Resultados de la osteosíntesis en fracturas intertrocantéricas inestables de fémur con clavo femoral proximal

Introducción: Las fracturas intertrocantéricas del extremo proximal del fémur constituyen el grupo nosológico con mayor morbilidad y mortalidad de las lesiones traumáticas del esqueleto. Objetivo: Evaluar la reducción, la colocación del implante y el tiempo de consolidación. Métodos: Se realizó un estudio descriptivo, longitudinal y prospectivo de 114 pacientes con diagnóstico de fracturas del extremo proximal del fémur tratadas con clavo femoral proximal, y un seguimiento posoperatorio de un año. Resultados: Se alcanzó un resultado clínico funcional de excelente a bueno en el 82,4 % de los casos. Se evidenciaron signos radiológicos de consolidación en un promedio de 4,2 meses en la mayor parte de la muestra. Conclusiones: La pérdida de la fijación constituyó la complicación más frecuente; por tanto, se considera que el enclavado femoral proximal ofrece buenos resultados en el tratamiento de fracturas intertrocantéricas inestables del fémur.

Introduction: Intertrochanteric fractures of the proximal end of the femur constitute the nosological group with the highest morbidity and mortality of traumatic skeletal injuries. Objective: To evaluate reduction, implant placement and consolidation time. Methods: A descriptive, longitudinal and prospective study was carried out in 114 patients with diagnosis of fractures of the proximal end of the femur treated with proximal femoral nailing, and a one-year postoperative follow-up. Results: A functional clinical result from excellent to good was achieved in 82.4% of the cases. Radiological signs of consolidation were evidenced in an average of 4.2 months in most of the sample. Conclusions: Loss of fixation was the most frequent complication; therefore, proximal femoral nailing is considered to offer good results in the treatment of unstable intertrochanteric fractures of the femur.

Geriatric intertrochanteric fractures – A challenge to manage

Background: Intertrochanteric fractures are among the frequently seen fractures in the elderly population. Treating these fractures is very challenging considering the fact that the quality of bone is poor and highly osteoporotic. The high failure rates with dynamic hip screw (DHS) especially in unstable fractures lead to the development of intramedullary devices such as proximal femoral nail (PFN) which has got multiple advantages over DHS. Materials and Methods: This prospective study included 30 patients above the age group of 60 years with unstable intertrochanteric fractures conducted in a tertiary institute between February 2021 and June 2022. Results were analyzed clinically and radiologically using the Modified Harris hip score. Results: Patients’ age group was 61–85 years with a mean age of 69 years, comprising 63% female and 37% male. The average Harris hip score was 83.76 at 24 weeks’ follow-up with 33.33% excellent, 56.66% good, 3.33% fair, and 6.67% poor. Postoperative complications included revision surgery in two patients, superficial infection in one patient, Z effect in one patient, peri-implant fracture in one patient. Conclusion: Treatment with PFN for unstable intertrochanteric fracture has the advantages of closed reduction, less tissue damage, early rehabilitation, and return to work. Osteosynthesis with short PFN resulted in good-to-excellent functional and radiological outcomes.

Effectiveness of proximal femur bionic nail for intertrochanteric fracture in the elderly / 中国修复重建外科杂志

OBJECTIVE@#To evaluate effectiveness of proximal femur bionic nail (PFBN) in treatment of intertrochanteric fractures in the elderly compared to the proximal femoral nail antirotation (PFNA).@*METHODS@#A retrospective analysis was made on 48 geriatric patients with intertrochanteric fractures, who met the selection criteria and were admitted between January 2020 and December 2022. Among them, 24 cases were treated with PFBN fixation after fracture reduction (PFBN group), and 24 cases were treated with PFNA fixation (PFNA group). There was no significant difference in baseline data such as age, gender, cause of injury, side and type of fracture, time from injury to operation, and preoperative mobility score, American Society of Anesthesiologists (ASA) score, Alzheimer's disease degree scoring, self-care ability score, osteoporosis degree (T value), and combined medical diseases between the two groups ( P>0.05). The operation time, intraoperative blood loss, number of blood transfusions, transfusion volume, length of hospital stay, occurrence of complications, weight-bearing time after operation, and postoperative visual analogue scale (VAS) score, walking ability score, mobility score, self-care ability score were recorded and compared between the two groups. And the radiographic assessment of fracture reduction quality and postoperative stability, and fracture healing time were recorded.@*RESULTS@#The operations in both groups were successfully completed. All patients were followed up 6-15 months with an average time of 9.8 months in PFBN group and 9.6 months in PFNA group. The operation time was significantly longer in PFBN group than in PFNA group ( P<0.05), but there was no significant difference in intraoperative blood loss, number of blood transfusions, transfusion volume, length of hospital stay, change in activity ability score, and change in self-care ability score between the two groups ( P>0.05). The weight-bearing time after operation was significantly shorter in PFBN group than in PFNA group ( P<0.05), and the postoperative VAS score and walking ability score were significantly better in PFBN group than in PFNA group ( P<0.05). Radiographic assessment showed no significant difference in fracture reduction scores and postoperative stability scores between the two groups ( P>0.05). All fractures healed and there was no significant difference in fracture healing time between the two groups ( P>0.05). The incidence of complications was significantly lower in PFBN group (16.7%, 4/24) than in PFNA group (45.8%, 11/24) ( P<0.05).@*CONCLUSION@#Compared with PFNA, PFBN in the treatment of elderly intertrochanteric fractures can effectively relieve postoperative pain, shorten bed time, reduce the risk of complications, and facilitate the recovery of patients' hip joint function and walking ability.

Outcome of buttress plate-nail construct used for reconstruction of broken lateral wall in intertrochanteric fractures / 中华创伤杂志(英文版)

PURPOSE@#Intramedullary implants are well accepted fixation of all types of intertrochanteric (IT) fractures, both stable and unstable types. Intramedullary nails have an ability to effectively support the posteromedial part, but fail to buttress the broken lateral wall requiring lateral augmentation. The aim of this study was to evaluate the outcome of proximal femoral nail augmented with trochanteric buttress plate for broken lateral wall with IT fractures, which was fixed to the femur through hip screw and anti-rotation screw nail.@*METHODS@#Of 30 patients, 20 had Jensen-Evan type III and 10 had type V fractures. Patients with IT fracture of broken lateral wall and aged more than 18 years, in whom satisfactory reduction was achieved by closed methods, were included in the study. Patients with pathologic or open fractures, polytrauma, prior hip surgery, non-ambulatory prior to surgery, and those who refused to participate were excluded. The operative time, blood loss, radiation exposure, quality of reduction, functional outcome, and union time were evaluated. All data were coded and recorded in Microsoft Excel spread sheet program. SPSS 20.0 was used for data analysis and normality of the continuous data was checked using Kolmogorv Smirnov test.@*RESULTS@#The mean age of patients in the study was 60.3 years. The mean duration of surgery (min), mean intra-operative blood loss (mL) and mean number of exposures were 91.86 ± 12.8 (range 70 - 122), 144.8 ± 3.6 (range 116 - 208), and 56.6 (range 38 - 112), respectively. The mean union time was 11.6 weeks and the mean Harris hip score was 94.1.@*CONCLUSION@#Lateral trochanteric wall in IT fractures is significantly important, and needs to be reconstructed adequately. Nail-plate construct of trochanteric buttress plate fixed with hip screw and anti-rotation screw of proximal femoral nail can be successfully used to augment, fix or buttress the lateral trochanteric wall giving excellent to good results of early union and reduction.

A comparative analysis of distal locked and unlocked long proximal femoral nail antirotation (PFNA-II) in the fixation of stable intertrochanteric fractures / 中华创伤杂志(英文版)

PURPOSE@#Long proximal femoral nail anti-rotation (PFNA-II) is a preferred implant in recent years for fixation of pertrochanteric fractures, especially in osteoporotic patients. The purpose of this study is to prospectively investigate the effect of distal locking in long PFNA-II fixation of stable intertrochanteric fractures.@*METHODS@#A total of 58 patients with isolated stable intertrochanteric fractures and treated in our hospital during the study period of 2017-2019 by distal locked or unlocked long PFNA-II fixation were included in this study. Patients who had multiple injuries or open fractures were excluded. There were 40 female and 18 male patients, with 33 affecting the left side and 25 the right side. Of them, 31 belonged to the distal locked group (group A) and 27 to the unlocked group (group B). Surgical procedures and implants used in both groups were similar except for the distal locking of the nails. General data (age, gender, fracture side, etc.) showed no significant difference between two groups (all p > 0.05). The intraoperative parameters like operative time, radiation exposure and follow-up parameters like functional and radiological outcomes were recorded and compared. Statistical tests like the independent samples t-test Fischer's exact and Chi-square test were used to analyze association.@*RESULTS@#The distribution of the fractures according to AO/OTA classification and 31A1.2 type of intertrochanteric fractures were most common in our study. All the included fractures united and the average functional outcome in both groups were good and comparable at the end of one year. The operative time (mL, 107.1 ± 12.6 vs. 77.0 ± 12.0, p < 0.001) and radiation exposure (s, 78.6 ± 11.0 vs. 40.3 ± 9.3, p < 0.001) were significantly less among the patients in group B. Fracture consolidation, three months after the operative procedures, was seen in a significantly greater proportion of patients in group B (92.6% vs. 67.7%, p = 0.025). Hardware irritation because of distal locking bolt was exclusively seen in group A, however this was not statistically significant (p = 0.241).@*CONCLUSION@#We conclude that, in fixation of stable intertrochanteric fractures by long PFNA-II nail, distal locking not only increases the operative time and radiation exposure but also delays the fracture consolidation and increases the chances of hardware irritation, and hence is not required.

Proximal femoral bionic nail versus proximal femoral nail antirotation in treatment of femoral intertrochanteric fracture: a comparison of short-term efficacy / 中华创伤骨科杂志

Objective:To compare the short-term effects of proximal femoral bionic nail (PFBN) and proximal femoral nail antirotation (PFNA) in the treatment of intertrochanteric fracture.Methods:Retrospectively analyzed were the data of 56 patients with intertrochanteric fracture of the femur who had been admitted to Department of Orthopedic Trauma, The People's Hospital of Juye County and Trauma Center, Central Hospital Affiliated to The First Medical University of Shandong from August 2020 to April 2022. The patients were divided into 2 even groups according to their internal fixation methods ( n=28). In the PFBN fixation group, there were 12 males and 16 females with an age of (70.4±7.8) years; by AO classification, there were 4 cases of type 31-A1, 16 cases of type 31-A2, and 8 cases of type 31-A3. In the PFNA fixation group, there were 10 males and 18 females with an age of (73.0±8.9) years; by AO classification, there were 2 cases of type 31-A1, 16 cases of type 31-A2, and 10 cases of type 31-A3. The operation time, intraoperative blood loss, fracture reduction, fracture healing time, Harris hip score, and complications were compared between the 2 groups. Results:There was no statistically significant difference between the 2 groups in the preoperative general data, showing comparability ( P>0.05). The follow-up time was (7.3±0.9) months for the PFBN group and (7.4±1.1) months for the PFNA group, showing no significant difference ( P>0.05). There was no significant difference either between the 2 groups in operation time, intraoperative blood loss or quality of fracture reduction ( P>0.05). The PFNA group had significantly shorter fracture healing time [(3.9±0.9) months] than the PFNA group [(4.7±1.1) months], and a significantly higher Harris hip score at the last follow-up [(83.9±4.3) points] than the PFNA group [(81.0±3.4) points] (both P<0.05). Fixation failed in one patient in the PFNA group due to cut-out of the head and neck screws while no complications were observed in the PFBN group. Conclusion:In the treatment of intertrochanteric fracture of the femur, PFBN fixation may result in stronger fixation to effectively avoid cut-out of the head and neck screws, and faster fracture healing and functional recovery of the hip than PFNA fixation.

Comparitive Analysis of Outcome of Proximal Femoral Nail Antirotation II (PFNA-II) and Dynamic Hip Screw (DHS) in the Management of Intertrochanteric Fractures of Femur

Background: To compare the clinical and radiological outcomes of patients with intertrochanteric fractures treated with PFNA-II versus DHS. Material & Methods:50 adult patients with inter-trochanteric fractures, >20 years old, were randomly distributed into the PFNA-II and DHS groups. DHS with side-plate and proximal femoral nail A-II of appropriate size was used. The patients were regularly followed up till 1 year post-operatively. The clinical, radiological and functional evaluations were done at regular intervals. The peri-operative, early and delayed complications were recorded, and the final outcome of either group was evaluated using the Harris Hip Score. Results:In the DHS group, the mean Harris Hip Score was slightly lower than that of the PFNA-II group at six month follow-up. However, at the 1 year follow-up, both the groups achieved similar Harris Hip Scores. Conclusion:PFNA-II provides a significantly shorter operative time with a smaller incision that leads to lesser blood loss and wound-related complications. However, the incidence of procedural errors was significantly higher in PFNA-II when compared with DHS as it is a technically more demanding procedure that leads to more implant failures and consequent re-operations.

Management of Subtrochanteric Fracture Femur- by ProximalFemoralNailing

Background: Numerous variations of intramedullary nailing have been evolved over the years for stable fixation and early mobilisation of subtrochanteric fracture, out of which one is proximal femoral nail. Aims and objectives 朩e conducted this study with an objective to evaluate the results of internal fixation of subtrochanteric fractures of the femur with proximal femoral nail � AO type Design.Methods:This was a prospective study carried out at our tertiary care institute on 30 patients who had suffered subtrochanteric fracture and were subsequently treated with a proximal femoral nail (PFN). Proximal femoral nail was inserted through the tip of greater trochanter. All patients were followed up for a period of one year; at an interval of 3 months and during each follow-up visit for the functional outcome by modified Harris Hip Score, was assessed in the form of walking, squatting, sitting and rising from chair.Results:Modified Harris hip score was used for the evaluation of results in our study which showed excellent result in 21 patients (70%), good results in 3 cases(10%), fair results in 3 patient (10%) and poor results in 3 cases(10%). The mean Harris hip score in our study was 90.6.Conclusion:PFN is an intramedullary load sharing implant. Reduction and management of subtrochanteric fractures is challenging in traumatology. Proximal femoral nailing spanning whole femur with proximal and distal locking appears to be a satisfactory implant in management of fractures of subtrochanteric femur.

A rare complication of pelvic perforation by an excessive medial slide of the helical blade after treatment of an intertrochanteric fracture with proximal femoral nail anti-rotation: A case report and literature review / 中华创伤杂志(英文版)

Intertrochanteric fractures have become a severe public health problem in elderly patients. Proximal femoral nail anti-rotation (PFNA) is a commonly used intramedullary fixation device for unstable intertrochanteric fractures. Pelvic perforation by cephalic screw is a rare complication. We reported an 84-year-old female who fell at home and sustained an intertrochanteric fracture. The patient underwent surgery with PFNA as the intramedullary fixation device. Routine postoperative examination revealed medial migration of the helical blade that eventually caused pelvic perforation. We performed a cemented total hip arthroplasty as the savage procedure. At the latest follow-up of 12 months after total hip arthroplasty, the patient had no pain or loosening of the prosthesis in the left hip. Pelvic perforation should be considered when choosing PFNA as the intramedullary fixation device, especially in patients with severe osteoporosis wherein the helical blade can be easily inserted during the operation. The lack of devices to avoid oversliding of the helical blade in PFNA is an unreported cause of this complication and should be considered in such cases.

Unstable trochanteric Fracture Fixation with P.F.N. augmented by T.B.W.

For inter trochanteric fracture Proximal Femoral Nail (PFN) is a better choice of implant biomechanically. But in communicated inter trochanteric fractures it is associated with screw breakage, cut out through femoral head, ”Z” & reverse “Z” effect and lateral migration of screws. The purpose of this study is to evaluate the results of PFN in terms of post-operative complication and failure rates in unstable trochanteric fracture with addition of 1 or 2 tension band wires. Material & Method:We did study of 21 unstable trochanteric fractures from January 2016 to November .2020. 14 patients were males & 7 patients were females. Age group between 25 to 80 was included in this group. There were 15 A0 A2 (2.2, 2.3) and 6 were A0 A3 (3.1, 3.2, 3.3). All fractures were ?xed with 25cm, 0135PFN mainly 11 mm, 12mm in diameter with addition of one or two 16 gauge tension band wire, strengthening lateral trochanteric wall and holding either communiated fragments or lesser trochanteric fracture. Results:The fracture was united in all cases with mean period of 16 weeks. Two patients developed complication of TBW (Tension Band Wire) breakage; one developed lateral migration of screws. Patients were followed till bone was united. At the end of follow up hip function were 30 (out of 40) in 80% patients by using Salvati and Wilson hip score. Conclusion: The stabilization of lateral trochanteric wall fracture and communiated fragments of inter trochanteric fractures, additional one or two TBW increases the stability of construct enhancing bony union & better results.

Efficacy of long-stem hemiarthroplasty for elderly unstable intertrochanteric fracture / 中国综合临床

Objective:To investigate the clinical effect of long-stem hemiarthroplasty in the treatment of unstable intertrochanteric fracture in elderly patients with severe osteoporosis.Methods:A retrospective analysis was performed on 48 elderly patients with unstable intertrochanteric fractures of the femur with severe osteoporosis in Liaocheng People′s Hospital from April 2017 to April 2019.Twenty three patients received long-stem hemiarthroplasty (LHA group). Twenty five patients were treated with proximal femoral nail anti-rotation (PFNA) (PFNA group). PFNA group was used as the control group.The operative time, intraoperative blood loss, perioperative blood transfusion volume, number of intraoperative fluoroscopy, weight-bearing time after operation, the incidence of postoperative complications, hospitalization time, and Harris hip score of 1, 3, 6, 12 months after surgery, to investigate the efficacy of the application of long-stem hemiarthroplasty.Results:In LHA group, 23 patients were followed up for (18.6±3.9) (range from 12.0 to 26.0) months, and 25 patients in the PFNA group were followed up for (17.8±3.3)(range from 12.0 to 24.0) months.There was no significant difference in follow-up time between the two groups ( Z=-0.552, P=0.581). The operation time of LHA Group (60 (55, 73) h) was longer than that of PFNA Group (55 (50, 60) h). The intraoperative blood loss in LHA Group ((179.35±63.47) mL) was more than that in PFNA Group ((122.80±49.03) mL). The number of fluoroscopy in LHA Group (2 (2, 2) times)was less than that in PFNA Group (16 (14.5, 19.5) times). The time of weight bearing in LHA Group (4 (3, 5) d) was earlier than that in PFNA Group (33 (30, 36) d), and the differences were statistically significant ( Z=2.459, t=3.470, Z=6.216, Z=5.959; all P<0.05). There were no significant differences in perioperative blood transfusion, hospital stay and postoperative complications between the two groups (all P>0.05). Harris hip function score was significantly higher in LHA Group ((76.70±5.96), (82.13±6.38), (85.96±7.16), (88.78±7.67) points) and PFNA Group ((63.80±3.46), (71.56±2.55), (81.60±3.38), (88.08±4.83) points) increased gradually with the increase of follow-up time ( Fintra-group=432.557, Pintra-group<0.001), and the score reached the highest 12 months after operation.Harris hip function score of LHA group was higher than that of PFNA group( Finter-group=25.437, Pinter-group<0.001). There was interaction effect between follow-up time point and operation mode( Finteraction=53.464, Pinteraction<0.001). Conclusion:For the elderly patients with unstable intertrochanteric fracture with severe osteoporosis, the application of lengthened stem hemiarthroplasty can get out of bed early, reduce the complications of bed rest, reduce the number of intraoperative fluoroscopy, and recover the function of hip joint earlier and better with satisfactory results.

Early Clinical Outcomes of Short versus Long Proximal Femoral Nail Anti-rotation (PFNA) in the Treatment of Intertrochanteric Fractures

@#Introduction: Both short and long PFNA are employed to treat intertrochanteric fractures. Controversy exists in the choice between the two nails as each implant has specific characteristics and theoretical advantages. This retrospective study seeks to examine the operative complication rates and clinical outcomes of short versus long (Proximal Femoral Nail Antirotation) PFNA in the treatment of intertrochanteric fractures. Materials and methods: Between July 2011 and February 2015, 155 patients underwent PFNA insertion. The decision on whether to use a short or long PFNA nail, locked or unlocked, was determined by the attending operating surgeon. Visual Analogue Pain Score (VAS) Harris Hip Scores (HHS), Short-form 36 Health Questionnaire (SF-36) and Parker Mobility Scores (PMS) were collected at six weeks, six months and one year post-operatively. Results: A total of 137 (88.4%) patients were successfully followed-up. Forty-two (30.7%) patients received a short PFNA. The patients were similar in baseline characteristics of age, gender, and comorbidities. Operative time was significantly longer in the short PFNA group (62 ±17 mins) versus the long PFNA group (56±17). While the patients in both groups achieved improvement in all outcome measures, there was no significant difference between the groups in terms of HHS (61.0 ±16.0 vs 63.0 ±16.8, p=0.443), PMS (2.3±1.5 vs 2.7±2.1, p=0.545) and VAS (1.7±2.9 vs 1.8 ±2.2 p=0.454). There were 3 (7.1%) and 7 (7.4%) complications in the short versus long PFNA group, respectively. Conclusion: Both short and long PFNA had similar clinical outcomes and complication rates in the treatment of intertrochanteric fractures in an Asian population.

A Prospective Study of the Functional Outcome of Intertrochanteric Femoral Fracture Managed with Short Proximal Femoral Nail

Introduction: Fractures through the intertrochanteric lineof the upper end of the femur, and peritrochanteric fractures,unite readily no matter what treatment is used because thebroad fractured surfaces are richly supplied with blood andthere is seldom wide displacement. But at the same time,unless suitable precautions are taken, the fracture may unitein a position of coxavara with shortening of the limb andlimitation of hip movements. Hence we conducted a studyin our set up to know the functional result of short proximalfemoral nail (PFN) in treatment of these fractures.Material and Methods: We included all intertrochantericfracture of femur in skeletally mature patient who are fit forsurgery in our study. Fifty patients treated with short PFNwere included in the study.Results: Majority of the patient in our study were between61-80 years with a mean age of 74.46 ± 12.04 years. About 52percent of the patients were female and 48 percent male. Fallat home was the most common mode of injury. Right hip wasinvolved in 48% of the patient and left hip was 52%. The shortPFN required shorter incisions, less blood loss and operativetimes. Average time for operation was 42.30±10.01. Postoperative complications included revision surgery 2 (4.0%)patients, superficial infection in 2 (4.0%), Z effect in 1 (2.0%)patient, inadequate reduction in 1 (2.0%) patient, difficultyin distal locking in 1 (2.0%) patient and varus in 1 (2.0%)patient. The average harris hip score came out to be 87.37at 24 weeks and 90% of the patients belonged to the ‘good’group and 6% of the patients belonged to the ‘excellent’group intertrochanteric fractures, treated with short PFN, hadsignificantly better outcomes with all patients having goodresults in 24 weeks which is very short time. Conclusion:Intra operative technical difficulties associated with short PFNcan be reduced by thorough knowledge and understanding ofboth the anatomy and implant. By using some technical tipsdifficult closed reduction can be done and internal fixationwith PFN can be attempted.

Evaluation of internal fixation with proximal femoral nail antirotation in elderly knee osteoarthritis patients with femoral intertrochanteric fractures / 中国组织工程研究

BACKGROUND: Proximal femoral nail antirotation is a commonly used internal fixation system for the treatment of femoral intertrochanteric fracture in the elderly. Simultaneously, the elderly are often associated with knee osteoarthritis, which may affect the postoperative effect of femoral intertrochanteric fracture. OBJECTIVE: To investigate the effect of knee osteoarthritis at the fracture side on the efficacy of postopenxtine proximal femoral nail antirotation in elderly femoral intertrochanteric fractures. METHODS: Totally 92 patients aged over 65 years old with femoral intertrochanteric fractures treated with proximal femoral nail antirotation internal fixation were divided into five groups according to the preoperative knee X-ray Kellgren-Lawrence grade: grade 0 as group A (13 cases), grade I as group B (18 cases), grade II as group C (23 cases), grade III as group D (22 cases), and grade IV as group E (16 cases). The hospitalization time, postoperative complications, postoperative landing time, fracture healing time, hip Harris score and Barthel index score of daily living ability at 1, 3 and 6 months after operation were recorded in the five groups. This study was approved by the Ethics Committee of Affiliated Hospital of Chengde Medical University. RESULTS AND CONCLUSION: (1) There was no significant difference in the length of hospital stay among the five groups (P > 0.05). (2) The postoperative landing time and fracture healing time of group D and group C were longer than those in group A, group B, and group C (P < 0.05). (3) The number of postoperative complications of group C was more than those in group A and group B (P < 0.05). The number of postoperative complications of group D and group E was more than that in group A, group B and group C (P < 0.05). (4) The scores of Harris and Barthel index of group C and D were lower than those in group A and B at 1, 3 and 6 months after operation (P < 0.05). The scores of Harris and Barthel index of group E was lower than those in group A, group B, group C and group D at 1, 3 and 6 months after operation (P < 0.05). (5) The results showed that the higher the grade of knee osteoarthritis, the greater the influence on the postoperative efficacy of proximal femoral nail antirotation in the treatment of elderly patients with femoral intertrochanteric fracture. It is manifested by increased postoperative complications, prolonged postoperative landing time and fracture healing time, and the decrease of hip function and ability of daily living.

Artificial femoral head arthroplasty versus proximal femoral nail antirotation for the injured lateral wall Intertrochanteric fracture in elderly adults / 中国组织工程研究

BACKGROUND: For the treatment of intertrochanteric fracture in elderly patients, if there is no operative contraindication, surgical treatment is recommended. Operative methods include internal fixation and joint replacement. Surgical techniques are mature, but the choice of surgical methods is controversial. OBJECTIVE: To compare the efficacy of artificial femoral head arthroplasty and proximal femoral nail antirotation in elderly patients with injured lateral wall femoral intertrochanteric fracture so as to provide the basis of clinical method selection and to provide the original data for the systematic analysis of large sample. METHODS: According to the case criterion, 48 cases of AO classification of type A2.2, A2.3 intertrochanteric fractures were selected in Department of Orthopedics, the 71 Group Army Hospital of Chinese PLA from January 2012 to December 2017. They were divided into femoral head arthroplasty group (n=29) and proximal femoral nail antirotation group (n=19). All patients signed the informed consent. This study was approved by the Hospital Ethics Committee. The patients were followed up for 1-3 years. Operation time, bleeding volume, hospitalization expenses, the incidence of complications, and Harris hip score at 1 month and 1 year after the surgery were compared between the two groups. RESULTS AND CONCLUSION: (1) After statistical analysis, operation time was significantly shorter in the femoral head arthroplasty group than in the proximal femoral nail antirotation group (P 0.05). The cost of hospitalization was significantly more in the femoral head arthroplasty group than in the proximal femoral nail antirotation group (P 0.05). (3) There was no significant difference in the incidence of complications between the two groups (P > 0.05). (4) For the patients over 70 years old with intertrochanteric fracture of injured lateral wall, artificial femoral head replacement has the advantages of early getting out of bed, high quality of life and quick recovery of joint function. It is suggested to choose artificial femoral head replacement first.

Relationship between blood loss of proximal femoral nail anti-rotation fixation and local use combined with intravenous injection of tranexamic acid / 中国组织工程研究

BACKGROUND: Tranexamic acid has been shown to effectively reduce dominant and hidden blood loss in patients undergoing proximal femoral nail antirotation fixation, and it is safe and effective. At present, the use of tranexamic acid in this operation is mainly divided into intravenous infusion and local intramedullary perfusion; intravenous infusion can be divided into single use or multiple uses, and most of the local use is single use. For the combined local use with intravenous infusion is rarely reported. However, the combined use of tranexamic acid in hip and knee arthroplasties has been proven to be safe and effective. OBJECTIVE: To explore the effectiveness and safety of intravenous combined with local application of tranexamic acid on the perioperative blood loss in proximal femoral nail antirotation. METHODS: Ninety patients with intertrochanteric fracture who underwent proximal femoral nail antirotation in Shantou Hospital of Traditional Chinese Medicine from January 2016 to December 2018 were enrolled, and randomly divided into combined, intravenous and local groups (n=30/group). All patients signed the informed consents and the study was approved by the hospital ethical committee. In the combined group, tranexamic acid (20 mg/kg dissolved in 20 mL normal saline) was injected intravenously at 30 minutes before surgery, followed by femoral intracavitary injection of tranexamic acid (1 g, dissolved in 20 mL normal saline) after proximal femoral nail antirotation. Intravenous group only underwent intravenous injection of tranexamic acid. Local group only received femoral intracavitary injection of tranexamic acid. The total blood loss, dominant blood loss, hidden blood loss, International Normalized Ratio, prothrombin time, activated partial thromboplastin time, blood transfusion rate and the incidence of deep venous thrombosis were counted and compared in the three groups. RESULTS AND CONCLUSION: (1) The total blood loss in the combined group was significantly less than that in the intravenous and local groups (P 0.05). (2) The hidden blood loss in the combined group was significantly less than that in the intravenous and local groups (P 0.05). (3) There was no significant difference in the dominant blood loss among groups (P > 0.05). (4) The International Normalized Ratio, prothrombin time, and activated partial thromboplastin time before and after surgery showed no significant difference among groups (P > 0.05). (5) The blood transfusion rate showed no significant difference among groups (P > 0.05). (6) None presented with deep venous thrombosis. (7) These results suggest that compared with single intravenous and intracavitary injection of tranexamic acid, their combination can obviously reduce total and hidden blood loss of proximal femoral nail antirotation without increasing the risk of deep venous thrombosis. In addition, single intravenous and intramedullary injection of tranexamic acid has no significant difference in total or hidden blood loss.

Relationship between tip-apex distance and stability of intertrochanteric femoral fractures with proximal femoral anti-rotation nail: A finite element analysis / 中国组织工程研究

BACKGROUND: The proximal femur anti-rotation intramedullary nail is an ideal internal fixation method for the treatment of intertrochanteric fractures, but there is still a 6% to 21% failure rate of internal fixation. Tip-apex distance is considered as an important cause of postoperative proximal femur anti-rotation intramedullary nail failure. Tip-apex distance is the sum of the distance from the tip of lag screw to the vertex of femoral head measured on anteroposterior and lateral X-ray films. Most scholars now believe that the tip-apex distance of head pulp nail ≤ 25 mm has a good prognosis, but there is still a lot of controversy. OBJECTIVE: To investigate the biomechanical differences of the treatment of intertrochanteric femoral fractures by proximal femoral anti-rotation intramedullary nail with different tip-apex distances and provide a new idea and experimental basis for the clinical treatment of intertrochanteric fractures. METHODS: CT data of one volunteer were imported into Mimics 19.0 and Geomagic studio 2017 software to extract and optimize the three-dimensional model of the right femur. SolidWorks 2017 software was used to draw the internal fixation model and assemble it with the AO2.1 type fracture femur model in different tip-apex distance according to the standard operation technology. Totally four models with tip-apex distance of 15, 20, 25, and 30 mm were obtained and imported into HyperMesh 14.0 software to mesh. The four models were imported into Abaqus 2016 software in inp format to set up with material property parameters, boundary conditions and applied loads. Finally, operation results were viewed in the visualization module. RESULTS AND CONCLUSION: (1) When tip-apex distance was too large (30 mm) or too small (15 mm), the stress at the proximal femur was reduced, but the displacement of the femur head and neck fragment and the lesser trochanter fragment was larger and the inversion was more serious. When tip-apex distance was in the middle (20, 25 mm), the displacement and varus of femoral head and neck fragment were small, and the lesser trochanteric fragment was basically unshifted. (2) In the treatment of intertrochanteric femur fractures, tip-apex distance should be adjusted to 20-25 mm to reduce displacement and obtain a better biomechanical effect.

Tranexamic acid controls postoperative hidden blood loss in senile intertrochanteric fracture / 中国组织工程研究

BACKGROUND: In the elderly patients with intertrochanteric fractures, a large amount of hidden bleeding appears after surgery, so reducing hidden bleeding has become an important problem to be solved urgently. OBJECTIVE: To evaluate the effect of preoperative intravenous injection of tranexamic acid on the hidden blood loss after proximal femoral nail antirotation implantation. METHODS: Eighty-two cases of senile intertrochanteric fractures at Department of Traumatic Orthopedics of Guang’an People’s Hospital from July 2018 to July 2019 were selected, and all the patients underwent internal fixation with proximal femoral nail antirotation. The patients were allocated into two groups based on usage of tranexamic acid (n=41/group). In trial group, intravenous injection of tranexamic acid (10 mg/kg) was conducted during anesthesia, and control group was given the same volume of normal saline via vein. Blood routine examination was conducted at baseline and 1, 3 and 5 days postoperatively to count the level of hemoglobin and hematocrit. The total blood loss was calculated by Gross equation. The transfusion rate and postoperative incidence of thrombosis were recorded. RESULTS AND CONCLUSION: (1) There was no significant difference in the dominant blood loss between two groups (P > 0.05). (2) The perioperative actual total blood loss and postoperative hidden blood loss in the trial group were significantly lower than those in the control group (P < 0.05). (3) Three cases of blood transfusion (7%) in the trial group, and eight cases (24%) in the control group (P < 0.05). (4) No thrombosis occurred in both groups. (5) These findings suggest that preoperative intravenous infusion of tranexamic acid can effectively reduce the hidden blood loss after proximal femoral nail antirotation implantation, and does not increase the risk of postoperative thrombosis.

Curative efficacy of proximal femoral nail antirotation versus intertrochanteric antegrade nail for treating intertrochanteric fracture in older adults / 中国组织工程研究

BACKGROUND: Proximal femoral nail is the first choice for treating intertrochanteric fractures. The studies concerning proximal femoral nail for senile intertrochanteric fractures mainly focus on proximal femoral nail antirotation/proximal femoral nail antirotation II, Gamma 3 and intertrochanteric antegrade nail. OBJECTIVE: To investigate the clinical efficacy of proximal femoral nail antirotation II versus intertrochanteric antegrade nail in the treatment of intertrochanteric fracture in the elderly. METHODS: Forty-two cases of senile intertrochanteric fractures at Department of Orthopedics, First People’s Hospital of Xuancheng City from January 2016 to December 2018 were included, involving 15 males and 27 females, aged 65-90 years. Among which, 22 patients received internal fixation using proximal femoral nail antirotation II and 20 patients using intertrochanteric antegrade nail. The operation time, intraoperative blood loss, fracture healing time, postoperative complications and the hip function scores at last follow-up were compared. The study was approved by the Ethics Committee of First People’s Hospital of Xuancheng City, approval No. (2015)(17). RESULTS AND CONCLUSION: (1) The operation time in the proximal femoral nail antirotation group was shorter than that in the intertrochanteric antegrade nail group [(69.4±11.5), (90.0±9.7) minutes, P 0.05]. (3) In the proximal femoral nail antirotation group, three cases suffered from pain at the affected limb, and one case of coxa vara deformity. One case in the intertrochanteric antegrade nail group appeared with pain at the affected limb. The postoperative incidence of complications between two groups showed no significant difference (18.2%, 5.0%, P > 0.05). (4) No significant difference was found in the Harris scores at the last follow-up between two groups (90.3±2.8, 91.5±2.4, P > 0.05). (5) There were no fracture adverse reactions related to internal fixation materials in the two groups. (6) In summary, proximal femoral nail antirotation II and intertrochanteric antegrade nail internal fixation are effective methods for intertrochanteric fractures in the elderly. However, proximal femoral nail antirotation II has short operation time and few intraoperative blood losses.

Osteoporosis effects on the treatment of intertrochanteric fracture of femur with proximal femoral anti-rotation intramedullary nail: A finite element simulation / 中国组织工程研究

BACKGROUND: Proximal femoral anti-rotation intramedullary nail for treating intertrochanteric fracture is widely used in clinical practice, but there are still some cases of failure of internal fixation after operation, and osteoporosis of proximal femur is considered as an important reason. Singh index is an important index to evaluate the severity of osteoporosis in the proximal femur. Based on the Singh index, it is of great significance to explore the effect of different degrees of osteoporosis on the treatment of intertrochanteric fracture with anti-rotation intramedullary nail in the proximal femur, so as to reduce the failure rate of internal fixation and increase the success rate of operation. OBJECTIVE: To explore the effect of different osteoporosis on the treatment of intertrochanteric fracture with proximal femoral anti-rotation intramedullary nail, so as to provide new ideas and experimental basis for clinical treatment of intertrochanteric fracture. METHODS: CT data of one patient with intertrochanteric fracture of the left femur were imported into Mimics 19.0 and Geomagic studio 2017 software to extract and optimize the three-dimensional model of the right femur. SolidWorks 2017 software was used to draw the internal fixation model and assemble it with the femur model according to the standard operation technology, and import it into HyperMesh 14.0 software in STEP format to cut the bone according to AO-2.1 type of intertrochanteric fracture. Trabecular bone based on Singh index 1-6 was established to obtain six models of A-F. Material property parameters, boundary conditions and applied loads were set. Finally, the data were stored as K files and imported into LS-DYNA software for solution. RESULTS AND CONCLUSION: (1) When the femoral head was stressed, the spiral blade in the bone block of the femoral head and neck of Singh 6-Singh 1 was cut, the common bone trabecula disappeared, the stress bone trabecula wrapped with the spiral blade did not disappear, but loaded with certain stress, so that the spiral blade still had a large contact area and holding force, maintained the reduction of the fracture, and reduced the varus and rotation of the bone block of the femoral head and neck. (2) From Singh 6-Singh 1, with the disappearance of stress bone trabecula, the more serious osteoporosis is, the more likely failure will be in the treatment of intertrochanteric fracture with proximal femoral anti-rotation intramedullary nail. (3) The spongy bone trabeculae, especially the stress bone trabeculae, play an important role in maintaining the elastic stability of the proximal femur by resisting and buffering the bending strain.