Treatment Of Trochanteric Fractures Research Articles

Factors Influencing Treatment of Proximal Femoral Fractures.

Orthopaedics and traumatology departments are dominated by patients with proximal femoral fractures, who represent 20-30% of all patients treated there. The aim of this study was identification and evaluation of factors influencing treatment of proximal femoral fractures. Between 2008 and 2015, we treated 424 femoral neck fractures and 442 trochanteric fractures in patients over 40 y/o. The impact of fracture location (femoral neck/trochanteric), character (non-displaced/displaced) and the patient's general condition (metrical/biological age, health condition) on qualification and treatment used (fixations/hip pro-sthesis/non-operative) was analyzed. The results show a significant impact of factors such as type of fracture and general health condition on treatment method selection (mainly in femoral neck fractures). The distinction between non-displaced and displaced fractures is significant in preoperative qualification. For displaced femoral neck fractures, total hip replacement (non-cemented) was performed in patients between 55 and 65 y/o, while total hip replacement (cemented) and hemiarthroplasty (bipolar/Austin Moore's) in patients between 75 and 90 y/o. In lateral fractures of the femoral neck, mostly total hip replacement and occasionally proximal femoral nail fixation was performed. The importance of qualification factors was much lower in preoperative qualification of trochanteric fractures, where internal fixation remains the primary method of treatment and total hip replacement was only used in patients with co-existing coxarthrosis. 1. The biggest impact on selection of femoral neck fractures treatment method was exerted by the degree of displacement of bone fragments, age and the patient's pre-injury walking status. 2. Besides general condition, the presence of coxarthrosis was the most important factor influencing trochanteric fracture treatment method.

Total hip arthroplasty after failed treatment of proximal femur fracture.

Total hip arthroplasty (THA) is a good option as a salvage procedure after failed treatment of proximal femur fracture. The anatomy of the proximal femur, however, makes this surgery complicated and challenging. The purpose of this study was to evaluate the radiographic and clinical outcomes of THA after failed treatment of proximal femur fractures. We retrospectively analysed 50 consecutive THAs (42 women, 8 men; mean age 77years) after failed treatment of a proximal femur fracture. Mean postoperative follow-up was 58.1months. Preoperative diagnoses were femoral neck fracture in 18 hips and trochanteric fracture in 32 hips, including three that were infected. Failure resulted from cutout in 22 cases, osteonecrosis in 12, non-union with failed fixation in nine, postoperative osteoarthritis in four, and infection in three. Factors compared included radiographic assessment, complication rate, visual analogue scale (VAS), and Harris Hip Scores (HHS). Radiographic variables included femoral neck anteversion and cup and stem alignment. Absolute values of the differences in femoral neck anteversion between the affected and healthy sides were 6.0° in the femoral neck fracture group and 19.2° in the trochanteric fracture group (p = 0.01). There were no significant differences in cup anteversion (p = 0.20) or stem anteversion (p = 0.08). The complication rate was significantly higher in the trochanteric fracture group than in the femoral neck fracture group (25 vs 0%, p < 0.0001). Postoperative complications in the trochanteric fracture group included three periprosthetic fractures (9.4%), two dislocations (6.3%), two surgical-site infections (6.3%), and one stem penetration (3.1%). Although no significant differences between groups were seen in the VAS or HHS at final follow-up (p = 0.32, 0.09, respectively), these measures were significantly improved at final follow-up in both groups (p < 0.0001 for both). Performing THA after failed treatment of trochanteric fractures requires consideration of complication risk and incorrect femoral neck anteversion.

Dynamic Hip Screw and Proximal Femoral Locking Compression Plate as a Surgical Treatment of Trochanteric Fracture of Femur a Comparative Study

Dynamic Hip Screw and Proximal Femoral Locking Compression Plate as a Surgical Treatment of Trochanteric Fracture of Femur a Comparative Study

Complications in Treatment of 31-A Fractures with Trochanteric Gamma Nail (TGN) Versus Gamma3 Nail (G3N) - A Review of 217 Cases.

Introduction:The aim of this study was to clinically evaluate two generations of intramedullary gamma-nail used in the treatment of 31-A femur fractures.Materials and Methods:In two consecutive series, 117 trochanteric gamma nails (TGN) and 100 Gamma3 nails (G3N) were implanted for the treatment of inter- and subtrochanteric fractures between 2009 and 2011. Clinical and radiological follow-up examinations were assessed. An analysis of surgical time, hemoglobin drop and complications were performed.Results:Average surgical time, fluoroscopy time, haemoglobin drop and length-of-stay (LOS) were similar in both groups. No significant differences were found in surgery-related complications like wound hematomas (p=0,59), abscesses (p=0,38), wound infections (p=0,69) and Cut-outs (p=0,69) between the two groups. The cumulative surgery-related complication rate was higher in the TGN group compared to the G3N group (13,68% vs. 8%) but this did not reach statistical significance (p=0,2).Conclusion:Our findings suggest that both TGN and G3N allow adequate treatment of trochanteric fractures with an acceptable complication rate.

Surgical treatment of proximal femur osteoporotic fractures (literature review)

Proximal femur fractures is the complex medical-social problem because of prevalence in the elderly patients and is related to the most dangerous complications of osteoporosis. Difficulties in the treatment of trochanteric fractures in the patients of this category not related only to osteoporotic changes, but to comorbities. Epidimeology, classification, treatment principles of proximal femur in the elderly patients are presented in this work. It is noted, that determination of the bone density is the main volume for the fracture risk prediction in the elderly patients, decreasing of the bone mass burdens the course of traumatological and orthopedic pathology. As the result of scientific publications analyses, we revealed debatable questions in the treatment of the elderly patients. At present, active surgical tactic is the most recognized, however, in spite of the implants manifold, precise indications for the definitive implant application and osteosynthesis methods are not well defined, especially in the light of the age aspect. Problems of the early rehabilitation for the weight bearing and motion, improving and preservation of the somatic status, lethality decreasing, demand further specification. In-depth studies are necessary for the determination of the differentiated osteosynthesis choice and treatment technology optimization for the improving of the surgical treatment in elderly patients with extraarticular proximal femur fractures. Perspective directions in the treatment of the extraarticular proximal femur fractures in the elderly patients are extracted.

Cutout of lag screw in the treatment of trochanteric fractures for 35 years

Cutout of lag screw in the treatment of trochanteric fractures for 35 years

Do PFNA devices and Intertan nails both have the same effects in the treatment of trochanteric fractures? A prospective clinical study

ObjectiveTo clinically and radiologically compare third-generation intramedullary nails used in the treatment of trochanteric hip fractures and to determine their efficacy. Materials and methodsSeventy-five of 88 patients admitted to our hospital with trochanteric fractures were enrolled in the study; 43 were treated with PFNA devices and 32 with Intertan nails. The amount of compression applied during the procedure, duration of the procedure, amount of subsequent shortening in the proximal femoral area, subsequent backup of proximal screws, and changes in the tip-apex and tip-cortex distances were compared between groups. The postoperative change in the varus angle of the proximal femur and times to mobilization, full weight bearing, and fracture union were also evaluated. ResultsOn early postoperative radiographs, the tip-apex distance was ≤25mm in 86% of patients in the PFNA group and 96.9% of those in the Intertan group. Twelvemonths postoperatively, the tip-apex distance did not differ between groups. No cut-out of the screws into the coxofemoral joint was observed. Fracture healing was achieved in all patients. At 12months postoperatively, the rates of proximal screw backup, proximal femoral shortening, and decrease in the varus angle of the proximal femur were significantly higher in the PFNA group than in the Intertan group. ConclusionsTrochanteric fractures may be treated effectively with PFNA devices or Intertan nails. During the healing period, the rates of reverse displacement of the proximal screw, shortening of the proximal femur, and decrease in the varus angle of the proximal femur were significantly higher in the PFNA group than in the Intertan group. Surgical technique, implant positioning, and the choice of implant play roles in the successful treatment of trochanteric fractures. Level of evidenceLevel 1, prospective, prognostic study.

Biomechanical effect of different femoral neck blade position on the fixation of intertrochanteric fracture: a finite element analysis.

Medial migration or cutout of the neck helical blade has commonly occurred in the treatment of trochanteric fracture of the femur. The position of the helical blade within the femoral head is one of the influencing factors that cause the blade to perforate the intact joint surface; however, the ideal placement of the helical blade is not currently known. A finite element model of a femur/nail construct was utilized to analyze five possible blade positions in the femoral head. Normal strain at the fracture surface, the minimum principal strain in the cancellous bone, and the von Mises stress in the implant itself were calculated and compared between different blade positions. The results showed that a large area of normal compressive strain at the fracture surface was observed in the inferior and posterior blade positions. The volume of cancellous bone strained to yielding in the femoral head and neck was lower for the inferior and posterior positions, whereas it was the highest for the superior position. The inferior and posterior positions had lower von Mises stress in the implant itself. The inferior and posterior positions may be the ideal position for the intramedullary nail with a helical neck blade.

Computational Study in Effects of Nail- and Plate-Implants on the Treatment of Pertrochanteric and Intertrochanteric Fractures

Abstract This research is to evaluate and identify the most suitable implants for the treatment of trochanteric fractures. Using finite element analysis method (FEM), we developed trochanteric-fractured 3D models based on Arbeitsgemeinschaftfür Osteosynthesefragen (AO) classification. Three types of trochanteric fractured models were assembled with four different implants leading to 12 models. The trochanteric fractures were identified as 31-A1.1, 31-A2.1, and 31-A3.1 fracture fixed with short proximal femur nail antirotation (PFNA), long PFNA, dynamic hip screw (DHS), and PF-locking compression plate 4.5/5.0. The assembled models were calculated and analyzed using the FEM. The simulation illustrated the von Mises stress distribution and displacement on 12 models. The intramedullary nail implant is superior to the external plate. Short PFNA and DHS are suitable to fix pertrochanteric fractures; long PFNA is considered a priority to treat intertrochanteric fractures.

Salvage of lag screw’s cut out after Gamma nail treatment of trochanteric fractures

Salvage of lag screw’s cut out after Gamma nail treatment of trochanteric fractures

Treatment of trochanteric fractures with the gamma3 nail - methodology and early results of a prospective consecutive monitored clinical case series.

Objectives: There is only sparse data on clinical results and complications of the third-generation Gamma nailing system (Gamma3, Stryker). Therefore, we started a large multi-centre case series in 2008. The aim of this paper is to present the study design and early results of a single arm of a prospective, consecutive, monitored, post-market follow-up evaluation of Gamma3 nails. Methods: From September 2009 to January 2012, 154 consecutive patients with an average age of 80 ± 1.43 years (50-99 years) and a trochanteric femoral fracture were included in the local arm of the trial. All patients that fulfilled the inclusion criteria were treated with a Gamma3 nail. Preoperative variables included age, gender, fracture classification, walking ability (Merle d’Aubigné score), daily activity level (retrospective Zuckerman score), ASA rating of operative risk, waiting time for operation, use of walker or crutches and body mass index (BMI). Skin-to-skin time, fluoroscopy time, blood loss, intraoperative complications and device information were recorded for each patient. Follow-up postoperative assessment was undertaken at 4, 12 and 24 months. Hip range of motion, pain around the hip and the tight, walking ability (Merle d’Aubigné score, Sahlgrenska mobility score) and management of daily life (Zuckerman score) were used to evaluate the outcome. Results: The descriptive data of age, gender, BMI, ASA classification, fracture type and skin-to-skin time is similar to other studies. Median fluoroscopy time was 62 seconds (range: 4-225 seconds) and significantly shorter in closed reductions. No intraoperative implant-related complication was recorded. A cut-out of the leg-screw during assessment period occurred in 2.6% patients (n = 4). At the 12-month assessment two (1.8%) non-unions were identified and two patients (1.8%) had broken the femoral shaft below the 180 mm nail after a fall. Analysis of the scores showed significantly declined mobility and activity in daily life four months after operation which increased significantly from four to 12 months and increased slightly between 12 and 24 months after fracture. Conclusion: A low implant-associated complication rate was achieved in geriatric patients with trochanteric femoral fractures using the Gamma3 nail. A better outcome concerning mobility, activity in daily life and complications compared to the Gamma2 nail could not be found in comparison to historic data.

A Comparison of Intramedullary and Extramedullary Fixation Devices in Unstable Trochanteric Fractures

Objectives: The main objective of the study was to compare functional outcome and complications associated with a proximal femoral nail, an intramedullary device with those of a traditional extramedullary device, the dynamic hip screw, in patients with unstable trochanteric fracture. Method: In this prospective, randomized study, total of 86 patients were randomized to the intramedullary group [Group A ( n = 40)] or the extrmedullary group [Group B ( n = 46)]. All relevant perioperative information and complications were recorded, and assessments of functional outcome were made. Results: The extramedullary group required a longer operative time (p value 0.001) and was associated with greater blood loss (p value 0.002) than the intramedullary group. The re-operation rate as well, was lower in the group A compared with the group B, although there were no statistically significant difference in the overall complication rate between the two groups (p value 0.221). There were no significant differences in functional outcome between both groups. Conclusions: The intramedullary device is useful in the treatment of unstable trochanteric fractures.

Gamma nail in the treatment of closed trochanteric fractures. Results and indications of 121 cases

The Gamma Nail is the latest advance in the treatment of trochanteric fractures based on intramedullary nailing principles during closed procedures. Its design is based on Küntscher's Y-nail and locking intramedullary (IM) nails. This paper reports the results from the first-ever series of 121 patients operated between 1988 and 1990. They were followed until bone union was achieved. The mean patient age was 75years. Most patients were in poor general health and had unstable fractures. Anatomical preoperative reduction was achieved in 72% of cases. Fixation was good in 66% of cases and acceptable in 27% of cases. Intra-operative complications consisted of nine fractures without consequences. Of the treated patients, 83.4% resumed weight-bearing during the first week. There was one case of deep infection that resolved with treatment. The mortality rate was 12.3% at three months. We noted 7 alunions in varus, 3 in valgus, 2 in external rotation and 1 in internal rotation. There were no cases of non-union. In six cases, the screw had cut out of the femoral head. The drawbacks associated with surgical treatment methods for trochanteric fractures also apply to the Gamma nail. Nevertheless, one of its primary advantages is the possibility of using a closed procedure. When compared to Ender nailing, knee pain is absent and weight-bearing can be achieved in all patients, no matter the fracture type.

Results of Asian Type Gamma 3 Nail in Treatment of Trochanteric Fractures

213 Copyright c 2014 The Korean Fracture Society. All rights reserved. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/ by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Received November 26, 2013 Revised May 30, 2014 Accepted May 30, 2014 Address reprint requests to: Ji Hyo Hwang, M.D., Ph.D. Department of Orthopedic Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, 1 Singil-ro, Yeongdeungpo-gu, Seoul 150-950, Korea Tel: 82-2-829-5165ᆞFax: 82-2-834-1728 E-mail: hwangjihyo7309@gmail.com

Management of intertrochanteric fracture in elderly high-risk patients using simple external fixation

Objectives The goal of this study was to report and evaluate the role of external fixation in the treatment of trochanteric fractures in patients with a high unacceptable operative risk to withstand conventional osteosynthesis and to obviate the many disadvantages of traction and prolonged rest in bed. Background External fixation has been used for the management of fractures for a long period of time. Good fixation, mild blood loss, and early ambulation are always the main advantages of this technique. Its other advantages are that it is simple, quick, inexpensive, and causes minimal surgical trauma. Materials and methods Between March 2011 and September 2012, 20 patients, six men and 14 women, mean age 65.9 years, with trochanteric fractures and considered preoperatively as 'poor medical status', were treated in the Orthopedic Department, El-Menufiya University Hospital, by external fixation and early mobilization. The technique was prescribed. Results All fractures were united at ~22.2 weeks (range 16-26 weeks). A superficial pin-tract infection was found in 14 patients. Two cases showed penetration of the femoral head; shortening of more than 2 cm was observed in four patients. Conclusion The use of the external fixator in these patients reduced their time in the hospital and facilitated their postoperative rehabilitation by allowing uncomplicated healing of a complicated fracture.

Complications following Treatment of Trochanteric Fractures with the Gamma3 Nail: Is the Latest Version of Gamma Nail Superior to Its Predecessor?

Gamma nail is a cephalomedullary implant that was developed for the treatment of pertrochanteric hip fractures and has been successfully used for over 20 years. During this period, modifications of design and instrumentation have occurred to combat the intra- and postoperative complications that were associated with the use of early designs. The purpose of this study was to compare the complications observed with the use of the Gamma3 nail (G3N) with those seen following use of the previous trochanteric gamma nail (TGN). This study prospectively recorded the intra- and postoperative complications of 175 patients treated with the Gamma3 nail and compared them with those of a historical cohort of 192 patients treated with the trochanteric gamma nail. We encountered less intra- and postoperative complications with the use of Gamma3 nail. Femoral fractures and lag screw cutout were significantly lower. The reoperation rate was significantly higher in the TGN group. Gamma3 nail has proved to be a safe and efficient implant for the treatment of pertrochanteric fractures. The improvement of the biomechanical characteristics has led to a significant decrease in complication rates, demonstrating superiority over its predecessor.

Japanease PFNA Compression Bladeを用いた治療経験

Japanease PFNA Compression Bladeを用いた治療経験

Indications for treatment of femoral trochanteric fractures with reversed less invasive stabilization system (LISS)

Objective To discuss outcomes of and indications for treatment of femoral trochanteric fractures with reversed less invasive stabilization system (LISS).Methods A retrospective study was performed for 72 consecutive patients with femoral trochanteric fracture who had been treated with reversed LISS at our institution between June 2005 and June 2011.They were 33 men and 39 women,with a mean age of 73.4 years (range,45 to 87 years).The operation time,intraoperative blood loss,intra-hospital complications and internal fixation-related complications at the last follow-up were analyzed.The fracture union was assessed by follow-up radiographs and hip functional recovery by Harris hip scoring.Results The operation time averaged 141.4 minutes and the intraoperative blood loss averaged 138.1 mL.The intra-hospital complications included deep venous thrombosis in 3 cases,pneumonia in one,gastrointestinal bleeding in one,postoperative delirium in one,and a death resulting from multiple organ failure.Sixty-five patients (90.3％) obtained a mean follow-up of 22.1 months (range,18 to 46 months).The fracture union was achieved after an average of 4.2 months (range,3 to 8 months).The mean Harris score at the last follow-up was 73.7 points (range,20 to 100 points).Eight patients were excellent,19 good,25 fair and 13 poor,giving an excellent to good rate of 41.5％.The internal fixation-related complications at the last follow-up were observed in 10 out of the 65 patients (15.4％),including 6 cases of screw breakage,one of nonunion,one of plate breakage,one of screw loosening and one of malunion.Conclusions Reversed LISS should not be a routine treatment for femoral trochanteric fractures because of its high rate of complications.We recommend its indications include fractures more complex than AO type 31A2.2,those with a narrow medullary canal,those with a severely bowed or deformed femur,pathologic and periprosthetic ones and those with multiple traumas and a priority of immediate trauma control. Key words: Hip fractures; Fracture fixation, internal; Bone plates; Surgical procedures,minimally invasive; Indication

Clinical and functional outcomes of the PCCP study: a multi-center prospective study in Italy.

The standard surgical management of hip fractures is associated with tissue trauma and bleeding which are added to the fracture injury. The percutaneous compression plate (PCCP) is a minimally invasive device that has been demonstrated in previous studies to reduce postoperative complications and blood loss. This prospective, multi-center, observational study assessed clinical and functional outcomes with PCCP as treatment for trochanteric fractures. Patients with a stable or unstable proximal femoral fracture of type AO 31.A1 or 31.A2 were enrolled in eight hospitals in Italy. The primary outcome of interest was the recovery of the pre-fracture functional status at 1-year follow-up; secondary outcomes of interest included blood transfusions, surgical time, complications, and mortality. A total of 273 patients were enrolled. The ASA score was 3 or 4 in 72.5 % of patients. The mean surgical time was 44.1 min; the mean post-surgery blood transfusions was 0.9 units. At 1 year, 48 patients (17.6 %) died, 28 (10.2 %) were lost to follow-up, 4 patients (1.5 %) were excluded, hence 193 patients (70.3 %) were available for final evaluation. At the 1-year follow-up visit, 51.9 % of patients recovered or improved their pre-fracture modified Harris Hip Score, 49.1 % of patients improved or maintained their walking abilities, and 66.6 % of patients residing at home pre-surgery maintained their domicile. The overall mortality rate was 17.6 %. Major complications included two fracture collapses, one excessive sliding of the cephalic screw leading to a partial fracture collapse and one back-out of the diaphyseal screw. This study demonstrates that treatment of trochanteric fractures with PCCP gives good outcomes and significant advantages such as low blood loss, short surgical time, low risk of complications, and good functional recovery in the majority of the patients.

Surgical Treatment of Trochanteric and Cervical Hip Fractures in the United States: 2000–2009

The objective of this study was to evaluate the most common treatments performed for hip fractures over the last decade in the United States. The leading treatment for trochanteric fractures was internal fixation, accounting for 96%–98% of surgical treatments each year. For cervical fractures, hemiarthroplasty (HA), total hip arthroplasty (THA), and internal fixation were performed nearly 61%, 5%, and 33% of the time, respectively, each year without any sign of change during the period assessed. The surgical choice for cervical fractures varied greatly by patient age. In 2009, two-thirds of patients younger than 60 years underwent internal fixation while two-thirds of patients 60 years or older underwent HA. Regardless of patient age, HA was performed more often than THA for cervical hip fractures.