ObjectiveTo evaluate the effectiveness of proximal femoral nail anti-rotation (PFNA) in treatment of high plane intertrochanteric femur fractures.MethodsA retrospective analysis was performed on 33 patients who underwent closed reduction and PFNA fixation for high plane intertrochanteric femur fracture between January 2016 and June 2019. There were 12 males and 21 females with an average age of 75.1 years (mean, 47-89 years). The fractures were caused by falling from height in 21 cases, by traffic accident in 7 cases, and by other injuries in 5 cases. Fractures were classified as type A in 14 cases and type B in 19 cases according to self-defined fracture classification criteria; and as type 31-A1.2 in 14 cases and as type 31-A2.2 in 19 cases according to AO/Orthopedic Trauma Association (AO/OTA) classification criteria. The time from injury to operation was 2-5 days (mean, 2.7 days). The operation time, intraoperative blood loss, hospital stay, fracture reduction quality, fracture healing time, internal fixation failure, and Parker-Palmer score were recorded.ResultsThe operation time was 40-75 minutes (mean, 55 minutes). The intraoperative blood loss was 50-150 mL (mean, 64 mL). The hospital stay was 5-15 days (mean, 8.7 days). All incisions healed by first intention. Twenty-eight patients were followed up 12-18 months with an average of 13.6 months. The fracture reduction quality was rated as excellent in 9 cases (32.1%), good in 17 cases (60.7%), and poor in 2 cases (7.1%) by Chang’s criteria. Parker-Palmer score was 6-9 (mean, 7.9) at last follow-up.ConclusionHigh plane intertrochanteric femur fracture is a special type of intertrochanteric fracture, which can be diagnosed by imaging examination. PFNA fixation can achieve satisfactory results and prevent the occurrence of internal fixation failure effectively.
ObjectiveTo compare the effectiveness of long and short proximal femoral nail anti-rotation (PFNA) in the treatment of type A2.3 intertrochanteric fracture of femur (IFF). Methods The clinical data of 54 patients with type A2.3 IFF admitted between January 2020 and December 2022 were retrospectively analyzed. According to the length of PFNA nail used in the operation, they were divided into long nail group (PFNA nail length>240 mm, 24 cases) and short nail group (PFNA nail length≤240 mm, 30 cases). There was no significant difference in baseline data such as gender, age, fracture side, body mass index, and time from fracture to operation between the two groups (P>0.05). The operation time, intraoperative blood loss, intraoperative fluoroscopy frequency, intraoperative reduction quality score, fracture healing, and complications of the two groups were recorded and compared. Harris score was used to evaluate the hip function of patients at 1 year after operation. According to the relationship between the fracture line of type A2.3 IFF and the lesser trochanter, the two groups of patients were divided into type Ⅰ(the fracture line extends to the level of the lesser trochanter), type Ⅱ(the fracture line extends to less than 2 cm below the lesser trochanter), and type Ⅲ (the fracture line extends to more than 2 cm below the lesser trochanter), and the postoperative stability and internal fixator loosening of each subtype were evaluated. Results The operation time, intraoperative blood loss, and intraoperative fluoroscopy frequency in short nail group were significantly less than those in long nail group (P<0.05). There was no significant difference in the intraoperative reduction quality score between the two groups (P>0.05). Patients in both groups were followed up 12-18 months, with an average of 13.5 months. The postoperative stability score of short nail group was significantly lower than that of long nail group (P<0.05). The Harris score in the long nail group was significantly higher than that in the short nail group at 1 year after operation (P<0.05), but there was no significant difference in Harris score grading between the two groups (P>0.05). Complications occurred in 3 cases of the long nail group (including 1 case of coxa varus caused by external nail entry point and 2 cases of loose internal fixator), and 7 cases of the short nail group (including 1 case of coxa varus caused by external nail entry point and 6 cases of loose internal fixator). Neither group had any anterior femoral arch damage, there was no significant difference in the incidence of complications between the two groups (P>0.05). The number of type Ⅲ patients was relatively small and not included in the statistics; there was no significant difference in the postoperative stability score and the incidence of internal fixator loosening between the long and short nail groups in type Ⅰ patients (P>0.05). In type Ⅱ patients, the postoperative stability score and the incidence of internal fixation loosening in the long nail group were significantly better than those in the short nail group (P<0.05).Conclusion Long PFNA fixation for type A2.3 IFF has longer operation time and more intraoperative blood loss, but the overall stability of fracture is better after operation. For type A2.3 IFF with fracture line extending to less than 2 cm below the lesser trochanter, long PFNA is used for fixation, although the surgical trauma is large, but the postoperative stability is better than that of short PFNA; for type A2.3 IFF with fracture line extending to the lesser trochanter, there is no significant difference in postoperative stability between long and short PFNAs.
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 investigate the feasibility and effectiveness of the novel bone hook combined with finger-guided technique in the treatment of irreducible intertrochanteric femoral fractures in elderly. Methods Between January 2021 and August 2023, 23 elderly patients with irreducible intertrochanteric femoral fractures were treated with the novel bone hook combined with finger-guided technique. There were 10 males and 13 females; the age ranged from 68 to 93 years (mean, 76.2 years). The time from injury to operation ranged from 36 to 76 hours (mean, 51.2 hours). According to the classification standard proposed by TONG Dake et al in 2021, there were 10 cases of typeⅠA, 1 case of typeⅠB, 6 cases of type ⅡA, 4 cases of type ⅡB, and 2 cases of type ⅡC. The operation time, intraoperative blood loss, intraoperative fluoroscopy frequences, and quality of fracture reduction were recorded. The fracture healing time and occurrence of postoperative complications were observed during follow-up. At last follow-up, the Harris scoring system was used to evaluate the hip joint function. Results The operation time was 42-95 minutes (mean, 52.1 minutes). The intraoperative blood loss was 40-420 mL (mean, 126.5 mL). Intraoperative fluoroscopy was performed 14-34 times (mean, 20.7 times). According to the criteria proposed by Chang et al, the quality of fracture reduction was rated as good in 20 cases and acceptable in 3 cases. All patients were followed up 6-20 months (mean, 10.2 months). X-ray film showed that all fractures healed with the healing time of 3.0-5.5 months (mean, 4.0 months). At last follow-up, the Harris score of the hip joint ranged from 82 to 97 points (mean, 90.4 points). Among them, 14 cases were rated as excellent and 9 cases as good. No complication such as coxa vara, cutting of the cephalomedullary nail, nail withdrawal, or nail breakage occurred during follow-up. Conclusion The treatment of elderly patients with irreducible intertrochanteric femoral fractures by using the novel bone hook combined with finger-guided technique can achieve high-quality fracture reduction and fixation, and has a good effectiveness.
ObjectiveTo summarize the characteristics of posterior coronal banana-shaped fragments and its research progress in treatment of intertrochanteric femoral fracture with cephalomedullary nail, provide valuable reference for clinical practice. Methods Relevant domestic and foreign literature was extensively reviewed to summarize the history, anatomical structure of posterior coronal banana-shaped fragments, and the need for reduction and fixation, the influence on the stability of cephalomedullary nail, and the remedies. Results The posterior coronal banana-shaped fragments refers to the second level fracture line of the intertrochanteric femoral fracture, involving four anatomical structures, namely, the posterior part of the greater trochanter, the intertrochanteric crest, the lesser trochanter, and the posteromedial cortex. With the wide application of three-dimensional-CT in clinical practice, the posterior coronal banana-shaped fragments were more comprehensively understood. According to whether the anterior extension of the fracture line affects the integrity of the lateral entry of the head and neck implant, the posterior coronal banana-shaped fragments can be divided into small and large ones, of which the large single banana-shaped fragment account for about 20% of the AO/Orthopaedic Trauma Association (AO/OTA) type A2 fractures. If the large fragment involving the posteromedial wall (lesser trochanter) will increase the difficulty of the medial cortical contact reduction; or involving the posterolateral wall and resulting in rupture of the entry portal (type A2.4), which will cause sagittal swing of the nail in the femoral marrow cavity, thereby affecting the stability of the nail. There is no effective technique for reduction and fixation of the banana-shaped fragment nowadays. However, the adverse effects of posterior coronal banana-shaped fragment can be compensated by improving the quality of fracture reduction and choosing high filling cephalomedullary nail. ConclusionThe posterior coronal banana-shaped fragments can easily lead to the rupture of the entry portal of head-neck implants, cause the sagittal swing of the cephalomedulis nail, and then lead to the loss of fracture reduction and affect the treatment effect. Whether the entry portal rupture or not and its risk factors still need further clinical and basic research.
目的:比较人工股骨头置换与骨折内固定治疗高龄股骨转子间骨折的临床疗效。方法:筛选1997年6月至2008年6月间收治的60例高龄新鲜不稳定性股骨转子间骨折患者分为A、B两组。A组为行人工股骨头置换者,B组为行骨折内固定者。A组30例,平均年龄83.6岁;B组30例,平均年龄81.7岁。随访时间8个月～9年(平均2.3年)。结果:两种术式在住院时间和术后引流量的差异无统计学意义(Pgt;0.05);而在手术时间、术中出血量、下地开始行走时间、术后早期并发症、术后内科合并症和髋关节功能恢复、术后1年内死亡率等方面,两组比较差异均有统计学意义(Plt;0.05)。结论:人工股骨头置换术可以作为治疗高龄股骨转子间骨折的一种选择,术后能早期离床负重活动、较快恢复伤前活动能力、降低术后短期并发症和内科合并症的发生率、减低术后一年内死亡率。
ObjectiveTo explore the clinical effect of applying the concept of enhanced recovery after surgery (ERAS) to the perioperative management of elderly patients with intertrochanteric fractures.MethodsThe clinical data of 64 elderly patients with intertrochanteric fractures admitted to West China Hospital of Sichuan University from January 2016 to December 2017 were retrospectively analyzed. Among them, 32 patients admitted from January to December in 2017 were in ERAS group, and 32 patients admitted from January to December 2016 were in control group. The control group used conventional orthopedic perioperative management measures, and the ERAS group combined the ERAS concept on the basis of conventional treatment measures for perioperative management. The incidence of perioperative complications, Visual Analogue Scale score, modified Barthel Index score, inpatient satisfaction and length of hospital stay were compared between the two groups.ResultsThere was no significant difference in age, gender, American Society of Anesthesiologists grade, combined disease, modified Barthel Index or Visual Analogue Scale score at admission, or time from injury to surgery between the two groups (P>0.05). The total incidence of perioperative complications (12.5% vs. 37.5%) and length of hospital stay [(8.09±2.33) vs. (10.41±3.63) d] in the ERAS group were lower than those in the control group (P<0.05). The Visual Analogue Scale scores of the two groups of patients before operation, on the first day and the third day after operation were lower than those at admission (P<0.05). The comparison between the two groups at each time point showed that the Visual Analogue Scale scores of patients in the ERAS group were lower than those in the control group before operation, on the first day and the third day after operation, and the differences were statistically significant (P<0.05). The modified Barthel Index scores of the two groups of patients on the third day, and 1 month, 3 months and 6 months after operation showed a rising trend with time. The modified Barthel Index scores of the ERAS group were better than those of the control group on the third day, and 1 month and 3 months after operation (P<0.05). There was no significant difference between the two groups 6 months after operation (P>0.05). The hospitalization satisfaction score of the ERAS group was 95.56±5.12, which was higher than that of the control group (92.84±5.62), and the difference was statistically significant (P<0.05).ConclusionsThe implementation of ERAS perioperative management for elderly patients with intertrochanteric fractures may reduce the incidence of perioperative complications, relieve patient pain, promote the short-term recovery of activities of daily living of patients, improve the inpatient satisfaction and shorten the length of hospital stay.
ObjectiveTo compare the biomechanical properties between the proximal femoral locking plate and Gamma3 for fixing stable intertrochanteric fracture so as to provide a theoretical basis for selecting internal fixation in the clinical application. MethodsFive pairs of antiseptic femur specimens were selected. Specimens of each pair of matching were randomly divided into groups A and B (n=5). All specimens were made the intertrochanteric fracture of 31A1.1 type according to AO/Association for the Study of Internal Fixation (AO/ASIF) classification. Fracture was fixed with Gamma3 in group A and with proximal femoral locking plate in group B. The axial compression, destruction, and torsion tests were carried out on the mechanical testing machine. ResultsAxial compression test:The load-displacement curve of groups A and B was basically a straight line; axial stiffness of groups A and B was (621.00±36.48) N/mm and (542.55±46.94) N/mm respectively, showing significant difference (t=3.648, P=0.036). Destruction test:The maximum yield load of groups A and B was (4 394.82±450.37) N and (2 987.54±112.14) N respectively, showing significant difference (t=5.433, P=0.032). After loading maximum yield load, femoral fracture occurred again, and internal fixation and bone interface loosening were observed in group A; bending and breaking of proximal locking screw for internal fixation were found in group B, but loosening of internal fixation and bone interface was more obvious in group A than in group B. Torsion test:The torque of specimens in 2 groups increased with the increase of torsion angle (P < 0.05), the torque corresponding to the torsion angle in group B was larger than that in group A, but the difference was not significant (P > 0.05). The torsional stiffness of groups A and B was (1.78±0.16) N·mm/deg and (2.01±0.08) N·mm/deg respectively, showing no significant difference (t=-3.833, P=0.162). ConclusionProximal femoral locking plate and Gamma3 in the treatment of stable intertrochanteric fracture have good biomechanical properties, which can meet the requirements of minimal invasion, strong internal fixation, and early activity.
ObjectiveTo analyze the reasons and the influence of internal fixation about the guide pin eccentricity of helical blade during proximal femoral nail anti-rotation (PFNA) internal fixation for femoral intertrochanteric fractures.MethodsA retrospective analysis of the intraoperative imaging data of 175 patients with femoral intertrochanteric fractures, who underwent closed reduction and PFNA internal fixation between January 2018 and January 2020, was performed. There were 76 males and 99 females with an average age of 79.8 years (mean, 61-103 years). The internal between admission and operation was 12-141 hours (median, 32 hours). According to AO/Orthopaedic Trauma Association (AO/OTA) classification, the fractures were rated as type 31-A1 in 64 cases and type 31-A2 in 111 cases. In the intraoperative fluoroscopy image by C-arm X-ray machine, the caputcollum-diaphysis (CCD) was measured after closed reduction and internal fixation, respectively; the angles between the center line of the head nail hole and the axis of proximal nail and between the axis of guide pin and proximal nail were measured, and the difference between the two angles was evaluated; the quality of fracture reduction was evaluated according to the alignment of the medial cortex, anterior cortex of the head and neck bone block, and femoral shaft cortex; the position of the helical blade in the femoral head was evaluated according to the Cleveland method.ResultsThe CCDs of proximal femur were (134.6±6.8)° after closed reduction and (134.9±4.3)° after internal fixation. There was no significant difference between pre- and post-internal fixation (t=0.432, P=0.766). The angles between the center line of the head nail hole and the axis of proximal nail and between the axis of guide pin and proximal nail were (125.4±2.44)° and (126.3±2.3)°, respectively, showing significant difference (t=2.809, P=0.044). The difference between the two angles was (0.8±2.2)°. The guide pin eccentricity of helical blade occurred in 47 cases. After tapping the helical blade along the eccentric guide pin, 10 cases had fracture reduction loss, and 5 cases had a poor position of the helical blade in the femoral head. ConclusionDuring PFNA internal fixation, a variety of reasons can lead to the eccentric position of the guide pin of helical blade, including unstable fracture, soft tissue inserted, severe osteoporosis, mismatched tool, and fluoroscopic imaging factors. It is possible that the fracture end would be displaced again and the helical blade position may be poor when knocking into the helical blade along the eccentric guide pin. During operation, it should be judged whether the direction of the guide pin needs to be adjusted according to the eccentric angle.