Is helical blade nailing superior to locked minimally invasive plating in unstable pertrochanteric fractures?
BACKGROUND
Technical advancements have produced many challenges to intramedullary implants for unstable pertrochanteric fractures. Helical blade fixation of the femoral head has the theoretical advantages of higher rotational stability and cutout resistance and should have a lower rate of reoperation than a locked plating technique.


OBJECTIVE
We asked whether (1) helical blade nailing reduces the rate of reoperation within 24 months compared with locked plating and (2) any of various preoperative, intraoperative, or postoperative factors predicted failure in these two groups.


METHODS
We prospectively enrolled 108 patients with unstable pertrochanteric fractures in a surgeon-allocated study between November 2005 and November 2008: 54 with percutaneous compression plates (PCCP) and 54 with proximal femoral nail antirotation (PFNA). We evaluated patients regarding reoperation, mortality, and function. Seventy-four patients had a minimum followup of 24 months (mean, 26 months; range, 24-30 months).


RESULTS
We found no differences in the number of reoperations attributable to mechanical problems in the two groups: PCCP = six and PFNA = five. Despite a greater incidence of postoperative lateral wall fractures with helical blade nailing, only postoperative varisation of the neck-shaft angle and tip-apex distance (33 mm versus 28 mm) predicted reoperation. Mortality and function were similar in the two groups.


CONCLUSIONS
Our data suggest unstable pertrochanteric fractures may be fixed either with locked extramedullary small-diameter screw systems to avoid lateral wall fractures or with the new intramedullary systems to avoid potential mechanical complications of a broken lateral wall. Tip-apex distance and preservation of the preoperative femoral neck-shaft angle are the key technical factors for prevention of reoperation.


METHODS
Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
Department of Orthopedic and Trauma Surgery, Medical Faculty, RWTH Aachen University, Aachen, Germany. mknobe@ukaachen.de
Matthias
M
Knobe
Wolf
W
Drescher
Nicole
N
Heussen
Richard Martin
RM
Sellei
Hans-Christoph
HC
Pape
D000368:Aged; D000369:Aged, 80 and over; D001858:Bone Nails; D001860:Bone Plates; D005260:Female; D005594:Fracture Fixation, Intramedullary / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*; D006620:Hip Fractures / Q000601:surgery*; D006621:Hip Joint / Q000473:pathology / Q000503:physiopathology; D006622:Hip Prosthesis; D006801:Humans; D007593:Joint Instability / Q000473:pathology / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods*; D011183:Postoperative Complications; D011474:Prosthesis Design; D012086:Reoperation / Q000706:statistics & numerical data