OBJECTIVE: In pertrochanteric femur fractures the risk for fracture healing complications increases with the complexity of the fracture. In addition to dynamization along the lag screw, successful fracture healing may also be facilitated by further dynamization along the shaft axis. The aim of this study was to investigate the mechanical stability of additional axial notch dynamization compared to the standard treatment in an unstable pertrochanteric femur fracture treated with cephalomedullary nailing.
METHODS: In 14 human cadaver femora, an unstable pertrochanteric fracture was stabilized with a cephalomedullary nail. Additional axial notch dynamization was enabled in half of the samples and compared against the standard treatment (n = 7). Interfragmentary motion, axial construct stiffness and load to failure were investigated in a stepwise increasing cyclic load protocol.
RESULTS: Mean load to failure (1414 ± 234 N vs. 1428 ± 149 N, p = 0.89) and mean cycles to failure (197,129 ± 45,087 vs. 191,708 ± 30,490, p = 0.81) were equivalent for axial notch dynamization and standard treatment, respectively. Initial construct stiffness was comparable for both groups (axial notch dynamization 684 [593-775] N/mm, standard treatment 618 [497-740] N/mm, p = 0.44). In six out of seven specimens the additional axial dynamization facilitated interfragmentary compression, while maintaining its mechanical stability. After initial settling of the constructs, there were no statistically significant differences between the groups for either subsidence or rotation of the femoral head fragment (p ≤ 0.30).
CONCLUSIONS: Axial notch dynamization provided equivalent mechanical stability compared to standard treatment in an unstable pertrochanteric fracture. Whether the interfragmentary compression generated by axial notch dynamization will promote fracture healing through improved fracture reduction needs to be evaluated clinically.

BACKGROUND: The intertrochanteric fracture is a frequently occurring fracture, often attributed to osteoporosis in older populations. Recently, there has been a proposal to perform early surgical fixation on elderly patients to facilitate early rehabilitation. This approach has been shown to have a beneficial effect in lowering comorbidities. The study aims to compare the efficacy of the twin screw derotation type cephalomedullary nail with that of the single helical blade type cephalomedullary nail in the management of unstable intertrochanteric fractures.
METHODS:  The research sample included patients from the orthopedic outpatient and emergency departments of Adesh Medical College and Hospital, Ambala Cantt, India, who were scheduled for surgery for unstable intertrochanteric femur fractures. The patients were categorized into two groups according to the kind of implant they were given: either a twin screw derotation cephalomedullary nail or a single helical blade cephalomedullary nail. The functional result was evaluated by comparing the modified Harris hip score (HHS). Patients with unstable intertrochanteric fractures, including reverse oblique fractures and fractures with posteromedial comminution, as well as patients who provided consent, were included in this study.
RESULTS:  Thirteen individuals received treatment with proximal femoral nail antirotation (PFNA2), whereas 19 individuals received treatment with proximal femoral nail (PFN). The mean age in the PFNA2 group was 69.51, whereas the mean age in the PFN group was 70.804. There were three patients in the PFNA2 group and five patients in the PFN group who had a tip apex distance of more than 25 mm. According to the Cleveland index, nine patients in the PFNA2 group and eight patients in the PFN group had an implant location that was not optimum. Four patients in the PFNA2 group and seven patients in the PFN group had a neck shaft angle difference of more than 10° between their undamaged and operated sides. The mean HHS was 74.55 for the PFNA2 group and 69.88 for the PFN group. The PFNA2 group exhibited four problems, whereas the PFN group had five issues.
CONCLUSIONS:  The study found that both implants offer similar functional outcomes, with adherence to specific radiological parameters optimizing results. While both face similar challenges with osteoporosis, there was no notable distinction between them. Notably, the PFNA2 group showed superior outcomes in perioperative morbidity.

BACKGROUND: Proximal femur fractures are common in older patients and typically require surgical treatment, with cephalomedullary nails being the gold standard device for this approach. This study aimed to identify the factors associated with the failure of cephalomedullary nailing.
METHODS: We retrospectively evaluated 380 patients treated with a cephalomedullary nail between August 2021 and August 2022 in a trauma referral center in Brazil. A total of 221 (58.1%) patients were included in the study after applying specific eligibility criteria. Data were collected and rates were determined by reviewing patients\' medical records and radiographs.
RESULTS: Of 221 patients, 14 (6.3%) had nail failures A significant association was found between post-fixation cervico-diaphyseal angle and the occurrence of nail failure (p<0.001). Furthermore, calcar-referenced tip-apex distance (CalTAD) and tip-apex distance (TAD) values were higher in cases with nail failure than in those without nail failure. Cutoff points were established for TAD and CalTAD to measure the correspondence with nail failures.
CONCLUSIONS: The present study supports previous evidence that varus reduction potentially causes collapse and nail failure in pertrochanteric fractures treated with cephalomedullary nailing and that high TAD and CalTAD values contribute to the incidence of cut-out.

UNASSIGNED: Conventional cephalomedullary nails (CMNs) are commonly employed for internal fixation in the treatment of reverse obliquity intertrochanteric (ROI) fractures. However, the limited effectiveness of conventional CMNs in addressing ROI fractures results in significant implant-related complications. To address challenges associated with internal fixation, a novel Proximal Femoral Bionic Nail (PFBN) has been developed.
UNASSIGNED: In this study, a finite element model was constructed using a normal femoral specimen, and biomechanical verification was conducted using the GOM non-contact optical strain measurement system. Four intramedullary fixation approaches-PFBN, Proximal Femoral Nail Antirotation InterTan nail (ITN), and Gamma nail (Gamma nail)-were employed to address three variations of ROI fractures (AO/OTA 31-A3). The biomechanical stability of the implant models was evaluated through the calculation of the von Mises stress contact pressure and displacement.
UNASSIGNED: Compared to conventional CMNs, the PFBN group demonstrated a 9.36%-59.32% reduction in the maximum VMS at the implant. The A3.3 ROI fracture (75% bone density) was the most unstable type of fracture. In comparison to conventional CMNs, PFBN demonstrated more stable data, including VMS values (implant: 506.33 MPa, proximal fracture fragment: 34.41 MPa), contact pressure (13.28 MPa), and displacement (17.59 mm).
UNASSIGNED: Compared to the PFNA, ITN, and GN, the PFBN exhibits improvements in stress concentration, stress conduction, and overall model stability in ROI fractures. The double triangle structure aligns better with the tissue structure and biomechanical properties of the proximal femur. Consequently, the PFBN has significant potential as a new fixation strategy for the clinical treatment of ROI fractures.

UNASSIGNED: The ideal treatment of peri-implant femur fractures (PIFFs) remains unclear due to the thin clinical and biomechanical evidence concerning the most suitable form of osteosynthesis. The purpose of the present study was thus to determine the biomechanical stability that results from combining a cephalomedullary nail and a plate for proximal PIFFs, especially when the nail-plate docking technique is applied.
UNASSIGNED: Twenty four PIFFs were simulated in both 12 foam and 12 composite specimens and were stabilized via a combination of a cephalomedullary nail and a plate. The control group (n = 6) had a nail and a plate without a connection, while the intervention group (n = 6) had a screw that connected the plate with the interlocking screw hole of the nail, thereby creating a nail-plate docking system. The specimens were evaluated under axial and torsional loading using a material-testing machine and a 3D metrology system.
UNASSIGNED: The data regarding stiffness, failure load, and failure displacement showed significantly higher stability for specimens without nail-plate docking. For docked specimens, a non-significant trend toward a higher resistance to torque was observed. Both techniques displayed no significant difference in fracture gap displacement or total displacement.
UNASSIGNED: The present study suggests that nail-plate docking of a cephalomedullary nail, and a plate significantly decreases the stiffness and stability of osteosynthesis under axial loading. However, there seems to be a tendency toward higher resistance to torque. Therefore, surgeons should consider this technique if higher torsional stability is necessary, and they should decide against it, if axial stability is preferred.

UNASSIGNED: The purpose of this study was to determine if augmentation of the helical blade with polymethylmethacrylate bone cement decreases the rates of varus cut-out and medial perforation in geriatric intertrochanteric hip fracture fixation.
UNASSIGNED: This was a retrospective comparative cohort study at two urban Level I trauma centers. Patients with an intertrochanteric hip fracture (classified as AO 31A1-3) who were treated with the TFN-Advanced Proximal Femoral Nailing System (TFNA) from 2018 to 2021 were eligible for the study. Medical records and post-operative radiographs were reviewed to determine procedure complications and reoperations.
UNASSIGNED: Of the 179 patients studied, cement augmentation (CA) was used in 93 patients (52%) and no cement augmentation (NCA) was used in 86 (48%). There were no significant differences between group demographics and fracture reduction grades. Varus cut-out occurred three times in the CA group and five times in the NCA group (p = 0.48). Medial perforation occurred three times, all in the NCA group (p = 0.11). The most frequent complication was symptomatic blade lateralization from fracture collapse, with eight occurrences in the CA group compared with two in the NCA group (p = 0.10). There were 10 reoperations in the CA group and 9 in the NCA group (p = 0.99). The most common reason for reoperation was varus cut-out and the most common revision procedure was hip arthroplasty.
UNASSIGNED: Intertrochanteric hip fractures treated with the TFNA fixation system with and without cement augmentation have similar complication profiles and reoperation rates.

UNASSIGNED: Operative management with intramedullary nail fixation remains the definitive treatment of choice for osteoporotic subtrochanteric (ST) fractures; however, there remains no consensus regarding the proper nail length. We aimed to use 3-dimensional finite element (FE) analysis to determine the optimal nail length for the safe fixation of osteoporotic ST fractures.
UNASSIGNED: Nine modes of FE models were constructed using 9 different lengths of cephalomedullary nails (short nails: 170, 180, and 200 mm; long nails: 280, 300, 320, 340, 360, and 380 mm) from the same company. The interfragmentary motion was analyzed. Additionally, the peak von Mises stress (PVMS) in the cortical bone, cancellous bone of the femoral head, and the nail were measured, and the yielding risk for each subject was investigated.
UNASSIGNED: Long nails were associated with less interfragmentary motion. In the cortical bone, the PVMS of short nails was observed at the distal locking screw holes of the femoral medial cortex; however, in long nails, the PVMS was observed at the lag screw holes on the lateral cortex. The mean yielding risk of long nails was 40.1% lower than that of short nails. For the cancellous bone of the femoral head, the PVMS in all 9 FE models was in the same area: at the apex of the femoral head. There was no difference in the yielding risk between short and long nails. For implants, the PVMS was at the distal locking screw hole of the nail body in the short nails and the nail body at the fracture level in the long nails. The mean yielding risk was 74.9% lower for long nails than that for short nails.
UNASSIGNED: Compared to short nails, long nails with a length of 320 mm or more showed less interfragmentary motion and lower yielding risk in low-level osteoporotic ST fractures. The FE analysis supports long nails as a safer option than short nails, especially for treating transverse-type low-level osteoporotic ST fractures.

BACKGROUND: Reduction quality is of paramount importance for an optimal outcome in unstable pertrochanteric fractures. The non-anatomical functional anteromedial buttress is proposed to prevent impending mechanical complications. We aimed to evaluate the role of anteromedial cortical support in preventing mechanical complications following fixation with the cephalomedullary nail.
METHODS: A prospective, single-arm interventional study was conducted in the Orthopaedics Department of a Combined Military Hospital (CMH) in Rawalpindi. The duration of the study was 24 months. Patients were recruited by the purposive sampling technique as per inclusion/exclusion criteria. Preoperatively, the reduction was categorized as per Baumgartner\'s and Chang\'s criteria. Post-operatively, weight bearing as tolerated was advised. Radiographs prior to discharge for loss of reduction were evaluated. Follow-up radiographic measurements of neck length, neck shaft angle, and their loss as per protocol were done at three and six months.
RESULTS: A total of 202 patients were operated on from October 21 until August 23. Mortality at six months in 39 patients (19.3%) and loss to follow-up in 31 patients (15.3%) resulted in 132 patients with complete follow-up and having developed complications in 12 patients (9.09%). The mean age was 76.3 ± 7.98 years; males were 105 (79.5%), and females were 27 (20.5%). Closed reduction was 58 (43.9%), and additional manoeuvres were required in 74 (56.1%). The mean tip apex distance (TAD) was 24.56 ± 2.76, and the Calcar gap was 5.16 ± 1.27. Cleveland zone centre-centre in 54 (40.9%), inferior-centre in 65 (49.2%), and inferior-posterior (9.9%) were statistically significant for mechanical complications (p≤0.001). There was a significant association between the grading of Chang\'s and Baumgartner\'s poor groups for the development of mechanical complications (p≤0.001). The mean time to full weight bearing without support was 21 ± 1.22 weeks. The mean Hip Harris score at six months was 69.27 ± 7.68.
CONCLUSIONS: Results suggest that anteromedial cortical support can lead to fewer potential mechanical complications at six months. A higher Chang\'s grade drives surgeons to engage in additional manoeuvres. Anteromedial cortical support is worth consideration for unstable pertrochanteric fractures.

BACKGROUND: The primary aim of this study was to evaluate the clinical and radiological outcomes after surgical treatment of proximal femoral fractures utilizing the Proximal Femoral Nail Antirotation (PFNA), with the main focus on complications and reoperations. The secondary aim was to compare the outcomes of patients with and without cement augmentation of the cephalomedullary nails.
METHODS: All patients with an acute proximal femoral fracture consequently treated with a PFNA between January 2011 and Dezember  2018 were evaluated. Clinical and radiological data were assessed for intra- and postoperative complications, including treatment failure. In addition, intra- and postoperative radiographs were used to determine the position of the implant, and any migration, via Tip-Apex-Distance (TAD) and the caput-collum-diaphyseal angle (CCD). The accuracy of the fracture reduction was rated according to Baumgaertners criteria.
RESULTS: Two hundred sixty-four consecutive patients (mean age 78.8 ± 12.0; 73.1% female) were included. The predominant OTA/AO fracture classification was 31A1 (153 cases, 58.0%). The average duration of surgery was 63.1 ± 28.0 min and showed no significant differences between PFNA and PFNA with augmentation. The implant positioning was rated as good in 222 cases (84.1%). Two hundred sixty-three patients (99.6%) showed evidence of healing within the time frame of three months postoperatively, one case of delayed union healed after secondary dynamization. During the observational period, 18 patients (6.8%) required a total of 23 additional surgeries. Overall, a lower reoperation rate was observed following the use of the augmentation option (2/86 patients (2.3%) vs. 16/178 patients (9.0%), p = 0.04). In particular, there were no cases of cut-out or cut-through among patients who underwent augmentation as part of osteosynthesis.
CONCLUSIONS: Overall reoperation rate after surgical treatment of proximal femoral fractures utilizing the Proximal Femoral Nail Antirotation (PFNA) was 6.8%, with 23 additional surgeries performed in 18 patients. The usage of the PFNA with augmentation showed equally good implant positioning, excellent healing rates and fewer postoperative complications compared to the PFNA implant alone with a similar overall duration of surgery.

BACKGROUND: The exact positioning of the cephalomedullary (CM) nail entry point for managing femoral fractures remains debatable, with significant implications for fracture reduction and postoperative complications. This study aimed to explore the variability in the selection of the entry point among trauma surgeons, hypothesizing potential differences and their association with surgeon experience.
METHODS: In this prospective multicenter study, 16 participants, ranging from residents to senior specialists, partook in a simulation wherein they determined the optimal entry point for the implantation of a proximal femoral nail antirotation (PFN-A; DePuy Synthes) in various femora. The inter- and intra-observer variability was calculated, along with comprehensive descriptive statistical analysis, to assess the variability in entry point selection and the impact of surgeon experience.
RESULTS: In this study, the mean distance from the selected entry points to the calculated mean entry point was 3.98 mm, with a smaller distance observed among surgeons with more than 500 implantations (ANOVA, p = 0.050). Intra-surgeon variability for identical femora averaged at 5.14 mm, showing no significant differences across various levels of surgical experience or training. Notably, 13.6% of selected entry points would not allow a proper intramedullary positioning of the implant, thereby rendering anatomical repositioning unfeasible. Among these impossible entry points, a significant skew towards anterior placement was observed (70.6% of the impossible entry points), with a smaller fraction being overly lateral (27.5%) or medial (13.7%). On a patient level, the impossibility rate varied widely from 0 to 35% among the different femora examined, with a significantly higher rate seen in younger patients (mean age 55.02 versus 60.32; t-test for independent samples, p = 0.04).
CONCLUSIONS: Significant variations exist in surgeons\' selection of entry points for proximal femoral nailing, underscoring the task\'s complexity. Experience does not prevent the choice of unfeasible entry points, emphasizing the inadequacy of a universal approach and pointing towards the necessity for a patient-specific strategy for improved outcomes.
BACKGROUND: DRKS00032465.