Temporary pelvi-femoral external fixation versus skeletal traction for displaced pertrochanteric fractures in the young: a retrospective case control study

doi:10.21203/rs.3.rs-2498655/v1

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Temporary pelvi-femoral external fixation versus skeletal traction for displaced pertrochanteric fractures in the young: a retrospective case control study

https://doi.org/10.21203/rs.3.rs-2498655/v1

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Background: Initial treatment of displaced pertrochanteric fractures in the young is extremely different with the elderly for high rate of co-morbidities. Comparing to skeletal traction (ST), temporary pelvic-femoral external fixation (PPEF) via the anterior inferior iliac spine could produce improved outcome.

Methods: 46 young polytraumatic patients with displaced pertrochanteric factures (average age 38.0±8.5 years) were included and retrospectively analyzed between January 2015 and December 2018. ST involved in 23 patients, and PPEF involved in 23 patients as the initial treatment options when other body injuries were treated surgically. Definite treatment was performed when patients’ general conditions permitted. General characteristics, surgical data and functional outcome were recorded and compared grouply statistically.

Results: The PPEF group was identified to have more reduced visual analog scales(3.7±0.3 vs. 2.0±0.9), greater fracture reduction degrees(13.5±6.9 vs. 6.5±3.0), less definitive surgical time(45.1±6.6 min vs. 52.7±8.5 min), less varus angulation>5°（2 vs. 3），less limb shortening (0.5±0.2 vs. 0.7±0.3), and high percentage of excellent Harris Hip scores (73.9% vs. 30.4%) than the ST group. Although the latter had less initial surgical time, no blood loss, and unsignificant time interval to definite surgery, hospital days, bedsores, healing time, deaths.

Conclusion: PPEF via the anterior inferior iliac spine is proved to be an optimal temporary treatment protocol for displaced pertrochanteric fractures in the young polytraumatic patients.

Femoral fracture

Traction

External fixator

Internal fixation

Pertrochanteric fractures are high-energy injuries and relatively uncommon in the young [1]. There is limited information to describe this type of injury from published literatures. The optimal treatment strategy remain vague to trauma surgeons in urgent situations. For the elderly, skeletal traction (ST) [2, 3] is often used as the initial treatment protocol and then intramedullary nailing is preferred to be the definite fixation [4–6]. Evenmore, some elderly patients receive ST or external fixation directly as the definitive fixation for poor general conditions or severe chronic diseases [7]. But ST has no compromise in final functional outcome and mortality, it could be considered as an alternative for the elderly [8].

For the young, it is unclear if we can treat this type of high-energy injuries like the elderly. Moreover, the question remains whether early external fixation will alter the functional outcome when the co-morbidities require acute surgical treatment.

We developed a novel protocol of pelvi-femoral external fixation (PPEF) via the anterior inferior iliac spine for displaced pertrochanteric femoral fractures in the young [9]. But there is no comparative study to further prove its clinical significance and optimize treatment strategy. The purpose of this study is to compare the validity of ST and PPEF, and identify the role of PPEF in treatment of pertrochanteric fractures in the young via a retrospective case control analysis.

Patients information and clinical assessment

A retrospective analysis of ST or PPEF was conducted for the young with displaced pertrochanteric fractures in our level I trauma centre between January 2015 and December 2018.

The clinical results were comparized statistically betweent ST group and PPEF group. The inclusion criteria were patients: 1) age < 65 years, 2) pertrochanteric fractures with major displacement (diastasis ≥ 5mm, angulation ≥ 20°)[10], 3) difficult to reset, 4) high risk of skin, vessel and nerve injuries, 5) requiring acute surgical treatment (head, chest, abdomen, or limbs), 6) PPEF, or ST was used meanwhile. Exclusion criteria were patients: 1)age ≥ 65 years, 2) isolated pertrochanteric fractures with little displacement, 3) severe open fractures (Gustilo III)[11], 4) severe medical conditions (e.g. diabetes mellitus, heart and respiratory diseases), and 5) severe osteoporosis.

A total of 46 younger polytraumatic patients (range, 28–45 years) with displaced pertrochanteric fractures were included. Patients were distributed equally, 23 patients were included into the ST group, and 23 patients were stratified into the PPEF group. The goal of reduction was to reset the fracture to diastasis < 5 mm and angulation < 20°.

Surgical Methods

In ST group, a 5-mm pin was inserted from lateral into medial in emergency room, ward or operation room, 2.5 cm posterior and 2.5 cm distal to tibial tubercle under local anesthesia, and traction of 10% of body weight was applied [2, 3]. It was a convenient surgical treatment without high medical facilities.

In PPEF group, an external fixator was used to initially stabilize the pertrochanteric fractures in operation room via C-arm when other body injuires received acute surgical treatment, postoperative treatment and clinical evaluation were performed according to our published methods [9]. Moreover, severe orthopaedic trauma such as pelvic fractures and other limb injuries could be initially fixed meanwhile. A young man, aged 29, fell from the height and sustained displaced both pertrochanteric and pelvic fractures. The fractures were initially reset manually, fixed with a pelvic-femoral external fixator via the anterior inferior iliac spine by use of C-arm, and stabilized with an intramedullary nail as a final treatment when general conditions permitted. (Fig.a-f).

Postoperative Treatment And Follow-up

General demographics, surgical characteristics, visual analog scale (VAS)[12] relief, fracture reduction degree (FRD), complications, follow-up period and the score of Harris scoring system (HHS)[13] were recorded and compared grouply. Surgical time of PPEF or ST was defined to be isolated from other surgical treatment. VAS and FRD were defined to be pre- and post-surgery in each group. Patients were followed and examined at least 12 months until bone union.

Statistical analysis

The Pearson chi-square test and the t-test were used to investigate the grouping variables. Statistical analysis was performed using SAS software (version 9.1; SAS Institute Inc., Cary, NC). P < 0.01 was considered to indicate a statistically significant difference.

The patients consisted of 26 (56.5%) men and 20 (43.5%) women. The mean age was 38.0 ± 8.5 years (range, 28–58 years). The mechanism of injury included 22 (47.8%) motor vehicle accidents, and 24 (52.2%) falls from the height. There were 20 intertrochanteric fractures, and 3 subtrochanteric fractures in each group, respectively. In 14 (30.4%) patients, the right femur was involved, and in 32 (69.6%) patients the left femur was involved. Chest injuries (39.1%) and abdominal injuries (34.8%) were identified to be the most common co-morbidities, which often needed acute surgical treatment. There was no significant difference between the two groups in general data. The results are tabulated in Table 1.

The time of ST was shorter than that of PPEF (10.3 ± 2.2 min vs. 20.3 ± 7.3 min, p < 0.01). The mean blood loss of ST group (0) was less than PPEF group (25.3 ± 10.8 ml)(p < 0.01). No iatrogenic nerve palsy and external fixation failure was observed in both groups. Furthermore, pin tract infection was none after initial treatment.

The mean VAS relief of PPEF group was larger than that of ST group (3.7 ± 0.3 vs. 2.0 ± 0.9, p < 0.01). This was also the case at mean FRD (13.5 ± 6.9° vs. 6.5 ± 3.0°, p < 0.01).

The time interval to definite fixation was not significant between two groups (7.0 ± 3.0 days vs. 7.6 ± 4.0 days, p > 0.01). The definite fixation time of PPEF group was shorter than that of ST group (45.1 ± 6.6 min vs. 52.7 ± 8.5 min, p < 0.01). However, the mean hospital time was not significant between ST group and PPEF group (29.0 ± 2.1 days vs. 28.7 ± 8.7 days, p > 0.01).

All patients were followed up until bone union, and the mean follow-up period was 23.5 ± 7.9 months. There were 3 (13.0%) deaths in ST group and there was none in PPEF group in our study (p > 0.01). No infection or hardware failure was observed at last follow-up. Two patients sustained bedsores in ST group and none in PPEF group, but it was not significant (p > 0.01). This was also the case at the mean healing time (20.5 ± 4.0 weeks vs. 22.8 ± 5.7 weeks, p > 0.01).

At final follow-up, complete normal alignment was achieved. Varus angulation > 5° was observed in 3 (13.0%) and 2 (8.6%) patients with limb shortening of 0.7 ± 0.3cm and 0.5 ± 0.2 cm in ST group and PPEF group respectively, which was significantly different (p < 0.01). The Harris Hip system revealed that 7 (30.4%) patients exhibited excellent results (> 90) in ST group and so were 17 (73.9%) patients in PPEF group. HHS of PPEF group had higher percentage of excellent results than that of ST group (p < 0.01). The results above are presented in Table 2.

Pertrochanteric fractures are common in the elderly, but relatively uncommon in the young [1]. To our knowledge, this type of injury is a result of high-energy, most commomly in young men, and often combined with co-morbidities [14]. Functional outcomes of pertrochanteric fracture patients (< 65 years) with co-morbidities are poor [15]. The initial treatment strategy are contradictory among available recommendations and complicated injuries.

Traditionally, ST is used as the initial treatment of pertrochanteric fractures with a high rate of complications [16, 17]. It is suitable for the majority of patients, especially the elderly. Besides, only a small portion of the elderly received external fixation as the definite treatment [3, 7, 18].

Unlike the elderly, it is often seen that the young have high rate of co-mobidities and limb injuries [1, 14, 15, 19]. A significant proportion of younger patients require acute surgical treatment for severe pathophysiological status. Optimal acute treatment is essential for saving patients’ lives and limbs in urgent situations. In addition, pertrochanteric fractures in the young are difficult to reset by closed means and proved to have more complications than the elderly [19]. However, another literature reported that nearly all patients with pertrochanteric fractures had good results [20].

This retrospective study identified that motor vehicle accidents or falling from the height were the most mechanism of injury [1, 14, 15, 19]. The mean age was 38 years old and women took a high proportion (43.5%), which was higher than 28.0%¹⁹⁾ and previous reports [1, 14, 15, 19]. Chest and abdominal injuries were identified to be the most common injuries and accounted for more than 70% in this study.

When acute surgical treatment was performed in co-morbidities, PPEF or ST was done meanwhile in this study. The time of PPEF was included into the surgical treatment of co-morbidities, and blood loss was negligible as the ST. Complications of PPEF was not obvious, the reason for this might be minimal invasion, short fixation time, and good bone stock in the young.

Comparing to ST, PPEF had two more reduced VAS scores, which made the care and mobilization of young patients easier in current study. So was the case in term of FRD, 7° more fracture reduction was found. This just showed the benefits of PPEF over ST on fracture reduction in the young [19].

Reduced time of definite fixation was identified in PPEF group (45 min) than that in ST group (53 min) in present study. The follow-up period was at least 12 months, and all fractures healed without hardware failure. Quality of reduction had an important effect on functional outcome. Only two (8.6%) patients were observed to have varus angulation > 5° in PPEF group, which was better than ST group (13.0%). Approximately, there was 6 mm shortening in two groups and it was not significant. It was reported [1, 19] that 13.5%-17% younger patients with pertrochanteric fractures had major complications requiring revision surgery, but we did not find that in this study. Initial good reduction, muscle contracture prevention, and improved blood supply were positive factors of PPEF for achieving satisfied functional outcome.

PPEF is considered to be an optimal treatment protocol for not only a positive effect on fracture reduction but overall recovery of functional outcome. PPEF has flexible extension to adjacent injuries (e.g. pelvic fractures, knee injuries) which also need temporary external fixation. The aforementioned might be a major advantage in the clinical practice of acute trauma surgery. Additionally, more than 70% patients in PPEF group achieved excellent scores of HHS, which was much higher than that in ST group (30.4%) and a previous literature (23%, fully recover; 39%, moderate disability)[15].

PPEF group had decreased percentage of mortality than ST group in young polytraumatic patients though it was not significant. For trauma sugeons, treatment algorithms involves both damage control orthopaedics (DCO) and early total care safely to reduce length of stay and total cost of treatment [20]. Open pertrochanteric fractures (Gustilo III) were not included for high risk of deep wound infection [21]. Staged treatment strategy was proved to be much safer [22], our study agreed with this sight.

However, the present study had certain limitations. First, a small number of patients were evaluated and sufficient data could not be obtained. Second, confounding factors from co-comidities might affect the result and cause data deviation. Thirdly, a retrospective design had its inherent defects.

Temporary PPEF via the anterior inferior iliac spine has significant advantages over ST in the initial treatment of displaced pertrochanteric fractures in the young polytraumatic patients. However, this treatment protocol still remains controversial and the indication is strictly selected. The benefits need long-term investigation and more young patients might be favoured.

Acknowledgements

We thank the patients for their consent to publish this work.

Authors contributions

QY and RG conceived the study and study design. QY collected, evaluated the data, performed data analysis, and wrote the manuscript. RG revised the manuscript, prepared the images and tables. All authors read and approved the final manuscript.

Funding

None.

Availablity of data and materials

The datasets are available under reasonable request.

Ethics approval and consent to participate

This study was reviewed and approved by our ethical unit (approval no: 2020-47) and the patients signed the consents, which were collected before the inclusion.

Consent for publication

All authors agree to publish this work.

Competing interests

The authors declare that they have no competing interests.

Author details

¹ Department of Orthopaedics, Qingpu Branch of Zhongshan Hospital affiliated to Fudan University Qingpu District Central Hospital Shanghai, 1158 East Gongyuan Road, Qingpu District, Shanghai, 201700, PR.China.

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Table I. Patients Characteristics

	Total	PPEF group	ST group	P value
Sex
Male	26(56.5)	13(28.3)	13(28.3)	P>0.01
Female	20(43.5)	10(21.7)	10(21.7)	P>0.01
Age(years)	38.0±8.5	38.6±9.2	37.5±8.2	P>0.01
Mechanism
Motor vehicle accidents	22(47.8)	11(23.9)	11(23.9)	P>0.01
Fall from the height	24(52.2)	12(26.1)	12(26.1)	P>0.01
Location
Left	32(69.6)	16(34.8)	16(34.8)	P>0.01
Right	14(30.4)	7(15.2)	7(15.2)	P>0.01
Intertrochanteric fractures	40(87.0)	20(43.5)	20(43.5)	P>0.01
Subtrochanteric fractures	6(13)	3(6.5)	3(6.5)	P>0.01
PPEF
AO	10(43.5)	10(43.5)
Trauson	5(21.7)	5(21.7)
Carefix	8(34.8)	8(34.8)
ST	23(50)		23(50)
Co-morbities
Head injuries	4(8.7)	2(4.4)	2(4.4)	P>0.01
Chest injuries	18(39.1)	9(19.6)	9(19.6)	P>0.01
Abdominal injuries	16(34.8)	8(17.4)	8(17.4)	P>0.01
Other limb injuries	8(17.4)	4(8.7)	4(8.7)	P>0.01
Values are expressed as n(%) or mean±SD. PPEF: pelvi-femoral external fixation; ST: skeletal traction.

Table II. Treatment Characteristics and Outcomes

	ST group	PPEF group	P value
Initial treatment time (min)	10.3 ±2.2	20.3±7.3	P<0.01
Blood loss of initial treatment (ml)	0	25.3±10.8	P<0.01
Reduced VASscores	2.0±0.9	3.7±0.3	p<0.01
FRD (°)	6.5±3.0°	13.5±6.9	p<0.01
Failure of external fixation Iatrogenic nerve palsy Pin tract infection Time interval to definite fixation (days)	0 0 0 7.0±3.0	0 0 0 7.6±4.0	p>0.01
Nailing time (min) Hospital time (days) Bedsores Follow-up (days)	52.7±8.5 29.0±2.1 2(8.7) 23.5±7.9	45.1±6.6 28.7±8.7 0 23.5±7.9	P<0.01 p>0.01 p>0.01
Healing time (weeks)	22.8±5.7	20.5±4.0	p>0.01
Varus (>5°)	3(13.0)	2(8.7)	P<0.01
Shortning	0.7 ±0.3	0.5±0.2	P<0.01
HHS (>90)	7(30.4)	17(73.9)	P<0.01
Deaths	3(13.0)	0	P>0.01
Values are expressed as n(%) or mean±SD. ST: skeletal traction;PPEF: pelvi-femoral external fixation; VAS: visual analogue scale; FRD: fracture reduction degree; HHS: harris hip score.

No competing interests reported.

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Temporary pelvi-femoral external fixation versus skeletal traction for displaced pertrochanteric fractures in the young: a retrospective case control study

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Abstract

Figures

Background

Materials And Methods

Patients information and clinical assessment

Surgical Methods

Postoperative Treatment And Follow-up

Statistical analysis

Results

Discussion

Conclusion

Declarations

References

Tables

Additional Declarations

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