Aims. Proximal femur fractures treatment can involve anterograde nailing with a single or double cephalic screw. An undesirable failure for this fixation is screw cut-out. In a single-screw nail, a tip-apex distance (TAD) greater than 25 mm has been associated with an increased risk of cut-out. The aim of the study was to examine the role of TAD as a risk factor in a cephalic double-screw nail. Methods. A retrospective study was conducted on 112 patients treated for intertrochanteric femur fracture with a double proximal screw nail (Endovis BA2; EBA2) from January to September 2021. The analyzed variables were age, sex, BMI, comorbidities, fracture type, side, time of surgery, quality of reduction, pre-existing therapy with bisphosphonate for osteoporosis, screw placement in two different views, and TAD. The last follow-up was at 12 months. Logistic regression was used to study the potential factors of screw cut-out, and receiver operating characteristic curve to identify the threshold value. Results. A total of 98 of the 112 patients met the inclusion criteria. Overall, 65 patients were female (66.3%), the mean age was 83.23 years (SD 7.07), and the mean follow-up was 378 days (SD 36). Cut-out was observed in five patients (5.10%). The variables identified by univariate analysis with p < 0.05 were included in the multivariate logistic regression model were screw placement and TAD. The TAD was significant with an odds ratio (OR) 5.03 (p = 0.012) as the screw placement with an OR 4.35 (p = 0.043) in the anteroposterior view, and OR 10.61 (p = 0.037) in the lateral view. The TAD threshold value identified was 29.50 mm. Conclusion. Our study confirmed the risk factors for cut-out in the double-screw nail are comparable to those in the single screw. We found a TAD value of 29.50 mm to be associated with a risk of cut-out in double-screw nails, when good fracture reduction is granted. This value is higher than the one reported with single-screw nails. Therefore, we suggest the role of TAD should be reconsidered in well-reduced fractures treated with double-screw intramedullary nail. Cite this article: Bone Jt Open 2024;5(6):457–463

Introduction

Failed operated intertrochanteric fractures (with screw cutout, joint penetration, varus collapse, nonunion, or femoral head avascular necrosis) pose treatment dilemmas. The ideal approach is re-osteosynthesis with autologous bone grafting. When the femoral head is unsalvageable, conversion to a prosthetic hip replacement is necessary.

Background. Dynamic Hip Screw (DHS) is the most frequently used implant in management of intertrochanteric femoral fractures. There is a known statistical relationship between a tip-apex distance (TAD) >25mm and higher rate of implant failure. Our aim was to analyse all DHS procedures performed in our trust from seventeen months and compare their TAD values to the acceptable standard of ≤25mm. Methods. All patients undergoing DHS between April 2020-August 2021 were identified from our theatre system. Additionally, those presenting to hospital with implant failures were included. Patient demographics, date of surgery, fracture classification (AO) and date/mode of failure were recorded. Intraoperative fluoroscopy images were reviewed to calculate TAD, screw location and neck shaft angles by two independent observers. Results. 215 patients were identified, five of which were excluded due to inadequate fluoroscopy. Failure was seen in 3.3% of the cohort (n=7), of which 71.4% had an unacceptable TAD. In total, 21 patients (10%) had TAD >25mm, of whom 12 had superiorly and 15 had posteriorly placed screws. There were no failures in patients with a TAD of <20mm whereas a TAD >30mm had 50% failure rate. Conclusion. This audit reinforces the importance of aiming for a low TAD (preferably <20mm) intraoperatively. It is also desirable to avoid superiorly and significantly posteriorly placed screws. Implications. Complex hip revision surgery in the elderly bears substantial financial implications to the NHS and, more importantly, causes prolonged morbidity to the patient. Adhering to established standards will ensure reduced implant failure and best patient care

Failure of cephalomedullary fixation for proximal femur fractures is an uncommon event associated with significant morbidity to the patient and cost to the healthcare system. This institution changed nailing system from the PFNA (DePuy Synthes) to InterTan (Smith and Nephew) in February 2020. To assess for non-inferiority, a retrospective review was performed on 247 patients treated for unstable proximal femur fractures (AO 31 A2; A3). Patients were identified through manual review of fluoroscopic images. Stable fracture patterns were excluded (AO 31 A1). Pre/post operative imaging, demographic data, operative time and ASA scores assessed. Internal/external imaging and national joint registry data were reviewed for follow up. No significant difference was found in overall failure rate of PFNA vs InterTan (4.84% vs 3.23%; p = 0.748). Overall, short nails were more likely to fail by cut-out than long nails (7.5% vs 1.2%; p = 0.015). Nails which failed by varus cut-out had a higher tip/apex distance (TAD) (26.2mm vs 17.0mm; p < 0.001). Of concern, varus cut-out occurred in two InterTan nails with TAD of <25mm. The PFNA enjoyed a shorter operative time for both the short (59.1 vs 71.8 mins; p = 0.022) and long nails (98.8 vs 114.3 mins; p = 0.016) with no difference in 120-day survival rate. Overall failure rates of the PFNA and InterTan nailing systems were comparable. However, the failure rate of short nails in this study is concerning. Using long nails with a lag screw design for unstable intertrochanteric femoral fractures may reduce failure rates. Cumulative frequency analysis suggests stringent tip-apex distances of less than 21mm may reduce failure rates in lag-screw design cephulomedullary nails. This dataset suggests that unstable intertrochanteric fractures may be more reliably managed with a long cephalomedullary device

A tip-apex distance (TAD) greater than 25 mm is a strong predictor of screw cut-out in patients with intertrochanteric femoral fracture treated with a dynamic hip screw (DHS). We aim to show you a simple and reliable way to check this. By calculating the sum of the distance from the tip of the screw to the apex of the femoral head on anteroposterior and lateral views the TAD is found. X-rays often have magnification errors and therefore measuring tools in digital x-ray systems will be inaccurate. The original method of calculating the TAD uses the known diameter of the screw to avoid magnification errors. We found that due to the no-cylindrical shape of the screw shaft there is potential of an inaccurate measurement. By using the distance across the highest points of the thread a more accurate TAD can be calculated. The distance across the highest points of the threads in all three of the most commonly used DHSs in the UK is 13 mm. If the measured distance from the tip of the screw to the apex of the femoral head in both the anteroposterior and lateral views is less than the measured distance across of the treaded diameter of the screw then the surgeon knows the TAD is less than 26 mm. This method can be used intraoperatively to check the TAD by looking at the fluoroscopy images in these two views

Cases of intertrochanteric hip fractures as a result of osteoporosis have been increasing in recent years. Treatment of these types of fractures is often performed with intramedullary (IM) nails or compression hip screws (CHS) . [1]. IM nails are composed of a stem, which is inserted into the medullary canal of the femur, and a lag screw that is placed inside the head of the femur. One problem with this type of device is that both the left and right femurs are fixed with IM nails that have right-hand threaded lag screws. Therefore, on left femurs, the right-handed threads may not provide satisfactory fixation in the bone. This insufficient fixation could cause rotary motion and slippage in the femoral head, which would inhibit fracture healing. This study used three-dimensional finite element analysis (FEA) to examine the fixation and rotational characteristics in reference to the thread direction of the lag screw and the relative angle between the stem and lag screw. In this study, a 3D CAD model of a left femur and four proximal femoral IM nail designs were analyzed in FEA for stress and displacement. An intertrochanteric femoral fracture was created so that the femoral head and diaphysis were separated. The four IM nails were designed to with either left or right-handed lag screw threads (figure .1) and with relative stem-lag screw angles of 125 or 135 degrees. (Traditional IM nails use a right-handed screw and a relative angle of 125 degrees.). The results showed the femoral head displacement was smaller when using the left-handed lag screw. It is thought that this difference between the left and right-handed screws is caused by the direction of rotation, which would cause the left-handed screw to tighten and the right-handed screw to loosen within the femoral head. The femoral head displacement also decreased with a screw-stem angle of 135 degrees in comparison to the standard 125 degree angle. The standard right-handed screw with 125 degree relative angle was shown to have the largest displacement of all four types of tested IM nails, whereas the left-handed, 135 relative degree design produced the smallest displacement of all four implants. These results show how using a left-handed lag screw with proper relative angles in the left femur, effectively reduces femoral head displacement when compared to traditional right-handed lag screw IM implants. This is important for the promotion of intertrochanteric fracture healing

The purpose of this investigation was to prospective compare the results of artificial femoral head replacement with those of treatment with a DHS internal fixation for unstable intertrochanteric fractures in elderly patients. Sixty-one cases of aged patients with intertrochanteric fractures were randomized into two treatment groups. All patients were followed for a minimum of four years from 9.1999 to 4.2003, 29 patients were treated with artificial femoral head replacement, the other were treated with DHS internal fixation. The clinical results of two ways for the treatment of aged patients with intertrochanteric fractures were observed. There were no significant differences between the groups in terms of functional outcomes, blood loss, or units of blood transfused. Patients treated with artificial femoral head replacement had a shorter hospital stay and operative time, less time to weight-bearing, fewer general complications, and lower mortality rate compared with those treated with the DHS internal fixation. We conclude that in elderly patients with an unstable intertrochanteric femoral fracture, a artificial femoral head replacement provides superior clinical outcomes but no advantage with regard to functional outcome when compared with a DHS internal fixation

Aims: Reverse oblique intertrochanteric fractures (OTA/ AO 31-A3) have unique biomechanical properties that confer difficulties in obtaining stable fixation with the conventional sliding dynamic condylar screw. Recent studies have recommended the use of cephalocondylic intramedullary devices for these unstable fractures. Both the Proximal Femoral Nail (PFN) and the Gamma Nail (GN) have shown good outcome results but the results of treatment with the IMHS have not been reported in the literature. Methods: Between 1999–2008 6724 consecutive hip fractures were treated at our institute. There were 2586 extracapsular fractures and 307 subtrochanteric fractures. 115 of the extracapsular fractures had a reverse oblique pattern and 63 of these were treated with the IMHS. We retrospectively reviewed clinical and radiological records for the reverse oblique intertrochanteric fractures treated with the IMHS. Follow-up duration ranged from 8 months to 6 years. Results: Among the 63 patients treated with the IMHS, 56 (88%) fractures were reduced satisfactorily with only one poorly positioned hip screw in the femoral head. There were no cases of femoral shaft fracture, screw cut-out or collapse at the fracture site. The orthopaedic complications were two cases of mal-rotation, two cases of non-union, two cases of distal locking bolts backing out, and one cracked nail. 30 day mortality was 6.5%. Conclusion: Cephalo-medullary nailing devices have been recommended for the treatment of reverse oblique intertrochanteric femoral fractures. Our clinical and radiological outcomes with the IMHS compare favourably to the results in reports where other cephalo-medullary devices have been used. Therefore we consider the IMHS a good option for the treatment of these unstable fractures

Background. Hip fractures affect annually over 350,000 people in the USA and over 1.6 million worldwide. About 50% of these numbers are intertrochanteric fractures,. The surgeon should be able to minimize the morbidity associated with the fracture by: recognizing the fracture pattern, choosing the appropriate fixation device, performing accurate reductions with ideal implant placement and being conscious of implant costs. In this study we assessed the ability of the orthopaedic surgeons to recognize fractures pattern, and choosing the ideal implant for the recognized fracture. Methods. We assessed 134 orthopaedic surgeons with questionnaires that assessed 14 different intertrochanteric femoral fractures. We evaluated the fractures as stable or unstable. We chose for each fracture the appropriate fixation device: either a Dynamic Hip Screw (for stable fractures) or an Intra Medullary Nail (for unstable ones), taking into consideration fracture's stability and implants’ costs. We compared the answers of the assessed surgeons to ours. Results. 134 orthopaedic surgeons fulfilled our questionnaires. The average agreement among the assessed surgeons and the authors for fractures’ stability distributed as follows: 78.2% agreement for the stable fractures, 86.2% for the unstable fractures. The agreement for the appropriate fixator between both groups (authors and surgeons) distributed as follows: in choosing the dynamic hip screws for the stable fractures 79.6% agreed with our choice. When choosing the Intra Medullary Nail for the unstable fractures 72.4% of the surgeons agreed with our choice. Interestingly, surgeons that their subspecialty is orthopaedic trauma tended to use more the Intra Medullary Nails in the stable fractures compared to the other surgeons. Conclusions. The majority of the assessed surgeons know to recognise inertrochanteric fractures’ stability and to choose the appropriate fixation device. 20% of surgeons did not agree with our choices. Choosing an Intra Medullary Nail for the stable fracture is not a mistake, but the wrong fixation device for the unstable fracture may cause non-union, mal-union or hardware failure, and might complicate patients’ rehabilitation and cure. We believe that a team discussion should take place for each and any case before operation, and whenever there is a doubt about fractures stability, the Iintra Medullary Nail should be chosen

Purpose: Purpose of the study is to compare the changing Tip Apex Distance (TAD) and therefore the cut out development risk during fracture healing in two different types of implant. Materials and Methods: 166 patients with intertrochanteric femur fracture were operated with proximal femoral nail between the years 1999 and 2006 in our clinic. 117 patients with avaible radiological data were studied. Group I defined as PFN, had 90 patients. Median age was 74.2 (25–93) years, 44 female and 46 male. Grup II defined as PFN-A had 27 patients. Median age was 75 (33–88) years, 18 females, 9 males. The mean of following time of patients was 48 months (12–84 months). We measured in AP radiograph the tip-apex distance (TAD) both of early postop and fracture healing time. Results: In group I change in TAD was observed in 70 (%77.7) patients. Average TAD change rate was %29 (%4–%230). In group II, change in TAD was observed in 15 (%55.6) patients, and the average TAD change rate was %12 (%5–%40). Among Group I, 3 patients had a revision surgery with cut-out complications (%3.3). Among Group II no patient had cut out complication. Discussion: While cut out was developed in 3 PFN patients, no cut-out was observed in any of PFN-A patients. Among the patients without cut-out development, 77.7 % of PFN patients and 55.6 % of PFN-A were under cut out risk. Average TAD change rate was 29% in PFN Group whereas 12% in PFN-A Group. When TAD change rates are considered, no cut-out was determined in PFN-A Group while its development risk was lower. When we investigate the cut out complication, the 3 cut out complications (%3.3) was seen in PFN. PFN-A group had no cut out complications

Aims

This study aimed to investigate the risk of postoperative complications in COVID-19-positive patients undergoing common orthopaedic procedures.

Purpose: Orthopaedic residency training requires intellectual and motor skill development. In this study we aim to develop a model to evaluate junior resident proficiency and efficiency versus senior residents in the placement of a center-center guidewire during fixation of an intertrochanteric proximal femur fracture utilizing a computer-based haptic simulator. We hypothesize the junior residents will utilize more fluoroscopy and require more time to complete the task. Method: Post-graduate year residents (PGY) 3–5s, labeled Group II, placed a single central guide pin into a femoral head utilizing a surgical simulator four times. PGY 1–2s, labeled Group I, completed the same task six times. The residents were then evaluated based on final tip-apex distance (TAD), fluoroscopy time, time to complete the task, total number of distinct attempts at pin placement for each femur construct as well as final three-dimensional location of the pin from the isometric center of the femoral head. This project was approved by the institutional IRB. Conclusion: In this study we displayed that based on our simulator model there was no statistical difference between Group I and II in time to completion, final placement on AP view, and tip-apex distance. There was a statistically significant difference in the anterior/posterior placement of the wire between the two groups, fluoroscopy time, and number of attempts per trial. Our findings suggest a computer based surgical simulator can identify measurable differences in surgical proficiency between junior and senior orthopaedic residents

Objectives

The paradoxical migration of the femoral neck element (FNE) superomedially against gravity, with respect to the intramedullary component of the cephalomedullary device, is a poorly understood phenomenon increasingly seen in the management of pertrochanteric hip fractures with the intramedullary nail. The aim of this study was to investigate the role of bidirectional loading on the medial migration phenomenon, based on unique wear patterns seen on scanning electron microscopy of retrieved implants suggestive of FNE toggling.

The February 2014 Trauma Roundup³⁶⁰ looks at: predicting nonunion; compartment Syndrome; octogenarian RTCs; does HIV status affect decision making in open tibial fractures?; flap timing and related complications; proximal humeral fractures under the spotlight; restoration of hip architecture with bipolar hemiarthroplasty in the elderly; and short versus long cephalomedullary nails for the treatment of intertrochanteric hip fractures in patients over 65 years.