Does augmentation of intramedullary nails by a buttress plate effectively restore lateral wall integrity in intertrochanteric fractures.

Abstract

Recent studies have proved the importance of intact lateral trochanteric wall, thus buttressing/fixing the broken lateral trochanteric wall irrespective of the implant, is likely to improve the alignment and outcome. We compared the outcome of lateral wall buttressing by trochanteric buttress plate (TBP) supplemented to proximal femoral nailing versus proximal femoral nailing alone in patients of broken lateral wall intertrochanteric fractures. Sixty patients of intertrochanteric factures (IT) of femur with broken lateral wall were randomized into group A or B and were treated with either proximal femoral nail (PFN) alone or proximal femoral nail augmented with trochanteric buttress plate (PFN + TBP), respectively. The TBP plate used was primarily fixed to proximal femur via 8mm hip screw and 6.4mm antirotation screw of the PFN. Operative time, blood loss, radiation exposure, quality of reduction, functional outcome, union time, and complications were compared. The mean age was 60.03 + 7.60 (range 42 to 70years), with male to female ratio of 4:1 and left to right ratio of approximately 1:1. The mean follow up in the series was 16.2months (range 13 to 36months). Mean duration of surgery, mean intra-operative blood loss, and mean number of exposures in group A (PFN alone) were 64.88 + 12.24min (48 to 88), 93 + 1.18ml (60 to 120), and 32.13 (24 to 46) and in group B (PFN with TBP plate) were 91.86 + 12.78min (70 to 122min), 144.8 + 3.6ml (116 to 208ml), and 56.6 (38 to 112), respectively. Twenty-five patients and 28 patients in groups A and B respectively achieved score of 4 Chang quality reduction. Mean union time was 13.4weeks in group A whereas in group B was 11.6weeks. Mean HHS score in group A was 87.86 with 90% patients in comparison to 94.13 and 97% cases having excellent to good results in group B. In group A, 24 patients, while 29 patients in group B, had excellent to good results. Four patients had hip pain, four had impingement of screws, two had screw migration, three had Z/reverse effect, and four patients had shortening of more than 1cm in group A. In group B, only one patient had impingement and none of the patient had hip pain, infection, implant failure, Z effect, or shortening. The lateral trochanteric wall in IT fractures is significantly important, and when the lateral wall is broken, it can lead to poor results. TBP plate which is applied laterally on femur along with nail and fixing the plate with hip screw and antirotational screw provides faster union, early weight bearing, better reduction, and so better hip functions. TBP can be used successfully to augment, fix, or buttress the lateral trochanteric wall giving excellent to good results but at the cost of surgical time, blood loss, and radiation exposure.