Influence of anterior fracture line on anterior cortical reduction loss after cephalomedullary nail fixation in intertrochanteric fractures_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

CHEN Shiyi ¹ ,  CHANG Shimin ² , XIONG Wenfeng ² , HU Sunjun ² , DU Shouchao ² , CHEN Shiyi ¹ ,  CHANG Shimin ² , XIONG Wenfeng ² , HU Sunjun ² , DU Shouchao ²

1. Department of Trauma and Orthopedics, Shanghai Fourth People’s Hospital, Tongji University, Shanghai, 200080, P. R. China;
2. Department of Orthopedics, Yangpu Hospital, Tongji University, Shanghai, 200082, P. R. China;

Corresponding author：

CHANG Shimin, Email: shiminchang11@aliyun.com; CHANG Shimin, Email: shiminchang11@aliyun.com

Keywords：

Intertrochanteric fracture; cortical support reduction; anterior fracture line

DOI：

10.7507/1002-1892.202402019

Video：

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Abstract Full text Figures/Tables Video References Cited by

Objective To investigate the position of the anterior fracture line in AO/Orthopaedic Trauma Association (AO/OTA) type A2 unstable intertrochanteric fractures and its impact on the incidence of anterior cortical reduction loss after cephalomedullary nail fixation. Methods A clinical data of 95 patients with intertrochanteric fractures who met the selection criteria between April 2020 and February 2023 was retrospectively analyzed. All patients were treated with cephalomedullary nail fixation, and the intra- and post-operative imaging data were complete. Among them, there were 37 males and 58 females. The age ranged from 61 to 97 years, with an average of 79.6 years. The time from injury to operation ranged from 7 hours to 11 days, with an average of 2.8 days. According to the 2018-AO/OTA classification standard, there were 39 cases of type 31-A2.2 and 56 cases of type 31-A2.3. Intraoperative fluoroscopy was used to record the number of patients with satisfactory fracture alignment. The preoperative CT data were imported into Mimics17.0 software to simulate the fracture reduction and measure the distance between the anterior fracture line and the intertrochanteric line bony ridge. The fractures were classified as transcapsular fractures, extra-capsular fractures, and intra-capsular fractures according to the distance. CT three-dimensional reconstruction was performed within 2 weeks after operation to observe the number of patients with anterior cortical reduction loss. Statistical analysis was performed on the anterior cortical reduction loss in patients with satisfactory fracture alignment, and the relationship between postoperative anterior cortical reduction loss and the position of the anterior fracture line was observed. Results There were 52 cases (54.7%) of transcapsular fractures, 24 cases (25.3%) of extra-capsular fractures, and 19 cases (20.0%) of intra-capsular fractures. Among them, 41 of the 52 transcapsular fractures had satisfactory fracture alignment, and 4 (9.8%) of them experienced anterior cortical reduction loss after operation; 19 of the 24 extra-capsular fractures had satisfactory fracture alignment, and no anterior cortical reduction loss occurred; 16 of the 19 intra-capsular fractures had satisfactory fracture alignment, and 7 (43.8%) of them experienced anterior cortical reduction loss after operation. There was a significant difference in the incidence of anterior cortical reduction loss between groups (χ²=8.538, P=0.003). All patients were followed up 3-26 months (mean, 9 months). Among them, 91 cases had fracture healing, and 4 cases had nonunion. Conclusion In AO/OTA type A2 unstable intertrochanteric fractures, where the anterior fracture line is located within the joint capsule, there is a high risk of anterior cortical reduction loss after operation.

Citation： CHEN Shiyi, CHANG Shimin, XIONG Wenfeng, HU Sunjun, DU Shouchao. Influence of anterior fracture line on anterior cortical reduction loss after cephalomedullary nail fixation in intertrochanteric fractures. Chinese Journal of Reparative and Reconstructive Surgery, 2024, 38(4): 391-397. doi: 10.7507/1002-1892.202402019 Copy

1.	聂少波, 张伟, 张里程, 等. 股骨转子间骨折术后内固定失效的危险因素研究进展. 中华创伤骨科杂志, 2021, 23(3): 233-238.
2.	聂少波, 张伟, 张里程, 等. 股骨转子间骨折术后内固定失效的危险因素研究进展. 中华创伤骨科杂志, 2021, 23(3): 233-238.
3.	张世民, 张英琪, 李清, 等. 内侧皮质正性支撑复位对老年股骨粗隆间骨折内固定效果的影响. 中国矫形外科杂志, 2014, 22(14): 1256-1261.
4.	张世民, 张英琪, 李清, 等. 内侧皮质正性支撑复位对老年股骨粗隆间骨折内固定效果的影响. 中国矫形外科杂志, 2014, 22(14): 1256-1261.
5.	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.
6.	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.
7.	Chang SM, Hou ZY, Hu SJ, et al. Intertrochanteric femur fracture treatment in Asia: What we know and what the world can learn. Orthop Clin North Am, 2020, 51(2): 189-205.
8.	Chang SM, Hou ZY, Hu SJ, et al. Intertrochanteric femur fracture treatment in Asia: What we know and what the world can learn. Orthop Clin North Am, 2020, 51(2): 189-205.
9.	张世民, 王振海, 田可为. 同时累及同侧股骨颈与转子间两个解剖区域的骨折类型与研究进展. 中国修复重建外科杂志, 2021, 35(9): 1079-1085.
10.	张世民, 王振海, 田可为. 同时累及同侧股骨颈与转子间两个解剖区域的骨折类型与研究进展. 中国修复重建外科杂志, 2021, 35(9): 1079-1085.
11.	Tamaki Y, Goto T, Wada K, et al. Anatomic evaluation of the insertional footprints of the iliofemoral and ischiofemoral ligaments: a cadaveric study. BMC Musculoskelet Disord, 2020, 21(1): 828. doi: 10.1186/s12891-020-03848-4.
12.	Tamaki Y, Goto T, Wada K, et al. Anatomic evaluation of the insertional footprints of the iliofemoral and ischiofemoral ligaments: a cadaveric study. BMC Musculoskelet Disord, 2020, 21(1): 828. doi: 10.1186/s12891-020-03848-4.
13.	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.
14.	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.
15.	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.
16.	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.
17.	Mao W, Yang AL, Chang SM, et al. The impact of banana-shaped fragments on trochanteric hip fractures treated by PFNA. Indian J Orthop, 2023, 57(9): 1452-1460.
18.	Mao W, Yang AL, Chang SM, et al. The impact of banana-shaped fragments on trochanteric hip fractures treated by PFNA. Indian J Orthop, 2023, 57(9): 1452-1460.
19.	Xiong WF, Zhang YQ, Chang SM, et al. Lesser trochanteric fragments in unstable pertrochanteric hip fractures: A morphological study using three-dimensional computed tomography (3-D CT) reconstruction. Med Sci Monit, 2019, 25: 2049-2057.
20.	Xiong WF, Zhang YQ, Chang SM, et al. Lesser trochanteric fragments in unstable pertrochanteric hip fractures: A morphological study using three-dimensional computed tomography (3-D CT) reconstruction. Med Sci Monit, 2019, 25: 2049-2057.
21.	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.
22.	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.
23.	Tsutsumi M, Nimura A, Akita K. Clinical anatomy of the musculoskeletal system in the hip region. Anat Sci Int, 2022, 97(2): 157-164.
24.	Tsutsumi M, Nimura A, Akita K. Clinical anatomy of the musculoskeletal system in the hip region. Anat Sci Int, 2022, 97(2): 157-164.
25.	Tsutsumi M, Nimura A, Akita K. New insight into the iliofemoral ligament based on the anatomical study of the hip joint capsule. J Anat, 2020, 236(5): 946-953.
26.	Tsutsumi M, Nimura A, Akita K. New insight into the iliofemoral ligament based on the anatomical study of the hip joint capsule. J Anat, 2020, 236(5): 946-953.
27.	Tamaki Y, Goto T, Iwase J, et al. Contributions of the ischiofemoral ligament, iliofemoral ligament, and conjoined tendon to hip stability after total hip arthroplasty: A cadaveric study. J Orthop Res, 2022, 40(12): 2885-2893.
28.	Tamaki Y, Goto T, Iwase J, et al. Contributions of the ischiofemoral ligament, iliofemoral ligament, and conjoined tendon to hip stability after total hip arthroplasty: A cadaveric study. J Orthop Res, 2022, 40(12): 2885-2893.
29.	van Arkel RJ, Ng KCG, Muirhead-Allwood SK, et al. Capsular ligament function after total hip arthroplasty. J Bone Joint Surg (Am), 2018, 100(14): e94. doi: 10.2106/JBJS.17.00251.
30.	van Arkel RJ, Ng KCG, Muirhead-Allwood SK, et al. Capsular ligament function after total hip arthroplasty. J Bone Joint Surg (Am), 2018, 100(14): e94. doi: 10.2106/JBJS.17.00251.
31.	Kweon SH, Lee SH, Kook SH, et al. Outcomes of cephalomedullary nailing in basicervical fracture. Hip Pelvis, 2017, 29(4): 270-276.
32.	Kweon SH, Lee SH, Kook SH, et al. Outcomes of cephalomedullary nailing in basicervical fracture. Hip Pelvis, 2017, 29(4): 270-276.
33.	Yoo JI, Cha Y, Kwak J, et al. Review on basicervical femoral neck fracture: definition, treatments, and failures. Hip Pelvis, 2020, 32(4): 170-181.
34.	Yoo JI, Cha Y, Kwak J, et al. Review on basicervical femoral neck fracture: definition, treatments, and failures. Hip Pelvis, 2020, 32(4): 170-181.
35.	Bartoníček J, Bartoška R, Alt J, et al. Pathoanatomy of pertrochanteric fractures—a postmortem study. Injury, 2023, 54(7): 110760. doi: 10.1016/j.injury.2023.04.047.
36.	Bartoníček J, Bartoška R, Alt J, et al. Pathoanatomy of pertrochanteric fractures—a postmortem study. Injury, 2023, 54(7): 110760. doi: 10.1016/j.injury.2023.04.047.
37.	Li C, Zhao D, Xu X, et al. Three-dimensional computed tomography (CT) mapping of intertrochanteric fractures in elderly patients. Med Sci Monit, 2020, 26: e925452. doi: 10.12659/MSM.925452.
38.	Li C, Zhao D, Xu X, et al. Three-dimensional computed tomography (CT) mapping of intertrochanteric fractures in elderly patients. Med Sci Monit, 2020, 26: e925452. doi: 10.12659/MSM.925452.
39.	Fu Y, Liu R, Liu Y, et al. Intertrochanteric fracture visualization and analysis using a map projection technique. Med Biol Eng Comput, 2019, 57(3): 633-642.
40.	Fu Y, Liu R, Liu Y, et al. Intertrochanteric fracture visualization and analysis using a map projection technique. Med Biol Eng Comput, 2019, 57(3): 633-642.
41.	卫禛, 熊文峰, 张世民. 转子间骨折中股骨干近侧断面环周皮质的CT影像学测量及其临床意义. 中国临床解剖学杂志, 2020, 38(6): 639-645.
42.	卫禛, 熊文峰, 张世民. 转子间骨折中股骨干近侧断面环周皮质的CT影像学测量及其临床意义. 中国临床解剖学杂志, 2020, 38(6): 639-645.
43.	Futamura K, Baba T, Homma Y, et al. New classification focusing on the relationship between the attachment of the iliofemoral ligament and the course of the fracture line for intertrochanteric fractures. Injury, 2016, 47(8): 1685-1691.
44.	Futamura K, Baba T, Homma Y, et al. New classification focusing on the relationship between the attachment of the iliofemoral ligament and the course of the fracture line for intertrochanteric fractures. Injury, 2016, 47(8): 1685-1691.
45.	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.
46.	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.

1. 聂少波, 张伟, 张里程, 等. 股骨转子间骨折术后内固定失效的危险因素研究进展. 中华创伤骨科杂志, 2021, 23(3): 233-238.
2. 聂少波, 张伟, 张里程, 等. 股骨转子间骨折术后内固定失效的危险因素研究进展. 中华创伤骨科杂志, 2021, 23(3): 233-238.
3. 张世民, 张英琪, 李清, 等. 内侧皮质正性支撑复位对老年股骨粗隆间骨折内固定效果的影响. 中国矫形外科杂志, 2014, 22(14): 1256-1261.
4. 张世民, 张英琪, 李清, 等. 内侧皮质正性支撑复位对老年股骨粗隆间骨折内固定效果的影响. 中国矫形外科杂志, 2014, 22(14): 1256-1261.
5. 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.
6. 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.
7. Chang SM, Hou ZY, Hu SJ, et al. Intertrochanteric femur fracture treatment in Asia: What we know and what the world can learn. Orthop Clin North Am, 2020, 51(2): 189-205.
8. Chang SM, Hou ZY, Hu SJ, et al. Intertrochanteric femur fracture treatment in Asia: What we know and what the world can learn. Orthop Clin North Am, 2020, 51(2): 189-205.
9. 张世民, 王振海, 田可为. 同时累及同侧股骨颈与转子间两个解剖区域的骨折类型与研究进展. 中国修复重建外科杂志, 2021, 35(9): 1079-1085.
10. 张世民, 王振海, 田可为. 同时累及同侧股骨颈与转子间两个解剖区域的骨折类型与研究进展. 中国修复重建外科杂志, 2021, 35(9): 1079-1085.
11. Tamaki Y, Goto T, Wada K, et al. Anatomic evaluation of the insertional footprints of the iliofemoral and ischiofemoral ligaments: a cadaveric study. BMC Musculoskelet Disord, 2020, 21(1): 828. doi: 10.1186/s12891-020-03848-4.
12. Tamaki Y, Goto T, Wada K, et al. Anatomic evaluation of the insertional footprints of the iliofemoral and ischiofemoral ligaments: a cadaveric study. BMC Musculoskelet Disord, 2020, 21(1): 828. doi: 10.1186/s12891-020-03848-4.
13. 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.
14. 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.
15. 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.
16. 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.
17. Mao W, Yang AL, Chang SM, et al. The impact of banana-shaped fragments on trochanteric hip fractures treated by PFNA. Indian J Orthop, 2023, 57(9): 1452-1460.
18. Mao W, Yang AL, Chang SM, et al. The impact of banana-shaped fragments on trochanteric hip fractures treated by PFNA. Indian J Orthop, 2023, 57(9): 1452-1460.
19. Xiong WF, Zhang YQ, Chang SM, et al. Lesser trochanteric fragments in unstable pertrochanteric hip fractures: A morphological study using three-dimensional computed tomography (3-D CT) reconstruction. Med Sci Monit, 2019, 25: 2049-2057.
20. Xiong WF, Zhang YQ, Chang SM, et al. Lesser trochanteric fragments in unstable pertrochanteric hip fractures: A morphological study using three-dimensional computed tomography (3-D CT) reconstruction. Med Sci Monit, 2019, 25: 2049-2057.
21. 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.
22. 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.
23. Tsutsumi M, Nimura A, Akita K. Clinical anatomy of the musculoskeletal system in the hip region. Anat Sci Int, 2022, 97(2): 157-164.
24. Tsutsumi M, Nimura A, Akita K. Clinical anatomy of the musculoskeletal system in the hip region. Anat Sci Int, 2022, 97(2): 157-164.
25. Tsutsumi M, Nimura A, Akita K. New insight into the iliofemoral ligament based on the anatomical study of the hip joint capsule. J Anat, 2020, 236(5): 946-953.
26. Tsutsumi M, Nimura A, Akita K. New insight into the iliofemoral ligament based on the anatomical study of the hip joint capsule. J Anat, 2020, 236(5): 946-953.
27. Tamaki Y, Goto T, Iwase J, et al. Contributions of the ischiofemoral ligament, iliofemoral ligament, and conjoined tendon to hip stability after total hip arthroplasty: A cadaveric study. J Orthop Res, 2022, 40(12): 2885-2893.
28. Tamaki Y, Goto T, Iwase J, et al. Contributions of the ischiofemoral ligament, iliofemoral ligament, and conjoined tendon to hip stability after total hip arthroplasty: A cadaveric study. J Orthop Res, 2022, 40(12): 2885-2893.
29. van Arkel RJ, Ng KCG, Muirhead-Allwood SK, et al. Capsular ligament function after total hip arthroplasty. J Bone Joint Surg (Am), 2018, 100(14): e94. doi: 10.2106/JBJS.17.00251.
30. van Arkel RJ, Ng KCG, Muirhead-Allwood SK, et al. Capsular ligament function after total hip arthroplasty. J Bone Joint Surg (Am), 2018, 100(14): e94. doi: 10.2106/JBJS.17.00251.
31. Kweon SH, Lee SH, Kook SH, et al. Outcomes of cephalomedullary nailing in basicervical fracture. Hip Pelvis, 2017, 29(4): 270-276.
32. Kweon SH, Lee SH, Kook SH, et al. Outcomes of cephalomedullary nailing in basicervical fracture. Hip Pelvis, 2017, 29(4): 270-276.
33. Yoo JI, Cha Y, Kwak J, et al. Review on basicervical femoral neck fracture: definition, treatments, and failures. Hip Pelvis, 2020, 32(4): 170-181.
34. Yoo JI, Cha Y, Kwak J, et al. Review on basicervical femoral neck fracture: definition, treatments, and failures. Hip Pelvis, 2020, 32(4): 170-181.
35. Bartoníček J, Bartoška R, Alt J, et al. Pathoanatomy of pertrochanteric fractures—a postmortem study. Injury, 2023, 54(7): 110760. doi: 10.1016/j.injury.2023.04.047.
36. Bartoníček J, Bartoška R, Alt J, et al. Pathoanatomy of pertrochanteric fractures—a postmortem study. Injury, 2023, 54(7): 110760. doi: 10.1016/j.injury.2023.04.047.
37. Li C, Zhao D, Xu X, et al. Three-dimensional computed tomography (CT) mapping of intertrochanteric fractures in elderly patients. Med Sci Monit, 2020, 26: e925452. doi: 10.12659/MSM.925452.
38. Li C, Zhao D, Xu X, et al. Three-dimensional computed tomography (CT) mapping of intertrochanteric fractures in elderly patients. Med Sci Monit, 2020, 26: e925452. doi: 10.12659/MSM.925452.
39. Fu Y, Liu R, Liu Y, et al. Intertrochanteric fracture visualization and analysis using a map projection technique. Med Biol Eng Comput, 2019, 57(3): 633-642.
40. Fu Y, Liu R, Liu Y, et al. Intertrochanteric fracture visualization and analysis using a map projection technique. Med Biol Eng Comput, 2019, 57(3): 633-642.
41. 卫禛, 熊文峰, 张世民. 转子间骨折中股骨干近侧断面环周皮质的CT影像学测量及其临床意义. 中国临床解剖学杂志, 2020, 38(6): 639-645.
42. 卫禛, 熊文峰, 张世民. 转子间骨折中股骨干近侧断面环周皮质的CT影像学测量及其临床意义. 中国临床解剖学杂志, 2020, 38(6): 639-645.
43. Futamura K, Baba T, Homma Y, et al. New classification focusing on the relationship between the attachment of the iliofemoral ligament and the course of the fracture line for intertrochanteric fractures. Injury, 2016, 47(8): 1685-1691.
44. Futamura K, Baba T, Homma Y, et al. New classification focusing on the relationship between the attachment of the iliofemoral ligament and the course of the fracture line for intertrochanteric fractures. Injury, 2016, 47(8): 1685-1691.
45. 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.
46. 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.

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Treatment of irreducible intertrochanteric femoral fracture in elderly by folding top technique combined with right-angle pliers prying and pulling under G-arm X-ray fluoroscopy

Chinese Journal of Reparative and Reconstructive Surgery

Influence of anterior fracture line on anterior cortical reduction loss after cephalomedullary nail fixation in intertrochanteric fractures

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