Computer-assisted navigation for intramedullary nail fixation of intertrochanteric femur fractures: A randomized, controlled trial

Abstract

IntroductionLag screw cutout is one of the most commonly reported complications following intramedullary nail fixation of intertrochanteric femur fractures. However, its occurrence can be minimized by a well-positioned implant, with a short Tip-to-Apex Distance (TAD). Computer-assisted navigation systems provide surgeons with the ability to track screw placement in real-time. This could allow for improved lag screw placement and potentially reduce radiation exposure to the patient and surgeon. MethodsBetween Oct 2014 and Jan 2016, patients with intertrochanteric femur fractures being treated with intramedullary nail fixation by one of three fellowship-trained orthopaedic traumatologists were enrolled. Inclusion criteria were low-energy mechanism of injury and fracture class 31-A1/A2. Open fractures and patients with multiple injuries to the lower extremity were excluded. Patients were randomly assigned to computer-assisted navigation or a conventional fluoroscopic technique for lag screw placement. The primary outcomes were TAD, measured by postoperative anteroposterior and lateral x-rays by an independent reviewer, and radiation exposure measured in seconds of fluoroscopy time. Surgical time was also recorded. Results50 patients were randomized, 26 to the computer-assisted navigation group and 24 to the control group. The mean manually-measured TAD in the computer-assisted navigation group was 14.1mm±3.2 and in the control group was 14.9mm±3.0 (p=0.394). There was no difference between groups in total radiation time (navigation: 58.8 s±23.6, control: 56.5 s±28.5, p=0.337) or radiation time during lag screw placement (navigation: 19.4 s±8.8, control: 18.8 s±8.0, p=0.522). The surgical time was significantly longer in the computer-assisted navigation group with a mean surgical time of 45.8min±9.8 compared to 38.4min±9.3 in the control group (p=0.009). ConclusionsComputer-assisted navigation consistently produced excellent TADs, however it was not significantly better than conventional methods when done by fellowship-trained orthopaedic traumatologists. Surgeons with a lower volume trauma practice could potentially benefit from computer-assisted navigation to obtain better TAD.