RESUMO
BACKGROUND: Intertrochanteric (IT) fracture is one of the most common fractures seen in an orthopaedic practice. Proximal femoral nailing (PFN) is a common modality of fixing IT femur fracture. We retrospectively studied whether a PFN with two proximal lag screws can be done without distal interlocking screws in the 31-A1 and 31-A2 fracture patterns according to the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) guidelines for IT femur fractures. AIM: To compare the outcomes of IT fractures (AO/OTA 31-A1 and 31-A2) treated by PFN with and without distal interlocking screws. METHODS: We carried out a retrospective study of 140 patients in a tertiary care centre who had AO/OTA type 31-A1 and 31-A2 IT fractures. We divided the patients into two groups, in which one of the groups received distal interlocking screws (group 1) and the other group did not (group 2). The subjects were followed up for a mean period of 14 mo and assessed for radiological union time, fracture site collapse, mechanical stability of implant, and complications associated with the PFN with distal interlocking and without distal interlocking. Then, the results were compared. RESULTS: PFN without distal interlocking screws has several advantages and gives better results over PFN with distal interlocking screws in the AO/OTA 31-A2 fracture pattern. However, similar results were observed in both groups with the fracture pattern AO/OTA 31-A1. In patients with fracture pattern AO/OTA 31-A2 treated by PFN without distal interlocking screws, there were minimal proximal lock-related complications and no risk of distal interlock-related complications. The operative time, IITV radiation time and time to radiological union were reduced. These patients also had better rotational alignment of the proximal femur, and the anatomy of the proximal femur was well maintained. It was also noted that in the cases where distal interlocking was performed, there was a gradual decrease in neck shaft angle, which led to varus collapse and failure of bone-implant construct in 21.40%. CONCLUSION: In fracture pattern AO/OTA 31-A2, PFN without distal interlocking had better results and less complications than PFN with distal interlocking.
RESUMO
[This corrects the article DOI: 10.1016/j.jcot.2020.10.038.].
RESUMO
OBJECTIVE: Delayed presentation of complex acetabular fractures isn't uncommon. Surgical treatment of such fractures demand special consideration with respect to surgical approach, reduction techniques, fixation and avoidance of complications. This paper intends to review the literature with regard to the suggested treatment modalities and the reported outcome in late presentations and conclude any recommendations appropriate to the practice in current times. BACKGROUND: Displaced fractures of acetabulum, when remained untreated for more than three weeks, pose significant challenge to fracture reduction due to rapid callus formation. In 1976, Letournel described the "Extended Ilio-Femoral Approach"(EIFA) to provide adequate exposure for effective reduction of such fractures. It offered greater exposure of both anterior and posterior columns through a single window, which allowed more precise and controlled reduction of the complex fractures under vision. But despite early enthusiasm in its practice, there has been a steep decline in its application due to reported higher risk of complications. Despite the challenges, the accuracy of fracture reduction in complex acetabular fractures with late presentation was found to be superior in EIFA than the reduction that were achieved by other approaches. Hence a debate to find out the utility of this approach for late reconstruction of complex acetabular fractures (in the face of reported risks of complications) is worthwhile especially in younger patients, who are not suitable candidates for an acute hip replacement surgery and who need their native hip to function well at least for a few years, for their professional and personal high demand activities in their active youthful period. METHODS: The articles for review were retrived using Google Scholar for data retrieval as Pubmed didn't yield any meaningful results due to paucity of publication in this subject. There were only very few papers in the English literature since 1979, which focused on this condition and were considered for this review. We have included our experience on using EIFA in late presentations of complex acetabular fractures spanning from 1999 to 2019, an experience over two decades to this report. RESULTS: It was observed that despite delayed presentation, good articular reduction was possible by using EIFA even in complex acetabular fractures. Ultimate functional outcomes were directly related to the accuracy of fracture reduction thus achieved. The risk of heterotrophic ossification in EIFA, though emphasized as significant in the published literature, was found to be least of a problem in our experience. DISCUSSION: Surgical fixation in delayed cases of complex acetabular fractures was found to be challenging. The choice of surgical approach was found to have a great bearing on the accuracy of fracture reduction and long term functional outcome. In complex acetabular fractures, despite delay in presentation, precise reduction of such fractures was found to be possible when operated using EIFA. CONCLUSION: It was concluded that Every effort must be made to reconstruct the displaced fractures of acetabulum, even in the complex types,despite when they present late, provided the fracture fits into the selection criteria described by Letournel and operated using EIFA. This is very much appropriate to younger patients, who are not great candidate for total hip replacement surgery.
