The role of preoperative computed tomography in surgical planning of intertrochanteric femur fractures fixation
Keywords:Intertrochanteric fracture, Dynamic hip screw, Harris hip score
Background: A precise preoperative evaluation of stability of intertrochanteric fractures is crucial for surgical planning. Three dimensional CT scanning is a useful tool for understanding the exact type of fracture pattern.
Methods: A prospective study included 40 patients with intertrochanteric femoral fractures. They were classified into stable and unstable intertrochanteric fractures according to the X-ray based AO/OTA classification and according to Nakano 3D-CT classification and both classifications were correlated. The patients were operated on using dynamic hip screw (DHS) and were assessed radiologically and clinically by Harris hip score (HHS) after 6 months.
Results: There was significant statistical difference (p=0.031) and relation (p<0.001) between X-ray based AO/OTA classification and 3D-CT classification. Six cases from the 24 cases with stable pattern in AO/OTA system have unstable patterns in the 3D-CT (25%) and their percent from the 22 unstable patterns in 3D-CT is 27.27% and their percent from the total number of patients in the study is 15%.
Conclusions: The superolateral support in the form of the greater trochanter which affects the lateral wall thickness is as important as the posteromedial lesser fragment in assessing the stability of the fracture pattern.
Laskin R, Gruber M, Zimmerman A. Intertrochanteric fractures of the hip in the elderly: a retrospective analysis of 236 cases. Clin Orthop Relat Res. 1979;141:188-95.
Evans E. The treatment of trochanteric fractures of the femur. J Bone Joint Surg Am. 1949;31(2):190-203.
Koval K, Zuckerman J. Hip fractures: II. Evaluation and treatment of intertrochanteric fractures. J Am Acad Orthop Surg. 1994;2(3):150-6.
Dimon J, Hughston J. Unstable intertrochanteric fractures of the hip. J Bone Joint Surg Am. 1967;49(3):440-50.
Kyle R, Gustilo R, Premer R. Analysis of six hundred and twenty-two intertrochanteric hip fractures. J Bone Joint Surg Am. 1979;61(2):216-21.
Russell T. Intertrochanteric fractures. In: Bucholz RW, Heckman JD, Court-Brown CM, et al, eds. Rockwood and green’s fractures in adults. 7th ed. Philadelphia: Lippincott Williams and Wilkins; 2009:1597-640.
Evans E. The treatment of trochanteric fractures of the femur. J Bone Joint Surg Br. 1949;31:190-203.
Jensen J. Classification of trochanteric fractures. Acta Orthopaedica Scandinavica. 1980;51:803-10.
Marsh J, Slongo T, Agel J, Broderick J, Creevey W, DeCoster T, et al. Fracture and dislocation classification compendium– 2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma. 2007;21(10):1-133.
Boyd H, Griffin L. Classification and treatment of trochanteric fractures. Arch Surg 1949;58:853-66.
Nakano T. Proximal femoral fracture. Seikeigeka (Orthopaedics). 2014;65:842–50.
Baumgaertner M, Curtin S, Lindskog D, Keggi J. The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J. Bone Joint Surg. Am. 1995;77(7):1058-64.
Goffin J, Pankaj P, Simpson A. The importance of lag screw position for the stabilization of trochanteric fractures with a sliding hip screw: A subject-specific finite element study. J Orthop Res. 2013;31(4):596- 600
Platzer P, Thalhammer G, Wozasek G, Vécsei V. Femoral shortening after surgical treatment of trochanteric fractures in nongeriatric patients. Journal of Trauma and Acute Care Surgery. 2008;64(4):982-9.
Harris W. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Joint Surg Am. 1969;51(4):737-55
Shoda E, Kitada S, Sasaki Y, Hirase H, Niikura T, Lee S, Sakurai A, Oe K, Sasaki T. Proposal of new classification of femoral trochanteric fracture by three-dimensional computed tomography and relationship to usual plain X-ray classification. J Orthopaed Surg. 2017;25(1):1-5.
Kumar V. Assessment of efficacy of DHS fixation in treatment of intertrochanteric fractures. J Advanc Medic Dent Sci Res. 2019;7(8):115-7.
Kumar R, Ranjan R, Jeyaraman M, Chaudhary D. Clinico-radiological and functional outcome of intertrochanteric fractures by dynamic hip screw. Nat J Clinic Orthopaed. 2020;4(1):19-22
Sharma G, Gn K, Khatri K, Singh R, Gamanagatti S, Sharma V. Morphology of the posteromedial fragment in pertrochanteric fractures: a three-dimensional computed tomography analysis. Injury. 2017;48(2):419-31.
Palm H, Lysén C, Krasheninnikoff M, Holck K, Jacobsen S, Gebuhr P. Intramedullary nailing appears to be superior in pertrochanteric hip fractures with a detached greater trochanter: 311 consecutive patients followed for 1 year. Acta orthopaedica. 2011;82(2):166-70.
Pradeep A, KiranKumar A, Dheenadhayalan J, Rajasekaran S. Intraoperative lateral wall fractures during Dynamic Hip Screw fixation for intertrochanteric fractures-Incidence, causative factors and clinical outcome. Injury. 2018;49(2):334-8.