Objective To explore the way and therapeutic effect of one stage total hi p replacement (THR) intreating ischemic necrosis of femoral head combined with intertrochanteric fracture. Methods From July 1997 to September 2005, one stage THR was performed in 18 cases (11 left and 7 right) of ischemic necrosis of femoral head combined with fresh intertrochanteric fracture, including 13 males and 5 females, with an age range of 32-60 years. There were 11 primary cases, 2 cases of ankylosing spondyl itis, 2 cases of rheumatic arthritis, 2 cases of congenital acetabular dysplasia and 1 case of femoral neck fracture fixed using cannulated cancellous screws postoperatively in all cases of ischemic necrosis of femoral head. They suffered from ischemic necrosis of femoral head for 8 years (4-23 years). According to Evan’s intertrochanteric fracture classification, there were 4 cases of type II, 6 cases of type III, 5 cases of type IV and 3 cases of type V. According to the Ficat ischemic necrosis of femoral head classification, there were 5 cases of type III, and 13 cases of type IV. The disease course was 2-12 hours. The average value of Harris evaluation was 35.2 preoperatively. The prosthesis of biology was used. Results All wounds healed by first intention. One case suffered deep venous thrombosis 3 days postoperatively and recovered completely after treatment. No infection of urinary system and lung as well as no bedsore occurred postoperatively. The X-ray films showed that the fracture ends healed and that prosthesis had good form attitude and position after 4 months of operation. All cases were followed up for 2 years. They could walk and take care of themselves after 6 months. The average value of Harris evaluation was 94.7 points postoperatively (P lt; 0.05). The results were excellent in 15 cases, good in 2 cases, fair in 1 case according to Harris evaluation standard of THR; the excellent and good rate was 94.4%. Conclusion One stage THR for treating ischemic necrosis of femoral head combined with intertrochanteric fracture can avoid secondary operation. It could resume the ideal function of the hip joint.
ObjectiveTo investigate the effectiveness and advantages of skeletal tractor in closed reduction and proximal femoral nail antirotation (PFNA) internal fixation of intertrochanteric fracture compared with traction table.MethodsThe clinical data of 86 patients with intertrochanteric fractures, who were treated with closed reduction and PFNA internal fixation between October 2016 and March 2018 and met the selection criteria, was retrospectively analysed. Among them, 44 cases were treated with skeletal tractor (trial group) and 42 cases were treated with traction table (control group). There was no significant difference between the two groups in gender, age, cause of injury, fracture side, AO classification, and degree of osteoporosis (P>0.05). The preoperative position time, operation time, intraoperative fluoroscopy times, intraoperative blood loss, fracture healing time, intraoperative and postoperative complications, and postoperative Harris score were compared between the two groups.ResultsThe operation was successfully completed in both groups. Compared with the control group, the patients in the trial group had shorter preoperative position time and operation time, fewer intraoperative fluoroscopy times, and less intraoperative blood loss (P<0.05). The patients were followed up 12-21 months in trial group (mean, 14.2 months) and 12-22 months in control group (mean, 14.3 months). Venous thrombosis of lower extremity occurred in 8 patients (3 cases of trial group and 5 cases of control group) after operation. Internal fixation failure occurred in 5 patients (2 cases of trial group and 3 cases of control group) during 1 year after operation. All fractures healed except for those with internal fixation failure, the fracture healing time was (11.6±2.9) weeks in trial group and (12.4±3.6) weeks in control group; and there was no significant difference between the two groups (t=1.250, P=0.214). At 1 year after operation, Harris score of the trial group was 86.2±5.9 and that of the control group was 84.1±6.1. There was no significant difference between the two groups (t=1.768, P=0.080).ConclusionCompared with traction table, skeletal tractor in closed reduction and PFNA internal fixation of intertrochanteric fracture can significantly shorten the preoperative position time and operation time, reduce the intraoperative fluoroscopy times, improve the operation efficiency, and have similar effectiveness.
Objective To review the research progress of the weak state of the lateral wall in intertrochanteric fracture, in order to provide clinical references. Methods The relevant research literature on the lateral wall of intertrochanteric fracture at home and abroad in recent years was summarized and analyzed in terms of morphology, fracture line in coronal plane, and bone density. Results Assessment of weak state of the lateral wall is particularly important in the treatment of intertrochanteric fractures. Lateral wall thickness is the main way to assess the weak state of the lateral wall, but there are still problems. Many scholars at home and abroad have studied various aspects such as width, height, and length of the anterior cortex, but there is a lack of a comprehensive assessment method. Coronal fractures affect lateral wall morphology and are difficult to detect on X-ray films, requiring vigilance on the part of the clinician. Further research is needed to clarify the correlation between bone density and the weak state of the lateral wall. The femur lesser trochanter fractures interacts with the latertal wall, and the lesser trochanter fracture exacerbates the weak state. The soft tissue around the lateral wall also affects the weak state, so attention must be paid to protecting the soft tissues during operation. Conclusion There are more methods for assessing the weak state of the lateral wall, but none of them has formed a unified standard. Most of the current studies assess the weak state from a single perspective and lack a comprehensive assessment of all aspects affecting the lateral wall. Fewer studies have been conducted to assess the residual lateral wall function after a partial fracture of the lateral wall, and further research is needed.
Objective To identify an evidence-based treatment for an elderly patient with intertrochanteric fractures. Methods Clinical problems were presented on the basis of the patient’s conditions, and evidence was collected from the NGC (2000 to 2009), The Cochrane Library (Issue 4, 2009), TRIP Database, PubMed (1966 to 2009) and CBM (1978 to 2009). Treating strategies were formulated in terms of the three-combination principle (best evidence, the doctor’s professional knowledge and the patient’s desire). Results Three guidelines and sixteen studies were included. The current evidence indicated that surgery was the preferred solution to intertrochanteric fractures of the elderly patient. The sliding hip screw (SHS) appeared superior to others. There was insufficient evidence to support the routine use of closed suction drainage in orthopedic surgeries. Early surgery was associated with shorter hospital stay and improved mortality. Antibiotic prophylaxis significantly reduced infections. In order to lower the risk of venous thromboembolism, pharmacological prophylaxis should be carried out when the patient was admitted to hospital and be assisted with mechanical prophylaxis after surgery. Nutritional supplementation was conducive to the recovery of the patient. Rehabilitation ought to be performed as soon as possible. Considering the patient’s condition, the treatment option was established according to the available evidence and guidelines. Short-term follow-up showed a good outcome. Conclusion Through the evidence-based method, an individual treatment plan could obviously improve the treatment effect and prognosis.
ObjectiveTo analyze the associated risk factors of hidden blood loss in the internal fixation of intertrochanteric fracture. MethodsA retrospective analysis was made on the clinical data of 317 cases of intertrochanteric fractures which were treated by internal fixation between January 1993 and December 2008. There were 154 males and 163 females with an average disease duration of 4.58 days (range, 7 hours to 33 days); the age was (69.86±15.42) years; the average height was 1.64 m (range, 1.50-1.84 m);and the average weight was 62.26 kg (range, 39-85 kg). Of them, intramedullary fixation was used in 203 patients and extramedullary fixation in 114 patients. The operation time was (61.99±18.25) minutes. The red blood cell transfusion was given to 84 patients, and the transfusion amount was 200-1 000 mL. The drainage volume was 0-750 mL (mean, 61.85 mL). Hidden blood loss was calculated through change of hematocrit level before and after operation. The multiple linear regression was performed to analyse the risk factors of hidden blood loss. ResultsThe total blood loss was (918.60±204.44) mL, the hidden blood loss was (797.77±192.58) mL, and intraoperative visible blood loss was (257.32±271.24) mL. Single factor analysis showed hidden blood loss was significantly higher in variables as follows:gender, age, injury cause, fracture type, American anesthesiologists grading, anesthesia mode, hypertension, diabetes, disease duration, operation time, intraoperative transfusion of red blood cells, and fixation type. Multiple linear regression showed age, fracture type, anesthesia mode, and fixation type were significant risk factors. ConclusionThe risk factors of hidden blood loss are advanced age (>60 years), unstable fracture, general anesthesia, and imtramedullary fixation. Especially in elder patients with unstable fracture treated by intramedullary fixation under general anesthesia, hidden blood loss is more significant.
Objective To compare the effectiveness of the proximal femoral nail anti-rotation (PFNA) and locking compression plate (LCP) in the treatment of intertrochanteric fractures with the lateral unsubstantial femoral wall in elderly patients. Methods Between May 2009 and August 2012, 69 elderly patients with intertrochanteric fractures with the lateral unsubstantial femoral wall were treated. Fractures were fixed with PFNA in 36 patients (PFNA group), and with LCP in 33 patients (LCP group). There was no significant difference in gender, age, injury cause, side of fracture, and fracture AO type between 2 groups (P > 0.05). The incision length, operation time, intraoperative blood loss, total blood loss, fluoroscopy frequency, time for ambulation, and early (within 3 months) and late (more than 12 months) complications were compared. Fracture healing was assessed according to X-ray reexamination, the function of the hip joint was assessed according to the Harris hip scoring system. Results The incision length, operation time, intraoperative blood loss, and time for ambulation of PFNA group were significantly less than those of LCP group (P < 0.05), but the fluoroscopy frequency of PFNA group was significantly more than that of LCP group (P < 0.05). There was no significant difference in total blood loss between 2 groups (t=-1.686, P=0.096). The patients were followed up 12-24 months in PFNA group and 15-30 months in LCP group. The X-ray reexamination revealed fracture healing at (12.667±2.527) weeks in patients of PFNA group, and at (13.364±1.194) weeks in the others of LCP group except 1 case of nonunion, showing no significant difference (t=-1.443, P=0.154). There was no significant difference in Harris hip score between PFNA group (84.611±7.076) and LCP group (81.785±7.500) at 12 months after operation (t=1.626, P=0.109). The early complication rate and late complication rate were 16.7% (6/36) and 5.6% (2/36) in PFNA group and were 9.1% (3/33) and 9.1% (3/33) in LCP group, all showing no significant difference between 2 groups (χ2=0.871, P=0.481; χ2=0.320, P=0.665). Conclusion Both PFNA and LCP have good effectiveness in the treatment of intertrochanteric fractures with the lateral unsubstantial femoral wall in the elderly patients. Each has its own advantages and disadvantages.
Objective To evaluate effectiveness of proximal femur bionic nail (PFBN) in treatment of intertrochanteric fractures in the elderly compared to the proximal femoral nail antirotation (PFNA). Methods A retrospective analysis was made on 48 geriatric patients with intertrochanteric fractures, who met the selection criteria and were admitted between January 2020 and December 2022. Among them, 24 cases were treated with PFBN fixation after fracture reduction (PFBN group), and 24 cases were treated with PFNA fixation (PFNA group). There was no significant difference in baseline data such as age, gender, cause of injury, side and type of fracture, time from injury to operation, and preoperative mobility score, American Society of Anesthesiologists (ASA) score, Alzheimer’s disease degree scoring, self-care ability score, osteoporosis degree (T value), and combined medical diseases between the two groups (P>0.05). The operation time, intraoperative blood loss, number of blood transfusions, transfusion volume, length of hospital stay, occurrence of complications, weight-bearing time after operation, and postoperative visual analogue scale (VAS) score, walking ability score, mobility score, self-care ability score were recorded and compared between the two groups. And the radiographic assessment of fracture reduction quality and postoperative stability, and fracture healing time were recorded. ResultsThe operations in both groups were successfully completed. All patients were followed up 6-15 months with an average time of 9.8 months in PFBN group and 9.6 months in PFNA group. The operation time was significantly longer in PFBN group than in PFNA group (P<0.05), but there was no significant difference in intraoperative blood loss, number of blood transfusions, transfusion volume, length of hospital stay, change in activity ability score, and change in self-care ability score between the two groups (P>0.05). The weight-bearing time after operation was significantly shorter in PFBN group than in PFNA group (P<0.05), and the postoperative VAS score and walking ability score were significantly better in PFBN group than in PFNA group (P<0.05). Radiographic assessment showed no significant difference in fracture reduction scores and postoperative stability scores between the two groups (P>0.05). All fractures healed and there was no significant difference in fracture healing time between the two groups (P>0.05). The incidence of complications was significantly lower in PFBN group (16.7%, 4/24) than in PFNA group (45.8%, 11/24) (P<0.05). ConclusionCompared with PFNA, PFBN in the treatment of elderly intertrochanteric fractures can effectively relieve postoperative pain, shorten bed time, reduce the risk of complications, and facilitate the recovery of patients’ hip joint function and walking ability.
Forty cases of intertrochanteric fractures of femur were treated with percutaneous nonmetallic external fixator. The patients were followed up for 6 months to 3 years, and the fractures were all united without coxa vara or shirtening deformities. There was no mortality in this series. This method had the advantages ofbeing simple, save time and effort, less traumatic and early ambulation. The design of the apparatus tallied with the biomechanics of the neck and shaft of the femur.
Objective To summarize the new research progress in distal interlocking screws of cephalomedullary nails for the treatment of intertrochanteric fractures. Methods Relevant domestic and foreign literature was extensively reviewed to summarize the static/dynamic types of distal interlocking screw holes, biomechanical studies, clinical studies and application principles, effects on toggling in the cavity, and related complications of distal interlocking screws.ResultsThe mode of the distal interlocking screw holes can be divided into static and dynamic. Distal interlocking screws play the role of anti-rotation, maintaining femur length, resisting compression stress, increasing torque stiffness, resisting varus stress, etc. The number of the screws directly affects the toggling of the main nail in the cavity. At present, regardless of whether long or short nails are used, distal interlocking screws are routinely inserted in clinical practice. However, using distal interlocking screws can significantly increase the duration of anesthesia and operation, increase fluoroscopy exposure time, surgical blood loss, and incision length. There is a trend of trying not to use distal interlocking screws in recent years. No significant difference is found in some studies between the effectiveness of dynamic and static interlocking for AO/Orthopaedic Trauma Association (AO/OTA) 31-A1/2 fractures. At present, the selection of the number and mode of distal interlocking screws is still controversial. When inserting distal interlocking screws, orthopedists should endeavor to minimize the occurrence of complications concerning miss shot, vascular injuries, local stress stimulation, and peri-implant fractures. Conclusion Distal interlocking screws are mainly used to prevent rotation. For stable fractures with intact lateral walls, long cephalomedullary nails can be used without distal interlocking screws. For any type of intertrochanteric fractures, distal interlocking screws are required when using short cephalomedullary nails for fixation. Different interlocking modes, the number of interlocking screws, and the application prospects of absorbable interlocking screws may be future research directions.
Objective To analyze the failure factors of proximal femoral nail antirotation (PFNA) in the treatment of geriatric intertrochanteric fractures. Methods The clinical data of 136 cases of intertrochanteric fracture treated with PFNA internal fixation between May 2015 and June 2017 were retrospectively analyzed. There were 106 males and 30 females, aged from 60 to 80 years, with an average age of 75.5 years. According to Evans-Jensen classification, there were 45 cases of type Ⅰ, 50 cases of type Ⅱ, 23 cases of type Ⅲ, 13 cases of type Ⅳ, and 5 cases of type Ⅴ. The time from injury to operation was 2-4 days, with an average of 3 days. According to the X-ray films before and after operation, the fracture types (stable and unstable), reduction quality (according to Baumgaertner’s criteria), integrity of lateral wall and posteromedial cortex of the patients with failure of PFNA internal fixation were summarized, and the causes of failure were analyzed. Results All the 136 patients were followed up 7-18 months (mean, 13.6 months). There were 17 cases (12.5%) of PFNA internal fixation failure after operation, including 3 cases of stable fracture and 14 cases of unstable fracture; the quality of fracture reduction was excellent in 2 cases, good in 5 cases, and poor in 10 cases; 10 cases with complete lateral wall and 7 cases with defect; 9 cases with complete posteromedial cortex and 8 cases with defect. Reasons for failure of internal fixation: ① There were 8 cases of coxa varus at 12 weeks after operation due to the loss of posteromedial cortex of femoral intertrochanteric, 7 of them continued non-weight-bearing observation and fracture healed at 6 months after operation; 1 case underwent total hip arthroplasty with spiral blade excision after operation. ② There were 7 cases of internal fixation failure caused by lateral wall defect, including 2 cases of screw blade retraction, continued non-weight-bearing observation, and removed the internal fixator after fracture healing; 2 cases of malunion of rotation with the rotation of no more than 15°, fracture healed at 6 months after operation without special treatment; and 3 cases of rupture of lateral intertrochanteric wall during operation, continued non-weight-bearing observation and fracture healed at 6 months after operation. ③ The distal locking of the main screw was deviated in 2 cases during operation. One of them was found and replanted in time during operation, and 1 case was found with fracture of femoral shaft on 3 days after operation, following 1 year of non-weight-bearing observation and fracture ending healing. Conclusion The types of intertrochanteric fractures (especially unstable fractures), the integrity of the proximal lateral wall of femur, and the defect of the posteromedial cortex are the internal risk factors for the success or failure of PFNA in the treatment of geriatric intertrochanteric fractures. The effective protection of the lateral wall during operation and the good quality of fracture reduction are the external factors that must be paid attention to.