SURGICAL TREATMENT OF REVERSED OBLIQUE SUBTROCHANTERIC FRACTURES OF THE HIP WITH PCCP DEVICE

Abstract

Introduction: Reversed oblique subtrochanteric fractures are unstable and pose a surgical challenge. Fixation with Dynamic Hip Screw is prone to collapse with medial displacement and high rate of non or mal union. The use of Proximal Femoral Nails may result in non anatomical reduction which delays union and impedes rehabilitation. PCCP is a percutaneous plate originally designed for fixation of intertrochanteric fractures. However, the plate supports the greater trochanter and can prevent collapse of subtrochanteric fractures and rigidly secure the femoral neck. This study summarized our experience in fixating reversed oblique subtrochanteric fracture with the PCCP technique.

Patients and Methods: Between January 2005 and March 2006 26 patients who sustained reversed oblique subtrochanteric fractures (AO-31A3) were consecutively treated with PCCP. Two patients died and were excluded from this study. Patients’ age ranged between 58 and 93 (average 86, median 80). Follow-up was between 6 to 20 months (average 12). All patients were operated on a standard fracture table with the use of posterior reduction device. An attempt to reduce the fracture was done in each case prior to the surgical incision. In the majority of cases the shaft was displaced medially to the greater trochanter. The PCCP plate was introduced percutaneously and the medially displaced shaft was pulled to the plate using the reduction clamp. The rest of the procedure was done according to the regular technique of the PCCP. All patients were instructed to refrain from weight bearing for six weeks after the surgery and then resume full weigh bearing. Follow-up was in the out patient clinic 6 weeks, 3 months and one year after the surgery.

Results: Time of surgery varied between 35 to 75 minutes. There were no patients who were planned to undergo this procedure and were diverted to a different modality of fixation. All the procedures were done percutaneously. Anatomic or near anatomic reduction was achieved in all cases. All patients resumed full weigh bearing six weeks after the surgery. All but one fracture united. The patient whose fracture did not unite was blind and fell a few times during rehabilitation and eventually suffered from pull-out of the plate from the femur with breakage of the shaft screws. She underwent revision surgery with bone graft and the fracture united. Follow-up radiograms showed that the reduction was maintained in all but three patients. Medial displacement of 8–15 mm occurred in 3 patients. There were no infections.

Conclusions: While there is an ongoing debate among “nailers” vs. “platers” for the fixation of femoral neck fractures, PCCP combines the theoretical advantages of both percutaneous technique and absolute stability. In this study this biological system was found to be a reliable solution for the challenging fixation of reversed oblique (AO-31A3) subtrochanteric fractures, with high union rate, fast recovery and low complication rate.