Unstable intertrochanteric fractures may be treated by several types of implants, most frequently by dynamic sliding hip screw or some form of intramedullary implant. Intramedullary implants began to be used in cases with an expectation of further improvement of osteosynthesis stability. A need to determine the advantages of single implants for selected types of fractures in randomized trials was defined. In addition to biomechanical principles, bone quality is considered, together with increasing possibilities in recent years of further improving density measurements, especially qCT with respect to local specificity. A series of 86 patients (24 men, 62 women, average age 77,6 years) was operated on from September 6, 2005 to June 30, 2009 for unstable intertrochanteric fracture (31 A2.1, A2.2, A2.3), either by DHS of PFN osteosynthesis after randomization. A CT examination of both hip joints in a predefined manner was performed before surgery. Using special software the relative density of the central spherical part of the femoral head 2 and 3 centimetres in diameter was determined. After fracture healing, the dynamization of the neck screw of both implants and the reduction of vertical distance between the tip of the neck screw and subchondral bone of the femoral head were determined. In addition to evaluation of osteosynthesis stability and osteosyntheis failure, clinical parameters such as surgical time, blood loss and length of hospital stay were compared between the two groups of patients. Survival of patients was evaluated with respect to April 21, 2010. In the patient series, 4 failures of DHS osteosynthesis (cut out) and 2 failures of PFN osteosynthesis (cut out) were noted. Sliding of the DHS was on average 11,9 mm, and was significantly higher in comparison to dynamization of the PFN neck screw, which was 6,9 mm (p=0,005). When comparing the vertical distance between the tip of the neck screw and subchondral bone of the femoral head immediately after surgery and after fracture healing the average reduction of the vertical distance was 1,6 mm in DHS osteosynthesis and 0,8 mm in PFN osteosynthesis. The difference was statistically significant (p=0,025). PFN seems to provide a more stable fixation, based on the measurements. The number of failed DHS osteosyntheses is higher in comparison to the number of failed PFN osteosyntheses but the difference is not statistically significant. The influence of femoral head density on osteosynthesis failure could not be determined due to a low number of failed osteosyntheses in both patient groups. At the same time, after statistical analysis, influence of the relative femoral head density on vertical distance reduction between the screw tip and femoral head subchondral bone in healed fractures was not proven. Statistically, average length of surgical time, length of hospital stay, mean blood loss and survival did not differ significantly between the two patient groups

Introduction. The sliding hip screw is the implant of choice for the operative treatment of stable trochanteric femur fractures. Surgeons have been using widely the four-hole side plate DHS (Dynamic Hip screw) with four bicortical screws, which allows adequate weight bearing after operation. However, there is lacking of scientific studies that support the use of such long plate and we question ourselves if we can accomplish the same results with the use of a smaller plate. The objective of this study is to compare the results accomplished with a four-hole and a two-hole DHS side plate in the treatment of transtrochanteric fractures. Material and Methods. This study included 140 patients (43 male and 97 female) that had stable transtrochanteric fractures between 1/01/2005 and 31/12/2008 and were submitted to osteossynthesis with DHS side-plate. 32 (22.9%) were treated with a two-hole DHS (group DHS2) and 108 (77.1%) with four-hole. The fractures were evaluated according to the AO/OTA classification and Evans for stability. The fracture reduction was assessed according to Sernbo criteria and was recorded also patient demographics, fracture patterns and fixation, comorbilities, mortality rate, capacity of ambulation and complications. Results. The patients had in medium 77.74 ± 49.52 years and 18 months of follow-up (range 6–36 months). Both groups had similar patient demographics. The etiology of the fracture was fall in 120 (85.7%) and 20 (14.3%) from traffic accident, 10 (7.1%) were patological. 15 (10.7%) died during hospital stay: 13 (12.0%) in DHS4 group and 2 (6.3%) in DHS2. In terms of capacity of ambulation in the group DHS2 15.6% didn't ambulate and 25% had walking aid; in the group DHS4 20.4% didn't ambulate and 29.7% had walking aid. Concerning fracture reduction there was varus (<125°) in 9.4% of DHS2 group and 9.3% in DHS4. Also in the group DHS4 there were 15 (13.9%) complications: 3 cut-out, 3 device failure, 8 infections and 1 pseudarthrosis. In the group DHS2 there were 4 (12.5%) complications: 1 cut-out, 2 infections and 1 device failure. 121 (28 group DHS2 and 93 group DHS4) fractures healed without complications in anatomical position with good function of the hip joint. Discussion. We found no significant differences between the two groups regarding reduction or percentage of complications. However we could observe that in the group DHS2 there was a lesser rate of mortality during hospital stay and a higher capacity of ambulation without walking aid. So the fixation of stable transtrochanteric fractures with a two-hole DHS side-plate is safe, less invasive, less surgical time and less blood loss than a four-hole. As our study reveled in these stable fractures there is lacking of benefit with the use of a larger slide-plate, the two-hole is adequate and its use should be increasing in our clinical practice

Introduction. The objective of this study was to determine if a synthetic bone substitute would provide results similar to bone from osteoporotic femoral heads during in vitro testing with orthopaedic implants. If the synthetic material could produce results similar to those of the osteoporotic bone, it could reduce or eliminate the need for testing of implants on bone. Methods. Pushout studies were performed with the dynamic hip screw (DHS) and the DHS Blade in both cadaveric femoral heads and artificial bone substitutes in the form of polyurethane foam blocks of different density. The pushout studies were performed as a means of comparing the force displacement curves produced by each implant within each material. Results. The results demonstrated that test material with a density of 0.16 g/cm. 3. (block A) produced qualitatively similar force displacement curves for the DHS and qualitatively and quantitatively similar force displacement curves for the DHS Blade, whereas the test material with a density of 0.08 g/cm. 3. (block B) did not produce results that were predictive of those recorded within the osteoporotic cadaveric femoral heads. Conclusion. This study demonstrates that synthetic material with a density of 0.16 g/cm. 3. can provide a good substitute for cadaveric osteoporotic femoral heads in the testing of implants. However we do recognise that no synthetic material can be considered as a definitive substitute for bone, therefore studies performed with artificial bone substrates may need to be validated by further testing with a small bone sample in order to produce conclusive results

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

Aims. To evaluate if, for orthopaedic trainees, additional cadaveric simulation training or standard training alone yields superior radiological and clinical outcomes in patients undergoing dynamic hip screw (DHS) fixation or hemiarthroplasty for hip fracture. Methods. This was a preliminary, pragmatic, multicentre, parallel group randomized controlled trial in nine secondary and tertiary NHS hospitals in England. Researchers were blinded to group allocation. Overall, 40 trainees in the West Midlands were eligible: 33 agreed to take part and were randomized, five withdrew after randomization, 13 were allocated cadaveric training, and 15 were allocated standard training. The intervention was an additional two-day cadaveric simulation course. The control group received standard on-the-job training. Primary outcome was implant position on the postoperative radiograph: tip-apex distance (mm) (DHS) and leg length discrepancy (mm) (hemiarthroplasty). Secondary clinical outcomes were procedure time, length of hospital stay, acute postoperative complication rate, and 12-month mortality. Procedure-specific secondary outcomes were intraoperative radiation dose (for DHS) and postoperative blood transfusion requirement (hemiarthroplasty). Results. Eight female (29%) and 20 male trainees (71%), mean age 29.4 years, performed 317 DHS operations and 243 hemiarthroplasties during ten months of follow-up. Primary analysis was a random effect model with surgeon-level fixed effects of patient condition, patient age, and surgeon experience, with a random intercept for surgeon. Under the intention-to-treat principle, for hemiarthroplasty there was better implant position in favour of cadaveric training, measured by leg length discrepancy ≤ 10 mm (odds ratio (OR) 4.08 (95% confidence interval (CI) 1.17 to 14.22); p = 0.027). There were significantly fewer postoperative blood transfusions required in patients undergoing hemiarthroplasty by cadaveric-trained compared to standard-trained surgeons (OR 6.00 (95% CI 1.83 to 19.69); p = 0.003). For DHS, there was no significant between-group difference in implant position as measured by tip-apex distance ≤ 25 mm (OR 6.47 (95% CI 0.97 to 43.05); p = 0.053). No between-group differences were observed for any secondary clinical outcomes. Conclusion. Trainees randomized to additional cadaveric training performed hip fracture fixation with better implant positioning and fewer postoperative blood transfusions in hemiarthroplasty. This effect, which was previously unknown, may be a consequence of the intervention. Further study is required. Cite this article: Bone Jt Open 2023;4(8):602–611

We compared the outcome of patients treated for an intertrochanteric fracture of the femoral neck with a locked, long intramedullary nail with those treated with a dynamic hip screw (DHS) in a prospective randomised study. Each patient who presented with an extra-capsular hip fracture was randomised to operative stabilisation with either a long intramedullary Holland nail or a DHS. We treated 92 patients with a Holland nail and 98 with a DHS. Pre-operative variables included the Mini Mental test score, patient mobility, fracture pattern and American Society of Anesthesiologists grading. Peri-operative variables were anaesthetic time, operating time, radiation time and blood loss. Post-operative variables were time to mobilising with a frame, wound infection, time to discharge, time to fracture union, and mortality. We found no significant difference in the pre-operative variables. The mean anaesthetic and operation times were shorter in the DHS group than in the Holland nail group (29.7 vs 40.4 minutes, p < 0.001; and 40.3 vs 54 minutes, p < 0.001, respectively). There was an increased mean blood loss within the DHS group versus the Holland nail group (160 ml vs 78 ml, respectively, p < 0.001). The mean time to mobilisation with a frame was shorter in the Holland nail group (DHS 4.3 days, Holland nail 3.6 days, p = 0.012). More patients needed a post-operative blood transfusion in the DHS group (23 vs seven, p = 0.003) and the mean radiation time was shorter in this group (DHS 0.9 minutes vs Holland nail 1.56 minutes, p < 0.001). The screw of the DHS cut out in two patients, one of whom underwent revision to a Holland nail. There were no revisions in the Holland nail group. All fractures in both groups were united when followed up after one year. We conclude that the DHS can be implanted more quickly and with less exposure to radiation than the Holland nail. However, the resultant blood loss and need for transfusion is greater. The Holland nail allows patients to mobilise faster and to a greater extent. We have therefore adopted the Holland nail as our preferred method of treating intertrochanteric fractures of the hip

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

Objectives. The use of two implants to manage concomitant ipsilateral femoral shaft and proximal femoral fractures has been indicated, but no studies address the relationship of dynamic hip screw (DHS) side plate screws and the intramedullary nail where failure might occur after union. This study compares different implant configurations in order to investigate bridging the gap between the distal DHS and tip of the intramedullary nail. Methods. A total of 29 left synthetic femora were tested in three groups: 1) gapped short nail (GSN); 2) unicortical short nail (USN), differing from GSN by the use of two unicortical bridging screws; and 3) bicortical long nail (BLN), with two angled bicortical and one unicortical bridging screws. With these findings, five matched-pairs of cadaveric femora were tested in two groups: 1) unicortical long nail (ULN), with a longer nail than USN and three bridging unicortical screws; and 2) BLN. Specimens were axially loaded to 22.7 kg (50 lb), and internally rotated 90°/sec until failure. Results. For synthetic femora, a difference was detected between GSN and BLN in energy to failure (p = 0.04) and torque at failure (p = 0.02), but not between USN and other groups for energy to failure (vs GSN, p = 0.71; vs BLN, p = 0.19) and torque at failure (vs GSN, p = 0.55; vs BLN, p = 0.15). For cadaveric femora, ULN and BLN performed similarly because of the improvement provided by the bridging screws. Conclusions. Our study shows that bicortical angled screws in the DHS side plate are superior to no screws at all in this model and loading scenario, and suggests that adding unicortical screws to a gapped construct is probably beneficial

Aims

Prior to the availability of vaccines, mortality for hip fracture patients with concomitant COVID-19 infection was three times higher than pre-pandemic rates. The primary aim of this study was to determine the 30-day mortality rate of hip fracture patients in the post-vaccine era.

Aims

Despite limited clinical scientific backing, an additional trochanteric stabilizing plate (TSP) has been advocated when treating unstable trochanteric fractures with a sliding hip screw (SHS). We aimed to explore whether the TSP would result in less post operative fracture motion, compared to SHS alone.

Introduction and aim. Avascular necrosis (AVN) of femoral head remains a major post-operative complication of the surgical fixation of femoral neck fractures (#NOF). In order to reduce the incidence of AVN following this type of fracture, the National Institute for Clinical Excellence (NICE) has stated that fixation must occur within 6 hours. However, there is a paucity of information concerning whether time to fixation influences the development of AVN. The aim of the present study was to assess whether time to fixation affects the development of AVN in patients aged under 60 who had sustained a fracture (#)NOF. Methods. We looked retrospectively at 101 patients (61 female, 40 male aged under 60 (mean age 47 years) who were admitted to a multi-tertiary centre having sustained an intracapsular #NOF. The underlying co morbidity of the patient sample was varied, as was the mechanism of trauma, though in the majority of cases the cause was a simple fall. The time delay (TD) between the time of injury and the time of operation for each patient was determined. Results. 72 patients sustained an intracapsular displaced fracture and 29 an intracapsular undisplaced fracture. Of these, 33 patients were treated with a dynamic hip screw (DHS), 10 received a DHS plus a cannulated screw, and 54 were treated with cannulated screws only. We looked at time to fixation(TD) as follows: Group A-less than 6 hours (7 patients), Group B-6 to 12 hours (16 patients), Group C-12 to 18 hours (15 patients), Group D-18 to 24 hours (18 patients), Group E −24 to 48 hours (26 patients) and Group F- more than 48 hours(15 patients). Out of 97 patients, 15 (15.46%) developed AVN. Of these, 13 were patients who had sustained an intracapsular displaced fracture, two had sustained an undisplaced fracture. Of the intracapsular displaced fractures patients, the time to fixation varied from 3 hours to 26 hours post-trauma. Of note, twelve of these patients received a cannulated screw and only one was treated with a DHS. The two patients with an undisplaced intracapsular fracture underwent fixation at 13 and 24 hours respectively. The method of fixation was a cannulated screw. Conclusion. Current NICE guidelines state that intracapsular #NOF must be fixed within 6 hours in order to prevent AVN of femoral head. In our sample, 15.46% of patients developed AVN post-fixation. Crucially, 2 patients out of the 7 patients (28.57%) developed AVN despite undergoing fixation within 6 hours. Interestingly, we have observed that fracture fixation with a cannulated screw has a greater propensity to develop AVN despite time to fixation, since 15.46% of patients treated in this manner developed AVN. Taken together, method of fixation rather than time to fixation appears to be a key factor in the incidence of AVN in our patient group

Simulation in surgical training has become a key component of surgical training curricula, mandated by the GMC, however commercial tools are often expensive. As training budgets become increasingly pressurised, low-cost innovative simulation tools become desirable. We present the results of a low-cost, high-fidelity simulator developed in-house for teaching fluoroscopic guidewire insertion. A guidewire is placed in a 3d-printed plastic bone using simulated fluoroscopy. Custom software enables two inexpensive web cameras and an infra-red led marker to function as an accurate computer navigation system. This enables high quality simulated fluoroscopic images to be generated from the original CT scan from which the bone model is derived and measured guidewire position. Data including time taken, number of simulated radiographs required and final measurements such as tip apex distance (TAD) are collected. The simulator was validated using a DHS model and integrated assessment tool. TAD improved from 16.8mm to 6.6mm (p=0.001, n=9) in inexperienced trainees, and time taken from 4:25s to 2m59s (p=0.011). A control group of experienced surgeons showed no improvement but better starting points in TAD, time taken and number of radiographs. We have also simulated cannulated hip screws, femoral nail entry point and SUFE, but the system has potential for simulating any procedure requiring fluoroscopic guidewire placement e.g. pedicle screws or pelvic fixation. The low cost and 3D-printable nature have enabled multiple copies to be built. The software is open source allowing replication by any interested party. The simulator has been incorporated successfully into a higher orthopaedic surgical training program

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.

Aims

Fractures of the distal femur can be challenging to manage and are on the increase in the elderly osteoporotic population. Management with casting or bracing can unacceptably limit a patient’s ability to bear weight, but historically, operative fixation has been associated with a high rate of re-operation. In this study, we describe the outcomes of fixation using modern implants within a strategy of early return to function.

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).

We treated 108 patients with a pertrochanteric femoral fracture using either the dynamic hip screw or the proximal femoral nail in this prospective, randomised series. We compared walking ability before fracture, intra-operative variables and return to their residence. Patients treated with the proximal femoral nail (n = 42) had regained their pre-operative walking ability significantly (p = 0.04) more often by the four-month review than those treated with the dynamic hip screw (n = 41). Peri-operative or immediate post-operative measures of outcome did not differ between the groups, with the exception of operation time. The dynamic hip screw allowed a significantly greater compression of the fracture during the four-month follow-up, but consolidation of the fracture was comparable between the two groups. Two major losses of reduction were observed in each group, resulting in a total of four revision operations.

Our results suggest that the use of the proximal femoral nail may allow a faster postoperative restoration of walking ability, when compared with the dynamic hip screw.

An MR scan was performed on all patients who presented to our hospital with a clinical diagnosis of a fracture of the proximal femur, but who had no abnormality on plain radiographs. This was a prospective study of 102 consecutive patients over a ten-year period. There were 98 patients who fulfilled our inclusion criteria, of whom 75 were scanned within 48 hours of admission, with an overall mean time between admission and scanning of 2.4 days (0 to 10). A total of 81 patients (83%) had abnormalities detected on MRI; 23 (23%) required operative management.

The use of MRI led to the early diagnosis and treatment of occult hip pathology. We recommend that incomplete intertrochanteric fractures are managed non-operatively with protected weight-bearing. The study illustrates the high incidence of fractures which are not apparent on plain radiographs, and shows that MRI is useful when diagnosing other pathology such as malignancy, which may not be apparent on plain films.

There have been recent reports linking alendronate and a specific pattern of subtrochanteric insufficiency fracture. We performed a retrospective review of all subtrochanteric fractures admitted to our institution between 2001 and 2007. There were 20 patients who met the inclusion criteria, 12 of whom were on long-term alendronate. Alendronate-associated fractures tend to be bilateral (Fisher’s exact test, p = 0.018), have unique radiological features (p < 0.0005), be associated radiologically with a pre-existing ellipsoid thickening of the lateral femoral cortex and are likely to be preceded by prodromal pain. Biomechanical investigations did not suggest overt metabolic bone disease. Only one patient on alendronate had osteoporosis prior to the start of therapy. We used these findings to develop a management protocol to optimise fracture healing. We also advocate careful surveillance in individuals at-risk, and present our experience with screening and prophylactic fixation in selected patients.

Incomplete intertrochanteric fractures do not extend across to the medial femoral cortex and are stable, without rotational deformity or shortening of the lower limb. The aim of our study was to establish whether they can be successfully managed conservatively. A total of 68 patients over a five-year period presented with a suspected fracture of the femoral neck and underwent an MRI scan for further assessment. From these, we retrospectively reviewed eight patients with normal plain radiographs but with an incomplete, intertrochanteric fracture on MRI scan. Five were managed conservatively and three operatively.

The mean length of hospital stay was 16 days for the conservatively-treated group and 15 days for those who underwent surgery; this was not statistically significant (p > 0.5) and all patients were mobilised on discharge. Although five patients were readmitted at a mean of 3.2 years after discharge, none had progressed to a complete fracture. We believe that patients with incomplete intertrochanteric fractures should be considered for conservative treatment.