Abstract
Purpose of the Work. To analyze duration of surgery in individual types of internal fixation of fractures of the trochanteric massif and identify factors which have an impact on it.
Material. Analysis covered a group of 137 patients treated with Ender nailing (EN), 314 patients by means of Dynamic Hip Screw (DHS), 74 patients by means of Gamma nail, 37 patients by means of Proximal Femoral Nail (PFN) and 13 patients by means of 130° angled blade plate.
The groups of patients included basicervical femoral neck fractures (29 cases), peritrochanteric and subtrochanteric fractures. Peritrochanteric fractures were evaluated according to Kyle classification, types I and II as stable (174 cases), type III unstable (159 cases) similarly as type IV (peri/subtrochanteric fractures or comminuted fractures of the whole trochanteric massif - 35 cases).
High subtrochanteric fractures (55 cases) were evaluated after Seinsheimer. From the viewpoint of AO/ASIF classification they were 31A1, 31A2, 31A3 fractures.
EN was indicated mainly in Kyle I through IV fractures, DHS for basicervical fractures and Kyle I through III fractures, Gamma nail for Kyle I through IV fractures and high subtrochanteric fractures, PFN mainly for high subtrochanteric fractures and Kyle III fractures, 130° angled blade plate was indicated only for stable peritrochanteric Kyle I fractures. Results.
The average duration of surgery, i.e. starting from the skin incision until the suture of the wound, was in DHS 47 min., in EN 52 min., in 130°angled blade plate 54 min., in PFN 58 min. and in Gamma nail 70 min. The shortest time intervals were achieved in stable peritrochanteric fractures of Kyle I and II (EN, DHS, Gamma), the longest ones in high subtrochanteric fractures (Gamma, PFN).
The impact of the learning curve was analyzed in DHS. In 1995 the average duration was 70 min. (35 patients/year), in 2000 already only 39 min. (123 patients/year).
Discussion. If we wish to make a serious evaluation of the duration of surgery of any method we must not forget that apart from it there is a whole number of other factors by which it is influenced.
In case of proximal femur it is the type of fracture, the number and experience of surgeons, mastering the learning curve, annual frequency of surgeries at the respective Department as well as variation within the surgical technique (e. g. in DHS the number of distal locking and the number of locking screws, etc.) A significant role in this study was also played by the development of internal fixation at the Department of the authors. For instance, considerably shorter duration of surgery as well as minimum of complications in PFN were achieved thanks to mastering of the learning curve on the Gamma nail which we had started to use 3 years before.
An objective evaluation requires also a sufficient number of cases in order to eliminate errors caused by low numbers and other variable factors. Conclusion.
Surgery duration data which we present are comparable with the values included in the world literature. It applies not only to the duration of surgery in individual implants but also in individual types of proximal femur fractures.
At present at our Department the average duration of surgery ranges in dependence on the applied implant, type of fracture and skills of the surgeon between 30 and 60 minutes. Relatively shortest duration can be achieved in DHS, in Gamma nail and PFN the duration is slightly longer.
However, the duration of surgery is only a supporting factor. Of much greater importance for the patient is the quality of the surgery.
Thus favouring any method only on the basis of the duration of surgery is absolutely irrelevant.