Femoral medialisation and functional outcome in trochanteric hip fractures Christopher Bretherton – Core Surgical Trainee Martyn Parker – Orthopaedic Consultant British Orthopaedic Trainees Association Educational Weekend June 12 th 2015

Disclosures Conflict of interest One or more of the Authors have previously received conference and accommodation expenses from Aesculap AG

Background This has been related to fixation failure 1 The aim of this study was to determine if femoral medialisation affects residual pain and long-term mobility Determine if fracture pattern and type of implant (extramedullary vs intramedullary) predispose to medialisation. 2 Recent studies have suggested improved mobility after IM nail fixation. 3,4 Femoral medialisation

Methods We used data from patients that had been entered into a randomised trial comparing the Targon Proximal Femoral intramedullary (IM) nail with the Sliding Hip Screw (SHS). Exclusion criteria Subtrochanteric fractures Trochanteric fractures with a subtrochanteric extension that required a plate longer than five holes to achieve satisfactory distal fixation of eight cortices Pathological fractures Lead trialist not available Trochanteric stabilization plates were not used for initial surgery

Methods Mobility assessed using a scale of 0 to 9. Pain assessed with Charnley Pain Score from 1 to 6. Fractures were grouped by AO classification as trochanteric (31A) stable (A1), unstable (A2), and transverse or reverse oblique (A3) The majority of post-op x-rays were taken during clinic follow up at 6 weeks from discharge (Range 28 – 1893 days, mean 117 days, median 63 days).

AO Classification of fractures Femoral medialisation Intramedullary nail

Exclusions Allocated to Intramedullary nail (266) 844 patients admitted between April 2002 and December 2013 and entered into the randomised trial Excluded from analysis (306) Died before one year follow-up (239) Not had 28 days X-ray follow up (40) X-rays not available for review (15) Lost to follow-up (8) Died after 1 year but before follow-up assessment (4) Included in study (538) Allocated to Sliding Hip Screw (272)

Results

Results summarised Post-operative femoral medialisation of >50% is associated with more fracture healing complications (p=0.021) and revision procedures (p=0.014). Medialisation is associated with increased pain scores (p=0.012) and poorer mobility scores (p=0.013) at one year. Femoral medialisation is more common in trochanteric fractures treated with SHS versus intramedullary nail (p<0.001) A2 (p=0.02) and A3 (p=0.006) fractures treated with SHS are more likely to experience >50% medialisation.

Limitations We assessed pain and mobility at one year but in most cases final x-rays were taken and interpreted earlier than this. 5 Femoral medialisation is only one factor/ only looked at the AP view. Small numbers in the >50% medialisation group

The most recent cochrane review finds no difference between outcomes of DHS and IM Nails, NICE guidelines recommend DHS. 6 Few RCT’s distinguish between fracture pattern Hardy 3 and Utrilla 4 agreed that intramedullary devices are associated with earlier return to mobility, especially when used to treat unstable fractures Discussion

Scientific Perspective Femoral mediatisation is related to long-term pain and mobility More medialisation with SHS vs Nails Conclusions

Clinical Perspective Supports the use of IM Nails for A3 fractures (in accordance with registry data) 7 May explain a tendency for better mobilisation in A2 fractures treated with nails Reminder that future studies should look specifically at A2 fractures Conclusions

References 1.Parker MJ. Trochanteric hip fractures. Fixation failure commoner with femoral medialisation, a comparison of 101 cases. Acta Orthop Scand 1996;67:329—32. 2.Curtis MJ, Jinnah RH, Wilson V, Cunningham BW. Proximal femoral fractures: a biomechanical study to compare intramedullary and extramedullary fixation. Injury 1994; 25:99— D. Hardy, P.-Y. Descamps, P. Krallis, et al. Use of an intramedullary hip-screw compared with a compression hip-screw with a plate for intertrochanteric femoral fractures. A prospective randomized study of one hundred patients. J Bone Joint Surg Am, 80 (1998), pp. 618–630 4.A. Utrilla, J. Reig, F. Munoz, C. Tufanisco. Trochanteric gamma nail and compression hip screw for trochanteric fractures: a randomized, prospective, comparative study in 210 elderly patients with a new design of the gamma nail. J Orthop Trauma, 19 (4) (2005), pp. 229–233 5.Pararinen J, Lindahl J, Savolainen V, Michelsson O, Hirvensalo E. Femoral shaft medialisation and neck- shaft angle in unstable pertrochanteric femoral fractures. Into Orthop Dec;28(6): Parker MJ, Handoll HH. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults. CochraneDatabase Syst Rev 2010;9:CD Matre K, Havelin Ll, Gjertsen JE, Vinje T, Espehaug B, Fevang JM. Sliding hip screw versus IM nail in reverse oblique trochanteric and subtrochanteric fractures. A study of 2716 patients in the Norwegian Hip Fracture Register. Injury Jun;44(6): Questions?