Should Pertrochanteric and Subtrochanteric Fractures Be Treated with a Short or Long Intramedullary Nail?

Abstract

Objective: To compare major reoperations in elderly patients with pertrochanteric and subtrochanteric fractures receiving a short versus a long intramedullary nail (IMN). Design: Multicenter cohort studySetting: Eleven orthopedic departments across Denmark delivered data from the Danish Multidisciplinary Hip Fracture Registry (DMHFR) and review of healthcare records.Patients: Using surgical procedure codes for pertrochanteric and subtrochanteric fractures treated with IMN, the DMRHF was used to identify patients over 65 years of age between 2008 and 2013.Outcome measures: Major reoperations, defined as any reoperation (simple hardware removal excluded), were retrieved from the DMHFR and all healthcare records were reviewed for type of IMN and missed reoperations, including peri-implant fractures, with 2 years of follow-up. Crude logistic regression and adjustment for age, sex, and comorbidity was performed, yielding odds ratios (ORs) with 95% confidence intervals.Results: Of 2,245 pertrochanteric fractures, 1,867 were treated with a short IMN and 378 were treated with a long IMN. There was a 4.0% rate of major reoperations in the short IMN group compared to a 6.4% rate in the long IMN group. This yielded a crude OR of 1.61 (1.01-2.60) and an adjusted OR of 1.67 (1.04-2.70).Of 909 subtrochanteric fractures, 308 were treated with a short IMN and 601 with a long IMN.The rate of major reoperations was 8.4% in the short IMN group and 4.0% in the long IMN group, yielding a crude OR of 0.45 (0.25-0.80) and an adjusted OR of 0.45 (0.25-0.81). Conclusion:This is the first study confirming the theory that, for subtrochanteric fractures, a long IMN has lower rate of major reoperations compared to a short IMN. In contrast, a short IMN has lower rate of major reoperations compared to a long IMN for pertrochanteric fractures but with a lower absolute risk reduction compared to subtrochanteric IMN results. There is a need for validation of these results in other large studies, especially for pertrochanteric fractures.

Periprosthetic Fractures in Long Versus Short Proximal Femoral Nailing for Intertrochanteric Fractures: A 10-Year Single-Centre Cohort Study

“…This study also showed a failure rate of 0.97% for short PFNs and 0.52% for long PFNs. This is lower than other studies' estimates of 4%-4.1% for short nails and 3.2%-6.4% [11,19]. This may be due to the length of follow-up of our sample at 120 days compared to two years, which may not have captured all of the failures [11,19].…”

“…Several studies from the 1990s [ 8 , 9 ] and a recent meta-analysis have shown a higher incidence of periprosthetic fractures in the short PFN cohort [ 10 ]. Other studies have shown a lower reoperation rate with short PFNs [ 11 , 12 ], and no statistically significant differences have been quoted in the rates of periprosthetic fractures in systematic reviews [ 12 ].…”

A Demographic Survey of Pertrochanteric Fractures Based on the Revised Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association (AO/OTA) Classification Using 3D CT Scan Images

“…The difference in results among these studies may be related to two main factors. First, plain radiograph-based classification studies underestimate fracture stability due to the difficulty in assessing the posterior osseous fragments, hence leading to possible errors in classification [ 11 , 17 , 19 ]. In our preliminary study, 20%-40% of A1-classified fractures using plain radiographs alone were reclassified as A2 using 3D CT scan images.…”

“…The first strength of this study is the use of a homogenous cohort with a complete set of two-directional plain radiographs and 3D CT scan images leading to higher reliability in fracture classification. The second strength of our study is that fracture classification was conducted by a single surgeon with knowledge of the revised AO/OTA classification system, effectively preventing misclassification, as may be seen in studies using national registries or mail-in systems [ 13 , 19 ]. It is usually difficult to detect the knowledge of reviewing surgeons, as this would greatly affect the reliability of classification between pertrochanteric and subtrochanteric fractures [ 19 , 20 ].…”

Angle-stable interlocking nailing in a canine critical-sized femoral defect model for bone regeneration studies: In pursuit of the principle of the 3R’s

“…Interlocking nails are considered by many to be the standard of care for stabilization of critical-sized bone defects (Rhorer, 2009;Dejardin et al, 2012;Shen et al, 2016;Flagstad et al, 2021;Kang et al, 2021;Viberg et al, 2021). Intramedullary fixation is commonly used for both rodent and large animal critical gap healing models (Lindsey et al, 2006;Schoen et al, 2008;Rhorer, 2009;MSc et al, 2013;Quirk et al, 2016;Shiels et al, 2018;Ozmeric et al, 2020).…”