To the Editor:
We read the article “Intramedullary Nails Result in More Reoperations Than Sliding Hip Screws in Two-part Intertrochanteric Fractures” by Matre et al. [3] with great interest, and we congratulate the authors for their valuable contribution to the orthopaedic literature. A fracture registration system database including more than 17,000 primary operations for hip fractures is a golden opportunity. The choice of implant for stable AO 31A1 fractures is a sliding hip screw and this is textbook knowledge [1, 2] that was confirmed by this article [3].
Another generally accepted piece of textbook knowledge is that the two disadvantages of intramedullary nails are local pain and fracture about the implant [2]. Matre et al. also confirmed this by reporting the two major reasons for increased reoperations for intramedullary nails other than sliding hip screws were local pain from the implant and fracture around the implant (with p values of 0.043 and 0.027, respectively; Table 4 [3]). Another statistically significant difference was the risk of implant removal (p = 0.028), which was lower for sliding hip screws.
In their article, Matre et al. discussed the limitations of their database, and stated that they did not have the radiographs of the patients in their register. However, we believe analyzing the reasons for reoperations by depending on the radiographic images and file records (at least the failures of osteosynthesis, nonunions, cutouts, fractures around implants, and pain) would be important. In Table 4 [3], it shows there were 249 reoperations, including 189 sliding hip screws and 60 intramedullary nails. If the authors are able to review the x-rays and file records of a reasonable number of patients, perhaps as the subject of a new article, they might discuss the tip apex distance, position of the lag screw, reasons for the observed failures, pain, infection, and other reasons leading to reoperations, which we believe would be valuable contributions to the literature, and in particular would help us to distinguish implant-related from surgeon-related causes of reoperations.
Footnotes
(Re: Matre K, Havelin LI, Gjertsen JE, Espehaug B, Fevang JM. Intramedullary nails result in more reoperations than sliding hip screws in two-part intertrochanteric fractures. Clin Orthop Relat Res. 2012 Dec 7. [Epub ahead of print]
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References
- 1.AO Foundation. AO Surgery Reference. Comprehensive online reference in daily clinical life. Available at: https://www2.aofoundation.org/wps/portal/surgery?bone=Femur&segment=Proximal&classification=31-A1&showPage=indication. Accessed February 11, 2013.
- 2.Koval KJ, Cantu RV. Intertrochanteric fractures. In: Bucholz RW, Heckman JD, Court-Brown CM, editors. Rockwood and Green’s Fractures in Adults. 6. Philadelphia, PA: Lippincott Williams & Wilkins; 2006. pp. 1794–1825. [Google Scholar]
- 3.Matre K, Havelin LI, Gjertsen JE, Espehaug B, Fevang JM. Intramedullary nails result in more reoperations than sliding hip screws in two-part intertrochanteric fractures. Clin Orthop Relat Res. 2012 Dec 7. [Epub ahead of print] [DOI] [PMC free article] [PubMed]