Analysis of the Radiological Anatomy of the Proximal Femur after the Intramedullary Nailing of Trochanteric Fractures
- Authors: Maiorov B.A.1,2,3, Belenkiy I.G.1,2, Sergeev G.D.1,2, Endovitskiy I.A.3, Sergeeva M.A.2, Isakhanyan D.A.1
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Affiliations:
- St. Petersburg I.I. Dzhanelidze Research Institute of Emergency Medicine
- Saint Petersburg State University
- Interdistrict Clinical Hospital of Vsevolozhsk
- Issue: Vol 31, No 1 (2025)
- Pages: 55-67
- Section: Clinical studies
- URL: https://journal-vniispk.ru/2311-2905/article/view/287978
- DOI: https://doi.org/10.17816/2311-2905-17575
- ID: 287978
Cite item
Abstract
Background. Despite the high rate of the intramedullary osteosynthesis of proximal femur fractures, the incidence of implant-associated complications exceeds 50%. Poor reduction and incorrect implant positioning significantly increase the risk of mechanical complications and the frequency of unsatisfactory treatment outcomes.
The aim of the study was to evaluate various fragment positions after the intramedullary nailing of proximal femur fractures using the developed radiological criteria for assessing the quality of reduction, and to determine the association between the quality of the restoration of the proximal femur, implant position and fracture type.
Methods. In a retrospective single-center study we analyzed the primary X-rays of 108 patients with type 31A fractures. Radiological criteria were preliminarily defined. According to them, the position of the fragments and implants was considered satisfactory if the value of the neck-diaphyseal angle was more than 125°, anteversion did not exceed 20°, medial diastasis was not more than 10 mm, and there were no negative medial support, no femoral neck lengthening of more than 10 mm compared with the healthy side, and no penetration of the blade into the joint. Patients were divided into three groups according to the fracture type. We analyzed and compared the proportions of satisfactory and unsatisfactory radiological results within the groups and between them.
Results. Satisfactory reduction was noted in 83 patients (76.9%) out of 108, unsatisfactory — in 25 patients (23.1%), and 16 patients (14.8%) had incorrect implant position. Patients with type 31A1 fractures were 3.5 times less likely to have an unsatisfactory reduction than patients with type 31A2 fractures (OR 3.511; 95% CI 1.202-10.261) and 6.7 times less likely to have an unsatisfactory reduction than patients with type 31A3 fractures (OR 6.714; 95% CI 1.685-26.752). The probability of incorrect implant positioning was 6 times higher in type 31A3 fractures than in type 31A1 fractures (OR 6.000; 95% CI 1.410-25.528).
Conclusion. To improve the quality of surgical treatment, it is worth paying an increased attention to the quality of the achieved reduction, implant selection, technical peculiarities of the fixation of types A2 and A3 fractures, improvement of preoperative planning algorithms, as well as development of criteria for intraoperative radiological assessment of the quality of the restoration of the proximal femur anatomy.
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##article.viewOnOriginalSite##About the authors
Boris A. Maiorov
St. Petersburg I.I. Dzhanelidze Research Institute of Emergency Medicine; Saint Petersburg State University; Interdistrict Clinical Hospital of Vsevolozhsk
Email: bmayorov@mail.ru
ORCID iD: 0000-0003-1559-1571
Cand. Sci. (Med.)
Russian Federation, St. Petersburg; St. Petersburg; VsevolozhskIgor G. Belenkiy
St. Petersburg I.I. Dzhanelidze Research Institute of Emergency Medicine; Saint Petersburg State University
Author for correspondence.
Email: belenkiy.trauma@mail.ru
ORCID iD: 0000-0001-9951-5183
Dr. Sci. (Med.)
Russian Federation, St. Petersburg; St. PetersburgGennadii D. Sergeev
St. Petersburg I.I. Dzhanelidze Research Institute of Emergency Medicine; Saint Petersburg State University
Email: gdsergeev@gmail.com
ORCID iD: 0000-0002-8898-503X
Cand. Sci. (Med.)
Russian Federation, St. Petersburg; St. PetersburgIvan A. Endovitskiy
Interdistrict Clinical Hospital of Vsevolozhsk
Email: bmayorov@mail.ru
ORCID iD: 0009-0005-1872-639X
Russian Federation, Vsevolozhsk
Mariya A. Sergeeva
Saint Petersburg State University
Email: masharik1990@mail.ru
ORCID iD: 0009-0003-3255-1771
Russian Federation, St. Petersburg
David A. Isakhanyan
St. Petersburg I.I. Dzhanelidze Research Institute of Emergency Medicine
Email: gdsergeev@gmail.com
ORCID iD: 0009-0008-2194-8673
Russian Federation, St. Petersburg
References
- Воронцова Т.Н., Богопольская А.С., Чёрный А.Ж., Шевченко С.Б. Структура контингента больных с переломами проксимального отдела бедра и расчет среднегодовой потребности в экстренном хирургическом лечении. Травматология и ортопедия России. 2016;(1):7-20. doi: 10.21823/2311-2905-2016-0-1-7-20. Vorontsova T.N., Bogopol’skaya A.S., Cherny A.Zh., Shevchenko S.B. Cohort Structure of Patients with Proximal Femur Fractures and Estimation of Average Annual Demand for Emergency Surgical Treatment. Traumatology and Orthopedics of Russia. 2016;(1):7-20. (In Russian). doi: 10.21823/2311-2905-2016-0-1-7-20.
- Bäcker H.C., Wu C.H., Maniglio M., Wittekindt S., Hardt S., Perka C. Epidemiology of Proximal Femoral Fractures. J Clin Orthop Trauma. 2021;12(1):161-165. doi: 10.1016/j.jcot.2020.07.001.
- Park J.W., Ha Y.C., Kim J.W., Kim T.Y., Kim J.W., Baek S.H. et al. The Korean Hip Fracture Registry Study. BMC Musculoskelet Disord. 2023;24(1):449. doi: 10.1186/s12891-023-06546-z.
- Veronese N., Maggi S. Epidemiology and Social Costs of Hip Fracture. Injury. 2018;49(8):1458-1460. doi: 10.1016/j.injury.2018.04.015.
- Maffulli N., Aicale R. Proximal Femoral Fractures in the Elderly: A Few Things to Know, and Some to Forget. Medicina (Kaunas). 2022;58(10):1314. doi: 10.3390/medicina58101314.
- Майоров Б.А., Тульчинский А.Э., Беленький И.Г., Сергеев Г.Д., Барсукова И.М., Ендовицкий И.А. Лечение пострадавших с чрезвертельными переломами бедренной кости в травмоцентре 1-го уровня Ленинградской области. Медико-биологические и социально-психологические проблемы безопасности в чрезвычайных ситуациях. 2021;(3):68-76. doi: 10.25016/2541-7487-2021-0-3-68-76. Maiorov B.A., Tulchinskii A.E., Belenkii I.G., Sergeev G.D., Barsukova I.M., Endovitskiy I.A. Management of Intertrochanteric Femoral Fractures at Level 1 Trauma Center in Leningrad Region. Medicо-Biological and Socio-Psychological Problems of Safety in Emergency Situations. 2021;(3):68-76. (In Russian). doi: 10.25016/2541-7487-2021-0-3-68-76.
- Клинические рекомендации «Переломы проксимального отдела бедренной кости (взрослые)» (одобрены Минздравом России), утверждены в 2021. Режим доступа: https://ator.su/recommendations#!/tab/846022167-2. Clinical recommendations “Proximal femur fractures (adults)” (approved by Ministry of Health of Russia), affirmed in 2021. Available from: https://ator.su/recommendations#!/tab/846022167-2.
- Baumgaertner M.R., Curtin S.L., Lindskog D.M., Keggi J.M. 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. doi: 10.2106/00004623-199507000-00012.
- Yamamoto N., Tsujimoto Y., Yokoo S., Demiya K., Inoue M., Noda T. et al. Association between Immediate Postoperative Radiographic Findings and Failed Internal Fixation for Trochanteric Fractures: Systematic Review and Meta-Analysis. J Clin Med. 2022;11(16): 4879. doi: 10.3390/jcm11164879.
- Kashigar A., Vincent A., Gunton M.J., Backstein D., Safir O., Kuzyk P.R. Predictors of Failure for Cephalomedullary Nailing of Proximal Femoral Fractures. Bone Joint J. 2014;96-B(8):1029-1034. doi: 10.1302/0301-620X.96B8.33644.
- Raghuraman R., Kam J.W., Chua D.T.C. Predictors of Failure Following Fixation of Intertrochanteric Fractures with Proximal Femoral Nail Antirotation. Singapore Med J. 2019;60(9):463-467. doi: 10.11622/smedj.2019114.
- Chang S.M., Zhang Y.Q., Ma Z., Li Q., Dargel J., Eysel P. Fracture Reduction with Positive Medial Cortical Support: a Key Element in Stability Reconstruction for the Unstable Pertrochanteric Hip Fractures. Arch Orthop Trauma Surg. 2015;135(6):811-818. doi: 10.1007/s00402-015-2206-x.
- Song H., Chang S.M., Hu S.J., Du S.C., Xiong W.F. Calcar fracture gapping: a reliable predictor of anteromedial cortical support failure after cephalomedullary nailing for pertrochanteric femur fractures. BMC Musculoskelet Disord. 2022;23(1):175. doi: 10.1186/s12891-021-04873-7.
- Barla M., Egrise F., Zaharia B., Bauer C., Parot J., Mainard D. Prospective Assessment of Trochanteric Fracture Managed by Intramedullary Nailing with Controlled and Limited Blade Back-Out. Orthop Traumatol Surg Res. 2020;106(4):613-619. doi: 10.1016/j.otsr.2019.11.028.
- Babhulkar S. Unstable Trochanteric Fractures: Issues and Avoiding Pitfalls. Injury. 2017;48(4):803-818. doi: 10.1016/j.injury.2017.02.022.
- Petrie J., Sassoon A., Haidukewych G.J. When Femoral Fracture Fixation Fails: Salvage Options. Bone Joint J. 2013;95-B(11, Suppl A):7-10. doi: 10.1302/0301-620X.95B11.32896.
- Liu P., Jin D., Zhang C., Gao Y. Revision Surgery due to Failed Internal Fixation of Intertrochanteric Femoral Fracture: Current State-of-the-Art. BMC Musculoskelet Disord. 2020;21(1):573. doi: 10.1186/s12891-020-03593-8.
- Werner-Tutschku W., Lajtai G., Schmiedhuber G., Lang T., Pirkl C., Orthner E. Intra- and perioperative complications in the stabilization of per- and subtrochanteric femoral fractures by means of PFN. Unfallchirurg. 2002;105(10):881-885. (In German). doi: 10.1007/s00113-002-0416-5.
- Hao Y., Zhang Z., Zhou F., Ji H., Tian Y., Guo Y. et al. Risk Factors for Implant Failure in Reverse Oblique and Transverse Intertrochanteric Fractures Treated with Proximal Femoral Nail Antirotation (PFNA). J Orthop Surg Res. 2019;14(1):350. doi: 10.1186/s13018-019-1414-4.
- Zhang Y., Hu J., Li X., Qin X. Reverse Wedge Effect Following Intramedullary Nailing of a Basicervical Trochanteric Fracture Variant Combined with a Mechanically Compromised Greater Trochanter. BMC Musculoskelet Disord. 2020;21(1):195. doi: 10.1186/s12891-020-03212-6.
- Соломин Л.Н., Щепкина Е.А., Кулеш П.Н., Виленский В.А., Корчагин К.Л., Скоморошко П.В. Определение референтных линий и углов длинных трубчатых костей : пособие для врачей. СПб.: РНИИТО им. Р.Р. Вредена; 2012. 48 с. Solomin L.N., Shchepkina E.A., Kulesh P.N., Vilenskii V.A., Korchagin K.L., Skomoroshko P.V. Definition of reference lines and angles of long bones. St. Petersburg: RNIITO im. R.R. Vredena; 2012. 48 р. (In Russian).
- O’Malley M.J., Kang K.K., Azer E., Siska P.A., Farrell D.J., Tarkin I.S. Wedge Effect Following Intramedullary Hip Screw Fixation of Intertrochanteric Proximal Femur Fracture. Arch Orthop Trauma Surg. 2015;135(10):1343-1347. doi: 10.1007/s00402-015-2280-0.
- Yen S.H., Lu C.C., Ho C.J., Huang H.T., Tu H.P., Chang J.K. et al. Impact of Wedge Effect on Outcomes of Intertrochanteric Fractures Treated with Intramedullary Proximal Femoral Nail. J Clin Med. 2021;10(21):5112. doi: 10.3390/jcm10215112.
- Nikoloski A.N., Osbrough A.L., Yates P.J. 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. doi: 10.1186/1749-799X-8-35.
- Rea L.M., Parker R.A. Designing and Conducting Survey Research. San Francisco, CA: Jossey-Bass; 2005. 283 p.
- Li J., Tang S., Zhang H., Li Z., Deng W., Zhao C. et al. Clustering of Morphological Fracture Lines for Identifying Intertrochanteric Fracture Classification with Hausdorff Distance-Based K-means Approach. Injury. 2019;50(4):939-949. doi: 10.1016/j.injury.2019.03.032.
- Parker M.J. Cutting-Out of the Dynamic Hip Screw Related to Its Position. J Bone Joint Surg Br. 1992;74(4):625. doi: 10.1302/0301-620X.74B4.1624529.
- Kuzyk P.R., Zdero R., Shah S., Olsen M., Waddell J.P., Schemitsch E.H. Femoral Head Lag Screw Position for Cephalomedullary Nails: A Biomechanical Analysis. J Orthop Trauma. 2012;26(7):414-421. doi: 10.1097/BOT.0b013e318229acca.
- Butler B.A., Selley R.S., Summers H.D., Stover M.D. Preventing Wedge Deformities When Treating Intertrochanteric Femur Fractures with Intramedullary Devices: A Technical Tip. J Orthop Trauma. 2018;32(3):e112-e116. doi: 10.1097/BOT.0000000000001033.
- Hsu C.E., Shih C.M., Wang C.C., Huang K.C. Lateral Femoral Wall Thickness. A Reliable Predictor of Post-Operative Lateral Wall Fracture in Intertrochanteric Fractures. Bone Joint J. 2013;95-B(8):1134-1138. doi: 10.1302/0301-620X.95B8.31495.
- Chang S.M., Hou Z.Y., Hu S.J., Du S.C. Intertrochanteric Femur Fracture Treatment in Asia: What We Know and What the World Can Learn. Orthop Clin North Am. 2020;51(2):189-205. doi: 10.1016/j.ocl.2019.11.011.
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