Implications of Surgery or Fracture Related Morbidity Factors in the Outcome of Pertrochanteric Fractures Managed by Dynamic Hip Screw


Vol 2 | Issue 1 | Jan - Apr 2014 | page 24-30 | Dube AS, Goel S, Rastogi A, Vashisht A, Swarop A


Author: Abhay Shankar Dube[1], Siddharth Goel[1], Anurag Rastogi[1], Arun Vashisht[1], Arunim Swarop[1]

[1] Subharti Medical College
Institute at which research was conducted: Subharti Medical College.
University Affiliation of Thesis: Swami Vivekanand Subharti University, Meerut, U.P
Year of Acceptance: 2012.

Address of Correspondence
Dr. Siddharth Goel
Dept. of Orthopaedics, Subharti Medical College,
Bye – Pass Road, Meerut, 250002.
Email: drsiddharthgoel@gmail.com


 Abstract

Background: Pertrochanteric fractures are the most commonly operated fracture type globally but have the highest fatality rate post-operatively. The conservative management of these fractures is associated with almost double the rate of fatality. The dynamic hip screw (DHS) plate system continues to be the preferred implant as “collapse to stability” remains a distinct advantage. This study was to analyze the implications of “surgeon unrelated” morbidities like age, gender, fracture type, degree of comminution, osteopenia and “surgeon related” morbidities like fracture reduction, screw placement and tip apex distance (TAD).
Methods: 96 fractures in mean 68.43 years subject age were selected, the fractures classified. The uninjured hip used to grade pre-existing osteopenia by Singh's index and compare neck shaft angle restored after surgery. All fractures operated by a standard lateral proximal femoral approach and fixed with 135° DHS. Post- operative skiagrams done to assess union and complications like varus mal-union or unacceptable fracture collapse and implant related complications like loosening, cut-out, intra-articular migration, impingement or breakage.
Results: 55.21% presented with medial, posterior or lateral wall comminution. 75.86% had grade 3 and 4 osteopenia and 18 patients had grade 1, 2 or 5 osteopenia. Valgus (68) and anatomical (14) reduction was the commonest choice of acceptance by operating surgeon in both stable and unstable fractures and this type of reduction showed least varus collapse or screw cut out risk as compared to varus (3) and medialized (11) reduction.
Conclusion: The 'surgery unrelated' morbidity factors did not affect the risk of varus collapse or screw cut out. The overall varus collapse, malunion or cut out risk correlated significantly with 'surgery related' factors related to screw placement and quality of reduction accepted. The central-central screw placement was found ideal for minimum 'cut out risk'.
Key Words: morbidity factors, pertrochanteric fractures, DHS, TAD.

                                                        THESIS SUMMARY                                                             

Introduction

The term extra-capsular fracture neck femur is now better defined as pertrochanteric fracture which extends from extacapsular basal neck to lesser trochanter before the anatomical differentiation of the medullary canal.
The evolution of surgical expertise and implant design makes surgery the choice in the management of these fractures. The conservative management of these fractures is associated with almost double the rate of fatality as compared to the operative group. Even in those who survive the risk of mortality by conservative treatment, the inevitability of complications like uncontrolled shortening and varus collapse leave behind considerable morbidity.
Even with the advantage of other modified sliding hip screw systems and cephalo-medullary nail, the use of dynamic hip screw (DHS) is preferred worldwide as “collapse to stability” remains a distinct advantage. The goal of surgery is strong and stable fixation to maintain reduction during union. Varus collapse and associated implant cut out in head region and intraarticular penetration remain the major unacceptable outcome especially in fractures rendered unstable due to posteromedial or lateral wall comminution, subtrochanteric extension, reverse oblique type, and intracapsular extension of fracture line.

Aims and Objectives

This study was conducted to analyze whether the personality of a pertrochanteric fracture treated with DHS in all types of these fractures is related to the patient, the fracture or the surgery by studying:

1. The surgery unrelated factors like fracture instability, degree of comminution, osteopenia, femoral neck shaft angle, irrespective of age and gender, which should concern the surgeon as possible factors influencing clinical and radiological outcome and to correlate their contribution in possibly increasing the morbidity.
2.The surgery related factors like implant placement, compromised reduction, inability to take care of comminution and provision of lateral buttressing.

Methods

Out of 1350 internal fixations by DHS done, between 2007 to 2012 for pertrochanteric fractures, 111 patients above the age of 50 years (mean age 68.43 years; range 50-100 years) were randomly selected for this study; 15 were excluded from the study (14 had died a natural death following post operative recovery; 1 had early post-operative infection). Remaining 96 fractures were operated by a standard lateral proximal femoral approach by 5 senior surgeons after optimizing existing medical illness in the patient and were studied over a period of two years. The exclusion criteria were:
1.Patients with significant medical or neuro-psychiatric co-morbidity.
2.Contralateral hip disease or deformity.
3.Any significant postoperative complication, e.g. infection, wound dehiscence, intra-operative nerve damage.
4.Intertrochanteric fractures managed with an implant other than DHS.
5.Patients who expired or were lost in followup.
The preoperative underlying morbid factors related to age, gender, smoking habit, alcohol excess, drug intake, fracture type, displacement and its plane, degree of comminution and osteopenia were observed to study the fracture personality. The pre-operative anteroposterior (AP) skiagram of pelvis with both hips and lateral (Lat) skiagrams of the fractured hip were studied to assess if the fracture was unstable, by authors individually to minimize inter-observational variance. Boyd and Griffin, Evans, Kyle's and Gustilo and AO/OTA classification systems were all used to identify instability related to posteromedial and lateral wall comminution and reverse obliquity. The image of uninjured hip was used to grade pre-existing osteopenia by Singh's index and comparison of neck shaft angle restored after surgery. The post-operative skiagrams in AP/Lat projection were studied to observe:
1.Type of reduction preferred by the surgeon – whether anatomical, medialized or valgus.
2.Screw placement in the quadrant of the head as accepted by the surgeon and seen in the AP/Lat post operative skiagram. The central placement of screw i.e. that placed in the axis of femoral neck in both AP/Lat skiagram was taken as the reference in assessing the quadrant of screw placement in the femur head.
3.TAD index achieved was measured as a sum of the distance between the tip of implant and head of femur in AP/Lat views. The change in magnification of the images was accounted for by the method standardized by Baumgartner et al.
4.Any post-operative change in neck shaft angle from that measured on the contralateral side for comparing the restored angle after surgery.
5.The ability of the implant to support any existing comminution of the lateral wall and to stabilize any major comminution in the medial wall especially a large displaced lesser trochanter fragments.
Post operative follow up and evaluation
Whether the fracture remained stably reduced and the implant did not migrate during union were evaluated by assessing post operative skiagrams for:
Occurrence of any union related complications like varus mal-union or unacceptable fracture collapse.
Implant related complications like loosening, cut-out, intra-articular migration, impingement or breakage.
Correlations of the observed outcome with the surgery related or unrelated morbidity factors were done using statistical tools like Chi-square test, Z test for proportion and ANOVA single factor test to establish their role.

Results

By the different classification system, 53 fractures were labelled ‘unstable’ and 43 fractures were ‘stable’ and out of 86 fractures in the 50-80 years age group, 48 were unstable and 38 were stable and 67 (77.01%) patients were in Singh’s index osteopaenia grade 3 and grade 4. Only 8 (8.33%) fractures had lateral wall comminution. Medial and posterior wall comminution of various magnitudes, although their degree of comminution could not be quantified, was seen in 53 fractures (55.21%). The neck shaft angle ranged from 1180 to 1400 (average 129.010), that in females ranged 1180 to 1400 (average 129.230) and in males from 1200 to 1400 (average 128.830). The surgeons “accepted” 68 fractures in valgus reduction, 14 fractures in anatomical reduction, 11 fractures with medialization and 3 fractures in varus reduction. In the 8 (8.33%) fractures which had lateral wall comminution, no mechanical or biological reconstruction of the lateral wall was done. Medialization was done in these patients for stability. No bone grafting was done for biological augmentation of comminution. Augmentation with a derotation screw or wire done as the need be. A correlation of the TAD with screw tip position in the quadrant of femoral head was observed. Among the 79 patients who had ideal (<25mm) TAD, the best accepted position was central-central (47) followed by inferior-posterior (19) followed by superior-anterior (8), central-posterior (5) in this order. Only two cases had unacceptable TAD (>30mm).
Follow up
The neck shaft angle achieved after reduction and its shift from the target contra-lateral neck shaft angle was evaluated along with the difference of TAD achieved from the ideal (<25 mm) in early follow up before union (average 6.84 weeks) and after clinical union (average 11.7 weeks). The shift from ideal TAD at union in the fractures with no change in neck shaft angle in the anatomical reduction group clearly indicated a controlled collapse. In the valgus reduction group, 61% fractures showed some loss in their valgus reduction but only 17.6% showed further shift in TAD at union, none with a cut out. In the varus reduction group, whether or not medialized, all fractures progressed to further varus with progressive shift of TAD with consequential ‘cut out risk’ in 20% fractures. In fractures with medialized reduction with valgus neck-shaft angle there was initial loss of valgus and shift in TAD but none further at union. In the group of 79 fractures with TAD < 25mm, 74 (93.7%) showed satisfactory union without varus collapse, 4 (5.06%) fractures showed union with varus collapse all with initial medialization, and 1 patient showed non-union with screw migration after initial medialization. In the group of 15 fractures with ‘acceptable’ TAD of 26-30mm, 11(73.3%) satisfactory union with 2 fracture showing some varus collapse was observed and 4 had non-union with screw migration. In the 2 patients with ‘unacceptable’ TAD more than 30mm, both with initial medialization, non-union with screw migration was seen.
The non-union observed in 7 (7.29%) fractures strongly correlated to two factors:
a) medialized reduction and
b) TAD >25mm (85.7%).

Conclusion

Despite variations in the normal neck shaft angle, a 1350 DHS is a preferred solution for stabilization of peritrochanteric fractures. A larger angle would risk the placement of screw tip in superior quadrant and a narrower angle would interfere with control of collapse by getting jammed. Good stable reduction in both anteroposterior and lateral view, valgus positioning, if required in maintaining good screw position even in osteoporotic situations, the target of central screw placement, non-acceptance of varus or medialization, central or inferior screw positioning in the anteroposterior view,  use of contra-lateral un-fractured hip image as a template for post-operative reconstruction and the judicious use of adjuvant, derotation cancellous screw are some of the important strategies the surgeon must use to achieve a good TAD and successful union without the risk of varus collapse and cut out. For the fractures with reverse obliquity, the use of DHS remains debatable. The limitations of this study are that the study of factors related to pre-existing osteoporosis in affecting the results is not feasible in this short-term study of associated morbidity, and the role of smoking, alcohol intake, associated medical co-morbidities in affecting outcome also needs a different study module.

Clinical Message

The risk of varus collapse or screw cut out relate to 'surgery related' factors concerned with reduction and screw placement. 'Surgery unrelated' morbidity factors like age, gender, fracture type, degree of comminution and osteopenia do not affect the outcome. The central-central screw placement is ideal for minimum cut out risk.

Bibliography

1. Lavella DG.: Fractures of Hip. Campbell's Operative Orthopaedics-ed. Canale ST, Beaty JH; Mosby Elsevier 10th ed. 2003; 3 (52): 2873-2938.
2. Horowitz BG.: Retrospective analysis of hip fractures. Surg Gynecol Obstet 1966; 123:565.
3. Guvena M, Yavuzb U, Kadıoglu B, Akmand B, Kılınc V, Oglu E, Unayc K, Altıntas F.: Importance of screw position in intertrochanteric femoral fractures treated by dynamic hip screw. Orthopaedics & Traumatology : Surgery & Research 2010; 96:21-27.
4. Boyd HB, Griffin LL.: Classification and treatment of trochanteric fractures. Arch Surgical 1949;58-85.
5. Evans E.: The treatment of trochanteric fracture of the femur. J Bone & Joint Surgery 1949; 31 (B):190-203.
6. Kyle RF, Gustilo RB, Premer RF.: Analysis of 622 intertrochanteric hip fractures: a retrospective and prospective study. J Bone & Joint Surgery 1979; 61 (A):216-221.
7. Orthopaedic Trauma Association.: Fracture and dislocation compendium. J Orthop Trauma 1996; 10 (1):31-35.
8. Koval KJ, Cantu RV.: Intertrochanteric fracture. In Rockwood & Green's: fractures in adult. 6th ed. 2006; 2 (45):1794-1825.
9. Kaufer H.: Mechanics of the treatment of hip injuries. Clinical Orthopaedic Related Res 1980; 146:53.
10. Baumgaertner MR, Solberg BD.: Awareness Of Tip-Apex Distance Reduces Failure Of Fixation Of Trochanteric Fractures Of The Hip. J Bone & Joint Surgery [Br] 1997; 79-B:969-971.
11. Gullberg B, Johnell O, Kanis JA.: World-wide prediction of hip fractures. Osteoporosis International 1997; 7:407-13.
12. Osteoporosis Society of India.: Action Plan Osteoporosis: Consensus statement of an expert group, New Delhi. 2003.
13. Cooper C, Campion G, Melton LJ 3rd.: Hip fractures in the elderly: a world-wide projection. Osteoporosis International 1992; 2:285-9.
14. Tsigaras H, MacDonald S.J.: Femoral neck fractures: epidemology and result and controverses in treatment. Controverses in hip surgery. Ed. Robert B. Bourne: Oxford university press, NY: Indian edition 2006; 123-124.
15. Xu L, Lu A, Zhao X, Chen X, Cummings SR.: Very low rate of hip fractures in Beijing, People Republic of China. The Beijing Osteoporosis Project. American Journal of Epidemiology 1996; 144:901-7.
16. Dhanwal DK, Dennison EM, Harvey NC, Cooper C.: Epidemiology of hip fracture: Worldwide geographic variation. Indain J Orthopaedics 2011Jan-March; 45 (1):15-22.
17. Hedlund R, Lindgren U, Ahlbom A.: Age and sex specific incidence of femoral neck and trochanteric fractures. An analysis based on 20538 fractures in Stockholm Country, Sweden. Clinical Orthopaedics and Related Research 1987; 222:132-9.
18. Farmer ME, White LR, Brody JA, Bailey KR.: Race and sex differences in hip fractures incidence. American Journal of Public Health 1984; 74:1374-80.
19. Hinton RY, Smith GS.: The association of age, sex and race with the location of proximal femoral factures in the elderly. J Bone & Joint Surgery (Am) 1993; 75:752-9.
20. Forsen L, Bjornal A, Bjartveit K et al.: Interaction between current smoking, leanness and physical inactivity in thr prediction of hip fractures. J of Bone and Mineral Research 1994; 9:1671-8.
21. Law MR, Hackshaw Ak.: A meta-analysis of cigarette smoking, bone mineral density and risk of hip fracture: recognition of a major effect. BMJ 1997 June; 315-841.
22. Hoidrup S, Prescott E, Sorensen TIA, Gottschau A, Lauritzen JB, Schroll M, Gronbaek M.: Tobacco smoking and risk of hip fractures in men and women. Int. J. of Epidem. 1999; 29 (2):253-259.
23. Olofsson H, Byberg L, Mohsen R, Melhus H, Lithell H, Michaëlsson K.: Smoking and the risk of fracture in older men. J Bone Miner Research 2005 July; 20 (7):1208-1215.
24. Kanis JA, Johnell O, Oden A, Johansson H, De Laet C, Eisman JA, Fujiwara S, Kroger H.: Smoking and fracture risk: a meta-analysis. Osteoporosis Int 2005; 16:155-162.
25. Kanis J, Johnell O, Gullberg B et al.: Risk factors for hip fractures in men from southern Europe: The MEDOS study. Osteoporosis International 1999; 9:45-54.
26. Hoidrup S, Gronbaek M, Gottschau A, Lautritzen JB, Schroll M.: Alcohol intake, beverage preferences and risk in hip fractures in men and women. Copenhagen Center for Prospective Population Studies. American journal of Epidemiology 1999; 149:993-1001.
27. Gregg EW, Cauley JA, Seely DG, Ensrud KE, Bauer DC.: Physical activity and osteoporotic fracture risk in older women. Study of Osteoporotic fracture Research Group. Animals of Internal Medicine 1998; 129:81-8.
28. Kujala UM, Kaprio J, Kannus P, Sarna S, Koskenvuo M.: Physical activity and osteoporotic fracture risk in men. Archives of Internal Medicine 2000; 160:705-800.
29. Coupland C, Wood D, Cooper C.: Physical inactivity in an independent risk factor for hip fracture in elderly. Journal of Epidemiology and Community Health 1993; 47:41-3.
30. Bernstein J, Grisso JA, Kaplan FS.: Body mass and fracture risk: A study of 330 patients. Clinical Orthopaedics and Clinical Research 1999; 364:227-30.
31. Pruzansky ME, Turano M, Luckey M, Senie R.: Low body weight as a risk factor for hip fractures in both black and white women. Journal of Orthopaedic research 1989; 7:192-7.
32. Langlois JA, Harris T, Looker AC, Madans J.: Weight change between age 50 years and old age is associated with risk of hip fractures in white women age 67 years and older. Archives of Internal Medicine 1996; 156:989-94.
33. Hemenway D, Azrael DR, Rimm EB, Feskanich D, Willett WC.: Risk factors for hip fractures in US men age 40 through 75 years. American Journal of Public Health 1994; 84:1843-5.
34. Chaupy MC, Arlot ME, Duboeuf F.: Vitamin D3 and calcium to prevent hip fractures in elderly women. New England Journal of Medicine 1992; 327:1637-42.
35. Forsen L, Meyer HE, Midthjell K, Edna TH.: Diabetes mellitus and the incidence of hip fractures in the elderly: results from the Nord-Trondelag Health Survey. Diabetologia 1999; 42:920-5.
36. Ramnemark A, Nyberg L, Borssen B, Olsson T, Gustafson Y.: Fractures after stroke. Osteoporosis International 1998; 8:92-5.
37. Desai KB, Ribbans WJ, Taylor GJ.: Incidence of five common fracture type in an institutional epileptic population. Injury 1996; 27:97-100.
38. Felson DT, Anderson JJ, Hannan MT, Milton RC, Wilson PW, Kiel DP.: Impaired vision and hip fractures. The Framingham Study. J of American Geriatric Society 1989; 37:495-500.
39. Faulker KG, Cummings SR, Black D, Palmero L, Glucer CC, Genant HK.: Simple measyrement of femoral geometry predicts hip fractures: the study of osteoporotic fractures. J of Bone and Mineral Research 1993; 8:1211-1217.
40. Douglas S, Bunyan A, Chiu KH, Twaddle B, Maffulli N.: Seasonal variation of hip fractures at three latitudes. Injury 2000; 31:11-19.
41. Tian TP, Chen Y, Loew WK, Hsu W, Howe TS, Png MA.: Neck-Shaft Angle of Femur for X-Ray Fracture Detection. Injury 2002; 33-38.
42. Ogata K, Goldsand EM.: A simple biplanar method of measuring femoral anteversion and neck shaft angle. J Bone Joint Surgery (Am) 1979; 61:846-851.
43. Saikia KC, Bhuyan SK, Rongphar R.: Anthropometric study of the hip joint in northeastern region population with computed tomography scan. Indian J Orthopaedics 2008 July; 42 (3):260-6.
44. Rawal BR, Ribeiro R, Malhotra R and Bhatnagar N.: Anthropometric measurements to design best-fit femoral stem for the Indian population. Indian J Orthopaedics 2012 Jan-Feb; 46 (1):46–53.
45. Muller ME, Nazarian S, Koch P, Schatzker J.: The comprehensive classification of fractures of long bones. Springer, Berlin Heidelberg NY 1990.
46. Kulkarni G.S, Limaye R, Kulkarni M, Kulkarni S.: Current Concept review Intertrochanteric Fractures. Indian Journal Of Orthopaedics 2006 Jan; 40 (1):16-23.
47. Lavelle DG.: Fractures and Dislocations of the Hip. Campbell's Operative Orthopaedics-Ed Canale ST, Beaty JH; Mosby Elsevier 11th ed. 2008; 3 (52):3237-3271.
48. Schatzker J, Tile M.: Intertrochanteric fractures. The rationale of operative fracture care, Springer 3rd ed. 2005; 357-365.
49. Keene GS, Parker MJ, Pryor GA.: Mortality and Morbidity after hip fractures. British Medical Journal 1993; 307:1248-50.
50. Holt G, Smith R, Duncan K, Finlayson DF, Gregori A.: Early mortality after surgical fixation of hip fractures in the elderly: an analysis of data from the scottish hip fracture audit. J Bone Joint Surgery (Br) 2008; 90 (B):1357-1363.
51. Tronzo RG.: Hip nails for all occasions. Orthopaedic Clinics of North America – Symposium on fractures of the hip- part 1 1974 July; 5 (3):479-491.
52. Koval KJ, Zuckerman JD.: Hip Fracture a Practical Guide to Management. Springer-Verlag 2005; 134.
53. Jansen JS, Michaelsen M.: Trochanteric fractures treated with McLaughlin osteosynthesis. Acta Orthop Scand 1975; 46:795-803.
54. Koval KJ, Zuckerman JD.: Ambulatory ability after hip fracture: a prospective study in geriatric. Clincal Orthopaedic Related Res 1995 Jan; 310:150-159.
55. Gundle R, Gargan MF, Simpson HRW.: How to minimize failures of fixation of unstable intertrochanteric fractures. Injury 1995 Nov; 26 (9):611-614.
56. Baumgaertner MR, Curtin SL, Lindskog DM and Keggi JM.: The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone & Joint Surgery (Am) 1995; 77:1058-1064.
57. Subramaniyam KN, Puranik G, Ali MA, Sahni V.: Radiographic assessment of dynamic hip screw fixation. J Bone & Joint Surgery (Br) 1995; 88 (B).
58. Ehmke LW, Fitzpatrick DC, Krieg JC, Madey SM, Bottlang M.: Lag screw for hip fractures fixation : Evaluation of migration resistance under simulated walking. Journal of Orthopaedic Research 2005; 23:1329-1335.
59. Lindsey RW, Ahmed S, Overturf S, Tan A, Gugala Z.: Accuracy of Lag Screw Placement for the Dynamic Hip Screw and the Cephalomedullary Nail. Orthopeadics 2009 July; 32 (1):488.
60. Cleveland M, Bosworth DM, Thompson FR, Wilson HJ Jr, Ishizuka T.: A 10 year analysis of intertrochanteric fractures of the femur. J Bone Joint Surgery (Am) 1959; 411:1399-1408.
61. Ward FO.: Human Anatomy. London, Renshaw 1838.
62. Frankel VH, Hirsch C.: The femoral neck: an experimental study of function, fracture mechanism. J. Bone Joint Surg.[Brit.] 1960; 42 (B):633.
63. Mulholland RC, Gunn DR.: Sliding screw plate fixation of intertrochanteric femoral fractures. J Trauma 1972 July; 12 (7):581-591.
64. Doherty JH Jr, Lyden JP.: Intertrochanteric fracturesofthe hiptreatedwiththe hipcompressionscrew:analysis of problems. Clin Orthop Relat Res 1979 June; 141:184-7.
65. Wolfgang GL, Bryant MH, O'Neil JP.: Treatment of intertrochanteric fracture of the femur using sliding screw plate fixation. Clin Orthop 1982; 163:148-58.
66. Simpson AHRW, Varty K, Dodd CAF.: Sliding hip screws: modes of failure. Injury 1989 July; 20:227-31.
67. Davis TRC, Sher JL, Horsman A, Simpson M, Porter B, Checketts RG.: Intertrochanteric femoral fractures: mechanical failures after internal fixation. J Bone & Joint Surgery (Br) 1990; 72 (1):26-31.
68. Parker MJ.: Valgus reduction of trochanteric fractures. Injury 1993 May; 24:313-316.
69. Pajarinen J, Lindahl J, Savolainen V, Michelsson O, Hirvensalo O.: Femoral shaft medialisation and neck-shaft angle in unstable pertrochanteric femoral fractures. International Orthopaedics (SICOT) 2004; 28:347–353.
70. Thomas AP.: Dynamic hip screws that fail. Injury 1991; 22:45–46.
71. Parker MJ.: Cutting-out of the dynamic hip screw related to its position. J Bone Joint Surg 1992; 74 (B):625.
72. Parmar V, Kumar S, Aster A, Harper WH.: Review of methods to quantify lag screw placement in hip fracture fixation. Acta Orthop. Belg 2005; 71:260-263.
73. Parker MJ.: Trochanteric hip fractures: Fixation failure commoner with femoral medialization, a comparison of 101 cases. Acta Orthop Scand 1996; 67:329-32.
74. Gotfried Y.: The lateral trochanteric wall: a key element in the reconstruction of unstable pertrochanteric hip fractures. Clin Orthop Relat Res. 2004; 425:82-86.
75. Gupta R: Meta-analysis of prevalence of hypertension in India. Indian Heart J. 1997 Jan-Feb; 49 (1):43-48.
76. Oger P, Katz V, Lecorre N, Beaufils P.: DHS plates for trochanteric fractures: Impaction analysis according to fracture type. Revue de Chirurgie orthopaedics 1998; 84:539-545.
77. Dieter ML, Baumgaertner MR.: Unstable intertrochanteric hip fractures in the elderly. J Am Acad Orthop Surg. 2004 May/June; 12 (3):179-190.
78. Bhatti A, Abbasi AJ.: Intra pelvic total migration of sliding screw in intertrochanteric fracture. J Coll Physicians Surg Park 2007 Jun; 17 (6):371-373.
79. Hsueh KK, Fang CK, Chen CM, Su YP, Wu HF, Chiu FY.: Risk factors in cutout of sliding hip screw in intertrochanteric fractures: an evaluation of 937 patients. Int Orthop 2010 Dec; 34 (8):1273-1276.
80. Malhotra N & Mithal A.: Osteoporosis in Indians. Indian J Med Res 2008 March; 127:263-268.
81. Singh M, Nagrath AR, Maini PS.: Changes in trabecular pattern of the upper end of the femur as an index of osteoporosis. J Bone & Joint Surgery (Am) 1970; 52:457-467.
82. Ilsar I, Har-Even A, Brocke L, Safran O, Leichter Z, Foldes AJ, Mattan Y and Liebergall M.: Evaluation Of Proximal Femur Bone Mineral Density Using Digitalized Plain X-Ray Radiography Of The Hip. J Bone & Joint Surgery 2005; 87 (B):376-377.
83. Leighton R K.: Fractures of the neck of femur. In Rockwood & Green's: fractures in adult, LWW. 6th ed. 2006; 2 (44):1753-1791.
84. Sahota.: Osteoporosis and the role of vitamin D and calcium. British Geriatric Society 2000; 29:301-304.
85. Bischoff-Ferrari HA, Dietrich T, Orav EJ, Dawson-Hughes B.: Higher 25-hydroxyvitamin D concentrations are associated with better lower extremity function in both active and inactive persons aged 60years. American J Clinical Nutrition 2004; 80 (3):752-758.
86. Bischoff-Ferrari HA, et al.: Positive association between 25-hydroxyvitamin D levels and bone mineral density: a population-based study of younger and older adults. American J Clinical Nutrition 2004; 116 (9):634-639.
87. Wicherts IS, Van Schoor NM, Boeke AJ et al.: Vitamin D status predicts physical performance and its decline in older persons. J Clinical Endocrinal Metab 2007; 92 (6):2058-2065.
88. Bischoff-Ferrari HA, Willett WC, Wong JB, Giovannucci E, Dietrich T, Dawson-Hughes B.: Fracture prevention with Vitamin D supplementation. JAMA 2005; 293 (18).
89. Bischoff-Ferrari HA, Willett WC, Wong JB, Stuck AE et al.: Prevention of non-vertebral fractures with oral Vitamin D and dose dependency: a meta-analysis of randomized controlled trials. Arch Internal Medicine 2009; 169 (6):551-61.
90. Dawson-Hughes B, Harris SS, Krall EA, et al. Effect of calcium and Vitamin D and supplementation on bone density in both men and women 65 years age or older. N England J Med 1997; 337:670-6.
91. Kalyani RR, Stein B, Valiyil R, Manno R, Maynard JW, Crews DC.: Vitamin D treatment for the prevention of falls in older adults: systemic review and meta-analysis. J American Geriatics Society 2010; 58 (7):1299-1310.
92. Rizzoli R, Boonen S, Brandi ML, Burlet N, Delmas V, Reginster JY.: The role of calcium and vitamin D in the management of osteoporosis. J Bone & Joint Surgery 2008; 42:246-249.
93. Hartholt KA, Oudshoorn C, Zielinski SM, Burgers PTPW, Panneman MJM, Beeck EdF, Patka P, Cammen TJM van der.: The Epidemic of Hip Fractures: Are We on the Right Track?. PLoS ONE 2011 July; 6 (7).
94. Russell TA.: Intertrochanteric fractures. In Rockwood & Green's: fractures in adult – Ed Bucholz RW, Court-Brown CM, Heckmen JD, Tornetta III P, LWW.7th ed. 2010; 2 (48):1597-1640.
95. Cummings SR, Navitt MC.: A Hypothesis: the causes of hip fractures. J Gerontol 1989; 44 (4):107-111.
96. Hopkinson-Woolley JA, Parker MJ.: Fracture of the Hip: does the type of fall really affect the site of fractures?. Injury 1998; 29 (8):585-587.
97. Vochteloo AJH' Burg BLSBVD, Mertens BJA' Niggebrugge AHP' Vries MRD, Tuinebreijer WE, Bloem RM, Nelissen RGHH, Pilot P.: Outcome in hip fractures patients related to anemia at admission and allogeneic blood transfusion: an analysis of 1262 surgically treated patients. BMC Musculoskeletal Disorders 2011; 12:262.
98. Gupta RK, Sangwan K, Kambo PJ, Punia SS, Walecha N.: Unstable trochanteric fractures: the role of lateral wall reconstruction. International Orthopaedics (SICOT) 2010; 34:125–129.
99. Koval KJ, Oh CK, Egol KA.: Does a traction-internal rotation radiograph help to better evaluate fractures of the proximal femur?. Bull NYU Hosp Jt Dis 2008; 66 (2):102-106.
100. Jensen JS.: Classification of trochanteric fractures. Acta Ortho Scand 1980 Oct; 51 (5):803-810.
101. Fung W, Jhonson A, Buhren V et al.: Classifying intertrochanteric fractures of proximal femur: does experience matter?. Med Princ Pract 2007; 16 (3): 198-202.
102. Bijlani RL.: Medical Research: all you wanted to know but did not know whom to ask. Jaypee Brothers Medical Publishers 2008.
103. Pervez H, Parker MJ, Vowler S.: Prediction of fixation failure after sliding hip screw fixation. Injury 2004; 35:994-998.
104. Wu CC, Shih CH, Lee MY.: Biomechanical analysis of location of lag screw of a dynamic hip screw in treatment of unstable intertrochanteric fractures. J Trauma 1996; 41:699-702.
105. Den Hartog BD, Bartal E, Cooke F.: Treatment of the unstable intertrochanteric fractures. Effect of the placement of the screw, its angle of insertion and osteotomy. J Bone Joint Surg (Am) 1991; 73:726-733.


How to Cite this Article: Dube AS, Goel S, Rastogi A, Vashisht A, Swarop A. Implications of surgery or fracture related morbidity factors in the outcome of pertrochanteric fractures managed by Dynamic Hip Screw.  Journal Medical Thesis 20134 Jan-Apr ; 2(1):24-30

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