Implicancia de la radiografía con tracción y rotación interna en la evaluación de las fracturas de fémur proximal / Implication of internal rotation traction radiography in proximal femoral fracture evaluation

Introducción: La correcta valoración de las radiografías cuando ingresa un paciente con una fractura de fémur proximal tiene una implicancia directa en el tratamiento propuesto. Materiales y Métodos: Se evaluó consecutivamente a 100 pacientes con diagnóstico de fractura de fémur proximal. Se tomaron radiografías de pelvis de frente, de la cadera afectada de frente y de la cadera afectada de frente con tracción y rotación interna. Se comparó la clasificación realizada por residentes con la clasificación de los médicos senior, todos utilizaron las tres radiografías para evaluar las fracturas. Resultados: El resultado global de concordancia entre la clasificación inicial de los residentes con la de los médicos senior fue del 68,9%. Cuando los médicos residentes utilizaron la radiografía con tracción y rotación interna, la concordancia aumentó al 81,5%. Cincuenta y una respuestas cambiaron con respecto a la clasificación inicial. De estas, en 42 (82,4%) casos, la clasificación inicial era incorrecta y cambió a una correcta. En 9 (17,6%) casos, la clasificación inicial era correcta y cambió a una incorrecta. Conclusiones: La radiografía con tracción y rotación interna es un estudio simple, de bajo costo y bien tolerado por el paciente que facilita la correcta interpretación de las fracturas de fémur proximal, lo que tiene un impacto directo en la indicación del tratamiento y su resultado final. Nivel de Evidencia: IV

Introduction: The correct assessment of radiographs at the time of admission of a patient with proximal femoral fracture has a direct effect on the choice of treatment. Materials and Method: We consecutively evaluated 100 patients with a diagnosis of proximal femoral fracture. Antero-posterior pelvic radiographs (A-P), A-P radiographs of the affected hip, and internal rotation traction radiographs of the affected hip were taken. A comparison was made between the classifications made by residents and the classification of senior doctors, who used the 3 radiographs to classify all fractures. Results: The overall agreement score between the initial classification of residents and that of senior doctors was 68.9%. When the resident physicians used internal rotation traction radiography, agreement increased to 78.75%. 51 responses changed with respect to the initial classification. Of these, in 42 (82.4%) cases the initial classification was incorrect and changed to a correct classification. While in 9 (17.6%) cases the initial classification was correct and changed to an incorrect one. Conclusion: Internal rotation traction radiography is a simple, low-cost study that is well-tolerated by the patient and facilitates correct interpretation of proximal femoral fractures with a direct impact on the choice of treatment and its outcome. Level of Evidence: IV

Efecto analgésico del bloqueo PENG (grupo de nervios pericapsulares) en pacientes con fractura de cadera / Analgesic effect of the PENG BLOCK (pericapsular nervous group) in patients with hip fracture

Ultrasound regional blockade emerged that blocks the branches of the femoral nerve, obturator and accessory obturator that innervate the anterior hip capsule, the PENG block (group of pericapsular nerves), which by its Recent description does not have enough evidence in medical practice. To verify the analgesic effect of the PENG block in patients with hip fracture and its analgesic permanence during the first 10 hours after the block in patients admitted with a diagnosis of hip fracture, at the General Interzonal Hospital of Acute "Dr Oscar E Alende "From Mar del Plata, Argentina, in the months of May to November 2019. A prospective descriptive observational study was carried out with a total of 53 patients, hospitalized patients with a diagnosis of hip fracture, with standardized intravenous analgesic scheme and who have not yet undergone hip surgery. Pain was evaluated with the EVA scale (visual analog scale) prior to the blockage, and then at 30 min and 10 hours after the blockade, 15 ml of 1% lidocaine and 15 ml of bupivacaine at 0 were used. 25%, convex or linear ultrasound probe according to patient weight and 100 mm needle. In order to reproduce and evaluate the pain, the patients had a 30º flexion of the hip. Prior to the blockade, 66% of the patients had severe pain and 34% moderate pain, none presented mild pain or absence, both at thirty minutes and ten hours after the blockade, no patient presented severe pain and all patients presented analgesia with a decrease in more than three points on the VAS scale, in some cases reaching a decrease of 10 points on that scale. The PENG block is a regional anesthesia technique that provides very good analgesia to patients with hip fractures, therefore, it is an excellent saving strategy for systemic analgesics. Knowing the analgesia provided by the blockade at 30 min and at 10 h, it could be performed both in the preoperative period for the transfer and mobilization of the patient, as well as in the postoperative period, which could save the use of opioids and decrease hospital stay.

INTRODUCCIÓN La fractura de cadera es una emergencia ortopédica común en ancianos asociada a gran morbimortalidad, una adecuada analgesia regional perioperatoria determina un ahorro en el uso de analgésicos sistémicos. Recientemente, en el año 2018, surgió un nuevo bloqueo regional ecoguiado muy prometedor que bloquea las ramas del nervio femoral, obturador y obturador accesorio que inervan la capsula anterior de la cadera, el bloqueo PENG (grupo de nervios pericapsulares), el cual por su reciente descripción no cuenta con la suficiente evidencia en la práctica médica. OBJETIVOS: Comprobar el efecto analgésico del bloqueo PENG en pacientes con fractura de cadera y su permanencia analgésica durante las 10 primeras horas posteriores al bloqueo en los pacientes internados con diagnóstico de fractura de cadera, en el Hospital Interzonal General de Agudos "Dr. Oscar E Alende" de Mar del Plata, Argentina, en los meses de mayo a noviembre del 2019. MATERIALES Y MÉTODOS: Se realizó un estudio observacional descriptivo prospectivo con un total de 53 pacientes, se incluyeron pacientes internados con diagnóstico de fractura de cadera, con esquema analgésico endovenoso estandarizado y que aún no hayan sido sometido a cirugía de cadera. Se evaluó el dolor con la escala EVA (escala análoga visual) previo al bloqueo, y luego a los 30 min y a las 10 Hs de haber realizado el bloqueo, para este se utilizaron 15 ml lidocaína 1% y 15 ml de bupivacaína al 0,25%, sonda ecográfica convexa o lineal según el peso del paciente y aguja 100 mm. Para reproducir y evaluar el dolor se les realizo a los pacientes una flexión de 30º de la cadera. RESULTADOS: Previo al bloqueo el 66% de los pacientes tuvieron dolor severo y 34% dolor moderado, ninguno presentaba dolor leve o ausencia del mismo, tanto a los treinta minutos como a las diez horas posteriores al bloqueo ningún paciente presento dolor severo y todos los pacientes presentaron analgesia con una disminución en más de tres puntos en la escala de EVA, llegando en algunos casos a una disminución de 10 puntos de dicha escala. CONCLUSIONES: El bloqueo PENG es una técnica de anestesia regional que brinda muy buena analgesia a los pacientes con fractura de cadera, por consiguiente, es una excelente estrategia ahorradora de analgésicos sistémicos. Conociendo la analgesia que brinda el bloqueo a los 30 min y a las 10 h de realizado, se podría realizar dicho bloqueo tanto en el preoperatorio para el traslado y movilización del paciente, como en el post-operatorio, lo que podría ahorrar el uso de opioides y disminuir la estancia hospitalaria.

Presence of a Nail in the Medullary Canal; Is It Enough to Prevent Femoral Neck Shortening in Trochanteric Fracture?

PURPOSE: Presence of a cephalomedullary nail (CMN) in the medullary canal has been thought as advantageous in the control of femoral neck shortening (FNS) and lag screw sliding in trochanteric fracture compared to extramedullary fixation system. However, researches on the factors that influence the degree of FNS after cephalomedullary nailing are lacking. MATERIALS AND METHODS: We observed 95 patients (mean age, 75+/-2.8 years) with trochanteric fractures who were treated with a CMN, and evaluated the relationship between FNS and patient factors including age, gender, fracture type (AO/OTA), bone mineral density, medullary canal diameter, canal occupancy ratio (COR=nail size/canal diameter), and tip-apex distance using initial, immediate postoperative, and follow-up radiography. RESULTS: Univariate regression analyses revealed that the degree of FNS was significantly correlated with fracture type (A1 versus A3, p<0.001), medullary canal diameter (p<0.001), and COR (p<0.001). Multiple regression analyses revealed that FNS was strongly correlated with fracture type (p<0.001) and COR (p<0.001). CONCLUSION: Presence of a CMN in the medullary canal could not effectively prevent FNS in patients with low COR and in A3 type fracture.

Total hip replacement after hip fracture: primary or secondary surgery? a comparison of clinical and radiological results

To compare clinical and radiological results of primary and secondary total hip replacement [THR] after displaced fracture of the femoral neck. Retrospective review of a cohort of 47 patients. All surgeries were performed by the senior author in Al Razi Hospital, Kuwait between 2002 and 2007. Follow- up assessment was done in Al Razi and in Farwaniya Hospital, Kuwait by all authors. Twenty-nine cases of primary THR compared with 18 cases of secondary THR. Cementless, cemented and hybrid implants were used for total hip replacements. Clinical assessment was done using Merle D' Aubigne hip score and radiological assessment was done using standard criteria of geometry of the implant and its stability. Clinical results were better in the primary THR group but radiological results were equivocal. There was tendency to position the cup horizontally in the secondary surgery group. Cementless, cemented and hybrid implants did equally well in our cohort. Primary THR seems to be a better option in displaced fracture of the femoral neck. Cemented cementless and hybrid hip can be used in these cases

Additional Fixations for Sliding Hip Screws in Treating Unstable Pertrochanteric Femoral Fractures (AO Type 31-A2): Short-Term Clinical Results

BACKGROUND: To evaluate the utility of additional fixation methods and to suggest a method of reduction in the treatment of unstable pertrochanteric femur fractures with a sliding hip screw (SHS). METHODS: A retrospective study was performed on thirty patients with unstable pertrochanteric femur fractures, who were operated on with a SHS between September 2004 and September 2009 and were followed up for at least 6 months. The additional fixation devices were as follows; antirotation screw (21 cases), fixation of displaced fractures of the posteromedial bone fragment (cerclage wiring, 21 cases and screw, 2 cases) and trochanter stabilizing plate (27 cases). Clinically, the Palmer's mobility score and Jensen's social function group were used. Radiologically, alignment and displacement were observed. The tip-apex distance (TAD) and sliding of the lag screw were measured, and the position of the lag screw within the femoral head was also examined. RESULTS: The mean age at the time of surgery was 76 years (range, 56 to 89 years) and the average follow-up period was 25 months (range, 6 to 48 months). At the last follow-up, the average mobility and social function score was 6.2 (+/- 3.5) and 2.3 (+/- 1.5). Postoperatively, the alignment and displacement indices were adequate in almost all the cases. The mean amount of lag screw sliding and the mean TAD was 5.1 mm (range, 2 to 16 mm) and 6 mm (range, 3 to 11 mm) respectively. The lag screws were located in the center-center zone in 21 cases. The average period to union was 18.7 weeks without any cases of nonunion or malunion. Mechanical failure was noted in one case with breakage of the lag screw and clinical failure was noted in another case with persistent hip pain related to excessive sliding (16 mm). CONCLUSIONS: With additional fixations, the unstable pertrochanteric femur fractures could be well stabilized by SHS until bone union.

Technique and Early Results of Percutaneous Reduction of Sagittally Unstable Intertrochateric Fractures

BACKGROUND: This paper introduces a percutaneous reduction technique using one or two Steinman pin(s) to reduce sagittally unstable intertrochanteric fractures. METHODS: A fracture was defined as a sagittally unstable intertrochanteric fracture when posterior sagging of a distal fragment and flexion of the proximal fragment worsens after usual maneuvers for a closed reduction. Of 119 intertrochanteric fractures treated from June 2007 to December 2008, twenty-one hips showed sagittal instability. The sagittal displacement was reduced using a Steinmann pin as a joystick, and stabilized with a nail device. Nineteen hips were followed up for more than one year. The clinical and radiological results were reviewed in 19 hips and compared with those of the remaining cases. RESULTS: The demographics were similar in both groups. The mean anesthetic time did not differ. Although the pre-injury and final activity levels were significantly lower in the study group, the degree of recovery was the same. No clinical complications related to this technique were encountered. Radiologically, the reduction was good in all hips in both groups. Union was obtained in all cases without any time differences. CONCLUSIONS: This less invasive reduction technique is simple and safe to use for this type of difficult fracture.

Cementless Bipolar Hemiarthroplasty for Unstable Intertrochanteric Fractures in Elderly Patients

BACKGROUND: Bipolar hemiarthroplasty for unstable intertrochanteric fractures in elderly patients is a viable option that can prevent the complications of an open reduction, such as nonunion and metal failure. This study evaluated the clinicoradiological results of cementless bipolar hemiarthroplasty for unstable intertrochanteric fractures in elderly patients. METHODS: Forty hips were followed for more than 2 years after cementless bipolar hemiarthroplasty using a Porocoat(R) AML Hip System. The mean age was 78.8 years and the mean follow-up period was 40.5 months. The Harris hip score and postoperative hip pain were analyzed clinically. The radiological results were assessed using a range of indices. RESULTS: At the last follow-up, the mean Harris hip score was 80.6 points. There were one case of hip pain and one case of thigh pain. Twenty-four cases (60%) showed no decrease in ambulation capacity postoperatively. Radiologically, there were 23 cases (57.5%) of fixation by bone ingrowth and 17 cases (42.5%) of stable fibrous fixation. There were no cases of osteolysis. Eleven cases (27.5%) of new bone formation were found around the stem. All stems were stable without significant changes in alignment or progressive subsidence. CONCLUSIONS: The short-term results of cementless bipolar hemiarthroplasty in elderly patients with unstable intertrochanteric fractures were satisfactory.

Fragility hip fractures

Fragility fractures, the major clinical problem have increased in recent decade due to any increase in expected age. There is a tremendous economic burden to manage this problem, the disability increased from 20% before hip fracture to 50% after this even if managed properly. Fragility hip fracture is associated with a 20% reduction in expected survival in best hands. To study the incidence; types of fractures; treatment options and their outcome. A retrospective study. Armed Forces Hospital Southern Region Khamis Mushayt, Kingdom of Saudi Arabia. From April 1996 to April 2006. 300 patients were included in the study, both males and females above the age of sixty years presented in Emergency Room with hip fractures due to minor or trivial trauma. Diagnosis was based on clinical and radiological grounds. Additional investigations were made when and where indicated to confirm diagnosis and to assess the patient form anesthesia and surgical point of view. Internal fixation was the main treatment to see the ultimate outcome. The incidence of fragility hip fractures increased with age. Sixty percent of the victims were females. The incidence increased with every passing year being 15% in the last year of study. 93% of the fractures were of intertrochanteric type and fixed with engineered metallic device [DHS]. Prevention or delay osteoporosis should be the main objective. Once there is fragility hip fracture internal fixation is the appropriate treatment

Intertrochanteric fractures of the femur: results of treatment with 95 degrees Condylar Blade Plate.

The aim of the present study was to analyze patients treated with 95 degrees Condylar Blade Plate and to describe the technique that can prevent complications. 69 patients with closed intertrochanteric femoral fractures were treated by one surgeon using the 95 degrees Condylar Blade Plate, and it was found that 56 of them met the minimum 10 months follow up requirement. 53 patients (94%) healed after the procedure. There were 4 patients (7%) requiring surgical intervention. One patient required bipolar arthroplasty because of the cutting through of the implant, two patients needed repeated open reduction and internal fixation (ORIF) with bone graft due to delayed union and broken implant, and one patient had an infection which was resolved after debridement and a course of antibiotics. The surgical time averaged 45 minutes and blood loss averaged 150 ml. It appeared that open reduction and internal fixation using the 95 degrees Condylar Blade Plate was effective in treating patients with intertrochanteric femoral fractures. The surgical time and blood loss were minimized. Early patient rehabilitation was initiated, and the complications were decreased.

Isolated Fractures of the Greater Trochanter Report of 6 Cases

Isolated fractures of the greater trochanter are unusual injuries. Because of their relative rarity and the unsettled controversy regarding their etiology and pathogenesis, several methods of treatment have been advocated. Furthermore, the reports on this particular type of injury are not plentiful and the average textook coverage afforded to this entiry is limited. These fractures are seen as two distinctly different types which occur in different age groups. The first type are epiphyseal separations which are found in the adolescent population, ususlly from seven to seventeen years of age. In this type, the mechanism of injury is muscle contraction that results in avulsion of the entire trochanteric apophysis and it can be displaced up to 6 cm. The second type is a comminuted fracture of the greater trochanter seen in adults. In this type, the mechanism of injury is usually a direct blow to the greater trochanter that results in a comminuted fracture, and only a part of the greater trochanter is generally involved.