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Intertrochanteric HipIntertrochanteric Hip

FractureFracture

plate versus nailplate versus nail

Dr CF ChanDr CF Chan

Specialist in TraumaSpecialist in Trauma

Queen Mary HospitalQueen Mary Hospital


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The incidence of hip fractures isThe incidence of hip fractures isincreasing in number worldwide.increasing in number worldwide.

Intertrochanteric hip fracture comprisesIntertrochanteric hip fracture comprises

about half of the hip fractureabout half of the hip fracture

The standard care for intertrochantericThe standard care for intertrochanteric

fracture today is operative internalfracture today is operative internalfixation.fixation.


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AimsAims

Short term operative goals are to provide aShort term operative goals are to provide a

construct that is stable enough to withstandconstruct that is stable enough to withstandearly transfers, mobilization, and at least someearly transfers, mobilization, and at least some

weight bearing.weight bearing.

The long term operative goal is a restore theThe long term operative goal is a restore the

patientpatients previous level of independence ands previous level of independence and

function.function.


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HistoryHistory

PlatePlate--type device was popularized in the 1903stype device was popularized in the 1903s

by Jewett.by Jewett.

This fixedThis fixed--angle triflanged nail allowedangle triflanged nail allowed

immediate fracture stability and earlyimmediate fracture stability and earlymobilization.mobilization.


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ThisThis staticstatic device oftendevice often

failedfailedto maintain theto maintain the

fixation of the fracturefixation of the fracture

fragment if there was anyfragment if there was any

collapse.collapse.


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Sliding Hip ScrewsSliding Hip Screws

Side plateLag screw


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Sliding hip screwSliding hip screw

Provide controlledProvide controlled

collapse and impactioncollapse and impactionof the intertrochantericof the intertrochantericfracture.fracture.

Help to achieve aHelp to achieve aposition of stabilityposition of stability

while maintaining awhile maintaining aconstant neckconstant neck--shaftshaftangleangle


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Can fail, whyCan fail, whyF/88 A1 fracture of left Hip


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Operative procedures for the fixation of theOperative procedures for the fixation of the

intertrochanteric fracture are challenging.intertrochanteric fracture are challenging.

ReRe--operation rate of 4operation rate of 4--12% have been report12% have been reportfollowingfollowing Gold standardGold standard fixation techniquefixation technique

of a sliding hip screwof a sliding hip screw


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The common complication of sliding hipThe common complication of sliding hip

screws arescrews are varus malreductionvarus malreduction

AA varus malreductionvarus malreduction leads to increased load on the proximal femur byleads to increased load on the proximal femur by

increasing the moment arm on the implantincreasing the moment arm on the implant

Also predispose patients to postoperative abductorAlso predispose patients to postoperative abductor

weaknessweakness


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Factors correlate with varus cut outFactors correlate with varus cut out

Age of the patientAge of the patient

Quality of boneQuality of bone

Pattern of fracturePattern of fracture

Stability of the reductionStability of the reduction

Position of the implantPosition of the implant


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The importance of proper screw positioning inThe importance of proper screw positioning in

the femoral head is well establishedthe femoral head is well established

Proper position of the screw depends on twoProper position of the screw depends on twofactors:factors:

Location of screw within the femoral headLocation of screw within the femoral head

The depth of screw insertion with respect toThe depth of screw insertion with respect to

articular surfacearticular surface


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Gustilo and KyleGustilo and Kyle

Ideal position of the screw should be in centerIdeal position of the screw should be in center--centercenter

positionposition


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TipTip--Apex Distance (TAD)Apex Distance (TAD)

by Baumgartner MRby Baumgartner MR


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Tip-Apex Distance

Prediction of femoral head cut-out rate:

Significant less cut out rate resulted when TAD

< 25mm


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M/78


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8 weeks. 4 months.

TAD : 28mmTAD : 28mm


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Unstable intertrochanteric fractureUnstable intertrochanteric fracture

What implant?What implant?


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F/76

A2 Fracture of Right Hip


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Unstable FractureUnstable Fracture

CommonCommon

Kyle and associates: 43% intertrochantericKyle and associates: 43% intertrochantericfracture are unstablefracture are unstable

Including fractures withIncluding fractures with

Comminution of the posteromedial buttressComminution of the posteromedial buttress

Fracture with subtrochanteric extensionFracture with subtrochanteric extension Reverse obliquity fracture pattern/loss of integrityReverse obliquity fracture pattern/loss of integrity

of the lateral femoral wallof the lateral femoral wall


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Limitation of Sliding hip screwLimitation of Sliding hip screw

Jacobs et al: the average settling of stableJacobs et al: the average settling of stable

fracture was 5.3mm and that of unstablefracture was 5.3mm and that of unstablefracture was 15.7mmfracture was 15.7mm

Steinberg: the mean sliding was 9.3mm andSteinberg: the mean sliding was 9.3mm and

sliding > 15mm correlated with a highersliding > 15mm correlated with a higher

prevalence of fixation failureprevalence of fixation failure


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Parker: medialization of the femoral shaft byParker: medialization of the femoral shaft by

greater than 1/3 diameter of the femur isgreater than 1/3 diameter of the femur isassociated with a 7x increase in fixation failureassociated with a 7x increase in fixation failure

EXCESSIVE SLIDINGEXCESSIVE SLIDING is the major factoris the major factor

causing failure of fixation.causing failure of fixation.


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Excessive slidingExcessive sliding loss of further slidingloss of further sliding

capabilitycapability leads to a functionally a rigidleads to a functionally a rigidconstructconstruct higher failure ratehigher failure rate


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In reverse Obliquity fracture(A3):

The fracture line is perpendicular to

the intertrochanteric line

The sliding of the compression hip screw

will apply a shearing force across the

fracture

The greater trochanter fragment will

shift laterally and the shaft of femur

will translate medially


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Retrospective studyRetrospective study

Between 1988 and 1998Between 1988 and 1998

2472 patients with hip fracture were included2472 patients with hip fracture were included

Reverse obliquity fracture accounted for 2% ofReverse obliquity fracture accounted for 2% of

all hip fracture and 5% of all intertrochantericall hip fracture and 5% of all intertrochanteric

fracturefracture


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32% (15/47) reverse obliquity fracture32% (15/47) reverse obliquity fracture

failed to heal or had a failure of fixationfailed to heal or had a failure of fixation

Failure rate:Failure rate:

(9/16) Sliding hip screws(9/16) Sliding hip screws (2/15) Blade plate(2/15) Blade plate

(3/10) Dynamic condylar screw(3/10) Dynamic condylar screw

(1/3 ) Cephalo(1/3 ) Cephalo--medullary nailsmedullary nails

(0/3 ) Intramedullary hip screws(0/3 ) Intramedullary hip screws


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Conclusion:Conclusion:

95 degree fixed95 degree fixed--angled internal fixationangled internal fixationdevices performed significantly better than diddevices performed significantly better than dida sliding hip screwsa sliding hip screws

Results were worse for fracture with poorResults were worse for fracture with poor

reduction and those with a poorly placedreduction and those with a poorly placedimplantimplant


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Other plating systemOther plating system

Controlled biaxial compressionControlled biaxial compression

1. Standard sliding hip screw1. Standard sliding hip screw

2. Side plate with inner and outer2. Side plate with inner and outersleeve, allow fracture to impactsleeve, allow fracture to impact

parallel to the longitudinal axis ofparallel to the longitudinal axis of

the femurthe femurMedoff Plate


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Prospective randomized studyProspective randomized study

WatsonWatson::

Stable fractureStable fracture: fractures united without: fractures united withoutcomplicationscomplications

Unstable fractureUnstable fracture: complication rate: 14% in SHS: complication rate: 14% in SHS

versus 3% in Medoff plateversus 3% in Medoff plate

Disadvantages:Disadvantages:

longer surgical timelonger surgical time

Greater blood lossGreater blood loss


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Trochanteric stabilization plateTrochanteric stabilization plate

As a lateral buttress toAs a lateral buttress to

prevent lateralization ofprevent lateralization of

the greater trochanterthe greater trochanter

Lower rate of collapseLower rate of collapseand medialization inand medialization in

comparison to the use ofcomparison to the use of

compression hip screwcompression hip screw

alonealone


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Intramedullary devicesIntramedullary devices

Can be insert proximal to distal (cephaloCan be insert proximal to distal (cephalo--

medullary) or from distal to proximalmedullary) or from distal to proximal

Cephalomedullary nailsCephalomedullary nails are inserted throughare inserted throughthe greater trochanter of the femur and securedthe greater trochanter of the femur and secured

by a cross pin or screw which is passed up inby a cross pin or screw which is passed up in

the femoral neck into the femoral headthe femoral neck into the femoral head


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Intramedullary devicesIntramedullary devices

Advantages:Advantages:

Insertion can be done in closed and percutaneousInsertion can be done in closed and percutaneous

mannermanner

Preserves fracture biologyPreserves fracture biology

Reduces blood lossReduces blood loss

Potential mechanical advantagesPotential mechanical advantages


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gg

Reduced lever arm (bending moments) and limitingReduced lever arm (bending moments) and limitingthe amount of collapse of the fracturethe amount of collapse of the fracture


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The nail acts as an intramedullary

Buttress to prevent excessive

Shaft medialization (like TSP)

Impaction in the axis of the shaft can be

Obtained if the nail is not distally

Interlocked (or impaction can be done

Before interlocking)

DESIGN of the nail


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First generation nail ----------------------------------------- Second Generation Nail


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Intrameduallry nailIntrameduallry nail

PFNA IMHS Gamma nail


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F/78F/78

Fall on level groundFall on level ground

Sustained A2 intertrochantericSustained A2 intertrochanteric

hip fracturehip fracture

1 week post op


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4 months..


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NO hip pain and walks with one stick only

F/88 A3 fF/88 A3 f t


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F/88 A3 fractureF/88 A3 fracture

Comparison between sliding hip screws andComparison between sliding hip screws and


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Comparison between sliding hip screws andComparison between sliding hip screws and

second Generation intramedullary nailsecond Generation intramedullary nail


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39 patients with AO/OTA 3139 patients with AO/OTA 31--A3 intertrochanteric hipA3 intertrochanteric hipfracturefracture

Fu for at least 1 yearFu for at least 1 year

19 patients treated with Dynamic condylar screws19 patients treated with Dynamic condylar screws 20 patients treated with intramedullary nail (PFN)20 patients treated with intramedullary nail (PFN)


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RESULT:RESULT:

Patients treated with IM nail hadPatients treated with IM nail had

Shorter operative timesShorter operative times Fewer blood transfusionFewer blood transfusion

Shorter hospital stayShorter hospital stay

Implant failures/nonunionImplant failures/nonunion

DCS: 7/19 (37%)DCS: 7/19 (37%)

PFN: 1/20 (5%)PFN: 1/20 (5%)


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214 patients with intertrochanteric hip fracture214 patients with intertrochanteric hip fracturewas treated with compression hip screwswas treated with compression hip screws

3% of 168 patients with intact lateral wall3% of 168 patients with intact lateral wallpostoperatively need repostoperatively need re--operation within 6operation within 6monthsmonths

22% of 46 patients with a fractured lateral wall22% of 46 patients with a fractured lateral wall

were operated againwere operated again


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The lateral femoral wall was the mainThe lateral femoral wall was the main

independent risk factor for a reindependent risk factor for a re--operation.operation.

The implant position (tipThe implant position (tip--apex distance) wasapex distance) wasalso found to have an important effect on thealso found to have an important effect on the

outcome in the multivariate regression analysisoutcome in the multivariate regression analysis

A2 2 fractureA2 2 fracture


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A2.2 fractureA2.2 fracture


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3 months6 weeks

RecommendationsRecommendations


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RecommendationsRecommendations

For stable fracture patterns the sliding hipFor stable fracture patterns the sliding hip

screw (DHS) is the implant of choice.screw (DHS) is the implant of choice.


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For unstable fracture including, especiallyFor unstable fracture including, especially

reverse obliquity fracture, intrareverse obliquity fracture, intra--medullary nailmedullary naildefinite have a beneficial outcome for fixingdefinite have a beneficial outcome for fixing

this group of fracturethis group of fracture


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BUTBUT


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BUTBUT..

GOOD implant choice cannot compensate forGOOD implant choice cannot compensate for

POOR reductionPOOR reduction


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