Unstable pertrochanteric femoral fractures

BACKGROUND: Fractures in the trochanteric region of the femur are classified as AO/OTA 31-A, as they are extracapsular. This report analyzes the relatively rare 31-A3 fracture, which has also been referred to as an "intertrochanteric femur fracture with subtrochanteric extension," "reverse obliquity intertrochanteric femur fracture," "unstable intertrochanteric femur fracture," or a "subtrochanteric femur fracture." The A3 fracture is characterized by having a fracture line exiting the lateral femoral cortex distal to the vastus ridge. Possible fixation constructs include compression hip screws, intramedullary hip screws, trochanteric intramedullary nails, cephalomedullary antegrade intramedullary nails, and 95 degrees plates. Most reports investigating 31-A fractures do not describe the 31-A3 fracture. For this analysis, only reports clearly indicating that the fracture treated was a 31-A3 were included. It should be understood that this approach therefore excludes reports on generic "subtrochanteric fractures" or "intertrochanteric fractures," some of which may have been 31-A3 fractures. OBJECTIVE: To determine the effect of fixation technique for the AO/OTA 31-A3 fracture on rates of union, infection, risk of reoperation, and functional outcomes.     

Are there advances in the treatment of extracapsular hip fractures in the elderly?

While the rate of failure following hip fracture surgery for extracapsular hip fractures in the elderly is low, an incidence of implant cutout from the femoral head remains regardless of whether fixation is by sliding hip screw or intramedullary nail. In general, a well-executed osteosynthesis is the best assurance of a good outcome with few complications, and typically a less than ideal placement of the implant in the femoral head is the reason for cut-out and failure of the operation. It is clear that there is no difference in the incidence of complications or functional outcome between a sliding hip screw and an intramedullary nail for pertrochanteric fractures (AO/OTA 31-A1 and A2), while the implant of choice in the elderly for the true intertrochanteric fracture (AO/OTA 31-A3; reverse intertrochanteric) is a nail. However, what is less clear is whether there are newer ideas and/or implant designs that represent true advances in the treatment of extracapsular fractures in the elderly. The following review focuses on just this issue.     

Potentially unstable intertrochanteric fractures

OBJECTIVES: Evaluation of risk factors for loss of reduction in initially stable intertrochanteric fractures. DESIGN: Retrospective database analysis. SETTING: University teaching hospital. PATIENTS/PARTICIPANTS: Sixty-six patients over the age of 55 years presenting with fractures of the trochanteric region caused by a low-energy injury, classified as AO/OTA type 31-A1 (stable fracture in Evans classification). INTERVENTION: Treatment with a sliding compression hip screw. MAIN OUTCOME MEASUREMENT: The outcome examined in this study was loss of reduction as measured by the amount of medialization of the femoral shaft. RESULTS: Increased age (P = 0.01) and comminution of the lateral cortex (P = 0.0001) were factors significantly associated with excessive displacement. These 2 factors had a high degree of correlation (r = 0.76). CONCLUSIONS: A surgeon must be aware of iatrogenic fragmentation of the lateral cortex at the time of surgery in apparently stable intertrochanteric fractures in older patients because of the potential for subsequent loss of reduction.     

Intramedullary nailing appears to be superior in pertrochanteric hip fractures with a detached greater trochanter

Background and purpose In recent years, intramedullary nails (INs) for the treatment of pertrochanteric hip fractures have gained prominence relative to conventional, sliding hip screws (SHSs). There is little empirical background for this development, however. A previous series of ours suggested that the use of SHS was not adequate in situations with fragile or fractured lateral femoral walls, where it often led to lack of healing in a maximally telescoped position. We hypothesized that INs would be the superior implant in these specific circumstances.

Methods We retrospectively examined 311 consecutive patients treated in our department between 2002 and 2008, with either an IN (n = 158) or an SHS (n = 153) mounted on a 4-hole side-plate, for an AO/OTA type 31A1–2 pertrochanteric fracture with a detached greater trochanter. The status of the lesser trochanter was assessed preoperatively and the integrity of the lateral femoral wall, fracture reduction, and position of the implants were assessed postoperatively. Reoperations due to technical failure were recorded for one year postoperatively.

Results Multivariate logistic regression analysis showed that the groups were similar regarding demographic and biomechanical parameters. The lateral femoral wall was more frequently fractured during SHS implantation (42 patients) than in the IN group (9 patients) (p < 0.001). 6 (4%) of the 158 patients operated with IN had to be reoperated, as compared to 22 (14%) in the SHS group of 153 patients (p = 0.001).

Interpretation IN had a lower reoperation rate than SHS in these pertrochanteric hip fractures with a detached greater trochanter. IN left more lateral femoral walls intact.     

PFNA治疗股骨转子间伴或不伴外侧壁骨折的疗效分析

 目的 探讨PFNA治疗股骨转子间伴或不伴外侧壁骨折的临床疗效。方法 回顾性分析2008 年5 月至2011 年6 月应用PFNA治疗102 例股骨转子间骨折资料。术前根据CT 三维重建图像所示外侧壁情况分为2 组: 外侧壁骨折组(A 组, 41 例, 其中AO/OTA 31-A2 型5 例, 31-A3 型36 例), 外侧壁未骨折组(B 组, 61 例, 均为AO/OTA 31-A2 型)。比较两组患者的手术时间、术中出血量、住: 天数, 根据术后2 周的X 线片及CT 三维重建图像比较外侧壁爆裂情况。采用老年髋部骨折功能恢复量表(functional recovery scale, FRS)对术后疗效进行评估。结果 A 组手术时间为(56±8)min、术中出血量为(238±21)ml、住: 天数为(17±3)d, 均高于B 组的(45±6)min、(175±11)ml、(15±3)d, 两者比较差异均有统计学意义。术后X 线片示A 组8 例(19.5豫, 8/41)、B 组3例(4.9豫, 3/61)发生外侧壁爆裂;而术后CT三维重建示A组36 例(87.8豫, 36/41)、B 组45 例(73.8豫, 45/61)发生外侧壁爆裂。82 例患者获得随访, 随访时间6~35 个月, 平均19.5 个月。随访时间在1 年以上有56 例, FRS 评分: A 组为(64.2±4.8)分, B 组为(76.5±7.9)分。结论 PFNA 治疗不稳定型股骨转子间骨折时, 容易造成股骨转子外侧壁骨折或加重外侧壁损伤, 影响患者髋部功能恢复。CT三维重建技术可有效评估该类医原性创伤。     

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.     

Integrated risk scoring model for predicting dynamic hip screw treatment outcome of intertrochanteric fracture

BackgroundDynamic hip screw (DHS) is a common device for treating intertrochanteric fracture (ITF). Various risk factors have been reported to be associated with the operative treatment outcome. However, an integrated risk scoring prediction model is lacking. In this study, we aimed to develop a prediction model for treatment outcome of intertrochanteric fracture.MethodsWe analyzed 442 AO/OTA 31-A1 and A2 fractures which were treated with DHS during the period January 2000 to June 2014 in a level I trauma center. Risk factors including age, gender, injured side, lag screw position, AO/OTA classification, tip-apex distance, postoperative lateral wall fracture, reduction patterns were analyzed to determine their influence on treatment outcome. Integrated risk scores of significant predictors were used to construct a prediction model.ResultsAO/OTA 31-A2 classification, postoperative lateral wall fracture, posteriorly inserted lag screw and varus reduction pattern were significant risk predictors for DHS failure. The failure risk for low- and high-risk groups were significantly different (P<0.001)ConclusionAO/OTA 31-A2 classification, postoperative lateral wall fracture, posteriorly inserted lag screw and varus reduction pattern were significant risk predictors for DHS failure. We developed a model that integrates these factors to predict the treatment outcome, which had excellent prediction accuracy and discriminatory ability. The models may provide useful information for orthopedic doctors to identify patients who need early intervention as well as ITF patients who require more frequent follow-up in the postoperative period.     

股骨外侧壁在股骨粗隆间骨折的髓内与髓外固定中的生物力学研究

目的：观察股骨外侧壁的完整性对髓内与髓外固定治疗股骨粗隆间骨折的生物力学影响,指导临床选择内固定方式。方法：采用成人尸体同侧股骨标本12具,均造成股骨粗隆间骨折AO 分型A1型骨折,随机分为外侧壁完整PFNA组、外侧壁完整PF-LCP组、外侧壁破损PFNA组、外侧壁破损PF-LCP组,每组3具,4组股骨标本采用万能材料测试机进行压缩载荷实验,观察股骨标本的最大载荷力,并用游标卡尺测量骨折断端的压缩前后的间隔位移及骨折远、近端沿粗隆间的滑动位移进行相互比较。结果：外侧壁完整PFNA组的最大载荷力大于外侧壁完整PF-LCP组,并且外侧壁破损PFNA组的最大载荷力也大于外侧壁破损PF-LCP组,差异均具有统计学意义（P<0.05）;压缩前4组股骨标本的骨折端间隔距离相互比较差异无统计学意义（P>0.05）,压缩后外侧壁完整PFNA组的骨折端间隔距离、压缩前后的骨折端位移及骨折远、近端的滑动位移与外侧壁完整PF-LCP组相互比较差异均无统计学意义（P>0.05）,但外侧壁破损PFNA组的骨折端间隔距离、压缩前后的骨折端位移及骨折远、近端的滑动位移均小于外侧壁破损PF-LCP组,差异均具有统计学意义（P<0.05）.结论：髓内固定治疗股骨粗隆间骨折具有更强的载荷力,股骨外侧壁完整时髓内与髓外固定均有较强的稳固性,但股骨外侧壁破损时髓内固定具有更强的稳固性,可见髓内固定是治疗股骨粗隆间骨折的首选方式。     

Prospective randomised controlled trial of an intramedullary nail versus a sliding hip screw for intertrochanteric fractures of the femur

Purpose

The purpose of this prospective randomised trial was to assess whether an intramedullary nail is superior to a sliding hip screw in the treatment of multifragmentary intertrochanteric fractures

Methods

Eighty patients with a 31-A2.2 or A2.3 Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) intertrochanteric fracture were randomly allocated to fixation with either the Gamma nail or the AMBI sliding hip screw device.

Results

All patients were followed up at one, three, six and 12 months postoperatively, except for nine who died. There was no statistical difference in Parker mobility score between groups. The Gamma nail group had significantly higher Barthel Index and EuroQol-5D (EQ-5D) scores than the AMBI group at 12 months. At the same time, the EQ-5D score had returned to its pre-operative values in the Gamma nail group but not in the AMBI group. There were no differences in mortality, radiation time and hospital stay. Duration of the operation, incision length and hip pain occurrence were significantly less in the Gamma nail group.

Conclusions

Few failures occur when unstable 31-A2.2 and A2.3 AO/OTA fractures are fixed with a sliding hip screw. Nevertheless, an intramedullary nail seems superior in reconstituting patients to their pre-operative state.     

Prospective randomised study comparing screw versus helical blade in the treatment of low-energy trochanteric fractures

Purpose  

The purpose of this study was to compare femoral head placement, rates of reoperation and cephalic implant cut-out of a screw versus a blade for patients over age 60 with low energy trochanteric fractures (AO/OTA 31-A1, A2, and A3) treated either with sliding hip screw or cephalomedullary nail.     

Transient retrograde interfragmentary compression technique in AO/OTA type 33-C distal femur fractures: A surgical technique and short-term radiographic follow up results

Surgical treatment of AO/OTA type 33-C fractures is a therapeutic challenge despite advances in surgical instruments and techniques. We introduce a novel surgical technique named transient retrograde interfragmentary compression (TRIC) to help intraarticular fragment reduction in AO/OTA type 33-C fracture. We inserted a partial threaded 7.0-cannulated screw with a washer along the transepicondylar axis from the medial femoral epicondyle during the articular block reduction process of AO/OTA type 33-C fractures to strengthen the compressive force between the condylar fragments and to enhance the handling of the articular block fragment in the alignmental correction stage. Following the provisional reduction and fixation using lateral distal femur locking compression plate, TRIC screw was removed. Fifteen AO/OTA type 33-C distal femoral intraarticular fractures of thirteen patients were surgically treated using the TRIC technique. We analyzed the radiographic result of the patients by measuring the horizontal gap and vertical step-off in the postoperative radiographs. Mean horizontal fracture gap was 0.34 mm and mean vertical step-off between bicondylar fragments was 0.63 mm. The median value of the horizontal fracture gap and vertical step off was 0 and 0.46 mm, respectively. Mean time to union in the bicondylar fracture fragment was 9 week. TRIC is considered to be a valuable surgical reduction technique in the treatment of the AO/OTA 33-C type fractures.     

Intramedullary nailing appears to be superior in pertrochanteric hip fractures with a detached greater trochanter: 311 consecutive patients followed for 1 year

Background and purpose

In recent years, intramedullary nails (INs) for the treatment of pertrochanteric hip fractures have gained prominence relative to conventional, sliding hip screws (SHSs). There is little empirical background for this development, however. A previous series of ours suggested that the use of SHS was not adequate in situations with fragile or fractured lateral femoral walls, where it often led to lack of healing in a maximally telescoped position. We hypothesized that INs would be the superior implant in these specific circumstances.

Methods

We retrospectively examined 311 consecutive patients treated in our department between 2002 and 2008, with either an IN (n = 158) or an SHS (n = 153) mounted on a 4-hole side-plate, for an AO/OTA type 31A1–2 pertrochanteric fracture with a detached greater trochanter. The status of the lesser trochanter was assessed preoperatively and the integrity of the lateral femoral wall, fracture reduction, and position of the implants were assessed postoperatively. Reoperations due to technical failure were recorded for one year postoperatively.

Results

Multivariate logistic regression analysis showed that the groups were similar regarding demographic and biomechanical parameters. The lateral femoral wall was more frequently fractured during SHS implantation (42 patients) than in the IN group (9 patients) (p < 0.001). 6 (4%) of the 158 patients operated with IN had to be reoperated, as compared to 22 (14%) in the SHS group of 153 patients (p = 0.001).

Interpretation

IN had a lower reoperation rate than SHS in these pertrochanteric hip fractures with a detached greater trochanter. IN left more lateral femoral walls intact.In the last decade, the use of intramedullary nails (INs) for the treatment of pertrochanteric fractures has become more common (Figure 1). There is little empirical background for the development, however (Stern 2007, Anglen and Weinstein 2008, Parker and Handoll 2008, Rogmark et al. 2010). The latest Cochrane review recommends conventional sliding hip screws (SHSs) for these fractures, but also recommends more studies to determine whether INs are of advantage for selected fracture types (Parker and Handoll 2008). In a randomized study, Saudan et al. (2002) found no advantages using INs for the AO/OTA type A1 and A2 fractures as a whole, but to our knowledge no studies comparing the rate of reoperation in the AO/OTA type A1 and A2 subgroups have been published.Open in a separate windowFigure 1.AO/OTA type-31-A pertrochanteric fractures. 31-A1 fractures are simple, whereas 31-A2 fractures are multifragmentary. Subgroups of 31-A2 pertrochanteric fractures are A2.1 (detachment of the lesser trochanter), A2.2 (several intermediate fragments including detachment of the lesser trochanter), and A2.3 (several intermediate fragments extending more than 1 cm distal to the lesser trochanter). 31-A3 intertrochanteric fractures all have a fracture line through the lateral femoral wall, anatomically defined as the lateral femoral cortex distal to the greater trochanter. (Reprinted, with permission from: Orthopaedic Trauma Association Classification, Database and Outcomes Committee. Fracture and dislocation classification compendium - 2007. J Orthop Trauma 2007; 10 Suppl.)Recently, we performed a cohort study that indicated that SHS is not adequate in patients with fragile lateral femoral walls (Palm et al. 2007). We found that this important lateral buttress area was fractured during the operative procedure in a third of patients with a detached greater trochanter preoperatively (Figure 2).Open in a separate windowFigure 2.An 82-year-old woman sustained a pertrochanteric hip fracture with a detached greater trochanter.We have now compared the rate of reoperations in the subgroup of pertrochanteric hip fractures with a detached greater trochanter treated either with IN or SHS. In particular, we wanted to assess whether there was a risk that the implants would cause a fracture of the lateral femoral wall.     

微创内固定系统治疗复杂股骨转子部骨折的初步报告

目的探讨微创内固定系统(LISS)治疗复杂股骨转子部骨折的可行性、手术技术及指征,并总结其近期临床治疗效果。方法自2005年6月～2006年5月,应用LISS治疗复杂股骨转子部骨折12例。骨折采用AO分类法,其中转子间骨折5例：31-A2．2型2例,31-A2．3型2例,31-A3．3型1例；转子下骨折7例：32-A3．1型1例,32-B1．1型3例,32-B2．1型1例,32-B3．1型2例。记录手术时间、术中出血量、术后住院时间,术后观察有无感染、下肢深静脉血栓、心肺疾患、应激性溃疡等并发症。术后1、2、3、6、12个月时常规随访。结果手术时间50～90 min,平均65 min；出血量50～400 mL,平均142 mL,术后住院时间6～15 d,平均9．3 d。无死亡病例。所有患者均未出现切口感染、下肢深静脉血栓、术后心肺疾患、应激性溃疡等并发症。12例均获得3～14个月(平均7．2个月)随访。10例在术后3个月复查骨折时达到临床愈合,1例假体周围骨折术后4个月、1例病理性骨折术后6个月达到临床愈合。所有患者在最后一次随访时均无骨折再移位、髋内翻畸形、内固定切出、内固定失败及股骨头坏死。结论微创反向使用股骨LISS从生物力学和解剖结构上都能满足股骨近端骨折内固定要求,并具有创伤小、操作简便、固定可靠、安全性高、并发症少的特点,尤其适用于老年人合并内科疾病、骨质疏松较重的转子间骨折及复杂的股骨近端骨折。熟练掌握间接复位技术,正确放置A孔导针,避免过早负重是手术成功的关键。     

伴有后方冠状面骨折的A2.3型股骨转子间骨折的临床特点和治疗

目的 :探讨伴有后方冠状面骨折的A2.3型股骨转子间骨折的特点、手术技巧和疗效。方法:2011年1月至2014年1月,采用股骨近端防旋髓内钉治疗33例伴有后方冠状面骨折的股骨转子间骨折的患者,其中男15例,女18例;年龄61~92岁,平均(73.1±8.2)岁;按照AO/OTA分型,均为A2.3型;均为闭合性骨折。均采取有限切开辅助复位内固定术,采用Harris髋关节评分标准对术后疗效进行评价。结果:1例术后19 d死亡,32例获得随访,随访时间9~24个月,平均(16.3±5.1)个月;根据X线片随访,骨折愈合时间6~9个月,平均(7.2±1.5)个月。末次随访Harris髋关节功能评分为76~95分,平均(85.3±5.6)分;其中优13例,良16例,可3例。结论:伴有后方冠状面骨折的A2.3型股骨转子间骨折类型特殊,复位困难,又相当不稳定,需使用辅助切口复位,并采用近端抗旋髓内钉固定,术后康复锻炼亦需个体化。     

A prospective, randomised study comparing the percutaneous compression plate and the compression hip screw for the treatment of intertrochanteric fractures of the hip

Limited access surgery is thought to reduce post-operative morbidity and provide faster recovery of function. The percutaneous compression plate (PCCP) is a recently introduced device for the fixation of intertrochanteric fractures with minimal exposure. It has several potential mechanical advantages over the conventional compression hip screw (CHS). Our aim in this prospective, randomised, controlled study was to compare the outcome of patients operated on using these two devices. We randomised 104 patients with intertrochanteric fractures (AO/OTA 31.A1-A2) to surgical treatment with either the PCCP or CHS and followed them for one year postoperatively. The mean operating blood loss was 161.0 ml (8 to 450) in the PCCP group and 374.0 ml (11 to 980) in the CHS group (Student's t-test, p < 0.0001). The pain score and ability to bear weight were significantly better in the PCCP group at six weeks post-operatively. Analysis of the radiographs in a proportion of the patients revealed a reduced amount of medial displacement in the PCCP group (two patients, 4%) compared with the CHS group (10 patients, 18.9%); Fisher's exact test, p < 0.02. The PCCP device was associated with reduced intra-operative blood loss, less postoperative pain and a reduced incidence of collapse of the fracture.     

Operative treatment of hip fractures in patients receiving hemodialysis

Fifteen hips in 13 patients with hip fracture were treated in patients receiving hemodialysis for chronic renal failure. There were four intertrochanteric and 11 femoral neck fractures. 10 of the 11 femoral neck fractures and one of the four intertrochanteric fractures were treated with cemented bipolar hemiarthroplasty. Two intertrochanteric fractures fixed with sliding compression screws. External fixation was used for stabilization in two patients who had femoral neck and intertrochanteric fractures. Two intertrochanteric fractures that were treated with sliding hip screw showed radiological union postoperatively at the 6th month. Of the 11 hemiarthroplasty, four hips developed aseptic loosening (36%). According to Harris hip score grading system, three (37.5%) poor, two (25%) fair, two (25%) good and one (12.5%) case had excellent outcome in the hemiarthroplasty group. The survival of dialysis patients with a hip fracture is markedly reduced. Initial treatment of hemiarthroplasty allows early mobilization and prevents revision surgery.     

Fracture morphology of AO/OTA 31-A trochanteric fractures: A 3D CT study with an emphasis on coronal fragments

AimsThis study was designed to assess the incidence and morphology of coronal plane fragments in AO/OTA 31-A trochanteric fractures.Patients and methods156 cases of AO/OTA 31-A trochanteric fractures were retrospectively evaluated. Lateral radiographs were analyzed for the presence of coronal plane fragments followed by analysis of 3D CT reconstructions in these fractures. The incidence of coronal fragments identified on the lateral radiograph and 3D CT reconstructions were both calculated. Coronal fragment morphology was described based upon the origin and exit points of fracture lines and the number of fragments.Results and conclusionOn plain radiographs, a coronal plane fracture was identified in 59 cases, an incidence of 37.8% (59/156). In comparison, 3D CT reconstructions identified coronal plane fractures in 138 cases for an incidence of 88.4% (138/156). 3D CT reconstructions identified coronal fracture fragments in 81.9% (50/61) of AO/OTA 31-A1 cases, 94.5% (69/73) of 31-A2 cases, and 86.3% (19/22) of 31-A3 cases. Incidence of coronal fractures identified on plain radiographs of 3 AO/OTA 31-A1,A2,A3 groups was lower when compared to the incidence of coronal fractures identified on 3D CT. Of the 138 cases that had coronal plane fracture, 82 cases (59.4%) had a single coronal fragment (GT fragment 35 cases, GLT fragment 19 cases, GLPC fragment 28 cases). The remaining 56 cases (40.5%) had two coronal fragments. There is a high incidence of coronal fragments in intertrochanteric femur fractures when analyzed with 3D CT reconstructions. Our study suggests that these coronal fragments are difficult to identify on plain radiographs. Knowledge of the incidence and morphology of coronal fragments helps to avoid potential intraoperative pitfalls.     

Pertrochanteric fractures: is there an advantage to an intramedullary nail?: a randomized,prospective study of 206 patients comparing the dynamic hip screw and proximal femoral nail

OBJECTIVES: To compare the results between a sliding compression hip screw and an intramedullary nail in the treatment of pertrochanteric fractures. DESIGN: Prospective computer-generated randomization of 206 patients into two study groups: those treated by sliding compression hip screw (Group 1; n = 106) and those treated by intramedullary nailing (Group 2; n = 100). SETTING: University Level I trauma center. PATIENTS: All patients over the age of fifty-five years presenting with fractures of the trochanteric region caused by a low-energy injury, classified as AO/OTA Type 31-A1 and A2. INTERVENTION: Treatment with a sliding compression hip screw (Dynamic Hip Screw; Synthes-Stratec, Oberdorf, Switzerland) or an intramedullary nail (Proximal Femoral Nail; Synthes-Stratec, Oberdorf, Switzerland). MAIN OUTCOME MEASUREMENTS: Intraoperative: operative and fluoroscopy times, the difficulty of the operation, intraoperative complications, and blood loss. Radiologic: fracture healing and failure of fixation. Clinical: pain, social functioning score, and mobility score. RESULTS: The minimum follow-up was one year. We did not find any statistically significant difference, intraoperatively, radiologically, or clinically, between the two groups of patients. CONCLUSIONS: There is no advantage to an intramedullary nail versus a sliding compression hip screw for low-energy pertrochanteric fractures AO/OTA 31-A1 and A2, specifically with its increased cost and lack of evidence to show decreased complications or improved patient outcome.     

Which AO/OTA 31-A2 pertrochanteric fractures can be treated with a dynamic hip screw without developing a lateral wall fracture? A CT-based study

Purpose

To determine whether radiographic measurements derived from standard computed tomography (CT) evaluation can be used to predict likelihood of a peri-operative lateral femoral wall fracture in AO/OTA 31-A2 pertrochanteric fractures treated with a dynamic hip screw (DHS).

Methods

Fifty-one patients with AO/OTA 31-A2 classified pertrochanteric fractures were evaluated using a pre-operative CT scan of the pelvis with both hips. Dimensions of the lateral wall were calculated for each patient using four parameters: (1) height of the lateral wall above the vastus ridge; (2) circumference of the lateral wall 2 cm below the vastus ridge at an angle of 135°; this circumference was further divided into an anterior, lateral and posterior component; (3) cortical thickness at the centre of the lateral component of the lateral wall; and (4) cortical index. All patients were treated with a 135° DHS. Postoperative radiographs were assessed for lateral femoral wall fracture.

Results

Patients with a lateral wall fracture (17/51) had a smaller circumference (4.47 cm vs 5.44 cm p value?<0.001) as well as a lower height of the lateral femoral wall (1.37 cm vs 2.21 p value?<?0.001). Analysis of the three components of the circumference revealed a significant difference for the anterior component only and not for the lateral and posterior components. There was no statistical difference in the cortical thickness or cortical index in the two groups. The cutoff values for height of the lateral wall and anterior component were calculated using ROC curves and found to be 1.68 cm (AUC 0.918) and 2.10 cm (AUC 0.851) respectively.

Conclusion

AO/OTA 31-A2 pertrochanteric fractures with a lateral wall height of > 1.68 cm and an anterior component of > 2.10 cm in circumference are not likely to sustain a lateral wall fracture when treated with a DHS.

     

Inter- and intra-observer reliability of the new AO/OTA classification of proximal femur fractures

IntroductionHip fractures are a global health burden, with an incidence that is projected to increase from 66,000/year currently in the United Kingdom to 100,000/year by 2033. The classification of intertrochanteric fractures is key to the treatment algorithms advising on their surgical management.The AO/OTA classification is the most commonly used system, initially published in 1990 and subsequently shown to have poor inter- and intra-observer reliability, it was revised in 2018 with the main aim of re-classifying and further defining the 31-A2 group.Methods150 plain film anteroposterior and lateral plain film radiographs of intertrochanteric fractures from three hospitals were classified using the 2018 AO/OTA classification of intertrochanteric fractures by six Orthopaedic Surgeons (2 Consultants, 4 Trainees), all were blinded to the definitive surgical treatment for patients. Radiographs were re-classified after a minimum of 3-months, Cohen's Kappa for inter-observer reliability was calculated from first round classifications and intra-observer reliability from first and second classifications.ResultsMean Kappa for inter-observer reliability for AO group classification (e.g. 31-A1) was 0.479 (0.220 - 0.771, for sub-group classification (e.g. 31-A1.1) reliability reduced to 0.376 (0.276 - 0.613). Intra-observer reliability was comparable for both group and sub-group classifications, 0.661 and 0.587 respectively.ConclusionsThe revised 2018 AO/OTA classification aimed to simply the classification of intertrochanteric fractures, however it remains unreliable with only a “moderate” inter-observer reliability at group level with this falling to “fair” when sub-group classifications are made. Identification of stable and unstable injuries using the new AO/OTA system remains fraught with difficulties and appears difficult to apply with consistent accuracy.