University of Cambridge School of Clinical Medicine, Box 111 Cambridge Biomedical Campus, Cambridge, CB2 0SP, UK.
Cambridge Orthopaedic Trauma Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK.
Eur J Orthop Surg Traumatol. 2021 Oct;31(7):1435-1441. doi: 10.1007/s00590-021-02895-4. Epub 2021 Feb 16.
A subtrochanteric proximal femur fracture occurs in the 5 cm of bone immediately distal to the lesser trochanter. UK national guidelines advise that adults with subtrochanteric fractures should be treated with an intramedullary nail (IMN). This study aims to compare peri-operative outcome measures of patients with subtrochanteric fractures treated with either an IMN or a dynamic hip screw (DHS) construct.
We retrospectively reviewed subtrochanteric fractures presenting at our institution over 4.5 years (October 2014-May 2019), classifying them into two treatment groups; IMN and DHS. These groups were compared on outcome measures including surgical time, blood loss, radiation dose area product (DAP), length of stay, re-operation rate and mortality.
During the time period studied, 86 patients presented with a subtrochanteric fracture of the femur; with 74 patients (86%) receiving an IMN and 12 (14%) receiving a DHS. The comparative outcome measures reaching statistical significance were blood loss and radiation DAP. The DHS group showed a significantly lower mean blood loss of 776 ml compared to 1029 ml in the IMN group. Also, the DHS group showed a significantly lower mean DAP of 150.30 mGy cm compared to 288.86 mGy cm in the IMN group.
Although UK national guidelines recommend treating all subtrochanteric fractures with an IMN; the outcome measures assessed in our study did not show use of an IMN to be superior to a DHS. The DHS group showed a lower estimated blood loss and a reduced DAP. This, along with the reduced financial cost associated with a DHS, may support the use of DHS over IMN for certain subtrochanteric fractures of the femur. There may not be a single favourable implant for the treatment of subtrochanteric fractures as a whole; instead different subtypes of fracture may be amenable to a number of fixation devices. Choice of implant should be determined locally and based on existing and future clinical and health economic research.
股骨转子下骨折发生在小转子远端 5 厘米的骨内。英国国家指南建议，股骨转子下骨折的成年人应采用髓内钉（IMN）治疗。本研究旨在比较采用髓内钉或动力髋螺钉（DHS）治疗的股骨转子下骨折患者的围手术期结果测量值。
我们回顾性分析了我院 4.5 年来（2014 年 10 月至 2019 年 5 月）收治的股骨转子下骨折患者，将其分为两组：髓内钉和 DHS。对这两组患者的手术时间、失血量、射线剂量面积乘积（DAP）、住院时间、再手术率和死亡率等结果测量值进行比较。
在研究期间，86 例患者股骨转子下骨折；其中 74 例（86%）采用髓内钉治疗，12 例（14%）采用 DHS 治疗。具有统计学意义的比较结果测量值为失血量和射线 DAP。DHS 组的平均失血量明显低于髓内钉组的 776ml，为 1029ml。此外，DHS 组的平均 DAP 也明显低于髓内钉组的 288.86mGycm，为 150.30mGycm。
尽管英国国家指南建议所有股骨转子下骨折均采用髓内钉治疗；但我们的研究结果测量值并未显示髓内钉的使用优于 DHS。DHS 组的失血量估计和 DAP 均较低。再加上 DHS 相关的经济成本降低，可能支持 DHS 用于某些股骨转子下骨折的治疗。对于整个转子下骨折而言，可能没有一种单一的有利植入物；相反，不同亚型的骨折可能适合多种固定装置。植入物的选择应根据当地情况确定，并基于现有和未来的临床和健康经济研究。
