Unstable Intertrochanteric Fractures Research Articles

Biomechanical comparison of an intramedullary nail combined with a reconstruction plate combination versus a single intramedullary nail in unstable intertrochanteric fractures with lateral femoral wall fracture: A finite element analysis

Biomechanical comparison of an intramedullary nail combined with a reconstruction plate combination versus a single intramedullary nail in unstable intertrochanteric fractures with lateral femoral wall fracture: A finite element analysis

Role of Anteromedial Cortical Support for Unstable Intertrochanteric Fractures Being Treated With Cephalomedullary Nails.

Reduction quality is of paramount importance for an optimal outcome in unstable pertrochanteric fractures. The non-anatomical functional anteromedial buttress is proposed to prevent impending mechanical complications. We aimed to evaluate the role of anteromedial cortical support in preventing mechanical complications following fixation with the cephalomedullary nail. A prospective, single-arm interventional study was conducted in the Orthopaedics Department of a Combined Military Hospital (CMH) in Rawalpindi. The duration of the study was 24 months. Patients were recruited by the purposive sampling technique as per inclusion/exclusion criteria. Preoperatively, the reduction was categorized as per Baumgartner's and Chang's criteria. Post-operatively, weight bearing as tolerated was advised. Radiographs prior to discharge for loss of reduction were evaluated. Follow-up radiographic measurements of neck length, neck shaft angle, and their loss as per protocol were done at three and six months. A total of 202 patients were operated on from October 21 until August 23. Mortality at six months in 39 patients (19.3%) and loss to follow-up in 31 patients (15.3%) resulted in 132 patients with complete follow-up and having developed complications in 12 patients (9.09%). The mean age was 76.3 ± 7.98 years; males were 105 (79.5%), and females were 27 (20.5%). Closed reduction was 58 (43.9%), and additional manoeuvres were required in 74 (56.1%). The mean tip apex distance (TAD) was 24.56 ± 2.76, and the Calcar gap was 5.16 ± 1.27. Cleveland zone centre-centre in 54 (40.9%), inferior-centre in 65 (49.2%), and inferior-posterior (9.9%) were statistically significant for mechanical complications (p≤0.001). There was a significant association between the grading of Chang's and Baumgartner's poor groups for the development of mechanical complications (p≤0.001). The mean time to full weight bearing without support was 21 ± 1.22 weeks. The mean Hip Harris score at six months was 69.27 ± 7.68. Results suggest that anteromedial cortical support can lead to fewer potential mechanical complications at six months. A higher Chang's grade drives surgeons to engage in additional manoeuvres. Anteromedial cortical support is worth consideration for unstable pertrochanteric fractures.

Influence of anterior fracture line on anterior cortical reduction loss after cephalomedullary nail fixation in intertrochanteric fractures

To investigate the position of the anterior fracture line in AO/Orthopaedic Trauma Association (AO/OTA) type A2 unstable intertrochanteric fractures and its impact on the incidence of anterior cortical reduction loss after cephalomedullary nail fixation. A clinical data of 95 patients with intertrochanteric fractures who met the selection criteria between April 2020 and February 2023 was retrospectively analyzed. All patients were treated with cephalomedullary nail fixation, and the intra- and post-operative imaging data were complete. Among them, there were 37 males and 58 females. The age ranged from 61 to 97 years, with an average of 79.6 years. The time from injury to operation ranged from 7 hours to 11 days, with an average of 2.8 days. According to the 2018-AO/OTA classification standard, there were 39 cases of type 31-A2.2 and 56 cases of type 31-A2.3. Intraoperative fluoroscopy was used to record the number of patients with satisfactory fracture alignment. The preoperative CT data were imported into Mimics17.0 software to simulate the fracture reduction and measure the distance between the anterior fracture line and the intertrochanteric line bony ridge. The fractures were classified as transcapsular fractures, extra-capsular fractures, and intra-capsular fractures according to the distance. CT three-dimensional reconstruction was performed within 2 weeks after operation to observe the number of patients with anterior cortical reduction loss. The postoperative anterior cortical reduction loss incidence in patients with satisfactory fracture alignment, and the relationship between postoperative anterior cortical reduction loss and the position of the anterior fracture line were observed. There were 52 cases (54.7%) of transcapsular fractures, 24 cases (25.3%) of extra-capsular fractures, and 19 cases (20.0%) of intra-capsular fractures. Among them, 41 of the 52 transcapsular fractures had satisfactory fracture alignment, and 4 (9.8%) of them experienced anterior cortical reduction loss after operation; 19 of the 24 extra-capsular fractures had satisfactory fracture alignment, and no anterior cortical reduction loss occurred; 16 of the 19 intra-capsular fractures had satisfactory fracture alignment, and 7 (43.8%) of them experienced anterior cortical reduction loss after operation. There was a significant difference in the incidence of anterior cortical reduction loss between groups ( χ 2=8.538， P=0.003). All patients were followed up 3-26 months (mean, 9 months). Among them, 91 cases had fracture healing, and 4 cases had nonunion. In AO/OTA type A2 unstable intertrochanteric fractures, where the anterior fracture line is located within the joint capsule, there is a high risk of anterior cortical reduction loss after operation.

Efficacy of poller screw in addition to lag screw in the treatment of intertrochanteric fractures with proximal femoral nail: a biomechanical evaluation.

The most common type of failure in treating intertrochanteric fractures with proximal femoral nails is cut-out due to varus collapse. We aim to evaluate the effect of the poller screw applied to the proximal fragment and the lag screw on varus collapse and stability in intertrochanteric fractures. An unstable intertrochanteric fracture model without medial support was simulated in 20 synthetic femur models. In the poller screw group, in addition to the lag screw, pole screws were applied to the proximal fragment superior and inferior to the lag screw. In the progressive cyclic loading test, starting from 100 N, the loading was increased by 50 N in each cycle, and the test was continued until the maximum load at which failure occurred as a result of conditioning cycles and progressive cyclic loading tests, stiffness, type of failure, force at failure, lag screw displacement, and varus collapse were recorded. The average stiffness was found to be 124.705 N/mm in the poller screw group and 102.77 N/mm in the control group (P < 0.001). The maximum load to failure was 1897.10 N in the poller screw group and 1475.20 N in the control group (P < 0.001). The average displacement of the lag screw within the femoral head was 0.85mm in the poller screw group and 3.60mm in the control group (P < 0.001). As a result, it has been shown that poller screws applied around the lag screw increase fixation stiffness and reduce varus collapse.

Evaluation of the outcome of proximal femoral nail in the treatment of unstable Intertrochanteric fracture in adult

Background &amp; Objectives: The incidence of intertrochanteric fractures among elderly patients is expected to be increased even further with the advancing age of the population, proximal femoral nail was introduced as a method of treatment for this fracture, which is currently the most effective surgical method. The goal is to find out the role of a proximal femoral nail in treating intertrochanteric fractures and assess the advantages and complications of this treatment method. Methods: This prospective study was conducted on seventy patients with unstable intertrochanteric fractures treated with Proximal femoral nails at Erbil teaching hospital. They were followed up for one year, from (May 2016 to May 2017). Patients were examined for the union of fracture and complications clinically and radiologically. The functional outcome was evaluated using the Harris Hip Score. Results: Total number of 70 patients were included in this study, 44 (62.85%) were females, and 26 (37.15%) were males. The mean operative time was (90.885 min. ±11.38SD). Infection developed in (1.42%) of the patients. The most common complication was Varus malalignment which was found in (5.7%) of the cases. Harris Hip Score-based findings were excellent-good in (85.7%) of patients Conclusion: Proximal femoral nail is a relatively effective treatment possibility for most unstable intertrochanteric fractures with good biological stabilization, better short-term outcomes, and minimal complications.

THE RETROSPECTIVE ANALYSIS OF TRIGEN INTERTAN NAIL IN THE TREATMENT OF UNSTABLE INTERTROCHANTERIC FEMORAL FRACTURES AT HOSPITAL FOR TRAUMATOLOGY AND ORTHOPAEDICS.

Intertrochanteric fractures are highly prevalent among the elderly population, with approximately 90% occurring in individuals aged over 65. These geriatric fractures are associated with elevated mortality rates and significant functional impairment. Common treatment modalities for unstable intertrochanteric fractures include proximal femoral nail antirotation (PFNA) and the InterTan nail (IT). PFNA and IT are frequently employed due to their lower failure rates and favorable biomechanical properties, resulting in positive clinical outcomes for the management of unstable intertrochanteric fractures. The unique design of the IT nail, featuring two cephalocervical screws within an integrated mechanism, permits linear intraoperative compression and rotational stability of the neck and head fragment. In this study, we assess the clinical outcomes of IT nail utilization in the treatment of intertrochanteric fractures at the Hospital for Traumatology and Orthopedics. This study comprises a retrospective analysis and case series report. Between February 2021 and August 2021, we retrospectively evaluated 35 patients who underwent treatment with the IT nail for unstable intertrochanteric fractures. Epidemiological data, operative duration, intraoperative blood loss, intraoperative blood transfusion requirements, length of hospital stay, bone healing rates, and IT nail-related complications were recorded. The mean age of the patients was 70.97 ± 16.97 years, with a mean operative time of 60 minutes, mean intraoperative blood loss of 160.86 ± 72.8 ml, mean intraoperative blood transfusion volume of 203.43 ± 189.29 ml, and a mean hospital stay of 7 days. Bone healing was observed in 97.14% of cases. The treatment of unstable intertrochanteric fractures using the IT nail in elderly patients was successful. Our findings indicate favorable clinical outcomes in terms of surgical duration, intraoperative blood loss, hospitalization duration, and union rates for elderly patients. Further investigations are warranted to validate these early results.

Provisional Reduction to Avoid the Wedge Effect and Control Rotational Deforming Force During Cephalomedullary Nail Insertion for Unstable Intertrochanteric and Basicervical Femoral Neck Fractures: A Novel Surgical Technique

Provisional Reduction to Avoid the Wedge Effect and Control Rotational Deforming Force During Cephalomedullary Nail Insertion for Unstable Intertrochanteric and Basicervical Femoral Neck Fractures: A Novel Surgical Technique

İntertrokanterik Kırıkların Tedavisinde Subkondral Pençe Yerleştirme Gecikmeli Vidanın Yanal Kayma Mesafesine ve Kesmeye Etkisi

Introduction: The incidence of intertrochanteric fractures has increased in recent years due to the growing elderly population at risk of hip fractures, primarily attributed to osteoporosis. Among hip fractures, the prevalence of intertrochanteric fractures is progressively rising. Aim: To evaluate clinical and radiological results of the lag screw that deploys the claw in the subchondral area of the femoral head in the treatment of advanced age unstable intertrochanteric fractures. Methods: We retrospectively reviewed patients with intertrochanteric fractures treated with proximal femoral nails between 2019 and 2021. A total of 107 patients were examined under two groups according to the choice of the nail (Interclaw lag screw(n=52), Proximal femoral nail anti-rotation (n=55) used in the treatment. The radiological parameters in the post-operative 1st-day radiographs of the patients were evaluated. The changes in the first month, three, six months, and one-year control radiographs of the patients were evaluated. Changes in tip apex distance and lateral sliding of the lag screw were compared between the two groups. Result: There was no statistically significant difference between the two groups regarding operation time, post-operative femoral neck/shaft angle, post-operative Calcar gap (mm), and tip-apex distance (TAD) (mm). In the last clinical follow-up, the two groups had a statistically significant difference in the femoral neck/shaft angle and TAD change. There was a significant difference in sliding distance between the two groups at the last follow-up. Conclusion: Using a subchondral claw-deploying lag screw is a reliable implant choice in the surgical treatment of geriatric intertrochanteric fractures. The claw mechanism increases fixation strength and restricts the movements of the lag screw in the femoral head.

Functional Outcomes of Primary Hemiarthroplasty for Unstable Intertrochanteric Fractures in the Elderly: A Prospective Observational Study.

Background and objective Intertrochanteric fractures pose a growing healthcare challenge among the elderly, demanding effective management strategies. This study addressed the rising incidence of hip fractures, emphasizing the complications associated with traditional nonsurgical approaches. It aimed to explore postoperative functional outcomes and complications associated withprimary hemiarthroplasty as an alternative to internal fixation for unstable intertrochanteric fractures in the elderly. Materials and methods This study included 20 elderly patients undergoing hemiarthroplasty for unstable intertrochanteric fractures. It evaluated key variables such as patient demographics, comorbidities, fracture characteristics, surgical approach, and postoperative metrics. To perform hemiarthroplasty, weutilized a nonmodular bipolar prosthesis with cement. Postoperative follow-up included an assessment of clinical and radiological parameters, focusing on outcomes and complications. Results The mean age of the participants was 71.65 years; it was found that a significant segment of the participants (n=9, 45%) did not have any comorbidities. The surgical outcomes were characterized by minimal blood loss (275 ± 57.35 ml), short hospital stays (6.55± 1.95 days), and satisfactory operative durations (80.25 ± 10.19 minutes). Additionally, 14 (70%) patients did not require blood transfusions. After the surgery, complications were minimal, and there were no cases of deep wound complications, prosthesis dislocations, or deep vein thrombosis. The Harris Hip Scores reflected favorable outcomes in 14 cases (72.7%), with good or excellent hip scores. Conclusions Our findings revealed that primary hemiarthroplasty is a reliable and effective strategy for managing unstable intertrochanteric fractures in the elderly, providing stable joints and acceptable complication rates. Early mobilization, facilitated by hemiarthroplasty, mitigates postoperative complications, making it a viable alternative for elderly patients.

Augmentation of intramedullary nail in unstable intertrochanteric fractures with plate or cable.

This study aims to evaluate the clinical outcome of intramedullary nail supplemented by buttress plate or cable in the treatment of intertrochanteric fracture with broken lateral wall. From May 2015 to January 2022, patients with unstable intertrochanteric femoral fractures underwent intramedullary fixations strengthened with buttress plates or cables, which depended on the lateral femur wall fragment type. The clinical and radiographic results were compared between the two groups. The hip function was evaluated according to the Harris Hip Scoring (HHS) system. Forty-one patients who sustained intertrochanteric fracture + broken lateral wall were enrolled. Of these, thirty-four received a minimum of twelve months of follow-ups. No statistically significant differences in baseline and operative data were proved between these groups (p > 0.05). Three patients were observed fat liquefaction after surgery (plate group: 2 cases, cable group: 1 case). All patients could sustain partial/full weight-bearing and no case underwent subsequent operation. The HHS of the last follow-up presented 83.6 ± 4.9 points in the plate group and 83.8 ± 3.7 points in the cable group. Intertrochanteric femoral fracture with broken lateral wall is an unstable injury type, the operative treatments of which have been challenging and controversial over the years. Augmentation of intramedullary nailing system using plate/cable contributes to reconstructing the lateral femur wall.

Proximal Femur Bionic Nail (PFBN): A Panacea for Unstable Intertrochanteric Femur Fracture

With the aging population, intertrochanteric femur fracture in the elderly has become one of the most serious public health issues and a hot topic of research in trauma orthopedics. Due to the limitations of internal fixation techniques and the insufficient mechanical design of nails, the occurrence of complications delays patient recovery after surgical treatment. Design of a proximal femur bionic nail (PFBN) based on Zhang’s N triangle theory provides triangular supporting fixation, which dramatically decreases the occurrence of complications and has been widely used for clinical treatment of unstable intertrochanteric femur fracture worldwide. In this work, we developed an equivalent biomechanical model to analyze improvement in bone remodeling of unstable intertrochanteric femur fracture through PFBN use. The results show that compared with proximal femoral nail antirotation (PFNA) and InterTan, PFBN can dramatically decrease the maximum strain in the proximal femur. Based on Frost’s mechanostat theory, the local mechanical environment in the proximal femur can be regulated into the medium overload region by using a PFBN, which may render the proximal femur in a state of physiological overload, favoring post-operative recovery of intertrochanteric femur fracture in the elderly. This work shows that PFBN may constitute a panacea for unstable intertrochanteric femur fracture and provides insights into improving methods of internal fixation.

Cemented bipolar hemiarthroplasty for unstable intertrochanteric fracture in elderly patients over 70years: Boon or bane?

The surgical management of intertrochanter femur fracture in elderly patient is still under debate. Various implants can be utilised but prosthetic replacement is gaining popularity. This study was performed to evaluate the functional and clinical outcomes of cemented bipolar arthroplasty as a primary treatment for unstable intertrochanteric fracture in elderly patients (> 70years). Thirty-seven patients with unstable intertrochanteric fracture in elderly patient (> 70years) who underwent cemented bipolar hemiarthroplasty. Intra-operative and post-operative complications were noted; functional outcomes were assessed using Harris hip score (HHS). All patients were followed up for a minimum of 12months. Overall 90% of patients has some minor or major intra or post-operative complication. One year mortality rate was 16% (6/37). Cardiopulmonary events were the most common life threatening incident. Mean fall in Haemoglobin was 1.6gm/dL. The average time for full weight bearing mobilisation with the help of walker was 2.8 ± 1.2days (1-8days). The average duration of surgery was 58 ± 6min (44-96min) with an average blood loss of 126 ± 24mL (90-380mL). HHS at the end of 12months was 77. The use of bipolar hemiarthroplasty in senile patient with unstable hemiarthroplasty gives an advantage of early weight bearing. However, it is associated with risk of significant intra or post-operative morbidity due to intra-operative trauma, surgical time and blood loss during the surgery. Although hemiarthroplasty can be a single-time solution to the complexities of intertrochanter fracture in elderly patients but should be performed in selected patients only.

Clinical research comparing the efficacy of long proximal femoral nail with short proximal femoral nail in treating unstable intertrochanteric fractures

Clinical research comparing the efficacy of long proximal femoral nail with short proximal femoral nail in treating unstable intertrochanteric fractures

Functional Outcome of Inter-Trochanteric and Sub-Trochanteric Fracture Femur Treated with Proximal Femur Nail Antirotation-II

Intertrochanteric femoral fractures are of great interest all around the world. They are the most often performed fracture type, and the high expense of treatment required following injury has made them a critical health resource concern. A higher predisposition towards Intertrochanteric fracture is observed in females than males due to osteoporosis A substantial demand is placed on the implanted hardware, as the subtrochanteric region of the femur experiences mechanical forces several multiples of the patient’s weight.The primary objective of this study was to evaluate the functional result of inter- and sub-trochanteric femur fractures treated with Proximal Femur Nail Antirotation-II. To improve the rotational stability of the proximal fracture fragment, the trochanteric fixation nail (TFN) was designed. To lessen bone tension at the isthmus, the diameter of the distal tip of the nail was lowered. The research was carried out in the Department of Orthopaedics, Krishna Institute of Medical Sciences, Karad. The research was carried out between June 2019 and June 2021. The Department of Ethics of Krishna Institute of Medical Sciences, Deemed to be University Karad, granted the ethics committee permission. There were 60 individuals in the research who had intertrochanteric and subtrochanteric femur fractures. After receiving informed written consent in the specified way, all participants were included. In summary, PFN A-II is a stable, biomechanically acceptable implant with a clear advantage over other implants for treating stable and unstable intertrochanteric fractures, particularly those in the elderly, and linked with osteoporotic bone. The benefits of the PFN A-II are noticeable with the right surgical approach, with a bare minimum complication rate.

Comparative study of functional and radiological outcomes of the usage of two devices, derotation type cephalomedullary nail and the helical blade type in unstable intertrochanteric fractures in the geriatric population at a tertiary-level center

Background: Intertrochanteric fracture is a common osteoporotic fracture among elderly populations in an aging society. Early surgical fixation on these aging patients has been proposed recently for early rehabilitation and has had a positive impact on reducing comorbidities. For unstable fractures, intramedullary implants generally present biomechanical advantages over their extramedullary counterparts. Methods: The study was a 2 years prospective comparative study from 1st December 2020 to 1st December 2022 conducted in the department of orthopaedics, Rajendra institute of medical sciences, Ranchi, Jharkhand, India. Total number of patients were 50, PFN done in 25 cases and PFN-A2 in another 25 cases. Results: Mean age is 64.4 years in PFN group as compared to 67.3 years in PFN-A2 group. PFN-A2 was done in 84% male while PFN in only 76 % male and in both groups right side was mostly affected. Average surgery time, amount of blood loss, average number of C-arm shoot was more in PFN group. Conclusions: In this study of 50 patients, 25 treated by PFN and 25 by PFN-A2, it was concluded that PFN-A2 was a better construct to treat patients of older age group having osteoporosis because here reaming was not done and helical blade was inserted by hammering which caused compaction of bones in head and neck region.

Assessment of Proximal Femoral Nail in Management of Unstable Intertrochanteric Femur Fractures

Assessment of Proximal Femoral Nail in Management of Unstable Intertrochanteric Femur Fractures

Surgical Management of Unstable Trochanteric Fractures of the Femur Using Cemented Hemi-Prosthesis in Elderly Patients: A Prospective Study.

Background In the case of elderly patients suffering from osteoporosis, the primary objectives of addressing comminuted intertrochanteric fractures are centered upon the recuperation of the patients' pre-fracture levels of activity, the expeditious promotion of full weight-bearing capacity, and the minimization of the likelihood of further surgical interventions. The adoption of hemiarthroplasty as a method for comminuted intertrochanteric fractures is proven as a means of hastening the recovery process, enabling early weight-bearing and mitigating the problems associated with extended bed rest. The outcomes that resulted from the application of this technique will be evaluated and analyzed as part of this study's objectives. Methodology A prospective study was conducted over the course of one year at a tertiary care hospital in the northern part of India. The study comprised a total of 30 individuals; however, unfortunately, one of the patients could not be located for further analysis. Patients of either gender in the age group of over 60 years old and with unstable osteoporotic intertrochanteric fractures were included (AO Foundation/Orthopaedic Trauma Association type 31-A2.2, A2.3, or 31-A3 group). Patients were observed at one, three, and six months after the surgical operation. The Harris Hip Score (HHS) was used for the functional outcome evaluation. Results Throughout the course of our analysis, we saw an increase in the overall HHS that was statistically significant. The HHS exhibited a mean value of 34.33 during the period of discharge, with a range of 32 to 39. It increased to 55.34 (range = 52-59) after one month of follow-up, and it continued to rise to 85.03 (range = 63-89) after three months of follow-up. It is important to note that the mean HHS reached 95.24 (range = 63-98) by the sixth month of follow-up. The study showed a statistically significant upward trend in HHS scores across all time periods (p < 0.001). Conclusions Early postoperative ambulation was made possible with the use of cemented prostheses, which contributed to patients' overall improvements in their functional results. Cemented primary bipolar hemiarthroplasty has emerged as a promising alternative for the treatment of unstable intertrochanteric fractures. The enhanced functional outcomes measured by the HHS provide evidence of this. The transtrochanteric technique has shown advantages in retaining the anatomical integrity of external rotators, minimizing the necessity for their resection, and reducing the danger of sciatic nerve injury. These advantages were displayed by the transtrochanteric approach. Moreover, owing to the implementation of wiring techniques, the larger trochanter could be conserved, resulting in enhanced postoperative recovery and expediting the return to the preoperative condition. When compared with other techniques of internal fixation, the utilization of cemented bipolar hemiarthroplasty demonstrated much-reduced rates of complications, such as the need for further surgery and implant failure.

Application of lesser trochanteric reduction fixator in the treatment of unstable intertrochanteric fractures.

Closed reduction and internal fixation with intramedullary nails has been widely accepted for treating intertrochanteric fractures. To focus on how to avoid displacement of the lesser trochanter in unstable intertrochanteric fractures. We developed a lesser trochanteric reduction fixator for treating intertrochanteric fractures through fixing the lesser trochanter by combining the loop plate through the fixator after reduction by the reducer. Five patients with intertrochanteric fractures treated with the newly developed lesser trochanteric reduction fixator and loop plate combined with intramedullary nails, and 20 patients with intertrochanteric fractures treated with simple intramedullary nails were selected from December 2020 to March 2021. The postoperative Harris hip score was significantly higher in patients treated with the lesser trochanteric reduction fixator than in patients treated without the lesser trochanteric reduction fixator, which indicated that this lesser trochanteric reduction fixator had a positive impact on rehabilitation of the hip joint after surgery and could significantly improve the quality of life of patients. We fully realize the significance of trochanteric reduction and fixation, namely, reconstruction of structures under pressure, in the treatment of intertrochanteric fractures. As long as the general condition of patients is favorable and they are willing to undergo surgery, fixation of the main fracture end should be performed and the lesser trochanter should be reduced and fixed at the same time.

Bipolar Hemiarthoplasty versus Proximal Femoral Nail in Management of Unstable Intertrochanteric Femur Fracture

Background Intertrochanteric fractures (ITFs), commonly occurred in the elderly, are still a big challenge for orthopedic surgeons due to the multitude of co-morbidities and high 1-year mortality rate associated with them. Aim of the Work The aim of this study is to review systematically studies about the use of bipolar hemiarthoplasty versus proximal femoral nail in management of unstable intertrochanteric femur fracture. Patients and Methods We included randomized control trails (RCTs), controlled clinical trials, retrospective comparative cohort studies and prospective comparative cohort studies and we excluded case reports, case series studies, cross sectional studies and non English studies. Search results was conducted to systematic review management software and manually screened for eligibility to be included. Surgical treatment of unstable intertrochanteric femur fractures by bipolar hemiarthoplasty versus proximal femoral nail. Results Regarding the patients included in the review there is no significant difference in the age or sex between the two groups of comparison. This review provides us with enough evidence regarding the superiority of PFN, which being a significantly faster surgery and has relatively lower incidence of intraoperative blood loss this in turn provides general wellbeing to the patient and gives better function. Although there is no significant difference between two group of comparison regarding percentage of failure and percentage of reoperation, PFN shows the superiority of duration of hospital stay which could be beneficial for the mental health of the patients, which adds to their overall quality of life, also PFN show the superiority regarding percentage of infection, decreasing patient suffering and risk of reoperation, also PFN show the superiority regarding percentage of mortality increasing life expectancy of patients, percentage of DVT decreasing pulmonary complications and also PFN show the superiority regarding Harris hip score so show better outcomes. Conclusion PFN proves itself as a better modality than hemiarthroplasty in unstable intertrochanteric femur fractures in the elderly, with decreased post-operative mortality and better functional results. Hemiarthroplasty is best reserved for individuals with short life expectancies who require immediate weight bearing and mobilization.

Lateral cortical notching facilitates dynamization of proximal femoral nailing – A finite element analysis

IntroductionDynamization of proximal femoral nailing by removal of distal interlocking is one of the recommended treatment options for nonunions of femur fractures. However, in certain inter-/subtrochanteric fractures, gliding of the nail along the femoral shaft is blocked by lateral femoral cortical support of the lag screw. For these cases, Biber et al. proposed lateral cortical notching (LCN), in which the supporting lateral bone is removed. This study investigates the biomechanical effect of LCN on gliding of proximal femoral nailing and stress distribution at the bone/implant interface. Materials and methodsIn this finite element analysis a three-dimensional model of an unstable intertrochanteric fracture with proximal femoral nailing without distal interlocking was simulated using the FebioStudio software suite. To simulate LCN, the lag screw hole was lengthened to 15.34 mm at the lateral cortex. Displacement of the nail along the femoral shaft axis and von Mises stress distribution were compared between LCN model and standard implantation model. ResultsDisplacement of the nail along the femoral shaft axis was higher in the LCN model than in the standard implantation model (0.48 mm vs. 0.07 mm). Highest von Mises stresses of 176–178 MPa at the implant and of 52–81 MPa at the proximal femur were detected. Maximum von Mises stresses of the implant were comparable at all sides, except for a reduced von Mises stress at the lateral inferior side in the LCN model (80 vs. 102 MPa). At the inferior lateral screw hole and the anterior/posterior lateral screw hole maximum von Mises stress was reduced in the LCN model (2 vs. 49 MPa and 52 vs. 81 MPa), whereas the maximum von Mises stress at the inferior medial screw hole was higher in the LCN model than in the standard implantation model (53 vs. 27 MPa). ConclusionsLateral cortical notching facilitates gliding of a distally dynamized proximal femoral nail along the femoral shaft axis in intertrochanteric fractures. Additionally, the lack of lateral cortical bone support at the lag screw reduces von Mises stress at the bone/implant interface and thus could lower the risk for implant breakage and peri‑implant fractures.