Intertrochanteric Femur Fractures - DHS Adam Starr, MD Chief, - - PowerPoint PPT Presentation

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
• ne 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

• f 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.

Extramedullary Compared with Intramedullary Implants for Intertrochanteric Hip Fractures: Thirty-Day Outcomes of 4432 Procedures from the ACS NSQIP Database Bohl, Daniel D. MPH; Basques, Bryce A. BS; Golinvaux, Nicholas S. BA; Miller, Christopher P. MD; Baumgaertner, Michael R. MD; Grauer, Jonathan N. MD The Journal of Bone and Joint Surgery Issue: Volume 96(22), 19 November 2014, p 1871–1877

• Background: For more than thirty-five years, the sliding hip screw, an extramedullary implant, has been the

standard treatment for the stabilization of intertrochanteric fractures. Over the last decade, intramedullary implants have replaced extramedullary implants as the most commonly used type of implant in the United States for the treatment of this condition, without strong evidence of superior outcomes.

• Methods: We conducted a retrospective cohort study with use of the American College of Surgeons National

Surgical Quality Improvement Program (ACS NSQIP) database. Patients seventy years of age or older who had sustained an intertrochanteric fracture treated with extramedullary or intramedullary implant during 2009 to 2012 were identified. General surgical outcomes were compared between implant types, with adjustment for demographic data and comorbidities.

• Results: A total of 4432 patients were identified; 1612 (36.4%) were treated with an extramedullary implant, and

2820 (63.6%) with an intramedullary implant. The rates of the composite outcomes “serious adverse events” and “any adverse events” did not differ by implant type. The mean postoperative length of stay was shorter for patients treated with an intramedullary implant compared with those treated with an extramedullary implant (5.4 compared with 6.5 days; p < 0.001). Operation time, operating room time, and the rate of hospital readmission did not differ by implant type.

• Conclusions: These results reinforce the results of previous randomized trials, demonstrating little difference in

rates of general surgical adverse events between implant types. The present study presents an important departure from previous trials in its finding that patients treated with intramedullary implants have, on average, a shorter postoperative length of stay (by 1.1 days). The finding may negate the perceived excess cost associated with intramedullary treatment. Limitations regarding the ACS NSQIP database include a lack of detail regarding fracture subtype, outcomes beyond thirty days, and orthopaedic-specific outcomes.

• Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of

evidence.

Sliding hip screw versus intramedullary nail for trochanteric hip fractures; a randomised trial of 1000 patients with presentation of results related to fracture stability MJ Parker - Injury, Oct 2017

• Aims
• To determine the optimum choice of implant for a patient with a the different types of trochanteric

hip fracture.

• Patients and methods
• 1000 patients with a trochanteric hip fracture were randomised to internal fixation of the fracture

with either a Sliding Hip Screw or an intramedullary nail. Fractures were subdivided into two part fractures, comminuted fractures and fractures at the level of the lesser trochanter (reversed/oblique and transverse). Functional assessment for up to one year from injury was undertaken by a research nurse blinded to the treatment allocation.

• Results
• The mean age of patients was 82 years and 77% were female. There was a significantly improved

regain of mobility for those treated with the intramedullary nail. No statistically significant differences between the two types of fixation methods was observed for mortality, fracture healing complications, re-operations, hospital stay, length of surgery, blood transfusion requirements, medical complications, degree of residual pain or regain of independence. These finding were valid for all fracture types.

• Conclusion
• This study is the first adequately powered randomised trial on this topic and demonstrates that

there are no notable differences in either process or functional outcomes between these two treatment methods, other than a tendency to better regain of mobility for those fractures fixed with an intramedullary nail.

TRIGEN INTERTAN Intramedullary Nail Versus Sliding Hip Screw: A Prospective, Randomized Multicenter Study

• n Pain, Function, and Complications in 684 Patients with an Intertrochanteric or Subtrochanteric Fracture and

One Year of Follow-up Matre, Kjell MD; Vinje, Tarjei MD; Havelin, Leif Ivar MD, PhD; Gjertsen, Jan-Erik MD, PhD; Furnes, Ove MD, PhD; Espehaug, Birgitte MSc, PhD; Kjellevold, Stein-Harald MD; Fevang, Jonas Meling MD, PhD JBJS 2013: 95:200-208

• Background: Both intramedullary nails and sliding hip screws are used with good results in the

treatment of intertrochanteric and subtrochanteric fractures. The aim of our study was to assess whether use of the TRIGEN INTERTAN nail, as compared with a sliding hip screw, resulted in less postoperative pain, improved functional mobility, and reduced surgical complication rates for patients with an intertrochanteric or subtrochanteric fracture.

• Methods: In a prospective, randomized multicenter study, 684 elderly patients were treated with

the INTERTAN nail or with a sliding hip screw with or without a trochanteric stabilizing plate. The patients were assessed during their hospital stay and at three and twelve months postoperatively. A visual analogue scale (VAS) pain score was recorded at all time points, and functional mobility was assessed with use of the timed Up & Go test. The Harris hip score (HHS) was used to assess hip function more specifically. Quality of life was measured with the EuroQol-5D (EQ-5D). Radiographic findings as well as intraoperative and postoperative complications were recorded and analyzed.

• Results: Patients treated with an INTERTAN nail had slightly less pain at the time of early

postoperative mobilization (VAS score, 48 versus 52; p = 0.042), although this did not influence the length of the hospital stay and there was no difference at three or twelve months. Regardless of the fracture and implant type, functional mobility, hip function, patient satisfaction, and quality-of-life assessments were comparable between the groups at three and twelve months. The numbers of patients with surgical complications were similar for the two groups (twenty-nine in the sliding-hip- screw group and thirty-two in the INTERTAN group, p = 0.67).

• Conclusions: INTERTAN nails and sliding hip screws are similar in terms of pain, function, and

reoperation rates twelve months after treatment of intertrochanteric and subtrochanteric fractures.

• Level of Evidence: Therapeutic Level I.

Bored Yet?

Could go on like this all day.

Differences?

• Not much.
• If the hospital

system (or payor) is looking to control costs, insistence upon use of DHS is an easy move.

My advice?

• There are cases where

a DHS or plate simply will not work.

• You need to be an

expert nailer.

• To become an expert,

you need lots of reps.

• Nailing the easy ones

makes you a better nailer.

Thank You