Injury (1991) 22, (3), 193-196
Printed in GreatBritain
193
Intertrochanteric fractures of the femur: a randomized prospective trial comparing the Pugh nail with the dynamic hip screw C. A. N. McLaren, J. R. Buckley and D. I. Rowley Department
of Orthopaedic
and Traumatic
Surgery, Dundee Royal Infirmary, Dundee, UK
Overa Id-month period, 700 consecutive uues of interfrochanfericfcture were randomly allocafed to be freafed by either pirgh nail-plafe or Dynamic Hip Screzu (DHS) ji.dion. Although there were 11 uzzs of mdreducfwn and/or suboptimal positioning of fhe jixation device in the femoral head, only fwo of these gave long-term problems. De#fe the differencein configurationof fhe devices and a considerable disparity in price, patient satisfaction and the incidence of unfoward radiologd features at an average of 6 months after surgery were sidar in the two groups. A tr$n-enaU devicp would thus appear to be a reliable alternative fo the more commonly used hip screw systems for interfrochanferic fvncfure.
Introduction Pugh first described his ‘self adjusting nail-plate for fractures about the hip joint’ in 1955. He primarily advocated its use in femoral neck fractures. Fielding et al. (1974) using the device, reported a 90 per cent union rate; Johnson and Crothers (1975) had a 71 per cent success rate. Pugh went on to state that because of its strength and adjustability, his nail could also be used successfully on intertrochanteric femoral fractures. Gibson and Espley (1987) reported an overall profile of the Pugh nail when used on various fractures of the proximal femur. They found a 4.6 per cent failure rate in their basicervical and intertrochanteric fracture fixations. There is no report to date which looks specifically at the use of the Pugh nail-plate in this group of fractures, nor one which looks at its reliability when compared with other available fixation devices. In recent years, however, there have been many review articles describing the results of intertrochanteric fracture fixation with the sliding hip screw (Schumpelick and Jantzen, 1955; Clawson, 1964; Mulholland and Gunn, 1972; Sahlstrand, 1974; Ecker et al., 1975). There seems little dispute that this device has certain advantages over the fixed length, one-piece nail-plates such as the Jewett (Kyle et al., 1979; Bannister and Gibson, 1983; Esser et al., 1986). Its advantages over the Pugh nail-plate are less clear. Certainly, because of its helical configuration, the head of the dynamic hip screw achieves a strong grip on the femoral head, 0 1991 Butterworth-Heinema Ltd 0020-1383/91/030193-04
permitting compression to be applied between it and the plate during the operative procedure. Frandsen et al. (1984), however, have shown that this compression does not influence fracture healing. The thread also prevents advancement of the screw once it is inserted in the femoral head, thus lessening the risk of penetration through the head during loading. Because of its circular cross-section, no rotational stability is conferred to the femoral head either during insertion of the device - a problem outlined by Rau et al. (1982) - or during fracture healing. The Pugh nail head, on the other hand, has a t&n shape in cross-section. This shape should confer greater rotational control over the proximal fracture fragment. It also requires that the nail be inserted by a punching mechanism, theoretically allowing little risk of rotationally induced loss of reduction during insertion. The Pugh nail has potential relative disadvantages in that it has a slightly smaller cross-sectional area than the DHS, and no thread to resist forward translocation; therefore there is a higher theoretical risk of penetration through the femoral head during loading. It should be noted that the Pugh nail-plate is one-third of the price of the DHS and its associated plate. Because of the potential savings which could be made by our unit, it seemed important to investigate whether the above theoretical advantages and disadvantages of the Pugh nail-plate when compared with the DHS were significant in practice.
Methods Between September 1986 and December 1987, 100 consecutive patients with intertrochanteric fractures of the femur were entered into the trial. According to whether their unit numbers were odd or even, they were allocated to either the first treatment group where a Pugh nail fixation was carried out, or to the second group where the DHS was used. Each patient was documented for age, sex, mobility before fracture, and type of fracture. Two-part fractures were defined as stable, and displaced three- or four-part fractures as unstable. Unless there were serious anaesthetic contraindications, patients were operated on within 24 h of admission. A
Injury: the British Journal of Accident Surgery (1991) Vol. 22/No.
194
3
Table I. Patient characteristics OHS (N = 50)
Pugh (N=50) Age range (average) No. males females No. stable unstable fractures Early deaths ( i 6 months) Operation time (mins) range (average) Grade of operator Consultant Sentor registrar Junior registrar Recorded techmcal problems/ open reduction Early postoperatlve complications No unsatisfactory ftxatlons
66-95 (81 1 10 40 28.22 10
68-97(802) 9 41 23 27 6
35-95
35-l 05 (57)
(53)
3 9 38
4 14 32
3 DVT’l
8 Deep Infection 1 DVT’l 4
7
‘Requmng active treatment with antlcoagulatlon
record was kept of the grade and experience of the operator. operative time, and whether the reduction and fixation were technically satisfactory. A satisfactory reduction was defined as one where the medial buttress of the proximal femur was in continuity, or where a loss of continuity had been compensated for by medial displacement of the shaft or valgus displacement of the femoral neck. There had to be adequate apposition of the major fracture fragments. A satisfactory fixation implied that the nail/screw passed through the central six-eighths of the femoral neck, came to lie in the central four-sixths of the femoral head, passed well beyond the fracture line, and did not penetrate the line of the subchondral bone in the femoral head. Any technical problems encountered af operation were noted. A postoperative record was kept of early complications, time to discharge from the ward, and mobility at that time Patients were seen at 6 weeks and again at 3 and 6 months postoperatively. Their degree of pain and mobiiity was reviewed and radiographs taken. Pain was classified as’ (n) severe, where it caused walking to be very laboured, gave rise to discomfort at rest in a chair or in bed, and led to the taking of regular analgesics; (b) moderate, where it occurred on walking only and limited walking distance; and (c) mild, where it was intermittent and interfered only minimally with walking. The position of the fracture, stage of healing and the position of the fixation devices on radiographs were noted. If all parameters were satisfactory and there had been no other complications at the 6 month visit, the patient was not seen again. If there were persistent problems, longer term records were kept of the patients concerned.
Results Patient characteristics are summarized in Table I. The two groups of patients were matched for age and sex. There was no statistical difference between the number of early deaths (P= 0.41 using Fisher’s exact test), operation time (t= 5.119 using single-tailed f testing) and the number of unsatisfactory fixations (P= 0.52 in each group). There was a slightly increased number of recorded technical difficulties with the DHS, although this did not appear to increase average operating time. The most common problem was rotation of the proximal fracture fragment while the screw was being inserted. This fre-
Figure I. Penetration of the femoral articular surface by a Pugh nail seen at 3 months after Insertion. The nail had orlginally been placed high in the femoral head and a gap left in the calcar.
quently necessitated the insertion of extra K-wires and often resulted in a change of position of the fracture during the operation. Eleven fixations were Judged initially unsatisfactory, seven in the Pugh group and four in the DHS group. Of these, only one in each group went on to give problems with healing in the long term. There were SIX patients with radiographs showing delayed healing, loss of position and/or protrusion of the pin/screw at 6 months. Two of these were following Pugh nail-plate fixation and four following DHS fixation. Two had had unsatisfactory initial reduction/fixation (one in each group).
Length of stay in the ward was similar in each group with an average of 23.3 days in the Pugh group and 25.1 days in the DHS group. Walking ability at 6 months was almost identical between the two groups. Only one patient in the Pugh group was in severe pain at 6 months - fhis was associated with late protrusion of the nail (F~gtcre I). Two patients in the DHS group had severe pain - one due to persisting infection and the other due to delayed union after an unsatisfactory initial reduction. Two patients in each group had moderate pain,
McLaren et al.: Pugh nail versus dynamic hip screw
195
Figure 2. Varus malunion of fracture after fixation with DHS. The original position at the time of operation had been satisfactory.
Table IL Findings at 6 months postoperatively
Walkmg ability
Pain Severe Moderate Mild Radiographic findings. Varus malunlon, nail wlthin head Varus malunion. nail protrudmg Infection (loosenrng)
Pugh (N=40)
DHS (N =44)
Frame 23 (57%) 2 Sticks 6 (15%) 1 Stick 11 (28%) 1 2 3
Frame 24 (65%) 2 Sticks 8(18%) 1 Stick 12 (27%) 2 2 4
1
3
1
0 1
0
while four in the DHS group and three in the Pugh group had mild pain. None of these nine patients had had an initially unacceptable reduction/fixation. Four patients (one Pugh and three DHS), although showing varus malunion of the fracture (F@re 2) did not complain of pain. Overall, 13/84 (16 per cent) of the patients complained of pain. If those with an unsatisfactory initial fixation/reduction, or where infection had been a complication, were excluded, there was no difference in terms of pain between patients treated by the Pugh device compared with those treated by the DHS. Although 50 patients in each group may be a relatively small cohort, any obvious differences between the two groups would readily be uncovered by this number; the fact that there was such a marked similarity between them remains significant.
Discussion In the paper by Esser et al. (1986), comparing the Jewett nail-plate with the DHS, it was admitted that the degree of accuracy of reduction and the position of the fixation device in intertrochanteric fractures had never been fully evaluated with relation to the outcome. It was noted, however, that certain fixation devices such as the DHS could, by their ability to slide within their barrels, compensate for loss of fracture position during impaction. The fixed length nail-
Figure 3. u, A comminuted intertrochanteric fracture which has been fixed by a Pugh nail leaving a wide gap in the medial buttress of the femoral neck. b, Seen at 3 months later, the gap has closed, the nail has slid successfully in its barrel and the fracture has united.
plates such as the Jewett’s could not do this. This article demonstrates that with both the Pugh and the DHS devices, there is a low incidence of long-term problems even if the fracture has been quite grossly malreduced (F&re 3u,b), or the fixation inserted in an extreme position. In the only case of late protrusion of one of the devices (Figure I), the problem was high placement of the nail in the femoral head associated with a gap in the medial buttress. Even if a gap is left in the medial buttress but the nail or screw is placed low or near the midline of the femoral head, both the Pugh and the DHS are seen to compensate well during fracture collapse (Figure 3a,b). Comments on several operation notes regarding problems arising during insertion of the DHS into the femoral head, led us to conclude that this was by no means unique to subcapital fracture fixation as previously recorded by Rau et al. (1982). On occasion, in our series, operation time had been prolonged to allow tapping and/or insertion of K-wires to hold basicervical fractures and those fractures with hard bone in position while the screw was being inserted. In some patients the position of the fracture before and after screw insertion was quite different. Overall, however, there was no significant difference between operating times for the Pugh nail compared to the DHS. Because we found no specific disadvantages for the Pugh nail and because of the price difference between it and the DHS, we have elected to use the Pugh device for fixing future intertrochanteric fractures in our unit.
Acknowledgements We would
like to thank Messrs A. J. G. Swanson and T. Thulboume, Consultant Orthopaedic Surgeons, for their help in setting up this project. We would also like to thank Dr Wynne Carter and Miss Dawn Denvie, Department of
Injury: the British Journal of Accident Surgery (1991) Vol. 22/No.
196
Medical Computing, Ninewells Hospital, assistance in preparing the data.
Dundee,
for their
References Bannister G. C. and Gibson A. G. F. (1983) Jewett nail plate or A0 dynamic hip screw for intertrochanteric fractures? - A randomised prospective controlled trial. J Bone ]oint Surg. 65B, 218. Clawsor, D. K. (1964) Trochanteric fractures treated by the sliding screw plate fixation method. 1. Trauma 4, 737 Ecker M. L., Joyce J. I. and Kohl E. J. (1975) The treatment of mtertrochanteric hip fractures using a compression screw J. Bone Joint Surg. 5 7A. 23. Esser M. P., Kassab J. Y. and Jones D. H. (1986) Trochanteric fractures of the femur: A randomised prospective trial comparing the Jewett nail-plate with the dynamic hip screw. 1. Bong Joint Surg. 688, 55 7. Fielding J. W., Wilson S. A. and Ratzan S. (1974) A continumg end-result study of displaced mtracapular fracture of the neck of the femur treated with the Pugh nail. ] Bone Joinf Sttrg. 56A, 1464. Frandsen P. A, Andersen P E., Chnstoffersen H. et al. (1981) Osteosynthesis of femoral neck fractures: the sliding screw plate with or without compression. Arta Orthop. Scund. 55,620
3
Gibson J. N. A. and Espley A. J. (1987) The Pugh nail plate-a low Incidence of device failure. lnjuy 18, 24. Johnson J. T. H. and Crothers 0. (1975) Nailing versus prosthesis for femoral neck fractures. 1. Bone ]ornt Surg. 5 7A, 686. Kyle R F.. Gustillo R. B. and Premer R. F. (1979) Analysis of six hundred and twenty two intertrochanteric hip fractures. 1. Bone ]owt surg. 61A, 216. Mulholland R. C. and Gunn D. R. (1972) Sliding screw plate fixation of intertrochanteric femoral fractures. 1. Trauma 12, 581. Pugh W. L. (1955 1A self-adjusting nail plate for fractures about the hip Joint. 1. Bone Joint Surg. 37A, 1085. Rau F D., ManoIl A. and Morawa L. G. (1982) Treatment of femoral neck fractures with the sliding compression screw. C/in. Orthop. 163, 137. Sahlstrand T. (1974) The Richards compression and sliding hip screw system in the treatment of intertrochanteric fractures. Acta Orthop. Scam! 45, 213. Schumpelick W. and Jantzen P. M. (1955) A new pnnciple m the operative treatment of trochanteric fractures of the femur. 1. Botle Jornt Surg. 37A, 693. Paper accepted
3 October
1990.
Requests for reprints should be addressed lo: Mr C. A. N. McLaren, Department of Orthopaedic and Traumatic Surgery, Dundee Royal Infirmary, Barrack Road, Dundee DDI 9ND. UK.
Printed in GreatBritain
193
Intertrochanteric fractures of the femur: a randomized prospective trial comparing the Pugh nail with the dynamic hip screw C. A. N. McLaren, J. R. Buckley and D. I. Rowley Department
of Orthopaedic
and Traumatic
Surgery, Dundee Royal Infirmary, Dundee, UK
Overa Id-month period, 700 consecutive uues of interfrochanfericfcture were randomly allocafed to be freafed by either pirgh nail-plafe or Dynamic Hip Screzu (DHS) ji.dion. Although there were 11 uzzs of mdreducfwn and/or suboptimal positioning of fhe jixation device in the femoral head, only fwo of these gave long-term problems. De#fe the differencein configurationof fhe devices and a considerable disparity in price, patient satisfaction and the incidence of unfoward radiologd features at an average of 6 months after surgery were sidar in the two groups. A tr$n-enaU devicp would thus appear to be a reliable alternative fo the more commonly used hip screw systems for interfrochanferic fvncfure.
Introduction Pugh first described his ‘self adjusting nail-plate for fractures about the hip joint’ in 1955. He primarily advocated its use in femoral neck fractures. Fielding et al. (1974) using the device, reported a 90 per cent union rate; Johnson and Crothers (1975) had a 71 per cent success rate. Pugh went on to state that because of its strength and adjustability, his nail could also be used successfully on intertrochanteric femoral fractures. Gibson and Espley (1987) reported an overall profile of the Pugh nail when used on various fractures of the proximal femur. They found a 4.6 per cent failure rate in their basicervical and intertrochanteric fracture fixations. There is no report to date which looks specifically at the use of the Pugh nail-plate in this group of fractures, nor one which looks at its reliability when compared with other available fixation devices. In recent years, however, there have been many review articles describing the results of intertrochanteric fracture fixation with the sliding hip screw (Schumpelick and Jantzen, 1955; Clawson, 1964; Mulholland and Gunn, 1972; Sahlstrand, 1974; Ecker et al., 1975). There seems little dispute that this device has certain advantages over the fixed length, one-piece nail-plates such as the Jewett (Kyle et al., 1979; Bannister and Gibson, 1983; Esser et al., 1986). Its advantages over the Pugh nail-plate are less clear. Certainly, because of its helical configuration, the head of the dynamic hip screw achieves a strong grip on the femoral head, 0 1991 Butterworth-Heinema Ltd 0020-1383/91/030193-04
permitting compression to be applied between it and the plate during the operative procedure. Frandsen et al. (1984), however, have shown that this compression does not influence fracture healing. The thread also prevents advancement of the screw once it is inserted in the femoral head, thus lessening the risk of penetration through the head during loading. Because of its circular cross-section, no rotational stability is conferred to the femoral head either during insertion of the device - a problem outlined by Rau et al. (1982) - or during fracture healing. The Pugh nail head, on the other hand, has a t&n shape in cross-section. This shape should confer greater rotational control over the proximal fracture fragment. It also requires that the nail be inserted by a punching mechanism, theoretically allowing little risk of rotationally induced loss of reduction during insertion. The Pugh nail has potential relative disadvantages in that it has a slightly smaller cross-sectional area than the DHS, and no thread to resist forward translocation; therefore there is a higher theoretical risk of penetration through the femoral head during loading. It should be noted that the Pugh nail-plate is one-third of the price of the DHS and its associated plate. Because of the potential savings which could be made by our unit, it seemed important to investigate whether the above theoretical advantages and disadvantages of the Pugh nail-plate when compared with the DHS were significant in practice.
Methods Between September 1986 and December 1987, 100 consecutive patients with intertrochanteric fractures of the femur were entered into the trial. According to whether their unit numbers were odd or even, they were allocated to either the first treatment group where a Pugh nail fixation was carried out, or to the second group where the DHS was used. Each patient was documented for age, sex, mobility before fracture, and type of fracture. Two-part fractures were defined as stable, and displaced three- or four-part fractures as unstable. Unless there were serious anaesthetic contraindications, patients were operated on within 24 h of admission. A
Injury: the British Journal of Accident Surgery (1991) Vol. 22/No.
194
3
Table I. Patient characteristics OHS (N = 50)
Pugh (N=50) Age range (average) No. males females No. stable unstable fractures Early deaths ( i 6 months) Operation time (mins) range (average) Grade of operator Consultant Sentor registrar Junior registrar Recorded techmcal problems/ open reduction Early postoperatlve complications No unsatisfactory ftxatlons
66-95 (81 1 10 40 28.22 10
68-97(802) 9 41 23 27 6
35-95
35-l 05 (57)
(53)
3 9 38
4 14 32
3 DVT’l
8 Deep Infection 1 DVT’l 4
7
‘Requmng active treatment with antlcoagulatlon
record was kept of the grade and experience of the operator. operative time, and whether the reduction and fixation were technically satisfactory. A satisfactory reduction was defined as one where the medial buttress of the proximal femur was in continuity, or where a loss of continuity had been compensated for by medial displacement of the shaft or valgus displacement of the femoral neck. There had to be adequate apposition of the major fracture fragments. A satisfactory fixation implied that the nail/screw passed through the central six-eighths of the femoral neck, came to lie in the central four-sixths of the femoral head, passed well beyond the fracture line, and did not penetrate the line of the subchondral bone in the femoral head. Any technical problems encountered af operation were noted. A postoperative record was kept of early complications, time to discharge from the ward, and mobility at that time Patients were seen at 6 weeks and again at 3 and 6 months postoperatively. Their degree of pain and mobiiity was reviewed and radiographs taken. Pain was classified as’ (n) severe, where it caused walking to be very laboured, gave rise to discomfort at rest in a chair or in bed, and led to the taking of regular analgesics; (b) moderate, where it occurred on walking only and limited walking distance; and (c) mild, where it was intermittent and interfered only minimally with walking. The position of the fracture, stage of healing and the position of the fixation devices on radiographs were noted. If all parameters were satisfactory and there had been no other complications at the 6 month visit, the patient was not seen again. If there were persistent problems, longer term records were kept of the patients concerned.
Results Patient characteristics are summarized in Table I. The two groups of patients were matched for age and sex. There was no statistical difference between the number of early deaths (P= 0.41 using Fisher’s exact test), operation time (t= 5.119 using single-tailed f testing) and the number of unsatisfactory fixations (P= 0.52 in each group). There was a slightly increased number of recorded technical difficulties with the DHS, although this did not appear to increase average operating time. The most common problem was rotation of the proximal fracture fragment while the screw was being inserted. This fre-
Figure I. Penetration of the femoral articular surface by a Pugh nail seen at 3 months after Insertion. The nail had orlginally been placed high in the femoral head and a gap left in the calcar.
quently necessitated the insertion of extra K-wires and often resulted in a change of position of the fracture during the operation. Eleven fixations were Judged initially unsatisfactory, seven in the Pugh group and four in the DHS group. Of these, only one in each group went on to give problems with healing in the long term. There were SIX patients with radiographs showing delayed healing, loss of position and/or protrusion of the pin/screw at 6 months. Two of these were following Pugh nail-plate fixation and four following DHS fixation. Two had had unsatisfactory initial reduction/fixation (one in each group).
Length of stay in the ward was similar in each group with an average of 23.3 days in the Pugh group and 25.1 days in the DHS group. Walking ability at 6 months was almost identical between the two groups. Only one patient in the Pugh group was in severe pain at 6 months - fhis was associated with late protrusion of the nail (F~gtcre I). Two patients in the DHS group had severe pain - one due to persisting infection and the other due to delayed union after an unsatisfactory initial reduction. Two patients in each group had moderate pain,
McLaren et al.: Pugh nail versus dynamic hip screw
195
Figure 2. Varus malunion of fracture after fixation with DHS. The original position at the time of operation had been satisfactory.
Table IL Findings at 6 months postoperatively
Walkmg ability
Pain Severe Moderate Mild Radiographic findings. Varus malunlon, nail wlthin head Varus malunion. nail protrudmg Infection (loosenrng)
Pugh (N=40)
DHS (N =44)
Frame 23 (57%) 2 Sticks 6 (15%) 1 Stick 11 (28%) 1 2 3
Frame 24 (65%) 2 Sticks 8(18%) 1 Stick 12 (27%) 2 2 4
1
3
1
0 1
0
while four in the DHS group and three in the Pugh group had mild pain. None of these nine patients had had an initially unacceptable reduction/fixation. Four patients (one Pugh and three DHS), although showing varus malunion of the fracture (F@re 2) did not complain of pain. Overall, 13/84 (16 per cent) of the patients complained of pain. If those with an unsatisfactory initial fixation/reduction, or where infection had been a complication, were excluded, there was no difference in terms of pain between patients treated by the Pugh device compared with those treated by the DHS. Although 50 patients in each group may be a relatively small cohort, any obvious differences between the two groups would readily be uncovered by this number; the fact that there was such a marked similarity between them remains significant.
Discussion In the paper by Esser et al. (1986), comparing the Jewett nail-plate with the DHS, it was admitted that the degree of accuracy of reduction and the position of the fixation device in intertrochanteric fractures had never been fully evaluated with relation to the outcome. It was noted, however, that certain fixation devices such as the DHS could, by their ability to slide within their barrels, compensate for loss of fracture position during impaction. The fixed length nail-
Figure 3. u, A comminuted intertrochanteric fracture which has been fixed by a Pugh nail leaving a wide gap in the medial buttress of the femoral neck. b, Seen at 3 months later, the gap has closed, the nail has slid successfully in its barrel and the fracture has united.
plates such as the Jewett’s could not do this. This article demonstrates that with both the Pugh and the DHS devices, there is a low incidence of long-term problems even if the fracture has been quite grossly malreduced (F&re 3u,b), or the fixation inserted in an extreme position. In the only case of late protrusion of one of the devices (Figure I), the problem was high placement of the nail in the femoral head associated with a gap in the medial buttress. Even if a gap is left in the medial buttress but the nail or screw is placed low or near the midline of the femoral head, both the Pugh and the DHS are seen to compensate well during fracture collapse (Figure 3a,b). Comments on several operation notes regarding problems arising during insertion of the DHS into the femoral head, led us to conclude that this was by no means unique to subcapital fracture fixation as previously recorded by Rau et al. (1982). On occasion, in our series, operation time had been prolonged to allow tapping and/or insertion of K-wires to hold basicervical fractures and those fractures with hard bone in position while the screw was being inserted. In some patients the position of the fracture before and after screw insertion was quite different. Overall, however, there was no significant difference between operating times for the Pugh nail compared to the DHS. Because we found no specific disadvantages for the Pugh nail and because of the price difference between it and the DHS, we have elected to use the Pugh device for fixing future intertrochanteric fractures in our unit.
Acknowledgements We would
like to thank Messrs A. J. G. Swanson and T. Thulboume, Consultant Orthopaedic Surgeons, for their help in setting up this project. We would also like to thank Dr Wynne Carter and Miss Dawn Denvie, Department of
Injury: the British Journal of Accident Surgery (1991) Vol. 22/No.
196
Medical Computing, Ninewells Hospital, assistance in preparing the data.
Dundee,
for their
References Bannister G. C. and Gibson A. G. F. (1983) Jewett nail plate or A0 dynamic hip screw for intertrochanteric fractures? - A randomised prospective controlled trial. J Bone ]oint Surg. 65B, 218. Clawsor, D. K. (1964) Trochanteric fractures treated by the sliding screw plate fixation method. 1. Trauma 4, 737 Ecker M. L., Joyce J. I. and Kohl E. J. (1975) The treatment of mtertrochanteric hip fractures using a compression screw J. Bone Joint Surg. 5 7A. 23. Esser M. P., Kassab J. Y. and Jones D. H. (1986) Trochanteric fractures of the femur: A randomised prospective trial comparing the Jewett nail-plate with the dynamic hip screw. 1. Bong Joint Surg. 688, 55 7. Fielding J. W., Wilson S. A. and Ratzan S. (1974) A continumg end-result study of displaced mtracapular fracture of the neck of the femur treated with the Pugh nail. ] Bone Joinf Sttrg. 56A, 1464. Frandsen P. A, Andersen P E., Chnstoffersen H. et al. (1981) Osteosynthesis of femoral neck fractures: the sliding screw plate with or without compression. Arta Orthop. Scund. 55,620
3
Gibson J. N. A. and Espley A. J. (1987) The Pugh nail plate-a low Incidence of device failure. lnjuy 18, 24. Johnson J. T. H. and Crothers 0. (1975) Nailing versus prosthesis for femoral neck fractures. 1. Bone ]ornt Surg. 5 7A, 686. Kyle R F.. Gustillo R. B. and Premer R. F. (1979) Analysis of six hundred and twenty two intertrochanteric hip fractures. 1. Bone ]owt surg. 61A, 216. Mulholland R. C. and Gunn D. R. (1972) Sliding screw plate fixation of intertrochanteric femoral fractures. 1. Trauma 12, 581. Pugh W. L. (1955 1A self-adjusting nail plate for fractures about the hip Joint. 1. Bone Joint Surg. 37A, 1085. Rau F D., ManoIl A. and Morawa L. G. (1982) Treatment of femoral neck fractures with the sliding compression screw. C/in. Orthop. 163, 137. Sahlstrand T. (1974) The Richards compression and sliding hip screw system in the treatment of intertrochanteric fractures. Acta Orthop. Scam! 45, 213. Schumpelick W. and Jantzen P. M. (1955) A new pnnciple m the operative treatment of trochanteric fractures of the femur. 1. Botle Jornt Surg. 37A, 693. Paper accepted
3 October
1990.
Requests for reprints should be addressed lo: Mr C. A. N. McLaren, Department of Orthopaedic and Traumatic Surgery, Dundee Royal Infirmary, Barrack Road, Dundee DDI 9ND. UK.
