Subtrochanteric Area Research Articles

Risk of complications and implant survival of surgical treatment of proximal femoral metastasis: a meta-analysis.

The patients with femoral metastasis in the inter- or subtrochanteric area could be treated with intramedullary nailing or prosthetic reconstruction, however, it is controversial which surgical treatment could offer less complications and implant failure. Our purpose was to define the risk of complications and implant survival in patients treated with intramedullary nailing or prosthetic reconstruction. We analyzed studies reporting the risk of complications, reoperations and removal of the implant in patients treated with intramedullary nailing, hemiarthroplasty, arthroplasty or megaprosthesis. We analyzed 27 studies (1346 patients) reporting patients treated with intramedullary nail (51%), hemiarthroplasty (15%), arthroplasty (2%), megaprosthesis with (25%) or without (7%) acetabular component. No difference was found in the overall risk of complications between patients treated with intramedullary nailing 6%, hemiarthroplasty or total hip arthroplasty 7% and megaprosthesis 11% (p = 0.23). However, patients treated with megaprosthesis had increased risk of reoperation due to infection (70%), compared to the patients treated with intramedullary nail (13%), and patients treated with hemiarthroplasty or total hip arthroplasty (23%) (p = 0.02). Revision due to disease progression was required in 61% of the patients treated with intramedullary nail, but not in patients treated with hemiarthroplasty, total arthroplasty, and megaprosthesis (p = 0.03). Patients treated with megaprosthesis had higher risk of reoperation due to infection, while patients treated with intramedullary nailing had higher risk of revision due to disease progression. Regarding patients treated with megaprosthesis, the risk of reoperation due to dislocation was higher in those treated with acetabular component.

Trochanteric and subtrochanteric fractures irreducible by closed reduction: a retrospective study

AimTo explore the preoperative radiographic features and reduction methods of irreducible trochanteric and subtrochanteric fractures of the femur and to compare the perioperative characteristics and prognoses of irreducible and reducible fractures.MethodsThe data of 1235 patients with femoral trochanteric fractures surgically treated in our hospital between January 2010 and January 2021 were retrospectively analyzed. According to the inclusion criteria and exclusion criteria, 1163 cases of femoral trochanteric and subtrochanteric fractures were included in this study. Fractures in which good or acceptable reduction could not be reached by closed manipulation were defined as irreducible fractures. The preoperative radiographic features, fracture displacement patterns after closed manipulation and intraoperative reduction methods used to treat irreducible fractures were analyzed, and the perioperative characteristics and prognoses of irreducible fractures and reducible fractures were compared.ResultsThere were 224 patients in the irreducible group and 939 patients in the reducible group. According to the radiographic features of fractures, irreducible fractures could be divided into four types: those with interlocking of the fracture, sagging of the femoral shaft, splitting of the lateral wall or medial wall, and comminution of the subtrochanteric area. Various kinds of reduction techniques were needed for different types.ConclusionsThe incidence of irreducible trochanteric fractures was 15.4%, while the incidence of irreducible subtrochanteric fractures was 84.6%. According to the radiographic features of fractures, they can be divided into four types. It is important to identify irreducible fractures preoperatively and make comprehensive plans to the greatest extent possible to shorten the operation time, reduce intraoperative blood loss, and reduce the incidence of complications.

Occurrence and clinical outcome of lateral wall fractures in proximal femoral fractures whose fracture line runs from femoral basal neck to subtrochanteric area.

Treatment methods for proximal femoral fractures, when the fractures run from the femoral basal neck to the subtrochanteric area, have not yet been fully reported. Thus, we aimed to clarify osteosynthesis methods based on the fracture frequency and clinical results. We classified the proximal femoral fractures using the Area classification method based on the location (area) of the fracture line. The proximal femur has 4 areas with 3 boundaries; the center of the femoral neck, the boundary between femoral neck and trochanter, and the plane connecting the lower ends of the greater trochanter and the lesser trochanter. Fractures occurring only in Area-1 (proximal from the center of the femoral neck) were classified as Type 1; those in both Areas 1 and 2 (base of the femoral neck) were classified as Type 1-2. Therefore, fractures running from femoral basal neck to the subtrochanteric area were classified as Type 2-3-4. We targeted 60 Type 2-3-4 cases (average age 81 years, 10 men, 50 women) out of 1042 proximal femoral fracture cases who visited 8 hospitals in 2 years. We investigated the presence or absence of lateral trochanteric wall fractures, the selection of internal fixator, and the proportion of poor results. The lateral trochanteric wall fracture was observed in 48% of subjects. Long nails were selected to treat 46% cases, and nails with 2 or 3 proximal lag screws were used in 58% cases. Long nails and those with 2 or 3 lag screws were also used in 59% and 69% of lateral trochanteric wall fractures. Poor results such as cutout or excessive telescoping of lag screw occurred in 11.7% of cases and 17.2% of lateral trochanteric wall fractures. Even in cases where long nails and multiple lag screws were used for femoral trochanteric fractures whose fracture line ran from the femoral basal neck to subtrochanteric area were used, the failure rate was high in the presence of a lateral wall fracture. Therefore, it is necessary to consider careful post-operative treatment for proximal femoral fractures with lateral wall fracture, whose fracture line runs from femoral basal neck to subtrochanteric area.

Bilateral Simultaneous Atypical Femoral Fracture: A Case Report

We report a rare case of bilateral subtrochanteric femoral fracture related to prolonged treatment with Alendronate.
 Introduction: Bisphosphonates are the most common drugs used for treatment of osteoporosis and prevention of the risk of osteoporosis-related fractures. Atypical femoral fractures (AFF) have been reported in patients who have been on long term treatment with bisphosphonates especially Alendronate. 
 Case Report: our case was a 68- year- old woman who sustained bilateral subtrochanteric femoral fracture after a simple falling down. She had a past medical history of osteoporosis and had been on treatment with alendronate for 5 years. Radiographs showed bilateral fractures in femur subtrochanteric area. We decided to use double plating technique and we used angled blade plate and locking plate (LCP). Alendronate was discontinued and Teriparatide was started.
 Discussion: Careful evaluation of hip or thigh pain in patients who are on prolonged courses of bisphosphonates is essential. Our method of fixation with double plating can be used in patients with poor bone quality.

Evaluation of Clinical Outcome of Subtrochanteric & Proximal Femur Fracture treated by Interlocking Intramedullary Nail with Side plate

Fractures of the subtrochanteric region and proximal femur can be especially challenging to manage, and they warrant special consideration to obtain consistently satisfactory results. The subtrochanteric zone of the femur is generally considered to include the area extending 5 cm distally from the inferior border of the lesser trochanter, or the junction of the proximal one third and middle third of the femoral shaft. Fractures that have their major displacement in this area are considered subtrochanteric fractures despite the possibility that some of them may extend into the trochanteric area proximally or the distal femoral shaft. The management of fractures of the subtrochanteric region and proximal femur has always held a particular interest for orthopedic surgeons. Biomechanically, the subtrochanteric area of the proximal femur is an area of high stress concentration, which has led to high rates of implant failures in the treatment of these fractures. Current evidence suggested that interlocking intramedullary nail with side plate offer better outcome.
 Objectives: To evaluate the operative efficacy and clinical outcome of interlocking intramedullary nail with side plate in the treatment of subtrochanteric & proximal femur fracture.
 Methods: This prospective cross sectional study was conducted in Cumilla General Hospital and private Clinics, Cumilla, from April 2018 to November 2019 among the 62 cases of subtrochanteric femur fractures. Objective of this study was to find out a safe, effective management of fracture, early mobility of patient, functional joint motion and short stay in hospital. All patients were treated by interlocking intramedullary nail with side plate. Routine follow up was carried out and outcomes were assessed. Radiographic examination was used to evaluate callus formation and fracture healing in postoperative 1, 3, 6 and 12 months follow-up. Functional recovery was evaluated by Harris Hip Scoring (HHS) system.
 Result: In this study, the mean age was 49.3±8.5 years. Among 62 cases 52 cases (83.9%) were male and 10 cases (16.1%) were female. The male and female ratio was 5.2:1. Regarding the causes of injury, out of 62 patients 50 (81%) had a history of fall from height. In 12 (19%) cases, motor vehicle accident was the cause of fracture. Average time of healing was 18 weeks. According to Harris hip score findings, 46 cases were considered as excellent in functional recovery, 11 good, 4 fair and 1 poor. The proportion of the patients with excellent and good recovery was 91.8%.
 Conclusion: Study showed interlocking intramedullary nail with side plate provides better functional outcome with early mobility of patients, and fracture unites without joint stiffness and less complication.
 Central Medical College Journal Vol 5 No 2 Jul 2021 PP 88-93

Evaluation of functional outcome of subtrochanteric fracture of femur treated surgically with long proximal femoral nail

Background: Subtrochanteric area is described as the region from the lesser trochanter to 5cm distal of proximal femur. It is one of the most challenging fractures for the orthopaedic surgeons. The cause of frequent commination is that these fractures occur at the junction of trabecular bone and cortical bone where the mechanical stress is highest. Non-Operative management of subtrochanteric femur fractures poses difficulties in obtaining and maintaining a reduction, making operative management the preferred treatment. This study is aimed to prospectively evaluate the clinical and functional outcomes of subtrochanteric fractures treated with Long PFN. Material and Methods: 24 patients above the age of 18 years with subtrochanteric fractures were included in the study. Patients were assessed clinically and radio logically at 6, 12, 18 and 24 weeks and at 9months and final follow-up was done at 1year. At each follow-up, functional evaluation of the patient was done. Results: A total of 24 patients(16 males and 8 females) were evaluated with age ranging from 18 years to 75 years with most patients in between 40-60 years; 58% of the cases were road traffic accidents, 33% due to fall from height and 9% due to trivial fall with right side being more common side affected. In our study most of the cases belong to Sensheimer type III B (25%) Mean duration of hospital stay was 12 days. Out of 24 cases, excellent results were seen in 70% of cases in our study. Conclusion: Long PFN is an effective, efficient and biomechanically stable device for the treatment of subtrochanteric fractures with a high rate of bony union and good functional outcome.

Peri-implant atypical femoral fracture after nail or plate osteosynthesis

BackgroundA lack of scientific information regarding the risk factors and diagnosis of peri-implant atypical femoral fracture (PI-AFF) exists. We report a case series of developed PI-AFF with a nail or plate construct wherein prior femoral fractures were already healed after osteosynthesis. This study aimed to identify the cause and risk factors of PI-AFF and to devise a preventive method based on this. MethodsWe identified 11 PI-AFFs displaying features of AFFs. All patients were ambulant females (mean age, 74.9 years). The mean T-score of the femur measured by DEXA (Dual Energy X-ray Absorptiometry) scan was 3.5. Osteosynthesis was performed with a plate and an intramedullary nail in six and five patients, respectively. Possible risk factors were investigated, including the used implant, the medication of bisphosphonate, the characteristics of previous fracture (AFF or non-AFF), and the co-existence of AFF on the contralateral side. ResultsThe PI-AFFs developed at an average of 6.6 years from the time of prior fracture. All fractures were located at the screw through the plate or nail. Regarding anatomic locations, seven and four fractures were at the subtrochanteric area and diaphysis, respectively. Diaphyseal PI-AFFs occurred in plating cases, all of which were associated with excessive femoral bowing. Subtrochanteric PI-AFFs included all five patients with nail fixation, which occurred near a proximal interlocking screw. Six of the 11 patients were on bisphosphonate treatment before or at the time of fracture. The duration of bisphosphonate treatment was 6 years on average. Concerning the previous femoral fractures, seven and four patients were AFF and non-AFF, respectively. Considering the pathology on the contralateral leg, eight had suffered diaphyseal AFF. Four patients were treated nonoperatively. Seven patients needed an operation; 6 of them healed after reconstruction nailing, and one needed hip arthroplasty because of the associated displaced femoral neck fracture. ConclusionsPI-AFFs may develop through the screw hole at the subtrochanteric or diaphyseal area due to femoral fragility and stress riser effect of the implant. An improved osteosynthesis strategy may be necessary to avoid PI-AFFs when fixing osteoporotic femoral fractures.

Kırk Yedi Hastada Fiksasyon veya Endoprotez ile Proksimal Femur Metastazı Tedavisi

Objective: Purpose of the present study was to compare patients with proximal femur metastasis with actual or impending fractures who were treated by fixation or prosthetic hip replacement. Method: Twenty-seven patients underwent fixation treatment (IM nail, DHS), and 20 patients prosthetic (endoprosthesis or total hip arthroplasty) replacement. Data were analyzed regarding patient demographics, cancer type, localization and type of metastasis, actual or impending fracture, number of bone metastasis, presence of spinal or visceral metastasis and treatment data (ASA class, length of hospital stay or surgery or survival, cement usage, adjuvant treatment, postoperative walking status). Results: Fixation group (63 years) was younger than prosthesis group (70 years) (p: 0.03). Fixation was more preferred at subtrochanteric area (p˂0.001). Cementation of the lesion was more preferred and surgery time was longer at fixation group (p: 0.01). Greater number of complications (mostly medical) were more likely to be seen in the fixation group (6 ‘1 loosening’ vs 3 ‘1 dislocation’). Conclusion: It is not still clear whether one implant is clearly superior to other one, however it was revealed again that nailing was mostly preferred for the subtrochanteric area and tended to have more complications although mostly medical and unrelated to implant placement as previously reported

Standalone Photodynamic Intramedullary Implants in the Treatment of Bilateral Refractory Femoral Nonunions in a Patient with Osteogenesis Imperfecta: Significant Utility in Load-Bearing Bones, But Not a Replacement for Biomechanical Optimization

A photodynamic implant is a useful modality for stabilizing intrinsically weak or osteoporotic bone defects or fractures in select patients. Advantages of these implants are their minimally invasive nature, quick annealing, and flexible accommodation of bowed medullary canals. We have determined experientially that these implants can be used successfully in the long bones of the lower extremity, even in patients with pathologic bone stock. However, creation of the appropriate biomechanical conditions for fracture healing is critical to technical success. This is evidenced in our experience managing a 30-year-old active male with osteogenesis imperfecta , who presented with chronic pain and disability after failing conventional intramedullary nailing of his left femur. He presented with distal implant cut-out and a mid-shaft stress fracture nonunion . He underwent implant removal and intramedullary stabilization using 3 photodynamic intramedullary implants. The patient healed uneventfully, returned to full weightbearing and work 1 month after surgery, and was asymptomatic 18 months postoperatively. At this time he complained of similar pain on his right side, and implant cutout and a nonunion at the apex of a large varus deformity of the subtrochanteric area of his hip was noted. A similar 3-implant photodynamic nailing was performed, but the patient began to complain of groin pain 1 month after surgery, and 2 months postoperatively was unable to weightbear. It was found that he had fractured through the nonunion. Plate fixation with deformity correction was performed, after which the patient healed uneventfully and is now being advanced to full weight bearing.

Minimal invasive plate osteosynthesis (MIPO) in fracture femur

Background The advantage of bridge plating in keeping the vascularity and the fracture healing promotes it to be widely used in comminuted fracture femur; the fracture site is not touched, the plate is inserted beneath the vastus lateralis from proximal and distal incisions away from the fracture itself, screws keep the alignment, and screws are limited only to the proximal and distal fragments. Longitudinal femoral fractures extending right to the trochanteric and or condylar areas are the main indication for minimally invasive plate fixations. Patient and methods This is a prospective study for minimal invasive plate osteosynthesis (MIPO) techniques in the treatment of the fractured femur. The study was carried out in Cairo University Hospitals from May 2009 to December 2014, on 60 patients, for an average follow-up of 3 years including 64% men (48 cases) and 36% women (22 cases), using both fixed angled plates (locked plates) in 34 cases (56%) and conventional dynamic compression plate (DCP) plates (nonlocked plates) in 26 cases (44%). Results Time taken for the union as shown by evidence of radiographic healing of the fracture was defined as the presence of callus around most of the fracture’s circumference. The fracture-healing process ranged from 9 to 40 weeks (median: 16 weeks). One (1.6%) patient suffered from malalignment in the form of varus deformity and two patients (3.3%) from malrotation within acceptable measures. None was the candidate for revision, two (3.3%) patients suffered from the shortening of insignificant value, eight cases (13.3%) suffered from the delayed union, four (6.7%) cases suffered from wound infection, and five (8.3%) cases suffered from decreased range of motion. Implant failure occurred in two cases and periprothetic fracture occurred in one case. Scoring of results according to Tegner and Lysholm was as follows: 27 cases (45%) with excellent outcome, 23 (38.3%) case with good results, 6 (10%) with fair outcome, and 4 (6.7%) with poor outcome. Conclusion The use of MIPO technique in fracture femur provides an easy, safe, and effective method of treatment especially in comminuted diaphyseal fracture with extension to the supracondylar or the subtrochanteric areas.

Treatment of hypertrophic pseudarthrosis developed in the femoral subtrochanteric area after intramedullary nail breaking – new application of the LAP system for peri-implant fractures

Treatment of hypertrophic pseudarthrosis developed in the femoral subtrochanteric area after intramedullary nail breaking – new application of the LAP system for peri-implant fractures

Management of Seinsheimer type IIB and type IIIA subtrochanteric fracture with proximal femoral nail (PFN) versus proximal femoral locking compression plate (PF-LCP): Prospective comparative study

Introduction: Seinsheimer subtrochanteric fracture of femur are important to treat and associated with high rate of complications. Among all fractures of hip upto 34% present in subtrochanteric area. Objectives: Comparison of clinical outcome in Seinsheimer type IIB and type IIIA subtrochanteric fractures treated with proximal femoral nail (PFN) versus proximal femoral locking compression plate (PF-LCP). Materials and Methods: Patients presented with Seinsheimer subtrochanteric fracture at our hospital i.e, R L Jalappa Hospital, Tamaka, Kolar, Karnataka, India between May 2018 to June 2019 among which fourty patients were included as per the inclusion criteria. In which twenty patients were treated with Proximal Femoral Nail and twenty patients with Proximal Femoral Locking Compression Plate. By using Modified Harris Hip Score results were assessed at final follow up. Results: Group PFN shows at final follow up 45% excellent outcome, 45% good outcome and 10% fair outcome whereas group PF-LCP shows 60% good outcome, 20% fair outcome and 20% poor. Conclusion: For Seinsheimer subtrochanteric fractures proximal femoral nail shows better results compared to plating group with respect to functional outcome and clinical outcome. Keywords: Subtrochanteric fracture, Seinsheimer, PFN, PF-LCP.

Incidence and Clinical Outcomes of Hip Fractures Involving Both the Subcapital Area and the Trochanteric or Subtrochanteric Area.

Purpose Proximal femoral fractures involving both the subcapital area and the trochanteric or subtrochanteric area have rarely been reported, but they are not uncommon. However, few studies have reported the incidence or clinical outcomes of such fractures. This study investigated such fractures. Methods In area classification, the proximal femur is divided into 4 areas by 3 boundary planes: the first plane is the center of femoral neck; the second plane is the border between femoral neck and femoral trochanter; and the third plane links the inferior borders of greater and lesser trochanters. A fracture only in the first area is classified as a Type 1 fracture; one in the first and second areas is classified as a Type 1-2 fracture. Therefore, proximal femoral fractures involving both the subcapital area and the trochanteric area are classified as Type 1-2-3, and those involving both the subcapital area and the subtrochanteric area are classified as Type 1-2-3-4. In this study, a total of 1042 femoral proximal fractures were classified by area classification, and the treatment methods and the failure rates were investigated only for Types 1-2-3 and 1-2-3-4 cases. The failure rate was defined as the incidence of internal fixator cut-out or telescoping >10 mm. Results Types 1-2-3 and 1-2-3-4 fractures accounted for 1.72%. Surgical treatment was performed for 89%. Of these, 56% underwent osteosynthesis, but the failure rate was 33%. The other patients (44%) underwent prosthetic replacement. Fracture lines of all these fractures were present along trochanteric fossa to intertrochanteric fossa in posterior aspect and just below the femoral head in anterior aspect. Conclusion Fracture involving the subcapital area to the trochanteric or subtrochanteric area was found in approximately 2%. In patients for whom prosthetic replacement was selected, good results were obtained. However, 1/3 of patients who underwent osteosynthesis had poor results.

Mechanical analysis of femoral stress-riser fractures

BackgroundA stress-riser fracture develops when stress in an object is higher than that in the surrounding material. The aim of this retrospective study was to evaluate all consecutive femoral stress-riser fractures during a period of >10 years and to verify high-risk factors by using mechanical analysis. MethodsForty clinical fractures caused by local stress concentration in the femoral cortical bone were included. Risk factors were analyzed, and Sawbones models were used to verify their effect. One hundred thirty-six models were divided into 6 groups to simulate clinical cases of stress-riser fractures. A dynamic test instrument was used to simulate weight-bearing on the femoral head by continuous application of increasing axial force; the lever arm was applied at a constant speed of 0.1 mm/s until a fracture developed. ResultsFemale gender (57.5%), subtrochanteric area (40%), osteoporosis (40%), and technical or surgical errors (50%) were risk factors for stress-riser fractures in clinical analysis. Cortical perforation, tiny cracks, sharp corners, and changes in hardness were the main risk factors in biomechanical aspects. Mechanical analysis identified that these factors contributed to stress-riser fractures (P = 0.000), especially cortical perforations and sharp corners. ConclusionA cortical perforation (screw hole), tiny crack (fracture line), sharp corner (bone cut), and change in hardness (tip of an implant or cement) can act as a stress riser. Screw holes are the most common and critical contributor to femoral stress-riser fractures.

Lessons Learned from Long-Term Management of Hip Fracture in Patients with Osteopetrosis: A Report of Nine Hips in Five Patients.

BackgroundTreating patients with osteopetrosis is very challenging even in very skilled surgeons with many experiences. We present an account of 5 patients treated for hip fracture related problems occurring throughout their life due to this disease. Difficulties encountered during their treatment prompted us to present some general management principles.MethodsFrom January 2003 to December 2016, 5 patients with osteopetrosis (9 hips; 3 men, 2 women), who underwent operative or conservative treatment were retrospectively reviewed. We evaluated their clinical features and rate of union, malunion and post-operative infection.ResultsFour of 5 patients (80%) suffered bilateral fracture, and 8 of 9 fractures (89%) are transverse and occurred at subtrochanteric area resulted from minor trauma. Among 9 hips, surgery was performed in seven hips. Nonunion were found in 3 hips (33%), malunion in 1 hip (11%) and oteomyelitis was developed in 2 hips (22%) at a median of 8.1 years.ConclusionsClinical features of hip fracture in osteopetrosis are very similar to atypical subtrochanteric femoral fractures. Patients should be informed of the possibilities of several anticipated complications including the risk of nonunion and infection after surgery.

Supracondylar femur fracture repair using IlluminOss in a patient with Osteogenesis Imperfecta type 4

A photodynamic implant is a useful modality for stabilizing intrinsically weak or osteoporotic bone defects or fractures in select patients. Advantages of these implants are their minimally invasive nature, quick annealing, and flexible accommodation of bowed medullary canals. We have determined experientially that these implants can be used successfully in the long bones of the lower extremity, even in patients with pathologic bone stock. However, creation of the appropriate biomechanical conditions for fracture healing is critical to technical success. This is evidenced in our experience managing a 30-year-old active male with osteogenesis imperfecta, who presented with chronic pain and disability after failing conventional intramedullary nailing of his left femur. He presented with distal implant cut-out and a mid-shaft stress fracture nonunion. He underwent implant removal and intramedullary stabilization using 3 photodynamic intramedullary implants. The patient healed uneventfully, returned to full weightbearing and work 1 month after surgery, and was asymptomatic 18 months postoperatively. At this time he complained of similar pain on his right side, and implant cutout and a nonunion at the apex of a large varus deformity of the subtrochanteric area of his hip was noted. A similar 3-implant photodynamic nailing was performed, but the patient began to complain of groin pain 1 month after surgery, and 2 months postoperatively was unable to weightbear. It was found that he had fractured through the nonunion. Plate fixation with deformity correction was performed, after which the patient healed uneventfully and is now being advanced to full weight bearing.

A review of atypical subtrochanteric femoral fractures in Northern Ireland between 2010 and 2014.

The term atypical femoral fractures most commonly occur in the subtrochanteric area. Concerns exist regarding the role of bisphosphonate treatment in their aetiology. Which surgical intervention provides the best outcome remains contentious. We reviewed all atypical subtrochanteric femoral fractures treated in Northern Ireland over 5years, specifically investigating incidence, prodromal symptoms, association with bisphosphonates and optimal fixation methods. All subtrochanteric fractures treated in the region were identified and reviewed for atypical features. Case notes and imaging were then reviewed for each patient. A total of 364 subtrochanteric femoral fractures were identified during the 5-year study period. Twenty-six of these met the criteria for an atypical fracture (7%). Thirteen patients (50%) had presented with prodromal symptoms prior to complete fracture, six of which had radiological evidence of an incomplete fracture of the lateral cortex. Thirteen patients had a history of bisphosphonate treatment. All were treated operatively, with twenty-five cephalomedullary nails and one dynamic hip screw. Twenty-one patients had follow-up for greater than 2months, nine of which (42.9%) achieved radiological union with a mean time to union of 297days. Dynamically locked nails had a higher union rate than statically locked (80% versus 33.3%). Four patients required major revision surgery (15.4%). The quality of reduction was statistically significant in predicting need for revision. Atypical fractures often present with prodromal symptoms. Complete fractures are difficult to successfully manage with longer than expected times to union. Treatment with a dynamically locked, cephalomedullary with a good reduction provided the best results.

Lateral Cortical Thickening and Bone Heterogeneity of the Subtrochanteric Femur Measured With Quantitative CT as Indicators for Early Detection of Atypical Femoral Fractures in Long-Term Bisphosphonate Users.

The objective of our study was to compare subtrochanteric femur bone mineral density (BMD) and bone quality of long-term bisphosphonate (BP) users who sustained an atypical femoral fracture (AFF) with BP users who did not sustain a femoral fracture and BP-naïve patients with no history of femoral fracture using quantitative CT (QCT). Fourteen female BP users with an AFF (mean age, 72.6 years; mean duration of BP use, 6.2 years; mean body mass index, 21.9) who had undergone QCT before fracture events were sex-, age-, BP use duration-, and body mass index-matched to 14 BP users who did not sustain a fracture and 14 BP-naïve patients. The lateral cortical thickness index (CTI) and the mean BMD (BMDmean) and SD of the BMD (BMDSD) within the lateral cortex and within the entire cross-sectional area of the subtrochanteric femur were measured on axial QCT. Femoral neck-shaft angles were measured on the QCT scout image. Parameters were analyzed using the Kruskal-Wallis test. Lateral CTIs were greater in the BP users with an AFF (median, 0.28) than in the BP users without a femoral fracture (median, 0.21) (p = 0.038) and the BP-naïve group (median, 0.21) (p = 0.009). The lateral cortex BMDSD was significantly higher in the BP users with an AFF (median, 59.59 mg/cm3) than the BP users without a femoral fracture (median, 39.27 mg/cm3; p = 0.049) and the BP-naïve group (median, 31.02 mg/cm3; p = 0.037). There was no significant difference among groups in lateral cortex BMDmean, BMDmean and BMDSD of the entire cross-sectional area, and femoral neck-shaft angle. Long-term BP users with a subsequent AFF had a thicker lateral cortex and higher lateral cortex BMDSD at the subtrochanteric area before the fracture on QCT than BP users who did not sustain a femoral fracture and BP-naïve patients.

Selection of implant based on CT evaluation of trochanteric & subtrochanteric fractures

Background: CT scan evaluation of the morphology of trochanteric & subtrochanteric fractures helps in the selection of appropriate implant for fixation of proximal femoral fractures, resulting in better surgical outcome. Materials and methods: CT scan evaluation done in 64 cases of intertrochanteric and subtrochanteric fractures since April 2012 to March2014. The fracture morphology of these fractures analyzed regarding stable or unstable fracture, integrity of posteromedial part of trochanter, severe comminution of lateral cortex of trochanter, quality of the bone based on their trabecular pattern, and fracture line extending into the subtrochanteric area. Dynamic hip screw, proximal femoral nailing, proximal femoral locking plate and cemented hemiarthroplasty were selected according to fracture morphology. Results compared with previous 60 surgically treated cases of trochanter & subtrochanteric fractures done based on the xray morphology of the fractures, for the period before April 2012. Results: 2 cases of implant penetration into the joint, 11 cases of hip screw cut out, 9 cases of varus angulations, 4 cases of implant failure with nonunion occurred of the 60 cases done with only x ray evaluation, study done from September 2008 to March 2012. After 2 years of follow up only 4 cases of nonunion occurred after implant selection for surgical treatment of intertrochanteric and subtrochanteric fractures based on CT scan evaluation. Conclusion: CT scan evaluation provides good method of choosing an implant in surgical management of trochanteric and subtrochanteric fractures.

Factors affecting fracture location in atypical femoral fractures: A cross-sectional study with 147 patients

IntroductionMany studies have tried to determine the characteristics of atypical femoral fractures (AFFs) through age-, sex-, and ethnicity-matched comparison with non-AFFs. However, we hypothesized that diaphyseal AFFs would have characteristics different from those of subtrochanteric AFFs. The aim of this study was to evaluate the clinical features of diaphyseal/subtrochanteric AFFs and determine the factors related to fracture location. Patients and methodsOne hundred forty-seven patients with AFF were enrolled, 114 patients (78%) had a history of bisphosphonate use. Forty-nine patients (33%) had bilateral lesion, and 35% of patients had thigh pain. Patients were divided into two groups according to fracture location: 52 patients (35.4%) with subtrochanteric AFF and 95 patients (64.6%) with diaphyseal AFF. The patient demographics and fracture characteristics of the two groups were compared. Multivariate logistic regression analysis was used to adjust for variables related to fracture location. ResultsThe patients in the diaphyseal AFFs group were older and had lower BMI, lower BMD, and larger lateral and anterior bowing. Multivariate analysis revealed that age greater than 65 years and low BMD were related with diaphyseal location. With greater lateral bowing angle, the AFF location was moved from the subtrochanteric area to the diaphyseal area. ConclusionThis study demonstrated that patients with diaphyseal AFFs had different characteristics compared with those with subtrochanteric AFFs.