Objective To evaluate the effectiveness of InterTan in the treatment of femoral intertrochanteric fractures. Methods Between April 2009 and July 2009, 57 patients with femoral intertrochanteric fracture were treated with InterTan. There were 33 males and 24 females with an average age of 68 years (range, 45-88 years). The locations were left side in 31 cases and right side in 26 cases and all fractures were closed fractures. According to Association for Osteosynthesis/Orthopaedic Trauma Association (AO/OTA) classification, there were 23 cases of type 31-A1, 27 of type 31-A2, and 7 of type 31-A3. The disease duration was 2 to 8 days with an average of 3.3 days. The data of operative time, blood loss, perioperative blood transfusion, hospital ization day, fracture heal ing time, and Harris hip score were recorded. Results The operative time and the blood loss were (74.5 ± 19.7) minutes and (148.8 ± 79.6) mL, respectively. There were significant differences in the operative time and the blood loss among the AO/OTA subgroups (P lt; 0.05). Twenty-five patients required a blood transfusion and the transfusion volume was (264.0 ± 90.7) mL. The average hospital ization days were 7 days (range, 6-9 days). Thirty-five patients were followed up 12 to 15 months (13.3 months on average). X-ray films showed that all fractures healed within (2.8 ± 0.8) months. The heal ing time of fracture was (2.4 ± 0.6), (2.9 ± 0.9), and (3.8 ± 0.5) months in 31-A1 subgroup, 31-A2 subgroup, and 31-A3 subgroup, respectively. There was no significant difference in heal ing time of fracture between 31-A1 subgroup and 31-A2 subgroup (P gt; 0.05), and there were significant differences between 31-A3 group and 31-A1 subgroup, 31-A2 subgroup (P lt; 0.05). No shortening, cut-out, varus malposition, femoral shaft fracture, or implant failures was found. The Harris score at the final follow-up was 84.5 ± 8.2 with an excellent and good rate of 80% (15 cases of excellent, 13 of good, 6 of fair, and 1 of poor). Twenty patients (57%) recovered the walking abil ity. Conclusion The new intertrochanteric antegrade nail of InterTan can be used to treat femoral intertrochanteric fractures with good cl inical outcomes, high union rate, and less compl ications.
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.
摘要:目的:探讨老年人股骨粗隆间骨折不同手术方式的选择。方法:我院2004年1月至2007年12月间应用不同术式治疗老年股骨粗隆间骨折110例,其中动力髋螺钉(DHS)25例, 股骨近端髓内钉(PFN)41例,人工股骨头置换44例。术后所有患者均获随访,平均12.6个月。对术后并发症和按照Kuderna 改良 Merli D’Aubigne标准得到的髋关节功能恢复优良数(率)进行评价。结果:术后出现并发症3例,其中PFN术式2例;人工股骨头置换术式1例。围手术期内无伤口感染,无死亡病例。三种术式总体优良数(率)为:107(97.3%)。结论:三种手术方式各有其优缺点,没有一种术式能普遍适用于各种类型粗隆间骨折,临床上,为了最大限度降低手术风险,我们没有必要专注或偏好于某一种手术方式,要根据患者的个体差异及每种术式的优缺点,灵活地为每例股骨粗隆间骨折患者制定出其最适宜的手术方式,大都能取得满意的疗效。Abstract: Objective: To investigate the chosen of 3 different surgical methods in the treatment of intertrochanteric femoral fractures in the elderly. Methods:From January, 2004 to December, 2007, 110 cases with the femoral intertrochanteric fractures in the elderly were treated with the followed 3 kinds of operations respectively:dynamic hip screw (25 cases), proximal femoral nail (41 cases), hip hemiarthroplasty (44 cases). After surgery all patients were followed up; Followedup period range from 6 months to 18 months(average 12.6 months). The good and excellent number (rate) of 3 surgical methods with Merli D’Aubigne evaluation criteria were evaluated, and compared in the postoperative complications. Results: 3 complications occurred postoperatively ( 2 with PFN,1 with hip hemiarthroplasty), none wound infection or died in Perioperatie. The total good successful number (rate) was 107(97.3%). Conclusion:Each has its advantages and its disadvantages. None of three kinds of surgical methods can be used generally all kinds of the femoral intertrochanter fracture. In clinical work, we don not need to focus on or prefer to the only one of them in order to minimize the risk. The good response to treatment will be get if we can choose the appropriate method according to the individual differences of the advantages and disadvantages of each method.
Objective To summarize the selection criteria and clinical application of surgical methods for hip fractures (femoral neck fracture and intertrochanteric fracture) in the elderly. Methods The related literature concerning the surgical methods for femoral neck fracture and intertrochanteric fracture in the elderly at home and abroad was extensively reviewed and summarized. Results Among the elderly patients with femoral neck fracture, the closed reduction and internal fixation or dynamic hip screw (DHS), and total hip arthroplasty are recommended for patients under 65 years old and 65–80 years old respectively and without special surgical contraindication; whereas hemiarthroplasty is recommended for patients with poor physical conditions. Among the patients with intertrochanteric fracture, DHS or the 3rd generation of Gamma nails is recommended for patients with stable fracture while the intramedullary fixation systems (e.g., proximal femoral nail anti-rotation, intertrochanteric antegrade nail) and the extramedullary fixation systems (e.g., proximal femoral locking compression plate and less invasive stabilization system) can be applied to the patients with unstable fracture according to the fracture type and bone conditions. Notably, hip arthroplasty is recommended for elderly patients with comminuted fracture. Conclusion The surgical method and internal fixator should be chosen according to the fracture type and bone condition in the elderly in order to improve the effectiveness and reduce the complication.
Objective To introduce a novel comprehensive classification for femoral intertrochanteric fractures, and to accommodate the clinical requirement for the world-wide outbreak of geriatric hip fractures and surgical operations. Methods On the basis of reviewing the history of classification of femoral intertrochanteric fractures and analyzing the advantages and disadvantages of AO/Orthopaedic Trauma Association (AO/OTA) classification in different periods, combined with the current situation of extensive preoperative CT scan and three-dimensional reconstruction and widespread use of intramedullary nail fixation in China, the “Elderly Hip Fracture” Research Group of the Reparative and Reconstructive Surgery Committee of the Chinese Rehabilitation Medical Association proposed a novel comprehensive classification for femoral intertrochanteric fractures, focusing on the structure of fracture stability reconstruction during internal fixation. Results The novel comprehensive classification of femoral intertrochanteric fractures incorporates multiple indicators of fracture classification, including the orientation of the fracture line, the degree of fracture fragmentation, the lesser trochanteric bone fragment and its distal extension length (>2 cm), the posterior coronal bone fragment and its anterior extension width (involving the lateral cortex of the head and neck implant entry point), transverse fracture of the lateral and anterior wall and its relationship with the implant entry point in the head and neck, and whether the cortex of the anteromedial inferior corner can be directly reduced to contact, etc. The femoral intertrochanteric fractures are divided into 4 types (type A1 is simple two-part fractures, type A2 is characterized by lesser trochanter fragment and posterior coronal fractures, type A3 is reverse obliquity and transverse fractures, type A4 is medial comminution which lacks anteromedial cortex transmission of compression force), each of which is subdivided into 4 subtypes and further subdivide into finer subgroups. In a review of 550 trochanteric hip fracture cases by three-dimensional CT, type A1 accounted for 20.0%, type A2 for 62.5%, type A3 for 15.5%, and type A4 for 2.0%, respectively. For subtypes, A2.2 is with a “banana-like” posterior coronal fragment, A2.4 is with distal cortex extension >2 cm of the lesser trochanter and anterior cortical expansion of the posterior coronal fragment to the entry portal of head-neck implants, A3.4 is a primary pantrochanteric fracture, and A4.4 is a concomitant ipsilateral segmental fracture of the neck and trochanter region. ConclusionThe novel comprehensive classification of femoral intertrochanteric fractures can describe the morphological characteristics of fractures in more detail, include more rare and complex types, provide more personalized subtype selection, and adapt to the clinical needs of both fractures and surgeries.
ObjectiveTo compare the efficacy of proximal femoral nail anti-rotation (PFNA), locking compression plate (LCP), and artificial femoral head replacement for femoral intertrochanteric fracture in aged patients so as to provide reference for clinical treatment.MethodsA retrospective analysis was made on the clinical data of 150 aged patients with femoral intertrochanteric fracture treated between September 2009 and March 2016. PFNA was used in 51 cases (group A), LCP in 53 cases (group B), and artificial femoral head replacement in 46 cases (group C). There was no significant difference in sex, age, side, cause of injury, injury to operation time, type of fracture, and combined medical diseases between groups (P>0.05). The incision length, operation time, intraoperative blood loss, time for full weight bearing, hip Harris score, and complications were recorded and compared between groups.ResultsThe patients were followed up 12-23 months (mean, 18.6 months) in group A, 12-25 months (mean, 19.0 months) in group B, and 12-24 months (mean, 18.9 months) in group C. The incision length, operation time, and intraoperative blood loss of group A were significantly less than those of groups B and C (P<0.05); the operation time of group C was significantly shorter than that of group B (P<0.05), but there was no significant difference in incision length and intraoperative blood loss (P>0.05). The time for full weight bearing was significantly shorter in group C than groups A and B, and in group A than group B (P<0.05). Postoperative complications occurred in 11 patients of group A (21.6%), 14 patients of group B (26.4%), and 2 patients of group C (4.3%), showing significant difference between group C and group A or group B (P<0.05), but no significant difference was found between groups A and B (P>0.05). Hip Harris score at 12 months after operation had no significant difference between groups (P>0.05).ConclusionPFNA, LCP, and artificial femoral head replacement are all effective methods to treat femoral intertrochanteric fracture in aged patients. PFNA has the advantages of small incision, short operation time, less bleeding and simple procedure, and artificial femoral head replacement has the advantages of early time for full weight bearing, less bed rest time, and less complications. For these patients, PFNA and artificial femoral head replacement are appropriate.
ObjectiveTo investigate the method to measure the tip-apex distance (TAD) in treatment of femoral intertrochanteric fracture with proximal femoral nail antirotation (PFNA). MethodsBetween March 2008 and March 2011, 35 patients with femoral intertrochanteric fracture underwent closed reduction and internal fixation with PFNA, which were all closed fractures. There were 14 males and 21 females with an average age of 72.3 years (range, 48-88 years). According to Evans classification, 1 case belonged to type III, 27 cases to type IV, and 7 cases to type V. The time between injury and operation was 2-7 days (mean, 4.3 days). The TAD was measured according to relationship between tip of helical blade and the center point of femoral head radius during operation, and according to X-ray films after operation. ResultsPrimary healing of incision was obtained in all cases, and no infection or deep venous thrombosis occurred. At 2 days after operation, the X-ray films showed TAD was 18-24 mm (mean, 22.6 mm). Thirty-two cases were followed up 10-22 months (mean, 16 months). All fractures healed, with a mean healing time of 7.6 months (range, 6-10 months). The patients could walk without stick at 11-16 weeks (mean, 13 weeks). Pulmonary infection occurred in 1 case at 5 days after operation; no breakage of femoral nail or cut-out helical blade from femoral head was observed. At 10 months after operation, the Parker hip scores were 9 in 23 cases, 8 in 4 cases, 7 in 3 cases, and 5 in 2 cases, with a mean score of 8.44. ConclusionIt is easy to control the TAD in treatment of femoral intertrochanteric fracture with PFNA with an simple method and important to prevent breakage and cut-out helical blade from the femoral head.
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.
ObjectiveTo explore the effectiveness of proximal femoral nail antirotation (PFNA) assisted by mesh locator in treatment of intertrochanteric fracture in the elderly.MethodsNinety-four elderly patients with intertrochanteric fractures admitted between August 2014 and July 2017 were selected as the study subjects. They were randomly divided into trial group (48 cases) and control group (46 cases). In trial group, PFNA was implanted assisted by mesh locator after closed reduction; while in control group, PFNA was implanted by conventional method. There was no significant difference between the two groups in terms of gender, age, cause of injury, time from injury to admission, fracture side and classification, and medical complications (P>0.05). The operation time, intraoperative blood loss, fluoroscopy times, hospital stay, incision length, and complications were recorded. Visual analogue scale (VAS) was used to evaluate the degree of pain at 3 days after operation, and Harris score was used to evaluate hip function before operation and at 3, 6, and 9 months after operation.ResultsCompared with control group, the operation time and incision length of trial group shortened, the blood loss and fluoroscopy times reduced, the pain after operation alleviated obviously; the differences between the two groups were significant (P<0.05). There was no significant difference in hospital stay between the two groups (P>0.05). The patients in both groups were followed up 9-12 months, with an average of 10.6 months. X-ray films showed that the fractures healed in both groups, and the healing time in control group was (11.2±3.2) weeks, while that in trial group was (11.6±2.9) weeks, showing no significant difference between the two groups (t=1.262, P=0.120). There was no significant difference in Harris score between the two groups before operation and at 3, 6, and 9 months after operation (P>0.05). There was 1 case of incision infection, 2 cases of coxa vara, and 1 case of pressure ulcer in trial group, and the incidence of complications was 8.3%. There was 1 case of coxa vara, 2 cases of pressure ulcer, and 1 case of internal fixation loss in control group, and the incidence of complications was 8.7%. There was no significant difference in the incidence of complications between the two groups (χ2=0.783, P=0.112).ConclusionIt is feasible to implant PFNA assisted by mesh locator in treatment of intertrochanteric fracture in the elderly. Compared with the traditional operation, it can shorten the operation time, shorten the incision, and relieve the pain after operation.
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.