Stable Intertrochanteric Fractures Research Articles

Comparison of Extramedullary and Intramedullary Implants for Stable Intertrochanteric Fractures: Have We Swung the Pendulum Too Far the Other Way?

Although intramedullary implants are commonly used to treat stable intertrochanteric (IT) fractures, there is a lack of evidence to demonstrate their superiority over extramedullary implants in treating these fractures. The purpose of this study was to compare short-term outcomes (<30 days) between intramedullary and extramedullary implants in patients with closed nondisplaced stable IT fractures. Patients with closed nondisplaced stable IT fractures were identified from the American College of Surgeons National Surgical Quality Improvement Program database between 2016 and 2019. Patients who either underwent extramedullary implant or intramedullary implant fixation were selected for this analysis. Postoperative outcomes included transfusion, surgical complications (stroke, myocardial infarction, venous thromboembolism, pneumonia, renal failure/insufficiency, surgical site infection, urinary tract infections, and sepsis), weight-bearing on postoperative day 1, discharge destination, place of residence at 30 days after the operation, days from operation to discharge, readmission related to the index procedure, any readmission, revision surgery, and mortality. Of the 3,244 cases identified for the study, 2,521 (77.7%) underwent intramedullary nailing (IMN). Based on adjusted multivariable analysis, surgical complications between the two intervention groups were not statistically significantly (odds ratio [OR] 1.142; confidence interval [CI], 0.838 to 1.558; P = 0.4). However, patients who underwent IMN were associated with higher rates of blood transfusions (OR, 1.35, CI, 1.042 to 1.748, P = 0.023), more likely discharged to a place other than home (OR, 1.372, CI, 1.106 to 1.700, P = 0.004), and more likely to get readmitted (OR, 1.783, CI, 1.157 to 2.75, P = 0.009). Patients treated with IMN were associated with lower postoperative length of stay (OR 0.982, CI 0.967 to 0.998, P = 0.030). Our study found that extramedullary implants were associated with lower transfusions rates, lower readmissions, and better patient disposition. We recommend surgeons to consider extramedullary implants when treating stable IT fractures, especially if the patient is anemic or at high risk for hospital readmission. Level III. Retrospective cohort study.

Minimally invasive versus conventional fixation of stable intertrochanteric fracture by dynamic hip screw – A prospective study comparing the two techniques

Background: Intertrochanteric fractures of femur are one of the most common fractures encountered in the elderly population. Dynamic hip screw (DHS) with a side plate is the standard modality of treatment especially in the case of stable fractures because it creates a controlled collapse at fracture site, leading to union. A comparative study between minimally invasive surgical technique with the conventional surgical technique for the fixation of intertrochanteric fractures with the DHS device was done. Methods: Thirty patients with stable intertrochanteric fractures (31A1.1, 31A1.2, and 31A1.3) were treated with the conventional open technique and another thirty with a new minimally invasive technique. Patients in both groups were followed up for at least 9 months. Results: There was less preoperative and postoperative blood loss, less soft-tissue destruction, less pain postoperatively, shorter hospital stays, and early mobilization and faster union with the minimally invasive technique. Conclusion: The study concludes that minimally invasive technique is superior to conventional (open) DHS in stable fractures.

Does Fracture Severity of Intertrochanteric Fracture in Elderly Caused by Low-Energy Trauma Affected by Gluteus Muscle Volume?

PurposeThe aim of this study was to determine whether there is a correlation between the type and stability of intertrochanteric fractures caused by low-energy trauma and gluteus muscle volume.Materials and MethodsA total of 205 elderly (>65 years) patients with intertrochanteric fractures caused by low-energy trauma treated from January 2018 to December 2020 were included in this study. The mean age of patients was 81.24 years (range, 65-100 years). Fractures were classified according to the Jensen modification of the Evans classification. The cross-sectional area of the contralateral gluteus muscle (minimus, medius, and maximus) was measured in preoperative axial computed tomography slices. An analysis and comparison of age, body mass index (BMI), weight, height, and the gluteus muscle area in each fracture type group was performed.ResultsIn the uni-variable analysis, statistically significant taller height was observed in patients in the stable intertrochanteric fracture (modified Evans 1 and 2) group compared with those in the unstable intertrochanteric fracture (modified Evans 3, 4, and 5) group (P<0.05). In addition, significantly higher BMI-adjusted gluteus muscle area (gluteus muscle area/BMI) was observed for the stable intertrochanteric fracture group compared with the unstable intertrochanteric fracture group except for the BMI-adjusted gluteus minimus area (P=0.112). In multivariable analysis, only the BMI-adjusted gluteus maximus (P=0.042) and total gluteus areas (P=0.035) were significantly higher in the stable group.ConclusionGluteal muscularity around the hip, especially the gluteus maximus, had a significant effect on the stability of intertrochanteric fractures.

Cost-effectiveness analysis of short versus long cephalomedullary nails for treatment of stable intertrochanteric femoral fractures: a theoretical cohort study: Erratum

Cost-effectiveness analysis of short versus long cephalomedullary nails for treatment of stable intertrochanteric femoral fractures: a theoretical cohort study: Erratum

Prospective study of Intertrochanteric femur fractures managed with proximal femoral nailing

Background: Elderly patients with a minor fall can sustain a fracture in this area because of debilitated bone due to osteoporosis or pathological fracture and this account for 90%. Benefits of intramedullary devices like PFN include preserved blood supply to the bone fragments, less operative blood loss and less disruption of the environment. The study was conducted to determine the union rate, functional outcome and the complication in intertrochanteric fractures treated by PFN. Materials and Methods: A prospective observational study on 30 patients with intertrochanteric fractures were done at a tertiary care centre between April 2018 to March 2019. All patients were managed by proximal femoral nail. The patients were evaluated radiologically and functionally. The radiographic evaluation was done for a minimum of three cortices union on anteroposterior and lateral views. The functional evaluation was done on the basis of Harris Hip Score (HHS).Results: The results of the treatment of stable intertrochanteric fractures using Proximal Femoral Nail were assessed by Harris Hip Score system. Most of the patients were having fair to excellent outcome.Conclusion: we consider that the PFN is a highly accepted minimally invasive implant for unstable proximal femoral fractures but future modification of the implant to avoid Z-effect phenomenon, careful surgical technique and selection of the patients should further reduce its complication rate. Early post-operative ambulation and physiotherapy improves the results of PFN.

Assessment of Usefulness of CT Scan in AO Classification of Intertrochanteric Fractures: A Prospective Observational Study.

The sliding hip screw (SHS) is the gold standard for the management of stable intertrochanteric (IT) fractures. However, intramedullary implants are now being increasingly used for management of unstable IT fractures especially those with a compromised or vulnerable lateral wall. Therefore, accurate classification of fracture is important to ensure proper surgical planning and choice of implant. The AO classification for IT fractures is based on plain radiographs alone and many authors have reported it to have poor inter- and intra-observer agreement. Therefore, the objectives of the study were to assess the improvement in inter- and intra-observer agreement of the AO classification after addition of CT scan to plain radiographs, to assess the change in pattern of AO classification on addition of CT scan to plain radiographs and to assess percentage of times, stable lateral wall seen on plain radiographs is classified as unstable or broken on CT scans. Fifty-four patients of intertrochanteric fracture were included in study. Plain radiographs of patients were shown to three orthopedic surgeons. They were asked to document the AO classification of the fracture, and comment on the integrity of the lateral wall. Then, CT scans with 3D reconstructions of the same patients were provided along with the radiographs and they were asked to classify the fracture again. Inter- and intra-observer agreement of the AO classification based on plain radiographs alone and once CT scan with 3D reconstruction was added to the plain radiographs was determined using Kappa coefficients. Pattern of change in classification on addition of CT scan to plain radiographs was also assessed. The mean kappa value for inter- and intra-observer agreement for AO classification on plain radiographs alone were 0.58 (moderate) and 0.66 (substantial), respectively. Upon addition of CT scan to plain radiographs, both improved to 0.70 (substantial) and 0.77 (substantial), respectively. The AO classification of the fracture changed 28.70% times (93 of 324 observations) upon addition of CT scan to plain radiographs. 96.77% times (90 of 93 observations) the classification was upgraded to higher group, while it was downgraded in only 3.22% times (3 of 93). 55.91% times this change was observed in AO 31 A 2 group (52 of 93 observations). In 17.59% cases (57 of 324 observations), fractures which were classified as stable (A1.1-A2.1) on radiographs alone, were reclassified as unstable (A2.2-3.3) upon addition of CT scan to plain radiographs. In 11.4% cases (37 of 324 observations), the lateral wall was classified as vulnerable or broken on CT scans where it was classified intact on plain radiographs. Addition of CT scans with 3D reconstructions to plain radiographs improves the intra- and inter-observer agreement of the AO classification. Addition of CT scan results in change in classification of the fracture in about one out of three cases. This most commonly happens in the AO 31 A 2 group. Most of the times, this results in the classification of fracture being upgraded. Many fractures which are initially classified as stable (A1.1-A2.1) on radiographs are reclassified as unstable (A2.2-3.3) on addition of CT scans. The lateral wall is also classified as vulnerable or broken more number of times on CT scans than plain radiographs alone. Therefore, we conclude that CT scan with 3 D reconstructions definitely helps in better pre-operative classification of intertrochanteric fractures especially in select group of fractures (AO 31 A 2) where stability and integrity of lateral wall is difficult to assess.

PROXIMAL FEMORAL NAILING VERSUS DYNAMIC HIP SCREW IN MANAGEMENT OF STABLE INTERTROCHANTERIC FEMUR FRACTURES: A COMPARISON OF CLINICAL AND RADIOLOGICAL OUTCOMES

Objective: The aim of this study was to compare the cost-effectivity, clinical and radiological outcomes of the proximal femoral nail (PFN) and Dynamic hip screw (DHS) in the management of stable intertrochanteric femur fractures (SIFFs). Material and Methods: Patients who underwent surgical treatment for a SIFF in our department were retrospectively identified and then divided into two groups according to the treatment modality: Group 1, 57 patients (36 female, 21 male; mean age = 74.5±9.9 years) treated with PFN and Group 2, 65 patients (34 female, 31 male; 72±10.2 years) treated with DHS. Primary outcome measures were: estimated blood loss (EBL), total operating time (TOT), duration of hospital stay (DHS), rate of postoperative complication, rate of mortality, and treatment cost. Radiographic assessment included anteroposterior/lateral tip-apex distance (TAD) and amount of limb length discrepancy (LLD). Results: No significant differences were observed in demographic characteristics between the two treatment groups (p&gt;0.05). The mean follow-up was 44.2±31 months in group 1 and 53.7±38 months in group 2 (p=0.077). The mean TOT and EBL were significantly shorter in group PFN than in group DHS (p&lt;0.001 and p=0.03). No significant difference was observed in the mean duration of hospital stay, rate of postoperative complication, rate of mortality, and treatment cost between the two treatment groups (p&gt;0.05). The post-operative complication rate was 9.5% in group PFN and 8.3% in group DHS, with no significant difference (p=0.83). There were significant differences in neither TAD nor LLD between the two treatment groups (p=0.69 and p=0.87, respectively). Conclusion: The two treatment modalities seem to have similar effect to maintain stability for patients with stable IFFs. However, less EBL and shorter operation time can be expected from PFN compared to DHS in such patients.

Cost-effectiveness analysis of short versus long cephalomedullary nails for treatment of stable intertrochanteric femoral fractures: a theoretical cohort study

Background: Cephalomedullary nails are the current preferred method of fixation for the treatment of intertrochanteric fractures. Both short and long nails are currently used, and physician and institutional preferences are highly variable. Methods: Literature on intertrochanteric fracture types as categorized by the AO/Orthopaedic Trauma Association (AO/OTA) 31-A1, A2, and A3, was reviewed to determine failure rates requiring reoperation and health utility values. A decision-tree baseline followed by a Monte Carlo simulation was used to determine cost-effectiveness of each nail length at an incremental cost-effectiveness ratio threshold of $100,000 per quality-adjusted life-year. Procedural costs were derived from Medicare reimbursement rates and incremental costs of long nails were calculated using primary literature. Results: The model demonstrates short nails to be the more cost-effective implant. At the mean incremental long nail cost of $1,950 the short nail had an incremental cost-effectiveness ratio greater than $100,000/quality-adjusted life-year when the secondary fracture rate of short nails was at the mean value of 1.5%. At a short nail fracture rate greater than 2.4%, long nails were more cost-effective. In our theoretical cohort, a probabilistic sensitivity analysis demonstrated the short nail to be the cost-effective method 70% of the time at a willingness to pay of $100,000. Conclusions: Given the current reported failure ranges, short nails are the more cost-effective approach for the treatment of stable intertrochanteric femoral fractures. These conclusions are highly sensitive to the secondary fracture rate, which could confound our analysis because of limitations in length and quality of follow-up in the available primary literature. Level of Evidence: Level III.

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.

Stable intertrochanteric hip fracture fixation: Device choice does not impact cost of care

Introduction There are over 300,000 hip fractures in the U.S. annually. Hip fractures create a substantial health and economic burden, with one-year mortality after a hip fracture approaching 30% and hip fractures creating healthcare costs of over $12 billion annually. Stable intertrochanteric hip fractures can be treated with either an extramedullary implant (sliding hip screw, SHS) or an intramedullary nail (IMN), which has a higher hardware cost. This study compared the cost of care between patients treated with IMN versus SHS after stable intertrochanteric hip fracture. Methods This was a retrospective cohort study of patients over age 55 with stable intertrochanteric hip fractures at a Level 1 trauma center over a 4-year period. We collected demographic information, fixation method, outcomes measures, and cost data. Statistical analysis compared patient characteristics, costs, and outcomes between SHS and IMN patients. Results 83 patients were included, of whom 57 received an SHS and 26 received an IMN. There were no differences in age, gender, BMI, and ASA score between patients who received SHS vs. IMN (p&gt;0.05 for all). There were no significant differences in mortality or readmission rates. SHS and IMN patients had no significant differences in length of stay (8.3 +/- 5.2 vs 8.0 +/- 3.5 days, p=0.76), direct costs ($22,324 +/- $10,603 vs $19,881 +/- $5,894, p=0.18), or health system profit (-$1,313 +/- $8,559 vs -$4,373 +/- $8,394, p=0.13). Discussion We compared the cost of care between patients treated with IMN versus SHS after stable intertrochanteric hip fracture. The use of IMN for the treatment of stable intertrochanteric hip fractures is controversial due to the significant cost of the implant. We found no differences in length of stay or care costs between patients treated with IMN versus SHS. Differences in implant cost were insignificant compared to the total cost of care.

Comparison of long vs short proximal femoral nailing with Intertan in stable intertrochanteric fractures

Aim: A comparative evaluation of the surgical treatment and outcome of patients with stable intertrochanteric fractures treated with long versus short INTERTAN nail. Objectives: Inter-trochanteric fractures of femur are among the most common orthopedic injury in elderly age group. Proximal femoral nailing with INTERTAN has become a popular method of stabilization of inter-trochanteric fractures in adults. stable trochanteric fractures can be treated using the conventional proximal femoral nailing method or the newly deviced proximal femoral nailing with INTERTAN nail. The present study was conducted to assess and evaluate the outcomes following treatment of stable inter-trochanteric fracture femur with long INTERTAN nail vs short INTERTAN nail.

Comparative study between proximal femoral nailing and dynamic hip screw in management of intertrochanteric fracture of femur

The PFN required significantly shorter incisions, less blood loss and operative times. The DHS group required 16sec less fluoroscopy time. Post operative complication in both group included malunion and infection, 5 malunion in DHS while 1 in PFN, 2 wound infections in DHS while 1 in PFN and 1 screw back out in DHS. Patients treated with PFN had a significantly lower pain score at the sixth month of follow up. Patient treated with DHS had more limb length shortening as compared to those treated with PFN. The outcomes of the stable fractures treated with either DHS or PFN were similar. Unstable intertrochanteric fractures, treated with PFN, had significantly better outcomes with all patients having good results. Though both PFN and DHS have similar functional outcome in stable fracture and PFN has better function outcome with unstable fractures, PFN requires shorter operative time and a smaller incision, it has distinct advantages over DHS even in stable intertrochanteric fractures. Hence, in our opinion, PFN may be the better fixation device for most intertrochanteric fracture.

English

BACKGROUND Current management of Intertrochanteric (IT) fractures has evolved with the introduction of dynamic hip screw (DHS) and proximal femoral nail (PFN). The purpose of this study was to compare the functional outcomes between the DHS and PFN for IT fracture fixation. METHODS This study is a retrospective comparative analysis of 455 patients with IT fractures; DHS (292) and PFN (163), who were treated from June 2012 to June 2015. The patients were reviewed postoperatively for a minimum of 12 months to evaluate functional outcome using Salvati-Wilson score. Categorical data was present as absolute number or percentages, and parametric variables were presented as Mean ± SD, while non parametric data were presented as median. Statistical significance was defined as P &lt; 0.05. RESULTS Intramedullary nails offer no advantage over extramedullary devices to treat IT fractures caused by low-energy trauma (AO 31 - A1). However, clinically significant outcomes were established for PFN group in terms of duration of surgery, x- ray exposure and SW Score for AO / OTA 31 - A2 and 31 - A3. Reoperations encountered for local pain due to implant prominence were significantly higher in the PFN group (4.90 % versus 1.02 %). Kaplan Meier survival probability of 69.3 % and 79.5 % predicted for DHS and PFN respectively, 3 years postoperatively. CONCLUSIONS Our conclusion reinforces indication for PFN in unstable IT fractures (31 - A2 and 31 - A3), owing to its better functional outcome and biomechanical properties. Functional outcomes for stable IT fracture (AO 31 - A1) were comparable between DHS and PFN, therefore final decision for implant choice depends on implant cost, surgeon’s preference for specific technique. However, understanding the morphology of proximal femur, peritrochanteric region is crucial to analyse the anatomical variations in Indian population which will provide the basis for intramedullary nail design modifications. KEYWORDS Intertrochanteric Fractures, DHS Fixation, PFN Fixation

A Novel Tracker-Less, Universal, Image-Based, Computer-Assisted Navigation in Orthopaedic Trauma- A pilot Study.

Computer-assisted navigation system is well-known orthopaedic advancement which allow surgeon to obtain a real-time feedback during surgeries, thus helps to reduce intraoperative errors. Currently used navigation systems are tracker based, invasive and non-universal. Therefore this study was conducted to test novel tracker-less, image-based, non-invasive, universal, real-time navigation system to predict future position of the guide wire, K wire, screws and plates in orthopaedic trauma surgeries. Firstly, the software was tested and validated on bone model. Then utilized for non-randomised comparative study conducted on 81 adult patients with stable intertrochanteric fracture treated by dynamic hip screw and barrel plate fixation. In one group, C-arm was used and in other, software navigation was used in addition to C-arm. Parameters such as time to insertion, number of C-arm shoots and number of attempts for guide wire insertion were documented and compared. Use of the navigation software for guide wire positioning in bone models and in the DHS barrel plate surgery proved to be significantly beneficial as compared to not using navigation. Intraoperative use of this new navigation system eliminates trial and error improving accuracy and reducing the operative time and radiation exposure. Thus this novel trackerless, C-arm image-based navigation system have potential to replace existing tracker-based navigation systems because of its universal nature, noninvasive and more effective properties.

Comparative study of short proximal femoral nail versus long proximal femoral nail in the management of stable intertrochanteric fractures

Aim: This study is intended to compare the clinical outcome of short proximal femoral nail vs long proximal femoral nail in the management of stable intertrochanteric fractures.Methods: This is a prospective comparative study of 40 cases of fresh stable intertrochanteric femur fractures admitted to Sanjay Gandhi Institute of Trauma and Orthopedics Bangalore between December 2018 to September 2019. The study population were randomly divided into 2 groups with 20 patients in each group. Group A: The patients who were operated with Short Proximal Femoral Nail. Group B: The patients who were operated with Long Proximal Femoral Nail. Cases were considered according to inclusion and exclusion criteria. Results were evaluated by fracture union on X-ray and Modified Harris hip score.Results: In our series, majority of the cases in short PFN group were males, i.e 15 (75%) and equal population of males and females in long PFN group, maximum age of 80 years and minimum age of 18 years, most of the patients were between 40 to 60 years. Mean age of 55.6 years in short PFN group and 56.6 in long PFN group, 85% of cases were admitted due to slip and fall. Functional outcome was evaluated by Modified Harris hip score at 3 months,6 months and 1 year follow up. In short PFN group 9 (45%) patients had excellent outcome, 8 (40%) patients had good outcome, 2 (10%) patients had fair outcome, 1 (5%) patient had poor outcome. In long PFN group 8 (40%) patients had excellent outcome, 9 (45%) patients had good outcome, 3 (15%) patients had fair outcome. Conclusion: Use of Long PFN has advantages over short PFN in terms of the less postoperative complications like peri implant fracture and anterior thigh pain & better functional outcome. The terms of successful outcome include a good understanding of fracture biomechanics, proper patient selection, good preoperative planning and accurate instrumentation.

Morphological variations in proximal femoral nails in Indian scenario and its clinical application

Background: There is an increasing trend of use of cephalomedullary nail for the management of both stable and unstable intertrochanteric and subtrochanteric femoral fractures. Various western and Indian proximal femoral nails with different morphologies are available in Indian market that sometimes creates confusion amongst orthopedic surgeons about which nail to be preferred in different clinical scenarios for accurate outcomes. Material and Methods: Ten different types of long femoral nails with 10 mm diameter (5 Western and 5 Indian) available in Indian market were taken and the morphology of these were studied and compared for 9 parameters. Results: A lot of variation was seen amongst the Indian nails and western nails in proximal diameter, shape of proximal part of nail, distance of lag screw from tip, distance at which actual size of nail becomes 10mm, M-L angle (medio lateral angle), shape of nail shaft, configuration of distal screws, morphology of neck screw and centrum-collum –diaphyseal (CCD) angle. Conclusion: Design of a nail may prove to be superior in some type of patients and fractures but may not be suitable for others. Pre-operative templating is must and surgeons need to consider all the factors in unison while deciding the type of nail to be used. Keywords: Intertrochantric fractures, Proximal femoral nail.

The Efficacy of Suture Fixation of the Greater Trochanter in Unstable Intertrochanteric Fractures.

BackgroudIntertrochanteric fractures are one of the most common fractures in the elderly, especially those having osteoporosis. Stable intertrochanteric fractures may be fixed with implants including the dynamic hip screw and proximal femoral nail antirotation; however, this method is difficult to apply to unstable fractures. Bipolar hemiarthroplasty can be applied to unstable fractures and it prevents complications by facilitating early ambulation in the elderly. Many studies reported on how to fix the greater trochanter in unstable fractures during arthroplasty. We suggest that suture fixation alone can be a useful, effective, and affordable method.MethodsWe retrospectively enrolled 294 patients who underwent hemiarthroplasty for an unstable intertrochanteric fracture, and 225 patients were included in this study after excluding 69 patients who had not been available for follow-up until 1 year after surgery or died. The patients were divided into suture fixation and wiring fixation groups. Relationships of operation time, estimated blood loss, tip-to-stem distance, union rate, and physical performance in the groups of suture fixation and wiring were analyzed respectively.ResultsChanges in the tip-to-stem distance between the initial assessment at 1 year after surgery were statistically significantly different between the suture fixation group and wiring group (p < 0.001). There was no significant difference in change of the Koval score between the suture fixation and wiring groups (p = 0.362). The operation time and estimated intraoperative blood loss were statistically significantly lower in the suture group than in the wiring group (p < 0.001). There was no significant difference in the union rate between the groups (p = 0.470).ConclusionsCompared to tension-band wiring, the suture fixation technique demonstrated an effective fixing force. In addition to the clinical results, it had an advantage of preventing complications due to shortening of the operation time and estimated intraoperative blood loss. Suture fixation of the greater trochanter is recommended for elderly patients with unstable intertrochanteric fractures.

Comparison of long vs short proximal femoral nailing with PFNA2 in intertrochanteric fractures

Aim: A comparative evaluation of the surgical treatment and outcome of patients with stable intertrochanteric fractures treated with long versus short PFNA2. Objectives: Inter-trochanteric fractures of femur are among the most common orthopedic injury in elderly age group. Proximal femoral nailing with A2 screws has recently become a popular method of stabilization of inter-trochanteric fractures in adults. Stable trochanteric fractures can be treated using the conventional proximal femoral nailing method or the newly deviced proximal femoral nailing with A2 screws. The present study was conducted to assess and evaluate the outcomes following treatment of stable inter-trochanteric fracture femur with proximal femoral nail A2 long vs short proximal femoral nail A2.

Management of intertrochanteric fractures by dynamic hip screw VS proximal femoral nail

Introduction: Inter trochanteric fractures are more common in the age group of 20 years to 60 years due to high velocity road traffic accidents, Whereas inter trochanteric fractures may also be seen in elderly people due to mild to moderate severity of trauma in addition to high velocity trauma. The management of stable intertrochanteric fractures in young and old individuals either by Dynamic Hip Screw (DHS) or by Proximal Femoral Nail (PFN) and management of unstable IT fractures by PFN in both the age groups young and old. Materials and Methods: The study is conducted in the department of orthopaedics at Shadan Institute of Medical Sciences (SIMS). A total no. of 43 patients are included in the study out of which 20 are stable fractures, remaining are unstable fractures. The mean age is 34 years (range 20-60 yrs). The mean follow up period is 34 months (12-36 months). Results: Out of 20 patients with stable fractures treated by DHS, 15 pts (%) are excellent outcome, 3pts (%) good, 2 pts (%) fair, poor result is nil. Out of 23 patients with unstable IT fractures treated by PFN, 18 pts (%) are excellent, 3 pts (%) good, 1 pt (%) fair & 1 pt (%) with poor result. Conclusion: All IT fractures which are stable in young and old patients can be treated either by DHS or PFN with satisfactory outcome and all unstable fractures in young and elderly people should be treated by PFN. Irrespective of type of fracture, fixed by PFN has got the advantage of early mobilisation and weight bearing. Keywords: Proximal Femoral Nail, Dynamic Hip Screw, Intertrochanteric fractures, Osteoporosis, Derotation screw.

Biomechanical Comparison of INTERTAN Nail and Gamma3 Nail for Intertrochanteric Fractures

ObjectiveTo compare the biomechanical stabilities of Gamma3 nail and INTERTAN nail (ITN) for stable (AO/OTA 31A1.1) and unstable (AO/OTA 31A2.2) femoral intertrochanteric fracture.MethodsTwenty‐four synthetic femora were randomly divided into four groups. After internal fixation (Gamma3 nail or ITN) had been implanted, stable and unstable intertrochanteric fracture models were produced. A cyclic testing protocol with increasing loads was performed for both stable and unstable intertrochanteric fracture models, and then torsional test and axial compression failure test were conducted. Stiffness, failure load, torque, and fragment displacement were recorded.ResultsFor stable fracture model: fragment displacement in ITN group were smaller than Gamma3 nail group (Gamma3 nail: 1.66 ± 0.13 mm; ITN: 1.55 ± 0.1 mm); stiffness (Gamma3 nail: 1142.6 ± 161.1 N/mm, ITN: 1159.3 ± 203.5 N/mm, P = 0.872) and failure load (Gamma3 nail: 5715.42 ± 616.34 N, ITN: 5690.27 ± 625.59 N, P = 0. 951) of the two nails were similar after cyclic test; torque of the ITN group was larger than the Gamma3 nail group. For unstable fracture model: fragment displacement in ITN group was significantly smaller than in the Gamma3 nail group when the axial load was larger than 800 N (Gamma3 nail: 3.59 ± 0.19 mm; ITN: 2.93 ± 0.28 mm); ITN group showed a significantly higher failure load than Gamma3 nail group (Gamma3 nail: 2942.77 ± 573.4 N, ITN: 3672.3 ± 790.5 N, P = 0. 011); torque was significantly higher for the ITN group compared to the Gamma3 nail group for three different angles.ConclusionsBoth ITN and Gamma3 nail can maintain sufficient biomechanical stability for stable intertrochanteric fractures, but ITN was a better choice for unstable intertrochanteric fractures.