Reverse Obliquity Research Articles

REVIEW OF A CLINICAL CASE OF TRANSTROCHANTERIC FRACTURE

Introduction: Intertrochanteric or transtrochanteric fractures are defined as extracapsular fractures of the proximal femur that occur between the greater and lesser trochanter. A clinical case is described below from the time of the initial incident to the final ambulatory control and updated notes on the management of intertrochanteric fractures are made. Objective: to describe this clinical case objectively and to make an analysis of the subject. Methodology: An objective description of the clinical case and a review with analysis of a total of 17 articles, including review and original articles, as well as cases and clinical trials, of which 9 bibliographies were used because the information collected was not sufficiently important to be included in this study. The sources of information were Cochrane, PubMed and Google Scholar; the terms used to search for information in Spanish, Portuguese and English were: transtrochanteric fracture, femur fracture, intertrochanteric fracture, femur osteosynthesis. Results: the use of cephalomedullary nails reduces fracture collapse in comparison with the screwed plate. Cephalomedullary nails have been more effective in intertrochanteric fractures with subtrochanteric extension and in fractures with a reverse obliquity pattern. The type of surgical treatment is based on the fracture pattern and its inherent stability, since the failure rate is highly correlated with the choice of implant and fracture pattern. Conclusions: it is of utmost importance to know the proper management of a fractured patient, especially when the fracture is severe and life-threatening. The management of proximal femoral fractures will depend on their classification and the condition of the affected individual. Therefore, a good imaging study is essential. When deciding on a surgical approach, the material to choose in the procedures has to be ordered with planning and caution, because this will vary according to the type of fracture, being usual to perform different types of surgeries in intertrochanteric fractures being more common the use of intramedullary nails compared to femoral neck fractures, where it is more common the use of cannulated screws, or prosthesis depending on the type of fracture trace. Our clinical case gives a brief view on the surgical management of the pathology, which has to be understood for the best performance of the patient. KEY WORDS: fracture, transtrochanteric, femur, intertrochanteric.

Functional Outcomes of Bipolar Hemiarthroplasty in Unstable Intertrochanteric Femur Fractures in the Elderly: A Prospective Study.

Background Intertrochanteric femur fractures are relatively common injuries among elderly individuals. Treatment options include fixation of intertrochanteric fractures using proximal femoral nails (PFNs), dynamic hip screws (DHSs), and unipolar and bipolar hemiarthroplasty. Unstable types of intertrochanteric fractures (Arbeitsgemeinschaft für Osteosynthesefragen (AO) types 31-A2 and A3) are more common in elderly osteoporotic people. Intertrochanteric femur fractures having a subtrochanteric extension, comminution at the posteromedial cortex, and reverse obliquity are considered to be unstable. The purpose of the study is to evaluate the functional outcomes of an unstable intertrochanteric femur fracture treated with bipolar hemiarthroplasty as the primary treatment option. Aims and objectives This study aims to assess the functional outcomes of bipolar hemiarthroplasty in unstable intertrochanteric fractures in the elderly using the Harris Hip Score (HHS) and the Merle d'Aubigné and Postel Criteria. The time point of assessment was from August 2016 to August 2018. Material and methods Fifteen elderly patients with unstable intertrochanteric fractures of the femur were treated with cemented bipolar hemiarthroplasty. Patients with unstable femur fractures or with osteoporosis and age above 65 years were included in the study. Harris Hip Score and the Merle d'Aubigné and Postel Criteria were used to measure functional outcomes. Patients were followed up at the first, third, and sixth months and subsequently at the end of one year. Results The mean age of the patients was 78.73 years. The majority (11) of the patients were female (73%). The average operative time was 119 minutes, the average blood loss was 380 ml, the mean postoperative hospital stay was 12 days, and the average time taken for mobilization was four days. An average of 15 elderly patients with unstable intertrochanteric fractures of the femur were treated with cemented bipolar hemiarthroplasty. The HHS on the first follow-up was 42.44 (SD of 6.52), followed by a score of 64.43 (SD of 8.11) on the second follow-up, 82.32 (SD of 2.81) on the third follow-up, and 84.23 (SD of 3.15) on the fourth follow-up. Eleven patients had good results, and two had fair results at the one-year follow-up, according to the HHS. According to the Merle d'Aubigné and Postel Criteria, 11 patients had very good results, and two had moderate results at the one-year follow-up. The average Merle d'Aubigné score was 14.6 on the final follow-up after one year. Conclusion Bipolar hemiarthroplasty in an unstable intertrochanteric femur fracture in the elderly results in better functional outcomes, as it helps in early full weight-bearing mobilization, which significantly decreases complications of prolonged immobilization and can be safely considered in the treatment of unstable intertrochanteric fractures in elderly patients.

Comparative study of a novel proximal femoral bionic nail and three conventional cephalomedullary nails for reverse obliquity intertrochanteric fractures: a finite element analysis

Comparative study of a novel proximal femoral bionic nail and three conventional cephalomedullary nails for reverse obliquity intertrochanteric fractures: a finite element analysis

No Difference in Clinical and Hospital Quality Outcomes in Treatment of Reverse Obliquity Intertrochanteric Hip Fractures (AO/OTA 31.A3) Based on Cephalomedullary Nail Length

IntroductionThe purpose of this study was to evaluate outcomes following reverse obliquity (RO) intertrochanteric hip fractures based on the use of short cephalomedullary nails (CMNs) compared to long CMNs for fixation. MethodsAn IRB-approved prospectively collected hip fracture registry at an urban academic medical center was queried for all AO/OTA 31A3.1-3 reverse obliquity intertrochanteric (RO) fractures. One hundred and seventy patients with age > 55 years old and minimum 6-month follow-up were identified for analysis. Data was collected for patient demographics, injury details, intraoperative radiographic parameters, perioperative physiologic parameters, hospital quality measures, and outcomes including radiographic time to healing, need for reoperation, nonunion, and mortality. Comparative analyses were conducted between cohorts. Additional multivariable binary logistic and linear regression analyses were performed to evaluate for factors independently associated with short and long nail usage. ResultsThe mean age of the entire cohort was 80.91±10.09 years: 103 patients had a long CMN implanted, and 67 patients had a short CMN implanted. There were no demographic differences or differences in radiographic time to healing, rates of mortality, readmission, nonunion, and need for reoperation. Univariable analysis revealed that short CMN had lower intraoperative blood loss (111.19±83.97mL vs 176.72±161.45mL, p=0.002), decreased need for transfusion (37% vs. 55%, p=0.022), and shorter procedures (118.67±57.87min vs. 148.95±77.83min, p=0.002. Multivariable analysis revealed that short nail usage was associated with decreased intraoperative blood loss, decreased need for transfusion, and shorter operative times. ConclusionNail length does not affect healing or hospital quality outcomes in the treatment of RO hip fractures. The use of short CMNs for these fractures did correlate with lower intraoperative blood loss, operative time, and need for blood transfusion, with non-inferior outcomes and similar hospital quality measures when compared to long CMNs.

Assessing the Necessity of Extra Reduction Aides in Intramedullary Nailing of Intertrochanteric Hip Fractures.

This study aims to determine which intertrochanteric (IT) hip fracture and patient characteristics predict the necessity for adjunct reduction aides prior to prep and drape aiming for a more efficient surgery. Institutional fracture registries from two academic medical centers from 2017-2022 were analyzed. Data on patient demographics, comorbidities, fracture patterns identified on radiographs including displacement of the lesser trochanter (LT), thin lateral wall (LW), reverse obliquity (RO), subtrochanteric extension (STE), and number of fracture parts were collected, and the need for additional aides following traction on fracture table were collected. Fractures were classified using the AO/OTA classification. Regression analyses identified significant risk factors for needing extra reduction aides. Of the 166 patients included, the average age was 80.84±12.7 years and BMI was 24.37±5.3 kg/m2. Univariate regression revealed increased irreducibility risk associated with RO (odds ratio [OR] 27.917, P≤0.001), LW (OR 24.882, P<0.001), and STE (OR 5.255, P=0.005). Multivariate analysis significantly correlated RO (OR 120.74, P<0.001) and thin LW (OR 131.14, P<0.001) with increased risk. However, STE (P=0.36) and LT displacement (P=0.77) weren't significant. Fracture types 2.2, 3.2, and 3.3 displayed elevated risk (P<0.001), while no other factors increased risk. Elderly patients with IT fractures with RO and/or thin LW are at higher risk of irreducibility, necessitating adjunct reduction aides. Other parameters showed no significant association, suggesting most fracture patterns can be achieved with traction manipulation alone.

Proximal Femoral Nail versus Dynamic Hip Screw in Unstable Intertrochanteric Fractures (Systemic Review and Meta-Analysis)

Objective To compare the results of operative management using two different kind of internal fixation modality devices either PFN or DHS, to achieve fracture union and to determine the rate of union, complications, operative risks and functional recovery and outcomes. Compare the results obtained and determine the effectiveness of PFN in comparison to DHS in treatment of intertrochanteric fractures. Introduction Intertrochanteric fractures form about 50% of all fractures that occur in proximal part of femur. The mean patient age is 66 to 76 years. In United States of America, the rate of intertrochanteric fractures in elderly men is about 34 per 100,000 and in women it is 63 per 100,000 annually. Intertrochanteric fractures mostly unite, provided that reduction and fixation are correctly done. There are large area of bone is involved, mostly consist of cancellous bone and both fragments are richly supplied by blood. Determination of stability is the most important aspect of intertrochanteric fracture classification. Stability is provided by an intact or a reconstructible posteromedial buttress. Reverse obliquity fractures, loss or comminution of the posteromedial buttress and subtrochanteric extension are factors that results in unstable fracture patterns. Management The treatment goal of intertrochanteric fracture is restoration of early mobility safely and adequately while decreasing the hazard of medical complications and technical failure and to restore the patient to preoperative status of function. Trochentric femoral fracures have been estimated to occur in more than 200,000 patients annually in the United States, with reported mortality rate from 15% to 30%. Study design Randomized controlled trials and quasi-random studies.

The Comparison of Dynamic Condylar Screw Plate to Proximal Femoral Nail in Reverse Oblique and Transverse Intertrochanteric Fractures: A Retrospective Study on 61 Patients.

Reverse oblique (RO) and transverse intertrochanteric fracture patterns constitute a challenge for the operating surgeon. Currently, no gold standard fixation method exists. This study aimed to retrospectively compare proximal femoral nail (PFN) to dynamic condylar screw (DCS) plating in the treatment of RO and transverse intertrochanteric fractures. A total of 61 patients fixated by PFN or DCS were included. Of these, 36 were treated with PFN (21 females and 15 males; mean age: 65.52 years), and 25 were treated with DCS (12 females and 13 males; mean age: 59.36 years). The mean follow-up time was 33.8 and 42.6 months (range: 24-108). Radiological evaluation included the quality of fracture reduction, neck-shaft angle change, posteromedial support presence, and bone union time. Complications such as mechanical failure, nonunion, and infection were noted. The only significant differences between the fixation methods were the superiority of DCS over PFN in earlier fracture union time (mean values: 8.9 versus14.1 weeks) and the superiority (p=0.007) of PFN in shorter hospital stay (3.4 days versus5.1 days). No significant difference was observed in radiological parameters. While similar mechanical complication rates were found, a significantly higher nonunion rate was detected with the DCS. The most crucial disadvantage of DCS was the high rate of nonunion. Closed fracture reduction in PFN seems to be the most critical parameter to prevent severe complications. The open reduction using DCS showed no advantages over closed reduction and PFN fixation in providing a more anatomical alignment in AO/Orthopaedic Trauma Association (OTA) 31-A3 fractures. However, we recommend PFN application in this type of fracture, since nonunion is more common in DCS.

Are The Lateral Wall Reduction And Ideal Tip-Apex Distance Important In Reverse Oblique And Transverse Intertrochanteric Femoral Fractures (31-A3) Treated With Gamma Nail?

Purpose: Reverse oblique and transverse intertrochanteric femoral fractures (31A3 AO/OTA classification) have their own mechanical and anatomical properties. The aim of our study is to verify whether the reduction of the lateral femoral wall and ideal tip-apex distance are important predictive factors in the future of these fractures treated by gamma nails in terms of healing and complication rates. Methods: The radiological and clinical outcomes of 35 fractures of this type treated by short and long gamma nail from June 2014 to April 2021 were retrospectively reviewed. The elements considered were the quality of the lateral femoral wall reduction, the tip-apex distance (TAD), the lag screw position and overall quality reduction using the Baumgaertner criteria. Union, nonunion, cutout, screw sliding, nail or screw breakage were also radiographically evaluated during follow-up. Results: The union rate was 97%. A significant association was not observed between the state of reduction of the lateral wall and the three types of complications considered (cutout: p=0.31; sliding screw: p=1.00; varus displacement: p=0.30), and the linear regression model obtained indicates that in subjects with a non-reduction of the lateral wall, the consolidation time is increased on average by approximately 3 months (β= 2.99; 95%CI: 1.79-4.20, p&lt;0.001). No significant association was found between TAD and complications (cut-out: p=1.00; sliding screw: p=1.00; varus displacement: p=0.13). Conclusion: Anatomic reduction of the lateral wall and an ideal TAD ≤ 25mm might not be as significant for 31A3 fractures treated with gamma nails. Acceptable reduction of the lateral wall and stable internal fixation are sufficient elements to achieve fracture healing and functional recovery.

AAOS Management of Hip Fractures in Older Adults Evidence-based Clinical Practice Guideline.

AAOS Management of Hip Fractures in Older Adults Evidence-based Clinical Practice Guideline.

Proposal of a novel comprehensive classification for femoral intertrochanteric fractures

To introduce a novel comprehensive classification for femoral intertrochanteric fractures, and to accommodate the clinical requirement for the world-wide outbreak of geriatric hip fractures and surgical operations. On the basis of reviewing the history of classification of femoral intertrochanteric fractures and analyzing the advantages and disadvantages of AO/Orthopaedic Trauma Association (AO/OTA) classification in different periods, combined with the current situation of extensive preoperative CT scan and three-dimensional reconstruction and widespread use of intramedullary nail fixation in China, the "Elderly Hip Fracture" Research Group of the Reparative and Reconstructive Surgery Committee of the Chinese Rehabilitation Medical Association proposed a novel comprehensive classification for femoral intertrochanteric fractures, focusing on the structure of fracture stability reconstruction during internal fixation. The novel comprehensive classification of femoral intertrochanteric fractures incorporates multiple indicators of fracture classification, including the orientation of the fracture line, the degree of fracture fragmentation, the lesser trochanteric bone fragment and its distal extension length (>2 cm), the posterior coronal bone fragment and its anterior extension width (involving the lateral cortex of the head and neck implant entry point), transverse fracture of the lateral and anterior wall and its relationship with the implant entry point in the head and neck, and whether the cortex of the anteromedial inferior corner can be directly reduced to contact, etc. The femoral intertrochanteric fractures are divided into 4 types (type A1 is simple two-part fractures, type A2 is characterized by lesser trochanter fragment and posterior coronal fractures, type A3 is reverse obliquity and transverse fractures, type A4 is medial comminution which lacks anteromedial cortex transmission of compression force), each of which is subdivided into 4 subtypes and further subdivide into finer subgroups. In a review of 550 trochanteric hip fracture cases by three-dimensional CT, type A1 accounted for 20.0%, type A2 for 62.5%, type A3 for 15.5%, and type A4 for 2.0%, respectively. For subtypes, A2.2 is with a "banana-like" posterior coronal fragment, A2.4 is with distal cortex extension >2 cm of the lesser trochanter and anterior cortical expansion of the posterior coronal fragment to the entry portal of head-neck implants, A3.4 is a primary pantrochanteric fracture, and A4.4 is a concomitant ipsilateral segmental fracture of the neck and trochanter region. The novel comprehensive classification of femoral intertrochanteric fractures can describe the morphological characteristics of fractures in more detail, include more rare and complex types, provide more personalized subtype selection, and adapt to the clinical needs of both fractures and surgeries.

A sophisticated fracture classification system of the proximal femur trochanteric region (AO/OTA-31A) based on3D-CT images.

ObjectiveFracture classification evolves dynamically with new and enhanced imaging modalities. This paper aims to introduce a novel hypothesis of a sophisticated fracture classification system for the proximal femur trochanteric region (AO/OTA-31A) based on 3D-CT images and accommodate the clinical requirement of the worldwide outbreak of geriatric hip fractures with large amounts of surgical operations.MethodsIn the current practice of widely preoperative 3D-CT application and cephalomedullary nailing, we attempt to propose a new comprehensive classification system to describe the fracture characteristics in a more detailed and sophisticated architecture, and pay the most important concern to the parameters that contribute to fracture stability reconstruction in osteosynthesis.ResultsThe new four-by-four comprehensive classification system, followed the structure of the AO/OTA system, incorporates many fracture characteristics as dividing indexes into multiple grade levels, such as fracture line direction, the number of fragments, the lesser trochanter fragment and its distal extension (>2 cm), the posterior coronal fragment and its anterior expansion (to the entry portal of head–neck implant at the lateral cortex), the lateral wall and anterior cortex fracture, and the anteromedial inferior corner comminution. From a panoramic perspective, there are four types and each type has four subtypes. A1 is simple two-part fractures (20%), A2 is characterized by lesser trochanter fragment and posterior coronal fractures (62.5%), A3 is reverse obliquity and transverse fractures with complete lateral wall broken (15.5%), and A4 is medial wall comminution which further lacks anteromedial cortex transmission of compression force (2%). For subtypes, A2.2 is with a banana-like posterior coronal fragment, A2.4 is with distal cortex extension >2 cm of the lesser trochanter and anterior expansion of the posterior coronal fragment(s) to the entry portal of head–neck implants, A3.4 is a primary pantrochanteric fracture, and A4.4 is a concomitant ipsilateral segmental fracture of the neck and trochanter region.ConclusionClassification represents diversity under consistency. The four-by-four sophisticated classification system delineates fracture characteristics in more detail. It is applicable in the time of rapid outbreak of trochanteric fractures in the older population, the large amounts of surgical operations, and incorporates various rare and/or more complicated subtypes which is unclassifiable before.

Dynamic Responses of Liquid Storage Tank Under Near Fault Pulse-Like Earthquakes With Different Focal Mechanisms

A liquid storage tank has a very extensive role in the petrochemical industry, and earthquake damage will cause very serious consequences. Considering the fluid-solid coupling, material nonlinearity and liquid level shaking dynamic behavior, three-dimensional calculation models of non-isolated and isolated liquid storage tanks are established, respectively. 12 earthquake waves are selected from Pacific Earthquake Engineering Research Center (PEER), and there are three earthquake waves of reverse (R), strike slip (SS), reverse oblique (RO) and normal (N) focal mechanisms, respectively. The influence of the focal mechanism on the dynamic responses of the liquid storage tank is investigated. The effectiveness control of sliding isolation on a near fault earthquake is discussed. The influence of the diameter of the limiting device on the shock absorption effect is analyzed. The results show that the order of influence of four types of focal mechanisms on liquid sloshing wave height is as follows: RO$mathrm{&gt;$R$mathrm{&gt;$SS$mathrm{&gt;$N. For the wall displacement, liquid pressure and effective stress of the tank wall, the response under N-type focal mechanism earthquake is generally larger than that of the other three types, and the difference of wall displacement, liquid pressure and wall effective stress under RO, R and SS focal mechanism earthquakes is small. The results show that the dynamic responses of the liquid storage tank under different focal mechanism earthquakes is quite different. Sliding isolation can significantly reduce the dynamic responses of the liquid storage tank under strong near-fault earthquakes, and the diameter of the limiting device will affect the shock absorption effect of sliding isolation.

Reverse Obliquity Intertrochanteric Fracture Treated with a Dynamic Distal Locked Intramedullary Hip Nail.

The aim of this study was to describe the clinical and radiological results of reverse obliquity intertrochanteric fractures treated with dynamic distal locked intramedullary hip nails. Patients with a reverse obliquity intertrochanteric fracture (AO/OTA type 31 A3.1 or A3.3) underwent surgical treatment with a dynamic distal locked intramedullary hip nail between August 2017 and September 2020. Fracture type, reduction quality, change in the position of the distal bone fragment, bone union, complications, and walking ability were evaluated. Ten patients with reverse obliquity intertrochanteric fractures (seven females and three males) underwent dynamic distal locked intramedullary hip nailing. The mean age was 72.0 ± 18.9 years. Two patients were classi fied as having A3.1 fractures; eight patients were classified as having A3.3 fractures. Anatomical reduction was achieved in six patients, medial displacement remained in three patients, and lateral displacement remained in one patient postoperatively. In 9 out of 10 patients, the center of the proximal end of the distal bone fragment had moved laterally between the time immediately after surgery and the time of the final evaluation. Bone union was obtained uneventfully without any additional treatments in all patients. There were no complications such as infection or implant failure. Walking ability decreased in four patients. In all patients, bone union was achieved due to good contact of the medial cortices or the migration of the distal bone fragment into the proximal bone fragment. This procedure can be an option for treating reverse obliquity intertrochanteric fractures.

TREATMENT INTERTROCHANTERIC FRACTURE OF FEMUR IN ELDERLY BY EXTERNAL FIXATION: PROSPECTIVE CASE-SERIES STUDY; IBN-SINA TRAINING HOSPITAL, BAGHDAD

Background: Internal fixation is gold standard in treatment of intertrochanteric fractures, but in patients with anesthesia or surgical hazards the external fixation should be explored as a safe approach to reduce operative time and complications risk. Objective: To assess the outcome of external fixation of an intertrochanteric fracture is in elderly patients with co-morbidities. Methods: Twenty-eight elderly patients with non-pathological fractures, closed, who were 65 years old or older, unsuited for surgery for a long period, and had chronic uncontrolled medical problems such as hypertension, diabetes mellitus, or heart disease were included in the study. Criteria for exclusion include reverse obliquity fractures, dementia, pathological fractures and prior hip fractures. Those patients treated with percutaneous external fixation under image intensifier from 2015 to 2020 in Ibn Sina Training Hospital in Baghdad. Results: At 1-year follow-up, 80% returned to pre-fracture ambulatory status. Average time to fixator removal was 12 weeks. There were no cases of pin loosening, breakage, or penetration of femoral head. All patients were evaluated clinically and radiologically for 24 months except 3 patients, 2 died 6 months’ post-operative due to causes unrelated to the surgery, and 1 lost follow up 3 months after surgery. Excellent and good results were found in 8 patients. The time of radiological union and fixator removal about 12 weeks. Pin tract infection occurred in most of the patients. Varus malalignment occurred in 20% of patients. Shortening ranged from 0 to 3 cm. Conclusion: External fixation of intertrochanteric fractures in elderly high-risk patients is a dependable, successful, and safe therapeutic option. Keywords: Intertrochanteric fracture, external fixator, elderly patient Citation: Alsudany FKI, Alhamashi AHS, Al-Abbody HHT, Ismael HA. Treatment intertrochanteric fracture of femur in elderly by external fixation: prospective case-series study; Ibn-Sina Training Hospital, Baghdad. Iraqi JMS. 2022; 20(1): 113-120. doi: 10.22578/IJMS.20.1.15

Sliding Hip Screw and Side Plate for Intertrochanteric Hip Fractures.

The sliding hip screw procedure can be divided into (1) preoperative planning; (2) patient positioning; (3) C-arm setup; (4) closed reduction of fracture; (5) sterile preparation and draping; (6) lateral hip approach; (7) guide pin insertion; (8) triple-reaming the proximal aspect of the femur; (9) sliding hip screw insertion into the femoral neck and head; (10) side plate insertion, engaging the sliding hip screw, and fixation to the femur; (11) lag compression screw insertion (if appropriate); and (12) final fluoroscopic images and wound closure. Intertrochanteric hip fractures must be surgically treated to avoid morbidity and increased risk of mortality. Nonoperative treatment is occasionally indicated in nonambulatory patients or those with high perioperative risk. If treated surgically, a common alternative implant option includes the intramedullary nail. Finally, for severely comminuted fractures or failed internal fixation, total hip arthroplasty may be necessary. Sliding hip screws are as effective as intramedullary nails and often less costly6. In general, the quality of fracture reduction is more critical than the choice of implant7. A prospective study found no significant difference in walking ability with either sliding hip screws or intramedullary nails for stable intertrochanteric fractures8. By 6 months, the majority of fractures will have healed; according to a prospective randomized study, 91% of stable fractures and 85% of unstable fractures had achieved radiographic union by that time9. Another study showed radiographically healed fractures in all 106 patients treated with sliding hip screws at median follow-up of 13.6 months8. Watch out for comminution of the greater or lesser trochanter, which may require supplemental fixation.Prior to completely reflecting the vastus lateralis muscle, control the bleeding from any perforators with use of 2-0 silk ties. This prevents recurrent bleeding, which often occurs if only cautery is utilized to coagulate these vessels.Utilize a 4.5-mm drill hole in the lateral cortex of the femur in order to allow for minor adjustments of the anterior femoral neck guide pin; otherwise, the pin will be held tightly and continue to be bound in the same direction by the lateral cortex on repeated attempts.If the guide pin is inadvertently withdrawn along with the reamer after reaming, a lag screw may be placed backward in the newly reamed hole and the guide pin passed back through the lag screw to reposition it.Extracapsular hip fractures should be carefully scrutinized for signs of instability, such as lateral wall comminution or reverse obliquity. The fracture may displace posteriorly when the patient is supine on the fracture table.While placing the guidewire, multiple entry attempts can weaken the lateral cortex and propagate the fracture into the subtrochanteric region.Superior placement of the lag screw results in poor tip-apex distance and a higher chance of screw cut-out.Be careful to prevent guidewire penetration into the hip joint.Loss of reduction or femoral head malrotation may occur during lag screw insertion. AP = anteroposteriorfx's = fracturesIMN = intramedullary nailIV = intravenousPDS = polydioxanone sutureSHS = sliding hip screwTFL = tensor fascia lata.

Fracture reduction has a dominant effect over cerclage wiring in increasing stiffness of intertrochanteric OTA/AO 31-A3.1 (reverse oblique) fractures managed with cephalomedullary osteosynthesis.

Objectives:To investigate the mechanical properties of cephalomedullary nailing of intertrochanteric OTA/AO 31-A3.1 (reverse oblique) fractures and to test the hypothesis that anatomical reduction and augmentation with cerclage wire produces a more stable construct.Methods:A standardized fracture model in composite saw bone was created to stimulate an intertrochaneric 31-A3.1 fracture, using a 3D printed cutting guide. Simulated osteosynthesis was performed with 12 femurs divided into anatomically reduced and varus malreduced groups. Each femur was tested with and without cerclage wire augmentation. All femurs were fixed with a 215 mm, 130 degree, 11.5 mm nail. An Instron 8874 biaxial materials testing machine was used to assess the axial stiffness. Cyclic loading consisted of 5000 cycles of sinusoidal combined axial-torsion loading at 3 Hz. Axial load was 100 N to 2000 N and torsion −4.5 Nm to +4.5 Nm. Stiffness was measured before and after cyclic loading.Results:Reduced constructs were stiffer than residual varus constructs. The mean overall fracture stiffness was 508.7 N/mm for reduced constructs and 379.2 N/mm for varus constructs. Removing the cables significantly decreased the fracture stiffness for both constructs (mean difference 60.0 N/mm, 95% CI 7.7–112.3, P = .032).Conclusions:Anatomical reduction has a dominant effect on facture stiffness. Anatomically reduced fractures are stiffer than varus malreduced fractures. A cerclage wire further improves construct stiffness if anatomical reduction is achieved. Cerclage wiring is less effective if anatomical reduction is not achieved.

Implant fracture of the TFNA femoral nail

BackgroundThe TFNA (Trochanteric Fixation Nail Advanced) Proximal Femoral Nailing System (DePuy Synthes) is frequently used for intramedullary fixation of proximal femoral fractures. The aim of this study was to evaluate all TFNA implant fractures at a UK trauma unit to ascertain any patient or surgical factors associated with implant failure. MethodsA retrospective study was carried out identifying all patients that sustained a TFNA implant fracture over a five-year period. Data was collected on demographic information, ASA, co-morbidities, mechanism of injury, fracture pattern according to the AO/OTA classification, procedure details and time to failure. Radiographs were assessed by two independent reviewers to identify tip-apex distance (TAD), calcar TAD, reduction quality and union status at time of implant failure. ResultsSix cases were identified, all with implant breakage at the aperture for the proximal screw. All femoral fractures were intertrochanteric reverse obliquity type (OA/OTA 31A3). Two were traumatic fragility fractures and the remainder atraumatic. Mean time from index surgery to revision was 441 days (104–963). Mean TAD was 20.5 mm (15–24) and mean calcar TAD 24 mm (18–32). All six cases displayed radiographic non-union at the time of implant fracture. ConclusionPathological fractures resulting in reverse obliquity type fracture patterns and subsequent non-union appear to be contributory factors to TFNA breakage at the proximal screw aperture. This may be further exacerbated by alterations to the nail design from previous generations. In these patients, close follow up with clinical and radiographic surveillance should be employed. Further biomechanical and clinical studies are required to compare this finding against other nail designs.

SHORT VS LONG PROXIMAL FEMORAL NAIL IN UNSTABLE INTERTROCHANTERIC FRACTURES OF FEMUR

BACKGROUND; The current methods of treatment of Inter Trochanteric fractures of femur are either DHS plating for a stable Intertrochanteric fracture or a Proximal Femoral Nail for an unstable IT fracture. There are increased surgical demands and complications associated with Unstable IT fractures. Fracture patterns like –Posteromedial large separate fragment, Basi cervical pattern, Reverse obliquity pattern, Displaced and/or avulsed greater trochanter, Lateral wall fractures pose challenges before operating surgeon. Failure to reduce the fracture before internal xation and failure to hold the reduction till denitive xation are the most frequent causes of poor results irrespective of the implant used for xation. . Present surgeon's usual preference is towards long PFN. There is an added advantage of increased stability due to splinting of the whole length of femur with the use of long PFN. However there are times where short PFN is preferred over long one when there is a mismatch of curvature between the nail and the femur. However, there is no pre-established treatment choice protocol in choosing long nail or short nail for trochanteric fractures, but many surgeons are reluctant to use short proximal femoral nails biased by literature showing more fracture rates with short PFN usage and with a belief that long nails can avoid stress risers in the diaphysis and make peri- prosthetic fracture rates acceptable. Some of the drawbacks of long PFN include increased operative duration, reaming of the medullary canal distally, unavailability of distal locking jig, leading to prolongation of distal locking time and exposing the surgical team to more radiation. Stacking the above facts the study tried to verify these in the practical scenario. The study was conducted at the department of orthopaedics Andhra Medical College Visakhapatnam Andhra Pradesh. Salvage procedures like Dimon osteotomy and Sarmiento osteotomy were not entertained in the present study.This effectively limits the study to cephalomedullary xation of un stable per trochanteric fractures with short and long Proximal Femoral Nail. METHODS: Study design: Hospital Based Comparative study. Study period: October 2017 to September 2019. Sample size: 30 (N=30, Short PFN-15, Long PFN-15) The study population was randomly divided into 2 groups with 15 patients in each group. Group S (odd): The patients who were operated with Short Proximal Femoral Nail. Group L (even): The patients who were operated with Long Proximal Femoral Nail. RESULTS Thirty cases of unstable inter-trochanteric fractures treated with reduction and internal xation with long or short proximal femoral nail were studied. In the present study minimum age was 29 years and maximum age was 75 years. Majority of the patients were between 51 to 70 years of age. Mean age for long PFN was 52.83 +/- 10.33 SD years, (Range 29-70). Mean age for short PFN was 58.16 +/- 13.94 SD years, (Range 35-75). In the present study males predominate females with a male to female ratio of 3:2. CONCLUSION We conclude that both short and long nails appear acceptable for use in unstable inter-trochanteric fractures. A reduction in operative duration and reduction in blood loss, which translates into a reduced blood transfusion requirement more importantly signicant reduction in image intensier exposures seen with short PFN makes it a surgeon friendly implant. We prefer long PFN for xation of unstable trochanteric fractures with osteoporosis so as to splint the whole femur.

Tectonic significance of the Virgin River shear zone of the Canadian Shield and implications for the origin of the Snowbird tectonic zone of Laurentia

The northwest-dipping Virgin River shear zone is part of the Snowbird tectonic zone, which divides the Churchill Province into Rae and Hearne subprovinces. Although Archean rocks are juxtaposed along most of the Snowbird tectonic zone, the Virgin River shear zone separates Paleoproterozoic intermediate orthogneiss from Archean orthogneiss of granitoid composition. Paleoproterozoic supracrustal rocks of the Virgin schist group core the shear zone. Kinematic indicators suggest that the oldest displacement in the northwest-dipping shear zone was reverse oblique. The shear zone was stitched by ca. 1830–1820 Ma granite plutons, which were deformed during reactivation of the structure.Very few modern age determinations are available for fundamental rocks internal to the Virgin River shear zone, with the exception being the youngest granite. Five rock samples were collected from within the structure for U-Pb zircon geochronology. Detrital zircon geochronology suggests that the previously undated metasedimentary rocks of the Virgin schist group were deposited after ~2150 Ma. A sample of leucotonalite collected metres from outcrops of Virgin schist group but with unclear contact relationships yielded a crystallization age of 3133 ± 14 Ma and a Sm-Nd depleted mantle age of 3.48 Ga. This rock is likely an equivalent of the Paleoarchean to Mesoarchean Chipman tonalite that is exposed directly along strike to the northeast. A sample of diorite from the Virgin River shear zone has a crystallisation age of 1940 ± 7 Ma with a 2.70 Ga Sm-Nd depleted mantle age. The sample could represent part of a previously unrecognised volcanic arc. Late tectonic granite that stitched the Virgin River shear zone has ca. 1820 and 1830 Ma crystallisation ages. A sample of granite that lies in the Snowbird tectonic zone beneath the Athabasca Basin to the northeast yielded an imprecise age of ca. 1833 ± 31 Ma, consistent with the previous ages, and a 3.48 Ga Sm-Nd depleted mantle age.Given that the Virgin River shear zone cross cuts 1.940–1.925 Ga gneissic fabrics contained in Paleoproterozoic plutonic rocks of the Rae subprovince, the age of the shear zone must be younger than this fabric. The strain recorded along this boundary, coupled with the drastic change in geology across it, support the notion of a collisional Snowbird orogeny along the Virgin River shear zone at ca. 1.90 Ga.

A comparative mechanical study of two types of femur bone implant using the finite element method.

The femoral bone fracture is one of the most common fractures that orthopedic surgeons deal with. These fractures are associated with a significant percentage of death due to non-orthopedic complications. For this reason, it is necessary that the surgeon be well-aware of the condition of the patient and also of the biomechanical conditions of the bone and implant before surgery, in order to use the best surgical technique. Nowadays, the use of implants is a popular technique among the available methods for the treatment of femoral fractures. In the present study, two patients with different ages, three types of femoral bone fractures, that is, oblique, reverse oblique, and neck fracture, and two types of implants, namely, the dynamic hip screw (DHS) and the Gamma nail have been investigated. The behavior of the implants has been investigated at the two stages of treatment, that is, before and after bone union. The analysis of implants was based on the amount of stress and displacement induced in different parts of the bone and the implant. From the viewpoint of the stresses induced in the bone, all models are quite similar and in terms of the implant stresses, the Gamma nail is more reliable than the DHS. Additionally, the relative displacement of the fractured bone segments at the fracture planes was calculated. According to the obtained results, it can be concluded that the relative displacement of the fracture planes with the use of Gamma nail is somewhat less than the DHS, but this difference is not significant.