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Original article
Results and complications of pertrochanteric hip fractures using an intramedullary nail with a helical blade (proximal femoral nail antirotation) in 200 patients
Resultados y complicaciones de la osteosíntesis de fracturas pertrocantéreas de fémur mediante clavo endomedular con espiral cefálica (clavo femoral proximal antirrotación) en 200 pacientes
I. Aguado-Maestro
Corresponding author
nacho.ams@gmail.com

Corresponding author.
, R. Escudero-Marcos, J.M. García-García, N. Alonso-García, D. Pérez-Bermejo, H.J. Aguado-Hernández, J. Nistal-Rodríguez, M. García-Alonso
Departamento de Cirugía Ortopédica y Traumatología, Hospital Universitario del Río Hortega, Valladolid, Spain
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blade&#44; anti-rotation accessory screw&#46;&#46;&#46;&#41; seek to reduce the rates of mechanical complications&#44; mainly &#8216;<span class="elsevierStyleItalic">cut out</span>&#8217;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> &#40;collapse of the cervicodiaphyseal angle toward varus and exit of the screw through the femoral head<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#41; and &#8216;<span class="elsevierStyleItalic">cut through</span>&#8217; &#40;perforation of the femoral head at the central level&#44; with intrusion of the blade within the hip joint&#44; without displacement of the fracture<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#41;&#46;The rate of reoperations due to complications caused by these nailing systems is estimated at between 4&#37; and 9&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;5&#8211;9</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The aim of our study is to evaluate the results of treatment of pertrochanteric femoral fractures&#44; 31-A in the AO&#47;OTA classification&#44; with a PFNA &#40;proximal femoral nail anti-rotation&#41; nailing system&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">The study included 200 patients who were consecutively admitted at our center with a diagnosis of pertrochanteric femoral fracture between April 2010 and February 2012&#46; The inclusion criteria were&#58; extracapsular fractures &#40;AO&#47;OTA 31-A&#41;&#44; low-energy trauma &#40;falls from standing height&#41; and osteoporosis&#46; The exclusion criteria were&#58; pathological fractures&#44; young patients &#40;&#60;60 years&#41; and high-energy trauma&#46; The series was composed of 56 males and 144 females&#44; with a mean age of 84&#46;74 years &#40;range&#58; 60&#8211;98 years&#41;&#46; We conducted a retrospective study based on medical records and imaging data collected by the Department of Radiology upon admission and during the evolution&#46; Evaluation of the results was carried out by an independent surgeon&#44; different from the one performing the interventions&#46; We compared the results with those obtained in 2 previous studies conducted at our center&#44; the first of them with 224 patients who underwent gamma nailing<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> and the second including 700 fractures intervened by gamma 3 nailing and TFN &#40;trochanteric femoral nail&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Typically&#44; these patients underwent operations at 36&#8211;48<span class="elsevierStyleHsp" style=""></span>h of admission&#44; unless a medical pathology caused a delay in surgery&#46; We conducted prophylaxis for thromboembolic disease with bemiparin&#46; The operation was predominantly performed under subarachnoid anesthesia&#44; occasionally associated to femoral nerve block for pain control&#46; We used 2<span class="elsevierStyleHsp" style=""></span>g of cefazolin &#40;fosfomycin in patients allergic to beta-lactam&#41; as antibiotic prophylaxis&#44; and an orthopedic traction table for reduction&#46; During the procedure&#44; usually performed jointly by a senior surgeon and a resident&#44; radioscopic images were obtained to assess the position of the components&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Except in cases with clinical decompensation of the overall condition&#44; sitting took place at 24<span class="elsevierStyleHsp" style=""></span>h postoperatively&#44; in all cases following an assessment of radiological and analytical postoperative monitoring&#46; Ambulation was allowed approximately 72&#8211;96<span class="elsevierStyleHsp" style=""></span>h after surgery in most patients&#46; The indication for early load was determined by previous or present functional condition&#44; but independently of the type of fracture and quality of reduction&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Monitoring was carried out at 1&#44; 3&#44; 6 and 12 months after discharge&#44; during routine outpatient consultations at our center&#46; We performed a comparison of previous ability for ambulation and the improvement achieved during follow-up&#44; assigning patients to one of the following groups<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&#58; group 1 &#40;able to walk independently or with a single&#44; simple aid&#44; like a crutch or tripod&#41;&#44; group 2 &#40;able to walk with the aid of 2 crutches&#44; walker or frame&#41; or group 3 &#40;unable to walk&#44; requiring a wheelchair for transport&#41;&#46; Fractures were classified according to the AO&#47;OTA scale&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The nail under study<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> is marketed in standard lengths of 170&#44; 200 and 240<span class="elsevierStyleHsp" style=""></span>mm&#44; as well as longer versions between 300 and 420<span class="elsevierStyleHsp" style=""></span>mm&#46; The diameters available range between 9 and 14<span class="elsevierStyleHsp" style=""></span>mm&#46; The proximal bolt was a perforated helical blade allowing cementation&#44; with cervicodiaphyseal angulation of 125&#176;&#44; 130&#176; or 135&#176;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Radiographic evaluation in the immediate postoperative period included an assessment of the reduction &#40;depending on the cervicodiaphyseal angle obtained and the reduction gap&#44; which should be less than 5<span class="elsevierStyleHsp" style=""></span>mm in both projections&#41;&#44; and was given a score of &#8220;good&#8221; if both criteria were present&#44; &#8220;acceptable&#8221; if only one of them was observed&#44; and &#8220;poor&#8221; if neither could be recorded&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The position of the helical blade was evaluated according to the quadrants of Cleveland and Bosworth<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18</span></a> &#40;dividing the cephalic circumference into 9 portions&#44; with each being assigned a number from left to right and top to bottom&#41;&#44; as well as the Baumgaertner tip-apex distance&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;19</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0055" class="elsevierStylePara elsevierViewall">The distribution of fracture types can be seen in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#44; with the most prevalent being 31-A1&#46;2 &#40;21&#37;&#41; and 31-A2&#46;2 &#40;26&#37;&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">The nails used in our study presented the distribution shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#44; with the most commonly used nail having 200<span class="elsevierStyleHsp" style=""></span>mm length&#44; 130&#176; angulation and 10<span class="elsevierStyleHsp" style=""></span>mm diameter&#46; Except for long nails &#40;over 240<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; we performed a dynamic distal block in all cases&#46; The mean surgery time was 42&#46;06<span class="elsevierStyleHsp" style=""></span>min&#46; The quality of reduction was classified as good in 154 cases &#40;77&#37;&#41;&#44; acceptable in 40 cases &#40;20&#37;&#41; and poor in 4 cases &#40;2&#37;&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">The position of the helical blade according to the Cleveland and Bosworth quadrants showed the following distribution by quadrants&#58; 1 &#40;0&#46;8&#37;&#41;&#44; 2 &#40;0&#37;&#41;&#44; 3 &#40;0&#37;&#41;&#44; 4 &#40;9&#46;4&#37;&#41;&#44; 5 &#40;64&#46;1&#37;&#41;&#44; 6 &#40;0&#46;8&#37;&#41;&#44; 7 &#40;11&#46;7&#37;&#41;&#44; 8 &#40;13&#46;2&#37;&#41; and 9 &#40;0&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The Baumgaertner tip-apex distance&#44; which should be less than 25<span class="elsevierStyleHsp" style=""></span>mm to decrease the incidence of <span class="elsevierStyleItalic">cut out</span>&#44;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;4&#44;14&#44;19&#44;20</span></a> was confirmed in 91&#46;5&#37; of cases&#44; with a mean distance of 17&#46;48<span class="elsevierStyleHsp" style=""></span>mm &#40;range&#58; 5&#46;84&#8211;35&#46;88<span class="elsevierStyleHsp" style=""></span>mm&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">The mean hospital stay of our patients was 9&#46;17 days &#40;range&#58; 4&#8211;35 days&#41;&#44; with a mean time prior to surgery of 3&#46;22 days &#40;range&#58; 0&#8211;19 days&#41; and a mean postoperative admission period of 5&#46;95 days &#40;range&#58; 3&#8211;18 days&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The mean follow-up period was 1&#46;6 years &#40;range&#58; 11&#8211;31 months&#41;&#46; We recorded 3 losses during follow-up&#44; in addition to cases of <span class="elsevierStyleItalic">exitus letalis</span>&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Regarding the functional capacity of patients&#44; 63&#37; belonged to group 1 &#40;no aid or a single&#44; simple support&#41;&#46; Of these&#44; only half &#40;47&#37;&#41; maintained this status in the postoperative period&#44; with the remaining cases presenting a reduction of functional capacity &#40;47&#37; required a walking frame or 2 crutches&#44; and the remaining 6&#37; required a wheelchair&#41;&#46; Prior to the fracture&#44; 34&#37; of patients needed 2 crutches or a walking frame for ambulation &#40;group 2&#41;&#44; whilst this figure increased to 57&#37; of the sample during follow-up&#46; The percentage of patients who required a wheelchair due to inability for ambulation &#40;group 3&#41; was tripled &#40;from 4&#37; at baseline to 12&#37; during follow-up&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The intrahospital mortality rate stood at 1&#46;5&#37;&#44; whilst the figure during the 1 year follow-up period was 15&#46;6&#37;&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Complications were classified into 3 groups&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0095" class="elsevierStylePara elsevierViewall">Intraoperative mechanical complications&#58; 1 case of failure upon insertion of the distal screw &#40;0&#46;5&#37;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0100" class="elsevierStylePara elsevierViewall">Postoperative mechanical complications&#58; 2 cases of <span class="elsevierStyleItalic">cut out</span> &#40;1&#37;&#41;&#44; 1 case of <span class="elsevierStyleItalic">cut through</span> &#40;0&#46;5&#37;&#41;&#44; 4 cases of helical blade sliding effect &#40;lateral movement of the trochanteric mass due to sliding of the blade and diaphyseal medialization and collapse at the level of the fracture&#41; &#40;2&#37;&#41;&#44; 2 cases of discomfort in the <span class="elsevierStyleItalic">fascia lata</span> unrelated to cases of blade retropulsion &#40;1&#37;&#41;&#44; 1 case of delayed consolidation which required dynamization &#40;0&#46;5&#37;&#41;&#44; 2 cases of pseudoarthrosis &#40;or nonunion&#41; which in both cases led to breakage of the device &#40;1&#37;&#41; and 1 case of avascular necrosis &#40;0&#46;5&#37;&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Non-mechanical complications&#58; 1 case of continuous active bleeding related to the intervention &#40;0&#46;5&#37;&#41; and 1 case of deep vein thrombosis &#40;0&#46;5&#37;&#41;&#46;</p></li></ul></p><p id="par0110" class="elsevierStylePara elsevierViewall">Overall&#44; mechanical complications accounted for 7&#46;5&#37;&#44; although only 3&#46;5&#37; required surgical revision&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Cut out</span>&#58; we observed 2 cases of <span class="elsevierStyleItalic">cut out</span>&#46; The first case presented concomitant infection in addition to the mechanical complication&#46; Thus&#44; after considering the age&#44; comorbidity and functional capacity of the patient&#44; we decided to extract the osteosynthesis material from the femoral head and neck &#40;Girdlestone technique&#41; in a single surgical action&#46; The patient was able to walk using a walking frame&#44; albeit with relative difficulty &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0120" class="elsevierStylePara elsevierViewall">In the other case&#44; a 31-A1&#46;2 fracture&#44; after analyzing the images we observed a delayed union and progressive mobilization of the blade&#44; which resulted in a subcapital fracture at the point of exit of the blade&#46; It was resolved by a Thompson hemiarthroplasty after extraction of the nail&#44; with satisfactory evolution after this intervention and requiring a walking frame for ambulation &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Cut through</span>&#58; we proceeded to extract the osteosynthesis material due to the low functional demands of the patient&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Pseudoarthrosis or nonunion&#58; there were 2 cases of nonunion&#46; Both cases were 31-A3&#46;3 fractures with an inverse oblique pattern&#44; showing a gap over 5<span class="elsevierStyleHsp" style=""></span>mm after surgical reduction&#46; In these patients&#44; nonunion conditioned the breakage of the osteosynthesis material&#46; Only 1 patient was surgically reoperated&#58; replacement of a short nail for a long one&#44; together with cementing through the helical blade&#46; In the other case&#44; the considerable morbidity and mortality and good tolerance to the condition led us to choose a conservative treatment&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">We stratified patients into 2 groups according to the presence or absence of mechanical complications&#46; Within these groups we analyzed the location of the blade in an ideal position &#40;center&#8211;center&#41; or other positions&#44; which were considered &#8220;suboptimal&#8221;&#46; We observed significant differences regarding the development of mechanical complications between the group with a center&#8211;center position with respect to the group with &#8220;suboptimal&#8221; positions &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;04&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; We then analyzed the tip-apex distance in these same 2 groups&#44; and found that the mean tip-apex distance in the group with mechanical complications was 18&#46;03<span class="elsevierStyleHsp" style=""></span>mm &#40;range&#58; 5&#46;84&#8211;33&#46;58<span class="elsevierStyleHsp" style=""></span>mm&#41; compared to 17&#46;38<span class="elsevierStyleHsp" style=""></span>mm &#40;range&#58; 5&#46;84&#8211;35&#46;88<span class="elsevierStyleHsp" style=""></span>mm&#41; in the group without complications&#46; These values were not statistically significant &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;897&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0140" class="elsevierStylePara elsevierViewall">Finally&#44; we stratified according to the quality of the reduction&#46; In the group with postoperative mechanical complications the quality of the reduction was good or acceptable in 86&#46;6&#37; of cases&#44; whereas in the group without complications this figure rose to 99&#46;46&#37;&#44; resulting in a statistically significant difference &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;04&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The results of our study were compared with those obtained in another study conducted 1 year earlier at our center with a sample of 700 patients intervened due to hip pertrochanteric osteoporotic fracture using a gamma 3 nail and TFN for 5 years&#46; This study only measured the following mechanical complications&#58; <span class="elsevierStyleItalic">cut out</span> &#40;3&#46;4&#37;&#41;&#44; <span class="elsevierStyleItalic">cut through</span> &#40;1&#46;6&#37;&#41;&#44; fracture varization &#40;0&#46;5&#37;&#41;&#44; helical blade sliding effect &#40;2&#46;5&#37;&#41;&#44; decoupling of the system &#40;0&#37;&#41;&#44; breakage of the device &#40;0&#37;&#41;&#44; failure of the distal screw guide &#40;0&#46;8&#37;&#41; and blade contact at the level of the <span class="elsevierStyleItalic">fascia lata</span> &#40;0&#46;4&#37;&#41;&#44; obtaining a total rate of 9&#46;2&#37; mechanical complications derived from the use of a nail&#44; compared to 7&#46;5&#37; obtained in our series &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;469&#41;&#46; Nevertheless&#44; reducing the observation to those complications studied in both works which required reoperation &#40;<span class="elsevierStyleItalic">cut out</span>&#44; <span class="elsevierStyleItalic">cut through</span> and nonunion&#41;&#44; we observed that the incidence was reduced from 5&#37; to 2&#46;5&#37; &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;13&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0150" class="elsevierStylePara elsevierViewall">Mechanical complications are the most frequent type of complications leading to implant failure and requiring reoperation&#46; The factors which condition such failures can be divided into &#8220;modifiable&#8221; and &#8220;non-modifiable&#8221;&#46; The first include bone mineral density and fracture type&#44; whilst the latter are those known as &#8220;surgeon-dependent&#8221; &#40;Baumgaertner tip-apex distance&#44; position of the blade&#44; fracture reduction and choice of implant&#41;&#46; It is on the latter that we can primarily act in order to improve the final results of osteosynthesis&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">The development and improvement of new osteosynthesis systems&#44; as well as a meticulous surgical technique&#44; have reduced the rate of surgeon-dependent mechanical complications&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">The results of our study are consistent with those obtained by other working groups which observe a reduction in the incidence of mechanical complications among those cases in which the blade was located in the center of the femoral head and neck&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;14</span></a> The percentage of patients in the sample with a suboptimal tip-apex distance has been reduced&#44; which may have had an influence on reducing the significant variability in terms of the relationship between this distance and the incidence of complications&#46; Other studies have found similar results regarding the tip-apex distance&#46; The series of Herman et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> reported a tip-apex distance of 20&#46;3<span class="elsevierStyleHsp" style=""></span>mm &#40;SD&#58; 6&#46;5&#41; in the group of patients without mechanical complications and 24&#46;0<span class="elsevierStyleHsp" style=""></span>mm &#40;SD&#58; 6&#46;5&#41; in the group of patients with <span class="elsevierStyleItalic">cut out</span> &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;175&#41;&#46; This could raise the point that the position of the blade in the Cleveland and Bosworth quadrants may be of greater importance than the Baumgaertner tip-apex distance&#46; There are very few research works with nail systems using a helical blade&#44; since the original study showed the results in patients treated with screw-sliding plate systems&#46; The first study to assess the tip-apex distance with nailing was conducted by Geller et al&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> with results similar to those of Baumgaertner&#46; Other studies have also been conducted which evaluated measurement using the PACS<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> fluoroscopy system during the surgical intervention&#44; allowing placement and correction during surgery until a suitable subchondral position was achieved&#46; In our previous series of 700 patients treated with other types of nails&#44; the mean value of this parameter was 21<span class="elsevierStyleHsp" style=""></span>mm &#40;range&#58; 9&#8211;37<span class="elsevierStyleHsp" style=""></span>mm&#41;&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">We did not carry out a radiographic evaluation of the degree of osteoporosis according to the method of Singh because there is controversy regarding the results of published studies&#44; which associate the Singh trabecular pattern with mechanical complications&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;23</span></a> In addition&#44; there is considerable intra- and interobserver variability in the classification of the Singh pattern&#44;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> making this parameter scarcely reliable in establishing whether osteoporosis is a determining factor in the results&#46; There are new studies which attempt to relate the diameter of the medial cortex and the degree of bone fragility&#44; which may become determinant in the future to establish whether or not there is a frank association between osteoporosis and mechanical complications&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Mortality data during the first year of follow-up reflected a survival of 84&#46;4&#37; versus the expected figure of 75&#37; according to other studies&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> This improvement could be the result of a precise coordination between the Departments of Traumatology&#44; Anesthesia and Geriatrics&#44; enabling ongoing medical care&#44; surgical intervention and early ambulation&#44; as well as prevention and treatment of complications arising during hospital stay&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">In the analysis of complications we found 4 cases of <span class="elsevierStyleItalic">cut out</span> related to fractures with a single basicervical stroke&#44; which led us to consider alternative causal mechanisms other than the position of the helical blade&#46; One possible explanation lies in cephalic rotation&#44;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#8211;27</span></a> conditioned by the absence of muscle insertions which stabilize the fracture line&#44; and cause the head to rotate on the nail&#44; both during insertion of the helical blade and during ambulation&#46; Some new theories suggest that the torsional forces exerted on the blade during ambulation cycles may cause the trabeculae surrounding the implant to rupture&#44; with a subsequent rotation of the femoral head on the blade&#44; causing a &#8220;shear&#8221; movement on the surrounding bone and initiating a progressive osteolysis during ambulation cycles &#40;&#8220;windshield effect&#8221;&#41; which will eventually lead to the development of <span class="elsevierStyleItalic">cut out</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> In order to prevent this cascade of events&#44; we are currently employing new technical variants&#44; including the use of anti-rotation screws or cementing through the blade&#44; in certain types of fractures with rotational instability&#44; which could further reduce the rates of mechanical complications&#46; The results have yet to be analyzed&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">In our opinion&#44; the first case of <span class="elsevierStyleItalic">cut out</span> could be attributed to an error in the surgical technique since&#44; after inserting the helical blade and conducting the relevant checks with the image intensifier&#44; the surgeon realized that the blade had been introduced too close to the articular cartilage&#44; and conducted a partial extraction and subsequent reintroduction in a position farther from the cartilage&#46; This extraction and subsequent reintroduction of the blade could have caused trabecular impaction&#44; initially beneficial to promote anchoring of the blade&#44; to be lost during reintroduction of the blade through the same channel&#46; This would allow the rotation of the femoral head during ambulation cycles due to the rupture of the trabeculae around the blade&#46; We suggest that cases such as this may be susceptible to cementing through the helical blade or to addition of a cannulated screw in order to block these torsional forces&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">As expected&#44; group 31-A3 fractures led to a notable number of delayed consolidations and nonunions compared with other types of fractures &#40;31-A1 and 31-A2&#41;&#44; attributable in part to a poor quality of reduction&#44; with gaps greater than 5<span class="elsevierStyleHsp" style=""></span>mm in the point of fracture&#44; and to the high instability thereof&#44; caused by the absence of the lateral wall&#44; which should act as a buttress for blade sliding&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">At present&#44; in our center we perform surgical treatment of all these fractures by the intramedullary&#44; proximal femoral nail anti-rotation &#40;PFNA&#41; system&#46; We choose this system because of its improved mechanical properties and lesser inflection compared to the screw-sliding plate system&#44; due to its more medial position&#46; Nailing has shown better results than the screw-plate system for unstable pertrochanteric fractures of the femur&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;29</span></a> When comparing with our historical series &#40;based on TFN and gamma 3 nailing&#41;&#44; we have observed a decrease in the incidence of these complications&#44; although follow-up periods were shorter&#46; This lower incidence of complications may be due to the fact that the helical blade provided angular and rotational stability by compacting the spongy tissue as it was inserted&#44; thus giving it greater anchoring capacity and allowing sliding&#44; once blocked&#44; which favored fracture point compression&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30&#44;31</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">The strength of the study was&#44; firstly&#44; that the intervention was performed by the same senior surgeon&#44; thus preventing the results from being influenced by technical implementation by different surgeons&#46; Secondly&#44; the scarce losses during follow-up&#44; both due to mortality and to absence from consultation&#44; did not substantially affect the variable being studied&#46; Thirdly&#44; monitoring was always longer than 6 months for all cases studied&#44; thus ruling out belated&#44; undocumented complications&#44; since almost all appeared within that time interval&#46; Lastly&#44; we did not only evaluate the primary&#44; qualitative&#44; dichotomous variable of presence or absence of &#8220;complications&#8221;&#44; but also secondary variables&#44; like the &#8220;functionality&#8221; of patients&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">The limitations of this study include it being a retrospective study&#44; thus making it impossible to assess certain variables not routinely collected in the evolution forms&#46; In addition&#44; a larger sample size could have provided more statistically significant results&#44; since the study variables were numerous and the rate of complications was low&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusions</span><p id="par0205" class="elsevierStylePara elsevierViewall">Nailing is an effective treatment for pertrochanteric fractures of the femur &#40;31-A&#41;&#46; The helical blade system of PFNA appears to reduce the incidence of <span class="elsevierStyleItalic">cut out</span> and <span class="elsevierStyleItalic">cut through</span>&#46; Lateral migration of the blade allows impaction of the fracture and consolidation thereof &#40;although it may increase rates of friction with the <span class="elsevierStyleItalic">fascia lata</span>&#44; varus consolidation and shortening&#41;&#46; The position of the blade represents one of the main parameters associated with mechanical complications&#46; Although other studies have shown the importance of the tip-apex distance&#44; given the characteristics of our series&#44; we could not observe this fact&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Level of evidence</span><p id="par0210" class="elsevierStylePara elsevierViewall">Level of evidence <span class="elsevierStyleSmallCaps">III</span>&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Ethical responsibilities</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Protection of people and animals</span><p id="par0215" class="elsevierStylePara elsevierViewall">The authors declare that this investigation did not require experiments on humans or animals&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Confidentiality of data</span><p id="par0220" class="elsevierStylePara elsevierViewall">The authors declare that this work does not reflect any patient data&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Right to privacy and informed consent</span><p id="par0225" class="elsevierStylePara elsevierViewall">The authors declare that this work does not reflect any patient data&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflict of interests</span><p id="par0230" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
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        0 => array:2 [
          "identificador" => "xres231460"
          "titulo" => array:5 [
            0 => "Abstract"
            1 => "Objective"
            2 => "Materials and methods"
            3 => "Results"
            4 => "Conclusions"
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        1 => array:2 [
          "identificador" => "xpalclavsec217964"
          "titulo" => "Keywords"
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          "titulo" => array:5 [
            0 => "Resumen"
            1 => "Objetivos"
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          "identificador" => "xpalclavsec217963"
          "titulo" => "Palabras clave"
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        4 => array:2 [
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          "titulo" => "Introduction"
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          "identificador" => "sec0010"
          "titulo" => "Materials and methods"
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          "identificador" => "sec0020"
          "titulo" => "Discussion"
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          "identificador" => "sec0025"
          "titulo" => "Conclusions"
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        9 => array:2 [
          "identificador" => "sec0030"
          "titulo" => "Level of evidence"
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        10 => array:3 [
          "identificador" => "sec0035"
          "titulo" => "Ethical responsibilities"
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            0 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Protection of people and animals"
            ]
            1 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Confidentiality of data"
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            2 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "Right to privacy and informed consent"
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          "identificador" => "sec0055"
          "titulo" => "Conflict of interests"
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    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2013-01-08"
    "fechaAceptado" => "2013-03-21"
    "PalabrasClave" => array:2 [
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec217964"
          "palabras" => array:6 [
            0 => "Proximal femoral nail antirotation"
            1 => "Hip"
            2 => "Fracture"
            3 => "Pertrochanteric"
            4 => "Cut out"
            5 => "Complications"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec217963"
          "palabras" => array:6 [
            0 => "Clavo femoral proximal antirrotaci&#243;n"
            1 => "Cadera"
            2 => "Fractura"
            3 => "Pertrocant&#233;rea"
            4 => "Cut out"
            5 => "Complicaciones"
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    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Evaluation of the surgical management&#44; outcome and complications in patients with pertrochanteric fractures treated with PFNA nail&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A retrospective study was conducted on 200 patients treated consecutively between April 2010 and February 2012&#46; Radiological assessments were performed before and after the surgery&#44; and during the follow-up &#40;fracture reduction&#44; blade position&#44; consolidation or collapse signs&#41;&#46; A clinical evaluation was performed as regards walking capabilities&#46; The results were compared with those of a previous study on 700 patients treated with gamma 3 and TFN nails&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The blade position was center&#8211;center in 64&#37; of patients&#44; and decreased to 53&#37; in the mechanical complications group&#46; Tip-apex distance was less than 25<span class="elsevierStyleHsp" style=""></span>mm in 91&#46;5&#37;&#46; The average hospital stay was 9&#46;17 days&#44; with a mean post-surgery stay of 5&#46;95 days&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Complications &#40;7&#46;5&#37;&#41;&#58; 2 cut out &#40;1&#37;&#41;&#44; one cut through &#40;0&#46;5&#37;&#41;&#44; 4 cases of helical blade sliding &#40;2&#37;&#41;&#44; one failure in distal locking procedure &#40;0&#46;5&#37;&#41;&#44; 2 cases with painful fasciae latae &#40;1&#37;&#41;&#44; one union delay &#40;0&#46;5&#37;&#41;&#44; 2 cases of non-union with hardware failure &#40;1&#37;&#41;&#44; one case of intense bleeding related to distal locking of the nail &#40;0&#46;5&#37;&#41;&#44; and one case of avascular necrosis &#40;0&#46;5&#37;&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The PFNA helical blade system seems to reduce the incidence of cut out and cut through in osteoporotic bone&#46; Blade position was one of the main parameters associated with mechanical complications&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Evaluaci&#243;n del manejo quir&#250;rgico&#44; evoluci&#243;n y complicaciones de pacientes afectados por fractura pertrocant&#233;rea de cadera tratados mediante enclavado PFNA&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Revisi&#243;n retrospectiva de 200 pacientes intervenidos entre abril de 2010 y febrero de 2012 de forma consecutiva&#46; Se realiza evaluaci&#243;n radiogr&#225;fica preoperatoria&#44; postoperatoria y durante el seguimiento &#40;reducci&#243;n de la fractura&#44; posici&#243;n de la espiral&#44; consolidaci&#243;n o signos de colapso&#41;&#46; La evaluaci&#243;n cl&#237;nica se realiz&#243; en funci&#243;n de la autonom&#237;a para la marcha&#46; Se comparan los resultados obtenidos con estudio previo&#44; sobre muestra de 700 pacientes y enclavado gamma 3 y TFN&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La posici&#243;n de la espiral es centro-centro en el 64&#37; de los pacientes&#44; que disminuye al 53&#37; en el grupo de las complicaciones mec&#225;nicas&#44; siendo la distancia punta-v&#233;rtice menor a 25<span class="elsevierStyleHsp" style=""></span>mm en el 91&#44;5&#37; de los casos&#46; La estancia hospitalaria media se sit&#250;a en 9&#44;17 d&#237;as con una estancia media postintervenci&#243;n de 5&#44;95 d&#237;as&#46;</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Las complicaciones &#40;7&#44;5&#37;&#41; fueron&#58; 2 casos de cut out &#40;1&#37;&#41;&#44; uno de cut through &#40;0&#44;5&#37;&#41;&#44; 4 casos de efecto telescopaje &#40;2&#37;&#41;&#44; un fallo en el encerrojado distal &#40;0&#44;5&#37;&#41;&#44; 2 casos de molestias en la fascia lata &#40;1&#37;&#41;&#44; un retardo en la consolidaci&#243;n &#40;0&#44;5&#37;&#41;&#44; 2 seudoartrosis que condicionaron la rotura del dispositivo &#40;1&#37;&#41;&#44; un caso de sangrado relativo al clavo &#40;0&#44;5&#37;&#41; y un caso de necrosis avascular &#40;0&#44;5&#37;&#41;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">El sistema de espiral cef&#225;lica PFNA parece reducir la incidencia de cut out y cut through en el hueso osteopor&#243;tico&#46; La posici&#243;n de la espiral supone uno de los principales par&#225;metros relacionados con las complicaciones mec&#225;nicas&#46;</p>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please&#44; cite this article as&#58; Aguado-Maestro I&#44; et al&#46; Resultados y complicaciones de la osteos&#237;ntesis de fracturas pertrocant&#233;reas de f&#233;mur mediante clavo endomedular con espiral cef&#225;lica &#40;clavo femoral proximal antirrotaci&#243;n&#41; en 200 pacientes&#46; Rev Esp Cir Ortop Traumatol&#46; 2013&#59;<span class="elsevierStyleBold">57</span>&#58;201&#8211;7&#46;</p>"
      ]
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Distribution of the position of the helical blade in the Cleveland and Bosworth quadrants within our patient sample&#46;</p>"
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        "etiqueta" => "Figure 2"
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Fracture with a basicervical line treated by PFNA nailing&#46; During its introduction&#44; the helical blade reached the subchondral bone so it was partially removed&#44; revealing the channel created by compaction of the trabeculae &#40;A&#41;&#46; Postoperative control &#40;B&#41;&#46; <span class="elsevierStyleItalic">Cut out</span> &#40;C&#41;&#46; Definitive treatment through a Girdlestone procedure &#40;D&#41;&#46;</p>"
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        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Pertrochanteric fracture with a simple line treated by PFNA nailing&#46; Postoperative control &#40;A&#41;&#46; A slight collapse took place during the evolution&#44; which was consolidated with lateral migration of the blade &#40;B&#41;&#46; The point of fracture can be observed at a subcapital level &#40;coinciding with the tip of the blade&#41;&#44; along with nonunion&#46; <span class="elsevierStyleItalic">Cut out</span>&#46; &#40;C&#41;&#46; We opted for surgical treatment by hemiarthroplasty with a Thompson type cemented prosthesis &#40;D&#41;&#46;</p>"
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                  \t\t\t\t"><span class="elsevierStyleItalic">Simple pertrochanteric</span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>31-A1&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">13&#37; &#40;26 patients&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>31-A1&#46;2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">21&#37; &#40;42 patients&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>31-A1&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">2&#37; &#40;4 patients&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Multifragment pertrochanteric</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>31-A2&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">9&#37; &#40;18 patients&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>31-A2&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">26&#37; &#40;52 patients&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>31-A2&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">18&#37; &#40;36 patients&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Intertrochanteric &#40;including inverse oblique&#41;</span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>31-A3&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">4&#37; &#40;8 patients&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>31-A3&#46;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7&#37; &#40;14 patients&#41;&nbsp;\t\t\t\t\t\t\n
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      "titulo" => "References"
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                    0 => array:2 [
                      "titulo" => "Central head perforation&#44; or &#8220;cut through&#8221;&#44; caused by the helical blade of the proximal femoral nail antirotation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "H&#46;C&#46; Frei"
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                            2 => "D&#46; Cadosch"
                            3 => "M&#46; Rudin"
                            4 => "K&#46; K&#228;ch"
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                    0 => array:2 [
                      "doi" => "10.1097/BOT.0b013e31822c53c1"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Orthop Trauma"
                        "fecha" => "2012"
                        "volumen" => "26"
                        "paginaInicial" => "e102"
                        "paginaFinal" => "e107"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22357090"
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                      "titulo" => "Helical blade versus sliding hip screw for treatment of unstable intertrochanteric hip fractures&#58; a biomechanical evaluation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
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