A COMPARATIVE STUDY ON FUNCTIONAL, CLINICAL AND...
Transcript of A COMPARATIVE STUDY ON FUNCTIONAL, CLINICAL AND...
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A COMPARATIVE STUDY ON FUNCTIONAL, CLINICALAND RADIOLOGICAL OUTCOME OF UNSTABLE
INTERTROCHANTERIC FRACTURES MANAGED BYPROXIMAL FEMORAL NAILING VERSUS DYNAMIC HIPSCREW WITH TROCHANTERIC STABILISATION PLATE.
Submitted to
THE TAMILNADU Dr.M.G.R MEDICAL UNIVERSITY
CHENNAI-600032.
In partial fulfillment of the regulations
for the award of
M.S.(ORTHOPAEDIC SURGERY)
BRANCH-II
Govt.Kilpauk Medical College and Hospital,
Chennai-600010.
MAY 2018
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CERTIFICATE
This is to certify that the dissertation entitled “A COMPARITIVE
STUDY ON FUNCTIONAL, CLINICAL AND RADIOLOGICAL
OUTCOME OF UNSTABLE INTERTROCHANTERIC
FRACTURES MANAGED BY PROXIMAL FEMORAL
NAILING VERSUS DYNAMIC HIP SCREW WITH
TROCHANTERIC STABILISATION PLATE” is a bonafide work
done by Dr.S.KAVIN KUMAR in M.S BRANCH-II
ORTHOPAEDIC SURGERY at Government Kilpauk Medical
College,Chennai-600010, to be submitted to The Tamil Nadu Dr.M.G.R
Medical University, in partial fulfillment of the university rules and
regulations for the award of M.S. Degree Branch - II orthopaedic
surgery, under my supervision and guidance during the period from May
2015 to May 2018.
Prof.Dr.S.Senthil Kumar, Prof.Dr.S.Senthil Kumar,M.S.Ortho, D.Ortho, M.S.Ortho,D.Ortho,
UNIT CHIEF, Professor and Head of the Department,Dept. of Orthopaedics, Dept. of Orthopaedics,Govt.Kilpauk Medical College, Govt.Kilpauk Medical College& Hospital,Chennai-10. Chennai-10.
DEAN,
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Govt.Kilpauk Medical College & Hospital,Chennai-10.
DECLARATION
I solemnly declare that this dissertation “A COMPARATIVE
STUDY ON FUNCTIONAL, CLINICAL AND RADIOLOGICAL
OUTCOME OF UNSTABLE INTERTROCHANTERIC
FRACTURES MANAGED BY PROXIMAL FEMORAL NAILING
VERSUS DYNAMIC HIP SCREW WITH TROCHANTERIC
STABILISATION PLATE” was prepared by me at Govt.Kilpauk
Medical College and Hospital,Chennai-10 under the guidance &
supervision of Prof.Dr.S.Senthil Kumar, M.S.Ortho, D.Ortho.,
Professor of Orthopaedic Surgery, Govt. Kilpauk Medical College and
Hospital,Chennai-10.
This dissertation is submitted to The Tamil Nadu Dr.M.G.R
Medical University, Chennai in partial fulfillment of the University
regulations for the award of the degree of M.S.Branch-II Orthopaedic
Surgery.
Place : Chennai-10.
Date: (Dr.S.Kavin Kumar)
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ACKNOWLEDGEMENT
I express my utmost gratitude to Prof.Dr.P.Vasanthamani, M.D,D.G.O, MNAMS, DCPSY, M.B.A, Dean, Government Kilpauk MedicalCollege and Hospital for providing me an opportunity to conduct thisstudy.
I would like to express my heartfelt thanks to my belovedProf.Dr.S.Senthil Kumar, M.S.Ortho, D.Ortho, Professor and Head ofthe department for allowing me to choose this topic and his valuablesuggestions and guiding me in every step of mine to make this study asuccessful one.
I would like to sincerely thank Prof.Dr.S.Veera Kumar,M.S.Ortho, Professor of Orthopaedics, for his excellent guidance andencouragement during this study.
I would like to express my gratitude and reverence to my respectedAssociate Prof.Dr.R.Prabhakar, M.S.Ortho, whose constant supporthelped to complete this study.
I would like to thank Prof.Dr.R.Balachandran, M.S.Ortho,D.Ortho, Dept of Orthopaedics, Govt.Royapettah Hospital, Chennai forhis support.
I would like to thank all my Assistant ProfessorsDr.M.Arunmozhi Rajan, M.S.Ortho, Dr.R.Prabhakar Singh,M.S.Ortho, Dr.G.Mohan, M.S.Ortho, Dr.R.K.S.KarthikeyanM.S.Ortho, Dr.S.Prabhakar, M.S.Ortho, Dr.S.Maheshram,M.S.Ortho, Dr.A.Anandh, M.S.Ortho, Dr.R.Manoj Kumar,M.S.Ortho for their valuable advice and guidance.
I would like to thank all my colleagues and hospital staff for all thehelp they rendered.
I would like to thank all my patients for their full co-operation forthis study without whom this study would not have been possible.
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Last but not the least I thank the lord all mighty for making thisstudy a successful one and offer my sincere prayers to him.
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CERTIFICATE - II
This is to certify that this dissertation work titled “A COMPARITIVE
STUDY ON FUNCTIONAL, CLINICAL AND RADIOLOGICAL
OUTCOME OF UNSTABLE INTERTROCHANTERIC FRACTURES
MANAGED BY PROXIMAL FEMORAL NAILING VERSUS
DYNAMIC HIP SCREW WITH TROCHANTERIC STABILISATION
PLATE” of the candidate Dr.KAVIN KUMAR .S with registration Number
221512157 for the award of M.S in the branch of ORTHOPAEDIC
SURGERY. I personally verified the urkund.com website for the purpose of
plagiarism Check. I found that the uploaded thesis file contains from
introduction to conclusion pages and result shows 5 percentage of plagiarism
in the dissertation.
Guide & Supervisor sign with Seal.
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A COMPARATIVE STUDY ON FUNCTIONAL,CLINICAL & RADIOLOGICAL OUTCOME OF
UNSTABLE INTERTROCHANTERIC FRACTURESMANAGED BY PROXIMAL FEMORAL NAILING
VERSUS DYNAMIC HIP SCREW WITHTROCHANTERIC STABILISATION PLATE
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CONTENTS
SL.NO TITLE PAGE NO
1 INTRODUCTION 1
2 OBJECTIVE 4
3 OSTEOLOGY 5
4 ANATOMY 12
5 CLASSIFICATIONS 16
6 REVIEW OF LITERATURE 24
7 MATERIAL AND METHODS 28
8 INSTRUMENTATION 31
9 OPERATIVE PROCEDURE 34
10 OVERVIEW & ANALYSIS 46
11 COMPLICATIONS 55
12 CASE ILLUSTRATIONS 61
13 DISCUSSION 69
14 CONCLUSION 75
15 BIBLIOGRAPHY
16 PROFOMA
17 MASTER CHARTS
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INTRODUCTION
Most frequent fractures of proximal femur are intertrochanteric
fractures which involve upper end of femur between both trochanters
with or without extending into the upper femoral shaft1 occuring
commonly in geriatric patients.
Since general life expectancy of population has increased in the
past two decades incidence of fractures of proximal femur are also
increasing.
In 1990 of over all hip fractures 26% occurred in Asia. This is
expected to rise upto 37% in 2025 and 45% in 2050.2,3
Only moderate or minimal trauma is enough to cause proximal
femur fractures in gediatric patients. Simple self fall causes
intertrochanteric fractures in elderly people due to osteoporosis and
increased incidence of self fall with increasing age is due to decreased
muscle power, decreased reflexes, poor vision and labile blood pressure.
In younger patients it requires high energy trauma.
Intertrochanteric fracture line involves along extra capsular basilar
neck region to region along the lesser trochanter, undisplaced fractures
and fractures with intact posteromedial cortex are said to be stable.4
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Unstable contribute to about 50%-60% of all intertrochanteric
fractures.5,6
There are five variables described by Kaufer which are found to
affect the biomechanical strength of the repair. Bone quality and fracture
pattern which are surgeon independent along with Implant choice, quality
of fracture reduction and positioning of implant which are surgeon
dependent.8
Main weight bearing bone of lower limb is femur. Intertrochanteric
fractures cause patients to be bedridden for prolonged period of time and
they are more prone for urinary tract infection, respiratory tract infection,
bed sores and joint stiffness etc.
To avoid these complications operative treatment is indicated.
In 1930 Jawett nail was introduced by Jawett to provide immediate
stability of fracture segments and early mobilisation and is failed due to
lack of controlled impaction.
In 1950 first sliding screw was used by Earnest roll in Germany.
In 1962 Sliding device was modified by Masie to allow collapse
and impaction of fragments.
Dynamic hip screw was first produced by Richard manufacturing
company of USA.
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Condylocephalic intramedullary devices were introduced in 1966
by kuntscher later by Ender in 1970.
Reconstruction intramedullary nail for peritrochanteric and
subtrochanteric fractures were introduced by Russell Taylor in 1984.
Parker first advocated the importance of lateral wall in preventing
varus collapse.
Trochanteric fractures are treated with dynamic hip screw and
intramedullary nailing. Dynamic compression screw permits proximal
fragment to collapse.
Failure rates of DHS in unstable fracture is as high as 50% and in
stable fractures the value drastically reduces to 5%.9,10.
The aim of fixation of intertrochanteric fractures is to prevent
morbidity and mortality. Early mobilisation depends on surgical
construct.
Trochanteric stablisation plate act as adjuvant to DHS plate by
providing lateral buttress.7,11,12.
With this aim of stable surgical reconstruct of intertrochanteric
fracture this study was done to evaluate functional, clinical and
radiological outcome of unstable intertrochanteric fracture operated with
dynamic hip screw with trochanteric stabilisation plate and proximal
femoral nailing.
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OBJECTIVE
To compare the functional, clinical & radiological outcome of
unstable intertrochanteric fractures operated with proximal femoral
nailing versus dynamic hip screw with trochanteric stabilization plate.
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OSTEOLOGY
The longest and strongest bone of the body is femur. The parts of
proximal end of femur are head, neck, greater trochanter, lesser
trochanter, intertrochanteric line and intertrochanteric crest.
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Head of femur
Femoral head forms more than half of sphere, directed medially
upwards and forwards and forms hip joint by articulating with
acetabulam.
Neck of femur
Long axis of neck makes an angle of 125° to 135° with long axis of
the shaft and is termed as neck shaft angle and angle of 10°-30° with
frontal plane which is termed angle of femoral torsion/anteversion.
Calcar
Dense vertical plate of bone extending from the posteromedial
portion of the femoral shaft under the lesser trochanter and radiating
laterally to greater trochanter reinforcing the femoral neck
posteriomedialy. Calcar is thicker medially and thinner laterally.
Greater trochanter
A quadrangular prominence present at upper part of the junction
between neck and shaft. This posterosuperior part projects upwards and
medially beyond the level of neck. Most of the muscles of gluteal region
are inserted into greater trochanter.
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Lesser trochanter
Conical eminence directed medially and backwards and gives
attachment to primary flexor of thigh, the ilopsoas.
Intertrochanteric line
Prominent roughed ridge begins at anterosuperior angle of greater
trochanter continues with spiral line below. It marks the junction of
anterior surface of neck with the shaft of femur.
Intertrochanteric crest
Smooth rounded ridge begins above the posterosuperior angle of
greater trochanter and ends at lesser trochanter.
Intertrochanteric region
Area between greater and lesser trochanter characterized by dense
trabecular bone serves to transmit and distribute stress.
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Blood supply
Blood supply to proximal end of femur is described into three
major groups :
1. Extra capsular arterial ring at the base of neck of femur.
2. Reticular vessels by extra capsular arterial ring on the surface of
femoral neck.
3. Arteries of round ligament.
The extra capsular arterial ring is formed posteriorly and anteriorly
by branch of medial femoral circumflex artery and branch of lateral
femoral circumflex artery, respectively.
Reticular vessels or ascending cervical branches ascend on the
surface of neck of femur in anterior, posterior, medial and lateral groups.
Lateral group vessels are most important.
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These proximal vessels most vulnerable to injury in femoral neck
fracture. Ascending cervical vessels forms a less distinct ring called sub
synovial intra articular arterial ring, from this epiphyseal arteries
penetrate the femoral head.
Lateral epiphyseal arterial group being the most important supplies
lateral weight bearing portion of femoral head.
Trabecular system of proximal femur
In 1838 Ward described the trabecular system of proximal femur.
Trabeculations arise along the lines of force to which bone exposes
(Wolff’s law).
Tensile trabeculations and primary compressive trabeculations pass
via the neck of femur which is separated by sparse cancellous bone called
Ward’s triangle.
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Trabecular groups
1. Principle compressive group.
2. Principle tensile group.
3. Greater trochanteric group.
4. Secondary compressive group.
5. Secondary tensile group.
Grades of trabecular system (Singh’s grading system)
Singh’s index grades 1 to 6 are indication of osteoporosis.
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Grade 6
All types trabecular groups are visible in grade 6.
Grade 5
Secondary tensile trabecular group are almost absent in grade 5.
Grade 4
Secondary compressive trabecular group are completely resorbed
in grade 4.
Grade 3
There is break in the continuity of principle tensile trabecular
group near greater trochanter.
Grade 2
Principle compressive trabecular group appears to stand out
prominently other have resorbed more or less completely.
Grade 1
Principle compressive trabecular group is markedly reduced and is
no longer prominent.
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ANATOMY
Soft tissues of the hip joint:
Extensors
Gluteus maximus.
Origin: Posterior 1/3 rd of iliac crest, sacrum and coccyx.
Insertion: Iliotibial band and Gluteal tuberosity in posterolateral
aspect of femur.
Innervation: Inferior gluteal nerve.
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ABDUCTORS
Gluteus medius and gluteus minimus
Originates from entire wing of Ilium and inserted into greater
trochanter innervated by superior gluteal nerve
External rotators:
Piriformis
Originates from lateral margin of anterior aspect of sacrum and
greater sciatic foramen and inserted into tip of greater trochanter.
Obturator internus
Originates from obturator foramen and inserted into tip of greater
trochanter, innervated by sacral plexus.
Obturator externus
Originates from medial aspect of obturator foramen and inserted
into trochanteric fossa, innervated by obturator nerve.
Quadratus femoris
Originates from upper part of Ilium and inserted into
intertrochanteric crest, innervated by sacral plexus.
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Flexors
Psoas major:
Originates from lumbar vertebrae and inserted into lesser
trochanter.
Iliacus:
Originates from iliac fossa and inserted into lesser trochanter.
Other flexors of hip joint are Sartorius, pectineus and gracilis (also
an adductor).
Adductors
Adductor longus, adductor brevis, adductor magnus originate from
ischiopubic ramus, ischial tuberosity and obturator foramen. They insert
into linea aspera of femur and adductor tubercle, innervated by obturator
nerve.
Biomechanical contributions of muscle
Muscles attached to proximal and distal fragments of fracture
produces characteristic deformity.
Proximal segment: external rotation, flexion and abduction.
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Distal fragment: adduction with shortening and overrides fracture
fragments.
Screw has to be placed in posteroinferior or center of femoral
where bone density is high. The pull out strength of dynamic hip screw
is related to bone density of femoral head. Degree of comminution and
quality of the bone determines the fracture fixation stability.
Pathomechanics of fracture
If line of fracture is above the insertion of external rotators the
proximal segment is rotated internally so the fracture reduced by
internally rotating the distal fragment.
If fracture line is with subtrochanteric extension proximal fragment
will go for external rotation so fracture reduced by externally rotating the
distal fragment.
Angulations at fracture site
Load over the implant will be more and it cause fracture to collapse
and implant failure. Fracture collapse with implant failure occurs in
unstable intertrochanteric fracture with lack of posteromedial incongruity.
Intact lateral wall is must for controlled compression of proximal
fragment as it prevents the rotational and varus collapse of fracture
segment.
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CLASSIFICATIONS
Various classification systems for intertrochanteric fractures are
Evan’s -1949.
Boyd and Griffin’s – 1949.
Ramadier’s – 1956.
Decoulx and Lavarde’s – 1969.
Enders’ – 1970.
Tronzo’s – 1973.
Jensen’s – 1975.
Deburge’s – 1976.
Briot’s – 1980.
AO classification – 1981.
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Evans classification (1949)
Type I: Fracture line extends upwards and outwards from the
lesser trochanter (stable). Type I fractures can be further subdivided as:
Type Ia: Undisplaced two-fragment fracture
Type Ib: Displaced two-fragment fracture.
Type Ic: Three-fragment fracture without posterolateral support,
owing to displacement of greater trochanter fragment.
Type Id: Three-fragment fracture without medial support, owing
to displaced lesser trochanter or femoral arch fragment.
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Type Ie: Four-fragment fracture without postero-lateral and medial
support (combination of Type III and Type IV).
Type II: Fracture line extends downwards and outwards from the
lesser trochanter (reversed obliquity/unstable). These fractures are
unstable and have a tendency to drift medially.
Jensen’s modification of Evan’s Classification :
Class 1-Stable two part fractures (Evan’s 1a and 1b).
Class 2-Unstable three part fractures (Evan’s Ic and Id).
Class 3-Very unstable fractures (Evan’s Ie).
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Body and Griffin’s classification:
Type 1 : undisplaced,stable (two part).
Type 2 : unstable with posteromedial communition.
Type 3 : subtrochanteric extension into lateral shaft, extension of
the fracture distally at or just below the lesser trochanter.
Type 4 : subtrochanteric with intertrochanteric extension with
fracture lying in at least two planes.
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Kyle’s classification:
Type 1 : Undisplaced / uncomminuted.
Type 2 : Displaced, minimal communition, lesser trochanteric
fracture, varus.
Type 3 : Displaced, greater trochanteric fracture, comminuted,
varus.
Type 4 : Severely comminuted, subtrochanteric extension.
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OTA Classification
Orthopedic trauma association classification system classifies
intertrochanteric fracture as 3.1A femur, proximal trochanteric
A1 - simple peritrochanteric fracture.
A1.1 - fracture along intertrochanteric line.
A1.2 - fracture through greater trochanter.
A1.3 - fracture below lesser trochanter.
A2 - peritrochanteric multifragmentary fracture.
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A2.1 - fracture with one intermediate fragment.
A2.2 - fracture with several intermediate fragments.
A2.3 - fracture extends more than 1 cm below lesser trochanter.
A3 - intertrochanteric fracture.
A3.1- simple oblique fracture.
A3.2 - simple transverse fracture.
A3.3- multifragmentary fracture.
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Unstable fractures:
Posteromedial comminution -after reduction there is no medial
cortical continuity.
Fracture with comminuted lateral wall,
Four part fracture,
Displaced large fragment including lesser trochanter,
Reverse oblique- due to adductors distal fragment goes for medial
displacement,
Fractures with subtrochanteric extension.
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REVIEW OF LITERATURE
In 1949, Evan classified interochanteric fractures into stable and
unstable. Evans said that 72% of his fractures fixed in stable
configuration. In 28% stability wasn’t achieved.
14%-due to fracture pattern.
14%-reduction wasn’t achieved.
During 1960s-1970s unstable intertrochanteric fractures were
corrected by non-anatomic stable reduction techniques by medial
(Dimon&Hughston) valgus osteotomy or lateral (wayne- county)
displacement osteotomy. In Gargan, Bundle and Simpson study on 100
patients found more fixation failures hence they advocated that there is no
benefit from osteotomy and advised anatomic reduction.
Koval and Zuckerman studied the contribution of posteromedial
cortex for fracture stability and the need of fixing posteromedial fragment
with a lag screw or cerclage wire.
Apel et al. study implies that the posteromedial fragment is
important for mechanical stability in intertrochanteric fractures.
Setiobudi et al. studied clinical outcome of unstable with stable
intertochanteric fractures after treatment with dynamic hip screw. Though
DHS was associated with higher incidence of malunion and excessive
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impaction they found that DHS fixation provided comparable
postoperative outcome in unstable intertrochanteric fractures.
In Lee et al. study outcome of cement augmentation technique in
unstable intertrochanteric fractures was studied and concluded that
PMMA cemented DHS reduced the complications of screw sliding,
femoral shortening and varus collapse.
Gotfried studied that lateral trochanteric wall a keystone in
stabilizing proximal femoral fractures.
Madsen et al. studied DHS with trochanteric stabilizing plate had
better outcome with lesser incidence of secondary fracture displacement
than gamma nail and compression hip screw.
Variety of implants are available for fixation of intertrochanteric
fractures with variable success rate.
1. Sliding Hip screw.
2. Cephalomedullary Femoral Nail (PFN A, PFN A2, Reconstruction
Nail, Gamma nail).
3. Trochanteric Stabilization Plate.
4. Proximal Femoral Locking Compression Plate.
5. Medoff Sliding Plate.
6. Percutaneous Compression Plate (Gotfried) .
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Disadvantages of Sliding hip screw in unstable intertrochanteric
fractures:
1. Significant medial displacement of the shaft.
2. Due to excessive sliding of hip screw increased chance of screw
cutout.
3. Excessive collapse leading to varus malpositioning.
4. Single point fixation leading to rotation of proximal fragment.
Role of DHS WITH TSP in Unstable Intertrochanteric fractures:
Advantages
1. Easy learning curve.
2. Lateral buttress effect
3. Controlled impaction in unstable Intertrochanteric fractures.
4. Prevents excessive collapse and shortening.6
5. Prevents varus malpositioning.6
6. Two point fixation leading to increased rotation stability.
Disadvantages
1. Increase in operating time.
2. Load bearing device.
3. More blood loss.
4. Theoritical increase in chance of infection.
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Role of PFN in unstable Intertrochanteric fractures:
Advantages
Less operating time.
Minimal blood loss.
Shortened lever arm.
Load sharing device.
Less chances of screw cut.
Prevents excessive collapse and neck shortening.
Prevents varus malpositioning.
Increased rotational stability.
Disadvantages
Increased duration of learing curve.
Costlier implant.
Chances of injury to abductor mechanism.
Chances of screw cut-out in osteoporotic head.
Indirect technique of reduction where provision foranchoring the fractured Greater trochanter using S.S wire is notavailable.
“Z effect”: Lag screw backs out and Antirotation screwpenetrates the head.
Reverse “Z’ effect.
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MATERIAL AND METHODS
Study centre: Department of Orthopaedics,
Govt. Kilpauk Medical College Hospital,
Kilpauk, Chennai – 10.
Period of study: December 2016 to September 2017.
Study design:
PROSPECTIVE RANDOMIZED CONTROL TRAIL.
Randomisation:
Block randamoisation with varying block sizes with 2 treatment
groups and allocation is done with the help of opaque envelope.
SAMPLE SIZE:
Using the sample size formula for difference in two means
{z(alpha)+z(beta)}^2*(S.D) ^2*2
n= _______________________________________.
d^2
To find a clinically significant difference of 5 between the Harris
Hip Score of the 2 interventions at 5% alpha level and 80% power
of the study we needed 26 subjects in each group with a pooled
standard deviation of 6 (from the previous studies), with 10% loss
in follow up.
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Inclusion Criteria:
1. Clinical diagnosis of unstable trochanteric femur fracture.
(AO Type 31A2.1to 31A2.3)
2. Age >40 years and <75 years.
3. Both genders.
Exclusion criteria:
1. Compound fractures.
2. Pathological fractures.
3. Polytrauma patients.
4. Patients non ambulant before the fracture.
5. Previous surgery done on proximal femur.
6. Below 40 years of age.
7. Reverse oblique fractures and fractures with subtrochanteric
extension.
8. Patients with cognitive disorders, on steroids or
immunosuppressants.
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Investigations:
1. Radiological: Plain X-ray of the affected hip with femur in two
standard projections (AP & cross table lateral view).
2. Complete hemogram.
3. Renal function test.
4. Bleeding time & Clotting time.
5. Chest X-ray & Electrocardiogram.
6. If needed CT of concerned hip joint with 3D reconstruction.
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DHS WITH TSP INSTRUMENTATION
a b
mj
n
hi
g
dc
e f
kl
a. tap, b. long barreled triple reamer, c. shortbarreled triple reamer, d.trochanteric stabilization
plate, e.short barrel DHS plate, f.long barrel DHSplate, g.shaftguide, h.angled guide, i.T-handle, j.6.5mm cancellous screw, k.4.0 mm cancellous screw,
l.4.5 mm cortical screw, m.Richard’s screw, n.punch
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SPECIFICATIONS: PROXIMAL FEMORAL NAIL
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OPERATIVE PROCEDURE
Patient prepared on the morning of day of surgery. Single dose
preoperative antibiotic given after test dose. Under suitable anaesthesia
patient was placed on fracture table with unaffected leg in flexion and
abduction attitude by using lithotomy post . Affected leg placed in
traction boot and fracture reduced by traction & internal rotation/external
rotation along with adduction or abduction. C arm checked and placed in
optimal position relative to patient’s position to ensure better
visualization of fracture reduction in both Anteroposterior and lateral
projections.
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DHS WITH TSP:-
Reduction maneuver:
Closed reduction maneuver planned by using preoperative x-raysand perioperative C arm image fracture pattern. Fracture reduced byusing traction and internal or external rotation.
Surgical approach:
Under aseptic precautions affected limb painted and draped instandard fashion for hip surgery in supine position. Fracture site isexposed by standard lateral approach to hip joint. Skin and subcutaneoustissue incised, tensor fascia lata and vastus lateralis was split andproximal part of femur exposed. Inadequate reduction corrected under Carm guidance.
Approximately 2 cm below vastus ridge guide wire is insertedunder C arm guidance and it passed through CCD angle inferiorly in APview and central in lateral view. This allows correct placement of anti-rotation screw. 5mm beneath subcondral bone guide wire is placed. Thenguide wire length measured and by using triple reamer, reaming done andlag screw inserted.
To lag screw a 5 hole barrel plate fixed then it fixed to femoralshaft using cortical screws in 2nd and 5th hole of plate. TSP fixed to Ist, 3rd
and 4th hole using 4.5mm cortical screws. Guide wire inserted for 6.5 mmcancellous screw under C-arm guidance and Screw fixed after drillingwith appropriate drill bit. If necessary greater trochanter fixed by usingSS wire or 4mm cancellous screw. Drain inserted. By using vicryl vastuslateralis, tensor fascia lata and subcutaneous tissue closed and skin closedusing ethilon. Dressing applied.
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PROXIMAL FEMORAL NAIL:-
Skin incision made about 2-3cm over tip of greater trochanter
extending up to plumb line dropped from anterior superior iliac spine.
Entry made through modified medial portal entry with patient in fracture
table and traction applied to ipsilateral leg.
Guide wire inserted and serial reaming done according to
intraoperative chattering. Appropriate sized nail inserted.
Guide wires inserted and checked in both AP and lateral
projections. First 8mm lag screw placed and 6.3mm. anti-rotationscrew of
size 15mm less than lag screw fixed proximally.2×4.9mm locking screws
both fixed distally using distal aiming device and wound closed in layers.
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50
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52
DISTAL LOCKING SCREWS PLACED
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POST OP PROTOCOL:
* Intravenous antibiotics given for 2 days.
* From day 3 oral antibiotics and analgesics given for another one
week.
* Drain removal done on 2nd post operative day.
* Dressing changed on 2nd, 5th and 8th post operative day
* Sutures removed on 12th post operative day
* Immediate weight bearing initiated depending on the stability of
the construct in either group.
* Patients followed up monthly once for 3 months with serial x-rays
and x-rays at the end of 6th month.
* Harris hip score, radiological union and neck shaft angle were
assessed at the end of 6th month.
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GRADING:
SCORE GRADE
90-100 Excellent
80-89 Good
70-79 Fair
60-69 Poor
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OVERVIEW & ANALYSIS
The study was conducted in Government Kilpauk Medical College
& Hospital, Chennai from December 2016 to September 2017.
In 52 consecutive patients suffering from unstable intertrochanteric
fracture 26 were treated with DHS with trochanteric stabilization plate
and 26 were treated with proximal femoral nailing.
AO/OTA classification system used for patient selection. We
included AO31A2 fractures in our study.
The distribution of fractures
SL.NO TYPE OFFRACTURE
NUMBER OF PATIENTS
DHS WITH TSP PFN
1 31A2.1 5 5
2 31A2.2 14 12
3 31A2.3 7 9
5
14
7
02468
10121416
DHS WITH TSP
DHS WITHTSP 5
129
02
4
6
8
1012
14
PFN
PFN
56
GENDER DISTRIBUTION
SIDE OF FRACTURE
1313
PFN
MALE
FEMALE
12
14
DHS WITH TSP
MALE
FEMALE
1313
PFN
RIGHT
LEFT 1412
DHS WITH TSP
RIGHT
LEFT
57
Age wise distribution of patients is as follows:
SL.NO AGE GROUP (INYEARS)
NO.OF PATIENTS
DHS WITH TSP PFN
1 50 - 59 3 4
2 60 - 65 8 9
3 66 - 70 7 6
4 71 - 75 8 7
In our study 9 patients suffered from Type 2 Diabetes Mellitus, 14
patients suffered from systolic hypertension, 1 patient suffered from
coronary artery disease, 2 patients suffered from chronic kidney disease
and 3 patients had completed treatment for primary pulmonary
tuberculosis.
3
8
7
8
DHS WITH TSP
50-59
60-65
66-70
71-75
4
96
7
PFN
50-59
60-65
66-70
71-75
58
5
6
1
11
COMORBIDITIES /DHS WITH TSP
diabetes mellitus
hypertension
coronary artery disease
chronic kidney disease
primary pulmonarytuberculosis
4
8
2
1
COMORBIDITIES IN PFN
diabetes mellitus
hypertension
coronary artery disease
primary pulmonarytuberculosis
chronic kidney disease
59
Operative details of intertrochanteric fractures treated by dynamic
hip screw with trochanteric stabilization plate and proximal femoral
nailing.
SL.
NOVARIABLES
DHS WITH
TSPPFN
1 Mean time of operation after
fracture in days
7.6 7.2
2 Mean duration of operation 88 minutes 62.5minutes
3 Mean blood loss in ml 172.6 58.26
4 Mean size of lag screw 85mm 85mm
5 Mean size of anti-rotation screw 75mm 70mm
6 Mean duration of hospital stay in
days
6.9 5.1
7 Average duration for full weight
bearing
13.27 weeks 10.15weeks
In postoperative period 3 patients in DHS with TSP group had pain
in hip region and 5 patients in PFN group had pain in thigh region hence
weight bearing was delayed till radiological union occurred and
symptoms subsided.
60
Functional outcome by Harris hip score
COMPLICATIONS
Wound complications
2 patients in DHS with TSP and 1 patient in PFN had superficial
wound infection. These patients were diabetic. The infection controlled
with continuation of intravenous antibiotics and regular wound dressings.
4 patients (2 in each group) had fever on 4th postoperative day.
These patients were diagnosed to have urinary tract infection which
subsided with course of antibiotics.
7
5
14
16
21
01
0
2
4
6
8
10
12
14
16
18
DHS WITH TSP PFN
EXCELLENT
GOOD
FAIR
POOR
61
Complications related to implants and union:
In DHS WITH TSP
2 patients suffered from loosing of greater trochanter screw loosing
at 13 weeks and they were followed up for another 8 weeks of duration
till radiological union to occur then the screw was removed under spinal
anaesthesia.
Due to varus collapse 2 patients had shortening of <2cm. one
patient had persistent hip and another had persistent thigh pain. Weight
bearing was delayed in these patients, after radiological union the pain
was relieved
62
In Proximal Femoral Nail:
One patient had self fall 1 month following surgery and sustained
peri implant fracture just distal to the end of nail. Non union was found in
2 cases with no progressive radiological union in subsequent monthly
follow up.
We had difficulty in placing anti-rotation screw in 2 cases.
63
In that one patient lag screw was found to be backed out in 1st
month post operative x-ray.
The case was operated with implant exit followed by cemented
hemiarthroplasty in single sitting after ruling out all markers of infection
as per the institutional protocol.
64
COMPLICATIONS
SL.NO COMPLICATION DHS WITH TSP PFN
1 Superficial wound infection 2 1
2 Urinary tract infection 2 2
3 Varus collapse withshortening of >1cm
2 0
4 Persistent thigh pain 1 0
5 Persistent hip pain 1 2
6 Non union 0 2
7 Peri –implant fracture 0 1
Cross tables
Group * Gender(Cross tabulation)
Sex Total
Male Female
Group
DHS
with
TSP
Count 14 9 23
% within group 60.9% 39.1% 100.0%
PFN
Count 12 11 23
% within group 52.2% 47.8% 100.0%
TotalCount 26 20 46
% within group 56.5% 43.5% 100.0%
65
Group Statistics(age)
Group N MeanStd.
Deviation
Std. Error
Mean
Age
DHS with
TSP 23 65.65 5.757 1.200
PFN23 65.26 6.032 1.258
66
Group * OTA
GROUP*OTA (Crosstab)
OTA Total
1 2 3
Group
DHSwith TSP
Count 5 10 8 23
% withingroup
21.7% 43.5% 34.8% 100.0%
PFN Count 5 10 8 23
% withingroup
21.7% 43.5% 34.8% 100.0%
Total Count 10 20 16 46
% withingroup
21.7% 43.5% 34.8% 100.0%
Group * R/L
GROUP*R/L (Crosstab)
R/L Total
Right Left
Group DHSwith TSP
Count 12 11 23
% withingroup
52.2% 47.8% 100.0%
PFN Count 11 12 23
% withingroup
47.8% 52.2% 100.0%
Total Count 23 23 46
% withingroup
50.0% 50.0% 100.0%
67
NoComorbids
cormobids
DM HTN CAD PTB CKD Total
Group DHSwithTSP
Count 9 5 6 1 1 1 23
%within
group
39.130434 21.7391 26.0869 4.34782 4.34782 4.34782 100
PFN Count 8 4 8 0 2 1 23%with
ingroup
34.782608 17.3913 34.7826 0 8.69565 4.34782 100
Total Count 17 9 14 1 3 2 46
%within
group
36.95652 19.565 30.434 2.1739 6.52173 4.3478 100
Group * RadiologicalunionGROUP*RADIOLOGICAL UNION(Crosstab)
Radiologicalunion Total P value
evidence ofprogressive
callusformation infollow up x
rays
Noevidence of
callusformation infollow up x
rays
Group DHS withTSP
Count 23 0 23 .244
% withingroup
100.0% 0.0% 100.0%
PFN Count 21 2 23
% withingroup
91.3% 8.7% 100.0%
TOTAL Count 44 2 46
% withingroup
95.7% 4.3% 100.0%
68
Group * Neck shaft angle
GROUP*NECK SHAFT ANGLE (Cross tab)
Neckshaftangle Total PvalueNo
VarusVarus
Group DHSwithTSP
Count 21 2 23 0.244
% within group 91.3% 8.7% 100.0%
PFN Count 23 0 23
% within group 100.0%
0.0% 100.0%
Total Count 44 2 46
% within group 95.7% 4.3% 100.0%
NPar Tests
Group Statistics
Group N Mean Std.Deviation
Std. ErrorMean
Duration surgeryin minutes
DHS withTSP
23 88.09 7.874 1.642
PFN 23 60.30 5.850 1.220
Blood loss in(ml)
DHS withTSP
23 172.61 16.846 3.513
PFN 23 58.26 7.777 1.622
Harris hipfunction score
DHS withTSP
23 85.74 5.336 1.113
PFN 23 83.61 6.720 1.401
69
Mann-Whitney Test
Ranks
Group N Mean
Rank
P value
Harris hip
function score
DHS with TSP 23 25.80 0.243
PFN 23 21.20
Total 46
B/L ML DHS with TSP 23 35.00 .000
PFN 23 12.00
Total 46
Duration
surgery minutes
DHS with TSP 23 35.00 .000
PFN 23 12.00
Total 46
Full weight
bearing initiated
(weeks)
DHS with TSP 23 33.63 .000
PFN 23 13.37
Total 46
70
CASE ILLUSTRATIONS
Case 1. A 48 year old male
Preoperative x-ray Postoperative x-ray
3rd month follow up 6th month follow up
71
Active SLRT External rotation
Sitting crossed legInternal rotation
72
Case 2: A 50 year old male
Preoperative x-ray Post operative x-ray
3rd month follow up 6th month follow up
73
Standing Active SLRT
Flexion External rotation
74
Case 3: A 57 year old male
Preoperative x-ray Postoperative x-ray
1st month follow up 6th month follow up
75
Active SLRT External rotation
Internal rotation Sitting crossed leg
76
Case 4: A 68year old female
Preoperative x-ray Postoperative x-ray
3rd month follow up 6th month follow up
77
Active SLRT External rotation
Internal rotation Sitting crossed leg
78
DISCUSSION
Intertrochanteric femoral fractures contribute to more than half of
total hip fractures in elderly osteoporotic patients ageing over 60 years.
With increasing life expectancy due to advancements in medical care, the
incidence of intertrochanteric fractures are also increasing.
Fall from standing height is the most common mode of injury in
these patients. Diminished vision, reduced reflexes, poor muscle tone and
balance also contribute to the increased incidence in elderly.
Various modalities of treatments are available which include
dynamic hip screw, cephalomedullary nail, dynamic condylar screw,
cemented hemiarthroplasty with or without augmented calcar
reconstruction, proximal femoral locking plate and trochanteric
stabilization plate.
The ultimate goal of the treatment being early mobilization of the
patients preventing the complications of fracture disease.
Sliding hip screw is still most widely used implant for these cases.
But in unstable fractures due to posteromedial and lateral wall
communition it has the disadvantage of recurring varus collapse and
screw cut out. It also has a disadvantage of having only a single point
fixation in head and neck.
79
Advantages of dynamic hip screw with trochanteric stabilization
plate and proximal femoral nailing in unstable fractures are as follows
SL.NO DHS with TSP PFN
1 Easy learning curve. Less operating time
and minimal blood loss.
2 Lateral butteress effect Load sharing device.
3 Controlled impaction inunstable Intertrochanteric
fractures.
Shortened lever arm there by lessdeforming forces at the fracture
site.
4
Prevents excessive collapseand shortening.
Prevents excessive varus collapseand neck shortening.
5 Two point fixation leadingto increased rotation
stability.
Increased rotation stability andless chances of screw cut out in
osteoporotic head.
6 Prevents varusmalpositioning
Prevents varus malpositioning.
80
Our study was conducted in Govt. Kilpauk Medical College &
Hospital, Chennai. 52 consecutive patients of unstable itertrochanteric
fractures were treated with DHS with TSP and PFN in equal numbers by
random sampling the fractures were classified according to AO/OTA
classification and fractures of AO type 31A2.1 to 31A2.3 were included
in our study. All patients were followed up at least for a period of 6
months and were assessed for clinical, radiological and functional
outcome. The overall response rate was 88.46%.
The results were analyzed and observations of our study are as
follows,
1. Age : Most of patients in our study were in the age of >60 years of
age.
2. Gender : In DHS with TSP 12 male and 14 female patients. In PFN
13 male and 13 female patients.
3. Mode of injury : Fall from standing height (trivial fall) was most
common mode of injury.
4. Type of fracture : In DHS with TSP group 5 patients AO type
31A2.1, 14 patients of AO type 31A2.2 and 7 patients had AO type
31A2.3.
In PFN group 5 patients had AO type 31A2.1,12 patients had
AO31A2.2 type fracture and 9 patients had AO31A2.3
81
5. Side of fracture : In DHS with TSP group 14 patients had right and
12 patients had left side fracture. In PFN group13 had right and 13
patients had left side fracture.
6. Comorbidities : In DHS with TSP group 5 patients had type 2
Diabetes Mellitus,6 patients were suffering from systemic
hypertension, 1 patient had coronary artery disease, 1 patient
suffered from pulmonary tuberculosis 10 years back and one
patient was suffering from chronic kidney disease.
In PFN group 4 patients had type 2 Diabetes Mellitus, 8 were
suffering from systemic hypertension, 2 had pulmonary
tuberculosis in their past and one was suffering from chronic
kidney disease.
7. All patients had good pretrauma mobility and were ambulating
independently unassisted.
8. Patients were operated within 7.6 days in DHS with TSP group
and 7.2 days in PFN group on an average.
9. Mean operating time in DHS with TSP was 88 minutes and in PFN
was 62.5 minutes.
10. Mean blood loss in DHS with TSP 172.6ml and in PFN was 58.26
ml.
82
11. Mean lag screw was 85 mm both in DHS with TSP and in PFN.
Mean anti-rotation screw size was 75mm in DHS with TSP and in
PFN was 70mm.
12. Mean hospital stay was 6.9 days in DHS with TSP and in PFN was
5.1 days.
13. On 3rd postoperative day partial weight bearing was allowed on the
basis of construct stability and bone quality.
14. All patients treated with DHS with TSP allowed to full weight
bearing on an average of 13.27 weeks and patients treated with
PFN were allowed full weight bearing on an average of
10.15weeks.
15. On basis of Harris Hip Score the functional outcome of all patients
were assessed: In DHS with TSP group we had 7 excellent results,
14 good results and 2 fair results. In PFN group we had 5 excellent
results, 16 good results, 1 fair and 1 poor result.
16. Complications: 2 patients in DHS with TSP group one patient in
PFN group had superficial wound infection. 2 patients in each
group had urinary tract infection. 2 patients in PFN group and one
patient DHS with TSP group had persistent hip pain. One patient in
DHS with TSP group had persistent thigh pain. 2 patients had
loosening of greater trochanter screw. 2 patients had varus collapse
83
with shortening <2cm (1.3cm & 1.5cm). In PFN group one patient
had peri-implant fracture. 2 patients in PFN we had difficulty in
placing anti-rotation screw of them lag screw was backed out in
one patient during follow up and she was operated with implant
exit with cemented hemiarthroplasty (all 3 cases weren’t included
in analyzing final outcome). Non-union at fracture site was found
in 2 cases operated with PFN and these patients denied any further
intervention.
84
CONCLUSION
We conclude that there is no statistically significant difference
between patients operated with Dynamic Hip Screw with Trochanteric
Stabilization Plate and Proximal Femoral Nail in terms of radiological
union, varus collapse and functional outcome at six months follow up,
which is consistent with Rho et al study13 & Patil et al study15.
Statistically significant differences were noted with ‘P’ values less
than 0.05 in terms of duration of surgery, blood loss during surgery and
time taken to full weight bearing.
85
BIBLIOGRAPHY
1. Kumar R, Singh RN, Singh BN. Comparative prospective study of
proximal femoral nail and dynamic hip screw in treatment of
intertrochanteric fracture femur. J Clin Orthop Trauma.
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2. Gullberg B, Johnell O, Kanis JA. World Wide Projection for Hip
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Huddleston JM, et al. Secular Trends in Hip Fracture Incidence and
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4. Kyle RF, Gustilo RB, Premer RF. Analysis of six hundred and
twenty-two intertrochanteric hip fractures. J Bone Joint Surg Am.
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peritrochanteric fractures of the hip. J Bone Joint Surg Am.
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6. Lindskog DM, Michael RB. Unstable Intertrochanteric Hip
Fractures in the Elderly. J Am Acad Orthop Surg. 2004;12:179-90.
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7. Babst R, Martinet O, Renner N, Rosso R, Bodoky A, Heberer M, et
al. Die DHS - Abstützplattefürdie Versorgung der instabilen
proximalen Femur-frakturen. Schweizer Med Wochenschr.
1993;123:566-8.
8. Kaufer H. Mechanics of the treatment of hip injuries. ClinOrthop.
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9. Haidukewych GJ, Israel TA, Berry DJ. Reverse obliquity fractures
of the inter-trochanteric region of the femur. J Bone Joint Surg Am.
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10. Medoff RJ, Maes K. A new device for the fixation of unstable
pertrochanteric fractures of the hip. J Bone Joint Surg Am.
1991;73:1192-9.
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Dynamische Hüftschraube (DHS) mit Abstützplatte-einesichere
Osteosynthese-fürhochinstabile "reverse" trochantere Frakturen.
Chirurg. 1996;67:1166-73.
12. Von Hasselbach C, Witzel U. Die Schenkelhals-zuggurtungsplatte.
Chir Praxis. 1987;38:235-60.
13. Rho JY, Kim SB, Heo YM, Cho SJ, SikChae D, Lee WS. Proximal
Femoral Nail Antirotation versus Compression Hip Screw with
Trochanter Stabilizing Plate for Unstable Intertrochanteric Hip
Fractures.J Korean Fracture Society. 2010;23(2):161-6.
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14. Shetty A, Ballal A, Kumar A, Sadasivan, Hedge A. Dynamic Hip
Screw with Trochanteric Stablization Plate Fixation of Unstable
Inter-Trochanteric Fractures: A Prospective Study of Functional
and Radiological Outcomes. J Clin Diagnos Res. 2016;10(9):6-8.
15. Patil SN, Srinivas P.comparitive study between proximal femoral
nail and dynamic hip screw with trochanteric stabilising plate in
unstable intertrochanteric femur fractures. Int J Res Orthop 2017.
16. Jonnes C, Shishir SM, Najimudeen S. Type II Intertrochanteric
Fractures: Proximal Femur. Arch Bone Jt Surg. 2016;4(1):23-8.
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et al. Trigen Intertan Intramedullary Nail Versus Sliding Hip
Screw. J Bone Joint Surg Am. 2013;95:200-8.
18. Gupta RK, Sangwan K, Kamboj P, Sarabjeet SP, Walecha P.
Unstable trochanteric fractures: the role of lateral wall
reconstruction. Int Orthop (SICOT). 2010;34:125–9.
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88
PROFORMA
Name :
Age/Sex :
IP Number :
Address :
Contact Number :
Occupation :
Education :
Socioeconomic Status :
Date of Admission :
Date of Surgery :
Date of Discharge :
History :
1. Mode of injury : Road traffic accident / self fall at home / fallfrom height / pedestrian struck injury.
2. Presenting complaints:Pain –site/durationSwelling- site/extentDeformityDisturbances in function of hip & knee-movements/sensationsOther associated injuries – head injury/limbinjuries/ spinal injuries.
89
3. Co morbid illnesses:
SL.NO COMORBIDS DETAILS1 Diabetes mellitus2 Hypertension3 Coronary heart disease4 Renal disorder5 Seizures / neurological
disorder6 Dyslipedemia7 Bronchial asthma8 Endocrine disorder9 Chronic obstructive lung
diseases10 Hepatic disorder11 Tuberculosis12 Neoplastic disorders
4. Drug history: steroids / disease modifying anti- rheumatoid drugs /immunosuppressant
PAST HISTORY:
Similar injuries
Previous surgeries or hospitalizations
Any major illnesses
90
PERSONAL HISTORY:
SL.NO1 Diet Vegetarian / mixed2 Marital status Married / single3 Bowel and bladder habits Regular / altered4 Habits Smoking / alcohol/ tobacco/drug
addictions/others
OBSTETRIC AND GYNECOLOGICAL HISTORY:
TREATMENT HISTORY:
FAMILY HISTORY:
CLINICAL EXAMINATION:
GENERAL EXAMINATION:
Appearance:
Built:
Pallor:
Icterus:
Cyanosis:
Clubbing:
Pedal edema:
Lymphadenopathy:
VITALS:
1. Pulse2. BP3. Respiratory Rate4. Temperature
SYSTEMIC EXAMINATION:
Cardiovascular system :
91
Respiratory system :
Abdomen :
Central nervous system :
REGIONAL EXAMINATION:
RIGHT/LEFT HIP
OTHER INJURIES
X-RAY FINDINGS
3D CT RIGHT/LEFT HIP JOINT (IF NEEDED)
INVESTIGATIONS:
SL.NO INVESTIGATIONS RESULTS1 HB%2 TC3 DC4 P L B E M5 ESR6 BT/CT7 RBS8 UREA9 S.CREATININE10 ELECTROLYTES(Na , K )11 HBsAg12 VDRL13 CXR14 ECG15 BLOOD G/T16 URINE ROUTINE
FINAL DIAGNOSIS:
INITIAL TREATMENT GIVEN:
PLANNED SURGERY:
92
PROCEDURE NOTES:
POST OP PERIOD:
SL.NO FOLLOWUP
CLINICLFINDINGS
X-RAYFINDINGS
ADVICE
1 1ST MONTH2 3RD MONTH3 6TH MONTH
FUNCTIONAL OUTCOME:
Harris hip score at 6 months follow up: ………/100.
93
INDEX FOR MASTER CHART
1. MOI – Mode of Injury.
1. Self Fall.
2. Road Traffic Accident.
2. OTA classification
31A2.1-1
31A2.2-2
31A2.3-3
3. R/L
R-Right
L-Left
4. COMORBIDS
1. No comorbids
2. DM
3. HTN
4. CAD
94
5. TB
6. CKD
5. DOS mts- Duration of surgery in minutes
6. B/L ml- blood loss in ml
7. FWB (wks): full weight bearing in weeks
8. HHS- Harris hip function score
9. RA.UN: radiological union
1. Evidence of progressive callous formation in follow up x-rays
2. NoEvidence of progressive callous formation in follow up
x- rays
10. NSF- neck shaft angle
1. No varus
2. Varus (<125°)
95
Master Chart for DHS WITH TSPSL.NO NAME AGE/ SEX MOI OTA R/L COMORBID DOS
(Mts)B/L(Ml)
FWB(WKS)
HHS RU NSF
1 Rajendran 61/M 1 1 1 1 81 170 10.5 93 1 12 Devi 71/F 1 3 1 2 86 180 11.6 81 1 13 Kanthan 69/M 1 2 2 3 89 190 10.3 86 1 14 Muthu 53/M 2 3 2 2 93 200 12.6 82 1 15 Sekar 63/M 1 1 1 5 80 150 14.4 90 1 16 Chandra 70/F 1 2 2 1 97 150 11.3 82 1 17 Kaasinathan 55/M 2 3 1 2 101 160 12.3 75 1 28 Selvi 72/F 1 2 2 1 103 160 12.5 85 1 19 Siva 66/M 1 1 1 3 84 150 13.6 94 1 1
10 Mary 64/F 1 3 2 1 88 160 14.2 83 1 111 Chitra 63/F 1 2 1 2 87 180 15.2 90 1 112 Govindan 67/M 1 2 1 6 89 190 14.3 85 1 113 Neelakandan 67/M 1 3 2 1 90 200 13.6 81 1 114 Munusamy 65/M 1 3 2 2 84 180 14.2 77 1 215 Jeyaraj 75/M 1 2 1 1 82 170 12.6 86 1 116 Dhanalaksmi 62/F 1 1 1 4 81 160 14.3 92 1 117 Thangavel 69/M 1 2 2 1 78 150 14.5 88 1 118 Sivagami 63/F 1 3 1 3 80 160 13.2 81 1 119 Ravi 74/M 1 2 2 3 85 170 13.3 87 1 120 Dhanam 59/F 1 2 1 1 98 180 14.0 91 1 121 Durairaj 61/M 2 2 2 1 75 190 15.0 86 1 122 Parthiban 73/M 1 3 1 3 98 200 14.5 82 1 123 Seetha 68/F 1 1 2 3 97 170 13.4 95 1 1
96
Master Chart for PFNSL.NO NAME AGE/ SEX MOI OTA R/L COMORBIDS DOS (Mts) B/L (Ml) FWB (WKS) HHS RU NSF
1 Ambika 61/F 1 1 1 2 52 50 8.2 92 1 12 Manoj 69/M 1 3 2 1 54 60 9.3 80 1 13 Saraswathy 70/F 1 2 1 3 53 50 9.0 86 1 14 Krishnan 63/M 1 1 2 1 57 50 10.4 93 1 15 Neela 71/F 1 3 1 6 62 60 11.6 81 1 16 Sabapathy 67/M 1 2 2 3 69 70 12.0 87 1 17 Alamelu 64/F 1 2 2 2 70 50 11.3 84 1 18 Jayavel 58/M 2 3 1 1 60 60 11.5 65 2 19 Kumar 73/M 1 3 2 5 69 60 11.2 80 1 1
10 Devan 69/M 1 2 2 3 56 60 9.2 85 1 111 Lakshmi 72/F 1 3 1 1 64 70 8.5 80 1 112 Nagammal 65/F 1 1 2 2 60 70 9.6 93 1 113 Rathnam 59/M 2 1 1 1 59 50 8.3 92 1 114 Senthamarai 68/F 1 2 2 3 58 60 9.4 86 1 115 Surya 73/M 1 3 1 1 63 50 8.6 80 1 116 Ashra 64/F 1 1 1 3 55 50 11.6 91 1 117 Naagarani 74/F 1 2 2 5 57 70 10.6 86 1 118 Mariyappan 65/M 1 2 1 2 66 50 11.3 84 1 119 Poongodi 53/F 1 3 2 1 59 60 10.4 80 1 120 Elumalai 61/M 1 2 1 3 67 60 12.2 71 2 121 Thirupathi 66/M 2 3 2 3 68 50 10.6 80 1 122 Jeya 64/F 1 2 2 1 59 70 10.3 84 1 123 Haribabu 52/M 1 2 1 3 50 60 8.4 83 1 1
97