Oral bisphosphonates and risk of subtrochanteric or diaphyseal femur fractures in a population‐based cohort

Bisphosphonates are the primary therapy for postmenopausal and glucocorticoid‐induced osteoporosis. Case series suggest a potential link between prolonged use of bisphosphonates and low‐energy fracture of subtrochanteric or diaphyseal femur as a consequence of oversuppression of bone resorption. Using health care utilization data, we conducted a propensity score–matched cohort study to examine the incidence rates (IRs) and risk of subtrochanteric or diaphyseal femur fractures among oral bisphosphonate users compared with raloxifene or calcitonin users. A Cox proportional hazards model evaluated the risk of these fractures associated with duration of osteoporosis treatment. A total of 104 subtrochanteric or diaphyseal femur fractures were observed among 33,815 patients. The estimated IR of subtrochanteric or diaphyseal femur fractures per 1000 person‐years was 1.46 [95% confidence interval (CI) 1.11–1.88] among the bisphosphonate users and 1.43 (95% CI 1.06–1.89) among raloxifene/calcitonin users. No significant association between bisphosphonate use and subtrochanteric or diaphyseal femur fractures was found [hazard ratio (HR) = 1.03, 95% CI 0.70–1.52] compared with raloxifene/calcitonin. Even with this large study size, we had little precision in estimating the risk of subtrochanteric or diaphyseal femur fractures in patients treated with bisphosphonates for longer than 5 years (HR = 2.02, 95% CI 0.41–10.00). The occurrence of subtrochanteric or diaphyseal femur fracture was rare. There was no evidence of an increased risk of subtrochanteric or diaphyseal femur fractures in bisphosphonate users compared with raloxifene/calcitonin users. However, this study cannot exclude the possibility that long‐term bisphosphonate use may increase the risk of these fractures. © 2011 American Society for Bone and Mineral Research.     

A rare case of a bisphosphonate-induced peri-prosthetic femoral fracture

An 81-year-old woman presented with a fracture in the left femur. She had well-fixed bilateral hip replacements and had received long-term bisphosphonate treatment. Prolonged bisphosphonate use has been recently linked with atypical subtrochanteric and diaphyseal femoral fractures. While the current definition of an atypical fracture of the femur excludes peri-prosthetic fractures, this case suggests that they do occur and should be considered in patients with severe osteopenia. Union of the fracture followed cessation of bisphosphonates and treatment with teriparatide. Thus, this case calls into question whether prophylactic intramedullary nailing is sufficient alone to treat early or completed atypical femoral fractures.     

Validation of diagnostic codes for subtrochanteric, diaphyseal, and atypical femoral fractures using administrative claims data

Administrative claims databases have large samples and high generalizability. They have been used to evaluate associations of atypical femoral fractures with bisphosphonates. We developed and assessed accuracy of claims-based algorithms with hospital and physician diagnosis codes for these fractures. Medical records and radiology reports of all adults admitted at University of Alabama at Birmingham Health System from 2004 to 2008 with International Classification of Diseases, Ninth Revision hospital discharges and surgeons' fracture repair codes for subtrochanteric femoral fractures and random sample of other femoral fractures were reviewed. We identified 137 persons with suspected subtrochanteric femoral fractures and randomly selected 50 persons with either suspected diaphyseal femoral fractures or hip fractures other than subtrochanteric and diaphyseal femoral fractures (typical hip fractures). Eleven patients had radiographic features indicative of atypical femoral fractures. The positive predictive value (PPV) of claims-based algorithms varied with primary or secondary positions on discharge diagnoses and the sources of diagnosis codes. The PPV for fractures ranged 69-89% for subtrochanteric femoral, 89-98% for diaphyseal femoral, and 85-98% for typical hip fractures. The PPV of administrative codes for defining a femoral fracture as atypical was low and imprecise. Claims-based algorithms combining hospital discharges with surgeon's diagnosis codes had high PPV to identify the site of subtrochanteric or diaphyseal femoral fractures vs typical hip fractures. However, claims-based data were not accurate in identifying atypical femoral fractures. These claims algorithms will be useful in future population-based observational studies to evaluate associations between osteoporosis medications and subtrochanteric and diaphyseal femoral fractures.     

Racial/ethnic differences in hip and diaphyseal femur fractures

Summary

Contemporary femur fracture rates were examined in northern California women and compared by race/ethnicity. During 2006–2012, hip fracture rates declined, but diaphyseal fracture rates increased, especially in Asians. Women with diaphyseal fracture were younger and more likely to be bisphosphonate-treated. These disparities in femur fracture should be further examined.

Introduction

The epidemiology of diaphyseal femur fracture differs from proximal femur (hip) fracture, although few studies have examined demographic variations in the current era. This study examines contemporary differences in low-energy femur fracture by race/ethnicity in a large, diverse integrated health-care delivery system.

Methods

The incidence of hip and diaphyseal fracture in northern California women aged ≥50 years old during 2006–2012 was examined. Hip (femoral neck and pertrochanteric) fractures were classified by hospital diagnosis codes, while diaphyseal (subtrochanteric and femoral shaft) fractures were further adjudicated based on radiologic findings. Demographic and clinical data were obtained from health plan databases. Fracture incidence was examined over time and by race/ethnicity.

Results

There were 10,648 (97.3 %) hip and 300 (2.7 %) diaphyseal fractures among 10,493 women. The age-adjusted incidence of hip fracture fell from 281 to 240 per 100,000 women and was highest for white women. However, diaphyseal fracture rates increased over time, with a significant upward trend in Asians (9 to 27 per 100,000) who also had the highest rate of diaphyseal fracture. Women with diaphyseal fracture were younger than women with hip fracture, more likely to be of Asian race and to have received bisphosphonate drugs. Women with longer bisphosphonate treatment duration were also more likely to have a diaphyseal fracture, especially younger Asian women.

Conclusion

During 2006 to 2012, hip fracture rates declined, but diaphyseal fracture rates increased, particularly among Asian women. The association of diaphyseal fracture and bisphosphonate therapy should be further investigated with examination of fracture pattern.     

Incidence of atypical nontraumatic diaphyseal fractures of the femur

Bisphosphonates reduce the rate of osteoporotic fractures in clinical trials and community practice. “Atypical” nontraumatic fractures of the diaphyseal (subtrochanteric or shaft) part of the femur have been observed in patients taking bisphosphonates. We calculated the incidence of these fractures within a defined population and examined the incidence rates according to duration of bisphosphonate use. We identified all femur fractures from January 1, 2007 until December 31, 2011 in 1,835,116 patients older than 45 years who were enrolled in the Healthy Bones Program at Kaiser Southern California, an integrated health care provider. Potential atypical fractures were identified by diagnostic or procedure codes and adjudicated by examination of radiographs. Bisphosphonate exposure was derived from internal pharmacy records. The results showed that 142 patients had atypical fractures; of these, 128 had bisphosphonate exposure. There was no significant correlation between duration of use (5.5 ± 3.4 years) and age (69.3 ± 8.6 years) or bone density (T‐score ?2.1 ± 1.0). There were 188,814 patients who had used bisphosphonates. The age‐adjusted incidence rates for an atypical fracture were 1.78/100,000/year (95% confidence interval [CI], 1.5–2.0) with exposure from 0.1 to 1.9 years, and increased to 113.1/100,000/year (95% CI, 69.3–156.8) with exposure from 8 to 9.9 years. We conclude that the incidence of atypical fractures of the femur increases with longer duration of bisphosphonate use. The rate is much lower than the expected rate of devastating hip fractures in elderly osteoporotic patients. Patients at risk for osteoporotic fractures should not be discouraged from initiating bisphosphonates, because clinical trials have documented that these medicines can substantially reduce the incidence of typical hip fractures. The increased risk of atypical fractures should be taken into consideration when continuing bisphosphonates beyond 5 years. © 2012 American Society for Bone and Mineral Research.     

Atypical Subtrochanteric and Femoral Shaft Fractures and Possible Association with Bisphosphonates

Several case series and multiple individual case reports suggest that some subtrochanteric and femoral shaft fractures might occur in patients who have been treated with long-term bisphosphonates. Several unique clinical and radiographic features are emerging: prodromal thigh pain prior to the fracture, complete absence of trauma precipitating the fracture, and bilateral fractures in some patients. Radiographic features include presence of stress reaction, transverse or short oblique fractures, and thick femoral cortices. The overall incidence of subtrochanteric and shaft fractures combined is below 30 per 100,000 person-years, so this type of fracture is much less common than proximal femur (hip) fracture. Furthermore, the unique “atypical” fracture type is a subset of all subtrochanteric and femoral shaft fractures. The putative mechanism is unknown, and more research is needed to identify distinctive characteristics and the pathophysiology of these atypical fractures. There is no rationale to withhold bisphosphonate therapy from patients with osteoporosis, although continued use of bisphosphonate therapy beyond a treatment period of 3 to 5 years should be re-evaluated annually.     

Clinical correlates of atypical femoral fracture

BackgroundReports of atypical femur fracture in bisphosphonate-exposed women have prompted interest in characterizing the clinical profiles of these patients.MethodsAmong women age ≥ 60 years with hip or femur fracture during 2007–2008, we identified 79 with low-trauma subtrochanteric or femoral shaft fracture. Radiographic images were reviewed to assign fracture pattern and distinguish atypical femur fracture from non-atypical femur fracture. Differences in clinical characteristics and pharmacologic exposures were compared.ResultsAmong 79 women (38 subtrochanteric and 41 femoral shaft fracture), 38 had an atypical femur fracture. Compared to those with a non-atypical femur fracture, women with atypical femur fracture were significantly younger (74.0 vs 81.0 years), more likely to be Asian (50.0 vs 2.4%) and to have received bisphosphonate therapy (97.4 vs 41.5%). Similarly, the contralateral femur showed a stress or complete fracture in 39.5% of atypical femur fractures vs 2.4% non-atypical femur fracture, and focal cortical hypertrophy of the contralateral femur in an additional 21.1% of atypical cases.ConclusionsWomen suffering atypical femur fractures have a markedly different clinical profile from those sustaining typical fractures. Women with atypical femur fracture tend to be younger, Asian, and bisphosphonate-exposed. The high frequency of contralateral femur findings suggests a generalized process.     

Trends in Media Reports,Oral Bisphosphonate Prescriptions,and Hip Fractures 1996–2012: An Ecological Analysis

Bisphosphonates are effective for the treatment of osteoporosis despite recent reports of safety concerns such as atypical femur fracture. We conducted an ecological analysis of relevant media reports, oral bisphosphonate use, and fracture outcomes in the United States. Trends in media reports and public interest of bisphosphonates were quantified using data from Google Trends. Data from the Medical Expenditure Panel Survey (MEPS) and the National Inpatient Sample (NIS) were used to estimate the trends in oral bisphosphonate use among patients aged 55 years and older and hospitalizations for intertrochanteric and subtrochanteric fractures, respectively. These trends in the prevalence of oral bisphosphonate use and the age‐adjusted incidence rate of intertrochanteric and subtrochanteric fractures were examined from 1996 to 2012. A series of spikes in Internet search activity for alendronate (Fosamax) occurred between 2006 and 2010 immediately following media reports of safety concerns. Oral bisphosphonate use declined by greater than 50% between 2008 and 2012 (p < 0.001) after increasing use for more than a decade. The decline was more common in patients with lower education levels. Intertrochanteric hip fractures declined from 1996 through 2006 (p < 0.001) and continued to decline from 2008 to 2012 (p < 0.05). Subtrochanteric and diaphyseal fractures showed a steady and significant increase from 2002 to 2011 (p < 0.05). However, the incidence decreased from a peak of 30.5 per 100,000 in 2011 to 26.7 per 100,000 in 2012. The plateauing and subsequent decline in oral bisphosphonate use since 2006 coincided with reports of safety concerns of bisphosphonates, despite the fact that U.S. Food and Drug Administration (FDA) and American Society of Bone and Mineral Research (ASBMR) reports did not recommend any safety restrictions on their use. This decline in oral bisphosphonate use was followed by the decline in the incidence of subtrochanteric and diaphyseal fractures. © 2015 American Society for Bone and Mineral Research.     

股骨近端外侧锁定钢板治疗Russell-TaylorⅡ型股骨转子下骨折

目的探讨股骨近端外侧锁定钢板治疗股骨转子下骨折的治疗效果。方法对28例Russell-TaylorⅡ型股骨转子下骨折患者采用股骨近端外侧锁定钢板固定。结果 28例均获得随访,时间10～24个月。根据髋关节Harris评分:优13例,良10例,中5例。结论股骨近端外侧锁定钢板治疗股骨转子下骨折可以达到可靠的固定效果,骨折愈合较快,短期临床疗效良好。     

Atypical fracture of the tibial diaphysis associated with bisphosphonate therapy: A case report

Atypical subtrochanteric femoral shaft fractures (AFFs) have recently emerged as a potential long-term complication of bisphosphonate therapy. In 2010, the American Society for Bone and Mineral Research (ASBMR) Task Force published a definition for AFF consisting of 5 major and 7 minor features. Little attention has so far been paid to the possibility that bisphosphonate-associated atypical fractures may also involve the diaphysis of other long bones. We report here the case of a patient on long-term bisphosphonate therapy who presented a diaphyseal tibial insufficiency fracture fulfilling all the major criteria (except for the location), and a number of the minor criteria of an atypical fracture. Our case report suggests the need for greater awareness of the possibility of atypical fractures at other sites, particularly in weight-bearing long bones other than the femur, and suggests that long-term bisphosphonate therapy may also contribute to the occurrence of these atypical fractures.     

Atypical femur fractures among breast cancer and multiple myeloma patients receiving intravenous bisphosphonate therapy

PurposeAtypical femur fractures represent a potential complication of chronic oral bisphosphonate therapy in women with osteoporosis, but the risk of atypical femur fractures among cancer patients receiving intravenous bisphosphonates at higher cumulative doses remains unclear. We examined femur fractures occurring in cancer patients treated with intravenous bisphosphonates (IVBP) to determine whether a subset may be atypical fractures.MethodsBetween 2005 and 2010, we identified patients with known IVBP therapy for multiple myeloma or metastatic breast cancer, who subsequently sustained a femur fracture based on hospitalization, oncology, pharmacy and chemotherapy visit records. Radiographs were examined by an orthopedic surgeon to determine anatomic fracture site and pattern. An atypical fracture was defined as a transverse or short oblique fracture occurring below the lesser trochanter with evidence of focal hypertrophy of the lateral cortex and absence of biopsy-proven malignancy or radiation therapy at the fracture site.ResultsA total of 62 patients with breast cancer (N = 39) or multiple myeloma (N = 23) with femur fracture and prior IVBP treatment for bone malignancy were identified. There were 30 proximal hip, 18 subtrochanteric and 14 femoral shaft fractures. Intraoperative bone samples were sent in 29 of 58 fracture cases undergoing operative repair, with 76% positive for malignancy. Six cases (4 breast cancer, 2 multiple myeloma) of atypical femur fracture were identified, two with negative intraoperative pathology and four with no bone biopsy samples sent. Five of the six patients with atypical fracture had bilateral femur findings, including two with transverse fracture in the contralateral femur and three with focal hypertrophy of the contralateral cortex. Two atypical fracture cases also experienced osteonecrosis of the jaw compared to 3 in the remaining cohort (33% vs. 5%, p = 0.07). Patients with atypical fracture received more IVBP (median 55 vs. 15 doses) and zoledronic acid (32 vs. 12 doses) and had longer treatment duration (median 5.9 vs. 1.6 years) compared to patients without atypical fracture (all p ≤ 0.01).ConclusionsAmong 62 patients who received IVBP for skeletal malignancy and experienced a femur fracture, we identified six cases of atypical fracture. While fractures in this population are often assumed to be pathologic, prospective studies investigating fracture pattern, microscopic bone pathology and pharmacologic exposures should be conducted to further examine the association of IVBP and atypical femur fractures.     

Evolution of bisphosphonate-related atypical fracture retrospectively observed with DXA scanning

We present a case of a 61-year-old female with history of long-term bisphosphonate therapy for osteoporosis initially diagnosed by screening dual-energy X-ray absorptiometry (DXA). After 4 years of treatment with bisphosphonates, the patient presented to primary care with left hip pain. Diagnostic hip radiographs were interpreted as normal, and she continued to take bisphosphonates. Two months later, she experienced a complete transverse subtrochanteric left femur fracture after minimal trauma. The patient underwent open reduction and internal fixation. Review of the patient's postoperative films revealed lateral subtrochanteric cortical beaking at the fracture. This type of "atypical" fracture has been reported to be a result of chronic bisphosphonate-associated fractures with high specificity. In addition, the right femur also showed cortical beaking with a horizontal linear lucency in an identical location, suggesting an impending fracture. Longitudinal review of the both diagnostic radiographs as well as DXA images shows a stepwise development of these subtrochanteric abnormalities in both femurs. A current hypothesis regarding the pathophysiology of bisphosphonate-associated fracture is that the medication inhibits bone turnover and repair of microscopic trauma. A cycle of defective repair and continual microtrauma compounded over time gradually weakens the bone and creates an architectural conduit for transverse or "atypical" fracture. Standard practice is not to use DXA as a diagnostic "image." We present this case to show that a common location and classic appearance of subtrochanteric bisphosphonate-associated fractures may be clearly visualized on absorptiometry images long before fracture. This observation is important because the majority of patients taking bisphosphonate therapy also receive regular DXA imaging. Because of the chronicity of standard bone-density monitoring for these patients throughout their treatment regimen, DXA may find a role for early detection of cortical abnormalities.     

Atypical femoral fractures and bisphosphonate treatment: experience in two large United Kingdom teaching hospitals

We performed a retrospective review of all patients admitted to two large University Hospitals in the United Kingdom over a 24-month period from January 2008 to January 2010 to identify the incidence of atypical subtrochanteric and femoral shaft fractures and their relationship to bisphosphonate treatment. Of the 3515 patients with a fracture of the proximal femur, 156 fractures were in the subtrochanteric region. There were 251 femoral shaft fractures. The atypical fracture pattern was seen in 27 patients (7%) with 29 femoral shaft or subtrochanteric fractures. A total of 22 patients with 24 atypical fractures were receiving bisphosphonate treatment at the time of fracture. Prodromal pain was present in nine patients (11 fractures); 11 (50%) of the patients on bisphosphonates suffered 12?spontaneous fractures, and healing of these fractures was delayed in a number of patients. This large dual-centre review has established the incidence of atypical femoral fractures at 7% of the study population, 81% of whom had been on bisphosphonate treatment for a mean of 4.6 years (0.04 to 12.1). This study does not advocate any change in the use of bisphosphonates to prevent fragility fractures but attempts to raise awareness of this possible problem so symptomatic patients will be appropriately investigated. However, more work is required to identify the true extent of this new and possibly increasing problem.     

Peri-implant atypical femoral fracture after nail or plate osteosynthesis

BackgroundA lack of scientific information regarding the risk factors and diagnosis of peri-implant atypical femoral fracture (PI-AFF) exists. We report a case series of developed PI-AFF with a nail or plate construct wherein prior femoral fractures were already healed after osteosynthesis. This study aimed to identify the cause and risk factors of PI-AFF and to devise a preventive method based on this.MethodsWe identified 11 PI-AFFs displaying features of AFFs. All patients were ambulant females (mean age, 74.9 years). The mean T-score of the femur measured by DEXA (Dual Energy X-ray Absorptiometry) scan was 3.5. Osteosynthesis was performed with a plate and an intramedullary nail in six and five patients, respectively. Possible risk factors were investigated, including the used implant, the medication of bisphosphonate, the characteristics of previous fracture (AFF or non-AFF), and the co-existence of AFF on the contralateral side.ResultsThe PI-AFFs developed at an average of 6.6 years from the time of prior fracture. All fractures were located at the screw through the plate or nail. Regarding anatomic locations, seven and four fractures were at the subtrochanteric area and diaphysis, respectively. Diaphyseal PI-AFFs occurred in plating cases, all of which were associated with excessive femoral bowing. Subtrochanteric PI-AFFs included all five patients with nail fixation, which occurred near a proximal interlocking screw. Six of the 11 patients were on bisphosphonate treatment before or at the time of fracture. The duration of bisphosphonate treatment was 6 years on average. Concerning the previous femoral fractures, seven and four patients were AFF and non-AFF, respectively. Considering the pathology on the contralateral leg, eight had suffered diaphyseal AFF. Four patients were treated nonoperatively. Seven patients needed an operation; 6 of them healed after reconstruction nailing, and one needed hip arthroplasty because of the associated displaced femoral neck fracture.ConclusionsPI-AFFs may develop through the screw hole at the subtrochanteric or diaphyseal area due to femoral fragility and stress riser effect of the implant. An improved osteosynthesis strategy may be necessary to avoid PI-AFFs when fixing osteoporotic femoral fractures.     

Dichotomous location of 160 atypical femoral fractures

Background and purpose The risk of atypical fracture of the femur is associated with bisphosphonate use. While characterizing atypical fractures from a previous nationwide study in radiographic detail, we had the impression that the fractures were located either in the subtrochanteric region or in the shaft. We determined whether there is a dichotomy in this respect.

Patients and methods The distance between the atypical fractures and the lesser trochanter was measured on plain radiographs from 129 of 160 patients with atypical fractures, taken from 2008 through 2010. Analysis of the distances measured showed 2 clusters, which were then analyzed with regard to bisphosphonate use and age.

Results The distribution of the distances would be best described as 2 clusters, with a dichotomy at 8 cm. The proximal (subtrochanteric) cluster comprised 25 patients who were generally younger (median 71 years) than the 104 patients in the cluster with shaft fractures (median 80 years). The 95% CI for the difference between medians was 4–11 years. Of the patients with subtrochanteric fractures, 18 of 25 used bisphosphonates as compared to 89 of 104 with shaft fractures.

Interpretation The younger age and possibly smaller proportion of bisphosphonate users in the subtrochanteric cluster may be compatible with a greater influence of mechanical stress in the underlying pathophysiology of proximal fractures.     

Retrograde entry portal for cephalomedullary nailing in difficult subtrochanteric fractures

An entry point medial to the tip of the greater trochanter is considered optimal for antegrade femur nailing. The deforming forces in a subtrochanteric fracture often make it difficult to establish a perfect entry point during antegrade cephalomedullary nailing. To overcome this problem, we report a simple technique of making a retrograde entry portal for select difficult subtrochanteric fractures. The technique was used in 12 subtrochanteric fractures. Our indications were morbid obesity, revision nailing and atypical fractures. The technique involves creating a nail entry portal through the fracture from distal to proximal taking advantage of the abducted proximal fragment. Fracture reduction and nail insertion then proceeds in a standard manner. Additional reaming of the thick endosteal lateral cortex through the fracture was performed in atypical fractures. Satisfactory fracture reduction was achieved in all patients and 11 out of the 12 fractures united in the series. 1 patient developed an infected nonunion and was considered failure of treatment. The retrograde entry portal is a valuable alternative method that can be considered in nailing of difficult subtrochanteric fractures to establish an ideal entry point and nail trajectory.     

Epidemiology of diaphyseal and distal femoral fractures in Rochester, Minnesota, 1965-1984

Over the 20-year period from 1965 to 1984, 370 residents of Rochester, Minnesota experienced 402 femoral fractures exclusive of the hip, giving an overall incidence rate of 37.1 per 100,000 person-years (95% confidence interval, 33.4-40.8). Of these, 54 were subtrochanteric and 210 were diaphyseal, while 123 involved the distal femur and 15 were at unspecified femoral sites. Fifty-eight percent of these fractures were caused by severe trauma. The incidence of femoral fractures due to severe trauma was greatest in young patients, especially for diaphyseal fractures, and showed a male excess. One-third of the fractures were associated with moderate trauma and were responsible for the rising incidence rates with age at all three fracture sites. These increases were greater in women. Eighty percent of patients 35 years of age or older with fractures due to moderate trauma had prior evidence of generalized osteopenia or a condition likely to cause localized osteopenia in the fractured femur. These data confirmed similar findings from Sweden, providing evidence for a relationship between osteoporosis and femoral fractures distal to the hip.     

Treatment of multifragmentary fractures of the femur by indirect reduction (biological) and plate fixation

We present a retrospective review of the results of 43 multifragmentary femur fractures treated under the principle of indirect reduction (biological) and plate fixation. Fractures were caused by high-energy trauma in all patients. Sixteen were subtrochanteric, 14 diaphyseal and 13 supracondylar. There were 13 open fractures. In six of the patients with diaphyseal fractures, a plate was inserted through isolated proximal and distal incisions only, deep to the vastus lateralis. None of the fractures was treated with bone graft. The mean follow-up time was 28.3 months. Union was achieved in 41 patients within a mean period of 4.25 months. There was delayed union in one patient (subtrochanteric), non-union in two, infection in three, malunion in three, leg shortening in six and mild knee stiffness in seven. In eight patients with diaphyseal fractures in whom a single incision was performed, the average time for fracture healing was 4.14 months in seven and non-union developed in one. In six patients with diaphyseal fractures, in whom proximal and distal incisions were performed, the average time for fracture healing was 4 months. There was no difference (P>0.05) between single and double incision with reference to infection and time to union, but the indirect reduction methods must be meticulously implemented. The implants we used are cheaper and more easily supplied than many others. The success rate is high when the technique is correctly implemented. We believe that this is a treatment of choice in countries with low socioeconomic status, no efficient health insurance system and no intraoperative image intensification.     

Gamma钉治疗股骨转子间及转子下骨折

目的：探讨Gamma钉治疗股骨转子间及转子下骨折的效果。方法：用Gamma钉固定治疗46例股骨转子间及转子下骨折。结果：随访6－22个月（平均13个月）,所有病例均获骨性愈合,平均愈合时间为股骨转子间骨折2个月、股骨转子下骨折5个月。患肢关节功能良好,无髋内翻畸形。结论：Gamma钉治疗股骨转子间及转子下骨折临床效果满意。