G Model

JINJ 6989 No. of Pages 5

Injury, Int. J. Care Injured xxx (2016) xxx–xxx

Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Risk factors for cut-out of double lag screw fixation in proximal femoral
fractures
Kadir Buyukdogana,b,* , Omur Caglara , Samet Isika , Mazhar Tokgozoglua , Bulent Atillaa
a
Hacettepe University Faculty of Medicine Department of Orthopaedics and Traumatology, Ankara, Turkey
b
Mardin Kiziltepe State Hospital, Mardin, Turkey

A R T I C L E I N F O A B S T R A C T

Article history: Objective: We assessed factors associated with cut-out after internal fixation of proximal femoral
Received 12 October 2016 fractures using double lag screw nails.
Accepted 17 November 2016 Design: Retrospective cohort study.
Setting: A university hospital.
Level of evidence: Patients and methods: Patients with non-pathological intertrochanteric femur fractures and a minumum
Prognostic level II 90 days follow-up who underwent internal fixation with dual lag screw nails were included. Potential risk
factors for lag screw cut-out investigated by our study were: age, gender, body mass index, comorbidities
Keywords:
Risk factors
(American Society of Anesthesiologists [ASA] classification), type of fracture (AO/OTA classification),
Logistic regression fracture stability, side, operation time, implant length, reduction quality, tip-apex distance (TAD), and lag
Intertrochanteric fractures screw configuration. Logistic regression was used to investigate potential predictors of screw cut-out.
Cut-out Results: Eighty-five of the 118 patients with hip fractures treated between February 2010 and November
Tip-apex distance 2013 at our institution met the inclusion criteria for the study. Fifty-eight patients were female (68.2%),
mean age was 77.4 (range: 50–95 years), mean follow up was 380 days (range: 150 days-2.5 years), and
cut of was observed in 9 patients (10.5%). The following variables identified through univariate analysis
with p < 0.2 were included in multivariant logistic regression model: age, side, reduction quality, implant
length, TAD and ASA score. Only TAD (p = 0.003) was found to be significant in the multivariant model.
Conclusions: Our study confirmed that risk factors for cut-out with single-lag screw devices are also
applicable to dual-lag screw implants. We found that TAD was a significant factor for cut-out in dual-lag
screw implants. Thus, screw cut-out can be minimized by optimizing screw position.
ã 2016 Elsevier Ltd. All rights reserved.

Introduction theoretical advantage of improved fracture fixation biomechanics

Hip fractures commonly lead to high rates of morbidity,
reduced life quality, and mortality [1]. Intertrochanteric hip
fractures account for approximately half of all hip fractures in
the elderly and the costs of care for this debilitating injury are a
social and financial burden [2]. Cost of treatment increases steeply
where complications occur and a previous study reported a 6.9%
rate of complications requiring a second procedure [3].
Current treatment options of intertrochanteric fractures
include cephalomedullary nails and compression dynamic hip
screws [4]. Cephalomedullary nails are thought to be superior for
the treatment of unstable intertrochanteric hip fractures with the
* Corresponding author at: Hacettepe University Faculty of Medicine Department
of Orthopaedics and Traumatology, 06100, Sıhhıye, Ankara, Turkey.
E-mail addresses: kadirbuyukdogan@gmail.com,
kadirbuyukdogan@hotmail.com (K. Buyukdogan).
[5,6]. The use of both short and long cephalomedullary nails has
been reported with positive clinical results [7]. Early nail designs
were associated with a high rate of complications and reopera-
tions, such that design modifications have been applied in recent
versions [8]. Dual-lag systems were designed to improve rotational
control and bony purchase within the femoral head, thus resisting
cut-out and subsequent fixation failure [9]. The Veronail (Veronail
Trochanteric System, Orthofix, Bussolengo, Italy) is a novel
intramedullary (IM) device that enables double axis sliding or
locked convergent fixation of the femoral head and enables
treatment of the full range of pertrochanteric fractures with a
single device. Two previous studies reported outcomes with this
nail [10,11], but to the best of our knowledge, variables associated
with cut-out have not been addressed before.
Cut-out is the most common cause of fixation failure with
cephalomedullary nails and, in the literature, there is strong
evidence that fracture type, reduction, and tip-apex distance (TAD)
show associations with cut-out of lag screws from the femoral

http://dx.doi.org/10.1016/j.injury.2016.11.018
0020-1383/ã 2016 Elsevier Ltd. All rights reserved.

Please cite this article in press as: K. Buyukdogan, et al., Risk factors for cut-out of double lag screw fixation in proximal femoral fractures, Injury
(2016), http://dx.doi.org/10.1016/j.injury.2016.11.018
G Model
JINJ 6989 No. of Pages 5
2 K. Buyukdogan et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx
head [12–14]. Previous studies exploring mechanical and clinical
factors for cut-out have used single-lag screw nails or dynamic hip
screws. Additionally, there are concerns that the smaller diameter
screws in dual-lag designs would be more prone to migration
through the femoral head, thereby increasing the incidence of
screw cut-out [15]. In contrast to these concerns, recent research
has shown that double-screw designs provide equivalent or
greater resistance against varus collapse and neck rotation in
comparison with a single-lag screw implant [9,15]. However, there
is still a paucity of literature concerning predictive factors for cut-
out in dual-lag system implants.
The aim of this study was to assess factors that are associated
with cut-out after internal fixation using the Veronail. In particular,
we wanted to know if reduction quality and the TAD might affect
the cut-out rate in fractures treated with Veronails.
Patients and methods
After approval by the local Ethics committee, all osteoporotic
intertrochanteric fracture patients treated with Veronails in our
institute between February 2010 and November 2013 were
evaluated retrospectively (n = 118). Patient records were reviewed
for age at the time of operation, gender, side of fracture, date of
operation, date of final clinical follow-up, fracture stability, body
mass index (BMI), reduction quality, and American Society of
Anesthesiologists (ASA) scores. Exclusion criteria included patho-
logical fracture and lack of radiological follow-up for at least 3
months post-operatively.
Both pre-operative and post-operative radiographs were
reviewed by two of the authors present in the operations (KB
and SI). Pre-operative radiographs were assesed to identify the
type of fracture and fracture stability. The fractures were grouped
into classes 31.A1, 31.A2, and 31.A3 based on the Orthopedic
Trauma Association (OTA) classification [16]. Fractures were also
grouped as stable (A1) or unstable (A2, A3). Immediate post-
operative radiographs were used to measure the quality of the
reduction and TAD with the use of a Picture Archiving and
Communication System (PACS) (Centricity; General Electric Health
Systems, Waukesha, WI, USA).
The patients were operated on within 3 days of admission. All
patients received prophylactic low-molecular-weight heparin
Fig. 1. In the AP view, to measure Xap we set a point in the middle between the tips of the two screws and measured the distance to the apex of the femoral head. Measured
diameter of the lag screw on an AP view is Dap. In lateral view, to measure Xlat we set a point at the tip of screw and measured the distance to the apex of the femoral head.
Measured diameter of the lag screw on an lateral view is Dlat.
Please cite this article in press as: K. Buyukdogan, et al., Risk factors for cut-out of double lag screw fixation in proximal femoral fractures, Injury
(2016), http://dx.doi.org/10.1016/j.injury.2016.11.018
(LMWH) treatment. A single dose of antibiotics was administered
within 30 min before surgery. Reduction and internal fixation were
performed in the supine position on a fracture table using an image
intensifier. From the first postoperative day, the patients were
encouraged to walk with crutches. Patients with mild (ASA 1–2) or
severe (ASA 3–5) systemic diseases were grouped using the ASA
classification system.
Veronail has a design with a proximal diameter of 15 mm, distal
diameter of 10 mm and lengths of 200 and 280 mm. This system
allows alternative configuration of cephalic screws, with either
two parallel sliding screws or two convergent screws locked to the
nail. Lag screws were inserted as two parallel sliding screws in A1
fractures where the cephalic screws pass across the fracture line to
permit controlled compaction. In A3 fractures, two converging
screws were used where the cephalic screws do not pass the
fracture line. A2 fractures were treated with both types of proximal
fixation. In both configurations, screws were fixed to nails. Lag-
screw diameter was 6.5 mm in the parallel configuration and
5.6 mm in the convergent configuration. Highly unstable and
comminuted fractures were fixed with the 280 mm long Veronail
system.
The TAD is the sum of the distance, in milimeters, from the tip of
the screw to the apex of the femoral head, on the anteroposterior
and lateral radiographs as described by Baumgartner et al. [12]. To
assess TAD of the two screws in the AP view, we set a point in the
middle between the tips of the two screws and measured the
distance to the apex of the femoral head in both proximal fixation
configurations [17]. In lateral view, TAD is determined as the
distance between apex of femoral head and tip of proximal lag
screw (Fig. 1). The apex of the femoral head is defined as the point
of intersection between the subchondral bone and a line in the
center of and parallel to the femoral neck.
The quality of the reduction was based on Baumgartner and
Sembro [18,19]. Reduction was considered good when there was
alignment (neck-shaft angle between 125 and 145 in the
anteroposterior AP view and under 20 angulation on the lateral
view) and the displacement of any fragment was 4 mm or less on
either view. A reduction was categorized as good if both criteria
were met, and moderate if only one criterion was met. Poor
reductions met neither criteria. Assessment of reduction quality
and TAD measurements were performed using the X-ray films that
G Model
JINJ 6989 No. of Pages 5

K. Buyukdogan et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx 3

were obtained immediately after the operation by two of authors
(KB and SI) blinded to each other’s measurements.
Statistical analysis
Statistical analyses were performed with SPSS for Windows
software (ver. 17.0; SPSS Inc., Chicago, IL, USA). The x2 test and
binary logistic regression were used for univariate analyses of the
categorical and continuous parameters. The independent variables
from the univariate analysis with a p value of <0.20 were entered
in a multivariate analysis with the occurrence of cut-out as the
dependent variable. We assessed any factor in the multivariate
model as significant if the corresponding p value was <0.05. The
likelihood ratio backward test was conducted to find the best-fit
model by selecting variables one by one. The probability for entry
was set at p < 0.05 and removal at p > 0.10. We performed the
Hosmer and Lemeshow goodness-of-fit test to assess the logistic
regression model fit to the data.
To assess interobserver reliability, the intraclass correlation
coefficient (ICC) was calculated using a two-way random effects
model with 95% confidence intervals (95% CI). To assess the
interobserver reliability of categorical data, kappa coefficients
were calculated using 95% CIs.
Results
In total, 118 patients who had had intertrochanteric hip
fractures and underwent fixation using Veronails between
February 2010 and November 2013 were identified. Ten patients
died within 3 months after surgery and were excluded. Five
patients with pathological hip fractures were excluded. Fourteen
patients did not have a complete follow-up at 3 months
postoperatively and were excluded. Two patients suffered from
nonunions and underwent internal fixation with an other intra-
medullary device. One patient received iv antibiotic theraphy and
debridment because of superficial infection. Lag screw brekage
was observed in one patient and excluded from study. Thus, 85
patients with 85 hip fractures were suitable for our study (Table 1).
There were 58 women (69%) and 27 men (31%). Their mean age was
77.0  9.6 years. The mean follow-up time was 380  36 days.
Statistical analysis
Cut-out was observed in nine (10.5%) patients during the study
period. Among them, cut-out occurred within 3 months after the
operation in five patients and after the third postoperative month
in four. No statistically significant difference was found in gender
(p = 0.923), BMI (p = 0.253), operation time (p = 0.202), or type of
lag screw configuration (p = 0.723) between the two groups. Cut-
out was more frequent in unstable fractures, but differences in
fracture stability (p = 0.727) and AO fracture classification
(p = 0.479) between groups were also not significant.
In the univariate logistic regression model, seven potential risk
factors turned out with p values below the threshold of 0.2,
including the variables implant length, side of fracture, moderate
and poor reduction, TAD, age, and ASA. All the p values together
with their corresponding CIs and odds ratios are presented in
Table 1.
To assess the interobserver reliability of continuous parameters
turned out with p < 0.2 in univariate analysis, the intraclass
correlation coefficient and k coefficient were calculated. The ICC
was calculated to assess the interobserver reliability of TAD
measurement and k coefficient was calculated for the interob-
server reliability of Baumgartner’s classification. The ICC of TAD

Table 1
Univariate Analyses.

Factor Total No cut-out (n = 76) Cut-out (n = 9) p value OR 95% CI for OR

Agea (years) 77.8  9.6 77.5  9.8 73.8  7.8 0.155 0.963 0.900–1.031
Genderb 1.000 0.923 0.213–4.006
Male 27 (31%) 24 (88%) 3 (12%)
Female 58 (69%) 52 (89%) 6 (11%)
Operation timea (min) 73.8  20.7 72.6  20.1 83.9  24.6 0.202 1.025 0.993–1.057
BMIa (kg/m2) 27.3  5.0 27.1  4.9 29.3  5.8 0.253 1.087 0.951–1.242
Sideb 0.170 3.321 0.648–17.025
Right 46 (54%) 39 (84.8%) 7 (15.2%)
Left 39 (46%) 37 (94.9%) 2 (5.1%)
ASA groupb 0.124 3.274 0.801–13.378
(1,2) 59 (69%) 55 (93.2%) 4 (6.8%)
(3–5) 26 (31%) 21 (80.8%) 5 (19.2%)
AO classificationb 0.479 undefined
31.A1 36 (42.4%) 33 (91.7%) 3 (8.3%)
31.A2 34 (40%) 31 (91.2%) 3 (8.8%)
31.A3 15 (17.6%) 12 (80%) 3 (20%)
Fracture stabilityb 0.727 1.535 0.357–6.658
Stable 36 (43.9%) 33 (91.7%) 3 (8.3%)
Unstable 49 (56.1%) 43 (87%) 6 (13%)
Implant lengthb 0.068 4.929 1.006–24.146
Short 75 (88.2%) 69 (92%) 6 (8%)
Long 10 (11.8%) 7 (70%) 3 (30%)
Lag screw configurationb 0.723 1.37 0.34–5.53
Parallel 53 (62.4%) 48 (90.6%) 5 (9.4%)
Convergent 32 (37.6%) 28 (87.5%) 4 (12.5%)
TADa (mm) 1.97  4.8 18.9  4.2 26.5  4.8 <0.001 1.328 1.129–1.562
Reductionb 0.071 undefined
Good 38 (44.7%) 37 (97.4%) 1 (2.6%)
Moderate 35 (41.1%) 29 (82.9%) 6 (17.1%)
Poor 12 (14.2%) 10 (83.3%) 2 (16.7%)
a
Values are provided as means plus standard deviation.
b
values are given as the number of patients, with percentage in parentheses. OR, odds ratio; CI, confidence interval; BMI, body mass index; ASA, American Society of
Anesthesiologists; TAD, tip-apex distance.

Please cite this article in press as: K. Buyukdogan, et al., Risk factors for cut-out of double lag screw fixation in proximal femoral fractures, Injury
(2016), http://dx.doi.org/10.1016/j.injury.2016.11.018
G Model
JINJ 6989 No. of Pages 5
4 K. Buyukdogan et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx
Table 2
Multivariate Analysis.
Factor p value OR 95% CI for OR
Age 0.374
Side 0.051
Implant length 0.374
ASA 0.123
Reduction
Moderate 0.045 59.8 1.09–3265.9
Poor 0.216
TAD 0.003 1.623 1.179–2.235
OR, odds ratio; CI, confidence interval; ASA, American Society of Anesthesiologists
classification system; TAD, tip-apex distance.
Table 3
Reliability Between the Two Observers for Different Variables.
Variable ICC (k) 95% CI
TAD (ICC) 0.909 0.864–0.940
Fracture Reduction (kappa) 0.884 0.838–0.960
ICC, intraclass correlation coefficient; CI, confidence interval; TAD, tip-apex
distance.
measurements was 0.909 (95% CI, 0.864–0.940) and the k
coefficient of the reduction system was 0.884 (95% CI, 0.838–
0.960), both indicating good reliability (Table 3).
In the multivariate logistic regression, variables with p < 0.2 in
the univariate model were analyzed (Table 2). Statistical differ-
ences were found in TAD (odds ratio (OR) = 1.62, 95% confidence
index (CI): 1.17–2.23, p = 0.003) and moderate reduction (OR = 59.8,
95% CI: 1.09–3265.9, p = 0.045). Other parameters found between
the groups in the univariate analysis were no longer significant.
The Hosmer and Lemeshow goodness-of-fit test indicated that the
model fitted the data very well (p = 0.749).
Discussion
Intertrochanteric hip fractures account for approximately half
of all hip fractures and the cost of treatment increases steeply
where complications occur in with injury [2,20]. Current treatment
options include sliding hip screws and nails, and there has been a
trend towards increased use of IM fixation [21]. Even with
improvements in the implants and techniques used to manage
these fractures, failures continue to occur. Cut-out is the most
common cause of failure in IM fixation [12,14]. To prevent a second
procedure, many studies reported the importance of technique
variables, such as TAD, reduction quality, and implant positioning
in cut-out [14,22,23]. Dual-lag systems were designed to improve
rotational control and bony purchase within the femoral head, thus
resisting cut-out and subsequent fixation failure. Kubiak et al.
compared the stability of one and two lag screw implants used in
the fixation of unstable intertrochanteric fractures. They have
found that single and dual lag screw implants demonstrated a
significantly different migration resistance under gait loading
stimulation in their biomechanical study. The dual screw construct
provided significantly greater resistance against varus collapse and
neck rotation in comparison to a single lag screw devices [9].
However, in the clinical setting, these biomechanical advantages
failed to decrease complication rates [24,25]. Additionally, unique
types of failure, namely the Z effect and reverse Z effect
phenomena, have been recognized in fractures fixed with these
devices [26–28]. The Z effect and reverse Z effect are described as
the opposite migrations of lag screws. Although these phenomena
are not of concern in the current study, two of the cut-outs
occurred due to a reverse Z effect.
The aim of this study was to assess factors associated with cut-
out after internal fixation using the Veronail. In particular, we
Please cite this article in press as: K. Buyukdogan, et al., Risk factors for cut-out of double lag screw fixation in proximal femoral fractures, Injury
(2016), http://dx.doi.org/10.1016/j.injury.2016.11.018
wanted to investigate the influence of TAD and the classification
system of Baumgaertner in fracture reduction. To the best of our
knowledge, the influence of these factors on cut-out rates in
patients undergoing internal fixation with Veronail dual lag screw
device has not been reported before.
TAD was described by Baumgaertner et al. and was considered a
major risk factor for cut-out of the implant [12]. Previous studies
reported the TAD of intramedullary devices as a predictor of cut-
out failure in the treatment of intertrochanteric fractures
[14,22,23]. Our study confirmed that TAD is a predictor of cut-
out in dual-lag systems (OR = 1.62, 95% CI: 1.17–2.23, p = 0.003). As
the Veronail has a dual-lag screw, we used the method described
by Schmidt-Rohlfing. In their studies, they mentioned that, by
inserting two cephalic screws into the femoral head, a greater TAD
can be generally expected [17]. However, in our study, the overall
mean TAD was 19.7 4.8 mm, consistent with previously reported
values [14,29]. This result may be because we were already aware
of the importance of the TAD. Although earlier studies showed that
patients who had a TAD >25 mm were at risk of screw cut-out,
recent studies suggest that lower thresholds would be effective in
reducing the risk of cut-out [29]. We observed that the patients
whose TAD values were <21.7 mm did not needed any reoperation.
Although performed with dual lag screw implants, our findings
confirm previous studies finding high TAD values to be a significant
predictor of cut-out of IM nails [14,23]. However, our TAD distances
were for a dual lag screw system and therefore research with larger
study groups is needed to obtain more reliable results.
Our study showed that beyond TAD, there was association
between moderate reduction and cut-out (OR = 59.8, 95% CI: 1.09–
3265.9, p = 0.045), but poor reduction was not associated with cut-
out (p = 0.216). We interpret this finding with caution because
confidence interval of this association was too wide. A wide
confidence interval indicates that we are less sure and the
conclusion is less certain. The size of the confidence interval
depends on the sample size and here is an inverse square root
relationship between confidence intervals and sample sizes. We
believe that this finding was due to the small sample size and we
cannot say that poor reduction is not of concern, especially because
previously published reports indicated that a poor reduction of
these fractures was associated with more complications [30,31].
Baumgaertner et al. reported that fractures with poor reductions
were more than three times as likely to progress to cut-out than
fractures with good reductions [12]. Suboptimal osteosynthesis
was also shown to be associated with cut-out in Lobo-Escobar’s
study [14]. Kashigar et al. did not find a correlation between
reduction accuracy and failure of cephalomedullary nails [23]. It
might be argued that reduction criteria are subjective evaluations
based on interpretation [14,29]. However, in our study, these
criteria showed high intraobserver reliability, which can be
explained by the fact that measurements were performed by
two consultant trauma surgeons. It is well known that sub-optimal
reduction produces poor results in hip fracture management [32].
We believe larger study groups are needed to confirm whether
reduction quality contribute significantly to cut-out in dual lag
screw implants.
Our study had several limitations. First, it used a retrospective
design and thus had all of the drawbacks associated with that
method; furthermore, we had a limited sample size because of a
high rate of absenteeism. In total, 85 of the 118 fractures met the
inclusion criteria for the study with at least 3 months of follow-up.
This situation can be explained by the relatively old age of the
patient population. We did not include radiographic osteoporosis
index as a variable in our study, because the Singh index has high
intra- and interobserver disagreement and we believe that dual-
energy X-ray absorptiometry might be a more objective way of
assessing any association between cut-out and osteoporosis
G Model
JINJ 6989 No. of Pages 5
K. Buyukdogan et al. / Injury, Int. J. Care Injured xxx (2016) xxx–xxx
severity [23,33]. Finally, we could not investigate the screw
positions in the femoral head, which is an another risk factor for
cut-out supported by evidence [34]. Cleveland’s classification
system for lag screw position was not a suitable means of assessing
two lag screws placed in the femoral head. However, we were
aware of the importance of placing lag screws in the lower part of
the femoral neck, to provide the highest stiffness to screws to
prevent cut-out [12,35].
In conclusion, to the best of our knowledge, this is the first
reported study to confirm that a risk factors for cut-out described
with single lag screw devices are also valid for dual lag screw
implants. We found TAD to be significant factors for cut-out in dual
lag screw implants and screw cut-out can be minimized by
optimizing screw position. Because of the small number of cut-out
cases (n = 9), research with larger populations is needed to confirm
these results.
Conflict of interest
The authors report no conflict of interest.
Source of funding
This study has no funding source.
References
[1] Schneider EL, Guralnik JM. The aging of America. Impact on health care costs.
JAMA 1990;263(17):2335–40.
[2] Koval KJ, Aharonoff GB, Rokito AS, Lyon T, Zuckerman JD. Patients with femoral
neck and intertrochanteric fractures. Are they the same? Clin Orthop
1996;330:166–72.
[3] Thakar JA C, Hamilton TW, Willett K. The cost and consequences of proximal
femoral fractures which require further surgery following initial fixation. J
Bone Joint Surg Br 2010;92B:1669–77.
[4] Aros B, Tosteson AN, Gottlieb DJ, Koval KJ. Is a sliding hip screw or im nail the
preferred implant for intertrochanteric fracture fixation? Clin Orthop
2008;466(11):2827–32.
[5] Matre K, Havelin LI, Gjertsen JE, Vinje T, Espehaug B, Fevang JM. Sliding hip
screw versus IM nail in reverse oblique trochanteric and subtrochanteric
fractures. A study of 2716 patients in the Norwegian hip fracture register.
Injury 2013;44(6):735–42.
[6] Leung KS, So WS, Shen WY, Hui PW. Gamma nails and dynamic hip screws for
peritrochanteric fractures: a randomised prospective study in elderly patients.
J Bone Joint Surg Br 1992;74(3):345–51.
[7] Winnock de Grave P, Tampere T, Byn P, Van Overschelde J, Pattyn C, Verdonk R.
Intramedullary fixation of intertrochanteric hip fractures: a comparison of two
implant designs. A prospective randomised clinical trial. Acta Orthop Belg
2012;78(2):192–8.
[8] Osnes EK, Lofthus CM, Falch JA, Meyer HE, Stensvold I, Kristiansen IS, et al.
More postoperative femoral fractures with the Gamma nail than the sliding
screw plate in the treatment of trochanteric fractures. Acta Orthop Scand
2001;72(3):252–6.
[9] Kubiak EN, Bong M, Park SS, Kummer F, Egol K, Koval KJ. Intramedullary
fixation of unstable intertrochanteric hip fractures: one or two lag screws. J
Orthop Trauma 2004;18(1):12–7.
[10] Kouzelis A, Kravvas A, Mylonas S, Giannikas D, Panagopoulos A. Double axis
cephalocondylic fixation of stable and unstable intertrochanteric fractures:
early results in 60 cases with the veronail system. Open Orthop J 2014;8:60–8.
[11] Lavini F, Renzi-Brivio L, Aulisa R, Cherubino F, Di Seglio PL, Galante N, et al. The
treatment of stable and unstable proximal femoral fractures with a new
trochanteric nail: results of a multicentre study with the Veronail. Strateg
Trauma Limb Reconstr (Online) 2008;3(1):15–22.
[12] Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM. The value of the tip-apex
distance in predicting failure of fixation of peritrochanteric fractures of the hip.
J Bone Joint Surg Am 1995;77(7):1058–64.
Please cite this article in press as: K. Buyukdogan, et al., Risk factors for cut-out of double lag screw fixation in proximal femoral fractures, Injury
(2016), http://dx.doi.org/10.1016/j.injury.2016.11.018
5
[13] Davis TR, Sher JL, Horsman A, Simpson M, Porter BB, Checketts RG.
Intertrochanteric femoral fractures: mechanical failure after internal
fixation. J Bone Joint Surg Br 1990;72(1):26–31.
[14] Lobo-Escolar A, Joven E, Iglesias D, Herrera A. Predictive factors for cutting-out
in femoral intramedullary nailing. Injury 2010;41(12):1312–6.
[15] Wang CJ, Brown CJ, Yettram AL, Procter P. Intramedullary femoral nails: one or
two lag screws? A preliminary study. Med Eng phys 2000;22(9):613–24.
[16] Marsh JL, Slongo TF, Agel J, Broderick JS, Creevey W, DeCoster TA, et al. Fracture
and dislocation classification compen-dium – 2007: orthopaedic trauma
association classification, database and outcomes committee. J Orthop Trauma
2007;21(Suppl. 10):1–133.
[17] Schmidt-Rohlfing B, Heussen N, Knobe M, Pfeifer R, Kaneshige JR, Pape HC.
Reoperation rate after internal fixation of intertrochanteric femur fractures
with the percutaneous compression plate: what are the risk factors? J Orthop
Trauma 2013;27(6):312–7.
[18] Baumgaertner MSB. Awareness of Tip-Apex Dis- tance reduces failure of
fixation of trochanteric fractures of the hip. J Bone Joint Surg Am. 1997;
(79):969–71.
[19] Sernbo IJO, Gentz CF, Nilsson JA. Unstable inter- trochanteric fractures of the
hip: treatment with Ender pins compared with a compression hip-screw. J
Bone Joint Surg Am 1998;70:1297–303.
[20] Thakar C, Alsousou J, Hamilton TW, Willett K. The cost and consequences of
proximal femoral fractures which require further surgery following initial
fixation. J Bone Joint Surg Br 2010;92(12):1669–77.
[21] Barton TM, Gleeson R, Topliss C, Greenwood R, Harries WJ, Chesser TJ. A
comparison of the long gamma nail with the sliding hip screw for the
treatment of AO/OTA 31-A2 fractures of the proximal part of the femur: a
prospective randomized trial. J Bone Joint Surg Am 2010;92(4):792–8.
[22] Geller JA, Saifi C, Morrison TA, Macaulay W. Tip-apex distance of
intramedullary devices as a predictor of cut-out failure in the treatment of
peritrochanteric elderly hip fractures. Int Orthop 2010;34(5):719–22.
[23] Kashigar A, Vincent A, Gunton MJ, Backstein D, Safir O, Kuzyk PR. Predictors of
failure for cephalomedullary nailing of proximal femoral fractures. The Bone
Joint J 2014;96b(8):1029–34.
[24] Makridis KG, Georgaklis V, Georgoussis M, Mandalos V, Kontogeorgakos V,
Badras L. Comparing two intramedullary devices for treating trochanteric
fractures: a prospective study. J Orthop Sur Res 2010;5:9.
[25] Kouvidis G, Sakellariou VI, Mavrogenis AF, Stavrakakis J, Kampas D, Galanakis J,
et al. Dual lag screw cephalomedullary nail versus the classic sliding hip screw
for the stabilization of intertrochanteric fractures. Prospective randomized
study. Strateg Trauma Limb Reconstr (Online) 2012;7(3):155–62.
[26] Boldin C, Seibert FJ, Fankhauser F, Peicha G, Grechenig W, Szyszkowitz R. The
proximal femoral nail (PFN) – a minimal invasive treatment of unstable
proximal femoral fractures: a prospective study of 55 patients with a follow-
up of 15 months. Acta Orthop Scand 2003;74(1):53–8.
[27] Strauss EJ, Kummer FJ, Koval KJ, Egol KA. The Z-effect phenomenon defined: a
laboratory study. J Orthop Res: Off Pub Orthop Res Soc 2007;25(12):1568–73.
[28] Werner-Tutschku W, Lajtai G, Schmiedhuber G, Lang T, Pirkl C, Orthner E. Intra-
and perioperative complications in the stabilization of per- and
subtrochanteric femoral fractures by means of PFN. Der Unfallchirurg
2002;105(10):881–5.
[29] De Bruijn K, den Hartog D, Tuinebreijer W, Roukema G. Reliability of predictors
for screw cutout in intertrochanteric hip fractures. J Bone Joint Surg Am
2012;94(14):1266–72.
[30] Guerra Pinto F, Dantas P, Moreira R, Mamede R, Amaral LB. Complications
relating to accuracy of reduction of intertrochanteric fractures treated with a
compressive hip screw. Hip Int: J Clin Exp Res Hip Pathol Ther 2010;20(2):221–
8.
[31] Baumgaertner MR, Curtin SL, Lindskog DM. Intramedullary versus
extramedullary fixation for the treatment of intertrochanteric hip fractures.
Clin Orthop 1998;(348):87–94.
[32] Matre K, Vinje T, Havelin LI, Gjertsen JE, Furnes O, Espehaug B, et al. TRIGEN
INTERTAN intramedullary nail versus sliding hip screw: a prospective,
randomized multicenter study on pain, function, and complications in 684
patients with an intertrochanteric or subtrochanteric fracture and one year of
follow-up. J Bone Joint Surg Am 2013;95(3):200–8.
[33] Koot VC, Kesselaer SM, Clevers GJ, de Hooge P, Weits T, van der Werken C.
Evaluation of the Singh index for measuring osteoporosis. J Bone Joint Surg Br
1996;78(5):831–4.
[34] Cleveland M, Bosworth DM, Thompson FR, Wilson Jr. HJ, Ishizuka T. A ten-year
analysis of intertrochanteric fractures of the femur. J Bone Joint Surg Am
1959;41a:1399–408.
[35] Kuzyk PR, Zdero R, Shah S, Olsen M, Waddell JP, Schemitsch EH. Femoral head
lag screw position for cephalomedullary nails: a biomechanical analysis. J
Orthop Trauma 2012;26(7):414–21.