Extent and Morbidity of Lateralization of a Trochanteric Fixation Nail Blade

Abstract

This study examined the incidence and risk factors associated with lateral helical blade migration and trochanteric pain with the trochanteric fixation nail. A retrospective review was performed of 141 cases of pertrochanteric femur fracture treated with a trochanteric fixation nail at a level I trauma center over a period of 42 months. Exclusion criteria included follow-up of less than 60 days, preexisting osteonecrosis of the femoral head, and prophylactic trochanteric fixation nail treatment. Patient demographics, operative findings, and radiographic findings were recorded. Medical records were reviewed to identify symptomatic hardware. Overall, 27 patients (19.1%) were symptomatic, and 3 (2.1%) required revision surgery for blade prominence. Of the patients, 42 (30%) had lateralization of greater than 1 cm, and 16 of these (38.1%) were symptomatic (P<.02). A risk factor for lateralization was AO classification, with 46.1% of type A2 fractures showing lateralization of greater than 1 cm. The quality of calcar reduction nearly reached statistical significance, and 44.8% of patients who had inadequate reduction had lateralization of greater than 1 cm compared with 26.4% of patients who had adequate reduction (P=.054). Lateralization of greater than 1 cm was directly associated with the presence of symptoms (P<.001) and removal of hardware because of trochanteric pain (P=.007). Multivariate analysis showed that increasing tip-apex distance, inadequate calcar reduction, and greater fracture severity were predictive of excessive lateralization of greater than 1 cm. Nearly 20% of patients had lateral hip pain associated with cephalomedullary fixation. Final lateralization of the helical blade of greater than 1 cm was a very strong predictor of symptoms. During preoperative counseling, surgeons should caution patients about this relatively frequent and likely underreported complication. [Orthopedics. 2017; 40(5):e886-e891.].

Trochanteric Fixation Nail® with Helical Blade Compared with Femoral Neck Screw for Operative Treatment of Intertrochanteric Femoral Fractures

“…The helical blade received regulatory approval in 2005 and was designed to provide stronger fixation through impaction of the cancellous bone which should increase resistance to cut-out67). However, several randomized controlled trials comparing helical blade with the lag screw in intramedullary fixations have demonstrated greatly different outcomes compared with published data and theoretical concepts789101112).…”

Laterally Protruded Cephalomedullary Nail Lag Screws are a Source of Consistent Thigh Pain After Pertrochanteric Fracture

“…When considering all reasons for revision, previous series have reported revision rates ranging from approximately 2.2%-5%. 4,27,28 In a study by Sandifer et al 10 involving 141 patients, only 2.1% of patients required reoperation due to implant lateralization, yet approximately 20% of patients exhibited lateral hip pain during the final follow-up. Conversely, in another series, only 9% of revisions were related to implant lateralization.…”

“…8,9 While a degree of protrusion from the lateral femoral cortex is intrinsic to the surgical technique and is recommended for maintaining biomechanical integrity, in certain instances, the lag screw may be overly protruded during the index procedure due to factors such as limited patient/femur size, miscalculation, or inadvertent oversight. 10 While there is no consensus as to the amount the lag screw should protrude from the lateral trochanteric cortex for a stable construct to be obtained, in some cases, revision surgery, such as change or removal of the lag screw, may be necessary. Considering the fact that most pertrochanteric fractures occur in geriatric patients and that frequent position change while lying in bed is paramount for the avoidance of pressure ulcers, painless laying on the side is further underscored.…”