Treatment of reverse oblique and transverse intertrochanteric fractures with use of an intramedullary nail or a 95 degrees screw-plate: a prospective, randomized study. One and two femoral neck screws with intramedullary nails for unstable trochanteric fractures of femur in the elderly--randomised clinical trial. The standard Gamma nail or the Medoff sliding plate for unstable trochanteric and subtrochanteric fractures. A randomised, controlled trial. Intramedullary nailing versus fixed angle blade plating for subtrochanteric femoral fractures: a prospective randomised controlled trial. Prospective randomized controlled trial of an intramedullary nail versus dynamic screw and plate for intertrochanteric fractures of the femur. Prospective randomized comparison of gliding nail and gamma nail in the therapy of trochanteric fractures. [Classic nail versus DHS. A prospective randomised study of fixation of trochanteric femur fractures]. Prospective randomized comparison between a dynamic hip screw and a mini-invasive static nail in fractures of the trochanteric area: preliminary results. Pertrochanteric fractures: is there an advantage to an intramedullary nail?: a randomized, prospective study of 206 patients comparing the dynamic hip screw and proximal femoral nail. The trochanteric gamma nail versus the dynamic hip screw: a prospective randomised study. One-year follow-up of 146 intertrochanteric fractures. Intertrochanteric fractures: a comparison between fixation with a two-piece nail plate and Ender's nails. [Osteosynthesis of per- and subtrochanteric fractures by blade plate versus gamma nail. A randomized prospective study]. Cephalomedullary nails in the treatment of high-energy proximal femur fractures in young patients: a prospective, randomized comparison of trochanteric versus piriformis fossa entry portal. Comparison of the use of the humerus intramedullary nail and dynamic compression plate for the management of diaphyseal fractures of the humerus. A randomised controlled study. [The gamma-nail as a resilient alternative to the dynamic hip screw in unstable proximal femoral fractures in the elderly]. Intramedullary fixation of intertrochanteric hip fractures: a comparison of two implant designs. Functional outcome in treatment of unstable trochanteric and subtrochanteric fractures with the proximal femoral nail and the Medoff sliding plate. Systematic effects of surgical treatment of hip fractures: gliding screw-plating vs intramedullary nailing. A comparison of proximal femoral nail antirotation and dynamic hip screw devices in trochanteric fractures. Treatment of intertrochanteric fracture with the Gamma AP locking nail or by a compression hip screw--a randomised prospective trial. Fixation of intertrochanteric fractures of the femur. A randomised prospective comparison of the gamma nail and the dynamic hip screw. A prospective trial comparing the Holland nail with the dynamic hip screw in the treatment of intertrochanteric fractures of the hip. Trochanteric gamma nail and compression hip screw for trochanteric fractures: a randomized, prospective, comparative study in 210 elderly patients with a new design of the gamma nail. A prospective comparative study of the compression hip screw and the gamma nail. Elastic stable intramedullary nailing versus nonoperative treatment of displaced midshaft clavicular fractures-a randomized, controlled, clinical trial. Intramedullary nailing of clavicular midshaft fractures in adults using titanium elastic nail. [Pertrochanteric fractures: a randomized prospective study comparing dynamic screw plate and intramedullary fixation]. Extramedullary fixation of 107 subtrochanteric fractures: a randomized multicenter trial of the Medoff sliding plate versus 3 other screw-plate systems. Treatment of unstable trochanteric fractures. Randomised comparison of the gamma nail and the proximal femoral nail. Extramedullary fixation of 569 unstable intertrochanteric fractures: a randomized multicenter trial of the Medoff sliding plate versus three other screw-plate systems. Slotted intramedullary hip screw nails reduce proximal mechanical unloading.
Intertrochanteric fractures are composed of different anatomic patterns that vary in their degree of stability following open reduction and internal fixation. A particularly unstable group is classified as AO/OTA 31-A3, with the fracture pattern described as reverse oblique or transverse. The purpose of this study was to compare the results of intramedullary fixation with those of plate fixation for these intertrochanteric fractures in elderly patients.
                Thirty-nine elderly patients with AO/OTA 31-A3 intertrochanteric fractures of the femur were randomized into two treatment groups and were followed for a minimum of one year. The nineteen patients in Group I were treated with a 95 fixed-angle screw-plate (Dynamic Condylar Screw), and the twenty patients in Group II were treated with an intramedullary nail (Proximal Femoral Nail). The treatment groups were comparable with regard to all demographic and injury variables.
                Patients treated with an intramedullary nail had shorter operative times, fewer blood transfusions, and shorter hospital stays compared with those treated with a 95 screw-plate. Implant failure and/or nonunion was noted in seven of the nineteen patients who had been treated with the 95 screw-plate. Only one of the twenty fractures that had been treated with an intramedullary nail did not heal.
                The results of our study support the use of an intramedullary nail rather than a 95 screw-plate for the fixation of reverse oblique and transverse intertrochanteric fractures in elderly patients. Intramedullary nailing has been the gold standard in the management of lower limb fractures by virtue of advantage of early joint mobilisation and weight bearing. They are being increasingly used in the peri-trochanteric fractures of femur. Biomechanical studies have proved the supremacy of single femoral neck screw construct over two femoral neck screws along with the intramedullary nails in osteoporotic bones due to lower incidence of complications. This randomised clinical trial was conducted to study the clinico-radiological outcome of single and two-femoral neck screw construct in the management of unstable trochanteric fractures in the elderly osteoporotic bones. Although there was no significant difference in the clinical outcome in the two groups, less sliding of the femoral neck screws was noted with two-femoral neck screw configuration. The tip-apex distance was also significantly lower in the two-screw construct compared to that of the single screw construct. This study to our knowledge is the first randomised control clinical trial evaluating the effectiveness of one and two femoral neck screw configuration of intra-medullary nails in the management of unstable trochanteric fractures. We studied 217 patients with an unstable trochanteric or subtrochanteric fracture who had been randomly allocated to treatment by either internal fixation with a standard Gamma nail (SGN) or a Medoff sliding plate (MSP, biaxial dynamisation mode). Their mean age was 84 years (65 to 99) and they were reviewed at four and 12 months after surgery. Assessments of outcome included general complications, technical failures, revision surgery, activities of daily living (ADL), hip function (Charnley score) and the health-related quality of life (HRQOL, EQ-5D). The rate of technical failure in patients with unstable trochanteric fractures was 6.5% (6/93) (including intra-operative femoral fractures) in the SGN group and 5.2% (5/96) in the MSP group. In patients with subtrochanteric fractures, there were no failures in the SGN group (n = 16) and two in the MSP group (n = 12). In the SGN group, there were intra-operative femoral fractures in 2.8% (3/109) and no post-operative fractures. There was a reduced need for revision surgery in the SGN group compared with the MSP group (8.3%; 9/108; p = 0.072). The SGN group also showed a lower incidence of severe general complications (p < 0.05) and a trend towards a lower incidence of wound infections (p = 0.05). There were no differences between the groups regarding the outcome of ADL, hip function or the HRQOL. The reduction in the HRQOL (EQ-5D(index) score) was significant in both groups compared with that before the fracture (p < 0.005). Our findings indicate that the SGN showed good results in both trochanteric and subtrochanteric fractures. The limited number of intra-operative femoral fractures did not influence the outcome or the need for revision surgery. Moreover, the SGN group had a reduced number of serious general complications and wound infections compared with the MSP group. The MSP in the biaxial dynamisation mode had a low rate of failure in trochanteric fractures but an unacceptably high rate when used in the biaxial dynamisation mode in subtrochanteric fractures. The negative influence of an unstable trochanteric or subtrochanteric fracture on the quality of life was significant regardless of the surgical method. To compare closed intramedullary nailing to open reduction and internal fixation using a fixed angle blade plate for the management of subtrochanteric femoral fractures.
                58 patients were equally randomised to undergo either an intramedullary nailing (IN) or fixed angle blade plating (BP).
                There were no significant differences between the 2 groups with regard to age, time to surgery, operating time, receipt of blood transfusions, duration of hospital stay, or fracture classification. The revision rate was 28% (8/29) in the BP group and none in the IN group; the difference was statistically significant.
                Internal fixation using a fixed angle blade plate for subtrochanteric femoral fractures has higher implant failure and revision rates, compared to closed intramedullary nailing. To compare the surgical complications and functional outcome of the Gamma nail intramedullary fixation device versus the Richards sliding hip screw and plate device in intertrochanteric femoral fractures.
                A prospective, randomised controlled clinical trial with observer blinding.
                A regional teaching hospital in the United Kingdom.
                All patients admitted from the local population with intertrochanteric fractured femurs were included. There were 400 patients entered into the study and 399 followed-up to one year or death.
                The devices were assigned by randomization to either a short-type Gamma nail (203 patients) or a Richard's-type sliding hip screw and plate (197 patients).
                The main surgical outcome measurements were fixation failure and reoperation. A functional outcome of pain, mobility status, and range of movement were assessed until one year.
                The requirement for revision in the Gamma nail group was twelve (6%); for Richard's group, eight (4%). This was not statistically different (p = 0.29; odds ratio, 1.48 [0.59-3.7]). A subcapital femoral fracture occurred in the Richard's group. Femoral shaft fractures occurred with four in the Gamma nail group (2%) and none in the Richard's group (p = 0.13). Three required revision to another implant. Lag-screw cut-out occurred in eight patients in the gamma nail group (4%) and four in the Richard's group (2%). This was not statistically significant (p = 0.37; odds ratio, 2.29 [0.6-9.0]). The development of other postoperative complications was the same in both groups. There was no difference between the two groups in terms of early or long-term functional status at one year.
                The use of an intramedullary device in the treatment of intertrochanteric femoral fractures is still associated with a higher but nonsignificant risk of postoperative complications. Routine use of the Gamma nail in this type of fracture cannot be recommended over the current standard treatment of dynamic hip screw and plate. In a prospective randomized study, we compared the new intramedullary implant of the gliding nail to the gamma nail in the fixation of 80 unstable trochanteric fractures in elderly patients. The preconditions of both groups were comparable. We found no differences concerning the operation time, blood loss, period of stationary treatment or social situation. Also, the anatomic reconstruction and the long-term function according to the Merle d'Aubigne score were comparable. Regarding postoperative complications, the gliding nail showed a minor tendency of cutting out; this we attribute to the special design of the dynamic blade and regard it as the most favourable advantage of this new implant. The intramedullary hip screw system Classic-Nail and the Dynamic Hip Screw (DHS) were evaluated in a prospective-randomized clinical trial for operative treatment of trochanteric femur fractures. Hundred and ten geriatric patients (mean age 82 years) were runningly included in the study (56 Classic Nail, 54 DHS). No significant differences between the two study groups were observed with regard to treatment and follow-up data. With the Classic-Nail one complete femur shaft fracture and one incomplete fracture occurred at the tip of the nail intraoperatively and could successfully be fixed with cerclage wires. In the DHS group two patients underwent reoperation for significant loss of reduction early postoperatively. At an average follow-up of 3.7 months all fractures were healed with no difference in functional outcome between the two groups.--Classic Nail and DHS both lead to equally good results in the operative treatment of trochanteric femur fractures. This study aimed at comparing the results obtained with a sliding screw plate and an experimental device including a small-diameter nail that can be placed with a mini-invasive approach and provides a stable fixation.
                Randomized prospective study.
                University hospital.
                The study included two groups with thirty fractures of the trochanteric area.
                In both groups, the surgical procedure was carried out on patients placed on a traction table in a supine position, under an x-ray amplifier. Sliding screw plates (THS) were set in place according to the usual open technique. Nails were placed through a twenty-millimeter supratrochanteric cutaneous incision. This experimental system comprised a locked intramedullary nail with two nonparallel seven-millimeter cervicocephalic screws.
                The comparison between the two groups was based on the surgical procedure (time, duration of x-ray irradiation, and total blood loss); the initial postoperative period (complications, duration of hospital stay, and the time before returning home); the time before full weight bearing became effective; the functional and social recovery; mortality; and the quality of immediate and final anatomic restitution and healing.
                Operating time (p < 0.001) and blood loss (p < 0.001) were lower in the nail group, and no blood transfusion was required. Postoperative pain (p < 0.01), time necessary to support full weight bearing (p < 0.02), and time before returning home (p < 0.05) were reduced in the nail group. All fractures healed in the same amount of time, with good anatomic results in the nail group, whereas ten impactions beyond ten millimeters occurred in the plate group. No difference was found between the two groups in walking ability and autonomy recovery, but hip function (p < 0.05) was better in the nail group.
                This preliminary clinical study has shown the advantages of this mini-invasive technique. It could not evaluate all the possible disadvantages inherent in the method. These points will be evaluated in a multicenter study justified by these preliminary results. To compare the results between a sliding compression hip screw and an intramedullary nail in the treatment of pertrochanteric fractures.
                Prospective computer-generated randomization of 206 patients into two study groups: those treated by sliding compression hip screw (Group 1; n = 106) and those treated by intramedullary nailing (Group 2; n = 100).
                University Level I trauma center.
                All patients over the age of fifty-five years presenting with fractures of the trochanteric region caused by a low-energy injury, classified as AO/OTA Type 31-A1 and A2.
                Treatment with a sliding compression hip screw (Dynamic Hip Screw; Synthes-Stratec, Oberdorf, Switzerland) or an intramedullary nail (Proximal Femoral Nail; Synthes-Stratec, Oberdorf, Switzerland).
                Intraoperative: operative and fluoroscopy times, the difficulty of the operation, intraoperative complications, and blood loss. Radiologic: fracture healing and failure of fixation. Clinical: pain, social functioning score, and mobility score.
                The minimum follow-up was one year. We did not find any statistically significant difference, intraoperatively, radiologically, or clinically, between the two groups of patients.
                There is no advantage to an intramedullary nail versus a sliding compression hip screw for low-energy pertrochanteric fractures AO/OTA 31-A1 and A2, specifically with its increased cost and lack of evidence to show decreased complications or improved patient outcome. In a prospective, randomized trial we compared the trochanteric gamma nail (TGN) and the dynamic hip screw (DHS) in the treatment of 146 intertrochanteric fractures. Follow-up was after four and 12 months. The operation time was significantly shorter in the DHS group. At discharge the need for walking aids was less in the DHS group. There were no differences in intraoperative blood loss, medical complications, mortality or length of hospital stay. Major fracture complications occurred twiceas often in the TGN group compared with the DHS group, however they were not statistically significant. Any potential for the TGN leading to a less invasive procedure and a more rapid postoperative mobilisation could not be demonstrated. Compared with the TGN we prefer the DHS for most intertrochanteric fractures in a setting where the majority of these fractures are treated by younger doctors and not by highly specialized hip/trauma surgeons. The TGN may have advantages in selected intertrochanteric fractures.; The progress of 182 patients who presented with intertrochanteric fractures was followed over a six month period. Eighty-seven patients were treated using Thornton/McLaughlin nail plates and 95 were treated using Ender's intramedullary nails. Each fracture was classified according to radiological position and mechanical stability. The results show that the more unstable fractures are more likely to develop unsatisfactory results. Post operatively, the different mechanical complications have been recorded at various stages. Those fractures fixed with a nail plate tended to develop varus deformity resulting from either bony collapse around the implant or implant failure, whereas those fixed with Ender's nails did not develop deformity at the fracture site but encountered distal migration of the nails at the knee. The use of a classification system in predicting post operative mechanical complications is considered, and the comparative merits and disadvantages of the two fixation systems is discussed, with suggestions for improvement in operative technique. To compare clinical and radiological results in per- and subtrochanteric fractures' management with 90 degrees blade plate or Gamma nail fixation; an implant allowing early weight-bearing and fracture healing in correct position remains still difficult.
                Between 1993 and 1995, 26 patients addressed to our Center for a Kyle IV [1] fracture were divided into 2 groups, one fixed with blade plate and the other with Gamma nail. The follow-up for all patients is 12 months.
                Gamma nail allows early weight-bearing in all patients, fracture healing is acquired at 4.2 months; an operative diaphyseal fracture needed conversion to a long Gamma nail. We observed a slight cut-out that didn't need reoperation. In the blade plate group, we noticed three femoral head necrosis without major flattening, two non-unions, one plate's breakage and two malunions; fracture healing is acquired at 6.3 months. The two non-unions and the plate's breakage didn't need reoperation because of low functional demand.
                We prefer Gamma nail in per- and subtrochanteric femoral fractures' management, it allows early and fast weight-bearing and fracture healing is acquired in all cases. The purpose of this study is to compare a cephalomedullary nail that uses a piriformis fossa starting point to one that uses a trochanteric starting point, in the treatment of high-energy proximal femur fractures in young patients. Our hypothesis was that a nail that uses a trochanteric starting point would result in less blood loss than a nail that uses a piriformis fossa starting point.
                Prospective, randomized.
                Level 1 trauma center.
                Thirty-four consecutive patients aged between 18 and 50 years who sustained a subtrochanteric, intertrochanteric, or ipsilateral femoral neck/shaft fracture due to a high-energy injury were enrolled.
                Patients were randomized to have their fractures repaired with a Russell-Taylor Recon Nail or Howmedica Long Gamma Nail. Surgery was performed on a fracture table, in supine or lateral position according to the surgeon's preference. Direct fracture exposure was avoided. Reduction was obtained through traction, patient positioning, and manual pressure. If necessary, stab-wound incisions were made to introduce instruments to improve reduction. Intramedullary reamers were used, and all nails were statically locked. Bone grafting was not used.
                Blood loss, incision length, duration of surgery, and body mass index were recorded for each patient. Surgeon's assessment of ease of use of the device and quality of reduction were noted. Patients were to be followed up to assess fracture union. Hip and knee ranges of motion at latest follow-up were measured. Radiographs obtained at the time of union were assessed for varus malalignment. Return to work status was recorded, and the Harris Hip Score was used to assess hip function.
                There were 17 patients in each group. The 2 groups did not differ with regard to blood loss, incision length, and duration of surgery or intraoperative complications. Body mass index was significantly linked to duration of surgery (P<0.001) and incision length (P<0.001). Surgeon's assessment of ease of use and reduction quality for the two devices did not differ. The rate of varus malunion did not differ between the 2 groups. Two patients were lost to follow-up before fracture union. All other fractures healed with no need for bone grafting or other procedures to obtain union. One obese patient developed a wound infection that resolved after debridement and a course of antibiotics. A total of 6 patients were lost prior to their 1-year follow-up visit. Among the remaining 28 patients, at an average follow-up of 14 months, no difference was noted between the 2 groups with regard to return to work status, Harris Hip Score, or hip and knee ranges of motion.
                Both devices yield predictably good results in these difficult fractures. We found no difference between the two devices with regard to incision length, duration of surgery, blood loss, reduction, ease of use, union rate, complication rate, or outcome. The aim of this study was to compare the results of the humerus intramedullary nail (IMN) and dynamic compression plate (DCP) for the management of diaphyseal fractures of the humerus. Forty-seven patients with diaphyseal fracture of the shaft of the humerus were randomised prospectively and treated by open reduction and internal fixation with IMN or DCP. The criteria for inclusion were grade 1 or 2a compound fractures, polytrauma, early failure of conservative treatment and unstable fractures. The patients with pathological fractures, grade 3 open fractures, refractures and old neglected fractures of the humerus were excluded from the study. Twenty-three patients underwent internal fixation by IMN and 24 by DCP. Reamed antegrade nailing was done in all cases. DCP was done through an anterolateral or posterior approach. The outcome was assessed in terms of the union time, union rate, functional outcome and the incidence of complications. Functional outcome was assessed using the American Shoulder and Elbow Surgeons' Score (ASES). On comparing the results by independent samples t test, there was no significant difference in ASES scores between the two groups (P>0.05). The average union time was found to be significantly lower for IMN as compared to DCP (P<0.05). The union rate was found to be similar in both groups. Complications such as infection were found to be higher with DCP as compared to IMN, while shortening of the arm (1.5-4 cm) and restriction of shoulder movements due to impingement by the nail were found to be higher with IMN as compared to DCP. However, this improved in all patients following the removal of the nail once the fracture had healed. This study proves that IMN can be considered a better surgical option for the management of diaphyseal fractures of the humerus as it offers a short union time and lower incidence of serious complications like infection. However, there appears to be no difference between the two groups in terms of the rate of union and functional outcome. In a prospective randomised trial between September 1989 and June 1990 one hundred patients with per- and subtrochanteric fractures were consecutively treated by gamma-nail or DHS. The average age of both groups was about 80 years. The operation time for gamma-nailing was longer than for DHS implantation and also the postoperative blood loss was higher in the gamma-nail group. We found no difference of intraoperative blood loss, of perioperative lethality and in duration of hospital care. 90% of gamma-nail patients and 80% of DHS patients were successfully able to walk four days after operation with full weight bearing on the operated limb. Three patients in the DHS group with unstable fractures got cranial perforation of the cephalic screw mobilisation. Five patients of the gamma-nail group were reoperated, one case because of missed distal locking, one because of cranial perforation of the cephalic screw after varus dislocation of the proximal fragment. One patient suffered intraoperatively a proximal femur shaft fracture which was corrected during operation. In one case a wound hematoma was evacuated, an other patient needed secondary wound closure. Despite technical imperfection of implant and instruments, we conclude that the gamma-nail allows a very high percentage early and full weight bearing immediately after operation. So we consider that in the treatment of unstable pertrochanteric fractures of geriatric patients, the gamma-nail has proven to be more efficient than the DHS. We report a randomised prospective study comparing two implants, the Gamma trochanteric nail and the ACE trochanteric nail, in the treatment of intertrochanteric femoral fractures in the elderly. One hundred and twelve patients were randomised on admission into two treatment groups. Fifty-six patients were treated with Gamma nail implants, and 56 were treated with ACE trochanteric nail. The average age of these patients was 78 years. Twenty fractures were stable and 92 unstable. The mean follow-up time was 8 months (6 -12). Regular clinical and radiological review was done 1, 3 and 6 months postoperatively. Operation time, fluoroscopy time, blood transfusion and complications were recorded. The mobility score was used to assess the pre-injury and postoperative mobility status. All the patients were treated within 36 h of their accident. There were no complications during surgery. All the patients were mobilised in the first 24 h postoperatively, regardless of the fracture type, and weight bearing was permitted as tolerated. Union of the fracture was achieved in all patients. There was no statistically significant difference between the two groups with regard to the studied parameters. There was no mechanical failure of the implants despite the early patient mobilisation. Early operation and early mobilisation resulted in a good functional outcome in all patients. Both the trochanteric gamma nail and ACE trochanteric nail provide effective methods of treatment for intertrochanteric fractures in elderly patients. To compare outcome between the proximal femoral nail (PFN) and the Medoff sliding plate (MSP) in patients with unstable trochanteric or subtrochanteric fractures.
                This was a consecutive prospective randomized clinical study. In all, 203 patients admitted to two university hospitals with an unstable trochanteric or a subtrochanteric fracture type were included. Surgery was performed with a short intramedullary nail or a dual-sliding plate device. Follow up visits occurred at 6 weeks, 4 months, and 12 months. Functional outcome was measured by walking ability, rising from a chair, curb test, and additional assessments of abductor strength, pain, living conditions, and complications.
                The ability to walk 15 m at 6 weeks was significantly better in the PFN group compared to the MSP group with an odds ratio 2.2 (P = 0.04, 95% confidence limits 1.03-4.67). No statistical difference in walking ability could be found between trochanteric and subtrochanteric fractures. The major complication rate (8% in the PFN group and 4% in the MSP group) did not differ statistically (P = 0.50) but reoperations were more frequent in the PFN group (9%) compared to the MSP group (1%; P < 0.02).
                There were no major differences in functional outcome or major complications between the treatment groups. Reasons other than the operated fracture seem to be equally important in determining the long-term functional ability of the patients in our study. An advantage with the MSP was the lower reoperation rate. Numerous studies have been published regarding the comparison between intramedullary nail and the dynamic hip screw and plate for the fixation of intertrochanteric fractures in elderly patients. In this paper we present a comparative study of these two methods regarding their systemic effects on this group of patients.
                This is a randomized trial of 120 consecutive patients with an intertrochanteric fracture treated with either extramedullary fixation (dynamic hip screw and plate; DHS, Synthes-Stratec, Oberdorf, Switzerland) or intramedullary nail (Gamma nail, Stryker Howmedica, Freiburg, Germany and Endovis BA, Citieffe, Bologna, Italy). The parameters that we assessed pre-operatively, in addition to their demographics, included their mental state (MMSE), their nutritional and immune state and their pulmonary function. Intra-operatively we calculated the amount of radiation exposure, the amount of blood loss and the length of operative time for each procedure. Postoperatively we repeated the calculation of the mental and pulmonary state and the blood loss, during days 1, 3, and 10 and related them to the ease of the patient's mobilization.
                Decreased bleeding and post-operative pain, reduced post-operative morbidity and faster recovery of function were better but not significant in the group of intramedullary fixation (all p>0.05). However, in the same group there were slightly more patients in whom the MMSE was falling, together with their pulmonary function, suggesting that this method probably predisposes to higher chances of pulmonary dysfunction and the possibility of pulmonary embolism.
                We found no significant differences between the two methods of stabilization of these fractures regarding their systemic effects perioperatively. The classic dynamic hip screw can preserve its position as a safe and effective solution for these already vulnerable patients having sustained a trochanteric fracture against the novel intramedullary techniques.
                Copyright 2009. Published by Elsevier Ltd. This prospective, randomized study compared the functional outcome and complications associated with a proximal femoral nail antirotation (PFNA) device with those of a traditional extramedullary device, the dynamic hip screw (DHS), in patients with trochanteric fracture. A total of 121 patients were randomized to the PFNA group (n = 58) or the DHS group (n = 63). Perioperative information and complications were recorded, and assessments of functional outcome were made. The DHS group required a longer operative time and was associated with greater blood loss than the PFNA group. The re-operation rate was lower in the PFNA group compared with the DHS group, especially in patients with unstable fractures, although there was no statistically significant difference in the overall complication rate between the two groups. There were no significant differences in functional outcome between the PFNA and the DHS groups. In conclusion, the PFNA device is useful in the treatment of trochanteric fractures. The Gamma AP (Asia-Pacific) locking nail (GAPN) is a modification of the standard Gamma locking nail made especially for use in Oriental patients. We made a randomised prospective comparison of the compression hip screw (CHS) and the Gamma AP locking nail for the internal fixation of 60 intertrochanteric fractures of the hip in elderly patients by comparing perioperative details and analysing the radiographic and clinical results. The operation time for the GAPN group was shorter than for the CHS group and the intraoperative blood loss was lower. The Gamma AP nail enabled earlier mobilisation. We found no significant difference in the time to union and the length of sliding of the lag screw between the two groups. The decrease in the neck shaft angle in the Gamma nail group was significantly smaller than in the CHS patients. There were no significant mechanical complications, such as fracture of the femoral shaft or failure of fixation in the Gamma nail group. On the basis of our observations we conclude that the Gamma AP locking nail is more efficient than the CHS in the treatment of intertrochanteric fractures in geriatric patients. We have prospectively compared the fixation of 100 intertrochanteric fractures of the proximal femur in elderly patients with random use of either a Dynamic Hip Screw (DHS) or a new intramedullary device, the Gamma nail. We found no difference in operating time, blood loss, wound complications, stay in hospital, place of eventual discharge, or the patients' mobility at final review. There was no difference in failure of proximal fixation: cut-out occurred in three cases with the DHS, and twice with the Gamma nail. However, in four cases fracture of the femur occurred close to the Gamma nail, requiring further major surgery. In the absence of these complications, union was seen by six months in both groups. We compared the outcome of patients treated for an intertrochanteric fracture of the femoral neck with a locked, long intramedullary nail with those treated with a dynamic hip screw (DHS) in a prospective randomised study. Each patient who presented with an extra-capsular hip fracture was randomised to operative stabilisation with either a long intramedullary Holland nail or a DHS. We treated 92 patients with a Holland nail and 98 with a DHS. Pre-operative variables included the Mini Mental test score, patient mobility, fracture pattern and American Society of Anesthesiologists grading. Peri-operative variables were anaesthetic time, operating time, radiation time and blood loss. Post-operative variables were time to mobilising with a frame, wound infection, time to discharge, time to fracture union, and mortality. We found no significant difference in the pre-operative variables. The mean anaesthetic and operation times were shorter in the DHS group than in the Holland nail group (29.7 vs 40.4 minutes, p < 0.001; and 40.3 vs 54 minutes, p < 0.001, respectively). There was an increased mean blood loss within the DHS group versus the Holland nail group (160 ml vs 78 ml, respectively, p < 0.001). The mean time to mobilisation with a frame was shorter in the Holland nail group (DHS 4.3 days, Holland nail 3.6 days, p = 0.012). More patients needed a post-operative blood transfusion in the DHS group (23 vs seven, p = 0.003) and the mean radiation time was shorter in this group (DHS 0.9 minutes vs Holland nail 1.56 minutes, p < 0.001). The screw of the DHS cut out in two patients, one of whom underwent revision to a Holland nail. There were no revisions in the Holland nail group. All fractures in both groups were united when followed up after one year. We conclude that the DHS can be implanted more quickly and with less exposure to radiation than the Holland nail. However, the resultant blood loss and need for transfusion is greater. The Holland nail allows patients to mobilise faster and to a greater extent. We have therefore adopted the Holland nail as our preferred method of treating intertrochanteric fractures of the hip. To compare the results between a new intramedullary Gamma nail and a compression hip screw in the treatment of trochanteric fractures.
                Prospective randomized.
                Level 1 trauma center.
                Two hundred ten consecutive patients older than 65 years with trochanteric femoral fractures.
                Treatment with a compression hip screw or a new design of the Trochanteric Gamma nail (180 mm in length with a mediolateral angle of 4 degrees and available only with a proximal diameter of 17 mm and distal diameter of 11 mm).
                Operative and fluoroscopy times, blood loss, functional outcome, complication rate, and failure of fixation.
                The Trochanteric Gamma nail was used in 104 patients and the compression hip screw in 106. The 2 groups were similar in terms of their preoperative data, with a median follow-up of 13.6 months (range 12-30). The results show no difference in operating time (P = 0.21), but the Trochanteric Gamma nail group had a significantly shorter fluoroscopy time (P = 0.006), and the number of patients transfused and the mean of units of blood transfused were significantly less in the Trochanteric Gamma nail group (P = 0.013, 0.046, respectively). Mortality within 12 months was similar in both groups (P = 0.83). All fractures were radiographically healed at the last visit. There was no difference in intraoperative and postoperative complications or rate of fixation failure between the 2 groups, and no case of secondary shaft fracture of the femur was encountered in this study. In the entire series, there was no difference in the functional outcome (P = 0.74), but the postoperative walking ability was better in those patients with unstable fractures who were treated with the Trochanteric Gamma nail (P = 0.017).
                The new Trochanteric Gamma nail is an effective method for the treatment of trochanteric femoral fractures in elderly patients. The indication for either Trochanteric Gamma nail or compression hip screw is similar in stable fractures, but we recommend the use of the Trochanteric Gamma nail for unstable trochanteric fractures. Achieving bony union and early weight bearing in peritrochanteric femur fractures poses a continuous challenge for the orthopedic surgeon. Current standards of surgical fixation for the myriad possible fracture patterns include the compression hip screw (CHS), the 90 degrees/95 degrees blade plate, and locked intramedullary nails. The gamma nail (GN) was designed as a "hybrid" of these devices, combining theoretical biomechanical advantages that should allow earlier postoperative weight bearing with surgical technique advantages that should decrease operative morbidity. Because these theoretical advantages were unproven in a clinical setting, we prospectively randomized 75 consecutive patients with peritrochanteric femur fractures into two groups to examine the fixation of these fractures with the GN as compared to the CHS. We found no significant differences in preoperative or intraoperative parameters. Postoperatively, the subtrochanteric fracture group treated with the GN achieved earlier weightbearing status, although this was not statistically significant. 72 patients were available for follow-up at a minimum of 6 months. All fractures had clinically and radiographically healed, and 94% of the patients continued to be ambulatory. Major complications included missed distal locking screws (one patient), cutting out of the lag screw superiorly in the femoral head (two patients), and a femur fracture at the distal end of the GN (one patient). In our series, the GN produced clinical results commensurate with current standards of fixation for peritrochanteric femur fractures. Although the GN allowed earlier independent weightbearing status in patients with subtrochanteric fractures, the procedure was technically more demanding and had a significant learning curve. To compare elastic stable intramedullary nailing (ESIN) with nonoperative treatment of fully displaced midshaft clavicular fractures in adults.
                The study was a randomized, controlled, clinical trial.
                Level 1 trauma center.
                Sixty patients between 18 and 65 years of age participated and completed the study. They were randomized to either operative or nonoperative treatment with a 2-year follow-up.
                Thirty patients were treated with a simple shoulder sling and 30 patients with ESIN within 3 days after trauma.
                Complications after operative and nonoperative treatments, Disabilities of the Arm, Shoulder and Hand (DASH) score and Constant Shoulder Score for outcome measurement, and clavicular shortening.
                Fracture union was achieved in all patients in the operative group, whereas nonunion was observed in 3 of 30 patients of the nonoperative group. Two symptomatic malunions required corrective osteotomy in the nonoperative group. Medial nail protrusion occurred in 7 cases in the operative group. Implant failure with revision surgery was necessary in 2 patients after an additional adequate trauma. DASH scores were lower in the operative group throughout the first 6 months and 2 years after trauma, with a significant difference during the first 18 weeks. Constant scores were significantly higher after 6 months and 2 years after intramedullary stabilization. Patients in the operative group showed a significant improvement of posttraumatic clavicular shortening; they were also more satisfied with cosmetic appearance and overall outcome.
                ESIN of displaced midshaft clavicular fractures resulted in a lower rate of nonunion and delayed union, a faster return to daily activities, and a better functional outcome. Clavicular shortening was significantly lower, and overall satisfaction was higher in the operative group. Objective: Studies showed elastic stable intramedullary nailing (ESIN) of displaced midclavicular fractures has excellent outcomes, as well as high complication rates and specific problems. The aim was to discuss ESIN of midshaft clavicular fractures. Methods: Totally 60 eligible patients (aged 18-63 years) were randomized to either ESIN group or non-operative group between January 2007 and May 2008. Clavicular shortening was measured after trauma and osseous consolidation. Radiographic union and complications were assessed. Function analysis including Constant shoulder scores and disabilities of the arm, shoulder and hand (DASH) scores were performed after a 15-month follow-up. Results: ESIN led to a signifcantly shorter time to union, especially for simple fractures. In ESIN group, all patients got fracture union, of which 5 cases had medial skin irritation and 1 patient needed revision surgery because of implant failure. In the nonoperative group, there were 3 nonunion cases and 2 symptomatic malunions developed requiring corrective osteotomy. At 15 months after intramedullary stabilization, patients in the ESIN group were more satisfied with the appearance of the shoulder and overall outcome, and they benefited a lot from the great improvement of post-traumatic clavicular shortening. Furthermore, DASH scores were lower and Constant scores were significantly higher in contrast to the non-operative group. Conclusion: ESIN is a safe minimally invasive surgical technique with lower complication rate, faster return to daily activities, excellent cosmetic and better functional results, restoration of clavicular length for treating mid-shaft clavicular fractures, resulting in high overall satisfaction, which can be regard as an alternative to plate fixation or nonoperative treatment of mid-shaft clavicular fractures. The objective of this study was to compare the dynamic hip screw (Synthes) and intramedullary fixation (Targon PF, Aesculap) for the treatment of pertrochanteric fractures in terms of stability, complications and cost effectiveness.
                This prospective randomized study included 60 patients hospitalized in an emergency setting for pertrochanteric fractures between December 2003 and June 2004. All surgeons in our unit participated in the study. Two fixation systems were used: the Targon proximal femoral nail (Aesculap) and the screw-plate dynamic hip screw (Synthes). We noted: patient status (ASA classification), operative data (type of implant, duration), postoperative data (blood loss, radiographic findings, early complications), and outcome (Harris score, time to walking, mortality). All patients were assessed three months after surgery. The series included 60 patients, 14 men (23%) and 46 women (77%). The Targon PF nail was used for 34 patients and the DHS for 26. In the intramedullary fixation group mean age was 81 years (SD = 12.8, range 23-96); it was 82 years (SD 9.8, range 47-97) in the screw-plate group. The AO classification was: intramedullary fixation 31A1 (n = 11), 31A2 (n = 20), 31A3 (n = 3); screw-plate 31A1 (n = 14), 31A2 (n = 11), 31A3 (n = 1). Thirty-one fractures were stable, 29 unstable. Unstable fractures were treated with the Targon PF nail (n = 18) and the DHS screw-plate (n = 11). Stable fractures were treated with the Targon PF nail (n = 15) and the DHS screw-plate (n = 15).
                Mean operative time was 35 minutes for intramedullary nailing and 42 mintues for screw-plate fixation. Mean blood loss was 410 ml for intramedullary nailing and 325 ml for screw-plate fixation (p = 0.07). Mean hospital stay was the same (11 days) in both groups. At three months, mechanical complications involved migration of the cervical screw outside the femoral head for three Targon PF fixations and for two DHS fixations. Screw migration was favored by fracture instability and presence of osteoporosis. There were two deaths in the intramedullary nailing group and one in the screw-plate group. Time to walking was 20 days on average in the intramedullary nailing group and 25 days in the screw-plate group. The mean Harris hip score was 60 in the intramedullary group and 59 in the screw-plate group.
                Data in the literature report an advantage for intramedullary nailing, particularly a mechanical advantage, for the treatment of pertrochanteric fractures. Our findings show that good results are obtained with the screw-plate fixation using the DHS with less blood loss and at a lower cost. We compared the efficacy of a load-sharing device, the Medoff sliding plate (MSP), with that of 3 other load-bearing screw-plate devices for the fixation of subtrochanteric fractures in a randomized multicenter trial of 107 elderly patients. 55 fractures were operated on with the MSP, and 52 with the dynamic hip screw (DHS) with or without a trochanteric stabilizing plate (TSP) or with the dynamic condylar screw (DCS). The patient material in the groups was similar regarding age, domestic situation, preinjury walking ability and fracture types. We followed the patients clinically and radiographically for a minimum of 1 year. There was no significant difference in walking ability or return rate to the home at follow-up. Fixation failure occurred in 1/55 fractures operated on with the MSP, in 3/32 with the DHS, in 3/12 with the DCS and in 2/8 with the DHS/TSR The difference in the rate of fixation failure was statistically significant, when the MSP group was compared to the 3 load-bearing devices in the other group (1 vs 8). On the basis of this experience, we think that the load-sharing principle of the MSP, which seems to facilitate fracture impaction and stability, appears to be a good alternative in extramedullary fixation of subtrochanteric fractures. The proximal femoral nail (PFN) is a recently introduced intramedullary system, designed to improve treatment of unstable trochanteric fractures of the hip. In a multicentre prospective clinical study, the intra-operative use, complications and outcome of treatment using the PFN (n = 211) were compared with those using the gamma nail (GN) (n = 213). The intra-operative blood loss was lower with the PFN (220 ml v 287 ml, p = 0.001). Post-operatively, more lateral protrusion of the hip screws of the PFN (7.6%) was documented, compared with the gamma nail (1.6%, p = 0.02). Most local complications were related to suboptimal reduction of the fracture and/or positioning of the implant. Functional outcome and consolidation were equal for both implants. Generally, the results of treatment of unstable trochanteric fractures were comparable for the PFN and GN. The pitfalls and complications were similar, and mainly surgeon- or fracture-related, rather than implant-related. We compared the efficacy of the Medoff sliding plate (MSP) with 3 other screw-plate systems for fixation of unstable intertrochanteric fractures in a randomized multicenter trial of 569 elderly patients. The MSP has biaxial dynamic capacity along both the neck and the shaft of the femur unlike the other systems, which lack dynamic capacity along the shaft. 268 fractures were operated on with the MSP, and 301 with the dynamic hip screw (DHS), with or without a trochanteric stabilizing plate (DHS/TSP) or with the dynamic condylar screw (DCS). The MSP had recently been shown to the surgeons. The patients in the groups were similar as regards age, domestic situation, preinjury walking ability and type of fracture. We followed the patients clinically and radiographically for at least 1 year. There was no significant difference in walking ability at follow-up or rate of return to home. Fixation failure occurred in 18/268 fractures operated on with the MSP, in 8/238 with the DHS, in 3/49 with the DHS/TSP and in 1/14 with the DCS. The difference in the rate of fixation failure was not statistically significant when the MSP group was compared to the 3 other groups. In 14 of the 18 fixation failures in the MSP group, the biaxial dynamic capacity of the MSP had not been used due to technical errors by surgeons, unfamiliar with the new method. No selection bias was found regarding fracture types in the 2 subgroups of patients with correct or inadequate biaxial dynamization. Extramedullary fixation of unstable intertrochanteric fractures with these implants showed a low failure rate. When using the MSP, biaxial dynamization must be correctly performed. The current prospective and randomized study was done to determine whether fixation of intertrochanteric femoral fractures that lack a medial buttress with a dynamically locked intramedullary hip screw prevents proximal stress shielding. Stress shielding was evident by the presence of cortical hypertrophy at the level of the tip of the nail and often was associated with midthigh pain. Of the 80 patients enrolled in this trial, 64 still were alive after 1 year. Among these patients, 30 had the nail classically locked with two screws transfixing the nail in two separate holes (Group A), and 34 had the nail locked with one screw passing through a slot (Group B). The average duration of followup was 37 months (range, 12-49 months). Tolerance to dynamically locked nails was significantly better, with only one patient in Group B having cortical hypertrophy of the femur at the level of the tip of the nail, compared with six patients in Group A. Other outcomes were equal in both groups. Late tolerance to this new dynamically locked intramedullary hip screw is good, while retaining the known advantages of nailing of these fractures.
With its lower complication rate in comparison with intramedullary nails, and absence of functional outcome data to the contrary, the SHS appears superior for trochanteric fractures. Further studies are required to confirm whether more recently developed designs of intramedullary nail avoid the complications of previous nails. Intramedullary nails may have advantages over fixed angle plates for subtrochanteric and some unstable trochanteric fractures, but further studies are required.