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Tien D, Chang WC, Cheng MF, Hsu KH, Su YP. The role of postoperative piriformis fossa and greater trochanter tubercle distance to predict cutout failure after cephalomedullary nail fixation. J Chin Med Assoc 2024; 87:179-188. [PMID: 38095570 DOI: 10.1097/jcma.0000000000001035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND This study investigated the association between postoperative piriformis fossa and greater trochanter tubercle distance (distance from the deepest point of piriformis fossa to the most lateral greater trochanter tubercle [PG]) and cutout failure after cephalomedullary nail (CMN) osteosynthesis for intertrochanter fracture (ITF). A rotating femur model was designed to analyze PG variation during femur rotation. METHODS From 2005 to 2010, 311 patients diagnosed of ITF (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association [AO/OTA] 31-A2 and A3) underwent CMN fixation at our institute were reviewed. Of these, 281 (90.3%) patients achieved union without complication, 21 (6.8%) had cutout failure, six (1.9%) had femoral head osteonecrosis, and three (1%) had nonunion during postoperative 2-year follow-up. The side difference of postoperative PG compared to contralateral uninjured hip (dPG) was analyzed between patients who had cutout failure and those who did not. In the rotating femur model, the PG was measured for every 2.5° increments of internal and external rotation from 0° to 50°. RESULTS The dPG was significantly higher in the failure group (10.2 ± 4.2 vs 6.6 ± 3.5 mm, p <0.001). The odds ratio for lag screw cutout was 6.35 (95% CI, 1.10-11.6, p =0.003) for every 1 mm dPG increment. dPG exhibited high diagnostic performance in predicting cutout failure according to receiver operating characteristic curve analysis. The area under the curve was 0.774 (95% CI, 0.711-0.837). dPG yielded the greatest sensitivity (78.4%) and specificity (78.4%) to predict lag screw cutout when cutoff value being 8.65 mm. In rotating femur model, PG change from baseline demonstrated significant ( p <0.001) positive and negative correlation with increased external and internal rotation, respectively. CONCLUSION Increased dPG is a risk factor of cutout failure for ITF osteosynthesis with CMN. In conjunction with tip-apex distance, fracture displacement, and reduction quality; dPG can help surgeons interpret postoperative radiograph and predict failure. However, it should be noticed that a proper and standard patient positioning is critical for accurate dPG measurement.
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Affiliation(s)
- Derming Tien
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Wen-Chieh Chang
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Ming-Fai Cheng
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Kuei-Hsiang Hsu
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Yu-Ping Su
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Orthopaedics, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
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Reis JPG, Lopes AL, Branco RJ, Sapage R, Sousa RA, Sousa D. Trochanteric fractures: Tip-Apex distance, Calcar Tip-Apex distance, and Chang criteria-a multiple variable analysis. Arch Orthop Trauma Surg 2023; 143:7035-7041. [PMID: 37561166 DOI: 10.1007/s00402-023-05018-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 07/25/2023] [Indexed: 08/11/2023]
Abstract
Failure of osteosynthesis is a common complication of the nailing of trochanteric fractures which typically occurs through form of cut-out. Tip-Apex distance (TAD), Calcar Tip-Apex distance (CalTAD), and Chang criteria are validated variables to predict failure of cephalomedullary nailing. This is a retrospective study which analyzes treatment of trochanteric fractures from 2018 to 2020 (n = 296) evaluating postoperative radiographs and factors of mechanical failure. Our objective was to assess correlation among these variables and their influence on mechanical failure, either individually or creating a new score. Our results support the CalTAD and Chang's criteria as valid predictors of mechanical failure. Furthermore, they empathize the importance of fracture reduction and proper placement of cervical screw. To our knowledge, this is the first study performing multivariate analysis including these 3 variables.
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Affiliation(s)
| | | | | | - Rita Sapage
- Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | | | - Diogo Sousa
- Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal
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Selim A, Al-Hadithy N, Diab NM, Ahmed AM, Kader KFA, Hegazy M, Azeem HA, Barakat AS. Proposal of a modified tip apex distance for prediction of lag screw cut-out in trochanteric hip fractures. SICOT J 2023; 9:28. [PMID: 37737668 PMCID: PMC10515705 DOI: 10.1051/sicotj/2023026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 08/12/2023] [Indexed: 09/23/2023] Open
Abstract
INTRODUCTION Lag screw cut-out is a serious complication of dynamic hip screw fixation of trochanteric hip fractures. The lag screw position has been acknowledged as one of the important factors affecting the lag screw cut-out. We propose a modification of the Tip Apex Distance (TAD) and hypothesise that it could improve the reliability of predicting lag screws cut-out in these injuries. MATERIALS AND METHODS A retrospective study was conducted for hip fracture entries in the period from Jan 2018 to July 2022. A hundred and nine patients were suitable for the final analysis. The modified TAD was measured in millimetres based on the sum of the traditional TAD in the lateral view and the net value of two distances in the AP view, the first distance is from the tip of the lag screw to the opposite point on the femoral head along the axis of the lag screw while the second distance is from that point to the femoral head apex. The first distance is a positive value, whereas the second distance is positive if the lag screw is superior and negative if inferior. A receiver operating characteristic curve was used to evaluate the reliability of the different parameters assessing the lag screw position within the femoral head. RESULTS Reduction quality, fracture pattern as per the AO/OTA classification, TAD, Calcar Referenced TAD, Axis Blade Angle, Parker's ration in the AP view, Cleveland Zone 1, and modified TAD were statistically associated with lag screw cut-out. Among the tested parameters, the modified TAD had 90.1% sensitivity and 90.9% specificity for lag screw cut-out at a cut-off value of 25 mm with a P-value < 0.001. CONCLUSION The modified TAD had the highest reliability in the prediction of lag screw cut-out. A value ≤ 25 mm could potentially protect against lag screw cut-out in trochanteric hip fractures.
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Affiliation(s)
- Amr Selim
- Cairo University Hospitals Cairo 11562 Egypt
- Oswestry/Stoke, The Shrewsbury and Telford Trust TF1 6TF UK
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Li H, Wang D, Zhang W, Xu G, Xu C, Zhang H, Zhang L, Li J, Tang P. Does computer-assisted orthopaedics system (ADAPT system) improve outcomes of intertrochanteric hip fractures? Injury 2023; 54:1047-1054. [PMID: 36759309 DOI: 10.1016/j.injury.2023.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 01/29/2023] [Accepted: 02/02/2023] [Indexed: 02/11/2023]
Abstract
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.
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Affiliation(s)
- Hua Li
- Senior Department of Orthopedics, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, 100048, China; National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, China
| | - Daofeng Wang
- Senior Department of Orthopedics, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, 100048, China; National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, China
| | - Wupeng Zhang
- Senior Department of Orthopedics, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, 100048, China; National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, China; School of Medicine, Nankai University, No.94 Weijin Road, Tianjin, 300071, China
| | - Gaoxiang Xu
- Senior Department of Orthopedics, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, 100048, China; National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, China
| | - Cheng Xu
- Senior Department of Orthopedics, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, 100048, China; National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, China
| | - Hao Zhang
- Senior Department of Orthopedics, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, 100048, China; National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, China
| | - Licheng Zhang
- Senior Department of Orthopedics, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, 100048, China; National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, China.
| | - Jiantao Li
- Senior Department of Orthopedics, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, 100048, China; National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, China.
| | - Peifu Tang
- Senior Department of Orthopedics, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, 100048, China; National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, China.
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Yang YF, Huang JW, Gao XS, Xu ZH. Standardized Tip-Apex Distance (STAD): a modified individualized measurement of cephalic fixator position based on its own femoral head diameter in geriatric intertrochanteric fractures with internal fixation. BMC Musculoskelet Disord 2023; 24:189. [PMID: 36915071 PMCID: PMC10009924 DOI: 10.1186/s12891-023-06286-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 03/02/2023] [Indexed: 03/16/2023] Open
Abstract
OBJECTIVE To design a standardized Tip-Apex Distance (STAD) and analyze the clinical significance of STAD in predicting cut-out in geriatric intertrochanteric fractures with internal fixation. METHODS Firstly, we designed STAD according to the rule of TAD. We measured the STAD individually based on its own femoral head diameter (iFHD) instead of the known diameter of the lag screw in calculating TAD, resulting in that the STAD is simply the relative quantitation relationship of iFHD (the times of iFHD). In this study, we assumed that all the iFHD was 6D (1iFHD = 6D, or 1D = 1/6 of iFHD) in order for complete match of the Cleveland zone system, easy comparison of the STAD, and convenient identification for artificial intelligence. Secondly, we calculated and recorded all the STAD of cephalic fixator in 123 eligible ITF patients. Thirdly, we grouped all the ITF patients into the Failure and Non-failure groups according to whether cut-out or not, and analyzed the correlation between the cut-out and the STAD. RESULTS Cleveland zone, Parker's ratio (AP), TAD, and STAD were associated with the cut-out in univariate analysis. However, only STAD was the independent predictor of the cut-out by multivariate analysis. No cut-out was observed when STAD ≤ 2D (1/3 of iFHD). The Receiver Operating Characteristic (ROC) curve indicated that STAD was a reliable predictor of cut-out, and the best cut-off value of STAD was 2.92D. Cut-out rate increased dramatically when STAD increased, especially when STAD > 3D (1/2 of iFHD). CONCLUSION Essentially, the STAD is a relative quantitation relationship of iFHD. The STAD is a reliable measurement of cephalic fixator position in predicting cut-out in geriatric ITF patients with single-screw cephalomedullary nail fixations. For avoiding cut-out, the STAD should be no more than a half of iFHD. LEVEL OF EVIDENCE Level III, Prognostic Study.
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Affiliation(s)
- Yun-Fa Yang
- Department of Orthopaedic Surgery, the Second Affiliated Hospital, School of Medicine, Guangzhou First People's Hospital, South China University of Technology, 1 Panfu Road, 510180, Guangzhou, Guangdong, China.
| | - Jian-Wen Huang
- Department of Orthopaedic Surgery, the Second Affiliated Hospital, School of Medicine, Guangzhou First People's Hospital, South China University of Technology, 1 Panfu Road, 510180, Guangzhou, Guangdong, China
| | - Xiao-Sheng Gao
- Department of Orthopaedic Surgery, the Second Affiliated Hospital, School of Medicine, Guangzhou First People's Hospital, South China University of Technology, 1 Panfu Road, 510180, Guangzhou, Guangdong, China
| | - Zhong-He Xu
- Department of Orthopaedic Surgery, the Second Affiliated Hospital, School of Medicine, Guangzhou First People's Hospital, South China University of Technology, 1 Panfu Road, 510180, Guangzhou, Guangdong, China
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Tang L, Yi X, Yuan T, Li H, Xu C. Navigated intramedullary nailing for patients with intertrochanteric hip fractures is cost-effective at high-volume hospitals in mainland China: A markov decision analysis. Front Surg 2023; 9:1048885. [PMID: 36726954 PMCID: PMC9885142 DOI: 10.3389/fsurg.2022.1048885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 12/23/2022] [Indexed: 01/17/2023] Open
Abstract
Objective Previous studies have reported that navigation systems can improve clinical outcomes of intramedullary nailing (IMN) for patients with intertrochanteric fractures. However, information is lacking regarding the relationship between the costs of navigated systems and clinical outcomes. The present research aimed to evaluate the cost-effectiveness of navigated IMN as compared with traditional freehand IMN for patients with intertrochanteric fractures. Methods A Markov decision model with a 5-year time horizon was constructed to investigate the costs, clinical outcomes and incremental cost-effectiveness ratio (ICER) of navigated IMN for a 70-year-old patient with an intertrochanteric fracture in mainland China. The costs [Chinese Yuan (¥)], health utilities (quality-adjusted life-years, QALYs) and transition probabilities were obtained from published studies. The willingness-to-pay threshold for ICER was set at ¥1,40,000/QALY following the Chinese gross domestic product in 2020. Three institutional surgical volumes were used to determine the average navigation-related costs per patient: low volume (100 cases), medium volume (200 cases) and high volume (300 cases). Results Institutes at which 300, 200 and 100 cases of navigated IMN were performed per year showed an ICER of ¥43,149/QALY, ¥76,132.5/QALY and ¥1,75,083/QALY, respectively. Navigated IMN would achieve cost-effectiveness at institutes with an annual volume of more than 125 cases. Conclusions Our analysis demonstrated that the navigated IMN could be cost-effective for patients with inter-trochanteric fracture as compared to traditional freehand IMN. However, the cost-effectiveness was more likely to be achieved at institutes with a higher surgical volume.
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Affiliation(s)
- Liang Tang
- Department of Orthopaedics, Hengyang Central Hospital, The Affiliated Hengyang Hospital of Southern Medical University, Hengyang, China,Correspondence: Liang Tang Hua Li Cheng Xu
| | - Xiaoke Yi
- Department of Orthopaedics, Hengyang Central Hospital, The Affiliated Hengyang Hospital of Southern Medical University, Hengyang, China
| | - Ting Yuan
- Department of Orthopaedics, Hengyang Central Hospital, The Affiliated Hengyang Hospital of Southern Medical University, Hengyang, China
| | - Hua Li
- Senior Department of Orthopaedics, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, China,National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, China,Correspondence: Liang Tang Hua Li Cheng Xu
| | - Cheng Xu
- Senior Department of Orthopaedics, The Fourth Medical Center of Chinese PLA General Hospital, Beijing, China,National Clinical Research Center for Orthopedics, Sports Medicine and Rehabilitation, Beijing, China,Correspondence: Liang Tang Hua Li Cheng Xu
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Predictors of and predictive nomogram for cut-out of proximal femur nail anti-rotation device in intertrochanteric fractures. Arch Orthop Trauma Surg 2022:10.1007/s00402-022-04676-y. [PMID: 36348087 DOI: 10.1007/s00402-022-04676-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 10/25/2022] [Indexed: 11/09/2022]
Abstract
PURPOSE This study determined independent predictors and developed a predictive nomogram for failed correction of intertrochanteric fractures due to cut-out of the proximal femur nail anti-rotation (PFNA) device. METHODS Demographic and radiological data of 592 adult patients with intertrochanteric fractures (AO 31A) treated by PFNA were collected retrospectively. Independent predictors of cut-out were obtained through univariate and multivariate analyses, and a predictive nomogram was established. The discrimination, calibration, and clinical utility of the nomogram were based on receiver operating characteristic curve (AUC), concordance index (C-index), calibration curve, and decision curve analysis, respectively. RESULTS Overall, 18 (3.04%) cases of cut-out occurred. Independent predictors according to the multivariate analysis were body mass index (BMI), poor-to-acceptable quality of reduction, PFNA blade position, and tip-apex distance (TAD). AUC of the nomogram was 0.849, and C-index was 0.849 (95% CI [0.844-0.854]). Bootstrapping yielded a corrected C-index of 0.849. The calibration and decision curves indicated good agreement and clinical benefit of the nomogram. CONCLUSION A reliable predictive nomogram was developed for cut-out of the PFNA in intertrochanteric fractures, based on BMI, quality of reduction, blade position, and TAD.
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Hernández-Pascual C, Santos-Sánchez JÁ, Hernández-Rodríguez J, Silva-Viamonte CF, Pablos-Hernández C, Villanueva-Martínez M, Mirón-Canelo JA. New Prognostic Factors in Operated Extracapsular Hip Fractures: Infection and GammaTScore. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:11680. [PMID: 36141949 PMCID: PMC9517159 DOI: 10.3390/ijerph191811680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 09/12/2022] [Accepted: 09/14/2022] [Indexed: 06/16/2023]
Abstract
There is no universal postoperative classification of extracapsular hip fractures (ECFs). We wondered if infection (according to infection after fracture fixation criteria (IAFF)), immediate partial weight bearing (PWB) and/or the new GammaTScore tool could predict early cut-out. We also examined the correlation between GammaTScore and time to consolidation and studied long-term survival. This was a retrospective cohort study of low-energy complete ECFs operated with Gamma3T nailing in 2014 and fully monitoring, in patients aged over 65. Ten not distally locked cases, one late cut-out, one cut-through, one osteonecrosis and one pseudarthrosis were discarded. Patients were classified into early cut-out (7/204; 3.55%) and no early cut-out (197/204; 96.45%). There was a lower percentage of A2 fractures according to the AO Foundation/Orthopaedic Trauma Association classification (AO/OTA, 1997) in early cut-out. IAFF and only the GammaTScore reduction parameter were different for early cut-out, in opposition to immediate PWB, tip-to-apex distance (TAD) or the Baumgaertner-Fogagnolo classification. GammaTScore inversely correlated with consolidation (p < 0.01). Long-term survival time was not statistically significantly lower in the early cut-out group. Small sample of cases may limit our results. Apart from an important role of IAFF, GammaTScore would be useful for predicting consolidation, avoiding complications and reducing costs. Further studies are needed for reliability.
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Affiliation(s)
- Carlos Hernández-Pascual
- Department of Human Anatomy and Histology, Faculty of Medicine, Campus Miguel de Unamuno, Universidad de Salamanca, Avda, Alfonso X el Sabio s/n, 37007 Salamanca, Spain
- Department of Traumatology and Orthopaedic Surgery, Hospital Universitario de Salamanca, Pso. San Vicente 58-182, 37004 Salamanca, Spain
| | - José Ángel Santos-Sánchez
- Department of Biomedical and Diagnostic Sciences (Area of Radiology and Physical Medicine), Faculty of Medicine, Campus Miguel de Unamuno, Universidad de Salamanca, Avda, Alfonso X el Sabio s/n, 37007 Salamanca, Spain
| | - Jorge Hernández-Rodríguez
- Department of Biomedical and Diagnostic Sciences (Area of Radiology and Physical Medicine), Faculty of Medicine, Campus Miguel de Unamuno, Universidad de Salamanca, Avda, Alfonso X el Sabio s/n, 37007 Salamanca, Spain
| | - Carlos Fernando Silva-Viamonte
- Department of Statistics, Faculty of Medicine, Campus Miguel de Unamuno, Universidad de Salamanca, Avda, Alfonso X el Sabio s/n, 37007 Salamanca, Spain
| | - Carmen Pablos-Hernández
- Department of Geriatrics, Hospital Universitario de Salamanca, Pso. San Vicente 58-182, 37004 Salamanca, Spain
| | | | - José Antonio Mirón-Canelo
- Department of Preventive Medicine and Public Health, Faculty of Medicine, Campus Miguel de Unamuno, Universidad de Salamanca, Avda, Alfonso X el Sabio s/n, 37007 Salamanca, Spain
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Xu Z, Tian G, Liu C, Xie Y, Zhang R. The predictive value of the Singh index for the risk of InterTAN intramedullary fixation failure in elderly patients with intertrochanteric fractures. BMC Musculoskelet Disord 2022; 23:769. [PMID: 35962387 PMCID: PMC9373533 DOI: 10.1186/s12891-022-05741-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 08/04/2022] [Indexed: 11/10/2022] Open
Abstract
Background To investigate the predictive value of the Singh index for the risk of InterTAN intramedullary fixation failure in elderly patients with intertrochanteric fracture to guide clinical treatment. Methods A total of 360 patients were divided into the Singh (I ~ II) (n = 120), Singh (III ~ IV) (n = 120) and Singh (V ~ VI) (n = 120) groups. Visual analog scale (VAS) and Harris scores were recorded at 1, 6, 12, 18 and 24 months after the operation. The correlation between the Singh index and the T-score of the total hip and femoral neck was analyzed. Logistic regression was used to analyze the relationship between the Singh index and internal fixation failure; the types of internal fixation failure were also analyzed. Results The Harris scores of the Singh (I ~ II) group were lower than those of the Singh (III ~ IV) and Singh (V ~ VI) groups 12, 18 and 24 months after surgery (P < 0.05). The Singh index was significantly correlated with the T-score of the total hip and femoral neck (P = 0.00, r = 0.89; P = 0.00, r = 0.83). The Singh (I ~ II) group had the lowest internal fixation survival rate within 24 months (P = 0.01). The Singh index was an independent predictor of internal fixation failure (P < 0.05). Lag screw cutting-out was the main type of internal fixation failure in the three groups (P = 0.00). Conclusion The Singh index is significantly correlated with the bone mineral density of the femoral neck and total hip. The Singh (I ~ II) group had lower Harris scores and a lower internal fixation survival rate than the other two groups. The Singh index is an independent predictor of internal fixation failure, especially lag screw cutting-out, after InterTAN fixation. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-022-05741-8.
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Affiliation(s)
- Zhe Xu
- Department of Orthopaedics, General Medical 300 Hospital, Guiyang, 550004, China.,National-Local Joint Engineering Laboratory of Cell Engineering and Biomedicine, Guiyang, 550004, China
| | - Guang Tian
- Department of Orthopaedics, General Medical 300 Hospital, Guiyang, 550004, China
| | - Chen Liu
- Department of Orthopaedics, General Medical 300 Hospital, Guiyang, 550004, China
| | - Yangjiang Xie
- Department of Orthopaedics, General Medical 300 Hospital, Guiyang, 550004, China
| | - Ruguo Zhang
- Department of Orthopaedics, General Medical 300 Hospital, Guiyang, 550004, China.
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Huang JW, Gao XS, Yang YF. Risk factors for cut-outs in geriatric intertrochanteric fractures with cephalomedullary nailing after obtaining acceptable reduction: a case-control study. BMC Musculoskelet Disord 2022; 23:354. [PMID: 35414068 PMCID: PMC9004191 DOI: 10.1186/s12891-022-05296-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 04/01/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND It is irresponsible if we disregard reduction quality to talk about cut-outs in intertrochanteric fractures (ITF) with internal fixation. The aim of this study is to analyze the risk-factors for cut-outs in geriatric ITF with cephalomedullary nailing after obtaining acceptable reduction. METHODS In order to investigate the risk-factors for cut-outs in geriatric ITF after obtaining acceptable reduction, we retrospectively reviewed 367 patients who underwent cephalomedullary nail for ITF in our department between September 2016 and December 2021. Potential variables including demographic data and radiological parameters (namely the fracture type, Singh index, lateral wall fracture, cephalic nail position, Parker's ratio index, tip-apex-distance (TAD), and calcar-referenced TAD (CalTAD)) were collected. Logistic regression analysis was performed to identify the significant risk factors for cut-outs. RESULTS One hundred twenty-one patients were suitable for this study. Of the 121 cases, nine cases (7.4%) were observed with cut-out or pending cut-out. We found that Age (adjusted odds ratio (OR) 1.158, 95% confidence interval (CI) 1.016 to 1.318, p = 0.028), lateral wall fracture (adjusted OR 11.07, 95%CI 1.790 to 68.380, p = 0.01), and CalTAD (adjusted OR 1.277, 95%CI 1.005 to 1.622, p = 0.045) were independent risk-factors for cut-outs. CONCLUSIONS Age, lateral wall fracture and CalTAD are independent risk-factors for cut-outs in geriatric ITF with cephalomedullary nailing after obtaining acceptable reduction. In order to avoid cut-outs, an optimal CalTAD is necessary even obtaining acceptable reduction, especially in the over-aged patients with lateral wall fracture.
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Affiliation(s)
- Jian-Wen Huang
- Department of Orthopaedic Surgery, Guangzhou First People's Hospital, the Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou, Guangdong, 510180, People's Republic of China
| | - Xiao-Sheng Gao
- Department of Orthopaedic Surgery, Guangzhou First People's Hospital, the Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou, Guangdong, 510180, People's Republic of China
| | - Yun-Fa Yang
- Department of Orthopaedic Surgery, Guangzhou First People's Hospital, the Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangzhou, Guangdong, 510180, People's Republic of China.
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11
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Yang YF, Huang JW, Gao XS. CalTAD is the Key Evaluation Tool for Measurement of Cephalic Fixation Position for Predicting Cut-Out in Geriatric Intertrochanteric Fracture Patients with Internal Fixations after Achieving Acceptable Reduction. Geriatr Orthop Surg Rehabil 2022; 13:21514593221083820. [PMID: 35386949 PMCID: PMC8977687 DOI: 10.1177/21514593221083820] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 02/02/2022] [Accepted: 02/09/2022] [Indexed: 11/16/2022] Open
Abstract
Objective To discover the key evaluation tool of the cephalic fixation position for
predicting implant failures in geriatric intertrochanteric fracture (ITF)
patients treated with internal fixations after achieving an acceptable
reduction. Methods We measured the geriatric ITF patients undergoing single-screw
cephalomedullary nailing (CMN) fixation surgery after obtaining the
acceptable reduction (including anatomical reduction and positive medial
cortex support reduction) in our treatment group between September 2016 and
March 2020 by using four kinds of cephalic fixation position evaluation
tools including Cleveland zone system, Parker’s ratio index, tip–apex
distance (TAD), calcar-referenced TAD (CalTAD), and analyzed which were the
key evaluation tools for measurement of cephalic fixation position for
prediction of implant failures in geriatric ITF patients with internal
fixations. Results Seventy-four ITF patients treated with single-screw CMN fixation after
obtaining the acceptable reduction were enrolled in this study. Of the 74
patients, nine cases were observed with implant failures. There were six
cases of cut-out and three of pending cut-out. We found that TAD (odds ratio
(OR)=1.149; 95% confidence interval (CI), 1.00–1.32; P=.046) and CalTAD
(OR=1.140; 95% CI, 1.00–1.30; P=.037) were risk factors for implant failures
by univariate analysis, while only CalTAD (OR=1.200; 95% CI, 1.032–1.395;
P=.018) was the independent risk factor for implant failures by multivariate
analysis. The Kappa coefficient (κ) of CalTAD was .976 (95% CI, .966–.984)
by ICC analysis. The ROC analysis showed that the best cut-off value of
CalTAD was 23.76 mm with a sensitivity of 77.8% and specificity of 72.3%
(area under the curve, AUC =.775; P = .001). Conclusions CalTAD is the key evaluation tool for measurement of cephalic fixation
position for predicting implant failures in geriatric ITF patients treated
with single-screw CMN after obtaining the acceptable reduction.
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Affiliation(s)
- Yun-Fa Yang
- Department of Orthopaedic Surgery, Guangzhou First People's Hospital, the Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangdong, China
| | - Jian-Wen Huang
- Department of Orthopaedic Surgery, Guangzhou First People's Hospital, the Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangdong, China
| | - Xiao-Sheng Gao
- Department of Orthopaedic Surgery, Guangzhou First People's Hospital, the Second Affiliated Hospital, School of Medicine, South China University of Technology, Guangdong, China
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12
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Caruso G, Corradi N, Caldaria A, Bottin D, Lo Re D, Lorusso V, Morotti C, Valpiani G, Massari L. 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. Sci Rep 2022; 12:357. [PMID: 35013492 PMCID: PMC8748913 DOI: 10.1038/s41598-021-04252-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 12/20/2021] [Indexed: 11/30/2022] Open
Abstract
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.
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Affiliation(s)
- Gaetano Caruso
- Department of Neurosciences and Rehabilitation, University of Ferrara, Via Aldo Moro 8, 44124, Ferrara, Italy. .,Orthopaedic and Traumatology Unit, S. Anna University Hospital of Ferrara, Ferrara, Italy.
| | - Nicola Corradi
- Department of Neurosciences and Rehabilitation, University of Ferrara, Via Aldo Moro 8, 44124, Ferrara, Italy.,Orthopaedic and Traumatology Unit, S. Anna University Hospital of Ferrara, Ferrara, Italy
| | - Antonio Caldaria
- Department of Neurosciences and Rehabilitation, University of Ferrara, Via Aldo Moro 8, 44124, Ferrara, Italy.,Orthopaedic and Traumatology Unit, S. Anna University Hospital of Ferrara, Ferrara, Italy
| | - Daniele Bottin
- Orthopaedic and Traumatology Unit, S. Anna University Hospital of Ferrara, Ferrara, Italy
| | - Dario Lo Re
- Department of Neurosciences and Rehabilitation, University of Ferrara, Via Aldo Moro 8, 44124, Ferrara, Italy.,Orthopaedic and Traumatology Unit, S. Anna University Hospital of Ferrara, Ferrara, Italy
| | - Vincenzo Lorusso
- Orthopaedic and Traumatology Unit, S. Anna University Hospital of Ferrara, Ferrara, Italy
| | - Chiara Morotti
- Research and Innovation Office, S. Anna University Hospital of Ferrara, Ferrara, Italy
| | - Giorgia Valpiani
- Research and Innovation Office, S. Anna University Hospital of Ferrara, Ferrara, Italy
| | - Leo Massari
- Department of Neurosciences and Rehabilitation, University of Ferrara, Via Aldo Moro 8, 44124, Ferrara, Italy.,Orthopaedic and Traumatology Unit, S. Anna University Hospital of Ferrara, Ferrara, Italy
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13
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Trochanteric fractures treated by internal fixation using short intramedullary nails: Does the visual intraoperative estimation of the Tip-Apex Distance (TAD) concur with its digital postoperative measurement? Orthop Traumatol Surg Res 2021; 107:103001. [PMID: 34216841 DOI: 10.1016/j.otsr.2021.103001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 01/08/2021] [Accepted: 02/01/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION The tip-apex distance (TAD) is the only predictor for mechanical failure after internal fixation of trochanteric fractures. The main objective of our study was to assess whether the intraoperative visual estimation of the TAD concurred with the measurement taken on postoperative digital X-rays. We hypothesized that there was a good concordance between these 2 different methods of measurement. MATERIALS AND METHODS Patients with an isolated trochanteric fracture were included in our study. A hardcopy of the intraoperative X-rays were printed, and the TAD was calculated manually. Radiological and clinical follow-ups were scheduled at 6 weeks, 3 months and 6 months during which numerical measurements of the TAD were taken. We also recorded the fracture type (AO/OTA classification), degree of osteoporosis (Singh index), surgeon experience, age and ASA score. RESULTS A total of 98 patients were included in our study. Of these, 70 had a 6-month follow-up and interpretable postoperative X-rays. The mean age was 87 years, with 77.14% women and a mean ASA score of 3. The coefficient of concordance between the intra and postoperative TAD was 0.7202 (95% CI=0.4905-0.9499). The secondary displacement rate was 3.28%. The univariate analysis showed no statistically significant association between an intraoperative TAD>25mm and fracture type (p=0.7290), degree of osteoporosis (p=0.5701) and surgeon experience (p=1). DISCUSSION/CONCLUSIONS There was a high degree of concordance between intraoperative visual estimation of the TAD and its measurement on postoperative digital X-rays. The treatment of unstable fractures in osteoporotic bone by junior surgeons was not a risk factor for intraoperative TAD>25mm. It is therefore important to educate young surgeons on the concept of TAD and its intraoperative visual estimation technique as it ensures that the cephalic screw is positioned properly during the fixation of trochanteric fractures. LEVEL OF EVIDENCE II.
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14
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Gargano G, Poeta N, Oliva F, Migliorini F, Maffulli N. Zimmer Natural Nail and ELOS nails in pertrochanteric fractures. J Orthop Surg Res 2021; 16:509. [PMID: 34407829 PMCID: PMC8371819 DOI: 10.1186/s13018-021-02634-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 07/26/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pertrochanteric fractures of the femur in the elderly are very common. As the average age of the population increases, the incidence of such fractures also raises, resulting in high healthcare costs. The type of surgical devices employed for their surgical management influences these costs. METHODS A comparative clinical study was conducted on patients operated by one single surgeon between December 2018 and November 2020 in a high-volume regional referral centre. All patients who received a Zimmer Natural Nail (ZNN) or ELOS devices were included. RESULTS In 119 (66.48%) of the 179 fractures, a ZNN nail was used. Post-operatively, the TAD (tip-to-apex distance) was measured at an average value of 17.05 (4.42-41.85) mm and the CalTAD (calcar-referenced TAD) at an average of 20.76 (10.82-43.63) mm. The mean hospitalization time was 10.19 (4-22) days. In the other 60 trochanteric fractures, an ELOS nail was used. Post-operative imaging indicated a TAD of 19.65 (5.08-31.4) mm and a CalTAD of 22.86 mm (12.66-33.77). The average time of the operation was 45.82 (20-110) min. The average period of hospitalization was 10.45 (5-24) days. CONCLUSION Both devices give similar results in terms of short-term post-operative outcome and hospitalization. The price difference between the devices does not translate in different short-term results on the operated patients.
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Affiliation(s)
- Giuseppe Gargano
- Department of Trauma and Orthopaedic Surgery, AOU San Giovanni Di Dio E Ruggi D'Aragona, Via San Leonardo 1, 84131, Salerno, Italy.,Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy
| | - Nicola Poeta
- Department of Trauma and Orthopaedic Surgery, AOU San Giovanni Di Dio E Ruggi D'Aragona, Via San Leonardo 1, 84131, Salerno, Italy.,Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy
| | - Francesco Oliva
- Department of Trauma and Orthopaedic Surgery, AOU San Giovanni Di Dio E Ruggi D'Aragona, Via San Leonardo 1, 84131, Salerno, Italy.,Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy
| | - Filippo Migliorini
- Department of Orthopedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, 52074, Aachen, Germany.
| | - Nicola Maffulli
- Department of Trauma and Orthopaedic Surgery, AOU San Giovanni Di Dio E Ruggi D'Aragona, Via San Leonardo 1, 84131, Salerno, Italy.,Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy.,Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, 275 Bancroft Road, London, E1 4DG, England.,School of Pharmacy and Bioengineering, Keele University School of Medicine, Thornburrow Drive, Stoke on Trent, England
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15
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Takai H, Mizuta K, Murayama M, Nakayama D, Kii S, Hayai C, Takahashi T. Comparing the usefulness of a fluoroscopic navigation system in femoral trochanteric fracture for orthopaedic residents with the conventional method. Injury 2020; 51:1840-1845. [PMID: 32540179 DOI: 10.1016/j.injury.2020.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 04/29/2020] [Accepted: 06/01/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Lag screw insertion into the ideal position is essential to obtain good results in open reduction and internal fixation for femoral trochanteric fracture. Tip-apex distance (TAD) is a widely adopted method for evaluating the risk of lag screw cut-out. Adaptive positioning technology (ADAPT) is a fluoroscopic computer-assisted surgery system that enables orthopaedic surgeons to guide the screw into a proper position intraoperatively. A randomized control study concluded that ADAPT resulted in excellent TAD. However, it was not significantly better than conventional methods when performed by fellowship-trained traumatologists. Therefore, we hypothesised that ADAPT would be useful to orthopaedic residents and evaluated this usefulness. METHODS We reviewed 102 patients who underwent open reduction and internal fixation for femoral trochanteric fracture from May 2017 to March 2019 using Gamma-3 intertrochanteric nails. Two residents performed all procedures; 51 patients underwent surgery using ADAPT and the others underwent surgery without navigation. The number of attempts to drill guide-wire, operation time, lag screw insertion time, radiation exposure time, TAD, and lag screw position were evaluated for each surgeon. RESULTS In one resident, when using the ADAPT system, the number of attempts to drill guide-wire (p=0.001), lag screw insertion time (p=0.000), radiational exposure time (p=0.009) and TAD (p=0.007) were lower, and the percentage of ideal lag screw position (p=0.035) were better than that in the conventional method. However, there was no significant difference in the performance of another resident with respect to the aforementioned factors, whether using ADAPT or not. CONCLUSION One resident showed better results with the ADAPT system than with conventional osteosynthesis. However, another resident received no benefit from ADAPT. The efficiency may not apply to everyone as individual competence can influence efficiency when using ADAPT system. Therefore, as a new device, it must be used cautiously because skill or experience may influence its use, especially by orthopaedic residents.
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Affiliation(s)
- Hirokazu Takai
- Department of Orthopaedic Surgery, Kumamoto Kinoh Hospital, Kumamoto, Japan.
| | - Kazutaka Mizuta
- Department of Orthopaedic Surgery, Kumamoto Kinoh Hospital, Kumamoto, Japan
| | - Masatoshi Murayama
- Department of Orthopaedic Surgery, Kumamoto Kinoh Hospital, Kumamoto, Japan
| | - Daisuke Nakayama
- Department of Orthopaedic Surgery, Kumamoto Kinoh Hospital, Kumamoto, Japan
| | - Sakumo Kii
- Department of Orthopaedic Surgery, Kumamoto Kinoh Hospital, Kumamoto, Japan
| | - Chihiro Hayai
- Imaging Diagnostic Center, Kumamoto Kinoh Hospital, Kumamoto, Japan
| | - Tomoki Takahashi
- Department of Orthopaedic Surgery, Kumamoto Kinoh Hospital, Kumamoto, Japan
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