The standard Gamma nail or the Medoff sliding plate for unstable trochanteric and subtrochanteric fractures

Abstract

We studied 217 patients with an unstable trochanteric or subtrochanteric fracture who had been randomly allocated to treatment by either internal fixation with a standard Gamma nail (SGN) or a Medoff sliding plate (MSP, biaxial dynamisation mode). Their mean age was 84 years (65 to 99) and they were reviewed at four and 12 months after surgery. Assessments of outcome included general complications, technical failures, revision surgery, activities of daily living (ADL), hip function (Charnley score) and the health-related quality of life (HRQOL, EQ-5D).The rate of technical failure in patients with unstable trochanteric fractures was 6.5% (6/ 93) (including intra-operative femoral fractures) in the SGN group and 5.2% (5/96) in the MSP group. In patients with subtrochanteric fractures, there were no failures in the SGN group (n = 16) and two in the MSP group (n = 12). In the SGN group, there were intraoperative femoral fractures in 2.8% (3/109) and no post-operative fractures. There was a reduced need for revision surgery in the SGN group compared with the MSP group (8.3%; 9/108; p = 0.072). The SGN group also showed a lower incidence of severe general complications (p < 0.05) and a trend towards a lower incidence of wound infections (p = 0.05). There were no differences between the groups regarding the outcome of ADL, hip function or the HRQOL. The reduction in the HRQOL (EQ-5D index score) was significant in both groups compared with that before the fracture (p < 0.005).Our findings indicate that the SGN showed good results in both trochanteric and subtrochanteric fractures. The limited number of intra-operative femoral fractures did not influence the outcome or the need for revision surgery. Moreover, the SGN group had a reduced number of serious general complications and wound infections compared with the MSP group. The MSP in the biaxial dynamisation mode had a low rate of failure in trochanteric fractures but an unacceptably high rate when used in the biaxial dynamisation mode in subtrochanteric fractures.The negative influence of an unstable trochanteric or subtrochanteric fracture on the quality of life was significant regardless of the surgical method.The treatment of stable trochanteric fractures of type 1 or type 2 according to the classification of Jensen and Michaelsen (J-M) 1 is uncontroversial and good results can be expected with various implants. 2 Most authors favour the sliding hip screw (SHS) and recent studies on this method have shown rates of failure below 2%. 3,4 In the case of unstable trochanteric fractures (J-M type 3 to 5) 1 and subtrochanteric fractures, 5 the treatment is more controversial and the rate of failure for the SHS in these fractures is considerably higher, ranging from 4% to 15%. 3,4,[6][7][8][9] The Medoff sliding plate (MSP) evolved from the SHS and gives axial compression along both the femoral neck (optional) and the femoral shaft. It has produced remarkably good results in prospective trials in both unstable trochanteric and subtrochanteric fractures with a rate of fa...

A Comparative Study of Short Proximal Femoral Nail and Dynamic Hip Screw in Treatment of Intertrochanteric Fractures

“…We (4,5,6) . Gallaghar et al, 1980 reported an eight fold increase in trochanteric fractures in men over age of 80 and women over 50 years of age (7) The reason why trochanteric region is the most common site of senile osteoporosis as the age advances.…”

CORR Insights™: Intramedullary Nails Result in More Reoperations Than Sliding Hip Screws in Two-part Intertrochanteric Fractures

“…Multiple studies have provided somewhat conflicting data [1][2][3][5][6][7][8][9][10][11][12].When all fracture patterns are considered, however, there does not appear to be any significant difference in blood loss, transfusion requirements, or operative times [1][2][3][5][6][7][8][9][10][11][12]. Postoperative complications, such as infection and thromboembolic phenomena, also are similar for the two groups [1][2][3][5][6][7][8][9][10][11][12].…”

“…Postoperative complications, such as infection and thromboembolic phenomena, also are similar for the two groups [1][2][3][5][6][7][8][9][10][11][12]. The presence of nonunions and fracture healing appear to be similar with the two types of implants as well [1][2][3][5][6][7][8][9][10][11][12].…”

“…Likewise, there does not appear to be any differences between the two methods regarding leg-length discrepancy, external rotation, or varus femoral neck deformity (although few studies look at these outcomes) [1-3, 7, 11, 12]. Operative fracture of the femur has been significantly worse when using the shorter cephalomedullary device, necessitating reoperation or changing the implant to a longer device [1][2][3][5][6][7][8][9][10][11][12]. This last finding was disputed by Bhandari et al [4], who performed a meta-analysis of more recent studies.…”

“…Short nails were used with 96% of the patients who had a cephalomedullary device, thus increasing the possibility of fracture around the implant. The main weakness of this study is that it does not compare the devices with the less stable fracture patterns, which is the primary indication for using a cephalomedullary device [1][2][3][4][5][6][7][8][9][10][11][12].…”