Risk factors for cut-out of double lag screw fixation in proximal femoral fractures

Tip-apex distance as a risk factor for cut-out in cephalic double-screw nailing of intertrochanteric femur fractures

Aims

Proximal femur fractures treatment can involve anterograde nailing with a single or double cephalic screw. An undesirable failure for this fixation is screw cut-out. In a single-screw nail, a tip-apex distance (TAD) greater than 25 mm has been associated with an increased risk of cut-out. The aim of the study was to examine the role of TAD as a risk factor in a cephalic double-screw nail.

Methods

A retrospective study was conducted on 112 patients treated for intertrochanteric femur fracture with a double proximal screw nail (Endovis BA2; EBA2) from January to September 2021. The analyzed variables were age, sex, BMI, comorbidities, fracture type, side, time of surgery, quality of reduction, pre-existing therapy with bisphosphonate for osteoporosis, screw placement in two different views, and TAD. The last follow-up was at 12 months. Logistic regression was used to study the potential factors of screw cut-out, and receiver operating characteristic curve to identify the threshold value.

Results

A total of 98 of the 112 patients met the inclusion criteria. Overall, 65 patients were female (66.3%), the mean age was 83.23 years (SD 7.07), and the mean follow-up was 378 days (SD 36). Cut-out was observed in five patients (5.10%). The variables identified by univariate analysis with p < 0.05 were included in the multivariate logistic regression model were screw placement and TAD. The TAD was significant with an odds ratio (OR) 5.03 (p = 0.012) as the screw placement with an OR 4.35 (p = 0.043) in the anteroposterior view, and OR 10.61 (p = 0.037) in the lateral view. The TAD threshold value identified was 29.50 mm.

Conclusion

Our study confirmed the risk factors for cut-out in the double-screw nail are comparable to those in the single screw. We found a TAD value of 29.50 mm to be associated with a risk of cut-out in double-screw nails, when good fracture reduction is granted. This value is higher than the one reported with single-screw nails. Therefore, we suggest the role of TAD should be reconsidered in well-reduced fractures treated with double-screw intramedullary nail.

Complication Rates and Survival of Nonagenarians after Hip Hemiarthroplasty versus Proximal Femoral Nail Antirotation for Intertrochanteric Fractures: A 15-Year Retrospective Cohort Study of 113 Cases

OBJECTIVE

Intertrochanteric fracture is a very common but serious type of hip fracture in nonagenarians. The surgical treatment remains a significant challenge for orthopedists. The objective of this study was to investigate postoperative complications and survival outcomes compared between bipolar hemiarthroplasty (HA) and proximal femoral nail anti-rotation (PFNA) in nonagenarians with intertrochanteric fractures, and to evaluate the efficacy and safety of the two surgical procedures in this patient population.

METHODS

A total of 113 consecutive nonagenarians who underwent bipolar HA or PFNA for the treatment of intertrochanteric fractures from January 2006 to August 2021 were retrospectively studied in the current paper. There were 34 males and 79 females, with a mean age of 92.2 years (range 90-101 years) at the time of operation. The average duration of follow-up was 29.7 months (range 1-120 months). The full cohort was divided into bipolar HA (77 cases) and PFNA (36 cases) groups. Damage control orthopedics was used to determine the optimal surgery time and assist in perioperative management. A restrictive blood transfusion strategy was employed, along with appropriate adjustments under multidisciplinary assessment, throughout the perioperative period. Perioperative clinical information and prognostic data were analyzed. Kaplan-Meier survival curves were used for survival analysis, and landmark analysis divided the entire follow-up period into 1-12 months (short-term), 13-42 months (medium-term) and 43-120 months (long-term) according to the configurations of Kaplan-Meier survival curves.

RESULTS

Both groups had similar general variables except for the proportion of high adjusted Charlson comorbidity index (aCCI) (≥6 points) (6.5% in bipolar HA group and 22.2% in PFNA group, p = 0.024). Intraoperative blood loss and transfusion requirements were greater, and the intraoperative transfusion rates were higher in the bipolar HA group compared to the PFNA group (all p < 0.05). The complications rates, 1- to 60-month cumulative all-cause mortality, postoperative optimal Harris hip score (HHS), and Barthel index (BI) presented no significant difference between the two groups (all p > 0.05). Both groups had similar overall survival curves (p = 0.37). However, landmark analysis revealed that bipolar HA group exhibited higher survival rates in medium-term (p = 0.01), while similar survival rates were observed in the short- and long-term post-operation periods (both p > 0.05). Cox regression with survival-time-dependent covariate calculated the hazard ratio (HR) of bipolar HA was 0.41 in medium-term (p = 0.039).

CONCLUSION

Bipolar HA is equally effective and reliable as PFNA for treating intertrochanteric fractures in nonagenarians. Despite resulting in more intraoperative blood loss and transfusions, bipolar HA therapy is associated with a higher medium-term survival rate compared to PFNA treatment. The application of damage control orthopedics and precise perioperative patient blood management could contribute to the positive clinical outcomes observed in this patient population.

Treatment of intertrochanteric fractures using cephalomedullary nail: One or two cephalic screws?

OBJECTIVES

To determine the incidence of cut-out, cut-in, cut-through, Z-effect, and reverse Z-effect in two cephalomedullary nail (CMN) systems: one with single cephalic screw fixation and the other with dual-screw fixation using a lag screw and an anti-rotation screw.

METHODS

A retrospective study from a cohort of patients was conducted between January 2017 and August 2019 in patients with intertrochanteric fractures treated with osteosynthesis using CMN.

RESULTS

One hundred ninety-six patients with intertrochanteric fractures who met the inclusion criteria were recruited. The median age was 81 years [interquartile range (IQR) 12]. Seventy-six percent had fractures classified as Orthopaedic Trauma Association/Arbeitsgemeinschaft für Osteosynthesefragen (OTA/AO) 31A2. Twenty-one mechanical complications occurred, 8.7% (17) was cut-out with a single cephalic screw CMN and 2% (4) was Z-effect with a dual-screw CMN non-integrated. The median tip-apex distance (TAD) was 19.4 mm (IQR 10.8) in patients who experienced cut-out and 19 mm (IQR 10) in those who experienced Z-effect. The median time to cut-out occurrence was 39,5 days (IQR 47,5), while the median time to Z-effect was 90 days (IQR 86).

CONCLUSIONS

The incidence of osteosynthesis failure using CMN is more frequent in patients treated with a single cephalic screw CMN.

LEVEL OF EVIDENCE

Therapeutic, Level III.

A biomechanical investigation of a novel intramedullary nail used to salvage failed internal fixations in intertrochanteric fractures

PURPOSE

The ideal approach for revision surgery following femoral head salvage treatments for an intertrochanteric fracture is still up for debate. A novel variety of proximal femoral bionic intramedullary nail (PFBN) has been created in clinical practice. We aimed to compare the biomechanical results of the novel implant to conventional intramedullary and extramedullary fixation in the treatment of intertrochanteric fracture following primary internal fixation failure.

METHODS

Using finite element analysis, we created a three-dimensional model of the intertrochanteric fracture's helical blade cut-out for this investigation. The PFBN 1 group, the PFBN 2 group, the PFNA group, and the DHS group were our four test groups. For each fracture group, the von Mises stress and displacements of the femur and internal fixation components were measured under 2100 N axial loads.

RESULTS

The values for the femoral displacement in the PFBN1 group, PFBN2 group, PFNA group, and DHS group were 6.802 mm, 6.716 mm, 8.080 mm, and 8.679 mm, respectively. The internal implant displacement values were 6.201 mm, 6.138 mm, 7.396 mm, and 8.075 mm in the PFBN1 group, PFBN2 group, PFNA group, and DHS group, respectively. The maximum von Mises Stress in the femoral was 187.2 MPa, 85.18 MPa, 106.6 MPa, and 386.2 MPa in the PFBN1 groups, PFBN2 groups, PFNA groups, and DHS groups, respectively. In the PFBN1 groups, PFBN2 groups, PFNA groups, and DHS groups, the maximum von Mises Stress in internal fixation was 586.7 MPa, 559.8 MPa, 370.7 MPa, and 928.4.8 MPa, respectively.

CONCLUSION

Our biomechanical research demonstrates that intramedullary fixation is more stable than extramedullary fixation when salvaging failed internal fixations in intertrochanteric fracture. Compared with PFNA and DHS, PFBN showed better biomechanical stability in the treatment of patients with revised intertrochanteric fractures. In light of this, we advocate PFBN fixation as the method of choice for intertrochanteric fracture revision. This result still has to be confirmed in more clinical research.

Clinical and Radiological Characteristics of Lesser Trochanter Splitting Irreducible Intertrochanteric Fractures

Background

The purpose of this study was to investigate the demographic factors and radiological characteristics of lesser trochanter splitting (LTS) irreducible intertrochanteric fractures and to report the clinical results of patients who underwent open reduction and internal fixation using dynamic hip screws (DHS).

Methods

Inclusion criteria were as follows: AO/Orthopedic Trauma Association type 31A1.2, a fracture line originating from the outside of the greater trochanter that passes through the lesser trochanter, and patients who were followed up for more than 1 year with a confirmed presence or absence of bone union. A total of 13 cases were identified, accounting for 3.1% (13/416 intertrochanteric fractures). Patients were classified according to posterior sagging of the distal shaft fragment relative to the head-neck fragment (posterior sagging group, 6; non-sagging group, 7). Demographic data, comorbidities, injury mechanism, type of anesthesia, operation time, blood loss, tip-apex distance, reduction quality, leg length discrepancy (> 5 mm), long lesser trochanter sign, postoperative complications, and presence of bony union were obtained by reviewing medical records and radiological findings.

Results

The mean age of the patients was 50.4 ± 10.4 years, and 12 were men. Except for 1 case (slip down), all were induced by high-energy trauma. According to the grade of reduction quality, 5 cases (38.5%) had good reduction quality and 8 cases (61.5%) had acceptable reduction quality. There were no postoperative complications, and bony union was observed in all cases. The long lesser trochanter sign was observed in 5 cases (38.5%) and leg length discrepancy greater than 5 mm was not observed. Compared with the non-sagging group, the posterior sagging group had more head-neck fragments containing more than 1/2 of the lesser trochanter length, longer operation time, and more blood loss (p < 0.05). Compared to the non-sagging group, the posterior sagging group had worse reduction quality and more long lesser trochanter signs (p < 0.05).

Conclusions

Open reduction and internal fixation using DHS for the LTS irreducible intertrochanteric fractures can achieve good clinical and radiological outcomes. However, in the posterior sagging type, reduction can be more difficult with a longer operation time and higher likelihood of blood loss.

Does computer-assisted orthopaedics system (ADAPT system) improve outcomes of intertrochanteric hip fractures?

INTRODUCTION

Intramedullary nailing (IMN) is a general treatment for intertrochanteric hip fractures. The computer-assisted orthopaedics system (CAOS), ADAPT system (Stryker, NJ), has been developed to facilitate lag screw insertion. When compared to the conventional freehand method, the efficacy of CAOS has not been clearly clarified. Therefore, we conducted this systematic review and meta-analysis to answer: does the CAOS performed better than freehand method in IMN.

MATERIALS AND METHODS

Studies published up to January 2023 were searched in the PubMed, Embase, Web of Science and Cochrane Library databases with predetermined key words. Comparative clinical studies between CAOS (ADAPT system) and freehand method were included. The primary outcomes of interest were the tip-apex-distance (TAD) and positions of lag screw. Fluoroscopy use, operation duration and intraoperative/postoperative complications were also extracted. A meta-analysis was performed for pooled analysis.

RESULTS

There were seven studies with 326 fractures in CAOS group and 325 fractures in Freehand group. All studies included presented high qualities. The CAOS group showed a statistically smaller TAD than Freehand group (weighted mean difference = -3.24 mm; 95% confidence interval [CI] -5.10 to -1.37 mm; p = 0.0007) and a better lag screw position (83/92 [90.2%] VS 64/92 [69.6%]; RR = 1.3; 95% CI 1.12 to 1.51; p = 0.0007). The operative time and radiation use revealed no difference between two groups.

CONCLUSIONS

The current evidence indicated that ADAPT system could help to perform a more accurate lag screw than freehand manipulation while the operative time and radiation time was not reduced as expectations on such new technique. Long-term follow-up studies are appealed.

Use of the Heracles straight blade in the treatment of intertrochanteric hip fractures: a prospective study with a 1-year follow-up

INTRODUCTION

The treatment of intertrochanteric fractures in the elderly remains challenging for orthopedic surgeons, due to aging, comorbidities, and poor bone quality. The Heracles straight blade has proven a lower rate of cut-out and femoral head displacement in biomechanical studies; however, there are currently no published clinical studies using this nail.

PURPOSE

To analyze the clinical and radiological results of the Heracles nail with the straight cephalic Heracles blade as a device to treat osteoporotic intertrochanteric fractures of the proximal femur.

METHODS

A total of 136 patients with trochanteric hip fractures were operated on by the same surgeon, using the Heracles nail with a straight cephalic blade. However, only 86 patients completed the 1-year follow-up both clinically and radiologically. According to the Association of Osteosynthesis classification, 38 patients (44.1%) had 31-A1, 36 patients (41.6%) had 31-A2, and 12 patients (14.1%) had 31-A3. Functional outcomes were assessed according to the Katz and Barthel scores, finding that 58% of patients recovered their original functional level, According to Barthel score, a mean loss of 11.8 points was found.

RESULTS

The mean hospital stay was 8.22 days (mean preoperative stay of 2.71 days). The mean tip-apex distance was 15.2 mm. During the follow-up, 6 complications (6.96%) were detected: 4 cut-out, 1 cut-in, and 1 nail breakage. According to the Katz score, 58% of the patients recovered their previous functional status and 20.58% needed an additional walking aid. The mean loss in the Barthel score was 11.8 points.

CONCLUSION

The Heracles nail using a cephalic straight blade has proven to be a valid treatment of trochanteric fractures, due to the functional recovery of the patients and low level of complications.

Blade Augmentation in Nailing Proximal Femur Fractures-An Advantage despite Higher Costs?

BACKGROUND

Proximal femoral fractures occur with increasing incidence, especially in the elderly. Commonly used implants for surgical treatment are cephalomedullary nails. To increase stability, a perforated femoral neck blade can be augmented with cement. The study investigated whether this results in a relevant clinical advantage and justifies the higher cost.

MATERIALS AND METHODS

This is a single-center retrospective study of 620 patients with proximal femur fractures treated with cephalomedullary nailing. Between January 2016 and December 2020, 207 male and 413 female patients were surgically treated with a proximal femur nail (DePuy Synthes) using a perforated blade and cement augmentation in cases with severe osteoporosis. Primary outcome measures were the rate of cut-out, tip apex distance and the positioning of the blade in the femoral head. Secondary outcome measures were the implant costs and operating times.

RESULTS

Of the 620 femoral neck blades, 299 were augmented with cement. A total of six cut-outs were seen in the first 3 months after the operation. There were three in the cement-augmented group (CAB = cement-augmented blade) and three in the conventional group (NCAB = non-cement-augmented blade). There was a significant positive correlation between age and augmentation, with a mean difference of 11 years between the two groups (CAB 85.7 ± 7.9 vs. NCAB 75.3 ± 15.1; p < 0.05). There was no difference in the tip-apex distance (CAB 15.97 vs. 15.69; p = 0.64) or rate of optimal blade positions between the groups (CAB 81.6% vs. NCAB 83.2%; p = 0.341). Operation times were significantly longer in the cemented group (CAB 62.6 21.2 min vs. NCAB 54.1 7.7 min; p < 0.05), and the implant cost nearly doubled due to augmentation.

CONCLUSION

When the principles of anatomic fracture reduction, optimal tip-apex distance and optimal blade position are combined with cement augmentation in cases of severe osteoporosis, a cut-out rate of less than 1% can be achieved. Nevertheless, it should be noted that augmentation remains expensive and prolongs surgery time without definite proof of mechanical superiority.

AP3×ML3 reduction quality classification for femoral trochanteric fractures: validation for reliability focusing on positive medial cortical support

INTRODUCTION

This study evaluated the validity of the AP3 × ML3 reduction quality classification, which applies the concept of positive medial cortical support.

METHODS

A total of 120 trochanteric fractures classified as AO Foundation/Orthopedic Trauma Association 31A1 and A2 were retrospectively analyzed. The validity of the AP3 × ML3 classification was evaluated by comparison with the Baumgaertner reduction quality criteria. When using the AP3 × ML3 classification, reduction quality was divided into three classes based on the degree of anterior cortical contact between the proximal and distal fragments. Reduction quality was also divided into three classes when using the Baumgaertner criteria. The frequency of mechanical complications, including cut-out, delayed union, and excessive migration of the lag screw, was retrospectively assessed. Intra-observer and inter-observer reliability was assessed using the intraclass correlation coefficient (ICC).

RESULTS

Mechanical complications included 4 cases of cutout (3.3%) and 1 of delayed union (0.8%). Mechanical complications occurred for all levels of reduction quality in both classifications, except for the acceptable of the Baumgaertner criteria. When reduction quality was rated as good, acceptable, and poor the incidence of mechanical complications was 2.5%, 5.7%, and 16%, respectively, under the AP3 × ML3 classification and 3.3%, 0%, and 15.0%, respectively, under the Baumgaertner criteria. The ICC was 0.80 for intra-observer reliability and 0.57 for inter-observer reliability when using the AP3 × ML3 classification and 0.85 and 0.34, respectively, when using the Baumgaertner criteria.

CONCLUSION

The AP3 × ML3 classification was reliable and easy to use compared with the widely used Baumgaertner reduction quality criteria. Level of evidence 4.

The postoperative prognosis of older intertrochanteric fracture patients as evaluated by the Chang reduction quality criteria

OBJECTIVE

The aim of this study was to investigate the relationship between the Chang reduction quality criteria (CRQC) and the outcome of intertrochanteric fractures in older adults according to follow-up time.

METHODS

This was a retrospective analysis of 389 older adult patients with intertrochanteric fractures treated surgically from January 2019 to June 2021, including 130 males and 259 females aged 84.6 (77.5-89.7) years. Patient survival was determined by telephone as the time between admission to hospital for fracture and death or until the study deadline (June 1, 2022). According to the CRQC, the patients were divided into the Poor, Acceptable, and Excellent groups. Univariate and multivariate Cox proportional hazard models were used to assess the association between CRQC and all-cause mortality in older adult intertrochanteric fractures at 1 year and the total follow-up time. Further subgroup analysis was performed according to different clinical and biological characteristics to improve the accuracy of the results.

RESULTS

The mortality rates were 24.7% and 15.4% at 1 year and the total follow-up time, respectively. Both at one year and the total follow-up time, the mortality of the CRQC-Excellent group was significantly lower than that of the CRQC-Acceptable group (p.adj < 0.05) and the CRQC-Poor group (p.adj < 0.05). After multifactor adjustment, CRQC grades of Acceptable and Poor were independent risk factors affecting the overall and 1-year mortality. In addition, advanced age, ≥ 1 comorbidities, ASA 3 + 4, and prolonged preoperative waiting time were independent risk factors for survival at the total follow-up time. At 1 year, only ASA 3 + 4 and prolonged preoperative waiting time were independent risk factors for survival. Subgroup analysis according to different characteristics at the total follow-up time and at one year showed that in most subgroups, a decrease in the CRQC grade was significantly associated with an increase in all-cause mortality (p for trend < 0.05).

CONCLUSIONS

This study highlights that CRQC grades of Acceptable and Poor are associated with increased all-cause mortality in older adult intertrochanteric fractures. We should attempt to achieve good reduction of these fractures.

U-blade gamma 3 vs. gamma 3 nails for intertrochanteric hip fracture: Meta-analysis

Background and Objective

Intertrochanteric fracture is a growing problem in the traumatology department. The use of intramedullary devices has increased, representing the first treatment option in intertrochanteric fractures. U-Blade devices appeared to avoid rotation of the femoral head over the femoral neck. The aim of this study was to conduct a meta-analysis of the surgical treatment of intertrochanteric fractures comparing in terms of safety and efficacy the U-Blade Gamma 3 nail vs. the conventional Gamma 3 nail.

Methods

A literature search for intertrochanteric fracture 31A1-31A3 according to the AO foundation/orthopaedic trauma association (AO/OTA) classification was performed. Baseline characteristics of each article were obtained; radiological outcomes were tip apex distance (TAD), sliding distance (mm), cut-out rate, and lateralization rate. Surgery time (min) was also recorded. A meta-analysis was performed with ReviewManager 5.4.

Results

Five retrospective studies (n = 993 patients) were included. With respect to TAD and sliding distance, there were no differences between two groups [mean difference (MD) 0.47, 95% confidence interval (CI), -0.46 to 1.40] and (MD 0.39, 95% CI, 0.13-0.66). The cut-out rate and lateralization rate did not show differences between two groups (p > 0.05). Finally, surgery time was significantly higher in the U-Blade Gamma 3 group (MD -4.84, 95% CI, -7.22 to -2.46).

Conclusions

The use of U-Blade Gamma 3 did not show significant differences in the radiological results compared with the conventional Gamma 3 nail.

Association between Immediate Postoperative Radiographic Findings and Failed Internal Fixation for Trochanteric Fractures: Systematic Review and Meta-Analysis

Failed internal fixations for trochanteric fractures have a strong negative impact owing to increased postoperative mortality and high medical costs. However, evidence on the prognostic value of postoperative radiographic findings for failed internal fixations is limited. We aimed to clarify the association between comprehensive immediate postoperative radiographic findings and failed internal fixation using relative and absolute risk measures. We followed the meta-analysis of observational studies in epidemiology guidelines and the Cochrane handbook. We searched specific databases in November 2021. The outcomes of interest were failed internal fixation and cut-out. We pooled the odds ratios and 95% confidence intervals using a random-effects model and calculated the number needed to harm for each outcome. Thirty-six studies involving 8938 patients were included. The certainty of evidence in the association between postoperative radiographic findings and failed internal fixation or cut-out was mainly low or very low except for the association between intramedullary malreduction on the anteromedial cortex and failed internal fixation. Moderate certainty of evidence supported that intramedullary malreduction on the anteromedial cortex was associated with failed internal fixation. Most postoperative radiographic findings on immediate postoperative radiographs for trochanteric fractures were uncertain as prognostic factors for failed internal fixations.

Finite Element Analysis of Proximal Femur Bionic Nail (PFBN) Compared with Proximal Femoral Nail Antirotation and InterTan in Treatment of Intertrochanteric Fractures

Objective

To compare the biomechanical properties of proximal femur bionic nail (PFBN), proximal femoral nail antirotation (PFNA) and InterTan in the treatment of elderly intertrochanteric fractures AO/OTA 31‐A1.3 by finite element analysis.

Methods

We used Mimics, Unigraphics and other software to establish normal femur and AO/OTA 31‐A1.3 fracture models, and reconstructed PFBN, PFNA and InterTan intramedullary nail models, and assembled them on the fracture model. The ANSYS software was used to compare the femoral von Mises stress distribution, deformation distribution, and internal fixation stress distribution of each group under a load of 2100 N.

Results

It could be seen that the femoral maximum stress, femoral maximum displacement, and maximum stress of internal fixation of the PFBN group were lower than those in the PFNA group and the InterTan group. The maximum femoral stress of the PFBN was 190.25 MPa, while the maximum stress of the femur of the PFNA and InterTan groups were 238.41 Mpa and 226.97 Mpa. The maximum femoral displacement of each group were located at the top of the femoral head, and the maximum displacement of the PFBN group was 14.373 mm, and the maximum displacement values of the PFNA and InterTan groups were 19.49 and 15.225 mm. For the stress distribution of intramedullary nail, the maximum stress of the three kinds of internal fixation was located on the main nail. The maximum stress of PFBN was 1191.8 MPa, compared with 2142.8 MPa for PFNA and 1702.3 MPa for InterTan. And the maximum stress on the PFBN pressure nail was 345.35 MPa, compared with 868.6 MPa for the PFNA spiral blade and 545.5 MPa for InterTan interlocking twin nails.

Conclusion

Compared with PFNA and InterTan, PFBN has better mechanical properties. The biomechanical characteristics of PFBN are more advantageous than PFNA and InterTan internal fixation system in the treatment of femoral intertrochanteric fractures.

Risk factors for cut-out in intertrochanteric fractures treated with proximal femoral nail of double proximal screw design

Background

Intertrochanteric femoral fractures (IFF) are often seen in the elderly after a simple fall because of osteoporosis, and treatment is generally provided with proximal femoral nail (PFN). The complication of cut-out, which can develop as a result of PFN treatment of IFF, is a significant cause of morbidity. The aim of this study was to examine the risk factors for cut-out in cases treated with double proximal screw design nail (DPSDN).

Methods

A retrospective examination was made of patients aged> 70 years, who were operated on for IFF using DPSDN between January 2018 and December 2020. A record was made of the potential risk factors of age, gender, osteoporosis level (Singh Osteoporosis Index), fracture classification (AO/OTA classification), reduction quality, tip-apex distance(calTAD), and proximal screw placement values. Using logistic regression analysis, it was attempted to determine predictive factors for cut-out complication in cases operated on with DPSDN.

Results

With 219 cases included in the study, two groups were formed as cut-out and non-cut-out. Reduction quality, calTAD, and proximal screw placement were seen to be risk factors for cut-out. According to the univariate logistic regression analysis, the cut-out risk was 57.917-fold greater in those with "poor" reduction quality compared to those with "good" reduction quality, the risk was 17-fold greater in those with "superior"screw placement compared to "central" placement (p < 0.001), and 9.24-fold greater in those with "anterior" placement compared to "central" placement (p < 0.001). The cutoff value for calTAD for the diagnosis of cut-out was found to be > 25.5 mm (p = 0.026).

Conclusion

The results of this study demonstrated that the most important risk factors in the use of DPSDN are reduction quality, calTAD and proximal screw placement,. It was also concluded that just as in implants designed with a single screw, there is an increased risk when calTAD is > 25 mm.

New tip-apex distance and calcar-referenced tip-apex distance cut-offs may be the best predictors for cut-out risk after intramedullary fixation of proximal femur fractures

Cut-out is one of the most common mechanical failures in the internal fixation of trochanteric hip fractures. The tip-apex distance (TAD), and the calcar-referenced tip apex distance (CalTAD) are the radiographic parameters that most predict the risk of cut-out. The optimal CalTAD value has not yet been defined, but the optimal TAD value is reported as 25 mm or less. However, this cut-off is highly specific but poorly sensitive. The aim of this study was to determine highly specific and sensitive TAD and CalTAD values and shed light on the role of other clinical variables. A total of 604 patients were included in this retrospective cross-sectional study. For each patient the following data were recorded: number of cut-out, AO/OTA classification, quality of the reduction, type of nail, cervicodiaphyseal angle, type of distal locking, post-operative weight-bearing, TAD and CalTAD values, and the position of the screw head in the femoral head according to the Cleveland system. The incidence of cut-out across the sample was 3.1%. The median TAD in the cut-out group was 38.72, while in the no cut-out group it was 22.16. The median CalTAD in the cut-out group was 39.34, while in the no cut-out group it was 22.19. The cut-off values for TAD and CalTAD with highest value of sensitivity and specificity for the risk of cut-out were 34.8 and 35.2, respectively. The incidence of cut-out can be reduced by performing careful minimal reduction and ensuring stable fixation by avoiding TAD > 34.8 mm and CalTAD > 35.2 mm.

Risk factors for implant failure of intertrochanteric fractures with lateral femoral wall fracture after intramedullary nail fixation

INTRODUCTION

Few studies have specifically evaluated the comminution extent of lateral femoral wall (LFW) fracture and risk factors of implant failure in intertrochanteric fractures with LFW fracture. The aim of present study was to evaluate the influence of comminution extent of LFW fracture on implant failure and identify risk factors of implant failure in cases with LFW fracture after intramedullary fixation.

METHODS

This retrospective study included 130 intertrochanteric fracture with LFW fracture treated with intramedullary fixation at a teaching hospital over a 13-year period from January 2006 to December 2018. Demographic information, cortical thickness index, the reduction quality, status of medial support, position of the screw/blade and status of lateral femoral wall were collected and compared. The logistic regression analyzes was performed to evaluate risk factors of implant failure in intertrochanteric fractures with LFW fracture after intramedullary nail fixation.

RESULTS

10 patients (7.69%) suffered from mechanical failure after intramedullary fixation. Univariate analyzes showed that comminuted LFW fracture (OR, 7.625; 95%CI, 1.437~40.446; p = 0.017), poor reduction quality (OR, 49.375; 95%CI, 7.217~337.804; p < 0.001) and loss of medial support (OR, 17.818; 95%CI, 3.537~89.768; p < 0.001) were associated with implant failure. After adjustment for confounding variables, the multivariable logistic regression analyzes showed that poor reduction quality (OR, 11.318; 95%CI, 1.126~113.755; p = 0.039) and loss of medial support (OR, 7.734; 95%CI, 1.062~56.327; p = 0.043) were independent risk factors for implant failure. Whereas, comminuted LFW fracture was not associated with implant failure (p = 0.429).

CONCLUSIONS

The comminution extent of the LFW fracture might influence the stability of intertrochanteric fractures; and intramedullary fixation might be an effective treatment method. Furthermore, poor reduction quality and loss of medial support could increaze the risk of implant failure in intertrochanteric fractures with LFW fractures after intramedullary fixation. Therefore, we should pay great emphasis on fracture reduction quality in future.

[Research on the classification criteria of femoral intertrochanteric fractures based on irreducibility or not]

OBJECTIVE

To formulate the classification criteria of femoral intertrochanteric fractures based on irreducibility or not in order to predict the difficulty of fracture recovery.

METHODS

A clinical data of 244 patients with closed femoral intertrochanteric fractures admitted between January 2017 and March 2020 was retrospectively analyzed. There were 116 males and 128 females with an average age of 77.9 years (range, 45-100 years). The cause of injury included falling in 190 cases, traffic accident in 36 cases, smashing in 13 cases, and falling from height in 5 cases. The time from injury to operation was 1-14 days (mean, 3.6 days). According toAO/Orthopaedic Trauma Association (AO/OTA) classification, the fractures were classified as type 31-A1 in 38 cases, type 31-A2 in 160 cases, and type 31-A3 in 46 cases. According to whether the recovery difficulty occurred after intraoperative closed traction reset, the patients were divided into reducible-group and irreducible-group; combined with the literature and preoperative imaging data of two groups, the classification criteria of femoral intertrochanteric fractures was formulated based on the irreducibility or not. The 244 fractures were classified by the doctors who did not attend the operation according to the classification criteria, predicted the difficulty of fracture reduction, and compared with the actual intraoperative reduction situation.

RESULTS

The 244 patients were divided into reducible-group ( n=164, 67.21%) and irreducible-group ( n=80, 32.79%) according to the intraoperative difficulty of reduction. Comparing the imaging data and characteristics of the two groups, and formulating the classification criteria of femoral intertrochanteric fractures based on irreducibility or not, the fractures were mainly divided into two categories of irreducibility and reducibility. The fractures of irreducibility category was divided into typesⅠ-Ⅴ, among which type Ⅲ was divided into subtypes 1-4; the fractures of reducibility category was divided into typesⅠand Ⅱ. Compared with the actual intraoperative evaluation results, the total accuracy rate of the doctors who did not attend the operation was 81.15% (198/244) based on the classification criteria of femoral intertrochanteric fractures. The accuracy rate of irreducibility category was 65.74% (71/108), and the reducibility category was 93.38% (127/136). All patients were followed up 13-25 months, with an average of 17.6 months. All fractures healed except 2 cases died of infection.

CONCLUSION

The classification criteria of femoral intertrochanteric fractures based on irreducibility or not can accurately predict the reducible cases preoperatively, and most of the irreducible cases can be correctly predicted in a wider way. But the classification criteria still need to be further improved and supplemented.

Cement augmentation for trochanteric fracture in elderly: A systematic review

BACKGROUND

Cement augmentation of internal fixation of hip fracture has reported to improve fracture stability in osteoporotic hip fractures, reducing the risk of cut-out of the sliding screw through the femoral head. The purpose of present study was to perform a systematic literature review on the effects of augmentation technique in patients with osteoporotic hip fractures.

MATERIAL AND METHODS

A comprehensive literature search was systematically performed to evaluate all papers published in English language included in the literature between January 2010 and July 2020, according to the PRISMA 2009 guidelines. In vivo and in vitro studies, case reports, review articles, cadaveric studies, biomechanical studies, histological studies, oncological studies, technical notes, studies dealing with radiological classifications and studies on revision surgery were excluded.

RESULTS

A total of 5 studies involving 301 patients were included. Patients had a mean age of 84.6 years and were followed up for a mean period of 11 months. The proximal femoral fractures were stabilized with implantation of the PFNA or Gamma nail and augmentation was performed with two different cements: polymethylmethacrylate (PMMA) in 4 studies and calcium phosphate (CP) in one study. Overall, 57.5% of patients reached the same or greater preoperative mobility, and postoperative Parker Mobility Score and Harris Hip Score were acceptable. No significantly complications were observed, and no additional surgery related to the implant was required.

CONCLUSION

The results of this systematic review show that cement augmentation is a safe and effectiveness method of fixation to treat trochanteric fractures.

Predictors and reduction techniques for irreducible reverse intertrochanteric fractures

BACKGROUND

Reverse intertrochanteric fractures are usually initially treated with closed reduction. However, sometimes these fractures are not amenable to closed reduction and require open reduction. To date, few studies have been conducted on predictors of and reduction techniques for irreducible reverse intertrochanteric fractures. Therefore, this study aimed to summarize the displacement patterns of irreducible reverse intertrochanteric fractures and corresponding reduction techniques, and explore predictors of irreducibility.

METHODS

We reviewed 1174 cases of trochanteric fractures treated in our hospital from January 2006 to October 2018, 113 of which were reverse intertrochanteric fractures. An irreducible fracture was determined according to intra-operative fluoroscopy imaging after closed manipulation. Fractures were assessed for displacement patterns, radiographic features of irreducibility, and reduction techniques. Logistic regression analysis was performed on potential predictors for irreducibility, including gender, age, body mass index, AO Foundation/Orthopaedic Trauma Association (AO/OTA) classification, and radiographic features.

RESULTS

Seventy-six irreducible fractures were identified, accounting for 67% of reverse intertrochanteric fractures. Six patterns of fracture displacement after closed manipulation were identified; the most common pattern was medial displacement and posterior sagging of the femoral shaft relative to the head-neck fragment. Multivariate logistic regression analysis identified three predictors of irreducibility: a medially displaced femoral shaft relative to the head-neck fragment on the anteroposterior (AP) view (odds ratio [OR], 8.00; 95% confidence interval [CI], 3.04-21.04; P < 0.001), a displaced lesser trochanter (OR, 3.61; 95% CI, 1.35-9.61; P = 0.010), and a displaced lateral femoral wall (OR, 2.92; 95% CI, 1.02-8.34; P = 0.046).

CONCLUSIONS

A high proportion of reverse intertrochanteric fractures are not amenable to closed reduction. Six patterns of fracture displacement after closed manipulation were identified. Different reduction techniques are required for different displacement patterns. Predictors of irreducibility include a medially displaced femoral shaft relative to the head-neck fragment on the AP view, a displaced lesser trochanter, and a displaced lateral femoral wall. These patients warrant special consideration in terms of recognition and management.

Risk factors for implant failure in reverse oblique and transverse intertrochanteric fractures treated with proximal femoral nail antirotation (PFNA)

BACKGROUND

The incidence of intertrochanteric hip fracture is expected to increase as the global population ages. It is one of the most important causes of mortality and morbidities in the geriatric population. The incidence of reverse oblique and transverse intertrochanteric (AO/OTA 31-A3) fractures is relatively low; however, the incidence of implant failure in AO/OTA 31-A3 fractures is relatively high compared with that in AO/OTA 31-A1 and A2 fractures. To date, the risk factors for implant failure in AO/OTA 31-A3 fractures treated with proximal femoral nail antirotation (PFNA) have remained ambiguous. The purpose of this study was to identify the predictive factors of implant failure in AO/OTA 31-A3 fractures treated with PFNA.

METHODS

The data of all patients who underwent surgery for trochanteric fractures at our institution between January 2006 and February 2018 were retrospectively reviewed. All AO/OTA 31-A3 fractures treated with PFNA were included. Logistic regression analysis of potential predictors of implant failure was performed. Potential predictors included age, sex, body mass index, fracture type, reduction method, status of posteromedial support and lateral femoral wall, reduction quality, tip-apex distance and position of the helical blade in the femoral head.

RESULTS

One hundred four (9.3%) patients with AO/OTA 31-A3 fractures were identified. Forty-five patients with AO/OTA 31-A3 fractures treated with PFNA were suitable for our study. Overall, implant failure occurred in six (13.3%) of forty-five patients. Multivariate analysis identified poor reduction quality (OR, 28.70; 95% CI, 1.91-431.88; p = 0.015) and loss of posteromedial support (OR, 18.98; 95% CI, 1.40-257.08; p = 0.027) as factors associated with implant failure.

CONCLUSIONS

Poor reduction quality and loss of posteromedial support are predictors of implant failure in reverse oblique and transverse intertrochanteric fractures treated with PFNA.

Comparison of Baumgaertner and Chang reduction quality criteria for the assessment of trochanteric fractures

Objectives

Different criteria for assessing the reduction quality of trochanteric fractures have been reported. The Baumgaertner reduction quality criteria (BRQC) are relatively common and the Chang reduction quality criteria (CRQC) are relatively new. The objectives of the current study were to compare the reliability of the BRQC and CRQC in predicting mechanical complications and to investigate the clinical implications of the CRQC.

Methods

A total of 168 patients were assessed in a retrospective observational study. Clinical information including age, sex, fracture side, American Society of Anesthesiologists (ASA) classification, tip-apex distance (TAD), fracture classification, reduction quality, blade position, BRQC, CRQC, bone quality, and the occurrence of mechanical complications were used in the statistical analysis.

Results

A total of 127 patients were included in the full analysis, and mechanical complications were observed in 26 patients. The TAD, blade position, BRQC and CRQC were significantly associated with mechanical complications in the univariate analysis. Only the TAD (p = 0.025) and the CRQC (p < 0.001) showed significant results in the multivariate analysis. In the comparison of the receiver operating characteristic curves, the CRQC also performed better than the BRQC.

Conclusion

The CRQC are reliable in predicting mechanical complications and are more reliable than the BRQC. Future studies could use the CRQC to assess fracture reduction quality. Intraoperatively, the surgeon should refer to the CRQC to achieve good reduction in trochanteric fractures.

Cite this article: Bone Joint Res 2019;8:502–508.

Predictors of cut-out after cephalomedullary nail fixation of pertrochanteric fractures: a retrospective study of 813 patients

BACKGROUND

Cut-out is the most common mechanical complication of the osteosynthesis of pertrochanteric fractures. This complication determines a significant increase in morbidity in elderly patient. Cut-out is defined as the varus collapse of the femoral head-neck fragment with the extrusion of the cephalic screw. Surgical treatment of cut-out might lead to further complications, longer rehabilitation, increased social burden and healthcare system costs. The aim of the study is to identify the predictors of cut-out to prevent its occurrence.

MATERIALS AND METHODS

Study population included all patients affected by extracapsular fracture of the proximal femur who were admitted and treated with short cephalomedullary nailing at the Cattinara Hospital-ASUITS of Trieste between 2009 and 2014. A retrospective analysis of clinical and radiographic data was carried out and cut-out cases recorded. The data collected on the study population were analyzed to find an eventual correlation with the occurrence of cut-out. The independent variables were age, gender, side of the fracture, ASA class, Evans classification, nailing system, quality of reduction, TAD, CalTAD, and Parker ratio.

RESULTS

The study population counted 813 cases, with an F:M ratio of 4:1 and a mean age of 84.7 years. The cut-out was recorded in 18 cases (2.2%). There was no statistically significant association between cut-out and age, sex, side of fracture, ASA class, and nailing system. The Evans classification, the quality of reduction, the TAD, the CalTAD, and the Parker's ratio demonstrated a significant correlation at univariate analysis with cut-out. The results of multivariate analysis confirmed that TAD, Parker AP, and quality of reduction were independently significantly correlated to cut-out.

CONCLUSION

The results of the present study demonstrate that good quality of reduction and correct position of the lag screw are likely to decrease the risk of cut-out complication. A nomogram for cut-out prediction is proposed for clinical validation.

Blood loss in trochanteric fractures: multivariate analysis comparing dynamic hip screw and Gamma nail

INTRODUCTION

Anaemia in patients with trochanteric fracture is associated with increased morbidity and mortality and it is an independent risk factor for functional mobility of patients. Several authors have reported the blood loss following operative treatment comparing different fixation systems but few authors have evaluated many associated variables that could influence the perioperative blood loss.

PURPOSE

To evaluate the blood loss in patients that had their trochanteric fracture stabilized with dynamic hip screw (DHS) or Gamma nail. Multivariate analysis of different variables that can influence blood loss was carried out (type of fracture, antiaggregant or anticoagulant therapy, time to surgery). The hypothesis was that there is no difference in terms of blood loss in patients with trochanteric fracture treated with DHS or Gamma nail considering all these variables.

MATERIALS & METHODS

Perioperative blood loss was evaluated in 417 consecutive patients treated for trochanteric fracture with DHS or Gamma nail between January 2010 and March 2013. The perioperative blood loss was calculated using the Lisander formula modified by Foss-Kehlet based on pre- and post-operative haemoglobin values and transfusion rates. Univariate and multivariate analysis were performed integrating the following variables: type of fracture (A1 vs A2), antiaggregant/anticoagulant therapy vs no therapy, time to surgery (<24 vs >24 hours from trauma), type of implant (DHS vs Gamma nail).

RESULTS

A significant blood loss (p <0.05) was observed between A1 and A2 fracture types (1247ml vs 1796.7ml), antiaggregant/anticoagulant therapy and no therapy (1592.7ml vs 1470.2ml), time-to-surgery <24 and >24 hours from trauma (1584.4ml vs 1323.9ml), DHS and Gamma nail (894.7ml vs 1720.6ml). At multivariate analysis, in the A1 fracture groups the DHS showed a significant lower blood loss compared to Gamma nail (p < 0.05).

CONCLUSIONS

According to the perioperative blood loss, DHS should be used in A1 fractures while Gamma nail can be taking in account for the unstable A2 fractures.

Outcomes of dynamic hip screw augmented with trochanteric wiring for treatment of unstable type A2 intertrochanteric femur fractures

BACKGROUND

Posteromedial and greater trochanteric fragments are a major cause of telescoping and medialization of the femoral shaft in an unstable intertrochanteric fracture. This leads to significant limb shortening, fracture collapse in varus position and implant failure, which can be prevented by trochanteric wiring in addition to dynamic hip screw (DHS) fixation. The purpose of our study is to assess the outcomes of DHS augmented with trochanteric wiring in unstable type A2 intertrochanteric fractures.

MATERIALS AND METHODS

One hundred and two retrospective cases of unstable intertrochanteric fractures treated with DHS between January 2010 and December 2015 with a minimum follow-up period of 12 months were reviewed. Out of 102 cases, 28 were treated with DHS and derotation screw alone (Group A), while in rest 74 cases trochanteric wiring was used as an augmentation to DHS and derotation screw (Group B). Patients were evaluated clinically for range of motion, Harris hip score and Oxford hip score. Radiologically, fracture reduction, change in neck shaft angle and neck length ratio in comparison to opposite hip and union status of greater trochanter were assessed.

RESULTS

The mean age of the patients at the time of surgery was 72 years (range 23-94 years) with 48 males and 54 females. The mean follow-up period was 20 months (range 12-48 months). The Harris hip score, Oxford hip score, shortening, attainment of weight bearing and change in neck shaft angle was not significantly different between the two groups (all p values >0.05). Incidence of greater trochanter nonunion was greater in group A (17.85%) as compared to group B (6.75%). We found significant association between occurrence of limp with varus change in neck shaft angle, decrease in neck length ratio and greater trochanteric non-union (all p values <0.05). We had 7 complications, one superficial infection, one deep vein thrombosis, 4 screw cut out and one deep infection treated with implant removal.

CONCLUSION

DHS augmented with trochanteric wiring in unstable intertrochanteric fractures gives similar result to group without no wiring, although greater trochanter non-union rate was more in the latter group. Limp can be prevented by anatomical or valgus fixation, augmentation of DHS to support posteromedial and greater trochanteric fragments and delayed weight bearing.

DHS osteosynthesis with internal bone grafting in unstable delayed presented intracapsular neck femur fractures

OBJECTIVES

The aim of this study was to assess fracture union and complications following use of dynamic hip screw (DHS) with internal bone grafting in treatment of unstable delayed presented intracapsular neck femur fractures in patients younger than 65 years of age.

MATERIAL AND METHODS

Thirty two patients with displaced intracapsular neck femur fractures(Garden III and IV, Pauwels III, with comminution) with delayed presentation (15-60 days) in the 45-65 year age group (mean 54.4±10.2 years) were included in this study. All patients were treated with dynamic sliding hip screw with closed cancellous bone grafting through a tunnel of a triple reamer. The average time to union was 3.8 months (3-5 months). Satisfactory union was achieved in all patients except two. One case developed avascular necrosis of the femoral head. Other complications were coxa vara in two, shortening of less than 10mm in three cases but there were no cases of infection or implant failure. Excellent results were achieved in 27, good/fair in 4 and poor in 1 patient.

CONCLUSION

Osteosynthesis with DHS and primary cancellous bone grafting in indicated cases is a simple, providing biological stimulation for early union. Failure in a particular case can be treated with any appropriate second procedure.

Unstable trochanteric fractures: Issues and avoiding pitfalls

The incidence of trochanteric fractures is rising because of increasing number of senior citizens with osteoporosis. There are various modalities for reduction and internal fixation. However, the incidence of complications remains high. In the herein article we discuss issues that influence the fixation and outcomes of unstable trochanteric fractures. Moreover, the results of a prospective, randomised, cohort, time bound, hospital based, comparative study is presented.