Hip Pelvis.  2018 Sep;30(3):168-174. 10.5371/hp.2018.30.3.168.

Local Postoperative Complications after Surgery for Intertrochanteric Fractures Using Cephalomedullary Nails

• Kim KH
• Han KY
• Kim KW
• Lee JH
• Chung MK

• KMID: 2419512
• DOI: http://doi.org/10.5371/hp.2018.30.3.168

Abstract

PURPOSE
Cephalomedullary nails (CMN) are commonly used for the surgical treatment of intertrochanteric fractures. This study aimed to evaluate overall postoperative local complications by reviewing patients who received surgical treatment using three different types of implants.
MATERIALS AND METHODS
The study sample included 353 patients (107 males, 246 females) who underwent surgery using CMN for intertrochanteric fractures. Three different types of implants were used: i) the Gamma3® (Stryker) in 80 cases, ii) the Targon® PF (Aesculap) in 225 cases, and iii) the Compression Hip Nail® (Trademedics) in 48 cases. The mean age was 82.6 (range, 60-109) years and the average follow-up period was 15 (range, 6-80) months. Postoperative local complications and risk factors of cut-out were assessed.
RESULTS
The most common complication was cut-out (n=26). Other complications included non-union (n=3), periprosthetic fracture (n=2), avascular necrosis (n=1), heterotopic ossification (n=1), and sleeve pull out (n=1). Multivariate analysis revealed that the cut-out group had a higher rate of poor reduction compared to the non-complicated group (P < 0.001). Although the mean tip-apex distance (TAD) was 18.4 mm in the non-complicated group, lower than that of the cut-out group (P=0.001), multivariate analysis revealed that TAD was not a significant risk factor for cut-out (P=0.065).
CONCLUSION
Cut-out is the most common local complication associated with surgical treatment of intertrochanteric fractures using CMN. Proper reduction appears to be important in lowering the risk of cut-out. Maintaining low TAD is another critical factor in achieving sufficient fixation of lag screw to the subchondral bone of the femoral head.

Keyword

Intertrochanteric fractures; Intramedullary nailing; Fracture reduction; Complications

MeSH Terms

Follow-Up Studies
Fracture Fixation, Intramedullary
Head
Hip
Hip Fractures*
Humans
Male
Multivariate Analysis
Necrosis
Ossification, Heterotopic
Periprosthetic Fractures
Postoperative Complications*
Risk Factors

Figure

• 

  Fig. 1 A 78-year old female patient sustained an intertrochanteric fracture due to slip down (A). Although closed reduction and Compression Hip Nail fixation (Trademedics, Seongnam, Korea) was performed, it showed slight varus alignment with engagement of the proximal fragment into the shaft in immediate postoperative radiographs (B). One month later, the patient had progressive hip pain, and cut-out of lag screw with varus collapse was observed in radiographs (C).

• 

  Fig. 2 A 87-year old female patient had closed reduction and internal fixation using Compression Hip Nail (Trademedics, Seongnam, Korea) for her right intertrochanteric fracture caused by slip down (A, B). At postoperative one month, a lag screw with sleeve was pulled out to the lateral side (C).

Reference

1. Anglen JO, Weinstein JN. American Board of Orthopaedic Surgery Research Committee. Nail or plate fixation of intertrochanteric hip fractures: changing pattern of practice. A review of the American Board of Orthopaedic Surgery database. J Bone Joint Surg Am. 2008; 90:700–707. PMID: 18381305.

2. Lee YK, Yoon BH, Nho JH, Kim KC, Ha YC, Koo KH. National trends of surgical treatment for intertrochanteric fractures in Korea. J Korean Med Sci. 2013; 28:1407–1408. PMID: 24015052.

3. Flahiff CM, Nelson CL, Gruenwald JM, Hollis JM. A biomechanical evaluation of an intramedullary fixation device for intertrochanteric fractures. J Trauma. 1993; 35:23–27. PMID: 8331708.

4. Lee YK, Chung CY, Park MS, Lee KM, Koo KH. Intramedullary nail versus extramedullary plate fixation for unstable intertrochanteric fractures: decision analysis. Arch Orthop Trauma Surg. 2013; 133:961–968. PMID: 23644897.

5. Socci AR, Casemyr NE, Leslie MP, Baumgaertner MR. Implant options for the treatment of intertrochanteric fractures of the hip: rationale, evidence, and recommendations. Bone Joint J. 2017; 99-B:128–133. PMID: 28053268.

6. Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM. 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. PMID: 7608228.

7. Gundle R, Gargan MF, Simpson AH. How to minimize failures of fixation of unstable intertrochanteric fractures. Injury. 1995; 26:611–614. PMID: 8550168.

8. Cleveland M, Bosworth DM, Thompson FR, Wilson HJ Jr, Ishizuka T. A ten-year analysis of intertrochanteric fractures of the femur. J Bone Joint Surg Am. 1959; 41-A:1399–1408. PMID: 13849408.

9. Fogagnolo F, Kfuri M Jr, Paccola CA. Intramedullary fixation of pertrochanteric hip fractures with the short AO-ASIF proximal femoral nail. Arch Orthop Trauma Surg. 2004; 124:31–37. PMID: 13680275.

10. Born CT, Karich B, Bauer C, von Oldenburg G, Augat P. Hip screw migration testing: first results for hip screws and helical blades utilizing a new oscillating test method. J Orthop Res. 2011; 29:760–766. PMID: 20830738.

11. Park BK, Plymale M, Capogna BM, Kim SJ. A new addition to the third-generation Gamma nail system. Curr Orthop Pract. 2011; 22:280–283.

12. Park IH, Won JK, Han KY. Treatment of intertrochanteric fractures using Targon proximal femoral nails. Hip Pelvis. 2012; 24:117–123.

13. Parker MJ, Bowers TR, Pryor GA. Sliding hip screw versus the Targon PF nail in the treatment of trochanteric fractures of the hip: a randomised trial of 600 fractures. J Bone Joint Surg Br. 2012; 94:391–397. PMID: 22371549.

14. Choo SK, Oh HK, Ko HT, Min DU, Kim Y. Effectiveness of controlled telescoping system for lateral hip pain caused by sliding of blade following intramedullary nailing of trochanteric fracture. Injury. 2017; 48:2201–2206. PMID: 28801201.

15. Geller JA, Saifi C, Morrison TA, Macaulay W. Tip-apex distance of intramedullary devices as a predictor of cut-out failure in the treatment of peritrochanteric elderly hip fractures. Int Orthop. 2010; 34:719–722. PMID: 19618186.

16. Carr JB. The anterior and medial reduction of intertrochanteric fractures: a simple method to obtain a stable reduction. J Orthop Trauma. 2007; 21:485–489. PMID: 17762483.

17. Yi JM, Han KY, Kim KW, Ryu CH. Treatment of intertrochanteric fractures using the Compression Hip Nail. Hip Pelvis. 2014; 26:166–172. PMID: 27536575.