Complications of standard versus long cephalomedullary nails in the treatment of unstable extracapsular proximal femoral fractures: A randomized controlled trial.

AIMS: To compare in a prospective randomized trial the mechanical complications in patients with unstable extracapsular proximal femur fractures without subtrochanteric extension (AO/OTA 31-A2 and 31-A3) METHODS: We prospectively studied 182 patients with unstable extracapsular proximal femur fractures without fractures lines extending more than 3 cm below the lesser trochanter, randomized to receive either a 'standard' (240 mm) nail or a long nail and followed them up for 1 year. RESULTS: We found no difference in the incidence of mechanical or general complications between the two groups, no cut-outs, no fractures of the tip the implant, 1 cut-through and 2 malrotations in the LN group, 2 non-unions that were reoperated, one on each group. The commonest complication was blade lateral migration, 13 (14%) patients in SN and 6 (9%) in the LN. The operating time was shorter in the SN group 51 minutes compared to 67 minutes in the LN group (p=0.000075). The mortality at 1,3 and 12 months in the SN group was of 2%, 6%, 12% while in the LN group was 12%, 18% and 22%. These differences where significative at 1 (p=0.007) and 3 months (p=0.013), but not at 12 months (p=0.075). CONCLUSIONS: We recommend the use of standard nails (240 mm) for this group of fractures, since it does not produce more mechanical complications, and it is faster, cheaper and easier to interlock distally.

Risk Factors of DAIR Failure and Validation of the KLIC Score: A Multicenter Study of Four Hundred Fifty-Five Patients.

Background: Debridement, antibiotic agents, and implant retention (DAIR) is a currently accepted approach for the treatment of early prosthetic joint infections (PJI). The success of a DAIR procedure has shown variable results throughout the published literature. Scoring systems such as the Kidney, Liver, Index surgery, Cemented prosthesis, and C-reactive protein value (KLIC) score for the selection of patients that are likely to benefit from DAIR have proved to be helpful in decision making. Our study aims to further validate the KLIC score using a large external multicentric cohort and to evaluate other risk factors for failure. Patients and Methods: A retrospective analysis of patients with an early acute PJI who were treated with DAIR and recorded in a database of eight Spanish university hospitals was performed. According to pre-operative variables of the KLIC study, patients were categorized into five groups: group A, ≤2 points; group B, 2.5-3.5 points; group C, 4-5 points; group D, 5.5-6.5 points; and group E, ≥7 points. Failure rates were compared between groups at 60 days and after 60 days of DAIR. Further variables for risk of failure were also analyzed. Results: A total of 455 patients with early acute PJI were included in the analyses. At 60 days, patients presenting with pre-operative elevated C-reactive protein serum levels, Staphylococcus aureus, and polymicrobial infections were associated with failure. Failure rates recorded were 12% for group A (n = 210), 18% for group B (n = 83), 26% for group C (n = 89), 24% for group D (n = 66), and 0% for group E (n = 7). Univariable analysis between consecutive groups of the KLIC score showed no differences for failure before 60 days of the DAIR procedure. Scheduled surgery and having the procedure performed by a specialized unit were also identified as important factors for DAIR success. Conclusions: Our results suggest the KLIC score was not useful for predicting failure in our cohort. Furthermore, our results indicate a specialized unit should conduct DAIR procedures.