Background. Cephalomedullary nails are widely used for fixation of unstable pertrochanteric fractures. In 2018, the Depuy Synthes Trochanteric Fixation Nail - Advanced (TFNA) implant was introduced at a level I academic trauma center. Thereafter, the TFNA swiftly replaced the older implant models used at the time. Subsequently, clinical concerns were raised about the use of the TFNA due to reports of nail breakage. The purpose of this study was to investigate whether the concerns raised about the performance of the TFNA were valid and to assess long-term outcomes. Methods. The data consisted of 2397 patients who had undergone a proximal femoral hip fracture procedure between 2014 and 2020. Data were handpicked from patient records. TFNA was compared with TFN, PFNA, Gamma3, and Intertan regarding nail breakage, breakage time and long-term outcomes. Results. After exclusion a total of 23/1667 (1.4%) nails broke during the follow-up period. The TFNA broke the most often with 15 cases (2.0%), followed by the Gamma3 with five cases (1.1 %) and the PFNA with three cases (1.3%). Overall, the mean (SD) nail breakage time was 233 (147.8) days. However, for the TFNA, PFNA, and Gamma3, the mean breakage times were 176.8 days (109.9), 419 days (108.6), and 291.8 (153.4), respectively. In cox regression analysis we observed significant reduction in nail breakage when using PFNA with adjusted hazard risk of 0.081 [95% Ci, 0.011-0.576, p=0.011]. Conclusions. In our data, the TFNA had a slightly higher risk for nail breakage when compared to the PFNA and the Gamma3, with a risk difference of 0.7% and 0.9%, respectively. On average, the TFNA broke nearly four months earlier than the Gamma3 and more than eight months earlier than the PFNA. It should be noted, however, that implant breakage is a relatively infrequent complication

Failure of cephalomedullary fixation for proximal femur fractures is an uncommon event associated with significant morbidity to the patient and cost to the healthcare system. This institution changed nailing system from the PFNA (DePuy Synthes) to InterTan (Smith and Nephew) in February 2020. To assess for non-inferiority, a retrospective review was performed on 247 patients treated for unstable proximal femur fractures (AO 31 A2; A3). Patients were identified through manual review of fluoroscopic images. Stable fracture patterns were excluded (AO 31 A1). Pre/post operative imaging, demographic data, operative time and ASA scores assessed. Internal/external imaging and national joint registry data were reviewed for follow up. No significant difference was found in overall failure rate of PFNA vs InterTan (4.84% vs 3.23%; p = 0.748). Overall, short nails were more likely to fail by cut-out than long nails (7.5% vs 1.2%; p = 0.015). Nails which failed by varus cut-out had a higher tip/apex distance (TAD) (26.2mm vs 17.0mm; p < 0.001). Of concern, varus cut-out occurred in two InterTan nails with TAD of <25mm. The PFNA enjoyed a shorter operative time for both the short (59.1 vs 71.8 mins; p = 0.022) and long nails (98.8 vs 114.3 mins; p = 0.016) with no difference in 120-day survival rate. Overall failure rates of the PFNA and InterTan nailing systems were comparable. However, the failure rate of short nails in this study is concerning. Using long nails with a lag screw design for unstable intertrochanteric femoral fractures may reduce failure rates. Cumulative frequency analysis suggests stringent tip-apex distances of less than 21mm may reduce failure rates in lag-screw design cephulomedullary nails. This dataset suggests that unstable intertrochanteric fractures may be more reliably managed with a long cephalomedullary device

The February 2023 Trauma Roundup³⁶⁰ looks at: Masquelet versus bone transport in infected nonunion of tibia; Hyperbaric Oxygen for Lower Limb Trauma (HOLLT): an international multicentre randomized clinical trial; Is the T-shaped acetabular fracture really a “T”?; What causes cut-out of proximal femur nail anti-rotation device in intertrochanteric fractures?; Is the common femoral artery at risk with percutaneous fragility pelvis fixation?; Anterior pelvic ring pattern predicts displacement in lateral compression fractures; Differences in age-related characteristics among elderly patients with hip fractures.

Introduction and Objective. When using radiation intraoperatively, a surgeon should aim to maintain the dose as low as reasonably achievable to obtain the diagnostic or therapeutic goal. The UK Health Protection Agency reported mean radiation dose-area-product (DAP) of 4 Gy cm2 for hip procedures. We aimed to investigate factors associated with increased radiation exposure in fixation of proximal femur fractures. Materials and Methods. We assessed 369 neck of femur fractures between April 2019 and April 2020 in one district general hospital. Fractures were classified as extracapsular or intracapsular and into subtypes as per AO classification. Data was collected on type of fractures, implants used, level of surgeon, duration of surgery and DAP. Types of fractures were subclassified as complex (multifragmentary, subtrochanteric and reverse oblique) or simple. Results. Patients with fractures fixed with DHS, short PFNA, long PFNA and cannulated screws were included. 50% of our patients were fixed with hemiarthroplasty or total hip replacement and were therefore excluded. 184 patients were included in the analysis. There was a significant association of higher DAP with fracture subtype (P=0.001), fracture complexity (P<0.001), if an additional implant was used (P=0.001), if fixation was satisfactory (P=0.002) and the operative time (P<0.001). DAP was higher in PFNA than DHS and greatest in Long PFNA. There was some evidence of association between the level of the surgeon and DAP, although this was not statistically significant (P=0.069) and remained not significant after adjusting for the variables (fracture complexity, fixation or implant used) (p=0.32). Conclusions. Increased radiation in proximal femur fractures is seen in fixation of complex fractures, certain subtypes, the type of implant used and if an additional implant was required. Seniority of surgeon did not result in less radiation exposure even when adjusting for other factors, which is in contrast to other published studies

Aims

Restoration of proximal medial femoral support is the keystone in the treatment of intertrochanteric fractures. None of the available implants are effective in constructing the medial femoral support. Medial sustainable nail (MSN-II) is a novel cephalomedullary nail designed for this. In this study, biomechanical difference between MSN-II and proximal femoral nail anti-rotation (PFNA-II) was compared to determine whether or not MSN-II can effectively reconstruct the medial femoral support.

Objectives

Different criteria for assessing the reduction quality of trochanteric fractures have been reported. The Baumgaertner reduction quality criteria (BRQC) are relatively common and the Chang reduction quality criteria (CRQC) are relatively new. The objectives of the current study were to compare the reliability of the BRQC and CRQC in predicting mechanical complications and to investigate the clinical implications of the CRQC.

Objectives

The paradoxical migration of the femoral neck element (FNE) superomedially against gravity, with respect to the intramedullary component of the cephalomedullary device, is a poorly understood phenomenon increasingly seen in the management of pertrochanteric hip fractures with the intramedullary nail. The aim of this study was to investigate the role of bidirectional loading on the medial migration phenomenon, based on unique wear patterns seen on scanning electron microscopy of retrieved implants suggestive of FNE toggling.

Hip fractures constitute the most debilitating complication of osteoporosis with a steadily increasing incidence in an aging population. Intramedullary nailing of osteoporotic proximal femoral fractures can be challenging because of poor implant anchorage in the femoral head. Recently, cement augmentation of PFNA blades with Polymethylmethycrylate (PMMA) has shown promising results by enhancing the cutout resistance in proximal femoral fractures. The aim of this biomechanical study was to assess the impact of cement augmentation on the fixation strength of TFNA blades and screws within the femoral head, and compare its effect with head elements placed in a center or antero–posterior off–center positions. Eight groups were formed out of 96 polyurethane foam specimens with low density, simulating isolated femoral heads with severe osteoporotic bone. The specimens in each group were implanted with either non–augmented or PMMA–augmented TFNA blades or screws in a center or antero–posterior off–center position, 7 mm anterior or 7 mm posterior. They were mechanically tested in a setup simulating an unstable pertrochanteric fracture with lack of postero–medial support and load sharing at the fracture gap. All specimens underwent progressively increasing cyclic loading until catastrophic construct failure. Varus–valgus and head rotation angles were monitored by an inclinometer mounted on the head. A varus collapse of 5° or a 10° head rotation were defined as the clinically relevant failure criterion. Load at failure for specimens with augmented TFNA head elements (screw center: 3799 N ± 326 (mean ± SD); blade center: 3228 N ± 478; screw off–center: 2680 N ± 182; blade off–center: 2591 N ± 244) was significantly higher compared to the respective non–augmented specimens (blade center: 1489 N ± 41; screw center: 1593 N ± 120; blade off–center: 1018 N ± 48; screw off–center: 515 N ± 73), p<0.001. In both non–augmented and augmented specimens, the failure load in center position was significantly higher compared to the respective off–center position, regardless of head element, p<0.001. Non–augmented TFNA blades in off–center position revealed significantly higher load at failure versus non–augmented screws in off–center position, p<0.001. Cement augmentation clearly enhances fixation stability of TFNA blades and screws. Non–augmented blades outperformed screws in antero–posterior off–center position. Positioning of TFNA blades in the femoral head is more forgiving than TFNA screws in terms of failure load. Augmentation with TFNA has not been approved by FDA

Introduction. In comminuted intertrochanteric fractures, various operative options have been introduced. The purpose of this study was to determine whether there were differences in clinical and radiologic outcomes among bipolar hemiarthroplasty(BH), compression hip screw(CHS) and proximal femur nail antirotatory(PFNA) in treating comminuted intertrochanteric fractures(AO type, A2(21, 22, 23)). Materials and Methods. We retrospectively evaluated total 150 patients(BH:50, CHS:50, PFNA: 50) who were operated due to intertrochanteric fractures from March 2010 to Dec 2012 and were older than 65 years at the time of surgery. We compared these three groups for radiologic and clinical outcomes at 12 months postoperatively, including Harris hip score, ability of ambulation(Koval stage), visual analogue scale and radiologic limb length discrepancy(shortening). Landmark and radiologic length was checked. –A: postoperative length. –A’: POD 1year. –B: immediate posteopative contralateral length(from hip center to distal tip of lesser trochanter). –B’: POD 1year contralateral length(from hip center to distal tip of lesser trochanter). –. Limb length(shortening) was adjusted considering difference of magnification. = {A × (B’/B)}− A’. Results. There was no statistical significance among three groups in clinical outcomes including Harris hip score, ability of ambulation(Koval stage), visual analogue scale. However, there was significant differences in radiologic limb discrepancy in plain radiographs at 12 months postoperatively.(radiologic shortening- BH: 2.3mm, PFNA: 3.0mm, CHS:5.1mm, p=0.000). Conclusions. There were no clinical differences among BH, PFNA and CHS in this study. However, notable differences were observed in limb length discrepancy according to selection of operative methods

Proximal Femoral Nail Antirotation (PFNA) I one of the implants commonly used to stabilise subtrochanteric fractures or communited inter/pertrochanteric fractures. The aim of this project was to assess the outcome of PFNA in a busy District General Hospital. Between November 2009 to November 2012, 76 patients underwent PFNA. These patients were identified from the local hip fracture database, which is prospectively collected. The mean age of the patients was 80.11 years (range of 26.83 to 98.53). 27 were male and 49 female. Right hip was involved in 36 cases and left hip in 40. 9 patients required revision surgery due to failure of the primary surgery. 2 patients died due to other causes. 5 out of the 9 patients who underwent revision surgery had their primary surgery performed by a trainee under consultant supervision and a consultant surgeon performed the other 4 cases. In our series failure rate was 11.8%. We conclude that although PFNA is an excellent device to fix subtrochanteric or communited intertrochanteric fractures of the proximal femur one needs to be cautious and follow the correct operative technique to avoid failures

The PFNA is used routinely at the RUH for unstable peri-trochanteric and femoral fractures. Failure of operative treatment is associated with increased morbidity and financial burden. We analysed surgical and fracture factors, aiming to identify those associated with fixation failure. Retrospective analysis of 76 consecutive patients treated with a PFNA between 2009–2012 was performed. Patient demographics were assessed, along with fracture classification, adequacy of reduction, tip apex distance (TAD) and grade of surgeon. Failure was defined as metal work failure, non-union or need for repeat procedure. The mean age was 78.9 years (25.9–97.4). 21 were male and 49 female. There were 17 failures (24.3%) (7 required further surgery). 10 failures were per-trochanteric, 2 sub-trochanteric and 5 mid-shaft fractures. Complications included 4 broken and 6 backed-out distal locking screws, 2 blade cut-outs, 1 nail fracture and 4 non-unions. All per-trochanteric were adequately reduced with a TAD <25 mm. 11/17 had consultant supervision. A high rate of backed-out distal locking screws was identified. We found no concerns with adequacy of reduction, TAD or consultant supervision

The first case was that of an 89-year-old woman with advanced dementia. After falling onto the left hip, she was admitted to the emergency room. Standard x-rays revealed an unstable intertrochanteric fracture. Closed reduction and internal fixation was performed using the long PFNA with a 105-mm helical blade, the second patient treated with this implant in our series. The operation was performed by an attending surgeon who was experienced with treatment of trochanteric fractures with intramedullary devices. Six weeks later the patient presented again with severe pain after she had fallen onto her left hip for a second time. Follow-up x-rays showed a perforation of the helical blade through the cortex of the femoral head after a shortening of the femoral neck by 2 cm. CCD angle was still 129 degrees, and there were no radiological signs of rotational displacement. The acetabular cartilage appeared intact. At her second operation, a replacement of the blade was performed using a shorter 95-mm implant. Postoperatively the patient was again mobilized under full weight bearing, and at 12 weeks follow-up, we found cut through again, we replaced hip with biopolar hemiarthroplasty

Aim:. To audit pertrochanteric fractures treated with a cephalomedullary device in a public health institution. Method:. A retrospective 3 year analysis from January 2007 to December 2010 using theatre records and patient files. Analysis was done in terms of age, time to surgery, duration of surgery, elective or emergency, type of device used, perioperative complications and other factors. Results:. A total of 96 cases were confirmed. The average age was 67.4 years (13 to 99 years). The average time to theatre was 6.9 days. The average duration of surgery was 2 hours 59 minutes. A Trigen reconstruction nail was used in 59.4 % of the cases followed by a PFNA (26%) and others (13.6%). In 30% of cases surgery time was >3 hours and most were done electively (85.4%) during normal working hours. Revision surgery due to poor surgical technique was reported in 8 of 96 (8.3%) cases. Conclusion:. Our audit confirms that pertrochanteric fractures are common in elderly and young patients involved in high velocity trauma especially motor vehicle accidents. Pertrochanteric fractures lead to prolonged morbidity in hospital stay and theatre time. Cephalomedullary devices have reduced these complications and resulted in early rehabilitation and hospital discharge with only 8% of revisions in 3 years

Objectives. Because of the contradictory body of evidence related to the potential benefits of helical blades in trochanteric fracture fixation, we studied the effect of bone compaction resulting from the insertion of a proximal femoral nail anti-rotation (PFNA). . Methods. We developed a subject-specific computational model of a trochanteric fracture (31-A2 in the AO classification) with lack of medial support and varied the bone density to account for variability in bone properties among hip fracture patients. Results. We show that for a bone density corresponding to 100% of the bone density of the cadaveric femur, there does not seem to be any advantage in using a PFNA with respect to the risk of blade cut-out. On the other hand, in a more osteoporotic femoral head characterised by a density corresponding to 75% of the initial bone density, local bone compaction around the helical blade provides additional bone purchase, thereby decreasing the risk of cut-out, as quantified by the volume of bone susceptible to yielding. Conclusions. Our findings indicate benefits of using a PFNA over an intramedullary nail with a conventional lag screw and suggest that any clinical trial reporting surgical outcomes regarding the use of helical blades should include a measure of the femoral head bone density as a covariable

Introduction. An important factor in the internal fixation of pertrochanteric fractures is the ability to maintain postoperative reduction. Excessive postoperative sliding of the lag screw or blade may result in reduction loss. We retrospectively analyzed the relationship between postoperative reduction and sliding. Methodology. From Oct. 2009 to Sept. 2011, we treated pertrochanteric fractures using J-PFNA (Synthes) and InterTAN (Smith & Nephew) in 91 cases and 82 cases, respectively. We used postoperative radiographs to classify its reduction. Fractures were classified for its interfragmentary contact using the calcar femorale as a reference on the A-P plane while using the anterior cortex as a reference on the M-L plane. Results. PFNA cases showed greater postoperative sliding than InterTAN cases. Both demonstrated greater sliding when the proximal fragment was positioned inside the medullary canal on the M-L plane than when positioned outside or anatomically. Conclusion. Although the InterTAN can maintain greater initial stability necessary for early weight-bearing, both implants demonstrate the loss of interfragmentary contact when the proximal fragment is positioned inside the medullary canal on the M-L plane resulting in greater risk of reduction loss. In order to maintain postoperative reduction, either anatomical reduction or reducing the proximal fragment outside the medullary canal is advised; no matter what type of internal fixation implants are used

Introduction. When translating the principle of intramedullary nailing for trochanteric femoral fractures to Asian patients, design modifications made to adjust for anatomic differences resulted in an PFNA Asia. The primary endpoint of this study was the rate of complications attributable to fracture fixation. Material and methods. A prospective multicenter case series was performed; 176 patients with a median age of 84 with unstable trochanteric fractures treated with a PFNA Asia were included and followed for one year postoperatively. Complications were reviewed by a complication review board (CRB). Intra- and postoperative fracture fixation complications are presented according to type and incidence proportions (risk). Results. The CRB identified a total of three intraoperative (1.7%) and 14 postoperative fracture fixation complications (8%). Intraoperative complications included a problem with distal locking (1) and poor intraoperative reduction (2). Postoperative fracture fixation problems included significant neck shortening (8), implant breakage (3), cut-outs (2), and one severe loss of reduction. Outcome for most complications was adequate and none were classified as definitely related to the implant design but rather to surgical technique. Discussion & Conclusion. The adaptation of size and geometry to Asian patients leads to a low incidence of intra- and postoperative fracture fixation complications comparable to other studies

Introduction. The reverse obliquity fractures of the proximal femur are anatomically and mechanically different from most intertrochanteric fractures. These fractures are complex and very difficult to treat. To evaluate the results of the treatment of reverse obliquity intertrochanteric fractures with cephalomedullary nails. Materials and Methods. Between 2005 and 2009, 1179 extracapsular fractures of the proximal femur were treated at our institution. Retrospective review of these x-rays identified 59 patients with reverse obliquity fracture pattern. We analysed our results of cephalomedullary nailing of these complex fractures and evaluated factors responsible for failure of fixation. Results. Of the 59 patients with reverse oblique fracture pattern, one patient was treated with DHS, and two other patients didn't have post-operative x-rays and therefore were excluded from the study. Of the remaining 56 patients treated with cephalomedullary nails, forty eight were treated with gamma nails, five with PFNA and three with ATN. There were 40 females and 16 males with median age of 81.3 years (17–103 years). Six of the fifty six (10.7%) failed to heal or had failure of fixation. The failure rate was four of forty eight for the gamma nails, one of five of the PFNA and one of three of ATN. One of thirty seven (2.7%) of anatomically reduced fractures and five of nineteen (26.3%) of non-anatomically reduced fractures had failure of treatment (p = 0.01). Three of thirteen (23.1%) with femoral medialisation and three of forty three (6.9%) without femoral medialisation had failure of treatment (p = 0.13). Four of forty four (9.1%) with avulsed lesser trochanter and two of twelve (16.6%) without avulsion had failure of treatment (p = 0.59). Three of thirty seven (8.1%) with tip apex distance (TAD) of less than twenty and three of nineteen (15.7%) with TAD more than twenty had failure of treatment (p = 0.65). Conclusion. Inspite of the recent advances in the methods of internal fixation available to surgeons, reverse obliquity intertrochanteric fractures continue to be a challenge for orthopaedic surgeons. In our study, although poor fracture reduction was observed to be the only significant factor associated with a high failure rate, femoral medialisation and tip apex distance of more than 20 had a high association with poor outcome

Introduction. Unstable intertrochanteric hip fractures (AO 31A2) continue to be a challenge, as non-locking implants have shown a considerable rate of loss of reduction. Intramedullary fixation has been recommended, although screw cut-out has been identified as problematic. This study was performed to ascertain whether treatments with the established proximal femoral nail (PFN) and the newer PFNA with blade design (proximal femoral nail antirotation) have advantages over the use of the Percutaneous Compression Plate (PCCP, developed by Gotfried). Methods. Cohort study. Between March 2003 and March 2008, 134 patients with unstable fractures were treated with a PCCP, (n=44, 78.3 yrs, ASA 2.8), a PFN (n=50, 77.2 yrs, ASA 2.8), or a PFNA (n=40, 75.8 yrs, ASA 2.6). The patients (31 PCCP, 33 PFN, 30 PFNA) were then reexamined clinically and radiologically after approximately 21 months. Results. The PCCP was found to require less implantation time than the PFN and the PFNA (60 vs. 80 vs. 84 min, p<0.001) and less radiation exposition time (PCCP 139 vs. PFN 283 vs. PFNA 188 seconds, p<0.001). The rate of reoperations due to wound infections and hematomas amounted to 2% for the PCCP, 4% for the PFN, and 5% for the PFNA (p=0.799). Due to mechanical complications, 9% of patients implanted with a PCCP, 13% of those implanted with a PFN, and 5% of those implanted with a PFNA had to be reoperated (p=0.353). The cut-out rate was 2% after implantation of the PCCP, 4% after the PFN, and 5% after implantation of the PFNA (p=0.799). In one case, the shaft was fractured intraoperatively (PFNA). The tip-apex distance for the lower femoral neck screw (PCCP 22mm vs. PFN 30mm vs. PFNA 30mm, p<0.001), stress-related varisation of the collodiaphyseal (CCD) angle (4° for all implants), impaction (PCCP 5mm vs. PFN 5mm vs. PFNA 6mm, p=0.662) and femoral shortening (PCCP 3mm vs. PFN 3mm vs. PFNA 4mm, p=0.876) were not determinants of the postoperative function. On the basis of their scores according to Merle d'Aubigné and Harris, there was no variation in the results of the follow-up examinations. Conclusions. The use of the PCCP for the treatment of unstable trochanteric fractures presents a minimally invasive method of implantation, as well as a promising therapy option with regards to operation time, radiologic examination time, and rate of complications. Processes of impaction due to stress are seldom observed. No benefits could be established in an intramedullary treatment with the PFN or the PFNA; thus, it appears that the higher cost of these implants is avoidable

A prospective, randomized, controlled trial was performed to compare the outcome of treatment of unstable fractures of the proximal part of the femur with either a sliding hip screw or a short proximal femoral nail antirotation (PFNA-XS, Synthes). Eighty one patients (April 2007 – May 2008) presenting with unstable fracture of the proximal part of the femur were randomized, at the time of admission, to fixation with use of either a short proximal femoral nail antirotation (n=42) or a sliding hip screw (n= 39). The primary outcome measure was reoperation within the first postoperative year and mortality at the end of one year. Operative time, fluoroscopy time, blood loss, and any intra-operative complication were recorded for each patient. Follow-up was undertaken at 3, 6, and 12 postoperative months and yearly thereafter. Plain AP and lateral radiographs were obtained at all visits. All changes in the position of the implant, complications, or fixation failure were recorded. Hip range of motion, pain about the hip and the thigh, walking ability score and return to work status were used to compare the outcomes. There was no significant difference between 1 year mortality rates for the two groups. Mean Operative time was significantly less in PFNA group (Mean 25 min, range 19 – 56 min) than DHS group (Mean 38 min, range 28 – 70 min). Patients treated with a PFNA experienced a shorter fluoroscopy time and less blood loss. 6 patients in DHS group had implant failure as compared to none in PFNA group. The functional outcome was also better in PFNA group. When compared to DHS, PFNA-XS provides better functional outcome for unstable trochanteric fractures with less operative time, less blood loss and less complications, however one year mortality rate remains the same