Gamma3 nail with U-Blade (RC) lag screw is effective with better surgical outcomes in trochanteric hip fractures.

The objective of this retrospective study was to investigate the surgical outcomes of AO/OTA 31 A1-3 trochanteric fractures treated with the new-generation Gamma3 nail with U-Blade (RC) lag screw and to analyze the risk factors related to fixation failure. A total of 318 consecutive patients who underwent cephalomedullary nailing using Gamma3 nail with U-Blade lag screw for trochanteric hip fractures between September 2015 and June 2018 were enrolled. The average age was 80 years and most patients (69%) were women. The mean follow-up was 12.2 months with a minimum of 6 months. 309 (97.2%) showed bony union with a mean time to union of 13.5 ± 8.7 weeks. Cut-out occurred in 2 patients (0.6%) and 7 patients showed excessive collapse (≥15 mm) of the proximal fragment. These 9 patients were assigned to the failure group. The presence of a basicervical fracture component and comminution of the anterior cortex on preoperative 3-D CT showed a significant association with fixation failure, including cut-out, although comminution of the anterior cortex was the only independent risk factor for fixation failure on multivariate logistic regression analysis. Gamma3 nail with U-Blade lag screw showed favorable results for trochanteric hip fractures, with low cut-out rate (0.6%). However, more caution is required in treating trochanteric fractures with a basicervical fracture component and anterior cortex comminution even with this nail.

Effect of fracture levels on the strength of bone-implant constructs in subtrochanteric fracture models fixed using short cephalomedullary nails: A finite element analysis.

OBJECTIVES: This study was conducted to investigate the stress around nails and cortical bones in subtrochanteric (ST) fractures fixed using short cephalomedullary nails (CMNs) in finite element models (FEMs) and to determine the appropriate short CMN type for different fracture levels. METHODS: The following three types of short CMNs were used: type A, which is 170 mm in length and has 1 distal locking screw; type B, 200 mm in length and 1 distal screw; and type C, 200 mm in length and 2 distal screws. A total of 24 FEMs were tested on a transverse ST fracture at 8 levels [0, 10, 20, 25, 30, 35, 40 and 50 mm below the lower margin of lesser trochanter (LT)], and were fixed using 3 different CMN types. Finite element analysis was then performed to evaluate the stress around the cortical bones and the CMNs under the assumption of anatomical reduction and fracture gap of 1 mm. RESULTS: Peak von Mises stress (PVMS) was greatest on the cortical bone around the distal screw hole and was greater than the yield strength at fracture levels ≥ 35 mm below the LT in FEMs fixed with type A and B. In contrast, FEMs fixed with type C showed PVMS less than the yield strength at all fracture levels. The PVMS within the implant was greater than the yield strength at the junction of the nail with the distal screw and distal screw itself at fracture levels ≥ 35 mm below the LT in FEMs fixed using type A. Conversely, in FEMs fixed using type B and C, all PVMSs within the implant were less than the yield strength, regardless of the fracture level. CONCLUSION: Short CMNs 170 or 200 mm in length with 1 distal screw may be used in a limited manner in high ST transverse fractures under the assumptions of anatomical reduction and fracture gap ≤ 1 mm. Meanwhile, short CMN 200 mm in length with 2 distal screws may be an available treatment option in most of ST transverse fractures regardless of the fracture level under the same set of assumptions.

Topical tranexamic acid in elderly patients with femoral neck fractures treated with hemiarthroplasty: efficacy and safety? - a case-control study.

BACKGROUND: Perioperative blood management is an important issue in the treatment of elderly patients at an increased risk of postoperative complications. Accordingly, tranexamic acid (TXA) is widely administered to reduce blood loss and transfusion requirements. In this case-control study, the effect of topical TXA on the outcomes of elderly patients with femoral neck fractures after hemiarthroplasty was evaluated. METHODS: This study enrolled elderly patients (age ≥ 70 years) who underwent cementless bipolar hemiarthroplasty for femoral neck fractures between January 2015 and January 2017. The study group comprised 72 patients who received TXA via topical administration during surgery. After propensity matching, the control group comprised 72 patients who did not receive topical TXA. The perioperative and postoperative parameters of the two groups were compared. RESULTS: The estimated blood loss, vacuum tube drainage, and total transfusion volume were significantly lower in the study group than the control (p = 0.024, 0.003, and 0.019, respectively). Despite a lack of significant intergroup differences in the lengths of ICU and hospital stays; rates of ICU admission, venous thromboembolism, delirium, and readmission; and rates of in-hospital and 1-year mortality, the incidence of postoperative medical complications was significantly lower in the study group (p = 0.003). CONCLUSION: Topical TXA administration appears to be a simple and effective option for reducing blood loss, transfusion requirements, and medical complications after hemiarthroplasty in elderly patients with femoral neck fractures.

Perioperative antiplatelet in elderly patients aged over 70 years treated with proximal femur fracture: continue or discontinue?

BACKGROUND: Antiplatelet medication has been frequently performed in elderly patients with hip fracture, because of comorbidities. This observational cohort study was to evaluate the effect of continuous perioperative antiplatelet medication on the outcomes after cephalomedullary nailing (CMN) in elderly patients with a proximal femur fracture. METHODS: One hundred and sixty-two consecutive patients aged ≥70 years undergoing CMN for proximal femur fracture between January 2015 and January 2017 were recruited. Of the 162 patients, 47 (study group) taking antiplatelets preoperatively due to comorbidities were compared with 107 (control group) who were not on antiplatelets. 8 patients taking anticoagulant medication were excluded. Postoperative hemoglobin (Hb) and hematocrit (Hct) levels, transfusion amount and estimated blood loss (EBL), occurrence of venous thromboembolism (VTE) and delirium, intensive care unit (ICU) admission, complications, length of hospital stay, readmission, and in-hospital and 1-year mortalities were measured and compared between the two groups. RESULTS: A higher number of patients in the study group had concomitant cardiovascular (p = 0.006) and endocrinologic (p = 0.004) diseases, received perioperative transfusion (p = 0.003), and were admitted to ICU postoperatively (p = 0.014). However, there were no significant differences in postoperative Hb and Hct levels, EBL, length of hospital stay, and the incidences of VTE and delirium between the two groups. In addition, in-hospital and 1-year mortalities as well as postoperative complications showed no significant differences between both groups. CONCLUSIONS: CMN can be performed without delay in elderly patients with proximal femoral fracture receiving antiplatelet therapy prior to admission without discontinuing antiplatelets, and is as safe as in patients who are not on antiplatelet medication. However, more caution is required with respect to transfusions and ICU care after surgery in these patients.

Management of anteromedially displaced acetabular fractures using a collinear reduction clamp through modified ilioinguinal approach.

The authors present a surgical technique using a collinear reduction clamp through the modified ilioinguinal approach (MIA) for anteromedially displaced acetabular fractures along with the surgical outcomes. Between October 2010 and June 2015, 15 patients underwent surgical treatment for anteromedially displaced acetabular fractures; 10 both-column fractures and 5 anterior column and posterior hemitransverse fractures. Anteriorly displaced anterior column fragment and medially displaced quadrilateral plate fragment were simultaneously reduced using a collinear clamp and fixed with a 3.5mm-reconstruction plate through MIA. Postoperatively, anatomical reduction was achieved in 12 patients, while imperfect reduction was achieved in 3. At a mean follow-up of 49.0 months (range, 24-93 months), the mean Postel Merle d'Aubigné score were 16.3 and the mean VAS score was 0.9. Final radiographic grades according to Matta system were excellent in 13 patients and good in 2. Surgical technique using a collinear reduction clamp through the MIA can provide satisfactory outcomes in anteromedially displaced acetabular fractures.

Biomechanical Comparison of Three Different Intramedullary Nails for Fixation of Unstable Basicervical Intertrochanteric Fractures of the Proximal Femur: Experimental Studies.

OBJECTIVES: This biomechanical study was conducted to compare fixation stability of the proximal fragments and their mechanical characteristics in proximal femur models of unstable basicervical IT fractures fixed by cephalomedullary nailing using 3 different types of the femoral head fixation. METHODS: A total of 36 composite femurs corresponding to osteoporotic human bone were used. These specimens were fixed with Gamma 3 (hip screw type; group 1) in 12, Gamma 3 U-blade (screw-blade hybrid type; group 2) in 12, and proximal femoral nail antirotation-II (helical blade type; group 3) in 12, respectively, and an unstable basicervical IT fracture was created by an engraving machine. After preloading and cyclic loading, the migration of the proximal fragment according to 3 axes was assessed by the stereophotogrammetric method and the migration of screw or blade tip within the femoral head was measured radiographically. Next, the vertical load was continued at a speed of 10 mm/min until the construct failure occurred. Finite element analysis was additionally performed to measure the stress and compressive strain just above the tip of screw or blade within the femoral head. RESULTS: The rotational change of the proximal fragment according to the axis of screw or blade was much greater in group 1 than in groups 2 and 3 (p=0.016 and p=0.007, respectively). Varus collapse was greater in group 3 than in group 2 (p=0.045). Cranial and axial migration of screw or blade within the femoral head were significantly greater in group 3 than in both group 1 (p=0.001 and p=0.002, respectively) and group 2 (p=0.002 and p=0.016, respectively). On finite element analysis, group 3 showed the highest peak von-Mises stress value (13.3 MPa) and compressive strain (3.2%) just above the tip of the blade within the femoral head. Meanwhile, groups 1 and 2 showed similar results on two values. CONCLUSIONS: Screw-blade hybrid type and blade type would be more effective in minimizing rotation instability of the proximal fragment in unstable basicervical IT fractures. However, varus collapse of the proximal fragment and cranial and axial migration within the femoral head were greater with blade type than screw-blade hybrid type.