| Background and Objective:With the rapid increase of the elderly population, the morbidity of intertrochantericfemoral fractures is also displaying a rising trend. Geriatric intertrochanteric fracture hasbecome a public health problem. As most geriatric patients are always accompanied withmultimorbidity, the none surgical treatments for intertrochanteric fracture requires longbedding time, which would increase the occurrence of complications, even higher mortality.In addition, even people have survived the treatments, few of them would regain the normalfunction before the injury., which adds extra economic and medical burden to the society andfamily. Operative interventions have gradually become preferred after the rise of AO/ASIF in1960’s. The purpose of surgery is to achieve good fracture reduction, rigid internal fixation,and reduce complications. Patients are encouraged to perform early functional exercise, inorder to restore limb function as soon as possible.Currently, there are two main types of implants available for these fractures, namelyextramedullary and intramedullary implants.The conventional DHS technique has thedisadvantages of requiring large skin incision and more soft tissue dissection with substantialblood loss. The surgical risk and perioperative mortality are higher for elderly patients withmultimorbidity. Furthermore, because of poor rotational stability and uncontrolled fracturecompression, the failure rate of unstable intertrochanteric fractures treated with DHS,especially those with loss of the posteromedial buttress, is relatively high. Since the1990s,intramedullary fixation has gradually become the predominante method for treatingintertrochanteric fracture. Theoretically it was considered that intramedullary fixation had theadvantage of better mechanical stability and less invasiveness. However, it has a large amountof hidden blood loss with no significant difference of soft tissue damage compared with extramedullary fixation and causes damage to the gluteus medius muscle during reaming andinvasion of the femoral medullary canal. Thus, intramedullary fixation is not considered agenuine minimally invasive treatment. Some unstable proximal femoral fractures, such asintertrochanteric fractures with extension into the piriform fossa, patients with short skeletonsand narrow femoral canals, and fractures where a closed reduction can only be performed inthe abduction position, are difficult to nail. Current evidence-based clinical research suggeststhat intramedullary nailing has no superiority over DHS in complications, fracture healing,functional recovery and reoperation rate. Some scholares do not support the routine use ofintramedullary nail treatment of intertrochanteric femoral fractures. Although the device ofinternal fixation has been continuously improved, there is a considerable controversy over thethe choice of internal fixation method.With the development of minimally invasive technique, Gotfried developed thepercutaneous compression plate (PCCP) technique in the late1990s, which minimisesoperative trauma by way of two small percutaneous portals, and small-diameter drillingprevents additional bone damage in the remaining lateral trochanteric wall. This technique hasa promising future in the elderly population. Although many literatures reported PCCPtreatment of intertrochanteric fractures, there are still controversies over surgical trauma andfunctional recovery, and few literature explored the reasons for complications.Therefore, the purpose of this study was to present the outcomes of the PCCP implant intreating intertrochanteric fractures, and to compare our results with the data published byother authors. And to decide the risk factors of post-operative complications for patientstreated with PCCP by long term follow-up study.Methods:From March2009to June2012,113patients with intertrochanteric femoral fractureswere treated using the PCCP method. There were43men and70women. The mean age ofthese patients was79.9years. According to the AO classification, the113fractures wereclassified as35cases of31A1fractures,59cases of31A2fractures, and19cases of31A3fractures. The clinical data and imaging results were retrospectively analysed.Results:1. The mean operation time was42.0（25-82）min, the mean intraoperative blood losswas40.5（10-100）ml, and the mean hospital stay was8.6(3-18) days. One patient died of renal failure in the perioperative period. Twelve patients died during the12months aftersurgery. The remaining100patients were followed-up for6-28months and healed theirfractures except one, whose neck screw cut out from the femoral neck after1postoperativemonth and resulting in a revision to a hemiarthroplasty. The mean time to bone healing was12.6(6-23) weeks. Sixteen patients had pain. There were13major device-relatedcomplications, including5cases of coxa vara,6cases of fracture collapse, and4cases of headpenetration. Two occurrences of head penetration combined with fracture collapse. At thetime of the last follow-up,81patients had regained a pre-injury level of function. The meanHarris hip score was87.4(61-100) points. The mean Parker-Palmer score was7.12(2-9)points. The mean Visual analogue scale (VAS) score was0.38(0-4) points.2. We compared the three types of fractures, and there were no significant differences inthe operation time, intraoperative blood loss and hospital stay (p>0.05). There was asignificant difference in the mean blood transfusion volume (p <0.05), and the fractureclassification was much higher, as was the blood transfusion volume. For the postoperativehaemoglobin fall values, no significant difference existed between the type A1and A2groups(p>0.05), but the type A3group had a significantly higher value than the type A1and A2groups (p <0.05). There were no significant differences in Harris hip score, Parker-Palmerscore, bone healing and change in neck shaft angle (p>0.05). No significant difference wasobserved for the postoperative complications, such as pain, hip varus deformity, delayedunion, collapse of fracture, and head penetration (p>0.05). There was a significant differencein the pure loosening of the sleeve of the neck screw and protrusion of the neck screw (p <0.05), where the occurrence was higher for the type A3fractures.3. Patients with poor quality of reduction or bad neck screw positioning were more likelyto suffer complications (p <0.05).4. Male patients with higher age, higher ASA scale values and a greater number ofmedical complications had an increased risk of dying within the first year after surgery (p <0.05).Conclusion:1. Due to the particularity of the onset ages, treatment of intertrochanteric fractureremains a challenge for orthopaedic surgeons regardless of the type of implant used.2. PCCP is an effective and safe method for the treatment of all types of intertrochanteric femoral fractures, and possesses the advantages of minimally invasive and stability based onclinical observation and follow-up.3. A good fracture reduction and an ideal placement position of the first neck screw areimportant for the success of PCCP. Implant-related complications was not associated with thetype of fracture, but closely associated with the poor quality of reduction and bad neck screwpositioning.4. For A3fracture, a good fracture reduction and an ideal placement position of the firstneck screw are prerequisites for the success of PCCP, and delay weightbearing can reduceinternal fixation failure rate.5. We suggest that PCCP should not be employed to fix fractures that cannot achieveclosed reduction. |
PDF Full Text Request