The percutaneous compression plate versus the dynamic hip screw for treatment of intertrochanteric hip fractures: a systematic review and meta-analysis of comparative studies

Influencing factors on morbidity and mortality in intertrochanteric fractures

We aimed to evaluate the effect of the patient's clinical and paraclinical condition before and after surgery on short-term mortality and complication and long-term mortality. A retrospective cohort study was conducted and multivariate logistic regression was applied to determine the effect of demographic characteristics (sex, age, AO/OTA classification, height, weight, body mass index), medical history (hypertension, ischemic heart disease, diabetes mellitus, thyroid malfunction, cancer, osteoporosis, smoking) lab data (Complete blood cell, blood sugar, Blood Urea Nitrogen, Creatinine, Na, and K), surgery-related factors (Anesthesia time and type, implant, intraoperative blood transfusion, postoperative blood transfusion, and operation time), duration of admission to surgery and anticoagulant consumption on short-term mortality and complication and long-term mortality. Three hundred ten patients from November 2016 to September 2020 were diagnosed with an intertrochanteric fracture. 3.23% of patients died in hospital, 14.1% of patients confronted in-hospital complications, and 38.3% died after discharge till the study endpoint. ΔNumber of Neutrophiles is the primary determinant for in-hospital mortality in multivariate analysis. Age and blood transfusion are the main determinants of long-term mortality, and Na before surgery is the primary variable associated with postoperative complications. Among different analytical factors Na before surgery as a biomarker presenting dehydration was the main prognostic factor for in hospital complications. In hospital mortality was mainly because of infection and long-term mortality was associated with blood transfusion.

Mortality and cardiorespiratory complications in trochanteric femoral fractures: a ten year retrospective analysis

PURPOSE

Despite intense research and innovations in peri-operative management, a high mortality rate and frequent systemic complications in trochanteric femoral fractures persist. The aim of the present study was to identify predictive factors for mortality and cardio-respiratory complications after different treatment methods in a ten year period at a level I trauma centre.

METHODS

Retrospectively, all patients above 60 years of age with trochanteric femoral fracture between January 2000 and May 2011 were analyzed at a level I trauma centre. Demographic variables, comorbidities, and data regarding the surgical procedures, including required transfusions and post-operative complications, were evaluated, and the in-hospital mortality was recorded. The grade of osteoporosis was classified radiographically using the Singh index.

RESULTS

The in-hospital mortality rate was 8.2% among 437 patients (male/female ratio = 110/327, mean age = 81 years) with extramedullary open (n = 144), intramedullary (n = 166), and extramedullary minimally invasive (n = 125) procedures. Significant influential factors on in-hospital mortality were identified with binary logistic regression analysis: an age of ≥90 years (P = 0.011), male sex (P = 0.003), a high American Society of Anesthesiologists (ASA) grade (3-5, P = 0.042), and a high osteoporosis grade (Singh index 3-1, P = 0.011). A total of 21.5% of the study population suffered cardio-respiratory complications post-operatively. The specific mortality was 28.7% (P < 0.001), which was influenced by a high ASA grade (3-5, P = 0.002) and a high transfusion rate (P = 0.004). Minimally invasive locked plating was associated with increased cardio-respiratory complications (P = 0.031).

CONCLUSIONS

This study identified high patient age, distinctive comorbidities, male sex, and high osteoporosis grade as significant risk factors for increased in-hospital mortality in the treatment of trochanteric femoral fractures. Furthermore, high ASA grade and a liberal transfusion regime led to an increased incidence of cardio-respiratory complications. Patient-specific characteristics, especially osteoporosis grade and pre-existing medical conditions, may assist in the identification of high-risk patients and allow a patient-specific geriatric co-management plan.

Proximal femoral nail antirotation versus dynamic hip screw fixation for treatment of osteoporotic type 31-A1 intertrochanteric femoral fractures in elderly patients

Objective To evaluate long-term radiographic and functional outcomes between dynamic hip screw (DHS) and proximal femoral nail antirotation (PFNA) fixation for treatment of osteoporotic type 31-A1 intertrochanteric femoral fractures (IFFs) among elderly patients Methods A retrospective comparative study was carried out. Follow-up was performed at 1, 3, 6, 9, and 12 months postoperatively and yearly thereafter. The primary outcome was the radiographic outcome, and the secondary outcome was the functional outcome. Results A significant difference in radiographic complications was observed between the DHS group (n = 45, 40.2%) and PFNA group (n = 15, 13.6%). The risk of femoral shaft fracture after implant removal at the 1-year follow-up was increased by 0.9% (n = 1) and 6.3% (n = 7) in the PFNA and DHS groups, respectively. This difference persisted with rates of 3.6% (n = 4) and 12.5% (n = 14) at the final follow-up. Additionally, significant differences were present in the Harris hip score at each visit. Conclusion Our results indicate that PFNA yields better outcomes than DHS fixation among elderly patients with osteoporotic type 31-A1 IFFs.

Can TAD and CalTAD predict cut-out after extra-medullary fixation with new generation devices of proximal femoral fractures? A retrospective study

BACKGROUND

Intramedullary and extramedullary strategies of pertrochanteric fracture fixation are still controversial, but new percutaneous devices may give advantages regarding operative time, blood loss and rate of cardiovascular complications. We retrospectively analyze our cases regarding Anteversa® plate (Intrauma, Turin, Italy) fixation of pertrochanteric femoral fractures, focusing on the correlation between two radiographical parameters (tip-apex distance "TAD" and calcar referenced tip-apex distance "CalTAD") and the occurrence of cut-out. The purpose of this study was to determine if these predicting factors of cut-out are reliable in the treatment of proximal femoral fractures with the Anteversa plate.

METHODS

A series of 77 patients with 53 31-A1 fracture types and 24-A2 fractures completed a 12-month-follow-up. Clinical outcomes were evaluated according to Parker-Palmer Mobility Score at the final follow-up. TAD and CalTAD were considered to determine their correlation with cut-out events.

RESULTS

The mean Parker-Palmer Score was 6.94 in A1 group and 7.41 in A2 group (p = 0.47). Mean value of TAD index was 29.58, 29.81 in the A1 group and 29.08 in the A2 group, and mean value of CalTAD index was 30.87, 31.03 in the A1 group and 30.50 in the A2 group. We observed 3 cases of implant cut-out. We shared our sample in two groups, one group with TAD and CalTAD indices lower than 25 mm and another group higher than 25 mm to evaluate how the Palmer Parker score changed and no statistical differences were found between the two groups.

CONCLUSIONS

Taking into consideration that good clinical results were obtained for TAD and CalTAD values superior to 25 mm, the prognostic value of 25 mm of TAD and CalTAD indices might not be appropriate to this new percutaneous plate.

Percutaneous compression plate versus dynamic hip screw for treatment of intertrochanteric hip fractures: A overview of systematic reviews and update meta-analysis of randomized controlled trials

PURPOSE

Intertrochanteric hip fractures lead to high morbidity and mortality rates. As a minimally invasive technique, many studies reported the efficacy of PCCP for the treatment of intertrochanteric fractures, but the controversy still existed in some outcomes. The purpose of this study was to evaluate the efficacy of PCCP and DHS by a overview of systematic reviews and well-designed, comprehensive update meta-analysis.

METHODS

PUBMED, SCOPUS, CCRCT, WANFANG and CNKI database were searched in all languages published up to April 2016. Systematic reviews and randomized controlled trials reporting outcomes of PCCP and DHS for intertrochanteric fractures were included. Meta-analyses comparing the two techniques were performed according to the Cochrane Handbook.

RESULTS

Five original trials and four systematic reviews met the inclusion criteria. Meta-analyses showed that the blood loss [SMD = -2.35, 95%CI(-4.26--0.44)], transfusion volume [SMD = -0.26, 95%CI(-0.47--0.06)] and complications [RR = 0.33, 95%CI(0.14-0.77)] was statistically less in PCCP group than DHS group while there was no significant difference between two groups in mortality rate, transfusion rate and length of hospital day.

CONCLUSIONS

PCCP is recommended to treat intertrochanteric hip fractures as an alternative minimally invasive method. More high-quality, randomized controlled trials that are adequately powered are needed to further evaluate the efficacy of PCCP and DHS.

The visible and hidden blood loss of Asia proximal femoral nail anti-rotation and dynamic hip screw in the treatment of intertrochanteric fractures of elderly high- risk patients: a retrospective comparative study with a minimum 3 years of follow-up

Background

The purpose of this study was to evaluate whether PFNA-II (Asia proximal femoral nail anti-rotation) and DHS (dynamic hip screw) carry substantial post-operative hidden blood loss and to compare PFNA-II with DHS in terms of post-operative hidden blood loss in elderly high-risk patients with intertrochanteric femur fractures(IFFs).

Methods

The clinical data from Jan 2005 to Apr 2015 of 186 patients with PFNA-II and 177 patients with DHS were analyzed retrospectively. Indexes including pre- and post-operative blood routine, intra- and post-operative blood loss and blood transfusion situation were analyzed. The situation of perioperative blood loss (visible and hidden) was assessed.

Results

The intra-operative blood loss in the PFNA-II group was 34.7 ± 2.5 ml, the post-operative visible blood loss was 54.7 ± 2.5 ml, and the hidden blood loss was 277.2 ± 7.6 ml. In the DHS group, the intra-operative blood loss was 102.0 ± 7.0 ml, the post-operative visible blood loss was 78.8 ± 4.7 ml, and the hidden blood loss was 139.3 ± 9.6 ml. The intra-operative blood loss and the post-operative visible blood loss in the PFNA-II group were significantly less than in the DHS group (p < 0.01). However, the post-operative hidden blood loss and the total blood loss in the PFNA-II group were larger than in the DHS group (p < 0.01).

Conclusion

This study demonstrated that with PFNA-II and DHS, much post-operative hidden blood loss exists in the treatment of intertrochanteric fractures in elderly high-risk patients and DHS is more favourable than PFNA-II in terms of post-operative hidden blood loss.

Comparison of Outcomes of Intertrochanteric Fracture Fixation Using Percutaneous Compression Plate Between Stable and Unstable Fractures in the Elderly

OBJECTIVES

To evaluate the outcomes of treatment with a percutaneous compression plate (PCCP) in stable and unstable intertrochanteric hip fractures.

DESIGN

Clinical prospective nonrandomized cohort study.

SETTING

San Cecilio University Hospital, Granada (Spain). A tertiary-care hospital.

PATIENTS

Patients older than 65 years undergoing surgery for an intertrochanteric hip fracture (n = 657) were divided according to the OTA/AO classification, into stable (31-A1) (group A, n = 363) and unstable fractures (31-A2) (group B, n = 294).

INTERVENTION

Osteosynthesis with a PCCP (Orthofix Inc).

MAIN OUTCOME MEASUREMENTS

Blood loss, wound complications, postoperative pain, operative and fluoroscopy time, functional outcomes, device-related complications, consolidation time, and mortality.

RESULTS

Patients with unstable fractures were significantly worse with respect to postoperative pain, immediately (P = 0.020), at 6 weeks (P = 0.0001), and at 3 months (P = 0.009), and with respect to independent walking ability at 6 weeks. No other significant differences were observed.

CONCLUSIONS

The outcomes of osteosynthesis with PCCP seem to be equally satisfactory in stable and unstable intertrochanteric fractures, with stable fractures having less pain and a greater ability to walk earlier.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Internal fixation treatments for intertrochanteric fracture: a systematic review and meta-analysis of randomized evidence

The relative effects of internal fixation strategies for intertrochanteric fracture after operation remain uncertain. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to address this important issue. We searched PubMed, EMBASE and CENTRAL for RCTs that compared different internal fixation implants in patients with intertrochanteric fracture at 6-month follow-up or longer. We ultimately included 43 trials enrolling 6911 patients; most trials were small in sample sizes and events. Their risk of bias was generally unclear due to insufficient reporting. Because of these, no statistically significant differences were present from most of the comparisons across all the outcomes, and no definitive conclusions can be made. However, a number of trials compared two commonly used internal fixation strategies, gamma nail (GN) and sliding hip screw (SHS). There is good evidence suggesting that, compared to SHS, GN may increase the risk of cut out (OR = 1.87, 95% CI, 1.08 to 3.21), re-operation (OR = 1.61, 95% CI, 1.02 to 2.53), intra-operative (OR = 3.14, 95% CI, 1.34 to 7.35) and later fractures (OR = 3.67, 95% CI, 1.37 to 9.83). Future randomized trials or observational studies that are carefully designed and conducted are warranted to establish the effects of alternative internal fixation strategies for intertrochanteric fracture.

Mid-term results after treatment of intertrochanteric femoral fractures with percutaneous compression plate (PCCP)

BACKGROUND

With the ageing of the population, intertrochanteric femoral fracture is associated with increased morbidity. There is continuing controversy over the best treatment for the injury, and the choice of internal fixation method has been a focus of dispute. The purpose of this study was to evaluate the results of these fractures being treated with the percutaneous compression plate (PCCP) technique.

METHODS

From March 2009 to May 2012, 154 patients with intertrochanteric femoral fractures were treated using the PCCP method. Forty-one patients were excluded from the study. According to the AO classification, the remaining 113 fractures were classified as 35 cases of 31A1 fractures, 59 cases of 31A2 fractures, and 19 cases of 31A3 fractures. The clinical data and imaging results were retrospectively analysed.

RESULTS

The mean operation time was 42.0 (range, 25-82) min, the mean intraoperative blood loss was 40.5 (range, 10-100) ml, and the mean hospital stay was 8.6 (range, 3-18) days. One patient died of renal failure in the perioperative period. Twelve patients died during the 12 months after surgery. The remaining 100 patients were followed-up for 12-36 months and healed their fractures except one, whose neck screw cut out from the femoral neck after 1 postoperative month and resulting in a revision to a hemiarthroplasty. The mean time to bone healing was 12.6 (range, 6-23) weeks. Sixteen patients had pain. There were 13 major device-related complications, including 5 cases of coxa vara, 4 cases of fracture collapse, 2 cases of head penetration, and 2 cases of fracture collapse combined with head penetration. At the time of the last follow-up, 81 patients had regained a pre-injury level of function. The median Harris hip score was 89 points. The median Parker-Palmer score was 7 points. Patients with poor quality of reduction and bad positioning of neck screw were more likely to suffer complications (p<0.05).

CONCLUSION

The results suggest that the PCCP is an effective and safe method in the treatment of all types of intertrochanteric femoral fractures, but good fracture reduction and ideal positioning of the neck screw are prerequisites for the success of the device.

Proximal femoral nails antirotation, Gamma nails, and dynamic hip screws for fixation of intertrochanteric fractures of femur: A meta-analysis

BACKGROUND

Which surgical strategy is the best one for intertrochanteric fractures remains a controversial issue. Dynamic hip screw (DHS) and Gamma nail were commonly used but often associated with some complications, such as fixation failure and implant-related fractures. Meanwhile, proximal femoral nail anti-rotation (PFNA) fixation has recently been developed for minimally invasive surgery to reduce the complications rate. To facilitate the clinical decision-making, we conducted an updated meta-analysis to discuss the optimal treatment of intertrochanteric fractures aiming to determine which implant gives the lower rates of blood loss, complications (peri-implant fracture, fixation failure, infection, thromboembolic), reoperation, and mortality, as well as the minimal duration related to surgery (fluoroscopic exposure, surgery and hospital stay).

PATIENTS AND METHODS

Seven electronic databases were searched for randomized controlled trials (including OVID, Springer, Google Scholar, PubMed, Cochrane library, Embase, and Web of Science). Fourteen studies with 1983 patients were included. The modified Jadad Scale was used to assess the methodological quality of these studies. Risk of bias in the included studies was assessed using the Cochrane Risk of Bias tool. Comparison among the three groups was based on twelve indicators, including operative time, fluoroscopy time, operative blood loss, length of hospital stays, wound infection or hematoma, pneumonia, thromboembolic complications, fixation failure, operative fracture of femur, later fracture of femur, reoperation, and mortality.

RESULTS

(1) PFNA group versus DHS group: PFNA was associated with less blood loss (mean difference (MD) -253.86, 95% CI -270.25 to 237.47; P<0.00001) and lower rate of fixation failure (MD 0.20, 95% CI 0.07 to 0.59; P=0.004), but led to more fluoroscopy time (MD 2.11, 95% CI 1.78 to 2.43; P<0.00001). (2) PFNA group versus Gamma nail group: PFNA led to less blood loss (MD -55.30, 95% CI -60.07 to -50.53; P<0.00001), shorter fluoroscopy time (MD -0.50, 95% CI -0.55 to -0.45; P<0.00001) and length of hospital stay (MD -0.20, 95% CI -0.27 to -0.13; P<0.00001). (3) DHS group versus Gamma nail group: DHS was associated with lower rate of operative fracture of femur (MD 0.31, 95% CI 0.11 to 0.89; P=0.03), later fracture of femur (MD 0.16, 95% CI 0.06 to 0.43; P=0.0004), and reoperation (MD 0.49, 95% CI 0.27 to 0.88; P=0.02), but caused more blood loss (MD 29.49, 95% CI 8.27 to 50.70; P=0.006). In contrast, there was no difference regarding operative time, infection hematoma, pneumonia, thromboembolic events, and mortality.

DISCUSSION

PFNA should be a priority choice for treatment of intertrochanteric fractures with minimal rate of fixation failure, less blood loss and shorter length of hospital stay. DHS has distinct advantages over Gamma nail with lower rate of plant-related complications and should be preferred device for intertrochanteric fractures. However, owing to the low quality evidence currently available, more high-quality RCTs are needed to confirm these findings.

LEVEL OF EVIDENCE

Level II.

A comparison of proximal femoral locking compression plates with dynamic hip screws in extracapsular femoral fractures

INTRODUCTION

The potential value of proximal femoral locking compression plate (PFLCP) for extracapsular femoral fractures has been discussed in several case reports; however, clinical control studies are lacking. Therefore, we performed a case control study to assess: (1) If PFLCP offers better functional results and fewer complications than dynamic hip screws (DHS)? (2) Which kind of extracapsular femoral fractures would benefit from PFLCP fixation?

HYPOTHESIS

The PFLCP fixation offers better functional results and fewer complications than the DHS for the treatment of extracapsular fractures.

PATIENTS AND METHODS

A total of 83 patients with extracapsular femoral fractures were recruited. Forty-one patients underwent PFLCP fixation, and 42 patients underwent DHS fixation. Patient information, operative time, blood loss, functional level (as assessed by Sanders' traumatic hip rating scale), bone union, and implant complications were compared for the two treatment groups.

RESULTS

Patients with stable intertrochanteric fractures who underwent PFLCP fixation demonstrated shorter bone union time than the DHS fixation group (3.3 ± 0.2 vs. 4.3 ± 0.1 month; P<0.0001); however, both groups had 100% bone union and good to excellent scores on Sanders' traumatic hip rating scale (P=1.000). Patients with unstable intertrochanteric fractures who underwent PFLCP fixation experienced greater blood loss (619.0 ± 23.9 vs. 474.1 ± 19.8 ml; P<0.0001), which was mainly due to the need for open reduction (64.3% vs. 12.5%; P=0.003), compared to the DHS fixation group. No differences were identified with respect to bony union, functional level, or complications. Patients with subtrochanteric fractures who underwent PFLCP fixation demonstrated significantly shorter operative times (82.1 ± 4.3 vs. 102.2 ± 2.2 minutes; P<0.0001), less blood loss (751.8 ± 25.4 vs. 987.6 ± 32.0 ml; P<0.0001), shorter bone union times (5.2 ± 0.4 vs. 8.8 ± 1.0 month; P=0.006), more good to excellent Sanders' traumatic hip rating scale scores (92.9% vs. 55.5%; P=0.009), and fewer complications (14.2% vs. 66.6%; P=0.005) than the DHS fixation group.

CONCLUSION

PFLCP fixation offers better functional outcomes and fewer complications for subtrochanteric femoral fractures but not for intertrochanteric femoral fractures.

LEVELS OF EVIDENCE

Case control study, level III.

Percutaneous compression plate versus dynamic hip screw for treatment of intertrochanteric Hip fractures: a meta-analyse of five randomized controlled trials

BACKGROUND

Percutaneous compression plating (PCCP) has been advocated to reduce blood loss, relieve pain, and lead to faster rehabilitation for the treatment of intertrochanteric fractures. The purpose of this meta-analysis was to estimate the outcomes and complications of the PCCP versus dynamic hip screw (DHS) fixation for intertrochanteric fractures.

METHODS

All randomized controlled trials (RCT) that compared PCCP with DHS in treating adult patients with intertrochanteric fractures were included. Main outcomes were collected and analysed using the RevMan 5.1 version.

RESULTS

Five trials met the inclusion criteria. Compared with DHS, PCCP had similar operation time (95% CI: -26.01~4.05, P = 0.15), length of hospitalization (95% CI: -1.79~1.25, P = 0.73), mortality (95% CI: 0.37~1.02, P = 0.06), incidence of implant-related complications (95% CI: 0.29~1.82, P = 0.49), and reoperation rate (95% CI: 0.41~3.05, P = 0.83). But blood loss (95% CI: -173.84~-4.81, P = 0.04) and transfusion need (95% CI: -0.53~-0.07, P = 0.01) significantly favored the PCCP.

CONCLUSIONS

The PCCP was associated with reduced blood loss and less transfusion need, but similar to DHS in other respects. Owing to the limitations of this systematic review, more high-quality RCTs are still needed to assess the clinical efficiency of PCCP.

Treatment of AO/OTA 31-A3 intertrochanteric femoral fractures with a percutaneous compression plate

OBJECTIVE

AO/OTA 31-A3 intertrochanteric femoral fractures have completely different fracture line directions and biomechanical characteristics compared with other types of intertrochanteric fractures. The choice of the fixation method has been a focus of dispute among orthopedic trauma surgeons. The purpose of this study was to review the outcomes of these fractures treated with a percutaneous compression plate at our institute.

METHOD

Seventeen patients with AO/OTA 31-A3 intertrochanteric femoral fractures were treated with a percutaneous compression plate at our institute from January 2010 to December 2011. The clinical data and imaging results were retrospectively analyzed.

RESULTS

The medical complication of popliteal vein thrombosis occurred in one patient. Sixteen patients were followed up for 12 to 21 months. Two patients had malunion and mild pain. Fracture collapse occurred in two patients, with one having head penetration. These two patients had moderate pain. There were no occurrences of nonunion or reoperation. The mean Harris hip score obtained during the last follow-up was 84.1 (61-97). Patients with a poor quality of reduction were more likely to have pain results (p = 0.001). A trend existed toward the presence of a poor quality of reduction (p = 0.05) in patients with a collapse of fracture. Patients with poor preoperative mobility were more likely to have a lower Harris hip score (p = 0.000).

CONCLUSION

The percutaneous compression plate is an alternative device for the treatment of AO/OTA 31-A3 intertrochanteric femoral fractures. Good fracture reduction and an ideal placement position of the neck screw are important in the success of the device.