Characteristics of intramedullary nail breakage in pertrochanteric femur fractures: a summary of 70 cases

Objective To reveal noteworthy characteristics of intramedullary (IM) nail breakage in pertrochanteric femur fractures. Materials and methods The data from 6 patients with IM nail breakage in our hospital between August 2008 and May 2018 were reviewed retrospectively. With an additional 64 cases reported in articles in the PubMed database prior to October 2019, a total of 70 cases were reviewed and analysed; epidemiological patient data and data on the initial trauma, fracture type, nail selected for the original surgery, time from surgery to breakage, mechanism and location of breakage, status of fracture healing, salvage treatment and prognosis were assessed. Results Seventy patients with pertrochanteric fractures, including 2 stable fractures and 68 unstable fractures, experienced IM nail breakage at a mean of 9.4 months after the initial surgery. Among them, 9 (12.9%) occurred within 3 months, 23 (32.9%) between 3 and 6 months and 38 (54.3%) after 6 months. The mean age was 72.3 years, and 16 (22.9%) patients were younger than 65 years old. When nail breakage occurred, 66 fractures (94.3%) exhibited delayed union/non-union. Self-dynamisation was found in 12 cases (17.1%). The salvage procedures included 4 partial/total implant removal procedures, 17 hemi/total hip arthroplasty procedures, 3 conservative treatment procedures, and 46 revised osteosyntheses, of which 7 cases (15.2%) sustained secondary implant failure. No significant differences were found between the failure rates of IM nails and extramedullary(EM) devices (odds ratio [OR], 3.429; 95% confidence interval [CI], 0.632–18.877; p = 0.330). Conclusion IM nail breakage is a rare complication lack of time regularity and mostly occurs in unstable pertrochanteric fractures in the presence of delayed union/non-union. Osteosynthesis revision can be conduct by a new IM nail or EM device but considerable secondary failure rate is noteworthy. Self-dynamisation may be a warning sign of nail breakage.

Bipolar Hemiarthroplasty as Coxofemoral Bypass Technique in Treating Unstable Pertrochanteric Comminuted Fracture of Elderly Patients

BACKGROUND Pertrochanteric fractures in the elderly are highly unstable and osteoporotic. Comminution of fragments and distraction fragments make union difficult owing to forces acting on the proximal hip joint. The internal fixation in these cases leads to prolonged bed rest and immobilization to prevent implant failure. The purpose of this study was to analyse the role of bipolar hemiarthroplasty in cases of unstable pertrochanteric femur fractures as bypassing forces transmission through the proximal femur. METHODS 30 patients with pertrochanteric fractures were randomized and operated on as bipolar hemiarthroplasty using the indigenous bipolar prosthesis between July 2017 and July 2021. The inclusion criteria were patients more than 65 years of age, Type 4 intertrochanteric fracture (As per Evans classification) AO/ OTA type 31A2.3, 31A3.2, 31A3.3. Patients with polytrauma, compound injuries, pathological fractures and medically unfit patients were excluded from the study. RESULTS The mean age was 67 ± 5 years. The most common mechanism of injury was domestic fall comprising 80 %. The average duration of surgery from the time of injury was 3.5 ± 1.5 days. The average surgical duration was 85.5 mins. The average duration of stay in the hospital was 8.5 ± 1.5 days. Final results were calculated using the Harris Hip score with 33.3 % cases as excellent, 56.6 % cases as good and 10 % cases had fair results respectively. Follow-up was done at 6 weeks, 3, 6, 12 and 24 months. CONCLUSIONS Bipolar hemiarthroplasty in pertrochanteric femur fractures has the advantage of stable adequate fixation with early return to activities of daily living, thus preventing serious life-threatening complications. KEY WORDS Intertrochanteric Fractures, Hemiarthroplasty, Femur, Harris Hip Score

The Pre-Loaded Set-Screw in InterTAN Nail: Should It Be Tightened or Not Tightened in Pertrochanteric Hip Fractures

Background: InterTAN is a specific type of cephalomedullary nail with a twin interlocking de-rotation and compression screw, which has inherent ability of anti-rotation. Whether to tighten or not to tighten the preloaded setscrew to allow or not allow secondary sliding in InterTan nail is controversial in clinical practice. Methods: We retrospectively collected 4 nonunion cases of unstable pertrochanteric femur fractures (AO/OTA-31A2), all were treated with InterTan nail and the preloaded setscrew was tightened in order to prevent further secondary sliding and femoral neck shortening. Results: After 6 months to 2 years follow-up, the fractures showed nonunion in radiography and the patients complained slight to middle degrees of pain, and had to use walking stick assistant in activities of daily life. Tightening the pre-loaded setscrew to prevent postoperative secondary sliding as static constructs might keep the femoral neck length, but lose the opportunity of telescoping for fracture impaction, and take the risk of healing complications, such as fracture nonunion, femoral head cutout or nail breakage. Conclusions: As the harm outweighs benefit, we advocate the preloaded setscrew in InterTan nail should not be tightened in standard-obliquity pertrochanteric hip fractures (AO/OTA-31A1 and A2).

The pre-loaded set-screw in InterTAN nail: should it be tightened or not tightened in pertrochanteric hip fractures

Background: InterTan is a specific type of cephalomedullary nail with a twin interlocking de-rotation and compression screw, which has inherent ability of anti-rotation. Whether to tighten or not to tighten the preloaded setscrew in InterTan nail is controversial in clinical practice.Methods: We retrospectively collected four nonunion cases of unstable pertrochanteric femur fractures (AO/OTA-31A2), all were treated with InterTan nail and the preloaded setscrew was tightened in order to prevent further sliding and femoral neck shortening. Results: After 6 months to 2 years follow-up, the fractures showed nonunion in radiography and the patients complained slight to middle degrees of pain, and had to use walking stick assistant in activities of daily life. Tightening the pre-loaded setscrew to prevent postoperative secondary sliding as static constructs might keep the femoral neck length, but lose the opportunity of telescoping for fracture impaction, and take the risk of healing complications, such as fracture nonunion, femoral head cutout or nail breakage.Conclusions: As the harm outweighs benefit, we advocate the preloaded setscrew in InterTan nail should not be tightened in pertrochanteric hip fractures (AO/OTA-31A1 and A2).