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[Treatment of aged intertrochanteric fractures with minimally invasive dynamic hip screws]
Abstract
To evaluate the effect of minimally invasive dynamic hip screws (MIDHS) in treating aged intertrochanteric fractures.
From April 2006 to March 2008, 49 aged patients with intertrochanteric fractures were treated with MIDHS. There were 22 males and 27 females, aged 65-78 years (average 70.2 years). Fracture was caused by traffic accident in 7 cases, by falling from height in 3 cases, and by injury from fall in 39 cases. The time from injury to operation was 2-12 days (average 5.5 days). According to Evans classification, there were 28 cases of types I, II (stable fracture) and 21 cases of types III, IV (unstable fracture). If the Singh index 3 was defined as osteoporosis, the osteoporotic rate was 71.4% (35/49). All patients were on a radiolucent fracture traction table and their fractures had satisfactory closed reduction. After the guide wire was inserted and reamed under fluoroscopy, the lag screw and side plate were introduced through the small incision. In all unstable fractures, an additional, antirotational and large cancellous bone screw was used cranial to the DHS.
The average operation time was 65.2 minutes. The average blood loss was 189.3 mL. All patients had satisfactory reduction and 79.6% (39/49) had adequate lag screw positions. The average postoperative hospitalization days was 5.8 days (3-12 days). All incision healed at stage I. There was no postoperative complications. Forty-nine patients were followed up 12 to 30 months (average 19.8 months). Fractures healed within 16 weeks in 47 patients and the average healing time was 13.1 weeks (12-16 weeks). The average Harris scoring was 90.8 (75-95). Implant failure and nonunion occurred in 2 cases, no serious complication occurred in other patients.
The MIDHS is a simple, safe and effective method for treatment of aged intertrochanteric fractures.
... The intertrochanteric femur fractures are among the most common injuries necessitating hospital admission to an orthopaedic trauma ward and for this indication, dynamic hip screw (DHS) with a side plate has been the gold standard and the most commonly used device in most centers [1][2][3][4][5][6][7][8] . However, the disadvantages of DHS techniques are a large skin incision and an extensive soft tissue dissection, dividing the vastus lateralis muscle for at least 10 cm, so it may be associated with significant blood loss and tissue damage that may worsen patients' status 5,6 . ...
Objective: To determine outcome of minimal invasive dynamic hip screw procedure for fixation of stable intertrochanteric fractures of the femur. Methodology: A total of 40 patients with closed stable intertrochanteric femur fractures (AO type A1.1 to A2.1) were operated with MIDHS technique. Reduction of postoperative haemoglobin and haematocrit, pain score, theatre time, length of hospital stay, evidence of wound infection, hip screw position and tip apex distance were studied. Results: Of 40 patients, 22 (55%) were female and 18 (45%) were male. 14 (35%) had left hip while 26 (65%) had right hip involvement. Mean age at the time of surgery was 54.5 years. Based on AO classification: 12 had A1.1, 17 had A1.2 and 11 had A2.1. Mean reduction of post-operative hemoglobin was 1.2g/dl and haematocrit was 0.07. The mean post-operative pain score was 2.8 (using Visual Analogue Scale). The mean duration of surgery was 38.6 minutes and mean time to discharge from hospital after surgery was 4.3 days. We had no instances of postoperative haematoma or infection, malalignmnent of lag screws position of the operated limb in any of the patients. Conclusion: The MIDHS fixation of intertrochanteric fractures in our view is a surgical esthetic procedure; it involves minimal bleeding, less post-operative pain, shorter duration of surgery and length of hospital stay without sacrificing reduction, alignment, screw position and fixation stability. Additionally, the technique is performed using a standard dynamic hip screw set and requires no additional equipment.
BACKGROUND: Determining the anchor point of femoral neck axial line tail on the femoral lateral wall is the most primary and critical steps for the placement of internal fixator during the treatment of femoral intertrochanteric fractures. OBJECTIVE: To radiological confirm the anchor point of femoral neck axial line tail on the femoral lateral wall. METHODS: The central line on the anterior surface of the femoral neck along femoral neck and the vertical central line on femoral proximal lateral wall were drawn on 80 adult femoral specimens. The intersection point of the above two central line was assumed as the anchor point of femoral neck axial line tail on the proximal femoral lateral wall. The thin steel wire was placed around the middle of femoral neck closely and a small steel ball was struck on the anchor point (A) and the on the point which located at 1.0 cm (B), 2.0 cm (C) and 3.0 cm (D) below the slope top point on the longitudinal center line on lateral surface of proximate femur, then the X-ray images were took along the femoral neck axis, and the location of the small steel ball imaging on the wire circle was observed. The distance between the center point of the small steel ball and the wire circle was measured, and the amount of the imaging point in the center. RESULTS AND CONCLUSION: The proportion of the small steel ball imaging that located on the point A, B, C and D on the center of the wire circle was 85%, 18.75%, 81.25% and 35%, and there was significant difference of the proportion between point B and D and point A (P < 0.05). The intersection point of the central line on the anterior surface of the femoral neck and the vertical central line on femoral proximal lateral wall can be regarded as the anchor point of femoral neck axis tail on femoral lateral wall.
The classic dynamic hip screw fixation of intertrochanteric fractures may be associated with significant blood loss and soft tissue damage, which may worsen existing comorbidities of frail elderly patients. Recently, minimally invasive dynamic hip screw (MIDHS) technique was developed for osteosynthesis of intertrochanteric fractures. A highly sensitive search strategy was used to identify all published randomized or quasi-randomized controlled trials (RCTs/ qRCTs) and comparative observational studies comparing the MIDHS technique with the conventional dynamic hip screw (CDHS) technique in patients with intertrochanteric fractures. A pooled estimate of effect size was produced using both random and fixed effects models. Four RCTs/qRCTs and 2 retrospective comparative studies were identified. The MIDHS technique resulted in less blood loss, shorter hospitalization, lower pain level, faster fracture healing, and better hip function when compared with the CDHS technique. There was no significance difference between the 2 groups with regard to postoperative complications and implant position. The MIDHS technique may achieve perioperative benefits when compared with the CDHS technique.
Two types of implants used for the surgical fixation of extracapsular hip fractures are cephalocondylic intramedullary nails, which are inserted into the femoral canal proximally to distally across the fracture, and extramedullary implants (e.g. the sliding hip screw).
To compare cephalocondylic intramedullary nails with extramedullary implants for extracapsular hip fractures in adults.
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (April 2010), The Cochrane Central Register of Controlled Trials (The Cochrane Library 2010, Issue 1), MEDLINE (1950 to March 2010), EMBASE (1980 to 2010 Week 13), and other sources.
All randomised and quasi-randomised controlled trials comparing cephalocondylic nails with extramedullary implants for extracapsular hip fractures.
Both authors independently assessed trial quality and extracted data. Wherever appropriate, results were pooled.
We included 43 trials containing predominantly older people with mainly trochanteric fractures. Twenty-two trials (3749 participants) compared the Gamma nail with the sliding hip screw (SHS). The Gamma nail was associated with increased risk of operative and later fracture of the femur and increased reoperation rate. There were no major differences between implants in wound infection, mortality or medical complications.Five trials (623 participants) compared the intramedullary hip screw (IMHS) with the SHS. Fracture fixation complications were more common in the IMHS group. Results for post-operative complications, mortality and functional outcomes were similar in both groups.Three trials (394 participants) showed no difference in fracture fixation complications, reoperation, wound infection and length of hospital stay for proximal femoral nail (PFN) versus the SHS.None of the 10 trials (1491 participants) of other nail versus extramedullary implant comparisons for trochanteric fractures provided sufficient evidence to establish definite differences between the implants under test.Two trials (65 participants) found intramedullary nails were associated with fewer fracture fixation complications than fixed nail plates for unstable fractures at the level of the lesser trochanter.Two trials (124 participants) found a tendency to less fracture healing complications with the intramedullary nails compared with fixed nail plates for subtrochanteric fractures.
With its lower complication rate in comparison with intramedullary nails, and absence of functional outcome data to the contrary, the SHS appears superior for trochanteric fractures. Further studies are required to confirm whether more recently developed designs of intramedullary nail avoid the complications of previous nails. Intramedullary nails may have advantages over fixed angle plates for subtrochanteric and some unstable trochanteric fractures, but further studies are required.
To compare minimally invasive dynamic hip screw (MIDHS) fixation with conventional dynamic hip screw (CDHS) fixation for treatment of intertrochanteric femoral fracture.
Of the 66 participants in this double-blind study, 35 were randomised to MIDHS and 31 to CDHS fixation. Main outcome measurements were wound size, haemoglobin decrease, blood transfusion rate, pain score, analgesic consumption, Elderly Mobility Scale score, hip screw position, tip-apex distance, union rate, time to healing and complication rate.
The groups had similar preoperative clinical data. Postoperatively the MIDHS group had significantly smaller wound size, less blood loss, lower blood transfusion rates, pain scores and rates of analgesic consumption, and higher early Elderly Mobility Scale scores. There were no significant differences in fracture alignment, hip screw position, tip-apex distance, union rate, time to healing or complication rate.
MIDHS fixation of intertrochanteric fractures is effective and safe and significantly reduces blood loss, pain and rehabilitation period, without sacrificing reduction alignment, screw position, fixation stability or bone healing.
A series of 1,071 patients with unstable trochanteric fractures were treated by the McLaughlin or Jewett nail-plate, the sliding screw-plate or condylocephalic nailing according to Ender. Deep infection was encountered in 2.5% of the cases following surgery in the hip region and in 3.3% of the Ender nailings. Statistical analyses showed that the quality of the reduction was determined by the comminution of the fracture, and the technical failure of fixation or secondary displacement of the fracture was determined by the quality of the reduction. Sliding screw-plate fixation was found to be the only suitable fixation method for unstable trochanteric fractures, because of a low failure rate, a low re-operation rate and the possibility of secondary impaction without disturbing the fracture union.
To present the principles of a surgical technique for percutaneous compression plating of intertrochanteric hip fractures and to report the clinical results of treatment using this method.
Retrospective.
University hospital.
Ninety-eight intertrochanteric hip fractures in ninety-seven patients with a minimum follow-up of twelve months.
Radiographic and clinical evidence of functional outcome and complications including fracture collapse and implant failure.
Mean perioperative blood loss was 92.4 milliliters (range 14 to 245 milliliters), and the mean postoperative hospital stay was 8.7 days (range 4 to 20 days). Complications included two minor wound hematomas and one soft tissue infection. Radiographically, one fracture with a varus deformity of 8 degrees and two fractures had minor screw pullout that did not affect the final results. No collapses, screw cutouts, or head penetrations were seen. Three patients required reoperation: one for avascular necrosis after a fracture at the base of the neck and two, after fracture healing, for trochanteric bursitis requiring plate removal. All surviving patients (80 of 98; 82 percent) had uneventful fracture healing with union achieved by six months in all patients.
Use of the percutaneous compression plating for intertrochanteric hip fractures resulted in reduced complications, event-free fracture healing, and improved rehabilitation.
To compare the surgical complications and functional outcome of the Gamma nail intramedullary fixation device versus the Richards sliding hip screw and plate device in intertrochanteric femoral fractures.
A prospective, randomised controlled clinical trial with observer blinding.
A regional teaching hospital in the United Kingdom.
All patients admitted from the local population with intertrochanteric fractured femurs were included. There were 400 patients entered into the study and 399 followed-up to one year or death.
The devices were assigned by randomization to either a short-type Gamma nail (203 patients) or a Richard's-type sliding hip screw and plate (197 patients).
The main surgical outcome measurements were fixation failure and reoperation. A functional outcome of pain, mobility status, and range of movement were assessed until one year.
The requirement for revision in the Gamma nail group was twelve (6%); for Richard's group, eight (4%). This was not statistically different (p = 0.29; odds ratio, 1.48 [0.59-3.7]). A subcapital femoral fracture occurred in the Richard's group. Femoral shaft fractures occurred with four in the Gamma nail group (2%) and none in the Richard's group (p = 0.13). Three required revision to another implant. Lag-screw cut-out occurred in eight patients in the gamma nail group (4%) and four in the Richard's group (2%). This was not statistically significant (p = 0.37; odds ratio, 2.29 [0.6-9.0]). The development of other postoperative complications was the same in both groups. There was no difference between the two groups in terms of early or long-term functional status at one year.
The use of an intramedullary device in the treatment of intertrochanteric femoral fractures is still associated with a higher but nonsignificant risk of postoperative complications. Routine use of the Gamma nail in this type of fracture cannot be recommended over the current standard treatment of dynamic hip screw and plate.
We have reviewed 178 intertrochanteric fractures treated by dynamic hip screw (DHS) fixation between March 1995 and December 1999 and followed for a minimum of 1 year. We used Singh's classification of the trabecular bone structure in the proximal femur as a measure of osteoporosis and also classified the fractures according to three different systems (Boyd-Griffin, Evans, AO). The postoperative radiographs were examined for loss of reduction, i.e. varus angulation >100, perforation of the femoral head, more than 20-mm extrusion of a lag screw or metal failure. We found 49 cases which showed radiographic failures. Two were stable fractures and 47 unstable fractures (Evans' classification). Unstable fractures with osteoporosis had a failure rate of more than 50%. In such cases DHS should not be the first choice for treatment.
This study evaluates the safety and outcome of a minimally invasive technique for inserting a standard dynamic hip screw for intertrochanteric fractures.
The use of standard plate in a minimally invasive technique is both possible and advantageous to patient outcome.
Prospective surgeon-randomized blinded outcome clinical study comparing new technique to conventional technique.
Pain, operative time and mean hemoglobin drop in percutaneous hip fixation.
The minimally invasive technique had significantly less blood loss (P < 0.001), operative time (P < 0.001) and a trend to less morphine use.
Minimal invasive technique significantly reduces blood loss and operative time for fixation of intertrochanteric hip fractures without sacrifice of fixation stability or bone healing.
We present the results of a technique of dynamic hip screw insertion through a very small incision, typically 2–2.5 cm.
The technique is performed using a standard dynamic hip screw set and requires no additional equipment. We compared the results to those of an age and sex-matched group who had undergone the operation through a traditional approach. We compared the time spent in theatre, the pre- and post-operative haemoglobin concentration, haematocrit and prevalence of wound infection.
Thirteen consecutive cases were performed by one surgeon using the percutaneous technique. There were nine females and four males with a mean age of 84 years (range 62–96 years). Each had a 135° four-hole plate.
The mean post-operative drop in haemoglobin concentration in the percutaneous group was 2.2 g/dl (range 0–4.4 g/dl) compared to 3.5 g/dl (range 1.2–5.4 g/dl) in the control group ( p = 0.014). The mean haematocrit drop was 0.07 (range 0–0.12) in the percutaneous group compared to 0.10 (range 0.03–0.17) in the control group ( p = 0.017).
The mean theatre time with the percutaneous technique was 57 min (range 40–75 min) and in the control group, 60 min (range 30–95 min). There were no wound problems.
It is likely that this minimally invasive technique offers a better clinical outcome at no extra expense and warrants further evaluation in a larger study.
The treatment of unstable trochanteric femoral fractures is still challenging. The ideal implant should be easy to handle, allow for immediate full weight-bearing postoperatively and should have sufficient purchase in the femoral head/neck-fragment to limit cut-outs due to varus-deviation and rotation. The proximal femoral nail antirotation (PFNA ®), designed by AO, is an intramedullary device with a helical blade rather than a screw for better purchase in the femoral head and was tested in a clinical study.
Consecutive patients with unstable trochanteric fractures (AO-classification 31.A.2 and A.3 only) were included and followed for 1 year. Primary objectives were assessment of operative and postoperative complications, whereas secondary objectives included surgical details, general complications and final outcome measurements.
In 11 European clinics, 315 patients were included and treated with a PFNA ®. Almost all fractures healed within 6 months. Fifty-six percent of the patients regained the pre-trauma mobility and 18% died within the follow-up period. Forty-six implant-related complications – leading to 28 unplanned re-operations – were recorded, with four acetabular penetrations (three of which were after a new fall on that hip) and seven ipsilateral femoral shaft fractures as the most serious ones.
As the joint-penetrations did not resemble the cut-out seen with other implants it is concluded that the PFNA ® – due to its helical blade – possibly limits the effects of early rotation of the head/neck-fragment in unstable trochanteric fractures and therefore seems currently to be the optimal implant for the treatment of these fractures especially in osteoporotic bone.