AWARENESS OF TIP-APEX DISTANCE REDUCES FAILURE OF
FIXATION OF TROCHANTERIC FRACTURES OF THE HIP
MICHAEL R. BAUMGAERTNER, BRIAN D. SOLBERG
From Yale University, New Haven, USA
We compared the results of the surgical treatment of
trochanteric hip fractures before and after surgeons
had been introduced to the tip-apex distance (TAD) as a
method of evaluating screw position. There were 198
fractures evaluated retrospectively and 118 after
instruction.
The TAD is the sum of the distance from the tip of the
screw to the apex of the femoral head on antero-
posterior and lateral views. This decreased from a mean
of 25 mm in the control group to 20 mm in the study
group (p = 0.0001). The number of mechanical failures
by cut-out of the screw from the head decreased from 16
(8%) in the control group at a mean of 13 months to
none in the study group at a mean of eight months
(p = 0.0015). There were significantly fewer poor
reductions in the study group.
Our study confirms the importance of good surgical
technique in the treatment of trochanteric fractures and
supports the concept of the TAD as a clinically useful
way of describing the position of the screw.
J Bone Joint Surg [Br] 1997;79-B:969-71.
Received 9 May 1997; Accepted 8 July 1997
A sliding hip screw with a fixed angle is commonly used to
fix trochanteric fractures of the hip, but has a reported
1,2
failure rate of 8% to 13%. Mechanical failure is usually
due to cut-out through the femoral head when the fracture
collapses into varus. There is known to be an increased risk
of cut-out in older or osteoporotic patients, those with
3-9
unstable fractures, and after poor reduction or fixation.
Accurate placement of the screw in the femoral head is
M. R. Baumgaertner, MD, Associate Professor
B. D. Solberg, MD, Clinical Instructor
Department of Orthopaedics and Rehabilitation, Yale University School of
Medicine, Yale Physicians Building, 800 Harvard Avenue, New Haven,
Connecticut 06510, USA.
Correspondence should be sent to Dr M. R. Baumgaertner.
©1997 British Editorial Society of Bone and Joint Surgery
0301-620X/97/67949 $2.00
VOL. 79-B, NO. 6, NOVEMBER 1997
essential, but there is no simple method of describing and
documenting this position.
We have devised the use of the tip-apex distance (TAD)
from anteroposterior (AP) and lateral radiographs to
describe the position of the screw within the femoral head
and have shown it to be highly predictive of failure by cut-
10
out. We now report a prospective study to assess the
effect of the introduction of this concept on the manage-
ment of trochanteric fractures of the hip in one hospital.
PATIENTS AND METHODS
We included all patients with trochanteric hip fractures
treated by a fixed-angle sliding hip screw and either a
sideplate or an intramedullary nail who had complete radio-
logical and clinical records and a minimum follow-up of
three months. Of 146 consecutive patients treated after the
TAD concept had been introduced, 118 (118 fractures) met
these criteria. Our retrospective control group was a series
of 198 fractures (193 patients) treated over the previous
four years.
For both groups, we recorded the patients’ age, gender
and medical condition on the rating of the American Soci-
11
ety of Anaesthesiologists. Fracture patterns were classi-
12
fied according to the systems of Müller et al and of
13 14
Evans as modified by Kyle, Gustilo and Premer, and
considered as stable (types I and II) or unstable (types III
and IV). Reduction was assessed on the amount of dis-
placement and neck-shaft alignment on immediate post-
operative AP and lateral radiographs, being categorised as
good, acceptable or poor. A good reduction had normal or
slightly valgus neck-shaft alignment on the AP radiograph,
under 20° of angulation on the lateral and displacement of
less than 4 mm on either view. Acceptable reductions met
the requirements as regards alignment or displacement, but
not both. Poor reductions met neither criteria. Implant type
and angle were recorded for both prospective and retro-
spective groups.
Tip-apex distance. The calculation of TAD (Fig. 1) has
10
previously been reported in detail. It is the sum of the
distances from the tip of the lag screw to the apex of the
femoral head on AP and lateral radiographs. For research
purposes we adjusted for radiological magnification using
969
970 M. R. BAUMGAERTNER,
Fig. 1
The TAD can be estimated during operation by measuring the distance
from the tip of the guide-pin to the apex of the femoral head on both the
AP and lateral fluoroscopic images.
the known diameter of the hip screw, but for intraoperative
use the TAD can easily be estimated from the fluoroscopic
images after guide-pin insertion (Fig. 1). It does not differ-
entiate between peripheral or shallow placement, but the
smaller values confirm that the implant is more central and
deeply located.
We recommended that the aim should be a TAD of under
25 mm, since we had no screw cut-out in our retrospective
series when this had been achieved, regardless of any other
fracture or patient variables. For purposes of comparison
we also recorded the location of the tip of the screw as
14 15
defined by Kyle et al and Cleveland et al. In this
method the femoral head is divided into superior, central
and inferior thirds on the AP view, and into anterior, central
and posterior thirds on the lateral view, giving a total of
nine separate zones.
A total of 41 attending surgeons operated during both
Fig. 2
The distribution of TAD for the study group of 118 fractures (white) and for the retrospective control group of
182 fractures, showing those which did not cut out (grey) and those which did (black). The shift to smaller TAD
values, implying more central and deep screw placement, is well shown.
B. D. SOLBERG
study periods. Seven were active only during the control
period, 28 (68%) during both periods, and six operated only
during the study period. At the end of the study, all were
asked to complete a questionnaire about their perceptions
of the fixation of trochanteric hip fractures.
We used Student’s t-test for analysis of interval data, a
chi-squared test for dichotomous variable data and con-
tingency table analysis for multiple categorical data.
RESULTS
The two groups were similar with respect to gender and
ASA medical rating, but the mean age of the study group
was 81 years as against 77 years for the control group
(p = 0.001). There were more stable fractures in the study
group (56%) than in the control group (45%) (p > 0.005).
There were 169 (85%) good or acceptable reductions and
29 (15%) poor reductions in the control group, as against
111 (94%) good or acceptable and 7 (6%) poor reductions
in the study group (p = 0.0002). Intramedullary implants
were used in 28% of the control group and 39% of the
study group (p = 0.05); the use of 135° sideplates had
increased, with significantly fewer 145° and 150° devices
being used in the study group (p = 0.001).
There were no cut-out failures in the 118 fractures of the
study group at a mean follow-up of eight months (3 to 19),
compared with 16 of 198 (8%) in the control group at a
mean follow-up of 13 months (3 to 48) (p = 0.0015). In the
study group, one patient had delayed union in a varus
position after fractures of the sideplate screws and another
had deep infection which required removal of the implant.
There were three non-cut-out failures in the control
group.
For the study group the mean TAD was 20 mm (6 to 40),
significantly less than the mean of 25 mm (9 to 63) for the
control group (p = 0.0001). The TAD was less than the
THE JOURNAL OF BONE AND JOINT SURGERY
 TIP-APEX DISTANCE IN FIXATION OF INTERTROCHANTERIC FRACTURES OF THE HIP
recommended maximum of 25 mm in 87% of the study
group and in 75% of the control group (p = 0.006; Fig. 2),
and the proportion of screws in the central zone in both
planes was 64% and 43%, respectively (p = 0.0002).
To reduce bias due to changes in surgeons and their skill
we specifically reviewed the results for the 28 attending
surgeons working throughout both periods. For this group
the average TAD fell from 26 to 20 mm and cut-out failures
from 7% to zero.
Only 62% of the questionnaires were returned. The
perception was that improved technique was responsible
for the decrease in the rate of cut-out. Of those who felt that
better technique was the cause for improvement, 80%
highlighted the importance of better screw position, often
using the term “central and deep”, but only 20% used the
term TAD in their answer, and only 25% mentioned
improved quality of reduction.
DISCUSSION
We have shown a significant improvement in surgical
technique and results after surgeons had been made aware
of the current local failure rate and were introduced to
intraoperative estimation of the TAD. Many previous
reports on the treatment of hip fracture have focused on
variables associated with the patient or the implants, but
our study has shown that continuing education and
increased interest in technique can improve results. Johans-
16
son et al showed significant improvement in reduction
and position of implants when fixation was performed by a
small number of interested surgeons. They did not report
outcomes, and it was not clear whether the smaller group of
surgeons had improved, or had been selected because they
were better technicians.
Our questionnaire showed that surgeons had not specifi-
cally measured the TAD during operation, but that the
increased emphasis on central and deep placement had led
to improved screw positions.
Other factors not related to improved surgical technique
could have influenced the results. Although not significantly
different, there were more stable fractures in the study
group, and this would be expected to decrease the rate of
cut-out. There was a shift away from the use of high-angle
plate fixation, possibly because the initial study had identi-
fied the use of a 150° device as an independent predictor of
cut-out, but the study group was older. An increase in
intramedullary fixation did occur, but such devices have not
17
been shown to influence the rate of cut-out.
As this was a prospective study, the surgeons were aware
of data collection, and the so-called Hawthorne effect must
apply: the outcome will have been influenced by the study
18,19
itself. During the duration of both treatment periods
VOL. 79-B, NO. 6, NOVEMBER 1997
971
there was no change in imaging technology or implant
availability.
We believe that our results confirm that surgical tech-
nique is an important factor in the outcome of treatment for
intertrochanteric hip fracture, and that it can be influenced
by education and improved methods of assessment.
Although none of the authors have received or will receive benefits for
personal or professional use from a commercial party related directly or
indirectly to the subject of this article, benefits have been or will be
received but are directed solely to a research fund, educational institution,
or other non-profit institution with which one or more of the authors is
associated.
REFERENCES
1. Bannister GC, Gibson AG, Ackroyd CE, Newman JH. The fixation
and prognosis of trochanteric fractures: a randomised prospective
controlled trial. Clin Orthop 1990;254:242-6.
2. Simpson AHRW, Varty K, Dodd CAF. Sliding hip screws: modes of
failure. Injury 1989;20:227-31.
3. Larsson S, Friberg S, Hansson LI. Trochanteric fractures: influence of
reduction and implant position on impaction and complications. Clin
Orthop 1990;259:130-9.
4. Mainds CC, Newman RJ. Implant failures in patients with proximal
fractures of the femur treated with a sliding screw device. Injury
1989;20:98-100.
5. Mulholland RC, Gunn DR. Sliding screw fixation of intertrochanteric
femoral fractures. J Trauma 1972;12:581-91.
6. Sernbo I, Johnell O, Gentz CF, Nilsson JA. Unstable intertrochanteric
fractures of the hip: treatment with Ender pins compared with a
compression hip screw. J Bone Joint Surg [Am] 1988;70-A:1297-
303.
7. Doherty JH, Lyden JP. Intertrochanteric fractures of the hip treated
with the hip compression screw. Clin Orthop 1979;141:184-7.
8. Brink PR, Bolhuis RJ, Runne WC, De Vries AC. Low nail-plate
fixation and early weight-bearing ambulation for stable trochanteric
fractures. J Trauma 1987;27:491-5.
9. Davis TRC, Sher JL, Horsman A, et al. Intertrochanteric femoral
fractures: mechanical failure after internal fixation. J Bone Joint Surg
[Br] 1990;72-B:26-31.
10. Baumgaertner MR, Curtin SL, Lindskg DM, Keggi JM. The value
of the tip-apex distance in predicting failure of fixation of peritrochan-
teric fracture fixation. J Bone Joint Surg [Am] 1995;77-A:1058-64.
11. American Society of Anesthesiologists. New classification of physical
status. Anesthesiology 1963;24:111.
12. Müller ME, Nazarian S, Koch P, Schatzker J. The comprehensive
classification of fractures of long bones. Berlin, etc; Springer-Verlag,
1990.
13. Evans EM. Trochanteric fractures: a review of 110 cases treated by
nail-plate fixation. J Bone Joint Surg [Br] 1951;33-B:192-204.
14. Kyle RF, Gustilo RB, Premer RF. Analysis of six hundred and
twenty-two intertrochanteric hip fractures: a retrospective and pro-
spective study. J Bone Joint Surg [Am] 1979;61-A:216-21.
15. Cleveland M, Bosworth DM, Thompson FR, Wilson HJ Jr, Ishizu-
ka T. A ten-year analysis of intertrochanteric fractures of the femur. J
Bone Joint Surg [Am] 1959;41-A:1399-1408.
16. Johansson A, Stromqvist B, Bauer G, Hansson LI, Pettersson H.
Improved operations for femoral neck fracture: a radiographic evalu-
ation. Acta Orthop Scand 1986;57:505-9.
17. Bridle SH, Patel AD, Bircher M, Calvert PT. Fixation of inter-
trochanteric fractures of the femur: a randomised prospective compar-
ison of the Gamma nail and the dynamic hip screw. J Bone Joint Surg
[Br] 1991;73-B:330-4.
18. Bouchet C, Guillemin F, Briancon S. Nonspecific effects in longitud-
inal studies: impact on quality of life measures. J Clin Epidemiol
1996;49:15-20.
19. Fletcher RM, Fletcher SW, Wagner EH. Clinical epidemiology: the
essentials. Baltimore: Williams & Wilkins, 1982:127-52.