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Complications and fixation techniques of trochanteric fractures with the TARGON® PF
Injury, Int. J. Care Injured 45S (2014) S44–S48
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Complications and fixation techniques of trochanteric fractures with the TARGON1 PF§ Naohide Takigawa *, Hiromitsu Moriuchi, Muneki Abe, Kenji Yasui, Hisako Eshiro, Mitsuo Kinoshita Department of Orthopaedic Surgery, Nishinomiya Kyoritsu Neurosurgical Hospital, Japan
A R T I C L E I N F O
A B S T R A C T
Keywords: Trochanteric fractures TARGON1 PF Complications Reduction
The purpose of this study was to analyse clinical results of elderly patients with trochanteric fractures that were treated with use of TARGON1 PF nail. Overall, 494 patients (113 males) were available for this study. On the basis of Jensen classification, there were 76 cases in type I, 164 cases in type II, 70 in type III, 129 in type IV and 55 in type V. (1) Sliding amount of lag screw in relation to the Jensen classification, (2) sliding amount of lag screw according to the Ikuta’s classification that categorises the reduction in lateral view in three, Subtype A, Subtype N and Subtype P, (3) sliding amount of lag screw in correlation between Jensen classification and Ikuta’s classification and (4) postoperative complications (9 cases; 1.7%) were assessed. Cut-out and back-out cases were seen in 6 cases (1.1%), and these severe complications were evaluated in details. In correlation between Jensen classification and Ikuta’s classification, the excessive sliding of lag screw was prominent with the Subtype P, which was preoperatively in Jensen type III or V. Cut-out or back-out cases were caused either from (1) Subtype P that were preoperatively Jensen types III or V, or from (2) the fracture where there was bony defect anteriorly. Therefore, special care must be taken for these types. ß 2013 Elsevier Ltd. All rights reserved.
Introduction Cephalomedullary implants are considered nowadays to be the gold standard of treatment of proximal femoral extracapsular fractures [1–5]. In spite of this, a number of complications have been reported associated with the use of these implants [6]. Loss of reduction related to cut-out or back-out of lag screw generally occurs within 3 months postoperatively. These complications are associated with the following causes: (1) eccentric placement of the lag screw, (2) improper reaming, (3) inability to obtain a stable reduction, (4) excessive fracture collapse and (5) severe osteopenia [7]. However, according to Kawatani et al. ‘suboptimal positioning of the lag screw or malreduction of the fracture cannot be avoided in certain occasions’ [8]. Therefore, it is essential to use a reliable implant system, which has been developed to address and minimise the development of these complications.
§ No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. * Corresponding author at: 12-1 Imazuyamanaka-Cho, Nishinomiya, Hyogo 6638211, Japan. Tel.: +81 798 33 2211; fax: +81 798 33 2438. E-mail address: [email protected] (N. Takigawa).
0020–1383/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.injury.2013.10.036
We have treated 522 patients with trochanteric fractures with the TARGON1 PF nail (B.BRAUN AESCULAP). In this study we investigated the effectiveness and complications encountered with this nailing system and paid special attention on the radiographic findings of post-operative reduction classifying the fractures according to the Ikuta’s classification [9,10]. Patients and methods Between July, 2005 and March, 2012, 522 patients with proximal femoral fractures were treated with TARGON1 PF nail. A retrospective review of prospectively documented data was carried out. The local hospital Ethical Committee gave approval for this study. Patients that were not available for follow up were excluded. In total 494 patients were enrolled in this study, which included 113 male and 381 female patients. The mean age at the time of operation was 84.3 years (range: 51–101 years). On the basis of Jensen classification [11], there were 76 cases in type I, 164 cases in type II, 70 in type III, 129 in type IV and 55 in type V. All nailing were performed on a fracture table. Traction was applied to facilitate closed reduction of the fracture. Where necessary a small incision was made to reduce the fracture. All patients received prophylactic antibiotics (1 dose second generation of cephalosporin). Full weight bearing on the affected
N. Takigawa et al. / Injury, Int. J. Care Injured 45S (2014) S44–S48
S45
Fig. 1. Ikuta’s classification (lateral view). The assessment of post operative reduction.
extremity was encouraged from the first post-operative. Following discharge from the hospital, patients were followed up at regular intervals in the outpatient clinic. Radiographically, the postoperative reduction in the lateral view was assessed by Ikuta’s classification – in ‘Subtype A’: the medial fragment is flexed anteriorly and it is placed extramedullarly, in ‘Subtype N’: the cortical congruence is gained between medial and distal fragments, and in ‘Subtype P’, the medial fragment is placed posteriorly and impacted into the medullary canal, which is called the ‘posterior sag’ (Fig. 1). In this study, we assessed: (1) sliding amount of lag screw in relation to the Jensen classification, (2) sliding amount of lag screw according to the Ikuta’s classification, (3) sliding amount of lag screw in correlation between Jensen classification and Ikuta’s classification, (4) postoperative complications. Kluskal–Wallis test and Chi-square test were used, and significance was set up at p = 0.05. The cut-out and back-out cases were especially evaluated in detail.
9.1 mm in type V, and a high tendency of longer sliding was revealed in type III and type V. (4) Postoperatively, complications developed in 9 cases (1.7%), which included 2 secondary traumatic fractures, 1 infection, 5 cut-out and 1 back-out cases. Of these complications, we focused on the cut-out and back-out cases that happened in 6 cases (1.1%) for further evaluation. The mean age of the patients was 85 years. There were one male and 5 female patients, and their fracture types were 2 cases in type III, 1 in type IV and 3 in type V. 4 out of the 6 cases were Subtype P. All the lag screws were placed in posterior position in the femoral head. The remainder of 2 cases were Subtype N with the fracture site being comminuted. In Subtype A, there were no cut-out or back-out cases. The average amount of telescoping was 14.7 mm (Tables 2 and 3).
Results
Case presentation
According to the Ikuta’s classification, there were 24 cases in Subtype A, 410 in Subtype N and 60 in Subtype P. The number of reduced fractures in Subtype P was significantly bigger in Jensen III, IV and V than in Jensen I and II (Table 1). The lag screw glided 3.4 mm on average (range: 0–17.5 mm). (1) The average amount of lag screw’s sliding on the basis of Jensen classification were: 0.67 mm in type I, 3.30 mm in type II, 4.96 mm in type III, 3.86 mm in type IV and 5.21 mm in type V. It was significantly greater with Jensen III and IV, V than in Jensen I and II (Fig. 2). (2) The average sliding amount of lag screw according to the postoperative reduction were: 4.6 mm in Subtype A, 2.6 mm in Subtype N and 8.9 mm in Subtype P, and it was considerably greater in Subtype P than that in Subtype A and N (Fig. 3). (3) The 60 Subtype P cases, which had the longest sliding amount on average, were then divided into the Jensen classification to take a closer look at average sliding amount per this classification’s type. The results were 8.4 mm in type II, 10.4 mm in type III, 8.0 mm in type IV and
Case 1. This was an 87 year-old woman who sustained a Jensen type V fracture. Comminution was seen anteriorly, which normally does not happen at this site. Bone defect was also
Fig. 2. sliding amount of lag screw in relation to the Jensen classifications. Kluskal– Wallis test.
Table 1 Jensen classification and Subtype (number of cases). Subtype A, N
Subtype P
Total
Jensen I, II Jensen III, IV, V
232 202
8 52
240 254
Total
434
60
494
Chi-square test p < 0.05.
Fig. 3. sliding amount of lag screw according to the postoperative reduction (Ikuta’s classification). Kluskal–Wallis test.
N. Takigawa et al. / Injury, Int. J. Care Injured 45S (2014) S44–S48
S46 Table 2 Cut-out and back-out cases. Case
Age
Complication
Reoperation
Jensen
Sliding (mm)
Subtype
1 2 3 4 5 6
85 92 93 80 77 87
Cut out Cut out Cut out Cut out Back out Cut out
BHA Long nail BHA BHA BHA BHA
V III III IV V V
15 10 15 17.5 15 15.4
P N P N P P
BHA, bipolar hip arthroplasty; sliding, amount of sliding of the lag screw; subtype, Ikuta’s classification.
Table 3 In review of published articles, the prevalence of cut-out and back out.
Stedfelt HW Kawatani Y Parker MJ Biber R Present study
2004 2011 2012 2012
Cut out
Back out or penetration
0.20% 0% 0.70% 1.10% 0.96%
1.20% 0.60% 0.30% 0.50% 0.20%
Discussion (n = 586) (n = 352) (n = 300) (n = 1516) (n = 512)
visible. The postoperative lateral view showed this was Subtype P, in which the medial fragment was impacted into the medullary canal, and a bony defect was seen anteriorly. Sliding of the lag screw progressed very fast, it went into a cut-out and then, hemi-arthroplasty was performed (Fig. 4). Case 2. This was a 77 year-old man, who had a Jensen type V fracture. At the time of injury, the fracture site was comminuted. Considering pronounced comminution, a shorter barrel should have been selected to allow for a longer sliding capacity. Sliding of the lag screw continued for three months, and it reached the point of maximum sliding capacity. As the fracture seemed to have healed, we did not decide for reoperation. Unfortunately, back-out happened at 6 months (Fig. 5).
The Targon1 PF implant offers parallel biaxial fixation with the insertion of the proximal antirotation pin and the inferior lag screw. The lag screw slides into the barrel that is locked in the nail by threads. This feature is especially beneficial because smooth telescoping of lag screw is induced, and this will diminish the rotational moment of the femoral head [12]. Surgeons often experience complex cases where the femoral neck is displaced anteriorly to the distal fragment in lateral view (Subtype A), the femoral neck is placed posteriorly (Subtype P) or a fracture line extents to the entry point of the nail and after a nail is inserted, the medial fragment is pushed medially [10]. To overcome the intraoperative difficulty in acquiring an optimal reduction and to reduce the incidence of complications, we developed special reduction instruments (Fig. 6). To reduce the Subtype A, either one-pointed edge or multipointed edge is connected to the pusher, depending on the fracture condition. A 1-cm skin incision is made antero-laterally, and then, the pusher-type reduction tool is inserted (Fig. 7). While an assistant holds the device inserted through anterolateral skin incision, the operation is continued. The shaft of the reduction tool is curved in order not to impede the image intensifier. The assistant keeps holding the device until a lag screw
Fig. 4. 87-Year-old woman sustained a Jensen type V fracture. (a) Post injury, (b) post op. radiograph shows this was in Subtype P, (c) lag screw slid very fast, (d) cut-out occurred and (e) hemi-arthroplasty was performed.
N. Takigawa et al. / Injury, Int. J. Care Injured 45S (2014) S44–S48
S47
Fig. 5. 77-Year-old man sustained a Jensen type V fracture. (a) Post injury, (b) post op., (c) at three months, lag screw fully slid; it was stopped by barrel. Fracture seemed to have healed, and re-operation was not decided, (d) at six months, back-out occurred.
is inserted into the femoral head. After the lag screw is inserted, the tool is removed. In regard to Subtype P, direct pressure alone cannot accomplish reduction [7]. Joseph et al. stated, while referring to Thomas AP’s article, ‘‘Significant posterior sag would not allow fixation in an aligned position. . .In the operating room, a crutch or lever device is used to facilitate reduction of the fracture fragments’’ [13,14]. In our case, we insert an elevator anteriorly, and try to reduce it by means of an ‘intrafocal pinning’ method. But under this condition, a
Fig. 6. Intraoperative reduction instrument. (a) For reduction of Subtype A, either one-pointed edge or multi-pointed edge is connected to the pusher, depending on the fracture type and (b) for reduction of Subtype P. This is also useful when the medial fragment is displaced medially.
lag screw cannot be inserted; we insert another reduction tool from the lateral side to hold the medial fragment, and then, we can insert a lag screw (Fig. 8). To look into the 6 of either cut-out or back-out cases, 4 of them were in Subtype P, though reduction was attempted intraoperatively. The causes of this consequence may have been (a) surgeons were not aware during the operation that the fracture was reduced in Subtype P and subsequently, it became a progressed Subtype P as the lag screw continued to slide, (b) the fracture was not sufficiently reduced and/or (c) the fracture displaced after implantation of nail and lag screw. In the review of trochanteric anatomy, the posterior cortex is thinner compared to the anterior cortex, and the iliofemoral ligament is widespread over the anterior intertrochanteric line, whereas few ligaments are attached to the posterior intertrochanteric crest. This anatomical structure often results in the posteriorly comminuted fracture [10]. According to the above-mentioned correlation between Subtype P and Jensen classification, the excessive sliding of lag screw was prominent with the Subtype P which were preoperatively in Jensen type III and V. These are the fractures where postero-lateral support is defective. Due to this fact, once sliding of the medial fragment occurred in these cases, it hardly had cortical contact with the distal fragment, and for this reason, they may have faced difficulty in consolidation. The TARGON1 PF nail was developed in an attempt to prevent ‘‘cut-out’’. In review of published articles [8,12,16,17], the prevalence of cut-out has been reported to be in very low percentages, which were extremely low as compared to other articles reporting complications with different implants Table 3 [18–23]. In our study, cut-out or back-out cases were caused either from (1) Subtype P that were preoperatively Jensen type III or V, or from (2) the fracture where there was a bony defect anteriorly. Therefore, special care must be taken for these types.
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N. Takigawa et al. / Injury, Int. J. Care Injured 45S (2014) S44–S48
Fig. 7. For the Subtype A fracture, through an antero-lateral 1-cm skin incision, the pusher-type reduction tool is inserted.
Fig. 8. An elevator is inserted anteriorly, and try to reduce it by means of ‘intrafocal pinning’ method. Under this condition, a lag screw cannot be inserted, and therefore, another reduction tool is inserted from lateral side to hold the medial fragment to allow a lag screw to be placed.
Conclusion Combination of the use of intra-operative reduction instruments with the implantation of the TARGON1 PF system lead to good fracture reduction and mechanical support with very good healing rates and low incidence of complications (1.1%). References [1] Vaquero J, Munoz J, Prat S, Ramirez C, Aguado HJ, Moreno E, et al. Proximal Femoral Nail Antirotation versus Gamma3 nail for intramedullary nailing of unstable trochanteric fractures. A randomised comparative study. Injury 2012;43(December (Suppl. 2)):S47–54. [2] Uzoigwe CE, Burnand HG, Cheesman CL, Aghedo DO, Faizi M, Middleton RG. Early and ultra-early surgery in hip fracture patients improves survival. Injury 2013;44(June (6)):726–9. [3] Elis J, Chechik O, Maman E, Steinberg EL. Expandable proximal femoral nails versus 958 dynamic condylar screw-plates for the treatment of reverse oblique intertrochanteric fractures. Injury 2012;43(August (8)):1313–7. [4] Acklin YP, Widmer AF, Renner RM, Frei R, Gross T. Unexpectedly increased rate of surgical site infections following implant surgery for hip fractures: problem solution with the bundle approach. Injury 2011;42(February (2)): 209–16.
[5] Brandt E, Verdonschot N. Biomechanical analysis of the sliding hip screw, cannulated screws and Targon FN in intracapsular hip fractures in cadaver femora. Injury 2011;42(2):183–7. [6] Yli-Kyyny TT, Sund R, Juntunen M, Salo JJ, Kro¨ger HP. Extra- and intramedullary implants for the treatment of pertrochanteric fractures – results from a Finnish National Database Study of 14,915 patients. Injury 2012;43(December (12)): 2156–60. [7] Russell TA. Intertrochanteric fractures. Rookwood and Green’s fractures in adults. 7th ed. Lippincott Williams & Wilkins; 2010, 1957-1640. [8] Kawatani Y, Nishida K, Anraku Y, Kunitake K, Tsutsumi Y. Clinical results of trochanteric fractures treated with Targon1 proximal femur intramedullary nailing fixation system. Injury 2011;42:522–7. [9] Ikuta T. Classification of trochanteric fracture of the femur. Kossetsu 2002;24: 158–62. [10] Tokunaga M. The management for unstable femoral trochanteric fractures using short femoral nail. Bessatsu Seikeigeka 2012;61:26–36. [11] Jensen JS. Classification of trochanteric fractures. Acta Orthop Scand 1980;51: 803–10. [12] Stedtfeld HW. The concept of a new proximal femoral nail. Kossetsu 2004;26: 31–8. [13] Carr JB. The anterior and medial reduction of intertrochanteric fractures: a simple method to obtain a stable reduction. J Orthop Trauma 2007;21:485–9. [14] Joseph TN, Chen AL, Kummer FJ, Koval KJ. The effect of posterior sag on the fixation stability of intertrochanteric hip fractures. J Trauma 2002;52:544–7. [16] Parker MJ, Bowers TR, Pryor GA. Sliding hip screw versus the Targon PF nail in the treatment of trochanteric fractures of the hip. J Bone Joint Surg Br 2012;94:391–7. [17] Biber R, Gru¨ninger S, Singler K, Sieber CC, Bail HJ. Is proximal femoral nailing a good procedure for teaching in orthogeriatrics? Arch Orthop Trauma Surg 2012;132:997–1002. [18] Leung KS, So WS, Shen WY, Hui PW. Gamma nails and dynamic hip screws for peritrochanteric fractures. A randomized prospective study in elderly patients. J Bone Joint Surg Br 1992;74:345–51. [19] Schipper IB, Marti RK, van der Werken C. Unstable trochanteric femoral fractures: extramedullary or intramedullary fixation. Review of literature. Injury 2004;35:142–51. [20] Bridle SH, Patel AD, Bircher M, Calvert PT. Fixation of intertrochanteric fractures of the femur. A randomized prospective comparison of the gamma nail and the dynamic hip screw. J Bone Joint Surg Br 1991;73:330–4. [21] Al-yassari G, Langstaff RJ, Jones JW, Al-Lami M. The AO/ASIF proximal femoral nail (PFN) for the treatment of unstable trochanteric femoral fracture. Injury 2002;33:395–9. [22] Schipper IB, Steyerberg EW, Castelein RM, van der Heijden FH, den Hoed PT, Kerver AJ, et al. Treatment of unstable trochanteric fractures. Randomised coparison of the gamma nail and proximal femoral nail. J Bone Joint Surg Br 2004;86:86–94. [23] Papasimos S, Koutsojannis CM, Panagopoulos A, Megas P, Lambiris E. A randomized comparison of AMBI, TGN and PFN for treatment of unstable trochanteric fractures. Arch Orthop Trauma Surg 2005;125:462–8.
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Complications and fixation techniques of trochanteric fractures with the TARGON1 PF§ Naohide Takigawa *, Hiromitsu Moriuchi, Muneki Abe, Kenji Yasui, Hisako Eshiro, Mitsuo Kinoshita Department of Orthopaedic Surgery, Nishinomiya Kyoritsu Neurosurgical Hospital, Japan
A R T I C L E I N F O
A B S T R A C T
Keywords: Trochanteric fractures TARGON1 PF Complications Reduction
The purpose of this study was to analyse clinical results of elderly patients with trochanteric fractures that were treated with use of TARGON1 PF nail. Overall, 494 patients (113 males) were available for this study. On the basis of Jensen classification, there were 76 cases in type I, 164 cases in type II, 70 in type III, 129 in type IV and 55 in type V. (1) Sliding amount of lag screw in relation to the Jensen classification, (2) sliding amount of lag screw according to the Ikuta’s classification that categorises the reduction in lateral view in three, Subtype A, Subtype N and Subtype P, (3) sliding amount of lag screw in correlation between Jensen classification and Ikuta’s classification and (4) postoperative complications (9 cases; 1.7%) were assessed. Cut-out and back-out cases were seen in 6 cases (1.1%), and these severe complications were evaluated in details. In correlation between Jensen classification and Ikuta’s classification, the excessive sliding of lag screw was prominent with the Subtype P, which was preoperatively in Jensen type III or V. Cut-out or back-out cases were caused either from (1) Subtype P that were preoperatively Jensen types III or V, or from (2) the fracture where there was bony defect anteriorly. Therefore, special care must be taken for these types. ß 2013 Elsevier Ltd. All rights reserved.
Introduction Cephalomedullary implants are considered nowadays to be the gold standard of treatment of proximal femoral extracapsular fractures [1–5]. In spite of this, a number of complications have been reported associated with the use of these implants [6]. Loss of reduction related to cut-out or back-out of lag screw generally occurs within 3 months postoperatively. These complications are associated with the following causes: (1) eccentric placement of the lag screw, (2) improper reaming, (3) inability to obtain a stable reduction, (4) excessive fracture collapse and (5) severe osteopenia [7]. However, according to Kawatani et al. ‘suboptimal positioning of the lag screw or malreduction of the fracture cannot be avoided in certain occasions’ [8]. Therefore, it is essential to use a reliable implant system, which has been developed to address and minimise the development of these complications.
§ No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. * Corresponding author at: 12-1 Imazuyamanaka-Cho, Nishinomiya, Hyogo 6638211, Japan. Tel.: +81 798 33 2211; fax: +81 798 33 2438. E-mail address: [email protected] (N. Takigawa).
0020–1383/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.injury.2013.10.036
We have treated 522 patients with trochanteric fractures with the TARGON1 PF nail (B.BRAUN AESCULAP). In this study we investigated the effectiveness and complications encountered with this nailing system and paid special attention on the radiographic findings of post-operative reduction classifying the fractures according to the Ikuta’s classification [9,10]. Patients and methods Between July, 2005 and March, 2012, 522 patients with proximal femoral fractures were treated with TARGON1 PF nail. A retrospective review of prospectively documented data was carried out. The local hospital Ethical Committee gave approval for this study. Patients that were not available for follow up were excluded. In total 494 patients were enrolled in this study, which included 113 male and 381 female patients. The mean age at the time of operation was 84.3 years (range: 51–101 years). On the basis of Jensen classification [11], there were 76 cases in type I, 164 cases in type II, 70 in type III, 129 in type IV and 55 in type V. All nailing were performed on a fracture table. Traction was applied to facilitate closed reduction of the fracture. Where necessary a small incision was made to reduce the fracture. All patients received prophylactic antibiotics (1 dose second generation of cephalosporin). Full weight bearing on the affected
N. Takigawa et al. / Injury, Int. J. Care Injured 45S (2014) S44–S48
S45
Fig. 1. Ikuta’s classification (lateral view). The assessment of post operative reduction.
extremity was encouraged from the first post-operative. Following discharge from the hospital, patients were followed up at regular intervals in the outpatient clinic. Radiographically, the postoperative reduction in the lateral view was assessed by Ikuta’s classification – in ‘Subtype A’: the medial fragment is flexed anteriorly and it is placed extramedullarly, in ‘Subtype N’: the cortical congruence is gained between medial and distal fragments, and in ‘Subtype P’, the medial fragment is placed posteriorly and impacted into the medullary canal, which is called the ‘posterior sag’ (Fig. 1). In this study, we assessed: (1) sliding amount of lag screw in relation to the Jensen classification, (2) sliding amount of lag screw according to the Ikuta’s classification, (3) sliding amount of lag screw in correlation between Jensen classification and Ikuta’s classification, (4) postoperative complications. Kluskal–Wallis test and Chi-square test were used, and significance was set up at p = 0.05. The cut-out and back-out cases were especially evaluated in detail.
9.1 mm in type V, and a high tendency of longer sliding was revealed in type III and type V. (4) Postoperatively, complications developed in 9 cases (1.7%), which included 2 secondary traumatic fractures, 1 infection, 5 cut-out and 1 back-out cases. Of these complications, we focused on the cut-out and back-out cases that happened in 6 cases (1.1%) for further evaluation. The mean age of the patients was 85 years. There were one male and 5 female patients, and their fracture types were 2 cases in type III, 1 in type IV and 3 in type V. 4 out of the 6 cases were Subtype P. All the lag screws were placed in posterior position in the femoral head. The remainder of 2 cases were Subtype N with the fracture site being comminuted. In Subtype A, there were no cut-out or back-out cases. The average amount of telescoping was 14.7 mm (Tables 2 and 3).
Results
Case presentation
According to the Ikuta’s classification, there were 24 cases in Subtype A, 410 in Subtype N and 60 in Subtype P. The number of reduced fractures in Subtype P was significantly bigger in Jensen III, IV and V than in Jensen I and II (Table 1). The lag screw glided 3.4 mm on average (range: 0–17.5 mm). (1) The average amount of lag screw’s sliding on the basis of Jensen classification were: 0.67 mm in type I, 3.30 mm in type II, 4.96 mm in type III, 3.86 mm in type IV and 5.21 mm in type V. It was significantly greater with Jensen III and IV, V than in Jensen I and II (Fig. 2). (2) The average sliding amount of lag screw according to the postoperative reduction were: 4.6 mm in Subtype A, 2.6 mm in Subtype N and 8.9 mm in Subtype P, and it was considerably greater in Subtype P than that in Subtype A and N (Fig. 3). (3) The 60 Subtype P cases, which had the longest sliding amount on average, were then divided into the Jensen classification to take a closer look at average sliding amount per this classification’s type. The results were 8.4 mm in type II, 10.4 mm in type III, 8.0 mm in type IV and
Case 1. This was an 87 year-old woman who sustained a Jensen type V fracture. Comminution was seen anteriorly, which normally does not happen at this site. Bone defect was also
Fig. 2. sliding amount of lag screw in relation to the Jensen classifications. Kluskal– Wallis test.
Table 1 Jensen classification and Subtype (number of cases). Subtype A, N
Subtype P
Total
Jensen I, II Jensen III, IV, V
232 202
8 52
240 254
Total
434
60
494
Chi-square test p < 0.05.
Fig. 3. sliding amount of lag screw according to the postoperative reduction (Ikuta’s classification). Kluskal–Wallis test.
N. Takigawa et al. / Injury, Int. J. Care Injured 45S (2014) S44–S48
S46 Table 2 Cut-out and back-out cases. Case
Age
Complication
Reoperation
Jensen
Sliding (mm)
Subtype
1 2 3 4 5 6
85 92 93 80 77 87
Cut out Cut out Cut out Cut out Back out Cut out
BHA Long nail BHA BHA BHA BHA
V III III IV V V
15 10 15 17.5 15 15.4
P N P N P P
BHA, bipolar hip arthroplasty; sliding, amount of sliding of the lag screw; subtype, Ikuta’s classification.
Table 3 In review of published articles, the prevalence of cut-out and back out.
Stedfelt HW Kawatani Y Parker MJ Biber R Present study
2004 2011 2012 2012
Cut out
Back out or penetration
0.20% 0% 0.70% 1.10% 0.96%
1.20% 0.60% 0.30% 0.50% 0.20%
Discussion (n = 586) (n = 352) (n = 300) (n = 1516) (n = 512)
visible. The postoperative lateral view showed this was Subtype P, in which the medial fragment was impacted into the medullary canal, and a bony defect was seen anteriorly. Sliding of the lag screw progressed very fast, it went into a cut-out and then, hemi-arthroplasty was performed (Fig. 4). Case 2. This was a 77 year-old man, who had a Jensen type V fracture. At the time of injury, the fracture site was comminuted. Considering pronounced comminution, a shorter barrel should have been selected to allow for a longer sliding capacity. Sliding of the lag screw continued for three months, and it reached the point of maximum sliding capacity. As the fracture seemed to have healed, we did not decide for reoperation. Unfortunately, back-out happened at 6 months (Fig. 5).
The Targon1 PF implant offers parallel biaxial fixation with the insertion of the proximal antirotation pin and the inferior lag screw. The lag screw slides into the barrel that is locked in the nail by threads. This feature is especially beneficial because smooth telescoping of lag screw is induced, and this will diminish the rotational moment of the femoral head [12]. Surgeons often experience complex cases where the femoral neck is displaced anteriorly to the distal fragment in lateral view (Subtype A), the femoral neck is placed posteriorly (Subtype P) or a fracture line extents to the entry point of the nail and after a nail is inserted, the medial fragment is pushed medially [10]. To overcome the intraoperative difficulty in acquiring an optimal reduction and to reduce the incidence of complications, we developed special reduction instruments (Fig. 6). To reduce the Subtype A, either one-pointed edge or multipointed edge is connected to the pusher, depending on the fracture condition. A 1-cm skin incision is made antero-laterally, and then, the pusher-type reduction tool is inserted (Fig. 7). While an assistant holds the device inserted through anterolateral skin incision, the operation is continued. The shaft of the reduction tool is curved in order not to impede the image intensifier. The assistant keeps holding the device until a lag screw
Fig. 4. 87-Year-old woman sustained a Jensen type V fracture. (a) Post injury, (b) post op. radiograph shows this was in Subtype P, (c) lag screw slid very fast, (d) cut-out occurred and (e) hemi-arthroplasty was performed.
N. Takigawa et al. / Injury, Int. J. Care Injured 45S (2014) S44–S48
S47
Fig. 5. 77-Year-old man sustained a Jensen type V fracture. (a) Post injury, (b) post op., (c) at three months, lag screw fully slid; it was stopped by barrel. Fracture seemed to have healed, and re-operation was not decided, (d) at six months, back-out occurred.
is inserted into the femoral head. After the lag screw is inserted, the tool is removed. In regard to Subtype P, direct pressure alone cannot accomplish reduction [7]. Joseph et al. stated, while referring to Thomas AP’s article, ‘‘Significant posterior sag would not allow fixation in an aligned position. . .In the operating room, a crutch or lever device is used to facilitate reduction of the fracture fragments’’ [13,14]. In our case, we insert an elevator anteriorly, and try to reduce it by means of an ‘intrafocal pinning’ method. But under this condition, a
Fig. 6. Intraoperative reduction instrument. (a) For reduction of Subtype A, either one-pointed edge or multi-pointed edge is connected to the pusher, depending on the fracture type and (b) for reduction of Subtype P. This is also useful when the medial fragment is displaced medially.
lag screw cannot be inserted; we insert another reduction tool from the lateral side to hold the medial fragment, and then, we can insert a lag screw (Fig. 8). To look into the 6 of either cut-out or back-out cases, 4 of them were in Subtype P, though reduction was attempted intraoperatively. The causes of this consequence may have been (a) surgeons were not aware during the operation that the fracture was reduced in Subtype P and subsequently, it became a progressed Subtype P as the lag screw continued to slide, (b) the fracture was not sufficiently reduced and/or (c) the fracture displaced after implantation of nail and lag screw. In the review of trochanteric anatomy, the posterior cortex is thinner compared to the anterior cortex, and the iliofemoral ligament is widespread over the anterior intertrochanteric line, whereas few ligaments are attached to the posterior intertrochanteric crest. This anatomical structure often results in the posteriorly comminuted fracture [10]. According to the above-mentioned correlation between Subtype P and Jensen classification, the excessive sliding of lag screw was prominent with the Subtype P which were preoperatively in Jensen type III and V. These are the fractures where postero-lateral support is defective. Due to this fact, once sliding of the medial fragment occurred in these cases, it hardly had cortical contact with the distal fragment, and for this reason, they may have faced difficulty in consolidation. The TARGON1 PF nail was developed in an attempt to prevent ‘‘cut-out’’. In review of published articles [8,12,16,17], the prevalence of cut-out has been reported to be in very low percentages, which were extremely low as compared to other articles reporting complications with different implants Table 3 [18–23]. In our study, cut-out or back-out cases were caused either from (1) Subtype P that were preoperatively Jensen type III or V, or from (2) the fracture where there was a bony defect anteriorly. Therefore, special care must be taken for these types.
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Fig. 7. For the Subtype A fracture, through an antero-lateral 1-cm skin incision, the pusher-type reduction tool is inserted.
Fig. 8. An elevator is inserted anteriorly, and try to reduce it by means of ‘intrafocal pinning’ method. Under this condition, a lag screw cannot be inserted, and therefore, another reduction tool is inserted from lateral side to hold the medial fragment to allow a lag screw to be placed.
Conclusion Combination of the use of intra-operative reduction instruments with the implantation of the TARGON1 PF system lead to good fracture reduction and mechanical support with very good healing rates and low incidence of complications (1.1%). References [1] Vaquero J, Munoz J, Prat S, Ramirez C, Aguado HJ, Moreno E, et al. Proximal Femoral Nail Antirotation versus Gamma3 nail for intramedullary nailing of unstable trochanteric fractures. A randomised comparative study. Injury 2012;43(December (Suppl. 2)):S47–54. [2] Uzoigwe CE, Burnand HG, Cheesman CL, Aghedo DO, Faizi M, Middleton RG. Early and ultra-early surgery in hip fracture patients improves survival. Injury 2013;44(June (6)):726–9. [3] Elis J, Chechik O, Maman E, Steinberg EL. Expandable proximal femoral nails versus 958 dynamic condylar screw-plates for the treatment of reverse oblique intertrochanteric fractures. Injury 2012;43(August (8)):1313–7. [4] Acklin YP, Widmer AF, Renner RM, Frei R, Gross T. Unexpectedly increased rate of surgical site infections following implant surgery for hip fractures: problem solution with the bundle approach. Injury 2011;42(February (2)): 209–16.
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