Avulsion fracture of the lesser trochanter in adolescents

IntroductionAvulsion fractures of the lesser trochanter in adolescents are rare. They are a result of a sudden and forceful contraction of the iliopsoas muscle. Functional results in the medium term after non-operative treatment are unknown. Therefore we aimed to report these in the present study.Materials and methodsA retrospective two-center study was performed in a case series treated between 2011 and 2017. All adolescents with an acute avulsion fracture of the lesser trochanter were included. Age, gender, mechanism of injury, fracture side, amount of displacement, and therapy were analyzed. In the follow-up, the Harris Hip Score (HHS), the sports level, the power of flexion in the hip, and signs of an ischio-femoral impingement (IFI) were investigated.ResultsAn avulsion fracture of the lesser trochanter was diagnosed in 4 boys and 1 girl. The mean age of the patients was 13.8 years (range: 13–15 years). We observed 2 type II and 3 type III fractures. The patients received similar non-operative treatment. Follow-up was performed at a mean of 4.9 years (range: 3.5–6.2 years) after injury. All patients returned to competitive sports. The Harris Hip Score (HHS) was 100 out of 100 points. History and provocation test concerning an IFI were negative in all patients.ConclusionOur study shows excellent results with non-operative treatment in acute avulsion fractures of the lesser trochanter in a case series of five adolescents. All patients returned to competitive sports. In our opinion, acute avulsion fractures of the lesser trochanter should be treated non-operatively.     

Comparison of elderly patients with and without intertrochanteric fractures and the factors affecting fracture severity

BackgroundIntertrochanteric fractures in elderly patients are common and normally caused by low-energy injuries, such as falls. The favored treatment method is closed reduction with internal fixation using plate or nail systems. In general, the severity of an intertrochanteric fracture is one of key factors that affects the success rate of fixation. However, the factors that affect the severity of intertrochanteric fractures in elderly patients are rarely reported in the literature. In this prospective study, several possible factors were investigated.MethodsThe bone mineral densities (BMD) of 48 elderly patients (≥ 65 years) with intertrochanteric fractures due to low-energy injuries were compared with the BMDs of 48 elderly persons without hip fractures. Both groups were composed of people of similar ages and male-to-female ratios. Furthermore, in the patients with fractures, BMD, body mass index (BMI), body weight, and body height were compared between patients with nonsevere (intact lesser trochanter; 14 patients) and severe (displaced lesser trochanter or reverse obliquity fractures; 34 patients) intertrochanteric fractures.ResultsPatients with intertrochanteric fractures had significantly lower BMDs compared with persons without hip fractures to the lesser trochanter, total hip area, femoral neck, or greater trochanter (p = 0.001, <0.001, <0.001, and <0.001, respectively). There was no statistical difference in terms of BMD, BMI, body weight, or body height between patients with nonsevere and severe fractures.ConclusionElderly patients with intertrochanteric fractures have lower BMDs than persons without hip fractures. However, the severity of intertrochanteric fractures cannot be predicted by local BMD, BMI, body weight, or body height.     

Surgical treatment of subtrochanteric fractures

This paper is a contribution to the study of the surgical treatment of subtrochanteric fractures. By the term ‘subtrochanteric fractures’ we mean fractures beginning at or directly below the lesser trochanter and extending down the shaft of the femur.     

New classification focusing on the relationship between the attachment of the iliofemoral ligament and the course of the fracture line for intertrochanteric fractures

PurposeThere are various types of intertrochanteric fractures that are unstable pertrochanteric fractures of the hip. The aim of this study was to develop a systematic and comprehensive classification of intertrochanteric fractures.Materials and methodsThis study enrolled 74 patients with intertrochanteric fractures treated by us between 2012 and 2015. The fractures were classified using 3D-CT images taken immediately after the fractures occurred based on the course of the lateral fracture line (LFL) that extends through the lateral femoral cortex distal to the vastus ridge of the greater trochanter in the intertrochanteric area. Furthermore, the presence or absence of additional typical fractures was also studied. Then, 4 orthopedic specialists examined the 3D-CT images of 20 patients randomly selected from the 74 patients to evaluate both the inter-rater and intra-rater agreement levels.ResultsIntertrochanteric fractures were classified into three types according to the LFL patterns. Type I (41.9%), the Lateral Wall Pattern, has a LFL that extends towards the lateral fiber bundle attachment area of the iliofemoral ligament. Type II (24.3%), the Transverse Pattern, has a LFL that extends towards the medial bundle attachment area. Type III (33.8%), the Reverse Oblique Pattern, has a LFL that extends between the lateral and medial fiber bundle area of the iliofemoral ligament. Each type showed characteristic displacement and was associated with various combinations of typical fractures (fracture across the intertrochanteric line, posteromedial fragment, including the lesser trochanter, posterolateral fragment posterior to the femoral greater trochanter, and banana-shaped big fragment, including both the greater trochanter and the lesser trochanter). The mean κ values for the interobserver and intraobserver agreement levels were 0.77 (0.70–0.85) and 0.76 (0.70–0.85), respectively, which were considered substantial agreement levels.ConclusionWe believe our new classification is a useful communication tool for medical professionals in the diagnosis of fractures.     

手术治疗股骨粗隆间骨折时对小粗隆的处理

目的探讨Ⅳ型股骨粗隆间骨折手术治疗时对小粗隆骨折固定与否的治疗效果。方法用股骨近端锁定钢板固定治疗新鲜Ⅳ型股骨粗隆间骨折78例,其中小粗隆骨折固定（以下称为A组）治疗36例,小粗隆骨折不固定（以下称为B组）治疗42例,随访8~36个月（平均19个月）。结果两组患者中手术时间及术中出血量比较有统计学意义（P〈0.05）,而骨折愈合时间及髋关节功能无统计学意义（P〉0.05）。结论Ⅳ型股骨粗隆间骨折小粗隆骨折固定与不固定,在骨折愈合及髋关节功能方面无统计学意义,但小粗隆骨折不固定组在术中出血及手术时间上明显优于固定组。     

Isolated lesser trochanter fractures in elderly--a case for prophylactic DHS fixation. A case series

Isolated lesser trochanter fractures are a rare presentation of hip fractures in the elderly. Classically, lesser trochanter fractures in adults are associated with tumours and result from little or no trauma. We present three elderly osteoporotic ladies who sustained isolated fractures of the lesser trochanter secondary to a definite history of trauma. Radiologically, none of them showed any evidence of pathological lesions or intertrochanteric fracture at presentation. Two patients subsequently developed displaced intertrochanteric fractures, which necessitated internal fixation. In the third patient, a dynamic hip screw (DHS) was inserted before mobilisation. Based on this experience, we recommend careful observation and follow-up of such cases and suggest that isolated lesser trochanteric fractures in the elderly osteoporotic population may be an indication for prophylactic DHS fixation.     

Subtrochanteric fracture after cannulated screw fixation of femoral neck fractures: a report of four cases

Subtrochanteric fractures after screw or pin fixation of femoral neck fractures are a recognized complication. No literature is available on this complication after fixation using the recently popularized cannulated screws. We present our experience in treating four of these complications. The common denominator for all four patients seemed to be an entry point in the lateral cortex below the level of the most inferior edge of the lesser trochanter.     

Periprosthetic femoral fracture after total hip arthroplast

Periprosthetic femoral fractures represent a significant complication in total hip arthroplasty. based on originand treatment considerations, these fractures are best considered on the basis of the proximal region, and middle region below the lesser trochanter, and distal region at the prosthetic tip and beyond. Proximal-region fractures are usually wired and treated conservatively. Middle-region fractures may require prosthetic revision in addition to fracture fixation.Distal-region fractures are most difficult and may need advanced techniques, such as distal prosthetic fixation and allograft femoral plates.     

Is distal locking with IMHN necessary in every pertrochanteric fracture?

Two groups of patients were treated for pertrochanteric fractures (AO/ASIF 31A1+A2) with an intramedullary hip nail. In the first group of 44 patients distal dynamic locking was used, and in the second group of 74 patients the nail was not distally locked. Comparison of the two groups of patients did not show any difference in terms of the period of fracture healing, radiological and functional results or frequency of complications. In the group with a distally locked nail the surgery took 40.4 minutes, while in the group without distal locking only 34.4 minutes. In total, we recorded only seven complications, none of which were caused by absence of distal locking of the nail. This study has shown that distal locking of IMHN is unnecessary in most pertrochanteric fractures (AO/ASIF 31A1+2). The only exceptions are comminution of the lateral wall of the greater trochanter, secondary diaphyseal fracture line, large posteromedial fragment extended distally below the level of the lesser trochanter and broad intramedullary canal.     

Clustering of morphological fracture lines for identifying intertrochanteric fracture classification with Hausdorff distance–based K-means approach

ObjectivesThe aim of this study was to develop a systematic three-dimensional (3D) classification of intertrochanteric fractures by clustering the morphological features of fracture lines using the Hausdorff distance–based K-means approach and assess the usefulness of it in the clinical setting.MethodsWe retrospectively analyzed the data of 504 patients with intertrochanteric fractures who underwent closed reduction and intramedullary internal fixation. The morphological fracture lines of all patients extracted from computed tomography were transcribed freehand onto the template. All fracture lines were then clustered into five distinct types using the Hausdorff distance–based K-means clustering method. Five radiographic parameters and four functional parameters were used to evaluate the postoperative functional states and mobilization levels. Postoperative complications were also recorded.ResultsIntertrochanteric fractures were classified into five types: type I (108/504, 21.4%), simple fracture with intact lateral femoral wall and greater trochanter fragment; type II (85/504, 16.9%), simple fracture with intact lateral femoral wall with/without lesser trochanter detachment; type III (147/504, 29.2%), fractures with intertrochanteric crest detachment involving the lesser trochanter and greater trochanter with an intact lateral femoral wall; type IV (113/504, 22.4%), fractures with large intertrochanteric crest detachment and large lesser trochanter and greater trochanter detachment partially involving the lateral femoral wall and less medial cortical support; type V (51/504, 10.1%), a combination of pertrochanteric and lateral fracture line involving the entire lateral femoral wall and lesser trochanter detachment. Parameters of femoral neck–shaft angle and sliding distance of the cephalic nail were significantly different among types. The complication rate generally increased from type I to type V (P = 0.035).ConclusionsThe unsupervised clustering can achieve identification of the type of intertrochanteric fractures with clinical significance. The Tang classification can be used to describe fracture morphology, predict the possibility of achieving stable reduction and the risk of complications following intramedullary fixation.     

Influence of fragment volume on stability of 3-part intertrochanteric fracture of the femur: a biomechanical study

Complex unstable fracture can complicate the treatment outcome of intertrochanteric fracture of the femur, and fixation failure after surgery is a significant problem in elderly patients. This study aimed to evaluate the effect of fracture geometry on the stability of 3-part intertrochanteric fracture by assessing the fragment size. Four categories (group I: large greater trochanter, small lesser trochanter; group II: large greater trochanter, large lesser trochanter; group III: small greater trochanter, small lesser trochanter; and group IV: small greater trochanter, large lesser trochanter) of a 3-part intertrochanteric fracture model were designed. Three-dimensional computer tomography scanning was performed to measure the volume of each fragment. After fixation with a dynamic hip screw, a cyclic loading study was conducted using a servohydraulic machine. There was a significant difference in fatigue failure between each group. After all specimens had endured 10,000 cycles with a range of loads (100–1,000 N), the mean number of cycles until fixation failure with a load range of 200–2,000 N was 1,467.67 ± 199.92 in group I; 579 ± 93.48, group II; 398.17 ± 37.92, group III; and 268.67 ± 19.92, group IV. Fixation strength was approximately 5 times greater in group I than in group IV. In 3-part intertrochanteric fracture, the sizes of the greater and lesser trochanteric fragments are important factors for determining stability after dynamic compression screw fixation. This study supports our hypothesis that the volumetric ratio of ?lesser trochanter/?greater trochanter can be used to predict stability of intertrochanteric femoral fracture.     

Laceration of a branch of the profunda femoris artery caused by a spike of the displaced lesser trochanter in an inter-trochanteric femoral fracture. A case report

IntroductionInjury of femoral vessels is an extremely rare complication in intertrochanteric femoral fractures. In most cases reported, the vascular lesion involves the superficial femoral artery, whereas in very few cases does it involve the profunda femoris artery.Presentation of case: We report a case of acute bleeding due to laceration of a perforating branch of the profunda femoris artery caused by a sharp fragment of the displaced lesser trochanter in an intertrochanteric femoral fracture; the lesion was treated by transcatheter embolization.DiscussionThe arterial injury may be iatrogenic, occurring during intramedullary internal fixation, or less frequently, the injury may be due to the fracture itself, caused by a sharp bone fragment that damages the profunda femoris artery or one of its perforating branches.ConclusionWe believe that intertrochanteric femoral fractures with avulsed lesser trochanter are at risk for femoral vessel injuries caused by the displaced bone spike, and we advise meticulous clinical and laboratory monitoring pre- and post-operatively to prevent serious complications.     

Predicting the rotationally neutral state of the femur by comparing the shape of the contralateral lesser trochanter.

The rotationally neutral state of the femur was measured by comparing the shape of the contralateral lesser trochanter in 100 adults. Three observers predicted a position presumed to be neutral by comparing the shape of the neutrally positioned contralateral lesser trochanter previously recorded by C-arm image intensification. The mean (SD) angular discrepancy between the neutral point and the predicted angle was 3.4 degrees (+/- 2.4) without interobserver variation (P = .87). Seventy-seven percent indicated the value within 4 degrees, and none of the observations exceeded 15 degrees. These findings suggest the outline of the contralateral lesser trochanter may be a useful reference during surgical treatment of femoral fractures to minimize rotational deformity.     

Risk factors for implant failure after fixation of proximal femoral fractures with fracture of the lateral femoral wall

IntroductionTo investigate potential predictors of implant failure following fixation of proximal femoral fractures with a fracture of the lateral femoral wall.Materials and methodsMedical records of 99 adult patients who had operative treatment for a proximal femoral fracture with a fracture of the lateral femoral wall between May 2004 and April 2015 were retrospectively analysed to determine factors associated with implant failure. Patients underwent routine surgical procedures for implantation of extramedullary or intramedullary devices. Potential predictors were age, gender, body mass index, comorbidities, type of fracture, reduction method, status of greater and lesser trochanters, course of the lateral fracture line, and presence/absence of a free bone fragment at the junction of the greater trochanter and lateral femoral wall.ResultsTen (10%) implant failures were identified. Univariate analysis identified a free bone fragment at the junction of the greater trochanter and lateral femoral wall (odds ratio [OR], 21.25; 95% confidence interval [CI], 4.31–104.67; p < 0.001) and a transverse fracture line across the lateral femoral wall (primary or iatrogenic) (OR, 5.36; 95% CI, 1.29–22.30; p = 0.021) as factors associated with implant failure. Using a multivariate model, only a free bone fragment at the junction of the greater trochanter and lateral femoral wall (OR, 16.05; 95% CI, 3.06–84.23; p = 0.001) was a risk factor for implant failure.ConclusionsA free bone fragment at the junction of the greater trochanter and lateral femoral wall and a transverse fracture line across the lateral femoral wall are predictors of implant failure in proximal femoral fractures with a fracture of the lateral femoral wall. Integrity of the lateral femoral wall correlates with prognosis of proximal femoral fracture. Lateral femoral wall reconstruction may be required for effective treatment of proximal femoral fractures with a fracture of the lateral femoral wall.     

Reliable anatomical landmarks for minimizing leg-length discrepancy during hip arthroplasty using the lateral transgluteal approach for femoral neck fracture

BackgroundThe purpose of this study was to describe our experience of a preoperative templating technique, and to investigate the most reliable anatomical reference to minimize leg length discrepancy (LLD) during hip arthroplasty using the lateral transgluteal approach for femoral neck fractures. We hypothesized that the medial fracture tip and greater trochanter would be viable alternative anatomical ReferencesMethodsA total of 156 hip arthroplasty cases were enrolled in the present study (103 women, 114 hemiarthroplasties, 42 total hip arthroplasties). Preoperative acetate overlay templating was conducted based on pelvic anteroposterior radiographs. Three different anatomical references were used to determine the bony resection level, including the uppermost point of the lesser trochanter, uppermost point of the greater trochanter, and medial fracture tip. The accuracy of preoperative templating and the reliability of each anatomical reference for minimizing LLD were assessed.ResultsSignificant differences in postoperative LLD after hip arthroplasty between the three groups were identified. Post-hoc analysis showed that postoperative LLD in group A was significantly larger than that in groups B or C in hip arthroplasty.ConclusionThe results of this study suggest that the use of the lesser trochanter as an anatomical reference to determine the level of femoral neck osteotomy should be discouraged, and that the medial fracture tip and greater trochanter may be better alternatives when using the lateral transgluteal approach.     

保留粗隆部的普通股骨假体置换在老年粗隆部不稳定骨折中的应用

[目的] 探讨保留粗隆部的普通股骨假体置换术治疗老年粗隆部不稳定骨折的方法及临床效果。[方法] 采用保留粗隆部的普通股骨假体置换术治疗老年粗隆部不稳定骨折15例，Evans分类：ⅢA2例，ⅢB4例，IV8例，逆粗隆骨折1例；所有病例均合并有内科系统疾病。[结果] 本组无1例死亡，14例顺利出院，1例因呼吸系统并发症转内科治疗，1个月后出院。1例于术后出现下肢深静脉血栓形成（DVT），经治疗痊愈。术后X线片显示假体位置均良好，骨折复位满意。随访14～27个月，无假体松动、下沉及骨折不愈合。髋关节功能Harris评分平均为91分，优12例，良2例，可1例，优良率为93．3％。[结论] 保留粗隆部的普通股骨假体置换术治疗老年粗隆部不稳定骨折，患者卧床时间短，并发症少，安全可靠，术后髋关节功能恢复良好，是治疗老年粗隆部不稳定骨折较为理想的方法。     

Biomechanical comparison of proximal interlocking screw constructs in different subtrochanteric fracture models

BackgroundDepending on the size of the proximal bone segment, either a standard locking construct or a recon locking construct can be used in intramedullary nailing for a subtrochanteric fracture. However, the most appropriate construct for a given size of proximal bone segment has not yet been determined. Therefore, this study aimed to identify the appropriate construct using biomechanical testing.MethodsFourteen intramedullary nails for each locking construct (standard and recon) were inserted into 28 synthetic femurs. Fourteen subtrochanteric fracture models were developed by creating parallel defects (2 cm in size) 2 cm distal to the lower edge of the lesser trochanter (low fracture group), and 14 fracture models were developed with identical defects situated 1 cm distal to the lower edge of the lesser trochanter (high fracture group). An axial load experiment was conducted to measure the stiffness and failure load for each proximal interlocking screw construct.ResultsThere were no statistically significant differences in the stiffness and failure load between the locking constructs in the low fracture group. However, the stiffness and failure load were significantly greater for the recon locking construct than for the standard locking construct in the high fracture group.ConclusionThe standard locking system allows for sufficient fixation strength when performing intramedullary nailing for subtrochanteric fractures located 2 cm distal to the lower edge of the lesser trochanter.     

Periprosthetic fractures of the proximal femur—Vancouver A type fracture

Introduction

Today, we encounter an increasingly high need for arthroplasty, with a high number of total hip arthroplasties. With this, complications also rise, such as periprosthetic fractures. The purpose of this article is to briefly expose the periprosthetic fracture type Vancouver A, which is located either around the greater or the lesser trochanter.

Lesser trochanter fractures

The fractures of the lesser trochanter occur either through a low-energy trauma or spontaneously in the context of an osteolysis after loosening of the stem. The healing can mostly be achieved conservatively. In rare cases, an operative treatment must be considered, as in cases of osteolysis or lack of medial support, where a stem revision can become necessary.

Greater trochanter fractures

Also, the greater trochanter fractures are an entity of low-energy trauma. In cases of little displacement or in patients with low demand, a conservative treatment is indicated. For all other cases, there are a number of different methods of fixation. They range from wire cerclages to angular stable plates or even gluteus maximus/fascia lata flap transfer. However, a relatively high incidence of non-unions has been reported with different fixation techniques. The high incidence of non-union of periprosthetic fractures of the greater trochanter could eventually solved with the use of angular stable implants. There seem to be certain advantages, but further and larger studies will be necessary to prove its value.     

Changes in total alkaline phosphatase level after hip fracture: comparison between femoral neck and trochanter fractures

Background Biochemical bone metabolic markers are affected by fractures, and total alkaline phosphatase (ALP) is considered one of the bone formation markers. Only a few reports have dealt with changes in bone formation markers during the healing process of bone fragility hip fractures. Despite the difference in the amount of callus formation and bone fusion rate, no significant differences in longitudinal change of total ALP between femoral neck and trochanter fracture have been reported. Methods A total of 69 osteoporotic patients with femoral neck or trochanter fracture whose serum concentrations of total ALP were examined at least four times at six periodic examination points (1, 2, 3, 4, 6, and 8 weeks after surgery) and whose state of bone union was obtained within 24 weeks after surgery were selected for this retrospective study. The characteristic longitudinal change of total ALP during the healing process was shown, and the possibility of total ALP as a predictive factor for the state of osteosynthesis of hip fractures is discussed. Results Changes in the total ALP level according to the healing process were similar for femoral neck and trochanter fractures. The concentration of total ALP rose to a maximum at 3 weeks after surgery and then gradually decreased for both fractures. However, the range of change was significantly greater for trochanter fractures than for femoral neck fractures. For trochanter fractures, total ALP decreased from 3 to 6 weeks after surgery in all but one patient. Conclusions Increases in the concentration of total ALP after surgery and the subsequent decreases may reflect the normal healing process. A significant difference in the changes of total ALP after surgery between femoral trochanter and neck fractures was shown. Periodic measurement of total ALP might be useful for obtaining information on the osteosynthesis state.     

Stem fracture of the cementless spongy metal lübeck hip prosthesis

We performed 204 cementless total hip arthroplasties using a fully porous stem made of a cast cobalt-chrome-molybdenum alloy. Five stems fractured at the middle part. Champagne-fluted canals (P<.0001) and low canal fillings 1 cm below the lesser trochanter (P = .02) significantly correlated with stem fractures. Subsequent surgery revealed that all of the proximal parts were surrounded by fibrous tissue, and the distal parts showed bone ingrowth. Numerous voids were present close to the surface of the implant body. The core diameters of the fractured stems were 4 to 5 mm. The fractures may be attributed to the combination of the lack of proximal support, a champagne-fluted canal, the fully porous stem made of a cast cobalt-chrome-molybdenum alloy, and the narrow dimension of the stem core.