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PubMed2005

Surgical approaches and ancillary techniques for internal fixation of intracapsular proximal femoral fractures.

BACKGROUND: In the fixation of intracapsular hip fractures, different implants, surgical approaches and ancillary manoeuvres have been employed to improve the reduction, and the stability of the reconstruction, in an attempt to reduce the frequency of non-union and aseptic necrosis of the femoral head. OBJECTIVES: To compare alternative surgical approaches and ancillary techniques in internal fixation of intracapsular hip fractures which have been subjected to randomised and quasi-randomised trials in adults. SEARCH STRATEGY: The Cochrane Musculoskeletal Injuries Group Specialised Register, MEDLINE, and reference lists of relevant articles were searched. Date of the most recent search: November 2004. SELECTION CRITERIA: All randomised and quasi-randomised trials investigating operative technique for the treatment of intracapsular hip fractures. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial quality, by use of a 10 item checklist, and extracted data. MAIN RESULTS: One trial with 103 participants studied the effect of impaction of the fracture at the time of surgery. The only outcome measure reported was bone scintimetry. There was some evidence that impaction, particularly of displaced fractures, resulted in a reduction of blood flow to the femoral head as assessed by bone scintimetry. One quasi-randomised trial with 220 participants compared compression of the fracture with no compression. Results for 156 individuals at one year showed a tendency to a lower incidence of non-union for those fractures treated without compression.Two trials, one involving 102 young adults under 50 years old and the other involving 49 older people aged 65 years or over, compared open versus closed reduction of the fracture. Both found open reduction significantly increased length of surgery. None of the other differences between open and closed reduction in the outcomes reported by the two trials were statistically significant. AUTHORS' CONCLUSIONS: Insufficient evidence exists from randomised trials to confirm the relative effects of open versus closed reduction of intracapsular fractures, or the effects of intra-operative impaction or compression of an intracapsular fracture treated by internal fixation.

Aged↗
PubMed1980

Irradiation of the surgeon during pinning of femoral fractures.

The intensity of scattered radiation in both a forward and a backward direction from a portable fluoroscope during pinning of the neck of the femur was measured by experiments on a cadaver. The intensity decreased rapidly with increasing distance from the flare of the greater trochanter. Hazard to the surgeon's hands from scattered radiation can be greatly reduced by positioning the C-arm of the fluoroscope so that the x-ray beam is directed laterally.

Background Radiation↗
PubMed1994

[The clinical course of surgically managed para-articular femoral fractures in geriatric surgery].

246 patients (average 82.4 years) with proximal femur fractures treated with bipolar endoprosthesis, sliding lag screw or Ender nailing, related to the fracture type were analysed in a retrospective study. Pre-existing diseases, duration of operation, postoperative complications, transfusions, hospital stay, mobility achieved and mortality were noted. In result we found a high multimorbidity related to the age, the highest requirement of transfusions in patients undergoing Ender nailing, a long period to achieve postoperative mobility, a long hospital stay and increasing mortality with average age and average hospital stay.

Aged↗
PubMed1993

The incidence of proximal femoral fractures in an English county.

We have studied the incidence of fractures of the proximal femur in one English county from 1968 to 1991. Numbers have increased steadily, but the age-specific incidence has remained relatively unchanged since 1981. The increase is due to the rise in the population most at risk; this is likely to continue causing a 20% increase in demand for treatment by the year 2000. Suitable allocation of resources must be planned.

Age Factors↗
PubMedDate not supplied

[Coxal femoral fractures--surgical management and internal medicine-cardiologic concomitant therapy in geriatric patients. 1. Surgical procedure and postoperative follow-up].

246 patients (average age 82.4 years) with proximal femur fractures treated with bipolar endoprothesis, sliding lag screw or Ender nailing, related to the fracture type were analyzed in a retrospective study. Preexistent diseases, duration of operation, postoperative complications, transfusions, hospital stay, mobility achieved and mortality were noted. As a result, we found a high multimorbidity related to the age, the highest requirement of transfusions in patients undergoing Ender nailing, a long period to achieve postoperative mobility, a long hospital stay, and increasing mortality with average age and average hospital stay.

Aged↗
PubMed1990

Acromegaly and proximal femoral fracture in an aged person: bone histomorphometry, vitamin D metabolites and parathormone.

Osteoporosis and fractures are rare in acromegaly. An 84-year-old acromegalic woman sustained a fractured neck of femur in a fall. Histomorphometric analysis of an iliac crest biopsy showed marked osteoporosis and augmented resorption parameters. Cortical plates were very thin and bone volume was 8.5%; 12.5% is the reference value for women at this age. The total resorption surfaces were 23.7% compared with the reference value of 8%. We conjecture that postmenopausal and involutional osteoporosis were far advanced before the development of acromegaly, explaining the coexistence of the two conditions. Parathormone (65 pmol/l) and 24,25-dihydroxyvitamin D (1.34 ng/ml) levels were within normal limits, but those of 25-hydroxyvitamin D (5.6 ng/ml) and 1,25-dihydroxyvitamin D (15 pg/ml) were markedly decreased.

Acromegaly↗
PubMed2000

[Early surgery after hip para-articular femoral fracture. Results of a prospective study of surgical timing in 161 elderly patients].

In a prospective analysis the question should be answered, wether the mortality rate of femur fractures close to the hip joint can be diminished by operating as early as possible. 161 patients elder than 65 years could be included in the study. 86% of the 161 patients were operated upon 24 hours after trauma. The infection rate amounted to 3.4% after endoprothesis and to 1.2% after osteosynthesis. The hospital mortality was 7.4%. More than 85% of the patients could be discharged into the usual domestic surroundings. The rate of systemic complications (25.3%) was similar to the rate reported by the Chamber of Physicians with 26.1%. The hospital length of stay could not be diminished by this concept. By operating as early as possible the patients' request for mobility is fulfilled without running unjustifiable risks regarding mortality and postoperative complications. The mortality rate corresponds to the literature.

Aged↗
PubMed2000

Surgical approaches and ancillary techniques for internal fixation of intracapsular proximal femoral fractures.

BACKGROUND: In fixation of intracapsular hip fractures, different implants, surgical approaches and ancillary manoeuvres have been employed to improve the reduction, and the stability of the reconstruction, in an attempt to reduce the frequency of non-union and aseptic necrosis of the femoral head. OBJECTIVES: To compare alternative surgical approaches and ancillary techniques in internal fixation of intracapsular hip fractures which have been subjected to randomised trials in elderly people. SEARCH STRATEGY: The Cochrane Musculoskeletal Injuries Group trials register, Medline, and reference lists of relevant articles were searched. Date of the most recent search: June 1998. SELECTION CRITERIA: All randomised and quasi-randomised trials investigating operative technique for the treatment of intracapsular hip fractures. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality, by use of a ten-item checklist, and extracted data. MAIN RESULTS: One study of 94 patients studied the effect of impaction of the fracture at the time of surgery. The only outcome measure was bone scintimetry. There was no difference in scintimetry for the 29 undisplaced fractures but in displaced fractures treated with impaction the scintimetry appearances were significantly reduced implying a reduction of blood flow to the femoral head. One study of 220 patients compared the results of fractures treated with compression against those without compression. Results for 156 patients at one year showed a tendency to a lower incidence of non-union for those fractures treated without compression. One study of 49 patients noted a tendency to a reduced mortality for closed reduction of the fracture as opposed to open reduction. Non-union of the fracture was more common after closed reduction. REVIEWER'S CONCLUSIONS: Insufficient evidence exists from randomised trials to confirm the benefits of open or closed reduction or for intra-operative impaction or compression of an intracapsular fracture treated by internal fixation.

Aged↗
PubMed1987

Proximal femoral fractures. A perspective from developing countries.

The approach to hip fractures in the developing world has been reviewed to give perspective to the problem on a larger scale. Hip fracture treatment in the developing world is a paradigm for treatment of other orthopedic problems as well as for medical care in general. The most successful approach has been to use the resources as sparingly as possible so as to provide care for the greatest number of people. Reliance on simpler, more basic techniques of nonoperative treatment reduces the complication rate and seems to provide a safer, more cost-effective approach, but the nonunion rate may be 30%-70%. The situation in which technical development exceeds resources is not unique to the developing world, although it is perhaps more apparent there because of a lower resource level. The "developed" world faces the same dilemma, the only real difference perhaps being a higher minimum. Probably no society today can provide the medical care it is technically capable of producing for all of its members. When viewed from a world-wide scale, the task of providing high-technology medical care seems daunting indeed. Development of more sophisticated, expensive technology may not be the appropriate direction; a more fundamental or preventive approach might in the long run be the most effective.

Developing Countries↗
PubMed1998

[Gliding nail osteosynthesis. A new universally applicable implant for management of per- and subtrochanteric femoral fractures].

Age, high physiological load and the great number and different fracture types of the proximal femur are the main challenges for implants used in the management of these fractures. For use in these types of fracture with immediate restoration of full weight-bearing capacity and for reduction of the intra- and postoperative complication rate, the gliding nail was developed. The development is based on a large number of experimental and clinical examinations of per- and subtrochanteric fractures. The advantages of an intramedullary implant and the gliding screw systems are combined with increased moment of resistance of the double-T femor-neck blade profile. We performed a prospective clinical evaluation of the first 186 patients with per- and subtrochanteric fractures who were treated between 15 September 1994 and 29 February 1996 in the Aschaffenburg Trauma Department with a follow-up examination at least 3 months after the operation. The intraoperative complication rate was 1.1%. The postoperative complication rate was 4.9%. Change of the blade because of fracture impaction and tractus iliotibialis problems was the most frequent problem with 2.2%. The most severe complication (1.1%) were caused by subchondral placement of the blade in the cranial one-third of the femur head. In these cases reosteosynthesis was indicated. Ninety-three percent of the survivors were able to return home. The rate of bed-ridden patients (7.7% and 11.7%) was not very different before or after the operation. However, many patients do not reach the condition they had before the fracture and they are one step worse in mobility and social independence.

Activities of Daily Living↗
PubMedDate not supplied

Comminuted trochanteric femoral fractures in geriatric patients: the results of 231 cases treated with internal fixation and acrylic cement.

Instability, osteoporosis and the requirement of early mobilization are the main problems in comminuted trochanteric fractures in elderly patients. Correct reduction and the use of acrylic cement as an adjunct to internal fixation provide the stability for immediate weightbearing and subsequent bone union. In 213 patients there was no evidence of femoral head necrosis or non-union.

Aged↗
PubMed2000

Comparison of ender nails, dynamic hip screws, and Gamma nails in the treatment of peritrochanteric femoral fractures.

Three hundred seventy-six patients with peritrochanteric fractures treated over a 10-year period were reviewed. In 85 patients treated with Ender nailing, the most frequent complications were leg shortening (34), external rotation failure (21), and postoperative distal gliding of the nails (7). In 183 patients treated with dynamic hip screws or a 95 degree condylar or a 130 degree blade plate, 3 presented with infection, 5 with instability, and 4 with femoral head necrosis. In 105 patients treated with Gamma nailing, the most serious complications were infections (3), inward rotation failure (2), postoperative bleeding at the insertion site (2), and shaft fracture (1). Because of its inherent instability, Ender nailing is no longer used. The implantation technique for the dynamic hip screw is safer and simpler than the various models of the ASIF blade plate. However, the dynamic hip screw has been superseded by the Gamma nail because of its absolute stability. In the beginning, Gamma nailing was technically more demanding with a higher number of intraoperative complications. In this study, the number of malalignments did not differ significantly between the dynamic hip screw (14) and the Gamma nail (11), but was high with Ender nailing (56).

Activities of Daily Living↗
PubMed1989

[Technical errors and early complications of osteosynthesis of pertrochanteric femoral fractures using the dynamic hip screw].

Within a period of 3 years, 198 patients with pertrochanteric fractures were operatively treated with implantation of the dynamic hip screw: 141 were female and 57 male (ratio of 2.5:1). The youngest patient was 27 and the oldest 100 years of age (average 74.4 years). Most preoperative failures in management were caused by insufficient reduction when no valgus of the femoral head and neck was achieved. Some patients had ulcers in the genital region because of forced reduction on the traction table, and in one of these cases plastic surgery was necessary. Intraoperative failures may occur because of too early removal of the guide pin, which should remain in the center of the femoral head until the screw is placed in the right position. Postoperative complications are caused by full weight bearing, which leads to varus and recurvation malposition. In 2 cases, deep wound infection occurred. The plate broke out in 3 cases, 2 of those required reoperation. Six patients between 61 to 84 years of age died in the early postoperative period during their stay in hospital.

Adult↗
PubMed1992

[Early and late results of 200 DHS osteosyntheses in the reconstruction of pertrochanteric femoral fractures].

We have treated more than 600 cases of trochanteric fractures by internal fixation with the dynamic hip screw. Between 1986 and 1988 we treated exactly 200 patients in this way, who were subsequently observed over follow-up times averaging 24 months. In 1% of this group we performed early revision osteosynthesis because of incorrect positioning of the lag screw; deep infections occurred in 2.5%; and in 6% revision interventions were necessary because of local hematomas. Late complications were necrosis of the femoral head (1%) and pseudarthrosis after head necrosis (0.5%). No reinterventions were necessary because of implant failure.

Aged↗
PubMed2006

Outcome of Girdlestone's resection arthroplasty following complications of proximal femoral fractures.

Twenty two patients who underwent a Girdlestone resection arthroplasty of the hip (pseudarthrosis coxae) following failed operative treatment for hip trauma from 1993 to 2002 were retrospectively reviewed. The indications included failed osteosynthesis of fractures of the neck of the femur (n=8), septic hemiarthroplasty (n=9), aseptic loosening of hemiarthroplasty (n=3) and recurrent dislocation of a hemiarthroplasty (n=2). The mortality was 68.2% (15 patients, mean age: 78.8 years, 80% females) with a mean time interval between operation and death of 25.6 months. All the seven surviving Girdlestone patients had failed hemiarthroplasties previously. One of these had subsequently undergone re-implantation of a femoral prosthesis, and was excluded from the study. There were four females and two males. The age ranged from 62 to 94 years with a mean age of 79.6 years. There were 4 right-sided and 2 left-sided operations. The patients were followed-up for a mean 37.1 months (range : 6 months to 8 years). Pain relief was achieved in 100% patients with none to mild pain. All the patients had infection control. Four patients needed a frame support for walking, while the remaining two were chairbound. Overall 83.3% patients expressed their satisfaction with the Girdlestone procedure. The Girdlestone operation appears as a viable solution to achieve pain relief and to control infection at the cost of limited mobility in this specific subgroup of patients with failed operative treatment for hip trauma.

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