Reverse Oblique Fractures Research Articles

Reverse oblique supracondylar fracture associated with knee replacement: Management with an anatomical medial buttress plate: A report of two cases

Reverse oblique supracondylar fracture associated with knee replacement: Management with an anatomical medial buttress plate: A report of two cases

Proximal Femoral Nail for the Treatment of Reverse Obliquity Intertrochanteric Fractures Compared With Gamma Nail

The reverse obliquity fracture of the proximal femur (AO/OTA 31-A3) is mechanically different from most intertrochanteric fractures. The purpose of this study was to compare the results of proximal femoral nail (PFN) fixation with those of gamma nail (GN) fixation for these fractures. Between 1993 and 2003, 635 of the fractures were classified as intertrochanteric or subtrochanteric. Clinical and radiographic records were retrospectively reviewed, and 22 fractures with reverse obliquity pattern were identified. The patients were divided into two treatment groups and were followed up for a minimum of 1 year (range, 12-67 months). Eleven patients in group I were treated with the PFN, and 11 patients in group II were treated with the GN. The two groups were comparable with regard to demographic and injury variables. The duration of follow-up averaged 18 months (range, 12-67 months). Radiographic changes during the follow-up, clinical outcome, and complications of the PFN group were compared with those of the GN group. Reverse obliquity intertrochanteric fractures accounted for 4.3% of intertrochanteric and subtrochanteric fractures. Bone union time averaged 16.5 weeks in the PFN group and 17.9 weeks in the GN group. Average sliding of lag screw was 2.5 mm in the PFN group and 3.1 mm in the GN group (p = 0.046). Change of the neck-shaft angle was 2.45 degrees in the PFN group and 3.75 degrees in the GN group (p = 0.032). A satisfactory functional outcome was found in eight patients in the PFN group and also in eight patients in the GN group. There was one osteonecrosis of femoral head in the PFN group. There was one cutting out of lag screw, one nonunion, and one varus deformity in the GN group. There was no difference in clinical outcome between the PFN and GN groups. However, the PFN demonstrated better results biomechanically than the GN did in terms of less sliding of lag screw, less change of neck-shaft angle, and less complications for the treatment of reverse obliquity intertrochanteric fractures.

Pelvic migration of lag screw from a nailing device

A 71-year-old male Caucasian tripped and fell ontohis right side, following which he had pain in theright hip and was unable to bear weight. He had apast history of a CVA some 9 months previously, butno other concurrent medical problems.Radiographs of his pelvis revealed an intertro-chanteric reverse oblique fracture of the rightfemur (Fig. 1). This was a type II fracture by Evan’sclassification (unstable).

Reverse obliquity and transverse fractures of the trochanteric region of the femur; a review of 101 cases

Reverse obliquity and transverse fractures of the proximal femur represent a distinct fracture pattern in which the mechanical forces displace the femur medially thus increasing the risk of fixation failure. There is a paucity of published literature in this area of trauma. This study constitutes the largest series of such fractures. Using a retrospective analysis of prospectively collected data from a single institution, 101 reverse obliquity and transverse fracture patterns were identified from 3336 consecutive hip fractures. All surviving patients were followed up for 1 year. Of 100 patients treated operatively, 59 were treated with 135 degrees sliding hip screws (SHS), 19 with a Medoff plates modification of the SHS, three with a sliding hip screw and trochanteric stabilising plate and 19 with intramedullary sliding hip screw devices. Nine fracture fixation-healing complications occurred, with cut-out being the commonest complication (seven cases). Cut-out of the implant was associated with femoral medialisation and a larger tip to apex distance. This fracture pattern is a challenge for the orthopaedic surgeon with a high risk of fracture healing complications. The 135 degrees SHS and the intramedullary devices had similar failure rates.

Second-generation cephalomedullary nails in the treatment of reverse obliquity intertrochanteric fractures of the proximal femur

Since 1996, in Tampere University Hospital, a second-generation cephalomedullary nail (CMN) has been the implant of first choice in reverse obliquity fractures of the proximal femur. Between 1996 and 1999 we treated 77 such fractures, of which 72 were fixed with the CMN. There were six re-operations (8.3%). An anatomic or nearly anatomic reduction and a properly placed implant were found in 47 cases with one failure. An unacceptable postoperative radiological result was seen in 25 cases resulting in five re-operations ( P=0.029). In 12 of 14 open procedures a cable was added to stabilise the greater trochanter and none failed. Four of five fractures fixed with the sliding hip screw failed. Our results using the CMN in reverse obliquity intertrochanteric fractures compares favourably to the results in earlier reports where extramedullary implants are used.

Treatment of Reverse Obliquity Fractures of the Intertrochanteric Region of the Femur

Treatment of Reverse Obliquity Fractures of the Intertrochanteric Region of the Femur

Treatment of Reverse Obliquity Fractures of the Intertrochanteric Region of the Femur

Treatment of Reverse Obliquity Fractures of the Intertrochanteric Region of the Femur

TREATMENT OF REVERSE OBLIQUE AND TRANSVERSE INTERTROCHANTERIC FRACTURES WITH USE OF AN INTRAMEDULLARY NAIL OR a 95° SCREW-PLATE

Intertrochanteric fractures are composed of different anatomic patterns that vary in their degree of stability following open reduction and internal fixation. A particularly unstable group is classified as AO/OTA 31-A3, with the fracture pattern described as reverse oblique or transverse. The purpose of this study was to compare the results of intramedullary fixation with those of plate fixation for these intertrochanteric fractures in elderly patients. Thirty-nine elderly patients with AO/OTA 31-A3 intertrochanteric fractures of the femur were randomized into two treatment groups and were followed for a minimum of one year. The nineteen patients in Group I were treated with a 95 fixed-angle screw-plate (Dynamic Condylar Screw), and the twenty patients in Group II were treated with an intramedullary nail (Proximal Femoral Nail). The treatment groups were comparable with regard to all demographic and injury variables. Patients treated with an intramedullary nail had shorter operative times, fewer blood transfusions, and shorter hospital stays compared with those treated with a 95 screw-plate. Implant failure and/or nonunion was noted in seven of the nineteen patients who had been treated with the 95 screw-plate. Only one of the twenty fractures that had been treated with an intramedullary nail did not heal. The results of our study support the use of an intramedullary nail rather than a 95 screw-plate for the fixation of reverse oblique and transverse intertrochanteric fractures in elderly patients.

Reverse obliquity fractures of the intertrochanteric region of the femur.

The reverse obliquity fracture of the proximal part of the femur is a distinct fracture pattern that is mechanically different from most intertrochanteric fractures. The purpose of this retrospective study was to determine the prevalence of these fractures and the results and complications of different types of internal fixation used in their treatment. Between 1988 and 1998, 2472 consecutive patients with a hip fracture were treated at our Level-One Trauma Center; 1035 of the fractures were classified as intertrochanteric or subtrochanteric. Clinical and radiographic records were retrospectively reviewed, and fifty-five fractures with a reverse obliquity pattern were identified. Forty-nine patients were followed until the fracture united or a revision operation was performed. The duration of clinical follow-up averaged eighteen months (range, three to sixty-seven months), and the duration of radiographic follow-up averaged fifteen months (range, three to sixty months). Fractures were classified with the Orthopaedic Trauma Association scheme. Results were analyzed according to the fracture pattern, type of implant, quality of the reduction, position of the implant, and use of bone graft at the index operation. Function was assessed on the basis of pain, living situation, need for walking aids, need for analgesics, and walking capacity. Thirty-two (68%) of forty-seven hips treated with internal fixation healed without an additional operation. Fifteen (32%) of the forty-seven failed to heal or had a failure of fixation. The failure rate was nine of sixteen for the sliding hip screws, two of fifteen for the blade-plates, three of ten for the dynamic condylar screws, one of three for the cephalomedullary nails, and zero of three for the intramedullary hip screws. Use of the fixed-angle devices (the blade-plate and the dynamic condylar screw) resulted in fewer failures than did use of the sliding hip screw (p = 0.023). Eleven (46%) of twenty-four nonanatomically reduced fractures and four (17%) of twenty-three anatomically reduced fractures had a failure of treatment (p = 0.060). Eleven (26%) of forty-two fractures with an ideally placed implant and four (80%) of five fractures with a non-ideally placed implant had a failure of treatment (p = 0.023). Of the fifteen fractures that failed to heal or had a failure of fixation, five were treated with revision to a calcar-replacement prosthesis, seven were treated with revision open reduction and internal fixation with bone-grafting, and one was treated with bone-grafting without revision of the fixation. Two patients refused additional surgery because they had limited functional demands. The two-year mortality rate was 33%. Functional results were poor, with many patients requiring walking aids and losing the capacity for independent walking and self-care. In this series, reverse obliquity fractures accounted for 2% of all hip fractures and 5% of all intertrochanteric and subtrochanteric fractures. Ninety-five-degree fixed-angle internal fixation devices performed significantly better than did sliding hip screws. Results were also worse for fractures with poor reduction and those with a poorly placed implant.

Use of the Medoff sliding plate for subtrochanteric hip fractures.

To evaluate the effects of dynamization of a sliding hip screw plate on the fixation stability for several types of subtrochanteric fractures. Clinical results of treating reverse oblique fractures occasionally show medialization of the femoral shaft. Two types of plate dynamization were compared using the same test protocol in identically prepared groups of uniform, artificial femurs. Sawbones composite femurs (Pacific Research Labs, Vashon, WA) having five orientations of simulated subtrochanteric fractures were used with the Medoff plate (Medpac, Inc., Valencia, CA) either fully dynamized or with the sliding lag screw locked. These specimens were physiologically loaded and cycled and displacements of the proximal femur determined. Significantly more shaft medialization occurred with reverse oblique fracture patterns when the Medoff plate was fully dynamized. Clinical treatment of reverse oblique fractures with the Medoff plate should be performed using the lag screw locked and only the plate dynamized.