Femoral intramedullary nailing is currently one of the most frequent surgical treatments for extracapsular hip-fracture fixation. Cutting-out of the lag screw is the main complication of this technique, but only few studies have approached the cutting-out focussed on femoral nailing. The aim of this study was to confirm in patients treated with intramedullary nailing not only with regard to previous reports about the association of cutting-out with technical factors, but also with regard to clinical factors not previously studied.
Case–control study of all patients sustaining a cut-out of the femoral nail was carried out and a control sample was randomly selected among all extracapsular hip-fracture patients during the study period (2005–2008). All clinical and technical variables were collected from medical records. Orthopaedic Trauma Association (AO/OTA) fracture classification, Singh Osteoporosis Index of the contralateral hip and the American Society of Anaesthesiology (ASA) criteria for preoperative clinical status were used. Statistical assessment included bivariant analysis and multivariant logistic regression analysis.
A total of 916 hip-fracture cases were treated in the study period: 33 of them (3.6%) were identified as suffering cutting-out, and 315 controls fulfilling inclusion criteria were also recruited. No statistical differences were found in age, sex or other socio-demographic variables between the two groups. Bivariant analysis showed significant differences between groups in technical variables (tip-apex distance, suboptimal placement of lag screw, fracture diastasis, inadequate fixation quality and distal static locking) and in clinical variables (osteoporosis severity, right hip affected, better previous ability for walking and better preoperative ASA status). Multivariant logistic regression analysis showed significant association only for tip-apex distance and inadequate fixation quality. Differences in distal static locking were close to statistical significance.
The strongest predictor of cutting-out in femoral nailing is tip-apex distance. This study suggests that distal static locking and other clinical conditions play an important role in this fixation failure.
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- New classification of physical status.Anesthesiology. 1963; 23: 111
- Implant-related complications in the treatment of unstable intertrochanteric fractures: meta-analysis of dynamic screw-plate versus dynamic screw-intramedullary nail devices.Int Orthop. 2003; 27: 197-203
- Costs induced by hip fractures: a prospective controlled study in Belgium.Osteopor Int. 2000; 11: 373-380
- Healing complications after internal fixation of trochanteric hip fractures: The prognostic value of osteoporosis.J Orthop Trauma. 1993; 7: 438-442
- The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip.J Bone Joint Surg Am. 1995; 77: 1058-1064
- Intramedullary versus extramedullary fixation for the treatment of intertrochanteric hip fractures.Clin Orthop Relat Res. 1998; : 87-94
- Treatment strategies for proximal femur fractures in osteoporotic patients.Osteoporos Int. 2005; 16 (Epub 2004 Oct 16): S93-S102
- Reverse obliquity and transverse fractures of the trochanteric region of the femur; a review of 101 cases.Injury. 2005; 36: 851-857
- Proximal femoral fractures: a biomechanical study to compare intramedullary and extramedullary fixation.Injury. 1994; 25: 99-104
- Intertrochanteric femoral fractures. Mechanical failure after internal fixation.J Bone Joint Surg. 1990; 72-B: 26-31
- Tip-apex distance of intramedullary devices as a predictor of cut-out failure in the treatment of peritrochanteric elderly hip fractures.Int Orthop. 2009; (July 18 [Epub ahead of print])
- How to minimize failures of fixation of unstable intertrochanteric fractures.Injury. 1995; 26: 611-614
- Failure of femoral head fixation: a cadaveric analysis of lag screw cut-out with the gamma locking nail and AO dynamic hip screw.Injury. 1997; 28: 337-341
- A comparative study of trochanteric fractures treated with the Gamma nail or the proximal femoral nail.Int Orthop. 2002; 26: 365-369
- Changes in population demographics and the future incidence of hip fracture.Injury. 2009; 40: 722-726
- Are short femoral nails superior to the sliding hip screw? A meta-analysis of 24 studies involving 3279 fractures.Int Orthop. 2006; 30: 69-78
- Cutting-out of the lag screw after internal fixation with the Asiatic gamma nail.Injury. 1998; 29: 47-53
- Failure of intertrochanteric fracture fixation with a dynamic hip screw in relation to pre-operative fracture stability and osteoporosis.Int Orthop. 2001; 25: 360-362
- Evaluation of the Singh index for measuring osteoporosis.J Bone Joint Surg Br. 1996; 78: 831-834
- Epidemiology of hip fractures in Belgrade, Serbia Montenegro, 1990–2000.Arch Orthop Trauma Surg. 2007; 127: 179-183
- A prospective trial comparing the Holland nail with the dynamic hip screw in the treatment of intertrochanteric fractures of the hip.J Bone Joint Surg Br. 2008; 90: 1073-1078
- Increased incidence of hip fractures. A population based-study in Finland.Bone. 2006; 39: 623-627
- Osteoporotic pertrochanteric hip fractures. Management and current controversies.J Bone Joint Surg Am. 2004; 86: 398-410
- Implant failures in patients with proximal fractures of the femur treated with a sliding screw device.Injury. 1989; 20: 98-100
- Fracture and dislocation classification compendium – 2007: orthopaedic trauma association classification, database and outcomes committee.J Orthop Trauma. 2007; 21: S1-S133
- The AO/ASIF proximal femoral nail antirotation (PFNA): a new design for the treatment of unstable proximal femoral fractures.Injury. 2009; 40: 428-432
- What's new in the management of proximal femoral fractures?.Injury. 2008; 39: 1309-1318
- The cost and implications of reoperation after surgery for fracture of the hip.J Bone Joint Surg. 2000; 82B: 864-866
- Cutting out of the dynamic hip screw related to its position.J Bone Joint Surg. 1992; 74B: 625
- Failure of femoral head fixation: a cadaveric analysis of lag screw cut-out with the gamma locking nail and the AO dynamic hip screw.Injury. 1998; 29: 596
- Valgus reduction of trochanteric fractures.Injury. 1993; 24: 313-316
- Review of methods to quantify lag screw placement in hip fracture fixation.Acta Orthop Belg. 2005; 71: 260-263
- Prediction of fixation failure after sliding hip screw fixation.Injury. 2004; 35: 994-998
- A prospective randomised comparison of the dynamic hip screw and the gamma locking nail.J Bone Joint Surg Br. 1993; 75: 789-793
- Changes in trabecular pattern of the upper end of the femur as an index of osteoporosis.J Bone Joint Surg Am. 1970; 52: 457-467
- Are there advances in the treatment of extracapsular hip fractures in the elderly?.Injury. 2008; 39: 140
- Prevention of hip lag screw cut-out in osteoporotic patients. Rationale and review of the literature.Bull Hosp Jt Dis. 2001–2002; 60: 84-88
- Dynamic hip screws that fail.Injury. 1991; 22: 45-46
- Femoral neck-shaft angle in extra-capsular proximal femoral fracture fixation; does it make a TAD of difference?.Injury. 2005; 36: 1361-1364
Accepted: August 6, 2010
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