ObjectiveTo summarize the research progress on the evaluation methods of head-neck nail positions in femoral intertrochanteric fractures. Methods The literature about the evaluation methods of head-neck nail positions for femoral intertrochanteric fractures in recent years was extensively reviewed, and research progress in the aspects of evaluation methods, clinical applications, and limitations were summarized. ResultsThe position of head-neck nails in femoral intertrochanteric fractures is closely related to postoperative complications of head-neck nail cutting. Currently, the tip-apex distance (TAD) and femoral head zoning are widely used to evaluate the position of head-neck nails. The main opinion in the literature is that the use of TAD and femoral head zoning can effectively reduce the incidence of head-neck nails cutting. Parker’s ratio, as one of the evaluation methods, has been controversial in subsequent studies and has not been widely used in clinical practice. The TAD as referenced to the calcar (CalTAD), which was modified based on TAD, has been gradually accepted by the clinic, but whether it is better than the TAD has not yet been conclusively determined. In recent years, new evaluation methods have been proposed to supplement the previous evaluation methods, such as the tip-neck distance ratio (TNDR) and the standardized TAD (STAD) to avoid the limitations of the TAD and the CalTAD by the volume of the femoral head, and the axis-blade angle (ABA) to supplement the direction of the head-neck nails channel, but at present the clinical application is relatively underutilized, and the validity of the method needs to be further verified. ConclusionCurrently, there are many methods for evaluating the position of head-neck nails in femoral intertrochanteric fractures, TAD<25 mm combined with head-neck nails placed in the middle-middle quadrant or lower-middle quadrant of the femoral head division is currently a highly recognized assessment in the literature, but the optimal assessment is still controversial, and further research needs to be studied.
ObjectiveTo summarize the application of distal fixated long stem in the treatment of intertrochanteric fracture (ITF) in the sequence of proximal femoral reconstruction, fixation materials, and other details after operation, in order to improve doctor’s attention to the reconstruction of the proximal femur and reduce complications.MethodsThe related literature about the application of distal fixated long stem in the treatment of ITF was extensively reviewed, summarized, and analyzed.ResultsThe sequence of reconstruction is divided into fracture reconstruction priority and prosthesis reconstruction priority. The former is mainly to provide an anatomical reference for the placement of joint prostheses, the latter is mainly to provide support for fracture fixation. The distal fixated cement long stem and cementless long stem have their own characteristics, and materials of reconstruction are used in combination. There is no uniform standard for the sequence and materials of reconstruction.ConclusionAlthough the stability of the distal fixated long stem depends on the distal femur, the accurate reconstruction of the proximal femur is still worthy of attention.
ObjectiveTo investigate the association between the tip apex distance (TAD) and migration of helical blade in the femoral head of geriatric intertrochanteric fractures.MethodsA retrospective study of intertrochanteric fractures treated with the proximal femoral nail antirotation (PFNA) between June 2015 and June 2018 was performed. There were 32 males and 55 females with an average age of 84.7 years (range, 80-101 years). All of them were unilateral fresh closed intertrochanteric fractures caused by low energy injury. According to AO/Orthopaedic Trauma Association (AO/OTA) classification, 33 cases belonged to type 31-A1, 35 cases to type 31-A2, and 19 cases to type 31-A3. The time interval from injury to operation was 1-16 days (mean, 3.7 days). The TAD was measured according to immediate postoperative X-ray films. The cases were divided into two groups: group A with TAD less than 20 mm and group B with TAD greater than 20 mm. The difference of fracture healing and migration of helical blade between the two groups were observed.ResultsAccording to the TAD value immediately after operation, 49 patients in group A had TAD of 8.9-19.7 mm, with an average of 18.6 mm; 38 patients in group B had TAD of 20.1-41.4 mm, with an average of 27.7 mm. The 87 patients were followed up for an average of 11.7 months, ranging from 4 to 28 months. Three cases (all in group B) underwent screw blade cutting and displacement, which resulted in internal fixation failure, including 1 case with femoral head cut upward and 2 cases with femoral head penetrated inward. The remaining 84 cases had bone healing without internal fixation related complications such as fracture of internal fixator and fracture of femoral shaft. There was significant difference in the incidence of internal fixation failure between group A and group B (P=0.049). ConclusionReducing the TAD value of helical blade appropriately (15-20 mm) in PFNA internal fixation for intertrochanteric fracture patients over 80 years old can increase initial stability without increasing the risk of helical blade migration.
ObjectiveTo summarize the evolving concept and research progress on stability reconstruction in the surgical treatment of intertrochanteric fracture.MethodsRelated literature and author’s own experience concerning the surgical treatment of intertrochanteric fracture were reviewed and analyzed in terms of fracture pathoanatomy, stable and unstable pattern, adequate and in-adequate reduction, primary and secondary stability, postoperative stability evaluation, and early weight-bearing.ResultsIntertrochanteric fracture occur at the translational area of cervico-trochanteric junction, which has a nature tendency to varus instability. Fracture reduction quality is the paramount factor and is evaluated by two views, the anteroposterior and lateral Garden alignment and cortex apposition between the head-neck fragment and the femoral shaft. Rather than the posteromedial lesser trochanteric frag ment, the cortical support concept (positive, neutral, negative) emphasizes the reduction of anteromedial cortex to a nonanatomic positive apposition or an " anatomic” neutral apposition in intraoperative fluoroscopy. Postoperative radiographic stability score provides a quantitative assessment for early weight-bearing standing and walking. However, some fractures may lose cortical contact and buttress (negative) during the process of postoperative telescoping and secondary stability. Further studies are needed to elucidate the risk factors such as tilting, swing or rotation of the head-neck fragment, and propose new preventive methods.ConclusionStability reconstruction of intertrochanteric fracture requires adequate fracture reduction with Garden alignment and anteromedial cortical support apposition, and reliable sustainment by internal fixation implants. Early weight-bearing standing and walking is safe in patients with perfect postoperative stability score.
ObjectiveTo investigate the effectiveness and advantages of skeletal tractor in closed reduction and proximal femoral nail antirotation (PFNA) internal fixation of intertrochanteric fracture compared with traction table.MethodsThe clinical data of 86 patients with intertrochanteric fractures, who were treated with closed reduction and PFNA internal fixation between October 2016 and March 2018 and met the selection criteria, was retrospectively analysed. Among them, 44 cases were treated with skeletal tractor (trial group) and 42 cases were treated with traction table (control group). There was no significant difference between the two groups in gender, age, cause of injury, fracture side, AO classification, and degree of osteoporosis (P>0.05). The preoperative position time, operation time, intraoperative fluoroscopy times, intraoperative blood loss, fracture healing time, intraoperative and postoperative complications, and postoperative Harris score were compared between the two groups.ResultsThe operation was successfully completed in both groups. Compared with the control group, the patients in the trial group had shorter preoperative position time and operation time, fewer intraoperative fluoroscopy times, and less intraoperative blood loss (P<0.05). The patients were followed up 12-21 months in trial group (mean, 14.2 months) and 12-22 months in control group (mean, 14.3 months). Venous thrombosis of lower extremity occurred in 8 patients (3 cases of trial group and 5 cases of control group) after operation. Internal fixation failure occurred in 5 patients (2 cases of trial group and 3 cases of control group) during 1 year after operation. All fractures healed except for those with internal fixation failure, the fracture healing time was (11.6±2.9) weeks in trial group and (12.4±3.6) weeks in control group; and there was no significant difference between the two groups (t=1.250, P=0.214). At 1 year after operation, Harris score of the trial group was 86.2±5.9 and that of the control group was 84.1±6.1. There was no significant difference between the two groups (t=1.768, P=0.080).ConclusionCompared with traction table, skeletal tractor in closed reduction and PFNA internal fixation of intertrochanteric fracture can significantly shorten the preoperative position time and operation time, reduce the intraoperative fluoroscopy times, improve the operation efficiency, and have similar effectiveness.
Objective To summarize the new research progress in distal interlocking screws of cephalomedullary nails for the treatment of intertrochanteric fractures. Methods Relevant domestic and foreign literature was extensively reviewed to summarize the static/dynamic types of distal interlocking screw holes, biomechanical studies, clinical studies and application principles, effects on toggling in the cavity, and related complications of distal interlocking screws.ResultsThe mode of the distal interlocking screw holes can be divided into static and dynamic. Distal interlocking screws play the role of anti-rotation, maintaining femur length, resisting compression stress, increasing torque stiffness, resisting varus stress, etc. The number of the screws directly affects the toggling of the main nail in the cavity. At present, regardless of whether long or short nails are used, distal interlocking screws are routinely inserted in clinical practice. However, using distal interlocking screws can significantly increase the duration of anesthesia and operation, increase fluoroscopy exposure time, surgical blood loss, and incision length. There is a trend of trying not to use distal interlocking screws in recent years. No significant difference is found in some studies between the effectiveness of dynamic and static interlocking for AO/Orthopaedic Trauma Association (AO/OTA) 31-A1/2 fractures. At present, the selection of the number and mode of distal interlocking screws is still controversial. When inserting distal interlocking screws, orthopedists should endeavor to minimize the occurrence of complications concerning miss shot, vascular injuries, local stress stimulation, and peri-implant fractures. Conclusion Distal interlocking screws are mainly used to prevent rotation. For stable fractures with intact lateral walls, long cephalomedullary nails can be used without distal interlocking screws. For any type of intertrochanteric fractures, distal interlocking screws are required when using short cephalomedullary nails for fixation. Different interlocking modes, the number of interlocking screws, and the application prospects of absorbable interlocking screws may be future research directions.
Objective To study the anteromedial cortical morphology of intertrochanteric fracture with CT three-dimensional reconstruction technique, and to provide a reference for further study of cortical buttress reduction theory. Methods CT data of 75 patients with unstable intertrochanteric fracture with complete imaging data treated between January 2016 and January 2019 were retrospectively analyzed, including 32 males and 43 females, aged 65-98 years (mean, 79.8 years). According to AO/Orthopaedic Trauma Association typing of 2018 edition, there were 46 cases of 31-A2.2 type and 29 cases of 31-A2.3 type. The image processing techniques such as segmentation modeling and virtual reset were performed. The thickness of the cortex at the anteromedial corner, the angle between the anterior wall fracture line and the coronal horizontal line, the angle between the medial wall fracture line and the sagittal horizontal line, the width of the cortex supported by the medial wall were measured, and the morphology of the cortical bone at the anteromedial corner were observed. Results The angle between the anterior wall fracture line and the coronal horizontal line was 51.8-72.6°, with an average of 62.4°; the angle between the medial wall fracture line and the sagittal horizontal line ranged from 17.6° to –47.3°, with an average of −15.8°; the thickness of the cortex at the anteromedial angle was 3.6-6.1 mm, with an average of 4.4 mm; and the width of the cortex supported by the medial wall was 14.3-21.2 mm, with an average of 16.8 mm. The morphology of the cortical bone at the anteromedial corner had 3 forms: angle with femoral neck axis >90°, 57 cases (76.0%); perpendicular to femoral neck axis, 7 cases (9.3%); angle with femoral neck axis <90° (including reverse angle), 11 cases (14.7%). Conclusion CT three-dimensional reconstruction can clearly show the cortical morphology and the direction of the fracture line of intertrochanteric fracture, which can indicate the stability of the intertrochanteric fracture after reduction, and has a good guiding on the form of cortical buttress reduction.