Intertrochanteric Fractures

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Michael R. Baumgaertner, MD
Original Authors: Steve Morgan, MD; March 2004;
New Author: Michael R. Baumgaertner, MD; Revised January 2007
Revised December 2010

Lecture Objectives
Review:

Principles of treatment

Understand & Optimize

Variables influencing patient

and fracture outcome

Introduce:

Recent Evidence-

based med

Suggest:

Surgical Tips to avoid common problems

Hip Fracture PATIENT

Outcome Predictors
Un
con
tro
lled

Pre-injury physical & cognitive status

Ability to visit a friend or go shopping

Su
Co rge
ntr on
oll
ed
!

Presence of home companion

Postoperative ambulation
Postoperative complications
(Cedar, Thorngren, Parker, others)

A public heath care cri$i$:

Fx / year in U.S.

130,000 IT

& will double by 2050

4-12% fixation failure

Even when surgery is successful:
1-2 units PRBC transfused
3-5+ days length of stay

We must do better!!

Preoperative Management
the evidence suggests:

Tune up correctable comorbidities

Operate within 48; avoid night surgery
JBJS(A) 95
Maintain extremity in positionZuckerman,
of comfort
Anderson, JBJS(B) 93
General versus spinal anaesthesia?
Bucks traction of no value (RCT)

Randomized, prospective trials (RCTs): no difference

Davis, Anaesth & IntCare 81;
Valentin, Br J Anaesth 86

Comprehensive Management
excellent evidence based single source:

Osteoporosis International
Preoperative Guidelines and Care Models for
Hip Fractures

Volume 21, Supplement 4 December 2010

Intertrochanteric Femur
Anatomic considerations
Capsule inserts on IT
line anteriorly, but at
midcervical level
posteriorly
Muscle attachments
determine deformity

Radiographs

Plain Films
AP pelvis
Cross-table lateral

ER Traction view

when in any doubt!!

Factors Influencing Construct

Strength:

ncontrolled factors
Bone Quality
Fracture Geometry

ontrolled factors
Quality of Reduction
Implant Placement
Implant Selection
Kaufer, CORR 1980
This lecture will examine each factor

Uncontrolled factor: Fracture geometry

STABILITY
The ability of the reduced fracture to
support physiologic loading
Fracture Stability relates not only to the #
of fragments but the fracture plane as well

31

AO / OTA

Uncontrolled factor: Fracture geometry

Stable

Unstable

Uncontrolled factor: Fracture geometry

AO/OTA31A3:

The highly unstable pertrochanteric fractures!

Uncontrolled factor: Bone quality

A 33 year old pt with intertrochanteric fracture following a fall from heightNote the dense, cancellous bone throughout the proximal femur;
Not at all like a geriatric fracture

Uncontrolled factor: Bone quality

83 yo white woman with unstable intertrochanteric fracture:

Note the marked loss of trabeculae

Uncontrolled factor: Bone quality

Implants must be placed where the remaining trabeculae reside!

Uncontrolled factor: Bone quality

Can / Should we strengthen the

bone-implant interface?

PMMA

12 to 37% increase load to failure

Choueka, Koval et al., ActaOrthop 96

CPPC
15% increased yield strength, stiffer

Moore, Goldstein, et al., JOT 97

Clinical Factors in 2010 influence use

delivery, cost, complications must be considered
Hydroxy-apatite
(HA) coated screws
Reduced cut out in poorly positioned fixation
Moroni, et al. CORR 04

Factors Influencing Construct

Strength:

Uncontrolled factors

Fracture Geometry
Bone Quality

Surgeon controlled factors

Quality of Reduction
Implant Placement
Implant Selection

t
e
g !!
to ght
d ri
e
e
Kaufer,
CORR
N eKauffer,
s80e CORR 1980
th

Surgeon controlled factor

Fracture Reduction

When employing sliding hip screws

No role for displacement osteotomy

RCT Desjardins, et al. JBJS (B) 93
RCT Gargan, et al. JBJS (B) 94

Limited role for reduction & fixation of

trochanteric fragments (biology vs stability)

Surgical goal: Biplanar, anatomic alignment

proximal & shaft fragments
Mild valgus reduction for instability to offset shortening

of

Surgeon controlled factor

Fracture Reduction

Discuss sequence of closed reduction steps

Consider adjuncts to fracture reduction
Crutch elevator joystick. etc.

Lever technique read this article:

Surgeon controlled factor

of
Fracture Reduction

Double density of medial cortex is evidence of

intussuscepted neck into shaft seen on lateral

Traction will not reduce this sag but a

lever into the fracture will

Traction will not reduce this sag but a

lever into the fracture will reduce it

Surgeon controlled factor

Fracture Reduction

The AP view before and after lever

redution: the medial cortex is restored

Surgeon controlled factor: Implant position

Apex of the femoral head

Defined as the point where a line parallel to, and in the

middle of the femoral neck intersects the joint

Surgeon controlled factor: Implant position

Screw Position: TAD

Xap

Tip-Apex Distance =

Xlat

Xap

Xlat

Surgeon controlled factor: Implant position

Baumgaertner, Curtin, Lindskog, Keggi JBJS (A) 95

Surgeon controlled factor: Implant position

Risk of Cut Out

Probability of Cut Out

Increasing TAD ->

Baumgaertner, Curtin, Lindskog, Keggi JBJS (A) 95

Surgeon controlled factor: Implant position

Logistic Regression Analysis

Multivariate (dependent variable:Cut Out)

Reduction Quality

p = 0.6

Screw Zone

p = 0.6

Unstable Fracture

p = 0.03

Increasing Age

p = 0.002

Increasing TAD

p = 0.0002

Baumgaertner, Curtin, Lindskog, Keggi JBJS (A) 95

Surgeon controlled factor: Implant position

Optimal Screw Placement

Dead Center
and

Very Deep
(TAD<25mm)

Best bone

No moment arm for

rotational instability

Maximum slide
Validates reduction

Surgeon controlled factor: Implant selection

Whats the big

deal?
IM vs Plate
Fixation

IM Fixation Recent History:

Theoretical Biologic Advantages
Percutaneous Procedure

EBL, Muscle stripping,

Complications, Rehab time?
Surgical wounds s/p ORIF with IM device

GAMMA
The First to Reach
the Market

Gamma Clinical Results

Advantages :
Complications : +++
Bridle JBJS(B) '91
Boriani Orthopaedics '91
Lindsey Trauma '91
Halder JBJS(B) '92

Williams Injury '92

LeungJBJS(B) '92
Aune ActOrthopScan '94

Surgeon controlled factor: Implant selection

Gamma Nail vs. CHS

1996 Meta-analysis of ten randomized trials

Shaft fractures: Gamma 3 x CHS (p < 0.001)

Required Re-ops: Gamma 2 x CHS (p < 0.01)

IM fixation may be superior for inter/subtroch

extension & reverse obliquity fractures

CHS is a forgiving implant when used by

inexperienced surgeons, the Gamma nail is not

MJParker,
Parker, International Orthopaedics '96

Gamma nails revisited

(risk of shaft fracture.)

Bhandari, Schemitsch et al. JOT 2009

No more increased risk with nails

Surgeon controlled factor: Implant selection

IM Fixation: Clinical Results

RCT, IMHS vs CHS, N = 135

No difference for stable fxs

Faster & less bloody for unstable fxs

Fewer IM complications than Gamma
Weaknesses:

No stratification of unstable fractures

Learning curve issues
No anatomic outcomes, wide functional outcomes

Baumgaertner, Curtin, Lindskog, CORR 98

Surgeon controlled factor: Implant selection

IM Fixation: Clinical Results

Well analyzed RCT, IMHS vs CHS, N = 100
Longer surgery, less blood loss
Improved post-op mobility
@ 1 & 3 months *

Improved community ambulation

@ 6 & 12 months *

45% less sliding, LLD*

(* p < 0.05)

Hardy, et. al JBJS(A) 98

Surgeon controlled factor: Implant selection

IM
IMFixation:
Fixation:Mechanical
MechanicalAdvantages
Advantages

Key point
It is not the reduced lever arm that
offers the clinically significant
mechanical advantage, but rather the
intramedullary buttress that the nail
provides to resist excessive fracture
collapse*
* Reduced collapse has been demonstrated in most every
randomized study that has looked at the variable

The nail substitutes for the incompetent posteromedial cortex

31.A33

2 weeks

7 months

The nail substitutes for the incompetent lateral cortex

CHS: Unique risk of failure

Palm, et al JBJS(A) 07

Iatrogenic, intraoperative lateral wall

fracture
31% risk in A2.2&3 fxs
22% failure rate
(vs. 3% overall)
A2 to A3 fx!

Surgeon controlled factor: Implant selection

IM Fixation: Selected Clinical Results

RCT, IMscrew vs CHS, N = 436
less sliding, shaft medialization*

Ahrengart, CORR 02

RCT, IMscrew vs CHS, N = 46

5 in neck shaft angle @ 6 wks (all)
shaft medialization @ 4mo *
Pajarinen, Int Orth 04

RCT, IMscrew vs CHS, N = 108

Improved post-op mobility (4 months)*
less sliding, shaft medialization*

(* p < 0.05)

Pajarinen, JBJS(B) 05

Surgeon controlled factor: Implant selection

CHS Improvements: 1975-2010

Trochanteric Stabilizing Plate (TSP)

plate adjunct to limit shaft medialization
major (20mm screw
slide) collapse
op time, blood loss

? complications,
length of rehab
Madsen, JOT '98
Su, Trauma 03
Bong, Trauma 04

Surgeon controlled factor: Implant selection

IM Fixation: Best Indications

Reverse Oblique
Fractures
Intertroch +
subtrochanteric
fractures

Surgeon controlled factor: Implant selection

Reverse Oblique Fractures

Retrospective review of 49 consecutive R/ob.
fractures @ Mayo: overall 30% failure rate

Poor Implant Position:

80% failure

Implant Type:
Compression Hip Screw:
95 blade / DCS:
IMHipScrew:

56% failure (9/16)

20% failure (5/25)
0% failure (0/3)

Haidukewych, JBJS(A) 2001

Surgeon controlled factor: Implant selection

Reverse Oblique Fractures

PFN vs 95 sliding screw plate(DCS)
RCT of 39 cases done by Swiss AO surgeons

PFN (IM) vs Plate

Open reductions
Op-time
All Significantly
Blood tx
Failure rate
reduced!
Major reoperations
Sadowski,Hoffmeyer JBJS(A) 2002

Recovery room control X-ray shows

loss of medial support, but nail
prevents excessive collapse

Surgeon controlled factor: Implant selection

Intertroch/
subtrochanteric
fxs
Greater mechanical demands,
poorer fracture healing

Surgeon controlled factor: Implant selection

Long Gamma
Nail for IT-ST Fxs
Barquet, JOT 2000

52 consecutive fractures; 43 with 1 year f/u

100% union
81 minutes, 370cc EBL

The authors describe the key percutaneous

reduction techniques that lead to successful
management of these difficult fractures

Reduction Aids

Surgeon controlled factor: Implant selection

Unstable Pertroch
Fractures (OTA31A.3)

347 articles reviewed: 10 relevant; 5 RCTs*

Evidence-based bottom line:

Unacceptable failure rates with CHS
Better results with 95 devices
Best results with I M devices*
Best functional outcome not known
Kregor, et al (Evidence Based
Working Group) JOT 05

CHS

31
AO / OTA

Surgeon controlled factor: Implant selection

Grossly displaced Stable (31A.1)

fracture treated with ORIF

Surgeon controlled factor: Implant selection

There is no data to support

nailing over sideplate fixation
for A1 fractures

CHS
????
31
AO / OTA

NAIL

Surgeon controlled factor: Implant selection

IM Fixation vs. CHS

Randomized/prospective trial of 210 pts.

Patients

Utrilla, et al. JOT 4/05

All ambulatory, no ASA Vs

Fractures
Excluded inter/subtrochs fractures (31A.3)

--excludes the fxs KNOWN to do best with IM

Surgeons
Only 4, all experienced

Technique
All got spinals, Closed reduction, percutaneous fixation
All overreamed 2mm, all got 130 x 11mm nail, one distal
interlock prn rotational instability (rarely used)

Surgeon controlled factor: Implant selection

IM Fixation vs. CHS

Randomized/prospective trial of 210 pts.

Results

Utrilla, et al. JOT 4/05

Skin to skin time unchanged

Fewer blood transfusions needed with IM
Better walking ability in Unstable fractures with IM
No shaft fxs
Fewer re-ops needed in IM group (1 vs 4)

Conclusion

IM fixation or CHS for stable fxs

Unlocked IM for most Unstable fxs

JBJS(A) 2010

No difference:
Transfusions
Hospital stay

Re-ops
Mobility
Residence

However.
Grossly underpowered (beta error)
300-500/arm needed

Any patient eligible (age 42-99)

Used Long Nails
Outcome measures perfunctory

No X-rays
32% mortality
21% phone /proxy only

This is gold?

Surgeon controlled factor: Implant selection

IM Hip Screws
Authors Opinion
Data supports use for unstable fractures
RCTs document improved anatomy and
early function
Iatrogenic problems decreased with current
designs and technique
Indicated only for the geriatric fracture

Surgeon controlled factor: Implant selection

IM Hip Screw: Contraindications

young patients (excess bone removal)
basal neck fxs (iatrogenic displacement)
stable fractures requiring open reduction
(inefficient)

stable fractures with very narrow canals

(inefficient)

Technical
Tips

Patient Set-up
Position for nailing:
Hip Adducted
Unobstructed AP &
lateral imaging
Fracture Reduced(?)

Strong traction (without well leg countertraction) abducts

fractured hip and prevents gaining proper entrance site

Strong traction (without well leg countertraction) abducts

fractured hip and prevents gaining proper entrance site

The solution is the Scissors position

for the extremities
Both feet in txn

Fx: flexed & add

Well leg extended &
abducted
Lateral Xray: a little
different, but adequate

Guide Pin Insertion

Guide Pin Insertion

(Usually by hand)

Ostrum, JOT 05: The entrance is

at the trochanteric tip or slightly MEDIAL

Ream a channel for implant!

(dont just displace the fracture as you pass
reamer through it)

Medial directed force prevents fracture

gapping during entrance reaming

Achieve a Neck-Shaft Axis > 130

Use at least a 130 nail
Varus Corrections

Advance nail

Increase traction

ABDUCT extremity!! (adduction

only necessary
of nail insertion)

at time

Postoperative Management
Allow all patients to WBAT
Patients self regulate force on hip
No increased rate of failure
Koval, et. al,JBJS(A)98

X-rays post-op, then 6 & 12 weeks

Epilogue: intertrochs
(Questions without good answers)

Unanswered questions

Wheres the evidence??

Minimally invasive PLATE fixation ??

2 hole DHS
Bolhofner
Dipaola

PCCP
Gotfried

Which nail design is best ??

Proximal diameter?
Nail Length?
Distal interlocking?
Proximal screw ?
Sleeve or no sleeve?

Loch

& Kyle, JBJS(A)98

One or two needed ?

Nobody knows!

Proximal fixation: 1 or 2 screws?

Kubiak, JOT 04

IMHS vs Trigen in vitro (cadaveric) testing

Results:
No difference in fx sliding or collapse
No difference in rigidity or stability
Trigen with higher ultimate strength @ failure

Clinical significance??

Nobody knows!

Small Screws protect

lateral wall
Gotfried, CORR 04
Im, JOT 05

Only relevant for plate fixation?

Small Screws protect

lateral wall from fx
Gotfried, CORR 04
Im, JOT 05

Only relevant for plate fixation?

But the Z effect

7/70, 10% Werner-Tutschku, Unfall 02
5/45 11% Tyllianakis Acta Orthop Belgica 04

Long vs.short nails?

Thigh pain from short,
locked nails?
Periprosthetic fracture:
Still an issue?
Anterior cortex perforation
with long nails?
6% impinge/ 2% fx Robinson,
JBJS(A) 05

Cost/ benefit?

-Nobody knows-

Just when you think you know whats best- -

Dont forget Ex-Fix!

?
RCT n=40 Exfix +HA vs DHS
Faster ops, fewer txfusions, no comps
Moroni, et al. JBJS(A) 4/05

Ex-fix (HApins) vs DHS

Randomized/prospective trial of 40 pts.
Patients

Moroni, et al. JBJS(A) 4/05

65yo+ walking women with osteoporosis

Results
Faster operations with Fewer transfusions
Less post op pain, similar final function
No pin site infxs, no increased post op care
Increased pin torque on removal @ 12 wks
One nonunion

Conclusions:
Remember Kaufers Variables
Uncontrolled factors
Fracture Geometry
Bone Quality

Surgeon controlled factors

Quality of Reduction
Implant Placement
Implant Selection

Conclusions:
Implants have different
traits-choose wisely

Position screw

centrally and
very deep
(TAD20mm)

Conclusions:
Things change
Healing is no longer success
Deformity & function matter
Perioperative insult counts

Audience
Response
Questions!
(save 5-8 minutes
for these)

81 y.o. female slipped & fell

3 part IT fx
Discuss:
Did the surgeon do a good job?

Yes or No

Post-op X-rays

Did the surgeon do a good

job?
Yes
No

Answer before advancing.

Now, consider specifically:

A.The reduction is satisfactory
B. The TAD (screw position) is OK
C. Both are satisfactory
D. Neither are satisfactory
Choose Best Answer

6 months
3months

Post op

The TAD was

acceptable but
the reduction
was grossly
short

Did the surgeon do a good

job?
Yes
No

27yo jogger struck

by car, closed,
isolated injury

27yo jogger
struck by car

Id reduce & fix with:

A. 95 blade
B. DCS plate
C. Recon Nail
D. DHS
E. Intramedullary hip

A.The reduction is satisfactory

B. The TAD is satisfactory
C. Both are satisfactory
D. Neither are satisfactory

*
*

Progressive pain 11-14 weeks

(varus + plate is rarely good)

Id Bonegraft & revise with:

A. 95 blade
B. DCS plate
C. Recon Nail
D. DHS
E. IMHS
F Other

95 DCS + autoBG

71 yo renal txplnt pt c CHF

What to do??

If my patient, I would use:

1. Hip screw and sideplate
2. Hip screw and IM nail (TFN)
3. Reconstruction Nail (2 proximal
medullary-cephalic screws)

4. Blade Plate
5. Other

percutaneous
reduction

Uneventful Healing, WBAT

6wks

12wks

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