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У 38 пацієнтів віком від 72 до 88 років (середній вік — 76,4 ± 2,1 року) застосовано первинну артропластику кульшового суглоба з приводу переломів вертлюжної ділянки стегнової кістки. Показання до артропластики зумовлені значним остеопорозом і обмеженими фізичними можливостями пацієнтів у зв’язку з надмірною масою тіла, наявністю дегенеративних змін у суглобах нижньої кінцівки. Терміни виконання первинної артропластики кульшового суглоба — від 3 до 9 діб після травми. Технічні особливості імплантації ніжки ендопротеза залежали від характеру перелому вертлюжної ділянки, який визначали за класифікацією АО. Розподіл пацієнтів був таким: тип А 1.2 — 4 особи; тип А 1.3 — 9; тип А 2.1 — 5; тип А 2.2 — 11; тип А 2.3 — 5; тип А 3.3 — 4. 35 осіб із числа оперованих пацієнтів були обстежені в період від 4 до 6 місяців після перенесеної первинної артропластики. Самостійно пересуватися в приміщенні з повною опорою на оперовану кінцівку за допомогою ходунка були здатні 8 пацієнтів, милиць — 4, трості або 1 милиці — 10, без сторонньої допомоги — 13.

OBJECTIVE: To assess the safety of senior residents performing trochanteric hip fracture surgery without immediate consultant supervision DESIGN: A retrospective chart review of trochanteric hip fractures (AO-OTA 31-A) operated in a single center between years 2011 and 2016 (inclusive). Operations were divided into three groups: Group 1 surgeon was a senior resident without any immediate supervision; Group 2 surgeon was a consultant and Group 3surgeon was a senior resident supervised by a consultant. The follow-up period was a minimum of 2 years or until death. All re-operations and surgical related mortality were assessed. SETTING: Helsinki University Hospital, Finland. A tertiary level trauma center. PARTICIPANTS: 987 consecutive trochanteric fractures on 966 patients treated by operative fixation of an intertrochanteric fracture with an intramedullary nail between 2011and 2016 (inclusive). RESULTS: The total number of reoperations was smaller in Group 1 where the surgeon was a senior resident without any immediate supervision compared to Group 2 where the surgeon was a consultant (5.5 % vs 8.8 %, p < 0.05). There were no significant differences in mortality or length of surgery. The total rate of mechanical complications was 2.0 %, with no significant differences between groups. The observed blade cut-out rate was low: 1.3 %, suggesting a good overall quality of surgery. CONCLUSIONS: Senior residents can safely perform intramedullary nailing of trochanteric fractures without immediate supervision. (C) 2021 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background/Aim. Cephalomedullary and extramedullary methods are used for the internal fixation of trochanteric fractures. The usage of the third generation Gamma Nail (GN) is a gold standard in this kind of treatments. Self-dynamisable Internal Fixator (SIF) is an extramedullary implant for trochanteric fractures? treatment. The aim of this study was to compare these two methods regarding operation time and intraoperative fluoroscopy time. Methods. A total of 89 patients with a surgical treatment of a trochanteric fracture were included in this study. There were two groups of patients ? GN group (43 patients) and SIF group (46 patients). Results. Average operation times were 67.5 min (GN group) and 56.0 min (SIF group). Average intraoperative fluoroscopy times were 84.8 s (GN group) and 36.7 s (SIF group). The difference between the groups was statistically significant for both of the given parameters (p < 0.05). The correlation between operation time and intraoperative fluoroscopy time was confirmed in the SIF group (p < 0.05; r = 0.405), while it was not confirmed in the GN group (p > 0.05). There was a higher variability in the GN method than in the SIF method regarding the duration and type of repeated surgical maneuvers followed by X-ray checks. Conclusion. The number of planned surgical interventions per day could depend on the type of trochanteric fracture internal fixation (intramedullary or extramedullary). Certain additional analyses including radiation dose assessment are desirable to clarify if shorter intraoperative fluoroscopy time in the SIF method can have the influence regarding intraoperative X-ray protection clothing. If there is the need to activate dynamization in long femoral axis after initial static fixation in that axis, the SIF method provides its spontaneous activation several weeks after the surgery without the need neither for additional surgery nor for additional intraoperative fluoroscopy

Introduction The AO/OTA classification for diagnosing femoral trochanteric fractures (31A fractures) was revised in 2018. No studies have investigated whether the addition of CT to radiographic diagnosis improves the inter-rater reliability of classifying 31A fractures with the current AO/OTA criteria. The study aimed to test the hypothesis that the addition of three-dimensional CT (3D-CT) to radiographic diagnosis would improve diagnostic reliability. Methods A retrospective review was conducted to assess the diagnostic reliability of classification of 31A fractures with current AO/OTA criteria. Radiographs and 3D-CT images from 89 cases were assessed. Major fracture types (A1, A2, and A3) and subgroups were diagnosed by nine orthopedic surgeons who were classified into three groups (high-, intermediate-, and low-experience) according to their clinical experience. Anterior–posterior and lateral radiographs were provided to diagnose fracture type (first assessment). After a 6-week interval, radiographs and 3D-CT images of all cases were evaluated by each rater (second assessment). Fleiss's Kappa was used to determine inter-rater reliability. Results In the first assessment, the Kappa value indicated fair inter-rater reliability in all groups (high-experience group: κ = 0.296, 95% confidence interval [CI] 0.239–0.352; intermediate-experience group: κ = 0.367, 95% CI 0.305–0.428; low-experience group: κ = 0.304, 95% CI 0.246–0.362). With the addition of 3D-CT (second assessment), reliability improved from fair to moderate in the high- and intermediate-experience groups (κ = 0.483, 95% CI 0.428–0.539 and κ = 0.409, 95% CI 0.352–0.466, respectively). By contrast, reliability remained fair in the low-experience group (κ = 0.322, 95% CI 0.322–0.431). The inter-rater reliability of diagnosing subgroup fracture types improved for A2.3 and A3.1 in all three groups and for A3.2 and A3.3 in the intermediate- and low-experience groups. Conclusion The current AO/OTA classification revised in 2018 provided fair reliability in diagnosing femoral trochanteric fractures in all three surgeon groups. The addition of 3D-CT to radiographic image evaluation improved reliability in high- and middle-expertise groups. The addition of 3D-CT to radiographic evaluation often improved the diagnostic reliability for unstable fractures, although there was some variation among fracture subgroups.

The goal of our retrospective study was to determine which radiological parameter after fixation of trochanteric fractures type AO 31 A2 is most important for the position of the fracture after six months. The additional goal was to find how the end position influences mechanical failure and the mobility of the patients.We analysed 92 patients operated in one-year period for A 2 type trochanteric fractures with sliding hip screw or proximal femur intramedullary nail. They were divided in two groups according to the radiological position of the proximal fragment six months after the surgery. In group A we had 46 patients with satisfactory and in group B 46 patients with unsatisfactory position. In anteroposterior view we evaluated neck-shaft angle (NSA) and medial cortical support (MCS) and in lateral view anterior cortical support (ACS). Unsatisfactory position was recognized if NSA was in varus or ACS or MCS were negative. We compared the groups regarding basic patients characteristics (age, gender, ASA score, preinjury mobility, and degree of osteoporosis), type and quality of fixation, the position of the fracture (postoperatively and after 6 months), mechanical failure and mobility after 6 months. Statistical significance level was set to p ≤ 0.05.Basic patients' characteristics as well as type and quality of fixation did not significantly differ between the groups. After the injury the difference between the groups in reduction quality was significant in lateral view (ACS; p=0.001), while after half a year there were significant differences in both views: NSA (p=0.003), ACS and MCS (both p0.001). Proximal fragment position after six months statistically significant correlated with postoperative ACS in B group (r = 0.386, p = 0.008), but not with NCA nor with MCS. There were also significantly more fixation failures in group B (p0.001) and less patients regain preinjury mobility (p=0.029).In trochanteric fractures reduction in lateral view is the most important prognostic factor for favourable radiological result after half a year. Unsatisfactory position of the proximal fragment after six months influences mechanical failures and walking ability.

Physiotherapeutic procedures after surgical treatment of trochanteric fractures of femurs are a very important element of a postoperative management because they have a significant influence on the final result of physiotherapy. This is due to the nature of the fracture and the frequency of its occurrence. The aim of the work is, in particular, to determine the relationship between functional assessment scales in patients after trochanteric fractures treated surgically using extended statistical analysis including regression equations. Statistical analysis included a group of patients, which participated in a specialized programme of a post-operative procedure, called the ‘Individual’ Group. The matrix of research results, calculations of basic statistical measures, such as position, variability, interdependence, asymmetry and concentration were presented for this group. Regression equations representing the relationships between the considered variables, in particular concerning the applied scales and post-operative tests, were presented. Their purpose, mathematical interpretation, results of calculations and statistical tests were discussed. Attention was paid to the high correlation between the Parker and Mobility tests. The extended statistical analysis makes it possible to create an own system for assessing the treatment results of patients after trochanteric fractures are treated surgically.

Hip fragility fractures incidence is constantly increasing, and outcomes are mostly poor in terms of both morbidity and mortality. Surgery is the treatment of choice for most hip fractures, but the choice between the various fixation devices is difficult. We conducted a survey on the treatment of trochanteric fractures among orthopedic surgeons in Campania using a Google form questionnaire. The preferred treatment was cephalomedullary distal locked nailing for most fractures, while sliding hip screws and hip replacement were limited to 31 A1.2 and 31.B2 fractures.

Introduction Isolated greater trochanteric fractures (IGTfs) of the femur are uncommon. At least 10% of these fractures have an occult intertrochanteric extension. Mobilisation too early without care can lead to fracture propagation, requiring surgical fixation. There is no definite consensus in the literature on how to manage initially diagnosed IGTf with potential occult intertrochanteric extension. We reviewed the management of IGTf in our major trauma centre (MTC) and propose a management flow chart. Methods The electronic notes and images for all IGTf admitted under or referred to the orthopaedic team at a MTC, from June 2015 to July 2017, were reviewed. Data were collected on fracture pattern and diagnostic imaging modalities. Periprosthetic fractures were excluded. Results 1550 neck of femur fracture patients were admitted over the 2-year period; 790 patients (51%) had a fracture around the intertrochanteric region and 49 (3.2%) were diagnosed with a IGTf on plain radiographs. 98% of patients had further imaging after initial plain film radiographs, and 58% of all IGTf were shown to have an intertrochanteric extension. Overall 16/49 patients (32.7%) needed an operation. Conclusions An IGTf not crossing the medullary canal into the calcar (i.e >50% of the diameter) does not require surgical fixation and can be managed with analgesia and supervised mobilisation. The 30-day mortalities in both operative and non-operative groups were similar at 2% and 2.2%, respectively. Overall mortality is half of the total neck of femur fracture population (4.1%) in our MTC. We propose a management flow chart for this patient cohort.

Aim: A comparative evaluation of the surgical treatment and outcome of patients with stable intertrochanteric fractures treated with long versus short INTERTAN nail. Objectives: Inter-trochanteric fractures of femur are among the most common orthopedic injury in elderly age group. Proximal femoral nailing with INTERTAN has become a popular method of stabilization of inter-trochanteric fractures in adults. stable trochanteric fractures can be treated using the conventional proximal femoral nailing method or the newly deviced proximal femoral nailing with INTERTAN nail. The present study was conducted to assess and evaluate the outcomes following treatment of stable inter-trochanteric fracture femur with long INTERTAN nail vs short INTERTAN nail.

The management of pertrochanteric fractures (PTF) in the very elderly relies on early verticalisation to limit complications of the decubitus and this requires stable osteosynthesis allowing immediate full support without risk of mechanical failure. The aim of the study was to analyse the value of cementing the cervicocephalic blade during osteosynthesis with a proximal femoral nail. A prospective bicentric comparative study was con- ducted. Patients over 90 years of age with PTF were included. Centre A used a PFNA (Proximal Femoral Nail Antirotation) nail without blade cementing and Centre B used the same nail with blade cementing. The primary endpoint was the occurrence of disassembly of the osteosynthesis requiring revision surgery. Secondary endpoints were functional out- come (resumption of walking), postoperative pain and duration of surgery. Sixty-four patients were included in Centre A and 23 patients were included in Centre B. Mean age, gender, functional abilities before fracture, fracture type and tip-apex distance were comparable between the groups. Postoperative pain and duration of surgery did not show significant differences between the groups. Four patients operated on with an uncemented PFNA (6.25%) and one patient operated on with a cemented PFNA nail (4.35%) showed early dismantling. The rate of patients returning to walking was significantly higher in the cemented group (p=0.00005). No significant differences in the rate of dismantling were observed between the two groups. However, the group operated on with a cemented PFNA showed better functional recovery with a significantly higher rate of walking recovery.

Intertrochanteric femur fractures (ITFF) are frequently fixed with proximal femoral nailing (PFN), and a common cause of fixation failure is cut-out of the lag screws. In the literature, many factors have been defined to determine the failure risk, including the tip–apex distance (TAD), calcar-referenced tip–apex distance (CalTAD), the Cleveland zone and Parker's ratio. In this study, a novel technique is described which favors infero-posterior placement of the lag screw and predicts failure risk for PFN. The purpose of this study was to evaluate the tip–neck distance ratio as a factor for the prediction of cut-out after PFN of ITFF. A retrospective evaluation was made of the data of 125 patients applied with PFN for ITFF between October 2016 and September 2019. The occurrence of mechanical complications was analyzed in relation to age, gender, fracture side, American Society of Anaesthesiologists classification, fracture classification, reduction quality, bone quality, Cleveland zone, Parker’s ratio, TAD, CalTAD and the TNDR. A total of 125 patients, including 16 with mechanical complications, were suitable for full analysis. In the univariate analysis, reduction quality (p = 0.003), the TAD (p = 0.048) and the TNDR (p = 0.030) were statistically associated with mechanical complications (p

Introduction: Hip fractures are common and disabling injuries, usually managed surgically. The most common type outside the joint capsule are trochanteric fractures, usually fixed with either sliding hip screw or intramedullary nail. Data are available in the National Hip Fracture Database (NHFD) on early failure and other major complications, but late or subtler complications may escape recording. This study sought to quantify such problems after fixation performed at 3different sites and identify their predictors. Methods: Patients with a trochanteric fracture treated at 1 of 3 sites were identified from the NHFD over a 3-year period. Any with further, related episodes of care were identified, and reasons recorded, then age- and sex-matched with those with no such episodes. Data was collected on Arbeitsgemeinschaft für Osteosynthesefragen classification, tip-apex distance, American Society of Anesthesiologists (ASA) grade, Abbreviated Mental Test Score and pre-injury mobility. The cohorts were compared, and a binomial logistic regression model used to identify predictors of problems. Results: A total of 4010 patients were entered in the NHFD across 3 sites between January 2013 and December 2015. Of these, 1260 sustained trochanteric fractures and 57 (4.5%) subsequently experienced problems leading to re-presentation. The most common was failure of fixation, occurring in 22 patients (1.7%). The binomial logistic regression model explained 47.6% of the variance in incidence of postoperative problems with ASA grade and tip-apex distance being predictive. Discussion: The incidence of re-presentation with problems was around of 5%. A failure rate of less than 2% was seen, in keeping with existing data. This study has quantified the incidence of subtler postoperative problems and identified their predictors. The type of implant used was not amongst them and patients with both implants experienced problems. Fixation continues to yield imperfect results, but patient health and robust surgical technique remain important factors in a good outcome.

Closed reduction and fixation using a cephalomedullary nail represents the accepted management of unstable intertrochanteric fractures. Cut-through has been described as a complication associated with the treatment. Although a hip arthroplasty may be the most predictable revision method, a non-prosthetic option can lead to similar results. The objective is to describe a non-prosthetic revision procedure in cases of cut-through.We performed a retrospective analysis of our Institutional Registry for Hip Fractures in elderly patients (RIAFC) from January 2010 to June 2018 searching for cut-through as a failure after unstable intertrochanteric fracture treatment. REVISION PROCEDURE: (A) Helical blade removal, introduction of structural bone graft (autologous or allograft) as a plug to obliterate the communication to the joint and a new blade insertion. (B) Same as in A but augmenting the blade/head purchase with poly(methyl methacrylate) (PMMA). Before the cement insertion, a radio-opaque solution was instilled to assure lack of joint leakage.We evaluated 1616 patients. Sixteen of them presented a cut-through complication (1%). Ten of them were females with an average age for all of 84 years. One patient denied an implant revision and opted for a total joint replacement. In four of the patients, the procedure A was done, 2 of them had a new failure, and an joint arthroplasty was performed. In the B group, only one patient needed a revision to a total hip. The other 10 patients healed uneventfully and did not need any further intervention.Cut-through revision after fixation of unstable intertrochanteric fractures treated with cephalomedullary nail by blocking of the joint communication and augmenting the head blade purchase with PMMA is a safe and minimal invasive procedure, generates low blood loss and rate of complications and allows bone healing preserving the native joint.Nil.

BACKGROUND Trochanteric fractures are commonly encountered in elderly patients, and the outcome may be bad, if not intervened early. Dynamic hip screw (DHS) fixation is the most common treatment in stable trochanteric fracture. In unstable trochanteric fractures, there is high incidence of failure in view of excessive collapse seen with dynamic hip screw. In order to limit the collapse, we have done a modification on dynamic hip screw implant. Here we have assessed fracture healing, collapse and implant failure, in unstable trochanteric fractures (Evan’s unstable fractures) treated by modified dynamic hip screw fixation. METHODS The present retrospective case record analysis was conducted among 31 patients with unstable trochanteric fracture classified according to Evan’s classification who were operated with modified DHS in a tertiary care hospital. The details about fracture healing, collapse of fracture fragments, implant failure were assessed in a structured checklist through the case record analysis. RESULTS Out of 31 patients in this study, 29 patients showed fracture healing (93.5 %) with or without minimal collapse and 2 patients had non-union (6.5 %) at the end of 5 months follow up. Ultimately, all fractures united at the end of 1-year follow-up. Out of 31 patients in this study, at first month follow-up, 26 patients showed no implant failure (83.9 %), 5 patient had implant migration not breaching cortex (16.1 %), at third month follow-up, out of 5 patients who had implant migration, two patients had implant migration not breaching cortex (6.4 %), 3 patients had implant migration breaching cortex (11.0 %), at fifth month follow-up, two patients had implant migration not breaching cortex (6.4 %), 3 patients who had implant migration breaching cortex underwent revision surgery (11.0 %). CONCLUSIONS Modified dynamic hip screw has shown improved results as compared to normal dynamic hip screw in treating unstable trochanteric fracture, which limits the collapse at fracture site. KEYWORDS Unstable Trochanteric Fractures, Collapse, Modified Dynamic Hip Screw

Functional results after internal fixation of trochanteric femoral fractures may be negatively affected by healing in a non-physiological position. The aim of this study was to evaluate the occurrence and severity of femoral malrotation after nailing of trochanteric fractures. The authors conducted a prospective study focused on a CT analysis of malrotation after intramedullary nailing of trochanteric fractures (AO 31A1-3) in 101 patients. We recorded the type of fracture, method of anesthesia, scheduled surgery vs. acute surgery, and the surgeon’s experience as possible risk factors for limb malrotation after trochanteric fracture surgeries. The average extent of malrotation was 9° of internal rotation ranging from 29° of external to 48°of internal rotation. In 35% of patients, we observed a rotation greater than 15°, and in 15 patients (15%), the rotation was greater than 25°. The risk of significant internal malrotation was significantly higher than external malrotation (37 vs. 4 patients). None of the factors observed proved to be statistically significant. The effect of general anesthesia and the type of intertrochanteric fracture came closest to having a significant effect on rotational error. Improper reduction of a trochanteric fracture is a common problem that can lead to femur malrotation. In our study, a rotational error greater than 15° occurred in 35% of the patients, but none of the monitored factors represented a statistically significant risk for this complication.

Aims This study evaluated variation in the surgical treatment of stable (A1) and unstable (A2) trochanteric hip fractures among an international group of orthopaedic surgeons, and determined the influence of patient, fracture, and surgeon characteristics on choice of implant (intramedullary nailing (IMN) versus sliding hip screw (SHS)). Methods A total of 128 orthopaedic surgeons in the Science of Variation Group evaluated radiographs of 30 patients with Type A1 and A2 trochanteric hip fractures and indicated their preferred treatment: IMN or SHS. The management of Type A3 (reverse obliquity) trochanteric fractures was not evaluated. Agreement between surgeons was calculated using multirater kappa. Multivariate logistic regression models were used to assess whether patient, fracture, and surgeon characteristics were independently associated with choice of implant. Results The overall agreement between surgeons on implant choice was fair (kappa = 0.27 (95% confidence interval (CI) 0.25 to 0.28)). Factors associated with preference for IMN included USA compared to Europe or the UK (Europe odds ratio (OR) 0.56 (95% CI 0.47 to 0.67); UK OR 0.16 (95% CI 0.12 to 0.22); p < 0.001); exposure to IMN only during training compared to surgeons that were exposed to both (only IMN during training OR 2.6 (95% CI 2.0 to 3.4); p < 0.001); and A2 compared to A1 fractures (Type A2 OR 10 (95% CI 8.4 to 12); p < 0.001). Conclusion In an international cohort of orthopaedic surgeons, there was a large variation in implant preference for patients with A1 and A2 trochanteric fractures. This is due to surgeon bias (country of practice and aspects of training). The observation that surgeons favoured the more expensive implant (IMN) in the absence of convincing evidence of its superiority suggests that surgeon de-biasing strategies may be a useful focus for optimizing patient outcomes and promoting value-based healthcare. Cite this article: Bone Joint J 2021;103-B(4):775–781.

Aims Surgical treatment of hip fracture is challenging; the bone is porotic and fixation failure can be catastrophic. Novel implants are available which may yield superior clinical outcomes. This study compared the clinical effectiveness of the novel X-Bolt Hip System (XHS) with the sliding hip screw (SHS) for the treatment of fragility hip fractures. Methods We conducted a multicentre, superiority, randomized controlled trial. Patients aged 60 years and older with a trochanteric hip fracture were recruited in ten acute UK NHS hospitals. Participants were randomly allocated to fixation of their fracture with XHS or SHS. A total of 1,128 participants were randomized with 564 participants allocated to each group. Participants and outcome assessors were blind to treatment allocation. The primary outcome was the EuroQol five-dimension five-level health status (EQ-5D-5L) utility at four months. The minimum clinically important difference in utility was pre-specified at 0.075. Secondary outcomes were EQ-5D-5L utility at 12 months, mortality, residential status, mobility, revision surgery, and radiological measures. Results Overall, 437 and 443 participants were analyzed in the primary intention-to-treat analysis in XHS and SHS treatment groups respectively. There was a mean difference of 0.029 in adjusted utility index in favour of XHS with no evidence of a difference between treatment groups (95% confidence interval -0.013 to 0.070; p = 0.175). There was no evidence of any differences between treatment groups in any of the secondary outcomes. The pattern and overall risk of adverse events associated with both treatments was similar. Conclusion Any difference in four-month health-related quality of life between the XHS and SHS is small and not clinically important. There was no evidence of a difference in the safety profile of the two treatments; both were associated with lower risks of revision surgery than previously reported. Cite this article: Bone Joint J 2021;103-B(2):256–263.

Background: Fragility hip fracture is a common condition with serious consequences. Most outcomes data come from Western and Asian populations. There are few data from African and Middle Eastern countries. Objective: The primary objective was to describe mortality rates after fragility hip fracture in a Level-1 trauma centre in Egypt. The secondary objective was to study the causes of re-admissions, complications, and mortality. Methods: A prospective cohort study of 301 patients, aged > 65 years, with fragility hip fractures. Data collected included sociodemographic, co-morbidities, timing of admission, and intraoperative,ostoperative, and post-discharge data as mortal- ity, complications, hospital stay, reoperation, and re-admission. Cox regression analysis was conducted to investigate factors associated with 1-year mortality. Results: In-hospital mortality was 8.3% (25 patients) which increased to 52.8% (159 patients) after one year; 58.5% of the deaths occurred in the first 3-months. One-year mortality was independently associated with increasing age, ASA 3-4, cardiac or hepatic co-morbidities, trochanteric fractures, total hospital stay, and postoperative ifection and metal failure. Conclusion: Our in-hospital mortality rate resembles developed countries reports, reflecting good initial geriatric health- care. However, our 3- and 12-months mortality rates are unexpectedly high. The implementation of orthogeriatric care after discharge is mandatory to decrease mortality rates. Keywords: Fragility hip fractures; trochanteric fractures; mortality rate.

The goal of this study is to gauge the radiological results and therefore the functional outcomes consistent with Parker mobility score of the patients after using of Dynamic hip screw with trochanteric stabilizing plate in fixation of unstable trochanteric fractures and assess the complication. Twenty patients (ages ranged from 51 to 70 with an average age of 64.20 ± 6.338 years, 12 of them (60%) were females and 8 (40%) were males) with unstable trochanteric fracture were treated with Dynamic Hip Screw with Trochanteric Stabilization Plate between first of September 2019 to end of March 2020 at Beni-Suef University Hospital. Most of the operations were done in the first week 16 (80%) and only 4 (20%) patients had intraoperative complication and the same percent had post-operative complications. Parkers score was higher in non-diabetic patients p value (p value 0.041).The ASIA score was higher in patients with good bone quality and without intraoperative complication and this difference was statistically significant significantly (p-value, 0.011). DHS with TSP fixation of unstable intertrochanteric fractures of femur is an effective technique and has excellent functional and radiological outcomes with minimal complications and early rehabilitations rates.

Background: Advancements in modern medicine have given people the opportunity to live longer. The resultant increase in the elderly population has led to a higher incidence of peri-trochanteric fractures of the femur. The preferred implant for the comminuted unstable variety has been intramedullary nails with one or two head/neck compression screws, which are known to have high rate of complications like screw cut-out, back out, Z-effect, varus collapse and rotational instability, especially in the osteoporotic patients leading to the development of helical blade systems. Here we have compared the results of trochanteric xation nail (TFN) and short proximal femoral nail antirotation (PFNA)-II. Methods: It was a retrospective, comparative study in seventy-ve patients with comminuted unstable trochanteric fractures (AO classication31A2) treated using TFN in 34 and short PFNA-II in 41 patients with a minimum follow up period of six months. Results: Most of the data were comparable between the two groups except: signicantly higher operation time and implant-related complications in the TFN group. No signicant differences in the functional outcome between the two groups were noted as indicated by Harris Hip Score at six months. Conclusion: Short PFNA-II should be used in preference to TFN for comminuted unstable trochanteric fractures with no sub-trochanteric extension in the elderly osteoporotic patients in view of the shorter operative time, easier insertion and lower complications rate.

Introduction . Despite the ability of MRI to identify intertrochanteric (IT) fracture extension for greater trochanteric (GT) fractures, there is no consensus about which fractures require operative intervention. Previous studies have suggested GT fractures with >50% extension into the IT region might benefit from fixation. We sought to evaluate the rate at which GT fractures with IT extension displaced, requiring operative fixation. Patients and methods . This is a Retrospective Chart Review performed at a Level 1 Trauma Center. Patients included all nonoperatively treated GT fractures (OTA/AO 31A1.1) with IT extension identified on MRI between 2010 and 2017 at our institution. Patients lost to follow up prior to radiographic evidence of healing or fracture displacement were excluded. Patient charts and imaging were reviewed for demographic data, treatment plan, percent extension into the IT region (as determined from coronal MRI images), and clinical and radiographic evidence of fracture healing. Percent extension into the IT region was measured using coronal T1-weighted MRI images. The primary outcome measures were fracture displacement requiring operation and nonunion. Results . Seventeen patients met initial inclusion criteria, with two subsequently excluded due to no radiographic follow-up. Of the 15 patients, zero had displacement of their IT fracture. None required operative intervention. All 15 patients healed their fractures. Fourteen of 15 (93%) had IT extension of 50% or less across the IT region. One patient had initial IT extension of 60%, this patient also healed without displacement. Discussion . Incomplete intertrochanteric femur fractures are a relatively newer diagnosis that have become more prevalent with the increased usage and availability of MRI. Currently, there is no consensus on the ideal treatment of these injuries. To our knowledge, this is the largest series of its kind to help guide treatment of these GT fractures with IT extension. Conclusions . Fractures with less than 50% extension into the IT region have a low likelihood of future displacement and high union rates when treated nonoperatively. Level of evidence . IV

Background. The reverse obliquity inter-trochanteric fracture is a distinct fracture pattern that is mechanically different from most inter-trochanteric fractures and the optional treatment of it is still controversial. The purpose of this study was to compare differences in the efficacy of a novel nail (medial support nail [MSN-II]) and proximal femoral nail anti-rotation (PFNA-II) in the treatment of reverse obliquity inter-trochanteric fractures (Arbeitsgemeinschaft fur Osteosynthesfrogen/Orthopedic Trauma Association [AO/OTA] 31-A3.1) using finite-element analysis. Methods. Modeling software was used to establish a three-dimensional model of MSN-II and PFNA-II and an A3.1 inter-trochanteric fracture model. Abaqus software was used to implement different force loads to compare finite-element biomechanical parameters such as the maximum stress in implant and the displacement of fracture site. Results. The femoral stress, implant stress and fracture site displacement of MSN-II was less than that of PFNA-II. The results indicated that the maximal femoral stress was 581 MPa for PFNA-II and 443 MPa for the MSN-II. The maximum stress values in the PFNA-II and MSN-II models were 291 and 241 MPa, respectively. The maximal displacements of the fracture site were 1.47 and 1.16 mm in the PFNA-II and MSN-II models, respectively. Conclusion. Compared with PFNA-II for inter-trochanteric fracture (AO/OTA 31-A3.1), MSN-II which was designed with a triangular stability structure can provide better biomechanical stability. The MSN-II may be a feasible option for the treatment of reverse obliquity inter-trochanteric fracture.

The aim of this prospective comparative study is to analyse the short term follow-up results of unstable inter-trochanteric fractures in the elderly treated with Bipolar hemi-arthroplasty and Dynamic hip screw fixation done in our institution from March 2017 to October 2018. Proximal femoral fractures in the elderly individuals have a tremendous impact on both the health care system and society. Upon treatment of inter-trochanteric factures with conservative management, it usually unites with a mal-union, non-union and with shortening, but the problem of non –union in trochanteric fractures has less incidence. Because of complications associated with prolonged recumbency and its associated morbidities. Primary hemiarthroplasty in these patients provides for adequate fixation and early mobilization. It alleviates pain and improves function. It also prevents post-operative complications such as pneumonia, lung atelectasis and pressure sores. From our clinical observation we would suggest that unstable intertrochanteric fractures in elderly result most frequently from accidental fall (52.5%), being the most common described mechanism of injury.

The objective of this retrospective study was to investigate the surgical outcomes of AO/OTA 31 A1-3 trochanteric fractures treated with the new-generation Gamma3 nail with U-Blade (RC) lag screw and to analyze the risk factors related to fixation failure. A total of 318 consecutive patients who underwent cephalomedullary nailing using Gamma3 nail with U-Blade lag screw for trochanteric hip fractures between September 2015 and June 2018 were enrolled. The average age was 80 years and most patients (69%) were women. The mean follow-up was 12.2 months with a minimum of 6 months. 309 (97.2%) showed bony union with a mean time to union of 13.5 ± 8.7 weeks. Cut-out occurred in 2 patients (0.6%) and 7 patients showed excessive collapse (≥15 mm) of the proximal fragment. These 9 patients were assigned to the failure group. The presence of a basicervical fracture component and comminution of the anterior cortex on preoperative 3-D CT showed a significant association with fixation failure, including cut-out, although comminution of the anterior cortex was the only independent risk factor for fixation failure on multivariate logistic regression analysis. Gamma3 nail with U-Blade lag screw showed favorable results for trochanteric hip fractures, with low cut-out rate (0.6%). However, more caution is required in treating trochanteric fractures with a basicervical fracture component and anterior cortex comminution even with this nail.

Background: In spite of improvement and modification for intertrochanteric fracture in the conservative line of treatment the ideal anatomical and functional result could not be achieved.Until now mentioned factors posteromedial support communition has been considered to bea major prognostic factor in the determination of the functional outcome. Current literature almost neglects other important potential prognostic factor i.e. lateral trochanteric wall fracture.The current study has aimed at studying Assessment of functional outcomes of Dynamic Hip screw fixation in intertrochanteric fracture Evans 3 and 4 types. Method: 126 cases were registered in the study out of which 64 cases of Trochanteric fractures which were admitted in the Orthopaedic wards and treated by internal fixation using standard Dynamic Hip Screw (DHS) were included in the study. Preoperative assessment of fracture geometry was done using Evan’s classification. Result: Age of patients ranged from 22 years to 88 years, with the average being 55 yrs. the anatomical reduction was achieved in 82.5% of group A with intact lateral trochanteric wall whereas it was achieved in only 33% of the other group. Average impaction in group A was found to be 5.5mm and average impaction in group B was 14mm. 85% of group A had functional outcome excellent to good whereas in 66% of group B it was fair to poor. Conclusion: Intact lateral trochanteric wall helps in achieving anatomical reduction, imparts inherent stability and prevents excessive collapse, limb shortening and sliding of the screw. Thus it helps in achieving good functional outcome making lateral trochanteric wall fracture good predictor of functional outcome.

Aims A lack of supporting clinical studies have been published to determine the ideal length of intramedullary nail in fixation of trochanteric fractures of the hip. Nevertheless, there has been a trend to use shorter intramedullary nails for the internal fixation of trochanteric hip fractures. Our aim was to determine if the length of nail affected the outcome. Methods We randomized 229 patients with a trochanteric hip fracture between two implants: a ‘standard’ nail of 220 mm and a shorter nail of 175 mm, which had decreased proximal angulation (4° vs 7°) and a reduced diameter at the level of the lesser trochanter. Patients were followed up for one year by a nurse blinded to the type of implant used to determine if there were differences in mobility and pain with two nail designs. Pain was assessed on a scale of 1 (none) to 8 (severe and constant) and mobility on a scale of 1 (full mobility) to 9 (immobile). Results The shorter nail did not require any reaming of the femur and was quicker to insert (mean difference 5.1 minutes; p < 0.001, 95% confidence interval (CI) of the difference 3.16 to 7.04). Those treated by the shorter nail were less mobile (mean difference in reduction in mobility score at one year 0.80; p = 0.007, 95% CI 1.38 to 0.22). In addition, there was a trend toward greater residual pain for those treated with the shorter nail, although this was not statistically significant (mean difference in pain score at one year 0.24; p = 0.064, 95% CI -0.01 to 0.49). Conclusion These results suggest that the increasing use of this very short intramedullary nail with its design modification may not be appropriate. Cite this article: Bone Joint J 2020;102-B(3):394–399

Introduction/Objective. There are extramedullary and intramedullary methods of trochanteric fractures internal fixation including implants with lag screws. The objective of this study was to examine the difference in impact of these fixation types on final hip function and health-related quality of life. Method. There were 75 patients treated for a trochanteric fracture, using Self-dynamisable Internal Fixator (SIF group), as an extramedullary method, or Gamma Nail (GN group), as an intramedullary method. These patients were called for evaluation of Harris Hip Score (HHS) and SF-12 questionnaire at least two years after surgery. The SF-12 questionnaire has dual expression - physical component score (PCS) and mental component score (MCS). Results. There were not significant differences between SIF group and GN group regarding HHS, PCS and MCS. Positive correlation was confirmed between HHS, PCS and MCS, with the most strength relation between HHS and PCS. Negative correlation was confirmed between age and HHS. Conclusion. There was no difference in final hip function and health-related quality of life between SIF and GN methods in trochanteric fractures treatment (p > 0.05). These parameters of outcome were confirmed to have positive interrelation (p < 0.05). Both submuscular presence of extramedullary implant with dimensions of SIF and the need for bone reaming in cephalomedullary fixation were considered not to have significant impact in HHS and SF-12 scores after trochanteric fractures treatment by internal fixation. [Project of the Serbian Ministry of Education, Science and Technological Development, Grant no. III41017: Virtual human osteoarticular system and its application in preclinical and clinical practice]

Background and purpose — Intramedullary nails (IMN) have become increasingly common as treatment for trochanteric hip fractures (THF) although they are costlier, and without proven superiority compared with sliding hip screws (SHS). We investigated whether the 2 methods differ in terms of short-term mortality when used in fractures where both methods are suitable. Patients and methods — We extracted data from the Swedish Fracture Register (SFR) on 19,935 patients ≥ 60 years with trochanteric fractures AO type 31-A1 or -A2 who had been treated with either SHS or IMN. We assessed absolute mortality rates and the relative risks (RR) of death after 7, 30, 90, and 365 days using generalized linear models, adjusting for age, sex, and fracture type. We performed a sensitivity analysis on a subgroup of 3,673 patients with information on comorbidity to address this potential confounder. Results — 69% of the patients were women and mean age was 84 years (60–107). IMN was used in 35% of A1 and in 71% of A2 fractures. The use of IMN was associated with a slightly increased adjusted risk of death within 30 days compared with SHS (RR = 1.1, 95% CI 1.0–1.2) with no difference at any other time point. Interpretation — The slightly increased risk of death up to 30 days postoperatively does not support the use of IMN instead of SHS in stable THF.

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.

Background. The hip joint is one of the most important joints in the human body. Although its multiaxial movements account for many benefits, they also render the hip one of the most hard-working joints. Injuries to the hip joint and thigh often occur as a result of a fall. According to epidemiologic data, such falls are most frequent in the elderly, particularly in osteoporosis sufferers. Material and methods. The “Services” component of the Statistics API version 1.0 provided by the National Health Fund (NHF) was used in order to evaluate the number of hospitalizations due to hip joint and thigh injuries. Information on the number of patients was obtained in a number of stages. The first stage involved determination of hip and thigh injuries as the main diagnosis. Then, the billing products which made possible settlement for hospitalization of patients with the selected diagnoses were chosen. The last stage consisted in the extraction of relevant medical data sets from the “Services” component of the NHF Sta­tistics API, which made possible this analysis. Results. According to the NHF reporting data, over the four-year period of interest there were approx. 42,000 hospitalizations per year. The most frequent causes of hospitalization were fractures of the neck of the femur (S72.0) and trochanteric fractures (S72.1), accounting for approx. 48% and 36% of all hospital stays, respectively. Conclusions. 1. Hip injuries constitute a significant health problem in Poland (approx. 42,000 hospitalizations per year). 2. The most frequent causes of hospitalization are injuries in the form of fractures of the neck of the femur or trochanteric fractures (corresponding to the ICD-10 codes S72.0 and S72.1, respectively). 3. It appears advisable to develop a tool to enable medical service providers to adjust their services to patients’ changing needs. This tool could em­ploy open-access data on injuries published in the NHF Statistics API.

Cephalomedullary nailing is considered the treatment of choice for trochanteric and subtrochanteric femoral fractures. The aim of this study was to report postoperative outcomes of one of the widely used trochanteric nail device, the Gamma 3 long nail. We retrospectively assessed 405 patients treated with Gamma 3 long nail in a single Level One Trauma Centre between 2010 and 2018. We finally included 261 ambulant patients with 65 years or older, a lowenergy trauma and a closed trochanteric or subtrochanteric femoral fracture. Clinical outcomes were evaluated using the Hip Fracture Functional Recovery Score (FRS), while radiological complications and failures were assessed on postoperative x-rays. More than two-thirds of patients had completed fracture consolidation within 4 months after surgery. Immediate full weight bearing was allowed postoperatively in 64.0% of patients. We reported a mortality of 24.5% at one year postoperatively. The leading clinical postoperative complication was anemia (69.3%), followed by deep venous thrombosis (7.7%). Coxa vara was observed in 73 patients (28%), followed by malreduction in flexion-external rotation of the proximal femoral fragment (26.8%). No case of lag screw cutout was reported. Our study indicated that last generation of Long Gamma nail is a reliable implant for trochanteric and subtrochanteric femoral fractures in the elderly patients, leading to high rate of bone union and reduced incidence of related complications. An excellent fracture reduction and prevention of postoperative varus malalignment are the main factors that can avoid the major postoperative complications and failures after Gamma 3 long nailing.

Introduction: In recent years, computer-assisted surgery has made it possible to undergo surgery with a high degree of precision. This study aimed to investigate the usefulness of computer-assisted surgery for femoral trochanteric fractures using the ADAPT (ADAptive Positioning Technology) system. Methods: A total of forty patients with femoral trochanteric fracture underwent intramedullary nailing for fracture fixation: in twenty patients, the ADAPT system (ADAPT group), and in the other twenty, it was not used (control group). The operative time, intraoperative fluoroscopy time, tip apex distance (TAD), and tip to head surface distance (TSD) were measured and compared between the two groups to assess the efficiency and accuracy of the surgery. Results: The operative time was significantly shorter (P P P Conclusion: Navigation systems have been developed to improve the efficiency of surgery. The ADAPT system was considered a very useful device for intramedullary nailing of femoral trochanteric fractures, as it reduced the intraoperative fluoroscopy time and improved the accuracy of implant placement, also reducing the operative time.

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

Background and purpose. Infections after intramedullary fixation of trochanteric femoral fractures are rare, but potentially life-threatening complications. There are limited data available to support decision making in these cases. Patients and methods. A retrospective study of 995 consecutive operatively treated trochanteric fractures was made to find out different risk factors for infection and to describe the results of treatment. Results. 28 patients developed a surgical site infection (2.8%) after intramedullary fixation of trochanteric fracture. 15 patients (1.5%) had a deep and 13 patients (1.3%) a superficial surgical site infection. Cigarette smoking ( p < 0.05) and prolonged operative time ( p < 0.05) were significant risk factors for an infection. 15 of 28 patients needed revision surgeries. Implant removal or exchange was needed only for 4 of 28 patients: 1 exchange of the blade, 1 removal of additional cable used to assist reduction and 2 removals of distal locking screws. None of the patients needed additional surgeries for problems with fracture healing. Mortality was not increased among patients with an infection. Interpretation. Infection after intramedullary fixation of trochanteric fractures can be successfully treated without removal or exchange of the fixation material. (c) 2020 Elsevier Ltd. All rights reserved.

Introduction The aim of this study was to clarify the relationship between the preoperative radiographic classification of trochanteric fractures and the success/failure of closed reduction. Identification of irreducible fractures would be important to proceed promptly to direct reduction. Patients and methods Our retrospective analysis included 141 trochanteric fractures, in 122 women and 17 men, with a mean age of 85.7 years (range, 45–101 years). Evans’ classification of trochanteric fractures, as modified by Jensen, and the lateral view classification were used, based on preoperative plain radiographs and computed tomography images. Features predictive of irreducible fractures were identified. Results Among the 141 fractures, 16 (11.3%) were irreducible by closed reduction. The position of the proximal fragment, relative to the shaft on lateral view, and the fracture pattern of the lesser and greater trochanters were predictive of the feasibility of obtaining a successful closed reduction. These criteria identified success/failure of closed reduction in 99.3% of cases. Conclusion Our findings should be useful for identifying patients in whom closed reduction would be suitable and for avoiding ineffectual manipulation in unsuitable patients.

Objectives Different criteria for assessing the reduction quality of trochanteric fractures have been reported. The Baumgaertner reduction quality criteria (BRQC) are relatively common and the Chang reduction quality criteria (CRQC) are relatively new. The objectives of the current study were to compare the reliability of the BRQC and CRQC in predicting mechanical complications and to investigate the clinical implications of the CRQC. Methods A total of 168 patients were assessed in a retrospective observational study. Clinical information including age, sex, fracture side, American Society of Anesthesiologists (ASA) classification, tip-apex distance (TAD), fracture classification, reduction quality, blade position, BRQC, CRQC, bone quality, and the occurrence of mechanical complications were used in the statistical analysis. Results A total of 127 patients were included in the full analysis, and mechanical complications were observed in 26 patients. The TAD, blade position, BRQC and CRQC were significantly associated with mechanical complications in the univariate analysis. Only the TAD (p = 0.025) and the CRQC (p < 0.001) showed significant results in the multivariate analysis. In the comparison of the receiver operating characteristic curves, the CRQC also performed better than the BRQC. Conclusion The CRQC are reliable in predicting mechanical complications and are more reliable than the BRQC. Future studies could use the CRQC to assess fracture reduction quality. Intraoperatively, the surgeon should refer to the CRQC to achieve good reduction in trochanteric fractures. Cite this article: Bone Joint Res 2019;8:502–508. DOI: 10.1302/2046-3758.810.BJR-2019-0032.R1.

Background: For trochanteric fractures many implants have been used successfully like sliding hip screws, cephalomedullary nails, angular blade plates, and rarely by primary hip arthroplasty. The Dynamic Hip Screw (DHS) is one of the most widely used implant for stabilization of intertrochanteric fractures. The Proximal Femoral Locking Compression Plate (PFLCP) is a relatively newly introduced implant for trochanter fractures, and there is no sufficient literature comparing DHS and PFLCP. Objective: (1) Compare the operative differences, radiological and clinical outcomes between the trochanter fractures treated by DHS with those treated by PFLCP. Methods: We studied 52 patients admitted and followed up at MGMCH. Out of which 26 patients were treated with DHS, and 26 patients with PFLCP. Results: The mean operative time and average intra-operative blood loss was more in the PFLCP group when compared with DHS group and it was found to be statistically significant (p< 0.05). DHS group had marginally better functional results than PFLCP group. There was no difference in the radiological outcome between two groups. Conclusions: In trochanteric fractures of femur, both PFLCP and DHS provide excellent results. Functional outcome is more influenced by quality of fracture reduction, rather than the type of implant used.

Background Cephalomedullary nails are presently the gold standard in management of unstable trochanteric fractures. The tip-apex distance (TAD) is one of the most important factors that determines success or failure of fixation, but was described originally in context of an extramedullary hip screw. Cephalomedullary nails use a different biomechanical approach to fixation; and it is hypothesized that the TAD rule may not apply similarly with these. The aim of this study is to assess whether a high TAD correlates with poor outcomes with cephalomedullary nails, and to elucidate other factors that may predict such outcome. Methods We retrospectively reviewed the clinical and radiographic records of patients with intertrochanteric fractures, treated at our institution over a 2-year period. Those with unstable fractures (31.A2 and 31.A3), and who were treated with cephalomedullary nails were included in the study. The TAD and the position of the device in the femoral head (Cleveland index) were assessed. Other factors that could influence outcome like age, gender, AO fracture type, restoration of neck-shaft angle and degree of osteoporosis were analysed. Radiographic records of up-to at-least 3 months post-operatively were assessed for complications. Results After applying the exclusion criteria, 75 patients were included in the analysis. The overall rate of complications was 12%. They occurred in two major patterns - varus collapse and cut-out occurred in 5 patients (6.67%), and device migration in 4 patients (5.33%). The average TAD of patients with cut-out was 28.78 mm, compared to 19.44 mm in those without cut-out (p = 0.002). Our data predicted a cut-off TAD >23.56 mm as most significant for cut-out with cephalomedullary nails. On univariate logistic regression, high TAD (p = 0.009), sub-optimal device positioning (p = 0.02) and poor restoration of neck-shaft angle (p = 0.04) were found to be significant for varus collapse and cut-out, but not for complications relating to device migration. On multivariate analysis, none of the above factors reached statistical significance in isolation. Conclusion As with extramedullary devices, TAD, along with sub-optimal device positioning and poor restoration of neck-shaft angle is a useful predictor of cut-out even with cephalomedullary nails, negating the initial hypothesis. The above factors in combination have a more significant effect than any one factor in isolation to cause varus collapse and implant cut-out. However these do not affect Z effect, reverse Z effect or other types of device migration seen especially with dual-screw nails.

Background: Dynamic hip screw (DHS) and proximal femoral nail anti-rotation (PFNA) are the two most commonly used fixation devices for inter-trochanteric fracture of femur. However, many clinical studies have shown lack of differences in the clinical outcome consistently with between these two fixation techniques. The main objective of this study is to compare the results of dynamic hip screw (DHS) and proximal femoral nail anti-rotation (PFNA) fixation in elderly patients with unstable inter-trochanteric fractures of femur. Methods: We retrospectively reviewed patients who underwent operative management for inter- trochanteric fractures of femur in our hospital between February 2013 and September 2017. Elderly patients (Age >60yrs) with unstable inter-trochanteric fracture of femur treated either with DHS fixation or with PFNA fixation were included and divided into two groups: DHS fixation group and PFNA fixation group. The comparative statistical analysis was done between two group using following parameters: average length of the incision, operation time, blood loss, fracture healing time, and degree of postoperative functional recovery. Results: The mean follow-up period, in DHS fixation group was 16 month (range 12 to 24 months) and in PFNA fixation group was 14 months (range 12 to 18 months). The differences between two groups regarding average length of the incision, operation time, and blood loss were statistically significant (p0.05). Conclusions: PFNA fixation may be better than DHS fixation for the treatment of unstable inter-trochanteric fractures of the femur in the elderly. However, the application and usage of DHS fixation could not be neglected and the choice of treatment depends upon the systemic condition and socioeconomic status of the patient, patient’s preferences, surgeon’s experience and availability of treatment facility.