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Submitted to
THE TAMILNADU Dr.M.G.R MEDICAL UNIVERSITY
CHENNAI-600032.
In partial fulfillment of the regulations
for the award of
M.S.(ORTHOPAEDIC SURGERY)
BRANCH-II
1
CERTIFICATE
surgery, under my supervision and guidance during the period from May
DEAN,
2
Govt.Kilpauk Medical College & Hospital,
Chennai-10.
DECLARATION
Place : Chennai-10.
3
ACKNOWLEDGEMENT
I express my utmost gratitude to Prof.Dr.P.Vasanthamani, M.D,
D.G.O, MNAMS, DCPSY, M.B.A, Dean, Government Kilpauk Medical
College and Hospital for providing me an opportunity to conduct this
study.
I would like to thank all my colleagues and hospital staff for all the
help they rendered.
I would like to thank all my patients for their full co-operation for
this study without whom this study would not have been possible.
4
Last but not the least I thank the lord all mighty for making this
study a successful one and offer my sincere prayers to him.
5
6
CERTIFICATE - II
plagiarism Check. I found that the uploaded thesis file contains from
in the dissertation.
7
A COMPARATIVE STUDY ON FUNCTIONAL,
CLINICAL & RADIOLOGICAL OUTCOME OF
UNSTABLE INTERTROCHANTERIC FRACTURES
MANAGED BY PROXIMAL FEMORAL NAILING
VERSUS DYNAMIC HIP SCREW WITH
TROCHANTERIC STABILISATION PLATE
8
CONTENTS
1 INTRODUCTION 1
2 OBJECTIVE 4
3 OSTEOLOGY 5
4 ANATOMY 12
5 CLASSIFICATIONS 16
6 REVIEW OF LITERATURE 24
8 INSTRUMENTATION 31
9 OPERATIVE PROCEDURE 34
11 COMPLICATIONS 55
12 CASE ILLUSTRATIONS 61
13 DISCUSSION 69
14 CONCLUSION 75
15 BIBLIOGRAPHY
16 PROFOMA
17 MASTER CHARTS
9
INTRODUCTION
increasing.
muscle power, decreased reflexes, poor vision and labile blood pressure.
10
Unstable contribute to about 50%-60% of all intertrochanteric
fractures.5,6
affect the biomechanical strength of the repair. Bone quality and fracture
pattern which are surgeon independent along with Implant choice, quality
dependent.8
they are more prone for urinary tract infection, respiratory tract infection,
company of USA.
11
Condylocephalic intramedullary devices were introduced in 1966
by kuntscher later by Ender in 1970.
femoral nailing.
12
OBJECTIVE
13
OSTEOLOGY
The longest and strongest bone of the body is femur. The parts of
14
Head of femur
acetabulam.
Neck of femur
Long axis of neck makes an angle of 125° to 135° with long axis of
the shaft and is termed as neck shaft angle and angle of 10°-30° with
Calcar
portion of the femoral shaft under the lesser trochanter and radiating
Greater trochanter
between neck and shaft. This posterosuperior part projects upwards and
medially beyond the level of neck. Most of the muscles of gluteal region
15
Lesser trochanter
Intertrochanteric line
Intertrochanteric crest
Intertrochanteric region
16
Blood supply
major groups :
femoral neck.
17
These proximal vessels most vulnerable to injury in femoral neck
fracture. Ascending cervical vessels forms a less distinct ring called sub
(Wolff’s law).
via the neck of femur which is separated by sparse cancellous bone called
Ward’s triangle.
18
Trabecular groups
19
Grade 6
Grade 5
Grade 4
in grade 4.
Grade 3
Grade 2
Grade 1
no longer prominent.
20
ANATOMY
Soft tissues of the hip joint:
Extensors
Gluteus maximus.
aspect of femur.
21
ABDUCTORS
External rotators:
Piriformis
Obturator internus
Obturator externus
Quadratus femoris
22
Flexors
Psoas major:
trochanter.
Iliacus:
Other flexors of hip joint are Sartorius, pectineus and gracilis (also
an adductor).
Adductors
nerve.
23
Distal fragment: adduction with shortening and overrides fracture
fragments.
where bone density is high. The pull out strength of dynamic hip screw
Pathomechanics of fracture
distal fragment.
Load over the implant will be more and it cause fracture to collapse
segment.
24
CLASSIFICATIONS
Evan’s -1949.
Ramadier’s – 1956.
Enders’ – 1970.
Tronzo’s – 1973.
Jensen’s – 1975.
Deburge’s – 1976.
Briot’s – 1980.
AO classification – 1981.
25
Evans classification (1949)
26
Type Ie: Four-fragment fracture without postero-lateral and medial
Type II: Fracture line extends downwards and outwards from the
27
Body and Griffin’s classification:
28
Kyle’s classification:
fracture, varus.
varus.
29
OTA Classification
30
A2.1 - fracture with one intermediate fragment.
A3 - intertrochanteric fracture.
31
Unstable fractures:
cortical continuity.
displacement,
32
REVIEW OF LITERATURE
patients found more fixation failures hence they advocated that there is no
cortex for fracture stability and the need of fixing posteromedial fragment
33
impaction they found that DHS fixation provided comparable
34
Disadvantages of Sliding hip screw in unstable intertrochanteric
fractures:
cutout.
Advantages
Disadvantages
35
Role of PFN in unstable Intertrochanteric fractures:
Advantages
Disadvantages
Costlier implant.
36
MATERIAL AND METHODS
Study design:
Randomisation:
SAMPLE SIZE:
{z(alpha)+z(beta)}^2*(S.D) ^2*2
n= _______________________________________.
d^2
in follow up.
37
Inclusion Criteria:
3. Both genders.
Exclusion criteria:
1. Compound fractures.
2. Pathological fractures.
3. Polytrauma patients.
extension.
immunosuppressants.
38
Investigations:
2. Complete hemogram.
39
DHS WITH TSP INSTRUMENTATION
d e f
c
a b
l
k
j
m n
g
h
i
40
41
SPECIFICATIONS: PROXIMAL FEMORAL NAIL
42
OPERATIVE PROCEDURE
patient was placed on fracture table with unaffected leg in flexion and
projections.
43
DHS WITH TSP:-
Reduction maneuver:
Surgical approach:
44
45
46
47
PROXIMAL FEMORAL NAIL:-
Entry made through modified medial portal entry with patient in fracture
size 15mm less than lag screw fixed proximally.2×4.9mm locking screws
both fixed distally using distal aiming device and wound closed in layers.
48
49
50
51
DISTAL LOCKING SCREWS PLACED
52
POST OP PROTOCOL:
* From day 3 oral antibiotics and analgesics given for another one
week.
* Harris hip score, radiological union and neck shaft angle were
53
GRADING:
SCORE GRADE
90-100 Excellent
80-89 Good
70-79 Fair
60-69 Poor
54
OVERVIEW & ANALYSIS
1 31A2.1 5 5
2 31A2.2 14 12
3 31A2.3 7 9
55
GENDER DISTRIBUTION
MALE 12 MALE
13 13
FEMALE 14 FEMALE
SIDE OF FRACTURE
RIGHT 12 RIGHT
13 13
LEFT 14 LEFT
56
Age wise distribution of patients is as follows:
NO.OF PATIENTS
AGE GROUP (IN
SL.NO
YEARS)
DHS WITH TSP PFN
1 50 - 59 3 4
2 60 - 65 8 9
3 66 - 70 7 6
4 71 - 75 8 7
3 4
8 7
50-59 50-59
60-65 60-65
8
66-70 66-70
9
71-75 6 71-75
7
tuberculosis.
57
COMORBIDITIES /DHS WITH TSP
1
diabetes mellitus
1
1 5 hypertension
primary pulmonary
6 tuberculosis
COMORBIDITIES IN PFN
1 diabetes mellitus
2 4
hypertension
primary pulmonary
tuberculosis
chronic kidney disease
8
58
Operative details of intertrochanteric fractures treated by dynamic
nailing.
in hip region and 5 patients in PFN group had pain in thigh region hence
symptoms subsided.
59
Functional outcome by Harris hip score
18
16
16
14
14
12
EXCELLENT
10
GOOD
8 7 FAIR
6 POOR
5
4
2
2 1 1
0
0
DHS WITH TSP PFN
COMPLICATIONS
Wound complications
60
Complications related to implants and union:
till radiological union to occur then the screw was removed under spinal
anaesthesia.
patient had persistent hip and another had persistent thigh pain. Weight
bearing was delayed in these patients, after radiological union the pain
was relieved
61
In Proximal Femoral Nail:
One patient had self fall 1 month following surgery and sustained
peri implant fracture just distal to the end of nail. Non union was found in
follow up.
62
In that one patient lag screw was found to be backed out in 1st
month post operative x-ray.
63
COMPLICATIONS
SL.NO COMPLICATION DHS WITH TSP PFN
6 Non union 0 2
Cross tables
64
Group Statistics(age)
DHS with
Age PFN
23 65.26 6.032 1.258
65
Group * OTA
GROUP*OTA (Crosstab)
OTA Total
1 2 3
Grou DHS Count 5 10 8 23
p with TSP % within 21.7% 43.5% 34.8% 100.0%
group
PFN Count 5 10 8 23
% within 21.7% 43.5% 34.8% 100.0%
group
Total Count 10 20 16 46
% within 21.7% 43.5% 34.8% 100.0%
group
Group * R/L
GROUP*R/L (Crosstab)
R/L Total
Right Left
Group DHS Count 12 11 23
with TSP % within 52.2% 47.8% 100.0%
group
PFN Count 11 12 23
% within 47.8% 52.2% 100.0%
group
Total Count 23 23 46
% within 50.0% 50.0% 100.0%
group
66
No cormobids
Comorbids
DM HTN CAD PTB CKD Total
Group DHS Count 9 5 6 1 1 1 23
with
TSP
%with 39.130434 21.7391 26.0869 4.34782 4.34782 4.34782 100
in
group
PFN Count 8 4 8 0 2 1 23
%with 34.782608 17.3913 34.7826 0 8.69565 4.34782 100
in
group
Total Count 17 9 14 1 3 2 46
%with 36.95652 19.565 30.434 2.1739 6.52173 4.3478 100
in
group
Group * Radiologicalunion
GROUP*RADIOLOGICAL UNION(Crosstab)
Radiologicalunion Total P value
evidence of No
progressive evidence of
callus callus
formation in formation in
follow up x follow up x
rays rays
Group DHS with Count 23 0 23 .244
TSP % within 100.0% 0.0% 100.0%
group
PFN Count 21 2 23
% within 91.3% 8.7% 100.0%
group
TOTAL Count 44 2 46
% within 95.7% 4.3% 100.0%
group
67
Group * Neck shaft angle
GROUP*NECK SHAFT ANGLE (Cross tab)
Neckshaftangle Total P
No Varus value
Varus
Group DHS Count 21 2 23 0.244
with % within group 91.3% 8.7% 100.0
TSP %
PFN Count 23 0 23
% within group 100.0 0.0% 100.0
% %
Total Count 44 2 46
% within group 95.7% 4.3% 100.0
%
NPar Tests
Group Statistics
Group N Mean Std. Std. Error
Deviation Mean
Duration surgery DHS with 23 88.09 7.874 1.642
in minutes TSP
PFN 23 60.30 5.850 1.220
Blood loss in DHS with 23 172.61 16.846 3.513
(ml) TSP
PFN 23 58.26 7.777 1.622
Harris hip DHS with 23 85.74 5.336 1.113
function score TSP
PFN 23 83.61 6.720 1.401
68
Mann-Whitney Test
Ranks
Group N Mean P value
Rank
Harris hip DHS with TSP 23 25.80 0.243
function score PFN 23 21.20
Total 46
B/L ML DHS with TSP 23 35.00 .000
PFN 23 12.00
Total 46
Duration DHS with TSP 23 35.00 .000
surgery minutes PFN 23 12.00
Total 46
DHS with TSP 23 33.63 .000
Full weight PFN 23 13.37
bearing initiated Total 46
(weeks)
69
CASE ILLUSTRATIONS
70
Active SLRT External rotation
71
Case 2: A 50 year old male
72
Standing Active SLRT
73
Case 3: A 57 year old male
74
Active SLRT External rotation
75
Case 4: A 68year old female
76
Active SLRT External rotation
77
DISCUSSION
these patients. Diminished vision, reduced reflexes, poor muscle tone and
stabilization plate.
Sliding hip screw is still most widely used implant for these cases.
screw cut out. It also has a disadvantage of having only a single point
78
Advantages of dynamic hip screw with trochanteric stabilization
79
Our study was conducted in Govt. Kilpauk Medical College &
fractures were treated with DHS with TSP and PFN in equal numbers by
follows,
1. Age : Most of patients in our study were in the age of >60 years of
age.
3. Mode of injury : Fall from standing height (trivial fall) was most
31A2.3.
80
5. Side of fracture : In DHS with TSP group 14 patients had right and
12 patients had left side fracture. In PFN group13 had right and 13
kidney disease.
independently unassisted.
8. Patients were operated within 7.6 days in DHS with TSP group
9. Mean operating time in DHS with TSP was 88 minutes and in PFN
10. Mean blood loss in DHS with TSP 172.6ml and in PFN was 58.26
ml.
81
11. Mean lag screw was 85 mm both in DHS with TSP and in PFN.
Mean anti-rotation screw size was 75mm in DHS with TSP and in
12. Mean hospital stay was 6.9 days in DHS with TSP and in PFN was
5.1 days.
13. On 3rd postoperative day partial weight bearing was allowed on the
14. All patients treated with DHS with TSP allowed to full weight
10.15weeks.
15. On basis of Harris Hip Score the functional outcome of all patients
group had urinary tract infection. 2 patients in PFN group and one
patient DHS with TSP group had persistent hip pain. One patient in
DHS with TSP group had persistent thigh pain. 2 patients had
82
with shortening <2cm (1.3cm & 1.5cm). In PFN group one patient
one patient during follow up and she was operated with implant
in 2 cases operated with PFN and these patients denied any further
intervention.
83
CONCLUSION
union, varus collapse and functional outcome at six months follow up,
than 0.05 in terms of duration of surgery, blood loss during surgery and
84
BIBLIOGRAPHY
3. Melton LJ, Kearns AE, Atkinson EJ, Bolander ME, Achenbach SJ,
Huddleston JM, et al. Secular Trends in Hip Fracture Incidence and
Recurrence. Osteoporosis Int. 2009;20(5):687- 94.
4. Kyle RF, Gustilo RB, Premer RF. Analysis of six hundred and
twenty-two intertrochanteric hip fractures. J Bone Joint Surg Am.
1979;61:216-21.
5. Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM. The value
of the tip apex distance in predicting failure of fixation of
peritrochanteric fractures of the hip. J Bone Joint Surg Am.
1995;77:1058-64.
85
7. Babst R, Martinet O, Renner N, Rosso R, Bodoky A, Heberer M, et
al. Die DHS - Abstützplattefürdie Versorgung der instabilen
proximalen Femur-frakturen. Schweizer Med Wochenschr.
1993;123:566-8.
10. Medoff RJ, Maes K. A new device for the fixation of unstable
pertrochanteric fractures of the hip. J Bone Joint Surg Am.
1991;73:1192-9.
13. Rho JY, Kim SB, Heo YM, Cho SJ, SikChae D, Lee WS. Proximal
Femoral Nail Antirotation versus Compression Hip Screw with
Trochanter Stabilizing Plate for Unstable Intertrochanteric Hip
Fractures.J Korean Fracture Society. 2010;23(2):161-6.
86
14. Shetty A, Ballal A, Kumar A, Sadasivan, Hedge A. Dynamic Hip
Screw with Trochanteric Stablization Plate Fixation of Unstable
Inter-Trochanteric Fractures: A Prospective Study of Functional
and Radiological Outcomes. J Clin Diagnos Res. 2016;10(9):6-8.
87
PROFORMA
Name :
Age/Sex :
IP Number :
Address :
Contact Number :
Occupation :
Education :
Socioeconomic Status :
Date of Admission :
Date of Surgery :
Date of Discharge :
History :
88
3. Co morbid illnesses:
PAST HISTORY:
Similar injuries
89
PERSONAL HISTORY:
SL.NO
1 Diet Vegetarian / mixed
2 Marital status Married / single
3 Bowel and bladder habits Regular / altered
4 Habits Smoking / alcohol/ tobacco/drug
addictions/others
TREATMENT HISTORY:
FAMILY HISTORY:
CLINICAL EXAMINATION:
GENERAL EXAMINATION:
Appearance:
Built:
Pallor:
Icterus:
Cyanosis:
Clubbing:
Pedal edema:
Lymphadenopathy:
VITALS:
1. Pulse
2. BP
3. Respiratory Rate
4. Temperature
SYSTEMIC EXAMINATION:
Cardiovascular system :
90
Respiratory system :
Abdomen :
REGIONAL EXAMINATION:
RIGHT/LEFT HIP
OTHER INJURIES
X-RAY FINDINGS
INVESTIGATIONS:
FINAL DIAGNOSIS:
PLANNED SURGERY:
91
PROCEDURE NOTES:
POST OP PERIOD:
FUNCTIONAL OUTCOME:
92
INDEX FOR MASTER CHART
1. Self Fall.
2. OTA classification
31A2.1-1
31A2.2-2
31A2.3-3
3. R/L
R-Right
L-Left
4. COMORBIDS
1. No comorbids
2. DM
3. HTN
4. CAD
93
5. TB
6. CKD
x- rays
1. No varus
2. Varus (<125°)
94
Master Chart for DHS WITH TSP
SL.NO NAME AGE/ SEX MOI OTA R/L COMORBID DOS B/L FWB HHS RU NSF
(Mts) (Ml) (WKS)
1 Rajendran 61/M 1 1 1 1 81 170 10.5 93 1 1
2 Devi 71/F 1 3 1 2 86 180 11.6 81 1 1
3 Kanthan 69/M 1 2 2 3 89 190 10.3 86 1 1
4 Muthu 53/M 2 3 2 2 93 200 12.6 82 1 1
5 Sekar 63/M 1 1 1 5 80 150 14.4 90 1 1
6 Chandra 70/F 1 2 2 1 97 150 11.3 82 1 1
7 Kaasinathan 55/M 2 3 1 2 101 160 12.3 75 1 2
8 Selvi 72/F 1 2 2 1 103 160 12.5 85 1 1
9 Siva 66/M 1 1 1 3 84 150 13.6 94 1 1
10 Mary 64/F 1 3 2 1 88 160 14.2 83 1 1
11 Chitra 63/F 1 2 1 2 87 180 15.2 90 1 1
12 Govindan 67/M 1 2 1 6 89 190 14.3 85 1 1
13 Neelakandan 67/M 1 3 2 1 90 200 13.6 81 1 1
14 Munusamy 65/M 1 3 2 2 84 180 14.2 77 1 2
15 Jeyaraj 75/M 1 2 1 1 82 170 12.6 86 1 1
16 Dhanalaksmi 62/F 1 1 1 4 81 160 14.3 92 1 1
17 Thangavel 69/M 1 2 2 1 78 150 14.5 88 1 1
18 Sivagami 63/F 1 3 1 3 80 160 13.2 81 1 1
19 Ravi 74/M 1 2 2 3 85 170 13.3 87 1 1
20 Dhanam 59/F 1 2 1 1 98 180 14.0 91 1 1
21 Durairaj 61/M 2 2 2 1 75 190 15.0 86 1 1
22 Parthiban 73/M 1 3 1 3 98 200 14.5 82 1 1
23 Seetha 68/F 1 1 2 3 97 170 13.4 95 1 1
95
Master Chart for PFN
SL.NO NAME AGE/ SEX MOI OTA R/L COMORBIDS DOS (Mts) B/L (Ml) FWB (WKS) HHS RU NSF
1 Ambika 61/F 1 1 1 2 52 50 8.2 92 1 1
2 Manoj 69/M 1 3 2 1 54 60 9.3 80 1 1
3 Saraswathy 70/F 1 2 1 3 53 50 9.0 86 1 1
4 Krishnan 63/M 1 1 2 1 57 50 10.4 93 1 1
5 Neela 71/F 1 3 1 6 62 60 11.6 81 1 1
6 Sabapathy 67/M 1 2 2 3 69 70 12.0 87 1 1
7 Alamelu 64/F 1 2 2 2 70 50 11.3 84 1 1
8 Jayavel 58/M 2 3 1 1 60 60 11.5 65 2 1
9 Kumar 73/M 1 3 2 5 69 60 11.2 80 1 1
10 Devan 69/M 1 2 2 3 56 60 9.2 85 1 1
11 Lakshmi 72/F 1 3 1 1 64 70 8.5 80 1 1
12 Nagammal 65/F 1 1 2 2 60 70 9.6 93 1 1
13 Rathnam 59/M 2 1 1 1 59 50 8.3 92 1 1
14 Senthamarai 68/F 1 2 2 3 58 60 9.4 86 1 1
15 Surya 73/M 1 3 1 1 63 50 8.6 80 1 1
16 Ashra 64/F 1 1 1 3 55 50 11.6 91 1 1
17 Naagarani 74/F 1 2 2 5 57 70 10.6 86 1 1
18 Mariyappan 65/M 1 2 1 2 66 50 11.3 84 1 1
19 Poongodi 53/F 1 3 2 1 59 60 10.4 80 1 1
20 Elumalai 61/M 1 2 1 3 67 60 12.2 71 2 1
21 Thirupathi 66/M 2 3 2 3 68 50 10.6 80 1 1
22 Jeya 64/F 1 2 2 1 59 70 10.3 84 1 1
23 Haribabu 52/M 1 2 1 3 50 60 8.4 83 1 1
96
97