Study on Surgical Management of Intertrochanteric Fractures of Femur with 95 Degrees Angle Blade Plate


Vol 2 | Issue 3 | Sep - Dec 2014 | page:12-16 | Kiran Kalaiah, Vivek N Savsani,  Harish U,  Sunil Kumar P C, Kaladagi P S


Author: Kiran Kalaiah[1], Vivek N Savsani[1],  Harish U[2],  Sunil Kumar P C[1], Kaladagi P S[1]

[1] Mysore Medical College & Research Institute

[2] Registrar,R.N Cooper Hospital,Mumbai.

Institute at which research was conducted: Mysore Medical College And Research Institute,Mysore.
University Affiliation of Thesis: Rajiv Gandhi University Of Health Sciences Karnataka.
Year of Acceptance: 2013.

Address of Correspondence
Dr. Harish U
S/o NO.3 2nd Main 7th Cross Amarjyothinagar, Vijayanagar, Bangalore, Karnataka - 560040
Email: 77harish36@gmail.com


 Abstract

Background: Intertrochanteric fractures are seen more commonly in the elderly. They occur commonly in osteoporotic bone. They are 3-4 times more common in women than in men. Although relatively uncommon, intertrochanteric fractures also occur in the young, most commonly in men after high energy injuries. By definition, Intertrochanteric fracture includes any fracture from the extra capsular part of the neck of the femur to a point 5 cm distal to the lesser trochanter. In the earlier days, intertrochanteric fractures were treated conservatively as these fractures unite invariably. Internal fixation of trochanteric fractures is a life saving measure in the elderly.There are many options available for internal fixation of trochantric fractures like dynamic hip screw(DHS),dynamic condylar screw(DCS),GAMMA nail,proximal femoral nail,95 degree angle blade plate etc. Our aim in this study is to evaluate surgical and functional outcome of 95° angle blade plate in treatment of , intertrochanteric fractures.
Methods: 20 patients,13 male,7 female. The mean age was 59 years with intertrochanteric fracture of femur were treated by open reduction and internal fixation with 95 degrees angle blade plate.
Results: Evaluation of cases using Kyle Criteria: Results were evaluated by Kyle criteria. 30% (6 patients) scored excellent results, 45% (9 patients) had good results, 15% (3 patients) had fair results and 10% (2 patients) had poor results. 2 patients had implant failure which needed re-doing.
Evaluation of cases according to anatomical outcome: 75% patients had a good result and 25% had fair result. Shortening of more than 1 cm was noted in 2 patients, varus angulation was noted in 4 patients, restriction of hip movements was noted in 5 patients and knee movement restrictions were noted in 1 patient.
Conclusion: The 95 degrees angle blade plate is a suitable option for the treatment of intertrochanteric fractures and subtrochanteric fractures.
Keywords: Intertrocantric fracture, 95 degrees angle blade plate.

                                                        THESIS SUMMARY                                                             

Introduction

Intertrochanteric fractures are seen more commonly in the elderly. They occur commonly in osteoporotic bone.1 Most of them result from a simple fall from standing height.  They are 3-4 times more common in women than in men. Though the energy is low, comminution of the fracture is usually seen due to osteoporosis. Although relatively uncommon, intertrochanteric fractures also occur in the young, most commonly in men after high energy injuries. A cadaver study has shown that the energy required to break this tough bone is very high in young adults. By definition, Intertrochanteric fracture includes any fracture from the extra capsular part of the neck of the femur to a point 5 cm distal to the lesser trochanter. Osteoporotic hip fracture is increasingly recognized as a growing problem in Asia as per the Asian Audit Report, 2009. It is estimated that the incidence of hip fracture will rise from 1.66 million in 1990 to 6.26 million by 2050. Also by 2050, more than 50% of all osteoporotic fractures will occur in Asia. Among elderly patients, hip fractures are associated with an in-hospital mortality of 7-14 %.10,11 In the earlier days, intertrochanteric fractures were treated conservatively as these fractures unite invariably. But this method is associated with high mortality and morbidity rates, 30% of elderly patients die within 1 year of fracture. After 1 year, patients resume their age-adjusted mortality rate. Current guidelines recommend that surgeons perform hip fracture surgery within 72 hours of injury as observational studies suggest earlier surgery is associated with better functional outcome and lower rates of non-union, shorter hospital stays and duration of pain and lower rates of complication and mortality. Internal fixation of trochanteric fractures is a life saving measure in the elderly. Proper precautions are to be taken during surgery to prevent complications like coxa vara deformity, shortening, limited hip movements and secondary osteoarthritic changes in the hip. Post-fracture rehabilitation is equally necessary. Early post-operative ambulation and physiotherapy is crucial and the best approach for the patient. The overall goal is returning of patient to pre-morbid level of function.

Materials and Methods

The present study includes 20 cases of intertrochanteric fracture of femur in adult patients above 16 years of age irrespective of sex treated by open reduction and internal fixation with 95 degrees angle blade plate, in the Department of Orthopaedics at K.R Hospital, Mysore, attached to the Mysore Medical College & Research Institute, Mysore, from November 2011 to October 2013, selected on the basis of purposive sampling (Judgment sampling) method. The average age incidence was 59 years. 13 males and 7 females. Among them the minimum age was 17 years and maximum age noted was 80 years. 45% of the patients were in the age group of 61 - 70 years with the mean age of 54 years for males and 67 years for females. Predominantly males were affected. Fall from standing height was the most common mechanism of injury. Type II fractures were the most common. The average duration of hospital stay was 20.15 days. 12 patients had fracture on the right side. And 8 patients had a fracture on the left side. In our study 7 fractures were Boyd and Griffin's type II fractures, followed by 6 cases of type III, 4 cases of type I and 3 cases of type IV. . The final results were evaluated by  Kyle criteria, anatomical outcome.

Results

Results were evaluated by Kyle criteria, anatomical outcome.
Evaluation of cases using Kyle Criteria: In our study, 30% (6 patients) scored excellent results, 45% (9 patients) had good results, 15% (3 patients) had fair results and 10% (2 patients) had poor results. 2 patients had implant failure which needed re-doing.

Evaluation of cases according to anatomical outcome:
In our study, 75% patients had a good result and 25% had fair result. Shortening of more than 1 cm was noted in 2 patients, varus angulation was noted in 4 patients, restriction of hip movements was noted in 5 patients and knee movement restrictions were noted in 1 patient.

Conclusion

Hip fractures are the leading cause of morbidity and mortality in the elderly. Intertrochanteric fractures are a common injury, more commonly seen in elderly females and arising out of trivial fall. Patients with trochanteric fractures are bed-ridden, which leads to severe health problems and reduced quality of life which increases the burden on the care-givers. Patients with trochanteric fractures undergoing early surgery have an improved ability to return to independent living and prevention of complications of prolonged immobilisation. The 95 degrees angle blade plate can be used for both stable and unstable intertrochanteric fractures, but the final outcome is dependent on various factors such as the type of fracture, the condition of the medial wall, the bony architecture, and the co-morbid conditions of the patient, the operative technique, implant position and post-operative care. The position of the implant should be such that the tip of the blade should be in the lower half of the femoral head and the blade should pass below the superior cortex of the neck. This study shows that the 95 degrees angle blade plate offers a reliable and effective alternative for the treatment of trochanteric fractures.
The 95 degrees angle blade plate is a stable and acceptable implant for the treatment of intertrochanteric fractures.

Bibliography

1. Cleveland M, Bosworth DM, Thompson FR, Wilson Hj Jr, Ishizuka T. A ten-year analysis of intertrochanteric fractures of the femur. J Bone Joint Surg Am. 1959 Dec;41-A:1399–1408.
2. Courtney AC, Wachtel EF, Myers ER, Hayes WC. Age-related reduction in the strength of the femur tested in a fall-loading configuration. J Bone Joint Surg Am. 1995 Mar;77(3):387–395.
3. Laros GS. Intertrochanteric fractures. In: Evarts CM. Surgery of the musculoskeletal system. 1st ed., New York: Churchill Livingstone. 1983;2(5):123-148.
4. Hwang LC, Lo WH, Chen WM, Lin CF, Huang CK, Chen CM. Intertrochanteric fractures in adults younger than 40 years of age. Arch Orthop Trauma Surg. 2001;121(3):123-6.
5. Robinson CM, Court-Brown CM, McQueen MM, Christie J. Hip fractures in adults younger than 50 years of age. Epidemiology and results. Clin Orthop Relat Res. 1995 Mar;(312):238-46.
6. Boyd HB, Griffin LL. Classification and Treatment of Trochanteric Fractures. Arch Surg. 1949;31B:190-203.
7. Mithal A, Dhingra V, Lau E. The asian audit: Epidemiology, costs and burden of osteoporosis in Asia. Beijing, China: An International Osteoporosis Foundation (IOF) publication. 2009.
8. Dhanwal DK, Dennison EM, Harvey NC, Cooper C. Epidemiology of hip fracture: Worldwide geographic variation. Indian J Orthop. 2011 Jan;45(1):15-22.
9. Cooper C, Campion G, Melton LJ 3rd. Hip fractures in the elderly: A world-wide projection. Osteoporos Int. 1992 Nov;2(6):285-9.
10. Bottle A, Aylin P. Mortality associated with delay in operation after hip fracture: observational study. Br Med J. 2006;332:947-51.
11. Weller I, Wai EK, Jaglal S, Kreder HJ. The effect of hospital type and surgical delay on mortality after surgery for hip fracture. J Bone Joint Surg Br 2005;87:361-6.
12. Canale ST, Beaty JH, editors. Campbell's Operative Orthopaedics, 11th ed. Elsevier; 2007.
13. Orosz GM, Magaziner J, Hannan EL, Morrison RS, Koval K, Gilbert M, McLaughlin M, Halm EA, Wang JJ, Litke A, Silberzweig SB, Siu AL. Association of timing of surgery for hip fracture and patient outcomes. JAMA 2004 April;291(14):1738-43.
14. Lyons AR. Clinical outcomes and treatment of hip fractures. Am J Med 1997;103:51-63.
15. Simunovic N, Devereaux P J, Bhandari M. Surgery for hip fractures: Does surgical delay affect outcomes?. Indian J Orthop 2011;45:27-32.
16. Ganz R, Thomas RJ & Hammerle CP: Trochanteric fracture of the femur. Treatment and results. Clin Orthop Relat Res. 1979;138:30-40.
17. Peltier LF. Orthopedics: A History and Iconography.
18. Rajasekaran S, Kamath V, Dheenadhayalan J. Intertrochanteric fractures. In: Sivananthan S, Sherry E, Warnke P, Miller MD, editors. Mercer's Textbook of Orthopaedics and Trauma.10th ed. Hodder Arnold; 2012.
19. Ponseti IV. History of Orthopaedic Surgery. Iowa Orthop J. 1991;11:59–64.
20. Jewett EL. One- piece Angle Nail for Trochanteric Fractures. J Bone Joint Surg Am. 1941;23:803-810.
21. Moore AT. Blade-plate internal fixation for intertrochanteric fractures. J Bone Joint Surg Am, 1944 Jan 01;26(1):52-62.
22. Jaslow IA. Blade-plate fixation Report of a case. J Bone Joint Surg Am, 1947 Jul 01;29(3):814-816.
23. Wilson JN. Chapter 29. Fractures and Joint Injuries. Watson – Jones. 6th ed. B.I. Churchill Livingstone 1992;2:878-973.
24. Evans EM. The Treatment of Trochanteric Fractures of the Femur. J Bone Joint Surg Am, 1949;31B:190-203.
25. Murray RC, Frew JFM. Trochanteric Fractures of the Femur. J Bone Joint Surg Am, 1949;31B:204-219.
26. Arden GP, Walley GJ. Treatment of Intertrochanteric Fractures of the Femur by Internal Fixation. Br Med J. 1950;2:1094-1097.
27. Taylor GM, Neufeld AJ, Nickel VL. Complications and failures in the operative treatment of intertrochanteric fractures of the femur. J Bone Joint Surg Am. 1955;37-A(2):306-316.
28. Sahlstrand T. The Richards Compression Screw and Sliding Hip Screw System in the Treatment of Intertrochanteric Fractures. Acta Orthop. Scand. 1974;45:213-219.
29. Dimon JH, Hughston JC. Unstable Intertrochanteric Fractures of the Hip. J Bone Joint Surg Am. 1967;49A:440-450.
30. 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 Surg Am. 1970;52(3):457-67.
31. Mann RJ. Avascular necrosis of the femoral head following intertrochanteric fractures. Clin Orthop Relat Res. 1973;(92):108-15.
32. Sarmiento A. Unstable Intertrochanteric Fractures of the Femur. Clin Orthop Relat Res. 1973;92:77-85.
33. Sgarbi G, Salvatore P, Zangrando A, Gemmati U. Osteosynthesis using the blade-plate method and early weight-bearing in pertrochanteric fractures. Chir Organi Mov. 1977;63(6):621-6.
34. Whatley JR, Garland DE, Whitecloud T 3rd, Wickstrom J. Subtrochanteric Fractures of the Femur: Treatment with ASIF Blade Plate Fixation. Southern Medical Journal 1978;71:1372-1375.
35. Jacobs RR, McClain O, Armstrong HJ. Internal fixation of intertrochanteric hip fractures: a clinical and biomechanical study. Clin Orthop Relat Res. 1980;146:62-70.
36. Kinast C, Bolhofner BR, Mast JW, Ganz R. Subtrochanteric fractures of the femur. Results of treatment with the 95 degrees condylar blade-plate. Clin Orthop Relat Res. 1989 ;238:122-30.
37. Senter B, Kendig R, Savoie FH. Operative stabilization of subtrochanteric fractures of the femur. J Orthop Trauma. 1990;4(4):399-405.
38. Brien WW, Wiss DA, Becker V Jr, Lehman T. Subtrochanteric femur fractures: a comparison of the Zickel nail, 95 degrees blade plate, and interlocking nail. J Orthop Trauma. 1991;5(4):458-64.
39. Curtis MJ, Jinnah RH, Wilson V, Cunningham BW. Proximal femoral fractures: a biomechanical study to compare intramedullary and extramedullary fixation. Injury. 1994 Mar;25(2):99-104.
40. Vanderschot P, Vanderspeeten K, Verheyen L, Broos P. A review on 161 subtrochanteric fractures--risk factors influencing outcome: age, fracture pattern and fracture level. Unfallchirurg. 1995 May;98(5):265-71.
41. Van Meeteren MC, van Rief YE, Roukema JA, van der Werken C. Condylar plate fixation of subtrochanteric femoral fractures. Injury. 1996 Dec;27(10):715-7.
42. Siebenrock KA, Müller U, Ganz R. Indirect reduction with a condylar blade plate for osteosynthesis of subtrochanteric femoral fractures. Injury. 1998;29 Suppl 3:C7-15.
43. Skoták M, Behounek J, Krumpl O. Solution of Intertrochanteric Fractures of Proximal Femur by 130 degrees Angled Blade Plate - Longterm Results. Acta Chir Orthop Traumatol Cech. 1999;66(6):336-41.
44. Lundy DW, Acevedo JI, Ganey TM, Ogden JA, Hutton WC. Mechanical comparison of plates used in the treatment of unstable subtrochanteric femur fractures. J Orthop Trauma. 1999 Nov;13(8):534-8.
45. Chinoy MA, Parker MJ. Fixed nail plates versus sliding hip systems for the treatment of trochanteric femoral fractures: a meta-analysis of 14 studies. Injury. 1999;30:157–63.
46. Becker CE, Keeler KA, Kruse RW, Shah SA. Complications of Blade Plate Removal. Journal of Pediatric Orthopaedics. 1999;19(2):188-193.
47. Segal LS. Custom 95 degree condylar blade plate for pediatric subtrochanteric femur fractures. Orthopedics. 2000 Feb;23(2):103-7.
48. Haidukewych GJ, Israel TA, Berry DJ. Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg Am. 2001 May;83-A(5):643-50.
49. Sadowski C, Lübbeke A, Saudan M, Riand N, Stern R, Hoffmeyer P. Treatment of Reverse Oblique and Transverse Intertrochanteric Fractures with Use of an Intramedullary Nail or a 95° Screw-Plate: A Prospective, Randomized Study. J Bone Joint Surg Am. 2002; 84:372-381.
50. Neher C, Ostrum RF. Treatment of subtrochanteric femur fractures using a submuscular fixed low-angle plate. Am J Orthop (Belle Mead NJ). 2003 Sep;32(9 Suppl):29-33.
51. SuriyajakyuthanaW. Intertrochanteric fractures of the femur: results of treatment with 95 degrees Condylar Blade Plate. J Med Assoc Thai. 2004 Dec;87(12):1431-8.
52. Yoo MC, Cho YJ, Kim KI, Khairuddin M, Chun YS. Treatment of unstable peritrochanteric femoral fractures using a 95 degrees angled blade plate. J Orthop Trauma. 2005 Nov-Dec;19(10):687-92.
53. Kregor PJ, Obremskey WT, Kreder HJ, Swiontkowski MF. Unstable pertrochanteric femoral fractures. J Orthop Trauma. 2005 Jan;19(1):63-6.
54. Bredbenner TL, Snyder SA, Mazloomi FR, Le T, Wilber RG. Subtrochanteric fixation stability depends on discrete fracture surface points. Clin Orthop Relat Res. 2005 Mar;(432):217-25.
55. Giannoudis PV, Schneider E. Principles of fixation of osteoporotic fractures. J Bone Joint Surg Br. 2006 Oct;88(10):1272-8.
56. Rahme DM, Harris IA. Intramedullary nailing versus fixed angle blade plating for subtrochanteric femoral fractures: a prospective randomised controlled trial. J Orthop Surg (Hong Kong). 2007 Dec;15(3):278-81.
57. Yong CK, Tan CN, Penafort R, Singh DA, Varaprasad MV. Dynamic Hip Screw Compared to Condylar Blade Plate in the Treatment of Unstable Fragility Intertrochanteric Fractures. Malaysian Orthopaedic Journal 2009;3(1):13-18
58. Kesemenli CC, Memişoğlu K, Necmioğlu S, Kayıkçı C. Treatment of intertrochanteric femur fractures with 95° fixed-angle blade plate in elderly patients. European Journal of Orthopaedic Surgery & Traumatology 2010 Dec;20(8):629-634.
59. Forward DP, Doro CJ, O'Toole RV, Kim H, Floyd JCP, Sciadini MF, Turen CH, Hsieh AH, Nascone JW. A Biomechanical Comparison of a Locking Plate, a Nail, and a 95° Angled Blade Plate for Fixation of Subtrochanteric Femoral Fractures. J Orthop Trauma 2012;26(6):334-340.
60. Laghari MA, Makhdoom A, Pahore MK, Memon A. Subtrochanteric Femoral Fractures Treated by Condylar Plate, A study of 56 cases. JLUMHS 2012;11:2.
61. Parker MJ, Das A. Extramedullary fixation implants and external fixators for extracapsular hip fractures in adults. Cochrane Database Syst Rev. 2013 Feb 28;2:CD000339.
62. Chaurasia BD. Human Anatomy Volume 2. 4th ed. CBS; 2004.
63. Standring S, editor. Gray's Anatomy. 39th ed. Elsevier; 2005.
64. Netter FH. Atlas of Human Anatomy. 5th ed. Elsevier; 2010.
65. Crock HV. An Atlas of the Arterial Supply of the Head and Neck of the Femur in Man. Clin Orthop. 1980;152:17-27.
66. Chung SMK. The Arterial Supply of the Developing Proximal End of the Human Femur. J Bone Joint Surg Am. 1976;58:961-965.
67. Trueta J, Harrison MHM. The Normal Vascular Anatomy of the Femoral Head in Adult Man. J Bone Joint Surg Br. 1953;35:442-460.
68. Hayes WC. Biomechanics of Falls and Hip Fracture in the Elderly. In: Apple DF, Hayes WC, editors. Prevention of Falls and Hip Fractures in the Elderly. Rosemont, Illinois: American Academy of Orthopaedic Surgeons; 1994.
69. Cummings SR, Nevitt MC. A Hypothesis: The Causes of Hip Fractures. J Gerontol 1989;44:107-111.
70. Kaufer H, Matthews LS, Sonstegard D. Stable Fixation of Intertrochanteric Fractures. J Bone Joint Surg Am. 1974;56A:899-907.
71. Yong CK, Tan CN, Penafort R, Singh DA, Varaprasad MV. Dynamic Hip Screw Compared to Condylar Blade Plate in the Treatment of Unstable Fragility Intertrochanteric Fractures. Malaysian Orthopaedic Journal 2009;3(1):13-18
72. Singh AK. Management of Trochanteric Fractures. Indian J Orthop 2006;40:100-102.
73. Babulkar SS. Management of Trochanteric Fractures. Indian J Orthop 2006;40:210-218.


How to Cite this Article: Kalaiah K, Savsani V N,  Harish U, Kumar S, Kaladagi P S. Study on Surgical Management of Intertrochanteric Fractures of Femur with 95 Degrees Angle Blade Plate. Journal Medical Thesis 2014  Sep-Dec ; 2(3):12-16

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