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Gotfried Percutaneous Compression Plating Compared with Sliding Hip Screw Fixation of Intertrochanteric Hip FracturesA Prospective Randomized Study
Edward Yang, MD1; Sheeraz Qureshi, MD, MBA2; Shawn Trokhan, MD2; David Joseph, MD1
1 Department of Orthopaedics, Elmhurst Hospital Center, 7901 Broadway, Elmhurst, NY 11373. E-mail address for E. Yang: yange@nychhc.org
2 Leni and Peter May Department of Orthopaedic Surgery, Mount Sinai School of Medicine, 5 East 98th Street, Box 1188, New York, NY 10029
View Disclosures and Other Information

Investigation performed at the Elmhurst Hospital Center, Elmhurst, New York



Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. One or more of the authors, or a member of his or her immediate family, received, in any one year, payments or other benefits of less than $10,000 or a commitment or agreement to provide such benefits from commercial entities (Synthes, Orthofix, Smith & Nephew, and Stryker). The Department of Orthopaedic Surgery received educational funding for one year in excess of $10,000.

Copyright © 2011 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2011 May 18;93(10):942-947. doi: 10.2106/JBJS.I.00849
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Abstract

Background: 

The use of a Gotfried percutaneous compression plate provides a minimally invasive technique for the fixation of intertrochanteric proximal femoral fractures. The purpose of this study was to determine if the percutaneous compression plate provided advantages compared with the sliding hip screw for treatment of A1 and A2 AO/OTA intertrochanteric proximal femoral fractures.

Methods: 

An institutional review board-approved, prospective, randomized, single-blinded study was conducted at a level-I trauma center between July 2004 and September 2007. All patients who met the study criteria and provided informed consent were randomized to treatment with a sliding hip screw or percutaneous compression plate. Of the sixty-six patients who consented to participate, thirty-three were randomized to be treated with a sliding hip screw and thirty-three, with a percutaneous compression plate. Data evaluated included surgical time, incision length, blood loss, need for blood transfusion, and postoperative functional status. Follow-up included clinical findings, radiographs until healing was confirmed, functional and pain assessment scores, and the Short Form-36. The median follow-up period for surviving patients was thirty-six months.

Results: 

Sixty-six patients, forty-seven women and nineteen men, with a mean age of seventy-seven years were entered into the study. The treatment groups were similar with respect to study variables (p > 0.05). Operative times (forty-eight vs. seventy-eight minutes), incision length (56 vs. 82 mm), and blood loss (41 vs. 101 mL) significantly favored the percutaneous compression plate group (p < 0.001). The groups were similar immediately postoperatively; however, by discharge, fewer patients with a percutaneous compression plate required walking aids (40% vs. 59%). This trend continued throughout the study but was not significant. Pain with activity was lower throughout the study for the percutaneous compression plate group, but the difference was significant only at the three-month interval.

Conclusions: 

Previously published reports showing shorter operative times and less blood loss with the percutaneous compression plate were reaffirmed. Compared with the sliding hip screw, the percutaneous compression plate resulted in a larger percentage of patients who were able to walk independently, consistently lower levels of pain with activity, and improved quality of life according to multiple scales of the Short Form-36, but the differences were not significant. Significant differences favoring the percutaneous compression plate were found with regard to operating times, incision length, and blood loss.

Level of Evidence: 

Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Nicola Maffulli1, Angelo Del Buono2, Vincenzo Denaro2
    Posted on July 13, 2011
    Minimally invasive sliding hip screw may well be all that is needed!
    (1) Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospital, 275 Bancroft Road, London E1 4DG, England.

    Dear Sir:Yang et al reported some advantages with the minimally invasive Gotfried percutaneous compression plate (PCCP) compared with conventional sliding hip screw (SHS) in patients with intertrochanteric proximal femoral fractures 1. Minimally invasive procedures are increasingly emerging in modern orthopaedic trauma surgery, and are to be preferred to conventional open procedures for decreased bleeding and postoperative pain, quicker recovery of function, at times, allow faster operating time, minimal blood loss and less time- and resource-intensive post-operative care. The authors reported significantly lower mean values in surgical time, incision length and blood loss using the PCCP. Ho et al.2 also found that the minimally invasive SHS technique produces acceptable outcome measures in operating time, length of hospital stay, and blood loss compared to the conventional approach, while maintaining equal fixation stability. In the study by Yang et al1, the mean surgical time was 48 minutes for the PCCP group and 78 minutes for the SHS group. Ho et al reported a mean time of 39 minutes for the minimally invasive group and 53.5 minutes for the conventionally managed patients. Yang et al reported a mean blood loss of 41 mL for PCCP patients and 101 mL for SHS patients, with no significant difference in terms of transfusion requirements at 0.72 unit. In the study by Ho et al, only 5 of 88 patients, all of whom had received a conventional SHS, were transfused two units of blood each. Iatrogenic comminution of the lateral cortex after implantation of a SHS is the main factor predisposing to loss of reduction of the fracture and long term poor mobility scores, even after healing of the fracture3. The PCCP should protect the lateral femoral wall from iatrogenic damage and almost eliminates the lateral wall failure, but, in our experience, contrary to what reported 4, this is not a common occurrence. Yang et al did not perform imaging studies to assess healing of the fracture and the status of the implanted SHS, and did not assess the SHS patients for occurrence of lateral wall factures. In Ho et al’s study lateral wall failure did not occur after minimally invasive and conventional SHS surgery. The PCCP seems to be similar to the SHS in relation to bone and stability 5, and provides promising but similar results to a conventional or minimally invasive SHS. From an economic and logistical view point, using the PCCP would increase hospital inventory and involves a learning curve to familiarize with the new equipment, whereas the minimally invasive SHS technique uses the existing instruments with which the operating team is familiar and confident. The operative technique for minimally invasive SHS is simple to learn and teach2 6, and results in significant time and resources savings without the need to learn a new technique and increase surgical inventory6.1Yang E, Qureshi S, Trokhan S, Joseph D. Gotfried percutaneous compression plating compared with sliding hip screw fixation of intertrochanteric hip fractures: a prospective randomized study. J Bone Joint Surg Am; 93: 942-7.2Ho M, Garau G, Walley G, Oliva F, Panni AS, Longo UG, Maffulli N. Minimally invasive dynamic hip screw for fixation of hip fractures. Int Orthop 2009; 33: 555-60.3Im GI, Shin YW, Song YJ. Potentially unstable intertrochanteric fractures. J Orthop Trauma 2005; 19: 5-9 4Gotfried Y. The lateral trochanteric wall: a key element in the reconstruction of unstable pertrochanteric hip fractures. Clin Orthop Relat Res 2004; 425: 82-6.5Brandt SE, Lefever S, Janzing HM, Broos PL, Pilot P, Houben BJ. Percutaneous compression plating (PCCP) versus the dynamic hip screw for pertrochanteric hip fractures: preliminary results. Injury 2002; 33: 413-8.6Alobaid A, Harvey EJ, Elder GM, Lander P, Guy P, Reindl R. Minimally invasive dynamic hip screw: prospective randomized trial of two techniques of insertion of a standard dynamic fixation device. J Orthop Trauma 2004,18:207-12.

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