Computer-Assisted Intramedullary Nailing of Intertrochanteric Fractures Did Not Prevent Tip-Apex Distance Outliers

Intertrochanteric femoral fractures are commonly treated with intramedullary nails (IMNs). A tip-apex distance (TAD) of more than 20-25 mm is associated with an increased risk of cut-out. The Stryker Adaptive Positioning System (ADAPT) is a computer-assisted navigation system designed to reduce TADs. We aim to assess if the ADAPT reduces the number of outliers with a TAD > 20 mm. All patients with intertrochanteric fractures treated with an IMN between 1 September 2020 and 12 March 2022 were included. Patients were included in three periods: a pre-ADAPT period (55 patients); an ADAPT period (50 patients), where it was compulsory to use the system; and a post-ADAPT period after the discontinuation of the system (59 patients). The TADs and lag screw protrusions beyond the lateral cortex were measured. The median TADs in the three periods were 17.0 mm (8-31 mm), 15.5 mm (9-30 mm), and 18.0 mm (11-32 mm), respectively. The absolute number of outliers with a TAD > 20 mm decreased from 15/55 patients in the pre-ADAPT period to 11/50 patients during the ADAPT period. This observation was not statistically significant, but this is likely due to the lack of power of the present study to show changes of this magnitude. However, our expectation that the ADAPT would diminish outliers markedly or close to zero outliers was not met, as we observed 11/50 = 22% outliers with a TAD > 20 mm when using computer-assisted surgery, i.e., ADAPT and Gamma3 for intertrochanteric fractures. Based on these findings, the use of the ADAPT was discontinued at our level 1 trauma center.