Intertrochanteric Femur Fractures - DHS Adam Starr, MD Chief, Orthopaedic Surgery Parkland Memorial Hospital Professor and Executive Vice Chair Department of Orthopaedic Surgery UT Southwestern Medical Center Dallas, Texas
Common -One of the most common orthopaedic injuries -Requires surgery -Requires hospitalization -Often requires nursing home placement or rehab stay -Often leads to failure to return to pre-injury functional level
Nail vs DHS • Common injuries. • Relatively easy to do comparative trials
COST and OUTCOMES -Cost is easy to track ~$300 vs $1500 -Outcomes are tougher -Revision surgery -Patient outcomes return to pre- injury status?
What’s the Literature Say?
Prospective Randomized Controlled Trial of an Intramedullary Nail Versus Dynamic Screw and Plate for Intertrochanteric Fractures of the Femur Adams, Christopher I.; Robinson, C. Michael; Court-Brown, Charles M.; McQueen, Margaret M. Journal of Orthopaedic Trauma Issue: Volume 15(6), August 2001 , pp 394-400 Objectives: To compare the surgical complications and functional outcome of the Gamma nail • intramedullary fixation device versus the Richards sliding hip screw and plate device in intertrochanteric femoral fractures. Design: A prospective, randomised controlled clinical trial with observer blinding. • Setting: A regional teaching hospital in the United Kingdom. • Patients: All patients admitted from the local population with intertrochanteric fractured femurs were • included. There were 400 patients entered into the study and 399 followed-up to one year or death. Intervention: The devices were assigned by randomization to either a short-type Gamma nail (203 • patients) or a Richard's-type sliding hip screw and plate (197 patients). Main Outcome Measurements: The main surgical outcome measurements were fixation failure and • reoperation. A functional outcome of pain, mobility status, and range of movement were assessed until one year. Results: The requirement for revision in the Gamma nail group was twelve (6%); for Richard's group, • eight (4%). This was not statistically different ( p = 0.29; odds ratio, 1.48 [0.59–3.7]). A subcapital femoral fracture occurred in the Richard's group. Femoral shaft fractures occurred with four in the Gamma nail group (2%) and none in the Richard's group ( p = 0.13). Three required revision to another implant. Lag- screw cut-out occurred in eight patients in the gamma nail group (4%) and four in the Richard's group (2%). This was not statistically significant ( p = 0.37; odds ratio, 2.29 [0.6–9.0]). The development of other postoperative complications was the same in both groups. There was no difference between the two groups in terms of early or long-term functional status at one year. Conclusions: The use of an intramedullary device in the treatment of intertrochanteric femoral fractures is • still associated with a higher but nonsignificant risk of postoperative complications. Routine use of the Gamma nail in this type of fracture cannot be recommended over the current standard treatment of dynamic hip screw and plate.
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 Barton, Tristan M. MBChB, MSc; Gleeson, Robert FRCS(Orth); Topliss, Claire FRCS(Orth); Greenwood, Rosemary MSc; Harries, William J. FRCS(Orth); Chesser, Timothy J.S. FRCS(Orth) The Journal of Bone & Joint Surgery Issue: Volume 92(4), April 2010 , p 792–798 Background: Controversy exists with regard to whether to treat AO/OTA 31-A2 fractures of the • proximal part of the femur with an intramedullary device or an extramedullary device. A prospective, randomized, controlled trial was performed to compare the outcome of treatment of these unstable fractures of the proximal part of the femur with either a sliding hip screw or a long gamma nail. Methods: Two hundred and ten patients presenting with an AO/OTA 31-A2 fracture of the proximal • part of the femur were randomized , at the time of admission, to fixation with use of either a long gamma nail or a sliding hip screw. The primary outcome measure was reoperation within the first postoperative year. Secondary measures included mortality, length of hospital stay, transfusion rate, change in mobility and residence, and quality of life as measured with the EuroQol 5D outcome score. Results: There was no significant difference between the reoperation rates for the two groups . In • total, five patients (three from the long-gamma-nail group and two from the sliding-hip-screw group) underwent revision surgery because of cut-out. Tip-apex distance was found to correlate with the implant cut-out rate. There was no significant difference between the two groups in terms of the EuroQol 5D outcome scores, the mortality rates after correction for the mini-mental score, or any of the secondary outcome measures. Conclusions: When compared with the long gamma nail, the sliding hip screw should remain the • gold standard for the treatment of AO/OTA 31-A2 fractures of the proximal part of the femur because it is associated with similar outcomes with less expense. Level of Evidence: Therapeutic Level I. See Instructions to Authors for a complete description of • levels of evidence.
Intramedullary Versus Extramedullary Fixation for Unstable Intertrochanteric Fractures : A Prospective Randomized Controlled Trial Reindl, Rudolf MD, FRCSC; Harvey, Edward J. MD, FRCSC; Berry, Gregory K. MD, FRCSC; Rahme, Elham PhD JBJS 2015 97:1905-1912 Background: The use of intramedullary devices for the management of intertrochanteric fractures • has steadily increased without good evidence of their clinical efficacy. This prospective randomized multicenter study was designed to compare the clinical and radiographic outcomes of patients who had been treated with a traditional extramedullary hip screw for an unstable (AO/OTA 31-A2) intertrochanteric hip fracture with those of patients who had been treated with the newer intramedullary device for the same injury. Methods: The Lower Extremity Measure (LEM) was used as the primary hip-specific outcome tool. • The Functional Independence Measure (FIM), the timed “Up & Go” (TUG) test, as well as a timed two-minute walk test were used as secondary clinical outcome tools. Specific radiographic parameters were collected to assess for fracture movement, heterotopic ossification, and implant failure. Results: No significant differences were noted between the intramedullary and extramedullary • treatment arms with regard to either the primary or the secondary clinical outcome tools. The radiographic parameters favored the intramedullary treatment arm, which had less femoral neck shortening. Conclusions: While the use of the intramedullary devices led to better radiographic outcomes in • this study, this did not translate to improved functional outcomes. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of • levels of evidence.
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