Comparative analysis of TAD and CalTAD in predicting lag screw cutout risk in trochanteric fractures treated with intramedullary devices: a retrospective study

Rajesh Kumar Vemparala; Giriprasad Rajan; Sathyanarayanan Narayanan; Syam S. Kumar; Praveen Kumar Thannimoottil Salim; Rangeen Chandran Ramachandran

doi:10.18203/issn.2455-4510.IntJResOrthop20251798

Authors

Rajesh Kumar Vemparala Department of Orthopedics, Athani Hospital, Palakkad, Kerala, India
Giriprasad Rajan Department of Orthopedics, Athani Hospital, Palakkad, Kerala, India
Sathyanarayanan Narayanan Department of Orthopedics, Athani Hospital, Palakkad, Kerala, India
Syam S. Kumar Department of Orthopedics, Athani Hospital, Palakkad, Kerala, India
Praveen Kumar Thannimoottil Salim Department of Orthopedics, Athani Hospital, Palakkad, Kerala, India
Rangeen Chandran Ramachandran Department of Orthopedics, Athani Hospital, Palakkad, Kerala, India

DOI:

https://doi.org/10.18203/issn.2455-4510.IntJResOrthop20251798

Keywords:

CalTAD, Cut out, Intramedullary device, TAD, Trochanteric fractures

Abstract

Background: Cutout is one of the common cause of mechanical failure after internal fixation of trochanteric fractures using intramedullary devices. Tip apex distance (TAD) and Calcar referenced tip apex distance (CalTAD) are the radiographic parameters to predict the cutout risk. The aim of the study is to compare CalTAD with TAD in predicting the screw cutout risk and also to assesses other parameters responsible for it.

Methods: A total of 100 patients were included in this retrospective study. For each patient the following data were recorded. Number of cutouts, AO/OTA classification, quality of the reduction, type of nail, center column diaphyseal angle, type of distal locking, post-operative weight-bearing, TAD, CalTAD values and the position of the screw in the femoral head according to the Cleveland system.

Results: The incidence of cutout across the sample was 6%. The median TAD in cutout group was 32.2±6.5 (Mean±SD) while in no cutout group it was 20.7±5.1(p<0.001). Similarly, the median CalTAD in cutout group was 33±5.6 (Mean±SD) while in no cutout group it was 21.1±4.6 (p<0.001). The highest value of sensitivity and specificity showed that the best cut off values of TAD is 30.06 (95% CI: 0.823-1.000, P<0.001) and Cal TAD is 30.93 (95% CI: 0.835-1.000, p<0.001).

Conclusions: In order to reduce the incidence of cutout it is advisable to achieve positive cortical reduction, placing the lag screw in centre-centre or centre-inferior in femoral head (Preferably in Cleveland Zone-5) and avoid TAD>30.06 and Cal TAD>30.93.

Metrics

Metrics Loading ...

References

Johnell O, Kanis J. An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteopor Int. 2006;17:1726-33. DOI: https://doi.org/10.1007/s00198-006-0172-4

Wolinsky FD, Fitzgerald JF, Stump TE. The effect of hip fracture on mortality, hospitalization and functional status: a prospective study. Am J Pub Health. 1997;87(3):398-403. DOI: https://doi.org/10.2105/AJPH.87.3.398

Tay E. Hip fractures in the elderly: operative versus nonoperative management. Singapore Med J. 2016;57(4):178. DOI: https://doi.org/10.11622/smedj.2016071

Simunovic N, Devereaux PJ, Sprague S, Guyatt GH, Schemitsch E, DeBeer J, Bhandari M. Effect of early surgery after hip fracture on mortality and complications: systematic review and meta-analysis. CMAJ. 2010;182(15):1609-16. DOI: https://doi.org/10.1503/cmaj.092220

Matre K, Havelin LI, Gjertsen JE, Vinje T, Espehaug B, Fevang JM. Sliding hip screw versus IM nail in reverse oblique trochanteric and subtrochanteric fractures. A study of 2716 patients in the Norwegian Hip Fracture Register. Injury. 2013;44(6):735-42. DOI: https://doi.org/10.1016/j.injury.2012.12.010

Leung KS, So WS, Shen WY, Hui PW. Gamma nails and dynamic hip screws for peritrochanteric fractures. A randomised prospective study in elderly patients. J Bone Joint Surg Br. 1992;74(3):345-51. DOI: https://doi.org/10.1302/0301-620X.74B3.1587874

Pascarella R, Fantasia R, Maresca A, Bettuzzi C, Amendola L, Violini S, et al. How evolution of the nailing system improves results and reduces orthopedic complications: more than 2000 cases of trochanteric fractures treated with the Gamma Nail System. Musculosk Surg. 2016;100:1-8. DOI: https://doi.org/10.1007/s12306-015-0391-y

Kashigar A, Vincent A, Gunton MJ, Backstein D, Safir O, Kuzyk PR. Predictors of failure for cephalomedullary nailing of proximal femoral fractures. Bone Joint J. 2014;1;96(8):1029-34. DOI: https://doi.org/10.1302/0301-620X.96B8.33644

De Bruijn K, Hartog D, Tuinebreijer W, Roukema. Reliability of predictors for screw cutout in intertrochanteric hip fractures. J Bone Joint Surg. Am. 2012;94(14):1266-72. DOI: https://doi.org/10.2106/JBJS.K.00357

Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM. The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. JBJS. 1995;1;77(7):1058-64. DOI: https://doi.org/10.2106/00004623-199507000-00012

Kuzyk PR, Zdero R, Shah S, Olsen M, Waddell JP, Schemitsch EH. Femoral head lag screw position for cephalomedullary nails: a biomechanical analysis. Journal of orthopaedic trauma. 2012;1;26(7):414-21. DOI: https://doi.org/10.1097/BOT.0b013e318229acca

Rubio-Avila J, Madden K, Simunovic N, Bhandari M. Tip to apex distance in femoral intertrochanteric fractures: a systematic review. J Orthop Sci. 2013;18:592-8. DOI: https://doi.org/10.1007/s00776-013-0402-5

Turgut A, Kalenderer Ö, Karapınar L, Kumbaracı M, Akkan HA, Ağuş H. Which factor is most important for occurrence of cutout complications in patients treated with proximal femoral nail antirotation. Retrospective analysis of 298 patients. Arch Orthop Trauma Surg. 2016;136:623-30. DOI: https://doi.org/10.1007/s00402-016-2410-3

Kane P, Vopat B, Heard W, Thakur N, Paller D, Koruprolu S, et al. Is tip apex distance as important as we think. A biomechanical study examining optimal lag screw placement. Clin Orthop Related Res. 2014;472(8):2492-8. DOI: https://doi.org/10.1007/s11999-014-3594-x

Goffin JM, Jenkins PJ, Ramaesh R, Pankaj P, Simpson AH. What is the relevance of the tip-apex distance as a predictor of lag screw cut-out. PloS one. 2013;28;8(8):71195. DOI: https://doi.org/10.1371/journal.pone.0071195

Goffin JM, Pankaj P, Simpson AH. The importance of lag screw position for the stabilization of trochanteric fractures with a sliding hip screw: a subject‐specific finite element study. J Orthopaed Res. 2013;31(4):596-600. DOI: https://doi.org/10.1002/jor.22266

Li S, Chang SM, Jin YM, Zhang YQ, Niu WX, Du SC, et al. A mathematical simulation of the tip-apex distance and the calcar-referenced tip-apex distance for intertrochanteric fractures reduced with lag screws. Injury. 2016;47(6):1302-8. DOI: https://doi.org/10.1016/j.injury.2016.03.029

Baumgaertner MR, Solberg BD. Awareness of tip-apex distance reduces failure of fixation of trochanteric fractures of the hip. J Bone Joint Surg British. 1997;79(6):969-71. DOI: https://doi.org/10.1302/0301-620X.79B6.0790969

Sernbo I, Johnell O, Gentz CF, Nilsson JA. Unstable intertrochanteric fractures of the hip. Treatment with Ender pins compared with a compression hip-screw. JBJS. 1988;70(9):1297-303. DOI: https://doi.org/10.2106/00004623-198870090-00003

Chang SM, Zhang YQ, Du SC, Ma Z, Hu SJ, Yao XZ, et al. Anteromedial cortical support reduction in unstable pertrochanteric fractures: a comparison of intra-operative fluoroscopy and post-operative three-dimensional computerised tomography reconstruction. Int Orthopaed. 2018;42:183-9. DOI: https://doi.org/10.1007/s00264-017-3623-y

Cuschieri S. The STROBE guidelines. Saudi J Anaest. 2019;13(1):314. DOI: https://doi.org/10.4103/sja.SJA_543_18

Niu E, Yang A, Harris AH, Bishop J. Which fixation device is preferred for surgical treatment of intertrochanteric hip fractures in the United States. A survey of orthopaedic surgeons. Clin Orthopaed Related Res. 2015;473(11):3647-55. DOI: https://doi.org/10.1007/s11999-015-4469-5

Kaufer H. Mechanics of the treatment of hip injuries. Clin Orthopaed Related Res. 1980;146:53-61. DOI: https://doi.org/10.1097/00003086-198001000-00008

Zhang W, Antony Xavier RP, Decruz J, Chen YD, Park DH. Risk factors for mechanical failure of intertrochanteric fractures after fixation with proximal femoral nail antirotation (PFNA II): a study in a Southeast Asian population. Arch Orthopaed Trauma Surg. 2021;141:569-75. DOI: https://doi.org/10.1007/s00402-020-03399-2

Caruso G, Corradi N, Caldaria A, Bottin D, Lo Re D, Lorusso V, et al. New tip-apex distance and calcar-referenced tip-apex distance cut-offs may be the best predictors for cut-out risk after intramedullary fixation of proximal femur fractures. Scientific reports. 2022;12(1):357. DOI: https://doi.org/10.1038/s41598-021-04252-1

Aicale R, Maffulli N. Greater rate of cephalic screw mobilisation following proximal femoral nailing in hip fractures with a tip–apex distance (TAD) and a calcar referenced TAD greater than 25 mm. J Orthopaed Surg Res. 2018;13:1-9. DOI: https://doi.org/10.1186/s13018-018-0814-1

Cai Y, Feng J, Chen Y, Shi M, Yu Z, Fang L, et al. Comparison of the predictive value of tip-apex distance and calcar referenced tip-apex distance in treatment of femoral intertrochanteric fractures with Asian type proximal femoral nail fixation. Chinese J Rep Reconst Surg. 2020;34(11):1359-63.

Puthezhath K, Jayaprakash C. Is calcar referenced tip-apex distance a better predicting factor for cutting out in biaxial cephalomedullary nails than tip-apex distance. J Orthopaed Surg. 2017;25(3):7920. DOI: https://doi.org/10.1177/2309499017727920

Parker MJ. Cutting-out of the dynamic hip screw related to its position. J Bone Joint Surg British. 1992;1;74(4):625-8. DOI: https://doi.org/10.1302/0301-620X.74B4.1624529

Gundle R, Gargan MF, Simpson AH. How to minimize failures of fixation of unstable intertrochanteric fractures. Injury. 1995;1;26(9):611-4. DOI: https://doi.org/10.1016/0020-1383(95)00125-S

Hsueh KK, Fang CK, Chen CM, Su YP, Wu HF, Chiu FY. Risk factors in cutout of sliding hip screw in intertrochanteric fractures: an evaluation of 937 patients. International Orthopaed. 2010;34:1273-6. DOI: https://doi.org/10.1007/s00264-009-0866-2

Pervez H, Parker MJ, Vowler S. Prediction of fixation failure after sliding hip screw fixation. Injury. 2004;1;35(10):994-8. DOI: https://doi.org/10.1016/j.injury.2003.10.028

Sahin S, Ertürer E, Oztürk I, Toker S, Seckin F, Akman S. Radiographic and functional results of osteosynthesis using the proximal femoral nail antirotation (PFNA) in the treatment of unstable intertrochanteric femoral fractures. Acta Orthop Traumatol Turc. 2010;44(2):127-34. DOI: https://doi.org/10.3944/AOTT.2010.2237