Introduction

The rapidly increasing number of hip fractures is posing one of the most severe Orthopaedic challenges in the new millennium. Intertrochanteric fractures of the femur once considered essentially a disorder of the elderly, are now equally common in young adults due to increased incidence of high energy trauma.

The overall increase in the incidence of intertrochanteric fracture can be attributed to two factors, one, increased life expectancy which increases the aged population, secondly high energy trauma which victimizes more number of young adults.Due to these reasons, both developing and developed countries are facing a sort of epidemic of intertrochanteric fractures.

Therefore, renewed attention should be paid to evaluate and improve the performance and longevity of Orthopaedic interventions aimed at treating intertrochanteric fractures.

The challenge the Orthopaedic surgeon faces lies in combining union in a good position with minimal morbidity, maximum comfort to the patient, early mobilization, decreased complication rate and the greatest economy of hospital beds,

Not much attention was paid to intertrochanteric fractures till 19^th century and the mortality rate of intertrochanteric fracture was about 80%, those who survived remained morbid due to bedsores, cystitis, joint stiffness deep vein thrombosis, hypostatic pneumonia, shortening and Coxa vara.

The treatment of intertrochanteric fractures has also passed through several stages, initially, theses fractures were treated conservatively by means of external splintage, skin traction, skeletal traction and balanced Russell traction.

In spite of improvement and modification in the conservative line of treatment, the ideal anatomical and functional result could not be achieved. Prolonged immobilization in bed was another important threat to the life of elderly patients. The problem is not of the union but of complications arising out of immobilization in bed till fractures heal.

Also in the young age group where high-energy trauma is often the culprit mode, the anatomy is distorted to the extent that, generally conservative treatment finds no scope.

Material and Methods

This prospective study was conducted in the Department of Orthopaedics, ARMCH and RC, Kumbhari from June 2016 to September 2018.

126 cases were registered in the study out of which 64 cases of Trochanteric fractures which were admitted in the Orthopaedic wards and treated by internal fixation using standard Dynamic Hip Screw (DHS) were included in the study.

These cases were selected on the basis ofthe following criterion.

1. Cases with trochanteric fractures who fit into any of the five grades of Evan’s classification of trochanteric fractures.
2. Closed trochanteric fractures in patients 50 years or above were included
3. Pathological trochanteric fractures were excluded as their functional results differ
4. Patient with associated lower limb injuries, vertebral column injuries and incompletely recovered surgical illness were excluded from the study group, as they act as confounding factors.

Selection of Cases for Post Op Follow Up

1. Those cases having a post-op neck-shaft angle between 130 to 140 degreeswere selected for follow up.
2. Those cases having TAD index less than 25 mm were selected for follow up
3. Those cases in which bone grafting was done were excluded from the study.
4. Those cases which were having the post-op complication of infection were excluded from the study.

Preoperative assessment of fracture geometry was done using Evan’s classification. Intraoperatively pattern of reduction achieved was seen on Anteroposterior and Lateral projections by the image intensifier.

Using a TAD index assessment of Screw placement was done in the postoperative period. Neck shaft angle measured on immediate post-op x-ray with the help of Goniometer.

During 1^st follow up (2 weeks post-op), 2^nd follow up (4 weeks post-op), 3^rd follow up (3 months post-op) and 4^th follow up plain radiographs (true AP and

fracture table in supine position under image intensifier control. Prophylactic antibiotics were used 30 minutes before surgery (third-generation IV cephalosporin).

Primary Bone grafting was done in cases where posteromedial cortical contact was not achieved after reduction and fixation. Interfragmentary screw fixation was done wherever needed.

The current study followed the standard technique for fixation of DHS as recommended by AO.

Dynamic hip screw fixation technique: Patient is positioned supine on the fracture table with a radiolucent, padded counter traction post placed between the patient’s legs at the perineal area. The uninjured leg is abducted and flexed at the hip joint and kept held in a well leg holder.

Alternatively, the uninjured leg can be held in wide abduction by a boot or footplate attached to one of the leg extensions of the fracture table. The injured leg is held by a footplate or boot attached to the other leg extension of the fracture table.

Both these positions allow the use of C-arm image intensifier positioned between patients leg to obtain AP and lateral images while keeping the C-arm on the non-sterile side.

The skin over the hip is prepared by a soap scrub and antiseptic solution. The lateral aspect of the hip joint is squared off from iliac crest to the distal thigh with towels and drapes, taking care not to place the towel clips so that they get superimposed over the fracture site on subsequent imaging.

Closed reduction of fracture is performed. Generally, trochanteric fractures can be reduced in neutral or slight internal rotation. Careful adjustment of traction is done to attain reduction avoiding too much traction, which can cause valgus over reduction.

The reduction is checked on both AP and Lateral images using image intensifier, paying special attention to cortical contact medially and posteriorly.

Exposure is done through a lateral approach from greater trochanter extending distally. The length of exposure depends upon the length of the implant used.

treated with primary bone grafting partial weight-bearing was delayed up to 6 weeks. Full weight-bearing was started after confirming sound healing of the fracture.

Fig-2: Assessment of screw position (implant placement).

In 1995 Baumgartner et al introduced the concept of the Tip-Apex Distance [5]. It describes the position of the screw within the head of the femur and was shown to be highly predictive of fixation failure by screw cut out regardless of other fracture variables. This measurement is the sum of the distance from the tip of the lag screw to the apex of the femoral head on an anteroposterior radiograph and this distance on a lateral radiograph, after controlling for magnification. If the x-rays were taken without magnification then the calculation of TAD index becomes simpler i.e. TAD = Xap + Xlat.

Measurement of lateral wall impaction/collapse: Lateral wall impaction measured after 6 months and correlated with functional outcome. Lateral wall impaction is directly proportional to sliding of the lag screw out of the barrel. Therefore if the screw has slide more out of barrel then it means there is more impaction. This can be measured by subtracting distance of screw thread from barrel tip in 6-month x-ray from a similar distance in immediate post-opx-ray.

If the distance of screw thread from barrel tip in 6 months post-op x-ray is B and distance between screw thread and barrel tip is A in immediate post-opx-ray then distance through which screw has a slide (C) is given by the formula:C=A – BThis C is directly proportional to lateral wall impaction(I). C= pI(p is coefficient of proportion and it varies with neck-shaft angle). The two groups were compared for their functional outcome at each follow up with Modified Harris Hip score [6]. Impaction /collapse was measured in both groups at each follow-up and correlated with the functional outcome, with the aim to found the relation between two if there is any.

was observed by grade III and V.

In the present study, it was observed that impaction achieved better in group A than group B

Table- 5:Type of plate used- long or short barrel.

Most of the plate used in the present study was a long barrel with lag screw length 85 mm and 90 mm.

Table:6:Functional Results in various fracture grades.

It was observed that the functional outcome was better seen in group A than group B.

Discussion

Management of Trochanteric fractures has always posed a challenge to the Orthopaedic surgeon because of the multitude of complications abound in the senile patients with the fracture. Therefore it involves a multidisciplinary approach. Hence there are multiple factors affecting functional outcome in these patients, and still, existing factors are not sufficient to predict the prognosis.

A total of 64 cases of trochanteric fractures treated by Dynamic hip screw fixation were followed in the study for 6 months. The age of patients varied from 22 yrs to 88 yrs. 70% of patients were younger than 60 yrs. The average age of the patient in this series was 55 yrs, which is significantly lower as compared to various studies published i.e. Parker – 71.5 yrs [7], Bhatti – 71 yrs [8].

The frequency of trochanteric fractures in relatively younger age group in this series may be related to the shorter life expectancy of the population and high-velocity trauma causing the fracture in several younger patients in the study.

index more than 25 mm were excluded to avoid postoperative failure to be included in the study and to avoid the effect of implant placement over the postoperative functional outcome. Rha JD et. al showed that complications were only found in unstable fractures. They occurred most frequently in elderly patients and when the distal fragment was displaced medially and anteriorly [15]. In the current study sliding of implant and impaction was found to be more in an unstable group which is according to this study by Rha JD et al. Parker showed the importance of angle of reduction in post-op results [7]. In the current study, only those cases with a neck-shaft angle 130 to 140 degree were included. This eliminated important confounding factor for comparison of functional outcome in both groups. Nakala K. et. alfound that there was a significant correlation between the extent of sliding at union and healing time. The average healing time in group B (The extent of sliding at the union of 8mm or greater) was 138 weeks postoperatively and that in group A (the extent of sliding at the union of less than 8mm) was 89 weeks. The phenomenon of sliding progressed mainly during the first 2 weeks postoperatively. There was a significant positive correlation between the extent of sliding at union and the extent of sliding at 2 weeks postoperatively. An assessment using the extent of sliding at 2 weeks postoperatively can accurately predict the extent of sliding at union and healing time. It is important to examine the phenomenon of sliding during the early postoperatively course, especially until 2 weeks postoperatively in order to predict fracture repair [16]. In the current study time at which union started is average 9.5 weeks in the stable group and average impaction in this group was 5.5 mm. In an unstable group average time at which union started was 12.5 weeks and average impaction was 14 mm. In 2005, Templeman, Baumgaertn, Leightonet al. in their landmark tutorial article stated that “the increasing number of hip fractures in the elderly constitutes a health care burden. The subset of unstable intertrochanteric hip fractures is important because the treatment of these fractures continues to be hampered by a moderate complication rate. Osteoporosis, fracture geometry, and the success of surgical treatment are strong predictors of outcome. The surgeon in control of fracture reduction, implant selection, and implant placement, all of which must be optimized to ensure the success of surgical intervention? [17]. Joseph, Thomas N, et al in their study evaluated the effects of posterior sag on the

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