Surgical Fixation of Hip Fractures – A Novel Technique for Pre-Operative Planning

Surgical Fixation of Hip Fractures – A Novel Technique for Pre-Operative Planning | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Surgical Fixation of Hip Fractures – A Novel Technique for Pre-Operative Planning Glen Zi Qiang Liau, Kamaraj Thirukumaran, Seth Ian Sim, Alexander Shao-Rong Pang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5219155/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose : Use of the dynamic hip screw (DHS) is considered the gold standard for hip fracture stabilisation, but conventional DHS (CHDS) fixations may be limited by longer surgical duration and delayed recovery compared to minimally invasive DHS (MIDHS) fixations. We describe a novel low-cost surgical method grounded in trigonometry that reduces intra-operative time, peri-operative complications, and improves overall patient outcomes. Methods : A prospective double-blinded study included 15 patients who underwent surgical fixation of IT hip fractures using a 4-hole DHS system. All surgeries were performed at a tertiary referral hospital between January 2019 and April 2023 by surgeons with similar levels of experience. Main outcome measurements included tip-apex distance (TAD), surgery duration, haemoglobin loss, and hospital stay duration. Two independent assessors measured TAD using the post-operative anteroposterior and lateral radiographs. Kyle's classification was used to categorize the IT fractures. IBM SPSS Statistics 26.0 for Mac (SPSS, Chicago, IL, USA) was used for the statistical analysis. Statistically significant difference was defined as p-value 0.05), except for Kyle's classification (p = 0.04). The MIDHS group had more complex fractures (40% MIDHS Kyle 3/4 vs 10% CDHS Kyle 3/4) but the mean surgical duration was significantly shorter (p = 0.019) (43.8 ± 12.3 minutes) compared to the CDHS group (73.4 ± 18.2 minutes). Postoperatively, there was no significant difference (p>0.05) in hospital stay duration, haemoglobin (Hb) loss, or TAD. Conclusions : Despite having more complex fractures, MIDHS group had even shorter surgical duration compared to CDHS group, with no significant difference in TAD, haemoglobin loss and hospital stay duration. Femur Intertrochanteric fractures Dynamic hip screw fixation Minimally invasive surgery Figures Figure 1 Figure 2 Figure 3 Figure 4 1 Introduction 1.1 Intertrochanteric Hip Fractures Hip fractures are a commonly encountered injury in the field of orthopaedic surgery. Globally, the number of hip fractures is expected to reach 4.5 million by the end of the year 2050, representing a significant increase from 1.26 million cases in 1991. 12 Asia will account for more than half of all hip fractures, due to its rapidly aging population and higher life expectancy. 3 Hip fractures represent 0.1% (1.75 million disability adjusted life years) of the global burden of disease world-wide. 4 Elderly adults are more susceptible to hip fractures as they tend to have reduced mobility and are more likely to have concomitant medical comorbidities. 5 In the United Kingdom (UK), after the age of 50, the lifetime risk of hip fracture is approximately 11% for women and 3% for men. 6 Medical comorbidities such as osteoporosis increase the likelihood of a fragility fracture. 7 An estimated 5.5 million men and 22 million women in the European Union (EU) alone were estimated to have osteoporosis in 2010. This led to 3.5 million new fragility fractures, including 520,000 vertebral fractures, 610,000 forearm fractures, and 1,800,000 hip fractures. 7 Majority of hip fractures are caused by falls sustained during regular activities, with a male to female ratio of one to four. 8 9 1.2 Minimally Invasive Dynamic Hip Screw Fixations Use of the Dynamic hip screw (DHS) is a common fixation technique in the stabilisation of intertrochanteric hip fractures. 10 11 However, conventional dynamic hip screw (CDHS) fixation may be limited by longer surgical duration, more extensive soft tissue dissection, increased blood loss, delayed recovery, and prolonged hospital stays. 12 The growing emphasis on optimising patient outcomes and minimisation of surgical trauma has given rise to the development and refinement of minimally invasive dynamic hip screw (MIDHS) fixation. Ideally, a minimally invasive technique should maintain the necessary fixation stability without noticeably shortening the femoral neck or causing rotation or tilting the femoral head. 13 Modification of current surgical techniques has been shown to result in reduced surgical duration, post-operative hospital stays, and blood loss. 14 15 This prospective study aims to evaluate and compare clinical outcomes of patients who have undergone MIDHS with those who have undergone CHDS. 1.3 Tip-Apex Distance Tip-apex distance (TAD) is the total distance measured from anteroposterior and lateral views, between the lag screw tip and the apex of the femoral head. 16 This is illustrated in Fig. 1 . For the purpose of the study, the known diameter of the hip screw was used to adjust for radiological magnification. 2 Methods A prospective single-blinded case control study was performed. Patients with intertrochanteric (IT) hip fractures who underwent surgical fixation with 4-hole DHS system in a tertiary referral hospital between January 2019 and April 2023 were identified and evaluated for inclusion in this trial. All cases were performed by Senior Orthopaedic Surgery Residents (Orthopaedic Surgery Registrars) of similar experience levels. Patients with complex fractures requiring open reduction were excluded from the study. The study protocol was approved by the Domain Specific Review Board (DSRB) of the institution under Reference number 2023/00715. 2.1 Novel Technique for Planning Minimally Invasive Surgical Fixation of Hip Fractures The authors propose a novel MIDHS technique for treating IT hip fractures, that considers the trajectory of the guidewire in all 3 planes – coronal, sagittal and axial, before any incision is made. Cases were performed either under general or spinal anaesthesia. Prior to starting surgery, patients were positioned on a radiolucent fracture table, and all fractures were successfully reduced by closed manipulation under fluoroscopic control to 10 degrees of valgus on AP radiographs and < 58 degrees of posterior angulation on lateral radiographs. The skin surface markings were performed prior to preparation of the surgical field. The intra-operative imaging that was performed during the drawing of the skin markings were performed with the primary surgeon fully protected and comfortable, without wearing lead gown and thyroid shield yet, by standing behind panelled lead shields and/or outside the theatre leaded doors. The primary surgeon re-positioned the protractor as required in between imaging shots. Only the surgical assistant was required to hold a long rod for the purpose of achieving the lateral femur axis marking in the Clements-Nakayama view. 17 Antero-posterior surface marking – Coronal consideration of plate position A metal (stainless steel) protractor that was commercially purchased, was adjusted to the desired pre-templated degree – 135 or 150 degrees and laid directly on top of the patient. Antero-posterior (AP) intraoperative imaging (II) X-rays were taken to obtain and mark the surface position of the DHS plate (Figures 2 and 3). The vertical limb of the protractor was overlaid on the patient’s lateral femoral cortex with the vertical limb overlaid on the patient’s lateral femoral cortex, and the caput-collum-diaphyseal (CCD) line at the desired height, typically in the lower half of femoral neck and head region (Figure 2). The metallic nature of a protractor provided a satisfactory semi-lucent appearance, overlayed clearly over the femur, on the fluoroscopic image taken. Lateral surface marking – Sagittal and Axial consideration of plate position With the Clements-Nakayama method 17 – a modified form of lateral view, resulted in a patient specific view of a collinear femoral head to the femoral shaft, which allowed the surgeon to take into consideration the amount of anteversion the specific patient had. With the II in the Clements-Nakayama tilt, a straight ruler was then used to mark the mid shaft of the femur along this view (Figure 4). Trigonometrical surface marking – (a) Entry point of guidewire trajectory on skin surface (b) Length of potential incision (a) The intersection of the extrapolation of the oblique CCD line distally, to meet the Lateral surface marking line, would be the Entry point of the guidewire trajectory on skin surface (Figure 4). This accounted for the thickness of the subcutaneous tissues and musculature of the specific patient. (b) A perpendicular line, from the junction of the vertical limb and CCD angle, was made posteriorly, to meet the Lateral surface marking line. The line between (a) and (b) – the Liau line – was the length of the potential skin incision to be made (Figure 4). In practice, depending on the thickness, and the turgor of the patient’s soft tissues, this line can be shortened up to 1-2cm proximally, and 2-4cm distally, and retractors may be used to allow for implant insertion. Skin preparation was then done carefully, to avoid erasure of the markings during cleansing. Intra-operatively, after skin incision and exposure, the surgeon may additionally use a free K-wire, and insert it freehand, anterior to the cortex of the femur, to end in the femoral head. This served as a secondary visual guide for the anteversion of the guidewire to be inserted. This abovementioned method enables surgeons to ascertain a more precise location and trajectory of the guidewire, starting from the entry point on the skin. This allows for a potentially smaller minimally invasive surgical incision. By accurately placing the guidewire with confidence on the first try, it allows surgeons to know the exact distal length of incision required for the DHS plate leading to reduction in soft tissue dissection. 2.2 Pre-operative Parameters Pre-operative clinical data for both groups is presented in Table 1. Participants’ age, gender, body mass index (BMI), and premorbid ambulatory status were recorded. Participants’ comorbidities were summarised into a score using the Charlson comorbidity index, alongside an estimated 10-year survival rate which was calculated. 2.3 Surgical Outcome Assessment Post-operatively, patients received the same treatment and standard rehabilitation protocol established at the tertiary referral hospital. Surgical duration was defined as knife to skin, to completion of skin closure. All patients had their wounds closed in layers, with sutures only - no staplers were used. In all cases, AP and lateral radiographs were obtained post-operatively to assess fracture fixation and implant positioning. Pre- and post-operative haemoglobin levels were measured to assess the amount of blood loss. Two independent assessors measured the TAD using the post-operative AP and lateral radiographs. Discrepancies of > 2mm between the measurements by the two assessors were identified and remeasured. The Kyle’s classification was used to group the IT fractures into four categories – 1, stable 2-part IT fractures without displacement and tearing; 2, stable 3-part IT fractures with displacement and minimal tearing; 3, unstable 4-part IT fractures with displacement and posterior-medial breakage; 4, unstable 4-part IT fractures with posterior displacement, posterior-medial breakage and inferior-trochanterion component. 18 2.4 Statistical Analysis IBM SPSS Statistics 26.0 for Mac (SPSS, Chicago, IL, USA) was used for the statistical analysis. Since variables had a frequency of five or more, the chi-squared test was used. Mann-Whitney U-test was used to analyse the continuous variables of non-parametric data. 95% confidence interval was used to provide us with the likely values of the true population mean. The significance tests for each were all two-tailed. Statistically significant difference was defined as p-value < 0.05. 3 Results 15 patients met the inclusion criteria and were sorted accordingly into the MIDHS or CDHS group. All MIDHS surgeries were performed by a single surgeon, a second- to third-year Senior Orthopaedic Resident (Orthopaedic Surgery Registrar). Other surgeons with similar experience performed CDHS fixation on the control group. Both groups utilised the same implants, sets and tools. The pre- and post-operative clinical information were documented for each case. The MIDHS and CDHS groups comprised of 5 and 10 patients respectively. Both groups had comparable preoperative demographics, body mass index, comorbidity factors (Charlson Comorbidity index), premorbid ambulatory status, injury mechanism, fracture pattern and time elapsed from injury to surgery. The American Society of Anaesthesiologists (ASA) classification for both groups was also similar. The ASA classification for one patient was not recorded and was excluded from the study. (Table 1 ) There was a significant difference in fracture type. MIDHS group had more complex fracture types compared to the CDHS group (40% vs 10% of patients being Kyle’s 3 or 4, p = 0.04). Despite having more complex fracture types, the mean surgical duration in the MIDHS group was significantly shorter as compared to the CDHS group (43.7 vs 73.4 minutes, p = 0.019). No significant difference was found for the following outcome measures: duration of hospital stays (p = 0.310), TAD (p = 0.594), haemoglobin (Hb) loss (p = 0.898), number of intraoperative radiographs (p = 0.825) and cumulative duration of radiation exposure (p = 0.604). The surgical and post-surgical data for both groups is summarised in Table 2 . Lower mean TAD, Hb loss and duration of hospital stay were observed in the MIDHS group, but the outcomes were not statistically significant. 4 Discussion Several methods and techniques have been described for the surgical treatment of IT fractures. 19 20 21 DHS is commonly used for treating IT fractures in the elderly as it allows for early remobilisation, is easy to use, and has low complication rates. 22 , 23 However, it is imperative to note that certain parameters such as patient's age, the amount of time elapsed between the injury and surgery, and the presence of medical comorbidities also play a role in treatment outcomes. 24 Several studies have explored MIDHS fixations with favourable clinical outcomes. However, there are various limitations can be identified in the existing literature. A similar study conducted by Wong et al. 15 , the MIDHS group had considerably smaller drops in Hb levels, lower rate of blood transfusions, significantly lower pain scores on the third postoperative day, and significantly lesser overall analgesic use in the first three days. However, Wong’s MIDHS method showed no significant difference in surgical duration. Our MIDHS method records lower mean surgical duration, in surgeons of similar surgical experience, suggesting that it may be a superior technique. This may be due to the additional consideration of the anteversion of the femur, with the incorporation of the Clements-Nakayama view. Although Wong’s MIDHS group average hospital stay was shorter than that of the CDHS group, neither the difference in complication rates nor the difference in hospital stay duration were statistically significant. Ho et al. 25 described a minimally invasive technique with significant shortening in the duration of surgery and length of hospital stay. However, the paper considered 2-hole, 3-hole and 4-hole DHS and is not fully relevant to our current study which only studies the use of a 4-hole DHS system. Furthermore, the TAD and Hb loss were also reported to be statistically insignificant as well. This is concurrent with our findings. Lee et al. 12 reported positive findings with MIDHS with statistically significant haemoglobin loss and length of hospital stay which is inconsistent with our data. However, unlike our novel technique, this study did not prove a statistically significant reduction in surgical duration. Furthermore, they preferred the use of 3-hole side plates, whereas this study used 4-hole side plates. Thus, a direct comparison to their study cannot be made. Wang et al. 26 reports an MIDHS technique with significantly lower average surgical duration, incision length, blood transfusion rate, and post-operative stay. While Wang had a significantly shorter mean surgical time in the MIDHS group, the mean of 64.8 minutes was much higher than that of ours, with a mean of 43.8 minutes. Our MIDHS group also showed superior outcomes in mean TAD, haemoglobin loss, and length of hospital stay, though they were not statistically significant. This shows that our novel technique is indeed an improvement to existing surgical techniques and increases the overall standard of care. While our mean TAD is better, there is no consensus in literature regarding the minimum clinically important difference (MCID) with regards to TAD. 5 Limitations Although the results proved that the proposed technique produced better results as compared to CDHS, there were several limitations of the study as well as the novel MIDHS technique. Firstly, the statistical power of the study was reduced given a small sample size (n = 15). The surgical technique was conducted by a single surgeon, and hence the reproducibility of the results must be validated by other surgeons of the same level of experience. Although a larger sample size would be ideal, the surgeon has shown that the duration of surgery was clinically and statistically significantly lower as compared to the CDHS. Although more intra-operative images were taken pre-incision using our novel method, this allowed for fewer intra-operative images, and fewer total images to be taken after skin incision. This reduced wound exposure time, blood loss, and attempts for entry of the guidewire. A further limitation for both the MIDHS and CDHS groups was the lack of recorded data on the number of repeated attempts needed to achieve satisfactory guidewire placement. However, in the author’s experience, a maximum of two to three passes with minimal adjustment were needed to reach the optimal position, due to improved accuracy from the surface markings. The Kyle screw position was not examined in this study. However, MIDHS had a lower TAD as compared to the CDHS control group, which was the most important independent factor when assessing for the optimal positioning of the DHS. All patients included in the study reached union with appropriate TAD targets of < 25mm achieved. Lastly, the Harris hip score and Elderly mobility scale, which assess long term rehabilitative progress of surgical patients, were not included as outcome measurements. 6 Conclusion Minimally invasive surgeries are known to reduce post-operative complications and morbidity. Our MIDHS technique proved that in comparison to the CDHS, there was no significant difference in hospital stay duration, haemoglobin loss or TAD. However, there was a significant reduction in surgical duration despite the complexity of the cases in our series. Furthermore, the number of passes before guidewire positioning could affect the clinical outcome of the patient and therefore the reliability of the conclusion. This suggests that to ascertain and validate our study further, we need to increase our cohort size, include the number of passes made in both case series, and follow up with our patients over the long term. Abbreviations AP, antero-posterior BMI, body mass index CCD, caput-collum-diaphyseal CDHS, conventional dynamic hip screw DHS, dynamic hip screw DSRB, Domain Specific Review Board EU, European Union Hb, haemoglobin IT, inter-trochanteric MCID, minimum clinically important difference MIDHS, minimally invasive dynamic hip screw TAD, tip-apex distance UK, United Kingdom Declarations Compliance with Ethical Standards Ethics Approval The study protocol was approved by the Domain Specific Review Board (DSRB) of the National Healthcare Group (NHG) under Reference number 2023/00715. Human Ethics and Consent to Participate All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Informed consent for the procedure was obtained from all individual participants involved in the study. Consent for Publication Not applicable. Funding Declaration This research received no external funding. Author Contribution Conceptualisation, Z.Q.G.L., K.T., A.S.-R.P., S.I.S.; Formal analysis, K.T., A.S.-R.P., S.I.S., Z.Q.G.L.; Writing—original draft preparation and design figures, K.T., A.S.-R.P., S.I.S., Z.Q.G.L.; Writing—review and editing, S.I.S., Z.Q.G.L.; Supervision, Z.Q.G.L. All authors have read and agreed to the published version of the manuscript. References Tan LT, Wong SJ, Kwek EB. Inpatient cost for hip fracture patients managed with an orthogeriatric care model in Singapore. 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Minimally invasive dynamic hip screw for fixation of hip fractures. Int Orthop . Apr 2009;33(2):555-60. doi:10.1007/s00264-008-0565-4 Wang JP, Yang TF, Kong QQ, et al. Minimally invasive technique versus conventional technique of dynamic hip screws for intertrochanteric femoral fractures. Arch Orthop Trauma Surg . May 2010;130(5):613-20. doi:10.1007/s00402-009-0978-6 Tables Table 1: Pre-operative Data For Both Groups Variable MIDHS (95% CI), n = 5 CDHS (95% CI), n = 10 p-value Age, M 75 (73.5, 80.5) 80 (69.3, 82.7) 0.322 Gender Men: Women 1:4 4:6 0.600 Body mass index (kg/m2), M ± S.D. (R) 22.4 ± 5.1 22.9 ± 3.4 0.354 Charlson comorbidity index, n , M ± S.D. (R) 4.2 ±1.6 2.5 ± 3.5 0.371 Estimated 10-year survival rate (%), M ± S.D. (R) 52 ± 31.4 33.0 ± 40.0 0.440 Premorbid ambulatory status, n Unaided 2 5 0.345 Walking stick 1 2 Walking frame 1 1 Wheelchair 1 1 Homebound 0 1 MIDHS, minimally invasive dynamic hip screw (fixation); CDHS, conventional dynamic hip screw (fixation); M, mean; S.D., standard deviation; R, range; n, number of participants; Hb, haemoglobin; ASA, American Society of Anaesthesiologists’ classification of physical status. *Statistically significant difference, p < 0.05. Table 2 : Surgical And Post-surgical Data For Both Groups Variable MIDHS (95% CI), n = 5 CDHS (95% CI), n = 10 p-value Tip-apex distance (mm), M ± S.D. (R) 12.6 ± 3.88, 95% CI [9.2, 16.0] 14.5 ± 5.23, 95% CI [11.3, 17.8] 0.594 Duration of surgery (min), M ± S.D. (R) 43.8 ± 12.26, 95% CI [33.0, 54.6] 73.4 ± 18.2, 95% CI [62.1, 84.7] 0.019* Days between injury and surgery, M ± S.D. (R) 3.4 ± 4.28, 95% CI [-0.4, 7.2] 1.9 ± 0.7, 95% CI [1.4, 2.4] 0.953 Days of hospital stay, M ± S.D. (R) 8.4 ± 5.5, 95% CI [3.6, 13.2] 9.8 ± 4.5, 95% CI [7.0, 12.6] 0.310 Kyle's classification, n I II III IV 0 3 1 1 6 3 1 0 0.04* ASA classification, n I II III IV 0 3 1 0 0 6 4 0 0.733 Hb loss (g/dl), M ± S.D. (R) 1.9 ± 1.1, 95% CI [1.0, 2.8] 2.1 ± 1.8, 95% CI [1.0, 3.2] 0.898 Number of intraoperative radiographs 91.3 [73.6,108.9] 97.7 [84.7, 110.7] 0.825 Cumulative duration of radiation exposure 72.0 [54.7, 89.3] 70.9 [63.2, 78.6] 0.604 MIDHS, minimally invasive dynamic hip screw (fixation); CDHS, conventional dynamic hip screw (fixation); M, mean; S.D., standard deviation; R, range; n, number of participants; Hb, haemoglobin; ASA, American Society of Anaesthesiologists’ classification of physical status. *Statistically significant difference, p < 0.05. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5219155","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":366005515,"identity":"f90dd751-3093-48eb-a4cc-d3e4dd76466a","order_by":0,"name":"Glen Zi Qiang Liau","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+ElEQVRIiWNgGAWjYDACdhBRIAFkNDAwg0UOENICVmYA1MJzgDQtQCyRQKQWeWfmYw8YDCzkDW6+PSZd8IdBju9GAvPHL3i0GB5mSzcAOsxww+28NOmZbQzGkjcS2KRl8Glp5jGTAGph3HA7x0yat4EhcQNQC7MEXi3830Ba7DfcPGMmzfOHoR6ohfkzPi3yzDxsIC1Aw3mAWtgYEgxuJDBIfsCjxYCZDeyw5JlncoytedskDGeeedgmjUcHg3x78zMJhoo6277jZwxv8/yxkec7nnz44w98thwARs0fBB/kCcYGZh58tjRgE2XEZ8soGAWjYBSMOAAAzfVDpqj5FrEAAAAASUVORK5CYII=","orcid":"","institution":"National University Hospital","correspondingAuthor":true,"prefix":"","firstName":"Glen","middleName":"Zi Qiang","lastName":"Liau","suffix":""},{"id":366005517,"identity":"4f424f97-b9ec-47c1-ac54-8a2a8e3a78a7","order_by":1,"name":"Kamaraj Thirukumaran","email":"","orcid":"","institution":"National University of Singapore","correspondingAuthor":false,"prefix":"","firstName":"Kamaraj","middleName":"","lastName":"Thirukumaran","suffix":""},{"id":366005519,"identity":"925d14c1-fac8-45b6-aadc-f060c1b7075f","order_by":2,"name":"Seth Ian Sim","email":"","orcid":"","institution":"National University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Seth","middleName":"Ian","lastName":"Sim","suffix":""},{"id":366005520,"identity":"11e3bccb-b1aa-4560-a1c6-9068eaa77c11","order_by":3,"name":"Alexander Shao-Rong Pang","email":"","orcid":"","institution":"National University of Singapore","correspondingAuthor":false,"prefix":"","firstName":"Alexander","middleName":"Shao-Rong","lastName":"Pang","suffix":""}],"badges":[],"createdAt":"2024-10-07 15:08:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5219155/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5219155/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":67282935,"identity":"f6fabb56-3f4a-49f4-8fe1-b857c226ebfc","added_by":"auto","created_at":"2024-10-23 09:09:06","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":70766,"visible":true,"origin":"","legend":"\u003cp\u003eIllustration and formula of Tip-Apex Distance \u003csup\u003e16\u003c/sup\u003e\u003c/p\u003e","description":"","filename":"Fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-5219155/v1/b5e2c870d8c4ae1e63e6a441.png"},{"id":67282937,"identity":"63b53008-6231-4c6a-ba09-ab4310012612","added_by":"auto","created_at":"2024-10-23 09:09:06","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":119849,"visible":true,"origin":"","legend":"\u003cp\u003eAP view of 135\u003csup\u003eo\u003c/sup\u003e metal protractor, the vertical limb was overlaid on the patient’s lateral femoral cortex, with the CCD line at the desired height, typically in the lower half of femoral neck and head region\u003c/p\u003e","description":"","filename":"Fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-5219155/v1/3ec9c38bf496acb4320b2761.png"},{"id":67282934,"identity":"2a55c68d-63ed-46e0-9d29-98960ccc9d36","added_by":"auto","created_at":"2024-10-23 09:09:04","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":549822,"visible":true,"origin":"","legend":"\u003cp\u003eAnterior surface markings\u003c/p\u003e","description":"","filename":"Fig3.png","url":"https://assets-eu.researchsquare.com/files/rs-5219155/v1/7212f474e2844cb8a71b9a60.png"},{"id":67282959,"identity":"9d09660f-0232-4c98-bb92-1d7a56cb00c7","added_by":"auto","created_at":"2024-10-23 09:09:06","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":181244,"visible":true,"origin":"","legend":"\u003cp\u003eLateral surface markings\u003c/p\u003e","description":"","filename":"Fig4.png","url":"https://assets-eu.researchsquare.com/files/rs-5219155/v1/b75f0d60f55ef7b55d5ffb91.png"},{"id":67283718,"identity":"7523cba0-49a9-493d-9111-0599d4991e7d","added_by":"auto","created_at":"2024-10-23 09:17:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2016359,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5219155/v1/cc6c07ad-61cc-4a09-901b-1f9b6f0b2ae8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Surgical Fixation of Hip Fractures – A Novel Technique for Pre-Operative Planning","fulltext":[{"header":"1 Introduction","content":"\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003e1.1 Intertrochanteric Hip Fractures\u003c/h2\u003e \u003cp\u003eHip fractures are a commonly encountered injury in the field of orthopaedic surgery. Globally, the number of hip fractures is expected to reach 4.5\u0026nbsp;million by the end of the year 2050, representing a significant increase from 1.26\u0026nbsp;million cases in 1991. \u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e Asia will account for more than half of all hip fractures, due to its rapidly aging population and higher life expectancy. \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Hip fractures represent 0.1% (1.75\u0026nbsp;million disability adjusted life years) of the global burden of disease world-wide. \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eElderly adults are more susceptible to hip fractures as they tend to have reduced mobility and are more likely to have concomitant medical comorbidities. \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e In the United Kingdom (UK), after the age of 50, the lifetime risk of hip fracture is approximately 11% for women and 3% for men. \u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Medical comorbidities such as osteoporosis increase the likelihood of a fragility fracture. \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e An estimated 5.5\u0026nbsp;million men and 22\u0026nbsp;million women in the European Union (EU) alone were estimated to have osteoporosis in 2010. This led to 3.5\u0026nbsp;million new fragility fractures, including 520,000 vertebral fractures, 610,000 forearm fractures, and 1,800,000 hip fractures. \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Majority of hip fractures are caused by falls sustained during regular activities, with a male to female ratio of one to four. \u003csup\u003e8 9\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e1.2 Minimally Invasive Dynamic Hip Screw Fixations\u003c/h2\u003e \u003cp\u003eUse of the Dynamic hip screw (DHS) is a common fixation technique in the stabilisation of intertrochanteric hip fractures. \u003csup\u003e10 11\u003c/sup\u003e However, conventional dynamic hip screw (CDHS) fixation may be limited by longer surgical duration, more extensive soft tissue dissection, increased blood loss, delayed recovery, and prolonged hospital stays. \u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe growing emphasis on optimising patient outcomes and minimisation of surgical trauma has given rise to the development and refinement of minimally invasive dynamic hip screw (MIDHS) fixation. Ideally, a minimally invasive technique should maintain the necessary fixation stability without noticeably shortening the femoral neck or causing rotation or tilting the femoral head. \u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Modification of current surgical techniques has been shown to result in reduced surgical duration, post-operative hospital stays, and blood loss. \u003csup\u003e14 15\u003c/sup\u003e This prospective study aims to evaluate and compare clinical outcomes of patients who have undergone MIDHS with those who have undergone CHDS.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e1.3 Tip-Apex Distance\u003c/h2\u003e \u003cp\u003eTip-apex distance (TAD) is the total distance measured from anteroposterior and lateral views, between the lag screw tip and the apex of the femoral head. \u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e This is illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. For the purpose of the study, the known diameter of the hip screw was used to adjust for radiological magnification.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"2 Methods","content":"\u003cp\u003eA prospective single-blinded case control study was performed. Patients with intertrochanteric (IT) hip fractures who underwent surgical fixation with 4-hole DHS system in a tertiary referral hospital between January 2019 and April 2023 were identified and evaluated for inclusion in this trial. All cases were performed by Senior Orthopaedic Surgery Residents (Orthopaedic Surgery Registrars) of similar experience levels. Patients with complex fractures requiring open reduction were excluded from the study. The study protocol was approved by the Domain Specific Review Board (DSRB) of the institution under Reference number 2023/00715.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e2.1 Novel Technique for Planning Minimally Invasive Surgical Fixation of Hip Fractures\u003c/h2\u003e\n\u003cp\u003eThe authors propose a novel MIDHS technique for treating IT hip fractures, that considers the trajectory of the guidewire in all 3 planes – coronal, sagittal and axial, before any incision is made.\u003c/p\u003e\n\u003cp\u003eCases were performed either under general or spinal anaesthesia. Prior to starting surgery, patients were positioned on a radiolucent fracture table, and all fractures were successfully reduced by closed manipulation under fluoroscopic control to 10 degrees of valgus on AP radiographs and \u0026lt; 58 degrees of posterior angulation on lateral radiographs. The skin surface markings were performed prior to preparation of the surgical field. The intra-operative imaging that was performed during the drawing of the skin markings were performed with the primary surgeon fully protected and comfortable, without wearing lead gown and thyroid shield yet, by standing behind panelled lead shields and/or outside the theatre leaded doors. The primary surgeon re-positioned the protractor as required in between imaging shots. Only the surgical assistant was required to hold a long rod for the purpose of achieving the lateral femur axis marking in the Clements-Nakayama view.\u0026nbsp;\u003csup\u003e17\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAntero-posterior surface marking – Coronal consideration of plate position\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eA metal (stainless steel) protractor that was commercially purchased, was adjusted to the desired pre-templated degree – 135 or 150 degrees and laid directly on top of the patient. Antero-posterior (AP) intraoperative imaging (II) X-rays were taken to obtain and mark the surface position of the DHS plate (Figures 2 and 3). The vertical limb of the protractor was overlaid on the patient’s lateral femoral cortex with the vertical limb overlaid on the patient’s lateral femoral cortex, and the caput-collum-diaphyseal (CCD) line at the desired height, typically in the lower half of femoral neck and head region (Figure 2). The metallic nature of a protractor provided a satisfactory semi-lucent appearance, overlayed clearly over the femur, on the fluoroscopic image taken.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eLateral surface marking – Sagittal and Axial consideration of plate position\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eWith the Clements-Nakayama method\u0026nbsp;\u003csup\u003e17\u003c/sup\u003e – a modified form of lateral view, resulted in a patient specific view of a collinear femoral head to the femoral shaft, which allowed the surgeon to take into consideration the amount of anteversion the specific patient had. With the II in the Clements-Nakayama tilt, a straight ruler was then used to mark the mid shaft of the femur along this view (Figure 4).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eTrigonometrical surface marking – (a) Entry point of guidewire trajectory on skin surface (b) Length of potential incision\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003e(a) The intersection of the extrapolation of the oblique CCD line distally, to meet the Lateral surface marking line, would be the Entry point of the guidewire trajectory on skin surface (Figure 4). This accounted for the thickness of the subcutaneous tissues and musculature of the specific patient.\u003c/p\u003e\n\u003cp\u003e(b) A perpendicular line, from the junction of the vertical limb and CCD angle, was made posteriorly, to meet the Lateral surface marking line.\u003c/p\u003e\n\u003cp\u003eThe line between (a) and (b) – the Liau line – was the length of the potential skin incision to be made (Figure 4). In practice, depending on the thickness, and the turgor of the patient’s soft tissues, this line can be shortened up to 1-2cm proximally, and 2-4cm distally, and retractors may be used to allow for implant insertion.\u003c/p\u003e\n\u003cp\u003eSkin preparation was then done carefully, to avoid erasure of the markings during cleansing. Intra-operatively, after skin incision and exposure, the surgeon may additionally use a free K-wire, and insert it freehand, anterior to the cortex of the femur, to end in the femoral head. This served as a secondary visual guide for the anteversion of the guidewire to be inserted.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis abovementioned method enables surgeons to ascertain a more precise location and trajectory of the guidewire, starting from the entry point on the skin. This allows for a potentially smaller minimally invasive surgical incision. By accurately placing the guidewire with confidence on the first try, it allows surgeons to know the exact distal length of incision required for the DHS plate leading to reduction in soft tissue dissection.\u003c/p\u003e\n\u003ch2\u003e2.2 Pre-operative Parameters\u003c/h2\u003e\n\u003cp\u003ePre-operative clinical data for both groups is presented in \u003cstrong\u003e\u003cu\u003eTable 1.\u003c/u\u003e\u003c/strong\u003e Participants’ age, gender, body mass index (BMI), and premorbid ambulatory status were recorded. Participants’ comorbidities were summarised into a score using the Charlson comorbidity index, alongside an estimated 10-year survival rate which was calculated.\u003c/p\u003e\n\u003ch2\u003e2.3 Surgical Outcome Assessment\u003c/h2\u003e\n\u003cp\u003ePost-operatively, patients received the same treatment and standard rehabilitation protocol established at the tertiary referral hospital. Surgical duration was defined as knife to skin, to completion of skin closure. All patients had their wounds closed in layers, with sutures only - no staplers were used. In all cases, AP and lateral radiographs were obtained post-operatively to assess fracture fixation and implant positioning. Pre- and post-operative haemoglobin levels were measured to assess the amount of blood loss. Two independent assessors measured the TAD using the post-operative AP and lateral radiographs. Discrepancies of \u0026gt; 2mm between the measurements by the two assessors were identified and remeasured. The Kyle’s classification was used to group the IT fractures into four categories – 1, stable 2-part IT fractures without displacement and tearing; 2, stable 3-part IT fractures with displacement and minimal tearing; 3, unstable 4-part IT fractures with displacement and posterior-medial breakage; 4, unstable 4-part IT fractures with posterior displacement, posterior-medial breakage and inferior-trochanterion component.\u0026nbsp;\u003csup\u003e18\u003c/sup\u003e\u003c/p\u003e\n\u003ch2\u003e2.4 Statistical Analysis\u003c/h2\u003e\n\u003cp\u003eIBM SPSS Statistics 26.0 for Mac (SPSS, Chicago, IL, USA) was used for the statistical analysis. Since variables had a frequency of five or more, the chi-squared test was used. Mann-Whitney U-test was used to analyse the continuous variables of non-parametric data. 95% confidence interval was used to provide us with the likely values of the true population mean. The significance tests for each were all two-tailed. Statistically significant difference was defined as p-value \u0026lt; 0.05.\u003c/p\u003e"},{"header":"3 Results","content":"\u003cp\u003e15 patients met the inclusion criteria and were sorted accordingly into the MIDHS or CDHS group. All MIDHS surgeries were performed by a single surgeon, a second- to third-year Senior Orthopaedic Resident (Orthopaedic Surgery Registrar). Other surgeons with similar experience performed CDHS fixation on the control group. Both groups utilised the same implants, sets and tools. The pre- and post-operative clinical information were documented for each case.\u003c/p\u003e\n\u003cp\u003eThe MIDHS and CDHS groups comprised of 5 and 10 patients respectively. Both groups had comparable preoperative demographics, body mass index, comorbidity factors (Charlson Comorbidity index), premorbid ambulatory status, injury mechanism, fracture pattern and time elapsed from injury to surgery. The American Society of Anaesthesiologists (ASA) classification for both groups was also similar. The ASA classification for one patient was not recorded and was excluded from the study. (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003e)\u003c/span\u003e There was a significant difference in fracture type. MIDHS group had more complex fracture types compared to the CDHS group (40% vs 10% of patients being Kyle\u0026rsquo;s 3 or 4, p\u0026thinsp;=\u0026thinsp;0.04). Despite having more complex fracture types, the mean surgical duration in the MIDHS group was significantly shorter as compared to the CDHS group (43.7 vs 73.4 minutes, p\u0026thinsp;=\u0026thinsp;0.019).\u003c/p\u003e\n\u003cp\u003eNo significant difference was found for the following outcome measures: duration of hospital stays (p\u0026thinsp;=\u0026thinsp;0.310), TAD (p\u0026thinsp;=\u0026thinsp;0.594), haemoglobin (Hb) loss (p\u0026thinsp;=\u0026thinsp;0.898), number of intraoperative radiographs (p\u0026thinsp;=\u0026thinsp;0.825) and cumulative duration of radiation exposure (p\u0026thinsp;=\u0026thinsp;0.604). The surgical and post-surgical data for both groups is summarised in Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. Lower mean TAD, Hb loss and duration of hospital stay were observed in the MIDHS group, but the outcomes were not statistically significant.\u003c/p\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eSeveral methods and techniques have been described for the surgical treatment of IT fractures. \u003csup\u003e19 20 21\u003c/sup\u003e DHS is commonly used for treating IT fractures in the elderly as it allows for early remobilisation, is easy to use, and has low complication rates. \u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e However, it is imperative to note that certain parameters such as patient's age, the amount of time elapsed between the injury and surgery, and the presence of medical comorbidities also play a role in treatment outcomes. \u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e Several studies have explored MIDHS fixations with favourable clinical outcomes. However, there are various limitations can be identified in the existing literature.\u003c/p\u003e \u003cp\u003eA similar study conducted by Wong et al. \u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e, the MIDHS group had considerably smaller drops in Hb levels, lower rate of blood transfusions, significantly lower pain scores on the third postoperative day, and significantly lesser overall analgesic use in the first three days. However, Wong\u0026rsquo;s MIDHS method showed no significant difference in surgical duration. Our MIDHS method records lower mean surgical duration, in surgeons of similar surgical experience, suggesting that it may be a superior technique. This may be due to the additional consideration of the anteversion of the femur, with the incorporation of the Clements-Nakayama view. Although Wong\u0026rsquo;s MIDHS group average hospital stay was shorter than that of the CDHS group, neither the difference in complication rates nor the difference in hospital stay duration were statistically significant.\u003c/p\u003e \u003cp\u003eHo et al. \u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e described a minimally invasive technique with significant shortening in the duration of surgery and length of hospital stay. However, the paper considered 2-hole, 3-hole and 4-hole DHS and is not fully relevant to our current study which only studies the use of a 4-hole DHS system. Furthermore, the TAD and Hb loss were also reported to be statistically insignificant as well. This is concurrent with our findings.\u003c/p\u003e \u003cp\u003eLee et al. \u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e reported positive findings with MIDHS with statistically significant haemoglobin loss and length of hospital stay which is inconsistent with our data. However, unlike our novel technique, this study did not prove a statistically significant reduction in surgical duration. Furthermore, they preferred the use of 3-hole side plates, whereas this study used 4-hole side plates. Thus, a direct comparison to their study cannot be made.\u003c/p\u003e \u003cp\u003eWang et al. \u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e reports an MIDHS technique with significantly lower average surgical duration, incision length, blood transfusion rate, and post-operative stay. While Wang had a significantly shorter mean surgical time in the MIDHS group, the mean of 64.8 minutes was much higher than that of ours, with a mean of 43.8 minutes.\u003c/p\u003e \u003cp\u003eOur MIDHS group also showed superior outcomes in mean TAD, haemoglobin loss, and length of hospital stay, though they were not statistically significant. This shows that our novel technique is indeed an improvement to existing surgical techniques and increases the overall standard of care. While our mean TAD is better, there is no consensus in literature regarding the minimum clinically important difference (MCID) with regards to TAD.\u003c/p\u003e"},{"header":"5 Limitations","content":"\u003cp\u003eAlthough the results proved that the proposed technique produced better results as compared to CDHS, there were several limitations of the study as well as the novel MIDHS technique. Firstly, the statistical power of the study was reduced given a small sample size (n\u0026thinsp;=\u0026thinsp;15). The surgical technique was conducted by a single surgeon, and hence the reproducibility of the results must be validated by other surgeons of the same level of experience. Although a larger sample size would be ideal, the surgeon has shown that the duration of surgery was clinically and statistically significantly lower as compared to the CDHS. Although more intra-operative images were taken pre-incision using our novel method, this allowed for fewer intra-operative images, and fewer total images to be taken after skin incision. This reduced wound exposure time, blood loss, and attempts for entry of the guidewire.\u003c/p\u003e \u003cp\u003eA further limitation for both the MIDHS and CDHS groups was the lack of recorded data on the number of repeated attempts needed to achieve satisfactory guidewire placement. However, in the author\u0026rsquo;s experience, a maximum of two to three passes with minimal adjustment were needed to reach the optimal position, due to improved accuracy from the surface markings. The Kyle screw position was not examined in this study. However, MIDHS had a lower TAD as compared to the CDHS control group, which was the most important independent factor when assessing for the optimal positioning of the DHS. All patients included in the study reached union with appropriate TAD targets of \u0026lt;\u0026thinsp;25mm achieved. Lastly, the Harris hip score and Elderly mobility scale, which assess long term rehabilitative progress of surgical patients, were not included as outcome measurements.\u003c/p\u003e"},{"header":"6 Conclusion","content":"\u003cp\u003eMinimally invasive surgeries are known to reduce post-operative complications and morbidity. Our MIDHS technique proved that in comparison to the CDHS, there was no significant difference in hospital stay duration, haemoglobin loss or TAD. However, there was a significant reduction in surgical duration despite the complexity of the cases in our series. Furthermore, the number of passes before guidewire positioning could affect the clinical outcome of the patient and therefore the reliability of the conclusion. This suggests that to ascertain and validate our study further, we need to increase our cohort size, include the number of passes made in both case series, and follow up with our patients over the long term.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAP, antero-posterior\u003c/p\u003e\n\u003cp\u003eBMI, body mass index\u003c/p\u003e\n\u003cp\u003eCCD, caput-collum-diaphyseal\u003c/p\u003e\n\u003cp\u003eCDHS, conventional dynamic hip screw\u003c/p\u003e\n\u003cp\u003eDHS, dynamic hip screw\u003c/p\u003e\n\u003cp\u003eDSRB, Domain Specific Review Board\u003c/p\u003e\n\u003cp\u003eEU, European Union\u003c/p\u003e\n\u003cp\u003eHb, haemoglobin\u003c/p\u003e\n\u003cp\u003eIT, inter-trochanteric\u003c/p\u003e\n\u003cp\u003eMCID, minimum clinically important difference\u003c/p\u003e\n\u003cp\u003eMIDHS, minimally invasive dynamic hip screw\u003c/p\u003e\n\u003cp\u003eTAD, tip-apex distance\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eUK, United Kingdom\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eCompliance with Ethical Standards\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved by the Domain Specific Review Board (DSRB) of the National Healthcare Group (NHG) under Reference number 2023/00715.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.\u003c/p\u003e\n\u003cp\u003eInformed consent for the procedure was obtained from all individual participants involved in the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no external funding.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eConceptualisation, Z.Q.G.L., K.T., A.S.-R.P., S.I.S.; Formal analysis, K.T., A.S.-R.P., S.I.S., Z.Q.G.L.; Writing\u0026mdash;original draft preparation and design figures, K.T., A.S.-R.P., S.I.S., Z.Q.G.L.; Writing\u0026mdash;review and editing, S.I.S., Z.Q.G.L.; Supervision, Z.Q.G.L. All authors have read and agreed to the published version of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eTan LT, Wong SJ, Kwek EB. Inpatient cost for hip fracture patients managed with an orthogeriatric care model in Singapore. \u003cem\u003eSingapore Med J\u003c/em\u003e. Mar 2017;58(3):139-144. doi:10.11622/smedj.2016065\u003c/li\u003e\n\u003cli\u003eVeronese N, Maggi S. Epidemiology and social costs of hip fracture. \u003cem\u003eInjury\u003c/em\u003e. Aug 2018;49(8):1458-1460. doi:10.1016/j.injury.2018.04.015\u003c/li\u003e\n\u003cli\u003eKanis JA, Od\u0026eacute;n A, McCloskey EV, et al. A systematic review of hip fracture incidence and probability of fracture worldwide. \u003cem\u003eOsteoporosis International\u003c/em\u003e. 2012/09/01 2012;23(9):2239-2256. doi:10.1007/s00198-012-1964-3\u003c/li\u003e\n\u003cli\u003eJohnell O, Kanis JA. 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Fragility Fracture Nursing: Holistic Care and Management of the Orthogeriatric Patient [Internet]: Springer; 2018.\u003c/li\u003e\n\u003cli\u003eEmmerson B, Varacallo M, Inman D. Hip Fracture Overview. Internet: StatPearls Publishing; 2023.\u003c/li\u003e\n\u003cli\u003eOrwig DL, Chan J, Magaziner J. Hip Fracture and Its Consequences: Differences Between Men and Women. \u003cem\u003eOrthopedic Clinics of North America\u003c/em\u003e. 2006/10/01/ 2006;37(4):611-622. doi:https://doi.org/10.1016/j.ocl.2006.08.003\u003c/li\u003e\n\u003cli\u003eKyle RF, Cabanela ME, Russell TA, et al. Fractures of the proximal part of the femur. \u003cem\u003eInstr Course Lect\u003c/em\u003e. 1995;44:227-53. \u003c/li\u003e\n\u003cli\u003eBolhofner BR, Russo PR, Carmen B. Results of intertrochanteric femur fractures treated with a 135-degree sliding screw with a two-hole side plate. \u003cem\u003eJ Orthop Trauma\u003c/em\u003e. Jan 1999;13(1):5-8. doi:10.1097/00005131-199901000-00002\u003c/li\u003e\n\u003cli\u003eLee YS, Huang HL, Lo TY, Huang CR. Dynamic hip screw in the treatment of intertrochanteric fractures: a comparison of two fixation methods. \u003cem\u003eInt Orthop\u003c/em\u003e. Oct 2007;31(5):683-8. doi:10.1007/s00264-006-0248-y\u003c/li\u003e\n\u003cli\u003eStoffel K, Zderic I, Gras F, et al. Biomechanical Evaluation of the Femoral Neck System in Unstable Pauwels III Femoral Neck Fractures: A Comparison with the Dynamic Hip Screw and Cannulated Screws. \u003cem\u003eJ Orthop Trauma\u003c/em\u003e. Mar 2017;31(3):131-137. doi:10.1097/bot.0000000000000739\u003c/li\u003e\n\u003cli\u003eAlobaid A, Harvey EJ, Elder GM, Lander P, Guy P, Reindl R. Minimally invasive dynamic hip screw: prospective randomized trial of two techniques of insertion of a standard dynamic fixation device. \u003cem\u003eJ Orthop Trauma\u003c/em\u003e. Apr 2004;18(4):207-12. doi:10.1097/00005131-200404000-00003\u003c/li\u003e\n\u003cli\u003eWong T-C, Chiu Y, Tsang W-L, Leung W-Y, Yeung S-H. A double-blind, prospective, randomised, controlled clinical trial of minimally invasive dynamic hip screw fixation of intertrochanteric fractures. \u003cem\u003eInjury\u003c/em\u003e. 2009;40(4):422-427. doi:10.1016/j.injury.2008.09.029\u003c/li\u003e\n\u003cli\u003eBaumgaertner MR, Solberg BD. Awareness of tip-apex distance reduces failure of fixation of trochanteric fractures of the hip. \u003cem\u003eJ Bone Joint Surg Br\u003c/em\u003e. Nov 1997;79(6):969-71. doi:10.1302/0301-620x.79b6.7949\u003c/li\u003e\n\u003cli\u003eClements RW, Nakayama HK. Radiographic methods in total hip arthroplasty. \u003cem\u003eRadiol Technol\u003c/em\u003e. Mar-Apr 1980;51(5):589-600. \u003c/li\u003e\n\u003cli\u003eBotean AI, Takacs IA, Hardau M. The Study of Massive Trochanterion Fractures. Springer Berlin Heidelberg; 2011:294-297.\u003c/li\u003e\n\u003cli\u003eAudig\u0026eacute; L, Hanson B, Swiontkowski MF. Implant-related complications in the treatment of unstable intertrochanteric fractures: meta-analysis of dynamic screw-plate versus dynamic screw-intramedullary nail devices. \u003cem\u003eInt Orthop\u003c/em\u003e. 2003;27(4):197-203. doi:10.1007/s00264-003-0457-6\u003c/li\u003e\n\u003cli\u003eAune AK, Ekeland A, Odegaard B, Gr\u0026oslash;gaard B, Alho A. Gamma nail vs compression screw for trochanteric femoral fractures. 15 reoperations in a prospective, randomized study of 378 patients. \u003cem\u003eActa Orthop Scand\u003c/em\u003e. Apr 1994;65(2):127-30. doi:10.3109/17453679408995418\u003c/li\u003e\n\u003cli\u003eBarquet A, Francescoli L, Rienzi D, L\u0026oacute;pez L. Intertrochanteric-subtrochanteric fractures: treatment with the long Gamma nail. \u003cem\u003eJ Orthop Trauma\u003c/em\u003e. Jun-Jul 2000;14(5):324-8. doi:10.1097/00005131-200006000-00003\u003c/li\u003e\n\u003cli\u003eM\u0026auml;kinen TJ, Gunton M, Fichman SG, Kashigar A, Safir O, Kuzyk PRT. Arthroplasty for Pertrochanteric Hip Fractures. \u003cem\u003eOrthopedic Clinics of North America\u003c/em\u003e. 2015/10/01/ 2015;46(4):433-444. doi:https://doi.org/10.1016/j.ocl.2015.06.001\u003c/li\u003e\n\u003cli\u003eJensen JS, Sonne-Holm S, T\u0026oslash;ndevold E. Unstable trochanteric fractures. A comparative analysis of four methods of internal fixation. \u003cem\u003eActa Orthop Scand\u003c/em\u003e. Dec 1980;51(6):949-62. doi:10.3109/17453678008990900\u003c/li\u003e\n\u003cli\u003eMarmor M, Guenthner G, Rezaei A, Saam M, Matityahu A. Reporting on quality of reduction and fixation of intertrochanteric fractures-A systematic review. \u003cem\u003eInjury\u003c/em\u003e. Mar 2021;52(3):324-329. doi:10.1016/j.injury.2021.02.014\u003c/li\u003e\n\u003cli\u003eHo M, Garau G, Walley G, et al. Minimally invasive dynamic hip screw for fixation of hip fractures. \u003cem\u003eInt Orthop\u003c/em\u003e. Apr 2009;33(2):555-60. doi:10.1007/s00264-008-0565-4\u003c/li\u003e\n\u003cli\u003eWang JP, Yang TF, Kong QQ, et al. Minimally invasive technique versus conventional technique of dynamic hip screws for intertrochanteric femoral fractures. \u003cem\u003eArch Orthop Trauma Surg\u003c/em\u003e. May 2010;130(5):613-20. doi:10.1007/s00402-009-0978-6\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1:\u003c/strong\u003e Pre-operative Data For Both Groups\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"601\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eMIDHS (95% CI), \u003cem\u003en = 5\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eCDHS (95% CI), \u003cem\u003en = 10\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eAge, \u003cem\u003eM\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e75 (73.5, 80.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e80 (69.3, 82.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.322\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eMen: Women\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e1:4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e4:6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;0.600\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eBody mass index (kg/m2), \u003cem\u003eM\u003c/em\u003e \u0026plusmn; S.D. (R)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e22.4 \u0026plusmn; 5.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e22.9 \u0026plusmn; 3.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.354\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eCharlson comorbidity index, \u003cem\u003en\u003c/em\u003e, \u003cem\u003eM\u003c/em\u003e \u0026plusmn; S.D. (R)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e4.2 \u0026plusmn;1.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e2.5 \u0026plusmn; 3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.371\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eEstimated 10-year survival rate (%), \u003cem\u003eM\u003c/em\u003e \u0026plusmn; S.D. (R)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e52 \u0026plusmn; 31.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e33.0 \u0026plusmn; 40.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.440\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePremorbid ambulatory status, \u003cem\u003en\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eUnaided\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\" valign=\"bottom\"\u003e\n \u003cp\u003e0.345\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eWalking stick\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eWalking frame\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eWheelchair\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eHomebound\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eMIDHS, minimally invasive dynamic hip screw (fixation); CDHS, conventional dynamic hip screw (fixation); \u003cem\u003eM,\u0026nbsp;\u003c/em\u003emean; S.D., standard deviation; R, range; \u003cem\u003en,\u0026nbsp;\u003c/em\u003enumber of participants; Hb, haemoglobin; ASA, American Society of Anaesthesiologists\u0026rsquo; classification of physical status.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e*Statistically significant difference, p \u0026lt; 0.05.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e: Surgical And Post-surgical Data For Both Groups\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"602\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eMIDHS (95% CI), \u003cem\u003en = 5\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eCDHS (95% CI), \u003cem\u003en = 10\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eTip-apex distance (mm), \u003cem\u003eM\u003c/em\u003e \u0026plusmn; S.D. (R)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e12.6 \u0026plusmn; 3.88, 95% CI [9.2, 16.0]\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e14.5 \u0026plusmn; 5.23, 95% CI [11.3, 17.8]\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.594\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eDuration of surgery (min), \u003cem\u003eM\u003c/em\u003e \u0026plusmn; S.D. (R)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e43.8 \u0026plusmn; 12.26, 95% CI [33.0, 54.6]\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e73.4 \u0026plusmn; 18.2, 95% CI [62.1, 84.7]\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.019*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eDays between injury and surgery, \u003cem\u003eM\u003c/em\u003e \u0026plusmn; S.D. (R)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3.4 \u0026plusmn; 4.28, 95% CI [-0.4, 7.2]\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.9 \u0026plusmn; 0.7, 95% CI [1.4, 2.4]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.953\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eDays of hospital stay, \u003cem\u003eM\u003c/em\u003e \u0026plusmn; S.D. (R)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e8.4 \u0026plusmn; 5.5, 95% CI [3.6, 13.2]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e9.8 \u0026plusmn; 4.5, 95% CI [7.0, 12.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.310\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eKyle\u0026apos;s classification, \u003cem\u003en\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eI\u003c/p\u003e\n \u003cp\u003eII\u003c/p\u003e\n \u003cp\u003eIII\u003c/p\u003e\n \u003cp\u003eIV\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.04*\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eASA classification, \u003cem\u003en\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003eI\u003c/p\u003e\n \u003cp\u003eII\u003c/p\u003e\n \u003cp\u003eIII\u003c/p\u003e\n \u003cp\u003eIV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.733\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eHb loss (g/dl), \u003cem\u003eM \u0026plusmn;\u003c/em\u003e S.D. (R)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e1.9 \u0026plusmn; 1.1, 95% CI [1.0, 2.8]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e2.1 \u0026plusmn; 1.8, 95% CI [1.0, 3.2]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.898\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eNumber of intraoperative radiographs \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e91.3 [73.6,108.9]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e97.7 [84.7, 110.7]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.825 \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003eCumulative duration of radiation exposure\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e72.0 [54.7, 89.3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e70.9 [63.2, 78.6]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\"\u003e\n \u003cp\u003e0.604\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eMIDHS, minimally invasive dynamic hip screw (fixation); CDHS, conventional dynamic hip screw (fixation); \u003cem\u003eM,\u0026nbsp;\u003c/em\u003emean; S.D., standard deviation; R, range; \u003cem\u003en,\u0026nbsp;\u003c/em\u003enumber of participants; Hb, haemoglobin; ASA, American Society of Anaesthesiologists\u0026rsquo; classification of physical status.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e*Statistically significant difference, p \u0026lt; 0.05.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Femur, Intertrochanteric fractures, Dynamic hip screw fixation, Minimally invasive surgery","lastPublishedDoi":"10.21203/rs.3.rs-5219155/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5219155/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e: Use of the dynamic hip screw (DHS) is considered the gold standard for hip fracture stabilisation, but conventional DHS (CHDS) fixations may be limited by longer surgical duration and delayed recovery compared to minimally invasive DHS (MIDHS) fixations. We describe a novel low-cost surgical method grounded in trigonometry that reduces intra-operative time, peri-operative complications, and improves overall patient outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: A prospective double-blinded study included 15 patients who underwent surgical fixation of IT hip fractures using a 4-hole DHS system. All surgeries were performed at a tertiary referral hospital between January 2019 and April 2023 by surgeons with similar levels of experience. Main outcome measurements included tip-apex distance (TAD), surgery duration, haemoglobin loss, and hospital stay duration. Two independent assessors measured TAD using the post-operative anteroposterior and lateral radiographs. Kyle's classification was used to categorize the IT fractures. IBM SPSS Statistics 26.0 for Mac (SPSS, Chicago, IL, USA) was used for the statistical analysis. Statistically significant difference was defined as p-value \u0026lt; 0.05.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Both groups had similar baseline characteristics (p \u0026gt; 0.05), except for Kyle's classification (p = 0.04). The MIDHS group had more complex fractures (40% MIDHS Kyle 3/4 vs 10% CDHS Kyle 3/4) but the mean surgical duration was significantly shorter (p = 0.019) (43.8 ± 12.3 minutes) compared to the CDHS group (73.4 ± 18.2 minutes). Postoperatively, there was no significant difference (p\u0026gt;0.05) in hospital stay duration, haemoglobin (Hb) loss, or TAD.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: Despite having more complex fractures, MIDHS group had even shorter surgical duration compared to CDHS group, with no significant difference in TAD, haemoglobin loss and hospital stay duration.\u003c/p\u003e","manuscriptTitle":"Surgical Fixation of Hip Fractures – A Novel Technique for Pre-Operative Planning","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-23 09:08:33","doi":"10.21203/rs.3.rs-5219155/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cec05e4a-e454-4fb9-b2bd-398fd4058369","owner":[],"postedDate":"October 23rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-10-23T09:08:54+00:00","versionOfRecord":[],"versionCreatedAt":"2024-10-23 09:08:33","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5219155","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5219155","identity":"rs-5219155","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}