early feel with the TFN-A appears to suggest that it is at least comparable to preceding proximal femur nail devices in terms of arrested development. absence of anterior cortical impingement or perforation suggests that the TFN-A shows promise in addressing this emergence. The incidence of “ retrograde cement filling ” is a previously unreported charge of pastime for head–neck element augmentation which requires further study. All thirty-four patients had neck-shaft angles within 5 degrees of the contralateral hip immediately post-surgery. Two patients had varus flop > 5 degrees on follow-up but did not progress to cut-out. Two patients had broken distal locking screws, albeit their fractures healed uneventfully. There were four cases of cement augmentation with “ retrograde filling ”, wherein most of the cement went into the femoral neck. No patients experienced distal anterior cortical impingement or perforation. All but one patient subsequently progressed to wide weight-bearing. thirty-four patients who undergo arrested development using the TFN-A at a one center from October 2016 to July 2018 were retrospectively reviewed for this survey. All surgeries were done by feel orthopedic surgeons. The decision for cementum augmentation of the femoral head element was made on a case-to-case footing. Radiographs of the hip, pelvis and femur were taken to monitor fracture heal and evaluate post-fixation neck-shaft fish ( NSA ) /varus collapse, cut-out/cut-through, implant failure and anterior cortical impingement/perforation. This descriptive study looked at the early outcomes of the TFN-A as used in a single trauma center. It attempts to shed light on the question of whether the TFN-A is at least equivalent to more established proximal femur implants in terms of fixation while reducing complication rates.

The Trochanteric Fixation Nail-Advanced ( TFN-A ) is offered as a “ next-generation ” solution to the ever-increasing incidence of pertrochanteric and intertrochanteric fractures. It aims to build upon the success of earlier-generation proximal femur implants, while at the like clock time attempting to address complications, like varus crumble, cut-out, implant failure and anterior cortical perforation/impingement. It besides aims to provide the surgeon with flexibility by offering vary options under a single implant system. This descriptive learn looks at the early outcomes of the TFN-A as used in a single trauma center in Singapore. To our cognition, there is only one other published study involving the results of obsession of proximal femur fractures utilizing the TFN-A [ 24 ]. The discussion of extra-capsular proximal femoral fractures remains challenging. In malice of a ten thousand of implant options that are available to the orthopedic surgeon, complication rates ranging from 5 to 14 % for arrested development of peri-trochanteric fractures are still quoted in recent literature [ 1 – 7 ]. The Trochanteric Fixation Nail-Advanced ( TFN-A ; Synthes GmbH, Oberdorf, Switzerland ) is presented as a “ next-generation ” solution to the ever-increasing incidence of pertrochanteric and intertrochanteric fractures, particularly in aged patients with poor bone quality. It aims to build upon the success of earlier-generation proximal femur arrested development implants, while at the same time attempting to improve less-than ideal results arising from the treatment of such fractures. It besides aims to streamline operating room and provide the surgeon with tractability by offering varied options under a single implant arrangement. By combining the features of by implants with raw, potentially advanced design elements, it is hoped that the TFN-A would provide better outcomes to patients by reducing complications and the motivation for subsequent revision operation. other parameters recorded and noted were the patients ’ demographics ( historic period, arouse and ethnicity ), bone mineral density ( BMD ) score, ability to weight-bear on the hurt extremity post-surgery, pre-operative Charlson Co-morbidity Index, and Modified Barthel Index of Activities of Daily Living pre- and post-surgery. The Charlson Co-morbidity Index ( CCI ) is a scale that measures 1-year deathrate gamble and load of disease by taking into consideration the affected role ’ s age and existing medical conditions. The Modified Barthel Index of Activities of Daily Living ( MBI ) is an assessment of a patient ’ randomness ability to perform activities considered substantive for day by day serve, ranging from 0 ( completely dependent ) to 100 ( completely mugwump ). Radiographs of the hip, pelvis and femur were taken immediately post-surgery and at regular follow-up intervals of 2 weeks, 6 weeks, 3 months, 6 months and 1 class post-surgery. Immediate post-op radiographic parameters included evaluation of head chemical element position, tip-apex distance ( TAD ) and neck-shaft angle. follow-up radiogram evaluated fracture mend, head–neck shortening, varus collapse and possible cut-out of the head element, possible implant breakage and possible front tooth cortical blowout of the distal end of long nails. Out of the initial 40 patients who undergo obsession with the TFN-A, 3 were for preventive obsession and were excluded. Another 3 patients did not have adequate follow-up ( less than 2 months ), due to either death from medical causes or decision to follow-up at a different institution, and were besides excluded. In the end, a total of 34 patients were included for final revue. Forty patients who undergo fixation using the TFNA from October 2016 to July 2018 were initially considered for review. The patients were drawn from the hip register of a single tertiary-level injury center with a big number of geriatric hip fractures due to low-energy falls, equally well as patients incurring pelvis and femur fractures from road-traffic accidents. Fractures were classified according to the AO/OTA Classification System. All surgeries were performed by know orthopedic surgeons using criterion nailing techniques and recommendations from the TFN-A technique manual of arms provided by the manufacturer [ 12, 13 ]. All cephalo-medullary components were fixed at 130° NSA. While there is literature that supports the use of cement augmentation as standard procedure, particularly in the geriatric population [ 8, 9, 15 ], the decision for cement augmentation of the femoral head chemical element was made by the surgeons based on radiographic appraisal of fracture stability and cram quality. New features previously not found in its predecessors include a smaller radius of curvature for longer nails that is said to more closely match the native femoral crouch ( specially in the asian population [ 10, 11 ] ), a smaller and specially-contoured proximal part of the breeze through that aims to reduce lateral pass impingement and varus mal-reduction during nail insertion, the option for three different cephalo-medullary fixation angles ( 125, 130 or 135° ) depending on the patient ’ s native neck–shaft angle ( NSA ), a built-in engage dash in the proximal fortune of the nail that gives the option for either dynamic or static lock of the cephalo-medullary fixation element, and greater plant forte and load to bankruptcy. The arrangement besides comes with instrumentality designed to make operating room less cumbersome and baffling, such as a radiolucent, quick-locking jig with radiographic markers that provide a better indicator of the placement of the head–neck element in the true lateral ( i.e. 15–20° from horizontal ) radiographic projection. [ 12, 13 ]. The Trochanteric Fixation Nail-Advanced ( TFN-A ; Synthes GmbH, Oberdorf, Switzerland ) is a titanium alloy implant which derives primarily from the Trochanter Fixation Nail ( TFN ) and Proximal Femoral Nail Antirotation ( PFNA and PFNA-II ) families of implants. noteworthy features of the TFN-A carried over from the TFN/PFNA lines include varying nail lengths ( 170 millimeter up to 480 millimeter ) and diameters ( 9 millimeter up to 12 millimeter ), options for either a coiling blade or lag fuck for cephalo-medullary fixation ( TFN alone ) and the choice for head–neck augmentation with cram cement via a specially-designed organization that is available for both the lag screw and coiling blade ( anterior to the TFN-A, this option was available for the PFNA coiling blade lone and not the PFNA-II ). The cement augmentation choice is particularly recommended for patients with osteoporotic bone [ 8, 9 ]. twenty-seven patients were immediately instructed—and were able—to fully slant have a bun in the oven on their post-surgical extremities with walking aids. Three patients—two precarious IT fractures and one patient with a multiple-level fracture—were initially instructed to do lone partial weight-bearing, but were finally progressed to full weight-bearing after 6 to 8 weeks. Four patients with unstable IT fractures were initially unable to ambulate independently but, with rigorous physical therapy, were subsequently able to do so at 6 to 8 weeks post-surgery. Two out of 34 patients experienced implant failure, specifically failure of the distal locking screws—one distal fuck from a light collar and two distal screws from a long breeze through. In both cases of implant failure, however, the fracture united rather normally and the screw failures were noted on the 6-month follow-up, a window of about 3 months between fracture union and screw failure. sixteen patients had shorten of the neck ( 15 coiling blades and 1 stave screw ), with five patients having more than 10 millimeter collapse ( all blades ). All patients with more than 10 millimeter of shortening were noted to have fracture patterns that were of the AO 31-A2 or 31-A3 type. notably, three patients who had more than 10 millimeter shorten had their coiling blades locked in moral force mood, while in two patients the locking mode for the coiling blade was not stipulated in the private detective report. All 34 patients had post-operative neck-shaft angles ( NSAs ) within 5° of the contralateral ( uninjured ) english. No hip was fixed with an NSA of less than 125° ( mean = 131° ). Four hips fixed with NSAs < 128° had contralateral hips that had NSAs between 125° and 127°. Two of 34 patients had varus collapse of the fixation construct greater than 5° on follow-up, but did not progress towards cut-out ( one had cement augmentation and one did not ).

thirty-two patients went on to complete fracture healing at 2 months post-surgery. Two patients showed no radiographic signs of fracture healing at 2 months post-surgery ; one of them was offered cram transplant ( the routine was cancelled because the patient had a non-fatal myocardial infarct and the patient ’ s fracture finally showed radiographic union 12 months post-surgery ) and the early was commenced on anabolic discussion ( Teriparatide 80 microgram once daily ), which induced callus formation at 5 months post-surgery. One patient with a multiple-level femoral fracture ( IT and beam ) had delayed healing at the rotating shaft section due to a large butterfly fragment, but at 6 months post-surgery demonstrated good fracture consolidation. Three patients were limited to barely immediate post-operative X-rays : 2 died of causes unrelated to the operation ( both from myocardial infarct ) before their scheduled follow-up, and 1 patient opted to return to her country of permanent wave residency for follow-up. The stay of the 37 patients had follow-ups that ranged from 2 to 18 months ( entail 5.8 months ). twenty-three fractures were fixed with long nails, while 11 were fixed with short nails. The coiling sword was used in 33 patients and the lag screw used in 1 affected role to fix the head–neck chemical element to the quill section. extra arrested development was performed for 6 patients in the form of cerclage wires about the subtrochanteric area, as they had subtrochanteric fractures with proximal and distal annex, and attempts at closed reduction resulted in unsatisfactory conjunction. Cement augmentation was abandoned in 1 patient due to contrast escape into the joint. A entire of 14 patients received head–neck element cement augmentation. The 34 patients included in the review were all of the geriatric population ( old age image 60 to 101 years, think of long time 79.7 years ) except for one ( age 34 years ), with 13 of the patients being male and 21 being female. The distribution of fracture patterns is as follows : 4 patients had stable intertrochanteric ( IT ) fractures ( AO/OTA 31-A1 ) ; 16 patients had mentally ill IT fractures ( AO/OTA 31-A2 ) ; 11 patients had subtrochanteric fractures with trochanteric extension ( AO/OTA 32-A3 ) ; and 3 patients sustain pure diaphyseal fractures ( AO/OTA32-A/B/C ) .

Discussion

While contemporary treatment of extracapsular proximal femoral fractures is largely successful, complications continue to be devastating and annual deathrate is hush relatively high [ 6, 7, 14 ]. The TFN-A attempts to build on the perceive success of its predecessors [ 4 – 9, 14 ] vitamin a well as address shortcomings in their habit. specifically, the issues of implant cut-out/cut-through, anterior cortical perforation/impingement and implant failure were highlighted as areas that the TFN-A attempts to improve upon compared to its forerunners [ 12 ]. As the TFN-A is a relatively new implant, there are distillery no rigorous criteria for favouring its use over existing plant systems. In particular, the PFNA-II, which is a raise device for proximal femur arrested development, is still more widely used in our hospital for most AO type 31-A fractures. The TFN-A was chosen for these 34 patients because the surgeons felt that the newer implant provided some class of advantage—either the head–neck obsession needed cement augmentation ( i.e. highly low BMD, fractures with excessive comminution or revision operating room for previous failure of fixation ), or the femoral crouch was solid adequate to warrant the use of a more curved implant to decrease the risk of anterior cortical impingement/blowout [ 8, 9, 11, 12 ]. A determination of note in using the TFN-A system was that in 4 out of 14 patients with cement augmentation, cement did not reach the gratuity of the head–neck component ( or the superior one-half of the femoral head ), and that most of the cement ( about 70–80 % ) settled within the femoral neck ( Fig. ). All four of these cases used the coiling blade for head–neck fixation. One potential explanation is that practice of the coiling blade resulted in promote impaction of the cancellate bone around the topple of the blade, as it is intended to [ 8, 9, 15 ]. however, this dense bone then blocks the antegrade egress of the cement towards the tiptoe of the blade. rather the cement escapes via the path of less resistance, in a retrograde fashion towards the femoral neck. Earlier studies describing the use of cement augmentation have not described this phenomenon before [ 8, 9, 15 ]. Further in vitro studies can be conducted to test this hypothesis, adenine well as CT read imagination of cement-augmented cephalo-medullary implants to analyse cement distribution in vivo. The authors are, however not discounting the hypothesis that these cases may precisely reflect a design flaw in the cement augmentation instrumentation of this new plant. Whether this phenomenon has an effect on the overall stability or bankruptcy rate of the manufacture, or the bring around of the fracture is besides an area that warrants far investigation. With regards to weight bearing and come back to function, figures in literature show rates of render to routine at around 55-84 % [ 3, 6, 8, 14, 16 ], with cement augmentation being a non-factor in refund to walking ability [ 25 ]. All patients in our analyze were able to finally progress to wax weight-bearing condition within 6 to 8 weeks of their respective surgeries ( 27 patients were fully weight-bearing immediately post-surgery, with the remainder progressing with the avail of physical therapy ) and subsequently return to activity about, if not equal to, their pre-injury levels. And while 34 patients are a small sample, the fact that all of them were able recover significant mobility is a very encourage resultant role. Two patients in our pond had implant failure, specifically breakage of the distal lock screws ( Fig. ). however, documentation reveals that the screws failed after their fractures had already healed, erstwhile between 3- and 6-months post-surgery. Both patients had cement augmentation, had been weight-bearing as tolerated on their surgically fixed limbs, and there was no eminence of any significant trauma anterior to screw failure. They were besides asymptomatic. other than being an incidental finding, one possible explanation for this is that the points of the screw failure were the either the weakest in the integral implant-bone interface, or the area with the greatest stress concentration—an area that is traditionally associated with the femoral head–neck region, which normally leads to either varus break down and cut-out, or complete breakage at the hole for head component interpolation [ 6, 17 – 19, 24 ]. This suggests that the TFN-A with an augment head–neck region in the set of a healed proximal femur fracture may have a different traffic pattern of push transmittance adenine well as areas of stress assiduity compared to those previously described for proximal femur intramedullary implants. Anterior cortical impingement or perforation is attributed to the mismatch between the femoral bow and the collar geometry. Our analyze, wherein 23 patients were fixed with a long collar, had no incidence of front tooth cortical impingement or runaway, which suggests that the TFN-A has a nail geometry that appears to more closely approximate the native femoral bow found in the asian population [ 10, 11 ] ( Fig. ). In three patients with a pure diaphyseal fracture ( AO/OTA 32.A3, the femoral bow was the factor noted to have influenced the surgeons to use the TFN-A as opposed to early implants more traditionally favoured for diaphyseal obsession. clinical studies that attempt to compare the femoral bow with implant geometry are sparse [ 10, 11 ] and with the second coming of the TFN-A, comparisons between it and more well-established implants may shed light on this relatively rare—but however severe—complication. Cut-out or cut-through of the head–neck chemical element is considered one of the most lay waste to complications of cephalo-medullary fixation devices, requiring rewrite operating room ( normally a sum hip successor ) and exacting a greater physiological and fiscal burden on patients. several studies have identified the quality of fault decrease ( i.e. NSA > 127° or within 5° of the contralateral hip ) and the tip-apex distance ( TAD ) to be the most significant factors that determine varus collapse of proximal femur obsession constructs. Varus collapse, along with forefront element placement in the postero-superior region of the head, in turn, increased the risk for cut-out [ 2, 16 – 21 ]. While most studies stipulate that the remainder between arrested development with a stave screw versus a coiling blade is not a significant as anatomic reduction, proper implant aligning and TAD, constructs which feature a coiling blade have been documented with well reduced cut-out rates ( somewhere between 1.5 and 7 % as compared to 2.9–14 % for lag screws ) and, as such, is the prefer cephalo-medullary fixation component, particularly in osteoporotic bone [ 1 – 5, 7, 16 ]. In our study, all patients were fixed with the coiling blade, except for one—a young male patient with a bifocal femoral fracture who, save for delayed union of his diaphyseal fracture by a few weeks, went on to heal uneventfully. additionally, two patients had varus flop of more than 5 degrees, but neither affected role progressed into cut-out/cut-through ( Fig. ). In summation to good reduction and implant stead, cement augmentation of the head–neck element has besides been shown by respective authors to biomechanically increase rotational and pull-out lastingness, and—more importantly—significantly reduce the rate of cut-out [ 8, 9, 15, 22, 25, 26 ]. As there is presently no standardize clinical guidepost for cephalo-medullary cement augmentation, it is however the surgeon ’ s prerogative whether to augment or not. late studies have, however, suggested that about 6 ml of cement is adequate to confer extra stability without any deleterious effects [ 8, 15, 25, 26 ]. In our study, 14 patients received cement augmentation, with no incidence of implant tease, cut-out or cut-through. While the technical foul skills of the surgeon can be a meaning component in the quality of fracture reduction, certain TFN-A design elements—specifically the flatten lateral pass part a well as a smaller proximal collar diameter—seem to hint at the likely of this new implant at minimizing the risks of mal-reduction. Taken together with the established benefits of the coiling blade and cement augmentation [ 8, 9, 15, 25, 26 ], all the design elements of the TFN-A may contribute to a well reduced rate of implant cut-out—and the morbidity and costs that inescapably come with such complications.

One have of the TFN-A that we were unable to evaluate in this discipline is the effectiveness of the built-in interlock mechanism for the skid of the head–neck component. This sport is purportedly designed to prevent excessive shorten of the neck in precarious fracture patterns [ 3 – 5, 23 ]. Our review revealed that in 18 cases, the operative report did not expressly indicate whether the locking mechanism was placed in dynamic or static mode. While we did note that there were only 5 patients with significant neck shorten of more than 10 millimeter ( 3 were locked in dynamic mood, 2 were unspecified ), the utilization of this feature of speech was rather ailing documented, possibly owing to unfamiliarity with this particular design element of the implant .

Study Limitations and Future Recommendations

true, the results shown here come from quite a little and heterogeneous sample distribution, which limits the intensity of conclusions that can be derived. furthermore, this study is strictly descriptive, american samoa well as retrospective in nature. consequently, future studies with a prospective analytic blueprint, larger sample size and more defined patient inclusion/exclusion parameters should be the future pace in the study of this new implant system. Likewise, the lack of reproducible documentation on whether the locking mechanism for the head–neck fixation is indeed effective in preventing excessive, uncontrolled neck shortening merits extra evaluation. While it is not the captive of this study to formulate a reliable road map or algorithm for augmenting the cephalo-medullary component, the options afforded by the TFN-A arrangement may lend itself well towards the development of a more count and objective measure for this emerging technique. ultimately, a longer menstruation of follow-up is recommended. In hurt of these limitations, this wallpaper is one of the inaugural attempts to describe and evaluate the results of the TFN-A system, which is important in determining whether the implant indeed accomplishes its mean determination .

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