Pertrochanteric Hip Fractures Research Articles

Fast track care for pertrochanteric hip fractures: How does it impact length of stay and complications?

IntroductionThe medical and economic impact of treating pertrochanteric hip fractures is growing. We hypothesized that fast track surgery of pertrochanteric fractures would reduce the length of stay (LOS) without compromising the quality of care. Materials and methodsThis was a prospective, observational, single-center cohort study conducted between 2014 and 2016 at the Angers Teaching Hospital in France. The enrolled patients had an isolated A1 or A2 proximal femur fracture (AO classification) that was treated surgically by intramedullary nailing and required post-acute rehabilitation (PAR) care. The exposed FT cohort was transferred into the PAR pathway on postoperative day 1. The non-exposed (control) group was provided with postoperative care in the surgery unit before transfer to PAR. The primary outcome was the total LOS (LOS in surgery+LOS in PAR). The secondary objectives were to determine the immediate survival, 1-year survival, postoperative complications and average cost of hospitalization. ResultsThe study enrolled 109 patients initially, with 54 patients eligible for analysis after matching (27 pairs). The LOS in PAR and total LOS were 45.85±19.24 days and 48.56±19.36 days in the FT group (n=27), and 68.41±48.77 days and 77.85±48.80 days in the control group (n=27). Thus the LOS in PAR and total LOS were significantly lower in the FT group (p=0.022, p=0.003). There was no significant difference in the number of early deaths, complications, and 1-year survival without rehospitalization between cohorts. The mean cost per patient was lower in the FT cohort. DiscussionThe FT pathway has already been adopted in orthopedics. For patient who suffer a hip fracture, it contributes to reducing the total LOS without negatively impacting the quality of care. Early health economics studies support this care pathway. ConclusionThe FT approach to treating pertrochanteric fractures reduces total LOS without increasing mortality or complication rates. The 1-year survival is comparable. Level of evidenceIIB, Exposed/Unexposed cohort.

Reoperations in intramedullary fixation of pertrochanteric hip fractures

Objective: This study evaluated the frequency of reoperation within 1 year of initial intramedullary fixation for patients with pertrochanteric hip fracture and compared 1-year healthcare resource utilization and cost burden for patients with and without reoperation.Methods: This is a retrospective evaluation of medical claims from the US Centers for Medicare and Medicaid Standard Analytic File. Patients aged ≥65 years who underwent fixation with an intramedullary implant for a pertrochanteric fracture between 2013 and 2015 were included. Healthcare resources that were evaluated included skilled nursing facility (SNF), inpatient rehabilitation facility (IRF), readmissions, and outpatient hospital visits. All-cause payments for these services comprised overall cost burden. Generalized Linear Models were used to evaluate healthcare resources and cost burden over 1-year post-surgery and to adjust for confounding between patients with and without a reoperation.Results: A total of 6,423 Medicare patients were included in the analysis. Mean (SD) age was 82.4 (7.8) years, 76.0% were female, and 93.3% were white. A second hip surgery within 1 year after the index fixation procedure was performed in 414 patients (6.4%): 121 (29.2%) contralateral, 115 (27.8%) ipsilateral, and 178 (43.0%) without specified laterality. After adjusting for confounding factors, Medicare patients with ipsilateral reoperations had statistically significantly higher readmissions (100% vs 32.5%, p < 0.0001), outpatient hospital visits (96.4% vs 88.8%, p = 0.018), admissions to a SNF (88.5% vs 80.4%, p = 0.024), and admissions to an IRF (38.8% vs 22.0%, p < 0.0001) compared to patients without reoperations. The adjusted mean total all-cause payments ($90,162 vs $55,131, p < 0.0001) during the 1-year follow-up were statistically significantly higher among patients with reoperations as compared to patients without reoperations.Conclusions: Patients who require a second hip surgery after initial fixation with an intramedullary implant for pertrochanteric hip fractures have significantly higher 1-year healthcare resource utilization and 63.5% higher costs than patients without reoperation.

Lesser Trochanteric Fragments in Unstable Pertrochanteric Hip Fractures: A Morphological Study Using Three-Dimensional Computed Tomography (3-D CT) Reconstruction.

BackgroundThe lesser trochanter (LT) posterior cortical extension (LTPE) fragment is important for joint stability during reconstruction in unstable pertrochanteric hip fractures. This study aimed to investigate the morphological characteristics of the LT fragments using three-dimensional computed tomography (3-D CT) reconstruction and to compare clinical outcomes in different subgroups of 31A2 fractures.Material/MethodsA retrospective study included CT images of 58 cases of 31A2 type unstable pertrochanteric fractures, using the Arbeitsgemeinschaft für Osteosynthesefragen and Orthopedic Trauma Association (AO/OTA) classification. After 3-D CT reconstruction, all the displaced fragments were reduced and the morphologic parameters of the LT fragments were measured.ResultsAt the mid-level of the LT, the mean cortical extension of the LT fragment was 33.5 mm in the posterior wall (83%), 19.0 mm in the medial wall (53%). The mean distal cortical extension from the lower edge of the LT was 13.0 mm. The LT fragment occupied 38% of the whole cortical circumference. Comparison of the subgroups showed that the LT fragment of A2.3 had a larger cortical extension in the posterior, medial, and distal cortex. The mean fracture collapse was 4.7 mm in A2.2 fractures and 5.4 mm in A2.3 fractures (p=0.311). Despite the increased size of the LT fragment in subtype A2.3 fracture compared with subtype A2.2 fracture, this did not influence the clinical outcome.ConclusionsThe 3-D morphology of the LT fragment from CT imaging provided a better understanding of the characteristics of subgroups of unstable pertrochanteric fractures, which may improve and guide implant choice.

Elderly Patients with Pertrochanteric Hip Fracture: In Hospital Care

Objective: To evaluate the improvement in the care of elderly patients hospitalized due to pertrochanteric hip fractures. Methods: A comparative study of two cohorts of patients admitted due to pertrochanteric hip fractu re before (2010) and after the application of in hospital management protocols (2018). The intervention consisted in the implementation of multidisciplinary measures during hospitalization based on current scientific evidence. An evaluation of the clinical results was performed, as well as the health care impact. Results: The characteristics of patients admitted for hip fracture in 2010 (216 patients) and 2018 (205 patients) were similar in age, sex, Barthel index and the Charlson abbreviated index. In 2018 patients had more comorbidity. A significant reduction of preoperative stay and overall stay in the cohort of 2018 was achieved. Detection of delirium, malnutrition and anaemia was higher in 2018, and a reduced incidence of infection and a better function al efficiency was achieved in this period. Conclusion: The introduction of measures for the improvement of the pertrochanteric hip fracture management reduces hospitalization with consequent cost reduction. Unification of criteria among professionals may b e an opportunity for better clinical results and reduction of complications.

Опыт применения комбинированной одноуровневой спинально-эпидуральной анестезии при операциях на бедре

In this study we analyze the experience of use combined single-level spinal epidural anesthesia among patients with high anesthetic risk in operations carried out at hip fractures in 2018. Patients of 1st group (26) operated for closed pertrochanteric hip fracture with high anesthetic risk of 3 st. according to American Society of Anesthesiologists, with age from 55 to 90 years (mean age 78.3 years). This group was operated with the use of combined single-level spinal epidural anesthesia. Patients of the 2nd group (25) were operated for femoral neck closed fracture in age from 80 to 96 years (mean age of 86.9 years). The operation for this group was performed using spinal anesthesia. In general 92 patients with this diagnosis were operated in 2018, but we selected for analysis 25 patients over the age of 80 years with an anesthetic risk of 3 st. according to American Society of Anesthesiologists. Patients of the 3rd group (6), were operated for fractures of the upper third, lower third and femoral neck, one patient had a combined fracture of the right femoral neck and the surgical neck of the right humerus. Age of patients varied from 81 to 91 years (mean age 86.8 years), and the risk according to American Society of Anesthesiologists - 3 st. These patients were operated with the use of epidural anesthesia. The aim of the analysis is to evaluate the advantages of combined single-level spinal epidural anesthesia in performing operations for femoral fractures.

Is the modified Harris hip score valid and responsive instrument for outcome assessment in the Indian population with pertrochanteric fractures?

IntroductionThe original Harris hip score (HHS) does not contain ability to perform squatting and sitting cross legged as items in the questionnaire and hence a need was felt to modify the Harris hip score so that it could stay relevant in functional assessment of Indian patients in the rural setting. Validity, responsiveness and ceiling floor effect of the Harris hip score after internal fixation of pertrochanteric fracture has not been previously described. The objective of the study was to investigate construct validity, responsiveness and ceiling floor effects of the modified Harris hip score (mHHS). MethodsFor evaluation of construct validity two hypotheses were formulated: first, there would be no difference in mHHS in cohort of patients treated with short or long proximal femoral nail and second, patients younger than 65 years will have higher mHHS compared to patients older than 65 years postoperatively. Proportion of patients obtaining lowest score of 0 point (floor effect) and those obtaining highest score of 100 points (ceiling effect) was evaluated at one, three and six months postoperatively. It is recommended that the proportion of ceiling and floor effect should be lower than 15% in order to deduce satisfactory internal and content validity of an outcome instrument. Responsiveness was evaluated using distribution based methods (effect size and standardised response mean) and anchor based method (area under the curve using receiver operating curve). Ability to perform cross leg sitting and squatting at six months postoperatively were chosen as two different external anchors. Effect size and standardised response mean values higher than 0.80 and area under the curve value higher than 0.70 are indicators of adequate responsiveness of an outcome instrument. ResultsEighty one consecutive patients with pertrochanteric hip fractures and treated with long and short proximal femoral nail were included in this prospective observational study. Six patients were lost to follow-up due to mortality and complete functional outcome data was available in 75 patients (92.6%). The mean age was 68 years (range: 38–89 years). The mHHS at one, three and six months postoperatively was 39.9 ± 9.5, 61.6 ± 14.7 and 81.0 ± 15.9 respectively. The improvement in mHHS was significant at all time intervals. In accordance with the hypothesis, there was no significant difference in mHHS at one, three and six months postoperatively in patients treated with short or long proximal femoral nail. In accordance with the hypothesis, patients younger than 65 years had significantly better mHHS at one, three and six months postoperatively as compared to patients older than 65 years. There were no floor or ceiling effects at one, three and six months postoperatively. mHHS showed adequate internal responsiveness (Effect size = 4.34; standardised response mean = 4.26) and adequate external responsiveness (Area under curve = 0.77 and 0.89) using different external anchors. ConclusionThe mHHS has adequate construct validity, internal validity and responsiveness to evaluate functional outcome of intramedullary nail fixation in pertrochanteric hip fractures in the Indian population.

Utility of Geriatric Assessment in the Projection of Early Mortality Following Hip Fracture in the Elderly Patients.

Hip fractures result in significant morbidity and mortality in elders. Indicators of frailty are associated with poor outcomes. Commonly used frailty tools rely on motor skills that cannot be performed by this population. We determined the association between the Charlson Comorbidity Score (CCS), intraoperative hypotension (IOH), and a geriatric medicine consult index (GCI) with short-term mortality in hip fracture patients. A retrospective cohort study was conducted at a single institution over a 2-year period. Patients aged 65 years and older who sustained a hip fracture following a low-energy mechanism were identified using billing records and our orthopedic fracture registry. Medical records were reviewed to collect demographic data, fracture classification and operative records, calculation of CCS, intraoperative details including hypotension, and assessments recorded in the geriatric consult notes. The GCI was calculated using 30 dichotomous variables contained within the geriatric consult note. The index, ranging from 0 to 1, included markers for physical and cognitive function, as well as medications. A higher GCI score indicated more markers for frailty. One hundred eight patients met inclusion criteria. Sixty-four (59%) were females and the average age was 77.3 years. Thirty-five (32%) patients sustained femoral neck fractures, and 73 (68%) patients sustained inter-/pertrochanteric hip fractures. The 30-day mortality was 6%; the 90-day mortality was 13%. The mean GCI was 0.30 in the 30-day survivor group as compared to 0.52 in those who died. The mean GCI was 0.28 in patients who were alive at 90 days as compared to 0.46 in those who died. In contrast, the CCS and IOH were not associated with 30- or 90-day mortality. In our older hip fracture patients, an index calculated from information routinely obtained in the geriatric consult evaluation was associated with 30- and 90-day mortality, whereas the CCS and measures of IOH were not.

不安定型大腿骨転子部骨折に対するTFNA middle nailの使用経験

不安定型大腿骨転子部骨折に対するTFNA middle nailの使用経験

Rate of Contralateral Hip Fracture After Dynamic Hip Screw Vs Intramedullary Nail for Treatment of Pertrochanteric Hip Fractures

A retrospective, comparative study was performed reviewing the electronic medical records and digital radiographs of patients who underwent treatment for intertrochanteric and pertrochanteric hip fractures with either a hip screw and side plate (HSSP) or intramedullary nail. A total of 430 patients were treated with HSSP, and 725 were managed with a cephalomedullary nail (CMN). Of these, 103 sustained a contralateral hip fracture. Fixation technique was not associated with a significant difference in the rate of contralateral fracture. Among the patients with a contralateral fracture, the median time to contralateral fracture was 119.28 months following HSSP and 81.97 months following CMN. Bisphosphonate use was found to be a significant predictor of contralateral fracture for all patients, but when matching using propensity scores, its use was found to be insignificant. In conclusion, there was no difference in the rate of subsequent contralateral hip fracture when comparing HSSP with CMN. Additionally, the time to second surgery between the two treatment modalities was found to be statistically insignificant. It is unclear if bisphosphonate use increased the odds of having a contralateral fracture, regardless of the surgical intervention. The difference in the bisphosphonate effect using propensity score matching suggests that the results may be due to confounding variables and bias.

Influence of Fracture Stability on Early Patient Mortality and Reoperation After Pertrochanteric and Intertrochanteric Hip Fractures: Erratum.

Influence of Fracture Stability on Early Patient Mortality and Reoperation After Pertrochanteric and Intertrochanteric Hip Fractures: Erratum.

Contralateral Prophylactic Reinforcement in Case of First Low-Energy Hip Fracture: First-in-Man Clinical Data of a New Percutaneous Internal Fixation Device

A prevention dedicated osteosynthesis device (Y-STRUT®, Hyprevention) was developed to reinforce the proximal femur on patients with high risk of fragility hip fracture. A multicentre pilot study was initiated to evaluate the feasibility, safety and tolerance of this device and the related operative procedure. This clinical study is an on-going prospective series of 15 patients. Between February 2013 and December 2016, 10 patients were implanted. Patients were recruited when arriving to emergencies following a low-energy trauma leading to a pertrochanteric hip fracture. The device was implanted in combination with bone cement into the contralateral hip during the same anaesthesia as the fractured hip fixation. Clinical evaluation includes pain evaluation, functional status, and osteointegration of the device. Mean age of patients was 82 ± 7 years. Mean duration of implantation was 56 ± 19 min for Y-STRUT® implantation and 37 ± 24 for fracture fixation in the opposite side. Mean cement quantity injected was 8 ± 1.6 ml. At 3 months, WOMAC scores for pain and functionality were 5 and 24, respectively and 4 and 18 at 12 months. Mean follow-up is 16 ± 12 months. No patient died during the follow-up. No osteolysis nor post-operative fracture were observed. Preliminary results of this prospective study showed the feasibility, safety and tolerance of the implantation of this new device. Further patients are required to confirm this experience and confirm efficacy of the device to reduce the risk of contralateral hip fracture during the first year after the first fracture when elderly patients are at the highest risk of fracture and mortality and the anti-osteoporosis medication prescribed at fracture is not yet efficient.

Effect of Teriparatide or Risedronate in Elderly Patients With a Recent Pertrochanteric Hip Fracture: Final Results of a 78-Week Randomized Clinical Trial.

We present final results of a study comparing teriparatide 20 μg every day (QD) with risedronate 35 mg once per week (QW) started within 2 weeks after surgery for a pertrochanteric hip fracture. Patients with BMD T-score ≤ -2.0 and 25OHD ≥9.2 ng/mL were randomized to receive 26-week double-dummy treatment plus calcium and vitamin D, followed by 52-week open-label treatment with the same assigned active drug. Primary endpoint was change from baseline in lumbar spine (LS) BMD at 78 weeks. Secondary and exploratory endpoints were change in BMD at the proximal femur, function, hip pain (Charnley score and 100 mm Visual Analog Scale [VAS]), quality of life (Short Form-36), radiology outcomes, and safety. Data were analyzed with mixed models for repeated measures (MMRM) and logistic regression. Totally, 224 patients were randomized; 171 (teriparatide: 86) contributed to the efficacy analyses (mean ± SD age: 77 ± 7.7 years, 77% females). Mean baseline LS, femoral neck (FN), and total hip (TH) T-scores were -2.16, -2.63, and -2.51, respectively. At 78 weeks, BMD increased significantly more with teriparatide compared to risedronate at the LS (+11.08% versus +6.45%; p < 0.001) and FN (+1.96% versus -1.19%; p = 0.003), with no significant between-group difference in TH BMD. Timed up-and-go (TUG) test was significantly faster with teriparatide at 6, 12, 18, and 26 weeks (differences: -3.2 to -5.9 s; p = 0.045 for overall difference). Hip pain during TUG test by 100 mm VAS was significantly lower with teriparatide at 18 weeks (adjusted difference: -11.3 mm, p = 0.033; -10.0 and -9.3 mm at 12 and 26 weeks, respectively; p = 0.079 for overall difference). Other secondary and exploratory outcomes were not different. Teriparatide group showed two new hip fractures versus seven with risedronate (p = 0.171) and more frequent hypercalcemia and hyperuricemia. In conclusion, 78-week treatment with teriparatide showed significantly greater increases in LS and FN BMD, less pain, and a faster TUG test versus risedronate. © 2016 American Society for Bone and Mineral Research.

Short Versus Long Intramedullary Nails in the Treatment of Pertrochanteric Hip Fractures: Incidence of Ipsilateral Fractures and Costs Associated With Each Implant.

Both short intramedullary nails (SIMNs) and long intramedullary nails (LIMNs) are routinely used in the surgical treatment of pertrochanteric hip fractures. The purpose of this study was to assess the incidence of ipsilateral femur fractures after the surgical treatment of hip fractures and the overall costs associated with each implant. Retrospective cohort study. Level I trauma center and 2 community hospitals. A total of 609 patients with pertrochanteric hip fractures treated with an SIMN or LIMN from 2005 to 2011. Review of patient demographics and clinical outcomes over a 5-year follow-up period. Ipsilateral femur refracture rates were recorded for both groups, and a cost analysis was then performed to compare SIMNs and LIMNs while accounting for their observed refracture rates and surgical/hospital costs to determine the overall cost of each implant. Union rates were equivalent between groups and averaged over 97%. The incidence of ipsilateral femur fractures in both groups steadily increased with greater follow-up time to reach nearly 10% at 5 years. Although only 47% of all nails were locked distally, 15 of the 16 refractures occurred in nails that were not distally locked. Cost analysis revealed no significant difference in the use of short versus LIMNs over a 5-year period (P = 0.76). The incidence of ipsilateral femur refractures steadily rose with greater follow-up in both SIMN and LIMNs. Distally locking the initial fixation seems to protect against future femur fractures and may also affect the refracture location when using LIMNs. No differences in overall costs were seen at 1, 2, or 5 years between SIMNs and LIMNs. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Assessment of Mortality in Postoperative Hip Fractures in a Rural Tertiary Care Centre

Background: Peritrochanteric hip fractures in elderly people leads to prolonged immobilization and increased risk of death. Elderly people having co morbidities such as diabetes, hypertension and cardiovascular diseases, along with hip fractures results in increase the mortality of the patients post operatively1,2. The objective of this study is to determine the relation of mortality during one year post operative period after hip surgery to associated co morbidities. Methods: In this retrospective study patients aged 60 and above admitted during the period from April 2014 to June 2015 in the department of orthopaedics at a rural tertiary care centre for surgical intervention for peri trochanteric hip fractures were included. A sample size of 56 patients operated during this period was considered in this study. Results: Out of 56 patients operated, 9 patients died during first year post operative period.Of them 4 were males and 5 females. 2 patients died in first one month of follow up, one due to aspiration pneumonia and second patient from septicaemia. 3 patients died in first 3 months of follow up due to deep vein thrombosis leading to pulmonary embolism, cardiac failure and cerebro-vasular accident. 4 patients died due to cardiac failure between 3 months to one year postoperative period. Out of 9 death 4 were in hospital 3 in home, one in old age home and one person in unknown place. In 9 deaths 3 patients had bipolar prosthesis,2 dynamic hip screws fixation, 2 with proximal femoral locking compression plate, 2 with proximal femoral nailing and 1 with Austin Moore prosthesis. Death of patients more than 75 years were 5 and between 65-74 years was 4. Conclusion: Hip fractures are one of the common causes of increasing mortality in elderly population. However early recognition of patients with hip fracture and admission to hospital, prompt identification of the co morbidities and treating them with early surgery and mobilization would geatly reduce the risk of morbidity and mortality.

Displaced trochanteric fragments lead to poor functional outcome in pertrochanteric fractures treated by cephalomedullary nails.

The importance of the greater trochanter and its attached abductor muscles for physiological gait is well accepted. However the influence of a displaced greater trochanter fracture after a pertrochanteric fracture is unknown. The aim of this study is to determine if there is an association between the greater trochanter position and the level of patient mobility following internal fixation of pertrochanteric fractures. One hundred and thirty-three consecutive elderly patients with a median age of 85 (interquartile range [IQR] 79-91) years, who were treated for pertrochanteric fractures at a level I trauma centre, were recruited. AO 31 A3.1 and A3.2 fracture types were excluded from the statistical analysis. Patient mobility was prospectively assessed before the fracture and one year following fracture treatment using the Parker mobility score. In a multivariable analysis, the influence of a displaced greater trochanter on patient mobility at one-year follow-up was assessed. The analysis was adjusted for age, gender, body mass index, Charlson comorbidity index, AO fracture classification, varus-/valgus malposition of the neck-shaft fragments, and Parker mobility score before fracture. Post-operative X-rays were available in 125 patients, out of which 66 (53%) patients were identified with a displaced or migrated greater trochanter. One year mortality rate was 22% (n=27). In the 82 patients who had functional assessment one year post-operatively, the median Parker mobility score before fracture and at one-year follow-up was 7 (IQR 4-9) and 7 (IQR 3-9) in patients without, and 7 (IQR 4-9) and 3 (IQR 2-5) in patients with a displaced greater trochanter. In multivariable analysis, a displaced greater trochanter was significantly associated with a lower Parker mobility score (-1.74, 95% confidence interval -2.37, -1.12, p<0.01). Greater trochanter displacement following internal fixation of extracapsular hip fractures with a cephalomedullary nail is associated with a poor functional outcome. Greater attention to achieve adequate reduction and stabilisation of this fragment during internal fixation of pertrochanteric hip fractures should be aimed for despite the inability of current cephalomedullary implants to do so. III prognostic and epidemiological study.

Loss of offset after pertrochanteric hip fractures affects hip function one year after surgery with a short intramedullary nail. A prospective cohort study.

We hypothesised that protruding collum screws in intramedullary nails used for pertrochanteric fractures cause lateral pain/discomfort and that loss of offset relates to poorer hip function. Seventy-six patients with an acute pertrochanteric femoral fracture AO types A1 and A2 were operated upon using a short intramedullary nail and were included in a prospective observational cohort study and followed-up for one year. The main outcome variables were lateral pain and hip function as evaluated with the Harris Hip Score. The main exposure was compression along the collum screw and lateral protrusion measured by anteroposterior X-ray images. Perioperative images were compared to images at the follow-up visit. Outcome variables were adjusted in regression models for reduction, fracture type, body mass index, sex and age. A total of 28 (36 %) patients experienced lateral pain at one year. We found a correlation between lateral protrusion and lateral pain, adjusted OR 4.5 per protruding centimetre (95 % CI, 1.1-17.5). Collum compression correlated with a poorer outcome with Harris Hip Score -14.2 per compressed centimetre (95 % CI, -21.8 to -6.7). In patients with type A1 and A2 pertrochanteric fractures operated on using intramedullary nailing, a large compression and lateral protrusion of the collum screw are associated with poorer hip function and lateral pain. New technical improvements for implants should focus on these factors to improve functional outcome after surgery.

Fracture reduction with positive medial cortical support: a key element in stability reconstruction for the unstable pertrochanteric hip fractures.

PurposeTo introduce the concept of fracture reduction with positive medial cortical support and its clinical and radiological correlation in geriatric unstable pertrochanteric fractures.MethodsA retrospective analysis of 127 patients (32 men and 95 women, with mean age 78.7 years) with AO/OTA 31A2.2 and 2.3 hip fractures treated with cephalomedullary nail (PFNA-II or Gamma-3) between July 2010 and June 2013 was performed. They were classified into three groups according the grade of medial cortical support in postoperative fracture reduction (positive, neutral, and negative). The positive cortex support was defined that the medial cortex of the head–neck fragment displaced and located a little bit superomedially to the medial cortex of the shaft. If the neck cortex is located laterally to the shaft, it is negative with no cortical buttress, and if the two cortices contact smoothly, it is in neutral position. The demographic baseline, postoperative radiographic femoral neck–shaft angle and neck length, rehabilitation progress and functional recovery scores of each group were recorded and compared.ResultsThere were 89 cases (70 %) in positive, 26 in neutral, and 12 in negative support. No statistical differences were found between the three groups among patient age, sex ratio, prefracture score of activity of daily living, walking ability score, ASA physical risk score, number of medical comorbidities, osteoporosis Singh index, fracture reduction quality (Garden alignments), and the position of lag screw or helical blade in femoral head (TAD). In follow-up, patients in positive medial cortical support reduction group had the least loss in neck–shaft angle and neck length, and got ground-walking much earlier than negative reduction group, with good functional outcomes and less hip–thigh pain presence.ConclusionFracture reduction with nonanatomic positive medial cortical support allows limited sliding of the head–neck fragment to contact with the femur shaft and achieve secondary stability, providing a good mechanical environment for fracture healing.

Postoperative analgesia in patients older than 75 years undergoing intervention for per-trochanteric hip fracture: a single centre retrospective cohort study.

The aim of this study was to compare the efficacy of four analgesia techniques on postoperative pain after per-trochanteric femur fracture. A retrospective cohort study was conducted on 131 consecutive patients older than 75 years enrolled in an 18-month period and who underwent per-trochanteric fracture repair under spinal analgesia. Patients received postoperative analgesia from: G1 (n = 36), intravenous analgesia on demand only; G2 (n = 28) administration of acetaminophen at fixed hours; G3 (n = 50) continuous morphine infusion; G4 (n = 17), preoperative echo-graphic guided femoral nerve block. Continuous opioid infusion failed to prevent the onset of pain at the end of the effects of subarachnoid anesthesia (rescue dose of analgesic in 48 % of patients in G3 vs. 22 % in G2 in the first day; p < 0.05). The greater effectiveness was achieved by preventing the onset of pain with drugs administered at time intervals (rescue dose of analgesic in 48 % of patients in G3, 58 % in G1 and 48 % in G4 vs. 22 % in G2 in the first day and rescue dose of analgesic in 32 % of patients in G3, 67 % in G1 and 76 % in G4 vs. 18 % in G2 in the second day; p < 0.05). Our study does not confirm the effectiveness of a single shot femoral nerve block on postoperative pain in per-trochanteric femur fracture (PAIN VAS score > 3 at t1 in 23 % of patients in G1 and 19 % in G4 vs. 10 % in G2 and G3; p < 0.05).

Rotationally Stable Fixation for Intertrochanteric Hip Fractures

Purpose: The surgical stabilization of intertrochanteric fractures remains a persistent challenge. The purpose of this paper was to describe the surgical technique and analyze the outcomes of these fractures treated with a novel intramedullary (IM) device that provides rotational stability, in addition to prompting compression across the fracture. Materials and Methods: In this IRB approved retrospective study, consecutive patients with peritrochanteric hip fractures were treated with an (Intertan) (a fourth generation proximal hip nail) IM nail. Clinical examination and radiographic analysis was obtained at routine intervals. Clinical and radiographic outcome parameters were evaluated. Outcome measurements included time to union, reoperating rate, change of femoral neck-shaft angle, migration of the lag screw, degree of lag screw telescoping, and tip-to-apex distance. Factors that may have affected outcomes were determined statistically. Results: A total of 20 patients were lost to follow-up with 80 patients available for long-term follow-up with complete data for statistical analysis. The majority of fractures (79%) were classified as unstable (OTA 31-A2). All fractures healed. The average time to union was 12.9 weeks. No patients sustained any intraoperative complications. One patient required revision surgery secondary to a peri prosthetic. Three patients demonstrated partial lag screw cut-out, but the fracture’s healed in an acceptable position. Six patients had leg shortening >1 cm, and 2 patients had femoral neck-shaft angle progression of >10 degrees. Further x-ray review demonstrated average change in neck-shaft angle of 3.1 degrees, average lag screw migration of 3.9 mm, and average lag screw telescoping of 3.8 mm. Radiologic changes occurred within the first 8 weeks postoperation. None of the previous shown determinants such as tip-to-apex distance, quality of reduction, and position of the lag screw appeared to significantly affect the small incidence of varus collapse, lag screw migration, and telescoping that we observed. Conclusions: We demonstrated the Intertan ability to function as an effective IM device for unstable intertrochanteric fractures. The implants’ unique design imparts substantial rotational stability and functions effectively to block excessive subsidence. This rotational stability seems to be unique to current IM hip fixation devices and warrants further randomized clinical trial to demonstrate its efficacy.

Favorable radiographic outcomes using the expandable proximal femoral nail in the treatment of hip fractures – A randomized controlled trial

AimTo compare the functional and radiographic results of dynamic hip screw (DHS) and expandable proximal femoral nail (EPFN) in the treatment of extracapsular hip fractures. MethodsA randomized controlled trial of sixty hip fracture patients. Outcomes included mortality, residency, independence, mobility, function and radiographic results at a minimum of 1 year. ResultsTwenty-nine EPFN patients demonstrated fewer cases of shaft medialization or femoral offset shortening compared to the 31 DHS patients. Mortality, complications and functional outcomes were similar. ConclusionEPFN provides stable fixation of pertrochanteric hip fractures and prevents neck shortening that is commonly observed after DHS fixation.