Top

Clinical Orthopaedics and Related Research®

Published in:

01-08-2012 | Clinical Research

Is Helical Blade Nailing Superior to Locked Minimally Invasive Plating in Unstable Pertrochanteric Fractures?

Authors: Matthias Knobe, MD, Wolf Drescher, MD, PhD, Nicole Heussen, MD, Richard Martin Sellei, MD, Hans-Christoph Pape, MD

Published in: Clinical Orthopaedics and Related Research® | Issue 8/2012

Abstract

Background

Technical advancements have produced many challenges to intramedullary implants for unstable pertrochanteric fractures. Helical blade fixation of the femoral head has the theoretical advantages of higher rotational stability and cutout resistance and should have a lower rate of reoperation than a locked plating technique.

Questions/purposes

We asked whether (1) helical blade nailing reduces the rate of reoperation within 24 months compared with locked plating and (2) any of various preoperative, intraoperative, or postoperative factors predicted failure in these two groups.

Methods

We prospectively enrolled 108 patients with unstable pertrochanteric fractures in a surgeon-allocated study between November 2005 and November 2008: 54 with percutaneous compression plates (PCCP) and 54 with proximal femoral nail antirotation (PFNA). We evaluated patients regarding reoperation, mortality, and function. Seventy-four patients had a minimum followup of 24 months (mean, 26 months; range, 24–30 months).

Results

We found no differences in the number of reoperations attributable to mechanical problems in the two groups: PCCP = six and PFNA = five. Despite a greater incidence of postoperative lateral wall fractures with helical blade nailing, only postoperative varisation of the neck-shaft angle and tip-apex distance (33 mm versus 28 mm) predicted reoperation. Mortality and function were similar in the two groups.

Conclusions

Our data suggest unstable pertrochanteric fractures may be fixed either with locked extramedullary small-diameter screw systems to avoid lateral wall fractures or with the new intramedullary systems to avoid potential mechanical complications of a broken lateral wall. Tip-apex distance and preservation of the preoperative femoral neck-shaft angle are the key technical factors for prevention of reoperation.

Level of Evidence

Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Audigé L, Hanson B, Swiontkowski MF. Implant-related complications in the treatment of unstable intertrochanteric fractures: meta-analysis of dynamic screw-plate versus dynamic screw-intramedullary nail devices. Int Orthop. 2003;27:197–203.PubMedCrossRef

Barton TM, Gleeson R, Topliss C, Greenwood R, Harries WJ, Chesser TJ. A comparison of the long gamma nail with the sliding hip screw for the treatment of AO/OTA 31-A2 fractures of the proximal part of the femur: a prospective randomized trial. J Bone Joint Surg Am. 2010;92:792–798.PubMedCrossRef

Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM. The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Joint Surg Am. 1995;77:1058–1064.PubMed

Browner BD, Alberta FG, Mastella DJ. A new era in orthopedic trauma care. Surg Clin North Am. 1999;79:1431–1448.PubMedCrossRef

Cooper C, Barker DJ, Hall AJ. Evaluation of the Singh index and femoral calcar width as epidemiological methods for measuring bone mass in the femoral neck. Clin Radiol. 1986;37:123–125.PubMedCrossRef

d’Aubigné RM, Postel M. The classic: functional results of hip arthroplasty with acrylic prosthesis. 1954. Clin Orthop Relat Res. 2009;467:7–27.PubMedCrossRef

Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205–213.PubMedCrossRef

Firth D. Bias reduction of maximum likelihood estimates. Biometrika. 1993;80:27–38.CrossRef

Gotfried Y. Percutaneous compression plating of intertrochanteric hip fractures. J Orthop Trauma. 2000;14:490–495.PubMedCrossRef

10.

Gotfried Y. The lateral trochanteric wall: a key element in the reconstruction of unstable pertrochanteric hip fractures. Clin Orthop Relat Res. 2004;425:82–86.PubMedCrossRef

11.

Hardy DC, Descamps PY, Krallis P, Fabeck L, Smets P, Bertens CL, Delince PE. Use of an intramedullary hip-screw compared with a compression hip-screw with a plate for intertrochanteric femoral fractures: a prospective, randomized study of one hundred patients. J Bone Joint Surg Am. 1998;80:618–630.PubMed

12.

Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Joint Surg Am. 1969;51:737–755.PubMed

13.

Janzing HM, Houben BJ, Brandt SE, Chhoeurn V, Lefever S, Broos P, Reynders P, Vanderschot P. The Gotfried PerCutaneous Compression Plate versus the Dynamic Hip Screw in the treatment of pertrochanteric hip fractures: minimal invasive treatment reduces operative time and postoperative pain. J Trauma. 2002;52:293–298.PubMedCrossRef

14.

Jones HW, Johnston P, Parker M. Are short femoral nails superior to the sliding hip screw? A meta-analysis of 24 studies involving 3,279 fractures. Int Orthop. 2006;30:69–78.PubMedCrossRef

15.

Knobe M, Münker R, Schmidt-Rohlfing B, Sellei RM, Schubert H, Erli HJ. [Surgical outcome in pertrochanteric femur fracture: the impact of osteoporosis. Comparison between DHS and percutaneous compression plate] [in German]. Z Orthop Unfall. 2008;146:44–51.PubMedCrossRef

16.

Knobe M, Münker R, Sellei RM, Schmidt-Rohlfing B, Erli HJ, Strobl CS, Niethard FU. Unstable pertrochanteric femur fractures. Failure rate, lag screw sliding and outcome with extra- and intramedullary devices (PCCP, DHS and PFN). Z Orthop Unfall. 2009;147:306–313.PubMedCrossRef

17.

Kosygan KP, Mohan R, Newman RJ. The Gotfried percutaneous compression plate compared with the conventional classic hip screw for the fixation of intertrochanteric fractures of the hip. J Bone Joint Surg Br. 2002;84:19–22.PubMedCrossRef

18.

Langford J, Pillai G, Ugliailoro AD, Yang E. Perioperative lateral trochanteric wall fractures: sliding hip screw versus percutaneous compression plate for intertrochanteric hip fractures. J Orthop Trauma. 2011;25:191–195.PubMedCrossRef

19.

Lenich A, Vester H, Nerlich M, Mayr E, Stöckle U, Füchtmeier B. Clinical comparison of the second and third generation of intramedullary devices for trochanteric fractures of the hip: blade vs screw. Injury. 2010;41:1292–1296.PubMedCrossRef

20.

Liu Y, Tao R, Liu F, Wang Y, Zhou Z, Cao Y, Wang H. Mid-term outcomes after intramedullary fixation of peritrochanteric femoral fractures using the new proximal femoral nail antirotation (PFNA). Injury. 2010;41:810–817.PubMedCrossRef

21.

Madsen JE, Naess L, Aune AK, Alho A, Ekeland A, Stromsoe K. Dynamic hip screw with trochanteric stabilizing plate in the treatment of unstable proximal femoral fractures: a comparative study with the Gamma nail and compression hip screw. J Orthop Trauma. 1998;12:241–248.PubMedCrossRef

22.

Mak PH, Campbell RC, Irwin MG; American Society of Anesthesiologists. The ASA Physical Status Classification: inter-observer consistency. American Society of Anesthesiologists. Anaesth Intensive Care. 2002;30:633–640.PubMed

23.

Marsh JL, Slongo TF, Agel J, Broderick JS, Creevey W, DeCoster TA, Prokuski L, Sirkin MS, Ziran B, Henley B, Audigé L. Fracture and dislocation classification compendium - 2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma. 2007;21(10 suppl):S1–S133.PubMedCrossRef

24.

Mereddy P, Kamath S, Ramakrishnan M, Malik H, Donnachie N. The AO/ASIF proximal femoral nail antirotation (PFNA): a new design for the treatment of unstable proximal femoral fractures. Injury. 2009;40:428–432.PubMedCrossRef

25.

Olsson O, Ceder L, Hauggaard A. Femoral shortening in intertrochanteric fractures: a comparison between the Medoff sliding plate and the compression hip screw. J Bone Joint Surg Br. 2001;83:572–578.PubMedCrossRef

26.

Palm H, Jacobsen S, Sonne-Holm S, Gebuhr P; Hip Fracture Study Group. Integrity of the lateral femoral wall in intertrochanteric hip fractures: an important predictor of a reoperation. J Bone Joint Surg Am. 2007;89:470–475.PubMedCrossRef

27.

Palm H, Lysén C, Krasheninnikoff M, Holck K, Jacobsen S, Gebuhr P. Intramedullary nailing appears to be superior in pertrochanteric hip fractures with a detached greater trochanter: 311 consecutive patients followed for 1 year. Acta Orthop. 2011;82:166–170.PubMedCrossRef

28.

Panesar SS, Mirza S, Bharadwaj G, Woolf V, Ravikumar R, Athanasiou T. The percutaneous compression plate versus the dynamic hip screw: a meta-analysis. Acta Orthop Belg. 2008;74:38–48.PubMed

29.

Parker MJ, Handoll HH. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults. Cochrane Database Syst Rev. 2010 Sep 8;(9):CD000093.

30.

Pervez H, Parker MJ, Vowler S. Prediction of fixation failure after sliding hip screw fixation. Injury. 2004;35:994–998.PubMedCrossRef

31.

Peyser A, Weil YA, Brocke L, Sela Y, Mosheiff R, Mattan Y, Manor O, Liebergall M. A prospective, randomised study comparing the percutaneous compression plate and the compression hip screw for the treatment of intertrochanteric fractures of the hip. J Bone Joint Surg Br. 2007;89:1210–1217.PubMedCrossRef

32.

Rudicel S, Esdaile J. The randomized clinical trial in orthopaedics: obligation or option? J Bone Joint Surg Am. 1985;67:1284–1293.

33.

Schipper IB, Marti RK, van der Werken C. Unstable trochanteric femoral fractures: extramedullary or intramedullary fixation. Review of literature. Injury. 2004;35:142–151.PubMedCrossRef

34.

Simmermacher RK, Ljungqvist J, Bail H, Hockertz T, Vochteloo AJ, Ochs U, Werken C; AO - PFNA study group. The new proximal femoral nail antirotation (PFNA) in daily practice: results of a multicentre clinical study. Injury. 2008;39:932–939.PubMedCrossRef

35.

Strauss E, Frank J, Lee J, Kummer FJ, Tejwani N. Helical blade versus sliding hip screw for treatment of unstable intertrochanteric hip fractures: a biomechanical evaluation. Injury. 2006;37:984–989.PubMedCrossRef

36.

Thomas AP. Dynamic hip screws that fail. Injury. 1991;22:45–46.PubMedCrossRef

37.

Varela-Egocheaga JR, Iglesias-Colao R, Suárez-Suárez MA, Fernández-Villán M, González-Sastre V, Murcia-Mazón A. Minimally invasive osteosynthesis in stable trochanteric fractures: a comparative study between Gotfried percutaneous compression plate and Gamma 3 intramedullary nail. Arch Orthop Trauma Surg. 2009;129:1401–1407.PubMedCrossRef

38.

Yaozeng X, Dechun G, Huilin Y, Guangming Z, Xianbin W. Comparative study of trochanteric fracture treated with the proximal femoral nail anti-rotation and the third generation of gamma nail. Injury. 2010;41:1234–1238.PubMedCrossRef

Title: Is Helical Blade Nailing Superior to Locked Minimally Invasive Plating in Unstable Pertrochanteric Fractures?
Authors: Matthias Knobe, MD
Wolf Drescher, MD, PhD
Nicole Heussen, MD
Richard Martin Sellei, MD
Hans-Christoph Pape, MD
Publication date: 01-08-2012
Publisher: Springer-Verlag
Published in: Clinical Orthopaedics and Related Research® / Issue 8/2012
Print ISSN: 0009-921X
Electronic ISSN: 1528-1132
DOI: https://doi.org/10.1007/s11999-012-2268-9

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Is Helical Blade Nailing Superior to Locked Minimally Invasive Plating in Unstable Pertrochanteric Fractures?

Abstract

Background

Questions/purposes

Methods

Results

Conclusions

Level of Evidence

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Questions/purposes

Methods

Results

Conclusions

Level of Evidence

Please log in to get access to this content

Other articles of this Issue 8/2012

What are Predictors of Mortality in Patients with Pelvic Fractures?

The Classic: An Account of a Case of Fracture and Distortion of the Pelvis, Combined with an Unusual Form of Dislocation of the Femur

Complications of Anterior Subcutaneous Internal Fixation for Unstable Pelvis Fractures: A Multicenter Study

Anti-TGF-β Antibody Combined with Dendritic Cells Produce Antitumor Effects in Osteosarcoma

Clinical Stability of Slipped Capital Femoral Epiphysis does not Correlate with Intraoperative Stability

What Is the Infection Rate of the Posterior Approach to Type C Pelvic Injuries?