Cephalic Screw Research Articles

One year "ADAPT system" use for proximal femoral fracture osteosynthesis with intramedullary nail . A case control study.

Proximal femoral fractures (PFF) are a significant health concern among the elderly, often leading to complications and high mortality rates. Intramedullary nailing is widely considered the most effective treatment for lateral proximal femoral fractures (LPFF), with the Tip Apex Distance (TAD) being a crucial predictor of surgical success. This study aimed to compare outcomes between patients treated with and without the ADAPT (ADAptive Positioning Technology) system, which aids in the precise placement of the cephalic screw. A retrospective analysis was conducted on 97 patients with intertrochanteric fractures treated in 2022. Patients were divided into two groups: those treated with the ADAPT system (group I, n=34) and those treated without it (group II, n=63). Fractures were classified according to AO/OTA classification. The primary outcomes measured were operative time, cephalic screw angle, TAD, and incidence of lag screw cut-out. Statistical analyses included chi-square tests and t-tests, with significance set at P < 0.05. The ADAPT system did not significantly reduce TAD (18.21 mm in the ADAPT group vs.19.94 mm in the control group, p=0.149). Operative times were similar between the groups. The incidence of lag screw cut-out was low in both groups, with no significant differences. The study confirmed a strong correlation between higher TAD and increased risk of screw cut-out, underscoring the importance of precise screw placement. Computer-assisted surgery, such as the ADAPT system, aims to enhance the accuracy of cephalic screw placement. In this study, the ADAPT system didn't demonstrate a statistically significant advantage in reducing TAD or preventing screw cut-out. Nevertheless, the critical role of TAD in preventing fixation failure was reaffirmed, emphasising the need for precise surgical techniques. While the ADAPT system did not show a significant advantage in reducing TAD or preventing screw cut-out in this study, the importance of achieving optimal TAD in cephalomedullary nailing was reinforced. Future research should continue to explore the role of computer-assisted systems in enhancing surgical accuracy and improving outcomes for patients with LPFF.

Tip-apex distance as a risk factor for cut-out in cephalic double-screw nailing of intertrochanteric femur fractures.

Proximal femur fractures treatment can involve anterograde nailing with a single or double cephalic screw. An undesirable failure for this fixation is screw cut-out. In a single-screw nail, a tip-apex distance (TAD) greater than 25 mm has been associated with an increased risk of cut-out. The aim of the study was to examine the role of TAD as a risk factor in a cephalic double-screw nail. A retrospective study was conducted on 112 patients treated for intertrochanteric femur fracture with a double proximal screw nail (Endovis BA2; EBA2) from January to September 2021. The analyzed variables were age, sex, BMI, comorbidities, fracture type, side, time of surgery, quality of reduction, pre-existing therapy with bisphosphonate for osteoporosis, screw placement in two different views, and TAD. The last follow-up was at 12 months. Logistic regression was used to study the potential factors of screw cut-out, and receiver operating characteristic curve to identify the threshold value. A total of 98 of the 112 patients met the inclusion criteria. Overall, 65 patients were female (66.3%), the mean age was 83.23 years (SD 7.07), and the mean follow-up was 378 days (SD 36). Cut-out was observed in five patients (5.10%). The variables identified by univariate analysis with p < 0.05 were included in the multivariate logistic regression model were screw placement and TAD. The TAD was significant with an odds ratio (OR) 5.03 (p = 0.012) as the screw placement with an OR 4.35 (p = 0.043) in the anteroposterior view, and OR 10.61 (p = 0.037) in the lateral view. The TAD threshold value identified was 29.50 mm. Our study confirmed the risk factors for cut-out in the double-screw nail are comparable to those in the single screw. We found a TAD value of 29.50 mm to be associated with a risk of cut-out in double-screw nails, when good fracture reduction is granted. This value is higher than the one reported with single-screw nails. Therefore, we suggest the role of TAD should be reconsidered in well-reduced fractures treated with double-screw intramedullary nail.

Biomechanical evaluation of a central collinear entry reconstruction nail for femoral neck fracture prophylaxis

IntroductionReconstruction nails are commonly used to treat proximal femur fractures, with cephalic screw placement for femoral neck “prophylaxis” becoming standard practice. These implants are traditionally introduced through piriformis fossa (PF) or greater trochanter (GT) entry portals. A third “central collinear” (CC) portal has been proposed that allows entry along the femoral anatomic axis and central placement of cephalic screws. The present study aimed to quantify and compare the CC portal femoral neck strength with the two traditional (PF and GT) entry portals. Materials and MethodsEighteen cadaveric femur specimens (nine matched pairs) were divided into three groups using a balanced incomplete block design to control for variations in age and sex: (1) GT, (2) CC, and (3) PF entry points. Specimens and implants were cut to a standard length and instrumented with straight or valgus bend nails of appropriate laterality and two cephalic screws. Specimens were mounted on a custom jig replicating load distribution along the mechanical axis. A 100 N compressive preload was applied to the femoral head, followed by loading to failure at a rate of 10 mm/s until fracture, indicated by 30 % drop in axial force. Results: The three entry points did not differ in load-to-failureGT (6378.7 ± 1494.9 N), P (6912.4 ± 4924.1 N) and CC (7044.2 ± 2911.4 N) (P = 0.948) or maximum displacement, stiffness, and toughness. Most PF specimens failed at the basicervical neck, whereas most GT specimens failed at the subcapital neck; these differences were not significant. CC specimens failed evenly split between subcapital and basicervical. ConclusionThere were no significant difference in femoral neck load-to-failure after placement of a reconstruction nail through a CC entry portal when compared to both GT and PF entry. Clinically, this suggests the CC entry portal is a viable option when clinical considerations warrant its use.

Correlation between cephalic screw positioning of Standard Gamma 3 Nail for intertrochanteric fractures and cut-out incidence.

Lateral fractures of proximal femur are the most frequent fractures in elderly people. Internal fixation using medullary nails is the gold standard of treatment (Gamma 3 nail is the most implanted device) due to reduced incidence of complications than other devices. We report our experience in treating this kind of fractures with Gamma 3 nail, between January 2015 and December 2021. We performed a retrospective cohort study of patients treated in our orthopaedic department; level of clinical care is III: 559 patients (431 females and 128 males, with an average age of 85.3years) with lateral femoral neck fracture. All patients were surgically treated with Gamma 3 standard nail (SGN). We evaluated preliminary X-rays to classify fractures, according to AO-OTA classification and post-operative X-ray to verify cephalic screw position site, according to areas described by Cleveland in 1959: we measured tip-to-apex distance (TAD) and tip-to-apex calcar referred distance (CalTAD). Finally Chang reduction quality criteria (CRQC) for fracture reduction of trochanteric fractures were determined using preoperative or postoperative Antero-Posterior (AP) and lateral radiographs in a Picture Archiving and Communication System (PACS). Incidence of cut-out was evaluated in relation with these parameters. Patients were divided into 2 groups: first group had cephalic screw in optimal positions (5-8-9), the other group had cephalic screw in other positions. In 328 patients (58.7%) screw was in positions 5-8-9, in 231 patients (41.2%) screw was in not-optimal position. Median TAD was 19.1±7.0mm (range=0.0-50.5); in 463 patients (82.8%) TAD was≤25mm. Median CalTAD was 21.4±4.7mm (range=5.7-39.2); in 105 patients (79.4%) CalTAD was≤25mm. Cut-out was observed in 8 cases (1.43%). Multivariate analysis showed a significant correlation (p<0,05) between incidence of cut-out and fracture type 31A2 and with TAD values>25mm. Cephalic screw position did not influence incidence of cut-out. In order to obtain fracture healing with a low risk of failure, in particular cut-out, it is necessary to obtain good reduction of fracture and optimal lag screw position in order to achieve a TAD inferior to 25mm.

FixThePig: a custom 3D-printed femoral intramedullary nailing for preclinical research applications.

Critical-size bone defects (CSBDs) pose significant challenges in clinical orthopaedics and traumatology. Developing reliable preclinical models that accurately simulate human conditions is crucial for translational research. This study addresses the need for a reliable preclinical model by evaluating the design and efficacy of a custom-made 3D-printed intramedullary nail (IMN) specifically for CSBDs in minipigs. The study aims to answer the following questions: Can a custom-made 3D-printed IMN be designed for femoral osteosynthesis in minipigs? Does the use of the custom-made IMN result in consistent and reproducible surgical procedure, particularly in the creation and fixation of CSBDs? Can the custom-made IMN effectively treat and promote bone consolidation of CSBDs? The custom-made 3D-printed IMN can be designed to effectively create, fix and treat CSBDs in minipigs, resulting in consistent surgical outcomes. The IMN was designed based on CT scans of minipig femurs, considering factors such as femoral curvature, length, and medullary canal diameters. It was 3D-printed in titanium and evaluated through both in vitro and in vivo testing. Female Aachen minipigs underwent bilateral femoral surgeries to create and fix CSBDs using the custom-made IMN. Post-operative follow-up included X-rays and CT scans every 2weeks, with manual examination of explanted femurs to assess consolidation and mechanical stability after 3months. The custom-made IMN effectively fitted the minipig femoral anatomy and facilitated reproducible surgical outcomes. Symmetric double osteotomies were successfully performed, and allografts showed minimal morphological discrepancies. However, proximal fixation faced challenges, leading to non-union in several cases, while most distal osteotomy sites achieved stable consolidation. The custom-made 3D-printed IMN demonstrated potential in modelling and treating CSBDs in minipigs. While the design effectively supported distal bone healing, issues with proximal fixation highlight the need for further refinements. Potential improvements include better screw placement, additional mechanical support, and adaptations such as a reduction clamp or a cephalic screw to enhance stability and distribute forces more effectively.

Treatment of intertrochanteric fractures using cephalomedullary nail: One or two cephalic screws?

ObjectivesTo determine the incidence of cut-out, cut-in, cut-through, Z-effect, and reverse Z-effect in two cephalomedullary nail (CMN) systems: one with single cephalic screw fixation and the other with dual-screw fixation using a lag screw and an anti-rotation screw. MethodsA retrospective study from a cohort of patients was conducted between January 2017 and August 2019 in patients with intertrochanteric fractures treated with osteosynthesis using CMN. ResultsOne hundred ninety-six patients with intertrochanteric fractures who met the inclusion criteria were recruited. The median age was 81 years [interquartile range (IQR) 12]. Seventy-six percent had fractures classified as Orthopaedic Trauma Association/Arbeitsgemeinschaft für Osteosynthesefragen (OTA/AO) 31A2. Twenty-one mechanical complications occurred, 8.7% (17) was cut-out with a single cephalic screw CMN and 2% (4) was Z-effect with a dual-screw CMN non-integrated. The median tip-apex distance (TAD) was 19.4 mm (IQR 10.8) in patients who experienced cut-out and 19 mm (IQR 10) in those who experienced Z-effect. The median time to cut-out occurrence was 39,5 days (IQR 47,5), while the median time to Z-effect was 90 days (IQR 86). ConclusionsThe incidence of osteosynthesis failure using CMN is more frequent in patients treated with a single cephalic screw CMN. Level of EvidenceTherapeutic, Level III

Reduction quality in lateral view of X-ray and hypoalbuminemia are associated with postoperative mortality in elderly pertrochanteric fracture patients.

Pertrochanteric fracture is one of the most prevalent public health issues across the world for the elderly population. The purpose of this study was to investigate the association between surgical factors and postoperative mortality in patients with intramedullary nail-treated pertrochanteric fractures. A retrospective cohort study was designed to evaluate the pertrochanteric fracture patients treated with intramedullary nail between January 2016 to February 2021. The surgical factors included the Dorr morphology, Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association (AO/OTA) classification of fractures, the tip-apex distance (TAD), location of the cephalic screw, reduction quality in anterior-posterior (AP) and lateral views, the integrity of the lateral wall, and the design of cephalic screws. Using univariate and multivariate Cox proportional hazard models, the association between these risk factors and postoperative mortality in patients with this type of fractures was evaluated. A total of 169 pertrochanteric fracture patients treated with intramedullary nails were included in our study, with the average age of 82.68±5.93 years. The mortality rates at 3 months, 1 year, and the end of follow-up were 4.14%, 11.24%, and 26.04%, respectively. According to the univariate Cox analysis, age, gender, preoperative levels of hemoglobin (Hb) and albumin (Alb) were associated with a poor overall survival (OS) (P<0.05). After multivariate adjustment, the pre-operative level of Alb (P<0.001) and the reduction in lateral view (P<0.001) were shown to be independent risk factors for poor OS. The preoperative hypoalbuminemia and reduction quality in lateral view were associated with postoperative mortality in our study. Therefore, optimizing both parameters could improve the prognosis in elderly pertrochanteric fracture patients.

Accuracy of radiographic projections to guide cephalic screw position in pertrochanteric fracture: a cadaveric study

PurposeThe aim of this study was to evaluate the relationship between the Löwenstein Lateral view and the True Lateral view for the positioning of the cephalic hip screw, through a cadaveric study.Materials and MethodsWe placed two Kirschner wires in eight femur specimens using an Antero-Posterior view, Löwenstein Lateral view and True Lateral view. The distances between the Kirschner wires and the anterior, posterior, superior and inferior cortex were measured in all projections. The head of the femur was then sectioned, and the same macroscopic distances were measured. Finally, we could calculate the accuracy of the two radiographic lateral projections.ResultsWhen the Kirschner wire was placed in the center of the head using the Antero-Posterior and the True Lateral view, the accuracy of Antero-Posterior view was 0.9705 while the accuracy of True Lateral view and Löwenstein Lateral view was 1.1479 and 1.1584, respectively. When the Kirschner wire was placed superior on the Antero-Posterior and centrally on the True Lateral view, the accuracy of Antero-Posterior view was 0.9930 while the accuracy of True Lateral view and Löwenstein Lateral view was 1.1159 and 0.7224, respectively.ConclusionWhen the Kirschner wire was positioned proximal in Antero-Posterior view and central in True Lateral view, only the True Lateral view showed high accuracy.

Experimental and numerical analysis of the influence of intramedullary nail position on the cut-out phenomenon

Background and objectiveProximal femur fractures, colloquially known as hip fractures, are a common pathology with increasing incidence in the last years due to the enhanced ageing population. Regarding the extracapsular fracture, the treatment for this pathology consists of a fixation of the fragments using an osteosynthesis device, mainly the intramedullary nail. This repairing method implies several complications, which may include the failure of the fixation device, frequently occurring due to the “cut-out” mechanism. The present work focuses on the study of how the position of the cephalic screw, which should be fixed during surgery, affects the cut-out risk. Through experimental tests and numerical models some variables that can be critical for the cut-out phenomenon are analysed. MethodsThis study has been carried out through a numerical model based on the finite element method and experimental tests. The digital image correlation technique has been used in experimental tests to measure displacements on the femoral surface with the objective of numerical model validation. Some basic daily activities with different intramedullary nail positions have been analysed through the numerical model, considering variables that can induce the cut-out complication. ResultsThe results show how the intramedullary nail position clearly influences the cut-out risk, showing that displacements in the upper, anterior and posterior direction increase the cut-out risk, while displacement in the lower direction endangers the intramedullary nail itself. Thus, the centred position is the one which reduces the cut-out risk. ConclusionsThis work supposes an improvement in the knowledge of the cut-out phenomenon thanks to the combination of experimental testing and validated numerical models. The effects of different intramedullary nail positions in the femoral head are studied, including a novelty variable as torque, which is critical for the structural integrity of the fixation. The main conclusion of the work is the determination of the central intramedullary nail position as the most favourable one for decreasing the cut-out risk.

Intravesical Migration of a Screw during Hip Osteosynthesis: A Case Report

The incidence of fractures of the upper extremity of the femur continues to increase as the population ages. Dynamic hip screw (DHS) is the treatment of choice for stable fractures. We report the case of an 80-year-old man with no notable pathological history presenting with a pertrochanteric fracture. Intraoperatively, the cephalic screw migrated unexpectedly into the pelvis. Several attempts were made to remove it, but the screw had penetrated deep into the pelvis, making removal impossible through the femoral neck. An emergency abdominal CT scan was performed showing that the screw had penetrated into the bladder. The urological surgeon was called in to remove the screw via a medial abdominal approach, which was fnally removed without any further complications. Intravesical migration of a DHS screw is a rare complication. Compliance with the DHS surgical technique, especially in very old osteoporotic patients, can avoid this complication.

Treatment of Trochanteric Hip Fractures with Cephalomedullary Nails: Single Head Screw vs. Dual Integrated Compression Screw Systems.

Extracapsular hip fractures are very common in the elderly. They are mainly treated surgically with an intramedullary nail. Nowadays, both endomedullary hip nails with single cephalic screw systems and interlocking double screw systems are available on the market. The latter are supposed to increase rotational stability and therefore decrease the risk of collapse and cut-out. A retrospective cohort study was carried out, in which 387 patients with extracapsular hip fracture undergoing internal fixation with an intramedullary nail were included to study the occurrence of complications and reoperations. Of the 387 patients, 69% received a single head screw nail and 31% received a dual integrated compression screw nail. The median follow-up was 1.1 years, and in that time, a total of 17 reoperations were performed (4.2%; 2.1% for single head screw nails vs. 8.7% for double head screws). According to the multivariate logistic regression model adjusted for age, sex and basicervical fracture, the adjusted hazard risk of reoperation required was 3.6 times greater when using double interlocking screw systems (p = 0.017). A propensity scores analysis confirmed this finding. In conclusion, despite the potential benefits of using two interlocking head screw systems and the increased risk of reoperation in our single center, we encourage to other researchers to explore this question in a wider multicenter study.

Clinical and radiological outcome of the Chimaera short nailing system in inter- and subtrochanteric fractures.

cephalomedullary devices are popular treatment for femoral intertrochanteric or subtrochanteric fractures. Various complications include post-surgical lateral thigh pain and cut-out. To prevent those complications, a new concept cephalomedullary device system was designed (Chimaera, Orthofix®). This study aimed to evaluate the clinical and radiological outcomes in patients with femoral intertrochanteric or subtrochanteric fractures treated with the proximal femoral cephalomedullary device system. A prospective cohort study involved consecutive patients with Arbeitsgemeinschaft für Osteosynthesefragen/ Orthopaedic Trauma Association type 31-A1, 2, 3 fractures treated with the Chimaera short cephalomedullary device system from October 2016 to September 2017 at our level 1 trauma center. The Parker and Palmer mobility score and Jensen social function scores and post-surgical lateral thigh pain were assessed at 3 months post-operatively and compared to before surgery. Radiologic assessment consisted of controlling the position of the cephalic screw by using the tip-apex distance (TAD) and Cleveland zone as well as union and cut-out rates. We included 99 patients (79 women; 100 hips; one bilateral fracture 3 months after a first trochanteric fracture) with a mean follow-up of 2 years. The Parker and Palmer mobility score decreased by 22% at 3 months post-operatively as compared with the pre-fracture score (42/99 patients showed a return to their pre-injury level). The Jensen social function score increased by 16.5% at 3 months post-operatively as compared with the pre-fracture score (68/99 patients showed a return to their pre-injury level). No major intra-operative complication was recorded. Nine TAD scores were > 25mm. The mean TAD was 16.5mm (range 5-36), and the lag screw position was well positioned in most (95%) hips according to Cleveland zones. Three patients required revision surgery (one for cut-out of the lag screw, one for hip osteoarthritis and one for gluteus medius insufficiency). All patients but the one with the cut-out showed fracture union. The Chimaera short cephalomedullary device exhibited good mid-term functional and radiological outcomes.

Predictors of Failure Following Fixation of Trochanteric Fractures

BACKGROUND: Trochanteric fractures are frequent and mainly affect the elderly causing autonomy loss. Their incidence is increasing, and they are associated with substantial morbidity and high cost. AIM: The aim of our study was to identify epidemiological, radiological, and technical predictors of failure of trochanteric fracture fixation in the elderly. METHODS: We conducted a retrospective study including 188 patients aged over 65 years, who underwent surgery for trochanteric fractures, in the period between 2015 and 2020 at the orthopedics department of the Military Hospital of Tunis. The minimum follow-up was 12 months. RESULTS: Thirty-four patients had a mechanical failure (18.1% of cases), including 12 cases of cephalic screw migration (CSM) (6.4%), 12 cases of disassembly (6.4%), eight cases of malunion (4.3%), and four cases of non-union (2.1%). Bone fragility with a Singh index ≤III was associated with CSM, disassembly of fixation material, and malunion (respectively, p &lt; 0.001; p = 0.01 and p = 0.044). Reduction quality was associated with disassembly (p &lt; 0.001) and CSM (p = 0.004). Eccentric screw positioning on anteroposterior (p &lt; 0.001) and lateral views (p = 0.018), high tip-apex distance (TAD) (p &lt; 0.001), and calcar-referenced TAD (p &lt; 0.001) were predictive of CSM. Logistic regression analysis showed that poor reduction quality was an independent factor associated with the occurrence of mechanical complications. Functional outcomes were assessed using Parker and Postel Merle d’Aubigné scores. CONCLUSION: To minimize the risk of mechanical complications, the surgeon must pay close attention to the fracture reduction and to the correct positioning of the cervical screw.

Medium-Term Outcomes of a Forward-Striking Technique to Reduce Fracture Gaps during Long Cephalomedullary Nailing in Subtrochanteric Femoral Fractures

IntroductionA residual fracture gap after intramedullary nailing is a known risk factor for delayed union and non-union. This study aimed to report the outcomes of a forward-striking technique to reduce fracture gaps during long cephalomedullary nailing in subtrochanteric femoral fractures (SFFs). MethodsA retrospective cohort study was conducted on patients with SFFs treated in a single institution between February 2013 and October 2018. A total of 58 patients treated via long cephalomedullary nailing with a forward-striking technique were included. The width of the fracture gap, location of the cephalic screw, tip-apex distance (TAD), and time to bone union were evaluated using intraoperative and postoperative radiographs. Complication rates, including fixation failure, non-union, implant breakage, and infection, were assessed. The mean follow-up duration was 4 (range, 2‒8) years. ResultsOf the 58 patients (mean age, 67.9 years), 38 (65.5%) were female. Thirty-two cases (55.2%) were classified as atypical femoral fractures. The mean fracture gap reduced from 5.1 mm to 1.6 mm by forward striking (P<0.001). The reduced fracture gap was significantly greater in atypical SFFs (mean, 4.9 mm vs. 1.7 mm; P<0.001). The lag screw was located in the center-center or center-inferior zones of the femoral head in 54 patients (93.1%). The mean TAD was 14.2 mm and was under 25 mm in 55 patients (94.8%). Bone union was achieved in all cases without reoperation at a mean of 5.4 months. One incident of lag screw breakage was noted at 5 months, but bone union was achieved at 7 months. ConclusionsThe forward-striking technique with a long cephalomedullary nail demonstrated a 100% bone union rate in a consecutive series of 58 SFFs. This technique is effective in reducing the fracture gap as well as placing the cephalic screw into the optimal position. The forward-striking technique was particularly effective in reducing atypical SFFs with a transverse or short oblique configuration.

A Special Technique to Remove a Jammed Cephalic Screw from an Intramedullary Nail: A Case Report

Background: The complexity of implant removal is a well-known problem in the field of orthopedics. It is encountered mainly during the removal of plates and screws and understood by the phenomenon of seizing or cold-welding, formerly known in mechanics. In this case study, we describe a complex experience during a gamma nail removal in a 21-year-old male patient, explained by the same phenomenon of seizing or cold-welding. The case is rather unusual and rare, with no similar reports in the literature, and required a special technique of extraction. Case Report: A 21-year-old male presented to our clinic with a 5-months history of right groin pain radiating to the anterior thigh. The patient was a victim of a car accident three years ago that resulted in right femoral neck and shaft fractures, which were managed by open reduction and internal fixation by a long gamma nail with distal locking. After proper examination, the team decided to remove the implant. There was difficulty loosening the cephalic screw as it was welded to the nail. For this reason, we opted for a technique that involved making a transverse slit at the level of the anterior part of the nail which is in contact with the cephalic screw. It was followed by a hammer blow at the level of the cephalic screw, allowing it to loosen and thus allowing the screws along the femoral nail to be removed successfully. Conclusion: Our report describes a rare case of a cephalic screw cold-welded/seized into the intramedullary nail, which can be an unexpected and serious complication during intramedullary nail removal. However, our technique described in this case can be an effective way to treat such a complication.

Positioning a navigation-guided cephalic screw standard gamma 3 nail in intertrochanteric fractures: preliminary experience

Objective. Hip fractures in elderly people occur in up to 18% of women and 6% of men, with almost 50% located at lateral proximal femur. Surgical treatment prevents complications secondary to immobilization. Intramedullary fixation has the advantages of reduced blood loss and shorter surgical time. The rate of complications rate is around 20%, represented by screw jamming, refractures, implant breakage, or its medial migration, although the most common is cut-out. As a general consensus, a tip-apex-distance (TAD) of &gt; 25 mm and incorrect cephalic screw position are predictive factors of cut-out. Methods. The aim of this study is to evaluate the incidence of cut-out in patients treated with intramedullary nail fixation associated with a computer-guided system to place the cephalic screw. We present a small case series of 10 patients. Results. Interventions were performed heterogeneously by different surgeons. Mean TAD was 13.3 mm. Positioning resulted on average 2 mm lower and 1 mm anterior than planned by the system. At a mean follow-up time of 6.5 months, there were no cut-outs. Conclusions. Further studies with longer follow-up are needed, but preliminary results showed that a navigation system for cephalic screw positioning can be helpful in intramedullary fixation of proximal lateral femur fractures to prevent cut-out.

Trochanteric fractures treated by internal fixation using short intramedullary nails: Does the visual intraoperative estimation of the Tip-Apex Distance (TAD) concur with its digital postoperative measurement?

IntroductionThe tip-apex distance (TAD) is the only predictor for mechanical failure after internal fixation of trochanteric fractures. The main objective of our study was to assess whether the intraoperative visual estimation of the TAD concurred with the measurement taken on postoperative digital X-rays. We hypothesized that there was a good concordance between these 2 different methods of measurement. Materials and methodsPatients with an isolated trochanteric fracture were included in our study. A hardcopy of the intraoperative X-rays were printed, and the TAD was calculated manually. Radiological and clinical follow-ups were scheduled at 6 weeks, 3 months and 6 months during which numerical measurements of the TAD were taken. We also recorded the fracture type (AO/OTA classification), degree of osteoporosis (Singh index), surgeon experience, age and ASA score. ResultsA total of 98 patients were included in our study. Of these, 70 had a 6-month follow-up and interpretable postoperative X-rays. The mean age was 87 years, with 77.14% women and a mean ASA score of 3. The coefficient of concordance between the intra and postoperative TAD was 0.7202 (95% CI=0.4905–0.9499). The secondary displacement rate was 3.28%. The univariate analysis showed no statistically significant association between an intraoperative TAD>25mm and fracture type (p=0.7290), degree of osteoporosis (p=0.5701) and surgeon experience (p=1). Discussion/ConclusionsThere was a high degree of concordance between intraoperative visual estimation of the TAD and its measurement on postoperative digital X-rays. The treatment of unstable fractures in osteoporotic bone by junior surgeons was not a risk factor for intraoperative TAD>25mm. It is therefore important to educate young surgeons on the concept of TAD and its intraoperative visual estimation technique as it ensures that the cephalic screw is positioned properly during the fixation of trochanteric fractures. Level of EvidenceII.

Optimal fracture site compression of trochanteric region fracture managed with proximal femoral nailing at the time of surgery: Analysis of clinico-radiological and functional outcome

Objectives: Proximal Femoral Nail (PFN) with dual cephalic screw configuration is now widely used for management of trochanteric region fracture. Good fracture reduction and intraoperative achievement of optimal fracture site compression are very important surgical steps of proximal femoral nailing. There is very limited information available in literature regarding trochanteric region fracture site compression while fixation by PFN with dual cephalic screws (lag and anti-rotation screws). We are practicing a technique of intraoperative compression of fracture site by alternate tightening of lag and anti-rotation screws of PFN. Aim of this study is to evaluate the clinico-radiological and functional outcome of trochanteric region fracture management by PFN with intraoperative adequate fracture site compression achieved by this method. Materials and Methods: Total 47 patients, who underwent PFN fixation for trochanteric region fractures during September 2017 to October 2019 with 12 months follow up period, were included in this prospective study. Fractures were classified according to the AO/OTA system; the most common fracture type 31A2 (n = 28), followed by 31A1 (n = 18) and 31A3 (n = 1). At the time of PFN fixation, fracture site compression was performed by combination of two surgical steps - 1) by giving firm manual pressure towards medial direction with the help of PFN Jig after nail insertion into medullary canal, maintaining this pressure till fixation of both lag and anti-rotation screws and 2) alternate tightening of the anti-rotation and lag screws till final sitting of both screws was achieved. Clinical and radiological parameters including quality of reduction, tip-apex distance (TAD), lateral slide of lag screw, length of both cephalic screws as well as complications were measured. Functional outcome was assessed using Harris Hip Score (HHS). Results: Good reduction was achieved in 89.4% cases. Mean TAD AP (anteroposterior) was 11.6 mm, mean TAD LAT (lateral) was 11.1 mm and mean TAD Total was 22.7 mm. Overall mean lateral slide was 3.2 mm and it was more in unstable 31A2fracture. The HHS at 12 months postoperatively was excellent in 20 (42.6%), good in 16 (34.0%), fair in 5 (10.6%), and poor in 6 patients (12.8%). Conclusion: Intraoperative fracture site compression achieved by alternate tightening of the anti-rotation and lag screws of PFN shows excellent to good results in the management of trochanteric region fractures and a low incidence of complications.

Salvage of cephalomedullary nail cutout with the variable angle proximal femoral plate

IntroductionExcellent results have been published in the treatment of the trochanteric fractures in the elderly with cephalomedullary nails or compression hip screws but not free of complications. The perforation of the lag screw through the superior cortex of femoral neck or head followed by rotation and varus collapse of the head-neck fragment, also known as cut-out, is one of them. Probably total hip arthroplasty is the most common solution, but there is no systematic technique for treatment. The objective of this study is to evaluate the results obtained in the treatment of this complication using a variable angle femoral plate. Material and methodsThis retrospective study concerns patients over 65 years with peritrochanteric fractures treated with cephalomedullary nail with cut-out failure solved by re-osteosyntesis with variable angle femoral plate between 1st January 2000 and 31 st December 2017. The series includes 29 patients, 26 women and 3 men with average age 87,3. Patients were followed up clinically and radiologically at regular intervals until fracture consolidation at least 9 months. ResultsNo patients died at the first 9 months after surgery. Fracture mean consolidation has occurred in all patients in 14th weeks (6-20). Operative time was 93,2 minutes (62-129) including removal of nail. No intraoperative complications were observed. Five patients experienced medical complications and two had a superficial wound infection. The mean tip-apex distance (TAD) was 5mm (2-7mm). The neck-shaft angle was 127 degrees. The mean valgization achieved was 32 degrees (15-40). Only one patient needed a second revision surgery due to aseptic hip joint subluxation after 8 weeks of the surgery solved with total hip arthroplasty. ConclusionsThe use of variable angle femoral plate in the cut-out treatment is an attractive option which allows the valgization of the fracture to virtually physiological limits and the placement of the cephalic screw in the most sutiable position with good outcomes and few complications.

Distal locked versus unlocked intramedullary nailing for stable intertrochanteric fractures, a systematic review and meta-analysis

BackgroundIntramedullary nails have become the main treatment for intertrochanteric fractures. However, a distal locking procedure during nailing gradually raised controversy. In this study, a systematic review and meta-analysis of clinical trials was performed to summarize existing evidence, aiming to determine the safety and efficacy of distal locking or unlocking in the nailing of stable intertrochanteric fractures.MethodsAppropriate articles were identified using the most common public databases, such as PubMed, Embase, the Cochrane Library, and Google Scholar from the inception of each database to April 2019, without restriction of language, publication date, and considering ongoing trials. Eligible studies were represented by randomized controlled trials or retrospective cohort studies, comparing distal locking and unlocking for the treatment of acute stable intertrochanteric fractures in adult patients. Information regarding methodological quality, patient demographics, and clinical outcomes were extracted independently by two reviewers. Subsequently, patients were divided into a locking and unlocking group.ResultsThis study included 9 articles, comprising a total of 1978 patients with a similar baseline. The results showed that the unlocking group had a shorter operation time, less intraoperative bleeding, lower transfusion rate, and less thigh pain after the treatment of femoral intertrochanteric fracture when compared with the distal locking group. No significant differences were observed in safety-related outcomes, including mortality, infection rate, cutting out, loss of reduction, backing out of lag screws, cephalic screw breakage, nail breakage, and peri-implant fractures between the two groups. In addition, efficacy-related outcomes including nonunion, delayed healing rates, and the Harris functional score were not significantly different between the two groups.ConclusionsOur pooled analysis demonstrated that distal unlocking of stable intertrochanteric fractures can shorten the operation time, reduce intraoperative bleeding, and reduce the blood transfusion rate. The use of locked or unlocked intramedullary nailing does not affect long-term outcomes regarding complications and function.