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Introduction The objectives of this study were to evaluate the correlation between bone attenuation around the shoulder joint assessed on conventional computed tomography (CT) and bone mineral density (BMD) based on dual-energy X-ray absorptiometry (DEXA) of the central skeleton and the correlation between the bone quality around the shoulder joint and the severity of the fracture pattern of the proximal humerus. Materials and methods A total of 200 patients with proximal humeral fracture who underwent preoperative 3-dimensional shoulder CT as well as DEXA within 3 months of the CT examination were included. Fracture types were divided into simple and comminuted fracture based on the Neer classification. After reliability testing, bone attenuation of the glenoid, three portions of the humeral head, and metaphysis was measured by placing a circular region of interest on the center of each bony region on CT images. Partial correlation analysis was used to assess the correlation between the bone quality around the shoulder joint on CT and the BMD on the central skeleton after adjusting for age and body mass index. Partial correlations between fracture classification and CT/DEXA results were also evaluated. Results Bone attenuation measurements of the glenoid and humeral head showed good to excellent reliability (intraclass correlation coefficient, 0.623–0.998). Bone attenuation of the central portion of the humeral head on CT showed a significant correlation with the BMD of L1, L4, the femoral neck, and femoral trochanter (correlation coefficient, 0.269–0.431). Bone attenuation of other areas showed a lower correlation with BMD by DEXA. As the level of the Neer classification increased from a 2 to 4-part fracture, bone attenuation of the central humeral head decreased significantly (r = −0.150, p = 0.034). However, the BMD on DEXA was not a predictive factor for comminuted fracture of the proximal humerus. Conclusions DEXA examination of the central skeleton may not reflect the bone quality of the proximal humerus and severity of proximal humeral fracture. Direct assessment of the bone quality of the proximal humerus is recommended to determine the osteoporotic nature of the fracture.

Purpose To evaluate the outcome after different types of revision operations for blade ‘cut-out’ and ‘cut-through’ after fixation of trochanteric fractures with proximal femoral nail antirotation (PFNA) or a trochanter fixation nail (TFN). Methods Twenty hospitals participated in this multicentre study. A total of 4109 patients were retrospectively screened for cut-out or cut-through complications after nailing of trochanteric fractures using PFNA or TFN. Fifty-seven patients (28 with ‘cut-through’ and 29 with ‘cut-out’) were included in the study. In the ‘cut-through’ group, 16 patients underwent a blade exchange, six patients had a blade exchange with bone cement augmentation, and six received total hip arthroplasty (THA). In the ‘cut-out’ group, three patients had a blade exchange, one had a blade exchange with augmentation, three underwent re-nailing of the fracture with a new PFNA, one had a girdlestone procedure and 21 had THA procedures. Results In the ‘cut-through’ group, eight patients who had a blade exchanges (50%) and two patients with blade exchange and augmentation (33%) required further revision operations. THA was the definite treatment in all 6 cases. In the ‘cut-out’ group, two patients (66%) who had blade exchanges and two (66%) who underwent re-nailing required additional revision operations during the subsequent course. One patient (4%) who had total hip arthroplasty needed revision surgery for acetabular replacement. Overall, a total of 81 revision procedures were performed. Conclusion Based on the data from this study, we recommend THA as the only valid salvage procedure for ‘cut-out’ and ‘cut-through’ of helical blades after fixation of trochanteric fractures with the PFNA and TFN.

Objective Extensive incision associated with large-scale callus exfoliation and internal fixation is the common therapeutic approach employed by the majority of orthopaedists in the treatment of old femoral fractures. Inspired by the surgical techniques of intramedullary fixation and reduction by traction, the present study attempted to treat old femoral fractures with minimally invasive methods utilising the principles of biological osteosynthesis (BO). Methods A retrospective analysis involving 16 patients with old femoral fractures treated with combined traction, small incision, limited callus treatment, reduction by leverage and intramedullary fixation was conducted. The operative effect was evaluated by the operation time, intraoperative blood loss, bone grafting, healing time of fractures during follow-up, VAS score, and Harris hip score. Results Intraoperative observation revealed an average operation time of 1.53 ± 0.34 h and average blood loss of 268.13 ± 97.29 ml without bone grafting in all patients. All enrolled patients had outcomes resulting in effective fixation restoration of limb alignment. Of the 16 enrolled patients, 13 patients completed follow-up with an average follow-up time of 7.42 ± 3.29 months. The average healing time for proximal femoral fractures was 3 months. The average healing time of femoral shaft fractures was 4 ± 1.09 months; two of these cases took 4 months to heal, whereas 1 case demonstrated a delayed healing time of 6 months. The VAS score was 1.15 ± 1.70, 1 patient experienced sciatica, and the Harris hip score was 92.92 ± 5.42. There were no complications of malunion, nonunion or infection among any of the patients who completed follow-up. Conclusions Minimally invasive treatment is feasible for most patients with old femoral fractures of the trochanter and femoral shaft. This finding is consistent with BO principles, thereby providing a possible new method for the treatment of old femoral fractures.

For AO/OTA 31-A2 fractures (A2 fractures) treated with dynamic hip screw (DHS), postoperative lateral wall fracture (PLWF) is thought to be a major cause of femoral medialisation and reoperation. Though trochanter stabilising plate (TSP) had been reported to have a good effect in preventing femoral medialization, its effects and indication in A2 fractures remain controversial. We hypothesized that TSP may improve treatment outcomes in patients with high risk of postoperative lateral femoral wall fractures. The purpose of this study was to investigate (1) the main risk factors predictive of PLWF in A2 fractures and, (2) whether TSP can improve treatment outcomes in patients with high risk of PLWF.Two hundred and fifty-two A2 fractures treated with DHS or DHS and TSP (DHS-TSP) during January 2000 and June 2013 were enrolled in this study. Standard univariate and multivariate analyses were performed to determine statistically significant risk factors for PLWF in 205 patients who were treated with DHS alone. The risk factor found to be associated with PLWF was utilized to include 171 patients who were at high risk of PLWF. Standard univariate and multivariate analyses were performed to evaluate the effect of TSP on treatment outcomes.Lateral wall thickness was found to be the main risk factor for PLWF in A2 fractures. A lateral wall thickness of 2.24 cm was found to be the best cutoff point to determine which patients were at high risk for PLWF. In 171 patients with a lateral wall thickness less than 2.24 cm, patients treated with DHS-TSP had significantly decreased lag screw sliding distances, PLWF rate, and reoperation rate (P=0.028,0.001 and P=0.003, respectively) compared to the corresponding values of those treated with DHS alone. In the multivariate analysis, TSP decreased the reoperation rate by 13 times compared to that of patients who were treated with DHS alone.Lateral wall thickness is the main risk factor for PLWF in A2 fractures treated with DHS. Use of TSP in A2 fractures with critical thin lateral wall thickness2.24 cm can significantly decrease the lag screw sliding distances, PLWF rate and reoperation rate.

The posterior dislocation remains one unresolved complication of the posterior approach to the hip joint. In this study, a variation of the posterior hip approach – a partial osteotomy of the greater trochanter – was performed in order to investigate whether it provides better stability to the operated hip joint and reduces the risk of dislocation. We carried out a partial intertrochanteric osteotomy, initially in a cadaveric model and then in 68 patients (30 acute neck of femur fractures and 38 patients with hip osteoarthritis) requiring a total hip replacement. The osteotomised fragment was reattached with wires. All arthroplasties were cemented with Muller acetabular component and Charnley-type stem with a 28-mm interchangeable neck. Intraoperatively, all hips were tested for stability. After the osteosynthesis of the osteotomised fragment, hip dislocation points were increased more than 15% in the flexion and 10% in the internal rotation plane of movement. At one year follow up, no dislocation was observed in the clinical component of the study. This technique was found reliable in providing a stable hip joint.

Purpose To verify the practical correlation between the topographical features of the femur neck base and the ideal entry point by analyzing three-dimensional (3D) models virtually implanted with an antegrade femoral nail. Materials and methods A total of 103 cadaveric femurs (50 males and 53 females) were enrolled. Specimens underwent continuous 1.0 mm slice computed tomography (CT) scans. CT images were rendered into 3D images using image-processing software (Mimics ® ) to reconstruct the geometry of the cortex and medullary canal. A real cannulated femoral nail (CFN) ® was processed into a 3D image using a 3D sensor at the actual size and optimally placed in the femur model using Mimics ® for virtual implantation. The correlation between the ideal entry point in the cranial view of the proximal femur and the trochanteric fossa was assessed and overlap of trochanter overhang was verified. Results The entry point of 68 models (66.0%) was the trochanteric fossa, while the others were placed around the anterior border of the trochanteric fossa. The proximal end of the nail overlapped in 50 models (48.1%), and among them, the central point of 23 models (22.3%) was obscured by trochanteric overhang. There was a statistically significant risk associated with female gender (6.02 times) and type IV overhang of Grenchenig’s classification (4.56 times). Despite the precise positioning of the trochanteric fossa, 11 models (10.7%) had the entry point covered by trochanteric overhang. Conclusion The ideal entry point was over the trochanteric fossa in just half of the models, and could be hindered by trochanteric overhang even though the CFN was ideally positioned.

In the medical literature, elderly patients with inter-trochanteric fractures are considered older than those with femoral neck fractures, but the reason for this age-related difference remains unclear. Inconsistent bone mass re-distribution with age in both regions was hypothesised and the change in bone mineral density (BMD) was studied. This study aims to investigate another possible pathomechanism of reducing bone strength in the proximal femur with increasing age. The findings might help in developing a better method for preventing osteoporotic hip fractures. Patients and methods In the BMD study, 400 consecutive female patients were divided into eight groups, comprising 50 individuals each. Except for the first group (16–20 years), all other groups were divided by 10-year age increments up to 90 years. Relative BMD change with age in different regions in each group was compared. Results The BMD ratio of the lateral trochanter to the neck gradually reduced with age, whereas that of the medial trochanter to the neck gradually increased. The comparisons were statistically significant (p Conclusion One important predisposing factor to affect patients with inter-trochanteric fractures older than those with femoral neck fractures may be that the BMD is further lowered in the lateral trochanter compared to the femoral neck with age. It may be caused by lack of compressive loads in the lateral trochanter in daily activity. All devices which may increase bone mass in the lateral trochanter, theoretically, may be helpful in lowering the incidence of hip fractures.

The possibility of occult hip fracture in older patients after a fall is a common problem in emergency and orthopaedic departments. Magnetic resonance imaging (MRI) scanning is the best investigation, but is expensive and may be difficult to obtain. The value of various clinical signs to determine which patients are at risk of occult hip fracture has not been reported. We reviewed all patients who had MRI scan for suspected hip fractures but had normal initial X-rays over a 6-year period. We identified 76 patients. Twelve patients were excluded. Two patients had MRI scan for suspected stress fracture and two patients had metastatic fractures. Eight patients had inadequate or untraceable clinical notes. Each patient's personal details, mobility, independence and detail clinical details were recorded. Following case review of 64 patients we excluded 5 patients with associated osteoarthritis of the hip joint, 1 patient with fibromyalgia and 1 patient with pre-existing multiple myeloma. Thirty-five patients had occult proximal femoral fractures. Of them four patients had isolated pubic ramus fractures and five patients had isolated greater trochanter fractures. Twenty-two patients had no fracture. The value of the individual tests was evaluated using Fisher exact and chi square analysis; with Bonferroni correction for multiple comparisons (10 tests) p

Summary Objective To assess the results of using sliding trochanteric osteotomy as an adjunct procedure for acetabular fractures. Design Retrospective review. Setting Level 1 trauma centre. Methods Thirty patients (19 men, 11 women, mean age 40 years, range 23–80 years) having fracture of acetabulum underwent sliding trochanteric osteotomy for a better exposure of the fracture involving the dome of acetabulum during the period January 1999–January 2004. Main outcome measurements Clinical evaluation was based on modified Merle d’ Aubigne and Postel scoring. Motor strength of the abductors was evaluated according to the Medical Research Council (MRC) grading system. Radiographic evaluation of the joint was also documented. Results All the osteotomies healed within 12 weeks without any proximal migration except for one patient with infection in whom nonunion occurred. Two patients underwent removal of implants from greater trochanter because of irritation. The strength of the abductors was of Grade 2/5 in one patient, Grade 3/5 in one patient, Grade 4/5 in six patients and Grade 5/5 in the rest. Clinical scoring was excellent to good in 77%. Heterotopic ossification occurred in six patients and was of modified Brooker's classes 1 and 2. Conclusions This technique can be relied upon to provide an adequate exposure of the dome of acetabulum without the associated complications like malunion, non-union, etc., known to occur with standard oblique osteotomy.

The objective of this review article is to present biomechanics concepts and data relevant to osteoporotic fractures. Fractures are mechanical events that occur when the applied load exceeds the fracture load (bone strength); both loading and strength must be considered to understand fracture risk. Hip fractures are almost always due to a fall, but only 5% of falls result in fracture. Hip fracture risk is greatest for a sideways fall that impacts on the greater trochanter. The loading events that cause vertebral fractures are poorly understood but include falls and heavy lifting. Activities that involve forward flexion and lifting generate the largest forces on the spine. Factors that affect bone strength include bone size (geometry) and bone density (vBMD). Men have larger bones at all ages compared to women and this is the main factor in the gender difference in whole-bone strength. Both men and women lose trabecular bone density and thus bone strength with aging, which is the main reason for the age-related loss of bone strength at the hip and spine, although dramatic decreases in the toughness of cortical bone may also contribute to osteoporotic fragility. The factor of risk (applied force/fracture force) is a useful concept for considering both the injury and the disease component of osteoporotic fractures. Within this article, I will review data on age-related changes in factors that affect fracture risk. Advanced engineering concepts will not be presented, but a familiarity with basic mechanical principles is assumed.

Operative problems in the application of femoral locking nails are frequently related to an unfavourable entry point at the greater trochanter. Especially in more distally located fractures the nail is forced to follow the cortex abutted medullary canal. A wrong defined entry point either in the medio-lateral or dorso-ventral direction inevitably leads to tension between nail and femur. Forceful insertion in this situation may cause disastrous iatrogenic comminution at the fracture side or additional fractures at the proximal femur. To avoid tension between nail and femur the best suited entry point must be defined according to the natural medullary cavity. In 16 human cadaver femora, the natural medullary cavity was opened and after cleaning filled with a radio-opaque substance (barium sulphate). Twelve radiographs where taken from each bone starting with the anterior-posterior view and then turning the bone axially in steps of 15 degrees. From these radiographs, the ideal entry point at the greater trochanter was calculated. In 88% of the specimen the ideal entry point for a straight nail was found constantly at the medial border of the greater trochanter overlaying the tendinous insertion of the piriformis muscle. The axis of the medullary cavity was in average 2.1cm anterior to the dorsal border of the greater trochanter. In a second step the ideal entry point for bend nails was calculated. According to this calculation a bend nail with a radius of 100 cm needs an entry point 0.7 mm anterior to the dorsal edge of the greater trochanter. Overlaying the hook like shape of the posterior part of the trochanter.

In order to compare accurately fixed nail plates with sliding implants 13 randomised, quasi-randomised or comparative studies, involving a total of 2,855 patients, which compared these implants, were systematically reviewed. In addition the results of a further 214 patients treated in a prospective audit are presented. Results showed an increased risk of cut-out (13% versus 4%), non-union (2% versus 0.5%), implant breakage (14% versus 0.7%) and re-operation (10% versus 4%) for fixed nail plates in comparison with the sliding implants. In addition patients treated with fixed nail plates had a higher mortality and the survivors were more likely to have residual pain in the hip and impaired mobility. The continued use of fixed nail plates cannot be justified given the unequivocal superiority of the sliding hip screw.

Isolated lesser trochanter fractures are a rare presentation of hip fractures in the elderly. Classically, lesser trochanter fractures in adults are associated with tumours and result from little or no trauma. We present three elderly osteoporotic ladies who sustained isolated fractures of the lesser trochanter secondary to a definite history of trauma. Radiologically, none of them showed any evidence of pathological lesions or intertrochanteric fracture at presentation. Two patients subsequently developed displaced intertrochanteric fractures, which necessitated internal fixation. In the third patient, a dynamic hip screw (DHS) was inserted before mobilisation. Based on this experience, we recommend careful observation and follow-up of such cases and suggest that isolated lesser trochanteric fractures in the elderly osteoporotic population may be an indication for prophylactic DHS fixation.

With industrial societies getting older the incidence of femoral fractures is increasing. Complication rates up to 20% have led to a continuous improvement of intramedullar nailing systems and the third generation of implants is in clinical application. They seem superior to the second generation. But as clinical data is still fragmentary, we wanted to compare a second generation implant, the Proximal Femur Nail with three devices of the third generation: the Gleitnagel, Trochanter Fixation Nail and the Proximal Femur Nail Antirotation with a clinical study. We analysed whether fracture reduction and implant position could possibly be indicators for implant complications. Patients with a trochanteric fracture type A1–A3 (AO/ASIF classification) admitted at the department of traumatology Augsburg were enrolled. Postoperative X-rays were analysed in the matter of fracture reduction for the fracture gap, the Garden Alignment Index and for the matter of implant position in the femur head with the cleaveland zones and the Tip Apex Distance. 322 patients were enrolled. Most frequent was the A2 ( n = 240) and the A3 type of fracture ( n = 80) followed by A1 ( n = 29). Time to hospital discharge was 17 days (9/25), 12 patients died (3.2%). The complication rate (cutting out) in the third generation was lower (2.5–7%) than in the second generation (14%). The postoperative range of mobilisation compared to the old social status was in the groups with 34% similar after 3 months. The third generation nails are safe and reliable implants. Compared with second generation devices, fewer complications are observed. A correlation might be seen in the postoperative X-rays between the fracture reduction or implant position and implant related mechanical complications (cutting out).

A simple laser pointer can be used to guide the radiographer to position the image intensifier during the insertion of a dynamic hip screw in the treatment of fractures of the trochanteric area of the proximal femur. This significantly reduces the screening time and, by implication, the amount of radiation for the theatre staff and patient.

In a retrospective study of 1126 children with fractures of the proximal third of the femur, three children were found to have isolated fractures of the lesser trochanter. This fracture occurred from a fall in one child and following sporting activities, without a history of injury, in the others. In the latter children, the clinical presentations were similar to those of children with transient synovitis of the hip or Perthes disease. In each child, plain radiographs showed an avulsion fracture of the bony portion of the lesser trochanter. Early and complete recovery followed symptomatic treatment even when there was marked proximal displacement of the avulsed segment of the lesser trochanter.

Optimal entry point for antegrade femoral intramedullary nailing (IMN) remains controversial in the current medical literature. The definition of an ideal entry point for femoral IMN would implicate a tenseless introduction of the implant into the canal with anatomical alignment of the bone fragments. This study was undertaken in order to investigate possible existing relationships between the true 3D geometric parameters of the femur and the location of the optimum entry point. A sample population of 22 cadaveric femurs was used (mean age=51.09+/-14.82 years). Computed-tomography sections every 0.5mm for the entire length of femurs were produced. These sections were subsequently reconstructed to generate solid computer models of the external anatomy and medullary canal of each femur. Solid models of all femurs were subjected to a series of geometrical manipulations and computations using standard computer-aided-design tools. In the sagittal plane, the optimum entry point always lied a few millimeters behind the femoral neck axis (mean=3.5+/-1.5mm). In the coronal plane the optimum entry point lied at a location dependent on the femoral neck-shaft angle. Linear regression on the data showed that the optimal entry point is clearly correlated to the true 3D femoral neck-shaft angle (R(2)=0.7310) and the projected femoral neck-shaft angle (R(2)=0.6289). Anatomical parameters of the proximal femur, such as the varus-valgus angulation, are key factors in the determination of optimal entry point for nailing. The clinical relevance of the results is that in varus hips (neck-shaft angle

It has been stated that 10-15 per cent of traumatic dislocations of the hip are anterior (Epstein, 1973; DeLee, 1980). In our series of 74 cases of dislocation of the hip over an y Aggarwal and Hardas, 1967; M’Bali, 1974; Gibbs, 1980; Zamon and Saltzman, 1981). anterior dislocation. Thus, a sufficient unloading period and long-fen-n follow-up are considered necessary in these patients.

This study evaluates and compares the efficacy of the two positions used for imaging of the hip in trochanteric fractures. One hundred patients with grade I or grade II trochanteric fractures were divided into two equal groups. In group I the fracture was reduced and the opposite hip was brought to full abduction, neutral flexion and neutral rotation. In group II, the fracture was reduced and the opposite hip was flexed beyond 90 degrees, abducted and externally rotated. Only patients with minimal or no comminution were included in this study. The radiation exposure time was considerably less in group II. The abduction angle between the two limbs of the fracture table was higher in group II and it was possible to visualize the femoral head completely in the lateral view in 96 per cent of patients in group II and 76 per cent in group I. We strongly recommend that the opposite hip should be flexed to about 90 degrees, abducted and externally rotated if it is not possible to see the femoral head completely in the lateral view.

A series of 87 trochanteric fractures of the femur treated by dynamic hip screw, was reviewed. The relationship between the position of the fracture fragments and the position of the hip screw in the femoral head was investigated. Hip screws inserted into some parts of the femoral head were more likely to cut out than others. Some fractures were undisplaced or had been perfectly reduced. A lateral radiograph of some of the others showed that the femoral head and neck were aligned with the shaft. Only among these fractures was the number of good screw placements as great as among those that were undisplaced or perfectly reduced.

The reliability of Evans' classification of trochanteric femoral fractures was examined using kappa (Kappa) statistics. Radiographs of 50 randomly chosen trochanteric fractures were evaluated by six observers. One set of radiographs was uniformly classified as a subtrochanteric fracture by all observers and was excluded from further analysis. Only 18 per cent of the fractures were classified identical by all observers and 57 per cent when differentiating between stable and unstable fractures. The corresponding kappa values showed moderate agreement ranging from 0.38 to 0.68.