Abstract

Purpose. The aim of this study is to evaluate the learning bend of performing surgery with the InterTan intramedullary pinpoint in treating femoral intertrochanteric fractures, to provide valuable information and know for surgeons who decide to learn a fresh procedure. Methods. We retrospectively analyzed data from 53 patients who underwent operating room using an InterTan intramedullary breeze through at our hospital between July 2012 and September 2015. The negative exponential curve-fit regression psychoanalysis was used to evaluate the determine curvature. According to 90 % learning milestone, patients were divided into two group, and the outcomes were compared. Results. The average operative time was 69.28 ( 95 % CI 64.57 to 74.00 ) minutes ; with the accumulation of surgical experience, the operation clock time was gradually decreased. 90 % of the potential improvement was expected after 18 cases. In terms of private detective prison term, intraoperative lineage personnel casualty, hospital stay, and Harris hip score meaning differences were found between two groups (, ,, and, resp. ). partial derivative weight bear clock time, fracture union time, peak vertex distance, and the number of blood transfusions and complications were like between two groups ( ). Conclusion. This learn demonstrated that the learning arch of performing surgery with the InterTan intramedullary smash is satisfactory and 90 % of the expert ’ sulfur proficiency level is achieved at around 18 cases .

1. Introduction

Femoral intertrochanteric fractures are the second most park character of hip fracture. Both intramedullary and extramedullary internal obsession devices are widely used to treat femoral intertrochanteric fractures. The sliding hip screw ( SHS ) was regarded as the standard arrested development device in caution for femoral intertrochanteric fractures [ 1 ]. however, intramedullary nail down has improved biomechanical features compared to SHS, and many surgeons would probably select intramedullary devices for the treatment of femoral intertrochanteric fractures [ 2 ]. The TRIGEN INTERTAN Intertrochanteric Antegrade nail ( Smith & Nephew, Memphis, TN ) was introduced in 2005 and increases intertrochanteric rotational constancy [ 3 ] and decreases stave screw cutout [ 4, 5 ]. The memorize curve for orthopedic surgery [ 6, 7 ] and nonorthopedic surgeries [ 8, 9 ] has been previously described, but the teach curvature of performing operating room with InterTan intramedullary nail ( IT ) has not been previously analyzed. Understanding the average eruditeness curl for surgery with a specific device is in the best interests of patient guard and an authoritative component of a surgeon ’ s learning process [ 10 ]. Therefore, the aim of this study was to evaluate the learning curves of performing operation with the InterTan intramedullary smash for treatment of femoral intertrochanteric fractures, to provide valuable information and feel for surgeons who decide to learn a new procedure.

2. Materials and Methods

2.1. Patients

We retrospectively analyzed data from 53 patients who underwent surgery using an InterTan intramedullary breeze through at our hospital between July 2012 and September 2015. Patients with femoral intertrochanteric fracture were considered eligible patients. Exclusion criteria were ( one ) historic period < 60 years, ( two ) pathological fracture, ( three ) old fracture or multiple fractures, ( intravenous feeding ) an inability to walk or hemiplegia before the fracture, and ( five ) hard dementia or Parkinson ’ s disease. All operations were performed by the like surgeon ( Y.M.Z ), who have more than 5 years ’ feel in DHS, and no experience with another cephalomedullary nail. The surgeon studied the operate instructions and the instructional video and performed a related drill on the cadaver model, finally operating on 10 patients with the help of an experience surgeons before the process of InterTan complete. Data were retrospectively collected from clinical records and outpatient follow-up for each affected role. official approval from the Investigational Ethical Review Board was waived by our hospital because of the retrospective design of the survey. Informed accept that data could be used for research purposes was obtained from all participants or their empower persons. Routine workup including routine blood test, blood biochemical analysis, electrocardiogram, lineage curdling serve, x ray, and other tests were collected as available. Physicians assisted in the treatment of vary medical conditions during the perioperative period. The patients received conventional postoperative intravenous injection of antibiotics for three days, and rake transfusion was performed in the case of Hb < 70 g/L. The anteroposterior and lateral position x-ray films of the hip joint in the moved english were reexamined 2 to 3 days after operation. The patient was instructed to conduct active compression exercise on quadriceps femoris on the 2nd day after operation and gradually performed running exercises in bed. The affected role was encouraged to sit up within 1 workweek according to his/her conditions, conducted off-bed non-weight-bearing activities with aid of waling aid 2 to 4 weeks after operation, began restrict burden bear activities with aid of walking help 5 to 8 weeks former, and completed burden bear activities without aid of waling aid after the clinical mend of the fault .

2.2. Outcomes Measurements

Baseline characteristics included patient demographics, fracture classification, and American Society of Anesthesiology score. Study variables included operation meter, intraoperative blood loss, weight digest clock time, Harris hep score, distance of hospital arrest, fracture coupling time, point vertex distance ( TDA ), postoperative complications, and deathrate. Harris pelvis scores were measured at one class after operating room. secret agent time is defined as the interval from the incision of bark to the incision being closed. It does not include close up reduction fourth dimension .

2.3. Surgical Technique

In this study, all patients were treated with the TRIGEN INTERTAN long nail ( Smith & Nephew, USA ), and the surgical procedure was performed according to the surgical technique specified by Smith & Nephew. Briefly, the surgical routine was performed as follows : ( 1 ) patient position : after general anesthesia or combined spinal anesthesia epidural anesthesia, the patient was laid in the supine side on an reference table. Abduct the insensible limb and place it on a foot holder. In order to facilitate nail access to the medullary cavity, adduct the affect arm by 10–15°. ( 2 ) preparation : close reduction of the fault was performed under the monitor of “ C ” arm roentgenogram machine. After operating room area disinfection, shop class sterile surgical towels, make a 4–6 curium longitudinal incision proximal from the tip of the greater trochanter. ( 3 ) Opening the proximal femur : A position slightly inside of the apex of the greater trochanter was used as the introduction point at which the scout wire was inserted to the appropriate position. The discipline placement of the steer telegram was confirmed by anteroposterior ( AP ) and lateral x ray. After the introduction portal vein instrumentation was inserted, touching the bone, the entry reamer was passed through it and was inserted into the proximal femur. then, the reamer assembly and guide personal identification number were removed. ( 4 ) Intramedullary ream : After opening the proximal femur, the ball topple steer rod was inserted, into the ideal positions. then, the length of the implant was measured and the intramedullary duct was reamed in increments to a size 1–1.5 millimeter larger than the selected nail size. Using a drill guide cover, the nail down was manually advance into the proximal femur. ( 5 ) Integrated interlocking screw interpolation : After confirming the position of the chief pinpoint, a longitudinal skin incision was made at the entrance locate of the stave fuck, and the interim screw drill sleeve was inserted. then, the guide pivot sleeve was passed through the lag screw drill sleeve until it touched the bone, and a guide pin was inserted into the femoral neck and head. Once the appropriate position of the template pin was confirmed, the length of the lag fuck was measured with a ruler, and a compression cheat crank bore was used to drill the lateral pass cerebral cortex. then, the compression screw drill was passed through the interim cheat drill sleeve, inserting into the femoral neck and mind, and then the compression screw drill was removed, and an antirotation bar was inserted through the lapp hole. After the scout fall sleeve was removed, the slowdown screw drill was then drilled to the measured astuteness. then, the lag screw was manually advance ( in compression or no compression mode according to fault gaps ), and the antirotation barroom was removed and the compression screw was manually boost. After the drill guide handle was removed, the breeze through cap was inserted on the exceed of the nail. ( 6 ) Distal lock : The free-hand technique was used for distal interlacing screw placement. After a shot skin incision was made at the locate of screw entrance, the short drill was inserted, touching the bone and drilling both cortices. then, the prison guard depth gauge was used to measure the length of the fuck and a lock screw with the appropriate duration was inserted. ( 7 ) closure : After verifying the implant position by both AP and lateral pass opinion using the C arm roentgenogram car, the incision was closed .

2.4. Learning Curve Model

The best general mathematic formulation for a aesculapian learn curvature is not known. The negative exponential curve-fit regression analysis has been used to describe the learning wind of radiofrequency ablation of tachyarrhythmias [ 11 ] and minimally incursive transforaminal lumbar interbody fusion [ 12 ]. The negative exponential curve-fit regression analysis was used to evaluate the learn crook. represents the private detective time ; represents the lawsuit number ;, Plateau, and represent the founder ’ s proficiency level, adept ’ south proficiency flat, and potential improvement individually ; and is the rate changeless. % represents the learning milestone, or the surgery measure needed to achieve a percentage of potential improvement, is computed as .

2.5. Statistical Analysis

continuous variables, such as operation clock, intraoperative rake loss, weight bearing time, Harris mark, duration of hospital stay, patient age, fracture union prison term, and TDA, were expressed as means with ranges and then the hateful differences between the groups were compared by -test. For categorical variables between the groups, the chi-square examination or Fisher exact test was used as allow. Data analysis was performed using the GraphPad Prism statistical software ( version 5.0 ), and a measure of was considered statistically meaning .

3. Result

fifty-three back-to-back patients with femoral intertrochanteric fractures ( 24 correctly and 29 impart ) who undergo surgery with InterTan intramedullary nail were included in our discipline. table 1 shows the baseline characteristics of all participants. The participants consisted of 22 males ( 41.5 % ) and 31 females ( 58.5 % ), with an average age of 80.36 ( 95 % CI 78.41 to 82.31 ) years. The hateful follow-up time was 15.26 ( 95 % CI 14.49 to 15.85 ) months .

Variable Early group Later group p
Age, mean (95% CI) (years) 80.56 (77.13 to 83.98) 80.26 (77.75 to 82.76) 0.886
Male : female (number) 8 : 10 14 : 21 0.756
Fracture side (right/left) (number) 7 : 11 17 : 18 0.502
Fracture type (AO/OTA) (number) 0.949
A1 5 10
A2 10 18
A3 3 7
Diabetes (number) 2 5 0.75
Hypertension (number) 2 10 0.15
Heart failure (number) 1 0 0.47
Coronary artery disease (number) 1 0 0.16
Chronic cerebral infarction (number) 1 5 0.49
Atrial fibrillation (number) 0 1 0.47
Pulmonary infection (number) 1 4 0.34
ASA score (number) 0.453
1 0 1
2 13 18
3 5 15
4 0 1
ASA, American Society of Anesthesiologists; CI, confidence interval;
AO/OTA, Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association.

The base time for hospital stay was 7.79 ( 95 % CI 7.21 to 8.38 ) days and the intend intraoperative blood loss was 207.25 ( 95 % CI 202.30 to 212.19 ) milliliter. The entail prison term to overtone weight have a bun in the oven was 38.57 ( 95 % CI 37.13 to 40.01 ) days. The hateful clock time for union was 11.81 ( 95 % CI 11.50 to 12.13 ) weeks. The mean Harris hip mark was 82.15 ( 95 % CI 80.85 to 83.46 ). The mean point apex distance ( TAD ) was 20.80 ( 95 % CI 19.75 to 21.85 ) millimeter. There were complications for case numbers : 12, 13, 17, 20, 24, 32, 42, 43, 47, 49, 50, and 54. There were postoperative complications in 12 patients ( 22.6 % ) including venous thromboembolism ( VTE ), pain of hep and second joint, and superficial wind contagion, as summarized in table 2 .

Variable Early group Later group p
Time of operation, mean (95% CI) (min) 77.67 (69.18 to 86.15) 64.97 (59.59 to 70.36) 0.009
Blood loss, mean (95% CI) (ml) 219.94 (211.44 to 228.45) 200.71 (195.65 to 205.77) 0.000
TAD, mean (95% CI) (mm) 21.34 (19.23 to 23.45) 20.52 (19.28 to 21.76) 0.463
Harris hip score, mean (95% CI) 79.39 (77.63 to 81.15) 83.57 (81.96 to 85.15) 0.002
Time to union, mean (95% CI) (weeks) 12.11 (11.48 to 12.75) 11.66 (11.29 to 12.02) 0.174
Time to partial weight bearing, 38.22 (35.33 to 41.11) 38.74 (37.03 to 40.45) 0.735
mean (95% CI) (days)
Hospital stay, mean (95% CI) (days) 8.67 (7.35 to 9.99) 7.34 (6.78 to 7.91) 0.030
Transfusion (number) 5 10 0.952
Complication (number) 3 9 0.456
Deep venous thrombosis (number) 0 4 0.136
Pain of hip and thigh (number) 2 3 0.765
Superficial wound infection (number) 1 2 0.981
Values in boldface indicate ; TAD, tip apex distance; CI, confidence interval.
3.1. Learning Curve of Performing Surgery with InterTan Intramedullary Nail

The mean running time was 69.28 ( 95 % CI 64.57 to 74.00 ) minutes, and with the accretion of surgical experience, the operation time was gradually decreased ( + 63.46 ; = 0.3122 ; Figure 1 ). 90 % of the potential improvement was expected after 18 cases ( 90 % learning milestone ). According to 90 % learning milestone, fifty-three were divided into two group ; the first 18 cases was early group and others were late group .

3.2. Comparison between Early Group and Late Group

A comparison of the early group and late group showed a significant remainder in the secret agent fourth dimension, intraoperative blood loss, and hospital quell. In terms of the Harris hip score, meaning differences were detected between the two groups ( table 2 ). With the accretion of surgical experience, the Harris hep score was gradually increased ( Figure 2 ). fond weight bear time, fracture union clock, and tip apex distance were similar between two groups ( postpone 2 ). There were no significant differences in the number of complications and rake transfusion between the two groups ( mesa 2 ).


4. Discussion

assorted inner arrested development devices have been used to treat femoral intertrochanteric fractures, including sliding hip screws ( SHS ), transdermal compression plate ( PCCP ), da gamma nail ( GN ), proximal femur collar ( PFN ), proximal femoral smash antirotation ( PFNA ), Proximal Femoral Nail Antirotation-I I ( PFNA-II ), and the InterTan intramedullary nail. Compared to other implants, the advantages of InterTan nail include the ability to maintain compression, eliminate -effect intertrochanteric rotational stability and medial migration, control rotation during reduction, and prevent periprosthetic fractures. additionally, it has a lower rate of plant failure and reoperation, lower hazard of secondary femoral fractures [ 4, 13 – 15 ], faster time to fracture coupling [ 14 – 16 ], and a high rate of return to prefracture status [ 2, 14, 15 ]. To our cognition, the learning curvature of performing surgery with the InterTan intramedullary pinpoint has not been previously studied. Our hypothesis is that surgical feel has significant effects on secret agent times [ 17 ]. The results of our sketch confirmed our hypothesis and demonstrated that, with the accumulation of surgical experience, the process time was gradually decreased, and the learn curve for InterTan intramedullary complete was considered satisfactory. As shown in Figure 1, the swerve declines quickly in the early phase and gradually reaches a relatively firm submit, or asymptote [ 17 ]. The mean duration of operation for InterTan intramedullary breeze through in the late group of patients was 64.97 ( 95 % CI 59.59 to 70.36 ) min, like to the operative time reported in earlier inquiry that ranged from 48 to 73.91 min [ 4, 5, 15, 18 – 20 ], excluding one study that reported an average meter that was less than 30 minutes [ 21 ]. These studies besides reported that the mean operative fourth dimension for GN, PFNA, or PFNA-II treatments [ 4, 5, 15, 18 – 20 ] was 44.41–72.98 minutes. Of these, two studies reported that there was no significant dispute in the running clock time between the InterTan intramedullary nail ( IT ) group and the GN or PFNA group [ 15, 20 ]. however, four studies reported that the IT group required a significantly longer surgical meter than the GN or PFNA or PFNA-II groups [ 4, 5, 18, 19 ], which indicates that InterTan intramedullary pinpoint may increase running meter after we had mastered the technique, although it has some likely clinical advantages, such as increasing Harris hip score, decreasing hospitalization time, and faster time to fracture union. To a certain extent, with an increased count of surgical cases, surgical technique is gradually improved and the operation time is shortened. With decrease prison term in surgery, surgical injury and intraoperative bleed are reduced and effects on the circulatory system are reduced. These factors promote the convalescence of patients and reduce the length of hospital stays. This is reproducible with our findings that, with the accumulation of experience, the operation time and intraoperative bleeding were gradually decreased, and the hospital stay was besides decreased. When comparing a new technique with conventional techniques, it is important that the surgeon should have reached the steadily state of the memorize curve, indicating that the surgeon acquired proficiency for the fresh proficiency [ 17 ]. If measured at an earlier point in the eruditeness process, the evaluation of the efficacy of the new technology will be biased. To more accurately compare DHS or PFN or PFNA with IT, surgeons who have mastered the TRIGEN INTERTAN technique by performing more than 18 operations should participate in the surgery group to facilitate an accurate comparison. We found that the incidence of complications varied well in different studies, with ranging from 0 % to 19.2 % for IT [ 2, 4, 5, 15, 18 – 21 ] and from 2.2 % to 34.6 % for GN, PFNA, PFNA-II, or DHS [ 2, 4, 5, 15, 18 – 21 ]. In our study, although no good procedure-related complications were observed, the incidence of complications may be slenderly high ( 22.6 % ). To compare with GN or PFNA or PFNA-II or DHS, the incidence of complications was not high, and the results were generated when the surgeons were distillery in the memorize phase. frankincense, this result can be considered acceptable. In summation, complications showed no meaning differences between the two groups. To reduce the incidence of complications, the surgeon will be more accurate during the operation [ 7 ], deoxyadenosine monophosphate well as careful treatment and reclamation train for patients after operation in early on phase of the learn curvature. Increased surgical time during early procedures may have been due to the requirement for supernumerary time to perform the placement equally correctly as possible in an attack to reduce complications. In addition, we compared two groups based on the result of the negative exponential function on operate on fourth dimension : 18 cases versus 33 cases. This comparison showed no significant differences in time to partial weight bear, clock for union, or the mean gratuity apex distance ( TAD ). The TAD was within the recommend charge of < 25 millimeter [ 22 ] in both groups in our study Binder et aluminum. [ 23 ] reported that progressive exercise under supervision can importantly promote the rehabilitation of arm serve and improve quality of life. As shown in Figure 2, the Harris hip sexual conquest increased slowly with growing of running case, suggesting that the improvement of surgical technique is one of the factors that increase the Harris score. however, rehabilitation exercises after operation in aged patients with pelvis fracture were more important for the limb serve recovery. This survey had some limitations. There are many factors that influence the operative times, including the complexity of fracture. Complicated fracture will inescapably increase the operation time. however, surgeons in the early stages of learning swerve normally choose relatively childlike cases, which is conducive to improving their assurance. This is like to our study ; in our cogitation, building complex cases are few which may lead to bias. The bias caused by this choice can only be reduced in the randomized study design. Because our learn is a retrospective study, this choice bias is difficult to eliminate. This will inescapably affect the evaluation of the learn curve. It is necessity to carry out a prospective randomize learn to reduce the effects of confounding factors such as individual fault complexity. Although there are many factors that affect the learn curve, it is important to follow the rules of learning curvature and realize the key points of study. It is of big significance to carry out a challenge operation in the future. In addition, this report is of the results from a single surgeon and may not be in full applicable to other surgeons. however this cogitation is to provide valuable information and feel for surgeons who decide to learn a raw secret agent method acting, making them mindful of the key learning points and strategies to avoid operative complications. If the eruditeness curvature is exorbitant or farseeing, more thorough learning strategies are required, including performing a relate drill on the cadaver model and respective cases with an experienced surgeon .

5. Conclusions

This study demonstrated that the learning curve of performing operation with the InterTan intramedullary smash is satisfactory and 90 % of the expert ’ randomness proficiency level was achieved at around 18 cases. After surgeons had mastered the proficiency, the InterTan intramedullary nail could be a dependable and effective option for intertrochanteric fracture.

Ethical Approval

There was no motivation for ethical approval .

Conflicts of Interest

The authors declare that they have no conflicts of interest .

Funding

There is no fund beginning .

reference : https://nailcenter.us
Category : Nail Technique

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