Accepted Manuscript

Title: What is the optimal salvage procedure for cut-out after

surgical fixation of trochanteric fractures with the PFNA or
TFN? - a multicentre study -

Author: Alexander Brunner Markus Büttler Uwe Lehmann

Hans Curd Frei Renato Kratter Marco Di Lazzaro Alexander
Scola An Sermon Rene Attal

PII: S0020-1383(15)00749-4
DOI: http://dx.doi.org/doi:10.1016/j.injury.2015.11.027
Reference: JINJ 6514

To appear in: Injury, Int. J. Care Injured

Received date: 13-7-2015

Accepted date: 13-11-2015

Please cite this article as: Brunner A, Büttler M, Lehmann U, Frei HC, Kratter R, Di
Lazzaro M, Scola A, Sermon A, Attal R, What is the optimal salvage procedure for
cut-out after surgical fixation of trochanteric fractures with the PFNA or TFN? - a
multicentre study -, Injury (2015), http://dx.doi.org/10.1016/j.injury.2015.11.027

This is a PDF file of an unedited manuscript that has been accepted for publication.
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 1 What is the optimal salvage procedure for cut-out after surgical fixation of

2 trochanteric fractures with the PFNA or TFN?

3 - a multicentre study -

5 Alexander Brunner,1 Markus Büttler,2 Uwe Lehmann,3 Hans Curd Frei,4

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Renato Kratter,5 Marco Di Lazzaro,6 Alexander Scola,7 An Sermon,8 Rene Attal1

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6

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8

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1
9 Medical University Innsbruck, Department of Trauma Surgery, Anichstrasse 35,

10 6020 Innsbruck, Austria

11 2
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DePuy Synthes, Luzernstrasse 21, 4528 Zuchwil, Switzerland
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3
12 Clinic Forchheim, Trauma Surgery Department, Krankenhausstraße 10,

13 91301 Forchheim, Germany

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4
14 Davos Hospital, Department of Trauma and Orthopaedic Surgery,

15 Promenade 4, 7270 Davos Platz, Switzerland

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5
16 Lachen Hospital, Department of Trauma Surgery, Oberdorfstrasse 41,
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17 8853 Lachen, Switzerland

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18 Männedorf Hospital, Asylstrasse 10, 8708 Männedorf, Switzerland
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7
19 Ulm University, Department of Orthopaedic Trauma, Albert-Einstein-Allee 23,

20 89081 Ulm, Germany

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21 University Hospitals Gasthuisberg, Department of Traumatology, Herestraat 49,

22 3000 Leuven, Belgium

23

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23

24 Conflicts of interest

25 Research for the present study was supported by Synthes Ltd., Zuchwil,

26 Solothurn, Switzerland. Markus Büttler is an employee of Synthes Ltd.

27 None of the authors has received personal payments or other benefits or a

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28 commitment or agreement to provide such benefits from a commercial entity. No

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29 commercial entity paid or directed, or agreed to pay or direct, any benefits to any

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30 research fund, foundation, educational institution, or other charitable or non-profit

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31 organisation with which the authors are affiliated or associated.

32

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34 Corresponding author:

35 Alexander Brunner, MD, PD

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36 Department of Traumatology

37 Medical University Innsbruck

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38 Anichstrasse 35
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39 6020 Innsbruck

40 Austria
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41 Phone: +43 699 150 79967

42 Fax: +43 512 504 22824

43 E-mail: a-r.brunner@web.de

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47
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50

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54 What is the optimal salvage procedure for cut-out after surgical fixation of

55 trochanteric fractures with the PFNA or TFN?

56 - a multicentre study –

57

58 Purpose: To evaluate the outcome after different types of revision operations for

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59 blade ‘cut-out’ and ‘cut-through’ after fixation of trochanteric fractures with

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60 proximal femoral nail antirotation (PFNA) or a trochanter fixation nail (TFN).

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61 Methods: Twenty hospitals participated in this multicentre study. A total of 4109

62 patients were retrospectively screened for cut-out or cut-through complications

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63 after nailing of trochanteric fractures using PFNA or TFN. Fifty-seven patients (28

64

65
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with ‘cut-through’ and 29 with ‘cut-out’) were included in the study. In the ‘cut-

through’ group, 16 patients underwent a blade exchange, six patients had a blade
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66 exchange with bone cement augmentation, and six received total hip arthroplasty

67 (THA). In the ‘cut-out’ group, three patients had a blade exchange, one had a
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68 blade exchange with augmentation, three underwent re-nailing of the fracture with

69 a new PFNA, one had a girdlestone procedure and 21 had THA procedures.
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70 Results: In the ‘cut-through’ group, eight patients who had a blade exchanges
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71 (50%) and two patients with blade exchange and augmentation (33%) required

72 further revision operations. THA was the definite treatment in all 6 cases.
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73 In the ‘cut-out’ group, two patients (66%) who had blade exchanges and two

74 (66%) who underwent re-nailing required additional revision operations during the

75 subsequent course. One patient (4%) who had total hip arthroplasty needed

76 revision surgery for acetabular replacement.

77 Overall, a total of 81 revision procedures were performed.

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78 Conclusion: Based on the data from this study, we recommend THA as the only

79 valid salvage procedure for ‘cut-out’ and ‘cut-through’ of helical blades after

80 fixation of trochanteric fractures with the PFNA and TFN.

81 Key words: cut-out, cut-through, PFNA, TFN, revision

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 82

83 Introduction

84 Trochanteric fractures of the proximal femur are common injuries in elderly

85 people, and treating them is likely to result in significant health-care costs in the

86 coming years.[1-3] During the last decade, proximal femoral nail antirotation

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87 (PFNA, Synthes, Oberdorf, Switzerland)[4, 5] and the trochanter fixation nail

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88 (TFN, Synthes Paoli, USA)[6] have become established as standard treatment

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89 devices for fixation of stable and unstable trochanteric fractures. Several single-

90 centre and multicentre studies have reported satisfactory results after the use of

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91 these devices.[5, 7-12]

92

93
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Two major types of implant-related complication have been reported with the two

implants: perforation of the helical blade through the superior cortex of the
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94 femoral head or neck, followed by rotation and varus collapse of the head–neck

95 fragment (cut-out)[13, 14]; and medial migration of the blade, with perforation of
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96 the blade tip into the hip joint without loss of reduction (cut-through).[15, 16]

97 A variety of surgical salvage procedures have been proposed in order to address

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98 these complications, including changing the helical blade,[17] changing the blade
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99 with additional cement augmentation,[15] re-nailing of the fracture[17] and

100 conversion of the procedure to a total hip arthroplasty (THA).[13, 15, 16] Until
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101 recently, information about success rates with these salvage procedures has

102 been limited to reports of small case series.[13, 15-17] Data-based

103 recommendations regarding the optimal treatment for cut-out and cut-through

104 complications remain sparse in the literature.

105 The retrospective multicentre study presented here was performed in order to

106 evaluate the outcomes of different types of salvage procedure for blade cut-out

107 and cut-through after nailing of trochanteric fractures using PFNA or TFN. The

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108 purpose of the study was to evaluate the failure and success rates of salvage

109 procedures for cutting-out and cutting-through of blades and to offer data-based

110 recommendations on the optimal treatment strategy for each type of complication.

111

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111
112 Materials and methods

113 Twenty hospitals in six countries in Europe participated in this multicentre study.

114 The study was approved by the ethics commission of the Medical University of

115 Innsbruck (Austria) and is in accordance with the Declaration of Helsinki.[18]

116 A total of 4109 patients were retrospectively screened for cut-out or cut-through

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117 complications after nailing of trochanteric fractures using PFNA or TFN between

118 2003 and 2010. ‘Cut-out’ was defined as perforation of the helical blade through

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119 the superior cortex of the femoral head or neck, followed by rotation or varus

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120 collapse of the head–neck fragment. ‘Cut-through’ was defined as medial

121 perforation of the blade through the cortex of the femoral head, without loss of

122 reduction of the head–neck fragment.

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123 Inclusion criteria for the study were trochanteric fractures classified as types 31-
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124 A1/A2/A3 in the AO/OTA classifications,[19, 20] surgical fixation with PFNA or

125 TFN, a postoperative cut-out or cut-through complication and revision surgery

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126 during the subsequent course. Exclusion criteria were missing or incomplete
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127 medical follow-up information, inadequate quality of radiographs or computed-

128 tomography scans and the use of any fixation devices other than PFNA or TFN.
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129 On the basis of these criteria, 57 patients (46 women, 11 men) with a mean age

130 of 81 years (range 56–95 y, SD: 8.9 y) were included for further evaluation.
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131 Twenty-eight patients had cut-through complications and 29 had cut-out

132 complications.

133 All preoperative, postoperative and follow-up radiographs, patients’ medical

134 records and surgical reports were obtained.

135 The radiographs were uploaded to a picture archiving and communication system

136 (PACS) workstation (ClearCanvas Workstation; ClearCanvas Inc., California,

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137 USA) for further evaluation. A radiological evaluation was carried out, including

138 classification of the fracture types using the AO/OTA criteria[19, 20] and

139 measurement of the initial postoperative tip–apex distances (TADs) as described

140 by Baumgaertner et al.[21]

141 The Garden alignment angle[8] (GAA) was measured in the anteroposterior and

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142 lateral views to evaluate the quality of postoperative reduction. On the basis of

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143 the recommendations given by Lenich et al.,[8] an anteroposterior GAA of 160°

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144 and a lateral GAA of 180° were rated as ‘very good’ reductions; an

145 anteroposterior GAA between 180° and 160° and a lateral GAA of 180° were

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146 rated as ‘good’ reductions; an anteroposterior GAA between 160° and 150° and a

147

148
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lateral GAA of 180° were rated as ‘moderate’ reductions; and an anteroposterior

GAA of less than 150° or a lateral GAA of less than 180° were rated as ‘poor’
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149 reductions. Two fellowship-trained trauma surgeons with several years of

150 experience in the treatment of hip fractures reviewed all of the radiographs and
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151 measured TADs and GAAs. The patients’ medical reports were reviewed for

152 American Society of Anesthesiologists (ASA) scores,[22] medical comorbidities,

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153 time between the initial surgical fixation and cut-out or cut-through, types and
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154 numbers of revision operations, and types and numbers of complications during

155 the follow-up period.

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156

157 Statistical analysis

158 The unpaired Student’s t-test was used to compare linear data between the cut-

159 through and cut-out groups. Differences between nominal data were calculated

160 using the chi-squared test.

161

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161
162 Results

163 Nine fractures were classified as type A1, 34 as type A2 and 14 as type A3. Initial

164 surgical fixation was performed with PFNA in 47 cases and with TFN in 10 cases.

165 The mean postoperative TAD was 26.2 mm (SD: 13.4).

166 The initial postoperative reductions were rated as ‘very good’ in five cases, ‘good’

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167 in five, ‘moderate’ in 21 and ‘poor’ in 26 cases. The patients’ mean ASA score

168 was 3.4 (SD: 0.8) and the mean number of comorbidities was 3.4 (SD: 2.5). The

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169 cut-out group was significantly older in comparison with the cut-through group

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170 (P < 0.01) (Table 1). Patients with a cut-through complication showed significantly

171 lower mean TAD values in comparison with patients with a cut-out complication

172
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(P < 0.01). Patients in the cut-out group showed a significantly higher rate of

173 ‘poor’ reductions after initial fixation in comparison with the cut-through group
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174 (P < 0.02). The rate of ASA type 4 patients was significantly higher in the cut-

175 through group in comparison with the cut-out group (P < 0.02). Similarly, the
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176 mean number of comorbidities was significantly higher in the cut-through group in
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177 comparison with the cut-out group (P < 0.01).

178 Detailed data for the patients are presented in Table 1.

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179

180 Cut-through of the helical blade (n = 28)

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181 The helical blade was changed in 16 patients. The fracture healed without further

182 complications in eight of these patients (50%).

183 In seven patients (44%), re-perforation of the blade through the femoral cortex

184 occurred (five cut-through, two cut-out) and one patient had lateral migration of

185 the blade during the subsequent course. One of these eight patients (cut-out)

186 developed an additional deep wound infection. These eight patients required a

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187 second revision operation, including repeat changing of the blade in two patients,

188 repeat changing of the blade with additional cement augmentation in two patients,

189 re-nailing with PFNA in one patient, re-nailing with a gamma nail in one patient,

190 and THA in one patient (Fig. 1). The patient with the deep wound infection

191 underwent metal removal, resection of the head–neck fragment and preliminary

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192 stabilization with an external fixator, removal of the external fixator and insertion

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193 of a cement spacer, and finally THA. The two patients who were treated with a

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194 blade exchange and the two who were treated with re-nailing required a third

195 revision operation with THA.

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196 Six patients had the helical blade changed with additional cement augmentation.

197

198
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This led to fracture healing in four of the patients (Fig. 1). One patient presented

with re-perforation of the blade and required a second revision operation,

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199 consisting of THA. One patient developed a superficial wound infection, which

200 healed after surgical debridement.

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201 THA was performed as the initial salvage procedure in six patients after cut-

202 through, and it was the definitive treatment in all of these cases (Fig. 1).
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203 One patient died after a follow-up period of 5.7 months for medical reasons
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204 unrelated to implant failure.

205 In summary, the 28 patients in whom cut-through of the helical blade occurred
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206 underwent a total of 44 revision operations (Table 2).

207

208 Cut-out of the helical blade (n = 29)

209 The helical blade was changed in three patients, two of whom developed re-

210 perforation of the blade and required a second revision operation with THA

211 (Fig. 2). One patient sustained a deep wound infection at the time of the cut-out.

212 A Girdlestone procedure was performed. The patient died of septic shock 6 days

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213 later. In one patient, the blade was changed with bone cement augmentation. The

214 fracture healed after 19 weeks.

215 Three patients underwent metal removal and re-nailing of the fracture with a new

216 PFNA. One of these fractures healed. One patient developed re-perforation of the

217 blade and required a second revision procedure with THA. One patient sustained

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218 a deep wound infection after re-nailing and required two more revision operations.

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219 Finally, the patient had a cement spacer inserted, which became the definite

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220 treatment (Fig. 2). One patient had the nail removed after repeat cutting-out of the

221 blade, with open repeat reduction and fixation with a dynamic hip screw. The

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222 fracture healed after 33 weeks.

223

224
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THA was performed as the primary revision procedure in 21 patients. Uneventful

healing followed in 20 of these patients, but one patient had multiple dislocations
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225 of the THA and required revision surgery with replacement of the acetabular cup

226 (Fig. 2).

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227 In summary, the 31 patients with cut-out of the helical blade underwent a total of

228 37 revision procedures (Table 2).

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229
230 Discussion

231 Over the last 10 years, blade ‘cutting-out’ and ‘cutting-through’ have been

232 frequently reported as typical complications after surgical fixation of trochanteric

233 fractures using PFNA and TFN.[5, 7, 8, 10, 11, 13-16, 23-30] However, these

234 complications are comparatively rare relative to the total number of operations

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235 performed. A literature search identified 20 English-language publications listed

236 on PubMed reporting a total of 47 cases of cut-out/cut-through complications after

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237 treatment of 2458 trochanteric fractures.[5, 7-11, 13-15, 23-33] This represents a

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238 complication rate of 1.9%, slightly higher than the 1.4% rate (57 of 4109) in the

239 present study. However, as the present study is a retrospective evaluation, some

240
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cut-out/cut-through cases may have remained undetected.

241 Recently, there have been a few reports[15, 16, 24, 28] on outcomes after
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242 revision operations for these complications, most of which recommend total hip

243 arthroplasty as the definitive treatment of choice. The maximum sample size
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244 evaluated in one of these studies was six patients.[24] The present study is the first
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245 evaluation of a larger group of patients with these complications after fixation of

246 trochanteric fractures with PFNA or TFN. The data show that patients who
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247 present with cut-out or cut-through complications are usually relatively elderly and

248 are suffering from several comorbid conditions. In the present study, 56% of the
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249 patients were classified as ASA 4, and the percentage was even higher in the cut-

250 through group (71%). The mean number of medical comorbidities was 3.4 per

251 patient. These patients are not good candidates for extensive revision operations.

252 In everyday clinical practice, surgeons may therefore opt for a relatively quick

253 change of the helical blade especially in cut-through cases, with no loss of

254 reduction of the head–neck fragment. The present data show that this procedure

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255 is associated with a failure rate of 50% and may require multiple revision

256 operations during the subsequent course (Fig. 4). We therefore do not

257 recommend this procedure for any patients in whom blade cut-out or cut-through

258 occurs.

259 The helical blade was designed to cause bone compaction around the implant

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260 during insertion.[4] Some studies have shown that this leads to greater resistance

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261 against torque and varus collapse.[34, 35] However, resistance to axial migration

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262 has been found to be lower with helical blades in comparison with conventional

263 lag screws.[36]

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264 In the present authors’ opinion, resistance to axial migration of the blade is

265

266
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minimal in cases in which the blade has already perforated through the femoral

head cortex (cut-through). This may not be affected by changing the blade,
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267 consequently leading to the high number of repeat perforations observed after

268 blade exchange.

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269 Some authors have proposed additional cement augmentation around the blade

270 tip in order to improve anchorage in osteoporotic bone.[37-39] Scola et al.[17]

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271 reported a case of near–cut-out that was treated by implant removal, re-
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272 osteosynthesis and augmentation of the helical blade. The patient died 4 weeks

273 later due to heart failure. There continues to be a scarcity of other reports on the
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274 outcome of revision operations for cut-out/cut-through complications with cement

275 augmentation. In the present study, the failure rate after blade change with

276 cement augmentation was 33% in the cut-through group. This high rate is not

277 acceptable, and in view of the data we do not recommend this technique as a

278 revision procedure for cut-through complications.

279 In the cut-out group, three patients were treated with metal removal, repeat

280 reduction of the fracture and re-nailing. One of these fractures healed during the

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281 subsequent course and two of the patients required revision surgery. This

282 represents a failure rate of 66% in the repeat nailing group. However, the size of

283 this subgroup is too small for any valid assessment of the value of the procedure.

284 One patient in the cut-out group was also treated with metal removal and repeat

285 fixation with a dynamic hip screw. Another patient was treated with a Girdlestone

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286 procedure. These single cases do not allow any valid outcome analysis.

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287 Overall, 27 patients (46%) were treated with THA as the initial salvage procedure.

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288 This was the definitive treatment in 95% of the patients in the cut-out group and in

289 100% of those in the cut-through group. No cases of deep wound infection

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290 occurred in patients treated with THA. This finding is consistent with the results

291

292
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reported by Liu et al.,[24] who described good outcomes without further

complications after THA as a salvage procedure in three patients with cut-out and
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293 three with cut-through.

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294
295 Conclusions

296 On the basis of the data presented in this study, the authors would recommend

297 THA as the only valid salvage procedure for cut-out and cut-through

298 complications with helical blades after fixation of trochanteric fractures with PFNA

299 and TFN. In cut-through cases in which the patient’s medical condition does not

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300 allow extensive revision surgery, surgeons may choose a blade change rather

301 than THA. However, surgeons should be aware that in this situation, a failure rate

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302 of around 50% must be expected.

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303
304 References

305 [1] Azagra R, Lopez-Exposito F, Martin-Sanchez JC, Aguye A, Moreno N, Cooper C, et

306 al. Changing trends in the epidemiology of hip fracture in Spain. Osteoporosis

307 international : a journal established as result of cooperation between the European

308 Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA.

t
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309 2014;25:1267-74.

310 [2] Cooper C, Cole ZA, Holroyd CR, Earl SC, Harvey NC, Dennison EM, et al. Secular

cr
311 trends in the incidence of hip and other osteoporotic fractures. Osteoporosis

us
312 international : a journal established as result of cooperation between the European

313 Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA.

314 2011;22:1277-88.
an
[3] Yoon BH, Lee YK, Kim SC, Kim SH, Ha YC, Koo KH. Epidemiology of proximal
M
315

316 femoral fractures in South Korea. Archives of osteoporosis. 2013;8:157.

ed

317 [4] PFNA. Leading the way to optimal stability: Synthes. Original Instruments and

318 implants of the Association for the Study of Internal Fixation. OA/ASIF. Stratec
pt

319 Medical. 2004:1-44.

[5] Mereddy P, Kamath S, Ramakrishnan M, Malik H, Donnachie N. The AO/ASIF

ce

320

321 proximal femoral nail antirotation (PFNA): a new design for the treatment of
Ac

322 unstable proximal femoral fractures. Injury. 2009;40:428-32.

323 [6] Lenich A, Fierlbeck J, Al-Munajjed A, Dendorfer S, Mai R, Fuchtmeier B, et al. First

324 clinical and biomechanical results of the Trochanteric Fixation Nail (TFN).

325 Technology and health care : official journal of the European Society for Engineering

326 and Medicine. 2006;14:403-9.

17
Page 16 of 33
327 [7] Gardner MJ, Briggs SM, Kopjar B, Helfet DL, Lorich DG. Radiographic outcomes of

328 intertrochanteric hip fractures treated with the trochanteric fixation nail. Injury.

329 2007;38:1189-96.

330 [8] Lenich A, Mayr E, Ruter A, Mockl C, Fuchtmeier B. First results with the

331 trochanter fixation nail (TFN): a report on 120 cases. Archives of orthopaedic and

t
332 trauma surgery. 2006;126:706-12.

ip
333 [9] Pu JS, Liu L, Wang GL, Fang Y, Yang TF. Results of the proximal femoral nail anti-

cr
334 rotation (PFNA) in elderly Chinese patients. International orthopaedics.

2009;33:1441-4.

us
335

336 [10] Simmermacher RK, Ljungqvist J, Bail H, Hockertz T, Vochteloo AJ, Ochs U, et al.

337 an
The new proximal femoral nail antirotation (PFNA) in daily practice: results of a

338 multicentre clinical study. Injury. 2008;39:932-9.

M
339 [11] Vaquero J, Munoz J, Prat S, Ramirez C, Aguado HJ, Moreno E, et al. Proximal

340 Femoral Nail Antirotation versus Gamma3 nail for intramedullary nailing of unstable
ed

341 trochanteric fractures. A randomised comparative study. Injury. 2012;43 Suppl

342 2:S47-54.
pt

343 [12] Yaozeng X, Dechun G, Huilin Y, Guangming Z, Xianbin W. Comparative study of

ce

344 trochanteric fracture treated with the proximal femoral nail anti-rotation and the

345 third generation of gamma nail. Injury. 2010;41:1234-8.

Ac

346 [13] Liu W, Zhou D, Liu F, Weaver MJ, Vrahas MS. Mechanical complications of

347 intertrochanteric hip fractures treated with trochanteric femoral nails. The journal

348 of trauma and acute care surgery. 2013;75:304-10.

349 [14] Nikoloski AN, Osbrough AL, Yates PJ. Should the tip-apex distance (TAD) rule be

350 modified for the proximal femoral nail antirotation (PFNA)? A retrospective study.

351 Journal of orthopaedic surgery and research. 2013;8:35.

18
Page 17 of 33
352 [15] Brunner A, Jöckel JA, Babst R. The PFNA proximal femur nail in treatment of

353 unstable proximal femur fractures--3 cases of postoperative perforation of the

354 helical blade into the hip joint. Journal of orthopaedic trauma. 2008;22:731-6.

355 [16] Frank MA, Yoon RS, Yalamanchili P, Choung EW, Liporace FA. Forward

356 progression of the helical blade into the pelvis after repair with the Trochanter

t
357 Fixation Nail (TFN). Journal of orthopaedic trauma. 2011;25:e100-3.

ip
358 [17] Scola A, Gebhard F, Dehner C, Roderer G. The PFNA(R) Augmented in Revision

cr
359 Surgery of Proximal Femur Fractures. The open orthopaedics journal. 2014;8:232-6.

[18] association WM. Declaration of Helsinki: ethical principles for research

us
360

361 involving human subjects. As amended by the 59th General Assembly, Seoul. 2008.

362 an
[19] Marsh JL, Slongo TF, Agel J, Broderick JS, Creevey W, DeCoster TA, et al. Fracture

363 and dislocation classification compendium - 2007: Orthopaedic Trauma Association

M
364 classification, database and outcomes committee. Journal of orthopaedic trauma.

365 2007;21:S1-133.
ed

366 [20] Müller M, Nazarian S, Koch P, Schatzker J. The comprehensive classification of

367 fractures of long bones. Berlin: Springer Verlag; 1990.

pt

368 [21] Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM. The value of the tip-apex
ce

369 distance in predicting failure of fixation of peritrochanteric fractures of the hip. The

370 Journal of bone and joint surgery American volume. 1995;77:1058-64.

Ac

371 [22] (ASA) ASoA. New classification of physical status. Anesthesiology. 1963;24:111.

372 [23] Gavaskar AS, Subramanian M, Tummala NC. Results of proximal femur nail

373 antirotation for low velocity trochanteric fractures in elderly. Indian journal of

374 orthopaedics. 2012;46:556-60.

375 [24] Liu JJ, Shan LC, Deng BY, Wang JG, Zhu W, Cai ZD. Reason and treatment of

376 failure of proximal femoral nail antirotation internal fixation for femoral

19
Page 18 of 33
377 intertrochanteric fractures of senile patients. Genetics and molecular research : GMR.

378 2014;13:5949-56.

379 [25] Sadic S, Custovic S, Jasarevic M, Fazlic M, Smajic N, Hrustic A, et al. Proximal

380 femoral nail antirotation in treatment of fractures of proximal femur. Medicinski

381 arhiv. 2014;68:173-7.

t
382 [26] Sahin EK, Imerci A, Kinik H, Karapinar L, Canbek U, Savran A. Comparison of

ip
383 proximal femoral nail antirotation (PFNA) with AO dynamic condylar screws (DCS)

cr
384 for the treatment for unstable peritrochanteric femoral fractures. European journal

of orthopaedic surgery & traumatology : orthopedie traumatologie. 2014;24:347-52.

us
385

386 [27] Sawaguchi T, Sakagoshi D, Shima Y, Ito T, Goldhahn S. Do design adaptations of

387 an
a trochanteric nail make sense for Asian patients? Results of a multicenter study of

388 the PFNA-II in Japan. Injury. 2014;45:1624-31.

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389 [28] Takigami I, Matsumoto K, Ohara A, Yamanaka K, Naganawa T, Ohashi M, et al.

390 Treatment of trochanteric fractures with the PFNA (proximal femoral nail
ed

391 antirotation) nail system - report of early results. Bulletin of the NYU hospital for

392 joint diseases. 2008;66:276-9.

pt

393 [29] Tang P, Hu F, Shen J, Zhang L, Zhang L. Proximal femoral nail antirotation versus
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394 hemiarthroplasty: a study for the treatment of intertrochanteric fractures. Injury.

395 2012;43:876-81.
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396 [30] Zhou JQ, Chang SM. Failure of PFNA: helical blade perforation and tip-apex

397 distance. Injury. 2012;43:1227-8.

398 [31] Gardenbroek TJ, Segers MJ, Simmermacher RK, Hammacher ER. The proximal

399 femur nail antirotation: an identifiable improvement in the treatment of unstable

400 pertrochanteric fractures? The Journal of trauma. 2011;71:169-74.

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401 [32] Liu Y, Tao R, Liu F, Wang Y, Zhou Z, Cao Y, et al. Mid-term outcomes after

402 intramedullary fixation of peritrochanteric femoral fractures using the new proximal

403 femoral nail antirotation (PFNA). Injury. 2010;41:810-7.

404 [33] Bienkowski P, Reindl R, Berry GK, Iakoub E, Harvey EJ. A new intramedullary

405 nail device for the treatment of intertrochanteric hip fractures: Perioperative

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406 experience. The Journal of trauma. 2006;61:1458-62.

ip
407 [34] Goffin JM, Pankaj P, Simpson AH, Seil R, Gerich TG. Does bone compaction

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408 around the helical blade of a proximal femoral nail anti-rotation (PFNA) decrease the

risk of cut-out?: A subject-specific computational study. Bone & joint research.

us
409

410 2013;2:79-83.

411 an
[35] O'Neill F, Condon F, McGloughlin T, Lenehan B, Coffey JC, Walsh M. Dynamic hip

412 screw versus DHS blade: a biomechanical comparison of the fixation achieved by
M
413 each implant in bone. The Journal of bone and joint surgery British volume.

414 2011;93:616-21.
ed

415 [36] Born CT, Karich B, Bauer C, von Oldenburg G, Augat P. Hip screw migration

416 testing: first results for hip screws and helical blades utilizing a new oscillating test
pt

417 method. Journal of orthopaedic research : official publication of the Orthopaedic

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418 Research Society. 2011;29:760-6.

419 [37] Erhart S, Kammerlander C, El-Attal R, Schmoelz W. Is augmentation a possible

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420 salvage procedure after lateral migration of the proximal femur nail antirotation?

421 Archives of orthopaedic and trauma surgery. 2012;132:1577-81.

422 [38] Erhart S, Schmoelz W, Blauth M, Lenich A. Biomechanical effect of bone cement

423 augmentation on rotational stability and pull-out strength of the Proximal Femur

424 Nail Antirotation. Injury. 2011;42:1322-7.

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425 [39] Kammerlander C, Doshi H, Gebhard F, Scola A, Meier C, Linhart W, et al. Long-

426 term results of the augmented PFNA: a prospective multicenter trial. Archives of

427 orthopaedic and trauma surgery. 2014;134:343-9.

428

429

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429 Figure Legends

430 Fig. 1Types and numbers of revision procedures performed in patients with

431 cut-through complications (red columns). The blue columns show the percentage

432 of patients who required additional revision operations after the first operation.

433 Fig. 2Types and numbers of salvage procedures performed in patients with

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434 cut-out complications (red column). The blue columns show the percentage of

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435 patients who required additional revision operations after the first operation.

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436 Fig. 3An 84-year-old woman with a type A2 fracture (a) was treated with PFNA

437 (b). Four weeks postoperatively, a cut-through of the helical blade was detected

438
an
(c). The blade was replaced (d). Four months after revision surgery, the patient

439 presented with groin pain. Radiography (e) revealed a repeat perforation of the
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440 blade. The blade was exchanged again. The fracture finally healed 4 weeks after

441 the second revision (f).

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443 Acknowledgements

444 The authors would like to thank the following persons for their contributions to this

445 multicentre study:

446

447 M. Blauth, Medical University of Innsbruck, Austria;

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448 K. Kaech, Cantonal Hospital Winterthur, Switzerland;

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449 R. Babst, Cantonal Hospital Lucerne, Switzerland;

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450 N. Renner, Cantonal Hospital Aarau, Switzerland;

451 F. Gebhard, Ulm University Hospital, Germany;

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452 B. Schuster and H. Hertz, Lorenz Böhler Hospital, Vienna, Austria;

453

454
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H. Clement and F.J. Seibert, Graz University Hospital, Austria;

S. Will and N. Schwarz, Klagenfurt University Hospital, Austria;

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455 M. Hessmann, Fulda Hospital, Germany;

456 D. Krüger and R. Engel, Ernst von Bergmann Clinic, Potsdam, Germany;
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457 P. Neidenbach, Limmattal Hospital, Zurich, Switzerland;

458 C. Meier, Waidspital Zurich, Switzerland;

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459 U. Schmidt, Hospital of the Sisters of Charity, Ried, Austria;

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460 M. Müller and A. Seekamp, Kiel University Hospital, Germany;

461 R. Raab and M. Wagner, Wilhelminenspital Vienna, Austria;

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462 R.K.J. Simmermacher, Utrecht University Medical Center, Netherlands;

463 M. Kirjavainen, Helsinki University Hospital, Finland.

464

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475 Table 1: Demographic data for the patients
476
477

Cut-through (n = 28) Cut-out (n = 29)

mean age 77.8 years (SD: 10.3) 83.3 years (6.8)

female / male 22 / 6 24 / 5

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left / right 20 / 8 12 / 17

ASA Score

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2 0 12
3 8 6

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4 20 11
AO/OTA type
A1 6 3
A2 15
7
an 19
7
A3
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PFNA / TFN 25 / 3 22 / 7
Postop. reduction
very good
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3 2
good 1 4
moderate 16 5
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poor 8 18

mean TAD 21.1 mm (SD: 7.0) 30.8 mm (7.9)

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Time between initial

surgery and
1.8 month (SD: 1.6) 1.9 month (SD: 2.3)
“cut-through”/”cut-
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out”
Mean No. of co-
4.4 (SD: 2.4) 2.5 (SD: 2.2)
morbidities
478
479

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479 Table 2: Mean numbers of surgical revision procedures (with SD) per patient in
480 the cut-through and cut-out groups, relative to the first revision operation
481
482
483
blade exchange
blade exchange re-nailing THA
with augment.
cut-through
(n = 28)
1.88 (1.02) 1.33 (0.52) - 1 (0)
cut-out
1.67 (0.58) 1 (-) 2.33 (1.53) 1.05 (0.22)

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(n = 31)

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484
485

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Figure 1

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Figure 2

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Figure 3a

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Figure 3b

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Figure 3c

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Figure 3d

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Figure 3e

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Figure 3f

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