000158 NV-OR1 13-18.

qxd 5/12/09 12:40 PM Page 13

Malaysian Orthopaedic Journal 2009 Vol 3 No 1 CK Yong, et al

Dynamic Hip Screw Compared to Condylar Blade Plate in

the Treatment of Unstable Fragility Intertrochanteric
Fractures

CK Yong, MS Ortho, CN Tan*, MS Ortho, R Penafort**, MS Ortho, DA Singh, MS Ortho,

MV Varaprasad***, FRCS (Edin)
Orthopaedic & Trauma Surgery, Prince Court Medical Centre, Kuala Lumpur, Malaysia
*Department of Orthopaedic Surgery, Putrajaya Hospital, Putrajaya, Malaysia
**Department of Orthopaedic and Trauma Surgery, KPJ Damansara Specialist Centre, Petaling Jaya, Malaysia
***Department of Orthopaedic Surgery, University Malaya Medical Centre, Kuala Lumpur, Malaysia

ABSTRACT injuries is going to increase dramatically 3,4. Hip fractures are

associated with high morbidity and mortality, a rate of up to
Dynamic hip screw (DHS) fixation is considered standard
20% can be expected in the year following the injury 5. The
treatment for most intertrochanteric fractures. However,
majority of those who survive are disabled with only 25%
excessive sliding at the fracture site and medialisation of
able to resume normal activities 6.
femoral shaft may lead in fixation failure. In contrast, fixed-
angled 95° condylar blade plate (CBP) has no effective
About half of the hip fragility fractures are intertrochanteric
dynamic capacity and causes little bone loss compared to
fractures. Dynamic hip screw (DHS) fixation has been
DHS. We compared the outcome of 57consecutive unstable
considered the gold standard for treatment of stable
intertrochanteric fragility fractures treated with these two
intertrochanteric fractures 7,8. DHS allows controlled
fixation methods. CBP instrumentation is more difficult
collapse of the fracture followed by progressive stabilization.
requiring longer incision, operating time and higher surgeon-
However, there are divergent opinions about the fixation of
reported operative difficulty. The six month post-operative
unstable intertrochanteric fractures in the elderly. Authors
mortality rate is 16%. Post-operative Harris hip scores were
reported high failure rates (range: 3% to 26%) for DHS
comparable between the two methods. Limb length
fixation in unstable intertrochanteric fractures. Failure
shortening more than 20 mm was 6-fold more common with
usually occurs due to loss of fixation of the lag screw with
DHS. In elderly patients with unstable intertrochanteric
resultant varus angulations and medial collapse at the
fragility fractures, fixed angled condylar blade plate appears
fracture site; plate pull-off from the shaft; implant
to be a better choice than dynamic hip screws for preventing
disassembly; or fatigue failure in cases of delayed union
fixation failures. 9,10,11,12
. Orthopaedists have questioned whether the fixation
should be dynamic by default allowing fracture compression
Key Words:
and union at the cost of reduced femoral neck length and
Unstable Intertrochanteric Fractures; Extramedullary
medialisation of the femur shaft. Or should rigid fixation
fixation; Low Fragility; Dynamic Hip Screw; 95º Condylar
applied to restore the pre-fracture anatomy to achieve
Blade Plate
immediate stability for early mobilization in a race towards
fracture union before implant fatigue?
INTRODUCTION
There are limitations as to how much of dynamic fracture
Fragility fractures can be caused by a fall from a standing compression is desirable. DHS fixation permits fracture
height or less. Osteoporosis which leads to bone fragility is compression along the femoral neck that leads to femoral
considered the major contributing factor to fragility fractures neck shortening; there is also an inherent tendency towards
and is directly linked to risk of hip fracture. Every year there medialisation of the femoral shaft 13. Jacobs et al found that
are 250,000 hip fractures in the United States, and it is the average length of lag screw sliding was 5.3 mm in stable
predicted that this number will double in the next 40 years 1. fractures, and 15.7 mm in unstable fractures. Excessive
A similar increase is expected in Asia 2. In general, as the sliding (more than 15 mm) correlates to higher prevalence of
population ages, the incidence and cost for treating these fixation failure 4, and is also associated with increased post-

Corresponding Author: Chee Khuen Yong, Orthopaedic & Trauma Surgery, Prince Court Medical Centre, 39, Jalan Kia Peng, 50450 Kuala
Lumpur Email : [email protected]

13
000158 NV-OR1 13-18.qxd 5/12/09 12:40 PM Page 14

Malaysian Orthopaedic Journal 2009 Vol 3 No 1 CK Yong, et al

operative pain and decreased post-operative mobility 14. standardized in both groups with emphasis on early gain of
Parker found that if medialisation of more than one-third of protected partial weight-bearing using a walking frame
the femoral shaft diameter occurs at the fracture site, there is before discharge.
a seven-fold increased risk of fixation failure 15.
Categorical variables were analyzed using chi-square tests of
A fixed-angled 95° condylar blade plate (CBP) can be used association (ambulatory status). Continuous variables were
in these difficult unstable fractures as well as in revision assessed by One-way ANOVA test or Student’s t-test (Harris
fixation for failed intertrochanteric fractures 16. This Hip Score, operating time, blood loss and Visual Analogue
technique results in improved resistance to rotation of the Score of operating difficulty). The level of significance was
proximal fragment, as it has no effective dynamic capacity. set at p < 0.05.
This is due to the fact that, on loading, the hip joint reaction
force is 159° towards the vertical plane. CBP does not allow
the proximal fragment to slide laterally thus avoiding the RESULTS
undesirable medialisation of the shaft.
The subjects in both groups were similar in terms of
demographic and premorbid functional status (Table I). With
We compared these two extramedullary fixation devices in
CBP the incision was typically longer and blood loss was
the treatment of unstable intertrochanteric fractures.
also more but these differences were not statistically
significant. Skin to skin operative time was significantly
longer using CBP, though the clinical relevance of a mean of
MATERIALS AND METHODS
extra 20 minutes is unclear. When coupled with a
Consecutive patients admitted in 2004 with unstable significantly higher surgeon-reported Visual Analogue Score
intertrochanteric fractures were prospectively randomized (VAS) in operating difficulty, a longer operative time rightly
(by drawing lots from sealed envelopes) into two study reflects the difficult CBP instrumentation (Table II).
groups. The study was approved by the hospital ethics
committee. Consent was also obtained from patients or, in Within 3 months following surgery, 10% of the patients
cases where they were confused, from their caretakers. passed away from medical complications unrelated to their
Inclusion criteria were: 55 years of age or older with low surgery, with another 5% in the following 3 months,
traumatic intertrochanteric fracture classified as AO/OTA contributing to a 16 % mortality 6 month after surgery (Table
Type 31 A2.2 and A2.3 and Kyle Type III and Type IV. They III). Harris Hip Scores 3 months and 6 months after surgery
were fractures with comminution, loss of postero-medial were comparable between the 2 groups. Twenty-one per cent
calcar, subtrochanteric extension, and reverse oblique of surviving patients at did not regain the ability to walk
fracture pattern 17. Two-part fractures were excluded since when assessed 6 months after surgery. There was no
they are considered stable fractures. Patients with fractures correlation between the ability to walk and limb length
associated with polytrauma, pathological fractures, and shortening or choice of implant. Despite early surgical
previous surgery on the ipsilateral hip or femur were intervention, the 16% 6 month mortality rate and the high
excluded. rate of failure to return to ambulatory status were attributed
to the systemic nature of osteoporosis in the elderly.
There were 61 patients with 63 hip fractures treated during
the study period. 57 hips are included in the resutls: 31 Complications
treated with DHS (Dynamic Hip Screw, Synthes-Stratec, There was no recognised deep vein thrombosis, pulmonary
Oberdorf, Switzerland) and 26 treated with CBP (95° embolism, or deep infection. There were 3 fixation failures
condylar blade plate; Synthes-Stratec, Oberdorf, in each group due to suboptimal surgical fixation (Table IV).
Switzerland). Six patients were excluded as five were unfit In the DHS group, poor reduction with medialisation of
for surgery and therefore treated conservatively, while one femoral shaft by 25%, a short lag screw and/or maximal
was transferred to other centre. Surgery was performed initial sliding leaving no room for further fracture impaction,
within four days in all patients. Best possible alignment is eventually led to superior cut out in 3 patients (Figure 1).
achieved either by closed manipulation under fluoroscopy This resulted in two patients remaining bedridden, and in the
control or open reduction. Standard method of third patient with no acetabulum involvement, revision
instrumentation and fixation were performed under fixation was performed 6 months later. Shortening (leg
fluoroscopy control. The modified Harris Hip Score without length difference of more than 20 mm, clinically reported
assessing the hip motion was used to determine pre-fracture and radiologically measured) was significantly more
status, and the Harris Hip Score (HSS) was used for post- common in the DHS group.
operative 3rd and 6th month functional assessment. Plain
radiographs were taken before and one day post-operatively, In the CBP group, the failure to primarily restore neck-shaft
followed by repeated radiographs at 1st, 3rd and 6th month angle, as evidenced by the post-operative pelvic antero-
postoperatively. Post-operative rehabilitation was posterior film, led to one case of excessive varus, nonunion

14
000158 NV-OR1 13-18.qxd 5/12/09 12:40 PM Page 15

Dynamic Hip Screw Compared to Condylar Blade Plate in the Treatment of Unstable Fragility Intertrochanteric Fractures

and subsequent implant fatigue at the 4th postoperative was lower in group CBP and approaching statistical
month. There was one nonunion leading to superior cut out significance with p value at 0.51. Medialisation of femoral
in the CBP group (Figure 2). The overall failure rate, when shaft was not compared, as it was not possible with the fixed-
limb length shortening and fixation failures were considered, angle CBP.

Table I: Demographic and premorbid functional evaluation and fracture pattern

Method of fixation
DHS (n=31) CBP (n=26)
Women: Men 28:3 17:9
Age (years) : mean (range) 78 (55-100) 78 (58-96)
QCT scan (mg/cm3) : mean BMD 74.72 77.66
Modified pre fracture Harris HIP score; mean (range) 80 (52-91) 77 (52-91)
Walking ability, prefracture
No aids 21 17
Aids 10 9
Non walker 0 0
Fracture Type (AO/OTA type 31)
A2.2 20 18
A2.3 11 8

Table II: Per operative parameters

Method of fixation P value
DHS (n=9) CBD (n=10)
Operating time (min) : mean (range) 74 (50-120) 94 (45-135) 0.001b
Operating blood loss (litre) : mean (range) 0.19 (0.05-0.80) 0.24 (0.05-0.80) 0.27b
Operating difficulty a mean (range) 3.4 (2-8) 4.3 (2-8) 0.018b
a
Visual Analogue Score: 1 (easy) – 10 (difficult)
b
One-way ANOVA test

Table III: Post-operative mortality rate

DHS (n=31) CBP (n=26) Percentage (%)
Deceased
< 3 months 1 5 10.5
3 – 6 months 1 2 5.3

Table IV: Complication and failures of the procedures

DHS (n=31) CBP(n=26) p value
Fixation complication
Greater trochanter fracture 2 3
Poor reduction 1 1
General complication
Superficial infection 1 1
Deep infection 0 0
Limb length shortening >20 mm 6 1 0.045a
Fixation failures
Superior cut out 3 1 0.391a
Breakage/loosening 0 1
Nonunion 0 1
Revision 1 0
Failure rate
Limb length shortening >20 mm & Fixation failures 9/31 (29%) 4/26 (15%) 0.051a
a
Pearson Chi-square test

Table V: Quantitative Computed Tomography (QCT) scan of selected patients

DHS (n=9) CBP (n=10)
QCT scan (mg/cm3) : mean (range) 74.72 77.66

15
000158 NV-OR1 13-18.qxd 5/12/09 12:40 PM Page 16

Malaysian Orthopaedic Journal 2009 Vol 3 No 1 CK Yong, et al

Fig. 1: Superior cut out and shaft medialization following Fig. 2: Failure patterns following treatment with 95° fixed angle
fixation with dynamic hip screw fixation. condylar blade plate fixation in 2 patients.

Fig. 3: A 3-part intertrochanteric fracture with no postero-medial calcar support united following dynamic hip screw fixation.

Fig. 4: Florid callus formation following 95° fixed angle condylar blade plate fixation for a comminuted intertrochanteric fracture using
bridge plating technique.

16
000158 NV-OR1 13-18.qxd 5/12/09 12:40 PM Page 17

Dynamic Hip Screw Compared to Condylar Blade Plate in the Treatment of Unstable Fragility Intertrochanteric Fractures

DISCUSSION 50% 23. In such cases DHS may still yield good outcome
(Figure 3) but DHS should not be automatically the first
For the fixation of stable intertrochanteric fractures, there
choice for treatment. Our results indicate that unstable
exists a plethora of choices of implants, whereas the ideal
intertrochanteric fractures, treated with fixed-angled 95°
implant remains elusive for unstable intertrochanteric
CBP have similar outcomes and near statistically significant
fractures. Unstable intertrochanteric fractures especially
lower failure rate compared to DHS. This fixed-angle device
those with a posterior medial defect are more prone to
acts as a bridge plate across the fracture site, and therefore
complications. Loss of posterior medial support leads to
may be of value in severe osteoporotic bones as well as in
increase hip screw telescoping and limb shortening. Further,
comminution where dynamic fixation may lead to excessive
these defects also lead to increased load transfer to the tip of
interfragmentary compression. Conversely, the two failure
the dynamic hip screw, thereby increasing superior cut out.
patterns of CBP observed in present study, namely implant
Loss of fixation of the lag screw in an osteoporotic head,
breakage and nonunion, may be due to lack of
with resultant varus angulation and medial collapse at the
intefragmentary compression. For optimal application of the
fracture site can also occur 18. Independent of the type of
bridging plate principle across fracture comminution, the
implant used, patients with unstable trochanteric hip
authors recommend the use of a longer 7 or 9-hole side plate
fractures and osteoporotic bone are at the highest risk for
CBP with 4 distal screws and 1 proximal lag screw for the
implant failure 19.
femoral head. Subsequent cases conducted using this
technique consistently led to fracture union (Figure 4).
Kaufer determined that the strength of the implant-fracture
composite is based on 5 variables: bone quality, fracture
The present study has several limitations. Though both
geometry, fracture reduction, placement of implant, and
devices analyzed in this study are extramedullary using
implant used 20. A CT scan of an intertrochanteric fracture
similar surgical exposure, the more difficult CBP
may reveal poor density of trabeculation and even emptiness
instrumentation may be subject to performance bias; hence a
within the head. Maximum bone density is likely found at the
larger studied population is warranted. Secondly, only some
site where the compressive and tensile trabeculae coalesce,
of the patients underwent a Quantitative Computed
in the centre-centre region of the femoral head 21. An ideal
Tomography (QCT) scan. Among the patients who were
implant should engage this region while taking as little
scanned, there was no difference in bone mineral density
remaining strong bone as feasible. The CBP at 95° to the
detected between the two groups, but inclusion of all patients
femur shaft is wedged below the densest trabeculae in the
may have reveal subtle differences (Table V). Thirdly,
centre-centre region of the femoral head. There is little bone
although body mass index was not studied, it may be an
loss in preparing the sitting bed for CBP especially as
important factor in early stability of fracture-implant
compared to DHS that requires bone coring.
construct and subsequent union rate. Of course, follow-up
longer than 6 months would have been optimal. Lastly as the
Of concern is unstable fracture geometry that include
focus was on extramedullary fixation, the present study did
fractures with increased comminution, loss of postero-
not include any intramedullary device options for these
medial calcar, subtrochanteric extension, and reverse oblique
fractures.
fractures. Anatomic reduction of femoral neck length, axial
length, and neck-shaft angle must be achieved before
implantation. In addition to the degree of osteoporosis, the
CONCLUSION
rate of superior cut out is strongly correlated to surgical
technique. Baumgaertner et al demonstrated that enhanced In the treatment of fragility fractures, it is important to
surgeon awareness of short tip-apex distance (TAD) recognise unstable fracture geometry and customise the
decreases the risk of fixation failure 22. choice of implant according to the fracture characteristics. In
elderly patients with unstable fragility intertrochanteric
Choice of implant should not be routine but customised fractures, fixed angled condylar blade plate appears to be a
according to fracture characteristics. Unstable fractures with better choice than dynamic hip screws with a lower rate of
osteoporosis are reported to have failure rate of more than fixation failure.

17
000158 NV-OR1 13-18.qxd 5/12/09 12:40 PM Page 18

Malaysian Orthopaedic Journal 2009 Vol 3 No 1 CK Yong, et al

REFERENCES

1. Cummings SR, Rubin SM, Black D. The future of hip fractures in the United States: Numbers, costs, and potential effects of post
menopausal estrogen. Clin Orthop Relat Res 1990; 252: 163-6.
2. Lau EMC, Lee JK, Suriwongpaisal P. The Incidence of hip fracture in four Asian countries: The Asian Osteoporosis Study (AOS).
Osteoporos Int 2001; 12: 239-43.
3. Jacob RR, McClain O, Armstrong HJ. Internal fixation of intertrochanteric hip fractures: A clinical and biomechanical study. Clin
Orthop Relat Res 1980; 146: 62-70.
4. Steinberg GG, Desai SS, Kornwitz NA, Sullivan TJ. The intertrochanteric fracture: A retrospective analysis. Orthop 1988; 11:
265-73.
5. Clayer MT, Bauze RJ. Morbidity and mortality following fractures of the femoral neck and trochanteric region: Analysis of risk
factors. J Trauma. 1989; 29(12): 1673-8.
6. Jensen JS, Bagger J. Long term social prognosis after hip fractures. Acta Orthop Scand 1982; 53(1): 97-101.
7. Clawson DK. Trochanteric fractures treated by the sliding screw plate fixation method. J Trauma 1964; 4: 737-52.
8. Kyle RF, Gustilo RB, Premer RF. Analysis of six hundred and twenty-two intertrochanteric hip fractures. J Bone Joint Surg 1979;
61-A, 216-21.
9. Chang CW, Lai KA and Yang CY. Failure of compression hip screw: Analysis of the failure mechanism. J Musculoskeletal
Research 2002; 6; 2; 101-6.
10. Leung KS, So WS, Shen WY, Hui PW. Gamma nails and dynamic hip screws for peritrochanteric fractures. A randomised
prospective study in elderly patients. J Bone Joint Surg 1992; 74-B: 345-51.
11. Barrios C, Walheim G, Brostrom LA, Olsson E, Stark A. Walking ability after internal fixation of trochanteric hip fractures with
Ender Nails or Sliding Screw Plate: A comparative study of gait. Clin Orthop Relat Res 1993; 294: 187-92.
12. Simpson AHRW, Varty K, Dodd CAF. Sliding hip screws: modes of failure. Injury 1989; 20: 227-31.
13. Ceder L, Lunsjö K, Olsson O, Stigsson L, Hauggaard A, Kummer FJ. Can controlled biaxial dynamization lead to improved
treatment of complex hip fractures? Orthop Trans 1996; 20: 162-3.
14. Jacob RR, McClain O, Armstrong HJ. Internal fixation of intertrochanteric hip fractures: A clinical and biomechanical study. Clin
Ortho Relat Res 1980; 146: 62-70.
15. Parker MJ. Trochanteric hip fractures. Fixation failure commoner with femoral medialization, a comparison of 101 cases. Acta
Orthop Scand 1996; 67(4): 329-32.
16. Arthur L, Malkani, Ninad K. Revision surgery for failed intertrochanteric fractures. Techniques in Orthopaedics 2003, 17(4):
443-7.
17. Kyle RF. Current treatment of difficult intertrochanteric fractures. Program and abstracts of the 15th Annual Vail Orthopaedic
Symposium; January 18-21, 2001; Vail, Colorado.
18. Laros GS, Moore JF. Complications of fixation in intertrochanteric fractures. Clin Orthop Relat Res 1974; 101: 110-19.
19. Barrios C, Brostrom LA, Stark A, Walheim G. Healing complications after internal fixation of trochanteric hip fractures: The
prognostic value of osteoporosis. J Orthop Trauma 1993; 7(5): 438-42.
20. Kaufer H. Mechanics of the treatment of hip injuries. Clin Orthop Relat Res 1980; 146: 53-61.
21. Singh M, Nagrath AR, Maini PS. Changes in trabecular pattern of the upper end of the femur as an index of osteoporosis. J Bone
Joint Sur. 1970; 52-A: 457-67.
22. Baumgaertner MR, Solberg BD. Awareness of tip-apex distance reduces failure of fixation of trochanteric fractures of the hip. J
Bone Joint Surg 1997, 79-B: 969-71.
23. Kim WY, Han CH, Park JI, Kim JY. Failure of intertrochanteric fracture fixation with a dynamic hip screw in relation to pre-
operative fracture stability and osteoporosis. Int Ortho 2001; 25: 360-2.

18