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.

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.

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

We investigated a new intramedullary locking nail that allows the distal interlocking screws to be locked to the nail. We compared fixation using this new implant with fixation using either a conventional nail or a locking plate in a laboratory simulation of an osteoporotic fracture of the distal femur. A total of 15 human cadaver femora were used to simulate an AO 33-A3 fracture pattern. Paired specimens compared fixation using either a locking or non-locking retrograde nail, and using either a locking retrograde nail or a locking plate. The constructs underwent cyclical loading to simulate single-leg stance up to 125 000 cycles. Axial and torsional stiffness and displacement, cycles to failure and modes of failure were recorded for each specimen. When compared with locking plate constructs, locking nail constructs had significantly longer mean fatigue life (75 800 cycles (sd 33 900) vs 12 800 cycles (sd 6100); p = 0.007) and mean axial stiffness (220 N/mm (sd 80) vs 70 N/mm (sd 18); p = 0.005), but lower mean torsional stiffness (2.5 Nm/° (sd 0.9) vs 5.1 Nm/° (sd 1.5); p = 0.008). In addition, in the nail group the mode of failure was either cut-out of the distal screws or breakage of nails, and in the locking plate group breakage of the plate was always the mode of failure. Locking nail constructs had significantly longer mean fatigue life than non-locking nail constructs (78 900 cycles (sd 25 600) vs 52 400 cycles (sd 22 500); p = 0.04).

The new locking retrograde femoral nail showed better stiffness and fatigue life than locking plates, and superior fatigue life to non-locking nails, which may be advantageous in elderly patients.

Cite this article: Bone Joint J 2014;96-B:114–21.

Purpose of the study: The constantly increasing incidence of extracapsular fractures of the proximal femur are a public health concern. The basic therapeutic options are screw-plate fixation and proximal reconstruction with nails. The purpose of this retrospective study was to assess the mid-term results with a new osteosynthesis material, the proximal femoral nail antirotation (PFN-A. ®. ) which has a spiral blade. Material and methods: One hundred eight 108 PNF-A. ®. performed from January 2007 to July 2008 were included in a retrospective clinical and radiographic study. These series included exclusively extracapsular fractures of the proximal femur in subjects aged over 70 years. All patients were assessed with the Parker score pre- and postoperatively. Blood loos, position of the spiral blade on the AP and laterals views and operative time were analysed. We searched for complications (femoral head slide, blade protrusion, head rotation, non-union, fracture on material, and operative site infection). We searched for risk factors. Results: One hundred eight patients (94% ASA 2 or 3) were reviewed at mean 5.3 months (±1.5). None of the patients were lost to follow-up. At revision, 19 patients had died (17.6%). The mean Parker score declined 1.4 points. All fractures healed at mean 10.4 weeks (±0.6). Six complications were noted: three operative site infections, three head slidings, one intraacetabular protrusion. No statistically significant could be identified. Nevertheless, the three cases with femoral head sliding occurred on fractures that were unstable (type 31-A2) which had a malpositioned blade. Discussion: There appears to be a consensus on the treatment of proximal fractures of the femur: screw-plate fixation for stable fractures, centromedullary nailing for the others. Arthroplasty is a second-line solution. There are few publications on the new spiral blade of the PFN-A. ®. This method spares bone stock and allows compaction of the cancellous bone, particularly adapted for osteoporotic bone: the efficacy is comparable with reference techniques with lower rates of sliding (2.%) and acetabular protrusion (< 1%)

Introduction: There is an increasing tendency for internal fixation of proximal metaphyseal fractures. Intra-medullary nailing only recently has been considered to be a valuable option in these cases. Through the development of new reliable implant types, nailing finds increasing acceptance. Questions: Is intramedually nailing with a new angle stable titanium nail a safe procedure in the treatment of proximal humeral fractures and is it combined with a good outcome?. Material and methods: A prospective international mul-ticenter study with standardized study control focused on the “Proximal Humeral Nail (PHN–Synthes Inc.), possible complications and clinical outcome. 151 fractures had been treated in 11 hospitals, where 72 were A-type, 67 B-type and 12 C-type (AO). There were 37 male, 114 female patients, median age 66 years ranging from 16 to 97 years. The outcome had been measured through Constant-Morley scores and DASH scores. 108 patients could be followed up until 1 year postoperatively. Results: Important complications were perforation of the articular surface by screw or spiral blade (n=8), pain due to the implant (n=10), dislocation of fragments (n=2), non union (n=2), humeral head necrosis (n=3) and wound infection (n=1). The Constant-Morley score shows in total mean values one year postoperatively 75.3 in the injured and 89.9 in the non-injured side. The DASH score pre-operatively was in total 5.9 and 9.3 one year postoperatively, where the best results could achieve 0 points, the worst 100 points. Discussion: Analyzing the complications, perforation of the articular surface by screw or spiral blade and pain due to the implant or impingement at the nail base are clearly related the technical failure in performing nailing. Here or the nail has not been introduced profoundly enough or the length for the spiral blade was not determined exactly and probably not controlled intraoperatively. This is due to the individual accuracy of the surgeon. The development of non-union (2/108) shows a ratio equal or even better to what is reported in conservative treatment or plate osteosynthesis. Dislocation of fragments n the other side, show the limit of this procedure, where in multifragmentary fracture type one spiral blade will not be able to fix a fragments. Using additional hardware is possible, but might reduce the effect of an initially low invasive approach. Constant score and Dash-score results perform similar to plate osteosynthesis, where clearly C-type-fractures present the worst prognosis. Conclusion: Proximal humeral nailing seems to be beneficial in A-type metaphyseal fractures. Even in many B-type fractures it is still a good alternative with limited incision to the plate osteosynthesis. In C-type fractures it is not advisable as a standard routine, only for experienced surgeons it might be a possible solution in selected cases

To evaluate if adequate restoration of the medial cortical buttress reduces the high reported incidence of mechanical complications when using the AO unreamed femoral nail with spiral blade (UFN-SB) in the management of subtrochanteric femoral fractures. The clinical notes and radiographs of sixty-five patients treated with the UFN-SB between November 1996 and February 1999 were retrospectively reviewed. Twenty-eight of these fractures were subtrochanteric. Mean patient age was seventy-five and thirteen patients had metastatic disease. At the time of review the patients or their doctor were contacted by telephone to establish accurately the associated morbidity and mortality. Follow up information was obtained for every patient. Post-operative radiographs were assessed for accuracy of fracture reduction. The medial cortical buttress was adequately restored in every case. This required open fracture reduction in eleven patients and cerclage wires augmented the reduction in eight of these cases. Open reduction did not significantly increase time to fracture union or transfusion requirement. Every surviving patient was fully weight bearing within three months. One patient required a second operation for spiral blade migration but there were no implant breakages or other mechanical complications after a mean follow-up of thirty-seven months. Conclusion: Adequate restoration of the medial cortical buttress allows the UFN-SB to function as a load-sharing device and achieves reliable skeletal stability in these potentially unstable fractures that typically occur in osteoporotic or pathological bone

We report positive and negative factors associated with the most commonly-used methods of reconstruction after pathological fracture of the proximal femur. The study was based on 142 patients treated surgically for 146 metastatic lesions between 1996 and 2003. The local rate of failure was 10.3% (15 of 146). Of 37 operations involving osteosynthetic devices, six failed (16.2%) compared with nine (8.3%) in 109 operations involving endoprostheses. Of nine cases of prosthetic failure, four were due to periprosthetic fractures and three to recurrent dislocation. In the osteosynthesis group, three (13.6%) of 22 reconstruction nails failed. The two-year risk of re-operation after any type of osteosynthesis was 0.35 compared with 0.18 after any type of endoprosthetic reconstruction (p = 0.07). Endoprosthetic reconstructions are preferable to the use of reconstruction nails and other osteosynthetic devices for the treatment of metastatic lesions in the proximal third of the femur.

In a retrospective study, we reviewed 45 peri-trochanteric fractures treated between April 1995 and November 2002. The mean age of the 24 men and 21 women was 71 years (57 to 91). There were 34 inter-subtrochanteric, four reverse obliquity intertrochanteric fractures and nine subtrochanteric fractures. On the AO classification, there were 11 type-31A2-2, 21 type-31A2-3 and four type-31A3-1 intertrochanteric fractures. The fracture extended into the femoral neck in one case and into the diaphysis in three. Cardiopulmonary diseases were present in more than 60% of patients. In most cases, fractures were reduced by closed reduction or reduction through a short incision. In 42 cases, a Smith and Nephew femoral reconstruction nail was used. Three fractures were stabilised with AO undreamed femoral nail with spiral blade. Distal locking screws were inserted in all cases. Progressive passive hip and knee movement was introduced from day one postoperatively. Partial weight-bearing was permitted from the onset. All but two fractures healed within 3 to 6 months. Union was delayed in two subtrochanteric fractures. Functional hip and knee movement was present in all patients. There was no sepsis. Proximal screws backed out in four cases, but this was of no functional significance. In one case the superior proximal screw was too long and required removal. In one case screws backed out of the femoral neck and further surgery was required. No breakage of screws or nail was observed. Inter-subtrochanteric and subtrochanteric fractures in the elderly may be successfully managed with intramedullary femoral reconstruction nails

Introduction: While recent guidelines for the treatment of such fractures do not recommend load-bearing devices, there is little evidence actually condemning them, and there is still a lack of literature on the reconstruction nails now generally used. Aim: To evaluate the clinical outcome of pathological (metastatic) proximal femoral fractures treated by either a long Gamma nail, an AO nail with a spiral blade plate (AO-SBP), or a dynamic hip screw (DHS). Method: Eighty-six operations in 80 patients with average age 63.9 years were followed for 18 months or until death. Thirty-one procedures were prophylactic. Results: Thirty Gamma nails (three bilateral), 28 AO SBP rods (three bilateral) and 28 DHS were implanted. The DHS had complications in 10 cases (35%), all occurred in less than 14 months; three implants fractured, four cut out, and three failed to relieve symptoms. The Gamma nail group had two (7%) complications, both after 20 months; one nail fractured and the other lost fixation. The AO-SBP group had two (7%) complications, with one SBP misplacement, and one postoperative death after bilateral nailing. Pain relief and function were greatly improved by the nailing procedures in 57 out of 58 cases. Survival averaged 5.5 months, and was related to primary disease, and presence of visceral metastases. Conclusion: Both the long Gamma and AO- SBP nails reliably treated metastatic proximal femoral fractures, but loss of fixation occurred with long-term survival. The DHS had a high complication rate when used in these cases, and we do not recommend its use

We present a retrospective clinical and radiological review to assess the use of the AO unreamed femoral nail and spiral blade in the treatment of subtrochanteric fractures. Treatment of the subtrochanteric fracture remains a challenge. A combination of high stress concentration, poor cortical bone quality and comminution leads to a high incidence of problems. The abovementioned implant has been recommended for use in such fractures. However, several authors have reported mechanical failure and spiral blade migration. We have used the unreamed femoral nail since 1996 in 65 femoral fractures, and of these 32 were subtrochanteric fractures. A retrospective clinical and radiological study was undertaken to assess the use of the implant. Clinical notes and radiographs were obtained for patients with subtrochanteric fractures treated with the AO unreamed femoral nail from November 1996 to November 1999. Fracture pattern was classified according to Seinsheimer. Assessments were made of callus formation and fracture healing. Any complication or implant failure was noted. Thirty-two patients required an unreamed femoral nail. There were 20 females and 12 males, with an average age of 75 years. There were 16 fractures due to a fall, 15 pathological fractures, and one due to a car accident. Classification was: Type I: 6; Type II: 13; Type III: 6; Type IV: 3; Type V: 1. Mean follow-up was five months (range 3 to 18). Eight deaths occurred within one month. There were two pain-free non-unions, one revision with bone graft for non-union, and one spiral blade back out. No breakage of implants occurred. We found that this implant provides stable fixation in these difficult fractures if adequate reduction is obtained. We have not experienced the implant failures reported in other series. We recommend the use of the implant, especially in those patients who are elderly or have pathological fractures