ObjectiveTo compare the clinical effect of day surgery mode and inpatient operation mode for intertrochanteric fracture in elderly patients.MethodsThirty-seven elderly patients with intertrochanteric fracture treated in day surgery mode in the Second Hospital of Shanxi Medical University from July 2018 to July 2019 were retrospectively included. At the same time, another 37 elderly patients with intertrochanteric fracture treated in general inpatient operation mode in the same period were randomly selected. The preoperative waiting time, operation time, length of hospital stay, hospital expenses, postoperative complications, and clinical effect were compared between the two groups.ResultsThere was no significant difference in operation time [(56.21±10.75) vs. (58.81±12.56) min] or postoperative Harris hip scores (1 month after surgery: 61.03±7.74 vs. 59.47±7.42; 3 months after surgery: 85.40±4.22 vs. 85.03±4.33) between the two groups (P>0.05). In terms of the preoperative waiting time [(23.17±3.18) vs. (52.64±10.12) h], length of hospital stay [(2.01±0.97) vs. (8.34±4.22) d], hospital expenses [(4.012±0.771)×104 vs. (4.679±1.117)×104 yuan], and the incidence of deep venous thrombosis during perioperative period (10.8% vs.37.8%), the day surgery mode group had more obvious advantages than general inpatient operation mode group (P<0.05).ConclusionsDay surgery mode is safe and effective for intertrochanteric fracture in elderly patients. It is worthy of great application for clinical work in the future.
ObjectiveTo investigate the association between the tip apex distance (TAD) and migration of helical blade in the femoral head of geriatric intertrochanteric fractures.MethodsA retrospective study of intertrochanteric fractures treated with the proximal femoral nail antirotation (PFNA) between June 2015 and June 2018 was performed. There were 32 males and 55 females with an average age of 84.7 years (range, 80-101 years). All of them were unilateral fresh closed intertrochanteric fractures caused by low energy injury. According to AO/Orthopaedic Trauma Association (AO/OTA) classification, 33 cases belonged to type 31-A1, 35 cases to type 31-A2, and 19 cases to type 31-A3. The time interval from injury to operation was 1-16 days (mean, 3.7 days). The TAD was measured according to immediate postoperative X-ray films. The cases were divided into two groups: group A with TAD less than 20 mm and group B with TAD greater than 20 mm. The difference of fracture healing and migration of helical blade between the two groups were observed.ResultsAccording to the TAD value immediately after operation, 49 patients in group A had TAD of 8.9-19.7 mm, with an average of 18.6 mm; 38 patients in group B had TAD of 20.1-41.4 mm, with an average of 27.7 mm. The 87 patients were followed up for an average of 11.7 months, ranging from 4 to 28 months. Three cases (all in group B) underwent screw blade cutting and displacement, which resulted in internal fixation failure, including 1 case with femoral head cut upward and 2 cases with femoral head penetrated inward. The remaining 84 cases had bone healing without internal fixation related complications such as fracture of internal fixator and fracture of femoral shaft. There was significant difference in the incidence of internal fixation failure between group A and group B (P=0.049). ConclusionReducing the TAD value of helical blade appropriately (15-20 mm) in PFNA internal fixation for intertrochanteric fracture patients over 80 years old can increase initial stability without increasing the risk of helical blade migration.
ObjectiveTo analyze the reasons and the influence of internal fixation about the guide pin eccentricity of helical blade during proximal femoral nail anti-rotation (PFNA) internal fixation for femoral intertrochanteric fractures.MethodsA retrospective analysis of the intraoperative imaging data of 175 patients with femoral intertrochanteric fractures, who underwent closed reduction and PFNA internal fixation between January 2018 and January 2020, was performed. There were 76 males and 99 females with an average age of 79.8 years (mean, 61-103 years). The internal between admission and operation was 12-141 hours (median, 32 hours). According to AO/Orthopaedic Trauma Association (AO/OTA) classification, the fractures were rated as type 31-A1 in 64 cases and type 31-A2 in 111 cases. In the intraoperative fluoroscopy image by C-arm X-ray machine, the caputcollum-diaphysis (CCD) was measured after closed reduction and internal fixation, respectively; the angles between the center line of the head nail hole and the axis of proximal nail and between the axis of guide pin and proximal nail were measured, and the difference between the two angles was evaluated; the quality of fracture reduction was evaluated according to the alignment of the medial cortex, anterior cortex of the head and neck bone block, and femoral shaft cortex; the position of the helical blade in the femoral head was evaluated according to the Cleveland method.ResultsThe CCDs of proximal femur were (134.6±6.8)° after closed reduction and (134.9±4.3)° after internal fixation. There was no significant difference between pre- and post-internal fixation (t=0.432, P=0.766). The angles between the center line of the head nail hole and the axis of proximal nail and between the axis of guide pin and proximal nail were (125.4±2.44)° and (126.3±2.3)°, respectively, showing significant difference (t=2.809, P=0.044). The difference between the two angles was (0.8±2.2)°. The guide pin eccentricity of helical blade occurred in 47 cases. After tapping the helical blade along the eccentric guide pin, 10 cases had fracture reduction loss, and 5 cases had a poor position of the helical blade in the femoral head. ConclusionDuring PFNA internal fixation, a variety of reasons can lead to the eccentric position of the guide pin of helical blade, including unstable fracture, soft tissue inserted, severe osteoporosis, mismatched tool, and fluoroscopic imaging factors. It is possible that the fracture end would be displaced again and the helical blade position may be poor when knocking into the helical blade along the eccentric guide pin. During operation, it should be judged whether the direction of the guide pin needs to be adjusted according to the eccentric angle.
ObjectiveTo introduce the reduction concept of anteromedial cortical support in the treatment of intertrochanteric fracture, summarize the history, characteristics, biomechanics, and clinical applications, discuss the unsolved problems and prospect the future directions.MethodsRelevant domestic and foreign studies on cortical support reduction of intertrochanteric fracture in recent years were reviewed. Conclusions were drawn combined with clinical experience.ResultsThe positive cortical supportive reduction of intertrochanteric fracture, as a stable non-anatomical fracture reduction technique, has dual effects on mechanical buttress and biological bone healing. It does not increase the difficulty of doctors’ surgical procedure. For patients, it decreases the loss of femoral neck length, the loss of neck-shaft angle, the incidence rate of coxa vara, and maintains stable mechanical structure of the pelvis. It also shows a lower rate of instrument-related complications, and higher limb function scores. The mechanical stability of medial cortex apposition is more important than that of anterior cortex. For the best stability of the fracture, both sides should get positive support reduction pattern.ConclusionAnteromedial cortical support reduction can improve the postoperative stability of intertrochanteric fracture, enable better imaging and functional prognosis. As a kind of non-anatomic form of functional reduction, it can be used as a suboptimal choice secondary to anatomic reduction.
ObjectiveTo investigate the morphology of coronal femoral intertrochanteric fracture and its effect on reduction and internal fixation.MethodsThe clinical and imaging data of 46 patients with femoral intertrochanteric fracture who met the selection criteria between August 2017 and October 2018 were reviewed. There were 15 males and 31 females; the age ranged from 62 to 91 years, with an average of 72.8 years. The causes of injury included walking falls in 35 cases, falling out of bed in 4 cases, and traffic accidents in 7 cases. The AO/Orthopaedic Trauma Association classification was type 31-A1 in 11 cases and type 31-A2 in 35 cases. All patients underwent closed reduction and internal fixation with intramedullary nails. During the operation, fracture reduction and fixation were performed according to the preoperative evaluation results. According to the patients’ preoperative X-ray film and CT three-dimensional reconstruction images, the direction of the coronal fracture line of the femoral intertrochanter and the morphological characteristics of the fracture block were observed; and the coronal fracture discrimination analysis was carried out for the fractures of different AO/OTA types. The percentages of coronal femoral intertrochanteric fractures diagnosed by preoperative X-ray film and CT three-dimensional reconstruction were calculated and statistically analyzed. The fracture reduction, the position of internal fixation [measurement of tip-apex distance (TAD)]. and the reliability of internal fixation were observed after operation.ResultsX-ray film was not easy to identify coronary fracture, and the coronal fracture line and the shape of the fracture piece weree clearly visible in CT three-dimensional reconstruction images. The morphological characteristics of the coronary fracture block: in AO/OTA 31-A1 type, the fracture line extended obliquely backward from the anterior tip of the large rotor, above the small rotor with or without small rotor fracture; in AO/OTA 31-A2 type, fracture line extended obliquely backward from the anterior tip of the large rotor to below the small rotor. Thirteen cases (28.3%) of coronal fractures were found on preoperative X-ray films, and 35 cases (76.1%) were found by CT three-dimensional reconstruction, showing significant difference (χ2=21.083, P=0.000). In AO/OTA 31-A1 type patients, the proportion of coronal fractures found by X-ray film and CT three-dimensional reconstruction was 18.2% (2/11) and 54.5% (6/11), respectively, and that in AO/OTA 31-A2 type patients was 31.4% (11/35) and 82.9% (29/35), respectively, showing significant differences (χ2=3.143, P=0.000; χ2=20.902, P=0.000). Among the 35 patients with coronal fractures, 6 cases (17.1%) of AO/OTA 31-A1 type, 29 cases (82.9%) of AO/OTA 31-A2 type. The operation time of the patient was 80-112 minutes, with an average of 95 minutes; the intraoperative blood loss was 180-450 mL, with an average of 360 mL. There was no complication such as infection, falling pneumonia, and deep vein thrombosis of the lower extremities. At 3 days after operation, the internal fixators were all in the proper position. The TAD was 0.9-1.8 cm, with an average of 1.4 cm. All patients were followed up 14-18 months, with an average of 16 months. All the fractures healed osseously, and there was no complication such as nonunion and loosening of internal fixation.ConclusionCT three-dimensional reconstruction can better identify coronal femoral intertrochanteric fractures than X-ray films, and accurately recognize and analyze the incidence and morphological characteristics of coronal fractures, which can help formulate more effective surgical strategies to promote patient recovery.
Objective To investigate the feasibility and effectiveness of the novel bone hook combined with finger-guided technique in the treatment of irreducible intertrochanteric femoral fractures in elderly. Methods Between January 2021 and August 2023, 23 elderly patients with irreducible intertrochanteric femoral fractures were treated with the novel bone hook combined with finger-guided technique. There were 10 males and 13 females; the age ranged from 68 to 93 years (mean, 76.2 years). The time from injury to operation ranged from 36 to 76 hours (mean, 51.2 hours). According to the classification standard proposed by TONG Dake et al in 2021, there were 10 cases of typeⅠA, 1 case of typeⅠB, 6 cases of type ⅡA, 4 cases of type ⅡB, and 2 cases of type ⅡC. The operation time, intraoperative blood loss, intraoperative fluoroscopy frequences, and quality of fracture reduction were recorded. The fracture healing time and occurrence of postoperative complications were observed during follow-up. At last follow-up, the Harris scoring system was used to evaluate the hip joint function. Results The operation time was 42-95 minutes (mean, 52.1 minutes). The intraoperative blood loss was 40-420 mL (mean, 126.5 mL). Intraoperative fluoroscopy was performed 14-34 times (mean, 20.7 times). According to the criteria proposed by Chang et al, the quality of fracture reduction was rated as good in 20 cases and acceptable in 3 cases. All patients were followed up 6-20 months (mean, 10.2 months). X-ray film showed that all fractures healed with the healing time of 3.0-5.5 months (mean, 4.0 months). At last follow-up, the Harris score of the hip joint ranged from 82 to 97 points (mean, 90.4 points). Among them, 14 cases were rated as excellent and 9 cases as good. No complication such as coxa vara, cutting of the cephalomedullary nail, nail withdrawal, or nail breakage occurred during follow-up. Conclusion The treatment of elderly patients with irreducible intertrochanteric femoral fractures by using the novel bone hook combined with finger-guided technique can achieve high-quality fracture reduction and fixation, and has a good effectiveness.