Injury, Int. J.

Care Injured 43 (2012) 856863

Contents lists available at SciVerse ScienceDirect

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

Radiological evaluation of intertrochanteric fracture xation by the proximal

femoral nail
Amir Herman a,b,*, Yair Landau a, Gabriel Gutman a, Vladislav Ougortsin a, Aharon Chechick a,
Nachshon Shazar a
a
b

Department of Orthopedic Surgery, Chaim Sheba Medical Center, Tel-Hashomer, Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
Talpiot Medical Leadership Program, Chaim Sheba Medical Center, Tel-Hashomer, Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel

A R T I C L E I N F O

A B S T R A C T

Article history:
Accepted 24 October 2011

Background: Successful treatment of intertrochanteric femoral fractures was reportedly inuenced by the
position of the xation devices, by reduction quality and by fracture type.
Methods: The records of 227 patients with intertrochanteric fractures treated by intramedullary hip
screws were analysed retrospectively. The angle and distance from the femur head apex were
transformed into Cartesian coordinates. Comparisons were performed between patients with no
mechanical failure (207 patients, 90.7%), with cutouts (15 patients, 6.6%) and with secondary loss of
reduction (5 patients, 2.2%).
Results: The standard tip apex distance (TAD) measurement above 25 mm did not predict failure
(p = 0.62). Mechanical failure rates increased from 4.8% to 34.4% when the centre of lag screw was not in
the second quarter of the headneck interface line (the so-called safe zone) (p = 0.001). Lag screw
insertion lower or higher than 11 mm of the head apex line were associated with failure rates of 5.5% and
18.6%, respectively (p = 0.004). Multivariate logistic regression showed that lag screw insertion not
within the safe-zone was associated an Odds Ratio of 13.4 (95% CI 2.2481) for mechanical failure
(p = 0.004).
Conclusions: The TAD scale focuses on length measurement and lacks the vector properties of
multidirectional measurements. Vector analysis revealed that the caudal-cranial correct lag screw
position is the most important factor in preventing mechanical failure.
2011 Elsevier Ltd. All rights reserved.

Keywords:
Intertrochanteric fractures
Tip apex distance
Proximal femoral nail

Introduction
Proximal femur fractures are amongst the most common
injuries encountered by the orthopaedic surgeon. The incidence of
these fractures in the US alone is expected to reach 500,000 per
year in 2040.1 Intertrochanteric fractures account for about half of
all proximal femur fractures.2 Fixation devices for intertrochanteric fractures include intramedullary devices (e.g., Gamma nail,
intramedullary hip screws, etc.) and extramedullary devices,
mainly sliding screws and plates (e.g., dynamic hip screws). The
former showed an advantage in xation of unstable intertrochanteric fractures and the latter yielded better results for xation of
stable intertrochanteric fractures.38
The correct insertion and positioning of both intra- and
extramedullary devices are known to prevent implant failure

* Corresponding author at: Department of Orthopedic Surgery, Chaim Sheba

Medical Center, Tel.:-Hashomer, 52621, Israel. Tel.: +972 3 5302623;
fax: +972 3 5302523.
E-mail address: amirherm@gmail.com (A. Herman).
00201383/$ see front matter 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.injury.2011.10.030

and cutout. Baumgaertner et al. (1995) had shown that small tip
apex distance, i.e., less than 25 mm, is associated with a lower
probability for cutout.9 Other authors have divided the femoral
head into nine areas, and recommended head screw insertion at
the middle-middle or lower-middle area.10 However, these
works focused either on dynamic hip screws or Gamma nails,
and other designs of intramedullary nails are currently available,
such as is the proximal femoral nail (PFN), which has a different
design by virtue of its additional antirotation hip screw proximal
to the main lag screw.8 This design was shown to have
biomechanical properties that are different from those of a
single-head screw.11
We evaluated the application of postoperative radiographic
parameters and measurements to predict success of intertrochanteric femoral fracture xation using PFN designed nails. These
parameters include reduction quality, screw placement parameters, nail length and tip apex distance amongst others. We also
performed a multivariate analysis to determine which parameter
is most important. Our expectation is that this analysis will prove
useful for surgeons in guiding them in achieving optimal clinical
results.

A. Herman et al. / Injury, Int. J. Care Injured 43 (2012) 856863

Patients and methods

Institutional review board approval was obtained for this
retrospective investigation. The study included 227 patients with
unstable intertrochanteric fractures that were treated in our
institute by PFN-like xation devices from 2000 to 2009. Inclusion
criteria were unstable intertrochanteric fracture, and a follow-up
of at least six months after the initial surgery and an X-ray that
demonstrated a radiological union, or patients with failed surgery.
The patients with pathologic fractures were excluded.
Mechanical failure was dened as either cutout (15 patients,
Fig. 1A) or secondary reduction loss (5 patients Fig. 1B and C). Two
hundred and seven patients did not have any mechanical failure.
Clinical and radiological parameters were compared between
these three groups. The patients with no mechanical failure were
also compared with the twenty patients who had either cutout or
secondary reduction loss. Pre and post injury mobility were
grouped as follows: Group 1 = Walking without any ambulation
aid or using one aid (cane, tripod etc.); Group 2 = Walking with a
walking frame and Group 3 = Wheelchair use. Osteoporosis level
was classied according to the Singh classication.12
Fracture classication was according to the orthopaedic trauma
association (OTA) classication,13 in which scores of OTA 31.A2 and
OTA 31.A3 were considered as unstable fracture patterns. Patients
with subtrochanteric fractures xed by the PFN devices were also
included. All the patients in our cohort had unstable intertrochanteric fractures. One hundred and forty-seven (64.8%) fractures had
been xed by means of the Targon proximal femur (Targon PF)
device (Aesculap, Tuttlingen, Germany), and eighty (35.2%) fractures
were xed with the antirotation trochanteric nailing system (ATN)
device (dePuy, Warsaw, IN, USA). One hundred seventy-six (77.5%)
fractures were xed with standard length nails, and fty-one (22.5%)
with long nails (more than 300 mm). All surgeries were performed in
accordance to standard surgery technique and the manufacturers
recommendations. Postoperative rehabilitation protocol included
weight bearing as tolerated for six weeks and than full weight
bearing ambulation protocol was used.
Radiological measurements
Radiological measurements of the post-surgery xation
device were performed using postoperative radiographic images.

857

All measurements were scales by a factor of the true lag screw

width divided by the radiographic lag screw width measurement. Reduction quality was dened using both anteroposterior
(AP) and axial radiographs. On AP radiographs, the neck shaft
angle was measured and used to assess reduction quality. On
axial radiographs, reduction quality was assessed by the
reduction gap, dened as the displacement (in millimetres)
between the medial cortexes of the distal and proximal fracture
parts.
We dened the neck-head transition points as the points where
the headneck contour changes from the head convex to neck
concave contour. The headneck interface line was dened as the
connection of these two points (Fig. 2, Line L1). The neck centre line
was dened as a line perpendicular to L1 which crosses L1 in its
centre (Fig. 2, Line L2). The head apex was dened as the point at
which the neck centre line crosses the femur head cortical bone.
Further measurements are D1 which represents the length of L1,
D2 which represents the distance from the central axis of the head
lag screw to the inferior edge of L1, and D3 which represents the
distance between the superior edge of L1 to the superior part of the
antirotation screw (Fig. 2).
On the AP radiograph, the length of the tip apex distance (TAD)
vector was measured for the lag screw and antirotational screw
AP
TADAP
LS and TADAR , respectively). The angle between the neck
central axis line and the TAD vector for the lag screw and
antirotational screw were measured (aAP and bAP, respectively). An
angle cranial to the neck central axis line was taken as being
positive, and an angle caudal to the neck central axis line as
negative. Fig. 3A and B presents the AP radiographic TAD and angle
measurements. Similar measurements were performed, only for
the lag screw, on the axial radiograph. Axial measurements were
Ax
marked by TADAx
(Fig. 3C). Axially measured angles were
LS and a
considered positive or negative when they were anterior or
posterior to the mid-femur neck line, respectively, i.e., anterior or
posterior screw placement.
We used a standard TAD multiplied by sine or cosine for
transformation from the Polar coordinate system (distance and
angle) to the Cartesian coordinate system, in which the headneck
interface line and the neck centre line were used as bases. The
centre of the axis which is the (0,0) point, is the femur head apex.
For example, in order to calculate the lag screw cranial-caudal
AP
position on an AP radiograph, we used TADAP
LS  sin a . In order to

Fig. 1. (A) A cutout of an intertrochanteric fracture. (B) The postoperative position of the centre of the lag screw is inferior in this 85-year-old female. (C) The same patient as in
(B) after reduction loss.

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A. Herman et al. / Injury, Int. J. Care Injured 43 (2012) 856863

screw tip-apex distance on the neck centre axis less or greater than
11 mm, centre of lag screw position within the second distal
quarter of the headneck interface line (safe zone, see Fig. 4),
gender, TAD less or greater than 25 mm, osteoporosis grade less or
equal 2, TAD on axial view and nail system used (ATN or Targon PF).
The Odds Ratio (OR) was calculated as exponent beta, and 95%
condence intervals were also calculated.
Results
General considerations and xation

Fig. 2. Femur neck measurements. The headneck interface line (L1) is a connecting
line between the two curving points where the convexity of the femur head contour
turns into the femur neck concavity. The centre neck line (L2) is a line perpendicular
to the headneck interface line in its mid-length. The apex is the point where the
centre neck line crosses the femur head cortex. D1 = the length of the headneck
interface line. D2 = the distance to the centre of lag screw. D3 = the distance to the
upper part of the antirotation screw.

determine the medial-lateral position of the lag screw, we used

AP
TADAP
LS  cos a . Beta angle measurements were used for antirotational screw transforms, and lag screw axial measurements
were used for similar axial calculations.
Statistical analysis
Data were analysed by SPSS 16.0 software (SPSS Inc., Chicago,
IL). Categorical variables are presented as count (percent). All data
was not available for all the patients. The percents are given from
available data. Continuous variables are presented as mean and
standard deviation (SD). The Chi-square test or Fishers exact test
were used to test for statistical signicance amongst categorical
variables. The latter was used when the expected count was lower
than ve in at least one cell. The WilcoxonMannWhitney rank
sum (KruskalWallis test) test was used to calculate statistical
signicance amongst two groups (or more) of continuous
variables. All p values are presented as two-sided. The level of
signicance was set at p < 0.05.
A post-surgery axial reduction gap cut-point of 5 mm was
found to maximize the Youdens index (1.3). The distance of tip of
the lag screw from the apex, on the neck centre axis
AP
TADAP
LS  cos a , was dichotomized using cut-point of 11 mm
which was found to maximize the Youdens index (1.28, see Fig. 4).
Multivariate logistic regression was performed using mechanical failure (either cutout or secondary reduction loss) as the
dependent covariate. Independent covariates in the model
included: an axial reduction gap less or greater than 5 mm, lag

The study included two hundred twenty-seven patients. The

mean postoperative follow-up time was 25.7 (SD 19.9) months.
Fifteen patients had a cutout of their xation devices (Fig. 1A), and
ve patients had a secondary reduction loss. The mean time from
surgery to cutout was 3.36 (SD 3.6) months, and the mean time
from surgery to secondary reduction loss was 2.63 (SD 1.44)
months (Fig. 1B and C). Demographics, and length characteristics
did not differ between the three patient groups (Table 1). Fixation
device types differed between patients groups. More failures were
noted in ATN type nailing system (p value = 0.01). More secondary
reduction losses were observed in male patients: three out of
the ve patients with secondary displacements were males
(p = 0.047).
Preinjury mobility status (aids used) was available for only 115
patients. Of 106 patients without mechanical complications, 81
patients (76.4%) used no walking aids or one aid, 25 patients
(23.6%) used walking frame. Of eight patients with cutout 7
patients (87.5%) used no or one ambulation aid, and one patient
(12.5%) used a wheelchair for ambulation. One patient (100% of
available data) with secondary displacement used no or one
walking aid. This difference was found to be statistically signicant
(p value = 0.003).
Post injury (nal visit) ambulation aids data was available in 87
patients. Of which 78 patients had no complication, 7 had a cutout
and 2 had secondary displacement. Of the overall available data 19
patients (21.8%) used no walking aid or one walking aid, 62
patients (71.3%) used a walking frame and 6 patients (6.9%) were
wheelchair bound.
Comparing the pre and post injury mobility aids in the total
patient group, 89 patients (77.4%) and 19 patients (21.8%) used
none or one walking aid pre and post injury, respectively. Twentyve patients (21.7%) and 62 patients (71.3%) had used a walking
frame pre and post injury, respectively. Wheelchair was used by
one patient (0.9%) and 6 patients (6.9%) pre and post injury,
respectively. These differences were found to be statistically
signicant (p value = 0.001).
The mean osteoporosis grade for the entire study group was
2.94 (SD 1.42). There was no statistically signicant difference
between the mechanical failure groups and patients with no failure
(Table 1).
Reduction quality
The AP postoperative displacement, as measured by the neck
shaft angle in the AP radiograph, measured a mean of 132.2 (SD
6.2) degrees. The axial reduction gap measurement were
available for 122 patents. Mean axial reduction gap was 8.4
(SD 6.55 mm, p value = 0.69, see Table 2). Thirty-seven (30.3%)
had an axial postoperative reduction gap less than 5 mm. Only
one of these patients (2.7%) had a cutout, and none had a
secondary reduction loss. Eighty-ve (69.7%) had an axial
reduction gap greater than 5 mm, and ve (of six, 83.3%)
had a cutout and 4 (100% of available 4) had a secondary
displacement (p value = 0.073).

A. Herman et al. / Injury, Int. J. Care Injured 43 (2012) 856863

859

Fig. 3. (A) Transformation of the anteroposterior (AP) lag screw polar coordinates (distance and angle) to the Cartesian components of the headneck interface axis
AP
AP
AP
TADAP
LS  sin a and centre neck axis TADLS  cos a . (B) Transformation of AP antirotational polar coordinates (distance and angle) to the Cartesian components of the
AP
AP
AP
headneck interface axis TADAP
AR  sin b and centre neck axis TADAR  cos b . (C) Transformation of axial lag screw polar coordinates (distance and angle) to the Cartesian
Ax
Ax
Ax
components of the headneck interface axis TADAx
LS  sin a and centre neck axis TADLS  cos a .

Femur neck radiographic measurements

The femur neck radiographic measurements revealed that the
centre of lag screw positioning as a fraction of the headneck
interface line (D2/D1 in Fig. 2) had an average of 0.39 (SD 0.09).
There was a statistically signicant difference in the centre of lag

screw position between the three study groups (p value = 0.001).

Lower values were associated with secondary displacements and
higher values were associated with cutouts (Table 2).
We identied the second lower quarter (D2/D1 between 0.25
and 0.5) of the headneck interface line (L1) as being the safe
zone for the centre of lag screw. The centre of the lag screw was

A. Herman et al. / Injury, Int. J. Care Injured 43 (2012) 856863

860

Fig. 4. The femur neck safe zone which is the second distal quadrant on the headneck interface line. The 11 mm medial-lateral mark on the neck central axis is depicted.

not in the safe zone in thirty-eight patients, and twelve of them

(31.6%) had either a cutout or a secondary reduction loss (Fig. 4). Of
the one hundred and eighty-seven patients in whom the centre of
lag screw was in the safe zone, only seven (3.7%) suffered either a
cutout or a secondary reduction loss (p value = 0.001).

Femur head radiographic measurements

The mean TADs were calculated for the lag screw as well as for
the antirotational screw and they were found to be 20.7 (SD 6.7)
mm and 53.6 (SD 17.7) mm, respectively (p = NS between groups)

Table 1
Demographic and clinical data.
No. failure (207 patients)
Age (year)
Gender
Female
Male
Side
Left
Right
Osteoporosis grade
Nail type
Targon PF
ATN
Nail length
Standard
Long
Reduction
Closed
Open

75.3 (SD 15.74)

159 (90.9%)
48 (92.3%)

Cutout (15 patients)

Secondary reduction loss (5 patients)

p value

78.2 (SD 14.9)

82.0 (SD 8.2)

0.529

14 (8.0%)
1 (1.9%)

2 (1.1%)
3 (5.3%)

0.046

107 (92.2%)
100 (90.1%)
2.95 (SD 1.42)

8 (6.9%)
7 (6.3%)
3 (SD 1.46)

1 (0.9%)
4 (3.6%)
2.4 (1.14)

0.369
0.712

140 (95.2%)
67 (83.8%)

6 (4.1%)
9 (11.2%)

1 (0.7%)
4 (5.0%)

0.01

163 (92.6%)
44 (86.3%)

10 (5.7%)
5 (9.8%)

3 (1.7%)
2 (3.9%)

0.355

194 (90.7%)
13 (100%)

15 (7.0%)

5 (2.3%)

0.514

PF: proximal femur; ATN: antirotation trochanteric nailing system.

A. Herman et al. / Injury, Int. J. Care Injured 43 (2012) 856863

861

Table 2
Radiographic reduction and femur neck measurements.

Reduction quality
AP neck shaft angle (8)
Axial reduction gap (mm)
Axial reduction gap above 5 mm
Femur neck screw positioning (see Fig. 2)
Lag screw centre position (D2/D1)
Lag screw centre in the safe zone (D2/D1 is 0.25-0.5)
Antirotation screw position (D3/D1)

No. failure (207 patients)

Cutout (15 patients)

Secondary reduction loss (5 patients)

p value

132.3 (SD 6.1)

8.2 (SD 6.3)
76/112 (67.9%)

130.7 (SD 6.5)

12.0 (SD 10.5)
5/6 (83.3%)

132.0 (SD 7.3)

8.9 (SD 2.1)
4 (100%)

0.755
0.699
0.073

0.38 (SD 0.08)

180 (87.4%)
0.17 (SD 0.11)

(Table 3). Comparisons between the AP and axial components of

the TAD for these two screws showed a statistically signicant
difference in the AP component alone (Table 3). One hundred and
nineteen (76.8%) patients had TAD less than or equal 25 mm, of
these 10 patients (8.4%) also had a cutout or secondary reduction
loss. Thirty-six patients (23.2%) had TAD higher than 25, of these 4
patients (11.1%) had also a cutout or secondary reduction loss. This
difference was not found to be statistically signicant (p
value = 0.62).
The AP positions of the lag screw on the headneck interface
AP
axis TADAP
LS  sin a differed between the study groups. Extreme
higher and lower values were signicantly (p = 0.001) associated
with cutouts and secondary loss of reduction, respectively (Table
3). The distance of the lag screw tip on the central neck axis
AP
TADAP
LS  cos a was greater than 11 mm in 43 (19.1%) patients
(Fig. 4). Eight of these patients (18.6% of 43 pts) had mechanical
AP
failure. The distance on the central neck axis TADAP
LS  cos a was
less than 11 mm in one hundred and eighty-two patients (80.9%),
ten (5.5% of 182 pts) of whom had mechanical failure (p
value = 0.004 for less than 11 mm vs. more than 11 mm).
Multivariate analysis
Multivariate logistic regression identied the centre of lag
screw positioning in the safe zone of the headneck interface as
the most important factor in preventing mechanical failure (Table
4). Failure attributed to positioning of the centre of lag screw
outside the safe zone had an OR of 13.4 (95% CI = 2.2481, p
value = 0.004). Differences in the other variables in the model were
not found to be statistically signicant (p value > 0.05).

0.52 (SD 0.07)

4 (28.6%)
0.08 (SD 0.04)

0.27 (SD 0.08)

3 (40%)
0.26 (SD 0.14)

0.001
0.001
0.001

Discussion
The ndings of this study demonstrate that the major factor
contributing to treatment success is correct lag screw xation
position. Lag screw position was divided into two perpendicular
axes, the headneck interface axis and the central neck axis.
Positioning of the lag screw tip within or higher than 11 mm of the
head apex, on the central neck axes, were associated with failure
rates of 5.5% and 19.1%, respectively. On the headneck interface
axis, we were able to dene a safe-zone as being the second
quarter (the lower 2550%) of the headneck interface line. Lag
screws placed in or out of this safe zone were associated with
failure rates of 3.7% and 31.6%, respectively. Multivariate analysis
identied the lag screw position within the headneck interface
safe zone as the most important cofactor in preventing
mechanical failure.
We believe these ndings are important for guiding the surgeon
in correct positioning of the xation device. It practically means
that for a successful xation the lag screw guide wire should be
placed within the safe zone as dened here. We have included
the vector analysis performed which led to the denition of the
safe-zone. However, intraoperative complicated calculations are
not necessary in order to use the safe-zone concept. Our study is
the rst radiographic analysis of the double screw PFN xation
device. Although our calculations were done on dual screw xation
devices, our results and recommendations are not that different
from those known for single screw xation devices (e.g., DHS and
Gamma nail).9,14 As such we recommend to use the safe-zone
criteria also for assessing the location of single screw xation
devices.

Table 3
Radiographic femur head xation device position measurements.

Lag screw
TADLS (mm)
TADAP
LS (mm)
TADAx
LS (mm)
On AP head neck interface axis
AP
TADAP
(mm)
LS  sin a
On AP neck centre axis
AP
AP
TADLS  cos a (mm)
On axial headneck interface axis
Ax
TADAx
(mm)
LS  sin a
On axial neck centre axis
Ax
TADAx
(mm)
LS  cos a
Antirotation screw
TADAR (mm)
TADAP
AR (mm)
TADAx
AR (mm)
On AP headneck interface
AP
TADAP
(mm)
AR  sin b
On AP neck centre axis
AP
TADAP
(mm)
AR  cos b

No. failure (207 patients)

Cutout (15 patients)

Secondary reduction loss (5 patients)

p value

20.3 (SD 6.5)

9.7 (SD 3.2)
10.0 (SD 3.9)

24.0 (SD 6.5)

11.7 (SD 2.6)
11.8 (SD 4.5)

25.5 (SD 12.9)

12.9 (SD 4)
12.2 (SD 7.2)

0.175
0.008
0.470

5.49 (SD 4.4)

0.001

10.7 (SD 4.7)

0.061

2.41 (SD 3.9)

8.6 (SD 3)
0.77 (SD 4.9)
9.3 (SD 3.6)
53.4 (SD 17)
26.9 (SD 7.3)
27.4 (SD 10.2

3.41 (SD 3.5)

10.7 (SD 3.3)
0.31 (SD 3.9)

0.67 (SD 6.4)

0.568

11.3 (SD 4.4)

11.1 (SD 6.9)

0.289

58.0 (SD 30.6)

30.2 (SD 10.3)
27.6 (SD 16.5)

25 (SD 11.9)

0.84
0.68
0.94

7.6 (SD 3)

12.2 (SD 2.5)

4.5 (SD 2.7)

0.001

25.6 (SD 7.6)

27.8 (SD 11.6

24.9 (SD 12.3)

0.92

AP: anteroposterior. Mean (SD) standard deviation are presented.

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A. Herman et al. / Injury, Int. J. Care Injured 43 (2012) 856863

Table 4
Multivariate logistic regression.
Covariate

Odds ratio (95% CI)

Lag screw tip distance from the apex, on the central neck axis
1
Less than or equal to 11 mm (baseline)
Greater than 11 mm
3.12 (0.2538.9)
Axial reduction gap
Less than 5 mm (baseline)
1
Greater than 5 mm
9.88 (0.65150)
Centre of lag screw position
1
Within the safe zone (baseline)
Outside the safe zone
13.4 (2.2481)
Gender
Female (baseline)
1
Male
1.95 (0.3211.7)
Hardware system used
TPF (baseline)
1
5.61 (0.8138)
ATN
Tip apex distance (TAD)
Less than 25 mm (baseline)
1
More than 25 mm
5.34 (0.19150)
TAD (Lag screwaxial view)
1.15 (0.831.61)
Osteoporosis
1
Osteoporosis grade 3 (baseline)
Osteoporosis grade 2
0.43 (0.072.55)

p value

0.375

0.099

0.004

0.464

of at least one or two years, respectively. This is, however, an

acceptable follow-up period for a retrospective study of intertrochanteric fractures, with others having used similar time
periods in their retrospective studies.4,9,23,24 Prospective studies
tend to have longer follow-up periods, i.e., up to one year.3,6,7,17,25
Data on the mobility aids used was available for only about 50% of
the patients in this cohort. Another drawback of this study is that it
does not take into account several parameters that were shown to
inuence the outcome of proximal femoral fractures, such as the
patients body mass index, and the American Society of Anaesthesiologist (ASA) score.15
We believe that this work may provide a guide for surgeons in
optimal screw position for reducing the risk of mechanical failure
when performing reduction and xation of intertrochantric fractures.

0.079

Conict of interest

0.323
0.384

The authors declare that there is no conict of interests in

preparing this manuscript. The authors state that neither they nor
any of their immediate family members has received any nancial
benet from this study or any commercial company mentioned
therein. No donation, due to this work, was made by any
commercial company mention in the text to the institute in which
the authors serve as surgeons.

0.352

CI: condence interval; TPF: Targon proximal femur device (Aesculap, Tuttlingen,
Germany); ATN: antirotation trochanteric nailing system (ATN) device (dePuy,
Warsaw, IN, USA).

This is the rst time the headneck interface line has been
dened. It is the line connecting the two transition points of the
contour change between femur head convexity to femur neck
concavity. We also dened the femur neck central axis as being a
perpendicular line that crosses the headneck interface line in its
middle. We believe that the delineation of the neck central axis is
more accurate and one that enables a unique denition of the head
apex as being the point at which the central neck line crosses the
head subchondral bone. Further studies are required in order to
validate this point. We believe that these denitions will prove to
be useful in other femur orthopaedic surgery elds, such as
intracapsular proximal femur fractures and hip arthroplasties.
In our study, the TAD as dened by Baumgaertner et al. (1995)
did not emerge as being an important factor in terms of inuencing
either cutouts or secondary reduction loss.9 Only its AP components, when checked separately, was found to predict either
cutouts or secondary reduction loss. This nding emphasizes the
weakness of the TAD parameter, since it is a scalar measurement
that calculates only distance and disregards direction. Our ndings
and denitions offer surgeons better understanding of the optimal
position of lag screws in proximal femur xation devices.
The mechanical failure rate reported herein was 8.8% (twenty of
two hundred and twenty-seven patients). This failure rate is
comparable to other technical failure rates reported elsewhere.5,7,10,1518 The Cochrane review by Parker and Handoll
(2008)6 includes three randomized clinical trials (Pajarinen et al.,
2005; Papasimos et al., 2005; Saudan et al., 2002)1921 that
compared the outcome of the PFN with that of the sliding hip
screw. The overall number of patients treated by a PFN was one
hundred and ninety-four, of whom ve (2.57%) had cutouts of the
xation nail whilst technical failure of the xation occurred in
eleven patients (5.6%). Giraud et al. (2005) compared thirty-four
patients treated by the Targon PF device with twenty-six patients
treated with sliding hip screw.22 They reported three cutouts
(8.8%) in the former and two (7.7%) in the latter.
One weakness of our study is that it is retrospective and has a
relatively short follow-up period. We included patients whose
follow-up was at least six months and who had signs of
radiological union. Note that of 207 patients with no mechanical
failure, 159 (76.8%) and 98 (47.3%) patients had a follow-up period

Acknowledgment
This research was funded by the Talpiot medical leadership
programme of the Sheba medical centre, grant number 20963. No
external (commercial) funding source was used.
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