Internal Fixation Of Intertrochanteric Fracture Research Articles

Letter to the Editor: Anterior Malreduction is Associated With Lag Screw Cutout After Internal Fixation of Intertrochanteric Fractures.

Letter to the Editor: Anterior Malreduction is Associated With Lag Screw Cutout After Internal Fixation of Intertrochanteric Fractures.

Anterior Malreduction is Associated With Lag Screw Cutout After Internal Fixation of Intertrochanteric Fractures.

Lag screw cutout is a devastating complication after internal fixation of an intertrochanteric fracture. Although the tip-apex distance (TAD) is known to be associated with this complication, another factor we thought was potentially important-fracture reduction on an oblique lateral view-has not, to our knowledge, been explored. (1) Is a well-reduced fracture position on an oblique lateral view after internal fixation of intertrochanteric fracture associated with a lower odds of postoperative cutout, independently of the TAD? (2) Is postoperative sliding of the lag screw after fixation associated with postoperative cutout? Patients with intertrochanteric fractures who were at least 65 years old and who had been treated with internal fixation in one of six facilities between July 2011 and December 2017 were included. All patients in the study group had lag screw cutout, and controls were selected by risk-set sampling of age-matched and sex-matched patients using a ratio of 4:1 for patients from each hospital. Of the 2327 intertrochanteric fractures, there were 36 patients (0.02 per person-year), with a mean age of 85 years; 89% (32) were women. In the control group, there were 135 controls. There was no difference in age or sex between the two groups. Sagittal reduction was evaluated using an immediate postoperative oblique lateral radiograph (anterior malreduction versus anatomic reduction or posterior malreduction). The association between anterior malreduction and the odds of cutout was estimated by conditional logistic regression analysis with the TAD and interaction between the TAD and the reduced position as covariates. As a sensitivity analysis, we estimated whether sliding within 2 weeks postoperatively was associated with cutout. After controlling for the potentially confounding variables of age and sex, we found that anterior malreduction was independently associated with a higher odds of cutout compared with anatomic reduction or posterior malreduction (adjusted OR 4.2 [95% CI 1.5 to 12]; p = 0.006). There was also an independent association between cutout and larger TAD (≥ 20 mm) (adjusted OR 4.4 [95% CI 1.4 to 14]; p = 0.01). However, the association between cutout and reduction was not modified by the TAD (adjusted OR of interaction term 0.6 [95% CI 0.08 to 4]; p = 0.54). Postoperative sliding ≥ 6 mm within 2 weeks was associated with higher odds of cutout after adjusting for age and sex (adjusted OR 11 [95% CI 3 to 40]; p < 0.001). In patients older than 65 years with intertrochanteric fractures, anterior malreduction on a lateral oblique view was associated with much greater odds of postoperative cutout than anatomic reduction or posterior malreduction. Because anterior malreduction is within the surgeon's control, our findings may help surgeons focus on intraoperative reduction on an oblique lateral view to prevent cutouts. Although this factor is a reliable indicator, the results should be applied to cephalomedullary nails, because there was only one patient with cutout among those with sliding hip screws. Because this study was conducted in a homogenous Japanese population, future studies should focus on the association between anterior malreduction and cutout in people of different ethnicities, adjusting for confounding factors such as implant type and surgeon level. Level III, therapeutic study.

Advances in the Restoration and Fixation of Lateral Femoral Wall Fracture

Hip fractures, especially intertrochanteric fractures, are more common with aging. After decades of progress, it is a general consensus to carry out internal fixation for this group of patients. However, the recent focus is on unstable intertrochanteric fractures to ensure better prognosis and prevent internal fixation failure. The lateral femoral wall, as a novel concept, is often disregarded. Many scholars have recognized that the lateral wall of the proximal femoral plays a crucial role in the stability of internal fixation for intertrochanteric fractures. In this paper, the historical evolution, definition, clinical significance, injury classification, choice of internal fixation, and possible prognosis of lateral femoral wall fracture are reviewed in order to provide clinicians strong evidence of treatment strategies.

Salvage total hip arthroplasty after failed internal fixation for proximal femur and acetabular fractures

BackgroundTotal hip arthroplasty (THA) is the treatment of choice for posttraumatic arthritis with failed internal fixation for hip fractures. However, the postoperative prognosis is not clear.Questions/purposesThe primary aim of the study is to report the postoperative outcome, prognosis, and complication rates of total hip arthroplasty in posttraumatic hip arthritis after failed internal fixation of fractures around the hip. The secondary aim of the study is to report results among different fracture types around the hip.Patients and methodsWe enrolled salvage THA patients after failed internal fixation of fractures around the hip and matched control patients undergoing primary THA for hip osteoarthritis. Subgroup analysis was performed to compare the postoperative outcomes, prognosis, and complication rates of salvage THA in posttraumatic hip arthritis after failed internal fixation of different fracture types around the hip.ResultsA total of 315 THAs (105 salvage THAs and 210 primary THAs) were analyzed. Patients with salvage THA had a longer operative time, lower postoperative hemoglobin (Hb) level, more Hb drop (2.2 ± 1.4 vs. 1.7 ± 1.2 gm/dl, p = 0.002), and delayed ambulation. The salvage THA group also had a higher dislocation rate within 2 months after salvage THA (9.5% vs. 1.9%, p = 0.002), reoperation rate (10.5% vs. 3.8%, p = 0.019, including debridement, open and closed reduction under sedation, revision surgery, surgical fixation for periprosthetic fractures), and revision rate (5.7% vs. 0.5%, p = 0.003) than patients undergoing primary THA. Patients who had failed fixation for acetabular fractures were younger and tended to recover well. Patients with previous intertrochanteric fracture had the longest operative time, more hip pain (83.8%, p = 0.022) and more complications.ConclusionSalvage THA in posttraumatic hip arthritis after failed internal fixation required a longer operative time and led to more blood loss and postoperative complications. The dislocation, reoperation, and revision rates after salvage THA were higher than those after primary THA. Patients with salvage THA after failed internal fixation for intertrochanteric fractures were the most susceptible to more complications compared to those with femoral neck fracture or acetabular fracture.Level of Evidence level III

Changes in the anatomical position of the superficial and deep femoral arteries during internal fixation of intertrochanteric fractures

Fixation for intertrochanteric proximal femoral fractures are increasing globally, one of the risks with surgical treatment is injury to the deep and superficial femoral arteries (DFA and SFA, respectively). The anatomic path of these vessels has been previously described, though the effect of reduction techniques, such as traction over a perineal post has not been well defined. This study addresses the question of: do closed reduction maneuvers on an orthopaedic trauma traction table affect the anatomical relationship of superficial and deep femoral arteries to the proximal femur in intertrochanteric proximal femoral fractures? Prospective observational single centre study of seventeen patients with pertrochanteric femoral fractures examined before and after applying traction for closed reduction. Doppler ultrasound was used to determine the proximity of these arteries to the proximal medial femoral cortex at three different levels. Our data demonstrates that internal rotation of the injured limb during reduction draws the arteries statistically closer to the medial cortex of the proximal femoral shaft at 3.5cm and 10.5cm distal to the lesser trochanter (SFA: 3.5cm - 38.0mm vs 34.7mm p 0.004, 10.5cm – 30.4mm vs 21.0mm p 0.02; DFA: 3.5cm – 26.4mm vs 22.3mm p 0.003, 10.5cm - 21.5mm vs 14.1mm p 0.007). No significant change in the artery position was noted in patients who did not require internal rotation to achieve fracture reduction. Surgeons performing these internal fixation procedures need to be aware of the anatomical changes to ensure patient safety and avoid complications including intramuscular haematomas and pseudoaneurysms. • Internal rotation laterally displaces the femoral artery during fixation on an orthopaedic traction table. • Care should be taken to avoid drill plunge beyond the medial femoral cortex. • Deep femoral artery is most ‘at risk’ of injury when using plate or distal locked nail constructs.

Conversion Hip Arthroplasty Using Standard and Long Stems after Failed Internal Fixation of Intertrochanteric Fractures.

Failed internal fixation of intertrochanteric fractures (FIF-ITF) is often treated by conversion hip arthroplasty (CHA). This study aimed to evaluate the results and complications of using standard and long femoral stems in this operation. This retrospective, multi-center study enrolled 31 total hip arthroplasty (THA) and 23 hemiarthroplasties (HA) cases (30 women, 24 men; mean age 76 years) after FIF-ITF between 2012 and 2019, divided into two groups: standard stem group (n=20) and long stem group (n=34). The initial internal fixation includes 38 cases of proximal femoral nail anti-rotation (PFNA), eight cases of the dynamic hip screw (DHS), and eight cases of locking proximal femoral plate (LPFP). The indications for CHA included 38 cases of failure of fixation, seven cases of nonunion, and nine cases of avascular necrosis or posttraumatic osteoarthritis. Perioperative data and complications related to fracture and operation were collected, and preoperative and postoperative clinical and radiological data were analyzed. Clinical outcomes were assessed using Harris hip score (HHS) and 36-item Short Form survey (SF-36: including physical function (PF) score and body pain (BP) score). Statistical analyses were performed using the chi-square or Fisher's exact test, and the 2-sample t-test or Wilcoxon rank sum test. At an average of 5.6 years with a minimum of 2 years follow-up. A significant overall surgeon-related complication rate was detected (27.8% [15/54]), five cases had an intraoperative femur fracture, one case had a late periprosthetic femoral fracture, two cases had a stem penetration, one case had a cement leakage, and two patients had an early postoperative dislocation, one infection and three cases of stem loosening or subsidence. Long stems had an increased risk of complication (13/34) compared to standard stems (2/20) (P=0.031). The operation time and blood loss in the long stem group were higher than those in the standard stem group (P=0.002; 0.017). HHS and SF-36 significantly improved in both groups from preoperative to the final follow-up and did not present significant differences at the final follow-up (P > 0.05). CHA following FIF-ITF showed a successful mid-term clinical result, long stem arthroplasty should be approached with caution for the risks of higher complication rate, especially intraoperative femoral fractures.

USG guided FICB in patients with it fracture: Bupivacaine with dexmedetomidine and bupivacaine a comparative study

Introduction: Positioning intertrochanteric fracture cases for subarachnoid block is challenging. Fascia iliaca compartment block (FICB) helps in positioning and provides analgesia. AIM: To study and compare FICB with inj bupivacaine with dexmedetomidine (DMT) and inj bupivacaine with regard to: 1. Positioning of patient during subarachnoid block 2. Duration of postoperative analgesia. Methods: After obtaining approval from institutional ethics committee and written informed consent from the patient,120 patients aged between 30-80 years belonging to American Society of Anaesthesiologist class 1 and 2 scheduled for closed reduction and internal fixation for intertrochanteric fracture were allocated into two groups. Group A received FICB with inj. bupivacaine 0.25% of 20ml and inj. DMT 0.5µg/kg and Group B received FICB with inj. bupivacaine 0.25% of 20ml. Onset and duration of analgesia were recorded in terms of VAS. Data were analyzed using SPSS 22.0 software and t-test was used as test of significance and P

Effect Analysis of Closed Reduction and PFNA Internal Fixation for Intertrochanteric Fractures on Fracture Healing and Quality of Life of Patients

Effect Analysis of Closed Reduction and PFNA Internal Fixation for Intertrochanteric Fractures on Fracture Healing and Quality of Life of Patients

X-Ray Film under Artificial Intelligence Algorithm in the Evaluation for Nursing Effect of Gamma Nail Internal Fixation in Elderly Patients with Intertrochanteric Fracture of Femur.

The aim of this work was to explore the effects of Gamma nail internal fixation for intertrochanteric fracture of femur by X-ray film classification and recognition method based on artificial intelligence algorithm. The study subjects were 100 elderly patients with intertrochanteric fracture of femur admitted to hospital. The cases were diagnosed as elderly (over 60 years old) femoral intertrochanteric fractures by X-ray or CT. They were divided into two groups, with 50 persons in each group: one group used the X-ray film evaluation image guidance based on the artificial intelligence algorithm (research group), and the other group did not use algorithmic guidance (control group). The results showed that the segmentation effect of the proposed algorithm was similar to the gold standard segmentation result, indicating that the algorithm was effective and feasible in the segmentation of fractures and bones. The global level set algorithm was set as the control. The ultimate measurement accuracy (UMA) value of the algorithm group was (1.77 ± 0.22), and the UMA value of the global level set algorithm group was (3.42 ± 0.36), indicating that the image processed by the algorithm group had obvious numerical effect, high accuracy, and good retention of details. The operation time, intraoperative blood loss, incision length, hospital stay, weight-bearing time, and fracture healing time of the two groups were all better than those of the control group. One month after surgery, the Harris score of the algorithm group was 67, and that of the control group was 51, with a 16-point difference between the two groups (p < 0.05). The patient had less pain and fast recovery speed, indicating that it was a good way to treat elderly intertrochanteric fractures with the nursing effect of X-ray Gamma nail internal fixation based on an artificial intelligence algorithm. The artificial intelligence algorithm not only can be applied to the Gamma nail internal fixation of elderly patients with intertrochanteric fractures but also can be applied to the X-ray image processing of other fractures and other surgical methods to provide effective treatment for fracture patients.

Influence of the PFNA screw position on the risk of cut-out in an unstable intertrochanteric fracture: a computational analysis

The position of the lag screw in the femoral head is a key factor to cut-out, the most reported complication in the internal fixation of intertrochanteric fractures. Considering that the best position for the lag screw remains controversial, the aim of this study was to evaluate the influence of different lag screw positions on the risk of cut-out of an unstable intertrochanteric fracture fixed with a Proximal Femoral Nail Anti-Rotation (PFNA) implant. The relationship between cut-out and the tip-apex distance (TAD) or the calcar referenced tip-apex distance (CalTAD) was also investigated.Finite element models of one male and one female femur treated with a PFNA implant were developed considering the lag screw positioned centrally and inferiorly on the anteroposterior view, and for each of these, the screw tip at 4 discrete positions along its longitudinal axis. All 8 positions simulated for each femur considered the lag screw in a centre position on the lateral view. The risk of cut-out was evaluated for two loading conditions assuming it is related with high compressive strains.The bone region at the fracture line, near the tip of the missing medial fragment, was always the most concerning regarding high compressive strains. The inferior positioning of the lag screw reduced the volume of bone susceptible to yielding compared to the centre positioning. The deep placement of the screw tip improved the outcome for both centre and inferior positions.The results suggested the inferior and deep placement of the screw to be the best position to reduce the risk of cut-out. The volume of bone susceptible to yielding was found not to be correlated to TAD or CalTAD, suggesting that further investigation is necessary to identify other, more reliable, predictors of cut-out.

Outcome of intertrochanteric fractures in elderly patients having comorbidities treated with proximal femoral nail: A single center observational study

Background and Objectives: Intertrochanteric fractures is one of the most frequently operated injuries in the elderly. The incidence of these fractures increases with increasing age. Many studies show certain parameters have an adverse effect on functional outcome and quality of life in patients with intertrochanteric fractures treated surgically. However, very few studies have evaluated the outcome of patients treated surgically having comorbidities such as hypertension, diabetes mellitus, anaemia and asthma.Methods: We conducted a prospective observational study of 30 patients aged 65 years or above, with at least one comorbidity (hypertension, diabetes mellitus, anaemia, asthma and cardiac dysfunction) who underwent PFN for closed intertrochanteric fractures at our hospital. Radiographs were reviewed at 1, 3, and 6 months or till fracture union, whichever came first. Result: In our study, 33% of patients (10) belonged to ASA grade 2, 47% of patients (14) belonged to grade 3, and 20% of patients (6) belonged to grade 4. In our study, 14 patients (46.6%) had one comorbidity, while 16 patients (53.4%) had two or more comorbidities. Harris Hip Score at the end of 3 months was 73.8 and at the end of 6 months was 84.3. Five patients had excellent, 17 patients had good, 7 patients had fair, and 1 patient had a poor functional outcome. Using Cox Regression analysis for hazard ratio of poor post-surgical Hip scores, we found a significant correlation between functional outcome and age of surgery, number of comorbidities, anaemia and length of hospital stay.Conclusion: Proximal femoral nail is a good choice for internal fixation of intertrochanteric fractures. The comorbidities and their correction should be taken into consideration before and after the operative procedure.

Hip arthroplasty for failed internal fixation of intertrochanteric fractures: A Systematic Review and Meta-Analysis

Abstract Background hip replacement is a satisfactory salvage procedure for failed fracture treatment despite the increased operative difficulty. Objectives the purpose of this systematic review and meta-analysis was to review and study literature regarding conversion arthroplasty in patients with failed internal fixation of intertrochanteric fractures to evaluate the results, technical problems and complications, as well as the impact of different variable factors and age. associated with hip arthroplasty and to evaluate the functional outcomes and complications.. Materials and Methods A systematic review of 3 databases (PubMed, Cochrane, and Embase) was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Inclusion criteria were English-language studies that reported complications or functional outcomes after failed fixation of IT fractures with hip arthroplasty in adult subjects (&amp;gt;18 years of age). Results About 2041 articles were found using search keywords as shown in PRISMA flow chart, By filtration and screening of the title and exclusion of unrelated articles, about 109 articles were found, By applications of all inclusion and exclusion criteria, only 8 articles were fit to undergo this meta-analysis. Conclusion So this study showed a significant improvement in functional outcome of hip arthroplasty after failed intertrochanteric fixations despite the relative complication rate of this procedure.

Evaluation of Clopidogrel Safety in Geriatric Patients with Hip Fracture: A Retrospective Study.

ObjectiveTo evaluate the risk of bleeding in elderly patients undergoing early hip fracture surgery with/without clopidogrel administration.MethodsThis was a retrospective study, and patients over 65 years with fresh hip fracture were enrolled. For the patients taking clopidogrel, early surgical treatment was performed without 5–7 days waiting time. The patients were divided into groups according to their fracture type and the surgical method. Within each fracture/surgery group, the patients were further divided into subgroups according to whether they had clopidogrel administration. The patients' age, gender, American Society of Anesthesiologists (ASA) score, hemoglobin level at admission, and the time from admission to surgery were compared in the different groups. The bleeding outcomes, such as intraoperative blood loss and blood transfusion status, as well as secondary outcomes, such as operation duration and length of hospital stay, were also compared in these groups.ResultsThere were no statistically significant differences in patients' baseline characteristics and outcomes, including intraoperative blood loss, blood transfusion rate, operation duration and length of hospital stay, between the clopidogrel‐administrated patients and the control patients. However, the percentage of patients taking general anesthesia was significantly higher in clopidogrel group than that in control group (P = 0.01). Similar intraoperative blood loss was found in the subgroups of hemi‐hip replacement, internal fixation for intertrochanteric fracture of the femur (fracture type A1‐2, short pin), and internal fixation of femoral neck fracture with cannulated nails. For the internal fixation of femoral neck fracture with cannulated nails, the blood loss is significantly less in both subgroups than that with other two surgical methods. Moreover, the total hip arthroplasty, with the highest bleeding risk among all the surgical methods involved, was rarely chosen to treat geriatric hip fracture in this study.ConclusionThis study indicated that compared with patients without clopidogrel administration, elderly patients with hip fractures who receive clopidogrel as long‐term anti‐platelet therapy are relatively safe for surgery in less than 5–7 days after discontinuation of clopidogrel.

Indications for cement augmentation in fixation of geriatric intertrochanteric femur fractures: a systematic review of evidence.

Achieving durable mechanical stability in geriatric intertrochanteric proximal femur fractures remains a challenge. Concomitant poor bone quality, unstable fracture patterns, and suboptimal reduction are additional risk factors for early mechanical failure. Cement augmentation of the proximal locking screw or blade is one proposed method to augment implant anchorage. The purpose of this review is to describe the biomechanical and clinical evidence for cement augmentation of geriatric intertrochanteric fractures, and to elaborate indications for cement augmentation. The PubMed database was searched for English language studies up to January 2021. Studies that assessed effect of calcium phosphate or methylmethacrylate cement augmentation during open reduction and internal fixation of intertrochanteric fractures were included. Studies with sample size < 5, nontraumatic or periprosthetic fractures, and nonunion or revision surgery were excluded. Study selection adhered to PRISMA criteria. 801 studies were identified, of which 40 met study criteria. 9 studies assessed effect of cement augmentation on fracture displacement. All but one found that cement decreased fracture displacement. 10 studies assessed effect of cement augmentation on total load or cycles to failure. All but one demonstrated that augmented implants increased this variable. Complication rates of cement augmentation during ORIF of intertrochanteric fractures ranged from 0 to 47%, while non-augmented implants ranged from 0 to 51%. Reoperation rates ranged from 0 to 11% in the cement-augmented group and 0 to 11% in the non-augmented group. Fixation failure ranged from 0 to 11% in the cement-augmented group and 0 to 20% in the non-augmented group. Nonunion ranged from 0 to 3.6% in the cement-augmented group and 0 to 34% in the non-augmented group. Calcium phosphate or PMMA-augmented CMN fixation of IT fractures increased construct stability and improved outcomes in biomechanical and early clinical studies. The findings of these studies suggest an important role for cement augmentation in patient populations at high risk of mechanical failure.

A comparative study on effectiveness of closed reduction and internal fixation of intertrochanteric fracture assisted with skeletal tractor and traction table

To investigate the effectiveness and advantages of skeletal tractor in closed reduction and proximal femoral nail antirotation (PFNA) internal fixation of intertrochanteric fracture compared with traction table. The clinical data of 86 patients with intertrochanteric fractures, who were treated with closed reduction and PFNA internal fixation between October 2016 and March 2018 and met the selection criteria, was retrospectively analysed. Among them, 44 cases were treated with skeletal tractor (trial group) and 42 cases were treated with traction table (control group). There was no significant difference between the two groups in gender, age, cause of injury, fracture side, AO classification, and degree of osteoporosis ( P>0.05). The preoperative position time, operation time, intraoperative fluoroscopy times, intraoperative blood loss, fracture healing time, intraoperative and postoperative complications, and postoperative Harris score were compared between the two groups. The operation was successfully completed in both groups. Compared with the control group, the patients in the trial group had shorter preoperative position time and operation time, fewer intraoperative fluoroscopy times, and less intraoperative blood loss ( P<0.05). The patients were followed up 12-21 months in trial group (mean, 14.2 months) and 12-22 months in control group (mean, 14.3 months). Venous thrombosis of lower extremity occurred in 8 patients (3 cases of trial group and 5 cases of control group) after operation. Internal fixation failure occurred in 5 patients (2 cases of trial group and 3 cases of control group) during 1 year after operation. All fractures healed except for those with internal fixation failure, the fracture healing time was (11.6±2.9) weeks in trial group and (12.4±3.6) weeks in control group; and there was no significant difference between the two groups ( t=1.250, P=0.214). At 1 year after operation, Harris score of the trial group was 86.2±5.9 and that of the control group was 84.1±6.1. There was no significant difference between the two groups ( t=1.768, P=0.080). Compared with traction table, skeletal tractor in closed reduction and PFNA internal fixation of intertrochanteric fracture can significantly shorten the preoperative position time and operation time, reduce the intraoperative fluoroscopy times, improve the operation efficiency, and have similar effectiveness.

Salvage treatment of failed internal fixation of intertrochanteric fractures: What factors determine the failure of treatment?

IntroductionThe purpose of this study is to evaluate the clinical and radiographic result in patients who got salvage treatment for the failed fixation of intertrochanteric fracture and to evaluate the factors that may affect healing of these treatment. Patients and methodsBetween 1997 and 2016, 39 patients who could be followed up for more than 1 year after treatment were enrolled. For determining of factor that may affect healing of treatment, the primary outcome was based on union. There were success group which achieved a restored union and failure group which had an additional revisional surgery because of another complication for analysis. And neck-shaft angle (NSA) was measured with a goniometer. ResultsFracture healing as a primary outcome (after revision surgery) was achieved 31 out of 39 patients (80%). There were no statistically significant differences between two groups in terms of age, sex, BMI and laterality. In the clinical outcomes, four categories of outcomes were compared between the success and failure groups and significant improvements were observed. In measurements at final follow-up, it the angle was 133.4° in the success group and 123.4° in the failure group. ConclusionThe clinical and radiographic results of the salvage treatment for the failed fixation of intertrochanteric fracture were satisfactory in our study. Restoration of femoral neck-shaft angle of failed intertrochanteric fracture is key factors for obtaining successful results.

Pseudoaneurysm of the Profunda Femoris Artery Following Internal Fixation for Intertrochanteric Fracture: A Report of 2 Cases and Review of the Literature

Inter-trochanteric femur fractures are one of the most common fractures among the elderly [1]. With the aging population it has now become one of the most frequent cause of referral in our trauma center in the elderly patients [2]. Their treatment includes a variety of surgical techniques from external fixation to internal fixation with sliding hip screw and mini invasive surgical procedures, like the use of the gamma nail, each having its own indication [2,3].

[Safety and efficacy of total hip arthroplasty following failed internal fixation of intertrochanteric fractures].

To evaluate the safety and efficacy of total hip arthroplasty (THA) following failed internal fixation of intertrochanteric fractures. Between January 2007 and January 2016, THAs were performed in 32 patients (33 hips) for failed internal fixation of intertrochanteric fractures. There were 15 males and 17 females, with mean age of 74.0 years old (range, 65-87 years). There were 3 hips of Evans-Jensen type Ⅱ, 10 hips of type Ⅲ, 8 hips of type Ⅳ, and 12 hips of type Ⅴ. The fractures were fixed with dynamic hip screw in 18 hips, proximal femoral nail antirotation in 9 hips, locking plate in 5 hips, and hollow screw in 1 hip. The internal fixation failure caused by fracture displacement and nonunion in 22 patients, traumatic arthritis in 6 patients, fracture nonunion and infection in 3 patients, and avascular necrosis of the femoral head in 2 patients. The mean interval from initial fracture fixation to THA was 20 months (range, 2-48 months). The safety evaluation indicators included operation time, amount of operative bleeding and postoperative drainage, blood transfusion, and perioperative complications. The efficacy indexes included the hip Harris score, the range of motion (ROM), visual analogue scale (VAS) score, and the length difference between both legs; the X- ray films were taken to assess the prosthesis survival condition. The average operation time was 92 minutes (range, 55-135 minutes). The average amount of operative bleeding and postoperative drainage were 480 mL (range, 360-620 mL) and 350 mL (range, 220-520 mL), respectively. Intraoperative proximal femur fissure fracture occurred in 2 hips. After operation, 10 cases received allogeneic blood transfusion, 1 case occurred cerebral infarction, 2 hips experienced dislocation, 1 hip occurred greater trochanter re-fracture and dislocation because of spraining, and 1 case died of myocardial infarction. Twenty-nine patients (30 hips) were followed up 2-10 years (mean, 4.9 years). At last follow-up, there was no infection recurrence in 3 infected hips, and there was no prosthesis loosening, subsidence, or rupture in all cases. The Harris score, ROM, VAS score, and the length difference between both legs were significantly superior to preoperative ones ( P<0.05). THA is an effective salvage procedure after failed internal fixation of intertrochanteric fracture. But its perioperative risks and complications are pretty high. Adequate preoperative evaluation, elaborate and individualized perioperative management are keys to make sure the patient can safely survive the perioperative period.

[Evolving concept in treatment of intertrochanteric fractures and development of internal fixation devices].

To summarize the evolving concept in treatment of intertrochanteric fractures and the development of internal fixation devices. Related literature concerning the implant devices to treat intertrochanteric fractures was reviewed and analyzed in terms of the biomechanical characteristics, clinical application, and complications. The treatment of intertrochanteric fractures has undergone an evolving concept from conservative treatment to surgical treatment. Surgery strategies include extramedullary fixation and intramedullary fixation. Intramedullary fixation has gradually become the main treatment of intertrochanteric fractures due to its minimally invasive and biomechanical advantages. However, the current intramedullary fixation system still can not reconstruct the medial cortical support of the proximal femur, which leads to some failures in the treatment of unstable fractures. The development of internal fixation of intertrochanteric fractures is based on the deep understanding and biomechanical theory of intertrochanteric fractures in clinical practice. In the future, the updated design of internal fixation devices will depend on the treatment principle of reconstruction of medial support and secondary stabilization of intertrochanteric fractures, and finally the purpose of improving success rate and reducing postoperative complications of intertrochanteric fracture will achieved.

The effect on outcomes of the application of circumferential cerclage cable following intramedullary nailing in reverse intertrochanteric femoral fractures.

The aim of this study was to evaluate the effect on union results of the application of cerclage cable around the lateral femoral wall (LFW) in postoperative fracture displacement. A retrospective evaluation was made of all the cases of reverse intertrochanteric fractures over a 7-year period in a trauma center. The study included 69 fractures treated with intramedullary nailing. The age of the patients, postoperative reduction quality and complications such as mechanical failure and non-union (1.4%) were obtained from the medical records. Changes in the neck-shaft angle, the amount of LFW displacement and telescoping of proximal femoral nail antirotation blades and lag screws were measured on anteroposterior and lateral radiographs. The functional evaluation of the Harris Hip Score was recorded at the final follow-up examination. The mean age of the patients was 56.31years (range 18-93years). Closed reduction was applied in 37 (53.7%) cases, open reduction in 10 (14.5%) and with cerclage cable in 22 (31.8%). Mechanical failure developed in 8 (11.5%) cases where cerclage cable was not used. In 2 of these 8 cases, open reduction was successful. In the patients where cerclage cable was applied, no mechanical failure developed and no case underwent revision surgery. In the cases where cerclage cable was not used, a significantly higher rate of telescoping was found. (p = 0.001). The application of cerclage cable was seen to significantly reduce the amount of LFW displacement (2.23mm vs 8.86mm) and shorten the time to partial weight bearing (p = 0.000). In reverse intertrochanteric fractures, the application of circumferential cerclage cable with cephalomedullary nailing contributes to primary stability and accelerates mobilization. Therefore, it can be considered a good option. It reduces the risk of failure internal fixation for intertrochanteric fracture.