The Effect of Intraoperative Patient Positioning on the Success of Intertrochanteric Fracture Surgery in Older Patients

Abstract

Background and Objectives: The incidence of hip fractures in people of advanced ages is increasing due to our aging society. Patient positioning for the intertrochanteric fractures of the femur can be performed in various ways. The aim of this study is to clinically and radiologically compare the use of the supine hemilithotomy position, the lateral decubitus position, and the traction table when performing proximal femoral nail (PFN) surgery for femoral intertrochanteric fractures in the geriatric age group. Materials and Methods: A total of 170 elderly patients with femoral intertrochanteric fractures were included in this cross-sectional study. The patients were divided into three groups (the supine hemilithotomy group, the lateral decubitus group, and the fracture table group). For the postoperative period, complications, length of stay in the intensive care unit, and length of stay in hospital were examined, while in postoperative radiographs, tip-apex distances (TADs), collodiaphyseal angles (CDAs), and Cleveland-Bosworth quadrants were examined to evaluate the placement of the lag screw in the femoral head. The quality of fracture reduction was evaluated according to the modified Baumgaertner criteria. Results: The mean age of the patients was 77.8 ± 8.8; 57.6% of patients were female. According to the modified Baumgaertner criteria, it was determined that patients with 'poor' reduction quality had an approximately ten times higher risk of cut-out than those with 'good' reduction quality (OR = 10.111, p = 0.002, 95% confidence interval; 2.313-44.207). The operative time for patients in the fracture table group was longer than that of the other groups Additionally, the CDA in the supine hemilithotomy position group was longer. Conclusions: Although PFN surgery using the traction table is longer in terms of surgical time compared to surgery performed in the lateral decubitus position and the supine hemilitotomy position, it is advantageous in terms of better TAD and CDA values and lower complication rates.

Keywords: PFN; intertrochanteric fracture; lateral decubitus; supine hemilithotomy; traction table.

Figure 1

Patient selection flow chart.

Figure 2

Methods of measuring TAD values. TAD = [Xap × (Dtrue/Dap)] + (Xlat × (D true/Dlat)] (Dtrue = known diameter of the lag screw) (a,b). Determination of quadrant in the anteroposterior view and lateral view (c,d). Measurement of the collodiaphyseal angle (CDA) (e).

Figure 3

Percentage of cut-out complications and mean tip–apex distances (millimeters) for each quadrant. (A). Lateral decubitus position; (B) supine hemilithotomy position; and (C) traction table.

Figure 4

(A) Intraoperative view and (B) C-arm setup of intramedullary nailing facilitated by manual traction applied by a surgical assistant in the supine hemilithotomy position.

Figure 5

(A) C-arm setup and antero-posterior images and (B) lateral images of intramedullary nailing facilitated by the traction table.

Figure 6

(A) Intraoperative view and (B) C-arm setup of intramedullary nailing facilitated by the lateral decubitus position.