To The Editor:
We welcomed Dr. Baumgaertner's analysis of our paper1 in his
commentary to "The Pertrochanteric External Fixator Reduced Pain,
Hospital Stay, and Mechanical Complications in Comparison with the Sliding Hip
Screw" (2002;84:1488) in the Evidence-Based Orthopaedics section of
The Journal. However, certain questions raised in that commentary
need to be answered.
Exclusion of reverse obliquity and intertrochanteric fractures with a
subtrochanteric extension should not be considered a limitation of our study.
Since the sliding hip screw is known to perform poorly with such fractures, we
tend not to use it for these injuries. Instead, we prefer the 90° sliding
screw, which provides increased stability for these fracture patterns. For
this reason, these fractures were excluded from our study.
In a previous study2, we also stressed the need for family
education and participation in pin care. In addition, home-visiting nursing
staff inspects and cleans the external fixator weekly. Outpatient visits at
monthly intervals are needed until the fixator is removed, but we have not
found such visits to greatly increase the outpatient workload.
We believe that external fixation is an effective treatment option for
pertrochanteric fractures, but we recommend that it be used only for the
indications that were stated in our paper.
It is known that when sliding hip screws are employed for certain
intertrochanteric femoral fractures, such as the ones excluded from the study
by Vossinakis and Badras, they are at high risk for cutout. My comments were
intended only to remind the reader that the 10% rate of cutout in a control
group from which these fracture types were excluded is somewhat higher than
typically reported.
In their paper, Vossinakis and Badras demonstrated that external fixation
was a safe and effective device when they used it to treat certain
intertrochanteric fractures. In their health-care setting, it was efficient as
well. It remains to be seen if the treatment would be as efficient in other
health-care environments, in which family support is limited and the cost of
medical goods, nursing care, and transportation is higher.
Vossinakis IC, Badras LS. The
external fixator compared with the sliding hip screw for pertrochanteric
fractures of the femur. J Bone Joint Surg Br.2002;84:
23-9.8423
2002
[PubMed][CrossRef]
Vossinakis IC, Badras LS.
Management of pertrochanteric fractures in high-risk patients with an external
fixation. Int Orthop.2001;25:
219-22.25219
2001
[PubMed][CrossRef]