Pertrochanteric Fractures Research Articles

Early mobilisation after pain relief for conservative management for intertrochanteric fractures: a pandemic enforced innovation and its results.

The COVID pandemic challenged the orthopaedic mind on several fronts. 1 of them was in the management of intertrochanteric fractures. A subset of these patients refused surgical intervention during the pandemic for related reasons. Faced with the goal of early verticalisation, the senior author used pain relief as a method to facilitate early mobilisation in 23 patients with peritrochanteric fractures. 23 patients with stable intertrochanteric fractures received a β 6 distal sodium channel block (DSCB) and were allowed to walk from day 1 without surgery, traction or spica. The goal was to prevent complications of recumbency in this subset of patients. The basic idea of immediate mobilisation from the time of fracture was based on Sarmiento's sausage theory. All the fractures united. There were no major complications. No shortening was seen in more than 50% cases and the shortening did not exceed 2 cm in any case. All patients were satisfied with the outcome and had good to excellent Harris Hip Scores. The block and walk method is a surprisingly satisfactory method of treatment for stable intertrochanteric fractures. It circumvents the risks of surgery whilst allowing immediate mobilisation preventing complications associated with the other modalities of fracture management.

Pericapsular Nerve Group (PENG) Block is a Novel Technique in the Hip Surgery

Background: Peritrochantric fracture is common especially in elderly patients. Very often we are faced with elderly and fragile patients with several comorbidities. In these cases a careful anesthetic technique is crucial to reduce comorbidity and mortality. Currently the pericapsular nerve group (PENG) block are introduced as an analgesic technique. We used PENG block for purpose of hip surgical Anesthesia.
 Methods: In this single-centre, case series, patients undergoing gama nailing for peritrochanteric fractures. The PENG block was performed with the patient in the supine position using ultrasound guidance. Pain scores were measured by numeric rating score (NRS) at rest and with a straight leg raise of the affected limb to 15 degrees before and 30 minutes after block performance.
 Results: Totally, 10 patients of ASA Grades II, III and were included who came with peritrochantric hip fracture and were scheduled for gamma nailing. The mean age of the study participants was 77 years. Significantly, pain scores reduced as compared with baseline. No such adverse events were recorded for any of the patients.
 Conclusion: In this article the PENG block has been determined to be safe and effective as an anesthetic technique in gamma nailing of peritrochantric fractures but more research in larger-sized studies are needed to better assess the PENG block.

EVALUATION OF NECK SHAFT ANGLE AS A PREDICTOR OF CUT-OUT FAILURE IN PERTROCHANTERIC FRACTURES- AN OBSERVATIONAL STUDY

Introduction: Femoral trochanteric fractures are extremely common fractures of old age. Due to the fracture, there is a change in the neck shaft angle (NSA) which if not restored can lead to further disability [1]. In this study, we aim to evaluate the neck shaft angle as a predictor of cut out failure in patients with pertrochanteric fractures after surgical xation by various xation methods. Materials and methods: A total of 100 patients with pertrochanteric fractures were enrolled in the study, who underwent surgical xation with either of three 3 methods- DHS/PFN/PFN-A. Patients were followed up at 6 weeks, 3months and 6 months. Neck shaft angle (NSA) of the normal side was calculated on pre-operative x-rays and of affected side on post operative radiographs. Results: The mean NSA of normal side (N) and operated side (O) across various xation methods in our study was as follows- DHS- Normal side(N)-127.890, Operated side(O)- 130.80; PFN- N-126.60, O-128.50; PFN-A- N-126.330, O-127.40. In all three groups, the fracture was xed in valgus position. 6 cases of cut-out failure observed in the study, 4 among the DHS group and 2 among the PFN group. The mean NSA on operated side, mean difference between normal and operated side, change at 6 weeks, 3 months and 6 months was signicantly more among DHS group compared to PFN and PFN-A groups.

Comparison of the functional outcome of trochanteric fixation nail (TFN-180mm) versus short proximal femoral nail (short PFN 250mm) for fixation of intertrochanteric fractures

Introduction: Pertrochanteric fractures are devastating injuries that most commonly affect the elderly. There are various forms of internal fixation devices used for Trochanteric Fractures; of them, the most commonly used device is the Dynamic Hip Screw with Side Plate assemblies. In unstable fracture patterns, intramedullary devices such as the PFN appear to have a biomechanical advantage over extramedullary devices. Aim: To compare the functional outcome of Trochanteric Fixation Nail (TFN-180mm) versus short Proximal Femoral Nail (short PFN 250mm) for fixation of intertrochanteric fractures. Material and Methods: A prospective study was conducted at Queen’s NRI Hospital, Visakhapatnam, Andhra Pradesh, India, on patients with intertrochanteric fracture of the femur the follow-up was recorded in 6 weeks, three months, six months. Observations are recorded in age, sex, affected side, post-Operative pain using the Visual Analogue scale Functional outcome assessed through the Harris Hip score and complications were recorded. Results & Conclusion: A total number of 30 cases of stable and unstable inter trochanteric fractures were treated with closed/ open reduction and internal fixation with short PFN and TFN with 15 in each group. Our study has a total female predominance of 2:1. The mean age for short PFN candidates was 67.46 years, it was 69.66 years for the TFN group. The average Harris Hip Score for the TFN group was 80.66 and PFN was 79.80. Indicating the functional outcome for both intramedullary devices were the same. Short PFN was associated with a more recurring complication of anterior thigh pain, which was seen more predominantly in the females.

Comparative Bony Union Time Analysis of Dynamic Hip Screw and Proximal Femoral Plate Implants

Objective: To determine the comparative and effective applicability of the Dynamic Hip Screw (DHS), and proximal femoral plate (PFP) in terms of the rapid bony union and complications for treating unstable pertrochanteric fractures. Methodology: This comparative study was conducted at the Department of Orthopedic surgery, Pakistan Institute of Medical Sciences, Islamabad during a period of 8 months from August 2016 to April 2017. Patients ages of 45 to 90 years, with close fresh unstable pertrochanteric fractures (one week) and of either gender were included. All the patients were divided into two groups. Patients in group A underwent PFP treatment and patients of group B underwent DHS treatment. Patients were followed up after 6 weeks and then every 2 weekly afterwards for a total period of 3 months for assessment of bony union both clinically and radiologically. The data was collected on a pre-structured Performa, and analysis was done using SPSS version 26. Results: A total of 84 patients were analysed, and average age of the patients in the PFP group was 66.57 ± 11.71 years and in the DHS group was 70.14 ± 9.03 years. Females were found in majority in both groups. No union was found till six weeks in both groups, while on 2nd month followup, union was found significantly high 19.0% in cases of the PFP group, compared to the 2.4% in the DHS group (p-0.014). On 2.5th months the union rate was significantly higher 59.5% in the PFP group, compared to the 7.1% DHS group (p-0.014), while on the 3rd month followup the union was almost in all cases in both groups (p-0.557) and the overall average union duration was significantly lower in PFP group compared to the DHS (p-0.001). Conclusion: The proximal femoral plate technique for treating unstable pertrochanteric fractures was observed to be more effective in terms of significant rapid bony union with minimum complications compared to the Dynamic Hip Screw (DHS).

Risk prediction models incorporating institutional case volume for mortality after hip fracture surgery in the elderly.

While higher institutional case volume is associated with better postoperative outcomes in various types of surgery, institutional case volume has been rarely included in risk prediction models for surgical patients. This study aimed to develop and validate the predictive models incorporating institutional case volume for predicting in-hospital mortality and 1-year mortality after hip fracture surgery in the elderly. Data for all patients (≥ 60years) who underwent surgery for femur neck fracture, pertrochanteric fracture, or subtrochanteric fracture between January 2008 and December 2016 were extracted from the Korean National Health Insurance Service database. Patients were randomly assigned into the derivation cohort or the validation cohort in a 1:1 ratio. Risk prediction models for in-hospital mortality and 1-year mortality were developed in the derivation cohort using the logistic regression model. Covariates included age, sex, type of fracture, type of anaesthesia, transfusion, and comorbidities such as hypertension, diabetes, coronary artery disease, chronic kidney disease, cerebrovascular disease, and dementia. Two separate models, one with and the other without institutional case volume as a covariate, were constructed, evaluated, and compared using the likelihood ratio test. Based on the models, scoring systems for predicting in-hospital mortality and 1-year mortality were developed. Analysis of 196,842 patients showed 3.6% in-hospital mortality (7084/196,842) and 15.42% 1-year mortality (30,345/196,842). The model for predicting in-hospital mortality incorporating the institutional case volume demonstrated better discrimination (c-statistics 0.692) compared to the model without the institutional case volume (c-statistics 0.688; likelihood ratio test p value < 0.001). The performance of the model for predicting 1-year mortality was also better when incorporating institutional case volume (c-statistics 0.675 vs. 0.674; likelihood ratio test p value < 0.001). The new institutional case volume incorporated scoring system may help to predict in-hospital mortality and 1-year mortality after hip fracture surgery in the elderly population.

In Silico Finite Element Modeling of Stress Distribution in Osteosynthesis after Pertrochanteric Fractures.

A stabilization method of pertrochanteric femur fractures is a contentious issue. Here, we assess the feasibility of rapid in silico 2D finite element modeling (FEM) to predict the distribution of stresses arising during the two most often used stabilization methods: gamma nail fixation (GNF) and dynamic hip screw (DHS). The modeling was based on standard pre-surgery radiographs of hip joints of 15 patients with pertrochanteric fractures of type A1, A2, and A3 according to the AO/OTA classification. The FEM showed that the stresses were similar for both GNF and DHS, with the medians ranging between 53–60 MPa and consistently lower for A1 than A3 fractures. Stresses also appeared in the fixation materials being about two-fold higher for GNF. Given similar bone stresses caused by both GNF and DHS but shorter surgery time, less extensive dissection, and faster patient mobilization, we submit that the GNF stabilization appears to be the most optimal system for pertrochanteric fractures. In silico FEM appears a viable perioperative method that helps predict the distribution of compressive stresses after osteosynthesis of pertrochanteric fractures. The promptness of modeling fits well into the rigid time framework of hip fracture surgery and may help optimize the fixation procedure for the best outcome. The study extends the use of FEM in complex orthopedic management. However, further datasets are required to firmly position the FEM in the treatment of pertrochanteric fractures.

Impact of subtrochanteric fractures in the geriatric population: better pre-fracture condition but poorer outcome than pertrochanteric fractures: evidence from the Spanish Hip Fracture Registry

BackgroundClinical management in orthogeriatric units and outcome indicators are similar for extracapsular fragility hip fractures, without discriminating between subtrochanteric and pertrochanteric fractures.HypothesisGeriatric patients, 75 years or older, with subtrochanteric fractures have worse clinical and functional outcomes than those with pertrochanteric fractures.Materials and methodsRetrospective observational study of data prospectively collected by the Spanish Hip Fracture Registry including patients 75 years or older, admitted for extracapsular hip fractures from January 2017 to June 2019. Demographic and baseline status, pre-operative, post-operative and 30-day follow-up data were included.ResultsA total of 13,939 patients with extracapsular hip fractures were registered: 12,199 (87.5%) pertrochanteric and 1740 (12.5%) subtrochanteric. At admission, patients with subtrochanteric fractures were younger (86.5 ± 5.8 versus 87.1 ± 5.6 years old), had better pre-fracture mobility (3.7 ± 2.7 versus 3.9 ± 2.8) (1-to-10 scale, 1 being independent) and were more likely to be living at home; those with pertrochanteric fractures had worse cognitive function (Pfeiffer 3.3 ± 3.3 versus 3.8 ± 3.5). The subtrochanteric fracture group showed worse post-fracture mobility (7.3 ± 2.7 versus 6.7 ± 2.7) and greater deterioration of mobility (3.7 ± 3.0 versus 2.9 ± 2.7). Among individuals living at home at baseline, those with subtrochanteric fractures were more likely to remain in an assisted facility at 30-day follow-up. In-hospital mortality during acute admission was higher for the subtrochanteric group (5.6% versus 4.5%) (p = 0.028). To our knowledge, this is the first paper highlighting the differences between these two fracture groups in the geriatric population.ConclusionsSubtrochanteric fractures in the older population are a different and worse entity, with greater morbimortality and functional decline than pertrochanteric fractures. Despite being younger and fitter at admission, older patients with subtrochanteric fractures have a higher risk of remaining non-weight bearing and undergoing re-operation and institutionalization. Orthogeriatric units should be aware of this and manage subtrochanteric fractures accordingly.Level of evidence: IV.

Impact of coronal plane fragments and anterior big neck fragments on the occurrence of perioperative lateral wall fractures in AO/OTA 31-A1,2 intertrochanteric fractures treated with cephalomedullary nailing

Cephalomedullary nails are used widely today for pertrochanteric fractures, and intraoperative lateral wall fractures can cause adverse effects. Recently, a high incidence of coronal fragments in pertrochanteric fractures was reported when analyzed with 3D CT reconstructions. In this study, we analyzed the association between the type of coronal fragments and perioperative lateral wall fractures. Patients diagnosed with pertrochanteric fractures and treated by cephalomedullary nails at three university hospitals from September 2016 to December 2020 were examined. A total of 463 patients were included. We examined the coronal fragments and divided the patients into two groups according to the involvement of the posteromedial cortex. Postoperative X-rays were scanned for fracture lines at the blade entry site. Twenty-two patients among 463 patients had perioperative lateral wall fractures. The AO type A2 fractures, use of provisional pins, existence of coronal fragments, involvement of the posteromedial cortex, and the existence of anterior big neck fragments were significantly relevant to perioperative lateral wall fractures. 11 of 22 lateral wall fracture patients were delayed fracture patients, identified 4weeks after surgery. A coronal fragment combined by anterior big neck fragments had a 9.24 times higher risk of lateral wall fractures compared to fractures with only coronal fragments. Pertrochanteric fractures with large coronal fragments and anterior big neck fragments have a high risk of perioperative lateral wall fractures when treated by cephalomedullary nails. Surgeons should examine the width of the intact lateral wall, and take caution to preserve its integrity.

Outcomes of Dynamic Condylar Screw Fixation for Unstable Peritrochanteric Fractures.

BackgroundThe optimal treatment modality and choice of implant for unstable peritrochanteric fractures is debatable, with multiple options ranging from intramedullary to extramedullary implants. The purpose of this study was to evaluate the radiological and functional outcomes of 95° dynamic condylar screws in unstable intertrochanteric fractures.Patients and methodsThis is a retrospective review of patients with unstable peritrochanteric fractures (31-A2 and A3 for Association for Osteosynthesis/Association for the Study of Internal Fixation (AO/ASIF) classification) who underwent open reduction and internal fixation with 95° dynamic condylar screw at Recep Tayyip Erdogan Hospital between 2014 and 2018. All the patients had a minimum of one year of follow-up. Clinical outcomes were measured in terms of time to full weight bearing, Harris Hip Score, and time to radiographic union.ResultsThis study comprised 84 patients (including 56 males and 28 females with a mean age of 57.2 ± 9.7 years). The average time to full weight bearing was 4.2 months (range: three to six months). The radiological union was seen at a mean of 5.8 months (range: 4-11 months). Functional outcome in terms of Harris Hip Score was graded as excellent, good, fair, and poor in 18, 45, 16, and five patients, respectively. Implant failure was observed in three patients. One patient sustained a peri-prosthetic fracture, which was treated with a longer plate.ConclusionDynamic condylar screw proves to be a reliable implant when used in unstable peritrochanteric fractures and results in satisfactory functional and radiological outcomes.

Evaluation of Quality of Life After Nonoperative or Operative Management of Proximal Femoral Fractures in Frail Institutionalized Patients

Decision-making on management of proximal femoral fractures in frail patients with limited life expectancy is challenging, but surgical overtreatment needs to be prevented. Current literature provides limited insight into the true outcomes of nonoperative management and operative management in this patient population. To investigate the outcomes of nonoperative management vs operative management of proximal femoral fractures in institutionalized frail older patients with limited life expectancy. This multicenter cohort study was conducted between September 1, 2018, and April 25, 2020, with a 6-month follow-up period at 25 hospitals across the Netherlands. Eligible patients were aged 70 years or older, frail, and institutionalized and sustained a femoral neck or pertrochanteric fracture. The term frail implied at least 1 of the following characteristics was present: malnutrition (body mass index [calculated as weight in kilograms divided by height in meters squared] <18.5) or cachexia, severe comorbidities (American Society of Anesthesiologists physical status class of IV or V), or severe mobility issues (Functional Ambulation Category ≤2). Shared decision-making (SDM) followed by nonoperative or operative fracture management. The primary outcome was the EuroQol 5 Dimension 5 Level (EQ-5D) utility score by proxies and caregivers. Secondary outcome measures were QUALIDEM (a dementia-specific quality-of-life instrument for persons with dementia in residential settings) scores, pain level (assessed by the Pain Assessment Checklist for Seniors With Limited Ability to Communicate), adverse events (Clavien-Dindo classification), mortality, treatment satisfaction (numeric rating scale), and quality of dying (Quality of Dying and Death Questionnaire). Of the 172 enrolled patients with proximal femoral fractures (median [25th and 75th percentile] age, 88 [85-92] years; 135 women [78%]), 88 opted for nonoperative management and 84 opted for operative management. The EQ-5D utility scores by proxies and caregivers in the nonoperative management group remained within the set 0.15 noninferiority limit of the operative management group (week 1: 0.17 [95% CI, 0.13-0.29] vs 0.26 [95% CI, 0.11-0.23]; week 2: 0.19 [95% CI, 0.10-0.27] vs 0.28 [95% CI, 0.22-0.35]; and week 4: 0.24 [95% CI, 0.15-0.33] vs 0.34 [95% CI, 0.28-0.41]). Adverse events were less frequent in the nonoperative management group vs the operative management group (67 vs 167). The 30-day mortality rate was 83% (n = 73) in the nonoperative management group and 25% (n = 21) in the operative management group, with 26 proxies and caregivers (51%) in the nonoperative management group rating the quality of dying as good-almost perfect. Treatment satisfaction was high in both groups, with a median numeric rating scale score of 8. Results of this study indicated that nonoperative management of proximal femoral fractures (selected through an SDM process) was a viable option for frail institutionalized patients with limited life expectancy, suggesting that surgery should not be a foregone conclusion for this patient population.

A New Augmentation Method for Improved Screw Fixation in Fragile Bone.

Pertrochanteric fractures (TF) due to osteoporosis constitute nearly half of all proximal femur fractures. TFs are treated with a surgical approach and fracture fixation is achieved using metallic fixation devices. Poor quality cancellous bone in osteoporotic patients makes anchorage of a fixation device challenging, which can lead to failure of the fracture fixation. Methods to reinforce the bone-implant interface using bone cement (PMMA) and other calcium phosphate cements in TFs have been described earlier but a clear evidence on the advantage of using such biomaterials for augmentation is weak. Furthermore, there is no standardized technique for delivering these biomaterials at the bone-implant interface. In this study, we firstly describe a method to deliver a calcium sulphate/hydroxyapatite (CaS/HA) based biomaterial for the augmentation of a lag-screw commonly used for TF fixation. We then used an osteoporotic Sawbones model to study the consequence of CaS/HA augmentation on the immediate mechanical anchorage of the lag-screw to osteoporotic bone. Finally, as a proof-of-concept, the method of delivering the CaS/HA biomaterial at the bone-implant interface as well as spreading of the CaS/HA material at this interface was tested in patients undergoing treatment for TF as well as in donated femoral heads. The mechanical testing results indicated that the CaS/HA based biomaterial increased the peak extraction force of the lag-screw by 4 times compared with un-augmented lag-screws and the results were at par with PMMA. The X-ray images from the patient series showed that it was possible to inject the CaS/HA material at the bone-implant interface without applying additional pressure and the CaS/HA material spreading was observed at the interface of the lag-screw threads and the bone. Finally, the spreading of the CaS/HA material was also verified on donated femoral heads and micro-CT imaging indicated that the entire length of the lag-screw threads was covered with the CaS/HA biomaterial. In conclusion, we present a novel method for augmenting a lag-screw in TFs, which could potentially reduce the risk of fracture fixation failure and reoperation in fragile osteoporotic patients.

TIP APEX DISTANCE AS A PREDICTOR OF FAILURE IN PERITROCHANTERIC FRACTURES TREATED WITH PFN-A.

Intertrochanteric fractures constitute around 50% of the hip fractures and half of which are unstable. In this study, we aim to determine the tip apex distance as a predictor of failure in patients with peri-trochanteric fractures treated with PFN-A. A total of 50 patients with peri-trochanteric fractures were enrolled in the study, who underwent surgical xation with PFNA and were followed up at 6 weeks, 3months and 6 months. Position of helical blade and TAD were calculated on the post operative radiographs. The mean TAD in our study was 22.5+6.7 mm, with 66% patients having a TAD &lt;25mm. The most common placement of the helical blade in the femoral head was in Centre-Centre position observed in 22 patients (44%) of the study population with 5 cases of cut-out failure observed in the study. The relationship between TAD and cut-out failure in PFNA was found to be statistically insignicant (p = 0.09).

Pilot study: To assess feasibility and tolerability of a minimal invasive implantable PEEK device for prevention of contralateral osteoporotic hip fracture.

A non-comparative multi-centre and international pilot study have been carried on Y-STRUT® (Hyprevention, France), an implantable medical device meant to reinforce the hip to reduce the risk of a contralateral hip fracture. Objectives of the study were to determine the feasibility and tolerance of the procedure. Methods Patients older than 60 years were recruited when presenting at the emergency departments with a low-energy pertrochanteric fracture on one side and with a fracture risk assessed for the contralateral side with BMD, T-Score or other bone quality evaluation tool, FRAX index, or fall risk assessment. Pain and functional ability were assessed at the different follow-up visits using VAS, WOMAC and OHS-12 scores. Results Twelve patients were included and reached a one-year follow-up. Mean age was 82 years old (65 - 91). The average hospital stay was 13 days (3 - 29). The prophylactic surgery did not delay the hospital discharge for any patient. The procedure did not lead to unresolvable serious adverse events. At 3 weeks, all patients were able to walk 6 meters, half of them in less of 30 seconds. Minimal pain was reported all along the follow-up visits, except at 3 years when one patient presented high pain in both hips. WOMAC and OHS-12 scores showed a moderate to mild hip impairment. Conclusion The good short and medium-term outcomes of this pilot study demonstrate the feasibility and the tolerability of the device. Further studies should focus on the efficacy of this immediate and lasting bone reinforcement technique.

Effect of the additional anteroposterior blocking screw on nail/medullary canal mismatch after cephalomedullary nailing in unstable pertrochanteric fracture : a finite element analysis.

AimsThere are concerns regarding nail/medullary canal mismatch and initial stability after cephalomedullary nailing in unstable pertrochanteric fractures. This study aimed to investigate the effect of an additional anteroposterior blocking screw on fixation stability in unstable pertrochanteric fracture models with a nail/medullary canal mismatch after short cephalomedullary nail (CMN) fixation.MethodsEight finite element models (FEMs), comprising four different femoral diameters, with and without blocking screws, were constructed, and unstable intertrochanteric fractures fixed with short CMNs were reproduced in all FEMs. Micromotions of distal shaft fragment related to proximal fragment, and stress concentrations at the nail construct were measured.ResultsMicromotions in FEMs without a blocking screw significantly increased as nail/medullary canal mismatch increased, but were similar between FEMs with a blocking screw regardless of mismatch. Stress concentration at the nail construct was observed at the junction of the nail body and lag screw in all FEMs, and increased as nail/medullary canal mismatch increased, regardless of blocking screws. Mean stresses over regions of interest in FEMs with a blocking screw were much lower than regions of interest in those without. Mean stresses in FEMs with a blocking screw were lower than the yield strength, yet mean stresses in FEMs without blocking screws having 8 mm and 10 mm mismatch exceeded the yield strength. All mean stresses at distal locking screws were less than the yield strength.ConclusionUsing an additional anteroposterior blocking screw may be a simple and effective method to enhance fixation stability in unstable pertrochanteric fractures with a large nail/medullary canal mismatch due to osteoporosis.Cite this article: Bone Joint Res 2022;11(3):152–161.

Functional outcome of peritrochanteric fracture fixation with modified gamma nail using tri-wire anchorage

&lt;p&gt;&lt;strong&gt;Background&lt;/strong&gt;: Pertrochanteric fractures comprise almost 50% of all proximal femoral fractures. Being common in elderly people, the quality of life deteriorates until the fracture is stabilized, followed by early mobilization. Intramedullary devices have been proven to improve biomechanics. In our study, we adopted modified gamma nail with additional tri-wire anchorage construct, which further stabilizes the rotational torque.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods: &lt;/strong&gt;A prospective study was undertaken on 39 skeletally mature patients of both sexes, with per-trochanteric fracture, from January 2019 to April 2020. The study included 23 females and 16 males. the 34 underwent CRIF while 5 underwent ORIF. One patient was lost to follow-up. Clinico-radiological evaluations of the patients were done for 12 months. Functional evaluation was based on the modified Harris hip score (mHHS). Statistical analysis was done by SPSS (version 27.0; SPSS Inc., Chicago, IL, USA) and GraphPad Prism version 5. &lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results: &lt;/strong&gt;The study showed 100% union rate. Radiologically at 3 months, the fracture united in all patients. At 6 months postoperatively all patients were ambulatory with or without walking aids. One patient had tri-wire cut through and one had tri-wire back-out. HHS was an average of 79 at 3 months representing a fair outcome. This increased to 90 at 6 months representing an excellent outcome.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions: &lt;/strong&gt;Modified gamma nail with tri-wire anchorage has distinct advantages over other techniques. It allows for early weight-bearing and mobilization with lesser complications. The tri-wire construct further provides additional rotational stability in osteoporotic bone.&lt;/p&gt;&lt;p&gt;nal stability in osteoporotic bone.&lt;/p&gt;

Mean Platelet Volume to Platelet Count Ratio as a Predictor of Mortality in Unstable Pertrochanteric Fracture Treated with Short Proximal Femoral Anterograde Nail.

The relationship between mean platelet volume (MPV) and platelet count (PC, MPV/PC) has been studied in detail in various diseases. The aim of this study was to investigate the effect of the MPV/PC ratio in estimating the risk of postoperative mortality in unstable pertrochanteric fractures. In addition, serum biomarkers such as the neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), and platelet-to-lymphocyte ratio (PLR) will be compared with the MPV/PC ratio in predicting mortality. We retrospectively reviewed the records of eligible adult patients with a pertrochanteric fracture who admitted to the Department of Orthopedics and Traumatology between January 2011 and December 2019. The MPV/PC ratio was estimated as the MPV value divided by the PC at admission, postoperative day 2, and postoperative day 5 of the surgery. The clinical outcome was 30-day mortality and overall mortality. We included 447 patients who received unstable pertrochanteric fracture surgery. In multivariate Cox proportional hazard models, higher MPV/PC ratios on admission were significant risk factors for 30-day mortality. In the ROC analysis, MPV/platelet ratio ≥ 0.048 at admission was critical for 30-day mortality (sensitivity 0.636, specificity 0.659, p < 0.001). The MPV/PC ratio alone predicted 30-day mortality in patients with pertrochanteric fracture. Further prospective and multicenter clinical trials supporting our findings and aiming to uncover the reason for the change in blood parameters will help to reduce mortality in unstable pertrochanteric fractures.

Calcar fracture gapping: a reliable predictor of anteromedial cortical support failure after cephalomedullary nailing for pertrochanteric femur fractures

BackgroundMaintaining anteromedial cortical support is essential for controlling sliding and decreasing postoperative implant-related complications. However, adequate fracture reduction with cortical support in immediate postoperative fluoroscopy is not invariable in postoperative follow-ups. This study was conducted to investigate the risk factors leading to anteromedial cortical support failure in follow up for pertrochanteric femur fractures treated with cephalomedullary nails.MethodsThis retrospective study enrolled 159 patients with pertrochanteric fractures (AO/OTA- 31A1 and 31A2) that fixed with cephalomedullary nails. All patients were evaluated as adequate fracture reduction in immediate postoperative fluoroscopy before leaving the operation theater. The patients were separated into two groups based on the condition of the anteromedial cortex in the postoperative 3D CT with full-range observation: those with calcar support maintained in Group 1 and those with calcar support lost in Group 2. Demographic information, fracture classification, TAD (tip-apex distance), Cal-TAD, Parker ratio, NSA (neck-shaft angle), reduction quality score, and calcar fracture gapping were collected and compared. Logistic regression analysis was conducted to explore the risk factors leading to anteromedial cortex change.ResultsAnteromedial cortical support failure was noted in 46 cases (29%). There was no significant difference between the two groups concerning age, sex, side injury, TAD, Cal-TAD, Parker ratio, or NSA. There was a significant difference in the AO/OTA fracture classification in univariate analysis but no difference in the multivariable analysis. The reduction quality score, calcar fracture gapping in the AP (anteroposterior), and lateral views were significantly associated with anteromedial cortical support failure in follow-up after cephalomedullary nailing in the multivariable analysis. The threshold value of calcar fracture gapping for the risk of loss was 4.2 mm in the AP and 3.8 mm in the lateral fluoroscopies. Mechanical complications (lateral sliding and varus) were frequently observed in the negative anteromedial cortical support group.ConclusionsGood reduction quality was a protective factor, and larger calcar fracture gapping in the AP and lateral views were risk factors leading to the postoperative loss of anteromedial cortical support. Therefore, we should pay close attention to fracture reduction and minimize the calcar fracture gap during surgery.

A comparison of the incidence of concomitant ipsilateral femoral neck fractures in ballistic versus blunt femur fractures.

The purpose of this study is to evaluate the rate of ipsilateral femoral neck fractures in ballistic femur fractures and compare this to similar non-ballistic blunt fractures. A retrospective review of an institutional trauma database was completed at a single Level 1 trauma academic medical center. All patients treated for a ballistic or blunt femur fracture presenting to our institution between May 1, 2018, and February 29, 2020, were included. In all, 270 femur fractures were identified. We excluded 73, including 29 pediatric fractures and 44 geriatric peritrochanteric fractures. The final cohort included 197 femur fractures in 187 patients. Of the 197 femur fractures included, 68 were ballistic and 129 were blunt mechanism. Four ipsilateral femoral neck fractures were identified in the ballistic fracture cohort. There was no significant difference between ipsilateral femoral neck fractures associated with blunt femur fractures when compared with ballistic fractures, 7.7 versus 5.8%, respectively. We identified one occult femoral neck fracture that was associated with a ballistic 32-B3 femoral shaft fracture. The ipsilateral femoral neck fracture associated with the 32-B3 ballistic femoral shaft fracture was not identified on plain films (Fig.3A, B) and review of CTA during initial trauma workup. Identification of this fracture intra-operatively changed the treatment plan from standard proximal locking to recon proximal locking for this case. Patients included in the blunt fracture cohort were more likely to be poly-trauma patients with a higher rate of associated fractures. We detected no difference in rate of associated femoral neck fracture between blunt and ballistic femur fractures. These fractures can be missed on initial evaluation, which may lead to a delayed diagnosis and alter treatment plans. The authors conclude that treating surgeons must remain vigilant with a high index of suspicion for occult femoral neck fractures in patients who suffer ballistic femoral shaft fractures. Low-energy ballistic injuries should not rule out the possibility of an occult femoral neck fracture.

Порівняльна характеристика ефективності оперативного лікування хворих із черезвертлюжними переломами стегнової кістки з використанням інтрамедулярних блокованих стрижней і тотального ендопротезування кульшового суглоба

З метою визначення оптимальної тактики оперативного втручання у хворих із черезвертлюжними переломами виконано комплексне клінічне дослідження. Матеріалом дослідження став аналіз історій хвороб, рентгенограм і клінічне обстеження 100 хворих із черезвертлюжними переломами стегнової кістки. Всі хворі були розподілені на дві групи залежно від використаного методу оперативного втручання. Першу групу становили хворі, яким проводилось тотальне ендопротезування кульшового суглоба. До другої групи увійшли хворі, яким проводили блокований інтрамедулярний остеосинтез. Переважно мінімально інвазивне оперативне втручання у групі хворих, яким виконувався інтрамедулярний блокований остеосинтез, дозволило знизити порівняно з групою, де хворим виконувалось тотальне ендопротезування кульшового суглоба, у 4 рази кількість післяопераційних гнійних ускладнень, у 5 разів — летальність і в 5,5 раза зменшити кількість негативних результатів оперативного втручання. Виконання ендопротезування у хворих із черезвертлюжними переломами стегнової кістки повинно виконуватись за чіткими абсолютними показаннями, до яких належить супутня IV стадія коксартрозу у травмованих осіб. Інтрамедулярний блокований остеосинтез може бути рекомендований як основний метод оперативного лікування хворих із черезвертлюжними переломами стегнової кістки.