Intertrochanteric Fractures - Ten Tips to Improve Results

Intertrochanteric Fractures:Ten Tips to Improve Results

By George J. Haidukewych, MD

An Instructional Course Lecture, American Academy of Orthopaedic Surgeons

Intertrochanteric fractures are becom-ing increasingly common as our popu-lation ages. These fractures typicallyoccur in frail patients with multiplemedical comorbidities and often resultin the end of the patients functionalindependence. The all-too-often prob-lematic dispositions and prolongedhospital stays result in a tremendouscost to patients, their families, andsociety. Effective treatment strategiesthat result in high rates of union of thesefractures and low rates of complicationsare important. As orthopaedic surgeons,we cannot control the quality of thebone, patient compliance, or comor-bidities, but we should be able tominimize the morbidity associated withthe fracture. This requires choosing theappropriate fixation device for thefracture pattern, recognizing the prob-lem fracture patterns, and performingaccurate reductions with ideal implantplacement while being conscious ofimplant costs. If we treat these fracturesexpeditiously, minimize fixation fail-ures, and recognize underlying osteo-porosis and treat it accordingly, we willimprove our patients outcomes and

minimize the cost of treating them. Thepurpose of this review is to summarizeten simple tips to help minimize failuresand improve outcomes when treatingintertrochanteric fractures of the hip.

Tip 1: Use the Tip-to-Apex DistanceThe tip-to-apex distance has been de-scribed by Baumgaertner et al.1,2 as auseful intraoperative indicator of deepand central placement of the lag screwin the femoral head, regardless ofwhether a nail or a plate is chosen to fixthe fracture (Fig. 1). This is perhaps themost important measurement of accu-rate hardware placement and has beenshown in multiple studies to be pre-dictive of success after the treatment ofstandard obliquity intertrochantericfractures. Older theories about screwplacement favored a low and occasion-ally a posterior position of the lag screw,thereby leaving more bone superior andanterior to the screw. This effectivelylengthens the tip-to-apex distance andshould be avoided. The ideal positionfor a lag screw in both planes is deepand central in the femoral head within10 mm of the subchondral bone (Fig.

2)3,4. A tip-to-apex distance of

Medoff device) are reported to havereasonably good results, I adhere to thebelief that if there is no lateral wall a hipscrew should not be used3-9. Locking

plates and 95 condylar blade-platesmay function as prosthetic lateral cor-tices, but the results of using thesedevices for more problematic fractures

of the proximal part of the femur arenot available9-11. Intramedullary nailsseem to be superior to dynamic con-dylar screws for reverse obliquity frac-tures, but I am not aware of anycomparative study of intramedullarynails and proximal femoral lockingplates.

Tip 3: Know the UnstableIntertrochanteric FracturePatterns, and Nail ThemThere are four classic intertrochantericfracture patterns that signify instability.When internally fixed, the osseousfragments of these unstable fractures arenot able to share the weight-bearingloads, and therefore the loads are pre-dominantly borne by the internal fixa-tion device. The unstable patternsinclude reverse obliquity fractures,transtrochanteric fractures, fractureswith a large posteromedial fragmentimplying loss of the calcar buttress, andfractures with subtrochanteric exten-sion (Figs. 4 through 7)3-5,9,12-16. Thesefractures, in general, should be treatedwith an intramedullary nail because ofthe more favorable biomechanical

Fig. 1

Technique for calculating the tip-to-apex distance (TAD). For clarity, a

peripherally placed screw is depicted in the anteroposterior (ap) view

and a shallowly placed screw is depicted in the lateral (lat) view. Dtrue =

known diameter of the lag screw. (Reprinted from: Baumgaertner MR,

Curtin SL, Lindskog DM, Keggi JM. The value of the tip-apex distance in

predicting failure of fixation of peritrochanteric fractures of the hip.

J Bone Joint Surg Am. 1995;77:1059.)

Fig. 2 Fig. 3

Fig. 2 Excellent reduction and deep, central placement of the lag screw in the femoral head. Fig. 3 Failed fixation of a reverse obliquity

fracture with lateralization of the proximal fragment and screw cutout.

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TH E J O U R N A L O F B O N E & JO I N T SU R G E RY d J B J S . O R GVO LU M E 91-A d NU M B E R 3 d M A R C H 2009

IN T E RT R O C H A N T E R I C F R AC T U R E S :TE N TI P S T O IM P R O V E RE S U LT S

properties of an intramedullary nailcompared with a sliding hip screw. Anintramedullary nail is located closer tothe center of gravity than is a sliding hip

screw, and therefore the lever arm onthe femoral fixation is shorter. Intra-medullary nails can more reliably resistthe relatively high forces across the

medial calcar that are typically borne bythe implant in an unstable fracture. Theintramedullary position of the implantalso prevents shaft medialization, which

Fig. 4 Fig. 5

Fig. 4 A reverse obliquity fracture. Fig. 5 A transtrochanteric fracture.

Fig. 6 Fig. 7

Fig. 6 A four-part fracture with a large posteromedial fragment. Fig. 7 A fracture with subtrochanteric extension.

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is a common complication associatedwith the transtrochanteric and reverseobliquity fracture patterns. Recognizingthe unstable patterns preoperatively andchoosing to use an intramedullary naildecrease the risk of fixation failure. Asimple fracture of the lesser trochanterdoes not, in itself, automatically implyan unstable fracture, as many three-partand four-part fractures can include asmall, relatively unimportant fracture ofthe lesser trochanter and yet have aprimary fracture line that will toleratecompression well. It is not knownhow large the posteromedial fragmentmust be to be mechanically important.When there is doubt about the statusof the calcar, however, an intramedul-lary nail is preferable to a sliding hipscrew.

Tip 4: Beware of the Anterior Bowof the Femoral ShaftAs a person ages, the femoral diaphysisenlarges and the femoral bow in-creases17. Most commercial intramed-ullary nails have gradually evolved into amore bowed design, and many of themnow have a radius of curvature of

be difficult in obese patients. Even ifcare was taken with the starting pointand the subsequent reaming, if the

intramedullary nail is inserted at anoblique angle, the nail itself can impactthe relatively soft bone of the lateral

aspect of the greater trochanter and leadto a relatively oval entry point and alateral position of the intramedullary

Fig. 9 Fig. 10

Fig. 9 The ideal starting point is slightly medial to the exact tip of the greater trochanter. Note the good position of the guidewire distally.

Fig. 10 An unreduced fracture will not reduce with nail passage because of the capacious metaphysis in most patients with osteopenia.

Fig. 11 Fig. 12

Fig. 11 Reduction has been achieved with a clamp placed through a small lateral incision. Fig. 12 Use of a clamp to reduce a

fracture with a subtrochanteric extension. Clamps can be inserted without evacuation of the fracture hematoma and with

minimal soft-tissue disruption.

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nail in the proximal fragment. It iscritical that the nail be inserted by handwith slight rotational motions. A ham-mer is not recommended since its usecan lead to iatrogenic femoral fracture.It is safe to tap the jig with a mallet forthe final seating, since this is an easy wayto fine-tune the final position of theintramedullary nail. The mallet shouldnot be used when difficulty is encoun-tered when inserting the intramedullarynail by hand. The variety of diameters atthe distal end and valgus angles at theproximal end of modern intramedullarynail systems have decreased the fre-quency of iatrogenic femoral fractures19.It is still important to realize that, if ahammer is needed to advance the nail(as opposed to simply tapping it in a fewfinal millimeters), there is a problem.The femoral shaft may need to bereamed further to prevent nail incar-ceration (this is not uncommon inyounger patients) or there may beimpingement on the anterior femoralcortex with a mismatch between thebows of the femur and the intramedul-

lary nail. The cause of the difficultyshould be identified and corrected be-cause the intramedullary nail should bepassed by hand. I ream the intramed-ullary canal to a diameter that is 1 mmlarger than the diameter of the selectedintramedullary nail, and I ensure thatthe starter reamer has been insertedto the recommended depth. Thisprevents the funnel shape of the prox-imal nail from impinging on the end-osteum proximally and preventing finalseating.

Tip 8: Avoid Varus Angulation of theProximal FragmentUse theRelationship Between the Tip ofthe Trochanter and the Centerof the Femoral HeadVarus angulation of the proximal frag-ment increases the lever arm on thefixation since it makes the femoral neckmore horizontal and therefore func-tionally longer when body weight isapplied. This also results in the femoralhead fixation being placed more supe-riorly in the head than is ideal and

increases the risk of the device cuttingout of the femoral head. It can bedifficult to determine the appropriatefemoral neck-shaft angle in a patientwith an intertrochanteric fracture.When using an intramedullary nail forfixation of an intertrochanteric fracture,most surgeons choose a nail with a 130neck-shaft configuration (Figs. 13 and14). It is important to know the neck-shaft angle of the device that is beingused. One way to assess varus or valgusposition during surgery is to look at therelationship between the tip of thegreater trochanter and the center of thefemoral head. These two points shouldbe coplanar. If the center of the femoralhead is distal to the tip of the greatertrochanter, the reduction is in varus. Ifthe center of the head is proximal to thegreater trochanter, the reduction is invalgus. Preoperative plain radiographsof the uninjured hip can be used toassess the patients normal neck-shaftangle as the two sides are normallysymmetric. Varus and high lag-screwplacement are associated with an in-

Fig. 13 Fig. 14

Fig. 13 A well-aligned fracture. Note the central position of the lag screw in the femoral head. Fig. 14 Radiograph

showing the relationship between the tip of the greater trochanter and the center of the femoral head. Normally, this

relationship is coplanar. Here, the proximal fragment is in varus, the starting point is lateral, and the screw is high

in the head.

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creased frequency of failure of fixationwith an intramedullary nail and slidinghip screw 20,21.

Tip 9: When Nailing, Lock the NailDistally if the Fracture Is Axially orRotationally UnstableMost unstable fractures of the proximalpart of the femur require a long intra-medullary nail. If there is any questionabout the stability of a fracture, then along nail should be chosen and, inmost instances, it should be lockeddistally15,22-24. Although short nails maybe used for minimally displaced ornondisplaced fractures or very stablepatterns, they can be associated with asubsequent fracture in the subtrochan-teric area. Although most modern short-nail designs have smaller-diameterlocking screws in this high-stress area toprevent the fractures that were encoun-tered with the older, large-diameterlocking-screw designs, it is probablywise to protect the length of the femurand choose a long nail. Using a long

internal fixation device to protect theentire bone is a common principle fortreating a pathologic fracture of bonecaused by metastatic disease, and Ibelieve that it is wise to consider mostfragility fractures in elderly patients tobe pathologic fractures; in addition, thispatient population has a propensity forfalls, increasing their risk of subsequentfractures.

Tip 10: Avoid Fracture DistractionWhen NailingWhen nails are used for fractures with atransverse or reverse oblique configu-ration, it is not uncommon for thefracture to be either malrotated ordistracted (Fig. 15). If a fracture islocked in distraction, osseous contactthat can accept some of the load withweight-bearing does not occur and thedevice must withstand all of the forcesassociated with the activities of dailyliving. Fractures that are internally fixedin distraction are at risk for nonunionand eventual hardware failure. The nail

breaks through its weakest point, whichis the large aperture in the nail for thelag screw (Fig. 16). To eliminate dis-traction, the traction on the lower limbshould be released during surgery priorto insertion of the distal locking screwsand fluoroscopy should be used toconfirm that there is bone-on-bonecontact.

Recent TrendsIntramedullary nail fixation has becomemore common, even for fractures thatare stable or nondisplaced25. Intramed-ullary nails should probably not be usedfor these simpler types of fractures, andit is probably better to choose slidinghip screws for relatively simple patternsand basicervical patterns. Fixation of astable or minimally displaced fracturewith a sliding hip screw is acceptable,and the complication rate and costs areless. Meta-analyses have demonstratedthat the rates of iatrogenic fracture with>intramedullary nailing have improvedover time, and the risk of femoral shaft

Fig. 15 Fig. 16

Fig. 15 A fracture locked in distraction. Note the typical lateral starting point and the high hip-screw placement.

Fig. 16 Distracted fractures in varus can result in high loads on the implant, causing nail fracture, typically through

the aperture for the lag screw.

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fracture with nail insertion has de-creased dramatically19. This is probablya reflection of the use of modernintramedullary nails with smaller di-ameters, smaller-diameter lockingscrews, and less acute proximal valgusangles of the proximal nail as well as therealization that aggressive impaction

should be avoided in the nailing of thesefractures.

George J. Haidukewych, MDFlorida Orthopaedic Institute, 13020 TelecomParkway, Temple Terrace, FL 33637.E-mail address: [email protected]

Printed with permission of the AmericanAcademy of Orthopaedic Surgeons. Thisarticle, as well as other lectures presented atthe Academys Annual Meeting, will beavailable in March 2010 in InstructionalCourse Lectures, Volume 59. The completevolume can be ordered online atwww.aaos.org, or by calling 800-626-6726(8 A.M.-5 P.M., Central time).

References

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2. Baumgaertner MR, Solberg BD. Awareness of tip-apex distance reduces failure of fixation of trochan-teric fractures of the hip. J Bone Joint Surg Br.1997;79:969-71.

3. Kyle RF, Cabanela ME, Russell TA, SwiontkowskiMF, Winquist RA, Zuckerman JD, Schmidt AH, KovalKJ. Fractures of the proximal part of the femur. InstrCourse Lect. 1995;44:227-53.

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7. Knight WM, DeLee JC. Nonunion of intertrochan-teric fractures of the hip: a case study and review[abstract]. Orthop Trans. 1982;6:438.

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9. Sadowski C, Lubbeke A, Saudan M, Riand N,Stern R, Hoffmeyer P. Treatment of reverse oblique

and transverse intertrochanteric fractures with useof an intramedullary nail or a 95 screw-plate: aprospective, randomized study. J Bone Joint Surg Am.2002;84:372-81.

10. Kinast C, Bolhofner BR, Mast JW, Ganz R.Subtrochanteric fractures of the femur. Resultsof treatment with the 95 degrees condylarblade-plate. Clin Orthop Relat Res. 1989;238:122-30.

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15. van Doorn R, Stapert JW. The long gamma nail inthe treatment of 329 subtrochanteric fractures withmajor extension into the femoral shaft. Eur J Surg.2000;166:240-6.

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22. Adams CI, Robinson CM, Court-Brown CM,McQueen MM. Prospective randomized controlledtrial of an intramedullary nail versus dynamic screwand plate for intertrochanteric fractures of the femur.J Orthop Trauma. 2001;15:394-400.

23. Barquet A, Francescoli L, Rienzi D, Lopez L.Intertrochanteric-subtrochanteric fractures: treat-ment with the long Gamma nail. J Orthop Trauma.2000;14:324-8.

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Intertrochanteric Fractures - Ten Tips to Improve Results

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