In Displaced Intracapsular Hip Fractures (ICHF) in young active patients, preservation of the femoral head and its blood supply are of high importance and urgent surgical treatment with anatomic reduction and internal fixation is the preferred intervention. Due to the strong varus displacement shear forces exerted across the hip, there are relatively high complication rates after fixation. There is no consensus regarding the optimal fixation device or technique. This retrospective study compared closed reduction internal fixation method using cannulated cancellous screw (CCS) with the Targon Femoral Neck (TFN) hip fixed angle screw. Data regarding, gender, operational data, duration of surgery, complications, NAS (Numerical Analogue Scale) pain score, Modified Harris Hip Score (MHHS) and SF-12 scores were retrieved for patients younger than 65 with displaced ICHF. Eighty-two patients were included in the study, 30 patients treated with CCS were compared to 52 patients treated with TFN. Fracture configuration (Garden and Pauwel classifications), mean time to surgery and complication rate did not differ significantly. Operative time did differ significantly between groups (CCS 56 minutes, TFN 92 minutes, p<0.001). At final follow-up the CCS group reported less pain (NAS 2.3 vs 3.5, p< 0.049) and better Mental Health Composite score of SF-12 (p=0.017) compared to the TFN group. Complication rates for the treatment of displaced ICHF with TFN and CCS showed no significant differences; however, the functional outcomes, as presented by the NAS and Mental Health Composite score of SF-12, showed superiority for CCS treatment. As this fixation method is related to reduce costs, we suggest CCS for the treatment of displaced ICHF in the young population.
We evaluated the efficacy of using the expandable nail for treating non-union and malunion of the tibial and femoral shafts. Records of 20 patients were retrospectively reviewed: 12 had femoral non-union, 7 had tibial non-union, and one had tibial malunion. The bones underwent reaming and the largest possible nail sizes were inserted during reoperation. The mean age of the patients was 35 years (26-49) in the tibia group and 53 years (23-85) in the femur group. The fractures were defined according to AO/OTA classification and divided between open and closed. The initial treatment was 6 interlocking intramedullary nails and 2 external fixation in the tibia group, and 6 interlocking intramedullary nails, 3 plates and screws and 2 proximal femoral nails in the femoral group. The respective intervals between the original trauma and re-operation were 12 months and 15 months and the respective operation times were 59 minutes (35-70) and 68 minutes (20-120). All fractures healed satisfactorily without the need for an additional procedure. Healing time was 26 weeks (6-52) and 14 weeks (6-26) in the tibia and femur group, respectively. Limb shortenings of 10cm and 4cm were recorded in one patient each in the tibia group and of 3cm in one patient in the femur group. Using the expandable nail system permitted us to ream the bone and expand the nail to its maximal diameter, i.e. up to 16mm in the tibia and 19mm in the femur. We believe that using a bigger nail diameter contributes to better stabilisation of the fracture and promotes better and faster bone healing. Based on our experience, we recommend the use of the expandable nail system to treat tibia and femur shaft non-unions and malunions.
We evaluated the efficacy of using the expandable nail for treating non-union and malunion of the tibial and femoral shafts. Records of 20 patients were retrospectively reviewed: 12 had femoral non-union, 7 had tibial non-union, and one had tibial malunion. The bones underwent reaming and the largest possible nail sizes were inserted during reoperation. The mean age of the patients was 35 years (26–49) and in the tibia group and 53 years (23–85) in the femur group. The fractures were defined according to AO/OTA classification and divided between open and closed. The initial treatment was 6 interlocking intramedullary nails and 2 external fixation in the tibia group, and 6 interlocking intramedullary nails, 3 plates and screws and 2 proximal femoral nails in the femoral group. The respective intervals between the original trauma and re-operation were 12 months and 15 months and the respective operation times were 59 minutes (35–70) and 68 minutes (20–120). All fractures healed satisfactorily without the need of an additional procedure. Healing time was 26 weeks (6– 52) and 14 weeks (6–26) in the tibia and femur group, respectively. Limb shortenings of 10 cm and 4 cm were recorded in one patient each in the tibia group and of 3 cm in one patient in the femur group. Using the expandable nail system permitted us to ream the bone and expand the nail to its maximal diameter, i.e., up to 16 mm in the tibia and 19 mm in the femur. We believe that using a bigger nail diameter contributes to better stabilization of the fracture and promotes better and faster bone healing. Based on our experience, we recommend the use of the expandable nail system to treat tibia and femur shaft non-unions and malunions.
Based on these advantages, as well as its simplicity in use and short surgical technique, we recommend it for treatment of long bone fractures.
All fractures healed at an average time of 9.2 weeks (5–26) and for the open fractures 19 (12–26) weeks. Hardware was removed in 8 cases with no complications. In two cases re-operation was needed. In one early case the nail was fractured and replaced. In the second case the bone was circlaged due to fragmentation around the fracture site and a bigger nail was inserted few days later (wrong smaller nail was inserted previously).
The incidence of comminuted proximal femur fractures is increasing, due to the growing proportion of elderly people in the general population. Severely depleted cancellous bone in the femoral head and neck prevent stable proximal purchase, mandatory for intertrochanteric and subtrochanteric fractures. Osteoporotic bones are associated with high implant failure rates, evidenced by cutout and upward screw penetration of the hip joint. A new method for femoral head fixation is described. The peg consists of a distal end that can expand in diameter from 7.8mm to 10.5mm by using pressurized saline, allowing good abutment into the femoral head. The peg may be connected to a side plate or an intramedullary device for inter or subtrochanteric fractures.
Preliminary positive results indicate that this new method may be suitable for inter or subtrochanteric femoral fracture fixation.
Between the years 1999 and 2001, approximately 3000 expandable intramedullary nails were used worldwide in various surgical procedures. From this number, 250 of these nails were used for traumatic fractures and are the focus of the study presented here. The subjects consisted of 160 males and 90 females with a mean age of 41 years. Initial radiographs were obtained for all subjects. Additional X-rays and follow-up data were reported for only 75 patients (30%) with follow-up time averaging 18 weeks. Most of the fractures occurred in the midshaft (64%), followed by distal thirds (22%), and then proximal (14%). The group was then divided according to fracture location: humerus, tibial and femur. The nail was used in 92 humerus fractures. Follow-up data was available for 35 patients with a follow-up time averaging 16 weeks. The nail was inserted retrograde in 61% of the patients and antigrade in 39% of the patients. Partial reaming was done in 42% of the cases. Mean operating time was 52 minutes and fluoroscopy time was 3.8 minutes. Anatomical reduction was achieved in 96% of the cases and in 4% of the cases, acceptable reduction was achieved with a varus <
10°. Surgical outcomes included 28 complete bone union, and 7 partial union. Eight nails were removed after complete union was achieved. In addition, the inflatable nail was used for treatment of 114 tibial fractures. In 39% of the cases a partial reaming was done. Average operating time was 39 minutes and fluoroscopy time was 3.4 minutes. All the fractures were reduced anatomically. In 25 patients with mean follow-up of 18 weeks, 14 united completely and 11 united partially. Nine nails were removed after completion of the union. Data on 44 patients with femoral fractures treated by the inflatable nail were also reported. Only 15 patients were available for follow-up with an average of 21 weeks follow-up time. Nail insertion by the antegrade approach was used in 89% of the patients and the retrograde approach was used in 11% of the patients. Partial reaming was done in 44% of the cases. Mean operating time was 60 minutes and fluoroscopy time 7.5 minutes. Anatomical reduction was achieved in all with the exception of two patients with mild valgus deformity (<
10°). By the end of the study period, 8 had complete union, 7 had partial union. In summary, the nail was found to be very effective and safe. The surgeons who performed the surgery reported that surgical and fluoroscopy time were both reduced by half. Reaming was not mandatory and this contributed to the shortened operating time. No complications were encountered during extraction of all the nails after completion of union, even in those patients in whom the nail developed an hour glass configuration according to the size of the medullary canal. It is still too early to conclude if this nail will produce better or equal results to the conventional interlocking nails. Nevertheless, the lack of reaming, locking, and the low contact area of the nail with the medullary canal, may explain the rapid healing observed in some cases.
Closed Reduction and Percutaneous Fixation (CRPF) is a minimal invasive procedure with a lower risk of damaging the blood supply. The main complication of this technique is loosening of the guide wires and displacement of the fragments requiring a second operation.
The mean age was 60 years old ranging from 16–90 with a male to female ratio of 1:1. The patients were placed in a beach chair position using an image intensifier for AP and axillary views. Because the closed reduction was unsatisfactory, six patients underwent open reduction and external fixation. The remaining 32 shoulders underwent CREF. Passive motion exercises were initiated on the first postoperative day. The external fixator was removed after four to six weeks (mean time for external fixator – 5.3 weeks). After removing the external fixator the patients began with active assisted mobilization of the shoulder and isometric strengthening exercises.