The migration of helical blade and the tip apex distance value in cephalomedullary nail for geriatric intertrochanteric fractures_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

 LI Haifeng , WANG Hua , ZHANG Yingqi , ZHOU Jiaqian , YUAN Feng

Department of Orthopaedics, Tongji Hospital of Tongii University, Shanghai, 200065, P.R.China;

Corresponding author：

LI Haifeng, Email: hftj2003@aliyun.com

Keywords：

Proximal femoral nail antirotation; intertrochanteric fracture; tip apex distance; helical blade; superior cut-out; medial perforation

DOI：

10.7507/1002-1892.201904125

Video：

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Objective To investigate the association between the tip apex distance (TAD) and migration of helical blade in the femoral head of geriatric intertrochanteric fractures.Methods A retrospective study of intertrochanteric fractures treated with the proximal femoral nail antirotation (PFNA) between June 2015 and June 2018 was performed. There were 32 males and 55 females with an average age of 84.7 years (range, 80-101 years). All of them were unilateral fresh closed intertrochanteric fractures caused by low energy injury. According to AO/Orthopaedic Trauma Association (AO/OTA) classification, 33 cases belonged to type 31-A1, 35 cases to type 31-A2, and 19 cases to type 31-A3. The time interval from injury to operation was 1-16 days (mean, 3.7 days). The TAD was measured according to immediate postoperative X-ray films. The cases were divided into two groups: group A with TAD less than 20 mm and group B with TAD greater than 20 mm. The difference of fracture healing and migration of helical blade between the two groups were observed.Results According to the TAD value immediately after operation, 49 patients in group A had TAD of 8.9-19.7 mm, with an average of 18.6 mm; 38 patients in group B had TAD of 20.1-41.4 mm, with an average of 27.7 mm. The 87 patients were followed up for an average of 11.7 months, ranging from 4 to 28 months. Three cases (all in group B) underwent screw blade cutting and displacement, which resulted in internal fixation failure, including 1 case with femoral head cut upward and 2 cases with femoral head penetrated inward. The remaining 84 cases had bone healing without internal fixation related complications such as fracture of internal fixator and fracture of femoral shaft. There was significant difference in the incidence of internal fixation failure between group A and group B (P=0.049). Conclusion Reducing the TAD value of helical blade appropriately (15-20 mm) in PFNA internal fixation for intertrochanteric fracture patients over 80 years old can increase initial stability without increasing the risk of helical blade migration.

Citation： LI Haifeng, WANG Hua, ZHANG Yingqi, ZHOU Jiaqian, YUAN Feng. The migration of helical blade and the tip apex distance value in cephalomedullary nail for geriatric intertrochanteric fractures. Chinese Journal of Reparative and Reconstructive Surgery, 2019, 33(10): 1234-1238. doi: 10.7507/1002-1892.201904125 Copy

1.	李明东, 胡稷杰, 黎早敏, 等. 不同手术方式治疗老年股骨粗隆间骨折的疗效比较. 中国修复重建外科杂志, 2017, 31(6): 653-658.
2.	Ciufo DJ, Zaruta DA, Lipof JS, et al. Risk factors associated with cephalomedullary nail cutout in the treatment of trochanteric hip fractures. J Orthop Trauma, 2017, 31(11): 583-588.
3.	李建涛, 张里程, 唐佩福. 股骨粗隆间骨折治疗理念与内固定器械的发展概述. 中国修复重建外科杂志, 2019, 33(1): 1-7.
4.	Baumgaertner MR, Curtin SL, Lindskog DM, et al. 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(7): 1058-1064.
5.	Mereddy P, Kamath S, Ramakrishnan M, et al. The AO/ASIF proximal femoral nail antirotation (PFNA): a new design for the treatment of unstable proximal femoral fractures. Injury, 2009, 40(4): 428-432.
6.	张世民, 余斌. AO/OTA-2018 版股骨转子间骨折分类的解读与讨论. 中华创伤骨科杂志, 2018, 20(7): 583-587.
7.	张世民. 老年髋部转子间骨折. 北京: 科学出版社, 2019: 359-367.
8.	Lobo-Escolar A, Joven E, Iglesias D, et al. Predictive factors for cutting-out in femoral intramedullary nailing. Injury, 2010, 41(12): 1312-1316.
9.	张世民, 祝晓忠, 黄轶刚, 等. 外侧壁危险型股骨粗隆间骨折 DHS 与 PFNA 治疗的回顾性对比研究. 中国矫形外科杂志, 2010, 18(22): 1868-1872.
10.	Born CT, Karich B, Bauer C, et al. Hip screw migration testing: first results for hip screws and helical blades utilizing a new oscillating test method. J Orthop Res, 2011, 29(5): 760-766.
11.	Li S, Chang SM, Jin YM, et al. A mathematical simulation of the tip-apex distance and the calcar-referenced tip-apex distance for intertrochanteric fractures reduced with lag screws. Injury, 2016, 47(6): 1302-1308.
12.	Baumgaertner MR, Solberg BD. Awareness of tip-apex distance reduces failure of fixation of trochanteric fractures of the hip. J Bone Joint Surg (Br), 1997, 79(6): 969-971.
13.	Pervez H, Parker MJ, Vowler S. Prediction of fixation failure after sliding hip screw fixation. Injury, 2004, 35(10): 994-998.
14.	Hsueh KK, Fang CK, Chen CM, et al. Risk factors in cutout of sliding hip screw in intertrochanteric fractures: an evaluation of 937 patients. Int Orthop, 2010, 34(8): 1273-1276.
15.	李海丰, 张世民. 股骨近端防旋髓内钉螺旋刀片向内穿出的研究进展. 中华创伤骨科杂志, 2013, 15(5): 442-444.
16.	Strauss E, Frank J, Lee J, et al. Helical blade versus sliding hip screw for treatment of unstable intertrochanteric hip fractures: a biomechanical evaluation. Injury, 2006, 37(10): 984-989.
17.	Weil YA, Gardner MJ, Mikhail G, et al. Medial migration of intramedullary hip fixation devices: a biomechanical analysis. Arch Orthop Trauma Surg, 2008, 128(2): 227-234.
18.	Frei HC, Hotz T, Cadosch D, et al. Central head perforation, or " cut through,” caused by the helical blade of the proximal femoral nail antirotation. J Orthop Trauma, 2012, 26(8): e102-e107.
19.	Zhou JQ, Chang SM. Failure of PFNA: helical blade perforation and tip-apex distance. Injury, 2012, 43(7): 1227-1228.
20.	Nikoloski AN, Osbrough AL, Yates PJ. Should the tip-apex distance (TAD) rule be modified for the proximal femoral nail antirotation (PFNA)? A retrospective study J Orthop Surg Res, 2013, 8: 35.
21.	Stern R, Lübbeke A, Suva D, et al. Prospective randomised study comparing screw versus helical blade in the treatment of low-energy trochanteric fractures. Int Orthop, 2011, 35(12): 1855-1861.
22.	Li S, Chang SM, Niu WX, et al. Comparison of tip apex distance and cut-out complications between helical blades and lag screws in intertrochanteric fractures among the elderly: a meta-analysis. J Orthop Sci, 2015, 20(6): 1062-1069.
23.	Kaufer H. Mechanics of the treatment of hip injuries. Clin Orthop Relat Res, 1980, (146): 53-61.
24.	李双, 张立智, 张世民. 尖顶距与股距尖顶距的研究进展. 中华创伤骨科杂志, 2016, 18(8): 733-736.

1. 李明东, 胡稷杰, 黎早敏, 等. 不同手术方式治疗老年股骨粗隆间骨折的疗效比较. 中国修复重建外科杂志, 2017, 31(6): 653-658.
2. Ciufo DJ, Zaruta DA, Lipof JS, et al. Risk factors associated with cephalomedullary nail cutout in the treatment of trochanteric hip fractures. J Orthop Trauma, 2017, 31(11): 583-588.
3. 李建涛, 张里程, 唐佩福. 股骨粗隆间骨折治疗理念与内固定器械的发展概述. 中国修复重建外科杂志, 2019, 33(1): 1-7.
4. Baumgaertner MR, Curtin SL, Lindskog DM, et al. 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(7): 1058-1064.
5. Mereddy P, Kamath S, Ramakrishnan M, et al. The AO/ASIF proximal femoral nail antirotation (PFNA): a new design for the treatment of unstable proximal femoral fractures. Injury, 2009, 40(4): 428-432.
6. 张世民, 余斌. AO/OTA-2018 版股骨转子间骨折分类的解读与讨论. 中华创伤骨科杂志, 2018, 20(7): 583-587.
7. 张世民. 老年髋部转子间骨折. 北京: 科学出版社, 2019: 359-367.
8. Lobo-Escolar A, Joven E, Iglesias D, et al. Predictive factors for cutting-out in femoral intramedullary nailing. Injury, 2010, 41(12): 1312-1316.
9. 张世民, 祝晓忠, 黄轶刚, 等. 外侧壁危险型股骨粗隆间骨折 DHS 与 PFNA 治疗的回顾性对比研究. 中国矫形外科杂志, 2010, 18(22): 1868-1872.
10. Born CT, Karich B, Bauer C, et al. Hip screw migration testing: first results for hip screws and helical blades utilizing a new oscillating test method. J Orthop Res, 2011, 29(5): 760-766.
11. Li S, Chang SM, Jin YM, et al. A mathematical simulation of the tip-apex distance and the calcar-referenced tip-apex distance for intertrochanteric fractures reduced with lag screws. Injury, 2016, 47(6): 1302-1308.
12. Baumgaertner MR, Solberg BD. Awareness of tip-apex distance reduces failure of fixation of trochanteric fractures of the hip. J Bone Joint Surg (Br), 1997, 79(6): 969-971.
13. Pervez H, Parker MJ, Vowler S. Prediction of fixation failure after sliding hip screw fixation. Injury, 2004, 35(10): 994-998.
14. Hsueh KK, Fang CK, Chen CM, et al. Risk factors in cutout of sliding hip screw in intertrochanteric fractures: an evaluation of 937 patients. Int Orthop, 2010, 34(8): 1273-1276.
15. 李海丰, 张世民. 股骨近端防旋髓内钉螺旋刀片向内穿出的研究进展. 中华创伤骨科杂志, 2013, 15(5): 442-444.
16. Strauss E, Frank J, Lee J, et al. Helical blade versus sliding hip screw for treatment of unstable intertrochanteric hip fractures: a biomechanical evaluation. Injury, 2006, 37(10): 984-989.
17. Weil YA, Gardner MJ, Mikhail G, et al. Medial migration of intramedullary hip fixation devices: a biomechanical analysis. Arch Orthop Trauma Surg, 2008, 128(2): 227-234.
18. Frei HC, Hotz T, Cadosch D, et al. Central head perforation, or " cut through,” caused by the helical blade of the proximal femoral nail antirotation. J Orthop Trauma, 2012, 26(8): e102-e107.
19. Zhou JQ, Chang SM. Failure of PFNA: helical blade perforation and tip-apex distance. Injury, 2012, 43(7): 1227-1228.
20. Nikoloski AN, Osbrough AL, Yates PJ. Should the tip-apex distance (TAD) rule be modified for the proximal femoral nail antirotation (PFNA)? A retrospective study J Orthop Surg Res, 2013, 8: 35.
21. Stern R, Lübbeke A, Suva D, et al. Prospective randomised study comparing screw versus helical blade in the treatment of low-energy trochanteric fractures. Int Orthop, 2011, 35(12): 1855-1861.
22. Li S, Chang SM, Niu WX, et al. Comparison of tip apex distance and cut-out complications between helical blades and lag screws in intertrochanteric fractures among the elderly: a meta-analysis. J Orthop Sci, 2015, 20(6): 1062-1069.
23. Kaufer H. Mechanics of the treatment of hip injuries. Clin Orthop Relat Res, 1980, (146): 53-61.
24. 李双, 张立智, 张世民. 尖顶距与股距尖顶距的研究进展. 中华创伤骨科杂志, 2016, 18(8): 733-736.

Chinese Journal of Reparative and Reconstructive Surgery

The migration of helical blade and the tip apex distance value in cephalomedullary nail for geriatric intertrochanteric fractures

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