FAILED FIXATION OF EXTRA-CAPSULAR PROXIMAL FEMORAL FRACTURES: AN ANALYSIS ON 252 CASES

Abstract

Fixation of extracapsular proximal femoral fractures with intra/extramedullary device is common operation in any trauma theatre. We audited our results of fixation of 307 similar fractures over the period of Feb’03 to Jan’06. Final analysis was on 252 cases (191 female and 61 male) with mean age of 86.7 years. The fractures were classified by AO classification (A1=116, A2=84, A3=52) and the implants used were DHS (204 cases) and Gamma nail (52 cases). Fixation failure was noted in 38 cases (15.07% failure rate). Failure incidence was higher in female patients and unstable fractures (A3). There was no difference in failure rate of DHS or Gamma nail fixation. The reasons identified for failures were inappropriate implant selection, inadequate reduction (p< 0.007), poor implant placement (screw head in anterior/superior quadrant p< 0.0029, TAD> 25mm p< 0.0037, oblique placement in relation to neck axis in lateral view). Multivariate logistic regression was used to identify the effect of each individual contributing factor. More than one factor was identified in all cases of failure. Out of 38 failures 3 patients died within 6 weeks after primary surgery, conservative treatment was done in 7 cases due to co-morbid conditions, 13 cases were treated by revised fixation, and 15 cases arthroplasty was carried out. The outcome after the second surgery was no different in revision fixation or arthroplasty. We conclude that failure of fixation of these fractures are serious event with disastrous consequences, so every effort should be made to produce a stable construct with any device during primary fixation.