Injury 52 (2021) 3397–3403

Contents lists available at ScienceDirect

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

Risk factors for implant failure of intertrochanteric fractures with

lateral femoral wall fracture after intramedullary nail fixation
Jixing Fan a,b, Xiangyu Xu a,b, Fang Zhou a,b,∗, Zhishan Zhang a,b, Yun Tian a,b, Hongquan Ji a,b,
Yan Guo a,b, Yang Lv a,b, Zhongwei Yang a,b, Guojin Hou a,b
a
Department of Orthopedics, Peking University Third Hospital, Beijing 100191, China
b
Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Beijing 100191, China

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

Article history: Introduction: Few studies have specifically evaluated the comminution extent of lateral femoral wall
Accepted 13 July 2021 (LFW) fracture and risk factors of implant failure in intertrochanteric fractures with LFW fracture. The
aim of present study was to evaluate the influence of comminution extent of LFW fracture on implant
Keywords: failure and identify risk factors of implant failure in cases with LFW fracture after intramedullary fixation.
Intertrochanteric fracture
Methods: This retrospective study included 130 intertrochanteric fracture with LFW fracture treated with
Lateral femoral wall
intramedullary fixation at a teaching hospital over a 13-year period from January 2006 to December
Intramedullary nail
Implant failure 2018. Demographic information, cortical thickness index, the reduction quality, status of medial support,
position of the screw/blade and status of lateral femoral wall were collected and compared. The logistic
regression analyzes was performed to evaluate risk factors of implant failure in intertrochanteric fractures
with LFW fracture after intramedullary nail fixation.
Results: 10 patients (7.69%) suffered from mechanical failure after intramedullary fixation. Univariate
analyzes showed that comminuted LFW fracture (OR, 7.625; 95%CI, 1.437~40.446; p = 0.017), poor re-
duction quality (OR, 49.375; 95%CI, 7.217~337.804; p < 0.001) and loss of medial support (OR, 17.818;
95%CI, 3.537~89.768; p < 0.001) were associated with implant failure. After adjustment for confounding
variables, the multivariable logistic regression analyzes showed that poor reduction quality (OR, 11.318;
95%CI, 1.126~113.755; p = 0.039) and loss of medial support (OR, 7.734; 95%CI, 1.062~56.327; p = 0.043)
were independent risk factors for implant failure. Whereas, comminuted LFW fracture was not associated
with implant failure (p = 0.429).
Conclusions: The comminution extent of the LFW fracture might influence the stability of in-
tertrochanteric fractures; and intramedullary fixation might be an effective treatment method. Further-
more, poor reduction quality and loss of medial support could increaze the risk of implant failure in in-
tertrochanteric fractures with LFW fractures after intramedullary fixation. Therefore, we should pay great
emphasis on fracture reduction quality in future.
© 2021 Elsevier Ltd. All rights reserved.

Introduction tertrochanteric fractures and a reoperation was usually required

With the increasing of elderly population, the incidence of in-
tertrochanteric fractures increazed year by year. Patients suffered
from intertrochanteric fractures had a high incidence of morbidity
and mortality [25]. An early surgical procedure was usually con-
sidered as prior option for the treatment of intertrochanteric frac-
tures in elderly patients [11]. However, implant failure remained
one of the serious complications after surgery for unstable in-
∗ [31]. Furthermore, reconstruction of the LFW with an angularly sta-
Corresponding author at: Department of Orthopedics, Peking University Third
Hospital, Beijing 100191, China.
E-mail address: zhouf@bjmu.edu.cn (F. Zhou).
[15,38]. Furthermore, reoperation itself could increaze morbidity
and mortality for fragile elderly patients. Therefore, it was impor-
tant to identify risk factors for implant failure in intertrochanteric
fractures after internal fixation.
The lateral femoral wall (LFW), which was first described by
Gotfried [15], could provide a natural buttress for the femoral
head-neck fragment and fixation. Some investigators had identi-
fied that the integrity of lateral wall was an important predic-
tor of a reoperation treated with a sliding compression hip screw
ble trochanter-stabilizing plate (TSP) with locking screws had been
proved to provide an additional buttress force and DHS with TSP

https://doi.org/10.1016/j.injury.2021.07.025
0020-1383/© 2021 Elsevier Ltd. All rights reserved.
J. Fan, X. Xu, F. Zhou et al.
could provide satisfactory surgical outcomes [12,16]. However, ap-
plying a TSP could cause additional soft tissue dissection, bleeding,
and increazed surgical time.
Recently, intramedullary nail was widely used for its biome-
chanical stability, functional outcome and minimally invasive ad-
vantages over sliding hip screw-plate constructs [30,36]. Previous
studies demonstrated that the nail itself could act as a lateral but-
tress and prevent excessive sliding of the proximal fragment or
medial translation of the distal shaft fragment [23,34]. In spite of
this potential advantage of a nail over a DHS, the broken lateral
wall could not be stabilized by nailing, which might influence the
stability and healing of the intertrochanteric fracture. In clinical
practice, implant failure remained one of the problems after in-
tramedullary nail fixation for intertrochanteric fractures [19]. Fur-
thermore, a comminuted LFW fracture, which could increaze the
difficulty of reduction and fixation, might increaze the instability
of intertrochanteric fractures. To our knowledge, there was still
a paucity of studies focusing on specifically evaluating the com-
minution extent of LFW fracture and risk factors of implant fail-
ure in intertrochanteric fractures with LFW injury. In this study,
we aimed to identify predictive factors of implant failure follow-
ing intramedullary nail fixation of intertrochanteric fractures with
a LFW fracture.
Materials and methods
Source of patients
This retrospective study was performed at a teaching hospi-
tal over a 13-year period from January 2006 to December 2018.
The inclusion criteria were as followed: (1) acute intertrochanteric
fracture (< 2 weeks from injury); (2) intramedullary nail (IMN)
fixation; (3) a minimum follow-up period of 12 months or un-
til the time of failure leading to revision surgery; (4) radiolog-
ical healing at the time of final follow-up; and (5) presence of
a fracture of the lateral femoral wall. Patients with pathological
fracture, delayed fracture, stress fracture, periprosthetic fracture,
open fracture, or ipsilateral knee or ankle fractures were excluded.
Overall, 1182 consecutive patients with intertrochanteric fractures
were admitted at our institution. Of these patients, 238 patients
suffered from lateral femoral wall fracture. Of these 238 patients,
67 patients were treated with extramedullary fixation, 19 patients
lacked of sufficient follow-up, 14 patients lacked of inadequate
pre-operative x-rays or CT scan that were available to review,
2 patients suffered from stress fracture and 6 patients suffered
from delayed fracture. Overall, 108 patients were excluded from
this study. Finally, 130 intertrochanteric fracture patients with LFW
fracture were included in this study. The mean age of total patients
was 76 years old and the mean BMI was 22.85 kg/m2. Of these
patients, 56 (43.1%) were male patients and 74 (56.9%) were fe-
male patients. Furthermore, 60 (46.2%) had right side injury and
the other 70 (53.8%) had left side injury (Table 1).
Classification of the lateral femoral wall fracture
The extent of the LFW was defined according to the previous
study published by our research group [13], which was described
as followed: (1) the superior extent, vastus lateralis ridge; (2) the
inferior extent, intersection between the lateral femoral cortex and
a line drawn at a tangent to the inferior femoral neck; and (3) the
anterior and posterior extent, the anterior or posterior femoral cor-
tex, respectively, on a left or right 3-dimensional (3-D) computed
tomography (CT) image of the hip joint generated using a volume
rendering technique (VRT; sample slices were rendered at an ap-
proximately 90 angle to the viewer). The LFW fracture was defined
3398
Injury 52 (2021) 3397–3403
as a fracture line which cross the LFW on preoperative or postoper-
ative radiography or CT scan. In our clinical practice, CT scans were
performed when fractures were classified as AO31-A2.3, AO31-A3.1,
AO31-A3.2, AO31- A3.3, or there was a suspected fracture of the
LFW on an X-ray.
Cortical thickness index (CTI) was measured to evaluate osteo-
porosis on plain radiograph. The CTI was measured on both an-
teroposterior and lateral radiographs at a point 10 cm distal and
parallel to mid lesser trochanteric line on both anteroposterior and
lateral view [33]. Cortical thickness index = Diaphyseal width mi-
nus Medullary canal width/Diaphyseal width).
It had been demonstrated that there was a high incidence of
coronal fragments in intertrochanteric fractures [7]. When a coro-
nal fracture line passed along the border (superior, inferior, or an-
terior) of the LFW, the LFW is partially fractured. On the basis of
one previous study published by Ma et al. [27], we divided the
LFW fractures into three groups based on the integrity and com-
minution of the LFW. Partial LFW fracture was defined as a coronal
fracture line passed through the border of the LFW. Complete LFW
fracture was defined as a transverse or reverse oblique fracture line
crossed the LFW. Comminuted fracture was defined as both coro-
nal and transverse or reverse oblique fracture line crossed the LFW,
or a free LFW fragment was observed (Fig. 1).
The demographic information and clinical characteristics were
collected, including age, gender, side of injury, body mass index
(BMI), American Society of Anesthesiologists (ASA) score and the
reduction method.
Operative protocol
All of the surgeries were performed by five experienced or-
thopaedic surgeons. Spinal anesthesia or general anesthesia was
used. Reduction and internal fixation were performed with the
patients. Routine surgical procedures were performed for implan-
tation of intramedullary devices according to the manufacturer’s
protocol. Postoperatively, patients had antibiotic and deep vein
thrombosis prophylaxis. Partial weight-bearing was initiated fol-
lowing the appearance of fracture healing on radiographs, and to-
tal weight-bearing began with clinical fracture healing. Follow-up
evaluations were performed at 1, 3, 6 and 12 months after the
surgery and yearly thereafter.
Outcomes
Postoperative radiographs were obtained immediately to evalu-
ate the reduction quality, status of medial support, position of the
screw/blade, status of lateral femoral wall.
The reduction quality was addressed by measuring alignment
and displacement of main fragments on the AP and lateral view,
which was described as good, acceptable or poor, according to the
modified criteria of Baumgaertner and Solberg [3] and Kim et al.
[24]. Two criteria were used in this system: the first was that the
fracture was not excessively angulated (as defined by a neck shaft
angle that was between 125° and 135°, and a lateral angulation of
less than 20°) and the second was that none of the fragments were
displaced by more than one cortical thickness on both AP and lat-
eral XR. Reduction was considered good if both criteria were met,
acceptable if only one criteria was met and poor if neither of the
criteria was met.
The status of medial support was defined as existence or loss
according to the displaced extent of the head–neck fragment.
Chang et al. [6] described the concept of positive medial corti-
cal support (PMCS) in intertrochanteric fracture reduction. They di-
vided postoperative fracture reduction into three groups (positive,
neutral, and negative) according to the grade of medial cortical
J. Fan, X. Xu, F. Zhou et al. Injury 52 (2021) 3397–3403

Table 1
Univariate analyzes of baseline characteristics and risk factors associated with implant failure among the groups.

Variable Control group (n = 120) Failure group (n = 10) OR(CI 95%) P value

Age 75.5(64~81.5) 81(76~84) ~ 0.168

Gender
Male 51(42.5%) 5(50.0%) 1.0 (reference)
Female 69(57.5%) 5(50.0%) 0.739(0.203~2.689) 0.646
Side of injury
Right 53(44.2%) 7(70.0%) 1.0 (reference)
Left 67(55.8%) 3(30.0%) 0.339(0.084~1.374) 0.130
BMI 22.83(20.81~24.93) 23.58(22.10~26.10) ~ 0.407
CTI-AP 0.50 ± 0.07 0.49 ± 0.07 ~ 0.447
CTI-LAT 0.54 ± 0.07 0.55 ± 0.08 ~ 0.658
ASA
1 17(14.2%) 1(10.0%) 1.0 (reference)
2 17(65.0%) 7(70.0%) 1.526(0.176~13.229) 0.701
3 17(20.8%) 2(20.0%) 1.360(0.114~16.212) 0.808
Fracture type of lateral wall
Partial 61(50.8%) 2(20.0%) 1.0 (reference)
Complete 35(29.2%) 2(20.0%) 1.743(0.235~12.924) 0.587
Comminuted 24(20.0%) 6(60.0%) 7.625(1.437~40.446) 0.017∗
Reduction method
Closed 84(70.0%) 6(60.0%) 1.0 (reference)
Open 36(30.0%) 4(40.0%) 1.556(0.414~5.847) 0.513
Device Position
Optimum 62(51.7%) 5(50.0%) 1.0 (reference)
Sub Optimum 58(48.3%) 5(50.0%) 1.069(0.294~3.884) 0.919
Lateral femoral wall
Reduced 96(80.0%) 7(70.0%) 1.0 (reference)
Displaced 24(20.0%) 3(30.0%) 1.714(0.412~7.125) 0.458
Reduction quality
Good 79(65.8%) 2(20.0%) 1.0 (reference)
Acceptable 37(30.8%) 3(30.01%) 3.203(0.513~19.991) 0.213
Poor 4(3.3%) 5(50.0%) 49.375(7.217~337.804) < 0.001∗
Medial support 0.035∗
Yes 98(81.7%) 2(20.0%) 1.0 (reference)
No 22(18.3%) 8(80.0%) 17.818(3.537~89.768) < 0.001∗
NSA 130.57(127.95~133.68) 135.00(127.47~135.50) ~ 0.986

Abbreviations: BMI, body mass index; CTI-AP, Cortical thickness index - anteroposterior view; CTI-LAT, Cortical thickness index
-lateral view; ASA, American Society of Anaesthesiologists; NSA, neck shaft angle; OR, odds ratio; CI, Confidence interval.
∗
The difference was significant.

Fig. 1. The classification of intertrochanteric fractures based on the integrity and comminution of Lateral Femoral Wall: A-a, Partial LFW fracture, a coronal fracture line
passed through the border of the LFW. B-b, Complete LFW fracture, a transverse or reverse oblique fracture line crossed the LFW. C, Comminuted LFW fracture: c1, both
coronal and transverse or reverse oblique fracture line crossed the LFW; c2, a free LFW fragment was observed. The red line is fracture line on lateral view. The blue line is
the outline of lateral femoral wall (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article).

3399
J. Fan, X. Xu, F. Zhou et al.
Fig. 2. The status of medial support. A, Positive medial cortex support (PMCS): the proximal femoral head–neck fragment was displaced medially to the upper medial edge
of the distal femoral shaft fragment; B, Neutral position (NP): the medial cortex of head–neck and the shaft fragment was smoothly contacted; C, Negative medial cortex
support (NMCS): the head–neck fragment was displaced laterally to the upper medial edge of the shaft fragment, which lost the medial cortex support from the femoral
shaft; D, More than one cortical thickness displacement. The PMCS and NP were defined as the existence of medial support; the NMCS and more than one cortical thickness
displacement were defined as the loss of medial support.
support. The PMCS was defined as the medial cortex of the head–
neck fragment located a little bit (one cortex thickness) superome-
dially to the medial cortex of the femoral shaft. In present study,
we defined the positive medial cortex support and neutral posi-
tion (NP) as the existence of medial support. Otherwise, the neg-
ative medial cortex support (NMCS) and a more than one cortical
thickness displacement were defined as the loss of medial support
(Fig. 2).
The position of the screw/blade in the femoral head was spec-
ified by the Cleveland zone index on antero-posterior and lateral
radiographs [9]. The position was classified as superior, center or
inferior on the AP view and anterior, center or posterior on the lat-
eral view. A center-center or inferior-center position had tradition-
ally been described as the optimal position [20,32]. Screw/blade
positioning was considered optimal if it was inferior-center or
center-center. Any deviation from these two positions was consid-
ered sub-optimal positioning [22].
The status of the lateral femoral wall was defined as reduced or
displaced according to the extent of displacement. Good alignment
and a displacement of less than the cortical thickness was defined
as reduced. Otherwise, the status of the lateral femoral wall was
recorded as displaced [18].
In present study, implant failure was defined as helical blade
cut out, perforation, back out, and nail breakage. Blade cut out was
defined as perforation of the helical blade through the superior
cortex of the femoral head or neck. Blade perforation was defined
as penetration of the helical blade from the femoral head into the
surrounding soft tissues and hip joint (Fig. 3).
Statistical analyzes
For quantitative data, the one-sample Kolmogorov-Smirnov test
was used to test the normal distribution. The Student t-test or the
Mann–Whitney test was used to compare continuous variables as
appropriate. For qualitative data, the Chi-square test was used. All
variables were evaluated with an unconditional univariate logistic
regression analyzes. When the factor’s P values was < 0.1, a mul-
tivariate logistic regression analyzes was then performed to evalu-
ate risk factors of implant failure in intertrochanteric fractures with
lateral wall injury after intramedullary nail fixation. The likelihood
ratio backward test was conducted to find the best-fit model by
selecting variables one by one. A P value < 0.05 was considered
3400
Injury 52 (2021) 3397–3403
statistically significant, and all tests were two-sided. SPSS 21.0 soft-
ware was used for statistical analyzes (SPSS, Chicago, Illinois, USA).
Results
In present study, different nailing systems and implant materi-
als were used (Table 2). Overall, 10 patients (7.69%) suffered from
mechanical failure after intramedullary fixation. The mean follow-
up was 7.5 months (range: 1 to 36 months). Of these patients, two
patients suffered from nail breakage, three patients suffered from
cut out, two patients suffered from blade perforation and three pa-
tients suffered from blade back out.
In the univariate analyzes, the patients were divided into
two groups: with and without implant failure. The results
showed that comminuted LFW fracture (OR, 7.625; 95%CI,
1.437~40.446; p = 0.017), poor reduction quality (OR, 49.375;
95%CI, 7.217~337.804; p < 0.001) and loss of medial support (OR,
17.818; 95%CI, 3.537~89.768; p < 0.001) were associated with im-
plant failure. However, no statistically significant differences were
observed in age, gender, injury side, BMI, CTI-AP, CTI-LAT, reduc-
tion method, device position, LFW reduction and NSA between
control and failure group (P > 0.05) (Table 1).
After adjustment for confounding variables, the multivariable
logistic regression analyzes showed that poor reduction quality
(OR, 11.318; 95%CI, 1.126~113.755; p = 0.039) and loss of medial
support (OR, 7.734; 95%CI, 1.062~56.327; p = 0.043) were inde-
pendent risk factors for implant failure. Whereas, the comminuted
LFW fracture (p = 0.429) was not associated with implant failure
(Table 3).
Discussion
Owing to the changes in population demographics, the inci-
dence of proximal femoral fractures was continually increasing.
Early surgery and regaining pre-fracture ambulatory function was
necessary. However, implant failure was one of the main concerns
of orthopaedic surgeons and might carry significant morbidity. In
particular, proximal femoral fractures with a LFW fracture might
have higher rates of implant failure after dynamic hip screw fix-
ation [31]. Compared with extramedullary fixation, intramedullary
nail was more popular for its biomechanical stability, shorter oper-
ating time, reduced intra-operative blood loss, and improved walk-
J. Fan, X. Xu, F. Zhou et al. Injury 52 (2021) 3397–3403

Fig. 3. Types of implant failure. A, Screw/blade cut out; B, Screw/blade perforation; C, Screw/blade back out; D, Nail breakage.

Table 2
Utilization of implant types.

Implant type Failure rate

Gamma 3 (Stryker, Mahwah, NJ) 1/28(3.57%)

Proximal femoral nail antirotation (PFNA, Synthes USA, Paoli, PA) 9/71(12.68%)
TRIGEN InterTan nail (Smith & Nephew, Inc., Memphis, USA) 0/17
Proximal femoral nail (PFN, Synthes USA, Paoli, PA) 0/1
TRIGEN Tan nail (Smith & Nephew, Inc., Memphis, USA) 0/3

Table 3 lyzes showed that comminuted LFW fracture was not significantly
Multivariable logistic regression analyzes for risk factors associated with
associated with implant failure. The association of poor reduction
implant failure.
quality and loss of medial support with implant failure remained
Predictor Adjusted OR 95%CI p Value significant in the multivariate analyzes.
Fracture type of LFW It was well-known that the integrity of the LFW was a predictor
Partial 1.0 (reference) for a reoperation after intertrochanteric fractures. Various studies
Complete 0.603 0.057~6.350 0.673 had noted that intertrochanteric fractures with a LFW fracture had
Comminuted 2.537 0.353~18.245 0.355
a higher rate of implant failure [8,15,31]. One study reported that
Reduction quality
Good 1.0 (reference) patients with a fractured LFW underwent a seven-times risk of re-
Acceptable 1.340 0.167~10.775 0.783 operation after sliding compression hip screw fixation compared
Poor 11.318 1.126~113.755 0.039∗ with patients with an intact LFW postoperatively [31]. Therefore,
Medial support
an additional trochanter-stabilizing plate (TSP) was necessary after
Yes 1.0 (reference)
No 7.734 1.062~56.327 0.043∗ dynamic hip screw fixation for the intertrochanteric fracture with
a LFW fracture [16]. Unlike dynamic hip screw, intramedullary nail
Abbreviations: LFW, lateral femoral wall; OR, odds ratio; CI, Confidence in-
itself could act as lateral buttress, which could prevent lateraliza-
terval.
The multivariable regression analyzes used backward selection with use of tion of the head/neck fragment. Nevertheless, implant failure could
the likelihood ratio test to assess significance. occur after nail fixation. The possible reason might be that the
∗
The difference was significant. LFW fragment could not be fixed by the nail, and the comminu-
tion extent of LFW fracture might influence the fixation stabil-
ity. Furthermore, the comminuted LFW might result in the greater
ing ability in unstable intertrochanteric fractures [39]. Although trochanter fracture, which might make fish mouth phenomenon,
nail itself could act as a lateral buttress, it could not fix the LFW causing varus angulation and shortening that could progress to fix-
fragment, which might influence the stability and result in im- ation failure. To our knowledge, this was the first study to specif-
plant failure. Previous study had demonstrated that intramedullary ically report the comminution extent of LFW fracture and its re-
nails have a failure rate between 3 and 22% [14,19,38]. However, lationship to implant failure after intramedullary nail fixation. In
it was unknown whether the extent of LFW comminution affected present study, we found that patients with comminuted LFW frac-
the implant failure. Furthermore, although a few studies had re- ture had greater risk of implant failure compared with partial LFW
ported risk factors of intertrochanteric fractures treated with in- fracture (OR, 7.625; 95%CI, 1.437~40.446; p = 0.017) in the univari-
tramedullary nails, these studies included both cases with and ate analyzes. After adjusted confounding factors, patients with the
without LFW fracture [4,14,19,31]. In present study, we evaluated comminuted LFW fracture remained a 2.5-fold greater risk com-
the extent of LFW comminution impacted on the implant failure pared with partial LFW fracture in the multivariate analyzes; how-
and risk factors of implant failure in cases with LFW fracture after ever, no statistically significant difference was observed. This im-
intramedullary fixation. plied that the extent of LFW fracture comminution might influence
In present study, the overall implant failure rate was 7.69% af- the stability of intertrochanteric fractures; further study was nec-
ter intramedullary nails fixation for intertrochanteric fractures with essary to verify this result.
LFW fracture. Furthermore, we found that patients with commin- Fracture reduction was the first step and reduction quality was
uted LFW fracture, loss of medial support and poor reduction qual- one of the most important factors in the management of in-
ity had higher rates of implant failure. In addition, after adjustment tertrochanteric fractures [5,17]. It was known that cortical continu-
for confounding variables, the multivariate logistic regression ana- ity might contribute to the ability of the cortex to resist collapse

3401
J. Fan, X. Xu, F. Zhou et al.
[35]; whereas, Mal-angulation, in particular varus mal-angulation,
might increaze bone-implant stresses and risk of collapse [28].
According to the modified criteria of Baumgaertner and Solberg
[3] and Kim et al. [24], which included both alignment and dis-
placement of main fragments, the reduction quality was described
as good, acceptable or poor. Previous studies had shown that poor
reduction quality of intertrochanteric fractures was associated with
the occurrence of implant failure [10,18,21]. Similarly, Zhang et al.
reviewed 295 consecutive patients who underwent PFNA fixation
for intertrochanteric fractures and found that good reduction qual-
ity could reduce the risk of mechanical failure [38]. In present
study, we found that a poor reduction quality was an independent
predictor of the occurrence of implant failure in intertrochanteric
fractures with LFW fracture after intramedullary nail fixation (OR,
11.318; 95%CI, 1.126~113.755; p = 0.039). This result was consis-
tent with previous studies, which implied the importance of frac-
ture reduction quality. Therefore, we should pay great emphasis
on the fracture reduction quality in the surgical treatment of in-
tertrochanteric fractures in the future.
It had been widely reported that posteromedial support
was considered as an important factor for the stability of in-
tertrochanteric fractures [29,37]. However, there was a contro-
versial on the role of posteromedial support in treating in-
tertrochanteric fractures. One study demonstrated that the in-
tegrity of the lesser trochanter had no significant influence on the
surgical outcome of intertrochanteric fractures after intramedullary
nail fixation [26]. Furthermore, it was difficult to fix the lesser
trochanteric fragment in clinical practice owing to technical restric-
tions, the longer operation time and greater blood loss. Therefore,
Chang et al. [6] described the concept of positive medial cortical
support (PMCS) in fracture reduction of unstable intertrochanteric
fractures treated with cephalomedullary nail, which was a func-
tional nonanatomic buttress reduction. The PMCS was easy to
achieve in clinical practice and was used for description of sec-
ondary stability after sliding impaction. Nevertheless, the study in-
volved only AO/OTA 31- A2 fractures, and the conclusion might not
be applicable to intertrochanteric fractures with LFW fracture. In
present study, we defined PMCS and anatomically contacted me-
dial cortex support as the existence of medial support. The re-
sult showed that loss of medial support could increase the risk
of implant failure in the univariate analyzes (OR, 10.394; 95%CI,
2.489~43.405; p = 0.001). The association of loss of medial sup-
port with implant failure remained significant in our multivariate
analyzes (OR, 7.734; 95%CI, 1.062~56.327; p == 0.043). Therefore,
our study confirmed the importance of satisfactory medial support
in reducing the incidence of implant failure for intertrochanteric
fractures after intramedullary fixation.
Previous studies had reported that a broken LFW was a risk fac-
tor in the healing of unstable intertrochanteric fractures, whereas
there was still no consensus on whether the displaced LFW should
be fixed or not [8,31]. A displaced LFW might increaze the risk
of excessive sliding of the proximal fragment and medial transla-
tion of the distal shaft fragment after dynamic hip screw fixation
in the treatment of intertrochanteric fractures, which would result
in implant failure and unsatisfactory function [1]. Therefore, a dis-
placed LFW should be reduced and fixed by a trochanteric stabi-
lizing plate (TSP) or other devices after DHS fixation [12]. How-
ever, one study reported that the displaced LFW fragment tended
to reduce spontaneously without any additional fixation during the
postoperative period after intramedullary nail fixation [23]. Sim-
ilarly, no significant difference was found between patients with
and without the reduction of displaced LFW fracture with regard to
the occurrence of implant failure after intramedullary nail fixation
in present study. The possible reason might be that intramedullary
nail itself could act as a lateral buttress against excessive sliding
of the proximal fragment or medial translation of the distal shaft
3402
Injury 52 (2021) 3397–3403
[34]. Another reason might be that the recovery of vastus lateralis
strength contributes to movement of the LFW fragment [23].
The major strength of present study was that this was the first
study to specifically evaluating the comminution extent of LFW
fracture and its relationship to implant failure after intramedullary
nail fixation. Nevertheless, there were some limitations in this
study. First, this was a retrospective study, and therefore had in-
herent bias. Second, the sample size in this study was relatively
small. Third, the bone mineral density was not measured to eval-
uate the osteoporosis. Previous study had shown that osteoporosis
was one of the main reasons for the failure of fixation in the ag-
ing population [2]. In present study, CTI was measured to evaluate
the osteoporosis status on both anteroposterior and lateral radio-
graphs. However, no significantly statistical difference was found.
Therefore, further study was necessary to evaluate the osteoporo-
sis in relation to the implant failure. Forth, all patients in this study
came from one trauma center. Therefore, a multi-center large sam-
ple study would be required to confirm our findings.
Conclusions
In present study, we found that the comminution extent of the
LFW fracture might influence the stability of intertrochanteric frac-
tures; and intramedullary fixation might be an effective treatment
method. In addition, CT scan was an efficient tool to identify frac-
ture type of the lateral femoral wall. Furthermore, poor reduction
quality and loss of medial support could increase the risk of im-
plant failure in intertrochanteric fractures with LFW fractures after
intramedullary fixation. Therefore, we should pay great emphasis
on fracture reduction quality in future.
Declaration of Competing Interest
The authors declare that they have no conflict of interest.
Acknowledgments
This study was supported by Science and Technology fund of
Winter Olympics (Grant No. 2018YFF0301100); and Peking Univer-
sity Third Hospital (Grant No. Y62419-06)
References
[1] Baixauli F, Vicent V, Baixauli E, Serra V, Sanchez-Alepuz E, Gomez V, et al. A
reinforced rigid fixation device for unstable intertrochanteric fractures. Clin Or-
thop Relat Res 1999:205–15.
[2] Barrios C, Brostrom LA, Stark A, Walheim G. Healing complications after inter-
nal fixation of trochanteric hip fractures: the prognostic value of osteoporosis.
J Orthop Trauma 1993;7:438–42.
[3] Baumgaertner MR, Solberg BD. Awareness of tip-apex distance reduces fail-
ure of fixation of trochanteric fractures of the hip. J Bone Joint Surg Br
1997;79:969–71.
[4] Buyukdogan K, Caglar O, Isik S, Tokgozoglu M, Atilla B. Risk factors for
cut-out of double lag screw fixation in proximal femoral fractures. Injury
2017;48:414–18.
[5] Chang SM, Hou ZY, Hu SJ, Du SC. Intertrochanteric femur fracture treatment
in Asia: what we know and what the world can learn. Orthop Clin North Am
2020;51:189–205.
[6] Chang SM, Zhang YQ, Ma Z, Li Q, Dargel J, Eysel P. Fracture reduction
with positive medial cortical support: a key element in stability reconstruc-
tion for the unstable pertrochanteric hip fractures. Arch Orthop Trauma Surg
2015;135:811–18.
[7] Cho JW, Kent WT, Yoon YC, Kim Y, Kim H, Jha A, et al. Fracture morphology
of AO/OTA 31-A trochanteric fractures: a 3D CT study with an emphasis on
coronal fragments. Injury 2017;48:277–84.
[8] Ciufo DJ, Zaruta DA, Lipof JS, Judd KT, Gorczyca JT, Ketz JP. Risk factors asso-
ciated with cephalomedullary nail cutout in the treatment of trochanteric hip
fractures. J Orthop Trauma 2017;31:583–8.
[9] Cleveland M, Bosworth DM, Thompson FR, Wilson HJ, Ishizuka T. A ten-year
analyzes of intertrochanteric fractures of the femur. J Bone Joint Surg Am
1959;41-A:1399–408.
[10] De Bruijn K, den Hartog D, Tuinebreijer W, Roukema G. Reliability of predic-
tors for screw cutout in intertrochanteric hip fractures. J Bone Joint Surg Am
2012;94:1266–72.
J. Fan, X. Xu, F. Zhou et al.
[11] Dehghan N, McKee MD. What’s new in orthopaedic trauma. J Bone Joint Surg
Am 2019;101:1138–43.
[12] Fu CW, Chen JY, Liu YC, Liao KW, Lu YC. Dynamic hip screw with
trochanter-stabilizing plate compared with proximal femoral nail antirotation
as a treatment for unstable AO/OTA 31-A2 and 31-A3 intertrochanteric frac-
tures. Biomed Res Int 2020;2020:1896935.
[13] Gao Z, Lv Y, Zhou F, Ji H, Tian Y, Zhang Z, et al. Risk factors for implant failure
after fixation of proximal femoral fractures with fracture of the lateral femoral
wall. Injury 2018;49:315–22.
[14] Geller JA, Saifi C, Morrison TA, Macaulay W. Tip-apex distance of in-
tramedullary devices as a predictor of cut-out failure in the treatment of per-
itrochanteric elderly hip fractures. Int Orthop 2010;34:719–22.
[15] Gotfried Y. The lateral trochanteric wall: a key element in the reconstruction
of unstable pertrochanteric hip fractures. Clin Orthop Relat Res 2004:82–6.
[16] Gupta RK, Sangwan K, Kamboj P, Punia SS, Walecha P. Unstable trochanteric
fractures: the role of lateral wall reconstruction. Int Orthop 2010;34:125–9.
[17] Haidukewych GJ. Intertrochanteric fractures: ten tips to improve results. J Bone
Joint Surg Am 2009;91:712–19.
[18] Hao Y, Zhang Z, Zhou F, Ji H, Tian Y, Guo Y, et al. Risk factors for implant fail-
ure in reverse oblique and transverse intertrochanteric fractures treated with
proximal femoral nail antirotation (PFNA). J Orthop Surg Res 2019;14:350.
[19] Hoffmann MF, Khoriaty JD, Sietsema DL, Jones CB. Outcome of intramedullary
nailing treatment for intertrochanteric femoral fractures. J Orthop Surg Res
2019;14:360.
[20] Hsueh KK, Fang CK, Chen CM, Su YP, Wu HF, Chiu FY. Risk factors in cutout of
sliding hip screw in intertrochanteric fractures: an evaluation of 937 patients.
Int Orthop 2010;34:1273–6.
[21] Irgit K, Richard RD, Beebe MJ, Bowen TR, Kubiak E, Horwitz DS. Reverse
oblique and transverse intertrochanteric femoral fractures treated with the
long cephalomedullary nail. J Orthop Trauma 2015;29:e299–304.
[22] John B, Sharma A, Mahajan A, Pandey R. Tip-apex distance and other predictors
of outcome in cephalomedullary nailing of unstable trochanteric fractures. J
Clin Orthop Trauma 2019;10:S88–94.
[23] Kim Y, Bahk WJ, Yoon YC, Cho JW, Shon WY, Oh CW, et al. Radiologic healing
of lateral femoral wall fragments after intramedullary nail fixation for A3.3
intertrochanteric fractures. Arch Orthop Trauma Surg 2015;135:1349–56.
[24] Kim Y, Dheep K, Lee J, Yoon YC, Shon WY, Oh CW, et al. Hook leverage tech-
nique for reduction of intertrochanteric fracture. Injury 2014;45:1006–10.
[25] Lee SH, Chen IJ, Li YH, Fan CC, Chang CH, Hsieh PH. Incidence of sec-
ond hip fractures and associated mortality in Taiwan: a nationwide popula-
tion-based study of 95,484 patients during 2006-2010. Acta Orthop Traumatol
Turc 2016;50:437–42.
[26] Liu X, Liu Y, Pan S, Cao H, Yu D. Does integrity of the lesser trochanter in-
fluence the surgical outcome of intertrochanteric fracture in elderly patients?
BMC Musculoskelet Disord 2015;16:47.
3403
Injury 52 (2021) 3397–3403
[27] Ma Z, Yao XZ, Chang SM. The classification of intertrochanteric fractures based
on the integrity of lateral femoral wall: letter to the editor, fracture morphol-
ogy of AO/OTA 31-A trochanteric fractures: a 3D CT study with an emphasis
on coronal fragments. Injury 2017;48:2367–8.
[28] Marmor M, Liddle K, Buckley J, Matityahu A. Effect of varus and valgus align-
ment on implant loading after proximal femur fracture fixation. Eur J Orthop
Surg Traumatol 2016;26:379–83.
[29] Marmor M, Liddle K, Pekmezci M, Buckley J, Matityahu A. The effect of frac-
ture pattern stability on implant loading in OTA type 31-A2 proximal femur
fractures. J Orthop Trauma 2013;27:683–9.
[30] Matre K, Havelin LI, Gjertsen JE, Vinje T, Espehaug B, Fevang JM. Sliding hip
screw versus IM nail in reverse oblique trochanteric and subtrochanteric frac-
tures. A study of 2716 patients in the Norwegian hip fracture register. Injury
2013;44:735–42.
[31] 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;89:470–5.
[32] Parker MJ. Cutting-out of the dynamic hip screw related to its position. J Bone
Joint Surg Br 1992;74:625.
[33] Pradeep AR, KiranKumar A, Dheenadhayalan J, Rajasekaran S. Intraoper-
ative lateral wall fractures during dynamic hip screw fixation for in-
tertrochanteric fractures-incidence, causative factors and clinical outcome. In-
jury 2018;49:334–8.
[34] Ruecker AH, Rupprecht M, Gruber M, Gebauer M, Barvencik F, Briem D,
et al. The treatment of intertrochanteric fractures: results using an in-
tramedullary nail with integrated cephalocervical screws and linear compres-
sion. J Orthop Trauma 2009;23:22–30.
[35] Socci AR, Casemyr NE, Leslie MP, Baumgaertner MR. Implant options for the
treatment of intertrochanteric fractures of the hip: rationale, evidence, and
recommendations. Bone Joint J 2017;99-B:128–33.
[36] Tucker A, Donnelly KJ, Rowan C, McDonald S, Foster AP. Is the best plate a
nail? A review of 3230 unstable intertrochanteric fractures of the proximal fe-
mur. J Orthop Trauma 2018;32:53–60.
[37] Ye KF, Xing Y, Sun C, Cui ZY, Zhou F, Ji HQ, et al. Loss of the posterome-
dial support: a risk factor for implant failure after fixation of AO 31-A2 in-
tertrochanteric fractures. Chin Med J (Engl) 2020;133:41–8.
[38] Zhang W, Antony XR, Decruz J, Chen YD, Park DH. Risk factors for mechanical
failure of intertrochanteric fractures after fixation with proximal femoral nail
antirotation (PFNA II): a study in a Southeast Asian population. Arch Orthop
Trauma Surg 2020;141(4):569–75.
[39] Zhang WQ, Sun J, Liu CY, Zhao HY, Sun YF. Comparing the intramedullary nail
and extramedullary fixation in treatment of unstable intertrochanteric frac-
tures. Sci Rep 2018;8:2321.