w w w . r b o . o r g . b r
Original
Article
Effectiveness
of
treatment
of
transtrochanteric
fractures
with
Dynamic
Hip
Screws
using
minimally
invasive
access
夽
Eduardo
Lima
de
Abreu
a,b,
Caroline
Brum
Sena
a,∗,
Sergio
Antonio
Saldanha
Rodrigues
Filho
baFundac¸ãoHospitalAdrianoJorge,Manaus,AM,Brazil bUniversidadeEstadualdoAmazonas,Manaus,AM,Brazil
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received29October2014 Accepted24April2015
Availableonline29January2016
Keywords:
Surgicalprocedures,operative Hipfractures
Fracturefixation,internal
a
b
s
t
r
a
c
t
Objective:Toanalyzetheshort-termresultsfromtreatingunstableintertrochanteric frac-tureswithDynamicHipScrews(DHS),usingaminimallyinvasiveroute,focusingonthe functionalaspectsandcomplicationandmortalityratesofthemethod.
Methods:Thiswasaprospectivelongitudinalstudyon140patientswhounderwent fixa-tionoftranstrochantericfractureswiththeDHSsystemwithalateralminimallyinvasive accessinthehip,betweenJanuaryandDecember2013.Thepatientswereevaluatedpreand postoperatively(aftersixmonthsoffollow-up)bymeansoftheParkerandPalmermobility score.Womencomprised65.7%ofthesample,and54.3%ofthefractureswereontheright side.Thepatients’meanagewas80years,rangingfrom60to93years.
Results:Weobservedanoveralldecreaseinthemobilityscoreandanincreaseinthedegree ofdependenceovertheshortterm.However,weencounteredonlytwodeathsinthestudy sampleandtherewerenocasesofinfectionornonunion.
Conclusion:DespitetheefficacyofthetreatmentwithDHS,withhighratesoffracture con-solidationanda lowmortalityrate,wenotedthatthepatientsstillshowed significant functionallimitationatthefollow-upsixmonthsaftertheoperation.
©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.
Eficácia
do
tratamento
das
fraturas
transtrocanterianas
com
Dynamic
Hip
Screw
com
acesso
minimamente
invasivo
Palavras-chave:
Procedimentoscirúrgicos operatórios
r
e
s
u
m
o
Objetivo:Analisarosresultadosdotratamentodefraturastranstrocantéricasinstáveiscom oDinamicHipScrew(DHS)porviaminimamenteinvasivaeavaliaraspectosfuncionais, taxasdecomplicac¸ãoeóbitosdométodo,emcurtoprazo.
夽
WorkperformedattheOrthopedicsandTraumatologyService,Fundac¸ãoHospitalAdrianoJorge,Manaus,AM,Brazil. ∗ Correspondingauthor.
E-mail:[email protected](C.B.Sena).
http://dx.doi.org/10.1016/j.rboe.2016.01.001
Fraturasdoquadril Fixac¸ãointernadefraturas
Métodos: Trata-sedeumestudolongitudinalprospectivo,com140pacientessubmetidosà fixac¸ãodefraturastranstrocantéricascomsistemaDHS,comacessominimamente inva-sivolateraldoquadril,dejaneiroadezembrode2013.Ospacientesforamavaliadosprée pós-operatoriamente(comseismesesdeseguimento),deacordocomoescorede mobili-dadedeParkerePalmer.Aamostraapresentou65,7%demulheres,comoladodireitomais acometido(54,3%).Amédiadeidadefoide80anos,variac¸ãoentre60e93.
Resultados: Notamosumadiminuic¸ãoglobalnoescoredemobilidadeeaumentonograude dependênciadessespacientesemcurtoprazo.Noentanto,obtivemosapenasdoisóbitos naamostraestudadaenenhumainfecc¸ãooufalhanaconsolidac¸ãodasfraturas.
Conclusão:ApesardaeficáciadotratamentocomDHS,comelevadosíndicesdeconsolidac¸ão ebaixataxademortalidade,notamos queospacientes,aindaassim,apresentamuma limitac¸ãofuncionalsignificativanoseguimentoatéseismesespós-operatórios.
©2016SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Todososdireitosreservados.
Introduction
Proximal fractures of the femur, among which transtrochantericfractures canbehighlighted,are apublic healthproblemthatespeciallyaffectstheelderlypopulation. Theyhavealargesocialandeconomicimpact.Theincidence of these fractures has been increasing as the population becomesincreasinglyelderly,thankstoimprovementsin liv-ingconditionsandgreaterattentiontopreventivemedicine.1 Anexponentialincreaseintheincidenceoffracturesofthe proximalthird ofthe femur hasbeen recorded, withpeak occurrencearoundtheagesof75–80years.1,2
Thesepatientspresentchronicdegenerativediseaseswith incapacitiesanddeficiencies.Theymakeuseofmedications thatcausesomnolence,balanceproblemsandalteredmuscle tone,andtheygiverisetolowbloodpressure.Together,these areresponsibleforanincreasedriskoffallsandthis,along withvaryingdegreesofosteoporosis,favorthistypeofinjury. Hipfracturesaccountfor30%ofhospitaladmissionsinthe UnitedStates3andthispercentagehasbeengradually increas-ing.Itisexpectedthatby2040,thenumberofpatientswill reacharound329,000,withanannualtreatmentcostofaround 16billiondollars.4AccordingtoTronzo,5thesefracturescan beclassifiedasstable(typesIandII)orunstable(III,IVand V),accordingtothedegreeofcomminutionofthe
posterome-dialcorticalbone.Thisisoneoftheprinciplesthatneedtobe understoodinchoosingtheosteosynthesismethod.
Theidealtreatmentissurgicalandthefixationtechnique needstobereproducibleandnon-aggressive,andtohavea lowcomplication rateand good functional results.In 1941 Jewetand Eugene6 conceptualizedanimplantwithastatic fixedanglethatwouldallowearlymobilizationforthepatient andreducetheincidenceofdeformitiesduetoskewedvarus consolidation.7,8
However, this implant was often found to fail, due to uncontrolledcollapseofthefractureandconsequentcut-out. ThisledsomeauthorssuchasFreitasetal.,9Smith-Petersen et al.,10 Thornton,11 Jewett and Eugene6 and McLaughlin12 toseek newimplant designswithcompatible biomechani-calprinciples.TheRichardsslidingcompressionscrewwas developedbyRichardsSurgicalLtdandthiswassubsequently
modifiedbySynthesLtd,underthenameDynamicHipScrews (DHS).ThisdevicewasrecommendedbySchatzker13andthe AOgroup.14 Unlikethe antiquated rigidimplants, theDHS broughtinthepossibilityofpromotingcontinuous compres-sionthroughthefocusofthefracture,whichhithertohadbeen impossible.15
Shortly after this,cephalomedullary nails emerged asa meansfortreatingthesefractures.Thistypeoffixationgained manyadherentsbecauseofthelowdegreeofaggressiveness inimplantingthem,theshorterdurationoftheoperationand hospitalstay,andtheconsequentlowerdegreeofmorbidity inrelationtotraditionalosteosynthesis methodsthatused extramedullarytutors,whichrequiredlarge-sizedaccessesfor theirinstallation.16,17Inaddition,theDHSmethodhasamajor biomechanical advantageintreating fractures that present severeinstability.However,withthissystem,thesefractures requireanatomicalreductionorvalgusreconstruction,likein thetechniqueofDimonandHughston,18inordertodiminish theriskoffailureofthesynthesis.Whenthese reconstruct-ionsarenecessary,thedurationoftheoperationrequiredis longerandthemorbidityofthetreatmentisgreater.
TheaimofthisstudywastoprovetheefficiencyoftheDHS systemforfixationofunstablefractures,withanatomicalor valgusreduction,bymeansofaminimallyinvasivesurgical access,andtoevaluatetheconsolidationrateandfunctional recoveryamongthepatients.
Material
and
methods
Anon-randomizedopenprospectivelongitudinalstudywas conductedamongpatients withtranstrochanteric fractures who wereadmittedtoand treatedatareferralhospitalfor orthopedictraumacasesinastatecapitalinBrazil,between JanuaryandDecember2013.
Inthisstudy,140patientswereevaluated,ofwhom65.7% werewomen(Fig.1).Thepatients’meanagewas79±9years, witharangefrom60(minimumage)to93(maximumage). Therelativefrequencyofpatientsbetweentheagesof80and 84yearswas28.6%(Fig.2).
Female 65.7%
Male 34.3%
Fig.1–Genderprevalenceamongelderlypeople hospitalizedwithtranstrochantericfracturesatan emergencyserviceinthecityofManaus,Amazonas.
alreadyreceivedtreatmentinotherservices(Table1).Itwas alsoobservedthatwhile52.9%wereclassifiedaspresenting normalweight,12.9%hadtypeIobesity.Mostofthepatients werelivingintheirownhomes(89.3%)and53.6%madeuseof alcoholicdrinks.Thedeathrateovertheperiodofthestudy was1.4%.
Amongthepatientsevaluated,242underlying pathologi-calconditionswerediagnosed.Amongthese,systemicarterial hypertensionwasthemostfrequentcondition(45.0%)(Fig.3). Theintensityofpainamongthesepatientsrangedfrommild tointractable,and47.1%presentedpainofmoderateintensity (Fig.4).
AccordingtothemobilityscoreofParkerandPalmer,19in whichninepointsisthemaximumscore,wefoundthatthe meanwas5.42inthepreoperativeevaluationand3.91inthe postoperativeevaluation,whichindicatesthattherewasa sig-nificantimprovementamongthepatientsevaluated(p<0.001) (Fig.5).
Youngpatients,patientspresentingpathologicalfractures duetoneoplasticdiseases,thosewithstabletranstrochanteric fracturesandthosewithunstablefractureswithaninverted fractureline wereexcluded. Inthis lastcase, thepreferred optionforosteosynthesiswasacephalomedullarynail.The Tronzoclassification5wasusedtoevaluatethepatientsinthis sample.
Thesepatientswereevaluatedbeforetheoperationusing themobilityscoreofParkerandPalmer,19whichwetranslated
35.0
30.0
25.0
20.0
%
Age group (years) 15.0
5.0
0.0 60 to 64
7.1 14.3
8.6 12.1
28.6
20.7
65 to 69 70 to 74 75 to 79 80 to 84 85 to 89 10.0
Fig.2–Agegroupprevalenceamongtheelderlypeople hospitalizedwithfractures.
Stroke 15.3%
Diabetes mellitus
26.0% Systemic arterial
hypertension 45.0%
Acute myocardial infarction
8.3% Cancer
5.4%
Fig.3–Underlyingpathologicalconditionsmostfrequently observedamongtheelderlypeoplehospitalizedwith fractures.
Intractable
15.9% Mild
37.0%
Moderate 47.1%
Fig.4–Intensityofpainamongtheelderlypeople hospitalizedwithfractures.
9.00
8.00 7.50
6.50 7.00
6.00 5.50 5.00 4.50 4.00 3.50
Score
Before After
P<.0001
Time 5.42
3.91
3.00 2.50 2.00 1.50
0.50 0.00 1.00 8.50
Table1–Personalcharacteristicsofthepatients evaluated.
Characteristics Frequency (n=140)
%
Sidewithfracture
Left 55 39.3
Right 76 54.3
Both 9 6.4
BMIclassification
Underweight 6 4.3
Normalweight 74 52.9
Overweight 33 23.6
TypeIobesity 18 12.9
TypeIIobesity 9 6.4
Housing
Ownhome 125 89.3
Nursinghome 15 10.7
Useofalcohol
Yes 75 53.6
No 65 46.4
Death
Yes 2 1.4
No 138 98.6
ourselves(Table2). For theseevaluations, informationwas gatheredfrom accompanyingpersonswhowerelivingwith thepatients,basedonthedaybeforethetrauma.Thepatients underwenttheoperationonaradiolucenttable,bymeansof aminimally invasivelateral accesstothe hip,under man-ualtraction, oflengthapproximately5cm. Allofthe cases werefixedusingaDHSof135◦,withathree-holeplate.The operationswereperformedbytheauthorsofthisstudy.
The patients were followed up as outpatients and full weight-bearingwasallowedfourweeksaftertheoperationon average.Sixmonthsaftertheoperation,thepatients under-wentanewevaluationusingthemobilityscoreofParkerand Palmer.
Descriptiveanalysiswasperformedonthedataand com-parisons between the mean scores before and after the operationweremadeusingStudent’sttest,takingthe signif-icanceleveltobe5%.Allthevariableswereevaluatedusing theMinitabAcademicstatisticalsoftware,version14.1.
Results
All ofthe140 patientsoperated presentedfracture consol-idationbythe sixth monthafterthe operation. Theseries presentedheredidnotshowuncontrolledcollapseorcut-out inanyofthecases.Therewerenoimmediateintraoperative complications, and noneed forany blood transfusion was
documentedbeforethepatientswerereleasedfromthe hos-pital. Twodeathswere observed: oneduetocomplications relatingtodeliriumandtheotherduetopneumonia,which bothoccurredduringthefirstpostoperativeweek.
Discussion
Transtrochanteric fracturesaretypicalofpatientswith vul-nerablehealth1,5,20–22andthereisnodoubtthattheyhavea majorsocialimpact.Managingthesecasesisachallengeand thefrequencyofoccurrenceofsuchfractureshasincreased exponentiallyasaconsequenceofgreaterlifeexpectancyfor the world’s population overall, thanksto improvementsin generalhealthconditions.Theseeventsprovideever-greater justificationforconductingmorestudies ontreatmentsfor thiscondition.9,18
Thedemographicdatashowthatwomenandindividuals ofmeanage80yearswerethegroupswithgreaterprevalence ofthesefracturesinoursample.Studiespublishedpreviously also showed that womenand individuals ofadvanced age presentedfracturesofthe proximalfemurmorefrequently, because oftheir association withosteoporosis.1,18,23–25 The sidepredominantlyaffectedbythesefractureswastheright side.
Thetreatmentfortranstrochantericfractureshasevolved overthelast50years,especiallywithregardtothesynthesis method.9,18,26
Slidingscrewsnowconstitute oneofthemethodsmost usedfortreatingthemajorityoftranstrochantericfractures.9 In Brazil, the results from surveys have proven the effi-ciency of DHS for surgical treatment of transtrochanteric fractures.8,16,27 Studies in the worldwide literature have proventhatthesefractures attaingoodconsolidationwhen treatedusingDHS.5,28,29Inourseries,weachieveda consoli-dationrateof100%andonlytwodeathsoccurredwithinthe firstsixmonthsoffollow-up.
However,thesepatients’functionalrecoverywaspoor.The mobilityscoreofParkerandPalmer19decreasedfromaround sixtofourpointsaftersixmonths,whichindicatesthatthe patientspresentedincreaseddifficultyinwalkingand conse-quentlydiminishedautonomy.Intheworldwideliterature,we notedthat,independentofthetreatmentmethodchosen,the timewhentheoperationwasperformedorthepreviouslevel ofautonomy,the patients’degreeofdependenceincreased considerablyaftersurgicaltreatment.23,30
Theincidenceofcomplicationswhenthissystemisused correctlyisaround5%.14Harrisonetal.31studied6,905cases ofhipfractureandfoundthatthedeepinfectionratewas0.7%. Reportsintheliteraturehaveshownthatthedeepinfection rateafteratranstrochantericfractureranges from0.15%to
Table2–Presentauthors’translationofthemobilityindexofParkerandPalmer.
Abilitytowalk Withoutdifficulty Withaids Helpedbyotherpeople Doesnotwalk
Walksinsidethehome 3 2 1 0
Walksoutsideofthehome 3 2 1 0
15%.29Inourpopulation,wedidnothaveanysuchcasesof infection.
Themortalityratetendstobehigh,rangingfrom12%to 41%overthefirstsixmonthsaftertheoperation.32Inour sam-ple,wefoundthatthenumberofdeathswithinthefirstsix postoperativemonthswaslow(1.4%),whichprovesthatitis importantthattreatmentsforthisconditionshouldpresenta lowdegreeofaggressiveness.
Conclusion
UseofDHSasthefixationmethodfortranstrochanteric frac-tures, with a minimally invasive access, presented a high consolidation rate and low morbidity and mortality, along withaverylow complicationrate.However,wenotedthat evenwiththesuccessofthetreatmentused,rehabilitationis difficultand precariousamongthesepatients.Thepatients usuallyevolvewithfunctional limitationsand asignificant degreeofdependence,asseeninthefollow-upsixmonths aftertheoperation.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
r
e
f
e
r
e
n
c
e
s
1. HamraA,MiguelOF,MarteliTK,BarciLP,LemeFM.DHSe
OPS:estudocomparativodafalênciadeosteossíntese.Acta
OrtopBras.2009;17(2):35–9.
2. Assunc¸ãoJH,FernandesTL,SantosALG,SakakiMH,Zumiotti
AV.Fatorespreditivosparamarchanafratura
transtrocanterianadofêmur.ActaOrtopBras.2009;17(1):35–9.
3. RusselTA.Fraturasdequadriledapelve.In:Cirurgia
ortopédicadeCampbell.8ed.SãoPaulo:Manole;1996.p.
955–1056.
4. McLoughlinSW,WheelerDL,RiderJ,BolhofnerB.
Biomechanicalevaluationofthedynamichipscrewwith
two-andfour-holesideplates.JOrthopTrauma.2000;14(5):318–23.
5. TronzoRG.Chirurgiadelacadera.BuenosAires:Médica
Panamericana;1995.p.690–5.
6. JewettEL,EugeneI.One-pieceanglenailfortrochanteric
fracture.JBoneJointSurgAm.1941;23:803–10.
7. RadfordPJ,NeedoffM,WebbJK.Aprospectiverandomised
comparisonofthedynamichipscrewandthegammalocking
nail.JBoneJointSurgBr.1993;75(5):789–93.
8. SaarenpääI,HeikkinenT,RistiniemiJ,HyvönenP,LeppilahtiJ,
JalovaaraP.Functionalcomparisonofthedynamichipscrew
andtheGammalockingnailintrochanterichipfractures:a
matched-pairstudyof268patients.IntOrthop.
2009;33(1):255–60.
9. FreitasA,MesquitaAQ,DaherWR,SoutoDRM,RangelCHC.
Ensaiosestáticosdeflexãoerigidezemplacasdotiposistema
dinâmicodoquadril(DHS).ActaOrtopBras.2009;17(4):215–8.
10.Smith-PetersenMN,CaveEF,VanGorderGW.Intracapsular
fracturesoftheneckofthefemur.ArchSurg.1931;23:715.
11.ThorntonL.Thetreatmentoftrochantericfracturesofthe
femur:twonewmethods.PiedmontHospBull.1937;10:
21–35.
12.McLaughlinHL.Anadjustableinternalfixationelementfor
thehip.AmJSurg.1947;73(2):150–61.
13.SchatzkerJ.Parafusoseplacasesuaaplicac¸ão.In:MüllerME,
AllgöwerM,SchneiderR,WilleneggerH,editors.Manualde
osteossíntese.TécnicasrecomendadaspeloGrupoAO-ASIF.
SãoPaulo:Manole;1993.p.179–290.
14.FreitasA,HaubertGO,BotelhoRZ,SoutoDM,DaherWR,
FranklinCE,etal.Ensaiodeaplicabilidadeinvitrodosistema
dinâmicodoquadrilAF(DHS-AF).ActaOrtopBras.
2011;19(2):83–6.
15.KovalKJ,ZuckermanJD.Hipfractures:II.Evaluationand
treatmentofintertrochantericfractures.JAmAcadOrthop
Surg.1994;2(3):150–6.
16.LimaALP,AzevedoFilhoAJ,AmaralNP,FranklinCE,Giordano
V.Tratamentodasfraturasintertrocanterianascomplacae
parafusodeslizante.RevBrasOrtop.2003;38(5):271–80.
17.KöberleG.Fraturastranstrocanterianas.RevBrasOrtop.
2001;36(9):325–9.
18.DimonJH,HughstonJC.Unstableintertrocantericfracturesof
thehip.JBoneJointSurgAm.1967;49(3):440–50.
19.ParkerMJ,PalmerCR.Anewmobilityscoreforpredicting
mortalityafterhipfracture.JBoneJointSurgBr.
1993;75(5):797–8.
20.CordeyJ,SchneiderM,BühlerM.Theepidemiologyof
fracturesoftheproximalfemur.Injury.2000;31Suppl.
3:C56–61.
21.OlssonO,CederL,LunsjöK,HauggaardA.Extracapsularhip
fractures:fixationwithatwinhookoralagscrew?Int
Orthop.2000;24(5):249–55.
22.GerberY,MeltonLJ3rd,McNallanSM,JiangR,WestonSA,
RogerVL.Cardiovascularandnoncardiovasculardisease
associationswithhipfractures.AmJMed.2013;126(2):169,
e19-26.
23.HungriaNetoJS,DiasCR,AlmeidaJDB.Características
epidemiológicasecausasdafraturadoterc¸oproximaldo
fêmuremidosos.RevBrasOrtop.2011;46(6):660–7.
24.RochaMA,CarvalhoWS,ZanquetaC,LemosSC.Estudo
epidemiológicoretrospectivodasfraturasdofêmurproximal
tratadosnoHospitalEscoladaFaculdadedeMedicinado
TriânguloMineiro.RevBrasOrtop.2001;36(8):311–6.
25.UlianaCS,AbaggeM,MalafaiaO,KalilFA,CunhaLAM.
Fraturastranstrocantéricas–Avaliac¸ãodosdadosda
admissãoàaltahospitalar.RevBrasOrtop.2014;49(2):121–8.
26.DeLeeJC.Fraturaseluxac¸õesdoquadril.In:RockwoodCA,
GreenDP,BucholzRW,editors.Fraturasemadultos.Traduc¸ão
deNelsonGomesdeOliveira.SãoPaulo:Manole;1993.p.
1453–620.
27.SawaiaR,BelangeroWD.Estudocomparativoentreatécnica
demini-incisãoeaviadeacessoafocoabertoparao
tratamentodasfraturastranstrocanterianas.RevBrasOrtop.
2005;40(3):106–18.
28.KimWY,HanCH,ParkJI,KimJY.Failureofintertrochanteric
fracturefixationwithadynamichipscrewinrelationto
pre-operativefracturestabilityandosteoporosis.IntOrthop.
2001;25(6):360–2.
29.BaumgaertnerMR,BrownerBD,JupiterJB,LevineAM,Trafton
PG.Intertrochanterichipfractures.In:Skeletaltrauma.
Philadelphia:Elsevier;2007.p.1776–816.
30.KovalK.Intertrochantericfractures.In:Rockwoodand
Green’sfractureinadults.Philadelphia:LippincottWilliams&
Wilkins;2006.p.1794–825.
31.HarrisonT,RobinsonP,CookA,ParkerMJ.Factorsaffecting
theincidenceofdeepwoundinfectionafterhipfracture
surgery.JBoneJointSurgBr.2012;94(2):237–40.
32.DahlE.Mortalityandlifeexpectancyafterhipfractures.Acta
