Migration of the Lag Screw after Intramedullary Treatment of AO/OTA 31.A2.1-3 Pertrochanteric Fractures Does Not Result in Higher Incidence of Cut-Outs, Regardless of Which Implant Was Used: A Comparison of Gamma Nail with and without U-Blade (RC) Lag Screw and Proximal Femur Nail Antirotation (PFNA).

Nikolaus Wilhelm Lang,Reinhard Windhager,Harald Kurt Widhalm,Hannes Beiglboeck,Stefan Hajdu,Alexandru Munteanu,Robert Breuer

doi:10.3390/jcm8050615

Nikolaus Wilhelm Lang, Reinhard Windhager + Show 5 more

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https://doi.org/10.3390/jcm8050615

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Abstract

The best intramedullary nail for the treatment of unstable AO/OTA 31.A2.1-3 fractures remains uncertain. A total of 237 patients (45 male, 192 female) were eligible for the assessment with an average age of 81.9 ± 10.5 years and a minimum follow-up of six months. We assessed the cut-out rate, the TAD and calTAD (Tip Apex distance) of three different implants. An overall cut-out rate of 2.5% (n = 6) was observed. The cut-out rate was 1.2% (n = 1) in the Proximal Femur Nail Antirotation (PFNA) group, 3.7% (n = 3) in the Gamma Nail group and 2.9% (n = 2) in the Gamma3® with a U-Blade (RC) lag-screw group. The TAD and calTAD differed between the cut-out and non-cut group—20.0 mm vs. 18.5 mm and 13.1 mm vs. 15.3 mm, respectively. A significantly higher TAD of 32.5 mm could be seen in the cut-out after PFNA (p < 0.0001). The only significant change in follow-up using Parker’s ratio was observed in the PFNA group (p < 0.0001). The rate of patients requiring surgery after complications was 8.4% (n = 20) without any significant difference between the three groups. The PFNA blade showed significant migration within the femoral head, however the cut-out rate remained the smallest compared to Gamma3 with or without additional U-Blade (RC) lag screw.

Highlights

Trochanteric femoral fractures are one of the most common injuries in the elderly population and the incidence will only increase due to demographic changes [1]
The compromised bone quality in the head and neck of the femur in the typical geriatric patient with osteoporotic bone changes requires an exact positioning of the head screw in the center-center or low-center position and, preferably, a small tip-apex distance (TAD) [13,14]
The aim of the study was to assess (1) the cut-out rate, (2) migration of the lag screw/ blade, and (3) implant failure in geriatric patients with unstable AO/OTA 31.A2.1-3 fractures treated with Proximal Femur Nail Antirotation (PFNA)®, Gamma3® or Gamma3® with U-Blade (RC) lag screw

Summary

Introduction

Trochanteric femoral fractures are one of the most common injuries in the elderly population and the incidence will only increase due to demographic changes [1]. The Gamma Nail ® (Stryker Trauma, Murnau, Germany) and Proximal Femur Nail Antirotation (PFNA)® (DePuy Synthes, Umkirch, Germany) are the most commonly used intramedullary nails for the treatment of pertrochanteric fractures. For both implants, the migration of the femoral head into varus and retroversion, and the subsequent cut-out of the lag screw/blade, is the most common mechanical complication and are described between 0–7% [10,11,12].

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