Treatment of pertrochanteric fractures in elderly patients: is dynamic fixation so important?

Introduction. The problem of complications after surgical treatment of pertrochanteric fractures in elderly patients is relevant and far from a solution.

Materials and methods. The retrospective study was based on the analysis of the results of treatment of 129 patients with pertrochanteric femoral fractures (average age 76 years). All fractures in the early time from trauma were fixed with two types of cephalomedullary nails, either dynamic or static. All patients could not limit the load on the operated limb after surgery because of different reasons.

Results. The results of treatment were evaluated in 109 patients after one year. In dynamic cephalomedullary fixator group (59 patients), there were 7 orthopedic complications with a functional Harris scale result of 68 points (range, 26 to 94 points). In static cephalomedullary fixator group (50 patients), there were 14 orthopedic complications with a functional Harris score of 56.5 points (range, 15 to 92 points).

Discussion. Higher results of treatment in the group of dynamic fixator in the condition of full-weight bearing on the operated limb may be associated with the possibility of dynamization of the part of fixator in response to bone resorption in the contact area of bone fragments. The use of dynamic cephalomedullary fixators instead of static ones for treatment of pertrochanteric femoral fractures in elderly patients exercising full weight-bearing leads to a decrease in orthopedic complications (from 28 to 11.9 %) and improves the functional results of treatment.

1. Casati A., Aldegheri G., Vinciguerra E., Marsan A., Fraschini G., Torri G. Randomized comparison between sevoflurane anaesthesia and unilateral spinal anaesthesia in elderly patients undergoing orthopaedic surgery. Eur. J. Anaesthesiol., 2003, vol. 20, no. 8, pp. 640-646. DOI: 10.1017/s0265021503001030.

2. Chechik O., Amar E., Khashan M., Kadar A., Rosenblatt Y., Maman E. In support of early surgery for hip fractures sustained by elderly patients taking clopidogrel: a retrospective study. Drugs Aging, 2012, vol. 29, no. 1, pp. 63-68. DOI: 10.2165/11598490-000000000-00000.

3. Iwata T., Nozawa S., Dohjima T., Yamamoto T., Ishimaru D., Tsugita M., Maeda M., Shimizu K. The value of T1-weighted coronal MRI scans in diagnosing occult fracture of the hip. J. Bone Joint Surg. Br., 2012, vol. 94, no. 7, pp. 969-973. DOI: 10.1302/0301-620X.94B7.28693.

4. Knobe M., Drescher W., Heussen N., Sellei R.M., Pape H.C. Is helical blade nailing superior to locked minimally invasive plating in unstable pertrochanteric fractures? Clin. Orthop. Relat. Res., 2012, vol. 470, no. 8, pp. 2302-2312. DOI: 10.1007/s11999-012-2268-9.

5. Radcliff T.A., Henderson W.G., Stoner T.J., Khuri S.F., Dohm M., Hutt E. Patient risk factors, operative care, and outcomes among older community-dwelling male veterans with hip fracture. J. Bone Joint Surg. Am., 2008, vol. 90, no. 1, pp. 34-42. DOI: 10.2106/JBJS.G.00065.

6. Saygi B., Ozkan K., Eceviz E., Tetik C., Sen C. Skin traction and placebo effect in the preoperative pain control of patients with collum and intertrochanteric femur fractures. Bull. NYU Hosp. Jt. Dis., 2010, vol. 68, no. 1, pp. 15-17.

7. Varela-Egocheaga J.R., Iglesias-Colao R., Suárez-Suárez M.A., Fernández-Villán M., González-Sastre V., Murcia-Mazón A. Minimally invasive osteosynthesis in stable trochanteric fractures: a comparative study between Gotfried percutaneous compression plate and Gamma 3 intramedullary nail. Arch. Orthop. Trauma Surg., 2009, vol. 129, no. 10, pp. 1401-1407. DOI: 10.1007/s00402-009-0955-0.

8. Sylliaas H., Brovold T., Wyller T.B., Bergland A. Progressive strength training in older patients after hip fracture: a randomised controlled trial. Age Ageing, 2011, vol. 40, no. 2, pp. 221-227. DOI: 10.1093/ageing/afq167.

9. Zhang S., Zhang K., Jia Y., Yu B., Feng W. InterTan nail versus Proximal Femoral Nail Antirotation-Asia in the treatment of unstable trochanteric fractures. Orthopedics, 2013, vol. 36, no. 3, pp. e288-e294. DOI: 10.3928/01477447-20130222-16.

10. Malko A.V., Savintsev A.M. «Cutout» effekt kak prichina oslozhnenii maloinvazivnogo osteosinteza perelomov proksimalnogo otdela bedrennoi kosti konstruktsiei PFN-A [“Cut-out” effect as a cause of complications of little-invasive osteosynthesis for fractures of proximal femur with PFN-A design]. Vestnik SPbGU, Ser. 2, 2014, no. 1, pp. 214-220. (in Russian)

11. Dubrov V.E., Kuzkin I.A., Shcherbakov I.M., Matveev A.L., Iudin A.V. Virtualno-eksperimentalnoe obosnovanie dinamicheskogo osteosinteza pri lechenii perelomov proksimalnogo otdela bedrennoi kosti [Virtual-experimental substantiation of dynamic osteosynthesis in the treatment of fractures of the proximal femur]. Biulleten Eksperimentalnoi Biologii i Meditsiny, 2017, vol. 163, no. 2, pp. 261-267. (in Russian)

12. AO/OTA Fracture and Dislocation Classification Compendium – 2018. Available at: https://classification.aoeducation.org/

13. 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 peritrochanteric fractures of the hip. J. Bone Joint Surg. Am., 1995, vol. 77, no. 7, pp. 1058-1064. DOI: 10.2106/00004623-199507000-00012.

14. Murena L., Moretti A., Meo F., Saggioro E., Barbati G., Ratti C., Canton G. Predictors of cut-out after cephalomedullary nail fixation of pertrochanteric fractures: a retrospective study of 813 patients. Arch. Orthop. Trauma Surg., 2018, vol. 138, no. 3, pp. 351-359. DOI: 10.1007/s00402-017-2863-z.

15. Glants S. Mediko-biologicheskaia Statistika [Medical and Biological Statistics]. Transl. from Engl. M., Praktika, 1999, 459 p. (in Russian)

16. Knobe M., Münker R., Sellei R.M., Schmidt-Rohlfing B., Erli H.J., Strobl C.S., Niethard F.U. Die instabile pertrochantäre Femurfraktur. Komplikationen, Fraktursinterung und Funktion nach extra- und intramedullärer Versorgung (PCCP™, DHS und PFN) [Unstable pertrochanteric femur fractures. Failure rate, lag screw sliding and outcome with extra- and intramedullary devices (PCCP, DHS and PFN)]. Z. Orthop. Unfall., 2009, Vol. 147, no. 3, pp. 306-313. (in German) DOI: 10.1055/s-0029-1185349.

17. Lenich A., Vester H., Nerlich M., Mayr E., Stöckle U., Füchtmeier B. Clinical comparison of the second and third generation of intramedullary devices for trochanteric fractures of the hip – Blade vs screw. Injury. 2010. vol. 41, no. 12, pp. 1292-1296. DOI: 10.1016/j.injury.2010.07.499.

18. Lang N.W., Breuer R., Beiglboeck H., Munteanu A., Hajdu S., Windhager R., Widhalm H.K. Migration of the Lag Screw after Intramedullary Treatment of AO/OTA 31.A2.1-3 Pertrochanteric Fractures does not result in higher incidence of cut-outs, regardless of which implant was used: A comparison of Gamma Nail with and without U-Blade (RC) Lag Screw and Proximal Femur Nail Antirotation (PFNA). J. Clin. Med., 2019, vol. 8, no. 5, pp. 615. DOI: 10.3390/jcm8050615.

19. Kawatani Y., Nishida K., Anraku Y., Kunitake K., Tsutsumi Y. Clinical results of trochanteric fractures treated with the TARGON® proximal femur intramedullary nailing fixation system. Injury, 2011, vol. 42, no. Suppl. 4, pp. S22-S27. DOI: 10.1016/S0020-1383(11)70008-0.

20. Takigawa N., Moriuchi H., Abe M., Yasui K., Eshiro H., Kinoshita M. Complications and fixation techniques of trochanteric fractures with the TARGON(®) PF. Injury, 2014, vol. 45, no. Suppl. 1, pp. S44-S48. DOI: 10.1016/j.injury.2013.10.036.

21. Kim K.H., Han K.Y., Kim K.W., Lee J.H., Chung M.K. Local Postoperative Complications after Surgery for Intertrochanteric Fractures using Cephalomedullary Nails. Hip Pelvis, 2018, vol. 30, no. 3, pp. 168-174. DOI: 10.5371/hp.2018.30.3.168.