Posterior Sagging After Cephalomedullary Nailing for Intertrochanteric Femur Fracture is Associated with a Separation of the Greater Trochanter

Kim, Keong-Hwan; Kang, Shin‐Geol; Lim, Eic Ju; Park, Mi Lan; Kim, Jung Jae

doi:10.1177/2151459320946013

Cited by 6 publications

(8 citation statements)

References 21 publications

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“…For the quality of fracture reduction, there has been a recent tendency for surgeons to pay more attention to the anteromedial cortex rather than to the posteromedial lesser trochanter, as has been previously described [ 31 ]. In addition, Kim et al [ 32 ] showed that greater trochanter separation was a risk factor for posterior sagging, which was caused by the instability of the posterior coronal fragment. Parry et al [ 33 ] demonstrated that calcar gapping and fracture classification were related to over-sliding of lag screws.…”

Section: Discussionmentioning

confidence: 99%

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

Song

Chang

et al. 2022

J Orthop Surg Res

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Background Anteromedial 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. Methods A 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. Results According 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. Conclusions The 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.

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Section: Discussionmentioning

confidence: 99%

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

Song

Chang

et al. 2022

J Orthop Surg Res

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“…C ustom-made synthetic osteoporotic bone samples that were designed with use of previously created computed tomography (CT) images of human hips (Tanac) were used in this study. These samples had a neck-shaft angle of 135°, anteversion of 25.8°, cancellous bone density of 7.5 pounds per cubic foot (pcf) (0.115 g/cm 3 ), cortical bone density of 60 pcf (0.92 g/cm 3 ), and a canal flare index (CFI) of 2.29. Two types of fracture lines were created.…”

Section: Sample Preparationmentioning

confidence: 99%

“…Furthermore, recent studies have shown that posterolateral fracture lines of trochanteric femoral fractures cause posterolateral instability [11][12][13][14] . Kim et al and Suzuki et al reported that the presence of a posterolateral fracture increases the risk of postoperative fragment displacement, resulting in a higher rate of implant failure and/or nonunion 3,15 . However, the etiology of instability associated with a posterolateral fracture morphology remains unclear.…”

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confidence: 99%

“…A n unstable trochanteric femoral fracture is a serious injury, with a high mortality rate of 5.4% to 24.9% within 1 year postoperatively 1,2 . Some poor postoperative outcomes may be explained by the etiology of the injury, including the presence of a lesser trochanteric fragment, severe osteoporosis, a reverse oblique trochanteric femoral fracture line, and a posterolateral fragment [3][4][5][6][7] . Recently, various options have been developed for the treatment of unstable trochanteric femoral fractures.…”

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confidence: 99%

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A Lateral Fracture Line Affects Femoral Trochanteric Fracture Instability and Swing Motion of the Intramedullary Nail

Usami,

Takada,

Kosuwon

et al. 2024

JBJS Open Access

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Background: An unstable trochanteric femoral fracture is a serious injury, with a 1-year mortality rate of 5.4% to 24.9%, for which there is currently no standard treatment method. The lag screw insertion site is one of the primary contact areas between the cortical bone and an intramedullary nail. We hypothesized that a posterolateral fracture causes intramedullary nail instability when the posterolateral fracture line interferes with lag screw insertion. The purpose of the present study was to investigate the effect of posterolateral fracture line morphology on intramedullary nail stability by simulating unstable trochanteric femoral fractures with a posterolateral fracture fragment. Methods: Eighteen custom-made synthetic osteoporotic bone samples were used in the present study. Nine samples had a posterolateral fracture line interfering with the lag screw insertion hole (Fracture A), and the other 9 had a fracture line 10 mm away from the hole (Fracture B). Cyclic loading (750 N) was applied to the femoral head 1,500 times. Movement of the end cap attached to the intramedullary nail was recorded. The amplitudes of motion in the coronal plane (coronal swing motion), sagittal plane (sagittal swing motion), and axial plane (total swing motion) were evaluated. The change in the neck-shaft angle was evaluated on photographs that were made before and after the test. Medial cortical displacement was measured before and after the test. Results: Two Fracture-A samples were excluded because the amplitude of sagittal swing motion was too large. The mean values for coronal, sagittal, and total swing motion were 1.13 ± 0.28 mm and 0.51 ± 0.09 mm (p < 0.001), 0.50 ± 0.12 mm and 0.46 ± 0.09 mm (p = 0.46), and 1.24 ± 0.24 mm and 0.69 ± 0.11 mm (p < 0.001) for Fractures A and B, respectively. The mean neck-shaft angle change was −8.29° ± 2.69° and −3.56° ± 2.35° for Fractures A and B, respectively (p = 0.002). The mean displacement of the medial cortex was 0.38 ± 1.12 mm and 0.12 ± 0.37 mm for Fractures A and B, respectively (p = 0.57). Conclusions: This study showed that an unstable trochanteric femoral fracture with a posterolateral fracture line that interferes with the lag screw insertion holes is a risk factor for increased intramedullary nail instability.

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“…It can be divided into stable and unstable fractures in Evans typing, which is mainly based on the integrity and continuity of the posterior inner wall cortex. After the stable interrotor fracture, the internal wall is intact or with a very small displacement, and the unstable interrotor fracture after the internal wall is comminuted (13). There is also a special classification in this classification.…”

Section: Introductionmentioning

confidence: 99%

Biomechanical study of extramedullary and intramedullary fixation in the treatment of unstable intertrochanteric reversed-tilt fractures of the femur

Li¹,

Li²

2022

Ann Transl Med

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Background: To investigate the efficacy of the 135° hip screw, 95° intramedullary hip screw (IMHS) and 95° hip screw in the treatment of intertrochanteric reverse dip fracture of the femur. Methods:We retrospectively analyzed 125 matched pairs of human femurs (median age 64 years) which were osteotomized at a 33° angle in the left femur and extended downward from the minor trochanter to simulate a reverse oblique intertrochanteric fracture. The right femur served as a control. The left femur (n=4) was implanted with a 135° hip screw, 95° hip screw, or IMHS. A strain detector was placed distal to the fracture site to monitor fragment strain. The lateral displacement of the proximal femur was measured by a linear variable differential transformer. An Instron tester measured stiffness, strain, and lateral displacement at 25° adduction, and 90° adduction with vertical loads on the femoral head. A 2 cm gap was then formed at the fracture site to simulate comminution and the mechanical test was repeated.Results: Before the formation of the gap, there was no significant difference in stiffness among different bone structures (P>0.05), but after the formation of the gap, the stiffness of all the adduction structures decreased (P=0.03), and the difference in adduction was statistically significant (135° hip screw: 46.6%±3%; 95° hip screw: 22.9%±2%; IMHS: 53.7%±7.8%; P<0.05). Similar results were found for the abduction and buckling positions. There was no significant difference in the lateral displacement of the gap before (P=0.92) and after (P=0.26), but a significant difference in the failure load was found (135° hip screw: 1,222±560 N; 95° hip screw: 2,566±283 N; IMHS: 4,644±518 N; P=0.02).Conclusions: There was no statistically significant difference in stiffness among different structures (P>0.05). However, in the presence of gaps, IMHS bone implant structures are much stiffer than 135° and 95° structures and have a greater destructive load.

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Posterior Sagging After Cephalomedullary Nailing for Intertrochanteric Femur Fracture is Associated with a Separation of the Greater Trochanter

Cited by 6 publications

References 21 publications

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

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

A Lateral Fracture Line Affects Femoral Trochanteric Fracture Instability and Swing Motion of the Intramedullary Nail

Biomechanical study of extramedullary and intramedullary fixation in the treatment of unstable intertrochanteric reversed-tilt fractures of the femur

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