Abstract
BackgroundIn treatment of unstable trochanteric fractures dynamic hip screw and Medoff sliding plate devices are designed to allow secondary fracture impaction, whereas intramedullary nails aim to maintain fracture alignment. Different treatment protocols are used by two similar Swedish regional emergency care hospitals. Dynamic hip screw is used for fractures considered as stable within the respective treatment protocol, whereas one treatment protocol (Medoff sliding plate/dynamic hip screw) uses biaxial Medoff sliding plate for unstable pertrochanteric fractures and uniaxial Medoff sliding plate for subtrochanteric fractures, the second (intramedullary nail/dynamic hip screw) uses intramedullary nail for subtrochanteric fractures and for pertrochanteric fractures with intertrochanteric comminution or subtrochanteric extension. All orthopedic surgeries are registered in a regional database.MethodsAll consecutive trochanteric fracture operations during 2011–2012 (n = 856) and subsequent technical reoperations (n = 40) were derived from the database. Reoperations were analysed and classified into the categories adjustment (percutaneous removal of the locking screw of the Medoff sliding plate or the intramedullary nail, followed by fracture healing) or minor, intermediate (reosteosynthesis) or major (hip joint replacement, Girdlestone or persistent nonunion) technical complications.ResultsThe relative risk of intermediate or major technical complications was 4.2 (1.2–14) times higher in unstable pertrochanteric fractures and 4.6 (1.1–19) times higher in subtrochanteric fractures with treatment protocol: intramedullary nail/dynamic hip screw, compared to treatment protocol: Medoff sliding plate/dynamic hip screw. Overall rates of intermediate and major technical complications in unstable pertrochanteric and subtrochanteric fractures were with biaxial Medoff sliding plate 0.68%, with uniaxial Medoff sliding plate 1.4%, with dynamic hip screw 3.4% and with intramedullary nail 7.2%.ConclusionsThe treatment protocol based on use of biaxial Medoff sliding plate for unstable pertrochanteric and uniaxial Medoff sliding plate for subtrochanteric fractures reduced the risk of severe technical complications compared to using the treatment protocol based on dynamic hip screw and intramedullary nail.
Highlights
In treatment of unstable trochanteric fractures dynamic hip screw and Medoff sliding plate devices are designed to allow secondary fracture impaction, whereas intramedullary nails aim to maintain fracture alignment
The operations were made by a surgeon having performed 25 or more previous trochanteric hip fracture surgeries in 68% of the patients in treatment protocol Medoff sliding plate (MSP)/dynamic hip screw (DHS) and in 87% in treatment protocol Intramedullary nail (IMN)/DHS, respectively. 16% of all fractures were classified as stable pertrochanteric, 70% unstable pertrochanteric and 14% subtrochanteric
The main mechanisms behind major technical complications were malalignment with varus dislocation and cut-out due to anteromedialisation of the femoral shaft in fractures without lateral or posterior support operated with DHS or biaxial MSP, varus dislocation and cut-out in fractures treated with DHS or IMN due to insufficient load-sharing, or bone or implant stress fracture or nonunion due to load-bearing in fractures treated with IMN
Summary
In treatment of unstable trochanteric fractures dynamic hip screw and Medoff sliding plate devices are designed to allow secondary fracture impaction, whereas intramedullary nails aim to maintain fracture alignment. Stable two-fragment pertrochanteric fractures are treated with good result with dynamic hip screw (DHS) devices [1, 2], but controversy remains regarding treatment of unstable pertrochanteric and subtrochanteric fractures. Dynamic fixation methods are designed to allow secondary fracture impaction to improve interfragmentary stress transfer, thereby facilitating fracture healing and unloading the implant. DHS allows dynamic compression along the axis of the femoral neck, which, depending on fracture geometry, may be more or less appropriate or effective [3, 4]. The Medoff sliding plate [5] (MSP) adds compression along the axis of the femoral shaft, allowing biaxial dynamisation. Poor load transfer may subject the implant to high loads with increased risk of nonunion, implant failure or fracture due to stress concentration [2, 7]
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