Damage-Based Assessment of the Risk of Cut-Out in Trochanteric Fractures for Different Proximal Femoral Nail Anti-Rotation (PFNA) Blade Positions

Featured Application: This study coupled three-dimensional finite element models of two femora with unstable trochanteric fractures and a bone damage model to investigate the risk of cut-out for different superior–inferior and medial–lateral blade positions. By including a computational model to simulate bone damage progression and an unstable trochanteric fracture that is more severe than those simulated in the literature, this study advances the body of knowledge on the risk of cut-out in trochanteric fractures of the hip. Cut-out of the hip blade of fracture fixation implants, defined as the perforation of the femoral head by the blade due to the collapse of the neck-shaft angle into varus, is the most relevant mechanical complication in the treatment of trochanteric fractures. Among the factors that contribute to cut-out, the blade positioning in the femoral head is reported as one of the most relevant. Since the optimal blade position in the superior–inferior and medial–lateral directions is unknown, the goal of this work was to investigate the impact of blade positioning in these directions, using three-dimensional finite element models of two femora with an unstable trochanteric fracture (31-A2.2 in the Müller AO classification system with an intrusion distance of 95% of the fracture line length). The finite element models developed were coupled with a stiffness-adaptive damage model for the evaluation of the risk of cut-out. The Proximal Femoral Nail Anti-rotation (PFNA) blade was placed in each model at four discrete distances from the femoral head surface in central and inferior positions. The damage distribution in bone resulting from a gait loading condition was visually and quantitatively assessed to compare the performance of the eight positions and predict the relative risk of cut-out for each. The results suggest that the closer the tip of the blade to the femoral head surface, the lower the risk of cut-out. In the superior–inferior direction, contradicting findings were obtained for the modelled femora. The depth of placement of the blade in the medial–lateral direction and its superior–inferior position were shown to have great influence in the risk of cut-out, with the medial–lateral position being the most relevant predictor. The optimal blade positioning may be subject-specific, depending on bone geometry and density distribution.