Internal fixation of pertrochanteric fractures using DHS with a two-hole side-plate

Pertrochanteric fracture in a group of 41 patients was internally fixed using a DHS with a two-hole side-plate. There were 20 male and 21 female patients with a mean age of 74 years. Thirty-two patients were followed up for more than one year and their final results were evaluated. There were 30 stable (31A1) and only two unstable (31A2) fractures. The average surgical time was 28 minutes, the average length of incision was 5.5 cm. All the patients, with one exception, healed without complications in anatomical position with good function of the hip joint. The only complication was caused by pulling-out of the plate from the femur in the fourth postoperative week when the patient (31A2 fracture) fell out of bed. A DHS with a four-hole side-plate was used at reoperation; subsequently the fracture had healed. Based on the results in this series of patients, the authors recommend fixation of stable pertrochanteric fractures with DHS and a two-hole side-plate. As proven by the authors, the benefit of DHS with a two-hole side-plate as compared to DHS with a four-hole side-plate is a shorter surgical time (28 and 36 minutes, respectively).     

动力髋和股骨近端髓内钉手术治疗股骨粗隆间骨折的系统评价

[目的]对动力髋和股骨近端髓内钉手术治疗股骨粗隆间骨折的疗效和安全性进行系统评价.[方法]在Pubmed、Cochrane Library、EMBASE、Science Direct以及CNKI、CBM、中国医学学术会议论文数据库等网站进行检索.文献检索起止时间为2000年1月～2010年9月.再对入选文献的参考文献进行手工检索.系统收集动力髋和股骨近端髓内钉手术治疗股骨粗隆间骨折的相关文献,并按临床科研方法的国际通用原则进行阅读和评价.采用Cochrane协作网提供的软件Revman 4.2进行Meta-分析,以获得动力髋和股骨近端髓内钉手术治疗股骨粗隆间骨折的疗效及其安全性指标的相关证据.[结果]共检索到183篇原始文献,有7篇符合最终的入选标准,总计随访患者919例.分析研究表明,股骨近端髓内钉平均手术时间短但术中接受X线的次数多于动力髋.股骨近端髓内钉组术后内固定移位发生多于动力髋.[结论]两种手术治疗术中失血量并无统计学差异,股骨近端髓内钉平均手术时间短但术中接受X线的次数多于动力髋;而术后切口感染率、再次手术率两者并无统计学差异,股骨近端髓内钉组术后内固定移位发生多于动力髋.     

动力髋螺钉内固定治疗高龄股骨粗隆间骨折

目的: 观察AO动力髋螺钉 (DHS) 治疗高龄股骨粗隆间骨折的疗效。方法:对使用DHS内固定治疗的 65例股骨粗隆间骨折的分类、手术方法、术后结果进行疗效分析。结果: 所有病例术后随访骨折均愈合, 髋关节功能优良率达 97%。结论: 动力髋螺钉内固定治疗高龄股骨粗隆间骨折疗效优良。只要操作规范、功能锻炼正确、负重时间掌握适当, 就可以减少各种并发症, 降低病残率。     

Biomechanical evaluation of the dynamic hip screw with two- and four-hole side plates

OBJECTIVES: To determine the biomechanical strength and stiffness of a dynamic hip screw (DHS; Synthes USA, Paoli, PA, U.S.A.) with a two-hole side-plate as compared with a four-hole side-plate design for the reconstruction of unstable three-part intertrochanteric fractures. DESIGN: Eight matched pairs of embalmed human femurs were tested in two modes: (a) 2,000 cycles of simulated physiologic loading; (b) test to failure. SETTING: Laboratory. Simulated single leg stance using a simulated pelvic loading mechanism with abductor loading. Strain and displacement sensors were used to measure fragment shear and distraction and surface strain in the proximal side plate. SPECIMENS: Eight pairs of skeletonized embalmed cadaveric specimens were selected on the basis of femoral neck angle and absence of old fracture, anatomic anomaly, or pathology. INTERVENTION: The specimens were divided into two groups: (a) left femurs received the two-hole side-plate design; (b) right femurs received the four-hole side-plate design. All fractures were reconstructed by the same surgeon using the manufacturer's instructions. MAIN OUTCOME MEASUREMENTS: Implant placement was verified by radiographic measurement of tip-to-apex distance. In cyclic testing, the amount of femoral neck fragment migration in both distraction and shear was quantified. Strain magnitude in the side plate was measured in both cyclic and failure testing. The peak load withstood by the reconstruction was quantified in the failure test. RESULTS AND CONCLUSIONS: Peak load in the failure test was not found to be statistically different between the two-hole and four-hole designs. In cyclic testing, the two-hole configuration exhibited statistically smaller fragment migration in both shear and distraction than the four-hole design (p < 0.05). The strain magnitude in the side plate was not statistically different in the cyclic or failure tests. The femurs with a greater neck angle failed by crushing of the bone in the neck. The femurs with a lesser neck angle failed due to bending of the hardware. The results of this investigation revealed that the two-hole DHS is biomechanically as stable as the four-hole DHS in cyclic and failure loads under the conditions tested. These results, in concert with clinical experience, can be used to support the use of the two-hole DHS for the reconstruction of intertrochanteric fractures without a diaphyseal extension.     

The gamma-nail as a resilient alternative to the dynamic hip screw in unstable proximal femoral fractures in the elderly]

In a prospective randomised trial between September 1989 and June 1990 one hundred patients with per- and subtrochanteric fractures were consecutively treated by gamma-nail or DHS. The average age of both groups was about 80 years. The operation time for gamma-nailing was longer than for DHS implantation and also the postoperative blood loss was higher in the gamma-nail group. We found no difference of intraoperative blood loss, of perioperative lethality and in duration of hospital care. 90% of gamma-nail patients and 80% of DHS patients were successfully able to walk four days after operation with full weight bearing on the operated limb. Three patients in the DHS group with unstable fractures got cranial perforation of the cephalic screw mobilisation. Five patients of the gamma-nail group were reoperated, one case because of missed distal locking, one because of cranial perforation of the cephalic screw after varus dislocation of the proximal fragment. One patient suffered intraoperatively a proximal femur shaft fracture which was corrected during operation. In one case a wound hematoma was evacuated, an other patient needed secondary wound closure. Despite technical imperfection of implant and instruments, we conclude that the gamma-nail allows a very high percentage early and full weight bearing immediately after operation. So we consider that in the treatment of unstable pertrochanteric fractures of geriatric patients, the gamma-nail has proven to be more efficient than the DHS.     

两孔动力髋螺钉微创内固定治疗股骨颈骨折

目的评价两孔动力髋螺钉（DHS）微创内固定治疗股骨颈骨折的疗效。方法回顾分析48例股骨颈骨折在C型臂X线机透视下闭合复位，采用微创手术入路经皮两孔DHS微创内固定治疗，评价其疗效。结果切口长度平均为3．0cm，出血量平均为41．5ml，手术时间平均为25min。46例骨折愈合，2例骨折不愈合，愈合率为95．8％。3例出现股骨头缺血坏死（其中骨折不愈合2例，骨折愈合后发生1例）。结论应用经皮微创两孔DHS内固定术治疗股骨颈骨折，手术简便快速，创伤少，固定牢固，是治疗股骨颈骨折理想的微创治疗技术。     

动力髋关节螺钉

目的 综述动力髋关节螺钉（dynamic hip screw，DHS）内固定治疗股骨粗隆间骨折（intertrochanteric femur fractures，IFF）的研究进展。方法 广泛查阅近年来有关DHS内固定治疗IFF生物力学、临床应用的相关文献，并作综合分析。结果 随着DHS的结构力学、手术操作研究进展，已成为临床治疗IFF的有效工具。结论 DHS仍然是治疗稳定性IFF的金标准，对于复杂IFF采用改良DHS同样可以取得良好疗效，但严格手术适应证、熟练手术操作、严格微创操作仍是应用的主要原则。     

Differentiated procedure in fractures of the coxal femur end in adults

After own clinical observations a choice of surgical treatment in coxofemoral fractures is pointed out: Femoral neck fractures of stage Garden I will be stabilized by lag screws. For the rest of subcapital fractures we use lag screws or Smith-Peterson nailing for stabilization; only old patients without the possibility of mobilisation without weight-bearing after operation are treated by endoprosthesis of the hip. In Garden-IV-fractures and fracture-type Pauwels III indication for endoprosthesis is conditioned in most elderly patients. In basocervical and pertrochanteric fractures of younger patients a dynamic hip screw will be performed; in older patients we use elastic nails described by Simon-Weidner and Ender with good success. For stabilization of subtrochanteric fractures different operations dependent on type of fracture, bone-structure and general condition are used: elastic nails with or without wire-loops, interlocking nailing, Y-nail, dynamic hip screw, angled plate and compound internal fixation.     

DHS和LCP内固定治疗青壮年股骨粗隆间骨折

目的比较动力髋螺钉(dynamic hip screw,DHS)和解剖型锁定钛板(locking compression plate,LCP)内固定治疗青壮年股骨粗隆间骨折的疗效。方法 151例青壮年股骨粗隆间骨折中DHS治疗62例,LCP治疗89例。其中男112例,女39例;年龄19~59岁,平均40.5岁。车祸伤74例,坠落伤51例,摔伤26例,均为闭合性骨折。结果 DHS、LCP组手术时间、术中出血量、卧床时间及骨折愈合时间相当,差异无统计学意义(P0.05),但末次随访Harris评分优良率LCP高于DHS组,差异有统计学意义(P0.05)。结论 LCP的疗效优于DHS,DHS只适用于稳定型股骨粗隆间骨折,对于不稳定型骨折,应选用LCP固定。青壮年患者不遵医嘱术后早期负重,是术后失败的主要原因,故术后功能锻炼要遵循"早活动,晚负重"的原则,待骨折端有明显骨痂形成后方可完全负重。     

Traumatology in the elderly. Treatment concept in per- and subtrochanteric fractures in the elderly]

The aim of treatment of trochanteric fractures in the elderly patient is a prompt procedure, which allows early load bearing. Between 1986 and 1988 272 patients were treated with per- and subtrochanteric fractures: pertrochanteric fractures were stabilised by means of the dynamic hip screw (DHS), subtrochanteric fractures via the 95 degree condylar plate. With both methods an early mobilisation of the patients is possible. In 70 per cent of cases treated with DHS, early load bearing could be achieved within one week. 80 per cent of the patients were operated on within the first 24 hours after trauma. Complications of the methods (incorrect position of the lag screw, plate protrusion) were seen in one case in each group. The overall infection rate was 2.2 per cent. Hospital mortality was 10 per cent. On reviewing the results obtained, we approved of the concept of treatment.     

The Gamma Nail in per- and intertrochanteric femoral fractures--alternative or supplement to the dynamic hip screw? A prospective randomized study of 100 patients with per- and intertrochanteric femoral fractures in the surgical clinic of the City Hospital of Triemli, Zurich, September 1989 - June 1990]

In a prospective randomised trial between September 89 and June 90 one hundred patients with per- and subtrochanteric fractures were consecutively treated by Gamma-nail or DHS. The average age of both groups was about 80 years. The operation time for Gamma-nailing was longer than for DHS-implantation and also the postoperative blood loss was higher in the Gamma-nail-group. We found no difference of intraoperative blood loss, of perioperative letality and in duration of hospital care. 90% of Gamma-nail-patients and 80% of DHS-patients were successfully able to walk four days after operation with full weight bearing on the operated limb. Six patients (12%) with DHS had to be reoperated within 6 weeks. Three patients with unstable fractures got cranial perforation of the cephalic screw after mobilisation. The other three patients had soft tissue complications. Five patients (10%) of the Gamma-nail-group were reoperated, one case because of missed distal locking, one because of cranial perforation of the cephalic screw after varus dislocation of the proximal fragment. One patient suffered intraoperatively a proximal femur shaft fracture which was corrected during operation. In one case a wound hematoma was evacuated, an other patient needed secondary wound closure. Despite technical imperfection of implant and instruments, we conclude that the Gamma-nail allows a very high percentage early and full weight bearing immediately after operation. So we consider that in the treatment of unstable pertrochanteric fractures of geriatric patients, the Gamma-nail has proven to be more efficient than the DHS.     

Trochanteric fractures in the elderly: the influence of primary hip arthroplasty on 1-year mortality

INTRODUCTION: The aim of the study was to compare the mortality risk and complication rate after operative treatment of pertrochanteric fractures with primary arthroplasty, dynamic hip screw (DHS) or proximal femoral nail (PFN). PATIENTS AND METHODS: Clinical records including X-rays of all patients with trochanteric femoral fractures, except pathologic fractures and a minimum age of 60 years, which were treated between 1992 and 2005 were entered in this retrospective study. Of these 283 patients, 132 were treated by primary arthroplasty, 109 with a DHS and 42 with a PFN. Survival after 1 year and complications, which had to be treated within this period were our main outcome measurement. Influencing cofactors such as age, gender and comorbidities were reduced by multivariate logistic regression analysis. RESULTS: Mortality was significantly influenced by age, gender and amount of comorbidities but not by fracture classification. Primary hip arthroplasty did not bear a higher 1-year mortality risk than osteosynthesis in a multiple regression analysis. The main complication with DHS and PFN were cutting out of the hip screw and non-union with a revision rate of 12.8%. With the introduction of hemiarthroplasty, the postoperative dislocation rate decreased from 12 to 0%. CONCLUSION: For stable fractures a dynamic hip screw (DHS) and for unstable fractures a short proximal femoral nail (PFN) can be recommended. The mortality risk of primary cemented arthroplasty did not differ significantly from the other treatment groups and because of its low complication rate it is a viable treatment option for trochanteric fractures if osteoporosis prevents from full weight bearing or if osteoarthritis makes further operations likely. Primary total hip replacement should be handled with care due to its significantly higher dislocation rate compared with hemiarthroplasty especially in unstable fractures.     

双小切口直视下复位动力髋螺钉内固定治疗老年股骨转子间骨折

目的探讨双小切口直视下复位动力髋螺钉(DHS)内固定治疗老年股骨转子间骨折的效果。方法对120例老年股骨转子间骨折患者行双小切口直视下复位DHS内固定。观察手术切口长度、手术时间、术中失血量、术后引流量、骨折复位情况、患者扶拐下地行走时间、骨折愈合时间及术后患肢髋关节功能恢复情况。结果手术时间40～50 min,术中失血量85～105 ml。骨折均获解剖复位。120例均获随访,时间6～20个月。骨折愈合时间6～8个月。Harris评分:优95例,良21例,可4例,优良率96.7%。结论双小切口直视下复位DHS内固定治疗老年股骨转子间骨折,更易于骨折断端的解剖复位和拉力螺钉放置于恰当的位置;手术时间短,术中失血量少,术后并发症少,疗效较好。     

透视图像导航下微创动力髋螺钉治疗老年股骨转子间骨折

目的探讨在X线透视导航下微创置入动力髋螺钉(DHS)治疗老年股骨转子间骨折的临床应用。方法自2005年12月～2006年6月,笔者应用导航下微创方法置入DHS治疗老年股骨转子间骨折18例,男5例,女13例;年龄60～92岁,平均76岁。结果术后随访5～12个月,平均9个月。18例股骨转子间骨折的应用结果令人满意。手术时间平均为105min。X线图像采集平均5次。术中和术后无并发症发生。结论使用导航系统微创置入DHS不仅进针方向精确、拉力螺钉位置好、切口小,而且还可以减少术者的X线暴露时间,是治疗老年股骨转子间骨折的理想方法。     

Hemi-arthroplasty with supplemental fixation of greater trochanter to treat failed hip screws of femoral intertrochanteric fracture

INTRODUCTION: Management for failed hip screw after femoral intertrochanteric fracture is a challenge for orthopaedic surgeons. The unfavorable factors include severe osteoporosis, unstable fracture geometry, improper placement of hip screw, and repeated trauma. Except revision fixation of the fractures, arthroplasty may be indicated in case of destructed femoral head. In this study, we reported the surgical outcomes of patients with concomitant failed hip screws and fractures of greater trochanter operated by hemi-arthroplasties. MATERIALS AND METHODS: We treated 16 patients of failed hip screws with concomitant fracture of greater trochanter surgically by hemi-arthroplasty and cable-grip system from January 2001 to December 2004. The reattachment of greater trochanter by cable-grip system enhanced abductor mechanism to reduce the dislocation rate of hip arthroplasty. The hemi-arthroplasties eliminated the pain from the destructed femoral head. Partial weight bearing was allowed postoperatively. The patients were followed every 6 weeks clinically and radiologically. Full weight bearing was not allowed until solid bony union was seen on the plain radiographs. RESULTS: Among these 16 patients, all patients achieved solid union of greater trochanter except one by 24 weeks postoperatively. No postoperative wound infection was found. No dislocation of hemi-arthroplasty occurred during the postoperative follow-up. The clinical assessment based on SF-36 questionnaire improved from 41.9 to 82.7. CONCLUSION: Hemi-arthroplasty with supplemental fixation of greater trochanter is a rational option to treat failed hip screws with fracture of greater trochanter in case of destructed femoral head.     

Gamma钉和DHS/Richard钉治疗股骨近端骨折相比较的Meta分析

目的评价Garoma钉和DyiS (Dynanlic Hip screw)／Rirhard钉治疗股骨近端骨折的疗效和安全性。方法 应用(Cochrance协作网Meta分析方法对关于Garoma钉和DHs／Richard钉治疗股骨近端骨折的随机或半随机对照试验进行Meta分析。结果 我们检索出1969～2003年间发表的88篇关于Ganmla钉和DHs／Richard钉治疗股骨近端骨折相比较的文献，经过筛选和评价，最后收集到已发表的7篇(共1256例患者)随机或半随机对照试验，符合本次Meta分析所纳入的试验标准。4个临床试验共包括62l例患者，提供了关于术后前6个月的死亡率的详细信息。我们发现Gamma钉术后头6个月与DHs／Richard钉相比较的死亡的相对危险度无明显统计学差异(相对危险度1．17，p=0．51)。6个试验包括1083例患者提供了并发症的资料。Garoma钉和DHS／Rithard钉内固定的相对危险度是1．4l(p：0．02)。Gamma钉明显的增加了股骨干骨折的危险(相对危险度6．99：p=0．00)，二次手术率增加(相对危险度1．85；p=0．20)。此外，Gamma钉与DHS／Richard钉相比较，患者的手术时间缩短，手术失血量及术后功能恢复相同。结论 通过此次Meta分析发现，对于治疗股骨近端骨折，Gamma钉与DHS／Richard钉相比较，在死亡率、伤口感染率、手术失血量、术后功能的相对危险度无明显统计学差异，但增加并发症，尤其明显的增加了股骨干骨折的危险，二次手术率有增加趋势。     

Management of unstable pertrochanteric and per- to subtrochanteric femoral fractures with the dynamic hip screw]

The operative treatment of fractures of the proximal end of femur with the dynamic hip screw (DHS) permits a weight-bearing stable osteosynthesis. In 5.2 years between 1985 and 1990 531 patients were treated with a DHS. The average age was 75 years. This method of osteosynthesis was also performed in 59 patients with unstable per- or per-subtrochanteric fractures. Complications such as pseudarthrosis, necrosis or penetration of the head of femur, implant bending or breaking were not observed. The dynamic hip screw is a valid procedure for an early and weight-bearing treatment also for unstable pertrochanteric fractures of the femur with special benefits for the elderly.     

Locking plates increase the strength of dynamic hip screws

INTRODUCTION: Failure of a dynamic hip screw (DHS) fixation leads to decreased mobility of the patient and frequently to a decrease in general health. The most common mode of failure of a DHS is cut out of the lag screw from the femoral head. The second most common mode of failure is lift-off of the plate from the femur. The aim of this laboratory-based experimental study was to determine whether a DHS secured to an osteoporotic femur with a locking screw plate would provide a stronger construct than the standard DHS plate. METHOD: The standard DHS design was compared to a DHS with fixed angle locking screws holding the DHS plate to the femur. Standard dynamic compression plates (DCP) and locking compression plates (LCP) were attached to synthetic, osteoporotic bone. A load was applied to replicate the forces occurring following the fixation of unstable, intertrochanteric hip fractures. A bracket on the proximal end of the plate replicated the lag screw in the femoral head. The constructs were cyclically loaded by a screw-driven material-testing machine and the number of cycles before failure occurred was determined. RESULTS: The mean number of cycles to failure for the locking plate construct was 2.6 times greater than for the standard screw construct (285 versus 108 cycles, respectively p=0.016). CONCLUSION: A dynamic hip screw with fixed angle locking screws would reduce the risk of DHS failure. A locking screw DHS would be particularly useful in patients with osteoporotic bone, and in patients with less stable fracture configurations.     

Breakage of sliding hip screw after fixation of pertrochanteric hip fracture: A rare complication

IntroductionThe authors report a rare case of lag screw breakage in a patient treated using locking DHS with home-made trochanteric stabilizing plate (TSP) for pertrochanteric hip fracture.Case presentationA 67 year-old female was operated for pertrochanteric hip fracture with incompetent lateral wall using locking DHS with home-made TSP. At seven months postoperative, there was radiographic nonunion with breakage of the sliding lag screw. Patient was consequently scheduled for total hip replacement.DiscussionBreakage of DHS lag screw has been attributed to multiple-cycle, low-stress fatigue failure associated with nonunion. Predisposing factors are: situation of the medial edge of the barrel at the level of the fracture site prohibiting fracture compression, and mechanical obstacle to the lag screw back sliding into the barrel. In our case, the use of handmade TSP interdicted lag screw back sliding and prevented fracture impaction which was already impaired by the location of the medial edge of the barrel at the fracture level. Additionally our fixation construct was very rigid because of the use of locking screws in the DHS side plate.ConclusionWhen DHS fixation is planned for unstable or potentially unstable trochanteric hip fracture the surgeon should be prepared by making available a TSP from the manufacturer in the operative room rather than improvising intra-operatively with handmade TSP; this augmentation device shouldn't interfere with lag screw back sliding. Furthermore the DHS barrel should ideally not impinge with the fracture site, and the use of locking screws in the DHS plate should be cautious.     

Percutaneous compression plating (PCCP) versus the dynamic hip screw for pertrochanteric hip fractures: preliminary results

The percutaneous compression plate (PCCP) is a new implant for the minimally invasive treatment of pertrochanteric hip fractures that might reduce blood loss, wound problems and prevent devascularization of bone fragments. A quicker operation with minimal blood loss is better in the older patients. We performed a prospective, randomized clinical trial to compare the PCCP with the well-known dynamic hip screw (DHS). A total of 71 patients with an Evans type 1A-D pertrochanteric hip fractures were included. We measured the operation duration, blood loss, wound healing, complications, fracture healing and functional outcome. In total, 33 PCCP and 38 DHS were implanted. The mean operation times were 69.2 and 46.6 min for DHS and PCCP, respectively (P = 0.000). Blood transfusions were given in 24 DHS patients compared with six PCCP patients (P = 0.000). There were 27 haematomas in the DHS group and eight in the PCCP group (P = 0.000). There were no differences in fracture healing and the functional outcome between the two implants (P = 0.767, ns). Although this is a preliminary study with a relatively small number of patients and short follow-up, the PCCP seems similar to the DHS in relation to bone healing and stability, but with significant advantages for blood loss, soft tissue healing and operation time.