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Failure of osteosynthesis is a common complication of the nailing of trochanteric fractures which typically occurs through form of cut-out. Tip-Apex distance (TAD), Calcar Tip-Apex distance (CalTAD), and Chang criteria are validated variables to predict failure of cephalomedullary nailing. This is a retrospective study which analyzes treatment of trochanteric fractures from 2018 to 2020 (n = 296) evaluating postoperative radiographs and factors of mechanical failure. Our objective was to assess correlation among these variables and their influence on mechanical failure, either individually or creating a new score. Our results support the CalTAD and Chang's criteria as valid predictors of mechanical failure. Furthermore, they empathize the importance of fracture reduction and proper placement of cervical screw. To our knowledge, this is the first study performing multivariate analysis including these 3 variables. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Aim The two most commonly used implants for treatment of trochanteric fractures are the dynamic hip screw (DHS) and proximal femoral nail antirotation (PFNA). The aim of this study was to evaluate blood loss in patients with trochanteric fracture treated with DHS or PFNA. Methods This retrospective comparative study included 61 patients with trochanteric fracture, who were divided according to a surgical method into DHS and PFNA groups. In the PFNA group, a short third generation gamma-nail was used for osteosynthesis (Supernail GT, Lima Corporate, Italy), and in the DHS group a dynamic hip screw was used (Synthes, Oberdorf, Switzerland). Complete blood count with haemoglobin and haematocrit values was taken preoperatively and on the first day postoperatively and a number of red blood cell transfusions (RBC) were evaluated. Electronic medical records from 2022 were used to collect patient data. Results There were no significant differences in terms of gender and age between the groups (p=0.510 and p=0.087, respectively), as well as in the fracture type distribution (p=0.886). The duration of postoperative hospitalisation was similar between the groups (p=0.643). There was no statistically significant association between the number of RBC transfusions and fixation method (p=0.091), as well as in postoperative haemoglobin and haematocrit levels between the groups (p=0.180 and p=0.225, respectively). Conclusion Both DHS and PFNA implants are safe surgical techniques for the treatment of trochanteric fractures, with similar blood loss, number of blood transfusions and hospital stay. [ABSTRACT FROM AUTHOR]

Fractures of the proximal extremity of the femur are some of the most common injuries treated by orthopedic surgeons, often associated with life-threatening polytrauma. Trochanteric fractures have an increased incidence, which is becoming more common due to the aging population. Femoral neck fractures are a particular type of intracapsular hip fracture, and the location of the junction makes the femoral neck prone to fracture. Fractures of the femoral shaft are found in approximately 6-9% of cases of femoral neck fractures. The management of these fractures is interdisciplinary, but in most cases, it requires surgical treatment to allow rapid elevation and recovery of autonomy. The present study is retrospective in which 140 cases of fracture of the upper femur extremity collected at the trauma department of Naousa and Kilkis Hospital over 4 years from December 2018 to December 2022 were analyzed, processed, and reviewed with a minimum follow-up of 6 months. The purpose of this article is to analyze the frequency of various types of fractures of the proximal extremity of the femur and to identify the etiological factors that contribute to these injuries, thus providing a comprehensive understanding of these traumatic events to treat them. The study showed that there is a preponderance of trochanteric fractures, with an increased frequency in the 75-89 age group and a predominance of femoral neck fractures in women, mainly caused by falls. External surgical approaches, standard gamma nail, and bipolar treatment had "excellent/good" functional results reflecting the success of the surgical interventions. The high frequency of anatomical reductions underlines the attention paid to the quality of the procedures. [ABSTRACT FROM AUTHOR]

Aim: To explore the preoperative radiographic features and reduction methods of irreducible trochanteric and subtrochanteric fractures of the femur and to compare the perioperative characteristics and prognoses of irreducible and reducible fractures. Methods: The data of 1235 patients with femoral trochanteric fractures surgically treated in our hospital between January 2010 and January 2021 were retrospectively analyzed. According to the inclusion criteria and exclusion criteria, 1163 cases of femoral trochanteric and subtrochanteric fractures were included in this study. Fractures in which good or acceptable reduction could not be reached by closed manipulation were defined as irreducible fractures. The preoperative radiographic features, fracture displacement patterns after closed manipulation and intraoperative reduction methods used to treat irreducible fractures were analyzed, and the perioperative characteristics and prognoses of irreducible fractures and reducible fractures were compared. Results: There were 224 patients in the irreducible group and 939 patients in the reducible group. According to the radiographic features of fractures, irreducible fractures could be divided into four types: those with interlocking of the fracture, sagging of the femoral shaft, splitting of the lateral wall or medial wall, and comminution of the subtrochanteric area. Various kinds of reduction techniques were needed for different types. Conclusions: The incidence of irreducible trochanteric fractures was 15.4%, while the incidence of irreducible subtrochanteric fractures was 84.6%. According to the radiographic features of fractures, they can be divided into four types. It is important to identify irreducible fractures preoperatively and make comprehensive plans to the greatest extent possible to shorten the operation time, reduce intraoperative blood loss, and reduce the incidence of complications. [ABSTRACT FROM AUTHOR]

Introduction: Proximal femoral nailing (PFN) compares favourably with dynamic hip screw in terms of surgical time, intra-operative blood loss and lag screw cut out in unstable inter-trochanteric fracture. However, data on difficulties faced during the fixation process are lacking. Therefore, the study was planned with the aim to identify difficulties encountered during fixation of trochanteric fractures with PFN in the patients. Materials and Methods: Two hundred patients with trochanteric fractures aimed for the operative procedure with PFN were included in the study. Patients with associated fracture of neck of femur, the shaft of the femur of the same side, with polytrauma, with multiple fractures, with pathological fractures and/or unwilling to participate in the study were excluded. Bone mineral density was evaluated using Singh's index. Fixation of trochanteric fractures was done using PFN. Results: More than 70% of the study participants were elderly, 53% of the participants were males, while 91% of the total participants belonged to a rural region. Hypertension was the most common comorbidity in 21% of the patients, followed by anaemia (14.5%) and diabetes (9%). 73% of the patients had grade 3 Singh's index. 53.5% of the patients had intra-trochanteric left femur while the remaining 46.5% of the patients had intra-trochanteric right femur. The reduction was the most common difficulty (26%) followed by entry point difficulty (21%) and guidewire passage (12.5%). No difficulty was observed in 29% of the patients. Conclusion: Achievement of good reduction between two main fragments without varus malalignment and placement of hip screw in a correct position are two important technical aspects that prevent most of the complications associated with these procedures. [ABSTRACT FROM AUTHOR]

Background: The treatments for trochanteric fractures try to regain early mobility and limit morbidity and risk of reoperations. The most currently used dynamic hip screw (DHS) and the proximal femoral nail (PFN) are both with pros and cons. We aimed to assess the comparative effectiveness of these interventions for trochanteric fractures by evaluating the surgical performance and postoperative outcomes. Methods: PubMed, Web of Science and Cochrane Central Register were searched for RCTs comparing DHS and PFN for trochanteric fractures. All selected studies and the risk of bias were assessed. Clinical data including operative time, intraoperative blood loss, intraoperative fluoroscopy time, successful closed reduction and complications like nonunion, implant failure and reoperation were recorded. Random-effects models were used in Review Manager software, and GRADE was applied for the interpretation of the evidence. Results: From 286 identified trials, twelve RCTs including 1889 patients were eligible for inclusion; six RCTs directly comparing DHS with PFN, while other six compared DHS with proximal femoral nail antirotation (PFNA). Compared to DHS, PFN had shorter operative time and led to less intraoperative blood loss. However, DHS need less intraoperative fluoroscopy time than PFN. No difference was seen for the achievement of closed reduction. For risk of postoperative complications, no difference was seen between PFN and DHS for non-union, risk of implant failure and revision surgery. Conclusions: PFN(A) resulted in a shorter operative time and less intraoperative blood loss compared to DHS. However, no difference was seen for postoperative complications. Trial registration PROSPERO: CRD42021239974. [ABSTRACT FROM AUTHOR]

Objective: To determine if there was a difference in the risk of post-operative complications associated with the use of different intramedullary (IM) devices in the treatment of unstable AO OTA 31-A trochanteric fractures.Design: Systematic literature review and meta-analysis.Methods: A systematic literature review was carried out in January 2022 in the Embase, MEDLINE and Cochrane databases. Studies comparing INTERTAN™ to other intramedullary nails for the treatment of AO OTA 31-A trochanteric fractures were selected for inclusion. After data extraction, meta-analyses were carried out on postoperative outcomes, with specific focus placed on unstable fracture patterns.Results: Twenty-three studies were suitable for inclusion, of which seventeen reported on outcomes in unstable fractures. INTERTAN reduced the risk of revision/reoperation by 64% (RR 0.36, 95% CI 0.25 to 0.54, p <0.0001), implant failures by 62% (RR 0.38, 95% CI 0.25 to 0.57, p<0.0001) and hip and thigh pain by 50% (RR 0.50, 95% CI 0.35 to 0.71, p=0.0001) in unstable fractures. No differences were noted between IM nail designs for infection rates, healing time, non-union rates, femoral shortening, or Harris Hip Score.Conclusions: The INTERTAN IM nail may reduce incidence of implant-related complications, hip and thigh pain, and the need for revision/reoperation without compromising clinical and functional outcomes. [ABSTRACT FROM AUTHOR]

Introduction and objectives: New generation cephalomedullary nails are, currently, widely used for the treatment of trochanteric proximal femoral fractures. This study aims to compare the midterm outcomes and complication rates in patients with unstable 31A2 fractures treated with two different lengths of nails. Materials and methods: Retrospective study including 123 pertrochanteric proximal femoral fractures 31A2 treated with Gamma3 nail® between January/2017 and January/2019. 19 patients were excluded, resulting in a total of 104 patients with a minimum follow-up of 1 year. Two groups, Long Dynamic Gamma3 Nail (LGN) and Short Static Gamma3 Nail (SGN), with 52 patients each were compared. Mean age was 81 years (range 50–99), being 78% female. Preoperative variables included: age, medical comorbidities, mobility, anesthetic risk, associated fractures, hemoglobin and hematocrit values. Postoperatively, functional and radiological results, quality of life, hemoglobin and hematocrit concentration, transfusion requirements, mobility, and pain were evaluated. Additionally, perioperative complications were also analyzed, such as malunion, non-union, infection rates, cut-outs, and peri-implant fractures. Results: A correct radiological fracture reduction was obtained in 73% of the cases (73% SGN/74% LGN). Two patients in LGN group had intraoperative complications (greater trochanter fractures). 38% of the patients with LGN presented nail tip impaction upon the distal anterior femoral cortex, associated with anterior knee pain. Blood loss and operative time was statistically different between groups. Despite the previous, no differences in clinical outcomes and quality of life were found. Conclusions: The present study comparing two lengths of the Gamma3 Nail in 31A2 fractures showed no overall differences in clinical and radiological outcomes, and complication rates. However, the use of LGN was associated with a statistically significant higher blood loss and operative time, and a tendency for increased need for transfusion, and anterior knee pain and reoperation rate. Therefore, we recommend the use of locked SGN in the treatment of 31A2 fractures. [ABSTRACT FROM AUTHOR]

Introduction: Trochanteric entry nailing potentially causes damage to the gluteus medius (GM) tendon. The aim of this study is to determine the amount of iatrogenic damage to the tendon during reaming by measuring the thickness and stiffness of the GM muscle in patients with trochanteric fractures who are treated with trochanteric entry nails using gray-scale ultrasound (GSUS) and shear-wave elastography (SWE). Methods: Thickness and stiffness values of bilateral GM muscles in 40 patients with trochanteric fractures treated with PFN-A were measured using GSUS and SWE at post-operative sixth week or later. Harris Hip Scores and bilateral active hip abduction measurements of the patients were recorded. The data was analyzed using statistical methods to assess the extent and amount of iatrogenic injury that occurred during trochanteric entry. Results: Mean age of the patients was 70. Thirty-three fractures occurred with low-energy trauma. In the SWE evaluation, there was no statistically significant difference between ipsi- and contralateral GM muscle thickness measurements or ipsi- and contralateral GM muscle stiffness measurements. Also, the difference between the clinical evaluation results of the ipsi- and contralateral hip functions was not statistically significant. Discussion: In this study, we used the Harris Hip Score and hip abduction range of motion in addition to SWE and GSUS in order to assess the patients' functional status. There are studies in the literature that report significant injury to the GM tendon with cephalomedullary nailing. The majority of these studies are cadaver studies with only clinically irrelevant or uncertain evidence. In this study, we aimed to evaluate the potential negative effects of the iatrogenic damage to the bone-tendon junction during nailing, by measuring the stiffness (consistency) and atrophy of the GM muscle alongside the functional evaluation. Conclusion: We have found no statistically significant difference between operated and intact side GM muscles in terms of stiffness, atrophy, and functional evaluation in patients with TFs treated using PFN-A. The results of our study should not be interpreted as trochanteric entry nailing does not cause any damage on the GM tendon. [ABSTRACT FROM AUTHOR]

Background: Fractures of the proximal femur are a big challenge in traumatology. Rapid strides in implant and instrumentations in quest of ideal fixation of subtrochanteric femoral fractures have made various options available. Objective: The present study aims to study the role of standard proximal femoral nail (PFN) in the management of these fractures. This study aimed to evaluate the results of treatment of subtrochanteric femoral fractures using PFN. Patients and methods: This prospective study conducted at Orthopedic Department, Zagazig University Hospital, from November 2020 to July 2021. It included 24 patients, complaining of closed subtrochanteric fractures treated with PFN (Gamma intramedullary nail). The age ranged from 23 to 87 years (with mean 54.21 years), 13 of them were males and 11 females. Road traffic accident (RTA) represented the most common mechanism of injury in 10 patients (41.7%) while fall down represented (37.5%) in 9 patients, and fall from height in 5 patients (20.8%). Results: there was statistically significant difference in HHS among patients with different age groups, mechanism of injury and presence of diabetes mellitus (DM) as associated condition. Statistically there was significant correlation between type of reduction and diabetes mellitus with Harris hip score. Conclusion: This study concluded that the Gamma nail is an excellent choice in treatment of subtrochanteric fractures as it has many advantages as allowing for early functional exercise and full weight-bearing of the affected limb, shortening the duration of operation, high rotation stability, small wounds and minimizing blood loss along with risk of infection. [ABSTRACT FROM AUTHOR]

Background : Fractures of the proximal femur are a big challenge in traumatology. Rapid strides in implant and instrumentations in quest of ideal fixation of subtrochanteric femoral fractures have made various options available. The present study aims to evaluate the treatment of subtrochanteric femoral fractures by Gamma nail. This study was aimed to evaluate the results of treatment of subtrochanteric femoral fractures using proximal femoral nail. Patients and methods: This prospective study conducted at orthopedic department, Zagazig university hospital, from November 2020 to July 2021, includes 24 patients, complaining of closed subtrochanteric fractures treated with proximal femoral nail (Gamma Intramedullary nail) The age was ranged from 23 to 87 years (with mean 54.21 years), 13 of them were males and 11 females. Road traffic accident (RTA) represent the most common mechanism of injury in 10 patients (41.7%) while fall down represent 9 patients) (37.5%) and fall from height 5 patients (20.8%). Results: there was statistically significant difference in HHS among patients with different age groups, mechanism of injury and presence of D.M as associated condition. Statistically there were significant correlation between type of reduction and diabetes mellitus with Harris hip score. Conclusion: This study concluded that the Gamma nail is a preferred choice in treatment of subtrochanteric fractures as it has many advantages as allows for early functional exercise and full weight-bearing of the affected limb, short the duration of operation, high rotation stability, small wounds and minimize blood loss along with risk of infection. [ABSTRACT FROM AUTHOR]

For femoral fractures of the trochanteric region in children and adolescents, only two mechanisms have been identified to cause a fracture of the proximal femur: high-energy trauma or predisposing bone pathologies with inadequate trauma (e.g., simple fall, movement). We identified 20 patients between 1993 and 2018 with a trochanteric fracture under the age of 18 (12 males; 8 females; mean age, 12 years; range, 4–17 years) who were treated operatively at our department. The mean follow-up of all patients was 50.06 months. All 20 patients were treated operatively. Complications occurred after a mean time of 6.27 months (range, 0.47 to 12.07 months) in two patients. Harris Hip Score was evaluated in all patients with a mean score of 94.16 (range 11 to 100). Eighty-five percent of the patients reached an excellent clinical outcome after treatment. Trochanteric femoral fractures in children and adolescents are very rare accounting for only 1% of all trochanteric fractures. Excellent long-term results can be achieved with an adequate fracture reduction. Conclusion: Physicians treating pediatric trauma have to be aware of other predisponding diseases when low-energy trauma leads to a trochanteric fracture as in this study, 50% of the trochanteric fractures were associated with bone pathologies. What is Known: • Trochanteric femoral fractures in children and adolescents are very rare • In all patients with trochanteric femoral fractures, malignancies have to be ruled out What is New: • Awareness of an underlying bone pathology in a high number of cases • Awareness for necessity of a good fracture reduction leading to highly satisfactory results [ABSTRACT FROM AUTHOR]

Background: The trochanteric stabilizing plate (TSP) is used as an adjunct to the sliding hip screw (SHS) in unstable trochanteric and subtrochanteric fractures. We wanted to describe the choice of implant for trochanteric fractures with a focus on the TSP in Norway. Methods: A total of 20,902 fractures from the Norwegian Hip Fracture Register treated surgically in 43 hospitals from 2011 to 2017 were included. Logistic regression analyses were performed to detect factors potentially influencing implant choice. Results: The mean age was 83 years, and 15,137 (72%) were women. An SHS was used in 13,273 (63%) fractures, of them 4407 (33%) with a TSP. Fracture classification was the most important determinant of TSP. In cases where an SHS was used, the odds ratio (OR) for using a TSP was 14 for AO/OTA 31A2 fractures and 71 for AO/OTA 31A3 and subtrochanteric fractures, compared to AO/OTA 31A1 fractures. The probability of receiving a TSP was higher in urban, academic, and high-volume hospitals (OR 1.2 to 1.3) and lower in Central and Northern Norway (OR 0.3 to 0.7). The use of an intramedullary nail (IMN) (n = 7629 (36%)) was also to a degree decided by fracture classification (OR 1.8 to 5.3). However, hospital factors, with OR 0.1 to 0.4 for IMN in academic, urban, and high-volume hospitals and OR 1.5 to 2.6 outside South-Eastern Norway (all p < 0.001), were also important. Conclusions: Fracture classification was the main determinant for TSP use. Any additional benefit from a TSP on postoperative fracture stability or clinical outcome needs to be clarified. [ABSTRACT FROM AUTHOR]

Trochanteric lateral wall fracture (LWF) indicates instability and is found to be an important predictor of reoperations following trochanteric fracture fixation. A single unified technique for lateral wall reconstruction may not adequately stabilize all the fracture patterns. We have presented morphology specific lateral wall reconstruction techniques using cerclage wire around proximal femoral nails. Various LWF patterns have been simplified into three types. Type-specific lateral wall reconstruction techniques using cerclage wire were adopted in 49 consecutive unstable trochanteric fractures presented to our institute between 2016 and 2018. We analyzed the fracture pattern, fixation method used, union time, and complications. The functional outcome was analyzed using the Harris hip score (HSS). The mean follow-up period was 13 months (range 10–36 months). The mean age of the population was 66 years (range 36–91 years). There were 15 patients with type 1 LWF pattern, 26 patients with type 2, and 8 were of type 3 pattern. The mean operating time was 66 min. The mean union time was 14 weeks (10–24 weeks). HSS was excellent in 9 patients, good in 33 patients, fair in 4 patients, and poor in 5 patients. Complications include one patient with avascular necrosis (AVN) of the femoral head, varus collapse with non-union in one patient, screws back out in one patient, superficial infection in 4 patients, and distal screw breakage in one patient. Type 2 is the most common LWF type in our study. In unstable trochanteric fractures, morphology specific lateral wall reconstruction using cerclage wire loops around the proximal femoral nail is a simple technique with promising results with minimal complications. [ABSTRACT FROM AUTHOR]

Background: A comparative analysis of the role of various proximal femoral nail antirotation (PFNA) lengths in the union of trochanteric fracture in elderly patients treated with long and short PFNA. Objective: To investigate the significance of PFNA length in trochanteric fracture union in elderly patient. Materials and methods: A retrospective review study was conducted in elderly patients with trochanteric fractures treated between March 2010 and December 2017 in a tertiary care hospital. Hospital records of 517 patients who were treated for trochanteric fracture with various sizes of PFNA, were analyzed as per inclusion criteria and finally 503 patients records were included in the study, of which 261 were treated with short PFNA and 242 with long PFNA. The patients were allocated to two groups: those treated with long nail (n   =   2 4 2) and short nail (n   =   2 6 1). Demographic data were comparatively analyzed regarding the time of fracture union and complications. Results: In this study, no remarkable differences were noted between two groups with regards to types of fracture, time from injury to surgery and duration of hospital stay. The duration of surgery in a short PFNA was significantly less (60.5 min) compared to that of a long PFNA (82.2 min). However, the time taken for fracture to unite was not statistically significant. Conclusions: The variation in the length of the nail whether short or long does not affect union in trochanteric fracture in the elderly however surgical duration for short nail was much less than the long nail. [ABSTRACT FROM AUTHOR]

Aim: Blade and screw type nail designs are widely used in the treatment of trochanteric fractures. Although, blade designs were put as last generation nails on the market, it remains unclear which design has better clinical and radiographic outcomes. The purposes of our study were to compare two cephalo medullary nail designs as helical blade and lag screw type for trochanteric fractures (AO/OTA 31-A type fractures), to analyse and compare clinical and functional outcomes, complication rates. Material and Methods: This study comprised 101 patients with trochanteric fractures treated with either proximal femoral nail antirotation (PFNA) as blade type nail, or Peritrochanteric nail (PTN) as screw type nail for a minimum of 6 months. We assessed comorbidities, fracture type pre-operatively, operation time, blood loss, reduction quality, tip apex distance intra and post operatively, medical and mechanical complications, partial, full weight bearing time, Harris hip scores and Short form 36 scores and mortality during follow up period. Results: There was no significant difference in the operation time, blood loss, total mechanical or medical complications, partial, full weight bearing time, mortality rate, and Harris Hip scores of PTN or PFNA groups. Lateral migration and varus collapse rates of patients treated with PFNA were significantly higher than patients treated with PTN. However particular SF 36 scores of PFNA group were significantly higher than PTN group. Conclusion: Blade type nail designs caused more varus collapse than screw type nails in the treatment of elderly trochanteric fractures, however these radiographic complications didn't influence on clinical outcomes of patients. [ABSTRACT FROM AUTHOR]

Introduction: For trochanteric fractures, helical blade placement is crucial to the prognosis of operations. Existing measurement methods used for blade placement include the Cleveland zone, the tip-apex distance (TAD), the calcar-referenced tip-apex distance (CalTAD), and the Parker's ratio. These methods all lack a direct view on blade direction. The current study proposed the axis-blade angle (ABA) to solve direction problem and investigated its clinical applicability.Methods: A retrospective study collected 156 patients between May 2014 and February 2018. The occurrence of mechanical complications was analyzed in relation to age, gender, fracture side, American Society of Anesthesiologists classification, fracture classification, reduction quality, bone quality, the Cleveland zone, the Parker's ratio, the TAD, the CalTAD, and the ABA.Results: 119 patients, including 25 with mechanical complications, were suitable for full analysis. In the univariate analysis, the Cleveland zone, reduction quality, the TAD, the CalTAD and the ABA were statistically associated with mechanical complications. In the multivariate analysis, reduction quality (p = 0.008) and the ABA (p < 0.001; adjusted OR 0.86;95% CI 0.77 to 0.96) showed significant results, which indicated that reduction quality and the ABA were two independent influencing factors for mechanical complications. Calculation of the receiver operating characteristic (ROC) curve indicated that the ABA was a reliable predictor of mechanical complications at the cut-off of -10°.Conclusions: The ABA provides instruction for the intraoperative adjustment of guide wire direction. Placing the helical blade with an ABA > -10° can effectively reduce the risk of mechanical complications. [ABSTRACT FROM AUTHOR]

Objective: To assess the differences in bone mineral density (BMD) and hip geometry in trochanteric and cervical hip fractures in elderly Chinese patients. Methods: A consecutive series of 196 hip fracture patients aged over 50 years was recruited from November 2013 to October 2015, including 109 cases of cervical fractures (36 males and 73 females) and 87 cases of trochanteric fractures (34 males and 53 females). All patients were evaluated through dual‐energy X‐ray absorptiometry, and baseline characteristics, BMD and structural parameters were collected and reviewed. Results: There were statistically significant differences in age, height, and body mass index between patients with each type of fracture, and patients with trochanteric fractures were older than those with cervical fractures, especially in women. The BMD in trochanteric fractures was markedly lower than in cervical fractures in all five sites of the hip by an approximate reduction of 10%, in both men and women. The cross‐sectional area, cross‐sectional moment of inertia, and the cortical thickness in the cervical fracture group were significantly higher than in the trochanteric fracture group. However, the buckling ratio of both the femoral neck and trochanteric region were significantly lower in the cervical fracture group. Age (/10 years), cross‐sectional moment of inertia in femoral neck and buckling ratio in trochanteric region were significant risk factors for trochanteric fractures compared with cervical fractures. Conclusions: Compared with cervical hip fractures, patients with trochanteric fractures were older, had a lower BMD, and had less bone mechanical strength, especially in female patients. Age, femoral neck cross‐sectional moment of inertia (FNCSMI), and trochanteric region buckling ratio (ITBR) were stronger risk factors for trochanteric hip fractures than for cervical fractures. [ABSTRACT FROM AUTHOR]

Purpose: Isolated greater trochanteric (GT) fractures are often identified using plain radiography of patients with post-traumatic hip pain. In many cases, the fracture extends to form an occult intertrochanteric fracture. We conducted a study to determine the frequency of occult intertrochanteric fractures in patients diagnosed with isolated GT fractures using plain radiographs. Materials and Methods: Among 3,017 individuals who visited our emergency department with a trauma-induced pertrochanteric femur fracture between July 2004 and March 2018, 100 patients diagnosed with isolated GT fractures using plain radiographs were retrospectively analyzed. Patients were divided into two groups, those with: i) isolated GT fractures (group A) and ii) occult intertrochanteric fractures (group B). In addition, plain radiographs, magnetic resonance imaging results, and treatment methods were further analyzed in each group. If surgery treatment was needed, it was performed by one surgeon, and in all cases, a 2-hole dynamic hip screw was used. Results: Among the 100 cases of isolated GT fractures diagnosed using plain radiograph, additional examinations revealed that 10 (10.0%) were suffering from isolated GT fractures alone, while the remaining 90 (90.0%) were further diagnosed with occult intertrochanteric fracture. Gender, age, mechanism of injury, and bone mineral density did not correlate with fracture type. Conclusion: In our analysis, 90% of injuries initially diagnosed as isolated GT fractures were found to extend into occult intertrochanteric fractures upon further examination with additional imaging modalities. Therefore, additional evaluation should be performed to test for the potential presence of occult intertrochanteric fractures and to establish appropriate treatment plans. [ABSTRACT FROM AUTHOR]

Objectives: Femoral intertrochanteric fractures are among the most common fractures in the elderly. There are various classification systems in intertrochanteric fractures. The aim of these classification systems is to help surgeons choose an appropriate treatment. The treatment of femoral intertrochanteric fractures depends on the results of a stability evaluation using imaging studies. However, it is difficult to evaluate the true fracture line using plain X‐ray films, especially on the sagittal plane and for intertrochanteric fractures with complex morphologies. The aim of the current study was to determine whether three‐dimensional CT (3DCT) improves the reproducibility of stability evaluation for femoral intertrochanteric fractures. Methods: This was a single‐center observational study of intertrochanteric fractures. We retrospectively collected patients in our hospital with intertrochanteric fractures that underwent plain X‐ray (anteroposterior, lateral view) CT scans with axial images (2DCT) and 3DCT for an injured hip between 1 December 2011 and 30 November 2015. The exclusion criteria were pathological fractures (due to metastasis or primary bone tumors) and previous intertrochanteric surgery. During this period, 61 patients were enrolled. Two patients were excluded because lateral view X‐rays were not available. A total of 59 patients (27 women, 32 men) with an average age of 77 years (range, 55–96 years) were included in our final analysis. The stability evaluation (i.e. stable or unstable) and implant choices (i.e. dynamic hip screws or Gamma nail) were recorded independently by four observers (two attending physicians and two residents). All images were reviewed and classified using the AO/OTA and Evans modified by Jensen (EVJE) classification systems. The session was repeated after a 3‐month wash‐out period. The inter‐observer agreement was evaluated using the Kappa test. Results: The inter‐observer agreements, measured by the mean weighted kappa values (expressed as X‐ray vs 3DCT) were as follows: For stability evaluation, the mean kappa values for attending physicians and residents were 0.68 versus 0.76 and 0.55 versus 0.56. For implant choices, the mean kappa values for attending physicians and residents were 0.68 versus 0.76 and 0.57 versus 0.65. For AO/OTA classification, the values for attending physicians and residents were 0.67 versus 0.65 and 0.70 versus 0.81. For EVJE classification, the values for attending physicians and residents were 0.66 versus 0.63 and 0.56 versus 0.55. Conclusions: Three‐dimensional CT improved the reproducibility of stability evaluation for femoral intertrochanteric fractures. Preoperative CT scanning may provide a diagnostic benefit for evaluating the stability of intertrochanteric fractures. [ABSTRACT FROM AUTHOR]

Cut-out complication remains a major unsolved problem in the treatment of trochanteric hip fractures. A better understanding of the three-dimensional fracture-implant motions is needed to enable further development of clinical strategies and countermeasures. The aim of this clinical study was to characterise and quantify three-dimensional motions between the implant and the bone and between the lag screw and nail of the Gamma nail. Radiostereometry Analysis (RSA) analysis was applied in 20 patients with trochanteric hip fractures treated with an intramedullary nail. The following three-dimensional motions were measured postoperatively, at 1 week, 3, 6 and 12 months: translations of the tip of the lag screw in the femoral head, motions of the lag screw in the nail, femoral head motions relative to the nail and nail movements in the femoral shaft. Cranial migration of the tip of the lag screw dominated over the other two translation components in the femoral head. In all fractures the lag screw slid laterally in the nail and the femoral head moved both laterally and inferiorly towards the nail. All femoral heads translated posteriorly relative to the nail, and rotations occurred in both directions with median values close to zero. The nail tended to retrovert in the femoral shaft. Adverse fracture-implant motions were detected in stable trochanteric hip fractures treated with intramedullary nails with high resolution. Therefore, RSA method can be used to evaluate new implant designs and clinical strategies, which aim to reduce cut-out complications. Future RSA studies should aim at more unstable fractures as these are more likely to fail with cut-out. [ABSTRACT FROM AUTHOR]

The ideal implant for the treatment of an unstable intertrochanteric femoral fracture is still a matter of discussion. The aim of this systematic review is to conduct a network meta-analysis of randomized controlled trials (RCTs) comparing clinical outcomes between dynamic hip screws (DHS), Medoff sliding plating, percutaneous compression plating (PCCP), proximal femoral nails (PFN), Gamma nails and less invasive stabilization system fixation in femoral trochanteric fractures in the elderly. These clinical outcomes consist of total intra-operative time, intra-operative fluoroscopy time, intra-operative blood loss, blood component transfusion, length of hospital stay, postoperative general complications, wound complications, late complications and reoperation rates. This systematic review was conducted using PubMed and Scopus search engines for RCTs comparing clinical outcomes between treatments from inception to February 22, 2015. Thirty-six of 785 studies identified were eligible. Compared to the other implants, PCCP showed the lowest total operative time and units of blood transfusion with an unstandardized mean difference (UMD) of 29.27 min (95% CI 5.24, 53.50) and 0.89 units (95% CI 0.52, 1.25). The lowest incidence of general complications, wound complications and late complications of PCCP was 0.09 (95% CI 0.04, 0.18), 0.01 (95% CI 0.01, 0.04) and 0.05 (95% CI 0.02, 0.11), respectively, when compared to others. The lowest fluoroscopic time was with DHS with an UMD of 0.24 min (95% CI 0.16, 0.32), whereas the lowest blood loss and shortest hospital stay were with PFN with an UMD of 233.61 ml of blood loss (95% CI 153.17, 314.04) and 7.23 days of hospital stay (95% CI 7.15, 7.31) when compared to all other fixation methods. Reoperation rates of all implants had no statistically significant difference. The network meta-analysis suggested that fixation with PCCP significantly shortens operative time and decreases the units of blood transfusion required, while also lowering risks of general complications, wound complications and late complications when compared to fixation. Use of PFN showed the least intra-operative blood loss and shortest hospital stay. Multiple active treatment comparisons indicate that PCCP fixation in trochanteric fractures in the elderly is the treatment of choice in terms of intra-operative outcomes and postoperative complications. [ABSTRACT FROM AUTHOR]

Background: The reverse oblique trochanteric fractures are common fractures and its treatment poses a challenge. The purpose of this study was to compare the biomechanical parameters of the construct using proximal femoral nail (PFN) and proximal femoral locking compression plates (PFLCP) in these fractures using cadaveric specimens.Materials and Methods: Twenty freshly harvested cadaveric femoral specimens were randomly assigned to two groups after measuring bone mineral density, ten of which were implanted with PFN and the other ten with PFLCP. The constructs were made unstable to simulate reverse oblique trochanteric fracture (AO type 31A3.3) by removing a standard size posteromedial wedge. These constructs were tested in a computer controlled cyclic compressive loading with 200kg at a frequency of 1 cycle/s (1Hz) and test was observed for 50,000 cycles or until implant failure, whichever occurred earlier. Peak displacements were measured and analysis was done to determine axial stiffness and subsidence in axial loading.Results: All the specimens in PFN group completed 50,000 cycles and in PFLCP group, seven specimens completed 50,000 cycles. Average subsidence in PFN group was 1.24±0.22mm and in PFLCP group was 1.48±0.38mm. The average stiffness of PFN group (72.6±6.8N/mm) was significantly higher than of PFLCP group (62.4±4.9N/mm) (P=0.04). The average number of cycles sustained by PFLCP was 46634 and for PFN group was 50,000 (P=0.06).Conclusion: The PFN is biomechanically superior to PFLCP in terms of axial stiffness, subsidence and number of specimens failed for the fixation of reverse oblique trochanteric fractures of femur. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study is to evaluate the risk factors for the occurrence of cut-out of proximal femoral nail by a lag screw as the treatment for intertrochanteric fractures. Materials and Methods: A total of 151 patients (76 males and 75 females; mean age, 73.7±12.1 years), who were diagnosed with intertrochanteric fracture at Gyeongsang National University Hospital between January 2011 and March 2016, with a follow-up of at least for 6 months were included in this retrospective study. Various risk factors, such as demographic data, osteoporosis, collodiaphyseal angle (CDA) (≤130˚ or >130˚), tip-apex distance (TAD) (≤25 mm or >25 mm), and the position of lag screw in the femur head (quadrant) related to the occurrence of cut-out were taken into consideration. The strength of association for each factor was determined through the calculation of the odds ratio (OR), within the 95% confidence interval (CI). First, we performed univariate logistic regression analyses for all variables; then, we performed a multivariate logistic regression analysis, using only the significant variables that had resulted from the univariate analysis. Results: Among the 151 cases, the occurrence of cut-out was observed in 14 cases (9.3%). In a univariate analysis, the fracture patterns based on the AO/OTA classification (p=0.045), CDA (p<0.001) and the position of lag screw in the femur head (quadrant) (p=0.001) showed a significant association with the occurrence of the cut-out. However, TAD was not significantly associated with the cut-out (p=0.886). Various factors, which were significant in univariate analyses, were included in multivariate analyses. In multivariate analyses, CDA (OR, 12.291; 95% CI, 2.559-59.034; p=0.002), and quadrant (OR, 7.194; 95% CI, 1.712-30.303; p=0.007) were significantly associated with the cut-out. Conclusion: Valgus reduction and proper position of lag screw were critical for the prevention of occurrence of cut-out when treating intertrochanteric fracture using proximal femur nail. [ABSTRACT FROM AUTHOR]

Introduction. Trochanteric fractures are frequent and generally associated with bone fragility. There is still debate on the best fixation device to treat stable or rather stable trochanteric fractures: we report our clinical and radiological results of fixation with Proximal Femoral Nail "antirotation" (PFNa) in a population of patients compared to a control group treated by Sliding Hip Screw (SHS). Materials and methods. A prospective study was conducted in 71 consecutive patients treated by PFNa (group A), and 69 by a SHS (group B), with a mean age of 81.6 and 83.4 years respectively. Short Form 12 was administered to check postoperative results, and the following parameters were evaluated: range of motion, evaluation of pain, gait ability, X-rays, and Tip Apex Distance Index. Results. A minimum follow-up was conducted in 128 patients: 66 subjects belonging to the PFNa group and 62 to the DHS group. All patients in the group A were able to reach partial or full weight-bearing on the operated leg before leaving the hospital. Forty-four patients (63.8%) of the group B were able to walk with partial weight-bearing before discharge. We recorded 17 complications with a final overall percentage of 17.2% on the overall study population with one single case of failure in both the two groups. Discussion. A statistical significance (p<0.01) of superiority for PFNa was demonstrated regarding surgical time, amplioscope time, intraoperative blood loss, hospital stay, recovery of weight-bearing before discharge. Less significant results (p<0.05) were found for walking ability at the three-months follow-up and patients' satisfaction 6 months after surgery. Conclusions. PFNa may be considered an useful choice for the treatment of stable or rather stable trochanteric fractures as well as DHS. The light superiority of PFNa may be principally related to its mechanical advantages. [ABSTRACT FROM AUTHOR]

The article reviews in detail various fixation methods for intertrochanteric fractures. These include the dynamic hip screw (DHS) as the most commonly used implant and extensively studied implant for extra-capsular hip fractures, the cephalomedullary nails which are the most commonly used fracture fixation device for intertrochanteric fractures and the proposed hemiarthroplasty as an alternative to internal fixation for unstable intertrochanteric fracture in elderly patients.

Vascular injury as a consequence of dislocated bone fragments after hip fractures is a rare complication. We report a case of a 78-year-old male who developed a pseudoaneurysm of the profunda femoris artery during rehabilitation after intramedullary fixation for a pertrochanteric hip fracture. As this procedure was minimally invasive, open reposition and fixation of the dislocated lesser trochanter were not performed. The pseudoaneurysm was diagnosed through duplex ultrasound and CT angiography and treated with thrombin injections and an endovascular Wallgraft covered stent. The imaging features are described in the article. Although a pseudoaneurysm is a rare complication after hip fractures, the development should be considered, in particular when symptoms such as pulsatile swelling or venous engorgement are presented. [ABSTRACT FROM AUTHOR]

Introduction Avascular necrosis of the femoral head (ANFH) following trochanteric fractures (TFx) is infrequent. The causal relationship between ANFH and TFx remains controversial. Although several major risk factors for ANFH have been proposed, most of them remain under discussion. In this study we undertook a systematic review of the literature to investigate the incidence of AVN, risk factors and outcomes following Tfx fixation. Materials and methods A comprehensive review of the literature was undertaken using the PRISMA guidelines with no language restriction. Case reports of ANFH and series of TFx with or without cases of ANFH published between inception of journals to December 2013 were eligible for inclusion. Relevant information was divided in two sections. Part I: included the analysis of detailed case reports of ANFH, either published isolated or included in series of TFx, with the objective of establishing potential risk factors, clinical and radiological presentation, time to development, treatment and outcome of this complication. Part II: analyzed series of TFx, which included cases of ANFH with or without details of aetiology, treatment modalities and outcomes, with the objective of assessing the incidence of ANFH in TFx. Results Overall 80 articles with 192 cases of ANFH after TFx met the inclusion criteria. The most probable developmental pathway appears to be a disruption of the extra osseous arterial blood supply to the femoral head. Suggested risk factors included high-energy trauma with fracture comminution and displacement, and an atypical course of the fracture line, more proximal, at the base of the neck. Most cases were diagnosed within the first two years after fracture. The clinical and radiological features appear to be similar to those of idiopathic avascular necrosis of the femoral head. The incidence of AVFH with a minimum of 1-year follow-up was calculated 0.95%, and with a minimum 2-year follow-up it was 1.37%. Total hip replacement was the mainstay of treatment. Conclusion The incidence of AVFH after Tfx fixation is small 1.37% within the first 2 years of injury. Risk factors for the development of this complication are related to the severity of trauma, fragment geometry and fracture displacement. Optimum surgery of these fractures cannot guarantee prevention of ANFH. [ABSTRACT FROM AUTHOR]

Background Trochanteric fractures (TF) have become a major source of morbidity and mortality in elderly. We conducted this study to compare the outcomes of unstable trochanteric fractures treated with the InterTan nail and Gamma3 nail. Methods Between January 2008 and May 2013, patients aged 60 years or older with a diagnosis of unstable TF treated with InterTan nail or Gamma3 nail were included. Patients treated with InterTan nail were pair-matched to patients treated with Gamma3 nail in a 1:2 ratio. Radiographs were obtained at 1, 3, 6, and 12 months follow-up, and all implant position changes, complications, fixation failures and functional scores were recorded. Results Eighty-seven patients were included in the InterTan nail group, and 174 pair-matched patients were included in the Gamma3 nail group. Preoperative scores were similar between the 2 groups. There are significant improvements postoperatively in both groups. The incidence of cut-out and femoral shaft fracture were significantly higher in the Gamma3 nail group than the InterTan nail group (P = 0.024 and P = 0.044, respectively). Patients treated with the InterTan nail experienced longer fluoroscopy and operative times. Conclusions The InterTan nail may have a tendency in better outcomes for patients with unstable TF. However, the limited period of follow-up and inherent defects of nonrandomized trials indicate that better-designed randomized controlled trials will be required. [ABSTRACT FROM AUTHOR]

The inverse relationship between proximal femoral fracture incidence and hip osteoarthritis remains controversial. However, femoral neck fractures rarely occur in patients with hip osteoarthritis, suggesting a protective effect of osteoarthritis. We sought to determine if the severity of osteoarthritis influenced fracture type. We examined the radiographs of 190 consecutive patients treated at our institution after hip trauma. They were divided into three groups according to the outcome of the trauma: femoral neck fracture; trochanteric fracture; and no fracture. We then analysed the severity of osteoarthritis within these groups. No relationship between the grade of hip osteoarthritis and the presence of a proximal femoral fracture was found. However, the grade of osteoarthritis was related both to the outcome of the trauma (p<0.0001) and to the location of the fracture (p<0.0001). Patients with osteoarthritis of the hip had a three-fold increased likelihood of trochanteric fracture compared to femoral neck fracture. Osteoarthritis does not protect against proximal femoral fractures, but strongly affects the location of the fracture in the proximal femur, increasing the possibility of a trochanteric location. [ABSTRACT FROM AUTHOR]

Purpose: This study is aimed to determine whether the Traumax dynamic hip screw reduces perioperative blood loss and transfusion rate compared to the Gamma nail in the treatment of pertrochanteric fractures. Materials and methods: A series of 331 patients were followed prospectively in a cohort study between February 2008 and October 2011 after a pertrochanteric fracture. Two types of fixation were used, 163 patients were treated with a Gamma nail and 168 patients with a minimally invasive screw plate Traumax. Perioperative blood loss, evaluated by the Mercuriali formula based on pre- and postoperative haemoglobin and transfusion rates were compared in order to assess risk factors. Results: Increased perioperative blood loss was significantly linked with patient-related parameters (age, anticoagulant and platelet aggregation inhibitor treatment). Type of osteosynthesis and type of fracture were also risk factors for blood loss and transfusion. The Traumax group had significantly lower blood loss (347 ml vs. 577 ml) and transfusion rate (33.9% vs. 63.8%) than the Gamma group. Involvement of the greater trochanter increased the risk of blood loss only in the Gamma group. Functional results and bone healing were comparable at six months follow-up. Conclusion: Screw plate Traumax significantly reduces perioperative bleeding after pertrochanteric fractures. It avoids fracture gaps that tend to maintain bleeding. Given the morbidity and complications related to acute anaemia and blood transfusion, the surgical management of these elderly patients is aided by this choice of fixation. [ABSTRACT FROM AUTHOR]

Purpose: The aim of the study was to report the musculoskeletal function and health-related quality of life (HRQoL) after an unstable trochanteric fracture treated with a cephalomedullary nail. Methods: One hundred and seventeen patients, mean age 84.1 years, were included in a 1-year prospective cohort study. Outcome measurements included musculoskeletal function according to the Short Musculoskeletal Function Assessment (SMFA) and HRQoL according to the EQ-5D. Results: Fourteen patients (12.0 %) were reoperated on, all but one being due to a secondary lag-screw penetration/cut-out. The need for revision surgery was significantly higher after a 4-part fracture according to the Jensen-Michaelsen classification as compared to after a 3-part fracture, i.e. 17 versus 6 % ( p = 0.048). The reoperation was a hip replacement in 12 of the 14 patients, a total hip replacement (THR) in 10 and a hemiarthroplasty in 2. The SMFA dysfunction and bother indices in all patients showed a significant deterioration at 12 months compared to before the fracture, from 24.8 to 42.4 ( p < 0.001) and 14.3 to 33.7 ( p < 0.001), respectively. The EQ-5D score decreased from 0.79 prefracture to 0.51 ( p < 0.001). The final outcome for the patients who underwent reoperation with THR was surprisingly good with an SMFA dysfunction index of 43.4, a bother index of 36.6 and an EQ-5D score of 0.58. Conclusions: An unstable trochanteric fracture treated with a cephalomedullary nail had a substantial negative impact on the patient's musculoskeletal function and HRQoL. The need for revision surgery was significantly higher after a 4-part fracture compared to after a 3-part fracture. The by far most common fracture complication, i.e. a secondary lag-screw penetration/cut-out, was successfully treated with a THR. [ABSTRACT FROM AUTHOR]

Background: The proximal femur nail antirotation (PFNA) is the recent addition to the growing list of intramedullary implants for trochanteric fracture fixation. The initial results in biomechanical and clinical studies have shown promise. We report our results of low velocity trochanteric fractures internally fixed by proximal femur nail antirotation. Materials and Methods: A prospective study was conducted to assess the results of 122 elderly patients with low velocity trochanteric fractures [39 -- stable (AO; 31-A1) and 83 -- unstable (AO; 31-A2 and A3)] treated with PFNA from December 2008 to April 2010. Followup functional and radiological assessments were done. Results obtained were compared between stable and unstable fracture patterns using statistical tools. Results: The mean followup was 21 months (12--28 months). 11 patients were lost in followup. Union was achieved in all but one patient. Varus collapse was seen in 14 patients and helical blade cut out in one patient. Stable and satisfactorily reduced fractures had a significantly better radiological outcome. Functional outcome measures were similar across fracture patterns. 65% of the patients returned to their preinjury status. The overall complication rate was also significantly higher in unstable fractures. Conclusion: Good results with relatively low complication rates can be achieved by PFNA in trochanteric fractures in the elderly. Attention to implant positioning, fracture reduction and a good learning curve is mandatory for successful outcomes. [ABSTRACT FROM AUTHOR]

Background: Unstable trochanteric fractures have been an enigma for the orthopedic surgeon in the community because of unpredictable results. Cephalic intramedullary nails with proximal antirotation device are the treatment of choice for such patients. Purpose: To report outcomes of 36 consecutive patients treated with a proximal femoral nail (PFNA) for osteoporotic trochanteric femoral fractures. Methods: The patients included 20 men and 16 women, aged 55-78 years (mean 65.3 years) years with trochanteric/proximal femoral fractures, which underwent PFNA fixation using an intramedullary nail and a spiral blade into the femoral head. We used AO system of classification of the fractures. Pertrochanteric (31 A1 and 31 A2), intertrochanteric fractures (31 A3), and high subtrochanteric (32 A1) fractures were included in the study. We had 16 A2 fractures, 12 A3 fractures, and 6 A1 fractures and 2 cases of 32 A1 fractures. 31 A2 was the commonest type. The operative time, the overall fluoroscopy time, intraoperative blood loss, the duration of hospitalization, and the surgical complications were noted. Patients were followed up for a mean of 24 months (range 18-36 months). Functional outcomes were assessed according to the Harris hip scoring system. Results: One patient required open reduction. The mean duration of surgery was 45 min (range 25-55 min). The mean image intensifier usage time was 70 ms with a range between 44 and 98 ms. The mean time of hospital stays was 5 days (4-10). Postoperative radiographs showed good reduction in 32 cases (out of 34) or acceptable in the 2 cases. There were three postoperative complications (one myocardial infarction, one patient developed DVT, and one patient developed bedsore). There were no cutouts of the spiral blade. Two patients expired due to medical illness unrelated to the fracture. All 34 patients available for follow-up had healed fractures without any implant-related complications, such as bending, breaking, or implant cutout. The average bone healing time was 18 weeks (12-22 weeks). At the time of the latest follow-up, all the 34 patients were full weight bearing on affected site, with return to their preinjury activity level. The mean Harris hip score was 96.4 points (range 69-100 points). A total of 32 patients had excellent or good outcome, and 2 patients had satisfactory outcome and none had poor outcome. Conclusion: PFNA is useful for the treatment of osteoporotic proximal femoral fractures, and our initial experience suggest that it has low implant-related complications. [ABSTRACT FROM AUTHOR]

Background: Trochanteric fractures are common fractures in the elderly. Due to characteristic demographic changes, the incidence of these injuries is rapidly increasing. Treatment of these fractures is associated with high rates of complications. In addition, the long-term results remain poor, with high morbidity, declines in function, and high mortality. Therefore, in this study, complication rates and patients' outcomes were evaluated after fixation of geriatric trochanteric fractures using the Gamma3™ nail. Methods: Patients aged 60 years old or older, with pertrochanteric and subtrochanteric femoral fractures, were included. Patients with polytrauma or pathological fractures were excluded. Age, sex, and fracture type were collected on admission. In addition, data were recorded concerning the surgeon (resident vs. consultant), time of operation, and local or systemic perioperative complications. Complications were also collected at the 6- and 12-month follow-ups after trauma. Barthel Index, IADL, and EQ-5D measurements were evaluated retrospectively on admission, as well as at discharge and during the follow-up. Results: Ninety patients were prospectively included between April 2009 and September 2010. The patients' average age was 81 years old, and their average ASA score was 3. The incision/suture time was 53 min (95% CI 46-60 min). Hospital mortality was 4%, and overall mortality was 22% at the 12-month follow-up. Eight local complications occurred (4 haematomas, 1 deep infection, 1 cutting out, 1 irritation of the iliotibial tract, 1 periosteosynthetic fracture). The incidence of relevant systemic complications was 6%. Forty-two percent of the patients were operated on by residents in training, without significant differences in duration of surgery, complication rate, or mortality rate. The Barthel Index (82 to 71, p < .001), IADL (4.5 to 4.3, p = .0195) and EQ-5-D (0.75 to 0.66, p = .068) values did not reach pre-fracture levels during the follow-up period of 12 months. Conclusion: The results showed a relatively low complication rate using the Gamma3™ nail, even if the nailing was performed by residents in training. The high mortality, declines in function, and low quality of life could probably be attributed to pre-existing conditions, such as physical status. In summary, the Gamma3™ nail seems to be a useful implant for the nailing of trochanteric fractures, although further studies are necessary comparing different currently available devices. [ABSTRACT FROM AUTHOR]

Abstract: We studied 80 patients (56 females) with an average age of 84 years (range 80–94). All patients were suffering from osteoporosis (1 or 2 Singh score) and had an unstable intertrochanteric fracture, defined as a fracture with three fragments or more. Patients were divided in group A (40 patients), treated by a cement augmentation technique and group B (40 patients) treated by Gamma Nail conventional technique. Augmentation was performed with MetilMetacrilate (Mendec Spine, Tecres) inserted through the cannulated cephalic screw at its apex. Such parameters were evaluated as the length of operating time, early functional recovery using the Harris hip score, assessment with radiography of the TAD index and development of implant related complications. The HHS average score was 48.2 and 49.31 after 1 month post-operation, 54.37 and 53.56 after 3 months, 54.71 and 56.42 after 6 months, 57.91 and 59.86 after 12 months, in groups A and B, respectively. The average drop of haemoglobin was 1.55g/dL and 1.05g/dL, in groups A and B, respectively. Except one joint penetration with the guide wire and some small amount of cement leakage, no other complications (infection, screw cut out and femoral head necrosis) were observed. We believe that in femoral intertrochanteric fractures cement augmentation could improve the mechanical stability of the implant, ensuring early functional recovery. [Copyright &y& Elsevier]

In unstable pertrochanteric fractures, there are still debates regarding the complications and long-term benefits after internal fixation using short or long cephalomedullary nails. Therefore, a study was developed regarding this idea. From May 2017 to April 2020, 61 patients with unstable (AO 31-A2) and intertrochanteric fractures (AO 31-A3) were surgically operated on. During follow-up, 8 patients were excluded (lost or deceased). A total of 26 patients received internal short nail system fixation and 27 received a long nail system. All cases followed the standard 6-week rehabilitation protocol. Follow-up was at 3, 6 weeks, 3, 6 and 12 months, and clinical and functional assessment were determined by a different surgeon using the Visual Analogue Scale (VAS), Harris Hip Score (HHS) and Functional Ambulation Categories (FAC). A total of 42 (79.2%) had a 31.A2 fracture (21 in the long nail group and 21 in the short nail group) and 11 (20.8%) had a 31.A3 fracture (6 in long nail group and 5 in the short nail group). Surgical time was significantly longer (P<0.05) in the long nail group (an average of 81.38±12.01 min), compared with the short nail group (53.11±8.36 min). Blood loss was significantly higher (P<0.05) in the long nail group (210±12.1 ml) compared to the short nail group (75.4±14.8 ml). No statistical differences were noted regarding tip-apex distance (TAD) and VAS score. At 6 months, HHS was better for the short nail group (84.76±3.68) (P<0.05). Regarding the FAC scale, no significant statistical differences were identified. Cut-out occurred in 2 cases in the short nail group and 1 case from the long nail group. Only 1 peri-implant fracture occurred in a patient with a long cephalomedullary nail. In conclusion, the long cephalomedullary nail requires a longer surgical time and is associated with an increase in intraoperative blood loss without improving the functional outcome after 12 months postoperatively. A larger sample of cases is required to thoroughly analyze the postoperative complications. [ABSTRACT FROM AUTHOR]

Summary: Intramedullary nailing has been the gold standard in the management of lower limb fractures by virtue of advantage of early joint mobilisation and weight bearing. They are being increasingly used in the peri-trochanteric fractures of femur. Biomechanical studies have proved the supremacy of single femoral neck screw construct over two femoral neck screws along with the intramedullary nails in osteoporotic bones due to lower incidence of complications. This randomised clinical trial was conducted to study the clinico-radiological outcome of single and two-femoral neck screw construct in the management of unstable trochanteric fractures in the elderly osteoporotic bones. Although there was no significant difference in the clinical outcome in the two groups, less sliding of the femoral neck screws was noted with two-femoral neck screw configuration. The tip–apex distance was also significantly lower in the two-screw construct compared to that of the single screw construct. This study to our knowledge is the first randomised control clinical trial evaluating the effectiveness of one and two femoral neck screw configuration of intra-medullary nails in the management of unstable trochanteric fractures. [Copyright &y& Elsevier]

Uncommon causes of nail failures and surgical reinterventions were determined. The study included 23 osteoporotic patients, 13 of whom followed a fast recovery program with early walking (FWB group). The other 10 patients were not allowed full weight bearing until 6 weeks (NFWB group). The T-score was determined before surgery for all cases. A case with a nail breakage after a failed DCS implant fixed in another clinic was also analyzed. The nail was revised and the broken implant underwent a metallurgic and microscopic examination. The average T-score was 2.5 for the patients that followed the fast recovery program and 2.7 for the patients from non-full weight bearing. Four patients, 1 from the NFWB group and 3 from FWB group, presented a screw cut-out. It was found that the errors of the guiding instruments may create dents, scratches or micro-fractures on the titanium coating that lead to an early implant failure. Imperfect reduction leads to incorrect implant placement and a high incidence of failure. Damaging the titanium protective coating, in a low force, high cycles scenario can cause structural failure. Delays in fracture healing and material fatigue are the most common causes of nail failure and can lead to catastrophic complications. [ABSTRACT FROM AUTHOR]

The aim of the study was to evaluate the results of minimally invasive treatment of trochanteric fractures with the use of intramedullary nails. Patients and methods. From September 2010 to September 2012 we treated 21 patients with pertrochanteric fractures by a minimally invasive technique using the Gamma 3 (Stryker, Howmedica) nail. There were 13 females and 8 men with a mean age of 74.1 years, ranging from 58 to 88 years. Fractures were classified as being stable (AO type 31-A1) in 5 cases and unstable (AO type 31-A2 and A3) in the rest of 16 cases. Patients were reviewed at 6 weeks and 3 months postoperatively. Results. Mean surgery time was 46.8 minutes and mean hospital stay was 14.9 days. No patients required blood transfusions. During the hospital stay all the patients were mobilized with weight bearing as tolerated. All patients were available for review at 6 weeks, and 2 were lost to the 3 months follow up. 16 patients regained the previous level of activity. Conclusions. This minimally invasive technique using a gamma nail device for pertrochanteric fractures gives reliable good results with excellent preservation of hip function. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to report our previous results of treatments for trochanteric fractures with proximal femoral locking plates (PFLP) and to analyze the underlying mechanisms and possible risk factors associated with the high failure rate of this technique. Methods: From January 2010 to October 2014, 273 consecutive patients with trochanteric femoral fractures were identified, and 95 patients (with 97 fractures) ultimately met the inclusion criteria. Clinical records regarding demographic features and intraoperative data including total incision length, operation time, blood loss, and failures detected in radiographs were documented and assessed. The collected data were analyzed with SPSS 19.0 software. Results: The stable group (AO/OTA 31 A1 and A2.1) had less blood loss than the unstable group (AO/OTA 31 A2.2, A2.3, and A3). The ultimate failure rate was 36% in 97 fractures. The obvious complications in this study included nonunion in 7 (7.2%) fractures, implant breakage in 4 (4.1%) fractures, varus deformity in 34 (35%) fractures, and loosening of the proximal femoral screw in 21 (21.6%) fractures. Six patients received reoperations. The total failure rate in the stable group was 17% and was 50% in the unstable group. In patients greater than 60 years old in the unstable group, the failure rate was 60.5%. Conclusions: High failure rates of PFLP were observed in patients with trochanteric fracture, especially in patients who were greater than 60 years old with unstable fracture types. PFLP was not an appropriate treatment for trochanteric fractures. [ABSTRACT FROM AUTHOR]

Introduction: Anaemia in patients with trochanteric fracture is associated with increased morbidity and mortality and it is an independent risk factor for functional mobility of patients. Several authors have reported the blood loss following operative treatment comparing different fixation systems but few authors have evaluated many associated variables that could influence the perioperative blood loss.Purpose: To evaluate the blood loss in patients that had their trochanteric fracture stabilized with dynamic hip screw (DHS) or Gamma nail. Multivariate analysis of different variables that can influence blood loss was carried out (type of fracture, antiaggregant or anticoagulant therapy, time to surgery). The hypothesis was that there is no difference in terms of blood loss in patients with trochanteric fracture treated with DHS or Gamma nail considering all these variables.Materials& Methods: Perioperative blood loss was evaluated in 417 consecutive patients treated for trochanteric fracture with DHS or Gamma nail between January 2010 and March 2013. The perioperative blood loss was calculated using the Lisander formula modified by Foss-Kehlet based on pre- and post-operative haemoglobin values and transfusion rates. Univariate and multivariate analysis were performed integrating the following variables: type of fracture (A1 vs A2), antiaggregant/anticoagulant therapy vs no therapy, time to surgery (<24 vs >24 hours from trauma), type of implant (DHS vs Gamma nail).Results: A significant blood loss (p <0.05) was observed between A1 and A2 fracture types (1247ml vs 1796.7ml), antiaggregant/anticoagulant therapy and no therapy (1592.7ml vs 1470.2ml), time-to-surgery <24 and >24 hours from trauma (1584.4ml vs 1323.9ml), DHS and Gamma nail (894.7ml vs 1720.6ml). At multivariate analysis, in the A1 fracture groups the DHS showed a significant lower blood loss compared to Gamma nail (p < 0.05).Conclusions: According to the perioperative blood loss, DHS should be used in A1 fractures while Gamma nail can be taking in account for the unstable A2 fractures. [ABSTRACT FROM AUTHOR]

Abstract: The purpose of this study was to analyse clinical results of elderly patients with trochanteric fractures that were treated with use of TARGON® PF nail. Overall, 494 patients (113 males) were available for this study. On the basis of Jensen classification, there were 76 cases in type I, 164 cases in type II, 70 in type III, 129 in type IV and 55 in type V. (1) Sliding amount of lag screw in relation to the Jensen classification, (2) sliding amount of lag screw according to the Ikuta's classification that categorises the reduction in lateral view in three, Subtype A, Subtype N and Subtype P, (3) sliding amount of lag screw in correlation between Jensen classification and Ikuta's classification and (4) postoperative complications (9 cases; 1.7%) were assessed. Cut-out and back-out cases were seen in 6 cases (1.1%), and these severe complications were evaluated in details. In correlation between Jensen classification and Ikuta's classification, the excessive sliding of lag screw was prominent with the Subtype P, which was preoperatively in Jensen type III or V. Cut-out or back-out cases were caused either from (1) Subtype P that were preoperatively Jensen types III or V, or from (2) the fracture where there was bony defect anteriorly. Therefore, special care must be taken for these types. [Copyright &y& Elsevier]