Session IX - Femur Fractures

Sunday, October 19, 1997 Session IX, 12:13 p.m.

A Comparison of 95 Degree Fixed Angle Plate Devices to Cephalomedullary Nails in the Treatment of High Subtrochanteric Femoral Fractures

William Pistel, DO, Paul Gregory, MD, Thomas DiPasquale, DO, Dolfi Herscovici, DO, Roy Sanders, MD

Florida Orthopaedic Institute, Tampa, Florida, USA

Hypothesis: No significant difference exists in functional outcome, union rate, blood loss, operative time, and complications in high subtrochanteric fractures treated with 95 degree fixed-angle devices compared to cephalomedullary nails.

Materials and Methods: Between January 1993 and July 1996, 42 high subtrochanteric fractures were treated in 42 patients at a regional Level I trauma center. All fractures occurred above the level of the lesser trochanter, making standard IM nailing inadvisable. Twenty-five fractures in 25 patients comprising Group I were treated with a 95 degree fixed angle device: an angled blade plate in 11 patients and a condylar screw and side plate in 10 patients. Seventeen fractures in 17 patients comprising Group II were conversely treated with a cephalomedullary device, the Spiral Lock Blade (Synthes, Paoli, PA). The decision to use a particular implant was based on surgeon preference. Fractures treated with plate fixation were reduced indirectly when possible, and none was bone grafted. With IM fixation, fracture reduction was facilitated in a few cases with a pointed reduction clamp through an extension of the surgical wound. All patients were studied retrospectively and followed until fracture union, death, or being lost to follow-up. One elderly patient in Group II died in the immediate post-operative period of unrelated causes and was eliminated from the data.

Results: Complete radiologic and clinical follow-up was available in 21 of 25 patients (84%) in Group I with an average follow-up of 20 months (7-35 months). Radiographic and clinical follow-up was available in 13 of 16 patients (81%) in Group II with an average follow-up of 13 months (7-20 months). Average age was similar in both groups: 41 years (21-89 years) in Group I and 46 years (15-82 years) in Group II. Also comparable were the mechanisms of injury, associated systemic injuries, and associated orthopedic injuries. The fractures were classified by the Seinsheimer classification. Group I had a significantly higher percentage of fractures with intertrochanteric extension ( Seinsheimer Type V ). Differences in length of follow-up between the two groups and fracture type were statistically significant (p=.002 and p=.0011, respectively).

All fractures in both groups united. No infection occurred in either group. Functional outcome utilizing the Traumatic Hip Score developed by Sanders showed 14 of 21 patients (66%) with good or excellent results, 6/21 (28%) poor results, and 1 failure in Group I. There were 10 of 13 patients ( 76% ) with good to excellent results, 2/13 patients (25%) with poor results, and 1 failure in Group II. Average blood loss was 1227cc (250-3500cc) in Group I and 397 cc (100-1300cc) in Group II. Operative time averaged 286 minutes (105-620 minutes) in Group I and 196 minutes (70-230 minutes) in Group II. There was one case of fixation failure requiring revision in one patient treated with a condylar screw and side plate. This was due to technical error. All patients treated with plates eventually healed in anatomic position. There were no fixation failures in the nail group; however, two elderly patients in this group had a final position of femoral neck varus and shortening requiring shoe lifts. Statistically significant differences were found for blood loss and operative time (p=.0004 and p=.02 respectively) between the two groups. There was no statistically significant difference in functional outcome between the two groups.

Discussion and Conclusion: The two patient populations were similar except that Group I had a longer time of follow-up and a higher proportion of subtrochanteric fractures with intertrochanteric extension (Sienshiemer Type V). The use of intramedullary devices decreased the blood loss and operative time. The use of plates yielded a more consistent anatomic reduction. Functional outcome and union rate were similar in the two groups. Radiographic outcome did not correlate with functional outcome.