Mean Tip-apex Distance Research Articles

Beyond 25 millimetres makes the difference: a prospective study on tip apex distance in dynamic hip screw treatment of intertrochanteric fractures

Background: The tip apex distance (TAD) is a key indicator of screw cut-out risk in dynamic hip screw (DHS) treatment for intertrochanteric fractures. This study sought to assess the prognostic significance of TAD in intertrochanteric fractures managed with DHS. Methods: This prospective observational study encompassed 50 patients with intertrochanteric fractures who had DHS fixing treatment. TAD was measured on postoperative radiographs. Patients were followed clinically and radiologically for a minimum of 3 months. The primary outcome was screw cut-out. Results: The mean TAD was 25.5 mm, with a range of 10 to 47 mm. Four screw cut-outs were seen, all in patients with TAD exceeding 35 mm. The mean TAD was 24.18 mm for successfully treated fractures, in contrast to 40.89 mm for those who experienced cut-out. No cut-outs were seen with TAD <25 mm. The inferior-central region of the femoral head was the predominant site for screw placement, occurring in 30% of cases. Conclusions: TAD is a dependable predictor of screw cut-out risk in DHS fixation of intertrochanteric fractures. Maintaining a TAD <25 mm and screw position in the inferior-central zone of the femoral head may help minimize cut-out risk. Surgeons should aim for proper screw placement and consider TAD when treating these fractures.

Proximal femoral fractures in the elderly. Does cement augmentation decrease mechanical failures and increase function? A retrospective cohort study

IntroductionThe management of extracapsular proximal femoral fractures (EPFF) with intramedullary nails in the elderly is hindered by osteoporosis, leading to complications that significantly impact functionality due to restrictions for full weight-bearing. We hypothesized that cement augmentation of the cephalic blade could enhance the bone-implant interface and reduce mechanical failure, thereby improving patient functionality in the management of EPFF. Materials and methodsA retrospective cohort study was conducted on patients ≥ 70 years old with type 31-A EPFF (AO/OTA classification) treated with intramedullary nailing between 2017 and 2021, with and without cephalic blade augmentation with bone cement. Evaluation included demographic, clinical/functional parameters, complications, mortality, and radiological assessment (tip-apex distance (TAD), position of the helical blade, cut-out, cut-through, and any fixation failure). ResultsFifty-eight patients were included, with 30 in the augmented group and 28 in the non-augmented group, with a median age of 88 and 86 years, respectively (p = 0.143), and a median follow-up of 17.9 and 18.2 months, respectively (p = 0.395). Both groups were comparable in terms of sex, Charlson Comorbidity Index, place of residence, pre-fracture mobility, and fracture stability. However, the non-augmented group showed worse ASA grade and pre-fracture cognitive status (p = 0.043). The most common position of the blade was center-center in both groups (96.7 % and 82.1 %, respectively) (p = 0.201). The mean TAD was 15.09 mm (±4.35) in the study group and 16.97 mm (±6.57) in the control group (p = 0.213). At one-year follow-up, there were no differences in medical complications (26.7 % and 28.6 %) (p = 1), surgical complications (6.7 % and 10.7 %) (p = 0.462), mortality (33.3 % and 21.4 %) (p = 0.385), or mechanical failure (0 % and 7.1 %) (p = 0.229). In the augmented group, one patient had intra-articular cement leak and implant infection, and a second patient presented avascular necrosis. In the non-augmented group, there was one periprosthetic fracture, one cut-out and one cut-through. ConclusionsCement augmentation in EPFF management does not improve functional outcomes or reduce mechanical complications. Furthermore, augmentation did not affect fracture reduction or the position of the helical blade in the head, nor was it associated with an increase in medical complications. However, augmentation can be considered a safe technique. Level of evidenceLevel IV.

Treatment outcomes of concomitant ipsilateral neck and trochanteric fractures using Gamma3 nails with U-blade lag screws.

This study aimed to investigate the outcomes of Gamma3 nails fitted with U-blade lag screws in the management of combined neck and trochanter fracture of the femur. Two hundred-fifty patients with fractures in the proximal femur underwent treatment using Gamma3 nails integrated with U-blade lag screws from 2015 to 2022. Among these cases, 33 had combined neck and trochanteric fractures; 8 patients were excluded because of follow-up for <1 year. The remaining data of 25 patients (7 males and 18 females) were reviewed. Bone mineral density (BMD), body mass index (BMI), tip-apex distance (TAD), extent of lag screw migration, femoral neck-shaft angle, callus formation, fracture type, and treatment failure were analyzed. The mean patient age was 76.3 (range, 61-91) years, and the mean follow-up duration was 17.3 (range, 12.5-57.3) months. The mean BMD T-scores for the spine and femoral neck were -2.3 ± 1.0 and -2.8 ± 0.7, respectively; 18 patients had T-scores ≤-2.5, indicating osteoporosis. The mean BMI was 23.2 ± 3.8 kg/m2 , and the mean operative time was 69.8 (range, 45-90) minutes. Twenty-one patients experienced injuries from slipping, 2 sustained injuries from falling, and 2 from car traffic accidents. The mean TAD was 21.6 ± 5.9 mm, with 16 patients showing <25 mm. The mean extent of lag screw migration was 5.7 ± 5.1 mm. The mean femoral neck-shaft angle on plain radiographs was 125.1 ± 8.6 degrees immediately postoperatively and 120.3 ± 9.5 degrees at the final follow-up. During the follow-up period, the first callus formation was observed at 3.8 months (range, 1.4-7.3) on plain radiographs in the anteroposterior and axial views. Based on our fracture criteria, 4 patients had a two-part fracture type, 12 patients had three-part, and 9 patients had four-part. Out of 25 patients, 3 exhibited treatment failure. No significant differences were observed between the groups with and without bone union regarding age, BMD, BMI, operative time, TAD of the lag screw, extent of lag screw migration, and femoral neck-shaft angle. The bone union was achieved in 88% of patients who underwent treatment utilizing the U-blade Gamma3 nail for concomitant ipsilateral neck and trochanteric fractures. Level IV, Therapeutic Study.

666 Audit of Tip-Apex Distance in Dynamic Hip Screw Fixation of Proximal Femoral Fractures

Abstract Aim Lag screw cutout is the commonest mechanical failure in dynamic hip screw (DHS) fixation of proximal femoral fractures. Tip-apex distance (TAD), the combined distance from the tip of the lag screw to the apex of the femoral head on AP and lateral views, is the most important predictive factor for cutout. TAD &amp;gt;25mm is associated with a high risk of cutout. The aim was to determine the proportion of DHS fixations performed in our department with ‘acceptable’ TAD (&amp;lt;25mm) and assess the impact of weekly departmental metalwork meetings. Method Retrospective data was collected of all DHS fixations performed in our department in a 6-month period. Intraoperative imaging was reviewed to determine TAD. Posters illustrating TAD recommendations were displayed in theatre, and a weekly departmental metalwork meeting was introduced, reviewing imaging from all surgeries performed. Post-intervention, a further audit cycle over a 6-month period was performed. Results 50 patients underwent DHS fixation during the initial audit cycle. Mean TAD was 22.85mm (range 15mm – 36mm); TAD exceeded 25mm in 13 cases (26%). In the second cycle (n=53), mean TAD reduced to 14.95mm (range 8.5mm – 29.4mm), with 1 case exceeding 25mm (2%). Conclusions The introduction of a weekly departmental metalwork meeting has significantly reduced the mean tip-apex distance of DHS fixations in our department, as well as the proportion of fixations with an unacceptable TAD. This should reduce the risk of lag screw cutout in these patients.

Role of Anteromedial Cortical Support for Unstable Intertrochanteric Fractures Being Treated With Cephalomedullary Nails.

Reduction quality is of paramount importance for an optimal outcome in unstable pertrochanteric fractures. The non-anatomical functional anteromedial buttress is proposed to prevent impending mechanical complications. We aimed to evaluate the role of anteromedial cortical support in preventing mechanical complications following fixation with the cephalomedullary nail. A prospective, single-arm interventional study was conducted in the Orthopaedics Department of a Combined Military Hospital (CMH) in Rawalpindi. The duration of the study was 24 months. Patients were recruited by the purposive sampling technique as per inclusion/exclusion criteria. Preoperatively, the reduction was categorized as per Baumgartner's and Chang's criteria. Post-operatively, weight bearing as tolerated was advised. Radiographs prior to discharge for loss of reduction were evaluated. Follow-up radiographic measurements of neck length, neck shaft angle, and their loss as per protocol were done at three and six months. A total of 202 patients were operated on from October 21 until August 23. Mortality at six months in 39 patients (19.3%) and loss to follow-up in 31 patients (15.3%) resulted in 132 patients with complete follow-up and having developed complications in 12 patients (9.09%). The mean age was 76.3 ± 7.98 years; males were 105 (79.5%), and females were 27 (20.5%). Closed reduction was 58 (43.9%), and additional manoeuvres were required in 74 (56.1%). The mean tip apex distance (TAD) was 24.56 ± 2.76, and the Calcar gap was 5.16 ± 1.27. Cleveland zone centre-centre in 54 (40.9%), inferior-centre in 65 (49.2%), and inferior-posterior (9.9%) were statistically significant for mechanical complications (p≤0.001). There was a significant association between the grading of Chang's and Baumgartner's poor groups for the development of mechanical complications (p≤0.001). The mean time to full weight bearing without support was 21 ± 1.22 weeks. The mean Hip Harris score at six months was 69.27 ± 7.68. Results suggest that anteromedial cortical support can lead to fewer potential mechanical complications at six months. A higher Chang's grade drives surgeons to engage in additional manoeuvres. Anteromedial cortical support is worth consideration for unstable pertrochanteric fractures.

Fellowship-Trained Orthopaedic Trauma Surgeons Achieve Better Postoperative Radiographic Parameters After Intramedullary Nailing of Intertrochanteric Femur Fractures when Compared With Non-trauma-Trained Surgeons.

Intertrochanteric femoral fractures are common orthopaedic injuries accounting for nearly 30% of all fracture-related hospitalizations. Because many factors predictive of failure are related to technical aspects of the surgery, the purpose of this study was to compare radiographic parameters after fixation, comparing fellowship-trained orthopaedic trauma surgeons with surgeons who did not complete an orthopaedic trauma fellowship. We initiated a search for CPT code 27245 across our hospital network to identify 100 consecutive patients treated by five fellowship-trained orthopaedic traumatologists and 100 consecutive patients treated by community surgeons. Patients were then stratified based on their surgeon's subspecialty training (trauma vs community). Primary outcome variables were neck-shaft angle (NSA), a comparison of the repaired NSA with the uninjured side, tip-apex distance, and reduction quality. One hundred patients were included in each group. The mean age in the community group was 77 years compared with 79 years in the trauma group. The mean tip-apex distance for the trauma group was 10 mm compared with 21 mm for the community group ( P < 0.001). The mean postoperative NSA for the trauma group was 133° compared with 127° for the community group ( P < 0.001). The mean difference of the NSA of the repaired side compared with the uninjured side was 2.5° of valgus in the trauma group compared with 5° of varus for the community group ( P < 0.001). There were 93 good reductions in the trauma group compared with 19 in the community group ( P < 0.001). There were 0 poor reductions in the trauma group and 49 in the community group ( P < 0.001). Overall, we have shown that fellowship-trained orthopaedic trauma surgeons achieve better reductions when treating intertrochanteric femur fractures with intramedullary nails. Orthopaedic residency training should emphasize teaching proper techniques and acceptable parameters for reduction and implant placement when treating geriatric intertrochanteric femur fractures.

Minimally invasive clamp-assisted reduction and long InterTAN nail fixation for Seinsheimer type V subtrochanteric fractures: a case series describing the technique and results

BackgroundSurgical treatment of Seinsheimer type V subtrochanteric fractures is extremely challenging due to the difficulty of obtaining and maintaining anatomic reduction and effective fixation. The purpose of this study was to describe a surgical technique for minimally invasive clamp-assisted reduction and long InterTAN nail fixation to manage Seinsheimer type V subtrochanteric fractures and report the clinical and radiological results.MethodsA retrospective study was conducted on patients with Seinsheimer type V subtrochanteric fractures between March 2015 and June 2021. A total of 30 patients treated via minimally invasive clamp-assisted reduction, long InterTAN nail fixation and selective augmentation with a cerclage cable were included. The following data were collected and evaluated: patient demographics, operative time, blood loss, reduction quality, tip apex distance (TAD), time to bone union, Harris hip score (HHS), visual analog score (VAS), and complications.ResultsThe mean age of the 30 patients was 64.8 years (range: 36-90 years). The mean operative time was 102.2 min (range: 70-150 min). The mean loss of blood was 318.3 ml (range: 150-600 ml). The reduction quality involved 27 cases of anatomic reduction and 3 cases of satisfactory reduction. The mean TAD was 16.3 mm (range: 8-24 mm). The mean follow-up time was 18.9 months (range: 12-48 months). The mean fracture healing time was 4.5 months (range: 3-8 months). The mean Harris score was 88.2 (range: 71-100), and the VAS score was 0.7 (range: 0-3). Delayed union of the subtrochanteric fracture site occurred in two patients. The limb length discrepancy, which was determined in 3 patients, was < 10 mm. There were no significant complications.ConclusionOur results indicate that minimally invasive clamp-assisted reduction with long InterTAN nail fixation is encouraging for Seinsheimer Type V subtrochanteric fractures, resulting in excellent reduction and fixation. Additionally, this reduction technique is simple, reliable, and effective in reducing and maintaining subtrochanteric fractures, particularly when intertrochanteric fractures are irreducible.

Improving Cephalad Lag Screw Placement in the Femoral Head During Cephalomedullary Nailing Using a Novel Augmented Reality System.

To measure the effect of a novel augmented reality software designed to aid in lag screw placement into the femoral head for cephalomedullary nails. Retrospective cohort study. Single Level I trauma center. Between November 2017 and December 2020, 114 consecutive patients with a hip fracture that underwent repair with a cephalomedullary nail by one of 2 orthopaedic trauma surgeons were reviewed. Fracture classifications included OTA/AO 31-A1, 31-A2, 31-A3, and 31-B3. The first 57 patients underwent fracture repair without the software (control) and the subsequent 57 patients underwent repair with use of the augmented reality software (AR). Tip apex distance (TAD) and femoral head zone (AP: superior, center, inferior; Lateral: anterior, center, posterior) were measured using standardized techniques. The mean TAD was lower for the AR versus control cohort (10.7 ± 2.9 mm vs. 15.4 ± 3.8 mm; P < 0.001). TAD <10 mm for AR versus control: 25 (43.9%) versus 3 (5.3%), P < 0.001. TAD <15 mm for AR versus control: 50 (87.7%) versus 44 (77.2%), P < 0.001. On the AP view, center position was achieved in 50.9% versus 7.0% of cases for the AR versus control cohort, respectively. On the lateral view, center position was achieved in 68.4% versus 12.3% of cases for the AR versus control cohort, respectively. This study suggests that use of the novel augmented reality software for assistance in lag screw positioning within the femoral head improves overall TAD and ability to achieve the center-center position. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Use of the Heracles straight blade in the treatment of intertrochanteric hip fractures: a prospective study with a 1-year follow-up.

The treatment of intertrochanteric fractures in the elderly remains challenging for orthopedic surgeons, due to aging, comorbidities, and poor bone quality. The Heracles straight blade has proven a lower rate of cut-out and femoral head displacement in biomechanical studies; however, there are currently no published clinical studies using this nail. To analyze the clinical and radiological results of the Heracles nail with the straight cephalic Heracles blade as a device to treat osteoporotic intertrochanteric fractures of the proximal femur. A total of 136 patients with trochanteric hip fractures were operated on by the same surgeon, using the Heracles nail with a straight cephalic blade. However, only 86 patients completed the 1-year follow-up both clinically and radiologically. According to the Association of Osteosynthesis classification, 38 patients (44.1%) had 31-A1, 36 patients (41.6%) had 31-A2, and 12 patients (14.1%) had 31-A3. Functional outcomes were assessed according to the Katz and Barthel scores, finding that 58% of patients recovered their original functional level, According to Barthel score, a mean loss of 11.8 points was found. The mean hospital stay was 8.22 days (mean preoperative stay of 2.71 days). The mean tip-apex distance was 15.2 mm. During the follow-up, 6 complications (6.96%) were detected: 4 cut-out, 1 cut-in, and 1 nail breakage. According to the Katz score, 58% of the patients recovered their previous functional status and 20.58% needed an additional walking aid. The mean loss in the Barthel score was 11.8 points. The Heracles nail using a cephalic straight blade has proven to be a valid treatment of trochanteric fractures, due to the functional recovery of the patients and low level of complications.

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.

Functional Outcome of Tip Apex Distance in Predicting Implant Failure in Intertrochanteric Fracture Femur Treated with Dynamic Hip Screw

Objective: To evaluate the importance of tip apex distance in implant failure in intertrochanteric fracture femur treated with Dynamic hip screw, so that optimum tip apex distance should maintain to decrease the implant failure in intertrochanteric fracture femur treated with DHS. Study Design: It was a descriptive cross sectional study. Study Setting and Duration: Patients were selected from orthopedic unit of Nishtar Hospital, Multan, from July 2020 to June 2021. Methodology: All patients meeting the inclusion criteria who presented with a femur fracture were included in the analysis. SPSS version 24.0 was used to analyse the data. Quantitative data analysis was done using means and standard deviations like age and tip apex distance. Categorical variables like gender, functional outcome and implant failure was calculated and presented as frequency and percentage. Results: A total of 81 patients with mean age of male patients were 38.51 and SD was 11.79, similarly in female patients mean age was 41.87 and SD 11.60. Mean tip apex distance in male was 16.08 and SD 8.49, in female mean tip apex distance was 15.40 and SD 9.368. Tip Apex distance was ≤ 25 cm in 61 (75.3%) patients and &gt;25 cm in 12 (24.7%) patients. As concern to the outcome variable (implant failure) 12 (14.8%) patients were having implant failure and 69 (85.2%) patients were having successful outcomes. Practical implication: The use of Dynamic Hip Screw in Intertrochanteric Fracture Femur treated would show improved clinical results and fewer hardware failures Conclusion: Tip Apex distance is a valuable measurement in dynamic hip screw fixation of Intertrochanteric fracture femur. Keywords: Fracture, Femur, Tip Apex Distance, Dynamic Hip Screw, Implant Failure, Orthopedic

Mean Tip Apex Distance in Patients undergoing Dynamic Hip Screw Fixation for Pertrochanteric Fractures without using Traction Table: A Descriptive Cross-sectional Study.

Dynamic Hip Screw fixation has shown to be equally effective compared to cephalomedullary nailing. The effectiveness of dynamic hip screw fixation for pertrochanteric fractures without using traction table is not well investigated. This study aimed to find out the mean tip apex distance in patients undergoing dynamic hip screw fixation for pertrochanteric fractures without using traction table. A descriptive cross-sectional study was conducted among patients undergoing dynamic hip screw fixation for pertrochanteric fractures without using traction table between 1 September 2021 and 30 June 2022, after getting approval from institutional review committee (Reference number: IRC-2021-08-23-02). All patients undergoing dynamic hip screw fixation for pertrochanteric fractures without using traction table were included in the study. Patients with pre-existing ipsilateral or contralateral hip deformity, contra-lateral hip prosthesis, bilateral hip fractures, and history of prior ipsilateral hip surgeries were excluded. Point estimate and 95% confidence interval were calculated. Among 45 patients, the mean tip apex distance was 20.45±6.13 mm (18.66-22.24 mm, 95% Confidence Interval). Among 45 patients, 24 (53.33%) were males and 21 (46.66%) were females. The average age of the participants was 67.75±21.33 years. The mean tip apex distance in patients undergoing dynamic hip Screw fixation for pertrochanteric fractures without using traction table was similar to that reported in other international studies. fracture fixation; hip fractures; operating tables.

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.

Treatment of Basicervical Femoral Fracture With Retractable Talon Hip Compression Screw.

BackgroundBasicervical femoral fractures (BFFs) are rare and biomechanically unstable. The goal of this study was to evaluate the effectiveness of the Talon™ DistalFix™ (Orthopedic Designs North America, Inc., Tampa, FL, USA) nail for the treatment of BFFs with a novel design.MethodologyIn this retrospective study, 25 patients with BFFs were analyzed between January 2016 and March 2020 at our institute. All patients were treated with the Talon™ DistalFix™ nail. Patients over the age of 60 years with basicervical fractures caused by low-energy trauma were included in this study. For inclusion into the study, the minimum follow-up time had to be longer than six months. The postoperative radiographic bone union, operative time, tip-apex distance (TAD), sliding distance of the lag screw, quality of fracture reduction, and major complications such as cut-out, non-union of the fracture, femoral head collapse, and cut-through were recorded. The Harris Hip Score was used to evaluate hip function at the end of the follow-up period.ResultsThe mean follow-up period was 22 months (range, 16-28 months), and the mean age was 77.8 years (range, 61-91 years). The average sliding distance of the lag screw was 5.7 mm (range, 0.2-13.1 mm). The mean TAD of immediate postoperative view was 20.8 mm (range, 18.7-23.7 mm), and the TAD was <25 mm in all cases. Radiographic union was confirmed in most cases, and the average time for radiographic union was 18.8 weeks (range, 12-25 weeks). Most fractures (90.5%) had healed with no postoperative mechanical complications (cut-out, cut-thorough, or lateral wall fracture) at the final follow-up, except for two patients. One of the two patients had no evidence of union at six months, and mild varus reduction was observed in the other patient who had shortening of >10 mm.ConclusionsAccording to the clinical and radiological findings of this study, treatment with the Talon™ DistalFix™ nail showed satisfactory results. Hence, it can be a suitable option in the treatment of BFFs.

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.

EFFECT OF LAG-SCREW POSITIONS ON FIXATION FAILURE IN PATIENTS WITH INTERTROCHANTERIC FRACTURES OF THE FEMUR

Background: The dynamic hip screw (DHS) is widely used in treating the intertrochanteric fractures of the femur in old patients. The positions of the lag screw in the femoral neck and the distance between the tip of the lag screw and the apex of the femoral head are very important for the procedure success. Objective: To assess lag-screw positions rule on failure of fixation intertrochanteric femur fractures. Patients and Methods: This was a case presentation study contained twenty patients aged ≥50 with unstable types of intertrochanteric fractures, and had been subjected to dynamic hip screws. Results: This study included (13) females and (7) males whose ages ranged between (58) to (86) years, Failure of fixation seen in 15 cases (75%) of all cases and union seen only in 5 cases (25%). The mean tip apex distance (TAD) was significantly longer when with fixation failure (p= 0.002). Relation of Location of Lag Screw to fixation failure had no statistically significant difference. Tip apex distance(TAD)was significantly longer among the studied cases with inferior-centeral (I-C) location of lag screw as compared with centeral-centeral (C-C) location of lag screw (p= 0.006). Conclusion: The Tip apex distance (TAD) wasan easy effective way which was very important to determine the location of the screw. Regardless place of the guide-pin was placed as long as the aimed position results in a tip-apex distance of greater than twenty-five millimeters. So, it was recommended to reconsider the guide pin reduction and redirection.

Implant fracture of the TFNA femoral nail

BackgroundThe TFNA (Trochanteric Fixation Nail Advanced) Proximal Femoral Nailing System (DePuy Synthes) is frequently used for intramedullary fixation of proximal femoral fractures. The aim of this study was to evaluate all TFNA implant fractures at a UK trauma unit to ascertain any patient or surgical factors associated with implant failure. MethodsA retrospective study was carried out identifying all patients that sustained a TFNA implant fracture over a five-year period. Data was collected on demographic information, ASA, co-morbidities, mechanism of injury, fracture pattern according to the AO/OTA classification, procedure details and time to failure. Radiographs were assessed by two independent reviewers to identify tip-apex distance (TAD), calcar TAD, reduction quality and union status at time of implant failure. ResultsSix cases were identified, all with implant breakage at the aperture for the proximal screw. All femoral fractures were intertrochanteric reverse obliquity type (OA/OTA 31A3). Two were traumatic fragility fractures and the remainder atraumatic. Mean time from index surgery to revision was 441 days (104–963). Mean TAD was 20.5 mm (15–24) and mean calcar TAD 24 mm (18–32). All six cases displayed radiographic non-union at the time of implant fracture. ConclusionPathological fractures resulting in reverse obliquity type fracture patterns and subsequent non-union appear to be contributory factors to TFNA breakage at the proximal screw aperture. This may be further exacerbated by alterations to the nail design from previous generations. In these patients, close follow up with clinical and radiographic surveillance should be employed. Further biomechanical and clinical studies are required to compare this finding against other nail designs.

Improved Implant Positioning of Cephalomedullary Nail for Trochanteric Fractures Using the Stryker ADAPT Navigation System

Background:Tip-apex distance (TAD) of greater than 25 mm increases the risk of cephalomedullary nail (CMN) cutout for trochanteric hip fractures. The Stryker ADAPT navigation system provides intraoperative feedback to guide implant positioning. This study compares lag screw positioning using the ADAPT to conventional methods and investigates if the use of ADAPT impacts operating room efficiency. Methods: Retrospective review of 82 consecutive patients who underwent Stryker Gamma3 CMN for a peritrochanteric hip fracture. Study groups were assigned based on use of ADAPT navigation. Primary outcome was TAD. Secondary outcomes were lag screw position, operative time, and radiation dose. Univariate analysis of covariance was used to compare primary outcome measures, controlling for fracture classification. Results: 41 patients were assigned to each group. When comparing ADAPT and conventional groups mean TAD was 14.45±3.68 and 16.41±3.78 mm (p = 0.023). A higher portion of ADAPT nails (85.4% vs 63.4%, p = 0.024) were center- center within the femoral head compared to conventional methods. There were no significant differences with regards to operative time, fluoroscopy time, or radiation dose. Conclusion: ADAPT navigation provides intraoperative feedback to achieve improved lag screw positioning, leading to improved TAD. The overall improvement in TAD does not likely reach clinical significance. The system requires minimal setup in the operating room, does not impact workflow, and the user interface is straight forward.

Outcomes of Wedge Wing in the Lag Screw for Unstable Intertrochanteric Fractures in Elderly Patients.

PurposeTo evaluate clinical-functional and radiologic outcomes of elderly patients with an unstable intertrochanteric femur fracture treated with a wedge wing in the lag screw.Materials and MethodsForty-eight patients treated with the Dyna Locking Trochanteric nail (DLT nail) to resolve an unstable intertrochanteric femur fracture were reviewed retrospectively. Based on AO/OTA classification, Fracture 31-A2 (34 cases) and 31-A3 (14 cases) were included in the analysis. We measured the femoral neck-shaft angle, tip-apex distance (TAD), Cleveland index, sliding distance of the lag screw, and time to the fracture union. The Harris Hip Score and Paker and Palmer's mobility score for clinical evaluation were used.ResultsThe mean follow-up period was 21.4 months (range, 12–34 months). The postoperative state of reduction was good in 28 cases and acceptable in 20 cases. The mean TAD was 20.5 mm. The position of the lag screw was center-center in 30 cases and center-inferior in 18 cases. The mean sliding distance of the lag screw was 3.4 mm at the last follow-up. The mean union time was 4.5 months. Two cases had complications which included a cut-out (1 case) and non-union (1 case). The mean Harris Hip Score was 86.5±8.3 (range, 76–90). Walking ability in 34 of the cases (70.8%) at last follow-up was similar to that prior to fracture.ConclusionFunctional and radiological outcomes are satisfactory using the DLT nail in the treatment of elderly patients with unstable intertrochanteric fractures; however, wedge wing in the lag screw does not prevent implant-related complications.

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.