Fracturas trocántereas inestables. ¿Fijación extramedular o intramedular? / Unstable trochanteric fractures. Extramedullary or intramedullary fixation?

Introducción: Las fracturas trocantéreas inestables presentan dificultad para lograr la osteosíntesis estable, el apoyo precoz y la rápida reintegración social. Se tratan mediante osteosíntesis extra o intramedular. La osteosíntesis extramedular mediante placa atornillada estática o dinámica. Los implantes intramedulares poseen clavos o tornillos deslizantes. Objetivo: Revisar la literatura publicada entre 2015 y 2020 que comparen los diferentes métodos de fijación quirúrgica de las fracturas trocantéreas inestables. Estrategia de búsqueda: En PubMed de publicaciones entre los años 2010-2020 en ingles con los términos: fracturas trocantéreas inestables, tratamiento de las fracturas extracapsulares de fémur proximal, osteosíntesis en fracturas trocantéreas femorales inestables. Conclusiones: Las fracturas trocantéreas inestables poseen tendencia al desplazamiento en varo con medialización de la diáfisis. El clavo-placa estático muestra elevados índices de fallo, superiores al del clavo-placa deslizante (DHS), pero la placa estabilizadora trocantérea (TSP) parece ser el mejor implante para osteosíntesis extramedular muy semejante a lo reportado con los implantes intramedulares(AU)

Introduction: Unstable trochanteric fractures show difficulty in achieving stable osteosynthesis, early support and rapid social reintegration. They are treated by intra or extramedullary osteosynthesis, the later, by using a static or dynamic screw plate. Intramedullary implants have sliding nails or screws. Objective: To review the literature published from 2015 and 2020 that compares the different methods of surgical fixation of unstable trochanteric fractures. Search strategy: We searched in PubMed for publications from 2010 to 2020 in English with the terms unstable trochanteric fractures, treatment of extracapsular fractures of the proximal femur, osteosynthesis in unstable femoral trochanteric fractures. Conclusions: Unstable trochanteric fractures have a tendency to varus displacement with medialization of the diaphysis. The static nail-plate shows high failure rates, higher than that of the sliding nail-plate (DHS), but the trochanteric stabilizing plate (TSP) seems to be the best implant for extramedullary osteosynthesis, which is very similar to that reported with intramedullary implants(AU)

Introduction: Les fractures trochantériennes instables présentent des difficultés pour obtenir une ostéosynthèse stable, un soutien précoce et une réinsertion sociale rapide. Ils sont traités par ostéosynthèse extra ou intramédullaire. Ostéosynthèse extramédullaire à l'aide d'une plaque vissée statique ou dynamique. Les implants intramédullaires ont des clous ou des vis coulissants. Objectif: Bilan des travaux 2015-2020 comparant les différentes méthodes de fixation chirurgicale des fractures trochantériennes instables. Stratégie de recherche: Dans PubMed des publications 2010-2020 en anglais avec les termes: instable trochanteric fractures, treatment of extracapsular fractures of the proximal fémur, Ostéosynthesis in instable fémoral trochantic fractures. Conclusions: Les fractures trochantériennes instables ont tendance à se déplacer en varus avec médialisation de la diaphyse. La plaque à clous statique présente des taux d'échec élevés, supérieurs à ceux de la plaque à clous coulissante (DHS), mais la plaque de stabilisation du trochanter (TSP) semble être le meilleur implant pour l'ostéosynthèse extramédullaire très similaire à celle rapportée avec les implants intramédullaires(AU)

Biomechanical study on the treatment of intertrochanteric fracture of A3.3 type with medial sustainable nail and proximal femoral anti-rotation nail / 中国骨伤

OBJECTIVE@#A3 intertrochanteric fracture is an extremely unstable fracture, which is often treated with intramedullary nail, but the implant failure is common due to the posterior medial fragment cannot be reconstructed. A new medial sustainable nail (MSN-Ⅱ) which can reconstruct the femoral medial support by sustainable screw was introduced in this study. The mechanical effect was verified by biomechanical experiment.@*METHODS@#The loss medial support model of intertrochanteric fracture (A3) was made by artificial Sawbones model, fixed with MSN-Ⅱ and PFNA-Ⅱ, underwent axial loading and axial failure tests. The axial stiffness, yield load, displacement of head-neck fragment and torsional angle of fracture site of these nails were recorded and compared for biomechanical differences. The effect of early reconstruction of medial support with MSN-Ⅱ was determined.@*RESULTS@#The axial stiffness, yield load, the displacement of head and neck fragment when the axial load was 1 800 N and torsional angle of the fracture site after the axial failure test of MSN-Ⅱ were (222.76 ±62.46) N /mm, (4 241.71 ±847.42) N, (11.51 ±0.62) mm, (1.71 ±0.10)° respectively, while the PFNA -Ⅱ was (184.58±40.59) N /mm, (3 058.76±379.63) N, (16.15±1.36) mm, (2.52±0.26)°respectively. The difference between the two groups was statistically significant.@*CONCLUSION@#The axial stiffness of MSN-Ⅱ is better than that of PFNA-Ⅱ. The MSN-Ⅱ can bear more loads when fixed A3.3 intertrochanteric fracture and has greater axial and rotational stability. It is an effective means to reconstruct the medial support of A3 intertrochanteric fracture.

The Frequency of Occult Intertrochanteric Fractures among Individuals with Isolated Greater Trochanteric Fractures / 대한고관절학회지

PURPOSE: Isolated greater trochanteric (GT) fractures are often identified using plain radiography of patients with post-traumatic hip pain. In many cases, the fracture extends to form an occult intertrochanteric fracture. We conducted a study to determine the frequency of occult intertrochanteric fractures in patients diagnosed with isolated GT fractures using plain radiographs. MATERIALS AND METHODS: Among 3,017 individuals who visited our emergency department with a trauma-induced pertrochanteric femur fracture between July 2004 and March 2018, 100 patients diagnosed with isolated GT fractures using plain radiographs were retrospectively analyzed. Patients were divided into two groups, those with: i) isolated GT fractures (group A) and ii) occult intertrochanteric fractures (group B). In addition, plain radiographs, magnetic resonance imaging results, and treatment methods were further analyzed in each group. If surgery treatment was needed, it was performed by one surgeon, and in all cases, a 2-hole dynamic hip screw was used. RESULTS: Among the 100 cases of isolated GT fractures diagnosed using plain radiograph, additional examinations revealed that 10 (10.0%) were suffering from isolated GT fractures alone, while the remaining 90 (90.0%) were further diagnosed with occult intertrochanteric fracture. Gender, age, mechanism of injury, and bone mineral density did not correlate with fracture type. CONCLUSION: In our analysis, 90% of injuries initially diagnosed as isolated GT fractures were found to extend into occult intertrochanteric fractures upon further examination with additional imaging modalities. Therefore, additional evaluation should be performed to test for the potential presence of occult intertrochanteric fractures and to establish appropriate treatment plans.

Interpretation of and discussion on AO/OTA-2018 fracture classification of femoral per/inter-trochanteric fractures / 中华创伤骨科杂志

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.

Risk Factors of Cut-Out in Treatment of Femoral Intertrochanteric Fractures by Proximal Femur Nail / 대한정형외과학회잡지

PURPOSE: The purpose of this study is to evaluate the risk factors for the occurrence of cut-out of proximal femoral nail by a lag screw as the treatment for intertrochanteric fractures. MATERIALS AND METHODS: A total of 151 patients (76 males and 75 females; mean age, 73.7±12.1 years), who were diagnosed with intertrochanteric fracture at Gyeongsang National University Hospital between January 2011 and March 2016, with a follow-up of at least for 6 months were included in this retrospective study. Various risk factors, such as demographic data, osteoporosis, collodiaphyseal angle (CDA) (≤130° or >130°), tip-apex distance (TAD) (≤25 mm or >25 mm), and the position of lag screw in the femur head (quadrant) related to the occurrence of cut-out were taken into consideration. The strength of association for each factor was determined through the calculation of the odds ratio (OR), within the 95% confidence interval (CI). First, we performed univariate logistic regression analyses for all variables; then, we performed a multivariate logistic regression analysis, using only the significant variables that had resulted from the univariate analysis. RESULTS: Among the 151 cases, the occurrence of cut-out was observed in 14 cases (9.3%). In a univariate analysis, the fracture patterns based on the AO/OTA classification (p=0.045), CDA (p<0.001) and the position of lag screw in the femur head (quadrant) (p=0.001) showed a significant association with the occurrence of the cut-out. However, TAD was not significantly associated with the cut-out (p=0.886). Various factors, which were significant in univariate analyses, were included in multivariate analyses. In multivariate analyses, CDA (OR, 12.291; 95% CI, 2.559-59.034; p=0.002), and quadrant (OR, 7.194; 95% CI, 1.712-30.303; p=0.007) were significantly associated with the cut-out. CONCLUSION: Valgus reduction and proper position of lag screw were critical for the prevention of occurrence of cut-out when treating intertrochanteric fracture using proximal femur nail.

Prediction of Mortality in Nonagenarians Following the Surgical Repair of Hip Fractures

BACKGROUND: The purpose of this study is to report on the mortality of nonagenarians who underwent surgical treatment for a hip fracture, specifically in regards to preexisting comorbidities. Furthermore, we assessed the effectiveness of the Deyo score in predicting such mortality. METHODS: Thirty-nine patients over the age of 90 who underwent surgical repair of a hip fracture were retrospectively analyzed. Twenty-six patients (66.7%) suffered femoral neck fractures, while the remaining 13 (33.3%) presented with trochanteric type fractures. Patient charts were examined to determine previously diagnosed patient comorbidities as well as living arrangements and mobility before and after surgery. RESULTS: Deyo index scores did not demonstrate statistically significant correlations with postoperative mortality or functional outcomes. The hazard of in-hospital mortality was found to be 91% (p = 0.036) and 86% (p = 0.05) less in patients without a history of congestive heart failure (CHF) and chronic pulmonary disease (CPD), respectively. Additionally, the hazard of 90-day mortality was 88% (p = 0.01) and 81% (p = 0.024) less in patients without a history of dementia and CPD, respectively. The hazard of 1-year mortality was also found to be 75% (p = 0.01) and 80% (p = 0.01) less in patients without a history of dementia and CPD, respectively. Furthermore, dementia patients stayed in-hospital postoperatively an average of 5.3 days (p = 0.013) less than nondementia patients and only 38.5% returned to preoperative living conditions (p = 0.036). CONCLUSIONS: Nonagenarians with a history of CHF and CPD have a higher risk of in-hospital mortality following the operative repair of hip fractures. CPD and dementia patients over 90 years old have higher 90-day and 1-year mortality hazards postoperatively. Dementia patients are also discharged more quickly than nondementia patients.

Removal Methods for Broken Proximal Femoral Nails Using Ball Tip Guide Wire: Technical Note and Two Cases Report

Recently, the use of intramedullary nailing for proximal femoral fractures has increased. Breakage of the nail usually occurs at the un-united fracture site, and it is a rare complication of intramedullary nailing of the femur. However, removal of the distal fragment of a broken nail is a challenging problem. Herein, the authors describe the methods used for removal of relatively fixed or strongly fixed broken intramedullary nails in two different cases.

Morbidity and Mortality of the Elderly after Early Operation for Trochanteric Fractures

PURPOSE: To find out the effect of early closed reduction and internal fixation (within 24 hours after admission to hospital) on the morbidity and mortality in the elderly with intertrochanteric fractures of the femur. MATERIALS AND METHODS: Retrospectively, we analyzed 99 patients with intertrochanteric fracture of the femur who underwent surgery from January, 2009 to December, 2010. We reviewed 89 of the 99 patients and checked for early complications and reviewed the mortality rates 3 months, 6 months and 1 year after surgery. There were 24 males and 65 females. The average age was 79.8 years (61-99 years). According to the American Society of Anesthesiologists classification, 25 patients were class 1, 37 patients were class 2, 26 patients were class 3, and 1 patient was class 4. All patients were operated on by one surgeon, who was skilled in inserting intramedullary nail. RESULTS: The average surgical time was 43 minutes and the average intraoperative blood loss was 165 ml. Sixteen patients experienced delirium but all of them recovered. One patient had pneumonia at one month after surgery. Pressure sores developed in one patient but improved with conservative treatment. Pulmonary thromboembolism developed in some patients one month after surgery. Three patients (3.4%) died within three months and one patient (1.1%) died between three and six months after surgery, but no patient died between six months and one year after surgery. CONCLUSION: If patients are optimized for the operation, early internal fixation of trochanteric fracture in elderly patients after arrival at the hospital should be considered to reduce early complications and mortality.

Perfil clínico e epidemiológico de pacientes com fratura de quadril internados em um hospital de referência traumatológica na cidade de Salvador, Bahia / Clinical and epidemiological profile of patients with hip fracture hospitalized in a traumatologic reference hospital in the city of Salvador, Bahia, Brazil / Perfil clínico y epidemiológico de los pacientes con fractura de cadera ingresados em un hospital traumatológico de referencia en la ciudad de Salvador, Bahia

As fraturas da extremidade proximal do fêmur são lesões graves que podem resultar em traumas intensos, muitas vezes associados a disfunções de outros órgãos. O objetivo deste artigo é avaliar o perfil clínico e epidemiológico de pacientes com fratura de quadril internados em um hospital de referência traumatológica da cidade de Salvador, Bahia. Trata-se de estudo descritivo com pacientes diagnosticados com fratura de quadril, submetidos a tratamento cirúrgico e internados entre março de 2009 a julho de 2011. Os resultados revelam que, dentre os pacientes, 49,8 por cento tinham, predominantemente, idade entre 71 e 90 anos, 56,9 por cento eram mulheres e 50,2 por cento eram pardos. Em relação ao tipo da fratura de quadril, o mais prevalente, com 46,9 por cento, foi a fratura do colo femoral. As quedas, com 82,4 por cento, foram a maior causa; 55,9 por cento tiveram desordens cardiovasculares, 64 por cento foram submetidos à osteossíntese e 92,4 por cento tiveram alta hospitalar. Concluiu-se que a fratura de quadril relaciona-se com o avançar da idade, sexo feminino e presença de comorbidades como influenciador no tempo de recuperação e independência funcional no qual uma adequada abordagem terapêutica diminui a incidência de complicações e das taxas de morbimortalidade.

Fractures of the proximal femur are serious injuries that can result in severe trauma, often associated with other organ dysfunction. The objective of this article is to evaluate the clinical and epidemiological profile of patients with hip fracture admitted to a trauma reference hospital in the city of Salvador, Bahia. This is a descriptive study of patients diagnosed with hip fractures, undergone surgeries that were hospitalized between March 2009 and July 2011. The results show that among the patients, 49.8 percent predominantly aged between 71 and 90 years, 56.9 percent were women and 50.2 percent were Afro descendants. Regarding the type of hip fracture, the most prevalent, with 46.9 percent , was the femoral neck fracture. The falls, with 82.4 percent , were the major cause, 55.9 percent had cardiovascular disorders, 64 percent underwent osteosynthesis and 92.4 percent were discharged. It is concluded that hip fracture is related to age advance, female gender, and presence of comorbidities such as influence in time recovery and functional independence in which an adequate therapeutic approach decreases the incidence of complications and mortality rates.

Las fracturas del fémur proximal son lesiones graves que pueden resultar en un trauma severo, a menudo asociadas a la disfunción de otros órganos. El objetivo de este artículo es evaluar el perfil clínico y epidemiológico de los pacientes con fractura de cadera ingresados en un hospital traumatológico de referencia en la ciudad de Salvador, Bahia. Se trata de un estudio descriptivo de pacientes con diagnóstico de fractura de cadera, sometidos a una cirugía e ingresados entre marzo de 2009 a julio de 2011. Los resultados muestran que, entre los pacientes, el 49,8 porciento tenía, predominantemente, edades comprendidas entre 71 y 90 años, el 56,9 porciento eran mujeres y el 50,2 porciento eran afrodescendientes. En cuanto al tipo de fractura de cadera, el más frecuente, con 46,9 porciento, fue el de fractura del cuello femoral. Las principales causas fueron las caídas, con un 82,4 porciento, el 55,9 porciento tuvo trastornos cardiovasculares, el 64 porciento se sometió a la osteosíntesis y un 92,4 porciento fueron dados de alta. Se concluye que la fractura de cadera se relaciona con la edad avanzada, el sexo femenino, y la presencia de comorbilidades como factores de influencia en el tiempo de recuperación y la independencia funcional, en la cual, un adecuado enfoque terapéutico, disminuye la incidencia de complicaciones y las tasas de morbimortalidad.

Bleeding Volume after Surgery for Trochanteric Fractures of the Femur in Patients Treated with Antiplatelet Agents: Comparison according to Surgical Timing

PURPOSE: We evaluated the bleeding volume after surgery for trochanteric fractures of the femur in patients treated with antiplatelet agents according to surgical timing. MATERIALS AND METHODS: We selected 20 patients who had trochanteric fractures of the femur treated with antiplatelet agents from January 2009 to June 2010. Group I included 9 patients who discontinued antiplatelet medication and had delayed operations at an average of 6.5 days and Group II included 11 patients who underwent early operations within 24 hours. Group I included 2 males and 7 females; their average age was 77.8 years (range 59~86). Group II included 4 males and 7 females, with an average age of 73.5 years (range 61~84). We compared the two groups' volume of intraoperative bleeding, the preoperative and postoperative hemoglobin levels and the volume of postoperative transfusion. The Mann-Whitney U test was used for statistical analysis. RESULTS: The volume of intraoperative bleeding was 88 ml in group I and 106 ml in group II (p>0.01). The difference in the hemoglobin was a decrease of 2.4 mg% in group I and a decrease of 2.2 mg% in group II (p>0.01). The volume of postoperative transfusion was 0.6 pints in group I and 1 pint in group II (p>0.01). CONCLUSION: We found a similar bleeding volume regardless of operative timing after surgery for trochanteric fractures of the femur in patients treated with antiplatelet agents.