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Fixation of Intertrochanteric Fractures with Dynamic Hip Screws: Randomized Controlled Trial Comparing Hardinge and Minimally Invasive Approaches.

ABSTRACT: Objective To compare the techniques for the osteosynthesis of intertrochanteric fractures with dynamic hip screws (DHSs) through the Hardinge and minimally-invasive access routes of the hip, evaluating the operative time, the degree of pain in the immediate postoperative period, the hematimetric loss, and the functional aspects of active mobility. Methods A randomized, double-blinded clinical trial in which 66 patients with intertrochanteric fractures were submitted to osteosynthesis by DHS. The patients were divided into a test group, submitted to the minimally-invasive access, and a control group, in whom the surgery was performed through the Hardinge route. Results Patients submitted to the minimally-invasive treatment presented a lower degree of postoperative pain compared to the group treated by the Hardinge lateral route ( p < 0.001), as well as lower hematimetric loss ( p < 0.001), shorter operative time ( p < 0.001), and improvement in immediate postoperative active mobility tests ( p <0.05). Conclusion The study demonstrated the clinical superiority of the minimally-invasive access route parameters analyzed in relation to the Hardinge access for the fixation of intertrochanteric fractures when DHS is the choice osteosynthesis method. Level of evidence I.

SUBMITTER: Abreu EL

PROVIDER: S-EPMC8856856 | biostudies-literature | 2022 Feb

REPOSITORIES: biostudies-literature

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Fixation of Intertrochanteric Fractures with Dynamic Hip Screws: Randomized Controlled Trial Comparing Hardinge and Minimally Invasive Approaches.

Abreu Eduardo Lima de EL Byk Jonas J Westphal Fernando F

Revista brasileira de ortopedia 20220218 1

<b>Objective</b> To compare the techniques for the osteosynthesis of intertrochanteric fractures with dynamic hip screws (DHSs) through the Hardinge and minimally-invasive access routes of the hip, evaluating the operative time, the degree of pain in the immediate postoperative period, the hematimetric loss, and the functional aspects of active mobility. <b>Methods</b> A randomized, double-blinded clinical trial in which 66 patients with intertrochanteric fractures were submitted to osteosynth ...[more]

PMID: 35198123

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Project description:BackgroundThere is uncertainty regarding delayed removal versus retention of minimally invasive screws following percutaneous fixation for thoracolumbar fractures. We conducted a systematic review and case-control study to test the hypothesis that delayed metalwork removal following percutaneous fixation for thoracolumbar fractures improves outcome.MethodsA systematic review was performed in accordance with the PRISMA guidelines. Our case-control study retrospectively evaluated 55 consecutive patients with thoracolumbar fractures who underwent percutaneous fixation in a single unit: 19 with metalwork retained (controls) and 36 with metalwork removed. Outcomes were the Oswestry Disability Index (ODI), a supplemental questionnaire, and complications.ResultsThe systematic review evaluated nine articles. Back pain was reduced in most patients after metalwork removal. One study found no difference in the ODI after versus before metalwork removal, whereas three studies reported significant improvement. Six studies noted no significant alterations in radiological markers of stability after metalwork removal. Mean complication rate was 1.7% (0-6.7). Complications were superficial wound infection, screw breakage at the time of removal, pull-out screw, and a broken rod. In the case-control study, both groups were well matched. For metalwork removal, mean operative time was 69.5 min (range 30-120) and length of stay was 1.3 days (0-4). After metalwork removal, 24 (68.6%) patients felt better, 10 (28.6%) the same and one felt worse. Two patients had superficial hematomas, one had a superficial wound infection, and none required re-operation. Metalwork removal was a significant predictor of return to work or baseline household duties (odds ratio 5.0 [1.4-18.9]). The ODI was not different between groups.ConclusionsThe findings of both the systematic review and our case-control study suggest that removal of metalwork following percutaneous fixation of thoracolumbar fractures is safe and is associated with improved outcome in most patients.

Project description:BackgroundOpen reduction internal fixation (ORIF) has long been the conventional procedure for managing displaced patella fracture. This surgical approach has certain drawbacks, which might affect clinical outcomes and patient prognosis. Minimally invasive percutaneous fixation (MIPF) was proposed to overcome these disadvantages. Few in-depth investigations have been performed to determine the superiority of MIPF over ORIF. The aim of this study was to compare the efficacies of MIPF and ORIF for patella fractures.MethodsThe PubMed, Cochrane Library, Embase, and Scopus databases were searched for relevant studies from November 26 to December 17, 2020. Non-English publications and pediatric orthopedic articles were excluded. Statistical analysis was performed using Review Manager, version 5.4, with mean differences (MDs), standardized mean differences (SMDs), odds ratios (ORs), and respective 95% confidence intervals (CIs) calculated using a random effects model. The primary outcomes were the pain score, knee range of motion, and joint functionality. The secondary outcomes were the surgical time, complications, and implant removal rate.ResultsSix articles with a total of 304 patients were included in the meta-analysis. Pooled analysis revealed that patients with MIPF had a significantly reduced pain score (MD = - 1.30, 95% CI = - 1.77 to -0.82; p < 0.00001) and increased knee extension angles (MD = 0.72, 95% CI = 0.18 to 1.25; p = 0.009) at 3-month follow-up. Furthermore, knee flexion angles (MD = 8.96, 95% CI = 5.81 to 12.1; p < 0.00001) and joint functionality (SMD = 0.54, 95% CI = 0.21 to 0.86; p = 0.001) had statistically improved at 2 years. However, no difference was observed between MIPF and ORIF with regard to the surgical time. The risk of complications (OR = 0.10, 95% CI = 0.05 to 0.18; p < 0.00001) and implant removal rate (OR = 0.20, 95% CI = 0.07 to 0.57; p = 0.003) were significantly lower with MIPF than with ORIF.ConclusionsMIPF is more favorable than ORIF in terms of the pain score, knee range of motion, joint functionality, complications, and implant removal rate. Thus, it can be adopted as an alternative to ORIF.

Project description:BackgroundThe best treatment for intertrochanteric hip fractures is controversial. The use of cephalomedullary nails has increased, whereas use of sliding hip screws has decreased despite the lack of evidence that cephalomedullary nails are more effective. As current orthopaedic trainees receive less exposure to sliding hip screws, this may continue to perpetuate the preferential use of cephalomedullary nails, with important implications for resident education, evidence-based best practices, and healthcare cost.Questions/purposesWe asked: (1) What are the current practice patterns in surgical treatment of intertrochanteric fractures among orthopaedic surgeons? (2) Do surgical practice patterns differ based on surgeon characteristics, practice setting, and other factors? (3) What is the rationale behind these surgical practice patterns? (4) What postoperative approaches do surgeons use for intertrochanteric fractures?MethodsA web-based survey containing 20 questions was distributed to active members of the American Academy of Orthopaedic Surgeons. Three thousand seven-hundred eighty-six of 10,321 invited surgeons participated in the survey (37%), with a 97% completion rate (3687 of 3784 responded to all questions in the survey). The survey elicited information regarding surgeon demographics, preferred management strategies, and decision-making rationale for intertrochanteric fractures.ResultsSurgeons use cephalomedullary nails most frequently for treatment of intertrochanteric hip fractures. Sixty-eight percent primarily use cephalomedullary nails, whereas only 19% primarily use sliding hip screws, and the remaining 13% use cephalomedullary nails and sliding hip screws with equal frequency. The cephalomedullary nail was the dominant approach regardless of experience level or practice setting. Surgeons who practiced in a nonacademic setting (71% versus 58%; p < 0.001), did not supervise residents (71% versus 61%; p < 0.001), or treated more than five intertrochanteric fractures a month (78% versus 67%; p < 0.001) were more likely to use primarily cephalomedullary nails. Of the surgeons who used only cephalomedullary nails, ease of surgical technique (58%) was cited as the primary reason, whereas surgeons who used only sliding hip screws cite familiarity (44%) and improved outcomes (37%) as their primary reasons. Of those who use only short cephalomedullary nails, ease of technique (59%) was most frequently cited. Postoperatively, 67% allow the patient to bear weight as tolerated. Nearly all respondents (99.5%) use postoperative chemical thromboprophylaxis.ConclusionsDespite that either sliding hip screw or cephalomedullary nail fixation are associated with equivalent outcomes for most intertrochanteric femur fractures, the cephalomedullary nail has emerged as the preferred construct, with the majority of surgeons believing that a cephalomedullary nail is easier to use, associated with improved outcomes, or is biomechanically superior to a sliding hip screw. The difference between what is evidence-based and what is done in clinical practice may be attributed to several factors, including financial considerations, educational experience, or inability of our current outcomes measures to reflect the experiences of surgeons. The educators, researchers, and policymakers among us must work harder to better define the roles of sliding hip screws and cephalomedullary nails and ensure that the increasing population with hip fractures receives high-quality and economically responsible care.Level of evidenceLevel V, therapeutic study.

Project description:BackgroundExtracapsular hip fractures comprise approximately half of all hip fractures and the incidence of hip fractures is exponentially increasing. Extramedullary fixation using a dynamic hip screw (DHS) has been the gold standard method of operative treatment for unstable extracapsular fractures, however, in recent years, intramedullary nails (IMN) have become a popular alternative. IMN versus DHS is continuously discussed and debated in literature. Therefore, the purpose of this systematic review and meta-analysis is to directly compare the peri- and post-operative outcomes of these two techniques to provide an up-to-date analysis of which method of fixation is superior.MethodsThe MEDLINE/PubMed, Embase and Web of Science Database were searched for eligible studies from 2008 to April 2022 that compared peri- and post-operational outcomes for patients undergoing IMN or DHS operations for fixation of unstable extracapsular hip fractures (PROSPERO registration ID:CRD42021228335). Primary outcomes included mortality rate and re-operation rate. Secondary outcomes included operation time, blood loss, transfusion requirement, complication, and failure of fixation rate. The risk of bias and quality of evidence were assessed using the Cochrane RoB 2.0 tool and GRADE analysis tool, respectively.ResultsOf the 6776 records identified, 22 studies involving 3151 patients were included in the final review. Our meta-analysis showed no significant differences between mortality rates (10 studies, OR 0.98; 95% CI 0.80 to 1.22, p = 0.88) or re-operation rates (10 studies, OR 1.03; 95% CI 0.64 to 1.64, p = 0.91) between the two procedures. There were also no significant differences found between complication rates (17 studies, OR 1.29; 95% CI 0.79 to 2.12, p = 0.31) and failure of fixation rates (14 studies, OR 1.32; 95% CI 0.74 to 2.38, p = 0.35). However, DHS operations had a significantly longer operation time (p < 0.0001) and blood loss (p < 0.00001) than IMN operations.ConclusionOverall, based on the outcomes assessed, this review has demonstrated that there is no significant difference in the post-operative outcomes for DHS vs IMN, however a significant difference exists in two of the intraoperative outcomes assessed in this review.

Dataset Information

Fixation of Intertrochanteric Fractures with Dynamic Hip Screws: Randomized Controlled Trial Comparing Hardinge and Minimally Invasive Approaches.

Publications

Fixation of Intertrochanteric Fractures with Dynamic Hip Screws: Randomized Controlled Trial Comparing Hardinge and Minimally Invasive Approaches.

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