Objectives: To determine the outcome of intertrochanteric femur fractures fixed with
dynamic hip screw (DHS) in terms of rate of union, infection and range of hip motion. Place and Duration of Study:Orthopaedic Department, Liaquat National Hospital, Karachi from April to October 2009. Study Design: Case series
Subject and Methods : Skeletally mature patients with closed intertrochanteric femur fractures were enrolled in the study. The fractures were fixed with DHS and outcome was observed at the end of 24th week postoperatively in terms of rate of union, infection and hip range of motion.
Results: Mean age of 30 patients were 63.17±12.49 and there were 16(53.3%) males and 14(46.7%) females. 3(10%) patient had superficial infection and one (3.3%) had deep infection at 2nd week postoperatively. These patient's infected wounds gradually healed and there were no infection at 6th week and in subsequent follow ups. The mean range of motion of flexion was 120±1.8 and that of extension was 10±1.0. Internal rotation and external rotation in extension was observed 30.5±7.1 and 30.2±6.9. Union was achieved in 30(100%) patients. Overall results were good.
Conclusion: This study revealed that Dynamic hip screw is a modality of choice in patients with intertrochanteric fracture. Keywords: dynamic hip screw, intertrochanteric fracture, femur
osteosynthesis that will permit early
Intertrochanteric fractures of femur have
mobilization and a rapid return to near the
been estimated to occur in more than
pre injury status of independence are
2,000,000 patients each year in the United
sought by surgeons who treat these States.1,2 These fractures commonly occurs patients. Treatment of intertrochateric and in elderly patients with osteoporotic bones femoral neck fracture varies according to due to simple falls. 3 The incidence of patient's age and fracture pattern.6,7 For the intertrochanteric fractures is gender and intertrochanteric fractures, rigid fixation race dependent and varies from country to with early mobilization of patients is the
country. 4The effect of these fractures is standard of treatment.8 Although many 5devices can achieve a rigid fixation but
frequently devastating, the social impact is
Dynamic hip screws (DHS) have been
high and relative costs of treatment are
commonly used to treat intertrochanteric
increasing. For these reasons methods of
Correspondence: Dr Shahid Noor FRCS, Consultant Orthopaedic Surgeon Liaqat National Hospital Karachi
The local as well as international studies conducted on patients with intertrochanteric femur fracture treated with DHS shows variable results from 65%¬100% bony union with few degree of terminal restriction of hip joint movement and rate of infection between 0.7% to
The aim of our study was to authenticate the results of these studies so that the same modality could be used and advocated in patients with intertrochanteric fractures world wide. The objective of the study was to determine the outcome of intertrochanteric fractures fixed with DHS in terms of rate of union, infection and range of hip motion.
MATERIAL & METHODS
This case series study was done from April to October 2009 at Department of Orthopaedic Liaquat National Hospital,Karachi. After getting approval of the ethical review committee, 30 consecutive skeletally mature patients of closed intertrochanteric fractures were enrolled in the study through accident and emergency department. Patients were diagnosed with the help of X-rays AP view of pelvis and lateral view of affected hip joint. The purpose and procedure of the study were explained to the patient and family. Informed and written consent was obtained. Patients with infection at the fracture site, open fractures, non-united or mal-united intertrochanteric fractures, immunocompromised patients, and pathological fractures, patients on chemotherapy and with previous hip or knee surgery were excluded from our Study. Surgery was performed by fellow surgeon Having more than ten years of experience. Postoperatively patients were mobilized
on 1 or 2nd day with the help of crutches or walker along with range of motion, abductor and quadriceps strengthening exercises. Patients were discharged on 3rd postoperative day and called for removal of stitches on 14th postoperative day.
Further follow up was carried out on 6 ,
12 , 18 and final assessment was done at the end of 24th week for union, infection and range of hip motion. Data was analyzed on SPSS version 15.
Demographic and preoperative characteristics of patients enrolled in the study are given in Table No. I. On 2nd week postoperatively superficial infection were found in 3(10%) and deep infection in 1(3.3%)patients, these cases were treated with local wound debridement , dressings and a course of antibiotic according to culture and sensitivity. These wounds healed gradually and there was no infection at 24th week postoperatively as shown in table 2. Partial weight bearing was allowed to 20(66.7%) patients at 6th week postoperatively, full weight bearing to 15(50%) patients at 12th week. At the end of 24th week full weight bearing was allowed to 29(96.7%) patients and 1(3.3%) was on partial weight bearing as shown in Table No.II. Radiological union was found in 29(96.7%) patients and 1(3.3%) patients fracture was not united at the end of 24th week, see Table II. The normal range for
flexion is 0 -120 and by the end of 24th week mean flexion was 120±1.8. The
normal range for extension is 5 -20 and by the end of 24th week mean extension was 10±1.0. The mean internal rotation in extension was 30.5±7.1 and mean external rotation in extension was 30.2±6.9 as shown in Table II.
Table II: Outcome of DHS at the end of 24 week
Although many devices can achieve a rigid fixation in patients with intertrochanteric fractures but Dynamic hip screws (DHS) have been commonly used in such cases.9,10 The advantage of the Dynamic hip screws (DHS) was interfragmental compression effect with a high union rate.13 Fractures treated with DHS achieved bone healing within six months with adequate reduction. Therefore, DHS is an effective, simple and safe method, in the treatment of intertrochanteric fractures.
Mean age of patients sustaining intertrochanteric fracture found to be around 60 and 70 years in multiple studies conducted locally and internationally respectively.11,14 The mean age of our study matches with the local data. The variation in local and international data may be due to better medical care in the West thereby increases the average life expectancy. The local data also differs from international data in male to female ratio. Males are more prone to have intertrochanteric fractures as compared to female locally. In the West the leading cause was simple fall in postmenopausal osteoporotic females. They suffer more intertrochanteric fractures than males.8,10,12,14 Initially in our study there were 3(10%) and 1(3.3%) patients with superficial and deep infection respectively. These cases were treated with local wound debridement, dressings and a course of antibiotic according to culture and sensitivity and were free of infection by 6th week postoperatively. Local and international studies reports the rate of infection as 3.9% to 6%,15,16 and 0.25%-16.9% respectively.3,12 The infection rate of our study are bit high and this may be due advance age, long operative time and time interval between injury and surgery. In our Study union was achieved in 29(96.7%) and were allowed full weight bearing. One patient did not achieve clinical and radiological union and were allowed partial weight bearing. Our results are consistent with local and International studies.3,8,11 The range of motions in our study was remarkable at the end of 24th week. The same is authenticated by various studies.3,11,15 On the other hand in one of the largest series of cases treated with DHS Showed that at one year follow up 35.1% were walking independently or with one stick. The difference in our results may be because of small sample size.
Were walking independently or with one stick. The difference in our results may be because of small sample size.
This study revealed that Dynamic hip screw is a modality of choice in patients with 9. intertrochanteric fracture.
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