Pertrochanteric fracture - operation for beginners?

Abstract

In patients over 65 years, pertrochanteric proximal femur fractures are very common, with an incidence of 966/100,000. Treatment of choice is nailing or dynamic hip screws. The operative approaches are standardised and easy to learn. Is nail fixation a good procedure for surgical training? From 1 January 2012 until 31 December 2013, 210 patients with an average age of 80.7 years and pertrochanteric fractures underwent treatment. 139 patients (66%) were treated by surgical trainees, 55 (26%) by staff surgeons, and 16 by the head of the department (8%). Preoperative delay averaged one day. Skin to skin operative time averaged 48 minutes for all patients. For trainees, the procedure averaged 45 minutes, while the more complex cases treated by staff surgeons (multi-fragment, markedly displaced) averaged 67 minutes and thus took significantly longer (p < 0.1). There was no difference in complications. There were 6 misplaced implants and cutouts (2.8%), one infection (0.5%), and 6 operative revisions because of hematoma or seroma (2.8%). Four patients (1.9%) died of cardiovascular failure with ASA 3 and 4 during the inpatient stay (2 in each group). Internal fixation with nailing in pertrochanteric femur fractures is a standard operative approach. It is suitable as a "beginner's" procedure, that is quickly and easily performed. Only complex, multifragmented or markedly displaced or long-segment fractures need to be treated by staff physicians. Mortality is not affected by the surgeon's experience, but rather by comorbidity and from the preoperative duration.