Intraoperative assessment of reduction quality during nail fixation of intertrochanteric fractures. Issue 2 (February 2020)

• Record Type: Journal Article
• Authors: Yoon, Yong-Cheol; Oh, Chang-Wug; Sim, Jae-Ang; Oh, Jong-Keon
• Is Part Of: Injury. Volume 51:Issue 2(2020)
• Page Start: 400
• Page End: 406
• Publication Date: 2020-02
• Subjects: Intraoperative reduction assessment -- Intertrochanteric fracture -- Image intensifier; Wounds and injuries -- Surgery -- Periodicals; Accidents -- Periodicals; Wounds and Injuries -- surgery -- Periodicals; Lésions et blessures -- Chirurgie -- Périodiques; Electronic journals; Electronic journals; 617.1
• DOI: 10.1016/j.injury.2019.10.087
• Languages: English
• ISSNs: 0020-1383

Abstract

Highlights: This study is the first to intraoperatively assess implant position and reduction adequacy and also compare clinical outcomes. AO/OTA 31A2 and 31A3 fractures require active intervention by the surgeon. Anteromedial cortex reduction with neck-shaft angle and anteversion restoration are essential for femoral intertrochanteric fractures. Abstract: Background: The quality of intertrochanteric fracture reduction has traditionally been evaluated using simple radiographs. However, subjective intraoperative evaluation and efforts to achieve a perfect reduction are essential for optimal outcomes. This study aimed to establish criteria for the intraoperative assessment of the quality of intertrochanteric fracture reduction and also analyzed postoperative outcomes in terms of reduction quality. Methods: This study included 106 patients who received cephalo-medullary nailing for the treatment of intertrochanteric fractures between March 2012 and May 2016 and were followed-up for at least 1 year. An image intensifier was used intraoperatively to evaluate reduction quality by examining the restoration of anteromedial cortex continuity, and neck-shaft angle and anteversion. Based on the reduction quality, the patients were classified into optimal, acceptable, and unacceptable groups, with intervention provided for the unacceptable group. The need for revision surgery and the degree of blade sliding were assessed, and postoperative outcomes related to implant position were analyzed. Results: Over 50% of patients with Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) type 31A2 and A3 fractures were assigned to the unacceptable group after closed reduction ( P = 0.006), and 60 cases required additional reduction. Approximately 40% of cases classified as clinically unacceptable required revision, and the rate of sliding was ≥2-fold higher in the unacceptable group than those in the optimal and acceptable groups ( P = 0.015), with an average excessive sliding of 9.85 mm. Regarding implant position, cut-out or penetration were observed in cases with superiorly-located blades ( P = 0.039). Conclusions: Good outcomes cannot be achieved with traction alone for femoral intertrochanteric fractures. Active management is required because accurate anteromedial cortex reduction, and restoration of neck-shaft angle and anteversion are essential in femoral intertrochanteric fractures.