The treatment of stable and unstable proximal femoral fractures with a new trochanteric nail: results of a multicentre study with the Veronail

The incidence of hip fractures continues to rise. This study is the first evaluation of a new intramedullary implant, the Veronail, that provides double axis fixation into the femoral head and allows the surgeon to choose whether to use sliding or fixed locked proximal screw fixation for trochanteric femoral fractures. The fractures were classified according to the AO classification, and function was assessed with the Modified Harris Hip Score. 111 patients with trochanteric fractures were evaluated in eight Italian hospitals. The stable 31.A1 fractures were treated with sliding proximal screws, the subtrochanteric 31.A3 fractures with converging proximal screws, and the unstable 31.A2 fractures were treated with both types of proximal fixation. The unstable fractures treated with locked converging screws had the same function at one year as those treated with sliding screws. This study suggests a possible new method of treating unstable trochanteric femoral fractures. This may be the solution to prevent excessive collapse of the fracture with the resultant poor function and persisting pain noted in the literature. Two converging locked proximal screws seem to provide stable fixation in 31.A2 femoral fractures and produce as good a result as the use of traditional sliding screws. The role of converging locked proximal screws in unstable trochanteric fractures requires further evaluation. Ethical consideration: This work has been approved, where necessary, by the appropriate ethical committees of the institutions where the study has been performed. Subjects gave informed consent prior to participation in the study.     

Ipsilateral hip and distal femoral fractures

We tried to find the trauma mechanism and treatment rationale of ipsilateral concomitant hip and distal femoral fractures involving the articular surface. Between 1988 and 1995, 15 cases of ipsilateral hip (confined to neck or trochanteric areas of the femur) and distal (confined to supra- and intercondylar area of the femur) femoral articular fractures were collected. The hip fractures consisted of 10 trochanteric fractures and five neck fractures, which were managed with reduction and fixation in 14 (Knowles' pin in eight, DHS in four and standard Gamma nail in two), and primary bipolar hemiarthroplastry in one. The distal femoral articular fractures were open in 11; these were managed with radical debridement, implantation of Septopal chains and immediate internal fixation, followed by prophylactic autogenous bone grafting 6 weeks later in the recent six cases (five Judet plates, four dynamic condylar screws and two condylar plates). The other four closed distal femoral fractures were managed with early reduction and internal fixation (two Judet plate, one dynamic condylar screw and one condylar plate). The union time was 20.3 (12-48) weeks for proximal fractures and 23.7 (12-36) weeks for distal fractures. Early infection developed in three cases. Nonunion of a femoral neck fracture developed in one case. The other complications were implant failure in one, coxa vara in one, refracture in one, delayed union in one and knee stiffness in one.     

Bone mass in women with hip fracture

The bone mineral density was determined by dual-photon absorptiometry on the proximal femur in 32 women with femoral neck fractures, 30 with trochanteric fractures, 39 with a fracture elsewhere than the hip, and 16 premenopausal healthy women. Single-photon absorptiometry was performed at two sites on the radius. The bone mineral density in the neck and intertrochanteric area was greater in the women with femoral neck fractures than in those with trochanteric fractures. The bone mineral distribution in the proximal femur was essentially the same for the femoral neck fracture group as for the reference group of healthy women. Neither the Singh index, determined in radiographs, nor the measurements on the radius by single photon absorptiometry provided a reliable estimate of the bone mineral density in the proximal femur     

In vivo discrimination of hip fracture with quantitative computed tomography: Results from the prospective European Femur Fracture Study (EFFECT)

In assessing osteoporotic fractures of the proximal femur, the main objective of this in vivo case‐control study was to evaluate the performance of quantitative computed tomography (QCT) and a dedicated 3D image analysis tool [Medical Image Analysis Framework—Femur option (MIAF‐Femur)] in differentiating hip fracture and non–hip fracture subjects. One‐hundred and seven women were recruited in the study, 47 women (mean age 81.6 years) with low‐energy hip fractures and 60 female non–hip fracture control subjects (mean age 73.4 years). Bone mineral density (BMD) and geometric variables of cortical and trabecular bone in the femoral head and neck, trochanteric, and intertrochanteric regions and proximal shaft were assessed using QCT and MIAF‐Femur. Areal BMD (aBMD) was assessed using dual‐energy X‐ray absorptiometry (DXA) in 96 (37 hip fracture and 59 non–hip fracture subjects) of the 107 patients. Logistic regressions were computed to extract the best discriminates of hip fracture, and area under the receiver characteristic operating curve (AUC) was calculated. Three logistic models that discriminated the occurrence of hip fracture with QCT variables were obtained (AUC = 0.84). All three models combined one densitometric variable—a trabecular BMD (measured in the femoral head or in the trochanteric region)—and one geometric variable—a cortical thickness value (measured in the femoral neck or proximal shaft). The best discriminant using DXA variables was obtained with total femur aBMD (AUC = 0.80, p = .003). Results highlight a synergistic contribution of trabecular and cortical components in hip fracture risk and the utility of assessing QCT BMD of the femoral head for improved understanding and possible insights into prevention of hip fractures. © 2011 American Society for Bone and Mineral Research.     

Bone mass in women with hip fracture

The bone mineral density was determined by dual-photon absorptiometry on the proximal femur in 32 women with femoral neck fractures, 30 with trochanteric fractures, 39 with a fracture elsewhere than the hip, and 16 premenopausal healthy women. Single-photon absorptiometry was performed at two sites on the radius. The bone mineral density in the neck and intertrochanteric area was greater in the women with femoral neck fractures than in those with trochanteric fractures. The bone mineral distribution in the proximal femur was essentially the same for the femoral neck fracture group as for the reference group of healthy women. Neither the Singh index, determined in radiographs, nor the measurements on the radius by single photon absorptiometry provided a reliable estimate of the bone mineral density in the proximal femur.     

A new classification and treatment protocol for combined fractures of the femoral shaft with the proximal or distal femur with closed locked intramedullary nailing: clinical experience of 63 fractures

The medical records and radiographs of 63 patients, who were admitted between 1989-1997, with a combined femur fracture, were reviewed. Associated injuries were present in 38 (60%) patients. The combined fractures were classified into four major types depending on their anatomical position: type I, femoral shaft fracture combined with hip neck fracture; type II, femoral shaft fracture combined with a trochanteric fracture; type III, femoral shaft fracture combined with a distal femur fracture; and type IV, femoral shaft fracture combined with a proximal or distal femur fracture. The fractures were treated with locked intramedullary nailing and additional free cancellous 6.5-mm screws as needed. Fifty-six fractures healed without further operations. Of the remaining 6 fractures, 2 were material failures, 1 malunion with 3-cm shortening and external rotation of the femoral diaphysis, 2 early infections of the surgical wound, and 1 pseudarthrosis of the femoral shaft. All fractures were healed between 16 and 32 weeks (average: 20 weeks).     

支撑-牵张效应对股骨转子间骨折内固定稳定的影响

股骨转子间骨折是常见的老年骨质疏松性骨折,手术内固定是首选的治疗方法,目的是利用内固定物分担髋关节传导的负荷。当前开展的研究大多围绕股骨近端的外侧壁、内侧壁、尖顶距及棘轮机制等学说,基于这些学说设计的单一头颈螺钉或双头颈螺钉的髓外、髓内设计均无法完全避免股骨头穿透的发生。根据股骨近端骨小梁的分布及骨折前后的生物力学变化...     

动力加压髋螺钉取出后钉道内植骨的生物力学意义

目的：探讨动力加压髋螺钉（DHS）内固定治疗股骨上段骨折愈合后,取出DHS以后不处理的股骨上段、钉道植骨的股骨上段和完整的股骨上段的生物力学特性,为临床DHS取出术后进一步治疗提供理论依据。方法：收集16具新鲜尸体股骨标本进行实验应力分析,分别测定完整股骨上段,DHS取出后不处理的股骨上段和DHS取出后钉道内植骨股骨的股骨上段的力学特性,结果：DHS取出术后,不处理的股骨上段与完整股骨上段、DHS取出术后钉道植骨的股骨上段的力学特性相比,差异有显著性（P＜0．01）。结论：股骨颈骨折DHS治疗骨折愈合取出固定后,应在股骨上段螺钉道内植骨补强,这有利于提高股骨上段的生物学性能,便于患者早期全负荷功能锻炼,防止再骨折和髋畸形等并发症的发生。     

The treatment of a fracture of proximal end of the femur in own material]

Results of treatment for fracture of proximal end of the femur in 263 patients (86 males and 177 females) aged between 7 and 104 years were analyzed. Ninety percent of the patients were older than 60 years. Mean follow-up was 4.6 years (range 1 to 9 years). Immediate Austin-Moore hip hemiarthroplasty in the elderly and screw fixation in younger patients rendered best results in the femoral neck fractures. Ender nailing in the elderly and angular plating or skeletal traction in the young proved most successful in trochanteric fractures.     

Reverse distal femoral locking compression plate a salvage option in nonunion of proximal femoral fractures

Background:When primary fixation of proximal femoral fractures with implants fails, revision osteosynthesis may be challenging. Tracts of previous implants and remaining insufficient bone stock in the proximal femur pose unique problems for the treatment. Intramedullary implants like proximal femoral nail (PFN) or surface implants like Dynamic Condylar Screw (DCS) are few of the described implants for revision surgery. There is no evidence in the literature to choose one implant over the other. We used the reverse distal femur locking compression plate (LCP) of the contralateral side in such cases undergoing revision surgery. This implant has multiple options of fixation in proximal femur and its curvature along the length matches the anterior bow of the femur. We aimed to evaluate the efficacy of this implant in salvage situations.Results:All fractures exhibited union without any complications. Union was assessed clinically and radiologically. One case of ipsilateral femoral neck and shaft fracture required bone grafting at the second stage for delayed union of the femoral shaft fracture.Conclusions:Reverse distal femoral LCP of the contralateral side can be used as a salvage option for failed fixation of proximal femoral fractures exhibiting nonunion.     

Reverse obliquity and transverse fractures of the trochanteric region of the femur; a review of 101 cases

BACKGROUND: Reverse obliquity and transverse fractures of the proximal femur represent a distinct fracture pattern in which the mechanical forces displace the femur medially thus increasing the risk of fixation failure. There is a paucity of published literature in this area of trauma. This study constitutes the largest series of such fractures. METHODS: Using a retrospective analysis of prospectively collected data from a single institution, 101 reverse obliquity and transverse fracture patterns were identified from 3336 consecutive hip fractures. All surviving patients were followed up for 1 year. RESULTS: Of 100 patients treated operatively, 59 were treated with 135 degrees sliding hip screws (SHS), 19 with a Medoff plates modification of the SHS, three with a sliding hip screw and trochanteric stabilising plate and 19 with intramedullary sliding hip screw devices. Nine fracture fixation-healing complications occurred, with cut-out being the commonest complication (seven cases). Cut-out of the implant was associated with femoral medialisation and a larger tip to apex distance. CONCLUSION: This fracture pattern is a challenge for the orthopaedic surgeon with a high risk of fracture healing complications. The 135 degrees SHS and the intramedullary devices had similar failure rates.     

Osteonecrosis of the femoral head after osteosynthesis of a proximal femur fracture with a 95° condylar plate

Summary Avascular necrosis of the femoral head is a frequent complication after osteosynthesis of femoral neck fractures. It is rarely seen after proximal femur fractures with intact trochanteric area. The choice of the implant varies from different blade systems (DHS, DCS and condylar plates) to intramedular nailing systems (gamma nail, classic nail). The complication of avascular necrosis of the femoral head after internal fixation of subtrochanteric and proximal femur fractures is reported following intramedullary nailing. We report a case of a femoral head necrosis after osteosynthesis of a proximal femur fracture with a 95 degree condylar plate.      

Stress fractures in the gapped area of a two implant construct: a case report

The concomitant occurrence of femoral shaft and hip fractures are not rare. The ideal management of ipsilateral intertrochanteric and femoral shaft fractures is still controversial and needs to be addressed. Cephalomedullary nail fixations of both the fractures have been described with excellent results. Similar results have been published with two implant constructs treating both of these injuries separately. We report the case of a stress fracture, in the gapped area above the proximal interlocking screw of a retrograde femoral nail placed for a segmental femur fracture and a trochanteric fracture treated with a sliding hip plate screw construct, 9?months after initial injury. The gapped area of a two implant construct is of concern and biomechanical studies have shown that the proximal end of the nail and the interlocking screws may act as a stress riser in the femur. A stress fracture in the gapped area of a two implant construct has not been described earlier, although a cadaveric study had shown that the area of the proximal screw hole of the retrograde nail is a common site for a fracture, on loading. Kissing or overlapping instrumentation increases the load to failure and creates a biomechanically stable construct.     

Dynamic internal fixation of the periprosthetic femoral fractures after total hip arthroplasty

Periprosthetic fractures of the femur after total hip arthroplasty are a big orthopaedic problem, particularly in elderly patients and quite a challenge for orthopaedic surgeons. There is no universal method in treating these fractures. Rigid plates fixation can be limited and aggravated especially in the proximal part of the femur where the endoprosthesis stem does not allow for an undisturbed fixation of both femur cortexes by means of screws. Mitkovic's dynamic internal fixator is an original implant allowing for an undisturbed fixation of both femur cortexes regardless of the presence of the endoprosthesis stem. Fixation is made possible by means of movable clamps and a convergent possibility to place screws. A dynamic internal fixator can fix all types of periprosthetic femoral fractures. The paper shows the early experience in fixating periprosthetic femoral fractures after total hip arthroplasty in 14 patients, average age 69.7. According to Vancouver classification, 3 patients had the type A fracture, 9 patients had the type B fracture, and 2 patients had the type C fracture. All fractures were fixed by Mitkovic's dynamic internal fixator. The fracture occurred 2-12 years after primary total hip arthroplasty. The follow-up of the operated patients was 12 months. The method is less invasive than the methods described in books. Mechanical complications are not likely to appear due to the fracture dynamics along the femoral shaft axis, which is made possible by this implant. Our initial experience in femur fracture fixation after hip arthroplasty ahows that it is modern and effective dynamic implant which will contribute significantly to the improving of the treatment of these often very complicated fractures.     

The PFNA proximal femur nail in treatment of unstable proximal femur fractures--3 cases of postoperative perforation of the helical blade into the hip joint

The proximal femur nail antirotation represents a new generation of intramedullary nailing devices for fixation of stable and unstable trochanteric fractures of the proximal femur. We report 3 cases of postoperative perforation of the helical blade through the femoral head into the hip joint without any signs of rotational or varus displacement of the fracture.     

Ipsilateral fractures of the femoral neck, shaft and distal end: long-term outcome of five cases

Out of 52 cases of ipsilateral femoral fractures treated at a level I trauma centre between June 1994 and March 2008, the diaphyseal fracture was accompanied by a intracapsular neck fracture in only 20 cases. In the rest of the cases, the diaphyseal fracture was combined with either an extracapsular or pertrochanteric fracture. Five of these patients also had fractures of the distal femur. In three of those patients we began treatment with osteosynthesis of the femoral neck and shaft, using a reconstruction nail, then stabilized the distal fracture with a 95° blade plate or with lag screws. In the other two cases, initial treatment dealt with the distal femoral fracture, stabilizing it with a 95° blade plate, which was also used for stabilization of the diaphyseal fracture. In these patients, the proximal fracture was treated using dynamic hip screws (DHS). All fractures healed, two after initial treatment, while the other three needed one reoperation. The follow-up period was 2–13 years after the injury. The order in which fractures are treated is best left to the discretion of the physician and the circumstances. In our experience, two implants are sufficient for osteosynthesis, one for stabilizing one end of the femur together with the shaft, and the other is used for treating the other end of the femur.     

Unstable pertrochanteric femoral fractures

BACKGROUND: Fractures in the trochanteric region of the femur are classified as AO/OTA 31-A, as they are extracapsular. This report analyzes the relatively rare 31-A3 fracture, which has also been referred to as an "intertrochanteric femur fracture with subtrochanteric extension," "reverse obliquity intertrochanteric femur fracture," "unstable intertrochanteric femur fracture," or a "subtrochanteric femur fracture." The A3 fracture is characterized by having a fracture line exiting the lateral femoral cortex distal to the vastus ridge. Possible fixation constructs include compression hip screws, intramedullary hip screws, trochanteric intramedullary nails, cephalomedullary antegrade intramedullary nails, and 95 degrees plates. Most reports investigating 31-A fractures do not describe the 31-A3 fracture. For this analysis, only reports clearly indicating that the fracture treated was a 31-A3 were included. It should be understood that this approach therefore excludes reports on generic "subtrochanteric fractures" or "intertrochanteric fractures," some of which may have been 31-A3 fractures. OBJECTIVE: To determine the effect of fixation technique for the AO/OTA 31-A3 fracture on rates of union, infection, risk of reoperation, and functional outcomes.     

PFLCP与PFNA治疗股骨粗隆间骨折的临床疗效比较

目的回顾总结应用股骨近端锁定加压接骨板(proximal femur locking compression plate,PFLCP)与股骨近端螺旋刀片抗旋髓内钉(proximal femoral nail antirotation blade,PFNA)两种手术内固定治疗股骨粗隆间骨折的临床疗效并进行对比分析。方法从2008年7月至2011年10月,收治股骨粗隆间骨折56例,随机分为两组,一组采用PFLCP内固定,另一组采用PFNA内固定。术后分析手术时间、伤口大小、失血量、完全负重时间、骨折愈合时间及内固定位置情况,并通过Harris功能评分评价下肢功能。结果两组顺利完成手术,术后均定期完成随访,平均随访12个月(8～18个月)。PFNA组在切口长度、术后负重时间均优于PFLCP组(P<0.05),两组在手术时间、术中失血量、骨折愈合时间方面比较差异无统计学意义(P>0.05)。PFLCP组出现2例髋内翻、螺钉松动退出、股骨大粗隆滑囊炎,PFNA组2例分别出现颈干角丢失、螺钉切出股骨头和下肢轻度短缩、螺钉稍退出。结论 PFNA和PFLCP两种内固定在股骨粗隆间骨折治疗中均具有较好疗效,PFNA固定允许患者早期负重,两种内固定均具有自己的优势。     

Osteonecrosis of the femoral head after osteosynthesis of a proximal femur fracture with a 95° condylar plate

Avascular necrosis of the femoral head is a frequent complication after osteosynthesis of femoral neck fractures. It is rarely seen after proximal femur fractures with intact trochanteric area. The choice of the implant varies from different blade systems (DHS, DCS and condylar plates) to intramedular nailing systems (gamma nail, classic nail). The complication of avascular necrosis of the femoral head after internal fixation of subtrochanteric and proximal femur fractures is reported following intramedullary nailing. We report a case of a femoral head necrosis after osteosynthesis of a proximal femur fracture with a 95 degree condylar plate.     

The use of the Richard's dynamic hip screw and hip Zespol fixator in the treatment of proximal femoral fracture]

A series of 49 patients (27 females, 22 males) aged 24-82 operated on due to proximal end of the femur fracture between 1990 and 1995 were included in this study. There were 23 femoral neck fractures and 26 trochanteric fractures. DHS was used in 35 patients and Zespol hip fixator in 14 cases. Good results have been achieved in 85.7%. Neither method proved superior to the other. Poor results occurred in subcapital neck fractures. DHS seems to offer advantage in trochanteric fractures and Zespol method in femoral neck fractures.