Trochanteric Entry Research Articles

Functional and Radiographic Outcomes of Intertrochanteric Hip Fractures Treated With Calcar Reduction, Compression, and Trochanteric Entry Nailing

Shortening after intertrochanteric hip fractures with sliding constructs is an increasingly recognized problem by the orthopaedic community. It often results in a limb length discrepancy causing maladaptation of the abductor lever arm. Functional limitations can also result from altered hip biomechanics and negatively influence patient outcomes. We hypothesized that with trochanteric entry nailing, calcar reduction, and intraoperative compression, a near-normal restoration of gait parameters and satisfactory outcomes can be achieved. Level 4, prospective descriptive study. Level 1 trauma care center. Fifty-eight patients with intertrochanteric hip fractures were managed operatively from 2007 to 2008. A strict exclusion criterion was used to analyze the data of interest for a final cohort of 30 patients. Stable fixation was achieved with trochanteric entry nail after calcar reduction and intraoperative compression of the fracture site. Patients were grouped into stable (n = 17) and unstable (n = 13) fracture types based on the OTA classification. OUTCOME/MEASUREMENTS: Postoperative collapse was measured as telescoping of the lag screw from lateral cortex and blade tip migration within the femoral head. Alteration in femoral head offset and abductor lever arm was measured at the last follow-up visit. Gait parameters were recorded and compared with contralateral side at 6-week, 3-, 6-, and 12-month follow-up visits. Functional outcomes were assessed through 36-item short form health survey (version 2) and Harris Hip Scores at 1 year. Fracture type (stable or unstable) significantly predicted telescoping (P = 0.007). Mean telescoping was 3.3 mm (SD = 2.41 mm) in the unstable group versus 1.2 mm (SD = 0.81 mm) in the stable group (P = 0.004). The stable group recovered 95% of the single limb stance versus 91% in the unstable group, at 1 year. (P = 0.02). Return of single limb stance improved from 76% to 95% between 6 weeks and 6 months. No improvement in gait was seen after 6 months (P > 0.05). The average scores on the physical and mental components of 36-item short form health survey and Harris Hip Scores were 44, 53, and 89, respectively. The radiographic union rate was 100%. There was 1 (3%) screw cutout that did not require a revision surgery in our series. There were no cases with implant failure, femur fracture, or any wound complications. Satisfactory functional outcomes with near-normal gait restoration can be achieved in cases of intertrochanteric hip fractures with an emphasis on calcar reduction and compression after fixation with trochanteric entry nail. Therapeutic Level IV. See page 128 for a complete description of levels of evidence.

Functional Outcome Following Intramedullary Nailing of the Femur: A Prospective Randomized Comparison of Piriformis Fossa and Greater Trochanteric Entry Portals

Functional Outcome Following Intramedullary Nailing of the Femur: A Prospective Randomized Comparison of Piriformis Fossa and Greater Trochanteric Entry Portals

Femoral bone strains during antegrade nailing: A comparison of two entry points with identical nails using finite element analysis

BackgroundAntegrade femoral nailing has become the standard treatment for diaphyseal femoral shaft fractures. Concerns linger that improper location of the nail entry point may lead to iatrogenic fracture and further complications. This study used finite element analysis to compare the strain magnitude and distribution resulting from each of two entry points in the proximal femur during antegrade nailing. MethodsA finite element model was created from a CT scan of a 37year old male femur and of a standard antegrade nail. Using implicit time-stepping, the nail was inserted through piriformis and trochanteric entry points and strain was computed at 9 anatomic locations. FindingsThe strain levels were higher overall when inserting a nail through the trochanteric starting point. The highest strain occurred immediately medial and lateral to the trochanteric entry point. The posterior greater trochanter also showed very high strain levels during nail insertion. All strain values for nail insertion through the piriformis entry point were less than 2000μm/m. InterpretationThe trochanteric entry will have a much greater potential of iatrogenic fracture of the proximal femur during insertion of a nail. Strains with this entry point exceed the yield level of bone and the repeated loading with the progression of the nail could cause fissures or fractures. Caution should be taken during insertion of an antegrade nail when utilizing a lateral trochanteric starting point secondary to an increased risk of trochanteric fracture and lateral cortex fracture.

Use of the Sheffield Telescopic Intramedullary Rod System for the Management of Osteogenesis Imperfecta

Elongating intramedullary rods have been used in the management of osteogenesis imperfecta for the past fifty years. The complication rates reported in many reviews of the available techniques have been high. This study reviews the long-term functional outcomes and complications following the use of the Sheffield system of telescopic intramedullary rods. We conducted a retrospective analysis of patients with osteogenesis imperfecta who were at least eighteen years of age and who had at least thirteen years of follow-up. Complications, reoperations, and data from a disease-specific questionnaire and the Short Form-36 questionnaire were recorded. Data for twenty-two patients with osteogenesis imperfecta who had been treated with Sheffield telescopic intramedullary rods were available at an average of nineteen years after the initial surgery. Reoperations involving thirty-three (50%) of the sixty-six rods were performed: ten rods (15%) were exchanged because of rod disengagement due to growth, thirteen rods (20%) were exchanged because of complications, and ten rods (15%) required further surgery other than exchange because of complications. Mobility was significantly improved at the initial postoperative visit (p = 0.0015), and this improvement was maintained into adulthood (p = 0.0077). Back pain was the most frequent symptom. Symptoms related to rod insertion across the knee and ankle were rare, but symptoms related to proximal femoral trochanteric entry were common. Physeal damage was not seen following surgery, and all rods elongated with growth. All patients were satisfied with the outcome of the surgical procedures. Short Form-36 scores for all physical domains and for social function and vitality were significantly worse than those in a normal population. The outcomes of this technique are satisfactory in adulthood; reoperation rates are high but are most commonly related to the patient outgrowing the rods. Concerns regarding insertion of this fixed device at the knee and ankle were unfounded, although proximal femoral fixation remains a problem.

A Systematic Review of Rigid, Locked, Intramedullary Nail Insertion Sites and Avascular Necrosis of the Femoral Head in the Skeletally Immature

Fracture of the femoral shaft is a common injury that has varying etiology in the pediatric population. Rigid, locked, intramedullary nailing allows for early mobilization, and is usually reserved for older children and adolescents with good success. Avascular necrosis (AVN) of the femoral head is a rare, but serious complication. The entry site of the nail has been speculated to have an effect on the risk of AVN, with different nail entry sites used to avoid the proximal femoral blood supply. The purpose of this study was to complete a review of the literature and elucidate the effects of nail entry site on the risk of AVN of the femoral head. The English medical literature (Pubmed and Embase) was searched and 1277 articles were identified and reviewed. Articles were excluded if they were case reports, did not examine long-term complications, or if the insertion location of the intramedullary nail could not be determined. Articles were also excluded if they examined both femoral neck and femoral shaft fractures. All of the patients using each insertion site were combined together for analysis to determine the overall AVN complication rate. From the 1277 articles found during the searches, 19 relevant articles were identified. The piriform fossa AVN rate was 2%. The AVN rate for the tip of the greater trochanter entry site was 1.4%. There were no reported cases of AVN using the lateral aspect of the greater trochanter as an entry site. The primary limitation of this study is that it reviewed retrospective data and the 3 research groups were not equal in size. The lateral trochanter as an insertion site for rigid, locked intramedullary nailing has the lowest risk of AVN when treating pediatric femur fractures based on the current literature.

Is There a Standard Trochanteric Entry Site for Nailing of Subtrochanteric Femur Fractures?

To evaluate the variability of the ideal trochanteric starting point as a possible cause for malreduction of subtrochanteric fractures and to analyze the accuracy of contralateral templating to predict correct entry site. Standardized anteroposterior pelvis radiographs of 50 patients were evaluated by two independent reviewers. Patients with advanced osteoarthritis, severe hip deformity, and radiographs with asymmetric hip rotation were excluded. Ideal nail entry site was established using a template for a trochanteric nail with a 6° proximal bend. The distance from the greater trochanteric tip to the ideal nail entry site was measured. Additionally, offset of the greater trochanter tip from the femoral longitudinal axis was measured. Interobserver reliability and accuracy of contralateral templating were evaluated. The ideal entry point ranged from 16 mm medial to 8 mm lateral to the trochanteric tip (mean, 3 mm medial; standard deviation, 5 mm). In 70% of patients, the ideal entry point was medial to and in 23% lateral to the tip of the greater trochanter. Ideal entry points were located within 2 mm of the trochanteric tip in 29% and within 4 mm in 44% of patients. The location of the ideal entry point relative to the trochanteric tip had a weak correlation with patient height and neck shaft angle (r: -0.23 and r: -0.35, respectively). Interobserver reliability and agreement between left and right side measurements were strong (intraclass correlation coefficient: >0.94 and >0.88, P < 0.001, respectively). The mean measurement differences between sides was 0 mm (95% confidence interval: -1 to 1). Greater trochanter offset averaged 15 mm (range, 5-26 mm; standard deviation: 5) on the right and 15 mm (range, 5-25 mm; standard deviation: 5.1) on the left (P = 0.95). A high degree of variability exists for the ideal trochanteric entry site. The trochanteric tip represents the ideal starting point in only the minority of cases. Preoperative contralateral templating provides an accurate means for establishing a patient-specific entry point to minimize fracture malreduction.

Pseudoaneurysm of the profunda femoris artery following a long anterograde intramedullary nail for an unstable intertrochanteric hip fracture: A case report and review of the literature

The incidence of hip fracture has been on the increase and projected to be higher than 6 million cases by the year 2050. Complications due to surgical fixation of hip fractures include, but are not limited to, infection, mal or nonunion, avascular necrosis, hardware failure, neurovascular injuries, and death. Vascular complications after surgical hip fracture fixation are very rare. We report a patient who developed Pseudoaneurysm of the profunda femoris artery following an anterograde trochanteric entry long intramedullary nail for an unstable hip fracture. This patient presented 2 weeks postoperatively with weakness, dizziness, and loss of strength. Her hematocrit on presentation was 19.7, and the arterial duplex showed a 6 × 7 cm pseudoaneurysm in the profunda femoris artery. Vascular coil embolization was performed, and the patient fully recovered. Discussion of this particular case and complication along with a full literature review on the topic of pseudoaneurysm after fracture fixation is presented.

Decreased Complications of Pediatric Femur Fractures With a Change in Management

Elastic intramedullary nails are commonly the preferred treatment option for operative stabilization of pediatric diaphyseal femur fractures. Increased complication rates have been reported in unstable fractures and older patients treated with TENs (titanium elastic nails). The reported complications have led to a change in management at our institution: limiting the use of TENs and using submuscular plating and trochanteric entry nails as alternatives. The purpose of this study is to analyze whether this change in management has improved outcomes defined by a decrease in complications between 2 time periods. This retrospective study compared 2 cohorts of femur fractures: those treated from January 2001 to January 2003 versus those treated from January 2003 to December 2006. Patient's age, weight, fracture type (stable or unstable), operative fixation technique, and complications were compared. Outcomes were measured by major or minor complications that occurred after operative treatment. Period I consisted of 46 patients and Period II of 95 patients. There was a significant decrease in TEN use in unstable fractures in Period II versus Period I. Submuscular plating increased from 9% in Period I to 28% in Period II. All complications decreased from 52% in Period I to 23% in Period II. Major complications decreased from 22% to 5%, and minor complications decreased from 30% to 18%. Complications in unstable fractures decreased from 57% to 26% and in stable fractures from 48% to 22%. Outcomes of pediatric femur fractures are improved with limiting the use of TENs to stable fractures. Complications resulting from unstable femur fracture management have decreased with other methods of stabilization such as submuscular plating or trochanteric entry nails.

Treatment of Pediatric Diaphyseal Femur Fractures

Methods of treating pediatric diaphyseal femur fractures are dictated by patient age, fracture characteristics, and family social situation. The recent trend has been away from nonsurgical treatment and toward surgical stabilization. The clinical practice guideline on pediatric diaphyseal femur fractures was undertaken to determine the best evidence regarding a number of different options for surgical stabilization. The recommendations address treatments that include Pavlik harness, spica casts, flexible intramedullary nailing, rigid trochanteric entry nailing, submuscular plating, and pain management. The guideline authors conclude that controversy and lack of conclusive evidence remain regarding the different treatment options for pediatric femur fractures and that the quality of scientific evidence could be improved for the revised guideline.

A Critical Analysis of the Eccentric Starting Point for Trochanteric Intramedullary Femoral Nailing

Antegrade femoral intramedullary nailing through a greater trochanteric insertion site has been proposed for the treatment of subtrochanteric fractures. The currently available trochanteric nails have dissimilar characteristics, and the most appropriate insertion site for satisfactory subtrochanteric fracture alignment has not been determined. This study is an analysis of 5 different trochanteric femoral nails and 3 different insertion sites using a cadaveric model of a reverse obliquity subtrochanteric femur fracture to determine the optimal trochanteric entry site. OSHA-approved cadaveric laboratory with an OEC 9800 (General Electric Company, Fairfield, CT) fluoroscopic C-arm. Twenty-one embalmed human cadaveric femurs were stripped of soft tissues. Three different starting points on the anteroposterior radiograph were used: at the tip of the greater trochanter, and 2 to 3 mm medial and lateral to the tip. A reverse obliquity subtrochanteric fracture was created. The Trochanteric Antegrade Nail (TAN), Gamma nail (2nd and 3rd generations), Trochanteric Fixation Nail (TFN), and the Holland Nail were then inserted. The proximal bend and radius of curvature were calculated for each nail. Varus and valgus angulation as well as lateral gapping were measured on radiographs; also calculated were the mean, range, and standard deviation. Statistical analysis was performed on angulation and gapping at the fracture site by using Fisher least significant differences analysis, based on a 2-way ANOVA test. The Holland nail had a proximal bend of 10 degrees and a radius of 300 cm. TAN was 5 degrees and 350 cm, TFN was 6 degrees and 150 cm, Gamma 2 was 4 degrees and 300 cm, and Gamma 3 was 4 degrees and 200 cm. The tip starting point led to the most neutral alignment regardless of nail. The lateral starting point led to varus with all nails. The medial starting point led to valgus of >6 degrees with the Holland and TFN; Gamma and TAN had better alignment with <4 degrees of valgus. Gapping of the lateral cortex was greatest with a lateral starting point. An analysis of 5 trochanteric intramedullary nails with different proximal bends and 3 different starting points in the greater trochanter showed that the tip of the trochanter is close to the "universal" starting point. In this cadaveric subtrochanteric fracture model, the tip starting point led to the most neutral alignment regardless of nail used. The lateral starting point led to varus and gapping of the lateral cortex with all nails. Subtrochanteric fractures treated with a trochanteric antegrade nail should have an acceptable reduction before nail insertion. The tip of the trochanter, or even slightly medial, on anteroposterior fluoroscopy is recommended as the universal starting point for these nails. However, slight deviations from this point and nail geometry can cause fracture site malalignment. A lateral starting point led to varus alignment and should be avoided.

Is There a Gluteus Medius Tendon Injury During Reaming Through a Modified Medial Trochanteric Portal? A Cadaver Study

The purpose of this cadaveric study was to evaluate whether there is any damage to the gluteus medius tendon when reaming through a modified medial trochanteric portal for antegrade intramedullary femoral nailing. Ten cadaver hips were used in this study. A guidewire was placed in the modified medial trochanteric portal using the assistance of C-arm fluoroscopy and a 14-mm reamer was advanced over the wire. After the reaming was complete, each hip was dissected and the gluteus medius muscle and tendon were inspected to evaluate the amount of intrasubstance and medial tendon damage. Precise localization of the modified medial trochanteric portal was achieved in 9 of 10 cadaver hips. Of those nine hips, the use of the modified medial trochanteric portal did not result in any visible damage to the tendinous insertion of the gluteus medius or the medial aspect of the tendon in any of the specimens. There is no damage to the gluteus medius tendon with the use of the modified medial trochanteric portal. Although the clinical implications of this finding are not known with certainty, the use of the modified medial trochanteric entry portal for antegrade femoral nailing could possibly result in less postoperative morbidity because it does not damage the gluteus medius tendon as compared to the traditional more lateral trochanteric portal.