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.

Surgical strategy of the treatment of atypical femoral fractures

The atypical femoral fracture(AFF)has been attracting significant attention because of its increasing incidence;additionally,its treatment is challenging from biological and mechanical aspects.Although surgery is often required to manage complete AFFs,clear guidelines for the surgical treatment of AFFs are currently sparse.We reviewed and described the surgical treatment of AFFs and the surveillance of the contralateral femur.For complete AFFs,cephalomedullary intramedullary nailing spanning the entire length of the femur can be used.Various surgical techniques to overcome the femoral bowing common in AFFs include a lateral entry point,external rotation of the nail,and the use of a nail with a small radius of curvature,or a contralateral nail.In the case of a narrow medullary canal,severe femoral bowing,or pre-existing implants,plate fixation may be considered as an alternative.For incomplete AFFs,prophylactic fixation depends on several risk factors,such as a subtrochanteric location,presence of a radiolucent line,functional pain,and condition of the contralateral femur;the same surgical principles as those in complete AFFs can be applied.Finally,once AFF is diagnosed,clinicians should recognize the increased risk of contralateral AFFs,and close surveillance of the contralateral femur is recommended.

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.

Current concepts in the management of bisphosphonate associated atypical femoral fractures

Bisphosphonates are a class of drugs used as the mainstay of treatment for osteoporosis.Bisphosphonates function by binding to hydroxyapatite,and subsequently targeting osteoclasts by altering their ability to resorb and remodel bone.Whilst aiming to reduce the risk of fragility fractures,bisphosphonates have been associated with atypical insufficiency fractures,specifically in the femur.Atypical femoral fractures occur distal to the lesser trochanter,until the supracondylar flare.There are a number of the differing clinical and radiological features between atypical femoral fractures and osteoporotic femoral fractures,indicating that there is a distinct difference in the respective underlying pathophysiology.At the point of presentation of an atypical femoral fracture,bisphosphonate should be discontinued.This is due to the proposed inhibition of osteoclasts and apoptosis,resulting in impaired callus healing.Conservative management consists primarily of cessation of bisphosphonate therapy and partial weightbearing activity.Nutritional deficiencies should be investigated and appro-priately corrected,most notably dietary calcium and vitamin D.Currently there is no established treatment guidelines for either complete or incomplete fractures.There is agreement in the literature that nonoperative management of bisphosphonate-associated femoral fractures conveys poor outcomes.Currently,the favoured methods of surgical fixation are cephalomedullary nailing and plate fixation.Newer techniques advocate the use of both modalities as it gives the plate advantage of best reducing the fracture and compressing the lateral cortex,with the support of the intramedullary nail to stabilise an atypical fracture with increased ability to load-share,and a reduced bending moment across the fracture site.The evidence suggests that cephalomedullary nailing of the fracture has lower revision rates.However,it is important to appreciate that the anatomical location and patient factors may not always allow for this.Although causation between bisphosphonates and atypical fractures is yet to be demonstrated,there is a growing evidence base to suggest a higher incidence to atypical femoral fractures in patients who take bisphosphonates.As we encounter a growing comorbid elderly population,the prevalence of this fracture-type will likely increase.Therefore,it is imperative clinicians continue to be attentive of atypical femoral fractures and treat them effectively.

Early acute fat embolism syndrome caused by femoral fracture: A case report

BACKGROUND Fat embolism syndrome(FES)is a rare complication caused by the presence of fat particles in the microcirculation,which usually occurs within 12-72 h after trauma.At present,there have been few cases of fat embolism presenting within 3 h after trauma.Here,we report a case of femoral fracture complicated with an acute fat embolism caused by a car accident.CASE SUMMARY A 29-year-old woman with pain,swelling and limited movement of her left lower limb after a car accident was taken by ambulance to our hospital.X-ray examination showed fracture of the middle and lower part of the left femur and fracture of the base of the left fifth metatarsal bone.She was hospitalized and admitted to the orthopedic ward.After the attending doctor performed tibial tubercle bone traction,the patient became confused,followed by respiratory distress.Finally,she was transferred to the intensive care unit.After nearly a month of treatment in the intensive care unit,the patient's cognitive function gradually recovered over 6 mo.CONCLUSION For patients with early traumatic fractures,young emergency physicians and orthopedics should be aware of the possibility of FES.

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.

Length unstable femoral fractures:A misnomer?

BACKGROUND Flexible intramedullary nailing(FIMN)is relatively contraindicated for pediatric length unstable femoral fractures.AIM To evaluate FIMN treatment outcomes for pediatric diaphyseal length unstable femoral fractures in patients aged 5 to 13 years.METHODS This retrospective study includes pediatric patients(age range 5-13 years)who received operative treatment for a diaphyseal femoral fracture at a single institution between 2013 and 2019.Length unstable femur fractures treated with FIMN were compared to treatment with other fixation methods[locked intramedullary nailing(IMN),submuscular plating(SMP),and external fixation]and to length stable fractures treated with FIMN.Exclusion criteria included patients who had an underlying predisposition for fractures(e.g.,pathologic fractures or osteogenesis imperfecta),polytrauma necessitating intensive care unit care and/or extensive management of other injuries,incomplete records,or no follow-up visits.Patients who had a length stable femoral fracture treated with modalities other than FIMN were excluded as well.RESULTS Ninety-five fractures from ninety-two patients were included in the study and consists of three groups.These three groups are length unstable fractures treated with FIMN(n=21),length stable fractures treated with FIMN(n=45),and length unstable fractures treated with either locked IMN,SMP,or external fixator(n=29).P values<0.05 were considered statistically significant.Patient characteristic differences that were statistically significant between the groups,length unstable with FIMN and length unstable with locked IMN,SMP,or external fixator,were average age(7.4 years vs 9.3 years,respectively),estimated blood loss(29.2 mL vs 98 mL,respectively)and body mass(27.8 kg vs 35.1 kg,respectively).All other patient characteristic differences were statistically insignificant.Regarding complications,length unstable with FIMN had 9 total complications while length unstable with locked IMN,SMP,or external fixator had 10.Grouping these complications into minor or major,length unstable with locked IMN,SMP,or external fixator had 6 major complication while length unstable with FIMN had 0 major complications.This difference in major complications was statistically significant.Lastly,when comparing patient characteristics between the groups,length unstable with FIMN and length stable with FIMN,all characteristics were statistically similar except time to weight bearing(39 d vs 29 d respectively).When analyzing complication differences between these two groups(9 total complications,0 major vs 20 total complications,4 major),the complication rates were considered statistically similar.CONCLUSION FIMN is effective for length unstable fractures,having a low rate of complications.FIMN is a suitable option for length stable and length unstable femur fractures alike.

A comparison of three fixations for intertrochanteric femoral fractures in the elderly

Objective To compare the efficacy of 3 internal fixations,locking proximal femoral plate (LPFP),ASI-AN IMHS and InterTAN,for intertrochanteric femoral fractures in elderly patients.Methods A retrospective study was done to analyse

Bipolar hip arthroplasty using conjoined tendon preserving posterior lateral approach in treatment of displaced femoral neck fractures

BACKGROUND Hip fractures account for 23.8%of all fractures in patients over the age of 75 years.More than half of these patients are older than 80 years.Bipolar hemiarthroplasty(BHA)was established as an effective management option for these patients.Various approaches can be used for the BHA procedure.However,there is a high risk of postoperative dislocation.The conjoined tendon-preserving posterior(CPP)lateral approach was introduced to reduce postoperative dislocation rates.AIM To evaluate the effectiveness and safety of the CPP lateral approach for BHA in elderly patients.METHODS We retrospectively analyzed medical data from 80 patients with displaced femoral neck fractures who underwent BHA.The patients were followed up for at least 1 year.Among the 80 patients,57(71.3%)were female.The time to operation averaged 2.3 d(range:1-5 d).The mean age was 80.5 years(range:67-90 years),and the mean body mass index was 24.9 kg/m^(2)(range:17-36 kg/m^(2)).According to the Garden classification,42.5%of patients were typeⅢand 57.5%of patients were typeⅣ.Uncemented bipolar hip prostheses were used for all patients.Torn conjoined tendons,dislocations,and adverse complications during and after surgery were recorded.RESULTS The mean postoperative follow-up time was 15.3 months(range:12-18 months).The average surgery time was 52 min(range:40-70 min)with an average blood loss of 120 mL(range:80-320 mL).The transfusion rate was 10%(8 of 80 patients).The gemellus inferior was torn in 4 patients(5%),while it was difficult to identify in 2 patients(2.5%)during surgery.The posterior capsule was punctured by the fractured femoral neck in 3 patients,but the conjoined tendon and the piriformis tendon remained intact.No patients had stem varus greater than 3 degrees or femoral fracture.There were no patients with stem subsidence more than 5 mm at the last follow-up.No postoperative dislocations were observed throughout the follow-up period.No significance was found between preoperative and postoperative mean Health Service System scores(87.30±2.98 vs 86.10±6.10,t=1.89,P=0.063).CONCLUSION The CPP lateral approach can effectively reduce the incidence of postoperative dislocation without increasing perioperative complications.For surgeons familiar with the posterior lateral approach,there is no need for additional surgical instruments,and it does not increase surgical difficulty.

Complication rates after direct anterior vs posterior approach for hip hemiarthroplasty in elderly individuals with femoral neck fractures

BACKGROUND Dislocation rates after hemiarthroplasty reportedly vary from 1%to 17%.This serious complication is associated with increased morbidity and mortality rates.Approaches to this surgery are still debated,with no consensus regarding the superiority of any single approach.AIM To compare early postoperative complications after implementing the direct anterior and posterior approaches(PL)for hip hemiarthroplasty after femoral neck fractures.METHODS This is a comparative,retrospective,single-center cohort study conducted at a university hospital.Between March 2008 and December 2018,273 patients(a total of 280 hips)underwent bipolar hemiarthroplasties(n=280)for displaced femoral neck fractures using either the PL(n=171)or the minimally invasive direct anterior approach(DAA)(n=109).The choice of approach was related to the surgeons’practices;the implant types were similar and unrelated to the approach.Dislocation rates and other complications were reviewed after a minimum followup of 6 mo.RESULTS Both treatment groups had similarly aged patients(mean age:82 years),sex ratios,patient body mass indexes,and patient comorbidities.Surgical data(surgery delay time,operative time,and blood loss volume)did not differ significantly between the groups.The 30 d mortality rate was higher in the PL group(9.9%)than in the DAA group(3.7%),but the difference was not statistically significant(P=0.052).Among the one-month survivors,a significantly higher rate of dislocation was observed in the PL group(14/154;9.1%)than in the DAA group(0/105;0%)(P=0.002).Of the 14 patients with dislocation,8 underwent revision surgery for recurrent instability(posterior group),and one of them had 2 additional procedures due to a deep infection.The rate of other complications(e.g.,perioperative and early postoperative periprosthetic fractures and infection-related complications)did not differ significantly between the groups.CONCLUSION These findings suggest that the DAA to bipolar hemiarthroplasty for patients with femoral neck fractures is associated with a lower dislocation rate(<1%)than the PL.

Peri-implant femoral fractures:Challenges,outcomes,and proposal of a treatment algorithm

Purpose:Non-prosthetic peri-implant fractures are challenging injuries.Multiple factors must be care-fully evaluated for an adequate therapeutic strategy,such as the state of bone healing,the type of implant,the time and performed personnel of previous surgery,and the stability of fixation.The aim of this study is to propose a rationale for the treatment.Methods:The peri-implant femoral fractures(PIFFs)system,a therapeutic algorithm was developed for the management of all patients presenting a subtype A PIFF,based on the type of the original implant(extra-vs.intra-medulllary),implant length and fracture location.The adequacy and reliability of the proposed algorithm and the fracture healing process were assessed at the last clinical follow-up using the Parker mobility score and radiological assessment,respectively.In addition,all complications were noticed.Continuous variables were expressed as mean and standard deviation,or median and range according to their distribution.Categorical variables were expressed as frequency and percentages.Results:This is a retrospective case series of 33 PIFFs,and the mean post-operative Parker mobility score was(5.60±2.54)points.Five patients(15.1%)achieved complete mobility without aids(9 points)and 1(3.0%)patient was not able to walk.Two other patients(6.1%)were non-ambulatory prior to PPIF.The mean follow-up was(21.51±9.12)months(range 6-48 months).There were 7(21.2%)complications equally distributed between patients managed either with nailing or plating.There were no cases of nonunion or mechanical failure of the original implant.Conclusion:The proposed treatment algorithm shows adequate,reliable and straightforward to assist the orthopaedic trauma surgeon on the difficult decision-making process regarding the management of PIFF occurring in previously healed fractures.In addition,it may become a useful tool to optimize the use of the classification,thus potentially improving the outcomes and minimizing complications.

Subchondral fatigue fracture of the femoral head in young military recruits:Potential risk factors

BACKGROUND Subchondral fatigue fracture of the femoral head(SFFFH)mainly occurs in young military recruits and might be confused with osteonecrosis of the femoral head.However,less research focuses on the risk factor for SFFFH.AIM To evaluate the intrinsic risk factors for SFFFH in young military recruits.METHODS X-ray and magnetic resonance imaging data were used for analysis.Acetabular anteversion of the superior acetabulum,acetabular anteversion of the center of the acetabulum(AVcen),anterior acetabular sector angle(AASA),posterior acetabular sector angle,superior acetabular sector angle,neck-shaft angle(NSA),inferior iliac angle(IIA),and ischiopubic angle were calculated.Then,logistic regression,receiver operating characteristic curve analysis,and independent samples t-test were performed to identify the risk factors for SFFFH.RESULTS Based on the results of logistic regression,age[odds ratio(OR):1.33;95%confidence interval(95%CI):1.12-1.65;P=0.0031]and treatment timing(OR:0.86;95%CI:0.75-0.96;P=0.015)could be considered as the indicators for SFFFH.AVcen(P=0.0334),AASA(P=0.0002),NSA(P=0.0007),and IIA(P=0.0316)were considered to have statistical significance.Further,AVcen(OR:1.41;95%CI:1.04-1.95)and AASA(OR:1.44;95%CI:1.21-1.77),especially AASA(area under curve:66.6%),should be paid much more attention due to the higher OR than other indicators.CONCLUSION We have for the first time unveiled that AASA and age could be key risk factors for SFFFH,which further verifies that deficient anterior coverage of the acetabulum might be the main cause of SFFFH.

Meta-analysis of the clinical efficacy of the Gamma3 nail vs Gamma3U-blade system in the treatment of intertrochanteric fractures

BACKGROUND The traditional Gamma3 nail is a mainstream treatment for femoral intertrochanteric fractures.Literature reports that the Gamma3U-blade system can increase the stability of the Gamma3 nail and reduce complication incidence.However,comparative studies between the Gamma3U-blade and Gamma3 systems are limited;hence,this meta-analysis was performed to explore the clinical efficacy of these two surgical methods.AIM To investigate the clinical efficacy of Gamma3 and Gamma3 U-blade for intertrochanteric fractures.METHODS A computerized search for Chinese and English literature published from 2010 to 2022 was conducted in PubMed,Cochrane,CNKI,Wanfang,and VIP databases.The search keywords were gamma 3,gamma 3 U blade,and intertrochanteric fracture.Additionally,literature tracking was performed on the references of published literature.The data were analyzed using Revman 5.3 software.Two individuals checked the inputs for accuracy.Continuous variables were described using mean difference and standard deviation,and outcome effect sizes were expressed using ratio OR and 95%confidence interval(CI).High heterogeneity was considered at(P<0.05,I2>50%),moderate heterogeneity at I2 from 25%to 50%,and low heterogeneity at(P≥0.05,I2<50%).RESULTS Following a comprehensive literature search,review,and analysis,six articles were selected for inclusion in this study.This selection comprised five articles in English and one in Chinese,with publication years spanning from 2016 to 2022.The study with the largest sample size,conducted by Seungbae in 2021,included a total of 304 cases.Statistical analysis:A total of 1063 patients were included in this meta-analysis.The main outcome indicators were:Surgical time:The Gamma3U blade system had a longer surgical time compared to Gamma3 nails(P=0.006,I2=76%).Tip-apex distance:No statistical significance or heterogeneity was observed(P=0.65,I2=0%).Harris Hip score:No statistical significance was found,and low heterogeneity was detected(P=0.26,I2=22%).Union time:No statistical significance was found,and high heterogeneity was detected(P=0.05,I2=75%).CONCLUSION Our study indicated that the Gamma3 system reduces operative time compared to the Gamma3 U-blade system in treating intertrochanteric fractures.Both surgical methods proved to be safe and effective for this patient group.These findings may offer valuable insights and guidance for future surgical protocols in hip fracture patients.

Should we change our approach to resuscitating victims of femoral fracture?A clinical experience in a busy trauma hospital in Shiraz,Iran

Purpose Traumatic hemorrhagic shock is a life-threatening event worldwide.Severe brain trauma accompanying femoral fractures can trigger inflammatory responses in the body and increase pre-inflammatory cytokines such as TNF-α,IL-1.The primary treatment in these cases is hydration with crystalloids,which has both benefits and complications.The purpose of this study was to investigate the effects of fluid therapy on the hemodynamics,coagulation profiles,and blood gases in such patients.Methods In this cross-sectional study,patients were divided into two groups:femoral fracture group and non-femoral group.The hemodynamic status,coagulation profile,and blood gases of patients in both groups were evaluated upon arrival at the hospital and again 2 h later.Data were analyzed by t-test and ANOVA with repeated data and paired samples t-test.Results A total of 681 trauma patients(605 men and 76 women)participated in this study,including 69(86.3%)men and 11(13.8%)women in femoral fracture group and 536 men(89.2%)and 65 women(10.8%)in non-femoral group.The laboratory parameters were evaluated in response to the equal amount of crystalloid fluid given upon arrival and 2 h later.Blood gases decreased in the fracture group despite fluid therapy(p<0.003),and the coagulation profile worsened although the change was not statistically significant.Conclusion The treatment of multiple-trauma patients with femoral bone fractures should be more concerned with the need for the infusion of vasopressors such as norepinephrine.If there is evidence of clinical shock,excessive crystalloid infusion(limited to 1 L)should be avoided,and blood and blood products should be started as soon as possible.

Efficacy of the femoral neck system in femoral neck fracture treatment in adults: A systematic review and meta-analysis

BACKGROUND Controversy remains around the available choices for the internal fixation of a femoral neck fracture.The femoral neck system(FNS)was developed in 2018 and has been widely applied since then as it can provide rigid fixation stability with less damage to the bone mass around the fracture.However,no systematic reviews and meta-analyses have investigated the efficacy of the FNS in comparison with that of traditional internal fixation in the treatment of femoral fractures.AIM To assess the efficacy of the FNS in comparison with that of cannulated compression screws(CCS)in the treatment of femoral fractures through systematic review and meta-analysis.METHODS Five electronic databases(PubMed,Embase,Cochrane Central Register of Controlled Trials,China National Knowledge Infrastructure,and Wanfang)were searched from the earliest publication date to December 31,2021.Reference Citation Analysis(https://www.referencecitationanalysis.com/)was used to check the results and further analyze the related articles.Controlled trials were included if the FNS was applied for the femoral neck fracture in adults and if it was compared with CCS for the achievement of internal fixation.The measurement outcomes included the required operation time,observed patient’s blood loss,extent of fracture healing,patient’s Harris Hip score(HHS)at the last follow-up,and records of any complications(such as failure of internal fixation,femoral neck shortness,avascular necrosis of the femoral head,and delayed union or nonunion).RESULTS Ten retrospective controlled studies(involving 711 participants)were included in this metaanalysis.The meta-analysis showed that compared with CCS,use of the FNS could not decrease the operation time[standardized mean difference(SMD):-0.38,95%confidence interval(CI):-0.98 to 0.22,P=0.21,I2=93%),but it could increase the intraoperative blood loss(SMD:0.59,95%CI:0.15 to 1.03,P=0.009,I2=81%).The pooled results also showed that compared with CCS,the FNS could better promote fracture healing(SMD:-0.97,95%CI:-1.65 to-0.30,P=0.005,I2=91%),improve the HHS at the last follow-up(SMD:0.76,95%CI:0.31 to 1.21,P=0.0009,I2=84%),and reduce the chances of developing femoral neck shortness(OR:0.29,95%CI:0.14 to 0.61,P=0.001,I2=0%)and delayed union or nonunion(OR:0.47,95%CI:0.30 to 0.73,P=0.001;I2=0%)in adult patients with femoral neck fractures.However,there was no statistically significant difference between the FNS and CCS in terms of failure of internal fixation(OR:0.49,95%CI:0.23 to 1.06,P=0.07,I2=0%)and avascular necrosis of the femoral head(OR:0.46,95%CI:0.20 to 1.10,P=0.08,I2=0%).CONCLUSION Compared with CCS,the FNS could decrease the chances of developing femoral neck shortness and delayed union or nonunion in adults with femoral neck fractures.Simultaneously,it could accelerate fracture healing and improve the HHS in these patients.

Effects of alendronate sodium combined with InterTan on osteoporotic femoral intertrochanteric fractures and fracture recurrence

BACKGROUND Osteoporosis is a global disease affecting 6.6%of the total population.Osteoporosis complications include fractures,increased bone fragility,and reduced bone strength.The most commonly affected parts are the vertebral body,hip,and wrist.AIM To examine the effect of alendronate sodium combined with InterTan for osteoporotic femoral intertrochanteric fractures on bone and fracture recurrence METHODS In total,126 cases of osteoporotic femoral intertrochanteric fractures were selected and divided into two groups according to the 1:1 principle by the simple random method.They were admitted to the Department of Orthopedics,First Affiliated Hospital of Xingtai Medical College,from January 2018 to September 2020.The control group was treated with InterTan fixation combined with placebo,and the observation group with alendronate sodium based on InterTan fixation.Operation-related indicators,complications,and recurrent fractures were compared between the groups.Changes in bone metabolism markers,t value for hip bone mineral density,and Harris Hip Score were observed.RESULTS Operation time,intraoperative blood loss,postoperative ambulation time,and complications were compared between the groups,and no significant difference was found.The fracture healing time was significantly shorter in the observation group than in the control group.β-Collagen-specific sequence(β-CTX)and total aminoterminal propeptide of type I procollagen(T-PINP)in the control group at 3 mo after operation were compared with those before operation,and the difference was not significant.Six months after the operation,theβ-CTX level decreased and T-PINP level increased.β-CTX level at 3 and 6 mo in the observation group after operation was lower,and TPINP level was higher,than that before operation.Compared with the control group,T-PINP level of the observation group was significantly higher andβ-CTX level was significantly lower at 3 and 6 mo after operation.The t value of hip bone mineral density was compared in the control group before and 1 mo after operation,and significant difference was not found.Compared with the control group,the t value of hip bone mineral density in the observation group was significantly higher at 1,3,6,and 12 mo after operation.Compared with the control group,the Harris score of the observation group was significantly higher at 1,3,6,and 12 mo after operation.The recurrence rate of fractures in the observation group within 12 mo was 0.00%,which was significantly lower than 6.35%in the control group.CONCLUSION Alendronate sodium combined with InterTan in the treatment of osteoporotic femoral intertrochanteric fractures can increase bone mineral density,improve hip joint function,promote fracture healing,and reduce fracture recurrence.

Efficacy of fascia iliaca compartment nerve block as part of multimodal analgesia after surgery for femoral bone fracture

BACKGROUND: Fascia iliaca compartment nerve block(FICNB) has been an established technique for postoperative analgesia after surgery for femoral bone fracture. FICNB is technically easy, effective for postoperative pain control after operation for femoral bone fracture and decreases the complications induced by systemic analgesic drugs. The severity of postoperative pain is affected by genetics, cultural and social factors across the world. In this study we assessed the efficacy of fascia iliaca compartment nerve block when it is used as part of multimodal analgesia after surgery for femoral bone fracture.METHODS: An institution-based case control study was conducted from September, 2013 to May, 2014. All patients who had been operated on under spinal anesthesia for femoral bone fracture were included. The patients divided into a FICNB group(n=20) and a control group(n=20). The FICNB group was given 30 mL of 0.25% bupivacaine at the end of the operation. Postoperative pain was assessed within the f irst 24 hours, i.e. at 15 minutes, 2 hours, 6 hours, 12 hours and 24 hours using 100 mm visual analogue scale(VAS), total analgesic consumption, and the time for the f irst analgesic request.RESULTS: VAS pain scores were reduced within the f irst 24 hours after operation in the FICNB group compared wtih the control group. VAS scores at 2 hours were taken as median values(IQR) 0.00(0.00) vs.18.00(30.00), P=0.001; at 6 hours 0.00(0.00) vs. 34.00(20.75), P=0.000; at 24 hours 12.50(10.00) vs. 31.50(20.75), P=0.004; and at 12 hours(17.80±12.45) vs.(29.95±12.40), P=0.004, respectively. The total analgesic consumption of diclofenac at 12 and 24 hours was reduced in the FICNB group, and the time for the fi rst analgesic request was signifi cantly prolonged(417.50 vs. 139.25 minutes, P=0.000).CONCLUSIONS: A single injection for FICNB could lead to postoperative pain relief, reduction of total analgesic consumption and prolonged time for the fi rst analgesic request in the FICNB group after surgery for femoral bone fracture. We recommend FICNB for analgesia after surgery for femoral bone fracture and for patients with femoral bone fracture at the emergency department.

Missed diagnosis of femoral deep artery rupture after femoral shaft fracture: A case report

BACKGROUND Vascular injury is a rare complication of femoral shaft fractures,and rupture of the deep femoral artery is more difficult to diagnose because of its anatomical location and symptoms.Despite its low incidence,deep femoral artery rupture can lead to life-threatening outcomes,such as compartment syndrome,making early identification and diagnosis critical.CASE SUMMARY A 45-year-old male patient was admitted to our hospital due to right lower limb trauma in a car accident,with complaints of severe pain and swelling on his right thigh.X-ray demonstrated a right femoral shaft fracture.During preparation for emergency surgery,his blood pressure and blood oxygen saturation dropped,and sensorimotor function was lost.Computed tomography angiography was performed immediately to confirm the diagnosis of rupture of the deep femoral artery and compartment syndrome,so fasciotomy and vacuum-assisted closure were performed.Rhabdomyolysis took place after the operation and the patient was treated with appropriate electrolyte correction and diuretic therapy.Twenty days after the fasciotomy,treatment with the Hoffman Type II External Fixation System was planned,but it was unable to be immobilized internally based on a new esophageal cancer diagnosis.We kept the external fixation for 1 year,and 3 years of follow-up showed improvement of the patient’s overall conditions and muscle strength.CONCLUSION For patients with thigh swelling,pain,anemia,and unstable vital signs,anterior femoral artery injury should be highly suspected.Once diagnosed,surgical treatment should be performed immediately and complications of artery rupture must be suspected and addressed in time.

Femoral neck stress fracture and medial tibial stress syndrome following high intensity interval training: A case report and review of literature

BACKGROUND Femoral and tibial stress injuries are commonly found in long distance running athletes.Stress fractures have rarely been reported in athletes performing high intensity interval training(HIIT)exercise.The objective of this study was to report a case of a patient who presented with medial tibial stress syndrome and femoral neck stress fracture after performing HIIT exercises.CASE SUMMARY A 26 year old female presented with bilateral medial tibial pain.She had been performing HIIT exercise for 45 min,five times weekly,for a seven month period.Her tibial pain was gradual in onset,and was now severe and worse on exercise,despite six weeks of rest.Magnetic resonance imaging(MRI)revealed bilateral medial tibial stress syndrome.As she was taking norethisterone for birth control,a dual energy X-ray absorbitometry scan was performed which demonstrated normal bone mineral density of her lumbar spine and femoral neck.She was managed conservatively with analgesia and physiotherapy,but continued to exercise against medical advice.She presented again six months later with severe right hip pain.MRI of her right hip demonstrated an incomplete stress fracture of her subtrochanteric region.Her symptoms resolved with strict rest and physiotherapy.CONCLUSION HIIT may cause stress injury of the tibia and femur in young individuals.

Comparative Study between the Elastic Nail versus Hip Spica Cast in Early Treatment of Pediatric Femoral Shaft Fractures

Introduction: Femoral shaft fractures are among the most common pediatric injury, which have the highest incidence among other pediatric fractures, and treatment of them carries a lot of controversies. Aim of the study: To compare the outcome of fixation of femoral shaft fracture by elastic nail with Spica cast. Patient and method: This prospective comparative study was carried out in Sulaimani Teaching Hospital, in the period from the 10th of December 2011 to the 10th of June 2012, for two groups of children whose ages were between 4 - 12 years (average 6.61 years), sustained traumatic femoral shaft fractures with follow-up period of about 6 months. The first group was consisting of 30 children treated by Elastic Intramedullary Nail, while the second group was consisted of 30 children treated by hip Spica. The selection was made on random bases. Results: Age range was between 4 - 12 years and showed male predominance in both groups with ratio of about 2:1 while fracture site showed predominance of the midshaft pattern in both groups. This study showed highly significant deference (P value of 0.001) between the two groups (Spica group of 3 days versus Nail group median of rate 4.5 days) in the admission period. Our sample showed shortening of about 2 cm in 2 case in the Nail group (6.7%) versus 6 cases (20%) in Spica group. We reported 4 cases of wound infection (13.3%) and 4 cases of pin site irritation (13.3%) in nail group. A higher rate of malunion was observed in the Spica group (10 cases more than 10° angulation in coronal plane) while the Nail group reported 2 case more than 10° in coronal plane. The mean operative time for Nail group was 55 minutes while in Spica group was 30 minutes. We reported shorter time to start mobilization and walking with support or independently in the nail group (weight bearing time 7.2 weeks) compared with the Spica casting group (weight bearing time 7.5 weeks). Conclusion: Elastic nail fixation yields better outcome for femoral shaft fracture in form of easier child handling, parent’s satisfaction, and maintaining acceptable fracture alignment.