Abstract:

Objective: The propose of this study was to asses the factors leading to complications in trochanteric femoral fractures treated with Dyna locking trochanteric (DLT) nails in geriatric patients, with respect to fracture stability pattern, postoperative reduction, screw placement, tip-apex distance (TAD), bone quality, and patient positioning. Methods: One hundred sixty nine patients operated using DLT nail, aged 65 years and older with a minimum follow-up of 12 months were screened retrospectively. The fracture patterns were grouped as AO Foundation/Orthopedic Trauma Association (AO/OTA) 31-A1, A2, and A3, and the patients were operated in the supine position using a traction table, in the supine position without using a traction table, or in the lateral decubitus position. Postoperative bone mineral density (BMD) measurements were performed in all patients. The Fogagnolo criteria, modified from Baumgartner, were used to evaluate the fracture reduction, and accordingly, the fracture reduction was subdivided into good, acceptable, or poor. TAD measurements were performed as described by Baumgartner. The position of the lag screw within the femoral head was determined according to Cleveland and Bosworth method, and the central-central and infero-central positions were evaluated as optimal and the other positions as suboptimal. Results: A total of 57 complications were determined, of which 14 (8.2%) were cut-out, cut-through, and intrapelvic migration of the lag screw and distal peri-implant fractures requiring additional interventions. A statistically significant association was found between suboptimal lag screw placement, decreased BMD, TAD measurement >25 mm, and decreased reduction quality with cut-out, cut-through, intrapelvic migration, and varus collapse. Varus collapse was seen at a significantly low rate in AO/OTA 31-A1 type fractures and in surgeries performed with a traction table (p=0.004, p<0.001), although there was no association between cut-out, cut-through, intrapelvic migration and fracture type and patient positioning (p=0.542, p=0.632). The optimal lag screw placement and TAD measurements were statistically significantly better in patients who were treated on a traction table (p<0.001, p<0.001). Conclusion: Decreased BMD, suboptimal lag screw position in the femoral head, a TAD of >25 mm, unstable fracture patterns, and poor reduction quality have an impact on complications. Performing the surgical intervention on a traction table ensures more favorable lag screw placement.

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