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Medial Calcar Comminution and Intramedullary Nail Failure in Unstable Geriatric Trochanteric Hip Fractures
Seth M Tarrant1,2, David Graan1,2, Drew J Tarrant1
1Department of Traumatology, John Hunter Hospital, Lookout Rd, New Lambton Heights, NSW 2305, Australia.
Insights
In unstable geriatric hip fractures, younger patient age, not implant length, predicts fixation failure. This finding is crucial for optimizing treatment strategies in an aging population.
Area of Science:
- Orthopedic Surgery
- Geriatric Trauma
- Biomechanical Engineering
Background:
- Geriatric hip fractures present a growing global health challenge, demanding efficient treatment strategies.
- Trochanteric fractures are common, with medial calcar stability being critical for successful outcomes.
- Existing literature on unstable trochanteric fractures has limitations, including small sample sizes and varied definitions of stability.
Purpose of the Study:
- To investigate factors predicting fixation failure in unstable geriatric trochanteric hip fractures.
- To evaluate the impact of implant (nail) length and medial calcar comminution on fracture stability and outcomes.
- To identify reliable predictors of treatment failure in this patient population.
Main Methods:
- Retrospective analysis of 617 operatively treated unstable trochanteric hip fractures (AO/OTA 31A2.3, A2.3, & A3.3) between 2012-2017.
- Comparison of treatment using long versus short intramedullary trochanteric nails.
- Competing risk regression analysis to assess predictors of fixation failure, with post-operative death as a competing event.
Main Results:
- Fixation failure occurred in 2.6% of patients (16 out of 617) at a median of 111 days post-operatively.
- Younger patient age was the sole significant predictor of fixation failure in both univariate and multivariate analyses (SHR: 0.91, p < 0.001).
- Implant length, degree of medial calcar loss, and reduction quality did not significantly influence nail failure rates.
Conclusions:
- In unstable geriatric trochanteric hip fractures with medial calcar insufficiency, younger patient age is the primary predictor of fixation failure.
- Neither the length of the intramedullary nail nor the extent of medial calcar comminution reliably predicts failure in this cohort.
- These findings suggest a need to re-evaluate treatment assumptions regarding implant length in managing these complex fractures.
Abstract:
Background and Objectives: An increasing global burden of geriatric hip fractures is anticipated. The appropriate treatment for fractures is of ongoing interest and becoming more relevant with an aging population and finite health resources. Trochanteric fractures constitute approximately half of all hip fractures with the medial calcar critical to fracture stability. In the management of unstable trochanteric fractures, it is assumed that intramedullary nails and longer implants will lead to less failure. However, the lack of power, inclusion of older generation femoral nails, and a variable definition of stability complicate interpretation of the literature. Materials and Methods: Between January 2012 and December 2017, a retrospective analysis of operatively treated geriatric trochanteric hip fracture patients were examined at a Level 1 Trauma Centre. The treatment was with a long and short version of one type of trochanteric nail. Unstable trochanteric fractures with medial calcar comminution were examined (AO31A2.3, 2.3 & 3.3). The length of the medial calcar loss, nail length, demographics, fracture morphology, and relevant technical factors were examined in univariate and multivariate analysis using competing risk regression analysis. The primary outcome was failure of fixation with post-operative death the competing event and powered to previously reported failure rates. Results: Unstable patterns with medial calcar comminution loss constituted 617 (56%) of operatively treated trochanteric fractures. Failure occurred in 16 (2.6%) at a median post-operative time of 111 days (40-413). In univariate and multivariate analysis, only younger age was a significant predictor of failure (years; SHR: 0.91, CI 95%: 0.86-0.96, p < 0.001). Nail length, medial calcar loss, varus reduction, and other technical factors did not influence nail failure. Conclusions: In a cohort of unstable geriatric trochanteric hip fractures with medial calcar insufficiency, only younger patient age was predictive of nail failure. Neither the length of the medial calcar fragment or nail was predictive of failure.
