External Fixation of Pertrochanteric Fractures

Abstract

Sliding hip screw fixation is the most common surgical treatment for pertrochanteric fractures. Intramedullary hip screw fixation is another popular surgical option; however, for either sliding hip screw or intramedullary hip screw fixation, mechanical complications such as lag screw cut-out are frequent. Furthermore with these fixation techniques, the inability to restore previous hip anatomy is common. Recently, external fixation has been proposed as a suitable fixation technique for pertrochanteric fractures. The main advantages of external fixation include: minimally invasive, short operative time, limited blood loss, and maintenance of the reduction obtained at surgery. For these reasons, we evaluated the results of pertrochanteric fractures treated with external fixation after a minimum follow-up of 6 months. Ten consecutive female osteoporotic patients (age ≥ 65 years) with AO/OTA fracture type A 1 or A 2 were included in the study. Fractures were treated with Orthofix pertrochanteric fixator (OPF) with four hydroxyapatite (HA)-coated pins. The mean patient age was 82 ± 7 years. The mean operative time was 34 ± 5 min. Fixators were removed three months postoperatively. There was union in all fractures. No blood transfusions were required postoperatively. There was no pin-track infection. The mean pin-insertion torque was 1 962 ± 1 215 N/mm and the mean pin extraction torque was 2 784 ± 1 648 N/mm. These latter results indicated improved pin fixation over time (p < 0.0005). There was no significant change in fracture reduction over time since there were no differences between the femoral-neck-shaft angle at 6 months and postoperatively. This study demonstrates that external fixation is a reliable treatment option for osteoporotic pertrochanteric fractures.

Key words

external fixation - intramedullary hip screw - sliding hip screw - hydroxyapatite-coated pins - pertrochanteric fractures

References

• 1 Ahrengart L, Tornkvist H, Fornander P, Thorngren K G, Pasanen L, Wahlstrom P, Honkonen S, Lindgren U. A randomized study of the compression hip screw and Gamma nail in 426 fractures.  Clinical Orthopaedics and Related Research. 2002;  401 209-222
• 2 Albareda J, Laderiga A, Palanca D, Paniagua L, Seral F. Complications and technical problems with the Gamma nail.  Int Orthop. 1992;  20 47-50
• 3 Alcivar E, Lavini F, Brivio R. The Orthofix Pertrochanteric Fixator. Operative technique. Orthofix Srl, Verona, Italy 1998
• 4 Baumgaertner M R. The pertrochanteric external fixator reduced pain, hospital stay, and mechanical complications in comparison with the sliding hip screw.  J Bone Joint Surg. 2002;  84 23-29
• 5 Baumgaertner M R, Curtin S L, Lindskog D M, Keggi J M. The value of the tip-apex distance in predicting failure of fixation of pertrochanteric fractures of the hip.  J Bone Joint Surg [Am]. 1995;  77 1058-1064
• 6 Bellabarba C, Herscovici D, Ricci W M. Percutaneous treatment of peritrochanteric fractures using the Gamma nail.  Clinical Orthopaedics and Related Research. 2000;  375 30-42
• 7 Boriani S, Bettelli G, Zmerly H. et al . Results of the multicentric Italian experience on the Gamma nail: a report on 648 cases.  Orthopaedics. 1991;  14 1307-1314
• 8 Bridle S H, Patel A D, Bircher M, Calvert P T. Fixation of intertrochanteric fractures of the femur: a randomised prospective comparison of the Gamma nail and dynamic hip screw.  J Bone Joint Surg [Br]. 1991;  73 330-334
• 9 Butt M S, Krikler S J, Nafie S, Ali M S. Comparison of dynamic hip screw and Gamma nail: a prospective, randomised, controller trial.  Injury. 1995;  26 615-618
• 10 Checketts R G, Otterburn M. Pin tract infection: Definition, prevention, incidence. Abstracts of the 2^nd Riva Congress; Current perspectives in external and intermedullary fixation.  J Bone Joint. 2005;  87 753-759
• 11 Christodoulou N A, Sdrenias C V. External fixation of select interotrochanteric fixation with single hip screw.  Clin Orthop. 2000;  381 204-211
• 12 Friedl W, Colombo-Benkmann M, Dockter S, Machens H G, Mieck U. Gamma nail osteosynthesis of per- and subtrochanteric femoral fractures: 4 years experience and their consequences for further implant development.  Chirurg. 1994;  65 953-963
• 13 Goldhagen P R, O'Connor D R, Schwarze D, Schwarze E. A prospective comparative study of the compression hip screw and the Gamma nail.  J Orthop Trauma. 1994;  8 367-372
• 14 Harler S C. The Gamma nail for peritrochanteric fractures.  J Bone Joint Surg [Br]. 1992;  74 340-344
• 15 Heinz T, Vécsei V. Complications and errors in use of the Gamma nail: causes and prevention.  Chirurg. 1994;  65 943-952
• 16 Kempf I, Grosse A, Tagland G, Favreul E. Gamma nail in the treatment of closed trochanteric fractures: results and indication apropos of 121 cases.  Rec Chir Orthop Reparatrice Appar Mot. 1993;  79 29-40
• 17 Larsson S. Treatment of osteoporotic fractures.  Scan J Surgery. 2002;  91 140-146
• 18 Leung K S, So W S, Shen W Y, Hui P W. Gamma nails and dynamic hip screws for peritrochanteric fractures: a randomised prospective study in elderly patients.  J Bone Joint Surg [Br]. 1992;  74 345-351
• 19 Lindsey R W, Teal P, Probe R A. et al . Early experience with the Gamma interlocking nail for peritrochanteric fractures of the proximal femur.  J Trauma. 1991;  31 1649-1658
• 20 Magyar G, Toksvig-Larsen S, Moroni A. Hydroxyapatite coating of threaded pins enhances fixation.  J Bone Joint Surg [Br]. 1997;  79 487-491
• 21 McConnell T, Tornetta P, Benson E, Manuel J. Gluteus medius tendon injury during reaming for Gamma nail insertion.  Clinical Orthopaedics and Related Research. 2003;  407 199-202
• 22 Moroni A, Toksvig-Larsen S, Maltarello M, Orienti L, Stea S, Giannini S. A comparison of hydroxyapatite-coated, titanium-coated, and uncoated tapered external-fixation pins: An in vivo study in sheep.  J Bone Joint Surg [Am]. 1998;  80 547-554
• 23 Moroni A, Heikkila J, Magyar G, Toksvig-Larsen S, Giannini S. Fixation strength and pin tract infection of hydroxyapatite-coated tapered pins.  Clin Orthop. 2001;  388 209-217
• 24 Moroni A, Faldini C, Marchetti S. et al . Improvement of the bone-pin interface strength in osteoporotic bone with use of hydroxyapatite-coated tapered external-fixation pins. A prospective, randomized clinical study of wrist fractures.  J Bone Joint Surg [Am]. 2001;  83 717-721
• 25 Moroni A, Faldini C, Pegreffi F, Giannini S. HA-coated screws decrease the incidence of fixation failure in osteoporotic trochanteric fractures.  Clinical Orthopaedics and Related Research. 2004;  425 87-92
• 26 Parker M J. Cutting-out of the dynamic hip screw related to its position.  J Bone Joint Surg [Br]. 1992;  74 625
• 27 Parker M J, Handoll H HG. Extramedullary fixation implants and external fixators for extracapsular hip fractures (Cochrane Review). In: The Cochrane Library 3, 2003
• 28 Radford P J, Needoff M, Webb J K. A prospective randomised comparison of the dynamic hip screw and the Gamma locking nail.  J Bone Joint Surg [Br]. 1993;  75 789-793
• 29 Rosenblum S F, Zuckerman J D, Kummer F J, Tam B S. A biomechanical evaluation of the Gamma nail.  J Bone Joint Surg [Br]. 1992;  74 352-357
• 30 Saklad M. Grading of patients for surgical procedures.  Anesthesiology. 1941;  2 281-284
• 31 Scott I H. Treatment of intertrochanteric fractures by skeletal pinning and external fixation.  Clin Orthop. 1957;  10 326-334
• 32 Sturmer K M, Dresing K. Pertrochanteric fractures.  Zentralbl Chir. 1995;  120 862-872
• 33 Valverde J A, Alonso M G, Porro J G. et al . Use of the Gamma nail in the treatment of fractures of the proximal femur.  Clin Orthop. 1998;  350 56-61
• 34 Vossinakis I C, Badras L S. Management of pertrochanteric fractures in high-risk patients with an external fixation.  Int Orthop. 2001;  25 219-222
• 35 Vossinakis I C, Badras L S. The external fixator compared with the sliding hip screw for pertrochanteric fractures of the femur.  J Bone Joint Surg [Br]. 2002;  84 23-29