title: Failure after osteosynthesis of trochanteric fractures. Where is the limit of osteoporosis?
abstract: CONCLUSIONS
  The aim of this study is to identify osteoporosis values, beyond which there is a high risk of osteosynthesis failure. Bone mineral density (BMD) of 30 cadaveric femora with a pertrochanteric fracture osteotomy was correlated to the risk of cut out after osteosynthesis on a biomechanical testing approach. For a BMD less than 250 mg/cm(3), there is a high risk of fixation failure after surgical treatment of pertrochanteric fractures. This value can be regarded as a reference value for future experimental and clinical studies.
  
  
  BACKGROUND
  Despite continuous modification of intramedullary load carriers for the surgical stabilization of trochanteric fractures, cut out remains the most frequent complication. The aim of this experimental study was to identify threshold osteoporosis values, beyond which there is a high risk of osteosynthesis failure.
  
  
  METHODS
  Bone mineral density (BMD) of 30 cadaveric femora was recorded for the femoral head by QCT measurement. Subsequently, a standardized osteotomy mimicking an unstable trochanteric type fracture was stabilized by intramedullary nailing. The constructs were loaded axially at a force of 2,100 N up to 20,000 cycles. Cut out at the femoral head was documented by radiograph. Statistical evaluation of the cohort group was performed by calculation of relative risk in relation to the BMD values.
  
  
  RESULTS
  In total, there were six cases of cut out after 10,000 cycles. The incidence of cut out for BMD less than 250 mg/cm(3) was 0.55 (5 of 9) and for BMD greater than 250 mg/cm(3), it was 0.05 (1 of 21). Therefore, the relative risk of cut out for BMD <250 mg/cm(3) is 11× greater than for a BMD >250 mg/cm(3). After 20,000 cycles, an additional test caused one cut out (relative risk of cut out for a BMD <250 mg/cm(3) 5.8).
  
  
  CONCLUSIONS
  For a BMD less than 250 mg/cm(3), there is a high risk of fixation failure after surgical treatment of pertrochanteric fractures. Although this value is based on an experimental in vitro study design with all its associated limitations, it can be regarded as a reference value for future experimental and clinical studies.
authors.affiliation: Department of Orthopedics and Traumatology, Albert-Ludwigs-University Freiburg, Freiburg im Breisgau, Germany, lukas.konstantinidis@uniklinik-freiburg.de.
authors.forename: L
authors.initials: L
authors.lastname: Konstantinidis
authors.forename: C
authors.initials: C
authors.lastname: Papaioannou
authors.forename: P
authors.initials: P
authors.lastname: Blanke
authors.forename: A
authors.initials: A
authors.lastname: Hirschmüller
authors.forename: N P
authors.initials: NP
authors.lastname: Südkamp
authors.forename: P
authors.initials: P
authors.lastname: Helwig
mesh_terms: D015519:Bone Density / Q000502:physiology; D005270:Femur Head / Q000000981:diagnostic imaging / Q000503:physiopathology; D005594:Fracture Fixation, Intramedullary / Q000009:adverse effects*; D006620:Hip Fractures / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D010024:Osteoporosis / Q000503:physiopathology*; D058866:Osteoporotic Fractures / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D012016:Reference Values; D018570:Risk Assessment / Q000379:methods; D013314:Stress, Mechanical; D014057:Tomography, X-Ray Computed; D017211:Treatment Failure; D016474:Weight-Bearing