Introduction: Bisphosphonates are effective in preventing osteoporotic fracture, however atypical femoralfractures with a well-defined radiological pattern have been described in association with prolonged treatment with bisphosphonates. Our objectives in this study were to characterize patients ≥ 65 years old with femoralfractures (subtrochanteric/diaphyseal) considered typical and atypical and the relationship between the occurrence of atypical fractures and bisphosphonate use.
Even though the rate of femoralfractures decreased we believe that more fractures can be prevented. The interaction between physicians and nursing staff is often suboptimal and, as a result, medication review  and vitamin D supplementation  are still underused. We recently published data on fracture rates of newly admitted nursing home residents. We observed that the risk of a fracture was highest during the first months after admission and declined thereafter . It is therefore a challenge to improve nursing processes during this initial period. As discussed above participation rates in the exercise program and prevalence of hip protectors differ considerably between the different nursing homes and are therefore also targets for future improvements. New approaches with real-fall analysis including video data and accelerometers might further improve our understanding of falls and fractures.
Advantages include minimal soft tissue exposure, closed reduction technique, shorter operating time, minimal blood loss and early recovery. There is need to put supracondylar nailing surgery into practice for distal femoralfractures because it is minimally invasive technique, better fixation and control of distal fragment, preservation of periosteal and fracture haematoma, negligible blood loss, less chance of post-operative infection, faster union and weight bearing associated with this procedure. (32) This prospective study aims to evaluate the surgical outcome of supracondylar
Results: 101,436 patients were included. There was a progressive increase in the number of hospitalizations per year over the period analyzed. The mean age at admission was 79.32 (± 12.33) years presenting a progressive and significant increase over the analyzed period (p < 0.001). 74.5% of the patients were female (p < 0.001). They had a significantly higher average age at admission, both globally and in each study year (p < 0.001). The age-adjusted incidence (≥ 65 years) was 597 fractures / year / 100,000 inhabitants. There was an increase in the incidence of proximal femoralfractures from 508.49 (2005) to 628.39 fractures per 100,000 person-years (2013). In the female sex the increase was from 616.78 to 762.88 and in the male sex from 339.95 to 419.06.
Clinical Cases: We present two cases of female patients under bisphosphonate treatment for over 10 years who were admitted to our institution for subtrochanteric and femoral shaft fractures after low-energy trauma. They presented, respectively, a transverse and a short oblique femoral fracture, with thickening of the lateral cortex. They underwent surgical treatment obtaining good functional and imaging result.
Kokoroghiannis et al. (26) considered intramedullary de- vices to be more appropriate for the very unstable AO31-A3 fractures. Although such devices have mechanical advan- tages in theory, the reported failure rates of intramedullary nails when used to treat these fractures vary greatly due to the different numbers of clinical cases (4,5,23,27-29). Some unstable proximal femoralfractures (7,8) are difficult to fix with an intramedullary nail. Additionally, intramedullary fixation is associated with a large amount of hidden blood loss (30), with no significant difference in the soft tissue damage compared with extramedullary fixation (31). Thus, the use of intramedullary nails is not considered to be a genuine minimally invasive treatment. Although the tech- nology of the intramedullary nail has been continuously improved, the systematic review by Norris et al. (32) reported that the incidence of a second fracture after internal fixation with an intramedullary nail was approxi- mately 1.7%.
CONTEXT AND OBJECTIVE: Femoralfractures are common in children between 2 and 12 years of age, and 75% of the lesions afect the femoral shaft. Traction followed by a plaster cast is universally accepted as conservative treatment. However, in some situations, a surgical approach is recommended. The objec- tive here was to compare treatments for femoral shaft fractures using intramedullary nails (titanium elastic nails, TEN) versus traction and plaster casts in children. The hypothesis was that TEN might provide better treatment, with good clinical results in comparison with plaster casts.
appears to influence mortality in elderly patients with femoralfractures. In a study of 8383 subjects, patients were divided into three groups: first group were operated within the first 24 hours after fracture; second group, after 24 hours of frac- ture, but without active disease; and third group was also operated after 24 hours, but with active pathology. Patients with active disease had their surgery postponed due to the presence of decompensated disease. At the end of the study, the mortality of the individuals operated within the first 24 hours was lower. However, when the groups were homog- enized for presence of associated diseases, this difference disappeared. 18
Atypical femoralfractures (AFFs) have been reported after prolonged intake of bisphosphonates (BPs). There has been a steady increase in published evidence associating BPs and AFFs, but a causal relationship has not yet been established. The updated case definition of an AFF is a fracture located along the femoral diaphysis from just distal to the lesser trochanter to just proximal to the supracondylar flare, with at least four of five major features present. These features are: (1) minimal or no trauma, (2) fracture line originates at the lateral cortex and is substantially transverse, (3) complete fractures may be associated with a medial spike while incomplete fractures involve only the lateral cortex, (4) non- comminuted or minimally comminuted, and (5) localized periosteal or endosteal thickening of the lateral cortex (“beaking” or “flaring”) 1 .
The general characteristics of the studied groups are described on Table 1. In three patients with femoralfractures caused by gun shots (cases 8, 15, and 17), we had a randomization break, because the surgeon was not experienced with insert- ing locked intramedullary nails, and the patients received plates and screws. These cases were excluded from the series, thus there were 37 cases left. Associated injuries were found in 12 patients (32.4% - n=37) of the study: two patients with TCE, two peripheral neurological injuries, one heart injury caused by gunshot, two tibial fractures, one contralateral femoral fracture, one ankle fracture, one pelvic ring fracture, one humeral shaft fracture and one fracture-dislocation of the knee. Regarding the mechanism of injury, there were 11 penetrating injuries and 6 blunt injuries in the plate group, and 5 penetrating and 15 blunt injuries in the nail group. Table 2 describes the fractures and their corresponding treatments according to Gustilo´s clas- sification. Regarding fractures configuration, according to the AO classification, 59.4% were found to be type B, 29.7% type A, and 10.8% type C.
middle third with a single line. Regarding fracture etiology, traffic accidents predominated overall in the sample. Most of the patients (74 to 77.1%) presented femoralfractures as their only injury. Conservative treatment predominated in the group younger than six years of age, and surgical treatment in the group aged 6 to 14 years and 11 months. The complications observed until bone union were: discrepancy, infection and movement limitation. The mean time taken for consolidation was 9.6 ± 2.4 weeks, varying with age. Conclusion: The fea- tures of these fractures were similar to those described in the literature and the treatment used showed good results. The Joana de Gusmão Children’s Hospital has used the treatment proposed in the literature for pediatric femoral shaft fractures.
Objective: To assess the adequacy to the Brazilian population of orthopedic implants used for treatment of proximal femoralfractures. Methods: The neck-shaft angle of the femur of 101 patients was measured in anteroposterior pelvis radiographs and these measurements were correlated to gender, age, height, weight and ethnicity. In addition, we compared the values of the neck -shaft angle with the angulation of the main implants avail- able in the Brazilian market for the treatment of transtrochanteric fractures. Results: Of the 101 measurements, an average of 130.9±6.7° was obtained, ranging from 112° to 150°. Correlating
7. Ritter MA, Thong AE, Keating EM, Faris PM, Meding JB, Berend ME, et al. The effect of femoral notching during total knee arthroplasty on the prevalence of postoperative femoralfractures and on clinical outcome. J Bone Joint Surg Am. 2005;87(11):2411–4.
diaphysis fractures treated with elastic titanium intrame- dullary nails with retrograde insertion were included in the study. There were two bilateral fractures and two exposed fractures. Seven patients were female and 17 were male, and the mean age was 8.3 years. The following were pre- sented at the end of the study: shortening, varus or valgus displacement, final retrocurvatum or antecurvatum of zero, and absence of delayed consolidation or pseudarthrosis. Conclusions: The elastic titanium intramedullary nails were easily placed and removed. We believe that using elastic titanium intramedullary nails is a good option for fixation of unstable femoralfractures in children.
It also needs to be considered that we were dealing with patients who, as well as being of advanced age, presented with femoralfractures. Hip fractures are often an epiphe- nomenon related to patients’ underlying diseases and frailty, with a particularly high mortality resulting from their or- ganic limitations. Under these conditions, delirium, al- though still having importance, may lose something of its reliability as an indicator of poor prognosis.
nailing couls be done before the breakage occurs, obviating the possibility of a difficult extraction. Further studies will need to be carried out to see if this can be extrapolated to the larger population of traumatic femoralfractures treated with locking nails which do not unite.
Ensuing outpatient follow-up showed excellent wound healing. At three months post-operative, there was radiographic evidence of bridging fracture site callus. Partial weight bearing was then allowed. At six months post operatively, radiographic evidence of fracture union was achieved and complete weight bearing on the affected limb Extruded Femoral Segment after Gamma Sterilization
Given that there are different fracture lines (sub- capital, mediocervical and basocervical) and that the femoral head can vary in size, the first 30, 40 and 50 mm of each screw were arbitrarily considered, to simulate different penetration lengths of the screws inside the femoral heads. The volume occupied by the DHS was compared with that occupied by the MCS, considering two, three and four cannulated screws.
Searches were conducted in the Medline database. The MeSH (Medical Subject Heading Terms) key-words used for the search were: “femoral neck”, “fractures/surgery”, “child”, “femoral neck fracture/complications”, “decom- pression surgical”, “internal fixation”. Thus, questions related to the topic were developed with a focus on the following aspects: types of treatment; best time to thera- peutic approach; and ideal treatment with lower compli- cation rates. Based on this, the questions were structured using PICO (pacient, intervention, comparison, outco- me) methodology, and the search began with the selec- tion of papers with better strength of scientific evidence.
Currently, the hip fractures represent a major economic burden on the health care systems in the world. In the United States, adjusted first-year costs associated with hip fracture for patients aged 65 years or older were US $ 15,196, compared with the costs of US $ 6701 for vertebral fracture . In 1997, an assessment of direct and indirect annual costs for hip fracture treatment in the world were $131,5 billion . In 2005 in the United States are registered 2 million fractures with patients over 50 years old, costing a total of $17 billion for medical care. From all registered fractures, 14% were fractures of the proximal femur, but they take up a huge share of the 72% of the total value for the treatment of fractures. The total allocation of costs according to the type of treatment was 57% for hospitalized patients; 13 percent for outpatient treatment and 30% for long-term inpatient and institutional treatment. From the total cost of fracture treatment, 89% account for patients over age of 65 .