Objectives. Distal humerus fractures in elderly population are often comminuted and presents multiple challenges. When managed with fixation the results are often complicated with stiffness, pain, and reduced function while total elbow replacement is fraught with lifelong restrictions on load bearing which can significantly affect elderly patients who rely assistive devices for ambulation. Elbow hemiarthroplasty however, presents a viable alternative in these cases. This series evaluates the results of the distal humerus hemiarthroplasty in a single centre. Designs and methods. Data was collected retrospectively. Comprehensive case reviews were done to collect demographic, intra-operative and post-operative data. Fractures were classified as per AO classification. The primary outcome was functional outcome and range of motion (ROM). The secondary outcomes were complications and patient satisfaction. Results. 22 cases were included in this study from 2016 – 2023 majority being females (n=18). Mean age was 74years (SD −11.2). Majority fractures were AO type C3 (n=15) with two A2 type fractures managed for non-union. Pre-existing bone on bone arthritis was present in 3 cases and CT scan was done for 12 patients to assess fracture configuration. Excluding those treated for non- union the median time between fracture and surgery was 8.5 days. Follow-up of more than 6 months was available for 16 patients with median follow-up of 18 months. ROM was available for 17 patients with 13 (50%) patients having functional ROM. No patients had full extension and there was a mean lag of 20. 0. Mean flexion was 118.2. 0. Nearly 2/3. rd. patients (73%- n=16) were satisfied with the surgery with no problems in activity of daily living. Complications seen were ulnar neuropathy (n=3), heterotopic ossification(n=2) and periprosthetic fracture (n=1). Conclusion. This single centre study suggests good outcomes following distal humerus hemiarthroplasty. It is a reasonable alternative to fixation and total elbow arthroplasty in complex fractures

Aims. This study aimed to compare mortality in trochanteric AO/OTA A1 and A2 fractures treated with an intramedullary nail (IMN) or sliding hip screw (SHS). The primary endpoint was 30-day mortality, with secondary endpoints at 0 to 1, 2 to 7, 8 to 30, 90, and 365 days. Methods. We analyzed data from 26,393 patients with trochanteric AO/OTA A1 and A2 fractures treated with IMNs (n = 9,095) or SHSs (n = 17,298) in the Norwegian Hip Fracture Register (January 2008 to December 2020). Exclusions were made for patients aged < 60 years, pathological fractures, pre-2008 operations, contralateral hip fractures, fractures other than trochanteric A1/A2, and treatments other than IMNs or SHSs. Kaplan-Meier and Cox regression analyses adjusted for type of fracture, age, sex, cognitive impairment, American Society of Anesthesiologists (ASA) grade, and time period were conducted, along with calculations for number needed to harm (NNH). Results. In unadjusted analyses, there was no significant difference between IMN and SHS patient survival at 30 days (91.8% vs 91.1%; p = 0.083) or 90 days (85.4% vs 84.5%; p = 0.065), but higher one-year survival for IMNs (74.5% vs 73.3%; p = 0.031) compared with SHSs. After adjustments, no significant difference in 30-day mortality was found (hazard rate ratio (HRR) 0.94 (95% confidence interval (CI) 0.86 to 1.02(; p = 0.146). IMNs exhibited higher mortality at 0 to 1 days (HRR 1.63 (95% CI 1.13 to 2.34); p = 0.009) compared with SHSs, with a NNH of 556, but lower mortality at 8 to 30 days (HRR 0.89 (95% CI 0.80 to 1.00); p = 0.043). No differences were observed in mortality at 2 to 7 days (HRR 0.94 (95% CI 0.79 to 1.11); p = 0.434), 90 days (HRR 0.95 (95% CI 0.89 to 1.02); p = 0.177), or 365 days (HRR 0.97 (95% CI 0.92 to 1.02); p = 0.192). Conclusion. This study found no difference in 30-day mortality between IMNs and SHSs. However, IMNs were associated with a higher mortality at 0 to 1 days and a marginally lower mortality at 8 to 30 days compared with SHSs. The observed differences in mortality were small and should probably not guide choice of treatment. Cite this article: Bone Joint J 2024;106-B(6):603–612

Appropriate surgical management of hip fractures has major clinical and economic consequences. Recently IMN use has increased compared to SHS constructs, despite no clear evidence demonstrating superiority of outcome. We therefore set out to provide further evidence about the clinical and economic implications of implant choice when considering hip fracture fixation strategies. A retrospective cohort study using Scottish hip fracture audit (SHFA) data was performed for the period 2016–2022. Patients ≥50 with a hip fracture and treated with IMN or SHS constructs at Scottish Hospitals were included. Comparative analyses, including adjustment for confounders, were performed utilising Multivariable logistic regression for dichotomous outcomes and Mann-Whitney-U tests for non-parametric data. A sub-group analysis was also performed focusing on AO-A1/A2 configurations which utilised additional regional data. Cost differences in Length of Stay (LOS) were calculated using defined costs from the NHS Scotland Costs book. In all analyses p<0.05 denoted significance. 13638 records were included (72% female). 9867 received a SHS (72%). No significant differences were identified in 30 or 60-day survival (Odds Ratio [OR] 1.05, 95%CI 0.90–1.23; p=0.532), (OR 1.10, 95%CI 0.97–1.24; p=0.138) between SHS and IMN's. There was however a significantly lower early mobilisation rate with IMN vs SHS (OR 0.64, 95%CI 0.59–0.70; p<0.001), and lower likelihood of discharge to domicile by day-30 post-admission (OR 0.77, 95%CI 0.71–0.84; p<0.001). Acute and overall, LOS were significantly lower for SHS vs IMN (11 vs 12 days and 20 vs 24 days respectively; p<0.001). Findings were similar across a sub-group analysis of 559 AO A1/A2 fracture configurations. Differences in LOS potentially increases costs by £1230 per-patient, irrespective of the higher costs of IMN's v SHS. Appropriate SHS use is associated with early mobilisation, reduced LOS and likely with reduced cost of treatment. Further research exploring potential reasons for the identified differences in early mobilisation are warranted

The lateral wall thickness (LWT) in trochanteric femoral fractures is a known predictive factor for postoperative fracture stability. Currently, the AO/OTA classification uses a patient non-specific measure to assess the absolute LWT (aLWT) and distinguish stable A1.3 from unstable A2.1 fractures based on a threshold of 20.5 mm. This approach potentially results in interpatient deviations due to different bone morphologies and consequently variations in fracture stability. Therefore, the aim of this study was to explore whether a patient-specific measure for assessment of the relative LWT (rLWT) results in a more precise threshold for prediction of unstable fractures. Part 1 of the study evaluated 146 pelvic radiographs to assess left-right symmetry with regard to caput-collum-angle (CCD) and total trochanteric thickness (TTT), and used the results to establish the rLWT measurement technique. Part 2 reevaluated 202 patients from a previous study cohort to analyze their rLWT versus aLWT for optimization purposes. Findings in Part 1 demonstrated a bilateral symmetry of the femur regarding both CCD and TTT (p ≥ 0.827) allowing to mirror bone's morphology and geometry from the contralateral intact to the fractured femur. Outcomes in Part 2 resulted in an increased accuracy for the new determined rLWT threshold (50.5%) versus the standard 20.5 mm aLWT threshold, with sensitivity of 83.7% versus 82.7% and specificity 81.3% versus 77.8%, respectively. The novel patient-specific rLWT measure can be based on the contralateral femur anatomy and is a more accurate predictor of a secondary lateral wall fracture in comparison to the conventional aLWT. This study established the threshold of 50.5% rLWT as a reference value for prediction of fracture stability and selection of an appropriate implant for fixation of trochanteric femoral fractures

Aims. Patients with A1 and A2 trochanteric hip fractures represent a substantial proportion of trauma caseload, and national guidelines recommend that sliding hip screws (SHS) should be used for these injuries. Despite this, intramedullary nails (IMNs) are routinely implanted in many hospitals, at extra cost and with unproven patient outcome benefit. We have used data from the National Hip Fracture Database (NHFD) to examine the use of SHS and IMN for A1 and A2 hip fractures at a national level, and to define the cost implications of management decisions that run counter to national guidelines. Methods. We used the NHFD to identify all operations for fixation of trochanteric fractures in England and Wales between 1 January 2021 and 31 December 2021. A uniform price band from each of three hip fracture implant manufacturers was used to set cost implications alongside variation in implant use. Results. We identified 18,156 A1 and A2 trochanteric hip fractures in 162 centres. Of these, 13,483 (74.3%) underwent SHS fixation, 2,352 (13.0%) were managed with short IMN, and 2,321 (12.8%) were managed with long IMN. Total cost of IMN added up to £1.89 million in 2021, and the clinical justification for this is unclear since rates of IMN use varied from 0% to 97% in different centres. Conclusion. Most trochanteric hip fractures are managed with SHS, in keeping with national guidelines. There is considerable variance between hospitals for implant choice, despite the lack of evidence for clinical benefit and cost-effectiveness of more expensive nailing systems. This suggests either a lack of awareness of national guidelines or a choice not to follow them. We encourage provider units to reassess their practice if outwith the national norm. Funding bodies should examine implant use closely in this population to prevent resource waste at a time of considerable health austerity. Cite this article: Bone Jt Open 2022;3(10):741–745

Aims

The aim of this study was to investigate if there are differences in outcome between sliding hip screws (SHSs) and intramedullary nails (IMNs) with regard to fracture stability.

Aims. This study evaluated variation in the surgical treatment of stable (A1) and unstable (A2) trochanteric hip fractures among an international group of orthopaedic surgeons, and determined the influence of patient, fracture, and surgeon characteristics on choice of implant (intramedullary nailing (IMN) versus sliding hip screw (SHS)). Methods. A total of 128 orthopaedic surgeons in the Science of Variation Group evaluated radiographs of 30 patients with Type A1 and A2 trochanteric hip fractures and indicated their preferred treatment: IMN or SHS. The management of Type A3 (reverse obliquity) trochanteric fractures was not evaluated. Agreement between surgeons was calculated using multirater kappa. Multivariate logistic regression models were used to assess whether patient, fracture, and surgeon characteristics were independently associated with choice of implant. Results. The overall agreement between surgeons on implant choice was fair (kappa = 0.27 (95% confidence interval (CI) 0.25 to 0.28)). Factors associated with preference for IMN included USA compared to Europe or the UK (Europe odds ratio (OR) 0.56 (95% CI 0.47 to 0.67); UK OR 0.16 (95% CI 0.12 to 0.22); p < 0.001); exposure to IMN only during training compared to surgeons that were exposed to both (only IMN during training OR 2.6 (95% CI 2.0 to 3.4); p < 0.001); and A2 compared to A1 fractures (Type A2 OR 10 (95% CI 8.4 to 12); p < 0.001). Conclusion. In an international cohort of orthopaedic surgeons, there was a large variation in implant preference for patients with A1 and A2 trochanteric fractures. This is due to surgeon bias (country of practice and aspects of training). The observation that surgeons favoured the more expensive implant (IMN) in the absence of convincing evidence of its superiority suggests that surgeon de-biasing strategies may be a useful focus for optimizing patient outcomes and promoting value-based healthcare. Cite this article: Bone Joint J 2021;103-B(4):775–781

Objectives

The Sliding Hip Screw (SHS) is commonly used to treat trochanteric hip fractures. Fixation failure is a devastating complication requiring complex revision surgery. One mode of fixation failure is lag screw cut-out which is greatest in unstable fracture patterns and when the tip-apex distance of the lag screw is > 25 mm. The X-Bolt Dynamic Hip Plating System (X-Bolt Orthopaedics, Dublin, Ireland) is a new device which aims to reduce this risk of cut-out. However, some surgeons have reported difficulty minimising the tip-apex distance with subsequent concerns that this may lead to an increased risk of cut-out.

Aims

The aim of this study was to identify patient- and surgery-related risk factors for sustaining an early periprosthetic fracture following primary total hip arthroplasty (THA) performed using a double-tapered cementless femoral component (Bi-Metric femoral stem; Biomet Inc., Warsaw, Indiana).

Aims

The aim of this paper is to review the evidence relating to the anatomy of the proximal femur, the geometry of the fracture and the characteristics of implants and methods of fixation of intertrochanteric fractures of the hip.

Aims

The aim of this study was to inform a definitive trial which could determine the clinical effectiveness of the X-Bolt Dynamic Hip Plating System compared with the sliding hip screw for patients with complex pertrochanteric fragility fractures of the femur.

Objectives

There are various pin-in-plaster methods for treating fractures of the distal radius. The purpose of this study is to introduce a modified technique of ‘pin in plaster’.

The spiral blade modification of the Dynamic Hip Screw (DHS) was designed for superior biomechanical fixation in the osteoporotic femoral head. Our objective was to compare clinical outcomes and in particular the incidence of loss of fixation.

In a series of 197 consecutive patients over the age of 50 years treated with DHS-blades (blades) and 242 patients treated with conventional DHS (screw) for AO/OTA 31.A1 or A2 intertrochanteric fractures were identified from a prospectively compiled database in a level 1 trauma centre. Using propensity score matching, two groups comprising 177 matched patients were compiled and radiological and clinical outcomes compared. In each group there were 66 males and 111 females. Mean age was 83.6 (54 to 100) for the conventional DHS group and 83.8 (52 to 101) for the blade group.

Loss of fixation occurred in two blades and 13 DHSs. None of the blades had observable migration while nine DHSs had gross migration within the femoral head before the fracture healed. There were two versus four implant cut-outs respectively and one side plate pull-out in the DHS group. There was no significant difference in mortality and eventual walking ability between the groups. Multiple logistic regression suggested that poor reduction (odds ratio (OR) 11.49, 95% confidence intervals (CI) 1.45 to 90.9, p = 0.021) and fixation by DHS (OR 15.85, 95%CI 2.50 to 100.3, p = 0.003) were independent predictors of loss of fixation.

The spiral blade design may decrease the risk of implant migration in the femoral head but does not reduce the incidence of cut-out and reoperation. Reduction of the fracture is of paramount importance since poor reduction was an independent predictor for loss of fixation regardless of the implant being used.

Cite this article: Bone Joint J 2015;97-B:398–404.

The aim of this study was to quantify the stability of fracture-implant complex in fractures after fixation. A total of 15 patients with an undisplaced fracture of the femoral neck, treated with either a dynamic hip screw or three cannulated hip screws, and 16 patients with an AO31-A2 trochanteric fracture treated with a dynamic hip screw or a Gamma Nail, were included. Radiostereometric analysis was used at six weeks, four months and 12 months post-operatively to evaluate shortening and rotation.

Migration could be assessed in ten patients with a fracture of the femoral neck and seven with a trochanteric fracture. By four months post-operatively, a mean shortening of 5.4 mm (-0.04 to 16.1) had occurred in the fracture of the femoral neck group and 5.0 mm (-0.13 to 12.9) in the trochanteric fracture group. A wide range of rotation occurred in both types of fracture. Right-sided trochanteric fractures seem more rotationally stable than left-sided fractures.

This prospective study shows that migration at the fracture site occurs continuously during the first four post-operative months, after which stabilisation occurs. This information may allow the early recognition of patients at risk of failure of fixation.

Cite this article: Bone Joint J 2015;97-B:391–7.

Although the importance of lateral femoral wall integrity is increasingly being recognised in the treatment of intertrochanteric fracture, little attention has been put on the development of a secondary post-operative fracture of the lateral wall. Patients with post-operative fractures of the lateral wall were reported to have high rates of re-operation and complication. To date, no predictors of post-operative lateral wall fracture have been reported. In this study, we investigated the reliability of lateral wall thickness as a predictor of lateral wall fracture after dynamic hip screw (DHS) implantation.

A total of 208 patients with AO/OTA 31-A1 and -A2 classified intertrochanteric fractures who received internal fixation with a DHS between January 2003 and May 2012 were reviewed. There were 103 men and 150 women with a mean age at operation of 78 years (33 to 94). The mean follow-up was 23 months (6 to 83). The right side was affected in 97 patients and the left side in 111. Clinical information including age, gender, side, fracture classification, tip–apex distance, follow-up time, lateral wall thickness and outcome were recorded and used in the statistical analysis.

Fracture classification and lateral wall thickness significantly contributed to post-operative lateral wall fracture (both p < 0.001). The lateral wall thickness threshold value for risk of developing a secondary lateral wall fracture was found to be 20.5 mm.

To our knowledge, this is the first study to investigate the risk factors of post-operative lateral wall fracture in intertrochanteric fracture. We found that lateral wall thickness was a reliable predictor of post-operative lateral wall fracture and conclude that intertrochanteric fractures with a lateral wall thickness < 20.5 mm should not be treated with DHS alone.

Cite this article: Bone Joint J 2013;95-B:1134–8.

Purpose. To evaluate outcome after cementless bipolar hemiarthroplasties using a standard(tapered, rectangular) stem for the treatment of above type A2 fractures in elderly patients. Material and methods. We reviewed the records of 37 patients who underwent bipolar hemiarthroplasty between February 2006 and Feburuary 2010 in our hospital who were followed for more than two years after surgery. The mean patient age was 73.5 years old (range 64∼88 years old). 16 patients were men, and 21 patients were women. We evaluated the results by analyzing operation time, amount of bleeding, recovery of walking ability, complications and radiologic findings. Result. The mean operation time was 75.3 minutes. The average total amount of bleeding was of 755.5 cc. At the last follow-up, 23 patients (62%) had recovered walking ability. Complications included a deep infection in one case, 1 cases of acetabular erosion, 2 cases of greater trochanter non-union. There were no revisions due to prosthesis loosening or another reason. Conclusion. Cementless bipolar hemiarthroplasty using a tapered, rectangular stem can be an alternative treatment for type A2 intertrochanteric fractures in elderly patients so as to achieve earlier mobilisation

INTRODUCTION. Short femoral nail is the most popular instrumentation for femoral trochanteric fractures. PFNA is in widely use and good results are reported. In these papers, fracture classification and evaluation of surgical results were based on plain X-ray. However, some cases of delayed union, non-union, and blade cut out showed no critical problems in immediate postoperative X-ray. Cause of these complications was not able to solve in X-ray analysis. CT scan provides more information about fracture pattern and position of nail and blade. CT analysis is likely to solve the cause of these complications. MATERIALS & METHODS. 20 cases of 36 femoral trochanteric fractures treated with PFNA-II were evaluated by CT scan (pre and post surgery). Four males and 16 females, and average age at surgery was 80.5 (65–100). Eleven cases were A1 fracture and 9 cases were A2 fracture in AO classification. Nail insertion hole was made by custom made Hollow Reamer. Fracture classification with 3D-CT (Nakano's classification), position of nail insertion hole (relationship between neck or head), and postoperative evaluation with 3D-CT insertion part of nail and blade were investigated. RESULTS. Nakano classified femoral trochanteric fracture into 7 types in 3D-CT. Two subtype in 2 part fracture, 4 subtype in 3 part fracture and 4part fracture. Seven cases were two part fracture, 11 were three part, and 2 were four part in our series. Five cases of 11 in 3 part fracture was considered unstable type. Nail insertion hole of six cases was made posteriory to the connecting line between neck center and head center. Fracture line of greater trochnater in lateral wall opened in 4 cases because of nail insertion. DISCUSSION. Femoral trochanteric fracture was classified by Evans classification or AO classification. However, it is very difficult to classify the fracture by plain X-P. Classification with 3D-CT is very usefull to distinguish which the fracture is stable or unstable. CT analysis will solve the postoperative complications in stable type in X-P classification

We undertook a trial on 60 patients with AO 31A2 fractures of the hip who were randomised after stabilisation of the fracture into two equal groups, one of which received post-operative treatment using a non-invasive interactive neurostimulation device and the other with a sham device. All other aspects of their rehabilitation were the same. The treatment was continued for ten days after operation.

Outcome measurements included the use of a visual analogue scale for pain, the brief pain inventory and Ketorolac for post-operative control of pain, and an overall assessment of outcome by the surgeon. There were significantly better results for the patients receiving treatment by active electrical stimulation (repeated measures analysis of variance, p < 0.001). The findings of this pilot trial justify a larger study to determine if these results are more generally applicable.

Introduction: Loss of the cervical lordosis is a common finding on the emergency department in patients who have been involved in a car accident as well as in those who have suffered head and neck injury. The difficult circumstances, under which the plain films are usually taken, make the use of CT indispensable. Our study presents the CT findings from the cervical spine in patients with loss of the cervical lordosis. Method-Patients We studied 120 patients from February 2003 to January 2004. Their mean age was 37 years old. Our protocol included the lateral-AP view, while in the absence of findings, except loss of cervical lordosis, from the plain films, the patients underwent spiral CT within 24 h. Results: Fractures of the cervical spine were found in 7 patients (5,8%). In 5 of them these involved the A1–A2 level. In two patients fractures of the occipital condyles were found. One A7 fracture coexisted with an A2 fracture. No patient had neurological symptoms. Conclusions: The complete investigation of the cervical spine at the emergency department is often quite difficult. The possible underlying injuries can be potentially life threatening. The percentage of positive findings in our study is quite high to justify the routine use of spiral CT for the detailed investigation of such patients