Prevention of excessive postoperative sliding of the short femoral nail in femoral trochanteric fractures

Ito, Junitsu; Takakubo, Yuya; Sasaki, Kan; Sasaki, Junya; Owashi, Kazuya; Takagi, Michiaki

doi:10.1007/s00402-015-2200-3

Cited by 49 publications

(57 citation statements)

References 14 publications

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“…Of these factors, good fracture reduction appears to be of paramount importance. This is logical because doing so also effectively restores maximal contact of any available bony buttress [ 15 , 21 , 22 ]. For a dynamic device to work without excessive collapse, a majority of bone along the femur's circumference should remain intact and in contact.…”

Section: Discussionmentioning

confidence: 99%

Increased Fracture Collapse after Intertrochanteric Fractures Treated by the Dynamic Hip Screw Adversely Affects Walking Ability but Not Survival

Fang

Gudushauri

Wong

et al. 2016

BioMed Research International

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In osteoporotic hip fractures, fracture collapse is deliberately allowed by commonly used implants to improve dynamic contact and healing. The muscle lever arm is, however, compromised by shortening. We evaluated a cohort of 361 patients with AO/OTA 31.A1 or 31.A2 intertrochanteric fracture treated by the dynamic hip screw (DHS) who had a minimal follow-up of 3 months and an average follow-up of 14.6 months and long term survival data. The amount of fracture collapse and shortening due to sliding of the DHS was determined at the latest follow-up and graded as minimal (<1 cm), moderate (1-2 cm), or severe (>2 cm). With increased severity of collapse, more patients were unable to maintain their premorbid walking function (minimal collapse = 34.2%, moderate = 33.3%, severe = 62.8%, and p = 0.028). Based on ordinal regression of risk factors, increased fracture collapse was significantly and independently related to increasing age (p = 0.037), female sex (p = 0.024), A2 fracture class (p = 0.010), increased operative duration (p = 0.011), poor reduction quality (p = 0.000), and suboptimal tip-apex distance of >25 mm (p = 0.050). Patients who had better outcome in terms of walking function were independently predicted by younger age (p = 0.036), higher MMSE marks (p = 0.000), higher MBI marks (p = 0.010), better premorbid walking status (p = 0.000), less fracture collapse (p = 0.011), and optimal lag screw position in centre-centre or centre-inferior position (p = 0.020). According to Kaplan-Meier analysis, fracture collapse had no association with mortality from 2.4 to 7.6 years after surgery. In conclusion, increased fracture collapse after fixation of geriatric intertrochanteric fractures adversely affected walking but not survival.

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Section: Discussionmentioning

confidence: 99%

Increased Fracture Collapse after Intertrochanteric Fractures Treated by the Dynamic Hip Screw Adversely Affects Walking Ability but Not Survival

Fang

Gudushauri

Wong

et al. 2016

BioMed Research International

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“…7,8) In order to avoid excessive sliding in unstable IT fractures with posteromedial (PM) comminution and in reverse obliquity fracture, EM reduction has been introduced to reduce the sliding distance and shortening of the lever arm. [9][10][11][12][13] In EM reduction, the AM cortical bone of the proximal fragment has early bony contact with the distal fragment during sliding, and it theoretically plays a role as a buttress from the beginning and prevents excessive sliding and varus deformity of the proximal fragment. From a functional point of view, Chang et al 12) defined EM reduction as 'positive medial cortical support'.…”

Section: Introductionmentioning

confidence: 99%

The Effects of Extramedullary Reduction in Unstable Intertrochanteric Fracture: A Biomechanical Study Using Cadaver Bone

2018

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To prevent excessive sliding and subsequent fixation failures in unstable intertrochanteric fractures with posteromedial comminution, extramedullary reduction through overlapping of the anteromedial cortices of both proximal and distal fragments as a buttress has been introduced. The purpose of this study was to compare the biomechanical properties between two reduction methodsintramedullary reduction and extramedullary reduction-in treating unstable intertrochanteric fractures with posteromedial comminution (AO/OTA classification 31-A2.2). Materials and Methods: Eight pairs of frozen human cadaveric femora were used. The femora of each pair were randomly assigned to one of two groups: the intramedullary reduction group or the extramedullary reduction group. A single axial load-destruction test was conducted after cephalomedullary nailing. Axial stiffness, maximum load to failure, and energy absorbed to failure were compared between the two groups. Moreover, the pattern of mechanical failure was identified. Results: The mean axial stiffness in the extramedullary reduction group was 27.3% higher than that in the intramedullary reduction group (422.7 N/mm vs. 332.0 N/mm, p=0.017). Additionally, compared with the intramedullary reduction group, the mean maximum load to failure and mean energy absorbed to failure in the extramedullary group were 44.9% and 89.6% higher, respectively (2,848.7 N vs. 1,966.5 N, p=0.012 and 27,969.9 N•mm vs. 14,751.0 N•mm, p=0.012, respectively). In the intramedullary reduction group, the mechanical failure patterns were all sliding and varus deformities. In the extramedullary reduction group, sliding and varus deformities after external rotation were noted in 3 specimens, sliding and varus deformities after internal rotation were noted in 3 specimens, and medial slippage was noted in 2 specimens. Conclusion: In unstable intertrochanteric fractures with posteromedial comminution, the biomechanical properties of extramedullary reduction are superior to those of intramedullary reduction. Anteromedial cortex could be the proper buttress, despite a comminuted posteromedial cortex. It could help enhance the stability of the bone-nail construct.

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“…These preoperative risks could result in increased TAD if the ensuing difficulty in performing the reduction results in a remaining varus deformity. This is intuitively understandable for orthopaedic surgeons if there is difficulty in internal fixation of complex fractures with a higher OTA/AO classification or in the presence of a posterolateral fragment 16 , 23 - 25 , 29 . Since previous studies suggesting unstable intertrochanteric fractures and posterolateral fragments as risks of cutout did not use other operative risks, such as TAD, they could not exclude the confounding between preoperative and operative risks 29 - 32 .…”

Section: Discussionmentioning

confidence: 99%

“…We evaluated 6 previously reported cutout risk factors that included (1) an unstable intertrochanteric fracture, which was defined using the OTA/AO classification as type A2.2 or A2.3 18 ; (2) a posterolateral fracture fragment, which was defined using the Jensen classification as type III or V 24 ; (3) a medial type of reduction pattern, in which the proximal fragment lay inward from the anatomical position in the postoperative anteroposterior radiograph 25 ; (4) an intramedullary type of reduction pattern, in which the anterior cortex of the proximal part of the femur was located at the rear of the anterior cortex of the distal fragment in the postoperative lateral radiograph 25 ; (5) an unstable position of the screw in femoral head zones other than the central-central and central-inferior zones (the position was plotted on the sagittal plane as seen on the postoperative radiograph 23 ); and (6) a TAD of ≥20 mm 15 , 23 . The TAD is the sum of the postoperative distances from the tip of the screw to the apex of the femoral head on the anteroposterior and lateral radiographs.…”

Section: Methodsmentioning

confidence: 99%

Tip-Apex Distance Is Most Important of Six Predictors of Screw Cutout After Internal Fixation of Intertrochanteric Fractures in Women

Fujii

Nakayama

Hara

et al. 2017

JBJS OA

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Background:Six risk factors for screw cutout after internal fixation of intertrochanteric fractures have been reported. The purpose of the present study was to evaluate and compare the impact of the 6 risk factors of screw cutout to clarify the most important one.Methods:We enrolled 8 consecutive patients who had screw cutout and 48 random control subjects after internal fixation of intertrochanteric fractures treated with proximal femoral nail antirotation systems at our institution. All of the patients were female. The group that had screw cutout and the control group were retrospectively evaluated and compared with respect to the OTA/AO classification, presence of a posterolateral fragment, types of reduction pattern on anteroposterior and lateral radiographic images, position of the screw, and the presence of a tip-apex distance (TAD) of ≥20 mm. The impact of each factor on screw cutout was assessed using backward stepwise multivariable logistic regression analysis with the Akaike information criterion. Risk stratification was assessed using classification and regression tree (CART) analysis.Results:Among 6 risk factors, only a TAD of ≥20 mm had a significant impact on screw cutout, with an adjusted odds ratio of 12.4 (95% confidence interval, 1.6 to 129.0; p = 0.019). CART analysis also demonstrated that a TAD of ≥20 mm was the most important risk stratification factor (p < 0.001).Conclusions:Among the 6 previously reported screw cutout-related factors, only a TAD of ≥20 mm was associated with screw cutout after internal fixation of intertrochanteric fractures with proximal femoral nail antirotation systems.Level of Evidence:Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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Prevention of excessive postoperative sliding of the short femoral nail in femoral trochanteric fractures

Abstract: Because the sliding distance increased in the intramedullary type in the lateral view of unstable fractures, an accurate reduction in the lateral view at surgery is important, particularly in unstable fractures.

Cited by 49 publications

References 14 publications

Increased Fracture Collapse after Intertrochanteric Fractures Treated by the Dynamic Hip Screw Adversely Affects Walking Ability but Not Survival

Increased Fracture Collapse after Intertrochanteric Fractures Treated by the Dynamic Hip Screw Adversely Affects Walking Ability but Not Survival

The Effects of Extramedullary Reduction in Unstable Intertrochanteric Fracture: A Biomechanical Study Using Cadaver Bone

Tip-Apex Distance Is Most Important of Six Predictors of Screw Cutout After Internal Fixation of Intertrochanteric Fractures in Women

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