Interpreting and reporting fracture classification and operation type in hip fracture

Aims This study explores data quality in operation type and fracture classification recorded as part of a large research study and a national audit with an independent review. Patients and Methods At 17 centres, an expert surgeon reviewed a randomly selected subset of cases from their centre with regard to fracture classification using the AO system and type of operation performed. Agreement for these variables was then compared with the data collected during conduct of the World Hip Trauma Evaluation (WHiTE) cohort study. Both types of surgery and fracture classification were collapsed to identify the level of detail of reporting that achieved meaningful agreement. In the National Hip Fracture Database (NHFD), the types of operation and fracture classification were explored to identify the proportion of “highly improbable” combinations. Results The records were reviewed for 903 cases. Agreement for the subtypes of extracapsular fracture was poor; most centres achieved no better than “fair” agreement. When the classification was collapsed to a single option for “extracapsular” fracture, only four centres failed to have at least “moderate” agreement. There was only “moderate” agreement for the subtypes of intracapsular fracture, which improved to “substantial” when collapsed to “intracapsular”. Subtrochanteric fracture types were well reported with “substantial” agreement. There was near “perfect” agreement for internal fixation procedures. “Perfect” or “substantial” agreement was achieved when the type of arthroplasty surgery was reported at the level of “hemiarthroplasty” and “total hip replacement”. When reviewing data submitted to the NHFD, a minimum of 5.2% of cases contained “highly improbable” procedures for the stated fracture classification. Conclusion The complexity of collecting fracture classification data at a national scale compromises the accuracy with which detailed classification systems can be reported. Data around type of surgery performed show similar tendencies. Data capture, reporting, and interpretation in future studies must take this into account. Cite this article: Bone Joint J 2019;101-B:1292–1299

Gamma nail in the management of intertrochanteric fractures of femur in adults

Background: Intertrochanteric fracture is an extracapsular fracture of the proximal femur. Gamma nail is a cephalomedullary nail that is emerging as the treatment of choice for intertrochanteric fractures. For intertrochanteric fractures, the use of cephalomedullary devices has increased dramatically to 67% among surgeons over the years. Aims of this study was to observe the results of operative treatment of intertrochanteric fractures with Gamma 3 trochanteric nail.Methods: This prospective study was conducted in the Post Graduate Department of Orthopaedics of Government Medical College, Srinagar. This study included 30 cases of intertrochanteric fractures who attended hospital for bone and joint surgery.Results: Excellent results were obtained in 80% patients and good results were obtained in rest 20% with an average Harris hip score of 93.8. Average time to union was 11.6 weeks. There were no non-unions, screw cut outs or peri-implant fractures. The most common complication was varus malunion occurring in 20% patients. However, significant malunion (greater than 10 degrees) was present in only one patient among them.Conclusions: This study finds Gamma 3 nail to be a versatile, easy to use and dependable implant in intertrochanteric fractures. Gamma 3 nail is an ideal implant for stable as well as unstable intertrochanteric fractures and is a distinct advance over the previous methods of treatment, though it has an initial learning curve.

Treatment With Helical Blade Cephalomedullary Nail for Two-Part Basicervical Proximal Femoral Fracture in Elderly Patients: A Retrospective Observational Study

Background: Basicervical proximal femoral fracture is a known subtype of extracapsular fracture and is mechanically unstable, especially for the rotational direction, which may lead to implant failure. A cephalomedullary nail (CMN) is widely used for the fixation of unstable extracapsular fracture; however, its application for basicervical fracture remains controversial. Helical blade CMN is proven to have more rotational stability than traditional lag screw implants and potentially advantageous in the treatment of basicervical fracture. The aim of this study is to assess the effectiveness of helical blade CMN for basicervical fracture in elderly patients. Methods: We conducted a retrospective review of 500 consecutive extracapsular fracture patients treated surgically between January 2005 and February 2015. Patients who had trochanteric extension or multifragment fracture were excluded. Sixteen cases of 2-part basicervical proximal femoral fracture were identified. All patients were treated with the same single helical blade CMN system (DePuy Synthes PFNA-II). Implant-related complications were recorded. Results: Two patients dropped out during follow-up and 14 patients were included in the analysis. The average follow-up period was 21.9 months. No major complication was observed. The patients were subcategorized into 2 groups: nondisplaced (displacement <2 mm at any point of the fracture line) or displaced. Excessive telescoping was observed in 2 patients, both of whom were in the displaced fracture group. The overall implant-related complication rate was 14.2% (2/16). Conclusion: Internal fixation with the helical blade CMN system can be considered as a treatment option for 2-part basicervical proximal femoral fracture in elderly patients.