Targon® Femoral Neck for femoral-neck fracture fixation: lessons learnt from a series of one hundred and thirty five consecutive cases

Purpose

Internal fixation versus joint replacement for treating intracapsular hip fractures is still a major debate. The Targon® FN fixation concept is innovative; two small case series are promising. We present the first larger series.

Methods

We conducted prospective documentation of all Targon® FN cases since 2006. The implant was used for all undisplaced fractures, and for displaced fractures in patients of a biological age ≤60 years. Besides demographic data and fracture classification, we analysed infection, haematoma, implant perforation, nonunion and operative revision procedures.

Results

In 135 cases (mean age 71 years; average operation time 60 minutes; average hospital stay ten days), we found a surgical complication rate of 16.4 %. Conversion to joint replacement was necessary in 9.6 %. Complication rate was significantly higher in displaced fractures.

Conclusions

Our study confirms low general complication rates. However, implant perforation seems to be underestimated. Optimised reduction technique may help to reduce this complication.     

Management pitfalls of fractured neck of femur in osteogenesis imperfecta

Introduction

Fractured neck of femur in osteogenesis imperfecta is rarely reported. Its management is always difficult because of bone fragility and the outcome is not well known. We, therefore, aimed to study the management pitfalls in this group of patients.

Methods

We retrospectively reviewed five cases of fractured neck of femur in four patients treated in our hospital between 2006 and 2009. The demographic data, mode of injury, fracture configuration, treatment, complications, clinical and radiological outcome were reviewed.

Results

According to the Sillence classification, one patient was type I, two were type III and one was type IV. There were two children (aged 8 and 15 years) and two adults (aged 21 and 22 years), with the 8 year-old girl suffering from hip fracture on different sides in two accidents. All five hip fractures were the result of low-energy injury and were associated with other fractures. Two undisplaced fractures required intra-operative fluoroscopic confirmation to demonstrate movement at the fracture site. The interval between the injury and fixation ranged from 6 h to 3 days. One hip required secondary surgery to openly reduce the fracture due to inadequate primary fixation and reduction. Two hips were fixed with paediatric dynamic hip screws and three hips were fixed with cannulated screws. All patients were immobilised in hip spica for 6 weeks. The average follow-up was 4 years (3–5 years). All patients had satisfactory union and none of them developed radiological evidence of avascular necrosis at the latest follow-up. All patients returned to their pre-injury functional level.

Conclusion

Fractured neck of femur is rare given the high prevalence of long bone fractures in osteogenesis imperfecta. They all have characteristic associated fractures of the extremity at the time of injury and neck of femur fractures could be easily missed. Fracture fixation is a great challenge to the orthopaedic surgeons because of the small size of the patients, poor bone quality with suboptimal imaging intra-operatively and compromised purchase of fixation devices. The choice of implants should be determined by the size of the patients and the presence of prior instrumentation close to the hip joint.     

FRAX? probabilities and risk of major osteoporotic fracture in France

Summary

The incidence of hip fracture, death and the estimated incidence of major osteoporotic fracture in France were used to determine the lifetime and 10-year probability of fracture and incorporated into a probability model (FRAX?) calibrated to the French population.

Introduction

Fracture probabilities in the French population have not been determined. Our aim was to determine the incidence of hip fracture in France and the estimated 10-year probabilities of hip and major osteoporotic fractures.

Methods

The study population included adults over 50?years living in France in 2004. Incident hip fracture cases were identified from the French PMSI database. Incidence of the other major osteoporotic fractures was imputed from the relationship between hip fracture incidence and other major fracture in Sweden. These data were used to calculate population-based fracture probabilities according to age and BMD using cutoff values for femoral neck T-scores from the NHANES III data in Caucasian women. The probability model (FRAX?) calibrated to the French population was used to compute individual fracture probabilities according to specific clinical risk factors.

Results

We identified 15,434 men and 51,469 women with an incident hip fracture. The remaining lifetime probability of hip fracture at 50?years was approximately 10 and 30% respectively. With a femoral neck T-score of ?2 SD, one in two women and one in five men would sustain a major osteoporotic fracture in their lifetime. The 10-year probability of other major osteoporotic fractures increased with declining T-score and increasing age. Low body mass index and other clinical risk factors had an independent effect on fracture probability whether or not BMD was included in the FRAX? model.

Conclusion

This analysis provides detailed estimation on the risk of fracture in the French population and may help to define therapeutic guidelines.     

Primary prosthetic replacement in per- and intertrochanteric fractures

Purpose

Hip arthroplasty is rarely indicated in the treatment of per- and intertrochanteric femur fractures. Although the majority of fractures are amenable to closed- or open reduction and internal fixation (CRIF/ORIF), in some patients the complexity of the fracture or other patient-related factors may cause the orthopaedic surgeon to consider arthroplasty as the treatment of choice. Decision-making is challenging, and a reliable score has not yet been established.

Results

Reviewing literature, several predictors of inferior outcome after CRIF/ORIF in per- and intertrochanteric fractures such as age, gender, poor bone quality, hip osteoarthritis, operation time and postoperative weight-bearing restrictions have been identified. Based on the literature review, a novel Hamburg Per- and Intertrochanteric Fracture Score (HPIFS) is proposed to support decision-making for per- and intertrochanteric fracture treatment.

Conclusions

CRIF/ORIF remain the workhorses in per- and intertrochanteric fracture management. Arthroplasty offers an advantageous treatment option for a well-defined patient and fracture collective. The HPIFS might support the decision-making process.     

Definitive treatment in a spiral-fracture of the distal humerus shaft with severe osteoporosis after two failed osteosynthesis: problem and solution. A case report and literature review

Introduction

Osteoporotic fractures in the elderly are often complicated by delayed union, pseudarthrosis or implant failure and are associated with considerable morbidity and prolonged reconvalescence. At present there is cumulating recommendation to treat this kind of fractures with angular stable implants.

Case presentation

Herein, we report on the successful definitive treatment of a displaced comminuted spiral-fracture of the distal humerus shaft in an 89-year-old woman after two attempts of internal fixation with angular stable implants had failed in severely osteoporotic bone.

Conclusion

The present case illustrates the problems we have faced with after a single locking plate fixation, especially in poor bone, and shows a possible solution by performing a double(-locking)-plate fixation.     

Femur ultrasound (FemUS)—first clinical results on hip fracture discrimination and estimation of femoral BMD

Summary

A quantitative ultrasound (QUS) device for measurements at the proximal femur was developed and tested in vivo (Femur Ultrasound Scanner, FemUS). Hip fracture discrimination was as good as for DXA, and a high correlation with hip BMD was achieved. Our results show promise for enhanced QUS-based assessment of osteoporosis.

Introduction

Dual X-ray absorptiometry (DXA) at the femur is the best predictor of hip fractures, better than DXA measurements at other sites. Calcaneal quantitative ultrasound (QUS) can be used to estimate the general osteoporotic fracture risk, but no femoral QUS measurement has been introduced yet. We developed a QUS scanner for measurements at the femur (Femur Ultrasound Scanner, FemUS) and tested its in vivo performance.

Methods

Using the FemUS device, we obtained femoral QUS and DXA on 32 women with recent hip fractures and 30 controls. Fracture discrimination and the correlation with femur bone mineral density (BMD) were assessed.

Results

Hip fracture discrimination using the FemUS device was at least as good as with hip DXA and calcaneal QUS. Significant correlations with total hip bone mineral density were found with a correlation coefficient R ² up to 0.72 and a residual error of about one half of a T-score in BMD.

Conclusions

QUS measurements at the proximal femur are feasible and show a good performance for hip fracture discrimination. Given the promising results, this laboratory prototype should be reengineered to a clinical applicable instrument. Our results show promise for further enhancement of QUS-based assessment of osteoporosis.     

Pertrochanteric fractures: tips and tricks in nail osteosynthesis

Introduction

Intramedullary fixation of intertrochanteric fractures has become the standard method of fixation especially in unstable fracture types. Even though there have been developments on implant design and technology, the surgical technique of reduction and implant positioning remains the mandatory factor in treating these fractures successfully. The advantages of nailing in the mainly elderly patients sustaining intertrochanteric femur fractures are a short lever arm and a lateral support in the trochanter supplied by the nail. The disadvantages are that it is often harder to achieve a closed reduction of a displaced fracture and to maintain the reduction with the intramedullary implant.

Tips and tricks

To obtain and maintain anatomic reduction and a secure fracture fixation, the surgical approach and fixation technique is of great importance. It starts with correct patient positioning, fracture reduction (accounting for varus dislocation and dislocation of flexed fragments), choosing the correct nail entry point and perfect lag screw positioning within the head-neck fragment and distal locking. To maintain the reduction achieved intraoperatively, the decision has to be made to use a cerclage wiring or to tolerate fracture gaps in the metaphyseal area. Intraoperative controlled compression of the neck or the subtrochanteric area is of great importance to reduce delayed unions or nonunions.

Summary

Intramedullary fixation of unstable per-, inter- or subtrochanteric fractures shows biomechanical advantages compared to extramedullry fixation techniques. Even though there have been several amendments and developments of implants, a better implant does not compensate for an inadequate surgical approach or deficient surgical techniques which are paramount for successful treatment. When fixing fractures with intramedullary nailing systems, the surgeon should always try to achieve anatomic reduction and a perfect implant positioning to allow immediate full weight bearing without an increased risk of cut-out, non-union and implant failure.     

Hüftgelenknahe Frakturen im hohen Lebensalter

Background

Osteoporotic fractures of the femoral neck and trochanteric region pose an ever-expanding existential problem both for the individual and for society. Despite numerous innovations and advances regarding implant design, mortality and the systemic and mechanical complication rates remain high.

Objectives

Depiction of treatment options for femoral neck fractures and trochanteric femur fractures in the elderly comparing joint replacement and osteosynthesis.

Methods

A search of the Medline, Embase and Cochrane databases was carried out focusing on hip fracture treatment. Randomized or quasi-randomized controlled trials, meta-analyses and reviews comparing joint replacement or fixation implants in the elderly were included.

Results

Displaced fractures of the femoral neck often require total joint arthroplasty whereas trochanteric fractures are amenable to internal fixation. Cemented total hip replacement as opposed to cementless techniques is recommended in the elderly and yields good functional results in active patients. Hemiarthroplasty is the treatment of choice in infirm patients with multiple comorbidities and cognitive impairment. Trochanteric fractures (AO/OTA types A1 and A2) can be successfully treated with intramedullary or extramedullary fixation. Adequate reduction and stable fixation are prerequisites for uneventful healing. A meticulous operative technique can prevent iatrogenic complications.

Conclusion

In summary, there are many parameters affecting the outcome in the treatment of fragility and hip fractures. Technical features as well as surgeon characteristics play an important role and the ultimate solution has yet to be developed. Even though fracture morphology may indicate a specific treatment option, patient characteristics play an important role in decision-making. The development of centers of fragility fracture care in Germany could help to lower the complication rate and increase quality of life in hip fracture patients in the future.     

Intramedullary nailing in pertrochanteric fractures of the proximal femur

Introduction

Pertrochanteric fractures of the proximal femur should be treated surgically, unless the medical condition of the patient does not allow it. Currently, there are two ways to fix these fractures; either with a sliding hip screw or with an intramedullary nail. However, there is much debate over which implant is the best for pertrochanteric fracture fixation. The sliding hip screw has been used over time with good clinical results. While it was true that with first generation intramedullary nails the risk of complications was higher, there is evidence supporting the superiority of intramedullary nails in these fractures when compared with sliding hip screws. This evidence is based on the good clinical results and fewer complications, due to an improvement in the design of the implants and surgical technique used by surgeons. In stable fractures, despite the method chosen for fixation, obtaining a good reduction prior to placing the implant is the most important factor that can be controlled by the surgeon. In stable fractures the surgeon experience is a strong factor to account for when choosing the type of implant. Clearly there are fracture patterns (reverse oblique and subtrochanteric extension) that benefit from the use of intramedullary devices due to the high risk of failure if plates are used.

Conclusion

It is very important that the surgeon identifies these fractures, so the type of fixation device which is chosen achieves the greatest stability possible. The aim of this paper is not to convince the surgeon about using intramedullary nails, but highlight the potential benefits intramedullary nailing has when compared with the use of extramedullary devices.     

Biomechanical comparison of two angular stable plate constructions for periprosthetic femur fracture fixation

Purpose

Fractures of the femur associated with total hip arthroplasty are a significant concern in orthopaedic and trauma surgery. However, little is known about the different biomechanical properties of internal fixation systems in combination with periprosthetic fractures. In this study two new internal fixation systems for periprosthetic fractures are investigated using a cadaver fracture model simulating a Vancouver B1 periprosthetic femur fracture.

Methods

Nine pairs of fresh-frozen cadaver femurs were scanned by dual X-ray absorptiometry. Cementless total hip prostheses were implanted and a periprosthetic femur fracture was simulated. Fractures were randomly fixed either with the fixed angle locking attachment plate (LAP®, Depuy Synthes®, Solothurn, Switzerland) or the variable angle non-contact bridging plate (NCB®, Zimmer GmbH, Winterthur, Switzerland). Each construct was cyclically loaded to failure in axial compression.

Results

Axial stiffness and cycles to failure were significantly higher in the NCB group. Both systems were able to be fixed well around the femoral stem.

Conclusion

The two different internal fixation systems for periprosthetic fractures differed significantly in our setup. The non-contact bridging plate system revealed significantly higher failure load and may be the preferred option where high stability and load capacity is needed right after operation.     

Epidemiology of fracture in the Russian Federation and the development of a FRAX model

Summary

The incidence of hip, forearm and humeral fractures was studied in two cities from the Russian Federation. Fracture rates were used to create a FRAX model for Russia and to estimate the current and future burden of fracture.

Purpose

There is scant information on the epidemiology of fracture in Russia. The aim of the study was to determine the incidence of major fractures in order to populate a new FRAX model and to characterise the burden and future burden of fractures.

Methods

The number of hip, forearm and humeral fractures was determined in two Russian cities with a well-defined catchment population over a 2?C3-year period. Incidence rates for the two cities were merged and used to populate a FRAX model for Russia. Incidence rates were also applied to the general population in 2010 and 25?years later in 2035.

Results

A total of 6,012 fractures were documented. For hip fracture, 27?% of cases in Pervouralsk and 1.8?% in Yaroslavl were not registered in the hospital data base. The incidence of index fractures increased with age and was higher in women than in men. The lifetime probability of hip fracture at the age of 50?years was 4?% in men and 7?% in women. The total number of hip fractures estimated in 2010 (112,000) is expected to rise to 159,000 in 2035. The estimated number of major fractures will rise from 590,000 to 730,000 over the same time interval.

Conclusions

Fragility fractures pose a serious health care problem in Russia. Urgent steps are needed to improve the acute management of hip fracture and long-term care of other osteoporotic fractures.     

Literature review of outcome parameters used in studies of geriatric fracture centers

Introduction

A variety of multidisciplinary treatment models have been described to improve outcome after osteoporotic hip fractures. There is a tendency toward better outcomes after implementation of the most sophisticated model with a shared leadership for orthopedic surgeons and geriatricians; the Geriatric Fracture Center. The purpose of this review is to evaluate the use of outcome parameters in published literature on the Geriatric Fracture Center evaluation studies.

Materials and methods

A literature search was performed using Medline and the Cochrane Library to identify Geriatric Fracture Center evaluation studies. The outcome parameters used in the included studies were evaluated.

Results

A total of 16 outcome parameters were used in 11 studies to evaluate patient outcome in 8 different Geriatric Fracture Centers. Two of these outcome parameters are patient-reported outcome measures and 14 outcome parameters were objective measures.

Conclusion

In-hospital mortality, length of stay, time to surgery, place of residence and complication rate are the most frequently used outcome parameters. The patient-reported outcomes included activities of daily living and mobility scores. There is a need for generally agreed upon outcome measures to facilitate comparison of different care models.     

Guidance for the prevention of bone loss and fractures in postmenopausal women treated with aromatase inhibitors for breast cancer: an ESCEO position paper

Summary

Aromatase inhibitors (AIs) are widely used in women with breast cancer, but they are known to increase bone loss and risk of fractures. Based on available evidence and recommendations, an ESCEO working group proposes specific guidance for the prevention of AIs-induced bone loss and fragility fractures.

Introduction

Aromatase inhibitors (AIs) are now the standard treatment for hormone receptor-positive breast cancer. However, deleterious effects of AIs on bone health have been reported. An ESCEO working group proposes guidance for the prevention of bone loss and fragility fractures in post-menopausal women with breast cancer receiving AIs.

Methods

A panel of experts addressed the issue of skeletal effects of AIs and effectiveness of antifracture therapies for the prevention of AI-induced bone loss and fractures. Recommendations by national and international organizations, and experts’ opinions on this topic were evaluated.

Results

All aromatase inhibitors are associated with negative effects on the skeleton, resulting in bone loss and increased risk of fragility fractures. Current guidelines suggest approaches that differ both in terms of drugs proposed for fracture prevention and duration of treatment.

Conclusion

The ESCEO working group recommends that all AI-treated women should be evaluated for fracture risk. Besides general recommendations, zoledronic acid 4?mg i.v. every 6?months, denosumab s.c., or possibly oral bisphosphonates should be administered for the entire period of AI treatment to all osteoporotic women (T-score hip/spine <?2.5 or ≥1 prevalent fragility fracture), to women aged ≥75 irrespective of BMD, and to patients with T-score <?1.5?+?≥1 clinical risk factor or T-score <?1.0?+?≥2 clinical risk factors. Alternatively, therapy could be considered in patients with a FRAX-determined 10-year hip fracture probability ≥3%.     

Minimally invasive periprosthetic plate osteosynthesis using the locking attachment plate

Objective

Stable fixation of periprosthetic or periimplant fractures with an angular stable plate and early weight bearing as tolerated.

Indications

Periprosthetic femur fractures around the hip, Vancouver type B1 or C. Periprosthetic femur and tibia fractures around the knee. Periprosthetic fractures of the humerus. Periimplant fractures after intramedullary nailing.

Contraindications

Loosening of prosthesis. Local infection. Osteitis.

Surgical technique

Preoperative planning is recommended. After minimally invasive fracture reduction and preliminary fixation, submuscular insertion of a large fragment femoral titanium plate or a distal femur plate. The plate is fixed with locking head screws and/or regular cortical screws where possible. If stability is insufficient, one or two locking attachment plates (LAP) are mounted to the femoral plate around the stem of the prosthesis. After fixing the LAP to one of the locking holes of the femoral plate, 3.5 mm screws are used to connect the LAP to the cortical bone and/or cement mantle of the prosthesis.

Postoperative management

Weight bearing as tolerated starting on postoperative day 1 is suggested under supervision of a physiotherapist.

Results

In 6 patients with periprosthetic fractures and 2 patients with periimplant fractures, no surgical complications (e.g., wound infection or bleeding) were observed. The mean time to bony union was 14 weeks. No implant loosening of the locking attachment plate was observed. At the follow-up examination, all patients had reached their prefracture mobility level.     

Mit Marknagelimplantation assoziierte Frakturen

Classification

A classification of fractures that occur during implantation of intramedullary nails does not exist.

Literature available

Most data are available for the implantation of elastic intramedullary nails (ESIN) in children, the implantation of retrograde nails in the humerus, and the implantation of different types of intramedullary nails with a joint component in the osteosynthetic treatment of femoral fractures near the hip joint.

Characteristics

The defining characteristic of an implant-related fracture when intramedullary nailing is performed is their location in relation to the implant. If the stability of intramedullary stabilization can no longer be guaranteed, then the newly occurring fracture is a relevant intraoperative complication that leads to a change in the surgical strategy.

Therapy

The challenge for the trauma surgeon during the operation is the necessity to recognize the complication of an iatrogenic fracture and to treat it adequately. Different methods of intraoperative change to a longer implant or an additional bridging plate for adequate stabilization of the new fracture may be necessary. Postoperative immobilization of the operated limb should be avoided in order not to combine the complications of operative fracture treatment and additional conservative treatment.

Conclusion

The correct technical execution of nailing procedure is the key factor to avoid an additional intraoperative fracture. The principles of intramedullary fracture stabilization should be strictly considered.     

Risikofaktoren für das Versagen von Osteosynthesen

Background

The increasing number of implantations of total knee endoprostheses shows a correlation with an increase in revision operations and periprosthetic fractures.

Objective

This article presents strategies for prevention of complications after open reduction internal fixation (ORIF) of periprosthetic fractures in addition to the classification of periprosthetic fractures of the knee joint.

Therapy strategies

Osteosynthetic treatment is only applicable in some of the cases. Although special periprosthetic, angle locking plates are available for osteosynthesis, treatment of periprosthetic fractures of the knee joint remains a challenge with a high complication rate. If the prosthesis becomes loosened, the prosthesis should be replaced and ORIF should not be performed.

Risk factors

The risk factors for failure of osteosynthesis include the prosthesis model and the associated reduction of residual bone and the mostly osteoporotic bone structures.     

Long-term results of the augmented PFNA: a prospective multicenter trial

Background

Pertrochanteric fractures are increasing and their operative treatment remains under discussion. Failures needing reoperations such as a cut-out are reported to be high and are associated with multiple factors including poor bone quality, poor fracture reduction and improper implant placement. The PFNA^® with perforated blade offers an option for standardized cement augmentation with a PMMA cement to provide more stability to the fracture fixation. It remains unclear if the augmentation of this implant does any harm in a longer time span. This prospective multicenter study shows clinical and radiological results with this implant with a mean follow-up time of 15 months.

Methods

In 5 European clinics, 62 patients (79 % female, mean age 85.3 years) suffering from an osteoporotic pertrochanteric fracture (AO 31) were treated with the augmented PFNA^®. The primary objectives were assessment of activities of daily living, pain and mobility. Furthermore, the X-rays were analyzed for the cortical thickness index, changes of the trabecular structure around the cement and the hip joint space.

Results

The mean follow-up time was 15.3 months. We observed callus healing in all cases. The surgical complication rate was 3.2 % with no complication related to the cement augmentation. A mean volume of 3.8 ml of cement was injected and no complication was reported due to this procedure. 59.9 % reached their prefracture mobility level until follow-up. The mean hip joint space did not change significantly until follow-up and there were no signs of osteonecrosis in the follow-up X-rays. Furthermore, no blade migration was assessed.

Conclusion

This study makes us believe that the standardized augmentation of the PFNA with a perforated blade is a safe method to treat pertrochanteric femoral fractures. It leads to good functional results and is not associated with cartilage or bone necrosis.     

Locking versus standard screw fixation for acetabular cups: is there a difference?

Introduction

Total hip replacement has been established as a valid treatment option for displaced subcapital fractures. However, insufficient primary fixation may be the reason for early loosening in these osteoporotic patients. Primary fixation of the cup is usually achieved by press-fit fixation that can be enhanced using screws. Locking the screws into their respective cups may seem to improve the primary fixation of the construct, as locked plates proved superior fixation for osteoporotic fractures.

Methods

The study consisted of three groups: in each group, three cups were fixed into blocks of foam bone using press-fit technique. In the first group, no additional screws were used, in the second group two standard screws were inserted, while in the third group two acetabular screws were cemented into the cup to simulate locked screw fixation. Load was applied onto the rim of the acetabular component to cause shearing between the cup and the block. Cup fixation was examined by a loading machine that acquired load versus displacement. The stiffness (load vs. displacement) was calculated.

Results

Screws, either locked or non-locked, enhanced cup fixation by 26 % (p value <0.01). No significant changes were found between the locking and non-locking screws groups.

Discussion

These experimental results indicate that acetabular screws enhance primary cup fixation. This may become significant in conditions where the acetabular bone stock is suboptimal, such as when performing total hip arthroplasty after displaced subcapital fractures. However, there is no superiority for locked screws over standard screw fixation.