New tip-apex distance and calcar-referenced tip-apex distance cut-offs may be the best predictors for cut-out risk after intramedullary fixation of proximal femur fractures

Cut-out is one of the most common mechanical failures in the internal fixation of trochanteric hip fractures. The tip-apex distance (TAD), and the calcar-referenced tip apex distance (CalTAD) are the radiographic parameters that most predict the risk of cut-out. The optimal CalTAD value has not yet been defined, but the optimal TAD value is reported as 25 mm or less. However, this cut-off is highly specific but poorly sensitive. The aim of this study was to determine highly specific and sensitive TAD and CalTAD values and shed light on the role of other clinical variables. A total of 604 patients were included in this retrospective cross-sectional study. For each patient the following data were recorded: number of cut-out, AO/OTA classification, quality of the reduction, type of nail, cervicodiaphyseal angle, type of distal locking, post-operative weight-bearing, TAD and CalTAD values, and the position of the screw head in the femoral head according to the Cleveland system. The incidence of cut-out across the sample was 3.1%. The median TAD in the cut-out group was 38.72, while in the no cut-out group it was 22.16. The median CalTAD in the cut-out group was 39.34, while in the no cut-out group it was 22.19. The cut-off values for TAD and CalTAD with highest value of sensitivity and specificity for the risk of cut-out were 34.8 and 35.2, respectively. The incidence of cut-out can be reduced by performing careful minimal reduction and ensuring stable fixation by avoiding TAD > 34.8 mm and CalTAD > 35.2 mm.

Improved control over implant anchorage under the use of the femoral neck system for fixation of femoral neck fractures: a technical note

Background The depth of bolt in Femoral neck system (FNS, DePuy Synthes, Oberdorf, Switzerland) is difficult to finely control as the length of the bolt is in units of 5 mm. Thus, this study introduces a method to control the depth of FNS bolt in analogue scale in patients with femoral neck fracture. Methods By the technique of control of reaming and retraction of bolt, the tip of implant could be positioned close to subchondral bone without harming it. The position of implant tip in four cases in which the introduced technique was applied was compared to that of eight cases where the standard technique was performed. Results The average tip-apex distance measured in the cases that underwent surgery using the suggested technique in this study was statistically significantly shorter than that measured in the cases that underwent surgery under manufacturer guidelines. Conclusion Even though the bolt of FNS is manufactured in the unit of 5 mm, the technique proposed in this study helps surgeons to adjust the depth of bolt for the fixation of femoral neck fracture using FNS.

Cementation of proximal femoral nails of the very elderly subject in per-trochanteric fractures

The management of pertrochanteric fractures (PTF) in the very elderly relies on early verticalisation to limit complications of the decubitus and this requires stable osteosynthesis allowing immediate full support without risk of mechanical failure. The aim of the study was to analyse the value of cementing the cervicocephalic blade during osteosynthesis with a proximal femoral nail. A prospective bicentric comparative study was con- ducted. Patients over 90 years of age with PTF were included. Centre A used a PFNA (Proximal Femoral Nail Antirotation) nail without blade cementing and Centre B used the same nail with blade cementing. The primary endpoint was the occurrence of disassembly of the osteosynthesis requiring revision surgery. Secondary endpoints were functional out- come (resumption of walking), postoperative pain and duration of surgery. Sixty-four patients were included in Centre A and 23 patients were included in Centre B. Mean age, gender, functional abilities before fracture, fracture type and tip-apex distance were comparable between the groups. Postoperative pain and duration of surgery did not show significant differences between the groups. Four patients operated on with an uncemented PFNA (6.25%) and one patient operated on with a cemented PFNA nail (4.35%) showed early dismantling. The rate of patients returning to walking was significantly higher in the cemented group (p=0.00005). No significant differences in the rate of dismantling were observed between the two groups. However, the group operated on with a cemented PFNA showed better functional recovery with a significantly higher rate of walking recovery.

Which TAD and CALTAD Cut-Offs Best Predict Cut-Out Risk for Intramedullary Fixation of Proximal Femur Fractures?

Purpose: Cut-out is one of the most common mechanical failures in the internal fixation of trochanteric hip fractures. The tip-apex distance (TAD), and the calcar-referenced tip apex distance (CalTAD) are the radiographic parameters that most predict the risk of cut-out. The optimal CalTAD value has not yet been defined, but the optimal TAD value is reported as 25 mm or less. However, this cut-off is highly specific but poorly sensitive. The aim of this study was to determine highly specific and sensitive TAD and CalTAD values and shed light on the role of other clinical variables.Methods: A total of 604 patients were included in this retrospective cross-sectional study. For each patient the following data were recorded: number of cut-out, AO/OTA classification, quality of the reduction, type of nail, cervicodiaphyseal angle, type of distal locking, post-operative weight-bearing, TAD and CalTAD values, and the position of the screw head in the femoral head according to the Cleveland system.Results: The incidence of cut-out across the sample was 3.1%. The median TAD in the cut-out group was 38.72, while in the no cut-out group it was 22.16. The median CalTAD in the cut-out group was 39.34, while in the no cut-out group it was 22.19. The cut-off values for TAD and CalTAD with highest value of sensitivity and specificity for the risk of cut-out were 34.8 and 35.2, respectively. Conclusions: The incidence of cut-out can be reduced by performing careful minimal reduction and ensuring stable fixation by avoiding TAD>34.8mm and CalTAD>35.2 mm.

How Safe and Time Consuming is the Surgical Training of Young Orthopaedic Surgeons? A Retrospective Analysis of Proximal Femur Fractures

Background Fractures of the proximal femur in the elderly population are rising. Teaching the appropriate surgical treatment of these fractures is of paramount importance. The aim of the study was to evaluate differences in outcome of surgical procedures between supervised trainees and senior surgeons. Objective Are there more surgical complications, poorer quality or an increased operating time if the procedure (in this case: fixation of proximal femur fractures) is performed by trainees under supervision in comparison to experienced surgeons. Material and Methods All patients treated with the proximal femur nail antirotation (PFNA) between 2015 and 2016 at a level one trauma centre were included in this study. The retrospective review of the 299 patients compared supervised surgical trainees and senior surgeons. Parameters included operating time, tip apex distance, position of the blade, Hb-difference, transfusion rate, surgical complications as well as mortality, and were compared between the groups. Results 153 of 299 procedures were performed by supervised surgical trainees. In comparison to senior surgeons, there was no significant difference in operating time (WA 54.48 min; OA 60.47 min; p > 0,05), Hb-difference (WA 2.8 g/dl; OA 2.6 g/dl; p > 0.05), tip-apex distance (WA 21.2 mm; OA 20.5 mm, p = 0.37) or rate of surgical complications. There was no difference in the rate of optimal blade positions between the groups (WA 87.5%; OA 89.0%; p = 0.366). Furthermore, mortality showed no difference between the groups, but was greater in older patients or high ASA grade. Conclusion Supervised surgical training during treatment of proximal femur fractures shows no increase in operating time, complications or mortality and no difference in quality. With the fast growth of the elderly population, surgical training of fragility fractures should receive more attention in the future.