A comparative study on functional, clinical and radiological outcome of unstable intertrochanteric fractures managed by proximal femoral nailing versus dynamic hip screw with trochanteric stabilisation plate

A COMPARATIVE STUDY ON FUNCTIONAL, CLINICAL

AND RADIOLOGICAL OUTCOME OF UNSTABLE

INTERTROCHANTERIC FRACTURES MANAGED BY

PROXIMAL FEMORAL NAILING VERSUS DYNAMIC HIP

SCREW WITH TROCHANTERIC STABILISATION PLATE.

Submitted to

THE TAMILNADU Dr.M.G.R MEDICAL UNIVERSITY

CHENNAI-600032.

In partial fulfillment of the regulations

for the award of

CERTIFICATE

This is to certify that the dissertation entitled “A COMPARITIVE

STUDY ON FUNCTIONAL, CLINICAL AND RADIOLOGICAL

OUTCOME OF UNSTABLE INTERTROCHANTERIC

FRACTURES MANAGED BY PROXIMAL FEMORAL

NAILING VERSUS DYNAMIC HIP SCREW WITH

TROCHANTERIC STABILISATION PLATE” is a bonafide work

done by Dr.S.KAVIN KUMAR in M.S BRANCH-II

ORTHOPAEDIC SURGERY at Government Kilpauk Medical

College,Chennai-600010, to be submitted to The Tamil Nadu Dr.M.G.R

Medical University, in partial fulfillment of the university rules and

regulations for the award of M.S. Degree Branch - II orthopaedic

surgery, under my supervision and guidance during the period from May

2015 to May 2018.

Prof.Dr.S.Senthil Kumar, Prof.Dr.S.Senthil Kumar, M.S.Ortho, D.Ortho, M.S.Ortho,D.Ortho,

UNIT CHIEF, Professor and Head of the Department, Dept. of Orthopaedics, Dept. of Orthopaedics,

Govt.Kilpauk Medical College, Govt.Kilpauk Medical College& Hospital,

Chennai-10. Chennai-10.

Govt.Kilpauk Medical College & Hospital, Chennai-10.

DECLARATION

I solemnly declare that this dissertation “A COMPARATIVE

STUDY ON FUNCTIONAL, CLINICAL AND RADIOLOGICAL

OUTCOME OF UNSTABLE INTERTROCHANTERIC

FRACTURES MANAGED BY PROXIMAL FEMORAL NAILING

VERSUS DYNAMIC HIP SCREW WITH TROCHANTERIC

STABILISATION PLATE” was prepared by me at Govt.Kilpauk

Medical College and Hospital,Chennai-10 under the guidance &

supervision of Prof.Dr.S.Senthil Kumar, M.S.Ortho, D.Ortho.,

Professor of Orthopaedic Surgery, Govt. Kilpauk Medical College and

Hospital,Chennai-10.

This dissertation is submitted to The Tamil Nadu Dr.M.G.R

Medical University, Chennai in partial fulfillment of the University

regulations for the award of the degree of M.S.Branch-II Orthopaedic

ACKNOWLEDGEMENT

I express my utmost gratitude to Prof.Dr.P.Vasanthamani, M.D, D.G.O, MNAMS, DCPSY, M.B.A, Dean, Government Kilpauk Medical College and Hospital for providing me an opportunity to conduct this study.

I would like to express my heartfelt thanks to my beloved Prof.Dr.S.Senthil Kumar, M.S.Ortho, D.Ortho, Professor and Head of the department for allowing me to choose this topic and his valuable suggestions and guiding me in every step of mine to make this study a successful one.

I would like to sincerely thank Prof.Dr.S.Veera Kumar, M.S.Ortho, Professor of Orthopaedics, for his excellent guidance and encouragement during this study.

I would like to express my gratitude and reverence to my respected Associate Prof.Dr.R.Prabhakar, M.S.Ortho, whose constant support helped to complete this study.

I would like to thank Prof.Dr.R.Balachandran, M.S.Ortho, D.Ortho, Dept of Orthopaedics, Govt.Royapettah Hospital, Chennai for his support.

I would like to thank all my Assistant Professors Dr.M.Arunmozhi Rajan, M.S.Ortho, Dr.R.Prabhakar Singh, M.S.Ortho, Dr.G.Mohan, M.S.Ortho, Dr.R.K.S.Karthikeyan M.S.Ortho, Dr.S.Prabhakar, M.S.Ortho, Dr.S.Maheshram, M.S.Ortho, Dr.A.Anandh, M.S.Ortho, Dr.R.Manoj Kumar, M.S.Ortho for their valuable advice and guidance.

I would like to thank all my colleagues and hospital staff for all the help they rendered.

CERTIFICATE - II

This is to certify that this dissertation work titled “A COMPARITIVE

STUDY ON FUNCTIONAL, CLINICAL AND RADIOLOGICAL

OUTCOME OF UNSTABLE INTERTROCHANTERIC FRACTURES

MANAGED BY PROXIMAL FEMORAL NAILING VERSUS

DYNAMIC HIP SCREW WITH TROCHANTERIC STABILISATION

PLATE” of the candidate Dr.KAVIN KUMAR .S with registration Number

221512157 for the award of M.S in the branch of ORTHOPAEDIC

SURGERY. I personally verified the urkund.com website for the purpose of

plagiarism Check. I found that the uploaded thesis file contains from

introduction to conclusion pages and result shows 5 percentage of plagiarism

in the dissertation.

A COMPARATIVE STUDY ON FUNCTIONAL,

CLINICAL & RADIOLOGICAL OUTCOME OF

UNSTABLE INTERTROCHANTERIC FRACTURES

MANAGED BY PROXIMAL FEMORAL NAILING

VERSUS DYNAMIC HIP SCREW WITH

CONTENTS

SL.NO TITLE PAGE NO

1 INTRODUCTION 1

2 OBJECTIVE 4

3 OSTEOLOGY 5

4 ANATOMY 12

5 CLASSIFICATIONS 16

6 REVIEW OF LITERATURE 24

7 MATERIAL AND METHODS 28

8 INSTRUMENTATION 31

9 OPERATIVE PROCEDURE 34

10 OVERVIEW & ANALYSIS 46

11 COMPLICATIONS 55

12 CASE ILLUSTRATIONS 61

13 DISCUSSION 69

14 CONCLUSION 75

15 BIBLIOGRAPHY

INTRODUCTION

Most frequent fractures of proximal femur are intertrochanteric

fractures which involve upper end of femur between both trochanters

with or without extending into the upper femoral shaft1 occuring commonly in geriatric patients.

Since general life expectancy of population has increased in the

past two decades incidence of fractures of proximal femur are also

increasing.

In 1990 of over all hip fractures 26% occurred in Asia. This is

expected to rise upto 37% in 2025 and 45% in 2050.2,3

Only moderate or minimal trauma is enough to cause proximal

femur fractures in gediatric patients. Simple self fall causes

intertrochanteric fractures in elderly people due to osteoporosis and

increased incidence of self fall with increasing age is due to decreased

muscle power, decreased reflexes, poor vision and labile blood pressure.

In younger patients it requires high energy trauma.

Intertrochanteric fracture line involves along extra capsular basilar

neck region to region along the lesser trochanter, undisplaced fractures

Unstable contribute to about 50%-60% of all intertrochanteric

fractures.5,6

There are five variables described by Kaufer which are found to

affect the biomechanical strength of the repair. Bone quality and fracture

pattern which are surgeon independent along with Implant choice, quality

of fracture reduction and positioning of implant which are surgeon

dependent.8

Main weight bearing bone of lower limb is femur. Intertrochanteric

fractures cause patients to be bedridden for prolonged period of time and

they are more prone for urinary tract infection, respiratory tract infection,

bed sores and joint stiffness etc.

To avoid these complications operative treatment is indicated.

In 1930 Jawett nail was introduced by Jawett to provide immediate

stability of fracture segments and early mobilisation and is failed due to

lack of controlled impaction.

Condylocephalic intramedullary devices were introduced in 1966

by kuntscher later by Ender in 1970.

Reconstruction intramedullary nail for peritrochanteric and

subtrochanteric fractures were introduced by Russell Taylor in 1984.

Parker first advocated the importance of lateral wall in preventing

varus collapse.

Trochanteric fractures are treated with dynamic hip screw and

intramedullary nailing. Dynamic compression screw permits proximal

fragment to collapse.

Failure rates of DHS in unstable fracture is as high as 50% and in

stable fractures the value drastically reduces to 5%.9,10.

The aim of fixation of intertrochanteric fractures is to prevent

morbidity and mortality. Early mobilisation depends on surgical

construct.

Trochanteric stablisation plate act as adjuvant to DHS plate by

providing lateral buttress.7,11,12.

With this aim of stable surgical reconstruct of intertrochanteric

fracture this study was done to evaluate functional, clinical and

radiological outcome of unstable intertrochanteric fracture operated with

dynamic hip screw with trochanteric stabilisation plate and proximal

OBJECTIVE

To compare the functional, clinical & radiological outcome of

unstable intertrochanteric fractures operated with proximal femoral

OSTEOLOGY

The longest and strongest bone of the body is femur. The parts of

proximal end of femur are head, neck, greater trochanter, lesser

Head of femur

Femoral head forms more than half of sphere, directed medially

upwards and forwards and forms hip joint by articulating with

acetabulam.

Neck of femur

Long axis of neck makes an angle of 125° to 135° with long axis of

the shaft and is termed as neck shaft angle and angle of 10°-30° with

frontal plane which is termed angle of femoral torsion/anteversion.

Calcar

Dense vertical plate of bone extending from the posteromedial

portion of the femoral shaft under the lesser trochanter and radiating

laterally to greater trochanter reinforcing the femoral neck

posteriomedialy. Calcar is thicker medially and thinner laterally.

Greater trochanter

Lesser trochanter

Conical eminence directed medially and backwards and gives

attachment to primary flexor of thigh, the ilopsoas.

Intertrochanteric line

Prominent roughed ridge begins at anterosuperior angle of greater

trochanter continues with spiral line below. It marks the junction of

anterior surface of neck with the shaft of femur.

Intertrochanteric crest

Smooth rounded ridge begins above the posterosuperior angle of

greater trochanter and ends at lesser trochanter.

Intertrochanteric region

Area between greater and lesser trochanter characterized by dense

Blood supply

Blood supply to proximal end of femur is described into three

major groups :

1. Extra capsular arterial ring at the base of neck of femur.

2. Reticular vessels by extra capsular arterial ring on the surface of

femoral neck.

3. Arteries of round ligament.

The extra capsular arterial ring is formed posteriorly and anteriorly

by branch of medial femoral circumflex artery and branch of lateral

These proximal vessels most vulnerable to injury in femoral neck

fracture. Ascending cervical vessels forms a less distinct ring called sub

synovial intra articular arterial ring, from this epiphyseal arteries

penetrate the femoral head.

Lateral epiphyseal arterial group being the most important supplies

lateral weight bearing portion of femoral head.

Trabecular system of proximal femur

In 1838 Ward described the trabecular system of proximal femur.

Trabeculations arise along the lines of force to which bone exposes

(Wolff’s law).

Tensile trabeculations and primary compressive trabeculations pass

via the neck of femur which is separated by sparse cancellous bone called

Trabecular groups

1. Principle compressive group.

2. Principle tensile group.

3. Greater trochanteric group.

4. Secondary compressive group.

5. Secondary tensile group.

Grades of trabecular system (Singh’s grading system)

Grade 6

All types trabecular groups are visible in grade 6.

Grade 5

Secondary tensile trabecular group are almost absent in grade 5.

Grade 4

Secondary compressive trabecular group are completely resorbed

in grade 4.

Grade 3

There is break in the continuity of principle tensile trabecular

group near greater trochanter.

Grade 2

Principle compressive trabecular group appears to stand out

prominently other have resorbed more or less completely.

Grade 1

Principle compressive trabecular group is markedly reduced and is

ANATOMY

Soft tissues of the hip joint:

Extensors

Gluteus maximus.

Origin: Posterior 1/3 rd of iliac crest, sacrum and coccyx.

ABDUCTORS

Gluteus medius and gluteus minimus

Originates from entire wing of Ilium and inserted into greater

trochanter innervated by superior gluteal nerve

External rotators:

Piriformis

Originates from lateral margin of anterior aspect of sacrum and

greater sciatic foramen and inserted into tip of greater trochanter.

Obturator internus

Originates from obturator foramen and inserted into tip of greater

trochanter, innervated by sacral plexus.

Obturator externus

Originates from medial aspect of obturator foramen and inserted

into trochanteric fossa, innervated by obturator nerve.

Quadratus femoris

Originates from upper part of Ilium and inserted into

Flexors

Psoas major:

Originates from lumbar vertebrae and inserted into lesser

trochanter.

Iliacus:

Originates from iliac fossa and inserted into lesser trochanter.

Other flexors of hip joint are Sartorius, pectineus and gracilis (also

an adductor).

Adductors

Adductor longus, adductor brevis, adductor magnus originate from

ischiopubic ramus, ischial tuberosity and obturator foramen. They insert

into linea aspera of femur and adductor tubercle, innervated by obturator

nerve.

Biomechanical contributions of muscle

Distal fragment: adduction with shortening and overrides fracture

fragments.

Screw has to be placed in posteroinferior or center of femoral

where bone density is high. The pull out strength of dynamic hip screw

is related to bone density of femoral head. Degree of comminution and

quality of the bone determines the fracture fixation stability.

Pathomechanics of fracture

If line of fracture is above the insertion of external rotators the

proximal segment is rotated internally so the fracture reduced by

internally rotating the distal fragment.

If fracture line is with subtrochanteric extension proximal fragment

will go for external rotation so fracture reduced by externally rotating the

distal fragment.

Angulations at fracture site

Load over the implant will be more and it cause fracture to collapse

and implant failure. Fracture collapse with implant failure occurs in

unstable intertrochanteric fracture with lack of posteromedial incongruity.

Intact lateral wall is must for controlled compression of proximal

fragment as it prevents the rotational and varus collapse of fracture

CLASSIFICATIONS

Various classification systems for intertrochanteric fractures are

Evan’s -1949.

Boyd and Griffin’s – 1949.

Ramadier’s – 1956.

Decoulx and Lavarde’s – 1969.

Enders’ – 1970.

Tronzo’s – 1973.

Jensen’s – 1975.

Deburge’s – 1976.

Briot’s – 1980.

Evans classification (1949)

Type I: Fracture line extends upwards and outwards from the

lesser trochanter (stable). Type I fractures can be further subdivided as:

Type Ia: Undisplaced two-fragment fracture

Type Ib: Displaced two-fragment fracture.

Type Ic: Three-fragment fracture without posterolateral support,

owing to displacement of greater trochanter fragment.

Type Id: Three-fragment fracture without medial support, owing

Type Ie: Four-fragment fracture without postero-lateral and medial

support (combination of Type III and Type IV).

Type II: Fracture line extends downwards and outwards from the

lesser trochanter (reversed obliquity/unstable). These fractures are

unstable and have a tendency to drift medially.

Jensen’s modification of Evan’s Classification :

Class 1-Stable two part fractures (Evan’s 1a and 1b).

Class 2-Unstable three part fractures (Evan’s Ic and Id).

Body and Griffin’s classification:

Type 1 : undisplaced,stable (two part).

Type 2 : unstable with posteromedial communition.

Type 3 : subtrochanteric extension into lateral shaft, extension of

the fracture distally at or just below the lesser trochanter.

Type 4 : subtrochanteric with intertrochanteric extension with

Kyle’s classification:

Type 1 : Undisplaced / uncomminuted.

Type 2 : Displaced, minimal communition, lesser trochanteric

fracture, varus.

Type 3 : Displaced, greater trochanteric fracture, comminuted,

OTA Classification

Orthopedic trauma association classification system classifies

intertrochanteric fracture as 3.1A femur, proximal trochanteric

A1 - simple peritrochanteric fracture.

A1.1 - fracture along intertrochanteric line.

A1.2 - fracture through greater trochanter.

A1.3 - fracture below lesser trochanter.

A2.1 - fracture with one intermediate fragment.

A2.2 - fracture with several intermediate fragments.

A2.3 - fracture extends more than 1 cm below lesser trochanter.

A3 - intertrochanteric fracture.

A3.1- simple oblique fracture.

A3.2 - simple transverse fracture.

Unstable fractures:

Posteromedial comminution -after reduction there is no medial

cortical continuity.

Fracture with comminuted lateral wall,

Four part fracture,

Displaced large fragment including lesser trochanter,

Reverse oblique- due to adductors distal fragment goes for medial

displacement,

REVIEW OF LITERATURE

In 1949, Evan classified interochanteric fractures into stable and

unstable. Evans said that 72% of his fractures fixed in stable

configuration. In 28% stability wasn’t achieved.

14%-due to fracture pattern.

14%-reduction wasn’t achieved.

During 1960s-1970s unstable intertrochanteric fractures were

corrected by non-anatomic stable reduction techniques by medial

(Dimon&Hughston) valgus osteotomy or lateral (wayne- county)

displacement osteotomy. In Gargan, Bundle and Simpson study on 100

patients found more fixation failures hence they advocated that there is no

benefit from osteotomy and advised anatomic reduction.

Koval and Zuckerman studied the contribution of posteromedial

cortex for fracture stability and the need of fixing posteromedial fragment

with a lag screw or cerclage wire.

impaction they found that DHS fixation provided comparable

postoperative outcome in unstable intertrochanteric fractures.

In Lee et al. study outcome of cement augmentation technique in

unstable intertrochanteric fractures was studied and concluded that

PMMA cemented DHS reduced the complications of screw sliding,

femoral shortening and varus collapse.

Gotfried studied that lateral trochanteric wall a keystone in

stabilizing proximal femoral fractures.

Madsen et al. studied DHS with trochanteric stabilizing plate had

better outcome with lesser incidence of secondary fracture displacement

than gamma nail and compression hip screw.

Variety of implants are available for fixation of intertrochanteric

fractures with variable success rate.

1. Sliding Hip screw.

2. Cephalomedullary Femoral Nail (PFN A, PFN A2, Reconstruction

Nail, Gamma nail).

3. Trochanteric Stabilization Plate.

4. Proximal Femoral Locking Compression Plate.

5. Medoff Sliding Plate.

Disadvantages of Sliding hip screw in unstable intertrochanteric

fractures:

1. Significant medial displacement of the shaft.

2. Due to excessive sliding of hip screw increased chance of screw

cutout.

3. Excessive collapse leading to varus malpositioning.

4. Single point fixation leading to rotation of proximal fragment.

Role of DHS WITH TSP in Unstable Intertrochanteric fractures:

Advantages

1. Easy learning curve.

2. Lateral buttress effect

3. Controlled impaction in unstable Intertrochanteric fractures.

4. Prevents excessive collapse and shortening.6 5. Prevents varus malpositioning.6

6. Two point fixation leading to increased rotation stability.

Disadvantages

Role of PFN in unstable Intertrochanteric fractures:

Advantages

Less operating time.

Minimal blood loss.

Shortened lever arm.

Load sharing device.

Less chances of screw cut.

Prevents excessive collapse and neck shortening.

Prevents varus malpositioning.

Increased rotational stability.

Disadvantages

Increased duration of learing curve.

Costlier implant.

Chances of injury to abductor mechanism.

Chances of screw cut-out in osteoporotic head.

Indirect technique of reduction where provision for anchoring the fractured Greater trochanter using S.S wire is not available.

“Z effect”: Lag screw backs out and Antirotation screw penetrates the head.

MATERIAL AND METHODS

Study centre: Department of Orthopaedics,

Govt. Kilpauk Medical College Hospital,

Kilpauk, Chennai – 10.

Period of study: December 2016 to September 2017.

Study design:

PROSPECTIVE RANDOMIZED CONTROL TRAIL.

Randomisation:

Block randamoisation with varying block sizes with 2 treatment

groups and allocation is done with the help of opaque envelope.

SAMPLE SIZE:

Using the sample size formula for difference in two means

{z(alpha)+z(beta)}^2*(S.D) ^2*2

n= _______________________________________.

Inclusion Criteria:

1. Clinical diagnosis of unstable trochanteric femur fracture.

(AO Type 31A2.1to 31A2.3)

2. Age >40 years and <75 years.

3. Both genders.

Exclusion criteria:

1. Compound fractures.

2. Pathological fractures.

3. Polytrauma patients.

4. Patients non ambulant before the fracture.

5. Previous surgery done on proximal femur.

6. Below 40 years of age.

7. Reverse oblique fractures and fractures with subtrochanteric

extension.

8. Patients with cognitive disorders, on steroids or

Investigations:

1. Radiological: Plain X-ray of the affected hip with femur in two

standard projections (AP & cross table lateral view).

2. Complete hemogram.

3. Renal function test.

4. Bleeding time & Clotting time.

5. Chest X-ray & Electrocardiogram.

DHS WITH TSP INSTRUMENTATION

a b

m j

n

h

i g

d

c e f

k l

a. tap, b. long barreled triple reamer, c. short

barreled triple reamer, d.trochanteric stabilization

plate, e.short barrel DHS plate, f.long barrel DHS

plate, g.shaftguide, h.angled guide, i.T-handle, j.6.5

mm cancellous screw, k.4.0 mm cancellous screw,

OPERATIVE PROCEDURE

Patient prepared on the morning of day of surgery. Single dose

preoperative antibiotic given after test dose. Under suitable anaesthesia

patient was placed on fracture table with unaffected leg in flexion and

abduction attitude by using lithotomy post . Affected leg placed in

traction boot and fracture reduced by traction & internal rotation/external

rotation along with adduction or abduction. C arm checked and placed in

optimal position relative to patient’s position to ensure better

visualization of fracture reduction in both Anteroposterior and lateral

DHS WITH

TSP:-Reduction maneuver:

Closed reduction maneuver planned by using preoperative x-rays

and perioperative C arm image fracture pattern. Fracture reduced by

using traction and internal or external rotation.

Surgical approach:

Under aseptic precautions affected limb painted and draped in

standard fashion for hip surgery in supine position. Fracture site is

exposed by standard lateral approach to hip joint. Skin and subcutaneous

tissue incised, tensor fascia lata and vastus lateralis was split and

proximal part of femur exposed. Inadequate reduction corrected under C

arm guidance.

Approximately 2 cm below vastus ridge guide wire is inserted

under C arm guidance and it passed through CCD angle inferiorly in AP

view and central in lateral view. This allows correct placement of

anti-rotation screw. 5mm beneath subcondral bone guide wire is placed. Then

guide wire length measured and by using triple reamer, reaming done and

lag screw inserted.

To lag screw a 5 hole barrel plate fixed then it fixed to femoral

shaft using cortical screws in 2nd and 5th hole of plate. TSP fixed to Ist, 3rd and 4th hole using 4.5mm cortical screws. Guide wire inserted for 6.5 mm cancellous screw under C-arm guidance and Screw fixed after drilling

with appropriate drill bit. If necessary greater trochanter fixed by using

SS wire or 4mm cancellous screw. Drain inserted. By using vicryl vastus

lateralis, tensor fascia lata and subcutaneous tissue closed and skin closed

PROXIMAL FEMORAL

NAIL:-Skin incision made about 2-3cm over tip of greater trochanter

extending up to plumb line dropped from anterior superior iliac spine.

Entry made through modified medial portal entry with patient in fracture

table and traction applied to ipsilateral leg.

Guide wire inserted and serial reaming done according to

intraoperative chattering. Appropriate sized nail inserted.

Guide wires inserted and checked in both AP and lateral

projections. First 8mm lag screw placed and 6.3mm. anti-rotationscrew of

size 15mm less than lag screw fixed proximally.2×4.9mm locking screws

POST OP PROTOCOL:

* Intravenous antibiotics given for 2 days.

* From day 3 oral antibiotics and analgesics given for another one

week.

* Drain removal done on 2nd post operative day.

* Dressing changed on 2nd, 5th and 8th post operative day

* Sutures removed on 12th post operative day

* Immediate weight bearing initiated depending on the stability of

the construct in either group.

* Patients followed up monthly once for 3 months with serial x-rays

and x-rays at the end of 6th month.

* Harris hip score, radiological union and neck shaft angle were

GRADING:

SCORE GRADE

90-100 Excellent

80-89 Good

70-79 Fair

OVERVIEW & ANALYSIS

The study was conducted in Government Kilpauk Medical College

& Hospital, Chennai from December 2016 to September 2017.

In 52 consecutive patients suffering from unstable intertrochanteric

fracture 26 were treated with DHS with trochanteric stabilization plate

and 26 were treated with proximal femoral nailing.

AO/OTA classification system used for patient selection. We

included AO31A2 fractures in our study.

The distribution of fractures

SL.NO TYPE OF

FRACTURE

NUMBER OF PATIENTS

DHS WITH TSP PFN

1 31A2.1 5 5

2 31A2.2 14 12

3 31A2.3 7 9

10 12 14 16

DHS WITH TSP

10 12 14

GENDER DISTRIBUTION

SIDE OF FRACTURE

13 13

PFN

DHS WITH TSP

MALE FEMALE 13 13

PFN

DHS WITH TSP

Age wise distribution of patients is as follows:

SL.NO AGE GROUP (IN

YEARS)

NO.OF PATIENTS

DHS WITH TSP PFN

1 50 - 59 3 4

2 60 - 65 8 9

3 66 - 70 7 6

4 71 - 75 8 7

In our study 9 patients suffered from Type 2 Diabetes Mellitus, 14

3

8

7 8

DHS WITH TSP

5

6 1

1 1

COMORBIDITIES /DHS WITH TSP

diabetes mellitus

hypertension

coronary artery disease

chronic kidney disease

primary pulmonary tuberculosis 4 8 2 1

COMORBIDITIES IN PFN

diabetes mellitus

hypertension

coronary artery disease

primary pulmonary tuberculosis

Operative details of intertrochanteric fractures treated by dynamic

hip screw with trochanteric stabilization plate and proximal femoral

nailing.

SL.

NO VARIABLES

DHS WITH

TSP PFN

1 Mean time of operation after

fracture in days

7.6 7.2

2 Mean duration of operation 88 minutes 62.5minutes

3 Mean blood loss in ml 172.6 58.26

4 Mean size of lag screw 85mm 85mm

5 Mean size of anti-rotation screw 75mm 70mm

6 Mean duration of hospital stay in

days

6.9 5.1

7 Average duration for full weight

bearing

Functional outcome by Harris hip score

COMPLICATIONS

Wound complications

2 patients in DHS with TSP and 1 patient in PFN had superficial

wound infection. These patients were diabetic. The infection controlled

with continuation of intravenous antibiotics and regular wound dressings.

4 patients (2 in each group) had fever on 4th postoperative day. These patients were diagnosed to have urinary tract infection which

subsided with course of antibiotics.

7 5 14 16 2 1 0 1 0 2 4 6 8 10 12 14 16 18

DHS WITH TSP PFN

Complications related to implants and union:

In DHS WITH TSP

2 patients suffered from loosing of greater trochanter screw loosing

at 13 weeks and they were followed up for another 8 weeks of duration

till radiological union to occur then the screw was removed under spinal

anaesthesia.

Due to varus collapse 2 patients had shortening of <2cm. one

patient had persistent hip and another had persistent thigh pain. Weight

In Proximal Femoral Nail:

One patient had self fall 1 month following surgery and sustained

peri implant fracture just distal to the end of nail. Non union was found in

2 cases with no progressive radiological union in subsequent monthly

follow up.

In that one patient lag screw was found to be backed out in 1st month post operative x-ray.

The case was operated with implant exit followed by cemented

hemiarthroplasty in single sitting after ruling out all markers of infection

COMPLICATIONS

SL.NO COMPLICATION DHS WITH TSP PFN

1 Superficial wound infection 2 1

2 Urinary tract infection 2 2

3 Varus collapse with shortening of >1cm

2 0

4 Persistent thigh pain 1 0

5 Persistent hip pain 1 2

6 Non union 0 2

7 Peri –implant fracture 0 1

Cross tables

Group * Gender(Cross tabulation)

Sex Total Male Female Group DHS with TSP

Count 14 9 23

% within group 60.9% 39.1% 100.0%

PFN

Count 12 11 23

% within group 52.2% 47.8% 100.0%

Total Count 26 20 46

Group Statistics(age)

Group N Mean

Std.

Deviation

Std. Error

Mean

Age

DHS with

TSP 23 65.65 5.757 1.200

PFN

Group * OTA

GROUP*OTA (Crosstab)

OTA Total

1 2 3

Grou

p

DHS

with TSP

Count 5 10 8 23

% within

group

21.7% 43.5% 34.8% 100.0%

PFN Count 5 10 8 23

% within

group

21.7% 43.5% 34.8% 100.0%

Total Count 10 20 16 46

% within

group

21.7% 43.5% 34.8% 100.0%

Group * R/L

GROUP*R/L (Crosstab)

R/L Total

Right Left

Group DHS

with TSP

Count 12 11 23

% within

group

52.2% 47.8% 100.0%

PFN Count 11 12 23

% within

group

47.8% 52.2% 100.0%

Total Count 23 23 46

% within

group

No Comorbids

cormobids

DM HTN CAD PTB CKD Total

Group DHS with TSP

Count 9 5 6 1 1 1 23

%with in group

39.130434 21.7391 26.0869 4.34782 4.34782 4.34782 100

PFN Count 8 4 8 0 2 1 23

%with in group

34.782608 17.3913 34.7826 0 8.69565 4.34782 100

Total Count 17 9 14 1 3 2 46

%with in group

36.95652 19.565 30.434 2.1739 6.52173 4.3478 100

Group * Radiologicalunion

GROUP*RADIOLOGICAL UNION(Crosstab)

Radiologicalunion Total P value

evidence of

progressive

callus

formation in

follow up x

rays

No

evidence of

callus

formation in

follow up x

rays

Group DHS with

TSP

Count 23 0 23 .244

% within

group

100.0% 0.0% 100.0%

Group * Neck shaft angle

GROUP*NECK SHAFT ANGLE (Cross tab)

Neckshaftangle Total P

value No Varus Varus Group DHS with TSP

Count 21 2 23 0.244

% within group 91.3% 8.7% 100.0

%

PFN Count 23 0 23

% within group 100.0

%

0.0% 100.0

%

Total Count 44 2 46

% within group 95.7% 4.3% 100.0

%

NPar Tests

Group Statistics

Group N Mean Std.

Deviation Std. Error Mean Duration surgery in minutes DHS with TSP

23 88.09 7.874 1.642

PFN 23 60.30 5.850 1.220

Blood loss in

(ml)

DHS with

TSP

23 172.61 16.846 3.513

PFN 23 58.26 7.777 1.622

Harris hip

function score

DHS with

TSP

23 85.74 5.336 1.113

Mann-Whitney Test

Ranks

Group N Mean

Rank

P value

Harris hip

function score

DHS with TSP 23 25.80 0.243

PFN 23 21.20

Total 46

B/L ML DHS with TSP 23 35.00 .000

PFN 23 12.00

Total 46

Duration

surgery minutes

DHS with TSP 23 35.00 .000

PFN 23 12.00

Total 46

Full weight

bearing initiated

(weeks)

DHS with TSP 23 33.63 .000

PFN 23 13.37

CASE ILLUSTRATIONS

Case 1. A 48 year old male

Preoperative x-ray _{Postoperative x-ray}

Active SLRT External rotation

Case 2: A 50 year old male

Preoperative x-ray Post operative x-ray

3rd month follow up ₆th

Standing Active SLRT

Case 3: A 57 year old male

Preoperative x-ray Postoperative x-ray

Active SLRT External rotation

Case 4: A 68year old female

Preoperative x-ray Postoperative x-ray

Active SLRT External rotation

DISCUSSION

Intertrochanteric femoral fractures contribute to more than half of

total hip fractures in elderly osteoporotic patients ageing over 60 years.

With increasing life expectancy due to advancements in medical care, the

incidence of intertrochanteric fractures are also increasing.

Fall from standing height is the most common mode of injury in

these patients. Diminished vision, reduced reflexes, poor muscle tone and

balance also contribute to the increased incidence in elderly.

Various modalities of treatments are available which include

dynamic hip screw, cephalomedullary nail, dynamic condylar screw,

cemented hemiarthroplasty with or without augmented calcar

reconstruction, proximal femoral locking plate and trochanteric

stabilization plate.

The ultimate goal of the treatment being early mobilization of the

patients preventing the complications of fracture disease.

Sliding hip screw is still most widely used implant for these cases.

But in unstable fractures due to posteromedial and lateral wall

communition it has the disadvantage of recurring varus collapse and

screw cut out. It also has a disadvantage of having only a single point

Advantages of dynamic hip screw with trochanteric stabilization

plate and proximal femoral nailing in unstable fractures are as follows

SL.NO DHS with TSP PFN

1 Easy learning curve. Less operating time

and minimal blood loss.

2 Lateral butteress effect Load sharing device.

3 Controlled impaction in unstable Intertrochanteric

fractures.

Shortened lever arm there by less deforming forces at the fracture

site.

4

Prevents excessive collapse and shortening.

Prevents excessive varus collapse and neck shortening.

5 Two point fixation leading to increased rotation

stability.

Increased rotation stability and less chances of screw cut out in

osteoporotic head.

Our study was conducted in Govt. Kilpauk Medical College &

Hospital, Chennai. 52 consecutive patients of unstable itertrochanteric

fractures were treated with DHS with TSP and PFN in equal numbers by

random sampling the fractures were classified according to AO/OTA

classification and fractures of AO type 31A2.1 to 31A2.3 were included

in our study. All patients were followed up at least for a period of 6

months and were assessed for clinical, radiological and functional

outcome. The overall response rate was 88.46%.

The results were analyzed and observations of our study are as

follows,

1. Age : Most of patients in our study were in the age of >60 years of

age.

2. Gender : In DHS with TSP 12 male and 14 female patients. In PFN

13 male and 13 female patients.

3. Mode of injury : Fall from standing height (trivial fall) was most

common mode of injury.

4. Type of fracture : In DHS with TSP group 5 patients AO type

31A2.1, 14 patients of AO type 31A2.2 and 7 patients had AO type

31A2.3.

In PFN group 5 patients had AO type 31A2.1,12 patients had

5. Side of fracture : In DHS with TSP group 14 patients had right and

12 patients had left side fracture. In PFN group13 had right and 13

patients had left side fracture.

6. Comorbidities : In DHS with TSP group 5 patients had type 2

Diabetes Mellitus,6 patients were suffering from systemic

hypertension, 1 patient had coronary artery disease, 1 patient

suffered from pulmonary tuberculosis 10 years back and one

patient was suffering from chronic kidney disease.

In PFN group 4 patients had type 2 Diabetes Mellitus, 8 were

suffering from systemic hypertension, 2 had pulmonary

tuberculosis in their past and one was suffering from chronic

kidney disease.

7. All patients had good pretrauma mobility and were ambulating

independently unassisted.

8. Patients were operated within 7.6 days in DHS with TSP group

11. Mean lag screw was 85 mm both in DHS with TSP and in PFN.

Mean anti-rotation screw size was 75mm in DHS with TSP and in

PFN was 70mm.

12. Mean hospital stay was 6.9 days in DHS with TSP and in PFN was

5.1 days.

13. On 3rd postoperative day partial weight bearing was allowed on the basis of construct stability and bone quality.

14. All patients treated with DHS with TSP allowed to full weight

bearing on an average of 13.27 weeks and patients treated with

PFN were allowed full weight bearing on an average of

10.15weeks.

15. On basis of Harris Hip Score the functional outcome of all patients

were assessed: In DHS with TSP group we had 7 excellent results,

14 good results and 2 fair results. In PFN group we had 5 excellent

results, 16 good results, 1 fair and 1 poor result.

16. Complications: 2 patients in DHS with TSP group one patient in

PFN group had superficial wound infection. 2 patients in each

group had urinary tract infection. 2 patients in PFN group and one

patient DHS with TSP group had persistent hip pain. One patient in

DHS with TSP group had persistent thigh pain. 2 patients had

with shortening <2cm (1.3cm & 1.5cm). In PFN group one patient

had peri-implant fracture. 2 patients in PFN we had difficulty in

placing anti-rotation screw of them lag screw was backed out in

one patient during follow up and she was operated with implant

exit with cemented hemiarthroplasty (all 3 cases weren’t included

in analyzing final outcome). Non-union at fracture site was found

in 2 cases operated with PFN and these patients denied any further

CONCLUSION

We conclude that there is no statistically significant difference

between patients operated with Dynamic Hip Screw with Trochanteric

Stabilization Plate and Proximal Femoral Nail in terms of radiological

union, varus collapse and functional outcome at six months follow up,

which is consistent with Rho et al study13 & Patil et al study15.

Statistically significant differences were noted with ‘P’ values less

than 0.05 in terms of duration of surgery, blood loss during surgery and

BIBLIOGRAPHY

1. Kumar R, Singh RN, Singh BN. Comparative prospective study of

proximal femoral nail and dynamic hip screw in treatment of

intertrochanteric fracture femur. J Clin Orthop Trauma.

2012;3(1):28–36.

2. Gullberg B, Johnell O, Kanis JA. World Wide Projection for Hip

Fracture. Osteoporosis Int. 1997;7(5):407-13.

3. Melton LJ, Kearns AE, Atkinson EJ, Bolander ME, Achenbach SJ,

Huddleston JM, et al. Secular Trends in Hip Fracture Incidence and

Recurrence. Osteoporosis Int. 2009;20(5):687- 94.

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twenty-two intertrochanteric hip fractures. J Bone Joint Surg Am.

1979;61:216-21.

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of the tip apex distance in predicting failure of fixation of

peritrochanteric fractures of the hip. J Bone Joint Surg Am.

7. Babst R, Martinet O, Renner N, Rosso R, Bodoky A, Heberer M, et

al. Die DHS - Abstützplattefürdie Versorgung der instabilen

proximalen Femur-frakturen. Schweizer Med Wochenschr.

1993;123:566-8.

8. Kaufer H. Mechanics of the treatment of hip injuries. ClinOrthop.

1980;146:53-61.

9. Haidukewych GJ, Israel TA, Berry DJ. Reverse obliquity fractures

of the inter-trochanteric region of the femur. J Bone Joint Surg Am.

2001;83:643-50.

10. Medoff RJ, Maes K. A new device for the fixation of unstable

pertrochanteric fractures of the hip. J Bone Joint Surg Am.

1991;73:1192-9.

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Dynamische Hüftschraube (DHS) mit Abstützplatte-einesichere

Osteosynthese-fürhochinstabile "reverse" trochantere Frakturen.

Chirurg. 1996;67:1166-73.

12. Von Hasselbach C, Witzel U. Die Schenkelhals-zuggurtungsplatte.

Chir Praxis. 1987;38:235-60.

13. Rho JY, Kim SB, Heo YM, Cho SJ, SikChae D, Lee WS. Proximal

Femoral Nail Antirotation versus Compression Hip Screw with

Trochanter Stabilizing Plate for Unstable Intertrochanteric Hip

14. Shetty A, Ballal A, Kumar A, Sadasivan, Hedge A. Dynamic Hip

Screw with Trochanteric Stablization Plate Fixation of Unstable

Inter-Trochanteric Fractures: A Prospective Study of Functional

and Radiological Outcomes. J Clin Diagnos Res. 2016;10(9):6-8.

15. Patil SN, Srinivas P.comparitive study between proximal femoral

nail and dynamic hip screw with trochanteric stabilising plate in

unstable intertrochanteric femur fractures. Int J Res Orthop 2017.

16. Jonnes C, Shishir SM, Najimudeen S. Type II Intertrochanteric

Fractures: Proximal Femur. Arch Bone Jt Surg. 2016;4(1):23-8.

17. Matre K, Vinje T, Havelin LI, Gjertsen JE, Furnes O, Espehaug B,

et al. Trigen Intertan Intramedullary Nail Versus Sliding Hip

Screw. J Bone Joint Surg Am. 2013;95:200-8.

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PROFORMA

Name :

Age/Sex :

IP Number :

Address :

Contact Number :

Occupation :

Education :

Socioeconomic Status :

Date of Admission :

Date of Surgery :

Date of Discharge :

History :

1. Mode of injury : Road traffic accident / self fall at home / fall from height / pedestrian struck injury.

2. Presenting complaints:

Pain –site/duration Swelling- site/extent Deformity

Disturbances in function of hip & knee-movements/sensations

3. Co morbid illnesses:

SL.NO COMORBIDS DETAILS

1 Diabetes mellitus 2 Hypertension 3 Coronary heart disease 4 Renal disorder 5 Seizures / neurological

disorder 6 Dyslipedemia 7 Bronchial asthma 8 Endocrine disorder 9 Chronic obstructive lung

diseases 10 Hepatic disorder 11 Tuberculosis 12 Neoplastic disorders

4. Drug history: steroids / disease modifying anti- rheumatoid drugs / immunosuppressant

PAST HISTORY:

Similar injuries

Previous surgeries or hospitalizations

PERSONAL HISTORY:

SL.NO

1 Diet Vegetarian / mixed

2 Marital status Married / single

3 Bowel and bladder habits Regular / altered

4 Habits Smoking / alcohol/ tobacco/drug addictions/others

OBSTETRIC AND GYNECOLOGICAL HISTORY:

TREATMENT HISTORY: FAMILY HISTORY: CLINICAL EXAMINATION: GENERAL EXAMINATION: Appearance: Built: Pallor: Icterus: Cyanosis: Clubbing: Pedal edema: Lymphadenopathy: VITALS: 1. Pulse 2. BP

3. Respiratory Rate 4. Temperature

SYSTEMIC EXAMINATION:

Respiratory system :

Abdomen :

Central nervous system :

REGIONAL EXAMINATION:

RIGHT/LEFT HIP

OTHER INJURIES

X-RAY FINDINGS

3D CT RIGHT/LEFT HIP JOINT (IF NEEDED)

INVESTIGATIONS:

SL.NO INVESTIGATIONS RESULTS

1 HB%

2 TC

3 DC

4 P L B E M

5 ESR

6 BT/CT

7 RBS

8 UREA

9 S.CREATININE

10 ELECTROLYTES(Na , K )

11 HBsAg

12 VDRL

13 CXR

PROCEDURE NOTES:

POST OP PERIOD:

SL.NO FOLLOW UP

CLINICL FINDINGS

X-RAY FINDINGS

ADVICE

1 1ST MONTH

2 3RD MONTH

3 6TH MONTH

FUNCTIONAL OUTCOME:

INDEX FOR MASTER CHART

1. MOI – Mode of Injury.

1. Self Fall.

2. Road Traffic Accident.

2. OTA classification

31A2.1-1

31A2.2-2

31A2.3-3

3. R/L

R-Right

L-Left

4. COMORBIDS

5. TB

6. CKD

5. DOS mts- Duration of surgery in minutes

6. B/L ml- blood loss in ml

7. FWB (wks): full weight bearing in weeks

8. HHS- Harris hip function score

9. RA.UN: radiological union

1. Evidence of progressive callous formation in follow up x-rays

2. NoEvidence of progressive callous formation in follow up

x- rays

10. NSF- neck shaft angle

1. No varus

Master Chart for DHS WITH TSP

SL.NO NAME AGE/ SEX MOI OTA R/L COMORBID DOS

(Mts) (Ml)B/L (WKS)FWB HHS RU NSF

1 Rajendran 61/M 1 1 1 1 81 170 10.5 93 1 1

2 Devi 71/F 1 3 1 2 86 180 11.6 81 1 1

3 Kanthan 69/M 1 2 2 3 89 190 10.3 86 1 1

4 Muthu 53/M 2 3 2 2 93 200 12.6 82 1 1

5 Sekar 63/M 1 1 1 5 80 150 14.4 90 1 1

6 Chandra 70/F 1 2 2 1 97 150 11.3 82 1 1

7 Kaasinathan 55/M 2 3 1 2 101 160 12.3 75 1 2

8 Selvi 72/F 1 2 2 1 103 160 12.5 85 1 1

9 Siva 66/M 1 1 1 3 84 150 13.6 94 1 1

10 Mary 64/F 1 3 2 1 88 160 14.2 83 1 1

11 Chitra 63/F 1 2 1 2 87 180 15.2 90 1 1

12 Govindan 67/M 1 2 1 6 89 190 14.3 85 1 1

13 Neelakandan 67/M 1 3 2 1 90 200 13.6 81 1 1

14 Munusamy 65/M 1 3 2 2 84 180 14.2 77 1 2

15 Jeyaraj 75/M 1 2 1 1 82 170 12.6 86 1 1

16 Dhanalaksmi 62/F 1 1 1 4 81 160 14.3 92 1 1

96

Master Chart for PFN

SL.NO NAME AGE/ SEX MOI OTA R/L COMORBIDS DOS (Mts) B/L (Ml) FWB (WKS) HHS RU NSF

1 Ambika 61/F 1 1 1 2 52 50 8.2 92 1 1

2 Manoj 69/M 1 3 2 1 54 60 9.3 80 1 1

3 Saraswathy 70/F 1 2 1 3 53 50 9.0 86 1 1

4 Krishnan 63/M 1 1 2 1 57 50 10.4 93 1 1

5 Neela 71/F 1 3 1 6 62 60 11.6 81 1 1

6 Sabapathy 67/M 1 2 2 3 69 70 12.0 87 1 1

7 Alamelu 64/F 1 2 2 2 70 50 11.3 84 1 1

8 Jayavel 58/M 2 3 1 1 60 60 11.5 65 2 1

9 Kumar 73/M 1 3 2 5 69 60 11.2 80 1 1

10 Devan 69/M 1 2 2 3 56 60 9.2 85 1 1

11 Lakshmi 72/F 1 3 1 1 64 70 8.5 80 1 1

12 Nagammal 65/F 1 1 2 2 60 70 9.6 93 1 1

13 Rathnam 59/M 2 1 1 1 59 50 8.3 92 1 1

14 Senthamarai 68/F 1 2 2 3 58 60 9.4 86 1 1

15 Surya 73/M 1 3 1 1 63 50 8.6 80 1 1

16 Ashra 64/F 1 1 1 3 55 50 11.6 91 1 1

17 Naagarani 74/F 1 2 2 5 57 70 10.6 86 1 1

18 Mariyappan 65/M 1 2 1 2 66 50 11.3 84 1 1

19 Poongodi 53/F 1 3 2 1 59 60 10.4 80 1 1

20 Elumalai 61/M 1 2 1 3 67 60 12.2 71 2 1

21 Thirupathi 66/M 2 3 2 3 68 50 10.6 80 1 1

22 Jeya 64/F 1 2 2 1 59 70 10.3 84 1 1