Thurs., 10/4/12 Hip Fractures, PAPER #32, 3:55 pm OTA-2012
Locked Plating of Proximal Femur Fractures: Outcomes and Predictors of Failure
Robert A. Hymes, MD1; Kelly G. Kilcoyne, MD2; Tyler G. Marks, MD3; James S. Melvin, MD4; Scott Yang, MD5; Jennifer H. Wood, MD6; Matt L. Graves, MD3; David S. Weiss, MD5;
Michael C. Tucker, MD6; Lisa K. Cannada, MD7; Elyse S. Brinkmann; J. Tracy Watson, MD7;
1Inova Fairfax Hospital, Fairfax, Virginia, USA;
2Walter Reed Medical Center, Bethesda, Maryland, USA;
3University of Mississippi, Jackson, Mississippi, USA;
4Carolinas Medical Center, Charlotte, North Carolina, USA;
5University of Virginia, Charlottesville, Virginia, USA;
6Palmetto Health, Columbia, South Carolina, USA;
7Saint Louis University, Saint Louis, Missouri
Background/Purpose: Locked plate fixation for proximal femur fractures is associated with low union rates and frequently requires secondary procedures. Fractures of the proximal femur with associated comminution, instability, and/or wide displacement remain a challenge to orthopaedic surgeons. These fractures are increasingly being treated with proximal femoral locking plates (PFLPs). The purpose of this study was to evaluate the clinical outcomes of patients with proximal femur fractures treated with locking plates and to identify factors associated with failure.
Methods: A multicenter retrospective chart review was conducted over a 5-year time period (2005 to 2010). 60 patients treated with PFLPs for femoral neck and pertrochanteric fractures were identified. Data were extracted from the medical record and included demographic information, medical comorbidities, fracture characteristics, mechanism of injury, fixation construct, and quality of reduction. The patients were followed to determine fracture union and need for secondary procedures.
Results: Mean patient age was 46.2 years. Mean follow-up was 17 months. There were 33 males and 27 females. Most common mechanisms were low-energy falls (18), motor vehicle collisions (17), direct blunt trauma (7), and high-energy falls (6). Fracture patterns were 45 pertrochanteric (OTA 31-A), 12 femoral neck (OTA 31-B), and 3 combined. The rate of healed fractures in this study was 76.7%, and the rate of secondary procedures was 38.3%. The most common secondary procedure was revision internal fixation for nonunion (14). Six patients required additional surgery for hardware-related issues and five patients eventually underwent total hip arthroplasty. Univariate and multivariable logistic regression models were calculated to determine factors associated with healing. Transcervical (31-B2) fractures had the lowest healing rate (29%). All other fracture types had greater odds of healing compared to transcervical: peritrochanteric (31-A1 and 31-A2) had a healing rate of 60% (odds ratio [OR] = 8.0; P = 0.034), intertrochanteric (31-A3) had a healing rate of 81% (OR = 27.5, P = 0.003), and subcapital (31-B1 and 31-B3) had a healing rate of 75% (OR = 7.5, P = 0.085). The use of standard screws distally was associated with an increase in healing rates (none = 44% healed vs 1-6 screws = 82% healed; OR = 5.8, P = 0.021). Additional screws outside of the implant had an inverse relationship with healing (no screws = 81% healed vs screws = 42% healed; OR = 0.17, P = 0.038). After adjusting for independent predictors in the model, intertrochanteric fractures were significantly more likely to heal compared to transcervical fractures (OR = 19.6, P = 0.02), and longer implants (6 or more distal holes) were significantly associated with healing (OR = 9.7, P = 0.025).
Conclusion: This study demonstrates that operative treatment with PFLPs has a high rate of failure and frequently requires a secondary procedure. Patients with intertrochanteric fractures had the highest healing rate whereas patients with transcervical fractures had the lowest healing rate. Other predictors of failure include shorter implants and increased numbers of locking screws distally.
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• 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.