Outcome of Pertrochanteric Femur Fractures with Proximal Femur Locking Compression Plate

Background: Fractures of the proximal femur, including fractures affecting the pertrochanteric region, have become a public health problem. Owing to aging of the population, we have to operate on even more elderly patients who sometimes present with significant co-morbidities. Although conventional implants have given good results in stable peritrochanteric fractures, proximal femur locking compression plate (PFLCP) which has been recently introduced is better suited for comminuted, unstable pertrochanteric fractures and osteoporotic bones. In PF-LCP, bone-implantconstruct so formed is mechanically stable and fixation failure due to screw loosening in osteoporotic bone can be reduced. Materials &Methods: This prospective study was conducted in our institute and was approved by local ethical committee. Twenty-five consecutive patients of either sex with age more than 60 years (range, 60-84) having pertrochanteric fractures were operated upon with PFLCP. A.O classification was followed in the study and Singh’s index for osteoporosis was calculated. Operating time, blood loss and any technical difficulty with the implant were recorded. Patients were followed clinically and radiologically for union at fracture site and implant-related complications for a period of 24 months. The Harris Hip Score was used to document hip functions at final follow-up. Observations: Amongst the 25 patients, the average operation time in our study was 66.60±10.57 minutes. The average radiological union was 3.40±0.63 months (13.6 weeks). Average time for full weight bearing was 13.12±1.90 weeks. There were two cases of wound infection, one case of coxa vara and one case of a proximal screw back-out. There was no case of plate lift or screw breakage. There was no case of non-union. Conclusion: The PFLCP can be a feasible alternative to the treatment of peritrochanteric fractures. Treatment with PFLCP can provide good-to-excellent healing in osteoporotic bones having comminuted and unstable peritrochanteric fractures, with a limited occurrence of complications.

Characteristics of intramedullary nail breakage in pertrochanteric femur fractures: a summary of 70 cases

Objective To reveal noteworthy characteristics of intramedullary (IM) nail breakage in pertrochanteric femur fractures. Materials and methods The data from 6 patients with IM nail breakage in our hospital between August 2008 and May 2018 were reviewed retrospectively. With an additional 64 cases reported in articles in the PubMed database prior to October 2019, a total of 70 cases were reviewed and analysed; epidemiological patient data and data on the initial trauma, fracture type, nail selected for the original surgery, time from surgery to breakage, mechanism and location of breakage, status of fracture healing, salvage treatment and prognosis were assessed. Results Seventy patients with pertrochanteric fractures, including 2 stable fractures and 68 unstable fractures, experienced IM nail breakage at a mean of 9.4 months after the initial surgery. Among them, 9 (12.9%) occurred within 3 months, 23 (32.9%) between 3 and 6 months and 38 (54.3%) after 6 months. The mean age was 72.3 years, and 16 (22.9%) patients were younger than 65 years old. When nail breakage occurred, 66 fractures (94.3%) exhibited delayed union/non-union. Self-dynamisation was found in 12 cases (17.1%). The salvage procedures included 4 partial/total implant removal procedures, 17 hemi/total hip arthroplasty procedures, 3 conservative treatment procedures, and 46 revised osteosyntheses, of which 7 cases (15.2%) sustained secondary implant failure. No significant differences were found between the failure rates of IM nails and extramedullary(EM) devices (odds ratio [OR], 3.429; 95% confidence interval [CI], 0.632–18.877; p = 0.330). Conclusion IM nail breakage is a rare complication lack of time regularity and mostly occurs in unstable pertrochanteric fractures in the presence of delayed union/non-union. Osteosynthesis revision can be conduct by a new IM nail or EM device but considerable secondary failure rate is noteworthy. Self-dynamisation may be a warning sign of nail breakage.

Bipolar Hemiarthroplasty as Coxofemoral Bypass Technique in Treating Unstable Pertrochanteric Comminuted Fracture of Elderly Patients

BACKGROUND Pertrochanteric fractures in the elderly are highly unstable and osteoporotic. Comminution of fragments and distraction fragments make union difficult owing to forces acting on the proximal hip joint. The internal fixation in these cases leads to prolonged bed rest and immobilization to prevent implant failure. The purpose of this study was to analyse the role of bipolar hemiarthroplasty in cases of unstable pertrochanteric femur fractures as bypassing forces transmission through the proximal femur. METHODS 30 patients with pertrochanteric fractures were randomized and operated on as bipolar hemiarthroplasty using the indigenous bipolar prosthesis between July 2017 and July 2021. The inclusion criteria were patients more than 65 years of age, Type 4 intertrochanteric fracture (As per Evans classification) AO/ OTA type 31A2.3, 31A3.2, 31A3.3. Patients with polytrauma, compound injuries, pathological fractures and medically unfit patients were excluded from the study. RESULTS The mean age was 67 ± 5 years. The most common mechanism of injury was domestic fall comprising 80 %. The average duration of surgery from the time of injury was 3.5 ± 1.5 days. The average surgical duration was 85.5 mins. The average duration of stay in the hospital was 8.5 ± 1.5 days. Final results were calculated using the Harris Hip score with 33.3 % cases as excellent, 56.6 % cases as good and 10 % cases had fair results respectively. Follow-up was done at 6 weeks, 3, 6, 12 and 24 months. CONCLUSIONS Bipolar hemiarthroplasty in pertrochanteric femur fractures has the advantage of stable adequate fixation with early return to activities of daily living, thus preventing serious life-threatening complications. KEY WORDS Intertrochanteric Fractures, Hemiarthroplasty, Femur, Harris Hip Score

Treatment of pertrochanteric fractures in elderly patients: is dynamic fixation so important?

Introduction The problem of complications after surgical treatment of pertrochanteric fractures in elderly patients is relevant and far from a solution. Materials and methods The retrospective study was based on the analysis of the results of treatment of 129 patients with pertrochanteric femoral fractures (average age 76 years). All fractures in the early time from trauma were fixed with two types of cephalomedullary nails, either dynamic or static. All patients could not limit the load on the operated limb after surgery because of different reasons. Results The results of treatment were evaluated in 109 patients after one year. In dynamic cephalomedullary fixator group (59 patients), there were 7 orthopedic complications with a functional Harris scale result of 68 points (range, 26 to 94 points). In static cephalomedullary fixator group (50 patients), there were 14 orthopedic complications with a functional Harris score of 56.5 points (range, 15 to 92 points). Discussion Higher results of treatment in the group of dynamic fixator in the condition of full-weight bearing on the operated limb may be associated with the possibility of dynamization of the part of fixator in response to bone resorption in the contact area of bone fragments. The use of dynamic cephalomedullary fixators instead of static ones for treatment of pertrochanteric femoral fractures in elderly patients exercising full weight-bearing leads to a decrease in orthopedic complications (from 28 to 11.9 %) and improves the functional results of treatment.

Management of pertrochanteric fractures in patients over 90 years: In-hospital mortality rate, complications and associated risk factors

Purpose This study aims primarily to investigate the outcome following surgical management of pertrochanteric fractures of patients over 90 years compared to the outcome of a control group below 90 years under special consideration of the timing of surgery. The second aim was to analyze potential risk factors for early deaths in very old patients. This study allows us to draw conclusions to minimize complications linked to this particular age segment. Methods The study group consisted of very old patients aged 90 years and older. Geriatric patients aged between 60 and 89 years of age were part of the control group. Type A1 pertrochanteric fractures were typically treated by dynamic hip crews, type A2 and A3 fractures by femoral nails. Full weight bearing physiotherapy was initiated on the day after surgery to improve mobility and muscle strength. Results A total of 71 patients belonged to the study group (mean age: 92.5 years ±2.3 years), whereas 223 patients formed the control group (mean age: 79.9 ± 7.4 years). The mortality rate and the number of detected and documented complications were significantly higher in the study group (p = 0.001; p = 0.009, respectively). Despite the significantly higher complication rate in the > 90-year-old patients, there was no significant difference in the mean length of in-hospital-stay between the both groups (> 90 yrs.: 12.1d; < 90 yrs.: 13.1 d) and the timing of surgery. Conclusion The number of co-morbidities, number of daily-administered medications and the time between admission and surgery have no impact on the outcome. We noticed a longer period between admission and surgery in very old patients who survived. Patients with pertrochanteric fractures should be screened for multimorbidity and cognitive disorders in a standardized manner.

Zimmer Natural Nail and ELOS nails in pertrochanteric fractures

Background Pertrochanteric fractures of the femur in the elderly are very common. As the average age of the population increases, the incidence of such fractures also raises, resulting in high healthcare costs. The type of surgical devices employed for their surgical management influences these costs. Methods A comparative clinical study was conducted on patients operated by one single surgeon between December 2018 and November 2020 in a high-volume regional referral centre. All patients who received a Zimmer Natural Nail (ZNN) or ELOS devices were included. Results In 119 (66.48%) of the 179 fractures, a ZNN nail was used. Post-operatively, the TAD (tip-to-apex distance) was measured at an average value of 17.05 (4.42–41.85) mm and the CalTAD (calcar-referenced TAD) at an average of 20.76 (10.82–43.63) mm. The mean hospitalization time was 10.19 (4–22) days. In the other 60 trochanteric fractures, an ELOS nail was used. Post-operative imaging indicated a TAD of 19.65 (5.08–31.4) mm and a CalTAD of 22.86 mm (12.66–33.77). The average time of the operation was 45.82 (20–110) min. The average period of hospitalization was 10.45 (5–24) days. Conclusion Both devices give similar results in terms of short-term post-operative outcome and hospitalization. The price difference between the devices does not translate in different short-term results on the operated patients.