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IINNTTEERRTTRROOCCHHAANNTTEERRIICC

FFRRAACCTTUURREESS

BBYY

DDYYNNAAMMIICC HHIIPP SSCCRREEWW FFIIXXAATTIIOONN

C E R T I F I C A T E

This is to certify that this dissertation entitled “ANALYSIS

OF RESULTS OF INTERTROCHANTRIC FRACTURES BY

DYNAMIC HIP SCREW FIXATION” is a bonafide record of the

work doneby DDrr.. NNAARREENNDDRRAA RREEDDDDYY NELLORE in partial

fulfillment of the requirement for the award of M.C.H. Orthopedic.

D E C L A R A T I O N

I, Dr.NARENDRA REDDY, hereby declare that this dissertation

entitled “ANALYSIS OF RESULS OF INTER

TROCHANTERIC FRACTURE BY DYNAMIC HIP

SCREW FIXATION” hhaass bbeeeenn pprreeppaarreedd bbyy mmee..

Place:

Date: Dr. NARENDRA REDDY

A C K N O W L E D G E M E N T S

I am deeply indebted to DR.Y.SIVAPRASAD, Prof. DDeepp.. ooff

..oorrtthhooppaaeeddiiccss,, NNaarraayyaannaa mmeeddiiccaall ccoolllleeggee,, NNEELLLLOORREE,, for his

inspiration and encouragement in the preparation of this

dissertation.

It gives me great pleasure to express my gratitude to Dr. KIRAN

CHOWDARY, Guntur, Dr. PRASAD, M.A.V.V., Nellore

Dr. KUMAR BABU, Nellore and for their valuable guidance and

support in completion of this dissertation.

I humbly express my gratitude to all the orthopaedic faculty and

fellow postgraduates for their immense help in the completion of

this study.

Last but not the least I am grateful to all MMYY PPAATTIIEENNTTSS,, MMYY

PPAARREENNTTSS and TTHHEE AALLMMIIGGHHTTYY for the kindness and co-

operation without whom this study could not have been embarked

upon

Dr. P. NARENDRA REDDY

CONTENTS

1. INTRODUCTION

2. AIM

3. REVIEW OF LITERATURE

4. MATERIALS AND METHODS

5. PROFORMA AND MASTER CHART

6. RESULTS

7. DISCUSSION

8. CONCLUSION

9. SUMMARY

10. BIBILIOGRAPHY

INTRODUCTION

INTRODUCTION

Intertrochanteric fractures are seen with increasing frequency and

severity as the life expectancy of our population increases. The primary goal

in the treatment of an elderly patient with Intertrochanteric fracture is to

return the patient to his / her pre - fracture activity as early as possible.

Rapid mobilization of these elderly patients reduces the morbidity and

mortality rate in geriatric patients.

Before the introduction of suitable fixation devices, treatment of

intertrochanteric fractures was nonoperative, consisting of prolonged bed

rest in traction until fracture healing occurred (usually 10 – 12 weeks ),

followed by a lengthy programme of ambulation training. In elderly patients,

this approach was associated with high complication rates; typical problems

included Decubitus ulcers, Urinary tract infection, Joint contractures,

Pneumonia and Thromboembolic complications, resulting in a high

mortality rate. In addition, fracture healing was generally accompanied by

varus deformity and shortening because of the inability of traction to

effectively counteract the deforming muscular forces.

For these reasons, the treatment of intertrochanteric fracture by

reduction and internal fixation has become the standard method of

treatment.

It is important to understand the principles behind the evolution of the

multitude of implants that have been used to stabilize intertrochanteric

fractures. The first implant to be used with success was Fixed-angle Nail-

plate (e.g., Jewett nail, Holt nail) consisting of Triflanged nail fixed to a

plate at an angle between 1300 and 150

0. Although these devices provided

stabilization of the femoral head and neck fragment to the femoral shaft,

they did not allow fracture impaction. If significant impaction of the fracture

site occurred, the implant would either penetrate into the hip joint or cut out

through the superior portion of the femoral head and neck. 45

(M J Parker) If,

on the other hand, no impaction occurred, lack of bone contact would result

in either plate breakage or separation of the plate and screws from the

femoral shaft. These complications occurred much more frequently when

these devices were used to treat unstable fractures.

The experience with fixed-angle nail plate devices indicated the need

for a device that allowed controlled fracture impaction. This gave rise to

Sliding Nail-Plate devices (e.g., Massie nail, Clawson Ken-Pugh nail), which

consisted of a nail that provided proximal fragment fixation a sideplate that

allowed the ―telescope‖ within a barrel35

Impaction provided bone-on-bone

contact, which promoted fracture union; implant sliding also decreased the

moment arm and stress on the implant, thereby lowering the risk of implant

failure.

The Sliding Nail-Plate devices gave rise to Sliding Hip Screw devices.

The nail portion was replaced by a blunt-ended screw with a large outside

thread diameter. The first author to describe a sliding hip screw device was

Schumpulick W.48

One early modification to the Sliding Hip Screw maximized fracture

impaction by allowing the proximal lag screw to telescope within the plate

barrel and the plate to slide axially along the femoral shaft. To accomplish

this bi-directional sliding, the plate was modified by replacing the round

screw holes with slotted screw holes (Egger’s plate). More recently, a two-

component plate device was introduced (Medoff plate, Medpac, Culver City,

CA)1 in which a central vertical channel constrains an internal sliding

component. Both devices have been used successfully for the treatment of

stable and unstable intertrochanteric fractures.

Intramedullary Sliding Hip Screw devices have recently been

developed for stabilization of pertrochanteric fractures (Gamma nail).3,17

These devices couple a sliding hip screw with a locked intramedullary nail.

However, patients treated with these devices are at increased risk for femoral

shaft fracture at the nail tip and the insertion sites of the distal locking

screws.

Hence, for these various complications associated with other

fixation devices in the treatment of unstable intertrochanteric fractures,

Dynamic Hip Screw Fixation has become the Gold standard treatment.

AIM

AIM

To analyse the results of the intertrochanteric fractures treated by

Dynamic Hip Screw fixation

REVIEW OF LITERATURE

PROXIMAL END OF FEMUR

ANTERIOR VIEW POSTERIOR VIEW

MUSCLE ORIGIN AND INSERTIONS ON PROXIMAL END

ANATOMY

ANATOMY

The upper end of femur includes the head, neck, greater trochanter,

lesser trochanter, intertrochanteric line and intertrochanteric crest.

The femur is the second long bone in the body to start ossifying. The

primary center appears in the shaft during 7th

fetal week. Four secondary

centers, one for lower end appears at the end of ninth month of intrauterine

life, one for head appears during first six months of life and fuses at around

16yrs , one for greater trochanter appears during fourth year and fuses at

around 14yrs, one for lesser trochanter appears during 12 yrs and fuses at

around 13yrs.

HEAD OF THE FEMUR:

It forms more than half of a sphere and is directed medially, upwards

and slightly forward. It articulates with the acetabulam to form the hip

joint. The roughened pit, situated just below and behind

its centre is called the fovea. It provides attachment to the ligament of

head of femur (the round ligament or ligamentum teres).

NECK OF THE FEMUR:

Its about 5 cm long; connects the head of the femur and the shaft with

which it forms an angle of about 1250

and an anteversion of 150 in adults.

The neck shaft angle is less in females due to their wider pelvis.

The neck of the femur is strengthened by calcar femorale along its concave

surface

ANATOMY

LATERAL ASPECT FEMORAL NERVE

LIGAMENTS OF HIP JOINT

GREATER TROCHANTER:

The greater trochanter has an upper border with an apex and three

surfaces (anterior, medial and lateral).

The apex is the posterior inturned part of the upper border. It provides

insertion to the pyriformis.

The anterior surface is rough (laterally) for insertion of the

gluteus minimus.

Medial surface presents a rough impression above and a deep

trochanteric fossa below. The upper rough impression provides insertion to

the common tendon of obturator internus and to the gamelli. The trochanteric

fossa is for the insertion of obturator

Lateral surface is crossed by an oblique ridge directed downwards and

forwards. It provides insertion to gluteus medius. There is a trochanteric

bursa of gluteusmedius in front of the ridge and trochanteric bursa of

gluteus maximus behind the ridge.

LESSER TROCHANTER:

It’s a conical eminence directed medially and backwards from the

junction of neck and shaft of the femur. Psoas major is inserted on the apex

and medial part of the rough anterior surface.

Iliacus is inserted on the anterior surface of the base of lesser

trochanter and the area below it. The smooth posterior surface is covered by

a bursa due to the upper horizontal fibres of adductor magnus.

INTERTROCHANTERIC LINE:

It marks the junction of anterior surface of the neck with shaft of

femur. It begins above at the antero - superior angle of the greater trochanter

and is continuous below with the spiral line in front of the lesser trochanter.

It provides attachment to,

1. Capsular ligament of the hip joint.

2. Upper band of iliofemoral ligament in upper part.

3. Lower band of iliofemoral ligament in lower part; origin to the

highest fibres of the vastus lateralis from the upper end and the origin

to the highest fibres of vastus medialis from the lower end of the line.

INTERTROCHANTERIC CREST:

This marks the junction of posterior part of neck with shaft of femur.

It begins above at the postero - superior angle of greater trochanter and

ends at the lesser trochanter. The rounded elevation, a little above its

middle is called the QUADRATE TUBERCLE, which provides insertion

to quadratus femoris extending to the area below it

BLOOD SUPPLY:

An extracapsular arterial ring is formed anteriorly by ascending

branch of lateral femoral circumflex artery and posteriorly by medial

circumflex femoral artery. The ascending cervical branch from this ring

pierce the hip capsule near its distal insertion, becoming the retinacular

arteries supply the femoral head. A subsynovial intracapsular arterial ring

enter the femoral head and unite to form the lateral epiphysial arteries.

These lateral epiphyseal arteries supply the majority of femoral head. The

artery of ligamentum teres , a branch of obturator artery supply a small

portion of femoral head around the fovea capitis

BLOOD SUPPLY TO HEAD OF THE FEMUR

TRABECULAR PATTERN

NUTRIENT ARTERY

This is derived from second perforating artery. In case of absence it is

replaced by two nutrient arteries derived from first and third perforating

arterie . The nutrient foramen is located on the medial side of the linea

aspera and is directed upwards.

TRABECULAR PATTERN:

The trabecular architecture of the proximal end of femur

comprises of 5 distinct groups

1) Principal compression trabeculae- there run from the weight

bearing portion of the femoral head to the region of the calcar

femoris and the medial cortex.

2) Principal tension trabeculae - there begin in the inferior portion of

the head and arch across the superior portion ,terminating in the

lateral cortex

3) Trochanteric trabeculae- these begin in the greater trochanter and

end in the lateral cortex

4) Secondary compression trabeculae

5) Secondary tension trabeculae - these are found between primary

trabeculae and act as tie beams.

The primary tensile and compression trabeculae, resist tensile and

compression stress respectively. Trabecular bone is concentrated as

thin layer deep to the subchondral bone

CLASSIFICATION

BOYD AND GRIFFIN CLASSIFICATION

Type 1

Type 2

Type 3

Type 4

CLASSIFICATION

A number of classifications of trochanteric fractures are recorded in the

literature. No standard classification is universally accepted. Stuck,(using

Boehler’s classification) Moore, Brigg’s and Keats and others classified

trochanteric fractures primarily from an anatomical standpoint.

Boyd and Griffin (1949) classified fractures in the trochanteric area

of femur into 4 types13

. Their classification included all fractures from

extracapsular part of the neck to a point 5 cm distal to the lesser trochanter.

Their classification is useful in planning treatment and estimating prognosis.

TYPE-1:

Fractures extending along the intertrochanteric line from the greater to

lesser trochanter

TYPE - 2 :

Comminuted fractures, the main fracture being along the

intertrochanteric line but with multiple fractures in the cortex

TYPE - 3 :

Fractures that are basically sub -trochanteric with at least one fracture

passing across the proximal end of the shaft just distal to or at the lesser

trochanter; Varying degrees of comminution are associated.

TYPE - 4 :

Fractures of the trochanteric region and proximal shaft with fractures

in at least 2 planes

EVAN’S CLASSIFICATION

STABLE

UNSTABLE

EVAN’S CLASSIFICATION:

Evan presented a simpler classification based on dividing fractures

into stable and unstable groups.21

He further divided the unstable into those

in which stability could be restored by anatomic or near anatomic reduction

and in those in which anatomic reduction would not create stability.

TYPE - 1 :

The fracture line extends upwards and outwards from the lesser

trochanter and there are 4 sub divisions.

In the first group, comprising 65% of all cases, the inner cortical

buttress has never been disturbed. There is no displacement and fractures

unite in perfect position.

In the second group, simple overlap of the inner cortical buttress can

be reduced by manipulation and the fracture thus becomes stable.

In the third and fourth group, there is unreduced overlap or destruction

of this cortical buttress and coxa vara deformity is to be expected.

TYPE - 2 :

The obliquity of major fracture line is reversed, that is it extends

outward and downward from the lesser trochanter. There is marked tendency

to inward displacement of the femoral shaft but this does not affect the

ultimate function.

KYLE CLASSIFICATION

TYPE 1 TYPE 2

TYPE 3 TYPE 4

KYLE CLASSIFICATION

34

TYPE- 1 (STABLE):

Two part fracture that is undisplaced

TYPE-2 ( STABLE):

Fractures that are displaced into varus with a smaller lesser

trochanteric fragment, but with an essentially intact posteromedial cortex

TYPE-3 (UNSTABLE):

Four part fractures that are displaced into varus with posteromedial

cortical communition and a greater trochanteric fragment.

TYPE-4 ( UNSTABLE):

Type 3 fracture with subtrochanteric extension

TRONZO

TRONZO CLASSIFICATION :

Tronzo proposed a classification based on the reduction potential.

According to him trochanteric fractures are divided into 5 types and each

type requires a specific mode of reduction and fixation with a nail plate

assembly.

TYPE - 1 :

Incomplete trochanteric fractures.

TYPE - 2 :

Non - comminuted trochanteric fractures with or without displacement

in which both trochanters are fractured.

TYPE - 3 :

Comminuted fractures in which the lesser trochanteric fragment is

large. The posterior wall is exploded with the back of the inferior neck

already displaced in the medullary cavity of the shaft fragment. These are

unstable fractures. A variant of type 3 fracture also has the greater trochanter

fractured off and separated.

TYPE - 4 :

Comminuted trochanteric fracture with disengagement of the two

main fragments. Again these are unstable with the posterior wall exploded,

but the spike of the neck fragment is displaced outside of or medial to the

shaft.

TYPE - 5 :

Trochanteric fractures with reverse obliquity. These are uncommon.

AO CLASSIFICATION

Type 1

A1.1 A1.2 A1.3

Type 2

A2.1 A2.2 A2.3

Type 3

A3.1 A3.2 A3.3

AO CLASSIFICATION:

AO group has classified the trochanteric fractures into stable and

unstable types4. The stable trochanteric fractures have an intact medial

buttress comprising 70% of the cases. The unstable problematic types have

large posterior fragment in addition to the medial fragment. They emphasize

that for stability, the medial and posterior cortex should be intact. In

treatment of unstable trochanteric fractures medial buttress should be

reconstructed before fixation with an implant.

TYPE A1:

Pertrochanteric simple (the typical oblique fracture line

extending from the greater trochanter to the medial cortex; the lateral

cortex of the greater trochanter remains intact - two fragments)

A1.1 : along the intertrochanteric line

A1.2 : through the greater trochanter

A1.3 : below the lesser trochanter

TYPE A2 :

Pertrochanteric multifragmentary (the typical oblique fracture line

extending from the greater trochanter to the medial cortex; the lateral cortex

of the greater trochanter remains intact - separate posteromedial fragment).

A2.1 : with one intermediate fragment.

A2.2 : with several intermediate fragments.

A2.3 : extending more than 1 cm below the lesser trochanter.

TYPE A3 :

Intertrochanteric fracture line extends across both the medial and

lateral cortices.

A3.1 : simple oblique ( reverse obliquity pattern ).

A3.2 : simple transverse.

A3.3 : multifragmentary.

STABLE INTERTROCHANTERIC FRACTURES:

A) The fracture runs from the greater trochanter obliquely downwards

and medially to exit just above the lesser trochanter. A good portion of

the calcar is attached to the proximal fragment anteromedially. Quite

commonly there is an avulsion fracture of the lesser trochanter. As a

rule the distal fragment is in external rotation. Rarely, the inferomedial

spike of the proximal fragment is impacted into the metaphysis of

proximal fragment.

B) An avulsion does not result in instability because it does not weaken

the medial buttress.

AUNSTABLE INTERTROCHANTERIC FRACTURES:

A) The medial fragment varies in size and reaches distally to a varying

degree. As a rule it contains the lesser trochanter. If the lateral wall

remains intact then the distal fragment migrates proximally because of

muscle pull. Commonly there is in addition quite a large posterior

fragment. Occasionally, the proximal fragment contains a long medial

spike made up of calcar and lesser trochanter. This makes it into a

long oblique or spiral fracture.

B) If the greater trochanter is fractured then the distal fragment is not

pulled upwards.

C) A badly comminuted intertrochanteric fracture has in addition to the

fractures of the lesser and greater trochanters further comminution

posteriorly and medially.

D) The intertrochanteric fracture is almost horizontal. Often one finds this

fracture associated laterally with a further anterior or posterior

fragment and occasionally both.

E) Occasionally the fracture has a reverse course beginning laterally and

distally and running upwards and medially. Medially it exits above the

lesser trochanter. Commonly it is associated with a fracture of the

greater trochanter.

HISTORICAL REVIEW

HISTORICAL REVIEW

Internal fixation in treatment of intertrochanteric fractures has gained

world wide acceptance.

From antiquity, the general apporach to these fractures consisted of

various methods of closed reduction and immobilisation.

Although, Von Langenbeck first reported an open reduction and

internal fixation of a fractured hip in 1878,28

it was only Smith Peterson's

refinement of the surgical approach and introduction of the Triflanged nail

some 40 years later that operative treatment became a practical alternative47

.

The problems and disadvantages of fixation by wires, threaded wires pins

and screw apparatuses rapidly forced it into the discard. Additions, deletions

and modifications to this armamentarium followed clinical trails in an

attempt to correct evident shortcomings in fixation.

In 1937, Thornton devised a plate attachment for the

S.P. Triflanged nail so that trochanteric fractures could be suitably fixed. 39

In 1941, Jewett developed a welded, single piece, angled nail. The Jewett

nail with a few minor structural changes has proven acceptable.31

A

simplification in design in the form of a "V" nail was introduced in 1944 by

Neufeld.

In the same year Austin Moore designed his blade plate for

trochanteric fractures but its use was short lived, for this fracture at least,

because of the superiority of other nails. In 1947, McLaughlin engineered a

variable angle nail plate, the advantage of which was the ease of adaptation

of the plate to the femoral shaft after the nail has been driven in.

In 1940, Godey - Moreira reported 10 fractures treated with a

cannulated "stut bolt screw" which impacted the fragments. Perfect results

were obtained in 7 of the 8 patients followed.

In 1955, Schumpelich and Jantzen described the use of a Sliding

Screw, the design of which they attributed to Ernst Pohl. Callender modified

the device further and it was used by Harrington and Johnson in a series of

unstable intertrochanteric fractures.47

In 1964, Clawson reported on the treatment of trochanteric fractures

using a Sliding Screw and plate.16

The device was developed independently

by the Richards' manufacturing company. Clawson made several further

modifications and in its current form the device is known as Richards'

Compression Hip Screw. 18

In recent years, the Sliding Hip Compression Screw system (Richards,

Zimmer, etc.) has become a widely used method of internal fixation for

trochanteric fractures.

This stabilisation of trochanteric fractures by remotely introduced

medullary implants was first recommended by Lezius, Kuentscher and later

Simon Weidner and especially Ender advanced in this direction and refined

this method.50

Since the development of AO Osteosynthesis technique many

orthopaedic units have added this versatile system to their armamentarium.

The Percutaneous compression plating system 33,52

is a new method in

managing trochanteric fractures which is composed of a plate, two

telescoping neck screws and three shaft screws. The plate is specially

designed to allow it to pass through soft tissue and to glide along the femoral

shaft. The system permits percutaneous screw fixation and fracture

compression.

In 2000 Elder S, Frankenburg E20

has introduced calcium phosphate

cement augumented fixation of osteoporotic unstable intertrochanteric

fractures

In 2002 Janzing HM,30

Huben B,J stated that percutaneous compression

plating system in peritrochanteric fractures of hip is a minimal invasive

technique with reduced operative time and postoperative pain than fixation

of sliding hip screw

In 2003 Hardy DC26

stated that sloted intramedullary hip screw nail

reduces proximal mechanical unlodindg on the femur

In 2006 N K Karn,44

G K singh proposed that external fixator in the

treatment of intertrochanrtic fracture needs less amout of operative time,

blood loss is minimal with mimal amount of shortening when compared to

sliding hip screw

In 200751

Yechiel Gotfried proposed that integrity of lateral femoral

wall in intertrochanteric hip fractures is predictor for reoperation in

peritrochanteric hip fractures

In 2008 Ricci46

, William M proposed that new implant designs for

intramedullary nails and for external fixation have recently challenged

compression hip screw as a best metyhod of treatment for intertrochanteric

fractures. External fixator as a result of new advances in its desigs like

reduced pintract infections and improved pin fixation strength has recently

shown to be reasonable alternative treatment option

The long list of devices that have been used to stabilize these fractures

is a testimonial to the fact that many did not work well. Thus there are

continuing attempts to improve both the design and materials of fixation

devices.

BIOMECHANICS OF INTERTROCHANTERICFRECTURES

BIOMECHANICS OF

INTER TROCHANTERIC FRACTURES

Operative treatment of intertrochanteric hip fractures with

internal fixation creates a fracture fragment – implant assembly

intended to withstand the forces acting on the fracture site. Since

avoiding recumbency is often the goal of internal fixation and

since many patients with trochanteric hip fractures lack the

balance, co- ordination and ability to avoid weight bearing upon

the fractured femur, it is often necessary that the fracture

fragment implant assembly be strong enough to withstand the

body weight and the very considerable muscle forces which act

on the trochanteric region of femur. These forces have been

shown to be equivalent to as much as three times the body

weight acting upon the femoral head.

Creating a fracture fragment – implant assembly capable of

withstanding loads of this magnitude is the bio - mechanical goal of the

surgeon who elects upon the operative treatments of intertrochanteric

fractures. Strength of the fracture fragment implant is determined by 5

independent variables. (Kaufer et al)

1 . Bone quality

2 . Fragment geometry

3 . Reduction

4 . Implant

5 . Implant placement.

BONE QUALITY:

The mechanical properties of bone (hardness, elasticity, strength,

etc) vary considerably depending upon age, sex, race, general state of

health, muscle mass, and level of activity. Bone strength varies in

different bones in same individual as well as in different areas in the

same bone.

Most of the unstable intertrochanteric fractures are relatively low

trauma injuries occurring in atrophic, osteoporotic or osteomalacic

bones. Singh has developed a roentgenographic method for determining

bone strength which is based upon the trabacular pattern of the proximal

femur.

FRAGMENT GEOMETRY:

Much clinical attention is focussed upon the number, size,

location and displacement of trochanteric fracture fragment.

Comminution, especially if it involves the posterior and medial portion

of the trochanteric region is recognized as a major factor contributing to

the complications of fixation. Multiple fragment fracture with

comminution extending into the medial and posterior femoral cortex is

far more likely to displace into varus and retro version. Fractures with

posterior and medial cortical comminution are therefore considered

unstable, while two parts trochanteric fractures are far more likely to be

stable.

Although reduction and inter fragmentary fixation of the lesser

fragment of a comminuted unstable intertrochanteric fractures can

contribute to the stability of the post fixation assembly , in practice ,

inter fragmentary fixation is time consuming, frequently disappointing

and may contribute to infection and other biological complications of

operative treatment. It is therefore generally agreed that one should

ignore the lesser fragments and concentrate on gaining stable fixation of

the major proximal fragment to the major distal fragment attaining

postero - medial cortical contact.

REDUCTION:

An unstable reduction is one in which there is insufficient contact

between the fragment to contribute to the post reduction integrity of the

proximal femur. Post fixation strength of an unstable fracture reduction

depends entirely upon the mechanical characteristics of the implant.

Stable reduction of a unstable intertrochantic fracture provides

sufficient medial and posterior cortical contact between the major

proximal fracture fragment and the major distal fragment to resist the

varus and the posterior distilling forces which predominate in these

fracture. Stable reduction contributes significantly to the strength of the

post fixation assembly.

Restoration of normal anatomy is the goal of all fracture

treatment. Cadaveric studies of unstable intertrochanteric fractures

stabilized with anatomic reduction, showed optimal stress distribution

(highest compression strain in the medial cortex and lowest strain on the

side plate).

Reduction and fixation of the postero medial fragment depends on

the size of the fragment. Anatomic reduction of a large postero medial

fragment increase the load resistance by 57 % whereas fixation of a

small postero medial fragment increase the stability only by 17%.

(Apel et al)

However, anatomic reduction of unstable intertrochanteric

fracture can be difficulty to achieve and is associated with a prohibitive

frequency of complication of fixation. Recognition of this problem has

stimulated recent interest in non – anatomical stable reduction. Of these,

the medial displacement reduction advocated by Dimon and Hughston

first described Rowe was most popular.

There is however no evidence to suggest that medial displacement

is mechanically superior to a perfect anatomic reduction. Non

anatomical reduction should therefore be reserved for those fractures in

which perfect anatomic reduction cannot be achieved.

Valgus reduction markedly decreases joint reaction force

moment arm and can markedly increase the fracture to varus deformity.

However, severe degrees valgus should be avoided because it demands

increased abductor muscle power to stabilize the pelvis during single leg

stance and increase the joint reaction force. Valgus reduction may

therefore contribute to an abductor limp or post traumatic arthiritis.

IMPLANTS:

Sliding hip screw includes traditional compression hip screw that

provide compression in the intertrochanteric plane and compression

plate that provide additional compression axially.

Sliding hip screws are available with plate angles from 1250 -

1550. 135

0 and 150

0 devices are more commonly used.

Even though the 1500 plates are preferable because the angle of

the lag screw more closely parallel with the compression forces within

the femoral neck and hence less chances of failure of implant due to

bending force, in clinical studies there is no difference in the

compression ability between 1350 hip compression screws and 150

0

devices.

Considering the problem of insertion of 1500 devices into the

center of the femoral head with more distal entry point below the lesser

trochanter, the higher angled plates are only rarely indicated for

extremely valgus femoral neck fractures and more distal fractures.

Moreover, 1350 devices are easily placed and their clinical results are

similar to those for the 1500 plates. Hence 135

0 devices are more

frequently used.

Depending upon the length of the measured sliding hip screw,

either short or long barrelled plate devices are used. Long barrelled

plates are used when the length of the measured sliding hip screw is

more than 85 mm.

NAIL PLACEMENT:

Optimal implant placement is determined by the distribution of

good bone within the proximal fragment as well as the net sum of force

vectors acting upon it. Telescoping implants are least likely to penetrate

into the joint and may therefore be inserted more deeply into the

proximal fragment, thus affording maximal proximal fragment control.

The center of pressure acting upon the femoral head lies within

the head’s antero-superior quadrant. It is therefore best to place the

fixation device in the postero-inferior quadrant of the head of the femur

so that the device must plough through the maximal quality of bone

before it cuts out.

Depth of screw insertion is always a compromise. Based upon a

consensus of laboratory and clinical data, the ideal position of screw

must be within 10 mm. from the subchondral cortex and in the postero-

inferior quadrant of the head of the femur.36

This position places the tip

of the implant into bone formed by the decussation of the tension and

compression trabaculae, thus assuming maximal proximal fragment

control. One of the major advantages of a telescoping device with a

blunt end is the ability to insert it close to the subchondral cortex of the

femoral head with minimal risk of joint penetration within the limits of

technical skill, implant placement is the surgeon’s choice.

Of the 5 determinants of trochanteric fracture fixation stability,

bone quality and fragment geometry are of great importance but are

entirely the product of the patient and the trauma which cannot be

modified by the treating Surgeon. Reduction, implant placement and

implant selection represent the Surgeon’s choice. The implant selection

and placement are of relatively greater importance than reduction.

MATERIALS AND METHODS

MATERIALS AND METHODS

Study has been conducted at VIJAYA HOSPITAL AND

ST.JOSEPH’s HOSPITAL, NELLORE during the period from June

2008 to December 2010. 30 patients with intertrochanteric fractures

treated with DHS fixation were selected for the study, of which

2 patients expired after the 6th month post operatively due to age factor

and other co-morbid conditions.

Hence the total number of patients included in the study was 28 patients.

The follow up period ranges from 6 months to 2 1/2 years.

INCLUSSION CRITERIA

. Intertrochanteric fractures in adults

. Stable intertrochanteric fractures

.Unstable intertrochanteric fractures

EXCLUSION CRITERIA

. Compound fractures

.pathological fracture

.Fractures in children

Age distribution:

Majority of the patients were in the 7th and 8

th decade of life.

Age No. of Patients

< 60 2

60 –70 14

70 –80 10

80 –90 2

0

5

10

15

20

male female

Sex distribution:

Sex No. of patients

Male 10

Female 18

Mode of violence:

No. of patients

RTA 2

Trivial violence 26

Side of injury:

Right 18

Left 10

Type of fracture:

BOYD & GRIFFIN classification:

TYPE-1------------- 03

TYPE-2--------------12

TYPE-3-------------- 05

TYPE-4-------------- 08

Associated injuries:

One patient had fracture neck of femur on opposite side

previously for which Hemiarthroplasty was done.

2 patients had ipsilateral Colles’ fractures which were managed

conservatively.

Associated medical problems:

Diabetes mellitus - 13 patients

Hypertension - 11 patients

IHD - 04 patients

Initial management:

Initiall to start with all the patients were put on skin traction on

admission.

Average time interval between admission and surgery was 8.5

(range 7– 10) days during which period patients were evaluated for

medical problems.

Spinal anesthesia was given for all the patients.

C-arm and fracture table were used for all the patients.

SURGICAL TECHNIQUE:

Patient positioning:

Patient is positioned supine on a fracture table with a radiolucent,

padded countertraction post between the patient’s legs and the uninjured

leg, flexed and abducted at the hip in a well leg holder. Pad the peroneal

nerve on the uninjured leg in this position. The injured leg is held by a

foot plate or boot attached to the other leg extension of the fracture

table. The adequacy of both anteroposterior and true lateral views

should be verified before surgical preparation.

Draping:

Prepare the skin over the hip and square off the lateral aspect of

the hip from the iliac crest to the distal thigh with towels and drapes,

taking care to place the towel clips so that they are not superimposed on

the fracture on subsequent imaging. Drape the C-arm separately.

Reduction technique:

Perform a closed reduction of the fracture. Generally, the fracture

can be reduced in neutral or slight internal rotation. Avoid too much

traction, which may cause valgus overreduction. Check for the reduction

by anterioposterior and lateral roentgenograms or by image intensifier,

paying special attention to cortical contact medially and posteriorly.

Exposure:

Skin incision is made from 5 cm above the tip of the greater

trochanter passing through center of tip of the greater trochanter and

extend down the line of shaft of the femur for approximately 8 cm.

Incise the fat and underlying deep fascia, retract the cut edges of the

fascia to pull the tensor fascia lata anteriorly. Split the fibres of vastus

lateralis along its line of fibres and elevate it from the lateral inter

muscular septum taking care to coagulate perforating branches of the

profunda femoris artery.

Insertion of guide pin:

The level of insertion of the guide pin varies with the angle of the

plate used. The proximal aspect of the osseous insertion of the gluteus

maximus and the tip of the lesser trochanter, which are approximately 2

cm below the vastus lateralis ridge, help identify the level of entry of a

1350 angle plate. If higher angle side plate is used, move the entrance

site 5 mm distally for each 5 – degree increase in barrel angle.

Place the appropriate fixed – angle guide midway on the lateral

cortex so that the guide pin enters at the designated level. Aim the guide

pin toward the apex of the femoral head, the point where a line parallel

to and in the center of the femoral head intersects the subchondral bone.

Confirm central placement on the lateral view as well.

Central and deep placement allows secure purchase and maximal

collapse of the screw without impinging on the barrel, two factors which

reduce the risk of mechanical failure of fixation. Another parallel guide

pin is inserted to provide temporary stability for unstable fractures, in

which the reduction can be lost if the guide pin backs out after reaming.

Reaming of femur:

Once the guide pin has been inserted and measured, advance it an

additional 5 mm into the subchondral bone, ream according to the exact

measurement of the lag screw length, and choose a lag screw that

matches the length measurement. As an alternative, insert the guide pin

into the subchondral bone, measure and set the reamer 5 mm shorter

than the length measured. Choose a lag screw that matches the length

reamed.

Set the power combination reamer to the lag screw length

indicated by the measuring gauge and ream until the distal aspect of the

positive stop reaches the lateral cortex.

Tapping of femoral head:

Generally, osteoporotic bones do not require tapping, but in

younger patients and abnormally sclerotic bone, tapping is indicated to

avoid excessive torque on the insertion wrench and to minimize the risk

of inadvertent malrotation of the femoral head fragment during final

seating of the screw.

Selection of Lag Screw:

A fully inserted Lag screw that equals the measured length will

allow 5 mm of compression when the compression screw is used or 5

mm of fracture collapse. A 5 mm shorter Lag screw will allow an

additional 5 mm of compression. Do not use a screw that is more than

10 mm shorter than indicated by the measuring gauge or the screw may

be insufficiently covered within the barrel. This may inhibit the screw

from sliding within the barrel.

Insertion of plate and lag screw:

Assemble the appropriate plate and Lag screw onto the insertion

wrench. Screw the Lag screw retaining rod into the distal end of the Lag

screw until a firm connection is obtained. Place the entire assembly over

he guide pin and introduce it into the reamed hole. Advance the Lag

screw into the proximal femur to the predetermined level and verify its

position with image intensification.

A 1800

turn represents a 1.5 mm advancement of the Lag screw.

Verify the position and depth of the screw with image intensification in

both planes. Remove the centering sleeve and advance the side plate

onto the Lag screw shaft. Use the plate tamper to fully seat the plate.

Unscrew the Lag screw retaining rod and remove the insertion wrench

from the back of the Lag screw. Then remove the threaded guide pin.

Attachment of plate:

Use plate clamp to secure the plate to the shaft. Release traction to

allow impaction of the fracture fragments especially in unstable

intertrochanteric fractures. Attach the plate to the shaft of femur using

4.5 mm cortical screws.

When all screws have been inserted and all traction has been

released, the fracture can be compressed with the compression screw,

(usually the 19 mm screw). If a short barrel is used, placement of

compression is mandatory to prevent potential disengagement of the

screw plate assembly.


PROFORMA

CASE NO:1

Name :R.Saradha IP. No.:41972

Age / Sex : 55\F DOA :2\11\2008

Occupation : House wife DOS :6\11\2008

Address: bujibuji nellore DOD :14\11\2008

nellore

Time between Injury and Admission: Same day

Nature of Injury: Trivial

Side of Injury : Left femur

Associated injuries: Nil

Associated Medical Problems: Nil

RADIOGRAHY : X-ray No. 76 Date:2\11\2008

Boyd-Griffin Classification: Type 2

Pre-Operative Traction: Skin traction for 4 days

Time between Admission and Surgery: 4 days

Operative Treatment

Anesthesia SA

Reduction Method. Closed

Approach Lateral approach

Implant DHS

Post Operative Treatment

Antibiotics yes

Analgesics yes

Blood transfusion No

Drain removal date 8\11\2008

Suture removal on 10.th

post operative day

Ambulation in Bed started 3 post operative day

Walking without support 6 months

Post operative complications: -Nil

Follow up of patients:

One Month : Radiologically implant insitu, Clinically looked

for tenderness . Adviced partial weight bearing with walker

Three Months : Radiologically implant insitu with compression at

the fracture site is seen. Clinically hip movements are near normal

no tenderness Adviced full weight bearing with walker

Six Months : Rdiologically healed fracture, Clinically hip

movements are near normal, shortening of 1cm. Adviced unaided

walking

One year : Patient was assessed by Harris Hip Score

Shortening by 1cm

Fracture united at 6 months

Score -92

CASE 1 Pre-op Imm Post op

3 Months Post - Op

1 Month Post - Op

6months Post - Op

1 year Post - Op

3 Months Post -Op

Case 1

Clinical Pictures

EXTENSION FLEXION

ABDUCTION ADDUCTION

INTERNAL ROTATION EXTERNAL ROTATION

Harris Hip Score -92

Shortening ---- 1 cm

CASE NO: 2

Name : S.Ram mohan IP. No.:38833

Age / Sex : 75\M DOA :7\6\2008

Occupation: Farmer DOS :13\6\2008

Address: Chithareddy palem DOD :21\6\2008

nellore

Time between Injury and Admission: One day

Nature of Injury : Trivial

Side of Injury : Right femur

Associated Injuries : Nil

Associated Medical Problems : Hypertensive

RADIOGRAHY : X-ray No.1 Date:7\6\2008

Boyd-Griffin Classification : Type 3

Pre-Operative Traction : Skin traction one day


Operative Treatment:

1. Anesthesia : SA

2. Reduction Method : CLOSED

3. Approach : LATERAL APROACH

4. Implant : DHS


5. Antibiotics Yes

6. Analgesics Yes

7. Blood transfusion Nil

8. Drain removal date 15\6\2008

9. Suture removal on 10 Post operative day

10. Ambulation in Bed started 2 Post operative day

11. Walking without support 6 M0NTHS

Post Operative Complications -Nil Follow up of patients:

One Month : Radiologically Implant insitu . Clinically no

tenderness . Partial weight bearing is adviced with help of a

walker after 2 wks

Three Months : Radiologically implant insitu with

compression at the fracture site is seen . Clinically hip

movements are near normal, no tenderness . Adviced Full weight

bearing with the help of a walker

Six Months :Radiologically Healed fracture . Clinically

Hip movements are normal, shortening of 0.5 cm. Adviced

unaided walking

One Year : Normal range of hip movements

Union occured by 5 months

Shortening of 0.5 cm

Harris hip score - 94

Case 2

Pre-op

Imm post-op 1 Month Post -Op

3 month post op 6 month post op

Case -2

Clinical Pictures

Harris Hip Score – 94

Shortening --0.5 cm

CASE NO: 3

Name : G.Ranga samy IP. No.:42645

Age / Sex : 76\M DOA :5\3\2009


Address: venkateswara puram DOD :20\3\2009

nellore

Time between Injury and Admission: Same day

Nature of Injury : Trivial

Side of Injury : Left femur

Associated Injuries : Colles fracture rt

Associated Medical Problems : Diabetic

RADIOGRAHY : X-ray No.17 Date:5\3\2009

Boyd-Griffin Classification : Type 2

Pre-Operative Traction : Skin traction for 5 days


Operative Treatment

Anaesthesia SA

Reduction Method. Closed

Approach Lateral Approach

Implant DHS


Antibiotics Yes

Analgesics Yes

Blood transfusion 1Unit

Drain removal date 2nd

post operative day

Suture removal on 10th

post operative day

Ambulation in Bed started 4th

post operative day


Post operative complications:- UTI


One Month : Radiologically implant insitu . Clinically no

tenderness. Partial weight bearing is allowed after 2 wks with the

help of walker

Three Months : Radiologically Implant insitu with

compression at the fracture site .Clinically hip movements are

near normal and no tenderness. Full weight bearing is adviced

with the help of walker

Six Months : Radiologically Fracture healed . Clinically

hip movements are near normal, shortening of 1.5 cm . Adviced

unaided walking

One Year : Hip movements are near normal

Shortening of 1.5 cm

Fracture healed by 6 months

Harrishirscorre-87

Case -3 Pre-op Imm post op

1 month post op

3 month post op 1 year post op

CASE -3

Clinical Pictures

HARRIS HIP SCORE—87

Shortening – 1.5 cm

CASE NO : 4

Name : P.Rama rao IP. No.:13246

Age / Sex :32\M DOA :3\10\2009

Occupation: Construction worker DOS : 8\10\2009

Address: Podhalakur road DOD :15\10\2009

Nellore

Time between Injury and Admission: 2 days

Nature of Injury: High velocity

Side of Injury: Left femur

Associated Injuries: Nil


RADIOGRAHY : X-ray No. 24 Date: 3\10\2009

Boyd-Griffin Classification Type 3




Anaesthesia SA

Reduction Method. Closed reduction


Implant DHS


Antibiotics Yes

Analgesics Yes

Blood transfusion No


Post operative day


post operative day

Ambulation in Bed started 2nd

post operative day

Walking without support 6months

Post operative complication : Nil


One Month : Radiologically Implant insitu. Clinically

mild tendrness present. Partial weight bearing is allowed with

help of walker after 4wks

Three Months : Radiologically Implant insitu with

compression at the fracture site. Clinically hip movements are

mildly restricted. moderate pain present

Adviced Full weight bearing with the help of a walker

Six Months : Radiologically headled fracture .Clinically

Mild restriction of hip movements . shortening of 1.5 cm present.

Adviced unaided walking

One Year : Moderate restriction of movements

Moderate pain and limp

Shortening of 1.5 cm with heterotrophic ossification

Harris hip score- 75

Case -4

Pre-op Imm post-op

3 Months Post -Op

6 Months Post -Op

1 Year Post –Op

Clinical Pictures-4 EXTENSION FLEXION

ABDUCTION EXTERNAL ROTATION

ADDUCTION INTERNAL ROTATION

Harris hip Score -75

Shortening—2.5 cm

CASE NO :5

Name : D.Venkata subbiah IP. No.:12426

Age / Sex : 78\M DOA :12\12\2009

Occupation: Labour DOS : 19\12\2009

Address: Venkatachalam DOD :27\12\2009

nellore

Time between Injury and Admission: On the day of injury




Associated Medical Problems: Hypertensive and diabetic






Anaesthesia S A

Reduction Method. Closed method


Implant DHS


Antibiotics Yes

Analgesics Yes

Blood transfusion One unit


post operative day


post operative day

Ambulation in Bed started 7th

post operative day

Post operative complications: Decubitus ulcer



tenderness present. Partial weight bearing was adviced after 2wks

with help of a walker


compression at fracture site Clinically Hip movemens are

moderately restricted with sever pain.

Six Months : Radiologically lag screw was cut through.

patient has undergone hemiarthoplasty. Walking with help of a

stick

One Year :Sever pain and limp

Hemiarthoplaty has been done


Complication

Case 5

Pre-op Immediate post-op

6 months post-op After bipolar arthroplasty

CASE NO:6

Name :S.Amanamma IP. No.:18647

Age / Sex :72\F DOA : 19\10\2009

Occupation: House wife DOS :25\10\2009

Address: Muthukuru DOD :2\11\2009

nellore

Time between Injury and Admission:10 days


Side of Injury: Right femur


Associated Medical Problems: Hypertensive





Operative Treatment:.

Anaesthesia SA



Implant DHS


Antibiotics Yes

Analgesics Yes

Blood transfusion 2 units

Drain removal date 2 post operative day

Suture removal on 12post operative day


Post operative complications:- Nil



Pain present. Adviced not to weight bear

Three Months : Radiologically implant insitu and fracture

site compression was not attained. Clinically Pain present and

movements are restricted . Adviced PWD with help of a walker

Six Months : Radiologically lag screw was cut through.

Clinically Sever pain and limp present. hip movements are

markedly restricted . Adviced surgery but pt refused for second

surgery

One Year : Sever pain with limp

Hip movements are restricted


COMPLICATION

CASE 6 Pre-op Immediate post-op

3 months post-op 6 months post-op

CASE NO:7

Name :J.Kasthuramma IP. No.:27785

Age / Sex :69\F DOA :6\9\2009


Address: Lakshmipuram DOD : 20\9\2009

sangam





Associated Medical Problems: Hypertension






Anaesthesia SA



Implant DHS


Antibiotics Yes

Analgesics Yes

Blood transfusion Nil


Suture removal on 10 post operative day



Post operative complication: Nil


One Month : Radiologically Implant insitu . Clinically

No tenderness. Partial weight bearing is adviced with the help of

walker after 3 wks


compression at the fracture site. Clinically Hip movements are

mildly restricted with shortening . Adviced FWB with walker

after 4 wks

Six Months : Radiologically fracture healed. Clinically

moderate restriction of hip movements with moderate pain and

shortening. Adviced unaided walking

One Year : Mild limp with restricted range of movements


CASE 7

PRE .OP POST.OP

1 month 3month

6 months

CASE NO : 8

Name :K.Subbamma IP. No.:40878

Age / Sex :60\F DOA : 11\7\2008

Occupation: house wife DOS : 14\7\2008

Address: Vasili DOD :24\7\2008

athmakur

Time between Injury and Admission: On the day of injury




Associated Medical Problems: Hypertensive






Anaesthesia SA



Implant DHS


Antibiotics Yes

Analgesics Yes

Blood transfusion One unit





Post operative complications: Nil



no tenderness. Adviced Partial weight bearing after 2 wks with

the help of a walker


compression at the fracture site . Clinically Hip movements are

near normal. Adviced Full weight bearing after 4 wks with the

help of a walker

Six Months : Radiologically fracture heald. Clinically Hip

movements are normal with 1 cm shortening . Adviced unaided

walking


Moderate limp and fracture united by 7 months


CASE 8

Pre op post op

1 month 6 months

1 year

CASE NO :9

Name :V.Lakshmi IP. No.:28038

Age / Sex :68\F DOA :16\9\2009


Address: Totapalli guduru DOD :27\9\2009

nellore








Pre-Operative Traction: Skin traction one day

Time between Admission and Surgery: 1 Day


Anaesthesia SA



Implant DHS


Antibiotics Yes

Analgesics Yes

Blood transfusion 2 units





Post operative complication : Nil


One Month : Radiologically implant insitu. Clinically mild

tenderness present. Partial weight bearing is adviced after 4wks

with the help of a walker

Three Months : Radiologically implant insitu with moderate

compression at the fracture site. Clinically Moderate restriction of

hip movement and pain. Adviced Full weight bearing with the

help of a walker

Six Months : Radiologically fracture healed. Clinically

restriction of hip movements with pain and shortening of 1.4 cm

One Year : Mild pain and limp

Moderate restriction of movements

Fracture healed by 5 months

Harris hip score 82

CASE 9

PRE- OP POST-OP

1 month 3 months

6 months

CASE NO :10

Name :V.Subramanyam IP. No.:45361

Age / Sex :52\M DOA :5\4\2009


Address: Maipadu DOD :17\4\2009

nellore


Nature of Injury: High velocity


Associated Injuries: NIL

Associated Medical Problems: HYPERTENSION


Boyd-Griffin Classification TYPE 4

Pre-Operative Traction: Skeletal traction for 2 days



Anaesthesia SA



Implant DHS


Antibiotics Yes

Analgesics Yes






Post operative complications:-- Nil



mild tenderness present. Partial weight bearing is adviced after 3

wks with the help of walker


compression at the frcture site . Clinically marked restriction of

movments occasional pain. Adviced to Full weight bearing after

1 month with the help of a walker.

Six Months : Radiologically fracture united. Clinically

Moderate restriction of movements with flexion deformity,

occasional pain and shortening of 1.8 cm. Adviced to walk

unaided

One Year : Restriction of hip movements

Fixed flexion deformity

Harris hip score- 84

CASE 10 PRE-OP POST-OP

3 month 6 months

1 year

CASE NO :11

Name : T.Radhamma IP. No.:42645

Age / Sex :86\F DOA :3\1\2009


Address: Mulapet DOD : 16\1\2009

nellore

Time between Injury and Admission: Day of injury




Associated Medical Problems: Diabetic






Anaesthesia SA

Reduction Method Closed method


Implant DHS


Antibiotics Yes

Analgesics Yes






Post operative complications:- UTI



tenderness present. Advice Partial weight bearing after 3wks with

help of a walker


compression at the fracture site . Clinically hip movements are

near normal with moderate pain. Adviced Full weight bearing

with help of a walker

Six Months : Radiologically fracture united. Clinically hip

movements are normal with moderate pain and shortening of

1 cm. Adviced walking un aided

One Year :Moderate limp and tenderness

Movements are normal

Fracture united by 5 months


CASE 11 Pre- op post- op

1 month 3 months

6 months 1 year

CASE NO:12

Name :P.Rajyalakshmi IP. No.:53421

Age / Sex :69\F DOA :9\8\2009

Occupation: Housewife DOS : 15\8\2009

Address: Venkatagiri DOD : 25\8\2009

Time between Injury and Admission 3days




Associated Medical Problems: Hypertension and diabetes

RADIOGRAHY : X-ray No.5 Date: 9\8\2009





Anaesthesia SA

Reduction Method. Closed reduction


Implant DHS


Antibiotics yes

Analgesics yes






Post operative complications : Nil



tenderness present. Adviced Partial weight bearing after 4 wks

with help of walker


compression at the fracture site . Clinically Near normal hip

movements. Adviced FWB with the help of a walker.

Six Months : Radiologically fracture heald. Clinically

normal movements of hip with occasional pain . Adviced to walk

unaided


Mild limp

Fracture united by 5 months


CASE 12

PRE –OP POST- OP

3 months

6 months 1 year

POST OPERATIVE PROTOCOL

POST OPERATIVE PROTOCOL

All patients were allowed to flex the knee from 2nd

Post operative

day and physical ambulation was started on 8th Post operative day on an

average.

All the patients were covered with appropriate antibiotics.

All the patients were checked both clinically and radiologically

for the first 6 wks partial weight bearing was allowed with the help of a

walker.all patients were reviewed at 3 months both clinically and

radiological assement were done for placement of implant , compression

at the fracture site, examined for range of movements, tenderness and

shortening . All patients were adviced to weight bear with the help of

walker

At 6 months both clinical and radiological assessment were done,

check x-ray is taken to see weather fracture has heald. Clinically

examined for range of movements and tenderness ,shortening and any

fixed deformities. All Patients were adviced to walk with full weight

bearing.

All Patient were assessed between 9month or 1year for harris hip score

by DHS fixation for the analysis of results of intretrochanteric

fractures.

RESULTS

RESULTS

Finally, 28 patients in my study an average age group of 70 years,

with intertrochanteric fractures were analysed with an average follow-up

period of 09 months and average duration of stay in the hospital of 13

days.

The results were analysed using the Harris Hip Scoring System.

Union occurred in 26 fractures and 2 non-unions with screw

cut through. All the patients had some amount of shortening with

majority of the patients (16 patients) having a shortening of 0-1 cm, 9

patients with 1-2 cm of shortening and 3 patients with >2 cm shortening.

12 patients had short limb gait and 6 patients were using a cane on

ipsilateral side for walking. 2 of the patients in our study were squatting

and sitting on the floor cross - legged in spite of the advice that they

should not squat or sit on the floor cross-legged following surgery.

2 of the patients with non-union with coxa - vara had screw

cut – through.

The results were analysed based on the Harris Hip Scoring

System and the patients were categorized according to the scores they

attained as follows:

Excellent : 100 - 90

Good : 89 - 80

Fair : 79 - 70

Poor : < 70

RATE OF UNION

NO.OF

CASES STUDIED

UNION

NON-UNION

28 26 2

AMOUNTOFSHORTENING

NO.OF

CASES

STUDIEd

0-1cm 1-2 cm >2 cm

28 patients 16 pts 9 pts 3 pts

Harris hip score: 23

Pain:

None or ignores it - 44.

Slight, occasional, no compromise in activities - 40.

Mild pain, no effect on average activities, rarely moderate pain with

unusual activity; may take aspirin - 30.

Moderate pain, tolerable but makes concessions to pain; some limitation

of ordinary activity or work; may require occasional pain medicine

stronger than aspirin - 20.

Marked pain, serious limitation of activities - 10

Totally disabled, crippled, pain in bed, bedridden -0

Limp:

None - 11

Slight - 8

Moderate - 5

Severe - 0

Support:

None - 11

Cane for long walks - 7

Cane most of the time - 5

One crutch - 3

Two canes - 2

Two crutches - 0

Not able to walk - 0

Distance walked:

Unlimited - 11

Six blocks - 8

Two or three blocks - 5

Indoors only - 2

Bed and chair - 0

Stairs:

Normally without using a railing - 4

Normally using a railing - 2

In any manner - 1

Unable to do stairs - 0

Put on shoes and socks:

With ease - 4

With difficulty - 2

Unable - 0

Sitting:

Comfortably in ordinary chair one hour - 5

On a high chair for one-half hour - 3

Unable to sit comfortably in any chair - 0

Enter public transportation (1):

Yes.

No.

Flexion contracture : …… (degrees ).

Limb length discrepancy : …… ( cm ).

Absence of deformity: (All Yes - 4; Less Than 4-0)

Less than 300 fixed flexion contracture: Yes - No

Less than 100 fixed adduction: Yes - No

Less than 100 fixed internal rotation

in extension : Yes - No

Limb length discrepancy less than 3.2 cm : Yes - No

Range of motion:

Flexion ( 1400 ) : ……

Abduction ( 400 ) : ……

Adduction ( 400 ) : ……

External rotation (400 ) : ……

Internal rotation ( 400 ) : …

Range of motion score :

2110 - 300

0 : 5

1610 - 210

0 : 4

1010 - 160

0 : 3

610 - 100

0 : 2

310 - 60

0 : 1

00 - 30

0 : 0

Range of Motion Score: ……

Total Harris Hip Score: ……

Readmission to Hospital: Yes / NO

Date of Readmission: ….\….\….

Implant Removal Date: ….\….\….

Based on the above criteria the results of our study were as follows:

Excellent: 16 patients (57.14%)

Good : 6 patients (21.4 %)

Fair : 4 patients (14.28%)

Poor : 2 patients (7.14 %)

Our results were comparable with the studies of Malcolm L. Ecker, et

al19

, Philadelphia, Pennsylvania, (JBJS, Vol.57-A, No.1, Jan.1995) on

unstable intertrochanteric fractures , studies of BOLHOFNER,

BRETT R11

(journal of orthopaedic trauma, 13(1):5-8, January 1998,

studies of Babst, Nikolaus 7 (journal of orthopaedic trauma

12(6):392-399, august 1998.

STUDY GOOD

RESUL

TS

FAIR

RESULT

S

POOR

RESULTS

BOLHOFNER

BRETT R

73% 17% 9%

BABST,

NIKOLAUS

77% 13% 8.30%

MALCOM,

ECKER et,al

90% - 9.40%

PRESENT

STUDY

78.5% 14.28% 7.1%

DISCUSSION

DISCUSSION

28 cases of intertrochanteric fractures were treated by Dynamic

hip screw implant system. The purpose of the study was to evaluate the

result of treatment in these patients.

In the present study two cases of implant cut through. N.D

Chatterjee et al 43

reported coxa vara in 3 cases due to cutting of

implants through head & neck of femur and also proximal migration of

DHS with avascular changes of femoral head in one case. Mattan et al40

in 2002 reported 10 patients with osteoporosis developed painful

avascular necrosis after DHS fixation.

Heyse-Moore et. al, retrospectively compared the results of 107

intertrochanteric fractures stabilized with a sliding hip screw to 103

fractures treated with a Jewett nail and concluded that those patients

treated with the sliding hip screw had shorter hospitalization stays and a

lower incidence of fixation failure.28

. In our study average hospital stay

was 13days with failure of fixation in 7.1%

Bannister et. al, in a prospective randomized study of 155

intertrochanteric fractures stabilized using sliding hip screw and Jewett

nail, found that fractures that fractures stabilized with sliding hip screw

had a significantly lower risk of mechanical failure and a lower

incidence of revision surgery.9 In our study 2 case got sliding hip

screw cut through the head and neck of femur and required revision

surgery

Jacobs et. al, reported on a series of 173 intertrochanteric

fractures treated with internal fixation, 72 with a Jewett nail and 101

with a Sliding Hip Screw.29

Treatment failure – defined as either loss of

fixation, symptomatic joint penetration, osteonecrosis, malunion or

nonunion – occurred in 25% of fractures stabilized with a Jewett nail

and in 6% of fractures stabilized using a Sliding Hip Screw. In our study

failure rate was 7.1% by using sliding hip screw

Sernbo et. al, compared use of Ender nails to use of a Sliding Hip

Screw for the treatment of unstable intertrochanteric fractures in a

prospective randomized trial.49

Butt et. al, reported on a prospective, randomized controlled trial

that compared results in 95 consecutive patients who sustained a

pertrochanteric fracture of the femur and were treated using a Sliding

Hip Screw ( no. = 48) or a Gamma nail (no. = 47).15

whereas clinical

and radiological outcomes were similar, the Gamma nail was associated

with a higher incidence of complications - in particular, femur fracture

distal to the implant. In our study implant cut through was seen in 2

cases and arthritis in 1 case

Aune et. al, reported on a series of 378 intertrochanteric and

subtrochanteric fractures prospectively randomized to treatment with

either a Gamma nail ( 177 fractures ) or a Sliding Hip screw ( 201

fractures ).6 At an average follow-up of 17 months, 15 patients needed

revision surgery: 13 in the Gamma nail group and 2 in the Sliding Hip

Screw group. In our study 2 patients required revision surgery due to

implant cut through

Leung et. al, reported on a prospective series of 186

peritrochanteric fractures stabilized with either a Gamma nail or Sliding

Hip Screw.37

Gamma nails were inserted in a significantly shorter

operative time using a smaller incision and were associated with a

smaller estimated blood loss. There was, however, no significant

difference between the two groups with regard to 6-month mortality

rate, post-operative mobility, or hip function at fo7low-up. A higher

number of intraoperative complications occurred in fractures stabilized

with a Gamma nail. In our study there was no intraoperative

complications by using sliding hip screw

Baumgaertner et. al, reported on a series of 131 patients ( 135

fractures ) who sustained an intertrochanteric fracture and were

randomly assigned to treatment with either a Sliding hip Screw or an

Intramedullary Hip Screw ( IMHS ).10

In patients with unstable

intertrochanteric fractures, the intramedullary device was associated

with significantly less surgical time and blood loss; however, use of the

Intramedullary Hip Screw in patients who had a stable fracture pattern

required significantly greater fluoroscopy time. Intraoperative

complications occurred exclusively in the Intramedullary Hip Screw

group. At latest follow-up, there was no difference in the percentage of

functional recovery between the two fixation groups.

Hardy et. al, performed a prospective, randomized study

comparing use of a Sliding Hip Screw to use of an Intramedullary Hip

Screw ( IMHS ) for stabilization of 100 intertrochanteric fractures in

patients age 60 years or older.22

The operative time was significantly

greater with use of the intramedullary device; however, estimated

intraoperative blood loss was significantly lower. One fracture stabilized

with a Sliding Hip Screw had loss of fixation. The in-hospital and 6-

month mortality rates were similar between the two treatment groups.

The Intramedullary Hip Screw was associated with significantly less

screw sliding and limb shortening than the Sliding Hip Screw,

particularly when used to stabilize unstable fracture patterns. Based on

the results of this study, the authors concluded that routine use of the

Intramedullary Hip Screw cannot be recommended for stabilization of

intertrochanteric hip fractures.

Based on the available literature sliding hip screw is the implant

of choice in Interttrochanteric fractures

CONCLUSION

CONCLUSION

From this study we conclude that DYNAMIC HIP SCREW is a

RELIABLE, VERSATILE and EFFECTIVE device for the treatment

of intertrochanteric fractures.

SUMMARY

Summary

This is a prospective study of 28 patients with

intertrochanteric fractures . All the patients were treated

with dyanamic hip screw fixation . Patients were followed

up for an average period of 9months and the results were

analyzed by using the harris hip scoring system. Among

these patients union occurred in 26 patients, non-union

occurred in 2 patients due to dynamic compression screw

cut out. The analized results with harris hip score system

are excellent in 16 patients, good in 6 patients, fair in 4

patients and poor in 2 patients and these results are almost

similar to other international studies done in the same

method . So from this study we have concluded that

dynamic hip screw fixation in an effective method of

fixation of intertrochanteric fractures

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