Clockwise torque results in higher reoperation rates in left-sided femur fractures

Jacobien H.F. Oosterhoff, Hidde Dijkstra*, Aditya V. Karhade, Rudolf W. Poolman, Inger B. Schipper, Rob G.H.H. Nelissen, Daphne van Embden, Ruurd L. Jaarsma, Joseph H. Schwab, Job N. Doornberg, Marilyn Heng, Bhavin Jadav

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

1 Citation (Scopus)
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Purpose: Effects of clockwise torque rotation onto proximal femoral fracture fixation have been subject of ongoing debate: fixated right-sided trochanteric fractures seem more rotationally stable than left-sided fractures in the biomechanical setting, but this theoretical advantage has not been demonstrated in the clinical setting to date. The purpose of this study was to identify a difference in early reoperation rate between patients undergoing surgery for left- versus right-sided proximal femur fractures using cephalomedullary nailing (CMN).

Materials and methods: The American College of Surgeons National Surgical Quality Improvement Program was queried from 2016-2019 to identify patients aged 50 years and older undergoing CMN for a proximal femoral fracture. The primary outcome was any unplanned reoperation within 30 days following surgery. The difference was calculated using a Chi-square test, and observed power calculated using post-hoc power analysis.

Results: In total, of 20,122 patients undergoing CMN for proximal femoral fracture management, 1.8% (n=371) had to undergo an unplanned reoperation within 30 days after surgery. Overall, 208 (2.0%) were left-sided and 163 (1.7%) right-sided fractures (p=0.052, risk ratio [RR] 1.22, 95% confidence interval [CI] 1.00–1.50), odds ratio [OR] 1.23 (95%CI 1.00–1.51), power 49.2% (α=0.05).

Conclusion: This study shows a higher risk of reoperation for left-sided compared to right-sided proximal femur fractures after CMN in a large sample size. Although results may be underpowered and statistically insignificant, this finding might substantiate the hypothesis that clockwise rotation during implant insertion and (postoperative) weightbearing may lead to higher reoperation rates. Level of evidence: Therapeutic level II.

Original languageEnglish
Article number110757
Number of pages6
Issue number7
Publication statusPublished - Jul-2023


  • Clockwise rotation
  • Implant surgery
  • Proximal femoral fracture
  • Reoperation rates


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