Bilateral intertrochanteric fractures in an elderly patient following high-energy trauma: a case report.

BACKGROUND: Cases of bilateral hip fractures are rare, and even more so are cases of bilateral intertrochanteric fractures. Common causes include trauma, internal diseases, and primary or secondary bone diseases. We report a case of bilateral intertrochanteric fractures in an elderly patient following a severe car accident, a scenario not extensively reported in existing literature. CASE PRESENTATION: We report on an 84-year-old male who suffered severe trauma from a car accident, resulting in multiple injuries and shock state, with pain and limited mobility in both hip joints. After examination and imaging studies, the patient was diagnosed with multiple injuries and bilateral intertrochanteric fractures. Following emergency resuscitation, he was admitted to the orthopedic ward. A pre-surgical multidisciplinary team (MDT) consultation was convened to optimize surgical conditions. The patient underwent successful one-stage bilateral intramedullary nailing. The patient was assisted to stand with a walker on the third day after surgery. Six months post-surgery, the patient resumed outdoor activities. CONCLUSION: Managing bilateral intertrochanteric fractures, particularly in the elderly with severe trauma, is notably challenging due to their rarity. However, a coordinated multidisciplinary approach and one-stage bilateral internal fixation can lead to effective treatment outcomes and favorable prognoses.

The effect of distal locking mode on postoperative mechanical complications in intertrochanteric fractures: a retrospective cohort study of five hundred and seven patients.

PURPOSE: The optimal choice of distal locking modes remains a subject due to limited available data, and therefore, this study aims to investigate the relationship between distal locking mode and postoperative mechanical complications in an intertrochanteric fracture (ITF) population who underwent closed reduction and intramedullary fixation with a PFNA-II. METHODS: Patients aged 65 years or older who underwent surgery with PFNA-II fixation in a university teaching hospital between January 2020 and December 2021 were potentially eligible. Based on the distal locking mode, patients were classified into static, dynamic, and limited dynamic groups, among which the differences were tested using univariate analysis. Multivariate logistic regression was used to examine whether the distal locking mode was independently associated with the risk of postoperative one year mechanical complications, adjusting for covariates and potential confounders. Subgroup analyses were performed to evaluate the robustness of the findings. RESULT: Among 507 eligible patients, 33 (6.5%) developed postoperative mechanical complications. In the univariate analysis, sex (P = 0.007), fracture type (P = 0.020), LAT Parker ratio (P = 0.023), and lateral femoral (P = 0.003) wall showed that the differences were significant. Compared to the static group, the limited dynamic group and the dynamic group showed higher odds of postoperative mechanical complications (OR = 3.314, 95% CI: 1.215-9.041; and OR = 3.652, 95% CI: 1.451-9.191, respectively). These associations were robust across a series of analyses, including adjusting for confounders and subgroup analyses. CONCLUSION: Using a distal non-static locking mode significantly increases the risk of postoperative mechanical complications, and static locking could be a preferable option when treating an intertrochanteric fracture.

Intramedullary administration of tranexamic acid reduces bleeding in proximal femoral nail antirotation surgery for intertrochanteric fractures in elderly individuals: A randomized controlled trial.

PURPOSE: Intertrochanteric fractures undergoing proximal femoral nail antirotation (PFNA) surgery are associated with significant hidden blood loss. This study aimed to explore whether intramedullary administration of tranexamic acid (TXA) can reduce bleeding in PFNA surgery for intertrochanteric fractures in elderly individuals. METHODS: A randomized controlled trial was conducted from January 2019 to December 2022. Patients aged over 60 years with intertrochanteric fractures who underwent intramedullary fixation surgery with PFNA were eligible for inclusion and grouped according to random numbers. A total of 249 patients were initially enrolled, of which 83 were randomly allocated to the TXA group and 82 were allocated to the saline group. The TXA group received intramedullary perfusion of TXA after the bone marrow was reamed. The primary outcomes were total peri-operative blood loss and post-operative transfusion rate. The occurrence of adverse events was also recorded. Continuous data was analyzed by unpaired t-test or Mann-Whitney U test, and categorical data was analyzed by Pearson Chi-square test. RESULTS: The total peri-operative blood loss (mL) in the TXA group was significantly lower than that in the saline group (577.23 ± 358.02 vs. 716.89 ± 420.30, p = 0.031). The post-operative transfusion rate was 30.67 % in the TXA group and 47.95 % in the saline group (p = 0.031). The extent of post-operative deep venous thrombosis and the 3-month mortality rate were similar between the 2 groups. CONCLUSION: We observed that intramedullary administration of TXA in PFNA surgery for intertrochanteric fractures in elderly individuals resulted in less peri-operative blood loss and decreased transfusion rate, without any adverse effects, and is, thus, recommended.

The "foothill" entry for cephalomedullary nailing in unstable proximal femoral fractures: a technical note with a review of the literature.

Cephalomedullary nailing for unstable proximal femoral fractures is widely utilized, especially for geriatric osteoporotic fractures. There are two starting points for entry, namely trochanteric tip entry and pyriformis fossa entry, both have advantages and disadvantages, the tip of the greater trochanter seems that it is not the ideal starting point for trochanteric entry nails, the study presents the foothill entry point as a reproducible, technically feasible entry point to overcome the shortcoming of both standard starting points, and it could be easy executed with clear intraoperative fluoroscopic landmarks and lead to appropriate nail position without intraoperative complications.

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.

The modified lymphocyte C-reactive protein score is a promising indicator for predicting 3-year mortality in elderly patients with intertrochanteric fractures.

BACKGROUND: Hip fractures are common in elderly patients, and almost all the patients undergo surgery. This study aimed to develop a novel modified lymphocyte C-reactive protein (CRP) score (mLCS) to simply and conveniently predict 3-year mortality in elderly patients undergoing intertrochanteric fracture surgery. METHODS: A retrospective study was conducted on elderly patients who underwent intertrochanteric fracture surgery between January 2014 and December 2017. The mLCS was developed according to the value of CRP and lymphocyte counts. Univariate and multivariate Cox regression analyses were used to identify independent risk factors for 3-year mortality after surgery. The performances of the lymphocyte CRP score (LCS) and mLCS to predict 3-year mortality were then compared using C-statistics, decision curve analysis (DCA), net reclassification index (NRI) and integrated discrimination improvement (IDI). RESULTS: A total of 291 patients were enrolled, of whom 52 (17.9%) died within 3 years after surgery. In the multivariate Cox regression analysis, mLCS (hazard ratio (HR), 5.415; 95% confidence interval (CI), 1.743-16.822; P = 0.003) was significantly associated with postoperative 3-year mortality. The C-statistics of LCS and mLCS for predicting 3-year mortality were 0.644 and 0.686, respectively. The NRI (mLCS vs. LCS, 0.018) and IDI (mLCS vs. LCS, 0.017) indicated that the mLCS performed better than the LCS. DCA also showed that mLCS had a higher clinical net benefit. CONCLUSIONS: mLCS is a promising predictor that can simply and conveniently predict 3-year mortality in elderly patients undergoing intertrochanteric fracture surgery.

Treating peri-trochanteric hip fractures with intramedullary nail, when a second anti-rotational screw is necessary?

INTRODUCTION: Fragility fractures around the proximal end of the femur have increased in recent years due to an aging population, adding to the pressure on national health care systems and to hospital expenses. Peri-trochanteric fractures have historically been treated successfully with anatomic intramedullary nails, giving stable fixation in order to allow early for mobilisation of these frail patients. Some of these nails allow a second (anti-rotational) screw through the nail into the femoral head. We assessed the use of this additional screw in terms of quality of reduction, post-operative mobilization and complications. MATERIALS & METHODS: All patients who were treated in the same hospital for peri-trochanteric fracture between January 2017 and December 2019 were included in the study. The patients were randomly assigned into group A, where the treatment included intramedullary nailing using one femoral hip screw, and group B, where the treatment additionally included a second anti-rotational screw. The patients were followed up clinically and radiologically, for at least 3 months post-operatively. Demographic and operative data were collected alongside radiographic and clinical data. RESULTS: A total of 118 patients with an average age of 82.7 years were included in the study after exclusion criteria was applied. There were no statistically significant differences between the two groups regarding the ASA grade, Nottingham Hip fracture score, Koval score, Mental score, operation time, transfusion requirements, and operative radiation dose and time (p > 0.05). In group A, more complications were observed (p < 0.05). The radiographic measurements were statistically significantly different. CART analysis revealed that the use of a single screw in the femoral head for the subgroup of the unstable peri-trochanteric fractures (Jensen Type 4-5 - AO31A2.2 and above), has a tendency toward developing more post-operative complications, though this was not statistically significant. CONCLUSION: The use of an additional anti-rotational screw for unstable peri-trochanteric fractures (Jensen Type 4-5 and AO 31A2.2 and above) could prevent complications such as varus collapse and cut-out.

Effect of knee osteoarthritis on the postoperative outcome of proximal femoral nail anti-rotation in the treatment of intertrochanteric fractures in the elderly: a retrospective analysis.

BACKGROUND: The proximal femoral nail anti-rotation (PFNA) is a commonly used internal fixation system for intertrochanteric fractures (IFs) in older adults. Knee osteoarthritis (KOA) is a degenerative lower extremity disease that occurs most frequently in the elderly. Some patients have already had KOA before the IFs. However, whether KOA impacts the postoperative outcome of IFs has not been reported. OBJECTIVE: This study aimed to investigate the effect of KOA on the fracture side on the outcome after PFNA for IFs in the elderly. METHODS: Between January 2016 and November 2021, 297 elderly patients treated with PFNA for IFs were enrolled in this study. They were divided into two groups according to the American Rheumatism Association KOA clinical and radiographic criteria: the control group and the KOA group. Intraoperative bleeding, operative time, length of hospital stay, postoperative time out of bed, fracture healing time, postoperative complications, postoperative Harris hip function score, and Barthel ability to daily living Score were compared between the two groups. Follow-up was routinely scheduled at 1, 3, 6, and 12 months postoperatively. RESULTS: Based on the exclusion criteria, 254 patients who met the requirements were left to be included in this study, including the control group (n = 133) and the KOA group (n = 121). Patients were followed up for a mean of 17.5 months (12-24 months). There was no significant difference between the two groups in preoperative demographic data, intraoperative blood loss, operation time, and length of stay in the hospital. The control group was statistically significant compared to the KOA group in terms of postoperative time out of bed (17.8 ± 4.0 days vs. 19.1 ± 5.8 days), fracture healing time (13.7 ± 2.2 weeks vs. 14.6 ± 3.7 weeks), and postoperative complications (12.8 vs. 23.1%). The Harris hip function score and Barthel ability to daily living score were higher in the control group than in the KOA group at 1, 3, 6, and 12 months postoperatively (the control group: 63.8 ± 10.9, 71.8 ± 10.3, 81.5 ± 8.7, and 91.6 ± 6.3 vs. The KOA group 61.0 ± 10.4, 68.6 ± 9.1, 79.0 ± 9.2, and 88.5 ± 5.9). CONCLUSIONS: In elderly patients with IFs combined with KOA of the fracture side treated with PFNA internal fixation, KOA increases the incidence of postoperative complications of the fracture, prolongs postoperative time out of bed and fracture healing, and reduces postoperative hip function and ability to daily living. Therefore, treating KOA on the fractured side needs to be considered when treating IFs in the elderly.

AO/OTA 31A3 fractures and postoperative complications in older patients.

BACKGROUND: AO/OTA 31A3 fractures (A3 fractures) have risk for postoperative complications with major impact on morbidity and mortality. For older patients, limited information is available for factors associated with postoperative complications. We aimed to assess factors associated with postoperative complications after surgery using cephalomedullary nails. METHODS: A retrospective cohort study was conducted using the information on patients aged ≥65 years who underwent surgery using cephalomedullary nails for trochanteric fractures due to low-energy trauma in three hospitals. Postoperative complications were diagnosed when patients were identified as nonunion, cutout of lag screw, or nail breakage. First, we compared differences including age, sex, body mass index, American Society of Anesthesiologists physical status classification system, preoperative waking ability, fracture type, nail length, neck shaft angle, reduction method, reduction quality and tip apex distance between patients with and without postoperative complications. Second, multivariable logistic regression analysis was employed to assess factors associated with postoperative complications resulting from A3 fractures. RESULTS: Among 120 patients with A3 fractures, postoperative complications were identified in 12 patients (10.0%). Postoperative complications were significantly more likely to develop among patients with poor reduction quality (adjusted odds ratio [95% confidence interval], 35.0 [4.43-275.9]) and a tip-apex distance ≥25 mm (16.4 [1.92-140.3]). CONCLUSIONS: These findings suggest that surgeons should aim to perform appropriate postoperative reduction and to prevent postoperative complications when using a cephalomedullary nail for A3 fractures among older patients.

Clinical observation and finite element analysis of femoral stable interlocking intramedullary nail in intertrochanteric fractures.

PURPOSE: This study was designed to compare clinical outcomes of the femoral stable interlocking intramedullary nail (FSIIN) with proximal femoral nail anti-rotation (PFNA) for the treatment of intertrochanteric fractures (OTA 31A1 + A2). METHODS: This study retrospectively analyzed a registered sample of 74 intertrochanteric fractures (OTA 31A1 + A2) surgically treated using FSIIN (n = 36) or PFNA (n = 38) from January 2015 to December 2021. The intra-operative variables (operation time, fluoroscopy time, intra-operative blood loss, length of incision) and fracture healing time were compared between the two groups in this study. Harris hip score (HHS) and visual analog scale (VAS) were used to evaluate the functional states. At the last follow-up, the incidence of related complications in patients was calculated. Eventually, the 3D finite element model was established to analyze the stress of FSIIN and PFNA. RESULTS: The distribution of all basic characteristics was similar between the two groups (p > 0.05). The operation time, fluoroscopy time, intra-operative blood loss, and length of incision were significantly decreased in the FSIIN group (p < 0.001). The FSIIN group had a shorter fracture healing time than the PFNA group (p < 0.001). There is no significant difference between the two groups in the Harris and VAS (p > 0.05). The incidences of post-operative anaemia, electrolyte imbalance, varus malalignment, and thigh pain were significantly lower in FSIIN than in PFNA groups (all p < 0.05). The finite element results show that the stress shielding effect of FSIIN is smaller. CONCLUSIONS: Our study revealed that FSIIN seemed to be superior to PFNA in the treatment of intertrochanteric fractures (OTA 31A1 + A2) due to less surgical damage and shorter fracture healing time.

A comparative analysis of distal locked and unlocked long proximal femoral nail antirotation (PFNA-II) in the fixation of stable intertrochanteric fractures.

PURPOSE: Long proximal femoral nail anti-rotation (PFNA-II) is a preferred implant in recent years for fixation of pertrochanteric fractures, especially in osteoporotic patients. The purpose of this study is to prospectively investigate the effect of distal locking in long PFNA-II fixation of stable intertrochanteric fractures. METHODS: A total of 58 patients with isolated stable intertrochanteric fractures and treated in our hospital during the study period of 2017-2019 by distal locked or unlocked long PFNA-II fixation were included in this study. Patients who had multiple injuries or open fractures were excluded. There were 40 female and 18 male patients, with 33 affecting the left side and 25 the right side. Of them, 31 belonged to the distal locked group (group A) and 27 to the unlocked group (group B). Surgical procedures and implants used in both groups were similar except for the distal locking of the nails. General data (age, gender, fracture side, etc.) showed no significant difference between two groups (all p > 0.05). The intraoperative parameters like operative time, radiation exposure and follow-up parameters like functional and radiological outcomes were recorded and compared. Statistical tests like the independent samples t-test Fischer's exact and Chi-square test were used to analyze association. RESULTS: The distribution of the fractures according to AO/OTA classification and 31A1.2 type of intertrochanteric fractures were most common in our study. All the included fractures united and the average functional outcome in both groups were good and comparable at the end of one year. The operative time (mL, 107.1 ± 12.6 vs. 77.0 ± 12.0, p < 0.001) and radiation exposure (s, 78.6 ± 11.0 vs. 40.3 ± 9.3, p < 0.001) were significantly less among the patients in group B. Fracture consolidation, three months after the operative procedures, was seen in a significantly greater proportion of patients in group B (92.6% vs. 67.7%, p = 0.025). Hardware irritation because of distal locking bolt was exclusively seen in group A, however this was not statistically significant (p = 0.241). CONCLUSION: We conclude that, in fixation of stable intertrochanteric fractures by long PFNA-II nail, distal locking not only increases the operative time and radiation exposure but also delays the fracture consolidation and increases the chances of hardware irritation, and hence is not required.

Risk factors for over-telescoping in reverse oblique intertrochanteric fractures.

PURPOSE: Postoperative over-telescoping (OT) with lag screws is often observed in reverse oblique intertrochanteric fractures. This study aimed to clarify the risk factors of OT in patients with reverse oblique intertrochanteric fractures. METHODS: Electronic medical records of patients diagnosed with reverse oblique intertrochanteric fractures using plain radiography who underwent operative fixation with an intramedullary nail between August 2013 and December 2019 were reviewed. Patients were classified into two groups according to the Futamura classification: lateral wall pattern (LW) and reverse oblique pattern (RO). The incidence of OT in the LW and RO groups was compared. Also, we compared the incidence of OT for each reduction type in the LW group. RESULTS: Twenty patients had LW, and nine had RO. OT was observed in eight fractures (42.1%) in the LW group but not in the RO group. The incidence of OT was significantly higher in the LW group than in the RO group (P = 0.0261). Among the 19 fractures with LW, OT was observed in 7 of 10 and 1 of 9 fractures with postoperative reduction in the intramedullary and extramedullary or anatomical types, respectively. In the LW group, the incidence of OT was significantly higher in fractures with postoperative reduction in the intramedullary type than in those of the extramedullary or anatomical type (P = 0.0198). CONCLUSION: Our study showed that the incidence of OT was significantly higher in LW than in RO and that postoperative reduction in the intramedullary type in LW was a risk factor for OT.

The postoperative prognosis of older intertrochanteric fracture patients as evaluated by the Chang reduction quality criteria.

OBJECTIVE: The aim of this study was to investigate the relationship between the Chang reduction quality criteria (CRQC) and the outcome of intertrochanteric fractures in older adults according to follow-up time. METHODS: This was a retrospective analysis of 389 older adult patients with intertrochanteric fractures treated surgically from January 2019 to June 2021, including 130 males and 259 females aged 84.6 (77.5-89.7) years. Patient survival was determined by telephone as the time between admission to hospital for fracture and death or until the study deadline (June 1, 2022). According to the CRQC, the patients were divided into the Poor, Acceptable, and Excellent groups. Univariate and multivariate Cox proportional hazard models were used to assess the association between CRQC and all-cause mortality in older adult intertrochanteric fractures at 1 year and the total follow-up time. Further subgroup analysis was performed according to different clinical and biological characteristics to improve the accuracy of the results. RESULTS: The mortality rates were 24.7% and 15.4% at 1 year and the total follow-up time, respectively. Both at one year and the total follow-up time, the mortality of the CRQC-Excellent group was significantly lower than that of the CRQC-Acceptable group (p.adj < 0.05) and the CRQC-Poor group (p.adj < 0.05). After multifactor adjustment, CRQC grades of Acceptable and Poor were independent risk factors affecting the overall and 1-year mortality. In addition, advanced age, ≥ 1 comorbidities, ASA 3 + 4, and prolonged preoperative waiting time were independent risk factors for survival at the total follow-up time. At 1 year, only ASA 3 + 4 and prolonged preoperative waiting time were independent risk factors for survival. Subgroup analysis according to different characteristics at the total follow-up time and at one year showed that in most subgroups, a decrease in the CRQC grade was significantly associated with an increase in all-cause mortality (p for trend < 0.05). CONCLUSIONS: This study highlights that CRQC grades of Acceptable and Poor are associated with increased all-cause mortality in older adult intertrochanteric fractures. We should attempt to achieve good reduction of these fractures.

Predictors of long-term mortality after intertrochanteric fractures surgery: a 3-year retrospective study.

INTRODUCTION: Intertrochanteric fractures are associated with high mortality rates; however, long-term data on survival and predictors remain scarce. Therefore, this study investigated risk factors associated with 3-year mortality in elderly patients with intertrochanteric fractures. METHODS: In a retrospective study, 156 elderly patients with intertrochanteric fractures who underwent surgery between January 2017 to January 2018 at our center were included. Association-affecting variables, such as gender, age, time from injury to surgery, hemoglobin (Hb), total lymphocyte count (TLC), albumin, malnutrition, and co-morbidities, were recorded and analyzed. Afterward, logistic regression was used to analyze the significant variables and find independent predictors for 3-year mortality. RESULTS: A total of 156 patients were followed up for 3 years. The 1-year, 2-year, and 3-year postoperative cumulative mortality rates were 9.6% (15/156), 16.7% (26/156), and 24.4% (38/156), respectively. Simple analyses found that age, Hb, albumin, and malnutrition were associated with 3-year mortality (p < 0.05). Multivariable analysis confirmed that advanced age (p < 0.001) and low albumin (p = 0.014) were independent risk factors for 3-year mortality. CONCLUSION: Low serum albumin and advanced age were independent risk factors for long-term mortality in elderly patients with intertrochanteric fractures.

The impact of the union of lesser trochanter fragments after intramedullary fixation of trochanteric femoral fractures: an X-ray based study.

BACKGROUND: Displacement of the lesser trochanter (LT) is not uncommon after managing intertrochanteric femoral fractures and the influence of nonunion of the LT-fragment on clinical outcomes remains controversial. This study aimed to investigate the relationship between the displacement distance and union of the LT-fragment and evaluate the influence of LT-fragment nonunion on hip function and complications. METHODS: This retrospective study included patients with intertrochanteric fractures and displaced LT treated with intramedullary fixation at Wenzhou Hospital of Integrated Traditional Chinese and Western Medicine from June 2015 to July 2017. The patients were grouped as union and nonunion of the LT-fragment at 1 year. The LT-fragment displacement distance of LT was measured by the anterior-posterior radiographs. RESULTS: Thirty-one and 22 patients showed union and nonunion at 1 year, respectively. The nonunion group had a higher postoperative complication rate than the union group (59% vs. 29%, P = 0.047), especially mechanical complications (45% vs. 6%, P = 0.001). There was no significant difference in hip function between the two groups (P > 0.05). The receiver operating characteristic (ROC) curve revealed an area under the curve of 0.933 of displacement ratio. Patients with a displacement ratio > 0.35 were more likely to have nonunion of the LT-fragment. CONCLUSIONS: The displacement ratio might be a reliable predictor of LT-fragment union. The incidence of postoperative complications might increase with LT-fragment nonunion.

Risk factors for cut-outs in geriatric intertrochanteric fractures with cephalomedullary nailing after obtaining acceptable reduction: a case-control study.

BACKGROUND: It is irresponsible if we disregard reduction quality to talk about cut-outs in intertrochanteric fractures (ITF) with internal fixation. The aim of this study is to analyze the risk-factors for cut-outs in geriatric ITF with cephalomedullary nailing after obtaining acceptable reduction. METHODS: In order to investigate the risk-factors for cut-outs in geriatric ITF after obtaining acceptable reduction, we retrospectively reviewed 367 patients who underwent cephalomedullary nail for ITF in our department between September 2016 and December 2021. Potential variables including demographic data and radiological parameters (namely the fracture type, Singh index, lateral wall fracture, cephalic nail position, Parker's ratio index, tip-apex-distance (TAD), and calcar-referenced TAD (CalTAD)) were collected. Logistic regression analysis was performed to identify the significant risk factors for cut-outs. RESULTS: One hundred twenty-one patients were suitable for this study. Of the 121 cases, nine cases (7.4%) were observed with cut-out or pending cut-out. We found that Age (adjusted odds ratio (OR) 1.158, 95% confidence interval (CI) 1.016 to 1.318, p = 0.028), lateral wall fracture (adjusted OR 11.07, 95%CI 1.790 to 68.380, p = 0.01), and CalTAD (adjusted OR 1.277, 95%CI 1.005 to 1.622, p = 0.045) were independent risk-factors for cut-outs. CONCLUSIONS: Age, lateral wall fracture and CalTAD are independent risk-factors for cut-outs in geriatric ITF with cephalomedullary nailing after obtaining acceptable reduction. In order to avoid cut-outs, an optimal CalTAD is necessary even obtaining acceptable reduction, especially in the over-aged patients with lateral wall fracture.

The performance of PROMIS computer adaptive testing for patient-reported outcomes in hip fracture surgery: a pilot study.

INTRODUCTION: Patient-reported outcome measures (PROMs) are essential to patient-centered care in orthopaedics. PROMIS measures have demonstrated reliability, validity, responsiveness, and minimal floor and ceiling effects in various populations of patients receiving orthopaedic care but have not yet been examined in hip fracture patients. This pilot study sought to evaluate the psychometric performance of the PROMIS Physical Function (PROMIS PF) and Pain Interference (PROMIS PI) computer adaptive tests and compare these instruments with legacy outcome measures in hip fracture patients. METHODS: This study included 67 patients who were 27-96 years old (median 76) and underwent osteosynthesis for a proximal femoral fracture. At 3, 6, and/or 12 months follow-up, patients completed both legacy (mHHS, SF-36-PCS, and VAS for pain) and PROMIS questionnaires (PROMIS PF and PROMIS PI). Respondent burden and floor/ceiling effects were calculated for each outcome measure. Correlation was calculated to determine concurrent validity between related constructs. RESULTS: A strong correlation was found between PROMIS PF and mHHS (rho = 0.715, p < 0.001) and moderately strong correlation between PROMIS PF and SF-36 PCS (rho = 0.697, p < 0.001). There was also a moderately strong correlation between the VAS and the PROMIS PI (rho = 0.641, p < 0.001). Patients who completed PROMIS PF were required to answer significantly fewer questions as compared with legacy PROMs (mHHS, SF-36). For the PROMIS measures, 1% of patients completing PROMIS PF achieved the highest allowable score while 34% of patients completing PROMIS PI achieved the lowest allowable score. Of the legacy outcome measures, 31% of patients completing the VAS for pain achieved the lowest allowable score and 7% of patients completing the mHHS achieved the highest allowable score. CONCLUSIONS: The results of this study support the validity of PROMIS CATs for use in hip fracture patients. The PROMIS PF was significantly correlated with SF-36 PCS and mHHS while requiring fewer question items per patient relative to the legacy outcome measures.

A rare complication of pelvic perforation by an excessive medial slide of the helical blade after treatment of an intertrochanteric fracture with proximal femoral nail anti-rotation: A case report and literature review.

Intertrochanteric fractures have become a severe public health problem in elderly patients. Proximal femoral nail anti-rotation (PFNA) is a commonly used intramedullary fixation device for unstable intertrochanteric fractures. Pelvic perforation by cephalic screw is a rare complication. We reported an 84-year-old female who fell at home and sustained an intertrochanteric fracture. The patient underwent surgery with PFNA as the intramedullary fixation device. Routine postoperative examination revealed medial migration of the helical blade that eventually caused pelvic perforation. We performed a cemented total hip arthroplasty as the savage procedure. At the latest follow-up of 12 months after total hip arthroplasty, the patient had no pain or loosening of the prosthesis in the left hip. Pelvic perforation should be considered when choosing PFNA as the intramedullary fixation device, especially in patients with severe osteoporosis wherein the helical blade can be easily inserted during the operation. The lack of devices to avoid oversliding of the helical blade in PFNA is an unreported cause of this complication and should be considered in such cases.

Strategies for managing the destruction of calcar femorale.

BACKGROUND: The calcar femorale was identified long ago. However, our current understanding of the calcar is insufficient, and its related concepts are sometimes confused. The calcar femoral is an important anatomical structure of the proximal femur, and its function can be overlooked. In trauma, tumors, or other diseases, the calcar femorale can be destroyed or changed pathologically. As a result, the mechanical structure of the proximal femur becomes destroyed, causing pathological fractures. How to address the destruction of the calcar femorale or the damage to the calcar femorale is discussed in this article. MAIN TEXT: Destruction of the calcar femorale is accompanied by many conditions, including trauma, tumors, and other diseases. The types of hip fractures caused by trauma include femoral neck fractures and intertrochanteric fractures. Dynamic hip screws, proximal femoral nail anti-rotation, and multiple parallel cannulate pins can be used in different conditions. When metastatic and primary bone tumors involve the calcar femorale, endoprostheses are widely used. Other diseases, such as fibrous dysplasia and aneurysmal bone cyst are treated differently. CONCLUSIONS: The calcar femorale can redistribute stresses and the destruction of the calcar femorale can lead to an increase in posterior medial stress. Many factors need to be considered when deciding whether to reconstruct the calcar femorale. Effective treatment strategies for managing the destruction of calcar femorale will need first establishing the precise mechanism of the destruction of the calcar and then designing therapies towards these mechanisms. Further investigation to the calcar needs to be carried out.

Intramedullary nails in combination with reconstruction plate in the treatment of unstable intertrochanteric femoral fractures with lateral wall damage.

BACKGROUND: The unstable intertrochanteric femur fracture remains a challenge for surgeons. However, few studies have compared the clinical effectiveness of intramedullary nail in combination with a reconstruction plate and intramedullary nail alone in the treatment of patients with unstable intertrochanteric femoral fractures with lateral wall damage. METHODS: This study retrospectively analyzed 16 patients with 31 A3 intertrochanteric fractures treated with the intramedullary nail in combination with reconstruction plate (the study group) and 19 patients with 31 A3 intertrochanteric fractures treated with intramedullary nail alone (the control group) between January 2012 and January 2018. The operation time, intra-operative blood loss, time of fracture healing, and complication rates of post-operative fixation failure were assessed between the two groups. At the follow-up of post-operative six and 12 months, Harris hip score (HHS) and the Parker-Palmer mobility score (PPMS) were used to evaluate the functional states and mobility levels. RESULTS: The distribution of all basic characteristics was similar between the two groups (P ˃ 0.05). The study group had longer operation time and more intra-operative blood loss in comparison with the control group (P < 0.001), while the study group had shorter fracture healing time (P = 0.03) and lower fixation failure rate as compared with the control group. Regarding the functional outcome, the study group had higher HHSs and PPMS than the control group (P = 0.003). CONCLUSIONS: Although intramedullary nails in combination with reconstruction plates had longer operation time and more intra-operative blood loss, it might be superior to intramedullary nail alone in terms of fracture healing time, fixation failure complication rate, and post-operative functional recovery.