- Email: [email protected]
Good outcome of 172 pertrochanteric hip fractures treated with Gamma-Nail in our department
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Abstracts / Injury, Int. J. Care Injured 40S (2009) S7–S24
per case and, therefore, to net savings for those health care systems. The main driver for cost savings is faster fracture healing with faster resumption of work and reduced expenses for sickness leave payments. For the UK rhBMP-2 is a cost-effective strategy with a costeffectiveness ratio of approx. £14,000/QALY which is well below the standard £30,000 benchmark for the NHS. From a societal perspective, rhBMP-2 is a cost-saving treatment. Conclusions: BMP-2 leads to net savings in grade III open tibia fractures in Germany and France which can be expected for other European countries where sickness payments are provided by health care insurers. For countries like UK where sickness are provided by third parties BMP-2 is a cost-effective treatment strategy from a health care system perspective and a cost-saving treatment from a societal perspective. doi:10.1016/j.injury.2009.07.015 3 Subtrochanteric fractures treatment with cephalomedullary nails: Open vs. close reduction? N. Tzachev ∗ , A. Baltov, A. Iotov Military Medical Academy, Sofia, Bulgaria Study rationale: To compare intra- and post-operative indicators in the cases of open and close reposition of the subtrohanteric fractures treated by cephalomedullary nails. Materials/patients and methods: For the period from March 2002 to 2009 we have used cephalomedullary ostheosynthesis in 155 patients with subtrochanteric and reverse obliquity intertrochanteric fractures. These were 83 men and 72 women at the age from 16 to 91(average age – 60.9). The reverse obliquity intertrochanteric fractures of 31A3-1 type were 55. We indicated and applied the implant in all subtrochanteric fractures from 32A type to C – their number was 100. In 95 of the cases the close reposition was good. In 40 of the cases we did open reposition and screw or cerclage fixation, after which osteosynthesis with cephalomedullary nails. In 20 of the cases we did not achieved a good primary reposition. In these cases an open reposition of the fragments was not done. Results: In close reposition we achieved the following operative data: mean operative time – 60 min, mean blood loss – 300 ml, Rö time – 3, 5 min, mean hospital stay – 10 days, mean time to full weight bearing – 40 days. In the cases of a good primary reposition we registered bone union about the 60th day. In the cases of bad reposition – bone union was registered between the 90th and 100th day. In the cases of open reposition we achieved the following operative data: Mean operative time – 90 min, mean blood loss – 400 ml, Rö time – 5 min, mean hospital stay – 12 days, mean time to full weight bearing – 30 days. Bone union – 60 days. Conclusions: The evacuation of the surrounding fracture haematoma, the duration of the intervention and the prolonged Rö time in open reposition are compensated by the earlier consolidation of the fracture and the earlier full weight bearing. doi:10.1016/j.injury.2009.07.016
4 Antegrade interlocking nailing in humeral shaft fracture – To ream or not? A. Baltov ∗ , N. Tzachev, A. Iotov Military Medical Academy, Sofia, Bulgaria Study rationale: Does the reaming with AILN influence the period of union, the pain in the shoulder and the final functional result in humeral shaft fractures? Materials/patients and methods: 72 patients divided into two groups, meeting the following criteria: acute fractures, open and non-open 1st degree, after AILN. Excluding criteria: open fractures 2nd and 3rd degree according to Gustilo-Anderson, associated fractures in the area of the shoulder gird, delayed union, nonunion, pathological fracture, ASA gr. III–IV and retrograde nailing. Group A – 36 shaft humeral fractures operated with AILN with reaming: 15 women and 21 men at the average age of 43 (18–81), 20 of them high-energetic and 13 with poly-trauma. Divided according to AO classification: A type – 16, B type – 13 and C type – 7. Group B – 36 shaft humeral fractures operated with AILN without reaming: 11 women and 25 men at the average age of 44 (17–77), 21 of them high-energetic and 12 with poly-trauma. Divided according to AO classification: A type – 14, B type – 15 and C type – 7. Follow up period: 1–6 years. Final functional result according to Constant score according to D. Boehm and DASH score. Results: There is no significant difference between the two groups regarding the period of union, pain and the function of the shoulder. Conclusions: The reaming does not influence the final functional result after AILN, does not increase the danger of damaging the rotator cuff with the right operative technique and does not shorten the period of union. It is advisable to be applied in narrow intramedullary channel only. doi:10.1016/j.injury.2009.07.017 5 Good outcome of 172 pertrochanteric hip fractures treated with Gamma-Nail in our department V. Goulidakis ∗ , S. Theocharakis, V. Chronopoulos, E. Drakoulakis, A. Pastroudis 6th Orthopaedic Department Asklipiion Voulas, General Hospital, Athens, Greece Study rationale: The intramedullary fixation with the 3rd generation Gamma-Nail is a surgical method for the treatment of pertrochanteric hip fractures. The goal of this study is to observe the results of this treatment in our patients. Materials/patients and methods: In this retrospective study we observe the results of our treatment with G3-Nail in patients with pertrochanteric hip fracture from June 2006 to December 2007. In this 19-month period of time 382 patients were admitted with this diagnosis in our department and of those 172 were treated with G3-Nail intramedullary fixation. Of those fractures 149 were intertrochanteric and the standard G3-Nail was applied and 23 were subtrochanteric and were treated with Long G3-Nail. The technique of the fracture fixation was the standard close reduction and intramedullary fixation. We documented demographic data, blood loss and transfusion needs postoperatively, length of hospital stay, time to full weight-bearing and return to pretrauma walking ability as well as time of union, functional ability using Harris hip score and complications.
Abstracts / Injury, Int. J. Care Injured 40S (2009) S7–S24
Results: The mean follow up time was 23 months (18–36). There were 36 male and 136 female with mean age of 76 years. The mean degrease of Hb was 2.3 and the mean need for blood was 1.2 units. The average length of hospital stay was 4.5 days, the time to full weight-bearing 7.1 days and the return to pretrauma ability 4.1 weeks. The mean time of union was 15 weeks (12–24) and the functional results using Harris hip score were good to excellent. As complications we had no case of deep infection, loss of reduction and nonunion, one case with PE and one with heart attack. The above cases finally died. Conclusions: Treatment of pertrochanteric hip fractures with G3Nail seems to be an excellent choice with very good results and low percentage of complications. doi:10.1016/j.injury.2009.07.018 6 Functional outcomes and health-related quality of life after intramedullary nailing of tibia shaft fractures D. Stengel ∗ , A. Ekkernkamp, M. Wich Unfallkrankenhaus Berlin Trauma Center, Germany Study rationale: Whilst most patients will achieve solid union after intramedullary nailing of closed and I◦ open tibia shaft fractures, data on function and health-related quality of life are still rare. Our objective was to assess patient-reported outcomes after this frequent procedure, and to identify potential predictors of treatment failure and success. Materials/patients and methods: After IRB approval, skeletally mature male and female subjects with isolated, unilateral closed or I◦ open tibia shaft fractures suitable for reamed intramedullary nailing (Versa, DePuy) were enrolled in this prospective single-center study. Full digital radiographs in two standard planes were obtained on hospital admission, post-operatively, and during follow-up on discretion of the surgeon on charge. Protocol-driven follow-up was conducted by a research assistant. Generic quality of life was assessed using the Short Form 36 (SF-36) physical and mental component scores (PCS/MCS). Function was evaluated by the Lower Extremity Functional Scale (LEFS). Because of the observational nature of this study, we did not pose a formal null-hypothesis. A sample size of 30 patients ensured standard errors of proportions and means <10%. Results: Between October 2005 and February 2007, 129 patients with tibial fractures were treated at our institution, 55 of whom met the inclusion criteria. Fifteen subjects later refused follow-up examinations. Altogether, 40 patients (23 men, 17 women, mean age 44 [SD 14] years) could be followed-up for a median of 12 months (interquartile range [IQR] 9–14 months). There were 30 closed and 10 I◦ open fractures. AO 42 A, B, and C type fractures were observed in 28, 10, and two cases. Sixteen patients had sustained an occupational injury. The median interval to fracture fixation was 0 (IQR 0–1) days. Median duration of sick leave was 19 (IQR 14–22, predicted 95% CI 16–22) weeks. All fractures showed solid union at the time of the last patient contact (lower 97.5% confidence limit 91%). There were other specific fracture- or implant-related complications (upper 97.5% confidence limit 9%). At the time of last patient contact, SF-36 PCS were still below population average (44, 95% CI 41–46 points), whereas mental component scores were about normal (50, 95% CI 48–52 points). The mean LEFS was rated at 61 (95% CI 57–65) points. By exploratory linear regression analysis, age, gender, BMI, smoking habit, and open fractures did not markedly contribute to SF-36 PCS and LEFS predictions. Of note, patients on workers’ compensation had slightly higher SF-36 PCS values.
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Conclusions: Despite modern intramedullary fixation techniques, high union and low complication rates, tibia shaft fractures are associated with functional deficits and limitations in the physical domain of health-related quality of life after 1 year of follow-up. doi:10.1016/j.injury.2009.07.019 7 A new locking plate and dynamic screw system for internal fixation of intracapsular hip fractures S. Adesina ∗ , M.J. Parker Orthopaedic Department, Peterborough District Hospital, UK Study rationale: The Targon Femoral Neck Hip Screw has been designed to improve the fixation of intracapsular hip fractures. Fracture healing complications after internal fixation occur in approximately 30–40% of displaced fractures and 5–10% of undisplaced fractures. Materials/patients and methods: The new implant consists of a small plate with six locking screw ports. The two distal holes are used to fix the plate to the lateral cortex of the femur. Three of four screws are passes through the proximal holes and across the fracture site. These 6.5 mm screws are dynamic to allow for collapse of the fracture across the femoral neck. Results: For the first 159 patients treated with this implant at one centre, the mean age of the patients was 77 years (range 42–103), 63% were female. The mean length of surgery was 44 min. The median length of hospital stay till discharge home was 8 days (mean 11 days, range 3–65). For the 57 undisplaced fractures there has been one case of non-union and one case of avascular necrosis. For the 99 displaced fractures there have been nine cases of fracture non-union, four cases of avascular necrosis and two cases of plate detachment from the femur treated by repeat fixation. In addition there was one deep wound sepsis treated by removal of the implant and girdlestone arthroplasty. Conclusions: The results to date show an incidence of fracture healing complications is about a third that which is to be expected with a parallel screw method. This new implant may be a significant advance in the treatment of this difficult and common fracture. doi:10.1016/j.injury.2009.07.020 8 Intramedullary fixation with a third generation nail versus the sliding hip screw for trochanteric hip fractures: A randomised trial of 512 patients S. Adesina ∗ , M.J. Parker Orthopaedic Department, Peterborough District Hospital, UK Study rationale: We conducted a large randomised trial to compare the Targon Proximal Femoral Nail with the sliding hip screw. Materials/patients and methods: Patients with trochanteric hip fractures as per the AO classification (A1–A3) were randomised to either implant. All surgeries were supervised by one surgeon. All patients were followed up for a minimum of one year months by a blinded observer. Results: The mean age was 82 years, range 27–104 years), 20% were male. Length of surgery was slightly increased for the nail (44 min versus 49 min, p = 0.0002). Fluoroscopic screening time was increased in the nail group (0.3 min versus 0.6 min, p < 0.0001). Intra-operative complications were more common with the nailing.
Abstracts / Injury, Int. J. Care Injured 40S (2009) S7–S24
per case and, therefore, to net savings for those health care systems. The main driver for cost savings is faster fracture healing with faster resumption of work and reduced expenses for sickness leave payments. For the UK rhBMP-2 is a cost-effective strategy with a costeffectiveness ratio of approx. £14,000/QALY which is well below the standard £30,000 benchmark for the NHS. From a societal perspective, rhBMP-2 is a cost-saving treatment. Conclusions: BMP-2 leads to net savings in grade III open tibia fractures in Germany and France which can be expected for other European countries where sickness payments are provided by health care insurers. For countries like UK where sickness are provided by third parties BMP-2 is a cost-effective treatment strategy from a health care system perspective and a cost-saving treatment from a societal perspective. doi:10.1016/j.injury.2009.07.015 3 Subtrochanteric fractures treatment with cephalomedullary nails: Open vs. close reduction? N. Tzachev ∗ , A. Baltov, A. Iotov Military Medical Academy, Sofia, Bulgaria Study rationale: To compare intra- and post-operative indicators in the cases of open and close reposition of the subtrohanteric fractures treated by cephalomedullary nails. Materials/patients and methods: For the period from March 2002 to 2009 we have used cephalomedullary ostheosynthesis in 155 patients with subtrochanteric and reverse obliquity intertrochanteric fractures. These were 83 men and 72 women at the age from 16 to 91(average age – 60.9). The reverse obliquity intertrochanteric fractures of 31A3-1 type were 55. We indicated and applied the implant in all subtrochanteric fractures from 32A type to C – their number was 100. In 95 of the cases the close reposition was good. In 40 of the cases we did open reposition and screw or cerclage fixation, after which osteosynthesis with cephalomedullary nails. In 20 of the cases we did not achieved a good primary reposition. In these cases an open reposition of the fragments was not done. Results: In close reposition we achieved the following operative data: mean operative time – 60 min, mean blood loss – 300 ml, Rö time – 3, 5 min, mean hospital stay – 10 days, mean time to full weight bearing – 40 days. In the cases of a good primary reposition we registered bone union about the 60th day. In the cases of bad reposition – bone union was registered between the 90th and 100th day. In the cases of open reposition we achieved the following operative data: Mean operative time – 90 min, mean blood loss – 400 ml, Rö time – 5 min, mean hospital stay – 12 days, mean time to full weight bearing – 30 days. Bone union – 60 days. Conclusions: The evacuation of the surrounding fracture haematoma, the duration of the intervention and the prolonged Rö time in open reposition are compensated by the earlier consolidation of the fracture and the earlier full weight bearing. doi:10.1016/j.injury.2009.07.016
4 Antegrade interlocking nailing in humeral shaft fracture – To ream or not? A. Baltov ∗ , N. Tzachev, A. Iotov Military Medical Academy, Sofia, Bulgaria Study rationale: Does the reaming with AILN influence the period of union, the pain in the shoulder and the final functional result in humeral shaft fractures? Materials/patients and methods: 72 patients divided into two groups, meeting the following criteria: acute fractures, open and non-open 1st degree, after AILN. Excluding criteria: open fractures 2nd and 3rd degree according to Gustilo-Anderson, associated fractures in the area of the shoulder gird, delayed union, nonunion, pathological fracture, ASA gr. III–IV and retrograde nailing. Group A – 36 shaft humeral fractures operated with AILN with reaming: 15 women and 21 men at the average age of 43 (18–81), 20 of them high-energetic and 13 with poly-trauma. Divided according to AO classification: A type – 16, B type – 13 and C type – 7. Group B – 36 shaft humeral fractures operated with AILN without reaming: 11 women and 25 men at the average age of 44 (17–77), 21 of them high-energetic and 12 with poly-trauma. Divided according to AO classification: A type – 14, B type – 15 and C type – 7. Follow up period: 1–6 years. Final functional result according to Constant score according to D. Boehm and DASH score. Results: There is no significant difference between the two groups regarding the period of union, pain and the function of the shoulder. Conclusions: The reaming does not influence the final functional result after AILN, does not increase the danger of damaging the rotator cuff with the right operative technique and does not shorten the period of union. It is advisable to be applied in narrow intramedullary channel only. doi:10.1016/j.injury.2009.07.017 5 Good outcome of 172 pertrochanteric hip fractures treated with Gamma-Nail in our department V. Goulidakis ∗ , S. Theocharakis, V. Chronopoulos, E. Drakoulakis, A. Pastroudis 6th Orthopaedic Department Asklipiion Voulas, General Hospital, Athens, Greece Study rationale: The intramedullary fixation with the 3rd generation Gamma-Nail is a surgical method for the treatment of pertrochanteric hip fractures. The goal of this study is to observe the results of this treatment in our patients. Materials/patients and methods: In this retrospective study we observe the results of our treatment with G3-Nail in patients with pertrochanteric hip fracture from June 2006 to December 2007. In this 19-month period of time 382 patients were admitted with this diagnosis in our department and of those 172 were treated with G3-Nail intramedullary fixation. Of those fractures 149 were intertrochanteric and the standard G3-Nail was applied and 23 were subtrochanteric and were treated with Long G3-Nail. The technique of the fracture fixation was the standard close reduction and intramedullary fixation. We documented demographic data, blood loss and transfusion needs postoperatively, length of hospital stay, time to full weight-bearing and return to pretrauma walking ability as well as time of union, functional ability using Harris hip score and complications.
Abstracts / Injury, Int. J. Care Injured 40S (2009) S7–S24
Results: The mean follow up time was 23 months (18–36). There were 36 male and 136 female with mean age of 76 years. The mean degrease of Hb was 2.3 and the mean need for blood was 1.2 units. The average length of hospital stay was 4.5 days, the time to full weight-bearing 7.1 days and the return to pretrauma ability 4.1 weeks. The mean time of union was 15 weeks (12–24) and the functional results using Harris hip score were good to excellent. As complications we had no case of deep infection, loss of reduction and nonunion, one case with PE and one with heart attack. The above cases finally died. Conclusions: Treatment of pertrochanteric hip fractures with G3Nail seems to be an excellent choice with very good results and low percentage of complications. doi:10.1016/j.injury.2009.07.018 6 Functional outcomes and health-related quality of life after intramedullary nailing of tibia shaft fractures D. Stengel ∗ , A. Ekkernkamp, M. Wich Unfallkrankenhaus Berlin Trauma Center, Germany Study rationale: Whilst most patients will achieve solid union after intramedullary nailing of closed and I◦ open tibia shaft fractures, data on function and health-related quality of life are still rare. Our objective was to assess patient-reported outcomes after this frequent procedure, and to identify potential predictors of treatment failure and success. Materials/patients and methods: After IRB approval, skeletally mature male and female subjects with isolated, unilateral closed or I◦ open tibia shaft fractures suitable for reamed intramedullary nailing (Versa, DePuy) were enrolled in this prospective single-center study. Full digital radiographs in two standard planes were obtained on hospital admission, post-operatively, and during follow-up on discretion of the surgeon on charge. Protocol-driven follow-up was conducted by a research assistant. Generic quality of life was assessed using the Short Form 36 (SF-36) physical and mental component scores (PCS/MCS). Function was evaluated by the Lower Extremity Functional Scale (LEFS). Because of the observational nature of this study, we did not pose a formal null-hypothesis. A sample size of 30 patients ensured standard errors of proportions and means <10%. Results: Between October 2005 and February 2007, 129 patients with tibial fractures were treated at our institution, 55 of whom met the inclusion criteria. Fifteen subjects later refused follow-up examinations. Altogether, 40 patients (23 men, 17 women, mean age 44 [SD 14] years) could be followed-up for a median of 12 months (interquartile range [IQR] 9–14 months). There were 30 closed and 10 I◦ open fractures. AO 42 A, B, and C type fractures were observed in 28, 10, and two cases. Sixteen patients had sustained an occupational injury. The median interval to fracture fixation was 0 (IQR 0–1) days. Median duration of sick leave was 19 (IQR 14–22, predicted 95% CI 16–22) weeks. All fractures showed solid union at the time of the last patient contact (lower 97.5% confidence limit 91%). There were other specific fracture- or implant-related complications (upper 97.5% confidence limit 9%). At the time of last patient contact, SF-36 PCS were still below population average (44, 95% CI 41–46 points), whereas mental component scores were about normal (50, 95% CI 48–52 points). The mean LEFS was rated at 61 (95% CI 57–65) points. By exploratory linear regression analysis, age, gender, BMI, smoking habit, and open fractures did not markedly contribute to SF-36 PCS and LEFS predictions. Of note, patients on workers’ compensation had slightly higher SF-36 PCS values.
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Conclusions: Despite modern intramedullary fixation techniques, high union and low complication rates, tibia shaft fractures are associated with functional deficits and limitations in the physical domain of health-related quality of life after 1 year of follow-up. doi:10.1016/j.injury.2009.07.019 7 A new locking plate and dynamic screw system for internal fixation of intracapsular hip fractures S. Adesina ∗ , M.J. Parker Orthopaedic Department, Peterborough District Hospital, UK Study rationale: The Targon Femoral Neck Hip Screw has been designed to improve the fixation of intracapsular hip fractures. Fracture healing complications after internal fixation occur in approximately 30–40% of displaced fractures and 5–10% of undisplaced fractures. Materials/patients and methods: The new implant consists of a small plate with six locking screw ports. The two distal holes are used to fix the plate to the lateral cortex of the femur. Three of four screws are passes through the proximal holes and across the fracture site. These 6.5 mm screws are dynamic to allow for collapse of the fracture across the femoral neck. Results: For the first 159 patients treated with this implant at one centre, the mean age of the patients was 77 years (range 42–103), 63% were female. The mean length of surgery was 44 min. The median length of hospital stay till discharge home was 8 days (mean 11 days, range 3–65). For the 57 undisplaced fractures there has been one case of non-union and one case of avascular necrosis. For the 99 displaced fractures there have been nine cases of fracture non-union, four cases of avascular necrosis and two cases of plate detachment from the femur treated by repeat fixation. In addition there was one deep wound sepsis treated by removal of the implant and girdlestone arthroplasty. Conclusions: The results to date show an incidence of fracture healing complications is about a third that which is to be expected with a parallel screw method. This new implant may be a significant advance in the treatment of this difficult and common fracture. doi:10.1016/j.injury.2009.07.020 8 Intramedullary fixation with a third generation nail versus the sliding hip screw for trochanteric hip fractures: A randomised trial of 512 patients S. Adesina ∗ , M.J. Parker Orthopaedic Department, Peterborough District Hospital, UK Study rationale: We conducted a large randomised trial to compare the Targon Proximal Femoral Nail with the sliding hip screw. Materials/patients and methods: Patients with trochanteric hip fractures as per the AO classification (A1–A3) were randomised to either implant. All surgeries were supervised by one surgeon. All patients were followed up for a minimum of one year months by a blinded observer. Results: The mean age was 82 years, range 27–104 years), 20% were male. Length of surgery was slightly increased for the nail (44 min versus 49 min, p = 0.0002). Fluoroscopic screening time was increased in the nail group (0.3 min versus 0.6 min, p < 0.0001). Intra-operative complications were more common with the nailing.