Comparative study of radiological outcomes of intertrochanteric fractures managed with intra medullary nailing with or without intraoperative temporary K-wire’s stabilization

INTRODUCTION

Every year, approximately 250,000 hip fractures occur in the United States, with half of these being intertrochanteric. Because of the large number of these fractures, successful treatment is obviously important both for the individual patient's benefit and for economic reasons. The surgeon's job is to choose the right fixation device and apply it correctly after the fracture has been properly reduced.¹

Because of changes in population demographics, the incidence of proximal femoral fractures is on the rise. Regaining pre-fracture ambulatory function and autonomy is critical, especially for elderly patients. For intra- and extracapsular fractures, intramedullary and extramedullary fixations are the most common options. The unique anatomy of the trochanteric region of the femur, as well as the occurrence of high varying forces, make it difficult and necessitate sophisticated surgical treatment.²

Because the majority of patients with intertrochanteric fractures are elderly, surgical treatment must be quick and allow for immediate weight bearing.³ The goal of treatment in this already vulnerable population is to achieve a rapid return to previous functional levels with a low rate of complications and mortality. As a result, for the vast majority of intertrochanteric femur fractures (IFF), surgical management is the mainstay of treatment. Internal fixation (IF) is often the preferred treatment option intramedullary nails for fixation is the most favoured modality of fixation now compared to other modalities. A wide range of extramedullary and intramedullary devices are available for this purpose.^4,5

The Boyd and Griffin classification is used to classify intertrochanteric fractures: type I- linear Intertrochanteric; type II- with comminution of trochanteric region; type III- with comminution associated with the reverse obliquity; type IV- intertrochanteric fracture with extension into the subtrochanteric region.^6,7 When treating trochanteric fractures, it is critical to distinguish between unstable and stable variants. A stable Intertrochanteric fracture has cortical contact without gaps posteriorly or medially when reduced.⁸

The primary concern with intertrochanteric fractures is a 20% to 30% mortality risk in the first year following the fracture. The majority of these fractures are treated surgically with a sliding hip screw or an intramedullary nail.¹²

Stable fracture patterns with an intact lateral wall are indications for the sliding hip screw. Intertrochanteric fractures can be treated with intramedullary nailing in a variety of ways, including the more unstable patterns like reverse obliquity.

Although the intramedullary fixation been one of the mainstay of treatment among other methods, maintenance of fracture reduction through surgery while reaming and passing nail posses an serious problem, causing loss of reduction. Use of temporary fracture stabilisation intraoperative with K-wires has been advocated to prevent loss of reduction in intraoperative/postoperative period. Compared to traditional open surgery, disadvantages for fracture fixation could be effectively addressed; operation and recovery times are significantly reduced. This technique is inexpensive, simple to use, quick to execute, safe, and repeatable with good results.¹³

In view of this, the present study aimed to compare the stability of reduction in patients with intertrochanteric fractures managed using intramedullary nailing with or without intraoperative temporary K-wire stabilization.

METHODS

The present study was prospective non-randomised control trail done in the Department of Orthopedics, Bharati Vidyapeeth (DTU) Medical College and Hospital, Pune. The research was carried out over the course of 18 months, from October 1, 2020 to March 31, 2022. A total of 80 patients with an intertrochanteric femur fracture attending IPD/OPD of the orthopaedics department, of either gender, and above the age of 18 years, treated with closed reduction using intramedullary nailing, were included in the present study. Total 45 patients were managed with intramedullary nailing and intraoperative temporary K-wire stabilisation as a study group, and 35 patients were managed without intraoperative temporary K-wire stabilisation as controls. The convenient sampling was used. Patients with pathological fractures were excluded from the study.

All the necessary preoperative work-up for the patients was done in the form of hematological and radiological examinations. After explaining the study, informed consent was obtained from each participant, and the study was approved by the institutional ethics committee.

Surgical technique used

After anaesthesia induction manual fracture reduction was performed on fracture table or in lateral position before painting and draping. Once an acceptable reduction was achieved, scrubbing painting and draping done. Using percutaneous reduction technique two 3 mm K wire inserted starting from the lateral femoral wall around 1 centimetre below the trochanteric ridge just beneath the anterior cortex and was advanced superiomedialy into the neck and head to avoid the path of the intramedullary nail posteriorly. Patient assessment was done intraoperatively.

The collected data was entered into a Microsoft Excel sheet. The data was analysed using SPSS (Statistical Package for Social Sciences) version 26.0 software. The quantitative parameters were presented as mean ± SD (standard deviation). The qualitative data was presented as frequencies and percentages and compared between groups using the Chi-square test. The p value of <0.05 was considered significant.

RESULTS

A total of 80 patients who had intertrochanteric fractures were included in the present study, of whom 45 were managed with intramedullary nailing with intraoperative temporary K-wire stabilisation and 35 without intraoperative temporary K-wire’s stabilization. The average age of the patients was 69.65±14.73 years. In the study population, the average neck shaft angle was 130.61±4.31 degrees. There were 42 (52.5%) males and 38 (47.5%) females, with a male-to-female ratio of 1.11:1. The mean age of the patients in whom K wire was used was 71.71±14.26 years, and that of the patients without K wire was 68.04±15.20 years, the difference in the means was non-significant (p=0.2706).

In 45 (56.3%) of all patients, the right side had a fracture, while the left side in 35 (43.8%).The patients were distributed according to Boyd and Griffin's classification, with more than half (53/80, (66.3%)) of patients having type 2 fractures, followed by type 1 (16 (20%)) and type 4 (11 (13.8%)). Among 80 patients, in the majority, 72 (90%) patients’ reduction was maintained, and it was not maintained among 8 (10%) patients. The results are indicated in Table 1.

Among 80 patients in study, 45 patients operated with temporary K-wire, 43 patients reduction was maintained and loss of reduction was noted in 2 patients (4.4 %) and 35 patients operated without K-wire, 29 patients reduction maintained and lost in 6 patients (17.1%).

DISCUSSION

With a variety of fracture geometries and a large selection of implants and techniques, unstable intertrochanteric fractures pose a challenge to Orthopaedic surgeons. Patients tend to be osteoporotic, have numerous co-morbidities, and have a low threshold for complications and repeat operations. For these challenging injuries, lateral wall reconstruction and the stability of the trochanteric fragments are thought to be crucial for a better outcome.¹⁴ Intertrochanteric fractures after reduction may often results in a limb length discrepancy causing maladaptation of the abductor lever arm. Functional limitations can also result from altered hip biomechanics.¹⁵

Elderly people frequently suffer from these fractures, which are typically brought on by falling from a standing position.^16,17 In contrast, these fractures are uncommon in young adults and are typically brought on by high-energy injuries. Young intertrochanteric femoral fractures are thus severely comminuted and displaced. Anatomical reduction through closed maneuver is very challenging because the muscular forces of the hip could worsen fragment deformation.^17,18

The present study compared the outcomes of intertrochanteric fractures managed with intramedullary nailing with or without intraoperative temporary K-wire stabilization. A total of 80 patients with intertrochanteric fractures were included, of whom 45 were managed with intramedullary nailing with intraoperative temporary K-wire stabilization and 35 without intraoperative temporary K-wire stabilization.

In our study, the distribution of patients according to laterality was almost equal, with a slightly higher number having a right-side fracture. According to Boyd and Griffin's classification; more than half of the patients had type 2 fractures, followed by type 1 and type 4. The majority of patients (90%) maintained the reduction, but the remaining 10% did not.

Among 80 patients in study, 45 patients operated with temporary K-wire, 43 patients reduction was maintained and loss of reduction was noted in 2 patients (4.4 %) and 35 patients operated without K-wire, 29 patients reduction maintained and lost in 6 patients (17.1%). In a related study, Gu-Hee J, demonstrated that provisional K-wire fixation in trochanteric fracture treated with PFN had an advantage in preventing loss of reduction as it facilitates a nail insertion in ideal position.²⁰

The effectiveness of K-wire stabilization with intramedullary nailing for intertrochanteric fractures has only been briefly studied. In a study by Wang ZH et al, have reported use of additional support techniques for intramedullary nailing like lateral locking plate and cerclage steel wire, the rate of fracture reduction quality was good in the plate group than in the encircalage wire group, with significantly lower fracture healing time.²²

With the use of same technique, Dr. Digambar S Maraskolhe et al, among the sample size of 30, intraoperative maintenance of reduction with temporary K-wire fixation was a good alternative for maintenance of reduction intraoperatively for AO-OTA31 A1 and A2 intertrochanteric fractures while passing intramedullary nail.²³ In our study also we found the technique to be good in maintaining intraoperative reduction with K-wire. However, in the above mentioned study there was no control group.

This study has some limitations. The current study provides valuable insights into the use of K-wire’s for intertrochanteric femur fractures fixation. However, due to the limited sample size, there is a potential for bias and the generalizability of the results may be compromised. Moreover, a larger sample size will increase statistical power and precision, reducing the risk of type II errors and providing more accurate estimates of effect sizes. Doing so will enhance the validity, reliability, and generalizability of the findings, ultimately contributing to the advancement of medical knowledge and improving patient care.

CONCLUSION

The present study was carried out to compare outcomes of intertrochanteric fractures managed with Intra medullary nailing with or without intraoperative temporary K-wire’s stabilization. Although we started with an assumption that temporary stabilisation with K-wire’s may be a better way to maintain reduction. The study did not reveal any statistically significant difference in both the groups, with regards to maintenance of reduction intraoperatively.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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