Clinical data: General Information:Data collection occuredfrom October 2015 to February 2018, and included data from patients with surgically corrected intertrochanteric fractures.. Participation in the study was determined based on the following inclusion criteria: (1) Clear history of trauma; (2) Age 62 to 95 years; (3) Imaging diagnosis of fresh intertrochanteric fractures (AO / OTA classification of 31-A1, 31-A2, 31-A3) (4)Internal fixation surgery with long intramedullary nail .Exclusion criteria: (1) Pathological fracture or old fracture (injury time ≥ 3 weeks); (2) Under 60 years old (<60 years old); (3) Multiple fractures; (4) Additional surgery other than intertrochanteric internal fixation and subsequent hospitalization for surgery besides internal fixation surgery; (5)Internal fixation surgery with short intramedullary nail.Patient information:28 patients including 10 males and 18 females with age ranging from 62 to 95 years old, with an average of 78.4 years. There were 16 cases with left sided intertrochanteric fracture and 12 cases with right sided intertrochanteric fracture. The fractures were classified according to AO/OTA, including 8 cases of type 31A1 , 12 cases of type 31A2 , and 8 cases of type 31A3 . The injury mechanism included 3 cases of traffic injuries, 23 cases of falls when walking, and 2 cases of falling from high altitude(Table 1).
Table 1
male
|
femal
|
60-70
|
71-90
|
>90
|
Traffic
|
Fall
|
High falling
|
10(35.7%)
|
18(64.3%)
|
9(32.1%)
|
15(53.6%)
|
4(14.3%)
|
5(17.9%)
|
17(60.7%)
|
6(21.4%)
|
Table 2
Harris score
|
excellent
(90-100)
|
good
(80-89)
|
fair
(70-79)
|
poor
(≤69)
|
dead
|
result
|
12(42.9%)
|
6(21.4%)
|
7(27.0%)
|
1(3.8%)
|
2(7.7%)
|
Treatment: Preoperative preparation: Before hospital admission, all patients were examined in the emergency department with pelvic orthotopic lateral X-ray (Figure 4a and 4b) and the intertrochanteric fracture classification was determined. Routine blood work, , liver and kidney function, blood coagulation testing, and blood typing were also performed in the emergency room20 patients underwent emergency surgery within 24 hours after their injury, 6 patients underwent surgery within 36 hours after their injury, and 2 patients underwent surgery within 72 hours after their injury (2 patients were complicated with diabetes, and it was necessary to control their blood sugar level prior to surgery). Operation method:All patients underwent surgery on the orthopedic traction bed. The affected limbs were simultaneously adducted, the lower leg was internally rotated, and the fracture end was restored under C-arm fluoroscopy. When we confirmed the lateral position, we used a medical tape to attach a 2.0 Kirschner wirethat helped to mark the position of the needle on the skin (Figure5).After the surgical field was disinfected, a sterile towel sheet was placed. The proximal tip of the femoral trochanter is about 5.0 cm along the axis of the mark, and an approximately 3.0 cm surgical incision was made in this location. After exposing the fascia, the incision was sharply cut and a vascular clamp was applied.Fingertip palpation was utilized to locate the frontal area of the apex of the large trochanter, and the guide pin was drilled along the direction of the body surface marker. After drilling the guide pin, confirmation of itsposition at the large trochanter from the positive side was determined under fluoroscopy. If only minor adjustment was required, the openerwas used (Figure6) to adjust the guide pin insertion.If fluoroscopy revealed that the guide needle needed to be adjusted inward, the operator slowly rotatedthe tip of the opener inward, which can enlarge the inner bone tunnel. If lateral fluoroscopic imaging revealed that the guide needle needed to be adjusted to the front, the operator slowly rotated the tip of the opener forward, which can enlarge the bone tunnel in front.According to the standard surgical procedure[6], when guiding the lateral position, the guide needle needs to be located at the front 1/3 of the proximal tip of the femur trochanter. However, we moved this point forward by 1-2mm, because according to the diagonal principle (Figure7), this method can avoid the compression of the anterior cortex at the distal end of the femur after the intramedullary nail is implanted. After the femoral trochanteric tunnelwasmade using an electric drill, the guide needle was removed and the guidewire was implanted along the bone tunnel, and the appropriate intramedullary nail was selected according to the length of the patient's femur. A guide needle was drilled in the long axis of the femoral neck, and then anteroposterior and lateral fluoroscopic imaging was used to confirm appropriate positioning of the guide needle. After confirming the TAD of the guide pin <10, the main nail and the lower lag screw were respectively implanted.When locking the distal end of the intramedullary nail, we followed the diagonal principle. After selecting the appropriate length of the intramedullary nail, we immediately used the positioner for general positioning in vitro (Figure 8). After the positioning was completed, the distal locking pin only had an error in the front-rear direction (Figure 9).The inner diameter of the distal sleeve was4.5 mm. We used a 2.5 mm Kirschner wire to drill through one side of the cortical bone from the center of the sleeve. The sleeve was then removed and the C-arm was placed in a lateral position so that the position of the Kirschner wire relative to the intramedullary nail could be confirmed.If the Kirschner wirewas found to be behindthe nail, we withdrew the K-wire. Then drilled this Kirschner pin under the sleeve in an obliquely upward direction (Figure 10 and 10b). Using this method, (the diagonal principle), the needle insertion point will be higher, so the 2.5 gram needle will generally enter the lock hole (Figure 11).Once again, it was confirmed that the Kirschner wire was placed in the intramedullary nail hole and then we drilled through the contralateral cortex. While maintaining the position of the Kirschner wire, we insertedanother lock nail after drilling. After removing the 2.5 mm K-wire, the locking operation wasperformed in sequence. This approach limited the time it took to obtain fluoroscopy whilethe oblique perspective of the C-arm ensured a successful operation(Figure 12 and 12b). Rehabilitation after surgery: After waking from anesthesia, the patient began passive and active activities on the affected limb. On the first day after surgery, the patient was assisted in partially weight bearing on the affected limb while walking. Total weight bearing on the affected limb was attempted two weeks post-operation.