Unstable Pertrochanteric Fractures Research Articles

Chronic haematogenous osteomyelitis of fibula diaphysis with pathological fracture and review of literature

Trochanteric femoral fractures are among the most common injuries necessitating hospital admission. Regardless the type of fracture, trochanteric fractures can lead to substantial morbidity and mortality, especially in elderly patients [1, 2]. Surgery is the mainstay of the treatment for both displaced and non displaced trochanteric fractures, to allow early mobilization of the patient, depending on the stability of the reduction and fixation achieved [4]. Dynamic Hip Screw [DHS] as extramedullary and Proximal Femoral Nail [PFN] as intramedullary systems are established and standard in treatment of trochanteric femoral fractures [5, 6]. Aim: To compare the results of Dynamic Hip Screw and Proximal Femoral Nail in the treatment of intertrochanteric fractures. Materials & Methods: In our study we compared DHS with PFN in a group of 60 patients admitted in a tertiary care hospital between August 2013 – December 2016. Patients with intertrochanteric fractures without having concomitant shaft femur or neck femur fractures were included. The preoperative morbidity was evaluated using Parker’s mobility scale. Salvati and Wilson’s scoring helped in measuring overall functional outcome at 16 & 24 weeks between the two study groups. Results: The preoperative Parker’s mobility scale was comparable between two study groups. Salvati and Wilson’s score at 16 & 24 weeks was significantly better with PFN group. The functional outcome based on SWS score was Fair in 39% of patients operated with DHS at 16 weeks while for PFN it was Fair to Good in 79% of patients. At 24 weeks it was Fair to Good in 84% patients operated with DHS while in case of PFN the score was Fair to Good in 59% of the patients & Excellent in 38% of the patients. Conclusion: Our conclusion from this study supported the use of PFN for both stable and unstable pertrochanteric fractures over DHS due to its lesser operation time, lesser blood loss, early weight bearing, limited open reduction & better functional outcome.

Management of unstable pertrochanteric fractures with proximal femoral locking compression plates and affect of neck-shaft angle on functional outcomes.

Management of unstable pertrochanteric fractures remains a challenge with various implant choices. Intramedullary devices are usually preferred for the management of the unstable fractures. When nailing is unsuitable for the configuration of the fracture extra medullary procedures are preferred. PFLCP is a contact limited implant that allows multiple angularly stable fixations with preserving more bone stock after implantation as an extramedullary implant. There are only a few reports in the literature about the osteosynthesis of unstable trochanteric fractures with proximal femoral locking compression plates and their results are conflicting. In the present study we aimed to evaluate the functional and radiological outcomes of proksimal femoral locking compression plates in open reduction and internal fixation of AO/OTA 31A2-2 and 3 fractures. Patients older than 18 years of age with a minimum follow-up time of 1year matching the inclusion criteria retrospectively evaluated. Patients' demographics, Singh index, intra and post-operative data, mobilization and union time gathered from the patients' files. Baumgaertner modified criteria of fracture reduction was used to assess the post-operative reduction quality. Early and last follow-up radiographs were used to evaluate malunion and change in neck- shaft angle. Final clinical outcome was assessed using the Harris Hip scoring system. 18 male and 13 female patients with the mean age of 74 (46-88) met the inclusion criteria. Reduction quality according to Baumgaertner modified criteria was good in 25 patients and acceptable in 6. Mean union time was 21.53±4.18 weeks. There was neither non-union nor malunion. The mean neck-shaft angle change was -3.1°±2.16°. The mean HHS was 77.90±4.84 and there was no significance in HHS according to reduction quality and change in neck-shaft angle (p=0.385, p=0.0059). HHS was negatively correlated with age, mobilization time and, longer union time (p<0.05). There was no correlation between Singh index and reduction quality (p=0.865). Singh index was only correlated with the patient's age (p=0.000, rho=-0.595). There were 2 infections and, 2 backing of the proximal screws. Even though PFLCP is not the first choice in management of unstable pertrochanteric fractures, it must be kept in mind as an alternative to the other conventional plates and intramedullary implants with the properties of an increased stability by multiaxial screw locking and the results are satisfactory when appropriate settlement achieved.

Prospective Study of the Effectiveness of Intramedullary Fixation of Unstable Peritrochanteric Fractures with Interlocking Proximal Femoral Nail

Prospective Study of the Effectiveness of Intramedullary Fixation of Unstable Peritrochanteric Fractures with Interlocking Proximal Femoral Nail

New classification focusing on the relationship between the attachment of the iliofemoral ligament and the course of the fracture line for intertrochanteric fractures

PurposeThere are various types of intertrochanteric fractures that are unstable pertrochanteric fractures of the hip. The aim of this study was to develop a systematic and comprehensive classification of intertrochanteric fractures. Materials and methodsThis study enrolled 74 patients with intertrochanteric fractures treated by us between 2012 and 2015. The fractures were classified using 3D-CT images taken immediately after the fractures occurred based on the course of the lateral fracture line (LFL) that extends through the lateral femoral cortex distal to the vastus ridge of the greater trochanter in the intertrochanteric area. Furthermore, the presence or absence of additional typical fractures was also studied. Then, 4 orthopedic specialists examined the 3D-CT images of 20 patients randomly selected from the 74 patients to evaluate both the inter-rater and intra-rater agreement levels. ResultsIntertrochanteric fractures were classified into three types according to the LFL patterns. Type I (41.9%), the Lateral Wall Pattern, has a LFL that extends towards the lateral fiber bundle attachment area of the iliofemoral ligament. Type II (24.3%), the Transverse Pattern, has a LFL that extends towards the medial bundle attachment area. Type III (33.8%), the Reverse Oblique Pattern, has a LFL that extends between the lateral and medial fiber bundle area of the iliofemoral ligament. Each type showed characteristic displacement and was associated with various combinations of typical fractures (fracture across the intertrochanteric line, posteromedial fragment, including the lesser trochanter, posterolateral fragment posterior to the femoral greater trochanter, and banana-shaped big fragment, including both the greater trochanter and the lesser trochanter). The mean κ values for the interobserver and intraobserver agreement levels were 0.77 (0.70–0.85) and 0.76 (0.70–0.85), respectively, which were considered substantial agreement levels. ConclusionWe believe our new classification is a useful communication tool for medical professionals in the diagnosis of fractures.

Hip Instability following DHS Fixation Surgery for Unstable Four Part Per-Trochanteric Fracture Femur

Background: In an ageing population, with resultant osteoporosis hip fractures are common indication for per-trochanteric fracture hip repairs. Various modalities of surgical treatment basically emphasis fracture reduction, fracture immobilization, and rehabilitation as a guide to treatment. Subluxation or dislocation following operative treatment of four part unstable per-trochanteric fracture with Sliding Hip Screw is rare and occasional cases have been reported. Material and Methods: An observational prospective study carried out at tertiary care hospital from Jan 1997 – Dec 2014. Our operative experience of total 510 patients of which 480 underwent DHS fixation surgery for unstable four part per-trochanteric fracture showed 6 cases of instability as subluxation and dislocation. Results: We report 6 cases out of 480 DHS fixation showing instability in 3 cases and subluxation and dislocation in 3 cases after 6 weeks of follow-up. These patients were offered arthroplasty and the follow-up results were evaluated after 8 months. Among 6 cases, four had instability after six weeks and remaining two developed dislocation after eight months which were associated with infection. 1 patient refused further investigations &amp; treatment, 3 other died with due course of time, 1 lost to follow -up and One patient with infection underwent excision arthroplasty. Conclusion: Hip instability following DHS fixation surgery for four part Per-trochanteric fracture femur is a rare complication. Cause of this complication could be mechanical factors (excessive collapse, rotational torque) and infection (superficial or deep) may serve as a contributing factor. Diagnosis was done mainly on the basis of clinical examination and investigations such as X-rays, USG and blood tests. Treatment for such complications consists of Hip arthroplasty. These complications can be prevented with the use of TFN or cemented bipolar prosthesis primarily for treating these type of fractures. Keywords: Intertrochanteric fracture, hip instability, surgical fixation

Operated unstable pertrochanteric fractures leading to osteonecrosis of femoral head

Operated unstable pertrochanteric fractures leading to osteonecrosis of femoral head

Comparison of outcome of management of unstable pertrochanteric femoral fractures with dynamic hip screw and proximal femoral nail

Context: Pertrochanteric fractures of the proximal femur are a common occurrence among elderly patients. The two types of implants most commonly used for internal fixation of these fractures are dynamic hip screw (DHS) and proximal femoral nail (PFN). However, limited data exist showing comparison between these implants for the treatment of unstable pertrochanteric fractures which are more difficult to manage than the stable ones.Aims: The purpose of this study was to compare the outcome of management between both implants in the treatment of pertrochanteric fractures.Settings and Design: It is a prospective study done at Sri Guru Ram Das Institute of Medical Sciences. Amritsar (Punjab), India.Materials and Methods: Totally, 30 cases of unstable pertrochanteric fractures (Arbeitsgemeinschaft für Osteosynthesefragen [AO] type 31A2 and 31A3) were included and treated using PFN and DHS (15 cases each) from July 2011 to June 2013. Alternate allocation to each implant group was done. Follow-up was for about 6 months. Results were obtained with regard to operation time, blood loss, fluoroscopy, time to union, time to full weight bearing, and the requirement for revision surgery. Functional scoring was done using the Salvati and Wilson hip score.Statistical Analysis Used: Clinical and radiological data were analyzed using the statistical software epi-info version 3.5.1 released in August 2008.Results: Patients who underwent fixation by PFN had a shorter operation time, lesser blood loss, and returned to full weight bearing earlier than those who had DHS. However, more fluoroscopic exposure was recorded in PFN than DHS. Time to union was more or less the same. Patients who underwent PFN fixation had better Salvati and Wilson hip scores than those with DHS.Conclusions: In unstable pertrochanteric fractures, PFN definitely holds an edge over DHS.

Effect of teriparatide on unstable pertrochanteric fractures.

We retrospectively analyzed the radiographic and clinical outcomes of unstable pertrochanteric fractures (AO/OTA 31-A2) in 44 patients who underwent dynamic hip screw (DHS) fixation and compared the results with 29 patients who received teriparatide in addition to DHS fixation. A significantly shorter time for fracture healing was recorded in the teriparatide-treated group than in the control group. Rates of lag screw sliding, femoral shortening, and varus collapse were all significantly reduced in the teriparatide-treated group. There were no significant differences with regard to superficial wound infection, pneumonia, urinary tract infection, mortality, malunion, and cutting of the lag screw. The mean overall mobility scores were significantly better in the teriparatide-treated group at 3 and 6 months (P < 0.001 and P < 0.001, resp.) but not at 12 months or the last follow-up. The pain scores were also significantly better in the teriparatide-treated group at 3 and 6 months (P = 0.040 and P = 0.041, resp.) but not at 12 months or the last follow-up. Teriparatide improves radiographic outcomes and yields better clinical outcomes at 3 and 6 months postoperatively. The improvement in union time may be important for elderly populations with unstable pertrochanteric fractures to enable them to return to daily activities and reduce morbidity and mortality.

Comparison of stable and unstable pertrochanteric femur fractures managed with 2- and 4-hole side plates.

Sliding hip screw (SHS) fixation traditionally involves the use of 4-hole side plates; however, 4-hole plates have disadvantages, including longer surgery and greater postoperative pain, and there is little evidence that they provide increased stability. We compared 2- and 4-hole side plates in stable and unstable pertrochanteric fractures. We prospectively enrolled consecutive patients with pertrochanteric femoral fractures treated between Jan. 1, 2004, and Apr. 30, 2009, with a 135° SHS using either a 2- or 4-hole side plate, based on surgeon preference. A total of 327 patients were managed with an SHS device (252 women, 75 men). There were 208 stable fracture patterns (AO/OTA 31 A1, A2.1) and 119 unstable (AO/OTA 31 A2.2, A2.3, A3). We managed 172 patients with 2-hole plates and 155 with 4-hole plates. The average duration of surgery (30.44 v. 51.45 min), blood loss (26.0 v. 31.3 g/L) and transfusion requirements (43% v. 31. 60% transfusion) were significantly lower with the 2-hole than the 4-hole plate. There was no significant difference in length of stay (19 v. 16 d). With stable fractures there was no significant difference in failure rate (6.3% v. 4.9%). In unstable fractures there was a significantly higher rate of failure using 2-hole side plates (24.4% v. 10.8%). In stable fractures, use of an SHS with a 2-hole side plate results in shorter surgery and less blood loss/transfusion than a 4-hole side plate, with equivalent survival. In unstable fractures, there is a greater than 2-fold rate of failure when a 2-hole side plate is used.

Short-term follow-up of pertrochanteric fractures treated using the proximal femoral locking plate.

The proximal femoral locking compression plate is a fixed angled anatomically contoured stainless steel plate used to treat pertrochanteric fractures of the proximal femur. Recent reports quote a high failure rate associated with this implant. We aimed to identify the common methods of failure and determine the elements of surgical techniques that could be altered to potentially improve outcomes should this implant be used for the treatment of unstable pertrochanteric fractures. Retrospective chart analysis. Three separate centers. Twenty-nine patients with 29 fractures. All patients were treated for pertrochanteric fractures using the proximal femoral locking compression plate. The patient demographics, fracture classification, implant details, and complications. Twelve of 29 fractures (41.4%) suffered a complication associated with the implant, and 83% of these occurred in elderly women. Complications included bending, backing-out, fracture, or cut-out of the proximal screws and plate fracture. Common technical errors included the following: (1) leaving the plate proud proximally, (2) malposition of the proximal screws within the femoral neck/head, (3) inappropriate use of the hook plate, (4) creating too ridged a construct when used as a bridging plate. Our experience with the use of this implant suggests an unacceptably high failure rate (41.4%). A knowledge of the common pitfalls encountered when using this device is critical in an effort to reduce failure rates. Based on our data, we would urge caution when considering this device for unstable pertrochanteric fractures, especially in the elderly female. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Double axis cephalocondylic fixation of stable and unstable intertrochanteric fractures: early results in 60 cases with the veronail system.

Introduction:This prospective case-series, without control group, study presents our early experience in the treatment of both stable and unstable peri-trochanteric fractures with a new cephalocondylic implant; the Veronail system.Materials & Methods:Enrolment in our study was from January 2008 through September 2009, with follow-up until October 2011 (at least 1 year). During this period 65 consecutively patients with a fracture in the trochanteric region of the femur (31.A1, A2 and A3 according to AO classification) were surgically managed and prospectively followed up for at least one year. Average age was 78 years old (range 42 to 93) with 40 female and 25 male patients. All patients were surgically treated using the Veronail system. Demographic and nursery data such as pre-existing illness, previous ambulatory status, type of anaesthesia, duration of surgery, volume of blood loss, transfusions, length of hospital stay, time to union and overall complications were systematically recorded and analysed.Results:Mean follow up was 17 months (range, 12 to 23 months). Radiological evaluation was performed at 1, 3, 6 and 12 months postoperatively, as well as at the last follow up visit. Clinical outcome was assessed using the parameters of Harris Hip score. Solid union was achieved in 57/60 patients (95%) at a mean time of 12.5 weeks. Two fractures did not progress to union. There were 3 superficial infections and 1 deep infection; all were successfully managed with appropriate antibiotic treatment. The Harris hip score at the last follow up visit was excellent or good in 46 (77%) of the patients.Conclusions:In the face of the good clinical and radiological results we consider the Veronail system to be of particular interest and perfectly adapted in primary surgery for both elderly and young patients.

Changes in the pattern of fractures of the hip in patients 60 years of age and older between 2001 and 2010

The purpose of this study was to identify changing trends in the pattern of distribution of the type and demographics of fractures of the hip in the elderly between 2001 and 2010. A retrospective cross-sectional comparison was conducted between 179 fractures of the hip treated in 2001, 357 treated in 2006 and 454 treated in 2010. Patients aged < 60 years and those with pathological and peri-prosthetic fractures were excluded. Fractures were classified as stable extracapsular, unstable extracapsular or intracapsular fractures. The mean age of the 179 patients (132 women (73.7%)) treated in 2001 was 80.8 years (60 to 96), 81.8 years (61 to 101) in the 357 patients (251 women (70.3%)) treated in 2006 and 82.0 years (61 to 102) in the 454 patients (321 women (70.1%)) treated in 2010 (p = 0.17). There was no difference in the gender distribution between the three study years (p = 0.68). The main finding was a steep rise in the proportion of unstable peritrochanteric fractures. The proportion of unstable extracapsular fractures was 32% (n = 57) in 2001, 35% (n = 125) in 2006 and 45% (n = 204) in 2010 (p < 0.001). This increase was not significant in patients aged between 60 and 69 years (p = 0.84), marginally significant in those aged between 70 and 79 years (p = 0.04) and very significant in those aged > 80 years (p < 0.001). The proportion of intracapsular fractures did not change (p = 0.94). At present, we face not only an increasing number of fractures of the hip, but more demanding and complex fractures in older patients than a decade ago. This study does not provide an explanation for this change.

Treatment of Unstable Pertrochanteric Fractures with a Long Intramedullary Nail

Purpose: The purpose of this study is to analyze the clinical and radiographic results of treatment of unstable pertrochanteric hip fractures in which the fracture line is extended distally or the width of the canal is wide using a long intramedullary nail. Materials and Methods: From January 2005 to January 2010, we conducted an analysis of 20 cases of unstable pertrochanteric hip fractures (over AO/OTA 31 A2.2) treated using a long intramedullary nailing and followed up for more than 12 months. Using postoperative and last follow-up radiographs, we measured TAD, Cleveland index, neck-shaft angle, sliding length of the lag screw, and union time. Clinically, we measured the operation time, the amount of transfusion, and Parker and Palmer’s mobility score. Results: The mean bony union time was 16.4 weeks(10-21 weeks). The mean sliding length of the lag screw was 4.3 mm(1-10 mm) and the mean varus angulation after surgery was 5.1。(3-8。). The mean operative time was 118 min(60-140 min), and the mean transfusion amount was 2.0 pint(0-4 pint). According to Parker and Palmer’s mobility score, mean preoperative score was 7.5 points and mean postoperative score at last follow-up was 6.9 points. Conclusion: In treatment of unstable pertrochanteric hip fractures, when the fracture line was extended to below the lesser trochanteric level or the medullary canal width was wide, use of a long intramedullary nail showed excellent clinical and radiologic results and can be regarded as a good treatment option.

Comparison of Postoperative Bleeding and Complications between Cemented and Non-cemented Bipolar Hemiarthroplasty in Treatment of Unstable Pertrochanteric Fracture

Purpose: In cases of patients who underwent bipolar hemiarthroplasty (BPHA) for treatment of a pertrochanteric fracture, we compared and analyzed the amount of blood loss and complications between a group using the cemented stem and a group using the cementless stem. Materials and Methods: A total of 104 patients who underwent BPHA for treatment of a pertrochanteric fracture in our hospital for three years and 10 months (From January 2008 to October 2011) were included in this study. Among the 104 patients, 64 patients with a cemented stem were categorized into group 1, and the other 40 patients with an uncemented stem were categorized into group 2. Before surgery, the type of stem was determined by the bone quality of the proximal femur, which had been evaluated with a simple X-ray. Then, after surgery, the amount of blood loss and complications were compared between the two groups. Results: Expected blood loss during the operation was 389.8 cc in group 1, and 395.3 cc in group 2(P=0.88). Postoperatively, average drained blood loss was 219.6 cc in group 1, and 338.1 cc in group 2. Cemented stem was associated with significantly less blood loss (P=0.004). The average operation time in group 1 and in group 2 was 96 minutes and 72 minutes. There was no significant difference in operating time (P=0.85). In addition, there was no difference in INR (International Normalized Ratio) and BMI (Body Mass Index) (P=0.28 and 0.08) regarding total amount of postoperatively drained blood loss. There was no occurrence of hypotensive shock or fatal pulmonary embolism in either group. Three cases of periprosthetic fracture occurred in group 2. Conclusion: Fewer occurrences of postoperative blood loss and fewer complications were observed in the cemented stem group than in the cementless stem group. Preoperative evaluation of bone quality and use of the cement stem for patients with poor bone quality may be a good treatment method that can help to reduce complications.

Comparison of proximal femoral nail antirotation (PFNA) with AO dynamic condylar screws (DCS) for the treatment for unstable peritrochanteric femoral fractures

PurposeThe aim of this study was to compare the results of intramedullary fixation with those of plate-screw fixation for peritrochanteric femoral fracture patients older than 60 years old.MethodsThis article reports on a retrospective review of patients who had peritrochanteric femoral fractures and were treated with a 95° fixed-angle screw plate (DCS) or an intramedullary nailing system (PFNA). Patients with 79 fractures were enrolled in the study; 47 of them were treated with the PFNA system and 37 with the DCS. Followed for at least 1 year, the treatment groups were compared by taking into consideration all demographic and trauma variables.ResultsNo significant differences were discovered between the two groups with regard to side of injury, mechanism of trauma, associated comorbidities, AO fracture classification, average follow-up duration, mortality, and fracture reduction quality at the 1-year follow-up. The average surgical time was significantly lower in the PFNA group (57 min.) compared to the DCS group (87 min.). Longer operative time was needed in the DCS group, and thus, greater blood loss occurred compared to the PFNA group. The functional results of the PFNA group were found to be significantly better than those of the DCS group.ConclusionsOwing to some advantages, such as minimal exposure, reduced operative blood loss, and the achievement of biological fixation, PFNA is a better choice for the treatment for unstable peritrochanteric fractures.

Letter to the Editor: Does PFNA II Avoid Lateral Cortex Impingement for Unstable Peritrochanteric Fractures?

To the Editor We read the article entitled “Does PFNA II Avoid Lateral Cortex Impingement for Unstable Peritrochanteric Fractures?” by Macheras et al. [3] with great interest. We commend the authors for confirming that the Proximal Femoral Nail Antirotation (PFNA)-II could avoid lateral cortex impingement; they concluded a flattened lateral surface and smaller mediolateral angle could decrease the pressure on the lateral trochanteric wall. Beginning in August 2009, we have used PFNA-II to treat more than 300 cases of pertrochanteric and intertrochanteric fractures (AO/OTA: 31A) [4]. In our opinion, the operative technical evolution in nail insertion may be more important than instrument modification. In cephalomedullary nailing, it is important to ensure the instrument insertion line (guide wire, reamer, and the nail) and the femoral canal line are coaxial. However, there are several reasons that make this unachievable in some patients [1, 2]. In addition to morphologic features of the fracture (some can be reduced only with the hip in abduction) and a stiff spine in geriatric patients, the soft tissue mass about the hip, operative drapes, or a laterally oriented operating trajectory of the side-standing surgeon can result in a shift of the ideal trochanteric tip entry point and gradual enlargement in a lateral direction. A laterally enlarged oval hole combined with the existing trochanteric fracture line will lead to more lateral placement of the intramedullary nail than intended. To avoid lateralization, we move the entry point slightly medial (approximately 5 mm) from the trochanteric tip, near the medial wall of the greater trochanter (Fig. 1). There are several advantages to medial reaming. First, it avoids the hard-crest bone of the head-neck fragment, preventing medial abutment and thus reduces the risk of varus reduction of the proximal head-neck fragment or a high helical blade position in the femoral head, both of which are undesirable. Second, it provides adequate space for nail insertion, preventing a wedge-opening effect between the head-neck fragment and the shaft fragment. Third, it provides a well-aligned tube after reaming (even with lateralization) for nail insertion, avoiding pressure on the trochanteric lateral cortex, and nail-cortex impingement or even lateral wall rupture.Fig. 1: Medial migration of the entry point (red point) from the exact tip of the greater trochanter produces an optimal aligned tube (blue area) after reaming.We thank the authors for sharing their experience. We agree with their conclusion that regardless of the implant choice and its specific technical characteristics, the technique of inserting is the key to ensuring a stable fixation and preventing major complications.

Reply to Letter to the Editor: Does PFNA II Avoid Lateral Cortex Impingement for Unstable Peritrochanteric Fractures?

We read the letter from Tao et al. with great interest. We very much appreciate their comments. In our study [4], we highlighted the fact that surgical technique is the key to achieve ideal nail positioning, ensure stable fixation, and prevent major complications. We agree with the importance of keeping the instrument insertion line (guide wire, reamer, and the nail) coaxial to the femoral canal line. Following the surgical technique guidance is the safest way to achieve that. In our practice, we always try to use the recommended entry point for the PFNA II according to the manufacturer’s suggested surgical technique; the entry point recommended by Synthes is at the tip of the greater trochanter or slightly lateral to it [6]. The decreased mediolateral angle of the PFNA II (5° compared with 6° for the PFNA) and its flattened lateral surface allow for that slightly more lateral entry point. To date, in our department, the PFNA-II has been used in more than 300 cases of unstable intertrochanteric fractures and no varus reduction of the proximal head-neck fragment or a wedge opening effect between the head-neck fragment and the shaft fragment has occurred. It is true that there are numerous cases where defining the exact position of the awl at the tip of the greater trochanter is not reliable [1, 2]. We agree that potential problems such as a stiff spine, soft tissue mass about the hip, operative drapes, or laterally oriented operating trajectory of the side-standing surgeon could arise, as Tao et al. noted. We still consider the greater trochanter entry point to be adequate for those cases. There also are cases with extension of the fracture line around the tip of the greater trochanter or with substantial comminution at the suggested entry point. In the latter cases we suggest a deeper awl insertion bypassing the fracture line and introduction of the guide wire under careful fluoroscopy in the AP and lateral views. Tao et al., in their letter, are in accordance with Streubel et al. [5] who suggested that the trochanteric tip represents the ideal starting point in only the minority of cases and an entry point 3 mm medial to the tip is the most suitable for the majority of the trochanteric nails. Nevertheless, the above suggestions are contrary not only to the manufacturer’s surgical technique, but also to the pioneering studies that introduced the PFNA II for Asian patients [3, 7]. We do not argue with the experience of Tao et al., as we do not have a medial entry point experience. However, we do stress the fact that the suggested entry point is at the tip of the greater trochanter and this specific approach was used in our published series. We thank Tao et al. for adding their experience. Adherence to the suggested surgical techniques should not discourage surgeons from trying to improve on or question some of details.

Differences in Survival Rates between Different Patterns of Unstable Pertrochanteric Femoral Fractures

Background: Unstable pertrochanter femur fractures are common in orthopedic practice. They pose a surgical challenge in both reduction and fixation. The fixation devices used are based on hip intramedullary nailing with femur head lag screw or blade. The aim of this paper is to compare different types of unstable pertrochanter fractures. Materials & Methods: We retrospectively reviewed 386 unstable pertrochanter femur fractures surgically treated in our hospital from 2000 to 2009. These included 62 (16.1%) unstable pertrochanter fractures with fractured lesser trochanter (31.A2-2, 31.A2-3); 63 (16.3%) reverse oblique fractures (31.A3-1), 51 (13.2%) transverse fractures (31.A3-2), 145 (37.6%) comminuted fractures (31.A3-3) and 65 (16.8%) subtrochanter fractures. We compared survival rates between fracture types. The clinical characteristics, surgery immediate outcome (e.g., tip apex distance, reduction quality), and long term results, i.e., complications were also compared between fracture types. Results: Survival analysis showed that the fracture types can be grouped into low and high risk fracture types. The former group included, reverse oblique and comminuted fractures. Lesser trochanter, transverse and subtrochanter fractures were included in the high risk group. The survival estimates for five years were 64.6% and 49.3% for the low and high risk fracture types, respectively (p value = 0.008). Multivariate survival analysis showed that the hazard ratio for the high risk fracture group was 1.9 (95% CI = 1.37-2.67). No differences were found between unstable pertrochanter femur fractures with regards to clinical and epidemiology characteristics. Optimal tip apex distance (TAD) of less than 25 mm was found in 66.7%, 57.1% and 66.7% of lesser trochanter, reverse oblique and sutrochanter fractures, respectively. TAD of less than 25 mm was found in 81.2% of both transverse and comminuted fractures (p value = 0.032). No statistically significant differ-ence was found between fracture types, in regards to complication or revision rates. Conclusions: Survival rates were higher in patients suffering from reverse oblique or comminuted pertrochanteric fractures. No differences were found between fracture types, in regards to clinical and other outcome parameters.

Transfusion after Intramedullary Nailing of Hip Fractures

Introduction: Patients with unstable multi-fragmentary trochanteric fractures in comparison to those with simple intra-capsular and inter-trochanteric fractures have a larger amount of fractured metaphyseal bone from which bleeding can occur at the time of injury. A detailed analysis was performed comparing haemoglobin (Hb) in the pre and postoperative periods between patients requiring transfusion and those not. This was to determine if pre-operative blood loss caused a greater magnitude of fall in Hb concentration compared to post-operative blood loss, demonstrating if bleeding from the fracture as opposed to the surgery that patients had undergone was associated with the need for transfusion. Methods: Retrospective review of patients undergoing third generation Gamma Nail (Stryker Trauma, Switzerland) fixation for unstable peritrochanteric fractures. Fracture type was classified according to the MUller AO/ OTA classification. Patients were excluded if they had prophylactic nailing for metastatic disease; had sustained a diaphyseal fracture; or if they had been on warfarin, had any previous documented anaemia or acute gastrointestinal haemorrhage. The pre and post-operative Hb was recorded, timing and volume of transfusion. The Hb levels were analysed using a repeated measures regression model. The mean arterial blood pressure (MAP), level of fitness prior to surgery according to the American Society Anaesthesiologists (ASA) grading and fracture type was defined for each patient. Results: There were 51 patients with a mean age of 78 years after exclusions. 23 patients received a transfusion and 28 did not. The mean pre-operative Hb in the non-transfused group was 118.4 g/L, higher than the Hb in the transfused group, 95.9 g/L (p < 0.00). In comparison, in the 48 hour period after their operation, the mean Hb concentrations were comparable in both groups (p=0.358). Conclusions: There was a significant difference in the starting Hb level between groups: in the group requiring transfusion patients were anaemic before surgery. The association of pre-operative anaemia with an unstable multifragmentary trochanteric fracture should alert clinicians that these patients are likely to require blood replacement.

Quality of life after pertrochanteric femoral fractures treated with a gamma nail: a single center study of 62 patients

BackgroundIntramedullary nailing of pertrochanteric femoral fractures has grown in popularity over the past 2 decades likely because this procedure is associated with a low risk for postoperative morbidity and a fast recovery of function. The evaluation of outcomes associated with pertrochanteric nailing has mainly been based on objective measures. The purpose of the present study is to correlate patients’ health-related quality of life results after intramedullary nailing of pertrochanteric fractures with objective outcome measures.MethodsWe conducted a single-center study including 62 patients (mean age 80 ± 10 years) with pertrochanteric fractures treated with a Gamma 3 Nail. Health related quality of life was measured using the Short Form-36. These results were compared to both US and Austrian age and sex-adjusted population norms. The objective outcome measures studied at one year postoperatively included Harris Hip Score, range of motion, leg length, body mass index, neck-shaft angle and grade of osteoarthritis.ResultsAccording to the Harris Hip Score 43 patients (67%) had excellent or good results. There was no significant difference in the average neck-shaft angle comparing affected hip to non-affected hip at 12 months postoperatively. The average osteoarthritis score, for both the injured and uninjured hip, did not differ significantly. We found significant differences between the bodily pain, social functioning and mental health subscales and two summary scores of the Short-Form 36 in comparison to Austrian population norms. Complication rate was 8%.ConclusionsThe results of this study confirm that intramedullary nailing with the use of a Gamma Nail is a safe treatment option for stable and unstable pertrochanteric fractures. Despite good functional and radiographic results we noticed a substantial fall off in patients’ quality of life up to 12 months after operation.