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.

Application of lesser trochanteric reduction fixator in the treatment of unstable intertrochanteric fractures

BACKGROUND Closed reduction and internal fixation with intramedullary nails has been widely accepted for treating intertrochanteric fractures.AIM To focus on how to avoid displacement of the lesser trochanter in unstable intertrochanteric fractures.METHODS We developed a lesser trochanteric reduction fixator for treating intertrochanteric fractures through fixing the lesser trochanter by combining the loop plate through the fixator after reduction by the reducer.Five patients with intertrochanteric fractures treated with the newly developed lesser trochanteric reduction fixator and loop plate combined with intramedullary nails,and 20 patients with intertrochanteric fractures treated with simple intramedullary nails were selected from December 2020 to March 2021.RESULTS The postoperative Harris hip score was significantly higher in patients treated with the lesser trochanteric reduction fixator than in patients treated without the lesser trochanteric reduction fixator,which indicated that this lesser trochanteric reduction fixator had a positive impact on rehabilitation of the hip joint after surgery and could significantly improve the quality of life of patients.CONCLUSION We fully realize the significance of trochanteric reduction and fixation,namely,reconstruction of structures under pressure,in the treatment of intertrochanteric fractures.As long as the general condition of patients is favorable and they are willing to undergo surgery,fixation of the main fracture end should be performed and the lesser trochanter should be reduced and fixed at the same time.

Effects of surgical treatment modalities on postoperative cognitive function and delirium in elderly patients with extremely unstable hip fractures

BACKGROUND As the perioperative risk of elderly patients with extremely unstable hip fractures(EUHFs)is relatively high and therapeutic effect is not satisfactory,new therapeutic strategies need to be proposed urgently to improve the efficacy and clinical outcomes of such patients.AIM To determine the influence of two surgical treatment modalities on postoperative cognitive function(CF)and delirium in elderly patients with EUHFs.METHODS A total of 60 elderly patients consecutively diagnosed with EUHF between September 2020 and January 2022 in the Chongqing University Three Gorges Hospital were included.Of them,30 patients received conventional treatment(control group;general consultation+fracture type-guided internal fixation),and the other 30 received novel treatment(research group;perioperative multidisciplinary treatment diagnosis and treatment+individualized surgical plan+risk prediction).Information on hip function[Harris hip score(HHS)],perioperative risk of orthopedic surgery[Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity(POSSUM)],CF[Montreal cognitive assessment scale(MoCA)],postoperative delirium[mini-cognitive(Mini-Cog)],adverse events(AEs;internal fixation failure,infection,nonunion,malunion,and postoperative delirium),and clinical indicators[operation time(OT),postoperative hospital length of stay(HLOS),ambulation time,and intraoperative blood loss(IBL)]were collected from both groups for comparative analyses.RESULTS The HHS scores were similar between both groups.The POSSUM score at 6 mo after surgery was significantly lower in the research group compared with the control group,and MoCA and Mini-Cog scores were statistically higher.In addition,the overall postoperative complication rate was significantly lower in the research than in the control group,including reduced OT,postoperative HLOS,ambulation time,and IBL.CONCLUSION The new treatment modality has more clinical advantages over the conventional treatment,such as less IBL,faster functional recovery,more effectively optimized perioperative quality control,improved postoperative CF,mitigated postoperative delirium,and reduced operation-related AEs.

Multi-slice spiral computed tomography in diagnosing unstable pelvic fractures in elderly and effect of less invasive stabilization

BACKGROUND Older people are more likely to experience pelvic fractures than younger people.Multi-slice spiral computed tomography(CT)uses three-dimensional(3D)reconstruction technology to generate 3D images that can clearly demonstrate the 3D space of fractures and detect fractures at a higher rate.AIM To investigate the clinical value of multi-slice spiral CT 3D reconstruction in the diagnosis of unstable pelvic fractures in the elderly as well as the effect of less invasive stabilization.METHODS A total of 86 patients with unstable pelvic fractures treated between March 2016 and March 2019 underwent femoral supracondylar bone traction before surgery.Pelvic radiography and multi-row spiral CT were performed successively once the patient’s vital signs and hemodynamic indices were stable.Secondary processing of the original data was performed to obtain 3D reconstruction images and determine the vertical displacement of the pelvis.After basic or complete reduction,minimally invasive internal fixation using hollow lag screws was performed.The detection rates of fracture location and classification by X-ray and CT reconstruction were compared.Patients were divided into two groups according to the presence or absence of preoperative 3D reconstruction to compare postoperative reduction,wound healing time,fracture healing time,hospitalization time,visual analog scale(VAS)score,poor internal fixation,and functional recovery.RESULTS The diagnostic coincidence rates of X-rays for pubic symphysis,ilium wing,sacroiliac periarticular,and sacral fractures were lower than those of CT reconstruction.The coincidence rate of CT reconstruction in the clinical classification of pelvic fractures was 100%,whereas 11 cases were misdiagnosed by X-ray;the total coincidence rate was 87.21%.The total excellent and good rates of postoperative reduction were significantly higher in the study group than in the control group(P<0.05).The wound healing,fracture healing,and hospitalization times were significantly shorter in the study group than in the control group(P<0.05).The VAS scores decreased in both groups postoperatively and were lower in the study group than in the control group(P<0.05).The total incidence of poor postoperative internal fixation was significantly lower in the study group than in the control group(P<0.05).The overall rate of postoperative functional recovery was significantly higher in the study group than in the control group(P<0.05).CONCLUSION Multi-slice spiral CT has high guiding significance for the diagnosis,classification,and treatment of unstable pelvic fractures in the elderly.Preoperative 3D reconstruction can effectively shorten the operation time and promote fracture healing,while minimally invasive internal fixation can effectively reduce pain and promote functional recovery of fracture sites,making it worthy of clinical application.

Application of proximal femur locking compression plate for unstable four part intertrochanteric fractures

Objective To evaluate the clinical results of proximal femur locking compression plate (LCP) for unstable four-part intertrochanteric femoral fractures.Methods Clinical data of53patients wiith unstable four-part intertrochanteric

External fixator with lumbopelvic distraction spondylodesis for vertically unstable pelvic fracture

Objective To evaluate the clinical outcomes of external fixator with lumbopelvic distraction spondylodesis in treatment of vertically unstable pelvic fractures.Methods From January 2008 to March 2009,9 patients(4 males and 5 females)

External fixation in early treatment of unstable pelvic fractures

Background Patients with pelvic fractures are often treated in hospitals without the capacity to implement an open reduction internal fixation （ORIF）. This often leads to pelvic malunion in patients with unstable pelvic fracture, shock or even death due to uncontrollable pelvic hemorrhage and unstable hemodynamics. This study explored the role of early external fixation （within 7 days） for patients with unstable pelvic fractures. Methods A retrospective analysis was conducted on 32 patients with unstable pelvic fractures treated with early external fixation from January 2005 to January 2010 （Tile type B： 18 cases; C： 14 cases）. The study comprised 28 males and 4 females, with a mean age of （32_＋8） years （range, 21-56 years）. Of these patients, 22 were treated with emergency pelvic external fixation and 10 were treated with external fixation within 1-7 days. Fifteen cases suffered traumatic hemorrhagic shock. A statistical analysis was conducted to compare fluid infusion and blood transfusion volumes within the first 24 hours of these shock patients with another cohort of patients treated without early external fixation from January 1993 to January 1998. Results The average follow-up was （34.7_＋14.6） months （range, 6-66 months）. Six to eight weeks after external fixation, patients could walk with crutches; by 12 weeks, external fixation was removed and all fractures had healed. Seven patients presented with sequelae, including 3 patients with long-term lumbosacral pain, 3 patients with erectile dysfunction and 1 patient with MoreI-Lavallee lesion and other complications. The 15 shock patients in this study （2005-2010 group） required significantly lower volumes of fluid infusion and blood transfusion （Pfluid=0.000; mtransfusion=0.000） as compared to the 1993-1998 cohort. Conclusions The early application of external fixation in unstable pelvic fracture patients positively affects hemodynamic stability, with outstanding efficacy as a final fixation option for unstable pelvic fractures.

Stabilization of unstable pelvic fractures with a novel internal-external fixator

An internal-external fixator for stabilization in three cases with unstable pelvic fractures were reported. Compared with external fixation, the internal-external fixator, which is placed in the subcutaneous layer, decreased the risk of pin-track infection, pin site pain, and bowel obstruction; meanwhile, it had the advantage of external fixation： it was easy to apply, controlled damage, and resulted in minimal injury.

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.

Fibula pro-tibia vs standard locking plate fixation in an ankle fracture saw bone model

BACKGROUND Locking plate fixation in osteoporotic ankle fractures may fail due to cut-out or metalwork failure.Fibula pro-tibia fixation was a technique prior to the advent of locking plates that was used to enhance stability in ankle fractures by achieving tri or tetra-cortical fixation.With locking plates,the strength of this fixation construct can be further enhanced.There is lack of evidence currently on the merits of tibiapro-fibula augmented locking plate fixation of unstable ankle fractures.AIM To assess if there is increased strength to failure,in an ankle fracture saw bone model,with a fibula pro-tibia construct when compared with standard locking plate fixation.METHODS Ten osteoporotic saw bones with simulated supination external rotation injuries were used.Five saw bones were fixed with standard locking plates whilst the other 5 saw bones were fixed with locking plates in a fibula pro-tibia construct.The fibula pro-tibia construct involved fixation with 3 consecutive locking screws applied across 3 cortices proximally from the level of the syndesmosis.All fixations were tested in axial external rotation to failure on an electromagnetic test frame(MTS 858 Mini-Bionix test machine,MTS Corp,Eden Praire,MN,United States).Torque at 30 degrees external rotation,failure torque,and external rotation angle at failure were compared between both groups and statistically analyzed.RESULTS The fibula pro-tibia construct demonstrated a statistically higher torque at 30 degrees external rotation(4.421±0.796 N/m vs 1.451±0.467 N/m;t-test P=0.000),as well as maximum torque at failure(5.079±0.694N/m vs 2.299±0.931 N/m;t-test P=0.001)compared to the standard locking plate construct.The fibula pro-tibia construct also had a lower external rotation angle at failure(54.7±14.5 vs 67.7±22.9).CONCLUSION The fibula pro-tibia locking plate construct demonstrates biomechanical superiority to standard locking plates in fixation of unstable ankle fractures in this saw bone model.There is merit in the use of this construct in patients with unstable osteoporotic ankle fractures as it may aid improved clinical outcomes.

Early results of reverse less invasive stabilization system plating in treating elderly intertrochanteric fractures： a prospective study compared to proximal femoral nail

Background Intertrochanteric femur fracture is common in elderly population. Though multiple treatment options are available, the choice of implant remains controversial. The reverse less invasive stabilization system （LISS） plating was introduced for treatment of a patient with ipsilateral intertrochanteric and midshaft femoral fractures. The aim of this research was to compare such technique to intramedullary nailing （proximal femoral nail, PFN） for intertrochanteric fractures.Methods Fifty-six patients with an age of at least sixty-five years and an AO/OTA type-A1 or A2 fractures were included and divided into LISS and PFN treatment group. Background parameters, fracture and surgery details were documented. Follow-up time was at least 12 months. Radiology, complication, Harris Hip Score and Rapid Disability Rating Score （RDRS） were recorded to evaluate fixation status and hip function for each patient during follow-up.Results There was no significant difference between the two groups in surgical time （（48.0±8.6） minutes, vs.（51.8±10.8） minutes, P=0.3836） and intraoperative blood loss （（149.1±45.1） ml vs. （176.4±25.4） ml, P=0.0712）. The LISS group had less postoperative haemoglobin （Hb） reduction （（10.2±4.5） g/L Hb, vs. （15.1-5.9） g/L Hb, P=0.0475）. There was no complication observed in PFN group. All 31A1 type fracture in LISS group showed 100% maintenance of reduction. One nonunion with locking screw breakage and 2 varus union were found in the LISS group. Postoperative hip function was similar between the two groups.Conclusions Though reverse LISS plating may not be recommended as a routine fixation method for elderly unstable intertrochanteric fractures compared to PFN, it may possibly be reserved for rapid fixation and damage control in polytrauma patients and ORIF of subtrochanteric and reverse oblique intertrochanteric fractures.