Objectives. Intramedullary fixation is considered the most stable treatment for pertrochanteric fractures of the proximal femur and cut-out is one of the most frequent mechanical complications. In order to determine the role of clinical variables and radiological parameters in predicting the risk of this complication, we analysed the data pertaining to a group of patients recruited over the course of six years. Methods. A total of 571 patients were included in this study, which analysed the incidence of cut-out in relation to several clinical variables: age; gender; the AO Foundation and Orthopaedic Trauma Association classification system (AO/OTA); type of nail; cervical-diaphyseal angle; surgical wait times; anti-osteoporotic medication; complete post-operative weight bearing; and radiological parameters (namely the lag-screw position with respect to the femoral head, the Cleveland system, the tip-apex distance (TAD), and the calcar-referenced tip-apex distance (CalTAD)). Results. The incidence of cut-out across the sample was 5.6%, with a higher incidence in female patients. A significantly higher risk of this complication was correlated with lag-screw tip positioning in the upper part of the femoral head in the anteroposterior radiological view, posterior in the latero-lateral radiological view, and in the Cleveland peripheral zones. The tip-apex distance and the calcar-referenced tip-apex distance were found to be highly significant predictors of the risk of cut-out at cut-offs of 30.7 mm and 37.3 mm, respectively, but the former appeared more reliable than the latter in predicting the occurrence of this complication. Conclusion. The tip-apex distance remains the most accurate predictor of cut-out, which is significantly greater above a cut-off of 30.7 mm. Cite this article: G. Caruso, M. Bonomo, G. Valpiani, G. Salvatori, A. Gildone, V. Lorusso, L. Massari. A six-year retrospective analysis of cut-out risk predictors in cephalomedullary nailing for pertrochanteric fractures: Can the tip-apex distance (TAD) still be considered the best parameter?. Bone Joint Res 2017;6:481–488. DOI: 10.1302/2046-3758.68.BJR-2016-0299.R1

Objectives. Because of the contradictory body of evidence related to the potential benefits of helical blades in trochanteric fracture fixation, we studied the effect of bone compaction resulting from the insertion of a proximal femoral nail anti-rotation (PFNA). . Methods. We developed a subject-specific computational model of a trochanteric fracture (31-A2 in the AO classification) with lack of medial support and varied the bone density to account for variability in bone properties among hip fracture patients. Results. We show that for a bone density corresponding to 100% of the bone density of the cadaveric femur, there does not seem to be any advantage in using a PFNA with respect to the risk of blade cut-out. On the other hand, in a more osteoporotic femoral head characterised by a density corresponding to 75% of the initial bone density, local bone compaction around the helical blade provides additional bone purchase, thereby decreasing the risk of cut-out, as quantified by the volume of bone susceptible to yielding. Conclusions. Our findings indicate benefits of using a PFNA over an intramedullary nail with a conventional lag screw and suggest that any clinical trial reporting surgical outcomes regarding the use of helical blades should include a measure of the femoral head bone density as a covariable

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. Cite this article: Bone Jt Open 2024;5(6):457–463

Aims. Fixation of osteoporotic proximal humerus fractures remains challenging even with state-of-the-art locking plates. Despite the demonstrated biomechanical benefit of screw tip augmentation with bone cement, the clinical findings have remained unclear, potentially as the optimal augmentation combinations are unknown. The aim of this study was to systematically evaluate the biomechanical benefits of the augmentation options in a humeral locking plate using finite element analysis (FEA). Methods. A total of 64 cement augmentation configurations were analyzed using six screws of a locking plate to virtually fix unstable three-part fractures in 24 low-density proximal humerus models under three physiological loading cases (4,608 simulations). The biomechanical benefit of augmentation was evaluated through an established FEA methodology using the average peri-screw bone strain as a validated predictor of cyclic cut-out failure. Results. The biomechanical benefit was already significant with a single cemented screw and increased with the number of augmented screws, but the configuration was highly influential. The best two-screw (mean 23%, SD 3% reduction) and the worst four-screw (mean 22%, SD 5%) combinations performed similarly. The largest benefits were achieved with augmenting screws purchasing into the calcar and having posteriorly located tips. Local bone mineral density was not directly related to the improvement. Conclusion. The number and configuration of cemented screws strongly determined how augmentation can alleviate the predicted risk of cut-out failure. Screws purchasing in the calcar and posterior humeral head regions may be prioritized. Although requiring clinical corroborations, these findings may explain the controversial results of previous clinical studies not controlling the choices of screw augmentation

The purpose of this study was to identify factors that predict implant cut-out after cephalomedullary nailing of intertrochanteric and subtrochanteric hip fractures, and to test the significance of calcar referenced tip-apex distance (CalTAD) as a predictor for cut-out. We retrospectively reviewed 170 consecutive fractures that had undergone cephalomedullary nailing. Of these, 77 met the inclusion criteria of a non-pathological fracture with a minimum of 80 days radiological follow-up (mean 408 days; 81 days to 4.9 years). The overall cut-out rate was 13% (10/77). The significant parameters in the univariate analysis were tip-apex distance (TAD) (p <  0.001), CalTAD (p = 0.001), cervical angle difference (p = 0.004), and lag screw placement in the anteroposterior (AP) view (Parker’s ratio index) (p = 0.003). Non-significant parameters were age (p = 0.325), gender (p = 1.000), fracture side (p = 0.507), fracture type (AO classification) (p = 0.381), Singh Osteoporosis Index (p = 0.575), lag screw placement in the lateral view (p = 0.123), and reduction quality (modified Baumgaertner’s method) (p = 0.575). In the multivariate analysis, CalTAD was the only significant measurement (p = 0.001). CalTAD had almost perfect inter-observer reliability (interclass correlation coefficient (ICC) 0.901). Our data provide the first reported clinical evidence that CalTAD is a predictor of cut-out. The finding of CalTAD as the only significant parameter in the multivariate analysis, along with the univariate significance of Parker’s ratio index in the AP view, suggest that inferior placement of the lag screw is preferable to reduce the rate of cut-out. Cite this article: Bone Joint J 2014; 96-B:1029–34

The February 2023 Trauma Roundup. 360. looks at: Masquelet versus bone transport in infected nonunion of tibia; Hyperbaric Oxygen for Lower Limb Trauma (HOLLT): an international multicentre randomized clinical trial; Is the T-shaped acetabular fracture really a “T”?; What causes cut-out of proximal femur nail anti-rotation device in intertrochanteric fractures?; Is the common femoral artery at risk with percutaneous fragility pelvis fixation?; Anterior pelvic ring pattern predicts displacement in lateral compression fractures; Differences in age-related characteristics among elderly patients with hip fractures

Objectives. The Sliding Hip Screw (SHS) is commonly used to treat trochanteric hip fractures. Fixation failure is a devastating complication requiring complex revision surgery. One mode of fixation failure is lag screw cut-out which is greatest in unstable fracture patterns and when the tip-apex distance of the lag screw is > 25 mm. The X-Bolt Dynamic Hip Plating System (X-Bolt Orthopaedics, Dublin, Ireland) is a new device which aims to reduce this risk of cut-out. However, some surgeons have reported difficulty minimising the tip-apex distance with subsequent concerns that this may lead to an increased risk of cut-out. Patients and Methods. We measured the tip-apex distance from the intra-operative radiographs of 93 unstable trochanteric hip fractures enrolled in a randomised controlled trial (Warwick Hip Trauma Evaluation, WHiTE One trial). Participants were treated with either the sliding hip screw or the X-Bolt dynamic hip plating system. We also recorded the incidence of cut-out in both groups, at a median follow-up time of 17 months. Results. There was a significantly increased tip-apex distance with the use of the X-Bolt (mean difference 3.7mm (95% confidence interval 1.58 to 5.73); SHS mean 17.1 mm, X-Bolt mean 20.8; p = 0.001. However, this was not associated with an increased incidence of cut-out at a median follow-up time of 17 months, with three cut-outs (6%) in the SHS group and 0 (0%) in the X-Bolt group. Conclusion. The X-Bolt is a safe implant with no increased risk for cut-out. Concerns about minimising the tip-apex distance may be justified but do not appear to be clinically important. Cite this article: M. A. Fernandez, A. Aquilina, J. Achten, N. Parsons, M. L. Costa, X. L. Griffin. The tip-apex distance in the X-Bolt dynamic plating system. Bone Joint Res 2017;6:–207. DOI: 10.1302/2046-3758.64.BJR-2015-0016.R2

Objectives. The paradoxical migration of the femoral neck element (FNE) superomedially against gravity, with respect to the intramedullary component of the cephalomedullary device, is a poorly understood phenomenon increasingly seen in the management of pertrochanteric hip fractures with the intramedullary nail. The aim of this study was to investigate the role of bidirectional loading on the medial migration phenomenon, based on unique wear patterns seen on scanning electron microscopy of retrieved implants suggestive of FNE toggling. Methods. A total of 18 synthetic femurs (Sawbones, Vashon Island, Washington) with comminuted pertrochanteric fractures were divided into three groups (n = 6 per group). Fracture fixation was performed using the Proximal Femoral Nail Antirotation (PFNA) implant (Synthes, Oberdorf, Switzerland; n = 6). Group 1 was subjected to unidirectional compression loading (600 N), with an elastomer (70A durometer) replacing loose fracture fragments to simulate surrounding soft-tissue tensioning. Group 2 was subjected to bidirectional loading (600 N compression loading, 120 N tensile loading), also with the elastomer replacing loose fracture fragments. Group 3 was subjected to bidirectional loading (600 N compression loading, 120 N tensile loading) without the elastomer. All constructs were tested at 2 Hz for 5000 cycles or until cut-out occurred. The medial migration distance (MMD) was recorded at the end of the testing cycles. Results. The MMDs for Groups 1, 2, and 3 were 1.02 mm, 6.27 mm, and 5.44 mm respectively, with reliable reproduction of medial migration seen in all groups. Bidirectional loading groups showed significantly higher MMDs compared with the unidirectional loading group (p < 0.01). Conclusion. Our results demonstrate significant contributions of bidirectional cyclic loading to the medial migration phenomenon in cephalomedullary nail fixation of pertrochanteric hip fractures. Cite this article: G. W. Law, Y. R. Wong, A. K-S. Yew, A. C. T. Choh, J. S. B. Koh, T. S. Howe. Medial migration in cephalomedullary nail fixation of pertrochanteric hip fractures: A biomechanical analysis using a novel bidirectional cyclic loading model. Bone Joint Res 2019;8:313–322. DOI: 10.1302/2046-3758.87.BJR-2018-0271.R1

Aims. Plating displaced proximal humeral fractures is associated with a high rate of screw perforation. Dynamization of the proximal screws might prevent these complications. The aim of this study was to develop and evaluate a new gliding screw concept for plating proximal humeral fractures biomechanically. Methods. Eight pairs of three-part humeral fractures were randomly assigned for pairwise instrumentation using either a prototype gliding plate or a standard PHILOS plate, and four pairs were fixed using the gliding plate with bone cement augmentation of its proximal screws. The specimens were cyclically tested under progressively increasing loading until perforation of a screw. Telescoping of a screw, varus tilting and screw migration were recorded using optical motion tracking. Results. Mean initial stiffness (N/mm) was 581.3 (. sd. 239.7) for the gliding plate, 631.5 (. sd. 160.0) for the PHILOS and 440.2 (. sd. 97.6) for the gliding augmented plate without significant differences between the groups (p = 0.11). Mean varus tilting (°) after 7500 cycles was comparable between the gliding plate (2.6; . sd. 1.9), PHILOS (1.2; . sd. 0.6) and gliding augmented plate (1.7; . sd. 0.9) (p = 0.10). Similarly, mean screw migration(mm) after 7500 cycles was similar between the gliding plate (3.02; . sd. 2.85), PHILOS (1.30; . sd. 0.44) and gliding augmented plate (2.83; . sd. 1.18) (p = 0.13). Mean number of cycles until failure with 5° varus tilting were 12702 (. sd. 3687) for the gliding plate, 13948 (. sd. 1295) for PHILOS and 13189 (. sd. 2647) for the gliding augmented plate without significant differences between the groups (p = 0.66). Conclusion. Biomechanically, plate fixation using a new gliding screw technology did not show considerable advantages in comparison with fixation using a standard PHILOS plate. Based on the finding of telescoping of screws, however, it may represent a valid approach for further investigations into how to avoid the cut-out of screws. Cite this article: Y. P. Acklin, I. Zderic, J. A. Inzana, S. Grechenig, R. Schwyn, R. G. Richards, B. Gueorguiev. Biomechanical evaluation of a new gliding screw concept for the fixation of proximal humeral fractures. Bone Joint Res 2018;7:422–429. DOI: 10.1302/2046-3758.76.BJR-2017-0356.R1

The augmentation of fixation with bone cement is increasingly being used in the treatment of severe osteoporotic fractures. We investigated the influence of bone quality on the mechanics of augmentation of plate fixation in a distal femoral fracture model (AO 33 A3 type). Eight osteoporotic and eight non-osteoporotic femoral models were randomly assigned to either an augmented or a non-augmented group. Fixation was performed using a locking compression plate. In the augmented group additionally 1 ml of bone cement was injected into the screw hole before insertion of the screw. Biomechanical testing was performed in axial sinusoidal loading. Augmentation significantly reduced the cut-out distance in the osteoporotic models by about 67% (non-augmented mean 0.30 mm (. sd. 0.08) vs augmented 0.13 mm (. sd. 0.06); p = 0.017). There was no statistical reduction in this distance following augmentation in the non-osteoporotic models (non-augmented mean 0.15 mm (. sd. 0.02) vs augmented 0.15 mm (. sd. 0.07); p = 0.915). In the osteoporotic models, augmentation significantly increased stability (p = 0.017). Cite this article: Bone Joint J 2013;95-B:1406–9

We investigated a new intramedullary locking nail that allows the distal interlocking screws to be locked to the nail. We compared fixation using this new implant with fixation using either a conventional nail or a locking plate in a laboratory simulation of an osteoporotic fracture of the distal femur. A total of 15 human cadaver femora were used to simulate an AO 33-A3 fracture pattern. Paired specimens compared fixation using either a locking or non-locking retrograde nail, and using either a locking retrograde nail or a locking plate. The constructs underwent cyclical loading to simulate single-leg stance up to 125 000 cycles. Axial and torsional stiffness and displacement, cycles to failure and modes of failure were recorded for each specimen. When compared with locking plate constructs, locking nail constructs had significantly longer mean fatigue life (75 800 cycles (. sd. 33 900) vs 12 800 cycles (. sd. 6100); p = 0.007) and mean axial stiffness (220 N/mm (. sd. 80) vs 70 N/mm (. sd. 18); p = 0.005), but lower mean torsional stiffness (2.5 Nm/° (. sd. 0.9) vs 5.1 Nm/° (. sd. 1.5); p = 0.008). In addition, in the nail group the mode of failure was either cut-out of the distal screws or breakage of nails, and in the locking plate group breakage of the plate was always the mode of failure. Locking nail constructs had significantly longer mean fatigue life than non-locking nail constructs (78 900 cycles (. sd. 25 600) vs 52 400 cycles (. sd. 22 500); p = 0.04). The new locking retrograde femoral nail showed better stiffness and fatigue life than locking plates, and superior fatigue life to non-locking nails, which may be advantageous in elderly patients. Cite this article: Bone Joint J 2014;96-B:114–21

Aims

To evaluate if, for orthopaedic trainees, additional cadaveric simulation training or standard training alone yields superior radiological and clinical outcomes in patients undergoing dynamic hip screw (DHS) fixation or hemiarthroplasty for hip fracture.

We studied the biomechanical behaviour of three sliding fixation devices for trochanteric femoral fractures. These were a titanium alloy sideplate and lag screw, a titanium alloy sideplate and dome plunger with cement augmentation, and a stainless-steel sideplate and lag screw. We used 18 mildly osteoporotic cadaver femora, randomly assigned to one of the three fixation groups. Four displacement and two strain gauges were fixed to each specimen, and each femur was first tested intact (control), then as a two-part fracture and then as a four-part intertrochanteric fracture. A range of physiological loads was applied to determine load-bearing, load-sharing and head displacement. The four-part-fracture specimens were subsequently tested to failure to determine maximum fixation strengths and modes of failure. The dome-plunger group failed at a load 50% higher than that of the stainless-steel lag-screw group (p < 0.05) and at a load 20% higher than that of the titanium-alloy lag-screw group (NS). All 12 lag-screw specimens failed by cut-out through the femoral head or neck, but none of the dome-plunger group showed movement within the femoral head when tested to failure. Strain-gauge analysis showed that the dome plunger produced considerably less strain in the inferior neck and calcar region than either of the lag screws. Inferior displacement of the femoral head was greatest for the dome-plunger group, and was due to sliding of the plunger. The dome plunger with cement augmentation was able to support higher loads and did not fail by cut-out through the femoral head.(ABSTRACT TRUNCATED AT 250 WORDS)

Aims

The management of fractures of the medial epicondyle is one of the greatest controversies in paediatric fracture care, with uncertainty concerning the need for surgery. The British Society of Children’s Orthopaedic Surgery prioritized this as their most important research question in paediatric trauma. This is the protocol for a randomized controlled, multicentre, prospective superiority trial of operative fixation versus nonoperative treatment for displaced medial epicondyle fractures: the Surgery or Cast of the EpicoNdyle in Children’s Elbows (SCIENCE) trial.

Aims

Total hip arthroplasty (THA) is considered the preferred treatment for displaced proximal femoral neck fractures. However, in many countries this option is economically unviable. To improve outcomes in financially disadvantaged populations, we studied the technique of concomitant valgus hip osteotomy and operative fixation (VOOF). This prospective serial study compares two treatment groups: VOOF versus operative fixation alone with cannulated compression screws (CCSs).

Aims

The Peri-Implant and PeriProsthetic Survival AnalysiS (PIPPAS) study aimed to investigate the risk factors for one-year mortality of femoral peri-implant fractures (FPIFs).

Aims

The aim of this study was to investigate if there are differences in outcome between sliding hip screws (SHSs) and intramedullary nails (IMNs) with regard to fracture stability.

We have prospectively compared the fixation of 100 intertrochanteric fractures of the proximal femur in elderly patients with random use of either a Dynamic Hip Screw (DHS) or a new intramedullary device, the Gamma nail. We found no difference in operating time, blood loss, wound complications, stay in hospital, place of eventual discharge, or the patients' mobility at final review. There was no difference in failure of proximal fixation: cut-out occurred in three cases with the DHS, and twice with the Gamma nail. However, in four cases fracture of the femur occurred close to the Gamma nail, requiring further major surgery. In the absence of these complications, union was seen by six months in both groups

In a prospective study we assessed the causes of mechanical failure in a series of 230 intertrochanteric femoral fractures which had been internally fixed with either a sliding hip screw or a Kuntscher Y-nail. The overall rate of mechanical failure was 16.5%; cutting-out of the implant from the femoral head was the cause in three-quarters of the instances. Implants placed posteriorly in the femoral head cut out more often (27%) than those placed centrally (7%). The cut-out rate was also determined by the quality of the fracture reduction, but age, walking ability and bone density (assessed by the Singh grade and metacarpal indices) had no significant influence. We conclude that these fractures should be reduced as accurately as possible and it is imperative that the implant is placed centrally within the femoral head