Choice of three different intramedullary nails in the treatment of trochanteric fractures: Outcome, analysis and consideration in midterm

Persiani, P.J.; Ranaldi, Filippo Maria; Gurzì, Michele Dario; Formica, Alessandro; Graci, Jole; Cristo, Claudia de; Grasso, R. F.; Villani, Ciro

doi:10.1016/j.injury.2019.01.012

Cited by 9 publications

(4 citation statements)

References 22 publications

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“…Only two patients had an arterial injury requiring intervention (in one patient the responsible branch was ligated intra-operatively and in the other embolised pre-operatively), whilst the remaining patients had 54%; open reduction group: 69%) revealed a smaller proportion of subtrochanteric femur fractures requiring blood transfusion. 26,27 Noteworthy, the number of units RBC required (mean: 1.4-1.7 units dependant on implant choice) by patients with intertrochanteric fractures was lesser than those with subtrochanteric fractures, as observed by both our study and Shukla et al 26,27 Taken altogether, the higher incidence for blood transfusion as observed in subtrochanteric fractures could be explained by the greater proportion of these patients being elderly fragility fractures, often with a lower biological reserve of baseline Hb. 23 In their regression analysis, Wertheimer et al examined the risk factors for blood transfusion in the first 48 h. 23 They identified admission Hb as the only statistically risk factor determining the need for blood transfusion (p < 0.01), with only a trend observed for male gender (p = 0.08).…”

Section: Discussionsupporting

confidence: 62%

“…Comparing the blood loss between femoral diaphyseal fractures and that of ‘extremity’ fractures (70.3% being subtrochanteric fractures), Wertheimer et al reported a higher incidence of blood transfusion (within first 48 h and overall total transfusion requirement) in patients with ‘extremity fractures’. Interestingly, when compared against intertrochanteric femoral fractures (95.8%), findings from both our study (overall: 62.7%) and Shukla et al (closed reduction group: 54%; open reduction group: 69%) revealed a smaller proportion of subtrochanteric femur fractures requiring blood transfusion 26,27 . Noteworthy, the number of units RBC required (mean: 1.4–1.7 units dependant on implant choice) by patients with intertrochanteric fractures was lesser than those with subtrochanteric fractures, as observed by both our study and Shukla et al 26,27 Taken altogether, the higher incidence for blood transfusion as observed in subtrochanteric fractures could be explained by the greater proportion of these patients being elderly fragility fractures, often with a lower biological reserve of baseline Hb 23 …”

Section: Discussionsupporting

confidence: 40%

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Blood loss and transfusion risk in intramedullary nailing for subtrochanteric fractures

Panteli

Vun

Ahmadi

et al. 2022

Transfusion Medicine

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Background The incidence of hip fractures and subtrochanteric fractures in particular is increasing, along with the globally expanding aging population. Intramedullary nailing remains the ‘gold standard’ of their treatment. Blood loss can be a result of the original trauma, but also secondary to the subsequent surgical insult, especially during the reaming of the intramedullary canal. Objectives The aim of our study was to report on the blood loss and incidence of blood transfusion in patients presenting with a subtrochanteric fracture treated with intramedullary nailing. Most importantly, we aim to identify factors associated with the need for transfusion within the first 48 h post‐operatively. Methods Following institutional board approval, 431 consecutive patients (131 males; age: 79.03 years old, SD 13.68 years) presenting in a Level 1 Trauma Centre with a subtrochanteric fracture treated with an intramedullary nail were retrospectively identified, over an 8‐year period. Exclusion criteria included patients with high energy injuries, pathological fractures, primary operations at other institutions and patients lost to follow‐up. To identify risk factors leading to increased risk of transfusion, we first compared patients requiring intra‐operative transfusion or transfusion during the first 48 h post‐operatively against those who did not require transfusion. This was then followed by multivariate regression analysis adjusted for confounding factors to identify the most important risk factors associated with need for transfusion within the first 48 h post‐operatively. Results Incidence of blood transfusion was 6.0% pre‐operatively, compared to 62.7% post‐operatively. A total of 230 patients (52.3%) required either intra‐operative transfusion or transfusion during the first 48 h following surgery. Patients having a transfusion within the first 48 h post‐operatively had a higher incidence of escalation in their care (p = 0.050), LOS (p = 0.015), 30‐day (p = 0.033) and one‐year mortality (p = 0.004). Multivariate regression analysis adjusted for confounding factors identified that the most important association of a need for transfusion within the first 48 post‐operative hours was a pre‐operative Hb <100 g/L (OR 6.64); a nail/canal ratio <70% (OR 3.92), followed by need for open reduction (OR 2.66). Fracture involving the lesser trochanter was also implicated with an increased risk (OR 2.08). Additionally, pre‐operative moderate/severe renal impairment (OR 4.56), as well as hypoalbuminaemia on admission (OR 2.10) were biochemical predictors of an increased risk of transfusion. Most importantly, the need for transfusion was associated with an increase in 30‐day mortality (OR 12.07). Conclusion Several patient, fracture and surgery related factors are implicated with an increased risk for transfusion within the first 48‐h post‐operatively. Early identification, and where possible correction of these factors can potentially reduce blood loss and risk of transfusion, along with all the associated sequelae and...

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Section: Discussionsupporting

confidence: 62%

Section: Discussionsupporting

confidence: 40%

Blood loss and transfusion risk in intramedullary nailing for subtrochanteric fractures

Panteli

Vun

Ahmadi

et al. 2022

Transfusion Medicine

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“…Subtrochanteric fractures have been widely reported to run a high risk of developing implant-related complications and fracture non-union [ 23 , 24 , 25 ], and most importantly high rates of re-operation [ 26 , 27 , 28 , 29 ]. However, despite SSI being such a common complication, published studies on subtrochanteric focus were mainly focused on outcomes in terms of fracture healing and survivorship [ 23 , 24 , 25 , 26 ]. As such, knowledge surrounding the incidence, associations, pathogenic micro-organisms and the management outcomes of SSIs in surgically treated subtrochanteric fracture remains lacking.…”

Section: Introductionmentioning

confidence: 99%

Surgical Site Infection Following Intramedullary Nailing of Subtrochanteric Femoral Fractures

Panteli

Vun

West

et al. 2021

JCM

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Aim: To investigate the incidence, risk factors and pathogenic micro-organisms causing superficial and deep infection in subtrochanteric femoral fractures managed with an intramedullary nail. Materials and Methods: Following institutional board approval, all consecutive patients presenting with a subtrochanteric fracture were retrospectively identified, over an 8-year period. Basic demographics, fracture characteristics, fracture union, revision operation, mortality and other complications were reported and analysed. Variables deemed statistically significant (p-value < 0.05) were then included into a revised adjusted model of logistic regression analysis, where we reported on the odds ratio (OR). Results: The overall incidence of infection was 6.4% (n = 36/561; superficial: 3.7%; deep: 2.7%). Associations with deep infection included: non-union (OR 9.29 (2.56–3.38)), the presence of an open fracture (OR 4.23 (3.18–5.61)), the need for massive transfusion (OR 1.42 (2.39–8.39)), post-operative transfusion (OR 1.40 (1.10–1.79)) and prolonged length of stay (OR 1.04 (1.02–1.06)). The Commonest causes of superficial infection were Staphylococcus aureus (28.5%), enteric flora (23.8%) and mixed flora (23.8%); whereas coliforms (60%) and Staphylococcus aureus (26.7%) were the commonest micro-organisms isolated in deep infection. Polymicrobial infection was identified in 38.5% and 80% of superficial and deep infections, respectively. Conclusion: Causative micro-organisms identified in both superficial and deep infection were similar to those reported in post-traumatic osteomyelitis. In an attempt to minimise infection, the treating clinician should focus on modifiable risk factors with adequate patient optimisation, prompt surgical treatment, adequate antibiotic coverage and wound care when treating patients with subtrochanteric femur fracture.

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“…Surgical time (Gamma nail: 104.1 min; Affixus nail: 114.5 min) and length of stay (Gamma nail: 23.7 days; Affixus nail: 23.6 days) were comparable between the two nails in our study group. This finding is similar to that of Persiani et al, who, to our knowledge, performed the only study that compared the use of Affixus and Gamma nails in the treatment of trochanteric fractures [ 26 ]. Mortality rates at 1 year were not significantly different between the two nail groups.…”

Section: Discussionmentioning

confidence: 88%

Subtrochanteric femoral fractures and intramedullary nailing complications: a comparison of two implants

et al. 2022

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Introduction Intramedullary (IM) nails are considered the ‘gold’ standard treatment for subtrochanteric femoral fractures. The incidence and risk factors for re-operation in subtrochanteric fractures remain unclear. Furthermore, no studies have compared the outcomes of different nailing systems used to treat subtrochanteric fractures in the same study population. Aims/objectives Our study aimed to (i) investigate the cumulative incidence and factors associated with an increased risk of re-operation in subtrochanteric fractures treated with a long intramedullary (IM) nail, (ii) compare the outcomes of subtrochanteric fractures treated with long Affixus and Gamma nails, and (iii) establish whether the addition of a proximal anti-rotation screw in the Affixus nail confers any clinical benefit. Methods A retrospective review of all adult patients admitted to a level 1 trauma centre with a subtrochanteric femur fracture treated with a long cephalomedullary IM nail over an 8-year period was conducted. Exclusion criteria were primary surgery performed at another institution, prophylactic nailing because of tumours, incomplete fractures, and patients who were lost to follow-up or died before fracture healing. Data variables were assessed for normality prior to determining the use of either parametric or non-parametric tests. Logistic regression analysis was performed to identify potential factors associated with re-operation. For the comparison between the two nail types, patients were matched into two groups of 119 each by age (10-year intervals), gender and mechanism of injury (low energy, high energy and pathological fractures). A p-value < 0.05 was considered significant. The Kaplan–Meier nail survival curve was used to demonstrate the survival of each nail. Data were analysed using the statistical package R (R version 3.6.0). Results A total of 309 subtrochanteric fractures were treated with a distally locked long IM nail (re-operation rate: 22.33%) over an 8-year period. Logistic regression identified six factors associated with an increased risk of re-operation, including age < 75 years old, use of a long Gamma nail, pre-injury coxa-vara femoral neck shaft angles, an immediate post-operative reduction angle of > 10° varus, deep wound infection and non-union. Following matching, we compared the two long cephalomedullary nailing systems used (Gamma versus Affixus nail). The only differences identified from the unadjusted analysis were a higher overall incidence of nail failure in Gamma nails due to any cause, re-operation, and impingement of the nail tip distally against the anterior femoral cortex. When we corrected for covariates, no significant differences remained evident between the two nails. From the Kaplan–Meier nail survival curves, however, the Affixus nail demonstrated better survivorship up to 5 years post-implantation in terms of nail failure and re-operation for all causes. Finally, the addition of a proximal anti-rotation screw in the Affixus nail did not seem to confer any benefit. Conclusion We reported a 22.3% re-operation rate in our cohort of subtrochanteric fractures treated with a long IM nail. We have identified six risk factors associated with re-operation: age < 75 years old, pre-injury femoral neck shaft angle, choice of nail, varus reduction angle, fracture-related infection and non-union. The addition of a proximal anti-rotation screw in the Affixus nail did not confer any benefit.

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Choice of three different intramedullary nails in the treatment of trochanteric fractures: Outcome, analysis and consideration in midterm

Cited by 9 publications

References 22 publications

Blood loss and transfusion risk in intramedullary nailing for subtrochanteric fractures

Blood loss and transfusion risk in intramedullary nailing for subtrochanteric fractures

Surgical Site Infection Following Intramedullary Nailing of Subtrochanteric Femoral Fractures

Subtrochanteric femoral fractures and intramedullary nailing complications: a comparison of two implants

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