Is immediate weight bearing safe for subtrochanteric femur fractures in elderly patients treated by cephalomedullary nailing? A multicentric study in one hundred eighty-two patients.

PURPOSE: Biomechanical superiority of intramedullary nails over extramedullary implants has been proved for subtrochanteric fractures. Nevertheless, postoperative management of these patients has not changed, with high rates of protected weight-bearing after intramedullary nailing. The purpose of this study is to determine the mechanical complications of immediate postoperative full weigh-bearing for subtrochanteric femur fractures in elderly patients treated with a cephalomedullary nail. METHODS: We performed a retrospective case series study from patients treated with a cephalomedullary nail for subtrochanteric fractures (AO/OTA 31A.3 and 32A-32C) over a nine-year period. Patients in the immediate full weight-bearing (IFWB) group received orders for immediate full weight bear as tolerated on postoperative 48 h. Patients in the non- or limited- weight-bearing (NLWB) group received orders not to full weight bear in the immediate postoperative. RESULTS: There were five (2.7%) cases of implant failure including four cutouts and one nail breakage that needed a reoperation. Of them, one (2.2%) followed the NLWB protocol and four (2.9%) followed the IFWB protocol. Mean length of stay was 7.9 days (median 8, range 3-21) in the NLWB group and 10.7 days (median 8, range 2-60) in the IWBAT group. The NLWB group observed a 2.8-day shorter postoperative length of stay when compared to the IFWB, but the median remained equal. CONCLUSION: This study suggests that geriatric patients with subtrochanteric fractures treated by intramedullary nailing and in which a good fracture reduction was achieved, may be able to tolerate immediate postoperative full weight-bearing, not increasing reoperation rates due to implant failure.

The effect of two surgical modalities for the treatment of subtrochanteric fractures of the femur on postoperative wound complications in patients: A meta-analysis.

Currently, there are two methods of treating subtrochanteric femur fractures: intramedullary nailing and extramedullary plate fixation. However, it remains to be seen whether internal or external fixation is the primary treatment for subrotator femur fractures in adults. In this meta-analysis, we reviewed the effects of internal and external fixation on the treatment of subrotator and subrotator fractures. Until July 2023, the researchers have been researching the Cochrane Library, Embase, Web of Science and PubMed, with English as their only language. The aims of the study are as follows: (1) to assess the efficacy of internal and external fixation for the treatment of postoperative wound infections in adult patients with subrotator femur fractures; (2) to assess the efficacy of various types of internal fixation for the treatment of adult patients with subrotator femur fractures, including postoperative complications, infections, and operative time. Meta-analysis showed that there was no significant difference in the treatment of subrotator fracture with internal versus external fixation in terms of wound infections, intra-operative bleeding, length of incision, and operative time were not significantly different. Therefore, more research is needed to support these findings with a number of large, high-quality randomized studies.

Titanium elastic nails vs locking plate in pediatric subtrochanteric femur fractures: A systematic review and meta-analysis.

Objective: Titanium elastic nails (TENs) and locking plates (LPs) are currently the main internal fixation for treating pediatric subtrochanteric femur fractures, and the optimal choice of internal fixation is controversial. This study aimed to systematically evaluate the effectiveness and safety of TENs and LPs in treating subtrochanteric fractures in children to provide a theoretical basis and reference for clinical treatment. Methods: The literature related to TENs and LPs for treating subtrochanteric fractures in children was searched using the CNKI, PubMed, Cochrane, Embase, and Web of Science, and the search time frame was from the establishment of the database to October 2022. Two evaluators screened the literature according to the inclusion and exclusion criteria and extracted relevant data. Meta-analysis was performed using Stata14.0 software. Results: A total of 9 studies with 407 patients with subtrochanteric femur fractures were included in the final screening, including 210 cases with TENs and 197 cases with LPs. Meta-analysis results showed that compared with the locking plate, TEN had a shorter operative time [WMD = -1.3, 95%CI(-1.94,-0.66), p < 0.01], less intraoperative bleeding [WMD = -84.45, 95%CI(-111.09, -57.82), p < 0.01], shorter fracture healing time [WMD = -1.3, 95%CI(-1.94,-0.66), P < 0.01], shorter hospital stays [WMD = -2.80, 95% CI(-4.63,-0.98), p < 0.01], and earlier full weight bearing [SMD = -0.48, 95% CI(-0.91,-0.04), p < 0.05] but more intraoperative fluoroscopy [WMD = 28.23, 95% CI(15.22,41.25), p < 0.05]. The overall complication rate was high [OR = 3.52, 95% CI(1.96,6.34), p < 0.05], and the postoperative period was prone to angulation, rotation, and inversion deformity [OR = 3.68, 95% CI(1.40, 9.68), p < 0.05]. No significant difference in the incidence of lower limb inequality between the two types of internal fixation [OR = 0.83, 95% CI(0.38, 1.85), p > 0.05] and no significant difference in the Harris score of the hip at the last follow-up between the two types of internal fixation [WMD = -0.67, 95% CI(-2.01,0.67), p > 0.05] were found. Conclusion: In comparison to LPs, TENs have a shorter operation time, less intraoperative bleeding, and a shorter fracture healing time, and the child can be fully weight-bearing earlier. Locking plates can reduce the operator's x-ray exposure, and the incidence rate of postoperative angulation, rotation, and inversion deformity is low. Therefore, TENs and LPs are the best internal fixation methods for treating subtrochanteric fractures in children.

Proximal femur geometry: a major predictor of proximal femur fracture subtypes.

INTRODUCTION: Proximal femur geometry (PFG) represents an important risk factor for the occurrence of hip fractures. There are currently few studies regarding the correlation between PFG and the occurrence of a specific fracture subtype, and those that exist have small cohorts and present with different methodologies and contradictory results. Therefore, there is no consensus in the literature regarding this topic. The present study aimed to establish the contribution of the PFG in the occurrence of different subtypes of proximal femur fractures (PFF): intertrochanteric, neck and subtrochanteric. METHODS: Analysis of 1022 plain anteroposterior pelvic radiographs of patients consecutively admitted to the emergency room of a Level 1 Trauma Centre between 2013 and 2019 after low energy trauma who presented with PFF and underwent surgical treatment. Patients were analysed considering age, gender and subtype of PFF (intertrochanteric, neck or subtrochanteric). Radiological parameters including cervicodiaphyseal angle (CDA), horizontal offset (HO), femoral neck width (FNW), femoral neck length (FNL), great trochanter-pubic symphysis distance (GTPSD), acetabular teardrop distance (ATD) and width of the intertrochanteric region (WIR) were measured and compared between the different subtypes of fractures (7154 measurements). Statistical analysis was conducted recurring to absolute measurements and measurements ratios. The correlation was assessed using t-test. RESULTS: There were statistically significant differences in proximal femur geometry between the different subtypes of fractures. Patients presenting with femoral neck fractures had greater CDA (132.5 ± 6.9 vs. 130.0 ± 7.3; p < 0.001) and lower HO (45.8 ± 7.4 vs. 49.0 ± 8.0; p < 0.001), HO/ATD (0.34 ± 0.068 vs. 0.37 ± 0.072; p < 0.001) and HO/GTPSD (0.26 ± 0.049 vs. 0.28 ± 0.039; p < 0.001) than patients with intertrochanteric/subtrochanteric fractures. CONCLUSIONS: PFG represents an important contributor to the occurrence of different fracture subtypes. Femoral neck fractures are associated with greater CDA and lower HO, HO/ATD and HO/GTPSD when compared to intertrochanteric or subtrochanteric fractures.

The role of cerclage wiring in the management of subtrochanteric and reverse oblique intertrochanteric fractures: a meta-analysis of comparative studies.

PURPOSE: Subtrochanteric and reverse oblique intertrochanteric fractures are challenging and often difficult to reduce. While intramedullary nailing (IMN) is considered the standard treatment, achieving anatomic reduction prior to fixation is essential. This study aimed to assess the impact of cerclage wiring with IMN on the outcomes and complication rate in treating subtrochanteric and reverse oblique intertrochanteric fractures. METHODS: This meta-analysis was conducted in line with PRISMA guidelines. The primary outcome was the time to union. The secondary outcomes were operative time, blood loss, quality of reduction, reduction alignment (if in varus), complications and reoperations. PubMed, Cochrane, Web of Science and Google Scholar were searched till July 2021. Articles that compared intramedullary nailing (IMN) versus intramedullary nailing and cerclage wiring (IMN-C) in the treatment of subtrochanteric and reverse oblique intertrochanteric fractures were included. The risk of bias was assessed using the Newcastle-Ottawa scale. RESULTS: This meta-analysis included 415 patients with subtrochanteric and reverse oblique intertrochanteric fracture from six comparative studies. Our findings showed that IMN-C was significantly associated with higher mean duration of surgery and blood loss. However, IMN-C had significantly lower mean time to union compared to IMN alone. In addition, IMN-C had lower pooled prevalence of varus reduction and overall complications. CONCLUSION: This study showed that the use of cerclage wiring is associated with lower time to union, lower prevalence of varus reduction and overall complications. Therefore, cerclage wiring augmentation is a safe technique with low complication rate and may be advised whenever open reduction is needed in the management of subtrochanteric and reverse oblique intertrochanteric fractures.

ATYPICAL FEMORAL FRACTURES DUE TO THE USE OF BISPHOSPHONATES: EPIDEMIOLOGIC STUDY IN A TERTIARY HOSPITAL.

Objective: Show the relationship between atypical femoral fractures and prolonged use of bisphosphonates and analyze the limit of its beneficial use. Methods: Retrospective cohort study (level of evidence 2B). From Atypical fracture cases, patients who used bisphosphonates were selected and the time period of their use was analyzed. Additionally, the variables sex, age, and the side most affected were studied. Results: Nine atypical femur fractures were found, all associated with the use of bisphosphonates. The average period of use of this medication was nine years (minimum of three years; maximum of 14 years). The patients' mean age was of 78 years (69-88 years) and all were women, with the right member being the most affected. Conclusion: The use of bisphosphonates to prevent osteoporotic fractures has been increasingly frequent and, when used for a prolonged period, it has been related to atypical fractures. Further scientific studies on doses, maximum periods of treatment, and risk-benefit in the indication of these medications are needed to assist in therapeutic management for each case. Level of Evidence II, Retrospective Study.

Objetivo: Demonstrar relação entre as fraturas atípicas de fêmur e o uso prolongado de bifosfonatos, descrever sua incidência e analisar até qual momento o seu uso é benéfico. Métodos: Estudo de coorte retrospectivo (nível de evidência 2B). Análise de 151 prontuários de pacientes com diagnóstico de fratura de fêmur em um hospital terciário, no período de janeiro de 2013 a dezembro de 2018. Foram selecionados os casos de fraturas atípicas e, dentre esses, os que faziam uso de bifosfonatos e o tempo de utilização. Ademais, foram estudadas as variáveis sexo, idade e lado mais acometido. Resultados: Constatadas 9 fraturas atípicas de fêmur, todas associadas ao uso de bifosfonatos. O período médio de uso dessa medicação foi de 9 anos (mínimo - 3 anos; máximo - 14 anos). A idade média dos pacientes foi de 78 anos (69-88 anos) e ocorrência unicamente em mulheres, tendo como membro mais acometido o direito. Conclusão: O uso dos bifosfonatos na prevenção de fraturas osteoporóticas tem sido cada vez mais frequente e relacionado às fraturas atípicas, quando empregado por tempo prolongado. A coleta de mais informações científicas que estudem doses, períodos máximos de tratamento e risco-benefício na indicação dessas medicações é essencial para auxiliar no manejo terapêutico apropriado para cada caso. Nível de Evidência II, Estudo Retrospectivo .

Biomechanical Study of Intramedullary Versus Extramedullary Implants for Four Types of Subtrochanteric Femoral Fracture.

OBJECTIVES: To compare the biomechanical performance of proximal femoral nail anti-rotation (PFNA), the "upside-down" less invasive plating system (LISS), and proximal femoral locking plate (PFLP) in fixing different fracture models of subtrochanteric fractures. METHODS: Thirty composite femurs were divided into three equal groups (PFNA, PFLP, and reverse LISS). The implant-femur constructs were tested under axial compression load (0-1400 N) from models I to IV, which represented the Seinsheimer type I subtrochanteric fracture, type IIIa subtrochanteric fracture with the posteromedial fragment reduced; type IIIa subtrochanteric fracture with the posteromedial fragment lost; and type IV subtrochanteric fracture, respectively. Axial stiffness was analyzed for each group. Each group was then divided into two subgroups, one of which underwent torsional and axial compression failure testing, while the other subgroup underwent axial compression fatigue testing. The torsional stiffness, failure load, and cycles to failure were analyzed. RESULTS: PFNA had the highest axial stiffness (F = 761.265, p < 0.0001) and failure load (F = 48.801, p < 0.0001) in model IV. The axial stiffness and failure load of the PFLP were significantly higher than those of the LISS (p < 0.0001, p = 0.001). However, no significant difference in axial stiffness was found between models I to III (model I: F = 2.439, p = 0.106; model II: F = 2.745, p = 0.082; model III: F = 0.852, p = 0.438) or torsional stiffness in model IV (F = 1.784, p = 0.187). In fatigue testing, PFNA did not suffer from construct failure after 90,000 cycles of axial compression. PFLP and LISS were damaged within 14,000 cycles, although LISS withstood more cycles than PFLP (t = 3.328, p = 0.01). CONCLUSION: The axial stiffness of the three implants was similar in models I to III. The biomechanical properties of PFNA were the best of the three implants in terms of axial stiffness, failure load, and fatigue testing cycles in model IV. The axial stiffness and failure load of the PFLP were better than those of the reverse LISS, but PFLP had fewer cycles in the fatigue tests than the reverse LISS.

Outcomes of Dynamic Condylar Screw Fixation for Unstable Peritrochanteric Fractures.

Background The optimal treatment modality and choice of implant for unstable peritrochanteric fractures is debatable, with multiple options ranging from intramedullary to extramedullary implants. The purpose of this study was to evaluate the radiological and functional outcomes of 95° dynamic condylar screws in unstable intertrochanteric fractures. Patients and methods This is a retrospective review of patients with unstable peritrochanteric fractures (31-A2 and A3 for Association for Osteosynthesis/Association for the Study of Internal Fixation (AO/ASIF) classification) who underwent open reduction and internal fixation with 95° dynamic condylar screw at Recep Tayyip Erdogan Hospital between 2014 and 2018. All the patients had a minimum of one year of follow-up. Clinical outcomes were measured in terms of time to full weight bearing, Harris Hip Score, and time to radiographic union. Results This study comprised 84 patients (including 56 males and 28 females with a mean age of 57.2 ± 9.7 years). The average time to full weight bearing was 4.2 months (range: three to six months). The radiological union was seen at a mean of 5.8 months (range: 4-11 months). Functional outcome in terms of Harris Hip Score was graded as excellent, good, fair, and poor in 18, 45, 16, and five patients, respectively. Implant failure was observed in three patients. One patient sustained a peri-prosthetic fracture, which was treated with a longer plate. Conclusion Dynamic condylar screw proves to be a reliable implant when used in unstable peritrochanteric fractures and results in satisfactory functional and radiological outcomes.

Use of the 95-degree angled blade plate with biological and mechanical augmentation to treat proximal femur non-unions: a case series.

BACKGROUND: Intertrochanteric and subtrochanteric non-union are rare but challenging complications. In the present study, we investigate the use of a 95° blade, in association with biological and mechanical augmentation, in the management of intertrochanteric and subtrochanteric femoral non-unions. METHODS: Between October 2015 and February 2021, a retrospective cohort study was conducted at our institution to investigate the use of a 95° blade, in association with biological and mechanical augmentation, in the management of intertrochanteric and subtrochanteric femoral non-unions, following the mechanical failure of the first device. All the patients underwent a clinical and radiographic follow-up at 6 weeks, 3, 6, 9, 12 and 18 months; at each follow-up, a plain radiograph of the femur was performed and patients were assessed using Harris Hip Score (HHS) and the Short Form-12 (SF-12) questionnaire. RESULTS: From October 2015 and February 2021, 40 proximal femur non-unions were managed at our Institution. Fifteen patients out of forty (37.5%) met the inclusion criteria. The main data of the study are summarized in Table 1; patients' mean was 57 years old (range 19-83); 10 males and 5 females were included in the study. All the patients completely healed clinically and radiologically at an average of 6.1 months (range 4-13). All these patients returned to their pre-injury mobility status. During an average follow-up period of 25 months (range 8-60), the observed complications included wound dehiscence, which was treated with a superficial surgical debridement, a below-the-knee deep vein thrombosis, and a blade plate failure 3 months after the first revision surgery. CONCLUSIONS: This study shows the treatment of inter-and sub-trochanteric non-unions with a 95° blade plate, medial strut allograft, and bone autograft obtained with RIA system, together with a varus malalignment correction, leads to a high percentage of bone healing, with a low incidence of complications and good clinical outcome.

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.

Risk of subtrochanteric and femoral shaft fractures due to bisphosphonate therapy in asthma: a population-based nested case-control study.

Concerns have been raised over the association between bisphosphonates and atypical fractures in subtrochanteric and femoral shaft regions, but the potential risk of these fractures due to bisphosphonate use in asthma has not been examined. INTRODUCTION: Bisphosphonates are used as first-line treatment for osteoporosis; however, concerns have been raised over their association with atypical subtrochanteric (ST) and femoral shaft (FS) fractures. The potential risk of atypical ST/FS fractures from bisphosphonate use in asthma has not been examined. METHODS: A nested case-control study was conducted using linked data from the Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics (HES) databases. Using an asthma cohort, we identified patients with atypical ST/FS fractures and sex, age, and practice-matched controls. Conditional logistic regression was used to determine the association between bisphosphonate exposure and atypical ST/FS fractures. RESULTS: From a cohort of 69,074 people with asthma, 67 patients with atypical ST/FS fractures and 260 matched control subjects were identified. Of the case patients, 40.3% had received bisphosphonates as compared with 14.2% of the controls corresponding to an adjusted odds ratio (aOR) of 4.42 (95%CI, 2.98 to 8.53). The duration of use influenced the risk with long-term users to be at a greater risk (> 5 years vs no exposure; aOR = 7.67; 95%CI, 1.75 to 33.91). Drug withdrawal was associated with diminished odds of atypical ST/FS fractures. CONCLUSION: Regular review of bisphosphonates should occur in patients with asthma. The risks and benefits of bisphosphonate therapy should be carefully considered in consultation with the patient. To improve AFF prevention, early signs which may warrant imaging, such as prodromal thigh pain, should be discussed.

Atypical femoral fractures due to the use of bisphosphonates: epidemiologic study in a tertiary hospital / Fraturas atípicas de fêmur por uso de bifosfonatos: estudo epidemiológico em um hospital terciário

ABSTRACT Objective: Show the relationship between atypical femoral fractures and prolonged use of bisphosphonates and analyze the limit of its beneficial use. Methods: Retrospective cohort study (level of evidence 2B). From Atypical fracture cases, patients who used bisphosphonates were selected and the time period of their use was analyzed. Additionally, the variables sex, age, and the side most affected were studied. Results: Nine atypical femur fractures were found, all associated with the use of bisphosphonates. The average period of use of this medication was nine years (minimum of three years; maximum of 14 years). The patients' mean age was of 78 years (69-88 years) and all were women, with the right member being the most affected. Conclusion: The use of bisphosphonates to prevent osteoporotic fractures has been increasingly frequent and, when used for a prolonged period, it has been related to atypical fractures. Further scientific studies on doses, maximum periods of treatment, and risk-benefit in the indication of these medications are needed to assist in therapeutic management for each case. Level of Evidence II, Retrospective Study.

RESUMO Objetivo: Demonstrar relação entre as fraturas atípicas de fêmur e o uso prolongado de bifosfonatos, descrever sua incidência e analisar até qual momento o seu uso é benéfico. Métodos: Estudo de coorte retrospectivo (nível de evidência 2B). Análise de 151 prontuários de pacientes com diagnóstico de fratura de fêmur em um hospital terciário, no período de janeiro de 2013 a dezembro de 2018. Foram selecionados os casos de fraturas atípicas e, dentre esses, os que faziam uso de bifosfonatos e o tempo de utilização. Ademais, foram estudadas as variáveis sexo, idade e lado mais acometido. Resultados: Constatadas 9 fraturas atípicas de fêmur, todas associadas ao uso de bifosfonatos. O período médio de uso dessa medicação foi de 9 anos (mínimo - 3 anos; máximo - 14 anos). A idade média dos pacientes foi de 78 anos (69-88 anos) e ocorrência unicamente em mulheres, tendo como membro mais acometido o direito. Conclusão: O uso dos bifosfonatos na prevenção de fraturas osteoporóticas tem sido cada vez mais frequente e relacionado às fraturas atípicas, quando empregado por tempo prolongado. A coleta de mais informações científicas que estudem doses, períodos máximos de tratamento e risco-benefício na indicação dessas medicações é essencial para auxiliar no manejo terapêutico apropriado para cada caso. Nível de Evidência II, Estudo Retrospectivo .

Numerical evaluation of the mechanical properties of a novel expandable intramedullary nailing: A new alternative to standard interlocking nailing.

INTRODUCTION: There has been a great effort in preventing the disadvantages of distal locking in intramedullary nailing to date. From this scope, a novel expandable nail fixation eliminating distal locking screws has been designed. The primary aim of this numerical parametric study is to investigate mechanical behavior of expandable nail fixation on the fractured femur model under different contact parameters which are effective in maintaining the nail position and to specify the appropriate values of these contact parameters for a safe fixation. The second aim is to compare mechanical behavior of the expandable nail fixation with the standard interlocking nail fixation. MATERIALS AND METHODS: The expandable nail has three wedges which are responsible for distal fixation by compressing the medullary canal in the radial direction. 4th generation Sawbones femur model was used as bone model. A transverse osteotomy with 20 mm gap was created to simulate a subtrochanteric fracture. The fixations have been examined under axial compression with 1200 N and torsion with 7 Nm. In the parametric study, the tightening torque and static friction coefficient in wedge-canal contact were selected as contact parameters. The outputs were stiffnesses of the fixations, equivalent von-Mises stress distribution on the models, and load sharing between the canal and distal locking elements. RESULTS: The results of the parametric study showed that the model with the tightening torque of 3 Nm and friction coefficient of 0.7 was the safest. The load borne by wedges is generally prone to increase with increased tightening torque and friction coefficient. The both fixations showed close stiffness and stress values. CONCLUSION: The tightening torque of the wedge locking mechanism is directly effective in maintaining the nail position constant in canal, and the safety of the fixation is better ensured with increased tightening torque but stress states on bone must be carefully evaluated. The expandable nail provided comparable results to standard interlocking nails with respect to the fixation stiffness, stress, and contact forces. The expandable nailing may be evaluated as an alternative in the fractures of long bones in the case that the numerical results are supported by future experimental studies.

Percutaneous Cerclage Wiring Combined with Cephalomedullary Nailing for Irreducible Subtrochanteric Fractures.

OBJECTIVE: To explore the surgical method, operation essentials and the clinical effect of the treatment of irreducible subtrochanteric femoral fractures by percutaneous cerclage wiring and Cephalomedullary nail. METHOD: From February 2016 to October 2019, 17 cases of irreducible subtrochanteric femoral fractures (SFFs) treated via a minimally invasive wire system and intramedullary nail fixation were reviewed retrospectively. Ten male and seven female patients were involved. The average age was 59.88 ± 16.13 years, ranging from 41 to 94 years. Among the patients, seven were injured in traffic accidents, five fell from a standing height, and five injured themselves from falling. The cases were classified based on the Seinsheimer classification. Specifically, five cases were type IIIA, five cases were type IIIB, one case was type IV, and six cases were type V. According to the AO/OTA classification, 10 cases were 32B3, and seven cases were 32C3. During surgery, the patients were placed on a traction bed andattempted closed reduction. For those patients whose closed reduction failed confirmed by fluoroscopy, we performed a small anterolateral incision through which a self-made minimally invasive percutaneous wire introducer (passer; patent Z: 2016 2 1002800.8) was employed for temporary fixation with a wire. A double-stranded steel wire was introduced into a self-made wire traction and lifting device (patent ZL 2020 2 0205658.7), the wire was pulled vertically and firmly fixed. Then an long InterTan nail was used for the fixation. The following information was recorded: (i) length of the invasive incision, (ii) blood loss on the third day after surgery, (iii) operation time; and (iv) maximum displacement and angulation of the fracture ends of the x-rayed front and side fractures before and after surgery and the maximum displacement and formation of the three-dimensional CT-scanned fracture ends in the coronal plane, sagittal plane, and cross section before and after surgery. RESULT: A total of 15 of the 17 patients were followed for 12 to 24 months. The 15 patients recovered, but one died from pulmonary infection 1 year after surgery. In the postoperative X-ray and three-dimensional CT observation reduction treatment, fracture displacement was less than 5 mm, each plane angle was less than 10 degrees, and postoperative fracture healing time was 3 to 14 months, with an average of 4.19 ± 4.04 months. The postoperative Harris hip function score ranged from 66 to 95 points, with an average of 80.81 ± 9.67 points. In terms of clinical outcomes, 11 cases were excellent, four cases were satisfactory, and one case was fair. CONCLUSION: For refractory subtrochanteric fractures, percutaneous wiring combined with Cephalomedullary nail fixation is a minimally invasive, rapid, and effective method, which can achieve satisfactory results in clinical practice and is worth promoting.

Management of Refractory Aseptic Subtrochanteric Non-union by Dual Plating.

BACKGROUND: Subtrochanteric fractures are challenging to treat because of their anatomical and biomechanical behaviours. Non-unions of this region become much more difficult to treat because of the previous surgical scar, fibrosis, mal-reduction, presence of an implant, compromised soft tissue, and osseous vascularity, bone-mass loss etc. The aim is to provide a stable mechanical environment by PF-LCP, augmented by LCP (dual plating) where biology can work uneventfully. Biology is re-initiated by decortication (shingling) and autologous cancellous bone graft. METHODS: Twelve cases of failed aseptic subtrochanteric non-union either with intact or broken implant were included in this study in a period of 3 years from August 2016 to July 2019. The interposing fibrous tissue resected in patients with mal-aligned fragments. The mechanical stabilization is achieved by orthogonal dual plating. PF-LCP on lateral and 4.5 mm LCP anteriorly, decortication, and cancellous graft applied before applying for the anterior plate. Patients were encouraged for a toe-touch walk with walking-frame from 3rd post-operative day. Functional outcomes were assessed using Parker Mobility Score (PMS). RESULTS: All fractures united in 7 ± 1.53 months. ROM at the knee remained unchanged but improved at the hip after revision surgery. Average PMS improved to 7.58 from pre-revision 1.75 validating the efficacy of this protocol. CONCLUSION: Adequate stability by dual-plate construct and re-initiation of cellular and biochemical processes by decortication and cancellous bone-graft reunited ununited subtrochanteric fractures. This particular combination of plates and decortication has not been employed earlier as per our review of the literature. AIM: To offer a new paradigm for the management of surgically failed subtrochanteric non-unions.

Retrograde entry portal for cephalomedullary nailing in difficult subtrochanteric fractures.

An entry point medial to the tip of the greater trochanter is considered optimal for antegrade femur nailing. The deforming forces in a subtrochanteric fracture often make it difficult to establish a perfect entry point during antegrade cephalomedullary nailing. To overcome this problem, we report a simple technique of making a retrograde entry portal for select difficult subtrochanteric fractures. The technique was used in 12 subtrochanteric fractures. Our indications were morbid obesity, revision nailing and atypical fractures. The technique involves creating a nail entry portal through the fracture from distal to proximal taking advantage of the abducted proximal fragment. Fracture reduction and nail insertion then proceeds in a standard manner. Additional reaming of the thick endosteal lateral cortex through the fracture was performed in atypical fractures. Satisfactory fracture reduction was achieved in all patients and 11 out of the 12 fractures united in the series. 1 patient developed an infected nonunion and was considered failure of treatment. The retrograde entry portal is a valuable alternative method that can be considered in nailing of difficult subtrochanteric fractures to establish an ideal entry point and nail trajectory.

Dynamic hip screw fixation of subtrochanteric femoral fractures.

INTRODUCTION: A subtrochanteric proximal femur fracture occurs in the 5 cm of bone immediately distal to the lesser trochanter. UK national guidelines advise that adults with subtrochanteric fractures should be treated with an intramedullary nail (IMN). This study aims to compare peri-operative outcome measures of patients with subtrochanteric fractures treated with either an IMN or a dynamic hip screw (DHS) construct. MATERIALS AND METHODS: We retrospectively reviewed subtrochanteric fractures presenting at our institution over 4.5 years (October 2014-May 2019), classifying them into two treatment groups; IMN and DHS. These groups were compared on outcome measures including surgical time, blood loss, radiation dose area product (DAP), length of stay, re-operation rate and mortality. RESULTS: During the time period studied, 86 patients presented with a subtrochanteric fracture of the femur; with 74 patients (86%) receiving an IMN and 12 (14%) receiving a DHS. The comparative outcome measures reaching statistical significance were blood loss and radiation DAP. The DHS group showed a significantly lower mean blood loss of 776 ml compared to 1029 ml in the IMN group. Also, the DHS group showed a significantly lower mean DAP of 150.30 mGy cm2 compared to 288.86 mGy cm2 in the IMN group. CONCLUSION: Although UK national guidelines recommend treating all subtrochanteric fractures with an IMN; the outcome measures assessed in our study did not show use of an IMN to be superior to a DHS. The DHS group showed a lower estimated blood loss and a reduced DAP. This, along with the reduced financial cost associated with a DHS, may support the use of DHS over IMN for certain subtrochanteric fractures of the femur. There may not be a single favourable implant for the treatment of subtrochanteric fractures as a whole; instead different subtypes of fracture may be amenable to a number of fixation devices. Choice of implant should be determined locally and based on existing and future clinical and health economic research.

Atypical Femoral Fracture in a Patient without Bisphosphonate or Denosumab Exposure-A Case Report.

Introduction: Atypical femoral fractures (AFF) are associated with the use of bisphosphonates (BPs) or denosumab. However, few cases that meet the characteristics of these fractures, as established by the American Society of Bone and Mineral Research, have occurred in patients who have never used antiresorptive drugs. Case Report: We report a case of AFF in a 67-year-old woman who had never used antiresorptive medications. The history and comorbidities of the patient, the characteristics of the fracture, and the subsequent treatment are presented. Conclusion: AFFs may occur even in patients who have never been exposed to BPs or denosumab. The absence of antiresorptive osteoporosis therapy and the lack of radiographic focal periosteal reaction in the lateral femoral cortex, as in our case, can make it difficult to detect and prevent the disorder. Prolonged use of proton pump inhibitors and Vitamin D deficiency-related osteomalacia may contribute to the occurrence of these fractures. Further studies are required to accurately understand all inciting factors contributing to the development of AFFs.

Tratamiento de las fracturas trocántero-subtrocantéricas asociadas a coxartrosis ipsilateral en pacientes mayores de 65 años / Treatment of trochanteric and subtrochanteric fractures associated to ipsilateral coxarthrosis in patients older than 65 years old / Tratamento de fraturas trocantéricas-subtrocantéricas associadas a coxartrose ipsilateral em pacientes com mais de 65 anos

Resumen: Introducción: las fracturas de cadera y la coxartrosis son patologías con alta incidencia en la población anciana. A pesar de esto es una observación clínica frecuente que no se presenten asociadas. No existe consenso de cuál es la mejor opción terapéutica para esta asociación. El objetivo del estudio es actualizar el conocimiento acerca del tratamiento de fracturas trocántero-subtrocantéricas asociadas a coxartrosis ipsilateral en pacientes mayores de 65 años. Materiales y métodos: se realizó una búsqueda sistematizada a través de los buscadores electrónicos PubMed y Ovid. La búsqueda alcanzó un total de 2,499 artículos, de acuerdo a los criterios de inclusión y exclusión se seleccionaron 12 trabajos para realizar nuestra revisión bibliográfica. Resultado: la mayoría de los trabajos analizados son estudios tipo serie de casos retrospectivos. Se realizaron tres subgrupos según tipo de tratamiento para analizar los resultados. Discusión: la asociación entre fracturas de fémur proximal y coxartrosis ipsilateral es poco frecuente. Dentro de este grupo de fracturas las de tipo trocantérico son las que muestran con mayor frecuencia esta asociación. Se plantean dos opciones terapéuticas para resolver esta asociación: tratar la fractura y la patología articular en un mismo acto quirúrgico mediante una artroplastia, o tratar primero la fractura mediante osteosíntesis y en una segunda cirugía la patología articular. El tratamiento mediante artroplastia disminuye el tiempo para la deambulación postoperatoria evitando así complicaciones médicas relacionadas a la enfermedad fracturaria, obteniendo mejores resultados funcionales a corto plazo. La osteosíntesis requiere un menor tiempo quirúrgico y una perdida sanguínea menor, siendo un procedimiento menos demandante técnicamente. La tasa de mortalidad no depende de la opción terapéutica, pero sí de la presencia de 3 o más comorbilidades y edad mayor a 80 años. Resulta importante conocer el tratamiento más adecuado para esta asociación de patologías, ello contribuiría a disminuir los efectos de la enfermedad fracturaria sobre este grupo de pacientes vulnerables. Conclusión: no existe la suficiente evidencia científica para afirmar que una opción terapéutica sea superior a la otra en estos pacientes.

Summary: Introduction: hip fractures and hip joint arthrosis are highly prevalent conditions among older adults. However, according to clinical examination, they are seldom seen together and today there is no general consensus on the best therapy for these associated conditions. The study aims to update existing knowledge on the treatment of trochanteric and subtrochanteric fractures that are associated to ipsilateral coxarthrosis in patients older than 65 years old. Method: we conducted a systematized search on Pubmed and Ovid including 2,499 articles and selected 12 studies to perform our bibliographic review based on inclusion and exclusion criteria. Result: most studies analysed are series of retrospective cases. Cases were classified them into three subgroups to analyse results. Discussion: the association between proximal femur fractures and ipsilateral coxarthrosis is rather unusual. When seen, trochanteric fractures are the most frequent ones. There are two therapeutic options to treat this condition: treating the fracture and the articulation in the same surgery, by means of an arthroplasty, or treating the fracture first with osteosynthesis and operating afterwards to treat the articulation condition. Arthroplasty reduces the time of postoperative ambulation and thus avoids medical complications in connection with the fracture disease, what results in better functional outcome in the short term. Osteosynthesis requires a shorter surgery and implies smaller blood loss, what makes it less technically demanding as a procedure. The mortality rate does not depend on the therapy chosen, but on the presence of three or more comorbilities, or the patient being older than 80 years old. It is important to define what the most appropriate treatment is for these associated conditions, what would contribute to reducing the effects of the fracture on this group of vulnerable patients. Conclusion: there is no sufficient scientific evidence to state whether one therapy is better than the other one in these patients.

Resumo: Introdução: as fraturas de quadril e coxartrose são patologias com alta incidência na população idosa. Apesar disso, é frequente a observação clínica de que não estão associados. Não há consenso sobre qual a melhor opção terapêutica para essa associação. O objetivo deste estudo é atualizar o conhecimento sobre o tratamento das fraturas trocantéricas-subtrocantéricas associadas à coxartrose ipsilateral em pacientes com mais de 65 anos. Materiais e métodos: foi realizada uma busca sistemática nas bases PubMed e Ovid. Foram encontrados 2.499 artigos; após aplicação dos critérios de inclusão e exclusão, foram selecionados 12 artigos para realização de nossa revisão bibliográfica. Resultado: a maioria dos estudos analisados são séries de casos retrospectivos. Para análise dos resultados, foram divididos em três subgrupos de acordo com o tipo de tratamento. Discussão: a associação entre fratura de fêmur proximal e coxartrose ipsilateral é rara. Dentro desse grupo de fraturas, as do tipo trocantérica são as que mais frequentemente apresentam essa associação. Duas opções terapêuticas são propostas para resolver essa associação: tratar a fratura e a patologia articular no mesmo ato cirúrgico por meio de uma artroplastia, ou tratar a fratura primeiro por osteossíntese e em uma segunda cirurgia a patologia articular. O tratamento por artroplastia reduz o tempo de deambulação pós-operatória, evitando complicações médicas relacionadas à doença da fratura, obtendo melhores resultados funcionais em curto prazo. A osteossíntese requer menos tempo cirúrgico e menos perda sanguínea, sendo um procedimento menos exigente tecnicamente. A taxa de mortalidade não depende da opção terapêutica, mas sim da presença de 3 ou mais comorbidades e idade superior a 80 anos. É importante identificar o tratamento mais adequado para esta associação de patologias, o que ajudaria a reduzir os efeitos da patologia da fratura neste grupo de pacientes vulneráveis. Conclusão: não há evidências científicas suficientes para afirmar que uma opção terapêutica seja superior a outra nestes pacientes.

[Clinical effectiveness of less invasive intramedullary nail fixation combined with titanium cable cerclage for subtrochanteric fractures].

OBJECTIVE: To evaluate the surgical technique and clinical effect of less invasive intrame-dullary nail fixation combined with titanium cable cerclage in the treatment of subtrochanteric fractures. METHODS: A retrospective study was performed in 46 cases of subtrochanteric fractures in Peking University People's Hospital from January 2015 to December 2017. Among them, there were 14 males and 32 females, with an average age of (77.83±10.66) years (44-92 years); 17 cases on the left side and 29 cases on the right side. The causes of injury included crash from a height, traffic accident and accidental fall. According to Seinsheimer classification, there were 26 cases of type Ⅱ, 11 cases of type Ⅲ, 9 cases of type Ⅳ, and these cases were all closed injury. After admission, these patients underwent continuous tibial tuberosity bone traction to maintain the length and force line of the lower extremity, so as to reduce the difficulty of intraoperative fracture reduction. Anticoagulant therapy was given before operation to reduce perioperative thrombotic complications. All the patients were treated with less invasive intramedullary nail fixation combined with titanium cable cerclage. Operation time, blood loss during surgery, time of fracture healing were recorded, Harris and Sanders scoring system were used to assess hip function after operation at each follow-up time point. RESULTS: All the included patients underwent surgery successfully. Average operative time and intraoperative blood loss of these patients were (131.09 ± 20.06) min and (191.96±111.03) mL, respectively. All the patients were followed up satisfactorily, with an average follow-up time of 28 months. The fractures received bone healing within 3-6 months, average hospital stay was (10.61±2.85) days. The Sanders score was excellent in 3 cases, good in 37 cases and common in 6 cases, with an excellent and good rate of 86.96%. The Harris score was excellent in 6 cases, good in 36 cases, with an excellent and good rate of 91.30%. There were no cases of wound infection, loss of reduction, nonunion of fracture or internal fixation failure. Hip pain symptoms were effectively relieved in most patients. CONCLUSION: Less invasive intramedullary nail fixation combined with titanium cable cerclage can obtain good alignment and stability of fracture ends, which is an effective method for the treatment of subtrochanteric fractures.