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

We compared the results of the surgical treatment of trochanteric hip fractures before and after surgeons had been introduced to the tip-apex distance (TAD) as a method of evaluating screw position. There were 198 fractures evaluated retrospectively and 118 after instruction. The TAD is the sum of the distance from the tip of the screw to the apex of the femoral head on antero-posterior and lateral views. This decreased from a mean of 25 mm in the control group to 20 mm in the study group (p = 0.0001). The number of mechanical failures by cut-out of the screw from the head decreased from 16 (8%) in the control group at a mean of 13 months to none in the study group at a mean of eight months (p = 0.0015). There were significantly fewer poor reductions in the study group. Our study confirms the importance of good surgical technique in the treatment of trochanteric fractures and supports the concept of the TAD as a clinically useful way of describing the position of the screw

Aims. To evaluate if, for orthopaedic trainees, additional cadaveric simulation training or standard training alone yields superior radiological and clinical outcomes in patients undergoing dynamic hip screw (DHS) fixation or hemiarthroplasty for hip fracture. Methods. This was a preliminary, pragmatic, multicentre, parallel group randomized controlled trial in nine secondary and tertiary NHS hospitals in England. Researchers were blinded to group allocation. Overall, 40 trainees in the West Midlands were eligible: 33 agreed to take part and were randomized, five withdrew after randomization, 13 were allocated cadaveric training, and 15 were allocated standard training. The intervention was an additional two-day cadaveric simulation course. The control group received standard on-the-job training. Primary outcome was implant position on the postoperative radiograph: tip-apex distance (mm) (DHS) and leg length discrepancy (mm) (hemiarthroplasty). Secondary clinical outcomes were procedure time, length of hospital stay, acute postoperative complication rate, and 12-month mortality. Procedure-specific secondary outcomes were intraoperative radiation dose (for DHS) and postoperative blood transfusion requirement (hemiarthroplasty). Results. Eight female (29%) and 20 male trainees (71%), mean age 29.4 years, performed 317 DHS operations and 243 hemiarthroplasties during ten months of follow-up. Primary analysis was a random effect model with surgeon-level fixed effects of patient condition, patient age, and surgeon experience, with a random intercept for surgeon. Under the intention-to-treat principle, for hemiarthroplasty there was better implant position in favour of cadaveric training, measured by leg length discrepancy ≤ 10 mm (odds ratio (OR) 4.08 (95% confidence interval (CI) 1.17 to 14.22); p = 0.027). There were significantly fewer postoperative blood transfusions required in patients undergoing hemiarthroplasty by cadaveric-trained compared to standard-trained surgeons (OR 6.00 (95% CI 1.83 to 19.69); p = 0.003). For DHS, there was no significant between-group difference in implant position as measured by tip-apex distance ≤ 25 mm (OR 6.47 (95% CI 0.97 to 43.05); p = 0.053). No between-group differences were observed for any secondary clinical outcomes. Conclusion. Trainees randomized to additional cadaveric training performed hip fracture fixation with better implant positioning and fewer postoperative blood transfusions in hemiarthroplasty. This effect, which was previously unknown, may be a consequence of the intervention. Further study is required. Cite this article: Bone Jt Open 2023;4(8):602–611

The treatment for trochanteric femoral fractures is still challenging. Since 2005, we are using 2 new implants: Gamma3™ nail and the PFN-A™. All patients with a fracture of the trochanteric area were included in an observational study during 3 years. Objectives were radiographics and clinics (complications) comparaison of these 2 new devices. We included 426 patients (236 Gamma3™ nails, 190 PFN-A™). We faced the epidemiological data, per and post-operative complications. The tip-apex distance and the position of the cephalic implant were studied. The 2 implants were well positionned in more than 80%, with no statistic diffferencie. We found a a cut-out rate of 1,4 % and a re-operation rate of 4,9 %. These rates of usual complications are very low in comparaison with litterature. We did not found a statistic difference between these 2 differents nails. But, we observed 2 unusual complications: for the Gamma3™ nail, a high rate of automatic distal locking failure, and for the PFN-A™, many patients complained of thigh pain resulting from a prominent cephalic blade. These 2 new complications can be avoided by small changes in the operative procedure. In our mind these 2 implants can be used for treating all patients with trochanteric fracture, but we need other studies to compare these nails with the new generation of sliding plate

Introduction. The purpose of the present study was to identify risk factors for lag-screw cut-out following osteosynthesis of intertrochanteric fractures. Materials and methods. The study was a case-control study using a sex and age matched control group. The fractures were classified according to Evans and OTA/AO classifications. Operative treatment was performed using dynamic hip-screw or cephalomedullary nailing systems. All patients were followed for at least 3–4 months postoperatively. The following risk factors were assessed: fracture type, quality of reduction by blinded assessment using a visual analogue scale, tip-apex distance (TAD) according to Baumgaertner, lag-screw positioning and other relevant additional risk factors in terms of walking ability, osteoporosis, cardio-vascular disease, neurological disease, diabetes, obesity, alcohol consumption and smoking. Results. 35 cases with lag-screw cut-out and 122 controls without cut-out, 124 women with a mean age of 84.9 (range: 51–95) years and 33 men with a mean age of 82.3 (range: 67–94) years were identified. Cut-out were significantly more frequent in OTA/AO type 31-A3 fractures (odds ratio (OR) 4.13; 95% CI: 1.50–11.36). The quality of reduction was significantly related to the risk of cut-out. The mean TAD was 26.5 mm in the case group and 21 mm in the control group. This difference was significant (chi square test p=0.046). Assessment of the lag-screw positioning showed that a central/central (OR 0.18; 95 % CI: 0.11–0.30) or central/inferior (OR 0.14; 95 % CI: 0.03–0.63) position was associated with a reduced risk for cut-out. None of the additional risk factors included in this study seemed to have any influence on the results. Conclusion. This study showed that fracture type, quality of reduction, TAD and lag-screw positioning were the most important risk factors for cut-out

Hip fracture treatment strategies continue to evolve with the goal of restoring hip fracture victims to Pre-injury Functional levels. Strategies for improved treatment have focused on fracture exposure, reduction, provisional fixation and definitive fixation with implant designs optimised for fracture union with minimal implant failure as originally proposed by Lambotte. Multiple implant designs have been conceived based on perceived inadequacies of previous generational designs. To better understand this evolutionary process, it is necessary to review the predecessors of modern fracture treatment and understand their design concepts and results. It is interesting that the modern era of surgical treatment of hip fractures actually began in 1902, when Dr Royal Whitman advocated the necessity of a closed reduction of adult hip fractures under general anesthesia and stabilisation by hip spica cast. Dr Whitman predicted the evolution of stabilisation by internal fixation and commented on this in his 1932 JBJS editorial emphasising the importance of surgical treatment of fractures. Dr Smith-Peterson, also from New York, in 1925 developed the 1st commercially successful hip implant, a tri–flanged nail. These first surgeries were performed with an open reduction, through a Smith-Petersen approach without radiographic control. This nail device was rapidly modified in the 1930's to permit insertion over a guide wire with a radiographic controlled insertion technique, a minimally invasive procedure. Nail penetration and implant failure in pertrochanteric fractures led to the rapid development of side-plates and a refocus on reduction stability. This led to a period of primary corrective osteotomies for enhanced stability, but fell out of failure after the sliding hip screw concept took hold. Originally conceived by Godoy-Moreira and Pohl independently in the 1940s, it became rapidly accepted as a method to avoid nail penetration and implant failure, unfortunately at the expense of accepting malunion and collapse of the fracture. Even the importance of rotational stability was discarded as insignificant by Holt in 1963. The concept of reduction of the Antero-Medial cortex was forgotten in favour of the Tip-apex distance as the only important variable in reduction to avoid implant cut-out. The concept of malunion of pertrochanteric fractures was simply deleted from consideration with disregard for the possible association of impaired functional recovery. Several recent papers that improved functional recovery is possible when these new implants are coupled with successful reduction strategies. Further studies are needed to identify the correct choice of implant for the appropriate fracture configuration, which may lead to a revision of our current fracture classification systems and our concepts of stability

Introduction. Unstable intertrochanteric hip fractures (AO 31A2) continue to be a challenge, as non-locking implants have shown a considerable rate of loss of reduction. Intramedullary fixation has been recommended, although screw cut-out has been identified as problematic. This study was performed to ascertain whether treatments with the established proximal femoral nail (PFN) and the newer PFNA with blade design (proximal femoral nail antirotation) have advantages over the use of the Percutaneous Compression Plate (PCCP, developed by Gotfried). Methods. Cohort study. Between March 2003 and March 2008, 134 patients with unstable fractures were treated with a PCCP, (n=44, 78.3 yrs, ASA 2.8), a PFN (n=50, 77.2 yrs, ASA 2.8), or a PFNA (n=40, 75.8 yrs, ASA 2.6). The patients (31 PCCP, 33 PFN, 30 PFNA) were then reexamined clinically and radiologically after approximately 21 months. Results. The PCCP was found to require less implantation time than the PFN and the PFNA (60 vs. 80 vs. 84 min, p<0.001) and less radiation exposition time (PCCP 139 vs. PFN 283 vs. PFNA 188 seconds, p<0.001). The rate of reoperations due to wound infections and hematomas amounted to 2% for the PCCP, 4% for the PFN, and 5% for the PFNA (p=0.799). Due to mechanical complications, 9% of patients implanted with a PCCP, 13% of those implanted with a PFN, and 5% of those implanted with a PFNA had to be reoperated (p=0.353). The cut-out rate was 2% after implantation of the PCCP, 4% after the PFN, and 5% after implantation of the PFNA (p=0.799). In one case, the shaft was fractured intraoperatively (PFNA). The tip-apex distance for the lower femoral neck screw (PCCP 22mm vs. PFN 30mm vs. PFNA 30mm, p<0.001), stress-related varisation of the collodiaphyseal (CCD) angle (4° for all implants), impaction (PCCP 5mm vs. PFN 5mm vs. PFNA 6mm, p=0.662) and femoral shortening (PCCP 3mm vs. PFN 3mm vs. PFNA 4mm, p=0.876) were not determinants of the postoperative function. On the basis of their scores according to Merle d'Aubigné and Harris, there was no variation in the results of the follow-up examinations. Conclusions. The use of the PCCP for the treatment of unstable trochanteric fractures presents a minimally invasive method of implantation, as well as a promising therapy option with regards to operation time, radiologic examination time, and rate of complications. Processes of impaction due to stress are seldom observed. No benefits could be established in an intramedullary treatment with the PFN or the PFNA; thus, it appears that the higher cost of these implants is avoidable

Aims

The aim of this paper is to review the evidence relating to the anatomy of the proximal femur, the geometry of the fracture and the characteristics of implants and methods of fixation of intertrochanteric fractures of the hip.

Although the importance of lateral femoral wall integrity is increasingly being recognised in the treatment of intertrochanteric fracture, little attention has been put on the development of a secondary post-operative fracture of the lateral wall. Patients with post-operative fractures of the lateral wall were reported to have high rates of re-operation and complication. To date, no predictors of post-operative lateral wall fracture have been reported. In this study, we investigated the reliability of lateral wall thickness as a predictor of lateral wall fracture after dynamic hip screw (DHS) implantation.

A total of 208 patients with AO/OTA 31-A1 and -A2 classified intertrochanteric fractures who received internal fixation with a DHS between January 2003 and May 2012 were reviewed. There were 103 men and 150 women with a mean age at operation of 78 years (33 to 94). The mean follow-up was 23 months (6 to 83). The right side was affected in 97 patients and the left side in 111. Clinical information including age, gender, side, fracture classification, tip–apex distance, follow-up time, lateral wall thickness and outcome were recorded and used in the statistical analysis.

Fracture classification and lateral wall thickness significantly contributed to post-operative lateral wall fracture (both p < 0.001). The lateral wall thickness threshold value for risk of developing a secondary lateral wall fracture was found to be 20.5 mm.

To our knowledge, this is the first study to investigate the risk factors of post-operative lateral wall fracture in intertrochanteric fracture. We found that lateral wall thickness was a reliable predictor of post-operative lateral wall fracture and conclude that intertrochanteric fractures with a lateral wall thickness < 20.5 mm should not be treated with DHS alone.

Cite this article: Bone Joint J 2013;95-B:1134–8.

The Gamma nail is frequently used in unstable peri-trochanteric hip fractures. We hypothesised that mechanical failure of the Gamma nail was associated with inadequate proximal three-point fixation. We identified a consecutive series of 299 Gamma nails implanted in 299 patients over a five-year period, 223 of whom fulfilled our inclusion criteria for investigation. The series included 61 men and 162 women with a mean age of 81 years (20 to 101). Their fractures were classified according to the Modified Evans’ classification and the quality of fracture reduction was graded. The technical adequacy of three points of proximal fixation was recorded from intra-operative fluoroscopic images, and technical inadequacy for each point was defined. All patients were followed to final follow-up and mechanical failures were identified. A multivariate statistical analysis was performed, adjusting for confounders. A total of 16 failures (7.2%) were identified. The position of the lag screw relative to the lateral cortex was the most important point of proximal fixation, and when inadequate the failure rate was 25.8% (eight of 31: odds ratio 7.5 (95% confidence interval 2.5 to 22.7), p < 0.001).

Mechanical failure of the Gamma nail in peri-trochanteric femoral fractures is rare (< 1%) when three-point proximal fixation is achieved. However, when proximal fixation is inadequate, failure rates increase. The strongest predictor of failure is positioning the lateral end of the lag screw short of the lateral cortex. Adherence to simple technical points minimises the risk of fixation failure in this vulnerable patient group.

Cite this article: Bone Joint J 2013;95-B:825–30.

This prospective multicentre study was undertaken to determine whether the timing of the post-operative administration of bisphosphonate affects fracture healing and the rate of complication following an intertrochanteric fracture. Between August 2008 and December 2009, 90 patients with an intertrochanteric fracture who underwent internal fixation were randomised to three groups according to the timing of the commencement of risedronate treatment after surgery: Group A (from one week after surgery), Group B (from one month after surgery), and Group C (from three months after surgery). The radiological time to fracture healing was assessed as the primary endpoint, and the incidence of complications, including excessive displacement or any complication requiring revision surgery, as the secondary endpoint. The mean time to fracture healing post-operatively in groups A, B and C was 10.7 weeks (sd 4.4), 12.9 weeks (sd 6.2) and 12.3 weeks (sd 7.1), respectively (p = 0.420). At 24 weeks after surgery, all fractures had united, except six that had a loss of fixation. Functional outcomes at one year after surgery according to the Koval classification (p = 0.948) and the incidence of complications (p = 0.386) were similar in the three groups.

This study demonstrates that the timing of the post-operative administration of bisphosphonates does not appear to affect the rate of healing of an intertrochanteric fracture or the incidence of complications.