EXTRAMEDULLARY FIXATION, FUNCTIONAL RESULTS AND THE CURRENT LITERATURE IN INTERTROCHANTERIC FRACTURES OF FEMUR

Abstract

Objective Pertrochanteric fractures consist 50% of the hip fractures with a high rate of morbidity. The primary aim in treatment is anatomic reduction, preserving of the reduction with stable fixation and early mobilization with rehabilitation. Dynamic hip screws (DHS) are accepted as the golden standard in treatment of the these fractures. On the other hand, fixed angle plates, intramedullary nails and external fixators are also used. However, there is no consensus on the implant choice in the management of intertrochanteric fractures particularly for the unstable fractures. The aim of the present study is to discuss the functional results of the extramedullary stabilization of intertrochanteric fractures in the light of the current literature. Materials and Methods In the present study, the patients over 18 years of age who had Evans type 1 and type 2 intertrochanteric fractures that were managed by open reduction and internal fixation and, completed post-operative 1year retrospectively evaluated. Varus, valgus angulation and loss of reduction evaluated in the anteriorposterior radiographs. Harris Hip Score (HHS) and Traumatic Hip Scale (THS) were used to assess functional evaluation. Results Eighteen patients were included in the study. Mean age of the patients was 52,5 years old, mean stay in the hospital was 7 days and mean follow-up time was 22 months. Cause of the admission to the hospital was traffic accident in 4 patients and was falling in 14 patients. Seventeen of the fractures were type 1 and one was type 2. Ten of the type 1 fractures were stable and, 7 were unstable. DHS was used in 13 of the patients and, DCS was used in 5 of the patients. Functional results according to HHS; 14 excellent, 3 good, 1 poor and according to THS; 9 excellent, 7 good, 1 poor and 1unsuccessful.Varus angulation occurred in 12 patients with a mean angle of 8,25°and, valgus angulation occurred in 3 patients with a mean angle of 4,6°. In 3 patients (Evans type 1 unstable) no change occurred in neck-shaft angle. Mean sliding was 5,34 mm in unstable fractures and, was 1,76 mm in stable fractures.Non-union, cutout and femoral shaft medialization, infection, deep venous thrombosis, pulmoner emboli and myositis ossificans was seen in none of the patients. Conclusion Type of the fracture is one of the important factors affecting mortality. Mechanically stable reduction and preserving of the reduction is the main effect that provides success. The increased revision incidence also increases mortality. The present literature is far away from describing the ideal implant. But, every implant has own advantages and disadvantages. Proximal femoral nails seem more advantageous than DHS considering implant failure, bleeding amount and shorter hospitalization time. And also, proximal anatomic plates must be kept in mind for the certain types of the fractures.

Keywords

• intertrochanteric fracture
• dynamic hip screw
• hip fracture

İNTERTROKANTERİK FEMUR KIRIKLARINDA EKSTRAMEDÜLLER TESPİT, FONKSİYONEL SONUÇLAR VE GÜNCEL LİTERATÜR

Abstract

Amaç Pertrokanterik kırıklar kalça kırıklarının yaklaşık %50’ sini oluşturan, yüksek oranlarda mortaliteye sahip kırıklardır. Tedavideki temel amaç anatomik redüksiyon, redüksiyonun stabil bir tespit ile korunması ve erken mobilizasyon ile rehabilitasyondur. Dinamik kalça vidaları (DHS) intertrokanterik kırıkların tedavisinde altın standart olarak kabul edilmekle beraber, sabit açılı plaklar, intramedüller çiviler ve eksternal fiksatörler de kullanılmaktadır. Ancak, özellikle instabil kırıklar olmak üzere kesin kabul görmüş bir tespit materyali yoktur. Bu çalışma ile intertrokanterik kırıkların ekstramedüller tespitinin fonksiyonel sonuçlarının güncel literatürün ışığında tartışılması amaçlandı. Gereç ve Yöntem Evans tip 1 ve tip 2 intertrokanterik femur kırığı tanısı ile açık redüksiyon ve internal tespit yapılan, ameliyat sonrası 1 yılı tamamlamış 18 yaş üstü hastalar retrospektif olarak değerlendirildi. Anteroposterior ve lateral radyografilerde, varus – valgus açılanması ve redüksiyon kaybına bakıldı. Fonksiyonel skorlama amacı ile Harris Kalça Skoru (HHS) ve Travmatik Kalça Skalası (TKS) kullanıldı. Bulgular Çalışmaya 18 hasta alındı. Yaş ortalaması 52,5 yıl, hastanede kalış süresi ortalama 7 gün ve takip süresi 22 ay idi. Hastaların 4’ü trafik kazası, 14’ü düşme nedeni ile başvurmuş idi. Kırıkların 17’si tip 1, biri tip 2 idi. Tip 1 kırıkların 10’u stabil, 7’si instabil idi. 13 hastada dinamik kalça vidası (DHS), 5 hastada dinamik kondiler vida (DCS) kullanılmış idi. Fonksiyonel sonuçlar HHS göre 14 hastada mükemmel, 3 hastada iyi, 1 hastada kötü sonuç. TKS göre 9 hasta mükemmel, 7 hasta iyi,1 hasta kötü, 1 hasta başarısız olarak değerlendirildi. 12 hastada varus açılanması (ortalama 8,25°), 3 hastada valgus açılanması (ortalama 4,6°) saptandı. 3 hastada (Evans tip 1 instabil) boyuncisim açısında değişim saptanmadı. Kayma miktarı instabil kırıklarda ortalama 5,34 mm. ve stabil kırıklarda 1,76 mm. idi. Hiçbir hastada non-union, cut-out ve femur cisim medializasyonu, enfeksiyon, derin ven trombozu, pulmoner emboli ve myositis ossifikans görülmedi. Bir hastada mal-union gelişti ancak revizyon yapılmadı. Sonuç Kırık tipi ameliyat sonrası dönemde mortaliteyi etkileyen önemli faktörlerden olup mekanik olarak stabil redüksiyon ve bunun korunması başarıyı sağlayan ana etkendir. Artan revizyon insidansı mortaliteyi de arttırmaktadır. Mevcut literatür ideal implantı tarif etmekten uzak olmakla beraber her bir implantın kendine özgü avantaj ve dezavantajları vardır. Proksimal femoral çiviler, implant yetmezliği, kanama miktarı, kısa hastanede kalış süresi ile DHS’ye göre daha avantajlı gözükmektedir. Proksimal femoral anatomik plaklar da kırık tipine göre alternatif olarak akılda bulundurulmalıdır.

Keywords

• intertrokanterik kırık
• dinamik kalça çivisi
• kalça kırıkları

References

1. 1. Guerra MT, Pasqualin S, Souza MP, Lenz R. Functional recovery of elderly patients with surgically-treated intertrochanteric fractures: preliminary results of a randomised trial comparing the dynamic hip screw and proximal femoral nail techniques. Injury. 2014 Nov;45 Suppl 5:26-31.
2. 2. Kovalak E, Ermutlu C, Atay T, Başal Ö. Management of unstable pertrochanteric fractures with proximal femoral locking compression plate and affects of neck shaft- angle on functional outcomes. J Clin Orthop Trauma. 2017 Jul-Sep;8(3):209-214.
3. 3. Kazemian GH, Manafi AR, Najafi F, Najafi MA. Treatment of intertrochanteric fractures in elderly highrisk patients dynamic hip screw vs. external fixation. Injury. 2014 Mar;45(3):568-72.
4. 4. Ma KL, Wang X, Luan FJ, Xu HT, Fang Y, Min J, Luan HX, Yang F, Zheng H, He SJ. Proximal femoral nails antirotation, Gamma nails, and dynamic hip screws for fixation of intertrochanteric fractures of femur: A meta-analysis. Orthop Traumatol Surg Res. 2014 Dec;100(8):859-66.
5. 5. Zha GC, Chen ZL, Qi XB, Sun JY. Treatment of pertrochanteric fractures with a proximal femur locking compression plate. Injury. 2011 Nov;42(11):1294-9.
6. 6. Aktselis I, Kokoroghiannis C, Fragkomichalos E, Koundis G, Deligeorgis A, Daskalakis E, Vlamis J, Papaioannou N. Prospective randomised controlled trial of an intramedullary nail versus a sliding hip screw for intertrochanteric fractures of the femur. Int Orthop. 2014 Jan;38(1):155-61.
7. 7. Wirtz C, Abbassi F, Evangelopoulos DS, Kohl S, Siebenrock KA, Krüger A. High failure rate of trochanteric fracture osteosynthesis with proximal femoral locking compression plate. Injury. 2013 Jun;44(6):751-6.
8. 8. Eberle S, Gerber C, von Oldenburg G, Hungerer S, Augat P. Type of hip fracture determines load share in intramedullary osteosynthesis. Clin Orthop Relat Res. 2009 Aug;467(8):1972-80.

9. 9. Dhamangaonkar AC, Joshi D, Goregaonkar AB, Tawari AA. Proximal femoral locking plate versus dynamic hip screw for unstable intertrochanteric fractures. J Orthop Surg 2013;21(3):317-22.
10. 10. Parker MJ, Handoll HH. Gamma and other cephalocondylic intramedullary nails versus extramedullaryimplants for extracapsular hip fractures in adults. Cochrane Database Syst Rev 2008;16(3), CD000093.
11. 11. Özkan K, Eceviz E, Unay K, Taşyıkan L, Akman B, Eren A. Treatment of reverse oblique trochanteric fractures with proximal femoral nail. Int Orthop 2011; 35:595-8
12. 12. Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures:treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Joint Surg [AM] 1969; 51:737-55.
13. 13. Sahin EK, Imerci A, Kınık H, Karapınar L, Canbek U, Savran A. Comparison of proximal femoral nail antirotation (PFNA) with AO dynamic condylar screws (DCS)for the treatment for unstable peritrochanteric femoral fractures. Eur J Orthop Surg Traumatol. 2014 Apr;24(3):347-52.
14. 14. Laufer Y, Lahav M, Lenger R, Sprecher E. Functional recovery following pertrochanteric hip fractures fixated with the dynamic hip screw vs. the percutaneous compression plate. The Scientific World Journal 2005;5:221-9
15. 15. Johnson B, Stevenson J, Chamma Ramsey, Patel A, Rhee SJ, Lever C et al. Short-term follow-up of pertrochanteric fractures treated using the proximal femoral locking plate. J Orthop Trauma 2014;5(28):283-7.
16. 16. Barwar N, Meena S, Aggarwal SK, Garhwal P. Dynamic hip screw with locking side plate: a viable treatment option for intertrochanteric fracture. Chinese Journal of Traumatology 2014;17(2):88-92.
17. 17. Chehade MJ, Carbone T, Awwad D, Taylor A, Wildenauer C, Ramasamy B, McGee M.Influence of Fracture Stability on Early Patient Mortality and Reoperation After Pertrochanteric and Intertrochanteric Hip Fractures. J Orthop Trauma. 2015 Dec;29(12):538-43.
18. 18. Barton TM, Gleeson R, Topliss C, Greenwood R, Harries WJ, Chesser TJ. A comparison of the long gamma nail with the sliding hip screw for the treatment of AO/OTA 31-A2 fractures of the proximal part of the femur: a prospective randomized trial. J Bone Joint Surg Am. 2010 Apr;92(4):792-8.
19. 19. Parker MJ, Bowers TR, Pryor GA. Sliding hip screw versus the Targon PF nail in the treatment of trochanteric fractures of the hip: a randomised trial of 600 fractures. J Bone Joint Surg Br. 2012 Mar;94(3):391-7.
20. 20. Kyle RF, WrightTM, Burnstein AH. Biomechanical anaysis of the sliding characteristics of compresssion hip screws. J Bone Joint Surg. 1980;62A (8):1308-14.
21. 21. Fogagnolo F, Kfuri JRM, Paccola CAJ. Intramedullary fixation of pertrochanteric hip fractures with short AO-ASIF proxiaml femoral nail. Arch Orthop Trauma Surg. 2004; 124: 31-7.
22. 22. Pakuts AJ. Unstable subtrochanteric fractures. Gamma nail versus dynamic condylar screw. Int Orthop (SICOT). 2004;28:21-4.
23. 23. Pajarinen J, Lindahl J, Savolainen V, Michelsson O, Hirvensalo E. Femoral shaft medialisation and neck-shaft angle in unstable pertrochanteric fractures. Int Orthop (SICOT). 2004;28:347-53.
24. 24. Olsson O, Ceder L, Hauggaard A. Femoral shortening in intertrochanteric fractures. A comparison between the Medoff sliding plate and the compression hip screw. J Bone Joint Surg (Br). 2001;83(4):572-8.
25. 25. Barwar N, Meena S, Aggarwal SK, Garhwal P. Dynamic hip screw with locking side plate: a viable treatment option for intertrochanteric fracture. Chin J Traumatol. 2014 Apr 1;17(2):88-92.
26. 26. Kumar R, Singh RN, Singh BN. Comparative prospective study of proximal femoral nail and dynamic hip screw in treatment of intertrochanteric fracture femur. J Clin Orthop Trauma. 2012 Jun;3(1):28-36.
27. 27. Saudan M, Lübbeke A, Sadowski C, Riand N, Stern R, Hoffmeyer P.Pertrochanteric fractures: is there an advantage to an intramedullary nail?: a randomized, prospective study of 206 patients comparing the dynamic hip screw and proximal femoral nail. J Orthop Trauma. 2002 Jul;16(6):386-93.
28. 28. Baumgaertner MR, Curtin SL, Lindskog DM. Intramedullary versus extramedullary fixation for the treatment intertrochanteric hip fractures. Clin Orthop Relat Res. 1998 Mar;(348):87-94.
29. 29. Saarenpää I, Heikkinen T, Ristiniemi J, Hyvönen P, Leppilahti J, Jalovaara P. Functional comparison of the dynamic hip screw and the Gamma locking nail in trochanteric hip fractures: a matched-pair study of 268 patients. Int Orthop. 2009 Feb;33(1):255-60.
30. 30. Dujardin FH, Benez C, Polle G, Alain J, Biga N, Thomine JM. Prospective randomized comparison between a dynamic hip screw and a mini-invasive static nail in fractures of the trochanteric area: preliminary results. J Orthop Trauma. 2001 Aug;15(6):401-6.
31. 31. Little NJ, Verma V, Fernando C, Elliott DS, Khaleel A. A prospective trial comparing the Holland nail with the dynamic hip screw in the treatment of intertrochanteric fractures of the hip. J Bone Joint Surg Br. 2008 Aug;90(8):1073-8.
32. 32. Eschler A, Brandt S, Gierer P, Mittlmeier T, Gradl G. Angular stable multiple screw fixation (Targon FN) versus standard SHS for the fixation of femoral neck fractures. Injury. 2014 Jan;45 Suppl 1:S76-80.