| Hip fracture is a common osteoporotic fracture,including femoral neck fracture and intertrochanteric fracture.It is a common condition in the elderly,mainly caused by low-energy injury,and more related to bone loss and falls.With the aging of the global population,the number of hip fractures is increasing rapidly,which is resulting in higher burden of the society and health system.Hip fracture is among the top ten disability diseases in the world.All over the world,there are about 4.5 million hip fractures every year,the number of which is expected to reach 21 million in the next 40 years.Besides,the cost for the treatment of hip fractures in United States and Canada will beyond $9.8 billion and $650 million in 2040,respectively.With the increasing of population aging and life expectancy in Asian countries,it is estimated that half of the intertrochanteric fractures will occur in Asia by 2050.With the aging of the population in our country,hip fracture will become a rigorous challenge for the health care system.Therefore,to fully understand the epidemiological characteristics of hip fracture,especially the epidemiological characteristics of elderly hip fracture,is helpful for orthopedic surgeons and public health department.Intertrochanteric fractures account for about 50% of hip fractures and 3.13% of fractures in adult.While,there are few studies on the epidemiology of femoral intertrochanteric fracture alone,most of which focused on the epidemiology of hip fractures(including femoral neck fracture and intertrochanteric fracture).Better understanding of its epidemiological characteristics can provide more guidance for the treatment and prevention of intertrochanteric fracture.The primary treatment for intertrochanteric fracture is surgery,which mainly includes intramedullary fixation and extramedullary fixation.However,the proffered implant for the treatment of intertrochanteric fracture is still controversial.With the introduction and increasing acceptance intramedullary devices,the application of intramedullary devices in the treatment of intertrochanteric fracture has been exceeded for the extramedullary fixation in the past two decades.Gamma nail is a classic intramedullary fixation for the treatment of intertrochanteric fracture,which is mainly suitable for the treatment of stable intertrochanteric fracture.One of the disadvantages of gamma nail in the treatment of intertrochanteric fractures is with a higher rate of implant failure for the stress concentration by the screws.In addition,the removal of intramedullary nail after fracture healing not only increases the trauma of patients,but also leads to the increasing in medical expenses.In view of those,our team designed a new type of bionic degradable magnesium alloy gamma nail,which can effectively reduce the stiffness of the implant.And the bionic holes in the screw can provide suitable conditions for the growth of cancellous bone,which was conduce to restore the original bone trabecular structure,promote the two-way healing of cortical bone and cancellous bone,and reshape the mechanical support and force line conduction.Therefore,the establishing of finite element model of intertrochanteric fracture could be used to compare the differences between the new type gamma nail and the traditional gamma nail,which could provide important reference for the biomechanics and clinical reference in the future.In the treatment of intertrochanteric fracture with intramedullary nail,the reduction of fractures is critical.And the traction device is always required to achieve and maintain the reduction of fractures until the insertion of intramedullary nail.The traction table is one of the most commonly used traction equipment in the treatment of intertrochanteric fracture with intramedullary nail.However,the related complications caused by the use of traction bed have been perplexing most of orthopedics surgeons.When patients with ipsilateral distal limb fracture,soft tissue injury,and bad ankle skin condition,the application of traction table is often limited.In addition,the high price of traction table makes some non orthopedic characteristic hospitals or grass-roots hospitals flinch from traction bed because of limited financial expenditure.In the past,many reports have proposed new traction equipment or methods to replace the traction table in the application of intertrochanteric fracture,but none of them was promoted for satisfactory traction effect.Double reverse traction repositor,a reduction device for the treatment of long bone fracture of extremities,has been successfully used in the treatment of femoral shaft fractures,tibial plateau fractures and so on.However,the efficacy of intramedullary nailing in the treatment of unstable intertrochanteric fractures remains to be observed.At present,the technology of intramedullary nail in the treatment of femoral intertrochanteric fracture has been more mature.However,how to reduce the incidence of postoperative complications and reduce the mortality of patients are still disturbing the orthopedic surgeons.Intertrochanteric fracture,because of its high mortality,is also known as the last fracture of life.Pneumonia is a common and serious complication after the operation of intertrochanteric fracture,and it is also the primary risk factor of short-term death.Understanding the incidence and risk factors of intertrochanteric fracture and taking corresponding preventive measures are very important to improve the prognosis of intertrochanteric fracture and reduce the corresponding medical expenses.To master the current epidemiological characteristics of intertrochanteric fracture is important for the treatment and prevention of intertrochanteric fracture.In the 1980 s,intramedullary nail was introduced in the treatment of intertrochanteric fractures,and then the application of intramedullary nail was hindered.In the past 20 years,with the continuous improvement of intramedullary nail and the improvement of related surgical techniques,intramedullary nail has been re-active in the treatment of intertrochanteric fracture,and gradually developed into one of the mainstream methods of intertrochanteric fracture treatment.With the development of internal fixation equipment and the progress of surgical technology,the surgical treatment of patients with intertrochanteric fracture has been quite mature,but the mortality rate after intertrochanteric fracture is still high.Complications are the main cause of high postoperative mortality,and pneumonia is the primary factor.Therefore,understanding the risk factors of pneumonia is very important for the prevention of pneumonia and the reduction of mortality.In conclusion,although the intramedullary nail technology has made great progress,only by continuously promoting the improvement of it’s design,improving the relevant surgical technology,strengthening the perioperative management,and reducing the occurrence of devasted complications,can we further promote the promotion of intramedullary nail,and promote the further development of the treatment of intertrochanteric fracture.Part 1 Titanium alloy Gamma nail versus biodegradable magnesium alloy bionic Gamma nail for treating intertrochanteric fractures: a finite element analysisdsObjective: To investigate the effects of traditional titanium alloy Gamma nail and biodegradable magnesium alloy bionic Gamma nail for treating intertrochanteric fractures using finite element analysis.Methods: Computed tomography(CT)images of an adult male volunteer of appropriate age and in good physical condition were used to establish a three-dimensional model of the proximal femur.Then,a model of Type 31A1 intertrochanteric fracture of the proximal femur was established,and the traditional titanium alloy Gamma nails and biodegradable magnesium alloy bionic Gamma nails were used for fixation,respectively.The von Mises stress,maximum principal stress,and minimum principal stress were calculated to evaluate the effect of bone ingrowth on stress distribution of the proximal femur after fixation.Results: In the intact model,the maximum stress was 5.8 Mpa,the minimum stress was-11.7 Mpa,and the von Mises stress was 11.4 Mpa,respectively.The maximum principal stress distribution of the cancellous bone in the intact model appears in a position consistent with the growth direction of the principal and secondary tensile zones.After traditional Gamma nail healing,the maximum stress was 32 Mpa,the minimum stress was-23.5 Mpa,and the von Mises stress was 31.3 Mpa,respectively.The stress concentration was quite obvious compared with the intact model.Along with simulation of the bone healing process and magnesium alloy degeneration,assumed to biodegrade completely 12 months post-operatively.The maximum stress was18.7 Mpa,the minimum stress was-12.6 Mpa,and the von Mises stress was14.0 Mpa,respectively.In the minimum principal stress,the region of minimum stress value less than-10 MPa was significantly improved compared with traditional titanium alloy Gamma nail models.Meanwhile,the stress distribution of the bionic Gamma nail model in the proximal femur was closer to that of the intact bone,which significantly reduced the stress concentration of the implant.Conclusions: The biodegradable magnesium alloy bionic Gamma nail implant can improve the stress distribution of fractured bone close to that of intact bone while reducing the risk of post-operative complications associated with traditional internal fixations,which provides a promising clinical value in the future.Part 2 Treatment of unstable intertrochanteric fractures with proximal femoral nailing antirotation: traction table or double reverse traction repositorObjective: The objective of this retrospective study was to compare the efficacy of the double reverse traction repositor(DRTR)and traction table with proximal femoral nailing antirotation(PFNA)in the treatment of unstable intertrochanteric fractures.Patients and Methods: Data from 66 patients(36 patients treated with the traction table and 30 patients treated with DRTR)with unstable intertrochanteric fractures were reviewed from January 2017 to June 2017.The demographics,fracture characteristics,surgical data,and prognostic parameters were collected to compare the differences between the two groups.Results: The collodiaphyseal angle(CDA)was significantly lower in the DRTR group than in the traction table group(129.37° ± 7.47 and 135.67° ±6.95,respectively,p<0.001).The open reduction rate was significantly lower in the DRTR group than in the traction table group(3.3% and 13.9%,respectively,p<0.001).No significant differences were found in the demographics,fracture characteristics,other surgical data,or prognostic parameters between the two groups.Conclusions: DRTR can effectively and safely facilitate the treatment of unstable intertrochanteric fractures with PFNA and can achieve similar results as the traction table.Furthermore,DRTR can reduce the open reduction rate and enable minimally invasive treatment of unstable intertrochanteric fractures.Part 3 In-hospital postoperative pneumonia following geriatric intertrochanteric fracture surgery treated with intramedullary nail:incidence and risk factorsObjective: The in-hospital death rate in cases of hip fracture ranges from6% to 10%.Pneumonia is a serious complication for hip fracture patients that contributes to longer hospital stays and higher mortality rates;however,the prevalence and risk factors are not well established.To address this issue,the present study investigated the incidence of and risk factors for in-hospital postoperative pneumonia(IHPOP)following geriatric intertrochanteric fracture surgery.Patients and Methods: Information on 1495 geriatric patients(>65years)who underwent intertrochanteric fracture surgery at our hospital between October 2014 and December 2018 was extracted from a prospective hip fracture database and reviewed.Demographic information,clinical variables including surgical data,and preoperative laboratory indices that could potentially influence IHPOP were analyzed.Receiver operating characteristic curve analysis was performed and the optimum cutoff value for quantitative data was determined.Univariate and multivariate analyses were carried out to identify risk factors for IHPOP.Results: The incidence of IHPOP following geriatric intertrochanteric fracture surgery was 3.5%(53/1495 cases).The multivariate analysis showed that age >82 years(odds ratio [OR]=2.54,p=0.004),male sex(OR=2.13,p=0.017),chronic respiratory disease(OR=5.02,p<0.001),liver disease(OR=3.39,p=0.037),urinary tract infection(OR=8.46,p=0.005),creatine kinase(CK)MB>20 U/l(OR=2.31,p=0.020),B-type natriuretic peptide(BNP)≥75 ng/l(OR=4.02,p=0.001),and D-dimer >2.26 mg/l(OR=2.69,p=0.002)were independent risks factor for the incidence of IHPOP following geriatric intertrochanteric fracture surgery.Conclusion: In conclusion,we found that the incidence of IHPOP following geriatric intertrochanteric fracture surgery was 3.5%.Age,male sex,chronic respiratory disease,liver disease,urinary tract infection,CKMB,BNP,and D-dimer were significant risk factors for the occurrence of IHPOP after the surgery,and the implant(intramedullary devices or extramedullary device)was not independent risk factor for the developing of IHPOP.Targeted preoperative management based on risk factors can potentially reduce the risk of IHPOP in geriatric patients undergoing surgery for intertrochanteric fractures and thereby improve their chances of full recovery. |
