Objective To investigate the treatment method of senile patients with femoral intertrochanteric fractures and its cl inical outcomes. Methods From January 2005 to December 2007, 192 senile patients with femoral intertrochanteric fractures were treated, including 85 males and 107 females aged 65-92 years old (average 75 years old). The injury was causedby fall on walking in 106 cases, fall when riding a bicycle in 55 cases, and traffic accidents in 31 cases. According to Evans classification, there were 12 cases of type I A, 43 cases of type I B, 29 cases of type II, 24 cases of type III A, 23 cases of type III B, 26 cases of type IV, and 35 cases of type V. One hundred and fifty patients were associated with cardio-cerebrovascular diseases, 120 patients were compl icated with chronicle hypertension, 90 cases were associated with bronchitis, and 75 cases were compl icated with diabetes. The time from injury to hospital admission was 1 hour to 14 days. Among those patients, 108 were treated with conservative treatment, 68 received dynamic hip screw (DHS) fixation, and 16 underwent proximal femoral Gamma nail fixation. Results All the patients were followed up for 12-36 months (average 18 months). The fracture all reached bone union without occurrence of nonunion and delayed union. Patients could take care of themselves, and there were no occurrences of serious pains and dysfunctions. The therapeutic effect was satisfactory. The conservative treatment group: the average hospital stay length was 48 days; the average bone heal ing time was 14 weeks; 23 cases had different degrees of coxa adducta; Harris score system was adopted to evaluate hip joint function, 45 cases were graded as excellent, 31 as good, 10 as fair, and 22 as poor, and the excellent and good rate was 70.4%. DHS internal fixation group: the average operation time was 60 minutes; the average bleeding volume during operation was 200 mL, the average hospital stay length was 24 days; the average bone heal ing time after operation was 12 weeks; Harris score system was adopted to evaluate the injured hip joint function, 38 cases were graded as excellent, 21 as good, 8 as fair, and 1 as poor, and the excellent and good rate was 86.8%. Gamma nailfixation group: the average operation time was 70 minutes; the average bleeding volume during operation was 200 mL, the average hospital stay length was 14 days; the average bone heal ing time after operation was 12 weeks; Harris score system was adopted to evaluate the injured hip joint function, 11 cases were graded as excellent, 4 as good, 1 as fair, and the excellent and good rate was 93.8%. Conclusion For geriatric femoral intertrochanteric fractures, operative treatment should be performed, the preoperative preparation should be sufficient, and individual-oriented treatment method should be selected on the basis of physical conditions of patients and the types of fractures.
ObjectiveTo investigate the morphology of coronal femoral intertrochanteric fracture and its effect on reduction and internal fixation.MethodsThe clinical and imaging data of 46 patients with femoral intertrochanteric fracture who met the selection criteria between August 2017 and October 2018 were reviewed. There were 15 males and 31 females; the age ranged from 62 to 91 years, with an average of 72.8 years. The causes of injury included walking falls in 35 cases, falling out of bed in 4 cases, and traffic accidents in 7 cases. The AO/Orthopaedic Trauma Association classification was type 31-A1 in 11 cases and type 31-A2 in 35 cases. All patients underwent closed reduction and internal fixation with intramedullary nails. During the operation, fracture reduction and fixation were performed according to the preoperative evaluation results. According to the patients’ preoperative X-ray film and CT three-dimensional reconstruction images, the direction of the coronal fracture line of the femoral intertrochanter and the morphological characteristics of the fracture block were observed; and the coronal fracture discrimination analysis was carried out for the fractures of different AO/OTA types. The percentages of coronal femoral intertrochanteric fractures diagnosed by preoperative X-ray film and CT three-dimensional reconstruction were calculated and statistically analyzed. The fracture reduction, the position of internal fixation [measurement of tip-apex distance (TAD)]. and the reliability of internal fixation were observed after operation.ResultsX-ray film was not easy to identify coronary fracture, and the coronal fracture line and the shape of the fracture piece weree clearly visible in CT three-dimensional reconstruction images. The morphological characteristics of the coronary fracture block: in AO/OTA 31-A1 type, the fracture line extended obliquely backward from the anterior tip of the large rotor, above the small rotor with or without small rotor fracture; in AO/OTA 31-A2 type, fracture line extended obliquely backward from the anterior tip of the large rotor to below the small rotor. Thirteen cases (28.3%) of coronal fractures were found on preoperative X-ray films, and 35 cases (76.1%) were found by CT three-dimensional reconstruction, showing significant difference (χ2=21.083, P=0.000). In AO/OTA 31-A1 type patients, the proportion of coronal fractures found by X-ray film and CT three-dimensional reconstruction was 18.2% (2/11) and 54.5% (6/11), respectively, and that in AO/OTA 31-A2 type patients was 31.4% (11/35) and 82.9% (29/35), respectively, showing significant differences (χ2=3.143, P=0.000; χ2=20.902, P=0.000). Among the 35 patients with coronal fractures, 6 cases (17.1%) of AO/OTA 31-A1 type, 29 cases (82.9%) of AO/OTA 31-A2 type. The operation time of the patient was 80-112 minutes, with an average of 95 minutes; the intraoperative blood loss was 180-450 mL, with an average of 360 mL. There was no complication such as infection, falling pneumonia, and deep vein thrombosis of the lower extremities. At 3 days after operation, the internal fixators were all in the proper position. The TAD was 0.9-1.8 cm, with an average of 1.4 cm. All patients were followed up 14-18 months, with an average of 16 months. All the fractures healed osseously, and there was no complication such as nonunion and loosening of internal fixation.ConclusionCT three-dimensional reconstruction can better identify coronal femoral intertrochanteric fractures than X-ray films, and accurately recognize and analyze the incidence and morphological characteristics of coronal fractures, which can help formulate more effective surgical strategies to promote patient recovery.
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 compare the effectiveness of proximal femoral nail anti-rotation (PFNA) between in the supine "scissors" position and in the lithotomy position for treating femoral intertrochanteric fractures of old patients. MethodsA retrospective study was performed on 58 patients with femoral intertrochanteric fractures treated with PFNA between January 2013 and January 2015. Fracture was treated with PFNA in the lithotomy position in 28 cases (group A) and in the supine "scissors" position in 30 cases (group B). There was no significant difference in gender, age, side, cause of injury, fracture type, and interval from injury to operation between 2 groups (P>0.05). The incision length, operation time, perspective times, intraoperative blood loss, complications, and fracture healing time were recorded; Harris hip score was used to access the effectiveness. ResultsThe wound healed by first intention without infection, pressure sores, deep vein thrombosis of lower extremity, and other complications. There was no significant difference in incision length between 2 groups (t=1.313, P=0.212). Group B was significantly better than group A in operation time, perspective times, and intraoperative blood loss (P<0.05). All patients were followed up 10-31 months (mean, 15.3 months). Stretch injury at normal side and perineal discomfort occurred in 1 case and 5 cases of group A respectively, and no nonunion and other complications was observed in the other patients. There was no significant difference in fracture healing time and Harris hip score at last follow-up between 2 groups (P>0.05). ConclusionPFNA in the supine "scissors" position has exact effectiveness and advantages of shorter operation time, less intraoperative blood loss, less perspective times, and fewer complications.
ObjectiveTo design a new type of short femoral intertrochanteric nail (FITN) with anterior curvature (19.5 cm in length and 120 cm in radius) and observe the geometric match with medullary cavity of the femur. MethodsBetween November 2015 and June 2016, 25 geriatric patients with femoral intertrochanteric fractures were treated with the newly designed FITN. There were 7 males and 18 females with an average age of 82.3 years (range, 65-94 years). According to AO/OTA fracture classification, 3 cases were rated as A1.2, 2 cases as A1.3, 5 cases as A2.1, 8 cases as A2.2, and 7 cases as A2.3. The interval between injury and operation was 3.2 days (range, 2-7 days). Postoperatively, the nail entry point position (anterior, central, and posterior) on sagittal plane, the nail tip position (6-grade scale) and the nail tail level (3-grade scale) were measured using fluoroscopy and X-ray films to evaluate the geometric match of the nail with medullary cavity of the femur. ResultsOne patient with Parkinson disease died of asphyxia and pulmonary infection. The other 24 patients were followed up 1-8 months (mean, 4 months). Fracture union time was 6-10 weeks (mean, 8 weeks). The mean Parker-Palmer mobility score was 5.5 (range, 4-8). No patient had hip-thigh pain. The nail entry point was positioned anterior in 2 cases (8%), central in 18 cases (72%), and posterior in 5 cases (20%). The distal nail tip located at the central canal axis (grade 0) in 15 cases (60%), at anterior without contact with the anterior inner cortex (grade 1) in 8 cases (32%), at posterior (grade -1) in 1 case (4%), and at anterior with slight nail-tip impingement with the anterior cortex (grade 2) in 1 case (4%). The proximal nail tail level did not protrude out beyond the greater trochanter (grade 0) in 13 cases (52%), protruded out less than 5 mm (grade 1) in 9 cases (36%), and more than 5 mm (grade 2) in 3 cases (12%). ConclusionThe newly designed FITN has a good geometric match with the femur medullary canal in Chinese population, which may reduce the nail related complications.
ObjectiveTo formulate the classification criteria of femoral intertrochanteric fractures based on irreducibility or not in order to predict the difficulty of fracture recovery.MethodsA clinical data of 244 patients with closed femoral intertrochanteric fractures admitted between January 2017 and March 2020 was retrospectively analyzed. There were 116 males and 128 females with an average age of 77.9 years (range, 45-100 years). The cause of injury included falling in 190 cases, traffic accident in 36 cases, smashing in 13 cases, and falling from height in 5 cases. The time from injury to operation was 1-14 days (mean, 3.6 days). According toAO/Orthopaedic Trauma Association (AO/OTA) classification, the fractures were classified as type 31-A1 in 38 cases, type 31-A2 in 160 cases, and type 31-A3 in 46 cases. According to whether the recovery difficulty occurred after intraoperative closed traction reset, the patients were divided into reducible-group and irreducible-group; combined with the literature and preoperative imaging data of two groups, the classification criteria of femoral intertrochanteric fractures was formulated based on the irreducibility or not. The 244 fractures were classified by the doctors who did not attend the operation according to the classification criteria, predicted the difficulty of fracture reduction, and compared with the actual intraoperative reduction situation.ResultsThe 244 patients were divided into reducible-group (n=164, 67.21%) and irreducible-group (n=80, 32.79%) according to the intraoperative difficulty of reduction. Comparing the imaging data and characteristics of the two groups, and formulating the classification criteria of femoral intertrochanteric fractures based on irreducibility or not, the fractures were mainly divided into two categories of irreducibility and reducibility. The fractures of irreducibility category was divided into typesⅠ-Ⅴ, among which type Ⅲ was divided into subtypes 1-4; the fractures of reducibility category was divided into typesⅠand Ⅱ. Compared with the actual intraoperative evaluation results, the total accuracy rate of the doctors who did not attend the operation was 81.15% (198/244) based on the classification criteria of femoral intertrochanteric fractures. The accuracy rate of irreducibility category was 65.74% (71/108), and the reducibility category was 93.38% (127/136). All patients were followed up 13-25 months, with an average of 17.6 months. All fractures healed except 2 cases died of infection.ConclusionThe classification criteria of femoral intertrochanteric fractures based on irreducibility or not can accurately predict the reducible cases preoperatively, and most of the irreducible cases can be correctly predicted in a wider way. But the classification criteria still need to be further improved and supplemented.
Objective To summarize the morphological characteristics of sagittal beak-like deformity of head-neck fragment in femoral intertrochanteric fractures and to investigate the technical skills in fracture reduction. Methods A clinical data of 31 patients with femoral intertrochanteric fractures between May 2021 and April 2023 was retrospectively analyzed. The fractures had sagittal beak-like deformity of head-neck fragment in all patients. There were 13 males and 18 females, with an average age of 76.2 years (range, 68-83 years). The time from injury to operation was 36-76 hours (mean, 51.2 hours). Fractures were classified as type A1.2 in 10 cases, type A1.3 in 11 cases, type A2.2 in 6 cases, and type A2.3 in 4 cases according to the AO/Orthopaedic Trauma Association (AO/OTA)-2018 classification; and as type A1.3 in 10 cases, type A2.1 in 11 cases, type A2.2 in 6 cases, type A2.3 in 2 cases, and type A2.4 in 2 cases according to a novel comprehensive classification for femoral intertrochanteric fractures proposed by the “Elderly Hip Fracture” Research Group of the Reparative and Reconstructive Surgery Committee of the Chinese Rehabilitation Medical Association. Based on preoperative X-ray films, CT scan and three-dimensional reconstruction, the fractures were classified into two types: type 1 (14 cases), with uncomplicated fracture morphology, severe bone interlocking and (or) soft tissue incarceration; type 2 (17 cases), with severe fracture crushing, obvious dissociation between bone blocks, and severe soft tissue hinge destruction. After the failure of the closed reduction, all patients underwent fracture reduction assisted with instrument via anterior minimal incision and proximal femoral nail antirotation nails internal fixation. The operation time, intraoperative fluoroscopy, intraoperative visible blood loss, length of hospital stay, and incidence of complications were recorded. The fracture reduction quality and stability score were assessed at immediate after operation under fluoroscopy. The fracture healing was evaluated and healing time was recorded by X-ray films. The pain visual analogue scale (VAS) score was performed at 48 hours after operation and Parker-Palmer activity score at 3 months after operation for function evaluation. ResultsThe operation time was 39-58 minutes (mean, 46.3 minutes); fluoroscopy was performed 13-38 times (mean, 23.5 times) during operation; the intraoperative visible blood loss was 45-90 mL (mean, 65.3 mL). The fracture reduction quality and stability score were rated as good in 29 cases and acceptable in 2 cases. The pain VAS score was 2-6 (mean, 3.1) at 48 hours after operation. Eleven patients developed deep vein thrombosis of the lower limbs after operation. Patients were hospitalized for 6-10 days (mean, 7.3 days). All patients were followed up 5-8 months (mean, 6.5 months). All fractures healed at 3.5-8.0 months after operation (mean, 4.5 months). Parker-Palmer activity score at 3 months after operation was 9 in 28 cases and 6 in 3 cases. Conclusion The femoral intertrochanteric fracture with sagittal beak-like deformity of head-neck fragment is difficult to manually reduce. The pin combined with cannulated screw insertion to the neck cortex can hold the fragment and assist fracture reduction, which is a simple and effective technique.
ObjectiveTo investigate the efficacy and safety of intravenous combined with topical administration of tranexamic acid (TXA) in reducing blood loss after intramedullary fixation of intertrochanteric femoral fractures by a prospective controlled trial.MethodsPatients with intertrochanteric femoral fractures, who were admitted for intramedullary fixation between June 2015 and July 2019, were selected as the study subjects, 120 of whom met the selection criteria. The patients were randomly assigned to 3 groups: intravenous administration group (group A, 41 cases), topical administration group (group B, 40 cases), and combined administrations group (group C, 39 cases). In group A, 4 patients occurred deep vein thrombosis of lower extremity before operation, 1 patient died of myocardial infarction on the 5th day after operation, and 1 patient developed severe pulmonary infection after operation. In group B, 2 patients occurred deep vein thrombosis of lower extremity before operation and 1 patient had iatrogenic fracture during operation. In group C, 3 patients occurred deep vein thrombosis of lower extremity before operation and 1 patient developed pulmonary infection before operation and gave up surgical treatment. All the above patients were excluded from the study, and the remaining 107 cases were included in the analysis, including 35, 37, and 35 cases in groups A, B, and C, respectively. There was no significant difference in gender, age, height, body mass, injury cause, fracture side and type, the interval between injury and operation, and preoperative hemoglobin (Hb), hematocrit between groups (P>0.05). Intraoperative TXA (15 mg/kg) was injected intravenously in group A at 30 minutes before operation, and 1 g of TXA was injected into the medullary cavity in group B after the proximal femur was grooted and before the intramedullary nail implantation, respectively. TXA was given in group C before and during operation according to the administration methods and dosage of groups A and B. Total blood loss, maximum Hb decrease, blood transfusion rate, operation time, fracture healing time, and the incidence of complications were recorded and compared between groups. The hip joint function were evaluated by Harris score. ResultsThere was no significant difference in operation time between groups (P>0.05). The total blood loss, the maximum Hb decrease, and the blood transfusion rate in group B were the highest, followed by group A and group C, and the differences between groups were significant (P<0.05). No incision infection or pulmonary embolism occurred in the 3 groups after operation. The incidence of anemia in group C was significantly lower than that in groups A and B, the difference was significant (P<0.05). There was no significant difference in the incidence of subcutaneous hematoma, aseptic exudation, and deep vein thrombosis of lower extremity between groups (P>0.05). All patients in the 3 groups were followed up 8-35 months, with an average of 16.2 months. The fracture healing time of groups A, B, and C was (6.12±1.78), (5.89±1.63), and (5.94±1.69) months, respectively, and there was no significant difference between groups (P>0.05). At last follow-up, the Harris scores of the hip joints in groups A, B, and C were 83.18±7.76, 84.23±8.01, and 85.43±8.34, and the difference was not significant (P>0.05). ConclusionPreoperative intravenous injection combined with intraoperative topical application of TXA can effectively reduce blood loss and blood transfusion after intramedullary fixation of femoral intertrochanteric fracture, without increasing the risk of deep vein thrombosis, and the efficacy is better than that of intravenous injection or topical administration.
Objective To investigate the feasibility and effectiveness of precise-guided temporary fixation assistive devices in assisting the main nail guide pin placement and precise temporary fixation in proximal femoral nail antirotation (PFNA) internal fixation of femoral intertrochanteric fractures. Methods A prospective randomized controlled study was conducted to analyze the clinical data of 60 patients with femoral intertrochanteric fractures over 65 years old who met the selection criteria between January 2020 and June 2022 and were treated with PFNA internal fixation. The patients were randomly divided into the trial group (auxiliary device guided main nail guide pin placement and temporary fixation) and the control group (conventional treatment), with 30 cases in each group. There was no significant difference in baseline data such as gender, age, cause of injury, time from injury to operation, fracture side, AO/Orthopaedic Trauma Association (AO/OTA) classification, and combined medical diseases between the two groups (P>0.05). The operation time, times of main nail guide pin placement, intraoperative fluoroscopy frequency, intraoperative blood loss, and perioperative blood transfusion were recorded and compared between the two groups. The quality of fracture reduction was evaluated by CHANG Shimin et al criteria. Harris score was used to evaluate the hip function at 1 year after operation. Results In the trial group, 2 temporary fixation needles were successfully placed 2-5 times, including 2 times in 13 cases (43.3%), 3 times in 8 cases (26.7%), 4 times in 7 cases (23.3%), and 5 times in 2 cases (6.7%). The operation time, times of main nail guide pin placement, intraoperative fluoroscopy frequency, and intraoperative blood loss in the trial group were significantly less than those in the control group, and the reduction quality score was significantly better than that in the control group (P<0.05). There was no significant difference in perioperative blood transfusion between the two groups (P>0.05). All patients were followed up 12-19 months (mean, 15 months). There was no complication such as incision infection, deep vein thrombosis, or internal fixation loosening. At 1 year after operation, the Harris score of the affected hip joint in the trial group was significantly higher than that in the control group (P<0.05). Conclusion The technique of main nail guide pin placement and temporary fixation under the guidance of auxiliary devices in PFNA internal fixation can achieve faster insertion of the main nail guide pin, accurate temporary fixation to maintain reduction, and avoid the subsequent operation space, so as to improve the effectiveness.
ObjectiveTo compare the clinical effect of proximal femoral nail antirotation (PFNA) and locking proximal femoral plate (LPFP) for femoral intertrochanteric fracture in elderly patients. MethodsWe respectively analyzed the clinical data of 116 senile patients with femoral intertrochanteric fracture treated between October 2008 and March 2014. Among them, 60 were treated with PFNA, and 56 were treated with LPFP. We compared the two groups of patients in terms of operating time, surgical blood loss, surgical complications, walking exercise time, fracture healing time and joint function recovery. ResultsA total of 115 patients had regular follow-up from 12 to 24 months (averaging 15.7 months). One patient died. The operating time was (83.26±14.81) minutes in PFNA group and (102.58±15.31) minutes in LPFP group. The surgical blood loss was (202.16±33.14) mL in PFNA group and (255.80±45.92) mL in LPFP group. The walking exercise time was (1.80±0.91) weeks in PFNA group and (3.48±3.03) weeks in LPFP group. The fracture healing time was (11.80±2.26) weeks in PFNA group and (12.14±2.21) weeks in LPFP group. The postoperative Harris score for hip joint was 84.56±9.55 in PFNA group and 82.47±9.22 in LPFP group. There were statistical differences in operating time, surgical blood loss and walking exercise time (P<0.05), while no statistical differences were found in fracture healing time and postoperative Harris score for hip joint (P>0.05). ConclusionPFNA and LPFP are effective methods for femoral intertrochanteric fracture in elderly people, but PFNA has a shorter operating time, less surgical blood loss and earlier walking exercise time.