Hip Pelvis.  2012 Jun;24(2):109-116. 10.5371/hp.2012.24.2.109.

A Comparison of Intramedullary and Extramedullary Fixations for the Treatment of Reverse Oblique or Transverse Intertrochanteric Femoral Fractures

• Sung YB
• Choi JY
• Jung EY

• KMID: 1439099
• DOI: http://doi.org/10.5371/hp.2012.24.2.109

Abstract

PURPOSE
This study was designed to compare the clinical and radiological results of intramedullary fixation to those of extramedullary fixation in patients with reverse oblique or transverse intertrochanteric femoral fractures.
MATERIALS AND METHODS
We retrospectively reviewed 39 cases of reverse oblique or transverse intertrochanteric femoral fractures between September 2001 and December 2010. There were 20 cases treated with intramedullary fixation (Group I) and 19 cases treated with extramedullary fixation (Group II). The operative time, intraoperative blood loss, amount of blood transfused, hospital day, and time to bone union were compared between the two groups. Radiologically, the position and sliding length of the lag screw or blade, change of femoral neck-shaft angle, and medialization of distal fragment were compared. Also, complications were assessed.
RESULTS
The mean operative time was 87.8 minutes with Group I and 153.8 minutes with Group II. The mean intraoperative blood loss was 375.0 ml with Group I and 1,015.8 ml with Group II. The mean amount of transfusion was 555.5 ml with Group I and 801.6 ml with Group II. The mean time to bone union was 12.1 weeks with Group I and 18.1 weeks with Group II. There were no statistical differences in other parameters between the two groups.
CONCLUSION
The intramedullary fixation group revealed better results in the aspects of invasiveness and time to bone union in comparison with the extramedullary fixation group for the treatment of reverse oblique or transverse intertrochanteric femoral fractures.

Keyword

Femur; Intertrochanteric fracture; Reverse obliquity; Transverse

MeSH Terms

Femoral Fractures
Femur
Humans
Operative Time
Retrospective Studies

Figure

• 

  Fig. 1 Anteroposterior radiographs of the right hip of an 86-year-old woman who underwent intramedullary fixation. (A) Preoperative radiograph showed 31-A3.3 transverse intertrochanteric fracture involving lesser trochanter. (B) Immediate postoperative radiograph after fixation with PFNA. (C) The blade was cut-through at postoperative 6 months. (D) Reoperation was performed to change the blade with shorter one and augmentation with allogenic bone graft and cement. This radiograph was taken 6 months after reoperation.

• 

  Fig. 2 Anteroposterior radiographs of the right hip of a 60-year-old man who underwent extramedullary fixation. (A) Preoperative radiograph showed a 31-A3.1 reverse oblique intertrochanteric fracture. (B) Immediate postoperative radiograph after fixation with CHS and TSP. (C) The TSP was broken at postoperative 4 months. (D) After removal of previous implants, refixation was performed with long PFNA and cerclage wires. This radiograph was taken 3 years and one month after reoperation.

Reference

1. Richmond J, Aharonoff GB, Zuckerman JD, Koval KJ. Mortality risk after hip fracture. 2003. J Orthop Trauma. 2003. 17:S2–S5.

2. Evans EM. Trochanteric fractures; a review of 110 cases treated by nail-plate fixation. J Bone Joint Surg Br. 1951. 33B:192–204.

3. Brammar TJ, Kendrew J, Khan RJ, Parker MJ. Reverse obliquity and transverse fractures of the trochanteric region of the femur; a review of 101 cases. Injury. 2005. 36:851–857.

4. Madsen JE, Naess L, Aune AK, Alho A, Ekeland A, Strømsøe K. Dynamic hip screw with trochanteric stabilizing plate in the treatment of unstable proximal femoral fractures: a comparative study with the Gamma nail and compression hip screw. J Orthop Trauma. 1998. 12:241–248.

5. Xu YZ, Geng DC, Mao HQ, Zhu XS, Yang HL. A comparison of the proximal femoral nail antirotation device and dynamic hip screw in the treatment of unstable pertrochanteric fracture. J Int Med Res. 2010. 38:1266–1275.

6. Ozkan K, Eceviz E, Unay K, Tasyikan L, Akman B, Eren A. Treatment of reverse oblique trochanteric femoral fractures with proximal femoral nail. Int Orthop. 2011. 35:595–598.

7. Kuzyk PR, Lobo J, Whelan D, Zdero R, McKee MD, Schemitsch EH. Biomechanical evaluation of extramedullary versus intramedullary fixation for reverse obliquity intertrochanteric fractures. J Orthop Trauma. 2009. 23:31–38.

8. Fogagnolo F, Kfuri M Jr, Paccola CA. Intramedullary fixation of pertrochanteric hip fractures with the short AO-ASIF proximal femoral nail. Arch Orthop Trauma Surg. 2004. 124:31–37.

9. Choo SK, Oh HK, Choi JY. PFNA and PFN in intertrochanteric fractures: Comparison study of sliding. J Korean Hip Soc. 2010. 22:79–85.

10. Chang JS, Lee SH, Jay SC, Kim KY, Hyung SA, Han BH, Hong SW. Treatment of comminuted trochanteric fractures with dynamic hip screw and DHS trochanter stabilizing plate. J Korean Orthop Assoc. 1997. 32:1206–1213.

11. Haidukewych GJ, Israel TA, Berry DJ. Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg Am. 2001. 83-A:643–650.

12. Min WK, Kim SY, Kim TK, et al. Proximal femoral nail for the treatment of reverse obliquity intertrochanteric fractures compared with gamma nail. J Trauma. 2007. 63:1054–1060.

13. Baek SK, Choi YJ, Kim CH, et al. Treatment of comminuted trochanteric fracture with dynamic hip screw and trochanteric stabilizing plate. J Korean Soc Fract. 2002. 15:278–285.

14. Rho JY, Kim SB, Heo YM, Cho SJ, Chae DS, Lee WS. Proximal femoral nail antirotation versus compression hip screw with trochanter stabilizing plate for unstable intertrochanteric hip fractures. J Korean Fract Soc. 2010. 23:161–166.

15. Baumgaertner MR, Curtin SL, Lindskog DM. Intramedullary versus extramedullary fixation for the treatment of intertrochanteric hip fractures. Clin Orthop Relat Res. 1998. (348):87–94.

16. Pajarinen J, Lindahl J, Michelsson O, Savolainen V, Hirvensalo E. Pertrochanteric femoral fractures treated with a dynamic hip screw or a proximal femoral nail. A randomised study comparing post-operative rehabilitation. J Bone Joint Surg Br. 2005. 87:76–81.

17. Simmermacher RK, Bosch AM, Van der Werken C. The AO/ASIF-proximal femoral nail (PFN): a new device for the treatment of unstable proximal femoral fractures. Injury. 1999. 30:327–332.

18. Lindsey RW, Teal P, Probe RA, Rhoads D, Davenport S, Schauder K. Early experience with the gamma interlocking nail for peritrochanteric fractures of the proximal femur. J Trauma. 1991. 31:1649–1658.

19. Barton TM, Gleeson R, Topliss C, Greenwood R, Harries WJ, Chesser TJ. 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. J Bone Joint Surg Am. 2010. 92:792–798.

20. Chung YK, Hwang JH, Kim HK. The treatment of peritrochanteric fracture of femur with proximal femoral nail: comparative study with dynamic hip screw. J Korean Hip Soc. 2007. 19:167–175.

21. Im GI. Treatment of unstable intertrochanteric fractures: a comparison of proximal femoral nail and dynamic hip screw. J Korean Hip Soc. 2007. 19:36–44.

22. Willoughby R. Dynamic hip screw in the management of reverse obliquity intertrochanteric neck of femur fractures. Injury. 2005. 36:105–109.

23. Park SY, Yang KH, Yoo JH, Yoon HK, Park HW. The treatment of reverse obliquity intertrochanteric fractures with the intramedullary hip nail. J Trauma. 2008. 65:852–857.

24. Simmermacher RK, Ljungqvist J, Bail H, et al. The new proximal femoral nail antirotation (PFNA) in daily practice: results of a multicentre clinical study. Injury. 2008. 39:932–939.

25. 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. 41:1292–1296.

26. Kammerlander C, Gebhard F, Meier C, et al. Standardised cement augmentation of the PFNA using a perforated blade: A new technique and preliminary clinical results. A prospective multicentre trial. Injury. 2011. 42:1484–1490.

27. Erhart S, Schmoelz W, Blauth M, Lenich A. Biomechanical effect of bone cement augmentation on rotational stability and pull-out strength of the Proximal Femur Nail Antirotation™. Injury. 2011. 42:1322–1327.

28. Lim JM, Kim JI, Oh JS, Suh KT, Ahn JM, Kang DJ. Comparison of the compression hip screw (CHS) and the proximal femoral nail antirotation (PFNA) for intertrochanteric femoral fracture. J Korean Fract Soc. 2010. 23:360–366.

29. Kim YC, An KC, Kim KY, et al. Treatment of osteoporotic unstable intertrochanteric fractures: comparative study between using dynamic hip screw and additional trochanter stabilizing plate. J Korean Orthop Assoc. 2005. 40:741–748.

30. Kim JH, Park JH, Kim HS, et al. Methods to increase the effectiveness of trochanteric stabilizing plate for unstable femoral intertrochanteric fractures with greater trochanteric fracture: fixation of greater trochanter with wire and screw. J Korean Hip Soc. 2007. 19:58–63.

31. Yoo JH, Yang KH, Park SY, Won JH, Yoon HK. The treatment of unstable reverse oblique intertrochanteric fractures with proximal femoral nail (PFN). J Korean Orthop Assoc. 2005. 40:733–740.