ObjectiveTo analyze the reasons and the influence of internal fixation about the guide pin eccentricity of helical blade during proximal femoral nail anti-rotation (PFNA) internal fixation for femoral intertrochanteric fractures.MethodsA retrospective analysis of the intraoperative imaging data of 175 patients with femoral intertrochanteric fractures, who underwent closed reduction and PFNA internal fixation between January 2018 and January 2020, was performed. There were 76 males and 99 females with an average age of 79.8 years (mean, 61-103 years). The internal between admission and operation was 12-141 hours (median, 32 hours). According to AO/Orthopaedic Trauma Association (AO/OTA) classification, the fractures were rated as type 31-A1 in 64 cases and type 31-A2 in 111 cases. In the intraoperative fluoroscopy image by C-arm X-ray machine, the caputcollum-diaphysis (CCD) was measured after closed reduction and internal fixation, respectively; the angles between the center line of the head nail hole and the axis of proximal nail and between the axis of guide pin and proximal nail were measured, and the difference between the two angles was evaluated; the quality of fracture reduction was evaluated according to the alignment of the medial cortex, anterior cortex of the head and neck bone block, and femoral shaft cortex; the position of the helical blade in the femoral head was evaluated according to the Cleveland method.ResultsThe CCDs of proximal femur were (134.6±6.8)° after closed reduction and (134.9±4.3)° after internal fixation. There was no significant difference between pre- and post-internal fixation (t=0.432, P=0.766). The angles between the center line of the head nail hole and the axis of proximal nail and between the axis of guide pin and proximal nail were (125.4±2.44)° and (126.3±2.3)°, respectively, showing significant difference (t=2.809, P=0.044). The difference between the two angles was (0.8±2.2)°. The guide pin eccentricity of helical blade occurred in 47 cases. After tapping the helical blade along the eccentric guide pin, 10 cases had fracture reduction loss, and 5 cases had a poor position of the helical blade in the femoral head. ConclusionDuring PFNA internal fixation, a variety of reasons can lead to the eccentric position of the guide pin of helical blade, including unstable fracture, soft tissue inserted, severe osteoporosis, mismatched tool, and fluoroscopic imaging factors. It is possible that the fracture end would be displaced again and the helical blade position may be poor when knocking into the helical blade along the eccentric guide pin. During operation, it should be judged whether the direction of the guide pin needs to be adjusted according to the eccentric angle.
ObjectiveTo compare the efficacy of proximal femoral nail anti-rotation (PFNA), locking compression plate (LCP), and artificial femoral head replacement for femoral intertrochanteric fracture in aged patients so as to provide reference for clinical treatment.MethodsA retrospective analysis was made on the clinical data of 150 aged patients with femoral intertrochanteric fracture treated between September 2009 and March 2016. PFNA was used in 51 cases (group A), LCP in 53 cases (group B), and artificial femoral head replacement in 46 cases (group C). There was no significant difference in sex, age, side, cause of injury, injury to operation time, type of fracture, and combined medical diseases between groups (P>0.05). The incision length, operation time, intraoperative blood loss, time for full weight bearing, hip Harris score, and complications were recorded and compared between groups.ResultsThe patients were followed up 12-23 months (mean, 18.6 months) in group A, 12-25 months (mean, 19.0 months) in group B, and 12-24 months (mean, 18.9 months) in group C. The incision length, operation time, and intraoperative blood loss of group A were significantly less than those of groups B and C (P<0.05); the operation time of group C was significantly shorter than that of group B (P<0.05), but there was no significant difference in incision length and intraoperative blood loss (P>0.05). The time for full weight bearing was significantly shorter in group C than groups A and B, and in group A than group B (P<0.05). Postoperative complications occurred in 11 patients of group A (21.6%), 14 patients of group B (26.4%), and 2 patients of group C (4.3%), showing significant difference between group C and group A or group B (P<0.05), but no significant difference was found between groups A and B (P>0.05). Hip Harris score at 12 months after operation had no significant difference between groups (P>0.05).ConclusionPFNA, LCP, and artificial femoral head replacement are all effective methods to treat femoral intertrochanteric fracture in aged patients. PFNA has the advantages of small incision, short operation time, less bleeding and simple procedure, and artificial femoral head replacement has the advantages of early time for full weight bearing, less bed rest time, and less complications. For these patients, PFNA and artificial femoral head replacement are appropriate.
ObjectiveTo compare the predictive value of the two concepts for complications by comparing the incidences of surgical complications associated with different tip-apex distance (TAD) and calcar referenced tip-apex distance (Cal-TAD) in the treatment of femoral intertrochanteric fractures with Asian type proximal femoral nail (APFN) fixation. MethodsA total of 188 cases of femoral intertrochanteric fractures treated with APFN fixation between January 2014 and December 2018 were collected according to inclusion criteria. TAD and Cal-TAD were measured on the X-ray film at immediate after operation; the patients were divided into two groups according to the measurement results: <25 mm and ≥25 mm. Gender, age, and fracture side and AO type were recorded. The patients in each group were reviewed whether there was delayed fracture union or nonunion, whether the screw blade moved axially, whether the femoral neck collapsed or even screw blade cut out, whether the internal fixator became loose or broken within 12 months after operation. Then statistical analysis was performed. ResultsThere were 119 patients with TAD<25 mm and 69 patients with TAD≥25 mm, and 142 patients with Cal-TAD<25 mm and 46 patients with Cal-TAD≥25 mm. There was no significant difference in gender, age, or fracture side and AO type between groups (P>0.05). During the follow-up, 6 patients (5.04%) with TAD<25 mm, 10 patients (14.49%) with TAD≥25 mm had complications, and 1 patient (0.70%) with Cal-TAD<25 mm and 15 patients (32.61%) with Cal-TAD≥25 mm had complications. There were significant differences in the incidence of complication between the patients with different TAD, between the patients with different Cal-TAD, and between patients with TAD<25 mm and Cal-TAD<25 mm (P<0.05). ConclusionIn the operation of femoral intertrochanteric fracture with APFN fixation, surgical complications can be significantly reduced when TAD or Cal-TAD was controlled within 25 mm, Cal-TAD is more significant in the prediction of postoperative complications.
ObjectiveTo compare the effectiveness of proximal femoral nail anti-rotation (PFNA) between in the supine "scissors" position and in the lithotomy position for treating femoral intertrochanteric fractures of old patients. MethodsA retrospective study was performed on 58 patients with femoral intertrochanteric fractures treated with PFNA between January 2013 and January 2015. Fracture was treated with PFNA in the lithotomy position in 28 cases (group A) and in the supine "scissors" position in 30 cases (group B). There was no significant difference in gender, age, side, cause of injury, fracture type, and interval from injury to operation between 2 groups (P>0.05). The incision length, operation time, perspective times, intraoperative blood loss, complications, and fracture healing time were recorded; Harris hip score was used to access the effectiveness. ResultsThe wound healed by first intention without infection, pressure sores, deep vein thrombosis of lower extremity, and other complications. There was no significant difference in incision length between 2 groups (t=1.313, P=0.212). Group B was significantly better than group A in operation time, perspective times, and intraoperative blood loss (P<0.05). All patients were followed up 10-31 months (mean, 15.3 months). Stretch injury at normal side and perineal discomfort occurred in 1 case and 5 cases of group A respectively, and no nonunion and other complications was observed in the other patients. There was no significant difference in fracture healing time and Harris hip score at last follow-up between 2 groups (P>0.05). ConclusionPFNA in the supine "scissors" position has exact effectiveness and advantages of shorter operation time, less intraoperative blood loss, less perspective times, and fewer complications.
Objective To investigate the treatment method of senile patients with femoral intertrochanteric fractures and its cl inical outcomes. Methods From January 2005 to December 2007, 192 senile patients with femoral intertrochanteric fractures were treated, including 85 males and 107 females aged 65-92 years old (average 75 years old). The injury was causedby fall on walking in 106 cases, fall when riding a bicycle in 55 cases, and traffic accidents in 31 cases. According to Evans classification, there were 12 cases of type I A, 43 cases of type I B, 29 cases of type II, 24 cases of type III A, 23 cases of type III B, 26 cases of type IV, and 35 cases of type V. One hundred and fifty patients were associated with cardio-cerebrovascular diseases, 120 patients were compl icated with chronicle hypertension, 90 cases were associated with bronchitis, and 75 cases were compl icated with diabetes. The time from injury to hospital admission was 1 hour to 14 days. Among those patients, 108 were treated with conservative treatment, 68 received dynamic hip screw (DHS) fixation, and 16 underwent proximal femoral Gamma nail fixation. Results All the patients were followed up for 12-36 months (average 18 months). The fracture all reached bone union without occurrence of nonunion and delayed union. Patients could take care of themselves, and there were no occurrences of serious pains and dysfunctions. The therapeutic effect was satisfactory. The conservative treatment group: the average hospital stay length was 48 days; the average bone heal ing time was 14 weeks; 23 cases had different degrees of coxa adducta; Harris score system was adopted to evaluate hip joint function, 45 cases were graded as excellent, 31 as good, 10 as fair, and 22 as poor, and the excellent and good rate was 70.4%. DHS internal fixation group: the average operation time was 60 minutes; the average bleeding volume during operation was 200 mL, the average hospital stay length was 24 days; the average bone heal ing time after operation was 12 weeks; Harris score system was adopted to evaluate the injured hip joint function, 38 cases were graded as excellent, 21 as good, 8 as fair, and 1 as poor, and the excellent and good rate was 86.8%. Gamma nailfixation group: the average operation time was 70 minutes; the average bleeding volume during operation was 200 mL, the average hospital stay length was 14 days; the average bone heal ing time after operation was 12 weeks; Harris score system was adopted to evaluate the injured hip joint function, 11 cases were graded as excellent, 4 as good, 1 as fair, and the excellent and good rate was 93.8%. Conclusion For geriatric femoral intertrochanteric fractures, operative treatment should be performed, the preoperative preparation should be sufficient, and individual-oriented treatment method should be selected on the basis of physical conditions of patients and the types of fractures.
Objective To evaluate the effectiveness of InterTan in the treatment of femoral intertrochanteric fractures. Methods Between April 2009 and July 2009, 57 patients with femoral intertrochanteric fracture were treated with InterTan. There were 33 males and 24 females with an average age of 68 years (range, 45-88 years). The locations were left side in 31 cases and right side in 26 cases and all fractures were closed fractures. According to Association for Osteosynthesis/Orthopaedic Trauma Association (AO/OTA) classification, there were 23 cases of type 31-A1, 27 of type 31-A2, and 7 of type 31-A3. The disease duration was 2 to 8 days with an average of 3.3 days. The data of operative time, blood loss, perioperative blood transfusion, hospital ization day, fracture heal ing time, and Harris hip score were recorded. Results The operative time and the blood loss were (74.5 ± 19.7) minutes and (148.8 ± 79.6) mL, respectively. There were significant differences in the operative time and the blood loss among the AO/OTA subgroups (P lt; 0.05). Twenty-five patients required a blood transfusion and the transfusion volume was (264.0 ± 90.7) mL. The average hospital ization days were 7 days (range, 6-9 days). Thirty-five patients were followed up 12 to 15 months (13.3 months on average). X-ray films showed that all fractures healed within (2.8 ± 0.8) months. The heal ing time of fracture was (2.4 ± 0.6), (2.9 ± 0.9), and (3.8 ± 0.5) months in 31-A1 subgroup, 31-A2 subgroup, and 31-A3 subgroup, respectively. There was no significant difference in heal ing time of fracture between 31-A1 subgroup and 31-A2 subgroup (P gt; 0.05), and there were significant differences between 31-A3 group and 31-A1 subgroup, 31-A2 subgroup (P lt; 0.05). No shortening, cut-out, varus malposition, femoral shaft fracture, or implant failures was found. The Harris score at the final follow-up was 84.5 ± 8.2 with an excellent and good rate of 80% (15 cases of excellent, 13 of good, 6 of fair, and 1 of poor). Twenty patients (57%) recovered the walking abil ity. Conclusion The new intertrochanteric antegrade nail of InterTan can be used to treat femoral intertrochanteric fractures with good cl inical outcomes, high union rate, and less compl ications.
ObjectiveTo formulate the classification criteria of femoral intertrochanteric fractures based on irreducibility or not in order to predict the difficulty of fracture recovery.MethodsA clinical data of 244 patients with closed femoral intertrochanteric fractures admitted between January 2017 and March 2020 was retrospectively analyzed. There were 116 males and 128 females with an average age of 77.9 years (range, 45-100 years). The cause of injury included falling in 190 cases, traffic accident in 36 cases, smashing in 13 cases, and falling from height in 5 cases. The time from injury to operation was 1-14 days (mean, 3.6 days). According toAO/Orthopaedic Trauma Association (AO/OTA) classification, the fractures were classified as type 31-A1 in 38 cases, type 31-A2 in 160 cases, and type 31-A3 in 46 cases. According to whether the recovery difficulty occurred after intraoperative closed traction reset, the patients were divided into reducible-group and irreducible-group; combined with the literature and preoperative imaging data of two groups, the classification criteria of femoral intertrochanteric fractures was formulated based on the irreducibility or not. The 244 fractures were classified by the doctors who did not attend the operation according to the classification criteria, predicted the difficulty of fracture reduction, and compared with the actual intraoperative reduction situation.ResultsThe 244 patients were divided into reducible-group (n=164, 67.21%) and irreducible-group (n=80, 32.79%) according to the intraoperative difficulty of reduction. Comparing the imaging data and characteristics of the two groups, and formulating the classification criteria of femoral intertrochanteric fractures based on irreducibility or not, the fractures were mainly divided into two categories of irreducibility and reducibility. The fractures of irreducibility category was divided into typesⅠ-Ⅴ, among which type Ⅲ was divided into subtypes 1-4; the fractures of reducibility category was divided into typesⅠand Ⅱ. Compared with the actual intraoperative evaluation results, the total accuracy rate of the doctors who did not attend the operation was 81.15% (198/244) based on the classification criteria of femoral intertrochanteric fractures. The accuracy rate of irreducibility category was 65.74% (71/108), and the reducibility category was 93.38% (127/136). All patients were followed up 13-25 months, with an average of 17.6 months. All fractures healed except 2 cases died of infection.ConclusionThe classification criteria of femoral intertrochanteric fractures based on irreducibility or not can accurately predict the reducible cases preoperatively, and most of the irreducible cases can be correctly predicted in a wider way. But the classification criteria still need to be further improved and supplemented.
Objective To investigate the validity of improving the femur’s mechanical characteristics by implanting calcium phosphate ceramic screws after removing dynamic hip screw (DHS). Methods The three dimensional finite element model of the femur was built based on the CT scanning of a normal male volunteer. Then the models of the femur with and without DHS were established. According to calcium phosphate ceramic screws with porosity and apparent elastic modulus, 80% and 0.1 GPa were set as group A, 50% and 1.0 GPa as group B, and 30% and 1.5 GPa as group C. Von Mises stress distribution and maximum stress were recorded when the joint was maximally loaded in a gait cycle. Results The Von Mises in normal femoral shaft was uniform; no phenomena of stress concentration was observed and the maximum stress located at the joint load-bearing site of the proximal femur. The stress concentration was observed in the femur without DHS, and the maximum stress located at the distal femur around the screw hole. By comparing several different calcium phosphate ceramic screws, the stress distribution of group B was similar to normal femur model, and the maximum stress located at the joint load-bearing site. The other screws of groups A and C showed varying degrees of stress concentration. Conclusion Implanting calcium phosphate ceramic screw can improve the mechanical characteristics of the femur after removing dynamic hip screw, and the calcium phosphate ceramic screw with 50% porosity and 1.0 GPa apparent elastic modulus is suitable for implanting.
ObjectiveTo design a new type of short femoral intertrochanteric nail (FITN) with anterior curvature (19.5 cm in length and 120 cm in radius) and observe the geometric match with medullary cavity of the femur. MethodsBetween November 2015 and June 2016, 25 geriatric patients with femoral intertrochanteric fractures were treated with the newly designed FITN. There were 7 males and 18 females with an average age of 82.3 years (range, 65-94 years). According to AO/OTA fracture classification, 3 cases were rated as A1.2, 2 cases as A1.3, 5 cases as A2.1, 8 cases as A2.2, and 7 cases as A2.3. The interval between injury and operation was 3.2 days (range, 2-7 days). Postoperatively, the nail entry point position (anterior, central, and posterior) on sagittal plane, the nail tip position (6-grade scale) and the nail tail level (3-grade scale) were measured using fluoroscopy and X-ray films to evaluate the geometric match of the nail with medullary cavity of the femur. ResultsOne patient with Parkinson disease died of asphyxia and pulmonary infection. The other 24 patients were followed up 1-8 months (mean, 4 months). Fracture union time was 6-10 weeks (mean, 8 weeks). The mean Parker-Palmer mobility score was 5.5 (range, 4-8). No patient had hip-thigh pain. The nail entry point was positioned anterior in 2 cases (8%), central in 18 cases (72%), and posterior in 5 cases (20%). The distal nail tip located at the central canal axis (grade 0) in 15 cases (60%), at anterior without contact with the anterior inner cortex (grade 1) in 8 cases (32%), at posterior (grade -1) in 1 case (4%), and at anterior with slight nail-tip impingement with the anterior cortex (grade 2) in 1 case (4%). The proximal nail tail level did not protrude out beyond the greater trochanter (grade 0) in 13 cases (52%), protruded out less than 5 mm (grade 1) in 9 cases (36%), and more than 5 mm (grade 2) in 3 cases (12%). ConclusionThe newly designed FITN has a good geometric match with the femur medullary canal in Chinese population, which may reduce the nail related complications.
ObjectiveTo investigate the morphology of coronal femoral intertrochanteric fracture and its effect on reduction and internal fixation.MethodsThe clinical and imaging data of 46 patients with femoral intertrochanteric fracture who met the selection criteria between August 2017 and October 2018 were reviewed. There were 15 males and 31 females; the age ranged from 62 to 91 years, with an average of 72.8 years. The causes of injury included walking falls in 35 cases, falling out of bed in 4 cases, and traffic accidents in 7 cases. The AO/Orthopaedic Trauma Association classification was type 31-A1 in 11 cases and type 31-A2 in 35 cases. All patients underwent closed reduction and internal fixation with intramedullary nails. During the operation, fracture reduction and fixation were performed according to the preoperative evaluation results. According to the patients’ preoperative X-ray film and CT three-dimensional reconstruction images, the direction of the coronal fracture line of the femoral intertrochanter and the morphological characteristics of the fracture block were observed; and the coronal fracture discrimination analysis was carried out for the fractures of different AO/OTA types. The percentages of coronal femoral intertrochanteric fractures diagnosed by preoperative X-ray film and CT three-dimensional reconstruction were calculated and statistically analyzed. The fracture reduction, the position of internal fixation [measurement of tip-apex distance (TAD)]. and the reliability of internal fixation were observed after operation.ResultsX-ray film was not easy to identify coronary fracture, and the coronal fracture line and the shape of the fracture piece weree clearly visible in CT three-dimensional reconstruction images. The morphological characteristics of the coronary fracture block: in AO/OTA 31-A1 type, the fracture line extended obliquely backward from the anterior tip of the large rotor, above the small rotor with or without small rotor fracture; in AO/OTA 31-A2 type, fracture line extended obliquely backward from the anterior tip of the large rotor to below the small rotor. Thirteen cases (28.3%) of coronal fractures were found on preoperative X-ray films, and 35 cases (76.1%) were found by CT three-dimensional reconstruction, showing significant difference (χ2=21.083, P=0.000). In AO/OTA 31-A1 type patients, the proportion of coronal fractures found by X-ray film and CT three-dimensional reconstruction was 18.2% (2/11) and 54.5% (6/11), respectively, and that in AO/OTA 31-A2 type patients was 31.4% (11/35) and 82.9% (29/35), respectively, showing significant differences (χ2=3.143, P=0.000; χ2=20.902, P=0.000). Among the 35 patients with coronal fractures, 6 cases (17.1%) of AO/OTA 31-A1 type, 29 cases (82.9%) of AO/OTA 31-A2 type. The operation time of the patient was 80-112 minutes, with an average of 95 minutes; the intraoperative blood loss was 180-450 mL, with an average of 360 mL. There was no complication such as infection, falling pneumonia, and deep vein thrombosis of the lower extremities. At 3 days after operation, the internal fixators were all in the proper position. The TAD was 0.9-1.8 cm, with an average of 1.4 cm. All patients were followed up 14-18 months, with an average of 16 months. All the fractures healed osseously, and there was no complication such as nonunion and loosening of internal fixation.ConclusionCT three-dimensional reconstruction can better identify coronal femoral intertrochanteric fractures than X-ray films, and accurately recognize and analyze the incidence and morphological characteristics of coronal fractures, which can help formulate more effective surgical strategies to promote patient recovery.