Sliding hip screw fixation of trochanteric hip fractures: outcome of 1024 procedures

The results for a consecutive series of 1024 trochanteric hip fractures surgically treated by internal fixation with a sliding hip screw in a single centre are presented. The mean age of patients was 81.7 years and 78% were female. Seventy-five percent of fractures were classified as unstable. At 1 year from injury, 69% of patients were surviving. Of these, 95% had minimal or no pain, 85% had at least returned to their pre-fracture level of accommodation and 50% to their pre-fracture level of mobility. Complications related to surgical fixation were encountered in 3.6% of cases. Overall, 2.6% of patients required further surgery as a result of these. While significant mortality remains an issue, the overall fixation failure rate and re-operation rate for trochanteric fractures fixed with a sliding hip screw is low. The final outcome of surgery for the survivors is good, with most patients returning to their pre-fracture level of accommodation and mobility, with minimal pain 1-year post-fracture.     

Origami in dynamic hip screw surgery

The insertion of a dynamic hip screw requires assessment of the native angle of the femoral neck. The two commonly used angles of DHS insertion are 135 and 150 degrees. We present a simple way of judging whether a 135 or 150 degrees angle plate is more suitable in the preoperative plan by using one or two sheets of A4 or letter paper, respectively.     

Prediction of fixation failure after sliding hip screw fixation

Cut-out of the lag screw is the commonest cause of fixation failure after sliding hip screw fixation of extracapsular hip fracture. A number of technical aspects of surgery have been used to asses the risk of cut-out. This study was to determine which of these indicators was the most reliable predictor of cut-out. The anterior-posterior and lateral post-operative radiographs of 23 cases of cut-out were compared with those of 77 cases of uneventful fracture healing. The tip-apex distance with correction for magnification was found to show the most significant difference between patients with cut-out against those without (P = 0.001), followed by the lag screw position on the lateral radiographs (P = 0.0095 and 0.014), reduction of the fracture on the anterior-posterior radiograph (P = 0.011 and 0.016) and the uncorrected tip-apex distance (P = 0.019). We recommend that for audit and research purposes the corrected tip-apex distance, fracture reduction and implant positioning methods should be used. For routine clinical practice, the uncorrected tip to apex distance, which is sum of the distance from the tip of the lag screw to the apex of the femoral head on anterior-posterior and lateral radiograph, and fracture reduction angle on the anterior-posterior radiograph are recommended.     

A rare complication of ceramic-on-ceramic bearings in total hip arthroplasty

Each year, approximately 217000 primary total hip arthroplasties (THAs) are performed in the United States (National Center for Health Statistics, 2003). This number is expected to increase as our population ages, and the indication for THA expands to younger and more active patients. Efforts are continually being made to improve implant design and, ultimately, patient outcomes. One area in particular that has undergone tremendous change is bearing surface technology. Ceramic-on-ceramic technology has gained widespread popularity in young patients because of its improved wear characteristics and durability. Bearing surface advancement must be tempered with analysis of implant-specific complications. We report a case of an audible hip complication after the use of ceramic components in THA.     

Dual lag screw cephalomedullary nail versus the classic sliding hip screw for the stabilization of intertrochanteric fractures. A prospective randomized study

This study is a randomized prospective study comparing two fracture fixation implants, the extramedullary sliding hip screw (SHS) and the dual lag screw cephalomedullary nail, in the treatment of intertrochanteric femoral fractures in the elderly. One hundred and sixty-five patients with low-energy intertrochanteric fractures, classified as AO/OTA 31A, were prospectively included during a 2-year period (2005–2006). Patients were randomized into two groups: group A included 79 hip fractures managed with sliding hip screws and group B included 86 fractures treated with cephalomedullary nails. Delay to surgery, duration of surgery, time of fluoroscopy, total hospital stay, implant-related complications, transfusion requirements, re-operation details, functional recovery, and mortality were recorded. The mean follow-up was 36 months (24–56 months). The mean surgical time was statistically significantly shorter and fluoroscopy time longer for the group B. No intraoperative femoral shaft fractures occurred. There was no statistically significant difference in the functional recovery score, reoperation, and mortality rates between the 2 groups. A new type of complication, the so-called Z-effect phenomenon, was noticed in the cephalomedullary nail group. There are no statistically significant differences between the two techniques in terms of type and rate of complications, functional outcome, reoperation and mortality rates when comparing the SHS and the cephalomedullary nail for low-energy AO/OTA 31A intertrochanteric fractures. Our data do not support recommendations for the use of one implant over the other.     

X线透视导航下动力髋(髁)螺钉治疗股骨转子间骨折

目的探讨X线透视导航技术在动力髋(髁)螺钉系统治疗股骨转子间骨折中的临床应用。方法应用连接在标准动力髋(髁)器械上的适配器,X线透视导航辅助完成术中松质骨拉力螺钉在股骨颈通道内的入点选择及拉力螺钉的置入。结果8例股骨转子间骨折的应用结果令人满意。手术时间平均为48.8min,X线图像采集平均3.4次。术中和术后无并发症发生。结论肯定了X线透视导航技术在动力髋(髁)螺钉系统治疗股骨转子间骨折中应用的可行性。术中只需1次X线成像就能做出虚拟的手术环境和路径;导航的瞬时追踪功能使术者能实时监测,减少了X线辐射量,缩短了手术时间,提高了拉力螺钉置入的准确度,减小了手术创伤。     

Radiographic quantification of dynamic hip screw migration

Purpose

This study aimed to propose a technique to quantify dynamic hip screw (DHS®) migration on serial anteroposterior (AP) radiographs by accounting for femoral rotation and flexion.

Methods

Femoral rotation and flexion were estimated using radiographic projections of the DHS® plate thickness and length, respectively. The method accuracy was evaluated using a synthetic femur fixed with a DHS® and positioned at pre-defined rotation and flexion settings. Standardised measurements of DHS® migration were trigonometrically adjusted for femoral rotation and flexion, and compared with unadjusted estimates in 34 patients.

Results

The mean difference between the estimated and true femoral rotation and flexion values was 1.3° (95 % CI 0.9–1.7°) and −3.0° (95 % CI – 4.2° to −1.9°), respectively. Adjusted measurements of DHS® migration were significantly larger than unadjusted measurements (p = 0.045).

Conclusion

The presented method allows quantification of DHS® migration with adequate bias correction due to femoral rotation and flexion.

Electronic supplementary material

The online version of this article (doi:10.1007/s00264-013-2146-4) contains supplementary material, which is available to authorised users.     

动力髋螺钉治疗股骨粗隆间骨折的临床疗效观察

目的：分析动力髋螺钉治疗股骨粗隆间骨折的临床疗效。方法选取76例股骨粗隆间骨折患者,随机分为对照组与观察组各38例,对照组给予支架外固定治疗,观察组给予动力髋螺钉内固定治疗,对两组患者治疗效果进行分析。结果观察组骨折愈合时间显著短于对照组,治疗总优良率显著高于对照组（P ＜0.05）。结论动力髋螺钉内固定治疗股骨粗隆间骨折效果显著,值得在临床中推广。     

A sliding hip screw augmented with 2 screws is biomechanically similar to an inverted triad of cannulated screws in repair of a Pauwels type-III fracture

ObjectivePauwels III femoral neck fractures are highly unstable. These fractures are commonly treated with three cannulated screws or sliding hip screw (SHS) implants, however high rates of non-union persist. A hybrid SHS construct has recently been proposed. The objective of the study was to compare this construct to the familiar inverted triad of cannulated screws and to a single SHS.MethodsFourth generation biomechanical femur analogs were used to create a highly repeatable injury model. The hybrid SHS construct contained a SHS with two superior cannulated screws in an inverted triangle configuration. Eight samples for each construct were biomechanically evaluated and the results compared using ANOVA (p < 0.05).ResultsThe cannulated triad and hybrid SHS provided similar stiffness and fracture gap motion. The single SHS exhibited significantly lower stiffness and larger fracture plane diastasis than either the inverted triangle of cannulated screws or hybrid SHS (p < 0.05). None of the constructs exhibited catastrophic failure during cyclic loading nor under loading up to 2.5 times body weight.ConclusionsThe single SHS provided the least stable fracture fixation, while the inverted triad and hybrid SHS constructs were mechanically similar. The fracture repair simulated here illustrates how these repairs have the potential to return near pre-fracture strength in ideal conditions with young, healthy bone. However; in clinical situations where comminution impairs load transfer through the cortices the hybrid SHS may be the most favorable option.     

Percutaneous dynamic hip screw

We present the results of a technique of dynamic hip screw insertion through a very small incision, typically 2-2.5 cm. The technique is performed using a standard dynamic hip screw set and requires no additional equipment. We compared the results to those of an age and sex-matched group who had undergone the operation through a traditional approach. We compared the time spent in theatre, the pre- and post-operative haemoglobin concentration, haematocrit and prevalence of wound infection. Thirteen consecutive cases were performed by one surgeon using the percutaneous technique. There were nine females and four males with a mean age of 84 years (range 62-96 years). Each had a 135 degrees four-hole plate. The mean post-operative drop in haemoglobin concentration in the percutaneous group was 2.2 g/dl (range 0-4.4 g/dl) compared to 3.5 g/dl (range 1.2-5.4 g/dl) in the control group (p = 0.014). The mean haematocrit drop was 0.07 (range 0-0.12) in the percutaneous group compared to 0.10 (range 0.03-0.17) in the control group (p = 0.017). The mean theatre time with the percutaneous technique was 57 min (range 40-75 min) and in the control group, 60 min (range 30-95 min). There were no wound problems. It is likely that this minimally invasive technique offers a better clinical outcome at no extra expense and warrants further evaluation in a larger study.     

有限动力髋螺钉内固定治疗股骨粗隆间骨折的生物力学研究

目的通过生物力学实验测试并评价有限动力髋螺钉（Limited dynamic hip screw,LDHS）内固定治疗股骨粗隆间骨折的生物力学性能。方法采集6具新鲜尸体中12根股骨中上段标本,造成EvansⅠ、Ⅱ型股骨粗隆间骨折模型（各6根）,分别采用LDHS、DHS固定,要求将主钉安放在股骨头颈中心,且保持前倾10°-15°。LDHS组和DHS组分别进行股骨固定强度测试、刚度测试、头颈部剪断测试、扭转强度测试和极限载荷测试。结果 LDHS组与DHS组中EvansⅠ、Ⅱ型骨折模型在1200N载荷作用下,LDHS组股骨内、外侧固定强度更高,股骨头颈的轴向刚度、水平剪切刚度更高,剪切应变较小,差异均有统计学意义（P〈0.05）。在EvansⅠ、Ⅱ型骨折模型中,LDHS组最大扭矩较DHS组大,抗扭转刚度更高,但差异无统计学意义（P〉0.05）;LDHS组能承受的极限载荷较DHS组大,差异有统计学意义（P〈0.05）。结论生物力学试验表明LDHS不仅在结构设计、整体生物力学性能上优于DHS,而且置入后未发生退钉现象。LDHS可能是治疗股骨粗隆间骨折更加理想的内固定器械。     

The treatment of trochanteric and femoral neck fractures using the dynamic hip screw (DHS)

Surgical Principles The goal of treating fractures in the trochanteric region is to restore the medial support in line with Shenton’s arch. The function of the compression trabeculae is insured by a screw introduced into the femoral head and neck. The shaft of the screw slides in a tunnel which forms part of the side plate. This permits early loading with impaction of the fracture without danger of the screw perforating the femoral head. The design of the screw shaft and the tunnel prevent rotation of the head fragment. This device does not function as a load-bearing but as a load-sharing implant. Load transmission occurs mostly through bone. Revised Version from: Operat. Orthop. Traumatol. 2 (1990), 203–214 (German Edition).     

动力髋螺钉治疗股骨转子间骨折86例临床分析

股骨转子间骨折高发于老年患者,且随着老龄化人口的增多,发病率呈明显上升趋势。手术治疗股骨转子间骨折已经取得了令人满意的效果,成为骨科同仁们的共识。但在实际应用中,也出现了髋内翻、颈短缩、跛行、钉拔出、头切割、螺钉穿出股骨头等问题。为此,我们回顾分析了2000年以来用动力髋螺钉(DHS)治疗的86例病例,意在观察此法治疗股骨转子间骨折的疗效和并发症,并探讨治疗经验。1临床资料本组86例中,男37例,女49例;年龄48~94岁,平均72·8岁;左侧52例,右侧34例;行走不慎等低能量损伤71例,车祸等高能量损伤15例。骨折采用Evans-Jenson分型[1]…     

动力髋螺钉治疗股骨粗隆间骨折并发症原因分析及防治

目的：分析动力髋螺钉（DHS）治疗股骨粗隆间骨折并发症的原因,并提出防治措施。方法：对65例采用DHS治疗股骨粗隆间骨折患者中发生并发症13例进行临床总结,分析其发生的主要原因,提出相应的防治措施。其中男8例,女5例;年龄56～82岁,平均70.2岁。结果：13例并发症中,术中股骨近端外侧皮质崩裂2例;术中髋螺钉穿破股骨头进入髋臼2例;髋内翻5例;股骨头坏死1例;切口感染3例,其中1例出现骨折不愈合。结论：导致并发症发生的主要原因有手术操作不规范,无菌操作不严格,骨折复位不理想,术后过早负重。预防措施主要有严格无菌操作,积极治疗内科疾病,规范手术操作,骨折尽量达到解剖复位,重视小粗隆及后内侧骨块的固定,术后合理进行功能锻炼。     

Iliopsoas tendonitis a complication after total hip arthroplasty

The causes of pain after total hip arthroplasty are multiple. We present a series of 15 patients (16 cases) who presented with pain related to the iliopsoas tendon. All patients had previously undergone cementless hip arthroplasty and presented with similar symptoms and clinical signs. Surgery was carried out after failure of conservative measures. Release of the iliopsoas tendon from the lesser trochanter gave good symptomatic relief in all except one patient who required reposition of acetabular prosthesis, with the average Harris Hip Score improving from 58 (range, 44-70) to 91 (range, 78-95) postoperatively. This relatively uncommon condition should be considered in the differential diagnosis of all patients who present with groin pain after total hip arthroplasty. Surgical release of the iliopsoas tendon can give excellent results in these patients.     

Outcomes of osteoporotic trochanteric fractures treated with cement-augmented dynamic hip screw

Background:

Dynamic hip screw (DHS) has been the standard treatment for stable trochanteric fracture patterns, but complications of lag screw cut out from a superior aspect, due to inadequate bone anchorage, occur frequently in elderly osteoporotic patients. Polymethylmethacrylate (PMMA) has been used as an augmentation tool to facilitate fixation stability in cadaveric femora for biomechanical studies and in pathological fractures. However, there are very few reports on the utilization of PMMA cement to prevent these complications in fresh intertrochanteric fractures. A prospective study was conducted to evaluate the outcome and efficacy of PMMA augmented DHS in elderly osteoporotic patients with intertrochanteric fractures.

Materials and Methods:

The study included 64 patients (AO type31-A2.1 in eight, A2.2 in 29, A2.3 in 17 patients, and 31-A3.1 in five, A3.2 in three, and A3.3 in two patients) with an average age of 72 years (60 – 94 years) of which 60 were available for final followup. PMMA augmentation of DHS was performed in all cases by injecting PMMA cement into the femoral head with a custommade gun designed by the authors. The clinical outcome was rated as per the Salvati and Wilson scoring system at the time of final followup of one year. Results were graded as excellent (score > 31), good (score 24 – 31), fair (score 16 – 23), and poor (score < 16).

Results:

Fracture united in all patients and the average time to union was 13.8 weeks (range 12 – 16 weeks). At an average followup of 18 months (range 12 – 24 months), no incidence of varus collapse or superior screw cut out was observed in any of the patients in spite of weightbearing ambulation from the early postoperative period. There was no incidence of avascular necrosis (AVN) or cement penetration into the joint in our series. Most of the patients were able to regain their prefracture mobility status with a mean hip pain score of 8.6.

Conclusion:

Cement augmentation of DHS appears to be an effective method of preventing osteoporosis related complications of fracture fixation in the trochanteric fractures. The technique used for cement augmentation in the present study is less likely to cause possible complications of cement augmentation like thermal necrosis, cement penetration into the joint, and AVN hip.     

动力髋螺钉治疗老年人股骨粗隆间骨折的手术风险及疗效

[目的] 探讨动力髋螺钉治疗老年人股骨粗隆间骨折的手术并发症，并评价其疗效。[方法] 对采用AO动力髋螺钉治疗的65岁以上老年人股骨粗隆间骨折的手术并发症进行统计学分析，并评价其随访疗效。[结果] 围手术期并发症发生率为17．2％。经过术后8～42个月（平均26．5个月）的随访，并发症发生率为16．4％，优良率为87．9％。[结论] 动力髋螺钉治疗老年人股骨粗隆间骨折可获得满意疗效，积极的围手术期处理是手术安全实施的必要条件。     

动力髋螺钉治疗股骨转子间骨折

目的 评价动力髋螺钉(DHS)治疗股骨转子间骨折的临床效果。方法 1996年3月～2002年3月用DHS共治疗患者29例．骨折按Evans分型，本组Evans ⅠA2例，Evans ⅠB 10例，Evans ⅡA 3例，Evanslib12例，Evans Ⅲ2例．结果 29例患者均获随访，随访12～48个月，平均26个月，根据Harris髋关节评分：优16例，良9例，中3例，差1例。结论 如能及时手术良好复位，DHS是治疗股骨转子间骨折的较好选择。     

Treatment of intertrochanteric fractures in elderly highrisk patients: Dynamic hip screw vs. external fixation

Introduction

Although the use of a dynamic hip screw (DHS) is considered to be the preferred treatment for intertrochanteric fractures, the external fixation device could produce clinical outcomes comparable to the outcomes obtained with conventional treatment. Furthermore, because external fixation is minimally invasive, we expected a lower rate of morbidity. Therefore, we compared the two treatments in a clinical trial of elderly patients with intertrochanteric fracture.

Methods

60 elderly high-risk patients with an average age of 78 years were treated for intertrochanteric fracture, resulting from a low energy trauma. Patients were randomly divided in two groups regarding to treatment. In Group A the patients were treated with DHS, while in Group B were treated with external fixator.

Results

The fixator was well accepted and no patient had significant difficulties while sitting or lying. The average intraoperative time was 73 min in Group A and 15 min in Group B (p < 0.05). 27 patients of Group A need blood transfusion postoperatively and none in Group B (p < 0.05). The mean duration of hospitalization in Group A and Group B was 8.4 and 2.2 days, respectively (p < 0.05). 9 of patients Group B had pin-track infection grade 2 that all were treated by oral antibiotics. There were no differences in comorbidities, quality of reduction, screw cut out, bed sore and HHS between the two groups.

Conclusion

Treatment with external fixator is an effective treatment for intertrochanteric fractures in elderly highrisk patients. The advantages include quick and simple application, minimal blood loss, less radiation exposure, adequate fixation, pain reduction, early discharge from hospital, low costs and favourable functional outcomes.     

动力髋螺钉治疗股骨粗隆间骨折并发症分析

目的：分析动力髋螺钉钢板系统（dynamic hip screw,DHS）治疗股骨粗隆间骨折的并发症及其原因。方法：2002年1月至2007年12月69例股骨粗隆间骨折采用DHS治疗,男27例,女42例;年龄53-96岁,平均72．9岁;按照Evans骨折分型：Ⅰ型10例,Ⅱ型21例,Ⅲ型22例,Ⅳ型16例。术前已明确诊断的各种内科系统伴随症的51例（73．9％）,观察分析其并发症的发生情况。结果：57例出院后通过门诊及电话获得随访,随访时间8-70个月,平均41个月。围手术期发生全身系统并发症17例,死亡4例;手术局部相关并发症12人18例次。其中包括滑动髋螺钉松动后退4例、拉力螺钉穿破股骨头3例、钢板断裂1例;髋内翻5例;深部组织感染再次手术取出内固定1例;伤口愈合不良2例,骨折延迟愈合2例。结论：不稳定性粗隆间骨折应用DHS内固定失败的发生率较高,不应作为治疗首选。应根据骨折分型,结合老年患者骨质疏松情况,选择适当的术式,充分重视高龄患者系统性疾病的预防和监护,可以提高股骨粗隆间骨折的疗效并减少术后并发症。