Trochanteric Femoral Fractures Research Articles

Comparative outcome of PFNA, Gamma nails, PCCP, Medoff plate, LISS and dynamic hip screws for fixation in elderly trochanteric fractures: a systematic review and network meta-analysis of randomized controlled trials.

The ideal implant for the treatment of an unstable intertrochanteric femoral fracture is still a matter of discussion. The aim of this systematic review is to conduct a network meta-analysis of randomized controlled trials (RCTs) comparing clinical outcomes between dynamic hip screws (DHS), Medoff sliding plating, percutaneous compression plating (PCCP), proximal femoral nails (PFN), Gamma nails and less invasive stabilization system fixation in femoral trochanteric fractures in the elderly. These clinical outcomes consist of total intra-operative time, intra-operative fluoroscopy time, intra-operative blood loss, blood component transfusion, length of hospital stay, postoperative general complications, wound complications, late complications and reoperation rates. This systematic review was conducted using PubMed and Scopus search engines for RCTs comparing clinical outcomes between treatments from inception to February 22, 2015. Thirty-six of 785 studies identified were eligible. Compared to the other implants, PCCP showed the lowest total operative time and units of blood transfusion with an unstandardized mean difference (UMD) of 29.27min (95% CI 5.24, 53.50) and 0.89 units (95% CI 0.52, 1.25). The lowest incidence of general complications, wound complications and late complications of PCCP was 0.09 (95% CI 0.04, 0.18), 0.01 (95% CI 0.01, 0.04) and 0.05 (95% CI 0.02, 0.11), respectively, when compared to others. The lowest fluoroscopic time was with DHS with an UMD of 0.24min (95% CI 0.16, 0.32), whereas the lowest blood loss and shortest hospital stay were with PFN with an UMD of 233.61ml of blood loss (95% CI 153.17, 314.04) and 7.23days of hospital stay (95% CI 7.15, 7.31) when compared to all other fixation methods. Reoperation rates of all implants had no statistically significant difference. The network meta-analysis suggested that fixation with PCCP significantly shortens operative time and decreases the units of blood transfusion required, while also lowering risks of general complications, wound complications and late complications when compared to fixation. Use of PFN showed the least intra-operative blood loss and shortest hospital stay. Multiple active treatment comparisons indicate that PCCP fixation in trochanteric fractures in the elderly is the treatment of choice in terms of intra-operative outcomes and postoperative complications.

Functional outcome of proximal femoral nailing in inter trochanteric fractures of femur: A prospective study

Background: The study was conducted to analyse the functional outcome of Proximal Femoral Nailing in Inter-Trochanteric Fractures of Femur. Methods: Over two years, after obtaining written consent, this prospective study was conducted among 22 patients (age group>18 years) who had Inter-trochanderic fracture treated with Proximal Femoral Nailing. The X-ray of the operated hip was taken whenever it was felt necessary and on 4th week, 8th week, 12th week and at 6th month. Functional outcome measures was done by using Harris Hip Scoring System (Modified) at the end of 6 months. Results: The present series includes, 14 males and 8 females in the age group of 47-82 years with the mean age of 62.09 years. Unstable inter-trochanteric fractures were commonly seen. Excellent results were see in 13 patients. Intraoperative and post-operative complications was seen in 9 patients. Conclusion: From this study, we consider that PFN is an excellent implant for the treatment of trochanteric fractures. With a proper technique, PFN gives excellent clinical results with almost negligible varus collapse even in unstable Inter trochanteric fractures.

Results of hip replacement in elderly patients with trochanteric femoral fractures

Fractures of the femur in the trochanteric zone in elder peo­ple dramatically change the life stereotype. This disruption of adaptation mechanisms often leads to a rapid exacerbation of concomitant chronic diseases. Current trends are reduced to the early surgical treatment of patients with femoral fractures in the trochanteric zone, which is due to better prognostic re­sults for the health and life of patients. Objective: to investigate and analyze the long-term results of hip arthroplasty in people of the older age group with trochanteric and intertrochanteric femoral fractures. Methods: clinical and radiologic examination of 47 patients (40 women, 7 men, mean age (74.2 ± 5.1) years) was performed with total cement, monopolar or bipolar hip arthroplasty. The choice of method of treatment depended on the degree of compensation of concomitant diseases. Long- term results (at least 1 year) of surgical treatment were analyzed using the Harris score. Results: excellent and good re­sults were obtained in 39 patients (82.94 %), satisfactory ones — in 7 (14.94 %), unsatisfactory ones — in 1 (2.12 %). The best long-term results were obtained by us in cases of using single-pole bipolar implants. All patients, regardless of age and before the operational functional state, quickly enough (up to 1 month) restored the previous level of efficiency and motor activity. Con­clusions: hip arthroplasty in femur fractures in the trochanteric is the method of choice for eldery people, since it provides early mobilization of patients and rapid recovery of the activity level.

A comparative study of 70 cases of inter-trochanteric fracture femur treated with dynamic hip screw and proximal femoral nailing

<p class="abstract"><strong>Background:</strong> Inter-trochanteric fracture femur is a common and grievous injury, mostly suffered in elderly people. It accounts for approximately half of hip fractures in elderly and out of this, more than 50% of fractures are unstable. In old age, it occurs mostly due to trivial trauma. Various procedures of internal fixation had been proposed as a treatment. DHS considered to be the standard procedure for comparison of outcomes. The advantage of proximal femur nailing fixation is that it provides a more biomechanically stable construct by reducing the distance between hip joint and implant. The goal of this study is to compare the clinical and radio-graphical results of the DHS and PFN for the treatment of Intertrochanteric hip fractures (load bearing vs. load sharing).</p><p class="abstract"><strong>Methods:</strong> Seventy patients (more than 55 years old) presented to Adesh Hospital from March 2015 to November 2015 with trochanteric fracture femur. Patients were treated with osteosynthesis with dynamic hip screw (DHS) and proximal femoral nailing (PFN). The clinical results were compared between the dynamic hip screw and proximal femoral nailing groups of 35 patients each. All surgeries done on traction table and were followed up at regular intervals of 4 weeks, 6 weeks, 8 weeks, 10 weeks, 12 weeks, 6 months and at 1 year.<strong></strong></p><p class="abstract"><strong>Results:</strong> We observed no statistically significant difference between two groups in view of late & early complications and time to union. We observed significantly better outcomes in PFN group for unstable inter-trochanteric fractures and in unstable fractures reduction loss is significantly lower in PFN group.</p><p><strong>Conclusions:</strong> We concluded that PFN may be the better fixation device for most unstable inter-trochanteric fractures. </p>

Factors influencing period from surgery to discharge in patients with femoral trochanteric fractures.

[Purpose] The purpose of this study was to investigate factors influencing the period from surgery to discharge in patients with femoral trochanteric fractures. [Subjects and Methods] Sixty patients with femoral trochanteric fractures were investigated retrospectively. Based on the mean period from surgery to discharge (85.6 ± 26.6 days), the patients were divided into two groups: an under-85-day group (range, 29–78 days) and an over-85-day group (87–128 days). Age, gender, fracture type, presence of lesser trochanteric displacement, discharge destination, and walking ability were investigated. The relationship between these factors and the period from surgery to discharge was analyzed with logistic regression analysis. [Results] Age and lesser trochanteric displacement were significantly higher in the over-85-day group, and walking ability before fracture and at discharge were significantly lower in the over-85-day group. Logistic regression analysis showed that lesser trochanteric displacement and age were predictors of the length from surgery to discharge. Lesser trochanteric displacement were observed in 87.5% of these. Immediate displacement after surgery occurred in 57.8% of lesser trochanteric fractures, while 26.3% displaced 1 to 3 weeks after surgery. [Conclusion] This study revealed that lesser trochanteric displacement, higher age, and lower walking ability before fracture and at discharge were associated with longer hospitalizations in patients with femoral trochanteric fractures. Lesser trochanteric displacement were observed in 87.5% of lesser trochanteric fractures. These displacements occurred within 3 weeks after surgery in 84.1% of cases.

Proposal of new classification of femoral trochanteric fracture by three-dimensional computed tomography and relationship to usual plain X-ray classification.

Classification of femoral trochanteric fractures is usually based on plain X-ray findings using the Evans, Jensen, or AO/OTA classification. However, complications such as nonunion and cut out of the lag screw or blade are seen even in stable fracture. This may be due to the difficulty of exact diagnosis of fracture pattern in plain X-ray. Computed tomography (CT) may provide more information about the fracture pattern, but such data are scarce. In the present study, it was performed to propose a classification system for femoral trochanteric fractures using three-dimensional CT (3D-CT) and investigate the relationship between this classification and conventional plain X-ray classification. Using three-dimensional (3D)-CT, fractures were classified as two, three, or four parts using combinations of the head, greater trochanter, lesser trochanter, and shaft. We identified five subgroups of three-part fractures according to the fracture pattern involving the greater and lesser trochanters. In total, 239 femoral trochanteric fractures (45 men, 194 women; average age, 84.4 years) treated in four hospitals were classified using our 3D-CT classification. The relationship between this 3D-CT classification and the AO/OTA, Evans, and Jensen X-ray classifications was investigated. In the 3D-CT classification, many fractures exhibited a large oblique fragment of the greater trochanter including the lesser trochanter. This fracture type was recognized as unstable in the 3D-CT classification but was often classified as stable in each X-ray classification. It is difficult to evaluate fracture patterns involving the greater trochanter, especially large oblique fragments including the lesser trochanter, using plain X-rays. The 3D-CT shows the fracture line very clearly, making it easy to classify the fracture pattern.

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

Augmentation of proximal femoral nail in unstable trochanteric fractures.

Introduction: Biomechanically proximal femoral nail (PFN) is a better choice of implant, still it is associated with screw breakage, cut out of screw through femoral head, Z effect, reverse Z effect, and lateral migration of screws. The purpose of this study is to evaluate the results of augmented PFN in terms of prevention of postoperative complications and failure rates in unstable trochanteric fractures. Material and methods: We carried out a prospective study of 82 cases with unstable trochanteric femoral fractures from April 2010 to December 2015. Forty-two females and 40 males in the age group between 58 and 81 years were included in this study. There were 45 cases of AO 31 A2 (2.2, 2.3) and 37 cases of AO 31 A3 (3.1, 3.2, 3.3). Fractures were fixed by PFN with augmentation by an additional screw from trochanter to inferior quadrant of femoral head or cerclage wire to strengthen the lateral trochanteric wall. Results: The bone healing is observed in all the cases in the mean period of 14.2 weeks. Nine patients developed complications, including lateral migration of neck screws (n = 5), Z effect (n = 1), infection (n = 2), and breakage of distal interlocking bolt in one case. Removal of screws was required in five cases. Patients were followed up for a mean of 8.4 months. At the end of follow-up the Salvati and Wilson hip function was 32 (out of 40) in 88% of patients. Conclusion: The stabilization of lateral trochanteric wall with additional screw or cerclage wire increases the stability of construct.

Trochanteric femoral fractures treated by proximal femoral nail, a review of 110 cases

Intertrochanteric fractures are one of the most common fractures in osteoporotic individual. It is associated with high rates of morbidity and mortality. Management of Intertrochanteric fractures causes more burden to the any orthopaedics center across the country and its create a great surgical dilemma for orthopaedician. The treatment options have evolved over time from conservative management of such kind of fractures to use of cephalomedullary nails (PFN). This study was conducted to study outcome of Trochanteric femoral fractures treated by Proximal Femoral Nail. 110 patients were included in the study.

The treatment of femoral trochanteric fractures with Two Extra Screw nail system

The treatment of femoral trochanteric fractures with Two Extra Screw nail system

A comparison of two fixation methods for femoral trochanteric fractures: a new generation intramedullary system vs sliding hip screw

A comparison of two fixation methods for femoral trochanteric fractures: a new generation intramedullary system vs sliding hip screw

Experience of use of Magnum nail for the treatment of femoral trochanteric fracture

Experience of use of Magnum nail for the treatment of femoral trochanteric fracture

Surgical results of Magnum nail for femoral trochanteric fracture

Surgical results of Magnum nail for femoral trochanteric fracture

Clinical study of post-operative results with intramedullary nail fixation to the femoral trochanteric fractures

Clinical study of post-operative results with intramedullary nail fixation to the femoral trochanteric fractures

Anchorage strategies in geriatric hip fracture management.

There is an enormous humanitarian and socioeconomic need to improve the quality and effectiveness of care for patients with hip fracture. To reduce mechanical complications in the osteosynthesis of proximal femoral fractures, improved fixation techniques have been developed including blade or screw-anchor devices, locked minimally invasive or cement augmentation strategies. However, despite numerous innovations and advances regarding implant design and surgical techniques, systemic and mechanical complication rates remain high. Treatment success depends on secure implant fixation in often-osteoporotic bone as well as on patient-specific factors (fracture stability, bone quality, comorbidity, and gender) and surgeon-related factors (experience, correct reduction, and optimal screw placement in the head/neck fragment). For fracture fixation, the anchorage of the lag screw within the femoral head plays a crucial role depending on the implant’s design. Meta-analyses and randomized controlled studies demonstrate that there is a strong trend towards arthroplasty treating geriatric femoral neck fractures. However, for young adults as well as older patients with less compromised bone quality, or in undisplaced fractures, head-preserving therapy is preferred as it is less invasive and associated with good functional results. This review summarizes the evidence for the internal fixation of femoral neck fractures and trochanteric femoral fractures in elderly patients. In addition, biomechanical considerations regarding implant anchorage in the femoral head including rotation, migration, and femoral neck shortening are made. Finally, cement augmentation strategies for hip fracture implants are evaluated critically.

Staged laparotomies based on the damage control principle to treat hemodynamically unstable grade IV blunt hepatic injury in an eight-year-old girl.

BackgroundSevere blunt hepatic injury is a major cause of morbidity and mortality in pediatric patients. Damage control (DC) surgery has been reported to be useful in severely compromised children with hepatic injury. We applied such a technique in the treatment of a case of hemodynamically unstable grade IV blunt hepatic injury in an eight-year-old girl. This case is the first to use multimodal approaches including perihepatic packing, temporary closure of the abdominal wall with a plastic sheet, transarterial embolization (TAE), and planned delayed anatomical hepatic resection in a child.Case presentationAn eight-year-old girl was run over by a motor vehicle and transferred to the emergency department of the local hospital. Her diagnoses were severe blunt hepatic injury (grade IV) with left femoral trochanteric fracture. No other organ injuries were observed. Because her hemodynamic state was stable under aggressive fluid resuscitation, she was transferred to our hospital for surgical management. On arrival at our institution about 4 h after the injury, her hemodynamic condition became unstable. Abdominal compartment syndrome also became apparent. Because her condition had deteriorated and the lethal triad of low BT, coagulopathy, and acidosis was observed, a DC treatment strategy was selected. First, emergent laparotomy was performed for gauze-packing hemostasis to control intractable bleeding from the liver bed, and the abdomen was temporarily closed with a plastic sheet with continuous negative pressure aspiration. Transarterial embolization of the posterior branch of the right hepatic artery was then carried out immediately after the operation. The lacerated right lobe of the liver was safely resected in a stable hemodynamic condition 2 days after the initial operation. Bleeding from the liver bed ceased without further need of hemostasis. She was transferred to the local hospital without any surgical complications on day 42 after admission. She had returned to her normal life by 3 months after the injury.ConclusionThe DC strategy was found to be effective even in a pediatric patient with hemodynamically unstable severe blunt hepatic injury. The presence of the deadly triad (hypothermia, coagulopathy, and acidosis) and abdominal compartment syndrome was an indication for DC surgery.

大腿骨転子部骨折に対するshort femoral nail手術におけるクラウンリーマー使用の注意点

大腿骨転子部骨折に対するshort femoral nail手術におけるクラウンリーマー使用の注意点

The choice of internal fixator for fractures around the femoral trochanter depends on area classification.

PurposeIn femoral trochanteric fractures, fractures whose fracture lines extend to the basal neck or to the subtrochanteric part have high instability. Area classification can identify such instable fractures. The best choices of internal fixators for femoral trochanteric fractures were investigated according to area classification.MethodsFemoral trochanteric fractures were investigated with respect to area classification. In area classification, the proximal femur is divided into 4 areas with 3 boundary lines: Line-1 is the center of the neck; Line-2 is the border between the neck and the trochanteric zone; and Line-3 links the inferior borders of the greater and lesser trochanters. A fracture in only the third area was classified as type 3; one in the second and third areas was classified as type 2–3.ResultsOf 284 femoral trochanteric fractures, 50.0 % were type 3, 21 % were type 2–3, 22 % were type 3–4, and 7.4 % were type 2–3–4. Cases with cut-out or excessive telescoping of the internal fixator were defined as the Failure-group; 5.3 % of type 3 and 10.9 % of type 2–3 were in the Failure-group only when short femoral nails with a single rag screw were used. On the other hand, there were no Failure-group cases of type 2–3 with double rag screws. Only 1 case involved a long nail for type 3, while a long nail was used in about half of type 3–4 cases (Chi square test: P < 0.0001).ConclusionsA double rag screw should be considered for type 2–3. A long nail should be considered for type 3–4.

Long versus short cephalomedullary nail for trochanteric femur fractures (OTA 31-A1, A2 and A3): a systematic review.

BackgroundBoth long and short cephalomedullary nails (CMN) may be used to treat trochanteric femur fractures. The objective of this paper was to compare the clinical outcomes between long and short CMN in the treatment of trochanteric hip fractures.Materials and methodsA literature search was performed, identifying 135 papers; 4 of which met inclusion and exclusion criteria. Papers included were those that compared cohorts of long and short nails for stable trochanteric femur fractures of level III evidence or superior. Data was pooled and analyzed, focusing on reoperation rate, secondary femoral shaft fracture rate, estimated blood loss, transfusion rate, operative time and length of stay.ResultsIncluded in the analysis were 1276 patients, with 438 short and 838 long CMN. The average age was 82.0 years for short CMN and 79.0 years for long CMN (P = 0.0002). The average follow up was 18 months, 46 % were male, and 71 % had an ASA (American Society of Anesthesiologists score) classification ≥3. The rate of reoperation was 5.0 % and 3.8 % for short and long CMN, respectively (P = 0.31). The rate of refracture was 1.6 % and 0.95 % for short and long CMN, respectively (P = 0.41). As compared to long nails, short nails had an average blood loss of 39 mL less (P = 0.0003), an 8.8 % decrease in transfusion rate (P = 0.07), and incurred 19 min less operative time (P < 0.0001). No significant differences between short and long nails were observed for either other complications, hardware complications, non-union, or mortality.ConclusionsFor trochanteric femur fractures, short CMN have a low reoperation rate while significantly decreasing operative time and estimated blood loss with the additional benefit of being cost effective.Level of evidenceLevel 3.

Which factor is most important for occurrence of cutout complications in patients treated with proximal femoral nail antirotation? Retrospective analysis of 298 patients.

Mechanical complications, such as cut-out of the head-neck fixation device, are the most common causes of morbidity after trochanteric femur fracture treatment. The causes of cut-out complications are well defined in patients who are treated with sliding hip screws and biaxial cephalomedullary nails but there are few reports about the patients who are treated with proximal femoral nail antirotation. The purpose of this study was to evaluate the most important factor about occurance of cutout complication and also to evaluate the risks of the combination of each possible factors. Overally 298 patients were enrolled in the study. Medical records were reviewed for patients' age, fracture type, gender, anesthesia type and occurance of cut-out complication. Postoperatively taken radiographs were reviewed for tip-apex distance, obtained collo-diaphyseal angle, the quadrant of the helical blade and Ikuta reduction subgroup. The most important factor (s) and also predicted probability of cut-out complication was calculated for each combination of factors. Cut-out complication was observed in 14 patients (4.7%). The most important factor about occurrence of the cut-out complication was found as varus reduction (p: 0.01), the second important factor was found as implantation of the helical blade in the improper quadrant (p: 0.02). Tip-apex distance was found as third important factor (p: 0.10). The predicted probability of cut-out complication was calculated as 45.6% when whole of the four surgeon dependent factors were improperly obtained. Althought obtaining proper tip-apex distance is important to prevent cutout complication in these fractures, if the fracture is not reduced in varus position and helical blade is inserted in the proper quadrant, possibility of cut-out complication is very low even in the patients with high tip-apex distance.