Fri., 10/15/10 Geriatrics, Paper #41, 10:12 am OTA-2010
The Orthopaedic Traumatologist and the Peritrochanteric Hip Fracture: Does Experience Matter?
Paul Tornetta, III, MD; T. William Axelrad, MD; Alex Dehaan, MD; William R. Creevy, MD;
Boston University Medical Center, Boston, Massachusetts, USA
Background: The choice of implant for peritrochanteric fractures is controversial. Evidence supports the use of an intramedullary (IM) device for unstable fractures (with comminution, subtrochanteric extension, or loss of lateral support) as more shortening has been noted with sliding hip screw devices in unstable fractures.
Purpose: The purpose of this study was to review our protocol of sliding hip screws for stable and IM devices for unstable peritrochanteric fractures to evaluate the correctness of the decisions made based on complication rates and on shortening (collapse) of the fractures.
Methods: Over a 5-year period, two orthopaedic traumatologists followed a protocol for peritrochanteric fractures utilizing a standard sliding hip screw (dynamic hip screw [DHS]) for all fractures that were felt to be stable and a cephallomedullary nail for unstable fractures. This was based on medial or subtrochanteric extension and the status of the lateral wall. Injury radiographs were reviewed independently by a blinded observer to classify each fracture pattern as stable or unstable based on the Evans classification. The tip apex distance, femoral neck-shaft angle, and shortening were evaluated in addition to any screw cut-out, screw loosening, nonunion, or loss of reduction. Operative data, transfusion requirements, and 30-day mortality were documented.
Results: 121 patients were treated over the 5-year period (62 male and 59 female; average age, 64 years). Of these, 62 were classified as stable and 59 unstable. 28 patients were operated on in the first 24 hours, 81 between 1 and 4 days, and 12 after 5 days, based on medical optimization. After a careful reclassification, stable fractures were treated with a DHS in 59 and an IM nail in 3 cases, whereas unstable fractures were treated with an IM nail in 55 and a plate in 4 cases. The average operating time was 86 ± 42 minutes for the DHS and 115 ± 30 minutes for IM devices. Blood transfusions occurred in 42% of the DHS group and 39% of the IM nail group. The tip apex distance was >25 for 2 of 61 plates (3.3%) and 6 of 60 (10%) of the IM nails. The average tip apex distance was 16 mm for the DHS and 22 for the IM nail group. Two partial cut-outs occurred, both in the DHS group, with 15- and 19-mm tip apex distances. At union, shortening was 5.9 ± 5 mm for the DHS group and 5.3 ± 5 mm for the IM nail group. The neck-shaft angle averaged 135° in the DHS group and 126° in the IM nail group, with neither group showing any loss of this relationship over time. There were 3 (2.5%) deaths within 30 days of surgery.
Discussion: This study validates a protocol utilizing sliding hip screws for stable and IM nails for unstable peritrochanteric fractures. We found that sliding hip screws resulted in less operative time and less occurrences of >25 mm tip apex distance, but no difference in blood requirements. Despite 10% of the IM nails having a tip apex angle of >25mm, there were no cases of cut-out, indicating that this measure may not be as important for IM nails. Overall shortening averaged <6 mm in both groups, validating the preoperative assessment of fracture stability. More anatomic restoration of the neck-shaft angle was accomplished with plates, but these were also more stable fractures. The minimal shortening and restoration of the neck-shaft angle support the use of sliding hip screws in stable fractures. 30-day mortality was low (2.5%), possibly owing to attempts to fully optimize patients prior to intervention.
Conclusion: A protocol utilizing sliding hip screws for stable and IM nails for unstable peritrochanteric hip fractures based on the judgment of experienced surgeons is reasonable and can save costs compared to using IM nails for all cases ($104,898 in this series).
Alphabetical Disclosure Listing (292K PDF)
• The FDA has not cleared this drug and/or medical device for the use described in this presentation (i.e., the drug or medical device is being discussed for an “off label” use). ◆FDA information not available at time of printing. Δ OTA Grant.