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Zhu F, Qiu J, Han L, Xu H, Xiao L, Zhang Q, Zhao Y. Research on Classification Criteria for the Reducibility and Irreducibility of Intertrochanteric Femoral Fractures. Orthop Surg 2025. [PMID: 40317913 DOI: 10.1111/os.70055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2024] [Revised: 04/03/2025] [Accepted: 04/13/2025] [Indexed: 05/07/2025] Open
Abstract
OBJECTIVE The current classification of intertrochanteric femoral fractures primarily follows the AO/OTA system, which guides treatment but fails to accurately predict preoperative reduction difficulty. Since reduction quality directly impacts fracture healing, internal fixation success, and patient rehabilitation, developing a classification standard that aids in predicting reduction difficulty holds significant clinical implications for achieving optimal outcomes. The purpose of this study was to develop classification criteria for femoral intertrochanteric fractures based on their reducibility and irreducibility and to provide a reference standard for preoperative predictions of the level of difficulty likely to accompany the fracture. METHODS Four hundred thirty-seven patients with intertrochanteric fractures of the femur treated at the Affiliated Hospital of Jining Medical University and several county hospitals from January 2015 to August 2023 were reviewed. The fractures were divided into irreducible and reducible types according to actual intraoperative reduction. The imaging data were collated and analyzed, the type of fracture that may have affected the reduction was selected, the data were collated according to the type of fracture as well as the AO type, unconditional univariate logistic regression analysis was performed, and the OR values were calculated. RESULTS Logistic regression revealed that the risk factors leading to irreducibility were 31A3, 31A3.3, 31A1 (with obvious separation displacement), 31A2 (with anterior angular exostosis) and 31A2 (with a concomitant proximal femur fracture) fractures. Intertrochanteric fractures were typed according to the risk factors suggested by the statistical results and the specific intraoperative imaging manifestations, with irreducibility divided into 3 types and reducibility divided into 2 types, each with their respective subtypes. The accuracy of this typing in predicting the degree of difficulty of intraoperative restoration was 78.4% (343/437), and the test of consistency showed kappa = 0.573 (moderate consistency). CONCLUSION Classifying intertrochanteric fractures into reducible and irreducible types can accurately preoperatively predict the difficulty of reduction for the vast majority of reducible fractures and most irreducible fractures, guide treatment, and predict the prognosis of the fracture.
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Affiliation(s)
- Fenghua Zhu
- Department of Traumatic Orthopedics, Affiliated Hospital of Jining Medical University, Jining, P. R. China
| | - Jinya Qiu
- Department of Clinical Medicine, Jining Medical University, Jining, P. R. China
| | - Liang Han
- Department of Traumatic Orthopedics, Affiliated Hospital of Jining Medical University, Jining, P. R. China
| | - Hongxing Xu
- Department of Orthopedics, Wenshang County Hospital of Traditional Chinese Medicine, Shandong, P. R. China
| | - Longtao Xiao
- Department of Orthopedics, Wenshang People's Hospital, Dehui, P. R. China
| | - Qiushun Zhang
- Department of Clinical Medicine, Jining Medical University, Jining, P. R. China
| | - Yifeng Zhao
- Department of Traumatic Orthopedics, Affiliated Hospital of Jining Medical University, Jining, P. R. China
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Mounisamy P, Suresh H, Chandrashekar S, D U, Jeyaraman N, Jeyaraman M, Muthu S. Medial cortical reduction does not influence outcomes in geriatric intertrochanteric femur fractures treated with proximal femoral nail. World J Orthop 2025; 16:106862. [PMID: 40290611 PMCID: PMC12019145 DOI: 10.5312/wjo.v16.i4.106862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2025] [Revised: 03/23/2025] [Accepted: 04/11/2025] [Indexed: 04/17/2025] Open
Abstract
BACKGROUND In intertrochanteric fractures, the positive medial cortex support reduction is considered to provide a non-anatomical buttress that helps in controlled collapse. AIM To analyze the concept of medial cortical reduction (MCR) and its clinical and radiological association in geriatric intertrochanteric femur fractures. METHODS Geriatric patients who presented with AO/OTA 31A1 and 31A2 femur fractures and treated with proximal femoral nailing between July 2021 and June 2023 were include in this prospective cohort study. Based on the degree of MCR, they were divided into positive, neutral, or negative MCR groups. The demographic baseline characteristics, postoperative radiographic femoral neck-shaft angle and neck length were analyzed at 6, 12 and 24 weeks post-surgery. Functional outcomes such as modified Harris Hip Score (HHS) and time to full-weight bearing were also analyzed. RESULTS 47 patients (Male: Famale 35:12) with mean age of 65.8 ± 4.2 years were included in this study. Twenty-two cases had neutral support, nine had negative support, and sixteen had positive support in the medial cortex post-operatively. Baseline characteristics of the three groups were comparable. No significant differences were found in the femur neck length and femur neck-shaft angle changes post-surgery between the groups. The modified HHS was not found to be significant between the groups (P = 0.883) as that of the time to full weight bearing (P = 0.789). CONCLUSION The type of reduction achieved based on medial cortical alignment does not affect the femur neck length shortening or varus collapse. Future randomized controlled trials are needed to validate the findings noted in the study.
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Affiliation(s)
- Prabu Mounisamy
- Department of Orthopaedics, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
| | - Hanoop Suresh
- Department of Orthopaedics, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
| | - Sushma Chandrashekar
- Department of Orthopaedics, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
| | - Udayakumar D
- Department of Orthopaedics, Sri Manakula Vinayagar Medical College and Hospital, Puducherry 605107, India
| | - Naveen Jeyaraman
- Department of Orthopaedics, ACS Medical College and Hospital, Dr MGR Educational and Research Institute, Chennai 600077, Tamil Nadu, India
- Department of Orthopaedics, Orthopaedic Research Group, Coimbatore 641045, Tamil Nadu, India
| | - Madhan Jeyaraman
- Department of Orthopaedics, ACS Medical College and Hospital, Dr MGR Educational and Research Institute, Chennai 600077, Tamil Nadu, India
- Department of Orthopaedics, Orthopaedic Research Group, Coimbatore 641045, Tamil Nadu, India
| | - Sathish Muthu
- Department of Orthopaedics, Orthopaedic Research Group, Coimbatore 641045, Tamil Nadu, India
- Central Research Laboratory, Meenakshi Medical College Hospital and Research Institute, Meenakshi Academy of Higher Education and Research, Chennai 600078, Tamil Nadu, India
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Graulich T, Omar M, Sehmisch S, Liodakis E. Controversies in the Treatment Strategies of Intertrochanteric Fractures: A Scoping Review and Discussion of a Literature-Based Algorithm. J Clin Med 2025; 14:2200. [PMID: 40217650 PMCID: PMC11989566 DOI: 10.3390/jcm14072200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2025] [Revised: 03/19/2025] [Accepted: 03/19/2025] [Indexed: 04/14/2025] Open
Abstract
Intertrochanteric fractures become more and more relevant in an aging population. Despite significant progress in the treatment of these fractures, some technical details, concerning the surgical procedure, are still a matter of strong debate. In this review of the literature, we have included the best evidence available from the last decade in an effort to shed light on some of the most controversial subjects related to intertrochanteric fractures: Treatment in the case of polytrauma or monotrauma? Reconstruction or arthroplasty? Open or closed reduction? Reconstruction with or without additional cables and plates? Cephalomedullary nail or dynamic hip screw (DHS)? Long cephalomedullary nail or short cephalomedullary nail? The results of this scoping review are controversial. By introducing a new therapeutic algorithm, we do not intend to present a new finished guideline but rather arouse a controversial debate about a relevant aspect in geriatric traumatology. These conflicting results are an indication that larger and more well-conducted, high-quality trials are needed in order to gain more secure answers.
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Affiliation(s)
- Tilman Graulich
- Department of Trauma Surgery, Hannover Medical School, Carl-Neuberg Str. 1, 30625 Hannover, Germany; (M.O.); (S.S.)
| | - Mohamed Omar
- Department of Trauma Surgery, Hannover Medical School, Carl-Neuberg Str. 1, 30625 Hannover, Germany; (M.O.); (S.S.)
| | - Stephan Sehmisch
- Department of Trauma Surgery, Hannover Medical School, Carl-Neuberg Str. 1, 30625 Hannover, Germany; (M.O.); (S.S.)
| | - Emmanouil Liodakis
- Department of Trauma, Hand and Reconstructive Surgery, Departments and Institutes of Surgery, Saarland University, 66123 Homburg, Germany;
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Li K, Du X, Chen Z, Shui W. Minimally invasive reduction of irreducible, sagittally unstable peritrochanteric fractures: Novel technique and early results. Chin J Traumatol 2024:S1008-1275(24)00172-X. [PMID: 39719713 DOI: 10.1016/j.cjtee.2024.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Revised: 07/31/2024] [Accepted: 08/01/2024] [Indexed: 12/26/2024] Open
Abstract
PURPOSE The management of irreducible, sagittally unstable peritrochanteric fractures presents a significant challenge due to the inability to achieve closed reduction using conventional techniques. This study introduces a novel minimally invasive technique leveraging the mechanical advantage principle with long, angled hemostatic clamps. METHODS A retrospective review was performed on 16 patients who sustained sagittally unstable peritrochanteric fractures and underwent a percutaneous hemostatic clamp leverage reduction procedure. INCLUSION CRITERIA (1) Preoperative confirmation of fracture type as peritrochanteric fracture; (2) Intraoperative imaging confirms the presence of sagittal plane displacement at the fracture site; (3) Age > 18 years. EXCLUSION CRITERIA (1) Open fractures, pathological fractures, and diabetes; (2) Long-term use of corticosteroids; (3) Patients with local skin or systemic conditions not suitable for surgery. Regular follow-ups at intervals of 6 - 8 weeks continued until evidence of bone consolidation was apparent in radiographic assessments. Evaluation of the alignment quality considered factors such as the re-establishment of the neck-shaft angle, the integrity of all cortical bone edges, and the rectification of any translational displacement, while the assessment of hip functionality was performed using the Harris scoring system. Statistical analysis of the relevant data was performed using SPSS 25.0 software. RESULTS The average age of these 16 patients was 56.8 years (ranging from 25 to 81 years), consisting of 8 males and 8 females. According to the AO/OTA fracture classification, the cohort included 13 cases of type 31A, 2 cases of type 32A, and 1 case of type 32C. The time from hospital admission to the day of surgery ranged from 3 to 11 days, with an average of 5.1 days. Closed reduction was successfully implemented in all 10 instances, negating the necessity for transition to open reduction procedures. The mean operative duration was 105.8 min (range 80 - 180 min). Satisfactory results of the quality of reduction were determined by comparison with the normal side. The average Harris hip score was 94.1 (range 87 - 99), and the fracture healing time was 4.2 months (3 - 6 months). Implant failure and malunion were not observed. CONCLUSIONS This study provides an alternative, minimally invasive technique for reducing sagittally unstable, irreducible peritrochanteric fractures. This technique holds the potential to manage complex fractures with the same efficacy as is typically reserved for simple and easily reducible fractures.
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Affiliation(s)
- Ke Li
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Xing Du
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Zhongyao Chen
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Wei Shui
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
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Gupta A, Rai D. Irreducible Intertrochanteric Fractures: Analysis of Various Fracture Patterns and Reduction Techniques. Cureus 2024; 16:e75014. [PMID: 39749093 PMCID: PMC11694229 DOI: 10.7759/cureus.75014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2024] [Indexed: 01/04/2025] Open
Abstract
Background Numerous classifications exist for intertrochanteric (IT) fractures, commonly focused on stability. However, the currently utilized Arbeitsgemeinschaft Osteosynthesefragen and Orthopaedic Trauma Association (AO/OTA) classification has limitations in identifying irreducible fractures. This study aims to answer the following questions: does fracture stability imply irreducibility; which fracture fragments complicate reduction; and which reduction techniques should be employed? Materials and methods Eligibility criteria included fractures in adult long bones without pathological fractures being treated by native conservative means. Preoperative pelvic X-rays were obtained from 49 patients who had intertrochanteric fractures and classified according to the 2018 AO Classification. Anterior-posterior pelvic X-rays were reviewed by six experienced surgeons, who reached a consensus on type, group, and subgroup classifications in this prospective observational study. The methods for intraoperative fracture reduction used by five different unit chiefs were recorded and tabulated. All fractures were reduced on a fracture table with traction and rotation and subsequently checked under C-arm imaging. Persistent non-anatomical alignment with displacement was classified as an irreducible IT fracture. Various reduction techniques, using either semi-open or open methods, were analyzed. Results Fractures classified as AO types A1.1, A1.3, and A2.1 were generally more reducible, while types A2.2, A2.3, A3.1, A3.2, and A3.3 were more frequently irreducible. Patients under 65 years of age were more likely to present with irreducible fracture patterns (P = 0.026), a statistically significant association. A semi-open method using spikes or Hohman's retractors was most commonly employed, with no preliminary cortical fixation using K-wires after reduction. Conclusion Irreducible fractures exhibit unique features on C-arm imaging, potentially leading to increased anxiety and longer operation times. Awareness of these fracture characteristics can assist surgeons in achieving effective reduction and reducing operation time. The 2018 AO classification alone does not reliably predict irreducible IT fractures.
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Affiliation(s)
- Anupam Gupta
- Orthopaedics, PSG Institute of Medical Sciences and Research, Coimbatore, IND
| | - Dinakar Rai
- Trauma and Orthopaedics, PSG Institute of Medical Sciences and Research, Coimbatore, IND
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Ren H, Zhang X, Liang Y, Yi C, Li D. Morphological analysis of posterior-medial intertrochanteric fracture patterns using fracture-mapping technique. Front Bioeng Biotechnol 2023; 11:1275204. [PMID: 38026860 PMCID: PMC10665526 DOI: 10.3389/fbioe.2023.1275204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 10/19/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction: The purpose of this study was to analyze the fracture patterns of different posterior-medial wall types of intertrochanteric fractures by 3-D fracture-mapping technique and to further assess their clinical utility. Methods: In a retrospective analysis of interochanteric fractures treated in a large trauma center, fractures were classified into predesigned groups based on 3D-CT imaging techniques, and a 3-D template of the intertrochanteric region was graphically superimposed on the fracture line. Fracture characteristics were then summarized based on fracture-mapping. Finally, radiographic parameters, function, and range of motion were recorded in different fracture classification states. Results: A total of 348 intertrochanteric fractures were included. There were 111 patients (31.9%) in the posterolateral + posteromedial + medial group, with the most severe fracture displacement (typically characterized by fragmentation of the posteromedial wall into three isolated fragments). There were 102 cases (29.3%) in the posterolateral + posteromedial + simple medial group, and the most common fracture feature was a complete fragment posteromedially. A total of 81 cases (23.3%) were classified into the posterolateral + medial group, with the medial fracture line extending the anterior fracture line but leaving the lesser trochanter intact. In the isolated medial group of 33 cases (9.5%), the fracture type was similar to type IV, but the integrity of the greater trochanter was ensured. In the posteromedial + medial group of 12 cases (3.4%), the fracture was characterized by an interruption when the fracture line of the anterolateral wall extended to the posteromedial wall, often resulting in a complete isolated fragment posteromedially and medially. There were nine patients (2.6%) in the isolated posterolateral group. In addition, we found significantly different radiographic scores and range of motion scores between groups. Discussion: This morphometric study helps us to further characterize posterior-medial fracture patterns of intertrochanteric fractures, which may be closely related to different clinical outcomes. Further studies are needed to verify the reliability of this classification scheme in clinical application.
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Affiliation(s)
- Hanru Ren
- Department of Orthopedics, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Shanghai, China
| | - Xu Zhang
- Department of Orthopedics, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Shanghai, China
| | - Yakun Liang
- Shanghai Institute of Precision Medicine, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chengqing Yi
- Department of Orthopedics, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Shanghai, China
- Research Institute of Digital and Intelligent Orthopedics, Fudan University Pudong Medical Center, Shanghai, China
| | - Dejian Li
- Department of Orthopedics, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Shanghai, China
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Yurek JW, Doerr NA, Tang A, Kohring AS, Liporace FA, Yoon RS. Assessing the Necessity of Extra Reduction Aides in Intramedullary Nailing of Intertrochanteric Hip Fractures. Hip Pelvis 2023; 35:183-192. [PMID: 37727297 PMCID: PMC10505845 DOI: 10.5371/hp.2023.35.3.183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 07/21/2023] [Accepted: 07/21/2023] [Indexed: 09/21/2023] Open
Abstract
Purpose This study aims to determine which intertrochanteric (IT) hip fracture and patient characteristics predict the necessity for adjunct reduction aides prior to prep and drape aiming for a more efficient surgery. Materials and Methods Institutional fracture registries from two academic medical centers from 2017-2022 were analyzed. Data on patient demographics, comorbidities, fracture patterns identified on radiographs including displacement of the lesser trochanter (LT), thin lateral wall (LW), reverse obliquity (RO), subtrochanteric extension (STE), and number of fracture parts were collected, and the need for additional aides following traction on fracture table were collected. Fractures were classified using the AO/OTA classification. Regression analyses identified significant risk factors for needing extra reduction aides. Results Of the 166 patients included, the average age was 80.84±12.7 years and BMI was 24.37±5.3 kg/m2. Univariate regression revealed increased irreducibility risk associated with RO (odds ratio [OR] 27.917, P≤0.001), LW (OR 24.882, P<0.001), and STE (OR 5.255, P=0.005). Multivariate analysis significantly correlated RO (OR 120.74, P<0.001) and thin LW (OR 131.14, P<0.001) with increased risk. However, STE (P=0.36) and LT displacement (P=0.77) weren't significant. Fracture types 2.2, 3.2, and 3.3 displayed elevated risk (P<0.001), while no other factors increased risk. Conclusion Elderly patients with IT fractures with RO and/or thin LW are at higher risk of irreducibility, necessitating adjunct reduction aides. Other parameters showed no significant association, suggesting most fracture patterns can be achieved with traction manipulation alone.
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Affiliation(s)
- John W. Yurek
- Division of Orthopaedic Trauma and Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center – RWJBarnabas Health, Jersey City, NJ, USA
| | - Nikki A. Doerr
- Division of Orthopaedic Trauma and Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center – RWJBarnabas Health, Jersey City, NJ, USA
| | - Alex Tang
- Division of Orthopaedic Trauma and Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center – RWJBarnabas Health, Jersey City, NJ, USA
| | - Adam S. Kohring
- Division of Orthopaedic Trauma and Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center – RWJBarnabas Health, Jersey City, NJ, USA
| | - Frank A. Liporace
- Division of Orthopaedic Trauma and Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center – RWJBarnabas Health, Jersey City, NJ, USA
| | - Richard S. Yoon
- Division of Orthopaedic Trauma and Adult Reconstruction, Department of Orthopaedic Surgery, Cooperman Barnabas Medical Center/Jersey City Medical Center – RWJBarnabas Health, Jersey City, NJ, USA
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Somasundaram V, Owen AR, Hidden KA, Barlow JD, Cross WW, Sems SA, Yuan BJ. Cephalomedullary Nailing of Unstable Geriatric Intertrochanteric Fractures on a Traction Table Combined With Percutaneous Reduction Techniques Is Safe and Results in a Low Rate of Cutout. J Orthop Trauma 2023; 37:323-329. [PMID: 36750432 DOI: 10.1097/bot.0000000000002577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/20/2023] [Indexed: 02/09/2023]
Abstract
OBJECTIVES To describe a reproducible technique for reduction assessment and percutaneous reduction of unstable intertrochanteric fractures treated with a cephalomedullary nail on a traction table. DESIGN Retrospective cohort study. SETTING Level-1 trauma center. PATIENTS Two-hundred 20 consecutive patients with intertrochanteric fractures. INTERVENTION Initial closed reduction performed on a traction table. Accessory incisions were used to facilitate a reduction in 77 patients (35%). All fractures were stabilized with a cephalomedullary nail. MAIN OUTCOME MEASUREMENTS Radiographic outcome including union, cutout, and fracture collapse (FC). Surgical outcomes including infection and hematoma were also reported. RESULTS Mechanical complications (nonunion, cutout, and varus collapse) occurred in 8.8% of patients at 1 year. Eleven of 13 patients who developed these complications had either suboptimal implant placement (tip-to-apex distance >25 mm) or a varus reduction. There was no difference in the incidence of reoperation, nonunion, lag screw cutout, or posttraumatic arthritis based on the use of an accessory incision for fracture reduction. There was a significant increase in FC in patients who received an accessory incision (6.8 mm vs. 5.4 mm, P = 0.04). One patient (1%) developed a hematoma in the accessory incision cohort, and 1 patient (0.7%) who did not have an accessory incision developed a postoperative infection. CONCLUSIONS The current study suggests utilization of accessory incisions assist in reduction is safe and is associated with a low rate of complications. The surgeon should prioritize fracture reduction and optimal implant placement and not hesitate to use an accessory incision to assist with fracture reduction. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | - Aaron R Owen
- Department of Orthopedic Surgery, Mayo Clinic, Rochester
| | | | | | | | - Stephen A Sems
- Department of Orthopedic Surgery, Mayo Clinic, Rochester
| | - Brandon J Yuan
- Department of Orthopedic Surgery, Mayo Clinic, Rochester
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Wu Z, Du B, Wang Q, Jiang T, Si Y, Zhang P, Wang Y. Minimally invasive clamp-assisted reduction and long InterTAN nail fixation for Seinsheimer type V subtrochanteric fractures: a case series describing the technique and results. BMC Musculoskelet Disord 2023; 24:256. [PMID: 37013548 PMCID: PMC10069127 DOI: 10.1186/s12891-023-06363-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 03/23/2023] [Indexed: 04/05/2023] Open
Abstract
BACKGROUND Surgical treatment of Seinsheimer type V subtrochanteric fractures is extremely challenging due to the difficulty of obtaining and maintaining anatomic reduction and effective fixation. The purpose of this study was to describe a surgical technique for minimally invasive clamp-assisted reduction and long InterTAN nail fixation to manage Seinsheimer type V subtrochanteric fractures and report the clinical and radiological results. METHODS A retrospective study was conducted on patients with Seinsheimer type V subtrochanteric fractures between March 2015 and June 2021. A total of 30 patients treated via minimally invasive clamp-assisted reduction, long InterTAN nail fixation and selective augmentation with a cerclage cable were included. The following data were collected and evaluated: patient demographics, operative time, blood loss, reduction quality, tip apex distance (TAD), time to bone union, Harris hip score (HHS), visual analog score (VAS), and complications. RESULTS The mean age of the 30 patients was 64.8 years (range: 36-90 years). The mean operative time was 102.2 min (range: 70-150 min). The mean loss of blood was 318.3 ml (range: 150-600 ml). The reduction quality involved 27 cases of anatomic reduction and 3 cases of satisfactory reduction. The mean TAD was 16.3 mm (range: 8-24 mm). The mean follow-up time was 18.9 months (range: 12-48 months). The mean fracture healing time was 4.5 months (range: 3-8 months). The mean Harris score was 88.2 (range: 71-100), and the VAS score was 0.7 (range: 0-3). Delayed union of the subtrochanteric fracture site occurred in two patients. The limb length discrepancy, which was determined in 3 patients, was < 10 mm. There were no significant complications. CONCLUSION Our results indicate that minimally invasive clamp-assisted reduction with long InterTAN nail fixation is encouraging for Seinsheimer Type V subtrochanteric fractures, resulting in excellent reduction and fixation. Additionally, this reduction technique is simple, reliable, and effective in reducing and maintaining subtrochanteric fractures, particularly when intertrochanteric fractures are irreducible.
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Affiliation(s)
- Zhen Wu
- Department of Orthopedic Surgery, the Affiliated Yixing Hospital of Jiangsu University, No. 75 Tongzhenguan Road, Yixing, 214200, Jiangsu, P.R. China
| | - Bin Du
- Department of Orthopedic Surgery, the Affiliated Yixing Hospital of Jiangsu University, No. 75 Tongzhenguan Road, Yixing, 214200, Jiangsu, P.R. China
| | - Qiang Wang
- Department of Orthopedic Surgery, the Affiliated Yixing Hospital of Jiangsu University, No. 75 Tongzhenguan Road, Yixing, 214200, Jiangsu, P.R. China
| | - Tao Jiang
- Department of Orthopedic Surgery, the Affiliated Yixing Hospital of Jiangsu University, No. 75 Tongzhenguan Road, Yixing, 214200, Jiangsu, P.R. China
| | - Yincong Si
- Department of Orthopedic Surgery, the Affiliated Yixing Hospital of Jiangsu University, No. 75 Tongzhenguan Road, Yixing, 214200, Jiangsu, P.R. China
| | - PanJun Zhang
- Department of Orthopedic Surgery, the Affiliated Yixing Hospital of Jiangsu University, No. 75 Tongzhenguan Road, Yixing, 214200, Jiangsu, P.R. China
| | - Yong Wang
- Department of Orthopedic Surgery, the Affiliated Yixing Hospital of Jiangsu University, No. 75 Tongzhenguan Road, Yixing, 214200, Jiangsu, P.R. China.
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Qiu J, Jiang Z, Han L, Li X, Zhang R, Wu B, Zhu F, Zhao Y. Treatment of irreducible intertrochanteric femoral fracture with a minimally invasive clamp reduction technique via the anterior approach. J Orthop Surg Res 2023; 18:167. [PMID: 36871013 PMCID: PMC9985279 DOI: 10.1186/s13018-023-03641-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 02/23/2023] [Indexed: 03/06/2023] Open
Abstract
OBJECTIVE To investigate the efficacy of the minimally invasive clamp reduction technique via the anterior approach in the treatment of irreducible intertrochanteric femoral fractures. METHODS From January 2015 to January 2021, 115 patients (48 males and 67 females) with irreducible intertrochanteric femoral fractures were treated. The average age of the patients was 78.7 (45-100 years old). The types of injuries were falls (91 cases), traffic accidents (12 cases), smashing (6 cases), and high falling (6 cases). The duration between injury and surgery ranged from 1 to 14 days, with an average of 3.9 days. The distribution of AO classification was as follows: 31-A1 in 15 cases, type 31-A2 in 67 cases and 31-A3 in 33 cases. RESULTS All patients achieved good reduction, with fracture reduction times ranging from 10 to 32 min (mean of 18 min), and were followed up for 12-27 months after surgery (mean of 17.9 months). Two patients with pronation displacement of the proximal fracture segment died of infection or hypostatic pneumonia after internal fixation failure; one patient with failed internal fixation switched to joint replacement. After internal fixation, the lateral wall of six reversed intertrochanteric femoral fractures showed repronation and abduction displacement, but all fractures achieved bony healing. The rest of the patients did not lose fracture reduction, and all fractures achieved bony healing with a healing time ranging from 3 to 9 months (mean of 5.7 months). While two patients died and one patient exhibited failed internal fixation and thus switched to joint replacement, 91 of the remaining 112 patients had an excellent Harris score of the hip joint function at the final follow-up, while 21 patients had a good Harris score. CONCLUSION The minimally invasive clamp reduction technique via the anterior approach for the treatment of irreducible intertrochanteric femoral fractures is simple, effective and minimally invasive. In the case of irreducible intertrochanteric femoral fractures associated with lateral wall displacement, the lateral wall needs to be strengthened after clamp reduction and intramedullary nail fixation to avoid loss of reduction and failure of internal fixation.
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Affiliation(s)
- Jinya Qiu
- Department of Clinical Medicine, Jining Medical University, 133 Hehua Road, Taibai Lake New District, Jining, 272067, Shandong, People's Republic of China
| | - Zhen Jiang
- Department of Traumatic Orthopedics, Affiliated Hospital of Jining Medical University, 129 Hehua Road, Taibai Lake New District, Jining, 272007, Shandong, People's Republic of China
| | - Liang Han
- Department of Traumatic Orthopedics, Affiliated Hospital of Jining Medical University, 129 Hehua Road, Taibai Lake New District, Jining, 272007, Shandong, People's Republic of China
| | - Xingwei Li
- Department of Orthopedics, Wenshang People's Hospital, 1, Dehui Road, Wenshang County, 272501, Shandong, People's Republic of China
| | - Rui Zhang
- Department of Traumatic Orthopedics, Affiliated Hospital of Jining Medical University, 129 Hehua Road, Taibai Lake New District, Jining, 272007, Shandong, People's Republic of China
| | - Bin Wu
- Department of Traumatic Orthopedics, Affiliated Hospital of Jining Medical University, 129 Hehua Road, Taibai Lake New District, Jining, 272007, Shandong, People's Republic of China
| | - Fenghua Zhu
- Department of Traumatic Orthopedics, Affiliated Hospital of Jining Medical University, 129 Hehua Road, Taibai Lake New District, Jining, 272007, Shandong, People's Republic of China.
| | - Yifeng Zhao
- Department of Traumatic Orthopedics, Affiliated Hospital of Jining Medical University, 129 Hehua Road, Taibai Lake New District, Jining, 272007, Shandong, People's Republic of China.
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11
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Hao Y, Zhang Z, Zhou F, Ji H, Tian Y, Guo Y, Lv Y, Yang Z, Hou G. Trochanteric and subtrochanteric fractures irreducible by closed reduction: a retrospective study. J Orthop Surg Res 2023; 18:141. [PMID: 36843011 PMCID: PMC9969640 DOI: 10.1186/s13018-023-03635-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Accepted: 02/22/2023] [Indexed: 02/28/2023] Open
Abstract
AIM To explore the preoperative radiographic features and reduction methods of irreducible trochanteric and subtrochanteric fractures of the femur and to compare the perioperative characteristics and prognoses of irreducible and reducible fractures. METHODS The data of 1235 patients with femoral trochanteric fractures surgically treated in our hospital between January 2010 and January 2021 were retrospectively analyzed. According to the inclusion criteria and exclusion criteria, 1163 cases of femoral trochanteric and subtrochanteric fractures were included in this study. Fractures in which good or acceptable reduction could not be reached by closed manipulation were defined as irreducible fractures. The preoperative radiographic features, fracture displacement patterns after closed manipulation and intraoperative reduction methods used to treat irreducible fractures were analyzed, and the perioperative characteristics and prognoses of irreducible fractures and reducible fractures were compared. RESULTS There were 224 patients in the irreducible group and 939 patients in the reducible group. According to the radiographic features of fractures, irreducible fractures could be divided into four types: those with interlocking of the fracture, sagging of the femoral shaft, splitting of the lateral wall or medial wall, and comminution of the subtrochanteric area. Various kinds of reduction techniques were needed for different types. CONCLUSIONS The incidence of irreducible trochanteric fractures was 15.4%, while the incidence of irreducible subtrochanteric fractures was 84.6%. According to the radiographic features of fractures, they can be divided into four types. It is important to identify irreducible fractures preoperatively and make comprehensive plans to the greatest extent possible to shorten the operation time, reduce intraoperative blood loss, and reduce the incidence of complications.
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Affiliation(s)
- Youliang Hao
- grid.411642.40000 0004 0605 3760Department of Orthopaedics, Peking University Third Hospital, Beijing, 100191 China ,Engineering Research Center of Bone and Joint Precision Medicine, Beijing, 100191 China
| | - Zhishan Zhang
- grid.411642.40000 0004 0605 3760Department of Orthopaedics, Peking University Third Hospital, Beijing, 100191 China ,Engineering Research Center of Bone and Joint Precision Medicine, Beijing, 100191 China
| | - Fang Zhou
- Department of Orthopaedics, Peking University Third Hospital, Beijing, 100191, China. .,Engineering Research Center of Bone and Joint Precision Medicine, Beijing, 100191, China.
| | - Hongquan Ji
- grid.411642.40000 0004 0605 3760Department of Orthopaedics, Peking University Third Hospital, Beijing, 100191 China ,Engineering Research Center of Bone and Joint Precision Medicine, Beijing, 100191 China
| | - Yun Tian
- grid.411642.40000 0004 0605 3760Department of Orthopaedics, Peking University Third Hospital, Beijing, 100191 China ,Engineering Research Center of Bone and Joint Precision Medicine, Beijing, 100191 China
| | - Yan Guo
- grid.411642.40000 0004 0605 3760Department of Orthopaedics, Peking University Third Hospital, Beijing, 100191 China ,Engineering Research Center of Bone and Joint Precision Medicine, Beijing, 100191 China
| | - Yang Lv
- grid.411642.40000 0004 0605 3760Department of Orthopaedics, Peking University Third Hospital, Beijing, 100191 China ,Engineering Research Center of Bone and Joint Precision Medicine, Beijing, 100191 China
| | - Zhongwei Yang
- grid.411642.40000 0004 0605 3760Department of Orthopaedics, Peking University Third Hospital, Beijing, 100191 China ,Engineering Research Center of Bone and Joint Precision Medicine, Beijing, 100191 China
| | - Guojin Hou
- grid.411642.40000 0004 0605 3760Department of Orthopaedics, Peking University Third Hospital, Beijing, 100191 China ,Engineering Research Center of Bone and Joint Precision Medicine, Beijing, 100191 China
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12
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Hu SJ, Chang SM, Du SC, Zhang LZ, Xiong WF. Two-Part Intertrochanteric Femur Fractures with Bisection of the Lesser Trochanter: An Irreducible Fracture Pattern. Geriatr Orthop Surg Rehabil 2023; 14:21514593231153827. [PMID: 36712599 PMCID: PMC9880592 DOI: 10.1177/21514593231153827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 01/10/2023] [Accepted: 01/11/2023] [Indexed: 01/24/2023] Open
Abstract
Objective To introduce the clinical features of and surgical techniques for a rare type of irreducible pertrochanteric femur fracture pattern with bisection of the lesser trochanter. Methods From January 2017 to December 2019, 357 patients with per/intertrochanteric femur fractures underwent surgery by closed reduction and internal fixation, of whom 12 patients were identified with rare preoperative imaging features, the lesser trochanter was almost equally bisected. The main fracture pathoanatomy of these cases included: The anterior fracture line passed along the intertrochanteric line to the medial lesser trochanter and bisected it into 2 equal parts from mid-level of the lesser trochanteric protrusion. The proximal part of the lesser trochanter connected to the head-neck fragment and attached by the psoas major tendon, while the distal part of the lesser trochanter connected to the femoral shaft and attached by the tendon of the iliac muscle. These fractures were irreducible by a closed maneuver and were reduced with limited assistance by some devices, and short intramedullary nails were used for fixation of these fractures. Results All patients were followed up for an average of 14.2 ± 2.1 months. Clinical fracture union occurred at an average of 10.8 ± 1.5 weeks, while radiographic union occurred at an average of 12.7 ± 1.2 weeks. No cut out of the helical blade was visible on radiographs. The average Parker-Palmer score was 6.9 ± 1.3 (range, 5-9) at the last follow up, including 8 cases rated as excellent, 2 as good and 2 as fair. Conclusion Two-part pertrochanteric femur fractures with bisection of the lesser trochanter have an irreducible fracture pattern with cortical locking and soft tissue incarceration. Soft tissue release and short cephalomedullary nail fixation for this fracture pattern provide stable fixation and allow early exercise. This treatment appears to have excellent outcomes in the short and medium terms.
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Affiliation(s)
- Sun-jun Hu
- Department of Orthopaedic Surgery,
Yangpu Hospital, Tongji University School of
Medicine, Shanghai, Republic of China
| | - Shi-Min Chang
- Department of Orthopaedic Surgery,
Yangpu Hospital, Tongji University School of
Medicine, Shanghai, Republic of China,Shi-Min Chang, Department of Orthopaedic
Surgery, Yangpu Hospital, Tongji University School of Medicine, 450 Tengyue
Road, Shanghai 200090, Republic of China. Emails:
,
| | - Shou-chao Du
- Department of Orthopaedic Surgery,
Yangpu Hospital, Tongji University School of
Medicine, Shanghai, Republic of China
| | - Li-zhi Zhang
- Department of Orthopaedic Surgery,
Yangpu Hospital, Tongji University School of
Medicine, Shanghai, Republic of China
| | - Wen-feng Xiong
- Department of Orthopaedic Surgery,
Yangpu Hospital, Tongji University School of
Medicine, Shanghai, Republic of China
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13
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赵 益, 朱 凤, 常 庆, 刘 继, 张 瑞, 宋 富, 褚 风, 宰 庆, 郭 伟, 杨 现, 石 强, 张 锋, 王 海, 姜 振. [Research on the classification criteria of femoral intertrochanteric fractures based on irreducibility or not]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2021; 35:1086-1092. [PMID: 34523271 PMCID: PMC8444130 DOI: 10.7507/1002-1892.202103233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 07/23/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To formulate the classification criteria of femoral intertrochanteric fractures based on irreducibility or not in order to predict the difficulty of fracture recovery. METHODS A clinical data of 244 patients with closed femoral intertrochanteric fractures admitted between January 2017 and March 2020 was retrospectively analyzed. There were 116 males and 128 females with an average age of 77.9 years (range, 45-100 years). The cause of injury included falling in 190 cases, traffic accident in 36 cases, smashing in 13 cases, and falling from height in 5 cases. The time from injury to operation was 1-14 days (mean, 3.6 days). According toAO/Orthopaedic Trauma Association (AO/OTA) classification, the fractures were classified as type 31-A1 in 38 cases, type 31-A2 in 160 cases, and type 31-A3 in 46 cases. According to whether the recovery difficulty occurred after intraoperative closed traction reset, the patients were divided into reducible-group and irreducible-group; combined with the literature and preoperative imaging data of two groups, the classification criteria of femoral intertrochanteric fractures was formulated based on the irreducibility or not. The 244 fractures were classified by the doctors who did not attend the operation according to the classification criteria, predicted the difficulty of fracture reduction, and compared with the actual intraoperative reduction situation. RESULTS The 244 patients were divided into reducible-group ( n=164, 67.21%) and irreducible-group ( n=80, 32.79%) according to the intraoperative difficulty of reduction. Comparing the imaging data and characteristics of the two groups, and formulating the classification criteria of femoral intertrochanteric fractures based on irreducibility or not, the fractures were mainly divided into two categories of irreducibility and reducibility. The fractures of irreducibility category was divided into typesⅠ-Ⅴ, among which type Ⅲ was divided into subtypes 1-4; the fractures of reducibility category was divided into typesⅠand Ⅱ. Compared with the actual intraoperative evaluation results, the total accuracy rate of the doctors who did not attend the operation was 81.15% (198/244) based on the classification criteria of femoral intertrochanteric fractures. The accuracy rate of irreducibility category was 65.74% (71/108), and the reducibility category was 93.38% (127/136). All patients were followed up 13-25 months, with an average of 17.6 months. All fractures healed except 2 cases died of infection. CONCLUSION The classification criteria of femoral intertrochanteric fractures based on irreducibility or not can accurately predict the reducible cases preoperatively, and most of the irreducible cases can be correctly predicted in a wider way. But the classification criteria still need to be further improved and supplemented.
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Affiliation(s)
- 益峰 赵
- 济宁医学院附属医院创伤骨科（山东济宁 272029）Department of Traumatic Orthopedics, Affiliated Hospital of Jining Medical University, Jining Shandong, 272029, P.R.China
| | - 凤华 朱
- 济宁医学院附属医院创伤骨科（山东济宁 272029）Department of Traumatic Orthopedics, Affiliated Hospital of Jining Medical University, Jining Shandong, 272029, P.R.China
| | - 庆华 常
- 济宁医学院附属医院创伤骨科（山东济宁 272029）Department of Traumatic Orthopedics, Affiliated Hospital of Jining Medical University, Jining Shandong, 272029, P.R.China
| | - 继恒 刘
- 济宁医学院附属医院创伤骨科（山东济宁 272029）Department of Traumatic Orthopedics, Affiliated Hospital of Jining Medical University, Jining Shandong, 272029, P.R.China
| | - 瑞 张
- 济宁医学院附属医院创伤骨科（山东济宁 272029）Department of Traumatic Orthopedics, Affiliated Hospital of Jining Medical University, Jining Shandong, 272029, P.R.China
| | - 富强 宋
- 济宁医学院附属医院创伤骨科（山东济宁 272029）Department of Traumatic Orthopedics, Affiliated Hospital of Jining Medical University, Jining Shandong, 272029, P.R.China
| | - 风龙 褚
- 济宁医学院附属医院创伤骨科（山东济宁 272029）Department of Traumatic Orthopedics, Affiliated Hospital of Jining Medical University, Jining Shandong, 272029, P.R.China
| | - 庆书 宰
- 济宁医学院附属医院创伤骨科（山东济宁 272029）Department of Traumatic Orthopedics, Affiliated Hospital of Jining Medical University, Jining Shandong, 272029, P.R.China
| | - 伟 郭
- 济宁医学院附属医院创伤骨科（山东济宁 272029）Department of Traumatic Orthopedics, Affiliated Hospital of Jining Medical University, Jining Shandong, 272029, P.R.China
| | - 现伟 杨
- 济宁医学院附属医院创伤骨科（山东济宁 272029）Department of Traumatic Orthopedics, Affiliated Hospital of Jining Medical University, Jining Shandong, 272029, P.R.China
| | - 强 石
- 济宁医学院附属医院创伤骨科（山东济宁 272029）Department of Traumatic Orthopedics, Affiliated Hospital of Jining Medical University, Jining Shandong, 272029, P.R.China
| | - 锋 张
- 济宁医学院附属医院创伤骨科（山东济宁 272029）Department of Traumatic Orthopedics, Affiliated Hospital of Jining Medical University, Jining Shandong, 272029, P.R.China
| | - 海滨 王
- 济宁医学院附属医院创伤骨科（山东济宁 272029）Department of Traumatic Orthopedics, Affiliated Hospital of Jining Medical University, Jining Shandong, 272029, P.R.China
| | - 振 姜
- 济宁医学院附属医院创伤骨科（山东济宁 272029）Department of Traumatic Orthopedics, Affiliated Hospital of Jining Medical University, Jining Shandong, 272029, P.R.China
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14
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He B, Zhao J, Liu R, Li Q. Application of the "Hand as Foot " teaching method to medial cortical support for intertrochanteric fractures of the femur. Asian J Surg 2021; 44:1312-1313. [PMID: 34330593 DOI: 10.1016/j.asjsur.2021.07.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 07/02/2021] [Indexed: 10/20/2022] Open
Affiliation(s)
- Bin He
- Inner Mongolia Medical University, Department of Orthopedics, Affiliated Hospital of Inner Mongolia Medical University, Hohhot North Street, Inner Mongolia, 010050, China
| | - Jianmin Zhao
- Inner Mongolia Medical University, Department of Orthopedics, Affiliated Hospital of Inner Mongolia Medical University, Hohhot North Street, Inner Mongolia, 010050, China.
| | - Rui Liu
- Inner Mongolia Medical University, Department of Orthopedics, Affiliated Hospital of Inner Mongolia Medical University, Hohhot North Street, Inner Mongolia, 010050, China
| | - Qiang Li
- Inner Mongolia Medical University, Department of Orthopedics, Affiliated Hospital of Inner Mongolia Medical University, Hohhot North Street, Inner Mongolia, 010050, China
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15
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赵 益, 姜 振, 李 涛, 徐 重, 韩 亮, 褚 风, 吴 彬, 高 明, 王 海. [Treatment of irreducible intertrochanteric femoral fracture with minimally invasive clamp reduction technique via anterior approach]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2021; 35:544-549. [PMID: 33998205 PMCID: PMC8175198 DOI: 10.7507/1002-1892.202012030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 02/18/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To explore the effectiveness of minimally invasive clamp reduction technique via anterior approach in treatment of irreducible intertrochanteric femoral fractures. METHODS Between January 2015 and January 2019, 59 patients with irreducible intertrochanteric femoral fractures were treated with minimally invasive clamp reduction technique via anterior approach. There were 29 males and 30 females with an average age of 77.9 years (range, 45-100 years). The causes of injury included falling in 46 cases, traffic accident in 6 cases, smashing in 2 cases, and falling from height in 5 cases. The time from injury to operation was 1-14 days (mean, 3.8 days). The fractures were classified as AO type 31-A1 in 12 cases, type 31-A2 in 25 cases, type 31-A3 in 22 cases. RESULTS All fractures were reduced well and the fracture reduction took 10 to 30 minutes, with an average of 19 minutes. All patients were followed up 13-25 months, with an average of 17.6 months. Among them, 2 cases of pronation displacement of proximal fracture segment died for infection or falling pneumonia after internal fixation failed. Six patients with reversed intertrochanteric femoral fractures experienced re-pronation and abduction displacement of the lateral wall after internal fixation, but the fractures all healed. The rest of the patients had no fracture reduction loss, and the fractures healed with an average healing time of 5.9 months (range, 3-9 months). Except for 2 patients who died, the Harris score of hip joint function of the remaining 57 patients was excellent in 49 cases and good in 8 cases at last follow-up. CONCLUSION The minimally invasive clamp reduction technique via anterior approach for irreducible intertrochanteric femoral fractures is simple and effective. For irreducible intertrochanteric femoral fractures related to lateral wall displacement, after clamp reduction and intramedullary nail fixation, the lateral wall should be reinforced in order to avoid reduction loss and internal fixation failure.
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Affiliation(s)
- 益峰 赵
- 济宁医学院附属医院创伤骨科（山东济宁 272029）Department of Traumatic Orthopedics, Affiliated Hospital of Jining Medical University, Jining Shandong, 272029, P.R.China
| | - 振 姜
- 济宁医学院附属医院创伤骨科（山东济宁 272029）Department of Traumatic Orthopedics, Affiliated Hospital of Jining Medical University, Jining Shandong, 272029, P.R.China
| | - 涛 李
- 济宁医学院附属医院创伤骨科（山东济宁 272029）Department of Traumatic Orthopedics, Affiliated Hospital of Jining Medical University, Jining Shandong, 272029, P.R.China
| | - 重阳 徐
- 济宁医学院附属医院创伤骨科（山东济宁 272029）Department of Traumatic Orthopedics, Affiliated Hospital of Jining Medical University, Jining Shandong, 272029, P.R.China
| | - 亮 韩
- 济宁医学院附属医院创伤骨科（山东济宁 272029）Department of Traumatic Orthopedics, Affiliated Hospital of Jining Medical University, Jining Shandong, 272029, P.R.China
| | - 风龙 褚
- 济宁医学院附属医院创伤骨科（山东济宁 272029）Department of Traumatic Orthopedics, Affiliated Hospital of Jining Medical University, Jining Shandong, 272029, P.R.China
| | - 彬 吴
- 济宁医学院附属医院创伤骨科（山东济宁 272029）Department of Traumatic Orthopedics, Affiliated Hospital of Jining Medical University, Jining Shandong, 272029, P.R.China
| | - 明 高
- 济宁医学院附属医院创伤骨科（山东济宁 272029）Department of Traumatic Orthopedics, Affiliated Hospital of Jining Medical University, Jining Shandong, 272029, P.R.China
| | - 海滨 王
- 济宁医学院附属医院创伤骨科（山东济宁 272029）Department of Traumatic Orthopedics, Affiliated Hospital of Jining Medical University, Jining Shandong, 272029, P.R.China
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16
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Ren H, Ao R, Wu L, Jian Z, Jiang X, Yu B. Effect of lesser trochanter posteromedial wall defect on the stability of femoral intertrochanteric fracture using 3D simulation. J Orthop Surg Res 2020; 15:242. [PMID: 32620138 PMCID: PMC7333289 DOI: 10.1186/s13018-020-01763-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 06/26/2020] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND This study investigated the effects of posteromedial fracture fragments on the postoperative stability of intertrochanteric fractures of the femur by analyzing the quantity and range of fragments in CT 3D reconstruction. MATERIALS AND METHODS Patients diagnosed with femoral lesser trochanter fractures were collected from September 2015 to February 2018. CT 3D reconstruction was applied to evaluate the quantity and extension of posteromedial fragments and the presence of isolated medial fragments. The stability of postoperative fracture was evaluated by comparing the changes of "neck-shaft angle" and "telescoping" from 1 week to 1 year after operation. RESULTS A total of 143 patients were finally confirmed, in which 63 patients contained isolated fragments on the medial side, and the average number of fragments in the posteromedial side was 1.93 ± 0.34, which accounted for an average of about 86.11% ± 8.20% in the whole posteromedial wall. When the number of posteromedial fragments was > 2 and the range of posteromedial fragments was > 75%, then the changes in the neck-shaft angle and "telescoping" showed statistical significance (12.27 ± 4.18 mm and 10.13 ± 6.17°, respectively), and when there were isolated medial isolated fragments, then the change in the neck-shaft angle was 10.66 ± 4.27°, showing statistical significance. CONCLUSIONS These findings revealed a certain correlation between the quantity and the range of posteromedial fragments and the postoperative "shortening" and "collapse" of femoral intertrochanteric fractures.
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Affiliation(s)
- Hanru Ren
- Department of Orthopaedics, Shanghai Pudong Hospital, Fudan University, Pudong Medical Center, No. 2800, Gongwei Road, Shanghai, 201399 China
| | - Rongguang Ao
- Department of Orthopaedics, Shanghai Pudong Hospital, Fudan University, Pudong Medical Center, No. 2800, Gongwei Road, Shanghai, 201399 China
| | - Lianghao Wu
- Department of Orthopaedics, Shanghai Pudong Hospital, Fudan University, Pudong Medical Center, No. 2800, Gongwei Road, Shanghai, 201399 China
| | - Zheng Jian
- Department of Orthopaedics, Shanghai Pudong Hospital, Fudan University, Pudong Medical Center, No. 2800, Gongwei Road, Shanghai, 201399 China
| | - Xinhua Jiang
- Department of Orthopaedics, Shanghai Pudong Hospital, Fudan University, Pudong Medical Center, No. 2800, Gongwei Road, Shanghai, 201399 China
| | - Baoqing Yu
- Department of Orthopaedics, Shanghai Pudong Hospital, Fudan University, Pudong Medical Center, No. 2800, Gongwei Road, Shanghai, 201399 China
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17
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Abstract
BACKGROUND Reverse intertrochanteric fractures are usually initially treated with closed reduction. However, sometimes these fractures are not amenable to closed reduction and require open reduction. To date, few studies have been conducted on predictors of and reduction techniques for irreducible reverse intertrochanteric fractures. Therefore, this study aimed to summarize the displacement patterns of irreducible reverse intertrochanteric fractures and corresponding reduction techniques, and explore predictors of irreducibility. METHODS We reviewed 1174 cases of trochanteric fractures treated in our hospital from January 2006 to October 2018, 113 of which were reverse intertrochanteric fractures. An irreducible fracture was determined according to intra-operative fluoroscopy imaging after closed manipulation. Fractures were assessed for displacement patterns, radiographic features of irreducibility, and reduction techniques. Logistic regression analysis was performed on potential predictors for irreducibility, including gender, age, body mass index, AO Foundation/Orthopaedic Trauma Association (AO/OTA) classification, and radiographic features. RESULTS Seventy-six irreducible fractures were identified, accounting for 67% of reverse intertrochanteric fractures. Six patterns of fracture displacement after closed manipulation were identified; the most common pattern was medial displacement and posterior sagging of the femoral shaft relative to the head-neck fragment. Multivariate logistic regression analysis identified three predictors of irreducibility: a medially displaced femoral shaft relative to the head-neck fragment on the anteroposterior (AP) view (odds ratio [OR], 8.00; 95% confidence interval [CI], 3.04-21.04; P < 0.001), a displaced lesser trochanter (OR, 3.61; 95% CI, 1.35-9.61; P = 0.010), and a displaced lateral femoral wall (OR, 2.92; 95% CI, 1.02-8.34; P = 0.046). CONCLUSIONS A high proportion of reverse intertrochanteric fractures are not amenable to closed reduction. Six patterns of fracture displacement after closed manipulation were identified. Different reduction techniques are required for different displacement patterns. Predictors of irreducibility include a medially displaced femoral shaft relative to the head-neck fragment on the AP view, a displaced lesser trochanter, and a displaced lateral femoral wall. These patients warrant special consideration in terms of recognition and management.
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Zhang Y, Hu J, Li X, Qin X. Reverse wedge effect following intramedullary nailing of a basicervical trochanteric fracture variant combined with a mechanically compromised greater trochanter. BMC Musculoskelet Disord 2020; 21:195. [PMID: 32222146 PMCID: PMC7102434 DOI: 10.1186/s12891-020-03212-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 03/13/2020] [Indexed: 12/04/2022] Open
Abstract
Background To introduce an unreported intraoperative complication in intramedullary nailing (IN) of an anatomically reduced trochanteric fracture variant characterized by a basicervical fracture line and coronally disrupted greater trochanter (GT). Methods A total of 414 trochanteric fractures (TF) treated with intramedullary nails from 2013 to 2017 were included in this study. After analysis of intraoperative fluoroscopy data, 33 cases, including 21 females and 12 males, with a mean age of 72.5 years (33 to 96 years) were identified for internal rotation of the cephalocervical fragment and inferior opening at the basicervical fracture line caused by nailing a satisfactorily reduced TF. The morphological features of this group of patients were analyzed on computed tomography (CT) scan. On radiograph, the magnitude of the displacement and final femoral neck-shaft angle (NSA) were measured. Results CT analysis demonstrated that the basicervical fracture line and the posterolateral fragment (PLF) detached from the GT were the two dominant features of this cohort. They were classified according to the number of main fragments: a 3-fragmentary subgroup containing three consistent fragments (cephalocervical fragment, PLF and distal femoral shaft) and a 4-fragmentary subgroup embracing one additional fragment (lesser trochanter). The four subtypes were as follows: the 3-fragmentary S indicating a small PLF (6 cases), the 3-fragmentary M presenting a moderate PLF (3 cases), the 3-fragmentary L standing for the PLF involving whole lesser trochanter (LT) (4 cases) and the 4-fragmentary GL incorporating separated PLF and LT fragments (20 cases). Geological analysis demonstrated that the majority of the basicervical fracture lines (81.8%) just crossed the center of the piriformis fossa, while the others marginally involved the medial wall of the GT. Postoperatively, the mean width of the inferior opening at the basicervical region was 9.2 ± 4.6 mm. The mean NSA was 135.2 ± 7.8 degrees. The comparison between the 3- and 4-fragmentary subgroups revealed no significant differences in magnitude of displacement and NSA. Conclusion This unreported intraoperative complication predominantly occurred in the intramedullary nailed basicervical trochanteric fracture variant combined with a PLF from the GT. The magnitude of the secondary displacement was substantial and resulted in a relative valgus reduction. This secondary displacement was caused by an impingement of the reamer with the superolateral cortex of the cephalocervical fragment and should be addressed during the operation. Level of evidence Therapy IV.
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Affiliation(s)
- Yu Zhang
- Department of Trauma, the First Affiliating Hospital of Nanjing Medical University & Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing, 210029, China
| | - Jun Hu
- Department of Trauma, the First Affiliating Hospital of Nanjing Medical University & Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing, 210029, China
| | - Xiang Li
- Department of Trauma, the First Affiliating Hospital of Nanjing Medical University & Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing, 210029, China
| | - Xiaodong Qin
- Department of Trauma, the First Affiliating Hospital of Nanjing Medical University & Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing, 210029, China.
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Agrawal A. New "epsilon" sign in "highly unstable" intertrochanteric fracture. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2019; 30:537-538. [PMID: 31650336 DOI: 10.1007/s00590-019-02583-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 10/18/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Anuj Agrawal
- Department of Orthopaedics, Max Super Speciality Hospital, Patparganj, New Delhi, India.
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Hsu CE, Huang KC, Lin TC, Tong KM, Lee MH, Chiu YC. Integrated risk scoring model for predicting dynamic hip screw treatment outcome of intertrochanteric fracture. Injury 2016; 47:2501-2506. [PMID: 27616004 DOI: 10.1016/j.injury.2016.09.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 07/23/2016] [Accepted: 09/06/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND Dynamic hip screw (DHS) is a common device for treating intertrochanteric fracture (ITF). Various risk factors have been reported to be associated with the operative treatment outcome. However, an integrated risk scoring prediction model is lacking. In this study, we aimed to develop a prediction model for treatment outcome of intertrochanteric fracture. METHODS We analyzed 442 AO/OTA 31-A1 and A2 fractures which were treated with DHS during the period January 2000 to June 2014 in a level I trauma center. Risk factors including age, gender, injured side, lag screw position, AO/OTA classification, tip-apex distance, postoperative lateral wall fracture, reduction patterns were analyzed to determine their influence on treatment outcome. Integrated risk scores of significant predictors were used to construct a prediction model. RESULTS AO/OTA 31-A2 classification, postoperative lateral wall fracture, posteriorly inserted lag screw and varus reduction pattern were significant risk predictors for DHS failure. The failure risk for low- and high-risk groups were significantly different (P<0.001) CONCLUSION: AO/OTA 31-A2 classification, postoperative lateral wall fracture, posteriorly inserted lag screw and varus reduction pattern were significant risk predictors for DHS failure. We developed a model that integrates these factors to predict the treatment outcome, which had excellent prediction accuracy and discriminatory ability. The models may provide useful information for orthopedic doctors to identify patients who need early intervention as well as ITF patients who require more frequent follow-up in the postoperative period.
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Affiliation(s)
- Cheng-En Hsu
- Department of Orthopedics, Taichung Veterans General Hospital, Taichung, Taiwan; Division of Traumatology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Kui-Chou Huang
- Department of Orthopedics, Asia University Hospital, Taichung, Taiwan; College of Medicine and Health Science, Department of Occupation Therapy, Asia University, Taichung, Taiwan
| | - Tzu-Chieh Lin
- Department of Orthopedics, Taichung Veterans General Hospital, Taichung, Taiwan; Division of Traumatology, Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan; Department of Public Health, College of Public Health, China Medical University, Taichung, Taiwan
| | - Kwok-Man Tong
- Department of Orthopedics, Taichung Veterans General Hospital, Taichung, Taiwan; Chaoyang University of Technology, Taichung, Taiwan
| | - Mei-Hsuan Lee
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan.
| | - Yung-Cheng Chiu
- School of Medicine,China Medical University, Taichung, Taiwan; Department of Orthopedics, China Medical University Hospital, Taichung, Taiwan.
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Can a trochanter stabilising plate prevent lateral wall fractures in AO/OTA 31-A2 pertrochanteric fractures with critical thin femoral lateral walls? Injury 2015; 46:2085-6. [PMID: 26250712 DOI: 10.1016/j.injury.2015.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 07/19/2015] [Indexed: 02/02/2023]
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