Outcome of intertrochanteric fractures treated by intramedullary nail with two integrated lag screws: A study in Asian population

Long Versus Short Twin-Screw Integrated Cephalomedullary Nail (InterTAN) for the Surgical Management of Intertrochanteric Fractures of the Hip in Indians

INTRODUCTION

With an increasing life expectancy, there has been an increase in the incidence of intertrochanteric fractures. These fractures in the elderly are disabling and have a tremendous impact on the healthcare system. Despite substantial improvements in implant design and surgical techniques, high failure rates have been observed, varying with the severity of the fracture and the type of fixation. Intramedullary nails have become popular in recent times, especially in unstable fractures. The purpose of the present study is to compare the functional outcomes and complications of long versus short InterTAN cephalomedullary nails (Smith & Nephew, Memphis, Tennessee) used for intertrochanteric fracture fixation.

MATERIALS AND METHODS

All patients who had intertrochanteric fractures classifiable as AO OTA (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association) 31-A and were treated with either a short InterTAN nail (SIN) or long InterTAN nail (LIN) between March 2017 and March 2020 were retrospectively assessed. AO subtype A1 fractures are considered to be stable whereas subtype A3 fractures are considered unstable. The stability of subtype A2 fractures is variable depending on the amount of posteromedial comminution. Both stable and unstable fractures were included. Patients aged above 18 years, who had a normal pre-injury gait and were operated on within seven days of trauma as per the records were included in the study. Postoperatively, functional outcome recorded using the modified Harris hip score (mHHS) was compared. The minimum follow-up period was 24 months.

RESULTS

A total of 89 patients fulfilling the inclusion criteria were included. The mean age was 67.5 ± 8.92 years. Of the patients, 72% were above 60 years of age and 68% of those were females. The mean follow-up period was 31 months (range: 24-54 months). Of the patients, 84.27% sustained fractures after a trivial trauma due to slip and fall at home. All fractures had united at nine to 12 months, except one had a screw cut-out, which required revision surgery. The mean mHHS at three months and nine to 12 months postoperatively was 42.46 ± 3.62 and 87.24 ± 6.44, respectively. The patients who were treated with LIN had a significantly better functional outcome at three-month follow-up (p-value < 0.05); however, post one year, this effect plateaued and no significant difference was seen when comparing SIN with LIN. The results also showed that there was no significant difference in complications among SIN and LIN.

CONCLUSION

Both LIN and SIN are equally effective for the surgical management of intertrochanteric fractures, and have similar functional outcomes. SIN, however, has shorter surgical procedure time and lesser estimated blood loss. LIN allowed in early recovery evidenced by better Harris hip scores at three months duration, thus improving the quality of life in the initial months post surgery. The choice of implant should be individualized according to fracture anatomy, patients' needs and expectations, and surgeons' expertise.

Reoperation rates after proximal femur fracture fixation with single and dual screw femoral nails: a systematic review and meta-analysis

Purpose

Methods

Results

Conclusion

Evaluation of the Inter and Intra-Observer Reliability of the AO Classification of Intertrochanteric Fractures and the Device Choice (DHS, PFNA, and DCS) of Fixations

Background

ArbeitsgemeinschaftfürOsteosynthesefragen (AO) classification is the most frequently used tool to classify intertrochanteric fractures. However, there is limited evidence regarding its reliability. Therefore, this study was designed to evaluate inter-observer and intra-observer reliability of the AO-2018 intertrochanteric fracture classification.

Method

A retrospective study was conducted in Imam Khomeini Hospital Complex, on radiography of patients who came with intertrochanteric fractures from March 21, 2018, to March 19, 2019. Four orthopedic trauma surgeons assessed 96 anteroposterior pelvic radiographs of intertrochanteric fractures and classified using an AO intertrochanteric fracture classification of 2018. The reading and review of radiography were performed in 2 separate occasions in a 1-month interval. The inter-observer and intra-observer reliability was assessed using kappa statistics.

Result

The level of both mean inter-observer (K =0.322; 95%CI: 0.321–0.323) and intra-observer agreement (K =0.317; 95%CI: 0.314–0.320) in AO intertrochanteric fracture classification subgrouping were not satisfactory. The inter-observer (K =0.61; 95%CI: 0.608–0.611) and intra-observers' (K=0.560; 95%CI: 0.544–0.566) reliability in AO main groupings showed moderate agreement.

Conclusion

The AO classification does not show adequate and acceptable inter-observer and intra-observer reliability and reproducibility. Therefore, it will be hard to base on the AO classification for treatment protocols.

Biomechanical Comparison of INTERTAN Nail and Gamma3 Nail for Intertrochanteric Fractures

Objective

To compare the biomechanical stabilities of Gamma3 nail and INTERTAN nail (ITN) for stable (AO/OTA 31A1.1) and unstable (AO/OTA 31A2.2) femoral intertrochanteric fracture.

Methods

Twenty‐four synthetic femora were randomly divided into four groups. After internal fixation (Gamma3 nail or ITN) had been implanted, stable and unstable intertrochanteric fracture models were produced. A cyclic testing protocol with increasing loads was performed for both stable and unstable intertrochanteric fracture models, and then torsional test and axial compression failure test were conducted. Stiffness, failure load, torque, and fragment displacement were recorded.

Results

For stable fracture model: fragment displacement in ITN group were smaller than Gamma3 nail group (Gamma3 nail: 1.66 ± 0.13 mm; ITN: 1.55 ± 0.1 mm); stiffness (Gamma3 nail: 1142.6 ± 161.1 N/mm, ITN: 1159.3 ± 203.5 N/mm, P = 0.872) and failure load (Gamma3 nail: 5715.42 ± 616.34 N, ITN: 5690.27 ± 625.59 N, P = 0. 951) of the two nails were similar after cyclic test; torque of the ITN group was larger than the Gamma3 nail group. For unstable fracture model: fragment displacement in ITN group was significantly smaller than in the Gamma3 nail group when the axial load was larger than 800 N (Gamma3 nail: 3.59 ± 0.19 mm; ITN: 2.93 ± 0.28 mm); ITN group showed a significantly higher failure load than Gamma3 nail group (Gamma3 nail: 2942.77 ± 573.4 N, ITN: 3672.3 ± 790.5 N, P = 0. 011); torque was significantly higher for the ITN group compared to the Gamma3 nail group for three different angles.

Conclusions

Both ITN and Gamma3 nail can maintain sufficient biomechanical stability for stable intertrochanteric fractures, but ITN was a better choice for unstable intertrochanteric fractures.

Comparison of clinical outcomes with proximal femoral nail anti-rotation versus InterTAN nail for intertrochanteric femoral fractures: a meta-analysis

Background

A meta-analysis to access the pros and cons of proximal femoral nail anti-rotation (PFNA) versus InterTAN nail for intertrochanteric femoral fractures including available evidence extracted from literature.

Methods

According to the Cochrane systemic analysis method, randomized control trials (RCTs) and retrospective comparative observational studies which were related to the comparison of PFNA and InterTAN nail in the treatment of the elderly with intertrochanteric fractures were retrieved. Data were independently extracted from the included studies by two reviewers and analyzed using RevMan 5.3, and the quality of the studies was assessed.

Results

Two RCTs and seven observational studies were recruited, which consisted of 681 patients with PFNA and 651 patients with InterTAN nail. The meta-analyses showed no significant differences between the two approaches on Harris Hip Score, operation time, blood loss, time to union, mean hospital stay, union problems, intraoperative complications, hematoma, infection, and other complications in both RCTs and observational studies. In terms of other outcomes, for the RCTs, results showed that there were shorter tip–apex distance and reduced pain at thigh or hip in InterTAN nail than in PFNA; however, InterTAN nail was not superior to PFNA in cutout, reoperation, and femoral shaft fracture; for observational studies, the risk of the screw migration (RR = 5.13, 95%CI [1.33,19.75], P = 0.02), cutout (RR = 3.26, 95%CI [1.64,6.47], P = 0.0008), the varus collapse of the femoral head (RR = 7.19, 95%CI [2.18,23.76], P = 0.001), femoral shaft fracture (RR = 5.73, 95%CI [2.24,14.65], P = 0.0003) treated by InterTAN nail were significantly decreased, compared with those by PFNA; however, no significant differences were observed in the aspects of tip–apex distance and pain at thigh or hip between these two groups.

Conclusion

Analysis of a large number of relevant clinical indicators available shows that InterTAN nail has better clinical manifestation than PFNA in treating unstable femoral intertrochanteric fractures.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-020-02031-8.

Safety and efficacy of a two-screw cephalomedullary nail for intertrochanteric femur fracture fixation: a retrospective case series in 264 patients

Introduction

Recent advances have led to the design of a new cephalomedullary nail, which aims to decrease the risk of failures in patients with intertrochanteric hip fractures by allowing for insertion of two interdigitating screws into the head segment. The goal of this study is to evaluate the safety and efficacy of this two-screw cephalomedullary nailing system.

Patients/participants

Patients 18 years of age and older who underwent intramedullary nailing of their intertrochanteric femoral fracture using the InterTAN nailing system (Smith and Nephew, Memphis, TN) from 2012 to 2016 were included in this retrospective study which was performed at two urban certified level-1 trauma centers and one urban certified level-3 trauma center. The study data was collected through a retrospective chart review and review of the existing radiographic studies. Primary outcome measure was mechanical hardware failure and screw cutout. Secondary outcome measures included nonunion, malunion, medical and surgical complications.

Results

A total of 264 patients were included in this analysis. Two patients (0.75%) were found to have a screw cut out requiring revision surgery. Two other revision surgeries were performed for malrotation (n = 1) and malunion (n = 1). Other implant-related complications occurred in 19 cases (7.9%), which included broken distal screws (n = 9), distal screw loosening (n = 8), and loose lag screws (n = 2). There was a total of 10 (3.8%) surgical wound complications, including four deep and six superficial infections.

Discussion

This modified cephalomedullary nail is a reliable, safe, and effective implant for management of intertrochanteric hip fractures. Surgical treatment of patients with intertrochanteric hip fractures can be performed in a safe fashion using this implant.

Z-effect after intramedullary nailing systems for trochanteric femur fractures

PURPOSE

The aim of this study was to investigate the incidence of Z-effect after dual lag screw intramedullary nailing systems and risk factors contributing to this effect. We hypothesized that long nails provide more neck strength due to a longer lever than short nails and are therefore less likely to develop a misbalance of a higher head compressive strength than neck compressive strength.

METHODS

In this retrospective cohort study 103 patients treated operatively with a dual lag screw intramedullary nailing device for (sub)trochanteric hip fracture were included. We analysed patient charts regarding patient and operation characteristics. Furthermore we conducted radiologic measurements within the 2-year follow-up period to investigate the quality of fracture fixation, implant failure and predictors for Z-effect. The re-operation risk was investigated with multivariate regression analysis.

RESULTS

The incidence of (reversed) Z-effect in this study was 9% (n = 80); 6 out of 7 Z-effects occurred in the short nail group, which was not significant. Patients who were treated with a long nail had a significant larger number of complications in comparison with the short nail group (median 2 vs 0.5, p = 0.001). The long nail group received more often erythrocytes blood transfusions (82% vs 31%, p < 0.01) and had a longer hospital stay (13 vs 21 days, p < 0.05). Migration of lag screws (p <0.05) and unstable fracture type (p < 0.05), were risk factors for re-operation. The re-operation rate within 2 year after surgery was 21%, of which one fourth was due to a Z-effect.

CONCLUSION

The nail length was not associated with the development of a Z-effect. Migration of lag screws after intramedullary nailing is common and a risk factor for re-operation.

Comparison of clinical outcomes with InterTan vs Gamma nail or PFNA in the treatment of intertrochanteric fractures: A meta-analysis

Intertrochanteric fractures are common injuries in the elderly. Conventional intramedullary nails including Gamma 3 locking nail and proximal femoral nail antirotation (PFNA) were designed for unstable intertrochanteric fractures. The InterTan (IT) nail system, introduced in 2005, has been reported superior biomechanical and clinical outcomes compared with 1-screw nailing system. However, some recent studies have reported that IT did not improve functional recovery in patients with intertrochanteric fractures. Randomized controlled trials (RCTs) or prospective cohort studies were included in our meta-analysis. We used the PRISMA guidelines and Cochrane Handbook to evaluate the quality of included studies to ensure that the pooled data of our meta-analysis were reliable and veritable. Our pooled data analysis demonstrated that IT was as effective as the control group in terms of Harris Hip Score (HHS), blood loss, total complications, union time, length of hospital stay, revision rate, and fluoroscopy time. IT shows less implant cut-out rate and femoral fractures when compared with control groups.

Dual head screw hip nailing for trochanteric fractures

INTRODUCTION

There are limited information and inconclusive results for dual head screw intramedullary hip nails for trochanteric fractures. Therefore, we performed a prospective study to evaluate the healing of fractures, and survival, function, and complications of patients operated with this implant.

METHODS

We prospectively studied 79 patients (61 women and 18 men; mean age: 84.7 years; range: 65-96 years) with a low-energy trochanteric fracture, treated with a dual head screw intramedullary hip nail from 2013 to 2016. The mean follow-up was 2.1 years (range: 1-3 years); seven patients were lost to follow up. This left 72 patients for further analysis. We evaluated the healing of fractures, and survival, function, and complications of patients.

RESULTS

Fracture healing was evident in 70 patients (97.2%) at 2-3 months postoperatively. One patient experienced cut-out and z-effect phenomenon of the head screws. Another patient experienced a periprosthetic femoral diaphysis fracture at the distal tip of the nail. A third patient experienced an acute postoperative superficial skin infection that was treated successfully with wound dressing changes and a course of antibiotics. Sixteen patients (22.2%) deceased within 12 months postoperatively. In the remaining patients, the Harris Hip Score (HHS) at 12 months postoperatively was excellent in 16 (28.6%), good in 23 (41.1%), fair in 10 (17.8%), and poor in 7 patients (12.5%). The function declined after the patients' fracture. Fair and poor results were related to age > 85 years, poor pre-fracture level of function, and AO/OTA-31-A3 fracture types.

CONCLUSION

The dual head screw intramedullary hip nail is associated with high healing and low complication rates for intertrochanteric fractures. The function of the patients is good or excellent in most cases; however, it declines, especially for those patients with age > 85 years, poor pre-fracture level of function, and AO/OTA-31-A3 fracture types.

INTERTAN nail versus proximal femoral nail antirotation-Asia for intertrochanteric femur fractures in elderly patients with primary osteoporosis

Objectives To compare the long-term functional and radiographic outcomes of the proximal femoral nail antirotation-Asia (PFNA-II) and INTERTAN nail (IT) in the management of intertrochanteric femoral fractures (IFFs) (AO/OTA Type 31A1.1-A2.3) in elderly patients with primary osteoporosis. Methods A retrospective comparative study was performed in our institution. From January 2009 to March 2012, 243 patients with osteoporosis (243 hips) with IFFs (AO/OTA Type 3.1A1.1-A2.3) underwent repair with either a PFNA-II or IT. Follow-up assessments were performed 1, 3, 6, 9, and 12 months postoperatively and every year thereafter. All implant position changes were noted. Patient-related functional outcomes were evaluated based on the Harris hip score. Results In total, 174 patients with osteoporosis (IT, n = 86; PFNA-II, n = 88) were evaluated during a mean follow-up period of 40 months (range, 38-60 months). An increased risk of femoral shaft fracture after implant removal was observed at month 9 of follow-up in 0.0% and 4.4% of the IT and PFNA-II groups, respectively. This difference remained over time with rates of 1.1% and 6.8%, respectively, at the last follow-up. Conclusion The IT nail appears to be a reliable implant in the management of IFFs (AO/OTA Type 3.1A1.1-A2.3) in elderly patients with primary osteoporosis.

Proximal femoral nail antirotation versus dynamic hip screw fixation for treatment of osteoporotic type 31-A1 intertrochanteric femoral fractures in elderly patients

Objective To evaluate long-term radiographic and functional outcomes between dynamic hip screw (DHS) and proximal femoral nail antirotation (PFNA) fixation for treatment of osteoporotic type 31-A1 intertrochanteric femoral fractures (IFFs) among elderly patients Methods A retrospective comparative study was carried out. Follow-up was performed at 1, 3, 6, 9, and 12 months postoperatively and yearly thereafter. The primary outcome was the radiographic outcome, and the secondary outcome was the functional outcome. Results A significant difference in radiographic complications was observed between the DHS group (n = 45, 40.2%) and PFNA group (n = 15, 13.6%). The risk of femoral shaft fracture after implant removal at the 1-year follow-up was increased by 0.9% (n = 1) and 6.3% (n = 7) in the PFNA and DHS groups, respectively. This difference persisted with rates of 3.6% (n = 4) and 12.5% (n = 14) at the final follow-up. Additionally, significant differences were present in the Harris hip score at each visit. Conclusion Our results indicate that PFNA yields better outcomes than DHS fixation among elderly patients with osteoporotic type 31-A1 IFFs.

A retrospective analysis of the InterTan nail and proximal femoral nail anti-rotation-Asia in the treatment of unstable intertrochanteric femur fractures in the elderly

BACKGROUND

The purpose of this study was to compare the clinical outcomes of elderly patients undergoing surgery for treatment of unstable trochanteric fractures receiving either proximal femoral nails anti-rotation-Asia (PFNA-IIs) or InterTan nails (ITs).

METHODS

Between January 1, 2012, and June 31, 2015, 168 elderly patients with unstable intertrochanteric femur fractures enrolled in this study. The only intervention was ITs or PFNA-IIs of the unstable trochanteric femur fractures. Follow-up was at 1, 3, 6, and 12 months postoperatively and yearly thereafter. Intraoperative variables and postoperative complications were compared between the two groups.

RESULTS

Eight patients died, six were too infirmed for follow-up, and seven were lost during follow-up, leaving 147 patients meeting the criteria were evaluated at a mean follow-up of 20 months (range 16-26 months). Significant differences were observed between the two groups regarding local complications (IT, n = 10 vs. PFNA-II, n = 20), varus collapse of the head/neck or femoral shaft fractures at the tip of the nail (IT, n = 1 vs. PFNA-II, n = 8), femoral neck shortening (IT, 4.4 ± 1.1 mm vs. PFNA-II, 7.4 ± 2.4 mm), fracture healing time (IT, 14.7 ± 2.1 weeks vs. PFNA-II, 15.7 ± 2.4 weeks), femoral shaft fractures (IT, n = 0 vs. PFNA-II, n = 4), rotational loss of reduction (IT, n = 0 vs. PFNA-II, n = 9), lateral cortex fractures of the proximal femur or lateral greater trochanter fractures (IT, n = 8 vs. PFNA-II, n = 1), operative time (IT, 71.9 ± 6.8 min vs. PFNA-II, 52.3 ± 4.0 min), intraoperative blood loss (IT, 190.6 ± 6.0 mL vs. PFNA-II, 180.9 ± 10.8 mL), fluoroscopy time (IT, 5.0 ± 0.48 min vs. PFNA-II, 2.8 ± 0.33 min), hospital stay (IT, 9.65 ± 0.95 days vs. PFNA-II, 8.58 ± 0.93 days), cut-out (IT, n = 0 vs. PFNA-II, n = 6), and tip-apex distance (IT, 26.7 ± 0.91 mm vs. PFNA-II, 23.2 ± 1.22 mm). No significant differences existed for the other observation indexes (p > 0.05).

CONCLUSIONS

The IT nail may have more advantage for patients with unstable intertrochanteric fractures of the femur. However, for those complicated with lateral greater trochanter fractures, lateral cortex fractures of the proximal femurs, or unfit for surgery, the PFNA-II nail could be a good option. In addition, a large-sample, multicenter observational study is required for evaluation of its long-term efficacy, and optimal management strategies for specific unstable fracture patterns, different sorts of bone quality, and different levels of patient demand.