Blade Augmentation in Nailing Proximal Femur Fractures-An Advantage despite Higher Costs?

Background: Proximal femoral fractures occur with increasing incidence, especially in the elderly. Commonly used implants for surgical treatment are cephalomedullary nails. To increase stability, a perforated femoral neck blade can be augmented with cement. The study investigated whether this results in a relevant clinical advantage and justifies the higher cost.

Materials And Methods: This is a single-center retrospective study of 620 patients with proximal femur fractures treated with cephalomedullary nailing. Between January 2016 and December 2020, 207 male and 413 female patients were surgically treated with a proximal femur nail (DePuy Synthes) using a perforated blade and cement augmentation in cases with severe osteoporosis. Primary outcome measures were the rate of cut-out, tip apex distance and the positioning of the blade in the femoral head. Secondary outcome measures were the implant costs and operating times.

Results: Of the 620 femoral neck blades, 299 were augmented with cement. A total of six cut-outs were seen in the first 3 months after the operation. There were three in the cement-augmented group (CAB = cement-augmented blade) and three in the conventional group (NCAB = non-cement-augmented blade). There was a significant positive correlation between age and augmentation, with a mean difference of 11 years between the two groups (CAB 85.7 ± 7.9 vs. NCAB 75.3 ± 15.1; < 0.05). There was no difference in the tip-apex distance (CAB 15.97 vs. 15.69; = 0.64) or rate of optimal blade positions between the groups (CAB 81.6% vs. NCAB 83.2%; = 0.341). Operation times were significantly longer in the cemented group (CAB 62.6 21.2 min vs. NCAB 54.1 7.7 min; < 0.05), and the implant cost nearly doubled due to augmentation.

Conclusion: When the principles of anatomic fracture reduction, optimal tip-apex distance and optimal blade position are combined with cement augmentation in cases of severe osteoporosis, a cut-out rate of less than 1% can be achieved. Nevertheless, it should be noted that augmentation remains expensive and prolongs surgery time without definite proof of mechanical superiority.