The lateral radiograph is useful in predicting shortening in 31A2 pertrochanteric hip fractures

Background

We sought to determine if angulation or translation measured on the lateral preoperative injury radiographs of patients with 31A2 pertrochanteric fractures is related to excessive postoperative shortening when treated with a sliding hip screw.

Methods

We retrospectively reviewed the radiographs of consecutive patients with hip fractures treated at a level I university trauma centre between 2003 and 2008. Patients with 31A2 pertrochanteric fractures treated with a sliding hip screw were identified through a search of medical records. The study variables were angulation and translation on the preoperative injury lateral radiograph. The outcome measure was radiographic evidence of fracture shortening, measured as the change in length of sliding hip screw visible outside the barrel between the time of fixation and final follow up.

Results

Of the 131 patients treated, 23 met our inclusion criteria and had sufficient follow-up (mean 6.4 mo). The average shortening for 31A2 fractures with angulation on the injury lateral radiograph was 1.83 (95% confidence interval [CI] 1.18–2.47) cm, compared with 0.93 (95% CI 0.49–1.36) cm for fractures with no angulation (p = 0.019). There was no statistical difference in quality of reduction, tip–apex distance, Orthopedic Trauma Association (AO/OTA) classification or incidence of lateral wall fracture across groups based on the presence of angulation.

Conclusion

Angulation on the lateral preoperative injury radiograph may be useful in predicting excessive shortening in 31A2 pertrochanteric fractures. Further investigation is warranted to confirm this result and to identify the role of other predictors, such as fracture comminution.     

Percutaneous compression plating versus gamma nail for the treatment of pertrochanteric hip fractures

The objective of this study is to compare percutaneous compression plating (PCCP) device with standard gamma nail (GN). A sample was prospectively followed and compared to a historical cohort: 82 intertrochanteric hip fractures in 81 patients treated with PCCP in 2004 versus 51 hip fractures treated with GN in 2003 (AO type 31A1, 31 A2). The main outcome measures were: surgery times, blood loss (Hb serum level and transfusions), complication, costs, for a 1-year follow-up. The minimally invasive PCCP technique resulted in a lower blood loss and consequently lower transfusion need (statistically significant), fewer implant-related complications and comparable surgery times. Overall surgical costs were lower for a comparable outcome in terms of healing and surgical time.     

Percutaneous compression plate for pertrochanteric fixation of hip fractures: surgical technique and first results

We have used a minimally invasive technique for fixation of trochanteric fractures since 2003. We use the percuntaneous compression plate described by Gotfried. We describe here the osteosynthsis technique and our special approach which limits operative time. This technique avoids wide opening of the aponeurosis of the tensor fascia lata, major detachment, and section of the vastus lateralis. The plate is inserted via a 2-cm incision over the greater trochanter. Head and shaft screws are inserted via a second incision measuring 3 to 4 cm. Perfect reduction before plate insertion is the key to success. The results of our first twenty cases have demonstrated an uneventful postoperative period and a short operative time of 25 minutes on average. Peri-operative bleeding has been very limited. Radiographic healing was obtained in three months. Weight bearing was possible immediately after fixation in five cases and was delayed in fifteen. There were two early displacements which were analyzed.     

Osteosynthesis of unstable pertrochanteric femoral fractures with the compression hip screw

Injuries of unstable pertrochanteric fractures of the upper femur represent a contingent with high multi-morbidity at highest average age. The only successful procedures within biologically set boundaries, would be those of an early and weight-bearing resistive osteo-synthesis. Starting in 1979 till the middle of 1982, we treated 70 unstable pertrochanteric fractures out of 350 proximal femur fractures, with this compression hip screw. Because of its underlying bio-mechanical principle, its advantageous operative handling, as well as high durability of the material used, this version of an osteosynthesis showed few complications. We found neither head penetration and pseudoarthrosis, nor did we find any implant bending and breaking so far. Although averaging almost 80 years, 63% of our patients could be released after hospitalization for an average of 39 days, leaving at full mobility. The set goal of an early weight-bearing with elderly patients was fully achieved by means of this version of osteo-synthesis, since dynamic compression of even comminuted fracture zones permitted a statically sound and unhindered possibility at weight-bearing.     

Late surgical treatment of lateral condylar fractures in children

We describe four cases of successful late surgical treatment of lateral condylar fractures of the humerus performed 8 weeks and 2, 5, and 14 years after injury and review the literature on the subject. We suggest that children with symptomatic nonunion and malunion of these fractures can benefit from late surgical treatment at the time of diagnosis. We describe the technique of functional reduction and the regions in which anatomic reduction is precluded by remodeling or gross displacement of the fragment.     

A new device for the fixation of unstable pertrochanteric fractures of the hip

A new type of fixation device for the treatment of pertrochanteric fractures of the hip is described. The device has an axial-compression screw to allow compression along an axis parallel to the femoral shaft. As the fracture settles postoperatively, dynamic axial compression continues. This axial-compression device was used in twenty-five patients who had an unstable intertrochanteric or proximal subtrochanteric fracture of the proximal part of the femur. The average extent of axial impaction or settling was five millimeters (standard deviation, 1.3 millimeters) at the most recent follow-up examination, and the relationship between the femoral head and shaft was altered less than with the use of a conventional compression screw-plate device. A larger proportion of the patients who had the new device were able to walk fifteen meters (fifty feet) independently by the time of discharge from the hospital, even though they left the hospital earlier. No technical failures were seen in the patients who were treated with the axial-compression screw device. We believe that the axial-compression screw-plate device is appropriate for the treatment of unstable pertrochanteric fractures of the hip.     

Postoperative radiographs or thermal prints after internal fixation of fractures? A study of DHS fixation of hip fractures.

Immediate postoperative radiographs confirm the quality of reduction and fixation of fractures. This information is already available from the image intensifier and can be saved as hard copy thermal prints. If thermal prints give the surgeon the necessary patient and clinical information them immediate postoperative radiography should not be required. In this retrospective study of 20 hip fractures treated by dynamic hip screw (DHS) fixation, plain radiographs and thermal prints were compared for the patient and clinical information they contained. Thermal prints were found to be deficient in some areas but, nevertheless, can potentially replace postoperative radiographs in many orthopaedic procedures saving time, money and radiation exposure.     

Factors delaying surgical treatment of hip fractures in elderly patients

BACKGROUND: Published guidelines recommend early surgical treatment of hip fractures in elderly patients. Understanding the factors that delay surgical intervention is essential in order to introduce changes that will facilitate early treatment. AIM: To determine the factors delaying surgical treatment of hip fractures in elderly patients for more than 24 h. PATIENTS AND METHODS: Assessment of 163 consecutive patients undergoing surgery for hip fractures at the trauma unit of Manchester Royal Infirmary. RESULTS: Only 72/163 (44.2%) patients had their operation within 24 h of presenting to hospital. The remaining 91 patients had a total of 239 days delay (in excess of the initial 24 h) for surgical treatment. Active medical problems (56.5%) and a wait for medical investigations (19.7%) caused most delays. Lack of operating theatre time and Sunday trauma lists caused 23.8% of delays. CONCLUSIONS: Medical problems account for most delays of surgical treatment of hip fractures. A multidisciplinary approach, with early input by medical and anaesthetic teams, is essential in managing such patients. Established protocols may reduce waiting times for essential investigations.