Pertrochanteric Fractures Research Articles

The effect of surgery type on mortality in elderly patients with pertrochanteric femoral fracture: A Korean nationwide cohort study

The purpose of this study is to analyze the effect of surgical methods on mortality and the relative risk of patients who underwent internal fixation (IF) or hemiarthroplasty (HA) after being diagnosed as a pertrochanteric fracture over 65 years old in a Korean nationwide cohort with a single insurance medical system. The Korean National Health Insurance Service-Senior cohort (NHIS-Senior, NHIS-2018-2-111) was used in this study. The eligibility criteria for incident hip fracture patients were the following: (1) first-time admission to acute care hospitals (index admission) with pertrochanteric fracture (ICD-10 S721), (2) three years of hip fracture-free period, (3) recipients of typical surgeries including IF, HA, (4) age between 65 and 99. a total of 7223 patients were enrolled in the cohort. There were 1662 patients (23%) in the HA group and 5561 patients (77%) in the IF group. Mortality rates of the IF group and HA group were 13.46 and 17.94 cases per 100 person-years, respectively. In the multivariable-adjusted Cox proportional hazard model, the HA group had 1.22 times more hazard of all-cause mortality than IF group (aHR 1.22, 95% CI 1.13-1.32). In subgroup analysis, aged 65-79 and female patients showed a prominent association between surgery type and mortality (aHR 1.52, 95% CI 1.29-1.79). In patients with pertrochanter fracture over 65 years, 1.22-fold mortality rate was observed when HA was performed compared to that of IF, and the difference in mortality was particularly prominent within 1-year after surgery.

Medial migration in cephalomedullary nail fixation of pertrochanteric hip fractures: A biomechanical analysis using a novel bidirectional cyclic loading model.

ObjectivesThe paradoxical migration of the femoral neck element (FNE) superomedially against gravity, with respect to the intramedullary component of the cephalomedullary device, is a poorly understood phenomenon increasingly seen in the management of pertrochanteric hip fractures with the intramedullary nail. The aim of this study was to investigate the role of bidirectional loading on the medial migration phenomenon, based on unique wear patterns seen on scanning electron microscopy of retrieved implants suggestive of FNE toggling.MethodsA total of 18 synthetic femurs (Sawbones, Vashon Island, Washington) with comminuted pertrochanteric fractures were divided into three groups (n = 6 per group). Fracture fixation was performed using the Proximal Femoral Nail Antirotation (PFNA) implant (Synthes, Oberdorf, Switzerland; n = 6). Group 1 was subjected to unidirectional compression loading (600 N), with an elastomer (70A durometer) replacing loose fracture fragments to simulate surrounding soft-tissue tensioning. Group 2 was subjected to bidirectional loading (600 N compression loading, 120 N tensile loading), also with the elastomer replacing loose fracture fragments. Group 3 was subjected to bidirectional loading (600 N compression loading, 120 N tensile loading) without the elastomer. All constructs were tested at 2 Hz for 5000 cycles or until cut-out occurred. The medial migration distance (MMD) was recorded at the end of the testing cycles.ResultsThe MMDs for Groups 1, 2, and 3 were 1.02 mm, 6.27 mm, and 5.44 mm respectively, with reliable reproduction of medial migration seen in all groups. Bidirectional loading groups showed significantly higher MMDs compared with the unidirectional loading group (p < 0.01).ConclusionOur results demonstrate significant contributions of bidirectional cyclic loading to the medial migration phenomenon in cephalomedullary nail fixation of pertrochanteric hip fractures.Cite this article: G. W. Law, Y. R. Wong, A. K-S. Yew, A. C. T. Choh, J. S. B. Koh, T. S. Howe. Medial migration in cephalomedullary nail fixation of pertrochanteric hip fractures: A biomechanical analysis using a novel bidirectional cyclic loading model. Bone Joint Res 2019;8:313–322. DOI: 10.1302/2046-3758.87.BJR-2018-0271.R1.

Evaluation of peritrochanteric fractures of femur with proximal femoral nail: A prospective study

Peritrochanteric fractures of femur are most commonly encountered fractures in orthopaedic practice which can be treated by various modalities of management each having its own advantages and disadvantages. With advent of PFN we are able to overcome most of the complications associated with other modalities. The aim of the study is to analyze clinical, functional & radiological outcomes of peritrochanteric fractures of femur managed with proximal femoral nail and were followed up until complete fracture union. The patients were assessed periodically with HARRIS HIP SCORE. 12 patients had excellent results, 28 patients had good results, 5 patients had fair results and 5 patients had poor. Based on our study we found PFN is an ideal modality of management of peritrochanteric fractures of femur.

Femoral offset loss and internal arch restoration defect are correlated with intramedullary nail cut-out complications after pertrochanteric fractures: a case-control study.

In a previous study, we investigated the link between the femoral offset (FO) loss by trochanteric impaction (TI) and cut-out complication occurrence after pertrochanteric fractures. Three major factors are likely to drive to failure after intramedullary nailing (IN): fracture stability, reduction quality and osteosynthesis quality. We wanted to investigate the quality of the fracture reduction through the TI and the neck-shaft angle (NSA) measurement and correlate these parameters with the risk of mechanical failure occurrence. It was a retrospective multicentric one case-one control match design study with age and gender randomization. The cases presented a mechanical failure of nailing: [Formula: see text] in percentage. Femoral rotation was taken into account, and all TI were rotation-corrected (TIcorrected). Rotation-corrected neck-shaft angles (NSAcorrected) were calculated. The neck-shaft angle gap between the fractured and the healthy sides (NSAgap) was a ratio: [Formula: see text] in percentage. The tip-apex distance (TAD) was measured. Absolute values of TIcorrected and NSAgap were analyzed. Twenty-one cases and 21 controls were examined. The average TIcorrected rate was 30% for the cases and 11% for the controls (p = 0.007). A 13% TIcorrected threshold had maximum specificity and sensitivity, equal to 71%. The average TAD was 27mm for cases and 19mm for controls (p = 0.004). The average NSAgap rate was 7% for the case group and 4% for the control group (p = 0.009). The areas under the ROC curves for TIcorrected, TAD and NSAgap were 0.73, 0.73 and 0.66, respectively. Closed reduction and exclusive implantation of IN do not seem optimal in case of FO or NSA restoration failure after pertrochanteric fractures. Level III, case-control study.

A comparative study between proximal femur locking compression plate and dynamic hip screw fixation in management of pertrochanteric fracture

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Pertrochanteric fracture is common in elderly people. Dynamic hip screw is still considered the gold standard for treating intertrochantric fracture. Proximal femoral locking compression plate is newer device. The purpose of the study was to compare the outcome of surgical treatment of trochanteric fracture by dynamic hip screw and proximal femoral locking compression plate.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; We study 60 patient admitted and followed up at J.L.N. Medical College Ajmer from June 2016 to April 2018 for minimum 6 month or till the bony union. Every fracture classified according to AO classification and functional result will be assessed according to Harris hip score using unpaired t test.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; The mean operative time and average intraoperative blood loss was more in PFLCP group when compared with DHS group it was statically significant. DHS group has marginally better functional result then PFLCP group. There was no difference in the radiological outcome between two group.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; DHS is best implant for stable intertrochantric fracture but PFLCP can also be good alternative for unstable IT femur fracture.&lt;/p&gt;

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.

FUNCTIONAL OUTCOME IN PATIENTS TREATED WITH PROXIMAL FEMORAL NAIL IN TYPE TWO UNSTABLE TROCHANTERIC FRACTURES: A PROSPECTIVE STUDY

Background: For many years, the sliding hip screw and plate had been the gold standard in treating pertrochanteric fractures. there is always a grey zone of decision of implant to be applied in unstable type A2.2 and A2.3 fractures. This study was designed for the functional outcome of the PFN device in patients with unstable type 2 trochanteric fractures (AO/ASIF classification: 31-A2.2 & 31-A2.3) Material and method: In this prospectively designed study, 30 consecutive patients having Fracture according to AO/ASIF classification 31-A2.2 and 31- A2.3 are included for the study. The functional outcome and clinical results of the patients was evaluated and graded using HARRIS HIP SCORE system. Patients were followed up fortnightly in the first month, then monthly until 6 months or till clinical or radiological union is achieved. Results: The average blood loss in PFN was 88.3ml. Hospital stay after surgery in PFN was average days 4.13. Harris hip score in PFN 22 (73.33%) were good, 06 (20%) were fair and 02 (6.66%). Average time of union in PFN was 13.4 weeks. Conclusion: Functional and radiological status of PFN was much better in unstable type of intertrochanteric fractures. It provides a advantage of lesser blood loss, shorter operating time, faster union, better functional outcome and low infection and complication rate. Keywords: Unstable trochanteric fractures, PFN

Pseudoaneurysm of the Deep Femoral Artery Following Internal Fixation for Pertrochanteric Fracture: A Report of 2 Cases

Pertrochanteric fractures count among the most frequent fractures in elderly persons but their vascular complications are rare. We present two cases of pseudoaneurysm following internal fixation for pertrochanteric fractures in relatively young patients aged 67 and 68 years old. The post-operative follow up was marked by the onset of a pulsatile swelling in the inner thigh. The diagnosis of pseudoaneurysm of the deep femoral artery was made by arterio-venous Doppler-ultrasound and CT-angiography. The pseudoaneurysms were managed by open surgery for the first case and by a stent for the other one. Both of them got a good outcome.

Weight bearing in patients with femoral neck fractures compared to pertrochanteric fractures: A postoperative gait analysis

Early mobilization following hip fracture surgery is of superior importance especially in elderly hip fracture patients. Reduced mobilization can result in complications and increased mortality. In this study a gait analysis was performed using force-measuring insoles. We hypothesized, that patients with femoral neck fractures treated with hip replacement surgery load the affected limb more compared to patients with pertrochanteric fractures treated with fracture fixation.All patients (> 65 years) treated for a femoral neck fracture with hip replacement or a pertrochanteric fracture, respectively using fracture fixation with intramedullary nailing, were consecutively included in this study. For gait analysis, specific insole forcesensors (Loadsol®) were inserted into the footwear. Five days after surgery gait analysis was performed with a defined walking distance and all patients were instructed to transpose full weight.20 patients following hip replacement surgery and 27 patients following intramedullary nailing were included. The hip replacement group loaded the affected limb with an average of 74.01% (SD 13.6) of bodyweight, while the fracture fixation group loaded a significantly reduced average of 62.70% (SD 8.3; p = 0.002).The results of the present study indicate that patients suffering from pertrochanteric fractures following fracture fixation are struggling to fully load the affected leg compared to patients suffering from femoral neck fractures treated with hip replacement surgery. The focus of further studies should concentrate on alternative analgesia and verify the cause of the observed difference in order to facilitate early full weight bearing especially in hip fracture patients following fracture fixation. The results indicate that in elderly patients, the fracture pattern and thus the surgical approach lead to a different weight bearing pattern. The primary therapeutic goal for elderly patients must be early mobilization at full weight bearing.

Migration of the Lag Screw after Intramedullary Treatment of AO/OTA 31.A2.1-3 Pertrochanteric Fractures Does Not Result in Higher Incidence of Cut-Outs, Regardless of Which Implant Was Used: A Comparison of Gamma Nail with and without U-Blade (RC) Lag Screw and Proximal Femur Nail Antirotation (PFNA).

The best intramedullary nail for the treatment of unstable AO/OTA 31.A2.1-3 fractures remains uncertain. A total of 237 patients (45 male, 192 female) were eligible for the assessment with an average age of 81.9 ± 10.5 years and a minimum follow-up of six months. We assessed the cut-out rate, the TAD and calTAD (Tip Apex distance) of three different implants. An overall cut-out rate of 2.5% (n = 6) was observed. The cut-out rate was 1.2% (n = 1) in the Proximal Femur Nail Antirotation (PFNA) group, 3.7% (n = 3) in the Gamma Nail group and 2.9% (n = 2) in the Gamma3® with a U-Blade (RC) lag-screw group. The TAD and calTAD differed between the cut-out and non-cut group—20.0 mm vs. 18.5 mm and 13.1 mm vs. 15.3 mm, respectively. A significantly higher TAD of 32.5 mm could be seen in the cut-out after PFNA (p < 0.0001). The only significant change in follow-up using Parker’s ratio was observed in the PFNA group (p < 0.0001). The rate of patients requiring surgery after complications was 8.4% (n = 20) without any significant difference between the three groups. The PFNA blade showed significant migration within the femoral head, however the cut-out rate remained the smallest compared to Gamma3 with or without additional U-Blade (RC) lag screw.

Weight-bearing restrictions reduce postoperative mobility in elderly hip fracture patients

Reduced mobility is a severe threat to the clinical outcomes and survival of elderly hip fracture patients. These patients generally struggle to comply with partial weight bearing, yet postoperative weight-bearing restrictions are still recommended by nearly 25% of surgeons. Therefore, we hypothesized that weight-bearing restrictions in elderly hip fracture patients merely leads to reduced mobility, while transposing full weight to the fractured extremity remains unaffected disregarding the prescribed aftercare. 41 equally treated patients with pertrochanteric fractures were enrolled consecutively in a maximum care hospital in a pre-post study design (level of evidence 2). A study group of 19 patients was instructed to maintain partial weight bearing (PWB), whereas the control group of 22 patients was instructed to mobilize at full weight bearing (FWB). All patients were asked to participate in a gait analysis using an insole force sensor (loadsol®, Novel, Munich, Germany) on the fifth postoperative day. The postoperative Parker Mobility Score in the PWB group compared to the FWB group was significantly reduced (3.21 vs. 4.73, p < 0.001). Accordingly, a significantly lower gait speed in the PWB group of 0.16m/s vs. 0.28m/s was seen (p = 0.003). No difference in weight bearing was observed in between the groups (average peak force 350.25N vs. 353.08N, p = 0.918), nor any differences in the demographic characteristics, ASA Score, Barthel Index or EQ5D. Weight-bearing restrictions in elderly hip fracture patients contributed to a loss of mobility, while no significant differences in loading of the affected extremity were observed. Therefore, postoperative weight-bearing restrictions in elderly hip fracture patients should be avoided, to achieve early mobilization at full weight bearing.

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.

Clinical profile of patients with acute fracture neck of femur

Femoral neck fractures and pertrochanteric fractures are of approximately equal incidence and together make up over 90% of the proximal femur fractures and the remaining 5–10% is subtrochanteric. The femoral neck fractures are only 2% in patients with age under 50 years. After 50 years, the incidence is doubled for each subsequent decade and it is 2 to 3 times higher in women than in men. The overall annual age-standardized rates of femoral neck fractures are higher among white women than among black women. A prospective study was conducted on patients with acute fracture neck of femur aged above 60 years treated with THA in the Department of Orthopedics. Clearance from the institutional ethics committee was obtained before the study was started. An informed, written and bilingual consent was obtained before the study was started. About 40% of study subjects presented to the hospital at 2 – 5 days, 35% presented on 1st day, 17.5% presented on 6 – 10 days and 7.5% presented after 10 days of fracture.

A solution to z effect and lateral wall comminution in nailing of per trochanteric fractures: A retrospective study of 54 cases

Background: Pertrochanteric femur fractures are fractures which extends from extra capsular basilar neck of the femur to the lesser trochanter. Since this region bears the maximum mechanical stress as compared to other parts of the femur it’s a site for comminuted fractures, and accounts for 10% to 34% of all hip fractures with the incidence estimated to double by 2040. In the quest for perfect implant in pertrochanteric femur fractures we have been using hip fracture nail since past 2 years for all pertrochanteric fractures in our institution. Methods: This is a retrospective study of 54 cases of pertrochanteric femur fractures operated using hip fracture nail from 2017 to 2019 in our institute. All the patients were above 55 years of age with an average age group of 67 years. We analyzed rate of union, complications and functional outcome. All the patients were followed up at 3 months interval up to 1 year. Results: Average modified Harris hip score were satisfactory in 48 patients. Average time taken for fracture union was 9 months. Conclusion: We concluded that hip fracture nail solves many a problem of earlier generation nailing systems for unstable pertrochanteric femur fractures. Our study suggests that a twin screw integrated cephalo-medullary nail system effectively prevents the z effect and provides a solution to the lateral wall comminution which is the key predictor for a revision surgery after an unstable intertrochanteric femur fracture.

The functional outcome in patients treated with THA with acute fracture neck of femur in patients aged above 60 years using Harris hip score

The incidence of femoral neck fractures is increasing continuously among the aging population. The numbers of hip fracture are expected to increase from 1.7 million in 1990 to 6.3 million during the year 2050. The femoral neck fractures and pertrochanteric fractures are of approximately equal incidence and together make up to 90% of the proximal femur fractures and the remaining 5 – 10% is subtrochanteric. A total 40 patients with acute fracture of neck of femur aged above 60 years treated with THA attending the Department of Orthopedics, constituted the sample size. The sample size was calculated by assuming a Harris hip score of 81 points with a standard deviation of 5, with a relative precision of 2% (Alpha of 5%, 95% confidence interval). The Harris hips score was 81.82 at the end of 6 months of follow up, 86.07 at the end of 3 months and 91.1 at the end of 6 months. The mean difference in Harris Hip score between the 6 weeks versus 3 months was 4.25, 9.27 between 6 weeks versus 6 months and 5.02 between 3 months versus 6 months. There was a statistically significant difference in the Harris Hip score in the period of follow up.

Ease of doing proximal femoral nailing in lateral position in the management of peri-trochanteric femoral fractures in adults: A prospective study

Introduction: Intertrochanteric fractures are among the most common pei-trochanteric fractures encountered in orthopaedic practice. Most of the hip fractures are managed in supine position on a fracture table with foot attached to foot plates and biplanar fluoroscopy supervision under c-arm. But this procedure has its own difficulties in managing especially comminuted peri-trochanteric fractures, where in different fragments and segments are being pulled by strong muscles around hip, and getting good reduction and satisfactory alignment is difficult due to displaced bony fragments being held in traction on fracture table and cannot be manipulated easily. This leads to prolonged operative time, opening of fracture site, increased bleeding, and increased chances of infection and over all increased anaesthesia time adding up to risk factors. The purpose of this study was to demonstrate the technique of surgery as well as to report how these difficulties can be overcome by using long Proximal Femoral Nail in complex comminuted unstable trochanteric fractures in lateral position on an ordinary radiolucent top table without fracture table. Materials and Methods: 30 cases of peri-trochanteric fractures with or without comminution were operated in lateral position on simple ordinary radioluscent top table with lesser attachments and adjustments to operating table during the study duration were included in the study. We used long Proximal Femur Nail (PFN) (length more than 25cms 34, 36, 38, 40cms long) to fix these fractures. Results: In the present study, age group of patients was 60yrs to 78yrs. Male patients (60%) were more than female patients (40%) An average of less than 150 ml in closed surgery and 350 ml in Open reduction cases. The average operative time for all cases was 80 minutes. Union time varied from 14 weeks in simple fractures to 26 weeks in comminuted fractures. Clinical function of hip and knee was excellent with full range of movements. Overall excellent to good results were achieved in 90% cases. Conclusions: The lateral decubitus position provides easy identification of entry point, a shorter operation time, less of hospital stay, blood loss, number of intraoperative X-ray, incision length and out-of-bed activity time Reduction and fixation of proximal femoral fractures in the lateral position with fluoroscopy in the anteroposterior view for small set ups and rural hospitals that lack a fracture table or advanced fluoroscopic devices may be executable and probably safe.

A clinical study to evaluate the effectiveness of proximal femoral nail antirotation in the management of peritrochanteric fractures of the femur

Background: Fractures around the trochanteric region of the femur are one of the commonest fractures encountered in orthopedics in elderly and young patients. In younger patients, the fractures usually result from high-energy trauma like RTA or fall from height and older patients suffering from a minor fall can sustain fracture in this area because of weakened bone due to osteoporosis. Methods: Forty-nine patients, aged above 40 years with closed intertrochanteric fractures who were operated using proximal femoral nail anti-rotation (PFN-A) were evaluated for functional outcome and analyzed for the technical problems and complications associated with surgery. Results: Nineteen patients were less than 60 years of age group and all patients of this group had excellent and good outcome. 25 patients who belonged to more than 60 years of age group of which 7 patients had fair and poor outcome and it was statistically significant (p=0.0139). Conclusion: Closed reduction and internal fixation using PFN-A is an excellent method of treatment for an intertrochanteric fracture, to provide rapid recovery and good functional outcome. Age is a significant predictor of final outcome following surgical treatment. Younger is the age better the outcome.

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.

The prognostic value of the hip screw position in intertrochanteric fractures

In our study, we analyzed one of the Hungarian population's most frequent injuries, the hip fracture, focusing mainly on the lateral femoral neck and the pertrochanteric fractures. According to the classification of the Swiss Association for Ostheosynthesis (AO), we focused on 31-A1 and 31-A2 fractures, the incidence of which increases by ageing. Between 2010 and 2016, we analyzed the data of 1179 patients. All of the fractures were stabilized with intramedullary nails. 992 patients received Stryker Gamma3®, whereas 187 patients' fractures were solved with Synthes PFNA® nail. In all cases, closed reduction method was used with fluoroscopy on an extension table. The surgeries were done in general or epidural anesthesia and performed by traumatology residents or specialists using standard lateral exploration. Data were collected using GEPACS software and statistical analysis was done with MS Excel. Cut-out occurred in 33 cases (2,79%): out of that 21 (1.78%) were left sided and 12 were (1,01%) right sided. 29 (87.87%) patients were treated with Gamma3 nail, and in 4 (12,12%) cases PFNA nail was used. The average TAD-index was 18 mm. According to recommendations of the TAD-index value, when using dynamic hip screw, it should be 20 mm or lower. The average index value was 18 mm which was equal in the complicated and non-complicated groups. Our study shows that the cut-out is independent from the TAD-index value, thus this recommendation cannot be applied for intramedullary nails. Orv Hetil. 2019; 160(9): 338-342.

Is Primary Fixation with the Sliding Hip Screw Introduced into the Non-ideal Position Sufficient for Stable Pertrochanteric Fracture Stabilisation? A Biomechanical Evaluation and Experimental Study

Purpose: Proximal femoral fractures are most commonly sustained fractures in the elderly. The one of the current treatment option of stable pertrochanteric fracture is Sliding Hip Screw. The necessity of a repeat surgery, due to the failure of the first osteosynthesis, may jeopardize the patient's life. Common causes of a failure include: fracture pattern, implant position, implant's properties and the bone quality. Each screw position variant results in damage to various load-bearing bone structures during healing. The aim of this study was analysis of different screw positions with focuse on the risky position with the need of the intra-operative implant reintroduction.Methods: With the use of a numerical computational model and finite element methods, the authors analyzed five positions of Sliding Hip Screw in the proximal femur, with the objective of determining positions with an increased risk of failure. The ideal position was in the middle third of the femoral neck anchored subchondrally.Results: In model situations, it has been shown that in stable fractures the screw position in proximal third of the femoral neck significantly increased the strain of the plate and screw and may lead to the osteosynthesis failure. The other analysed positions do not significantly increase the risk of failure for entire fixation. Conclusions: It is not necessary to re-introduce Sliding Hip Screw into the ideal position (except placening in the proximal third of the neck) during the surgery. Damage to load-bearing structures relative to various implant placements does not impact the resultant overall fixation stability.