Session IX - Femur Fractures
*DHS versus Medoff Plate for the Treatment of Unstable Intertrochanteric Fractures: A Randomized Prospective Study
J. Tracy Watson, MD, Berton R. Moed, MD, David E. Karges, DO, Kathryn E. Cramer, MD
Henry Ford Hospital, Detroit, Michigan, USA
Introduction: Hip fractures continue to be a major cause of death and disability among the elderly. Many complications of this injury are directly related to factors beyond the surgeon's control such as advanced age and associated medical illness. Type of fracture fixation has been shown to have a significant influence on outcome. The Medoff sliding plate has a vertical channel that forms a sliding tract allowing subsequent axial compression as the fracture settles. The hip screw portion of the plate performs in standard fashion and allows compression along the femoral neck. These factors may help reduce the incidence of fixation failure especially in the unstable fracture pattern. The purpose of this study was to compare the standard compression hip screw versus the Medoff sliding plate for the treatment of intertrochanteric hip fractures in a randomized prospective fashion.
Materials and Methods: From November 1994 thru December 1996 all intertrochanteric hip fractures were treated with either a standard compression hip screw device DHS, (Synthes) or Medoff sliding plate (Medpak). Patients were randomized according to medical record number. Following medical clearance, surgery was performed by the Orthopaedic Trauma Service. Intraoperative blood loss, surgical time and immediate fracture reduction and hardware placement were recorded. Fractures were classified according to the modified Evans (Jensen classification) for intertrochanteric fractures. Additionally, the Seinsheimer Type V grouping was used to identify those peritrochanteric fractures with reverse obliquity.
Follow-up was obtained at routine intervals with clinical and radiographic exam until fracture union. X-rays were examined to determine degree of compression screw collapse in both plates, as well as axial slide plate compression, in addition to assessment of fracture healing.
Results: One-hundred eighty-two fractures in 178 patients were randomized to the study group. One-hundred and seventeen females, 61 males, average age 76 (range 25-99). 14% of the study group was not available for long-term follow-up. Ten patients died during the perioperative period and an additional 12 patients were lost to follow-up within two months of surgery. For the study group, 160 fractures, follow-up averaged 9.5 months (range 6-26 months). Ninety-one fractures were treated with DHS versus 69 with the Medoff. The stable fractures (J, 1-2) (29 DHS and 17 Medoff) healed without complication in both treatment groups. For unstable fracture patterns (J, 3-4-5 & S-5) (62 DHS and 52 Medoff) the overall rate of fracture related failure was 9.5%. Failure for the DHS group was significant at 13% (9 patients) versus the Medoff group 3% (2 patients) (p=0.01). Mode of failure in both groups consisted of screw cut out thru the femoral head with varus collapse and could not be attributed to technical error. Average screw/barrel collapse was 10 mm for both groups. Medoff slide plate axial compression averaged 15 mm. Average blood loss and OR time was significantly more p=0.0001 (Welches T test) for the Medoff implant, when used for both stable and unstable fractures.
Conclusion: The two-piece Medoff plate requires a larger surgical exposure with an associated increase in OR time and blood loss. These disadvantages preclude its routine use for stable IT fracture patterns. Our results demonstrate the benefits of additional axial impaction (Medoff plate) in reducing implant-related failure for the treatment of the unstable IT fracture. We would currently recommend the use of the Medoff plate for those unstable IT fractures.