BackgroundIntertrochanteric hip fractures are common and devastating injuries especially for the elderly. Surgical treatment is the optimal strategy for managing intertrochanteric fractures as it allows early rehabilitation and functional recovery. The relative effects of internal fixation strategies for intertrochanteric fracture after operation remain limited to relatively small studies which create uncertainty in attempts to establish evidence-based best practice.MethodsWe conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) and observational studies to assess the clinical effectiveness of two commonly used intramedullary devices: a twin screw integrated cephalomedullary nail (InterTAN) versus a single screw cephalomedullary nail (proximal femoral nail antirotation) in patients with intertrochanteric fractures. The following outcomes were considered: revisions, implant-related failures, non-unions, pain, Harris Hip Score and intraoperative outcomes. Odds ratios or mean differences with 95% confidence intervals in brackets are reported.ResultsSix studies met the inclusion criteria, two randomised controlled trials and four observational studies enrolling 970 patients with mean age of 77 years, and 64% of patients were female. There was a statistically significant difference (p value < 0.05) for revisions OR 0.27 (0.13 to 0.56), implant-related failures OR 0.16 (0.09 to 0.27) and proportion of patients complaining of pain OR 0.50 (0.34 to 0.74). There was no difference in non-unions and Harris Hip Score (p value > 0.05). There was a significant difference in blood loss and fluoroscopy usage in favour of PFNA, whilst no difference in operating times were observed between the two devices.ConclusionsOur meta-analysis suggests that a twin screw integrated cephalomedullary nail InterTAN is clinically more effective when compared to a single screw cephalomedullary nail proximal femoral nail antirotation resulting in fewer complications, fewer revisions and fewer patients complaining of pain. No difference has been established regarding non-unions and Harris Hip Score. Intraoperative outcomes favour PFNA with less blood loss and fluoroscopy usage. Further studies are warranted to explore the cost-effectiveness of these and other implants in managing patients with intertrochanteric fractures.
Aims The aim of this study was to compare the incidence of anterior knee pain after antegrade tibial nailing using suprapatellar and infrapatellar surgical approaches Patients and Methods A total of 95 patients with a tibial fracture requiring an intramedullary nail were randomized to treatment using a supra- or infrapatellar approach. Anterior knee pain was assessed at four and six months, and one year postoperatively, using the Aberdeen Weightbearing Test – Knee (AWT-K) score and a visual analogue scale (VAS) score for pain. The AWT-K is an objective patient-reported outcome measure that uses weight transmitted through the knee when kneeling as a surrogate for anterior knee pain. Results A total of 53 patients were randomized to a suprapatellar approach and 42 to an infrapatellar approach. AWT-K results showed a greater mean proportion of weight transmitted through the injured leg compared with the uninjured leg when kneeling in the suprapatellar group compared with the infrapatellar group at all timepoints at all follow-up visits. This reached significance at four months for all timepoints except 30 seconds. It also reached significance at six months at 0 seconds, and for one year at 60 seconds. Conclusion The suprapatellar surgical approach for antegrade tibial nailing is associated with less anterior knee pain postoperatively compared with the infrapatellar approach Cite this article: Bone Joint J 2019;101-B:1138–1143
Ultra-high-molecular-weight polyethylene (UHMWPE) has a long history of use in medical devices, primarily for articulating surfaces due to its inherent low surface energy which limits tissue integration. To widen the applications of UHMWPE, the surface energy can be increased. The increase in surface energy would improve the adsorption of proteins and attachment of cells to allow tissue integration, thereby allowing UHMWPE to potentially be used for a wider range of implants. The attachment and function of human primary osteoblast-like (HOB) cells to surfaces of UHMWPE with various levels of incorporated surface oxygen have been investigated. The surface modification of the UHMWPE was produced by exposure to a UV/ozone treatment. The resulting surface chemistry was studied using X-ray photoelectron spectroscopy (XPS), and the topography and surface structure were probed by atomic force microscopy (AFM) and scanning electron microscopy (SEM), which showed an increase in surface oxygen from 11 to 26 atom % with no significant change to the surface topography. The absolute root mean square roughness of both untreated and UV/ozone-treated surfaces was within 350-450 nm, and the water contact angles decreased with increasing oxygen incorporation, i.e., showing an increase in surface hydrophilicity. Cell attachment and functionality were assessed over a 21 day period for each cell-surface combination studied; these were performed using SEM and the alamarBlue assay to study cell attachment and proliferation and energy-dispersive X-ray (EDX) analysis to confirm extracellular mineral deposits, and total protein assay to examine the intra- and extracellular protein expressed by the cells. HOB cells cultured for 21 days on the modified UHMWPE surfaces with 19 and 26 atom % oxygen incorporated showed significantly higher cell densities compared to cells cultured on tissue culture polystyrene (TCPS) from day 3 onward. This indicated that the cells attached and proliferated more readily on the UV/ozone-treated UHMWPE surfaces than on untreated UHMWPE and TCPS surfaces. Contact guidance of the cells was observed on the UHMWPE surfaces by both SEM and AFM. Scanning electron micrographs showed that the cells were confluent on the modified UHMWPE surfaces by day 10, which led to visible layering of the cells by day 21, an indicator of nodule formation. In vitro mineralization of the extracellular matrix expressed by the HOB cells on the modified UHMWPE surfaces was confirmed by SEM and EDX analysis; spherulite structures were observed near cell protrusions by day 21. EDX analysis confirmed the spherulites to contain calcium and phosphorus, the major constituents in calcium phosphate apatite, the mineral phase of bone. Overall cell attachment, functionality, and mineralization were found to be enhanced on the UV/ozone-modified UHMWPE surfaces, demonstrating the importance of optimizing the surface chemistry for primary HOB cells.
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