Table 1.
Demographics/characteristics of patients with a subtrochanteric fracture treated with a long cephalomedullary nail, stratified according to re-operation
| All patients | No re-operation | Re-operation | |
|---|---|---|---|
| Demographics | |||
| Total number | 309 | 240 (77.7%) | 69 (22.3%) |
| Age < 75 y.o. | 143 (46.3%) | 99 (41.2%) | 44 (63.8%) |
| Gender | |||
| Male | 111 (35.9%) | 85 (35.4%) | 26 (37.7%) |
| Female | 198 (64.1%) | 155 (64.6%) | 43 (62.3%) |
| Injury characteristics | |||
| Mechanism of injury | |||
| Low energy | 244 (78.9%) | 197 (82.1%) | 47 (68.1%) |
| High energy | 47 (15.2%) | 32 (13.3%) | 15 (21.7%) |
| Pathological | 18 (5.8%) | 11 (4.6%) | 7 (10.1%) |
| Isolated | 266 (86.1%) | 206 (85.8%) | 60 (87.0%) |
| ISS > 16 | 18 (5.8%) | 13 (5.4%) | 5 (7.2%) |
| Side | |||
| Left | 161 (52.1%) | 119 (49.6%) | 42 (60.9%) |
| Right | 148 (47.9%) | 121 (50.4%) | 27 (39.1%) |
| Open fracture | 3 (0.9%) | 1 (0.4%) | 2 (2.9%) |
| Medical comorbidities | |||
| ASA | |||
| 1 | 28 (9.1%) | 21 (8.8%) | 7 (10.1%) |
| 2 | 93 (30.1%) | 66 (27.5%) | 27 (39.1%) |
| 3 | 148 (47.9%) | 118 (49.2%) | 30 (43.5%) |
| 4 | 40 (12.9%) | 35 (14.6%) | 5 (7.2%) |
| Charlson Comorbidity Score | 4.97 (2.95) | 5.20 (2.92) | 4.16 (2.92) |
| Diabetes | 46 (14.9%) | 39 (16.2%) | 7 (10.1%) |
| Steroids | 17 (5.5%) | 15 (6.2%) | 2 (2.9%) |
| Malignancy | 72 (23.3%) | 55 (22.9%) | 17 (24.6%) |
| Dementia | 44 (14.2%) | 41 (17.1%) | 3 (4.3%) |
| Osteoporosis | |||
| Bisphosphonates pre-admission | 63 (20.4%) | 47 (19.6%) | 16 (23.2%) |
| Bisphosphonates on discharge | 90 (29.1%) | 71 (29.7%) | 19 (27.9%) |
| Calcium/vitamin D pre-admission | 93 (30.1%) | 76 (31.7%) | 17 (24.6%) |
| Calcium/vitamin D on discharge | 155 (50.2%) | 126 (52.7%) | 29 (42.6%) |
| Vitamin D loading on admission | 42 (13.6%) | 37 (15.5%) | 5 (7.4%) |
| Fragility fractures before | 61 (19.7%) | 50 (20.8%) | 11 (15.9%) |
| Fragility fractures after | 67 (21.7%) | 51 (21.2%) | 16 (23.2%) |
| Social history | |||
| Smoking | 62 (20.1%) | 39 (16.2%) | 23 (33.3%) |
| Alcohol > 10 units/week | 63 (20.4%) | 44 (18.3%) | 19 (27.5%) |
| Pre-operative mobility | |||
| Independent | 161 (52.1%) | 120 (50.0%) | 41 (59.4%) |
| Stick(s)/crutch(es) | 98 (31.7%) | 77 (32.1%) | 21 (30.4%) |
| Frame | 37 (11.9%) | 32 (13.3%) | 5 (7.2%) |
| Wheelchair/hoisted | 13 (4.2%) | 11 (4.6%) | 2 (2.9%) |
| Frequent falls | 85 (27.5%) | 68 (28.3%) | 17 (24.6%) |
| Operation characteristics | |||
| Operation in less than 48 h | 245 (79.3%) | 194 (80.8%) | 51 (73.9%) |
| Simultaneous procedures | 23 (7.4%) | 19 (7.9%) | 4 (5.8%) |
| Type of nail | |||
| Long Affixus nail | 170 (55.0%) | 143 (59.6%) | 27 (39.1%) |
| Long Gamma nail | 139 (44.9%) | 97 (40.4%) | 42 (60.9%) |
| Nail diameter (mm) | |||
| 9 | 14 (4.5%) | 10 (4.2%) | 4 (5.9%) |
| 11 | 202 (65.4%) | 156 (65.5%) | 46 (67.6%) |
| 13 | 90 (29.1%) | 72 (30.3%) | 18 (26.5%) |
| Open reduction | 148 (47.9%) | 110 (45.8%) | 38 (55.1%) |
| Use of cerclage wires | 43 (13.9%) | 37 (15.4%) | 6 (8.7%) |
| Post-op mobilisation (first 6 weeks) | |||
| FWB | 151 (48.9%) | 124 (51.7%) | 27 (39.1%) |
| PWB | 76 (24.6%) | 57 (23.8%) | 19 (27.5%) |
| TTWB | 50 (16.2%) | 37 (15.4%) | 13 (18.8%) |
| NWB | 32 (10.4%) | 22 (9.2%) | 10 (14.5%) |
| Surgical time (min) | 111.20 (43.61) | 108.95 (42.50) | 119 (46.75) |
| Anaesthetic time (min) | 48.91 (22.89) | 49.03 (22.93) | 48.48 (22.91) |
| Time from induction to recovery (min) | 179.75 (49.73) | 177.56 (48.86) | 187.36 (52.28) |
| Level of first surgeon | |||
| Registrar | 192 (62.1%) | 148 (61.9%) | 44 (63.8%) |
| Consultant | 116 (37.5%) | 91 (38.1%) | 25 (36.2%) |
| Level of senior surgeon present | |||
| Registrar | 141 (45.6%) | 137 (57.3%) | 41 (59.4%) |
| Consultant | 130 (42.1%) | 102 (42.7%) | 28 (40.6%) |
| Complications | |||
| Failure at lag screw junction* | 24 (7.8%) | 7 (2.9%) | 17 (24.6%) |
| Self-dynamisation | 20 (6.5%) | 8 (3.3%) | 12 (17.4%) |
| Cut-out** | 7 (2.3%) | 1 (0.4%) | 6 (8.7%) |
| Nail infection | 5 (1.6%) | 0 (0.0%) | 5 (7.2%) |
| Peri-implant fracture | 8 (2.6%) | 5 (2.1%) | 3 (4.3%) |
| Non-union*** | 74 (23.9%) | 28 (11.7%) | 46 (66.7%) |
| HAP/CAP | 45 (14.6%) | 35 (14.6%) | 10 (14.5%) |
| UTI | 43 (13.9%) | 37 (15.4%) | 6 (8.7%) |
| Fracture-related infection | 11 (3.6%) | 2 (0.8%) | 9 (13.0%) |
| Revision for fracture-related infection | 5 (1.6%) | 0 (0%) | 5 (7.4%) |
| CKD stage pre-operatively | |||
| Mild | 211 (68.3%) | 159 (67.9%) | 52 (75.4%) |
| Moderate/severe | 92 (29.8%) | 75 (32.1%) | 17 (24.6%) |
| CKD stage post-operatively | |||
| Mild | 220 (71.2%) | 166 (71.6%) | 54 (79.4%) |
| Moderate/severe | 80 (25.9%) | 66 (28.4%) | 14 (20.6%) |
| Pre-operative transfusion | 22 (7.1%) | 19 (7.9%) | 3 (4.3%) |
| Post-operative transfusion (48 h) | 190 (61.5%) | 142 (59.2%) | 48 (69.6%) |
| Hb drop (g/L) | 43.24 (18.04) | 43.17 (17.63) | 43.46 (19.48) |
| Radiographic measurements | |||
| Femoral neck shaft angle† | |||
| Normal | 209 (67.6%) | 156 (65.5%) | 53 (77.9%) |
| Coxa valga | 83 (26.9%) | 76 (31.9%) | 7 (10.3%) |
| Coxa vara | 14 (4.5%) | 6 (2.5%) | 8 (11.8%) |
| Number of fragments (comminution) | |||
| Simple | 90 (29.1%) | 69 (28.7%) | 21 (30.4%) |
| Moderate | 147 (47.6%) | 122 (50.8%) | 25 (36.2%) |
| Severe | 72 (23.3%) | 49 (20.4%) | 23 (33.3%) |
| Isolated subtrochanteric extension | 50 (16.2%) | 38 (15.8%) | 12 (17.4%) |
| Distal extension**** | 116 (37.5%) | 91 (37.9%) | 25 (36.2%) |
| Lesser trochanter fracture | 202 (65.4%) | 157 (65.4%) | 45 (65.2%) |
| Medial calcar comminution | 22 (7.1%) | 16 (6.7%) | 6 (8.7%) |
| Lateral cortex gap size (mm) | |||
| ≤ 4 | 183 (59.2%) | 156 (65.0%) | 27 (39.1%) |
| 5–9 | 86 (27.8%) | 59 (24.6%) | 27 (39.1%) |
| ≥ 10 | 40 (12.9%) | 25 (10.4%) | 15 (21.7%) |
| Medial cortex gap size (mm) | |||
| ≤ 4 | 208 (67.3%) | 169 (70.4%) | 39 (56.5%) |
| 5–9 | 69 (22.3%) | 49 (20.4%) | 20 (29.0%) |
| ≥ 10 | 32 (10.4%) | 22 (9.2%) | 10 (14.5%) |
| Anterior cortex gap size (mm) | |||
| ≤ 4 | 199 (64.4%) | 160 (66.7%) | 39 (56.5%) |
| 5–9 | 61 (19.7%) | 49 (20.4%) | 15 (21.7%) |
| ≥ 10 | 46 (14.9%) | 31 (12.9%) | 15 (21.7%) |
| Posterior cortex gap size (mm) | |||
| ≤ 4 | 234 (75.7%) | 193 (80.4%) | 41 (59.4%) |
| 5–9 | 57 (18.4%) | 37 (15.4%) | 20 (29.0%) |
| ≥ 10 | 18 (5.8%) | 10 (4.2%) | 8 (11.6%) |
| Reduction angle grouped ‡ (degrees) | |||
| Valgus 5–varus 5 | 218 (70.6%) | 184 (76.7%) | 34 (49.3%) |
| Valgus > 5 | 17 (5.5%) | 13 (5.4%) | 4 (5.8%) |
| Varus 5–10 | 56 (18.1%) | 35 (14.6%) | 21 (30.4%) |
| Varus > 10 | 18 (5.8%) | 8 (3.3%) | 10 (14.5%) |
| Anti-rotation screw | 101 (32.7%) | 84 (35.0%) | 17 (24.6%) |
| TAD (mm) | |||
| < 25 | 271 (87.7%) | 214 (89.5%) | 57 (82.6%) |
| ≥ 25 | 37 (11.9%) | 25 (10.5%) | 12 (17.4%) |
| Distal locking (number of screws) | |||
| 1 | 11 (3.6%) | 11 (4.6%) | 0 (0.0%) |
| 2 | 298 (96.4%) | 229 (95.4%) | 69 (100.0%) |
| Method of locking | |||
| Static locking | 201 (65.0%) | 158 (66.1%) | 43 (62.3%) |
| Secondary dynamisation | 105 (33.9%) | 79 (33.1%) | 26 (37.7%) |
| Dynamic | 2 (0.6%) | 2 (0.8%) | 0 (0.0%) |
| Distance of tip of the nail from centre (AP) (mm) | |||
| −4 to 4 | 196 (63.4%) | 154 (64.4%) | 42 (60.9%) |
| Lateral ≥ 5 | 63 (20.4%) | 51 (21.3%) | 12 (17.4%) |
| Medial ≥ 5 | 49 (15.9%) | 34 (14.2%) | 15 (21.7%) |
| Distance of tip of the nail from centre (LAT) (mm) | |||
| −4 to 4 | 244 (78.9%) | 187 (78.2%) | 57 (82.6%) |
| Anterior ≥ 5 | 58 (18.8%) | 47 (19.7%) | 11 (15.9%) |
| Posterior ≥ 5 | 6 (1.9%) | 5 (2.1%) | 1 (1.4%) |
| Distance of tip of the nail from knee (mm) | |||
| < 10 | 2 (0.6%) | 2 (0.8%) | 0 (0.0%) |
| 10 to 19 | 23 (7.4%) | 15 (6.3%) | 8 (11.6%) |
| 20–29 | 96 (31.1%) | 79 (33.1%) | 17 (24.6%) |
| ≥ 30 | 187 (60.5%) | 143 (59.8%) | 44 (63.8%) |
| Nail/canal ratio | 0.83 (0.07) | 0.82 (0.08) | 0.83 (0.07) |
| Hospital stay/mortality | |||
| HDU/ICU stay | 32 (10.4%) | 25 (10.4%) | 7 (10.1%) |
| Total length of hospital stay (days) | 21.76 (19.58) | 22.24 (19.13) | 20.09 (21.13) |
| Died within a year | 17 (5.5%) | 14 (5.8%) | 3 (4.3%) |
Dichotomous variables are presented as absolute numbers (percentages) of the positive event
Continuous variables are presented as mean (SD)
* Seven patients in the “no re-operation” group had a failure of the nail at the lag screw junction; this happened at a later stage following the primary operation (> 6 months), and patients either had minimal or no symptoms or were unfit for an operation; therefore, conservative management was deemed appropriate
** One patient presenting with lag screw cut-out was unfit for an operation and was managed conservatively
*** Even though 28 patients in the “no re-operation” group had an established non-union, they were managed conservatively because they had minimal or no symptoms or were unfit for an operation
**** More than 5 cm distal to the lesser trochanter
† Femoral neck shaft angle: pre-injury angles, assumed to be the same and measured from the opposite uninjured hip. In cases of bilateral fractures, measurements were taken from the radiographs closest to the date of injury
‡ Reduction angle: measured in the immediate post-operative period
ISS: Injury Severity Score; ASA: American Society of Anaesthesiologists classification; DEXA: dual-energy X-ray absorptiometry; FWB: full weight bearing; PWB: partial weight bearing; TTWB: toe-touch weight bearing; NWB: non-weight bearing; HAP: hospital acquired pneumonia; CAP: community acquired pneumonia; UTI: urinary tract infection; CKD: chronic kidney disease; DVT: deep vein thrombosis; VTE: venous thromboembolism; AO: Arbeitsgemeinschaft für Osteosynthesefragen; OTA: Orthopaedic Trauma Association; TAD: tip apex distance; AP: anterior–posterior view; LAT: lateral view; HDU: high dependency unit; ICU: intensive care unit