In a prospective study we assessed the causes of mechanical failure in a series of 230 intertrochanteric femoral fractures which had been internally fixed with either a sliding hip screw or a Kuntscher Y-nail. The overall rate of mechanical failure was 16.5%; cutting-out of the implant from the femoral head was the cause in three-quarters of the instances. Implants placed posteriorly in the femoral head cut out more often (27%) than those placed centrally (7%). The cut-out rate was also determined by the quality of the fracture reduction, but age, walking ability and bone density (assessed by the Singh grade and metacarpal indices) had no significant influence. We conclude that these fractures should be reduced as accurately as possible and it is imperative that the implant is placed centrally within the femoral head

The aim of this study was to determine whether an osteoplasty of the femoral neck performed at the same time as an intertrochanteric Imhäuser osteotomy led to an improved functional outcome or increased morbidity. A total of 20 hips in 19 patients (12 left, 8 right, 13 male, 6 female), who underwent an Imhäuser intertrochanteric osteotomy following a slipped capital femoral epiphysis were assessed over an eight-year period. A total of 13 hips in 13 patients had an osteoplasty of the femoral neck at the same time. The remaining six patients (seven hips) had intertrochanteric osteotomy alone. The mean age was 15.3 years (13 to 20) with a mean follow-up of 57.8 months (15 to 117); 19 of the slips were severe (Southwick grade III) and one was moderate (grade II), with a mean slip angle of 65.3° (50° to 80°); 17 of the slips were stable and three unstable at initial presentation. The mean Non-Arthritic Hip Scores (NAHS) in patients who underwent osteoplasty was 91.7 (76.3 to 100) and the mean NAHS in patients who did not undergo osteoplasty was 76.6 (41.3 to 100) (p = 0.056). Two patients required a subsequent arthroplasty and neither of these patients had an osteoplasty. No hips developed osteonecrosis or chondrolysis, and there was no increase in complications related to the osteoplasty. We recommend that for patients with a slipped upper femoral epiphysis undergoing an intertrochanteric osteotomy, the addition of an osteoplasty of the femoral neck should be considered.

Cite this article: Bone Joint J 2014;96-B:1119–23.

1. Fibrous union of an osteotomy occurred in only 3 per cent of osteotomies done during a four-year period.

2. Delayed union sometimes gives rise to pain on bearing weight while union is in progress, and non-union is usually associated with disabling pain.

3. The most significant factors predisposing to delayed or fibrous union are inefficient fixation and excessive displacement. A high or very oblique osteotomy may also have an adverse effect upon the rate of bony union.

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.

We report a series of 50 patients under 70 years of age who had an ununited femoral neck fracture treated by a Pauwels abduction osteotomy. At an average follow-up of 7.1 years, seven patients had required prosthetic replacement and 37 others were reviewed in detail. In these patients the Harris hip score averaged 91. Twenty-two hips showed radiographic evidence of avascular femoral head necrosis, but only three of these had been replaced. For active patients with non-union of a femoral neck fracture, Pauwels osteotomy provides a high proportion of good results even in the presence of avascular necrosis of the head, providing there has been no collapse. If osteotomy fails, prosthetic replacement is still possible.

Intertrochanteric fractures of the femur are usually classified into stable and unstable groups, partly to predict the likelihood of displacement with early weight-bearing after internal fixation. Of 82 internally fixed intertrochanteric fractures which would normally be classified as stable, 25 subsequently underwent impaction along the axis of the nail or screw; varus displacement occurred in another six. Of these 31 fractures, 10 were two-part fractures which had been anatomically reduced, and 12 were originally undisplaced. It did not seem possible to predict the subsequent instability from the pre-operative radiographs. Of the 82 fractures, 47 had been treated with a Jewett nail-plate and 35 by a Richards compression screw-plate. Two groups of stable fractures were recognised: Group 1 was undisplaced and Group 2 displaced. Axial impaction occurred in a quarter of all Group 1 fractures however treated. In Group 2 fractures it occurred in a quarter of those treated with a nail-plate, and in over a third of those treated with a sliding screw-plate. The six fractures that underwent varus displacement had all been treated with Jewett nail-plates. Penetration into the joint occurred in 10 patients, all of them in the group treated with Jewett nail-plates; four required re-operation.

The results of 757 intertorchanteric osteotomies for osteoarthritis of the hip carried out between 1958 and 1970 were reviewed. After osteotomy the joint space in two thirds of the hips was increased and a similar proportion experienced relief of pain lasting at least five years. However, the effect of the osteotomy declined after some ten years; only a quarter of the hips had a lasting "good result" as defined in this investigation. The best results were obtained in active patients under 70 years of age with unilateral hip disease in which a fair range of movement had been preserved despite some shortening and where the radiographs showed loss of joint space with a break in Shenton's line. In this study a displaced osteotomy fixed with a spline emerged as the most successful surgical technique.

1. The Moe plate has been used in 256 of 270 consecutive intertrochanteric fractures of the femur. There was an operative mortality of l8·8 per cent and an overall mortality of 20·7 per cent in a group averaging 75·2 years of age.

2. The method proved satisfactory, giving secure fixation and also approximation of the fragments by the lag action of the three large screws driven into the head. There was only one case of non-union.

3. In the survivors anatomical and functional results have been satisfactory in about 70 per cent, with half of these showing full functional recovery and the other half requiring only occasional use of a stick or crutch.

4. There are a few intertrochanteric fractures of the femur too comminuted for any form of internal fixation. Traction should be used in this group.

5. A varus deformity developed in about one half of the cases. This is consistent with a good functional result.

6. The main difficulty in these aged people has been survival. The problems have been discussed with suggestions that may perhaps reduce in part a mortality that seems inherent in this injury and at this age.

1. One hundred and eight osteotomies were reviewed with regard to union, and fourteen were found to be ununited. In only one was non-union detected clinically; the others required radiographic demonstration. Tomographs were particularly helpful in confirming non-union.

2. Nine patients with non-union had pain, equal to or worse than before operation. The pain could not be distinguished from that of osteoarthritis of the hip.

3. Six of the patients with non-union needed an operation. Five had cancellous bone grafts followed by union in all except one.

4. The causes of non-union are reviewed. This complication was found to be less frequent in patients above sixty with stiff hips and bony collapse on the radiograph. Horizontal osteotomy with a displacement of not more than one-third of the diameter of the shaft reduced the incidence of non-union. The variable-angle nail-plate provided the best fixation. Traction provided no benefit and increased the incidence of non-union. Weight bearing is best avoided for eight weeks.

Aims. To investigate whether idiopathic osteonecrosis of the femoral head (ONFH) is related to impaired osteoblast activities. Methods. We cultured osteoblasts isolated from trabecular bone explants taken from the femoral head and the intertrochanteric region of patients with idiopathic ONFH, or from the intertrochanteric region of patients with osteoarthritis (OA), and compared their viability, mineralization capacity, and secretion of paracrine factors. Results. Osteoblasts from the intertrochanteric region of patients with ONFH showed lower alkaline phosphatase (ALP) activity and mineralization capacity than osteoblasts from the same skeletal site in age-matched patients with OA, as well as lower messenger RNA (mRNA) levels of genes encoding osteocalcin and bone sialoprotein and higher osteopontin expression. In addition, osteoblasts from patients with ONFH secreted lower osteoprotegerin (OPG) levels than those from patients with OA, resulting in a higher receptor activator of nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) ligand (RANKL)-to-OPG ratio. In patients with ONFH, osteoblasts from the femoral head showed reduced viability and mineralized nodule formation compared with osteoblasts from the intertrochanteric region. Notably, the secretion of the pro-resorptive factors interleukin-6 and prostaglandin E. 2. as well as the RANKL-to-OPG ratio were markedly higher in osteoblast cultures from the femoral head than in those from the intertrochanteric region. Conclusion. Idiopathic ONFH is associated with a reduced mineralization capacity of osteoblasts and increased secretion of pro-resorptive factors. Cite this article: Bone Joint Res 2021;10(9):619–628

The April 2024 Trauma Roundup. 360. looks at: The infra-acetabular screw in acetabular fracture surgery; Is skin traction helpful in patients with intertrochanteric hip fractures?; Reducing pain and improving function following hip fracture surgery; Are postoperative splints helpful following ankle fracture fixation?; Biomechanics of internal fixation in Hoffa fractures: a comparison of four different constructs; Dual-plate fixation of periprosthetic distal femur fractures; Do direct oral anticoagulants necessarily mean a delay to hip fracture surgery?; Plate or retrograde nail for low distal femur fractures?

Aims. Total hip arthroplasty (THA) is considered the preferred treatment for displaced proximal femoral neck fractures. However, in many countries this option is economically unviable. To improve outcomes in financially disadvantaged populations, we studied the technique of concomitant valgus hip osteotomy and operative fixation (VOOF). This prospective serial study compares two treatment groups: VOOF versus operative fixation alone with cannulated compression screws (CCSs). Methods. In the first series, 98 hip fixation procedures were performed using CCS. After fluoroscopic reduction of the fracture, three CCSs were placed. In the second series, 105 VOOF procedures were performed using a closing wedge intertrochanteric osteotomy with a compression lag screw and lateral femoral plate. The alignment goal was to create a modified Pauwel’s fracture angle of 30°. After fluoroscopic reduction of fracture, lag screw was placed to achieve the calculated correction angle, followed by inter-trochanteric osteotomy and placement of barrel plate. Patients were followed for a minimum of two years. Results. Mean follow-up was 4.6 years (4.1 to 5.0) in the CCS group and 5.5 years (5.25 to 5.75) in the VOOF group. The mean Harris Hip Score at two-year follow-up was 83.85 in the CCS group versus 88.00 in the VOOF group (p < 0.001). At the latest follow-up, all-cause failure rate was 29.1% in the CCS group and 11.7% in the VOOF group (p = 0.003). The total cost of the VOOF technique was 7.2% of a THA, and total cost of the CCS technique was 6.3% of a THA. Conclusion. The VOOF technique decreased all-cause failure rate compared to CCS. The total cost of VOOF was 13.5% greater than CCS, but 92.8% less than a THA. Increased cost of VOOF was considered acceptable to all patients in this series. VOOF technique provides a reasonable alternative to THA in patients who cannot afford a THA procedure. Cite this article: Bone Jt Open 2023;4(5):329–337

Aims. The aim of this study was to examine whether hips with unilateral osteoarthritis (OA) secondary to developmental dysplasia of the hip (DDH) have significant asymmetry in femoral length, and to determine potential related factors. Patients and Methods. We enrolled 90 patients (82 female, eight male) with DDH showing unilateral OA changes, and 43 healthy volunteers (26 female, 17 male) as controls. The mean age was 61.8 years (39 to 93) for the DDH groups, and 71.2 years (57 to 84) for the control group. Using a CT-based coordinate measurement system, we evaluated the following vertical distances: top of the greater trochanter to the knee centre (femoral length GT), most medial prominence of the lesser trochanter to the knee centre (femoral length LT), and top of the greater trochanter to the medial prominence of the lesser trochanter (intertrochanteric distance), along with assessments of femoral neck anteversion and neck shaft angle. Results. The percentages of hips with an absolute difference of > 5 mm in femoral GT and LT lengths were significantly larger in the DDH group (24% for both) compared with those of the control group (2% and 7%, respectively). The femoral length GT of the affected femur was significantly shorter in Crowe I and longer in Crowe IV than that of the unaffected side. The affected-to-unaffected difference of the intertrochanteric distance showed positive correlation with that of the femoral length GT in Crowe I and Crowe II/III, and negative correlation with that of the femoral length LT in the Crowe I and Crowe IV groups. Conclusion. Hips with unilateral end-stage OA secondary to DDH show significant asymmetry in femoral length between both the greater and lesser trochanter and the knee compared with controls. The intertrochanteric distance was a morphological factor related to femoral-length asymmetry. When undertaking total hip arthroplasty (THA) in the presence of DDH, long leg radiographs or CT measurements should be used to assess true leg-length discrepancy. Cite this article: Bone Joint J 2019;101-B:297–302

Aims. Osseointegrated prosthetic limbs allow better mobility than socket-mounted prosthetics for lower limb amputees. Fractures, however, can occur in the residual limb, but they have rarely been reported. Approximately 2% to 3% of amputees with socket-mounted prostheses may fracture within five years. This is the first study which directly addresses the risks and management of periprosthetic osseointegration fractures in amputees. Methods. A retrospective review identified 518 osseointegration procedures which were undertaken in 458 patients between 2010 and 2018 for whom complete medical records were available. Potential risk factors including time since amputation, age at osseointegration, bone density, weight, uni/bilateral implantation and sex were evaluated with multiple logistic regression. The mechanism of injury, technique and implant that was used for fixation of the fracture, pre-osseointegration and post fracture mobility (assessed using the K-level) and the time that the prosthesis was worn for in hours/day were also assessed. Results. There were 22 periprosthetic fractures; they occurred exclusively in the femur: two in the femoral neck, 14 intertrochanteric and six subtrochanteric, representing 4.2% of 518 osseointegration operations and 6.3% of 347 femoral implants. The vast majority (19/22, 86.4%) occurred within 2 cm of the proximal tip of the implant and after a fall. No fractures occurred spontaneously. Fixation most commonly involved dynamic hip screws (10) and reconstruction plates (9). No osseointegration implants required removal, the K-level was not reduced after fixation of the fracture in any patient, and all retained a K-level of ≥ 2. All fractures united, 21 out of 22 patients (95.5%) wear their osseointegration-mounted prosthetic limb longer daily than when using a socket, with 18 out of 22 (81.8%) reporting using it for ≥ 16 hours daily. Regression analysis identified a 3.89-fold increased risk of fracture for females (p = 0.007) and a 1.02-fold increased risk of fracture per kg above a mean of 80.4 kg (p = 0.046). No increased risk was identified for bilateral implants (p = 0.083), time from amputation to osseointegration (p = 0.974), age at osseointegration (p = 0.331), or bone density (g/cm2, p = 0.560; T-score, p = 0.247; Z-score, p = 0.312). Conclusion. The risks and sequelae of periprosthetic fracture after press-fit osseointegration for amputation should not deter patients or clinicians from considering this procedure. Females and heavier patients are likely to have an increased risk of fracture. Age, years since amputation, and bone density do not appear influential. Cite this article: Bone Joint J 2020;102-B(2):162–169

The February 2014 Trauma Roundup. 360 . looks at: predicting nonunion; compartment Syndrome; octogenarian RTCs; does HIV status affect decision making in open tibial fractures?; flap timing and related complications; proximal humeral fractures under the spotlight; restoration of hip architecture with bipolar hemiarthroplasty in the elderly; and short versus long cephalomedullary nails for the treatment of intertrochanteric hip fractures in patients over 65 years

We reviewed the long-term results of the treatment of slipped upper femoral epiphysis (SUFE) using realignment procedures in 36 patients (37 hips) at an average follow-up of 33.8 years (26 to 42). There were serious short-term complications in seven of the 22 hips treated by subcapital osteotomy, three of the 11 hips treated by intertrochanteric osteotomy and three of the four hips treated by manipulative reduction. At re-examination, the clinical and radiological results were excellent or good in 41% of the hips treated by subcapital osteotomy, in 36% treated by intertrochanteric osteotomy and in none treated by manipulative reduction. In all, seven hips (19%) had had arthrodesis or total hip replacement. The natural history of SUFE was probably not improved by any of the treatments used in our study. We therefore discourage the use of subcapital and intertrochanteric osteotomy as well as manipulative reduction in the primary treatment of chronic SUFE

Most hip fractures treated with modern internal fixation techniques will heal. However, failures occasionally occur and require revision procedures. Salvage strategies employed during revision are based on whether the fixation failure occurs in the femoral neck, or in the intertrochanteric region. Patient age and remaining bone stock also influence decision making. For fractures in young patients, efforts are generally focused on preserving the native femoral head via osteotomies and repeat internal fixation. For failures in older patients, some kind of hip replacement is usually selected. Disuse osteopenia, deformity, bone loss, and stress-risers from previous internal fixation devices all pose technical challenges to successful reconstruction. Attention to detail is important in order to minimise complications. In the majority of cases, good outcomes have been reported for the various salvage strategies. Cite this article: Bone Joint J 2013;95-B, Supple A:7–10

The December 2013 Trauma Roundup. 360 . looks at: Re-operation for intertrochanteric hip fractures; Are twin incisions better than one round the acetabulum?; Salvage osteotomy for calcaneal fractures; Posterior dislocation; Should MRSA be covered in open fractures?; Characterising the saline load test; Has it healed: hip fractures under the spotlight; and stem cells present in atrophic non-union

We have previously described the mid- to long-term results of conventional simple varus intertrochanteric osteotomy for osteonecrosis of the femoral head, showing that 19 of the 26 hips had good or excellent results. We extended the follow-up to a mean of 18.1 years (10.5 to 26) including a total of 34 hips in 28 patients, with a mean age at surgery of 33 years (19 to 53). There were 18 men and ten women and 25 hips (74%) had a satisfactory result with a Harris hip score ≥ 80. In all, six hips needed total hip replacement (THR) or hemiarthroplasty. The collapse of the femoral head or narrowing of the joint space was found to have progressed in nine hips (26%). Leg shortening after osteotomy was a mean of 19 mm (8 to 36). With conversion to THR or hemiarthroplasty as the endpoint, the ten-year survival rate was 88.2% (95% confidence interval (CI) 82.7 to 93.7) and the 20-year survival rate was 79.7% (95% CI 72.1 to 87.3); four hips were converted at ten years and other two hips were converted at 20 years. Shortening of the leg after osteotomy remains a concern; however, the conventional varus half-wedge osteotomy provides favourable long-term results in hips with less than two-thirds of the medial part of the femoral head affected by necrotic bone and with normal bone superolaterally