Outcome of the treatment of the intertrochanteric femoral with the osteosynthesis by locking plate in Tay Nguyen general hospital
Journal OF MILITARY PHARMACO - MEDICINE N05 - 2021
OUTCOME OF THE TREATMENT OF THE INTERTROCHANTERIC
FEMORAL WITH THE OSTEOSYNTHESIS BY LOCKING PLATE
IN TAY NGUYEN GENERAL HOSPITAL
Le Tat Thang1, Pham Dang Ninh2
SUMMARY
Objectives: To evaluate the outcomes of proximal femoral locking plate in intertrochanteric
femur fractures. Subjects and methods: A prospective, cross-sectional study on 61 intertrochanteric
femur fractures treated with proximal femoral locking plate at the Department of Traumatology
and Orthopedics, Tay Nguyen General Hospital from September 2015 to May 2020. Results:
The mean age was 68.18 15.95 (range. 23 to 94 years). Mean duration time of operation:
56.72 13.81 minutes, the average neck-shaft angle at time union: 126.610 7.09. 33 patients
had excellent results (57.89%), 16 good (28.08%), 7 fair (12.28%), and one poor (1.75%) result
according to Harris hip score. Conclusion: The proximal femoral locking plate is a good stable
alternative in the treatment of intertrochanteric femur fractures. It provides good to excellent
bone healing with limited complications.
* Keywords: Proximal femoral locking plate; Intertrochanteric fractures.
INTRODUCTION
Options for treating intertrochanteric
femur fractures include dynamic hip screw
(DHS), Gamma nail, angular blade plates,
locking plate. A proximal femoral locking
plate can provide a stress shield for the
lateral trochanteric wall and prevent lateral
migration of proximal fracture fragments.
The three locking screw holes of the
proximal femoral locking plate insertions
within the complex trabecular zone of the
head-neck region of the proximal femur
provide for optimal mechanical stability.
It is also ideal in osteoporosis bones.
Intertrochanteric femur fractures are
one of three the most common fractures
in old patients. In recent studies, the rate
of intertrochanteric femur fracture increases
with the rising life expectancy of the
population. In the elder age group, most
of the fractures were osteoporosis,
resulting from a trivial fall. Conversation
management had many limitations, high
risk of death, so it only indicated for
undisplaced intertrochanteric fractures or
contraindicated for surgery. The aim of
the surgery is to achieve initial stability
and early mobilization of the patients and
to avoid complications such as deep vein
thrombosis, pulmonary embolism, urinary
and lung infections, and ulcers...
We do this research with the aim
:
To evaluate of the outcome of the
treatment of the intertrochanteric femur
fracture by proximal femoral locking plate.
1Tay Nguyen General Hospital
2Vietnam Military Medical University
Corresponding author: Le Tat Thang (thangleorth1@gmail.com)
Date received: 13/5/2021
Date accepted: 3/6/2021
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Journal OF MILITARY PHARMACO - MEDICINE N05 - 2021
SUBJECTS AND METHODS
1. Subjects
61 patients with proximal femur fractures treated with proximal femoral locking plate
from September 2015 to May 2020 in Tay Nguyen General Hospital.
* Inclusion criteria:
- Skeletally mature > 18 years.
- Intertrochanteric femur fractures type A1, A2, and A3 in AO/ASIF classification
were treated with a proximal femoral locking plate.
- No medical contraindication for anesthesia.
- There are radiography and CT scan.
- Having the documentation protocol.
* Exclusion criteria:
- Pathological fractures, leg deformity or trauma sequel.
Figure 1: Osteosynthesis by proximal femoral locking plate.
2. Methods
neck-shaft angle; excellent: 1250 - 1300,
good: 1200 -< 1250, fair: 1100 -< 1200,
poor: < 1100).
* Study design: Prospective, case series
study.
- Screw positioning in femur neck-head.
3. Evaluation outcome
- Medical complications and postoperative
complications.
* The primary outcome measures:
- Surgical scar: Wound healing, superficial
infection, deep infection.
* Final follow-up: Minimum postoperative
follow-up time: after 12 months.
- Pain, gait, leg short.
- The quality of the reduction of the
fracture that was assessed based on restore
- Hip rank flexion motion.
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Journal OF MILITARY PHARMACO - MEDICINE N05 - 2021
- Union fracture, neck-shaft angle of (6.55%) diabetes, 7 patients (11.47%)
femur, plate status.
other chronic diseases, 9 patients (14.75%)
had more than two chronic diseases.
- Complications: non-union, femoral head
avascular necrosis.
-
Classified according to ASA
(American Society of Anesthesiology):
9 patients (14.75%) grade I, 37 patients
(60.66%) grade II; 12 patients (19.67%)
grade III, 3 patients (4.92%) grade IV.
- The functional outcome was evaluated
by Harris hip score [5].
4. Data processing: Using SPSS 20.0
software.
2. Operative technique
RESULTS
The mean duration from fracture to
surgery was 4.87 3.29 days (from day 1
to day 21).
1. Patient characteristics
A total of 61 patients (32 males,
29 females; mean age 68.18 15.95 years,
(23 - 94 years). The mean age of males is
Table 1: Surgery technique.
Surgery
Mean duration of operation
(SD) (min - max) (minutes)
62.31
16.48 years, and females are
technique
74.66 12.71 years. There was a significant
relationship (p = 0.002).
Minimally invasive
(n = 39)
52.05 7.04 (45 - 85)
- The causes of injury fall with trivial
trauma in 45 patients (73.77%), 14 (22.95%)
traffic accidents, 2 (3.28%) accidents
at labor.
Conventional
65.00 18.51 (50 - 120)
56.72 13.81
surgery (n = 22)
Total (n = 61)
3. Results
- Classification according AO: 12 patients
(19.67%) were classified as AO types A1,
37 patients A2 (60.65%) and 12 patients
A3 (19.67%). 32.79% of fractures involved
type A2.2. Fractures of the lateral wall
occurred in 29 (47.54%) patients.
* Early results:
- 59/61 patients (96.72%) wound healing,
we had two patients with superficial skin
infections.
- The result of the reduction and
fixation of the fracture, good: 54 patients
(88.52%); accept: 7 patients (11.48%).
The differences between the groups of
patients were not significant (p > 0.05).
- Degree of osteoporosis (Classification
according Singh): type IV 28/61 patients
(45.90%), type III 14/61 patients (22.95%),
type V 12/61 patients (19.67%), type VI
6/61 patients (9.84%). Type II had one
case (1.64%).
+ Neck-shaft angle ≥ 125°: 59 patients
(96.72%).
- Associated medical problems: 15 patients
(24.59%) patients had hypertension,
16 patients (26.22%) cardiopathy, 4 patients
+ Neck - shaft < 125°: 2 patients
(3.27%). No patients had neck-shaft angle
< 1200 in postoperation radiography.
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Journal OF MILITARY PHARMACO - MEDICINE N05 - 2021
Table 2: Postoperation neck-shaft angle (n = 61).
Neck-shaft angle
Excellent: 125o - 130o
Number of patients (n)
Percentage (%)
96.72
59
2
Good: 1200 - < 1250
Fair 1100 - < 1200
Poor < 1100
3.28
0
0.00
0
0.00
Total
Mean
61
100.00
129.230 1.84
+ Technique failures: There are not case cut out orintra-articular protrusion of screws.
* Final results:
- There are 57 patients who have been followed up for 1 year or more. The mean
follow-up time is 26.63 11.73 months (12 - 47 months). There are 4 patients who died
before one year, during the follow-up period.
- Radiological union was noted in 57 patients.
Table 3: Neck shaft angle in final follow up (n = 57).
Neck-shaft angle
Excellent: 1250 - 1300
Number of patients (n)
Percentage (%)
85.96
49
3
Good: 1200 -<1250
Fair 1100 -<1200
Poor < 1100
5.26
3
5.26
2
3.51
Total
57
100.00
Average femoral neck angle
126.610 7.09
- Mean femoral neck angle before surgery was 117.700 9.32, postoperation is
129.230 1.840 and at the last follow-up was 126.610 7.09. The difference between
the mean neck angle after surgery and at the time of the last examination was not
statistically significant.
- 4 patients (7.01%) had resulted in limb shortening 1 -< 2 cm: mean limb shortening
is 2.35 4.15 mm.
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Journal OF MILITARY PHARMACO - MEDICINE N05 - 2021
Table 4: The Harris hip score in final follow-up (n = 57).
Final follow-up
Good
After 6 months
Total
Excellent
Fair
Poor
Excellent
Good
Fair
10
0
1
0
11
39
7
22
14
3
0
1
2
3
0
1
0
Poor
Total
p
0
0
33 (57.89%)
16 (28.07%)
7 (12.28%)
0.002
1 (1.75%)
57
The mean Harris hip score was 85.82 8.08, including 33 patients (57.89%) had
excellent results, 16 patients (28.07%) had good results, 7 patients (12.28%) had fair
results and 1 patient (1.75%) had poor result. The rate of good-excellent was 85.96%.
4. Complications
axial and angular stability of the screw
relative to the plate, avoid screws
loosening, screws back out, plate back-out.
- One case of proximal screw breakage.
- One case of cut out.
The current study showed that
proximal femoral locking plate provides
for optimal mechanical stability, it is also
ideal in osteoporotic bones due to the
varied angle of multiple screw insertions
within the complex trabecular zone of the
head-neck region of the proximal femur,
prevent cut out, varus collapse when
weight-bearing, especially on unstable
intertrochanteric fractures.
- Collapse varus: At the time of the last
examination, there are 3 patients had
femoral neck angle < 1200, 2 patients had
femoral neck angle < 1100.
DISCUSSION
1. Indication
We choose the PFLP (proximal femoral
locking plate) for the treatment of adult
intertrochanteric fractures, patients with
type A1, A2, A3 according to AO
classification, Singh type 2, 3, 4, 5, 6
among that type 2, 3: 48.85% patients
and in the most patients upon 60 years old.
In our study, 78.68% of patients, upon
60 years old, poor bone quality but the
need for mobility and return to activities of
daily living. So that, they have to surgery
to anatomy reconstruction and stable
fixation fracture. We choose the proximal
femoral locking plate because it is a
stable fixation implant, promoting an
early mobilization of the patient, avoid
complications screws loosening, screws
In Vietnam, the locking plate was used
about a decade ago as a new implant.
Difference conventional plating, the locking
head screws of those implants are designed
to lock tightly in the plate. This provides back out and plate back out.
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Journal OF MILITARY PHARMACO - MEDICINE N05 - 2021
Stabilization of intertrochanteric femur study, the outcome had 57.89% excellent,
fractures is one of the most key roles that 28.07% good, 12.28% fair, and 1,75%
is needed assessed preoperation. Etsuo, poor results. Our result similar studies
Wada [6, 7] showed that proximal femoral were done by Nguyen Nang Gioi [1] and
nail and DHS failure common reasons Dinh The Hai [4].
included assessed inadequate stabilization
Zha et al. [8] performed proximal
of interintertrochanteric fractures. The
femoral locking plate on 110 cases with
problems of instability of those fractures
intertrochanteric
and subtrochanteric
are related to discontinuity of the lateral
wall, the medial femoral component…
This may make it difficult to distinguish
this fracture pattern on conventional X-ray.
CT-3D may provide exact information
about the fracture pattern in the trochanteric
area, helping exact intertrochanteric fracture
classification.
fractures and reported union in 100% of
case. Zha showed that the varied angle of
three screw insertions within the complex
trabecular zone of the head-neck region
of the proximal femur, provides for a
mechanical stability neck shaft angle,
even in unstable intertrochanteric fractures
or osteoporosis.
2. Discussing the result
CONCLUSION
* Early result:
- Proximal femoral locking plate fixation
in intertrochanteric fractures was the best
treatment in intertrochanteric fracture,
provides good bone healing with a limited
number of complications and instrument
failure.
- Wound healing was the first period in
59/61 patients (96.72%).
- Postoperative reduction quality was
good in 59 patients, femur neck-shaft
angle > 1250, and was acceptable in
2 patients femur neck-shaft angle < 1250.
Most of the patients had union after
12 weeks, maintain fracture reduction.
Our results similar studies were done by
Nguyen Van Tien Luu [2] and Doan Manh
Linh [3].
- Bone union was seen in 100% of
patients in the follow-up period upon one
year.
- The assessment by Harris Hip Score,
the results were excellent in 33 patients
(57.89%), good in 16 patients (28.07%),
fair in seven patients (12.28%). There was
one poor result.
* Final result:
In our study of 57 patients, we were
able to achieve a union rate of 100%. We
had no cases of plate broken infections.
One patient had a screw has broken, four
patient screw backout, one patient had
cut out varus collapse.
- The complications in this study
included implant breakage in 1 patient
(1.75%), and loosening of a proximal
femoral screw in 4 patients (7.01%)
fractures, varus deformity in 5 patients
(8.77%) fractures.
- Harris hip scoring system was used
to evaluate the functional result in our
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Journal OF MILITARY PHARMACO - MEDICINE N05 - 2021
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