 TRAUMA
Implant options for the treatment of
intertrochanteric fractures of the hip
RATIONALE, EVIDENCE, AND RECOMMENDATIONS
A. R. Socci,
N. E. Casemyr,
M. P. Leslie,
M. R. Baumgaertner
From Yale University
School of Medicine,
Connecticut, United
States
Aims
The aim of this paper is to review the evidence relating to the anatomy of the proximal
femur, the geometry of the fracture and the characteristics of implants and methods of
fixation of intertrochanteric fractures of the hip.
Materials and Methods
Relevant papers were identified from appropriate clinical databases and a narrative review
was undertaken.
Results
Stable, unstable, and subtrochanteric intertrochanteric fractures vary widely in their
anatomical and biomechanical characteristics, as do the implants used for their fixation. The
optimal choice of implant addresses the stability of the fracture and affects the outcome.
Conclusion
The treatment of intertrochanteric fractures of the hip has evolved along with changes in the
design of the implants used to fix them, but there remains conflicting evidence to guide the
choice of implant. We advocate fixation of 31A1 fractures with a sliding hip screw and all
others with an intramedullary device.
Cite this article: Bone Joint J 2017;99-B:128–33.
 A. R. Socci, MD, Assistant
Professor
 N. E. Casemyr, MD, Assistant
Professor,
 M. P. Leslie, DO, Associate
Professor
 M. R. Baumgaertner, MD,
Professor
Yale University School of
Medicine, Department of
Orthopaedics and
Rehabilitation, 800 Howard
Ave, New Haven, CT 06520,
USA.
Correspondence should be sent
to A. R. Socci; email:
adrienne.socci@yale.edu
©2017 The British Editorial
Society of Bone & Joint
Surgery
doi:10.1302/0301-620X.99B1.
BJJ-2016-0134.R1 $2.00
Bone Joint J
2017;99-B:128–133.
Received 24 March 2016;
Accepted after revision 17
August 2016
128
Fractures of the hip are arguably the most
important public health problem faced by
orthopaedic surgeons. More than 250 000 lowenergy fractures of the hip occur in the United
States each year.1 The International Osteoporosis Foundation2 estimates that approximately
1.6 million such fractures occur per year worldwide, a figure which may rise to six million by
2050. Their treatment consumes a growing
percentage of healthcare expenditure.2
The goals of care are to restore function with
the lowest possible rate of surgical and medical
complications. Achieving stable reduction and fixation of the fracture, permitting immediate mobilisation, is key to these goals.
The last 25 years has seen the introduction and
increasing acceptance and use of intramedullary
devices in preference to the sliding hip screw
(SHS) for the treatment of intertrochanteric fractures.3 Despite little good quality evidence to support their use, most clinicians use them for most
fractures, and practice guidelines from the American Association of Orthopaedic Surgery
(AAOS)4 support their use.5 In this paper we
review the evidence and highlight the weaknesses
or absence. We also present our practice with its
rationale and recommendations.
The pertrochanteric region has many thickenings of trabecular bone in compressive and
tensile groups. The most structurally significant of these are the primary compressive trabeculae along the posteromedial femoral neck
and shaft.6 While several classification systems
exist for these fractures, they are all based on
the concept of stability. A stable fracture is a
simple one that, once reduced and fixed, is
compressed and minimally impacted by the
nearly perpendicular weight-bearing force of
single leg stance.7 Unstable fractures due either
to comminution, ‘reverse oblique’ orientation,
or both, are associated with collapse on axial
loading. Both the posteromedial cortex and the
lateral cortical buttress beneath the vastus
ridge contribute to the stability of these fractures. The instability increases with the degree
of comminution of the posteromedial cortex.
Increased comminution implies less support
for axial loading through cortical contact. The
lateral cortex beneath the vastus ridge provides
the final buttress to impaction of the fracture
after fixation, further contributing to its stability and avoiding collapse.8,9 Incompetence of
either of these cortical regions therefore renders a fracture unstable.
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IMPLANT OPTIONS FOR THE TREATMENT OF INTERTROCHANTERIC FRACTURES OF THE HIP
Fig. 1
Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma
Association classification of pertrochanteric fractures. Copyright the
AO Foundation, Switzerland. (Source: AO Surgery Reference).
The quality of reduction, regardless of the pattern of the
fracture, is one of the most important modifiable factors in
the management of intertrochanteric fractures.10 The ability of the cortex to resist collapse in stable fractures
depends on the restoration of cortical continuity. In unstable fractures, where the ability to restore this is limited by
comminution or the orientation of the fracture, the boneimplant interface will be subject to increased stress.
Implants used to fix unstable fractures must, therefore, be
capable of bearing more load, in order to avoid loss of
reduction through collapse. A valgus reduction is one way
of increasing interfragmentary compression and of reducing bone-implant stresses, as well as minimising collapse
and leg length discrepancy.
Studies of implant loading confirm that the load borne
by an implant is increased with varus mal-reduction and
with decreasing stability of the fracture, and that in both
cases an intramedullary device can bear greater load than
an extramedullary device.11,12
The Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association classification system13 (Fig. 1)
offers both a universal descriptive language and reliable eviVOL. 99-B, No. 1, JANUARY 2017
129
dence on prognosis,7 and is also useful for research and has
been shown to have greater inter-observer reliability than
other classification systems.14 Simple, two-part pertrochanteric fractures with a single line of extension into the medial
cortex are classified as 31-A1. These fractures are stable after
reduction because bony continuity is restored and a significant proportion of the load transmitted through the proximal femur can be safely borne. Multi-fragmentary
pertrochanteric fractures beginning anywhere in the greater
trochanter with medial extension in two or more places creating a third fracture fragment, including the lesser trochanter, are classified as 31-A2. Many of these are unstable
after reduction because the medial buttress is compromised. Fracture patterns 31-A1.1 to 31-A2.1 are typically
stable and those from 31-A2.2 to 31-A3.3, which have
more than one intermediate fragment, are usually unstable.15 True intertrochanteric fractures with a fracture line
that passes between the trochanters, above the lesser trochanter medially and below the vastus ridge laterally are
classified as 31-A3. These fractures are unstable after
reduction because both posteromedial and lateral buttresses are lost. This classification is particularly valuable in
its identification of reverse oblique and ‘intertrochanteric
subtrochanteric’ fractures as challenging to reduce and fix
with stability.
Involvement of the lateral cortex is only a specific criterion of fractures in the 31-A3 category and is an important
factor in loss of reduction when using an extramedullary
SHS system.16 Intra-operative fracture of the lateral cortical
buttress is significantly more common in A2.2 and A2.3
fractures than in A2.1 fractures,8 emphasising the importance of recognising the A2 sub-type when choosing the
implant by which it will be managed.
A surgeon’s familiarity with a specific implant may have
a measurable effect on the operating time, the use of fluoroscopy, intra-operative blood loss and the need for transfusion, but a systematic review of the evidence reported
significant heterogeneity in published data and an implantassociated effect has not therefore been shown.17
There is an increasing cost associated with SHSs, short
nails and long nails, respectively.18,19 Intramedullary
implants are between 20% and 40% more expensive than
SHSs and so, if each is appropriate for fracture fixation, the
less expensive device should be used. A recent American
College of Surgeons National Surgical Quality Improvement Program database study reported a shorter mean
post-operative length of stay following treatment with an
intramedullary implant.20 This study did not stratify the
patients by the type of fracture and hence the effect was
seen across all groups, implying that the greater cost of the
implant may be offset against the ongoing cost of care by
using the intramedullary device in all patients.
Cost-effectiveness analysis that models length of stay,
rehabilitation or re-operation is dependent on the data used
for the model, in particular those used to inform the rate of
failure. One such study suggested that extramedullary
130
A. R. SOCCI, N. E. CASEMYR, M. P. LESLIE, M. R. BAUMGAERTNER
implants are more cost-effective for A2 fractures, but
assumed an equivalent rate of failure between SHSs and
nails.18 Such an assumption ignores differences in outcomes, especially when considering the A2 group as a
homogenous one.
Late costs are more difficult to measure and tend to
relate to failure, requiring prolonged rehabilitation or reoperation.21 First-generation intramedullary implants had
a significantly higher incidence of periprosthetic fracture,
thereby compounding their already increased cost. A 4.5fold increased risk of periprosthetic fracture in 1997
decreased to 1.87 in 2005 and is no longer evident in the
most recent data.22,23
Despite a large number of randomised controlled trials
(RCTs), meta-analyses have not shown differences in functional outcomes between intra- and extra-medullary
devices. These studies have often used inappropriate outcome measures and reported the outcome of diverse
cohorts of patients, pooled without reference to pre-operative functional status.17,24 Some authors have, however,
shown differences in the rates of recovery of function. In a
RCT of intramedullary versus extramedullary fixation in
210 patients with A1 or A2 fractures, Utrilla et al25
reported no difference in outcome in stable fractures, but
better mobility at one year following intramedullary fixation of unstable fractures. Improved early functional recovery following intramedullary fixation has also been shown
in several studies which also recorded sliding of SHSs, indicating shortening of the femoral neck, leg length discrepancy, and/or medialisation of the shaft.26-28 Pajarinen et al26
reported improved mobility and less shortening of the femoral neck after intramedullary fixation in agreement with
the findings of Hardy et al27 of improved early mobility, less
sliding and less leg length discrepancy. The early functional
recovery is better in those in whom the SHS slides less, suggesting that excessive alteration of the biomechanics of the
hip can impair the recovery of mobility. A recent RCT by
Reindl et al29 found less shortening of the femoral neck in
the intramedullary group, but this did not significantly alter
the timed up and go scores. It is likely that the ability of a
patient to tolerate malunion is related to pre-injury function, but there is currently no evidence to support this as
studies tend to pool all patients. Information about functional outcomes such as return to social integration, driving
and participation in recreational activities is urgently
needed.
Implant details
The length of the nail. Early intramedullary nails used for
fractures of the hip were short and associated with a risk of
fracture at the tip of the nail, with an incidence of 8% to
11% historically.30 Long nails can prevent this complication but risk anterior cortical impingement or intraoperative iatrogenic fracture with incidences of 1.5%30 and
< 1% recorded.31,32 For this reason, the surgeon must be
conscious of the design of the nail including its radius of
curvature and the anterior bow of the femur. A stress riser
can, in this scenario, lead to a fracture which is even more
challenging to manage, especially with a nail in situ.
No significant difference in the rates of periprosthetic
fracture between short and long nails have been recorded at
one, two or five years post-operatively.21,30
Longer nails can cost up to 45% more than short nails.30
Lindvall et al21 reported that, based on a rate of periprosthetic fracture of 12% and an increased cost of $439 of
long nails over short, long nails were cheaper than short
ones when the cost of managing complications was taken
into account. A more recent study reported equivalence
between short and long nails, except for hospital costs
(which can include facility fees, cost of medications given,
administration of the medications, lab costs, cost of surgery
and anesthesia).19
Leaving aside the biomechanically dissimilar subtrochanteric fractures, there is little evidence relating to short
versus long nails in terms of functional outcome and until
these data are known, meaningful assessment of cost benefit is difficult.
Distal locking. The effect of distal locking on the incidence
of periprosthetic fracture is not fully understood. Lindvall
et al21 reported that distal locking may be protective against
periprosthetic fracture in both short and long nails. In their
cohort of 609 patients, 47% of nails were distally locked
but 15 of 16 periprosthetic fractures occurred in the 53%
of patients with unlocked nails at 21.5 months (standard
deviation (SD) 18.6) follow-up in the short nail group and
14.8 months (SD 13.8) follow-up for long nails. They also
noted that patients with unlocked long nails experienced
periprosthetic fracture around the shaft, while those with
locked long nails had fractures at the tip of the nail. In short
unlocked nails, fractures occurred at the tip of the nail, in
keeping with early findings in studies of intramedullary fixation.33-35 This is important as, in relative terms, it is easier
to treat a diaphyseal fracture by closed reduction with the
introduction of a distal locking screw than it is to perform
open reduction and internal fixation of a peri-articular fracture around a locked nail.
Current evidence supports distal locking in axially or
rotationally unstable fractures, including those with subtrochanteric extension or comminution, or in osteoporotic
femora in which it is hard to achieve an isthmic fit.32
Femoral head fixation: blade vs screw, one vs two
Some intramedullary implants use a helical blade for fixation of the femoral head instead of a cancellous screw. Biomechanical studies in artificial, cadaveric and living bone
have shown that a blade resists rotational and translational
displacement better36,37 but this has not translated into evidence of a difference in rates of cut-out, complications, or
post-operative function.38,39 Consistently, loss of fixation is
more related to the quality of reduction of the fracture and
a high tip-apex distance (TAD) rather than the choice of
implant.37,39
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IMPLANT OPTIONS FOR THE TREATMENT OF INTERTROCHANTERIC FRACTURES OF THE HIP
The use of blades may be associated with the phenomenon of ‘cut-through’ with medial perforation of the articular surface of the femoral head without loss of reduction of
the fracture.40 This is in contrast to ‘cut-out’, superior and
anterior migration of the screw as the fracture displaces and
the femoral head moves into varus and retroversion. In
order to avoid ‘cut-through’, it has been suggested that the
full length of the trajectory of the blade is not pre-drilled
and that the tip of the blade should be a minimum of
10 mm from the joint surface.40,41
There are variants with both one (uniaxial) and two
(biaxial) screws in the femoral head. Greater load to failure
has been reported with biaxial screws in a biomechanical
study,42 but this advantage has not been reported clinically
and complications of axial and reverse axial migration (the
‘Z’ and ‘reverse Z’ effects) have been described.43 A prospective RCT by Kouvidis et al43 showed no difference in
outcome (activities of daily living or mobility) between an
SHS group (60 patients) and a biaxial intramedullary nail
group (62 patients) at 1 year follow-up. The single systematic review of such devices suggests that biaxial fixation
leads to a lower risk of post-operative periprosthetic fracture than uniaxial fixation.44 This review examined only
periprosthetic fracture however, without recording any
other outcome or complication, including those specific to
biaxial fixation.
Proximal femoral locking plates offer a lower load to
failure than cephalomedullary devices and have higher
rates of mechanical failure and re-operation.45
Much of the evidence supporting the use of newer designs
of implant is biomechanical and must be interpreted carefully to understand the clinical relevance. The native hip may
be loaded in different directions and different ways and the
evidence should be evaluated with caution.
Tip-apex distance and other targets
Both ‘cut-out’ and ‘cut-through’ emphasise the importance
of the correct placement of the screw in the femoral head,
namely central and deep.46 The TAD is an accepted and
reproducible means of evaluating this.46 A recent variation,
the ‘calcar-TAD’, aims to target a slightly inferior placement of the screw when using cephalomedullary devices.
This reflects existing practice in both SHSs and intramedullary devices, based on there being stronger bone in the calcar and inferior femoral head.47,48 It has not, however, been
confirmed that this offers better fixation than when placing
the screw in the centre of the femoral head.49,50 In the multivariate analysis of Kashigar et al,49 only the calcar-TAD
was found to be a statistically significant predictor of failure and although the authors concluded that inferior placement conferred benefit, the reduction of the fracture was
classified as poor in almost half of the 77 patients at a mean
follow-up of 408 days (81 days to 4.9 years). This, therefore, confounded the suggestion that the position of the
screw was predictive of the outcome, as varus mal-reduction was also significantly associated with failure.
VOL. 99-B, No. 1, JANUARY 2017
131
Discussion
Stable intertrochanteric fractures (A1 to A2.1). There is cur-
rently little evidence of the superiority of one device over
another in the management of these fractures.5,25,28,51
The quality of reduction remains paramount, with stable
fractures having direct cortical contact following accurate
reduction. At our institution there is a preference for SHS
fixation after careful reduction.
Subtrochanteric and reverse oblique fractures (A3). There is
strong evidence to support the use of intramedullary fixation in subtrochanteric and reverse oblique fractures. The
biomechanics of these fractures are such that fixation with
a SHS is inappropriate, as the line of collapse is not perpendicular to the fracture line and the lateral cortical buttress
cannot resist collapse. The use of a trochanteric sliding
plate (TSP) offers increased resistance to collapse, but the
fixation is less reliable than when using an intramedullary
device, which offers better functional outcomes and rates of
union.27,52,53-57 Worse outcomes are also associated with
the use of proximal femoral locking plates.58 Intramedullary nails resist collapse both by their intramedullary position and by an enlarged proximal end, offering an internal
buttress. The minimally invasive nature of the surgery also
preserves the vastus soft tissue envelope, maintaining stability and vascularity.
Unstable intertrochanteric fractures (A2.2 to A2.3). Current
guidelines recommend the use of an intramedullary device
for the treatment of these fractures.5
As in subtrochanteric and reverse oblique fractures, the
use of a TSP may prevent excessive collapse in unstable
fractures lacking a posteromedial or lateral cortical buttress
in which an SHS is used.
A randomised prospective study comparing fixation
using a SHS (343 patients) or intramedullary nail (341
patients) for all intertrochanteric and subtrochanteric fractures showed no long-term differences in outcome at three
and 12 month follow-up, with improved early pain on
mobilisation scores in the intramedullary group.59 Importantly, a TSP was used in A3 fractures and optional in
osteoporotic A1 and A2 fractures when the lateral cortical
buttress was questionable. The equivalence of outcome
between these constructs emphasises that maintenance of a
good reduction and prevention of collapse offers optimum
function. Medialisation of the femoral shaft was seen more
frequently in the SHS/TSP group and was associated with
increased post-operative pain. Overall, an intramedullary
device appears from the evidence to offer more benefit than
an SHS with TSP.
Basicervical fracture. True basicervical fractures are uncommon and, although extracapsular, have similar rotational
instability to those occurring more medially in the femoral
neck. A simple two-part basicervical fracture requires
reduction with direct cortical contact, and stable, compressed fixation. A de-rotation screw may offer increased
protection against rotational loss of reduction. A comminuted fracture with basicervical extension should be treated
132
A. R. SOCCI, N. E. CASEMYR, M. P. LESLIE, M. R. BAUMGAERTNER
as a comminuted, unstable intertrochanteric fracture with
an intramedullary device.
The role of arthroplasty. Certain unstable intertrochanteric
fractures of the hip can be treated by arthroplasty. Indications include existing arthritis, osteonecrosis of the femoral
head, poor quality of bone or complications following
internal fixation.60 There is limited evidence for the role of
arthroplasty in treating unstable intertrochanteric fractures, with benefits including early mobilisation.60 The surgery is technically challenging and should be undertaken by
an experienced arthroplasty surgeon.
In conclusion, decision-making in the management of
intertrochanteric fractures requires a thorough understanding of the stability of the fracture and the implants which
are available. More evidence on functional outcomes is
needed, especially in higher-functioning patients. It remains
of critical importance to pay careful attention to the quality
of the reduction and central and deep positioning of the
screw or blade, regardless of implant.
Take home message:
There is conflicting evidence about the choice of implant in the
treatment of intertrochanteric fractures of the hip, but assessing the stability of the fracture allows one to choose between fixation
using a SHS or an intramedullary device.
Author contributions:
A. R. Socci: Primary researcher and writer.
N. E. Casemyr: Researched and wrote significant portion of introduction, Editing and revising.
M. P. Leslie: Wrote a section on technical aspects of reduction which was not
included, Participated in revision process.
M. R. Baumgaertner: Provided necessary oversight and guidance, Focused the
work on the most relevant references, concepts and controversies, Heavily
involved in editing and revision.
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
This article was primary edited by P. Page and first proof edited by J. Scott.
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