Validation of the Geriatrics at Risk Score (GeRi-Score) on 120-day follow-up, the influence of preoperative geriatric visits, and the time to surgery on the outcome of hip fracture patients: an analysis from the Registry for Geriatric Trauma (ATR-DGU).

A validation of the GeRi-Score on 120-day mortality, the impact of a pre-operative visit by a geriatrician, and timing of surgery on the outcome was conducted. The score has predictive value for 120-day mortality. No advantage was found for surgery within 24 h or a preoperative geriatric visit. PURPOSE: Numerous tools predict mortality among patients with hip fractures, but they include many variables, require time-consuming assessment, and are difficult to calculate. The GeRi-Score provides a quick method of pre-operative assessment. The aim of this study is to validate the score in the 120-day follow-up and determine the impact of a pre-operative visit by a geriatrician and timing of surgery on the patient outcome. METHODS: A retrospective analysis of the AltersTraumaRegister DGU® from 2017 to 2021 was conducted, including all proximal femur fractures. The patients were divided into low-, moderate-, and high-risk groups based on the GeRi-Score. Mortality was analyzed using logistic regression. To determine the influence of the time to surgery and the preoperative visit by a geriatrician, matching was performed using the exact GeRi-Score, preoperative walking ability, type of fracture, and the time to surgery. RESULTS: The study included 38,570 patients, divided into 12,673 low-risk, 18,338 moderate-risk, and 7,559 high-risk patients. The moderate-risk group had three times the mortality risk of the low-risk group (OR 3.19 (95% CI 2.68-3.79; p<0.001)), while the high-risk group had almost eight times the mortality risk than the low-risk group (OR 7.82 (95% CI 6.51-9.93; p<0.001)). No advantage was found for surgery within the first 24 h across all groups. There was a correlation of a preoperative geriatric visit and mortality showing an increase in the moderate and high-risk group on in-house mortality. CONCLUSIONS: The GeRi-Score has predictive value for 120-day mortality. No advantage was found for surgery within 24 h. The analysis did not demonstrate a benefit of the preoperative geriatric visit, but more data are needed.

Is nail-plate docking worth the effort? A biomechanical analysis of docking a plate and a nail in peri-implant femur fractures.

Purpose: The ideal treatment of peri-implant femur fractures (PIFFs) remains unclear due to the thin clinical and biomechanical evidence concerning the most suitable form of osteosynthesis. The purpose of the present study was thus to determine the biomechanical stability that results from combining a cephalomedullary nail and a plate for proximal PIFFs, especially when the nail-plate docking technique is applied. Methods: Twenty four PIFFs were simulated in both 12 foam and 12 composite specimens and were stabilized via a combination of a cephalomedullary nail and a plate. The control group (n = 6) had a nail and a plate without a connection, while the intervention group (n = 6) had a screw that connected the plate with the interlocking screw hole of the nail, thereby creating a nail-plate docking system. The specimens were evaluated under axial and torsional loading using a material-testing machine and a 3D metrology system. Results: The data regarding stiffness, failure load, and failure displacement showed significantly higher stability for specimens without nail-plate docking. For docked specimens, a non-significant trend toward a higher resistance to torque was observed. Both techniques displayed no significant difference in fracture gap displacement or total displacement. Conclusion: The present study suggests that nail-plate docking of a cephalomedullary nail, and a plate significantly decreases the stiffness and stability of osteosynthesis under axial loading. However, there seems to be a tendency toward higher resistance to torque. Therefore, surgeons should consider this technique if higher torsional stability is necessary, and they should decide against it, if axial stability is preferred.

[Examination of Optimal Frequency Processing in X-ray Images for Occult Femoral Neck Fractures].

PURPOSE: Osteosclerotic images are known as an image appearance of occult femoral neck fractures in X-ray images. The aim of this study is to investigate frequency enhancement processing that improves the visibility of the osteosclerotic image. METHODS: We acquired three sclerotic bone images with different thicknesses, and self-made bone equivalent phantoms were set up on a pelvic phantom. The frequency processing type and high-density enhancement coefficients were applied to the X-ray images taken at RF-A(1.0, 2.0), C(2.0, 4.0), D(1.0), and H(2.0, 4.0). For the physical index, we compared the difference in signal values between the sclerotic and background normal bone. We evaluated the preference using Scheffé's paired comparison methods for the visual index. RESULTS: For the physical index, RF-C(4.0) had the most significant signal value difference for all 3 bone stiffness images. For the visual index, RF-C(4.0) showed the highest preference. CONCLUSION: Using frequency-enhanced processing, RF-C(4.0) was suggested to improve the visibility of the osteosclerosis image.

The Characteristics and Outcomes of Contralateral Non-Concurrent Hip Fractures: A Retrospective Study in Geriatric Patients.

Background and Objectives: This study aimed to determine the relationship between non-simultaneous contralateral hip fractures, urban and rural differences, fracture localization, time between fractures, physiotherapy applications, comorbidity, and the second fracture outcomes. Materials and Methods: We retrospectively analyzed 107 patients aged 65 and older with proximal femur fractures (PFFs) who underwent surgery at Düzce University Medical Faculty between January 2010 and December 2022. High-energy fractures, pathological fractures, and patients with a history of old fractures were excluded. Results: The study included 66 females (61.7%) and 41 males (38.3%), with a mean age of 83.76 years. The mean interval between two fractures was 28.3 months. There was no statistical difference between the localization of the first and second fractures (p = 0.107). However, there was a significant difference in the first PFF localizations of patients living in rural areas (p = 0.023). Patients with heart failure, respiratory failure, osteoporosis, and cognitive impairment had shorter intervals between fractures (p < 0.001). Conclusions: This study shows that age, female gender, place of residence, comorbid diseases, and whether physical therapy is received after the first fracture are significant risk factors for a second hip fracture in patients over 65 years of age.

Functional and Radiological Results Following Revision Blade Plating and Cephalomedullary Nailing in Aseptic Trochanteric and Subtrochanteric Nonunion.

Background: Trochanteric and subtrochanteric fractures result in nonunion in more than 20% of cases. The aim of this study was to assess the functional and radiological results following revision cephalomedullary nailing and 95-degree angled blade plating in aseptic trochanteric and subtrochanteric nonunion. Methods: In a retrospective multi-center study between January 2010 and December 2020, a total of 68 consecutive patients (21 women and 47 men) from two European level I trauma centers with the diagnosis of aseptic nonunion were recruited. Follow-up assessment and the patients' convenience were assessed using the Harris Hip Score, Visual Analog Scale for pain at rest and on stress/exertion and Short Form-12. Results: The patients' mean age was 57 (range 26-85) years. After a follow-up period of 12 months, one case of persistent nonunion in the cephalomedullary nail group and 10 cases in the blade plate group were identified. The mean duration of surgery was 137 ± 47 min in the cephalomedullary nail group and 202 ± 59 min in the blade plate group (<0.0001). Short-term postoperative complications included wound dehiscence, bleeding, mismatched screw and hematoma. The mid-term results 12 months after surgical revision demonstrated significantly different osseous union rates (p = 0.018). The long-term functional outcome according to the Harris Hip Score 6 years (range 2-10) after revision surgery demonstrated 81 ± 21 points in the cephalomedullary nail group and 64 ± 23 points in the plate group (p = 0.026). Conclusions: This study demonstrated that the revision treatment of trochanteric and subtrochanteric nonunion using a 95-degree blade plate or cephalomedullary nail resulted in a high percentage of osseous union, with a low incidence of complications and good functional results for both methods.

The clinical implications of using a low threshold for computed tomography scans in older patients presenting with a proximal femur fracture.

PURPOSE: Current guidelines recommend a low threshold for computerized tomography (CT) scanning in older patients presenting with low-energy trauma (LET). With the ageing of the population, this results in increased use of healthcare resources and costs. We aim to assess (1) the number of CT scans performed as part of the initial trauma screening, (2) their traumatic clinical implications, and (3) their non-traumatic clinical implications. METHODS: A retrospective study in patients ≥ 70 years presenting at a Dutch trauma centre with a proximal femur fracture following a LET between 2021 and 2022. We collected data concerning demographics, Clinical Frailty Scale, Injury Severity Score, number of CT scans and whether the results of these scans altered clinical management. RESULTS: We included 278 patients. Median age was 83.0 years (IQR 77.0-89.0), median ISS was 9 (IQR 9-10) and, most common mechanism of injury was a ground level fall (n = 159, 57.2%). In 49 patients (17.6%) one or more CT scans were performed. These scans did not reveal co-existing traumatic injuries altering clinical management. In 2 patients (0.7%) incidental findings were found that immediately affected treatment. CONCLUSION: Our study concludes that (1) approximately one in five patients with a proximal femur fracture received a CT scan as part of the initial trauma screening, resulting in (2) no traumatic and (3) minimal non-traumatic clinical implications. Therefore, a restrictive policy can be justified in patients with no additional clinical signs or symptoms and admission to the hospital. Further prospective research would be valuable to confirm our results.

Bone turnover markers and muscle decay indicator in patients with proximal femur fracture - a case-control study.

Introduction: Fracture of the proximal femur is common in elderly patients, in fact threatening their lives. Age-related sarcopenia may be involved in the imbalance resulting in the injury. Handy and readily accessible biochemical tests would be useful to assess the musculoskeletal system condition in daily practice. The aim of the study was to determine whether there is any relation between muscle decay and fracture of the proximal femur and to assess bone quality in elderly patients. Material and methods: In the study 22 patients who represented the treatment group were hospitalized due to proximal femur fracture. Eighteen patients from the control group with no fracture in their history were admitted to the Internal Medicine Department. Anyone treated for osteoporosis, immune disease affecting protein balance, neoplasm, mental illness, heart failure, or myocardial infarction was excluded from the study. In every case a blood sample from an elbow vein was drawn, collected in EDTA-K2 tubes, and then centrifuged to separate plasma from the whole blood. Subsequently, the concentrations of C-terminal cross-linked telopeptide of type I collagen (CTX-I), sex hormone binding globulin (SHBG) and creatine kinase (CK) in plasma were determined using commercial enzyme-linked immunosorbent assays. Results: The CK plasma concentration differed between the patient groups (p = 0.011). The SHBG plasma concentration was significantly higher in the treatment group (p = 0.006), whereas a slight difference in CTX-I plasma concentration between the groups was found (p = 0.038). No significant correlations between plasma CK, SHBG or CTX-I were found (p > 0.05). Conclusions: Creatine kinase is actually not an appropriate marker for the clinical assessment of muscle tissue quality in patients with or at risk of proximal femur fracture. Analyzing the quality of bone tissue, we can conclude it was poorer in patients with proximal femur fracture than in the control group.

Proximal femur fracture: Direct medical costs of hospital treatment.

INTRODUCTION: Proximal femur fractures are one of the most common injuries in older adults representing a serious health condition in developed as well as developing countries. AIM: This study aimed to assess the hospitalization costs of the proximal femur fracture. METHODS: We conducted a prospective descriptive study spread over six months about patients hospitalized and operated on for proximal femur fractures. In order to estimate the cost we referred to the nomenclature of professional acts and the prices set by the Ministry of Public Health and the Ministry of Finance. RESULTS: The study included 100 patients, 55 females and 45 males with an average age of 76 years. The average hospital length of stay was 5 days. The preoperative stay was at a mean of three days. The average total hospitalization cost for these fractures was 2877 Tunisian Dinars depending on the type of fracture and surgical treatment. The main components of the costs were hospital stay costs and human resources costs 40%, cost of the implant 25.9%, cost of consumables 12%, operating cost 10%, cost of additional examinations 9% and cost of medications 2%. CONCLUSION: Proximal femur fractures represent an important cause of health resource consumption. To reduce the cost of hospital care, we recommend limiting the length of hospital stay as much as possible, investing in total hip and hemi-arthroplasties and adapting economical behavior taking into account the cost of consumables.

Factors associated with increased radiation exposure in the fixation of proximal femoral fractures.

INTRODUCTION: When using radiation intraoperatively, a surgeon should aim to keep the radiation dose as low as is reasonably achievable to obtain the therapeutic goal. We aimed to investigate factors associated with increased radiation exposure in fixation of proximal femur fractures. METHODS: We assessed 369 neck of femur fractures over a 1-year period in a district general hospital. All hip fracture subtypes that had undergone surgical fixation were included. We assessed the relationship between type of fracture, implants used and surgeon level of experience with the dose-area product (DAP; cGy/cm2) and screening time (dS). We also looked at the quality of reduction and fixation and its effect on the radiation exposure. RESULTS: A total of 184 patients were included in our analysis; 185 patients who were treated with hip arthroplasty were excluded. There was a significant association between higher DAP and fracture subtype (p = 0.001), fracture complexity (p < 0.001), if an additional implant was used (p = 0.001), if fixation was satisfactory (p = 0.002) and operative time (p < 0.001). DAP was higher with a proximal femoral nail than with a dynamic hip screw, especially when a long nail was used. There was some evidence of an association between the surgeon's level of experience and DAP exposure, although this was not statistically significant (p = 0.069). CONCLUSIONS: Increased radiation in proximal femur fractures is seen in the fixation of complex fractures, some subtypes, with certain types of implants used and if an additional implant was required. Surgeon seniority did not result in less radiation exposure, which is in contrast to other published studies.

ORTHOPOD: Linking ambulatory future trauma injury distribution from fragility proximal femur fracture caseload.

INTRODUCTION: The age of those experiencing traumatic injury and requiring surgery increases. The majority of this increase seen in older patients having operations after accidents is in fragility proximal femur fractures (FPFF). This study designed a model to predict the distribution of fractures suitable for ambulatory trauma list provision based on the number of FPFF patients. METHODS: The study utilized two datasets which both had data from 64 hospitals. One derived from the ORTHOPOD study dataset, and the other from National Hip Fracture Database. The model tested the predictability of 12 common fracture types based on FPFF data from the two datasets, using linear regression and K-fold cross-validation. RESULTS: The predictive model showed some promise. Evaluation of the model with mean RMSE and Std RMSE demonstrated good predictive performance for some fracture types, although the r-squared values showed that large variation in these fracture types was not always captured by the model. The study highlighted the dominance of FPFFs, and the strong correlation between these and numbers of ankle and distal radius fractures at a given unit. DISCUSSION: It is possible to model the numbers of ankle and distal radius fractures based off the number of patients admitted with hip fractures. This has great significance given the drive for increased day case utilisation and bed pressures across health services. While the model's current predictability was limited, with methodological improvements and additional data, a more robust predictive model could be developed to aid in the restructuring of trauma networks and improvement of patient care and surgical outcomes.

Outcomes of conversion total hip arthroplasty for failed fixation of intertrochanteric fractures with monoblock distal-loading reconstruction stem.

PURPOSE: The aim of our study was to analyze the clinical and radiological outcomes of conversion total hip arthroplasty (THA) for failed fixation of proximal femur fractures with monoblock grit-blasted titanium reconstruction stem (Wagner self-locking stem, Zimmer). PATIENTS AND METHODS: Thirty-nine patients were included in this retrospective analysis undergoing conversion THA for failed cephalomedullary nail or dynamic hip screw fixation for intertrochanteric fractures from January 2017 to January 2022. The clinical evaluation was done using Harris hip score. The radiological outcomes measured were subsidence, level of osteointegration, stem-canal fill ratio and heterotopic bone formation. The complications were noted postoperatively and during the follow-up. RESULTS: The mean follow-up at the end of the study was 27.8 months (range, 14-72 months). There was a significant improvement in the Harris hip score over serial follow-ups (p < 0.001), but after 2 years, there was no statistically significant difference (p = 0.46). According to Engh's criteria, stable ingrowth was noted in 35 stems, fibrous stable ingrowth was noted in 4 stems and no patients had progressive subsidence and unstable stem. The mean stem-canal fill percentages were 91.8 ± 5.4% at the mid-stem and 80.3 ± 11.5% at the stem tip. Heterotopic ossification Brooker grade 2 was noted in 8 patients, and no patients had grade 3 or 4 heterotopic ossification. There were 7 (17.9%) intraoperative periprosthetic fractures, and greater trochanteric avulsion was noted in 2 patients in the follow-up. CONCLUSION: Conversion THA using monoblock tapered distal loading stems bypasses the calcar deficiency and gives stable fixation in failed fixation of intertrochanteric fractures. It gives good radiological outcome and significant improvement in the clinical outcomes compared to the preoperative disability. However, caution should be noted for risk of intraoperative periprosthetic fractures in this subgroup of patients.

Outcome of early versus delayed presentation of proximal femur fractures in children: A prospective cohort study.

OBJECTIVE: We hypothesized that the exact time of fixation of paediatric proximal femur fractures will have an effect on the ultimate clinical and radiological outcome. This article aimed to compare the clinical-radiological outcomes in paediatric proximal femur fractures having early and delayed presentation. METHODOLOGY: A prospective cohort study was conducted from January 2019 to November 2022 in patients of age of 5 to 16 years presented with proximal femur fracture and divided into two groups: group A: early presentation, presented <48hours of injury; group B: delayed presentation, presented >48hours of injury. Patients underwent internal fixation treatment modality and followed up to assess clinical outcomes and radiological outcomes, and final outcome was assessed as per Ratliff's criteria. RESULTS: In the study of 44 patients, 72.72% were male, and 27.27% were female, with male-to-female ratio to be 2.6:1. The commonest mode of injury was fall from height accounting for 52.27% followed by road traffic accidents (RTA) in 38.63%. The most common fracture type observed was Delbet type II, which was observed in 43.18%. There was significant shorter duration of surgery in group A (p-value=0.013), VAS score (p=0.045), and limb length discrepancy (p=0.022). Also, there was a statistical difference in AVN (p-value=0.0295) and growth disturbance (p-value=0.0394) between two groups. Also, there was statistically significant difference between Ratliff's criteria two groups (p-value=0.030). CONCLUSION: Early presentation has shorter duration of surgery, less VAS score at final follow-up, and less limb length discrepancy, less development of complications like avascular necrosis of the femoral head, and growth disturbance. LEVEL OF EVIDENCE: III.

Is Regional Bone Mineral Density the Differentiating Factor Between Femoral Neck and Femoral Trochanteric Fractures?

Background Osteoporosis is globally recognized as a prevalent bone disease, and proximal femoral fractures constitute a serious complication associated with it. In recent years, the frequency of hip fractures has increased rapidly, with ramifications that extend into the social and economic aspects of both patients' lives and healthcare systems. The primary goal of this study is to discover whether bone mineral density (BMD) in specific regions of the hip could be related to femoral neck or trochanteric fractures. Methodology This prospective cohort study employed dual-energy X-ray absorptiometry (DEXA) measurements on 70 individuals with proximal femoral fractures. The participants sought treatment at the emergency department of our unit for hip fractures and adhered to our predefined eligibility criteria. These criteria primarily included (i) age exceeding 60 years and (ii) a diagnosis of either femoral neck or trochanteric fracture attributed to (iii) a low-energy lateral fall and (iv) a previously established state of complete ambulation before the occurrence of the fracture. In this context, we recorded the BMD of the hip, as well as the BMD values of the upper and lower halves of the neck, trochanteric region, and diaphysis. For the comparison of the categorical variables, Pearson's χ2 criterion was used, whereas Student's t-test was applied for the comparison of means of quantitative variables across fracture types. Results No statistical differences were identified when comparing regional BMDs and T-scores with the fracture type. This conclusion was also reconfirmed concerning age, gender, and Tonnis classification. Only a moderate correlation was observed, demonstrating lower values of regional BMDs in women compared to men. Conclusions The inability of our study to establish a direct correlation between BMD measurements across diverse areas of the proximal femur underlines the imperative need for subsequent investigations. These studies should not only integrate more precise techniques for measuring and mapping the BMD of different hip regions but should also encompass a comprehensive examination that would consider both intrinsic and extrinsic characteristics of the proximal femur.

Effect of operative time in outcomes following surgical fixation of hip fractures: a multivariable regression analysis of 35,710 patients.

BACKGROUND: Prolonged operative time is a risk factor for increased morbidity and mortality after open reduction and internal fixation (ORIF) of hip fractures. However, the quantitative nature of such association, including graduated risk levels, has yet to be described. This study outlines the graduated associations between operative time and (1) healthcare utilisation, and (2) 30-day complications after ORIF of hip fractures. METHODS: The National Surgical Quality Improvement Program (NSQIP) database was queried (January 2016-December 2019) for all patients who underwent ORIF of hip fractures (n = 35,710). Demographics, operative time, fracture type, and comorbidities were recorded. Outcomes included healthcare utilisation (e.g., prolonged length of stay [LOS>2 days], discharge disposition, 30-day readmission, and reoperation), inability to weight-bear (ITWB) on postoperative day-1 (POD-1), and any 30-day complication. Adjusted multivariate regression models evaluated associations between operative time and measured outcomes. RESULTS: Operative time <40 minutes was associated with lower odds of prolonged LOS (odds ratio [OR] 0.77), non-home discharge (OR 0.85), 30-day readmission (OR 0.85), and reoperation (OR 0.72). Operative time ⩾80 minutes was associated with higher odds of ITWB on POD-1 (OR 1.17). Operative time ⩾200 minutes was associated with higher odds of deep infection (OR 7.5) and wound complications (OR 3.2). The odds of blood transfusions were higher in cases ⩾60 minutes (OR1.3) and 5-fold in cases ⩾200 minutes (OR 5.4). The odds of venous thromboembolic complications were highest in the ⩾200-minute operative time category (OR 2.5). Operative time was not associated with mechanical ventilation, pneumonia, delirium, sepsis, urinary tract infection, or 30-day mortality. DISCUSSION: Increasing operative time is associated with a progressive increase in the odds of adverse outcomes following hip fracture ORIF. While a direct cause-effect relationship cannot be established, an operative time of <60 minutes could be protective. Perioperative interventions that shorten operative time without compromising fracture reduction or fixation should be considered.

Micro-Structural and Biomechanical Evaluation of Bioresorbable and Conventional Bone Cements for Augmentation of the Proximal Femoral Nail.

Osteoporotic proximal femur fractures are on the rise due to demographic change. The most dominant surgical treatment option for per/subtrochanteric fractures is cephalomedullary nailing. As it has been shown to increase primary stability, cement augmentation has become increasingly popular in the treatment of osteoporotic per/subtrochanteric femur fractures. The ultimate goal is to achieve stable osteosynthesis, allowing for rapid full weight-bearing to reduce possible postoperative complications. In recent years, bioresorbable bone cements have been developed and are now mainly used to fill bone voids. The aim of this study was to evaluate the biomechanical stability as well as the micro-structural behaviour of bioresorbable bone cements compared to conventional polymethylmethacrylate (PMMA)-cements in a subtrochanteric femur fracture model. Biomechanical as well as micro-computed tomography morphology analysis revealed no significant differences in both bone cements, as they showed equal mechanical stability and tight interdigitation into the spongious bone of the femoral head. Given the positive risk/benefit ratio for bioresorbable bone cements, their utilisation should be evaluated in future clinical studies, making them a promising alternative to PMMA-bone cements.

Value of Proximal Femur Geometry in Predicting Occult Hip Fracture.

Background and Objectives: Patients with occult hip fractures are a difficult subgroup to treat. MRI is the gold standard for diagnosing occult proximal femur fractures but is costly and may not be readily available in an emergency setting. The purpose of this study was to determine whether changes in the proximal femur geometry can predict the likelihood of an occult hip fracture in patients presenting with hip pain following a ground-level fall. Material and Methods: Patients admitted to the hospital with a clinical suspicion of a hip fracture but initial negative radiographs over a seven-year period were included. All patients were additionally investigated with an MRI scan, and retrospectively, six radiologic parameters were obtained on plain radiographs: The cortical thickness index (CTI), the canal to calcar ratio (CCR), the canal flare index (CFI), the morphological cortical index (MCI), the canal bone ratio (CBR) and the canal bone aria ratio (CBAR). Subsequently the result of the plain radiographic indices of the patients with a negative MRI (Group A, no occult fracture) were compared to those with a positive MRI (Group B, occult fracture). Results: A total of 78 patients (59 female, 19 male) could be included in the study. The mean age was 82 years. The univariate analyses revealed a poor predictive ability of all radiological parameters with AUC values ranging from 0.515 (CBR) to 0.626 (CTI), whereas a multivariate prognostic model demonstrated improved prognosis (AUC = 0.761) for the CTI (p = 0.024), CBAR (p = 0.074) and CRR (p = 0.081) as the most promising predictive radiological parameters. Conclusions: Single radiologic indices obtained from conventional X-rays of the proximal femur have a weak predictive value in detecting occult fractures of the hip and cannot be used as clinical decision-making factors.

Intraosseous Retrieval of Broken Guide Wire while Fixing Proximal Femur Fractures - A Report of 2 Cases and Review of Literature.

Introduction: Hardware breakage during surgery is a known risk that may result in serious complications. Drill bits and guide wires are particularly prone to breakage, and if not promptly recognized and removed, can cause damage to intrapelvic structures, or may lead to hip arthritis later. Herein, we present two cases in which broken guide wire fragments were safely retrieved through the same incision, resulting in good outcomes and reduced morbidity. Case Report: In the first case, a broken guide wire piece that had been pushed into the hip joint during intertrochanteric fracture surgery was retrieved using disc forceps after reaming over the same guide tract. In the second case, the broken tip of a partially withdrawn guide wire was removed from a transcervical femur fracture using a cannulated drill bit. Conclusion: Our approach highlights the importance of attempting retrieval of broken hardware through the same tract using unconventional instruments, such as disc forceps, before resorting to more invasive methods, such as arthrotomy or separate incisions. These cases demonstrate the feasibility of this approach and its potential to reduce morbidity associated with hardware retrieval.

Ipsilateral proximal and shaft femoral fractures: Results of two treatment strategies / Fracturas ipsilaterales proximales y diafisarias del fémur: resultados de 2 estrategias de tratamiento

Introduction: Ipsilateral proximal and shaft femoral fractures typically occur in young adults after high-energy trauma. No consensus exists regarding the optimal internal fixation device or surgical strategy for these complex fractures. Our main objective is to identify differences on outcomes and complications between patients treated with one or combined implants. Material and method: This is a single-center retrospective cohort study in patients with associated fractures of the proximal (31 AO) and shaft femur (32 AO). We divided the patients into two groups according to the use of single (Group I) or combined implants (Group II). Demographic, clinical, radiological, surgical data and development of complications were collected.Results: We identified 28 patients (19 men and 9 women) with an average age of 43 years. We used an anterograde femoral nail in group I (17 patients) and a retrograde femoral nail or a plate associated with hip lag screws or sliding hip screw in Group II (11 patients). Patients were followed up for 26.28 (9.12–62.88) months. Osteonecrosis of the femoral head, osteoarthritis, infection or nonunion was found in 9 patients (32%). No significant differences (p 0.70) were found in complications between two groups or between definitive surgical fixation before or after the first 24h. Conclusions: No differences in the development of complications or timing of definitive fixation were found between the use of one or combined implants in ipsilateral proximal femur and shaft fractures. Regardless of the implant chosen, an appropriate osteosynthesis technique is crucial, even so high complication rates are expected.

Introducción: Las fracturas ipsilaterales proximales y diafisarias del fémur suelen ocurrir en adultos jóvenes después de un traumatismo de alta energía. No existe consenso sobre el dispositivo de fijación interna óptimo o la estrategia quirúrgica para estas fracturas complejas. Nuestro principal objetivo es identificar las diferencias en los resultados y complicaciones entre los pacientes tratados con un implante o combinados. Material y método: Este es un estudio de cohorte retrospectivo unicéntrico en pacientes con fracturas asociadas del fémur proximal (31 AO) y diafisarias (32 AO). Dividimos a los pacientes en 2 grupos según el uso de implantes únicos (grupo i) o combinados (grupo ii). Se recogieron datos demográficos, clínicos, radiológicos, quirúrgicos y complicaciones. Resultados: Se identificaron 28 pacientes (19 hombres y 9 mujeres) con una edad promedio de 43 años. Utilizamos un clavo femoral anterógrado en el grupo i (17 pacientes) y un clavo femoral retrógrado o una placa con tornillos a compresión o tornillo deslizante de cadera en el grupo ii (11 pacientes). Los pacientes fueron seguidos durante 26,28 (9,12-62,88) meses. Se encontró osteonecrosis de la cabeza femoral, osteoartritis, infección o seudoartrosis en 9 pacientes (32%). No se encontraron diferencias significativas (p=0,70) en las complicaciones entre los 2 grupos o entre la fijación quirúrgica definitiva antes o después de las primeras 24h. Conclusiones: No se encontraron diferencias en el desarrollo de complicaciones o el momento de la fijación definitiva entre el uso de un implante o combinado en fracturas ipsilaterales de fémur proximal y diafisario. Independientemente del implante elegido, una técnica de osteosíntesis adecuada es crucial; aun así son esperables altas tasas de complicaciones.(AU)

[Artículo traducido] Fracturas ipsilaterales proximales y diafisarias del fémur: resultados de dos estrategias de tratamiento / Ipsilateral proximal and shaft femoral fractures: Results of two treatment strategies

Introduction: Ipsilateral proximal and shaft femoral fractures typically occur in young adults after high-energy trauma. No consensus exists regarding the optimal internal fixation device or surgical strategy for these complex fractures. Our main objective is to identify differences on outcomes and complications between patients treated with one or combined implants. Material and method: This is a single-center retrospective cohort study in patients with associated fractures of the proximal (31 AO) and shaft femur (32 AO). We divided the patients into two groups according to the use of single (Group I) or combined implants (Group II). Demographic, clinical, radiological, surgical data and development of complications were collected.Results: We identified 28 patients (19 men and 9 women) with an average age of 43 years. We used an anterograde femoral nail in group I (17 patients) and a retrograde femoral nail or a plate associated with hip lag screws or sliding hip screw in Group II (11 patients). Patients were followed up for 26.28 (9.12–62.88) months. Osteonecrosis of the femoral head, osteoarthritis, infection or nonunion was found in 9 patients (32%). No significant differences (p 0.70) were found in complications between two groups or between definitive surgical fixation before or after the first 24h. Conclusions: No differences in the development of complications or timing of definitive fixation were found between the use of one or combined implants in ipsilateral proximal femur and shaft fractures. Regardless of the implant chosen, an appropriate osteosynthesis technique is crucial, even so high complication rates are expected.

Introducción: Las fracturas ipsilaterales proximales y diafisarias del fémur suelen ocurrir en adultos jóvenes después de un traumatismo de alta energía. No existe consenso sobre el dispositivo de fijación interna óptimo o la estrategia quirúrgica para estas fracturas complejas. Nuestro principal objetivo es identificar las diferencias en los resultados y complicaciones entre los pacientes tratados con un implante o combinados. Material y método: Este es un estudio de cohorte retrospectivo unicéntrico en pacientes con fracturas asociadas del fémur proximal (31 AO) y diafisarias (32 AO). Dividimos a los pacientes en 2 grupos según el uso de implantes únicos (grupo i) o combinados (grupo ii). Se recogieron datos demográficos, clínicos, radiológicos, quirúrgicos y complicaciones. Resultados: Se identificaron 28 pacientes (19 hombres y 9 mujeres) con una edad promedio de 43 años. Utilizamos un clavo femoral anterógrado en el grupo i (17 pacientes) y un clavo femoral retrógrado o una placa con tornillos a compresión o tornillo deslizante de cadera en el grupo ii (11 pacientes). Los pacientes fueron seguidos durante 26,28 (9,12-62,88) meses. Se encontró osteonecrosis de la cabeza femoral, osteoartritis, infección o seudoartrosis en 9 pacientes (32%). No se encontraron diferencias significativas (p=0,70) en las complicaciones entre los 2 grupos o entre la fijación quirúrgica definitiva antes o después de las primeras 24h. Conclusiones: No se encontraron diferencias en el desarrollo de complicaciones o el momento de la fijación definitiva entre el uso de un implante o combinado en fracturas ipsilaterales de fémur proximal y diafisario. Independientemente del implante elegido, una técnica de osteosíntesis adecuada es crucial; aun así son esperables altas tasas de complicaciones.(AU)

Trans-Table Intraoperative Fluoroscopic Technique for Obtaining a True Lateral View of the Proximal Femur in the Lateral Decubitus Position.

The management of proximal femoral fractures, especially comminuted subtrochanteric ones, poses a surgical challenge. It is relatively easier to perform the open reduction of these fractures in the lateral position on a standard radiolucent table, but obtaining an accurate lateral view of the femoral head and neck remains difficult. This study presents a method that overcomes the limitations of fluoroscopy in the lateral decubitus position and improves the accuracy of obtaining a true lateral view. The technique involves positioning the patient in the lateral decubitus position with the unaffected hip flexed at a 45° angle. Additionally, the C-arm is tilted 30-35° cephalad, eliminating the need for position changes or leg manipulation. This method reduces the risk of losing reduction, particularly in cases involving obese patients or complex fractures. By simplifying proximal femur fixation in the lateral decubitus position, this technique can potentially improve patient outcomes.