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European Journal of Orthopaedic Surgery & Traumatology (2022) 32:1617–1625
https://doi.org/10.1007/s00590-021-03124-8
ORIGINAL ARTICLE
No difference betweenlag screw andhelical blade
forcephalomedullary nail cut‑out asystematic review
andmeta‑analysis
MitchellNg1· NiharS.Shah2· IvanGolub1· MatthewCiminero1· KevinZhai3· KevinK.Kang1· AhmedK.Emara3·
NicolasS.Piuzzi3
Received: 5 June 2021 / Accepted: 13 September 2021 / Published online: 19 October 2021
© The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature 2021
Abstract
Introduction Cephalomedullary nail (CMN) cut-out is a severe complication of treatment of intertrochanteric femur frac-
tures. This study aimed to identify modifiable risk factors predictive of implant cut-out including: CMN proximal fixation
type (lag screw vs. helical blade), tip-apex distance (TAD), reduction quality, nail length, screw location, and surgeon fel-
lowship training.
Methods A systematic review of the published literature was conducted on Pubmed/MEDLINE and Cochrane Library data-
bases for English language papers (January 1st, 1985–May 10th, 2020), with 21 studies meeting inclusion/exclusion criteria.
Studies providing quantitative data comparing factors affecting CMN nail cut-out were included, including fixation type (lag
screw vs. helical blade), tip-apex distance (TAD), reduction quality, nail length, and screw location. Twelve studies were
included and graded by MINOR and Newcastle–Ottawa Scale to identify potential biases. Meta-analysis and pooled analysis
were conducted when possible with forest plots to summarize odds ratios (OR) and associated 95% confidence interval (CI).
Results There was no difference in implant cut-out rate between lag screws (n = 745) versus helical blade (n = 371) (OR:
1.03; 95% CI: 0.25–4.23). Pooled data analysis revealed TAD > 25mm (n = 310) was associated with higher odds of increased
cut-out rate relative to TAD < 25mm (n = 730) (OR: 3.72; 95% CI: 2.06–6.72).
Conclusion Our review suggests that cephalomedullary implant type (lag screw vs. helical blade) is not a risk factor for
implant cut-out. Consistent with the previous literature, increased tip-apex distance > 25mm is a reliable predictor of implant
cut-out risk. Suboptimal screw location and poor reduction quality are associated with increased risk of screw cut-out.
Level of evidence Level III.
Keywords Cephalomedullary nail· Intertrochanteric fracture· Lag screw· Helical blade· Implant cut-out· Tip-apex
distance
Introduction
The incidence of intertrochanteric hip fractures has increased
over recent years [1]. The mainstays for implant fixation of
intertrochanteric fractures include the use of intramedullary
nails or dynamic hip screws [2–4]. Nonetheless, the gold
standard for treating unstable intertrochanteric hip fractures
is internal fixation with a cephalomedullary nail (CMN) [5].
One of the most common complications of CMN fixation is
cut-out, defined as implant protrusion outside the femoral
head, which can lead to varus displacement [6, 7]. While the
incidence is low, ranging from 1.6 to 4.3% in most studies
[8–10], implant cut-out is a severe complication associated
with subsequent increased patient morbidity and mortality
* Nicolas S. Piuzzi
piuzzin@ccf.org
1 Department ofOrthopaedic Surgery, Maimonides Medical
Center, 4803 10th Avenue, Brooklyn, NY11219, USA
2 Department ofOrthopaedic Surgery, Case Western Reserve
University, Cleveland, OH45219, USA
3 Department ofOrthopaedic Surgery, Orthopaedic
andRheumatologic Institute, Cleveland Clinic, 9500 Euclid
Avenue, Mailcode A41, Cleveland, OH44195, USA
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