 TRAUMA

Lateral femoral wall thickness

A RELIABLE PREDICTOR OF POST-OPERATIVE LATERAL WALL
FRACTURE IN INTERTROCHANTERIC FRACTURES

C-E. Hsu, Although the importance of lateral femoral wall integrity is increasingly being recognised in
C-M. Shih, the treatment of intertrochanteric fracture, little attention has been put on the development
C-C. Wang, of a secondary post-operative fracture of the lateral wall. Patients with post-operative
K-C. Huang fractures of the lateral wall were reported to have high rates of re-operation and
complication. To date, no predictors of post-operative lateral wall fracture have been
From Taichung reported. In this study, we investigated the reliability of lateral wall thickness as a predictor
Veterans General of lateral wall fracture after dynamic hip screw (DHS) implantation.
Hospital, Taichung, A total of 208 patients with AO/OTA 31-A1 and -A2 classified intertrochanteric fractures
Taiwan who received internal fixation with a DHS between January 2003 and May 2012 were
reviewed. There were 103 men and 150 women with a mean age at operation of
78 years (33 to 94). The mean follow-up was 23 months (6 to 83). The right side was affected
in 97 patients and the left side in 111. Clinical information including age, gender, side,
fracture classification, tip–apex distance, follow-up time, lateral wall thickness and outcome
were recorded and used in the statistical analysis.
Fracture classification and lateral wall thickness significantly contributed to post-
operative lateral wall fracture (both p < 0.001). The lateral wall thickness threshold value for
risk of developing a secondary lateral wall fracture was found to be 20.5 mm.
To our knowledge, this is the first study to investigate the risk factors of post-operative
lateral wall fracture in intertrochanteric fracture. We found that lateral wall thickness was a
reliable predictor of post-operative lateral wall fracture and conclude that intertrochanteric
fractures with a lateral wall thickness < 20.5 mm should not be treated with DHS alone.
Cite this article: Bone Joint J 2013;95-B:1134–8.

 C-E. Hsu, MD, Orthopaedic
Surgeon
 C-M. Shih, MD, Orthopaedic
Surgeon
 C-C. Wang, MD, Orthopaedic
Surgeon
 K-C. Huang, MD, Orthopaedic
Surgeon
Taichung Veterans General
Hospital, Department of
Orthopedics, Taichung, Taiwan.
Correspondence should be sent
to Mr K-C. Huang; e-mail:
quechouyell@gmail.com
©2013 The British Editorial
Society of Bone & Joint
Surgery
doi:10.1302/0301-620X.95B8.
31495 $2.00
Bone Joint J
2013;95-B:1134–8.
Received 19 December 2012;
Accepted after revision 21
March 2013
The importance of the integrity of the lateral
femoral wall is increasingly being recognised in
the treatment of intertrochanteric fracture
(ITF).1,2 Previously, the condition of the pos-
teromedial portion was regarded as the most
important prognostic factor in the outcome of
fixation using a dynamic hip screw (DHS; Syn-
thes, Bochum, Germany),1 but recently is has
been demonstrated that integrity of the lateral
wall is essential for successful results.2,3 Little
consideration has been given to post-operative
fracture of the lateral wall, although it has
been reported that it takes place in 21% of ITF
following fixation in the presence of an ini-
tially intact lateral wall, with 22% of these
patients undergoing re-operation,4 and the
remainder experiencing a protracted healing
period and excessive shortening.1,5 The identi-
fication of patients at risk of a secondary lat-
eral wall fracture would greatly improve the
outcome of DHS treatment.
To date, no studies have reported predictors
of post-operative fracture of the lateral wall.
Thickness of the lateral wall is a simple and
quantifiable parameter for pre-operative eval-
uation of the anatomical structure. Biome-
chanical studies have shown that the resistance
to deforming force increases with thickening of
cortical bone.6,7 In this study, we investigated
the reliability of lateral wall thickness as a pre-
dictor of lateral wall fracture after DHS
implantation.
Patients and Methods
The medical records of patients with AO/OTA
31-A1 (A1) and AO/OTA 31-A2 (A2)8 ITF
who were treated with DHS fixation in our
department between January 2003 and May
2012 were reviewed retrospectively. The exclu-
sion criteria were non-traumatic fractures, pre-
vious fracture at trochanteric region, fixation
other than with a DHS, poor fracture reduc-
tion (as defined below), tip-apex distance
(TAD)9 > 25 mm, and a follow-up period < six
months. In all, 208 patients were identified
who satisfied the inclusion criteria. There were

1134 THE BONE & JOINT JOURNAL

 LATERAL FEMORAL WALL THICKNESS
Fig. 1
Diagram showing the lateral wall thickness (d), defined as the distance
in mm from a reference point 3 cm below the innominate tubercle of the
greater trochanter, angled at 135° upward to the fracture line (the mid-
line between the two cortex lines) on anteroposterior radiograph.
103 males (49%) and 105 females (51%) with a mean age
at operation of 78 years (33 to 94). Their mean follow-up
was 23 months (6 to 83). The right side was affected in
97 patients (47%) and the left side in 111 (53%).
Fracture fixation was undertaken in a conventional man-
ner using a DHS according to the manufacturer’s instruc-
tions on a fracture-table under fluoroscopic control. No
other fixation devices were used except for the DHS and
barrel-plate.
Under the supervision of physiotherapists, all patients
were mobilised at between 24 and 72 hours post-opera-
tively with a walking frame or crutches. Unrestricted
weight-bearing was allowed as tolerated. Clinical follow-
up was mandatory at the first, second, third and sixth
month. Post-operative lateral wall fracture was defined as
the presence of new fracture lines occurring at the site of
insertion of the barrel-plate or lateral displacement of frac-
ture fragment on the radiographs.
Failure of the treatment was defined when the following
events occurred: 1) penetration of the screw into the hip
joint or loosening within the femoral head; 2) breakage of
the barrel-plate or its screws; or 3) patient underwent a sec-
ond operation due to other cause of implant failure. Suc-
cessful treatment was defined as continuous bridging callus
seen on the anterolateral and lateral radiographs, and no
pain during the movement of the injured hip. The TAD was
measured according to the method described by Baum-
gaertner et al9: this is the sum of the distance from the tip of
the screw to the apex of the femoral head on anteroposte-
rior (AP) and lateral radiographs. Poor fracture reduction
was defined as > 20° angulation on the lateral radiograph,
and > 4 mm of displacement of any fragment.9 The lateral
wall thickness was defined as the length of the channel cre-
ated by the triple reamer on the lateral wall (Fig. 1). Two
VOL. 95-B, No. 8, AUGUST 2013
1135
blinded observers (CEH, CTH) performed measurements
of TAD and lateral wall thickness on the Picture Archive
and Communication System monitor. We performed a reli-
ability analysis and the intraclass correlation coefficient
(ICC) was good (ICC 0.724). One observer was a trauma
surgeon and the other was a resident in our department.
The mean value of the two observers’ measurements was
used for statistical analysis. All measured lengths were cor-
rected by the radiological magnification ratio of 120%.10
Statistical analysis. Clinical information including age,
gender, fracture classification, TAD, follow-up time, thick-
ness of lateral wall, and treatment outcomes of the patients
were subjected to statistical analysis. Fisher’s exact test,
Student’s t-tests, and Receiver Operating Characteristics
(ROC) curves were used to investigate the potential rela-
tionship between the nominal measures using SPSS 20.0
software (SPSS Inc., Chicago, Illinois). Findings were con-
sidered significant if p-value was < 0.05 (two-sided).
Results
The data of the 208 patients according to the integrity of
the lateral femoral wall is summarised in Table I. A fracture
of the lateral wall occurred in 42 patients (20%). The mean
pre-operative lateral wall thickness of the 42 patients with
lateral wall fracture was 18.4 mm (SD 5.54) compared with
27.0 mm (SD 7.35) in the 166 patients without lateral wall
fracture (p < 0.001, Student’s t-test). The incidence of post-
operative lateral wall fracture was significantly higher in
A2 fractures than in A1 fractures (p < 0.001, Fisher’s exact
test). Other variables (age, gender, side, TAD and duration
of follow-up) did not have any relationship with the devel-
opment of a post-operative lateral wall fracture (Table I).
The mean lateral wall thickness of 97 A1 fractures was
29.8 mm (SD 6.63), which was significantly thicker than the
mean of 21.2 mm (SD 6.43) found in 111 A2 fractures
(p < 0.001, Student’s t-test). Further stratification of the
data revealed that lateral wall thickness still significantly
contributed to lateral wall fracture in A2 fractures
(p < 0.001, Student’s t-test), while no statistical significance
for lateral wall fracture in A1 fracture was observed
(p = 0.071, Student’s t-test) (Table II). For A2 fractures, the
mean lateral wall thickness of 72 patients without lateral
wall fracture was 22.9 mm (SD 6.40), which was signifi-
cantly greater than 18.1 mm (SD 5.25) in 39 patients with
lateral wall fracture. The mean lateral wall thickness of
94 patients without lateral wall fracture was 30.0 mm
(SD 6.50), which was not significantly different from the
mean of 23.0 mm (SD 8.43) in three patients with lateral
wall fracture in A1 fractures (Table II). For A2 fractures,
the rate of treatment failure for patients with lateral wall
fracture was significantly higher than those without lateral
wall fracture (p < 0.001, Fisher’s exact test). Of
111 patients, 39 (35.1%) with A2 fractures had a post-
operative lateral wall fracture. Of these 39 patients, 19
(49%) had treatment failure and the remaining 20 patients
achieved uneventful bone union. Of the 72 patients who
1136 C-E. HSU, C-M. SHIH, C-C. WANG, K-C. HUANG

Table I. Overview of the 208 patients with intertrochanteric fracture

Lateral wall fracture

Total (n = 208) Yes (n = 42) No (n = 166) p-value
Gender (n, %) 0.541*
Male 103 21 (20.4) 82 (79.6)
Female 105 21 (20.0) 84 (80.0)
Mean age (yrs) (range) 78 (33 to 94) 80 (62 to 92) 77 (33 to 94) 0.134†
Fracture side 0.730*
Right 97 21 (21.6) 76 (78.4)
Left 111 21 (18.9) 90 (81.1)
AO/OTA Classification (n, %) < 0.001*
31-A1 97 3 (3.1) 94 (96.9)
31-A2 111 39 (35.1) 72 (64.9)
Mean tip-apex distance (mm) (range) 18.3 (8 to 24.9) 18.7 (8.0 to 24.9) 18.2 (9.8 to 24.9) 0.481†
Mean follow-up (mths) (range) 23 (6 to 83) 20 (6 to 55) 23 (6 to 83) 0.216†
Mean lateral wall thickness (mm) (range) 25.2 (8.2 to 49.9) 18.4 (8.2 to 35.6) 27.0 (11.2 to 49.9) < 0.001†
* Fisher’s exact test
† Student’s t-test

Table II. The relationship between treatment outcome and lateral wall thickness in different fracture classifications

Patients (n) Mean lateral wall thickness (mm) (range) p-value*

AO/OTA 31-A1
Lateral wall fracture 3 23.0 (13.7 to 30.1) 0.071
No lateral wall fracture 94 30.0 (16.6 to 49.9)
AO/OTA 31-A2
Lateral wall fracture 39 18.1 (8.2 to 35.6) < 0.001
No lateral wall fracture 72 22.9 (11.2 to 39.6)
* Student’s t-test

Table III. The relationship between treatment outcome and lateral wall fracture in different fracture classifications

Patients (n) Failure (n, %) Success (n, %) p-value

AO/OTA 31-A1 *
Lateral wall fracture 3 0 (0) 3 (100)
No lateral wall fracture 95 2 (2.1) 93 (97.9)
AO/OTA 31-A2 < 0.001†
Lateral wall fracture 39 19 (48.7) 20 (51.3)
No lateral wall fracture 72 6 (8.3) 66 (91.7)
* not performed
† Fisher’s exact test

did not have lateral wall fracture, six (8.3%) patients
encountered treatment failure and the remaining
66 (91.7%) patients achieved uneventful bone union. Of
97 patients with A1 fracture, three (3.1%) had a post-oper-
ative lateral wall fracture but achieved bone union without
further surgical intervention. In contrast, neither of the two
treatment failure cases in A1 fracture had lateral wall frac-
ture (Table III).
We use an ROC curve to estimate a threshold value that
could predict lateral wall fracture. When lateral wall thick-
ness was at 20.5 mm, the sensitivity was 82.7% and specific-
ity was 77.8%. The area under the curve (AUC) was 0.823
(Fig. 2), which was statistically significant (p < 0.001).
Discussion
To our knowledge, this is the first study to investigate risk
factors of post-operative lateral wall fracture in ITF. We
found that lateral wall thickness was a reliable predictor
of post-operative lateral wall fracture with a threshold
value of 20.5 mm being a reliable predictor for secondary
lateral wall fracture. From this we suggest that treatment
with a DHS is not advisable in the presence of a lateral
wall thickness < 20.5 mm.
The lateral wall thickness had no statistically significant
effect on lateral wall fracture in A1 fractures because very
few patients had lateral wall fractures in this group
(Table II). This does not mean that lateral wall thickness is

THE BONE & JOINT JOURNAL

 LATERAL FEMORAL WALL THICKNESS
1.0
Sensitivity: 0.758
0.8 Specificity: 0.889
Criterion: > 20.5
Sensitivity
0.6
0.4
0.2
0.0
0.0 0.2 0.4 0.6 0.8 1.0
100 – specificity
Fig. 2
Receiver Operating Characteristic curve showing the sensitivity against
the 100 – specificity. The area under the curve (AUC 0.823 (95% confi-
dence interval 0.76 to 0.90)) measures the ability of the lateral wall thick-
ness to classify correctly the patients with and without a high risk of
lateral wall fracture. The best cut-off point for balancing sensitivity and
specificity was 20.5 mm.
not important in A1 fractures. In fact, the generally
thicker lateral wall greatly reduced the occurrence of lat-
eral wall fracture in A1 fractures. Greater numbers of
patients should be evaluated to clarify this observation.
Among the 42 patients with lateral wall fracture in
Table III, all three patients in A1 group achieved bone
union, while only 20 (51.3%) of 39 patients achieved bone
union in the A2 group. The high success rate in the A1
group may be as a result of the posteromedial section of the
femur preventing excessive sliding of the screw and proxi-
mal fragment after lateral wall fracture. However, when a
lateral wall fracture occurs in an A2 fracture, the screw and
proximal fragment slide laterally and there is no structure
to block this movement. Further stress on the femoral head
will cause screw penetration or loosening. This suggests
that the intact posteromedial femoral section imparts
important support in the event of lateral wall fracture in
DHS treatment. However, if the femur does not have a sta-
ble posteromedial section, the quality of the lateral wall
plays a decisive role in the DHS outcome. This hypothesis
could explain why A2 fracture patients with trochanter
buttress plate-mounted DHS had better outcomes in than
those with DHS-alone.5,11
A previous study revealed that lateral wall fracture
occurs more frequently in AO/OTA 31-A2.2 and 31-A2.3
than in 31-A1 and 31-A2.1 fractures.4 In our study, AO/
OTA subgroup classification was not used because large
inter-observer and intra-observer biases between A2.1 and
A2.2 fractures were reported in a previous study.8 Our
VOL. 95-B, No. 8, AUGUST 2013
1137
Fig. 3a Fig. 3b
Drawings showing a) preservation of adequate lateral wall thickness
when the fracture line passes higher in the trochanteric region in A1
fractures, and b) the lateral wall decreases and the posteromedial sec-
tion comminutes when the fracture line passes lower in the trochanteric
region, resulting in A2 fractures.
result showed that the lateral wall fracture occurred more
frequently in A2 fractures where the bone was generally
thinner, than that in A1 fractures. We postulate that the
thinner lateral wall was created by the lower fracture line
that simultaneously caused comminution of the postero-
medial section (Fig. 3).
A number of previous studies used rate of re-operation to
evaluate the effect of lateral wall on treatment outcome.3,4 The
rate of re-operation can be readily influenced by a patient's
medical condition and his/her willingness to receive an opera-
tion. In the present study, we used implant failure as a criterion
for treatment failure rather than rates of re-operation, which
for DHS, increased defined failures almost two-fold.
There were several limitations in this study. First, the
operations were not performed by a single surgeon. The
operative skills of surgeons may have been different and
this could have affected the treatment outcome. Second, the
lateral wall fractures were only evaluated by radiography,
so linear fractures of lateral wall could have been missed.
Third, the sample size was relatively small. Factors that
may confound the effects of treatment method on out-
comes, such as bone density and bone quality, BMI and
mental status, were not included in our statistical analysis.
We conclude that: 1) lateral wall thickness is a reliable
predictor of post-operative lateral wall fracture; 2) apply-
ing a > 20.5 mm threshold value for the use of a DHS can
be expected to minimise the risk of post-operative lateral
wall fracture; and 3) ITF with a lateral wall thickness
< 20.5 mm should not be treated with a DHS alone.
1138 C-E. HSU, C-M. SHIH, C-C. WANG, K-C. HUANG
The authors would like to thank the Biostatistics Task Force of Taichung Veter-
ans General Hospital, Taichung, Taiwan, for assisting with the statistical analy-
ses, and Dr. C-T. Hsu for performing the radiological measurements. The first
three authors have contributed equally to this work.
No benefits in any form have been received or will be received from a com-
mercial party related directly or indirectly to the subject of this article.
This article was primary edited by D. Rowley and first-proof edited by G. Scott.
References
1. Gotfried Y. The lateral trochanteric wall: a key element in the reconstruction of
unstable pertrochanteric hip fractures. Clin Orthop Relat Res 2004;425:82–86.
2. Haidukewych GJ. Intertrochanteric fractures: ten tips to improve results. J Bone
Joint Surg [Am] 2009;91-A:712–719.
3. Haidukewych GJ, Israel TA, Berry DJ. Reverse obliquity fractures of the intertro-
chanteric region of the femur. J Bone Joint Surg [Am] 2001;83-A:643–650.
4. Palm H, Jacobsen S, Sonne-Holm S, Gebuhr P. Integrity of the lateral femoral
wall in intertrochanteric hip fractures: an important predictor of a reoperation. J Bone
Joint Surg [Am] 2007;89-A:470–475.
5. Madsen JE, Naess L, Aune AK, et al. Dynamic hip screw with trochanteric stabi-
lizing plate in the treatment of unstable proximal femoral fractures: a comparative
study with the Gamma nail and compression hip screw. J Orthop Trauma
1998;12:241–248.
6. Flynn J. Orthopaedic knowledge update 10. Chicago: American Academy of Ortho-
paedic Surgeons 2011:59–72.
7. Zdero R, Bougherara H, Dubov A, et al. The effect of cortex thickness on intact
femur biomechanics: a comparison of finite element analysis with synthetic femurs.
Proc Inst Mech Eng H 2010;224:831–840.
8. Pervez H, Parker MJ, Pryor GA, Lutchman L, Chirodian N. Classification of tro-
chanteric fracture of the proximal femur: a study of the reliability of current systems.
Injury 2002;33:713–715.
9. Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM. The value of the tip-apex
distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone
Joint Surg [Am] 1995;77-A:1058–1064.
10. Barton TM, Gleeson R, Topliss C, et al. A comparison of the long gamma nail with the
sliding hip screw for the treatment of AO/OTA 31-A2 fractures of the proximal part of the
femur: a prospective randomized trial. J Bone Joint Surg [Am] 2010;92-A:792–798.
11. Babst R, Renner N, Biedermann M, et al. Clinical results using the trochanter sta-
bilizing plate (TSP): the modular extension of the dynamic hip screw (DHS) for internal
fixation of selected unstable intertrochanteric fractures. J Orthop Trauma
1998;12:392–399.
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