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

Fujii, Tatsuya; Nakayama, S.; Hara, Masahiko; Koizumi, Wataru; Itabashi, Takeshi; Saito, Masahito

doi:10.2106/jbjs.oa.16.00022

Cited by 34 publications

(24 citation statements)

References 31 publications

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“…Cut-out can be defined as ''the collapse of the neckshaft angle into varus, leading to extrusion, or so-called cut-out, of the device from the femoral head.'' 12 This pattern of failure has been described consistently with both extramedullary and intramedullary devices. 4e8 In almost all cases, this requires revision surgery, and causes further morbidity.…”

Section: Introductionmentioning

confidence: 67%

Tip-apex distance and other predictors of outcome in cephalomedullary nailing of unstable trochanteric fractures

John

Sharma

Mahajan

et al. 2019

Journal of Clinical Orthopaedics and Trauma

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Background: Cephalomedullary nails are presently the gold standard in management of unstable trochanteric fractures. The tip-apex distance (TAD) is one of the most important factors that determines success or failure of fixation, but was described originally in context of an extramedullary hip screw. Cephalomedullary nails use a different biomechanical approach to fixation; and it is hypothesized that the TAD rule may not apply similarly with these. The aim of this study is to assess whether a high TAD correlates with poor outcomes with cephalomedullary nails, and to elucidate other factors that may predict such outcome. Methods: We retrospectively reviewed the clinical and radiographic records of patients with intertrochanteric fractures, treated at our institution over a 2-year period. Those with unstable fractures (31.A2 and 31.A3), and who were treated with cephalomedullary nails were included in the study. The TAD and the position of the device in the femoral head (Cleveland index) were assessed. Other factors that could influence outcome like age, gender, AO fracture type, restoration of neck-shaft angle and degree of osteoporosis were analysed. Radiographic records of up-to at-least 3 months post-operatively were assessed for complications. Results: After applying the exclusion criteria, 75 patients were included in the analysis. The overall rate of complications was 12%. They occurred in two major patterns -varus collapse and cut-out occurred in 5 patients (6.67%), and device migration in 4 patients (5.33%). The average TAD of patients with cut-out was 28.78 mm, compared to 19.44 mm in those without cut-out (p ¼ 0.002). Our data predicted a cutoff TAD >23.56 mm as most significant for cut-out with cephalomedullary nails. On univariate logistic regression, high TAD (p ¼ 0.009), sub-optimal device positioning (p ¼ 0.02) and poor restoration of neckshaft angle (p ¼ 0.04) were found to be significant for varus collapse and cut-out, but not for complications relating to device migration. On multivariate analysis, none of the above factors reached statistical significance in isolation. Conclusion: As with extramedullary devices, TAD, along with sub-optimal device positioning and poor restoration of neck-shaft angle is a useful predictor of cut-out even with cephalomedullary nails, negating the initial hypothesis. The above factors in combination have a more significant effect than any one factor in isolation to cause varus collapse and implant cut-out. However these do not affect Z effect, reverse Z effect or other types of device migration seen especially with dual-screw nails.

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Section: Introductionmentioning

confidence: 67%

Tip-apex distance and other predictors of outcome in cephalomedullary nailing of unstable trochanteric fractures

John

Sharma

Mahajan

et al. 2019

Journal of Clinical Orthopaedics and Trauma

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“… 25 As shown by our results, TAD in “Extramedullary” and “Intramedullary” reductions did not exceed the recommended standard value of 20 mm. 26 Although TAD in “Intramedullary” was significantly lower than that in “Extramedullary,” “Intramedullary” showed a significantly greater amount of blade telescoping and distal screw hole diameter than did “Extramedullary.” Thus, the “Extramedullary” reduction pattern was preferable in unstable femoral trochanteric fractures.…”

Section: Discussionmentioning

confidence: 95%

Biomechanical Evaluation of Extramedullary Versus Intramedullary Reduction in Unstable Femoral Trochanteric Fractures

Kawamura

Minehara

Tazawa

et al. 2021

Geriatr Orthop Surg Rehabil

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Introduction: The failure rate of operations involving the cephalomedullary nail technique for unstable femoral trochanteric fractures is 3-12%. Changing the reduction strategy may improve the stability. This study aimed to confirm whether reducing the proximal fragment with the medial calcar contact, as opposed to utilizing an intramedullary reduction, would improve the stability of such fractures. Materials and Methods: The unstable femoral trochanteric fracture model was created with fixation by cephalomedullary nails in 22 imitation bones. The 2 reduction patterns were as follows: one was with the proximal head-neck fragment external to the distal bone in the frontal plane and anterior in the sagittal plane as “Extramedullary,” while the other was the opposite reduction position, that is, bone in the frontal plane and sagittal plane as “Intramedullary.” We evaluated the tip-apex distance, compression stiffness, change in femoral neck-shaft angle, amount of blade telescoping, and diameter of the distal screw hole after the compression test. Statistical analysis was conducted using the Mann-Whitney U test. Results: No significant differences were seen in compression stiffness ( p = 0.804) and femoral neck-shaft angle change ( p = 0.644). Although the “Extramedullary” tip-apex distance was larger than the “Intramedullary” distance ( p = 0.001), it indicated clinically acceptable lengths. The amount of blade telescoping and the distal screw hole diameter were significantly larger in “Intramedullary” than in “Extramedullary” ( p < 0.001, p = 0.019, respectively). Our results showed that “Intramedullary” had significantly larger blade telescoping and distal screw hole diameters than “Extramedullary,” and contrary to our hypothesis, no significant differences were seen in compression stiffness and femoral neck-shaft angle change. Conclusions: As opposed to the “Intramedullary” reduction pattern, the biomechanical properties of the “Extramedullary” reduction pattern improved stability during testing and decreased sliding.

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“…Compared to a regular PFN implant, PFNA 2 has certain advantages like less blood loss, reduced number of fluoroscopy shots, reduced duration of surgery, and shorter hospital stay [ 13 ]. If the TAD of the neck screw is kept adequate, then the failure rate in PFNA 2 is less than that in regular PFN [ 20 ]. PFNA 2 has less complication rate in comparison to other cephalomedullary nails like PFN [ 11 ].…”

Section: Discussionmentioning

confidence: 99%

Outcomes of Ipsilateral Femoral Neck and Shaft Fractures Treated With Proximal Femoral Nail Antirotation 2

Rana¹,

Behera²,

Behera³

et al. 2021

Cureus

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Ipsilateral femoral neck and shaft fractures are relatively rare fractures, which most commonly occur in young adults following high-energy trauma. In most cases of such fractures, neck fracture is undisplaced and often of basicervical type. Many treatment methods have been described, but there is still no generalized consensus on the same. Cephalomedullary nails are one of the preferred modalities of treatment. A cephalomedullary nail-like proximal femoral nail antirotation 2 (PFNA 2) of recent design is being widely used currently. In this study, we present 13 cases of ipsilateral femoral neck and shaft fractures treated with PFNA 2 implants. The advantages of the PFNA 2 system include reduced blood loss, reduced operative time, and fewer fluoroscopy shots. PFNA 2 is a biomechanically better implant than many cephalomedullary implants. It provides satisfactory results in ipsilateral femoral neck and shaft fractures, especially where neck fracture is of a basicervical type. Some aspects have to be taken care of when employing PFNA 2, such as anatomical reduction, and length, angulation, and rotation of both neck and shaft.

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

Cited by 34 publications

References 31 publications

Tip-apex distance and other predictors of outcome in cephalomedullary nailing of unstable trochanteric fractures

Tip-apex distance and other predictors of outcome in cephalomedullary nailing of unstable trochanteric fractures

Biomechanical Evaluation of Extramedullary Versus Intramedullary Reduction in Unstable Femoral Trochanteric Fractures

Outcomes of Ipsilateral Femoral Neck and Shaft Fractures Treated With Proximal Femoral Nail Antirotation 2

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