Orthopaedics & Traumatology: Surgery & Research 100 (2014) S75–S83

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Review article

Treatment of recent trochanteric fracture in adults

P. Adam ∗
Service de chirurgie orthopédique et de traumatologie, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, 67098 Strasbourg, France

a r t i c l e i n f o a b s t r a c t

Article history: Recent trochanteric fracture is frequent in adults, and mainly affects elderly patients who risk loss of
Accepted 8 November 2013 independence. Treatment is surgical, of various sorts. Open reduction internal fixation (ORIF) with intra-
or extra-medullary implants is the most frequent attitude in these fractures, which usually heal easily.
Keywords: In elderly patients, arthroplasty is an alternative of choice for some authors. These different treatment
Trochanteric fractures modalities are presented, focusing on technical details. Possible technical difficulties and the means of
Internal fixation dealing with them are considered. Published results help in choosing the treatment most suitable for a
Arthroplasty
particular type of fracture in a particular patient.
Surgical technique
© 2013 Elsevier Masson SAS. All rights reserved.

1. Introduction • the Evans classification [10], modified by Jensen and Michaelsen

Recent trochanteric fracture in adults overwhelming affects
elderly subjects. Frequency is increasing with population aging [1]
despite the development of treatments for osteoporosis. Preventive
measures based on anti-shock trousers have failed to demonstrate
efficacy, due to poor compliance [2,3].
In elderly subjects, fracture entails a serious risk of loss of inde-
pendence best reduced with surgery (usually conservative) that
should be undertaken with minimal delay.
The two most widely used types of open reduction internal fix-
ation (ORIF) are intra-medullary nailing and screw-plate fixation,
often performed by trainee surgeons due to their frequency and
reputed simplicity [4,5].
[11], is based on fracture site stability and comprises 5 types, from
non-displaced 2-fragment (Type I) to medially and posterolater-
ally comminuted fracture (Type V) (Fig. 1);
• The AO classification [12] comprises 3 groups:
◦ 31A1: simple 2-fragment pertrochanteric
◦ 31A2: multi-fragment pertrochanteric
◦ 31A3: intertrochanteric, each subdivided into 3 subgroups
(Figs. 2–3).
Both classifications have limited inter- and intra-observer
reproducibility, although this is better in the AO classification at
the level of the 3 principal groups [13].

2. Definition
Trochanteric fracture involves the proximal femur between the
cervical region and the shaft. Subtrochanteric fracture, with a frac-
ture line running from an area within 5 cm distal to the lesser
trochanter, is usually also included in the definition [6].
3. Classifications
There are numerous classifications of trochanteric fractures,
based on fracture line location [7,8] and on displacement and the
consequences for external reduction maneuvers [9]. Two classifi-
cations are particularly widely used:
∗ Tel.: +33 388 127 716.
E-mail addresses: philippe.adam@chru-strasbourg.fr, phradam@gmail.com
4. Epidemiology
Trochanteric fracture mainly affects the elderly. Together with
femoral neck fracture, it constitutes the category of proximal
femoral fractures, for which more than 80,000 cases were reported
in France in 2005.
In elderly subjects, trochanteric fracture results from bone
fragility associated with frequent falls, induced by certain medical
drugs such as hypnotics and also recent antihypertensive treat-
ments [14].
5. Diagnosis
Classically, trochanteric fracture affects subjects aged > 75 years,
with a distinct female predominance.
It often follows a simple high fall, resulting in total lower-limb
impotence. The classic deformity pattern of shortening, adduction
and external rotation may not apply when there is no displacement.

1877-0568/$ – see front matter © 2013 Elsevier Masson SAS. All rights reserved.
http://dx.doi.org/10.1016/j.otsr.2013.11.007
S76 P. Adam / Orthopaedics & Traumatology: Surgery & Research 100 (2014) S75–S83
Fig. 1. Jensen–Michaelsen classification.
Fig. 2. AO classification.
AP pelvic and lateral hip X-ray confirms diagnosis and determines
classification.
CT is indicated only to screen for occult fracture.
General examination screens for comorbidities in decompensa-
tion. Screening for denutrition is important, to anticipate possible
difficulties in functional recovery [15].
6. Treatment objectives
In the elderly, there is a risk of general complications and espe-
cially of loss of independence and, in particular, of walking capacity.
The chosen treatment should allow verticalization and early
seating, to avoid the serious complications associated with decubi-
tus.
Treatment should involve as little shock, surgery time and blood
loss as possible so as not to impair recovery.
Ideally, it should allow resumption of unrestricted weight-
bearing, which is the best guarantee of conserving walking capacity.
Whatever the treatment, associated measures comprise pre-
and post-operative pain management, prevention of venous
Fig. 3. 31A3 fracture.
thromboembolism, dietary supplementation if necessary, and mus-
cle exercise.
7. Treatments
7.1. Functional treatment
Functional treatment of trochanteric fracture is reserved to
strictly non-displaced fractures in cooperative patients. It com-
prises non-weight-bearing for the fractured limb and limited hip
flexion awaiting radiologic fusion. The main risk is of secondary
displacement. Elderly patients are not ideal candidates, due to the
serious risk of loss of independence. In case of absolute anesthesi-
ological or surgical contra-indication, functional treatment may be
the only option in a situation of obligatory therapeutic abstention,
but with a mortality rate exceeding that of surgery.
7.2. Conservative treatment
Conservative management was codified by Böhler, specifying
traction time (10–14 weeks) and direction according to fracture
line location and fragment displacement.
Due to the long decubitus required, conservative treatment is
nowadays exceptional, reserved to rare cases of anesthesiological
contra-indication.
 P. Adam / Orthopaedics & Traumatology: Surgery & Research 100 (2014) S75–S83 S77

7.3. Surgical treatment

Surgical treatment is the rule. It should be performed as quickly

as possible after stabilization of vital functions [16,17].

7.3.1. ORIF
7.3.1.1. Patient positioning. Positioning seeks to achieve at least
partial fracture site reduction. ORIF is greatly helped if the fracture
site is already reduced before the procedure. These initial reduction
techniques are performed closed or semi-open, under fluoroscopy.
Whichever the type of ORIF (intra-medullary nailing or screw-
plate), installation is on a traction table. Transosseous traction is
not usually required: traction using a shoe of appropriate size is
enough. Dorsal decubitus has the advantage of simplicity and good
hemodynamic and ventilatory tolerance in patients whose general
health status may be poor; some teams, however, prefer lateral Fig. 5. Frontal reduction control.
decubitus, which provides good control of rotation.
It is essential to check that AP and lateral views can easily be
taken by the electroradiological operator at any time. When pos-
sible, use of two fluoroscopes allows simultaneous AP and lateral
control of reduction.
Once the patient is positioned in traction along the axis of the
limb, reduction is checked, comparing morphology to that of the
healthy hip on AP pelvic view.
If the fractured femur is in varus relative to the healthy side,
axial traction should be increased; if it is in valgus, traction should
be relaxed.
Once femoral morphology has been satisfactorily restored
frontally, the lateral view is controlled. Lateral reduction can be
adjusted by rotating the limb, starting with the patella at the
zenith. As there is often posterior comminution, reduction is often
achieved in internal rotation, which should, however, be moder-
ate due to the risk of malunion in internal rotation, which would
greatly hinder recovery of walking capacity [18]. Certain fractures
are reduced in external rotation, as the pelvic and trochanteric
Fig. 6. Lateral reduction control after initiation of traction.
muscles conserve their external rotational action on the proximal
fragment: these are what are called “extradigital” fractures [19].
Thus simple limb positioning on the fracture table can adjust
7.3.1.2. Reduction-aid techniques. Various reduction-aid tech-
varus/valgus frontally and rotation laterally (Figs. 4–6). It cannot,
niques can be used.
however, reduce displacement of fragments in sagittal translation
Posterior support: this can be used to avoid posterior translation
or flexion of the proximal with respect to the distal fragment:
of the distal fragment in subtrochanteric or trochanteric-diaphyseal
these displacements require peroperative action directly on the
fracture, especially in obese patients (Figs. 7 and 8).
fragments themselves. Such complementary reduction should be
A Wagner raspatory on the anterior side of the neck reduces
performed before creating the entry points for the fixation material.
proximal fragment flexion caused, notably, by non-compensated
Quality of reduction and appropriate implant positioning deter-
psoas-iliac muscle traction (Figs. 9 and 10).
mine the final result [20].

Fig. 4. Trochanteric fracture. Fig. 7. Posterior support.

S78 P. Adam / Orthopaedics & Traumatology: Surgery & Research 100 (2014) S75–S83
Fig. 8. Lateral reduction with posterior support.
Fig. 9. Lateral displacement due to proximal fragment flexion.
Fig. 10. Wagner raspatory on anterior side of proximal fragment.
A K-wire in the proximal fragment reduces rotation disorder,
especially excessive external rotation of the proximal fragment.
Without prior correction, there is a major risk of malpositioning
the entry point of an intra-medullary nail and of excessive femoral
anteversion.
Fig. 11. Persistent displacement in trochanteric-diaphyseal fracture.
Open reduction with positioning of a bone-holding forceps may
be necessary in subtrochanteric fracture with muscle incarceration
within the fracture site [21] (Figs. 11 and 12).
Temporary cerclage can prevent reduction loss during osteosyn-
thesis.
Precise reduction facilitates the location of the intra-medullary
nail entry point, enabling reaming to prepare the nail lodge, reduc-
ing the risk of correction loss when the nail is introduced [22].
The advantages of anatomic reduction outweigh the harmful
impact of local devascularization on fusion [23]. Optimal reduction
is also important with screw-plates, to locate the entry point of
the cervical screw and align the plate with the lateral side of the
proximal shaft.
7.3.1.3. Types of internal fixation. Rather than contrasting open
versus closed techniques, we shall distinguish internal fixation
according to the extra- versus intra-medullary position of the mate-
rial.
7.3.1.3.1. Extra-medullary material.
7.3.1.3.1.1. Blade- and nail-plates. Historically, blade-plates
and nail-plates were the first types of internal fixation.
After reduction, implantation used a lateral approach, raising
the vastus lateralis.
Material angulation varied according to fracture line type: 130◦
in pertrochanteric fracture and 95◦ in intertrochanteric fracture
with horizontal line or subtrochanteric fracture.
Blade or nail position was determined using K-wires under flu-
oroscopy.
For 130◦ blades, a minimum 10 mm distance between the end
of the blade and the contour of the femoral head was aimed at, to
ensure against initial protrusion.
The monoblock design of these implants had the advantage of
maintaining correct reduction. In case of comminution, fracture site
Fig. 12. Reduction using bone-holding forceps.
 P. Adam / Orthopaedics & Traumatology: Surgery & Research 100 (2014) S75–S83
Fig. 13. Minimally invasive implantation of dynamic plate screw.
impaction along the blade or nail, however, entailed a serious risk
of material penetrating the joint.
7.3.1.3.1.2. Screw-plates. Screw-plates encountered great suc-
cess, due to their ease of implantation and the possibility of
controlled sliding of the cervical screw, inducing fracture site
impaction to promote fusion with a reduced risk of joint penetra-
tion by the material.
The technique is as follows:
• after fracture site reduction, a lateral subtrochanteric approach
is performed, raising the vastus lateralis;
• femoral neck anteversion is estimated, and a cervical guide-wire
is placed in a central position frontally and laterally using a guide
angled according to the plate used (130◦ , 135◦ or 140◦ , depending
on the model) under fluoroscopy. In subtrochanteric fracture, an
angle of 95◦ is used [24];
• screw length should take account of the possibility of compres-
sion of the site;
• the trajectory of the cervical screw and of the plate barrel is pre-
pared using a triple reamer;
• a temporary anti-rotation wire may be fitted if necessary before
inserting the cervical screw;
• a flat section on the screw and plate avoids one rotating with
respect to the other;
• the fracture site can be compressed peroperatively; otherwise,
compression is ensured by the dynamic assembly;
• a supplementary cervical screw may be positioned in parallel
proximal to the first screw, to neutralize rotation force;
• in complex fracture, a lateral greater trochanter support plate
may be associated, allowing extra screws for fixation.
Screw-plates may be fitted on a minimally invasive approach
(Fig. 13), limiting blood loss [25].
Locking the distal diaphyseal screws has been recommended to
improve stability in case of osteoporosis, with encouraging exper-
imental results [26]. There is, however, a risk of perforation of the
head and of fracture of material in case of varization of the fracture
site, due to the lack of play between plate and screws [27].
7.3.1.3.2. Intra-medullary material.
7.3.1.3.2.1. Ender’s flexible nailing. Flexible nailing, following
Ender, was very much in fashion in the 1970s and 1980s.
Introducing a small-diameter elastic nail very remotely from
the fracture site, in the medial side of the distal femur, may still
be indicated in case of pre-existing skin lesions in the trochanteric
region.
With the surgeon between the lower limbs, the patient is pos-
itioned with both lower limbs in abduction, enabling the site to
be valgized to facilitate nailing. A large enough metaphyseal bone
window allows 3 precurved nails to be introduced.
S79
Fig. 14. Patient positioning for intra-medullary nailing with lateral truncal inclina-
tion.
Although the use of locking nails limits sliding and the occur-
rence of skin problems at the knee [28], weight-bearing is not
allowed and there is a high rate of malunion in external rotation.
For these reasons, this technique has been abandoned in favor of
more rigid internal fixation.
7.3.1.3.2.2. Intra-medullary nailing. Intra-medullary nailing is
an effective attitude in trochanteric fracture [29]. With the
optimization of positioning instrumentation, favoring minimally
invasive insertion, and the mechanical advantage inherent to
intra-medullary material in complex fracture, nailing has become
increasingly widespread compared to screw-plate fixation [30,31].
After reduction, the introduction area is located under fluo-
roscopy. Laterally, introduction follows the long axis of the femoral
shaft, so that the trochanteric entry point can be determined only
after reduction.
To optimize access to the summit of the greater trochanter,
the lower limb must not be placed in adduction, varizing the frac-
ture site; rather, the trunk should be inclined laterally on the side
opposite the fracture (Fig. 14] and the position maintained by a lat-
eral thoracic support. In obese patients, the incision is then shifted
proximally.
The angle of the nail is adapted to the morphology of the prox-
imal femur, and the entry point is determined according to the
specifications for the particular nail.
There is a risk of over-reaming the lateral part of the proximal
femur, especially when the guide is lateral to the fracture site. To
avoid such excentric reaming, a slight hyper-reduction in valgus
during reaming prevents the trochanter being weakened laterally
and thus prevents varus displacement when introducing the nail
[32].
The metaphyseal and proximal diaphyseal region must be
reamed sufficiently, at least 2 mm more than the diameter of the
nail, to avoid the nail, which is straight whereas the proximal femur
is curved, becoming stuck when it descends.
The descent of the nail determines the subsequent position of
the cervical screw.
S80 P. Adam / Orthopaedics & Traumatology: Surgery & Research 100 (2014) S75–S83
Figs. 15 and 16. Pertrochanteric fracture: planning of nail angle and cervical screw
position on frontal pelvic view. Control at bone fusion (+ 8 weeks).
On AP view:
• giving the screw a low position delays joint breakage in case of
varization of the fracture site;
• positioning the screw in the center of the femoral head provides a
more solid bone anchorage while allowing the distance between
the end of the screw and the apex of the head to be reduced, to
improve stability [33] (Figs. 15–16).
On lateral view:
o ideally, the screw is centered in the femoral neck and epiphysis,
maximizing before cut-out [34];
o excentric lateral positioning could trigger rotation of the prox-
imal fragment, leading eventually to perforation of the femoral
head [35].
If the fracture line is at the base of the head, fitting an anti-
rotation wire before inserting the cervical screw reduces the risk of
proximal fragment rotation.
The cervical screw needs to be long enough and go far enough
into the epiphysis (“combined tip-apex distance”: the sum of the
distance measured frontally and laterally, < 25 mm), while keeping
a safety margin of at least 5 mm between the top of the screw and
the projection of the femoral head on AP and lateral views [36].
The lateral end of the cervical screw should go slightly beyond
the lateral cortex of the femur, so as subsequently to be able to slide.
There are various specificities to different manufacturers’ mod-
els: the cervical screw may have the form of an “anti-rotation
blade”, intended to provide better epiphyseal anchorage in porotic
bone [37].
Associating a blocking system prevents the screw or blade rotat-
ing with respect to the nail, without preventing sliding, thereby
allowing compression of the fracture site. Without such locking,
there is a risk of post-operative intrapelvic migration of cervical
material [38,39] (Figs. 17–19).
Distal locking of short intra-medullary nails is performed using
the nail-holder device.
A short nail may be used in pertrochanteric fracture detaching
the lesser trochanter if the fracture line does not extend more than
5 cm distally to the lesser trochanter and the patient is not morbidly
obese.
For more distal fracture lines and subtrochanteric fracture and
in morbidly obese patients, a long nail is required. In that case,
distal targeting classically uses the “round holes” technique. Distal
locking aids (e.g., the Distal Targeting Device, StrykerTM ), intended
to reduce the radiation involved in distal targeting, have recently
been assessed.
7.3.1.3.3. Improving epiphyseal bone anchorage. Intra-osseous
acrylic cement may improve epiphyseal anchorage. After an exper-
imental validation phase [40,41], acrylic cement was successfully
associated to treat unstable trochanteric fracture in severe osteo-
porosis, using screw-plates or intra-medullary nails [42,43].
7.3.1.3.4. External fixation. External fixation represents an
interesting alternative for stabilizing type 31A1 or 31A2 fracture
in fragile patients, as it involves little shock.
The various assemblies available all begin with reduction on the
fracture table, followed by fitting two series of pins: one oblique at
130◦ to the diaphyseal axis with epiphyseal fixation, and one using
bicortical diaphyseal pins.
The most frequent complication is infection on the pins, with
an incidence of 7% for standard pins [44]. With the advent of
hydroxyapatite-coated pins, this complication has almost com-
pletely disappeared [45].
In case of non-union, revision using internal fixation entails a
risk of infection.
7.3.1.4. Hip replacement. Some teams prefer hip replacement,
especially in unstable fracture in elderly patients who remain able
to walk, in whom internal fixation anchorage may be problematic.
The rate of early mechanical failure in ORIF at advanced stages on
the Singh classification is indeed an indication for hip replacement,
as in cervical fracture [46–49].
Mortality seems no higher after hip replacement than after ORIF
[50,51]. Comparative studies between the two are, however, few,
and no definite conclusion can be drawn [47,52].
Pre-operative planning and landmarking (lesser trochanter,
greater trochanter, trochanteric fossa, femoral expansion of gluteus
maximus, etc.) allows lower-limb length to be almost equalized.
All approaches are feasible. In case of continuity between the
gluteus medius and vastus lateralis caused by a fracture detaching
the greater trochanter, a transfracture approach provides excel-
lent access to both acetabulum and femur, but requires painstaking
reconstruction, repositioning the greater trochanter by cerclages or
a trochanteric hook plate.
Implants may be cephalic, bipolar or total, using standard or
revision femoral components. Large heads, bipolar heads or dual
mobility sockets provide extra stability, which is useful because of
the risk of dislocation [51] (Fig. 20).
8. Clinical forms and therapeutic specificities
8.1. Fracture in young subjects
In young subjects, trochanteric fracture results from violent
trauma, and is usually displaced. Muscle incarceration in the
 P. Adam / Orthopaedics & Traumatology: Surgery & Research 100 (2014) S75–S83 S81

Figs. 17–19. Intra-articular migration of cervical screw due to insufficient tightening of the blocking screw.

fracture site is not unusual and hinders reduction by isolated exter-
nal maneuver.
In young subjects, the greater frequency of material ablation and
the room taken up proximally by intra-medullary nails may justify
more frequent resort to screw-plates, especially in stable fractures.
8.2. Fracture of pathological bone
The proximal femur, and the metaphyseal region in particular,
is a common location for bone metastasis. Absence of apparent
trauma, presence of osteolysis and isolated lesser trochanteric
fracture suggest tumor, especially metastatic or myelomatous in
elderly subjects.
Depending on expected survival and tumor location and exten-
sion, treatment may comprise resection of the affected area and
implantation of a mega-prosthesis or, if survival is more limited,
internal fixation by intra-medullary nailing to reinforce the femur
all the way down [53], possibly associating acrylic cement.
8.3. Fracture in osteoarthritic hip
Osteoarthritis is an argument for hip replacement. Total hip
replacement is a logical attitude in case of trochanteric fracture
S82 P. Adam / Orthopaedics & Traumatology: Surgery & Research 100 (2014) S75–S83
Fig. 20. Treatment of trochanteric fracture by total hip replacement with dual
mobility socket and trochanteric cerclage.
associated with symptomatic osteoarthritis and a sufficient pre-
operative Parker score. A dual mobility socket reduces the risk of
post-operative instability in this particular indication [51].
In patients with a very low pre-operative Parker score, on the
other hand, ORIF is sufficient, allowing nursing care and avoiding
the problems of decubitus.
9. Associated measures
In trochanteric fracture, ORIF is performed under antibiopro-
phylaxis.
Thromboprophylaxis is initiated post-operatively if there is no
hemorrhagic syndrome.
A suction drain is reserved to wide approaches. Weight-bearing
up to the pain threshold is allowed post-operatively after intra-
medullary nailing or in stable fracture managed by screw-plate.
Only touch weight-bearing is allowed if the assembly seems less
secure in unstable fracture.
In elderly patients, hardware is not ablated except in case of
infectious or mechanical complications or of prosthesis replace-
ment.
10. Treatment results
In trochanteric fracture, ORIF shortens the affected limb by a
mean 11 mm at fusion, and more in unstable fractures.
For a given type of fracture, there is less shortening with intra-
medullary nailing than with a screw-plate [54].
Intra-medullary nailing is increasingly used, but seems to give
better results than screw-plates only in subtrochanteric fracture
[55] (Figs. 19 and 20).
Reduction defect in varus is to be avoided, using direct manoeu-
vres if needed, as it is more often associated with defective fusion.
Depending on the assessment criteria, functional results do not
significantly differ between hip replacement and ORIF [56].
In elderly subjects, prognosis for trochanteric fracture is poor,
with 6-month mortality exceeding 25% and lowered walking scores
and Parker independence scores for survivors [57].
11. Conclusion
Treatment of trochanteric fracture is well codified. Risk of failure
increases with imperfect reduction, poor implant positioning and
advanced osteoporosis.
The development of ORIF simulation, which is still in its early
stages, should reduce the rate of technical error [58].
Disclosure of interest
Philippe Adam: Consultant for Synthes.
Acknowledgments
Thanks to Dr Taglang and Dr Ehlinger.
References
[1] White S, Griffiths R. Projected incidence of proximal femoral fracture in
England: a report from the NHS Hip Fracture Anaesthesia Network (HIPFAN).
Injury 2011;42:1230–3.
[2] Gillespie W, Gillespie L, Parker M. Hip protectors for preventing hip fractures
in older people. Cochrane Database Syst Rev 2010 [CD001255].
[3] Cameron I, Kurrle S, Quine S, Sambrook P, March L, Chan D, et al. Improving
adherence with the use of hip protectors among older people living in nursing
care facilities: a cluster randomized trial. J Am Med Dir Assoc 2011;12:50–7.
[4] Bjorgul K, Novicoff W, Saleh K. Learning curves in hip fracture surgery. Int
Orthop 2011;35:113–9.
[5] Biber R, Gruninger S, Singler K, Sieber C, Bail H. Is proximal femoral nailing
a good procedure for teaching in orthogeriatrics? Arch Orthop Trauma Surg
2012;132:997–1002.
[6] Loizou C, Mcnamara I, Ahmed K, Pryor G, Parker M. Classification of sub-
trochanteric femoral fractures. Injury 2010;41:739–45.
[7] Ramadier J, Duparc J, Rougemont D, De Ferrari G. Surgical treatment of
trochanteric and juxta-trochanteric fractures. Rev Chir Orthop Reparatrice
Appar Mot 1956;42:759–82 [Discussion, 782–786].
[8] Decoulx P, Lavarde G. Fractures de la région trochantérienne. J Chir (Paris)
1969;98:75–100.
[9] Ender J, Simon-Wiedner R. Die Fixierung der trochanteren Bruche mit runden
elstichen Condylennageln. Acta Chir Austriaca 1970;1:40–5.
[10] Evans E. The treatment of trochanteric fractures of the femur. J Bone Joint Surg
Br 1949;31B:190–203.
[11] Jensen J, Michaelsen M. Trochanteric femoral fractures treated with McLaughlin
osteosynthesis. Acta Orthop Scand 1975;46:795–803.
[12] Muller ME, Nazarian S, Koch S, Koch P. In: Springer-Verlag, editor. Classification
des fractures des os longs. New York: Berlin Heidelberg; 1990.
[13] Pervez H, Parker M, Pryor G, Lutchman L, Chirodian N. Classification of
trochanteric fracture of the proximal femur: a study of the reliability of current
systems. Injury 2002;33:713–5.
[14] Huang A, Mallet L, Rochefort C, Eguale T, Buckeridge D, Tamblyn R. Medication-
related falls in the elderly: causative factors and preventive strategies. Drugs
Aging 2012;29:359–76.
[15] Mizrahi E, Fleissig Y, Arad M, Blumstein T, Adunsky A. Rehabilitation outcome of
hip fracture patients: the importance of a positive albumin gain. Arch Gerontol
Geriatr 2008;47:318–26.
[16] Al-Ani AN, Samuelsson B, Tidermark J, Norling A, Ekstrom W, Cederholm T.
Early operation on patients with a hip fracture improved the ability to return
to independent living. A prospective study of 850 patients. J Bone Joint Surg
Am 2008;90:1436–42.
[17] Holt G, Smith R, Duncan K, McKeown D. Does delay to theatre for medical
reasons affect the peri-operative mortality in patients with a fracture of the
hip? J Bone Joint Surg Br 2010;92:835–41.
[18] Ramanoudjame M, Guillon P, Dauzac C, Meunier C, Carcopino J. CT evalua-
tion of torsional malalignment after intertrochanteric fracture fixation. Orthop
Traumatol Surg Res 2010;96:844–8.
[19] Ottolenghi C, Japas L. Fractures latérales du fémur: variété extradigitale. Rev
Chir Orthop Reparatrice Appar Mot 1964;50:389–98.
[20] Haidukewych G. Intertrochanteric fractures: ten tips to improve results. Instr
Course Lect 2010;59:503–9.
[21] Afsari A, Liporace F, Lindvall E, Infante AJ, Sagi H, Haidukewych G. Clamp-
assisted reduction of high subtrochanteric fractures of the femur: surgical
technique. J Bone Joint Surg Am 2010;92(Suppl. 1 Pt 2):217–25.
[22] Muller T, Topp T, Kuhne C, Gebhart G, Ruchholtz S, Zettl R. The benefit of
wire cerclage stabilisation of the medial hinge in intra-medullary nailing for
the treatment of subtrochanteric femoral fractures: a biomechanical study. Int
Orthop 2011;35:1237–43.
[23] Kennedy M, Mitra A, Hierlihy T, Harty J, Reidy D, Dolan M. Subtrochanteric
hip fractures treated with cerclage cables and long cephalomedullary nails: a
review of 17 consecutive cases over 2 years. Injury 2011;42:1317–21.
[24] Sanders R, Regazzoni P. Treatment of subtrochanteric femur fractures using the
dynamic condylar screw. J Orthop Trauma 1989;3:206–13.
[25] Alobaid A, Harvey E, Elder G, Lander P, Guy P, Reindl R. Minimally invasive
dynamic hip screw: prospective randomized trial of two techniques of insertion
of a standard dynamic fixation device. J Orthop Trauma 2004;18:207–12.
[26] Jewell D, Gheduzzi S, Mitchell M, Miles A. Locking plates increase the strength
of dynamic hip screws. Injury 2008;39:209–12.
[27] Glassner P, Tejwani N. Failure of proximal femoral locking compression plate:
a case series. J Orthop Trauma 2011;25:76–83.
[28] Kempf I, Briot B, Bitar S, Ben Abid M, Graf H. The Ender nailing: state of the art
and new improvements. The sliding nailing (author’s transl). Rev Chir Orthop
Reparatrice Appar Mot 1982;68:199–205.
 P. Adam / Orthopaedics & Traumatology: Surgery & Research 100 (2014) S75–S83
[29] Kempf I, Grosse A, Taglang G, Favreul E. Gamma nail in the treatment of closed
trochanteric fractures. Results and indications apropos of 121 cases. Rev Chir
Orthop Reparatrice Appar Mot 1993;79:29–40.
[30] Anglen J, Weinstein J. Nail or plate fixation of intertrochanteric hip fractures:
changing pattern of practice. A review of the American Board of Orthopaedic
Surgery Database. J Bone Joint Surg Am 2008;90:700–7.
[31] Forte M, Virnig B, Eberly L, Swiontkowski M, Feldman R, Bhandari M, et al.
Provider factors associated with intra-medullary nail use for intertrochanteric
hip fractures. J Bone Joint Surg Am 2010;92:1105–14.
[32] Hak D, Bilat C. Avoiding varus malreduction during cephalomedullary nailing
of intertrochanteric hip fractures. Arch Orthop Trauma Surg 2011;131:709–10.
[33] Herman A, Landau Y, Gutman G, Ougortsin V, Chechick A, Shazar N. Radiological
evaluation of intertrochanteric fracture fixation by the proximal femoral nail.
Injury 2012;43:856–63.
[34] Bojan A, Beimel C, Taglang G, Collin D, Ekholm C, Jonsson A. Critical factors in
cut-out complication after gamma nail treatment of proximal femoral fractures.
BMC Musculoskelet Disord 2013;14:1.
[35] Lenich A, Bachmeier S, Prantl L, Nerlich M, Hammer J, Mayr E, et al. Is the
rotation of the femoral head a potential initiation for cutting out? A theoretical
and experimental approach. BMC Musculoskelet Disord 2011;12:79.
[36] Mao Y, Song J, Wei J, Wang M. Prevention of unrecognized joint penetration
during internal fixation of hip fractures: a geometric model based on Steinmetz
Solid. Hip Int 2010;20:547–50.
[37] Simmermacher R, Ljungqvist J, Bail H, Hockertz T, Vochteloo A, Ochs U, et al.
The new proximal femoral nail antirotation (PFNA) in daily practice: results of
a multicentre clinical study. Injury 2008;39:932–9.
[38] Li X, Heffernan M, Kane C, Leclair W. Medial pelvic migration of the lag screw
in a short gamma nail after hip fracture fixation: a case report and review of
the literature. J Orthop Surg Res 2010;5:62.
[39] Frank M, Yoon R, Yalamanchili P, Choung E, Liporace F. Forward progression of
the helical blade into the pelvis after repair with the Trochanter Fixation Nail
(TFN). J Orthop Trauma 2011;25:e100–3.
[40] Stoffel K, Leys T, Damen N, Nicholls R, Kuster M. A new technique for cement
augmentation of the sliding hip screw in proximal femur fractures. Clin
Biomech (Bristol, Avon) 2008;23:45–51.
[41] Erhart S, Schmoelz W, Blauth M, Lenich A. Biomechanical effect of bone cement
augmentation on rotational stability and pull-out strength of the Proximal
Femur Nail Antirotation. Injury 2011;42:1322–7.
[42] Lee P, Hsieh P, Chou Y, Wu C, Chen W. Dynamic hip screws for unsta-
ble intertrochanteric fractures in elderly patients–encouraging results with a
cement augmentation technique. J Trauma 2010;68:954–64.
[43] Dall’Oca C, Maluta T, Moscolo A, Lavini F, Bartolozzi P. Cement augmentation
of intertrochanteric fractures stabilised with intra-medullary nailing. Injury
2010;41:1150–5.
S83
[44] Badras L, Skretas E, Vayanos E. Treatment of trochanteric fractures by external
fixator. Rev Chir Orthop Reparatrice Appar Mot 1997;84:461–5.
[45] Moroni A, Faldini C, Pegreffi F, Hoang-Kim A, Vannini F, Giannini S. Dynamic
hip screw compared with external fixation for treatment of osteoporotic
pertrochanteric fractures. A prospective, randomized study. J Bone Joint Surg
Am 2005;87:753–9.
[46] Saragaglia D, Carpentier E, Gordeff A, Legrand J, Faure C, Butel J. Trochanteric
fractures in the elderly: Ender nails, prostheses or direct osteosyntheses Apro-
pos of a continuous series of 265 cases. Rev Chir Orthop Reparatrice Appar Mot
1985;71:179–86.
[47] Haentjens P, Casteleyn P, De Boeck H, Handelberg F, Opdecam P. Treatment
of unstable intertrochanteric and subtrochanteric fractures in elderly patients.
Primary bipolar arthroplasty compared with internal fixation. J Bone Joint Surg
Am 1989;71:1214–25.
[48] Chan K, Gill G. Cemented hemiarthroplasties for elderly patients with
intertrochanteric fractures. Clin Orthop Relat Res 2000:206–15.
[49] Broos P, Rommens P, Deleyn P, Geens V, Stappaerts K. Pertrochanteric frac-
tures in the elderly: are there indications for primary prosthetic replacement?
J Orthop Trauma 1991;5:446–51.
[50] Geiger F, Zimmermann-Stenzel M, Heisel C, Lehner B, Daecke W. Trochanteric
fractures in the elderly: the influence of primary hip arthroplasty on 1-year
mortality. Arch Orthop Trauma Surg 2007;127:959–66.
[51] Bonnevialle P, Saragaglia D, Ehlinger M, Tonetti J, Maisse N, Adam P, et al.
Trochanteric locking nail versus arthroplasty in unstable intertrochanteric
fracture in patients aged over 75 years. Orthop Traumatol Surg Res
2011;97:S95–100.
[52] Kim S, Kim Y, Hwang J. Cementless calcar-replacement hemiarthroplasty com-
pared with intra-medullary fixation of unstable intertrochanteric fractures. A
prospective, randomized study. J Bone Joint Surg Am 2005;87:2186–92.
[53] Parker M, Khan A, Rowlands T. Survival after pathological fractures of the prox-
imal femur. Hip Int 2011;21:526–30.
[54] Platzer P, Thalhammer G, Wozasek G, Vecsei V. Femoral shortening after sur-
gical treatment of trochanteric fractures in nongeriatric patients. J Trauma
2008;64:982–9.
[55] Parker M, Handoll H. Gamma and other cephalocondylic intra-medullary
nails versus extramedullary implants for extracapsular hip fractures in adults.
Cochrane Database Syst Rev 2010 [CD000093].
[56] Parker M, Handoll H. Replacement arthroplasty versus internal fixation for
extracapsular hip fractures in adults. Cochrane Database Syst Rev 2006
[CD000086].
[57] Bonnevialle P, Féron JM, Jacquot F, et al. Fractures in very old patients (over 80
years). Rev Chir Orthop Reparatrice Appar Mot 2003;89(S5):132–75.
[58] Froelich J, Milbrandt J, Novicoff W, Saleh K, Allan D. Surgical simulators and hip
fractures: a role in residency training? J Surg Educ 2011;68:298–302.