Session X - Geriatrics
Sun., 10/10/04 Geriatrics, Paper #59, 8:28 am
·The Standard Gamma Nail or the Medoff Sliding Plate for Unstable Trochanteric and Sub-trochanteric Fractures: A Randomized Controlled Trial
Purpose: The treatment of unstable trochanteric and subtrochanteric fractures is controversial. and the failure rate for the Sliding Hip Screws (SHS) in these fracture types is high even in modern studies. The Medoff Sliding Plate (MSP) is an evolution of the SHS allowing axial compression along both the femoral neck (optional) and the femoral shaft. The MSP has shown remarkably good results in prospective trials in both unstable trochanteric and subtrochanteric fractures. The cephalocondylic intramedullary nails have obvious theoretical advantages. One of these, the Standard Gamma Nail (SGN), have been evaluated in several clinical trials, but the theoretical advantages have not been proven in clinical outcome. The main drawback has been intra- and postoperative femoral shaft fractures. However, many of these trials have been performed in institutions not experienced in the surgical technique, thus including the learning curve in the results. Studies performed in institutions well-experienced in the surgical technique show better results. The health-related quality of life (HRQoL) is an important outcome measure but has not been described on a longer time scale for patients with trochanteric or subtrochanteric fractures. The primary aim of the study was to compare the outcome of patients with unstable trochanteric and subtrochanteric fractures randomized to internal fixation with the SGN or the MSP. The secondary aim was to describe the HRQoL within this group of patients with trochanteric and subtrochanteric fractures.
Methods: A total of 217 patients with a mean age of 84 years with an unstable trochanteric or subtrochanteric fracture were randomly allocated to treatment either by internal fixation with a SGN or a MSP (biaxial dynamization mode). The patients were reviewed at 4 and 12 months after surgery. Outcome measurements included general complications, technical failures, revision surgery, activities of daily living (ADL) function, hip function (Charnley score), and health-related quality of life (HRQoL, EQ-5D).
Results: The patients were observed at 4 (mean 4.2, SD 1.1) and 12 (mean 13.0, SD 2.3) months. Six patients (2.8%) were lost to follow-up. The technical failure rate in patients with unstable trochanteric fractures was 6.5% (including intraoperative femoral fractures) in the SGN group and 5.2% in the MSP group. Among patients with subtrochanteric fractures there were no failures in the SGN group (N = 16) compared with two in the MSP group (N = 12). In the SGN group there were 2.8 % intraoperative femoral fractures and no postoperative fractures. There was a trend for a reduced need for revision surgery in the SGN group, 2.8%, compared with the MSP group, 8.3% (P = 0.072). The SGN group also had a lower incidence of severe general complications (P <0.05) and a trend toward a lower incidence of wound infections (P = 0.05). There were no differences between groups regarding outcome in ADL, hip function, or HRQoL. The reduction in HRQoL (EQ-5D index score) was significant in both groups compared with before the fracture (P <0.005).
Conclusion/Significance: The SGN displayed good results in both trochanteric and subtrochanteric fractures. The limited number of intraoperative femoral fractures did not influence the outcome or the necessity of revision surgery. Moreover, the SGN group had a reduced number of severe general complications and wound infections compared with the MSP. The MSP in biaxial dynamization mode showed a low failure rate in trochanteric fractures but an unacceptably high failure rate used in the biaxial dynamization mode in subtrochanteric fractures. The negative influence of an unstable trochanteric or subtrochanteric fracture on quality of life was significant regardless of surgical method. If improved implant design in cephalocondylic intramedullary nails could further reduce the risk for intraoperative femoral fractures, the intramedullary technique is probably preferable to the extramedullary technique in unstable trochanteric and subtrochanteric fractures.