Research progress on distal interlocking screws of cephalomedullary nails in intertrochanteric fractures_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

QI Yiming , WANG Xiaoxu ,  CHANG Shimin

Department of Orthopaedic Surgery, Yangpu Hospital, School of Medicine, Tongji University, Shanghai, 200090, P. R. China;

Corresponding author：

CHANG Shimin, Email: shiminchang11@aliyun.com

Keywords：

Intertrochanteric fractures; cephalomedullary nail; distal interlocking screw; biomechanical study; clinical study; complication

DOI：

10.7507/1002-1892.202312052

Video：

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Objective To summarize the new research progress in distal interlocking screws of cephalomedullary nails for the treatment of intertrochanteric fractures. Methods Relevant domestic and foreign literature was extensively reviewed to summarize the static/dynamic types of distal interlocking screw holes, biomechanical studies, clinical studies and application principles, effects on toggling in the cavity, and related complications of distal interlocking screws.Results The mode of the distal interlocking screw holes can be divided into static and dynamic. Distal interlocking screws play the role of anti-rotation, maintaining femur length, resisting compression stress, increasing torque stiffness, resisting varus stress, etc. The number of the screws directly affects the toggling of the main nail in the cavity. At present, regardless of whether long or short nails are used, distal interlocking screws are routinely inserted in clinical practice. However, using distal interlocking screws can significantly increase the duration of anesthesia and operation, increase fluoroscopy exposure time, surgical blood loss, and incision length. There is a trend of trying not to use distal interlocking screws in recent years. No significant difference is found in some studies between the effectiveness of dynamic and static interlocking for AO/Orthopaedic Trauma Association (AO/OTA) 31-A1/2 fractures. At present, the selection of the number and mode of distal interlocking screws is still controversial. When inserting distal interlocking screws, orthopedists should endeavor to minimize the occurrence of complications concerning miss shot, vascular injuries, local stress stimulation, and peri-implant fractures. Conclusion Distal interlocking screws are mainly used to prevent rotation. For stable fractures with intact lateral walls, long cephalomedullary nails can be used without distal interlocking screws. For any type of intertrochanteric fractures, distal interlocking screws are required when using short cephalomedullary nails for fixation. Different interlocking modes, the number of interlocking screws, and the application prospects of absorbable interlocking screws may be future research directions.

Citation： QI Yiming, WANG Xiaoxu, CHANG Shimin. Research progress on distal interlocking screws of cephalomedullary nails in intertrochanteric fractures. Chinese Journal of Reparative and Reconstructive Surgery, 2024, 38(3): 356-362. doi: 10.7507/1002-1892.202312052 Copy

1.	李清, 张世民. 头髓钉治疗股骨粗隆间骨折中远侧交锁螺钉应用的研究进展. 中国修复重建外科杂志, 2014, 28(9): 1177-1180.
2.	Lewis SR, Macey R, Gill JR, et al. Cephalomedullary nails versus extramedullary implants for extracapsular hip fractures in older adults. Cochrane Database Syst Rev, 2022, 1(1): CD000093.
3.	Konda SR, Maseda M, Leucht P, et al. Observational prospective unblinded case-control study to evaluate the effect of the Gamma3^® distal targeting system for long nails on radiation exposure and time for distal screw placement. Injury, 2023, 54(2): 677-682.
4.	Gao H, Liu Z, Wang G, et al. A new accurate, simple and less radiation exposure device for distal locking of femoral intramedullary nails. Int J Gen Med, 2021, 14: 4145-4153.
5.	Buruian A, Silva Gomes F, Roseiro T, et al. Distal interlocking for short trochanteric nails: static, dynamic or no locking? Review of the literature and decision algorithm. EFORT Open Rev, 2020, 5(7): 421-429.
6.	Saggi SS, Chou SM, Wong HPN, et al. Effect of distal interlocking of a cephalomedullary femoral nail on peri-implant fractures: A sawbone biomechanical analysis. Injury, 2022, 53(12): 3894-3898.
7.	Kane P, Vopat B, Paller D, et al. A biomechanical comparison of locked and unlocked long cephalomedullary nails in a stable intertrochanteric fracture model. J Orthop Trauma, 2014, 28(12): 715-720.
8.	Vopat BG, Kane PM, Mansuripur PK, et al. The effects of distal interlocking screws on torsional stability in three-part intertrochanteric hip fractures. Springerplus, 2015, 4: 413.
9.	Tisherman RT, Hankins ML, Moloney GB, et al. Distal locking of short cephalomedullary nails decreases varus collapse in unstable intertrochanteric fractures-a biomechanical analysis. Injury, 2021, 52(3): 414-418.
10.	Hegde A, Khanna V, Mane P, et al. A comparative analysis of distal locked and unlocked long proximal femoral nail antirotation (PFNA-Ⅱ) in the fixation of stable intertrochanteric fractures. Chin J Traumatol, 2023, 26(2): 111-115.
11.	Lil NA, Makwana VR, Patel TD, et al. Comparative study of intertrochanteric fracture fixation using proximal femoral nail with and without distal interlocking screws. World J Orthop, 2022, 13(3): 267-277.
12.	Li YH, Yu T, Shao W, et al. Distal locked versus unlocked intramedullary nailing for stable intertrochanteric fractures, a systematic review and meta-analysis. BMC Musculoskelet Disord, 2020, 21(1): 461.
13.	Ciaffa V, Vicenti G, Mori CM, et al. Unlocked versus dynamic and static distal locked femoral nails in stable and unstable intertrochanteric fractures. A prospective study. Injury, 2018, 49 Suppl 3: S19-S25.
14.	Caiaffa V, Vicenti G, Mori C, et al. Is distal locking with short intramedullary nails necessary in stable pertrochanteric fractures? A prospective, multicentre, randomised study. Injury, 2016, 47 Suppl 4: S98-S106.
15.	Li X, Zhang L, Hou Z, et al. Distal locked and unlocked nailing for perthrochanteric fractures—a prospective comparative randomized study. Int Orthop, 2015, 39(8): 1645-1652.
16.	Skála-Rosenbaum J, Džupa V, Bartoška R, et al. Distal locking in short hip nails: Cause or prevention of peri-implant fractures? Injury, 2016, 47(4): 887-892.
17.	Hernández-Pascual C, Santos-Sánchez JÁ, García-González JM, et al. Long-term outcomes of distal locking in extracapsular fractures treated with trochanteric Gamma3 nails. J Orthop Traumatol, 2021, 22(1): 48.
18.	Hulshof GWL, van der Stelt M, Schutte H, et al. Locking in trochanteric fractures: a comparison of static versus dynamic locking using the Gamma3 nail. Eur J Orthop Surg Traumatol, 2023, 33(5): 1797-1804.
19.	Vopat BG, Kane PM, Truntzer J, et al. Is distal locking of long nails for intertrochanteric fractures necessary? A clinical study. J Clin Orthop Trauma, 2014, 5(4): 233-239.
20.	Song H, Chang SM, Hu SJ, et al. Low filling ratio of the distal nail segment to the medullary canal is a risk factor for loss of anteromedial cortical support: a case control study. J Orthop Surg Res, 2022, 17(1): 27.
21.	Chang SM, Wang ZH, Tian KW, et al. A sophisticated fracture classification system of the proximal femur trochanteric region (AO/OTA-31A) based on 3D-CT images. Front Surg, 2022, 9: 919225.
22.	George AV, Bober K, Eller EB, et al. Short cephalomedullary nail toggle: a closer examination. OTA Int, 2022, 5(1): e185.
23.	Shivashankar B, Keshkar S. Intertrochanteric fractures: Ten commandments for how to get good results with proximal femoral nailing. Indian J Orthop, 2021, 55(3): 521-524.
24.	Vergouwen M, James MG, You DZ, et al. Trends in implementation of evidence-based hip fracture management in a major Canadian city. OTA Int, 2023, 6(2): e274.
25.	张世民. 老年髋部转子间骨折. 北京: 科学出版社, 2023: 181-282, 507-513.
26.	Sammarco GJ, Burstein AH, Davis WL, et al. The biomechanics of torsional fractures: the effect of loading on ultimate properties. J Biomech, 1971, 4(2): 113-117.
27.	Burstein AH, Currey J, Frankel VH, et al. Bone strength. The effect of screw holes. J Bone Joint Surg (Am), 1972, 54(6): 1143-1156.
28.	Reilly DT, Burstein AH. The elastic and ultimate properties of compact bone tissue. J Biomech, 1975, 8(6): 393-405.
29.	Cho HM, Choi SM, Park JY, et al. A finite element analysis and cyclic load experiment on an additional transcortical-type hole formed around the proximal femoral nail system’s distal locking screw. BMC Musculoskelet Disord, 2022, 23(1): 92.
30.	Vande Voorde K, Dauwe J, Van Oost J. Late presentation of an iatrogenic pseudoaneurysm of the profunda femoris artery following intramedullary nailing. Case Rep Orthop, 2018, 2018: 8270256.
31.	Segal D, Yaacobi E, Marom N, et al. The incidence of life threatening iatrogenic vessel injury following closed or open reduction and internal fixation of intertrochanteric femoral factures. Int Orthop, 2017, 41(9): 1845-1850.
32.	Barquet A, Gelink A, Giannoudis PV. Proximal femoral fractures and vascular injuries in adults: Incidence, aetiology and outcomes. Injury, 2015, 46(12): 2297-2313.
33.	Yang KH, Yoon CS, Park HW, et al. Position of the superficial femoral artery in closed hip nailing. Arch Orthop Trauma Surg, 2004, 124(3): 169-172.
34.	Lanzetti RM, Caraffa A, Lupariello D, et al. Comparison between locked and unlocked intramedullary nails in intertrochanteric fractures. Eur J Orthop Surg Traumatol, 2018, 28(4): 649-658.
35.	Breceda A, Sands A, Zderic I, et al. Biomechanical analysis of peri-implant fractures in short versus long cephalomedullary implants following pertrochanteric fracture consolidation. Injury, 2021, 52(1): 60-65.
36.	Daner WE, Owen JR, Wayne JS, et al. Biomechanical evaluation of the risk of secondary fracture around short versus long cephalomedullary nails. Eur J Orthop Surg Traumatol, 2017, 27(8): 1103-1108.
37.	Hesse B, Gächter A. Complications following the treatment of trochanteric fractures with the gamma nail. Arch Orthop Trauma Surg, 2004, 124(10): 692-698.
38.	Halonen LM, Stenroos A, Vasara H, et al. Peri-implant fracture: a rare complication after intramedullary fixation of trochanteric femoral fracture. Arch Orthop Trauma Surg, 2022, 142(12): 3715-3720.
39.	Efstathopoulos N, Nikolaou VS, Xypnitos FN, et al. Investigation on the distal screw of a trochanteric intramedullary implant (Fi-nail) using a simplified finite element model. Injury, 2010, 41(3): 259-265.

1. 李清, 张世民. 头髓钉治疗股骨粗隆间骨折中远侧交锁螺钉应用的研究进展. 中国修复重建外科杂志, 2014, 28(9): 1177-1180.
2. Lewis SR, Macey R, Gill JR, et al. Cephalomedullary nails versus extramedullary implants for extracapsular hip fractures in older adults. Cochrane Database Syst Rev, 2022, 1(1): CD000093.
3. Konda SR, Maseda M, Leucht P, et al. Observational prospective unblinded case-control study to evaluate the effect of the Gamma3^® distal targeting system for long nails on radiation exposure and time for distal screw placement. Injury, 2023, 54(2): 677-682.
4. Gao H, Liu Z, Wang G, et al. A new accurate, simple and less radiation exposure device for distal locking of femoral intramedullary nails. Int J Gen Med, 2021, 14: 4145-4153.
5. Buruian A, Silva Gomes F, Roseiro T, et al. Distal interlocking for short trochanteric nails: static, dynamic or no locking? Review of the literature and decision algorithm. EFORT Open Rev, 2020, 5(7): 421-429.
6. Saggi SS, Chou SM, Wong HPN, et al. Effect of distal interlocking of a cephalomedullary femoral nail on peri-implant fractures: A sawbone biomechanical analysis. Injury, 2022, 53(12): 3894-3898.
7. Kane P, Vopat B, Paller D, et al. A biomechanical comparison of locked and unlocked long cephalomedullary nails in a stable intertrochanteric fracture model. J Orthop Trauma, 2014, 28(12): 715-720.
8. Vopat BG, Kane PM, Mansuripur PK, et al. The effects of distal interlocking screws on torsional stability in three-part intertrochanteric hip fractures. Springerplus, 2015, 4: 413.
9. Tisherman RT, Hankins ML, Moloney GB, et al. Distal locking of short cephalomedullary nails decreases varus collapse in unstable intertrochanteric fractures-a biomechanical analysis. Injury, 2021, 52(3): 414-418.
10. Hegde A, Khanna V, Mane P, et al. A comparative analysis of distal locked and unlocked long proximal femoral nail antirotation (PFNA-Ⅱ) in the fixation of stable intertrochanteric fractures. Chin J Traumatol, 2023, 26(2): 111-115.
11. Lil NA, Makwana VR, Patel TD, et al. Comparative study of intertrochanteric fracture fixation using proximal femoral nail with and without distal interlocking screws. World J Orthop, 2022, 13(3): 267-277.
12. Li YH, Yu T, Shao W, et al. Distal locked versus unlocked intramedullary nailing for stable intertrochanteric fractures, a systematic review and meta-analysis. BMC Musculoskelet Disord, 2020, 21(1): 461.
13. Ciaffa V, Vicenti G, Mori CM, et al. Unlocked versus dynamic and static distal locked femoral nails in stable and unstable intertrochanteric fractures. A prospective study. Injury, 2018, 49 Suppl 3: S19-S25.
14. Caiaffa V, Vicenti G, Mori C, et al. Is distal locking with short intramedullary nails necessary in stable pertrochanteric fractures? A prospective, multicentre, randomised study. Injury, 2016, 47 Suppl 4: S98-S106.
15. Li X, Zhang L, Hou Z, et al. Distal locked and unlocked nailing for perthrochanteric fractures—a prospective comparative randomized study. Int Orthop, 2015, 39(8): 1645-1652.
16. Skála-Rosenbaum J, Džupa V, Bartoška R, et al. Distal locking in short hip nails: Cause or prevention of peri-implant fractures? Injury, 2016, 47(4): 887-892.
17. Hernández-Pascual C, Santos-Sánchez JÁ, García-González JM, et al. Long-term outcomes of distal locking in extracapsular fractures treated with trochanteric Gamma3 nails. J Orthop Traumatol, 2021, 22(1): 48.
18. Hulshof GWL, van der Stelt M, Schutte H, et al. Locking in trochanteric fractures: a comparison of static versus dynamic locking using the Gamma3 nail. Eur J Orthop Surg Traumatol, 2023, 33(5): 1797-1804.
19. Vopat BG, Kane PM, Truntzer J, et al. Is distal locking of long nails for intertrochanteric fractures necessary? A clinical study. J Clin Orthop Trauma, 2014, 5(4): 233-239.
20. Song H, Chang SM, Hu SJ, et al. Low filling ratio of the distal nail segment to the medullary canal is a risk factor for loss of anteromedial cortical support: a case control study. J Orthop Surg Res, 2022, 17(1): 27.
21. Chang SM, Wang ZH, Tian KW, et al. A sophisticated fracture classification system of the proximal femur trochanteric region (AO/OTA-31A) based on 3D-CT images. Front Surg, 2022, 9: 919225.
22. George AV, Bober K, Eller EB, et al. Short cephalomedullary nail toggle: a closer examination. OTA Int, 2022, 5(1): e185.
23. Shivashankar B, Keshkar S. Intertrochanteric fractures: Ten commandments for how to get good results with proximal femoral nailing. Indian J Orthop, 2021, 55(3): 521-524.
24. Vergouwen M, James MG, You DZ, et al. Trends in implementation of evidence-based hip fracture management in a major Canadian city. OTA Int, 2023, 6(2): e274.
25. 张世民. 老年髋部转子间骨折. 北京: 科学出版社, 2023: 181-282, 507-513.
26. Sammarco GJ, Burstein AH, Davis WL, et al. The biomechanics of torsional fractures: the effect of loading on ultimate properties. J Biomech, 1971, 4(2): 113-117.
27. Burstein AH, Currey J, Frankel VH, et al. Bone strength. The effect of screw holes. J Bone Joint Surg (Am), 1972, 54(6): 1143-1156.
28. Reilly DT, Burstein AH. The elastic and ultimate properties of compact bone tissue. J Biomech, 1975, 8(6): 393-405.
29. Cho HM, Choi SM, Park JY, et al. A finite element analysis and cyclic load experiment on an additional transcortical-type hole formed around the proximal femoral nail system’s distal locking screw. BMC Musculoskelet Disord, 2022, 23(1): 92.
30. Vande Voorde K, Dauwe J, Van Oost J. Late presentation of an iatrogenic pseudoaneurysm of the profunda femoris artery following intramedullary nailing. Case Rep Orthop, 2018, 2018: 8270256.
31. Segal D, Yaacobi E, Marom N, et al. The incidence of life threatening iatrogenic vessel injury following closed or open reduction and internal fixation of intertrochanteric femoral factures. Int Orthop, 2017, 41(9): 1845-1850.
32. Barquet A, Gelink A, Giannoudis PV. Proximal femoral fractures and vascular injuries in adults: Incidence, aetiology and outcomes. Injury, 2015, 46(12): 2297-2313.
33. Yang KH, Yoon CS, Park HW, et al. Position of the superficial femoral artery in closed hip nailing. Arch Orthop Trauma Surg, 2004, 124(3): 169-172.
34. Lanzetti RM, Caraffa A, Lupariello D, et al. Comparison between locked and unlocked intramedullary nails in intertrochanteric fractures. Eur J Orthop Surg Traumatol, 2018, 28(4): 649-658.
35. Breceda A, Sands A, Zderic I, et al. Biomechanical analysis of peri-implant fractures in short versus long cephalomedullary implants following pertrochanteric fracture consolidation. Injury, 2021, 52(1): 60-65.
36. Daner WE, Owen JR, Wayne JS, et al. Biomechanical evaluation of the risk of secondary fracture around short versus long cephalomedullary nails. Eur J Orthop Surg Traumatol, 2017, 27(8): 1103-1108.
37. Hesse B, Gächter A. Complications following the treatment of trochanteric fractures with the gamma nail. Arch Orthop Trauma Surg, 2004, 124(10): 692-698.
38. Halonen LM, Stenroos A, Vasara H, et al. Peri-implant fracture: a rare complication after intramedullary fixation of trochanteric femoral fracture. Arch Orthop Trauma Surg, 2022, 142(12): 3715-3720.
39. Efstathopoulos N, Nikolaou VS, Xypnitos FN, et al. Investigation on the distal screw of a trochanteric intramedullary implant (Fi-nail) using a simplified finite element model. Injury, 2010, 41(3): 259-265.

Chinese Journal of Reparative and Reconstructive Surgery

Research progress on distal interlocking screws of cephalomedullary nails in intertrochanteric fractures

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