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Evaluation of the Clinical and Functional Outcome of the Patients with Intertrochanteric Fractures Treated with a Proximal Femoral Nail in Northern Tanzania

Article Information

Casto Elilindia Mlay 1,2 *, Rogers Joackim Temu1,2 , Tumaini Fredrick Minja1,2

1Kilimanjaro Christian Medical University College, P. O. Box 2240 Moshi, United Republic of Tanzania

2Kilimanjaro Christian Medical Centre. P. O. Box 3010   Moshi, United Republic of Tanzania

*Corresponding Author: Dr. Casto Elilindia Mlay, Kilimanjaro Christian Medical University College, P. O. Box 2240 Moshi, United Republic of Tanzania; Kilimanjaro Christian Medical Centre. P. O. Box 3010   Moshi, United Republic of Tanzania

Received: 16 November 2020; Accepted: 23 November 2020; Published: 28 April 2021

Citation: Juma Mohamed Nahonyo, Anthony Japhet Pallangyo, Honest Herman Lord Massawe, Casto Elilindia Mlay. Evaluation of the Clinical and Functional Outcome of the Patients with Intertrochanteric Fractures Treated with a Proximal Femoral Nail in Northern Tanzania. Journal of Orthopaedics and Sports Medicine 3 (2021): 052-061.

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Abstract

Background: Hip fracture is common and it is escalating, lead to one-fifth of the orthopedic operative work and it is associated with significant morbidity, mortality and leads to a burden to the health care system while over half of the patient does not returns to premorbid mobility status. The goal of the treatment is to attain anatomical reduction with internal fixation to facilitate rapid mobilization of the patient and prevent morbidity and mortality. This study intends to establish the clinical and functional outcome of the patients with intertrochanteric fractures treated with a proximal femoral nail.

Method: This was a hospital-based cross-sectional study conducted at KCMC from January 2018 to November 2019 involving a total of 92 patients with intertrochanteric fractures who were called and evaluated for clinical and functional outcome using Harris score after treatment thereafter data was analyzed.

Result: This study included a total of 92 study participants, 63.1% were males with a mean age of 55years, the majority come from rural areas 58.7% and had a longer hospital stay of > 14days 51.4%, simple fall was the common cause of injury 41.3%, while the majority had excellent hip status 42.4%, good hip status was 28.5%, fair hip status was 10.8%. In this study, 76.1% had appropriate implant position, 18.5% had screw cut out, 81.5 had fracture union, 82.6% had proper fracture reduction, apex distance was less than 25 mm in 77.2% and 81.5% had 120 – 135 degrees diaphyseal angle, the main leading complication 9.8%, followed by reoperation 6.5%, 9.8% had fascia late pain, 8.7% had acetabula penetration//irritation, death was 4.3%, periprosthetic was fracture 3.3% and, 6.50% had limb discrepancy shortening.

Conclusion: Therefore, the proximal femoral nail is a better method of intertrochanteric fracture fixation with a good both clinic and function outcome and minimal complication after the operation.

Keywords

Intertrochanteric fracture; Proximal femoral nail; Harris hip score; Tanzania

Open fractures articles; Infection articles; Debridement articles; Tanzania articles

Article Details

1. Introduction

An open fracture is one in which a break in the skin allows for direct communication of the fracture or fracture haematoma with the external environment and 11.5/100000 people per annum is estimated to have open fracture [1, 2]. Exposed fractured bone to the external surrounding and soft injury eventually affect the healing process and result to increased risk of infections, delayed unions, non-unions and results to a significant financial drain, physiological, social impact and a burden to the health care system as well [3].

In low and middle income (LMIC’s) like Tanzania open fracture is rapidly escalating due to increased motorized transport with underdeveloped trauma care in these countries hence result in significant morbidity and mortality [4-6]. Open fractures treatment is intending to attain bone union, prevent infection, non-union, and complete functional recovery. Thus, contains early initiation of intravenous antibiotics and early wound debridement with copious irrigation using normal saline, bone stabilization, early soft tissue coverage to overcome complications [7]. This study aims to determine the incidence and predictors of infection after open fracture treatment in our Centre (Kilimanjaro Christian Medical Centre, Tanzania) highlights the magnitude of open fracture related infection and their predictors at our Centre.

2. Method

We conducted a hospital based longitudinal cross-sectional study involved a total of 124 participants conducted at Kilimanjaro Christian Medical Centre (KCMC), Northern Tanzania, from October 2018 and April 2019. KCMC is a zonal referral hospital, catering for around 15 million people. The orthopedic and trauma department is located on the second floor at KCMC is one of the departments within the hospital with 55 bed capacity. All patients admitted with open fractures were enrolled and recruited after obtaining informed consent to participate in the study. Fracture etiology, time of initiation of intravenous antibiotic, open fracture grade, fracture stabilization mode was obtained from the patient’s file.

5th day and 2nd 4th 8th weeks post-operative all patients were assessed for infection using ASEPSIS score, a score of 0-10 was regarded normal wound healing, 10-20 score disturbed wound healing, 21-30 as mild infection, 31-40 score as moderate infection and score of >40 was regarded as severe infection and pus swab culture was taken for isolation of the organism. Data were analyzed using the SPSS version 25 package. Percentages, proportions, mean and tables were used to summarize the study findings. Fisher’s exact tests was used to determine predictors of infection after open fracture treatment and a p-value of ≤0.05 was considered statistically significant.

3. Results

3.1 Characteristics of the study participants

This study included a total of 124 study participants. The mean age of the study participants was 33 (11.9) years.

This study included a total of 124 study participants. The mean age of the study participants was 33 (11.9) years.

Characteristics

n (%)

Age (years) (mean (SD))

33 (11.9)

Age (years)

< 25

30 (24.2)

25 - 34

46 (37.1)

35 - 44

26 (20.9)

45 - 54

12 (9.7)

≥ 55

10 (8.1)

Residence

Rural

82 (66.1)

Urban

42 (33.9)

Sex

Male

110 (88.7)

Female

14 (11.3)

Mechanism of injury

Road traffic crash

102 (82.3)

Fall from height

8 (6.5)

Assault

6 (4.8)

Industrial / mining accidents

6 (4.8)

Gunshot

2 (1.6)

Table 1: Social demographic characteristics of the study participants (n=124).

The majority of the study participants 46 (37.1%) were aged 25 to 34 years, 82 (66.1%) living in rural areas, 110 (88.7%) were males, 102 (82.3%) were due to road traffic crashes, 122 (98.4%), 74 (59.7%) had grade IIIA open fracture, 100 (80.6%), 70 (56.5%) had comminuted fractures while 62 (50.0%) were managed by external fixators, 58 (46.8%) received their first dose of antibiotic within six hours of injury and 54 (43.5%) received initial wound debridement between six to twelve hours of injury. As shown in Tables 1 and 2.

Characteristics

n (%)

Fracture patterns

Transverse

38 (30.6)

Oblique

8 (6.5)

Comminuted

70 (56.5)

Segmental

8 (6.5)

Fracture grade

I

2 (1.6)

II

22 (17.7)

IIIA

74 (59.7)

IIIB

22 (17.7)

IIIC

4 (3.2)

Time between injury and first antibiotic dose (hours)

< 6

58 (46.8)

6 to 12

46 (37.1)

> 12

20 (16.1)

Time between injury and initial wound debridement (hours)

< 6

26 (20.9)

6 to 12

54 (43.5)

13 to 24

42 (33.9)

> 24

2 (1.6)

Fracture stabilization

Back slab

20 (16.1)

K-wire

20 (16.1)

External fixator

62 (50.0)

Internal fixation e.g. IMN, plate and screws

22 (17.7)

The incidence of infection after an open fracture treatment at KCMC was 25.8% (32).

Table 2: Clinical characteristics of the study participants (n=124).

Wound infection

No

Yes

n (%)

n (%)

Total

Factors

92 (74.2)

32 (25.8)

n (%)

p-value

Fracture patterns

Transverse

34 (89.5)

4 (10.5)

38 (100.0)

Oblique

4 (50.0)

4 (50.0)

8 (100.0)

Comminuted

50 (71.4)

20 (28.6)

70 (100.0)

Segmental

4 (50.0)

4 (50.0)

8 (100.0)

0.012

Fracture grade

I

2 (100.0)

0 (0.0)

2 (100.0)

II

20 (90.9)

2 (9.1)

22 (100.0)

IIIA

56 (75.7)

18 (24.3)

74 (100.0)

IIIB

12 (54.6)

10 (45.4)

22 (100.0)

IIIC

2 (50.0)

2 (50.0)

4 (100.0)

0.036

Time between injury and first antibiotic dose (hours)

< 6

44 (75.9)

14 (24.1)

58 (100.0)

6 to 12

32 (69.6)

14 (30.4)

46 (100.0)

> 12

16 (80.0)

4 (20.0)

20 (100.0)

0.651

Time between injury and initial wound debridement (hours)

< 6

20 (76.9)

6 (23.1)

26 (100.0)

6 to 12

44 (81.5)

10 (18.5)

54 (100.0)

13 to 24

26 (61.9)

16 (38.1)

42 (100.0)

> 24

2 (100.0)

0 (0.0)

2 (100.0)

0.161

Fracture stabilization

Back slab

16 (80.0)

4 (20.0)

20 (100.0)

K-wire

16 (80.0)

4 (20.0)

20 (100.0)

External fixator

42 (67.7)

20 (32.3)

62 (100.0)

Internal fixation

18 (81.8)

4 (18.2)

22 (100.0)

0.493

Table 3: The predictors of infection after open fractures treatment (n=124).

In this study predictors of infection after open fracture treatment was fracture grade classified by Gustilo and Anderson (p=0.036) and fracture patterns (p=0.012) were significantly associated with infection in long bone open fracture however other factors were not significant with infection. This is shown in Table 3.

4. Discussion

This study included 124 study participants who met the inclusion criteria. The mean age of the participants was 33 years while male was 88.7% and road traffic crashes account for a vast majority 82.3% and 59.7%% had Gustilo and Anderson grade IIIA.

Our findings were similar to other studies done in Brazil, Rwanda and Nigeria they both found the mean age of 31.76 and 31 years and majority were male 78.14% while the leading cause was road traffic crash 74.18%, 71.5%, and 91.4% and Gustilo and Anderson grade III represent the majority of the open fractures [5-7].

In this study, the incidence of infection in open fracture treated at KCMC was 25.8 % (32) the result observed was similar to the study done in Chadi and California they observed the overall incidence of infection was 28% and 22.6 % after open fracture treatment respectively [8, 9].

This study found that fracture patterns and Gustilo and Anderson grade were predictors of infection, comminuted fracture and grade IIIA open fracture had a high number of infections 20 (28.6%) and 18(24.3%) respectively and were statistically significant.

A similar results observed a high rate of infection IIIA fractures and up to 17% for type IIIB fractures. The overall infection rate was 13–15% in open fracture grade III fractures [10].

Time of initial surgical debridement was not a predictor for infection although patients who had surgical debridement after six hours 6-12 hours had more infection, however, the observation was not statistically significant similar study observe time of surgical debridement was not an independent predictor of infection after open fracture treatment [11].

Time of initiation antibiotic initiation was not associated with infection in contrary to study done in Tanzania found patients who had antibiotics in less than six hours post had less infection 4.8% compared to those who had antibiotics after six hours post injury 7.8%.

These results could be explained a high resistance pattern to the antibiotic used in the hospital a study at KCMC observed resistance to cefazolin 72.9% and ceftriaxone 51.8% [12, 13].

5. Conclusion

This study found that the incidence of infection was 25.8%, after open fracture treatment while predictors of infection in open fractures were fracture patterns, fracture grade, fracture etiology and mode of fracture stabilization should be considered while dealing with an open fracture to reduce the incidence of major complications.

Acknowledgments

We would like to thank the nurses in the Orthopedic and trauma department at Kilimanjaro Christian Medical Centre for their support in data collection. We would also like to thank all colleagues, specialists, and consultants in the Department of Orthopedic and Trauma for their input on this study.

Disclosure

The authors report no conflicts of interest in this work.

References

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