Comparison of proximal femoral nail and dynamic hip screw for treating intertrochanteric fractures

Abstract

Aim: In this study, the use of proximal femoral nail and dynamic hip screw for treatment of intertrochanteric hip fractures were compared in terms of mortality and morbidity.

Methods: 131 patients who had an operation due to intertrochanteric hip fractures were evaluated demographic characteristics and surgical data (72 female, 59 male, mean age 77.85, range 65-98 years). 98 patients (74.8%) PFN method, 33 patients (25.2%) DHS method was applied. The age and gender of patients, etiology, type of anesthesia, preoperative waiting period, preoperative ASA (American Society Anesthesiologists) score calculated by anesthesia physicians, Singh index, track time, the type of fracture, complication rate, the degree of reduction, tip-apex distance, shortening the existence and mortality were investigated. The Harris Hip Score was used for functional assessment.

Results: The average post-operative follow-up period was 25.23 (1-66) months. The group that were applied DHS were found significantly different for reduction success (p<0.05). Harris Hip Scoring of patients in the DHS group were found significantly better (p<0.05). The success of the reduction in the DHS group was significantly related with the Harris HipScore (p<0.05).

Conclusion: We have concluded that the preoperative waiting time has no impact on mortality, increasing age increases the systemic disease, therefore increases ASA score. So that increasing ASA score increases the mortality. Unstable intertrochanteric fractures of the femur PFNA, due to the higher success rate of reduction should be preferred. But between two methods there were no significant differences about healing time and mortality. In conclusion, surgical techniques to be used should be selected according to the fracture type and age of the patient.

Keywords

• Femur fracture,Osteosynthesis,Mortality

İntertrokanterik femur kırıklı olgularda proksimal femur çivisi ile dinamik kalça

Öz

Amaç: Bu çalışmada Intertrokanterik kalça kırığı tedavisinde kullanılan Proksimal femur çivisi ve dinamik kalça vidası cerrahi yöntemleri mortalite ve morbidite açısından karşılaştırıldı. 

Yöntemler: Intertrokanterik kırık nedeniyle opere olan 131 hastanın (72 kadın, 59 erkek, ort yaş 77.85; dağılım 65-98 yıl) demografik özellikleri ve ameliyat verileri değerlendirildi. Doksan sekiz hastaya (%74,8) PFNA, otuz üç hastaya ise (%25,2) DHS uygulanmıştır. Hastaların yaş, cinsiyet, kırık olan kalça tarafı, kırık etyolojisi, anestezi tipi, preoperatif bekleme süresi, anestezi hekimince hesaplanan preop ASA (American Society Anesthesiologists) skoru, Singh indeksi, takip süresi, kırık tipi, komplikasyon oranı, redüksiyon derecesi, tip-apeks mesafesi, kısalık varlığı ve kaynama düzeyi ve mortalite incelendi. Fonksiyonel değerlendirmede Harris Kalça Skoru kullanıldı.

Bulgular: Ameliyat sonrası ortalama takip süresi 25.23 (1-66) ay idi. Redüksiyon başarısı açısından DHS grubu lehine anlamlı fark saptanmıştır (p<0.05). DHS grubundaki hastaların Harris Kalça Skorları istatistiksel olarak daha iyi bulundu (p<0.05). Redüksiyon başarısı açısından DHS grubu lehine anlamlı ilişki saptandı (p<0.05). DHS grubunda redüksiyon başarısı ile Harris Kalça Skoru doğru orantılı olacak şekilde anlamlı bulundu (p<0.05). 

Sonuç: Preoperatif bekleme süresinin mortalite üzerine bir etkisinin olmadığına, yaş arttıkça sistemik hastalıkların, dolayısıyla da ASA skorlarının arttığına ve ASA skorunun artmasının da mortaliteyi arttırdığı sonucuna varıldı. İnstabil intertrokanterik femur kırıklarında PFNA, redüksiyon başarısı oranlarının daha yüksek olması sebebiyle tercih edilmelidir. Ancak kaynama zamanı ve mortalite açısından belirgin bir fark saptanmadı. Hangi cerrahi yöntemin kullanılacağına hastanın yaşına ve kırık tipine göre kararlaştırılmasının daha uygun olacağına kanaat getirildi.

Anahtar Kelimeler

• Femur kırığı,Osteosentez,Mortalite

References

1. 1. Braithwaite RS, Col NF, Wong JB. Estimating hip fracture morbidity, mortality and costs. J Am Geriatr Soc. 2003;51:364-70.
2. 2. Zethraeus N, Gerdtham UG. Estimating the costs of hip fracture and potential savings. Int J Technol Assess Health Care. 1998;14:255-67.
3. 3. Hardy DC, Drossos K: Slotted intramedullaryhip screw nails reduce proximal mechanical unloading. Clin Orthop Relat Res. 2003; 406:176-84
4. 4. Baumgartner MR: Curtin SL, Lindskog DM: The Value of the Tip-Apex Distance in Predicting Failure of Peritrochanteric Fractures of the Hip. J. Bone Joint Surg. Vol. 77-A, No. 7, 765-787, 1995.
5. 5. Koval JK. Intertrochanteric fractures. In: Koval JK, Zuckerman DJ (Eds.). Atlas of orthopaedic surgery. Philadelphia: Lipincott Williams Wilkins; 2004. p.232-9.
6. 6. Ege R. Kalça Eklemi Biyomekaniği, Kalça cerrahisi ve sorunları. 1 baskı. Ankara: Türk Hava Kurumu matbaası, 1996:53-62.
7. 7. Browner DB, Jüpiter JB, Levine AM, Trafton PG. Skeletal Trauma, V:2, WB Saunders Company, 1996.
8. 8. DeLee JC. Fractures and Dislocations of the Hip. In: Rockwood CA, Green DP, Buckholz RW, Heckman JD (Eds.). Rockwood and Green's Fractures in Adults. 4th ed. Philadelphia: Lippincott-Raven, 1996.p.1659-1827.

9. 9. Green S, Moore T, Proano F. Bipolar prosthetic replacement for the management of unstable intertrochanteric hip fractures in the elderly. Clin Orthop Relat Res. 1987;(218):169-77.
10. 10. Haentjens P, Casteleyn PP, De Boeck H, Hendelberg F, Opdecam P. Treatment of unstable intertrochanteric and subtrochanteric fractures in elderly patients. J Bone Joint Surg Am. 1989;71:1214-24.
11. 11. Akçalı Ö, Kıter E, Kabaklıoğlu T, Araç Ş. Femoral kalkar bütünlüğünün bozulduğu kalça kırıklarında Leinbach tipi protez uygulamaları. Acta Orthop Traumatol Turc. 1998;32:116-9.
12. 12. Kesemenli C, Subaşı M, Arslan H, Kırkgöz T, Necmioğlu S. İleri yaşlarda intertrokanterik kırıkların Leinbach tipi endoprotezle tedavisi. Ulusal Travma Dergisi. 2001;7:254-7.
13. 13. Kenzora JE, McCarthy RE, Lowell JD. Hip fracture mortality. Relation to age, tretment, preoperative illness, time of surgery and complications. Clin Orthop. 1984;186:45-56.
14. 14. Zuckerman, JD, Skovron ML, Koval KJ, Aharonoff G, Frankel VH. Treatment outcome associated with operative delay in older patients who have a fracture of the hip. J Bone Joint Surg. 1995;77(10):1995.
15. 15. Moran CG. Early mortality after hip fracture: Is delay before surgey important? J.Bone Joint Surg. 2005;87-A(3):483-9.
16. 16. Kim SY, Kim YG, Hwang JK. Cementless Calcar Replacement Hemiarthroplasty Compared with Intramedullary Fixation of Unstable Intertrochanteric Fractures. J Bone Joint Surg. 2005;87(A):2186-92.
17. 17. Wolfgang GL, Bryant MH, O Neill JP. Treatmant of intertrochanteric fracture of the femur using sliding screw plate fixation. Clin. Orthop. 1982;163:148-58.
18. 18. Orhun H, Kavaklı B, Eren H, Bilgiç E. Femur intertrokanterik kırıklarında osteosentez komplikasyonları. Acta Orthop Traumatol Turc. 1995:29:10-6.
19. 19. Burnett JW, Gustilo RB, Williams DN, Kint AC. Prophylactic Antibiotics in Hip Fractures. J Bone Joint Surg. 1980;62:457-61.
20. 20. YZ Xu, DC GENG, A comparison of the proksimal femoral nail antirotation device and dynamic hip screw inthe treatment of unstable pertrochanteric fracture The Journal of İnternational Medical Research. 2010;38:1266-75.
21. 21. Henry W, Phili J, Martyn P. Are short femoral nails superior to the sliding hip screw?A meta-analysis of 24 studies involving 3279 fractures, İnternational Orthopeadics. 2006;30:69-78.
22. 22. Klinger HM, Baums MH, A comparative study of unstable per-and intertrochanteric femoral fractures treated with DHS and trochanteric butt-plate vs. PFN Zentralbl. 2005;130(4):301-6.
23. 23. Pajarinen J, Lindahl J, Michelsson O, Savolainen V, Hirvensalo E. Pertrochanteric femoral fractures treated with a dynamic hip screw or a proximal femoral nail. A randomised study comparing post-operative rehabilitation. J Bone Joint Surg Br. 2005;87:76-81.
24. 24. Baixauli F, Vincent V, Baixauli E, et al. A reinforced rigid fixation device of unstable intertrochanteric fractures. Clin Orthop. 1999;361:205-15.
25. 25. Wilson HJ, Rubin BD, Helbig FEJ, Fielding JW, Unis GL. Treatment of İnterotrochanteric Fractures with the Jewett Nail. Experience with 1,015 Cases. Clin Orthop. 1980;148:186–91.
26. 26. Laohapoonrungsee A, Arpornchayanon O, Phornputkul C. Two-hole side-plate DHS in the treatment of intertrochanteric fracture. Results and complications. Injury Int J Care Injured. 2005;36:355-60.
27. 27. Foulongne E, Gilleron M, Roussignol X, Lenoble E, Dujardin F. Mini-invasive nail versus DHS to fix pertrochanteric fractures: A case-control study. Surgery and Research. 2009;95:592-8.
28. 28. Guo Q, Shen Y, Zong Z, Zhao Y, Liu H, Hua X, Chen H. Percutaneus compression plate versus proximal femoral nail anti-rotation in treating elderly patients with intertrochanteric fractures: a prospective randomized study. J Orthop Sci. 2013;18:977-86.
29. 29. Chua ITH, Rajamoney GN, Kwek EBK. Cephalomedullary nail versus sliding hip screw for unstable intertrochanteric fractures in elderly patients. Journal of Orthopaedic Surgery 2013;21(3):308-12.
30. 30. Varela-Egocheaga JR, Iglesias RC, Suarez MA, Fernandez mv, Gonzalez VS, Murcia AM. Minimally invasive osteosynthesis in stable trochanteric fractures: a comarative study. Arch Orthop Trauma Surg. 2009;129:1401-7.
31. 31. Shen L,Zhang Y, Shen Y,Cui Z. Antirotation proksimal femoral nail versus dynamic hip screw for intertrochanteric fractures: A meta analysis of randomized controlled studies. Orthopaedics and Traumatology: Surgery and Research. 2013;99:377-83.
32. 32. Yuan X, Yao Q, Ni J, Peng L, Yu D. Proximal femoral nail antirotation versus dynamic hip screw for intertrochanteric fracture in elders: a meta-analysis. Zhonghua Yi Xue Za Zhi. 2014;94(11):836-9.