Objective To analyse the factors of complications aftertreatment of intertrochanteric fractures with Gamma nail. Methods From January 1998 to May 2004, 50 patients were treated with Gamma nail, including 18 males and 32 females and ageing from 47 to 82 years. The locations were the left side in 16 cases andthe right in 34 cases. According to Evans classification, there were 4 cases oftype Ⅰ, 2 cases of type Ⅱ, 23 cases of type Ⅲ, 10 cases of type Ⅳ and 11 cases of type Ⅴ. Results Fifty patients were followed up 429 months. Accordingto the Harris criterion for evaluation, the results were excellent and good in 35 cases, showing sthenic weight loading walking and normal range of motion of the hip joint. The postoperative complications appeared in 15 cases: 5 cases of coxa vara or coxa valga, 3 cases of rotation deformity of lower limb, 2 cases oftension screwprotrusions and lower shorten, 1 case of failure of internal fixation, 1 case of femoral fracture, 2 cases of coxalgia and 1 case of pain in knee joint and stiff knee joint. Conclusion The reason of complications was various, mainly lies in insufficient comprehension and analysis of the types of fractures, unfamiliarity with the characteristics and usage of the instruments and neglected rehabi litation instruction, inappropriate functional training and too early weight loading after operation.
Objective To investigate the difference in the effectiveness between proximal femoral nail anti-rotation (PFNA) and proximal femoral locking compression plate (PFLCP) for intertrochanteric fracture in elderly patients combined with hemiplegia due to cerebral infarction. Methods The clinical data of 67 cases of intertrochanteric femoral fractures combined with hemiplegia due to cerebral infarction between October 2013 and January 2017 were retrospectively analyzed. Among them, 32 cases were treated with PFNA internal fixation (PFNA group), and 35 cases were treated with PFLCP internal fixation (PFLCP group). There was no significant difference in gender, age, injury side, modified Evans classification of fracture, preoperative medical disease, and interval from injury to operation between 2 groups (P>0.05). The operation time, intraoperative blood loss, postoperative bed time, incidence of perioperative complications, time of fracture healing, and hip Harris score at 6 months and 1 year after operation were recorded and compared. Results Both groups were followed up 12-24 months with an average of 14 months. Compared with the PFLCP group, the PFNA group had shorter operation time, less intraoperative blood loss, and shorter bed time, and the differences were significant (P<0.05). X-ray films showed that the fractures healed in both groups. The fracture healing time of the PFNA group was shorter than that of the PFLCP group, but the difference was not significant (t=0.743, P=0.460). During hospitalization, there were 3 cases of pulmonary infection, 2 cases of deep venous thrombosis of lower limbs, and 1 case of urinary tract infection in the PFNA group; and the incidence of perioperative complications was 18.8% (6/32). There were 4 cases of pulmonary infection, 6 cases of deep venous thrombosis of lower limbs, 1 case of recurrent cerebral infarction, and 1 case of stress ulcer in the PFLCP group; and the incidence of perioperative complications was 34.3% (12/35). There was no significant difference in the incidence of perioperative complications between 2 groups (χ2=2.053, P=0.152). At 6 months after operation, the Harris total score and individual scores in the PFNA group were higher than those in the PFLCP group (P<0.05). At 1 year after operation, there was no significant difference in the Harris total score and pain score, life ability score, and walking ability score between the PFNA group and the PFLCP group (P>0.05); However, the joint deformity and activity score of the PFNA group was significantly better than that of the PFLCP group (t=4.112, P=0.000). Conclusion For intertrochanteric fracture in elderly patients with cerebral infarction hemiplegia, the PFNA has shorter operative time, less intraoperative blood loss, shorter bed time after operation, and better short-term hip function when compared with the PFLCP.
Objective To evaluate the clinical effect of bipolar long-stem prosthetic replacement on the treatment of comminuted intertrochanteric fracture of hip in the elderly osteoporotic patients. Methods From March 2000 to August 2003, 18 patients who were more than 72 years old with comminuted intertrochanteric fracture were treated with bipolar longstem prosthetic replacement. There were 8 males and 10 females (aged from 72 to 91). Fractured fragments of large trochanter and minor trochanter should be preserved during the operation so that the fragments can be fixed with steel wires and insertion of artificial femoral head.The surgical approach and operative technique, the average course of treatment in hospital, the average time to ambulate with full-weight bearing on the operated limb after the operation, complication, and mortality were observed. Results All patients were followed up 6 to 28 months(16.2 months on average). The average course of stay at hospital was 16 days. The average time to ambulate was 32 days. The incidence of the pain of the hip joint was one-eighteenth, and one patient due to another disease was unable to walk without using twocrutches one month after the surgery. The mortality of the patients was oneeighteenth one year after the surgery. Conclusion Bipolar longstem prosthetic replacement for the treament of comminuted intertrochanteric fractures in the elderly osteoporotic patients proves to be a suitable alternative.Patients have better prognosis, early full-weight bearing, rapid rehabilitation, and fewer complications.
Objective To compare the inter-observer agreement, consistency with the gold standard, and accuracy of the 2007 and 2018 versions of the AO/OTA classification in femoral intertrochanteric fractures, and to identify easily confused fracture types. Methods X-ray images of patients with femoral intertrochanteric fractures at Daping Hospital, Army Medical University between 2017 and 2021 were retrospectively collected. Three senior orthopedic trauma surgeons independently classified the fractures using both the 2007 and 2018 AO/OTA versions. A committee of five experts established the gold standard. Kappa coefficients were used to evaluate inter-observer agreement and consistency with the gold standard, while a confusion matrix was used to analyze accuracy and confusion points. Results A total of 236 patients were included. Regarding inter-observer agreement, the 2007 version was superior to the 2018 version at the subtype level [Kappa value: (0.473-0.739) vs. (0.322-0.658)], with no significant difference at the subgroup level [Kappa value: (0.234-0.453) vs. (0.204-0.442)]. Regarding consistency with the gold standard, the 2018 version was slightly better than the 2007 version [Kappa value: (0.332-0.629) vs. (0.269-0.581)] at the subgroup level. In terms of accuracy, the 2007 version showed higher accuracy at the subtype level (72.50% vs. 70.11%), whereas the 2018 version demonstrated better accuracy at the subgroup level (59.04% vs. 51.99%). The most easily confused subtypes in both versions were A1 and A2. At the subgroup level, A2.2 was the most easily confused type in both versions. Conclusions There is inconsistency in the application of both classification versions by surgeons. The 2007 version demonstrates slightly better inter-observer agreement at the subtype level, while the 2018 version shows better accuracy at the subgroup level. The A2.2 subgroup is a major point of confusion, suggesting that clinical attention should be focused on this type or that auxiliary tools may be needed to improve accuracy.
ObjectiveTo explore the efficacy and safety of intravenous injection of tranexamic acid (TXA) combined with local use of TXA cocktail in intertrochanteric fracture fixation with proximal femoral nail antirotation (PFNA).MethodsPatients with intertrochanteric fractures who underwent close reduction and internal fixation with PFNA between February 2018 and March 2019 were enrolled in the study. Among them, 45 patients who met the selection criteria were included in the study and randomly allocated into 3 groups (n=15). The patients in group A were not received TXA during perioperative period. The patients were intravenously injected of 1.0 g TXA before operation in group B and combined with local use of TXA cocktail during operation in group C. There was no significant difference in the age, gender, body mass index, fracture classification, disease duration, and complications between groups (P>0.05). The perioperative blood loss and blood transfusion rate, the visual analogue scale (VAS) score before operation and at 12, 24, and 48 hours after operation, the levels of prostaglandin E2 (PGE2) and bradykinin (BK) before operation and at 1 and 3 days after operation, postoperative complications, and the maximum amplitude (MA) of thromboelastogram were recorded and compared between groups.ResultsThe total blood loss, hidden blood loss, and visible blood loss were significantly lower in groups B and C than those in group A (P<0.05), and the total blood loss and hidden blood loss were significantly lower in group C than those in group B (P<0.05). There was no significant difference in the blood transfusion rate, preoperative VAS scores and the levels of PGE2 and BK between groups (P>0.05). The postoperative VAS scores and the levels of PGE2 and BK were significantly lower in group C than in groups A and B (P<0.05). There was no significant difference in pre- and post-operative MA of thromboelastogram between groups (P>0.05). The incidences of postoperative complications were 33.33% (5/15), 20.00% (3/15), and 13.33% (2/15) in groups A, B, and C, respectively, with no significant difference between groups (χ2=1.721, P=0.550).ConclusionFor intertrochanteric fractures, application of intravenous injection of TXA combined with local use of TXA cocktail in PFNA fixation can reduce perioperative blood loss, relieve pain after operation, and do not increase the risk of complications.
Objective To study the technique and effect of adjunctive cancellous screw in treatment of intertrochanteric fractures with dynamic hi p screw (DHS) fixation. Methods Between April 2004 and August 2007, 33 patients with intertrochanteric fracture were treated with DHS fixation and adjunctive cancellous screw. There were 13 males and 20 females, aging 43-82 years with an average age of 67 years. Fractures were caused by traffic accident in 7 patients, by fall ing from height in 11 patients, by sprain in 15 patients. All fractures were closed. The patients were operated 3-12 days after injury. According to Evans classification, there were 12 cases of type II, 15 cases of type III, and 6 cases of type IV. Twenty-twocases had osteoporosis. Weight bear time and compl ication were recorded. Fracture heal ing and neck-shaft angle were observed on radiogram. Hip functions were evaluated using Radford criterion. Results Thirty-three patients had no intraoperative compl ications with incision heal ing by first intension. All patients were followed up from 14 months to 38 months, with an average of 21 months. Fracture heal ing was achieved within 14 weeks to 21 weeks, with an average of 17 weeks after operations. The neck-shaft angles were (134.2 ± 13.7)° 3 days after operation, (128.6 ± 8.9)° 8 weeks after operation, and (128.5 ± 9.3)° after fracture heal ing, showing no significant difference when compared with that of the third day after operation (P gt; 0.05). According to the Radford criterion at last follow-up, the excellent and good rate of hi p function was 93.9% (excellent in 21 cases, good in 10 cases, and poor in 2 cases). Compl ications such as loosening, breakage, or grievous migration of hardware were not observed. Conclusion The adjunctive cancellous screw in treatment of intertrochanteric fractures with DHS fixation can provide counteraction of tension and rotation, promote fixation stabil ity, enhance fracture heal ing and decrease compl ication.
ObjectiveTo analyze the effectiveness of fast track protocol of geriatric intertrochanteric fracture on operative waiting time, operation time, perioperative blood loss, providing data support for clinical therapy.MethodsThe clinical data of 240 elderly patients with intertrochanteric fracture admitted between January 2015 and December 2018 were retrospectively analyzed. They were divided into traditional protocol group (148 cases, group A) and fast track group (92 cases, group B). All patients were treated with closed reduction intramedullary nail (proximal femoral nail antirotation) surgery. There was no significant difference in gender, age, sides, fracture classification, fracture type, complications, the proportion of patients with more than 3 kinds of medical diseases, and the time from injury to admission between the two groups (P>0.05). Analysis index included operative waiting time (hospitalization to operation time), operation time, percentage of operation performing in 48 and 72 hours, percentage of transfusion, changes of hematocrit (Hct) at different stage (admission, operation day, and postoperative 1, 3 days), blood loss by fracture and cephalomedullary nail, intraoperative dominant blood loss, total blood loss in perioperative period were recorded and compared.ResultsThe operative waiting time, operation time, Hct on operation day and postoperative 3 days, blood loss by fracture, transfusion volume, and total blood loss in perioperative period in group B were significantly less than those in group A (P<0.05), and the percentage of operation performing in 48 and 72 hours in group B were significantly higher than those in group A (P<0.05). There was no signifcant difference in Hct on admission and postoperative 1 day, intraoperative dominant blood loss, percentage of transfusion, blood loss by cephalomedullary nail between the two groups (P>0.05).ConclusionFast track can shorten the operative waiting time of geriatric intertrochanteric fracture, reduce the blood loss by fracture, total blood loss in perioperative period, and transfusion volume. Early operation is conducive to improve the anemia status of patients during perioperative period.
Objective To evaluate the effect of minimally invasive dynamic hip screws (MIDHS) in treating aged intertrochanteric fractures. Methods From April 2006 to March 2008, 49 aged patients with intertrochanteric fractures were treated with MIDHS. There were 22 males and 27 females, aged 65-78 years (average 70.2 years). Frature was caused by trafficaccident in 7 cases, by fall ing from height in 3 cases, and by injury from fall in 39 cases. The time from injury to operation was 2-12 days (average 5.5 days). According to Evans classification, there were 28 cases of types I, II (stable fracture) and 21 cases of types III, IV (unstable fracture). If the Singh index≤3 was defined as osteoporosis, the osteoporotic rate was 71.4% (35/49). All patients were on a radiolucent fracture traction table and their fractures had satisfactory closed reduction. After the guide wire was inserted and reamed under fluoroscopy, the lag screw and side plate were introduced through the small incision. In all unstable fractures, an additional, antirotational and large cancellous bone screw was used cranial to the DHS. Results The average operation time was 65.2 minutes. The average blood loss was 189.3 mL. All patients had satisfactory reduction and 79.6% (39/49) had adequate lag screw positions. The average postoperative hospital ization days was 5.8 days (3-12 days). All incision healed at stage I. There was no postoperative complications. Forty-nine patients were followed up 12 to 30 months (average 19.8 months). Fractures healed within 16 weeks in 47 patients and the average healing time was 13.1 weeks (12-16 weeks). The average Harris scoring was 90.8 (75-95). Implant failure and nonunion occurred in 2 cases, no serious compl ication occurred in other patients. Conclusion The MIDHS is a simple, safe and effective method for treatment of aged intertrochanteric fractures.
Objective To investigate the appl ication of anti-rotation screw after dynamic hi p screw (DHS) in treatment of intertrochanteric fracture. Methods Between April 2006 and January 2010, 22 cases of intertrochanteric fractures underwent DHS fixation operation with an anti-rotation screw, including 15 males and 7 females with an average ageof 66.3 years (range, 54-83 years). Fractures were caused by sl ipping in 16 cases, traffic accident in 5 cases, and fall ing from height in 1 case. All cases showed closed fractures, including 13 cases in the left and 9 cases in the right. Eighteen cases were simple intertrochanteric fracture, 4 cases were intertrochanteric fractures compl icated with Colles fractures. According to Evans classification standard, there were 14 cases of type I, 6 cases of type II, 1 case of type III, and 1 case of type IV. The time from wound to operation was 3-7 days (mean, 4.5 days). Results The operation time ranged from 51-95 minutes (mean, 72 minutes). The intraoperative blood loss was 150-350 mL (mean, 270 mL). The hospital ization days were 12-35 days (mean, 16.8 days). Primary heal ing was observed in all cases. All cases were followed up 6-17 months (mean, 14 months). Union of fracture was observed at 12-16 weeks (mean, 13.6 weeks); no fracture or internal fixation loosening occurred. According to HUANG Gongyi’s standard of efficacy assessment, the results were excellent in 19 cases and good in 3 cases. Conclusion Appl ication of an anti-rotation screw can help to improve the strength of the DHS for the internal fixation of intertrochanteric fracture, especially the anti-rotation abil ity, which does not increase the operation time obviously.
ObjectiveTo investigate the effect of the screw blade position on the effectiveness of proximal femoral nail anti-rotation (PFNA) internal fixation for unstable intertrochanteric fractures in the elderly.MethodsA clinical data of 131 elderly patients with unstable intertrochanteric fractures who were treated with PFNA internal fixation between January 2010 and January 2017 was retrospectively analyzed. According to the anteroposterior X-ray films, the screw blades were placed in the middle of the femoral neck in 72 patients (group A) and at one-third of the femoral neck in 59 patients (group B). There was no significant difference between the two groups (P>0.05) in the gender, age, bone density, classification of fractures, other medical diseases, and the time between injury and operation. Multiple treatment indexes were analyzed, including complications, hip Harris score, the healing status of fracture, tip-apex distance (TAD), and the height of the tail nail.ResultsAll patients were followed up 11-14 months, with an average of 12.1 months. All incisions healed by first intention with no complications. All fractures healed and no significant difference in bone healing time between the two groups (Z=?0.190, P=0.849). At 6 months after operation, TAD was (2.23±0.07) cm in group A and (2.85±0.12) cm in group B, showing significant difference (t=?47.643, P=0.000); and the height of the tail nail was (1.72±0.14) cm in group A and (0.53±0.26) cm in group B, showing significant difference (t=31.031, P=0.000). According to the Harris score, the hip functions were rated as excellent in 48 cases, good in 15 cases, and poor in 9 cases in group A, while as excellent in 38 cases, good in 16 cases, and poor in 5 cases in group B, with no significant difference between the two groups (Z=?0.075, P=0.941).ConclusionFor the unstable intertrochanteric fracture in the elderly, the PFNA internal fixation with appropriated TAD and the screw blades placed in the middle or at one-third of the femoral neck can obtain good effectiveness.