The AO/ASIF proximal femoral nail antirotation (PFNA): A new design for the treatment of unstable proximal femoral fractures

Introduction

PFNA design compacts the cancellous bone to provide increased stability and has been bio-mechanically proven to retard rotation and varus collapse.

Methods

Between 2006 and 2007, 62 consecutive patients with unstable proximal femoral fractures were treated with the PFNA.

Results

Twenty males and 42 females with a mean age of 78 years (44-94) were reviewed. In 48 patients, the fracture resulted from a low energy injury. The majority of the fractures belonged to AO/ASIF types 31A2.3 (22) and 31A3.2 (29). Twelve patients required open reduction. The PFNA blade position was central in 52 patients with a mean tip-apex distance (TAD) of 12 mm (range 4-34 mm). Post-operatively, five patients died within 3 months and two patients were lost to follow-up. Forty-nine fractures united between 3 and 4 months. Four patients had delayed union. The PFNA blade cut out rate was 3.6%.

Conclusions

Unstable proximal femoral fractures were treated successfully with the PFNA. The PFNA blade appears to provide additional anchoring in osteoporotic bone. No results have been published on this new design.     

Correction of malalignment in proximal femoral nailing—Reduction technique of displaced proximal fragment

Introduction

External rotation, abduction, and flexion of the proximal fragment in proximal femoral fracture are one of the main obstacles in nailing. We introduced simple surgical technique using a long hemostatic forceps to achieve fracture reduction and to facilitate preparation of the nail entry site.

Method

Using this reduction method, 16 patients with displaced subtrochanteric or proximal femoral shaft fracture were treated through cephalomedullary or femoral nailing between January 2005 and May 2007.

Results

The difference of the neck-shaft angle in the AP view compared to the normal side was 2.2° (range, 0-5°). Anterior angulation in the lateral view was 1.6° (range, 0-15°). One case of malunion was caused by too anterior nail insertion in the lateral view. Bone union was achieved in all cases with an average consolidation time of 5.1 months (range, 3-9 months).

Conclusion

A simple reduction technique using readily available instruments in the operating room (hemostatic forceps) is quite useful in reducing proximal femoral fragments in cephalomedullary or femoral nailing.     

Evaluation of proximal femoral locking plate in unstable extracapsular proximal femoral fractures: Surgical technique & mid term follow up results

Background

Stable trochanteric femur fractures can be treated successfully with conventional implants such as sliding hip screw, cephalomedullary nails, angular blade plates. However comminuted and unstable inter or subtrochanteric fractures with or without osteoporosis are challenging & prone to complications. The PF-LCP is a new implant that allows angular stability by creating fixed angle block for treatment of complex, comminuted proximal femoral fractures.

Method

We reviewed 30 patients with unstable inter or subtrochanteric fractures, which were stabilized with PF-LCP. Mean age of patient was 65 years, and average operative time was 80 min. Patients were followed up for a period of 3 years (June 2010–June 2013). Patients were examined regularly at 3 weekly interval for signs of union (radiological & clinical), varus collapse (neck-shaft angle), limb shortening, and hardware failure.

Result

All patients showed signs of union at an average of 9 weeks (8–10 weeks), with minimum varus collapse (<10°), & no limb shortening and hardware failure. Results were analysed using IOWA (Larson) hip scoring. Average IOWA hip score was 77.5.

Conclusion

PF-LCP represents a feasible alternative for treatment of unstable inter- or subtrochanteric fractures.     

Lower limb malrotation following MIPO technique of distal femoral and proximal tibial fractures

Objective

To determine the incidence of rotational malalignment in distal femoral and proximal tibial fractures using computed tomography (CT) scanograms following indirect reduction and internal fixation with the minimally invasive percutaneous osteosynthesis (MIPO) technique.

Design

Prospective Cohort.

Setting

Level I Trauma Centre.

Patients/Participants

A total of 27 consecutive subjects, and 14 proximal tibia and distal femur fractures.

Intervention

All patients underwent indirect reduction and internal fixation with a MIPO plating system. A CT scanogram to measure rotational malalignment between the injured and non-injured extremity was then undertaken.

Main outcome measure(s)

Femoral anteversion angles and tibial rotation angles between the injured and non-injured extremities were compared. Malrotation was defined as a side-to-side difference of >10°.

Results

A total of 14 postoperative tibias and 13 femurs underwent CT scanograms. Three females and 11 males with an average age of 38.1 years sustained proximal tibia fractures and six females and seven males with an average age of 55.8 years sustained distal femur fractures. The difference between tibial rotation in the injured and the non-injured limbs ranged from 2.7 to 40.0° with a mean difference of 16.2° (p = 0.656, paired T-test). Fifty percent of the tibias fixed with MIPO plates were malrotated >10° from the uninjured limbs. The difference between femoral anteversion in the injured and non-injured limbs ranged from 2.0 to 31.3° with a mean difference of 11.5° (p = 0.005, paired T-test). A total of 38.5% of the distal femurs fixed with MIPO plates were malrotated >10° from the uninjured limb.

Conclusions

Following fixation of distal femoral and proximal tibial fractures, the incidence of malrotation was 38.5% and 50%, respectively. The difference of the mean measures was significant for femoral malrotation; however, statistical significance could not be demonstrated for tibial malrotation. The incidence of malrotation following MIPO plating in this study is much higher than that quoted in previous studies.     

Humeral head necrosis rate at mid-term follow-up after open reduction and angular stable plate fixation for proximal humeral fractures

Introduction

Short-term follow-up of angular stable fixation for proximal humeral fractures has been well documented in the literature. Longer follow-up series are difficult to find. However, especially regarding the risk of avascular humeral head necrosis longer follow-up series are high of clinical relevance.

Methods

Forty-eight patients with a mean age of 66 years and treated with open reduction and angular stable internal fixation for proximal humeral fractures were followed up for a mean of 45 months. The clinical and radiographic follow-up (Constant Score (CS), age and gender related Constant Score (agCS), Constant Score in comparison to the contralateral side (%CS) and shoulder anterior-posterior and lateral view and axial view X-rays) was performed postoperatively.

Results

Clinical results after 45 months showed a mean CS of 66.2 ± 15.4 points with a mean agCS of 90.0 ± 23.1%. Evaluation of the %CS showed 77.7 ± 17.8%. %CS results showed no significant differences after 45 months in comparison to those obtained after 12 months. However, incidence of avascular necrosis of the humeral head doubled over the follow-up period from 4 cases at 12 months follow-up to 9 cases at final follow-up.

Conclusion

Results of open reduction and internal fixation with angular stable implants for proximal humeral fractures are reliable, however long-term complications such as avascular necrosis of the humeral head need to be evaluated further on since its incidence increases over the time.     

Surgical treatment of two-part fractures of the proximal humerus: Comparison of fixed-angle plate osteosynthesis and Zifko nails

Introduction

Closed reduction and percutaneous pinning using Zifko nails offer the advantage of a minimal soft-tissue dissection but have been criticised for limited stability and secondary fracture dislocation. Angular stable plate osteosynthesis enables anatomic reduction, but carries the risk of soft-tissue traumatisation and consecutive humeral head necrosis. The present study compares the clinical and radiological outcome of patients with dislocated two-part fractures of the proximal humerus, who were treated with either Zifko nails or angular stable plate fixation.

Material and methods

A matched-pair analysis was performed and patient groups were matched according to age (±3 years), sex and fracture type. As many as 11 pairs of patients with a minimum follow-up of 3 years were formed and investigated radiographically and clinically using the Constant score (CS) and the visual analogue scale (VAS) for the patients’ satisfaction.

Results

At the time of follow-up, the absolute CS was 83 points in the PHP group and 78 points in the Zifko group (n.s.). Neither in the age and gender-corrected CS was found a significant difference between the study groups (PHP 104 ± 29, Zifko 95 ± 17, n.s.) nor in terms of subjective patient satisfaction (PHP 6.54; Zifko 7.8, n.s.). The complication rate was also comparable in both groups.

Conclusion

In conclusion, Zifko nailing represents a cost-effective minimally invasive surgical method with a complication rate and clinical outcome comparable to that after angular stable osteosynthesis by angular stable plate fixation in the treatment of two-part fractures of the proximal humerus.     

Patterns of cytokine release and evolution of remote organs from proximal femur fracture in COPD rats

Background

Chronic obstructive pulmonary disease (COPD) is at increased risk for developing osteoporosis (OP) with subsequent proximal femur fracture. The presence of COPD is suggested to be a strong risk factor for proximal femur fracture or hip fracture. However, what happen behind it is not clearly understood.

Objective

To investigate the pattern of cytokine (TNF-a, IL-6, and IL-10) releases in pulmonary and hepatic in rats with COPD suffering from proximal femur fracture, and its possible adverse effect on pulmonary and hepatic.

Methods and subjective

This paper has two parts. In the first part, we describe the procedure of COPD model in detail. In the second part, we study the influences of fracture on the COPD rats. 5 months WISTAR rats with 37 weeks cigarette smoking exposure (CS group) were dynamically determined for pulmonary function, inflammatory response in bronchoalveolar lavage fluid (BALF), histological changes in pulmonary in the first part. When the COPD model is proved to be successful, we begin the second part. COPD rats were euthanized at 2, 24, 48, 72, and 96 h after proximal femur fracture (fracture group) or anaesthesia (control group). Cytokines (TNF-a, IL-6, and IL-10) and myeloperoxidase activity of pulmonary and hepatic (MPO) were measured with enzyme-liked immunosorbent assay technique. Permeability changes of the lung were assessed via bronchoalveolar lavage, and those of the liver via assessment of oedema formation. Tissues were further examined microscopically.

Results

The current sidestream cigarette smoke induced rat COPD model has been proved an adequate animal model with several advantages as assessed by dynamically monitored lung mechanics and pathological changes for 37 weeks. In the second part, TNF-a, IL-6, and IL-10 levels of pulmonary tissue were significantly increased after proximal femur fracture compared to control rats. TNF-a, and IL-6 levels in pulmonary peaked at 2 h, 24 h in fracture group, whereas IL-10 level peaked at 24 h and 96 h. Pulmonary myeloperoxidase activity, permeability and histological score in fracture group were remarkably elevated, and peaked at 24 h. In addition to TNF-a, all above parameters did not return to normal through our study. Hepatic in COPD rats showed notable increase of cytokines (TNF-a, IL-6, and IL-10), myeloperoxidase activity, histological score, and permeability in fracture group compared to control rats, and severity of these changes were much lower than in pulmonary. Apart from TNF-a, the peak of these parameters was at 24 h after fracture. Changes of cytokines, MPO activity, permeability and histological score in pulmonary and hepatic in control rat were little changed.

Conclusion

COPD rats produced a remarkably increase of inflammatory response (TNF-a, IL-6, IL-10) in lung (liver) after proximal femur fracture, which lead to lung (liver) injury, as evidence by changes of MPO, permeability, and histological scores in local organs.     

The primary determinants of radiation use during fixation of proximal femur fractures

Objectives

To establish the primary determinants of operative radiation use during fixation of proximal femur fractures.

Design

Retrospective cohort study.

Setting

Level I trauma centre.

Cohort

205 patients treated surgically for subtrochanteric and intertrochanteric femoral fractures.

Main outcome measures

Fluoroscopy time, dose-area-product (DAP).

Results

Longer fluoroscopy time was correlated with higher body mass index (p = 0.04), subtrochanteric fracture (p < 0.001), attending surgeon (p = 0.001), and implant type (p < 0.001). Increased DAP was associated with higher body mass index (p < 0.001), subtrochanteric fracture (p = 0.002), attending surgeon (p = 0.003), lateral body position (p < 0.001), and implant type (p = 0.05).

Conclusion

The strongest determinants of radiation use during surgical fixation of intertrochanteric and subtrochanteric femur fractures were location of fracture, patient body position, patient body mass index, and the use of cephalomedullary devices. Surgeon style, presumably as it relates to teaching efforts, seems to strongly influence radiation use.     

Outcome of proximal femoral fractures caused by cycling in the young and mid-aged

Background

Cycling is gaining more popularity both as a sport, on and off-road and also as a means of commute. Cycling accidents harbour significant injury risks including fractures. Proximal femoral fractures are uncommonly associated with cycling in the young adult population. The purpose of this study is to describe this unique pattern of injury as well as the outcome of proximal femoral fractures caused by cycling in the young to mid age population.

Methods

Study design: retrospective cohort study. 23 fractures in 22 patients were available for analysis. 11 were femoral neck fractures, with six displaced ones, and the rest trochanteric fractures. 21 patients were male patients, and the average age was 42 (range 27–60). All patients but two were operated within 24 h from admission. Radiographic analysis included reduction quality, fracture classification and arthritic changes. Clinical outcome was measured using SF-12 and Oxford hip scores.

Results

All fractures healed. Two patients with displaced femoral neck fractures developed avascular necrosis requiring arthroplasty. One patient developed an AVN 2 years after a stable trochanteric fracture but did not require an arthroplasty as of yet. Eight patients required hardware removal due to symptoms. 77% of patients had resumed cycling at the pre-injury level. Mean SF-12 score was 47.1 ± 11.7 for the physical component and 53.7 ± 6.3 for the mental component. Mean oxford hip score as was 40.1 ± 12.2. Radiographic analysis revealed good to acceptable reduction quality. Fracture type, age, cycling type and reduction were not significantly associated with outcome.

Conclusion

Proximal femoral fractures caused by cycling in young to mid-aged adults are an emerging pattern of injury. Overall favourable result can be expected in the majority of cases, with displaced femoral neck fractures having a risk for AVN. Further delineation of the exact cause for this phenomenon is required with possible intervention for injury prevention.     

Mid-term outcomes after intramedullary fixation of peritrochanteric femoral fractures using the new proximal femoral nail antirotation (PFNA)

Background

Controversy persists concerning the preferred treatment of peritrochanteric femoral fractures. The purpose of the present study was to evaluate the mid-term outcomes of the newly developed implants - proximal femoral nail antirotation (PFNA) for the stabilisation of this type of fracture.

Methods

Between April 2006 and March 2008, 169 patients with peritrochanteric femoral fractures were treated with PFNA. As many as 26 patients were excluded from the study. According to the Orthopaedic Trauma Association (OTA) classification system, the remaining 143 fractures were classified as 19 cases of AO/OTA 31A1 fractures, 83 cases of 31A2 fractures, 28 cases of 31A3 fractures and 13 cases of 31A combined with proximal 32 fracture or separate proximal 32 fracture. The mean age of these patients was 67 years (range, 20-93 years). The operative time, the overall fluoroscopy time, the duration of hospitalisation and the surgical complications were noted. Patients were followed up for a mean of 21 months (range, 12-36 months). Functional outcomes were assessed according to the Harris hip scoring system.

Results

Fifteen patients (10%) required open reduction. The mean duration of surgery (from the beginning of close reduction to wound closure) was 72 min with a range between 45 and 170 min. The mean fluoroscopy time was 164 s with a range between 92 and 396 s. The mean time of hospital stay was 15 days. Postoperative X-rays showed a good or acceptable reduction in 134 cases (94%), and an ideal implant position in 131 cases (92%). There were 12 (8%) postoperative complications. All patients except one healed their fractures without any implant-specific complication (bending, breaking of the implant, cut out of the PFNA blade, femoral head penetration of the blade or ipsilateral fractures of the femoral shaft at the tip of the implant). The average time to bone healing was 16 weeks (range, 12-25 weeks). At the time of the latest follow-up, 106 patients (74%) were restored to their preoperative mobility. The mean Harris hip score was 84 points (range, 46-100 points). A total of 106 patients (74%) had an excellent or good outcome. According to the patients and/or their caregivers, outcome was described as satisfactory in 120(84%) of the 143 patients, and 36(90%) of the 40 patients, who were more than 80 years old.

Conclusion

The results suggest that PFNA is a very effective and safe method in the treatment of different patterns of peritrochanteric femoral fractures. The fixation is adequate to maintain reduction over time even in osteoporotic bones.     

A comprehensive update on current fixation options for two-part proximal humerus fractures: A biomechanical investigation

Background

Recent advancements in implant technology offer updated options for surgical management that have been rapidly adopted into clinical practice. The objective of this study is to biomechanically test and compare the current fixation options available for surgical fixation of two-part proximal humerus fractures and establish load to failure and stiffness values.

Methods

Sixteen match-paired (32 total) fresh-frozen, cadaveric specimens were randomized to receive 1 of 4 fixation constructs following creation of an AO/OTA Type 11A3 (two-part) proximal humerus fractures. Fixation constructs tested consisted of 3.5 mm fixed angle plate (3.5-FAP), 4.5 mm fixed angle plate (4.5-FAP), humeral intramedullary nail (IMN), and a humeral intramedullary nail with a fixed angle blade (IMN-FAB). Specimen bone density was measured to ensure no adequate, non-osteoporotic bone. Constructs were tested for stiffness and ultimate load to failure and compared via one-way ANOVA analysis with subsequent post hoc Tukey HSD multiple group comparison statistical analysis.

Results

The IMN-FAB construct was significantly stiffer than the 3.5-FAP construct (123.8 vs. 23.9, p < 0.0001), the 4.5-FAP construct (123.8 vs. 33.3, p < 0.0001) and the IMN construct (123.8 vs. 60.1, p = 0.005). The IMN-FAB construct reported a significantly higher load to failure than the 3.5-FAB construct (4667.3 N vs. 1756.9 N, p < 0.0001), and the 4.5-FAP construct (4667.3 N vs. 2829.4 N, p = 0.019, Table 2). The IMN construct had a significantly higher load to failure than the 3.5-FAP construct (3946.8 vs. 1756.9, p = 0.001, Table 2).

Conclusion

Biomechanical testing of modern fixation options for two-part proximal humerus fracture exhibited that the stiffest and highest load to failure construct was the IMN-FAB followed by the IMN, 3.5-FAP and then the 4.5-FAP constructs. However, prospective clinical trials with longer-term follow-up are required for definitive assessment of the ideal fixation construct for surgical management of two-part proximal humerus fractures.     

Risk factor analysis of proximal junctional kyphosis after posterior fusion in patients with idiopathic scoliosis

Study design

A retrospective analysis of 150 adolescents who underwent spinal fusion for idiopathic scoliosis.

Objective

To analyse the incidence of the postoperative proximal junctional kyphosis after posterior fusion to the upper thoracic vertebra in adolescents with idiopathic scoliosis and to explore its risk factors.

Summary of background data

The reported incidence of the proximal junctional kyphosis after the posterior fusion in patients with idiopathic scoliosis varies depending on surgical methods and strategies adopted by the institution.

Methods

The changes in the Cobb angle of the proximal junctional kyphosis on the lateral spine X-ray were measured and the presence of PJK was recorded. The risk factors were screened using statistical analysis.

Results

PJK occurred in 35 out of 123 patients with an overall incidence of 28%. Among them, 28 patients (80%) experienced PJK within 1.5 years after surgery. The PJK-inducing factors included greater than 10° intraoperative decrease in thoracic kyphosis, thoracoplasty, the use of a pedicle screw at the top vertebra, autogenous bone graft and fusion to the lower lumbar vertebra (below L2).

Conclusions

There is a high incidence of postoperative proximal junctional kyphosis after posterior fusion to the upper thoracic vertebra within 1.5 years after surgery in adolescents with idiopathic scoliosis. In order to reduce its incidence, the risk factors for PJK should be carefully evaluated before surgery.     

The influence of osteoporosis in femoral fracture healing time

Aim

In order to assess the effect of osteoporosis on healing time, the files of 165 patients with femoral shaft fractures that were treated in our institution with locked-reamed intramedullary nailing were retrospectively reviewed.

Patients and methods

Patients with open fractures, pathological fractures, revision surgery, severe brain injuries and prolonged ITU stay were excluded. In all patients the Singh-index score for osteoporosis and the canal bone ratio (CBR) were assigned. Sixty-six patients fulfilled the inclusion criteria. Patients were divided into two groups; group A (29 patients) consisted of patients over 65 years old with radiological evidence of osteoporosis and group B (37 patients) of patients between 18 and 40 years old with no signs of osteoporosis.

Results

In all group A patients Singh score ≤4 and CBR > 0.50 were assigned, suggesting the presence of osteoporosis, whereas all group B patients were assigned with Singh score ≥5 and CBR < 0.48. Fractures of group A healed in 19.38 ± 5.9 weeks (12-30) and in group B 16.19 ± 5.07 weeks (10-28), P = 0.02.

Conclusions

Fracture healing of nailed femoral diaphyseal fractures is significantly delayed in older osteoporotic patients. Further studies are required to clarify the exact impact of osteoporosis in the whole healing process.     

Risk of axillary nerve injury during percutaneous proximal humerus locking plate insertion using an external aiming guide

Objectives

The purpose of this study was to determine which screws could be safely inserted percutaneously into a proximal humerus locking plate using a new external aiming guide without injuring the axillary nerve. We also sought to evaluate that all the screws could be accurately inserted in a locked position with the external guide.

Methods

Eight cadaveric specimens were implanted with a proximal humerus locking plate using a minimally invasive direct-lateral deltoid splitting approach using an attached external aiming guide for screw insertion. The anatomic proximity of the axillary nerve to the guidewires and screws was measured following soft tissue dissection and inspection of the nerve.

Results

The two superior holes (C1 and C2) were proximal to the axillary nerve with an average distance of 15.1 mm. Screw F was on average 6.6 mm distal to the axillary nerve but within 2 mm of the nerve in two specimens. In all specimens, the locking screws were appropriately seated in a locked position using the external aiming guide.

Conclusions

This study suggests that percutaneous fixation of a proximal humerus locking plate with an external aiming guide can be safely used for proximal humerus fractures. The limited number of screws that can be inserted into the proximal fragment using the current external guide arm may compromise fixation of more unstable fractures. Therefore, the indications for percutaneous locking plate fixation of the proximal humerus using an external aiming guide should be limited to stable fracture patterns that can be anatomically reduced.     

A comparative biomechanical study of proximal femoral nail (InterTAN) and proximal femoral nail antirotation for intertrochanteric fractures

Purpose

The purpose of this study was to compare the biomechanical strength of the cephalomedullary nail InterTAN in cases of intertrochanteric fractures with the commonly used PFNA.

Methods

Sixteen fresh specimens of the proximal femur were used as intertrochanteric fracture models and were fixed using two fixation devices: the new proximal femoral nail (InterTAN) and proximal femoral nail antirotation (PFNA). An intertrochanteric fracture was created in composite bone models. Each specimen was loaded to simulate single leg stance while stiffness, migration (cut out), compressive force across the fracture site, and distal fragment rotation were monitored. The different internal fixation methods were tested by an experimental press analysis.

Results

Results of tests for femoral strength, stiffness, stability, and bearing capacity demonstrated that the biomechanical function of InterTAN was better than that of PFNA (P < 0.05). Compared with the PFNA nail, InterTAN showed increased strength, stiffness, and resistance torque of 30 %, 15 %, and 27 %, respectively.

Conclusion

Comparison of the treatment of intertrochanteric fractures with InterTAN and PFNA internal fixation showed that the InterTAN yielded improvement relative to the PFNA. InterTAN has a firmer and biomechanically superior performance and is therefore an ideal internal fixation method for treating intertrochanteric fractures. Additional research in osteopenic bone is necessary to comprehensively characterize the effects of the design enhancements of these two implants.     

A systematic review of locking plate fixation of proximal humerus fractures

Purpose

Technique for the fixation of two, three, and four part proximal humerus fractures has rapidly shifted towards the use of specially contoured proximal humerus locking plates. The purpose of this study is to evaluate the short to medium term functional results and common complications associated with the fixation of proximal humerus fractures with locking plates.

Methods

The PubMed and EMBASE databases were used to perform a systematic review of the English literature to assess the functional results and complications associated with proximal humerus locking plates. Our inclusion criteria were proximal humerus fracture due to trauma (excluding pathologic fractures), patients greater than 18 years of age, more than 15 patients in the study or subgroup of interest, at least 18 months follow-up, at least one relevant functional outcome score, and quality outcome score of at least 5/10. Studies that did not meet these criteria were excluded. All institutional, author, and journal information was concealed to minimize reviewer bias.

Results

Twelve studies including 514 patients met the inclusion criteria. At most recent follow-up patients achieved a mean Constant score of 74 and a mean DASH score of 27. The overall rate of complications was 49% including varus malunion, 33% excluding varus malunion, and reoperation rate was 14%. The most common complications included varus malunion 16%, AVN 10%, screw perforation of the humeral head into the joint 8%, subacromial impingement 6%, and infection 4%.

Discussion

Fixation of proximal humerus fractures with proximal humerus locking plates is associated with a high rate of complications and reoperation. Further study is needed to determine what technical errors and patient characteristics are risk factors for failure of this now common fixation technique.     

Health and cost consequences of surgical versus conservative treatment for a comminuted proximal humeral fracture in elderly patients

Objective

This study aims to evaluate the costs and health outcome for surgical and conservative treatment of displaced proximal humeral fractures.

Design

This study is a randomised controlled trial.

Participants

This study included 50 patients aged 60 or older admitted to hospital with a severely displaced three- or four-part fracture.

Interventions

The patients were treated surgically with an angular stable interlocking implant (25 patients) or conservative treatment (25 patients).

Main outcome measure

The outcomes measured included quality-adjusted life years (QALYs) and societal costs.

Results

At 12 months’ follow-up, the mean difference in the number of QALYs was 0.027 (95% confidence interval (CI) = −0.025, 0.078) while the mean difference in total health-care costs was €597 in favour of surgery (95% CI = −5291, 3777).

Conclusion

There was no significant difference in QALYs or costs between surgical and conservative treatment of severe displaced proximal humeral fractures.     

Factors influencing neck anteversion during femoral nailing: a retrospective analysis of 220 torsion-difference CTs

Background

Rotational malalignment is a well-known complication following intramedullary nailing of femoral shaft fractures. The hypothesis of this study is that various modifiable factors, such as position on the surgical table or nailing technique, influence the incidence of torsional abnormalities.

Methods

For this retrospective study, we analysed the data of 220 consecutive patients with femoral shaft fractures and postoperative torsion-difference computed tomographies (CTs), performed from 2001 to 2009 in our institution. Mean age of the patients was 33 ± 15 years. Average delay to surgery was 8 ± 11 days. The average postoperative neck anteversion difference between both sides was 11 ± 8°. A p value <0.05 was considered to be statistically significant.

Results

The average postoperative neck anteversion difference between both sides was not significantly affected from the position of the patient on the surgical table (supine or lateral, p = 0.698), the delay till surgery (p = 0.989), the nailing technique (antegrade or retrograde, p = 0.793; reamed or unreamed, p = 0.930), the type of the implant (p = 0.885) and the experience of the surgeon (p = 0.055). Furthermore, the learning curve regarding this complication was long and not predictable.

Conclusions

We could not identify any risk factors that are associated with an increased incidence of torsional deformities, and thus our hypothesis could not be confirmed. The inability to identify such risk factors renders the prevention of this complication particularly problematic. The invention of new techniques for better intra-operative control of the torsion is probably the only solution to further reduce the incidence of postoperative malrotational deformities.     

The difficult choice between total and proximal gastrectomy in proximal early gastric cancer

Background

Surgical results including postoperative complications, prognoses, body weight changes, and nutritional statuses were compared in patients with early gastric cancer in the upper third of the stomach who were treated by total gastrectomy or proximal gastrectomy.

Methods

The authors reviewed clinicopathologic features, postoperative complications, survivals, body weight changes, and biochemical markers after surgery in 423 patients who underwent total or proximal gastrectomy for early gastric cancer in the upper third of the stomach.

Results

The proximal gastrectomy group (n = 89) had smaller tumors, shorter resection margins, and smaller numbers of retrieved lymph nodes than the total gastrectomy group (n = 334). N stages and 5-year survival rates were similar after total and proximal gastrectomy. Postoperative complication rates after total gastrectomy and proximal gastrectomy were 12.6% and 61.8%, respectively, which was significant (P < .001). Rates of anastomotic stenosis and reflux esophagitis were 6.9% and 1.8% after total gastrectomy and 38.2% and 29.2% after proximal gastrectomy, respectively. The parameters that reflect nutritional status (ie, body weight, serum hemoglobin, total protein, albumin, glucose, and cholesterol) were similar in the proximal and total gastrectomy groups at 6, 12, 24, and 36 months postoperatively.

Conclusion

Although the surgical safeties and curabilities of proximal and total gastrectomy were similar, proximal gastrectomy was found to be associated with a markedly higher rate of complications such as anastomotic stenosis and reflux esophagitis and to provide no benefit in terms of postoperative weight loss. The authors conclude that proximal gastrectomy is not a better option for upper-third early gastric cancer than total gastrectomy.     

Subtrochanteric hip fractures treated with cerclage cables and long cephalomedullary nails: a review of 17 consecutive cases over 2 years

Background

The conflict between the anatomist and biologist surgeons is exemplified by the debate about subtrochanteric hip fractures. Closed intramedullary nailing is biologically friendly but may result in prolonged procedures and malunion. By contrast, accurate anatomical open reduction may disturb the biological composition of the fracture environment.

Methods

There were 17 patients at our institution over a 2-year period whose long oblique subtrochanteric fractures would not reduce perfectly in an anatomical fashion using closed methods. All these patients had their fractures treated identically using a new policy at our unit. This strategy involved reduction of the fracture through an open approach, and then employing cerclage cables to stabilise the fracture in an anatomical position before finally inserting a cephalomedullary nail. These patients were retrospectively reviewed at an average of 18 months postoperatively, to assess their progressive functional and radiological outcome up to that point.

Results

One patient had nonunion and required a secondary procedure. One patient died 8 days postoperatively from a medical complication. The remaining 15 healed within 6 months and all returned to independent living.

Conclusions

The results demonstrate that judicious use of cerclage cables to augment fixation of subtrochanteric femur fractures does not have a deleterious effect on healing. One should endeavour, however, to minimise the number of cables used. The basic science literature underpinning our approach to these unstable fractures is also discussed.