Abstract
Introduction
Achieving durable mechanical stability in geriatric intertrochanteric proximal femur fractures remains a challenge. Concomitant poor bone quality, unstable fracture patterns, and suboptimal reduction are additional risk factors for early mechanical failure. Cement augmentation of the proximal locking screw or blade is one proposed method to augment implant anchorage. The purpose of this review is to describe the biomechanical and clinical evidence for cement augmentation of geriatric intertrochanteric fractures, and to elaborate indications for cement augmentation.
Methods
The PubMed database was searched for English language studies up to January 2021. Studies that assessed effect of calcium phosphate or methylmethacrylate cement augmentation during open reduction and internal fixation of intertrochanteric fractures were included. Studies with sample size < 5, nontraumatic or periprosthetic fractures, and nonunion or revision surgery were excluded. Study selection adhered to PRISMA criteria.
Results
801 studies were identified, of which 40 met study criteria. 9 studies assessed effect of cement augmentation on fracture displacement. All but one found that cement decreased fracture displacement. 10 studies assessed effect of cement augmentation on total load or cycles to failure. All but one demonstrated that augmented implants increased this variable. Complication rates of cement augmentation during ORIF of intertrochanteric fractures ranged from 0 to 47%, while non-augmented implants ranged from 0 to 51%. Reoperation rates ranged from 0 to 11% in the cement-augmented group and 0 to 11% in the non-augmented group. Fixation failure ranged from 0 to 11% in the cement-augmented group and 0 to 20% in the non-augmented group. Nonunion ranged from 0 to 3.6% in the cement-augmented group and 0 to 34% in the non-augmented group.
Conclusions
Calcium phosphate or PMMA-augmented CMN fixation of IT fractures increased construct stability and improved outcomes in biomechanical and early clinical studies. The findings of these studies suggest an important role for cement augmentation in patient populations at high risk of mechanical failure.
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References
Cummings SR, Rubin SM, Black D. The future of hip fractures in the United States. Numbers, costs, and potential effects of postmenopausal estrogen. Clin Orthop Relat Res. 1990(252):163–6.
He S, Yan B, Zhu J, Huang X, Zhao J (2018) High failure rate of proximal femoral locking plates in fixation of trochanteric fractures. J Orthop Surg Res 13(1):248. https://doi.org/10.1186/s13018-018-0951-6
Lobo-Escolar A, Joven E, Iglesias D, Herrera A (2010) Predictive factors for cutting-out in femoral intramedullary nailing. Injury 41(12):1312–1316. https://doi.org/10.1016/j.injury.2010.08.009
Hsueh KK, Fang CK, Chen CM, Su YP, Wu HF, Chiu FY (2010) Risk factors in cutout of sliding hip screw in intertrochanteric fractures: an evaluation of 937 patients. Int Orthop 34(8):1273–1276. https://doi.org/10.1007/s00264-009-0866-2
Konstantinidis L, Papaioannou C, Blanke P, Hirschmuller A, Sudkamp NP, Helwig P. Failure after osteosynthesis of trochanteric fractures. Where is the limit of osteoporosis? Osteoporos Int. 2013;24(10):2701–6. doi:https://doi.org/10.1007/s00198-013-2392-8.
Liu W, Zhou D, Liu F, Weaver MJ, Vrahas MS (2013) Mechanical complications of intertrochanteric hip fractures treated with trochanteric femoral nails. J Trauma Acute Care Surg 75(2):304–310. https://doi.org/10.1097/TA.0b013e31829a2c43
Parry JA, Sapp T, Langford JR, Koval KJ, Haidukewych GJ (2020) Variables Associated With Lag Screw Sliding After Single-Screw Cephalomedullary Nail Fixation of Intertrochanteric Fractures. J Orthop Trauma. https://doi.org/10.1097/bot.0000000000001730
Ciufo DJ, Zaruta DA, Lipof JS, Judd KT, Gorczyca JT, Ketz JP (2017) Risk Factors Associated With Cephalomedullary Nail Cutout in the Treatment of Trochanteric Hip Fractures. J Orthop Trauma 31(11):583–588. https://doi.org/10.1097/bot.0000000000000961
Stern LC, Gorczyca JT, Kates S, Ketz J, Soles G, Humphrey CA (2017) Radiographic Review of Helical Blade Versus Lag Screw Fixation for Cephalomedullary Nailing of Low-Energy Peritrochanteric Femur Fractures: There is a Difference in Cutout. J Orthop Trauma 31(6):305–310. https://doi.org/10.1097/bot.0000000000000853
Ibrahim I, Appleton PT, Wixted JJ, DeAngelis JP, Rodriguez EK (2019) Implant cut-out following cephalomedullary nailing of intertrochanteric femur fractures: Are helical blades to blame? Injury 50(4):926–930. https://doi.org/10.1016/j.injury.2019.02.015
Bojan AJ, Beimel C, Taglang G, Collin D, Ekholm C, Jönsson A (2013) Critical factors in cut-out complication after Gamma Nail treatment of proximal femoral fractures. BMC Musculoskelet Disord 14:1. https://doi.org/10.1186/1471-2474-14-1
Murena L, Moretti A, Meo F, Saggioro E, Barbati G, Ratti C et al (2018) Predictors of cut-out after cephalomedullary nail fixation of pertrochanteric fractures: a retrospective study of 813 patients. Arch Orthop Trauma Surg 138(3):351–359. https://doi.org/10.1007/s00402-017-2863-z
Tsai SW, Lin CJ, Tzeng YH, Lin CC, Huang CK, Chang MC et al (2017) Risk factors for cut-out failure of Gamma3 nails in treating unstable intertrochanteric fractures: An analysis of 176 patients. J Chin Med Assoc 80(9):587–594. https://doi.org/10.1016/j.jcma.2017.04.007
Thiele OC, Eckhardt C, Linke B, Schneider E, Lill CA (2007) Factors affecting the stability of screws in human cortical osteoporotic bone: a cadaver study. J Bone Joint Surg Br 89(5):701–705. https://doi.org/10.1302/0301-620x.89b5.18504
Seebeck J, Goldhahn J, Morlock MM, Schneider E (2005) Mechanical behavior of screws in normal and osteoporotic bone. Osteoporos Int 16(Suppl 2):S107–S111. https://doi.org/10.1007/s00198-004-1777-0
Namdari S, Rabinovich R, Scolaro J, Baldwin K, Bhandari M, Mehta S (2013) Absorbable and non-absorbable cement augmentation in fixation of intertrochanteric femur fractures: systematic review of the literature. Arch Orthop Trauma Surg 133(4):487–494. https://doi.org/10.1007/s00402-012-1677-2
Moher D, Liberati A, Tetzlaff J, Altman DG (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 6(7):e1000097. https://doi.org/10.1371/journal.pmed.1000097
Murad MH, Sultan S, Haffar S, Bazerbachi F (2018) Methodological quality and synthesis of case series and case reports. BMJ Evid Based Med 23(2):60–63. https://doi.org/10.1136/bmjebm-2017-110853
Yee DKH, Lau W, Tiu KL, Leung F, Fang E, Pineda JPS et al (2020) Cementation: for better or worse? Interim results of a multi-centre cohort study using a fenestrated spiral blade cephalomedullary device for pertrochanteric fractures in the elderly. Arch Orthop Trauma Surg 140(12):1957–1964. https://doi.org/10.1007/s00402-020-03449-9
Kulachote N, Sa-Ngasoongsong P, Sirisreetreerux N, Chulsomlee K, Thamyongkit S, Wongsak S (2020) Predicting Factors for Return to Prefracture Ambulatory Level in High Surgical Risk Elderly Patients Sustained Intertrochanteric Fracture and Treated With Proximal Femoral Nail Antirotation (PFNA) With and Without Cement Augmentation. Geriatr Orthop Surg Rehabil 11:2151459320912121. https://doi.org/10.1177/2151459320912121
Goodnough LH, Wadhwa H, Tigchelaar SS, DeBaun MR, Chen MJ, Bishop JA et al (2020) Trochanteric fixation nail advanced with helical blade and cement augmentation: early experience with a retrospective cohort. Eur J Orthop Surg Traumatol. https://doi.org/10.1007/s00590-020-02762-8
Rai AK, Goel R, Bhatia C, Singh S, Thalanki S, Gondane A (2018) Cement Augmentation of Dynamic Hip Screw to Prevent Screw Cut Out in Osteoporotic Patients with Intertrochanteric Fractures: A Case Series. Hip Pelvis 30(4):269–275. https://doi.org/10.5371/hp.2018.30.4.269
Kammerlander C, Gebhard F, Meier C, Lenich A, Linhart W, Clasbrummel B et al (2011) Standardised cement augmentation of the PFNA using a perforated blade: A new technique and preliminary clinical results. A prospective multicentre trial Injury 42(12):1484–1490. https://doi.org/10.1016/j.injury.2011.07.010
Kammerlander C, Doshi H, Gebhard F, Scola A, Meier C, Linhart W et al (2014) Long-term results of the augmented PFNA: a prospective multicenter trial. Arch Orthop Trauma Surg 134(3):343–349. https://doi.org/10.1007/s00402-013-1902-7
Kammerlander C, Hem ES, Klopfer T, Gebhard F, Sermon A, Dietrich M et al (2018) Cement augmentation of the Proximal Femoral Nail Antirotation (PFNA) - A multicentre randomized controlled trial. Injury 49(8):1436–1444. https://doi.org/10.1016/j.injury.2018.04.022
Neuerburg C, Mehaffey S, Gosch M, Böcker W, Blauth M, Kammerlander C (2016) Trochanteric fragility fractures : Treatment using the cement-augmented proximal femoral nail antirotation. Oper Orthop Traumatol 28(3):164–176. https://doi.org/10.1007/s00064-016-0449-5
Dall’Oca C, Maluta T, Moscolo A, Lavini F, Bartolozzi P (2010) Cement augmentation of intertrochanteric fractures stabilised with intramedullary nailing. Injury 41(11):1150–1155. https://doi.org/10.1016/j.injury.2010.09.026
Chow SP, Tang SC, Pun WK, Lee PC, Lau HK, Lim J et al (1987) Treatment of unstable trochanteric fractures with Dimon-Hughston osteotomy displacement fixation and acrylic cement. Injury 18(2):123–127. https://doi.org/10.1016/0020-1383(87)90188-4
Kim SJ, Park HS, Lee DW, Lee JW (2018) Is calcium phosphate augmentation a viable option for osteoporotic hip fractures? Osteoporos Int 29(9):2021–2028. https://doi.org/10.1007/s00198-018-4572-z
Pun WK, Chow SP, Chan KC, Ip FK, Tang SC, Lim J et al (1987) Treatment of unstable intertrochanteric fractures with Sarmiento valgus osteotomy and acrylic cement augmentation. Injury 18(6):384–389. https://doi.org/10.1016/0020-1383(87)90283-x
Lee PC, Hsieh PH, Chou YC, Wu CC, Chen WJ (2010) Dynamic hip screws for unstable intertrochanteric fractures in elderly patients–encouraging results with a cement augmentation technique. J Trauma 68(4):954–964. https://doi.org/10.1097/TA.0b013e3181c995ec
Lau HK, Lee PC, Tang SC, Lim JK, Chow SP (1983) Treatment of comminuted trochanteric femoral fractures with Dimon Hughston displacement fixation and acrylic cement–a preliminary report of sixteen cases. Injury 15(2):129–135. https://doi.org/10.1016/0020-1383(83)90041-4
Wu MH, Lee PC, Peng KT, Wu CC, Huang TJ, Hsu RW (2012) Complications of cement-augmented dynamic hip screws in unstable type intertrochanteric fractures–a case series study. Chang Gung Med J 35(4):345–353. https://doi.org/10.4103/2319-4170.106135
Cheng CL, Chow SP, Pun WK, Leong JC (1989) Long-term results and complications of cement augmentation in the treatment of unstable trochanteric fractures. Injury 20(3):134–138. https://doi.org/10.1016/0020-1383(89)90082-x
Gupta RK, Gupta V, Gupta N (2012) Outcomes of osteoporotic trochanteric fractures treated with cement-augmented dynamic hip screw. Indian J Orthop 46(6):640–645. https://doi.org/10.4103/0019-5413.104193
Bartucci EJ, Gonzalez MH, Cooperman DR, Freedberg HI, Barmada R, Laros GS (1985) The effect of adjunctive methylmethacrylate on failures of fixation and function in patients with intertrochanteric fractures and osteoporosis. J Bone Joint Surg Am 67(7):1094–1107
Schuetze K, Ehinger S, Eickhoff A, Dehner C, Gebhard F, Richter PH (2020) Cement augmentation of the proximal femur nail antirotation: is it safe? Arch Orthop Trauma Surg. https://doi.org/10.1007/s00402-020-03531-2
Schatzker J, Ha’eri GB, Chapman M (1978) Methylmethacrylate as an adjunct in the internal fixation of intertrochanteric fractures of the femur. J Trauma 18(10):732–735. https://doi.org/10.1097/00005373-197810000-00011
Muhr G, Tscherne H, Thomas R (1979) Comminuted trochanteric femoral fractures in geriatric patients: the results of 231 cases treated with internal fixation and acrylic cement. Clin Orthop Relat Res 138:41–44
Mattsson P, Alberts A, Dahlberg G, Sohlman M, Hyldahl HC, Larsson S. Resorbable cement for the augmentation of internally-fixed unstable trochanteric fractures. A prospective, randomised multicentre study. J Bone Joint Surg Br. 2005;87(9):1203–9. doi:https://doi.org/10.1302/0301-620x.87b9.15792.
Harrington KD (1975) The use of methylmethacrylate as an adjunct in the internal fixation of unstable comminuted intertrochanteric fractures in osteoporotic patients. J Bone Joint Surg Am 57(6):744–750
Sermon A, Boner V, Boger A, Schwieger K, Boonen S, Broos PL et al (2012) Potential of polymethylmethacrylate cement-augmented helical proximal femoral nail antirotation blades to improve implant stability–a biomechanical investigation in human cadaveric femoral heads. J Trauma Acute Care Surg 72(2):E54–E59. https://doi.org/10.1097/ta.0b013e31821852ed
Sermon A, Hofmann-Fliri L, Richards RG, Flamaing J, Windolf M (2014) Cement augmentation of hip implants in osteoporotic bone: how much cement is needed and where should it go? J Orthop Res 32(3):362–368. https://doi.org/10.1002/jor.22522
Ehrnthaller C, Olivier AC, Gebhard F, Dürselen L (2017) The role of lesser trochanter fragment in unstable pertrochanteric A2 proximal femur fractures - is refixation of the lesser trochanter worth the effort? Clin Biomech (Bristol, Avon) 42:31–37. https://doi.org/10.1016/j.clinbiomech.2016.12.013
Fliri L, Lenz M, Boger A, Windolf M (2012) Ex vivo evaluation of the polymerization temperatures during cement augmentation of proximal femoral nail antirotation blades. J Trauma Acute Care Surg 72(4):1098–1101. https://doi.org/10.1097/TA.0b013e318248bfa7
Erhart S, Schmoelz W, Blauth M, Lenich A (2011) Biomechanical effect of bone cement augmentation on rotational stability and pull-out strength of the Proximal Femur Nail Antirotation. Injury 42(11):1322–1327. https://doi.org/10.1016/j.injury.2011.04.010
Augat P, Rapp S, Claes L (2002) A modified hip screw incorporating injected cement for the fixation of osteoporotic trochanteric fractures. J Orthop Trauma 16(5):311–316. https://doi.org/10.1097/00005131-200205000-00004
Blankstein M, Widmer D, Götzen M, Hofmann-Fliri L, Richards RG, Gueorguiev B et al (2014) Assessment of intraosseous femoral head pressures during cement augmentation of the perforated proximal femur nail antirotation blade. J Orthop Trauma 28(7):398–402. https://doi.org/10.1097/bot.0000000000000069
Yetkinler DN, Goodman SB, Reindel ES, Carter D, Poser RD, Constantz BR (2002) Mechanical evaluation of a carbonated apatite cement in the fixation of unstable intertrochanteric fractures. Acta Orthop Scand 73(2):157–164. https://doi.org/10.1080/000164702753671731
Elder S, Frankenburg E, Goulet J, Yetkinler D, Poser R, Goldstein S (2000) Biomechanical evaluation of calcium phosphate cement-augmented fixation of unstable intertrochanteric fractures. J Orthop Trauma 14(6):386–393. https://doi.org/10.1097/00005131-200008000-00002
Fensky F, Nüchtern JV, Kolb JP, Huber S, Rupprecht M, Jauch SY et al (2013) Cement augmentation of the proximal femoral nail antirotation for the treatment of osteoporotic pertrochanteric fractures–a biomechanical cadaver study. Injury 44(6):802–807. https://doi.org/10.1016/j.injury.2013.03.003
Stoffel KK, Leys T, Damen N, Nicholls RL, Kuster MS (2008) A new technique for cement augmentation of the sliding hip screw in proximal femur fractures. Clin Biomech (Bristol, Avon) 23(1):45–51. https://doi.org/10.1016/j.clinbiomech.2007.08.014
Moore DC, Frankenburg EP, Goulet JA, Goldstein SA (1997) Hip screw augmentation with an in situ-setting calcium phosphate cement: an in vitro biomechanical analysis. J Orthop Trauma 11(8):577–583. https://doi.org/10.1097/00005131-199711000-00006
von der Linden P, Gisep A, Boner V, Windolf M, Appelt A, Suhm N (2006) Biomechanical evaluation of a new augmentation method for enhanced screw fixation in osteoporotic proximal femoral fractures. J Orthop Res 24(12):2230–2237. https://doi.org/10.1002/jor.20299
Choueka J, Koval KJ, Kummer FJ, Zukerman JD (1996) Cement augmentation of intertrochanteric fracture fixation: a cadaver comparison of 2 techniques. Acta Orthop Scand 67(2):153–157. https://doi.org/10.3109/17453679608994661
Mattsson P, Larsson S. Unstable trochanteric fractures augmented with calcium phosphate cement. A prospective randomized study using radiostereometry to measure fracture stability. Scand J Surg. 2004;93(3):223–8. doi:https://doi.org/10.1177/145749690409300310.
Sermon A, Boner V, Schwieger K, Boger A, Boonen S, Broos P et al (2012) Biomechanical evaluation of bone-cement augmented Proximal Femoral Nail Antirotation blades in a polyurethane foam model with low density. Clin Biomech 27(1):71–76. https://doi.org/10.1016/j.clinbiomech.2011.07.006
Boner V, Kuhn P, Mendel T, Gisep A (2009) Temperature evaluation during PMMA screw augmentation in osteoporotic bone–an in vitro study about the risk of thermal necrosis in human femoral heads. J Biomed Mater Res B Appl Biomater 90(2):842–848. https://doi.org/10.1002/jbm.b.31353
Palm H, Jacobsen S, Sonne-Holm S, Gebuhr P (2007) Integrity of the lateral femoral wall in intertrochanteric hip fractures: an important predictor of a reoperation. J Bone Joint Surg Am 89(3):470–475. https://doi.org/10.2106/jbjs.f.00679
Haidukewych GJ, Israel TA, Berry DJ (2001) Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg Am 83(5):643–650. https://doi.org/10.2106/00004623-200105000-00001
Gavaskar AS, Tummala NC, Srinivasan P, Gopalan H, Karthik B, S S. Helical Blade or the Integrated Lag Screws: A Matched Pair Analysis of 100 Patients With Unstable Trochanteric Fractures. J Orthop Trauma. 2018;32(6):274–7. doi:https://doi.org/10.1097/bot.0000000000001145.
Serrano R, Blair JA, Watson DT, Infante AF Jr, Shah AR, Mir HR et al (2017) Cephalomedullary Nail Fixation of Intertrochanteric Femur Fractures: Are Two Proximal Screws Better Than One? J Orthop Trauma 31(11):577–582. https://doi.org/10.1097/bot.0000000000000967
Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM (1995) The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg Am 77(7):1058–1064. https://doi.org/10.2106/00004623-199507000-00012
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Goodnough, L.H., Wadhwa, H., Tigchelaar, S. et al. Indications for cement augmentation in fixation of geriatric intertrochanteric femur fractures: a systematic review of evidence. Arch Orthop Trauma Surg 142, 2533–2544 (2022). https://doi.org/10.1007/s00402-021-03872-6
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DOI: https://doi.org/10.1007/s00402-021-03872-6