Incidence and predictive factors of problems after fixation of trochanteric hip fractures with sliding hip screw or intramedullary devices

Abstract

Introduction: Hip fractures are common and disabling injuries, usually managed surgically. The most common type outside the joint capsule are trochanteric fractures, usually fixed with either sliding hip screw or intramedullary nail. Data are available in the National Hip Fracture Database (NHFD) on early failure and other major complications, but late or subtler complications may escape recording. This study sought to quantify such problems after fixation performed at 3different sites and identify their predictors. Methods: Patients with a trochanteric fracture treated at 1 of 3 sites were identified from the NHFD over a 3-year period. Any with further, related episodes of care were identified, and reasons recorded, then age- and sex-matched with those with no such episodes. Data was collected on Arbeitsgemeinschaft für Osteosynthesefragen classification, tip-apex distance, American Society of Anesthesiologists (ASA) grade, Abbreviated Mental Test Score and pre-injury mobility. The cohorts were compared, and a binomial logistic regression model used to identify predictors of problems. Results: A total of 4010 patients were entered in the NHFD across 3 sites between January 2013 and December 2015. Of these, 1260 sustained trochanteric fractures and 57 (4.5%) subsequently experienced problems leading to re-presentation. The most common was failure of fixation, occurring in 22 patients (1.7%). The binomial logistic regression model explained 47.6% of the variance in incidence of postoperative problems with ASA grade and tip-apex distance being predictive. Discussion: The incidence of re-presentation with problems was around of 5%. A failure rate of less than 2% was seen, in keeping with existing data. This study has quantified the incidence of subtler postoperative problems and identified their predictors. The type of implant used was not amongst them and patients with both implants experienced problems. Fixation continues to yield imperfect results, but patient health and robust surgical technique remain important factors in a good outcome.

Is new always better: comparison of the femoral neck system and the dynamic hip screw in the treatment of femoral neck fractures

“…The relative risk for cut out significantly increased sevenfold for none optimal blade positioning. Despite that, multiple studies already showed an increased rate of cut out with blade position deviating from center-center and inferior-center [17][18][19][20] there were still around 88% of the patient had optimal blade positions in this study. This highlights the importance of the correct surgical technique regardless of the implant.…”

“…The tip apex distance was no significant predictor of implant failure in this study. In both groups mean tip apex distance was less than 25 mm, what might have prevented further cut outs compared to the results of studies including more cases with tip apex distance higher than 25 mm [ 19 , 20 ]. Tip apex distance was slightly less in FNS group.…”

A Good Tip-Apex Distance Does Not Make Up For a Poor Reduction in Intertrochanteric Hip Fractures Treated with an Cephalomedullary Nail: The Utility of the Neck-Shaft Angle in Preventing Fixation Failure

“…Baumgaertner et al reported that a TAD of 25 mm or less significantly decreases the risk of screw cutout in patients with peri-trochanteric fractures that were treated with fixed-angle sliding hip screw, but this principle has been extrapolated and applied to cephalomedullary nails. 13,30,31 Subsequent biomechanical studies have suggested that when the lag screw is placed in a more inferior position, as opposed to the ideal center-center position, a TAD greater than 25mm is biomechanically stable and recent clinical studies have suggested a higher threshold TAD of 35mm. 14,32 Although TAD is the most commonly used radiographic intraoperative parameter used to assess cephalomedullary fixation, our analysis did not find a correlation between TAD greater than 25mm and fixation failure.…”

Orthogeriatric Care: Reviewing Improvements in Outcomes

“…Regarding internal fixation for extracapsular intertrochanteric fractures, evidence behind the different implants used is weak considering the number of implants used worldwide. Failure of internal fixation is the most common cause of revision; in a recent retrospective study, ASA grade and the tip-apex distance are predictive of failure, while the type of implant used for internal fixation was not found to be predictive of failure [195]. Cutout rates are strongly related to the quality of reduction, more than the degree of osteoporosis, age or type of fracture [196][197][198].…”