Injury, Int. J.

Care Injured 48 (2017) 803–818

Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Review

Unstable trochanteric fractures: Issues and avoiding pitfalls

Sushrut Babhulkar
Sushrut Institute of Medical Sciences, Research Centre & Post-Graduate Institute of Orthopedics, Central Bazar Road, Ramdaspeth, Nagpur, 440 010, India

A R T I C L E I N F O A B S T R A C T

Keywords: The incidence of trochanteric fractures is rising because of increasing number of senior citizens with
Unstable trochanter osteoporosis. There are various modalities for reduction and internal fixation. However, the incidence of
PFNA 2 complications remains high. In the herein article we discuss issues that influence the fixation and
DHS
outcomes of unstable trochanteric fractures. Moreover, the results of a prospective, randomised, cohort,
Sirus nail
time bound, hospital based, comparative study is presented.
Cerclage wire
Bhabhulkar classification © 2017 Elsevier Ltd. All rights reserved.
Harris hip score
Lateral and posterior wall fractures

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 803
Review of literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 803
Our experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 808
Statistical analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 809
Surgical technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 809
Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 810
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 810
Conflict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 817
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 817
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 818

Introduction lateral wall, vi) Posterior wall Fracture/Coronal Split, vii) Extension
into femoral neck area/piriformis fossa, and viii) Poor bone quality
It is universally accepted that the treatment of trochanteric [1].
fractures necessitates stable internal fixation allowing early Appropriate selection of implant, good reduction intraoper-
mobilisation as soon as possible. Stable fixation till fracture union atively and proper surgical technique from the surgeon’s point of
is the keystone to a successful outcome. view can minimise the risk of failure and necessity for re-
Several factors have been reported to be essential for the pre- intervention.
operative planning prior to reconstruction of these fractures In the herein study, we endeavour to review the literature and
including: i)Fracture geometry ii) Bone quality, iii) Amount of to evaluate the treatment of unstable trochanteric fractures in our
comminution and iv) Fracture extensions in nearby areas like neck institution. This study also introduces a modification of the well
femur or subtrochanteric extension [1]. The surgeon should also be accepted AO/OTA classification with addition of CT based analysis
familiar with parameters which may contribute to inherent of comminuted fractures in unstable patterns.
instability and failure of fixation such as i) Loss of posteromedial
support, ii) Severe comminution at the Greater Trochanter leading Review of literature
to difficulty in passing an intramedullary nail, iii) Subtrochanteric
extension of fracture, iv) Reverse oblique fracture pattern, v) Burst Evans in 1948 observed that the key to a stable fracture
reduction is rest7oration of the posteromedial cortical continuity.
He further observed that the reverse obliquity pattern is inherently
E-mail address: sushrutdsurgeon@gmail.com (S. Babhulkar). unstable because of the tendency for medial displacement of the

http://dx.doi.org/10.1016/j.injury.2017.02.022
0020-1383/© 2017 Elsevier Ltd. All rights reserved.
804 S. Babhulkar / Injury, Int. J. Care Injured 48 (2017) 803–818
femoral shaft [2]. He also stressed the importance of the cortical
buttress of bone on the inner side of the femoral neck and shaft.
Dimon and hughston in 1967 developed a technique whereby
the spike of the proximal head neck fragment is impacted within
the medullary canal of the femoral shaft, which previously was
displaced medially beneath that spike. This however, leaves a
posteromedial defect and thereby stability is not achieved. If
stability by primary medial displacement fixation is achieved
initially, then it seems reasonable to expect the complication rate
to decrease as fracture no longer needs to settle and migrate into a
position of stability [3].
Bannister GC et al. using the Evans classification reported the
outcome on two or three part (62%) and four part (38%) fractures
respectively. Open reduction proved necessary in four cases. They
found that neutral rotation gives the best reduction most often.
Internal rotation was almost equally valuable in two and three part
fractures. External rotation was significantly more useful in four
part fractures yet was the position of choice to only 25% [4].
Baumgaertner et al. in 1997 compared the results of the surgical
treatment of trochanteric hip fractures before and after surgeons
had been introduced to the tip-apex distance (TAD) as a method of
evaluating screw position. There were 198 fractures evaluated
retrospectively (control group) and 118 after introduction to the
TAP concept (study group). The TAD is the sum of the distance from
the tip of the screw to the apex of the femoral head on
anteroposterior and lateral views. This decreased from mean of
25 mm in the control group to 20 mm in the study group. The
number of mechanical failures by cut-out of the screw from the
head decreased from 16 (8%) in the control group at a mean of 13
months to none in the study group at a mean of 8 months. There
were significantly fewer poor reductions in the study group. Their
study confirms the importance of awareness of TAD and good
surgical technique in the treatment of trochanteric fractures and
supports the concept of TAD as a clinically useful way of describing
the position of the screw (Fig. 1) [5].
Madsen et al. conducted a prospective study to compare the
results after operative treatment of unstable per- and subtrochan-
teric fractures with the Gamma nail, compression hip screw (CHS),
or dynamic hip screw with a laterally mounted trochanteric
stabilising plate (DHS/TSP) [6]. They analysed 170 patients with
unstable trochanteric fractures surviving 6 months after operation.
85 patients were randomised to treat with either gamma nail or
the compression hip screw and compared with a consecutive series
of 85 patients operated with the dynamic hip screw with a laterally
mounted trochanteric stabilising plate (DHS/TSP group). They
concluded that the trochanteric stabilising plate (TSP) may be an
aid in the treatment of these difficult fractures because the
problem with the femoral shaft fractures using the Gamma nail is
Fig. 1. Technique for calculating the tip-to-apex distance (TAD). For clarity, a
peripherally placed screw is depicted in the anteroposterior (ap) view and a
shallowly placed screw is depicted in the lateral (lat) view. D true = known diameter
of the lag screw.
avoided and the medialisation of the distal fracture fragment
frequently associated with the CHS is prevented [6].
Haidukewych et al. in 2001 in their retrospective study reported
that the reverse oblique fractures of the intertrochanteric region is
a distinct pattern, when treated with cephalomedullary implant. It
has advantage of shorter lever arm for the fixation device, and it
has less potential for the fracture collapse and limb shortening
when used for unstable intertrochanteric fracture [7].
Kim et al. in 2001 studied the failure of intertrochanteric
fracture fixation with a DHS in relation to preoperative fracture
stability and osteoporosis. They concluded that unstable fractures
with osteoporosis had a failure rate of more than 50% and in such
cases DHS should not be the first choice of treatment [8].
Sadowki et al. in 2002 performed a comparative study between
dynamic condylar screw (DCS) and PFN. Patients treated with an
intramedullary nail had shorter operative time, fewer blood loss
and shorter hospital stay compared with those treated with a 95 
DCS. Implant failure and/or non-union was noted in seven of the
nineteen cases who had been treated with 95  DCS. Only one of the
twenty fractures that had been treated with an intramedullary
implant did not heal. Their study supported the use of an
intramedullary nail rather than a 95  screw-plate for the fixation
of reverse oblique and transverse intertrochanteric fractures in
elderly patients [9].
Zickel et al. in 2002 advocated that circumstances that favour
the use of cephalomedullary implant include fracture pattern that
extends from intertrochanteric region into subtrochanteric region
without comminution of proximal fragment, particularly in the
region of greater trochanter [10].
Valverde et al. reported a series of 224 fractures of the proximal
femur in which Gamma nail was used. They found, the Gamma nail
to provide adequate stability and to represent an efficient
technique in the management of these fractures. The device
allowed for early mobilisation and full weight bearing of the
affected hip regardless of the type of fracture. They concluded that
with adequate surgical technique and experience, the advantages
of the Gamma nail increases as the complication rate diminishes
[11] (Table 1).
Lorich et al. in 2004 stated that a cephalomedullary implant has
biomechanical advantage in the treatment of unstable intertro-
chanteric fracture by virtue of its intramedullary placement and
inhibition of excessive sliding. Cephalomedullary implants provide
the functional advantage of early patient mobility at one or three
months postoperatively [12].
Babhulkar in 2006 concluded in his study that stable fractures
can be easily dealt with DHS but unstable trochanteric fractures
needs to be fixed with cephalomedullary implant to prevent
rotational instability [13]. Similarly, Kulkarni et al. in 2006
concluded that DHS is still the gold standard for treatment of
stable trochanteric fractures but unstable trochanteric fractures
should be treated with cephalomedullary implant [1].
Haidukewych et al. in 2009 summarised 10 simple tips to
minimise failure and improve outcomes when treating intertro-
chanteric fractures of the hip. They are: Measurement of the Tip to
Apex distance; No lateral wall: no use of hip screw; Know the
unstable intertrochanteric fracture patterns and nail them; Beware
of the anterior bow of the femoral shaft; When using a trochanteric
entry nail, start slightly medial to exact tip of greater trochanter;
Do not ream an unreduced fracture; Be cautious about the nail
insertion trajectory and do not use a hammer to seat the nail; Avoid
varus angulation of the proximal fragment- Use the relationship
between the tip of trochanter and centre of femoral head; When
nailing, lock the nail distally if the fracture is axially or rotationally
unstable; Avoid fracture distraction when nailing. They concluded
that intramedullary nail fixation has become more common, even
for fractures that are stable or nondisplaced [14].
 S. Babhulkar / Injury, Int. J. Care Injured 48 (2017) 803–818
Table 1
demonstrates a summary of relevant studies focusing on important parameters about the characteristics and treatment of proximal femoral fractures.
Year Author Topic
1940 Cleary and Lock-Bolt fixation of fractures of the
Morrison femoral neck and of
intertrochanteric fractures J Bone
Joint Surg Am, 1940; 22:125–36 [4]
1941 Jewett One piece angle nail for
trochanteric fractures J Bone Joint
Surg Am, 1941: 23:803–10 [5]
1955 Schumpelick A new principle in the operative
and Jantzen treatment of trochanteric fractures intertrochanteric
of the femur J Bone Joint Surg Am, fractures
1955;37:693–8 [10]
1967 Dimon and Unstable intertrochanteric fracture
Hughston of hip J Bone Joint Surg Am, 1967;
49:440–50 [13]
1991 Bridal et al. Fixation of intertrochanteric
fractures of the femur J Bone Joint
Surg Br, 1991; 73:330–4 [18]
1991 Medoff and A new device for the fixation of
Maes unstable pertrochanteric fractures
of hip J Bone Joint Surg Am, 1991;
73:1192–9 [19]
1997 Baumgaertner Awareness of Tip-Apex distance
et al. reduces failure of fixation of
trochanteric fractures of the hip J
Bone Joint Surgery Br 1997;
79:969–71 [22]
1998 Madsen et al. Dynamic Hip screw with
trochanteric stabilising 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(4):241–8 [25]
1998 Hardy et al. Use of an intramaedullary hip
screw compared with a
compression hip screw with a plate
for intertrochanteric femoral
fractures J Bone Joint Surg Am,
1998; 80:618–30 [26]
2001 Haidukewych Reverse obliquity fractures of the
et al. intertrochanteric region of the
femur J Bone Joint Surg Am, 2001;
83:643–50 [27]
2002 Zickel et al. Fixation of reverse obliquity
fractures of the subtrochanteric and trochanteric
intertrochanteric region of the
femur J Bone Joint Surg Am, 2002;
84:494–5 [30]
2004 Lindskog and Unstable intertrochanteric hip
Baumgaertner fractures in the elderly J Am Acad
Othop Surg, 2004; 12:179–190 33]
805
Type of fracture Implant used Complication Conclusion
Femoral neck and Lock-bolt device – Internal fixation by means of lock-
intertrochanteric bolt device has facilitated general
fractures care, promoted comfort, lessened
incidence of complication
Intertrochanteric Smith-Peterson nail and – The difficulties encountered in their
fractures Hawley bone plate combined use have been greatly
lessened by welding them together
in one piece flanged nail.
Unstable Sliding screw developed – The screw was made of stainless
by Ernst Pohl magnetic steel (V2A) and could
slide in the 135  barrel of slide plate
during collapse at fracture site and
hence help in achieving stable
fixation
Intertrochanteric Jewett nail plate (JNP) Impingement of A good way of stabilisation with
fracture blade large medial beak.This however,
leaves a posteromedial defect
Intertrochanteric Dynamic hip screw and Screw cut-out For difficult fractures with a
fractures Gamma nail occurred in 3 cases subtrochanteric extension or
of DHS and 2 cases reverse obliquity, and for high
of Gamma nail subtrochanteric fractures, where
other forms of fixation are less
satisfactory, the Gamma nail may
prove useful
Pertrochanteric Medoff plate – The average axial impaction of
fractures 5 mm was noted with no technical
failure, and the relationship
between the femoral head and
shaft was altered less than with the
use of a conventional compression
screw-plate device.
Trochanteric – – The TAD is the sum of the distance
fractures from the tip of the screw to the apex
of the femoral head on
anteroposterior and lateral views.
Their study confirms the
importance of good surgical
technique and the concept of TAD
as a clinically useful way of
describing the position of the
screw.
Unstable per- and Gamma nail, – The trochanteric stabilising plate
sub-trochanteric Compression hip screw (TSP) may be an aid in the
fractures (CHS) and Dynamic hip treatment of these difficult
screw with trochanteric fractures, medialisation of the
stabilising plate (DHS/ distal fracture fragment frequently
TSP) associated with the CHS is
prevented.
Trochanteric Intramedullary Hip – Less sliding of the lag screw after
fractures screw and Compression the intramedullary hip-screw
hip screw procedures, the intramedullary nail
stops the telescoping displacement
of the proximal fragment. The
proximal part of the nail blocks the
head and the neck fragment,
preventing its complete impaction
thus there is less subsequent
shortening of the affected limb.
Reverse oblique Cephalomedullary – It has advantage of shorter lever
fractures of implant arm and has less potential for the
intertrochanteric fracture collapse and limb
region shortening when used for unstable
intertrochanteric fracture.
Inter- and sub- Cephalomedullary – Circumstances that favour the use
implant of cephalomedullary implant
fractures include fracture pattern that
extends from intertrochanteric
region into subtrochanteric region
without comminution of proximal
fragment, particularly in the region
of greater trochanter
Unstable – – Accurate realignment, an
intertrochanteric independent predictor of successful
fractures surgical outcome, should be the
goal of each fracture reduction.
Proper implant positioning, with
806 S. Babhulkar / Injury, Int. J. Care Injured 48 (2017) 803–818

Table 1 (Continued)
Year Author Topic Type of fracture Implant used Complication Conclusion
the lag screw placed centrally and
very deeply on both
anteroposterior and lateral
radiographic projections, is crucial.
2005 Gunn et al. Potentially unstable Unstable Sliding compression hip 9 out of 66 patients A surgeon should be aware of the
intertrochanteric fractures J Orthop intertrochanteric screw lost initial reduction possibility of iatrogenic
Trauma 2005;19(1):5–9 34] fractures and had excessive fragmentation of the lateral cortex
displacement of the and use surgical techniques to
distal fragment mitigate against potential loss of
reduction and future mobility
problems.
2006 Babhulkar Management of trochanteric Trochanteric DHS and – Stable fractures can be easily dealt
fractures Indian J Orthop fractures cephalomedullary with DHS but unstable trochanteric
2006:40:210–18 [35] implant fractures needs to be fixed with
cephalomedullary implant to
prevent rotational instability
2006 Kulkarni et al. Intertrochanteric fractures Indian J Trochanteric DHS and – DHS is still gold standard for
Orthop 2006;40(1):16–23 1] fractures cephalomedullary treatment of stable trochanteric
implant fractures but unstable trochanteric
fractures should be treated with
cephalomedullary implant
2015 Akhil et al. What makes an intertrochanteric Unstable – – The currently used classification for
fracture unstable in 2015? Does trochanteric unstable trochanteric fracture
lateral wall play a role in the fractures (fracture with posteromedial
decision matrix? J Orthop Trauma, comminution, reverse oblique, and
2015; 29:S4–S9 [36] IT with subtrochanteric extension)
and the recently added fracture
patterns (IT fractures with
detached greater trochanter and
lateral wall breach) is still
incomplete. They suggested that
lateral wall fractures can be further
classified into lateral wall blow out
fractures, reverse oblique variant
(reverse obliquity exists in both
sagittal and coronal planes) and
rotationally unstable fracture.
2009 Haidukewych Intertrochanteric fractures: Ten tips Intertrochanteric – – Some tips to minimise failure and
to improve results J Bone Joint Surg fractures improve Outcomes: Tip to Apex
Am, 2009; 91(3):712–9 [37] distance; No lateral wall, no hip
screw; Know the unstable patterns
and nail them; Beware of the
anterior bow of the shaft; Entry
point slightly medial to exact tip
of greater trochanter; Do not ream
an unreduced fracture; Be cautious
about the nail insertion trajectory
and do not use a hammer to seat the
nail; Avoid varus angulation of the
proximal fragment- Use the
relationship between the tip of
trochanter and centre of femoral
head; When nailing, lock the nail
distally if the fracture is axially or
rotationally unstable; Avoid
fracture distraction.
2010 Gupta et al. Unstable trochanteric fractures: the Unstable DHS and TSP 3 cases had The combination of TSP and DHS
role of lateral wall reconstruction trochanteric impingement, 2 creates a biomechanically stable
Int Orthop 2010; 34(1):124–9 [38] fractures cases had varus construction allowing
malunion reconstruction of the lateral wall to
maintain adequate lever arm and
abductor strength. In addition it
allows passage of an antirotation
screw, thereby providing two-point
fixation with additional rotational
stability. Superior overall functional
and radiological outcome in
patients with unstable trochanteric
fractures does indicate that the
combination of DHS and modular
TSP is likely to be a better option in
the management of these fractures
as compared to DHS alone.
2012 Knobe et al. Is helical blade nailing superior to Unstable Percutaneous Greater incidence of Unstable pertrochanteric fractures
locked minimally invasive plating trochanteric compression plate postoperative may be fixed either with locked
in unstable pertrochanteric fractures (PCCP) and Proximal lateral wall extramedullary small-diameter
screw systems to avoid lateral wall
 S. Babhulkar / Injury, Int. J. Care Injured 48 (2017) 803–818 807

Table 1 (Continued)
Year Author Topic Type of fracture Implant used Complication Conclusion
fractures? ClinOrthop 2012; femoral nail antirotation fractures with fractures or with the new
470:2302–12 [39] (PFNA) helical blade nailing intramedullary systems to avoid
potential mechanical complications
of a broken lateral wall. Tip-apex
distance and preservation of the
preoperative femoral neck-shaft
angle are the key technical factors
for prevention of reoperation.
2013 Knobe et al. Unstable intertrochanteric femur Unstable – – Despite varying opinions in the
fractures: Is there a consensus on trochanteric literature in recent years, some
definition and treatment in fractures instability criteria (lateral wall
Germany? ClinOrthop 2013; 471 breach, a detached greater
(9): 2831–40 [40] trochanter) played a minor role in
defining an unstable
intertrochanteric fracture pattern.
Despite recent meta-analyses
suggesting clinical equivalence of
intra- and extramedullary
implants, few respondents
routinely treat unstable
intertrochanteric fractures with
extramedullary plates. Additional
studies are required to specify the
influence of fracture characteristics
on complication rate and function
and to establish a classification
system with clear treatment
recommendations for unstable
intertrochanteric fractures.
2013 Hsu et al Lateral femoral wall thickness. A Unstable DHS and Barrel plate 20% of patients had They concluded that: 1) lateral wall
reliable predictor of post-operative trochanteric lateral wall fracture thickness is a reliable predictor of
lateral wall fracture in fractures post-operative lateral wall fracture;
intertrochanteric fractures J Bone 2) applying a > 20.5 mm threshold
Joint Surg Br,2013; 95:1134–8 [41] value for the use of a DHS can be
expected to minimise the risk of
post-operative lateral wall fracture;
and 3) Intertrochanteric fractures
with a lateral wall thickness
< 20.5 mm should not be treated
with a DHS alone.
2015 Bryan Tan et al. Morphology and fixation pitfalls of Intertrochanteric Proximal femoral nail – The intertrochanteric fracture
a highly unstable intertrochanteric fracture variant antirotation (PFNA), variant is highly unstable with a
fracture variant J Ortho Surg, 2015; Proximal femur locking high failure rate. Loss of
23(2):142–5 [42] plate (PFLP), Less superolateral support rather than
invasive stabilisation the medial calcar buttress is the
system (LISS) main contributing factor to
mechanical failure. Computed
tomography is important in
preoperative planning.
Intramedullary nailing is more
appropriate than extramedullary
plating for such unstable fractures.

Gupta et al. in 2010 in their article on Role of Lateral wall
reconstruction carried out prospective study comprising 80
consecutive patients, of all ages and either gender with trochan-
teric fracture using DHS along with TSP. They concluded that a
combination of TSP and DHS is a useful technique in the treatment
of unstable trochanteric femoral fractures with burst lateral wall. It
creates a biomechanically stable construction allowing recon-
struction of the lateral wall to maintain adequate lever arm and
abductor strength. In addition, it allows passage of an anti-rotation
screw, thereby providing two-point fixation with additional
rotational stability. Superior overall functional and radiological
outcome in patients with unstable trochanteric fractures does
indicate that the combination of DHS and modular TSP is likely to
be a better option in the management of these fractures as
compared to DHS alone [15].
Knobe et al. in 2012 carried out prospective study of 108
patients with unstable pertrochanteric fractures in a surgeon-
allocated study between November 2005 and November 2008.
They concluded that data suggested unstable pertrochanteric
fractures may be fixed either with locked extramedullary small-
diameter screw systems to avoid lateral wall fractures or with the
new intramedullary systems to avoid potential mechanical
complications of a broken lateral wall. Tip-apex distance and
preservation of the preoperative femoral neck-shaft angle are the
key technical factors for prevention of reoperation [16].
Knobe et al. in 2013 conducted a national survey of practicing
chairpersons of German institutions to determine current per-
spectives and perceptions of practice in the diagnosis, manage-
ment, and surgical treatment of unstable intertrochanteric
fractures. Absence of medial support was considered the main
criterion for fracture instability (84%), whereas a broken lateral
wall and detached greater trochanter were considered by 4% and
5% of the respondents, respectively, to determine instability. Two
percent routinely fixed unstable intertrochanteric fractures with
extramedullary devices. Ninety-eight percent of German hospitals
reportedly perform surgery within 24 h after admission. Time to
808 S. Babhulkar / Injury, Int. J. Care Injured 48 (2017) 803–818
surgery was dependent on hospital level, with more direct
surgeries in Level I hospitals [17].
Hsu et al. in 2013 in their study on lateral femoral wall thickness
did a retrospective study on 208 patients treated with DHS and
barrel plate. The results showed that fracture of the lateral wall
occurred in 42 patients (20%). They 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 they suggest
that treatment with a DHS is not advisable in the presence of a
lateral wall thickness <20.5 mm. They concluded that: 1) lateral
wall thickness is a reliable predictor of post-operative lateral wall
fracture; 2) applying 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) Intertrochanteric fracture with a lateral wall
thickness <20.5 mm should not be treated with a DHS alone
(Figs. 2 and 3 [18].
Bryan Tan et al. in 2015 in their article on Morphology and
fixation pitfalls of a highly unstable intertrochanteric fracture
variant studied a variant of intertrochanteric fracture not well-
characterised in the existing classification systems and concluded
in their study that this intertrochanteric fracture variant is highly
unstable with a high failure rate. Loss of superolateral support
rather than the medial calcar buttress is the main contributing
factor to mechanical failure. Computed tomography is important in
preoperative planning. Intramedullary nailing is more appropriate
than extramedullary plating for such unstable fractures [19].
Similarly, Akhil et al. in 2015 proposed that the currently used
classification for unstable trochanteric fracture (fracture with
posteromedial comminution, reverse oblique, and intertrochan-
teric (IT) with subtrochanteric extension; and the recently added
fracture patterns (IT fractures with detached greater trochanter
and lateral wall breach) is incomplete. A comprehensive radiologic
evaluation comprising of an anteroposterior view, lateral view, and
traction internal rotation view (in most cases) must be obtained
before any intervention. In the presence of an unusual or a highly
comminuted fracture, CT scan with 3-dimensional reconstruction
can aid in better assessment of the fracture pattern. They suggested
that lateral wall fractures can be further classified into lateral wall
blow out fractures, reverse oblique variant (reverse obliquity exists
Fig. 2. 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 midline between the two
cortex lines) on anteroposterior radiograph.
Fig. 3. (A) & (B): 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 section
comminutes when the fracture line passes lower in the trochanteric region,
resulting in A2 fractures.
in both sagittal and coronal planes) and rotationally unstable
fracture [20].
Whilst several classification systems have been proposed to
define the unstable trochanteric regions in past, the majority of
them have their limits in describing the fracture pattern [4,19].
Lately, the lateral trochanteric wall fracture has gained importance
and many studies have tried to define them and classify them, but
none of them have reached a conclusion. The unstable trochanteric
fracture has been classified into fracture with posteromedial
comminution, reverse oblique, and intertrochanteric with sub-
trochanteric extension and the recently added fracture patterns
including intertrochanteric fractures with detached greater
trochanter and lateral wall breach. Other fractures suggested for
inclusion include fractures demonstrating lateral wall blow out,
reverse oblique variant and rotationally unstable intertrochanteric
fracture [20].
Our experience
In order to investigate in our institution (Sushrut Institute of
Medical Sciences, Research Centre and Post graduate Institute of
Orthopaedics, Ramdaspeth, Nagpur, India) the results of fixation of
unstable trochanteric fractures and identify factors associated with
poor outcome, we conducted a prospective study. All the patients
presenting to the hospital during September 2014 to November
2015 with history of trauma to proximal femur and diagnosed as
having unstable trochanteric fracture of femur on x-ray and were
further evaluated by CT scan were eligible to participate. Inclusion
criteria were: adults patients, unstable trochanteric fracture of
femur, patients fit to undergo surgery, and follow-up of at least 6
months. Exclusion criteria included: patient not willing for
surgery, pathological fracture of any cause other than osteoporosis,
open fractures, and neurological and psychiatric disorders that
would hamper assessment. Institutional board review was
obtained for the study (SIMS/2014/res 16).
Fractures were classified according to the AO classification [21].
Furthermore, we added to the current classification so as to exactly
describe the fracture pattern and the measures taken to fix the
comminuted fragments in various planes, (Babhulkar’s Modifica-
tion), (Fig. 4).
Patient demographic and clinical details were recorded in a
specially designed proforma and then entered in a computerised
database. Outcome measurement was studied using Harris Hip
Score (Figs. 5 and 6 [22].
 S. Babhulkar / Injury, Int. J. Care Injured 48 (2017) 803–818 809

Fig. 4. Babhulkar’s Modified OTA Classification of Intertrochanteric hip fractures (based on 3D CT reconstruction). Unstable fractures are within the outline and then are
further subdivided into A,B and C subtypes.
Type A- Lateral trochanteric wall fracture as seen on lateral CT.
Type B- Posterior wall fracture as seen on Posterior and Oblique CT.
Type C- Burst Lateral wall with posterior wall fracture with Medial column (Lesser Trochanter) dissociation and overall Comminution.

Statistical analysis All fractures were stabilized in combination with or without

Statistical analysis was performed using the One-way ANOVA
test using SPSS 11.5 for windows software package; a p-value less
than 0.05 was considered significant [23].
Surgical technique
Type of anaesthesia to be used was decided by anaesthetist.
Patients underwent standard surgical procedure with either DHS/
Sirus Nail/PFN A2. Patients were allocated the modality of
treatment based on a sealed envelope draw done before surgery.
trochanteric reconstruction using either a single loop or double
loop method.
On fracture table, under image intensifier control fracture is
assessed and reduced by traction. Incision is made laterally and
comminuted fracture fragments then reduced using towel clips
and reduction forceps. Wire loops are then passed using Circlage
wire loop passer. Loops (either single or double) are minimally
tightened so as to close the petals of opened and widened
trochanter antero-posteriorly. Subsequently, the procedure is
executed using either DHS or Cephalo medullary nail. Both the
loops encircle the Greater Trochanter antero-posteriorally and
810 S. Babhulkar / Injury, Int. J. Care Injured 48 (2017) 803–818
Fig. 5. Modified Harris Hip score sheet.
then swirl round the Shaft to Lesser trochanter to hold the Medial
column separation. Loops are finally tightened once primary
fixation is done.
Outcomes
We evaluated 86 patients with unstable trochanteric fractures
with a follow-up of 6 months. Their mean age was 68.85 years
ranging from 23 to 87 years. 19.76% of patients were seen in age
group of 80 years. The sex distribution was 58.13% males and
41.87% females respectively (Fig. 7). Fracture type is shown in
Fig. 8.
The mean duration between injury and surgery was 4.6 days
(range 1–25days). Delays to access to surgery included patients
coming from far distance and presence of comorbidities requiring
optimisation of physical condition prior to surgery, (Fig. 9). Based
on the fracture configuration, ten modalities of treatment were
used and shown in Fig. 10.
Patients in all the groups were comparable with regards to age
and sex. There was no major difference between all the groups
regarding, the duration of operation, amount of fluoroscopy
required and technical problems with implant (P > 0.05).
Intra-operatively there were no instances of femoral shaft
fractures or extension of the existing fracture. Post-operatively the
groups were similar in regards to medical complications, time to
begin physiotherapy, ambulation and hospital discharge.
With regard to the Harris Hip score most patients had poor
score at the end of 6 weeks, (Tables 2 and 3. At the end of 3 months,
47.67% of patients had poor score, 31.39% had fair score, 15.11% had
good score and 5.83% had excellent score. (Tables 4 and 5). At the
end of 6 months, 18.60% of patients had poor score, 25.58% had fair
score, 27.92% had good score and remaining 27.92% had excellent
score. (Tables 6 and 7).
The overall complication rate was 11.62%. 50% of complications
were seen in extramedullary group and 3 in PFN A2 group and 2 in
Sirus nail group. Table 8, summarizes the complications encoun-
tered in 10 patients. Example of cases included in the study are
shown in Figs. 11 and 12.
Discussion
Trochanteric fractures are one of the most common hip
fractures especially in the elderly population with osteoporotic
bone and continue to be a topic of vivid discussion amongst
clinicians and scientists [24–34]. They occur usually following low
 S. Babhulkar / Injury, Int. J. Care Injured 48 (2017) 803–818
Fig. 6. Modified Harris Hip score criteria.
PERCENTAGE
42.86%
57.14% MALE
FEMALE
Fig. 7. Sex distribution of patients.
energy trauma. The incidence of trochanteric fractures is rising
because of the increasing number of senior citizens with
osteoporosis [1]. The primary goal of treatment is to return the
patients to their pre-fracture activity level as soon as possible [35].
Surgery remains the treatment of choice for reducing morbidity
and mortality [36]. Of interest, treatment of unstable trochanteric
fractures has been the topic of discussion for years. Several factors
have been identified to influence outcome such as the age of
patient, the patient’s general health, the time from fracture to
treatment and the stability of fixation [1]. The ideal implant to
811
choose to fix unstable trochanteric fractures remains a topic of
debate with proponents of the various implants, each claiming
advantages over the other methods [36].
The DHS implant, initially introduced by Clawson in 1964,
remains the implant of choice because of its favorable results, user
friendly profile and low rate of non-union and failure. It provides
controlled compression at the fracture site. It is still the implant of
choice in all stable fractures of proximal femur.
The use of DHS has been supported by its biomechanical
properties which have been assumed to improve the healing of
fractures. DHS requires a relatively larger exposure, more tissue
handling and anatomical reduction, all of which increase the
morbidity, the probability of infection and significant blood loss,
the possibility of varus collapse and the inability of the implant to
survive until fracture union. The side plate and screws may weaken
the bone mechanically. The common causes of fixation failure are
instability of the fractures, osteoporosis, lack of anatomical
reduction, failure of the fixation device and incorrect placement
of the lag screw in femoral head [37].
Control of axial telescoping and rotational stability are essential
in unstable trochanteric fractures. An intramedullary implant
inserted in a minimally invasive manner is better tolerated in the
elderly. The cephalomedullary femoral reconstruction nails with a
trochanteric entry point have gained popularity in recent years.
They have been shown to be biomechanically stronger than
extramedullary implants [38].
812 S. Babhulkar / Injury, Int. J. Care Injured 48 (2017) 803–818

12
10
8
6
Male
4
2 Female
0 A.2.2.A Total
A.2.2.B
A.2.2.C
A.2.3.A
A.2.3.B
A.2.3.C
A.3.1
A.3.1.A
A.3.1.B
Male

A.3.1.C
A.3.2.A
A.3.2.B
A.3.2.C
A.3.3.A
A.3.3.B

A.3.3.C
Fig. 8. Fracture type according to AO classification.

primary restoration of the medial support. The IM nail temporarily

compensates for the function of the medial column.
Percentage of paents There have been lot of studies which have stated that the
2.34% Gamma nail and similar intramedullary devices are appealing
because they combine the advantages of intramedullary fixation
28% with those of a sliding hip screw and can be inserted in a limited
open fashion. Yet it seems clear from all the available documented
1-4 DAYS studies that such implants are not superior to the sliding hip screw
69.76% 5-10 DAYS for the majority of intertrochanteric fractures, especially stable
>10 DAYS ones. The results from these studies (Kulkarni et al. [1]) do not
support the use of an intramedullary device such as the PFN
compared with a sliding compression hip screw for AO/OTA Type
31-A1 and A2 low-energy pertrochanteric fractures, specifically
with its increased cost and lack of evidence to show decreased
Fig. 9. Duration between injury and surgery.
complications or improved patient outcome.

25

DHS

DHS with TSP

20
DHS with TSP with single loop

DHS with TSP with double

15 loop
PFNA2

PFNA2 with single loop

10
PFNA2 with double loop

Sirus nail
5
Sirus nail with single loop

Sirus nail with double loop

0
NUMBER OF PATIENTS

Fig. 10. Type of surgery performed.

Intramedullary implants for internal fixation of the proximal One of the few controlled studies of PFN and DHS was carried
femur withstand higher static and a several-fold higher cyclical out by Saudan et al. [39] in which several intraoperative,
loading than DHS. As a result, the fracture heals without the radiographic and clinical measures of outcome were compared
 S. Babhulkar / Injury, Int. J. Care Injured 48 (2017) 803–818 813

Table 2 Table 4
Harris Hip score at end of 6 weeks. Harris Hip score at the end of 3 months.

Harris Hip score Harris Hip score

Poor(<70) 60 Poor(<70) 41
Fair(70–79) 17 Fair(70–79) 27
Good(80–89) 9 Good(80–89) 13
Excellent(90–100) 0 Excellent(90–100) 5
Total 86 Total 86

Table 3
Harris Hip score at end of 6 weeks in different groups.

Poor (<70) Fair (70–79) Good (80–89) Excellent (90–100) Total

DHS 2 1 0 0 3
DHS with TSP 3 1 0 0 4
DHS with TSP with single loop 4 1 1 0 6
DHS with TSP with double loop 5 1 1 0 7
PFNA2 8 3 1 0 12
PFNA2 with single loop 5 2 1 0 8
PFNA2 with double loop 15 3 2 0 20
Sirus nail 4 2 0 0 6
Sirus nail with single loop 6 1 1 0 8
Sirus nail with double loop 9 2 1 0 12

Table 5
Harris Hip score at end of 3 months in different groups.

Poor (<70) Fair (70–79) Good (80–89) Excellent (90–100) Total

DHS 2 1 0 0 3
DHS with TSP 3 1 0 0 4
DHS with TSP with single loop 3 2 1 0 6
DHS with TSP with double loop 5 1 1 0 7
PFNA2 6 5 1 0 12
PFNA2 with single loop 2 3 2 1 8
PFNA2 with double loop 8 6 4 2 20
Sirus nail 2 3 1 0 6
Sirus nail with single loop 4 2 1 1 8
Sirus nail with double loop 6 3 2 1 12

Table 6 region. In contrast, patients in our study, who were treated with
Harris Hip score at end of 6 months. intramedullary device, were able to ambulate early and received
physiotherapy with less pain. However, this finding did not reach
Harris Hip score
significance; this can be attributed to a type II statistical error.
Poor(<70) 16
We firmly believe that Pre-operative assessment of Fracture
Fair(70–79) 22
Good(80–89) 24 pattern on 3D CT reconstruction aids in formulating a better
Excellent(90–100) 24 preoperative planning allowing a near anatomic reconstruction of
Total 86 Proximal Femur, which is usually associated with better outcome.
For this purpose, our suggested classification method should be
used as it helps in assessing and planning the reduction of
after a minimum follow-up of 1 year. The results from that study comminuted fragments, lateral wall and posterior wall fixation and
suggest that the use of DHS may allow more patients to return to medial wall stabilisation. We also feel that our method of single or
their previous level of activity. But the above study was diverse and double loop be employed to reconstruct the comminution thus
employed more stable variety of fractures in the trochanteric avoiding early or late failures of these complex injuries. Late

Table 7
Harris Hip score at end of 6 months in different groups.

Poor (<70) Fair (70–79) Good (80–89) Excellent (90–100) Total

DHS 2 1 0 0 3
DHS with TSP 3 1 0 0 4
DHS with TSP with single loop 3 2 1 0 6
DHS with TSP with double loop 4 2 1 0 7
PFNA2 1 4 4 3 12
PFNA2 with single loop 1 2 3 2 8
PFNA2 with double loop 0 4 6 10 20
Sirus nail 1 1 2 2 6
Sirus nail with single loop 1 2 2 3 8
Sirus nail with double loop 0 3 5 4 12
814 S. Babhulkar / Injury, Int. J. Care Injured 48 (2017) 803–818

Table 8
Type of complications encountered in 10 patients.

Type of implant Total patients operated Complications Type of complication Percentage

DHS 3 1 DHS screw cut-out 33.33%
DHS with TSP 4 1 DHS screw cut-out 25%
DHS with TSP with single loop 6 1 DHS screw cut-out 16.67%
DHS with TSP with double loop 7 2 A) DHS screw cut-out 1 28.57%
B) DHS plate breakage-1
PFNA2 12 2 A) Blade cut-out 1 16.66%
B) Z-effect 1
PFNA2 with single loop 8 0 – 0
PFNA2 with double loop 2 1 Helical Blade cut-out 5%
Sirus nail 6 1 Screw cutout 16.66%
Sirus nail with single loop 8 0 – 0
Sirus nail with double loop 12 1 Reverse Z-effect 8.33%

postoperative mobilisation and follow-up results were similar in Werner et al. [40] were the first that introduced the term Z-
all the groups which suggest that the difference in implants were effect, detected in 5 (7.1%) of 70 cases. The Z-effect phenomenon is
insignificant. referred as a characteristic sliding of the proximal screws to

Fig. 11. A 76 year old female presented with history of domestic fall. Trochanteric fracture Modified AO/OTA type 31 A3.3.C (Burst Lateral wall with posterior wall fracture with
Medial column (Lesser Trochanter) dissociation and overall Comminution).Treated with Initial reduction with Circlage double loops followed by PFN A2 (Depuy Synthes).
Preoperative X-ray. a) Pare-operative 3-D CT scan images. b) Ibntraoperative pictures demonstrating the procedure. c) Post-operative X-rays and model demonstrating the
final fixation.
 S. Babhulkar / Injury, Int. J. Care Injured 48 (2017) 803–818
Fig. 11. (Continued)
opposite directions during the postoperative weight-bearing
period. Normally a vertical force passing from the centre of the
femoral head tends to move the affected hip into varus as soon as
the patient is mobilized. This leads to normal sliding of both
proximal screws achieving the expected compression at the
fracture site. In some cases this sliding occurs only to one of the
proximal screws while the other remains in its initial position
leading to penetration of the femoral head. A possible explanation
for the Z-effect phenomenon is the impaction of the hip pin into
the proximal hole of the nail while the neck screw is normally
sliding back during the weight-bearing period. The proximal
fragment and the femoral head are moved back normally, whereas
the impacted hip pin protrudes through the head into the joint.
The reverse Z-effect described by Boldin et al. [41] occurred
with movement of the hip pin towards the lateral side, which
required early removal. The mechanism is similar, but here the hip
pin is sliding back, whereas the neck screw remains impacted to
the hole of the nail. In their prospective study of 55 patients with
unstable trochanteric fractures followed up for 15 months on
average, they had 3 cases with Z-effect and 2 with reverse Z-effect.
The authors in an effort to prevent the Z-effect phenomenon
suggest the use of a “ring” in the lateral side of the hip pin.
In the present study, functional assessment was carried out by
the modified Harris hip score in which 16 patients had poor scores,
22 had fair scores, 24 had good scores and remaining 24 patients
had excellent scores at the end of 6 months follow up. These results
are comparable with the study done by Macheras et al. [42] who
reported that about 60% of their patients had good or excellent
outcomes when they used PFNA2. However, they also showed 50%
good or excellent outcome when extramedullary implant was used
according to Harris hip score.
In our study, DHS and TSP did not produce excellent results in
any patients. However, 69.69% of patients who underwent
intramedullary nailing showed fair to excellent results at the
end of 6 months. The overall complication rate in our study was
11.62% mostly seen in the extramedullary implant group. However,
complications like avascular necrosis as mentioned by some
815
authors was not noted in our patient cohort. This might be due to
the short follow up period.
A significantly shorter operation time and a considerably
shorter in-patient stay were common with the intramedullary
nailing group. The application of early partial weight bearing and
full weight bearing after the operation was possible for most of the
intramedullary nail group patients with augmentation by loop
method and only some of the DHS patients.
In conclusion, a new CT based modification of AO/OTA
classification system is described in the herein study based on
our experience. This system requires further clinical evidence and
validation. The results of our study indicate that unstable
trochanteric femoral fractures represent a distinct pattern and
can be treated with either intramedullary or extramedullary
implants. However, with all the available data, and in spite of the
limitations of our study (small number of patients recruited) we
believe that intramedullary nail should be the implant of choice in
unstable trochanteric femoral fractures. Augmenting the primary
fixation by use of loop methods to avoid early or late fixation
failures in this complex injury pattern is advisable.
A summary of tips on how to avoid pitfalls is shown below:
 Augmentation techniques should be considered for fixation of
unstable trochanteric fractures.
 Unstable trochanteric fractures should not be classified only on
the basis of radiological findings, but three dimensional
computed tomography scans should be considered for more
accurate diagnosis, planning and further management.
 Lateral and posterior wall fractures need to be identified before
planning any procedure.
 Reverse oblique fractures need separate attention.
 Intramedullary devices tend to give better stable fixation
compared to extramedullary devices in the treatment of unstable
trochanteric fractures.
Finally recommended treatment plan based on Modified AO/OTA
classification for Unstable trochanteric fractures is seen in Table 9.
816 S. Babhulkar / Injury, Int. J. Care Injured 48 (2017) 803–818

Fig. 12. A 45 year old male,RTA, trochanteric fracture Modified AO/OTA type 31 A3.1.B (Posterior wall fracture as seen on Posterior and Oblique CT) .Treated with Single loop
and PFN A2 (Depuy Synthes). Loop position and holding comminuted fragments can well be appreciated on post operative 3 D CT scan. b) Pre-operative 3-D CT scan. c)
Immediate Post-Operative X Ray. d) Post operative 3D CT showing single Loop wrap around holding Lateral, Posterior and Medial wall as a single complex. e) 3 months Post-
Operative X-ray. Patient full weight bearing. f) Model demonstrating the final fixation with single loop.
 S. Babhulkar / Injury, Int. J. Care Injured 48 (2017) 803–818 817

Fig. 12. (Continued)

Table 9
Recommended treatment plan based on Modified AO/OTA classification for Unstable trochanteric fractures.

A B C
A1-A2.1 DHS/INTRAMEDULLARY NAIL DHS/INTRAMEDULLARY NAIL DHS/INTRAMEDULLARY NAIL
A2.2 DHS + TSP/INTRAMEDULLARY NAIL INTRAMEDULLARY NAILING + LOOP INTRAMEDULLARY NAILING + LOOP
A2.3 DHS + TSP/INTRAMEDULLARY NAIL INTRAMEDULLARY NAILING + LOOP INTRAMEDULLARY NAILING + LOOP
A3.1 INTRAMEDULLARY NAILING + LOOP INTRAMEDULLARY NAILING + LOOP INTRAMEDULLARY NAILING + LOOP
A3.2 INTRAMEDULLARY NAILING + LOOP INTRAMEDULLARY NAILING + LOOP INTRAMEDULLARY NAILING + LOOP
A3.3 INTRAMEDULLARY NAILING + LOOP INTRAMEDULLARY NAILING + LOOP INTRAMEDULLARY NAILING + LOOP

Conflict of interest Acknowledgements

The authors declare that they have no conflict of interest. I wish to thank Dr Neel Dani, Dr Aditya Vasudev Post Graduate
residents who helped me in compiling the data, Dr Nidhi
Shrivastava, Mr Majumdar, Delhi for doing the illustrations.
818 S. Babhulkar / Injury, Int. J. Care Injured 48 (2017) 803–818
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