Subtrochanteric femoral fractures and intramedullary nailing complications: a comparison of two implants

Abstract

Introduction Intramedullary (IM) nails are considered the ‘gold’ standard treatment for subtrochanteric femoral fractures. The incidence and risk factors for re-operation in subtrochanteric fractures remain unclear. Furthermore, no studies have compared the outcomes of different nailing systems used to treat subtrochanteric fractures in the same study population. Aims/objectives Our study aimed to (i) investigate the cumulative incidence and factors associated with an increased risk of re-operation in subtrochanteric fractures treated with a long intramedullary (IM) nail, (ii) compare the outcomes of subtrochanteric fractures treated with long Affixus and Gamma nails, and (iii) establish whether the addition of a proximal anti-rotation screw in the Affixus nail confers any clinical benefit. Methods A retrospective review of all adult patients admitted to a level 1 trauma centre with a subtrochanteric femur fracture treated with a long cephalomedullary IM nail over an 8-year period was conducted. Exclusion criteria were primary surgery performed at another institution, prophylactic nailing because of tumours, incomplete fractures, and patients who were lost to follow-up or died before fracture healing. Data variables were assessed for normality prior to determining the use of either parametric or non-parametric tests. Logistic regression analysis was performed to identify potential factors associated with re-operation. For the comparison between the two nail types, patients were matched into two groups of 119 each by age (10-year intervals), gender and mechanism of injury (low energy, high energy and pathological fractures). A p-value < 0.05 was considered significant. The Kaplan–Meier nail survival curve was used to demonstrate the survival of each nail. Data were analysed using the statistical package R (R version 3.6.0). Results A total of 309 subtrochanteric fractures were treated with a distally locked long IM nail (re-operation rate: 22.33%) over an 8-year period. Logistic regression identified six factors associated with an increased risk of re-operation, including age < 75 years old, use of a long Gamma nail, pre-injury coxa-vara femoral neck shaft angles, an immediate post-operative reduction angle of > 10° varus, deep wound infection and non-union. Following matching, we compared the two long cephalomedullary nailing systems used (Gamma versus Affixus nail). The only differences identified from the unadjusted analysis were a higher overall incidence of nail failure in Gamma nails due to any cause, re-operation, and impingement of the nail tip distally against the anterior femoral cortex. When we corrected for covariates, no significant differences remained evident between the two nails. From the Kaplan–Meier nail survival curves, however, the Affixus nail demonstrated better survivorship up to 5 years post-implantation in terms of nail failure and re-operation for all causes. Finally, the addition of a proximal anti-rotation screw in the Affixus nail did not seem to confer any benefit. Conclusion We reported a 22.3% re-operation rate in our cohort of subtrochanteric fractures treated with a long IM nail. We have identified six risk factors associated with re-operation: age < 75 years old, pre-injury femoral neck shaft angle, choice of nail, varus reduction angle, fracture-related infection and non-union. The addition of a proximal anti-rotation screw in the Affixus nail did not confer any benefit.

Efficacy of minimally invasive reduction with cerclage fixation in spiral or oblique subtrochanteric femoral fractures: A retrospective cohort study comparing cables and wires

“…In previous studies comparing different IM nails in SFFs, there were no differences in nail failure or reoperation. 12,36 Therefore, the effect of the implant type in this study may have been minimal.…”

“…In a study of SFFs treated with long IM nails over an eight-year period, the rates of varus reduction exceeding 58 and nonunion were reported to be 23.9%, respectively. 12 This demonstrates that maintaining good reduction while strongly resisting deformational forces in SFFs is challenging. Various MIR techniques have been used in addition to IM nailing to achieve a better reduction quality.…”

“…[6][7][8] Although intramedullary (IM) nails are currently considered the standard treatment for SFFs, a few reports have indicated that achieving high-quality reduction with IM nail alone is challenging, often resulting in frequent varus malalignment, nonunion, and implant failure. [9][10][11][12] Recently, minimally invasive reduction (MIR) techniques have been employed to improve the quality of reduction of spiral or oblique SFFs by passing the wire through a cerclage wire passer (DePuy-Synthes, West Chester, PA). [13][14][15][16] Unlike previous open reduction approaches, MIR techniques can achieve the desired reduction while preserving blood supply, leading to favorable outcomes.…”

Efficacy and complications of blocking screws fixation in the treatment of lower limb long bone fracture: a Meta-analysis

“…The bone debris produced by reaming can produce the autogenous bone grafting effect, and the fretting effect produced by muscle contraction can stimulate the end of the fracture, which is bene cial to fracture healing. The orthopedic doctors who are keen on the application of intramedullary nails have gradually expanded the application range of intramedullary nails, and at the same time, many problems have gradually been exposed, especially, the middle and lower 1/3 fractures of the femur and tibia were complicated with comminuted or segmental fracture, long oblique fracture, malalignment and angular deformity [25].…”

Sterile Inflammatory Response and Surgery-Related Trauma in Elderly Patients with Subtrochanteric Fractures

“…Subtrochanteric fractures (STFs) are common among the elderly and constitute a significant cause of mortality and increased morbidity [1,2]. Despite various treatment options, closed reduction and internal fixation (CRIF) with intramedullary nails has become the predominant approach [3][4][5]. Surgical decisions, including technique, duration, and blood loss, are influenced by factors such as fracture characteristics, patient body type, surgeon experience, and technical skill [6].…”