|Year : 2022 | Volume
| Issue : 1 | Page : 46-52
Minimally invasive versus conventional fixation of stable intertrochanteric fracture by dynamic hip screw – A prospective study comparing the two techniques
Arnab Karmakar1, Pinaki Das1, Ayon Ghosh2
1 Department of Orthopaedics, Institute of Post Graduate Medical Education and Research and Seth Sukhlal Karni Memorial Hospital, Kolkata, West Bengal, India
2 Department of Orthopaedics, Nil Ratan Sircar Medical College and Hospital, Kolkata, West Bengal, India
|Date of Submission||30-Dec-2021|
|Date of Decision||16-Jan-2022|
|Date of Acceptance||18-Jan-2022|
|Date of Web Publication||15-Mar-2022|
B 1512 Sector 6 CDA Cuttack - 753 014, Odisha
Source of Support: None, Conflict of Interest: None
Background: Intertrochanteric fractures of femur are one of the most common fractures encountered in the elderly population. Dynamic hip screw (DHS) with a side plate is the standard modality of treatment especially in the case of stable fractures because it creates a controlled collapse at fracture site, leading to union. A comparative study between minimally invasive surgical technique with the conventional surgical technique for the fixation of intertrochanteric fractures with the DHS device was done. Methods: Thirty patients with stable intertrochanteric fractures (31A1.1, 31A1.2, and 31A1.3) were treated with the conventional open technique and another thirty with a new minimally invasive technique. Patients in both groups were followed up for at least 9 months. Results: There was less preoperative and postoperative blood loss, less soft-tissue destruction, less pain postoperatively, shorter hospital stays, and early mobilization and faster union with the minimally invasive technique. Conclusion: The study concludes that minimally invasive technique is superior to conventional (open) DHS in stable fractures.
Keywords: Dynamic hip screw, intertrochanteric, minimally invasive surgery, stable
|How to cite this article:|
Karmakar A, Das P, Ghosh A. Minimally invasive versus conventional fixation of stable intertrochanteric fracture by dynamic hip screw – A prospective study comparing the two techniques. J Orthop Dis Traumatol 2022;5:46-52
|How to cite this URL:|
Karmakar A, Das P, Ghosh A. Minimally invasive versus conventional fixation of stable intertrochanteric fracture by dynamic hip screw – A prospective study comparing the two techniques. J Orthop Dis Traumatol [serial online] 2022 [cited 2022 May 24];5:46-52. Available from: https://www.jodt.org/text.asp?2022/5/1/46/339683
| Introduction|| |
Hip fractures are among the most common fractures encountered in orthopaedic trauma. Intertrochanteric fractures comprise approximately 50% of all hip fractures. The incidence is more in female population compared to males due to osteoporosis. In spite of advances in anaesthesia, nursing care, and surgical techniques, hip fractures remain a significant cause of morbidity and mortality in the elderly population. These fractures have to be treated properly in modern times because as the average life expectancy increases in the elderly population, the incidence of senile osteoporosis tends to be more and orthopedic surgeons encounter more number of cases.,,, Intertrochanteric fractures in the elderly are associated with high rates of mortality, ranging from 15% to 20%, as they are at a substantial risk for deep-vein thrombosis, urinary tract infections, and pulmonary embolism, if they fail to mobilize or ambulate early. Stabilization of the fracture surgically ensures early mobilization and anatomical union. Thus, operative stabilization is now the gold standard treatment in intertrochanteric fractures. Although other options are available, the standard approach is to use a dynamic hip screw (DHS) with a 4-holed side plate in stable fractures at most centers especially in stable fractures.,
Traditionally, a wide surgical exposure is preferred due to which there are a large skin incision, considerable soft-tissue damage, significant blood loss, and increased operative time and pain. Several studies are available describing that the minimally invasive DHS technique provides better outcome regarding the operating time, length of hospital stay, and blood loss compared to those of the conventional approach.,,,
| Methods|| |
The study was conducted at a tertiary care center in eastern India. Prior to the commencement of the study, ethical clearance was obtained from the institutional review board. Informed consent was taken from all patients prior to their inclusion. The study population constituted of patients presenting to outdoor and emergency with proximal femur fractures, from January 2017 to January 2019. The senior authors were the treating physicians in all the cases. All the patients included were above 18 years of age, with a body mass index <30 and who gave consent for the surgery.
Considering the inclusion and exclusion criteria, thirty patients for each operative procedure were selected consecutively for comparative analysis. All had stable intertrochanteric fractures (AO Classification- 31A1.1, 31A1.2, and 31A1.3). All the patients underwent surgical fixation within 10 days of admission. Reduction was achieved using a fracture table and fixed with 135° DHSs with 4-hole side plate: 30 patients using conventional (open) technique (conventional DHS) and another 30 patients with minimally invasive technique (minimally invasive DHS). The method of randomization was alternate patient selection. Patients in both the groups were matched with respect to age, preoperative hemoglobin level, and morbidity. Stainless steel implants were used and each of them belonged to the same manufacturer. Preoperative and postoperative clinical details were recorded for all the cases. The various comorbidities of the patients included are tabulated in [Table 1]. In particular, the difference between pre- and postoperative hemoglobin levels (hemoglobin drop) was also measured, which is an indicator of blood loss. Patients received routine antibiotic prophylaxis that was given intravenously on induction of anesthesia. The operating time was measured from the beginning of skin incision to skin closure. In all the cases of both conventional DHS group and minimally invasive group, drains were removed 48 h after surgery. All patients were rehabilitated using the same standard postoperative hip fracture management protocol by starting mobilization as soon as pain subsided. The length of hospital stay was noted for each case and complications were also recorded for both the groups. The surgical technique for both the procedures is described below.,,
A longitudinal skin incision of 10–15 cm in length was made over the lateral aspect of the upper thigh, starting from the middle of the greater trochanteric prominence and extending down the lateral aspect of femoral shaft. The fascia lata was incised longitudinally in the line of skin incision. The vastus lateralis muscle was split under direct vision. Fracture was reduced and its confirmation was done with a fluoroscope. Following fixation of the fracture in the standard fashion with 135° DHS with 4-hole side plate, a number 16 suction drain was inserted, and the incision was closed in layers.
Minimally invasive dynamic hip screw
All fractures in this study received adequate closed reduction under fluoroscopy guidance (anatomical to 10° of valgus on anteroposterior radiograph and anatomical on lateral radiograph) prior to the start of operation. Proximal fragment's rotational deformity was corrected by direct thumb pressure over the anterior aspect of the neck. The guide wire was inserted under fluoroscopic guidance by the identification of the site on the hip that corresponded to the position of the fracture. The guide wire was kept in center-center position in both antero-posterior and lateral views [Figure 1] and [Figure 2]. Another guide wire was inserted above the first guide wire through the fracture which prevented rotation [Figure 3]. Then, an incision was given just from above the point of entry of the first guide wire and laterally along the femur. The size of the incision was within 5 cm. The iliotibial band was cut longitudinally with scissors both proximally and distally, and the vastus lateralis muscle was split through the incision. Reaming was carried out through this incision with Tripple reamer in standard fashion after taking in account the length of the lag screw to be inserted. The lag screw was inserted as usual. At the end, the handle of the lag screw inserter was kept at 90° with respect to the floor/horizontal in contrary to the conventional technique where it is kept parallel to the floor [Figure 4]. Then, the first guide wire was removed. After this, barrel of the plate was introduced around the lag screw and it was rotated 90° upward with the help of an artery forceps in the last hole of the plate sliding it beneath the skin which was kept retracted by the assistant. The 2nd and 3rd screws were inserted after proper measurement. Then, slight hammering was done at the barrel junction with the help of an impactor. After that, the traction was released a little and the top screw was inserted to achieve fracture site compression. The remaining side plate screws were then placed in the usual manner through side plate holes by retracting the skin and subcutaneous tissue with a right-angled soft-tissue retractor. Final construct was checked under C-arm [Figure 5] and [Figure 6].
|Figure 1: Intraoperative fluoroscopy image – AP view; guide wire placement postreduction|
Click here to view
|Figure 2: Intraoperative fluoroscopy image – Lateral view; guide wire placement postreduction|
Click here to view
|Figure 3: Intra-operative fluoroscopy image – AP view; insertion of additional guide wire for de-rotation|
Click here to view
|Figure 4: Schematic diagram demonstrating the introduction of dynamic hip screw barrel perpendicular to the intended direction. The screw-plate construct is rotated 90° underneath the soft tissue envelope in the minimally invasive technique|
Click here to view
|Figure 6: Intraoperative fluoroscopy image – Lateral view; final construct|
Click here to view
A number 12–16 suction drain was used. The deep layers and the skin incision were closed in the usual fashion [Figure 7]. Bedside knee bending and chest physiotherapies were started as soon as pain subsided. Partial weight bearing walking with walker was allowed after 2 weeks. Stitches were removed after 14 days. Full weight bearing was started after achievement of radiological bony union [Figure 8]a and [Figure 8]b. X-rays were done at 6 weeks, 8 weeks, 10 weeks, 3 months, 6 months, and 9 months.
|Figure 7: Postoperative – Clinical image demonstrating the 5-cm incision|
Click here to view
|Figure 8: (a) Preoperative radiograph. (b) 6-week postoperative radiograph- AP and lateral views demonstrating union of the fracture|
Click here to view
| Results|| |
Compared to patients in the conventional group, those in the minimally invasive group had shorter operating time and less blood loss. The drain output at the 2nd postoperative day did not show any significant difference in them. The decrease in hemoglobin also did not show any significant difference between the groups. At the 2nd postoperative day, visual analog scale pain scoring was done; among the conventional DHS group, 50% (15/30) of the patients had severe pain, whereas in the minimally invasive group, most of the patients (56.66% [17/30]) patients had moderate pain. Patients undergoing minimally invasive DHS also had a shorter duration of hospital stay and could be discharged early. There was no early postoperative mortality in both the groups, but the 6-month mortality was 10% (3/30) in the conventional group, while in the minimally invasive group, it was 3.33% (1/30). A 9-month mortality of 13.3% (4/30) was found in the conventional DHS group, whereas 6.66% (2/30) was found in the minimally invasive group. The average time of bony union among the conventional group was 10 weeks as compared to 8 weeks in the minimally invasive DHS group. Among the conventional DHS group, two patients had superficial discharge (both of them were diabetic) for 2 weeks which subsided on starting culture-specific antibiotic and strict control of diabetes. The results are tabulated in [Table 1].
| Discussion|| |
Fractures around hip are a common occurrence among the elderly and often occur due to low-energy trauma/fall. Intertrochanteric fractures are often encountered in such scenarios. Although an array of implants, both intramedullary and extramedullary, are present in the armamentarium of the surgeon, the operative treatment of intertrochanteric femoral fractures remains a challenge. The DHS provides rigid fixation and allows early mobilization by enabling optimal collapse and compression at the fracture site. It is the most commonly used extramedullary device for intertrochanteric fractures and reports excellent outcome., The controlled collapse at fracture site facilitates the bony union.
Intertrochanteric fractures often occur in the elderly, having multiple comorbid conditions, which may be worsened by the trauma associated with the surgery. Therefore, a minimally invasive DHS technique, with less bleeding and shorter operative time, can provide good stable fixation while avoiding extensive soft-tissue injury.,,
The conventional technique with a long 10–15 cm incision causes significant bleeding and damage to the underlying soft tissues. Minimally invasive trauma surgeries are the emerging trends in the field of orthopedics. In orthopedics, minimally invasive surgery has been extensively used for the management of distal tibia fractures, distal femur fractures, humerus shaft fractures, proximal humerus fractures, and also for fixation of spine fractures. The procedures though technically demanding with a steep learning curve, with adequate training and surgical skills, provide good outcomes. The benefits are due to early rehabilitation and decreased surgical site complications. The local tissue biology remains largely undisturbed.
In previous studies by Alobaid et al. and Wong et al.,, it was found that decreased operative time is crucial for elderly patients, decreasing the time of anesthesia, which is of immense importance in patients with poor cardio-pulmonary reserve. The reduced surgical trauma may be significant in reducing postoperative morbidity and mortality in such patients and aiding in early mobilization., The present study reports reduced surgical time for the patients undergoing invasive surgery [Figure 9]. Postoperative morbidity and mortality shall be decreased, and there is decreased requirement of blood transfusions., Similar conclusions were made in the current study. In the minimally invasive group, there were decreased blood loss intraoperatively [Figure 10], postoperative drain output, and fall in hemoglobin, which were also less as compared to those of the conventional technique [Table 2].
|Figure 9: Graph demonstrating difference in surgery duration between the two groups|
Click here to view
|Figure 10: Graph demonstrating difference in intraoperative blood loss between the two groups|
Click here to view
|Table 2: Demographic data, early and late postoperative parameters, and radiological parametres|
Click here to view
In the study by Prete et al., the surgical trauma in per-trochanteric fractures was quantified in the conventional and minimally invasive surgical techniques based on variations in the levels of inflammation markers (interleukins). Significantly higher level of interleukin 6 (IL-6) was found in the postoperative period in patients operated by conventional technique than in those operated by minimally invasive technique. IL-6 levels enable measurement of not only local tissue trauma but also the subsequent systemic response. By measuring the invasiveness of the intervention (second hit/additional tissue trauma) based on levels of interleukins, it could become possible not only to detect local damage but also to obtain an independent predictor of risk/outcome in elderly patients with per-trochanteric fracture. However, a study by Lee et al. showed a relatively high incidence of avascular necrosis of the femoral head with the minimally invasive technique. Vascular insult to the femoral head may therefore be considered as one potential drawback of this technique.
A meta-analysis of studies on minimally invasive versus conventional DHS,,, performed by Zhou et al. concluded that there was a lower rate of serious postoperative complications in the minimally invasive DHS group compared with the conventional DHS group. Significant differences were seen in the average operative time, hemoglobin depreciation, and length of inpatient stay in the minimally invasive DHS group. The results reported in this study are also statistically significant for the above parameters [Figure 11].
|Figure 11: Graph demonstrating difference in hospital stay between the two groups|
Click here to view
Some of the recent studies by Verhofstad et al. and McLoughlin et al., inferred that stable per-trochanteric fixation can be successfully achieved with two-hole DHS plate. Thus, it appears that the use of four-hole DHS plate is a traditional trend with no definitive advantage in outcomes. Therefore, using the two-hole DHS in nonosteoporotic patients can be easily performed with smaller surgical exposure, thus decreasing the operative time. However, two-hole DHS plates were not available for the current study, hence could not be implemented. In the present study, a significant number of patients were osteoporotic, with the vast majority being elderly females from poor socioeconomic background. Thus, fracture fixation using longer side plates were desirable as per literature.
The average time to union in the present study in patients fixed with conventional techniques was reported to be 10 weeks, while in the minimally invasive technique, it was around 8 weeks [Figure 12]. Hence, the average time to union was shorter in the minimally invasive group.
|Figure 12: Graph demonstrating difference in union time between the two groups|
Click here to view
Use of intramedullary nails such as PFN and gamma nail is on the rise. The perceived benefits are the smaller incision, rapid surgery, and better biomechanical stability.,,,,, However, in the meta-analysis by Parker and Handoll, there was no statistical difference in the operative time, blood loss, or radiation exposure among the 3500 patients included in the study. There were more chances of intra and postoperative fractures, technical complications, and reoperation rates associated with the nailing group. Song et al., prospectively analyzed the systemic effects by comparing the pre-operative and postoperative values of creatine phosphokinase (CPK) and C-reactive protein (CRP) in intertrochanteric fracture patients operated with DHS and gamma nail. The levels of CRP were statistically lowerDHS than that in the gamma nail group on the 1st and 2nd postoperative days, concluding that though the incisions may be smaller or equal in gamma nail group than DHS, the latter is systemically less invasive than the former, as CRP is widely accepted as a marker of systemic inflammation. This finding probably reflects the tissue injury due to intramedullary reaming. Also, the serum CPK levels were not lower in the gamma nail group even with a smaller incision, which could be due to muscle damage during reaming or muscle compression as speculated by the authors.
The present study was of a relative short duration and constituting a small study group. Further prospective studies with a larger number of patients, proper randomization and blinding procedures, and robust analysis will provide more significant results. Another limitation of the present study was the deficiency of documentation of the radiological position of the lag screws. It should also be taken into consideration that performing a minimally invasive DHS in obese patients is cumbersome. Thus, utilizing the novel technique illustrated in this study, DHS can be performed in a minimally invasive manner, and with proper technique and patient selection, excellent outcomes can be achieved.
| Conclusion|| |
To conclude, both the minimally invasive DHS and the conventional DHS are effective, simple, and safe for the treatment of stable intertrochanteric fractures. Compared to the conventional DHS, the minimally invasive DHS reports a shorter operative time, less blood loss, decreased hospital stay, early mobilization, less postoperative pain, and early bony union.
We would like to acknowledge all the faculty members and junior residents who helped relentlessly in conducting our research work.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Koval KJ, Zuckerman JD. Hip Fractures: A Practical Guide to Management. 2000: Springer New York, NY. p. 138-40.
Evans EM. The treatment of trochanteric fractures of the femur. J Bone Joint Surg Br 1949;31B: 190-203.
LaVelle DG. Fractures of hip. In: Campbell's Operative Orthopaedics. Vol. 1. ELsevier: Mosby; 2003. p. 28-75.
Alobaid A, Harvey EJ, Elder GM, Lander P, Guy P, Reindl R. Minimally invasive dynamic hip screw: Prospective randomized trial of two techniques of insertion of a standard dynamic fixation device. J Orthop Trauma 2004;18:207-12.
Wong TC, Chiu Y, Tsang WL, Leung WY, Yeung SH. A double-blind, prospective, randomised, controlled clinical trial of minimally invasive dynamic hip screw fixation of intertrochanteric fractures. Injury 2009;40:422-7.
Kaplan K, Miyamoto R, Levine BR, Egol KA, Zuckerman JD. Surgical management of hip fractures: An evidence-based review of the literature. II: Intertrochanteric fractures. J Am Acad Orthop Surg 2008;16:665-73.
Verhofstad MH, van der Werken C. DHS osteosynthesis for stable pertrochanteric femur fractures with a two-hole side plate. Injury 2004;35:999-1002.
Lyons AR. Clinical outcomes and treatment of hip fractures. Am J Med 1997;103:51S-63S.
Lee YS, Huang HL, Lo TY, Huang CR. Dynamic hip screw in the treatment of intertrochanteric fractures: A comparison of two fixation methods. Int Orthop 2007;31:683-8.
Wang JP, Yang TF, Kong QQ, Liu SJ, Xiao H, Liu Y, et al.
Minimally invasive technique versus conventional technique of dynamic hip screws for intertrochanteric femoral fractures. Arch Orthop Trauma Surg 2010;130:613-20.
Mattisson L, Bojan A, Enocson A. Epidemiology, treatment and mortality of trochanteric and subtrochanteric hip fractures: Data from the Swedish fracture register. BMC Musculoskelet Disord 2018;19:369.
Mahmood A, Kalra M, Patralekh MK. Comparison between conventional and minimally invasive dynamic hip screws for fixation of intertrochanteric fractures of the femur. ISRN Orthop 2013;2013:484289.
del Prete F, Nizegorodcew T, Regazzoni P. Quantification of surgical trauma: Comparison of conventional and minimally invasive surgical techniques for pertrochanteric fracture surgery based on markers of inflammation (interleukins). J Orthop Traumatol 2012;13:125-30.
Zhou Z, Zhang X, Tian S, Wu Y. Minimally invasive versus conventional dynamic hip screw for the treatment of intertrochanteric fractures in older patients. Orthopedics 2012;35:e244-9.
McLoughlin SW, Wheeler DL, Rider J, Bolhofner B. Biomechanical evaluation of the dynamic hip screw with two- and four-hole side plates. J Orthop Trauma 2000;14:318-23.
Pajarinen J, Lindahl J, Michelsson O, Savolainen V, Hirvensalo E. Pertrochanteric femoral fractures treated with a dynamic hip screw or a proximal femoral nail. A randomised study comparing post-operative rehabilitation. J Bone Joint Surg Br 2005;87:76-81.
Shankar N, Sapthagirivasan V, Vijay A, Kirthika K, and Anburajan, M. Evaluation of osteoporosis using radiographic hip geometry, compared with dual energy X-ray absorptiometry (DXA) as the standard. International Conference on Systems in Medicine and Biology 2010. p. 259-64.
Ekström W, Karlsson-Thur C, Larsson S, Ragnarsson B, Alberts KA. Functional outcome in treatment of unstable trochanteric and subtrochanteric fractures with the proximal femoral nail and the Medoff sliding plate. J Orthop Trauma 2007;21:18-25.
Gadegone WM, Salphale YS. Proximal femoral nail – An analysis of 100 cases of proximal femoral fractures with an average follow up of 1 year. Int Orthop 2007;31:403-8.
Menezes DF, Gamulin A, Noesberger B. Is the proximal femoral nail a suitable implant for treatment of all trochanteric fractures? Clin Orthop Relat Res 2005;439:221-7.
Simmermacher RK, Bosch AM, Van der Werken C. The AO/ASIF-Proximal Femoral Nail (PFN): A new device for the treatment of unstable proximal femoral fractures. Injury 1999;30:327-32.
Parker MJ, Handoll HH. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults. Cochrane Database Syst Rev 2008;3:CD000093. Published 2008 Jul 16. doi:10.1002/14651858.CD000093.pub4.
Song W, Chen Y, Shen H, Yuan T, Zhang C, Zeng B. Biochemical markers comparison of dynamic hip screw and Gamma nail implants in the treatment of stable intertrochanteric fracture: A prospective study of 60 patients. J Int Med Res 2011;39:822-9.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]
[Table 1], [Table 2]