Should Pertrochanteric and Subtrochanteric Fractures Be Treated with a Short or Long Intramedullary Nail?: A Multicenter Cohort Study

What is the Optimal Nail Length to Treat Osteoporotic Subtrochanteric Fractures? A Finite Element Analysis

Background

Operative management with intramedullary nail fixation remains the definitive treatment of choice for osteoporotic subtrochanteric (ST) fractures; however, there remains no consensus regarding the proper nail length. We aimed to use 3-dimensional finite element (FE) analysis to determine the optimal nail length for the safe fixation of osteoporotic ST fractures.

Methods

Nine modes of FE models were constructed using 9 different lengths of cephalomedullary nails (short nails: 170, 180, and 200 mm; long nails: 280, 300, 320, 340, 360, and 380 mm) from the same company. The interfragmentary motion was analyzed. Additionally, the peak von Mises stress (PVMS) in the cortical bone, cancellous bone of the femoral head, and the nail were measured, and the yielding risk for each subject was investigated.

Results

Long nails were associated with less interfragmentary motion. In the cortical bone, the PVMS of short nails was observed at the distal locking screw holes of the femoral medial cortex; however, in long nails, the PVMS was observed at the lag screw holes on the lateral cortex. The mean yielding risk of long nails was 40.1% lower than that of short nails. For the cancellous bone of the femoral head, the PVMS in all 9 FE models was in the same area: at the apex of the femoral head. There was no difference in the yielding risk between short and long nails. For implants, the PVMS was at the distal locking screw hole of the nail body in the short nails and the nail body at the fracture level in the long nails. The mean yielding risk was 74.9% lower for long nails than that for short nails.

Conclusions

Compared to short nails, long nails with a length of 320 mm or more showed less interfragmentary motion and lower yielding risk in low-level osteoporotic ST fractures. The FE analysis supports long nails as a safer option than short nails, especially for treating transverse-type low-level osteoporotic ST fractures.

Short versus long intramedullary nails for intertrochanteric hip fracture: Meta-analysis

OBJECTIVE

To compare short versus long intramedullary nails for intertrochanteric hip fractures in terms of efficacy and safety.

METHODS

We included cohort studies and randomized clinical trials. The methodological quality of the studies was assessed by the Newcastle-Ottawa Scale. The meta-analysis was performed using the Review Manager 5.4. Heterogeneity was checked with the I2 test. A fixed effects model was adopted if there was no heterogeneity.

RESULTS

Twelve studies were included. The reoperations rate was lower in the short nail group (OR: 0.58, 95%CI: 0.38-0.88) and there were no differences regarding the peri-implant fracture rate (OR: 1.77, 95%CI: 0.68-4.60). Surgery time and blood loss was significantly higher in the long nail group (MD: -12.44, 95%CI: -14.60 -10.28) (MD: -19.36, 95%CI: -27.24 -11.48). There were no differences in functional outcomes.

CONCLUSIONS

The long nail showed a higher reoperation rate, blood loss and surgery time compared to the short nail.

LEVEL OF EVIDENCE

III.

Comparison of post-op opioid use and pain between short and long cephalomedullary nails in elderly intertrochanteric fractures

PURPOSE

It remains unknown if cephalomedullary nail (CMN) length has an impact on pain and opioid use following fixation. Given the lack of level I evidence favoring a specific CMN length to prevent adverse surgical outcomes, we investigated if CMN length impacts acute postoperative pain and opioid use. The authors hypothesize that the use of longer CMNs results in increased pain scores and morphine milligram equivalents (MME) intake during the 0-24 h (h) and 24-36 h postoperative period.

METHODS

A retrospective chart review was performed from 2010 to 2020 of patients ≥ 65 years-old who underwent CMN for IT fractures and fractures with subtrochanteric extension (STE). We compared patients who received short and long CMNs using numeric rating scale (NRS) pain scores and MME intake at 0-24 h and 24-36 h postoperatively.

RESULTS

330 patients receiving short (n = 155) and long (n = 175) CMNs met criteria. CMN length was found to not be associated with higher pain scores in the early postoperative phase. However, patients with long CMNs received higher MME from 0-24 h (25.4% estimated mean increase, p value = 0.02) and 24-36 h (22.3% estimated mean increase, p value = 0.04) postoperatively, even after adjusting for covariates, gender, and age.

CONCLUSION

Patients with long CMNs received greater MME postoperatively. Additionally, differences in pain and MME were not significantly different between patients with and without STE, suggesting our findings were not influenced by this pattern. These results suggest longer CMNs are associated with higher acute postoperative opioid intake among patients with IT fractures.

LEVEL OF EVIDENCE

Therapeutic level III.

Comparison of Intramedullary Nails in the Treatment of Trochanteric and Subtrochanteric Fractures: An Observational Study of 13,232 Fractures in the Norwegian Hip Fracture Register

BACKGROUND

Intramedullary nails are commonly used in the treatment of trochanteric and subtrochanteric fractures. We aimed to compare intramedullary nails in widespread use in Norway on the basis of reoperation risk.

METHODS

We assessed data from 13,232 trochanteric or subtrochanteric fractures treated with an intramedullary nail and registered in the Norwegian Hip Fracture Register between 2007 and 2019. The primary outcome measure was the risk of reoperation for various types of short and long intramedullary nails. Secondly, we compared risk of reoperation for the selected nails with respect to fracture type (AO/OTA type A1, A2, A3, and subtrochanteric fractures). Cox regression analysis adjusted for sex, age, and American Society of Anesthesiologists class was used to estimate hazard rate ratios (HRRs) for reoperation.

RESULTS

The mean patient age was 82.9 years, and 72.8% of the nails were used in the treatment of female patients. We included 8,283 short and 4,949 long nails. A1 fractures accounted for 29.8%, A2 for 40.6%, A3 for 7.2%, and subtrochanteric fractures for 22.4%. When comparing short nails regardless of fracture type, the TRIGEN INTERTAN had an increased risk of reoperation at 1 year (HRR, 1.31 [95% confidence interval (CI), 1.03 to 1.66]; p = 0.028) and 3 years (HRR, 1.31 [95% CI, 1.07 to 1.61]; p = 0.011) postoperatively compared with the Gamma3. For individual fracture types, we found no significant differences in reoperation risk between the various types of short nails. When comparing long nails, the TRIGEN TAN/FAN had an increased risk of reoperation at 1 year (HRR, 3.05 [95% CI, 2.10 to 4.42]; p < 0.001) and 3 years (HRR, 2.54 [95% CI, 1.82 to 3.54]; p < 0.001) postoperatively compared with the long Gamma3.

CONCLUSIONS

This study may indicate a slightly increased risk of reoperation for the short TRIGEN INTERTAN compared with other short nails in widespread use in Norway. In analyses of long nails, the TRIGEN TAN/FAN nail was associated with a higher risk of reoperation in the treatment of trochanteric and subtrochanteric fractures.

LEVEL OF EVIDENCE

Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Comparison of Outcomes of Long Versus Short Cephalomedullary Nails for the Fixation of Intertrochanteric Femur Fractures: A Systematic Review and Meta-analysis of 14,547 Patients

Purpose

Intertrochanteric Femur Fractures (IFF) fixation could be done with short or long Cephalomedullary Nails (CMNs). Nevertheless, despite several studies in the literature, there has been a continued lack of consensus on which design of CMN is better than the other. Hence, the current review aimed to evaluate the evidence about short versus long CMNs for the fixation of IFF.

Methodology

PRISMA guidelines were followed, and the protocol for the study was registered to PROSPERO. Four databases, Medline/PubMed, Embase, Scopus, and Cochrane Library, were searched. A total of 31 studies with 6 randomized trials (RCTs) and 25 non-randomized studies were included. Demographic data, follow-up period, and primary and secondary outcomes were extracted and evaluated from each of the included studies; statistical analysis was done by Review Manager Software version 5.4.1.

Results

Fourteen thousand five hundred forty-seven patients were included in this review.

Primary Outcomes

Long CMNs showed statistically significant lower rates of ipsilateral shaft femur refracture (OR 1.60, 95% CI 1.14, 2.24, p = 0.007); however, the difference was not statistically significant between the two groups for mortality at 30 days and within 1 year.

Secondary Outcomes

Statistically significant shorter duration of surgery (MD-17.83 (95% CI - 22.03, - 13.63, p < 0.05), less intra-operative blood loss (MD - 62.65, 95% CI - 97.13 to - 28.17, p =  < 0.05), and lower blood transfusion rates (OR 0.71, 95% CI 0.62, 0.83, p < 0.05) for short CMNs; no statistically significant difference for the length of hospital stay, implant-related complications, overall complications, re-operation rates, fluoroscopy time, and functional outcome between two groups of CMNs was seen.

Conclusion

With shorter operative time, lesser intra-operative blood loss, and lower postoperative transfusion rates for short CMNs, they have certain benefits over longer CMNs. However, more distal shaft femur fractures were seen in the shorter version of nail, which should be considered before offering these nails to a patient; careful and individualized postoperative weight-bearing protocol could minimize the same.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43465-023-00915-5.

Short versus long intramedullary nails for intertrochanteric hip fracture: Meta-analysis

OBJECTIVE

To compare short versus long intramedullary nails for intertrochanteric hip fractures in terms of efficacy and safety.

METHODS

We included cohort studies and randomized clinical trials. The methodological quality of the studies was assessed by the Newcastle-Ottawa Scale. The meta-analysis was performed using the Review Manager 5.4. Heterogeneity was checked with the I2 test. A fixed effects model was adopted if there was no heterogeneity.

RESULTS

Twelve studies were included. The reoperations rate was lower in the short nail group (OR 0.58, 95% CI 0.38-0.88) and there were no differences regarding the peri-implant fracture rate (OR 1.77, 95% CI 0.68-4.60). Surgery time and blood loss was significantly higher in the long nail group (MD -12.44, 95% CI -14.60 to (-10.28)) (MD -19.36, 95% CI -27.24 to (-11.48)). There were no differences in functional outcomes.

CONCLUSIONS

The long nail showed a higher reoperation rate, blood loss and surgery time compared to the short nail.

Positive medial cortical support versus anatomical reduction for trochanteric hip fractures: Finite element analysis and biomechanical testing

BACKGROUND AND OBJECTIVES

The anatomical reduction (AR) is usually considered the best option for fractures. Nevertheless, in unstable trochanteric hip fractures (UTHF), previous clinical reports found that the positive medial cortical support (PMCS, an over-reduction technique) attained higher mechanical stability, but this challenging clinical finding still needs experimental validation.

METHODS

This study constructed in-silico and biomechanical PMCS and AR models, with the use of the most clinically-representative geometry design of fracture models, the multi-directional design in FE analysis, and the subject-specific (osteoporotic) bone material properties, to make the models better mimic the actual condition in clinical settings. Then multiple performance variables (von-Mises stress, strain, integral axial stiffness, displacement, structural changes, etc.) were assessed to uncover details of integral and regional stability.

RESULTS

Among in-silico comparison, PMCS models showed significantly lower maximum displacement than AR models, and the maximum von Mises stress of implants (MVMS-I) was significantly lower in PMCS models than in AR models (highest MVMS-I in -30°-A3-AR of 1055.80 ± 93.37 MPa). Besides, PMCS models had significantly lower maximum von Mises stress along fracture surfaces (MVMS-F) (highest MVMS-F in 30°-A2-AR of 416.40 ± 38.01 MPa). Among biomechanical testing comparison, PMCS models showed significantly lower axial displacement. Significantly lower change of neck-shaft angle (CNSA) was observed in A2-PMCS models. A fair amount of AR models converted into the obvious negative medial cortical support (NMCS) condition, whereas all PMCS models kept the PMCS condition. The results were also validated through comparison to previous clinical data.

CONCLUSIONS

The PMCS is superior to the AR in the UTHF surgery. The current study opens up the second thought of the role of over-reduction technique in bone surgery.

Minimally invasive clamp-assisted reduction and long InterTAN nail fixation for Seinsheimer type V subtrochanteric fractures: a case series describing the technique and results

BACKGROUND

Surgical treatment of Seinsheimer type V subtrochanteric fractures is extremely challenging due to the difficulty of obtaining and maintaining anatomic reduction and effective fixation. The purpose of this study was to describe a surgical technique for minimally invasive clamp-assisted reduction and long InterTAN nail fixation to manage Seinsheimer type V subtrochanteric fractures and report the clinical and radiological results.

METHODS

A retrospective study was conducted on patients with Seinsheimer type V subtrochanteric fractures between March 2015 and June 2021. A total of 30 patients treated via minimally invasive clamp-assisted reduction, long InterTAN nail fixation and selective augmentation with a cerclage cable were included. The following data were collected and evaluated: patient demographics, operative time, blood loss, reduction quality, tip apex distance (TAD), time to bone union, Harris hip score (HHS), visual analog score (VAS), and complications.

RESULTS

The mean age of the 30 patients was 64.8 years (range: 36-90 years). The mean operative time was 102.2 min (range: 70-150 min). The mean loss of blood was 318.3 ml (range: 150-600 ml). The reduction quality involved 27 cases of anatomic reduction and 3 cases of satisfactory reduction. The mean TAD was 16.3 mm (range: 8-24 mm). The mean follow-up time was 18.9 months (range: 12-48 months). The mean fracture healing time was 4.5 months (range: 3-8 months). The mean Harris score was 88.2 (range: 71-100), and the VAS score was 0.7 (range: 0-3). Delayed union of the subtrochanteric fracture site occurred in two patients. The limb length discrepancy, which was determined in 3 patients, was < 10 mm. There were no significant complications.

CONCLUSION

Our results indicate that minimally invasive clamp-assisted reduction with long InterTAN nail fixation is encouraging for Seinsheimer Type V subtrochanteric fractures, resulting in excellent reduction and fixation. Additionally, this reduction technique is simple, reliable, and effective in reducing and maintaining subtrochanteric fractures, particularly when intertrochanteric fractures are irreducible.

A Demographic Survey of Pertrochanteric Fractures Based on the Revised Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association (AO/OTA) Classification Using 3D CT Scan Images

Introduction A demographic survey of femoral pertrochanteric fractures provides several important information for the healthcare system of a country since this fracture is commonly seen in the elderly and has a poor postoperative functional prognosis that is a burden on society. The importance of accurately classifying pertrochanteric fractures as stable or unstable cannot be understated. However, the use of plain radiograph images alone is known to underestimate fracture severity with low inter- or intra-observer agreement. Computed tomography (CT) images offer information for a more accurate classification of pertrochanteric fractures. With this three-dimensional (3D) CT-based study using the revised Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association (AO/OTA) classification, the purpose of this study is to elucidate the epidemiological demography of patients with pertrochanteric fractures. Material and methods We retrospectively collected 808 patients from five hospitals, classified into two groups: stable (A1) or unstable (A2). Age, gender, fracture laterality, and surgery timing were identified as epidemiological variables. Patients with both preoperative plain radiographs and 3D CT scans were included in the study. The exclusion criteria were AO/OTA A3 type fractures, pathological fractures, previous ipsilateral surgery, 60 years old or younger, and conservatively treated patients. The primary outcome involved detailing the total number of fractures based on classification (A1 or A2) and variables. The secondary outcome involved a comparison between the A1 and A2 groups. Results The mean age of patients at the time of surgery was 85 years (range: 61-103 years). There were 637 female and 171 male patients. There were 463 left-sided fractures and 345 right-sided fractures. Of the 808 patients, 371 (45.9%) were classified to have A1 fractures, and 437 (54.1%) had A2 fractures. The age at surgery, gender, fracture laterality, and surgery timing between the A1 and A2 groups were compared. The mean and standard deviation of the age at surgery for patients in the A1 and A2 groups were 84.9±7.7 and 86.9±6.8, respectively. The number of patients for each age distribution of 61-69, 70-74, 75-79, 80-84, 85-89, 90-94, and 95 or older for the A1 and A2 groups was 18 and 7, 18 and 12, 43 and 44, 76 and 82, 107 and 132, 79 and 110, and 30 and 50, respectively, showing that the difference in categorial distribution was statistically significant (p=0.002). Overall, 278 females and 93 males were classified to have A1 fractures compared with 359 females and 78 males with A2 fractures (p=0.01). There were 166 right-sided and 205 left-sided stable A1 fractures and 179 right-sided and 258 left-sided A2 fractures (not significant (NS)). Among the total number of A1 and A2 surgeries by month, the most were in December with 77 surgeries (37 and 40, respectively), and the least was in June with 37 (18 and 19, respectively). The seasonal classification for A1 and A2 surgeries is as follows: spring with 172 (74 and 98, respectively), summer with 150 (70 and 80, respectively), autumn with 193 (90 and 103, respectively), and winter with 208 (97 and 111, respectively) (NS). Conclusion In this demographic study of 808 patients with pertrochanteric fractures classified by 3D CT images, 371 had A1 fractures and 437 had A2 fractures. A2 fractures were significantly more in females with an age peak of 85-89 years.

Periprosthetic Fractures in Long Versus Short Proximal Femoral Nailing for Intertrochanteric Fractures: A 10-Year Single-Centre Cohort Study

Background Neck of femur (NOF) fractures, including intertrochanteric fractures, are common fragility fractures seen in the elderly population and are often amenable to fixation with a proximal femoral nail (PFN). However, there is conflicting evidence regarding the incidence of peri-prosthetic fractures with each device. Several studies from the 1990s and a recent meta-analysis have shown a higher incidence of peri-prosthetic fractures in the short PFN cohort. Other studies have shown a lower reoperation rate with short PFNs, and no statistically significant differences have been quoted in the rates of peri-prosthetic fractures in systematic reviews. Aim The purpose of this retrospective study, therefore, was to assess the peri-prosthetic fracture rate and failure rates of elderly neck of femur (NOF) fractures implanted with either a short or long proximal femoral nail (PFN). Materials and methods A retrospective study was conducted in a single orthopaedic department (University Hospital Dorset, Poole, GBR) using collected data on all extracapsular neck of femur fracture patients from the national hip fracture database (NHFD) from January 1, 2011, to December 23, 2021. The data collected included patient age, sex, the American Society of Anesthesiologists (ASA) type of neck of femur fracture, type of surgery performed, any further peri-prosthetic fractures, and time to re-operation in that subset of the group. The implants used were the Stryker Gamma 3 Nail and the Smith Nephew (Trigen and Intertan). All patients were allowed to fully weight bear as tolerated and received both orthopaedic and elderly medical care. Failure was defined as a cut-out or implant fracture. Results From January 1, 2011, to December 23, 2021, there were 1010 extracapsular neck of femur fractures recorded on the National Hip Fracture Database (NHFD) treated with a PFN from the study centre. Of those patients, 11 had pathological fractures and were excluded. 649 patients had long PFNs, and 350 had short PFNs. Of the total of 999 patients, 254 (25%) were male and 745 (75%) were female. More than 80% of the patients in the sample were over the age of 75. The majority of patients in both groups had A1/A2 fractures (short 84.3%, long 49.1%). The rate of periprosthetic fractures in the short PFNs was 1.71%, and the failure rate was 0.57%. The rate of periprosthetic fractures in the long PFNs was 0.62%, with a failure rate of 0.92%. The multi-nominal logistic regression model did not show statistically significant odds ratios (OR) for the following variables: long/short nails, male/female gender, age, ASA, or type of fracture. The female gender was associated with a higher risk of both periprosthetic fractures and failures (OR of 2.232 and 2.95), but this was not found to be statistically significant. Similarly, unstable A3 fractures had a much higher risk of failure (OR of 2.691) compared to periprosthetic fractures (OR of 0.985). However, this was not statistically significant. Conclusion Overall, this study has identified that in a patient population that is predominantly female and over the age of 75, the risk of periprosthetic fracture rate and the failure rate is similar in both the use of a short or a long PFN for intertrochanteric fractures.

Angle-stable interlocking nailing in a canine critical-sized femoral defect model for bone regeneration studies: In pursuit of the principle of the 3R’s

Introduction: Critical-sized long bone defects represent a major therapeutic challenge and current treatment strategies are not without complication. Tissue engineering holds much promise for these debilitating injuries; however, these strategies often fail to successfully translate from rodent studies to the clinical setting. The dog represents a strong model for translational orthopedic studies, however such studies should be optimized in pursuit of the Principle of the 3R’s of animal research (replace, reduce, refine). The objective of this study was to refine a canine critical-sized femoral defect model using an angle-stable interlocking nail (AS-ILN) and reduce total animal numbers by performing imaging, biomechanics, and histology on the same cohort of dogs.

Methods: Six skeletally mature hounds underwent a 4 cm mid-diaphyseal femoral ostectomy followed by stabilization with an AS-ILN. Dogs were assigned to autograft (n = 3) or negative control (n = 3) treatment groups. At 6, 12, and 18 weeks, healing was quantified by ordinal radiographic scoring and quantified CT. After euthanasia, femurs from the autograft group were mechanically evaluated using an established torsional loading protocol. Femurs were subsequently assessed histologically.

Results: Surgery was performed without complication and the AS-ILN provided appropriate fixation for the duration of the study. Dogs assigned to the autograft group achieved radiographic union by 12 weeks, whereas the negative control group experienced non-union. At 18 weeks, median bone and soft tissue callus volume were 9,001 mm³ (range: 4,939–10,061) for the autograft group and 3,469 mm³ (range: 3,085–3,854) for the negative control group. Median torsional stiffness for the operated, autograft treatment group was 0.19 Nm/° (range: 0.19–1.67) and torque at failure was 12.0 Nm (range: 1.7–14.0). Histologically, callus formation and associated endochondral ossification were identified in the autograft treatment group, whereas fibrovascular tissue occupied the critical-sized defect in negative controls.

Conclusion: In a canine critical-sized defect model, the AS-ILN and described outcome measures allowed refinement and reduction consistent with the Principle of the 3R’s of ethical animal research. This model is well-suited for future canine translational bone tissue engineering studies.

A Simple Method to Improve Detection of Femoral Nail Abutment in the Distal Femur: A Computer Modeling Study

BACKGROUND

Proximal femur fractures are more frequently treated with long femoral nails. Lateral radiographs are used to assess the nail position in the distal femur. However, because of the asymmetric shape of the distal femur, standard lateral radiographs alone are suboptimal for assessing anteriorly positioned nails in the distal femur. Consequently, instances of nail abutment or even perforation might be missed intraoperatively.

QUESTION/PURPOSE

Using a three-dimensional (3D) modelling approach, we asked: When the nail is in the anterior fifth of the canal, will rotating the femur to align the simulated x-ray beam with the anterior femoral condyles instead of the posterior femoral condyles increase the diagnostic accuracy of detecting nail perforation of the anterior cortex?

METHODS

3D models of 42 unilateral femora from a population sample representative of patients with hip fractures (mean age of 76 ± 7 years, 10 males and 32 females, and 16 left and 26 right femora) were used. The patients had a mean height of 158 ± 9 cm; 27 femora were from Asians and 15 were from Caucasians. Clinically appropriately sized nails had already been virtually implanted previously as part of a quantitative nail fit assessment study. In a preliminary step, the mean angles of inclination of the distal anterior supracondylar region were quantified using four axial sections of the distal femur. For the femora with the nail tip in the anterior fifth of the canal, projections representing a lateral radiograph were generated along with rotated projections at mean angle (5°, 8°) rotations, with the anterior femoral condyles aligned, and anterior femoral condyle alignment followed by internal and external rotation to detect maximum nail perforation. The distance from the nail to the distal anterior cortex was measured for each rotational projection and used to detect anterior nail perforation. The accuracy of detection was assessed using the area under the curve (AUC) of the receiver operating characteristic (ROC) analysis.

RESULTS

Rotating the 3D models by aligning the x-ray beam with the anterior femoral condyles improves the diagnostic ability of detecting anterior nail perforation compared with standard lateral radiographs. The AUC increased with rotation from 0.50 (95% confidence interval 0.50 to 0.50) on the lateral projection to 0.73 (95% CI 0.57 to 0.88, difference = -0.23; p = 0.004) at 5° of rotation, 0.77 (95% CI 0.62 to 0.93, difference = -0.27; p = 0.001) at both 8° of rotation and with the anterior femoral condyles aligned, and to 0.82 (95% CI 0.67 to 0.97, difference = -0.32; p < 0.001) with internal/external rotations past the anterior femoral condyles. There were no differences in accuracy between the four methods of rotation.

CONCLUSION

This study shows that rotating the femur to align the anterior femoral condyles on a lateral radiograph and then internally/externally rotating it, improves the accuracy assessed via the AUC of detecting anterior perforation when long nails are positioned in the anterior fifth of the distal femur.

CLINICAL RELEVANCE

This approach can easily be used in a clinical setting. Intraoperatively, the image intensifier can be rotated around the leg to produce an image with the anterior femoral condyle aligned, providing surgeons with an opportunity to identify and improve the nail's position or exchange the nail while the patient is still under anesthesia.

Periprosthetic fracture rate after short and long hip nails: Analysis of a regional health database

INTRODUCTION

Intertrochanteric hip fractures are a major socio-economic burden, and a significant source of morbidity and mortality. Treatment is generally surgical, with either a dynamic hip screw or a cephalomedullary hip nail. Recently, there has been a trend toward the use of hip nails. The use of short nails over long nails, which span the length of the femur, remains a source of controversy. Historically, short nails were associated with a higher periprosthetic fracture rate compared with long nails, however newer nail designs, appear to have resolved this issue. Small retrospective studies show a refracture rate similar in both long and short nails. Given the small sample size of current studies, it remains unclear if the refracture rate is indeed the same between treatment arms, or if studies are not sufficiently large to identify a difference between the two. A large database review would provide the practical next step to further explore this question.

METHODS

Intertrochanteric hip fracture cases from our Regional Hip Fracture Registry were reviewed. All patients with an intertrochanteric fracture treated with a cephalomedullary nail from June 2009 to December 2017 were included. Patient demographics were compared using the t-test. Fracture rate was compared using the chi square test.

RESULTS

655 short nails and 315 long nails were reviewed. Patients in the short nail (SN) group were older than in the long nail group (LN) (SN: 81, LN 76 p < 0.001). The periprosthetic fracture rate was 2.1% overall with 1.3% in LN group and 2.4% in SN group (p = 0.34). There was no difference identified in the rate of blood transfusions (SN 38% LN 40% p = 0.5), however the procedure time was shorter in the SN group (SN: 81 min LN: 112 min p < 0.001).

DISCUSSION

This study did not find a statistical difference in periprosthetic fracture rate when comparing short and long cephalomedullary nails for the treatment of intertrochanteric fractures. Procedure time was shorter in the SN group. However, no difference in rate of blood transfusion was noted between patient groups. This study supports use of both nail type for hip fracture fixation, on the basis of periprosthetic fracture rate.