Intertrochanteric fracture with distal extension: When is the short proximal femoral nail antirotation too short?

IntroductionThe lesser trochanter (LT) fragment in the multifragmentary intertrochanteric femur fracture (AO 31A2.2) may extend distally. If the fragment extends too distally, fixation with a short proximal femoral nail antirotation (PFNA-II) device may not be sufficient. The exact length of distal extension that can be tolerated by the short PFNA-II is not known, therefore it is our objective to determine it.Materials and methodsA finite element analysis was performed on AO 31A2.2 fracture fixed with a 200mm length size 10 PFNA-II. The construct was loaded vertically to clinical failure of 10mm displacement. This was repeated with the size of the LT fragment increasing distally at intervals, up to 120mm from the base of the LT. The process was also repeated with the bone properties substituted with osteoporotic properties. The stiffness, maximum vertical reaction force, and the plastic deformation area were investigated.ResultsIn both non-osteoporotic and osteoporotic model, the stiffness and the maximum vertical reaction force of the construct dropped significantly when the LT fragment is larger than 40mm. Beyond 40mm of LT fragment size, there was a rapid increase in the area of plastic deformation of the cortical bone distal to the intertrochanteric fracture, signifying structural failure of the construct.ConclusionA long PFNA-II should be considered when fixing a multifragmentary intertrochanteric fracture if the LT fragment extends 40mm distal to the distal base of the LT as the construct fails rapidly upon uniaxial load to failure. Clinically, this threshold may be smaller to account for the multi-axial and dynamic stresses.     

Is augmentation a possible salvage procedure after lateral migration of the proximal femur nail antirotation?

Introduction

Failed fracture fixation of proximal femur fractures in the elderly usually results in prosthetic replacement. In case of the proximal femur nail antirotation (PFNA), during lateral blade migration or periimplant fracture at the femoral shaft, the femoral head remains intact and therefore a joint preserving procedure might be performed. However, implant anchorage in the femoral head after the second blade implantation generally results in reduced anchorage in the remaining cancellous bone. Therefore, we hypothesize that in the above mentioned cases augmentation of the PFNA blade could be a treatment option before prosthetic surgery has to be performed.

Materials

Biomechanical investigations were performed in eight fresh frozen femoral heads. Implant anchorage in case of blade extraction and reinsertion was investigated by rotation and pull out of a PFNA blade with a servohydraulic testing machine. After reinsertion of the blade and augmentation with bone-cement, the anchorage of the blade was investigated again to observe changes in torque and pull-out force.

Results

Rotational stability of the implant significantly increased after augmentation of the prior extracted PFNA blade. Pull-out strength was higher in the revised case than in the initial tests but without statistical significance. After augmentation, correlation between bone mineral density and pull-out strength which was found during initial pull-out disappeared.

Discussion

Augmentation of simulated blade exchange after lateral blade migration demonstrated a good anchorage. There was superior rotational stability in the revised case and no inferiority during pull out for the investigated specimens. Furthermore, augmentation could compensate for destroyed trabeculae and poor bone stock. It could furthermore be an option when a failed implant has to be replaced by a long PFNA in case of shaft fracture at the tip of the implant to increase anchorage in the femoral head. From a biomechanical point of view, reosteosynthesis and augmentation in selected cases of PFNA revision could be an alternative to initial prosthetic replacement. In the case of cut-out or medial implant protrusion, the suggested salvage technique is not feasible.     

Femur-LISS and distal femoral nail for fixation of distal femoral fractures: are there differences in outcome and complications?

We evaluated the functional and radiologic outcomes after stabilization of distal femoral fractures using the distal femoral nail and a less invasive stabilization system to determine if the new implants are superior to other implants (especially the condylar blade plate) regarding the rates of axial deviation, nonunion, and infection and if one of these new implants (Less Invasive Stabilization System, or distal femoral nail) is superior to the other. Two groups, each with 16 patients, were documented prospectively and the results were compared. To record the findings objectively, the Lysholm-Gillquist score was used. A conversion procedure was done in two patients in the plate group and one patient of the nail group. At the 1-year followup mobility of the knee was on average 110 degrees in the plate group and 103 degrees in the nail group. The Lysholm-Gillquist score did not show any significant differences between the groups. There were clinically relevant varus or outer rotation deviations in three patients in the plate group and two patients in the nail group. The two minimally invasive implants used were good in terms of technique and outcome for treatment of distal femoral fractures and did not differ significantly for epidemiology, fracture type, conversion procedures, infection rate, malalignments, and subjective and objective findings at the 1-year followup. They were also superior to the condylar plate in terms of infection and axial malalignments.     

Dynamic hip screw versus proximal femoral nail for treatment of trochanteric hip fractures: an outcome analyses with a minimum 2?years of follow-up

The goal of this study is to compare the clinical and radiographical results of Dynamic hip screw (DHS) and Proximal femoral nail (PFN) for the treatment of trochanteric hip fractures. One hundred and eighty-one patients (89 male and 92 female, mean age, 77.1?years) surgically treated for trochanteric fractures were divided into two groups. Group 1: 86 hips treated with DHS and group 2: 98 hips treated with PFN. The outcome for each group was analyzed, and total operative time, time to union, complications (early and late), and mortality were recorded. The results were statistically compared. Mean follow-up was 26.8?months. The mean duration of surgery was 85.2?min for group 1 and 55.3?min for group 2. The mean time to union for group 1 was 2.09?months and 1.69?months for group 2. Early and late complication rates between treatment groups revealed no statistically significant differences. Total duration of surgery was significantly lower for PFN than it was for DHS. A comparison of time to union and overall mortality demonstrated no statistically significant differences. We detected no differences between the two treatment groups in regard to early versus late complications, time to union, and overall mortality; however, with its shorter operative period, PFN is a good alternative to the DHS. For this reason, we believed that it might be the implant of choice for the treatment of trochanteric fractures by surgeons who have an experience in interlocked femoral nailing systems.     

Does total hip arthroplasty provide better outcomes than hemiarthroplasty for the femoral neck fracture? A systematic review and meta-analysis

Purpose: By comparing the outcomes of total hip arthroplasty with hemiarthroplasty in elderly patients with a femoral neck fracture to investigate the one-year mortality, dislocation, infection, reoperation rate, and thromboembolic event. Methods: The PubMed, EMBASE databases, and Cochrane library were systematically searched from the inception dates to April 1, 2020 for relevant randomized controlled trials in English language using the keywords: “total hip arthroplasty”, “hemiarthroplasty” and “femoral neck fracture” to identify systematic reviews and meta-analyses. Two reviewers independently selected articles, extracted data, assessed the quality evidence and risk bias of included trials using the Cochrane Collaboration’ stools, and discussed any disagreements. The third reviewer was consulted for any doubts or uncertainty. We derived risk ratios and 95% confidence intervals. Mortality was defined as the primary outcome. Secondary outcomes were other complications, dislocation, infection, reoperation rate, and thromboembolic event. Results: This meta-analysis included 10 studies with 1419 patients, which indicated that there were no significant differences between hemiarthroplasty and total hip arthroplasty in reoperation, infection rate, and thromboembolic event. However, there was a lower mortality and dislocation rate association with total hip arthroplasty at the one-year follow-up. Conclusion: Based on our results, we found that total hip arthroplasty was better than hemiarthroplasty for a hip fracture at one-year follow-up.     

Does screen-detected breast cancer have better survival than symptomatic breast cancer?

OBJECTIVES: Evidence obtained from several randomized control trials suggest that mortality from breast cancer could be reduced by mammographic screening. However, a recent meta-analysis questioned the general acceptance that screening for breast cancer is beneficial. The purpose of the study was to analyze prospectively collected data from our unit and produce overall and comparative 5-year survival rates for screen-detected and symptomatic breast cancer. METHODS: Prospectively collected data on all patients diagnosed with invasive breast cancer between January 1993 and December 1994 (24 months), and monitored until the end of 1999, were collated and analyzed. Five-year survival was estimated and broken down by age at diagnosis, tumour size, grade and nodal status. The overall 5-year survival for women with screen-detected cancers was compared with that for women with symptomatically presenting cancers. RESULTS: Between January 1993 and December 1994, 308 patients with invasive breast cancer were referred to the unit (162 via the breast screening programme and 146 presenting symptomatically). The overall 5-year survival was 85.5% (confidence interval [CI], 80.8-89.1). Small tumour size, low grade and negative nodal status were associated with higher survival rates. Five-year survival of the screen-detected cancer patients (91.7%; CI, 85.8-95.2) was higher than that of patients presenting symptomatically (78.6%; CI, 70.6-84.6; p < 0.001). CONCLUSIONS: These findings suggest that patients with screen-detected breast cancer may have better survival compared to those with symptomatically detected breast cancer. The results support the argument in favour of a beneficial impact of breast screening programmes on patients' survival.     

A comprehensive multidisciplinary care pathway for hip fractures better outcome than usual care?

IntroductionHip fracture surgery is among the most performed surgical procedures in elderly patients. Mortality rates are high, however, and patients often fail to live independently following a hip fracture. To improve outcome, multidisciplinary care pathways have been initiated, but longer-term results are lacking. Aim of this study was to compare functional outcome and living situation six months after hip fracture treatment with and without a care pathway.Patients and methodsA multicentre prospective controlled trial was conducted with three hospitals: in one hospital patients were treated with a care pathway, in the other hospitals patients received usual care. All patients aged ≥ 60 years with a hip fracture were asked to participate. Besides basic characteristics, health-related quality of life (EQ-5D) and performance scores of activities of daily living (Katz Index and Lawton IADL) were assessed. Differences in scores were analysed using linear regression. Propensity score adjustment was used to correct for differences between the care pathway and the usual care group. Missing data were imputed.ResultsNo differences in rate of return to prefracture ADL level were found between patients in the care pathway group and the usual care group. The percentage of participants in the same situation as before the fracture was the same in both treatment groups (81%). There were no significant differences in quality of life, activities of daily living or mortality (15% vs 10%, p = 0.17), but hospital stay in the care pathway group was significantly shorter (median 7 vs 10 days).DiscussionTreatment of elderly patients with a hip fracture is commonly organised in care pathways. Although short-term advantages are reported, positive effects on longer-term functional results could not be proven in our study. This study confirmed a shorter hospital stay in the care pathway group, which potentially may lead to a reduction in costs.ConclusionsFunctional outcome and living situation six months after a hip fracture is the same for patients treated with or without a care pathway.     

Does femoral offset recover and affect the functional outcome of patients with displaced femoral neck fracture following hemiarthroplasty?

BackgroundRestoring preoperative horizontal femoral offset (FO) promised good functional outcome in patients receiving total hip arthroplasty. However, relatively little was known regarding the clinical relevance of restoring the offset in patients with bipolar hemiarthroplasty to treat displaced femoral neck fracture. Therefore, the objective of this study was to evaluate postoperative FO accurately and verify its relation with functional outcome.MethodsOne hundred elderly patients who received bipolar hemiarthroplasty to treat displaced femoral neck fracture were identified. Preoperative CT scanning of contralateral hip joint and reconstruction of images led to rotation-free FO. By referencing postoperative implant specification and comparing to measured values in Picture Archive and Communication System, rotation-free postoperative FO and the amount of change were acquired. Postoperative Harris Hip Score (HHS) and Modified Barthel Index (MBI) were evaluated to measure functional outcome at 12-month after the surgery. Patients with significant FO change were identified. Multiple regression analysis was conducted to determine if the FO change might independently affect the outcome regardless of confounding factors.ResultsThe mean preoperative offset was 37.4 ± 2.5 increased by 12.7 ± 9.6% after the surgery. Only 25.0% of postoperative offset after hemiarthroplasty was changed within ±5% of preoperative offset. A total of 45.0% of postoperative offset changed within ±10% while 77.0% of postoperative offset changed within ±20%. 23% of patients whose FO changed more than 20% showed significantly worse outcome score than the patients whose FO change remained within ±20% of initial value. Mean MBI and HHS were negatively correlated with FO change. After adjusting for confounding factors, significant correlation remained between modification of FO and MBI, but not between FO change and HHS (B = 4.576; β = 0.235; 95% confidence interval of B: 0.534 to 8.135).ConclusionsFO was not properly restored in 23% of subjects receiving bipolar hemiarthroplasty due to femoral neck fracture. FO restoration independently predicted fair MBI after the surgery. Therefore, surgeons should pay attention to restoring FO with meticulous templating.     

Does hospital structure influence the outcome of operative treatment of femoral neck fractures?

Data on 32 007 patients suffering from a medial fracture of the femoral neck have been collected between 1993 and 1999 in a database for external quality assurance organized by the chamber of physicians in Westfalia-Lippe. A statistical analysis (ANOVA, chi-square-test) has been performed to find out whether factors like specialization, annual volume or level of the hospital (primary, secondary or tertiary hospital) influence the outcome. RESULTS: Patients with higher preoperative risk-factors are treated more often in primary hospitals. These clinics perform conservative treatment significantly more often than tertiary hospitals (6.5 % vs. 3.8 %). Osteosyntheses are performed more often in departments specialized in traumatology (13 %) or tertiary hospitals (16.8 %). Preoperative length of stay was 0.5-0.7 days shorter in these hospitals. There is no significant difference in postoperative complications all together (23.2-25.6 %), but a significantly lower rate in postoperative complications after osteosynthesis performed by departments specialized in traumatology (11.3 % vs. 18.8 %). A volume load of more than 50 cases per year correlates with a significant decline in postoperative complications (22.5 % vs. 28.2 %). Risk adjusted mortality does not show significant differences among the different levels of hospitals. CONCLUSIONS: There are distinct differences regarding the way of treatment and procedural quality, but not concerning the short-term outcome between hospitals of different levels.     

Does the radial artery provide better long-term patency than the saphenous vein?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether the radial artery provides better long-term patency than the saphenous vein. Altogether 379 papers were found using the reported search, of which 12 presented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We concluded that there is evidence that radial artery grafts have a higher rate of patency than saphenous vein grafts. Surgeons can confidently use the radial artery as a second arterial bypass graft, particularly in patients with severe native-vessel stenosis.