Watson-Jones Anatomical Approach for Open Reduction and Internal Fixation of Proximal Femoral Fractures without Image Intensifier in a Low-Resource Setting

Introduction: Standard procedures for surgical fixation of proximal femoral fractures (PFF) require an image intensifier which in developing countries remains a luxury. We hypothesized that, with a well-codified technique, the Watson Jones approach (WJA) without image intensifier nor traction table, can allow open reduction and internal fixation (ORIF) of PFF using Dynamic hip screw (DHS), with satisfactory outcome. Patients and methods: Forty one consecutive patients (mean age 59.5 ± 21.6 years, 61% males) who were followed in a Teaching Hospital for PFF treated by ORIF using the WJA and DHS from January 2016 to December 2020 were reassessed. The outcome measures were the quality of the reduction, the positioning of the implants, the tip-apex distance (TAD), the rate and delay of consolidation, the functional results using Postel Merle d’Aubigné (PMA) score, the rate of surgical site infection (SSI) and the overall mortality. Logistic regression was used to determine factors associated with mechanical failure. Results: The mean follow-up period was 33.8 ± 15.0 months. Fracture reduction was good in 31 (75.6%) cases and acceptable in 8(19.5%) cases. Implant position was fair to good in 37 (90.2%) patients. The mean TAD was 26.1 ± 3.9 mm. Three patients developed SSI. Consolidation was achieved in 38 (92.6%) patients. The functional results were good to excellent in 80.5% of patients. The overall mortality rate was 7.3%. There were an association between mechanical failure and osteoporosis (p = 0.04), fracture reduction (p = 0.003), and TAD (p = 0.025). In multivariate logistic regression, no independent factors were predictive of mechanical failure. Conclusion: This study shows that ORIF using DHS for PFF via the Watson-Jones approach without an image intensifier can give satisfactory anatomical and functional outcomes in low-resource settings. It provides and validates a reliable and reproducible technique that deserves to be diffused to surgeons in austere areas over the world.

Does proximal femoral nail antirotation achieve better outcome than previous-generation proximal femoral nail?

BACKGROUND There are few studies in the literature comparing the clinical outcomes and radiographic results of proximal femoral nail(PFN)and proximal femoral nail antirotation(PFNA)for pertrochanteric femoral fracture(PFF)in elderly patients.AIM To evaluate both clinical and radiographic outcomes after fixation with PFN and PFNA in an elderly patient population.METHODS One hundred fifty-eight patients older than 65 years with PFF who underwent fixation with either PFN or PFNA were included.Seventy-three patients underwent fixation with PFN,whereas 85 were fixed with PFNA.The mean follow-up was 2.4 years(range,1-7 years).Clinical outcome was measured in terms of operation time,postoperative function at each follow-up visit,and mortality within one year.Radiographic evaluation included reduction quality after surgery,Cleveland Index,tip-apex distance(TAD),union rate,time to union,and sliding distance of the screw or blade.Complications including nonunion,screw cutout,infection,osteonecrosis of the femoral head,and implant breakage were also investigated.RESULTS Postoperative function was more satisfactory in patients who underwent PFNA than in those who underwent PFN(P=0.033).Radiologically,the sliding difference was greater in PFN than in PFNA patients(6.1 and 3.2 mm,respectively,P=0.036).The rate of screw cutout was higher in the PFN group;eight for PFN(11.0%)and two for PFNA patients(2.4%,P=0.027).There were no differences between the two groups in terms of operation time,mortality rate at one year after the operation,adequacy of reduction,Cleveland Index,TAD,union rate,time to union,nonunion,infection,osteonecrosis,or implant breakage.CONCLUSION Elderly patients with PFF who underwent PFNA using a helical blade demonstrated better clinical and radiographic outcomes as measured by clinical score and sliding distance compared with patients who underwent PFN.

Arthroplasty vs proximal femoral nails for unstable intertrochanteric femoral fractures in elderly patients: a systematic review and metaanalysis

BACKGROUND Proximal femoral nails(PFNs)are the most common method for the treatment of unstable intertrochanteric femoral fractures(IFFs),but postoperative bed rest is required.There is a large amount of blood loss during the operation.Osteoporosis in elderly patients may cause nonunion of fractures and other complications.Arthroplasty can give patients early weight bearing and reduce financial burden,but whether it can replace PFNs remains controversial.AIM To compare the clinical outcomes of arthroplasty and PFNs in the treatment of unstable IFFs in elderly patients.METHODS A search was conducted in the PubMed,Embase,and Cochrane Library databases and included relevant articles comparing arthroplasty and PFN.The search time was limited from January 1,2005 to November 1,2020.Two investigators independently screened studies,extracted data and evaluated the quality according to the inclusion and exclusion criteria.According to the research results,the fixed effect model or random effect model were selected for analysis.The following outcomes were analyzed:Harris Hip score,mortality,complications,operation time,blood loos,hospital stay,weight-bearing time,fracture classification and type of anesthesia.RESULTS We analyzed four randomized controlled trials that met the requirements.A total of 298 patients were included in these studies.According to the AO/OTA classification,there are 20 A1 types,136 A2 types,42 A3 types and 100 unrecorded types.Primary outcome:The Harris Hip Score at the final follow-up of the PFN group was higher[mean difference(MD):9.01,95%confidence interval(CI):16.57 to 1.45),P=0.02].There was no significant difference between the two groups in the rate of overall mortality[risk ratio(RR):1.44,P=0.44]or the number of complications(RR:0.77,P=0.05).Secondary outcomes:blood loss of the arthroplasty group was higher(MD:241.01,95%CI:43.06–438.96,P=0.02);the operation time of the PFN group was shorter(MD:23.12,95%CI:10.46–35.77,P=0.0003);and the length of hospital stay of the arthroplasty group was shorter[MD:0.97,95%CI:1.29 to 0.66),P<0.00001].There was no difference between the two groups in the type of anesthesia(RR:0.99).There were only two studies recording the weight-bearing time,and the time of full weight bearing in the arthroplasty group was significantly earlier.CONCLUSION Compared with PFN,arthroplasty can achieve weight bearing earlier and shorten hospital stay,but it cannot achieve a better clinical outcome.Arthroplasty cannot replace PFNs in the treatment of unstable IFFs in elderly individuals.

Comparative study of intertrochanteric fracture fixation using proximal femoral nail with and without distal interlocking screws

BACKGROUND Intertrochanteric(IT)fracture is one of the most common fractures seen in an orthopaedic practice.Proximal femoral nailing(PFN)is a common modality of fixing IT femur fracture.We retrospectively studied whether a PFN with two proximal lag screws can be done without distal interlocking screws in the 31-A1 and 31-A2 fracture patterns according to the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association(AO/OTA)guidelines for IT femur fractures.AIM To compare the outcomes of IT fractures(AO/OTA 31-A1 and 31-A2)treated by PFN with and without distal interlocking screws.METHODS We carried out a retrospective study of 140 patients in a tertiary care centre who had AO/OTA type 31-A1 and 31-A2 IT fractures.We divided the patients into two groups,in which one of the groups received distal interlocking screws(group 1)and the other group did not(group 2).The subjects were followed up for a mean period of 14 mo and assessed for radiological union time,fracture site collapse,mechanical stability of implant,and complications associated with the PFN with distal interlocking and without distal interlocking.Then,the results were compared.RESULTS PFN without distal interlocking screws has several advantages and gives better results over PFN with distal interlocking screws in the AO/OTA 31-A2 fracture pattern.However,similar results were observed in both groups with the fracture pattern AO/OTA 31-A1.In patients with fracture pattern AO/OTA 31-A2 treated by PFN without distal interlocking screws,there were minimal proximal lockrelated complications and no risk of distal interlock-related complications.The operative time,IITV radiation time and time to radiological union were reduced.These patients also had better rotational alignment of the proximal femur,and the anatomy of the proximal femur was well maintained.It was also noted that in the cases where distal interlocking was performed,there was a gradual decrease in neck shaft angle,which led to varus collapse and failure of bone-implant construct in 21.40%.CONCLUSION In fracture pattern AO/OTA 31-A2,PFN without distal interlocking had better results and less complications than PFN with distal interlocking.

Proximal Femoral Nail in Reverse Trochanteric Femoral Fractures: An Analysis of 53 Cases at One Year Follow-Up

Treatment of reverse oblique trochanteric femoral fractures poses a lot of challenges. There have been proponents of intramedullary devices as well as extramedullary devices. We present the results of proximal femoral nailing surgery performed for reverse obliquity intertrochanteric fractures using two proximal lag screws and a nail of 250 mm. There is prospective study of fifty three patients with AO/OTA 31 A-A3 fractures being treated by proximal femoral nailing in our institute after seeking approval from the Hospital ethics board. The quality of the reduction, the operative time, complications and the functional status of the patients were the parameters on which the results were evaluated. The mean Harris hip score was 76.66 (range 70 - 93) and the mean Barthel activity score was 16.21 (range 12 - 20). The average surgical time was 50 minutes and the mean consolidation time was 11.5 weeks. Intramedullary nailing with proximal femoral nails seems to be a good option in the treatment of reverse obliquity intertrochanteric fractures as against the various existing options available for the management.

Proximal Femoral Nailing: Getting the Trajectory Right

Getting the trajectory of the proximal femoral nail in the right direction is essential to achieve a good result in the technically demanding surgery of proximal femoral fracture. Either an inappropriate starting point or a failure to match the chosen implant’s lateral entry angle may cause coronal plane deformity after trochanteric entry nailing. The lateral view is the critical view for localization of the proper starting point. For the right execution of the surgery, getting the trajectoy right is fully under the control of the surgeon and should always be attempted.

Complex proximal femoral fracture in a young patient followed up for 3 years: A case report

BACKGROUND Ipsilateral femoral neck and intertrochanteric fractures in young patients are extremely rare,and there is no reference for fracture classification and treatment options.CASE SUMMARY We report a 27-year-old male patient who sustained ipsilateral femoral neck and intertrochanteric fractures and was treated with a proximal femoral locking compression plate(PFLCP).The literature on these fractures was also reviewed.At the last follow-up three years after surgery,the patient had no obvious pain in the hip,and the range of motion in the hip joint was slightly limited,but met the normal life and work needs.There were no complications such as necrosis of the femoral head.CONCLUSION The PFLCP can be used to treat these complex proximal femoral fractures,and selection should be based on the patient's specific fractures.

Clinical Outcomes of Artificial Total Hip Arthroplasty for Proximal Femoral Bone Tumors

Objective:To investigate the clinical outcome of artificial hip replacement for proximal femoral bone tumors.Methods:One hundred patients with proximal femur bone tumors admitted to the hospital for treatment from June 2018 to May 2020 were selected and divided into a control group and an experimental group of 50 patients each using central randomization.The control group received conventional treatment and the experimental group underwent artificial total hip arthroplasty,and the results of treatment were compared between the two groups.Results:The operative time and hospitalization time of the experimental group were shorter than that of the control group,and the blood loss was less than that of the control group;after the replacement surgery,the range of flexion and extension,internal and external rotation activity and abduction activity scores were better than those of the control group;and the total incidence of adverse reactions in the experimental group was 6.0%,which was significantly lower than that of the control group(14.0%).By comparing the treatment effects of the two groups,the differentiation was significant,and P<0.05 was statistically significant.Conclusion:Artificial hip arthroplasty can effectively treat proximal femoral tumors,shorten operative time,hospitalization time and intraoperative bleeding,and alleviate patients’therapeutic pain,which has good promotion value in clinical practice.

Treatment of long-segment fracture in middle-up part of femoral shaft with long proximal femoral nail anti-rotation of AO/ASIF

Objective To investigate the operative method and evaluate the clinical outcomes of long proximal femoral nail anti-rotation (PFNA-long) in treating long-segment fracture in middle-up part of femoral bone.Methods From June 2006 to

A comparative analysis of distal locked and unlocked long proximal femoral nail antirotation (PFNA-II) in the fixation of stable intertrochanteric fractures

Purpose:Long proximal femoral nail anti-rotation (PFNA-II) is a preferred implant in recent years for fixation of pertrochanteric fractures,especially in osteoporotic patients.The purpose of this study is to prospectively investigate the effect of distal locking in long PFNA-II fixation of stable intertrochanteric fractures.Methods:A total of 58 patients with isolated stable intertrochanteric fractures and treated in our hospital during the study period of 2017–2019 by distal locked or unlocked long PFNA-II fixation were included in this study.Patients who had multiple injuries or open fractures were excluded.There were 40 female and 18 male patients,with 33 affecting the left side and 25 the right side.Of them,31 belonged to the distal locked group (group A) and 27 to the unlocked group (group B).Surgical procedures and implants used in both groups were similar except for the distal locking of the nails.General data (age,gender,fracture side,etc.) showed no significant difference between two groups (allp > 0.05).The intraoperative parameters like operative time,radiation exposure and follow-up parameters like functional and radiological outcomes were recorded and compared.Statistical tests like the independent samplest-test Fischer’’s exact and Chi-square test were used to analyze association.Results:The distribution of the fractures according to AO/OTA classification and 31A1.2 type of intertrochanteric fractures were most common in our study.All the included fractures united and the average functional outcome in both groups were good and comparable at the end of one year.The operative time (mL,107.1 ± 12.6vs.77.0 ± 12.0,p < 0.001) and radiation exposure (s,78.6 ± 11.0vs.40.3 ± 9.3,p < 0.001) were significantly less among the patients in group B.Fracture consolidation,three months after the operative procedures,was seen in a significantly greater proportion of patients in group B (92.6%vs.67.7%,p = 0.025).Hardware irritation because of distal locking bolt was exclusively seen in group A,however this was not statistically significant (p = 0.241).Conclusion:We conclude that,in fixation of stable intertrochanteric fractures by long PFNA-II nail,distal locking not only increases the operative time and radiation exposure but also delays the fracture consolidation and increases the chances of hardware irritation,and hence is not required.

Medial support nail and proximal femoral nail antirotation in the treatment of reverse obliquity inter-trochanteric fractures(Arbeitsgemeinschaft fur Osteosynthesfrogen/Orthopedic Trauma Association 31-A3.1):a finite-element analysis

Background:The reverse obliquity inter-trochanteric fracture is a distinct fracture pattern that is mechanically different from most inter-trochanteric fractures and the optional treatment of it is still controversial.The purpose of this study was to compare differences in the efficacy of a novel nail(medial support nail[MSN-II])and proximal femoral nail anti-rotation(PFNA-II)in the treatment of reverse obliquity inter-trochanteric fractures(Arbeitsgemeinschaft fur Osteosynthesfrogen/Orthopedic Trauma Association[AO/OTA]31-A3.1)using finite-element analysis.Methods:Modeling software was used to establish a three-dimensional model of MSN-II and PFNA-II and an A3.1 inter-trochanteric fracture model.Abaqus software was used to implement different force loads to compare finite-element biomechanical parameters such as the maximum stress in implant and the displacement of fracture site.Results:The femoral stress,implant stress and fracture site displacement of MSN-II was less than that of PFNA-II.The results indicated that the maximal femoral stress was 581 MPa for PFNA-II and 443 MPa for the MSN-II.The maximum stress values in the PFNA-II and MSN-II models were 291 and 241 MPa,respectively.The maximal displacements of the fracture site were 1.47 and 1.16 mm in the PFNA-II and MSN-II models,respectively.Conclusions:Compared with PFNA-II for inter-trochanteric fracture(AO/OTA 31-A3.1),MSN-II which was designed with a triangular stability structure can provide better biomechanical stability.The MSN-II may be a feasible option for the treatment of reverse obliquity inter-trochanteric fracture.

A rare complication of pelvic perforation by an excessive medial slide of the helical blade after treatment of an intertrochanteric fracture with proximal femoral nail anti-rotation:A case report and literature review

Intertrochanteric fractures have become a severe public health problem in elderly patients.Proximal femoral nail anti-rotation(PFNA)is a commonly used intramedullary fixation device for unstable intertrochanteric fractures.Pelvic perforation by cephalic screw is a rare complication.We reported an 84-year-old female who fell at home and sustained an intertrochanteric fracture.The patient underwent surgery with PFNA as the intramedullary fixation device.Routine postoperative examination revealed medial migration of the helical blade that eventually caused pelvic perforation.We performed a cemented total hip arthroplasty as the savage procedure.At the latest follow-up of 12 months after total hip arthroplasty,the patient had no pain or loosening of the prosthesis in the left hip.Pelvic perforation should be considered when choosing PFNA as the intramedullary fixation device,especially in patients with severe osteoporosis wherein the helical blade can be easily inserted during the operation.The lack of devices to avoid oversliding of the helical blade in PFNA is an unreported cause of this complication and should be considered in such cases.

Treatment of Pathological Fractures of the Proximal Femur Due to Advanced Metastasis of Highly Malignant Tumors: A Clinical Controlled Study of Enterostenosis Reconstruction and Conservative Treatment

Objective: To investigate whether different treatment methods have an impact on the quality of life and life span after fracture of patients with proximal femoral pathological fractures caused by advanced metastasis of highly malignant tumors. Methods: Karnofsky performance status (KPS) and visual analogue score (VAS) were counted at the time of admission and 2 months after the treatments. Survival analysis was implemented to compare the median survival time and 6-month survival rate of the 2 groups. Musculoskeletal score (MSTS) was used to evaluate limb function in the surgical group at 2 months after the treatment. Results: There was no significant difference in KPS score and VAS score between the two groups at the time of admission (p > 0.05). At 2 months after treatment, the KPS score of the surgical group was higher than that of the conservative group (P < 0.05), and the VAS score of the survivors of the surgical group was lower than that of the conservative group (P < 0.05). Survival analysis showed that the median survival time and 6-month survival rate after fracture in the surgical group were higher than those in the conservative group (P < 0.05). After 2 months of treatment, the average MTST score of survivors in the surgical group was 20.38 ± 0.9 (16 - 26 points). Conclusion: Surgical intervention can benefit patients with pathological fractures of the proximal femur due to metastasis of highly malignant tumors in terms of quality of life and survival. Local tumor resection and endoparasitic replacement, which can be tolerated by most patients, can effectively reconstruct the limb function of these patients and restore their self-care ability.

PFNA2 versus 95 Degree Condylar Blade Plate in the Management of Unstable Trochanteric Fractures

Purpose: The proximal femoral nail anti-rotation (PFNA) is known to have advantages in enhancing the anchorage ability of internal fixation in elderly unstable osteoporotic intertrochanteric fracture patients. However whether it is superior to condylar blade fixation is not clear. This study aimed to determine which treatment has better clinical outcomes in older patients. Materials and Methods: A total of 86 patients over the age of 60 with unstable trochanteric fractures within the past 3 weeks, were included in this prospective study conducted from June 1, 2018, to May 31, 2021. All the intertrochanteric fractures were classified according to AO/OTA classification. Among them, 44 cases were treated with the Proximal Femoral Nail (PFNA2) with or without an augmentation screw, and 42 cases were treated with the Condylar Blade Plate. In addition, the operative time, intraoperative blood loss, intraoperative and postoperative blood transfusion, postoperative weight-bearing time, hospitalization time, Harris score of hip function, Kyle’s criteria and postoperative complications were compared between the two groups. Results: The mean duration of surgery for the PFN group was 66.8 minutes (on average), whereas for the condylar blade plate group, it was 99.30 minutes (on average). The PFNA2 group experienced less blood loss (average of 80 mL) compared to the condylar blade plate group (average of 120 mL). Union and partial weight-bearing occurred earlier in the PFNA2 group (14.1 weeks and 10.6 weeks, respectively) compared to the Condylar blade plate group (18.7 weeks and 15.8 weeks). In two patients from the PFNA2 group, screw backing out and varus collapse complications were encountered;however, these patients remained asymptomatic and did not require revision surgery. In two other patients, screw cut out and breakage of the nail at the helical screw hole leading to non-union of the proximal femur were observed during the nine-month follow-up, necessitating revision surgery with prosthetic replacement. Among the condylar blade plate group, three patients experienced complications, including blade breakage at the blade and plate junction. In two cases, the fracture united in varus, and in one case, the blade cut through, resulting in non-union of the femoral head, which required revision surgery. According to the Harris hip score and Kyle’s criteria, a good-excellent outcome was observed in 92.85% of cases in the PFNA2 group and 90.90% of cases in the condylar blade plate group. Conclusion: Both the Proximal Femoral Nail A2 and Condylar blade plate are effective implants for the treatment of unstable trochanteric fractures. The intramedullary implant promotes biological healing and allows for early ambulation with minimal complications. Similarly satisfactory restoration of anatomy and favorable radiological and functional results can be achieved with the biological fixation provided by the 95-degree condylar blade plate. However, the use of PFNA2 internal fixation technique has the advantage of less trauma in elderly patients than the 95-degree condylar blade plate.

Outcome of buttress plate-nail construct used for reconstruction of broken lateral wall in intertrochanteric fractures

Purpose:Intramedullary implants are well accepted fixation of all types of intertrochanteric(IT)frac-tures,both stable and unstable types.Intramedullary nails have an ability to effectively support the posteromedial part,but fail to buttress the broken lateral wall requiring lateral augmentation.The aim of this study was to evaluate the outcome of proximal femoral nail augmented with trochanteric buttress plate for broken lateral wall with IT fractures,which was fixed to the femur through hip screw and anti-rotation screw nail.Methods:Of 30 patients,20 had Jensen-Evan typeⅢand 10 had type V fractures.Patients with IT fracture of broken lateral wall and aged more than 18 years,in whom satisfactory reduction was achieved by closed methods,were included in the study.Patients with pathologic or open fractures,polytrauma,prior hip surgery,non-ambulatory prior to surgery,and those who refused to participate were excluded.The operative time,blood loss,radiation exposure,quality of reduction,functional outcome,and union time were evaluated.All data were coded and recorded in Microsoft Excel spread sheet program.SPSS 20.0 was used for data analysis and normality of the continuous data was checked using Kolmogorv Smirnov test.Results:The mean age of patients in the study was 60.3 years.The mean duration of surgery(min),mean intra-operative blood loss(mL)and mean number of exposures were 91.86±12.8(range 70-122),144.8±3.6(range 116-208),and 56.6(range 38-112),respectively.The mean union time was 11.6 weeks and the mean Harris hip score was 94.1.Conclusion:Lateral trochanteric wall in IT fractures is significantly important,and needs to be recon-structed adequately.Nail-plate construct of trochanteric buttress plate fixed with hip screw and anti-rotation screw of proximal femoral nail can be successfully used to augment,fix or buttress the lateral trochanteric wall giving excellent to good results of early union and reduction.