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Aims: To investigate if preoperative CT improves detection of unstable trochanteric hip fractures. Methods: A single-centre prospective study was conducted. Patients aged 65 years or older with trochanteric hip fractures admitted to Stavanger University Hospital (Stavanger, Norway) were consecutively included from September 2020 to January 2022. Radiographs and CT images of the fractures were obtained, and surgeons made individual assessments of the fractures based on these. The assessment was conducted according to a systematic protocol including three classification systems (AO/Orthopaedic Trauma Association (OTA), Evans Jensen (EVJ), and Nakano) and questions addressing specific fracture patterns. An expert group provided a gold-standard assessment based on the CT images. Sensitivities and specificities of surgeons’ assessments were estimated and compared in regression models with correlations for the same patients. Intra- and inter-rater reliability were presented as Cohen’s kappa and Gwet’s agreement coefficient (AC1). Results: We included 120 fractures in 119 patients. Compared to radiographs, CT increased the sensitivity of detecting unstable trochanteric fractures from 63% to 70% (p = 0.028) and from 70% to 76% (p = 0.004) using AO/OTA and EVJ, respectively. Compared to radiographs alone, CT increased the sensitivity of detecting a large posterolateral trochanter major fragment or a comminuted trochanter major fragment from 63% to 76% (p = 0.002) and from 38% to 55% (p < 0.001), respectively. CT improved intra-rater reliability for stability assessment using EVJ (AC1 0.68 to 0.78; p = 0.049) and for detecting a large posterolateral trochanter major fragment (AC1 0.42 to 0.57; p = 0.031). Conclusion: A preoperative CT of trochanteric fractures increased detection of unstable fractures using the AO/OTA and EVJ classification systems. Compared to radiographs, CT improved intra-rater reliability when assessing fracture stability and detecting large posterolateral trochanter major fragments. Cite this article: Bone Jt Open 2024;5(6):524–531.

Aims: Despite limited clinical scientific backing, an additional trochanteric stabilizing plate (TSP) has been advocated when treating unstable trochanteric fractures with a sliding hip screw (SHS). We aimed to explore whether the TSP would result in less post operative fracture motion, compared to SHS alone. Methods: Overall, 31 patients with AO/OTA 31-A2 trochanteric fractures were randomized to either a SHS alone or a SHS with an additional TSP. To compare postoperative fracture motion, radiostereometric analysis (RSA) was performed before and after weightbearing, and then at four, eight, 12, 26, and 52 weeks. With the “after weightbearing” images as baseline, we calculated translations and rotations, including shortening and medialization of the femoral shaft. Results: Similar migration profiles were observed in all directions during the course of healing. At one year, eight patients in the SHS group and 12 patients in the TSP group were available for analysis, finding a clinically non-relevant, and statistically non-significant, difference in total translation of 1 mm (95% confidence interval -4.7 to 2.9) in favour of the TSP group. In line with the migration data, no significant differences in clinical outcomes were found. Conclusion: The TSP did not influence the course of healing or postoperative fracture motion compared to SHS alone. Based on our results, routine use of the TSP in AO/OTA 31-A2 trochanteric fractures cannot be recommended. The TSP has been shown, in biomechanical studies, to increase stability in sliding hip screw constructs in both unstable and intermediate stable trochanteric fractures, but the clinical evidence is limited. This study showed no advantage of the TSP in unstable (AO 31-A2) fractures in elderly patients when fracture movement was evaluated with radiostereometric analysis. Cite this article: Bone Jt Open 2024;5(1):37–45.

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

Abstract Background Hip fractures are a major public health problem worldwide and can lead to disability, increased mortality, and reduced quality of life. We aim to provide a nationwide epidemiological analysis of trochanteric and subtrochanteric fractures and their respective surgical treatments. Methods Data were retrieved from the national database of the German Department of the Interior. ICD-10-GM and OPS data from the period of 2006 to 2020 were analysed and all patients with trochanteric and subtrochanteric fractures as their main diagnosis, who were treated in a German hospital, were included. Patients were grouped by age and gender and linear regression was performed where suitable to calculate statistically significant correlations between variables and incidences. Results 985,104 pertrochanteric fractures and 178,810 subtrochanteric fractures were reported during the analysed period. We calculated a mean incidence of 80.08 ± 6.34 for pertrochanteric and 14.53 ± 1.50 for subtrochanteric fractures per million inhabitants. In both fracture types, a distinct dependence of incidence on age can be determined. Incidence rates equally rise in both sexes through the age groups with an increase of about 288-fold from those under the age of 60 to those over the age of 90 in pertrochanteric fractures, and about 123-fold in subtrochanteric fractures. Intramedullary nailing was the most common kind of treatment for both fracture types with augmentative cerclages on the rise throughout the whole period. Plate and dynamic compression screws were decreasing in frequency over the analysed period in both fractures. Conclusions We provided incidence data on per- and subtrochanteric fractures and their treatment. We calculated an economic impact of approximately 1.563 billion € per year in Germany. With regards to recent literature on costs of treatment and our findings regarding the implementation and utilization of different treatment methods, we conclude that the reinforcement of nationwide prevention programs is a relevant step in lessening the economic burden. We welcome the increased utilisation of intramedullary nailing as many studies show beneficiary outcomes and cost effectiveness in most of the included fracture types.

A trochanteric fracture is one type of hip fracture. Management of postoperative pain after trochanteric fracture that is caused by decreased gliding between tissues in the lateral thigh is not established. The aim of this study was to examine the effect of compression of the thigh using an elastic bandage on trochanteric fracture after surgery. Multicenter randomized controlled trial was conducted in collaboration with the Comprehensive Rehabilitation Unit (sub-acute rehabilitation Unit) in two hospitals. Eligible volunteers (n = 34) with trochanteric fractures after surgery were randomly assigned to two groups. In the treatment group, participants practiced standing and walking under compression of the thigh with an elastic bandage. The control group was blinded to the intervention and practiced standing and walking under non-compression of the thigh with an elastic bandage. Both groups underwent a standard physical therapy program 2 times a day, daily. Two-way repeated measures of ANOVA showed significant main effect between the groups for gliding between tissue (p <.001), lateral femoral pain (p <.001), subcutaneous tissue thickness (p =.044). Compression of the thigh with an elastic bandage significantly improved subcutaneous tissue thickness, gliding between tissues, lateral thigh pain. Gait velocity improved with these functional improvements. [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]

Featured Application: This study coupled three-dimensional finite element models of two femora with unstable trochanteric fractures and a bone damage model to investigate the risk of cut-out for different superior–inferior and medial–lateral blade positions. By including a computational model to simulate bone damage progression and an unstable trochanteric fracture that is more severe than those simulated in the literature, this study advances the body of knowledge on the risk of cut-out in trochanteric fractures of the hip. Cut-out of the hip blade of fracture fixation implants, defined as the perforation of the femoral head by the blade due to the collapse of the neck-shaft angle into varus, is the most relevant mechanical complication in the treatment of trochanteric fractures. Among the factors that contribute to cut-out, the blade positioning in the femoral head is reported as one of the most relevant. Since the optimal blade position in the superior–inferior and medial–lateral directions is unknown, the goal of this work was to investigate the impact of blade positioning in these directions, using three-dimensional finite element models of two femora with an unstable trochanteric fracture (31-A2.2 in the Müller AO classification system with an intrusion distance of 95% of the fracture line length). The finite element models developed were coupled with a stiffness-adaptive damage model for the evaluation of the risk of cut-out. The Proximal Femoral Nail Anti-rotation (PFNA) blade was placed in each model at four discrete distances from the femoral head surface in central and inferior positions. The damage distribution in bone resulting from a gait loading condition was visually and quantitatively assessed to compare the performance of the eight positions and predict the relative risk of cut-out for each. The results suggest that the closer the tip of the blade to the femoral head surface, the lower the risk of cut-out. In the superior–inferior direction, contradicting findings were obtained for the modelled femora. The depth of placement of the blade in the medial–lateral direction and its superior–inferior position were shown to have great influence in the risk of cut-out, with the medial–lateral position being the most relevant predictor. The optimal blade positioning may be subject-specific, depending on bone geometry and density distribution. [ABSTRACT FROM AUTHOR]

In this study, a meta‐analysis was conducted to comprehensively analyse the effectiveness of using proximal femoral nail anti‐rotation (PFNA) and dynamic hip screws (DHS) to treat intertrochanteric fractures on postoperative surgical site infections (SSI). PubMed, EMBASE, Cochrane Library, China National Knowledge Infrastructure (CNKI), and Wanfang databases were searched from their inception until December 2022 to identify studies that compared PFNA and DHS in the treatment of intertrochanteric fractures. Two investigators independently screened the retrieved studies to assess their quality and verify their eligibility for inclusion. Meta‐analyses were performed with RevMan 5.4 software. Thirty studies, including 3158 patients, met the inclusion criteria. These studies included 1574 patients treated with PFNA, and 1584 were treated with DHS. The findings of the meta‐analysis revealed a significant reduction in the incidence of SSI in patients treated with PFNA compared with those treated with DHS (2.64% vs 6.76%, odds ratio [OR]: 0.40, 95% confidence intervals [CIs]: 0.28–0.57, P <.001), superficial SSI (2.58% vs 5.01%, OR: 0.53, 95% CIs: 0.33–0.85, P =.008) and deep SSI (1.26% vs 3.43%, OR: 0.41, 95% CIs: 0.19–0.92, P =.03). PFNA was more effective than DHS in reducing the incidence of SSI. Even so, significant variations in sample sizes among the included studies meant that the methodology for some studies had qualitative deficiencies. Therefore, additional studies with large sample sizes are needed to validate these results. [ABSTRACT FROM AUTHOR]

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

We examine the hypothesis that internal dual-energy X-ray absorptiometry (DXA) structural variables measured at the femoral neck and trochanter cross sections will improve prediction of fractures at these sites in addition to areal BMD (aBMD). We present an analysis of the internal distribution of bone at the site of these fractures using baseline hip DXA measurement of 1151 participants, mean age (SD) 75 (3) years, in the 14.5-year Perth Longitudinal Study of Aging in Women. Structural differences at the femoral neck (FN) and trochanter (TR) cross sections were compared in 69 participants who went on to sustain femoral neck fracture (FNF) and 59 participants who went on to sustain trochanter fracture (TRF), on average 10 years later, to those who did not fracture. The new structural variables, in addition to aBMD and bone width (W), were Sigma (distribution of bone within scanned area) and Delta (distance between center-of-mineral mass and geometric center), which can be assessed by current DXA programs. At baseline, compared with nonfracture cases, FNF cases had a FNaBMD 7% lower, a FNWidth 3% higher and a FNDelta 29% higher, associated with reduced bone in the superior segment. In FNF Cox proportional hazard analysis, age (hazard ratio [HR 1.39]), total hip aBMD (THaBMD; 0.79), and Delta (1.70) were significant. Addition of FN Delta to the base case of THaBMD and age improved the C statistic from 0.62 to 0.69, p = 0.01. At baseline, TRF cases had a 15% lower TRaBMD with minor differences in Sigma (1%) and Width (2%). In TRF Cox analysis, neither addition of Sigma nor Width improved the model that included age and THaBMD as predictors and did not alter the C-statistic of 0.81. In conclusion, adding measurement of FN Delta, an assessment of superior sector bone loss, to hip aBMD and age substantially improved clinical FNF prediction in older women. [ABSTRACT FROM AUTHOR]

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

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

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

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

Cut-out of the hip blade of fracture fixation implants, defined as the perforation of the femoral head by the blade due to the collapse of the neck-shaft angle into varus, is the most relevant mechanical complication in the treatment of trochanteric fractures. Among the factors that contribute to cut-out, the blade positioning in the femoral head is reported as one of the most relevant. Since the optimal blade position in the superior–inferior and medial–lateral directions is unknown, the goal of this work was to investigate the impact of blade positioning in these directions, using three-dimensional finite element models of two femora with an unstable trochanteric fracture (31-A2.2 in the Müller AO classification system with an intrusion distance of 95% of the fracture line length). The finite element models developed were coupled with a stiffness-adaptive damage model for the evaluation of the risk of cut-out. The Proximal Femoral Nail Anti-rotation (PFNA) blade was placed in each model at four discrete distances from the femoral head surface in central and inferior positions. The damage distribution in bone resulting from a gait loading condition was visually and quantitatively assessed to compare the performance of the eight positions and predict the relative risk of cut-out for each. The results suggest that the closer the tip of the blade to the femoral head surface, the lower the risk of cut-out. In the superior–inferior direction, contradicting findings were obtained for the modelled femora. The depth of placement of the blade in the medial–lateral direction and its superior–inferior position were shown to have great influence in the risk of cut-out, with the medial–lateral position being the most relevant predictor. The optimal blade positioning may be subject-specific, depending on bone geometry and density distribution.

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

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

Introduction In the UK, hip fractures are a common reason for presentations to the emergency departments, which places significant pressure on NHS hospitals, appropriate choice of an implant to treat the hip fracture is one among many other factors that affect patients' outcomes. This audit aims to identify and compare the outcome difference between the dynamic hip screws (DHS) and short cephalomedullary nails in the treatment of extracapsular hip fractures. Methods In a retrospective study of 52 patients admitted as a result of hip fractures in one NHS trust, data collection was done from the patients' records using the trust's online system, we studied different variables to compare the outcome difference between DHS and short intramedullary (IM) nails, two senior authors interpreted the patients' X-rays and verified the coding and classification of the neck of femur fractures. Results This retrospective study examined 52 extracapsular hip fracture cases, including 37 females and 15 males. Forty-six (88%) of the included patients were ASA 3 and 4 (American Society of Anesthesiologists), and the average days to discharge from therapies were 8.4 (SD-+ 4) days compared to 11 (SD-+ 5.2) days for short IM nails and DHS, respectively (P= 0.03), the 30-day mortality rate for short nails was 7% (n= 4/52) patients and 6% (n= 3/52) for DHS (P =0.69). The mean operating times for the different implants were 58.11 (SD-+ 15.1) minutes for DHS and 58.03 (SD-+ 23.2) minutes for the short nail (P =0.98). Compliance with the national guidelines for providing an appropriate operation to treat hip fractures initially went from 63% (n=33/52) initially to 73% (n=38/52). This means that more patients who are appropriate for nailing are being treated with IM nails. Conclusion Short IM nails are associated with faster hospital discharge; this fact may be reflecting the lower postoperative pain as a result of avoiding soft tissue dissection associated with extramedullary devices. keeping in mind that IM devices have mechanical advantages over sliding hip screws; hence, they are more commonly used for more complex fracture patterns, leading to nearly similar outcomes when compared to extramedullary devices, this can be a source of bias in retrospective studies, larger randomized trials may lead to different outcomes., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Trust's Audit Office issued approval RN1303879. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Al-Dahan et al.)

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

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

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

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

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

Introduction: Lag screw cut-out is a serious complication of dynamic hip screw fixation of trochanteric hip fractures. The lag screw position has been acknowledged as one of the important factors affecting the lag screw cut-out. We propose a modification of the Tip Apex Distance (TAD) and hypothesise that it could improve the reliability of predicting lag screws cut-out in these injuries. Materials and Methods: A retrospective study was conducted for hip fracture entries in the period from Jan 2018 to July 2022. A hundred and nine patients were suitable for the final analysis. The modified TAD was measured in millimetres based on the sum of the traditional TAD in the lateral view and the net value of two distances in the AP view, the first distance is from the tip of the lag screw to the opposite point on the femoral head along the axis of the lag screw while the second distance is from that point to the femoral head apex. The first distance is a positive value, whereas the second distance is positive if the lag screw is superior and negative if inferior. A receiver operating characteristic curve was used to evaluate the reliability of the different parameters assessing the lag screw position within the femoral head. Results: Reduction quality, fracture pattern as per the AO/OTA classification, TAD, Calcar Referenced TAD, Axis Blade Angle, Parker’s ration in the AP view, Cleveland Zone 1, and modified TAD were statistically associated with lag screw cut-out. Among the tested parameters, the modified TAD had 90.1% sensitivity and 90.9% specificity for lag screw cut-out at a cut-off value of 25 mm with a P-value

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

Intertrochanteric femur fractures are common in older patients and often have a significant impact on disability. The treatment aims to achieve a rapid return to the prior functional level with a low rate of complications and mortality. Surgical management by internal fixation is the mainstay of treatment for most of these fractures. Even when treated with intramedullary nails, the overall complication rates are high, especially for unstable or highly comminuted fractures or in the presence of poor bone quality. Hip arthroplasty is an alternative in older patients with intertrochanteric femur fractures at high risk of fixation failure or with concomitant intraarticular pathologies. Especially patients whose condition precludes prolonged bedrest and who are at risk of significant deterioration if their locomotor function cannot be restored rapidly are likely to benefit from hip arthroplasty. The choice of the surgical technique mainly depends on the surgeon's preferences and the fracture characteristics. Bipolar hemiarthroplasty is the most common type of prosthesis used with primary or revision femoral stems. Compared with intramedullary nails, hip arthroplasty has a better early functional outcome and lower rates of surgical complications as well as reoperations. However, the functional outcome and the mortality rate in the longer term tend to favor intramedullary nails, even though the results are inconsistent, and a statistically significant difference cannot always be obtained. Currently, there are no guidelines that define the role of hip arthroplasty in the treatment of intertrochanteric femur fractures in older patients. The literature only offers an overview of the possibilities of the usage of hip arthroplasty, but methodological limitations are common, and evidence levels are low. Further studies are needed to identify the intertrochanteric fractures that are at high risk of internal fixation failure, the characteristics that determine which patients may benefit most from hip arthroplasty, and the optimal surgical technique. [ABSTRACT FROM AUTHOR]

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

Relevance — the need for an objective justification in choosing the type of fixation in the treatment patients with pertrochanteric hip fractures.Objective — to study the changes in the properties of a consolidating trochanteric fracture fixed by a dynamic cephalomedullary nail when subjected to cyclic dynamic loads.Materials and methods. A mathematical model was developed for trochanteric fracture of the femur (A1 according to AO classification) when fixed with a dynamic cephalomedullary nail. Then, the properties of the system were studied (pressure between fragments, mechanical stress in the bone and fixation device, displacement amplitude, neck-diaphysis angle) under a virtual load of a 80 kg body at various amount of insertion of the dynamic screw (from 10 mm to 0 mm).Results. In the process of shortening the femoral neck axis by 1 cm, the stability of the ‘bone-metal fixation device’ system increases, as indicated by a decrease in the maximum amplitude of displacements in the system under load by 16.8%, a decrease in the maximum stress in the fixation elements by 20.2%, a decrease in pressure at the site of contact of fragments by 19.8%. In addition, there was a decrease in the neck-diaphysis angle by 2.8%.Conclusion. The mathematical modeling of the ‘bone-metal fixation device’ system simulating conditions of dynamic osteosynthesis showed that there is a potential increase in the stability of the cephalomedullary system and that favorable conditions are created for the consolidation of the fracture when subjected to cyclic load of body mass.

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

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

Background: Reverse oblique intertrochanteric fractures (ROFs) are unstable extracapsular hip fractures that present a mechanical challenge. These fractures are classified as AO/Orthopaedic Trauma Association (OTA) 31-A3 according to the Trauma Association classification system and can further be subclassified into 3 subtypes based on their specific characteristics. The study aimed to evaluate and compare the radiographic and clinical outcomes of the 3 subtypes of ROFs., Methods: A retrospective study was conducted at a single high-volume, tertiary center, where data were collected from electronic medical records of consecutive patients who underwent surgical fixation of AO/OTA 31-A3 fractures. Patients with less than 1-year follow-up, pathological fractures, and revision surgery were excluded. The subtypes of fractures were classified as 31-A3.1 (simple oblique), 31-A3.2 (simple transverse), and 31-A3.3 (wedge or multi-fragmentary). The operation was done using 4 different fixation methods, and radiological evaluation was performed at routine intervals., Results: The final population consisted of 265 patients (60.8% women) with a mean age of 77.4 years (range, 50-100 years) and the mean follow-up time was 35 months (range, 12-116 months). The incidence of medical complications was similar across the groups. However, there was a trend toward a higher incidence of orthopedic complications and revision rates in the 31-A3.2 group, although this was not statistically significant ( p = 0.21 and p = 0.14, respectively)., Conclusions: Based on the findings of this study, no significant differences were observed between the groups, indicating that the subclassifications of AO/OTA 31-A3 fractures do not have a significant impact on surgical outcomes or the occurrence of postoperative complications., Competing Interests: CONFLICT OF INTEREST: No potential conflict of interest relevant to this article was reported., (Copyright © 2024 by The Korean Orthopaedic Association.)

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

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

Aims and objectives: This study was done to evaluate the functional and radiographic outcome of PFN in treatment of proximal femoral fracture and more common technical, mechanical complications and intraoperative difficulties during the implant implementation. Materials & Methods: We conducted a retrospective study with ten cases of proximal femoral fractures treated between September 2017 and September 2018, which were accepted at the Department of Orthopedics, the University Hospital of Trauma and the American Hospital in Tirana. Fractures are classified according to classification AO and Boyd-Griffin. The age range of patients taking the study was 20-90 years. Ten cases were followed at regular intervals and the final assessment was made at the end of the 6 month period. In the result, functional clinical assessment according to Harris hip score was done . Results: In our study,mean age was 66 y.o, 7 male and 3 females. Mean of hospitalization time 6 days, mean operation time 120 min. In our study at 6 months follow up, union was achieved in 9 cases, open reduction was performed in 3 cases (10 cases). Technical and mechanical complications were noted in one case. Reoperation rate was 10 % (one case). According Harris hip scoring system excellent results were seen 40 % of cases (4 cases), good results in 50 % cases (5 cases), and poor results in 10% cases (1 case). Conclusions: In our study, in spite of low experience in proximal femoral nailing in cases with unstable trochanteric / subtrocanteric fractures, it was found that PFN is an attractive implant and suitable for proximal femoral fractures and its use in unstable trochanteric / subtrocanteric fractures is very encouraging. This study has also shown that this device can safely be used by an average surgeon to handle common but sometimes tough fractures. Operation is technically not difficult, but gradual learning and great patience is needed to make this method really minimal invasive.

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

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

Purpose: The aim of this study was to investigate the incidence of Z-effect after dual lag screw intramedullary nailing systems and risk factors contributing to this effect. We hypothesized that long nails provide more neck strength due to a longer lever than short nails and are therefore less likely to develop a misbalance of a higher head compressive strength than neck compressive strength. Methods: In this retrospective cohort study 103 patients treated operatively with a dual lag screw intramedullary nailing device for (sub)trochanteric hip fracture were included. We analysed patient charts regarding patient and operation characteristics. Furthermore we conducted radiologic measurements within the 2-year follow-up period to investigate the quality of fracture fixation, implant failure and predictors for Z-effect. The re-operation risk was investigated with multivariate regression analysis. Results: The incidence of (reversed) Z-effect in this study was 9% (n = 80); 6 out of 7 Z-effects occurred in the short nail group, which was not significant. Patients who were treated with a long nail had a significant larger number of complications in comparison with the short nail group (median 2 vs 0.5, p = 0.001). The long nail group received more often erythrocytes blood transfusions (82% vs 31%, p

Intertrochanteric femur fractures are common in older patients and often have a significant impact on disability. The treatment aims to achieve a rapid return to the prior functional level with a low rate of complications and mortality. Surgical management by internal fixation is the mainstay of treatment for most of these fractures. Even when treated with intramedullary nails, the overall complication rates are high, especially for unstable or highly comminuted fractures or in the presence of poor bone quality. Hip arthroplasty is an alternative in older patients with intertrochanteric femur fractures at high risk of fixation failure or with concomitant intraarticular pathologies. Especially patients whose condition precludes prolonged bedrest and who are at risk of significant deterioration if their locomotor function cannot be restored rapidly are likely to benefit from hip arthroplasty. The choice of the surgical technique mainly depends on the surgeon’s preferences and the fracture characteristics. Bipolar hemiarthroplasty is the most common type of prosthesis used with primary or revision femoral stems. Compared with intramedullary nails, hip arthroplasty has a better early functional outcome and lower rates of surgical complications as well as reoperations. However, the functional outcome and the mortality rate in the longer term tend to favor intramedullary nails, even though the results are inconsistent, and a statistically significant difference cannot always be obtained. Currently, there are no guidelines that define the role of hip arthroplasty in the treatment of intertrochanteric femur fractures in older patients. The literature only offers an overview of the possibilities of the usage of hip arthroplasty, but methodological limitations are common, and evidence levels are low. Further studies are needed to identify the intertrochanteric fractures that are at high risk of internal fixation failure, the characteristics that determine which patients may benefit most from hip arthroplasty, and the optimal surgical technique.

Most trochanteric fractures are treated by fixation, most often intramedullary. Nevertheless, the desire to have patients walk as soon as possible and the fear of fixation failure has driven some surgeons to carry out an arthroplasty instead, especially for unstable fractures and/or in patients with severe osteoporosis, in order to avoid the difficult conversion to arthroplasty later on if the fixation fails. The aim of this review was to specify the role, technique and results of performing arthroplasty in this context. In which fractures? Unstable fractures (A2.2, A2.3 and A3), especially in osteoporotic bone, which are the most difficult to reduce and fix, and in cases with associated osteoarthritis. For which patients? Arthroplasty should not be done in patients who have ASA≤3 due to greater blood loss and longer operative time. Since the postoperative Parker score often drops, arthroplasty should not be done in patients having a Parker score<6. What are the technical problems? Arthroplasty must be done by an experienced surgeon because of the lack of anatomical landmarks, although fracture fixation has its own demands (satisfactory reduction, appropriate length and position of cervicocephalic screw). What are the results and complications? Despite several comparative studies (randomized trials, meta-analysis and prospective studies), it is difficult to draw any conclusions. These studies show worse performance of dynamic hip screws relative to intramedullary nails. The complication and revision rates were higher for nails than arthroplasty, but not in every study, while the functional outcomes with nails (with or without immediate weightbearing) were better than those of arthroplasty beyond 6 months. What is the mortality rate? It was lower after nailing in a few studies but was mainly determined by the patient's comorbidities and preoperative Parker score. The best indication for arthroplasty may be self-sufficient patients over 70 years of age who have an unstable fracture with severe osteoporosis. Nevertheless, new studies should be done to compare arthroplasty to nailing with immediate return to weightbearing in patients having the same type of fracture, defined using 3D CT scan. Level of evidence: Expert advice., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

Intraoperative trochanteric fractures during primary and revision total hip arthroplasty typically occur during femoral canal preparation and component placement. Several fixation strategies, including wires, cables, cable grips, and plating, are available for fracture fixation. Surgeons should consider patient activity level preoperatively, bone mineral density, and fracture morphology when deciding on fixation strategies. Patient activity must be modified postoperatively to prevent fracture displacement and additional complications. Patients must be counseled postoperatively about the possibility of decreased clinical outcomes., (Copyright © 2023 Elsevier Inc. All rights reserved.)

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

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

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