Abstract
Objective: Determine whether preoperative AP pelvis radiographies under manual traction influence surgeon choice for implants in intertrochanteric fractures compared with standard radiographies. Methods: Fifty-eight patients with intertrochanteric fractures were prospectively enrolled from four tertiary teaching hospitals. All patients had standard AP pelvis radiographies taken as well as radiographies under manual traction of affected limb, 116 images total. Three fellowship trained trauma surgeons and three hip surgeons blindly reviewed the images and indicated their implant choice for each case: extra or intramedullary fixation. The observers received randomly assigned images and were unaware of the radiography technique, patient number, and repetition of patients within the set of images. Statistical analyses were performed using Cohen Kappa method and McNemar, Q Cochran, and Wilcoxon tests. Results: Manual traction radiographies changed surgeon-implant choice in 35.06% (range: 27.6% to 43.1%). However, traction radiographies provided no improvement in weak inter-observer reliability for treatment indication (k=0.264, p<0.001) compared to standard radiographies (k=0.220, p<0.001), when using Mann-Whitney test (p=0.359). Traction views did not increase predilection for either method. Hip surgeons agreed more than trauma surgeons concerning implant choice. Conclusions: Manual traction radiographies modified surgeon choice in up to one third of intertrochanteric fracture cases.
Highlights
Intertrochanteric femoral fractures are life-threatening lesions common in the elderly
Standard technique for regular AP pelvis radiographies consisted of supine whole pelvis radiographs with X-ray beam centered on pubic symphysis, directed vertically, 1 meter from film
According to Mann-Whitney test (U= 1.534; p=0.359), traction views provided no improvement in inter-observer reliability for implant choice
Summary
Intertrochanteric femoral fractures are life-threatening lesions common in the elderly. The lesions may decrease life expectancy and quality [1]. Appropriate treatment normally includes surgery; implant design and surgical techniques lack a uniform standard and may vary according to fracture type, bone quality, patient characteristics, implant availability, and surgeon choice. Recent data have suggested that some unstable fracture patterns, such as reverse obliquity, and highly comminuted, could benefit from intramedullary nailing. Other fracture patterns could be treated preferably with extramedullary implants such as sliding screw plates. Disagreement exists concerning treatment, it is well established that adequate radiographs and fracture classifications can provide useful guidelines for surgeon choice
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