Routine early post-operative X-ray following internal fixation of intertrochanteric femoral fractures is unjustified: a quality improvement study

David Segal, Ezequiel Palmanovich, Ali Faour, Elad Marom, Viktor Feldman, Eyal Yaacobi, Omer Slevin, Benjamin Kish, Yaron S Brin, David Segal, Ezequiel Palmanovich, Ali Faour, Elad Marom, Viktor Feldman, Eyal Yaacobi, Omer Slevin, Benjamin Kish, Yaron S Brin

Abstract

Background: There is no consensus regarding the proper radiographic protocol following closed or open reduction and internal fixation for intertrochanteric femoral fractures. The objective of this study was to assess the role of early postoperative imaging studies when deciding about weight bear limitations and reoperations.

Methods: A prospective cohort study of 100 patients (26 men and 74 women, at a mean age of 79.8 years) treated by closed or open reduction and internal fixation for AO31A fractures was conducted. According to the AO classification, there were 25 cases of 31A1, 54 cases of 31A2, and 21 cases of 31A3. For every patient, the intraoperative fluoroscopy studies were recorded and post-operative radiograms were taken during the first week. Excluded were patients for whom the early X-rays were clinically indicated. The intraoperative AP and axial fluoroscopy studies were compared with the radiograms taken during the first post-operative week. The investigators compared the decisions regarding weight-bearing limitations and the need for re-operation before and after conducting the radiograms.

Results: The early post-operative imaging studies did not change weight-bearing limitations nor did they lead to consecutive surgical treatments.

Conclusions: Unless indicated by physical examination, there is no value to routine post-operative radiograms within the first few days after closed reduction and internal fixation of intertrochanteric femoral fractures with regard to weight-bearing limitations and re-operation decisions.

Trial registration: Identifier: NCT02868125 .

Keywords: Check X-ray; Follow-up; Intertrochanteric; Post-operative radiography.

Conflict of interest statement

Ethics approval and consent to participate

The study described in the article was approved by the Meir Medical Center IRB committee.

Consent for publication

Not applicable

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Post-operative imaging protocol following CRIF/ORIF of IFF

References

    1. Gehlbach SH, Avrunin JS, Puleo E. Trends in hospital care for hip fractures. Osteoporos Int. 2007;18:585–591. doi: 10.1007/s00198-006-0281-0.
    1. Bhandari M, Devereaux PJ, Tornetta P, Swiontkowski MF, Berry DJ, Haidukewych G, et al. Operative management of displaced femoral neck fractures in elderly patients. An international survey. J Bone Joint Surg Am. 2005;87:2122–2130. doi: 10.2106/JBJS.E.00535.
    1. Tufescu T. Working toward reducing postoperative fracture radiographs: a survey of Canadian surgeons. Can J Surg. 2016;59:26–28. doi: 10.1503/cjs.005715.
    1. Hsueh K-K, Fang C-K, Chen C-M, Su Y-P, Wu H-F, Chiu F-Y. Risk factors in cutout of sliding hip screw in intertrochanteric fractures: an evaluation of 937 patients. Int Orthop. 2010;34:1273–1276. doi: 10.1007/s00264-009-0866-2.
    1. Cooney AD, Campbell AC. Do check X-rays influence the management of patients who have undergone hip fracture fixation using image intensifier guidance? Injury. 2006;37:763–767. doi: 10.1016/j.injury.2005.12.019.
    1. Mohanty K, Gupta SK, Evans RM. Check radiography after fixation of hip fractures: is it necessary? J R Coll Surg Edinb. 2000;45:398–399.
    1. Chakravarthy J, Mangat K, Qureshi A, Porter K. Postoperative radiographs following hip fracture surgery. Do they influence patient management? Int. J Clin Pract. 2007;61:421–424. doi: 10.1111/j.1742-1241.2006.01279.x.
    1. Haddad FS, Williams RL, Prendergast CM. The check X-ray: an unnecessary investigation after hip fracture fixation? Injury. 1996;27:351–352. doi: 10.1016/0020-1383(95)00225-1.
    1. Khurana A. Do check X-rays influence the management of patients who have undergone hip fracture fixation using image intensifier guidance? Injury. 2007.
    1. Marsh JL, Slongo TF, Agel J, Broderick JS, Creevey W, DeCoster TA, et al. Fracture and dislocation classification compendium - 2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma. 2007;21:S1–133. doi: 10.1097/00005131-200711101-00001.
    1. Cleveland M, Bosworth DM, Thompson FR, Wilson HJ, Ishizuka T. A ten-year analysis of intertrochanteric fractures of the femur. J. Bone Joint Surg. Am. 1959;41–A:1399–1408. doi: 10.2106/00004623-195941080-00003.
    1. Herman A, Landau Y, Gutman G, Ougortsin V, Chechick A, Shazar N. Radiological evaluation of intertrochanteric fracture fixation by the proximal femoral nail. Injury. 2012;43:856–863. doi: 10.1016/j.injury.2011.10.030.
    1. Güven M, Yavuz U, Kadıoğlu B, Akman B, Kılınçoğlu V, Ünay K, et al. Importance of screw position in intertrochanteric femoral fractures treated by dynamic hip screw. Rev Cir Ortop Traumatol. 2010;96:33–34.
    1. Lobo-Escolar A, Joven E, Iglesias D, Herrera A. Predictive factors for cutting-out in femoral intramedullary nailing. Injury. 2010;41:1312–1316. doi: 10.1016/j.injury.2010.08.009.
    1. Turgut A, Kalenderer Ö, Karapınar L, Kumbaracı M, Akkan HA, Ağuş H. Which factor is most important for occurrence of cutout complications in patients treated with proximal femoral nail antirotation? Retrospective analysis of 298 patients. Arch. Orthop. Trauma Surg. 2016;136:623–630. doi: 10.1007/s00402-016-2410-3.
    1. Flores SA, Woolridge A, Caroom C, Jenkins M. The utility of the tip–apex distance in predicting axial migration and cutout with the trochanteric fixation nail system helical blade. J Orthop Trauma. 2016;30:e207–e211. doi: 10.1097/00005131-201606000-00014.
    1. Liu W, Zhou D, Liu F, Weaver MJ, Vrahas MS. Mechanical complications of intertrochanteric hip fractures treated with trochanteric femoral nails. J Trauma Acute Care Surg. 2013;75:304–310. doi: 10.1097/TA.0b013e31829a2c43.
    1. Geller JA, Saifi C, Morrison TA, Macaulay W. Tip apex distance of intramedullary devices as a predictor of cut-out failure in the treatment of peritrochanteric elderly hip fractures. Int Orthop. 2010;34:719–722. doi: 10.1007/s00264-009-0837-7.
    1. Nikoloski AN, Osbrough AL, Yates PJ. Should the tip apex distance (TAD) rule be modified for the proximal femoral nail antirotation (PFNA)? A retrospective study. J Orthop Surg Res. 2013;8:35. doi: 10.1186/1749-799X-8-35.
    1. Mingo-Robinet J, Torres-Torres M, Martínez-Cervell C, Alonso Del Olmo JA, Rivas Laso JA, Aguado-Hernández H, et al. Comparative study of the second and third generation of gamma nail for trochanteric fractures: review of 218 cases. J Orthop Trauma. 2015;29:e85–e90. doi: 10.1097/BOT.0000000000000190.
    1. van Embden D, Stollenwerck GANL, Koster LA, Kaptein BL, Nelissen RGHH, Schipper IB. The stability of fixation of proximal femoral fractures: a radiostereometric analysis. Bone Joint J. 2015;97–B:391–397. doi: 10.1302/0301-620X.97B3.35077.
    1. Gardner MJ, Briggs SM, Kopjar B, Helfet DL, Lorich DG. Radiographic outcomes of intertrochanteric hip fractures treated with the trochanteric fixation nail. Injury. 2007;38:1189–1196. doi: 10.1016/j.injury.2007.03.014.
    1. Pajarinen J, Lindahl J, Savolainen V, Michelsson O, Hirvensalo E. Femoral shaft medialisation and neck-shaft angle in unstable pertrochanteric femoral fractures. Int Orthop. 2004;28:347–353.
    1. Pannell WC, Alluri RK, Sivasundaram L, Heckmann N, Ghiassi A. Utility of postoperative imaging in radial shaft fractures. HAND. SAGE Publications; 2016;11:10.1177/1558944715627629.
    1. Mettler FA, Huda W, Yoshizumi TT, Mahesh M. Effective doses in radiology and diagnostic nuclear medicine: a catalog. Radiology. 2008;248:254–263. doi: 10.1148/radiol.2481071451.
    1. Chehade MJ, Carbone T, Awward D, Taylor A, Wildenauer C, Ramasamy B, et al. Influence of fracture stability on early patient mortality and reoperation after pertrochanteric and intertrochanteric hip fractures. J Orthop Trauma. 2015;29:538–543. doi: 10.1097/BOT.0000000000000359.
    1. Aguado-Maestro I, Escudero-Marcos R, García-García JM, Alonso-García N, Pérez-Bermejo DD, Aguado-Hernández HJ, et al. Results and complications of pertrochanteric hip fractures using an intramedullary nail with a helical blade (proximal femoral nail antirotation) in 200 patients. Rev Esp Cir Ortop Traumatol. 2013;57(3):201–207.

Source: PubMed

Sponsorer og samarbejdspartnere

Medicinske tilstande

Narkotikainterventioner

3
Abonner