Loss of the posteromedial support: a risk factor for implant failure after fixation of AO 31-A2 intertrochanteric fractures.

BACKGROUND: The purpose of this study was to analyze cases of AO31-A2 intertrochanteric fractures (ITFs) and to identify the relationship between the loss of the posteromedial support and implant failure. METHODS: Three hundred ninety-four patients who underwent operative treatment for ITF from January 2003 to December 2017 were enrolled. Focusing on posteromedial support, the A2 ITFs were divided into two groups, namely, those with (Group A, n = 153) or without (Group B, n = 241) posteromedial support post-operatively, and the failure rates were compared. Based on the final outcomes (failed or not), we allocated all of the patients into two groups: failed (Group C, n = 66) and normal (Group D, n = 328). We separately analyzed each dataset to identify the factors that exhibited statistically significant differences between the groups. In addition, a logistic regression was conducted to identify whether the loss of posteromedial support of A2 ITFs was an independent risk factor for fixation failure. The basic factors were age, sex, American Society of Anesthesiologists (ASA) score, side of affected limb, fixation method (intramedullary or extramedullary), time from injury to operation, blood loss, operative time and length of stay. RESULTS: The failure rate of group B (58, 24.07%) was significantly higher than that of group A (8, 5.23%) (χ = 23.814, P < 0.001). Regarding Groups C and D, the comparisons of the fixation method (P = 0.005), operative time (P = 0.001), blood loss (P = 0.002) and length of stay (P = 0.033) showed that the differences were significant. The logistic regression revealed that the loss of posteromedial support was an independent risk factor for implant failure (OR = 5.986, 95% CI: 2.667-13.432) (P < 0.001). CONCLUSIONS: For AO31-A2 ITFs, the loss of posteromedial support was an independent risk factor for fixation failure. Therefore, posteromedial wall reconstruction might be necessary for the effective treatment of A2 fractures that lose posteromedial support.

Comparison of a Novel Tension Band and Patellotibial Tubercle Cerclage in the Treatment of Comminuted Fractures of Inferior Pole of the Patella.

OBJECTIVE: To assess the therapeutic effect of a novel tension band using 3.0 mm cannulated screw combined with a titanium cable and specific shims comparatively with patellotibial tubercle cerclage in comminuted fractures of the inferior pole of the patella. METHODS: The retrospective study from March 2012 to July 2017 was conducted in Peking University Third Hospital and comprised 63 patients with comminuted fractures of the inferior pole of the patella: 41 treated with new tension band using 3.0 mm cannulated screw combined with a titanium cable and specific shims (new tension band group) and 22 with patellotibial tubercle cerclage (tubercle cerclage group). Gender, age, AO/OTA fracture type, injury mechanism, inter-fragmentary gap, and follow-up time of patients were recorded. Two groups were compared regarding: operation time, blood loss, partial weight-bearing time, fracture-healed time, Bostman score and knee mobility at 12-month follow-up, and postoperative complications. Continuous and categorical parameters were analyzed by Mann-Whitney U test and the chi-squared test, respectively. Fisher's exact test was used for small data subsets. RESULTS: Between the two groups, no statistically significant difference was found in mean age, gender, AO/OTA fracture type, injury mechanism, mean inter-fragmentary gap, or mean follow-up time (P > 0.05). The mean operation time of new tension band group was significantly longer than that of tubercle cerclage group (76.4 min vs 64.2 min, P = 0.006), while there was no significant difference in blood loss. After surgery, new tension band group had a significantly earlier mean partial weight-bearing time (5.2 weeks vs 7.4 weeks, P < 0.001) and fracture-healed time (9.6 weeks vs 11.6 weeks, P < 0.001). At 12-month follow-up, patients of new tension band group had a significantly higher mean Bostman score (28.5 vs 25.8, P < 0.001) and knee mobility (126.7 vs 117.3, P < 0.001). Ten complications related with internal fixation were found in tubercle cerclage group including two cases of loose internal fixation, two cases of cerclage breakage, and six cases of low patella position who undertook secondary operation. No complications were found in new tension band group (0 in 41 vs 10 in 22, P < 0.001). CONCLUSION: Patients with comminuted fractures of the inferior pole of the patella treated with a novel tension band experienced a longer operation time, but earlier partial-weight-bearing and fracture-healed time, better clinical outcomes at 12-month follow-up, and less complications. It should be considered an alternative therapy for the treatment of distal pole patellar fractures.

Predictors and reduction techniques for irreducible reverse intertrochanteric fractures.

BACKGROUND: Reverse intertrochanteric fractures are usually initially treated with closed reduction. However, sometimes these fractures are not amenable to closed reduction and require open reduction. To date, few studies have been conducted on predictors of and reduction techniques for irreducible reverse intertrochanteric fractures. Therefore, this study aimed to summarize the displacement patterns of irreducible reverse intertrochanteric fractures and corresponding reduction techniques, and explore predictors of irreducibility. METHODS: We reviewed 1174 cases of trochanteric fractures treated in our hospital from January 2006 to October 2018, 113 of which were reverse intertrochanteric fractures. An irreducible fracture was determined according to intra-operative fluoroscopy imaging after closed manipulation. Fractures were assessed for displacement patterns, radiographic features of irreducibility, and reduction techniques. Logistic regression analysis was performed on potential predictors for irreducibility, including gender, age, body mass index, AO Foundation/Orthopaedic Trauma Association (AO/OTA) classification, and radiographic features. RESULTS: Seventy-six irreducible fractures were identified, accounting for 67% of reverse intertrochanteric fractures. Six patterns of fracture displacement after closed manipulation were identified; the most common pattern was medial displacement and posterior sagging of the femoral shaft relative to the head-neck fragment. Multivariate logistic regression analysis identified three predictors of irreducibility: a medially displaced femoral shaft relative to the head-neck fragment on the anteroposterior (AP) view (odds ratio [OR], 8.00; 95% confidence interval [CI], 3.04-21.04; P < 0.001), a displaced lesser trochanter (OR, 3.61; 95% CI, 1.35-9.61; P = 0.010), and a displaced lateral femoral wall (OR, 2.92; 95% CI, 1.02-8.34; P = 0.046). CONCLUSIONS: A high proportion of reverse intertrochanteric fractures are not amenable to closed reduction. Six patterns of fracture displacement after closed manipulation were identified. Different reduction techniques are required for different displacement patterns. Predictors of irreducibility include a medially displaced femoral shaft relative to the head-neck fragment on the AP view, a displaced lesser trochanter, and a displaced lateral femoral wall. These patients warrant special consideration in terms of recognition and management.

[Analysis of the blood loss in perioperative period of femoral intertrochanteric fractures in old patients treated with different internal fixations].

OBJECTIVE: To analyze blood loss in perioperative period of femoral intertrochanteric fractures in old patients treated with Gamma interlocking intramedullary nail (Gamma3), proximal femoral nail antirotation (PFNA) and dynamic hip screw (DHS), and to comprehend the character of blood loss in perioperative period of femoral intertrochanteric fractures. METHODS: A retrospective analysis was made of the medical records of 408 old patients with femoral intertrochanteric fractures admitted to our hospital between January 1, 2007 and to December 31, 2012. The estimated blood loss was calculated by Gross equation, according to the height, weight and changes of blood test pre- and post-operation and the differences of blood loss among Gamma3 group, PFNA group and DHS group were compared. The statistical analysis was conducted using One-Way ANOVA analysis with SPSS 13.0. A P value less than 0.05 was considered statistically significant. RESULTS: In the Gamma3 group (96 cases, 39 males, 57 females), the average operation time was (74.7 ± 25.0) min, the mean obvious blood loss was (103.5 ± 83.0) mL, the mean total blood loss was (831.9 ± 474.8) mL, and the mean hidden blood loss was (728.3 ± 455.5) mL. In the PFNA group (84 cases,31 males, 53 females), the average operation time was (69.0 ± 27.1) min, the mean obvious blood loss was (91.5 ± 111.4) mL, the mean total blood loss was (825.7 ± 478.0) mL, and the mean hidden blood loss was (734.2 ± 455.7) mL. In the DHS group (40 cases, 14 males, 26 females), the average operation time was (97.5 ± 25.0) min, the mean obvious blood loss was (283.6 ± 142.1) mL, the mean total blood loss was (695.7 ± 502.4) mL, and the mean hidden blood loss was (412.1 ± 457.6) mL. CONCLUSION: By comparing the three kinds of internal fixation methods we find that the Gamma3 and PFNA groups have a smaller size of incision, shorter time of operation and less intraoperative bleeding than the DHS group, but there is a considerable perioperative hidden blood loss. We should give enough attention to reducing the incidence of postoperative complications.