Intertrochanteric Fractures in Elderly Adults: Analysis of Risk Factors Associated With Failure in Osteosynthesis With a Cephalomedullary Nail
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Published:
Feb 14, 2022
Keywords:
Intertrochanteric fractures, cephalomedullary nail, risk factors, cut-out, pull-out
Main Article Content
Abstract
Objectives: Intertrochanteric fractures are increasingly frequent due to population aging. Osteosynthesis with cephalomedullary nail is widely used for the treatment of these fractures. The objective of this study is to analyze the rate of failure in osteosynthesis associated with cephalomedullary nail and the risk factors for this event.
Materials and Methods: All cases of patients older than 75 years with intertrochanteric fractures treated in our center with cephalomedullary nails between January 2016 and December 2019 were retrospectively analyzed. The cervico-diaphyseal angle of the operated hip was determined in the immediate postoperativeperiod. We also analyzed the tip-apex distance (TAD) and the position of the lag screw in the femoral head.
Results: 66 patients were included in the study. There were 8 cases of failure in osteosynthesis (12.12%). It was found that previously recognized factors in the literature (TAD>25 mm and reduction in varus) were also significant risk factors for failure in osteosynthesis in our cohort. The inadequate position of the lag screw was a risk factor that showed statistical significance in the univariate analysis, but not in the multivariate one in this study.
Conclusions: When treating intertrochanteric fractures with cephalomedullary nail, a neutral or slightly valgus reduction aiming for a TAD ≤25 mm significantly reduced the risk of failure in osteosynthesis. We found evidence that a superior or posterior location of the lag screw increases the risk of fixation failure, although the location of the screw was not a significant risk factor in the multivariate analysis.
Materials and Methods: All cases of patients older than 75 years with intertrochanteric fractures treated in our center with cephalomedullary nails between January 2016 and December 2019 were retrospectively analyzed. The cervico-diaphyseal angle of the operated hip was determined in the immediate postoperativeperiod. We also analyzed the tip-apex distance (TAD) and the position of the lag screw in the femoral head.
Results: 66 patients were included in the study. There were 8 cases of failure in osteosynthesis (12.12%). It was found that previously recognized factors in the literature (TAD>25 mm and reduction in varus) were also significant risk factors for failure in osteosynthesis in our cohort. The inadequate position of the lag screw was a risk factor that showed statistical significance in the univariate analysis, but not in the multivariate one in this study.
Conclusions: When treating intertrochanteric fractures with cephalomedullary nail, a neutral or slightly valgus reduction aiming for a TAD ≤25 mm significantly reduced the risk of failure in osteosynthesis. We found evidence that a superior or posterior location of the lag screw increases the risk of fixation failure, although the location of the screw was not a significant risk factor in the multivariate analysis.
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Cangiano, L. V., Yapur, P. M., & Talamo, F. (2022). Intertrochanteric Fractures in Elderly Adults: Analysis of Risk Factors Associated With Failure in Osteosynthesis With a Cephalomedullary Nail. Revista De La Asociación Argentina De Ortopedia Y Traumatología, 87(1), 41-50. https://doi.org/10.15417/issn.1852-7434.2022.87.1.1368
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Clinical Research
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References
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the treatment of unstable proximal femoral fractures. Injury 1999; 30(5):327-32. https://doi.org/10.1016/s0020-1383(99)00091-1
4. Fogagnolo F, Kfuri M, Paccola CAJ. Intramedullary fixation of pertrochanteric hip fractures with the short AO-ASIF proximal femoral nail. Arch Orthop Trauma Surg 2004;124(1):31-37. https://doi.org/10.1007/s00402-003-0586-9
5. Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM. The value of the tip-apex distance in predicting failure
of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg Am 1995;77(7):1058-64.
https://doi.org/10.2106/00004623-199507000-00012
6. Hsueh KK, Fang CK, Chen CM, Su YP, Wu HF, Chiu FY. Risk factors in cutout of sliding hip screw in
intertrochanteric fractures: an evaluation of 937 patients. Int Orthop 2010;34(8):1273-6.
https://doi.org/10.1007/s00264-009-0866-2
7. Ostrum RF, Marcantonio A, Marburger R. A critical analysis of the eccentric starting point for trochanteric
intramedullary femoral nailing. J Orthop Trauma 2005;19(10):681-6. https://doi.org/10.1097/01.bot.0000184145.75201.1b
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subtrochanteric femur fractures? J Orthop Trauma 2011;25:202-7. https://doi.org/10.1097/BOT.0b013e3181e93ce2
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https://doi.org/10.1186/s12891-017-1472-x
10. Marsh JL, Slongo TF, Agel J, Broderich JS, Creevey W, DeCoster TA, et al. Fracture and dislocation classification
compendium-2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop
Trauma 2007;21(10 Suppl):S1-S133. https://doi.org/10.1097/00005131-200711101-00001
11. Lindskog DM, Baumgaertner MR. Unstable intertrochanteric hip fractures in the elderly. J Am Acad Orthop Surg 2004;12(3):179-90. https://doi.org/10.5435/00124635-200405000-00006
12. Committee on Trauma. Initial Assessment and Management Advanced Trauma Life Support - Student Course
Manual. 9th ed. Chicago: American College of Surgeons; 2012.
13. Jiamton C, Boernert K, Babst R, Beeres FJP, Link BC. The nail-shaft-axis of the proximal femoral nail antirotation (PFNA) is an important prognostic factor in the operative treatment of intertrochanteric fractures. Arch Orthop Trauma Surg 2018;138(3):339-49. https://doi.org/10.1007/s00402-017-2857-x
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https://doi.org/10.1302/0301-620X.74B4.1624529
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17. Adams CI, Robinson CM, Court-Brown CM, McQueen MM. Prospective randomized controlled trial of an
intramedullary nail versus dynamic screw and plate for intertrochanteric fractures of the femur. J Orthop Trauma
2001;15(6):394-400. https://doi.org/10.1097/00005131-200108000-00003
18. Turgut A, Kalenderer Ö, Karapınar L, Kumbaracı M, Akkan HA, Ağuş H. Which factor is most important for
occurrence of cutout complications in patients treated with proximal femoral nail antirotation? Retrospective
analysis of 298 patients. Arch Orthop Trauma Surg 2016;136(5):623-30. https://doi.org/10.1007/s00402-016-2410-3
19. Andruszkow H, Frink M, Frömke C, Matityahu A, Zeckey C, Mommsen P, et al. Tip apex distance, hip screw
placement and neck shaft angle as potential risk factors for cut-out failure of hip screws after surgical treatment of intertrochanteric fractures. Int Orthop 2012;36(11):2347-54. https://doi.org/10.1007/s00264-012-1636-0
20. Kashigar A, Vincent A, Gunton MJ, Backstein D, Safir O, Kuzyk PRT. Predictors of failure for cephalomedullary
nailing of proximal femoral fractures. Bone Joint J 2014;96B(8):1029-34. https://doi.org/10.1302/0301-620X.96B8.33644
21. De Bruijn K, den Hartog D, Tuinebreijer W, Roukema G. Reliability of predictors for screw cutout in
intertrochanteric hip fractures. J Bone Joint Surg Am 2012;94:1266-72. https://doi.org/10.2106/JBJS.K.0035
22. Angelini AJ, Livani B, Flierl MA, Morgan SJ, Belangero WD. Less invasive percutaneous wave plating of simple
femur shaft fractures: a prospective series. Injury 2010;41(6):624-8. https://doi.org/10.1016/j.injury.2010.01.101
Indian J Orthop 2011;45(1):15. https://doi.org/10.4103/0019-5413.73656
2. Anglen JO, Weinstein JN, American Board of Orthopaedic Surgery Research Committee JN. Nail or plate fixation
of intertrochanteric hip fractures: changing pattern of practice. A review of the American Board of Orthopaedic
Surgery Database. J Bone Joint Surg Am 2008;90(4):700-7. https://doi.org/10.2106/JBJS.G.00517
3. Simmermacher RK, Bosch AM, Van der Werken C. The AO/ASIF-proximal femoral nail (PFN): a new device for
the treatment of unstable proximal femoral fractures. Injury 1999; 30(5):327-32. https://doi.org/10.1016/s0020-1383(99)00091-1
4. Fogagnolo F, Kfuri M, Paccola CAJ. Intramedullary fixation of pertrochanteric hip fractures with the short AO-ASIF proximal femoral nail. Arch Orthop Trauma Surg 2004;124(1):31-37. https://doi.org/10.1007/s00402-003-0586-9
5. Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM. The value of the tip-apex distance in predicting failure
of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg Am 1995;77(7):1058-64.
https://doi.org/10.2106/00004623-199507000-00012
6. Hsueh KK, Fang CK, Chen CM, Su YP, Wu HF, Chiu FY. Risk factors in cutout of sliding hip screw in
intertrochanteric fractures: an evaluation of 937 patients. Int Orthop 2010;34(8):1273-6.
https://doi.org/10.1007/s00264-009-0866-2
7. Ostrum RF, Marcantonio A, Marburger R. A critical analysis of the eccentric starting point for trochanteric
intramedullary femoral nailing. J Orthop Trauma 2005;19(10):681-6. https://doi.org/10.1097/01.bot.0000184145.75201.1b
8. Streubel PN, Wong AHW, Ricci WM, Gardner MJ. Is there a standard trochanteric entry site for nailing of
subtrochanteric femur fractures? J Orthop Trauma 2011;25:202-7. https://doi.org/10.1097/BOT.0b013e3181e93ce2
9. Pan S, Liu X-H, Feng T, Kang H-J, Tian Z-G, Lou C-G. Influence of different great trochanteric entry points on the
outcome of intertrochanteric fractures: a retrospective cohort study. BMC Musculoskelet Disord 2017;18(1):107.
https://doi.org/10.1186/s12891-017-1472-x
10. Marsh JL, Slongo TF, Agel J, Broderich JS, Creevey W, DeCoster TA, et al. Fracture and dislocation classification
compendium-2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop
Trauma 2007;21(10 Suppl):S1-S133. https://doi.org/10.1097/00005131-200711101-00001
11. Lindskog DM, Baumgaertner MR. Unstable intertrochanteric hip fractures in the elderly. J Am Acad Orthop Surg 2004;12(3):179-90. https://doi.org/10.5435/00124635-200405000-00006
12. Committee on Trauma. Initial Assessment and Management Advanced Trauma Life Support - Student Course
Manual. 9th ed. Chicago: American College of Surgeons; 2012.
13. Jiamton C, Boernert K, Babst R, Beeres FJP, Link BC. The nail-shaft-axis of the proximal femoral nail antirotation (PFNA) is an important prognostic factor in the operative treatment of intertrochanteric fractures. Arch Orthop Trauma Surg 2018;138(3):339-49. https://doi.org/10.1007/s00402-017-2857-x
14. Cleveland M, Bosworth DM, Thompson FR, Wilson HJ Jr., Ishizuka T. A ten-year analysis of intertrochanteric
fractures of the femur. J Bone Joint Surg Am 1959;41(8):1399-408. Disponible en: http://jbjs.org/content/41/8/1399.abstract
15. Parker J. Cutting-out of the dynamic hip screw related to its position. J Bone Joint Surg Br 1992;74(4):625.
https://doi.org/10.1302/0301-620X.74B4.1624529
16. Wadhwani J, Gil Monzó ER, Pérez Correa JI, García Álvarez J, Blas Dobón JA, Rodrigo Pérez JL. No todo es “cutout”: reclasificación de las complicaciones mecánicas del tornillo cefálico del clavo intramedular. Revista Española de Cirugía Osteoarticular 2019;54(280):136-42. https://doi.org/10.37315/SOTOCAV201928054136
17. Adams CI, Robinson CM, Court-Brown CM, McQueen MM. Prospective randomized controlled trial of an
intramedullary nail versus dynamic screw and plate for intertrochanteric fractures of the femur. J Orthop Trauma
2001;15(6):394-400. https://doi.org/10.1097/00005131-200108000-00003
18. Turgut A, Kalenderer Ö, Karapınar L, Kumbaracı M, Akkan HA, Ağuş H. Which factor is most important for
occurrence of cutout complications in patients treated with proximal femoral nail antirotation? Retrospective
analysis of 298 patients. Arch Orthop Trauma Surg 2016;136(5):623-30. https://doi.org/10.1007/s00402-016-2410-3
19. Andruszkow H, Frink M, Frömke C, Matityahu A, Zeckey C, Mommsen P, et al. Tip apex distance, hip screw
placement and neck shaft angle as potential risk factors for cut-out failure of hip screws after surgical treatment of intertrochanteric fractures. Int Orthop 2012;36(11):2347-54. https://doi.org/10.1007/s00264-012-1636-0
20. Kashigar A, Vincent A, Gunton MJ, Backstein D, Safir O, Kuzyk PRT. Predictors of failure for cephalomedullary
nailing of proximal femoral fractures. Bone Joint J 2014;96B(8):1029-34. https://doi.org/10.1302/0301-620X.96B8.33644
21. De Bruijn K, den Hartog D, Tuinebreijer W, Roukema G. Reliability of predictors for screw cutout in
intertrochanteric hip fractures. J Bone Joint Surg Am 2012;94:1266-72. https://doi.org/10.2106/JBJS.K.0035
22. Angelini AJ, Livani B, Flierl MA, Morgan SJ, Belangero WD. Less invasive percutaneous wave plating of simple
femur shaft fractures: a prospective series. Injury 2010;41(6):624-8. https://doi.org/10.1016/j.injury.2010.01.101