fractures in adults

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Editors: Bucholz, Robert W.; Heckman, James D.; Court-Brown, Charles M.; Tornetta, PaulTitle: Rockwood And Green's Fractures In Adults, 7th Edition

Copyright 2010 Lippincott Williams & Wilkins

> Table of Contents > Section Four - Lower Extremity > 48 - Intertrochanteric Fractures

48

Intertrochanteric Fractures

Thomas A. Russell

INTRODUCTIONPertrochanteric fractures are those occurring in the region extending from the extracapsular basilar neck region to theregion along the lesser trochanter before the development of the medullary canal. Intertrochanteric and peritrochantericare generic terms for pertrochanteric fractures. Injury creates a spectrum of fractures in this proximal metaphyseal regionof bone, with damage to the mechanically optimized placement of intersecting cancellous compression and tensilelamellae networks and the weak cortical bone with resulting displacement from the respective attachment of musclegroups to the fracture fragments and an adjacent high mobility joint. These structures are subject to multiplanar stressesafter surgical repair. This region of the femur shares many common biomechanical properties with other shortend-segment metaphyseal-diaphyseal fractures with regard to the difficulty in obtaining stable fixation. Althoughpredominantly associated with low-energy older age patients, high-energy trauma in young patients can result in similarpatterns of fracture.

Pertrochanteric femoral fractures are of intense interest globally. They are the most frequently operated fracture type,have the highest postoperative fatality rate of surgically treated fractures, and have become a serious health resourceissue because of the high cost of care required after injury. The reason for the high cost of care is primarily related to thepoor recovery of functional independence after conventional fracture care in many patients. Interestingly there has beenno significant improvement in mortality or functional recovery over the past 50 years of surgical treatment. Paradoxicallythe last 50 years of acquiescence to the status quo of hip fracture treatment are

related to false assumptions that have been a hindrance to improvement in the management of the hip fracture patient: (i)uncontrolled shortening and varus collapse are acceptable in hip fractures but not other fractures; (ii) reduction does notmatter with sliding screw systems, as the fracture will collapse to stability because rotation is not a problem andplacement of the head fixation takes precedence over fracture reduction; (iii) union without implant failure overrides therequirement of a stable anatomic reduction to the detriment of optimal functional recovery; and (iv) the orthopaedicsurgeon just fixes the fracture, as opposed to treating the total musculoskeletal needs of the patient. The reasons forthese assumptions relate directly to the historical evolution of hip fracture treatment and the arguments that shaped ourcurrent understanding. A new paradigm regarding hip fracture care and treatment is currently evolving, which hopefullywill advance our treatment goal back to optimal functional recovery and prevention of future hip fractures.

In 1997 Gullberg et al. estimated that the future incidence of hip fracture worldwide would double to 2.6 million by 2025,

and 4.5 million by 2050.79 The percentage increase will be greater in men (310%) than women (240%). In 1990 26% of all hip

fractures occurred in Asia, whereas this figure could rise to 37% in 2025 and 45% in 2050.143 Hagino et al. reported a

lifetime risk of hip fracture for individuals at 50 years of age of 5.6% for men and 20.0% for women.82 Since 1986 in theTottori Prefecture, Japan, the acceleration of hip fracture incidence continues for both genders.

There is hope that hip fracture risk has begun to decline in certain areas of the world, but the reason is unknown. InDenmark the incidence of hip fractures has declined about 20% from 1997 to 2006; Nonetheless, this decline cannot beexplained by antiosteoporotic medications, whose effect should only be an approximate reduction of 1.3% in men and 3.7%

in women.2 Epidemiologic studies among Olmsted County, Minnesota, residents in 1980 to 2006 revealed that the incidenceof a first-ever hip fracture declined by 1.37%/year for women and 0.06%/year for men. The cumulative incidence of asecond hip fracture after 10 years was 11% in women and 6% in men.

The focus of surgical research regarding internal fixation in the late twentieth century was to minimize implant failure andavoidance of cutout of the femoral head and neck fixation components. Because many of these fractures are associatedwith osteoporosis, the current paradigm shift regarding hip fracture care relates to three main strategies: (i) Prevention byaggressive screening and treatment of patients with high risk for fragility fracture; (ii) standardization of hip fracturecenters with aggressive early intervention and protocols to avoid complications; and (iii) optimization of fracturereduction and new designs of implant component fixation in osteoporotic bone with conceptual design changes in fixationstability and augmentation of the bone-implant interface.

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PRINCIPLES OF MANAGEMENT

Mechanisms of InjuryLow-energy falls from a standing height account for approximately 90% of community hip fractures in patients more than 50years of age, with a higher proportion of women. Higherenergy hip fractures are relatively rare; they are more common in

men less than 40 years of age and are usually referred to regional trauma centers for treatment.100 Cummings et al.43

noted that neither age-related osteoporosis, nor the increasing incidence of falls with age sufficiently explains the

exponential increase in the incidence of hip fracture with aging.43 Their hypothesis was that four conditions correlated fora fall to cause a hip fracture:

(a) the faller must be oriented to impact near the hip; (b) protective responses must fail; (c) localsoft tissues must absorb less energy than necessary to prevent fracture; and (d) the residual energyof the fall applied to the proximal femur must exceed its strength.

This concept applies primarily to strategies to prevent hip fractures. Fall with a rotational component is more common with

extracapsular hip fractures.98

Associated InjuriesIn low-energy falls resulting in hip fractures, associated injuries are most commonly distal radius and proximal humerusfractures and minor head injuries that occur during the fall. High-energy hip fractures are more commonly associated withipsilateral extremity trauma, head injury, and pelvic fractures. Associated injuries or premorbid diseases may coexist withthe fracture diagnosis. Syncopal episodes resulting in a fall may bring attention to cardiovasular and neurologic diseasestates. Primary neoplastic and metastatic disease may reveal their presence with preceding hip discomfort and subsequentfall resulting in fracture.

History and Physical ExaminationPatients most commonly present with a history of pain and inability to ambulate after a fall or other injury. The pain islocalized to the proximal thigh and is exacerbated by passive or active attempts of hip flexion or rotation. Drug use, eitherillicit or precribed pharmacologics, must be sought out as a confounding and contributing factor. Nursing home andinstitutionalized patients must be examined for the potential of neglect and abuse in the form of previous fractures, andinjuries in different states of repair and decubiti.

The physical findings of a displaced hip fracture are shortening of the extremity and deformity of rotation in the restingposition compared with the contralateral extremity. Pain with motion or crepitance testing is not elicited unless there areno physical signs of deformity and radiographic studies are negative for an obvious fracture. Pain with axial load on the hiphas a high correlation with occult fracture. The auscultation Lippmann Test is quite sensitive for the detection of occult

fractures of the proximal femur or pelvis.132 By placement of a stethescope bell on the symphysis pubis and tapping on thepatella of both extremities, variations in sound conduction through the pelvis and hip from the patella result when there isany discontinuity. A decreased tone or pitch implies fracture within this arc of bone.

Laboratory studies in addition to the standard workup for surgery should include the following for all low-energy fractures(osteopenic or fragility fractures): serum calcium, phosphate, and alkaline phosphatase; a complete blood-cell count(CBC); 25 hydroxyvitamin D, thyroid-stimulating hormone (TSH); parathyroid hormone (PTH intact); serum proteinelectrophoresis

(SPEP); and kidney-function tests, including blood urea nitrogen (BUN), creatinine, and glomerular filtration rate

(GFR).45,206

A search for high-risk potentially preventable complication includes: previous DVT/PE, anticoagulation medications,immune deficiency disorders, malabsorption disease, angina or CVA prodromal symptoms of atherosclerotic disease, andactive infection (pulmonary, genitourinary), which might result in sepsis postoperatively. Protein-calorie malnutrition andvitamin D deficiency are now recognized as serious risk factors for mortality and recovery. Foster reports 70% mortality for

patients with albumin less than 3 compared with a mortality rate of 18% in patents with albumin 3.61 Vitamin D deficiencyis now viewed as an epidemic because of dietary changes and lack of sunlight exposure; current recommendations are to

administer 50,000 IU of vitamin D immediately to all elderly patients on admission with hip fracture.206

Imaging and Other Diagnostic StudiesPlain radiographs including an AP pelvis, AP, and cross table lateral of the affected hip are usually recommended fordiagnosis and preoperative planning. Traction films are helpful is comminuted and high-energy fractures in determining


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implant selection.117 Subtrochanteric extension requires full-length femoral AP and lateral radiographs for implant lengthselection. If a long nail implant is a consideration, then AP and lateral radiographs of the affected femur to the knee arerequired, with special attention to femoral bow and medullary canal diameter. Traction views with internal rotation may

be of benefit preoperatively as an aide in the selection of definitive internal fixation.117

Computed tomography (CT) or magnetic resonance imaging (MRI) scans are rarely required for displaced fractures but may

be useful in establishing the diagnosis in nonobvious fractures and atypical fractures in high-energy trauma patients.181,209

The MRI does not necessarily require a full study, as the frontal images are most often diagnostic. Nonetheless, completestudies usually detect other diagnosis for hip pain in addition to occult fractures of the proximal femur. MRI is preferredover the CT or the older radionuclide scans because of a higher sensitivity and specificity for a more rapid decision

process.*

In actual practice, the best radiographic analysis of hip fractures occurs in the operative suite with fluroscopic C-armviews. This technology gives the surgeon an excellent modality for fracture analysis in complex fractures and immediatefeedback as to the stability of the fracture after the initial reduction. In many institutions this has led to elimination ofpreoperative lateral radiographs. Unfortunately this practice may also result in a change in the selected type of fixationwith inherent stress on the operative team and resource management.

DIAGNOSIS AND CLASSIFICATIONClassifications for extracapsular fractures of the hip occurring from the basicervical to the level of the subtrochantericregions have not been particularly helpful in clinical situations. Nonetheless, increased sugical complexity and recoveryare associated with unstable fracture patterns. Unstable characteristics include posteromedial large separatefragmentation, basicervical patterns, reverse obliquity patterns, displaced greater trochanteric (lateral wall fractures),and failure to reduce the fracture before internal fixation. Stability after surgical treatment connotes anticipated unionwithout deformity or implant failure. The current controversy of implant selection is largely focused on what amount ofdeformity and fracture site motion is still compatible with a functional recovery to the patient's preinjury status.

There is no single classification system that has achieved reliable reproducible validity. In 1822 Astley Cooper (London)described the first (pre-radiographic) classification of hip fractures: intracapsular and extracapsular fractures (with themain complication of nonunion and avascular necrosis in the first and the second of coxa vara).

In 1949 Boyd and Griffin described the first treatment recommendation classification, predictive of the difficulty ofachieving, securing, and maintaining the reduction in four fracture types: (i) Stable (two part); (ii) unstable withposteromedial comminution; (iii) subtrochanteric extension into lateral shaft extension of the fracture distally at or just

below the lesser trochanter (the term reverse obliquity was coined by Wright);220 and (iv) subtrochanteric withintertrochanteric extension with the fracture lying in at least two planes (Figure 48-1). They were the first to report theuse of lateral buttress plating of the greater trochanter to avoid medialization of the shaft in type 3 fractures, the needfor two-plane fixation for type 4 subtrochanteric fractures with a coronal fracture line, and the possibility ofiatrogenicconversion of type 1 and 2 fractures to type 3 during implant preparation and insertion.


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FIGURE 48-1 Boyd and Griffin classification: (i) stable (two-part), (ii) unstable comminuted, (iii) unstable reverseobliquity, (iv) intertrochanteric-subtrochanteric with two planes of fracture.

Also in 1949 M. Evans (Birmingham, England) reported on a post-treatment classification with five types described. Hecompared nonoperative treatment and fixed angle device surgical treatment. He documented that 72% of his fracturescould be fixed in a stable configuration. Stability was not achieved in 28% of the fractures; 14% as a result of the fracturepattern or comminution and 14% of which he felt the reduction was never achieved (Figure 48-2). This paper was primarilyused to argue the value of internal fixation over nonoperative treatment of hip fractures, which was controversial inEngland in the 1940s and 1950s.

In 1979 and 1980, respectively, Kyle et al. and Jensen et al. reported independently on a revision of the Evansclassification incorporating the lateral radiographic position of the posteromedial fracture component and its relation to


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stability with sliding fixation systems.104,122 Kyle et al. showed an increased rate of deformity and collapse with increasinginstability classification. Jensen et al. related the ability to reduce the fracture and secondary displacement risk with aCHS-type device in their classification system.

FIGURE 48-2 Evans classification of trochanteric fractures. Type 1: Stable because either undisplaced or displacedbut anatomically reduced to stability (intact medial cortex). Type 2: Unstable implies displaced and fixed in anunreduced position, comminuted with destruction of the anteromedial cortex, or reversed obliquity.

The OTA/AO classification is now the most quoted in recent scientific articles and is a derivative of the Muller classification(Figure 48-3). There is a higher interobserver agreement with the AO/OTA classification than Evans/Jensen, but neither

meets the acceptable threshold for reliability.64 The AO/OTA has nine main types; however, correlation is best with only

three categories; also there is no lateral radiographic parameter with the AO/OTA classification.156,175,188 Generally 31A1fractures are thought of as the most stable, 32A2 fractures are more unstable, and 31A3 fractures are the most unstablewith plate device

fixation. Unfortunatedly, the fifth digit of the classification has not been found to be reliably identifiable in prospectiveevaluation.


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FIGURE 48-3 In the OTA alphanumeric fracture classification, intertrochanteric hip fractures comprise type 31A.These fractures are divided into three groups, and each group is further divided into subgroups based on obliquityof the fracture line and degree of comminution. Group 1 fractures are simple (two-part) fractures, with the typicaloblique fracture line extending from the greater trochanter to the medial cortex. The lateral cortex of the greatertrochanter remains intact. Group 2 fractures are comminuted with a posteromedial fragment. The lateral cortex ofthe greater trochanter, however, remains intact. Fractures in this group are generally unstable, depending on thesize of the medial fragment. Group 3 fractures are those in which the fracture line extends across both the medialand lateral cortices. This group includes the reverse obliquity pattern.

Gottfried and Kulkami et al. have developed the most recent therapeutic-based classification, again derived from a

modification of the Evans and Jensen classification,120 primarily focusing on the stability of the lateral wall as a buttress tominimize medialization and uncontrolled collapse after single screw device fixation. Kyle has recently added another veryunstable pattern to his previous classification. In this variant, the fracture line includes a separate femoral neck fracture;

he concluded that this variant should not be treated with a sliding hip screw device.121

SURGICAL AND APPLIED ANATOMY AND COMMON SURGICAL APPROACHES

Surgical and Applied AnatomyThe pertrochanteric region is quite variable in its combination of cortical and cancellous bone structure. Thewell-vascularized pertrochanteric region is dependent on the structural integrity of a laminated cancellous bone arcadefrom the femoral head and epiphyseal scar, around Ward's triangle to the lesser trochanter, where the solid nature of thestructure changes to a tubular construct with the origin of the femoral medullary canal; the strong plate of bone

posteriorly is named the calcar femorale (Figure 48-4).65 This is the region most affected with the posteromedial fracturecomminution leaving only the anteromedial cortex potentially stable.

The main structural attachments to the proximal femur include the hip capsule and the musculotendinous junctions of thegluteus medius and minimus (greater trochanter), iliopsoas (lesser trochanter), pirifomis and short external rotators(posterior trochanteric region from the greater trochanteric region to the lesser trochanter), the oblique head of therectus femoris (anterior capsule), and the vastus lateralis (lateral femur distal to the greater trochanter). The hip capsuleis especially important in reduction of pertrochanteric fractures and its continuity with the distal fragment is the softtissue attachment on which a stable reduction is possible (Figure 48-5).

With capsular disruption, the displacement of the fracture fragments is dependent on the musculotendinous attachment tothe respective fragments. The greater trochanter is abducted and externally rotated by the gluteus medius and shortexteral rotators, the shaft is displaced posteriorly and medially by the adductors and hamstrings. This accounts for theusual shortening and coxa vara deformity of displaced fractures. With aging the morphology of the hip changes withthinning of the cortex and expansion of the diameter of the bone (Figure 48-4C). The younger hip fracture patients has arelatively narrow metaphysis and a high narrow isthmus with a very thick cortex in the diaphysis. Further aging results in aslight widening and thinning of a cortex of the metaphysis, with bone loss and a decreased thickness of the diaphysealcortical bone stock and a widening of the isthmus. In the advanced age group, there is a very wide vacuous metaphysis


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proximally with loss of tension and compression trabeculae, a loss of the constriction of the isthmus, and a very roundexpanded tubular-shaped femur with a thin cortex Three types of morphologic anatomy were grouped together by Dorr et

al. in 1983 referencing the selection of cemented versus non-cemented arthroplasty femoral components48 (Figure 48-6).The same rationale applies to implant selection for hip fracture patients. Type A femurs occur primarily in young patientsand have a narrow metaphysis, thick cortex, and high constricting isthmus. Excessive bone removal is required forintramedullary devices, and either a plate-type construct or smaller-diameter reconstruction nail may be more boneconserving. Type B fracture morphology has a wider metaphysis and larger medullary canal, but relatively good cortex andisthmus constriction. Type C is the most problematic in geriatric populations with hip fractures: a wide metaphysis, widemedullary canal, and loss of isthmus constriction in association with loss of cortical diaphyseal bone stock. There

is a trend to prefer long intramedullary implants in these patients; however, care must be taken that the straightened thin

diaphyseal cortex may be at risk of perforation distally by long devices in the anterior supracondylar area.157

FIGURE 48-4 A. Posteromedial calcar shelf, which is usually damaged with unstable fracture patterns. B. Wardcrosssection of proximal femur. Best quality bone is within 10 to 30 mm of subarticular surface. Note tensile


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trabeculae between Ward's triangle and greater trochanter. C. Changes in morphology of bone with age: adaptationto maintain whole bone strength. Note expansion of geometry and thinning of cortical bone with aging. (C adaptedfrom Seeman E. Pathogenesis of bone fragility in women and men. Lancet 2002;359: 1841-1850, and Seeman E.Periosteal bone formationa neglected determinant of bone strength. N Engl J Med 2003;349:320-323.)

FIGURE 48-5 A. Anterior hip capsule. Y-Ligament of Bigalow as structure for ligamentotaxis in closed reduction ofstable Fractures. B. Posterior hip capsule. Note more-proximal position of capsule posteriorly and course of arteriesto head.

The neurologic structures of interest are the femoral nerve anteriorly and sciatic nerve posteriorly; however, they arerarely encountered in surgical approaches for repair of pertrochanteric fractures and are injured only rarely by

penetrating trauma, usually by displaced fracture fragments.49,112,140,152,179,212 Vascular injury affecting the femoral head

is rarely involved in nonpenetrating injuries.192 Brodetti noted the rare possibility of injury to the vascularity of thefemoral head with femoral head fixation screws and nails with injection studies, and found that the central and inferior

locations were safe zones.28 Avascular necrosis after pertrochanteric fracture is extremely rare because of the relativeprotected area of the medial circumflex artery with pertrochanteric fractures, but may develop in 0.5% to 1% of

pertrochanteric fractures usually within 4 years of injury.13,69


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FIGURE 48-6 Dorr classification of morphology of femur. Type A corresponds to a small metaphysis, thick cortex,and high narrowed isthmus. Type B corresponds to a wider metaphysis, thinner cortex, and a tapering but wideristhmus. Type C corresponds to a wide metaphysis, thin cortex, and a straight or varus curvature in the diaphysiswith loss of isthmus constriction.

Common Surgical Approaches

Lateral Approach to the Proximal FemurThis approach has been relatively standardized over the past 70 years for plate fixation. The patient is commonly operatedon with a fracture table and the leg and foot secured after closed reduction. The entire proximal thigh from the iliac areato the distal femur is prepared in the standard fashion. The incision length is based on the length of the proposedplate-shaft component;

the incision is started with reference from intraoperative C-arm fluoroscopy views and is centered over the lessertrochanter. Commonly the incision length is 5 to 10 cm in length. The iliotibial band is incised and the proximal portion isextended sufficiently to develop the area of the intertrochanteric line for palpation anteriorly. The fascia of the vastuslateralis is incised near its attachment posteriorly at the linea aspera. Leave sufficient fascia posteriorly (5 to 10 mm) forclosure and to identify and obtain hemostasis of all perforator arteriovenous structures. Reflect the vastus anteriorly,exposing the lateral femoral shaft. There are no significant neurologic or vascular structures at risk with this approach(Figure 48-7).

Intramedullary ApproachThe incision for nail insertion is determined by the intersection of a line from the anterior superior iliac spine directedposteriorly and a line parallel to the long axis of the femur. Overlay a 3.2 guidewire on the skin anteriorly and laterally andconfirm alignment with the proximal femur with C-arm. Incise the skin proximal to the greater trochanter. Usually a 3- to5-cm incision is adequate. The fascia is incised, but the gluteus medius fibers are not dissected, as this approach isdesigned to minimize soft tissue damage around the proximal femur. A targeting guide and trocar system protects thegluteus medius. Separate incisions for the femoral head fixation are made through the short version of the lateralapproach to the femur (Figure 48-8).

Watson Jones ApproachThis anterolateral approach to the hip is actually a proximal expansion of the straight lateral approach previously


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described. The muscular interval proximally is between the tensor fasciae latae and the gluteus medius. The intervalbetween these two muscles is best begun distally and exposed proximally. Follow the anterior border of the vastus lateralisproximally to reach the anterior trochanteric ridge and hip capsule. The use of Schanz pins drilled into the proximal femuris an aide in retraction for better visualization and may be used for manipulation of the shaft. Further capsulotomy andgreater trochanteric osteotomy are rarely required for pertrochanteric fracture management. The main vascular obstacleis the ascending branch of the lateral femoral circumflex artery, which should be isolated and ligated in the approach.Complete proximal dissection of the gluteus medius and tensor fasciae latae interval to the iliac crest is rarely necessary;the superior gluteal nerve to the tensor fasciae latae is sacrificed with full proximal dissection; however, this not clinicallysignificant (Figure 48-9).

FIGURE 48-7 Lateral surgical approach to the hip. Slight curvature of proximal extent of incision to allow palpationof the anterior cortex. Vastus lateralis reflection distally as needed for length of plate.

CURRENT TREATMENT OPTIONS

Evolution of TreatmentThe importance of understanding the evolution of treatment concepts regarding pertrochanteric fractures is critical toadvancing treatment modalities. Those who are ignorant of the past are condemned to repeat its mistakes.

Initial treatment in the 1800s in England focused on the work of Pott and Cooper, who advocated supporting the thigh in aflexed position. Early mobilization of the patient from bed rest to chair to protective ambulation was the primary goal forsurvival of the patient. They espoused benign neglect of the

fracture in an attempt to save life over limb.41 The other school was founded by Hugh Owen Thomas of Liverpool, who

advocated immobilization and prolonged bed rest.20


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FIGURE 48-8 Intramedullary approach. Incision is placed center to slightly posterior to line of femoral shaftcentered between the anterior superior and inferior iliac spines anteriorly. Incision length is 2 to 4 cm.

Whitman in 1902 re-evaluated the role of neglect of this type of fracture and advocated reduction and stabilization with

traction, abduction, and internal rotation, to better restore the anatomy of the hip.217 This was performed under generalanesthesia; then the patient was placed in a long leg hip spica cast to maintain the reduction. This basically moved thetreatment of hip fractures from a passive to an active role by the surgeon.


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FIGURE 48-9 Watson-Jones approach. Key interval between TFL and G. Medius to visualize anterior femoral neckand capsule.

Whitman reflected in 1938 on the evolution of hip fracture treatment from 1900.218

At the beginning of this century, fracture of the neck of the femur was a therapeutic derelict. Thefutility of conventional treatment, demonstrated by Sir Astley Cooper, had been accepted as afinality and permanent disability as an inevitable sequence of the injury. Neglect of the fracture inthe alleged interest of the patient entailed no responsibility, either moral or legal. Positivetreatment, by contrast, could appeal only to adventurous spirits, because the correction ofdeformity might

break up the sacrosanct impaction, the only hope of union; whereas the restraint of the plasterspica must endanger the life of the patient. During the lapse of years, nonetheless, in spite ofopposition and inertia, the abduction treatment has come into general use, and experience hasdisproved every assumption on which the negative doctrine was based.

Whitman foresaw the replacement of nonoperative treatment with operative treatment, with the success of the Smith-Petersen nail as the next progression to restore the limb and decrease mortality.

In the 1800s, Langebeck and others attempted internal fixation of the hip from a transtrochanteric insertion, but problems

with material compatibility and the rigors of surgery resulted in the failure of these techniques.127 William Lane, Albin

Lambotte, and Ernest Hey-Groves were the pioneers, who developed the modern principles of osteosynthesis.93,124,125,126

The advent of radiology prompted a re-evaluation of hip fracture treatment, and in 1911 the Section of Surgery of theBritish Medical Association reviewed a series of patients with the use of a new technique of radiographic imaging andconcluded that operative treatment should be performed early when necessary and that function seemed to be correlated

with absence of radiographic deformity.93 The real modern era of internal fixation of hip fractures began with the report

of the technique by Smith-Petersen in 1925 and his invention of the triflange nail for hip fractures.197 The triflange designcontrolled rotational instability and was strong enough for patient mobilization. It was used for both trochanteric andfemoral neck fractures. Brittain using a very low placement on the lateral cortex of the femur treated pertrochanteric

fractures with the Smith-Petersen nail, presaging the later high angle type devices.27,108 Sven Johansson in Sweden


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developed the technique simultaneously with Westcott in the United States of a radiographic controlled insertion of the

Smith-Petersen Nail without arthrotomy 1932.68,215 This was termed blind nailing, and began the movement towardminimally invasive surgery. Johansson also is credited with developing the first cannulated Smith-Petersen nail. In 1934King and Henderson independently reported the use of K-wires for provisional fixation, as described by Lambotte for

guidance and proper placement of the Smith-Petersen nail.90,115

In the 1930s, Henry, Littman, Henderson, and others reported on the use of a lag screw type devices instead of

nails.91,92,131 It was not until the late 1930s and early 1940s that plate attachment to the femoral head fixation truly lay thegroundwork for the movement from nonoperative to surgical treatment for pertrochanteric fractures. Lawson Thornton is

credited with the first attachable side plate bolted to a Smith-Petersen nail205 in 1937. Within 10 years there was an

explosion of new devices. The Jewett Nail, which was a triflange nail welded to a plate for shaft fixation.107 Jewett wasthe first to advocate the open reduction of the lesser trochanter (posteromedial fragment) with separate screws toincrease the stability of the fracture. Blount in conjunction with Moore in the 1940s actually coined the terminology and

concept of blade plates.22,144 Neufeld in California and Capener in the United Kingdom developed the fixed-angle type nail

plate in 1944.33,203 Trochanteric buttress plates were first reported by Boyd and Griffin in 1949 (they were invented by

Richardson at the Campbell Clinic) for preventing medialization with the Neufeld plate in unstable fractures.26 Boyd

reported on refinements of the buttress technique in 1961, including screw fixation into the trochanter.25

The primary motivation of surgical implants in the 1930s and 1940s was the belief that surgical fixation decreased mortalityfrom prolonged bed rest and eliminated the need for spica casts. Early reports suggested that patients could be mobilizedmore rapidly and with less hospitalization time. In 1949, Evans reported on the use of a Neufeld nail type technique withopen reduction compared with nonoperative treatment for fractures and favored surgical repair on the basis of fourparameters that are still pertinent today: (i) Greater pain relief and comfort of the patient; (ii) improved early patientmobility; (iii) economy of bed control for nursing and hospital efficiency; and (iv) lower mortality rate (18% compared with

33% for nonoperative treatment).56

The mechanical analysis of hip fracture fixation began in the 1940s with the realization of the magnitude of the hip forces

by Inman and the effect of compression on healing by Eggers.51,103 Smith developed mechanical cadaver testing to

reproduce fractures and determine the forces required for their causation.196 In a review of implant failures, Taylor and

Neufeld proposed the need for implants with sufficient fatigue life and the importance of stable reductions.203 In 1956

Martz presented the first load to failure testing for common hip implants of the day.138 In analyzing stresses on the humanfemur, Martz pointed out that on average walking subjects the femoral head to forces in the vicinity of 400 lb because ofmomentum and leverages. He applied the engineering rule of thumb, calling for a safety factor of two, arriving at a forceof 800 lb (3200 Newtons) as adequate resistance to load of a proximal fixation system. Foster advocated higher angle

nail-plates to minimize the load on the implants base on geometric assumptions on loading.60 Cleveland argued that even

with optimized designs some small percentage of implant failure would still occur.40

In 1963 Holt argued that implant failure was related to inadequate mechanical design.95 He was the first to theorize thatthe rotation was unlikely for pertrochanteric fractures to justify his design of a round nail plate (fixed angle design)eliminating flanges on the femoral head component for rotational control in distinction to previous derivative plates fromSmith-Petersen's original concept. He believed it unlikely that the proximal fragment of an intertrochanteric fracturecould rotate after the fracture was reduced, the nail inserted, and the plate fixed to the shaft because of engagement ofbone fragments at the fracture site. He did not detect any evidence of rotation in the follow-up of the 100 fracturesincluded in the using his design and technique. He also was the first to advocate full weight-bearing after surgery when theimplant's fatigue resistance was adequate for unrestricted loading. Interestingly, he used bolted shaft fixation screwsthrough the plate.

The invention of sliding compression with a cannulated system of drilling and insertion was invented by Godoy-Moreira and

is the precursor of this class of implants in 1938.73 As with other devices, it was originally designed for femoral neckfractures with the focus of minimizing implant failure. The author also believed that the compression generated by thescrew and side bolt would prevent any rotation or flexion at the fracture site. Schummpelick et al. described an implantdesigned by E. Pohl in Kiel, Germany (the same man who designed for G. Kntscher) of a sliding cannulated system with a

side-plate in 1952.190 Interestingly they did report telescoping of the implant

with collapse of the fracture, leading to a Trendelenburg gait in some patients. They also reported on the concept of earlyweight-bearing with the sliding hip screw.

In 1955 to 1958 Pugh and Massie reported success with the application of sliding with a nail plate device to minimize medial

penetration of the femoral head and early fatigue failure.139,178 Full weight-bearing was not advised for 4 to 6 months withthese devices. Interestingly Pugh attempted to classify the results on a functional basis, but because of the variations inage, as well as the variation in the general physical status of these patients this was deemed impractical. In the cases inwhich solid union occurred the result was considered good or satisfactory. The first commercially available slidingcompression hip screw in the United States was introduced in 1956 in cooperation with K. Clawson of Seattle and McKenzie


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of Scotland manufactured by Richards Manufacturing Company of Memphis, Tennessee.38,39 Their modifications included ablunt-tipped cannulated screw design coupled to a forged side plate of optional lengths and neck angles. There was akeyed slot for enhanced rotational stability. The follow-up series from Mullholland at Clawson' institution (now HarborviewTrauma Center) in 1975 showed that functional status preoperatively correlated with the postoperative recovery and

mortality seemed to improve with experience with the use of this device.151

The desire to increase stability of unstable fracture patterns with proactive valgus oteotomies was popularized by Dimon

and Houston, Sarmiento, Harrington, and others in the 1960s to 1970s.47,87,187 Nonetheless, prospective studies andmeta-analysis comparing the results with sliding hip screws type designs showed no mortality or functional improvement

with osteotomies and a higher risk of blood loss.46,67,87,169

In 1979 to 1980 the issue of stability versus union with sliding devices was focused by Kyle et al. and Jensen et al., both ofwhom reported independently on a revision of the Evans classification incorporating the lateral radiographic position of

the posteromedial fracture component and its relation to stability with sliding fixation systems.104,122 Kyle et al. showed anincreased rate of deformity and collapse with increasing instability classification. Nonetheless, they reported that the useof a high-angle sliding nail technique with prophylactic antibiotic, thromboembolism prophylaxis, and early mobilizationwas acceptable for mortality and fixation failure. They did not advocate the use of osteotomy. In their functionalevaluation they considered occasional pain, permanent limp, and use of a cane a good result. Jensen et al. related theability to reduce the fracture and secondary displacement risk with a CHS type device in their classification system. Withanatomic reduction in both planes with a stable medial cortex, no secondary displacement occurred. In nonanatomicand/or unstable fractures they reported a 25% to 69% rate of secondary displacement. In their statistical analysis, thecorrelation with secondary displacement was not an unstable pattern but a lack of reduction. Regarding the position of thetip of the device, Jensen et al. advised placement over 10 mm from the articular surface and Kyle et al. within 10 mm tominimize cutout. The question that has persisted is how to address the secondary displacement problem.

In the 1980s to 1990s renewed interest in hip fracture failures led to a new approach to fixation. In the plate field, Medoffintroduced the biaxial compression hip screw for unstable fractures, which actually allowed axial compression along theshaft reminiscent of an Egger's plate concept in addition to dynamic compression at the screw plate interface in the

head.142 This biaxial compression concept was proved effective to minimize implant failure in unstable fractures, but with

increased shortening of the leg.135,213 The re-emergence of the importance of rotational instability as a problem in 2000prompted Gottfried to develop the PCCP plate system, which consisted of a side plate with two constrained partiallythreaded lag type screws reminiscent of a reconstruction nail-type pattern that optimized the rotational stability of the

hip and minimized damage to the greater trochanter (lateral wall of the femur).75 Preliminary reports suggest that patientsmay have a trend toward earlier functional recovery with this type of device, although further studies are needed. Lockedand hybrid locking plates have been applied recently for unstable fractures with only preliminary reports thus far.

Cephalomedullary implants are devices inserted with a closed technique and fluoroscopic control with variable lengthfemoral geometry and enhanced proximal geometry to permit fixation with nails or screws into the femoral head. Theyevolved from the Y-nail design of G. Kntscher in 1940, described in the marrow nailing method in the translation prepared

by the U.S. naval forces, Germany technical section in 1947, discovered in 2006.123 This was a nonlocking unreamed nailwith an impaction-type nail component for the femoral head driven through a perforation in the centromedullary nail. TheZickel nail primarily developed for subtrochanteric fractures was another impaction-type nail for the femoral head, butwith no distal locking capability. The TFN (Synthes, Paoli, PA) is the most recent addition to this class of implant.

The Grosse-Kempf gamma nail and the Russell-Taylor reconstruction nail were the start of two new classes ofintramedullary devices designed for the hip region; they coincided with the widespread adoption and popularity of closedinterlocking techniques in the 1980s and 1990s. These devices made use of a compression screw inserted into anintramedullary device instead of a nail for the femoral head component. The gamma nail used an expanded head geometryof 17 to 18 mm with a large single lag screw, and the reconstruction nail allowed a smaller head geometry of 15 mm withtwo smaller lag screws for the head component. Both devices have evolved over the past 20 years, with the moderndesigns moving toward a 4- to 5-degree proximal bend with a medial or tip trochanteric portal instead of a lateraltrochanteric or piriformis portal, respectively.

In 2004 the InterTAN class cephalomedullary nail (Smith-Nephew, Memphis, TN) began clinical studies. It has a trapezoidalcross-sectional geometry to protect the lateral wall of the greater trochanter and a hybrid nail design similar to a hipprosthesis stem for proximal nail stability in the shaft as well as linear compression through an integrated screw constructin the femoral head, resulting in much greater resistance to rotational instability and cutout.

Nonoperative TreatmentNonoperative treatment should only be considered in nonambulatory or chronic dementia patients with pain that iscontrollable with analgesics and rest, terminal disease with less than 6 weeks of life expected, unresolvable medicalcomorbidites that preclude surgical treatment, and active infectious diseases that preclude insertion of a surgical implant.


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An exception to this consideration are incomplete pertrochanteric fractures diagnosed by MRI, which have been shown toheal with conservative

measures in selected patients.4,189 Nonoperative management must include attentive nursing care with frequentpositioning to avoid decubiti, attention to nutrition and fluid homeostasis, and adequate analgesis/narcotic painsuppression. Fracture callus formation at 3 weeks markedly decreases motion-related pain, and by 6 weeks most patientscan be lifted into a wheelchair or reclining chair. Ambulatory capablility should not be anticipated after nonoperativetreatment. Meta-analysis of randomized trials does not suggest major differences in outcome between conservative andoperative management programs for extracapsular femoral fractures, but operative treatment appears to be associated

with a reduced length of hospital stay and improved rehabilitation.162 Opponents of nonoperative treatment even fornonambulatory patients suggest that surgery is more effective for pain relief and does not result in unacceptable increasedmortality or complications.

If nonoperative care is selected because of an excessively high risk of mortality form anesthesia and surgery, the patient isnonambulatory and has minimal discomfort from the fracture, or modern medical facilities are unavailable, then the

strategy previously discussed by Cooper20 of rapid mobilization to chair and an upright chest position is recommended.Mobilization is necessary to minimize decubitus, pneumonia, and dementia. This form of treatment precludes any future

independent mobility.170

Operative TreatmentOnce selected, surgical management should be performed as soon as any correctable metabolic, hematologic, or organsystem instability has been rectified. Usually this is within the first 24 to 48 hours. The literature is inconclusive as toincreased mortality after this time, but patient suffering and hospital efficiencies demand timely intervention. Holt et al.found that case mix variables (age, gender, fracture type, prefracture residence, prefracture mobility, and ASA scores)were the critical aspects of potential for mortality even when corrected for time of fracture to treatment, admission timeto surgery, and grade of surgical and anesthetic staff undertaking the procedure. Centers with experience and protocolsfor the rapid diagnosis and treatment of hip fractures can effectively decrease the hospitalization time and complication

risks for these injuries.172,204 Interestingly, earlier surgery has not been found to be associated with a higher mortality or

morbidity.113 Browne et al. found that surgeons with low volumes of experience (fewer than seven cases per year)compared with high-volume hip fracture surgeons (more than 15 cases per year) had higher rates of mortality andcomplication, but that high- versus low-volume hospitals were associated only with shorter hospital stay and lower nonfatal

morbidity.30

TABLE 48-1 Classification of Plates

Class Examples Failure Modes

Impaction Blade plates Medial penetration

Nail plates Breakage

Dynamic compression Sliding hip screw Cutout

Adjustable hip nails Plate pull-off

Dynamic helical blades

Linear compression Gotfried PCCP Less risk of cutout?

InterTAN CHS


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Hybrid locking Proximal femoral locking plates Plate failure

Surgical implant options included plate and screw constructs, either nail or screws for the head fixation, nail constructswith either nail or screws, external fixation, and arthroplasty. Generically these options can be grouped to designs withcommon biomechanical behaviors, techniques, complications, and results. The literature is exhaustive, with series ofspecific techniques and implants designs and a fair number of meta-analyses and randomized prospective studies.

Plate constructs may be grouped into four functional types:

Impaction class: Impacted nail-type plate devices (e.g., blade plates, fixed angle nail plate devices)1.

Dynamic compression class: Large single sliding screw or nail femoral head components with side plate attachments(e.g., standard sliding hip screws)

2.

Linear compression class: Multiple head fixation components controlling rotation and translation but allow linearcompression (e.g., Gotfried PCCP and the InterTAN CHS)

3.

Hybrid locking class: Multiple fixation components with compression initially for fracture reduction followed by lockingscrews which prevent further axial compression; these types of fixation are the most stable (e.g., proximal femorallocking plates [Synthes, Paoli, PA, and Smith-Nephew, Memphis]) (Table 48-1).

4.

Impaction or fixed angle plating today is more commonly used for corrective osteotomies rather than as a primarytreatment for hip fractures. MacEachern reported on the difference of failure mechanisms with medial penetration of the

joint with the Jewett Nail compared with the sliding hip screw.136 Attempts at modifying the results of nail plates withosteotomies fell out of favor when comparisons were made with sliding hip screw devices with anatomic reduction only

giving equivalent results with less blood loss and more rapid operative times.169

Chinoy et al.169 in a 1999 meta-analysis, compared accurately fixed nail plates with sliding implants involving a total of 2855patients. Results showed an increased risk of cutout (13% vs. 4%), nonunion (2% vs. 0.5%), implant breakage (14% vs. 0.7%),and reoperation (10% vs. 4%) for fixed nail plates in comparison with the sliding implants. In addition, patients treated withfixed nail plates had a higher mortality and the survivors were more likely to have residual pain in the hip and

impaired mobility. The continued use of fixed nail plates gave way in the 1980s to the unequivocal superiority of the sliding

hip screw due to these complications.36,166

Dynamic Compression PlatingFrom the 1980s to 2000, sliding compression hip screws became the gold standard for hip fracture fixation, and manysurgeons still contend its usefulness in all fractures largely because of the reports of Clawson, Mulholland, and

meta-analysis studies by Parker et al. from 2000 to now (Figure 48-10).164,167,168 In 1983 Rao evaluated 162 cases ofunstable intertrochanteric fractures treated by anatomic reduction and compression hip screw fixation. After compressionwas applied, 90% of the fractures moved into medial displacement position; 8% laterally displaced; and 2% maintained theiranatomic alignment. Loss of fixation with unacceptable varus angulation of the fracture occurred in 4% of cases. Onehundred ten patients were bearing full weight an average of 3 weeks after operation. They stated that the advantages ofthe sliding hip screw were that weight-bearing could start early; the device was applicable to stable and unstableintertrochanteric fractures with identical technique; and the fixation maintained acceptable alignment.

Kyle et al. advocated 150-degree Massie telescoping nails with a center-center head position within 10 mm of thesubchondral bone for all fractures, anatomic reduction, prophylactic antibiotics, prophylactic anticoagulation, and earlyambulation, without osteotomy or interfragmentary fixation except as a consideration for unstable components in Kyletype 4 in conjunction with delayed ambulation (although they noted its ineffectiveness). In classifying their outcome data,they considered a good result as normal hip range of motion, a noticeable limp, occasional pain, and routine use of acane; and with this definition they achieved a 96% good and excellent functional result.

The Medoff sliding plate (Medpac, Culver City, CA) design uses a biaxial sliding hip screw (Figure 48-11). It has a standardlag screw/barrel component for compression along the femoral neck. In place of the standard femoral side plate, it uses acoupled pair of sliding components that enable the fracture to impact parallel to the longitudinal axis of the femur. Alocking set-screw may be used to prevent independent sliding of the lag screw within the plate barrel; if the locking setscrew is applied, the plate can only slide axially on the femoral shaft (uniaxial dynamization). If the surgeon applies theimplant without placement of the locking set screw, sliding may occur along both the femoral neck and femoral shaft(biaxial dynamization). For most intertrochanteric fractures, biaxial dynamization is suggested.


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FIGURE 48-10 Compression hip screw components: lag screw, blunt tip, side-plate of fixed angle and cortical shaftscrews.


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FIGURE 48-11 Medoff sliding plate.

Watson et al. compared the Medoff plate with a standard sliding hip screw in a prospective randomized series of 160 stable

and unstable intertrochanteric fractures; follow-up averaged 9.5 months (range, 6 to 26 months).213 Although stablefracture patterns united without complication in both treatment groups, there was a significantly higher failure rate withuse of the sliding hip screw for unstable fractures (14% vs. 3%). No differences were observed between the two devices interms of length of hospitalization, return to prefracture ambulatory status, postoperative living status, or need forpostoperative analgesic medication. Nonetheless, use of the Medoff plate for all fracture types was associated withsignificantly greater blood loss and operating time.

Olsson et al. reported on a prospective randomized series of intertrochanteric fractures stabilized using either a Medoff

plate or conventional sliding hip screw.153,154 In unstable fracture patterns, mean femoral shortening was significantlygreater with use of the Medoff plate (15 vs. 11 mm), but the sliding hip screw was associated with more medialization ofthe femoral shaft. All failures occurred in the sliding hip screw group.

Ekstrom et al. compared the proximal femoral nail (PFN, Synthes) and the Medoff sliding plate (MSP) in patients withunstable trochanteric or subtrochanteric fractures. They reported that the ability to walk 15 meters at 6 weeks wassignificantly better in the PFN group compared with the MSP group, with an odds ratio 2.2 (P = 0.04, 95% confidence limit,1.03 to 4.67). Reoperations were more frequent in the PFN group (9%) compared with the MSP group (1%), but there were

no other significant differences.53

The current literature suggests that there is no difference in mortality or functional recovery between compression hipscrews and intramedullary nails with single device fixation in the femoral head. Interestingly the term malunion of apertrochanteric fracture dropped out of usage after the 1970s and the emphasis was placed on implant failure.

Recently the sliding hip screw and similar devices have come

under scrutiny for its application to all fractures. Haidukewych et al. noted a higher rate of failure with sliding hip screws

for reverse obliquity intertrochanteric fractures caused by excessive medialization.85 Gotfried noted the high failure rate

with associated lateral wall fractures with compression hip screws.76 The effect of shortening of the limb and changes inabductor function with collapse has always been in the background of the hip literature.

In a retrospective analysis of postoperative fracture collapse in 142 patients with intertrochanteric hip fractures fixedanatomically with sliding hip screws, Bendo et al. found collapse (as defined by strict radiographic criteria relating theheight of the femoral head to the greater trochanter and Doppelt's criteria) was seen in 26 of the unstable fractures. Ofthe patients with moderate or severe collapse, 93% had a poor functional result, whereas all the patients with minimalcollapse remained asymptomatic. Although postoperative fracture impaction of hips fixed with sliding screws may promoteearly healing, a high rate of union, and a low rate of hardware failure, excessive collapse is a problem that must be


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addressed.18

Platzer et al. expressed concern about the amount of shortening with compression hip screws in non-geriatric patients

with compression hip screw fixation.177 The concern that many surgeons share is the question of functional impairmentwith excessive dynamic collapse. Zlowodzki et al. recently quantified a lower SF-36 score with shortening more than 5 mm

in femoral neck fractures;224 it may be that the transitional displacement during the first 6 weeks after surgery withcompression side plates may be an underlying problem with recovery after surgery. Kamath et al. documented significantly

more collapse with compression hip screws in basicervical fractures compared with reconstruction nail type constructs.109

When the lesser trochanter was intact, plate fixation was associated with ten times more collapse than nail fixation (8.1 vs.0.7 mm); and with complete displacement of the lesser trochanter, the relative shortening was twice as much for the plategroup versus the nail group (16.1 vs. 8.1 mm). Su et al. reported a greater tendency to collapse and pain increase with

basicervical fractures compared with intertrochanteric fractures treated with compression hip screws (Figure 48-12).200

Pajarinen et al. reported less deformity with nail devices compared with SHS and recommended over correction of the hip

into valgus to anticipate the varus collapse with SHS.160

Moroni et al. have explored the potential of augmenting the stability of the compression hip screw with hydroxyapatitecoating. One hundred twenty patients with AO, A1, or A2 trochanteric fractures were selected. Patients were divided intotwo groups and randomized to receive a 135-degree four-hole dynamic hip screw fixed with either standard lag andcortical AO/ASIF screws or HA-coated lag and cortical AO/ASIF screws. Lag screw cutout occurred in four patients in withconventional uncoated lag screws but no cutout occurred in the HA group. The femoral neck shaft angle collapse from anaverage 134 degrees postoperatively to 127 degrees at 6 months in the standard CHS group; but in the HA-coated group,the femoral neck shaft angle was 134 degrees postoperatively and 133 degrees at 6 months. The Harris hip score was higher

at 6 months in the coated group (60 vs. 71), although the study was relatively small.146

Rotationally Stable PlatingRotational stable plating differs from dynamic compression plating by adding enhanced rotational stability with multiplescrew fixation in the femoral head. Because the screws are coupled to the plate, the rotational stability is much betterthan an accessory screw adjacent to standard single screw fixation (Figure 48-13). The percutaneous compression plate byGotfried (Orthofix, McKinney, TX) has two smaller-diameter lag screw/barrel components, which stabilize the femoralhead and neck. This device was designed with a minimally invasive surgical technique. The two lag screw components (9.3-

and 7.0-mm diameter) provide enhanced rotational stability of the proximal fracture.77 The device is available only in135-degree angles. It was reported initially by Gotfried in 98 fractures with good results and no collapse, head penetration,or cutout. The InterTAN CHS (Smith-Nephew) consists of a 127- and 135-degree design with two integrated screws, withthe option of locked or standard shaft fixation.


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FIGURE 48-12 Healing short CHS AP radiograph. Healing of 31A1 fracture with shortening. Note accessory lag screwback out and compression screw prominence in soft tissues.

In 2007 Peyser et al. found in their randomized trial comparing dynamic hip screw and PCCP that the pain score and abilityto bear weight were significantly better in the PCCP group at 6 weeks postoperatively. Radiographically there was areduced amount of medial displacement in the PCCP group (two patients, 4%) compared with the CHS group (10 patients,

18.9%).176 In a recent presentation of a randomized prospective group of dynamic hip screw versus PCCP, Yang

documented improvements in pain and ambulatory ability with improved SF-36 scores in the PCCP group.222

Panesar161 performed a meta-analysis review of comparative trials (1995 to 2006) comparing the dynamic hip screw and thePCCP. There was a decreased trend in overall mortality in the PCCP group [CI 0.84 (0.48 to 1.47)]. Similar trends favoring


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the PCCP technique were seen with other outcomes. A large randomized controlled trial was recommended. Other deviceswith enhanced rotational stability, such as the InterTAN CHS

and the helical blade plate, are now being studied (Figures 48-14 and 48-15).

FIGURE 48-13 A. Percutaneous compression plate (PCCP). B. InterTAN CHS device. Similar to CHS design butincorporates compression mechanism in second inferior screw for enhanced rotational stability.

Hybrid Locking PlatesWith the success of locking and hybrid locking plates with unstable fractures of the distal femur, the same concepts arebeing applied to the proximal femur. The devices offer maximal stability with initial compression, and fixed angle stability

from locking screws.106 Initial results are mixed because of early failure rate with original plate designs and three screwlimitations. Newer devices with enhanced fixation strength may be helpful in complex intertrochanteric fractures withsubtrochanteric extension (Figure 48-16).


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FIGURE 48-14 PCCP reduction and fixation. Note inferior placement of bottom screw and protection of the greatertrochanter by distal plate position.

Cephalomedullary DevicesCephalomedullary devices are inserted through the piriformis fossa, lateral greater trochanter, or medial greatertrochanter. The femoral head portion of the fixation construct consists of one or more screw or blade devices interlockedwith the nail component of the construct. Cephalomedullary nails are most commonly indicated in pertrochanteric andsubtrochanteric fractures, and although there is occasional overlap of these regions, the personality of the fracture will bepredominantly one of these major types. These nails are designed to have either a pirforimis portal for insertion, usuallywith the shaft component straight in the AP plane, or a trochanteric portal, with the shaft component laterally angulated


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proximally. Modern trochanteric designs have moved to a 4-degree proximal bend positioned above the lesser trochanteric

region, which seem to function best.158

Cephalomedullary nail constructs have been similarly classified by Russell into four classes (Table 48-2),183 listed here inorder of invention:

The impaction class or Y nail class originated with the Kntscher Y nail and current TFN Nail (Synthes) (Figure 48-17A).1.

The dynamic compression or gamma class pioneered by the Grosse and Kempf Gamma Nail (Stryker-Howmedica), whichconsists of a large head nail component (15.5 to 18 mm) with a single large lag screw (Figure 48-17B and 17E).

2.

The reconstruction class developed by Russell and Taylor (Smith-Nephew) (Figure 48-17C), with a smaller headdiameter (13 to 15 mm) and using two lag screws that are independent of each other.

3.

The integrated class, consisting of a nail design cross-section with the stability of a arthroplasty hip stem andintegrated two-screw construct with linear compression at the fracture site, developed by Russell and Sanders (Smith-Nephew) (Figure 48-17D).

4.

FIGURE 48-15 InterTAN CHS case. A. Preoperative radiograph showing 31A2 fracture with greater trochanteric


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fracture lines and lesser trochanteric fracture. B. AP postoperative radiograph showing fixation. Stability of greatertrochanter is maintained. C. Lateral postoperative radiograph.

Impaction Class (Y-Nail, TFN)Davis et al. assessed outcomes and the etiology of mechanical failure in a series of 230 intertrochanteric femoral fractures

internally fixed with either a sliding hip screw or a Kntscher Y-nail.44 The cutout rate for the Y-nail was 8.8% versus 12.6%for the sliding hip screw overall. Cutout was related to the quality of the fracture reduction; age, walking ability, andbone density had no significant influence on cutout. Center-center placement of the head component correlated with lesscutout, and posterior placement increased cutout with both groups. Y-nail cutout or medial penetration increased witharticular placement less than 10 mm from the tip of the nail (23% Y-nail, 11% CHS), whereas Y-nail medial penetration

decreased with tip placement greater than 10 mm (3% Y-nail vs. 18% CHS).44

The TFN (Synthes) device reintroduced an impaction nail component for the femoral head of a helical blade design of 11

mm inserted into a nail with a 17-mm proximal geometry. There are short and long interlocking versions.66 In abiomechanical study Sommers et al. showed better resistance to rotation with the helical blade compared with single screw

designs.198 The surgical technique precludes reaming of the femoral head, thus saving bone stock and preventing

instability of the fracture by a loose nail. Gill et al.,72 comparing CHS with TFN, revealed fewer blood transfusions withCHS and faster operative time for the TFN group. Gardner et al. reported subtle migration (approximately 2 mm) of the tipof the blade within the femoral head in all fractures, but this did not preclude maintenance of reduction and fracturehealing. They noted that telescoping averaged 4 mm and did not affect stable fixation or fracture healing. All positionchanges occurred within the first 6 weeks

postoperatively.66 Weil et al.214 reported medial penetration with the TFN analogous to the Y-nail type penetrationsdescribed earlier. All eight clinical cases involved an unstable intertrochanteric fracture pattern (AO/OTA 32A2).


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FIGURE 48-16 Hybrid locking plate system (Smith-Nephew, Memphis, TN).

Dynamic Compression Class (Single Screw Head Component)Since the introduction of the Gamma nail in the early 1980s, an exhaustive series of studies have guided its use andmodifications. Although initially a lateral trochanteric entry nail with a 10-degree angle and a short nail, the design is nowin its third major revision with decreases to 15.5 mm in head geometry from 17 mm. Angulation has decreased to 4 degreesfor a tip trochanter entry site, and its distal geometry has been tapered for less risk of periprosthetic femur fractures (itsmain detraction in early studies). The IMHS is a similar class nail with a sliding sleeve in the barrel to promote dynamiccompression (Figure 48-17E). The clinical studies must be referenced to the different designs and time periods for correctanalysis. Adams et al. reported a prospective randomized study comparing a sliding hip screw with an intramedullary nail


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for treatment of intertrochanteric fractures.3 Two hundred and three patients were stabilized with a short gamma nail, 197received a sliding hip screw. Patients were followed for 1 year. Use of the gamma nail was associated with a nonsignificanthigher risk of postoperative complications and equivalent union and functional results.

TABLE 48-2 Classification of Nails

Class Examples Failure Modes

Impaction Y-Nail, TFN Medial penetration

Dynamic compression Gamma, IMHS Cutout

Peri-implant failure with short designs

Two-screw dynamic compression Reconstruction Z-effect

Linear compression integrated InterTAN Unknown

In 1988 Hardy et al. reported the intramedullary hip-screw device compared with the CHS was associated with significantlyless sliding of the lag-screw and subsequent shortening of the limb in the region of the thigh. Patients whose fractureswere stabilized using the intramedullary hip screw experienced significantly better mobility at 1 and 3 months follow-up.This difference was no longer seen at 6 and 12 months, although patients who received the intramedullary device enjoyedsignificantly better walking ability outside the home at all time periods.

Currently Parker et al. report that there is no consensus regarding the superiority of the dynamic compression nails or

plate type devices and that future studies with the same devices are unneccesasry.168 There is also evidence that thecomplications with nail devices are more frequent. Despite this evidence, the trend for intramedullary fixation has

increased in the United States.7

Reconstruction Nail Class (Two Screw Head Components)Reconstruction nails (Smith-Nephew) were initially developed by Russell and Taylor in the early 1980s primarily for complexsubtrochanteric fractures and pathologic fractures. In 1991, the Russell-Taylor reconstruction nail was first described for

intertrochanteric fractures in four cases.97 Different versions of this class have in common a smaller diameter head (13 to15 mm) with two lag screws of various diameters with long and short interlocking versions. The original piriformisreconstruction nail has been modified for medial trochanteric portal insertion, which simplifies treatment forpertrochanteric fractures. Piriformis reconstruction nails do no have optimal containment in the trochanter because oftheir posterior placement in relation to the femoral head and neck; they transfer essentially all the load to the headscrews. Trochanteric versions allow better containment of the nail in the proximal femur and are optimally placed tominimize femoral neck shortening (Figure 48-18).

Seif-Asaad reported good results in 40 patients using the Variwall reconstruction nail for unstable intertrochanteric

fractures with 12 patients having subtrochanteric extension.191 Thirty-nine patients healed without deformity, shortening,or varus collapse.

Little et al., using the Holland nail in a comparative series with CHS, demonstrated less blood loss and transfusion, nocutout in the nail group, and all fractures united in the Holland

nail group.133 In a more complex group with both pathologic and multiple trauma cases, Krastman et al. reported an 89%

union rate with Holland nails in two cases with screw penetration of the femoral head.118 The PFN (Synthes) was associatedwith a high implant failure rate and the Z-effect of overpenetration of the cephalic screw proximally and backing out of

the inferior screw and has been discontinued in the United States.10,31,59,194 The device brought attention to the

differences in bone quality and effect of rotation with this type of fixation (Figure 48-19).199


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FIGURE 48-17 A. Short trochanteric fixation nail (TFN). B. Short gamma 3 intramedullary nail. C. Short trochantericantegrade nail (TAN). D. Short InterTAN cephalomedullary nail with integrated screw design and hybrid stem design.E. Short intramedullary hip screw (IMHS).

InterTAN Class (Integrated Nail and Screws with Linear Compression)The InterTAN nail is a titanium alloy nail with a proximal femoral cross-section similar to a press-fit arthroplasty stem forshaft stability, an integrated screw mechanism that provides linear compression of the fracture while moving the stemtoward the medial femoral cortex with compression and stress relieving the lateral wall. It is a trapezoidal designproximally with a 16-mm diameter that tapers like a hip stem with a 4-degree bend for medial trochanteric insertion. It isavailable in 125- and 130-degree

designs, long and short. The short version includes dynamic locking above a split tapered tip design to minimize implantstress in the diaphysis. Like the gamma and Y-nail class nails, it is indicated for older patients with pertrochantericfractures with Dorr B and C type morphology (Figure 48-20).


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FIGURE 48-18 A. 31A3 with subtrochanteric extension. B. Reduction and repair with long TriGen trochantericreconstruction nail. C. Recon case lateral postoperative radiograph.

In 2009 Ruecker et al. reported results with the InterTan femoral head for the treatment of intertrochanteric fracturesthat uses two screws in an integrated mechanism, allowing linear intraoperative compression and rotational stability of the

head/neck fragment.182 One hundred consecutive patients with an intertrochanteric fracture were treated with the newtrochanteric antegrade nail (Smith-Nephew). The mean age of the patients was 81.2 years. Thirty-seven patients died. Theaverage surgical time was 41 minutes (13 to 95 minutes). All fractures healed within 16 weeks (range, 10 to 16 weeks).Forty-eight remaining cases had detailed radiographic analysis at healing that revealed no loss of reduction, nouncontrolled collapse of the neck, no nonunions, no femoral shaft fractures, and no implant failures. Two cases in theseries were poorly reduced and settled into varus malalignment. No varus malposition was seen in the remaining 46fractures. The mean prefracture Harris hip score was 75.1 13.4, and at the time of follow-up was 70.3 14.5 (P = 0.003);58% of the patients recovered prefracture status. They concluded that the InterTAN device appeared to be a reliableimplant with stability against rotation and resultant neck malunions (shortening) through linear intraoperative compressionof the head/neck segment to the shaft. Further studies are in process for comparative analysis.


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FIGURE 48-19 Demonstration of the Z effect, with one screw penetrating the hip joint and the other screwbacking out of the nail. (Courtesy of Enes Kanlic MD, Texas Tech University Health Sciences Center, El Paso, TX.)

External FixationExternal fixation as a treatment for pertrochanteric fractures was evaluated in the 1950s, but its use was unsuccessful

because of high rates of pin-tract infections, subsequent pin loosening, instability, and failure.12,78,119 Renewed interestin this technique occurred recently with the new fixation designs and the addition of hydroxyapatite coated pintechnology. The addition of the HA coated half-pins with the Orthofix pertrochanteric fixator by Moroni et al. has resulted

in equivalent if not better results than compression hip screws in 31A1-A2 osteoporotic fractures.148 There were no pintract infections and equivalent functional results by the Harris hip score comparisons (approximately 62 for both groups).


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More interesting is the lower rate of varus collapse of on average 2 degrees versus 6 degrees for the CHS group. The CHSgroup averaged 2 units of blood replacement versus none for the external fixation group. Surprisingly, the externalfixation group reported equivalent or slightly less pain than the CHS group (Figure 48-21).

FIGURE 48-20 A. 31A3 fracture with C-type morphology. B. Reduction and stabilization with InterTAN nail. Notealignment of nail paralleling the anterior cortex proximally. C. InterTAN case lateral postoperatively. D. Long nailselection due to wide diaphysis with loss of isthmus anatomy owing to aging and osteoporosis. E. Union withoutcollapse or backing out of proximal fixation. F. Note medialized nail position owing to integrated screw mechanisminducing translation of nail to medial cortex, unloading lateral wall.

External fixation as reported by Moroni et al. may be indicated in osteoporotic hip fractures in elderly patients, who maybe deemed at high risk for conventional open reduction and internal fixation, or for those who cannot receive bloodtransfusions because of personal conviction or religion. It may be superior to standard compression hip screws in thesepatient groups.

ArthroplastyArthroplasty either hemiarthroplasty or total hip arthroplasty, often with calcar replacement type components, is rarely

indicated in pertrochanteric fractures.211 Arthroplasty may be justified in neoplastic fractures, severe osteoporoticdisease, renal dialysis patients, and pre-existing arthritis under consideration

for hip replacement before the fracture occurred. Hemiarthroplasty, usually cemented, has been reported to have a lowerdislocation rate compared with total hip arthroplasty. Haentjens et al. reported on 37 patients more than 75 year old withunstable intertrochanteric or subtrochanteric fractures from 1983 to 1986. Functional results were rated as good to

excellent in 75% of patients, but there was a mortality rate of 36% and a dislocation rate of 44%.81 In a review of 29 THA


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and 5 HA patients with an average age of 80 years, Berend et al. reported 26/34 deaths within the study period of 12 years,with five patients requiring revision surgery for dislocation. They did not believe their results supported the routine use of

arthroplasty in this elderly patient group.19

FIGURE 48-21 A. Preoperative radiograph showing a pertrochanteric fracture in an 83-year-old woman. B.Immediate postoperative radiograph. (From Moroni A, Faldini C, Pegreffi F, et al. Osteoporotic pertrochantericfractures can be successfully treated with external fixation. J Bone Joint Surg Am 2005;87:47.)

Conversely, between 1992 and 2005 Geiger et al.70 compared the mortality risk and complication rate after operativetreatment of pertrochanteric fractures with primary arthroplasty, dynamic hip screw (DHS), or proximal femoral nail in thisretrospective study. Of these 283 patients, 132 were treated by primary arthroplasty, 109 with a DHS, and 42 with a PFN.Mortality was significantly influenced by age, gender, and comorbidities, but not by fracture classification. Primary hiparthroplasty did not bear a higher 1-year mortality risk than osteosynthesis in a multiple regression analysis. The maincomplication with DHS and PFN were cutting out of the hip screw and nonunion, with a revision rate of 12.8%. With theintroduction of hemiarthroplasty instead of total hip arthroplasty, the postoperative dislocation rate decreased from 12%to 0%. In a randomized study, Kim et al. found a lower mortality and less blood loss with a cephalomedullary nail compared

with a cementless calcar replacement arthroplasty with equivalent functional results.114

The general consensus is that arthroplasty is a better salvage operation for failed internal fixation than a first-line choicein the geriatric fracture patient; and there is no level-one evidence to show any difference between compression hip

screw and arthroplasty, with the exception of a higher blood transfusion rate with arthroplasty.165

AUTHORS' PREFERRED TREATMENTPreoperative Planning

Lambotte described the four components of surgical treatment of fractures at the turn of the twentiethcentury, and they are as applicable today as then.124,125 The first is exposure of the fracture, whichtoday means visualization of the fracture deformity, and the safest approach to ensure reduction


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and placement of the implant in the correct position. The second is reduction of the fracture, which iscritical to the stability and functional recovery of the patient. Inadequate reduction is the majorpreventable etiology for lost reduction and implant failure in pertrochanteric fractures. The third stepis provisional fixation in an anatomically reduced position; this is frequently the most neglected step inhip fracture surgery. This involves the reduction of the fracture and then maintenance of the fracturewith either provisional Kirschner pins and/or clamps to hold the fracture in position while the bone isprepared for the definitive implant. The last step is definitive fixation, which should maintain thereduced fracture in an acceptable anatomic and functionally correct position until fracture healing iscomplete.

Definitive fixation selection is a process of elimination. The OTA/AO classification is a good startingpoint for determination of fracture treatment. Conceptually, the 31 A1 fracture can be treated withbasically any of the previous implants if the bone quality and morphology are acceptable. The mostcommon plan is the sliding hip screw system. Nevertheless, external fixation, intramedullary nailtechniques, and linear compression type devices could be chosen for osteopenic individuals. Externalfixation might be used for patients who are too ill for conventional open reduction based on thesuggestions from medical and anesthesia consultants. For 31A2 and A3, I prefer techniques with lesspotential for instability after fixation (Figure 48-22).

I use the fracture morphology Dorr classification to optimize the size of the implant footprint for thebone stock available. For Dorr A type fractures, with small canals, a plate device or reconstructionclass nail is chosen for bone conservation. For Dorr B type fractures, either a short nail or side plateis equally efficacious. For Dorr C type anatomy, a larger diameter cephalomedullary nail may offeradvantages. My personal preference is to use a longer nail for A3 type fractures. The results withlocking plates are relatively recent and most reports have primarily been descriptive in nature. Theprimary indication of these devices may be A3 type fractures with multifragmentary type patterns (31A 3.3) and those with the extensive subtrochanteric extension. Trochanteric buttress plating is helpfulfor compression hip screws to minimize medialization of the shaft in unstable fractures or fixation ofdisplaced trochanteric wall fractures.

FIGURE 48-22 Implant selection variables.

Intraoperative length measurements with the C-arm of the normal femur may be helpful in selectingthe correct length nail in complex fractures (Figure 48-23). Determination of preoperative neck-shaftangle and medullary canal diameter is paramount to selection of the correct nail device, as differentmanufacturers have different neck shaft angle and diameter nails. Another important consideration isnail curvature for long nails. One and a half to two meter radius nails are applicable to mostsituations. It is important to note that multiple variables come into play in deciding on the treatmentof hip fracture. As the entry portal and hip fracture nailing has moved from a piriformis or a lateraltrochanteric portal to a medial trochanteric portal at the tip of the trochanter, the alignment of thecurvature of the long nails is more compatible with the distal femoral anatomy. For the intermediatesizes of bone, either plate and screw devices or short intramedullary nails may be appropriate.

Positioning


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Intramedullary techniques for the proximal femur are best managed with a modern fracture table withimage intensification (C-arm) capabilities. Although the lateral decubitus approach may be helpful forreverse obliquity patterns, the supine position is usually preferred because of the ease of setup andradiographic visualization in a familiar frame of reference. We prefer bilateral foot traction with kneesin extension with the legs scissored. The operative leg is raised to approximately 20 to 30 degrees offlexion, and the nonoperative extremity is extended 20 to 30 degrees. The legs arepulled in line with the body to avoid varus positioning of the hip. The C-arm is brought in from theopposite side with the base parallel to the operative extremity centered on the mid-femur such thatthe cepalad-caudad movement of the C-arm gives good visualization of the femoral head and shaft inAP and Lateral views. With this type of set up, the true AP of the hip is usually obtained with 10 to 20degrees of rotation of the C-arm over the top, and the true lateral corresponds to approximately 15 to30 degrees over the horizontal position (Figure 48-24).

FIGURE 48-23 Using contralateral extremity to measure nail selection for comminuted fracture. Nail packagewith anticipated nail length measured with intraoperative C-arm. Locate nail to lie at tip of greater

trochanter to distal physeal scar. This length allows adequate length restoration.


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FIGURE 48-24 A. Conventional C-arm position will

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