Osteotomy, compression and reaming techniques for internal fixation of extracapsular hip fractures
M J Parker1, G Tripuraneni, J McGreggor-Riley
1Orthopaedic Department, Peterborough District Hospital, Thorpe Road, Peterborough, Cambridgeshire, UK, PE3 6DA. mjparker@doctors.org.uk
Insights
This review found limited evidence on surgical techniques for hip fractures. Osteotomy may benefit fixed nail-plate fixation, but evidence for sliding hip screw fixation is insufficient.
Area of Science:
- Orthopedic Surgery
- Trauma Surgery
Background:
- Internal fixation of extracapsular hip fractures employs various surgical techniques, including osteotomy.
- Randomized trials in adults have investigated different operative approaches.
Purpose of the Study:
- To compare surgical techniques for internal fixation of extracapsular hip fractures based on randomized trials.
- Evaluate the efficacy and outcomes of different operative methods.
Main Methods:
- Searched specialized registers and reference lists for randomized and quasi-randomized trials.
- Two independent reviewers assessed trial quality and extracted data.
- Pooled outcome measures where appropriate.
Main Results:
- Eight trials (824 participants) showed modest methodological quality.
- Osteotomy showed a tendency towards reduced fixation failure with fixed nail-plates.
- Osteotomy with sliding hip screws (SHS) was linked to increased blood loss, surgery length, hospital stay, and limb shortening.
Conclusions:
- Insufficient evidence exists to support routine osteotomy with SHS for unstable trochanteric fractures.
- Osteotomy may be relevant with fixed nail plates.
- Limited evidence for compression in SHS fixation and inadequate data on reaming techniques for SHS/Gamma nail fixation.
Background:
Many different surgical techniques, such as osteotomy, have been used in internal fixation of extracapsular hip fractures.
Objectives:
To compare different aspects of surgical technique in internal fixation of extracapsular hip fractures that have been subjected to randomised trials in adults.
Search Strategy:
We searched the Cochrane Musculoskeletal Injuries Group specialised trials register (February 2001), the Cochrane Controlled Trials Register (The Cochrane Library Issue 1, 2001) and reference lists of relevant articles.
Selection Criteria:
All randomised and quasi-randomised trials investigating operative technique for the treatment of extracapsular hip fractures.
Data Collection And Analysis:
Two reviewers independently assessed trial quality, by use of an 11 item check list, and extracted data. Wherever possible and appropriate, results of outcome measures were pooled.
Main Results:
All eight included trials (824 participants) were of only modest methodological quality. One trial of 65 patients undergoing fixation with a fixed nail-plate compared osteotomy versus anatomical reduction. There was a tendency to a reduced fixation failure rate after osteotomy. Four trials involving 465 patients undergoing fixation with a sliding hip screw (SHS) compared osteotomy versus anatomical reduction. Osteotomy was associated with an increased operative blood loss and length of surgery. There was also a tendency to an increased length of hospital stay and limb shortening for the osteotomy group. One trial of 200 patients undergoing fixation with a SHS compared results with or without compression across the fracture site. The only significant difference in outcomes was increased varus deformity in those fractures treated with compression. One trial of 19 patients reported reduced temperatures generated by a modified method of reaming the femoral head. Another study used oesophageal ultrasound to demonstrate reduced bone marrow intravascular embolism when a Gamma nail was inserted in 50 patients with, rather than without, a distal pressure venting hole in the femur.
Reviewer'S Conclusions:
There is inadequate evidence to determine if any benefits exist for the routine use of osteotomy in conjunction with a SHS for the internal fixation of an unstable trochanteric femoral fracture. Osteotomy may be relevant if used in conjunction with a fixed nail plate. Based on the evidence of one trial only, there is inadequate evidence to support the application of compression across the fracture site of a trochanteric fracture during SHS fixation. Inadequate information exists for different reaming techniques during SHS or Gamma nail fixation to make definite conclusions.
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