Intertrochanteric Fractures
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Unanswered clinical issues and audience questions
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Michael R. Baumgaertner, MD
Original Authors: Steve Morgan, MD; March 2004;
New Author: Michael R. Baumgaertner, MD; Revised January 2007
Revised December 2010
Lecture Objectives
Review:
 Principles
of treatment
Understand & Optimize

Variables influencing patient
and fracture outcome
Introduce:
 Recent
Evidence-
based med
Suggest:
 Surgical
Tips to avoid common problems
Hip Fracture PATIENT
Outcome Predictors
 Pre-injury physical & cognitive status
 Ability to visit a friend or go shopping
 Presence of home companion
 Postoperative ambulation
 Postoperative complications
(Cedar, Thorngren, Parker, others)
A public heath care cri$i$:
130,000 IT
Fx / year in U.S.
& will double by 2050…
 4-12% fixation failure
Even when surgery is “successful”:
 1-2 units PRBC transfused
 3-5+ days length of stay
We must do better!!
Preoperative Management
the evidence suggests:
 “Tune up” correctable comorbidities
 Operate within 48°; avoid night surgery
Zuckerman, JBJS(A) ‘95
 Maintain extremity in position of comfort
Buck’s traction of no value (RCT)
Anderson, JBJS(B) ‘93
 General versus spinal anaesthesia?
Randomized, prospective trials (RCTs): no difference
Davis, Anaesth & IntCare ‘81;
Valentin, Br J Anaesth ‘86
Comprehensive Management
excellent evidence based single source:
Osteoporosis International
“Preoperative Guidelines and Care
Models for Hip Fractures”
Volume 21, Supplement 4 December 2010
Intertrochanteric Femur
Anatomic considerations
 Capsule inserts on IT
line anteriorly, but at
midcervical level
posteriorly
 Muscle attachments
determine deformity
Radiographs
Plain Films
AP pelvis
Cross-table lateral

ER Traction view

when in any doubt!!
Factors Influencing Construct
Strength:
Uncontrolled factors
Bone Quality
Fracture Geometry
Controlled factors
Quality of Reduction
Implant Placement
Implant Selection
Kaufer, CORR 1980
This lecture will examine each factor
Uncontrolled factor: Fracture geometry
“STABILITY”
The ability of the reduced fracture to
support physiologic loading
Fracture Stability relates not only to the #
of fragments but the fracture plane as well
31
AO / OTA
Uncontrolled factor: Fracture geometry
Stable
Unstable
Uncontrolled factor: Fracture geometry
AO/OTA31A3:
The highly unstable “pertrochanteric” fractures!
Uncontrolled factor: Bone quality
A 33 year old pt with intertrochanteric fracture following a fall from heightNote the dense, cancellous bone throughout the proximal femur;
Not at all like a geriatric fracture
Uncontrolled factor: Bone quality
83 yo white woman with unstable intertrochanteric fracture:
Note the marked loss of trabeculae
Uncontrolled factor: Bone quality
Implants must be placed where the remaining trabeculae reside!
Uncontrolled factor: Bone quality
Can / Should we strengthen the
bone-implant interface?
 PMMA
12 to 37% increase load to failure
Choueka, Koval et al., ActaOrthop ‘96
 CPPC
15% increased yield strength, stiffer
Moore, Goldstein, et al., JOT ‘97
Elder, Goulet, et al., JOT ‘00
 Clinical Factors in 2010 influence use
delivery, cost, complications must be considered
 Hydroxy-apatite (HA) coated screws
Reduced cut out in poorly positioned fixation
Moroni, et al. CORR ‘04
Factors Influencing Construct
Strength:
Uncontrolled factors


Fracture Geometry
Bone Quality
Surgeon controlled factors



Quality of Reduction
Implant Placement
Implant Selection
Kaufer, CORR ‘80
Kauffer, CORR 1980
Surgeon controlled factor
Fracture Reduction
When employing sliding hip screws…
 No role for displacement osteotomy
RCT Desjardins, et al. JBJS (B) ‘93
RCT Gargan, et al. JBJS (B) ‘94
 Limited role for reduction & fixation of
trochanteric fragments (biology vs stability)
Surgical goal: Biplanar, anatomic alignment
of proximal & shaft fragments
Mild valgus reduction for hinstability to offset shortening
Surgeon controlled factor
Fracture Reduction
 Discuss sequence of closed reduction steps
 Consider adjuncts to fracture reduction
Crutch… elevator… joystick…. etc.
Lever technique– read this article:
Surgeon controlled factor
Fracture of
Reduction
Double density of medial cortex is evidence of
intussuscepted neck into shaft seen on lateral
Traction will not reduce this “sag” but a
lever into the fracture will
Traction will not reduce this “sag” but a
lever into the fracture will reduce it
Surgeon controlled factor
Fracture Reduction
The AP view before and after lever
redution: the medial cortex is restored
Surgeon controlled factor: Implant position
Apex of the femoral head
Defined as the point where a line parallel to, and in the
middle of the femoral neck intersects the joint
Surgeon controlled factor: Implant position
Screw Position: TAD
Xap
Tip-Apex Distance =
Xlat
Xap
+
Xlat
Surgeon controlled factor: Implant position
Baumgaertner, Curtin, Lindskog, Keggi JBJS (A) ‘95
Surgeon controlled factor: Implant position
Probability of Cut Out
Increasing TAD ->
Baumgaertner, Curtin, Lindskog, Keggi JBJS (A) ‘95
Surgeon controlled factor: Implant position
Logistic Regression Analysis
Multivariate (dependent variable:Cut Out)

Reduction Quality
p = 0.6

Screw Zone
p = 0.6

Unstable Fracture
p = 0.03

Increasing Age

Increasing TAD p = 0.0002
p = 0.002
Baumgaertner, Curtin, Lindskog, Keggi JBJS (A) ‘95
Surgeon controlled factor: Implant position
Optimal Screw Placement
Dead Center
and
Very Deep
(TAD<25mm)

Best bone

No moment arm for
rotational instability
Maximum slide
 Validates reduction

Surgeon controlled factor: Implant selection
What’s the big
deal?
IM vs Plate
Fixation
IM Fixation Recent History:
Theoretical Biologic Advantages
Percutaneous Procedure
EBL, Muscle stripping,
Complications, Rehab time?
Surgical wounds s/p ORIF with IM device
GAMMA
The First to Reach
the Market
Gamma Clinical Results
Advantages :
±
Complications :
Bridle JBJS(B) '91
Boriani Orthopaedics '91
Lindsey Trauma '91
Halder JBJS(B) '92
+++
Williams Injury '92
LeungJBJS(B) '92
Aune ActOrthopScan '94
Surgeon controlled factor: Implant selection
Gamma Nail vs. CHS
1996 Meta-analysis of ten randomized trials
• Shaft fractures: Gamma 3
•
Required Re-ops: Gamma 2
x CHS (p < 0.001)
x CHS (p < 0.01)
• IM fixation may be superior for inter/subtroch
extension & reverse obliquity fractures
• “ CHS is a forgiving implant when used by
inexperienced surgeons, the Gamma nail is not”
MJParker,
Parker, International Orthopaedics '96
Gamma nails revisited
(risk of shaft fracture….)
Bhandari, Schemitsch et al. JOT 2009
No more increased risk with nails
Surgeon controlled factor: Implant selection
IM Fixation: Clinical Results
RCT, IMHS vs CHS, N = 135
 No difference for stable fxs
 Faster & less bloody for unstable fxs
 Fewer IM complications than Gamma
 Weaknesses:
No stratification of unstable fractures
Learning curve issues
No anatomic outcomes, wide functional outcomes
Baumgaertner, Curtin, Lindskog, CORR ‘98
Surgeon controlled factor: Implant selection
IM Fixation: Clinical Results
Well analyzed RCT, IMHS vs CHS, N = 100
 Longer surgery, less blood loss
 Improved post-op mobility
@ 1 & 3 months *
 Improved community ambulation
@ 6 & 12 months *
 45% less sliding, LLD*
(* p < 0.05)
Hardy, et. al JBJS(A) ‘98
Surgeon controlled factor: Implant selection
IM
IMFixation:
Fixation:Mechanical
MechanicalAdvantages
Advantages
?
!
Key point
It is not the reduced lever arm that
offers the clinically significant
mechanical advantage, but rather the
intramedullary buttress that the nail
provides to resist excessive fracture
collapse*
* Reduced collapse has been demonstrated in most every
randomized study that has looked at the variable
The nail substitutes for the incompetent posteromedial cortex
31.A33
2 weeks
7 months
The nail substitutes for the incompetent lateral cortex
CHS: Unique risk of failure
Palm, et al JBJS(A) ‘07
Iatrogenic, intraoperative lateral wall
fracture
31% risk in A2.2&3 fxs
22% failure rate
(vs. 3% overall)
A2 to A3 fx!
Surgeon controlled factor: Implant selection
IM Fixation: Selected Clinical Results
RCT, IMscrew vs CHS, N = 436
 less sliding, shaft medialization*
Ahrengart, CORR ‘02
RCT, IMscrew vs CHS, N = 46
5° in neck shaft angle @ 6 wks (all)
shaft medialization @ 4mo *
Pajarinen, Int Orth ‘04
RCT, IMscrew vs CHS, N = 108
 Improved post-op mobility (4 months)*
 less sliding, shaft medialization*
(* p < 0.05)
Pajarinen, JBJS(B) ‘05
Surgeon controlled factor: Implant selection
CHS Improvements: 1975-2010
Trochanteric Stabilizing Plate (TSP)
plate adjunct to limit shaft medialization
major (≥20mm screw
slide) collapse
op time, blood loss
? complications,
length of rehab
Madsen, JOT '98
Su, Trauma ‘03
Bong, Trauma ‘04
Surgeon controlled factor: Implant selection
IM Fixation: Best Indications
Reverse Oblique
Fractures
Intertroch +
subtrochanteric
fractures
Surgeon controlled factor: Implant selection
Reverse Oblique Fractures
Retrospective review of 49 consecutive R/ob.
fractures @ Mayo: overall 30% failure rate
 Poor Implant Position:
80% failure
 Implant Type:
Compression Hip Screw:
95° blade / DCS:
56% failure (9/16)
20% failure
(5/25)
IMHipScrew:
0% failure (0/3)
Haidukewych, JBJS(A) 2001
Surgeon controlled factor: Implant selection
Reverse Oblique Fractures
PFN vs 95° sliding screw plate(DCS)
RCT of 39 cases done by Swiss AO surgeons
PFN (IM) vs Plate
Open reductions
Op-time
All Significantly
Blood tx
reduced!
Failure rate
Major reoperations
Sadowski,Hoffmeyer JBJS(A) 2002
Recovery room control X-ray shows
loss of medial support, but nail
prevents excessive collapse
Surgeon controlled factor: Implant selection
Intertroch/
subtrochanteric
fxs
Greater mechanical demands,
poorer fracture healing
Surgeon controlled factor: Implant selection
Long Gamma
Nail for IT-ST Fxs
Barquet, JOT 2000
52 consecutive fractures; 43 with 1 year f/u


100% union
81 minutes, 370cc EBL
The authors describe the key percutaneous
reduction techniques that lead to successful
management of these difficult fractures
Reduction Aids
Surgeon controlled factor: Implant selection
Unstable Pertroch
Fractures (OTA31A.3)
347 articles reviewed: 10 relevant; 5 RCTs*
“Evidence-based bottom line:”
 Unacceptable failure rates with CHS
 Better results with 95° devices
 Best results with I M devices*
 Best “functional outcome” not known
Kregor, et al (Evidence Based
Working Group) JOT ‘05
CHS
31
AO / OTA
Surgeon controlled factor: Implant selection
Grossly displaced Stable (31A.1)
fracture treated with ORIF
Surgeon controlled factor: Implant selection
There is no data to support
nailing over sideplate fixation
for A1 fractures
CHS
????
31
AO / OTA
NAIL
Surgeon controlled factor: Implant selection
IM Fixation vs. CHS
Randomized/prospective trial of 210 pts.
Patients

Utrilla, et al. JOT 4/05
All ambulatory, no ASA Vs
Fractures
Excluded inter/subtrochs fractures (31A.3)

--excludes the fxs KNOWN to do best with IM
Surgeons
Only 4, all experienced

Technique
All got spinals, Closed reduction, percutaneous fixation
All overreamed 2mm, all got 130° x 11mm nail, one distal
interlock prn rotational instability (rarely used)

Surgeon controlled factor: Implant selection
IM Fixation vs. CHS
Randomized/prospective trial of 210 pts.
Results
Utrilla, et al. JOT 4/05
•
Skin to skin time unchanged
•
Fewer blood transfusions needed with IM
•
Better walking ability in Unstable fractures with IM
No shaft fxs
Fewer re-ops needed in IM group (1 vs 4)
•
•
Conclusion
•
IM fixation or CHS for stable fxs
•
Unlocked IM for most Unstable fxs
JBJS(A) 2010
No difference:
• Transfusions
• Hospital stay
 Re-ops
 Mobility
 Residence
However….
 Grossly underpowered (beta error)
300-500/arm needed
 Any patient eligible (age 42-99)
 Used Long Nails
 Outcome measures perfunctory



No X-rays
32% mortality
21% phone /proxy only
•This is gold?
Surgeon controlled factor: Implant selection
IM Hip Screws
Author’s Opinion
 Data supports use for unstable fractures
 RCTs document improved anatomy and
early function
 Iatrogenic problems decreased with current
designs and technique
 Indicated only for the geriatric fracture
Surgeon controlled factor: Implant selection
IM Hip Screw: Contraindications
 young patients (excess bone removal)
 basal neck fxs (iatrogenic displacement)
 stable fractures requiring open reduction
(inefficient)
 stable fractures with very narrow canals
(inefficient)
Technical
Tips
Patient Set-up
Position for nailing:
Hip Adducted
Unobstructed AP &
lateral imaging
Fracture Reduced(?)

Strong traction (without well leg countertraction) abducts
fractured hip and prevents gaining proper entrance site
Strong traction (without well leg countertraction) abducts
fractured hip and prevents gaining proper entrance site
The solution is the “Scissors position”
for the extremities
•Both feet in txn
•Fx: flexed & add
•Well leg extended &
abducted
• Lateral Xray: a little
different, but adequate
Guide Pin Insertion
Guide Pin Insertion
(Usually by hand…)
Ostrum, JOT 05: The entrance is
at the trochanteric tip or slightly MEDIAL
Ream a channel for implant!
(don’t just displace the fracture as you pass
reamer through it)
Medial directed force prevents fracture
gapping during entrance reaming
Achieve a Neck-Shaft Axis > 130°
Use at least a 130° nail
Varus Corrections
Advance nail

Increase traction
ABDUCT extremity!! (adduction

only necessary
of nail insertion)
at time
Postoperative Management
 Allow all patients to WBAT
 Patients “self regulate” force on hip
 No increased rate of failure
Koval, et. al,JBJS(A)’98
 X-rays post-op, then 6 & 12 weeks
Epilogue: intertrochs
(Questions without good answers)
Unanswered questions
Where’s the evidence??
Minimally invasive PLATE fixation ??
2 hole DHS
Bolhofner
Dipaola
PCCP
Gotfried
Which nail design is best ??
Proximal diameter?
Nail Length?
Distal interlocking?
Proximal screw ?
Sleeve or no sleeve?
Loch & Kyle, JBJS(A)‘98
One or two needed ?
Nobody knows!
Proximal fixation: 1 or 2 screws?
Kubiak, JOT ‘04
IMHS vs Trigen in vitro (cadaveric) testing
Results:
 No difference in fx sliding or collapse
 No difference in rigidity or stability
 Trigen with higher ultimate strength @ failure
Clinical significance??
Nobody knows!
Small Screws protect
lateral wall
Gotfried, CORR ‘04
Im, JOT ‘05
Only relevant for plate fixation?
Small Screws protect
lateral wall from fx
Gotfried, CORR ‘04
Im, JOT ‘05
Only relevant for plate fixation?
But… the “Z effect”
 7/70, 10% Werner-Tutschku, Unfall ’02
 5/45 11% Tyllianakis Acta Orthop Belgica ‘04
Long vs.short nails?
Thigh pain from short,
locked nails?
Periprosthetic fracture:
Still an issue?
Anterior cortex perforation
with long nails?
6% impinge/ 2% fx Robinson,
JBJS(A) 05
Cost/ benefit?
-Nobody knows-
Just when you think you know whats best--
Don’t forget Ex-Fix!
?
RCT n=40 Exfix +HA vs DHS
Faster ops, fewer txfusions, no comps
Moroni, et al. JBJS(A) 4/05
Ex-fix (HApins) vs DHS
Randomized/prospective trial of 40 pts.
Patients

Moroni, et al. JBJS(A) 4/05
65yo+ walking women with osteoporosis
Results
Faster operations with Fewer transfusions
Less post op pain, similar final function
No pin site infxs, no increased post op care
Increased pin torque on removal @ 12 wks
One nonunion

Conclusions:
Remember Kaufer’s Variables
Uncontrolled factors
Fracture Geometry
Bone Quality
Surgeon controlled factors
Quality of Reduction
Implant Placement
Implant Selection
Conclusions:
Implants have different
traits-choose wisely
Position screw
centrally and
very deep
(TAD≤20mm)
Conclusions:
Things change
 Healing is no longer “success”
 Deformity & function matter
 Perioperative insult counts
Audience
Response
Questions!
(save 5-8 minutes
for these)
81 y.o. female slipped & fell
3 part IT fx
Discuss:
Did the surgeon do a good job?
Yes or No
Post-op X-rays
Did the surgeon do a good
job?
 Yes
 No
Answer before advancing.
Now, consider specifically:
A.The reduction is satisfactory
B. The TAD (screw position) is OK
C. Both are satisfactory
D. Neither are satisfactory
…Choose Best Answer
6 months
3months
Post op
The TAD was
acceptable but
the reduction
was grossly
short
Did the surgeon do a good
job?
 Yes
 No
27yo jogger struck
by car, closed,
isolated injury
27yo jogger
struck by car
I’d reduce & fix with:
A. 95° blade
B. DCS plate
C. “Recon” Nail
D. DHS
E. Intramedullary hip
screw (PFN, TFN, IMHS,
GAMMA)
A.The reduction is satisfactory
B. The TAD is satisfactory
C. Both are satisfactory
D. Neither are satisfactory
*
*
Progressive pain 11-14 weeks
(varus + plate is rarely good)
I’d Bonegraft & revise with:
A. 95° blade
B. DCS plate
C. “Recon” Nail
D. DHS
E. IMHS
F Other
95° DCS + autoBG
71 yo renal txplnt pt c CHF
What to do??
If my patient, I would use:
1. Hip screw and sideplate
2. Hip screw and IM nail (TFN)
3. Reconstruction Nail (2 proximal
medullary-cephalic screws)
4. Blade Plate
5. Other
percutaneous
reduction
Uneventful Healing, WBAT
6wks
12wks
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