Trochanter Research Articles

Clinical effect of acupoint injection of salmon calcitonin in the treatment of senile osteoporosis

Objective To observe the clinical effect of acupoint injection of salmon calcitonin in the treatment of senile osteoporosis. Methods From February 2016 to July 2017, 136 elderly patients with osteoporosis admitted to Wenzhou Hospital of Traditional Chinese Medicine were included.The patients were randomly divided into two groups, with 68 cases in each group.The acupoint-injection group was given 50IU salmon calcitonin on day 1, day 2 100IU, one time per day, continuously used for 15 days for a course of treatment, and with an interval of 90 days, and repeat the course of treatment.The patients were given 0.9% sodium chloride diluted to 2mL, inject 0.5mL into bilateral Shenshu and Zusanli these two points.The intramuscular injection group was given the same dose of salmon calcitonin gluteus maximus injected intramuscularly.At the same time, both two groups were given calcium Erqi D tablets one tablet a day, alendronate once a week, each time 70mg fasting taken orally.The type Ⅰ collagen β-CTx, PINP, NBAP, femoral neck, femur trochanter, lumbar (L1-L4) lumbar BMD and osteoporosis symptom score before and after treatment were compared. Results After treatment, the NBAP and BMD of the two groups were significantly higher than those before treatment (all P<0.05), and the β-CTx, PINP and symptoms scores were lower than before treatment (P<0.05). After treatment, NBAP in the acupoint injection group was (32.36±3.03)μg/L, which was higher than (29.66±3.20)μg/L in the intramuscular injection group(t=10.477, P<0.05). The β-CTx and PINP in the acupoint injection group were decreased to (0.10±0.05)μg/L and (28.78±5.23)μg/L, which were significantly lower than those in the intramuscular injection group[β-CTx(0.20±0.05)μg/L, PINP(35.77±6.49)μg/L(t=5.983, 2.662, all P<0.05)]. After treatment, the BMD of the femoral neck, femur trochanter and lumbar vertebra (L1-L4) in the acupoint injection group were (0.690±0.032)g/m2, (0.620±0.010)g/m2 and (0.822±0.012)g/m2, respectively, which were higher than those in the intramuscular injection group[(0.652±0.012)g/m2, (0.572±0.022)g/m2 and (0.801±0.011)g/m2(t=5.055, 6.133, 1.956, all P<0.05)]. After treatment, the improvements of TCM syndromes such as weakness in the waist and knees, tinnitus and deafness, loss of appetite, release of teeth, relaxation of two feet, weak tongue, weak pulse in the acupoint injection group were better than those in the intramuscular injection group (all P<0.05). Conclusion The acupoint injection of salmon calcitonin at Zusanli and Shenshu points is more effective than the intramuscular injection in the treatment of senile osteoporosis.It can significantly increase the serum NBAP, decrease the serum β-CTx, PINP, improve the BMD and improve the patients' clinical symptoms, which means acupoint injection is a safe and effective way to treat senile osteoporosis. Key words: Osteoporosis; Acupuncture points; Shenshu; Tsusanli; Injections, intramuscular; Salmon calcitonin; Aged; Comparative study

The treatment of nonunion of femoral shaft fractures after intramedullarynaildynamizationwith temporary compression using external fixator followed by relocking of the internal intramedullary nail

Objective To introduce the technique we invented to treat hypertrophic and oligotrophic nonunion of femoral shaft fracture after dynamization of intramedullary nail (IMN) and to report its preliminary results. Methods The data of 2 cases with hypertrophic nonunions of femoral shaft fracture and 1 case with oligotrophic nonunion following IMN dynamization who had been treated by the technique from March 2006 to July 2017 in Beijing Jishuitan hospital were retrospectively studied. There were 2 females and 1 male, aged 50, 66 and 24 years old. 2 parallel half pins were inserted from anterior to posterior at the trochanteric and condylar zones of the femur for antegrade intramedullary nailing patients, and from lateral to medial sides for retrograde intramedullary nailing patient respectively, then the pins were connected with monolateral limb reconstruction fixator. The fracture nonunion site was compressed by the fixator up to 10-15 mm. The holes at the end of intramedullary nail where their screws were removed for dynamization were locked again with 2 locking screws, and then the frame was removed. The patients are allowed to start their rehabilitation and fully bear their body weight 1 day after the operation. Results The three patients were followed up for 25, 22, and 7 months after the surgery, respectively. The X-ray films showed the fracture healed at 7 months in two case, and at 12 months in one. One patient got her nail removed 25 months after the operation, feeling good 37 months after the removal. Conclusion This technique is an option to manage the hypertrophic and oligotrophic fracture nonunion of the femur after dynamization of IMN. It is mini-invasive to the nonunion site, easy to practice and allows early rehabilitation. Key words: Femoral fractures; Fractures, ununited; Fracture fixation, intramedullary; External fixators

Pulsed electromagnetic fields improve bone mineral density and bone metabolism after stroke

Objective To investigate the effect of a pulsed electromagnetic field (PEMFS) on bone mineral density and bone metabolism in males with osteoporosis after a stroke. Methods Fifty male stroke survivors with osteoporosis were randomly divided into a control group and a treatment group, both of 25. Both groups were treated with routine rehabilitation, oral calcium carbonate and vitamin D3 tablets, while the treatment group was additionally provided with PEMFS treatment. The subjects′ bone mineral density (BMD) and their blood levels of bone-specific alkaline phosphatase (B-ALP), type I procollagen amino-terminal peptide (PINP) and type β-I collagen cross-linked carboxy-terminal peptide (β-CTx) were measured before and after the 12 weeks of treatment. Results After the treatment the BMD values of the lumbar spine, femoral neck, trochanter and Ward′s triangle had increased significantly in both groups, but the average BMD values of the lumbar spine and femoral neck in the treatment group were significantly higher than those of the control group. After the treatment, the average B-ALP, PINP and β-CTx levels of both groups had also improved significantly compared with before the treatment, but the average improvement in all three among the treatment group was significantly greater than among the controls. Conclusion PEMFS treatment supplementing routine rehabilitation, oral calcium carbonate and vitamin D3 tablets can improve bone formation, reduce bone resorption and increase bone mineral density in men after a stroke. Key words: Electromagnetic fields; Pulsed electromagnetic fields; Bone metabolism; Bone mineral density

Hemiarthroplasty with Wagner SL prosthesis for failed internal fixation of intertrochanteric fractures in elderly patients

Objective To investigate the clinical outcomes of hemiarthroplasty with Wagner SL prosthesis in treating failed internal fixation of intertrochanteric fractures of elderly patients. Methods A retrospective case series study was conducted on the clinical data of 14 patients with failed internal fixation of intertrochanteric fractures admitted between March 2015 to April 2018. There were seven males and seven females with a mean age of 82.2 years (range, 75-94 years). The primary internal fixators were proximal femoral nail anti rotation in nine patients, dynamic hip screw in three patients, and proximal femoral locking plate in two patients. The main causes of internal fixation failure were screw loosening in six patients, cutting out of screws in five patients, nonunion in two patients, and plate breakage with nonunion in one patient. Affected limb shortening and coxa varus deformity to various degrees were seen in all the patients before operation. The mean interval from internal fixation to hemiarthroplasty was 6.6 months (range, 2-12 months). All patients received hemiarthroplasty using Wagner SL prosthesis, of which nine patients had additional trochanter claw plate with titanium cable fixation and two patients had tension band wire fixation. The operation time, intraoperative, and postoperative complications were recorded. Harris hip scores were measured before operation and at the last follow up to evaluate hip function. Radiographs were performed to assess the fracture healing, prosthesis position, and biological fixation. Results All patients were followed up for 6-30 months (mean, 14.5 months). The mean operation time was (108.0±12.4)minutes (range, 88-130 minutes). No iatrogenic fracture occurred during the operation. One patient was seen contralateral intertrochanteric fracture during follow-up, and no complications such as periprosthetic fracture, prosthetic sinking, and infection occurred in the 13 patients. The Harris score increased from (26.1±7.5)points before operation to (83.1±4.1)points after operation (P<0.01). All patients were able to stand and walk, of which four needed crutch assistance. At the last follow-up, X-ray film showed that the prosthesis was well positioned and that all of them reached bony fixation. Fourteen cases of greater trochanteric fracture were healed, with two cases of slight displacement. Conclusions Hemiarthroplasty is an effective remedial treatment for failed internal fixation of intertrochanteric fractures in the elderly, which can improve hip function and enhance the life quality of patients. Wagner SL prosthesis can obtain stable fixation. Key words: Arthroplasty, replacement, hip; Hip fractures; Treatment failure

Interpretation of and discussion on AO/OTA-2018 fracture classification of femoral per/inter-trochanteric fractures

The value of fracture classification lies in describing fracture features, representing injury severity, guiding treatment choice and predicting outcomes. The OA/OTA fracture classifications system (its first edition in 1996 and its second edition in 2007) is accepted worldwide. Its third revised edition published in 2018 has completely renewed the classification of femoral per/inter-trochanteric fractures, in which the cortical lateral wall is used as the secondary key element to replace the former lesser trochanter. The new classification gives clear directions for selecting extramedullary side-plate fixation (e.g.dynamic hip screw, DHS) for intact lateral wall (31A1) and intramedullary nailing (cephalomedullary nail) for vulnerable (31A2) or broken lateral wall (31A3). This paper will interpret and discuss the new classification. We believe that this classification system will be more accurate with high inter/intra-observer agreement if more 3D-CT images are supplemented. Key words: Hip; Fractures, bone; Internal fixators; Femoral trochanteric fractures; Fracture classification; AO/OTA society

Morphological differences of proximal femoral medullary cavity in elderly patients and its effect on proximal femoral nail fixation

Objective To investigate the morphological differences of proximal femoral medullary cavity in elderly patients with intertrochanteric fracture and its effect on the treatment efficacy of proximal femoral nail antirotation (PFNA). Methods A retrospective case series study was conducted on the clinical data of 112 elderly patients with intertrochanteric fracture of the femur from December 2012 to January 2017, including the preoperative and postoperative hip joints orthotopic X ray (including the proximal femur), lateral X ray, and pelvic orthotopic X ray films. The proximal femoral canal flare index (CFI) and the metaphyseal canal flare index (MCFI) were measured. The proportion of patients with different types of medullary cavity and the gender difference were analyzed according to Dorr typing. The fractures were classified according to the modified Evans classification. Operation time, fracture reduction quality, tip apex distance (TAD), incidence of intraoperative split fracture around the rotors, postoperative fracture reduction loss rate, weight bearing time, and fracture healing time were recorded. Results The proximal femoral canal flare index (CFI) was significantly correlated with the intramedullary diameter above the lesser trochanter, the inner diameter of the affected side medullary cavity isthmus, and metaphyseal canal flare index (MCFI) (P 0.05). In this group, the medullary cavity of proximal femur was classified by Dorr: the proportion of funnel type, normal type, and chimney type was 5.4% (6/112), 73.2% (82/112), and 21.4% (24/112), respectively. There was no significant difference in the modified Evans fracture stability among different morphological types of the proximal femoral medullary cavity. The difference of weight bearing time between normal group and chimney group was statistically significant [normal type: (21.4±16.9)d, chimney type: (45.5±11.2)d](P 0.05). Conclusions The occurrence and development of osteoporosis can cause significant changes in the morphology of proximal femoral medullary cavity, mainly manifesting as the gradual increase of the proportion of chimney type. The efficacy of PFNA in treatment of the intertrochanteric fracture is satisfactory. However, the risk of intraoperative cleavage fracture and postoperative reduction loss should be taken seriously. Key words: Hip fractures; Fracture fixation, intramedullary; Anatomy; Histology; Aged

What Is the Best Treatment Approach for Greater Trochanteric Pain Syndrome

Lateral hip pain sometimes is called “greater trochanteric bursitis,” but the preferred term now is greater trochanteric pain syndrome (because this

Morphology of femur, tibiotarsus and fibula of local hill fowl of Uttarakhand.

This study was conducted on femur, tibiotarsus and fibula from six adult local hill fowl of Uttarakhand. The femur of the local hill fowl was a long cylindrical bone consisted of a shaft and two extremities. The shaft was curved and twisted in appearance. The proximal extremity had spherical head separated from shaft by neck. The trochanter minor was indistinct. The distal extremity hadposteriorly medial and lateral condyles and anteriorly trochlea. The tibiotarsus was the longest bone among the leg bones. The shaft was anteriorly curved in its proximal half and posteriorly curved in its distal half. The fibular crest was well developed and on posterior-lateral aspect of it’smid-shaft very small nutrient foramen was observed. The cnemial crest was originates from cranial border of transverse ridge and extended ventro-medially. The distal extremity showed large medial and small lateral condyles separated by the deep intercondylerfossa. The fibula was a reduced long bone with distinct head and rudimentary shaft. The shaft of fibula extended up to the distal one third of the shaft of tibiotarsus.

The optimal depth for femoral cement insertion in total hip replacement. An anatomical and clinical study into cementing technique in the proximal femur.

In retrograde cementing, blood often rises proximally on the surface of injected cement. This blood contamination weakens the cement-bone interface. The major source of bleeding into the proximal femoral medullary canal is the severed nutrient artery. The aims of this study were to define the clinically relevant anatomy of the nutrient artery supplying the proximal femur and establish the optimum depth of cement insertion to minimise blood contamination. Sixty cadaveric femora were radiographed with a wire placed in the nutrient foramen to assess the distance from the tip of the greater trochanter to its entry into the proximal femoral medullary canal. The nutrient artery entered the medullary canal at an average of 13.9 cm from the tip of the greater trochanter and never more proximal than 10.3cm. In 30 patients undergoing primary total hip replacement, cement was inserted retrogradely at 7.5cm, 10 cm or 15 cm from the tip of the greater trochanter and blood contamination recorded. There was blood in significantly fewer cases when cement was inserted at 10cm. Cement insertion 10cm distal to the tip of the greater trochanter appears to occlude the bleeding nutrient artery and should give a stronger proximal cement-bone interface. (Hip International 2002; 2: 135-8).

Mechanical stability of custom and anatomical femoral stems: an experimental study in human femora.

In this study we have compared the mechanical stability of custom (n=8) and anatomical (n=8) uncemented femoral components, following insertion into human cadaveric femurs, during simulated single leg stance and stair climbing. In the custom group two specimens were excluded from the study due to detachment of the greater trochanter during cyclical loading. As a consequence of their mechanical behaviour both types of stems could be divided into subgroups of "unstable" and "stable" implants. In the course of one thousand loading cycles three anatomical stems and one custom stem migrated more than 1 mm, which was interpreted as mechanical loosening. This difference in rate of mechanical loosening was not significant. However, the majority of the stems were remarkably stable and showed micromotion of less than 18 m and migration of less than 35 m at the proximal implant-bone interface. The corresponding figures for the tip of the stems were 243 m and 170 m, respectively. During torsional loading the custom stems showed less rotatory motion than the anatomical stem (p<0.05). There were no significant differences in the magnitude of cyclical micromotion or migration for the two types of femoral stems. (Hip International 2002; 12: 263-73).

Anatomic distribution and clinical target volume of metastatic inguinal nodes in gynecological malignancies

Objective To determine the anatomic distribution of metastatic inguinal nodes in gynecological malignancies, and to explore the delineation of clinical target volume (CTV). Methods A retrospective study was performed among 34 patients with gynecological malignancies and inguinal lymph node metastases. According to the anatomic distribution of metastatic inguinal nodes, CTV covering more than 95% of inguinal lymph nodes and the relationship of inguinal nodes with the femoral vein, greater saphenous vein and its branches, superficial fascia, and deep fascia were analyzed using vascular enhancement images obtained by computed tomography and magnetic resonance imaging as well as 3D reconstruction using the Eclipse Planning System. Results The 34 patients had a total of 145 positive inguinal nodes. In the 131 superficial nodes below the inguinal ligament, 129 were located between the superficial fascia and the deep fascia; the upper group of superficial nodes, containing 25 nodes, was located at 1 cm above the public symphysis and along superficial iliac circumflex vein; the middle group, containing 85 superficial nodes and 11 patients with single superficial node metastasis, was located at the same level of the public symphysis and close to the junction of the saphenous vein and the femoral vein; the lower group, containing 21 superficial nodes, was beneath the public symphysis and along the greater saphenous vein and medial and lateral superficial femoral veins. The 14 deep nodes were located on the medial side of the femoral vein. There were no positive nodes on the posterolateral side of the link between the posterolateral edge of the femoral vein and medial edge of the sartorius muscle. The upper edge of CTV kept 142 lymph nodes beneath the upper edge of the superior pubis ramus and left 3 lymph nodes up to the upper edge of the femoral head. The lower edge of CTV kept 143 lymph nodes above the lower edge of the lesser trochanter and left 2 lymph nodes at 2 cm beneath the lower edge of the lesser trochanter. Conclusions For CTV covering 98% of positive inguinal nodes, the anterior edge is the superficial fascia; the medial edge is composed by the inguinal ligament and the border of medial muscle to the femoral vessels; the posterolateral edge is the link between the posterolateral edge of the femoral vein and the medial edge of the sartorius muscle; the upper edge is the upper border of the femoral head; the lower edge is the lower border of the lesser trochanter. Key words: Gynecologic oncology; Inguinal metastasis nodes; Anatomic distribution; Clinical target volume

Clinical outcomes of femoral revision using restoration modular stem

Objective To investigate the early outcomes of revision hip arthroplasty using restoration modular (RM) stem. Methods Fifty-nine patients underwent revision hip arthroplasty with RM stem from April 2012 to June 2015 in our center with a minimal of two years follow-up. The patients including 24 male and 35 female had a median age of 61.0 (56, 66) years. The median BMI was 24.0 (22.5, 26.0) kg/m2, while the median interval from the primary surgery was 10.5 (6.0, 14.5) years. The reasons for revision inculded infection in 8 patients, aseptic loosening in 45, recurrent dislocation in 1, and periprosthetic fracture in 5. There were 3 cases of type B2 and 2 cases of B3 periprosthetic fracture according to Vancouver classification. The bone defects severity was conducted according to Paprosky classification that 14 patients in type II, 31 in type IIIA, 8 in type IIIB, and 1 in type IV. Acetabular component were revised in 56 cases. Patients were followed up at 3 months, 6 months, 1 year and annually thereafter for clinical and radiological evaluation. Results All the patients were followed up with a median duration of 30.4 (27.3, 37.9) months, the median Harris score significantly improved from 37 (31, 53) points preoperatively to 84 (80, 95) points at the last follow up (Z=-6.681, P=0.000). There were 3 patients had perforation or fracture intra-operatively, two of them were fixed by strut allograft. The other one who did not compromise the implant stability was not fixed. Extended trochanteric osteotomy was applied in 14 cases and they healed well at 3-6 months during follow-up. There was one case of early dislocation at 6 days postoperatively, which was treated with close reduction and immobilization without recurrence. No infection, stem fracture, hematoma formation and sciatic nerve injury were reported. No femoral component loosening was identified at the latest follow-up. Median subsidence was 1.0 (0, 2.0) mm with the maximum case 6.0 mm and 3 cases 3.5 mm. All of subsidence developed within the first year postoperatively but without further aggravation. The affected leg lengthened 17.5±10.1 mm (range 2-40 mm) after operation. The affected leg was shorter 17.5±12.6 mm (shorter 44.4 mm to longer 3.0 mm) than that in the normal side pre-operatively. However, the distinction decreased to 0.1±9.6 mm postoperatively (shorter 24.8 mm to longer 22.4 mm, t=-10.538, P=0.000). Conclusion Early satisfactory results are achieved in hip revision using RM modular stem at the femoral side. The modular design could simplify the surgical procedure with better control of leg length and joint stability. Long-term follow-up is still required for further evaluation. Key words: Arthroplasty, replacement, hip; Femur; Reoperation; Prosthesis design; Osteolysis; Periprosthetic fractures; Prosthesis failure

Association of incident hip fracture with the estimated femoral strength by finite element analysis of DXA scans in the Osteoporotic Fractures in Men (MrOS) study.

Bone fractures occur only when it is loaded beyond its ultimate strength. The goal of this study was to determine the association of femoral strength, as estimated by finite element (FE) analysis of DXA scans, with incident hip fracture as a single condition or with femoral neck (FN) and trochanter (TR) fractures separately in older men. This prospective case-cohort study included 91 FN and 64 TR fracture cases and a random sample of 500 men (14 had a hip fracture) from the Osteoporotic Fractures in Men study during a mean ± SD follow-up of 7.7 ± 2.2years. We analysed the baseline DXA scans of the hip using a validated plane-stress, linear-elastic FE model of the proximal femur and estimated the femoral strength during a sideways fall. The estimated strength was significantly (P < 0.05) associated with hip fracture independent of the TR and total hip (TH) BMDs but not FN BMD, and combining the strength with BMD did not improve the hip fracture prediction. The strength estimate was associated with FN fractures independent of the FN, TR and TH BMDs; the age-BMI-BMD adjusted hazard ratio (95% CI) per SD decrease of the strength was 1.68 (1.07-2.64), 2.38 (1.57, 3.61) and 2.04 (1.34, 3.11), respectively. This association with FN fracture was as strong as FN BMD (Harrell's C index for the strength 0.81 vs. FN BMD 0.81) and stronger than TR and TH BMDs (0.8 vs. 0.78 and 0.81 vs. 0.79). The strength's association with TR fracture was not independent of hip BMD. Although the strength estimate provided additional information over the hip BMDs, its improvement in predictive ability over the hip BMDs was confined to FN fracture only and limited.

Efficacy of alendronate combined with atorvastatin in the treatment of type 2 diabetes mellitus with osteoporosis

Objective To explore the therapeutic effect of alendronate combined with atorvastatin in the treatment of patients with type 2 diabetes mellitus complicated with osteoporosis. Methods 80 patients with diabetic osteoporosis(DOP) treated by endocrinology were selected.They were divided into observation group and control group by random number table method.The patients in the control group were given alendronate sodium, and the patients in the observation group were given alendronate and atorvastatin at the same time.The bone mineral density (BMD) of the forearm, lumbar vertebra, femoral neck and femoral trochanter Numeric rating scales(NRS score) were measured before and after treatment. Results Before treatment, the BMD in forearm, lumbar vertebra, femoral neck and femoral trochanter, and NRS score between the two groups had no statistically significant differences (all P>0.05). After treatment, the BMD of forearm[(0.64±0.10)g/cm2 vs.(0.68±0.11)g/cm2, t=2.563]and lumbar vertebrae[(0.82±0.28)g/cm2 vs.(0.70±0.11)g/cm2, t=2.448], femoral neck[(0.71±0.09)g/cm2 vs.(0.66±0.05)g/cm2, t=3.002], femoral trochanter[(0.76±0.14)g/cm2 vs.(0.70±0.08)g/cm2, t=2.302] of the observation group were higher than those of the control group, and the NRS score[(1.32±0.10)points vs.(2.47±0.67)points]was lower than the control group(t=23.651, P<0.05). There were 2 cases of nausea, 1 case of abdominal pain and 1 case of muscle pain in the observation group, and 1 case of nausea occurred in the control group, the incidence rate of adverse reaction between the two groups had no statistically significant difference(χ2=1.478, P=0.224). Conclusion Alendronate combined with atorvastatin can improve BMD, relieve pain in patients with DOP, and it is safe and worthy of clinical application. Key words: Diabetes mellitus; Osteoporosis; Alendronate; Atorvastatin

Comparison of rush pins with titanium elastic nails for treatment of pediatric femoral shaft fractures

Background: Pediatric femoral shaft fracture accounts for 1-2% of all pediatric fractures. Closed reduction and internal fixation with intramedullary devices is the treatment of choice for children older than 4 years. However, antegrade intramedullary devices are associated with concerns regarding possibility of injury to the vascular supply of the proximal femur. Therefore, retrograde titanium elastic nails (TENs) have become increasingly popular in recent years. Purpose: The purpose of this study was to compare the clinical outcomes of children with femoral shaft fractures treated with antegrade Rush pin and retrograde TENs. Methods: After obtaining the approval of the review board, we retrospectively reviewed the charts of 61 children who presented with femoral shaft fractures between 1991 and 2010. Thirty-eight boys and 23 girls (mean age: 8.8 years) were studied. Thirty-two children were treated with a Rush pin and the other 29 children with TENs. The radiographic and clinical outcomes were compared between the two groups. Results: The coronal alignment of the femur was not significantly different between the two groups (2.46° vs. 1.07°, p = 0.16). However, the sagittal bowing is significantly greater in children treated with TENs (1.2° vs. 7.7°, p ＜ 0.001). Leg length discrepancy is 2.4mm and 2.7mm longer than the uninjured side in Rush pin and TENs group respectively (p = 0.85). No femoral head osteonecrosis or proximal femoral deformity was revealed on the final radiographs. The clinical outcomes were comparable between the two groups. Conclusion: The outcomes in the children treated with a Rush pin inserted through the tip of the greater trochanter were not inferior to those treated with TENs. Therefore, the Rush pin may continue to be an alternative device if the TENs are not affordable or not available in medical facilities.

Injuries of the trochanteric region: can analysis of radiographic indices help in prediction of recurrent osteoporotic hip fractures?

In a context of bone fragility, primitive and subsequent fractures are a growing problem in the industrialized countries where the mean age of the population is constantly increasing. Among the various factors that favor a fragility fracture, the most important is osteoporosis, a pathology that can be prevented through diagnostic screenings and treated by pharmacological and rehabilitative therapies. The aim of this study is to identify the subjects who are likely to have a higher risk of subsequent fractures of the trochanteric region through a retrospective radiographic evaluation of patients affected by low-energy trochanteric fractures and operated by intramedullary fixation between June 2013 and June 2015, so they can be targeted for prevention interventions. Three hundred and sixty-one patients yet alive were analyzed 2 years after surgery. Fifty-one (group 1), characterized by another contralateral trochanteric femoral fracture, were included. All subjects were retrospectively examined with the analysis of contralateral femur X-ray performed at the time of initial trauma in order to detect a condition of bone fragility and a predisposition to fractures by evaluating three radiographic indices (Singh index, Dorr's classification and Cortical Thickness Index). Patients of group 1 were compared to the other 310 patients (group 2) affected by isolated trochanteric fracture. Group 1 had all radiographic indices worse than group 2. The results observed suggest that orthopedists can use radiographic indices, in particular Cortical Thickness Index, as a valuable, simple and inexpensive screening tool for prevention of recurrent osteoporotic fractures.

Effects of morphological characteristics of femoral intertrochanteric fractures on internal fixation

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

Great trochanteric digastric osteotomy and surgical dislocation for treatment of Pipkin IV fractures

Objective To discuss the clinical outcomes of trochanteric digastric osteotomy and surgical hip dislocation for treatment of Pipkin Ⅳ fractures. Methods We retrospectively reviewed the 12 patients with Pipkin Ⅳ fracture who had been treated by trochanteric digastric osteotomy and surgical hip dislocation from February 2012 to June 2016. They were 10 males and 2 females, with an average age of 44.1 years (from 24 to 63 years). According to the Pipkin classification for femoral head fractures, 9 fractures were type Ⅰ and 3 type Ⅱ; according to Letournel-Judet classification for acetabular fractures, 10 were posterior wall fractures(9 belonging to the posterior superior subgroup) and 2 transverse plus posterior wall fractures (one involving the posterior wall belonging to the posterior superior subgroup). The operation time, blood loss, complications and functional results were recorded. Results The operation time averaged 165 min (from 150 to 195 min); the blood loss averaged 850 mL (from 500 to 1,200 mL). A spring plate was used additionally for posterior wall fracture in 7 cases. All the 12 cases obtained an average follow-up of 19 months (from 6 to 52 months). Motion function was fully recovered from 6 weeks to 4 months after operation in 2 cases of preoperative incomplete sciatic nerve injury and in one case of iatrogenic incomplete sciatic nerve injury. Anatomical reduction was achieved in all femoral head fractures. According to the Matta criteria for acetabular fractures, anatomical reduction was achieved in 9 cases, good reduction in 2 and poor reduction in one. Heterotopic ossification occurred in 4 cases (grade Ⅰ in one, grade Ⅱ in 2 and grade Ⅲ in one by the Brooker grading system). The trochanteric osteotomy was repeated in one case. No femoral head avascular necrosis was found. According to the modified Merle d’Aubigne and Postel scoring at the final follow-ups, the functional results of the affected hip were excellent in 4 cases, good in 7 and poor in one. Conclusion Trochanteric digastric osteotomy and surgical hip dislocation is a safe and effective treatment for Pipkin Ⅳ fractures. Key words: Hip dislocation; Femoral head; Acetabulum; Fractures, bone; Surgical ap-proach

Uncemented modular stems used for Vancouver B2 and B3 periprosthetic femoral fractures

Objective To evaluate the clinical outcome of Vancouver B2 and B3 periprosthetic femoral fractures treated with uncemented modular stems. Methods From September 2011 to April 2014, Twenty-four patients (12 males and 12 females, with the average age 63 years, ranging from 28 to 85 years) with periprosthetic femoral fractures (16 Vancouver B2 and 8 Vancouver B3) were treated with uncemented modular stems. Revision arthroplasty was conducted in all cases by using modular stems with 12 cerclage wirings and 11 great trochanter claw plates. One patient was treated with revision arthroplasty without additional fixations. Extended trochanter osteotomy was performed on 11 patients. Cortical strut allograft was used in 9 patients with severe femoral bone loss. Intraoperative complications including vascular or nerve injury and systemic complications including cardiovascular events, cerebrovascular events and deep vein thrombosis were recorded. Severe postoperative complications such as nonunion, re-fracture, periprosthetic joint infection and dislocation were recorded. The clinical outcome was evaluated by Harris score, Visual Analogue Score and Parker Mobility Score. The radiological outcome was taken to observe the healing status, stem subsidence and stability of the prosthesis. Results Two patients were lost to follow-up. Twenty-two patients were clinically followed-up. Radiological data was recorded in 16 patients. The average follow-up was 33 months (range, 12-68 months). All fractures healed within 6 months. The average Harris score improved from 4.0±1.1 preoperatively to 78.8±16.2 postoperatively (t= -20.195, P=0.000). The mean Parker Mobility Score improved from 0.5±0.9 preoperatively to 7.0±1.8 postoperatively (t=-14.835, P=0.000). The mean Visual Analogue Score decreased from 6.4±1.2 preoperatively to 2.0±1.5 postoperatively (t=10.879, P=0.000). No nonunion, infection or dislocation was found. One patient underwent re-operation because of re-fracture. Eight mm of prosthesis subsidence was observed in one case at 3 months postoperatively, and reached stable fixation at 6 months postoperatively without further subsidence. Conclusion Uncemented modular stems can achieve distal fixation and implant stability of periprosthetic femoral fractures while retaining optimal biomechanics of the hip. Assisted by femoral reconstruction techniques such as extended trochanter osteotomy, cortical strut allograft, great trochanter claw plates and cerclage wiring, revision arthroplasty using uncemented modular stems could realize optimal outcomes in treating Vancouver B2 and B3 periprosthetic femoral fractures. Key words: Arthroplasty, replacement, hip; Periprosthetic fractures; Femur; Reoperation; Prosthesis design

Primary outcomes of femoral head reduction osteotomy for coxa magna or coxa plana

Objective To investigate the clinical efficiency and safety of femoral head reduction osteotomy for young patients with coxa magna or coxa plana. Methods Between June 2012 and September 2015, the clinical characteristics of 12 patients (13 hips) with coxa magna or coxa plana who underwent femoral head reduction osteotomy were analyzed retrospectively. There were 6 males (7 hips) and 6 females (6 hips) with average age 18.1 years (range, 10-25 years). The etiology of the femoral head deformity was multiple epiphyseal dysplasia in 6 hips and Legg-Calve-Perthes sequela in 7 hips. The head reduction osteotomy was conducted through the surgical hip dislocation approach combined with extended retinacular soft-tissue flap extending technique. All patients underwent simultaneous periacetabular osteotomy and relative lengthening of the femoral neck, of which four also underwent proximal femur derotational osteotomy. All patients received the standardized rehabilitation procedures. The postoperative complications, gaits, the range of motion (ROM) of the hip, Harris hip scores, iHOT scores and VAS were analyzed postoperatively. In addition, the lateral center-edge (LCE) angle, sphericity index and coverage rate of femoral head were assessed as well. Results The average follow-up duration was 28.8 months (range, 12-45 months). All patients achieved osteotomy healing of the femoral head and greater trochanter with average healing time 3.7 months (range, 3-7 months). Nine of 12 patients had significant gaits improvement. The Harris hip scores (81.08±12.36 vs. 88.38±8.96, t=2.41, P=0.033), iHOT score (51.90±15.07 vs. 67.69±8.70, t=3.63, P=0.003), LCE angle (-1.82°±16.57° vs. 36.02°±7.72°, t=10.52, P=0.000), sphericity index of anteroposterior pelvic radiographs (71.08%±10.32% vs. 81.22%±8.61%, t=7.17, P=0.000) and the coverage index (48.79%±11.85% vs. 87.46%±10.44%, t=8.56, P=0.000) were all significantly improved when compared to those preoperatively. The VAS score (4.46±2.37 vs. 1.23±0.93, t=4.25, P=0.001) was significantly decreased when compared with that preoperatively. However, for the sphericity index of 65° false profile (78.96%±10.39% vs. 80.36%±8.42%, t=0.411, P=0.688) and the average hip ROM (264.62°±32.05° vs. 255.00°±40.31°, t=0.89, P=0.391), they did not achieve statistical significant difference. One case of femoral head necrosis site was localized at the lateral-superior part of femoral head, and there was no progression after 3 years follow-up. Moreover, no revision or total hip arthroplasty were observed due to other complications (osteoarthritis, hip pain or non-union). Conclusion The femoral head reduction osteotomy can correct deformity, improve femoral head sphericity, relieve pain and improve gaits and hip function. This procedure leads to satisfied clinical outcomes for patients with coxa magna or coxa plana in early follow-up. Key words: Osteochondrodysplasias; Legg-Calve-Perthes disease; Reconstructive surgical procedures; Hip dislocation, congenital