Direct reduction may need to be considered to avoid postoperative subtype P in patients with an unstable trochanteric fracture: a retrospective study using a multivariate analysis

Kozono, Naoya; Ikemura, Satoshi; Yamashita, Akihisa; Harada, Takashi; Watanabe, Tetsuya; Shirasawa, Kenzo

doi:10.1007/s00402-014-2089-2

Cited by 50 publications

(27 citation statements)

References 13 publications

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“…5 ). The anterior cortical contact after head–neck sliding can also provide rigid buttress for secondary stability [ 23 , 24 ]. However, considering the essence of lateral sliding direction, we think positive medial cortical support maybe more effective than anterior cortical contact [ 14 ].…”

Section: Discussionmentioning

confidence: 99%

Fracture reduction with positive medial cortical support: a key element in stability reconstruction for the unstable pertrochanteric hip fractures

Chang

Zhang

et al. 2015

Arch Orthop Trauma Surg

181

150

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PurposeTo introduce the concept of fracture reduction with positive medial cortical support and its clinical and radiological correlation in geriatric unstable pertrochanteric fractures.MethodsA retrospective analysis of 127 patients (32 men and 95 women, with mean age 78.7 years) with AO/OTA 31A2.2 and 2.3 hip fractures treated with cephalomedullary nail (PFNA-II or Gamma-3) between July 2010 and June 2013 was performed. They were classified into three groups according the grade of medial cortical support in postoperative fracture reduction (positive, neutral, and negative). The positive cortex support was defined that the medial cortex of the head–neck fragment displaced and located a little bit superomedially to the medial cortex of the shaft. If the neck cortex is located laterally to the shaft, it is negative with no cortical buttress, and if the two cortices contact smoothly, it is in neutral position. The demographic baseline, postoperative radiographic femoral neck–shaft angle and neck length, rehabilitation progress and functional recovery scores of each group were recorded and compared.ResultsThere were 89 cases (70 %) in positive, 26 in neutral, and 12 in negative support. No statistical differences were found between the three groups among patient age, sex ratio, prefracture score of activity of daily living, walking ability score, ASA physical risk score, number of medical comorbidities, osteoporosis Singh index, fracture reduction quality (Garden alignments), and the position of lag screw or helical blade in femoral head (TAD). In follow-up, patients in positive medial cortical support reduction group had the least loss in neck–shaft angle and neck length, and got ground-walking much earlier than negative reduction group, with good functional outcomes and less hip–thigh pain presence.ConclusionFracture reduction with nonanatomic positive medial cortical support allows limited sliding of the head–neck fragment to contact with the femur shaft and achieve secondary stability, providing a good mechanical environment for fracture healing.

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Section: Discussionmentioning

confidence: 99%

Fracture reduction with positive medial cortical support: a key element in stability reconstruction for the unstable pertrochanteric hip fractures

Chang

Zhang

et al. 2015

Arch Orthop Trauma Surg

181

150

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“…7,8) In order to avoid excessive sliding in unstable IT fractures with posteromedial (PM) comminution and in reverse obliquity fracture, EM reduction has been introduced to reduce the sliding distance and shortening of the lever arm. [9][10][11][12][13] In EM reduction, the AM cortical bone of the proximal fragment has early bony contact with the distal fragment during sliding, and it theoretically plays a role as a buttress from the beginning and prevents excessive sliding and varus deformity of the proximal fragment. From a functional point of view, Chang et al 12) defined EM reduction as 'positive medial cortical support'.…”

Section: Introductionmentioning

confidence: 99%

The Effects of Extramedullary Reduction in Unstable Intertrochanteric Fracture: A Biomechanical Study Using Cadaver Bone

2018

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To prevent excessive sliding and subsequent fixation failures in unstable intertrochanteric fractures with posteromedial comminution, extramedullary reduction through overlapping of the anteromedial cortices of both proximal and distal fragments as a buttress has been introduced. The purpose of this study was to compare the biomechanical properties between two reduction methodsintramedullary reduction and extramedullary reduction-in treating unstable intertrochanteric fractures with posteromedial comminution (AO/OTA classification 31-A2.2). Materials and Methods: Eight pairs of frozen human cadaveric femora were used. The femora of each pair were randomly assigned to one of two groups: the intramedullary reduction group or the extramedullary reduction group. A single axial load-destruction test was conducted after cephalomedullary nailing. Axial stiffness, maximum load to failure, and energy absorbed to failure were compared between the two groups. Moreover, the pattern of mechanical failure was identified. Results: The mean axial stiffness in the extramedullary reduction group was 27.3% higher than that in the intramedullary reduction group (422.7 N/mm vs. 332.0 N/mm, p=0.017). Additionally, compared with the intramedullary reduction group, the mean maximum load to failure and mean energy absorbed to failure in the extramedullary group were 44.9% and 89.6% higher, respectively (2,848.7 N vs. 1,966.5 N, p=0.012 and 27,969.9 N•mm vs. 14,751.0 N•mm, p=0.012, respectively). In the intramedullary reduction group, the mechanical failure patterns were all sliding and varus deformities. In the extramedullary reduction group, sliding and varus deformities after external rotation were noted in 3 specimens, sliding and varus deformities after internal rotation were noted in 3 specimens, and medial slippage was noted in 2 specimens. Conclusion: In unstable intertrochanteric fractures with posteromedial comminution, the biomechanical properties of extramedullary reduction are superior to those of intramedullary reduction. Anteromedial cortex could be the proper buttress, despite a comminuted posteromedial cortex. It could help enhance the stability of the bone-nail construct.

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“…For example, a very small number of fracture lines in zones 2, 3, and 4 are an inverted “V” shape. The different types of fracture lines aside, it is not easy to perfectly reduce an anterior fracture [ 18 , 20 ] because the iliofemoral ligament restrains the anterior displacement of the femoral neck [ 21 ]. The lines in Type A3 fractures have the same features as in Type A1 and A2 fractures, but their range is larger in the lateral femur, affecting the femoral shaft.…”

Section: Discussionmentioning

confidence: 99%

Three-Dimensional Computed Tomography (CT) Mapping of Intertrochanteric Fractures in Elderly Patients

Liu

Zhao

et al. 2020

Med Sci Monit

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Background The complex anatomy of the trochanter and the diversity in mechanisms of injury to it complicate intertrochanteric fracture patterns. Using digital technology, we created three-dimensional (3D) computed tomography (CT) mapping to show the relevant characteristics of intertrochanteric fractures in elderly patients. Material/Methods This was a retrospective analysis of a case series of closed intertrochanteric fractures in patients older than age 60 years who had sustained single-sided injuries less than 1 week previously. High-quality CT scans of the cases were used to create a 3D reconstruction fracture model, and fracture maps of the proximal femur were created by overlapping the fracture lines. Results A total of 115 patients were enrolled in this study, with mean age of 78 years (SD 7.98 years; range, 60 to 96 years). The essential features of the fracture lines were recorded in each case. Fracture maps revealed that the fracture lines were mainly concentrated in the area of the lesser and greater trochanter, intertrochanteric line, and intertrochanteric crest. As for fracture subtypes, results between patients were similar for Types A1 and A2 fractures, and differed for Type A3 fractures. Conclusions Detailed analysis of essential features of fracture lines revealed fracture fragments, some of which may be difficult to see using traditional imaging methods. Fracture maps composed of interindividual fracture lines revealed the relevant characteristics of intertrochanteric fractures in elderly patients. The resulting information about characteristics of distribution of fracture lines may be helpful in clinical practice.

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Direct reduction may need to be considered to avoid postoperative subtype P in patients with an unstable trochanteric fracture: a retrospective study using a multivariate analysis

Abstract: The results of this study suggest that direct reduction via a small elevator with a small skin incision or percutaneous intrafocal pinning may be needed in these cases.

Cited by 50 publications

References 13 publications

Fracture reduction with positive medial cortical support: a key element in stability reconstruction for the unstable pertrochanteric hip fractures

Fracture reduction with positive medial cortical support: a key element in stability reconstruction for the unstable pertrochanteric hip fractures

The Effects of Extramedullary Reduction in Unstable Intertrochanteric Fracture: A Biomechanical Study Using Cadaver Bone

Three-Dimensional Computed Tomography (CT) Mapping of Intertrochanteric Fractures in Elderly Patients

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