International Orthopaedics

, Volume 37, Issue 7, pp 1363–1368

How to prevent cut-out and cut-through in biaxial proximal femoral nails: is there anything beyond lag screw positioning and tip–apex distance?

  • Birgit Zirngibl
  • Roland Biber
  • Hermann Josef Bail
Original Paper



Hip perforation is a major complication in proximal femoral nailing. For biaxial nails, knowledge of their biomechanics is limited. Besides re-evaluation of accepted risk factors like the tip–apex distance (TAD), we analysed the influence of anti-rotational pin length.


We compared 22 hip perforation cases to 50 randomly chosen controls. TAD, lag-screw position, angle between lag-screw and femoral neck axis, lag-screw gliding capacity, displacement and anti-rotational pin length were investigated.


Hip perforation was associated with a higher angle of deviation between lag-screw and femoral neck axis (p = 0.001), a lower telescoping capacity of the lag screw (p = 0.02), and higher TAD (p = 0.048). If the anti-rotational pin exceeded a line connecting the tip of the nail and the lag screw (NS line), hip perforation incidence was increased (p = 0.009). Inadequate pin length resulted in an odds ratio of 10.8 for hip perforation (p = 0.001).


In biaxial nails anti-rotational element positioning is underestimated, however, crucial.


  1. 1.
    Schipper IB, Bresina S, Wahl D, Linke B, Van Vugt AB, Schneider E (2002) Biomechanical evaluation of the proximal femoral nail. Clin Orthop Relat Res 405:277–286PubMedCrossRefGoogle Scholar
  2. 2.
    Heinert G, Parker MJ (2007) Intramedullary osteosynthesis of complex proximal femoral fractures with the Targon PF nail. Injury 38:1294–1299PubMedCrossRefGoogle Scholar
  3. 3.
    Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM (1995) The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg Am 77:1058–1064PubMedGoogle Scholar
  4. 4.
    Cleveland M, Bosworth DM, Thompson FR, Wilson HJ Jr, Ishizuka T (1959) A ten-year analysis of intertrochanteric fractures of the femur. J Bone Joint Surg Am 41:1399–1408PubMedGoogle Scholar
  5. 5.
    Hsueh KK, Fang CK, Chen CM, Su YP, Wu HF, Chiu FY (2010) Risk factors in cutout of sliding hip screw in intertrochanteric fractures: an evaluation of 937 patients. Int Orthop 34:1273–1276PubMedCrossRefGoogle Scholar
  6. 6.
    Bonnaire F, Weber A, Bösl O, Eckhardt C, Schwieger K, Linke B (2007) “Cutting out” in pertrochanteric fractures—problem of osteoporosis? Unfallchirurg 110:425–432PubMedCrossRefGoogle Scholar
  7. 7.
    De Bruijn K, den Hartog D, Tuinebreijer W, Roukema G (2012) Reliability of predictors for screw cutout in intertrochanteric hip fractures. J Bone Joint Surg Am 94:1266–1272PubMedCrossRefGoogle Scholar
  8. 8.
    Kawaguchi S, Sawada K, Nabeta Y (1998) Cutting-out of the lag screw after internal fixation with the Asiatic gamma nail. Injury 29:47–53PubMedCrossRefGoogle Scholar
  9. 9.
    Frei HC, Hotz T, Cadosch D, Rudin M, Käch K (2012) Central head perforation, or “cut through”, caused by the helical blade of the proximal femoral nail antirotation. J Orthop Trauma 26:e102–e107PubMedCrossRefGoogle Scholar
  10. 10.
    Helwig P, Faust G, Hindenlang U, Hirschmüller A, Konstantinidis L, Bahrs C, Südkamp N, Schneider R (2009) Finite element analysis of four different implants inserted in different positions to stabilize an idealized trochanteric femoral fracture. Injury 40:288–295PubMedCrossRefGoogle Scholar
  11. 11.
    Parker MJ, Bowers TR, Pryor GA (2012) Sliding hip screw versus the Targon PF nail in the treatment of trochanteric fractures of the hip. J Bone Joint Surg Br 94:391–397PubMedGoogle Scholar
  12. 12.
    Kawatani Y, Nishida K, Anraku Y, Kunitake K, Tsutsumi Y (2011) Clinical results of trochanteric fractures treated with the TARGON® proximal femur intramedullary nailing fixation system. Injury 42(S4):22–27CrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  • Birgit Zirngibl
    • 1
  • Roland Biber
    • 1
    • 2
  • Hermann Josef Bail
    • 1
  1. 1.Department of Trauma and Orthopaedic SurgeryKlinikum NuernbergNuernbergGermany
  2. 2.Institute for Biomedicine of AgingFriedrich-Alexander University Erlangen-NuernbergNürnbergGermany

Personalised recommendations