The measurement and clinical significance of the rotation angles of head-neck fragments after cephalomedullary nail fixation in intertrochanteric fractures_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

DU Shouchao , XIONG Wenfeng ,  ZHANG Shimin , HU Sunjun , ZHANG Lizhi , CHEN Shiyi , WEI Zhen

Department of Orthopedics, Yangpu Hospital, Tongji University, Shanghai, 200090, P.R.China;

Corresponding author：

ZHANG Shimin, Email: shiminchang11@aliyun.com

Keywords：

Intertrochanteric fracture; anteromedial cortex; fracture reduction; head-neck fragment rotation; cortical support reduction

DOI：

10.7507/1002-1892.201905003

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Objective To measure the rotation angle of the head-neck fragment of intertrochanteric fracture after cephalomedullary nail fixation by three-dimensional CT imaging, and to explore its clinical significance.Methods The clinical data of 68 patients with unstable intertrochanteric fracture of AO/Orthopaedic Trauma Association (AO-OTA) type 31-A2 treated with cephalomedullary nail fixation and with complete intraoperative fluoroscopy and postoperative three-dimensional CT imaging data between July 2016 and October 2018 were retrospectively analyzed. Among them, there were 21 males and 47 females, aged 68-93 years, with an average age of 81.8 years. There were 31 cases of AO/OTA type 31-A2.2 and 37 cases of 31-A2.3. Fracture reduction quality was evaluated according to Baumgaertner et al. and Chang et al. criteria. The anteromedial cortical contact or not of each patient was observed by three-dimensional CT imaging on T3DView software after operation. The rotation of head-neck fragments were divided into three types: non-rotation, flexion rotation, and hyperextension rotation. The rotation angles of each type were measured and the relationship between the rotation type of the head-neck fragments and the contact of the anteromedial cortex was analyzed.Results The reduction and fixation of the small trochanter were not performed in 68 patients. According to Baumgaertner et al. criteria, the quality of fracture reduction was excellent in 15 cases (22.1%), acceptable in 50 cases (73.5%), and poor in 3 cases (4.4%). According to Chang et al. criteria, 31 cases were excellent (45.6%), 33 cases were acceptable (48.5%), and 4 cases were poor (5.9%). Thirty-nine cases (57.4%) received anteromedial cortical support and 29 cases (42.6%) did not receive cortical support. Three-dimensional CT imaging showed non-rotation in 12 cases (17.6%), flexion rotation in 39 cases (57.4%), and hyperextension rotation in 17 cases (25.0%). There were 7 cases (58.3%), 30 cases (76.9%), and 2 cases (11.8%) of cortical support in non-rotation group, flexion rotation group, and hyperextension rotation group, respectively. The rotation angles were (1.05±0.61), (13.96±6.17), (8.21±3.88)°, respectively. There were significant differences between groups (P<0.05).Conclusion In the unstable intertrochanteric fracture after cephalomedullary nail fixation, the rotation of head-neck fragment exists in most patients, and the types of flexion rotation and non-rotation can easily obtain cortical support reduction.

Citation： DU Shouchao, XIONG Wenfeng, ZHANG Shimin, HU Sunjun, ZHANG Lizhi, CHEN Shiyi, WEI Zhen. The measurement and clinical significance of the rotation angles of head-neck fragments after cephalomedullary nail fixation in intertrochanteric fractures. Chinese Journal of Reparative and Reconstructive Surgery, 2019, 33(10): 1228-1233. doi: 10.7507/1002-1892.201905003 Copy

1.	Konstantinidis L, Papaioannou C, Hirschmuller A, et al. In-tramedullary nailing of trochanteric fractures: central or caudal posi-tioning of the load carrier? A biomechanical comparative study on cadaver hones Injury, 2013, 44(6): 784-790.
2.	Kashigar A, Vincent A, Gunton MJ, et al. Predictors of failure for cephalomedullary nailing of proximal femoral fractures. Bone Joint J, 2014, 96-B(8): 1029-1034.
3.	Chang SM, Zhang YQ, Du SC, 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 Orthop, 2018, 42(1): 183-189.
4.	Chang SM, Zhang YQ, Ma Z, et al. Fracture reduction with positive medial cortical support: a key element in stability reconstruction for the unstable pertrochanteric hip fractures. Arch Orthop Trauma Surg, 2015, 135(6): 811-818.
5.	张世民, 李海丰, 俞光荣. 老年髋部骨折的临床治疗流程. 中国矫形外科杂志, 2005, 13(18): 1365-1368.
6.	杜守超, 张世民, 张英琪, 等. 不稳定股骨转子间骨折前内侧皮质支撑复位的影像学研究. 中国矫形外科杂志, 2018, 26(18): 1633-1638.
7.	Baumgaertner MR, Curtin SL, Lindskog DM, et al. The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fracture fixation. J Bone Joint Surg (Am), 1995, 77(7): 1058-1064.
8.	李毅中, 李建龙, 林金矿, 等. 应用 CT 扫描观察老年股骨近端皮质骨变化的初步研究. 中国骨质疏松杂志, 2010, 16(10): 737-740.
9.	Napoli N, Jin J, Peters K, et al. Are women with thicker cortices in the femoral shaft at higher risk of subtrochanteric/diaphyseal fractures? The study of osteoporotic fractures J Clin Endocrinol Metab, 2012, 97(7): 2414-2422.
10.	Albertsson DM, Mellström D, Petersson C, et al. Validation of a 4-item score predicting hip fracture and mortality risk among elderly women. Ann Fam Med, 2007, 5(1): 48-56.
11.	李绍光, 刘智, 孙天胜, 等. 老年人髋部骨折术后 1 年死亡率及危险因素分析. 北京医学, 2015, 37(11): 1031-1035.
12.	Ramanoudjame M, Guillon P, Dauzac C, et al. CT evaluation of torsional malalignment after intertrochanteric fracture fixation. Orthop Traumatol Surg Res, 2010, 96(8): 844-848.
13.	Kim TY, Lee YB, Chang JD, et al. Torsional malalignment, how much significant in the trochanteric fractures? Injury, 2015, 46(11): 2196-2200.
14.	张立智, 张世民, 李清, 等. Gamma 钉治疗左侧股骨粗隆间骨折导致头颈骨块旋转. 外科研究与新技术, 2014, 3(1): 34-37.
15.	Kaufer H. Mechanics of the treatment of hip injuries. Clin Orthop Relat Res, 1980, (146): 53-61.
16.	Fogagnolo F, Kfuri M Jr, Paccola CA. Intramedullary fixation of pertrochanteric hip fractures with the short AO-ASIF proximal femoral nail. Arch Orthop Trauma Surg, 2004, 124(1): 31-37.
17.	Guerra Pinto F, Dantas P, Moreira R, et al. Complications relating to accuracy of reduction of intertrochanteric fractures treated with a compressive hip screw. Hip Int, 2010, 20(2): 221-228.
18.	Ehrnthaller C, Olivier AC, Gebhard F, et al. 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), 2017, 42: 31-37.
19.	Kim GM, Nam KW, Seo KB, et al. Wiring technique for lesser trochanter fixation in proximal IM nailing of unstable intertrochanteric fractures: A modified candy-package wiring technique. Injury, 2017, 48(2): 406-413.
20.	张江, 乔晓红, 牛建军, 等. 股骨转子间骨折内侧皮质正性支撑复位对股骨近端防旋髓内钉内固定效果的影响. 中华临床医师杂志 (电子版), 2017, 11(9): 1512-1517.
21.	Cho MR, Lee JH, Kwon JB, et al. The effect of positive medial cortical support in reduction of pertrochanteric fractures with posteromedial wall defect using a dynamic hip screw. Clin Orthop Surg, 2018, 10(3): 292-298.
22.	侯宇, 姚琦, 张亘瑷, 等. 第三代 Gamma 钉与防旋股骨近端髓内钉治疗股骨粗隆间骨折术后股骨近端短缩的比较研究. 中国修复重建外科杂志, 2018, 32(3): 338-345.
23.	李双, 张世民, 张立智, 等. 不同组合前内侧皮质支撑复位对股骨转子间骨折髓内钉术后稳定性影响的生物力学研究. 中华创伤骨科杂志, 2019, 21(1): 57-64.
24.	Xu Z, Zhang M, Yin J, et al. Redisplacement after reduction with intramedullary nails in surgery of intertrochanteric fracture: cause analysis and preventive measures. Arch Orthop Trauma Surg, 2015, 135(6): 751-758.

1. Konstantinidis L, Papaioannou C, Hirschmuller A, et al. In-tramedullary nailing of trochanteric fractures: central or caudal posi-tioning of the load carrier? A biomechanical comparative study on cadaver hones Injury, 2013, 44(6): 784-790.
2. Kashigar A, Vincent A, Gunton MJ, et al. Predictors of failure for cephalomedullary nailing of proximal femoral fractures. Bone Joint J, 2014, 96-B(8): 1029-1034.
3. Chang SM, Zhang YQ, Du SC, 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 Orthop, 2018, 42(1): 183-189.
4. Chang SM, Zhang YQ, Ma Z, et al. Fracture reduction with positive medial cortical support: a key element in stability reconstruction for the unstable pertrochanteric hip fractures. Arch Orthop Trauma Surg, 2015, 135(6): 811-818.
5. 张世民, 李海丰, 俞光荣. 老年髋部骨折的临床治疗流程. 中国矫形外科杂志, 2005, 13(18): 1365-1368.
6. 杜守超, 张世民, 张英琪, 等. 不稳定股骨转子间骨折前内侧皮质支撑复位的影像学研究. 中国矫形外科杂志, 2018, 26(18): 1633-1638.
7. Baumgaertner MR, Curtin SL, Lindskog DM, et al. The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fracture fixation. J Bone Joint Surg (Am), 1995, 77(7): 1058-1064.
8. 李毅中, 李建龙, 林金矿, 等. 应用 CT 扫描观察老年股骨近端皮质骨变化的初步研究. 中国骨质疏松杂志, 2010, 16(10): 737-740.
9. Napoli N, Jin J, Peters K, et al. Are women with thicker cortices in the femoral shaft at higher risk of subtrochanteric/diaphyseal fractures? The study of osteoporotic fractures J Clin Endocrinol Metab, 2012, 97(7): 2414-2422.
10. Albertsson DM, Mellström D, Petersson C, et al. Validation of a 4-item score predicting hip fracture and mortality risk among elderly women. Ann Fam Med, 2007, 5(1): 48-56.
11. 李绍光, 刘智, 孙天胜, 等. 老年人髋部骨折术后 1 年死亡率及危险因素分析. 北京医学, 2015, 37(11): 1031-1035.
12. Ramanoudjame M, Guillon P, Dauzac C, et al. CT evaluation of torsional malalignment after intertrochanteric fracture fixation. Orthop Traumatol Surg Res, 2010, 96(8): 844-848.
13. Kim TY, Lee YB, Chang JD, et al. Torsional malalignment, how much significant in the trochanteric fractures? Injury, 2015, 46(11): 2196-2200.
14. 张立智, 张世民, 李清, 等. Gamma 钉治疗左侧股骨粗隆间骨折导致头颈骨块旋转. 外科研究与新技术, 2014, 3(1): 34-37.
15. Kaufer H. Mechanics of the treatment of hip injuries. Clin Orthop Relat Res, 1980, (146): 53-61.
16. Fogagnolo F, Kfuri M Jr, Paccola CA. Intramedullary fixation of pertrochanteric hip fractures with the short AO-ASIF proximal femoral nail. Arch Orthop Trauma Surg, 2004, 124(1): 31-37.
17. Guerra Pinto F, Dantas P, Moreira R, et al. Complications relating to accuracy of reduction of intertrochanteric fractures treated with a compressive hip screw. Hip Int, 2010, 20(2): 221-228.
18. Ehrnthaller C, Olivier AC, Gebhard F, et al. 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), 2017, 42: 31-37.
19. Kim GM, Nam KW, Seo KB, et al. Wiring technique for lesser trochanter fixation in proximal IM nailing of unstable intertrochanteric fractures: A modified candy-package wiring technique. Injury, 2017, 48(2): 406-413.
20. 张江, 乔晓红, 牛建军, 等. 股骨转子间骨折内侧皮质正性支撑复位对股骨近端防旋髓内钉内固定效果的影响. 中华临床医师杂志 (电子版), 2017, 11(9): 1512-1517.
21. Cho MR, Lee JH, Kwon JB, et al. The effect of positive medial cortical support in reduction of pertrochanteric fractures with posteromedial wall defect using a dynamic hip screw. Clin Orthop Surg, 2018, 10(3): 292-298.
22. 侯宇, 姚琦, 张亘瑷, 等. 第三代 Gamma 钉与防旋股骨近端髓内钉治疗股骨粗隆间骨折术后股骨近端短缩的比较研究. 中国修复重建外科杂志, 2018, 32(3): 338-345.
23. 李双, 张世民, 张立智, 等. 不同组合前内侧皮质支撑复位对股骨转子间骨折髓内钉术后稳定性影响的生物力学研究. 中华创伤骨科杂志, 2019, 21(1): 57-64.
24. Xu Z, Zhang M, Yin J, et al. Redisplacement after reduction with intramedullary nails in surgery of intertrochanteric fracture: cause analysis and preventive measures. Arch Orthop Trauma Surg, 2015, 135(6): 751-758.

Chinese Journal of Reparative and Reconstructive Surgery

The measurement and clinical significance of the rotation angles of head-neck fragments after cephalomedullary nail fixation in intertrochanteric fractures

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