures Treated with Twin Interlocking Derotation and Compression Screw Cephalomedullary Nail (InterTAN).

Intertrochanteric hip fractures in elderly patients are a significant cause of morbidity and mortality, with increasing incidence due to the aging population. Despite advancements in intramedullary nailing (IMN) technology, fixation failure remains a concern. This study aims to evaluate pre-and postoperative radiographic risk factors for varus collapse in geriatric intertrochanteric fractures treated with twin interlocking derotation and compression screw cephalomedullary nail (InterTAN, Smith & Nephew). This retrospective study included patients over 60 years with AO 31A1 and 31A2 intertrochanteric femur fractures treated with InterTAN at a tertiary referral center from August 2012 to August 2017. Patients with high-energy fractures, AO 31A3 fractures, or those requiring open reduction were excluded. Data on demographics, fracture classification, implant sizes, imaging studies, and follow-up were collected. Radiographic assessments included Chang's medial cortical support concept, tip-apex distance (TAD), calcar-referenced TAD (CalTAD), neck-shaft angles (NSA), and screw placement according to Cleveland zones. Varus collapse was defined as a >5° change in NSA within three months postoperatively. Multivariate logistic regression analysis was used to identify risk factors for varus collapse. The study included 136 patients with a mean age of 79.8 years, of whom 38.2% were male. The early postoperative tipapex distance (TAD) averaged 21.9mm, with 30.1% of patients experiencing varus collapse greater than 5°. Positive medial cortical support (PMCS) or neutral position (NP) type reduction was highly protective against varus collapse (p < 0.001), as well as TAD less than 25mm (p < 0.001). Additionally, the placement of screws in the central-central or central-inferior zones provided a protective effect against varus collapse (p = 0.031). Conversely, having an OTA/AO type A2.2 or A2.3 fracture significantly increased the risk of varus collapse (p = 0.030). Other factors, such as CalTAD and the nail width to medullary canal ratio, did not significantly predict varus collapse (p = 0.831 and p = 0.952, respectively). Our findings align with previous studies highlighting TAD and screw placement as critical factors in preventing fixation failure. The protective effect of PMCS or NP reduction and the increased risk associated with OTA/AO type A2.2 and A2.3 fractures are noteworthy. Unlike previous studies, CalTAD was not significantly associated with varus collapse in our cohort. The study underscores the importance of surgical technique and radiographic parameters in optimizing outcomes for elderly patients with intertrochanteric fractures. In elderly patients treated with InterTAN nails, varus collapse is influenced by fracture type, TAD, reduction quality, and screw placement. Ensuring a TAD <25mm, achieving PMCS or NP reduction, and placing screws in central-central or central-inferior zones are crucial for minimizing varus collapse. These findings highlight the importance of meticulous surgical technique and radiographic assessment in managing intertrochanteric fractures in the elderly. hip fractures, intertrochanteric fractures, internal Fixation, geriatrics, cephalomedullary nail.

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.

Lateral cortical notching for impaired healing of extra-articular proximal femur fractures (case report)

Introduction Dynamization of the nail can be used to improve osteoreparation during intramedullary interlocking nailing (IIN). The procedure can be difficult to perform in some sub- and intertrochanteric femoral fractures due to anatomical and functional features.The objective was to demonstrate a case of successful use of an original version of the lateral cortical notching (LCN) technique for dynamization of an intramedullary proximal nail in a patient with a nonunited subtrochanteric fracture.Material and methods The treatment was performed for a 66-year-old patient with a non-united intertrochanteric fracture of the right femur complicated by the breakage of an intramedullary nail. The LCN technique was successfully used to dynamize the IM nail.Results Radiological healing of the fracture and functional recovery of the patient were observed at a two-month follow-up. The absence of interfragmental compression in IIN could be caused by blocking of the sliding screw by the lateral cortical bone of the peripheral femur fragment. The complication could be prevented with LCN during primary osteosynthesis of the above fractures.Discussion Based on scientific publications and our clinical experience, we assumed that LCN can be indicated for failed healing of intertrochanteric AO/OTA 31A3.1–3 fractures, type 3 Boyd and Griffin trochanteric fractures and all types of subtrochanteric fractures as graded by Seinsheimer with a vector of interfragmental compression to be created along the femur axis during cephalomedullary osteosynthesis. The case report showed the mechanism of impaired consolidation in some intertrochanteric and subtrochanteric fractures of the femur.Conclusion The case report demonstrateed the successful use of the original version of the lateral cortical notching (LCN) technique for dynamization of an intramedullary proximal nail.

Treatment of a femoral neck fracture combined with ipsilateral femoral head and intertrochanteric fractures: A case report

Treatment of a femoral neck fracture combined with ipsilateral femoral head and intertrochanteric fractures: A case report

Perioperative changes of serum interleukin 6 levels in elderly male patients with intertrochanteric fracture

To investigate the perioperative changes in serum interleukin 6 (IL-6) levels in elderly male patients with intertrochanteric fractures, and provide evidence for inflammatory control in this patient population. The clinical data of 40 male patients aged more than 60 years with intertrochanteric fractures who met the selection criteria between January 2021 and December 2022 were retrospectively analyzed, including 25 non-osteoporosis patients (T value>-2.5, group A) and 15 osteoporosis patients (T value≤-2.5, group B). In addition, 40 healthy men aged more than 60 years old were included as controls (group C) according to the age matching rule. There was no significant difference in age, smoking history, drinking history, body mass index, complications (hypertension and diabetes), alanine aminotransferase, aspartate aminotransferase, blood urea nitrogen, creatinine, and total protein among the 3 groups ( P>0.05). Serum samples were collected from group C subjects and from groups A and B patients preoperatively and on postoperative days 1, 3, 5, and 7. IL-6 levels were measured using ELISA assay. Pearson correlation analysis was used to assess the relationship between IL-6 levels and T values at various time points in groups A and B. Postoperative complications during hospitalization and 1-year mortality rates were recorded for groups A and B. Preoperative IL-6 levels were significantly higher in groups A and B than in group C ( P<0.05), with group B being significantly higher than group A ( P<0.05). In groups A and B, IL-6 levels increased significantly on postoperative day 1 compared to preoperative levels and then gradually decreased, approaching preoperative levels by postoperative day 7. IL-6 levels in group B were significantly higher than those in group A at all postoperative time points ( P<0.05). Correlation analysis showed that IL-6 levels were negatively correlated with T values at all perioperative time points in all patients from groups A and B ( P<0.05). Complications occurred in 4 patients (16.0%) in group A, including 2 cases of pulmonary infection, 1 case of urinary tract infection, and 1 case of heart failure, and in 3 patients (20.0%) in group B, including 2 cases of pulmonary infection and 1 case of gastrointestinal bleeding. There was no significant difference in the incidence of complications between the two groups ( χ 2=0.104, P=0.747). There were 2 cases (8.0%) and 4 cases (26.7%) died within 1 year after operation in groups A and B, respectively, and there was no significant difference in 1-year mortality rates between the two groups ( χ 2=2.562, P=0.109). Serum IL-6 levels significantly increase in the early postoperative period in elderly male patients with intertrochanteric fractures, especially in those with osteoporosis. Monitoring the inflammatory state and promptly controlling the inflammatory response during the perioperative period, may reduce complications and improve postoperative survival in this patient population.

Flexible reamer use to overcome entry point errors in proximal femoral nail application in severe obese intertrochanteric fracture patients

IntroductionProximal femoral nailing (PFN) offers biomechanical benefits for intertrochanteric fractures but can lead to higher complication rates from poor reduction and technique errors, particularly in obese patients. Incorrect entry points may cause reduction loss, iatrogenic fractures, and misplaced lag screws. The study aims to investigate the effect of using an oriented flexible reamer instead of a rigid reamer on clinical and radiological results to obtain a medial entry point and better positioning of the nail in the intramedullary area in obese intertrochanteric fracture patients.Materials and methodsA retrospective analysis was conducted on patients aged 65 years and older who underwent PFN treatment between March 2020 and June 2022 at a single institution, with at least 1-year postoperative follow-up. Patients were divided into two groups: those applied with a flexible reamer and a rigid reamer. Parameters analyzed from postoperative radiographs included tip-apex distance (TAD), calcar-referenced tip-apex distance (CalTAD), reduction quality, femoral neck-shaft angle, and lag screw placement. Complication rates and types were recorded for each group.ResultThe analysis included 91 patients, with 45 treated using a flexible reamer and 46 treated using a rigid reamer. There was no statistical difference between the two groups regarding age, gender, BMI, and AO class distributions of the patients (p > 0.05). The Femur neck shaft angle was significantly higher in the flexible reamer group (p < 0.001). As a result of the reduction types analysis, medial type reduction was significantly higher in the group where the flexible reamer was applied (p < 0.001). The CalTAD was shorter in the Flexible reamer group (p = 0.005). Complications and the need for reoperation were statistically significantly higher in the rigid reamer group (p < 0.048).ConclusionThe oriented flexible reamer reduces application-related errors in patients undergoing proximal femoral nail (PFN) treatment due to intertrochanteric fracture. The oriented flexible reamer technique allows a more medial entry point. Oriented flexible reamer creates enough space on both fracture sides at the level of intertrochanteric fracture to avoid nail pass-related complications.Level of evidenceLevel III, Case-control study.

Propensity score matching analysis of early vs. delayed surgery for intertrochanteric fracture in older patients: a retrospective multicenter cohort study of 7414 patients with a mean 4-year follow up

BackgroundThe widespread acceptance of early surgery as a treatment for acute intertrochanteric fracture (ITF) has been accompanied by ongoing controversy due to conflicting conclusions presented in previous studies. This study aims to compare the occurrence of perioperative complications and mortality, as well as functional outcomes in older patients with ITF who underwent either early or delayed surgery.MethodsA retrospective multicenter cohort study involving 7414 patients with ITF between Jan. 2017 and Dec. 2021 was conducted. After predefined participants selection inclusion and exclusion criteria, 2323 surgically treated ITF patients were included and analyzed utilizing propensity score matching (PSM) method. Their demographics, injury-related data, surgery-related data, and perioperative adverse outcomes during hospitalization were collected and compared between the early or delayed surgery groups by PSM with a 1:4 ratio. All participants received a minimum of two-year follow-up and perioperative outcomes, functional outcomes, and survival analyses were conducted and compared.ResultsAfter adjustment for potential confounders, there were no significant difference in surgery duration, intraoperative blood loss, transfusion rate, mortality rates, functional outcomes, and perioperative complications rates including severe complications, cardiac complications, pulmonary complications, and neurological complications regardless of whether the patient was treated with early or delayed surgery (all P > 0.05). Although length of hospital stay (mean, 11.5 versus 14.4 days, P < 0.001), total hospital costs (mean, 39305 versus 42048 yuan, P < 0.001), and minor complications rates including hematological complications (31.7% versus 41.2%, P = 0.007) and nutritional/metabolic complications (59.3% versus 66.4%, P = 0.039) were lower in the early surgery group, our result indicated patients with early surgery were more inclined to receive more blood transfusion (mean, 2.8 versus 2.2 units, P = 0.004).ConclusionsOur findings suggest that a 48-hour delay in surgical intervention for older patients with an ITF does not result in a higher mortality rate, worse functional outcomes, and increased incidence of major perioperative complications when compared to early surgery. While expedited surgery is undoubtedly necessary for suitable patients, a reasonable preoperative delay of 48 h may be justified and safe for those with severe conditions, rather than strictly adhering to the current guidelines.

Functional outcomes of proximal femoral nail versus dynamic hip screw in intertrochanteric fracture.

Objective: To compare the functional and radiological outcomes of Dynamic Hip Screw (DHS) and Proximal Femoral Nail (PFN) treatments for patients with unstable intertrochanteric fractures. Study Design: Comparative study. Setting: Trauma Centre, Hayatabad Medical Complex Peshawar. Period: May 2020 to June 2022. Methods: The study comprised 150 patients aged over 40 years old and had Type 2 intertrochanteric fractures, as classified by Boyd and Griffin. Radiographs, functional assessments, and demographic information were collected and patients were followed for up to two years at regular intervals. Results: The mean age of patients was 70 years. The PFN group had significantly shorter surgery duration (57.47 minutes) compared to the DHS group (85.30 minutes), less blood loss (74 ml vs. 195 ml), and a shorter hospital stay (6.5 days vs. 11.8 days). Early weight bearing was achieved faster in the PFN group, with mean times to partial and full weight bearing of 3.12 and 8.45 weeks, respectively, compared to 5.52 and 12.32 weeks in the DHS group. Radiological union at three months was significantly better in the PFN group. Complications were fewer in the PFN group, with notable differences in screw cutout, migration, and backout rates. Pain levels were lower in the PFN group at three and six months post-operatively. Conclusion: PFN demonstrated superior outcomes in terms of reduced surgical time, blood loss, hospital stay, and faster weight-bearing capabilities compared to DHS. Radiological and functional outcomes also favoured PFN, making it a preferable option for treating unstable intertrochanteric fractures.