Fixation of intraoperative proximal femoral fractures during THA using two versus three cerclage wires - a biomechanical study

Abstract Background Intraoperative proximal femoral fractures (IPFF) are relevant complications during total hip arthroplasty. Fixation using cerclage wires (CW) represents a minimally-invasive technique to address these fractures through the same surgical approach. The goal of treatment is to mobilise the patient as early as possible, which requires high primary stability. This study aimed to compare different cerclage wire configurations fixing IPFF with regard to biomechanical primary stability. Methods Standardised IPFF (type II, Modified Mallory Classification) were created in human fresh frozen femora and were fixed either by two or three CW (1.6 mm, stainless steel). All cadaveric specimens (n = 42) were randomised to different groups (quasi-static, dynamic) or subgroups (2 CW, 3 CW) stratified by bone mineral density determined by Dual Energy X-ray Absorptiometry. Using a biomechanical testing setup, quasi-static and dynamic cyclic failure tests were carried out. Cyclic loading started from 200 N to 500 N at 1 Hz with increasing peak load by 250 N every 100 cycles until failure occurred or maximum load (5250 N) reached. The change of fracture gap size was optically captured. Results No significant differences in failure load after quasi-static (p = 0.701) or dynamic cyclic loading (p = 0.132) were found between the experimental groups. In the quasi-static load testing, all constructs resisted 250% of the body weight (BW) of their corresponding body donor. In the dynamic cyclic load testing, all but one construct (treated by 3 CW) resisted 250% BW. Conclusions Based on this in vitro data, both two and three CW provided sufficient primary stability according to the predefined minimum failure load (250% BW) to resist. The authors recommend the treatment using two CW because it reduces the risk of vascular injury and shortens procedure time.

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Biomechanical Comparison of Onlay Distal Biceps Tendon Repair: All-Suture Anchors Versus Titanium Suture Anchors

The American Journal of Sports Medicine ◽

10.1177/0363546519860489 ◽

2019 ◽

Vol 47 (10) ◽

pp. 2478-2483 ◽

Cited By ~ 5

Author(s):

Alexander Otto ◽

Julian Mehl ◽

Elifho Obopilwe ◽

Mark Cote ◽

Lucca Lacheta ◽

...

Keyword(s):

Cyclic Loading ◽

Biceps Tendon ◽

Peak Load ◽

Tendon Repair ◽

Suture Anchors ◽

Mineral Density ◽

Distal Biceps Tendon ◽

Distal Biceps ◽

Load To Failure ◽

Biceps Tendon Repair

Background: A rupture of the distal biceps tendon is the most common tendon rupture of the elbow and has received increased attention in the past few years. Newly developed all-suture anchors have the potential to minimize surgical trauma and the risk of adverse events because of the use of flexible drills and smaller drill diameters. Purpose/Hypothesis: The purpose was to biomechanically compare all-suture anchors and titanium suture anchors for distal biceps tendon repair in cadaveric specimens. The hypothesis was that all-suture anchors would show no differences in load to failure or displacement under cyclic loading compared with titanium suture anchors. Study Design: Controlled laboratory study. Methods: Sixteen unpaired, fresh-frozen human cadaveric elbows were randomized to 2 groups, which underwent onlay distal biceps tendon repair with 2 anchors. Bone mineral density at the radial tuberosity was evaluated in each specimen. In the first group, distal biceps tendon repair was performed using all-suture anchors. In the second group, titanium suture anchors were applied. After cyclic loading for 3000 cycles, the repair constructs were loaded to failure. The peak load to failure as well as repair construct stiffness and mode of failure were determined. Results: The mean (±SD) peak load was 293.53 ± 122.15 N for all-suture anchors and 280.02 ± 69.34 N for titanium suture anchors ( P = .834); mean stiffness was 19.78 ± 2.95 N/mm and 19.30 ± 4.98 N/mm, respectively ( P = .834). The mode of failure was anchor pullout for all specimens during load to failure. At the proximal position, all-suture anchors showed a displacement of 1.53 ± 0.80 mm, and titanium suture anchors showed a displacement of 0.81 ± 0.50 mm ( P = .021) under cyclic loading. At the distal position, a displacement of 1.86 ± 1.04 mm for all-suture anchors and 1.53 ± 1.15 mm for titanium suture anchors was measured ( P = .345). A positive correlation between bone mineral density and load to failure was observed ( r = 0.605; P = .013). Conclusion: All-suture anchors were biomechanically equivalent at time zero to titanium suture anchors for onlay distal biceps tendon repair. While the proximally placed all-suture anchors demonstrated greater displacement than titanium suture anchors, the comparable displacement at the distal position as well as the similar load and mechanism of failure make this difference unlikely to be clinically significant. Clinical Relevance: All-suture anchors performed similarly to titanium suture anchors for onlay distal biceps tendon repair at time zero and represent a reasonable alternative.

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Bone Staples Provide Favorable Primary Stability in Cortical Fixation of Tendon Grafts for Medial Collateral Ligament Reconstruction: A Biomechanical Study

Orthopaedic Journal of Sports Medicine ◽

10.1177/23259671211017880 ◽

2021 ◽

Vol 9 (7) ◽

pp. 232596712110178

Author(s):

Johannes Glasbrenner ◽

Adrian Deichsel ◽

Michael J. Raschke ◽

Thorben Briese ◽

Andre Frank ◽

...

Keyword(s):

Cyclic Loading ◽

Medial Collateral Ligament ◽

Ligament Reconstruction ◽

Failure Load ◽

Primary Stability ◽

Tendon Graft ◽

Materials Testing ◽

Collateral Ligament ◽

Load To Failure ◽

Tendon Grafts

Background: The use of the interference screw (IFS) for the cortical fixation of tendon grafts in knee ligament reconstruction may lead to converging tunnels in the multiligament reconstruction setting. It is unknown whether alternative techniques using modern suture anchor (SA) or bone staple (BS) fixation provide sufficient primary stability. Purpose: To assess the primary stability of cortical fixation of tendon grafts for medial collateral ligament (MCL) reconstruction using modern SA and BS methods in comparison with IFS fixation. Study Design: Controlled laboratory study. Methods: Cortical tendon graft fixation was performed in a porcine knee model at the tibial insertion area of the MCL using 3 different techniques: IFS (n = 10), SA (n = 10), and BS (n = 10). Specimens were mounted in a materials testing machine, and cyclic loading for 1000 cycles at up to 100 N was applied to the tendon graft, followed by load-to-failure testing. Statistical analysis was performed using 1-way analysis of variance. Results: There were no statistical differences in elongation during cyclic loading or peak failure load during load-to-failure testing between BS (mean ± standard deviation: 3.4 ± 1.0 mm and 376 ± 120 N, respectively) and IFS fixation (3.9 ± 1.2 mm and 313 ± 99.5 N, respectively). SA fixation was found to have significantly more elongation during cyclic loading (6.4 ± 0.9 mm; P < .0001) compared with BS and IFS fixation and lower peak failure load during ultimate failure testing (228 ± 49.0 N; P < .01) compared with BS fixation. Conclusion: BS and IFS fixation provided comparable primary stability in the cortical fixation of tendon grafts in MCL reconstruction, whereas a single SA fixation led to increased elongation with physiologic loads. However, load to failure of all 3 fixation techniques exceeded the loads expected to occur in the native MCL. Clinical Relevance: The use of BS as a reliable alternative to IFS fixation for peripheral ligament reconstruction in knee surgery can help to avoid the conflict of converging tunnels.

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Management of Subtrochanteric Femur Fracture Using Proximal Femoral Nail

Surgical Update: International Journal of Surgery and Orthopedics ◽

10.17511/ijoso.2020.i05.06 ◽

2020 ◽

Vol 6 (5) ◽

pp. 321-324

Author(s):

Dr. Navin Gagal ◽

◽

Dr. Anand Hirani ◽

Keyword(s):

Femur Fracture ◽

Femoral Fractures ◽

The Body ◽

Proximal Femoral Nail ◽

Proximal Femoral Fractures ◽

Operative Techniques ◽

Femoral Nail ◽

Study Results ◽

Proximal Femur Nail ◽

Subtrochanteric Femur Fracture

Injuries to the femur, the longest bone in the body presents a challenging situationto the orthopedic surgeon. The proximal femoral intramedullary devices are useful for the treatmentof isolated pathological lesions in the subtrochanteric region. Biomechanically, the nail can withstandbetween 3to 5 times body weight. Hence the present study was planned to study the managementof these fractures with the proximal femoral nail. Materials and Methods: A total of 44 patientswith proximal femoral fractures of the subtrochanteric region admitted in the department wereincluded in the study. Patients age more than 25 years and diagnosed with subtrochanteric femurfracture were included in the study. Results: The age of the patients was more than 25 years. Therewere 34 males and 10 females included in the study. In the clinical evaluation as per the functionalGrading of the patient as per Kyle’s Criteria excellent and good results were considered satisfactory,whereas fair and poor results were considered unsatisfactory. In this series 92%, satisfactory resultswere obtained. Conclusion: Proximal femur nail (PFN) is an effective device in the management ofcomplex femoral fractures. The use of PFN in such fractures provides various advantages: Closedprocedure, Minimal soft tissue damage. It offers superior stabilization than other currently usedmethods of internal fixation. The use of PFN is technically demanding and needs expertise.Complications can be avoided by proper operative techniques. Early postoperative mobilization andphysiotherapy improve the results of PFN.

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Concepts and Potential Future Developments for Treatment of Periprosthetic Proximal Femoral Fractures

The Open Orthopaedics Journal ◽

10.2174/1874325001509010405 ◽

2015 ◽

Vol 9 (1) ◽

pp. 405-411 ◽

Cited By ~ 4

Author(s):

Stephan Brand ◽

Max Ettinger ◽

Mohamed Omar ◽

Nael Hawi ◽

Christian Krettek ◽

...

Keyword(s):

Revision Arthroplasty ◽

Femoral Fractures ◽

Early Mobilization ◽

Primary Stability ◽

Osteoporotic Bone ◽

Complication Rates ◽

Proximal Femoral Fractures ◽

Hip Replacements ◽

Aging Populations ◽

The Stability

Periprosthetic proximal femoral fractures are a major challenge for the orthopaedic surgeon, with a continuously increasing incidence due to aging populations and concordantly increasing numbers of total hip replacements. Surgical decision-making mainly depends on the stability of the arthroplasty, and the quality of bone stock. As patients final outcomes mainly depend on early mobilization, a high primary stability of the construct is of particular relevance. Osteosynthetic procedures are usually applied for fractures with a stable arthroplasty, while fractures with a loosened endoprosthesis commonly require revision arthroplasty. Osteoporotic bone with insufficient anchoring substance for screws poses one major concern for cases with well-fixed arthroplasties. Complication rates and perioperative mortality have remained unacceptably high, emphasizing the need for new innovations in the treatment of periprosthetic fractures. Transprosthetic drilling of screws through the hip stem as the most solid and reliable part in the patient might represent a promising future approach, with auspicious results in recent biomechanical studies.

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Association of hip osteoporosis with pattern of proximal femoral fractures

Journal of Analytical Research in Clinical Medicine ◽

10.15171/jarcm.2019.008 ◽

2019 ◽

Vol 7 (2) ◽

pp. 41-44

Author(s):

Nasrin Navaeifar ◽

Ali Tabrizi ◽

Fatemeh Shirzadi

Keyword(s):

Vitamin D ◽

Mortality Rate ◽

Elderly Patients ◽

Femoral Fractures ◽

The Elderly ◽

Proximal Femoral Fractures ◽

Mineral Density ◽

Articular Fracture ◽

Articular Fractures ◽

Significant Difference

Introduction: Proximal femoral fractures account for a large number of hospitalization cases among the elderly patients. The proximal femoral fractures pattern based on intra-articular or extra-articular could affect the treatment options and induce several complications. The aim of this study is to evaluate the relationship between the severity of osteoporosis and pattern of proximal femoral fractures among elderly patients. Methods: In this cross-sectional study, 83 patients over than 65 years old were enrolled from 2014 to 2018 in the orthopedic department of Urmia University of Medical Sciences, Urmia, Iran. Bone mineral density (BMD) was determined by dual energy x-ray absorptiometry (DXA) at the time of hospitalization. Vitamin D level was also measured. Finally, the mortality rate was determined in 12-month follow-up after the operation. Results: In this study, 83 patients with proximal femoral fractures including 60 cases (72.3%) with extra-articular fractures and 23 cases (27.7%) with intra-articular fractures were investigated. The mean vitamin D level of these two groups [patients with intra-articular fracture (34.4 ± 24.7 nmol/l) and extra-articular fracture (11.3 ± 5.4 nmol/l)] was significantly different (P = 0.020). A significant difference was also observed in the bone densities (based on T-score) of these two groups (P < 0.001). The patients’ mortality rate was significantly different and it was higher in patients with extra-articular fracture (23.0%) compared to those with intra-articular fracture (17.3%) (P = 0.020). Conclusion: In the case of elderly patients, the hip bone density and vitamin D levels play a decisive role in predicting the pattern of proximal femoral fractures. It was also associated with increased mortality among the elderly patients.

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Mortality escalates in patients of proximal femoral fractures with COVID-19: A systematic review and meta-analysis of 35 studies on 4225 patients

Journal of Clinical Orthopaedics and Trauma ◽

10.1016/j.jcot.2021.03.023 ◽

2021 ◽

Author(s):

Mohit Kumar Patralekh ◽

Vijay Kumar Jain ◽

Karthikeyan P. Iyengar ◽

Gaurav Kumar Upadhyaya ◽

Raju Vaishya

Keyword(s):

Systematic Review ◽

Meta Analysis ◽

Femoral Fractures ◽

Proximal Femoral Fractures

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Duration of Bisphosphonate Drug Holidays in Osteoporosis Patients: A Narrative Review of the Evidence and Considerations for Decision-Making

Journal of Clinical Medicine ◽

10.3390/jcm10051140 ◽

2021 ◽

Vol 10 (5) ◽

pp. 1140

Author(s):

Kaleen N. Hayes ◽

Elizabeth M. Winter ◽

Suzanne M. Cadarette ◽

Andrea M. Burden

Keyword(s):

Surrogate Marker ◽

Femoral Fractures ◽

Osteonecrosis Of The Jaw ◽

Bisphosphonate Therapy ◽

Narrative Review ◽

Drug Holiday ◽

Future Research ◽

Mineral Density ◽

First Line Therapy

Bisphosphonates are first-line therapy for osteoporosis, with alendronate, risedronate, and zoledronate as the main treatments used globally. After one year of therapy, bisphosphonates are retained in bone for extended periods with extended anti-fracture effects after discontinuation. Due to this continued fracture protection and the potential for rare adverse events associated with long-term use (atypical femoral fractures and osteonecrosis of the jaw), a drug holiday of two to three years is recommended for most patients after long-term bisphosphonate therapy. The recommendation for a drug holiday up to three years is derived primarily from extensions of pivotal trials with alendronate and zoledronate and select surrogate marker studies. However, certain factors may modify the duration of bisphosphonate effects on a drug holiday and warrant consideration when determining an appropriate time off-therapy. In this narrative review, we recall what is currently known about drug holidays and discuss what we believe to be the primary considerations and areas for future research regarding drug holiday duration: total bisphosphonate exposure, type of bisphosphonate used, bone mineral density and falls risk, and patient sex and body weight.

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