The vast majority of intertrochanteric fractures treated with cephalomedullary nails (CMN) will heal. Occasionally even though bony union occurs excessive lag screw sliding can cause persistent pain and soft tissue irritation and return to surgery for hardware removal. The purpose of this study was to evaluate if fracture stability, lag screw tip-apex distance (TAD), and quality of reduction have any impact excessive lag screw sliding and potential cutout. As part of our level one trauma center's institutional hip fracture registry, a retrospective analysis identified 199 intertrochanteric fractures fixed with CMN between 2009 and 2015 with follow up to union or a minimum of three months. The mean follow-up was 22 months (3 to 94 months). Mean patient age was 75 years (50 to 97 years) and 72% were women. Postoperative radiographs were used to measure the TAD, quality of reduction, neck-shaft angle (NSA), and lateral lag screw prominence. Follow-up radiographs were reviewed to assess fracture union, translation, and progression of lateral lag screw prominence. Complications and reoperations were recorded.Introduction
Methods
In a meta-analysis of fourteen trials (N=1901 patients) in patients with displaced hip fractures, we identified significant reductions in the risk of revision surgery with internal fixation compared to arthroplasty. A trend towards increased mortality with arthroplasty was identified. The purpose of this study was to determine the effect of arthroplasty (hemi-arthroplasty, bipolar arthroplasty and total hip arthroplasty) in comparison to internal fixation for displaced femoral neck fractures on rates of mortality and revision surgery Arthroplasty for displaced femoral neck fractures, in comparison to internal fixation, significantly reduces the risk of revision surgery at the cost of greater infection rates, blood loss and operative time, and a possible increase in early mortality. Over 220,000 fractures of hip occur per year in North America representing an annual seven billion dollar cost to the health care system. Current evidence suggests internal fixation may reduce mortality risk at the consequence of increased revision rates. A large trial is needed to resolve this issue. We searched computerized databases (MEDLINE, COCHRANE and SCISEARCH) for published clinical studies from 1969–2002 and identified additional studies through hand searches of major orthopaedic journals, bibliographies of major orthopaedic texts and personal files. We found a non-significant trend toward an increase in the relative risk of dying with arthroplasty when compared to internal fixation (relative risk=1.27, 95% confidence interval, 0.84–1.92, p = 0.25; homogeneity p= 0.45). Arthroplasty appeared to increase the risk of dying when compared to pin and plate, but not in comparison to internal fixation using screws (relative risk= 1.75 vs 0.86, respectively, p<
0.05). Fourteen trials provided data on revision surgery (n=1901 patients). The relative risk of revision surgery with arthroplasty was 0.23 (95% confidence interval, 0.13–0.42, p = 0.0003, homogeneity p = <
0.01).
The aim of our study was to assess the efficacy and complications of treatment of limb deformities using six axes deformity analysis and the Taylor TM Spatial Frame [TSF] Between January 1997 and March 2000, we treated 75 lower limbs in 66 patients with deformities. Patients were divided into four groups. The groups were Blount’s disease, congenital deformities, traumatic deformities, and a miscellaneous group. The data was prospectively collected. This was a consecutive series of the first 66 patients treated at our institution with the TSF. Deformity correction using the TSF is done with the aid of computer software. The mean age of the 66 patients was 18.7 years (range 0.5 to 72 years). The average frame time was 18.6 weeks (range 9 to 49 weeks). There was shortening present in 31 limbs with a mean of 18.6 mm (range 5 to 50 mm). Deformity correction with distraction osteogenesis was begun 7 days after the osteotomy. The mean length of time until correction was 6.7 weeks (range 3 to 13 weeks). There were a total of 10 complications (13.3%) in the series. 27 tibiae in 23 patients underwent correction with the TSF for Blount’s disease. There were 11 infantile and 16 adolescent forms. Correction of congenital deformity was performed in 20 tibiae and 8 femurs in 18 patients. There were 9 males and 9 females. There were 13 male and 8 female patients with traumatic lower limb injuries. There were 11 malunions and 10 nonunions (including 2 infected nonunions) that were corrected with the TSF. The TaylorTM Spatial Frame is an effective technique in treating deformity. Angulation, translation, shortening and rotation can be corrected simultaneously. Based on our results, we conclude that the TSF allows safe, gradual correction that is accurate and well tolerated.
To determine the effectiveness of six-axis analysis deformity correction using the Taylor Spatial Frame for the treatment of post-traumatic tibial malunions and non-unions, the study design was a retrospectively reviewed, consecutive series. Mean duration of follow-up: 3.2 years (range 2–4.2 years). All patients had been referred to a tertiary referral centre for deformity correction. Eighteen patients were included in the study (11 mal-unions and 7 nonunions). All deformities were post-traumatic in nature. The mean number of operations prior to the application of the spatial frame was 2.6 (range 1–6 operations). All patients completed the study. Six-axis analysis deformity correction using the Taylor Spatial Frame (Smith &
Nephew, Memphis, TN) was used for correction of post-traumatic tibial malunion or nonunion. Nine patients had bone grafting at the time of frame application. One patient with a tibial plafond fracture simultaneously had deformity correction and an ankle fusion for a mobile atrophic nonunion. Two patients had infected tibial nonunions that were treated with multiple debridements, antibiotic beads, and bone grafting at the time of spatial frame application. A rotational gastrocnemius flap was used to cover a proximal third tibial defect in one patient. The average length of time the spatial frame was worn, time to healing, was 18.5 weeks (range 12–32 weeks). The main outcome measurements involved assessment of deformity correction in six axes, knee and ankle range of motion, incidence of infection, and return to preinjury activities.
We studied the biomechanical behaviour of three sliding fixation devices for trochanteric femoral fractures. These were a titanium alloy sideplate and lag screw, a titanium alloy sideplate and dome plunger with cement augmentation, and a stainless-steel sideplate and lag screw. We used 18 mildly osteoporotic cadaver femora, randomly assigned to one of the three fixation groups. Four displacement and two strain gauges were fixed to each specimen, and each femur was first tested intact (control), then as a two-part fracture and then as a four-part intertrochanteric fracture. A range of physiological loads was applied to determine load-bearing, load-sharing and head displacement. The four-part-fracture specimens were subsequently tested to failure to determine maximum fixation strengths and modes of failure. The dome-plunger group failed at a load 50% higher than that of the stainless-steel lag-screw group (p <
0.05) and at a load 20% higher than that of the titanium-alloy lag-screw group (NS). All 12 lag-screw specimens failed by cut-out through the femoral head or neck, but none of the dome-plunger group showed movement within the femoral head when tested to failure. Strain-gauge analysis showed that the dome plunger produced considerably less strain in the inferior neck and calcar region than either of the lag screws. Inferior displacement of the femoral head was greatest for the dome-plunger group, and was due to sliding of the plunger. The dome plunger with cement augmentation was able to support higher loads and did not fail by cut-out through the femoral head.(ABSTRACT TRUNCATED AT 250 WORDS)
