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Tip-Apex Distance Is Most Important of Six Predictors of Screw Cutout After Internal Fixation of Intertrochanteric Fractures in Women

Fujii Tatsuya MD; Nakayama, Shun MD; Hara, Masahiko MD, PhD; Koizumi, Wataru MD, PhD; Itabashi, Takashi MD, PhD; Saito, Masahito MD, PhD
doi: 10.2106/JBJS.OA.16.00022
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Six risk factors for screw cutout after internal fixation of intertrochanteric fractures have been reported. The purpose of the present study was to evaluate and compare the impact of the 6 risk factors of screw cutout to clarify the most important one.


We enrolled 8 consecutive patients who had screw cutout and 48 random control subjects after internal fixation of intertrochanteric fractures treated with proximal femoral nail antirotation systems at our institution. All of the patients were female. The group that had screw cutout and the control group were retrospectively evaluated and compared with respect to the OTA/AO classification, presence of a posterolateral fragment, types of reduction pattern on anteroposterior and lateral radiographic images, position of the screw, and the presence of a tip-apex distance (TAD) of ≥20 mm. The impact of each factor on screw cutout was assessed using backward stepwise multivariable logistic regression analysis with the Akaike information criterion. Risk stratification was assessed using classification and regression tree (CART) analysis.


Among 6 risk factors, only a TAD of ≥20 mm had a significant impact on screw cutout, with an adjusted odds ratio of 12.4 (95% confidence interval, 1.6 to 129.0; p = 0.019). CART analysis also demonstrated that a TAD of ≥20 mm was the most important risk stratification factor (p < 0.001).


Among the 6 previously reported screw cutout-related factors, only a TAD of ≥20 mm was associated with screw cutout after internal fixation of intertrochanteric fractures with proximal femoral nail antirotation systems.

Level of Evidence:

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

E-mail address for T. Fujii:

* Tatsuya Fujii, MD, and Shun Nakayama, MD, contributed equally to the writing of this article.

Investigation performed at Narita Red Cross Hospital, Narita, Japan

Disclosure: There were no sources of funding to be declared for this study. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (

© 2017 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The Journal of Bone and Joint Surgery, Incorporated.