Biomechanical effects of three internal fixation modes on femoral subtrochanteric spiral fractures in osteoporotic patients by finite element analysis / 中国修复重建外科杂志

OBJECTIVE@#The biomechanical characteristics of three internal fixation modes for femoral subtrochanteric spiral fracture in osteoporotic patients were compared and analyzed by finite element technology, so as to provide the basis for the optimization of fixation methods for femoral subtrochanteric spiral fracture.@*METHODS@#Ten female patients with osteoporosis and femoral subtrochanteric spiral fractures caused by trauma, aged 65-75 years old, with a height of 160-170 cm and a body weight mass of 60-70 kg, were selected as the study subjects. The femur was scanned by spiral CT and a three-dimensional model of the femur was established by digital technology. The computer aided design models of proximal intramedullary nail (PFN), proximal femoral locking plate (PFLP), and the combination of the two (PFLP+PFN) were constructed under the condition of subtrochanteric fracture. Then the same load of 500 N was applied to the femoral head, and the stress distribution of the internal fixators, the stress distribution of the femur, and the displacement of femur after fracture fixation were compared and analyzed under the three finite element internal fixation modes, so as to evaluate the fixation effect.@*RESULTS@#In the PFLP fixation mode, the stress of the plate was mainly concentrated in the main screw channel, the stresses of the different part of the plate were not equal, and gradually decreased from the head to the tail. In the PFN fixation mode, the stress was concentrated in the upper part of the lateral middle segment. In the PFLP+PFN fixation mode, the maximum stress appeared between the first and the second screws in the lower segment, and the maximum stress appeared in the lateral part of the middle segment of the PFN. The maximum stress of PFLP+PFN fixation mode was significantly higher than that of PFLP fixation mode, but significantly lower than that of PFN fixation mode ( P<0.05). In PFLP and PFN fixation modes, the maximum stress of femur appeared in the medial and lateral cortical bone of the middle femur and the lower side of the lowest screw. In PFLP+PFN fixation mode, the stress of femur concentrated in the medial and lateral of the middle femur. There was no significant difference in the maximum stress of femur among the three finite element fixation modes ( P>0.05). The maximum displacement occurred at the femoral head after three finite element fixation modes were used to fix subtrochanteric femoral fractures. The maximum displacement of femur in PFLP fixation mode was the largest, followed by PFN, and PFLP+PFN was the minimum, with significant differences ( P<0.05).@*CONCLUSION@#Under static loading conditions, the PFLP+PFN fixation mode produces the smallest maximum displacement when compared with the single PFN and PFLP fixation modes, but its maximum plate stress is greater than the single PFN and PFLP fixation mode, suggesting that the combination mode has higher stability, but the plate load is greater, and the possibility of fixation failure is higher.

Comparison of effectiveness of lower extremity axial distractor and traction table assisted closed reduction and intramedullary nail fixation in femoral subtrochanteric fracture / 中国修复重建外科杂志

OBJECTIVE@#To compare the effectiveness of lower extremity axial distractor (LEAD) and traction table assisted closed reduction and intramedullary nail fixation in treatment of femoral subtrochanteric fracture.@*METHODS@#The clinical data of 117 patients with subtrochanteric fracture of femur treated by closed reduction and intramedullary nail fixation between May 2012 and May 2022 who met the selection criteria were retrospectively analyzed. According to the auxiliary reduction tools used during operation, the patients were divided into LEAD group (62 cases with LEAD reduction) and traction table group (55 cases with traction table reduction). There was no significant difference in baseline data, such as gender, age, injured side, cause of injury, fracture Seinsheimer classification, time from injury to operation, and preoperative visual analogue scale (VAS) score, between the two groups ( P>0.05). Total incision length, operation time, intraoperative blood loss, fluoroscopy frequency, closed reduction rate, fracture reduction quality, fracture healing time, weight-bearing activity time, and incidence of complications, as well as hip flexion and extension range of motion (ROM), Harris score, and VAS score at 1 month and 6 months after operation and last follow-up were recorded and compared between the two groups.@*RESULTS@#There were 14 cases in the LEAD group from closed reduction to limited open reduction, and 43 cases in the traction table group. The incisions in the LEAD group healed by first intention, and no complication such as nerve and vascular injury occurred during operation. In the traction table group, 3 cases had perineal crush injury, which recovered spontaneously in 1 week. The total incision length, operation time, intraoperative blood loss, fluoroscopy frequency, and closed reduction rate in the LEAD group were significantly better than those in the traction table group ( P<0.05). There was no significant difference in the quality of fracture reduction between the two groups ( P>0.05). Patients in both groups were followed up 12-44 months, with an average of 15.8 months. In the LEAD group, 1 patient had delayed fracture union at 6 months after operation, 1 patient had nonunion at 3 years after operation, and 1 patient had incision sinus pus flow at 10 months after operation. In the traction table group, there was 1 patient with fracture nonunion at 15 months after operation. X-ray films of the other patients in the two groups showed that the internal fixator was fixed firmly without loosening and the fractures healed. There was no significant difference in fracture healing time, weight bearing activity time, incidence of complications, and postoperative hip flexion and extension ROM, Harris score, and VAS score at different time points between the two groups ( P>0.05).@*CONCLUSION@#For femoral subtrochanteric fracture treated by close reduction and intramedullary nail fixation, compared with traction table, LEAD assisted fracture reduction can significantly shorten the operation time, reduce intraoperative blood loss and fluoroscopy frequency, reduce incision length, effectively improve the success rate of closed reduction, and avoid complications related to traction table reduction. It provides a new method for good reduction of femoral subtrochanteric fracture.

Fracturas subtrocantéricas periosteosíntesis tras fijación de fracturas de cuello femoral con tornillos canulados / Periosteosynthesis subtrochanteric fractures after fixation of femoral neck fractures with cannulated screws

Resumen: Introducción: el objetivo del presente estudio fue analizar la incidencia y factores predisponentes en las fracturas subtrocantéreas sobre caderas tratadas previamente con tornillos canulados tras sufrir una fractura subcapital, con base en ocho casos registrados en los últimos 20 años. Material y métodos: se trata de un estudio retrospectivo observacional sobre una serie de pacientes con el diagnóstico de fractura subtrocantérica de cadera, los cuales habían sido tratados en los últimos meses de una fractura subcapital de la misma cadera mediante osteosíntesis con tornillos canulados. El período de estudio fue de 20 años (2000-2020). Resultados: de los ocho casos, cinco eran mujeres y tres hombres, con una media de edad de 75.12 años (rango 59-87 años). En todos los casos, la fractura subtrocantérica ocurrió antes de un año tras la primera fractura, el tiempo transcurrido entre las dos fracturas fue de cuatro meses de media (rango de uno a nueve meses). En cuanto a la disposición de los tornillos canulados, la mayoría de casos 7/8 fue en forma de triángulo de vértice superior y sólo un caso en forma de triángulo invertido o vértice inferior. El punto de entrada en la cortical externa femoral fue a nivel del trocánter menor en seis casos y en dos casos dicha entrada era distal al trocánter menor. Conclusión: según nuestra experiencia, en la etiología de las fracturas subtrocantéricas, la introducción de los tornillos distales al trocánter menor y la distribución de los tornillos en forma triangular son los dos factores predisponentes objetivables principales.

Abstract: Introduction: the objective of this study was to analyze the incidence and predisposing factors in subtrochanteric fractures on hips previously treated with cannulated screws after suffering a subcapital fracture, based on eight cases registered in the last 20 years. Material and methods: this is a retrospective observational study on a series of patients with a diagnosis of subtrochanteric hip fracture, who have been treated in recent months for a subcapital fracture of the same hip by osteosynthesis with cannulated screws. The study period was 20 years (2000-2020). Results: of the eight cases, five were women and three were men, with a mean age of 75.12 years (range 59-87 years). In all cases, the subtrochanteric fracture occurred within a year after the first fracture, the time elapsed between the two fractures was four months on average (range 1-9 months). Regarding the disposition of the cannulated screws, most of the 7/8 cases were in the shape of an upper vertex triangle, and only one case was in the shape of an inverted triangle or lower vertex. The entry point into the femoral external cortex was at the level of the lesser trochanter in six cases, and in two cases this entry was distal to the lesser trochanter. Conclusion: in our experience, in the etiology of subtrochanteric fractures, the introduction of screws distal to the lesser trochanter, and the distribution of the screws in a triangular shape are the two main objective predisposing factors.

Analysis of Fracture Union in Patients with Subtrochanteric Femoral Fractures Managed with Dynamic Condylar Screw

Objective: To evaluate thefracture union in patients with subtrochanteric femoral fractures managed with dynamic condylar screw. Material and methods: This was a case series study and was conducted at Department of Orthopedic Surgery, Sahiwal Medical College, Sahiwal from June 2016 to May 2017. Total 90 patients with closed subtrochanteric fractures (within the 1 week of fracture), having age from 20-70 years either male or female were selected. Results: Mean age of the patients was 39.53 ± 15.08 years. Mean duration of fracture was 4.10 ± 1.99 days. Out of 90 patients with subtrochanteric fracture, union was noted in 71 (79%) patients. In age group 20-45 years, union rate was 53 (85.48%) and in age group 46-70 years and union rate was 18 (64.29%). Union of fracture was seen in 5 (29.41%) patients, 39 (92.86%) patients and 27 (87.17%) patients respectively in Type A, B and C fractures. Union was strongly (P = 0.000) associated with type of fracture. Higher number of union was noted in type B fracture. Conclusion: A higher rate of fracture union was observed in cases of subtrochanteric femoral fractures treated by fixation with dynamic condylar screw system. Findings of present also revealed that fracture union is not associated with gender. But significant association of fracture union with age group, duration of disease and type of fracture.

No unión infectada de fractura subtrocantérica de fémur, tratada con autoinjerto y placa / No infected union of subtrochanteric fracture of femur, treated with autograft and plate

Resumen: Las fracturas de cadera se consideran un problema de salud pública en el mundo, entre las fracturas de cadera encontramos las subtrocantéricas, que se definen como fracturas proximales de fémur situadas en la región trocantérea dentro de los 5 cm debajo del trocánter menor; tienen una incidencia aproximada de 15 a 20 por cada 100,000 personas. El objetivo de este de caso es reportar el éxito de la reconstrucción de una fractura subtrocantérica infectada, con un segmento del peroné no vascularizado y una placa de soporte condíleo de fémur distal. Caso clínico: masculino de 41 años de edad que sufre fractura subtrocantérica derecha producto de un accidente de tránsito que requirió manejo de osteosíntesis. Con posterior ruptura del clavo cefalomedular en su tercio proximal, no unión de la fractura e infecciones en sitio de la fractura. Fue tratado con múltiples lavados quirúrgicos, antibioticoterapia y un procedimiento ortopédico y quirúrgico poco convencional como el uso de una placa de soporte condíleo de fémur distal y un injerto óseo endomedular con un segmento de 10 cm de peroné no vascularizado. Paciente con evolución satisfactoria y favorable.

Abstract: Hip fractures are considered a public health problem in the world. Among hip fractures we find subtrochanteric fractures that are defined as proximal femur fractures located in the trochanteric region within 5 cm below the lesser trochanter; and they have an approximate incidence of 15 to 20 per 100,000 people. The objective of this case is to report the success of the reconstruction of an infected subtrochanteric fracture, with a non-vascularized fibular segment and a distal femur condylar support plate. Clinical case: 41-year-old male patient suffering from a right subtrochanteric fracture as a result of a traffic accident that required the use of osteosynthesis material. With subsequent rupture of the cephalomedullary nail in its proximal third, non-union of the fracture and infections at the fracture site. He was treated with multiple surgical lavages, antibiotic therapy, and an unconventional orthopedic and surgical procedure, such as the use of a distal femur condylar support plate and an endomedullary bone graft with a 10-cm segment of non-vascularized fibula. Patient with satisfactory and favorable evolution.

A COMPARATIVE PROSPECTIVE STUDY OF DYNAMIC HIP SCREW AND PROXIMAL FEMORAL NAIL IN TREATMENT OF SUBTROCHANTERIC FRACTURE FEMUR

Subtrochanteric fractures are relatively rare, accounting for 10 - 34% of all hip fractures1,2,3. They may be very difficult to fix, and the risk of failure has been high with loss of the lesser trochanter and the medial buttresses 3,4, Various intramedullary and extramedullary devices have been developed in an attempt to address potential complications of device failure, mal- or non-union and deformities. In our prospective case series 29 subtrochanteric fractures were involved. The aim of this study is to assess fracture union and functional outcome in subtrochanteric fracture femur treated with proximal femoral nailing and dynamic hip screw, and also to evaluate advantages, disadvantages and major postoperative complications associated with the proximal femoral nailing and dynamic hip screw. Conclusion: The average functional scores for the PFN group at 6 months was 31.5 (excellent) which was significantly greater than the DHS group 27.1(good) (p = 0.03). There was no significant difference in time to union in both groups (average 5.7 months for DHS group and 5.2 months for PFN group) (p = 0.26). The intraoperative complication rate for the PFN group was 36% which was significantly higher than the DHS group (0%) (p =0.001). The PFN had a significantly better functional outcome than DHS plating at 6 months. Long term studies may be needed to observe whether the difference persists on further follow ups. The PFN had a significant advantage over the DHS with side plate in subtrochanteric fractures with regards to less blood loss, less requirement for transfusions, better functional scores, less shortening and fewer incidences of postoperative complications. From the study, we consider PFN as better alternative to DHS in the treatment of subtrochanteric fracture femur but is technically difficult procedure and requires more expertise compared to DHS.

Atypical femoral fractures due to the use of bisphosphonates: epidemiologic study in a tertiary hospital / Fraturas atípicas de fêmur por uso de bifosfonatos: estudo epidemiológico em um hospital terciário

ABSTRACT Objective: Show the relationship between atypical femoral fractures and prolonged use of bisphosphonates and analyze the limit of its beneficial use. Methods: Retrospective cohort study (level of evidence 2B). From Atypical fracture cases, patients who used bisphosphonates were selected and the time period of their use was analyzed. Additionally, the variables sex, age, and the side most affected were studied. Results: Nine atypical femur fractures were found, all associated with the use of bisphosphonates. The average period of use of this medication was nine years (minimum of three years; maximum of 14 years). The patients' mean age was of 78 years (69-88 years) and all were women, with the right member being the most affected. Conclusion: The use of bisphosphonates to prevent osteoporotic fractures has been increasingly frequent and, when used for a prolonged period, it has been related to atypical fractures. Further scientific studies on doses, maximum periods of treatment, and risk-benefit in the indication of these medications are needed to assist in therapeutic management for each case. Level of Evidence II, Retrospective Study.

RESUMO Objetivo: Demonstrar relação entre as fraturas atípicas de fêmur e o uso prolongado de bifosfonatos, descrever sua incidência e analisar até qual momento o seu uso é benéfico. Métodos: Estudo de coorte retrospectivo (nível de evidência 2B). Análise de 151 prontuários de pacientes com diagnóstico de fratura de fêmur em um hospital terciário, no período de janeiro de 2013 a dezembro de 2018. Foram selecionados os casos de fraturas atípicas e, dentre esses, os que faziam uso de bifosfonatos e o tempo de utilização. Ademais, foram estudadas as variáveis sexo, idade e lado mais acometido. Resultados: Constatadas 9 fraturas atípicas de fêmur, todas associadas ao uso de bifosfonatos. O período médio de uso dessa medicação foi de 9 anos (mínimo - 3 anos; máximo - 14 anos). A idade média dos pacientes foi de 78 anos (69-88 anos) e ocorrência unicamente em mulheres, tendo como membro mais acometido o direito. Conclusão: O uso dos bifosfonatos na prevenção de fraturas osteoporóticas tem sido cada vez mais frequente e relacionado às fraturas atípicas, quando empregado por tempo prolongado. A coleta de mais informações científicas que estudem doses, períodos máximos de tratamento e risco-benefício na indicação dessas medicações é essencial para auxiliar no manejo terapêutico apropriado para cada caso. Nível de Evidência II, Estudo Retrospectivo .

Assessment of fracture union in patients of subtrochanteric femoral fractures managed with dynamic condylar screw system and its association with type of fracture

Objective: To assessthe fracture union in patients of subtrochanteric femoral fractures managed with dynamic condylar screw system and its association with type of fracture. Material and methods: This was case series study and was conducted at Department of Orthpaedic Surgery DHQ Hospital Vehari. Total 80 patients with closed subtrochanteric fractures (within the 1 week of fracture) either male or female having age from 20 years to 70 years were recruited. Patients were managed with dynamic condylar screw system. Union of fracture was assessed after 8 weeks of surgery. Results: Mean age of the patients with subtrochanteric femoral fractures was 38.75±14.33 years and mean duration of fracture was 4.33±1.42 days. Total 80 patients were managed with dynamic condylar screw system and after 8 weeks, all the patients were assessed for union of fracture and union was found in 55 (69%) patients. Union of fracture was noted in 4 (26.27%) patients, 33 (89.19%) patients and 18 (64.29%) patients respectively in type A, B and C fracture. Highly significant association between union and type of fracture was noted with p value 0.000. Conclusion: Findings of present study showed high rate of union in patients of subtrochanteric femoral fractures treated by fixation with dynamic condylar screw system. Union of fracture is significantly associated with type of fracture and duration of fracture.

Tratamiento de las fracturas trocántero-subtrocantéricas asociadas a coxartrosis ipsilateral en pacientes mayores de 65 años / Treatment of trochanteric and subtrochanteric fractures associated to ipsilateral coxarthrosis in patients older than 65 years old / Tratamento de fraturas trocantéricas-subtrocantéricas associadas a coxartrose ipsilateral em pacientes com mais de 65 anos

Resumen: Introducción: las fracturas de cadera y la coxartrosis son patologías con alta incidencia en la población anciana. A pesar de esto es una observación clínica frecuente que no se presenten asociadas. No existe consenso de cuál es la mejor opción terapéutica para esta asociación. El objetivo del estudio es actualizar el conocimiento acerca del tratamiento de fracturas trocántero-subtrocantéricas asociadas a coxartrosis ipsilateral en pacientes mayores de 65 años. Materiales y métodos: se realizó una búsqueda sistematizada a través de los buscadores electrónicos PubMed y Ovid. La búsqueda alcanzó un total de 2,499 artículos, de acuerdo a los criterios de inclusión y exclusión se seleccionaron 12 trabajos para realizar nuestra revisión bibliográfica. Resultado: la mayoría de los trabajos analizados son estudios tipo serie de casos retrospectivos. Se realizaron tres subgrupos según tipo de tratamiento para analizar los resultados. Discusión: la asociación entre fracturas de fémur proximal y coxartrosis ipsilateral es poco frecuente. Dentro de este grupo de fracturas las de tipo trocantérico son las que muestran con mayor frecuencia esta asociación. Se plantean dos opciones terapéuticas para resolver esta asociación: tratar la fractura y la patología articular en un mismo acto quirúrgico mediante una artroplastia, o tratar primero la fractura mediante osteosíntesis y en una segunda cirugía la patología articular. El tratamiento mediante artroplastia disminuye el tiempo para la deambulación postoperatoria evitando así complicaciones médicas relacionadas a la enfermedad fracturaria, obteniendo mejores resultados funcionales a corto plazo. La osteosíntesis requiere un menor tiempo quirúrgico y una perdida sanguínea menor, siendo un procedimiento menos demandante técnicamente. La tasa de mortalidad no depende de la opción terapéutica, pero sí de la presencia de 3 o más comorbilidades y edad mayor a 80 años. Resulta importante conocer el tratamiento más adecuado para esta asociación de patologías, ello contribuiría a disminuir los efectos de la enfermedad fracturaria sobre este grupo de pacientes vulnerables. Conclusión: no existe la suficiente evidencia científica para afirmar que una opción terapéutica sea superior a la otra en estos pacientes.

Summary: Introduction: hip fractures and hip joint arthrosis are highly prevalent conditions among older adults. However, according to clinical examination, they are seldom seen together and today there is no general consensus on the best therapy for these associated conditions. The study aims to update existing knowledge on the treatment of trochanteric and subtrochanteric fractures that are associated to ipsilateral coxarthrosis in patients older than 65 years old. Method: we conducted a systematized search on Pubmed and Ovid including 2,499 articles and selected 12 studies to perform our bibliographic review based on inclusion and exclusion criteria. Result: most studies analysed are series of retrospective cases. Cases were classified them into three subgroups to analyse results. Discussion: the association between proximal femur fractures and ipsilateral coxarthrosis is rather unusual. When seen, trochanteric fractures are the most frequent ones. There are two therapeutic options to treat this condition: treating the fracture and the articulation in the same surgery, by means of an arthroplasty, or treating the fracture first with osteosynthesis and operating afterwards to treat the articulation condition. Arthroplasty reduces the time of postoperative ambulation and thus avoids medical complications in connection with the fracture disease, what results in better functional outcome in the short term. Osteosynthesis requires a shorter surgery and implies smaller blood loss, what makes it less technically demanding as a procedure. The mortality rate does not depend on the therapy chosen, but on the presence of three or more comorbilities, or the patient being older than 80 years old. It is important to define what the most appropriate treatment is for these associated conditions, what would contribute to reducing the effects of the fracture on this group of vulnerable patients. Conclusion: there is no sufficient scientific evidence to state whether one therapy is better than the other one in these patients.

Resumo: Introdução: as fraturas de quadril e coxartrose são patologias com alta incidência na população idosa. Apesar disso, é frequente a observação clínica de que não estão associados. Não há consenso sobre qual a melhor opção terapêutica para essa associação. O objetivo deste estudo é atualizar o conhecimento sobre o tratamento das fraturas trocantéricas-subtrocantéricas associadas à coxartrose ipsilateral em pacientes com mais de 65 anos. Materiais e métodos: foi realizada uma busca sistemática nas bases PubMed e Ovid. Foram encontrados 2.499 artigos; após aplicação dos critérios de inclusão e exclusão, foram selecionados 12 artigos para realização de nossa revisão bibliográfica. Resultado: a maioria dos estudos analisados são séries de casos retrospectivos. Para análise dos resultados, foram divididos em três subgrupos de acordo com o tipo de tratamento. Discussão: a associação entre fratura de fêmur proximal e coxartrose ipsilateral é rara. Dentro desse grupo de fraturas, as do tipo trocantérica são as que mais frequentemente apresentam essa associação. Duas opções terapêuticas são propostas para resolver essa associação: tratar a fratura e a patologia articular no mesmo ato cirúrgico por meio de uma artroplastia, ou tratar a fratura primeiro por osteossíntese e em uma segunda cirurgia a patologia articular. O tratamento por artroplastia reduz o tempo de deambulação pós-operatória, evitando complicações médicas relacionadas à doença da fratura, obtendo melhores resultados funcionais em curto prazo. A osteossíntese requer menos tempo cirúrgico e menos perda sanguínea, sendo um procedimento menos exigente tecnicamente. A taxa de mortalidade não depende da opção terapêutica, mas sim da presença de 3 ou mais comorbidades e idade superior a 80 anos. É importante identificar o tratamento mais adequado para esta associação de patologias, o que ajudaria a reduzir os efeitos da patologia da fratura neste grupo de pacientes vulneráveis. Conclusão: não há evidências científicas suficientes para afirmar que uma opção terapêutica seja superior a outra nestes pacientes.

Effectiveness analysis of closed or limited open reduction and intramedullary nail fixation in treatment of Seinsheimer type Ⅴ subtrochanteric fracture / 中国修复重建外科杂志

Objective: To investigate the effectiveness of closed or limited open reduction and intramedullary nail fixation in the treatment of Seinsheimer type Ⅴ subtrochanteric fracture. Methods: Between May 2014 and July 2018, 36 patients with Scinsheimer type Ⅴ subtrochanteric fractures were treated with closed or limited open reduction and intramedullary nail fixation. There were 25 males and 11 females with an age of 23-86 years (mean, 55.8 years). The cause of injury included falling in 19 cases, traffic accident in 9 cases, falling from height in 7 cases, and heavy object injury in 1 case; all were fresh closed injuries. The interval between injury and operation was 1-14 days (mean, 6.8 days). There were 18 cases of closed reduction and 18 cases of limited open reduction during the operation. Seventeen cases were fixed with femoral reconstruction intramedullary nail, 5 with InterTan long nail, 14 with lengthened proximal femoral nail anti-rotation, and 7 cases were assisted with auxiliary steel wire binding. After operation, through X-ray film and clinical follow-up, the fracture reduction and maintenance status, internal fixation position, and fracture healing were judged; the range of motion, walking ability, and complications of hip joint were observed, and the function of hip joint was evaluated according to Merle d'Aubigne Postel hip joint scoring standard. Results: All the incisions of medullary operation healed by first intention, and no vascular, nerve injury, or infection occurred. All patients were followed up 12-24 months, with an average of 14.2 months. Among the 36 patients, 1 patient received revision surgery due to varus displacement of femoral head and screw penetration at 2 months after closed reduction, with poor recovery of hip function. X-ray film re-examination showed that the fractures of the other 35 patients healed after 9-15 months, with an average of 11.5 months. During follow-up, there was no complication such as internal fixation failure, fracture redisplacement, bone nonunion or malunion, and deep vein thrombosis of lower extremity occurred. The function of hip joint recovered well, and the patients could walk and squat normally without affecting daily life or work. At last follow-up, according to Merle d'Aubigne Postel hip joint scoring standard, 28 cases were rated as excellent, 4 cases as good, 3 cases as fair, and 1 case as poor, the excellent and good rate was 88.9%. Conclusion: C-arm X-ray fluoroscopic closed or limited open reduction and intramedullary nail fixation for the treatment of Seinheimer Ⅴ type subtrochanteric fracture, if necessary, with the aid of auxiliary steel wire binding, it has the advantages of less blood supply destruction at the fracture end, satisfactory reduction, firm fixation, and early rehabilitation training, with definite effectiveness.

Clinical effectiveness of less invasive intramedullary nail fixation combined with titanium cable cerclage for subtrochanteric fractures / 北京大学学报(医学版)

OBJECTIVE@#To evaluate the surgical technique and clinical effect of less invasive intrame-dullary nail fixation combined with titanium cable cerclage in the treatment of subtrochanteric fractures.@*METHODS@#A retrospective study was performed in 46 cases of subtrochanteric fractures in Peking University People's Hospital from January 2015 to December 2017. Among them, there were 14 males and 32 females, with an average age of (77.83±10.66) years (44-92 years); 17 cases on the left side and 29 cases on the right side. The causes of injury included crash from a height, traffic accident and accidental fall. According to Seinsheimer classification, there were 26 cases of type Ⅱ, 11 cases of type Ⅲ, 9 cases of type Ⅳ, and these cases were all closed injury. After admission, these patients underwent continuous tibial tuberosity bone traction to maintain the length and force line of the lower extremity, so as to reduce the difficulty of intraoperative fracture reduction. Anticoagulant therapy was given before operation to reduce perioperative thrombotic complications. All the patients were treated with less invasive intramedullary nail fixation combined with titanium cable cerclage. Operation time, blood loss during surgery, time of fracture healing were recorded, Harris and Sanders scoring system were used to assess hip function after operation at each follow-up time point.@*RESULTS@#All the included patients underwent surgery successfully. Average operative time and intraoperative blood loss of these patients were (131.09 ± 20.06) min and (191.96±111.03) mL, respectively. All the patients were followed up satisfactorily, with an average follow-up time of 28 months. The fractures received bone healing within 3-6 months, average hospital stay was (10.61±2.85) days. The Sanders score was excellent in 3 cases, good in 37 cases and common in 6 cases, with an excellent and good rate of 86.96%. The Harris score was excellent in 6 cases, good in 36 cases, with an excellent and good rate of 91.30%. There were no cases of wound infection, loss of reduction, nonunion of fracture or internal fixation failure. Hip pain symptoms were effectively relieved in most patients.@*CONCLUSION@#Less invasive intramedullary nail fixation combined with titanium cable cerclage can obtain good alignment and stability of fracture ends, which is an effective method for the treatment of subtrochanteric fractures.

A Study of Dynamic Condylar Screw in the Management of Subtrochanteric Fractures of Femur

Introduction: The subtrochanteric fractures are one of thecommon fractures that every trauma surgeon come acrosson daily basis. The most of these fractures are treated eitherintramedullary device or a side plate. Among side plates, thechoice between the implants like DCS and DHS is variedamong the different surgeons. We made an analysis of resultsof Dynamic Condylar Screw with the aim to find out the useof that implant in selective fracture types.Material and Methods: A prospective study during 2014 to2015 was done in our institute. The study period is 1 year. Thepatients who opted for surgical treatment only were chosen.They were undergoing surgery under spinal anaesthesia, usingfracture table under image intensifier. The position of fracturereduction was checked in anterior posterior and lateral imageintensifier views. The post-operative assessment was doneat 3weeks, 6 weeks and 3months intervals with regard toradiological union and clinical outcomes. Data was analysedand expressed in terms of percentages.Result: the female to male ratio was 1:1.55. The average ageamong males is 58years and of females is 54 years. The rightside and left side were involved equally (n=28). Most of thepatients were injured by fall at home 39.2% (n=11), due toRTA 32.1% (n=9) and 28.5% (n=8) subjects were injureddue to self-inflicted road accidents. Limb shortening is mostcommon complication, which is there for 17.85% (n=5) ofpatientsConclusion: Dynamic Condylar Screw (DCS) provide goodfixation for subtrochanteric fractures with better results interms of stability and fracture union. Procedure has a fewercomplication rates if cases were selected carefully.

Treatment Of Subtrochanteric Femur Fractures With Proximal Femoral Nails: A Prospective Study

Introduction: Present study was conducted to study the modes of injury in Subtrochanteric fractures of femur and to know the outcome of Proximal Femoral Nail in the treatment of Subtrochanteric fractures of femur. Material & Methods: A prospective observational study was conducted on a total of 30 cases of subtrochanteric fractures of femur. All patients were radiographed at an interval of 6 weeks after nailing, till evidence of union. The patient followed up for one year after the surgery at regular interval. Clinically, union of fracture was assessed and also examination for shortening and deformity was done. Functional outcome was assessed based on Modified Harris Hip Score. Results: Out of 30 cases, 24 cases gave history of road traffic accidents and 6 cases gave history of slip and fall. Full range of flexion of hip at 12 weeks post–operative was observed in 80% of cases and about 20% of patients showed minimally limited flexion. On a whole, all the patients had a satisfactory range of movements post operatively. Our study showed 80% of patients showed full range of movements and 20% showed minimally limited movements at 12 weeks post–operative. On a whole the range of knee movements was satisfactory. Conclusion: Proximal Femoral Nail is a relatively easy procedure and a biomechanically stable construct allows early weight beå. It offers the advantages of high rotational stability of the head–neck fragment, an unreamed implantation technique and the possibility of static or dynamic distal locking. Thus, the Proximal Femoral Nail is a suitable implant for treatment of all Subtrochanteric fractures

Management of Non-United Subtrochanteric fractures Using Augmentataion Plates

Subtrochanteric fractures are more susceptible to nonunion than any other fractures in the neighboring areas, like intertrochanteric region. Accordingly, the researchers feel that rigid and tough fixation is important to create a steady condition for healing of non-united cases of subtrochanteric fractures. The usage of an intramedullary device with fixation of augmentation plate is a well-known technique for management of nonunion cases of diaphysis fractures of femur and tibia. The present study was conducted to evaluate the effectiveness of managing subtrochanteric nonunions with augmentation plates. Methods: The study was conducted in the department of orthopedics for a period of 2 years. The area 5 cm distal to the lower border of lesser trochanter is the subtrochanteric area. Non united fractures were the fractures that completely failed to heal within 9 months. The demographic details of patients, the time of fixation device used for prior surgery, the type of surgery, the time elapsed were noted amongst all the patients. All subjects were called for regular follow up, and union was judged on the basis of painless ambulation and the presence of bridging callus on anteroposterior and lateral radiographs. All the data obtained was arranged in a tabulated form and analyzed statistically. Results: All the patients achieved clinical and radiographic union at a mean duration of 6.8 months. Superficial infection and bursitis were amongst the complication encountered by 2 patients. Gamma nails was used as prior treatment in 3 subjects, interlocking nailing was used by 4 subjects, proximal femoral nailing by 2 patients and dynamic hip screw by 1 patient. Conclusion: From the present study we can say that the use of intramedullary device, bone grafts and augmentation side plating can be relied upon for the management of nonunions.

Subtrochanteric Fracture Reduction during Intramedullary Nailing: Technical Note

The subtrochanteric area is the place where mechanical stress is most concentrated in the femur. When a fracture happens, bone union is delayed and nonunion often occurs. The recommended treatment for atypical fractures is an anatomical reduction of the fracture site as the frequency of nonunion is higher than that of ordinary fractures. Various reduction methods have been suggested, and good results have been obtained. On the other hand, the occurrence of posterior displacement of the distal fragment during the insertion of an intramedullary nail is often overlooked. This is probably because the bone marrow of the femur tends to form an elliptical shape in the anteroposterior direction. The author attempted to insert a blocking screw into the distal part of the fracture to prevent posterior displacement of the distal fragment while performing intramedullary nailing of the femur fracture and achieved a good reduction state easily.

Total hip arthroplasty with Wagner Cone stem and subtrochanteric shortening osteotomy in treatment of Crowe Ⅳ developmental dysplasia of hip in adults / 中国修复重建外科杂志

Objective: To investigate the short-term effectiveness of total hip arthroplasty with Wagner Cone stem combined with subtrochanteric shortening osteotomy for adult patients with Crowe Ⅳ developmental dysplasia of the hip (DDH). Methods: A clinical data of 18 patients (20 hips) with Crowe Ⅳ DDH between January 2015 and June 2017 was retrospectively analyzed. There were 5 males (6 hips) and 13 females (14 hips), with an average age of 42 years (range, 20-67 years). There were 18 cases with unilateral DDH and 2 cases with bilateral DDHs. The "4" sign and Trendelenburg sign of affected hip were positive. Preoperative Harris score and visual analogue scale (VAS) score were 41.95±6.90 and 5.05±1.15, respectively. The length discrepancy was (4.76±2.59) cm in patients with unilateral DDH. And the lengths of bilateral lower limbs in patients with bilateral DDH were equal. The acetabular anteversion angle, femoral anteversion angle, and combined anteversion angle were (32.82±2.79), (46.18±6.80), and (79.01±7.54) °, respectively. All patients were treated by total hip arthroplasty with Wagner Cone stem and subtrochanteric shortening osteotomy. The length of osteotomy ranged from 2.0 to 3.5 cm (mean, 2.38 cm). Results: The operation time was 116-161 minutes (mean, 138.4 minutes); the volume of intraoperative blood loss was 600-1 200 mL (mean, 795 mL); the volume of drainage after operation was 100-630 mL (mean, 252 mL). All incisions healed by first intention. The symptom of sciatic nerve injury occurred in 1 case and relieved after symptomatic treatment. All patients were followed up 12-29 months (mean, 18.4 months). The "4" sign and Trendelenburg sign of affected hip were negative. The Harris score and VAS score at last follow-up were 87.50±5.06 and 0.75±0.85, respectively. The acetabular anteversion angle, femoral anteversion angle, and combined anteversion angle were (16.21±4.84), (18.99±2.55), and (35.20±5.80)°, respectively. There were significant differences in above indexes between pre- and post-operation ( P<0.05). The length discrepancy was (0.72±0.70) cm in patients with unilateral DDH, which was significant shorter than the preoperative value ( t=7.751, P=0.000). And the lengths of bilateral lower limbs in patients with bilateral DDH were equal. X-ray films showed that the osteotomy of femur healed at 3-6 months (mean, 4.1 months) without the signs of loosening, sinking, osteolysis, and dislocation. Conclusion: Total hip arthroplasty with Wagner Cone stem and subtrochanteric shortening osteotomy can obviously improve the hip joint function and restore the length of lower limb. The short-term effectiveness is satisfactory, but the long-term effectiveness and survival rate of prosthesis need to be further observed.

Failure of Intramedullary Nailing for Subtrochanteric Atypical Femoral Fractures Caused by Endosteal Cortical Thickening

PURPOSE: Recent literature has noted incidences of subtrochanteric atypical femoral fractures (AFFs) in patients who have taken long-term bisphosphonates (BPs). Most cases of subtrochanteric AFFs have been treated with intramedullary nailing and cases of delayed union have been reported. On the other hand, there is no data available on the complications associated with endosteal thickening or cortical thickening. This study evaluated the results of surgical treatment according to the endosteal thickening of the lateral cortex in subtrochanteric AFFs. MATERIALS AND METHODS: Investigation was performed at the Department of Orthopaedic Surgery, Jeju National University Hospital. The study consisted of patients with subtrochanteric AFFs, defined by the American Society for Bone and Mineral Research (ASBMR) major criteria, who underwent intramedullary nailing from March 2012 to October 2014. The cases were categorized into two groups based on the presence of endosteal thickening. The evaluation included the demographic data, radiographic data of initial reduction state, and duration of BPs. RESULTS: The demographic data and duration of BPs were similar in the two groups. On the other hand, varus reduction (Group I: 12.5% vs. Group II: 78.9%; p=0.001), delayed union (Group I: 0% vs. Group II: 70.0%; p=0.003), nonunion (Group I: 0% vs. Group II: 47.4%; p=0.017), and union time (Group I: 5.5 months vs. Group II: 8.3 months; p<0.001) were significantly different in the two groups. CONCLUSION: Endosteal thickening of the lateral cortex in subtrochanteric AFFs was identified as an independent factor that decides the reduction of the fracture and nonunion. The endosteal thickening should be removed to obtain anatomical alignment for successful surgical results.

Characteristics and Surgical Outcomes of Intertrochanteric or Subtrochanteric Fractures Associated with Ipsilateral Femoral Shaft Fractures Treated with Closed Intramedullary Nailing: A Review of 31 Consecutive Cases over Four Years at a Single Institution / 대한고관절학회지

PURPOSE: To evaluate the clinical characteristics of intertrochanteric or subtrochanteric fractures associated with ipsilateral femoral shaft fractures and assess the surgical outcomes of a novel, closed intramedullary nailing surgical approach designed to minimize fixation failure. MATERIALS AND METHODS: Between May 2013 and April 2017, 31 patients with intertrochanteric or subtrochanteric fractures associated with ipsilateral femoral shaft fractures treated with closed intramedullary nailing or long proximal femoral nail antirotation (PFNA) were enrolled in this study. Preoperative data included age, sex, injury severity score, body mass index, location of shaft fracture, injury mechanism, accompanying traumatic injury, walking ability before injury, and surgical timing. Perioperative outcomes, including follow-up period, types of intramedullary nails, number of blocking screws used, operation time, and blood loss were assessed. Radiologic outcomes, including union rate, time from surgery to union, and femoral shortening, and clinical outcomes, including hip flexion, walking ability, and Harris hip score were also evaluated. RESULTS: A total of 29 unions (93.5%) were achieved. The time to union was 16.8 months (range, 11–25 months) for hip fractures (15.7 weeks for intertrochanteric fractures and 21.7 weeks for subtrochanteric fractures) and 22.8 months for femoral shaft fractures. There were no significant differences in surgical outcomes between the two groups except for type of intramedullary nail. CONCLUSION: Closed intramedullary nailing in the treatment of intertrochanteric or subtrochanteric fractures associated with ipsilateral femoral shaft fractures may be a good surgical option. However, fixation of femoral shaft fractures might not be sufficient depending on the implant design.

Comparison of long Gamma 3 nail and proximal femur locking plate for the treatment of femoral subtrochanteric fractures / 中国骨伤

OBJECTIVE@#To compare clinical efficacy of long Gamma 3 nail and proximal femur locking plate (PFLP) in treating femoral subtrochanteric fractures.@*METHODS@#From January 2010 to January 2017, clinical data of 58 patients with subtrochanteric fractures followed more than 12 months were retrospective analyzed. Among them, 35 patients were treated with long Gamma 3 nail including 18 males and 17 females aged from 25 to 78 years old with an average of(66.5±23.5) years old;Causes of injury included fall on the ground in 18 cases, traffic accidents in 7 cases, and fall from height in 10 cases. The other 23 patients were treated with PFLP fixation including 8 males and 15 females aged from 31 to 81 years old with an average of (63.4±22.4) years old;Causes of injury included fall on the ground in 12 cases, traffic accidents in 6 cases, and fall from height in 5 cases. Operative time, blood loss (intraoperative and hidden blood loss), hospital stays, bone healing and complications were observed and compared. Harris hip score after 1-year following-up was used to evaluate postoperative clinical effect.@*RESULTS@#Fifty-one patients were followed up from 14 to 36 months with an average of 24.8 months, including 31 patients were treated with long Gamma 3 and 20 patients were treated with PFLP. Blood loss(intraoperative and hidden blood loss) in PFLP group was less than that of long Gamma 3 nail group(0.05). There was no significant differences in healing time of fractures between long Gamma 3 nail group (17.2±2.4) weeks and PFLP group (18.1±2.6) weeks(<0.05). At 1-year following-up, there was no significant differences in Harris hip score between long Gamma 3 nail group(80.29±10.28) and PFLP group (76.49±12.28)(<0.05). No complications such as pulmonary embolism and nonunion occurred. Two patients were treated with fitler whose occurred deep vein thrombosis. Postoperative pulmonary infection curred in 4 cases and was cured by anti-infection therapy.@*CONCLUSIONS@#Both of long Gamma 3 nail and PFLP in treating patients with femoral subtrochanteric fractures can receive good clinical effects, long Gamma 3 nail is not suitable for the patients of the narrow medullary cavity and prominent anterior arch. PFLP is eccentric fixation, so early weight-bearing was not stress.

Lateral decubitus intramedullary nailing for femoral subtrochanteric fractures / 中华创伤骨科杂志

Objective To investigate the efficacy of lateral decubitus intramedullary nailing for treatment of subtrochanteric fractures of the femur.Methods From January 2012 to December 2015,23 patients with simple femoral subtrochanteric fracture were treated at Department of Orthopedic Trauma,Changhai Hospital.They were 15 males and 8 females,aged from 19 to 77 years (average,48.3 years).According to the Seinsheimer classification,there were 6 cases of type ⅡB,8 cases of type ⅡC,6 cases of type Ⅲ A,and 3 cases of type ⅢB.Their injuries were caused by traffic accident in 10 cases,falling from a height in 5 cases,and sprain in 8 cases.All patients were treated by closed reduction and anterograde intrarnedullary nailing at lateral decubitus.Their operative time,bleeding volume,fluoroscopic frequency,fracture healing time,functional recovery and complications were recorded and analyzed.Results Their operative time ranged from 55 to 80 min,averaging 65.7 min;their bleeding volumes ranged from 240 to 420 mL,averaging 304.3 mL;their fluoroscopic frequency ranged from 30 to 60 times,averaging 42.7 times.This cohort was followed up for 12 to 28 months (average,17.9 months).Their fracture healing time ranged from 4 to 10 months,averaging 5.5 months.Nonunion occurred in one patient but was cured by secondary operation.The HSS evaluation at the final follow-ups showed 17 excellent cases and 6 good ones,yielding an excellent to good rate of 100％.All the wounds healed by the first intention.No infection,deep vein thrombosis or implant failure was observed.Conclusion As lateral decubitus intramedullary nailing can achieve satisfactory clinical efficacy for subtrochanteric fractures of the femur,the body position of lateral decubitus may be a good alternative.