Search Results (28)

Lateral femoral neck and peritrochanteric fractures are common and clinically challenging injuries, particularly in the elderly population, with significant implications for morbidity, mortality, and functional recovery. Traditional classification systems are widely used to guide treatment, yet their reproducibility and clinical applicability remain debated. Increasing attention has been directed toward trabecular architecture and its role in fracture behavior and reduction strategies. This review aims to summarize current evidence on classification systems, trabecular-based fracture patterns, pre-operative reduction techniques, and fixation strategies. A narrative review was conducted using PubMed/MEDLINE, Embase, and Scopus databases up to May 2026. Original studies, reviews, and biomechanical investigations focusing on proximal femur fracture classification, reliability, trabecular alignment, reduction techniques, and fixation methods were included. Data were qualitatively analyzed, with emphasis on interobserver reliability, biomechanical implications, and clinical outcomes. Conventional classification systems, including anatomical, Evans–Jensen, and AO/OTA frameworks, demonstrated variable and generally moderate reproducibility, with reported interobserver agreement ranging from approximately κ = 0.30 to 0.60. Emerging evidence highlights the importance of trabecular architecture, distinguishing intradigital fractures—confined within trabecular pathways and relatively stable—from extradigital fractures, which disrupt load-bearing structures and are associated with increased mechanical instability and higher failure rates. Biomechanical and clinical studies indicate that inadequate reduction with trabecular misalignment significantly increases the risk of varus collapse and implant cut-out. Reduction strategies tailored to fracture pattern, such as internal rotation for intradigital fractures and external or combined maneuvers for extradigital patterns, improve alignment and load transfer. In terms of fixation, dynamic hip screws remain effective in stable fractures, whereas cephalomedullary nails demonstrate superior performance in unstable patterns, with lower reoperation rates reported (approximately 5–8% vs. 10–15%). Management of lateral femoral neck and peritrochanteric fractures should extend beyond traditional classification systems to incorporate trabecular biomechanics. Restoration of trabecular alignment, alongside established parameters such as neck–shaft angle and tip–apex distance, is critical for optimizing outcomes. Further prospective studies are needed to validate trabecular-based classifications and standardize reduction strategies. Full article

Background/Objectives: A floating hip injury, defined as an ipsilateral fracture of the pelvis or acetabulum combined with a femoral fracture, represents a rare and devastating musculoskeletal injury resulting from high-energy trauma. Although Müller type A floating hip injuries comprising an acetabular fracture with an ipsilateral femoral fracture are recognized for their clinical complexity, the long-term prognostic factors influencing functional outcomes remain poorly elucidated. This study aimed to identify independent prognostic factors associated with unsatisfactory long-term functional outcomes in patients with Müller type A floating hip injuries. Methods: A retrospective study was performed on 68 consecutive patients with Müller type A floating hip injuries who underwent surgical fixation at a single tertiary trauma center, with a minimum follow-up period of 5 years. Functional outcomes were assessed using the Majeed score, and patients were dichotomized into satisfactory (n = 48; 70.6%) and unsatisfactory (n = 20; 29.4%) outcome groups. Acetabular fractures were classified according to the Judet–Letournel system, and femoral fractures were classified by fracture level (proximal, shaft, or distal). Radiological outcomes were evaluated using Matta’s radiological grading system. Demographic, injury-specific, and treatment-related variables were compared between groups using the Mann–Whitney U test and chi-square test with Bonferroni correction. A multivariate binary logistic regression model was constructed to determine independent predictors of unsatisfactory outcomes. Results: The mean age was 37.15 ± 12.07 years, with a male predominance (67.6%). The predominant mechanism of injury was pedestrian struck by vehicle (54.4%), followed by motor vehicle collision (27.9%) and fall from height (17.6%); collectively, high-energy vehicular trauma accounted for 82.3% of cases. In the univariate analysis, transverse with posterior wall acetabular fracture pattern (p = 0.001), proximal femur fracture level (p = 0.001), associated lower extremity fractures (p = 0.001), nerve damage (p = 0.001), higher body mass index (BMI) (p = 0.001), and lower Matta’s radiological scores (p = 0.001) were significantly associated with unsatisfactory outcomes. Three independent predictors emerged in the multivariate logistic regression: BMI (OR = 1.50; 95% CI: 1.05–2.15; p = 0.025), the presence of associated lower extremity fractures (OR = 29.02; 95% CI: 2.83–297.67; p = 0.005), and Matta’s radiological score (OR = 0.06; 95% CI: 0.01–0.56; p = 0.014). The model yielded internal discriminatory metrics within the acceptable range (overall accuracy 89.7%, sensitivity 95.8%, specificity 75.0%, Nagelkerke R² = 0.757); however, given the limited events-per-variable ratio (~6.7) and the wide confidence intervals observed for some predictors, these internal performance estimates are likely optimistic due to potential overfitting, and the findings should be interpreted as exploratory pending external validation. Conclusions: Elevated BMI, the presence of associated ipsilateral lower extremity fractures, and poor quality of acetabular reduction, assessed via Matta’s radiological criteria, are independent determinants of unsatisfactory long-term functional outcomes in Müller type A floating hip injuries. These findings underscore the critical importance of achieving anatomical reduction in the acetabulum and highlight the compounding effect of additional ipsilateral limb injuries on patient prognosis. Full article

Background/Objectives: The combined effect of femoral neck–shaft angle and lag screw position on unstable intertrochanteric fracture fixation has not been well established. This biomechanical study evaluated the effects of two caput–collum–diaphyseal (CCD) angles and two lag screw positions on construct stability. Methods: Twenty-four synthetic femurs with identical AO/OTA 31-A2.2 fracture gaps (2 mm) were fixed using cephalomedullary nails with CCD angles of either 125° or 130°, each with a central or inferior (calcar) lag screw (n = 6/group). Constructs were tested in a single-leg stance under preloading, cyclic loading (75–750 N, 10,000 cycles, and 2 Hz), and axial loading to failure. Lag screw migration was measured radiographically, and femoral head rotation was recorded using a three-dimensional coordinate-measuring device. Stiffness, failure load, and rotations were compared using the Kruskal–Wallis and Bonferroni post hoc tests. Results: The 125° inferior configuration showed the highest stiffness (188 ± 15 N/mm, p = 0.038) and failure load (1350 ± 97 N, p = 0.047), with the least screw migration (0.54 ± 0.11 mm, p = 0.003), significantly outperforming the 125° central and 130° central constructs. However, it exhibited greater varus collapse (2.25 ± 0.27°, p = 0.013) and axial rotation (~20–30% higher than others, p = 0.025). Screw position had a stronger effect on stability than the CCD angle, although the 130° inferior construct showed slightly less varus deformation. Conclusions: An inferior calcar-guided lag screw improves fixation strength and stiffness in unstable intertrochanteric fractures, particularly in those with a 125° nail. However, this configuration increases varus and rotational displacement, warranting adjunct measures to enhance rotational control in clinical applications. Full article

Background and Clinical Significance: Non-prosthetic peri-implant fractures (NPPIFs) are rare injuries occurring around internal fixation devices, and are distinct from periprosthetic fractures. While most studies focus on the femur, humeral NPPIFs remain poorly documented. This case illustrates a complex humeral NPPIF and highlights key surgical considerations. Case Presentation: A 62-year-old woman presented with a spiral humeral shaft fracture (AO 12B2) after a fall. Following closed reduction and antegrade intramedullary nailing, an intraoperative peri-implant fracture occurred at the distal interlocking screw. CT imaging revealed a complex fracture extending from the lateral condyle to the proximal humerus. Treatment included implant removal and open reduction with dual plate fixation—lateral distal and helically contoured proximal plates—plus cerclage bands and antibiotic-loaded beads. Recovery was uneventful, with a full range of motion achieved at six months. At one year, the DASH score and MEPS were 86 and 75, respectively. Conclusions: Humeral NPPIFs are challenging and require individualized, biomechanically sound strategies. This case reinforces the importance of intraoperative assessment and careful implant selection in humeral fracture management. Full article

Background: Curettage represents a reliable therapeutic option for large-sized benign and locally aggressive bone tumors. In cases of impending fractures, internal fixation with plates and screws can be necessary to stabilize the treated bone after curettage. Metal plates have been the only fixation devices available on the market for decades, but Carbon-fiber-reinforced polyetheretherketone (CFR-PEEK) now represents an alternative in orthopedic oncology. Methods: We reviewed our patients with benign or locally aggressive bone tumors treated with curettage and fixation with CFR-PEEK plates. Plate length and curettage technique were chosen considering the characteristics of each lesion. We recorded the size and location of the lesions, adjuvant treatments and fillers used after curettage, complications, and local recurrences. Postoperative functionality was assessed using the MSTS score. Results: Forty cases were included in our study. The tumors were located in the distal femur (19 cases), femur shaft (1), humerus (17), or proximal tibia (3). Local adjuvants were used in 20 cases. Cavities were filled with bone allografts in 30 cases and cement in 10 cases. Only four cases suffered postoperative complications, and two developed local recurrences. The mean postoperative follow-up was 29.2 months. The mean postoperative upper and lower limb MSTS was 28.0 and 26.7, respectively. Conclusions: After an accurate curettage and an adequate filling of the resulting bone gap, CFR-PEEK plates can provide good mechanical resistance, and their radio-transparency can ease the early diagnosis of local recurrences. CFR-PEEK plates should be considered in selected cases, in a personalized surgical approach. Full article

Background and Objectives: The superficial femoral artery (SFA) can be injured during an intramedullary femoral nailing procedure with proximal and distal cross fixation, performed for proximal femoral fractures and intertrochanteric fractures. The aim of this study was to determine the safe and dangerous zones for the SFA during operative interventions on the femoral body in Turkish society and to define the relationship of these zones with femur length and sex. Materials and Methods: Using a computed tomography angiography, the relationship between the SFA and the medial shaft of the femur was examined in 160 limbs of 80 patients. The upper and lower cut points of the medial part of the SFA in the sagittal plane were defined. The distance of these points to the adductor tubercle was measured and the ratio of this value to the femur length was calculated. Results: The average distance of the SFA to the adductor tubercle in women was 214.2 ± 25.9 mm at the anterior border of the femur, while in men it was 229.8 ± 26.2 mm (p = 0.000). The danger zone length was 85 mm in women and 102 mm in men, and the difference was statistically significant (p = 0.000). The average distance of the SFA to the adductor tubercle at the anterior border of the femur was 223.1 ± 27.3 mm, the average femur length was 374.9 ± 30.2 mm, and a moderate correlation was found between them (r = 0.568). Conclusions: When determining the intraoperative danger zone using anatomical reference points in surgical approaches to the femur, variables such as sex and femur length should not be ignored. Full article

Background: Delayed and failed fracture repair and bone healing remain significant public health issues. Dietary supplements serve as a safe, inexpensive, and non-surgical means to aid in different stages of fracture repair. Studies have shown that amorphous calcium carbonate (ACC) is absorbed 2 to 4.6 times more than crystalline calcium carbonate in humans. Objectives: In the present study, we assessed the efficacy of ACC on femoral fracture healing in a male Wistar rat model. Methods: Eighty male Wistar rats were randomly divided into five groups (n = six per group): sham, fracture + water, fracture + 0.5× (206 mg/kg) ACC, fracture + 1× ACC (412 mg/kg), and fracture + 1.5× (618 mg/kg) ACC, where ACC refers to the equivalent supplemental dose of ACC for humans. A 21-gauge needle was placed in the left femoral shaft, and we then waited for three weeks. After three weeks, the sham group of rats was left without fractures, while the remaining animals had their left mid-femur fractured with an impactor, followed by treatment with different doses of oral ACC for three weeks. Weight-bearing capacity, microcomputed tomography, and serum biomarkers were evaluated weekly. After three weeks, the rats were sacrificed, and their femur bones were isolated to conduct an evaluation of biomechanical strength and histological analysis. Results: Weight-bearing tests showed that treatment with ACC at all the tested doses led to a significant increase in weight-bearing capacity compared to the controls. In addition, microcomputed tomography and histological studies revealed that ACC treatment improved callus formation dose-dependently. Moreover, biomechanical strength was improved in a dose-dependent fashion in ACC-treated rats compared to the controls. In addition, supplementation with ACC significantly lowered bone formation and resorption marker levels two–three weeks post-fracture induction, indicating accelerated fracture recovery. Conclusions: Our preliminary data demonstrate that ACC supplementation improves fracture healing, with ACC-supplemented rats healing in a shorter time than control rats. Full article

(1) Background: The prevention of proximal femoral fractures among people of very advanced age is relevant as they are common and increasing in number. The aim of this study was to determine if the hip axis length (HAL) and the neck-shaft angle (caput–collum–diaphyseal CCD) are risk factors for those fractures among people aged 80 years and over. Consequently, it was additionally analysed if these parameters are associated with a certain fracture type. (2) Methods: Anteroposterior radiographs of the pelvis were collected to form three groups (femoral neck fractures (FNFx), trochanteric fractures (TFx) and non-fractured femora (NFx)). Two independent blinded observers separately conducted each measurement of the HAL and CCD. Statistical analysis was performed to determine the association between the measured parameters and type of fracture. (3) Results: One hundred and fifty patients (50 per group) were examined, of which the mean age was 92.7 ± 3.5 (range 81–104) years. Both the HAL and CCD of the FNFx group were significantly larger than in the TFx group (p = 0.013, 0.003). The CCD was higher in the FNFx than that of the NFx group (p = 0.001). No further significant differences of HAL and CCD were observed between the groups. (4) Conclusions: For people aged 80 years and over, an increased HAL represented no risk factor for proximal femur fractures, and a large HAL was associated with an increased occurrence of FNFx instead of TFx. A large CCD was associated with an increased risk of suffering a femoral neck fracture, showing evidence of the CCD being a risk factor for the extremely old population. Full article

Proximal femur fracture risk depends on subject-specific factors such as bone mineral density and morphological parameters. Here, we aim to analyze the dependency of the femoral strength on sixteen morphological parameters. Therefore, finite-element analyses of 20 human femurs during stumbling and lateral falls on the hip were conducted. Pearson correlation coefficients were calculated and morphological parameters with significant correlations were examined in principal component analysis and linear regression analysis. The dependency of the fracture strength on morphological parameters was more pronounced during lateral falls on the hip compared to stumbling. Significant correlations were observed between the neck shaft angle (r = −0.474), neck diameter (r = 0.507), the true distance between the femoral head center and femoral shaft axis (r = 0.459), and its projected distance on the frontal plane (r = 0.511), greater trochanter height (r = 0.497), and distance between the femoral head center and a plane parallel to the frontal plane containing the projection of the femoral head center to the femoral neck axis (r = 0.669). Principal component analysis was strongly weighted by parameters defining the lever arm during a lateral fall as well as the loaded cross-section in the femoral neck. Full article

Background and Objectives: The incidence of proximal femoral fractures is escalating rapidly, generating a significant challenge for healthcare systems globally and, carrying serious social and economic implications. The primarily object of this study was to discover potential distinguishing factors between fractures occurring in the femoral neck and trochanteric region. Materials and Methods: We performed a prospective cohort study of the radiographic images of 70 people over 65 years of age who were admitted to the orthopedic department with hip fracture and who fulfilled our eligibility criteria. Neck Length (NL), Offset Lenth (OL), Hip Axis Length (HAL), Neck Shaft Angle (NSA), Wiberg Angle (WA), Acetabular Angle (AA), Femoral Neck Diameter (FND), Femoral Head Diameter (FHD), Femoral Shaft Diameter (FSD), Femoral Canal Diameter (FCD) and Tonnis classification were recorded. For the comparison of the categorical variables, Pearson’s χ2 criterion was used, while Student’s t-test was applied for the comparison of means of quantitative variables across fracture types. Results: There were no statistically significant variances observed while comparing the selected geometric parameters of the proximal femur with the type of fracture. This finding was reaffirmed in relation to age, gender, and Tonnis classification. However, a moderate correlation was noted, revealing comparatively reduced values of HAL, FHD, and FND in women as opposed to men. Conclusions: The inability of our research to establish the differentiative geometric factors between femoral neck and trochanteric fractures underscores the need for further investigations, which would take into consideration the intrinsic characteristics of the proximal femur. Full article

Objectives: As currently there is no existing biomechanical work on the topic of interest, the aim of the current study was to investigate the effect of cerclage banding distally to an intraoperatively occurring proximal periprosthetic femoral clamshell fracture versus a non-fractured femur after total hip arthroplasty. Methods: A diaphyseal anchoring stem was implanted in twenty paired human cadaveric femora, assigned to a treatment and a control group. In the treatment group, each specimen was fitted with a cerclage band placed 3 mm distally to a clamshell fracture, created with an extent of 40% of the anchoring length of the stem. The resulting fragment was not treated further. The contralateral specimens were left with the stems without further fracture creation or treatment. All constructs were tested under progressively increasing cyclic axial loading until failure. Relative bone-implant movements were monitored by motion tracking. Results: Number of cycles and the corresponding load at stem loosening, defined as 1 mm displacement of the stem along the shaft axis, were 31,417 ± 8870 and 3641.7 ± 887 N in the control group, and 26,944 ± 11,706 and 3194.4 ± 1170.6 N in the treatment group, respectively, with no significant differences between them, p = 0.106. Conclusion: From a biomechanical perspective, cerclage banding distally to an intraoperative clamshell fracture with an extent of 40% of the anchoring length of the stem demonstrated comparable resistance against hip stem loosening versus a non-fractured femur. It may therefore represent a valid treatment option to restore the full axial stability of a diaphyseal anchoring stem. In addition, it may be considered to keep the medial wall fragment unfixed, thus saving operative time and minimizing associated risks. Full article

Background: Infection of orthopaedic implants after internal fixation of bone fractures remains a major complication with occasionally devastating consequences. Recent studies have reported that the use of absorbable materials, instead of metallic ones, may lead to a lower incidence of postoperative infection. In this experimental pre-clinical animal study, we compared the infection rate between absorbable implants consisting of copolymers composed from trimethylene carbonate, L-polylactic acid, and D, L-polylactic acid monomers, and titanium implants after the inoculation of a pathogenic microorganism. Material and Methods: We used an experimental implant-related infection model in rabbits. Sixty animals were randomly and equally divided into two groups. In all animals, the right femur was exposed via a lateral approach and a 2.5 mm two-hole titanium plate with screws (Group A), or a two-hole absorbable plate and screws (Group B), were applied in the femoral shaft. Afterwards, the implant surface was inoculated with Pseudomonas Aeruginosa at a concentration of 2 × 10⁸ CFU/mL. The primary outcome was the comparison of the incidence of developed infection between the two groups. The wound condition was monitored on a daily basis and radiographies were obtained at 12 weeks postoperatively. Infection-related laboratory markers (white blood cell count, erythrocyte sedimentation rate, and C-reactive protein values) were assessed at 3, 6, and 16 weeks postoperatively. Histologic analysis and cultures of tissue samples were also performed to evaluate the presence of infection. Results: Clinical and laboratory signs of infection were evident in 11 rabbits in Group A (36.7%), and 4 in Group B (13.3%). The difference between the groups was statistically significant (p = 0.04). Five animals in Group B (16.7%) had clinical and histologic signs of a foreign-body reaction with significantly elevated CRP and ESR values but no simultaneous presence of infection was identified (p = 0.04). Bone remodelling with thickening of the periosteum and surrounding sclerosis was demonstrated radiologically in animals developing infection or foreign-body reactions. Conclusions: Absorbable plates and screws show lower susceptibility to infection compared to titanium ones. However, their application is associated with foreign-body reaction and the potential need for a second surgical intervention. Full article

Purpose: Bilateral fatigue femoral fractures (BFFF) represent an extremely rare clinical entity. The present study introduces a novel classification, in order to categorize the BFFFs and provide a thorough review of all these, so far in the literature, reported cases. Methods: The BFFF were classified taking into account the anatomical region of the femoral fracture; (fh): femoral head, (sc): sub-capital, (pt): peri-trochanteric, (st): sub-trochanteric, (s): shaft, (d): distal femur and the fracture type (complete or incomplete); type I: bilateral incomplete fractures, type II: unilateral incomplete fracture, and type III: bilateral complete fractures. Type III was further subdivided into type IIIA: bilateral non-displaced fractures, type IIIB: unilateral displaced fracture, and type IIIC: bilateral displaced fractures. Furthermore, a meticulous review of the PubMed and MEDLINE databases was conducted to locate all articles reporting these injuries. Results: A total of 38 patients (86.8% males), with a mean age of 25.3 years, suffering BFFFs were identified from the literature search. The mean time interval from symptoms’ onset to diagnosis was 54 days. According to the proposed classification, 2.6% of the fractures were categorized as type I (h), 36.8% as type I (sc), 2.6% as type I(st/s), 7.9% as type I (s), 2.6% as type I (d), 5.4% as type II (fh), 26.3% as type II (sc), 2.6% as type IIIA (st), 2.6% as type IIIA (d), 5.4% as type IIIB (sc), 2.6% as type IIIB (d) and 2.6% as type IIIC (sc). Surgery was performed in 52.6%, while non-operative treatment was followed in 47.4% of the population. Regarding the fracture type, 75% of type I fractures were conservatively treated, while 91.7% and 66.6% of type II and III fractures were surgically treated. For patients treated conservatively, the mean time from diagnosis to return to previous status was 260 days, while for patients treated surgically, 343 days. Conclusions: BFFFs, although rare, may pose a diagnostic and therapeutic challenge. The present classification offers valuable information and may act as a guide for the management of these patients. Full article

Glycogen storage disease type IV (GSD IV) (OMIM #232500) is an autosomal recessive disorder caused by deficiency of the glycogen-branching enzyme. Here, we report a patient presenting with prematurity and severe hypotonia resulting from a complicated pregnancy with polyhydramnios. During her stay in the neonatal unit, the infant remained dependent on a ventilator, and her movements were mostly absent, except for occasional small movements of her fingers. A spontaneous fracture of femur shaft occurred in the postnatal fourth week. Whole-exome sequencing of DNA from the patient revealed a homozygous missense variant in the GBE1 gene (c.1693C>T, p.Arg565Trp). The variation detected in the index case was also confirmed by Sanger sequencing in the patient and respective parents. This study showed that the neuromuscular subtypes of GSD-IV should be considered as a possible differential diagnosis in severe neonatal hypotonia cases. Full article

In March 2020, Germany imposed a nationwide lockdown to curb the spread of COVID-19, prompting questions about the impact on the incidence of common fractures. This study examined 15 fracture types in pre-outbreak (2010–2019) and post-outbreak (2020–2021) periods, using data categorized by age (18–64 years, >65 years) and sex (male, female). Linear regression assessed annual growth rates, and mean fracture numbers were compared across periods for significant differences. Results indicated a positive correlation between fracture incidence rates and time for various types, such as cervical, thoracic, lumbar, and pelvic spine fractures, rib fractures, femoral neck, pertrochanteric femur, femoral shaft, and ankle fractures. Frequencies of proximal humerus, distal radius, femoral neck, pertrochanteric femur, femoral shaft, and ankle fractures in 2020 and 2021 were within predicted ranges from previous years. However, rib fractures and spinal fractures (cervical, thoracic, lumbar, and pelvic spine) occurred less frequently during this time. Notably, this study found a consistent decline in most fracture types for individuals aged 18–64 after the pandemic’s onset, while the fracture incidence of hip fractures, often referred to as fragility fractures, for those over 65 remained unchanged. Fibula fractures showed the most considerable decrease in both age groups. In conclusion, the COVID-19 pandemic substantially impacted fracture incidence, with lower rates among individuals under 65 and unchanged fragility fractures in the elderly population. Full article