PEARLS & PITFALLS OF MANAGING INTERTROCHANTERIC FRACTURES WITH D.H.

DR. ZAKRIA TARIQ

PGR, ORTHOPEDICS

INTERTROCHANTERIC FRACTURES
Intertrochanteric or Pertrochanteric or Peritrochanteric Accounts for nearly 50% of all proximal femur fractures Average patient age of incidence is 66-76 yrs In females, annual incidence is 63/100,000 population per year while it is 34/100,000 in males (USA) Female to male ratio 2:1 to 8:1, likely because of postmenopausal metabolic changes in bone

Some factors found to be associated with intertrochanteric rather than femoral neck fractures
Advancing age Increased number of comorbidities Increased dependency in activities of daily living A history of other osteoporosis related (fragility) fractures

ANATOMY
Intertrochanteric fracture occurs in the region between G.T and L.T of proximal femur Occasionally extend into subtrochanteric area Extracapsular fractures Occur in cancellous bone with an abundant blood supply Nonunion and osteonecrosis are not major problems Deforming forces produce shortening, ER and varus position at the fracture.
Abductors displace GT laterally & proximally Iliopsoas displace LT medially & proximally Hip Flexors, Extensors & Adductors - pull distal fragment proximally

Fracture stability determined by presence of posteromedial bony contact, which acts as a buttress against fracture collapse

MECHNISM OF INJURY
IN YOUNGER INDIVIDUALS
Usually high energy trauma such as RTA or fall from height

IN ELDERLY
90% result from a simple fall Most fractures from a direct impact to GT area

MECHNISM OF INJURY
The tendency to fall increases with patient age and is exacerbated by several factors including
poor vision, decreased muscle power, labile blood pressure, decreased reflexes, vascular disease, and coexisting musculoskeletal pathology.

CLINICAL EVALUATION
Patients presentation vary depending upon displacement Displaced fractures are non ambulatory on presentation, with shortening and ER of lower extremity Pain is evident on attempted range of hip motion Nondisplaced fractures may go unnoticed

CLINICAL EVALUATION
Patient may experience delay before presentation at hospital Mostly are dehydrated with nutrition depletion at presentation Potential for VTE, pressure ulceration as well as hemodynamic instability Intertrochanteric fractures may be associated with as much as a full unit of hemorrhage into the thigh.

RADIOGRAPHIC EVALUATION
AP view of Pelvis
Allows comparison of involved with contralateral side Can help to identify nondisplaced fractures

Lateral view
Assess posterior communition of proximal femur

AP & Cross Table View of the involved proximal femur

Preferred over frog leg lateral as latter requires FABER of the affected leg and involves risk of fracture displacement

Physician assisted IR view of injured hip (10-15 degree)

IR offsets the anteversion of femoral neck Provides true AP view of the Proximal femur

RADIOGRAPHIC EVALUATION
MRI imaging study of choice
Delineates nondisplaced or occult fractures that are not apparent on plain radiographs Reveals fracture within 24 hours of injury

CT Scan & Bone Scan

where MRI contraindicated

BOYD AND GRIFFIN CLASSIFICATION

Type I:
A single fracture along the intertrochanteric line, stable and easily reducible.

Type II:
Major fracture line along the intertrochanteric line with comminution in the coronal plane.

Type III:
Fracture at the level of the lesser trochanter with variable comminution and extension into the subtrochanteric region (reverse obliquity).

Type IV:
Fracture extending into the proximal femoral shaft in at least two planes.

TYPE I

TYPE II

TYPE III

TYPE IV

EVANS CLASSIFICATION
Type I:

(A) Stable: - Undisplaced fractures. - Displaced but after reduction overlap of the medial cortical buttress make the fracture stable.
(B) Unstable: - Displaced and the medial cortical buttress is not restored by reduction of fracture. - Displaced and comminuted fractures in which the medial cortical buttress is not restored by reduction of the fracture. Type II: Reverse obliquity fractures.

UNDISPLACED

DISPLACED but reduced

DISPLACED not Reduced COMMUNITED

REVERSED OBLIQUITY Trochanteric fractures. (Reproduced with permission and copyright of the British Editorial Society of Bone and Joint Surgery. Ewans EM. The treatment of trochanteric fractures of the femur. J Bone Joint Surg 1949;31-B:190203.)

OTA CLASSIFICATION
31-A Femur, proximal trochanteric 31-A1 Peritrochanteric simple 31-A1.1 Along intertrochanteric line 31-A1.2 Through greater trochanter 31-A1.3 Below lesser trochanter

31-A2 31-A2.1 31-A2.2 31-A2.3 31-A3 31-A3.1 31-A3.2 31-A3.3

Peritrochanteric multifragmentary With one intermediate fragment With several intermediate fragments Extending more than 1 cm below lesser trochanter Intertrochanteric Simple oblique Simple transverse Multifragmentary

Otota CLASSIFICATION

UNUSUAL FRACTURE PATTERNS

BASICERVICAL FRACTURES
located just proximal to or along the intertrochanteric line Anatomically included in femoral neck fractures Usually extracapsular Behave and treated as intertrochanteric fractures At greater risk for AVN than the more distal intertrochanteric fractures Lack the cancellous interdigitation seen with fractures through intertrochanteric region More likely to sustain rotation of femoral head during implant

UNUSUAL FRACTURE PATTERNS

REVERSE OBLIQUITY FRACTURES
Unstable fractures. An oblique fracture line extending from medial cortex proximally to lateral cortex distally. Location and direction of fracture line results in a tendency to medial displacement from the pull of adductors. Treated as subtrochanteric fractures.

TREATMENT
NONOPERATIVE
INDICATIONS Patients who are at extreme medical risk for surgery Demented nonambulatory patients with mild hip pain Nondisplaced fractures can be considered for nonoperative because displacement changes neither operation type nor outcome Early bed to chair mobilization Avoid complications like poor pulmonary toilet, atelectasis, venous stasis, pressure sores. Resultant hip deformity is both expected and accepted in cases of displacement

TREATMENT
OPERATIVE
GOAL
Stable internal fixation to allow early mobilization and full weight bearing ambulation.

STABILITY OF FRACTURE FIXATION depends on

Bone quality Fracture pattern Fracture reduction Implant design Implant placement

TIMING OF SURGERY
Should be performed in timely fashion once the patient is medically stabilized

OPTIONS
Available options for treating intertrochanteric fractures include SLIDING HIP SCREW

INTRAMEDULLARY HIP SCREW NAIL

EXTERNAL FIXATION

PROSTHETIC REPLACEMENT

EVOLUTION OF SLIDING HIP SCREW

Fixed-Angle Nail-Plate Devices
First successful implants were fixed-angle nail-plate devices (e.g., Jewett nail, Holt nail) Consisting of a tri-flanged nail fixed to a plate at an angle of 130 to 150 degrees While these devices provided stabilization of the femoral head and neck fragment to the femoral shaft, They did not allow fracture impaction.

Sliding-nail-plate Devices
Experience with fixed-angle nail-plate devices indicated the need for a device that would allow controlled fracture impaction. This gave rise to sliding nail-plate devices (e.g., Massie nail, Ken-Pugh nail), Massie nail ,Ken-Pugh nail consisting of a nail that provided proximal fragment fixation and a side plate that allowed the nail to telescope within a barrel allowing bone on bone contact

The sliding nail-plate devices gave rise to

Sliding Hip Screw Devices

The sliding hip screw is the most widely used implant for stabilization of both stable and unstable intertrochanteric fractures. Sliding hip screw side plate angles are available in 5 degree increments from 130 to 150 degrees. The 135 degree plate is most commonly utilized
this angle is easier to insert in the desired central position of the femoral head and neck than higher angle devices and creates less of a stress riser in the subtrochanteric region.

SLIDING HIP SCREW

The most important technical aspect of screw insertion are
Placement within 1 cm of subchondral bone to provide secure fixation Central position in the femoral head (Tip Apex Distance)

TIP-APEX DISTANCE
This can be used to determine lag screw position within femoral head. This measurement, expressed in millimeters, is the sum of distance from the tip of lag screw to the apex of femoral head on both AP and lateral radiographic views (after controlling for radiographic magnification). The sum should be <25mm to minimize the risk of lag screw cutout.

SURGICAL PEARLS FOR INSERTION OF A SLIDING HIP SCREW

Ascertain that there is no impingement of the labia or scrotum from the fracture table Assess the fracture reduction before prepping the patient and ensure that non-obstructive biplanar radiographic visualization of the entire proximal femur, including the hip joint, is obtainable Check for residual varus angulation, posterior sag, or malrotation prior to starting the procedure Use a 135 degree angle guide to insert the guide pin Position the guide pin in the center of the femoral head and neck on both the AP and lateral planes within 1 cm of the subchondral bone

SURGICAL PEARLS FOR INSERTION OF A SLIDING HIP SCREW

Ream the femoral neck and head under image intensification to detect guide pin advancement Tap the entire screw path to prevent femoral head rotation during lag screw insertion Confirm a minimum of 20 mm available for lag screw/barrel slide Impact the fracture before insertion of the plate holding screws Use a compression screw if the lag screw cannot be visualized within the plate barrel

PITFALLS WITH USE OF A SLIDING HIP SCREW

Misinterpretation of the fracture pattern.
This pitfall can be avoided by obtaining both AP and crosstable lateral x-rays when evaluating proximal femur fractures. If these x-rays do not clarify the nature of the fracture pattern, an x-ray taken with the extremity internally rotated should be taken.

Use a sliding screw for the reverse obliquity type pattern. Place the lag screw away from the center-center position and farther than 1 cm from the subchondral bone. Bending the guide pin during reaming. Bending the guide pin within the reamer resulting in intraarticular or intra-pelvic penetration.

PITFALLS WITH USE OF A SLIDING HIP SCREW

Loss of reduction during lag screw insertion.
During reaming or lag screw insertion, rotation of the proximal fragment with loss of fracture reduction can occur. To prevent rotation of the proximal fragment, the authors routinely tap the femoral head and neck prior to lag screw insertion.

Improper lag screw-plate barrel relationship.

When a sliding hip screw loses its capacity to slide, it behaves as a fixed-angle device and is at risk for multiple complications.

Disengagement of the lag screw from the barrel.

This uncommon complication results from inadequate lag screw-plate barrel engagement secondary to use of either a short lag screw or short barrel side plate.

VARIATIONS ON THE SLIDING HIP SCREW DESIGN

NAME
Conventional Sliding Hip screw (SHS)

CHARACTERISTICS
Lag screw and side plate

ADVANTAGES
1. Controlled fracture collapse 2. Well established device 3. Cost effective

DISADVANTAGES
1. Limb shortening 2. Fracture deformity

Variable Angle Sliding Hip Screw (VHS)

Angular adjustment of 1. Reduced inventory Beefed up proximal side plate barrel 2. Allows free hand width of plate guide pin insertion 3. Allow fracture adjustment one implant inserted

Talon compression Hip Prongs protrude from screw lag screw

Increased purchase in femoral head

Difficulty with hardware removal

NAME
Trochanteric stabilizing plates

CHARACTERISTICS
Plate attaches to conventional 4-hole side plate to buttress the GT

ADVANTAGES
1. Limits the amount of fracture collapse 2. Allows screw fixation of GT

DISADVANTAGES
1. Compromise fracture union 2. Trochanteric bursitis 3. Requires additional exposure 4. expensive

Medoff plate

Biaxial loading plate

1. Limits the amount of facture collapse 2. Expands use of SHS to S/T and Reverse obliquity fractures

1. Expensive 2. Learning curve 3. Only available in 135 degree angle

Percutaneous compression plate (PCCP)

1. Two smaller diameter lag screw 2. Designed for percutaneous insertion

1. Less exposure 2. Less blood loss 3. Limited fracture collapse 4. Better rotational control of femoral head

1. Expensive 2. Learning curve 3. Only available in 135 degree angle

Talon compression hip screw

Trochanteric Stabilizing Plates

Percutaneous Compression Plate

Medoff plate Biaxial Sliding Hip Screw

INTRAMEDULLARY HIP SCREW NAIL

Combines features of sliding hip screw and intramedullary nail Indicated in unstable fractures intertrochanteric fracture with subtrochanteric extension reverse obliquity fractures

Advantages
Theoretically, these implants can be inserted in a closed manner with limited fracture exposure, decreased blood loss, less tissue damage than sliding hip screw. Subjected to a lower bending movements than sliding hip screw owing to their intramedullary location. Limits the amount of fracture collapse, compared with sliding hip screw. No clinical advantage of intramedullary hip screw compared with sliding hip screw in stable fracture pattern.

EXTERNAL FIXATION
Not commonly considered for treatment of intertrochanteric fractures Early experiences with external fixator for intertrochanteric fractures associated with pin loosening, infection and varus collapse. Indicated in patients at unacceptably high risk for complication related to general or regional anesthesia One or two half pins placed into femoral neck within 10 mm of subchondral bone. Two or three half pins placed in proximal femur. Satisfactory healing rates 95-100% Advantages
Shorter operative time, minimal blood loss and application with local anesthetic with adjuvant analgesia

Duration of external fixation averages 90 days Complications

Malalignment in varus - 12% Pin tract complication 7% to 44 % Progression to osteomyelitis - rare

PROSTHETIC REPLACEMENT
INDICATIONS
Elderly, debilitated patient with a communited, unstable intertrochanteric fracture in severely osteoporotic bone Unsuitable candidates for repeated Internal Fixation

Disadvantages
Greater implant cost More extensive procedure than ORIF Greater blood loss Longer surgical and anesthetic time Potential for more frequent complications Hip dislocation (3% Hemiarthoplasty; 45% THR) Pressure sores Pulmonary infections, atelectasis Periprosthetic fracture Femoral nonunion

Complications

IMPLANT CHOICE FOR INTERTROCHANTERIC FRACTURE STABILIZATION (ROCKWOOD)

STABLE FRACTURE PATTERN
Sliding hip screw with a two hole side plate

UNSTABLE FRACTURE PATTERN

Intramedullary-type hip screw

BASICERVICAL FRACTURE
Sliding hip screw with two hole side plate and anti-rotation screw

REVERSE OBLIQUITY AND INTERTROCHANTERIC FRACTURE WITH SUBTROCHNATERIC EXTENSION

Intramedullary-type hip screw

POSTOPERATIVE CARE
Mobilization of hip fracture patients out of bed and ambulation training should be initiated on post-op day 1 Allow weight bearing as tolerated Often difficult for elderly patients with decreased upper extremity strength to comply with partial weight bearing protocol Restricted WB after hip fracture has little biomechanical justification Moving around in bed and use of bedpan generates force across the hip Foot and ankle ROM exercises produce substantial load on femoral head secondary to muscle contraction Ecker et al., Unrestricted WB does not increase complication rates following fixation of intertrochanteric fractures
62 cases with #P/T treated with DHS early WB-22, non WB for 6 weeks-33, no ambulation-7. Follow up 15 months 3 required revision surgery secondary to nonunion, all three occurred in unstable fractures No effect of WB on need for revision surgery.

COMPLICATIONS
LOSS OF FIXATION NONUNION MALROTATION DEFORMITY OTHER Complications

LOSS OF FIXATION
Commonly result from varus collapse of proximal fragment with cutout of lag screw from the femoral head Incidence - 20% in unstable fractures Lag screw cutout from femoral head occurs within 3 months of surgery Causes of lag screw cutout
Eccentric placement of lag screw within femoral head - most common Improper reaming second channel created Inability to attain a stable reduction Excessive fracture collapse such that sliding capacity of device is exceeded. Inadequate screw-barrel engagement, which prevents sliding Severe osteopenia, which precludes secure fixation.

Management
Acceptance of deformity Revision ORIF with bone cement Conversion to prosthetic replacement

NONUNION
Rare as fracture occurs through well vascularized bone <2% patients Especially in unstable fractures (loss of posteromedial support) Suspected in
Patient with persistent hip pain Radiographs reveal a persistent radiolucency at fracture site 4-7 months after fracture fixation. Progressive loss of alignment strongly suggests nonunion

Presence of occult infection must be considered and excluded Management

With adequate bone stock, repeat internal fixation combined with valgus osteotomy and bone grafting. Calcar replacement prosthesis preferred in most elderly patients

MALROTATION DEFORMITY
Results from Internal Rotation of distal fragment at the time of internal fixation. In unstable fractures, distal and proximal fragments may move independently
Place distal fragment in neutral to slight external rotation during fixation of plate to the shaft

When severe and interferes with ambulation, revision surgery with plate removal and rotational osteotomy of femoral shaft is done.

OTHER COMPLICATIONS
With full length IM nails, impingement or perforation of distal aspect of nail on the anterior femoral cortex can occur, secondary to a mismatch of nail curvature and femoral bow. Z-effect - most common with dual screw CMTN
proximal screw penetrating hip joint distal screw backing out of femoral head

Osteonecrosis
Rare No association between location of implant within femoral head and development of ON

Side plate separation and lag screw migration into pelvis

Use compression screw if inadequate screw-barrel engagement

OTHER COMPLICATIONS
Traumatic laceration of superficial femoral artery by a displaced LT fragment Binding of guide pin within reamer intra-articular or intra
pelvic penetration

Periprosthetic fractures
first generation short trochanteric gamma nails Due to large distal diameter , large proximal bend and large distal screws

Nail breakage
either short or long trochanteric nails Typically occur at lag screw site area of maximal stress and thinnest metal

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