[Removal due to cut-out effect in pertrochanteric femoral fractures: what is the rescue treatment of choice?]

Abstract

Objective: The goal of the study was to compare functional results in different treament options in cutting-out, and analize factors associated to failure.

Material and methods: Retrospective cohort study in 56 patients diagnosed with cutting-out between 2000-2010. Groups were based on rescue treatment: arthroplasty versus alternative treatment. Demographics, fracture characteristics, osteosynthesis, tip to apex distance (TAD), follow-up, complications, and final functional capacity were analyzed.

Results: Rescue treatment: 36 (64.28%) hip replacement (arthroplasty group), and 20 (35.72%) alternative treatment preserving femoral head (alternative group). Groups comparable on demographic parameters, fracture pattern and osteosynthesis characteristics. Radiography analysis: low inter-observer variability (k=0.83, 95% CI 0.78-0.88), mean TAD 28.66mm (arthroplasty group 32.9mm, 21.5mm control group; p=0.01), insufficient fracture reduction 39.3% (p=0.001). Cutting-out diagnosis median 60 days (arthroplasty group 90 days, 18 days alternative group; p=0.001). Follow up at least 12 months from rescue treatment. Similar complications rate in both groups (p=0.16). Re-operation rate 3.57% (11.7% arthroplasty group, alternative group 0%; p=0.01). Better final functional capacity in arthroplasty group (p=0.004).

Discussion: Hip arthroplasty offers better results, being considered the gold standard in geriatric patients, although re-operation rate is higher. We recommend new nailing before arthroplasty in early failure (4 weeks) in patients with femoral head integrity. An insufficient fracture reduction is the main short term factor predicting failure; and TAD higher than 20mm is a middle-long term one.

Keywords: Cut-out; Enclavado trocantérico; Fractura pertrocantérea fémur; Intertrochanteric femur fracture; Trochanteric nailing.