Abstract  OBJECTIVE:
To evaluate early experience with helical hip system in osteoporotic elderly patients with per-trochanteric fractures.  METHODS:
The retrospective study was conducted at Aga Khan University Hospital, Karachi, and comprised records of patients having low-velocity pertrochanteric fractures who were fixed with spiral blade Dynamic Helical Hip Systemfrom July to December 2014 and were followed up for a minimum of 3 months. Demographic variables and clinical outcomes were noted from the medical records whereas operative details were recorded from the operative note. Radiological variables and outcomes were assessed by viewing appropriate pre-operative, post-operative and follow-up radiographs.  RESULTS:
Of the 32 patients in the study, 14(44%) were men and 18(56%) were women, with an overall mean age of 77.81±7.04 years and mean body mass index of 25.99±4.13 kg/m2. Of the total, 1(3.13%) patient had implant cut-out, 1(3.13%) had myocardial infarctionand 2(6.2) expired.  CONCLUSIONS:
The introduction of spiral blade dynamic hip screw manifested favourable results and good clinical and radiological outcomes with low cut-out rates

Hashmi, Pervaiz

Jaleel Zubair, Akbar

Rashid, Rizwan Haroon

umer, masood

Zahid, Marij

English

eCommons@AKU

eCommons@AKUDepartment of Surgery Department of SurgeryNovember 2016Early experience of dynamic hip screw with spiralblade and locking side plate for the stabilization oftrochanteric fractures.Akbar Jaleel ZubairAga Khan University, akber.jaleel@aku.eduRizwan Haroon RashidAga Khan University, rizwan.haroonrashid@aku.eduMarij ZahidAga Khan University, marij.zahid@aku.edumasood umerAga Khan University, masood.umer@aku.eduPervaiz HashmiAga Khan University, pervaiz.hashmi@aku.eduFollow this and additional works at: http://ecommons.aku.edu/pakistan_fhs_mc_surg_surgPart of the Orthopedics CommonsRecommended CitationJaleel Zubair, A., Rashid, R., Zahid, M., umer, m., Hashmi, P. (2016). Early experience of dynamic hip screw with spiral blade andlocking side plate for the stabilization of trochanteric fractures.. JPMA: Journal of Pakistan Medical Association, 65(11), S-45-S-48.Available at: http://ecommons.aku.edu/pakistan_fhs_mc_surg_surg/142IntroductionHip fractures are a common occurrence in the elderly andtheir worldwide incidence is rising, making it an alarminghealth problem.1 Pertrochanteric fractures comprise amajor portion of these fractures which are usually theresult of trivial trauma like ground-level fall. The Dynamichip screw (DHS) has stood the test of time as the implantof choice for these fractures. Even the recent popularity ofintramedullary devices has failed to document anysuperiority over the conventional DHS.2,3Unstable fracture patterns and poor bone quality of thepatients, secondary to osteoporosis, present a significantchallenge to surgeons due to the relatively high rate offixation failure.4 Some surgeons have recommendedconcurrent cementation with the implant whereas othershave advocated primary hemi-arthroplasty for thesetypes of fractures.5 But these methods have not gainedwidespread acceptance yet and most surgeons still use asliding extra-medullary or intra-medullary implant.A recent development is the use of the helical or spiralblade instead of the conventional lag screw (Figure-1).This implant has shown promise in biomechanical studieswith improved bone purchase, resistance to loading andpreservation of bone stock in case of failure.6,7 Few studieshave been done to see the outcomes of this implant,7-10and the current study was planned to evaluate our earlyexperience with the use of this technique.Patients and MethodsThe retrospective study was conducted at Aga KhanUniversity Hospital, Karachi, and comprised records ofpatients having low-velocity pertrochanteric fractureswhich were fixed with spiral blade Dynamic Helical HipSystem (DHHS) from July to December 2014.Demographic variables and clinical outcomes were notedfrom the medical records whereas operative details wererecorded from the operative note.All patients aged 60 years or above with pertrochantericfractures were included and had a minimum follow-up of3 months. Cases related to younger patients, revisionsurgery and pathological fractures were excluded.Patients underwent the procedure after necessary medicalVol. 65, No.11 (Suppl. 3), November 201529th Pak Orthocon 2015 S-45ORIGINAL ARTICLEEarly experience of dynamic hip screw with spiral blade and locking side platefor the stabilization of trochanteric fracturesAkbar Jaleel Zubairi, Rizwan Haroon Rashid, Marij Zahid, Masood Umer, Pervaiz Mahmood HashmiAbstractObjective: To evaluate early experience with helical hip system in osteoporotic elderly patients with per-trochanteric fractures.Methods: The retrospective study was conducted at Aga Khan University Hospital, Karachi, and comprised recordsof patients having low-velocity pertrochanteric fractures who were fixed with spiral blade Dynamic Helical HipSystemfrom July to December 2014 and were followed up for a minimum of 3 months. Demographic variables andclinical outcomes were noted from the medical records whereas operative details were recorded from the operativenote. Radiological variables and outcomes were assessed by viewing appropriate pre-operative, post-operative andfollow-up radiographs.Results: Of the 32 patients in the study, 14(44%) were men and 18(56%) were women, with an overall mean age of77.81±7.04 years and mean body mass index of 25.99±4.13 kg/m2. Of the total, 1(3.13%) patient had implant cut-out, 1(3.13%) had myocardial infarctionand 2(6.2) expired.Conclusion: The introduction of spiral blade dynamic hip screwmanifested favourable results and good clinical andradiological outcomes with low cut-out rates.Keywords: Helical blade, Hip fractures, Osteoporosis, Pertrochanteric fractures. (JPMA 65: S-45 (Suppl. 3); 2015)Department of Orthopedics, The Aga Khan University, Karachi, Pakistan.Correspondence: Akbar Jaleel Zubairi. Email: akbar.jaleel@aku.eduFigure-1: Spiral blade Dynamic Hip System.optimisation in supine position on the traction table. Astandard lateral approach was adopted after closedreduction of the fracture and open reduction was donewhere required. A 135º angle guide was used to place a2.5-mm guide-wire centrally in the femoral head, withconfirmation using image intensification. After measuringthe length of the guide wire, a tapered reamer was used toream the trochanter and lateral femoral neck. A spiralblade of the measured length was impacted into positionwith the insertion device which applied atorsional force tothe blade as it was inserted over the guide-wire. Theappropriate locking side plate was then inserted over theblade and fixed to the femoral shaft with screws. The bladewas then rotationally locked within the barrel, with itstorque limiting screwdriver, so that it did not rotate furtherbut allowed guidedollapse. A coupling screw was used forcompression when required (Figure-2).Radiological variables and outcomes were assessed byviewing appropriate pre-operative, post-operative andfollow-up radiographs.Data was analyzed using SPSS 20.ResultsOf the 32 patients, 14 (43.75%) were men. Overall meanJ Pak Med Assoc (Suppl. 3)S-46 29th Pak Orthocon 2015Figure-2: X-rays of fracture fixed with Spiral blade dynamic hip screw 4 monthspostoperatively.Table-1: Patient's characteristics.Mean age 77.81±7.041Mean body mass index 25.99±4.135GenderMale/Female 14/18 (43.75%/56.25%)Number of comorbidsNone 2 (6.25%)1 6 (9.75%)2 14 (43.75%)>2 10 (31.25%)ASA Grade - I 2 (6.25%II 8 (25%)III 18 (56.25%)IV 4 (12.5%)V 0 (0%)Type of AnaesthesiaGeneral 10 (31.25%)Spinal 22 (68.75%)ASA: American Society of Anaesthesia.Table-2: Classification of Pertrochanteric fractures.AO/OTA Classification Modified Evan's ClassificationType Frequency Percentage Type Frequency PercentageA1 8 25% 2 8 25%3 4 12.5%A2 24 75% 4 12 37.5%5 8 25%AO/OTA: Arbeitsgemeinschaftfür Osteosynthesefragen/ Orthopaedic Trauma Association.Table-3: Perioperative and follow-up findings.LateralizationRight IT# 14 (43.75%)Left IT# 18 (56.25%)Mode of InjuryFall 30 (93.75%)RTA 2 (6.25%)Mean hospital stay (in days) 7.62±1.37Mean Duration of surgery (in hours) 3.643±0. 359Ambulation on DischargeNWB 18 (56.25%)FWB 14 (43.75%)Ambulation on Follow upNWB 6(18.75%)FWB 26 (81.25%)IT: Intertrochanteric. RTA: Road traffic accident. NWB=Non-weight bearing.FWB=Full weight bearing.age was 77.8±7 years (Table-1).Ground-level fall was the most commonmode of injury in30(94%) patients, while with the remaining 2(6%) sufferedlow-speed road traffic accidents (RTAs). The left side wasinvolved in 18(56%) patients, and 14(44%) had a rightpertrochanteric fracture. According to AO/OTAclassification most patients 24(75%) had a type 31 A2fracture whereas according to the modified Evan'sclassification a similar number of patients had unstablefracture patterns. (Table-2). Full weight-bearingambulatory status was achieved by 26(81%) at 6-weekfollow-up (Table-3).Mena tip-apex distance was 21.06±4.03mm, with meansliding of the blade being 3.8±2.5mm. There was a single(3%) instance of varus collapse and cut through, whereas2(6.2%) patients developed medialisation of the femoralshaft (Table-4).Complications included 2(6.2%) surgical site infections,2(6.2%) mortalities and 1(3%) myocardial infarction (MI)(Table-5). Only a single (3%) octogenarian patientrequired a revision secondary to infected non-unionleading to varus collapse and cut-through of the blade 3months after the index surgery (Figure-3). This patientwas managed with debridement and Girdle stone hemi-arthroplasty.DiscussionPertrochanteric fractures are one of the most commonfractures in orthopaedic trauma. Management of choicehas been controversial for a long time. Many implantshave been designed to strive for a better outcome. Thehelical blade DHS has shown promising results for repairof pertrochanteric fractures in elderly and osteoporoticbone. The shape of the helical blade is so designed that itenhances the contact surface area between the femoralhead and the device, has a better locking capacity andbiomechanical anchorage.1Strauss et al. carried out a biomechanical studycomparing the stability of helical blade with sliding hipscrew system and found helical blade dynamic hip systemto be less prone to inferior displacement and a bettersubstitute for elderly and osteoporotic bone thanconventional sliding hip screw.11Vol. 65, No.11 (Suppl. 3), November 201529th Pak Orthocon 2015 S-47Table-4: Radiological characteristics.Mean Tip-Apex distance (in mm) 21.06±4.039Mean Femoral Shaft angle (in degrees) 135.56±8.864Sliding of screw (in mm) 3.8±2.5Frequency of Varus collapse with cut through 1 (3.13%)Frequency of Late medialisation of shaft 2 (6.25%)Frequency of Helical blade migration 0 / 0%Table-5: Complications.Mortality 2 (6.25%) Secondary to Cardio-pulmonary arrest on 6th and 8th post op day. Both patients were ASA IV.Myocardial Infarction 1 (3.13%) On 5th post op day, recovered with medical interventionRevision surgery 1 (3.13%) Secondary to implant infection in an immuno-compromised patient.Infection 2 (6.25%) -ASA: American Society of Anaesthesia.Figure-3: X-rays of implant Cut-out 4 due to infection.Stern et al. compared the Dynamic Helical Hip System(DHHS) implant with trochanteric entry nail and reportedthat in Arbeitsgemeinschaftfür Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) 31-A1 and 31-A2 pertrochanteric fractures, the DHHS andintramedullary nail both had comparable outcomes.12Fitzpatrick et al. compared quality of surgery, tip-apexdistance, fracture reduction and screw-tip location in DHS(24 patients) and DHHS groups (27 patients). Both groupshad comparable mean tip-apex distance, but there were 2failures in the DHHS group by central cut-out.13Even though biomechanical studies have shown superiorstability of this implant, it has not translated into betterclinical outcomes when comparing it with other implants,opening a gateway for further research.Recently, DHHS manufactured by Double Medical wasintroduced in our institution and has shown encouragingresults. This study highlights its functional andradiological outcomes and shows low cut through rates(3.1%), medialisation of the shaft (6.3%) and lesserrequirement for revision surgery (3.1%) even in unstablefracture types compared to other studies.ConclusionEven though our study design does not permit us to drawdefinitive conclusions, we believe that the helical bladehip system may be a superior implant for fixation ofpertrochanteric fractures in elderly and osteoporoticpatients. However, prospective clinical trials are requiredto confirm the suggestion.References1. Cheng SY, Levy AR, Lefaivre KA, Guy P, Kuramoto L, Sobolev B.Geographic trends in incidence of hip fractures: a comprehensiveliterature review. Osteoporos Int 2011; 22: 2575-86.2. Bohl DD, Basques BA, Golinvaux NS, Miller CP, Baumgaertner MR,Grauer JN. Extramedullary compared with intramedullaryimplants for intertrochanteric hip fractures: thirty-day outcomesof 4432 procedures from the ACS NSQIP database. J Bone JointSurg Am 2014; 96: 1871-7.3. Huang X, Leung F, Xiang Z, Tan PY, Yang J, Wei DQ, et al. Proximalfemoral nail versus dynamic hip screw fixation for trochantericfractures: a meta-analysis of randomized controlled trials.ScientificWorldJournal 2013; 2013: 805805. doi:10.1155/2013/805805.4. Karthik K, Natarajan M. Unstable trochanteric fractures in elderlyosteoporotic patients: role of primary hemiarthroplasty. OrthopSurg 2012; 4: 89-93.5. Singh S, Shrivastava C, Kumar S. Hemi replacement arthroplastyfor unstable inter-trochanteric fractures of femur. J Clin Diagn Res2014; 8: LC01-4.doi: 10.7860/JCDR/2014/10171.4972.6. Luo Q, Yuen G, Lau TW, Yeung K, Leung F. A biomechanical studycomparing helical blade with screw design for sliding hip fixationsof unstable intertrochanteric fractures. ScientificWorldJournal2013; 2013: 351936. doi: 10.1155/2013/351936.7. O'Neill F, Condon F, McGloughlin T, Lenehan B, Coffey JC,Walsh M.Dynamic hip screw versus DHS blade: a biomechanicalcomparison of the fixation achieved by each implant in bone. JBone Joint Surg Br 2011; 93: 616-21.8. Knobe M, Drescher W, Heussen N, Sellei RM, Pape HC. Is helicalblade nailing superior to locked minimally invasive plating inunstable pertrochanteric fractures? Clin Orthop Relat Res 2012;470: 2302-12.9. Leung F, Gudushauri P, Yuen G, Lau TW, Fang C, Chow SP. Dynamichip screw blade fixation for intertrochanteric hip fractures. JOrthop Surg. 2012; 20(3).10. O'Malley NT, Deeb AP, Bingham KW, Kates SL.Outcome of thedynamic helical hip screw system for intertrochanteric hipfractures in the elderly patients. Geriatr Orthop Surg Rehabil 2012;3: 68-73.11. Siwach RC, Rohilla R, Singh R, Singla R, Sangwan SS, GognaP.Radiological and functional outcome in unstable, osteoporotictrochanteric fractures stabilized with dynamic helical hip system.Strategies Trauma Limb Reconstr 2013; 8: 117-22.12. Strauss E, Frank J, Lee J, Kummer FJ, Tejwani N.Helical blade versussliding hip screw for treatment of unstable intertrochanteric hipfractures: a biomechanical evaluation. Injury 2006; 37: 984-9.13. Stern R, Lübbeke A, Suva D, Miozzari H, Hoffmeyer P.Prospectiverandomised study comparing screw versus helical blade in thetreatment of low-energy trochanteric fractures. Int Orthop 2011;35: 1855-61.14. Fitzpatrick DC, Sheerin DV, Wolf BR, Wuest TK.A randomized,prospective study comparing intertrochanteric hip fracturefixation with the dynamic hip screw and the dynamic helical hipsystem in a community practice. Iowa Orthop J 2011; 31: 166-72.J Pak Med Assoc (Suppl. 3)S-48 29th Pak Orthocon 2015

Early experience of dynamic hip screw with spiral blade and locking side plate for the stabilization of trochanteric fractures.

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Early experience of dynamic hip screw with spiral blade and locking side plate for the stabilization of trochanteric fractures.

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