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Femoral medialisation and functional outcome in trochanteric hip fractures
Christopher Bretherton – Core Surgical TraineeMartyn Parker – Orthopaedic Consultant
British Orthopaedic Trainees Association Educational Weekend
June 12th 2015
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Disclosures
Conflict of interest
One or more of the Authors have previously received conference and accommodation expenses from Aesculap AG
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Background
• This has been related to fixation failure1
• The aim of this study was to determine if femoral medialisation affects residual pain and long-term mobility
• Determine if fracture pattern and type of implant (extramedullary vs intramedullary) predispose to medialisation.2
• Recent studies have suggested improved mobility after IM nail fixation.3,4
Femoral medialisation
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Methods• We used data from patients that had been entered into a
randomised trial comparing the Targon Proximal Femoral intramedullary (IM) nail with the Sliding Hip Screw (SHS).
Exclusion criteria • Subtrochanteric fractures• Trochanteric fractures with a subtrochanteric extension that
required a plate longer than five holes to achieve satisfactory distal fixation of eight cortices
• Pathological fractures • Lead trialist not available
• Trochanteric stabilization plates were not used for initial surgery
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Methods• Mobility assessed using a scale of 0 to 9.
• Pain assessed with Charnley Pain Score from 1 to 6.
• Fractures were grouped by AO classification as trochanteric (31A) stable (A1), unstable (A2), and transverse or reverse oblique (A3)
• The majority of post-op x-rays were taken during clinic follow
up at 6 weeks from discharge (Range 28 – 1893 days, mean 117 days, median 63 days)
.
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AO Classification of fractures
Femoral medialisation Intramedullary nail
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Exclusions
Allocated to Intramedullary nail (266)
844 patients admitted between April 2002 and December 2013 and entered into the randomised trial
Excluded from analysis (306)Died before one year follow-up (239)Not had 28 days X-ray follow up (40)X-rays not available for review (15)
Lost to follow-up (8)Died after 1 year but before follow-up assessment (4)
Included in study (538)
Allocated to Sliding Hip Screw (272)
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Results
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Results
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Results summarised
• Post-operative femoral medialisation of >50% is associated with more fracture healing complications (p=0.021) and revision procedures (p=0.014).
• Medialisation is associated with increased pain scores (p=0.012) and poorer mobility scores (p=0.013) at one year.
• Femoral medialisation is more common in trochanteric fractures treated with SHS versus intramedullary nail (p<0.001)
• A2 (p=0.02) and A3 (p=0.006) fractures treated with SHS are more likely to experience >50% medialisation.
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Limitations
• We assessed pain and mobility at one year but in most cases final x-rays were taken and interpreted earlier than this.5
• Femoral medialisation is only one factor/ only looked at the AP view.
• Small numbers in the >50% medialisation group
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• The most recent cochrane review finds no difference between outcomes of DHS and IM Nails, NICE guidelines recommend DHS.6
• Few RCT’s distinguish between fracture pattern
• Hardy3 and Utrilla4 agreed that intramedullary devices are associated with earlier return to mobility, especially when used to treat unstable fractures
Discussion
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Scientific Perspective
• Femoral mediatisation is related to long-term pain and mobility
• More medialisation with SHS vs Nails
Conclusions
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Clinical Perspective
• Supports the use of IM Nails for A3 fractures (in accordance with registry data)7
• May explain a tendency for better mobilisation in A2 fractures treated with nails
• Reminder that future studies should look specifically at A2 fractures
Conclusions
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References1. Parker MJ. Trochanteric hip fractures. Fixation failure commoner with femoral medialisation, a
comparison of 101 cases. Acta Orthop Scand 1996;67:329—32.
2. Curtis MJ, Jinnah RH, Wilson V, Cunningham BW. Proximal femoral fractures: a biomechanical study to compare intramedullary and extramedullary fixation. Injury 1994; 25:99—104.
3. D. Hardy, P.-Y. Descamps, P. Krallis, et al. Use of an intramedullary hip-screw compared with a compression hip-screw with a plate for intertrochanteric femoral fractures. A prospective randomized study of one hundred patients. J Bone Joint Surg Am, 80 (1998), pp. 618–630
4. A. Utrilla, J. Reig, F. Munoz, C. Tufanisco. Trochanteric gamma nail and compression hip screw for trochanteric fractures: a randomized, prospective, comparative study in 210 elderly patients with a new design of the gamma nail. J Orthop Trauma, 19 (4) (2005), pp. 229–233
5. Pararinen J, Lindahl J, Savolainen V, Michelsson O, Hirvensalo E. Femoral shaft medialisation and neck-shaft angle in unstable pertrochanteric femoral fractures. Into Orthop. 2004 Dec;28(6):347-53
6. Parker MJ, Handoll HH. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults. CochraneDatabase Syst Rev 2010;9:CD000093.
7. Matre K, Havelin Ll, Gjertsen JE, Vinje T, Espehaug B, Fevang JM. Sliding hip screw versus IM nail in reverse oblique trochanteric and subtrochanteric fractures. A study of 2716 patients in the Norwegian Hip Fracture Register. Injury. 2013 Jun;44(6):735-42.
Questions?