What Is Cut Out In Cm Nail

Every bit the mean historic period of the population increases, the incidence of hip fractures is predicted to keep rising.^1,two Hip fractures are associated with substantial morbidity, mortality and cost to social club,^3-5 which is increased in the event of failure of the initial treatment in this elderly group of patients.^1,3 Intertrochanteric and subtrochanteric hip fractures are frequently fixed with a cephalomedullary (CM) nail; the most common crusade of failure of fixation is cut-out of the lag spiral.^six,vii Consequently, the ability to predict and prevent the causes of CM boom cutting-out is important.

Although predictors of lag spiral cut-out have been extensively investigated for the sliding hip screw (SHS),^viii only two previous studies take looked solely and specifically at the cutting-out rate of CM nails.^9,ten The biomechanics of lag screws differ between SHS and CM nails for two reasons; variation in the location of contact with the shaft construct, and the potential for the static locking of lag screws of CM nails using a set screw. Tip-apex distance (TAD) has been shown to be an of import predictor for cut-out in CM nails⁸ (Fig. 1) and favours cardinal–central positioning of the lag screw.⁶ Although there is full general consensus that a central position on the lateral view is optimal,^six,11-xv there is continuing argue nigh the ideal position of the lag screw on the anteroposterior (AP) view, with support for both deep, central placement^{half dozen,eleven,12,16} and inferior placement.^{13-15,17-nineteen} It is therefore useful to evaluate alternate measurement techniques for predicting cut-out which favour a more junior placement of the lag screw. The calcar referenced tip-apex altitude (CalTAD) is a novel measurement tool that favours inferior-primal lag screw placement (Fig. 1).¹⁸ The purpose of this study was to place factors which predict cut-out afterwards intramedullary nailing of intertrochanteric and subtrochanteric fractures of the hip.

Figs. 1a - 1b The calcar referenced tip-apex distance (CalTAD) is a novel measurement tool that uses the same measurement technique as the tip-apex altitude (TAD) in the lateral view, but differs in the anteroposterior (AP) view. Figure 1a - TAD in the AP view (TAD_AP)is measured past determining the apex of the femoral head using a guideline through the midline of the femoral head (in mm). Figure 1b - CalTAD in the AP view (CalTAD_AP) is measured (in mm) by moving this guideline to be adjacent to the medial cortex of the femoral neck. TAD in the lateral view (TAD_LAT) is added to both these measurements to obtain TAD and CalTAD respectively.

Patients and Methods

All patients who were treated with a CM nail for an inter- or sub-trochanteric fracture between February 2003 and April 2013 were retrospectively reviewed (n = 170). Patient records were reviewed for historic period at the time of operation, gender, engagement of operation, date of last clinical follow-upwards and type of CM nail used. The lag screws in all CM nails were locked to the smash using a set spiral. Exclusion criteria included patients with a pathological fracture and those who did not have radiological follow-up at least 80 days post-operatively. In all, 77 of the 170 fractures reviewed (xv men and 62 women), with a hateful age of 77.6 years (23 to 100) met the inclusion criteria for the study (Tabular array I).

Table I Univariate analysis. Pregnant p-values (p < 0.01) are indicated in bold

Factor*	All	No cut-out (n = 67 (%))	Cutting-out (n = ten(%))	p-value	Odds ratio	95% CI for odds ratio
Age	77.six (23 to 100)	77.1 (23 to 100)	81.5 (56 to 93)	0.325	0.969	0.906 to 1.033
Gender				i.000	0.963	0.182 to 5.083
Male	15 (19)	13 (87)	2 (13)
Female person	62 (81)	54 (87)	8 (xiii)
Side				0.507	0.421	0.148 to 2.222
Left	xl (52)	36 (xc)	4 (x)
Right	37 (48)	31 (84)	six (sixteen)
Fracture blazon				0.197	undefined
Intertrochanter	55 (80)	52 (84)	10 (16)
Subtrochanter	13 (twenty)	13 (100)	0 (0)
AO classification				0.381
31.A1	four (v.2)	four (100)	0 (0)
31.A2	21 (27.3)	xviii (86)	three (xiv)
31.A3	37 (48.i)	30 (82)	7 (18)
32	xiii (16.9)	13 (100)	0 (0)
Mixed	2 (two.6)	two (100)	0 (0)
Fracture stability (intertrochanter)				0.610	undefined
Stable	four (5.2)	4 (100)	0 (0)
Unstable	60 (77.9)	50 (83)	10 (17)
Nail blazon				0.175	2.688	0.690 to 10.473
Natural smash	30 (39)	24 (eighty)	6 (twenty)
ITST	47 (61)	43 (91)	iv (ix)
Cervical angle difference†	half-dozen.forty (-12 to 25)	5.32 (-12 to 15)	13.2 (1 to 25)	0.004	ane.237	1.072 to one.426
Parker's ratio index (AP)	0.557 (0.350 to 0.762)	0.545 (0.350 to 0.702)	0.633 (0.469 to 0.762)	0.003	0.000	0.000 to 0.002
Parker's ratio index (LAT)	0.492 (0.299 to 0.716)	0.489 (0.360 to 0.676)	0.510 (0.299 to 0.716)	0.437	0.041	0.000 to 128.98
Lag spiral placement (AP)				0.014	0.072	0.010 to 0.505
Central	72 (94)	65 (90)	seven (x)
Superior	5 (6)	two (40)	3 (60)
Inferior	0 (0)	0 (0)	0 (0)
Lag spiral placement (LAT)				0.123
Anterior	3 (4)	2 (67)	1 (33)
Key	72 (94)	64 (89)	viii (xi)
Posterior	1 (1)	0 (0)	ane (100)
TAD (mm)	17.78 (7.75 to 48.98)	fifteen.98 (7.75 to 29.25)	29.66 (21.14 to 48.98)	< 0.001	0.679	0.550 to 0.839
CalTAD (mm)	xviii.50 (half dozen.47 to 40.88)	sixteen.67 (half dozen.47 to 27.02)	30.61 (20.98 to twoscore.88)	0.001	0.571	0.405 to 0.804
Singh Osteoporosis Index	iv.20	4.23	four.00	0.575	1.193	0.643 to 2.216
I	0 (0)	0 (0)	0 (0)
II	4 (6)	3 (75)	1 (25)
III	18 (27)	xv (83)	3 (17)
IV	12 (xviii)	xi (92)	1 (eight)
V	25 (38)	22 (88)	iii (12)
Six	7 (11)	6 (86)	ane (14)
Reduction quality				0.575
Good	25 (32)	23 (92)	two (8)
Acceptable	19 (25)	17 (89)	2 (11)
Poor	33 (43)	27 (82)	vi (18)

Pre-operative radiographs were reviewed by two of the authors (AK and MJG) to identify the type of fracture and fracture stability. Discrepancies in classification were resolved through the aid of a third author (PRTK). Based on the Orthopaedic Trauma Clan (AO) fracture classification, the fractures were grouped into classes 31.A1, 31.A2, 31.A3 and 32.^xx Intertrochanteric fractures were categorised as stable (A1) or unstable (A2, A3). The severity of osteoporosis at the time of fracture was determined from contralateral radiographs using the Singh Osteoporosis Alphabetize.²¹ All patients who had contralateral implants at the time of fracture diagnosis were excluded from this measurement.

Immediate postal service-operative radiographs were used to measure the TAD and CalTAD through the aid of an in-firm movie archiving and communication system (PACS) tool (Fig. 1). AP and lateral placement of the lag screws were measured using Parker's ratio index.¹³ Furthermore, the femoral head was divided into three regions on the AP (superior, central, junior) and lateral views (anterior, cardinal, posterior), and the placement of the lag screw was based on these regions as first reported by Cleveland et al.²²

Difference in neck angle was measured between the contralateral femoral neck angle and the reduced femoral neck bending. The quality of the reduction was categorised into three grades based on a modification of the method adult by Baumgaertner et al.⁶ The start criterion used was an AP neck angle of 120° to 135° and a lateral angulation <  20°. The second criterion used was the presence of < 4 mm of displacement of any fragments in the AP and lateral views. A reduction was categorised every bit skillful if both criteria were met, acceptable if merely i criterion was met and poor if neither criterion was met.

Statistical analysis

Statistical analysis was performed using SPSS version 21 (SPSS Inc., Chicago, Illinois). The Chi-foursquare test and binary logistic regression were used for univariate analysis of the categorical and continuous parameters, respectively. To business relationship for the small sample size, significance was defined as p < 0.01. A multivariate analysis was performed with all the parameters with p < 0.05 in the univariate assay. Historic period and gender were included every bit potential confounders. A backwards likelihood ratio was performed to identify the all-time-fit model, with the entry set at p < 0.05 and removal at p > 0.ten. The Nagelkerke pseudo R-squared was calculated to judge the fit of the logistic regression model to the data (a value of ane indicating a perfect fit).

Inter-observer reliability was calculated for all parameters that were significant in the univariate analysis. A 2-way random-effects model with a 95% confidence interval was used to make up one's mind the mean measures intra-class correlation coefficient (ICC). In accordance with Landis and Koch,²³ the ICC estimation scale used was: poor to fair (< 0.4), moderate (0.41 to 0.60), excellent (0.61 to 0.80) and almost perfect (0.81 to 1). For categorical data, κ co-efficients were calculated using 95% CI.

Results

There were a full of 77 fractures in 73 patients; four of the patients included in the study underwent carve up cephalomedullary nailing of each of their femurs during the study period. The hateful radiological follow-upwards time for the fractures was 408 days (81 days to iv.9 years).

There were 62 intertrochanteric fractures, thirteen subtrochanteric fractures, and two fractures with both intertrochanteric and subtrochanteric components. The intertrochanteric fractures were further subcategorised co-ordinate to the AO nomenclature into 4 A1 (vi.5%), 21 A2 (33.9%), and 37 A3 (59.7%). A full of four of the 64 (6.3%) fractures classified as intertrochanteric or mixed were considered to be stable.

Univariate assay

A full of ten cut-outs occurred (13%), for which the hateful follow-up was 243 days (34 to 709 days). Age (p = 0.325), gender (p = 0.963), and fracture side (p = 0.421) were non statistically unlike between the two groups. Although in that location were no cut-outs amidst the subtrochanteric fractures, there was no statistically significant divergence between the intertrochanteric and the subtrochanteric fractures (p = 0.197). Amid intertrochanteric fractures, stability was also not significant (p = 0.610).

Two types of cephalomedullary boom were used during this time: ITST nails (Zimmer, Warsaw, Indiana) and Natural Nail cephalomedullary nails (Zimmer). The diameters of the lag screws for these devices were 11 mm and 10.5 mm, respectively. In that location were no statistical differences between the two types of nail (p = 0.175).

Parameters that were establish to be significant included: TAD (p < 0.001), CalTAD (p = 0.001), neck angle difference (p = 0.004), and Parker's ratio alphabetize in the AP view (p = 0.003). A higher TAD and a higher CalTAD were associated with nail cut-out. A college Parker'south ratio¹³ in the AP view (more superior placement of nail) was also associated with cutting-out. There was no statistical significance to Parker's ratio in the lateral view (p = 0.437). When categorised according to Cleveland's method,²² a superior screw placement in the AP view was not statistically associated with cut-out based on a p-value cut-off of 0.01 (p = 0.014). No significance was seen in the placement of the screw in the lateral view (p = 0.123).

Based on the modified Baumgaertner'south classification,⁶ the quality of reduction of the fractures was divided into 25 good (32.5%), 19 acceptable (24.7%) and 33 poor (42.9%). Reduction quality was not constitute to be statistically significant (p = 0.575). The Singh Osteoporosis Index was likewise non significant (p = 0.575).

Inter-observer reliability

The ICC was calculated for all continuous significant parameters from the univariate assay (Table II). For both TAD and CalTAD, the mean measures of ICC were > 0.8, indicating an almost perfect reliability with these measures.²³ Deviation in neck angle had moderate reliability, whereas Parker's ratio¹³ index in the AP view had about perfect reliability. The κ coefficient was calculated for Cleveland's²² lag spiral placement in the AP view and showed poor reliability (κ < 0).

Table II Reliability betwixt the two observers for significant variables.

Factor	Mean measures intra-class correlation coefficient (κ)	95% CI
Cervical angle divergence	0.516	-0.948 to 0.880
Parker'due south ratio index (AP)	0.837	0.393 to 0.956
Cleveland's lag screw placement (AP)	-100	0.732 to 1.107
TAD	0.915	0.684 to 0.977
CalTAD	0.901	0.633 to 0.973

Multivariate analysis

The multivariate model included age, gender, and all parameters with p < 0.05 in the univariate analysis. Statistical significance was observed only with CalTAD (p = 0.001) (Table 3). The Nagelkerke pseudo R-squared value for the logistic regression model was 0.78, indicating that the model fit the data very well.

Table III Multivariate analysis

Factor	p-value	Odds ratio	95% Confidence intervals for odds ratio
Historic period	0.472
Gender	0.398
Cervical bending difference	0.299
Parker's ratio index (AP)	0.369
Cleveland'due south lag screw placement (AP)	0.915
TAD	0.594
CalTAD	0.001	0.576	0.409 to 0.809

Word

A number of handling options are available for hip fractures which include plates, nails and screws.²⁴ Fixation with a stock-still-angle device, such as a sliding hip screw (SHS) plate or CM nail, is the preferred treatment option for intertrochanteric fractures of the hip.²⁵ CM nailing has proved peculiarly popular for the treatment of unstable intertrochanteric and subtrochanteric hip fractures.²⁶ Compared with SHS, CM nailing is associated with a shorter operating time, reduced intra-operative blood loss, and improved walking ability in unstable hip fractures.^27-29 A full of two previous studies found loftier TAD values to be a significant predictor of cut-out of IM nails.^9,10 Our study further confirms this.

A more than varus reduction has been associated with a higher cutting-out rate later on SHS fixation.^eleven,30 Although Lobo-Escolar et al¹⁰ did not observe a meaning relationship between the reduction angle and CM nail cut-outs, our report shows a significant association between a more varus reduction (compared with the contralateral unaffected hip) and cut-out (p = 0.004). Farther studies are therefore required to confirm this clan in patients who undergo CM nailing.

We did not find any pregnant relationship between the Singh Osteoporosis Alphabetize and rate of cut-out.²¹ This contradicts the findings of Lobo-Escolar et al,¹⁰ which might be explained by poor inter- and intra-observer agreement for this measurement.³¹

In terms of lag screw placement in the lateral view, we found no meaning association with Parker's ratio alphabetize or Cleveland'southward method of categorisation.^thirteen,22 We had a very pocket-sized number of cases of eccentric placement of a lag spiral in the lateral view (iv of 77 fractures). At that place is, nonetheless, a clear tendency towards a higher rate of cutting-out with non-cardinal placement of the lag screw (fifty% versus eleven%). This is in agreement with previous studies and confirms that primal placement of the lag spiral in the lateral view is ameliorate.^6,11-15

In terms of lag screw placement on the AP view, nosotros plant a higher Parker's ratio^thirteen (more superior lag screw placement) to be significantly associated with an increased charge per unit of cut-out. There is a generalised consensus in the literature that placing the lag screw in the upper part of the femoral caput increases the hazard of cut-out. Nevertheless, opinion remains divided every bit to whether deep and central^6,xi,12,xvi or inferior^{13-fifteen,17} placement of the lag screw is better.

A recent biomechanical written report by Kuzyk et al¹⁸ establish that inferior placement of the lag spiral gives the highest axial and torsional stiffness. In a finite element written report, Goffin et al¹⁹ have also shown that inferior heart and junior posterior positions are to be preferred, which argues confronting the accuracy of a TAD > 25 mm cut-off for prediction of cut-out, as TAD measurement suggests a higher rate of cut-out with a more inferior placement of the lag screw and favours a primal–cardinal placement.

CalTAD differs from TAD just in the AP view, with the noon of the femoral head determined using a line parallel to the femoral cervix that runs adjacent to the calcar instead of the centre of the femoral neck. Information technology therefore favours inferior–cardinal placement of the lag screw. The significance of CalTAD in both the univariate (p < 0.01) and the multivariate (p < 0.05) assay, along with the excellent inter-observer reliability seen in this written report, supports its use as a predictor of cut-out for CM nails.

Interestingly, there were no failures in any of the xiii pure subtrochanteric fractures. In this group a central–central lag spiral position was noted in 11 and a superior–cardinal screw position in two. The absenteeism of failure in this grouping may be the result of stabilisation of the proximal fragment past the nail itself every bit the fracture behaves biomechanically more like a fracture of the femoral shaft than a fracture of the hip: lag spiral position may non therefore be as important. Yet, we are aware that the lag screws were poorly placed in just two patients: consequently we cannot say definitively that poor lag spiral placement is not of concern.

The limitations of our study include its retrospective design and the limited sample size owing to poor patient compliance with follow-upwards. This can be explained by the older patient population studied (mean 77.half-dozen years old, 23 to 100). Equally a event, only 77 of the 170 fractures reviewed met the inclusion criterion of at least 80 days of follow-up. Our investigation provides the beginning wait at CalTAD as a predictor of cut-out in this patient population. Although no cut-out was seen with a CalTAD < 20.98 mm, prospective studies are needed to investigate the affect of using a CalTAD cut-off guideline intra-operatively for the prevention of cut-out.

In conclusion, our study addresses the paucity of literature currently available concerning the predictors of cutting-out in IM smash fixation of hip fractures.^9,10 Information technology supports the validity of TAD every bit a predictor of cut-out in this patient population. It further confirms the findings from previous biomechanical,¹⁸ mathematical¹⁹ and clinical^13-xv,17 studies suggesting that the inferior placement of a lag screw reduces cut-out. It provides the first clinical evidence behind the validity and reliability of CalTAD as a predictor of lag screw cut-out, a measurement method that favours the junior–central region for siting the lag spiral. Prospective studies are needed to validate the use of CalTAD in the operating theatre as a guide for surgeons in the prevention of cutting-out in this grouping of patients.

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