While reconstructing coronal plane fracture fragments during fixation of multifragmentary pertrochanteric fractures may improve the recovery of hip abductor strength, particularly in patients with larger fracture fragments, although overall hip function may be similar to fixation alone at 18 months.
In a single-center randomized controlled trial at a level I trauma center in India between January 2022 and December 2023, researchers randomly assigned 142 patients older than 60 years with AO Foundation/Orthopaedic Trauma Association 31-A2 multifragmentary pertrochanteric fractures to receive treatment with Proximal Femur Nail Antirotation Asia (PFNA-II) fixation either with or without wire augmentation of coronal fracture fragments. Preoperative computed tomography was used to quantify coronal fragment size, and a modified intention-to-treat analysis included 116 patients who completed 18 months of follow-up.
The co-primary outcomes included hip abductor strength recovery and the modified Harris Hip Score (mHHS) at follow-up. Secondary outcomes included fracture union, pain measured via the Visual Analog Scale, complications, and differences in treatment effects according to coronal fragment size.
At 18 months, the patients who underwent wire augmentation recovered an adjusted 8 percentage points more hip abductor strength compared with those treated with PFNA-II alone. However, the mHHS was similar between the groups, indicating no measurable improvement in overall hip function. The researchers observed no statistically significant differences in fracture union or pain at follow-up.
Prespecified subgroup analyses showed that the benefit was concentrated among patients whose coronal fracture fragments accounted for more than 50% of the trochanteric mass. In this subgroup, wire augmentation improved hip abductor strength by approximately 11 percentage points, exceeding the study's predefined minimal clinically significant difference. However, mHHS remained comparable regardless of fragment size. Regression analyses suggested that the benefit of wire augmentation increased as fragment size increased.
Compared with PFNA-II alone, wire augmentation was associated with longer operative time, greater blood loss, higher drain output, and increased transfusions. Patients in the control group experienced more varus collapse, whereas rates of fracture union and final pain scores were similar between the treatment groups.
The researchers noted several limitations. The study was conducted at a single center and included older patients of Asian race and Indian ethnicity, which may limit generalizability. Surgeons could not be blinded because of the nature of the intervention, follow-up was limited to 18 months, and the higher-than-anticipated attrition rate was largely attributable to mortality following hip fracture. In addition, changes to the protocol prior to enrollment designated hip abductor strength as a co-primary outcome, and patient-reported outcomes were not collected because the planned questionnaire was omitted.
"The results support the selective use of wire augmentation in appropriate patients, provided the potential benefits outweigh the associated risks," wrote lead study author Velmurugesan Purnaganapathi Sundaram, MS, of the Department of Orthopaedics and Trauma at the Ganga Medical Centre and Hospitals in India, and colleagues.
The study authors reported no competing interests.
Source: JBJS Open Access
