Surgical Treatment Of Intertrochanteric Fractures Research Articles

Proximal femoral nail antirotation versus InterTan nail for the treatment of intertrochanteric fractures: A systematic review and meta-analysis.

This meta-analysis compared the efficacy and safety of Proximal Femoral Nail Antirotation (PFNA) and InterTan Nail in the treatment of intertrochanteric fractures. Given the high incidence of femoral intertrochanteric fractures in the elderly population and its impact on quality of life, choosing the most effective and safest surgical option is crucial. PFNA and InterTan are currently two commonly used techniques, but there is a lack of systematic evaluation comparing their safety and effectiveness. This study aims to fill this knowledge gap through Meta-analysis, providing clinicians with evidence-based treatment recommendations. A computer search was used to search for published literature on PFNA and InterTan in the treatment of intertrochanteric fractures in PubMed (Medline), Web of Science, Embase, Cochrane Library (CENTRAL), Cinahl, CBM, and CNKI.A total of 853 related literatures were retrieved, and 15 literatures were finally included. Newcastle-Ottawa-Scale and Cochrane systematic review methodologies were used to assess the quality of the literature. Meta-analysis was performed using Review Manager 5.4 software, following data extraction. The comparison found that during the surgical treatment of intertrochanteric fractures, the operation time, fluoroscopy time, and blood loss in the PFNA group were significantly shorter than those in the InterTan group, and the difference was statistically significant. In terms of postoperative complication rates, the InterTan group had a significant advantage over the PFNA group. Shaft fracture, varus collapse, cut out, screw migration, and pain of hip and thigh were the most likely to occur in the PFNA group, and the differences were all statistically significant. In terms of postoperative efficacy, the results of the PFNA group and the InterTan group were comparable, and there was no significant differences. When selecting surgical techniques for the treatment of femoral intertrochanteric fractures, it is necessary to conduct individualized assessments based on the patient's overall health status, surgical tolerance, and post-operative recovery needs. For patients who cannot tolerate long-term surgery or are in poor physical condition, PFNA may be more appropriate. While for patients who can tolerate long-term surgery or have more complex conditions, InterTan may be more suitable.

Comparison of Cephalomedullary Nails with Sliding Hip Screws in Surgical Treatment of Intertrochanteric Fractures: A Cumulative Meta-Analysis of Randomized Controlled Trials.

The primary objective of the present study was to compare surgical failures of intertrochanteric fractures of the femur through a meta-analysis of randomized controlled trials and to assess the change in surgical outcomes over time in a cumulative meta-analysis. To identify studies evaluating the surgical outcomes of internal fixation using sliding hip screws (SHS) or cephalomedullary (CM) nails for the treatment of intertrochanteric fractures of the femur, all records until August 2021 in the PubMed, Embase, and Cochrane Library databases were searched. Studies with the following characteristics were considered eligible: patients who had an intertrochanteric fracture of the femur (population); patients who received surgical treatment using a CM nail (intervention); patients who received surgical treatment using SHS (comparator); surgical failures that required reoperation, including cut-out or cut-through of lag screws, varus collapse or posterior angulation of proximal fragments, loosening of lag screws or helical blades, and fracture nonunion (outcomes); and two reviewers independently reviewed the titles and abstracts of the randomized controlled trials and selected relevant studies for a full-text review (study design). Twenty-one studies were included in the final analysis consisting of 1,777 cases in the SHS group and 1,804 cases in the CM nail group. The cumulative standard mean difference was 0.87, indicating that CM nails had no significant effect in improving the surgical outcomes. There was no significant difference in surgical failure between SHS and CM nails for all intertrochanteric fractures (odds ratio [OR], 1.07; 95% confidence interval [CI], 0.76-1.49). Pooled data showed no significant difference between the two groups in terms of surgical failure in unstable intertrochanteric fractures (OR, 0.80; 95% CI, 0.42-1.54). Although the use of CM nails has become a current trend in the treatment of intertrochanteric fractures, there is no literature supporting their clinical superiority when compared with SHS.

The effect of preexisting radiographic hip osteoarthritis on the functional recovery after surgical treatment of intertrochanteric fractures in elderly patients.

The aim of this study was to evaluate the effect of the grade of preexisting radiographic hip osteoarthritis on the functional outcome of elderly patients with intertrochanteric fractures treated by intramedullary fixation. We retrospectively examined the impact of the grade of preexisting osteoarthritis on the functional outcome of 88 patients older than 60 years with intertrochanteric fractures treated by intramedullary fixation. The patients were divided into 2 groups accord ing to the grade of osteoarthritis: group 1, including 52 patients (32 females and 20 males) with Kellgren-Lawrence grades 1 and 2, and group 2, including 36 patients (24 females and 12 males) with Kellgren-Lawrence grades 3 and 4. Functional outcomes were evaluated using the Harris hip score, visual analog scale, EuroQoL general health questionnaire, and the Barthel index. The mean age was 74.8 ± 5.5 (range=63-87) years in group 1 and 75.06 ± 5.3 (range=64-87) years in group 2. At the last follow-up, the mean Harris hip score was significantly higher in group 1 (71.3 ± 4.3) than that of group 2 (69.5 ± 3.5) (P=.047). There was no signifi cant difference between the groups in terms of the visual analog scale (P=.102), EuroQoL general health questionnaire (P=.144), and the Barthel index (P=.261) scores. The EuroQoL general health questionnaire and Barthel index scores were worse with increasing age. As the grade of hip osteoarthritis increases, it may adversely affect the specific hip score, but this parameter alone may not be a poor prognostic factor that affects the quality of life and daily activity level. Level III, Prognostic Study.

U-blade gamma 3 vs. gamma 3 nails for intertrochanteric hip fracture: Meta-analysis.

Intertrochanteric fracture is a growing problem in the traumatology department. The use of intramedullary devices has increased, representing the first treatment option in intertrochanteric fractures. U-Blade devices appeared to avoid rotation of the femoral head over the femoral neck. The aim of this study was to conduct a meta-analysis of the surgical treatment of intertrochanteric fractures comparing in terms of safety and efficacy the U-Blade Gamma 3 nail vs. the conventional Gamma 3 nail. A literature search for intertrochanteric fracture 31A1-31A3 according to the AO foundation/orthopaedic trauma association (AO/OTA) classification was performed. Baseline characteristics of each article were obtained; radiological outcomes were tip apex distance (TAD), sliding distance (mm), cut-out rate, and lateralization rate. Surgery time (min) was also recorded. A meta-analysis was performed with ReviewManager 5.4. Five retrospective studies (n = 993 patients) were included. With respect to TAD and sliding distance, there were no differences between two groups [mean difference (MD) 0.47, 95% confidence interval (CI), -0.46 to 1.40] and (MD 0.39, 95% CI, 0.13-0.66). The cut-out rate and lateralization rate did not show differences between two groups (p > 0.05). Finally, surgery time was significantly higher in the U-Blade Gamma 3 group (MD -4.84, 95% CI, -7.22 to -2.46). The use of U-Blade Gamma 3 did not show significant differences in the radiological results compared with the conventional Gamma 3 nail.

Relationship between Charlson comorbidity index, early recovery and 2-year mortality in elderly patients undergoing surgical treatment of inter-trochanteric fractures: a retrospective analysis

The aim of this study was to evaluate how the Charlson Comorbidity Index (CCI) scores contribute to early recovery and 2-year mortality in elderly patients undergoing surgical treatment of inter-trochanteric fractures. 60 cases with unilateral intertrochanteric fracture were retrospectively analyzed and divided into Low-CCI group (CCI: 1–4) or high-CCI groups (CCI: 5–6). All the patients’ electronic hospital records were reviewed. The preoperative situations (demographic data, comorbidities and fracture conditions), perioperative situations (wait time, operation time, implant choice, blood loss, transfusion or not) and postoperative situations (complications, first time out of bed, function about 1-/2- week and 2-year mortality) were recorded. 51.67% were in low-CCI group and 48.33% in high-CCI group. The survival rates in low- and high-CCI group were 93.5% and 86.2% respectively. According to the functional results of 1- or 2- week after operation, no significant difference was found (P = 0.955, 0.140). Log-rank analysis showed that the main prognostic factors were blood loss, first time out of bed and complication (P < 0.05). Multivariate analysis confirmed that complication and first time out of bed were significant factor on survival rate (P = 0.029, 0.010). Charlson comorbidity index maybe not the indicator of 2-year mortality in older patients with intertrochanteric fractures. In order to improve the prognosis, more attentions should be paid to reduce the complications and encourage postoperative earlier excise out of bed.

Evaluation of the quadrants of femoral neck-head in the cephalomedullary fixation of intertrochanteric fractures with a helical blade: Is inferior posterior quadrant also safe? A clinical study.

Objectives This study aims to investigate the positioning of the helical blade to prevent mechanical complications in surgically fixed intertrochanteric fractures (ITFs).Patients and methods In this retrospective study, 392 patients (158 males, 234 females; mean age: 75.5±13.4; range, 20 to 101) years) with ITFs treated in lateral decubitus position with proximal femoral nail anti-rotation in a single center between January 2009 and January 2017 were evaluated. The fractures were classified according to the Orthopedic Trauma Association classification preoperatively and grouped as stable or unstable. Postoperatively, tip-apex distance (TAD), Baumgaertner reduction criteria, and obtained quadrants were evaluated. Patients with an unstable fracture, proper TAD, and acceptable or good reduction were included in the final evaluation for statistical analysis to investigate the safest quadrant to prevent cut-out complication.Results Cut-out complications were observed in 19 (4.8%) patients. The scenario; unstable fracture, TAD <25 mm, acceptable or good reduction consisted of 111 patients in total and cut-out complication occurred in four of them (3.6%) (one in center-posterior, one in center-center, one in superior-anterior, and one in superior-center quadrants). There was no statistically significant difference between center-center, inferior-center, and inferior-posterior quadrants (p=0.49).Conclusion Inferior-posterior placement is as safe as central-central or inferior-central placement for blade fixation in the surgical treatment of ITF.

A comparative study of surgical management of intertrochanteric fractures using dynamic hip screw (DHS) and proximal femoral nail (PFN)

Intertrochanteric fractures are common fractures seen in patients over 60yrs of age, mostly due to trivial trauma. Incidence has increased primarily due to increasing life span & more sedentary life style brought by urbanization. As conservative methods resulted in higher mortality rates and complications, Stable Internal fixation and early mobilization has been the standard method of treatment. DHS with side plate assembly is most commonly used device for fixation of intertrochanteric fractures, The latest implant for management of intertrochanteric fracture is PFN. This implant is a cephalomedullary device and has many potential advantages. In view of these conditions, this study is taken up to compare the results of DHS and PFN in the treatment of intertrochanteric fractures. Studies have shown that when compared to DHS, PFN had certain advantages. Aims and objectives: To compare surgical treatment of intertrochanteric fractures of femur with PFN and DHS with respect to fluoroscopic time, duration of surgery, post operative shortening and functional outcome.

Description of a minimally invasive technique with a modified instrument for the osteosynthesis of proximal femoral fractures using the standard DHS and case series

ABSTRACT Introduction: the number of hip fractures is estimated to increase from 1.66 million in 1990 to 6.26 million by 2050. Internal fixation is the most common surgical treatment for intertrochanteric fractures. Objectives: the objective of the present research is to describe a minimally invasive technique with a modified instrument for the treatment of stable proximal femoral trochanteric fractures using the standard DHS, classified as Tronzo types 1 and 2 (AO 31A1.2), and presenting a case series. Methods: a case was selected to present the technique. Patients operated by this technique undergo a clinical evaluation and preoperative preparation as routine. The criteria for inclusion in the study were the presence of stable fracture of the proximal femur verified by two hip specialist orthopedists, and operated by the minimally invasive technique with a modified instrument using a standard DHS. Exclusion criteria were cases of patients operated for unstable fractures, and the use of other surgical techniques. A case series of 98 patients was performed and discussed. Results: minimally invasive technique with a modified instrument using the standard DHS device can reduce bleeding, it decreases soft tissue injuries, surgical time, and hospital stay, as any other MIPO procedures. Ninety-eight patients underwent the operation (Tronzo types I and II), 59 female and 39 male, ages from 50 to 85 years old. Immediate post-operative complications were shortening of the lower limb, loss of fracture reduction, and death by clinical complications. Conclusion: the present study describes a minimally invasive surgical technique using a modified instrument to perform proximal femoral osteosynthesis for stable trochanteric fractures, using the standard DHS.

Clinical outcomes of PFNA-II in the Asian intertrochanteric fracture patients: Comparison of clinical results according to proximal nail protrusion

PurposeThis study intended to explore the clinical outcomes of PFNA-II, one of the commonly used fixation devices for intertrochanteric fractures and the association of clinical results with the extent of proximal nail protrusion. Materials and MethodsOf 315 cases that underwent internal fixation using PFNA-II between September 2010 and June 2018 among intertrochanteric fracture patients aged over 65 years, a total of 86 patients with an ability to communicate clearly and a minimum follow-up of 6 months were retrospectively reviewed. We classified the subjects according to PFNA-II protrusion over the greater trochanter area on anteroposterior radiographs. Differences between the two groups were examined by comparing demographic characteristics including gender, age, height, weight and BMI, instrumental characteristics including PFNA nail size, nail diameter, blade length and blade position, radiologic characteristics including reduction quality, Dorr type and bone union, and clinical characteristics including GT pain,VAS score and Harris Hip Score (HHS). ResultsA total of 86 cases were divided into 30 (34.9%) in the protrusion group (group A) and 56 (65.1%) in the non-protrusion group (group B). No significant difference was found in demographic characteristics such as gender, age, height, weight and BMI between the two groups. Two groups had no statistically significant difference in PFNA nail length, nail diameter and blade length, but showed a statistically significant difference in blade position.At the latest follow-up, the mean HHS shows no statistically significant difference between the two groups. On the contrary, the number of patients complaining of GT pain and VAS score were statistically significantly higher in group A. Removal of metal implants was performed in two patients in the protrusion group due to a complaint of persistent GT pain. ConclusionNail protrusion over the greater trochanter area occurs frequently after the surgical treatment of intertrochanteric fracture using PFNA-II. When the nail protruded into the greater trochanter, the number of patients who clinically complained of pain was statistically significantly high. We recommend a modification to the PFNA-II that would further shorten the proximal nail end suitable for the Asian population to achieve better clinical results in the fixation of intertrochanteric fractures.

Concept evolution and research progress of stability reconstruction for intertrochanteric fracture

To summarize the evolving concept and research progress on stability reconstruction in the surgical treatment of intertrochanteric fracture. Related literature and author's own experience concerning the surgical treatment of intertrochanteric fracture were reviewed and analyzed in terms of fracture pathoanatomy, stable and unstable pattern, adequate and in-adequate reduction, primary and secondary stability, postoperative stability evaluation, and early weight-bearing. Intertrochanteric fracture occur at the translational area of cervico-trochanteric junction, which has a nature tendency to varus instability. Fracture reduction quality is the paramount factor and is evaluated by two views, the anteroposterior and lateral Garden alignment and cortex apposition between the head-neck fragment and the femoral shaft. Rather than the posteromedial lesser trochanteric frag ment, the cortical support concept (positive, neutral, negative) emphasizes the reduction of anteromedial cortex to a nonanatomic positive apposition or an "anatomic" neutral apposition in intraoperative fluoroscopy. Postoperative radiographic stability score provides a quantitative assessment for early weight-bearing standing and walking. However, some fractures may lose cortical contact and buttress (negative) during the process of postoperative telescoping and secondary stability. Further studies are needed to elucidate the risk factors such as tilting, swing or rotation of the head-neck fragment, and propose new preventive methods. Stability reconstruction of intertrochanteric fracture requires adequate fracture reduction with Garden alignment and anteromedial cortical support apposition, and reliable sustainment by internal fixation implants. Early weight-bearing standing and walking is safe in patients with perfect postoperative stability score.

Local Postoperative Complications after Surgery for Intertrochanteric Fractures Using Cephalomedullary Nails

PurposeCephalomedullary nails (CMN) are commonly used for the surgical treatment of intertrochanteric fractures. This study aimed to evaluate overall postoperative local complications by reviewing patients who received surgical treatment using three different types of implants.Materials and MethodsThe study sample included 353 patients (107 males, 246 females) who underwent surgery using CMN for intertrochanteric fractures. Three different types of implants were used: i) the Gamma3® (Stryker) in 80 cases, ii) the Targon® PF (Aesculap) in 225 cases, and iii) the Compression Hip Nail® (Trademedics) in 48 cases. The mean age was 82.6 (range, 60–109) years and the average follow-up period was 15 (range, 6–80) months. Postoperative local complications and risk factors of cut-out were assessed.ResultsThe most common complication was cut-out (n=26). Other complications included non-union (n=3), periprosthetic fracture (n=2), avascular necrosis (n=1), heterotopic ossification (n=1), and sleeve pull out (n=1). Multivariate analysis revealed that the cut-out group had a higher rate of poor reduction compared to the non-complicated group (P<0.001). Although the mean tip-apex distance (TAD) was 18.4 mm in the non-complicated group, lower than that of the cut-out group (P=0.001), multivariate analysis revealed that TAD was not a significant risk factor for cut-out (P=0.065).ConclusionCut-out is the most common local complication associated with surgical treatment of intertrochanteric fractures using CMN. Proper reduction appears to be important in lowering the risk of cut-out. Maintaining low TAD is another critical factor in achieving sufficient fixation of lag screw to the subchondral bone of the femoral head.

Effects of morphological characteristics of femoral intertrochanteric fractures on internal fixation

Objective To explore the effects of internal fixation in surgical treatment of intertrochanteric fractures by proximal femoral locking compression plate (PFLCP) and proximal femoral nail anti-rotation (PFNA) on fracture morphological features. Methods 43 patients with femoral intertrochanteric fractures were treated with PFLCP or PFNA from January 2013 to December 2015. There were 23 patients treated with PFLCP and 20 cases with PFNA. There were 29 males and 14 females, the average age was 62.6 years old (ranged from 46-85 years). Observed the fracture type (AO/OTA, Evans, the lateral trochanteric wall injury), the direction of key fracture line (lateral superior to medial inferior/medial superior to lateral inferior), preoperative days, preoperative bone mineral density value, operation time, the volume of intraoperative blood loss, the supportive contact rate at the medial cortex of proximal femur after surgery, the surgical intervention rate for medial cortical fracture, postoperative partial load bearing time, full weight bearing time, complications of internal fixation and Harris scores. And analyzed the relationship between the direction of key fracture line and the internal fixation failure. SPSS13.0 software was used for statistical analysis. Results No statistical significance was found in age distribution, fracture types, preoperative days, preoperative bone mineral density value, the internal fixation failure rate (loss of fracture reduction, screw cutting or plate fracture). The operative time of PFLCP group was obviously longer than that of PFNA group and the difference was statistically significant (t=2.216, P=0.032). The intraoperative blood loss was more in PFLCP group than PFNA group and significant difference was found between the two groups (t=4.142, P=0.000) .Though the initial postoperative partial load bearing time is earlier in the PFNA group than PFLCP group, but no statistical difference bewtween the two groups (t=0.833, P=0.902). Full weight bearing time had no statistical difference between the two groups. Harris scores in the PFNA group was slightly lower than in the PFLCP group, but there was no statistical difference (t=0.833, P=0.902). The postoperative medial cortical support rate was higher in the PFLCP group than PFNA group, but no statistical difference between them. The surgical intervention rate for medial cortical fracture was higher in the PFLCP group and difference was statistically significant (χ2=4.768, P=0.029). No correlation had found between invalid support at medial cortex and the direction of key fracture line in all internal fixation failure cases. Distribution of the direction of key fracture line in the two groups had no statistical difference, while the relative risk ratio in terms of internal fixation failure between 2 types of the direction of key fracture line (OR=lateral superior to medial inferior/medial superior to lateral inferior) had statistical difference (χ2=6.081, P=0.014; OR=9.600, P=0.037). Conclusion The direction of key fracture line can foresee the underlying displacement direction of intertrochanteric fractures at postsurgical load bearing, combining with restore the supportive contact at the medial cortex of the proximal femur and timing of load bearing may be determined to avoid internal fixation failure. Key words: Hip fractures; Internal fixators; Fracture fixation, internal

A comparative study of proximal femoral nailing versus dynamic hip screw device in the surgical management of intertrochanteric fractures

Introduction: Trochanteric fractures are one of the most common injuries sustained predominantly in patients over sixty years of age. Studies have shown that when compared to the dynamic hip screw, proximal femoral nailing had certain advantages over the former. Aim: To compare the surgical treatment of intertrochanteric fractures of the femur with the proximal femoral nail and dynamic hip screw device, with respect to fluoroscopic time, duration of surgery, post-operative shortening and functional outcome. Materials and Methods: The study was conducted in Father Muller Hospital, Mangalore from July 2015 to July 2016 where 60 patients with 60 intertrochanteric fractures of femur were selected. The fractures were fixed with either dynamic hip screw device (DHS) or a proximal femoral nail (PFN). Of the 60 patients in the study, 30 were treated with DHS and 30 with PFN. Fluoroscopy time was recorded intraoperatively. Results and Discussion: The difference in the operative times in both the groups was found to be highly significant and we attributed this difference to the smaller incisions in the PFN group. The fluoroscopy time in the PFN group (average 72.60secs) was significantly higher as compared to that of the DHS group (average 48.60secs). In this study the average limb length shortening of patients in the DHS group was 1.25cm as compared to 0.63cm in the PFN group which was highly significant (p=0.009). The overall functional outcome of patients treated with the PFN was significantly better than those treated with DHS (p=0.037). This is in accordance to a study by Kukla and co-workers8 and also Ahrengart and associates. Conclusion: We conclude that in stable intertrochanteric fractures, both the PFN and DHS have similar outcomes. However, in unstable intertrochanteric fractures the PFN has significantly better outcomes in terms of earlier restoration of walking ability. In addition, as the 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 fractures.

The assessment of mortality and quality of life after intertrochanteric fracture of femur in elderly patients

Objective:To investigate the mortality and disability rates after surgical treatment of intertrochanteric fractures in patients older than 60 years old.Method:In this retrospective study, 385 patients aged 60 or older who were admitted because of intertrochanteric fracture to treatment and teaching center of Emam Khomeini hospital of Ahvaz, Iran between Mar. 2010 to Feb. 2015 and underwent surgery were included. All the patients were treated by open reduction and internal fixation by dynamic hip screw. Two hundred and six patients were men (53.5%) and 179 were women (46.4%). Age of patients was between 60 to 89 years old with the average of 75.2 years old. Minimum time required after surgery to enter this study was one year. Results were gathered based on examination of patient or calling patients and their families by phone number.Result:Rate of mortality was 36.9%, including 54.9% for men and 41.9% for women. In eleven patients (2.85%), initial reduction was lost because of failure of fixation device. For these patients reoperation was performed, and 7 of them (63.63%) expired within the mean of 10.1 months after reoperation. Time delay for surgery after occurrence of the fracture was in range of 2 to 15 days with an average of 4.8 days.24 patients (6.23%) went under surgery later than one week after fracture had been happened which seven of them (29.16%) expired. Highest mortality rate was in the age group of 80-89 years old with 50 patients (63.01%) and lowest one was in the group of 60-69 years old with three patients (4.67%). Disability rate and quality of life of the patients was measured by Modified Harris Hip Score and divided in 3 group of good (with a score of 71 to 90), fair (with a score of 51 to 70) and weak (with a score of 0 to 50). Patients who had good score consisted of 35.54% of patients with the average age of 64.63 years old and majority of male patients, fair group consisted of 30.5% of patients with average age of 73.45 years old and equal percentage of male and female patients and for Weak group it was 34.2% and 73.45 years old and by majority of male patients.Conclusion:Mortality rate of intertrochanteric fracture of femur is high even after treated with surgery and it’s highly related to age of patient. Furthermore, quality of life after surgery is still low and follow up of the patients should be improved.

Effects of Zoledronate on Mortality and Morbidity after Surgical Treatment of Hip Fractures.

We aimed to evaluate the effects of intertrochanteric femoral fractures on mortality, morbidity, and cost of zoledronate treatment in elderly patients treated by osteosynthesis. Based on Evans classification, 114 patients with unstable intertrochanteric femoral fractures were treated with osteosynthesis. After the surgical treatment of intertrochanteric fractures, the treatment group (M/F, 24/32; mean age, 76.7 ± SD years) received zoledronate infusion, and the control group (M/F, 20/38; mean age, 80.2 ± SD years) received placebo. Postoperative control visits were performed at 6-week, 3-month, 6-month, and 12-month time points. Functional level of patients was evaluated by the modified Harris hip score and Merle d'Aubigné hip score. By 12 months, the mean HHS in treatment and control groups was 81.93 and 72.9, respectively. For time of death of the patients, mortality was found to be 57.1% (16/28) on the first 3 months and 92.9% (26/28) on the first six months. The mortality rate in the treatment and control groups was 14.3% (8/56) and 34.5% (20/58), respectively. The use of zoledronic acid after surgical treatment of intertrochanteric femoral fractures in osteoporotic elderly patients is a safe treatment modality which helps to reduce mortality, improves functional outcomes, and has less side effects with single dose use per year.

Which Fixation Device is Preferred for Surgical Treatment of Intertrochanteric Hip Fractures in the United States? A Survey of Orthopaedic Surgeons.

The best treatment for intertrochanteric hip fractures is controversial. The use of cephalomedullary nails has increased, whereas use of sliding hip screws has decreased despite the lack of evidence that cephalomedullary nails are more effective. As current orthopaedic trainees receive less exposure to sliding hip screws, this may continue to perpetuate the preferential use of cephalomedullary nails, with important implications for resident education, evidence-based best practices, and healthcare cost. We asked: (1) What are the current practice patterns in surgical treatment of intertrochanteric fractures among orthopaedic surgeons? (2) Do surgical practice patterns differ based on surgeon characteristics, practice setting, and other factors? (3) What is the rationale behind these surgical practice patterns? (4) What postoperative approaches do surgeons use for intertrochanteric fractures? A web-based survey containing 20 questions was distributed to active members of the American Academy of Orthopaedic Surgeons. Three thousand seven-hundred eighty-six of 10,321 invited surgeons participated in the survey (37%), with a 97% completion rate (3687 of 3784 responded to all questions in the survey). The survey elicited information regarding surgeon demographics, preferred management strategies, and decision-making rationale for intertrochanteric fractures. Surgeons use cephalomedullary nails most frequently for treatment of intertrochanteric hip fractures. Sixty-eight percent primarily use cephalomedullary nails, whereas only 19% primarily use sliding hip screws, and the remaining 13% use cephalomedullary nails and sliding hip screws with equal frequency. The cephalomedullary nail was the dominant approach regardless of experience level or practice setting. Surgeons who practiced in a nonacademic setting (71% versus 58%; p < 0.001), did not supervise residents (71% versus 61%; p < 0.001), or treated more than five intertrochanteric fractures a month (78% versus 67%; p < 0.001) were more likely to use primarily cephalomedullary nails. Of the surgeons who used only cephalomedullary nails, ease of surgical technique (58%) was cited as the primary reason, whereas surgeons who used only sliding hip screws cite familiarity (44%) and improved outcomes (37%) as their primary reasons. Of those who use only short cephalomedullary nails, ease of technique (59%) was most frequently cited. Postoperatively, 67% allow the patient to bear weight as tolerated. Nearly all respondents (99.5%) use postoperative chemical thromboprophylaxis. Despite that either sliding hip screw or cephalomedullary nail fixation are associated with equivalent outcomes for most intertrochanteric femur fractures, the cephalomedullary nail has emerged as the preferred construct, with the majority of surgeons believing that a cephalomedullary nail is easier to use, associated with improved outcomes, or is biomechanically superior to a sliding hip screw. The difference between what is evidence-based and what is done in clinical practice may be attributed to several factors, including financial considerations, educational experience, or inability of our current outcomes measures to reflect the experiences of surgeons. The educators, researchers, and policymakers among us must work harder to better define the roles of sliding hip screws and cephalomedullary nails and ensure that the increasing population with hip fractures receives high-quality and economically responsible care. Level V, therapeutic study.

Functional Improvement in Geriatric Hip Fractures: Does Vitamin D Deficiency Affect the Functional Outcome of Patients With Surgically Treated Intertrochanteric Hip Fractures.

Introduction:The “Integrated Care Pathway” for geriatric intertrochanteric (IT) fractures in Singapore’s Tan Tock Seng Hospital has shown significant functional recovery in patients’ activities of daily living. However, the influence of preoperative vitamin D on functional recovery remains equivocal. This retrospective study therefore aims to determine whether patients with preoperative vitamin D deficiency have poorer functional outcomes.Method:A total of 171 patients who had surgical treatment for IT fractures were recruited in the study. They were categorized into group A (vitamin D deficient) and group B (normal vitamin D). Charlson Comorbidity Index (CCI) score and nutritional parameters including hemoglobin, albumin, and adjusted calcium levels on admission were recorded. The Modified Barthel Index (MBI) score was used to measure functional recovery at the following time intervals: at pre-fall, at discharge after surgery, at 6 months, and at 1-year follow-up.Results:The mean age of both the groups (A: 79.7 years, n = 45; B: 83.0 years, n = 126) was statistically different (P < .05). However, the mean CCI (A: 9.42 and B: 10.13), hemoglobin (A: 12.4 and B 11.1), adjusted calcium (A: 2.39 and B: 2.38), and mean albumin (A: 33.6 and B: 33.0) of the groups were not significantly different. Furthermore, the MBI scores were not significantly different for both groups at preinjury (A: 91.5 and B: 89.4), at discharge (A: 55.2 and B: 58.9), at 6 months (A: 70.9 and B: 75.1), and at 1 year (A: 75.8 and B: 79.4).Conclusion:In our cohort, patients with vitamin D deficiency were younger. However, vitamin D deficiency at time of injury had no significant influence on functional recovery in patients with surgically treated hip fracture in our Integrated Care Pathway. In addition, patients who had a normal vitamin D levels had similar functional scores and improvement postoperatively and at 1 year (A: 82.8% and B: 88.9%).

Intramedullary Osteosynthesis in Treatment of Unstable Intertrochanteric Femur Fractures

Intramedullary Osteosynthesis in Treatment of Unstable Intertrochanteric Femur Fractures

National Trends of Surgical Treatment for Intertrochanteric Fractures in Korea

Intramedullary nailing has been reported to have better outcome compared with traditional plate fixation in surgical treatment of intertrochanteric fractures. We evaluated the trends of surgical treatment of intertrochanteric fracture in Korea. Data of patients with intertrochanteric fractures, who were operated between the years of 2006 and 2011, was obtained from the Health Insurance Review and Assessment Service. The ratio of intramedullary nailing increased from 27.9% in 2006 to 64.3% in 2011 (P < 0.001), while the ratio of plate fixation decreased. During recent 5 yr, the utilization of intramedullary nailing doubled in clinical practice of intertrochanteric fractures in Korea.

Tip apex distance, hip screw placement, and neck shaft angle as potential risk factors for cut-out failure of hip screws after surgical treatment of intertrochanteric fractures

To describe the quality of osteosynthesis after intertrochanteric fractures evaluation of tip apex distance (TAD) and position of the hip screw have been established. Furthermore, a slightly valgus fracture reduction has been suggested to reduce the risk of cut-out failure. However, uniform recommendations for optimal screw positioning and fracture reduction are still missing. The purpose of our study was to confirm potential risk factors for cut-out of hip screws of intertrochanteric fractures and to provide recommendations for practical clinical use. A retrospective analysis of all patients with intertrochanteric fractures treated with a DHS or a gamma nail between January of 2007 and May of 2010 was performed at a level I trauma center. Two hundred thirty-five patients with intertrochanteric fractures after intra- and extramedullary stabilization were analyzed. A TAD of more than 25 mm was demonstrated to be the most important factor for cut-out in stable and unstable fractures. Fracture reduction with a valgus NSA of 5-10° was associated with a trend towards a lower rate of screw cut-out while an anterior placement of the screw (Parker's ratio index of <40) significantly increased cut-out incidence. According to our results, the TAD should not exceed 25 mm in stable (AO/OTA A1) as well as unstable (AO/OTA A2) fractures. An increased anterior hip screw placement should be avoided while fracture reduction with a slight valgus Neck Shaft seems favorable.