ObjectiveTo summarize the patterns and research progress of the concomitant ipsilateral fractures of intracapsular femoral neck and extracapsular trochanter, and to provide a common language among orthopedic surgeons for scientific exchange.MethodsAccording to related literature and authors own experiences concerning the anatomic border between femoral neck and trochanter region, the intertrochanteric line (or intertrochanteric belt) and its capsularligament attachment footprint, fracture patterns, and treatment strategies were reviewed and analyzed.ResultsWith the rapid growing of geriatric hip fractures, an increased incidence was noted in recent years regarding the proximal femoral comminuted fractures that involving ipsilateral intracapsular neck and extracapsular trochanter regions simultaneously. But the concept of femoral neck combined with trochanter fractures was ambiguous. Based on the anatomic type of femoral neck fracture, the location of fracture center, and the ability to achieve direct inferior calcar or anteromedial cortex-to-cortex apposition and buttress, we classified these complex fractures into 3 sub-types: ① Segmental femoral neck fractures (two separate fracture centers at subcapital and trochanteric region respectively); ② Femoral neck fracture (trans-cervical) with extension to the supero-lateral trochanteric region (fracture center in femoral neck); ③ Trochanteric fracture with extension to the medio-inferior femoral neck region (fracture center in trochanter, comminuted basicervical fracture, or variant type of comminuted trochanter fracture). For treatment strategy, surgeons should consider the unique characteristics of femoral neck and trochanter, usually with combined fixation techniques, or arthroplasty supplemented with fixation.ConclusionCurrently there is no consensus on diagnosis and terminology regarding the concomitant ipsilateral fractures of femoral neck and trochanter. Further studies are needed.
ObjectiveTo compare the predictive value of the two concepts for complications by comparing the incidences of surgical complications associated with different tip-apex distance (TAD) and calcar referenced tip-apex distance (Cal-TAD) in the treatment of femoral intertrochanteric fractures with Asian type proximal femoral nail (APFN) fixation. MethodsA total of 188 cases of femoral intertrochanteric fractures treated with APFN fixation between January 2014 and December 2018 were collected according to inclusion criteria. TAD and Cal-TAD were measured on the X-ray film at immediate after operation; the patients were divided into two groups according to the measurement results: <25 mm and ≥25 mm. Gender, age, and fracture side and AO type were recorded. The patients in each group were reviewed whether there was delayed fracture union or nonunion, whether the screw blade moved axially, whether the femoral neck collapsed or even screw blade cut out, whether the internal fixator became loose or broken within 12 months after operation. Then statistical analysis was performed. ResultsThere were 119 patients with TAD<25 mm and 69 patients with TAD≥25 mm, and 142 patients with Cal-TAD<25 mm and 46 patients with Cal-TAD≥25 mm. There was no significant difference in gender, age, or fracture side and AO type between groups (P>0.05). During the follow-up, 6 patients (5.04%) with TAD<25 mm, 10 patients (14.49%) with TAD≥25 mm had complications, and 1 patient (0.70%) with Cal-TAD<25 mm and 15 patients (32.61%) with Cal-TAD≥25 mm had complications. There were significant differences in the incidence of complication between the patients with different TAD, between the patients with different Cal-TAD, and between patients with TAD<25 mm and Cal-TAD<25 mm (P<0.05). ConclusionIn the operation of femoral intertrochanteric fracture with APFN fixation, surgical complications can be significantly reduced when TAD or Cal-TAD was controlled within 25 mm, Cal-TAD is more significant in the prediction of postoperative complications.
ObjectiveTo investigate the efficacy and safety of intravenous combined with topical administration of tranexamic acid (TXA) in reducing blood loss after intramedullary fixation of intertrochanteric femoral fractures by a prospective controlled trial.MethodsPatients with intertrochanteric femoral fractures, who were admitted for intramedullary fixation between June 2015 and July 2019, were selected as the study subjects, 120 of whom met the selection criteria. The patients were randomly assigned to 3 groups: intravenous administration group (group A, 41 cases), topical administration group (group B, 40 cases), and combined administrations group (group C, 39 cases). In group A, 4 patients occurred deep vein thrombosis of lower extremity before operation, 1 patient died of myocardial infarction on the 5th day after operation, and 1 patient developed severe pulmonary infection after operation. In group B, 2 patients occurred deep vein thrombosis of lower extremity before operation and 1 patient had iatrogenic fracture during operation. In group C, 3 patients occurred deep vein thrombosis of lower extremity before operation and 1 patient developed pulmonary infection before operation and gave up surgical treatment. All the above patients were excluded from the study, and the remaining 107 cases were included in the analysis, including 35, 37, and 35 cases in groups A, B, and C, respectively. There was no significant difference in gender, age, height, body mass, injury cause, fracture side and type, the interval between injury and operation, and preoperative hemoglobin (Hb), hematocrit between groups (P>0.05). Intraoperative TXA (15 mg/kg) was injected intravenously in group A at 30 minutes before operation, and 1 g of TXA was injected into the medullary cavity in group B after the proximal femur was grooted and before the intramedullary nail implantation, respectively. TXA was given in group C before and during operation according to the administration methods and dosage of groups A and B. Total blood loss, maximum Hb decrease, blood transfusion rate, operation time, fracture healing time, and the incidence of complications were recorded and compared between groups. The hip joint function were evaluated by Harris score. ResultsThere was no significant difference in operation time between groups (P>0.05). The total blood loss, the maximum Hb decrease, and the blood transfusion rate in group B were the highest, followed by group A and group C, and the differences between groups were significant (P<0.05). No incision infection or pulmonary embolism occurred in the 3 groups after operation. The incidence of anemia in group C was significantly lower than that in groups A and B, the difference was significant (P<0.05). There was no significant difference in the incidence of subcutaneous hematoma, aseptic exudation, and deep vein thrombosis of lower extremity between groups (P>0.05). All patients in the 3 groups were followed up 8-35 months, with an average of 16.2 months. The fracture healing time of groups A, B, and C was (6.12±1.78), (5.89±1.63), and (5.94±1.69) months, respectively, and there was no significant difference between groups (P>0.05). At last follow-up, the Harris scores of the hip joints in groups A, B, and C were 83.18±7.76, 84.23±8.01, and 85.43±8.34, and the difference was not significant (P>0.05). ConclusionPreoperative intravenous injection combined with intraoperative topical application of TXA can effectively reduce blood loss and blood transfusion after intramedullary fixation of femoral intertrochanteric fracture, without increasing the risk of deep vein thrombosis, and the efficacy is better than that of intravenous injection or topical administration.
ObjectiveTo investigate the position of the anterior fracture line in AO/Orthopaedic Trauma Association (AO/OTA) type A2 unstable intertrochanteric fractures and its impact on the incidence of anterior cortical reduction loss after cephalomedullary nail fixation. MethodsA clinical data of 95 patients with intertrochanteric fractures who met the selection criteria between April 2020 and February 2023 was retrospectively analyzed. All patients were treated with cephalomedullary nail fixation, and the intra- and post-operative imaging data were complete. Among them, there were 37 males and 58 females. The age ranged from 61 to 97 years, with an average of 79.6 years. The time from injury to operation ranged from 7 hours to 11 days, with an average of 2.8 days. According to the 2018-AO/OTA classification standard, there were 39 cases of type 31-A2.2 and 56 cases of type 31-A2.3. Intraoperative fluoroscopy was used to record the number of patients with satisfactory fracture alignment. The preoperative CT data were imported into Mimics17.0 software to simulate the fracture reduction and measure the distance between the anterior fracture line and the intertrochanteric line bony ridge. The fractures were classified as transcapsular fractures, extra-capsular fractures, and intra-capsular fractures according to the distance. CT three-dimensional reconstruction was performed within 2 weeks after operation to observe the number of patients with anterior cortical reduction loss. Statistical analysis was performed on the anterior cortical reduction loss in patients with satisfactory fracture alignment, and the relationship between postoperative anterior cortical reduction loss and the position of the anterior fracture line was observed. Results There were 52 cases (54.7%) of transcapsular fractures, 24 cases (25.3%) of extra-capsular fractures, and 19 cases (20.0%) of intra-capsular fractures. Among them, 41 of the 52 transcapsular fractures had satisfactory fracture alignment, and 4 (9.8%) of them experienced anterior cortical reduction loss after operation; 19 of the 24 extra-capsular fractures had satisfactory fracture alignment, and no anterior cortical reduction loss occurred; 16 of the 19 intra-capsular fractures had satisfactory fracture alignment, and 7 (43.8%) of them experienced anterior cortical reduction loss after operation. There was a significant difference in the incidence of anterior cortical reduction loss between groups (χ2=8.538, P=0.003). All patients were followed up 3-26 months (mean, 9 months). Among them, 91 cases had fracture healing, and 4 cases had nonunion. Conclusion In AO/OTA type A2 unstable intertrochanteric fractures, where the anterior fracture line is located within the joint capsule, there is a high risk of anterior cortical reduction loss after operation.
ObjectiveTo analyze the risk factors for postoperative mortality of elder patients with intertrochanteric fractures.MethodsPatients with intertrochanteric fractures who underwent proximal femoral interlocking intramedullary nail fixation between January 2014 and December 2015 were enrolled in the study. Among them, 135 patients who met the selection criteria were included in the study, and the clinical data were collected, including gender, age, time from admission to surgery, comorbidities, and preoperative hemoglobin, albumin, and total lymphocyte count (TLC), and nutritional status. Univariate analysis and Cox proportional hazards regression model were used to screen the risk factors for postoperative mortality.ResultsTwenty-seven patients (20.0%) died within 2 years after surgery, and 16 (11.9%) died within 1 year after surgery. Univariate analysis showed that age, coronary atherosclerotic heart disease, number of comorbidities, preoperative hemoglobin and albumin levels were the influencing factors of postoperative mortality in elder patients with intertrochanteric fractures treated with proximal femoral interlocking intramedullary nail fixation (P<0.05). Multivariate analysis showed that age (≥80 years), combined more than 2 medical diseases, and preoperative albumin (<35 g/L) were the independent risk factors for postoperative mortality (P<0.05).ConclusionTo improve the clinical outcomes, perioperative risk should be comprehensively evaluated and perioperative management strengthened in the elder patients with intertrochanteric fractures, especially those with advanced age, more combined diseases, and low albumin, for the high postoperative mortality.