Proximal Femur Bionic Nail (PFBN): A Panacea for Unstable Intertrochanteric Femur Fracture

With the aging population,intertrochanteric femur fracture in the elderly has become one of the most serious public health issues and a hot topic of research in trauma orthopedics.Due to the limitations of internal fixation techniques and the insufficient mechanical design of nails,the occurrence of complications delays patient recovery after surgical treatment.Design of a proximal femur bionic nail(PFBN)based on Zhang’s N triangle theory provides triangular supporting fixation,which dramatically decreases the occurrence of complications and has been widely used for clinical treatment of unstable intertrochanteric femur fracture worldwide.In this work,we developed an equivalent biomechanical model to analyze improvement in bone remodeling of unstable intertrochanteric femur fracture through PFBN use.The results show that compared with proximal femoral nail antirotation(PFNA)and InterTan,PFBN can dramatically decrease the maximum strain in the proximal femur.Based on Frost’s mechanostat theory,the local mechanical environment in the proximal femur can be regulated into the medium overload region by using a PFBN,which may render the proximal femur in a state of physiological overload,favoring post-operative recovery of intertrochanteric femur fracture in the elderly.This work shows that PFBN may constitute a panacea for unstable intertrochanteric femur fracture and provides insights into improving methods of internal fixation.

Knee Osteoarthritis Progression after Distal Femur Closing Wedge Osteotomy

Background: Despite the conservative treatment of tibio-femoral osteoarthritis through realignment osteotomies, the rate of total knee replacements following an osteotomy is increasing. The aim of this study was to identify the factors associated with the progression of knee osteoarthritis after a medial closing-wedge distal femoral osteotomy. Methods: Hospital-based observational study on 20 patients who underwent a medial closing-wedge distal femoral osteotomy evaluating the progression of osteoarthritis using the Kellgren and Laurence classification. The Wilcoxon test was used to compare the variation in the progressive stage of the Kellgren and Laurence classification of knee osteoarthritis preoperatively and at the final follow up. Univariate analysis made it possible to determine the factors associated with progression. The final significance threshold for statistical tests was set at 5% (p Results: Overall, the mean follow-up of 46 months ± 6.6 months, with a mean age of 43 years (range: 27 - 69 years) and a female predominance (M: F = 3/7). The progression of tibiofemoral osteoarthritis following a medial closing-wedge distal femoral osteotomy is associated with valgus or varum malalignment been a moderate valgus (OR 6.2 [1.5 - 42.7] at 95% CI;p-value = 0.02), a correction of the mechanical deviation angle with a valgus alignment (OR 2.7 [0.9 - 8.3] at 95% CI), and loss of correction (OR 3.8 [1.3 - 11.6] at 95% CI;p -value) for the lateral compartment while varus alignment (OR 1.7 [0.9 - 8.3] 95% CI, p-value = 0.05) and with rupture of the lateral cortex (OR 2.8 [1.7 - 11.5] 95% CI, p-value = 0.02) were those of the medial compartment. Conclusion: Distal femur closing wedge osteotomy does not definitively interrupt the progression of valgus knee osteoarthritis. The factors associated with the progression of this pathology are modifiable. Taking them into account when performing this surgical technique could improve the osteotomy survival curve.

What are the Risks of Death in Elderly Patients after a Proximal Femur Fracture at Aristide le Dantec Hospital?

Introduction: Proximal femur fractures are traumatic injuries involving the neck and trochanteric region of the femur. The aim was to identify risk factors for death following proximal femur fractures in elderly patients. Patients and methods: This was a prospective, observational, longitudinal study conducted over an 18-month period in the Orthopedics-Traumatology Department of Aristide Le Dantec Hospital in Dakar. We evaluated a total of 93 patients aged at least 60 years with a proximal femur fracture whose date of onset was less than 3 weeks. The identification of risk factors for death took into account socio-demographic, clinical and therapeutic parameters. Results: The number of patients who died was 19 (20.43%). There was no significant difference in mortality according to age, gender or residence. There was no association between admission time and mortality. The association between the number of comorbidities and mortality was significant. The association between mortality and ASA score and type of treatment was highly significant. Operating time had no influence on mortality. Type of anesthesia, on the other hand, did influence mortality. Conclusion: Mortality due to proximal femur fractures in the elderly remains high. In our practice, this mortality was related to the presence of comorbidity, impaired cognitive function, ASA score, type of treatment and type of anesthesia.

基于Composite Femur三维有限元股骨模型的建立及实验验证

背景:随着计算机技术的发展,三维有限元分析越来越多地应用于骨骼生物力学的研究,股骨作为人体最大最粗的长骨具有典型生理意义,其生物力学问题需要深入研究。目的:建立长管状骨的有限元分析模型,并通过力学实验验证有关参数。方法:通过CT扫描3rd generation composite femurs,获得连续断层图片,导入MIMICS医学建模软件生成实体模型后,应用通用有限元分析软件进行网格划分、材料属性赋值生成有限元模型,约束边界条件,模拟受力状态进行加载,得出有限元模型上的应力与应变结果,并与实测实验结果对比。结果与结论:股骨有限元生成节点数为52 772,单元格为45 127,进行股骨干单向压缩实验仿真,有限元模型相对位移与验证实验和实验计算结果一致性良好。提示用MIMICS建立的股骨模型,在Ansys下进行有限元分析,得到的结果与生物力学基本吻合,说明建立的股骨模型是可靠的。

Valgus osteotomy for nonunion and neglected neck of femur fractures

Nonunion neck of femur can be a difficult problem to treat, particularly in the young, and is associated with high complication rates of avascular necrosis due to the precarious blood supply and poor biomechanics.The various treatment options that have been described can be broadly divided according to the aim of improving either biology or biomechanics. Surgeries aimed at improving the biology, such as vascularized fibula grafting, have good success rates but require high levels of expertise and substantial resources. A popular surgical treatment aimed at improving the biomechanics-valgus intertrochanteric osteotomyoptimizes conditions for fracture healing by converting shear forces across the fracture site into compressive forces. Numerous variations of this surgical procedure have been developed and successfully applied in clinical practice. As a result, the proximal femoral orientation for obtaining a good functional outcome has evolved over the years, and the present concept of altering the proximal femoral anatomy as little as possible has arisen. This technical objective supports attaining union as well as a good functional outcome, since excessive valgus can lead to increased joint reaction forces. This review summarizes the historical and current literature on valgus intertrochanteric osteotomy treatment of nonunion neck of femur, with a focus on factors predictive of good functional outcome and potential pitfalls to be avoided as well as controversies surrounding this procedure.

Management bone loss of the proximal femur in revision hip arthroplasty: Update on reconstructive options

The number of revision total hip arthroplasties is expected to rise as the indications for arthroplasty will expand due to the aging population. The prevalence of extensive proximal femoral bone loss is expected to increase subsequently. The etiology of bone loss from the proximal femur after total hip arthroplasty is multifactorial. Stress shielding, massive osteolysis, extensive loosening and history of multiple surgeries consist the most common etiologies. Reconstruction of extensive bone loss of the proximal femur during a revision hip arthroplasty is a major challenge for even the most experienced orthopaedic surgeon. The amount of femoral bone loss and the bone quality of the remaining metaphyseal and diaphyseal bone dictate the selection of appropriate reconstructive option. These include the use of impaction allografting, distal press-fit fixation, allograft-prosthesis composites and tumor megaprostheses. This review article is a concise review of the current literature and provides an algorithmic approachfor reconstruction of different types of proximal femoral bone defects.

Age-related Marrow Conversion and Developing Epiphysis in the Proximal Femur: Evaluation with STIR MR Imaging

In order to observe the feature of age-related marrow conversion and maturation of epiphyseal cartilage and analyze the distribution of red and yellow marrow in the proximal femur at STIR MR imaging, STIR and T1 weighted MR imaging of the proximal femur in 52 subjects, aged 4 months to 25 years old, were retrospectively analyzed for the distribution and appearance of red and yellow marrow. The subjects with no known bone marrow abnormalities were divided into 6 age groups. The signal intensity of the marrow in the proximal epiphysis, proximal metaphysis, proximal diaphysis, distal diaphysis and greater trochanter was compared with the signal intensity and homogeneity of surrounding muscle and fat and graded by two observers. The results showed that the conversion of hematopoietic marrow in the proximal femur followed a well-defined sequence, occurring first in the proximal epiphysis, followed by the distal diaphysis, and then greater trochanter and metaphysis. STIR in combination with T1-weighted imaging could display clearly the origin of ossification center and the course of conversion from red to yellow marrow in proximal epiphysis and greater trochanter. STIR imaging showed that the marrow conversion in proximal metaphysic began below epiphyseal plate and intertrochanter. The site of red yellow was distributed in weight-bearing axis by 20 years of age. The marrow conversion of diaphysis was from distal end to proximal end, and the consequence of conversion was that distal diaphysis contained yellow marrow but proximal diaphysis partly red marrow connected with the red marrow of metaphysic. The epiphyseal cartilage had different characters of signal-intensity with age in STIR sequence. The distribution of red marrow in STIR imaging was more close to that of anatomy than T1-weighted imaging. It was concluded that STIR could dynamically display the feature of morrow conversion and the development of epiphyseal cartilage and accurately reveal the age-related distribution of red and yellow marrow on STIR imaging in the proximal femur.

Clinical and functional comparison of endoprosthetic replacement with intramedullary nailing for treating proximal femur metastasis

Objective： To evaluate the clinical and functional outcomes of modular endoprosthetic replacement （EPR） compared to proximal femur intramedullary nailing （IMN） for the treatment of proximal femur metastases. Methods： We retrospectively studied the records of patients with proximal femur metastatic lesions treated with surgical stabilization between January 2007 and December 2014 in terms of operation time, blood loss, postoperative score, soreness, Karnofsky performance score （KPS） and survival time. Results： There were 34 patients treated with surgical stabilization. The mean follow-up period was 12.1~8.6 months （range： 10-47 months）. Thirteen were treated with EPR and 21 were stabilized with IMN （20 males, 14 females; mean age： 68.7 years）. The median survival time was 11.0 months for both groups （P=0.147）. The operation time, blood loss and Harris score of IMN group were lower than those of EPR group （P=0.001, P=0.001, P=0.002, respectively）. Conclusions： Both EPR and IMN for treating proximal femur metastasis achieved effective clinical outcomes. Therefore, the suitable surgical methods depended on the general conditions and medical requirements of patients, as well as the technical advantages of the doctor.

Optimization of transdisciplinary management of elderly with femur proximal extremity fracture:A patient-tailored plan from orthopaedics to rehabilitation

Fractures of femur proximal extremity(FFPE)are the most common fragility fractures requiring hospitalization,with a high risk of mortality,low independence in the activities of daily living and severe consequences on healthrelated quality of life.Timing for surgery has a key role in the management of elderly patients with FFPE as recommended by the Australian and New Zealand guidelines and the National Institute for Health and Care Excellence guidelines.Early surgery(within 48 h from hospital admission)allows significant benefits in terms of lower rates of postoperative complications and risk of death and can provide better functional outcomes.Therefore,time for surgery could be considered as a comorbidity marker.The choice between conservative or surgical approach surprisingly seems to be still not strongly supported by available literature,but it seems that both 30 d and 1 year risk of mortality is higher with the conservative treatment rather than with surgery.In light of these considerations,the optimization of FFPE management care is mandatory to improve functional outcomes and to reduce sanitary costs.Albeit it is widely accepted that transdisciplinary approach to patients suffering from FFPE is mandatory to optimize both short-term and long-term outcomes,the feasibility of a comprehensive approach in clinical practice is still a challenge.In particular,the large variability of figures involved could be considered both a resource and an additional disadvantage taking into account the difficulty to coordinate multidisciplinary approach covering care in all settings.Therefore,the aim of the present article was to summarize current evidence supporting transdisciplinary management of patients with FFPE,highlighting the benefits,feasibility and limitations of this approach.

Clinical and functional comparison of dynamic hip screws and intramedullary nails for treating proximal femur metastases in older individuals

Objective:To compare the outcomes of dynamic hip screws(DHS)and intramedullary nailing(IMN)in the treatment of extra-capsular metastatic carcinoma of the proximal femur.Methods:A retrospective case analysis method was used to examine data of patients with proximal metastatic cancer of the femur who were treated with internal fixation in Department of Orthopaedics,Beijing Friendship Hospital,from January 2007 to December 2018.Blood loss,postoperative pain,functional score,length of stay,and survival rates were compared,and postoperative complications were assessed.Results:Complete follow-up data were available for 33 patients.The mean follow-up period was 12.2±3.6(range:9-32)months and the average age was 72.3±4.7(range:59-83)years old.There were 20 females and 13 males.Twenty-three patients had undergone IMN and 10 DHS,according to bone defects and the patient’s overall condition.The median survival time was 10 months in the IMN group and 11 months in the DHS group.Duration of surgery(t=-7.366,P<0.001)and length of hospital stay(t=-3.509,P<0.001)differed significantly between the two groups.There was one case of breakage of internal fixation in the IMN group.Conclusions:There was no significant difference between DHS and IMN in terms of surgical efficacy.IMN and DHS were different in terms of surgical time and hospital stay.However,due to the limited number of cases in this study,multi-factor analysis has not been performed and needs to be further verified in future analysis.When developing a surgical plan,it is recommended to consider the patient’s condition and the surgeon’s experience.

Effect of proximal femur nail anti-rotation on unstable intertrochanteric fractures: A prospective observational study

Objective:To assess the effect of proximal femur nail anti-rotation on the functional and radiological outcome of unstable intertrochanteric fractures.Methods:This prospective observational study was conducted in the orthopedic department of a tertiary care hospital.Altogether 86 patients with unstable intertrochanteric fractures treated with proximal femur nail anti-rotation between January 2010 and January 2015 were included.Patients were followed in the outpatient clinic at regular intervals after discharge to assess the radiological union of fractures and complications.The functional outcomes were evaluated after 2 years by Harris hip score.Results:All patients achieved a radiological union of fractures after a mean duration of 24.6 weeks.The follow up showed 23 complications(systemic and local).Eight patients developed urinary tract infections,and three patients developed chest infections,two patients had screw cut-out,one patient had knee stiffness,one patient developed superficial surgical site infection,and four patients developed varus collapse and shortening subsequently.The two year follow up showed that 69(80.2%)patients had an excellent and good functional outcome according to Harris hip score.Conclusions:With lower complication rates,proximal femur nail is a valid and reasonable option especially in treating unstable intertrochanteric fractures.

Low-grade central osteosarcoma of distal femur, resembling fibrous dysplasia

We report a case of a 32 year-old male, admitted for a lytic lesion of the distal femur. One month after the first X-ray, clinical and imaging deterioration was evident. Open biopsy revealed fibrous dysplasia. Three months later, the lytic lesion had spread to the whole distal third of the femur reaching the articular cartilage. The malignant clinical and imaging features necessitated excision of the lesion and reconstruction with a custom-made total knee arthroplasty. Intraoperatively, no obvious soft tissue infiltration was evident. Nevertheless, an excision of the distal 15.5 cm of the femur including 3.0 cm of the surrounding muscles was finally performed. The histological examination of the excised specimen revealed central low-grade osteosarcoma. Based on the morphological features of the excised tumor, allied to the clinical findings, the diagnosis of low-grade central osteosarcoma was finally made although characters of a fibrous dysplasia were apparent. Central low-grade osteosarcoma is a rare, well-differentiated sub-type of osteosarcoma, with clinical, imaging, and histological features similar to benign tumours. Thus, initial misdiagnosis is usual with the condition commonly mistaken for fibrous dysplasia. Central low-grade osteosarcoma is usually treated with surgery alone, with rare cases of distal metastases. However, regional recurrence is quite frequent after close margin excision.

Treatment of distal femur fractures in a regional Australian hospital

AIM:To review our outcomes and compare the results of the Less Invasive Stabilization System(LISS)to other implants for distal femur fracture management at a regional Australian hospital.METHODS:The LISS is a novel implant for the management of distal femur fractures.It is,however,technically demanding and treatment results have not yet been assessed outside tertiary centres.Twenty-seven patients with 28 distal femur fractures who had been managed surgically at the Mackay Base Hospital from January 2004 to December 2010 were retrospectively enrolled and assessed clinically and radiologically.Outcomes were union,pain,Lysholm score,knee range of motion,and complication rates.RESULTS:Twenty fractures were managed with the LISS and eight fractures were managed with alternative implants.Analysis of the surgical techniques re-vealed that 11 fractures managed with the LISS were performed according to the recommended principles(LISS-R)and 9 were not(LISS-N).Union occurred in67.9%of fractures overall:9/11(82%)in the LISS-R group vs 5/9(56%)in the LISS-N group and 5/8(62.5%)in the alternative implant group.There was no statistically significant difference between pain,Lysholm score,and complication rates between the groups.However,there was a trend towards the LISS-R group having superior outcomes which were clinically significant.There was a statistically significant greater range of median knee flexion in the LISS-R group with compared to the LISS-N group(P=0.0143)and compared with the alternative implant group(P=0.0454).CONCLUSION:The trends towards the benefits of the LISS procedure when correctly applied would suggest that not only should the LISS procedure be performed for distal femur fractures,but the correct principle of insertion is important in improving the patient’s outcome.

Ipsilateral femur and tibia fractures in pediatric patients:A systematic review

AIM To better understand how pediatric floating knee injuries are managed after the wide spread use of new orthopaedic technology.METHODS We searched EMBASE, COCHRANE and MEDLINE computerized literature databases from the earliest date available in the databases to February 2017 using the following search term including variants and pleural counterparts: Pediatric floating knee. All studies were thoroughly reviewed by multiple authors. Reference lists from all articles were scrutinized to identify any additional studies of interest. A final database of individual patients was assembled from the literature. Univariate and multivariate statistical tests were applied to the assembled database to assess differences in outcomes.RESULTS The English language literature contains series with a total of 97 pediatric patients who sustained floating knee injuries. Patients averaged 9.3 years of age and were mostly male(73). Approximately 25% of the fractures were open injuries, more tibia(27) than femur(10). Over 75% of the fractures of both the tibia and the femur involved the diaphysis. More than half(52) of the patients were treated non-operatively for both fractures. As a sequela of the injury 32(33%) patients were left with a limb length discrepancy, 24(25%) patients had lengthening of the injured limb at follow up, while 8(8%) had shortening of the affected limb. Infection developed in 9 patients and 3 had premature physeal closure. Younger patients were more likely to be treated non-operatively(P < 0.001) and patients treated with operative intervention had statistically significant shorter hospital length of stays(P = 0.001).CONCLUSION Given the predominance of non-operative managementin published studies, the available literature is not clinically relevant since the popularization of internal fixation for pediatric long-bone

An Abduction－Traction Frame for the Treatment of Intertrochanteric Fracture of Femur

We present a detailed outline of treatment of intertrochanteric fractures of femur with a new technique on the basis of principles of combined traditional chinese and western medicine. We use pins and an outer fixation frame, which keeps the injured limb in abduction and under traction and at the same time allows for functional exercise of all the joints in the extremity. The procedure is discussed and compared with other different techniques.

Is Distal Femur Locking Plate a Superior Implant in Distal Femur Fracture?

In spite of advances in techniques and improvements in surgical implants, confusion still prevails regarding use of specific implants in distal femur fracture. Fractures in the distal femur have posed considerable therapeutic challenges throughout the history of fracture treatment. Most of these surgical failures were due to inadequate fixation of the fracture fragments. The Aim of the study is to determine whether distal femur locking plates are superior implants than dynamic condylar screw and distal femur nail. A prospective and observational study was done in Department of Orthopaedics and Traumatology, Sri Ramachandra Medical Collage, Chennai between Jan. 2011 and Jan. 2015. Patients with distal femoral fractures, admitted into the hospital, were treated using various modes of internal fixation and followed up over a period of six months to one year and their functional outcome was evaluated. The functional and radiological assessment of patients during follow-up was done using Neer’s criteria. The use of any one of the implant, i.e. distal femur locking plates, dynamic condylar screw or distal femur nailing for internal fixation, depends on the type of fracture and the pre operative planning and intra operate decision of the surgeon. In our study, 38% of fractures treated by Dynamic condylar screw, 72% of fractures treated by distal femur locking plate and 42% of fractures treated by Distal femur supracondylar nail had excellent/satisfactory results. Locking plates had better outcome in both extra-articular and intra-articular group. They also had better outcome in both younger and older age groups.

Total femur replacement with 18 years of follow-up:A case report

BACKGROUND Osteosarcoma is one of the most common primary malignant bone tumors and is more common in adolescents.The femur is the most common site of osteosarcoma,and many patients require total femur replacement.We reviewed the relevant literature and case findings,summarized and analyzed this case in combination with relevant literature,and in doing so improved the understanding of the technology.CASE SUMMARY The case we report was a 15-year-old patient who was admitted to the hospital 15 days after the discovery of a right thigh mass.The diagnosis was osteosarcoma of the right femoral shaft.After completion of neoadjuvant chemotherapy and preoperative preparation,total right femoral resection+artificial total femoral replacement was performed.Then,chemotherapy was continued after surgery.The patient recovered well after treatment,and the function of the affected limb was good.No recurrence,metastasis,prosthesis loosening,dislocation,fracture or other complications were found during 18 years of follow-up.At present,the patient can still work and lives normally.The results of the medium-and longterm follow-up were satisfactory.CONCLUSION Artificial total femur replacement is a feasible limb salvage operation for patients with femoral malignant tumors,and the results of medium-and long-term follow-up are satisfactory.

Comparison of Clinical Effect of PFNA and Internal Fixation with Anatomical Locking Plate of Proximal Femur in Treatment of Intertrochanteric Fracture of Femur

Purpose:To investigate the clinical value of proximal femoral nail antirotation and anatomical locking plate of proximal femur in the treatment of intertrochanteric fracture of femur.Methods:The study group is treated with PFNA internal fixation.The control group is treated by internal fixation with anatomical locking plate of proximal femur.Results:The time of operation,the amount of intraoperative bleeding and the time of fracture healing in the study group are significantly less than those in the control group.The incidence rate of complication in the study group(3.23%)is significantly lower than that in the control group(17.2%).Data comparison shows P<0.05.Conclusion:The curative effect and prognosis for patients with intertrochanteric fracture of femur treated by PFNA internal fixation are more ideal.

Comparison of Concentrations of Lead and Cadmium in Various Parts of The Femur Head in Patients after Arthroplasty of The Hip Joint in Northwest Poland

Abstract Objective To determine the concentrations of lead （Pb） and cadmium （Cd） in three kinds of materials （cartilage, cortical bone, and cancellous bone） of the femur head obtained from patients in the process of operation. Methods Concentrations of Pb and Cd were determined in selected parts of the femur head of 30 patients after total hip arthroplasty, using ICP-AES （atomic absorption spectrophotometry）. Results Pb contained the highest concentration in cortical bone, while Cd did so in cancellous bone. There were statistically significant differences in the concentrations of both elements between the cartilage and cortical bone, and also differences in the concentration of Pb between the cartilage and cancellous bone. There were no significant differences in the concentrations of Pb or Cd between cortical and cancellous bone. Conclusion Comparative studies on toxic metals should take into account both analogous bones and their fragments, as even if they come from the same kind of bones （e.g. femur head）, clear differences exist in concentrations of heavy metals related to the sampling site and type of tissue （cartilage, cortical bone, and cancellous bone）.

Single-legweight limit of fixation model of simple supracondylar fracture of the femur

Postoperative early rehabilitation training for supracondylar fracture of femur aids in accelerating the healing of fractures with shorter recovery periods. Presently, clinical studies on post-operative early weight training are still in the nascent stages. The weight bearing capacity at different healing stages typically depends on clinical experience and there is a lack of standards to quantify the weight that would be conducive to the healing of fractures. In this paper, a 3D geometric model of the femur is obtained using imaging data, a locking plate fixation model of a simple supracondylar fracture of the femur, which considers the angle and spatial direction of the fracture surface, is established, the stress distribution and load transmission mechanism of the fracture fixation model on a single leg standing posture are studied and the weight bearing capacity of a standing single leg at the early stage of fracture is given. This provides the basis for objective quantification of postoperative early weight bearing capacity.