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A prospective controlled trial of valgus osteotomy in the fixation of unstable pertrochanteric fractures of the femur
228 Injury,11,228-232 Printedin GreatBritain
A prospective controlled trial of valgus osteotomy in the fixation of unstable pertrochanteric fractures of the femur M. J. S. Hubbard, F. D. Burke, G. R. Houghtonand D. J. Bracey Robert Jones a n d A g n e s Hunt Orthopaedic Hospital
Summary A total of 62 patients with unstable pertrochanteric fractures of the neck of the femur was subjected to
either nail plating with 130° neck-shaft angle or valgus osteotomy using a neck-shaft angle of at least 140°. The patients were assessed in terms of ability to walk and stability of fracture fixation. A clear superiority of valgus osteotomy over the controls was demonstrated in terms of fracture fixation, but the difference in terms of ability to walk was less remarkable. INTRODUCTION IT is well known that the surgical treatment of some pertrochanteric fractures is unsatisfactory (Evans, 1949; Hafner, 1961). These pertrochanteric fractures usually have a comminuted medial buttress and in view of the technical difficulties of fixation are regarded as 'unstable' (Dimon and Hughston, 1967). By contrast, the majority of pertrochanteric fractures of the femur do not have a comminuted medial buttress, are stable and have a good prognosis. Good results in the treatment of unstable pertrochanteric fractures have been reported using nail plates combined with a valgus osteotomy (Sarmiento and Williams, 1970). The valgus osteotomy makes the fracture line less vertical, re-apposes the medial cortical buttress and produces a neck-shaft angle of 140" or more. In this way an unstable fracture is rendered stable. To date, there has been no prospective, comparative trial between valgus osteotomy and conventional nail plating. This short contribution describes such a tri~l.
Tablel. Method of grading walking ability Ability Bedridden Walks with frame Walks with sticks Walks with one stick Walks freely without aids
Grade 0 1 2 3 4
PATIENTS AND METHODS All patients admitted with unstable pertrochanteric fractures during the 30-month period ending on l April 1977 were put into the trial (Fig. l). Each patient was allotted to the test or control groups by computer random numbers. Any patient who was unfit for operation was withdrawn from the trial (Table /). The patient's preoperative walking ability was assessed using the rough and ready classification described in Table I. The patients allotted to the test group were treated by insertion of a nail plate, combined with a valgus osteotomy as described by Sarmiento and Williams (1970). In the control group the same 135" Jewett nail plate was inserted after anatomical reduction of the fracture. In both groups great care was taken to reposition the medial buttress (Figs. 2 and 3). All the patients were given antibiotics for five days beginning with the pre-medication. They were allowed to bear weight within 48 h and were transferred to the rehabilitation unit
Hubbard et al.: Unstable Pertrochanteric Fractures
229
Fig. l. A typical example of an unstable pertrochan-
Fig. 2. Fixation of an unstable pertrochanteric fracture
teric fracture with a comminuted medial buttress.
by valgus osteotomy and nail plating, showing the increased neck-shall angle.
Fig. 3. Fixation of an unstable pertrochanteric fracture by nail plating only, showing a normal neck-shaft angle.
Fig. 4. Impaction of the head of the femur with the tip of the nail plate in the hip joint (Control group).
230
Injury: the British Journal of Accident SurgeryVol. 11/No. 3
Fig. 5. Cutting out of the nail plate from the neck of
Fig. 6. Bendingof a nail plate (Control group).
the femur (Control group). between the fourth and tenth postoperative day. The patients were assessed one week after operation and again at three months. The clinical assessment of walking ability was based on the same criteria used before operation. Serial radiographs were examined for any signs of impaction, cutting out, bending or fracture of the implant (Figs. 4, 5, 6, and 7). RESULTS
A total of 65 patients with unstable pertrochanteric fractures was admitted to hospital. Three patients were unfit for operation. Of the remaining 62 patients, 32 were allotted to the control group and 30 to the test group. The age distribution and mortality were identical in both groups (Fig. 8). The mean age of the patients was 82"5 years, and this may well explain the high mortality (24 per cent) at three months. All the patients who died had begun to walk and had borne weight on the fracture before death. The most striking observation was the difference in the stability of fixation between the two groups (Table H) (P = 0"04). On review at one month, 7 patients of the control group had impaction of the nail in the head of the femur, or
Table I1. 3-month mortality and loss of stability of the fractures Test group" Control group? Alive No loss of stability Loss of stability
21 1
12 13
Dead No loss of stability Loss of stability
8 0
5 2
30
32
Total
"Valgus osteotomy and nail plating. tNail plating only.
into the joint. In 2 patients the nail cut right out of the neck, and in 2 others the nail plate bent and broke. The two patients with breakage of the implant underwent subsequent valgus osteotomy and nail plating as a salvage procedure, and their fractures united without incident. The only patient in the test group with an unstable fracture had a deep wound infection and this was the only infected implant in the series.
Hubbard et al.: Unstable Pertrochanteric Fractures
231 I
=12
I
I
I
I
I
I
30-50
51-60
~ J
I Alive Dead
E]DI', =
=-
c 12 61-70 71-80 Ageof patients
12 81-90
91-100
Fig. 8. Age distribution and mortality in the two patient groups.
Fig. 7. Fracture of a nail plate (Control group). Table III. Re-assessment of the patient's walking ability 3-months after operation and its relation to the stability of the fracture Test group *
Control group t
No loss of stability
Loss of stability
No loss of stability
Loss of stability
No change One point lost Two points lost Three points lost
11 3 3 4
0 1 0 0
4 5 0 2
5 2 3 4
Total
21
1
11
14
*Valgus osteotomy and nail plating. tNail plating only.
The differences in walking ability between the two groups were less marked, with the results in the test group more favourable than the control group (Table II1). The obscured difference between the walking ability scores and the radiological assessment is possibly explained by the greater number of medical complications in the test group and by the fact that the majority of the patients who had impaction had fewer symptoms.
DISCUSSION
This small prospective trial shows that a valgus osteotomy combined with nail plating with a neck-shaft angle of 140" or greater has significant advantages over the conventional nail plating with a neck-shaft angle of 130" in the management of unstable pertrochanteric fractures. The valgus osteotomy and nail plate procedure did not take longer, nor did it cause more bleeding than a simple nail plating.
232
Injury: the British Journal of Accident Surgery Vol. 11/No. 3
Another advantage of this is that nail plates with a wide range of neck-shaft angles do not have to be stocked and the results are as satisfactory as those with the 150" nail plate (Sarmiento, 1963).
Evans E. M. (1949) The treatment of trochanteric fractures of the femur. J. Bone Joint Surg. 31B, 190, Hafner R. H. V. (1961) Trochanteric fractures of the femur: a review of eighty cases with a description of the low nail method. J. Bone Joint Surg. 33B, 573. Sarmiento A. A. (1963) Intertrochanteric fractures of the femur: 150" angle nail plate fixation and early rehabilitation. J. Bone Joint Surg. 45A, 706. Sarmiento A. A. and Williams E. M. (1970) The unstable pertrochanteric fracture treatment with valgus osteotomy and 1 beam nail plate. J. Bone Joint Surg. 52A, 1309.
REFERENCES
Dimon J. H. and Hughston J. C. (1967) Unstable pertrochanteric fractures of the hip. J. Bone Joint Surg. 49A, 440.
Requests for reprints should be addressed to: Mr M. J. S. Hubbard, Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, Salop,STI0 7AG.
He has a point there, Sister--will the hospital still be here when the date for his op. comes round?
A prospective controlled trial of valgus osteotomy in the fixation of unstable pertrochanteric fractures of the femur M. J. S. Hubbard, F. D. Burke, G. R. Houghtonand D. J. Bracey Robert Jones a n d A g n e s Hunt Orthopaedic Hospital
Summary A total of 62 patients with unstable pertrochanteric fractures of the neck of the femur was subjected to
either nail plating with 130° neck-shaft angle or valgus osteotomy using a neck-shaft angle of at least 140°. The patients were assessed in terms of ability to walk and stability of fracture fixation. A clear superiority of valgus osteotomy over the controls was demonstrated in terms of fracture fixation, but the difference in terms of ability to walk was less remarkable. INTRODUCTION IT is well known that the surgical treatment of some pertrochanteric fractures is unsatisfactory (Evans, 1949; Hafner, 1961). These pertrochanteric fractures usually have a comminuted medial buttress and in view of the technical difficulties of fixation are regarded as 'unstable' (Dimon and Hughston, 1967). By contrast, the majority of pertrochanteric fractures of the femur do not have a comminuted medial buttress, are stable and have a good prognosis. Good results in the treatment of unstable pertrochanteric fractures have been reported using nail plates combined with a valgus osteotomy (Sarmiento and Williams, 1970). The valgus osteotomy makes the fracture line less vertical, re-apposes the medial cortical buttress and produces a neck-shaft angle of 140" or more. In this way an unstable fracture is rendered stable. To date, there has been no prospective, comparative trial between valgus osteotomy and conventional nail plating. This short contribution describes such a tri~l.
Tablel. Method of grading walking ability Ability Bedridden Walks with frame Walks with sticks Walks with one stick Walks freely without aids
Grade 0 1 2 3 4
PATIENTS AND METHODS All patients admitted with unstable pertrochanteric fractures during the 30-month period ending on l April 1977 were put into the trial (Fig. l). Each patient was allotted to the test or control groups by computer random numbers. Any patient who was unfit for operation was withdrawn from the trial (Table /). The patient's preoperative walking ability was assessed using the rough and ready classification described in Table I. The patients allotted to the test group were treated by insertion of a nail plate, combined with a valgus osteotomy as described by Sarmiento and Williams (1970). In the control group the same 135" Jewett nail plate was inserted after anatomical reduction of the fracture. In both groups great care was taken to reposition the medial buttress (Figs. 2 and 3). All the patients were given antibiotics for five days beginning with the pre-medication. They were allowed to bear weight within 48 h and were transferred to the rehabilitation unit
Hubbard et al.: Unstable Pertrochanteric Fractures
229
Fig. l. A typical example of an unstable pertrochan-
Fig. 2. Fixation of an unstable pertrochanteric fracture
teric fracture with a comminuted medial buttress.
by valgus osteotomy and nail plating, showing the increased neck-shall angle.
Fig. 3. Fixation of an unstable pertrochanteric fracture by nail plating only, showing a normal neck-shaft angle.
Fig. 4. Impaction of the head of the femur with the tip of the nail plate in the hip joint (Control group).
230
Injury: the British Journal of Accident SurgeryVol. 11/No. 3
Fig. 5. Cutting out of the nail plate from the neck of
Fig. 6. Bendingof a nail plate (Control group).
the femur (Control group). between the fourth and tenth postoperative day. The patients were assessed one week after operation and again at three months. The clinical assessment of walking ability was based on the same criteria used before operation. Serial radiographs were examined for any signs of impaction, cutting out, bending or fracture of the implant (Figs. 4, 5, 6, and 7). RESULTS
A total of 65 patients with unstable pertrochanteric fractures was admitted to hospital. Three patients were unfit for operation. Of the remaining 62 patients, 32 were allotted to the control group and 30 to the test group. The age distribution and mortality were identical in both groups (Fig. 8). The mean age of the patients was 82"5 years, and this may well explain the high mortality (24 per cent) at three months. All the patients who died had begun to walk and had borne weight on the fracture before death. The most striking observation was the difference in the stability of fixation between the two groups (Table H) (P = 0"04). On review at one month, 7 patients of the control group had impaction of the nail in the head of the femur, or
Table I1. 3-month mortality and loss of stability of the fractures Test group" Control group? Alive No loss of stability Loss of stability
21 1
12 13
Dead No loss of stability Loss of stability
8 0
5 2
30
32
Total
"Valgus osteotomy and nail plating. tNail plating only.
into the joint. In 2 patients the nail cut right out of the neck, and in 2 others the nail plate bent and broke. The two patients with breakage of the implant underwent subsequent valgus osteotomy and nail plating as a salvage procedure, and their fractures united without incident. The only patient in the test group with an unstable fracture had a deep wound infection and this was the only infected implant in the series.
Hubbard et al.: Unstable Pertrochanteric Fractures
231 I
=12
I
I
I
I
I
I
30-50
51-60
~ J
I Alive Dead
E]DI', =
=-
c 12 61-70 71-80 Ageof patients
12 81-90
91-100
Fig. 8. Age distribution and mortality in the two patient groups.
Fig. 7. Fracture of a nail plate (Control group). Table III. Re-assessment of the patient's walking ability 3-months after operation and its relation to the stability of the fracture Test group *
Control group t
No loss of stability
Loss of stability
No loss of stability
Loss of stability
No change One point lost Two points lost Three points lost
11 3 3 4
0 1 0 0
4 5 0 2
5 2 3 4
Total
21
1
11
14
*Valgus osteotomy and nail plating. tNail plating only.
The differences in walking ability between the two groups were less marked, with the results in the test group more favourable than the control group (Table II1). The obscured difference between the walking ability scores and the radiological assessment is possibly explained by the greater number of medical complications in the test group and by the fact that the majority of the patients who had impaction had fewer symptoms.
DISCUSSION
This small prospective trial shows that a valgus osteotomy combined with nail plating with a neck-shaft angle of 140" or greater has significant advantages over the conventional nail plating with a neck-shaft angle of 130" in the management of unstable pertrochanteric fractures. The valgus osteotomy and nail plate procedure did not take longer, nor did it cause more bleeding than a simple nail plating.
232
Injury: the British Journal of Accident Surgery Vol. 11/No. 3
Another advantage of this is that nail plates with a wide range of neck-shaft angles do not have to be stocked and the results are as satisfactory as those with the 150" nail plate (Sarmiento, 1963).
Evans E. M. (1949) The treatment of trochanteric fractures of the femur. J. Bone Joint Surg. 31B, 190, Hafner R. H. V. (1961) Trochanteric fractures of the femur: a review of eighty cases with a description of the low nail method. J. Bone Joint Surg. 33B, 573. Sarmiento A. A. (1963) Intertrochanteric fractures of the femur: 150" angle nail plate fixation and early rehabilitation. J. Bone Joint Surg. 45A, 706. Sarmiento A. A. and Williams E. M. (1970) The unstable pertrochanteric fracture treatment with valgus osteotomy and 1 beam nail plate. J. Bone Joint Surg. 52A, 1309.
REFERENCES
Dimon J. H. and Hughston J. C. (1967) Unstable pertrochanteric fractures of the hip. J. Bone Joint Surg. 49A, 440.
Requests for reprints should be addressed to: Mr M. J. S. Hubbard, Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, Salop,STI0 7AG.
He has a point there, Sister--will the hospital still be here when the date for his op. comes round?