Which fixation produces the best outcome for distal femoral fractures? Meta-analysis and systematic review of retrograde nailing versus distal femoral plating in 2432 patients and 33 studies.

PURPOSE: The distal femur comprises a wide intramedullary cavity and thin cortical bone. Firm internal fixation of comminuted fractures with displacement is challenging. Although many comparative studies have reported retrograde intramedullary nailing (RIN) and distal femoral plating (DFP) as the usual fixation methods for distal femoral fractures, no clear conclusion has been reached. Therefore, a meta-analysis and systematic review of the clinical and radiological results were conducted to determine the appropriate treatment method for distal femoral fractures. METHODS: A systematic search of the PubMed, Embase, Scopus, and Cochrane Library databases from their inception to December 19, 2022, was performed using predefined criteria. Studies comparing the effects of RIN and DFP were considered. The analyzed outcome measures included duration of surgery, blood loss, time to union, delayed union, nonunion, malalignment, implant failure, infection, reoperation, limb length discrepancy, range of motion, persistent anterior knee pain, knee stiffness, and functional scores. Meta-analysis of pooled data was conducted using a random-effects model to determine the standard mean difference (SMD) or odds ratio (OR) with 95% confidence intervals (CIs). RESULTS: Thirty-three studies with 2,432 patients were included. Compared to DFP, RIN was associated with a shorter time to fracture union (SMD, 1.83 months; 95% CI - 2.76 to - 0.90; P < 0.001) and a lower incidence of postoperative infection (OR 0.54; 95% CI 0.31-0.94; P = 0.03). Pooled analysis revealed no significant differences in other outcome measures between the two treatment modalities. CONCLUSION: In distal femoral fractures, RIN had a shorter bone union time and was more resistant to infection than DFP. However, there were no significant differences in the other clinical parameters. Therefore, the characteristics, strengths, and weaknesses of RIN and DFP should be carefully identified, and appropriate treatment should be provided based on the patient's medical condition and fracture pattern.

Risk factors for templating mismatch of uncemented stems in bipolar hemiarthroplasty for femoral neck fracture.

Preoperative templating needs to be precise to optimize hip arthroplasty outcomes. Unexpected implant mismatches can occur despite meticulous planning. We investigated the risk factors for oversized and undersized stem mismatch during uncemented hemiarthroplasty using a double-tapered wedge rectangular stem for femoral neck fracture. Out of 154 consecutive patients who underwent hemiarthroplasty for femoral neck fracture, 104 patients were divided into three groups: (1) oversized (n = 17; 16.3%), (2) matched (n = 80; 76.9%), and (3) undersized stem group (n = 7; 6.7%). A smaller femoral head offset (odds ratio [OR] = 0.89, 95% confidence interval [95% CI] = 0.81-0.98, P = 0.017), smaller isthmus diameter (OR = 0.57, 95% CI = 0.35-0.92, P = 0.021), and smaller canal flare index (OR = 0.20, 95% CI = 0.04-0.98, P = 0.047) were significantly associated with oversized stem insertion, while older age (OR = 1.18, 95% CI = 1.01-1.39, P = 0.037) was associated with undersized stem insertion in logistic regression. In conclusion, when performing hemiarthroplasty for a femoral neck fracture with a double-tapered wedge rectangular stem, surgeons must pay close attention to proximal femoral geometry and patient age during preoperative planning to avoid stem mismatch.

The Association between Hip Joint Morphology and Posterior Wall Fracture: Analysis of Radiologic Parameters in Computed Tomography.

Although numerous radiologic parameters of abnormal hip joint morphology are utilized in practice, studies on the relation of these parameters to acetabular fractures are limited. This study hypothesized that certain morphological features of hip joints are associated with acetabular posterior wall (PW) fracture patterns and aimed to identify morphological characteristics predictive of acetabular PW fracture. The records of 107 consecutive patients, who were diagnosed with acetabular fractures in a level I trauma center from August 2017 to April 2021, were initially reviewed. After excluding patients who lacked proper radiographic evaluation and had previous surgery or concomitant injury on the ipsilateral lower limb, a total of 99 patients were analyzed to investigate the morphological characteristics of the hip joint, measured in computed tomography, associated with acetabular posterior wall fracture. We included patient demographics, acetabular index (AI), sharp angle, acetabular depth-to-width ratio (AD/WR), center-edge angle (CEA), head-neck offset ratio (HNOR), acetabular head index (AHI), anterior acetabular sector angle (AASA), posterior acetabular sector angle (PASA), and acetabular version angle (AVA) in the univariate and multivariate analyses. The injury mechanism (p = 0.001) and AD/WR (p = 0.021) were predictors of PW fracture in the univariate analysis. In the multivariable analysis, injury mechanism (p = 0.011), AI (coefficient B = 0.320; Exp (B) = 1.377; p = 0.017), and AD/WR (coefficient B = 33.047; Exp (B) = 2.250 × 1014; p = 0.028) were significant predictors of PW fracture. This study highlights the importance of morphological factors, such as a larger AI and AD/WR, that may influence joint stress distribution, resulting in acetabular PW fracture. Understanding these pathomechanisms may protect the hip joint and prevent future injuries through the early identification and treatment of pathological conditions.

Revision Total Hip Arthroplasty Utilizing an Acetabular Reinforcement Ring with a Metal Augment: A Minimum Eight-Year Follow-Up Study.

Background and Objectives: An acetabular reinforcement ring (ARR) with a structural allograft is conventionally used to treat large acetabular bone defects or discontinuity during revision hip arthroplasty. However, ARR is prone to failure due to bone resorption and lack of incorporation. Here, we investigated the surgical outcomes of the patients who underwent revision total hip arthroplasty (THA) using ARR combined with a metal augment (MA). Materials and Methods: We retrospectively reviewed data from 10 consecutive patients who had a minimum 8-year follow-up after revision hip arthroplasty using ARR with MA in Paprosky type III acetabular defect. We collected patient demographics, surgical details, clinical scores (including Harris Hip Score (HHS)), postoperative complications, and 8-year survival rates. Results: Six male and four female patients were included. The mean age was 64.3 years, and the mean follow-up duration was 104.3 months (96.0-112.0 months). Trauma-related diagnosis was the most common reason for index surgery. Three patients underwent all component revision, and seven underwent cup revision. Six were confirmed as Paprosky type IIIA and four as type IIIB. The mean HHS at the final follow-up was 81.5 (72-91). One patient was diagnosed with prosthetic joint infection at the 3-month follow-up; therefore, the minimum 8-year survival rate with our technique was 90.0% (95% confidence interval, 90.3-118.5%). Conclusions: The satisfactory mid- to long-term results of revision THA suggest that ARR combined with tantalum MA is a viable revision option for treating severe acetabular defects with pelvic discontinuity.

Impact of concomitant upper-extremity injuries in patients with hip fractures: a systematic review and meta-analysis.

INTRODUCTION: Combined hip and upper-extremity fractures raise clinical concerns because upper-extremity fractures may hinder early mobilization, thereby affecting rehabilitation and mortality. This systematic review and meta-analysis aimed to evaluate the effects of combined upper-extremity and hip fractures on rehabilitation and mortality. MATERIALS AND METHODS: We systematically searched MEDLINE, Embase, and the Cochrane Library for studies published before March 20, 2022, that evaluated the impact of concomitant upper-extremity injuries in geriatric patients with hip fractures. The pooled analysis identified differences in the (1) length of hospital stay, (2) discharge destination, and (3) mortality rates between the isolated and combined hip fracture groups. RESULTS: A total of 217,233 patients with isolated hip fractures (n = 203,816) and combined hip and upper-extremity fractures (n = 13,417) from 12 studies were analyzed. The average length of hospital stay was significantly longer in the combined upper-extremity fracture group than in the isolated hip fracture group (mean difference = 1.67 days; 95% confidence interval [CI] 0.63-2.70; P = 0.002). Patients in the combined upper limb fracture group were less likely to be discharged directly home (odds ratio [OR] = 0.64; 95% CI 0.52-0.80; P < 0.001) and showed significantly higher 30-day mortality (OR = 1.44; 95% CI 1.32-1.58; P < 0.001). The mortality rate after 30 days was not significantly different between the two groups. CONCLUSIONS: Concomitant upper-extremity fractures have debilitating effects on rehabilitation and early mortality in geriatric patients with hip fractures. Therefore, more focus should be placed on the early ambulation of patients with hip fractures and simultaneous upper limb fractures to promote rehabilitation and alleviate the public health burden. LEVEL OF EVIDENCE: III meta-analysis.

What Is the Best Treatment Choice for Concomitant Ipsilateral Femoral Neck and Intertrochanteric Fracture? A Retrospective Comparative Analysis of 115 Consecutive Patients.

PURPOSE: Although a concomitant ipsilateral femoral neck and intertrochanteric fracture has been considered to be a rare type of injury, its incidence has been increasing, especially among elderly hip fracture patients. However, there is limited evidence on the optimal treatment option. This study surveys surgical outcomes of different implants in order to assist in selecting the best possible implant for a combined femoral neck and intertrochanteric fracture. METHODS: The postoperative complications after the treatment of a concomitant ipsilateral femoral neck and intertrochanteric fracture via cephalomedullary nail (CMN), dynamic hip screw (DHS), and hip arthroplasty groups were analyzed by retrospectively reviewing the electronic medical records of 115 consecutive patients. RESULTS: The patient demographics and perioperative details showed no significant discrepancies amongst different surgical groups, except for the operative time; a CMN had the shortest mean operative time (standard deviation) of 85.6 min (31.1), followed by 94.7 min (22.3) during a DHS, and 107.3 min (37.2) during an HR (p = 0.021). Of the 84 osteosynthesis patients, 77 (91.7%) achieved a fracture union. Only one (3.2%) of the 31 HR cases had a dislocation. The sub-analysis of the different osteosynthesis methods showed a higher incidence of excessive sliding and the nonunion of the fracture fragment in the DHS group than that in the CMN group (p = 0.004 and p = 0.022, respectively). The different surgical methods did not significantly vary in other outcome variables, such as the re-operation rate, mortality, and hip function. CONCLUSIONS: For the surgical treatment of combined femoral neck and trochanteric fractures, osteosynthesis did not differ significantly from an HR in terms of the overall postoperative complications, reoperation and mortality rate, and hip function, however, the risk of nonunion and more mechanical complications should be considered when choosing a DHS. Our suggestion for the treatment of a femoral neck and ipsilateral trochanteric fracture is that a surgeon should choose wisely between an HR and a CMN depending on the patient's age, the displacement of the femoral neck, and one's expertise.

Additional Reduction Screw Fixation Technique for Pertrochanteric Hip Fractures: A Novel Method to Prevent Excessive Sliding in Cephalomedullary Nail Surgery.

Extramedullary (EM) reduction, defined as the medial cortex of the head-neck fragment located outside the medullary canal of the distal shaft fragment, has been introduced to prevent excessive postoperative sliding or failure of the lag screw in pertrochanteric fracture surgeries. Favorable EM reduction results have recently been reported in several clinical and biomechanical studies. Despite these efforts, maintaining the head-neck fragment in an EM position is periodically a difficult and challenging problem. Herein, the technique for reduction and maintenance of the head-neck fragment was introduced in an EM position using a Kirschner wire and partially threaded cannulated screw fixation via screw fixation from EM to the head-neck fragment, which was positioned inferior to the lag screw on the femoral calcar, also called the reduction screw. The authors utilized this reduction screw in 34 pertrochanteric fracture surgeries using a cephalomedullary nail and fracture union was acheive in all cases by a minimum one-year follow-up period without surgical complications.

Does the Helical Blade Lead to Higher Rates of Fixation Failure as Compared to Lag Screw in the Cephalomedullary Nailing Treatment of Hip Fractures? A Systematic Review and Meta-Analysis.

OBJECTIVES: Recently, several studies have suggested that blade-type cephalomedullary nails (CMNs) have a higher risk of fixation failure than that of lag screws, but no clinical consensus exists. This study compared fixation failure between helical blade-type and lag screw-type CMNs with cut-out and cut-through rates as primary outcomes and degree of sliding length, time to union, and nonunion rate as secondary outcomes. DATA SOURCES: MEDLINE, Embase, and Cochrane Library were systematically searched for studies published before March 4, 2020, using the PRISMA guidelines. STUDY SELECTION: Studies were included if they directly compared helical blade and lag screw for treating hip fractures. Data could be extracted for CMN alone to avoid mixing CMN and extramedullary plate devices, such as the dynamic hip screw. DATA EXTRACTION: Two board-certified orthopaedic surgeons specializing in hip surgery independently extracted data from the selected studies, and the data collected were compared to verify agreement. DATA SYNTHESIS: All data were pooled using a random-effects model. For all comparisons, odds ratios (ORs) and 95% confidence intervals (CIs) were calculated as dichotomous data, whereas continuous data were analyzed using mean differences with 95% CIs. CONCLUSIONS: Fixation failure (OR = 1.88, 95% CI: 1.09-3.23, P = 0.02), especially cut-through (OR = 5.33; 95% CI, 2.09-13.56; P < 0.01), was more common with helical blades than with lag screws, although the cut-out rate was not significantly different between both the 2 groups (OR = 0.87, 95% CI: 0.38-1.96, P = 0.73). Surgeons should carefully select a blade-type CMN when treating hip fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Clinical outcome of staged surgery after primary amputation for mangled extremity.

INTRODUCTION: Amputation for a mangled extremity is an effective and reliable life-saving treatment method, which requires a relatively shorter duration for treatment than limb salvage. However, only a few studies have focused on treatment with amputation. Herein, we report good clinical outcomes achieved through staged surgery performed after amputation. MATERIALS AND METHODS: This study included 47 patients (38 men, 9 women; average age, 52.4 years) diagnosed with mangled extremity, who underwent primary amputation between March 2014 and January 2019. The patients were divided into the initial closure (IC) groups (including 26 patients who underwent IC after amputation) and staged surgery (SS) (including 21 patients who underwent SS after amputation) groups. The presence of complications including necrosis and infection, consequent additional surgery, duration of hospitalization and expense for treatment, and functional scores of upper and lower extremities were assessed. RESULTS: No specific postoperative complication was found in the SS group. However, additional surgeries were performed in the IC group because of complications including three cases of infection and two cases of necrosis. The differences between the hospitalization period, treatment cost, and functional examination conducted 1 year after surgery of the two groups were not statistically significant. The patients in the IC group who underwent additional surgery were hospitalized for a longer period and presented with lower functional scores due to delayed rehabilitation. CONCLUSION: Staged surgery is a definitive and safe treatment option that can effectively reduce complications including infection and necrosis in patients with mangled extremity.

Arthroscopy versus nonoperative treatment of symptomatic femoroacetabular impingement syndrome: A systematic review and meta-analysis.

BACKGROUND: Presently, hip arthroscopy is a widely adopted surgical intervention for the treatment of femoroacetabular impingement (FAI). However, there is insufficient evidence regarding which between arthroscopy and nonoperative treatment is more optimal for symptomatic FAI. METHODS: MEDLINE, Embase, Web of Science, and the Cochrane Library were systematically searched for studies that compared arthroscopy and nonoperative interventions for FAI treatment from inception to August 4, 2020. We included studies that directly compared surgical and nonsurgical treatment for symptomatic FAI and excluded those that did not use arthroscopic treatment as a surgical technique and studies performed on patients with concomitant diagnoses instead of pure FAI. We compared the following clinical outcome scores at 6 and 12 months of follow-up: International Hip Outcome Tool 33 (iHOT-33), hip outcome score (HOS), EuroQol-visual analog scale (EQ-VAS), modified Harris hip score (mHHS), and nonarthritic hip score (NAHS). RESULTS: Five studies totaling 838 patients were included in the qualitative and quantitative synthesis; 382 patients underwent hip arthroscopy, and 456 patients were treated by nonoperative interventions. At 6 months of follow-up, there were no statistically significant differences in iHOT-33 ratings (mean difference [MD] = 7.92, P = .15), HOS (MD of HOS-ADL = 5.15, P = .26 and MD of HOS-Sports = 2.65, P = .79, respectively), and EQ-VAS (MD = 1.22, P = .76) between the 2 treatment strategies. At 12 months of follow-up, the arthroscopy group had a greater mean improvement in iHOT-33 score than the conservative treatment group (MD = 8.42, P = .002), but there was no difference between the groups in terms of mHHS rating (MD = -0.24, P = .83) and NAHS (MD = -2.08, P = .09). CONCLUSION: Despite arthroscopy being associated with significantly superior iHOT-33 scores after 12 months of follow-up, we were unable to discern the difference between the treatment strategies using other scoring methods, such as HOS, EQ-VAS, mHHS, and NAHS. Further studies will be needed to conclusively determine if 1 strategy is superior to the other for treating FAI.