ObjectiveTo summarize the research progress of osteonecrosis of femoral head (ONFH) following femoral intertrochanteric fractures in adults.MethodsRelevant literature at home and abroad was extensively reviewed to summarize the pathogenesis, high-risk factors, and treatment of ONFH after femoral intertrochanteric fracture in adults.ResultsONFH after femoral intertrochanteric fracture mostly occurs within 2 years after operation, with a lower incidence. At present, it is believed that comminuted and large displacement fractures caused by high-energy injuries, fracture line close to the base of neck, excessive external rotation deformity, improper intramedullary nail entry points, and rough intraoperative manipulating may injury the deep branch of the medial circumflex femoral artery, causing ONFH. Hip replacement is the main treatment for necrosis, which can achieve good results.ConclusionAddressing the above risks, excessive external rotation, overstretching, and rough manipulating should be avoided. Anatomical reduction should be performed during the operation, the nail entry point should be accurate and avoid repeated drilling and thermally bone necrosis.
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 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.
Objective To investigate the validity of improving the femur’s mechanical characteristics by implanting calcium phosphate ceramic screws after removing dynamic hip screw (DHS). Methods The three dimensional finite element model of the femur was built based on the CT scanning of a normal male volunteer. Then the models of the femur with and without DHS were established. According to calcium phosphate ceramic screws with porosity and apparent elastic modulus, 80% and 0.1 GPa were set as group A, 50% and 1.0 GPa as group B, and 30% and 1.5 GPa as group C. Von Mises stress distribution and maximum stress were recorded when the joint was maximally loaded in a gait cycle. Results The Von Mises in normal femoral shaft was uniform; no phenomena of stress concentration was observed and the maximum stress located at the joint load-bearing site of the proximal femur. The stress concentration was observed in the femur without DHS, and the maximum stress located at the distal femur around the screw hole. By comparing several different calcium phosphate ceramic screws, the stress distribution of group B was similar to normal femur model, and the maximum stress located at the joint load-bearing site. The other screws of groups A and C showed varying degrees of stress concentration. Conclusion Implanting calcium phosphate ceramic screw can improve the mechanical characteristics of the femur after removing dynamic hip screw, and the calcium phosphate ceramic screw with 50% porosity and 1.0 GPa apparent elastic modulus is suitable for implanting.
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.
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.
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.
Objective To investigate the perioperative changes in serum interleukin 6 (IL-6) levels in elderly male patients with intertrochanteric fractures, and provide evidence for inflammatory control in this patient population. Methods The clinical data of 40 male patients aged more than 60 years with intertrochanteric fractures who met the selection criteria between January 2021 and December 2022 were retrospectively analyzed, including 25 non-osteoporosis patients (T value>?2.5, group A) and 15 osteoporosis patients (T value≤?2.5, group B). In addition, 40 healthy men aged more than 60 years old were included as controls (group C) according to the age matching rule. There was no significant difference in age, smoking history, drinking history, body mass index, complications (hypertension and diabetes), alanine aminotransferase, aspartate aminotransferase, blood urea nitrogen, creatinine, and total protein among the 3 groups (P>0.05). Serum samples were collected from group C subjects and from groups A and B patients preoperatively and on postoperative days 1, 3, 5, and 7. IL-6 levels were measured using ELISA assay. Pearson correlation analysis was used to assess the relationship between IL-6 levels and T values at various time points in groups A and B. Postoperative complications during hospitalization and 1-year mortality rates were recorded for groups A and B. Results Preoperative IL-6 levels were significantly higher in groups A and B than in group C (P<0.05), with group B being significantly higher than group A (P<0.05). In groups A and B, IL-6 levels increased significantly on postoperative day 1 compared to preoperative levels and then gradually decreased, approaching preoperative levels by postoperative day 7. IL-6 levels in group B were significantly higher than those in group A at all postoperative time points (P<0.05). Correlation analysis showed that IL-6 levels were negatively correlated with T values at all perioperative time points in all patients from groups A and B (P<0.05). Complications occurred in 4 patients (16.0%) in group A, including 2 cases of pulmonary infection, 1 case of urinary tract infection, and 1 case of heart failure, and in 3 patients (20.0%) in group B, including 2 cases of pulmonary infection and 1 case of gastrointestinal bleeding. There was no significant difference in the incidence of complications between the two groups (χ2=0.104, P=0.747). There were 2 cases (8.0%) and 4 cases (26.7%) died within 1 year after operation in groups A and B, respectively, and there was no significant difference in 1-year mortality rates between the two groups (χ2=2.562, P=0.109). Conclusion Serum IL-6 levels significantly increase in the early postoperative period in elderly male patients with intertrochanteric fractures, especially in those with osteoporosis. Monitoring the inflammatory state and promptly controlling the inflammatory response during the perioperative period, may reduce complications and improve postoperative survival in this patient population.
Objective To explore the feasibility and effectiveness of maintaining the reduction of unstable intertrochanteric fractures by Kirschner wire-fixation-cortical bone technique. Methods Forty patients with intertrochanteric fracture [AO/Orthopaedic Trauma Association (AO/OTA) type 31-A2.2] admitted between May 2015 and January 2017 and requiring closed reduction and proximal femoral nail antirotation (PFNA) were randomly divided into trial group (intraoperative Kirschner wire-fixation-cortical bone technique group, 20 cases) and control group (conventional treatment group, 20 cases). There was no significant difference in general data of gender, age, side, body mass index, cause of injury, time from injury to operation between the two groups (P>0.05). The operation time, intraoperative blood loss, and intraoperative fluoroscopy times of the two groups were recorded; the reduction quality of fracture was observed according to the corresponding relationship between medial and anterior cortex (positive, neutral, and negative support) of intraoperative fluoroscopy proposed by ZHANG Shimin, and the stability of internal fixation and fracture healing were observed; Harris score was used to evaluate the recovery of hip function at 12 months after operation. Results In the trial group, 6 cases (30%) had 2 Kirschner wires implanted less than 4 times, 7 cases (35%) had 5-8 times, and 7 cases (35%) had 9 times or more. There was no significant difference in operation time and intraoperative blood loss between the two groups (P>0.05), but the blood transfusion volume and intraoperative fluoroscopy times in the trial group were significantly less than those in the control group (P<0.05). Both groups were followed up 13-21 months, with an average of 17 months. There was no complications such as wound infection, deep venous thrombosis of lower extremities, refracture, and internal fixation-related complications. The quality of intraoperative reduction in the trial group was significantly better than that in the control group (Z=–2.794, P=0.024). The Harris score of the trial group was significantly better than that of the control group at 12 months after operation (t=2.98, P=0.01). Conclusion The use of Kirschner wire-fixation-cortical bone technique during intertrochanteric fracture closed reduction and PFNA internal fixation surgery can effectively maintain the reduction effect, reduce the number of fluoroscopy, improve the reduction quality, reduce allogeneic blood input, obtain better hip function, and do not increase the operation time and intraoperative blood loss.
Objective To evaluate the biomechanical properties of proximal femoral medial buttress plate (PFMBP) for fixing the reverse oblique intertrochanteric fractures by comparing with proximal femoral locking compression plate (PFLCP) and proximal femoral nail antirotation (PFNA). Methods Eighteen synthetic femoral bone models (Synbone) were divided into 3 groups (group PFLCP, group PFNA, and group PFMBP), 6 models in each group; an AO 31-A3.1 reverse oblique femoral intertrochanteric fracture was made based on the same criterion. After being fixed and embeded, the axial load testing, torsion testing, and axial load-to-failure testing were performed on each model. The axial displacement of different loads, torque of different torsion angles, and failure load of each model were recorded, and the stiffness of axial load and torsion were calculated. Results The axial stiffness in groups PFLCP, PFNA, and PFMBP were (109.42±30.14), (119.13±29.14), and (162.05±22.05) N/mm respectively, showing significant differences between groups (P<0.05). There were significant differences in torque between different torsion angles in the same group, as well as in the torque between groups at the same torsional angle (P<0.05). The torsion stiffness in groups PFLCP, PFNA, and PFMBP were (1.45±0.44), (1.10±0.13), and (1.36±0.32) N·mm/deg respectively; there were significant differences when compared groups PFLCP and PFMBP with group PFNA (P<0.05), but no significant difference was found between group PFLCP and group PFMBP (P>0.05). The failure loads of groups PFLCP, PFNA, and PFMBP were (1 408.88± 0.17), (1 696.56±0.52), and (2 154.65±0.10) N respectively, showing significant differences between groups (P<0.05). Conclusion The newly-designed PFMBP is better than PFNA and PFLCP in axial load stiffness and torsion stiffness for fixing reverse oblique intertrochanteric fracture by biomechanical test, indicating that reconstruction of medial stability is a key element for unstable intertrochanteric fracture.