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Introduction: fixation of unstable intertrochanteric fractures presents a significant challenge, especially in the context of osteoporosis. Intramedullary implants have been established as superior to plate constructs. Our aim is to compare the complications and clinical outcomes of the Proximal Femur Nail (PFN) and Proximal Femur Nail Antirotation-2 (PFNA2) in managing unstable intertrochanteric fractures. Material and methods: a total of 212 patients meeting inclusion and exclusion criteria underwent fixation of trochanteric fractures using either a standard PFN (n = 110) or PFNA2 (n = 102). Their intraoperative and postoperative clinical and radiographic data were evaluated along with the quality of fixation. Data analysis was performed using the student's t-test, χ² test, and Mann-Whitney U test. Results: PFNA2 demonstrated more favorable outcomes compared to PFN in terms of a better intraoperative profile, functional outcomes (PFNA2: PFN = 82:75), and fewer implant-related complications. Significant issues in the PFN group included screw backout, guidewire breakage, and proximal protrusion of the nail tip. In contrast, locking mechanism failure and lateral screw prominence were significant problems in the PFNA2 group. Conclusion: PFNA2 is the preferred implant for managing osteoporotic unstable intertrochanteric fractures, given the bone's weak inherent tendency to secure the implant. [ABSTRACT FROM AUTHOR]

Introduction: A minority of geriatric hip fracture patients pursue non-operative treatment. Compared with surgical patients, non-operative patients have higher mortality rates. However, patient satisfaction following non-operative vs operative treatment has not been investigated extensively. The purpose of this study was to compare satisfaction among non-operatively vs operatively treated hip fracture patients. Methods: We identified patients aged 60+ years with proximal femur fractures treated over a 10-year period. Excluded were patients with isolated greater/lesser trochanteric fractures. Patients or relatives were asked to complete a 6-question survey about their treatment satisfaction. Results: Survey responses from 56 operative and 28 non-operative patients were recorded. Overall, 91.1% of operative and 82.1% of non-operative patients were satisfied with their treatment course (P = 0.260). However, only 71.4% of non-operative patients were satisfied with treatment option explanations vs 83.9% of operative patients (P = 0.014). While only 64.3% of non-operative respondents were satisfied with the ultimate treatment outcome (vs 85.7% of operative patients, P = 0.025), 89.3% of patients in each cohort would choose the same treatment plan again. Discussion: Our findings highlight the complexity of defining patient satisfaction, particularly in a geriatric hip fracture population. Unlike previous studies, we chose a direct approach to quantifying patient satisfaction by asking participants specifically about satisfaction with treatment outcome and the overall treatment course. Additional survey questions were then included to assess factors considered important in treatment satisfaction, such as health care provider treatment explanations, post-treatment mobility, and palliative care service involvement. Conclusions: We identified significant differences between non-operatively and operatively treated geriatric hip fracture patients regarding satisfaction with the explanation of treatment options, and ultimate treatment outcomes. There was no significant difference in overall satisfaction with the treatment course or likelihood of choosing the same treatment again. Further research investigating patient satisfaction following geriatric hip fracture treatment is warranted. [ABSTRACT FROM AUTHOR]

Cephalomedullary nailing for unstable proximal femoral fractures is widely utilized, especially for geriatric osteoporotic fractures. There are two starting points for entry, namely trochanteric tip entry and pyriformis fossa entry, both have advantages and disadvantages, the tip of the greater trochanter seems that it is not the ideal starting point for trochanteric entry nails, the study presents the foothill entry point as a reproducible, technically feasible entry point to overcome the shortcoming of both standard starting points, and it could be easy executed with clear intraoperative fluoroscopic landmarks and lead to appropriate nail position without intraoperative complications. [ABSTRACT FROM AUTHOR]

Objective To evaluate the clinical effect of two different internal fixation methods in elderly patients in artificial femoral head replacement for intertrochanteric fracture in elderly patients. Methods A total of 100 elderly patients with intertrochanteric fractures who underwent artificial femoral head replacement in the Department of Orthopaedics, this hospital from December 2017 to December 2020 were retrospectively analyzed. They were divided into observation group and control group according to the use of ordinary steel wire or greater trochanter plate internal fixation. 78 patients in the observation group were fixed with ordinary steel wire, while 22 patients in the control group were fixed with greater trochanter plate. The operation time. intraoperative blood loss, hospitalization expenses, hospitalization time, postoperative complications, hip joint visual analogue scale (VAS) score and Harris score were used to evaluate the clinical efficacy of the two groups. Results The patients were followed up for 6-18 months, with an average of (10.89±4.29) months. By the last follow-up, 13 patients had died, including four in the control group and nine in the observation group. All patients successfully completed the operation, and the difference of Tronzo-Evans classification between the two groups was statistically significant(P<0.05). There was no significant difference in other general data(P>0.05). There were no significant differences in hospitalization time, intraoperative blood loss, hip VAS score and Harris score at the last follow-up between the two groups (P>0.05). The operation time of the observation group was shorter than that of the control group and the hospitalization cost was lower than that of the control group, the differences were statistically significant (P<0.05). The incidence of postoperative complications in the observation group was lower than that in the control group, the difference was statistically significant (P<0.05). Conclusion Although the ordinary steel wire binding fixation has more advantages than the trochanter plate fixation in terms of operation time, hospitalization expenses and postoperative complications, the application of the trochanter plate can simplify the operation and make the fixation more reliable during the operation, which is especially suitable for patients with complex intertrochanteric fractures. The choice of the two methods depends on the degree of fracture and the actual situation of the patient, and there is no uniform standard at present. [ABSTRACT FROM AUTHOR]

Purpose: The optimal choice of distal locking modes remains a subject due to limited available data, and therefore, this study aims to investigate the relationship between distal locking mode and postoperative mechanical complications in an intertrochanteric fracture (ITF) population who underwent closed reduction and intramedullary fixation with a PFNA-II. Methods: Patients aged 65 years or older who underwent surgery with PFNA-II fixation in a university teaching hospital between January 2020 and December 2021 were potentially eligible. Based on the distal locking mode, patients were classified into static, dynamic, and limited dynamic groups, among which the differences were tested using univariate analysis. Multivariate logistic regression was used to examine whether the distal locking mode was independently associated with the risk of postoperative one year mechanical complications, adjusting for covariates and potential confounders. Subgroup analyses were performed to evaluate the robustness of the findings. Result: Among 507 eligible patients, 33 (6.5%) developed postoperative mechanical complications. In the univariate analysis, sex (P = 0.007), fracture type (P = 0.020), LAT Parker ratio (P = 0.023), and lateral femoral (P = 0.003) wall showed that the differences were significant. Compared to the static group, the limited dynamic group and the dynamic group showed higher odds of postoperative mechanical complications (OR = 3.314, 95% CI: 1.215–9.041; and OR = 3.652, 95% CI: 1.451–9.191, respectively). These associations were robust across a series of analyses, including adjusting for confounders and subgroup analyses. Conclusion: Using a distal non-static locking mode significantly increases the risk of postoperative mechanical complications, and static locking could be a preferable option when treating an intertrochanteric fracture. [ABSTRACT FROM AUTHOR]

Background: Intertrochanteric fractures are common injuries, particularly in the elderly population, and are associated with significant morbidity and mortality. The proximal femoral nail (PFN) has gained popularity in the treatment of unstable intertrochanteric fractures. This prospective study aimed to evaluate the clinical and functional outcomes of PFN in the management of these fractures. Methods: Twenty patients with intertrochanteric fractures (9 males, 11 females; mean age: 61.7 years) were included in this study. Fractures were classified according to the Boyd and Griffin system, with 35% type 2, 40% type 3, and 25% type 4 fractures. All patients underwent PFN fixation by a single experienced surgeon. Functional outcomes were assessed using the Harris Hip Score, and complications were recorded. The mean follow-up duration was 12.5 months (range: 8-17 months). Results: The mean surgical time was 32 minutes (range: 20-65 minutes), and the average intraoperative blood loss was approximately 100 ml. Functional outcomes were excellent in 55% of patients, good in 20%, fair in 20%, and poor in 5%. Superficial surgical site infections occurred in 10% of patients, and varus collapse with limb shortening was observed in 10%. No cases of Z-effect, reverse Z-effect, or implant cutout were reported. Conclusion: PFN is an effective treatment option for intertrochanteric fractures, offering a minimally invasive approach, satisfactory functional outcomes, and an acceptable complication rate. Further research with larger sample sizes and longer follow-up is needed to establish the long-term efficacy of PFN in the management of these fractures. [ABSTRACT FROM AUTHOR]

Abstract Objective Elderly patients with hip fractures are at a greater risk of developing postoperative delirium (POD), which significantly impacts their recovery and overall quality of life. Neuroinflammation is a pathogenic mechanism of POD. Taohong Siwu Decoction (THSWD), known for its ability to promote blood circulation and remove blood stasis, can effectively reduce inflammation in the nervous system. Therefore, the objective of this article is to provide a comprehensive summary of the clinical efficacy of THSWD in the prevention of POD. Additionally, it aims to investigate the underlying mechanism of THSWD in the prevention and treatment of POD using network pharmacology and molecular docking. Methods We conducted a retrospective analysis of patients with intertrochanteric fractures between January 2016 and October 2021. The patients were divided into two groups: the control and THSWD group. We performed a comparative analysis of hemoglobin (HB), albumin (ALB), C-reactive protein (CRP), blood urea nitrogen (BUN), and the blood urea nitrogen to creatinine ratio (BCR) on two different time points: the day before surgery (D0) and the third day after surgery (D3). Furthermore, we examined the incidence and duration of delirium, as well as the Harris Hip Score (HHS) at 3 months and 12 months post-surgery. Network pharmacology was employed to identify the primary targets and mechanisms of THSWD in the management of delirium. Molecular docking was employed to confirm the interaction between active ingredients and COX-2. Inflammatory cytokines, including cyclooxygenase-2 (COX-2), interleukin-1β (IL-1β), interleukin-6 (IL-6), and tumor necrosis factor- (TNF-α), were measured using the enzyme-linked immunosorbent assay (ELISA). The cognitive status of the patients was assessed using the Mini-Mental State Examination (MMSE) scoring system. Results Regardless of whether it is in D0 or D3, THSWD treatment can increase HB levels while decreasing BCR. In D3, the THSWD group demonstrated a significant reduction in the expression of CRP and BUN when compared to the control group. However, there were no significant differences in ABL levels, surgery duration, and blood loss between the two groups. Additionally, THSWD treatment requires fewer blood transfusions and can reduce the incidence and duration of POD. The results of the logistic analysis suggest that both CRP levels and BCR independently contribute to the risk of POD. Network pharmacology analysis indicates that THSWD has the potential to prevent and treat POD possibly through inflammatory pathways such as IL-17 signaling pathways and NF-kappa B signaling pathways. Molecular docking validated the interaction between the active ingredient of THSWD and COX-2. Furthermore, THSWD treatment can reduce the levels of COX-2, IL-1β, IL-6, TNF-α, BUN and CRP in the blood of patients with POD, increase HB levels, and enhance MMSE scores. The expression of COX-2 is positively associated with other inflammatory markers (IL-1β, IL-6, TNF-α, and CRP), and inversely associated with MMSE. Conclusion THSWD has been found to have a preventive and therapeutic effect on POD in intertrochanteric fracture patients possibly through inflammatory pathways. This effect may be attributed to its ability to increase hemoglobin levels and reduce the levels of certain detrimental factors, such as blood urea nitrogen and inflammatory factors.

Objective: Elderly patients with hip fractures are at a greater risk of developing postoperative delirium (POD), which significantly impacts their recovery and overall quality of life. Neuroinflammation is a pathogenic mechanism of POD. Taohong Siwu Decoction (THSWD), known for its ability to promote blood circulation and remove blood stasis, can effectively reduce inflammation in the nervous system. Therefore, the objective of this article is to provide a comprehensive summary of the clinical efficacy of THSWD in the prevention of POD. Additionally, it aims to investigate the underlying mechanism of THSWD in the prevention and treatment of POD using network pharmacology and molecular docking. Methods: We conducted a retrospective analysis of patients with intertrochanteric fractures between January 2016 and October 2021. The patients were divided into two groups: the control and THSWD group. We performed a comparative analysis of hemoglobin (HB), albumin (ALB), C-reactive protein (CRP), blood urea nitrogen (BUN), and the blood urea nitrogen to creatinine ratio (BCR) on two different time points: the day before surgery (D0) and the third day after surgery (D3). Furthermore, we examined the incidence and duration of delirium, as well as the Harris Hip Score (HHS) at 3 months and 12 months post-surgery. Network pharmacology was employed to identify the primary targets and mechanisms of THSWD in the management of delirium. Molecular docking was employed to confirm the interaction between active ingredients and COX-2. Inflammatory cytokines, including cyclooxygenase-2 (COX-2), interleukin-1β (IL-1β), interleukin-6 (IL-6), and tumor necrosis factor- (TNF-α), were measured using the enzyme-linked immunosorbent assay (ELISA). The cognitive status of the patients was assessed using the Mini-Mental State Examination (MMSE) scoring system. Results: Regardless of whether it is in D0 or D3, THSWD treatment can increase HB levels while decreasing BCR. In D3, the THSWD group demonstrated a significant reduction in the expression of CRP and BUN when compared to the control group. However, there were no significant differences in ABL levels, surgery duration, and blood loss between the two groups. Additionally, THSWD treatment requires fewer blood transfusions and can reduce the incidence and duration of POD. The results of the logistic analysis suggest that both CRP levels and BCR independently contribute to the risk of POD. Network pharmacology analysis indicates that THSWD has the potential to prevent and treat POD possibly through inflammatory pathways such as IL-17 signaling pathways and NF-kappa B signaling pathways. Molecular docking validated the interaction between the active ingredient of THSWD and COX-2. Furthermore, THSWD treatment can reduce the levels of COX-2, IL-1β, IL-6, TNF-α, BUN and CRP in the blood of patients with POD, increase HB levels, and enhance MMSE scores. The expression of COX-2 is positively associated with other inflammatory markers (IL-1β, IL-6, TNF-α, and CRP), and inversely associated with MMSE. Conclusion: THSWD has been found to have a preventive and therapeutic effect on POD in intertrochanteric fracture patients possibly through inflammatory pathways. This effect may be attributed to its ability to increase hemoglobin levels and reduce the levels of certain detrimental factors, such as blood urea nitrogen and inflammatory factors. [ABSTRACT FROM AUTHOR]

Purpose: The objective of this study was to assess postoperative direct medical expenses and medical utilization of elderly patients who underwent either hemiarthroplasty (HA) or internal fixation (IF) for treatment of a femoral intertrochanteric fracture and to analyze differences according to surgical methods and age groups. Materials and Methods: Data from the 2011 to 2018 Korean National Health Insurance Review & Assessment Service database were used. Risk-set matching was performed for selection of controls representing patients with the same sex, age, and year of surgery. A comparative interrupted time series analysis was performed for evaluation of differences in medical expenses and utilization between the two groups. Results: A total of 10,405 patients who underwent IF surgery and 10,405 control patients who underwent HA surgery were included. Medical expenses were 18% lower in the IF group compared to the HA group during the first year after the fracture (difference-in-difference [DID] estimate ratio 0.82, 95% confidence interval [CI] 0.77-0.87, P <0.001), and 9% lower in the second year (DID estimate ratio 0.91, 95% CI 0.85-0.99, P =0.018). Length of hospital stay was significantly shorter in the IF group compared to the HA group during the first two years after time zero in the age =80 group. Conclusion: A noticeable increase in medical expenses was observed for patients who underwent HA for treatment of intertrochanteric fractures compared to those who underwent IF over a two-year period after surgery. Therefore, consideration of such findings is critical when designing healthcare policy support for management of intertrochanteric fractures. [ABSTRACT FROM AUTHOR]

BACKGROUND: Treatment of reverse oblique fractures has the highest complication rate among proximal femur fractures. Although intramedullary nailing is the preferred treatment option, a high failure rate has been reported. Previous studies have identified several contributing factors to these failures, yet the significance of posterolateral wall integrity in ensuring postoperative stability has not been emphasized. This study aims to investigate the impact of posterolateral wall integrity on the failure rates of reverse oblique intertrochanteric fractures treated with intramedullary nails (IMN) and assess the vulnerability of certain IMN designs to these failures. METHODS: Between 2010 and 2016, 53 patients with reverse oblique fractures were analyzed to identify factors associated with IMN failure. Variables such as posterolateral wall integrity, quality of reduction, posteromedial support, and IMN design were considered as potential risk factors. Logistic regression analysis was conducted to evaluate these risk factors, with statistical significance defined as p<0.05. RESULTS: Eleven cases of implant failure were identified. Univariate statistical analysis indicated that loss of posterolateral support (p=0.002), IMN with single-screw proximal fixation (p=0.048), poor reduction quality (p=0.004), and loss of posteromedial support (p=0.040) were associated with implant failure. Multivariate analysis confirmed loss of posterolateral support (p=0.009), poor reduction quality (p=0.039), and loss of posteromedial support (p=0.020) as independent risk factors for failure. However, IMN with single proximal fixation (p=0.859) did not significantly impact fixation failure. CONCLUSION: Reverse oblique intertrochanteric fractures with compromised posterolateral support exhibit a high rate of mechanical failure when treated with IMN. Additionally, poor reduction quality and loss of posteromedial support increase the risk for failure of these fractures. An IMN design featuring dual separate proximal screw fixations could provide better stability compared to a design with a single proximal screw, thereby reducing the risk of mechanical failure. [ABSTRACT FROM AUTHOR]

About half of hip fractures in the elderly are caused by intertrochanteric fractures, of which more than 50% are unstable. Restoring mobility safely, effectively, and as close to the patient's pre-operative state as possible are the main objectives of treatment for any intertrochanteric fracture. Over the past 20 years, the dynamic hip screw (DHS) has become widely accepted and is now the gold standard for outcome comparison. Recently, proximal femoral nailing (PFN) is the intramedullary device that has frequently been claimed to have helped with these fractures, hence reducing the lever arm aspect on the implant. The Objectives of the present study is to compare the functional outcomes between dynamic hip screw versus proximal femoral nailing for the treatment of inter-trochanteric fractures of hip. Methods: The present study was conducted in the department of orthopedics, the study included a total of 80 patients presented with hip fractures based on inclusion and exclusion criteria after taking informed consent. These patients were randomized by simple random sampling into two groups DHS and PFN group. The functional outcomes using HHS was compared between the two groups at 6th, 12th and 24 weeks respectively. Results: The comparison of mean scores between DHS and PFN group at 6th, 12th and 24 week followup shows that the mean scores were statistically significantly better in PFN group at 12 weeks and 24 weeks, there was no significant differences found between the two groups at 6th week, as presented in Table 3. The functional outcomes were evaluated between the two groups, it is found that 12 (30%), 18 (45%), 8 (20%) and 2 (5%) patients had Excellent, Good, Fair and Poor outcomes in DHS group, whereas in PFN group 17 (42.5%), 19 (47.5%), and 4 (10%) patients had Excellent, Good and Fair outcomes in PFN group and none of them had poor outcome in PFN group as represented in Table 4. Discussion and conclusion: It can be inferred from the study that PFN performed better in intertrochanteric fractures than DHS fixation, based on the functional outcome determined by the Harris Hip Score. This was determined by looking at the end result, movement range, and HHS. Comparing the PFN group to the DHS group, the PFN group's subjects had a higher percentage of excellent to good results, and none of them had poor results. At 12 weeks, 24 weeks, and the Conclusion: of the follow-up, the PFN group's HHS scores were higher. With fewer complications, PFN offers a quicker recovery and a better functional outcome for all kinds of intertrochanteric fractures. [ABSTRACT FROM AUTHOR]

IntroductionCut-out, a biomechanical complication, is one of the most common causes of internal fixation failure of trochanteric hip fractures. The tip-apex distance (TAD) and the calcar-referenced tip-apex distance (CalTAD) have been suggested as the radiographic parameters that most predict the risk of cut-out. The purpose of this study was to check whether these two factors could predict implant cut-out in a series 398 of intertrochanteric hip fractures, treated by dynamic intramedullary nailing with the Trigen Intertan short nail.MethodsWe reviewed 398 consecutive intertrochanteric fractures included in a prospective study and treated in a single private hospital by the same surgeon. The radiographic parameters were obtained from anteroposterior (AP) and axial hip plain radiographs before surgery, immediately postoperatively, and every 3 weeks after surgery until 3 months postoperatively, and every month until the 6-month follow-up. The concept of medial cortex support (MCS) was also analyzed as a criterion for evaluating the quality of fracture reduction.ResultsThe overall cut-out rate was 2.3% (9/398). The significant parameters in the univariate analysis were AO fracture type, quality of fracture reduction (p = 0.02), TAD (p 25 mm reduced the occurrence of cut-out after dynamic intramedullary nailing of intertrochanteric fractures.

Aims: This study aimed to determine whether lateral femoral wall thickness (LWT) < 20.5 mm was associated with increased revision risk of intertrochanteric fracture (ITF) of the hip following sliding hip screw (SHS) fixation when the medial calcar was intact. Additionally, the study assessed the association between LWT and patient mortality. Methods: This retrospective study included ITF patients aged 50 years and over treated with SHS fixation between 2019 and 2021 at a major trauma centre. Demographic information, fracture type, delirium status, American Society of Anesthesiologists grade, and length of stay were collected. LWT and tip apex distance were measured. Revision surgery and mortality were recorded at a mean follow-up of 19.5 months (1.6 to 48). Cox regression was performed to evaluate independent risk factors associated with revision surgery and mortality. Results: The cohort consisted of 890 patients with a mean age of 82 years (SD 10.2). Mean LWT was 27.0 mm (SD 8.6), and there were 213 patients (23.9%) with LWT < 20.5 mm. Overall, 20 patients (2.2%) underwent a revision surgery following SHS fixation. Adjusting for covariates, LWT < 20.5 mm was not independently associated with an increased revision or mortality risk. However, factors that were significantly more prevalent in LWT < 20.5 mm group, which included residence in care home (hazard ratio (HR) 1.84; p < 0.001) or hospital (HR 1.65; p = 0.005), and delirium (HR 1.32; p = 0.026), were independently associated with an increased mortality risk. The only independent factor associated with increased risk of revision was older age (HR 1.07; p = 0.030). Conclusion: LWT was not associated with risk of revision surgery in patients with an ITF fixed with a SHS when the calcar was intact, after adjusting for the independent effect of age. Although LWT < 20.5 mm was not an independent risk factor for mortality, patients with LWT < 20.5 mm were more likely to be from care home or hospital and have delirium on admission, which were associated with a higher mortality rate. Cite this article: Bone Jt Open 2024;5(2):123–131.

BackgroundThe integrity of the lateral wall in femoral intertrochanteric fractures significantly impacts fracture stability and internal fixation. In this study, we compared the outcomes of treating intertrochanteric fractures with lateral wall involvement using the ortho-bridge system (OBS) combined with proximal femoral nail antirotation (PFNA) versus simple PFNA from a biomechanical perspective.MethodsFinite-element models of femoral intertrochanteric fractures with lateral wall involvement were subjected to fixation with OBS combined with PFNA and simple PFNA. Von Mises stress measurements and corresponding displacement assessments for each component of the model, including the proximal femur and lateral wall, were used to evaluate the biomechanical effects of OBS fixation on bone and intramedullary nail stability.ResultsUsing PFNA alone to fix intertrochanteric fractures with lateral wall involvement resulted in von Mises stress levels on the lateral wall exceeding safe stress tolerances for bone growth. OBS fixation significantly reduced stress on the lateral wall of the femur and minimized the stress on each part of the intramedullary nail, reducing the overall displacement.ConclusionIn cases of intertrochanteric fractures with lateral wall involvement, PFNA fixation alone may compromise the biomechanical integrity of the lateral femoral wall, increasing the risk of postoperative complications. The addition of OBS to PFNA significantly reduces stress on the lateral femoral wall. Consequently, OBS should be considered for lateral wall fixation when managing intertrochanteric fractures combined with lateral wall fractures.

Background: Intertrochanteric fracture is one of the most common fractures of the hip. But the implant of choice for type II intertrochanteric fracture is still under debate. The aim of this study was to compare the functional outcomes of proximal femoral nail (PFN) and dynamic hip screw (DHS) in treatment of intertrochanteric fractures. Methods: We did prospective comparative study on 60 patients of type II intertrochanteric fractures operated with closed/open reduction & internal flxation with either Dynamic Hip Screw (DHS) or Proximal Femoral Nail (PFN) between October 2018 to March 2023. During each follow-up the functional outcome of patients was calculated using the Harris Hip Score (HHS). Results: There was a statistically significant difference present in average functional scores between two groups at 1 month, 3 months, and 6 months; however no difference was seen at the end of 12th month follow up. Functional outcomes in DHS group were excellent in 34.78%, fair in 17.39%, good in 43.48%, and poor in 4.35%. In the PFN group, results were excellent in 56.52%, fair in 8.70%, good in 34.78% and no poor results were seen. Conclusion: In stable twopart intertrochanteric femur fractures both PFN and DHS are equally effective but because of minimal invasiveness PFN is a better implant of choice than DHS in the treatment of elderly patients with intertrochanteric fracture. [ABSTRACT FROM AUTHOR]

Background: Gluteus medius is the steering muscle of the hip joint and is very important for pelvic balance. It is damaged surgically when we do antegrade nailing for an intertrochanteric femur fracture. There is not much study available in literature regarding the status of this muscle in postoperative phase. Aims: The aim of the study is to evaluate the effect of surgical trauma on gluteus medius muscle using cross-sectional area (CSA) and adipose tissue ratio (ATR) in computed tomography (CT) scan after intramedullary nailing in patients with intertrochanteric fractures comparing with the contralateral normal side and assess the postoperative strength of gluteus medius muscle. Subjects and Methods: A total of 31 patients with intertrochanteric fracture femur who were treated by intramedullary nailing underwent CT scan after 3 months of surgery. In CT, CSA and adipose tissue infiltration were measured at different levels. Clinically, muscle strength was assessed with Medical Research Council (MRC) grading and active hip abduction test (AHAT). Results: All 31 patients showed decrease in CSA and increase in adipose tissue infiltration in operated side gluteus medius muscle compared to the normal side. However, there was not much difference in MRC grading and AHAT scoring. Conclusions: Our imaging findings documented decrease in CSA and increase in ATR in gluteus medius muscle postoperatively. However, compared to other studies, this overall decrease is in small dimensions, possibly due to the small diameter of proximal portion of the nail which is evolved for the Asian population. Clinically, there was not much decrease in the strength of the gluteus medius muscle and it has not caused any functional problems.

Objective Intertrochanteric fracture is a very common but serious type of hip fracture in nonagenarians. The surgical treatment remains a significant challenge for orthopedists. The objective of this study was to investigate postoperative complications and survival outcomes compared between bipolar hemiarthroplasty (HA) and proximal femoral nail anti‐rotation (PFNA) in nonagenarians with intertrochanteric fractures, and to evaluate the efficacy and safety of the two surgical procedures in this patient population. Methods A total of 113 consecutive nonagenarians who underwent bipolar HA or PFNA for the treatment of intertrochanteric fractures from January 2006 to August 2021 were retrospectively studied in the current paper. There were 34 males and 79 females, with a mean age of 92.2 years (range 90–101 years) at the time of operation. The average duration of follow‐up was 29.7 months (range 1–120 months). The full cohort was divided into bipolar HA (77 cases) and PFNA (36 cases) groups. Damage control orthopedics was used to determine the optimal surgery time and assist in perioperative management. A restrictive blood transfusion strategy was employed, along with appropriate adjustments under multidisciplinary assessment, throughout the perioperative period. Perioperative clinical information and prognostic data were analyzed. Kaplan–Meier survival curves were used for survival analysis, and landmark analysis divided the entire follow‐up period into 1–12 months (short‐term), 13–42 months (medium‐term) and 43–120 months (long‐term) according to the configurations of Kaplan–Meier survival curves. Results Both groups had similar general variables except for the proportion of high adjusted Charlson comorbidity index (aCCI) (≥6 points) (6.5% in bipolar HA group and 22.2% in PFNA group, p = 0.024). Intraoperative blood loss and transfusion requirements were greater, and the intraoperative transfusion rates were higher in the bipolar HA group compared to the PFNA group (all p 0.05). Both groups had similar overall survival curves (p = 0.37). However, landmark analysis revealed that bipolar HA group exhibited higher survival rates in medium‐term (p = 0.01), while similar survival rates were observed in the short‐ and long‐term post‐operation periods (both p > 0.05). Cox regression with survival‐time‐dependent covariate calculated the hazard ratio (HR) of bipolar HA was 0.41 in medium‐term (p = 0.039). Conclusion Bipolar HA is equally effective and reliable as PFNA for treating intertrochanteric fractures in nonagenarians. Despite resulting in more intraoperative blood loss and transfusions, bipolar HA therapy is associated with a higher medium‐term survival rate compared to PFNA treatment. The application of damage control orthopedics and precise perioperative patient blood management could contribute to the positive clinical outcomes observed in this patient population.

Abstract Background The proximal femoral nail anti-rotation (PFNA) is a commonly used internal fixation system for intertrochanteric fractures (IFs) in older adults. Knee osteoarthritis (KOA) is a degenerative lower extremity disease that occurs most frequently in the elderly. Some patients have already had KOA before the IFs. However, whether KOA impacts the postoperative outcome of IFs has not been reported. Objective This study aimed to investigate the effect of KOA on the fracture side on the outcome after PFNA for IFs in the elderly. Methods Between January 2016 and November 2021, 297 elderly patients treated with PFNA for IFs were enrolled in this study. They were divided into two groups according to the American Rheumatism Association KOA clinical and radiographic criteria: the control group and the KOA group. Intraoperative bleeding, operative time, length of hospital stay, postoperative time out of bed, fracture healing time, postoperative complications, postoperative Harris hip function score, and Barthel ability to daily living Score were compared between the two groups. Follow-up was routinely scheduled at 1, 3, 6, and 12 months postoperatively. Results Based on the exclusion criteria, 254 patients who met the requirements were left to be included in this study, including the control group (n = 133) and the KOA group (n = 121). Patients were followed up for a mean of 17.5 months (12–24 months). There was no significant difference between the two groups in preoperative demographic data, intraoperative blood loss, operation time, and length of stay in the hospital. The control group was statistically significant compared to the KOA group in terms of postoperative time out of bed (17.8 ± 4.0 days vs. 19.1 ± 5.8 days), fracture healing time (13.7 ± 2.2 weeks vs. 14.6 ± 3.7 weeks), and postoperative complications (12.8 vs. 23.1%). The Harris hip function score and Barthel ability to daily living score were higher in the control group than in the KOA group at 1, 3, 6, and 12 months postoperatively (the control group: 63.8 ± 10.9, 71.8 ± 10.3, 81.5 ± 8.7, and 91.6 ± 6.3 vs. The KOA group 61.0 ± 10.4, 68.6 ± 9.1, 79.0 ± 9.2, and 88.5 ± 5.9). Conclusions In elderly patients with IFs combined with KOA of the fracture side treated with PFNA internal fixation, KOA increases the incidence of postoperative complications of the fracture, prolongs postoperative time out of bed and fracture healing, and reduces postoperative hip function and ability to daily living. Therefore, treating KOA on the fractured side needs to be considered when treating IFs in the elderly.

Objective To explore the effect of various input resolution of X-ray images on the performance of the You Only Look Once (YOLO) network in recognition of intertrochanteric fractures. Methods X-ray anteroposterior data of the patients with intertrochanteric fractures admitted in Army Medical Center of PLA from 2017 to 2022 were collected, and finally, 426 patients and 847 images were retained after exclusion criteria. Based on the 2018 guideline of Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) and actual clinical incidence, these intertrochanteric fractures were reclassified into grades A1.2/A1.3/A2.2/A2.3/A3, and the X-ray images were assigned into training set (678 images), validation set (84 images), and test set (85 images) in a ratio of 8 ∶1 ∶1 in order to maintain strict consistency across each experiment. Eight common resolutions were set as input size for YOLOX-Swin-Transformer, YOLOX, YOLOv5, and YOLOv4 object detection networks. The training set was trained using both training from scratch and transfer learning. The training time was recorded, the test set was used to test the model, and evaluation metrics was recorded. SPSS20.0 statistical software was employed for statistical analysis. Regression analysis was applied to test curve fitting of training time and mean average precision (mAP) values. Frequency statistics function was performed to count the frequencies of evaluation indicators rated as excellent at each input resolution in order to determine the optimal range. Results The image input resolution was positively correlated with the training time of various networks, with all P-values < 0.05, showing statistical significance by linear regression analysis. The quadratic curve fitting of the image input resolution and the mAP mean value of the network resulted in an R2=0.834 (R2>0.5) and P=0.011 (P < 0.05), indicating a good fit of the curve and statistical significance in the regression analysis. When the input image resolution was in a range of 480×480, 576×576, 640×640, the frequency of optimal evaluation index showed the highest, accounting for 42.86%. Conclusion The training time is extended with the increase of resolution. To achieve optimal recognition performance when using YOLO series networks for downstream tasks in medical image recognition, the image input resolution should be controlled within the range of 480×480, 576×576, 640×640, without altering the network architecture.

Aims: This work aimed at answering the following research questions: 1) What is the rate of mechanical complications, nonunion and infection for head/neck femoral fractures, intertrochanteric fractures, and subtrochanteric fractures in the elderly USA population? and 2) Which factors influence adverse outcomes? Methods: Proximal femoral fractures occurred between 1 January 2009 and 31 December 2019 were identified from the Medicare Physician Service Records Data Base. The Kaplan-Meier method with Fine and Gray sub-distribution adaptation was used to determine rates for nonunion, infection, and mechanical complications. Semiparametric Cox regression model was applied incorporating 23 measures as covariates to identify risk factors. Results: Union failure occured in 0.89% (95% confidence interval (CI) 0.83 to 0.95) after head/neck fracturs, in 0.92% (95% CI 0.84 to 1.01) after intertrochanteric fracture and in 1.99% (95% CI 1.69 to 2.33) after subtrochanteric fractures within 24 months. A fracture-related infection was more likely to occur after subtrochanteric fractures than after head/neck fractures (1.64% vs 1.59%, hazard ratio (HR) 1.01 (95% CI 0.87 to 1.17); p < 0.001) as well as after intertrochanteric fractures (1.64% vs 1.13%, HR 1.31 (95% CI 1.12 to 1.52); p < 0.001). Anticoagulant use, cerebrovascular disease, a concomitant fracture, diabetes mellitus, hypertension, obesity, open fracture, and rheumatoid disease was identified as risk factors. Mechanical complications after 24 months were most common after head/neck fractures with 3.52% (95% CI 3.41 to 3.64; currently at risk: 48,282). Conclusion: The determination of complication rates for each fracture type can be useful for informed patient-clinician communication. Risk factors for complications could be identified for distinct proximal femur fractures in elderly patients, which are accessible for therapeutical treatment in the management. Cite this article: Bone Jt Open 2023;4(10):801–807.

Intertrochanteric Femur fractures comprise approximately 50% of all hip fracture caused by low intensity injury. Intertrochanteric fractures are difficult to manage and associated with many complications. Aims and Objectives: To evaluate effectiveness and strength of Short PFN with early mobilization and functional recovery of patient in management of fracture intertrochanteric femur Materials and Methods: Forty patients with Fracture Intertrochanteric Femur visiting Orthopaedic Casualty and OPD were studied. Fractures are evaluated as stable and unstable fractures according to Modified Evan-Jensen classification. Elderly patients with unstable intertrochanteric fractures, Short PFN was applied and followed up for a period of 6 months at regular intervals. The clinical data collected and evaluated with pre injury activity and present functional levels with Harris Hip Score. Results: Majority of the patients were males (65%) and had age between 61-80 years (52.5%) with mean age of 71.58 ± 12.37 years. Majority of the patients had operative time more than equal to 1 hour. Harris Hip Score at 1 month was 71.10 ± 5.52, while at 3 months it was 80.13 ± 7.97. There was a statistically significant increase in the mean Harris Hip Score at 3 months in comparison to 1 month. The mean Harris Hip Score at 1 month was 71.10 ± 5.52. There was a statistically significant increase in the mean Harris Hip Score at 6 months in comparison to 3 months. Conclusion: For Intertrochanteric fractures the Short PFN is a good minimal invasive implant which gives significant functional result with good anatomical reduction. [ABSTRACT FROM AUTHOR]

Objective: Intertrochanteric fracture is a very common but serious type of hip fracture in nonagenarians. The surgical treatment remains a significant challenge for orthopedists. The objective of this study was to investigate postoperative complications and survival outcomes compared between bipolar hemiarthroplasty (HA) and proximal femoral nail anti‐rotation (PFNA) in nonagenarians with intertrochanteric fractures, and to evaluate the efficacy and safety of the two surgical procedures in this patient population. Methods: A total of 113 consecutive nonagenarians who underwent bipolar HA or PFNA for the treatment of intertrochanteric fractures from January 2006 to August 2021 were retrospectively studied in the current paper. There were 34 males and 79 females, with a mean age of 92.2 years (range 90–101 years) at the time of operation. The average duration of follow‐up was 29.7 months (range 1–120 months). The full cohort was divided into bipolar HA (77 cases) and PFNA (36 cases) groups. Damage control orthopedics was used to determine the optimal surgery time and assist in perioperative management. A restrictive blood transfusion strategy was employed, along with appropriate adjustments under multidisciplinary assessment, throughout the perioperative period. Perioperative clinical information and prognostic data were analyzed. Kaplan–Meier survival curves were used for survival analysis, and landmark analysis divided the entire follow‐up period into 1–12 months (short‐term), 13–42 months (medium‐term) and 43–120 months (long‐term) according to the configurations of Kaplan–Meier survival curves. Results: Both groups had similar general variables except for the proportion of high adjusted Charlson comorbidity index (aCCI) (≥6 points) (6.5% in bipolar HA group and 22.2% in PFNA group, p = 0.024). Intraoperative blood loss and transfusion requirements were greater, and the intraoperative transfusion rates were higher in the bipolar HA group compared to the PFNA group (all p < 0.05). The complications rates, 1‐ to 60‐month cumulative all‐cause mortality, postoperative optimal Harris hip score (HHS), and Barthel index (BI) presented no significant difference between the two groups (all p > 0.05). Both groups had similar overall survival curves (p = 0.37). However, landmark analysis revealed that bipolar HA group exhibited higher survival rates in medium‐term (p = 0.01), while similar survival rates were observed in the short‐ and long‐term post‐operation periods (both p > 0.05). Cox regression with survival‐time‐dependent covariate calculated the hazard ratio (HR) of bipolar HA was 0.41 in medium‐term (p = 0.039). Conclusion: Bipolar HA is equally effective and reliable as PFNA for treating intertrochanteric fractures in nonagenarians. Despite resulting in more intraoperative blood loss and transfusions, bipolar HA therapy is associated with a higher medium‐term survival rate compared to PFNA treatment. The application of damage control orthopedics and precise perioperative patient blood management could contribute to the positive clinical outcomes observed in this patient population. [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]

Introduction Case Presentation Intervention Outcomes Conclusion Chronic obstructive pulmonary disease (COPD)-induced osteoporosis, myasthenia, and disequilibrium are important risk factors for hip fracture, and decreased respiratory function after hip fracture surgery can decelerate recovery of activities of daily living (ADL) in elderly patients.A 90-year-old male patient underwent an open reduction and intramedullary pinning surgery for right femoral intertrochanteric fracture. After surgery, he remained confined to bed with pain and swelling in the right lower extremity. Due to his history of COPD, he had a postoperative pulmonary infection and respiratory insufficiency.This patient received routine rehabilitation after surgery. However, severe respiratory symptoms prevented him from completing the rehabilitation procedure. Therefore, comprehensive pulmonary rehabilitation including airway clearance techniques, inspiratory resistance training, aerobic training, respiratory muscle training, and intermittent low-flow oxygen inhalation was carried out to enhance the recovery process.After 4 weeks of treatment, the patient improved from continuous oxygen inhalation to being able to complete bed resistance training without supplemental oxygen. After 8 weeks, ADL reached independence, while lower limb muscle strength, pulmonary function parameters, fatigue index, and cough efficiency were improved as compared to test values obtained before treatment.Compared with the 6-month recovery time reported in the literature for patients with hip fractures to achieve independence with basic ADLs, the recovery time of this patient was shortened to 2 months with the application of comprehensive pulmonary rehabilitation. It is feasible to carry out pulmonary rehabilitation for elderly patients after fracture surgery, but prospective clinical trials are needed to verify its efficacy. [ABSTRACT FROM AUTHOR]

Background: In elderly people, common injuries are caused because of low energy trauma and osteoporosis. These common injuries are called proximal femoral fractures. The category of proximal femoral fractures includes pertrochanteric fractures, femur fractures, subtrochanteric fractures, and intertrochanteric fractures. Intertrochanteric fractures are hip fractures that are common in old people. Objective: Our research aims to evaluate the functional results when intertrochanteric fractures are cured with Proximal Femoral Nail anti-rotation (PFNA). Study design: A cross-sectional study Place and Duration: This study was conducted at Dow International Medical college, Dow University of Health Sciences, Karachi hospital from December 2021 to December 2022 Methodology: All of the patients were having type III and type IV intertrochanteric fractures (Boyd and Griffin) for about 1 week. PFNA with a helical screw (240 millimeters) was used to treat the participants. After the treatment, participants had to visit the hospital after 2 weeks in the starting. Later, they had a monthly follow-up for the next 6 months. Harris Hip Score (HHS) was used to assess the functional outcome in every visit. Results: Overall, 80 participants were treated with PFNA in this research study. The mean age was 49.51±12.31 years. A total of 4.66 days were the mean duration of the fracture. Boyd and Griffin type III fracture was seen in the majority of the participants. All participants achieved the radiological union at 15.4 weeks. The mean HHS was 84.52 at the 6th monthly follow-up. Conclusion: The majority of the participants showed good and excellent results when intertrochanteric fractures were cured with Proximal Femoral Nail anti-rotation (PFNA). [ABSTRACT FROM AUTHOR]

Abstract Background There is no consensus about intertrochanteric fractures with lateral wall treated with intramedullary nail—proximal femoral nail antirotation (PFNA). The aim of the present study was to compare function outcomes between lateral wall and no lateral wall fractures after surgery by PFNA. Methods This retrospective study evaluated patients with or without lateral wall fractures who underwent PFNA between January 2015 and June 2018. The operative time, intraoperative blood loss, time to fracture healing, complications and functional outcomes qualified by Harris hip score and Parker − Palmer mobility score (PPMS) were compared between the two groups. Results Two groups were comparable with regard to patient age, sexual distribution, mechanism of injury, fracture type, body mass index (BMI), Time to surgery, American Society of Anesthesiologists (ASA) score and quality of reduction. The incomplete group had a longer operation time (54.1 ± 8.74 min vs. 51.0 ± 9.86 min) and more intraoperative blood loss (228.4 ± 48.8 ml vs. 151.3 ± 43.5 ml) in comparison with the control group (P 0.05), respectively. Similar results were obtained about PPMS. We found no difference in Weight bearing time, Time of fracture healing, and Complications between incomplete group and intact group. Conclusions There is no substantial difference in functional results or complication rates for intertrochanteric fractures with lateral wall fractures, except from increased blood loss and operation time. We believe that an intramedullary nail will be sufficient to repair an intertrochanteric fracture with or without a lateral wall fracture.

Abstract Background Hip fractures are an increasingly common consequence of falls in older people that are associated with a high risk of death and reduced function. The vast majority of intertrochanteric fractures require surgical treatment to withstand early mobilization and weight bearing, which prevents complications due to prolonged bed rest and aids in fracture healing. Methods This study is compromised by two parts, the experimental study and the clinical part. In the first part, a standard 130° nail will be used with the appropriate lag screw(s) and dynamic distal locking in synthetic osteoporotic femurs and the transmission of forces in the proximal femur, measured by a cortical surface-strain distribution, will be evaluated using digital image correlation. Finite element parametric models of the bone, the nails and their interface will be also developed. Finite element computations of surface strains in implanted femurs, after being validated against biomechanical testing measurements, will be used to assist the comparison of the nails by deriving important data on the developed stress and strain fields, which cannot be measured through biomechanical testing. In the other part, will set up a prospective, randomized, comparative clinical study among the Gamma3 and IT cephalomedullary nailing, in order to investigate if there are any statistical important differences in the main radiological measurements and functional status in closed unstable intertrochanteric fractures (A21-3) in patients aged over 70 years old at the 24-week follow-up evaluation using patient reported disease-specific outcomes. Discussion This study will be the first to compare clinical, radiological and biomechanical measurements of the two different cephalomedullary nails. Our main hypothesis is that the IT nail would provide better radiological outcome and probably better clinical results than the Gama3 nail. Clinical trial registration International Standard Randomized Controlled Trial Number (ISRCTN): https://doi.org/10.1186/ISRCTN15588442 , registered on 19/4/2022.

Abstract Background Hip fractures are common in elderly patients, and almost all the patients undergo surgery. This study aimed to develop a novel modified lymphocyte C-reactive protein (CRP) score (mLCS) to simply and conveniently predict 3-year mortality in elderly patients undergoing intertrochanteric fracture surgery. Methods A retrospective study was conducted on elderly patients who underwent intertrochanteric fracture surgery between January 2014 and December 2017. The mLCS was developed according to the value of CRP and lymphocyte counts. Univariate and multivariate Cox regression analyses were used to identify independent risk factors for 3-year mortality after surgery. The performances of the lymphocyte CRP score (LCS) and mLCS to predict 3-year mortality were then compared using C-statistics, decision curve analysis (DCA), net reclassification index (NRI) and integrated discrimination improvement (IDI). Results A total of 291 patients were enrolled, of whom 52 (17.9%) died within 3 years after surgery. In the multivariate Cox regression analysis, mLCS (hazard ratio (HR), 5.415; 95% confidence interval (CI), 1.743–16.822; P = 0.003) was significantly associated with postoperative 3-year mortality. The C-statistics of LCS and mLCS for predicting 3-year mortality were 0.644 and 0.686, respectively. The NRI (mLCS vs. LCS, 0.018) and IDI (mLCS vs. LCS, 0.017) indicated that the mLCS performed better than the LCS. DCA also showed that mLCS had a higher clinical net benefit. Conclusions mLCS is a promising predictor that can simply and conveniently predict 3-year mortality in elderly patients undergoing intertrochanteric fracture surgery.

Abstract Objective Postoperative delirium (POD) is a common complication along with poor prognosis in geriatric intertrochanteric fracture (ITF) patients. However, the prevention and treatment of POD remain unclear. Previous studies have confirmed that POD is essentially a consequence of neuro-inflammatory responses. Dexamethasone is a glucocorticoid with comprehensive anti-inflammatory effects, while a high dose of dexamethasone correlates with many side effects or even adverse consequences. Thus, this prospective study aims to discuss whether a single preoperative low-dose dexamethasone can reduce the impact of POD on geriatric ITF patients with internal fixation surgery. Methods Between June 2020 and October 2022, there were 219 consecutive ITF patients assessed in our department. Of the 219 ITF patients, 160 cases who met the inclusion and exclusion criteria were finally enrolled and randomly allocated to the dexamethasone group and the placebo group (80 geriatric ITF patients in each group) in this prospective study. The patients in the dexamethasone group received intravenous 10 mg (2 ml) dexamethasone while the patients in the placebo group received intravenous 2 ml saline in 30 min before being sent to the operating room, respectively. The baseline characteristics, surgical information, incidence and severity of POD as the efficacy-related outcomes, and infection events and hyperglycemia as safety-related outcomes (adverse events), were collected and analyzed between the two groups. The severity of POD was evaluated by Memorial Delirium Assessment Scale (MDAS) score. Results There were no differences in baseline characteristics and surgical information between the dexamethasone group and the placebo group. The dexamethasone group had a lower incidence of POD than the placebo group within the first 5 days after surgery [(9/80, 11.3% vs. 21/80, 26.3%, RR = 0.83, 95% CI 0.71–0.97, P = 0.015]. The dexamethasone group had lower MDAS scores (Mean ± SD) than the placebo group [13.2 ± 1.0 (range 11 to 15) vs. 15.48 ± 2.9 (range 9 to 20), P = 0.011, effect size = 0.514]. There were no differences in infection events and hyperglycemia between the two groups. Conclusions A single preoperative low-dose dexamethasone may reduce the incidence and severity of POD in geriatric ITF patients with internal fixation surgery. Trial registration: ChiCTR2200055281.

Background: There is no consensus about intertrochanteric fractures with lateral wall treated with intramedullary nail—proximal femoral nail antirotation (PFNA). The aim of the present study was to compare function outcomes between lateral wall and no lateral wall fractures after surgery by PFNA. Methods: This retrospective study evaluated patients with or without lateral wall fractures who underwent PFNA between January 2015 and June 2018. The operative time, intraoperative blood loss, time to fracture healing, complications and functional outcomes qualified by Harris hip score and Parker − Palmer mobility score (PPMS) were compared between the two groups. Results: Two groups were comparable with regard to patient age, sexual distribution, mechanism of injury, fracture type, body mass index (BMI), Time to surgery, American Society of Anesthesiologists (ASA) score and quality of reduction. The incomplete group had a longer operation time (54.1 ± 8.74 min vs. 51.0 ± 9.86 min) and more intraoperative blood loss (228.4 ± 48.8 ml vs. 151.3 ± 43.5 ml) in comparison with the control group (P < 0.01). Regarding functional outcome, the HHSs of the two groups were 76.2 ± 11.6 vs 75.6 ± 12.5 at the 3 months (P = 0.603), 81.9 ± 9.4 vs 82.6 ± 8.7 at the six months (P = 0.224), 83.8 ± 6.6 vs 84.5 ± 6.0 at the twelve months 85.2 ± 5.5 vs 86.0 ± 5.8 at the twenty-four months (P > 0.05), respectively. Similar results were obtained about PPMS. We found no difference in Weight bearing time, Time of fracture healing, and Complications between incomplete group and intact group. Conclusions: There is no substantial difference in functional results or complication rates for intertrochanteric fractures with lateral wall fractures, except from increased blood loss and operation time. We believe that an intramedullary nail will be sufficient to repair an intertrochanteric fracture with or without a lateral wall fracture. [ABSTRACT FROM AUTHOR]

Purpose: This study was designed to compare clinical outcomes of the femoral stable interlocking intramedullary nail (FSIIN) with proximal femoral nail anti-rotation (PFNA) for the treatment of intertrochanteric fractures (OTA 31A1 + A2). Methods: This study retrospectively analyzed a registered sample of 74 intertrochanteric fractures (OTA 31A1 + A2) surgically treated using FSIIN (n = 36) or PFNA (n = 38) from January 2015 to December 2021. The intra-operative variables (operation time, fluoroscopy time, intra-operative blood loss, length of incision) and fracture healing time were compared between the two groups in this study. Harris hip score (HHS) and visual analog scale (VAS) were used to evaluate the functional states. At the last follow-up, the incidence of related complications in patients was calculated. Eventually, the 3D finite element model was established to analyze the stress of FSIIN and PFNA. Results: The distribution of all basic characteristics was similar between the two groups (p > 0.05). The operation time, fluoroscopy time, intra-operative blood loss, and length of incision were significantly decreased in the FSIIN group (p < 0.001). The FSIIN group had a shorter fracture healing time than the PFNA group (p < 0.001). There is no significant difference between the two groups in the Harris and VAS (p > 0.05). The incidences of post-operative anaemia, electrolyte imbalance, varus malalignment, and thigh pain were significantly lower in FSIIN than in PFNA groups (all p < 0.05). The finite element results show that the stress shielding effect of FSIIN is smaller. Conclusions: Our study revealed that FSIIN seemed to be superior to PFNA in the treatment of intertrochanteric fractures (OTA 31A1 + A2) due to less surgical damage and shorter fracture healing time. [ABSTRACT FROM AUTHOR]

Purpose: Cephalomedullary (CM) nailing is widely performed in treatment of elderly patients with femoral intertrochanteric fractures. However, in cases of fixation failure, re-operation is usually necessary, thus determining factors that may contribute to fixation failure is important. In this study, we examined factors affecting the occurrence of fixation failure, such as age or fracture stability, after CM nailing in elderly patients. Materials and Methods: This study was conducted retrospectively using registered data. From April 2011 to December 2018, CM nailing was performed in 378 cases diagnosed with femoral intertrochanteric fractures, and 201 cases were finally registered. Cases involving patients who were bed-ridden before injury, who died from causes unrelated to surgery, and those with a follow-up period less than six months were excluded. Results: Fixation failure occurred in eight cases. Comparison of the surgical success and fixation failure group showed that the mean age was significantly higher in the fixation failure group compared with the control group (81.3±6.4 vs. 86.4±6.8; P=0.034). A significantly high proportion of unstable fractures was also observed (139/54 vs. 3/5; P=0.040), with a significantly high ratio of intramedullary reduction (176/17 vs. 5/3; P=0.034). A significantly higher ratio of unstable fractures compared with that of stable fractures was observed in the intramedullary reduction group (132/49 vs. 10/10; P=0.033). Conclusion: Fixation failure of CM nailing is likely to occur in patients who are elderly or have unstable fracture patterns. Thus, care should be taken in order to avoid intramedullary reduction. [ABSTRACT FROM AUTHOR]

Purpose: This study aims to determine which intertrochanteric (IT) hip fracture and patient characteristics predict the necessity for adjunct reduction aides prior to prep and drape aiming for a more efficient surgery. Materials and Methods: Institutional fracture registries from two academic medical centers from 2017-2022 were analyzed. Data on patient demographics, comorbidities, fracture patterns identified on radiographs including displacement of the lesser trochanter (LT), thin lateral wall (LW), reverse obliquity (RO), subtrochanteric extension (STE), and number of fracture parts were collected, and the need for additional aides following traction on fracture table were collected. Fractures were classified using the AO/OTA classification. Regression analyses identified significant risk factors for needing extra reduction aides. Results: Of the 166 patients included, the average age was 80.84±12.7 years and BMI was 24.37±5.3 kg/m2. Univariate regression revealed increased irreducibility risk associated with RO (odds ratio [OR] 27.917, P= 0.001), LW (OR 24.882, P<0.001), and STE (OR 5.255, P=0.005). Multivariate analysis significantly correlated RO (OR 120.74, P<0.001) and thin LW (OR 131.14, P<0.001) with increased risk. However, STE (P=0.36) and LT displacement (P=0.77) weren't significant. Fracture types 2.2, 3.2, and 3.3 displayed elevated risk (P<0.001), while no other factors increased risk. Conclusion: Elderly patients with IT fractures with RO and/or thin LW are at higher risk of irreducibility, necessitating adjunct reduction aides. Other parameters showed no significant association, suggesting most fracture patterns can be achieved with traction manipulation alone. [ABSTRACT FROM AUTHOR]

Background: Hip fractures are an increasingly common consequence of falls in older people that are associated with a high risk of death and reduced function. The vast majority of intertrochanteric fractures require surgical treatment to withstand early mobilization and weight bearing, which prevents complications due to prolonged bed rest and aids in fracture healing. Methods: This study is compromised by two parts, the experimental study and the clinical part. In the first part, a standard 130° nail will be used with the appropriate lag screw(s) and dynamic distal locking in synthetic osteoporotic femurs and the transmission of forces in the proximal femur, measured by a cortical surface-strain distribution, will be evaluated using digital image correlation. Finite element parametric models of the bone, the nails and their interface will be also developed. Finite element computations of surface strains in implanted femurs, after being validated against biomechanical testing measurements, will be used to assist the comparison of the nails by deriving important data on the developed stress and strain fields, which cannot be measured through biomechanical testing. In the other part, will set up a prospective, randomized, comparative clinical study among the Gamma3 and IT cephalomedullary nailing, in order to investigate if there are any statistical important differences in the main radiological measurements and functional status in closed unstable intertrochanteric fractures (A21-3) in patients aged over 70 years old at the 24-week follow-up evaluation using patient reported disease-specific outcomes. Discussion: This study will be the first to compare clinical, radiological and biomechanical measurements of the two different cephalomedullary nails. Our main hypothesis is that the IT nail would provide better radiological outcome and probably better clinical results than the Gama3 nail. Clinical trial registration International Standard Randomized Controlled Trial Number (ISRCTN): https://doi.org/10.1186/ISRCTN15588442, registered on 19/4/2022. [ABSTRACT FROM AUTHOR]

Background: Hip fractures are common in elderly patients, and almost all the patients undergo surgery. This study aimed to develop a novel modified lymphocyte C-reactive protein (CRP) score (mLCS) to simply and conveniently predict 3-year mortality in elderly patients undergoing intertrochanteric fracture surgery. Methods: A retrospective study was conducted on elderly patients who underwent intertrochanteric fracture surgery between January 2014 and December 2017. The mLCS was developed according to the value of CRP and lymphocyte counts. Univariate and multivariate Cox regression analyses were used to identify independent risk factors for 3-year mortality after surgery. The performances of the lymphocyte CRP score (LCS) and mLCS to predict 3-year mortality were then compared using C-statistics, decision curve analysis (DCA), net reclassification index (NRI) and integrated discrimination improvement (IDI). Results: A total of 291 patients were enrolled, of whom 52 (17.9%) died within 3 years after surgery. In the multivariate Cox regression analysis, mLCS (hazard ratio (HR), 5.415; 95% confidence interval (CI), 1.743–16.822; P = 0.003) was significantly associated with postoperative 3-year mortality. The C-statistics of LCS and mLCS for predicting 3-year mortality were 0.644 and 0.686, respectively. The NRI (mLCS vs. LCS, 0.018) and IDI (mLCS vs. LCS, 0.017) indicated that the mLCS performed better than the LCS. DCA also showed that mLCS had a higher clinical net benefit. Conclusions: mLCS is a promising predictor that can simply and conveniently predict 3-year mortality in elderly patients undergoing intertrochanteric fracture surgery. [ABSTRACT FROM AUTHOR]

Objective: Intertrochanteric femur fractures are common fractures with increasing life expectancy. The aim of treatment is to provide early mobilization and pre-fracture function in patients. In this study, we aimed to compare the mortality and function scores of two treatment modalities (proximal femoral nail and bipolar hemiarthroplasty) commonly used in the treatment of intertrochanteric femur fractures in a secondary care hospital. Materials and Methods: The study was planned for patients who underwent proximal femoral nail (PFNA) and bipolar hemiarthroplasty (BHA) due to femoral intertrochanteric fracture in a second-care hospital between 2017 and 2020. The data from a total of 199 patients were analyzed retrospectively. The operation method, age, sex, vitality, operation time, and hospitalization were recorded. The short form-36 (SF-36) questionnaire, recorded at the last visit, was evaluated in the surviving patients. Results: No significant difference has been found for gender and age compared to the operation method. However, the mortality rate of BHA is found to be higher than the rate of PFNA (p<0.001). Compared to the time of death, no significant difference is found between operation methods. The operative time and hospitalization were significantly lower in the PFNA (p<0.01, p<0.05; respectively). At postoperative measurements, SF-36 physical functioning, energy/fatigue, emotional well-being, social functioning, pain, general health, and total scores were higher in the PFNA. Conclusion: In this study, PFNA has low mortality and high functional scores in treating femoral intertrochanteric fractures. Therefore, PFNA is safer in a secondary hospital treating femoral intertrochanteric fractures and is recommended as a primary treatment option. [ABSTRACT FROM AUTHOR]

Dong-Yang Li,1,2 Chun-Gui Liu,1,2 Kun Zhang1 1Department of Orthopedic Trauma, Honghui Hospital, Xi’an Jiaotong University, Xi’an, People’s Republic of China; 2Xi’an Medical University, Xi’an, People’s Republic of ChinaCorrespondence: Kun Zhang, Email xahhzhangkun@163.comPurpose: Despite promising clinical outcome proposals, there has been relatively little published regarding the use of traction table-assisted intramedullary nail implantation for intertrochanteric fractures. The purpose of this study is to further summarize and evaluate published clinical studies comparing the clinical outcomes of using traction table and without traction table in the management of intertrochanteric fracture.Methods: A comprehensive literature search using PubMed, Cochrane Library, and Embase was systematically performed to evaluate all studies included in the literature up to May 2022. The search terms included “intertrochanteric fractures”, “hip fractures”, and “traction table” with Boolean operators “AND” and “OR”. The following information was extracted and summarized: demographic information, setup time, surgical time, amount of bleeding, fluoroscopy exposure time, reduction quality, and Harris Hip Score (HHS).Results: A total of eight clinical controlled studies involving 620 patients were eligible for the review. The mean age at the time of injury was 75.3 years (traction table group 75.7 years, non-traction table group 74.9 years). The most common assisted intramedullary nail implantation method of non-traction table group included lateral decubitus position (4 studies), traction repositor, (3 studies) and manual traction (1 studies). Included studies results all support that there was no difference between the two groups in terms of reduction quality and Harris Hip Score, and the non-traction table group had an advantage in terms of setup time. However, there were still disputes in terms of surgical time, amount of bleeding and fluoroscopy exposure time.Conclusion: For patients with intertrochanteric fractures, assisting intramedullary nail implantation without traction table is as safe and effective as using traction table and doing so without a traction table may be more advantageous in terms of setup time.Keywords: intertrochanteric fractures, traction table, closed reduction, internal fixation, systematic review

Purpose: Long proximal femoral nail anti-rotation (PFNA-II) is a preferred implant in recent years for fixation of pertrochanteric fractures, especially in osteoporotic patients. The purpose of this study is to prospectively investigate the effect of distal locking in long PFNA-II fixation of stable intertrochanteric fractures. Methods: A total of 58 patients with isolated stable intertrochanteric fractures and treated in our hospital during the study period of 2017–2019 by distal locked or unlocked long PFNA-II fixation were included in this study. Patients who had multiple injuries or open fractures were excluded. There were 40 female and 18 male patients, with 33 affecting the left side and 25 the right side. Of them, 31 belonged to the distal locked group (group A) and 27 to the unlocked group (group B). Surgical procedures and implants used in both groups were similar except for the distal locking of the nails. General data (age, gender, fracture side, etc.) showed no significant difference between two groups (all p > 0.05). The intraoperative parameters like operative time, radiation exposure and follow-up parameters like functional and radiological outcomes were recorded and compared. Statistical tests like the independent samples t-test Fischer's exact and Chi-square test were used to analyze association. Results: The distribution of the fractures according to AO/OTA classification and 31A1.2 type of intertrochanteric fractures were most common in our study. All the included fractures united and the average functional outcome in both groups were good and comparable at the end of one year. The operative time (mL, 107.1 ± 12.6 vs. 77.0 ± 12.0, p

Background: Intertrochanteric fractures are among the frequently seen fractures in the elderly population. Treating these fractures is very challenging considering the fact that the quality of bone is poor and highly osteoporotic. The high failure rates with dynamic hip screw (DHS) especially in unstable fractures lead to the development of intramedullary devices such as proximal femoral nail (PFN) which has got multiple advantages over DHS. Materials and Methods: This prospective study included 30 patients above the age group of 60 years with unstable intertrochanteric fractures conducted in a tertiary institute between February 2021 and June 2022. Results were analyzed clinically and radiologically using the Modified Harris hip score. Results: Patients' age group was 61–85 years with a mean age of 69 years, comprising 63% female and 37% male. The average Harris hip score was 83.76 at 24 weeks' follow-up with 33.33% excellent, 56.66% good, 3.33% fair, and 6.67% poor. Postoperative complications included revision surgery in two patients, superficial infection in one patient, Z effect in one patient, peri-implant fracture in one patient. Conclusion: Treatment with PFN for unstable intertrochanteric fracture has the advantages of closed reduction, less tissue damage, early rehabilitation, and return to work. Osteosynthesis with short PFN resulted in good-to-excellent functional and radiological outcomes.

Objective: Postoperative delirium (POD) is a common complication along with poor prognosis in geriatric intertrochanteric fracture (ITF) patients. However, the prevention and treatment of POD remain unclear. Previous studies have confirmed that POD is essentially a consequence of neuro-inflammatory responses. Dexamethasone is a glucocorticoid with comprehensive anti-inflammatory effects, while a high dose of dexamethasone correlates with many side effects or even adverse consequences. Thus, this prospective study aims to discuss whether a single preoperative low-dose dexamethasone can reduce the impact of POD on geriatric ITF patients with internal fixation surgery. Methods: Between June 2020 and October 2022, there were 219 consecutive ITF patients assessed in our department. Of the 219 ITF patients, 160 cases who met the inclusion and exclusion criteria were finally enrolled and randomly allocated to the dexamethasone group and the placebo group (80 geriatric ITF patients in each group) in this prospective study. The patients in the dexamethasone group received intravenous 10 mg (2 ml) dexamethasone while the patients in the placebo group received intravenous 2 ml saline in 30 min before being sent to the operating room, respectively. The baseline characteristics, surgical information, incidence and severity of POD as the efficacy-related outcomes, and infection events and hyperglycemia as safety-related outcomes (adverse events), were collected and analyzed between the two groups. The severity of POD was evaluated by Memorial Delirium Assessment Scale (MDAS) score. Results: There were no differences in baseline characteristics and surgical information between the dexamethasone group and the placebo group. The dexamethasone group had a lower incidence of POD than the placebo group within the first 5 days after surgery [(9/80, 11.3% vs. 21/80, 26.3%, RR = 0.83, 95% CI 0.71–0.97, P = 0.015]. The dexamethasone group had lower MDAS scores (Mean ± SD) than the placebo group [13.2 ± 1.0 (range 11 to 15) vs. 15.48 ± 2.9 (range 9 to 20), P = 0.011, effect size = 0.514]. There were no differences in infection events and hyperglycemia between the two groups. Conclusions: A single preoperative low-dose dexamethasone may reduce the incidence and severity of POD in geriatric ITF patients with internal fixation surgery. Trial registration: ChiCTR2200055281. [ABSTRACT FROM AUTHOR]