Management of unstable pertrochanteric fractures, evaluation of forgotten treatment options

Abstract

Introduction: Unstable trochanteric fractures are challenging with a high rate of implant failure and re-operation. Cephalomedullary nails proved to be a rational management choice for these injuries, yet other management options have not been well assessed. The aim of this study was to compare the use of DHS with trochanteric stabilizing plate (TSP) and proximal femoral locked plate (PFLP) in unstable pertrochanteric fractures.

Methods: This randomized controlled trial (RCT) included 40 patients (22 males, 18 females) with unstable pertrochanteric fractures (AO/OTA 31A2.2/A2.3). The patients were randomized into group 1 managed by DHS with TSP while group 2 was managed by PFLP. All patients were followed up for 1 year. Patients were assessed radiographically and clinically using Harris hip score (HHS) at 3, 6 and 12 months. Operative time, estimated blood loss and time to union were also compared.

Results: The difference of intra-operative variables, including operative time and intra-operative blood loss, between both groups was statistically insignificant. Time to bony union was faster in the first group with a statistically significant P value (p = 0.04). Functional outcome per HHS was significantly better in group 1 (p < 0.01) and implant failure in group 1 occurred statistically lesser (p < 0.01).

Discussion: DHS with TSP appears to be a good option of management for unstable pertrochanteric fractures. In contrast, the use of PFLP in unstable pertrochanteric fractures in the elderly does not appear to be a good alternative.

Keywords: Dynamic Hip Screw DHS; Elderly; Hip fractures; Proximal femoral locked plate PFLP; Trochanteric Stabilization Plate TSP; Unstable pertrochanteric fracture.

Figure 1

X-rays of 63-year-old male patient with AO 31A2.2 pertrochanteric fracture (lateral wall thickness < 20 mm) managed by DHS with TSP: (A) Pre-operative X-rays; (B) X-rays at 6 months follow-up.

Figure 2

X-rays of 62-year-old male patient with AO 31A2.2 pertrochanteric fracture managed by PFLP; (A) Pre-operative X-rays; (B) X-rays at 6 months follow-up.

Figure 3

Comparison of Harris hip scores and Failure rate at 1 year between the two groups (in percentages).