Elsevier

Injury

Volume 52, Issue 7, July 2021, Pages 1813-1818
Injury

Reduction quality and nail fixation ratio as bone-implant stability factors associated with reoperation for trochanteric fractures

https://doi.org/10.1016/j.injury.2021.04.048Get rights and content

Highlights

  • Bone quality, fracture type, reduction quality, implant selection, and implant placement affect bone-implant stability.

  • We evaluated the association between bone-implant stability factors, including nail construct, and the rate of reoperation.

  • Reduction quality and fracture type, but not nail length and diameter, affect bone-implant stability for reoperation.

  • A nail length with a distal femoral fragment fixation ratio >0.8 is preferred if inadequate reduction remains.

Abstract

Introduction

Geriatric trochanteric fractures are a major global issue, and their incidence is steadily rising. Bone quality, fracture type, fracture reduction quality, implant selection, and implant placement affect bone-implant stability in osteoporotic fractures. Our aim in this study was to evaluate the association between bone-implant stability factors, including nail construct, and the rate of reoperation in a more extensive case series with comprehensive variables.

Methods

This was a retrospective cohort study of 390 patients with trochanteric fractures aged ≥60 years and treated with intramedullary nailing. The primary outcome was the rate of reoperation due to any cause. Univariate and multivariable logistic regression analyses were used to identify factors associated with reoperation.

Results

In this study, 15 patients (3.8%) required reoperation. Univariate analysis showed that the following variables were significantly different between patients who required reoperation and those who did not: T-score at the total hip and lumbar spine, cortical thickness index, fracture type, and reduction quality. Multivariable logistic regression analysis showed that the odds ratio (OR) for A3 fracture type was 2.76 (95% confidence interval [CI], 0.77-9.76; p=0.116) and that for inadequate reduction, assessed by computed tomography, was 2.94 (95% CI, 0.89-9.69; p=0.076). These were independent predictors of reoperation. There was only one case (6.7%) of reoperation among patients with a distal femoral fragment fixation ratio (FR) >0.8. Considering the intraoperative decision-making process, the combination of inadequate reduction and an FR ≤0.8 were associated with the highest reoperation at a rate of 9.3% (OR, 3.327; 95% CI, 1.091-10.142; p=0.043).

Conclusions

Risk factors on bone-implant stability for reoperation were the reduction quality and fracture type. Regarding the intraoperative decision-making process, the selection of a nail length with an FR >0.8 is a better option when the intramedullary reduction has been maintained intraoperatively.

Introduction

Geriatric trochanteric fractures are a major global issue, and their incidence is steadily rising [1]. An intramedullary nail (IMN) is widely used as a surgical treatment option for these fractures [2]. For an IMN selection, the optimal length and diameter of the nail are essential to achieve mechanical strength. Poor mechanical strength due to the selection of a suboptimal IMN leads to mechanical failure of the implant, resulting in a considerable burden for the patient, such as reoperation. Factors affecting bone-implant stability for osteoporotic fractures include the following five factors: bone quality, fracture type, fracture reduction quality, implant selection, and implant placement [3]. Surgeons often select the IMN construct based on the fracture type, bone quality, and morphology.

Nail length is known to be essential in ensuring the mechanical strength of the IMN. Studies have shown that a short nail (SN) working length may be insufficient to achieve stability for fractures with a distal fracture extension [4]. On the other hand, long nails (LNs) offer the mechanical benefit of protecting the femur's longer working length, particularly in elderly patients with an osteoporotic bone, which potentially decreases secondary femoral shaft fracture rates [5]. However, the indication for an LN for the following fracture types is yet to be determined: wide proximal medullary canal diameter, more distal extension of the fracture line to the subtrochanteric region including the greater trochanter (lateral wall), or posteromedial fragment including the lesser trochanter [6]. Recent systematic reviews and randomized control trials reported that there were no statistically significant differences in the rate of reoperation between the SNs and LNs [7], [8], [9], [10]. The LN is associated with an increased operative time and blood loss [11,12]. In addition, LN procedures cost considerably more than SN procedures [13,14]. To the best of our knowledge, only one biomechanical study has comprehensively reported on the failure of the IMN in relation to its diameter and length [15], and there has been no clinical study on this topic. In terms of the optimal IMN selection strategy, whether nail length and diameter function are the most biomechanically efficient remains controversial [15].

This study aimed to evaluate the association between bone-implant stability factors, including the IMN construct, and postoperative outcomes, especially reoperation, in a more extensive case series and with comprehensive variables. We focused on reduction quality and mechanical factors of fracture line extension. We hypothesized that modifiable factors such as fracture reduction quality and IMN selection (length and diameter) would be related to the rate of reoperation.

Section snippets

Study design

This retrospective cohort study was conducted at a single general hospital in accordance with the Declaration of Helsinki. The ethics committee approved the study protocol (Approval No. 965), and patients provided written informed consent to participate in this study. This retrospective study focused on the association between bone-implant stability factors including nail construct and reoperation following intramedullary nailing for trochanteric fractures.

Patient data collection

We included 391 consecutive patients

Results

The study sample included 390 patients, with a mean age of 82.9 ± 8.3 years at the time of surgery and included 306 (78.5%) women and 84 (21.5%) men. Fifteen patients required reoperation (3.8%). The reasons for reoperation in the SN group included cut-out (n=4), nonunion (n=1), blade perforation (n=1), implant breakage (n=1), secondary femoral fracture due to falling (n=1), osteonecrosis (n=1), infection (n=1), and iatrogenic surgical error (n=1). The reasons for reoperation in the LN group

Discussion

This comprehensive study on bone-implant stability indicated that the factors affecting reoperation were reduction quality and fracture type, not nail length or diameter. Surgeons should perform sufficient extramedullary or anatomic reduction. In addition, as an intraoperative decision-making process, selecting a nail length with an FR >0.8 is preferable when intramedullary reduction has been maintained intraoperatively.

Risk factors for reoperation were reduction quality and fracture type. On

Author contributions

All authors contributed to the study conception and design. Data collection was performed by Norio Yamamoto and Tomoo Inoue. Yosuke Tomita conducted statistical analysis. The first draft of the manuscript was written by Norio Yamamoto and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Funding

No external source of funding was received for this study.

Ethical approval

The study protocol was approved by the ethics committee (Approval No. 965).

Informed consent

Informed consent was obtained from all individual participants included in the study.

Declaration of Competing Interest

The authors have no conflicts of interest to declare that are relevant to the content of this article.

Acknowledgments

This work was supported by the Systematic Review Workshop Peer Support Group (SRWS-PSG).

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