Cement augmentation of the Proximal Femur Nail Antirotation (PFNA) is associated with enhanced weight-bearing in older adults

Safety of Cement-augmented Femoral Cephalomedullary Nails: A Meta-analysis and Systematic Review

Trochanteric fractures of the femur pose an increasing burden for elderly people. The standard treatment for these types of fractures includes cephalomedullary nailing, which can be augmented with cement. Although many studies have reported on the stability of this augmented construct, few studies have examined its clinical benefit and safety. Therefore, the objective of this meta-analysis is to examine the perioperative complications and postoperative mortality associated with cement-augmented nails in the management of intertrochanteric and pertrochanteric fractures of the hip. A search of PubMed, Cochrane, and Google Scholar (pages 1-20) until January 2024 was conducted. Analysis of the outcomes included perioperative complications and postoperative mortality. Seven studies were included in this meta-analysis. Fewer perioperative complications were observed when using a cemented femoral nail (P=0.002), although there was no difference in postoperative mortality (P=0.30). This meta-analysis is the first to assess the safety of a cement-augmented femoral nail in management of intertrochanteric and pertrochanteric fractures. The results showed a reduced rate of perioperative complications, which may be attributed to a more a solid construct, which reduced the duration of postoperative immobilization as well as use of a proper augmentation technique, resulting in a reduced rate of cement-associated complications.

Construction and validation of a nomogram prediction model for factors affecting hip functional recovery after PFNA internal fixation of intertrochanteric femur fractures in the elderly

A nomogram prediction model was developed with the aim of identifying and analyzing which independent risk factors affect the recovery of hip function in elderly patients with intertrochanteric femur fractures after undergoing proximal femoral anti-rotation intramedullary nailing (PFNA) internal fixation. We collected detailed data on elderly patients with intertrochanteric femur fractures from January 2018 to December 2022 in a tertiary hospital in China. By applying univariate and multivariate logistic regression analysis, we systematically screened and identified the independent risk factors affecting the recovery of hip function after PFNA internal fixation. Based on these risk factors, we further constructed a corresponding nomogram prediction model. In order to comprehensively evaluate the predictive performance of the model, we not only plotted the receiver operating characteristic curve and calculated the area under the curve, but also produced the calibration curve and decision curve. Of the total 646 patients included, 510 patients had good hip function recovery and were categorized as the excellent hip function group, while the other 136 patients had poor hip function recovery and were categorized as the poor hip function group. After rigorous unifactorial and multifactorial logistic regression analyses, we identified 5 key risk factors, which were: fracture instability, posterolateral wall type III, posterolateral wall thickness less than or equal to 2 cm, cusp distance >25 mm, and delayed postoperative weight-bearing. Together, these factors constitute the main risk factors affecting the recovery of hip function after PFNA internal fixation of intertrochanteric femur fractures in the elderly. In this study, a nomogram prediction model for the recovery of hip function after PFNA internal fixation of intertrochanteric femur fractures in the elderly was successfully constructed, and the model demonstrated good prediction accuracy. This not only provides a powerful tool for orthopedic surgeons so that they can identify and intervene in advance with risk factors that may affect patients' hip functional recovery, but also provides a scientific basis for developing more precise and personalized treatment strategies.

Proximal femoral fractures in the elderly. Does cement augmentation decrease mechanical failures and increase function? A retrospective cohort study

INTRODUCTION

The management of extracapsular proximal femoral fractures (EPFF) with intramedullary nails in the elderly is hindered by osteoporosis, leading to complications that significantly impact functionality due to restrictions for full weight-bearing. We hypothesized that cement augmentation of the cephalic blade could enhance the bone-implant interface and reduce mechanical failure, thereby improving patient functionality in the management of EPFF.

MATERIALS AND METHODS

A retrospective cohort study was conducted on patients ≥ 70 years old with type 31-A EPFF (AO/OTA classification) treated with intramedullary nailing between 2017 and 2021, with and without cephalic blade augmentation with bone cement. Evaluation included demographic, clinical/functional parameters, complications, mortality, and radiological assessment (tip-apex distance (TAD), position of the helical blade, cut-out, cut-through, and any fixation failure).

RESULTS

Fifty-eight patients were included, with 30 in the augmented group and 28 in the non-augmented group, with a median age of 88 and 86 years, respectively (p = 0.143), and a median follow-up of 17.9 and 18.2 months, respectively (p = 0.395). Both groups were comparable in terms of sex, Charlson Comorbidity Index, place of residence, pre-fracture mobility, and fracture stability. However, the non-augmented group showed worse ASA grade and pre-fracture cognitive status (p = 0.043). The most common position of the blade was center-center in both groups (96.7 % and 82.1 %, respectively) (p = 0.201). The mean TAD was 15.09 mm (±4.35) in the study group and 16.97 mm (±6.57) in the control group (p = 0.213). At one-year follow-up, there were no differences in medical complications (26.7 % and 28.6 %) (p = 1), surgical complications (6.7 % and 10.7 %) (p = 0.462), mortality (33.3 % and 21.4 %) (p = 0.385), or mechanical failure (0 % and 7.1 %) (p = 0.229). In the augmented group, one patient had intra-articular cement leak and implant infection, and a second patient presented avascular necrosis. In the non-augmented group, there was one periprosthetic fracture, one cut-out and one cut-through.

CONCLUSIONS

Cement augmentation in EPFF management does not improve functional outcomes or reduce mechanical complications. Furthermore, augmentation did not affect fracture reduction or the position of the helical blade in the head, nor was it associated with an increase in medical complications. However, augmentation can be considered a safe technique.

LEVEL OF EVIDENCE

Level IV.

Feasibility biomechanical study of injectable Biphasic Calcium Phosphate bone cement augmentation of the proximal femoral nail antirotation (PFNA) for the treatment of two intertrochanteric fractures using cadaveric femur

This study evaluated the feasibility of the femoral bone after fixation using biphasic calcium phosphate cement-augmentation of the proximal femoral nail antirotation (PFNA) compared with PFNA without cement. This study presented to compare the stiffness, fatigue testing, and compressive strength between stable (AO31-A2.1) and unstable (AO31-A3.3) intertrochanteric fractures treated by cement augmented PFNA of the cadaveric femoral. Biphasic calcium phosphate cement was injected to align and compatible with PFNA and the reconstructive procedure was monitored the cement placement using x-ray imaging during operation. The testing demonstrated that the cement could be injected through a small needle (13 G, 16 cm length, 1.8 mm inner diameter) within a suitable operating time. The feasibility study of the biomechanical testing was divided into three tests: stiffness test, fatigue cyclic load, and compression test. The results showed that the cement-augmented specimens exhibited higher stiffness than the control specimens without cement. The cement-augmented specimens also showed lower strain energy during the fatigue test, resulting in higher compressive strength (4730.7 N) compared to the control specimens (3857.4 N). There is a correlation between BMD and fracture load and the increase in compression load of the cement-augmented femoral compared to the controls as well as an increase in strain energy of fatigue cyclic testing was found. Biphasic calcium phosphate cement-augmented of the PFNA biomechanically enhanced the cut-out resistance in intertrochanteric fracture. This procedure is especially efficient for unstable intertrochanteric fracture suggesting the potential benefits of using biphasic calcium phosphate cement in medical applications.

Finite element study on the micromechanics of cement-augmented proximal femoral nail anti-rotation (PFNA) for intertrochanteric fracture treatment

Blade cut-out is a common complication when using proximal femoral nail anti-rotation (PFNA) for the treatment of intertrochanteric fractures. Although cement augmentation has been introduced to overcome the cut-out effect, the micromechanics of this approach remain to be clarified. While previous studies have developed finite element (FE) models based on lab-prepared or cadaveric samples to study the cement-trabeculae interface, their demanding nature and inherent disadvantages limit their application. The aim of this study was to develop a novel 'one-step forming' method for creating a cement-trabeculae interface FE model to investigate its micromechanics in relation to PFNA with cement augmentation. A human femoral head was scanned using micro-computed tomography, and four volume of interest (VOI) trabeculae were segmented. The VOI trabeculae were enclosed within a box to represent the encapsulated region of bone cement using ANSYS software. Tetrahedral meshing was performed with Hypermesh software based on Boolean operation. Finally, four cement-trabeculae interface FE models comprising four interdigitated depths and five FE models comprising different volume fraction were established after element removal. The effects of friction contact, frictionless contact, and bond contact properties between the bone and cement were identified. The maximum micromotion and stress in the interdigitated and loading bones were quantified and compared between the pre- and post-augmentation situations. The differences in micromotion and stress with the three contact methods were minimal. Micromotion and stress decreased as the interdigitation depth increased. Stress in the proximal interdigitated bone showed a correlation with the bone volume fraction (R2 = 0.70); both micromotion (R2 = 0.61) and stress (R2 = 0.93) at the most proximal loading region exhibited a similar correlation tendency. When comparing the post- and pre-augmentation situations, micromotion reduction in the interdigitated bone was more effective than stress reduction, particularly near the cement border. The cementation resulted in a significant reduction in micromotion within the loading bone, while the decrease in stress was minimal. Noticeable gradients of displacement and stress reduction can be observed in models with lower bone volume fraction (BV/TV). In summary, cement augmentation is more effective at reducing micromotion rather than stress. Furthermore, the reinforcing impact of bone cement is particularly prominent in cases with a low BV/TV. The utilization of bone cement may contribute to the stabilization of trabecular bone and PFNA primarily by constraining micromotion and partially shielding stress.

Proximal Femur Fractures - How Decisive are Reduction and the Chosen Implant?

Proximal femoral fractures are frequent and complex injuries requiring prompt and targeted care. Numerous treatment strategies have been described, some of which have been assessed and clinically implemented clinically. The aim of surgical is always the restoration of a pain-free and stable extremity. Mostly elderly patients are affected and treatment is associated with high postoperative complications and mortality rates. With increasing numbers of patients, the topic is of great medical and economic relevance. In this work, the choice of implants for the osteosynthesis of proximal femoral fractures - as depending on the fracture type - will be examined, as based on a review of current literature. Standard care includes cannulated screws, sliding hips screws and cephalomedullary nails. In addition, the influence of implant positioning, fracture reduction and additional measures such as cement augmentation are evaluated and discussed. Careful fracture reduction and the quality of implant positioning are paramount in order to avoid complications.

Nail fixation of unstable trochanteric fractures with or without cement augmentation: A cost-utility analysis in the United States: Cost-utility of cement augmentation

OBJECTIVES

Recent clinical studies have shown favorable outcomes for cement augmentation for fixation of trochanteric fracture. We assessed the cost-utility of cement augmentation for fixation of closed unstable trochanteric fractures from the US payer's perspective.

METHODS

The cost-utility model comprised a decision tree to simulate clinical events over 1 year after the index fixation surgery, and a Markov model to extrapolate clinical events over patients' lifetime, using a cohort of 1,000 patients with demographic and clinical characteristics similar to that of a published randomized controlled trial (age ≥75 years, 83 % female). Model outputs were discounted costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (ICER) over a lifetime. Deterministic and probabilistic sensitivity analyses were performed to assess the impact of parameter uncertainty on results.

RESULTS

Fixation with augmentation reduced per-patient costs by $754.8 and had similar per-patient QALYs, compared to fixation without augmentation, resulting in an ICER of -$130,765/QALY. The ICER was most sensitive to the utility of revision surgery, mortality risk ratio after the second revision surgery, mortality risk ratio after successful index surgery, and mortality rate in the decision tree model. The probability that fixation with augmentation was cost-effective compared with no augmentation was 63.4 %, 58.2 %, and 56.4 %, given a maximum acceptable ceiling ratio of $50,000, $100,000, and $150,000 per QALY gained, respectively.

CONCLUSION

Fixation with cement augmentation was the dominant strategy, driven mainly by reduced costs. These results may support surgeons in evidence-based clinical decision making and may be informative for policy makers regarding coverage and reimbursement.

Failure of Fixation in Trochanteric Hip Fractures: Does Nail Design Matter?

OBJECTIVE

The objective of this study was to compare clinical outcomes of patients with trochanteric hip fractures treated with specific different cephalomedullary nail (CMN) designs.

METHODS

A scoping review of the English literature was performed. Inclusion criteria were studies comparing perioperative and postoperative outcomes of trochanteric hip fractures fixated by CMNs for one of the following CMN designs: short versus long nails, blade versus screw fixation, dual versus single lag screw fixation, and application of cement augmentation. Inclusion criteria consisted of human comparative clinical trials (randomized and observational). Exclusion criteria included noncomparative studies, studies comparing CMN with non-CMN devices or with arthroplasty, studies with less than 3 months follow-up, studies that did not provide relevant clinical outcome measures, biomechanical, finite element analyses, animal, or in vitro publications. Data regarding reoperations, peri-implant fractures, mechanical failure, nonunion, infection rates, and functional outcomes were reviewed.

RESULTS

Twenty-two studies met the inclusion criteria and formed the basis of this study. Failure of fixation rates and reoperation rates for each of the nail designs selected for evaluation is presented, in addition to specific outcome measures relevant to that nail design which was explored: peri-implant fracture-short versus long nails, and specific mechanism of failure-blade versus plate.

CONCLUSIONS

Decreased failure of fixation and reoperations rates were found for integrated dual lag screw fixation. Similar fixation failure and reoperation rates were found for the long versus short nails and for blade versus screw fixation.

LEVEL OF EVIDENCE

Diagnostic, Level IV.

Augmentation in fragility fractures, bone of contention: a systematic review

BACKGROUND

Osteoporosis is a complex multifactorial disease characterized by reduced bone mass and microarchitectural deterioration of bone tissue linked to an increase of fracture risk. Fragility fractures occur in osteoporotic subjects due to low-energy trauma. Osteoporotic patients are a challenge regarding the correct surgical planning, as it can include fixation augmentation techniques to reach a more stable anchorage of the implant, possibly lowering re-intervention rate and in-hospital stay.

METHODS

The PubMed database and the Google Scholar search engine were used to identify articles on all augmentation techniques and their association with fragility fractures until January 2022. In total, we selected 40 articles that included studies focusing on humerus, hip, spine, and tibia.

RESULTS

Literature review showed a quantity of materials that can be used for reconstruction of bone defects in fragility fractures in different anatomic locations, with good results over the stability and strength of the implant anchorage, when compared to non-augmented fractures.

CONCLUSION

Nowadays there are no recommendations and no consensus about the use of augmentation techniques in osteoporotic fractures. Our literature review points at implementing the use of bone augmentation techniques with a specific indication for elderly patients with comminuted fractures and poor bone quality.

Biomechanical analysis of recently released cephalomedullary nails for trochanteric femoral fracture fixation in a human cadaveric model

BACKGROUND

Recently, two novel concepts for intramedullary nailing of trochanteric fractures using a helical blade or interlocking dual screws have demonstrated advantages as compared to standard single-screw systems. However, these two concepts have not been subjected to a direct biomechanical comparison so far. The aims of this study were to investigate in a human cadaveric model with low bone quality (1) the biomechanical competence of nailing with the use of a helical blade versus interlocking screws, and (2) the effect of cement augmentation on the fixation strength of the helical blade.

METHODS

Twelve osteoporotic and osteopenic human cadaveric femoral pairs were assigned for pairwise implantation using either a short TFN-ADVANCED Proximal Femoral Nailing System (TFNA) with a helical blade head element or a short TRIGEN INTERTAN Intertrochanteric Antegrade Nail (InterTAN) with interlocking screws. Six osteoporotic femora, implanted with TFNA, were augmented with bone cement. Four groups were created: group 1 (TFNA) paired with group 2 (InterTAN), both consisting of osteopenic specimens, and group 3 (TFNA augmented) paired with group 4 (InterTAN), both consisting of osteoporotic specimens. An unstable trochanteric AO/OTA 31-A2.2 fracture was simulated and all specimens were tested until failure under progressively increasing cyclic loading.

RESULTS

Stiffness in group 3 was significantly higher versus group 4, p = 0.03. Varus (°) and femoral head rotation around the femoral neck axis (°) after 10,000 cycles were 1.9 ± 1.0/0.3 ± 0.2 in group 1, 2.2 ± 0.7/0.7 ± 0.4 in group 2, 1.5 ± 1.3/0.3 ± 0.2 in group 3 and 3.5 ± 2.8/0.9 ± 0.6 in group 4, being significantly different between groups 3 and 4, p = 0.04. Cycles to failure and failure load (N) at 5° varus or 10° femoral head rotation around the neck axis in groups 1-4 were 21,428 ± 6020/1571.4 ± 301.0, 20,611 ± 7453/1530.6 ± 372.7, 21,739 ± 4248/1587.0 ± 212.4 and 18,622 ± 6733/1431.1 ± 336.7, being significantly different between groups 3 and 4, p = 0.04.

CONCLUSIONS

Nailing of trochanteric femoral fractures with use of helical blades is comparable to interlocking dual screws fixation in femoral head fragments with low bone quality. Bone cement augmentation of helical blades provides significantly greater fixation strength compared to interlocking screws constructs.

Cost-Effectiveness of Cement Augmentation Versus No Augmentation for the Fixation of Unstable Trochanteric Fractures

BACKGROUND

A previous randomized controlled trial (RCT) demonstrated a trend toward a reduced risk of implant-related revision surgery following fixation with use of a Proximal Femoral Nail Antirotation (PFNA) with TRAUMACEM V+ Injectable Bone Cement augmentation versus no augmentation in patients with unstable trochanteric fractures. To determine whether this reduced risk may result in long-term cost savings, the present study assessed the cost-effectiveness of TRAUMACEM V+ cement augmentation versus no augmentation for the fixation of unstable trochanteric fractures from the German health-care payer's perspective.

METHODS

The cost-effectiveness model comprised 2 stages: a decision tree simulating clinical events, costs, and utilities during the first year after the index procedure and a Markov model extrapolating clinical events, costs, and utilities over the patient's lifetime. Sources of model parameters included the previous RCT, current literature, and administrative claims data. Outcome measures were incremental costs (in 2020 Euros), incremental quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). Model uncertainty was assessed with deterministic and probabilistic sensitivity analyses.

RESULTS

The base-case analysis showed that fixation with cement augmentation was the dominant strategy as it was associated with cost savings (€50.3/patient) and QALY gains (0.01 QALY/patient). Major influential parameters for the ICER were the utility of revision, rates of revision surgery within the first year after fixation surgery, and the costs of augmentation and revision surgery. Probabilistic sensitivity analyses demonstrated that estimates of cost savings were more robust than those of increased QALYs (66.4% versus 52.7% of the simulations). For a range of willingness-to-pay thresholds from €0 to €50,000, the probability of fixation with cement augmentation being cost-effective versus no augmentation remained above 50%.

CONCLUSIONS

Fixation with use of cement augmentation dominated fixation with no augmentation for unstable trochanteric fractures, resulting in cost savings and QALY gains. Given the input parameter uncertainties, future analyses are warranted when long-term costs and effectiveness data for cement augmentation are available.

LEVEL OF EVIDENCE

Economic and Decision Analysis Level II . See Instructions for Authors for a complete description of levels of evidence.

Effectiveness of Cement Augmentation on Early Postoperative Mobility in Patients Treated for Trochanteric Fractures with Cephalomedullary Nailing: A Prospective Cohort Study

Fixation using cephalomedullary nails (CMNs) with additional cement augmentation (CA) was developed as a novel treatment option for the osteosynthesis of osteoporotic trochanteric fractures, though the effectiveness of CA on early postoperative mobility remains uncertain. This multicenter prospective cohort study aimed to estimate the effectiveness of CA on early postoperative mobility in patients with trochanteric fractures. We enrolled patients with femoral trochanteric fractures aged >60 years who were able to walk independently before the injury. The primary outcome was the postoperative 3-day cumulated ambulation score (CAS); the secondary outcome was the visual analog scale (VAS) pain score at rest and during movement on postoperative days 1−3. The outcomes of the patients treated using CMNs with or without CA were compared. Sixty-three eligible patients were categorized into CA (n = 32) and control (n = 31) groups. In univariate analysis, the CA group had significantly higher CAS values, lower VAS scores at rest on day 1 postoperatively, and lower VAS scores during movement on day 3. In multivariable linear regression analyses, the CA group had significantly higher CAS values (beta, 2.1; 95% confidence interval, 0.5 to 3.6; p = 0.01). The CA group had a negative adjusted beta value in their VAS scores during movement. This study indicated that CA was associated with a high CAS value in patients with geriatric trochanteric fractures. However, CA was not associated with pain reduction at rest and during movement during the initial postoperative days.