Impact of the nail insertion angle on the wedge effect in intramedullary nail fixation of intertrochanteric hip fractures.

IF 2.3 3区 医学 Q2 ORTHOPEDICS
Wenhui Zhang, Ping Chen, Ji Qi, Zhirong Fan, Xiubing Yu, Haizhou Wang
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引用次数: 0

Abstract

Background: The wedge effect is known to be influenced by the insertion of the proximal femoral intramedullary nail through the fracture line and the large proximal diameter of the nail. However, the impact of the nail insertion angle (NIA) on the wedge effect remains unclear. This study aimed to investigate: (1) how to evaluate the NIA intraoperatively, (2) whether the NIA is associated with the wedge effect, (3) whether the NIA can serve as a reliable predictor of the wedge effect, (4) which factors affect the NIA, and (5) which surgical techniques can prevent the occurrence of the wedge effect associated with the NIA.

Hypothesis: We hypothesized that an excessive NIA is related to the wedge effect and that lateral deviation of the entry point is associated with an excessive NIA.

Patients and methods: Intraoperative fluoroscopy images of patients who underwent intramedullary nail fixation for intertrochanteric hip fractures between 2013 and 2023 were analyzed. NIA and insertion point distance (IPD) were measured on hip anteroposterior radiographs with the guidewire inserted. Femoral shaft lateralization (FSL) and neck-shaft angle (NSA) were measured on hip anteroposterior radiographs before and after nail insertion; differences in FSL and NSA were calculated. A negative difference in FSL combined with a positive difference in NSA indicated the occurrence of the wedge effect. Pearson's correlation test was used to determine relationships between continuous variables (NIA, FSL, NSA, and IPD). Binary logistic regression analyzed the association between NIA and the wedge effect. Receiver operating characteristic (ROC) curve analysis was used to determine the threshold value of NIA, with predictive performance assessed using the area under the ROC curve (AUC). Other potential factors influencing the wedge effect were also examined.

Results: A total of 408 patients were included. The mean NIA was 15.61 ± 4.49 °. Post-nail insertion, the average increase in FSL was 3.20 mm, and the average decrease in NSA was 1.90 °. Pearson's correlation test revealed that NIA was negatively correlated with the difference in FSL (R = 0.565, P < 0.001) and positively correlated with the difference in NSA (R = 0.509, P < 0.001). Binary logistic regression showed a significant correlation between NIA and the wedge effect (P < 0.001). ROC analysis indicated that the AUC for NIA was 0.813, with an optimal cutoff point of 14.85 °. IPD was positively correlated with NIA (R = 0.519, P < 0.001). Unstable fractures were associated with increased lateralization of the femoral shaft after nail insertion (P = 0.003).

Discussion: The NIA is positively correlated with the wedge effect in intramedullary nail fixation of intertrochanteric hip fractures. The wedge effect tends to occur when the NIA is >14.85 °, particularly in unstable fractures. Lateral deviation of the entry point is associated with an excessive NIA. Adducting the affected limb, moving the entry point slightly medial and using a medial pusher may help control the NIA to less than 14.85 ° to reduce the wedge effect.

Level of evidence: III.

髓内钉固定髋关节转子间骨折时,髓内钉插入角度对楔形效应的影响。
背景:众所周知,楔形效应受股骨近端髓内钉通过骨折线插入和髓内钉近端直径过大的影响。然而,钉子插入角度(NIA)对楔形效应的影响仍不清楚。本研究旨在探究:1)如何在术中评估 NIA;2)NIA 是否与楔形效应相关;3)NIA 是否可作为楔形效应的可靠预测指标;4)哪些因素会影响 NIA;5)哪些手术技术可防止发生与 NIA 相关的楔形效应:假设:我们假设NIA过大与楔形效应有关,而切入点的侧向偏离与NIA过大有关:分析了2013年至2023年间接受髓内钉固定治疗的髋关节转子间骨折患者的术中透视图像。在插入导丝的髋关节前后位X光片上测量了NIA和插入点距离(IPD)。在插入钢钉前后的髋关节前胸X光片上测量股骨干侧位(FSL)和颈轴角(NSA);计算FSL和NSA的差异。FSL 的负差和 NSA 的正差表明存在楔形效应。皮尔逊相关检验用于确定连续变量(NIA、FSL、NSA 和 IPD)之间的关系。二元逻辑回归分析了 NIA 与楔形效应之间的关系。受试者操作特征(ROC)曲线分析用于确定 NIA 的阈值,并使用 ROC 曲线下面积(AUC)评估预测性能。此外,还研究了影响楔形效应的其他潜在因素:共纳入 408 名患者。平均 NIA 为 15.61 ± 4.49°。插甲后,FSL 平均增加 3.20 mm,NSA 平均减少 1.90 °。皮尔逊相关性检验显示,NIA 与 FSL 的差异呈负相关(R = 0.565,P 讨论:髓内钉固定髋关节转子间骨折时,NIA 与楔形效应呈正相关。当 NIA >14.85 °时,尤其是在不稳定骨折中,往往会出现楔形效应。切入点的侧向偏离与 NIA 过大有关。将受累肢体内收、将入路点稍向内侧移动并使用内侧推杆可能有助于将NIA控制在14.85°以下,以减少楔形效应:证据等级:III.
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来源期刊
CiteScore
5.10
自引率
26.10%
发文量
329
审稿时长
12.5 weeks
期刊介绍: Orthopaedics & Traumatology: Surgery & Research (OTSR) publishes original scientific work in English related to all domains of orthopaedics. Original articles, Reviews, Technical notes and Concise follow-up of a former OTSR study are published in English in electronic form only and indexed in the main international databases.
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