Cephalomedullary Nail Research Articles

Calcar fracture gapping: a reliable predictor of anteromedial cortical support failure after cephalomedullary nailing for pertrochanteric femur fractures

BackgroundMaintaining anteromedial cortical support is essential for controlling sliding and decreasing postoperative implant-related complications. However, adequate fracture reduction with cortical support in immediate postoperative fluoroscopy is not invariable in postoperative follow-ups. This study was conducted to investigate the risk factors leading to anteromedial cortical support failure in follow up for pertrochanteric femur fractures treated with cephalomedullary nails.MethodsThis retrospective study enrolled 159 patients with pertrochanteric fractures (AO/OTA- 31A1 and 31A2) that fixed with cephalomedullary nails. All patients were evaluated as adequate fracture reduction in immediate postoperative fluoroscopy before leaving the operation theater. The patients were separated into two groups based on the condition of the anteromedial cortex in the postoperative 3D CT with full-range observation: those with calcar support maintained in Group 1 and those with calcar support lost in Group 2. Demographic information, fracture classification, TAD (tip-apex distance), Cal-TAD, Parker ratio, NSA (neck-shaft angle), reduction quality score, and calcar fracture gapping were collected and compared. Logistic regression analysis was conducted to explore the risk factors leading to anteromedial cortex change.ResultsAnteromedial cortical support failure was noted in 46 cases (29%). There was no significant difference between the two groups concerning age, sex, side injury, TAD, Cal-TAD, Parker ratio, or NSA. There was a significant difference in the AO/OTA fracture classification in univariate analysis but no difference in the multivariable analysis. The reduction quality score, calcar fracture gapping in the AP (anteroposterior), and lateral views were significantly associated with anteromedial cortical support failure in follow-up after cephalomedullary nailing in the multivariable analysis. The threshold value of calcar fracture gapping for the risk of loss was 4.2 mm in the AP and 3.8 mm in the lateral fluoroscopies. Mechanical complications (lateral sliding and varus) were frequently observed in the negative anteromedial cortical support group.ConclusionsGood reduction quality was a protective factor, and larger calcar fracture gapping in the AP and lateral views were risk factors leading to the postoperative loss of anteromedial cortical support. Therefore, we should pay close attention to fracture reduction and minimize the calcar fracture gap during surgery.

Surgical interventions for treating extracapsular hip fractures in older adults: a network meta-analysis.

Surgical interventions for treating extracapsular hip fractures in older adults: a network meta-analysis.

Anterior Lag Screw Position and Suboptimal Reduction in Lateral Plain as Predictors of Failure in Cephalomedullary Nailing of Intertrochanteric Fractures

Anterior Lag Screw Position and Suboptimal Reduction in Lateral Plain as Predictors of Failure in Cephalomedullary Nailing of Intertrochanteric Fractures

Cut-out risk factor analysis after intramedullary nailing for the treatment of extracapsular fractures of the proximal femur: a retrospective study

BackgroundsThe basic method of surgical treatment for extracapsular hip fractures (ECFs), including intertrochanteric fracture and basicervical fracture (BCF), is osteosynthesis. Intramedullary nails are among the most commonly used fixation devices for these fractures. Our study aimed to report the clinical outcomes of ECF treatment with two different nail devices and to analyze the risk factors associated with screw cut-out.Methods We retrospectively reviewed the medical records of 273 patients (300 cases) from a single institution who underwent surgical treatment for ECF between January 2013 and October 2018. Overall, 138 patients were eligible for the study and were divided into two groups according to the osteosynthesis device used. We evaluated the clinical outcomes of fracture surgery and performed univariate and multivariate regression analyses to identify risk factors associated with screw cut-out in each group.ResultsWe used proximal femoral nails (group 1) to treat 83 patients and cephalomedullary nails (group 2) to treat 55 patients. Nine cut-outs (group 1, 6 cases; group 2, 3 cases) occurred during follow-up. The patients’ high body mass index (BMI) (p = 0.019), BCFs (p = 0.007), non-extramedullary reduction in the anteroposterior and lateral planes (p = 0.032 and p = 0.043, respectively), and anti-rotation screw pull-outs (p = 0.041) showed a positive correlation to screw cut-out in the univariate analysis of group 1. In group 2, only BCFs was positively correlated (p = 0.020). In the multivariate analysis of group 1, the patients’ BMIs (p = 0.024) and BCFs (p = 0.024) showed a positive correlation with cut-out. Meanwhile, the multivariate analysis of group 2 did not identify any factors associated with cut-out.ConclusionsThe cut-out risk was significantly higher in the BCF cases, regardless of the nail design used. Considerable attention should be paid to treating such unstable fractures. We expect that new-generation nails using a helical blade, or interlocking derotation and interlocking screws may improve surgical outcomes.

How do cephalomedullary nails compare with extramedullary implants for adults with extracapsular hip fractures?

How do cephalomedullary nails compare with extramedullary implants for adults with extracapsular hip fractures?

Cephalomedullary nails versus extramedullary implants for extracapsular hip fractures in older adults.

Cephalomedullary nails versus extramedullary implants for extracapsular hip fractures in older adults.

Intramedullary nailing of subtrochanteric fractures in elderly patients: Comparative study of helical blade cephalomedullary nail versus reconstruction nail

IntroductionIntramedullary nailing (IMN), which is a common method for treating subtrochanteric fractures, is conducted as cephalomedullary (CMN) or reconstruction (RCN) nailing. Numerous studies have reported the effectiveness of CMN, which requires a shorter surgery time and provides stronger fixation strength with blade-type devices. However, the radiographic and clinical outcomes of the use of CMN and RCN in elderly patients aged ≥65 years have not been compared yet. This study aimed to investigate whether CMN offers superior outcomes over RCN in the treatment of subtrochanteric fractures in elderly patients. Materials and methodsThis retrospective study included 60 elderly patients (17 men and 43 women; mean age: 74.9 years) diagnosed with subtrochanteric fractures and treated with IMN with helical blade CMN (CMN group: 30 patients) or RCN (RCN group: 30 patients) between January 2013 and December 2018 with at least 1 year of follow-up period. Radiologic outcomes were evaluated based on the postoperative state of alignment and the achievement and timing of bony union at the final follow-up. Clinical outcomes were evaluated using the Merle d'Aubigné–Postel score. Radiologic and clinical outcomes in the two groups were compared and analyzed, and the occurrence of complications was examined. ResultsThe difference in malalignment between the two groups was not significant; however, the RCN group achieved more effective reduction. At the final follow-up, bony union was achieved within 18.9 weeks, on average, in 28 patients in the CMN group and within 21.6 weeks, on average, in 27 patients in the RCN group. Twenty patients in the CMN group and 26 in the RCN group showed good or better results according to the Merle d'Aubigné–Postel score. No significant differences were found for any of the parameters. ConclusionsIn the treatment of difficult subtrochanteric fractures in elderly patients, RCN can provide excellent reduction and strong fixation similar to CMN and can result in outstanding clinical and radiologic outcomes.

Low filling ratio of the distal nail segment to the medullary canal is a risk factor for loss of anteromedial cortical support: a case control study

BackgroundAnteromedial cortical support apposition (positive and/or neutral cortical relations) is crucial for surgical stability reconstruction in the treatment of trochanteric femur fractures. However, the loss of fracture reduction is frequent in follow-ups after cephalomedullary nail fixation. This paper aimed to investigate the possible predictive risk factors for postoperative loss of anteromedial cortex buttress after nail fixation.MethodsA retrospective analysis of 122 patients with AO/OTA 31A1 and A2 trochanteric femur fractures treated with cephalomedullary nails between January 2017 and December 2019 was performed. The patients were classified into two groups according to the postoperative status of the anteromedial cortical apposition in 3D CT images: Group 1 with contact “yes” (positive or anatomic) and Group 2 with contact “No” (negative, loss of contact). The fracture reduction quality score, tip-apex distance (TAD), calcar-referenced TAD (Cal-TAD), Parker ratio, neck-shaft angle (NSA), and the filling ratio of the distal nail segment to medullary canal diameter in anteroposterior (AP) and lateral fluoroscopies (taken immediately after the operation) were examined in univariate and multivariate analyses. Mechanical complications were measured and compared in follow-up radiographs.ResultsAccording to the postoperative 3D CT, 84 individuals (69%) were categorized into Group 1, and 38 individuals (31%) were classified as Group 2. The multivariate logistic regression analysis showed that the poor fracture reduction quality score (P < 0.001) and decreasing filling ratio in the lateral view (P < 0.001) were significant risk factors for the loss of anteromedial cortical contact. The threshold value for the distal nail filling ratio in lateral fluoroscopy predicting fracture reduction re-displacement was found to be 53%, with 89.3% sensitivity and 78.9% specificity. The mechanical complication (varus and over lateral sliding) rate was higher in Group 2.ConclusionsThe fracture reduction quality score and the decreasing filling ratio of the distal nail to the medullary canal in the lateral view (a novel parameter causing pendulum-like movement of the nail) were possible risk factors for postoperative loss of anteromedial cortical support.

Atypical Femur Fracture in the Setting of Long-Term Bisphosphonate use for Osteogenesis Imperfecta: A Case Report

Bisphosphonate (BP) therapy for moderate to severe osteogenesis imperfecta (OI) has become a mainstay of treatment in the last three decades. Given the significant improvements in bone mineral density and theoretical reductions in fracture risk, many patients are treated with bisphosphonates for prolonged periods of time. There currently lacks consensus in the optimal duration of BP therapy for patients with OI, and patients are often treated on a case-by-case basis. Long-term BP therapy has been associated with atypical femur fractures in adult patients treated for osteoporosis. The American Society for Bone and Mineral Research concluded that the median duration of BP therapy in patients with atypical femur fractures was 7 years. The role of long-term BP therapy in OI patients with atypical femur fractures remains unclear. Here, a case report is presented of an adolescent patient with type V OI that sustained a subtrochanteric femur fracture with features of an atypical pattern following treatment with intravenous pamidronate for 10.5 years. At the time of injury, the contralateral femur was also found to have atypical features suggestive of an impending fracture. The completed fracture was treated with closed reduction and cephalomedullary nail fixation. The impending fracture was prophylactically stabilized using the same technique. Prior to the injury, limb-length radiographs obtained to evaluate lower extremity alignment demonstrated features of an impending fracture but went unnoticed. Further studies are needed to clarify the role of long-term BP therapy in patients with OI suffering from atypical femur fractures.

Cephalomedullary Nailing versus Dynamic Hip Screw Fixation in Basicervical Femoral Neck Fracture: A Systematic Review and Meta-Analysis.

PurposeAlthough many studies have reported the use of dynamic hip screws (DHS) and cephalomedullary nailing (CMN) for basicervical femoral neck fracture (BFNF), no clear treatment protocols have been recommended. The present study aimed to compare the surgical outcomes associated with DHS and CMN to determine the appropriate fixation method for BFNF.Materials and MethodsWe systematically searched MEDLINE, Embase, and the Cochrane Library for studies published up to January 9, 2021 that compared the treatment outcomes between CMN and DHS in BFNF. The primary outcomes of the present meta-analysis were fracture union time, postoperative cut-out rate, and reoperation rate.ResultsWe included seven studies involving 353 cases of BFNF in our review. Of these, 206 patients were treated using CMN, and DHS were utilized in 147 patients. In a pooled analysis, the DHS group required a longer time to achieve fracture union compared to the CMN group [mean difference (MD): -0.41; 95% confidence interval (CI): -0.70, -0.12; p=0.006; I2=0%]. However, the cut-out and reoperation rates exhibited no statistically significant differences between the DHS and CMN groups [cut-out odds ratio (OR): 0.54; 95% CI: 0.10, 2.82; p=0.47; I2=24%, reoperation rate OR: 0.65; 95% CI: 0.15, 2.86; p=0.57; I2=19%, respectively].ConclusionStable fixation using DHS and CMN does not show a significant clinical or radiographical difference in BFNF, and the implant can be selected based on the surgeon’s preference.

Countersinking the Lag Screw or Blade During Cephalomedullary Nailing of Geriatric Intertrochanteric Femur Fractures: Less Collapse and Implant Prominence Without Increased Cutout Rates.

The lag screw or helical blade of a cephalomedullary nail facilitates controlled collapse of intertrochanteric proximal femur fractures. However, excessive collapse results in decreased hip offset and symptomatic lateral implants. Countersinking the screw or helical blade past the lateral cortex may minimize subsequent prominence, but some surgeons are concerned that this will prevent collapse and result in failure through cutout. We hypothesized that patients with countersunk lag screws or helical blades do not experience higher rates of screw or blade cutout and have less implant prominence after fracture healing. A retrospective review of 175 consecutive patients treated with cephalomedullary nails for AO/OTA 31A1-3 proximal femur fractures and a minimum 3-month follow-up and 254 patients with a 6-week follow-up at a single US level I trauma center. Patients were stratified based on countersunk versus noncountersunk lag screw or helical blade in a cephalomedullary nail. The primary outcome was the cutout rate at minimum 3 months, and the secondary outcome was radiographic collapse at minimum 6 weeks. Cutout rates were no different in patients with countersunk and noncountersunk screws and blades, and countersinking was associated with less collapse and less implant prominence at 6 weeks. Surgeons can countersink the lag screw or blade when treating intertrochanteric proximal femur fractures with a cephalomedullary nail without increasing failure rates and with the potential benefits of less prominent lateral implants and decreased collapse.

Subtrochanteric fractures: case report

Background: Subtrochanteric fractures account for around 7% to 34% of all femur fractures. Cephalo-medullary nailing is the gold standard in the repair of subtrochanteric femur fractures. Case presentation: We present a case of a medically free 21-year-old man, who was admitted with right thigh deformity and inability to bear weight after a motor vehicle accident. Standard pelvis and right femur radiographs showed a subtrochanteric femur with deformity forces of the fracture fragments. The patient was operated on with cephalo-medullary nailing using a Lowman bone holder. The fracture remained stable after cephalo-medullary fixation. The patient was discharged and was advised to continue follow-up. Conclusion: Fixation of femur subtrochanteric fracture with cephalo-medullary nailing technique using a Lowman clamp showed excellent clinical and radiographic results and a low complication rate.

Proximal femur anatomy-implant geometry discrepancies.

Objectives: Due to ongoing concern about femur anatomy-implant mismatches, this cross-sectional study aimed to create a geometric femur profile and used it to identify and quantify possible mismatches between femur anatomy and cephalomedullary nail dimensions. The work further aimed to assess whether patient demographics affect anatomy-implant coherence. Methods: One hundred skeletally mature complete femur computer tomography (CT) scans were collected and exported to software enabling landmark placement and measures with multiplanar reconstruction techniques. Results: Clinically relevant anatomy-implant discrepancies included the femur neck and shaft axis offset 6.1 ± 1.7 mm (95% CI [5.7–6.4]), femur radius of curvature 1.2 ± 0.3 m (95% CI [1.1–1.2]), femur anteversion 18.8 ± 9.2 (95% CI [16.9–20.6]). The implants reviewed in this study did not compensate for the femur neck and shaft axis offset and had a larger radius of curvature than the studied population. Clinically significant demographic geometry differences were not identified. Conclusion: There were discrepancies between femur anatomy and cephalomedullary nail implant design; however, no clinically significant femur feature inconsistency was identified among the demographic subgroups. Due to the identified anatomy-implant discrepancies, including the femur neck and shaft axis offset, we suggest that these measurements be considered for future implant design and surgical technique.

Revision Surgery in a Middle-Aged Patient with Pertrochanteric Fracture Nonunion Due to Wedge Effect Caused by Cephalomedullary Nail: A Case Report

Revision Surgery in a Middle-Aged Patient with Pertrochanteric Fracture Nonunion Due to Wedge Effect Caused by Cephalomedullary Nail: A Case Report

EPIDEMIOLOGY OF PROXIMAL FEMUR FRACTURE IN OLDER ADULTS IN A PHILANTHROPICAL HOSPITAL IN SÃO PAULO.

To evaluate the age and anthropometry profile of patients with a diagnosis of fracture of the proximal femur in older adults admitted to a philanthropic hospital in São Paulo. Retrospective observational cross-sectional study. All patients older than 59 years with femoral fractures diagnosed and hospitalized between January, 2019 and April, 2020 were included. The analysis of the 85 medical records resulted in the data collected in the present study. Anthropometry, age, sex, ethnicity, presence of comorbidities and mechanism of trauma of these patients were considered in this study. Most traumas, as expect, presented low energy mechanisms. Prevalence of 3:1 in females, aged between 60-104 and mean of 78.5 years, with an increased risk in patients over 80 years. The body mass index (BMI) between 16.53 and 39.80 with an average of 24.16 kg/m2. Being 89.4% cases of fall from own height. Proximal femur fractures in older adults occur more often in women, with a mean age of 78.5 years, normal BMI range, whose main trauma mechanism is fall to ground level. The most prevalent injury is transtrochanteric fracture, with a mean of 70.5% and the most performed treatment is internal fixation with cephalomedullary nail, with a mean of 66.1%. Level of Evidence VI, Descriptive Epidemiological Study.

Liposomal Bupivacaine Associated with Cost Savings during Postoperative Pain Management in Fragility Intertrochanteric Hip Fractures.

BackgroundIntertrochanteric hip fractures are among the most common and most expensive diagnoses in the Medicare population. Liposomal bupivacaine is a novel preparation of a commonly used analgesic agent that, when used intraoperatively, decreases narcotic requirements and hospital length of stay and increases the likelihood of discharge to home. The purpose of this investigation was to determine whether there was an economic benefit to utilizing intraoperative liposomal bupivacaine in patients with fragility intertrochanteric hip fractures in comparison to a group of patients who did not receive liposomal bupivacaine.MethodsThis is a retrospective observational study performed at two academic medical centers. Fifty-six patients with intertrochanteric hip fractures treated with cephalomedullary nail implant who received standard hip fracture pain management protocol were compared to a cohort of 46 patients with intertrochanteric hip fractures who received additional intraoperative injections of liposomal bupivacaine. All other standards of care were identical. A cost analysis was completed including the cost of liposomal bupivacaine, operating room costs, and discharge destination. Statistical significance was set at p < 0.05.ResultsAlthough the length of hospital stay was similar between the two groups (3.2 days vs. 3.8 days, p = 0.08), patients receiving intraoperative liposomal bupivacaine had a lower likelihood of discharge to a skilled nursing facility (84.8% vs. 96.4%, p = 0.002) and a longer operative time (73.4 minutes vs 67.2 minutes, p = 0.004). The cost-benefit analysis indicated that for an investment of $334.18 in the administration of 266 mg of liposomal bupivacaine, there was a relative saving of $1,323.21 compared to the control group. The benefit-cost ratio was 3.95, indicating a $3.95 benefit for each $1 spent in liposomal bupivacaine.ConclusionsDespite the increased initial cost, intraoperative use of liposomal bupivacaine was found to be a cost-effective intervention due to the higher likelihood of discharge to home during the postoperative management of patients with intertrochanteric hip fractures.

Cost-effectiveness analysis of short versus long cephalomedullary nails for treatment of stable intertrochanteric femoral fractures: a theoretical cohort study: Erratum

Cost-effectiveness analysis of short versus long cephalomedullary nails for treatment of stable intertrochanteric femoral fractures: a theoretical cohort study: Erratum

Evaluate Intraoperative Variables and Postoperative Outcomes of Intertrochanteric Fractures with Vulnerable/Broken Lateral Wall Managed with Short and Long Cephalomedullary Nail

Purpose: To evaluate intraoperative variables and postoperative outcomes of intertrochanteric fractures with vulnerable/broken lateral wall managed with short and long cephalomedullary nail. Materials and Methods: Twenty prospective cases of patients treated with LCMN and twenty retrospective cases treated with SCMN were included in the study. Intraoperative variables compared were duration of surgery, blood loss during surgery, and surgeon’s perception of surgery. Functional outcome was assessed by Parker Palmer mobility score (PPMS), Harris hip score (HHS), and Short Form-12 at one year. Radiological assessment were done at six months/one year to look for progress of fracture union, change in neck shaft angle and any signs of implant failure. Results: Duration of surgery (p&lt;0.001), blood loss during surgery (p=0.002) and surgeon’s perception of surgery (p=0.002) were significantly more in the LCMN group. The LCMN group had better functional outcome. HHS for the LCMN group was 89.15±9.53 and for the SCMN group it was 81.53±13.21 (p=0.021). PPMS for LCMN group was 8.85± 0.67 and for the SCMN group was 7.53±1.807 (p=0.005). There were four implant failures in the LCMN group as compared to none in the SCMN group (p=0.036). Conclusion: Both SCMN and LCMN are effective treatment modality for unstable intertrochanteric fractures with vulnerable/broken lateral wall and in the absence of larger study and long term follow up the superiority of one implant over the other cannot be recommended.

Early prediction of implant failures in geriatric intertrochanteric fractures with single-screw cephalomedullary nailing fixation

ObjectiveThe implant failures of intertrochanteric fractures (ITF) after single-screw cephalomedullary nailing (CMN) were multifactorially associated with various related factors. However, a comprehensive scoring system for the early prediction of implant failures is still lacking. Thus, this study aims to establish a quantification scoring system (QSS) and verify whether the QSS is reliable for predicting implant failures in geriatric ITF patients. MethodsWe established the QSS of geriatric ITF with single-screw cephalomedullary nailing within three days after surgery. The QSS included eight points totally at eight parameters, including bone quality, fracture type, reduction quality, and internal fixation placement. Then we retrospectively analyzed seventy-seven ITF (seventy-six patients) with surgical treatment between October 2016 and July 2020 in our hospital to verify whether the QSS scoring is suitable for predicting implant failures in ITF patients. ResultsImplant failures were in fifteen fractures (fifteen patients), including six cases of cut-out, eight of pending cut-out, and one of cut-through. There were three cases with 2 points in QSS, three with 3 points, five with 4 points, four with 5 points in these fifteen fractures. No fractures were with 1 point in QSS, and no implant failures when scoring over 5 points in QSS. Except for QSS scoring, no significant difference was in the collected data by binary logistic regression analysis. QSS scoring was significantly associated with implant failures (Adjusted odds ratio (OR) = 7.312; 95% confidence intervals (CI), 2.561 to 20.871; p < 0.001). In the analysis of Spearman's correlation, there was a strong correlation between QSS scoring and the occurrences of implant failures (RQSS = -0.964, p < 0.001). The ROC result indicated that QSS was reliable in predicting implant failures at the cut-off of 5 points (AUC (the area under the curve) = 0.944; 95% CI, 0.866 to 0.983; p < 0.001). ConclusionThe QSS is a useful early prediction of implant failures in geriatric ITF with cephalomedullary nailing fixation. QSS scoring more than 5 points can effectively reduce the risk of implant failures.

Reverse Contralateral Distal Femoral Locking Compression Plate for Subtrochanteric Femoral Fractures: A Comparative Retrospective Study with Cephalomedullary Nail and Technical Note

Background: Cephalomedullary nails (CMN) have been proven to be the implant of choice in Subtrochanteric Femoral Fractures. The reverse contralateral distal femoral locking compression plate (DF-LCP) is an alternative fixation in cases that are unsuitable for nailing. The comparative studies made of these two fixation techniques are inadequate. Objective: To retrospectively analyze and compare the outcomes of these two fixation techniques and demonstrate the apparent surgical technique for applying the reverse contralateral DF-LCP. Materials and Methods: The present study included patients over 18 years of age diagnosed of subtrochanteric fractures and treated with either DF-LCP or CMN. Retrospective comparative analyses of union time, operative times, estimated blood loss, and complications were conducted from their medical records and serial radiographs. The surgical technique for reverse contralateral DF-LCP fixation is also described in the present study. Results: The present study enrolled 106 eligible patients, in which 33 patients were treated with reverse contralateral DF-LCP, and 73 patients with CMN. There were no significant differences in age, gender, type of fracture, or history of smoking between the two groups. However, there were significant differences in the requirements of the open reduction technique with 26 fractures (78.8%) in the DF-LCP group and 17 fractures (23.3%) in the CMN group (p&lt;0.001). The comparative outcomes of the DF-LCP and CMN groups demonstrated the statistically significant difference in the number of malreductions or malunions, comprising four events (12.1%) and 22 events (30.1%), respectively (p=0.036). There were no statistically significant differences in terms of union time, operative time, and the amounts of estimated blood loss. Conclusion: The reverse contralateral DF-LCP fixation technique demonstrated comparable outcomes in terms of union time, operative time, and blood loss, and was deemed a safe procedure for subtrochanteric femoral fracture. Lower occurrences of malreduction or malunion complication were shown in DF-LCP group. Keywords: Subtrochanteric fracture; Reverse contralateral distal femoral locking compression plate; Cephalomedullary nail