Exploring Appropriate Positioning of the Spiral Blade in Treatment of Subtrochanteric Fractures of the Femur Using Proximal Femoral Nail Antirotation

Abstract

Objectives: Subtrochanteric fractures have anatomic characteristics distinct from intertrochanteric fractures that may affect the positioning of the spiral blade during surgical treatment. Tip-apex distance (TAD) and calcar-referenced tip-apex distance (Cal-TAD) were measured to determine if these measures are reliable indicators to assist in the accurate placement of intramedullary nails and minimize postoperative complications.

Methods: For patients treated with proximal femoral nail antirotation (PFNA) internal fixation between 2016 and 2020, we analyzed the TAD, Cal-TAD, and postoperative complications. Fracture healing was assessed radiographically at 6-week intervals until union. The incidences of axial cut-off, cephalad cut-off, and non-union were also examined. Analysis of variance and Fisher's exact test were performed to evaluate differences in complications between the TAD and Cal-TAD groups.

Results: Data from 104 patients (58 males, 46 females) with a mean age of 56.9 years were analyzed. Fracture healing was observed in 90 (86.5%) patients at an average time of 14.92 ± 1.81 weeks. The healing rate was significantly higher when the TAD and Cal-TAD were controlled within the 20–25 mm range (p < 0.05). Postoperative complications occurred in 14 (13.5%) cases [cephalad cut-off, n = 5 (4.8%); axial cut-off, n = 4 (3.8%); non-union, n = 5 (4.8%)]. Five (4.8%) complications occurred without internal fixation failure. The fracture healing time and incidence of complications differed among groups defined by TAD and Cal-TAD measurements, and were shortest and lowest, respectively, in the 20 mm < TAD/Cal-TAD < 25 mm group.

Conclusions: In our cohort, use of PFNA internal fixation for treatment of unstable femoral subtrochanteric fractures and placement of the spiral blade in the middle or lower 1/3 of the femoral neck did not increase the incidence of complications. Therefore, we propose that the TAD rule of 20–30 mm should not apply to subtrochanteric fractures, and TAD and Cal-TAD should be controlled within the range of 20–25 mm to reduce the incidence of complications.

Keywords

calcar-referenced tip-apex distance (Cal-TAD) / proximal femoral nail antirotation (PFNA) / subtrochanteric fractures / tip-apex distance (TAD)

References

[1] C. P. Bretherton and M. J. Parker, “Femoral Medialization, Fixation Failures, and Functional Outcome in Trochanteric Hip Fractures Treated With Either a Sliding Hip Screw or an Intramedullary Nail From Within a Randomized Trial,” Journal of Orthopaedic Trauma 30 (2016): 642-646.

[2] S. Papapoulos, H. Bone, F. Cosman, et al., “Incidence of Hip and Subtrochanteric/Femoral Shaft Fractures in Postmenopausal Women With Osteoporosis in the Phase 3 Long-Term Odanacatib Fracture Trial,” Journal of Bone and Mineral Research 36 (2021): 1225-1234.

[3] J. Tomás, J. Teixidor, L. Batalla, D. Pacha, and J. Cortina, “Subtrochanteric Fractures: Treatment With Cerclage Wire and Long Intramedullary Nail,” Journal of Orthopaedic Trauma 27 (2013): e157-e160.

[4] A. Howard and P. V. Giannoudis, “Proximal Femoral Fractures: Issues and Challenges,” Injury 43 (2012): 1975-1977.

[5] M. Panteli, C. Mauffrey, and P. V. Giannoudis, “Subtrochanteric Fractures: Issues and Challenges,” Injury 48 (2017): 2023-2026.

[6] J. Wang, J. X. Ma, B. Lu, H. H. Bai, Y. Wang, and X. L. Ma, “Comparative Finite Element Analysis of Three Implants Fixing Stable and Unstable Subtrochanteric Femoral Fractures: Proximal Femoral Nail Antirotation (PFNA), Proximal Femoral Locking Plate (PFLP), and Reverse Less Invasive Stabilization System (LISS),” Orthopaedics & Traumatology, Surgery & Research 106 (2020): 95-101.

[7] G. P. Guan, X. Wang, C. Wang, et al., “Comparison of PFNA and DHS in the Treatment of Sarcopenia With Seinsheimer Type V Subtrochanteric Fracture,” European Review for Medical and Pharmacological Sciences 27 (2023): 4442-4449.

[8] Y. J. Seong, J. H. Jang, S. B. Jeon, and N. H. Moon, “Characteristics and Surgical Outcomes of Intertrochanteric or Subtrochanteric Fractures Associated With Ipsilateral Femoral Shaft Fractures Treated With Closed Intramedullary Nailing: A Review of 31 Consecutive Cases Over Four Years at a Single Institution,” Hip Pelvis 31 (2019): 190-199.

[9] I. Garrison, G. Domingue, and M. W. Honeycutt, “Subtrochanteric Femur Fractures: Current Review of Management,” EFORT Open Reviews 6 (2021): 145-151.

[10] M. Vélez, U. Palacios-Barahona, M. M. Arango-Posada, and J. Ramos-Castañeda, “Functional Results and Complications of the Use of the Proximal Femoral Nail in the Treatment of Intertrochanteric Hip Fractures,” Acta Ortopédica Mexicana 32 (2018): 126-130.

[11] S. R. Lee, S. T. Kim, M. G. Yoon, M. S. Moon, and J. H. Heo, “The Stability Score of the Intramedullary Nailed Intertrochanteric Fractures: Stability of Nailed Fracture and Postoperative Patient Mobilization,” Clinics in Orthopedic Surgery 5 (2013): 10-18.

[12] R. Aicale and N. Maffulli, “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,” Journal of Orthopaedic Surgery and Research 13 (2018): 106.

[13] V. Khanna and M. Tiwari, “Significance of Tip Apex Distance in Intertrochanteric Fracture Femur Managed With Proximal Femoral Nailing,” Orthopaedics & Traumatology, Surgery & Research 107 (2021): 103009.

[14] A. Sedighi, J. G. Sales, and S. Alavi, “The Prognostic Value of Tip-To-Apex Distance (TAD Index) in Intertrochanteric Fractures Fixed by Dynamic Hip Screw,” Orthopedic Reviews 4 (2012): e32.

[15] A. Kashigar, A. Vincent, M. J. Gunton, D. Backstein, O. Safir, and P. R. Kuzyk, “Predictors of Failure for Cephalomedullary Nailing of Proximal Femoral Fractures,” Bone & Joint Journal 96-b, no. 8 (2014): 1029-1034, https://doi.org/10.1302/0301-620X.96B8.33644.

[16] M. Cleveland, D. M. Bosworth, F. R. Thompson, H. J. Wilson, and T. Ishizuka, “A Ten-Year Analysis of Intertrochanteric Fractures of the Femur,” Journal of Bone and Joint Surgery. American Volume 41 (1959): 1399-1408.

[17] M. R. Baumgaertner, S. L. Curtin, D. M. Lindskog, and J. M. Keggi, “The Value of the Tip-Apex Distance in Predicting Failure of Fixation of Peritrochanteric Fractures of the Hip,” Journal of Bone and Joint Surgery. American Volume 77 (1995): 1058-1064.

[18] H. Song, S. J. Hu, S. C. Du, W. F. Xiong, and S. M. Chang, “Sub-Classification of AO/OTA-2018 Pertrochanteric Fractures Is Associated With Clinical Outcomes After Fixation of Intramedullary Nails,” Geriatric Orthopaedic Surgery & Rehabilitation 12 (2021): 21514593211056739.

[19] A. N. Nikoloski, A. L. Osbrough, and P. J. Yates, “Should the Tip-Apex Distance (TAD) Rule Be Modified for the Proximal Femoral Nail Antirotation (PFNA)? A Retrospective Study,” Journal of Orthopaedic Surgery and Research 8 (2013): 35.

[20] S. B. Joglekar, E. M. Lindvall, and A. Martirosian, “Contemporary Management of Subtrochanteric Fractures,” Orthopedic Clinics of North America 46 (2015): 21-35.

[21] D. Krappinger, B. Wolf, D. Dammerer, M. Thaler, P. Schwendinger, and R. A. Lindtner, “Risk Factors for Nonunion After Intramedullary Nailing of Subtrochanteric Femoral Fractures,” Archives of Orthopaedic and Trauma Surgery 139 (2019): 769-777.

[22] H. Pervez, M. J. Parker, and S. Vowler, “Prediction of Fixation Failure After Sliding Hip Screw Fixation,” Injury 35 (2004): 994-998.

[23] K. K. Hsueh, C. K. Fang, C. M. Chen, Y. P. Su, H. F. Wu, and F. Y. Chiu, “Risk Factors in Cutout of Sliding Hip Screw in Intertrochanteric Fractures: An Evaluation of 937 Patients,” International Orthopaedics 34 (2010): 1273-1276.

[24] J. Johnson, M. Deren, A. Chambers, D. Cassidy, S. Koruprolu, and C. Born, “Biomechanical Analysis of Fixation Devices for Basicervical Femoral Neck Fractures,” Journal of the American Academy of Orthopaedic Surgeons 27 (2019): e41-e48.

[25] J. Q. Zhou and S. M. Chang, “Failure of PFNA: Helical Blade Perforation and Tip-Apex Distance,” Injury 43 (2012): 1227-1228.

[26] G. Caruso, M. Bonomo, G. Valpiani, et al., “A Six-Year Retrospective Analysis of Cut-Out Risk Predictors in Cephalomedullary Nailing for Pertrochanteric Fractures: Can the Tip-Apex Distance (TAD) Still Be Considered the Best Parameter?,” Bone & Joint Research 6 (2017): 481-488.

[27] A. Lenich, S. Bachmeier, L. Prantl, et al., “Is the Rotation of the Femoral Head a Potential Initiation for Cutting Out? A Theoretical and Experimental Approach,” BMC Musculoskeletal Disorders 12 (2011): 79.

[28] S. Akçay and I. S. Satoğlu, “A Biomechanical Evaluation of Proximal Femoral Nail Antirotation With Respect to Helical Blade Position in Femoral Head: A Cadaveric Study,” Indian Journal of Orthopaedics 48 (2014): 343.

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2025 The Author(s). Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.