ORIGINAL ARTICLE
Radiographic Review of Helical Blade Versus Lag Screw
Fixation for Cephalomedullary Nailing of Low-Energy
Peritrochanteric Femur Fractures: There is a Difference
in Cutout
Lorraine C. Stern, MD,* John T. Gorczyca, MD,† Stephen Kates, MD,‡ John Ketz, MD,†
Gillian Soles, MD,† and Catherine A. Humphrey, MD†
Objectives: To compare the rate of cutout of helical blades and lag
screws in low-energy peritrochanteric femur fractures treated with
a cephalomedullary nail (CMN).
Design: Retrospective review.
Setting: Academic medical center.
Patients: Overall, this study included 362 patients with an average
age of 83 year old, a majority of whom were women, and had
sustained a low-energy peritrochanteric femur fracture treated with
a CMN. All patients had at least 3 months of clinical and
radiographic follow, with an average follow-up of 11 months and
a range of 3–88 months follow-up.
Intervention: Cephalomedullary nailing with the use of a helical
blade or single lag screw for proximal fixation.
Main Outcome Measurements: Cutout of the helical blade or
lag screw.
Results: Twenty-two cutouts occurred, 14 (15.1%) of 93 patients
with helical blades and 8 (3.0%) of 269 patients with lag screws.
Cutout with the helical blade was significantly more frequent than
with the lag screw (P = 0.0001). The average tip–apex distance
(TAD) was significantly greater for those patients who experienced
cutout both for the helical blades (23.5 vs. 19.7 mm; P = 0.0194) and
lag screws (24.5 vs. 20.0 mm; P = 0.0197). An absolute TAD pre-
dictive of cutout could not be determined.
Accepted for publication March 17, 2017.
From the *Advanced Orthopedics and Hand Surgery Institute, Wayne, NJ;
†Department of Orthopedic Surgery, University of Rochester Medical Cen-
ter, Rochester, NY; and ‡Department of Orthopedic Surgery, Virginia
Commonwealth University, Richmond, VA.
The authors report no conflict of interest.
Presented in part at the 31st Annual Meeting of the Orthopedic Trauma
Association, October 7–10, 2015, San Diego, CA.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF
versions of this article on the journal’s Web site (www.jorthotrauma.
com).
Reprints: Lorraine C. Stern, MD, Advanced Orthopedics and Hand Surgery
Institute, 504 Valley Rd, Suite 201 Wayne, NJ 07470 (e-mail:
docLstern@gmail.com).
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/BOT.0000000000000853
J Orthop Trauma  Volume 31, Number 6, June 2017
Copyright Ó 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Conclusions: When the helical blade was used, implant cutout
occurred at a significantly higher rate compared with lag screw
fixation. There was not a threshold TAD that was predictive of
cutout for either implant.
Key Words: femur fracture, low energy, cephalomedullary nailing,
cutout
Level of Evidence: Therapeutic Level III. See Instructions for
Authors for a complete description of levels of evidence.
(J Orthop Trauma 2017;31:305–310)
INTRODUCTION
With the aging population, there continues to be an
increase in the number of peritrochanteric femur fractures
treated each year. A recent study demonstrated a changing
practice pattern among orthopaedic surgeons in the treat-
ment of these fractures, from the use of a plate and screw
construct to the use of intramedullary devices.1 The original
design for the cephalomedullary nail (CMN) used a lag
screw for proximal fixation into the femoral head, similar
to the lag screw design found in compression screw and
sideplate constructs. A common complication with this
device has been lag screw cutout, causing the femoral head
to displace into varus.2–4 Causes for implant cutout have
been related to osteoporotic bone, unstable fractures, and
inadequate reduction and malposition of the lag screw in
the femoral head.5–7 As a result of these failures, the helical
blade was designed with the intent to provide stronger fix-
ation by compacting the cancellous bone as the helical blade
is inserted.8 The blade may also be more effective at sup-
porting torsional load, thereby making it more forgiving to
less precise placement in the femoral head.8
The aim of this study was to determine the rate of
cutout of lag screws and helical blades in low-energy
peritrochanteric femur fractures treated with third generation
(cephalomedullary) femoral nails. We hypothesized that
those fractures stabilized proximally with helical blades
would demonstrate a lower rate of cutout. Tip–apex distance
(TAD) was also evaluated for each patient to determine if
increasing TAD could be used as a predictor of cutout for
both implants.
www.jorthotrauma.com | 305
Stern et al
METHODS
A retrospective review was performed at an academic
medical center of all peritrochanteric femur fractures treated
with a trochanteric entry CMN between January 1, 2007 and
September 30, 2014. The complete cohort was obtained by
querying the billing records with the CPT code 27,245 (open
treatment of an intertrochanteric, pertrochanteric, or subtro-
chanteric femur fracture with intramedullary implant). Pa-
tients were included if they were 55 years or older at the time
of injury and had sustained the fracture by a low-energy
mechanism of injury. Those patients with pathologic fractures
and periprosthetic fractures were excluded, as were patients
with postoperative clinical and radiographic follow-up of less
than 3 months. The CMN’s that were used were the Stryker
gamma nail (Gamma) (Mahwah, NJ) with a lag screw for
proximal fixation and the Synthes trochanteric fixation nail
(TFN) (Paoli, PA) with either a lag screw or helical blade for
proximal fixation, according to surgeon preference. The deci-
sion to use a lag screw or helical blade was also made accord-
ing to surgeon preference. Treatment was carried out by 26
surgeons, 6 of whom had completed formal fellowship train-
ing in orthopaedic traumatology.
Sex, age at the time of injury and mechanism of injury
were recorded. Fractures were classified by the OTA/AO
Classification and further subclassified as stable (31A1.1-
31A2.1) or unstable (31A2.2-31A3.3).9 TAD was calcu-
lated for each patient as described by Baumgaertner
et al10 and modified by Johnson et al11 for digital images.
All measurements were completed by a single investigator.
Cutout was defined as protrusion of the blade or screw past
the subchondral bone on either the AP or lateral projection.
For those patients who had experienced cutout of their prox-
imal fixation, time to cutout and direction of cutout were
recorded. The type of revision surgery, if performed, was
also documented.
The Fisher exact test was used to analyze the difference
in the rate of cutout between the 2 implants. An unpaired t test
was used to analyze differences in TAD. Significance for all
statistical testing was set at P , 0.05. This study was
approved by our institutional review board and had no sour-
ces of external funding. The authors of this study do not have
financial relationships with the manufacturers of the implants
used in this study.
FIGURE 1. Example of helical blade cutout.
306 | www.jorthotrauma.com
Copyright Ó 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
J Orthop Trauma  Volume 31, Number 6, June 2017
RESULTS
A total of 932 patients were treated with a CMN for
a peritrochanteric femur fracture during the study-time
period, of which only 362 met the inclusion
criteria (see Figure, Supplemental Digital Content 1,
http://links.lww.com/BOT/A958, which demonstrates the
included and excluded patients). The average age of patients
included was 83 years and 76.8% were women. A majority of
patients (95.9%) had fallen from a standing or seated height. A
CMN with a helical blade was used in 93 patients, whereas
a CMN with a lag screw was used in 269 patients (151 TFN
and 118 Gamma). The average length of follow-up was 11.5
months. According to the OTA/AO classification, 64.6% of the
fractures were classified as unstable. There was no statistically
significant difference in the proportion of fractures that were
unstable in either group (65.6% in the helical blade group vs.
61.7% in the lag screw group; P = 0.5359; Fisher exact test).
The average TAD was not significantly different between the
helical blade group (20.3 mm) and the lag screw group
(20.2 mm) (P = 0.8245; t test).
Implant cutout occurred in a total of 22 fractures, 14
(15.1%) of which occurred with helical blades and 8 (3.0%)
of which occurred with lag screws (Figs. 1 and 2). Cutout
occurred significantly more frequently in the helical blade
group than in the lag screw group (P = 0.0001; Fisher exact
test). When looking only at patients treated with the TFN,
only 3 (2.0%) cutouts occurred with the lag screw, versus
15.1% in the helical blade group. The data on patients in
whom cutout occurred are summarized in Supplemental Dig-
ital Content 2 (see Table, http://links.lww.com/BOT/A959)
and Supplemental Digital Content 3 (see Table,
http://links.lww.com/BOT/A960). The percentage of unsta-
ble fractures did not differ between those patients that had
cutout compared with those that did not for both the helical
blade group (P = 0.7645; Fisher exact test) and the lag screw
group (P = 1.00; Fisher exact test). The average time to cutout
was 5.3 weeks in the helical blade group was and 6.6 weeks in
the lag screw group (P = 0.4172; t test). Eighteen of the 22
(81.8%) failures occurred within 8 weeks of surgery and no
cutouts were observed after 12 weeks. The average TAD was
significantly greater in those patients who experienced cutout
than those that went on to uneventful union both for the helical
blade group (23.5 vs. 19.7 mm; P = 0.0194) and the lag screw
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
J Orthop Trauma  Volume 31, Number 6, June 2017
FIGURE 2. Example of lag screw cutout.
group (24.5 vs. 20.0 mm; P = 0.0197), respectively (Figs. 3
and 4, Table 1).
The direction of cutout from the femoral head was
variable. For the helical blade group, most occurred in either
a superior (7/14 = 50%) or medial (6/14 = 42%) direction, and
one implant (7%) cutout posteriorly. In the lag screw group, 7
of the 8 implants cutout superiorly and one (12%) implant
cutout posteriorly.
Six patients in the helical blade group were asymptom-
atic from the cutout and did not undergo revision surgery.
Eight patients were symptomatic, of which 6 underwent
revision surgery. Of the 2 symptomatic patients who did not
undergo revision, one patient died before surgery and one
elected not to pursue revision surgery. Of the 8 patients in the
lag screw group with cutout, 7 were symptomatic. Six of the
symptomatic patients underwent revision surgery with one
electing to pursue nonoperative treatment.
FIGURE 3. Distribution of TAD in those pa-
tients who underwent cephalomedullary nail-
ing with a helical blade. Editor’s note: A color
image accompanies the online version of this
article.
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
Copyright Ó 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Helical Blade Versus Lag Screw Fixation
DISCUSSION
In this large cohort of low-energy peritrochanteric
femur fractures that were treated with trochanteric entry of
CMN, the helical blade demonstrated a significantly higher
rate of cutout from the femoral head when compared with the
lag screw for proximal fixation. Although TAD was signif-
icantly larger for both groups in those patients who cutout, no
threshold value could be identified that was predictive of
cutout in either group. Although cutout was asymptomatic
and tolerated in some of our patients, in others it was painful
and destructive to the hip joint requiring conversion to
arthroplasty. Conversion to arthroplasty after failed fixation
of an intertrochanteric femur fracture is more technically
demanding and is associated with higher blood loss, longer
operative times, greater need for a revision femoral compo-
nent, longer operative times, higher blood loss, and higher
risk of periprosthetic fracture and dislocation, when
www.jorthotrauma.com | 307
Stern et al
FIGURE 4. Distribution of TAD in those pa-
tients who underwent cephalomedullary with
a lag screw. Editor’s note: A color image ac-
companies the online version of this article.
compared with conversion from failed femoral neck fracture
fixation.12,13
Others have studied lag screw cutout after CMN. Geller
et al reported a series of 82 intertrochanteric fractures that
were treated with a CMN which used a lag screw for proximal
fixation.5 Their rate of cutout was 8.54% and they found
a strong correlation between cutout and the severity of the
fracture as well as a TAD greater than 25 mm. Likewise,
Lobo-Escolar et al, reported a cutout rate of 3.6% with lag
screw fixation and noted a significant correlation between
cutout and an increasing TAD on their multivariate analysis.6
Finally, Bojan et al reported a cutout rate of 2.3% in a large
series of fractures treated with gamma nails; however, this
included all ages and mechanisms of injury.7 Although the
overall rate of lag screw cutout in our series (3.0%) is com-
parable with previously published rates, we were unable to
demonstrate an association between unstable fracture patterns
and cutout. In addition, although we were able to demonstrate
that the average TAD was significantly larger in the group
that had cutout, there were patients in both groups who expe-
rienced cutout with a TAD less than 25 mm. This suggests
that the mechanical function of the CMN is different from that
of the screw and sideplate causing the TAD to have less value
in predicting cutout when the CMN is used.
Gardner et al, reviewed the early results of 97 patients
treated with the helical blade. They attributed cutout to
unstable fracture patterns and technical error in all 5 of their
cases in which cutout occurred.14 They noted that all cutouts
TABLE 1. Rate of Cutout for Each Device by Tip–Apex Distance
0–9 mm 10–14 mm 15–19 mm 20–24 mm
Helical Blade 0/1 1/15 (6.67%) 5/32 (15.63%) 2/27 (7.41%)
(n = 93)
Lag Screw 0/5 0/30 3/109 (2.75%) 2/79 (2.53%)
(n = 269)
308 | www.jorthotrauma.com
Copyright Ó 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
J Orthop Trauma  Volume 31, Number 6, June 2017
occurred during the first 20% of patients who were treated
with the helical blade, with an overall cutout rate of 5.15%. In
addition, 4 out of the 5 cutouts occurred in patients with
basicervical femoral neck fractures. Liu et al noted a cutout
rate of 6.7% in 223 patients treated with a CMN.15 They
determined that a TAD less than 15 mm was significantly
associated with cutout. Nikoloski et al demonstrated a rate
of 6.2% rate of cutout when the TAD was either less than
20 mm or greater than 30 mm.16 No cutouts were seen in their
series with a TAD between 20 and 30 mm. However, their
series reviewed the proximal femoral antirotation nail instead
of the trochanteric femoral nail. An additional study by Tur-
gut et al looking at cutouts in 298 patients who were treated
with the proximal femoral antirotation nail noted that the
factors most important in determining cutout were varus
reduction and improper quadrant placement of the helical
blade.17 TAD was only the third most important factor and
was not found to be statistically significant in predicting cut-
out. In a recent publication by Flores et al looking at cutout
with the helical blade only in 258 patients, a cutout rate of
3.4% was noted with a significant increase in the rate of
cutout with a TAD less than 20 mm.18
Our rate of cutout with the helical blade is significantly
higher than that which has been previously published. There
was no significant difference in the percentage of unstable
fractures in the group that cutout versus those that did not,
further supporting the concept that the complexity of the
fracture is not the defining factor predictive of helical blade
25–29 mm 30–34 mm 35–39 mm 40–44 mm 45–49 mm
3/13 (23.08%) 2/4 (50%) 1/1 (100%) 0/0 0/0
2/35 (5.71%) 0/8 0/2 0/0 1/1 (100%)
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
J Orthop Trauma  Volume 31, Number 6, June 2017
cutout. However, unlike a more recently published study, we
did not specifically evaluate reduction quality as a factor in
cutout, which perhaps is the best predictor of failure.17 More-
over, TAD is also not the defining factor: 9 of the 14 patients
who experienced cutout had a TAD less than 20 mm or
greater than 30 mm, with only one patient who had a TAD
less than 15 mm. However, the helical blades that cutout had
an average TAD significantly greater than those that did not
cutout suggesting that with the helical blade it may be the
extremes of TAD rather than an absolute number which is
predictive of failure, as has been suggested by others.15,16,18
In looking at the direction of cutout, almost half of the
helical blades in our series cutout medially rather than
superiorly, the usual pattern of cutout for the lag screw and
the pattern of cutout noted in the lag screw in every case in
this cohort except for one. Other authors have also noted this
so called “axial migration” of the helical blade.18 The differ-
ent direction of failure may be related to the proposed com-
paction of bone around the helical blade as it is seated which
could act as a potential barrier to superior migration. This
mode of cutout may also explain the reported increased risk
of cutout with smaller TAD’s.18
This study is unique in that, it is one of the first to look at
a side by side comparison of the lag screw to the helical blade
in the same generation of CMN’s. Previous studies have looked
at cadaveric data,19 a cohort that included both plates and
nails,20 and a comparison between a second generation device
and 3 different third generation implants.21 In a prospective
study published by Yaozeng et al in 2010, a comparison
between the third generation short gamma nail and the proxi-
mal femoral antirotation nail demonstrated a cutout rate of
zero.22 However, this study was a smaller cohort (107 patients)
in an elderly Chinese population. Strengths of our study
include the large number of patients, and the ability to look
at the same device with 2 different types of proximal fixation.
There are several limitations to this study. The retrospec-
tive nature of the study could introduce bias, as all data were
obtained by review of charts and imaging. In addition, there
were 350 patients who were excluded on the basis of the fact
that they did not have at least 3 months follow-up or were dead
before 3 month follow-up. It is possible that by excluding these
patients a significant number of patients who experienced
cutout were not evaluated, as all previous studies and our own
data support the concept that cutout occurs before 12 weeks
postoperatively. Finally, our cohort contains surgeries that have
been performed by 26 different surgeons which may lead to
a certain amount of variance in technique that cannot be
controlled. Because of the small number of cutouts overall, we
could not determine what effect if any surgeon experience had
on cutout rate. It is notable however, that there was no trend in
cutout occurring with one or 2 particular surgeons only. There
was also no difference in whether the surgeon had completed
a formal trauma fellowship. We did not specifically evaluate the
reduction quality of each fracture that experienced failure, but it
is possible that there is an association between a poor reduction
and/or imperfect placement of the implant that leads to a higher
likelihood of failure, as has been suggested by other authors.17
In conclusion, we report a significantly higher rate of
cutout when using a helical blade versus a lag screw for
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
Copyright Ó 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Helical Blade Versus Lag Screw Fixation
proximal fixation during CMN of low-energy peritrochanteric
femur fractures in elderly patients. Although those patients who
experienced cutout had a significantly higher TAD for both the
helical blade and lag screw, we were unable to demonstrate an
absolute value that is predictive of cutout. This suggests an
issue with the helical blade itself rather than the placement of
the device in the femoral head. Further prospective studies are
warranted to evaluate the effects of reduction quality, fracture
pattern, and bone quality to truly establish whether ongoing use
of a helical blade should be reconsidered.
ACKNOWLEDGMENTS
The authors would like to recognize Kyle Judd, MD for
editorial assistance.
REFERENCES
1. Anglen JO, Weinstein JN. Nail or plate fixation of intertrochanteric hip
fractures: changing pattern of practice. JBJS. 2008;90:700–707.
2. Kukla C, Heinz T, Gaebler C, et al. The standard gamma nail: a critical
analysis of 1,000 cases. J Trauma. 2001;51:77–83.
3. Hesse B, Gachter A. Complications following the treatment of trochan-
teric fractures with the gamma nail. Arch Orthop Trauma Surg. 2004;
124:692–698.
4. Bojan AJ, Beimel C, Speitling A, et al. 3066 consecutive gamma nails. 12
years experience at a single centre. BMC Musculoskelet Disord. 2010;11:133.
5. Geller JA, Saifi C, Morrison TA. Tip-apex distance of intramedullary
devices as a predictor of cut-out failure in the treatment of peritrochan-
teric elderly hip fractures. Int Orthop. 2010;34:719–722.
6. Lobo-Escolar A, Joven E, Iglesias D, et al. Predictive factors for cutting
out in femoral intramedullary nailing. Injury. 2010;41:1312–1316.
7. Bojan AJ, Beimel C, Taglang G, et al. Critical factors in cut-out com-
plication after gamma nail treatment of proximal femur fractures. BMC
Musculoskelet Disord. 2013;14:1–9.
8. Sommers MB, Roth C, Hall H, et al. A laboratory model to evaluate
cutout resistance of implants for pertrochanteric fracture fixation. J
Orthop Trauma. 2004;18:361–368.
9. Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation compendium—
2007: orthopaedic Trauma Association classification, database, and out-
comes committee. J Orthop Trauma. 2004;21:S1–S133.
10. Baumgaertner MR, Solberg BD. Awareness of tip-apex distance reduces
failure of fixation of trochanteric fractures of the hip. JBJS-B. 1997;79:
969–971.
11. Johnson LJ, Cope MR, Shahrokhi S, et al. Measuring tip-apex distance
using a picture archiving and communication system (PACS). Injury.
2008;39:786–790.
12. Mortazavi SMJ, Greenky MR, Bican O, et al. Total hip arthroplasty after
prior surgical treatment of hip fracture. Is it always challenging? J
Arthroplasty. 2012;27:31–36.
13. Archibeck MJ, Carothers JT, Tripuraneni KR, et al. Total hip arthroplasty
after failed internal fixation of proximal femoral fractures. J Arthroplasty.
2013;28:168–171.
14. Gardner MJ, Briggs SM, Kopjar B, et al. Radiographic outcomes of
intertrochanteric hip fractures treated with the trochanteric fixation nail.
Injury. 2007;38:1189–1196.
15. Liu W, Zhou D, Liu F, et al. Mechanical complications of intertrochan-
teric hip fractures treated with trochanteric femoral nails. J Trauma Acute
Care Surg. 2013;75:304–310.
16. Nikoloski AN, Osbrough AL, Yates PJ. Should the tip-apex distance rule
be modified for the proximal femoral antirotation nail? A retrospective
study. J Orthop Surg Res. 2013;8:35.
17. Turgut A, Kalenderer O, Karapinar L, et al. Which factor is most impor-
tant for occurrence of cutout complications in patient treated with prox-
imal femoral nail antirotation? Retrospective analysis of 298 patients.
Arch Orthop Trauma Surg. 2016;136:623–630.
18. Flores SA, Woolridge A, Caroom C, et al. The utility of the tip-apex
distance in predicting axial migration and cutout with the trochanteric
fixation nail system helical blade. J Orthop Trauma. 2016;30:e207–e211.
www.jorthotrauma.com | 309
Stern et al J Orthop Trauma  Volume 31, Number 6, June 2017

19. Schwarzkopf R, Takemoto RC, Kummer FJ, et al. Helical blade vs
telescoping lag screw for intertrochanteric fracture fixation. Am J Orthop.
2011;40:452–456.
20. Stern R, Lubbeke A, Suva D, et al. Prospective randomized study com-
paring screw versus helical blade in the treatment of low-energy trochan-
teric fractures. Int Orthop. 2011;35:1855–1861.
21. Lenich A, Vester H, Nerlich M, et al. Clinical comparison of the second
and third generation of intramedullary devices for trochanteric fractures
of the hip—blade vs screw. Injury. 2010;41:1292–1296.
22. Yaozeng X, Dechun G, Huilin Y, et al. Comparative study of trochanteric
fracture treated with the proximal femoral nail antirotation and the third
generation of gamma nail. Injury. 2010;41:1234–1238.

310 | www.jorthotrauma.com Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.

Copyright Ó 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.