Periprosthetic fractures of the greater trochanter through osteolytic cysts with uncemented MicroStructured Omnifit prosthesis

Background Periprosthetic fractures of the greater trochanter through osteolytic cysts are rare. The proper treatment and its influence on the prosthetic survival remains unknown.

Patients and methods We retrospectively evaluated 887 hips with uncemented MicroStructured Omnifit total hip prostheses at a mean follow-up time of 11 (5–14) years. We found 23 (2.6%) fractures of the greater trochanter through a cystic lesion, occurring 4–11 years postoperatively.

Results Nonoperative treatment healed 15 of the 17 fractures that were minimally displaced. At a mean follow-up of 3 (2–5) years after the fracture, 16 had had revision of the components because of excessive wear, loosening, or nonunion.

Interpretation We conclude that a periprosthetic fracture of the greater trochanter through an osteolytic lesion is usually stable and heals without treatment. However, it is associated with poor prosthetic survival because of excessive polyethylene wear.     

Surgical treatment of high-standing greater trochanter

Eleven patients with high-standing greater trochanter (13 joints) aged 13-36 years underwent surgery. Distal transfer of the greater trochanter (group T) was performed in 4 patients (5 joints) and lateral displacement osteotomy (group L) in 7 (8 joints). The average follow-up duration was 13.4 years in group T and 5.9 years in group L. Clinical results were evaluated by the hip score according to Merle d'Aubigne. The mean hip score in group T was 13.4 points before operation and 15.4 points after operation, and in group L, 12.8 and 17.4 points, respectively. The postoperative clinical results of group L were significantly better than those of group T (P = 0.0494). In radiological evaluation, although the articulo-trochanteric distance (ATD) increased in both groups in group L it improved remarkably from 9.8 to 24.3, indicating a large descending distance of the greater trochanter. The lever arm ratio (LAR) did not change significantly in group T, but it decreased from 1.97 to 1.60 in group L (P = 0.004). This means that the lever arm of the abductors can certainly be extended by lateral displacement osteotomy. Lateral displacement osteotomy is the most effective procedure for high-standing greater trochanter.     

Isolated fractures of the greater trochanter with occult intertrochanteric extension

Introduction

Isolated fractures of the greater trochanter (GT) are relatively rare. The diagnosis can be done on routine radiographs, but it is difficult to fully define the geographic extent of these injuries. This study examined the pattern and extent of an injury shown by magnetic resonance imaging (MRI) and radionuclide bone scan (RBS) in patients whose plain radiographs revealed fractures limited to the GT.

Materials and methods

Between July 2004 and October 2008, 25 patients who displayed an isolated GT fracture on plain radiograph examination were examined by both MRI and RBS due to a suspicion of an extension into the intertrochanteric (ITC) region. The patients were then divided into two groups. Group A patients had an isolated fracture of GT, and group B patients had an occult fracture of ITC.

Results

All 25 cases were caused by a low-energy injury and plain radiographs showed non-displaced or minimally displaced isolated GT fractures. For 22 of the 25 patients, the result agreed with MRI and RBS. However, three patients had focal increased uptake at the GT region only according to RBS and an extension of signal intensity into the ITC region according to MRI. Group A and B comprised 5 and 20 patients, respectively. Of the group B patients, 8 had fractures with MRI evidence of complete extension across the ITC region and 12 had incomplete extension. Eleven of the 12 incomplete types showed an extension more than half way to the medial cortex. Fifteen group B patients underwent an internal fixation using a two-hole dynamic hip screw.

Conclusion

Patients with an isolated fracture of GT can have a broader fracture extending into the ITC region than that diagnosed by standard radiographs. We recommend that all patients presenting with an isolated GT fracture on the plain radiographs should undergo MRI examination.     

Surgical treatment of overgrowth of the greater trochanter in children and adolescents

After developmental dislocation of the hip, Perthes disease, bacterial coxitis, and other pediatric hip conditions, the femoral neck may develop short, with an overgrowth of the greater trochanter. Forty-four patients with trochanter overgrowth (47 hips) ages 6 to 17 years underwent surgery. Trochanteric epiphysiodesis was performed in 13 patients (group A), distal transfer of the greater trochanter in 24 patients (26 hips; group B), and femoral neck lengthening osteotomy in 7 patients (8 hips; group C). The mean follow-up time was 8.3 years. Clinical results were evaluated by the hip score according to Merle d'Aubigné. Radiological parameters were evaluated by 2 of the authors.Each operative method led to an improvement of clinical symptoms. In group A, no significant changes in the radiological parameters could be found. Groups B and C showed significant improvements in the radiological parameters. However, no difference was found between these 2 groups.     

Evaluation of isolated fractures of the greater trochanter with magnetic resonance imaging

The diagnosis of an isolated fracture of the greater trochanter can be done on routine radiographs, but this may not be the whole story. We evaluated fractures of the greater trochanter of the femur by magnetic resonance imaging (MRI). MR images were obtained within 5 days of the time of clinical presentation. Coronal images were performed on T1- and T2-weighted spin-echo images. Eight elderly patients who were diagnosed as having a greater trochanter fracture on standard radiographs underwent MRI. Three were men aged 62–76 (mean 63.4) years, and five were women aged 80–101 (mean 88.6) years. MRI showed that in seven of the eight cases, the fracture line was observed leading from the greater trochanter towards other trochanter regions. In only one case was the fracture limited to the greater trochanter and corresponded to the line observed on the standard radiographs. We suggest that in cases of greater trochanter fracture with somewhat severe symptoms, MRI should be performed in order to discover the appropriate diagnosis and treatment. Received: 12 September 1998     

Periprosthetic fractures of the greater trochanter through osteolytic cysts with uncemented MicroStructured Omnifit prosthesis: retrospective analyses pf 23 fractures in 887 hips after 5-14 years

Background Periprosthetic fractures of the greater trochanter through osteolytic cysts are rare. The proper treatment and its influence on the prosthetic survival remains unknown.

Patients and methods We retrospectively evaluated 887 hips with uncemented MicroStructured Omnifit total hip prostheses at a mean follow-up time of 11 (5-14) years. We found 23 (2.6%) fractures of the greater trochanter through a cystic lesion, occurring 4-11 years postoperatively.

Results Nonoperative treatment healed 15 of the 17 fractures that were minimally displaced. At a mean follow-up of 3 (2-5) years after the fracture, 16 had had revision of the components because of excessive wear, loosening, or nonunion.

Interpretation We conclude that a periprosthetic fracture of the greater trochanter through an osteolytic lesion is usually stable and heals without treatment. However, it is associated with poor prosthetic survival because of excessive polyethylene wear.     

不稳定骨盆骨折合并髋臼骨折的手术治疗

目的 探讨不稳定骨盆骨折合并髋臼骨折的治疗方法及临床疗效.方法 对26例不稳定骨盆骨折合并髋臼骨折进行切开复位内固定手术治疗.结果 25例获得随访3～42个月.骨盆骨折愈合时间8～18周,按照Matta和Tornetta的评分进行复位情况的评价,优良率92％,采用Majeed功能评分进行功能等评价,优良率84％;髋臼骨折愈合时间8～16周,采用Matta影像学评定复位质量,优良率84％,采用Matta改良的Merle d'Aubigne和Postel评分系统行功能评价,优良率84％.5例神经损伤患者4～6个月后均完全恢复.结论 对于不稳定骨盆骨折合并髋臼骨折患者早期运用损伤控制骨科的理念抢救生命为主,病情稳定后先固定骨盆后环,然后行骨盆、髋臼骨折内固定手术,恢复骨盆环的稳定,解剖复位髋臼骨折,术后早期功能锻炼,可以取得良好的治疗效果.     

Bone graft from greater trochanter in posterior wall fractures with impacted fragments

Background

Posterior wall fracture is the most common acetabular fracture. Comminuted fractures with an impacted segment represent a subtype of this injury. The subchondral bone of the articular zone is compressed and causes a bone defect. The impacted fragment should be isolated, mobilized, and then reduced. A bone graft should be used to fill the gap. The other fragments are fixed following the reduction of the impacted segment.

Materials and methods

Ten patients with comminuted fractures and impacted segments with bone defects were enrolled in our study, from January 2010 to July 2012. Autogenous bone grafts from the greater trochanter were used to fill the gap in all patients. The reduction was achieved through the insertion of the graft above the impacted fracture, and plate fixation was performed subsequently. Merle d’Aubigne and Postel scoring, modified by Matta, was applied to evaluate the patients during follow-up. The mean follow-up was 12 months.

Results

The clinical results included one “excellent”, four “very good”, four “good” and one “poor”. Pain in the zone of graft harvesting was not detected in any patient. Femoral head necrosis was observed in one case. No other severe complications were detected.

Conclusions

Using an autogenous bone graft to fill the bone defect supplies excellent mechanical stability without any severe complications at the donor site. This surgical technique seems to be effective and safe in treating a comminuted fracture of the posterior wall in association with an impacted segment.

Level of evidence

Level IV.     

The efficiency of various osteosynthesis techniques in fractures of the greater trochanter

Experimental investigations concerning the strength of different common used techniques of osteosyntheses of the greater trochanter were carried out on 22 cadaver femora. The maximal loading values were measured and analysed. Loading of the tilted femur corresponding to the bended-hip position decreased the tolerable loading values essentially.     

踝关节骨折合并距骨软骨损伤的手术治疗

2010年1月～2012年8月,我科共收治踝关节骨折患者36例,术中发现有15例合并距骨软骨损伤,经治疗疗效满意,报道如下。1材料与方法1.1病例资料本组15例,男13例,女2例,年龄25～52岁。踝关节骨折按Lauge-Hansen分类:旋后内收型2例,旋后外旋型6例,旋前外展型3例,旋前外旋型4例。距骨软骨损伤按Berndt-Har-ty分类[1]:Ⅰ型3例,Ⅱ型5例,Ⅲ型3例,Ⅳ型4例。     

肱骨大结节移位骨折的手术治疗探讨

目的 探讨手术治疗肱骨大结节移位骨折的要点和疗效. 方法 回顾性分析2006年6月至2011年6月收治且获得随访的20例肱骨大结节移位骨折患者资料,男11例,女9例;年龄30～69岁,平均49.6岁.受伤至手术时间为1～122 d,平均8.2d.17例患者采用开放手术,2例采用关节镜手术,1例采用开放手术加关节镜手术;开放手术采用三角肌-胸大肌入路7例,经三角肌入路10例;骨折固定采用7种方法,以空心钉固定最多(11例).患肩功能采用加州大学洛杉矶分校(UCLA)肩关节功能评分系统进行评定. 结果 20例患者术后获6～51个月(平均13.6个月)随访.术后6周所有患者骨折均获愈合.末次随访时20例患者患肩功能采用UCLA肩关节功能评分系统评定:7例采用三角肌-胸大肌入路患者UCLA评分平均为28.4分,10例经三角肌入路患者UCLA评分平均为30.4分,2例关节镜手术患者UCLA评分平均为34.5分,1例开放手术加关节镜手术患者UCLA评分为34分;其中优10例,良3例,差7例,优良率为65.0％. 结论 切开复位内固定是治疗肱骨大结节移位骨折的主要方法,手术入路多采用经三角肌入路.关节镜技术治疗单纯大结节骨折的适应证为骨折块不大、骨折线靠近近端、移位小及粉碎不严重者.     

Outcomes of osteosynthesis of periprosthetic fractures of the greater trochanter with an anatomic claw plate

BackgroundThe treatment of periprosthetic trochanteric fractures, especially older fractures, is often a challenge. The aim of this study was to investigate the clinical and radiological outcomes of periprosthetic fracture treatment with the anatomic Peri-Plate claw plate.Material and methodsThirteen new fractures (≤6 weeks after occurrence) and 8 older Vancouver A_G fractures (35.4 ± 26.1 weeks after occurrence) were followed radiologically and clinically with a follow-up of 44.6 ± 18.8 (24–81) months.ResultsAt 6 months, osseous consolidation had occurred in 12 cases and fibrous union in 9 cases. At 12 months one additional osseous consolidation was shown. The Harris hip score (HHS) increased from 37.2 ± 10.3 preoperatively to 87.6 ± 10.3 12 months after surgery. Thirteen patients reported no, 7 mild and one patient significant local trochanteric pain.ConclusionsThe Peri-Plate claw plate can achieve reproducibly good outcomes in terms of fracture stabilization and bony consolidation, as well as with regard to clinical outcomes in the treatment of new and older periprosthetic trochanteric fractures.     

Predicting intertrochanteric extension of greater trochanter fractures of the hip on plain radiographs

IntroductionIt is important to distinct between isolated greater trochanter (GT) fractures and complete intertrochanteric (IT) extension to prevent unwanted morbidities. Aim of this study was to determine if there was any particular fracture pattern, of GT fractures on a plain radiograph of the hip which could predict IT extension.MethodRetrospective review of radiographs of 49 patients with a GT fracture who presented in the last 10 years (January 2005–December 2015). All images were reviewed by a consultant musculoskeletal radiologist and an orthopaedic surgeon. The AP plain radiographs were assessed to look for fracture angle and length of the fracture. The fracture length was taken as a percentage and was measured as the length of the fracture crossing the intertrochanteric line/the total length of the intertrochanteric line. The fracture angle was measured as the angle between a line drawn from the most superior point of the fracture on the lateral cortex of the GT, to a perpendicular line along the medial cortex of the femoral shaft. The subsequent MRI and CT scans were assessed to see if there was true intertrochanteric extension.Results32 patient were female and 17 male. 27 CT scans of which 8 showed complete IT extension. 22 had MRI scan of which 6 showed complete extension. The mean fracture length of patients with complete extension was 56% with a range of 50%–63%. The mean fracture length of patients with incomplete extension was 33% with a range of 12%–55%. The mean fracture angle for patients with complete extension was 39 ° with a range of 35–42°. The mean fracture angle for patients with incomplete extension was 58 ° with a range of 44–124°.ConclusionFor greater trochanter fractures that do not cross >50% of the IT line and do not have a fracture angle between 35 and 42° do not require further imaging as they will not have complete intertrochanteric extension.