Comparison of Supine Position and Traction Table in the Surgical Treatment of Unstable Intertrochanteric Fractures with PFNA

Abstract

Aim: Intertrochanteric femur fractures (IFF) are a major cause of morbidity and mortality in the elderly population. Proximal femoral nail-anti-rotation (PFNA) is one of the most preferred surgical treatment methods. This study aimed to compare the clinical and radiologic results of two different patient positions used during PFNA and to reveal the intraoperative advantages and disadvantages. Material and Method: Cases operated due to IFF between January 2020 and December 2022 were retrospectively analyzed. The study was conducted with 123 patients meeting the inclusion criteria. The minimum follow-up period was determined as one year. Two groups were formed: those operated on the traction table (opereted-TT) and those operated in supine lithotomy without traction table (operated-SP). The groups were compared regarding operative time, reduction quality, type-apex distance (calTAD), and radiologic and clinical results. Results: There were 76 patients in the operated-TT group and 47 in the operated-SP group. The mean age of the operated-TT group was 81.00±8.52 years, and the mean age of the operated-SP group was 79.30±8.12 years. (p=0.213) Gender, follow-up time, time from trauma to surgery, and fracture classification were similar for the groups. The mean operative time was 95.18±8.54 minutes in the operated-TT group and 88.23±7.12 minutes in the operated-SP group, and the operation was completed in a shorter time in the operated-SP group. (p=0.001) There were no differences between the groups in terms of reduction quality, calTAD, Harris Hip Score, VAS score, infection rates, and cut-out rates. Conclusion: Based on this study, the radiologic and clinical results of the cases operated with manual traction in the supine position and those operated using a traction table in treating IFF with PFNA are similar. In addition, it was concluded that shorter operation time was an advantage of the operated-SP group.

Keywords

• Intertrochanteric fracture
• proximal femoral nail anti-rotation
• position

İnstabil İntertrokanterik Kırıkların PFNA ile Cerrahi Tedavisinde Supin Pozisyon ile Traksiyon Masasının Karşılaştırılması

Abstract

Amaç: İntertrokanterik femur kırıkları (IFF) yaşlı popülasyonda önemli morbidite ve mortalite sebebidir. Cerrahi tedavisinde proksimal femoral nail-antirotation (PFNA) en sık tercih edilen yöntemlerden biridir. Çalışmanın amacı; PFNA uygulanırken kullanılan iki farklı hasta pozisyonunun klinik ve radyolojik sonuçlarını karşılaştırmak, intraoperatif avantaj ve dezavantajlarını ortaya çıkarmaktır. Gereç ve Yöntem: Ocak 2020 ile Aralık 2022 yılları arasında IFF nedeni ile opere edilen olgular retrospektif olarak incelendi. Dahil edilme kriterlerine uyan 123 olgu ile çalışma yürütüldü. Minimum takip süresi bir yıl olarak belirlendi. Traksiyon masasında opere edilenler (opereted-TT) ile traksiyon masasız supin litotomi pozisyonda opere edilenler (opereted-SP) olarak iki grup oluşturuldu. Gruplar ameliyat süresi, redüksiyon kalitesi, type-apex distance (calTAD), radyolojik ve klinik sonuçlar açısından karşılaştırıldı. Bulgular: Opereted-TT grubunda 76, opereted-SP grubunda 47 hasta yer aldı. Opereted-TT grubunun yaşı ortalama 81.00±8.52 yıl, opereted-SP grubunun yaşı ortalama 79.30±8.12 yıl idi. (p=0.213) Cinsiyet, takip süresi, travmadan ameliyata kadar geçen süre ve kırık sınıflaması gruplar için benzerdi. Ameliyat süresi opereted-TT grubunda ortalama 95.18±8.54 dakika, opereted-SP grubunda ortalama 88.23±7.12 dakika olarak tespit edildi ve opereted-SP grubunda ameliyatın daha kısa sürede tamamlandığı görüldü. (p=0.001) Reduction quality, calTAD, Harris Hip Score, VAS skoru, enfeksiyon oranları, cut-out oranları açısından gruplar arasında fark tespit edilmedi. Sonuçlar: Bu çalışmaya göre; IFF’nin PFNA ile tedavisinde supin pozisyonda manuel traksiyon ile opere edilen olgular ile traksiyon masası kullanarak opere edilen olguların radyolojik ve klinik sonuçları benzerdir. Bunun yanında ameliyat süresinin daha kısa olmasının opereted-SP grubunun avantajı olduğu sonucuna ulaşılmıştır.

Keywords

• İntertrokanterik kırık
• proksimal femoral çivi anti-rotasyon
• pozisyon

References

1. Dimai HP, Reichardt B, Zitt E, Concin H, Malle O, Fahrleitner-Pammer A. Thirty years of hip fracture incidence in Austria: is the worst over? Osteoporosis int 2022;33:97-104.
2. 2. Cui Q, Liu YS, Li DF, Zhang P, Guo J, Liu C, et al. Cemented hip hemiarthroplasty clinical observations on unstable intertrochanteric fracture in elderlies. J Trauma Emerg Surg 2016;42:651-6.
3. 3. Socci AR, Casemyr NE, Leslie MP, Baumgaertner MR. Implant options for the treatment of intertrochanteric fractures of the hip: rationale, evidence, and recommendations. Bone Joint J 2017;99:128-33.
4. 4. Kim SS, Kim HJ, Lee CS. Clinical outcomes of PFNA-II in the Asian intertrochanteric fracture patients: Comparison of clinical results according to proximal nail protrusion. Injury 2020;51:361-6.
5. 5. Turgut A, Kalenderer Ö, Günaydın B, Önvural B, Karapınar L, Ağuş H. Fixation of intertrochanteric femur fractures using Proximal Femoral Nail Antirotation (PFNA) in the lateral decubitus position without a traction table. Acta Orthop Traumatol Turc 2014;48:513-20.
6. 6. Bilekli AB, Bahtiyar EE, Zeybek H, Neyişci Ç, Erdem Y, Çankaya D. Radiation exposure during proximal femoral nailing: Traction table versus conventional table. Jt Dis Relat Surg 2022;33:338-44.
7. 7. Şahin E, Songür M, Kalem M, Zehir S, Aksekili MA, Keser S, et al. Traction table versus manual traction in the intramedullary nailing of unstable intertrochanteric fractures: A prospective randomized trial. Injury 2016;47:1547-54.
8. 8. Flierl MA, Stahel PF, Hak DJ, Morgan SJ, Smith WR. Traction table-related complications in orthopaedic surgery. J Am Acad Orthop Surg 2010;18:668-75.

9. 9. Chang SM, Zhang YQ, Ma Z, Li Q, Dargel J, Eysel P. Fracture reduction with positive medial cortical support: a key element in stability reconstruction for the unstable pertrochanteric hip fractures. Arch Orthop Trauma Surg 2015;135:811-8.
10. 10. Buyukdogan K, Caglar O, Isik S, Tokgozoglu M, Atilla B. Risk factors for cut-out of double lag screw fixation in proximal femoral fractures. Injury. 2017;48:414-8.
11. 11. Fischer H, Maleitzke T, Eder C, Ahmad S, Stöckle U, Braun KF. Management of proximal femur fractures in the elderly: current concepts and treatment options. Eur J Med Res 2021;26:86.
12. 12. Lee SR, Kim ST, Yoon MG, Moon MS, Heo JH. The stability score of the intramedullary nailed intertrochanteric fractures: stability of nailed fracture and postoperative patient mobilization. Clin Orthop Surg 2013;5:10-8.
13. 13. Kessler S, Kinkel S, Käfer W, Puhl W, Schochat T. Influence of operation duration on perioperative morbidity in revision total hip arthroplasty. Acta Orthop Belg 2003;69:328-33.
14. 14. Peersman G, Laskin R, Davis J, Peterson MG, Richart T. Prolonged operative time correlates with increased infection rate after total knee arthroplasty. HSS journal 2006;2:70-2.
15. 15. Lee J, Singletary R, Schmader K, Anderson DJ, Bolognesi M, Kaye KS. Surgical site infection in the elderly following orthopaedic surgery. Risk factors and outcomes. J Bone Joint Surg Am 2006;88:1705-12.
16. 16. Ercole FF, Franco LM, Macieira TG, Wenceslau LC, de Resende HI, Chianca TC. Risk of surgical site infection in patients undergoing orthopedic surgery. Rev Lat Am Enfermagem 2011;19:1362-8.
17. 17. Brin YS, Palmanovich E, Aliev E, Laver L, Yaacobi E, Nyska M, et al. Closed reduction and internal fixation for intertrochanteric femoral fractures is safer and more efficient using two fluoroscopes simultaneously. Injury. 2014;45:1071-5.
18. 18. Kannus P, Parkkari J, Sievänen H, Heinonen A, Vuori I, Järvinen M. Epidemiology of hip fractures. Bone. 1996;18:57-63.
19. 19. Çelik H, Kara A, Sağlam Y, Türkmen İ, Aykut S, Erdil M. Can double fluoroscopy in the oblique position reduce surgical time and radiation exposure during intertrochanteric femur fracture nailing? Ulus Travma Acil Cerrahi Derg 2018;24:581-6.
20. 20. Du G, Wang Z, Yang S, Jia L, Li P, Zhang K, et al. [A comparative study on effectiveness of closed reduction and internal fixation of intertrochanteric fracture assisted with skeletal tractor and traction table]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2020;34:469-74.
21. 21. Carson JL, Poses RM, Spence RK, Bonavita G. Severity of anaemia and operative mortality and morbidity. Lancet . 1988;1:727-9.
22. 22. Doğan N, Ertürk C, Gülabi D. Is proximal femoral nailing of unstable intertrochanteric fractures in the lateral decubitus position without a traction table as safe and effective as on a traction table? Injury. 2022;53:555-60.
23. 23. Yang X, Wu Q, Wang X. Investigation of perioperative hidden blood loss of unstable intertrochanteric fracture in the elderly treated with different intramedullary fixations. Injury. 2017;48:1848-52.
24. 24. Çepni SK, Şişman A, Batar S. A simple minimally invasive technique providing anterior and medial reduction in intertrochanteric femur fractures: A case-control study. Ulus Travma Acil Cerrahi Derg 2022;28:1328-34.
25. 25. Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM. The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg Am 1995;77:1058-64.
26. 26. Şişman A, Avci Ö, Çepni SK, Batar S, Polat Ö. Risk factors for cut-out in intertrochanteric fractures treated with proximal femoral nail of double proximal screw design. J Clin Orthop Trauma 2022;28:101832.