Is Helical Blade Nailing Superior to Locked Minimally Invasive Plating in Unstable Pertrochanteric Fractures?
- First Online:
- 573 Downloads
Technical advancements have produced many challenges to intramedullary implants for unstable pertrochanteric fractures. Helical blade fixation of the femoral head has the theoretical advantages of higher rotational stability and cutout resistance and should have a lower rate of reoperation than a locked plating technique.
We asked whether (1) helical blade nailing reduces the rate of reoperation within 24 months compared with locked plating and (2) any of various preoperative, intraoperative, or postoperative factors predicted failure in these two groups.
We prospectively enrolled 108 patients with unstable pertrochanteric fractures in a surgeon-allocated study between November 2005 and November 2008: 54 with percutaneous compression plates (PCCP) and 54 with proximal femoral nail antirotation (PFNA). We evaluated patients regarding reoperation, mortality, and function. Seventy-four patients had a minimum followup of 24 months (mean, 26 months; range, 24–30 months).
We found no differences in the number of reoperations attributable to mechanical problems in the two groups: PCCP = six and PFNA = five. Despite a greater incidence of postoperative lateral wall fractures with helical blade nailing, only postoperative varisation of the neck-shaft angle and tip-apex distance (33 mm versus 28 mm) predicted reoperation. Mortality and function were similar in the two groups.
Our data suggest unstable pertrochanteric fractures may be fixed either with locked extramedullary small-diameter screw systems to avoid lateral wall fractures or with the new intramedullary systems to avoid potential mechanical complications of a broken lateral wall. Tip-apex distance and preservation of the preoperative femoral neck-shaft angle are the key technical factors for prevention of reoperation.
Level of Evidence
Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
- 2.Barton TM, Gleeson R, Topliss C, Greenwood R, Harries WJ, Chesser TJ. A comparison of the long gamma nail with the sliding hip screw for the treatment of AO/OTA 31-A2 fractures of the proximal part of the femur: a prospective randomized trial. J Bone Joint Surg Am. 2010;92:792–798.PubMedCrossRefGoogle Scholar
- 11.Hardy DC, Descamps PY, Krallis P, Fabeck L, Smets P, Bertens CL, Delince PE. Use of an intramedullary hip-screw compared with a compression hip-screw with a plate for intertrochanteric femoral fractures: a prospective, randomized study of one hundred patients. J Bone Joint Surg Am. 1998;80:618–630.PubMedGoogle Scholar
- 13.Janzing HM, Houben BJ, Brandt SE, Chhoeurn V, Lefever S, Broos P, Reynders P, Vanderschot P. The Gotfried PerCutaneous Compression Plate versus the Dynamic Hip Screw in the treatment of pertrochanteric hip fractures: minimal invasive treatment reduces operative time and postoperative pain. J Trauma. 2002;52:293–298.PubMedCrossRefGoogle Scholar
- 23.Marsh JL, Slongo TF, Agel J, Broderick JS, Creevey W, DeCoster TA, Prokuski L, Sirkin MS, Ziran B, Henley B, Audigé L. Fracture and dislocation classification compendium - 2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma. 2007;21(10 suppl):S1–S133.PubMedCrossRefGoogle Scholar
- 29.Parker MJ, Handoll HH. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults. Cochrane Database Syst Rev. 2010 Sep 8;(9):CD000093.Google Scholar
- 31.Peyser A, Weil YA, Brocke L, Sela Y, Mosheiff R, Mattan Y, Manor O, Liebergall M. A prospective, randomised study comparing the percutaneous compression plate and the compression hip screw for the treatment of intertrochanteric fractures of the hip. J Bone Joint Surg Br. 2007;89:1210–1217.PubMedCrossRefGoogle Scholar
- 32.Rudicel S, Esdaile J. The randomized clinical trial in orthopaedics: obligation or option? J Bone Joint Surg Am. 1985;67:1284–1293.Google Scholar
- 37.Varela-Egocheaga JR, Iglesias-Colao R, Suárez-Suárez MA, Fernández-Villán M, González-Sastre V, Murcia-Mazón A. Minimally invasive osteosynthesis in stable trochanteric fractures: a comparative study between Gotfried percutaneous compression plate and Gamma 3 intramedullary nail. Arch Orthop Trauma Surg. 2009;129:1401–1407.PubMedCrossRefGoogle Scholar