Torsional stability of fixation methods in basicervical femoral neck fractures: a biomechanical study.

BACKGROUND: Basicervical femoral neck fracture is a rare proximal femur fracture with a high implant failure rate. Biomechanical comparisons between cephalomedullary nails (CMNs) and dynamic hip screws (DHSs) under torsion loading are lacking. This study compared the biomechanical performance of three fixations for basicervical femoral neck fractures under torsion load during early ambulation. METHODS: The biomechanical study models used three fixations: a DHS, a DHS with an anti-rotation screw, and a short CMN. Finite element analysis was used to simulate hip rotation with muscle forces related to leg swing applied to the femur. The equivalent von Mises stress (EQV) on fixation, fragment displacement, and strain energy density at the proximal cancellous bone were monitored for fixation stability. RESULTS: The EQV of the short CMN construct (304.63 MPa) was comparable to that of the titanium DHS construct (293.39 MPa) and greater than that of the titanium DHS with an anti-rotation screw construct (200.94 MPa). The proximal fragment displacement in the short CMN construct was approximately 0.13 mm, the greatest among the constructs. The risk of screw cutout for the lag screw in short CMNs was 3.1-5.8 times greater than that for DHSs and DHSs with anti-rotation screw constructs. CONCLUSIONS: Titanium DHS combined with an anti-rotation screw provided lower fragment displacement, stress, and strain energy density in the femoral head than the other fixations under torsion load. Basicervical femoral neck fracture treated with CMNs may increase the risk of lag screw cutout.

A Digital Health Intervention Platform (Active and Independent Management System) to Enhance the Rehabilitation Experience for Orthopedic Joint Replacement Patients: Usability Evaluation Study.

BACKGROUND: Optimal rehabilitation programs for orthopedic joint replacement patients ensure faster return to function, earlier discharge from hospital, and improved patient satisfaction. Digital health interventions show promise as a supporting tool for re-enablement. OBJECTIVE: The main goal of this mixed methods study was to examine the usability of the AIMS platform from the perspectives of both patients and clinicians. The aim of this study was to evaluate a re-enablement platform that we have developed that uses a holistic systems approach to address the de-enablement that occurs in hospitalized inpatients, with the older adult population most at risk. The Active and Independent Management System (AIMS) platform is anticipated to deliver improved patient participation in recovery and self-management through education and the ability to track rehabilitation progression in hospital and after patient discharge. METHODS: Two well-known instruments were used to measure usability: the System Usability Scale (SUS) with 10 items and, for finer granularity, the User Experience Questionnaire (UEQ) with 26 items. In all, 26 physiotherapists and health care professionals evaluated the AIMS clinical portal; and 44 patients in hospital for total knee replacement, total hip replacement, or dynamic hip screw implant evaluated the AIMS app. RESULTS: For the AIMS clinical portal, the mean SUS score obtained was 82.88 (SD 13.07, median 86.25), which would be considered good/excellent according to a validated adjective rating scale. For the UEQ, the means of the normalized scores (range -3 to +3) were as follows: attractiveness=2.683 (SD 0.100), perspicuity=2.775 (SD 0.150), efficiency=2.775 (SD 0.130), dependability=2.300 (SD 0.080), stimulation=1.950 (SD 0.120), and novelty=1.625 (SD 0.090). All dimensions were thus classed as excellent against the benchmarks, confirming the results from the SUS questionnaire. For the AIMS app, the mean SUS score obtained was 74.41 (SD 10.26), with a median of 77.50, which would be considered good according to the aforementioned adjective rating scale. For the UEQ, the means of the normalized scores were as follows: attractiveness=2.733 (SD 0.070), perspicuity=2.900 (SD 0.060), efficiency=2.800 (SD 0.090), dependability=2.425 (SD 0.060), stimulation=2.200 (SD 0.010), and novelty=1.450 (0.260). All dimensions were thus classed as excellent against the benchmarks (with the exception of novelty, which was classed as good), providing slightly better results than the SUS questionnaire. CONCLUSIONS: The study has shown that both the AIMS clinical portal and the AIMS app have good to excellent usability scores, and the platform provides a solid foundation for the next phase of research, which will involve evaluating the effectiveness of the platform in improving patient outcomes after total knee replacement, total hip replacement, or dynamic hip screw.

Angle-Adjustable Dynamic Hip Screw Plate for Unstable Trochanteric Fractures in Middle-Aged Patients: Mid-Term Outcomes and Return to Sport.

BACKGROUND: There are conflicting results in the literature regarding the superiority of proximal femoral nails over dynamic hip screw (DHS) plates. The primary aim of this study is to evaluate mid-term post-injury patient-reported outcome measures (PROMs) and return to sport (RTS) in middle-aged patients treated with the DHS plate for unstable trochanteric fractures. METHODS: Fifty-seven middle-aged patients (35-64 years) treated for proximal femoral fractures of type 31-A2 and 31-A3 according to the AO/OTA classification with the DMS Dynamic Martin Screw (KLS Martin Group, Jacksonville, FL, USA) between January 2017 and December 2019 were enrolled. RESULTS: Forty-nine patients were included in this retrospective study, and the average age was 54.1 years (SD 8.4). The average follow-up duration at final follow-up was 60.5 months (SD 8.6). Post-operative complications included only one case of aseptic loosening of the implant, with a complication rate of 2%. There were no infections, peri-implant fractures, or other complications reported. Two out of the forty-nine patients (4.1%) required treatment with a total hip arthroplasty due to post-traumatic arthritis. The Harris Hip Score at final follow-up was 77.1 (SD 20.1), and the Western Ontario and McMaster Universities Osteoarthritis Index was 21.6 (SD 13.7). The overall rate of RTS was 57.7%. CONCLUSIONS: Treatment with DHS for unstable trochanteric fractures is a safe option in middle-aged patients, ensuring a good functional recovery.

Does the angle between dynamic hip screw and anti-rotation screw affect the outcome of vertically oriented femoral neck fractures? A biomechanical analysis and clinical results.

OBJECTIVE: To analyze the effects of the angle between dynamic hip screw (DHS) and anti-rotation screw (AS) on vertically oriented femoral neck fractures (VOFNFs) and investigate the clinical results of them. METHODS: Eighteen synthetic femurs were simulated and divided into 3 groups. The angle between DHS and AS in anteroposterior-view was marked as α, and in lateral-view was marked as ß, thus the total angle (TA) was defined as the summation of α and ß. The groups were categorized as group A (TA ≤ 5°), B (5° < TA ≤ 10°), and C (TA > 10°), respectively. All samples were tested under incremental, cyclical loading, and loading to failure. In clinic, 80 consecutive VOFNFs in 78 patients were treated with DHS plus AS. The patients were divided into 2 groups, including 48 fractures in parallel group (TA ≤10°) and 32 in angular group (TA >10°). RESULTS: Group A and B survived during incremental and cyclical loading and endured longer than group C. Axial stiffness and failure loads were not different between group A and B, and greater than group C. Fracture gaps compressive stress was highest in group A, followed by group B and C. Forty-one fractures in parallel group and 23 in angular group healed at final follow-up. Nonunion and osteonecrosis occurred in 3 and 4 of parallel group, and 4 and 5 of angular group. CONCLUSION: The construction with TA ≤10° between DHS and AS showed superior biomechanical performance and clinical results than those with TA >10°.

Dynamic hip screw in proximal femoral fractures followed by "single-stage" hip arthroplasty-retrospective analysis.

The aim of this study is to present the results of single-stage total hip arthroplasty (THA) after Dynamic Hip Screw (DHS) failure, or secondary posttraumatic osteoarthrosis. From 2003 to 2020, 15 THAs were performed in group of 15 patients for the treatment of DHS failure, or for late complications following femoral neck and pertrochanteric fractures. The mean follow-up period after arthroplasty was 46.9 months (range 7-139). The patients were evaluated retrospectively-both clinically and radiographically, focussing on the demography, infection rate and other complications (revision surgery), during the year 2023. 9 males and 6 females were included in the study, with a mean age of 56.5 years (range 29-93) at the time of primary osteosynthesis. Each of them had proximal femoral fracture treated primarily with a DHS and then late one-stage revision surgery, with hardware removal and THA implantation. The median time between DHS osteosynthesis and THA was 41.2 months (range 4-114). Four patients (26.6%) had complications after THA, with the need for revision in two cases (13.3%). Dislocation rate was 6.6% (one case), with the need for repeated-revision of THA. The infection rate was 6.6% (one patient) with the need for revision of THA. Peroperative periprosthetic femoral fracture was observed in 13.3% (two patients) without any other problems. Six patients (40%) died during the follow-up period. Single-stage total hip arthroplasty with concomitant hardware removal bears a high- mortality rate, with a higher incidence of postoperative complications compared to elective THA.

Efficacy of preoperative Tranexamic Acid in patients undergoing intertrochanteric hip fracture surgery: A randomized placebo controlled trial.

Objective: To determine the efficacy of preoperative Tranexamic Acid (TXA) in reducing perioperative allogenic blood transfusion frequency in patients with intertrochanteric fractures treated with Dynamic Hip Screw (DHS). Methods: We conducted this placebo controlled double-blinded randomized trial in Orthopaedics & Traumatolgy Division Lady Reading Hospital, Peshawar from 1st January 2020 to 25th December 2022. All patients with intertrochanteric hip fractures fulfilling the inclusion criteria were treated with Dynamic Hip Screw (DHS) and were randomly divided into two equal groups. One group was administered single dose IV Tranexamic Acid (TXA) in a dose of 15mg/kg body weight in 100ml of saline while the other group (Placebo) was given 100 ml normal saline preoperatively. Post-operative Hemoglobin was measured on first, second and third day. The frequency of allogenic blood transfusions in the perioperative period was determined in both groups based upon the transfusion trigger (Hemoglobin 9g/dl). Categorical variables were compared with Chi-square test and mean with Independent sample t-test. P value of <0.05 was considered significant. Results: The total number of patients in our trial were 200 which were equally but randomly allocated into TXA group and Placebo group each containing 100 patients. The mean age of the patients in TXA group was 48.16±1.75 years and the age of patients in the Placebo group was 48.35±1.60. The baseline demographic and clinical variables of both groups were identical (p< 0.05). The average preoperative hemoglobin was 11.5±4.2 g/dl in TXA group and 11.3±2.4g/dl in the Placebo group (p>0.05). The frequency of allogenic blood transfusion was significantly lower (p<0.05) in TXA group (13%, n=13) than in the Placebo group (41%, n=41). Conclusion: Tranexamic acid (TXA) significantly reduces the frequency of peri operative allogenic blood transfusion in patients undergoing Dynamic Hip Screw (DHS) for intertrochanteric fractures.

[Clinical and radiographic factors associated with failure of the dynamic hip screw system]. / Factores clínicos y radiográficos asociados a la falla del sistema del tornillo dinámico de cadera.

Background: The most widely used fixation system for transtrochanteric fractures is the dynamic hip screw system, which has a failure prevalence of 10 to 17% and it is associated with the presence of clinical and radiographic factors. Objective: To evaluate the association of clinical and radiographic factors with the failure of the screw system in post-operative patients for transtrochanteric hip fracture. Material y methods: A case-control study was carried out. The inclusion criteria were: patients > 18 years, who underwent surgery due to transtrochanteric fracture, were treated with the hip screw system, and who attended the Trauma Service. The patient with failure of the hip screw system was selected as the case and the patient without failure of the system as control. The variables analyzed in these groups were: age, gender, body mass index and radiographic variables. Statistical analysis was performed with chi-squared and Mann-Whitney U. Results: 163 patients (median 73 years), 20 cases and 143 controls, were included. The radiographic factors with a significant association with hip screw system failure were the AO classification of fractures (p < 0.001), the tip apex distance (p = 0.03), the calcar-referenced tip apex (p = 0.02), the position of the screw (p < 0.001), and quality of reduction (p < 0.003). Clinical factors did not show a significant association. Conclusions: Radiographic factors are associated with failure in the hip screw system in patients in post-operative care due to transtrochanteric fracture.

Introducción: el sistema de fijación más usado para fracturas transtrocantéricas es el sistema del tornillo dinámico de cadera, el cual tiene una prevalencia de falla del 10 al 17% y se asocia a la presencia de factores clínicos y radiográficos. Objetivo: evaluar la asociación de los factores clínicos y radiográficos con la falla del sistema del tornillo en pacientes postoperados de fractura transtrocantérica de cadera. Material y métodos: se hizo un estudio de casos y controles. Los criterios de inclusión fueron: pacientes > 18 años, postoperados de fractura transtrocantérica, tratados con el sistema del tornillo de cadera, que acudieron a la consulta de Traumatología. Se seleccionó como caso al paciente con falla del sistema del tornillo de cadera y como control al paciente sin falla de este. Las variables analizadas en los grupos fueron la edad, el género, el índice de masa corporal y las variables radiográficas. El análisis estadístico se hizo con chi cuadrada y U de Mann-Whitney. Resultados: se incluyeron 163 pacientes (mediana de 73 años), 20 casos y 143 controles. Los factores radiográficos con asociación significativa con la falla del sistema del tornillo de cadera fueron la clasificación AO de la fractura (p < 0.001), la distancia punta-ápex (p = 0.03), punta ápex calcar (p = 0.02), la posición del tornillo (p < 0.001) y la calidad de la reducción (p < 0.003). Los factores clínicos no mostraron asociación significativa. Conclusiones: los factores radiográficos se asocian con la falla en el sistema del tornillo de cadera en pacientes postoperados de fractura transtrocantérica.

Hip Fracture Post-operative Mortality and Polypharmacy: A New Risk Predictor?

Introduction Hip fractures include intra- and extracapsular fractures with hip hemiarthroplasty, intramedullary (IM nailing), dynamic hip screw (DHS) fixation and cannulated cancellous screws being the main treatment options. The Nottingham Hip Fracture Score (NHFS) is used to predict the risk of 30-day mortality with some studies investigating its use for one-year mortality. This study aims to investigate the impact of polypharmacy on post-operative hip fracture mortality and the correlation with NHFS predicted mortality. Methods A retrospective single-centre analysis was carried out on hip fracture patients aged 65 years and over who underwent operative management. Primary outcome measures were 30-day and one-year mortality along with the presence of polypharmacy. Secondary outcome measures were mortality based on procedure type, NHFSs for polypharmacy and non-polypharmacy groups, number of medications, American Society of Anesthesiologists (ASA) grade, age and gender. Polypharmacy was defined as five or more long-term medications from a selected list of drug classes. Results Thirty-day mortality was 19.3% for the polypharmacy group and 2.4% for the non-polypharmacy group (P≤0.00001), while one year mortality was 50.9% for the polypharmacy group and 2.4% for the non-polypharmacy group (P≤0.00001), the NHFS was 5.16 (±1.38) on average for the polypharmacy group and 5.07 (±1.47) for the non-polypharmacy group. Thirty-day mortality was 10/116 (8.6%) for the hemiarthroplasty patients, 3/66 (4.5%) for the DHS fixation patients and 1/32 (4.5%) for the IM nailing patients. One-year mortality was 33/116 (28.4%) for the hemiarthroplasty patients, 11/66 (16.7%) for the DHS fixation patients and 4/32 (12.6%) for the IM nailing patients. Conclusion Polypharmacy correlated with a significantly higher one-year and 30-day postoperative mortality after hip fractures with the NHFS predicting no difference in mortality. This finding could assist in decision making and help facilitate discussions with patients and family members regarding post-operative mortality risks. The NHFS may also benefit from integrating polypharmacy possibly leading to more accurate risk predictions. The IM nailing and DHS fixation patients were found to have a lower 30-day and one-year mortality than the hemiarthroplasty patients.

Surgical management of neck of femur fractures in patients younger than sixty-five years: a comparative study of three fixation methods.

PURPOSE: Several surgical implants have been used for the treatment of neck of femur fracture (NOF) in younger patients such as dynamic hip screw (DHS) and cannulated compression screw. However, the superiority of one or another osteosynthesis device remains a matter of debate. The aim of this work is to evaluate and compare three fixation modalities: Cannulated Hip Screws (CHS), DHS and DHS associated to anti-rotating screw for surgical treatment of femoral neck fracture in young adults. METHODS: It is a retrospective comparative study of three series of NOF fractures treated surgically over a period of ten years; including young adult patients (age > 18 years and < 65 years) treated conservatively using closed or open reduction and internal fixation. All types of NOF fractures according to Garden classification were included. Pathological, basi-cervical fractures and fractures on previously operated hips were excluded. The minimum follow-up recommended was two years. Clinical evaluation was based on the Postel Merle d'Aubigné score (PMA), the visual analogue scale (VAS), the Parker score, and the Hip Disability and Osteoarthritis Outcome Score (HOOS score). Reduction quality was assessed on X-rays. RESULTS: Our series included 72 patients that were divided in three groups: Group A: Fixation using cannulated hip screws (33 patients). Group B: Fixation using DHS only (21 patients). Group C: Fixation using DHS associated to anti-rotation screw (18 patients). The patients of group A had better PMA and VAS scores, but there was no statistically significant difference. However, a significant difference (p=0.001) was found for the HOOS score. The fractures treated with DHS associated with anti-rotating screws, had the highest loss of reduction in the vertical axis (Yp) with the highest femoral head collapse (Zp) values. Group A had the lowest loss of reduction in the horizontal axis (Xp). There was no significant difference between the three methods of osteosynthesis in terms of loss of correction though. CONCLUSION: We found comparable results in terms of healing and complication rates and loss of reduction for the three groups with no significant difference. However, the HOOS score was significantly better in the cannulated hip screw group.

Restoration of Hip Geometry after Femoral Neck Fracture: A Comparison of the Femoral Neck System (FNS) and the Dynamic Hip Screw (DHS).

BACKGROUND: The femoral neck system (FNS) was introduced as a minimally invasive fixation device for managing femoral neck fractures. OBJECTIVE: To compare radiographic, clinical, and patient-reported outcome measures (PROMs) of femoral neck fracture patients following FNS compared to dynamic hip screw (DHS) implantation combined with an anti-rotational screw. METHODS: Patients who underwent closed reduction and internal fixation of a femoral neck fracture between 2020 and 2022 were retrospectively included. We measured leg length, femoral offset, and centrum-collum-diaphyseal (CCD) angle in plain radiographs. Scar length, Harris Hip Score, short-form health survey 36-item score (SF-36), and Numeric Rating Scale (NRS) were assessed during follow-up visits. RESULTS: We included 43 patients (22 females) with a median age of 66 (IQR 57, 75). In both groups, leg length differences between the injured and the contralateral side increased, and femoral offset and CCD angle differences were maintained over time. FNS patients had shorter scars and reported fewer emotional problems and more energy. There were no differences between groups regarding the remaining SF-36 sub-scores, Harris Hip Score, and NRS. CONCLUSIONS: The FNS allows for a comparable leg length, femoral offset, and CCD angle reconstruction while achieving similarly high functional and global health scores to the DHS.

Cannulated screws versus dynamic hip screw versus hemiarthroplasty versus total hip arthroplasty in patients with displaced and non-displaced femoral neck fractures: a systematic review and frequentist network meta-analysis of 5703 patients.

BACKGROUND: Our aim was to determine the best operative procedure in human participants with a displaced or non-displaced femoral neck fracture comparing cannulated screw (CS) fixation, dynamic hip screw (DHS) fixation, hemiarthroplasty (HA), and total hip arthroplasty (THA) in terms of surgical and functional outcomes, reoperation and postoperative complications. METHODS: We searched PubMed, The Cochrane Library, Clinical trials, CINAHL, and Embase for randomized controlled trials (RCTs) or quasi-RCTs up to 31 July 2022. A frequentist network meta-analysis was performed to assess the comparative effects of the four operative procedures, using fixed-effects and random-effects models. Mean differences (MDs) with 95% confidence intervals (CIs) were estimated for continuous variables and odds ratios (ORs) with 95% CIs were estimated for binary variables. RESULTS: A total of 33 RCTs with 5703 patients were included in our network meta-analysis. CS fixation was best in terms of operation time (CS: MD = - 57.70, 95% CI - 72.78; - 42.62; DHS: MD = - 53.56, 95% CI - 76.17; - 30.95; HA: MD = - 20.90, 95% CI - 30.65; - 11.15; THA: MD = 1.00 reference) and intraoperative blood loss (CS: MD = - 3.67, 95% CI - 4.44; - 2.90; DHS: MD = - 3.20, 95% CI - 4.97; - 1.43; HA: MD = - 1.20, 95% CI - 1.73; - 0.67; THA: MD = 1.00 reference). In life quality and functional outcome, measured at different time points with EQ-5D and the Harris Hip Score (HHS), THA ranked first and HA second (e.g. EQ-5D 2 years postoperatively: CS: MD = - 0.20, 95% CI - 0.29; - 0.11; HA: MD = - 0.09, 95% CI - 0.17; - 0.02; THA: MD = 1.00 reference; HHS 2 years postoperatively: CS: MD = - 5.50, 95% CI - 9.98; - 1.03; DHS: MD = - 8.93, 95% CI - 15.08; - 2.78; HA: MD = - 3.65, 95% CI - 6.74; - 0.57; THA: MD = 1.00 reference). CS fixation had the highest reoperation risk, followed by DHS fixation, HA, and THA (CS: OR = 9.98, 95% CI 4.60; 21.63; DHS: OR = 5.07, 95% CI 2.15; 11.96; HA: OR = 1.60, 95% CI 0.89; 2.89; THA: OR = 1.00 reference). CONCLUSION: In our cohort of patients with displaced and non-displaced femoral neck fractures, HHS, EQ-5D, and reoperation risk showed an advantage of THA and HA compared with CS and DHS fixation. Based on these findings, we recommend that hip arthroplasty should be preferred and internal fixation of femoral neck fractures should only be considered in individual cases. LEVEL OF EVIDENCE I: a systematic review of randomized controlled trials. TRIAL REGISTRATION: PROSPERO on 10 August 2022 (CRD42022350293).

Complications and Outcomes of the Internal Fixation of Non-displaced Femoral Neck Fracture in Old Patients: A Two-Year Follow-Up.

Background Fractures of the proximal femur are amongst the most common injuries in the elderly population. While there is a clear consensus regarding the management of displaced femoral neck fractures, the management of non-displaced fractures is less clear. Both fixation and arthroplasty are valid treatment options. Internal fixation is a less invasive procedure, but it carries the risks of non-union and avascular necrosis (AVN) of the femoral head. The literature describes varying complication rates associated with these risks. We aim to describe a series of elderly patients above the age of 65 years with non-displaced fractures of the femoral neck who were treated with internal fixation. Our objectives are to determine the union rate and complications in this group and to elucidate the factors that influence these outcomes. Methods We conducted a retrospective review of all patients aged 65 years and older who presented with femoral neck fractures at our level 1 trauma unit between 2018 and 2020. Fractures were classified using the Garden classification system, and only those with Garden 1 or 2 fractures (non-displaced) were included. Preoperative radiographs or intraoperative fluoroscopy images were used to classify fractures using the Pauwels classification. Serial postoperative radiographs and clinical notes (up to 24 months postoperatively) were reviewed to assess the union rate and the development of complications. Both non-union and AVN were analysed for their associations with age, sex, Pauwels grade and comorbidities. A subgroup analysis of the complications was performed to elucidate their association with age groups (<80 and >80 years) and types of fixations (dynamic hip screws {DHS} and cannulated screws). Results A total of 148 patients, consisting of 60 males and 88 females, were included in the analysis. The patients had a mean age of 78.5 years (ranging from 65 to 98 years). The union rate without any degree of AVN was 90.7%, with six non-unions (4.05%) and six patients experiencing AVN (4.05%). No difference in outcome was detected between the two groups based on age. High (type 2 or 3) Pauwels grade (p = 0.05) and treatment with cannulated screws (p = 0.02) were indicated as significant factors for non-union. All patients who developed AVN were noted to have a comorbidity that is known to predispose them to AVN. Conclusion Our series shows a union rate of 90.7%, which is comparable to the union rates reported in other published literature. Our results suggest that age does not independently influence the outcome of fixation for these fractures. We conclude that fractures with vertical orientation (Pauwels grade 2 or 3), when treated with cannulated screws, are more likely to result in non-union. AVN is the second most common complication after non-union, which is also associated with other risk factors for AVN.

Does intramedullary nail have advantages over dynamic hip screw for the treatment of AO/OTA31A1-A3? A meta-analysis.

BACKGROUND: Hip fractures are still unsolved problems nowadays. We evaluated the functional outcomes and complications in the treatment of hip fractures (AO/OTA31A1-A3) to find potential difference and risk between intramedullary nail (IMN) and dynamic hip screw (DHS). METHOD: We searched PubMed, Embase, Cochrane library up to 19 June 2023 and retrieved any studies comparing IMN and DHS in treatment of Hip fractures. The main outcomes and complications were extracted from the included studies. The fixed-effect model was selected to pool the data for homogeneous studies (I2 < 50%). Otherwise, the random effects model was selected (heterogeneity, I2 > 50%). The analysis of sensitivity and subgroup was performed to explore the homogeneous studies among studies. The p-value of less than 0.05 was considered statistically significant. RESULTS: 30 RCT studies were included in this meta-analysis. There were significant difference of in the items of blood loss, screening time, femoral neck shortening, non-union, and femoral fractures (p < 0.05). Significant difference was found in the parameter of open reduction of fracture after sensitive analysis (p < 0.05). No significant difference was found in the parameter of Mobility Score at the last follow-up after sensitive analysis (p ≥ 0.05). There was no significant difference in the parameters of open reduction of fracture, required blood transfusion, mean surgical time, hospital stays, time to healing, mean Harris Hip Score, infection, cut out, poor reduction, breakage of implant, failure of fixation, reoperation, and systemic complications of chest infection, decubital ulcer, urinary tract infection and persistent pain in the hip (p ≥ 0.05). CONCLUSIONS: Our meta-analysis revealed that hip fractures treated with IMN have merits with lower rate of blood loss, femoral neck shortening and non-union; shortcoming of increased risk of femoral fractures. It is suggested that special attention should be paid to the risk of femoral fracture when intramedullary nail was inserted in the intraoperative.

A Comparison of Tip-Apex Distance at Various Angles of Fixation Devices in Hip Fractures.

Background Intertrochanteric neck of the femur (NOF) fractures are very common, and the majority are fixed using dynamic hip screws (DHS) or intramedullary (IM) nails with a fixed angle. The aim of this study was to assess which angle of fixation has a better tip-apex distance (TAD) on X-ray and lower complication rates. Methods We included patients with intertrochanteric hip fractures fixed using a DHS or an IM nail. We included patients who had complete radiological and clinical records and a minimum follow-up of 24 months. We measured the TAD and recorded the number of implant cutouts, fracture site nonunions, and periprosthetic fractures. Results A total of 107 patients were included, 35 IM nails and 72 DHS. There were four cases of implant cutouts within the DHS group and none in the IM nail group. All four cutout cases were fixed using 135° angle DHS, and two had TAD of more than 25 mm. Multivariable regression analysis revealed that the implant fixation device (p=0.002) and the angle of fixation (p<0.001) are the most important predictors of TAD. Conclusion Smaller angle (130° or 125°) fixation devices allow better positioning of the lag screw and consequently better TAD, which leads to a lower probability of implant cutout in patients undergoing fracture of the neck of the femur surgery.

Proximal femoral nail anti-rotation vs dynamic hip screws decrease the incidence of surgical site infections in patients with intertrochanteric fractures: A meta-analysis.

In this study, a meta-analysis was conducted to comprehensively analyse the effectiveness of using proximal femoral nail anti-rotation (PFNA) and dynamic hip screws (DHS) to treat intertrochanteric fractures on postoperative surgical site infections (SSI). PubMed, EMBASE, Cochrane Library, China National Knowledge Infrastructure (CNKI), and Wanfang databases were searched from their inception until December 2022 to identify studies that compared PFNA and DHS in the treatment of intertrochanteric fractures. Two investigators independently screened the retrieved studies to assess their quality and verify their eligibility for inclusion. Meta-analyses were performed with RevMan 5.4 software. Thirty studies, including 3158 patients, met the inclusion criteria. These studies included 1574 patients treated with PFNA, and 1584 were treated with DHS. The findings of the meta-analysis revealed a significant reduction in the incidence of SSI in patients treated with PFNA compared with those treated with DHS (2.64% vs 6.76%, odds ratio [OR]: 0.40, 95% confidence intervals [CIs]: 0.28-0.57, P < .001), superficial SSI (2.58% vs 5.01%, OR: 0.53, 95% CIs: 0.33-0.85, P = .008) and deep SSI (1.26% vs 3.43%, OR: 0.41, 95% CIs: 0.19-0.92, P = .03). PFNA was more effective than DHS in reducing the incidence of SSI. Even so, significant variations in sample sizes among the included studies meant that the methodology for some studies had qualitative deficiencies. Therefore, additional studies with large sample sizes are needed to validate these results.

Comparison of Dynamic Hip Screw and Proximal Femoral Nailing Techniques in Stable Intertrochanteric Fractures.

Introduction Dynamic Hip Screw (DHS) and Proximal Femoral Nail (PFN) are two well-accepted modes of surgical treatments for intertrochanteric (IT) hip fractures. While studies have extensively explored the efficacy of one over the other in unstable fractures, the comparison is sparsely available for stable fractures. The main aim of this study is to compare DHS or PFN corrective surgeries in cases of stable IT fractures operated at the Hamad General Hospital, Doha, Qatar, between 2016 and 2018. Methods We conducted a retrospective data review of all stable IT fractures operated at the Hamad General Hospital, Doha, Qatar, between 2016 and 2018. Data were extracted from electronic medical CERNER records, including demographics, clinical notes, operative reports, radiographs, and imaging reports. Data review was followed by prospective data collection via phone about the current post-operative functional status of all cases. Data analysis was done on SPSS v.23. Study was approved by Medical Research Center (MRC) and Institutional Review Board (IRB) at Hamad Medical Corporation (HMC). Study Protocol ID: MRC-01-19-108 Results Out of 62 stable IT fractures operated at our center during the study period, 42 underwent DHS correction, while 20 had PFN. The mean age of the studied cohort was 66.56 years (± 15.95). Males were twice more than females. The mean duration of surgery was 83.73 minutes for DHS and 120.25 minutes for PFN. This difference was statistically significant (p < 0.001). Differences in intraoperative blood loss, duration between fracture and surgery, and length of hospital stay were all statistically insignificant. Patients who underwent PFN showed a higher frequency of return to ambulation (assisted and unassisted), while the number of patients with DHS was less for the functional outcome. Similarly, more post-PFN radiographs displayed union than post-DHS radiographs (55% and 38%, respectively). This difference was statistically insignificant. Conclusion Our study showed promising results for stable IT fractures treated with PFN. However, more data and prospective observational studies are required to establish more statistically significant results.

Iatrogenic Injury to Profunda Femoris During a Dynamic Hip Screw Fixation for Intertrochanteric Fracture.

We present a case of a profunda femoris artery injury during a dynamic hip screw fixation for an intertrochanteric fracture. This was identified clinically on the ward and confirmed with a CT angiogram. The bleeder was then treated by coil embolization, and laboratory results showed significant improvement in hemoglobin level after blood transfusion.

Dynamic hip screws versus cephalocondylic intramedullary nails for unstable extracapsular hip fractures in 2021: A systematic review and meta-analysis of randomised trials.

Background: Extracapsular hip fractures comprise approximately half of all hip fractures and the incidence of hip fractures is exponentially increasing. Extramedullary fixation using a dynamic hip screw (DHS) has been the gold standard method of operative treatment for unstable extracapsular fractures, however, in recent years, intramedullary nails (IMN) have become a popular alternative. IMN versus DHS is continuously discussed and debated in literature. Therefore, the purpose of this systematic review and meta-analysis is to directly compare the peri- and post-operative outcomes of these two techniques to provide an up-to-date analysis of which method of fixation is superior. Methods: The MEDLINE/PubMed, Embase and Web of Science Database were searched for eligible studies from 2008 to April 2022 that compared peri- and post-operational outcomes for patients undergoing IMN or DHS operations for fixation of unstable extracapsular hip fractures (PROSPERO registration ID:CRD42021228335). Primary outcomes included mortality rate and re-operation rate. Secondary outcomes included operation time, blood loss, transfusion requirement, complication, and failure of fixation rate. The risk of bias and quality of evidence were assessed using the Cochrane RoB 2.0 tool and GRADE analysis tool, respectively. Results: Of the 6776 records identified, 22 studies involving 3151 patients were included in the final review. Our meta-analysis showed no significant differences between mortality rates (10 studies, OR 0.98; 95% CI 0.80 to 1.22, p = 0.88) or re-operation rates (10 studies, OR 1.03; 95% CI 0.64 to 1.64, p = 0.91) between the two procedures. There were also no significant differences found between complication rates (17 studies, OR 1.29; 95% CI 0.79 to 2.12, p = 0.31) and failure of fixation rates (14 studies, OR 1.32; 95% CI 0.74 to 2.38, p = 0.35). However, DHS operations had a significantly longer operation time (p < 0.0001) and blood loss (p < 0.00001) than IMN operations. Conclusion: Overall, based on the outcomes assessed, this review has demonstrated that there is no significant difference in the post-operative outcomes for DHS vs IMN, however a significant difference exists in two of the intraoperative outcomes assessed in this review.

Conversion hip arthroplasty for failed internal fixation of ipsilateral femoral neck and shaft fractures: a case report.

BACKGROUND: Ipsilateral femoral neck and hip fractures are uncommon high energy injuries. In the literature no single method of treatment has emerged as superior to the others. A recent publication has documented the successful application of the rendezvous technique using dual-implants for treating these injuries. However in some cases, this technique may fail and revision surgery is required. CASE PRESENTATION: A 67-year old man sustained ipsilateral fractures of his femur and femoral neck in a road traffic accident. His injuries were treated by a dual construct consisting of a retrograde femoral nail and dynamic hip screw. Three months after surgery the hip screw cut out of the femoral head necessitating revision to a total hip arthroplasty. Surgery was carried out using a single stage two part procedure on a standard operating table without having to reposition or redrape the patient. There were no postoperative complications and at 1 year from surgery the patient is satisfied with the result and has returned to work. CONCLUSION: Conversion hip arthroplasty in the presence of dual implants is a technically challenging and unpredictable procedure, with an increased risk of complications. Our surgical approach provides a framework for orthopedic surgeons to safely perform this complex procedure.

Comparison of femoral neck system to multiple cancellous screws and dynamic hip screws in the treatment of femoral neck fractures.

OBJECTIVE: To compare the short-term outcomes of the femoral neck system (FNS) with multiple cancellous screws (MCS) and dynamic hip screws (DHS) in the treatment of femoral neck fractures. METHODS: A retrospective analysis was performed on 157 patients with fresh femoral neck fractures treated with FNS (from September 2019 to October 2020), MCS, and DHS (from January 2018 to October 2020). According to internal fixation methods, all patients were divided into the FNS group (54 cases), MCS group (51 cases), and DHS group (52 cases). Demographic data were also collected, recorded, and compared, including the follow-up time, days of hospitalization, operation time, blood loss, intraoperative fluoroscopy times (IFT), weight-bearing time (WBT), length of femoral neck shortening (LFNS), Harris hip score, and complications (such as internal fixation failure, bone nonunion, and avascular necrosis of the femoral head) between the three groups. RESULTS: Overall, 157 patients with a mean age of 61.8 (range, 18-89) years were analyzed. In the FNS group, IFT (median 10.5) was significantly lower than that in the MCS group (median 21) and DHS group (median 20.5) (P<0.05), and WBT was significantly earlier than that of the MCS group (P<0.05). In the FNS group, the median hospitalization time, operation time, and blood loss were 2 (2, 4) days, 45 (40-59) min, and 30 (20, 50) ml, respectively. They were all significantly less than 3.5 (3, 6) days, 72 (55-88.75) min, and 50 (30, 50) ml in the DHS group, respectively (P < 0.05). There was no statistical difference in LFNS, quality of reduction, internal fixation failure rate, and Harris hip score at the latest follow-up (P>0.05). No surgical complications such as incision infection, deep infection, pulmonary embolism, or femoral head necrosis were found in any of the three groups. CONCLUSION: FNS, MCS, and DHS are all effective for femoral neck fractures. However, a lower IFT of FNS shortens the operation time. Compared to MCS, FNS has the advantages of being a simple operation, with early WBT; compared to DHS, a minimally invasive operation is the main advantage of FNS.