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Percutaneous dynamic hip screw
Injury, Int. J. Care Injured (2006) 37, 751—754
www.elsevier.com/locate/injury
Percutaneous dynamic hip screw T.S. Waters *, D.M.R. Gibbs, J.H. Dorrell, D.P. Powles Department of Orthopaedics, The Lister Hospital, Stevenage, Hertfordshire, UK Accepted 6 March 2006
KEYWORDS Hip fractures; Minimally invasive surgery; Dynamic hip screw; Intertrochanteric fractures; Blood loss
Summary We present the results of a technique of dynamic hip screw insertion through a very small incision, typically 2—2.5 cm. The technique is performed using a standard dynamic hip screw set and requires no additional equipment. We compared the results to those of an age and sex-matched group who had undergone the operation through a traditional approach. We compared the time spent in theatre, the pre- and post-operative haemoglobin concentration, haematocrit and prevalence of wound infection. Thirteen consecutive cases were performed by one surgeon using the percutaneous technique. There were nine females and four males with a mean age of 84 years (range 62—96 years). Each had a 1358 four-hole plate. The mean post-operative drop in haemoglobin concentration in the percutaneous group was 2.2 g/dl (range 0—4.4 g/dl) compared to 3.5 g/dl (range 1.2—5.4 g/dl) in the control group ( p = 0.014). The mean haematocrit drop was 0.07 (range 0—0.12) in the percutaneous group compared to 0.10 (range 0.03—0.17) in the control group ( p = 0.017). The mean theatre time with the percutaneous technique was 57 min (range 40— 75 min) and in the control group, 60 min (range 30—95 min). There were no wound problems. It is likely that this minimally invasive technique offers a better clinical outcome at no extra expense and warrants further evaluation in a larger study. # 2006 Elsevier Ltd. All rights reserved.
Introduction Minimally invasive surgery has become increasingly popular, particularly in the field of trauma surgery.
* Correspondence to: 7 West Hill Way, London N20 8QX, UK. Tel./fax: +44 2083437918. E-mail address: [email protected] (T.S. Waters).
Instrumentation and surgical techniques have been devised to enable bone fixation with less damage to the surrounding soft tissues.5 We report a technique of dynamic hip screw insertion using the standard equipment and a four-hole plate through a small incision, typically less than 1 in. (2.5 cm). We compared the results to those of an age and sex-matched group who had undergone the ‘‘traditional’’ operation.
0020–1383/$ — see front matter # 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2006.03.005
752
T.S. Waters et al.
Figure 3
Figure 1 Positioning the guide parallel to the femoral shaft using fluoroscopy.
Operative technique Closed reduction, skin preparation and draping are performed as normal on the traction table. The guide-wire is inserted percutaneously. Fluoroscopy is used to ensure that the 1358 guide is parallel to the femoral shaft (Fig. 1). An incision is made down to bone along the guidewire and for approximately 2 cm distally. The length of the guidewire is then measured as usual (Fig. 2). The insertion of the three-stage reamer dictates the length of the incision. It may need to be
Figure 2
Guidewire measurement.
Insert plate-side first.
extended slightly to allow the skin to retract. The lag screw is then inserted and the screw assembly and guidewire removed. A periosteal elevator is inserted from the end of the screw moving distally to ensure a gap between vastus lateralis and shaft of femur. The plate is inserted plate-side first underneath the vastus lateralis (Figs. 3 and 4). The barrel is manipulated onto the screw using a guide-wire (Fig. 5). The screw assembly or the cannulated screwdriver is then re-introduced over the guide-
Figure 4
Plate underneath vastus lateralis.
Percutaneous dynamic hip screw
753 (range 1.2—5.4 g/dl) in the control group ( p = 0.014). The mean haematocrit drop was 0.07 (range 0—0.12) in the percutaneous group compared to 0.10 (range 0.03—0.17) in the control group ( p = 0.017). The mean theatre time with the percutaneous technique was 57 min (range 40—75 min) and in the control group, 60 min (range 30—95 min). There were no wound problems in the percutaneous group. In the control group two patients had minor wound problems which healed completely within 2 weeks of surgery.
Figure 5 wire.
Manipulation of plate onto screw using guide-
wire to ensure correct alignment. The plate is then advanced onto the screw with ease. The four transverse screws are now inserted in the normal manner. The proximal three are usually directly opposite the incision. The bottom hole may need drilling obliquely.
Patients and methods Between January and June 2004 13 consecutive patients with intertrochanteric fractures were operated upon by one surgeon (TW) using the miniincision technique. They were compared with an aged and sex-matched group of patients who had undergone the same procedure through the traditional approach. We analysed the pre- and postoperative haemoglobin concentration and haematocrit, evidence of wound infection and theatre time. This study does not compare the post-operative pain or mobility of the patients due to the variety of co-morbidity in a relatively small patient group, which would confound the results. The results were analysed using SPSS Software (SPSS Inc., Chicago, IL, USA).
Results There were nine females and four males with a mean age of 84 years (range 62—96 years). With the numbers available there was a statistically significant difference in the post-operative haemoglobin and haematocrit drop between the groups. The mean post-operative drop in haemoglobin concentration in the percutaneous group was 2.2 g/dl (range 0—4.4 g/dl) compared to 3.5 g/dl
Discussion The available treatment options for intertrochanteric fractures include the dynamic/sliding hip screw and plate, intramedullary nails and external fixation. Intramedullary nails are ideally suited for a minimally invasive surgery but are relatively expensive. Saudan et al.11 concluded, in a randomised trial of 206 patients, that there was no justification for the use of the proximal femoral nail (PFN) in place of a sliding hip screw. They found no significant difference in clinical or radiological outcome and the intramedullary implants cost at least twice as much. A recent Cochrane review10 of trials comparing several intramedullary devices with the sliding hip screw, showed the Gamma nail and intramedullaryhip screw (IMHS) to have an increased rate of periand post-operative femoral fracture. No increased benefit was seen in terms of fracture healing and the overall conclusion was that for trochanteric fractures, the sliding hip screw was superior. External fixation has been advocated in selected high-risk patients or where resources are scarce, as it can be performed quickly under local anaesthesia.3,4,7,9,12 Complications included pin-track infection, and displacement of the fracture fragments. One other study has been published regarding a minimally invasive technique of dynamic hip screw insertion.1 This multi-centre study with predominantly two-hole plates found less blood loss and operative time. As a precursor to their study they also performed angiography of the proximal femur. Reassuringly, they confirmed that the first major perforating vessel lies a minimum of 8 cm below the trochanteric flare. The Percutaneous Compression Plate (Orthofix) is a relatively new device consisting of two narrower sliding hip screws and plate which are inserted in a minimally invasive manner, through several incisions. Three randomised trials comparing this with
754 a standard dynamic hip screw have been published.2,6,8 These showed variable results with similar outcomes for bone healing and stability, but with probable advantages for blood loss. It is however technically demanding6 and requires the additional expense of further equipment and training. Our technique, all performed with standard fourhole plates through one small incision, has been shown to be reproducible and requires no additional theatre time or equipment. It can also be applied to situations requiring longer plates with the more distal transverse screws put in through stab incisions.
Conclusion This is a simple technique that is likely to improve patient morbidity without any extra expense. It merits further evaluation in a larger study with parameters including post-operative pain and mobility.
References 1. Alobaid A, Harvey EJ, Elder GM, et al. 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. 2. Brandt SE, Lefever S, Janzing HM, et al. Percutaneous compression plating (PCCP) versus the dynamic hip screw for pertrochanteric hip fractures: preliminary results. Injury 2002;33:413—8.
T.S. Waters et al. 3. Christodoulou NA, Sdrenias CV. External fixation of select intertrochanteric fractures with single hip screw. Clin Orthop Relat Res 2000;204—11. 4. Dhal A, Varghese M, Bhasin VB. External fixation of intertrochanteric fractures of the femur. J Bone Joint Surg Br 1991;73:955—8. 5. Egol KA. Minimally invasive orthopaedic trauma surgery: a review of the latest techniques. Bull Hosp Jt Dis 2004;62: 6—12. 6. Janzing HM, Houben BJ, Brandt SE, et al. 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—8. 7. Kamble KT, Murthy BS, Pal V, Rao KS. External fixation in unstable intertrochanteric fractures of femur. Injury 1996; 27:139—42. 8. Kosygan KP, Mohan R, Newman RJ. The Gotfried percutaneous compression plate compared with the conventional classic hip screw for the fixation of intertrochanteric fractures of the hip. J Bone Joint Surg Br 2002;84:19—22. 9. Moroni A, Faldini C, Pegreffi F, et al. Dynamic hip screw compared with external fixation for treatment of osteoporotic pertrochanteric fractures. A prospective, randomized study. J Bone Joint Surg Am 2005;87:753—9. 10. Parker MJ, Handoll HH. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults. Cochrane Database Syst Rev 2005 [CD000093]. 11. Saudan M, Lubbeke A, Sadowski C, et al. Pertrochanteric fractures: is there an advantage to an intramedullary nail?: a randomized, prospective study of 206 patients comparing the dynamic hip screw and proximal femoral nail. J Orthop Trauma 2002;16:386—93. 12. Vossinakis IC, Badras LS. The external fixator compared with the sliding hip screw for pertrochanteric fractures of the femur. J Bone Joint Surg Br 2002;84:23—9.
www.elsevier.com/locate/injury
Percutaneous dynamic hip screw T.S. Waters *, D.M.R. Gibbs, J.H. Dorrell, D.P. Powles Department of Orthopaedics, The Lister Hospital, Stevenage, Hertfordshire, UK Accepted 6 March 2006
KEYWORDS Hip fractures; Minimally invasive surgery; Dynamic hip screw; Intertrochanteric fractures; Blood loss
Summary We present the results of a technique of dynamic hip screw insertion through a very small incision, typically 2—2.5 cm. The technique is performed using a standard dynamic hip screw set and requires no additional equipment. We compared the results to those of an age and sex-matched group who had undergone the operation through a traditional approach. We compared the time spent in theatre, the pre- and post-operative haemoglobin concentration, haematocrit and prevalence of wound infection. Thirteen consecutive cases were performed by one surgeon using the percutaneous technique. There were nine females and four males with a mean age of 84 years (range 62—96 years). Each had a 1358 four-hole plate. The mean post-operative drop in haemoglobin concentration in the percutaneous group was 2.2 g/dl (range 0—4.4 g/dl) compared to 3.5 g/dl (range 1.2—5.4 g/dl) in the control group ( p = 0.014). The mean haematocrit drop was 0.07 (range 0—0.12) in the percutaneous group compared to 0.10 (range 0.03—0.17) in the control group ( p = 0.017). The mean theatre time with the percutaneous technique was 57 min (range 40— 75 min) and in the control group, 60 min (range 30—95 min). There were no wound problems. It is likely that this minimally invasive technique offers a better clinical outcome at no extra expense and warrants further evaluation in a larger study. # 2006 Elsevier Ltd. All rights reserved.
Introduction Minimally invasive surgery has become increasingly popular, particularly in the field of trauma surgery.
* Correspondence to: 7 West Hill Way, London N20 8QX, UK. Tel./fax: +44 2083437918. E-mail address: [email protected] (T.S. Waters).
Instrumentation and surgical techniques have been devised to enable bone fixation with less damage to the surrounding soft tissues.5 We report a technique of dynamic hip screw insertion using the standard equipment and a four-hole plate through a small incision, typically less than 1 in. (2.5 cm). We compared the results to those of an age and sex-matched group who had undergone the ‘‘traditional’’ operation.
0020–1383/$ — see front matter # 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2006.03.005
752
T.S. Waters et al.
Figure 3
Figure 1 Positioning the guide parallel to the femoral shaft using fluoroscopy.
Operative technique Closed reduction, skin preparation and draping are performed as normal on the traction table. The guide-wire is inserted percutaneously. Fluoroscopy is used to ensure that the 1358 guide is parallel to the femoral shaft (Fig. 1). An incision is made down to bone along the guidewire and for approximately 2 cm distally. The length of the guidewire is then measured as usual (Fig. 2). The insertion of the three-stage reamer dictates the length of the incision. It may need to be
Figure 2
Guidewire measurement.
Insert plate-side first.
extended slightly to allow the skin to retract. The lag screw is then inserted and the screw assembly and guidewire removed. A periosteal elevator is inserted from the end of the screw moving distally to ensure a gap between vastus lateralis and shaft of femur. The plate is inserted plate-side first underneath the vastus lateralis (Figs. 3 and 4). The barrel is manipulated onto the screw using a guide-wire (Fig. 5). The screw assembly or the cannulated screwdriver is then re-introduced over the guide-
Figure 4
Plate underneath vastus lateralis.
Percutaneous dynamic hip screw
753 (range 1.2—5.4 g/dl) in the control group ( p = 0.014). The mean haematocrit drop was 0.07 (range 0—0.12) in the percutaneous group compared to 0.10 (range 0.03—0.17) in the control group ( p = 0.017). The mean theatre time with the percutaneous technique was 57 min (range 40—75 min) and in the control group, 60 min (range 30—95 min). There were no wound problems in the percutaneous group. In the control group two patients had minor wound problems which healed completely within 2 weeks of surgery.
Figure 5 wire.
Manipulation of plate onto screw using guide-
wire to ensure correct alignment. The plate is then advanced onto the screw with ease. The four transverse screws are now inserted in the normal manner. The proximal three are usually directly opposite the incision. The bottom hole may need drilling obliquely.
Patients and methods Between January and June 2004 13 consecutive patients with intertrochanteric fractures were operated upon by one surgeon (TW) using the miniincision technique. They were compared with an aged and sex-matched group of patients who had undergone the same procedure through the traditional approach. We analysed the pre- and postoperative haemoglobin concentration and haematocrit, evidence of wound infection and theatre time. This study does not compare the post-operative pain or mobility of the patients due to the variety of co-morbidity in a relatively small patient group, which would confound the results. The results were analysed using SPSS Software (SPSS Inc., Chicago, IL, USA).
Results There were nine females and four males with a mean age of 84 years (range 62—96 years). With the numbers available there was a statistically significant difference in the post-operative haemoglobin and haematocrit drop between the groups. The mean post-operative drop in haemoglobin concentration in the percutaneous group was 2.2 g/dl (range 0—4.4 g/dl) compared to 3.5 g/dl
Discussion The available treatment options for intertrochanteric fractures include the dynamic/sliding hip screw and plate, intramedullary nails and external fixation. Intramedullary nails are ideally suited for a minimally invasive surgery but are relatively expensive. Saudan et al.11 concluded, in a randomised trial of 206 patients, that there was no justification for the use of the proximal femoral nail (PFN) in place of a sliding hip screw. They found no significant difference in clinical or radiological outcome and the intramedullary implants cost at least twice as much. A recent Cochrane review10 of trials comparing several intramedullary devices with the sliding hip screw, showed the Gamma nail and intramedullaryhip screw (IMHS) to have an increased rate of periand post-operative femoral fracture. No increased benefit was seen in terms of fracture healing and the overall conclusion was that for trochanteric fractures, the sliding hip screw was superior. External fixation has been advocated in selected high-risk patients or where resources are scarce, as it can be performed quickly under local anaesthesia.3,4,7,9,12 Complications included pin-track infection, and displacement of the fracture fragments. One other study has been published regarding a minimally invasive technique of dynamic hip screw insertion.1 This multi-centre study with predominantly two-hole plates found less blood loss and operative time. As a precursor to their study they also performed angiography of the proximal femur. Reassuringly, they confirmed that the first major perforating vessel lies a minimum of 8 cm below the trochanteric flare. The Percutaneous Compression Plate (Orthofix) is a relatively new device consisting of two narrower sliding hip screws and plate which are inserted in a minimally invasive manner, through several incisions. Three randomised trials comparing this with
754 a standard dynamic hip screw have been published.2,6,8 These showed variable results with similar outcomes for bone healing and stability, but with probable advantages for blood loss. It is however technically demanding6 and requires the additional expense of further equipment and training. Our technique, all performed with standard fourhole plates through one small incision, has been shown to be reproducible and requires no additional theatre time or equipment. It can also be applied to situations requiring longer plates with the more distal transverse screws put in through stab incisions.
Conclusion This is a simple technique that is likely to improve patient morbidity without any extra expense. It merits further evaluation in a larger study with parameters including post-operative pain and mobility.
References 1. Alobaid A, Harvey EJ, Elder GM, et al. 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. 2. Brandt SE, Lefever S, Janzing HM, et al. Percutaneous compression plating (PCCP) versus the dynamic hip screw for pertrochanteric hip fractures: preliminary results. Injury 2002;33:413—8.
T.S. Waters et al. 3. Christodoulou NA, Sdrenias CV. External fixation of select intertrochanteric fractures with single hip screw. Clin Orthop Relat Res 2000;204—11. 4. Dhal A, Varghese M, Bhasin VB. External fixation of intertrochanteric fractures of the femur. J Bone Joint Surg Br 1991;73:955—8. 5. Egol KA. Minimally invasive orthopaedic trauma surgery: a review of the latest techniques. Bull Hosp Jt Dis 2004;62: 6—12. 6. Janzing HM, Houben BJ, Brandt SE, et al. 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—8. 7. Kamble KT, Murthy BS, Pal V, Rao KS. External fixation in unstable intertrochanteric fractures of femur. Injury 1996; 27:139—42. 8. Kosygan KP, Mohan R, Newman RJ. The Gotfried percutaneous compression plate compared with the conventional classic hip screw for the fixation of intertrochanteric fractures of the hip. J Bone Joint Surg Br 2002;84:19—22. 9. Moroni A, Faldini C, Pegreffi F, et al. Dynamic hip screw compared with external fixation for treatment of osteoporotic pertrochanteric fractures. A prospective, randomized study. J Bone Joint Surg Am 2005;87:753—9. 10. Parker MJ, Handoll HH. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults. Cochrane Database Syst Rev 2005 [CD000093]. 11. Saudan M, Lubbeke A, Sadowski C, et al. Pertrochanteric fractures: is there an advantage to an intramedullary nail?: a randomized, prospective study of 206 patients comparing the dynamic hip screw and proximal femoral nail. J Orthop Trauma 2002;16:386—93. 12. Vossinakis IC, Badras LS. The external fixator compared with the sliding hip screw for pertrochanteric fractures of the femur. J Bone Joint Surg Br 2002;84:23—9.