Treatment Of Femoral Intertrochanteric Fractures Research Articles

Wing-augmentation reduces femoral head cutting out of dynamic hip screw

The dynamic hip screw (DHS) is commonly used in the treatment of femoral intertrochanteric fracture with high satisfactory results. However, post-operative failure does occur and result in poor prognosis. The most common failure is femoral head varus collapse, followed by lag screw cut-out through the femoral head. In this study, a novel-designed DHS with two supplemental horizontal blades was used to improve the fixation stability. In this study, nine convention DHS and 9 Orthopaedic Device Research Center (ODRC) DHSs were tested in this study. Each implant was fixed into cellular polyurethane rigid foam as a surrogate of osteoporotic femoral head. Under biaxial rocking motion, all constructs were loaded to failure point (12mm axial displacement) or up to 20,000 cycles of 1.45kN peak magnitude were achieved, whichever occurred first. The migration kinematics was continuously monitored and recorded. The final tip-to-apex distance, rotational angle and varus deformation were also recorded. The results showed that the ODRC DHS sustained significantly more loading cycles and exhibited less axial migration in comparison to the conventional DHS. The ODRC DHS showed a significantly smaller bending strain and larger torsional strain compared to the conventional DHS. The changes in tip-to-apex distance (TAD), post-study varus angle, post-study rotational angle of the ODRC DHS were all significantly less than that of the conventional DHS (p < 0.05). We concluded that the ODRC DHS augmented with two horizontal wings would increase the bone–implant interface contact surface, dissipate the load to the screw itself, which improves the migration resistance and increases the anti-rotational implant effect. In conclusion, the proposed ODRC DHS demonstrated significantly better migration resistance and anti-rotational effect in comparison to the conventional DHS construct.

Risk Factors of Cut-Out in Treatment of Femoral Intertrochanteric Fractures by Proximal Femur Nail

Risk Factors of Cut-Out in Treatment of Femoral Intertrochanteric Fractures by Proximal Femur Nail

Efficacy analysis of Asian proximal femoral nail anti rotation intramedullary nail(PFNAII) in the treatment of unstable intertrochanteric femoral fractures in senile patients

Objective To retrospectively analyze the results of treatment with Asian proximal femoral nail anti rotation intramedullary nail(PFNAⅡ) in senile patients with unstable intertrochanteric femoral fractures. Methods 106 cases of unstable intertrochanteric femoral fracture with internal fixation of PFNAⅡ were analyzed retrospectively, and the treatment effect was observed. Results 106 cases were followed-up(mean 13.5 months, ranged 10-22 months). Bone union occurred in all cases, average fracture healing time was 3.8 months.The average operation time was 48 minutes, the average volume of blood loss was 106mL.The hip functions were analyzed using Harrison score.And found 80 excellent cases, 14 good cases, 12 fair cases, with 88.7% of excellent and good rate. Conclusion For the senile patients of unstable intertrochanteric femoral fractures, PFNAⅡ has the biomechanical advantages of intramedullary fixation, small trauma, short operation time, reliable internal fixation, early functional exercise, low incidence of complications, significant functional recovery, and is a preferred treatment option. Key words: Femoral fractures; Bone nails; Fracture fixation, intramedullary; Aged

Surgical Results of the Cephalomedullary Nail for the Femoral Intertrochanteric Fracture: Comparison between Non-experienced Surgeons and Experienced Surgeon.

PurposeCephalomedullary nail (CM nail) in the treatment of femoral intertrochanteric fractures is in the lime light in recent years. The purpose of this study is to compare surgical outcomes between experienced surgeon and non-experienced surgeons in respect of CM nail for femoral intertrochanteric fractures.Materials and MethodsThe 129 patients underwent CM nail for femoral intertrochanteric fracture more than six months of follow-up from April 2011 to March 2014 in Seoul Medical Center (Seoul, Korea) were participated in this study. For this study, group A consisted of experienced surgeons who performed more than 500 times of CM nail, and group B consisted of non-experienced surgeons who performed less than 50 times of CM nail. Clinical and radiologic outcomes, complications and the need for reoperation between both groups were compared in the study.ResultsAccording to clinical result, both the mean operation time and transfusion volume were significantly longer and greater in group B (P<0.05). In the radiologic outcomes, adequacy of reduction, tip-apex distance and numbers of case placed in the Cleveland zones 5, 6 and 8; there was no statistical difference between both groups. Moreover, rate of complication and reoperation had same results as radiologic outcomes.ConclusionThere was no significant difference with statistical data in complications from CM nail for femoral intertrochanteric fractures between experienced surgeon and non-experienced surgeon. Although the operation time and transfusion volume were significantly longer and greater in the case of operation by non-experienced surgeon, satisfactory performance was seen in the complications and the need for reoperation.

Application of 3D printing fracture models in treatment of intertrochanteric fracture

Objective To report the application of 3D printing fracture models to assist the treatment of femoral intertrochanteric fracture using proximal femoral nail anti-rotation(PFNA)fixation. Methods From August 2014 to February 2015, 27 unstable intertrochanteric fractures were treated using PFNA. Of them, 12 used a 3D printing fracture model to assist the surgery and 15 did not. CT scanning was performed for the patients in 3D printing model group. Their anatomical data of . Dicom form were reconstructed into the . STL form data through M3D software. The 3D printing model was constructed using fused deposition modeling(FDM)technique. The length and diameter of the main screw and blade were measured based on the 3D printing prototyping before surgical planning. The 2 groups were compared in terms of operation time, intraoperative blood loss, postoperative drainage volume, hospital stay and Harris hip score at the final follow-up. Results No significant differences were found in the 3D printing model between surgical planning and actual operation in the respects of diameter of main PFNA screw(9. 42 ±0. 64 mm versus 9. 58 ±0. 16 mm), length of main PFNA screw(177. 50 ± 12. 90 mm versus 178. 33 ±20. 34 mm), or length of blade(84. 58 ±5. 94 mm versus 85. 42 ± 5. 57 mm)( P> 0. 05). The 27 patients obtained an average follow-up of 12. 4 months(from 10 to 16 months). The operation time(47. 8 ±5. 1 min), intraoperative blood loss(101.6±3.9 mL)and postoperative drainage volume(47. 3 ±5.9 mL)in the 3D printing model group were significantly less than those in the conventional group(61. 1 ±7. 5 min, 122. 3 ±9. 8 mL and 58. 6 ±6. 3 mL, respectively)(P 0. 05). Both groups obtained fine fracture union. No varus deformation of the hip joint or failure of implants was observed during the follow-up period. Conclusion 3D printing technique can manufacture an accurate model of intertrochanteric fracture, which may play an important role in improving efficiency and accuracy of reduction and PFNA fixation. Key words: Hip fractures; Fracture fixation, intramedullary; Bone nails; 3D printing

Reverse polyaxial less invasive stabilization systems for treatment of femoral intertrochanteric fractures of the distal femur.

The reverse less invasive stabilization system (LISS) for the distal femur remains generally regarded as a safe and satisfactory option for the treatment of unstable proximal femoral fractures. The polyaxial LISS provides a reverse plating technique that leverages the advantages of proximal screws by allowing the adjustable locking screw to be better positioned and providing more reliable fixation on the proximal femur compared with the standard axial LISS. To assess this fixation method, a detailed evaluation of institutional outcomes of femoral intertrochanteric fractures treated with reverse polyaxial LISS was performed. A total of 29 patients presenting with femoral intertrochanteric fractures were treated with the reverse polyaxial LISS system between January 2010 and March 2011. Patients were classified into stable and unstable fracture groups according to the Orthopaedic Trauma Association's (OTA) classification. Clinical data, including operative time, blood loss, radiological records and complications, Harris Hip scores and Parker scores, were collected and analyzed. There were no significant between-group differences in age, sex, or American Society of Anesthesiologists score. Operative time and blood loss were significantly higher in the unstable fracture group compared with the stable fracture group. Four cases of fixation failure, consisting of one case of A2.3, one case of A3.2 and two cases of A3.3, occurred 4-7m postoperatively. Treatment of femoral intertrochanteric fractures with unstable pattern using polyaxial reverse LISS results in high failure rates; therefore, it should not be recommended as a routine alternative method for the treatment of femoral intertrochanteric fractures with unstable pattern.

Comparison of DHS, Gamma nail and PFNA fixations for treatment of intertrochanteric femoral fractures in elderly patients

Objective To compare the clinical effects of dynamic hip screw(DHS), Gamma interlocking intramedullary nail and proximal femoral nail antirotation(PFNA)in the treatment of intertrochanteric femoral fractures in elderly patients. Methods From January 2008 to June 2015, 103 elderly patients with intertrochanteric femoral fracture were treated with DHS(DHS group, 33 cases), Gamma nails(Gamma group, 30 cases), or PFNA(PFNA group, 40 cases). By the AO classification, there were 44 cases of type 31-A1, 30 cases of type 31-A2 and 29 cases of type 31-A3. The 3 groups were compared in terms of incision length, operation time, intraoperative blood loss, fracture healing time, postoperative weight-bearing time, Harris scoring, and incidence of postoperative complications. Results PFNA group incurred significantly shorter incision length(5. 4 ±0. 5 cm)and operation time(70. 8 ± 16. 2 min)than DHS group(12. 6 ± 2. 7 cm and 102. 6 ± 17. 4 min)and Gamma group(7. 5 ±0. 8 cm and 93. 0 ±35. 9 min)(P< 0. 05). The intraoperative blood loss in PFNA group(163. 2 ±60. 6 mL)was significantly less than in DHS group(280. 5 ±89. 8 mL)and in Gamma group(204. 9 ±62. 2 mL), and that in Gamma group was also significantly less than in DHS group(P< 0. 05). PFNA group had significantly shorter weight-bearing time(11. 0 ±0. 8 weeks), fracture healing time(13. 6 ±1. 5 weeks)and significantly higher Harris good to excellent rate(92. 5%)than DHS group(13. 3 ±1. 0 weeks, 15. 8 ±1. 2 weeks and 84. 8%)and Gamma group(12. 5 ±1. 3 weeks, 14. 2 ±1. 0 weeks and 86. 1%)(P< 0. 05). The incidence of postoperative complications in DHS group(21. 2%)was significantly higher than in Gamma group(10. 0%)and in PFNA group(7. 5%)(P<0. 05). Conclusions DHS, Gamma nail and PFNA are effective means for the treatment of intertrochanteric femoral fractures in the elderly. Intramedullary fixation, especially by PFNA, shows superiority in the clinical outcomes. Key words: Hip fractures; Fracture fixation, internal; Bone nails; Aged

Treatment of femoral intertrochanteric fracture by early non general anesthesia and proximal femoral nail antirotation in patients over 90 years old

Objective To study the efficacy of early non general anesthesia and proximal femoral nail anti-rotation (PFNA) in the treatment of femoral intertrochanteric fracture in senile patients over 90 years old. Methods From June 2009 to June 2015, 37 senile patients with femoral intertrochanteric fracture were treated by early non general anesthesia and PFNA internal fixation. They were 14 men and 23 women, from 90 to 107 years of age (average, 93 years). By the AO classification, 11 cases were type 31-A1, 14 ones type 31-A2, and 12 ones type 31-A3. The time from injury to surgery ranged from 8 hours to 4 days (average, 3 days). All the patients underwent closed reduction and PFNA internal fixation in non general anesthesia. Results The operation time in this group ranged from 30 to 70 minutes (average, 40 minutes). Their intraoperative bleeding ranged from 50 to 150 mL (average, 100 mL). They were followed up for an average time of 12 months (range, from 6 to 16 months). All the fractures healed after an average time of 12.5 weeks (range, from 10 to 16 weeks). Incision exudates occurred in one case postoperation. No postoperative complications such as deep vein thrombosis of lower limb, bedsore, urological infection, hip varus deformity, implants loosening and breakage, and delayed union were observed during follow-ups. According to the Harris scores at the final follow-ups, the hip function was rated as excellent in 11 cases, good in 19, medium 6, and poor in one, yielding a good to excellent rate of fine rate of 81.1%. Conclusions PFNA in early non general anesthesia is a successful treatment of femoral intertrochanteric fracture for elderly patients. Advantages of the remedy include simple manipulation, limited trauma, shorter operation time, less bleeding, early ambulation, and reduced postoperative complications. Key words: Hip fractures; Fracture fixation, intramedullary; Bone nails; Aged, 80 and over

Comparison of postoperative hidden blood loss and deep venous thrombosis between dynamic hip screw, InterTan and proximal femoral nail antirotation-II in treatment of femoral intertrochanteric fracture

Objective To compare dynamic hip screw (DHS), InterTan and proximal femoral nail antirotation-Ⅱ (PFNA-Ⅱ) in the treatment of femoral intertrochanteric fracture in terms of their effects on postoperative hidden blood loss (HBL) and deep venous thrombosis (DVT). Methods We retrospectively analyzed the 133 patients with femoral intertrochanteric fracture who had been treated in our hospital from November 2011 to November 2015. Of them, 42 received DHS treatment, including 22 males and 20 females; 43 underwent InterTan fixation, including 21 males and 22 females; 48 had PFNA-Ⅱ treatment, including 25 males and 23 females. At preoperation, 1, 3 and 7 days postoperation, all of them had tests of hemoglobin (Hb), hematocrit value (Hct), blood platelet (PLT), thrombin time (TT), activated partial thromboplastin time (APTT), prothrombin time (PT), human fibrinogen (FIB) and D-dimer. DVT was detected using color Doppler ultrasound at 7 days postoperation. Results At 1, 3 and 7 days postoperation, the DHS patients had the smallest values of Hb, Hct, TT, PT and APTT while the PFNA-Ⅱ patients the largest. The DHS patients had the largest values of intraoperative bleeding, PLT, FIB and D-dimer while the PFNA-Ⅱ patients the smallest. There were significant differences between the 3 groups in all the indexes (P 0.05). The incidence of DVT in the InterTan group (2.3%, 1/43) and in the PFNA-Ⅱ group (0) was significantly lower than in the DHS group (7.1%, 3/42) (P<0.05). Conclusion In the treatment of femoral intertrochanteric fracture, PFNA-Ⅱ may be superior to InterTan and DHS in reducing postoperative HBL and control of DVT. Key words: Hip fractures; Fracture fixation, internal; Bone nails; Postoperative hemorrhage; Embolism and thrombosis

Lateral decubitus versus supine position in treatment of intertrochanteric fractures with proximal femoral nail antirotation

Objective To compare the lateral decubitus and supine position in the treatment of femoral intertrochanteric fractures with femoral proximal nail antirotation (PFNA). Methods A retrospective analysis was performed of the 85 patients with intertrochanteric fracture who had been treated at our hospital between September 2013 and September 2014. They were 24 men and 61 women, 28 to 99 years of age (average, 78.5 years). By Evans-Jensen classification, one case was type Ⅰ, 15 cases were type Ⅱ, 40 type Ⅲ, 23 type IV, and 6 type V. All the patients were treated with internal fixation with PFNA. Lateral decubitus position was adopted in 45 cases and supine position in 40. The 2 groups were compared in terms of operation time, intraoperative bleeding volume, difference between preoperative and postoperative hemoglobin values, tip-apex distance (TAD), calcar tip-apex distance (Cal-TAD), fracture healing time, and Harris score of the hip joint. Results The 85 patients were followed up for 9 to 21 months (average, 13.6 months). Both 2 groups obtained fracture healing, with no screw cut-out. The lateral decubitus group had significantly less operation time (60.3±17.5 min) and intraoperative bleeding volume (70.8±37.8 mL) than the supine position group (72.7±19.7 min and 90.3±20.9 mL, respectively) (P 0.05). Conclusion In the treatment of femoral intertrochanteric fractures with PFNA, lateral decubitus position may be associated with shorter operation time and less intraoperative blood loss compared with supine position. Key words: Hip fractures; Fracture fixation, intramedullary; Bone nails; Position

Analysis of trabecular bone microstructure in osteoporotic femoral heads in human patients: in vivo study using multidetector row computed tomography.

BackgroundLag screw position is very important in the treatment of intertrochanteric femoral fracture to prevent complications such as screw cut-out. Current studies recommend central or inferior placement of the lag screw on the anteroposterior radiograph, and central placement on the lateral radiographs. These reports are based on radiographic evaluation, but few studies have investigated the importance of bone quality at the site of lag screw placement. In this study, we used multidetector row computed tomography (MDCT) to perform in vivo evaluation of the bone microstructure of the femoral head in patients with intertrochanteric femoral fractures.MethodsThis study was approved by the Ethics Committee of Okanami General Hospital. MDCT images were obtained in our hospital from ten patients who had sustained intertrochanteric femoral fracture. Patients who needed computed tomography to confirm fracture morphology were included. We defined six areas as regions of interest (ROI): ROI 1–3 were defined as the femoral head apex area, and ROI 4–6 were defined as the femoral neck area. Trabecular microstructure parameters, including mean bone volume to total volume (BV/TV), trabecular thickness (Tb.Th), trabecular separation (Tb.Sp), and structure model index (SMI), were evaluated with bone analysis software (TRI/3D-BON). Statistical analyses were performed using EZR software; each parameter among the ROIs was statistically evaluated by analysis of variance (ANOVA) and Tukey’s test. Statistical significance was established at p < 0.05.ResultsIn the apical area, all parameters indicated that ROI 1 (superior) had the highest bone quality and ROI 2 (central) was higher in bone quality than ROI 3 (inferior). In the femoral neck, all parameters indicated that bone quality was significantly greater in ROI 6 (inferior) than ROI 5 (central).Discussion and ConclusionsWe could evaluate bone quality with clinical MDCT in vivo. Bone quality in the central area of the femoral head apical was greater than in the inferior area, and bone quality in the inferior area of the femoral neck was greater than in the central area. Recognizing which area of femoral head has greater bone quality may lead to a better clinical result in treating intertrochanteric femoral fracture.

Treatment of intertrochanteric femoral fracture with proximal femoral medial sustainable intramedullary nails: study protocol for a randomized controlled trial

Background: Conservative management of intertrochanteric femoral fracture often yields poor therapeutic outcomes, and surgical fixation is generally warranted. Biomechanical instability of intertrochanteric femoral fracture is a major cause of fixation failure. To increase the stability of intramedullary nails in intertrochanteric femoral fracture, it is critical to strengthen the support between the nail and the cortical bone. Our previously designed proximal femoral medial sustainable intramedullary nail has been proven to be able to provide this internal support and stabilization by finite element analysis. We aim to examine the efficacy and safety of internal fixation with this new type of intramedullary nail in the treatment of stable and unstable intertrochanteric femoral fractures. Methods/Design: This will be a single-center, two-arm, parallel, randomized controlled trial conducted at the Chinese PLA General Hospital, China. Seventy-two patients with stable or unstable intertrochanteric femoral fracture diagnosed according to AO/OTA Classification of Fractures and Dislocations will be randomly assigned to receive internal fixation either with proximal femoral medial sustainable intramedullary nails, or proximal femoral nail antirotation. The primary outcome measure will be bone healing condition 6 months postoperatively; secondary outcomes will be requirement for revision surgery, quality of life and complications 1 year postoperatively. Discussion: Our findings will provide an evidence base for the use of proximal femoral medial sustainable intramedullary nails for the treatment of intertrochanteric femoral fracture. Trial registration: ClinicalTrial.gov identifier: NCT01437176; registered on 1 September 2011. Ethics: This protocol was approved by Ethics Committee of Chinese PLA General Hospital of China (approval No. 07/06/2011) and will be performed in accordance with the Declaration of Helsinki formulated by the World Medical Association. Informed consent: Written informed consent will be obtained prior to involvement in the clinical trial.

Safety and effectiveness of proximal femoral nail antirotation for the treatment of intertrochanteric femoral fracture: study protocol for a prospective case series

Background: The root cause of intertrochanteric femoral fracture in elderly patients is osteoporosis manifested by reduced bone strength, decreased bone mineral density, and subsequently decreased anchoring between the internal fixator and bone. This is also a major cause of ineffective internal fixation and leads to surgical failure. Because of the special anatomical structure and biomechanical requirements of the proximal femur, internal fixation must have two basic functions, to prevent inversion and rotation of the proximal fractured femur. Reducing the incidence of coxa vara is also one of the treatment objectives. Methods/Design: This is a single-center, prospective, self-controlled case series. The objective of this study is to validate the safety and effectiveness of minimally invasive proximal femoral nail antirotation (PFNA) in the treatment of intertrochanteric femoral fracture. Twenty patients with intertrochanteric femoral fracture scheduled to undergo PFNA implantation will be recruited from the Department of Orthopedics, Chaohu Hospital of Anhui Medical University, China. The primary outcome measure of this study is the percentage of patients having PFNA implantation-related safety problems manifested as pain in the affected region, wound nonunion, incisional infection, and gross findings observed at the time of nail removal, including inflammatory reaction, tissue proliferation, and the appearance of a fibrous capsule wall 3 and 6 months after PFNA implantation. The secondary outcome measures are operative time, intraoperative blood loss, duration of intraoperative fluoroscopy, patients' quality of life evaluated by the EuroQol five-dimension questionnaire and the Barthel Index of Activities of Daily Living, fracture healing examined by X-ray images, and hip joint function evaluated by Harris hip scores 3 and 6 months after PFNA implantation. Discussion: The currently reported clinical studies on PFNA for the treatment of intertrochanteric femoral fracture are mainly case series, a few of which are retrospective, randomized, controlled trials. Here, we will perform a normalized prospective case series to validate the safety and effectiveness of PFNA in the treatment of intertrochanteric femoral fracture. Trial registration: ClinicalTrial.gov identifier: NCT02880501; registered on 18 August 2016. Ethics: This trial has been approved by Ethics Committee, Chaohu Hospital of Anhui Medical University, China and will be performed in accordance with the Declaration of Helsinki, formulated by the World Medical Association. Informed consent: Signed informed consent will be obtained from the patients or their relatives.

How does the material variation of dynamic hip screw affect the cut-out risk in the treatment of intertrochanteric femoral fractures?

The material selection of dynamic hip screw (DHS) is not usually considered from the point of mechanical effects. In this study, the effects of the titanium alloy and stainless steel DHS was investigated in the cut-out risk of femur using finite element analysis (FEA). Intertrochanteric femur fracture (IFF) (31-A2 type according to AO classification) was created in the 3D femur model obtained from computer tomography images. The DHS model was inserted to the fractured femur model in two different positions (inferior and middle). The material properties of DHS were defined for the FEA. The force applied to the femoral head was determined according to the maximum value that is observed during walking. The results show that the safest model was obtained in the middle placement of titanium alloy DHS according to the safety factor. Consequently, the use of stainless steel DHS for IFF could cause higher failure risk of DHS than the use of titanium alloy DHS.

How does the material variation of dynamic hip screw affect the cut-out risk in the treatment of intertrochanteric femoral fractures?

The material selection of dynamic hip screw (DHS) is not usually considered from the point of mechanical effects. In this study, the effects of the titanium alloy and stainless steel DHS was investigated in the cut-out risk of femur using finite element analysis (FEA). Intertrochanteric femur fracture (IFF) (31-A2 type according to AO classification) was created in the 3D femur model obtained from computer tomography images. The DHS model was inserted to the fractured femur model in two different positions (inferior and middle). The material properties of DHS were defined for the FEA. The force applied to the femoral head was determined according to the maximum value that is observed during walking. The results show that the safest model was obtained in the middle placement of titanium alloy DHS according to the safety factor. Consequently, the use of stainless steel DHS for IFF could cause higher failure risk of DHS than the use of titanium alloy DHS.

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.

A comparative study of the therapeutic effect between long and short intramedullary nails in the treatment of intertrochanteric femur fractures in the elderly

PurposeTo compare the clinical effects of long vs. short intramedullary nails in the treatment of intertrochanteric fractures in old patients more than 65 years old. MethodsA retrospective analysis of 178 cases of intertrochanteric fractures of the femur (AO type A1 and A2) in the elderly was conducted from January 2008 to December 2013. There were 85 males (47.8%) and 93 females (52.2%) with the age of 65–89 (70.2 ± 10.8) years. The patients were treated by closed reduction and long or short intramedullary nail (Gamma 3) fixation. The length of short nail was 180 mm and that for long nail was 320–360 mm. The general data of patients, operation time, intraoperative blood loss, length of hospital stay, preoperative hemoglobin level, blood transfusion rate, postoperative periprosthetic fractures, infections, complications, etc were carefully recorded. ResultsThere were 76 cases (42.7%) in the long intramedullary nail group and 102 cases (57.3%) in the short nail group. All the cases were followed up for 12–48 (21.3 ± 6.8) months, during which there were 21 deaths (11.8%), mean (13.8 ± 6.9) months after operation. The intraoperative blood loss was (90.7 ± 50.6) ml in short nail group, greatly less than that in long nail group (127.8 ± 85.9) ml (p = 0.004). The short nail group also had a significantly shorter operation time (43.5 min ± 12.3 min vs. 58.5 min ± 20.3 min, p = 0.002) and lower rate of postoperative transfusion (42.3% vs. 56.7%, p = 0.041). But the length of hospital stay showed no big differences. After operation, in each group there was 1 case of periprosthetic fracture with a total incidence of 1.1%, 1.3% in long nail group and 0.9% in short nail group. At the end of the follow-up, all patients achieved bony union. The average healing time of the long nail group was (6.5 ± 3.1) months, and the short nail group was (6.8 ± 3.7) months, revealing no significant differences (p = 0.09). Postoperative complications showed no great differences either. ConclusionBoth the intramedullary long and short nail fixation has a good clinical effect in treating intertrochanteric femur fractures in the elderly. They showed no significant difference in terms of therapeutic effect, hospital stay and postoperative complications. The incidence of periprosthetic fractures treated by either length of nails was low. But short intramedullary nailing can obviously decrease the intraoperative blood loss, operation time and postoperative blood transfusion.

A biomechanical comparison of proximal femoral nails and locking proximal anatomic femoral plates in femoral fracture fixation: A study on synthetic bones.

Background:The incidence of fractures in the trochanteric area has risen with the increasing numbers of elderly people with osteoporosis. Although dynamic hip screw fixation is the gold standard for the treatment of stable intertrochanteric femur fractures, treatment of unstable intertrochanteric femur fractures still remains controversial. Intramedullary devices such as Gamma nail or proximal femoral nail and proximal anatomic femur plates are in use for the treatment of intertrochanteric femur fractures. There are still many investigations to find the optimal implant to treat these fractures with minimum complications. For this reason, we aimed to perform a biomechanical comparison of the proximal femoral nail and the locking proximal anatomic femoral plate in the treatment of unstable intertrochanteric fractures.Materials and Methods:Twenty synthetic, third generation human femur models, obtained for this purpose, were divided into two groups of 10 bones each. Femurs were provided as a standard representation of AO/Orthopedic Trauma Associationtype 31-A2 unstable fractures. Two types of implantations were inserted: the proximal femoral intramedullary nail in the first group and the locking anatomic femoral plate in the second group. Axial load was applied to the fracture models through the femoral head using a material testing machine, and the biomechanical properties of the implant types were compared.Result:Nail and plate models were locked distally at the same level. Axial steady load with a 5 mm/m velocity was applied through the mechanical axis of femur bone models. Axial loading in the proximal femoral intramedullary nail group was 1.78-fold greater compared to the plate group. All bones that had the plate applied were fractured in the portion containing the distal locking screw.Conclusion:The proximal femoral intramedullary nail provides more stability and allows for earlier weight bearing than the locking plate when used for the treatment of unstable intertrochanteric fractures of the femur. Clinicians should be cautious for early weight bearing with locking plate for unstable intertrochanteric femur fractures.

Intramedullary Nail Versus Dynamic Hip Screw; Intramedullary Nail (Advantages And Disadvantages)

since 1950s surgical treatment of extracapsular hip fractures is done using a variety of different implants. Unstable fractures are fractures with lateral wall or posteromedial comminution,fractures with reverse obliquity patterns and fractures extending into the femoral neck or subtrochanteric regions. These types are not well controlled by the sliding compression hip screw and side plate and are associated with a high rate of fixation failure when treated with dynamic hip screw. Theoretical biomechanical advantages of intramedullary nails over screw and plate fixation are attributed to a reduced distance between the hip joint and the implant. Success of Proximal femoral nail for the treatment of such fractures is based on biomechanical principles,cadaver studies and clinical series. Although it is seems that nail fixation is superior to sliding compression hip screw and side plate fixation for the treatment of unstable fractures, this point is not well proven till date. Orthopedic literature does not support the superiority of intramedullary nail fixation over sliding hip screw fixation for the treatment of intertrochanteric femoral fractures and intramedullary nail fixation is associated with a higher complication rate. Till date the debate over superiority of extramedullary fixation versus intramedullary implants continues especially in unstable intertrochanteric fractures. This article highlights the advantages and disadvantages of proximal femoral nail in intertrochanteric fractures with review of literature. Keywords: Intertrochanteric fractures, intramedullary nail, dynamic hip screw

A prospective comparative evaluation for the use of an intramedullary hip-screw versus a compression hip-screw with a plate for intertrochanteric femoral fractures

Background Combining the advantages of intramedullary fixation with those of a sliding screw theoretically overcomes the usual complications of dynamic hip-screw fixation. A comparative study was conducted to evaluate the credibility of the use of intramedullary screw over the conventional dynamic hip-screw. Patients and methods A total of 100 elderly patients who had an intertrochanteric femoral fracture were randomized to treatment with a compression hip-screw with a plate (50 patients) or intramedullary hip-screw (50 patients). All patients were followed up prospectively for 1 year. A detailed assessment of the functional status and the plain radiographs of the hip was performed at 1, 3, 6, and 12 months postoperatively. The two treatment groups were strictly comparable. Results The operative time needed to insert the intramedullary hip-screw was significantly greater than that needed to insert the compression hip-screw with the plate, but use of the intramedullary hip-screw was associated with less estimated intraoperative blood loss. There were one intraoperative fracture of the femoral shaft and two intraoperative fractures of the greater trochanter in the group managed with the intramedullary hip-screw. One patient had pulling-out of the compression hip-screw on the seventh postoperative day. Four patients had a wound hematoma after insertion of an intramedullary hip-screw. All but one of the fractures healed. The one nonunion, which was in a patient who had a compression hip-screw, was treated with a hemiarthroplasty. Fourteen patients who had an intramedullary hip-screw had cortical hypertrophy at the level of the tip of the nail at 12 months postoperatively. Six of these patients also had pain in the mid-portion of the thigh; three of the six patients had the hardware removed because of the pain, and the symptoms resolved. Conclusion Routine use of intramedullary hip-screws cannot be recommended for the treatment of intertrochanteric femoral fractures because of the reported complications. However, the intramedullary device is a promising alternative, especially for a comminuted fracture with subtrochanteric extension or a reverse oblique pattern.