Trochanteric stabilizing plate in the treatment of trochanteric fractures: a scoping review.

Background and purpose - The trochanteric stabilizing plate (TSP) may be used as an adjunct to a sliding hip screw (SHS) in the treatment of trochanteric fractures to increase construct stability. We performed a scoping review of the literature to clarify when and how the TSP may be useful.Methods - A systematic search was performed in 5 databases and followed by a backwards-and-forwards citation search of the identified papers. 24 studies were included.Results - 6 biomechanical studies and 18 clinical studies were included in the review. The studies presented mainly low-level evidence. All studies were on unstable trochanteric fractures or fracture models. Due to the heterogeneity of methods and reporting, we were not able to perform a meta-analysis. In the biomechanical trials, the TSP appeared to increase stability compared with SHS alone, up to a level comparable with intramedullary nails (IMNs). We identified 1,091 clinical cases in the literature where a TSP had been used. There were 82 (8%) reoperations. The rate of complications and reoperations for SHS plus TSP was similar to previous reports on SHS alone and IMN. It was not possible to conclude whether the TSP gave better clinical results, when compared with either SHS alone or with IMN.Interpretation - The heterogeneity of methods and reporting precluded any clear recommendations on when to use the TSP, or if it should be used at all.

Improved outcome after hip fracture surgery in Norway.

Background and purpose - The operative treatment of hip fractures in Norway has changed considerably during the last decade. We used data in the Norwegian Hip Fracture Register to investigate possible effects of these changes on reoperations and 1-year mortality. Patients and methods - 72,741 femoral neck (FFN) fractures and trochanteric fractures in patients 60 years or older were analyzed. The fractures were divided into 5 time periods (2005-2006, 2007-2008, 2009-2010, 2011-2012, 2013-2014). Cox regression models were used to calculate unadjusted and adjusted (age group, sex, and ASA class) relative risks (RRs) of reoperation and of 1-year mortality in the different time periods. Results - For undisplaced FFNs treatment with hemiarthroplasty increased from 2.1% to 9.7% during the study period. For displaced FFNs treatment with arthroplasty increased from 56% to 93%. The use of intramedullary nails increased from 9.1% to 26% for stable 2-fragment (AO/OTA A1) trochanteric fractures, from 15% to 33% for multifragment (AO/OTA A2) trochanteric fractures, and from 27% to 61% for intertrochanteric fractures (AO/OTA A3)/subtrochanteric fractures. Compared with the first time period the adjusted 1-year RR for reoperation was 0.43 (95% CI: 0.37-0.49) for displaced FFNs in the last time period. The adjusted 1-year mortality in the last time period was lower for all fractures (RR: 0.87 (0.83-0.91)), displaced FFNs (RR: 0.86 (0.80-0.93)), AO/OTA A1 trochanteric fractures (RR: 0.79 (0.71-0.88)), and AO/OTA A2 trochanteric fractures (RR: 0.87 (0.77-0.98)) when compared with the first study period. Interpretation - Hip fracture treatment in Norway has improved: The risk of reoperation and the 1-year mortality after displaced femoral neck fractures have decreased over a 10-year period. National registration is useful to monitor trends in treatment and outcomes after hip fractures.

Evaluation of Timed Up and Go Test as a tool to measure postoperative function and prediction of one year walking ability for patients with hip fracture.

OBJECTIVE: To evaluate if the Timed Up and Go Test is a useful tool to measure postoperative function and to predict one-year results of rehabilitation in patients operated owing to hip fracture. DESIGN: Prospective cohort study. SETTING: The department of orthopaedic surgery at five hospitals in Norway. Patients were assessed five days postoperatively and after one year. SUBJECTS: A total of 684 patients over 60 years with trochanteric or subtrochanteric hip fractures were included. A total of 171 (25%) patients died within a year and 373 (73% of patients still alive) attended follow-up one year after surgery. MAIN MEASURES: Timed Up and Go Test and walking ability. RESULTS: A total of 258 (38%) patients passed the postoperative Timed Up and Go Test. A total of 217 (56%) patients with a prefracture independent outdoor walking ability, passed the test. The average Timed Up and Go Test score was 71 seconds. A total of 171 (25%) patients could not rise from a chair without assistance; 8% of the patients with cognitive impairment, and 8% of those admitted from nursing homes, were able to pass the postoperative Timed Up and Go Test. The sensitivity and specificity of the Timed Up and Go Test in predicting walking ability one year after the operation were low. At one year follow-up, 38% of the patients not able to perform the postoperative Timed Up and Go Test, passed the test. A total of 81 (21%) patients did not use any walking-aid, 17 of them did not pass the postoperative Timed Up and Go Test. CONCLUSION: The Timed Up and Go Test performed the fifth postoperative day was not a suitable tool to assess functional mobility for the majority of the patients with hip fractures in our study. Neither was the postoperative Timed Up and Go Test a suitable tool to predict the walking ability one year after the operation.

Equivalent mortality after operation with sliding hip screw or intramedullary nail for trochanteric AO/OTA A1 and A2 fractures reported in the Norwegian Hip Fracture Register 2008 to 2020.

Aims: This study aimed to compare mortality in trochanteric AO/OTA A1 and A2 fractures treated with an intramedullary nail (IMN) or sliding hip screw (SHS). The primary endpoint was 30-day mortality, with secondary endpoints at 0 to 1, 2 to 7, 8 to 30, 90, and 365 days. Methods: We analyzed data from 26,393 patients with trochanteric AO/OTA A1 and A2 fractures treated with IMNs (n = 9,095) or SHSs (n = 17,298) in the Norwegian Hip Fracture Register (January 2008 to December 2020). Exclusions were made for patients aged < 60 years, pathological fractures, pre-2008 operations, contralateral hip fractures, fractures other than trochanteric A1/A2, and treatments other than IMNs or SHSs. Kaplan-Meier and Cox regression analyses adjusted for type of fracture, age, sex, cognitive impairment, American Society of Anesthesiologists (ASA) grade, and time period were conducted, along with calculations for number needed to harm (NNH). Results: In unadjusted analyses, there was no significant difference between IMN and SHS patient survival at 30 days (91.8% vs 91.1%; p = 0.083) or 90 days (85.4% vs 84.5%; p = 0.065), but higher one-year survival for IMNs (74.5% vs 73.3%; p = 0.031) compared with SHSs. After adjustments, no significant difference in 30-day mortality was found (hazard rate ratio (HRR) 0.94 (95% confidence interval (CI) 0.86 to 1.02(; p = 0.146). IMNs exhibited higher mortality at 0 to 1 days (HRR 1.63 (95% CI 1.13 to 2.34); p = 0.009) compared with SHSs, with a NNH of 556, but lower mortality at 8 to 30 days (HRR 0.89 (95% CI 0.80 to 1.00); p = 0.043). No differences were observed in mortality at 2 to 7 days (HRR 0.94 (95% CI 0.79 to 1.11); p = 0.434), 90 days (HRR 0.95 (95% CI 0.89 to 1.02); p = 0.177), or 365 days (HRR 0.97 (95% CI 0.92 to 1.02); p = 0.192). Conclusion: This study found no difference in 30-day mortality between IMNs and SHSs. However, IMNs were associated with a higher mortality at 0 to 1 days and a marginally lower mortality at 8 to 30 days compared with SHSs. The observed differences in mortality were small and should probably not guide choice of treatment.

Intramedullary nails result in more reoperations than sliding hip screws in two-part intertrochanteric fractures.

BACKGROUND: Sliding hip screws (SHSs) and intramedullary (IM) nails are well-documented implants for simple two-part intertrochanteric fractures; however, there is no consensus regarding which type of implant is better. QUESTIONS/PURPOSES: We asked whether patients with simple two-part intertrochanteric fractures treated with IM nailing had (1) a lower reoperation rate and (2) less pain and better quality of life than patients treated with SHSs. METHODS: We used data from the Norwegian Hip Fracture Register on 7643 operations for simple two-part intertrochanteric fractures (AO/OTA Type A1) treated with an SHS (n=6355) or an IM nail (n=1288) between 2005 and 2010. Kaplan-Meier analysis was used to assess reoperation percentages and a Cox regression model was used to assess the risk of reoperation. Questionnaires regarding pain and quality of life were answered by the patients at 4, 12, and 36 months postoperatively. RESULTS: We found an increased risk of reoperation after IM nailing within 1 postoperative year: 2.4% and 4.2% for SHS and IM nails, respectively. The difference persisted with time: 4.5% and 7.1% at 3 years. We also found minor differences for pain and quality of life which we judged clinically unimportant. CONCLUSIONS: Based on our findings and a critical review of the literature, we suggest an SHS is likely the preferred implant for simple two-part intertrochanteric fractures. LEVEL OF EVIDENCE: Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Comparison of Intramedullary Nails in the Treatment of Trochanteric and Subtrochanteric Fractures: An Observational Study of 13,232 Fractures in the Norwegian Hip Fracture Register.

BACKGROUND: Intramedullary nails are commonly used in the treatment of trochanteric and subtrochanteric fractures. We aimed to compare intramedullary nails in widespread use in Norway on the basis of reoperation risk. METHODS: We assessed data from 13,232 trochanteric or subtrochanteric fractures treated with an intramedullary nail and registered in the Norwegian Hip Fracture Register between 2007 and 2019. The primary outcome measure was the risk of reoperation for various types of short and long intramedullary nails. Secondly, we compared risk of reoperation for the selected nails with respect to fracture type (AO/OTA type A1, A2, A3, and subtrochanteric fractures). Cox regression analysis adjusted for sex, age, and American Society of Anesthesiologists class was used to estimate hazard rate ratios (HRRs) for reoperation. RESULTS: The mean patient age was 82.9 years, and 72.8% of the nails were used in the treatment of female patients. We included 8,283 short and 4,949 long nails. A1 fractures accounted for 29.8%, A2 for 40.6%, A3 for 7.2%, and subtrochanteric fractures for 22.4%. When comparing short nails regardless of fracture type, the TRIGEN INTERTAN had an increased risk of reoperation at 1 year (HRR, 1.31 [95% confidence interval (CI), 1.03 to 1.66]; p = 0.028) and 3 years (HRR, 1.31 [95% CI, 1.07 to 1.61]; p = 0.011) postoperatively compared with the Gamma3. For individual fracture types, we found no significant differences in reoperation risk between the various types of short nails. When comparing long nails, the TRIGEN TAN/FAN had an increased risk of reoperation at 1 year (HRR, 3.05 [95% CI, 2.10 to 4.42]; p < 0.001) and 3 years (HRR, 2.54 [95% CI, 1.82 to 3.54]; p < 0.001) postoperatively compared with the long Gamma3. CONCLUSIONS: This study may indicate a slightly increased risk of reoperation for the short TRIGEN INTERTAN compared with other short nails in widespread use in Norway. In analyses of long nails, the TRIGEN TAN/FAN nail was associated with a higher risk of reoperation in the treatment of trochanteric and subtrochanteric fractures. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Intramedullary nail versus sliding hip screw for stable and unstable trochanteric and subtrochanteric fractures : 17,341 patients from the Norwegian Hip Fracture Register.

AIMS: The aim of this study was to investigate if there are differences in outcome between sliding hip screws (SHSs) and intramedullary nails (IMNs) with regard to fracture stability. METHODS: We assessed data from 17,341 patients with trochanteric or subtrochanteric fractures treated with SHS or IMN in the Norwegian Hip Fracture Register from 2013 to 2019. Primary outcome measures were reoperations for stable fractures (AO Foundation/Orthopaedic Trauma Association (AO/OTA) type A1) and unstable fractures (AO/OTA type A2, A3, and subtrochanteric fractures). Secondary outcome measures were reoperations for A2, A3, and subtrochanteric fractures individually, one-year mortality, quality of life (EuroQol five-dimension three-level index score), pain (visual analogue scale (VAS)), and satisfaction (VAS) for stable and unstable fractures. Hazard rate ratios (HRRs) for reoperation were calculated using Cox regression analysis with adjustments for age, sex, and American Society of Anesthesiologists score. RESULTS: Reoperation rate was lower after surgery with IMN for unstable fractures one year (HRR 0.82, 95% confidence interval (CI) 0.70 to 0.97; p = 0.022) and three years postoperatively (HRR 0.86, 95% CI 0.74 to 0.99; p = 0.036), compared with SHS. For individual fracture types, no clinically significant differences were found. Lower one-year mortality was found for IMN compared with SHS for stable fractures (HRR 0.87; 95% CI 0.78 to 0.96; p = 0.007), and unstable fractures (HRR 0.91, 95% CI 0.84 to 0.98; p = 0.014). CONCLUSION: This national register-based study indicates a lower reoperation rate for IMN than SHS for unstable trochanteric and subtrochanteric fractures, but not for stable fractures or individual fracture types. The choice of implant may not be decisive to the outcome of treatment for stable trochanteric fractures in terms of reoperation rate. One-year mortality rate for unstable and stable fractures was lower in patients treated with IMN. Cite this article: Bone Joint J 2022;104-B(2):274-282.

Clinical outcome after undisplaced femoral neck fractures.

BACKGROUND AND PURPOSE: Little attention has been paid to undisplaced femoral neck fractures. By using data from the Norwegian Hip Fracture Register, we investigated the risk of reoperation and the clinical outcome after treatment of these fractures in patients over 60 years of age. METHODS: Data on 4,468 patients with undisplaced femoral neck fractures who were operated with screw osteosynthesis were compared to those from 10,289 patients with displaced femoral neck fractures treated with screw osteosynthesis (n = 3,389) or bipolar hemiarthroplasty (n = 6,900). The evaluation was based on number of reoperations and patient assessment at 4 and 12 months of follow-up. RESULTS: The 1-year implant survival was 89% after screw fixation for undisplaced fractures, 79% after screw fixation for displaced fractures, and 97% after hemiarthroplasty for displaced fractures. Patients with displaced fractures who were operated with internal fixation had a higher risk of reoperation (RR = 1.9, CI: 1.7-2.2), reported more pain, were less satisfied, and had lower quality of life than patients with undisplaced fractures treated with internal fixation (p < 0.05). Patients with displaced fractures who were operated with hemiarthroplasty had a lower risk of reoperation than patients with undisplaced fractures who were operated with internal fixation (RR = 0.32, CI: 0.27-0.38). Furthermore, they had the lowest degree of pain, were most satisfied, and reported the highest quality of life. INTERPRETATION: The differences in clinical outcome found were less than what is considered to be of clinical importance. The results support the use of screw osteosynthesis for undisplaced femoral neck fractures in elderly patients, although even better results were obtained in the hemiarthroplasty group in patients with displaced fractures.

Implants for trochanteric fractures in Norway: the role of the trochanteric stabilizing plate-a study on 20,902 fractures from the Norwegian hip fracture register 2011-2017.

BACKGROUND: The trochanteric stabilizing plate (TSP) is used as an adjunct to the sliding hip screw (SHS) in unstable trochanteric and subtrochanteric fractures. We wanted to describe the choice of implant for trochanteric fractures with a focus on the TSP in Norway. METHODS: A total of 20,902 fractures from the Norwegian Hip Fracture Register treated surgically in 43 hospitals from 2011 to 2017 were included. Logistic regression analyses were performed to detect factors potentially influencing implant choice. RESULTS: The mean age was 83 years, and 15,137 (72%) were women. An SHS was used in 13,273 (63%) fractures, of them 4407 (33%) with a TSP. Fracture classification was the most important determinant of TSP. In cases where an SHS was used, the odds ratio (OR) for using a TSP was 14 for AO/OTA 31A2 fractures and 71 for AO/OTA 31A3 and subtrochanteric fractures, compared to AO/OTA 31A1 fractures. The probability of receiving a TSP was higher in urban, academic, and high-volume hospitals (OR 1.2 to 1.3) and lower in Central and Northern Norway (OR 0.3 to 0.7). The use of an intramedullary nail (IMN) (n = 7629 (36%)) was also to a degree decided by fracture classification (OR 1.8 to 5.3). However, hospital factors, with OR 0.1 to 0.4 for IMN in academic, urban, and high-volume hospitals and OR 1.5 to 2.6 outside South-Eastern Norway (all p < 0.001), were also important. CONCLUSIONS: Fracture classification was the main determinant for TSP use. Any additional benefit from a TSP on postoperative fracture stability or clinical outcome needs to be clarified.

Surgical Treatment of Distal Radial Fractures with External Fixation Versus Volar Locking Plate: A Multicenter Randomized Controlled Trial.

BACKGROUND: The use of volar locking plate fixation (VLP) for unstable extra-articular distal radial fractures has increased in the last decades. External fixation (EF) is less frequently used. This change of surgical approach has only to some extent been evidence-based. METHODS: In this multicenter, randomized controlled trial, we compared VLP and EF in patients between 18 and 70 years of age who had a displaced extra-articular distal radial fracture (OTA/AO type A3). The patients were examined at 6 weeks, 3 months, and 1 year postoperatively. The primary outcome measure was the Patient-Rated Wrist/Hand Evaluation score (PRWHE). Secondary outcomes were the shortened version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH), pain score on a visual analog scale (VAS), and radiographic measurements. Range of motion, grip strength, finger stiffness, complications, and reoperations were also recorded. RESULTS: One hundred and fifty-six patients were included. One hundred and forty-two (91%)-127 women (89%) and 15 men (11%)-completed 1 year of follow-up. Sixty-nine patients were treated with VLP and 73, with EF. The mean age was 56 years. At 6 weeks, the median PRWHE score was significantly higher in the EF group (44) compared with the VLP group (27) (p < 0.001). At 3 months and 1 year, the difference between groups was not significant. The median QuickDASH score was 27 in the VLP group and 43 in the EF group at 6 weeks (p < 0.001), and a significant difference persisted at 3 months (p = 0.023). The VLP group had superior results in terms pain during activity, wrist extension, and ulnar and radial deviation at 1 year, whereas the number of major complications was similar in the 2 groups. CONCLUSIONS: Patients treated with VLP had earlier recovery of function compared with patients treated with EF. One year postoperatively, we found no significant functional difference. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Is there a correlation between functional results and radiographic findings in patients with distal radius fracture A0 type A3 treated with volar locking plate or external fixator?

The aim of this study was to test the hypothesis that precise restoration of distal radius fractures is correlated to better patient-reported outcome. METHODS: The correlation between radiographic results and functional outcome was explored in 156 patients with extra-articular distal radius fractures included in a multicenter, randomized controlled trial comparing 2 surgical interventions, Volar Locking Plate or External Fixator. The primary functional outcome was the Patient Rated Wrist and Hand Evaluation score (PRWHE). Radiographically we assessed volar tilt, radial inclination, radial height, ulnar variance, and the presence of ulnar styloid fracture. The Pearson correlation analysis was used to estimate correlations between parameters. RESULTS: At 1-year follow-up the mean difference in radiographic findings compared with the uninjured side (min, max) was: reduced volar tilt 5.3° (-15°, 25°), reduced radial inclination 2.3° (-6°, 12°), radial height 1.3 mm (-4 mm, 7 mm), and ulnar variance -0.5 mm (-6 mm, 3 mm). Overall, we found no correlation between radiographic parameters and the PRWHE at 1-year follow-up within the whole group, regardless of which treatment was chosen. At the time of injury 53% (N = 80) had sustained an additional ulnar styloid fracture. After 1 year this fracture was still radiographically present in 31% (N = 43) of the patients. No correlation between PRWHE score and the presence of an ulnar styloid fracture at 1-year follow-up was found. CONCLUSIONS: We found no correlation between functional outcome (PRWHE) and radiographic findings after 1 year in patients operated on with a Volar Locking Plate or External Fixator. Patient-specific factors were more important than radiographic measurements in this study group.Level of evidence: Therapeutic Level 2Trial registration: Norway: National Committee for Medical and Health Research Ethics 213/555ClinicalTrials.gov ID: NCT01904084Randomization of first patient: 02.09.2013.

Sliding hip screw versus IM nail in reverse oblique trochanteric and subtrochanteric fractures. A study of 2716 patients in the Norwegian Hip Fracture Register.

BACKGROUND: Intramedullary nailing is commonly recommended as the treatment of choice for transverse/reverse oblique trochanteric (AO/OTA type A3=intertrochanteric) and subtrochanteric fractures. However, only to a limited extent is this approach supported by superior results in well designed clinical trials, and the sliding hip screw (SHS) is still a frequently used implant for these fractures. The aim of the present study was to compare IM nails and SHS in the treatment of transverse/reverse oblique trochanteric and subtrochanteric fractures using data from the Norwegian Hip Fracture Register (NHFR). METHODS: Data on 2716 operations for acute transverse/reverse oblique trochanteric or subtrochanteric fractures were collected from the NHFR from 2005 to 2010. Surgeons reported patient characteristics and details from initial surgery and reoperations, and patients answered questionnaires about pain, satisfaction, and quality of life (EQ-5D) 4, 12, and 36 months postoperatively. Reoperation rates were calculated using Kaplan-Meier analyses. Primary outcome measures were pain (Visual Analogue Scale (VAS)), satisfaction (VAS), quality of life (EQ-5D), and reoperation rates at one year. RESULTS: The treatment groups were similar regarding age, gender, ASA-class, cognitive impairment, and preoperative EQ-5Dindex score. At one year reoperation rates were 6.4% and 3.8% for SHS and IM nails, respectively (p=0.011). Patients treated with SHS also had slightly more pain (VAS 30 vs. 27, p=0.037) and were less satisfied (VAS 31 vs. 36, p=0.003) compared to patients treated with IM nail. There was no statistically significant difference in the EQ-5Dindex score, but the mobility was significantly better for the IM nail group. CONCLUSION: 12 months postoperatively patients with transverse/reverse oblique trochanteric and subtrochanteric fractures operated with a SHS had a higher reoperation rate compared to those operated with an IM nail. Small differences regarding pain, satisfaction, quality of life, and mobility were also in favour of IM nailing. Consequently, a change in our treatment strategy for these fractures could be considered.

TRIGEN INTERTAN intramedullary nail versus sliding hip screw: a prospective, randomized multicenter study on pain, function, and complications in 684 patients with an intertrochanteric or subtrochanteric fracture and one year of follow-up.

BACKGROUND: Both intramedullary nails and sliding hip screws are used with good results in the treatment of intertrochanteric and subtrochanteric fractures. The aim of our study was to assess whether use of the TRIGEN INTERTAN nail, as compared with a sliding hip screw, resulted in less postoperative pain, improved functional mobility, and reduced surgical complication rates for patients with an intertrochanteric or subtrochanteric fracture. METHODS: In a prospective, randomized multicenter study, 684 elderly patients were treated with the INTERTAN nail or with a sliding hip screw with or without a trochanteric stabilizing plate. The patients were assessed during their hospital stay and at three and twelve months postoperatively. A visual analogue scale (VAS) pain score was recorded at all time points, and functional mobility was assessed with use of the timed Up & Go test. The Harris hip score (HHS) was used to assess hip function more specifically. Quality of life was measured with the EuroQol-5D (EQ-5D). Radiographic findings as well as intraoperative and postoperative complications were recorded and analyzed. RESULTS: Patients treated with an INTERTAN nail had slightly less pain at the time of early postoperative mobilization (VAS score, 48 versus 52; p = 0.042), although this did not influence the length of the hospital stay and there was no difference at three or twelve months. Regardless of the fracture and implant type, functional mobility, hip function, patient satisfaction, and quality-of-life assessments were comparable between the groups at three and twelve months. The numbers of patients with surgical complications were similar for the two groups (twenty-nine in the sliding-hip-screw group and thirty-two in the INTERTAN group, p = 0.67). CONCLUSIONS: INTERTAN nails and sliding hip screws are similar in terms of pain, function, and reoperation rates twelve months after treatment of intertrochanteric and subtrochanteric fractures.