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The modified Cleveland system used in our study. Nine areas we reduced to three, specifically the central (reference category) and two peripherals denoted “ + ” (in green) and “x” (in yellow).
Source publication
Cut-out is one of the most common mechanical failures in the internal fixation of trochanteric hip fractures. The tip-apex distance (TAD), and the calcar-referenced tip apex distance (CalTAD) are the radiographic parameters that most predict the risk of cut-out. The optimal CalTAD value has not yet been defined, but the optimal TAD value is reporte...
Citations
... Los factores radiográficos, DPA y DPAC, son los parámetros reportados en la literatura que mejor predicen el desanclaje del tornillo. 15,16 Ambos parámetros radiográficos se han reportado como factores independientes para predecir la falla del sistema. 17 Con respecto a la posición del tornillo, encontramos que los pacientes con una posición central/anterior y superior/ anterior tuvieron mayores probabilidades de falla del sistema DHS. ...
Introducción: el sistema de fijación más usado para fractu-ras transtrocantéricas es el sistema del tornillo dinámico de cadera, el cual tiene una prevalencia de falla del 10 al 17% y se asocia a la presencia de factores clínicos y radiográficos. Objetivo: evaluar la asociación de los factores clínicos y ra-diográficos con la falla del sistema del tornillo en pacientes postoperados de fractura transtrocantérica de cadera. Material y métodos: se hizo un estudio de casos y contro-les. Los criterios de inclusión fueron: pacientes > 18 años, postoperados de fractura transtrocantérica, tratados con el sistema del tornillo de cadera, que acudieron a la consulta de Traumatología. Se seleccionó como caso al paciente con falla del sistema del tornillo de cadera y como control al paciente sin falla de este. Las variables analizadas en los grupos fueron la edad, el género, el índice de masa corporal y las variables radiográficas. El análisis estadístico se hizo con chi cuadrada y U de Mann-Whitney. Resultados: se incluyeron 163 pacientes (mediana de 73 años), 20 casos y 143 controles. Los factores radiográfi-cos con asociación significativa con la falla del sistema del tornillo de cadera fueron la clasificación AO de la fractura (p < 0.001), la distancia punta-ápex (p = 0.03), punta ápex calcar (p = 0.02), la posición del tornillo (p < 0.001) y la ca-lidad de la reducción (p < 0.003). Los factores clínicos no mostraron asociación significativa. Conclusiones: los factores radiográficos se asocian con la falla en el sistema del tornillo de cadera en pacientes posto-perados de fractura transtrocantérica. Resumen Abstract Background: The most widely used fixation system for transtrochanteric fractures is the dynamic hip screw system, which has a failure prevalence of 10 to 17% and it is associated with the presence of clinical and radiographic factors. Objective: To evaluate the association of clinical and radio-graphic factors with the failure of the screw system in post-operative patients for transtrochanteric hip fracture. Material y methods: A case-control study was carried out. The inclusion criteria were: patients > 18 years, who underwent surgery due to transtrochanteric fracture, were treated with the hip screw system, and who attended the Trauma Service. The patient with failure of the hip screw system was selected as the case and the patient without failure of the system as control. The variables analyzed in these groups were: age, gender, body mass index and ra-diographic variables. Statistical analysis was performed with chi-squared and Mann-Whitney U. Results: 163 patients (median 73 years), 20 cases and 143 controls, were included. The radiographic factors with a significant association with hip screw system failure were the AO classification of fractures (p < 0.001), the tip apex distance (p = 0.03), the calcar-referenced tip apex (p = 0.02), the position of the screw (p < 0.001), and quality of reduction (p < 0.003). Clinical factors did not show a significant association. Conclusions: Radiographic factors are associated with failure in the hip screw system in patients in post-operative care due to transtrochanteric fracture.
... 13,30,31 Subsequent biomechanical studies have suggested that when the lag screw is placed in a more inferior position, as opposed to the ideal center-center position, a TAD greater than 25mm is biomechanically stable and recent clinical studies have suggested a higher threshold TAD of 35mm. 14,32 Although TAD is the most commonly used radiographic intraoperative parameter used to assess cephalomedullary fixation, our analysis did not find a correlation between TAD greater than 25mm and fixation failure. Although increased age has been cited as a risk factor for fixation failure due to screw cut-out, patients that progressed to fixation failure were younger compared to controls in this study. ...
Purpose
Determine if any fracture characteristics or radiographic parameters were predictive of fixation failure [FF] within 1 year following cephalomedullary nailing for intertrochanteric fractures.
Methods
A consecutive series of intertrochanteric hip fracture patients (AO/OTA 31A) treated with a cephalomedullary nail were reviewed. Pre-fixation (neck-shaft angle [NSA], distance from ischial tuberosities to greater and lesser trochanters, integrity of lesser trochanter, and fracture angulation) and post-fixation (post-fixation NSA, posteromedial cortex continuity, lag screw position, tip to apex distance [TAD], and post-fixation angulation and translation) radiographic parameters were measured by blinded independent reviewers. The FF and non-FF groups were statistically compared. Logistic regression was performed to determine radiographic parameter correlates of FF.
Results
Of 1249 patients, 23 (1.8%) developed FF within 1 year. The FF patients were younger than their non-FF counterparts (77.2 years vs 81.0 years, p=0.048), however there were no other demographic differences. The FF cohort did not differ in frequency of TAD over 25 mm (4.3% vs 9.6%, p=0.624) and had decreased mean TAD (13.6mm vs 16.3mm, p=0.021) relative to the non-FF cohort. The FF cohort had a higher rate of a post-fixation coronal plane NSA more than 10° different from the contralateral side (delta NSA>10°, 34.8% vs 13.7%, p=0.011) with the majority fixed in relative varus. For every 1° increase in varus compared to the contralateral side the odds of FF increased 7% (OR=1.065, 95%CI[1.005–1.130], p=0.034) on univariate analysis. On univariate logistic regression, patients with an absolute post-fixation NSA of 10° or more of varus compared to contralateral were significantly more likely to have a FF (OR=3.139, 95%CI[1.067–8.332], p=0.026).
Conclusion
Despite an acceptable TAD, post-fixation NSA in relative varus as compared to the contralateral side was significantly associated with failure in intertrochanteric hip fractures fixed with a cephalomedullary nail.
Level of evidence
Prognostic Level III.
... Conditions that may influence the stability of the lag screw will be assessed and discussed with special consideration towards TAD as a prophylactic measure in decreasing lag screw cut-out risk by minimizing peripheral screw insertion and achieving an ideal cut-off measurement of less than 25mm on both lateral and AP X-ray views combined. Given the encouraging results of that study [7]. The aim of the work was to use tip apex distance as a tool for decreasing the incidence of lag screw cutout in managing proximal femur fractures using cephalo-medullary nailing and dynamic hip screws. ...
... In our study, two-thirds of the studied group (66.7%) were females, and one-third (33.3%) were males. This agreed with Caruso et al., [7] who reported that 35% of the cases were males and 65% were females. In our study, fall was the most common mode of injury (72.2%) followed by road traffic accidents (27.8%). ...
... Regarding our results, Patients who underwent reductions with cut-outs had better results than those who did not, all patients with no cut-outs had excellent reduction quality. That was in agreement with Caruso et al. [7] who reported that There was a nearly statistically significant link between the quality of reduction, distal locking, and nail selection and the risk of cut-out. According to our results, there was a statistically significant increase in TAD at 6 months postoperative among patients with cut-outs than without cut-outs while regarding TAD at operation, non-statistically significant differences were found. ...
... It is paramount to practice diligent operative techniques to achieve anatomic fracture reduction because proper implant placement cannot be accomplished prior to an anatomic reduction [3]. TAD and CalTAD values are of great significance concerning the risk for postoperative cut-out [4,5]. Precise intraoperative fracture compression enhances stability and promotes fracture healing, resulting in greater benefits for the patient with early mobilization and full weight-bearing while avoiding the complications of prolonged bed rest [2][3][4]. ...
... Particular attention should be paid to fracture site reduction and lag screw positioning to diminish mechanical complications such as lag screw cut-out, which aggravate morbidity and mortality associated with proximal femur fractures [4]. Studies have provided the first clinical evidence bolstering the validity and reliability of CalTAD as a predictor of lag screw cut-out, which is a measurement method that favors the inferior-central region of the femoral head for placing the lag screw [4,5]. The value of CalTAD appears to be more effectual than the TAD value in predicting the risk of the cut-out in the postoperative period. ...
... The value of CalTAD appears to be more effectual than the TAD value in predicting the risk of the cut-out in the postoperative period. However, the discrepancy between the two methods is minimal [5]. In addition, searching the existing literature, no studies demonstrate greater sensitivity and specificity of CalTAD than TAD and vice-versa. ...
Cephalomedullary nailing of unstable intertrochanteric fractures has been established as a fruitful surgical approach with relatively limited complications. Anatomic fracture reduction and proper implant positioning are vital to attaining a favorable long-term surgical outcome. Appropriate intraoperative fracture compression augments stability and invigorates healing. The amount of compression permitted by cephalomedullary nails cannot always adequately reduce large fragment gaps. This paper presents a novel technical trick of double compression of the fracture site, in order to achieve the essential extra compression and reduction when required, thus decreasing the risk of postoperative implant cut-out. The technique was used in 14 out of 277 peritrochanteric fractures treated with cephalomedullary nailing in our trauma center for 12 months, with satisfactory outcomes regarding both fracture site union and postoperative functional capacity.
... Moreover, the correlation between TAD and fixation failure was not proven in our findings. In general, a TAD <25mm is recommended to lessen the risk of fixation failure in intramedullary hip nails, although evidence for this is limited [13] and several authors have reported that longer TAD and calcar-referenced tip-apex distance (CalTAD) do not, in fact, increase cutout risk [14]. In our study, 29% of patients had a TAD >25 mm, and yet none of them presented a mechanical failure. ...
Purpose: Reverse oblique and transverse intertrochanteric femoral fractures (31A3 AO/OTA classification) have their own mechanical and anatomical properties. The aim of our study is to verify whether the reduction of the lateral femoral wall and ideal tip-apex distance are important predictive factors in the future of these fractures treated by gamma nails in terms of healing and complication rates. Methods: The radiological and clinical outcomes of 35 fractures of this type treated by short and long gamma nail from June 2014 to April 2021 were retrospectively reviewed. The elements considered were the quality of the lateral femoral wall reduction, the tip-apex distance (TAD), the lag screw position and overall quality reduction using the Baumgaertner criteria. Union, nonunion, cutout, screw sliding, nail or screw breakage were also radiographically evaluated during follow-up. Results: The union rate was 97%. A significant association was not observed between the state of reduction of the lateral wall and the three types of complications considered (cutout: p=0.31; sliding screw: p=1.00; varus displacement: p=0.30), and the linear regression model obtained indicates that in subjects with a non-reduction of the lateral wall, the consolidation time is increased on average by approximately 3 months (β= 2.99; 95%CI: 1.79-4.20, p<0.001). No significant association was found between TAD and complications (cut-out: p=1.00; sliding screw: p=1.00; varus displacement: p=0.13). Conclusion: Anatomic reduction of the lateral wall and an ideal TAD ≤ 25mm might not be as significant for 31A3 fractures treated with gamma nails. Acceptable reduction of the lateral wall and stable internal fixation are sufficient elements to achieve fracture healing and functional recovery.
... The standard cut-off for TAD is 25 mm [11], but no value for CalTAD has been definitive. Caruso et al. [27] reported cut-off values of 30.7 mm and 37.3 mm for TAD and CalTAD, respectively; a more recent study by the same author recommended 34.8 mm and 35.2 mm [39]. Another study suggested a 20-mm optimal threshold for TAD [37]. ...
Purpose
This study determined independent predictors and developed a predictive nomogram for failed correction of intertrochanteric fractures due to cut-out of the proximal femur nail anti-rotation (PFNA) device.
Methods
Demographic and radiological data of 592 adult patients with intertrochanteric fractures (AO 31A) treated by PFNA were collected retrospectively. Independent predictors of cut-out were obtained through univariate and multivariate analyses, and a predictive nomogram was established. The discrimination, calibration, and clinical utility of the nomogram were based on receiver operating characteristic curve (AUC), concordance index (C-index), calibration curve, and decision curve analysis, respectively.
Results
Overall, 18 (3.04%) cases of cut-out occurred. Independent predictors according to the multivariate analysis were body mass index (BMI), poor-to-acceptable quality of reduction, PFNA blade position, and tip-apex distance (TAD). AUC of the nomogram was 0.849, and C-index was 0.849 (95% CI [0.844–0.854]). Bootstrapping yielded a corrected C-index of 0.849. The calibration and decision curves indicated good agreement and clinical benefit of the nomogram.
Conclusion
A reliable predictive nomogram was developed for cut-out of the PFNA in intertrochanteric fractures, based on BMI, quality of reduction, blade position, and TAD.
... 11 Cutting-out of the lag screw is the main complication of proximal femur fracture fixation. 12 The strongest predictor of cutting-out in femoral nailing is tip-apex distance (TAD). 13 Distances less than 25 mm are associated with a significantly decreased risk of slippage of the cephalic screw, 14 while there is a very strong statistical relationship between a TAD greater than 25 mm and mobilization of the cephalic screw. ...
Introduction
Reverse oblique intertrochanteric fractures are classified by the Orthopaedic Trauma Association [OTA]/[AO] as 31A3, and account for up to one-third of all hip fractures, and 2–23% of all trochanteric fractures. The treatment of choice of those fractures is intramedullary nailing as it decreases soft tissue damage and permits early weight bearing.
Material and methods
A retrospective comparative study was conducted on patients surgically treated for 31A3 fractures from October 2018 to January 2022 in a high-volume regional referral centre. All the patients had been treated with intramedullary nailing.
Results
The selected group included 11 males (16%) and 59 females (84%), with a mean age of 83.6 years (range 61 to 96 years). A Trigen Intertan Nail was the most frequent choice of intramedullary nailing in 33 patients (47%), an Elos Long nail was chosen in 19 cases (27%), while a ZNN nail was used in 18 patients (26%). The mean time between admission and surgery was 2.5 days, with a mean Hb value of 10.5 g/dl reported preoperatively.
Conclusion
Patients treated with an Intertan nail reported the lowest TAD, CALTAD, and TALCALTAD mean radiographic values, and the lowest rate of Hb loss and blood transfusions.
... The relative risk for cut out significantly increased sevenfold for none optimal blade positioning. Despite that, multiple studies already showed an increased rate of cut out with blade position deviating from center-center and inferior-center [17][18][19][20] there were still around 88% of the patient had optimal blade positions in this study. This highlights the importance of the correct surgical technique regardless of the implant. ...
... The tip apex distance was no significant predictor of implant failure in this study. In both groups mean tip apex distance was less than 25 mm, what might have prevented further cut outs compared to the results of studies including more cases with tip apex distance higher than 25 mm [19,20]. Tip apex distance was slightly less in FNS group. ...
Background
Hip fractures in the elderly population are common and the number of patients is rising. For young and geriatric patients with undisplaced fractures osteosynthesis is the primary type of treatment. The dynamic hip screw (DHS) is around for many years and proved its value especially in displaced fractures. Since 2018 the femoral neck system (FNS) is available as an alternative showing promising biomechanical results. The aim of this study is to evaluate clinical results of the FNS and compare it to the DHS.
Materials and methods
Patients older than 18 years with Garden I–IV fractures that were treated with osteosynthesis in a level 1 trauma center were included in the study. Between January 2015 and March 2021, all patients treated with FNS (1-hole plate, DePuy-Synthes, Zuchwil, Switzerland) or DHS (2-hole plate, DePuy-Synthes, Zuchwil, Switzerland) for proximal femur fractures were included in the study. Closed reduction was achieved using a traction table. All operations were carried out by experienced orthopedic trauma surgeons. Primary outcome measures were rate of implant failure (cut out) and surgical complications (hematoma, infection). Secondary outcome measures were Hb-difference, length of hospital stay and mortality.
Results
Overall, 221 patients were included in the study. 113 were treated with FNS, 108 with DHS. Mean age was 69 ± 14 years. There were 17.2% Garden I, 47.5% Garden II, 26.7% Garden III and 8.6% Garden IV fractures. No difference between the groups for age, body mass index (BMI), Charlson comorbidity index (CCI), time to surgery, Pauwels and Garden classification, rate of optimal blade position or tip apex distance was found. FNS showed lower pre- to postoperative Hb-difference (1.4 ± 1.1 g/l vs. 2.1 ± 1.4 g/l; p < 0.05), shorter operating time (36.3 ± 11.6 min vs. 54.7 ± 17.4 min; p < 0.05) and hospital stay (8.8 ± 4.3 d vs. 11.2 ± 6.8 d; p < 0.05). Surgical complications (FNS 13.3% vs. DHS 18.4%, p > 0.05), rate of cut out (FNS 12.4% vs. DHS 10.2%, p > 0.05) and mortality (FNS 3.5%; DHS 0.9%; p > 0.05) showed no difference between the groups. Logistic regression showed that poor blade position was the only significant predictor for cut out and increased the risk by factor 7. Implant related infection ( n = 3) and hematoma/seroma ( n = 6) that needed revision was only seen in DHS group.
Conclusion
FNS proved to be as reliable as DHS in all patients with hip fractures. Not the type of implant but blade positioning is still key to prevent implant failure. Still due to minimal invasive approach implant related infections and postoperative hematomas might have been prevented using the FNS.
Aims
Proximal femur fractures treatment can involve anterograde nailing with a single or double
cephalic screw. An undesirable failure for this fixation is screw cut-out. In a single-screw nail,
a tip-apex distance (TAD) greater than 25 mm has been associated with an increased risk of
cut-out. The aim of the study was to examine the role of TAD as a risk factor in a cephalic
double-screw nail.
Methods
A retrospective study was conducted on 112 patients treated for intertrochanteric femur fracture
with a double proximal screw nail (Endovis BA2; EBA2) from January to September 2021. The
analyzed variables were age, sex, BMI, comorbidities, fracture type, side, time of surgery, quality
of reduction, pre-existing therapy with bisphosphonate for osteoporosis, screw placement in
two different views, and TAD. The last follow-up was at 12 months. Logistic regression was used
to study the potential factors of screw cut-out, and receiver operating characteristic curve to
identify the threshold value.
Results
A total of 98 of the 112 patients met the inclusion criteria. Overall, 65 patients were female
(66.3%), the mean age was 83.23 years (SD 7.07), and the mean follow-up was 378 days (SD 36).
Cut-out was observed in five patients (5.10%). The variables identified by univariate analysis with
p < 0.05 were included in the multivariate logistic regression model were screw placement and
TAD. The TAD was significant with an odds ratio (OR) 5.03 (p = 0.012) as the screw placement
with an OR 4.35 (p = 0.043) in the anteroposterior view, and OR 10.61 (p = 0.037) in the lateral
view. The TAD threshold value identified was 29.50 mm.
Conclusion
Our study confirmed the risk factors for cut-out in the double-screw nail are comparable to
those in the single screw. We found a TAD value of 29.50 mm to be associated with a risk of
cut-out in double-screw nails, when good fracture reduction is granted. This value is higher
than the one reported with single-screw nails. Therefore, we suggest the role of TAD should be
reconsidered in well-reduced fractures treated with double-screw intramedullary nail.
Take home message
Risk factors for cut-out in the double-screw nail are comparable
to those in the single-screw device, with a larger tipapex
distance when good reduction is granted.
This study aims to explore the feasibility of employing convolutional neural networks for detecting and localizing implant cutouts on anteroposterior pelvic radiographs.
The research involves the development of two Deep Learning models. Initially, a model was created for image-level classification of implant cutouts using 40191 pelvic radiographs obtained from a single institution. The radiographs were partitioned into training, validation, and hold-out test datasets in a 6/2/2 ratio. Performance metrics including the area under the receiver operator characteristics curve (AUROC), sensitivity, and specificity were calculated using the test dataset. Additionally, a second object detection model was trained to localize implant cutouts within the same dataset. Bounding box visualizations were generated on images predicted as cutout-positive by the classification model in the test dataset, serving as an adjunct for assessing algorithm validity.
The classification model had an accuracy of 99.7%, sensitivity of 84.6%, specificity of 99.8%, AUROC of 0.998 (95% CI: 0.996, 0.999) and AUPRC of 0.774 (95% CI: 0.646, 0.880). From the pelvic radiographs predicted as cutout-positive, the object detection model could achieve 95.5% localization accuracy on true positive images, but falsely generated 14 results from the 15 false-positive predictions.
The classification model showed fair accuracy for detection of implant cutouts, while the object detection model effectively localized cutout. This serves as proof of concept of using a deep learning-based approach for classification and localization of implant cutouts from pelvic radiographs.
