Proximal Femoral Intramedullary Nail Research Articles

Fracture-related infection in revision proximal femoral intramedullary nails

BackgroundThe proximal femoral nail is a commonly used fixation device for extra-capsular neck of femur fractures at our UK NHS Trust. Fracture-related infection (FRI) is a catastrophic complication that can be associated with internal fixation. FRI is often diagnosed late, and causes significant impact on the patient and healthcare system, leading to extended hospital stays, reduced quality of life, high healthcare costs and increased mortality and morbidity. AimThis study aims to evaluate whether failed proximal femoral nails treated at a major trauma centre in the United Kingdom are undergoing routine intraoperative microbiology sampling, as outlined by the FRI Consensus Group in 2020, and also to establish how often fracture-related infection is present in failed proximal femoral nails. MethodElectronic patient record systems were reviewed over a 4-year period between 2018–2022 to identify patients who had a proximal femoral nailing, and those who required revision surgery. From this cohort, we then identified whether sampling had taken place during revision surgery, and the number of samples taken. Results1041 proximal femoral nails were performed at our trust during the 4-year period. 60 of these implants failed, with 52 of these undergoing revision surgery at our hospital. Only 56% cases had intra-operative samples taken for microbiology testing, with an average of 9 samples sent per case. Intra-operative sampling confirmed infection in 25% of cases with samples sent. Of the cases requiring ≥ 3 operations, 75% of cases had confirmed infection. DiscussionThe data shows that more can be done to ensure earlier diagnosis of fracture-related infection in failed proximal femoral nails. We should have a high suspicion of FRI in this cohort of patients. This study highlights the importance of a standardised protocol to ensure routine intra-operative sampling during proximal femoral nail revision surgery.

A novel intramedullary nail design of intertrochanteric fracture fixation improved by proximal femoral nail antirotation

A proper and reliable fracture fixation is important for fracture healing. The proximal femoral intramedullary nail (IN), such as proximal femoral nail anti-rotation (PFNA) or Gamma nail, is widely used for intertrochanteric fracture fixation. However, it still suffers considerable stress concentrations, especially at the junction between the nail and the blade or lag screw. In this study, we propose a novel intramedullary nail design to enhance the intramedullary nail integrity by introducing a bolt screw to form a stable triangular structure composed of the nail, the lag screw, and the bolt screw (PFTN, Proximal femoral triangle nail). Systematic finite element numerical simulations were carried out to compare the biomechanical performances of PFTN and PFNA under both static and dynamic loads during the postures of ascending and descending stairs. The simulation results highlight the advantages of the proposed PFTN design with lower stresses, less stress concentration, and higher structure stability.

Intertrochanteric Femoral Fractures: A Comparison of Clinical and Radiographic Results with the Proximal Femoral Intramedullary Nail (PROFIN), the Anti-Rotation Proximal Femoral Nail (A-PFN), and the InterTAN Nail

Background and Objectives: The aim of this study was to evaluate retrospectively the radiological and functional outcomes of closed reduction and internal fixation for intertrochanteric femoral fractures (IFF) using three different proximal femoral nails (PFN). Materials and Methods: In total, 309 individuals (143 males and 166 females) who underwent surgery for IFF using a PFN between January 2018 and January 2021 were included in the study. Our surgical team conducted osteosynthesis using the A-PFN® (TST, Istanbul, Turkey) nail, the PROFIN® (TST, Istanbul, Turkey), and the Trigen InterTAN (Smith & Nephew, Memphis, TN, USA) nail. The PFNs were compared based on age, gender, body mass index (BMI), length of stay (LOS) in intensive care, whether to be admitted to intensive care, mortality in the first year, amount of transfusion, preoperative time to surgery, hospitalisation time, duration of surgery and fluoroscopy, fracture type and reduction quality, complication ratio, and clinical and radiological outcomes. The patients' function was measured with the Harris Hip Score (HHS) and the Katz Index of Independence in Activities of Daily Living (ADL). Results: Pain in the hip and thigh is the most common complication, followed by the V-effect. The Z-effect was seen in 5.7% of PROFIN patients. A-PFN was shown to have longer surgical and fluoroscopy durations, lower HHS values, and much lower Katz ADL Index values compared to the other two PFNs. The V-effect occurrence was significantly higher in the A-PFN group (36.7%) than in the InterTAN group. The V-effect was seen in 33.1% of 31A2-type fractures but in none of the 31A3-type fractures. Conclusions: InterTAN nails are the best choice for IFFs because they have high clinical scores after surgery, there is no chance of Z-effect, and the rate of V-effect is low.

Topical tranexamic acid in intramedullary nailing for the treatment of intertrochanteric fractures in the elderly: A protocol for systematic review and meta-analysis.

Numerous studies have demonstrated that the use of tranexamic acid (TXA) intravenously minimizes bleeding, lowers transfusion rates, and does not raise the risk of complications during major orthopedic surgery. Concerning the effectiveness of the topical application, there are, nevertheless, inconsistent findings. We aimed to develop a protocol for systematic review and meta-analysis on the benefits and safety of topical TXA in intramedullary nailing for the treatment of intertrochanteric fractures in the elderly. PubMed, Embase, and the Cochrane Library will all be searched for randomized controlled trials published from the database inception to October 15, 2022. The primary outcomes will be intraoperative blood loss, hidden blood loss, total blood loss, transfusion rate, transfusion units, operative time, thromboembolic events, and mortality. The risk of bias will be evaluated using the Cochrane risk of bias assessment tool. Review Manager 5.3 will be used for the analysis. The effects and safety of topical TXA in intramedullary nailing for the treatment of intertrochanteric fractures in the elderly will be quantified in this study. The study's findings will assist doctors in determining if topical TXA use is secure and efficient.

Does matching degree matter for proximal femoral intramedullary nail on reoperation rate in intertrochanteric fractures?

IntroductionPrevious articles reported on the tip–apex distance, lag screw placement, fracture pattern, reduction quality, osteoporosis and other factors associated with second surgery. The current study focused on investigating the association of the matching degree between proximal femoral intramedullary nail and femoral medullary cavity on reoperation rate.Patients and methodsA retrospective cohort study was conducted. It included patients with intertrochanteric fracture who were treated with proximal femoral anti-rotatory intramedullary nail (PFNA) between January 2016 and April 2021. The gap between the intramedullary nail and the femoral medullary cavity was equal to the difference in diameter between the two. According to the gap size, all patients were divided into three groups, as follows: high-matching group: gap ≤ 2 mm; middle-matching group: 2 < gap < 4 mm; and low-matching group: gap ≥ 4 mm. The mean gap was measured through standard images. The primary observational index was whether the reoperation was needed, and secondary observational indexes included operative time, length of hospital stay. Patient characteristics were recorded, as follows: age, sex, follow-up time, fracture pattern, reduction grade and length of intramedullary nail.ResultsA total of 203 eligible patients were recorded, including 78 males (38.4%) and 125 females (61.6%). They had a mean age of 77.8 ± 9.9 years old and an average follow-up time of 58.1 ± 24.0 weeks. Twenty-seven patients (13.3%) needed a second operation. Coxa varus combined with screw cutting was the most common reason for reoperation (11 cases). Unstable fracture pattern with poor reduction grade tended to contribute to reoperation, whose odds ratio (OR) was 6.61 (95% confidence interval [CI], 1.98–22.09; P = 0.002). The three groups had 11 cases (13.7%), 12 cases (13.8%) and 4 cases (11.1%) of reoperation, respectively, and logistic regression showed no significant association was noted between matching degree of intramedullary nail and reoperation rate.ConclusionsThe matching degree between proximal femoral intramedullary nail and femoral medullary cavity did not seem to be an important factor for reoperation, which offered more options of intramedullary nail size intraoperatively and reduced implants stock from inventory.

Analysis of risk factors of healthy side fracture after hip fracture surgery in the elderly

To investigate the incidence and related risk factors of healthy side fracture after hip fracture surgery in the elderly, so as to provide basis for the prevention of re-fracture. The data of 452 patients over 65 years old with femoral neck fracture or intertrochanteric fracture treated with hip arthroplasty or proximal femoral intramedullary nailing from June 2012 to June 2017 were analyzed, including 168 males and 284 females, the age ranged from 65 to 97(75.5±7.5) years. There were 191 cases of femoral neck fracture and 261 cases of femoral intertrochanteric fracture. According to whether there was a fracture in the healthy hip after operation, the patients were divided into fracture group and no fracture group. The gender, age, body mass index, fracture type, initial treatment method, bone mineral density, bed time, medical compliance, postoperative short-term delirium, whether there were medical diseases before injury and Harris score of hip joint in the final follow-up were recorded. Univariate Logistic regression analysis was used to screen out the risk factors of healthy side fracture after operation, and then statistically significant risk factors were included in multi factor Logistic regression analysis to screen out the independent risk factors of healthy side fracture after operation of hip fracture in the elderly. Among them, 42 of the 452 patients had hip fractures on the healthy side with an incidence of 9.3%. The average interval between the two fractures was (2.9±2.1) years. Univariate Logistic regression analysis showed that there were significant differences in age, bone mineral density, medical compliance, short-term postoperative deliriun, pre-injury complicated with medical diseases and Harris score of hip joint in the final follow-up (P<0.05). Multivariate Logistic analysis showed that age(OR=4.227), bone mineral density(OR=4.313), combined with medical diseases (OR=5.616) and low hip Harris score at the final follow-up (OR=3.891) were independent risk factors for healthy side fractures after hip fracture surgery in elderly(P<0.05). The age, bone mineral density, combined with medical diseases and low Harris score of hip joint in the final follow-up are the main risk factors of healthy side fracture after hip fracture in the elderly. It is necessary to strengthen the treatment of medical diseases, anti osteoporosis and improve hip joint function within 3 years after operation, so as to prevent the occurrence of healthy side hip fracture.

Intraoperative IPC combined with 3M warming instrument to prevent lower extremity deep venous thrombosis in patients undergoing proximal femoral anti rotation intramedullary nailing

To explore the effect of intermittent pneumatic compression(IPC) combined with 3M thermometer on the prevention of deep venous thrombosis(DVT) in patients with femoral intertrochanteric fracture. From March 2016 to August 2019, 127 patients with femoral intertrochanteric fractures who underwent proximal femoral nail antirotation(PFNA) were retrospectively analyzed. They were divided into two groups according to different methods of thrombus prevention and treatment. Among them, 63 patients in group A did not use IPC and 3M thermometer;64 cases in group B were treated with IPC combined with 3M thermometer. Color Doppler ultrasound was used to dynamically monitor the DVT and changes of lower limbs during perioperative period. The venous thrombosis of lower limbs was monitored at 0, 24, 72 h and > 72 h after operation(recheck every 3 days until discharge). Occurrence of DVT of lower limbs after PFNA operation in two groups:there were 5 cases (7.8%) in group B and 20 cases (31.7%) in group A, there was significant difference between two groups (P=0.001). There was no significant difference in lower limb DVT between two groups at 0, 72 and > 72 h after operation(P>0.05), but the formation rate of group A was significantly higher than that of group B at 24 h after operation (P=0.049). There was no significant difference in DVT formation between group A and group B(P>0.05). However, the formation of DVT in group A was significantly higher than that in group B(P=0.012). Intraoperative IPC combined with 3M thermostat can effectively prevent DVT of lower limbs in patients undergoing PFNA surgery.

Comparative study of femoral head replacement and internal fixation in the treatment of unstable intertrochanteric fractures in the elderly

To compare the clinical efficacy of femoral head replacement and internal fixation in the treatment of unstable intertrochanteric fractures in the elderly. Retrospective analysis of 70 cases of unstable intertrochanteric fractures treated from January 2016 to January 2019 and meeting the inclusion and exclusion criteria, 39 cases were fixed with closed reduction and new proximal femoral intramedullary nail(InterTAN), and 31 cases were treated with open trochanter reconstruction and artificial femoral head replacement. The operation time, intraoperative bleeding, hospital stay, weight bearing time, postoperative complication rate and hip function recovery (Harris score) were compared between two groups. All cases were followed up for 12 to 24 months. There were no significant differences in intraoperative bleeding and hospital stay between the two groups (P>0.05). The operation time in replacement group was longer than that in internal fixation group (P< 0.05). The postoperative weight-bearing time in replacement group was significantly earlier than that in internal fixation group (P<0.05). In the replacement group, there were 1 case of pulmonary infection, 1 case of deep venous thrombosis and 1 case of periprosthetic fracture;in the internal fixation group, there were 4 cases of pulmonary infection, 3 cases of internal fixation failure, 3 cases of cerebral infarction and 2 cases of urinary infection;there was significant difference between two groups (P< 0.05). The Harris score in replacement group was higher than that in internal fixation group one month after operation (P< 0.05), but there was no significant difference between two groups at 12 months after operation(P>0.05). InterTAN and femoral head replacement can treat unstable intertrochanteric fractures in the elderly, but femoral head replacement can move down early, improve the quality of life at the end of life, reduce postoperative complications and facilitate the treatment of coexisting diseases in internal medicine.

Reduction of trochanteric fractures in lateral view is significant predictor for radiological and functional result after six months

The goal of our retrospective study was to determine which radiological parameter after fixation of trochanteric fractures type AO 31 A2 is most important for the position of the fracture after six months. The additional goal was to find how the end position influences mechanical failure and the mobility of the patients. We analysed 92 patients operated in one-year period for A 2 type trochanteric fractures with sliding hip screw or proximal femur intramedullary nail. They were divided in two groups according to the radiological position of the proximal fragment six months after the surgery. In group A we had 46 patients with satisfactory and in group B 46 patients with unsatisfactory position. In anteroposterior view we evaluated neck-shaft angle (NSA) and medial cortical support (MCS) and in lateral view anterior cortical support (ACS). Unsatisfactory position was recognized if NSA was in varus or ACS or MCS were negative. We compared the groups regarding basic patients characteristics (age, gender, ASA score, preinjury mobility, and degree of osteoporosis), type and quality of fixation, the position of the fracture (postoperatively and after 6 months), mechanical failure and mobility after 6 months. Statistical significance level was set to p ≤ 0.05. Basic patients' characteristics as well as type and quality of fixation did not significantly differ between the groups. After the injury the difference between the groups in reduction quality was significant in lateral view (ACS; p=0.001), while after half a year there were significant differences in both views: NSA (p=0.003), ACS and MCS (both p<0.001). Proximal fragment position after six months statistically significant correlated with postoperative ACS in B group (r=0.386, p=0.008), but not with NCA nor with MCS. There were also significantly more fixation failures in group B (p<0.001) and less patients regain preinjury mobility (p=0.029). In trochanteric fractures reduction in lateral view is the most important prognostic factor for favourable radiological result after half a year. Unsatisfactory position of the proximal fragment after six months influences mechanical failures and walking ability.

Effects of ethnicity on proximal femoral intramedullary nail protrusion-a 3D computer graphical analysis.

Antegrade nailing of proximal femur or femoral shaft fractures is a proven treatment with good to excellent results. Nonetheless, clinical evidence from Asia indicates that proximal femur nails can be too proud at the greater trochanter (GT) causing irritation for some Asian patients. This study aimed to identify any significant differences in proximal nail misfit for a set of Asian and Caucasian femora. Two nails (Gamma3, TFNA) were virtually inserted into 63 femoral 3D models (28 Japanese, 4 Thai, 31 Caucasian). In AP, the entry point was 4° lateral for Gamma3 and 5° for TFNA; laterally the same location was used for both. Insertion depth was controlled by aligning the lag screw centre head. The distance of the nail end from the GT was measured at five (medial, lateral, anterior, posterior and centre) reference points (RPs). The correlation between GT height, CCD angle and proximal nail distance to GT was analysed. There was no significant difference between either nail (p = 1.0). The TFNA was overall less prominent than the Gamma3, and significantly less prominent at all RPs except lateral. The Asian femora were 3.76 (p = 0.016) times more likely to have the nail protruding proximally. The Asian subjects were shorter (p < 0.05) than the Caucasians. Their GT height was slightly shorter and CCD angles larger compared to Caucasian (Asian: 41.1mm, 128.1°, Caucasian: 42.2mm, 126.4°), but the differences were not significant (p = 0.36). Stature, GT height and CCD angle significantly correlated with nail distance to GT. This study illustrated a significantly increased incidence of proximal nail protrusion in Asian compared to Caucasian femora, corroborating clinical findings. The combination of shorter stature and GT height and a larger CCD angle in Asians likely contributes to this difference.

Clinical and radiological outcomes of patients treated with the talon distalfix proximal femoral nail for intertrochanteric femur fractures

BackgroundThe Talon™ DistalFix™ Proximal Femoral Nail (Talon-PFN) is a new proximal femoral intramedullary nail designed for the treatment of intertrochanteric femoral fractures. This study aimed to report the clinical and radiological outcomes of patients treated using a proximal femoral intramedullary nail with a novel design. MethodsPatients with either stable or unstable (AO/OTA type 31-A1, 2, 3) intertrochanteric fractures who were treated with the Talon-PFN between October 2014 and January 2018 in our department participated in this retrospective study. Patients’ demographics, clinical characteristics, and functional and radiographical outcomes were evaluated. ResultsA total of 110 patients (65 females, 45 males) with a mean age of 80.6 ± 9.1 years participated in this study. The mean follow-up time was 24 ± 13.4 months. The overall mortality rate during follow-up was 50.48%. The most common perioperative complications were a malposition of the femoral neck screw and talon cutout, both of which occurred in 17 patients (15.5%). The most common complications observed during follow-up were a lesser trochanter nonunion/malunion in 34 patients (30.9%), valgus malunion in 18 patients 16.4%), lateral screw migration in four patients (3.6%), and varus malunion in 15 patients (13.7%). A late screw cutout through the femoral head was seen in four patients (3.6%). At least one complication was detected in 53 patients (48.2%). However, revision surgery was performed in only six of these cases (5.5%). ConclusionAccording to the results obtained in this study, the Talon-PFN, which has similar clinical and radiological outcomes compared to other proximal femoral intramedullary nail designs according to the reported studies, can be a suitable alternative in the treatment of intertrochanteric fractures.

Application of early holistic therapy in the treatment of intertrochanteric fracture in the elderly

Objective To investigate the clinical effect of early holistic treatment in elderly patients with intertrochanteric fracture. Methods From January 2017 to December 2017, 84 elderly patients with intertrochanteric fracture received by orthopaedics department of Shaoxing Central Hospital were divided into two groups.The observation group (46 patients) received early holistic therapy, and the control group (38 patients) received traditional orthopaedic trauma treatment.Two groups of patients were treated with proximal femoral anti-rotation intramedullary nail fixation, and the therapeutic effect was compared between the two groups. Results After 12 months of follow-up, the scores of Harris(evaluation standard of total hip joint curative effect) pain, mobility, deformity, function and total scores in the observation group were (39.13±2.66)points, (3.40±0.44)points, (3.30±0.38)points, (37.73±2.44)points, (83.56±2.51)points, respectively, which were higher than those in the control group[(37.05±2.95)points, (3.17±0.59)points, (3.09±0.52)points, (35.67±3.19)points, (78.98 ±3.37)points], there were statistically significant differences between the two groups (pain: t=3.395, P=0.001; activity: t=2.044, P=0.044; deformity: t=2.135, P=0.035; function: t=3.352, P=0.001; total score: t=7.131, P=0.000). After 12 months of follow-up, the excellent and good rate of operation in the observation group was 84.78%, which was higher than 71.05% in the control group, there difference was statistically significant between the two groups (χ2=5.477, P=0.019). The clinical statistics showed that the time from injury to operation, the time of ambulation and hospitalization in the observation group were (2.31±0.53) d, (3.53±0.69)d, (15.86±2.60)d, respectively, which were shorter than those in the control group[(3.45±1.02)d, (5.02±1.13)d, (19.73±3.12)d], the differences were statistically significant between the two groups (the time from injury to operation: t=6.585, P=0.000; the time of ambulation after operation: 7.128, P=0.000; hospitalization time: t=6.202, P=0.000). The incidence of complication was 6.52% in the observation group and 23.68% in the control group, the difference was statistically significant between the two groups (χ2=11.484, P=0.000). There was no death in the observation group at 12 months after operation, and the mortality rate in the control group was 2.63%, the difference was no statistically significant between the two groups (χ2=2.665, P=0.102). Conclusion The application of early holistic treatment concept in the treatment of elderly patients with intertrochanteric fracture can improve the therapeutic effect and shorten the rehabilitation process of the patients. Key words: Hip fractures; Fracture fixation, intramedullary; Femur; Early holistic treatment concept; Joint function; Complications

Lateral imaging technique of the femoral neck in a supine-semilithotomy position without a fracture table

Treatment of proximal femoral fractures in the supine position poses has certain challenges, especially due to difficulties in lateral imaging of the femoral neck in cases where there is no fracture table, such as prolonging the surgery time and increasing the dose of radiation exposure. The purpose of this study is to present the lateral imaging technique of the femoral neck by fluoroscopy on the conventional operating table in the treatment of proximal femoral fractures. We applied proximal femoral nail by positioning the healthy leg in a semilithotomy position to facilitate lateral imaging of the femoral neck by fluoroscopy while the patients were in the supine position.The study analyzed 22 patients (12 women, 10 men) with femoral pertrochanteric and basicervical fractures with the following types of fractures (9 patients had AO type 31-A1, 9 patients had AO type 31-A2, 4 patients had AO type 31-B2.1), and with a mean age of 62.1 years (33-75 years). The preparation time of the supine-semilithotomy position was about 2 minutes, and the reduction was finished within 9 intraoperative fluoroscopy exposure times. No patient suffered from a postoperative complication. The mean surgery time was 20 minutes (18-22 minutes), the average number of scopy shots was 8 (7-9), and the mean hospital stay duration was 2 days (2-2 days). We believe that the supine-semilithotomy technique is a suitable treatment option for proximal femoral intramedullary nailing and cannulated screw application. Since the lateral view of the femoral neck is obtained quickly and clearly with this technique, fluoroscopy does not need to be performed repeatedly, so fluoroscopy time and the number of shots are reduced, and the time spent by the patient and the surgical team in the surgery is shortened.

Evaluation of the positional relationship between femoral arteries and distal screws in the proximal femoral intramedullary nail for preventing iatrogenic vascular injury

Background and AimsIatrogenic vascular injury associated with distal screw in the intramedullary nail for femoral trochanteric fracture is a rare but serious complication. This study aimed to investigate the positional relationship between distal screws and superficial (SFA), deep (DFA), and perforating femoral artery (PFA) using computed tomography (CT) angiography and to identify the risk factors of vascular injury. Patients and MethodsThirty-eight patients (11 patients who underwent osteosynthesis with proximal femoral intramedullary nail and 27 healthy people) who underwent CT angiography were included. The distance from the great trochanter tip and insertion angle from posterior condylar axis (reference line) of the distal screws were measured, and the presence rates and distances from the femur of each artery within the insertion angle were investigated. ResultsThe distance from the great trochanter tip to the distal screw was 142.5 ± 8.8 mm. The insertion angle from the reference line was 27.3°±15° The measurement points were set at 130, 140, and 150 mm distal from the great trochanter tip, and the assumed insertion angle as 27°±15° Within this angle, the presence rates and distances were 50.8%/34.2 ± 7.0 mm (130 mm), 38.5%/34.3 ± 6.0 mm (140 mm), 30.8%/33.4 ± 6.0 mm (150 mm) in SFA; 12.3%/14.2 ± 3.3 mm (130 mm), 3.1%/13.1 ± 5.9 mm (140 mm), and 0% (150 mm) in DFA; and 0% (130−150 mm) in PFA. The presence rate of DFA increased at the posteromedial area in the thigh, and the distance from the femur became closer. ConclusionWithin the angle that distal screws were likely to be inserted, the risk of DFA injury was the highest. Therefore, anatomical reduction of the femoral neck anteversion should be performed so that the distal screw will be inserted towards the anteromedial area in the thigh, and great attention should be paid not to over-drill the medial femoral cortex.

Expression of programmed death receptor-1 and its prediction of postoperative infectious complications in elderly patients with hip fracture

Objective To investigate the expression of programmed death receptor-1 (PD-1) and its value in predicting the infectious complications in elderly patients with hip fracture. Methods A total of 119 elderly patients with intertrochanteric fracture(observation group) were prospectively enrolled for this study from August 2015 to August 2016 at Department of Orthopaedics, The Seventh Medical Center of PLA. They were 86 males and 33 females with an age of 80.7±8.1 years. Another 20 elderly out-patients with gonarthritis but without trauma or major medical disease were enrolled as a control group. The observation group received closed reduction and internal fixation with proximal femoral intramedullary nails. The PD-1 expression in peripheral blood T cells was detected at preoperation, 1, 3 and 5 days postoperation in the patients of observation group. They were further divided into an infection group and a non-infection group depending on whether infectious complications occurred during the follow-up period. The association between PD-1 and infectious complications was analyzed and its predictive value was calculated. Results The observation group and the control group, as well as the infection group and the non-infection group, were compatible due to their insignificant differences in baseline data(P>0.05).Compared with the control group, the expression of PD-1 in the peripheral blood T cells in the observation group was all significantly increased at preoperation, 1, 3 and 5 days postoperation (P<0.05). The PD-1 expression in patients of the infection group (24 cases) increased significantly higher at 1, 3 and 5 days postoperation (33.60%±2.44%, 35.68%±4.05% and 30.36%±4.42%) than in those of the non-infection group (29.57%±3.20%, 21.45%±2.20% and 20.94%±2.30%) (P<0.05). The PD-1 expression in the infection group reached its peak at 3 days postoperation and did not fall to the preoperative level at 5 days postoperation. However, the PD-1 expression in patients of the non-infection group (95 cases) showed a transient rise only on the first day postoperation. The cutoff value of the difference in PD-1 expression between 1 and 3 days postoperation that could predict the infectious complications was 3.4%, with a sensitivity of 95.6% and a specificity of 92.6%. Conclusions The expression of PD-1 may significantly increase after intramedullary fixation of hip fracture in elderly patients. The patients with infectious complications may exhibit a greater and longer increase in PD-1 expression than those without infectious complications. The difference in PD-1 expression between 1 and 3 days postoperation has a good predictive value for infectious complications because its high sensitivity and specificity. Key words: Hip fractures; Infections; Complications; Programmed death receptor-1

Curative effect of surgery within 48 hours after hip fracture in elderly patients

Objective To compare the clinical effects of surgery within and over 48 hours for hip fractures in elderly patients. Methods From May 2017 to April 2018, 47 patients over 75 years old with hip fracture were operated in our hospital and met with inclusion criteria. The patients were divided into two groups: within 48-hour group and over 48-hour group according to study design. In the within 48-hour group, there were 22 patients including 5 males and 17 females, aged from 76 to 97 years, with an average age of 83.6±5.0 years, and there were 10 femoral neck fractures (3 total hip arthroplasty, 7 hemiarthroplasty) and 12 femoral intertrochanteric fractures (proximal femoral intramedullary nail fixation). There were 25 patients (7 males and 18 females) in the over 48-hour group, aged from 76 to 98 years, with an average age of 83.8±5.8 years, and there were 10 femoral neck fractures (2 total hip arthroplasty, 8 hemiarthroplasty) and 15 femoral intertrochanteric fractures (proximal femoral intramedullary nail fixation). At the end of the follow-up period, the clinical data of the two groups were compared. The differences in the length of stay, cost of stay (excluding implants), postoperative complications within 1 month, hip function score (Harris score) within 1 month and 3 months, and mortality within 3 months and at the end of follow-up were analyzed. Results Both groups were followed up for 12 to 24 months, with an average of 17.7 months. The hospitalization time (7.9±3.0 d), hospitalization expenses (16 627.5±6 428.8 yuan), the incidence of early complications after operation (59.1%) and Harris score (80.9±8.6) in the within 48-hour group were significantly better than those in the over 48-hour group (12.3±4.1 d, 23 799.0±9 785.3 yuan, 88.0%, 71.1±9.2, respectively). At 3 months after operation, there was no significant difference in Harris score between the two groups (83.9±7.3 in within 48-hour group and 82.3±8.9 in over 48-hour group; t=0.668, P=0.507). Within 3 months, there was no death inwithin 48-hour group, but 2 in over 48-hour group; and 1 in within 48-hour group at the last follow-up. Conclusion Elderly patients with hip fracture benefit significantly from surgery within 48 hours after admission. Key words: Aged; Hip; Fractures, bone

Effectiveness of distally slotted proximal femoral nails on prevention of femur fractures during and after intertrochanteric femur fracture surgery

IntroductionIntra- and post-operative femoral shaft fractures related with nailing remain of concern. Although manufacturers have sought to solve the problem by providing distally slotted nails, it is not clear that these implants reduce fractures.We compare two distally slotted proximal femoral nails [trochanteric nail (TRON) and proximal femur intramedullary nail (PROFIN)]. Patients and MethodsThe medical records of 195 hips treated with TRONs (distally slotted in four places in the sagittal and coronal planes) and 583 hips treated with PROFINs (distally slotted in two places in the coronal plane) in two institutes were retrospectively evaluated. The inclusion criteria were follow-up for at least 6 months; pertrochanteric fractures and age over 55 years. ResultsIn total, 161 hips in the TRON group and 512 hips in the PROFIN group were included. The mean follow-up time was 28.5 (range: 6–84) months in whole group. The demographic characteristics of the groups were similar. Only 2 intraoperative shaft and 3 proximal lateral cortex fracture was detected in PROFIN group, there wasn’t any postoperative fracture. Four proximal lateral cortex and 2 femur shaft fractures were detected in TRON group (one during operation and one at postoperative 8th month after a fall at pedestrian way). ConclusionsDistal cephalomedullary nail slotting prevented intra- and post-operative femoral fractures. A distal slot 50 mm in length may increase nail elasticity and reduce nail tip stress to a greater extent than a 30-mm slot. Distal slotting in both the sagittal and coronal planes afforded no advantage compared to coronal slotting only. Level of evidenceLevel III retrospective study

Clinical study of recombinant human erythropoietin combined with iron to correct perioperative anemia in elderly patients with intertrochanteric fractures

To investigate the effectiveness of recombinant human erythropoietin (rHuEPO) combined with iron in treatment of anemia in elderly patients with intertrochanteric fractures during perioperative period. A clinical data of 71 patients with intertrochanteric fractures met the inclusion criteria between April 2016 and October 2017 was retrospectively analyzed. All patients were treated with closed reduction and proximal femoral intramedullary nail fixation. Thirty-one patients were treated with rHuEPO and iron before operation as trial group, and 40 patients were not treated with rHuEPO and iron as control group. There was no significant difference in gender, age, body mass index, cause of injury, fracture side and classification, American Society of Anesthesiologists (ASA) classification, combined medical diseases, time from fracture to admission, preoperative hospital stay, and operation time between the two groups ( P>0.05).The hemoglobin levels before operation and at 1, 3, and 7 days after operation, number of blood transfusion, blood transfusion rate, blood transfusion volume, postoperative hospital stay, complications were recorded and compared. After operation, 8 patients (25.8%) in trial group and 22 patients (55.0%) in control group received blood transfusion; the blood transfusion volume was (1.96±0.85) units in trial group and (3.19±1.61) units in control group. There were significant differences in blood transfusion rate and volume between the two groups ( P<0.05). There was no significant difference in preoperative hemoglobin level between the two groups ( P>0.05). The postoperative hemoglobin level was higher in trial group than in control group, and the difference between the two groups was significant at 7 days ( P<0.05). The postoperative hospital stay was (6.16±3.97) days in trial group and (9.25±4.47) days in control group, showing significant difference between the two groups ( P<0.05). There were 8 patients (25.8%) with pulmonary infection in trial group and 14 (35.0%) in control group after operation; 6 patients (19.4%) with deep venous thrombosis in trial group and 8 (20.0%) in control group. There was no significant difference in the incidences of complications between the two groups ( P>0.05). All patients were discharged from hospital normally, and no one died during hospitalization. The application of rHuEPO combined with iron before operation in elderly patients with intertrochanteric fractures can rapidly increase the hemoglobin level after operation, shorten the hospital stay, and do not increase the risk of deep venous thrombosis after operation.

A comparative prospective study of osteosynthesis in intertrochanteric fractures, using dynamic hip screw (DHS) and proximal femoral nailing (PFN)

Background: Intertrochanteric fractures (IT) are fragility fractures of hip and mostly associated with senile osteoporosis with trivial trauma or low velocity injuries. Traditionally extramedullary osteosynthesis in form of dynamic hip screw (DHS) was treatment of choice for these fractures in past but recent trends are more in favors of intramedullary osteosynthesis as proximal femoral intramedullary nailing (PFN). Here we studied and compared the radiological and functional evaluation of treatment parameters of these fractures managed with both modalities of treatment. Methods: This prospective randomized study was conducted on 42 patients (21 patients in each group, group A, DHS; group B, PFN) with intertrochanteric fracture managed in two years of duration (July 2014 to June 2016). All the per-operative findings and complications were compared, while radiological assessment with radiographs and functional evaluation with Harris hip score was done at 1, 3 and 6 months post-operative follow-ups. Results: Mean age of patients were 56.14 years (range 25-84), and 56.19 years (range 28-80), in group A and B respectively. We observed that PFN had less mean blood loss (144 ml), less mean limb length shortening (0.5 cm) and gained better mean functional results at 6 months (Harris hip score, 86.9) due to early mobilization while patients managed with DHS had more blood loss (155 ml), more shortening (1.07 cm) and less functional outcomes at 6 months follow-up (scores, 77.2). Intra-operative radiation exposure was more in PFN group, while there was no significant difference in radiological union, neck-shaft angle and implant sliding in both groups. Conclusion: PFN was better than DHS in management of intertrochanteric fractures in terms of per-operative parameters (decreased blood loss, less complications), and as well as in functional outcomes (early weight bearing and mobilization, better Harris hip scores), while other parameters are not significantly different.

Proximal femoral nailing-intra operative complications: A retrospective analysis of 200 cases of proximal femoral fractures

Background: Proximal femoral fractures are common in elderly and with high velocity trauma in younger age groups too. Nailing of proximal femoral fractures is technically demanding procedure which needs experience to tackle the difficulties. Detailed literature regarding the difficulties faced during the procedure is lacking. Methods: Analysis of the intra operative complications faced during closed and open proximal femoral intra-medullary nailing. Conclusions: Technical difficulties arise due to many reasons starting from improper positioning of the patient. With good instrumentation and with experience these problems can be minimized with attention to each surgical step.