Chapter 50: Intertrochanteric Fractures of the Hip

Thomas A. Russell

Chapter Outline

Introduction to Intertrochanteric Fractures of the Hip

Pertrochanteric fractures involve those occurring in the region extending from the extracapsular basilar neck region to the region along the lesser trochanter proximal to the development of the medullary canal. Intertrochanteric and peritrochanteric are generic terms for pertrochanteric fractures. Injury creates a spectrum of fractures in this proximal metaphyseal region of bone, with damage to the intersecting cancellous compression and tensile lamellar networks and the weak cortical bone. This results in displacement of the fracture fragments and attached muscle groups. These structures are subject to multiplanar stresses after surgical repair. This region of the femur shares many common biomechanical properties with other metaphyseal–diaphyseal fractures with regard to the difficulty in obtaining stable fixation. Though predominately associated with low-energy older age patients, high-energy trauma in young patients can result in similar patterns of fracture. 
Pertrochanteric femoral fractures are of intense interest globally. They are the most frequently operated fracture type, have the highest postoperative fatality rate of surgically treated fractures, and have become a serious health resource issue due to the high cost of care required after injury. The reason for the high cost of care is primarily related to the poor recovery of functional independence after conventional fracture care in many patients. Interestingly there has been no significant improvement in mortality or functional recovery over the past 50 years of surgical treatment. Paradoxically, the last 50 years of acquiescence to the status quo of hip fracture treatment are related to false assumptions that have been a hindrance to improvement in the management of the hip fracture patient: (1) Uncontrolled shortening and varus collapse are acceptable in hip fractures, but not other fractures; (2) reduction does not matter with sliding screw systems as the fracture will “collapse to stability” since rotation is not a problem and that placement of the head fixation takes precedence over fracture reduction; (3) union without implant failure overrides the requirement of a stable anatomic reduction to the detriment of optimal functional recovery; and (4) the orthopedic surgeon just fixes the fracture as opposed to treating the total musculoskeletal needs of the patient. The reasons for these assumptions relate directly to the historical evolution of hip fracture treatment and the arguments that shaped our current understanding. A new paradigm regarding hip fracture care and treatment is currently in evolution, which hopefully will advance our treatment goal back to optimal functional recovery and prevention of future hip fractures.192 
Gullberg et al. in 1997 estimated the future incidence of hip fracture worldwide would double to 2.6 million by the year 2025, and 4.5 million by the year 2050. The percentage increase will be greater in men (310%) than in women (240%). In 1990, 26% of all hip fractures occurred in Asia, whereas this figure could rise to 37% in 2025 and to 45% in 2050.153 Hagino et al.89 reported a lifetime risk of hip fracture for individuals at 50 years of age as 5.6% for men and 20% for women. Since 1986, in the Tottori Prefecture, Japan, the acceleration of hip fracture incidence continues for both genders. 
There is some evidence that hip fracture risk has begun to decline in certain areas of the world but the reason is unknown. In Denmark, the incidence of hip fractures has declined about 20% from 1997 to 2006; however, this decline cannot be explained by antiosteoporotic medications whose effect should only be an approximate reduction in men of 1.3% and a 3.7% reduction in women.2 Epidemiologic studies among Olmsted County, Minnesota residents in 1980 to 2006 revealed that the incidence of a first-ever hip fracture declined by 1.37% per year for women and 0.06% per year for men; the cumulative incidence of a second hip fracture within 10 years was 11% in women and 6% in men.153 
Brown et al. in an analysis of future US projections suggests two possible trends in frequency yielding a conservative estimate of 458,000 fractures by 2050 and a high estimate of 1,037,000. The largest number of fractures will occur in females older than 65.35 In the Hip Fracture Database Report in 2012 of over 59,000 cases from 180 hospitals in England, Wales, Northern Ireland, and the Channel Islands from 2011 to 2012, extremely detailed demographic data was obtained. Interestingly, pertrochanteric fractures make up 34% of all hip fractures. The ability to review stratified data on items such as a diverse population mix, ASA grading, and implant usage make these reports required reading when one considers the research that is required for the future.52 It is also painfully clear that the United States must follow the lead of other nations to establish a National Hip Registry. 
The focus of surgical research regarding internal fixation in the late 20th century was to minimize implant failure and cutout of the femoral head and neck fixation components, with the complicit acceptance of loss of reduction of the fracture. Functional recovery was not considered to be related to fracture malunion. Since many of these fractures are associated with osteoporosis, the current paradigm shift regarding hip fracture care relates to three main strategies: (1) prevention by aggressive screening and treatment of patients at high risk for fragility fracture; (2) standardization of hip fracture centers with aggressive early intervention and protocols to avoid complications; and (3) optimization of the fracture reduction and new implant component fixation in osteoporotic bone with conceptual design changes in fixation stability and augmentation of the bone–implant interface. 

Assessment of Pertrochanteric Fractures of the Hip

Injury Mechanisms for Pertrochanteric Fractures of the Hip

Low-energy falls from a standing height account for approximately 90% of community hip fractures in patients over 50 years of age with a higher proportion of females. Higher-energy hip fractures are relatively rare, more common in males under 40 years of age, and usually referred to regional trauma centers for treatment.110 Cummings and Nevitt51 noted that neither age-related osteoporosis nor the increasing incidence of falls with age sufficiently explains the exponential increase in the incidence of hip fracture with aging. Their hypothesis was that four conditions correlated for a fall to cause a hip fracture: (a) The faller must be oriented to impact near the hip; (b) protective responses must fail; (c) local soft tissues must absorb less energy than necessary to prevent fracture, and (d) the residual energy of the fall applied to the proximal femur must exceed its strength. This concept applies primarily to strategies to prevent hip fractures. Falls with a rotational component are more common with extracapsular hip fractures.108 

Associated Injuries with Pertrochanteric Hip Fractures

In low-energy falls resulting in hip fractures, associated injuries are most commonly fractures of the distal radius or proximal humerus, and minor head injuries. High-energy hip fractures are more commonly associated with ipsilateral extremity trauma, head injury, and pelvic fractures. Associated injuries or premorbid diseases may coexist with the fracture diagnosis. Syncopal episodes resulting in a fall may bring attention to cardiovasular and neurologic disease states. Primary neoplastic and metastatic diseases may reveal their presence with preceding hip discomfort and subsequent fall resulting in fracture. 

Signs and Symptoms of Pertrochanteric Fractures of the Hip

Patients most commonly present with a history of pain and inability to ambulate after a fall or other injury. The pain is localized to the proximal thigh and is exacerbated by passive or active attempts of hip flexion or rotation. Drug use, either illicit or prescribed pharmacologic as a confounding and contributing factor must be sought out. Nursing home and institutionalized patients must be examined for the potential of neglect and abuse in the form of previous fractures, injuries in differing states of repair, and decubiti. 
The physical findings of a displaced hip fracture are shortening and external rotation of the extremity. Pain with motion or crepitance testing is not performed unless there are no physical signs of deformity, and radiographic studies are negative for an obvious fracture. Pain with axial load on the hip has a high correlation with occult fracture. The auscultation Lippmann test is quite sensitive for the detection of occult fractures of the proximal femur or pelvis.142 By placement of a stethoscope bell on symphysis pubis and tapping on the patella of both extremities, variations in sound conduction through the pelvis and hip from the patella result when there is any discontinuity. A decreased tone or pitch implies fracture within this arc of bone. 

Imaging and Other Diagnostic Studies for Pertrochanteric Hip Fractures

Plain radiographs including an AP pelvis and AP cross-table lateral of the affected hip are usually recommended for diagnosis and preoperative planning. Subtrochanteric extension or the possibility of a pathologic fracture requires full length femoral AP and lateral radiographs for implant length selection. If a long nail implant is a consideration, then AP and lateral radiographs of the affected femur to the knee are required with special attention to femoral bow and medullary canal diameter. Traction views with internal rotation may be of benefit preoperatively as an aid in the selection of definitive internal fixation.126 
CT or MRI scans are rarely required for displaced fractures but may be useful in establishing the diagnosis in undisplaced fractures and atypical fractures in high-energy trauma patients.188 The MRI does not necessarily require a full study as the frontal (T1 and T2) images are most often diagnostic. However, complete studies will usually detect other diagnosis for hip pain in addition to occult fractures of the proximal femur. MRI is preferred over CT or older radionuclide scans due to a higher sensitivity and specificity and a more rapid decision process.16,73,109,144 
The best radiographic analysis of the hip fracture occurs in the operative suite with fluoroscopic C-arm views. This technology gives the surgeon an excellent modality for fracture analysis in complex fractures and immediate feedback as to the stability of the fracture after the initial reduction. In many institutions this has led to elimination of preoperative lateral radiographs. Unfortunately, this practice may also result in a change in the selected type of fixation with inherent stress on the operative team and resource management. In general, it is beneficial to obtain a good quality lateral radiograph of the hip prior to operation. 
Laboratory studies for low-energy osteopenic fractures (in addition to the standard investigations for surgery), should include serum calcium, phosphate, and alkaline phosphatase; a complete blood count (CBC); 25-hydroxy vitamin D, thyroid-stimulating hormone (TSH); parathyroid hormone (PTH intact); serum protein electrophoresis (SPEP); and kidney function tests, including blood urea nitrogen (BUN), creatinine, and glomerular filtration rate (GFR).54,218 
A search for high-risk potentially preventable complications include previous deep vein thrombosis/pulmonary embolism (DVT/PE), anticoagulation medications, immune deficiency disorders, malabsorption disease, angina or CVA prodromal symptoms of atherosclerotic disease, aortic stenosis, and active infection (pulmonary or genitourinary) which might result in sepsis postoperatively. Protein–calorie malnutrition and vitamin D deficiency are now recognized as serious risk factors for increased mortality and slower recovery. Foster et al.71 reported a 70% mortality for patients with a serum albumin <3 compared to a mortality rate of 18% in patients with an albumin level ≥3. Vitamin D deficiency is now viewed as an epidemic due to dietary changes and lack of sunlight exposure; current recommendations are to administer 50,000 IU of vitamin D immediately to all elderly patients on admission with hip fracture. 

Classification of Pertrochanteric Hip Fractures

Classifications for extracapsular fractures of the hip occurring from the basicervical to the level of the subtrochanteric regions have not been particularly helpful in clinical situations. However, increased surgical complexity and recovery is associated with unstable fracture patterns. Unstable characteristics include posteromedial fragmentation, basicervical patterns, reverse obliquity patterns, displaced greater trochanteric (lateral wall) fractures, and failure to reduce the fracture prior to internal fixation. Stability after surgical treatment connotes anticipated union without deformity or implant failure. Unfortunately, sliding implant systems may result in significant deformity. The current controversy of implant selection is largely focused on what amount of deformity and fracture site motion is still compatible with a complete functional recovery. Since original reports of surgical repair for pertrochanteric fractures, the literature has revealed certain fracture patterns which are not amenable to simple screw/nail side plate devices, such as subtrochanteric fractures, reverse obliquity fractures, and fractures with lateral wall fracture extension. 
There is no single classification system that has achieved reliable reproducible validity. In 1822, Astley Cooper49 (London) described the first (preradiographic) classification of hip fractures: Intracapsular or extracapsular fractures with the main complication of nonunion and avascular necrosis in the first and malunion with coxa vara in the second. 
In 1949, Boyd and Griffin described the first treatment recommendation classification, predictive of the difficulty of achieving, securing, and maintaining the reduction in four fracture types: 
  1.  
    Stable (two-part)
  2.  
    Unstable with posteromedial comminution
  3.  
    Subtrochanteric extension with lateral shaft extension of the fracture distally at or just below the lesser trochanter (termed “reverse obliquity” by Wright234)
  4.  
    Subtrochanteric with intertrochanteric extension with the fracture lying in at least 2 planes (Fig. 50-1).31  
    Figure 50-1
    Boyd and Griffin classification.
     
    Type 1, stable (two-part); Type 2, unstable comminuted; Type 3, unstable reverse obliquity; Type 4, intertrochanteric–subtrochanteric with two planes of fracture.
    Type 1, stable (two-part); Type 2, unstable comminuted; Type 3, unstable reverse obliquity; Type 4, intertrochanteric–subtrochanteric with two planes of fracture.
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    Figure 50-1
    Boyd and Griffin classification.
    Type 1, stable (two-part); Type 2, unstable comminuted; Type 3, unstable reverse obliquity; Type 4, intertrochanteric–subtrochanteric with two planes of fracture.
    Type 1, stable (two-part); Type 2, unstable comminuted; Type 3, unstable reverse obliquity; Type 4, intertrochanteric–subtrochanteric with two planes of fracture.
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They were the first to report the use of lateral buttress plating of the greater trochanter to avoid medialization of the shaft in type 3 fractures, and the need for two-plane fixation for type 4 subtrochanteric fractures with a coronal fracture line. In addition, they discussed the possibility of iatrogenic conversion of type 1 and 2 fractures to type 3 during implant preparation and insertion. 
Also in 1949, Evans63 (Birmingham, England) reported on a posttreatment classification with five types described. He compared nonoperative treatment and fixed-angle device surgical treatment. He documented that 72% of his fractures could be fixed in a stable configuration. In 28% of the fractures stability was not achieved; 14% as a result of the fracture pattern or comminution and 14% of which he felt the reduction was never achieved (Fig. 50-2). This article was primarily used to argue for the value of internal fixation over nonoperative treatment of hip fractures, a controversial topic in England in the 1940 to 1950. 
Figure 50-2
Evans classification of trochanteric fractures.
 
Type 1, stable: Either undisplaced or displaced but anatomically reduced (intact medial cortex). Type 2, unstable: Implies displaced and fixed in an unreduced position, comminuted with destruction of the anteromedial cortex, or reverse obliquity.
Type 1, stable: Either undisplaced or displaced but anatomically reduced (intact medial cortex). Type 2, unstable: Implies displaced and fixed in an unreduced position, comminuted with destruction of the anteromedial cortex, or reverse obliquity.
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Figure 50-2
Evans classification of trochanteric fractures.
Type 1, stable: Either undisplaced or displaced but anatomically reduced (intact medial cortex). Type 2, unstable: Implies displaced and fixed in an unreduced position, comminuted with destruction of the anteromedial cortex, or reverse obliquity.
Type 1, stable: Either undisplaced or displaced but anatomically reduced (intact medial cortex). Type 2, unstable: Implies displaced and fixed in an unreduced position, comminuted with destruction of the anteromedial cortex, or reverse obliquity.
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In 1979 to 1980, Kyle et al.133 and Jensen,114 both reported independently on a revision of the Evans classification incorporating the lateral radiographic view indicating the extent of the posteromedial fracture component and its relation to stability with sliding fixation systems. Kyle et al. showed an increased rate of deformity and collapse with increasing instability classification. Jensen et al. related the ability to reduce the fracture and secondary displacement risk with the use of a sliding hip screw (SHS)-type device in their classification system. The AO/OTA classification is the most referenced in recent scientific articles and is a derivative of the Muller classification (Fig. 50-3).44 The AO/OTA has nine main “types,” however correlation is best with only level 3 designation: 31A1, 31A2, and 31A3 categories; also there is no lateral radiographic parameter with the AO/OTA classification. Generally, the 31A1 fracture is the most stable, 31A2 more unstable, and the 31A3 the most unstable with SHS fixation. Unfortunately, the 4th and 5th subgroups of the classification have not been found to be reliably reproducible in prospective evaluation. There is a higher interobserver agreement with the AO/OTA classification than Evans/Jensen but neither have met the acceptable threshold for reliability.74,197 
Figure 50-3
In the OTA alphanumeric fracture classification, intertrochanteric hip fractures comprise type 31A.
 
These fractures are divided into three groups, and each group is further divided into subgroups based on obliquity of the fracture line and degree of comminution. Group 1 fractures are simple (two-part) fractures, with the typical oblique fracture line extending from the greater trochanter to the medial cortex. The lateral cortex of the greater trochanter remains intact. Group 2 fractures are comminuted with a posteromedial fragment. The lateral cortex of the greater trochanter, however, remains intact. Fractures in this group are generally unstable, depending on the size of the medial fragment. Group 3 fractures are those in which the fracture line extends across both the medial and lateral cortices. This group includes the reverse obliquity pattern.
These fractures are divided into three groups, and each group is further divided into subgroups based on obliquity of the fracture line and degree of comminution. Group 1 fractures are simple (two-part) fractures, with the typical oblique fracture line extending from the greater trochanter to the medial cortex. The lateral cortex of the greater trochanter remains intact. Group 2 fractures are comminuted with a posteromedial fragment. The lateral cortex of the greater trochanter, however, remains intact. Fractures in this group are generally unstable, depending on the size of the medial fragment. Group 3 fractures are those in which the fracture line extends across both the medial and lateral cortices. This group includes the reverse obliquity pattern.
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Figure 50-3
In the OTA alphanumeric fracture classification, intertrochanteric hip fractures comprise type 31A.
These fractures are divided into three groups, and each group is further divided into subgroups based on obliquity of the fracture line and degree of comminution. Group 1 fractures are simple (two-part) fractures, with the typical oblique fracture line extending from the greater trochanter to the medial cortex. The lateral cortex of the greater trochanter remains intact. Group 2 fractures are comminuted with a posteromedial fragment. The lateral cortex of the greater trochanter, however, remains intact. Fractures in this group are generally unstable, depending on the size of the medial fragment. Group 3 fractures are those in which the fracture line extends across both the medial and lateral cortices. This group includes the reverse obliquity pattern.
These fractures are divided into three groups, and each group is further divided into subgroups based on obliquity of the fracture line and degree of comminution. Group 1 fractures are simple (two-part) fractures, with the typical oblique fracture line extending from the greater trochanter to the medial cortex. The lateral cortex of the greater trochanter remains intact. Group 2 fractures are comminuted with a posteromedial fragment. The lateral cortex of the greater trochanter, however, remains intact. Fractures in this group are generally unstable, depending on the size of the medial fragment. Group 3 fractures are those in which the fracture line extends across both the medial and lateral cortices. This group includes the reverse obliquity pattern.
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Gotfried and Kulkarni et al.130 have developed a treatment-based classification derived from a modification of the Evans and Jensen classification primarily to focus on the stability of the lateral wall as a buttress to minimize medialization and uncontrolled collapse after SHS fixation. Kyle has recently added another very unstable pattern to his previous classification. In this variant, the fracture line includes a separate femoral neck fracture and it was concluded that this variant should not be treated with an SHS device.132 
There remains no validated classification system to dictate the surgical procedure of choice. Interestingly, Evans and Jensen reached this same conclusion years ago when they advocated classification after fracture treatment. The logical solution would be to make an implant selection after reduction of the fracture and provisional stabilization; however, this is difficult logistically for most institutions and surgeons. The next evolution may be a two-phase classification system where fracture implant selection is based on pre- and intraoperative findings and prognostic classifications are based on the evaluation of the success of obtaining fracture reduction and definitive stabilization without loss of fixation and subsequent deformity. 

Outcome Measures for Pertrochanteric Hip Fractures

Outcomes data research has received enthusiastic support, especially with insurance carriers and government health services selecting the best treatments with the best value and avoiding high risk or ineffective treatment strategies. The problem has been the development of validated outcome instruments which actually contribute to treatment and prognosis. Many hip fracture outcome tools have been borrowed from general health assessments and hip arthroplasty systems, such as the SF-36 and Harris Hip Score. More focused tools have included the timed up and go (TUG) instrument which predicts the patient’s ability for postdischarge independence and residential planning. 
Twenty-four different instruments measuring body function, thirteen instruments evaluating activity and participation, and eight composite scores were identified in a recent meta-analysis by Hoang-Kim et al.103 They concluded that an instrument with low respondent burden and minimal examiner burden demonstrated better potential for being applicable in randomized trials of elderly hip fracture patients presenting with comorbidities. Bryant et al.39 provides an excellent review of the controversy and critical aspects of the different outcome measures (Table 50-1). A parameter which has not received adequate attention is the patient’s level of pain and its duration after surgical treatment which may be related to the fracture stability obtained. This parameter may be included in newer outcome study planning. 
Table 50-1
Evaluation of Outcomes for Patients with Hip Fracture: Common Outcome Measures that have Good Measurement Properties
Body Structure Function (Impairment) Limitations to Activities (Disability) Limitations to Participation (Handicap)
Radiographic parameters(e.g., union) Performance based Reintegration to normal living index (RNL)96
Pain (e.g., numerical pain rating scale [NPRS], visual analog scale [VAS]) Timed up and go (TUG)97 Region-specific HRQOL
Range of motion Walk test (2-, 6-, 12-minute, self-paced, shuttle)98102
Strength a WOMAC3640
Balance (Berg balance scale103106 or ABC scale107,108) Disease specific
Gait pattern Functional recovery score41,42
Bone mineral density (e.g., DEXA) Hip specific Generic HRQOL
Beck depression scale120,121 Oxford hip score112118 SF-36, SF-126,8,109111
AAOS hip and knee score122 Euro-QOL(EQ-5D)15,16,119
Harris hip score46,47,49,123,124 (physician rated) Sickness impact profile1722
Nottingham health profile1722
Lower-extremity specific Utilities
Lower-extremity functional scale (LEFS)125 Feeling thermometer8590
Lower extremity measure (LEM)126 Health utilities index (HUI mark 3)91,93,127
Standard gamble27
Musculoskeletal specific Time trade-off68
Musculoskeletal function assessment (MFA)128,129
Generic
Functional index measure (FIM)29,8184
Barthel index35
OARSb-ADI.130132
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Pathoanatomy and Applied Anatomy Relating to Pertrochanteric Hip Fractures

The pertrochanteric region of anatomy is quite variable in its combination of cortical and cancellous bone. The well-vascularized pertrochanteric region is dependent on the structural integrity of a laminated cancellous bone arcade from the femoral head and epiphyseal scar, around Ward’s triangle to the lesser trochanter where the solid nature of the structure changes to a tubular construct with the origin of the femoral medullary canal. The strong plate of bone posteriorly is named the calcar femorale in the English literature, but was first described as Adams Arch after Robert Adams in the mid-1800s from anatomical studies (Fig. 50-4A, B).57,77,11 This is the region most affected with posteromedial fracture comminution leaving only the anteromedial cortex potentially stable for repair. 
Figure 50-4
 
A: Calcar femorale or Adam’s arch posteromedial calcar shelf which is usually damaged with unstable fracture patterns. B: Ward’s triangle cross-section proximal femur best quality femoral bone within 10–30 mm of subarticular surface of the head. Note tensile trabeculae pattern between Ward’s triangle and Greater trochanter. C: Changes in morphology of bone with age, Note expansion of geometry and thinning of cortical bone with aging.
A: Calcar femorale or Adam’s arch posteromedial calcar shelf which is usually damaged with unstable fracture patterns. B: Ward’s triangle cross-section proximal femur best quality femoral bone within 10–30 mm of subarticular surface of the head. Note tensile trabeculae pattern between Ward’s triangle and Greater trochanter. C: Changes in morphology of bone with age, Note expansion of geometry and thinning of cortical bone with aging.
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Figure 50-4
A: Calcar femorale or Adam’s arch posteromedial calcar shelf which is usually damaged with unstable fracture patterns. B: Ward’s triangle cross-section proximal femur best quality femoral bone within 10–30 mm of subarticular surface of the head. Note tensile trabeculae pattern between Ward’s triangle and Greater trochanter. C: Changes in morphology of bone with age, Note expansion of geometry and thinning of cortical bone with aging.
A: Calcar femorale or Adam’s arch posteromedial calcar shelf which is usually damaged with unstable fracture patterns. B: Ward’s triangle cross-section proximal femur best quality femoral bone within 10–30 mm of subarticular surface of the head. Note tensile trabeculae pattern between Ward’s triangle and Greater trochanter. C: Changes in morphology of bone with age, Note expansion of geometry and thinning of cortical bone with aging.
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The main structural attachments to the proximal femur include the hip capsule and the musculotendinous junctions of the gluteus medius and minimus (greater trochanter), iliopsoas (lesser trochanter), piriformis and short external rotators (posterior trochanteric region from the greater trochanteric region to the lesser trochanter), the oblique head of the rectus femoris (anterior capsule), and the vastus lateralis (lateral femur distal to the greater trochanter). The hip capsule is especially important in reduction of pertrochanteric fractures and this continuity with the distal fragment is the soft tissue attachment on which a stable reduction is possible (Fig. 50-5A, B). 
Figure 50-5
 
A: Anterior hip capsule. Y-Ligament of Bigelow is structure critical for ligamentotaxis in closed reduction of stable fractures. B: Posterior hip capsule. Note more proximal position of capsule posteriorly and course of arteries to head.
A: Anterior hip capsule. Y-Ligament of Bigelow is structure critical for ligamentotaxis in closed reduction of stable fractures. B: Posterior hip capsule. Note more proximal position of capsule posteriorly and course of arteries to head.
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Figure 50-5
A: Anterior hip capsule. Y-Ligament of Bigelow is structure critical for ligamentotaxis in closed reduction of stable fractures. B: Posterior hip capsule. Note more proximal position of capsule posteriorly and course of arteries to head.
A: Anterior hip capsule. Y-Ligament of Bigelow is structure critical for ligamentotaxis in closed reduction of stable fractures. B: Posterior hip capsule. Note more proximal position of capsule posteriorly and course of arteries to head.
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With capsular disruption, the displacement of the fracture fragments is dependent on the musculotendinous attachment to the respective fragments. The greater trochanter is abducted and externally rotated by the gluteus medius and short external rotators, and the shaft is displaced posteriorly and medially by the adductors and hamstrings. This accounts for the usual shortening and coxa vara deformity of displaced fractures. With aging, the morphology of the hip changes with thinning of the cortex and expansion of the diameter of the bone (Fig. 50-4C). Younger hip fracture patients will have a relatively narrow metaphysis, a high narrow isthmus, and a very thick cortex in the diaphysis. Further aging results in slight widening and thinning of the cortex of the metaphysis with bone loss, decreased thickness of the diaphyseal cortical bone stock, and a widening of the isthmus. In the advanced age group, there is a very wide vacuous metaphysis proximally with loss of tension and compression trabeculae, loss of the constriction of the isthmus, and a very round expanded tubular shaped femur with a thin cortex. Three types of morphologic anatomy of the proximal femur were described by Dorr et al. in 1983 for the selection of cemented or noncemented femoral arthroplasty components (Fig. 50-6).57 The same rationale applies to implant selection for hip fracture patients. Type A femurs occur primarily in young patients and have a narrow metaphysis, thick cortex, and a high constricting isthmus. Excessive bone removal would be required for intramedullary devices and either a plate-type construct or a smaller diameter reconstruction nail are more bone conserving. Type B femurs have a wider metaphysis and a larger medullary canal but relatively good cortex and isthmus constriction. The type C femur is the most problematic in geriatric populations with hip fractures: A wide metaphysis, wide medullary canal, and loss of the isthmus constriction in association with loss of cortical diaphyseal bone stock. 
Figure 50-6
Dorr classification of morphology of femur.
 
Type A corresponds to a small metaphysis, thick cortex, and high narrowed isthmus. Type B corresponds to a wider metaphysis, thinner cortex, and a tapering but wider isthmus. Type C corresponds to a wide metaphysis, thin cortex, and a straight or varus curvature in the diaphysis with loss of isthmus constriction.
Type A corresponds to a small metaphysis, thick cortex, and high narrowed isthmus. Type B corresponds to a wider metaphysis, thinner cortex, and a tapering but wider isthmus. Type C corresponds to a wide metaphysis, thin cortex, and a straight or varus curvature in the diaphysis with loss of isthmus constriction.
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Figure 50-6
Dorr classification of morphology of femur.
Type A corresponds to a small metaphysis, thick cortex, and high narrowed isthmus. Type B corresponds to a wider metaphysis, thinner cortex, and a tapering but wider isthmus. Type C corresponds to a wide metaphysis, thin cortex, and a straight or varus curvature in the diaphysis with loss of isthmus constriction.
Type A corresponds to a small metaphysis, thick cortex, and high narrowed isthmus. Type B corresponds to a wider metaphysis, thinner cortex, and a tapering but wider isthmus. Type C corresponds to a wide metaphysis, thin cortex, and a straight or varus curvature in the diaphysis with loss of isthmus constriction.
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The neurologic structures of interest are the femoral nerve anteriorly and the sciatic nerve posteriorly. However they are rarely encountered in surgical approaches for repair of pertrochanteric fractures and are injured only rarely, typically from damage by displaced fracture fragments. Vascular injury affecting the femoral head is rare in nonpenetrating injuries.201 Brodetti33 noted the rare possibility of injury to the vascularity of the femoral head with femoral head fixation screws and nails with injection studies and found that the central and inferior locations were safe zones. Avascular necrosis after pertrochanteric fracture is extremely rare but may develop in 0.5% to 1% of pertrochanteric fractures, usually within 4 years of the injury.15,78 

Pertrochanteric Hip Fracture Treatment Options

Evolution of Treatment of Pertrochanteric Hip Fractures

The evolution of treatment concepts regarding pertrochanteric fractures is critical to advancing our treatment modalities. Those who are ignorant of the past are condemned to repeat the same mistakes. Initial treatment in the 1800s in England focused on the work of Pott and Cooper who advocated supporting the thigh in a flexed position and that early mobilization of the patient from bed rest, to chair, to protective ambulation was the primary goal for survival of the patient. The second school of treatment was founded by Hugh Owen Thomas of Liverpool, which advocated immobilization and prolonged bed rest.24 
In 1902 Whitman reevaluated the role of conservative treatment of this type of fracture and advocated reduction and stabilization with traction, abduction, and internal rotation, to better restore the anatomy of the hip.231 This was performed under general anesthetic and then the patient was placed in a long leg hip spica cast to maintain the reduction. This basically moved the treatment of hip fractures from a passive role by the surgeon to an active role. 
Whitman232 reflected on the progress and evolution of hip fracture treatment in 1938. “At the beginning of this century, fracture of the neck of the femur was a therapeutic derelict. The futility of conventional treatment, demonstrated by Sir Astley Cooper, had been accepted as a finality and permanent disability as an inevitable sequence of the injury. Neglect of the fracture in the alleged interest of the patient entailed no responsibility, either moral or legal. Positive treatment, by contrast, could appeal only to adventurous spirits, since the correction of deformity might ‘break up the sacrosanct impaction,’ the only hope of union, while the restraint of the plaster spica must endanger the life of the patient. During the lapse of years, however, in spite of opposition and inertia, the abduction treatment has come into general use, and experience has disproved every assumption on which the negative doctrine was based.” He foresaw the replacement of nonoperative treatment with operative treatment with the success of the Smith-Petersen nail as the next progression to stabilize the limb and decrease mortality. His observations regarding the resistance to change of treatment dogma is reflected in many of the debates on hip fracture fixation today. 
In the 1800s, Langebeck137 and others had attempted internal fixation of the hip from a transtrochanteric insertion, but problems with material compatibility and the rigors of surgery resulted in failure of these techniques. Lane, Lambotte, and Hey-Groves were the pioneers who developed the modern principles of osteosynthesis.102,134,136 The advent of radiology prompted a reevaluation of hip fracture treatment and in 1911, the Section of Surgery of the British Medical Association reviewed a series of patients with the use of a new technique of radiographic imaging and concluded that operative treatment should be performed early when necessary and that function seemed to be correlated with absence of radiographic deformity.102 The real modern era of internal fixation of hip fractures began with Smith-Petersen in 1925 and his invention of the triflange nail for hip fractures.207 The triflange design controlled rotational instability and was strong enough for patient mobilization. It was used for both trochanteric and femoral neck fractures. Brittain32, using a very low placement on the lateral cortex of the femur, treated pertrochanteric fractures with the Smith-Petersen nail, presaging the later high-angle–type devices.117 Johansson117 in Sweden developed the technique (simultaneously with Wescott229 in the United States) of the radiographically guided insertion of the Smith-Petersen nail without arthrotomy in 1932. This was termed “blind nailing” and began the movement toward minimally invasive surgery. Johansson also is credited with developing the first cannulated Smith-Petersen nail. In 1934 King124 and Henderson100 independently reported the use of K-wires for provisional fixation, as described by Lambotte for guidance and proper placement of the Smith-Petersen nail. 
In 1930s, Henry, Lippmann, Henderson and others reported on the use of lag-screw–type devices instead of nails.100,101,141 It was not until the late 1930s that plate attachment to the femoral head fixation screw truly lay the groundwork for the movement from nonoperative treatment to surgical treatment for pertrochanteric fractures. Thornton217 in 1937 is credited with the first attachable side plate bolted to a Smith-Petersen nail. Within 10 years there was an explosion of new devices. The Jewett nail was a triflange nail welded to a plate for shaft fixation.116 Jewett was the first to advocate the open reduction of the “lesser trochanter” (or posteromedial fragment) with separate screws to increase the stability of the fracture. Blount27 in conjunction with Moore154 in the 1940s coined the terminology and the concept of blade plates. In 1944, Neufeld from California and Capener40 in the United Kingdom developed fixed-angle–type nail plates.215 Trochanteric buttress plates were first reported by Boyd and Griffin31 in 1949 (invented by Richardson at the Campbell Clinic) for preventing medialization with the Neufeld plate in unstable fractures. Boyd30 reported on refinements of the buttress technique including screw fixation into the trochanter for further fixation of the trochanteric fragment. 
The primary motivation behind surgical implants in the 1930s and 1940s was the belief that surgical fixation decreased the mortality from prolonged bed rest and eliminated the need for spica casts. Early reports suggested that patients could be mobilized more rapidly and with less hospitalization time. In 1949, Evans reported on the use of a Neufeld nail–type technique compared to nonoperative treatment for pertrochanteric fractures and favored surgical repair on the basis of four parameters which are still pertinent today: (1) greater pain relief and comfort of the patient, (2) improved early patient mobility, (3) the economy of bed control for nursing and hospital efficiency, and (4) a lower mortality rate (18% compared to 33% for nonoperative treatment).63 
The mechanical analysis of hip fracture fixation began in the 1940s with the realization of the magnitude of the hip forces by Inman113 and the effect of compression on healing by Eggers et al.59 Smith206 developed mechanical cadaver testing to reproduce fractures and determine the forces required for their causation. In a review of implant failures, Taylor and Janzen215 and Neufeld proposed the need for implants with sufficient fatigue life and the importance of stable reductions. In 1956, Martz148 presented the first load to failure testing for common hip implants of the day. In analyzing stresses on the human femur, Martz pointed out that walking subjects the femoral head to forces in the vicinity of 400 lb because of momentum and leverages. He applied the engineering rule of thumb, calling for a safety factor of two, arriving at a force of 800 lbs (3,200 N) as adequate resistance to load of a proximal fixation system. Foster70 advocated higher angle nail plates to minimize the load on the implants based on geometric assumptions on loading. Cleveland et al.47 argued that even with optimized designs, a small percentage of implant failure would still occur. 
Holt105 in 1963 argued that implant failure was related to inadequate mechanical design. He was the first to theorize that rotational movement was unlikely for pertrochanteric fractures to justify his design of a round nail plate (fixed-angle design) eliminating flanges on the femoral head component designed for rotational control. He believed it is unlikely that the proximal fragment of an intertrochanteric fracture could rotate after the fracture was reduced, the nail inserted, and the plate fixed to the shaft because of engagement of bone fragments at the fracture site. He did not detect any evidence of rotation in the follow-up of the first 100 fractures using his design and technique. He also was the first to advocate full weight bearing after surgery when the implant’s fatigue resistance was adequate for unrestricted loading. Interestingly, he used bolted shaft fixation screws through the plate. 
The invention of sliding compression with a cannulated system of drilling and insertion was invented by Godoy-Moreira81 and is the precursor of this class of implants in 1938. As with other devices, it was originally designed for femoral neck fractures with the focus of minimizing implant failure. The author also believed that the compression generated by the screw and side bolt would prevent any rotation or flexion at the fracture site. Schumpelick and Jantzen199 described an implant designed by Pohl in Kiel, Germany (who also designed instruments and nails for Küntscher) of a sliding cannulated system with a side plate in 1952. Interestingly, they did report telescoping of the implant with collapse of the fracture leading to a Trendelenburg gait in some patients. They also reported on the concept of early weight bearing with the SHS. 
In 1955 to 1958, Pugh185 and Massie149 reported success with the application of an SHS device to minimize medial penetration of the femoral head and early fatigue failure. Full weight bearing was not advised for 4 to 6 months with these devices. Interestingly, Pugh attempted to classify the results on a functional basis but “because of the variations in age, as well as the variation in the general physical status of these patients this was deemed impractical. In the cases in which solid union occurred, the result was considered good or satisfactory.” The first commercially available sliding compression hip screw in the United States was introduced in 1956 in cooperation with Dr. Clawson45,46 of Seattle and Dr. McKenzie of Scotland and was manufactured by Richards Manufacturing Company of Memphis, Tennessee. Their modifications included a blunt-tipped cannulated screw design coupled to a forged side plate of optional lengths and neck angles. There was a keyed slot for enhanced rotational stability. The follow-up series from Mullholland161 at Clawson’s Institution (now Harborview Medical Center) published in 1975 showed that functional status preoperatively correlated with the postoperative recovery and that mortality seemed to be improving with the use of this device. 
The desire to increase stability of unstable fracture patterns with proactive valgus osteotomies was poplularized by Dimon and Hughston,56 Sarmiento and Williams,196 and Harrington and Johnston96 in the 1960 to 1970s. However, prospective studies and meta-analysis comparing the results with SHS-type designs showed no mortality or functional improvement with osteotomies and a higher risk of blood loss,55,76,96,177 and these techniques have largely been abandoned. 
In 1979 to 1980, the issue of instability with sliding devices was described independently by Kyle et al.133 and Jensen114 with both reporting on a revision of the Evans classification incorporating the lateral radiographic position of the posteromedial fracture component and its relation to stability with sliding fixation systems. Kyle et al. showed an increased rate of deformity and collapse with increasing degrees of instability. However, they reported that the use of a high-angle sliding nail technique with prophylactic antibiotics, thromboembolism prophylaxis, and early mobilization produced good results with regard to mortality and fixation failure. In their functional evaluation they considered occasional pain, a permanent limp, and use of a cane as a good result. Jensen related the ability to reduce the fracture and secondary displacement risk with an SHS device in their classification system. With anatomic reduction in both planes and a stable medial cortex, no secondary displacement occurred. In nonanatomic and/or unstable fractures they reported a 25% to 69% rate of secondary displacement. In their statistical analysis, the correlation with secondary displacement was not with an unstable pattern but with a lack of reduction. Regarding the position of the tip of the SHS, Jensen advised placement over 10 mm away from the articular surface and Kyle et al. within 10 mm to minimize the cutout. 
In the 1980 to 1990s, renewed interest in hip fracture failures led to a new approach to fixation. In the plate field, Medoff and Maes152 introduced the biaxial compression hip screw for unstable fractures, which actually allowed axial compression along the shaft reminiscent of an Eggers plate concept in addition to dynamic compression at the screw–plate interface in the head. This biaxial compression concept was proven effective to minimize implant failure in unstable fractures, but with increased shortening of the leg.145,227 The reemergence of the importance of rotational instability as a problem prompted Gotfried83 to develop the percutaneous compression plate system (PCCP, Orthofix, Verona, Italy) which consisted of a side plate with two constrained partially threaded lag screws in a reconstruction nail–type pattern which optimized the rotational stability of the hip and minimized damage to the greater trochanter and lateral wall of the femur. There are preliminary reports suggesting that patients may have a trend toward earlier functional recovery with this type of device though further comparative studies are needed. Locked and hybrid locking plates have recently been applied for unstable fractures with only preliminary early reports thus far (Table 50-2). 
 
Table 50-2
Classification of Plates
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Table 50-2
Classification of Plates
Class Examples Failure Modes
Impaction Blade plates Medial penetration
Nail plates Breakage
Dynamic compression Sliding hip screw Cutout
Adjustable hip nails Plate pull-off
Dynamic helical blades
Linear compression Gotfried PCCP Less risk of cutout?
InterTAN CHS
Hybrid locking and trochanteric buttress Proximal femoral locking plates
Trochanteric stabilization plates
Plate failure
X
Cephalomedullary implants are devices inserted with a closed technique and fluoroscopic control with variable length femoral geometry and proximal screw holes to permit fixation with nails or screws into the femoral head (Table 50-3). They evolved from the Y-nail design of Küntscher131 in 1953 with his initial cases described in the Marrow Nailing Method textbook. This was a nonlocking unreamed nail with an impaction–type nail component for the femoral head driven through a perforation in the centromedullary nail. The Zickel nail primarily developed for subtrochanteric fractures was another impaction–type nail for the femoral head, but had no distal locking capability. The titanium trochanteric fixation nail (TFN, DePuy Synthes, West Chester, PA) is the most recent addition to this class of implant. 
 
Table 50-3
Classification of Nails
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Table 50-3
Classification of Nails
Class Examples Failure Modes
Impaction Y-nail, TFN Medial penetration
Dynamic compression Gamma, IMHS Cutout periimplant failure with short designs
Two-screw dynamic compression Reconstruction Z-effect
Linear compression integrated InterTAN Unknown
X
The Grosse–Kempf gamma nail and the Russell–Taylor reconstruction nail were two new intramedullary devices designed for the hip region and coincided with the widespread adoption and popularity of closed interlocking techniques in the 1980 to 1990s. These devices made use of a compression screw inserted into an intramedullary device instead of a nail for femoral head and neck fixation. The gamma nail used an expanded proximal nail section of 17 to 18 mm with a large single lag screw and the reconstruction nail allowed a smaller proximal nail section of 15 mm with two smaller lag screws for head fixation. Both devices have evolved over the past 20 years with the modern designs moving toward a 4- to 5-degree proximal bend with a medial or trochanteric entry portal instead of a lateral trochanteric or piriformis portal respectively. 
In 2004, the InterTAN class cephalomedullary nail (Smith & Nephew, Memphis, TN) was introduced. It has a trapezoidal cross-sectional geometry to protect the lateral wall of the greater trochanter and a hybrid nail design similar to a hip prosthesis stem for proximal nail stability in the shaft. In addition, linear compression through an integrated screw construct in the femoral head results in much greater resistance to rotational instability and cutout. Augmented internal fixation by the addition of polymethylmethacrylate (PMMA) or calcium phosphate cements has been considered for over 30 years. Recent developments in implant design and biomaterials have reinvigorated this research and clinical studies are now being reported. 

Nonoperative Treatment of Pertrochanteric Hip Fractures

Nonoperative treatment should only be considered in nonambulatory or severely demented patients with controllable pain, or patients with terminal disease with less than 6 weeks of life expected. Severe medical comorbidities that preclude surgical treatment and active infectious diseases that preclude insertion of a surgical implant are also relative contraindications. An exception to this consideration is incomplete pertrochanteric fractures diagnosed by MRI, which have shown to heal with conservative measures in selective patients.5,198 If nonoperative care is selected due to an excessively high risk of mortality from anesthesia and surgery, then the strategy previously discussed by Cooper of rapid mobilization to chair and an upright chest position is recommended. Mobilization is necessary to minimize decubiti, pneumonia, and dementia (Table 50-4). 
 
Table 50-4
Hip Fractures: Nonoperative Treatment
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Table 50-4
Hip Fractures: Nonoperative Treatment
Indications Relative Contraindications
Nonambulatory preinjury Desire to return to ambulatory status
Recent AMI, CVA Intractable pain
End-of-life from terminal disease (cancer, progressive neurologic disease) Surgical solution with acceptable risk
Active systemic sepsis
X

Techniques

Bed rest with the lower extremity in extension and braced with pillows or pads for 1 to 2 weeks is usually required for pain control. Femoral or proximal tibial traction is usually only necessary in patients with subtrochanteric extension or preoperative flexion contractures of the hip. Nonoperative management must include attentive nursing care with frequent positioning to avoid decubiti, attention to nutrition and fluid homeostasis, and adequate analgesis/narcotic pain suppression. Fracture callus formation at 3 weeks markedly decreases motion-related pain and by 6 weeks most patients can be lifted into a wheelchair or reclining chair. Union occurs in 12 to 16 weeks. 

Outcomes

Meta-analyses of randomized trials do not suggest major differences in outcome between conservative and operative management programs for extracapsular femoral fractures, but operative treatment appears to be associated with a reduced length of hospital stay and improved rehabilitation.174 Opponents of nonoperative treatment for nonambulatory patients suggest that surgery is more effective for pain relief and does not result in unacceptable increased mortality or complications. Ambulatory capability with nonoperative treatment was usually viewed as poor, however some patients do regain some degree of ambulation ability.93,174 

Operative Treatment of Pertrochanteric Hip Fractures

Pertrochanteric fractures are globally viewed as an injury best treated with surgical repair. Multiple modalities of surgical treatment must be mastered and available for the surgeon’s treatment since the fracture patterns are not uniform, the morphology of the femur has significant variation, and the comorbidities of the elderly patient confound simple algorithms. Surgical management once selected should be performed as soon as any correctable metabolic, hematologic, or organ system instability has been rectified. This is within the first 24 to 48 hours for most patients. The literature suggests increased mortality after this time, but patient suffering and hospital efficiencies demand timely intervention of themselves. Holt et al. found that case-mix variables (age, gender, fracture type, prefracture residence, prefracture mobility, and ASA scores) were the critical predictors of mortality even when corrected for time to surgery, admission time to surgery, or grade of surgical and anesthetic staff undertaking the procedure. Centers with experience and protocols for the rapid diagnosis and treatment of hip fractures can effectively decrease the hospitalization time and complication risks for these injuries.180,216 Interestingly, earlier surgery has not been found to be associated with a higher mortality or morbidity.122 Browne et al.36 found that surgeons with low volumes of experience (<7 cases per year) compared to high volume hip fracture surgeons (>15 cases per year) had higher rates of mortality and complication, but that high versus low volume hospitals were associated only with shorter hospital stay and lower nonfatal morbidity. 
Surgical implant options included plate and screw constructs, either nail or screws for the head fixation, nail constructs with either nail or screws, external fixation, and arthroplasty. Generically, these options can be grouped to designs with common biomechanical behaviors, techniques, complications, and results. There are meta-analysis and randomized prospective studies comparing different implants and techniques, but controversy still abounds. 
Parker and Handoll177 reported that there is no consensus regarding the superiority of the dynamic compression nails- or plate-type devices. Most studies have shown essentially equivalent outcome measures if one considers mortality, functional outcomes at 1 year, implant mechanical failure rates, and time of hospitalization. Proponents of plates value a simple mechanical procedure with a lower-cost implant and a long history of usage. Proponents of nails value a limited exposure surgical procedure with the possibility of less deformity and possible improvement in walking ability in some studies. Though still the most used device around the world, the SHS is associated with two serious complications: Uncontrolled collapse and migration of the lag screw within the femoral head leading to varus and possible screw cutout. The incidence of this is increased in malreduced fractures or those with iatrogenic fracture of the lateral wall and construct collapse. Gotfried has described this latter complication as a “pantrochanteric hip fracture” specific to intraoperative damage of the lateral wall of the proximal femur.238 The main advantages at this time of the SHS implant and technique are reduced cost and ease of teaching the technique. The cost of the implant should be a consideration, but not at the risk of compromising patient outcome. There is also evidence that some complications with nail devices are more frequent than with sliding screws. Despite this, the trend for intramedullary fixation continues to increase in the United States.8 This may be related to the familiarity of intramedullary nailing techniques with the current generation of surgeons and the desire to avoid malunion and collapse. Hopefully, large-scale multinational studies will help discern risks and benefits of differing implant selections in the future. This will be an evolving topic as new implants are designed to avoid the complications of previous generations of implants and their implementation and study in sufficiently powered studies will take considerable time and resources. In this chapter, the randomized comparative trials and case series will be presented from the perspective of the different devices that have been compared to SHSs. 

Open Reduction and Internal Fixation Plating Surgical Procedure

Plate constructs may be grouped into four functional types: (1) fixed-angle devices: Impacted nail–type plate devices (i.e., blade plates, fixed-angle nail plate devices), (2) sliding hip screws: Large single sliding screw or nail femoral head components with side plate attachments (e.g. standard SHSs), (3) linear compression class: Multiple head fixation components controlling rotation and translation but allow linear compression (e.g. Gotfried PCCP), and (4) hybrid locking class where multiple fixation components with compression initially for fracture reduction followed by locking screws which prevent further axial compression; these types of fixation are the most rigid (e.g. proximal femoral locking plates, DePuy Synthes, West Chester, and Smith & Nephew, Memphis). Lateral trochanteric buttress plates best fall into this category as well since they serve to more rigidly stabilize the proximal femur. 
Fixed-angle plating is more commonly used for corrective osteotomies rather than as a primary treatment for hip fractures. MacEachern and Heyse-Moore146 reported on the difference of failure mechanisms with medial penetration of the joint with the Jewett nail compared to the SHS. Attempts at improving the results of SHS devices with medial displacement osteotomies fell out of favor when comparative trials showed no advantages with increased blood loss and longer operative times.178 
Chinoy et al. in a 1999 meta-analysis, compared accurately fixed-nail plates with sliding implants involving a total of 2,855 patients. Results showed an increased risk of cutout (13% vs. 4%), nonunion (2% vs. 0.5%), implant breakage (14% vs. 0.7%), and reoperation (10% vs. 4%) for fixed-nail plates in comparison with the sliding implants. In addition patients treated with fixed-nail plates had a higher mortality and the survivors were more likely to have residual pain with impaired mobility. The continued use of fixed-nail plates gave way in the 1980s to the unequivocal superiority of the SHS with regard to these complications. 

Sliding Hip Screw Fixation

From the 1980s to 2000, SHSs became the gold standard for hip fracture fixation, reinforced by the reports of Clawson, Mulholland, and meta-analysis studies by Parker and Handoll.174 The device consists of a large fragment side plate attached with 4.5-mm cortical screws to the shaft of the femur with a barrel on the proximal plate for connection with a large threaded screw inserted over a guidewire into the femoral head. These devices, made from stainless steel or titanium alloys, come in varying barrel angles of 125 to 150 degrees with 12.5-mm large diameter lag screws in lengths from 65 to 130 mm. The plates typically used have two to four holes but longer versions are available. They are commercially available internationally as a generic device from many orthopedic companies (Fig. 50-7). 
Figure 50-7
Sliding hip screw components: Lag screw, blunt tip, side plate of fixed angle, and cortical shaft screws.
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The Medoff sliding screw and plate (Medpac, Culver City, California) design uses a biaxial SHS (Fig. 50-8). It has a standard lag screw/barrel component for compression along the femoral neck. In place of the standard femoral side plate, however, it utilizes a coupled pair of sliding components that enable the fracture to impact parallel to the longitudinal axis of the femur. A locking set screw may be used to prevent independent sliding of the lag screw within the plate barrel; if the locking set screw is applied, the plate can only slide axially on the femoral shaft (uniaxial dynamization). If, however, the surgeon applies the implant without placement of the locking set screw, sliding may occur along both the femoral neck and the femoral shaft (biaxial dynamization). For most intertrochanteric fractures, biaxial dynamization is suggested; however, this accentuates the possibility for shortening. 
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Figure 50-8
Medoff sliding plate.
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The current literature suggests that there is no difference in mortality or functional recovery between compression hip screws and intramedullary nails with single large diameter screw fixation in the femoral head. Recently however, the SHS and similar devices have come under scrutiny with regard to shortening and changes in abductor function with the controlled collapse the device is designed to allow. This issue of collapse has driven the search for more stable treatment options. 
Cephalomedullary nailing for subtrochanteric fractures became increasingly popular in the 1990s. Haidukewych et al.91 noted a higher rate of failure with SHSs for reverse obliquity intertrochanteric fractures due to excessive medialization, and based on this and other studies cephalomedullary nails became the preferred treatment for reverse obliquity fractures. Kregor et al.128 in an analysis of the literature from 1980 to 2002 regarding the AO/OTA classification 31A3 group (reverse obliquity pattern) suggests that cephalomedullary nails are the preferred device for this subgroup of fractures. 
Preoperative Planning.
 
Table 50-5
Preoperative Planning Checklist
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Table 50-5
Preoperative Planning Checklist
Traction OR table C-arm compatible with optional foot or skeletal traction
Supine position primarily, lateral decubitus position option for reverse obliquity
Fluoroscopy C-arm opposite surgeon with ability to rotate over and under
Equipment: Soft tissue retractors, Schanz pins for joysticks, elevators, bone hook, large bone forceps, 3.2-mm K-wires for provisional stabilization, power drivers
Implant system with complete inventory of sizes
Backup plan for alternative internal fixation choice
X

ORIF of Pertrochanteric Hip Fractures: Plate and Nail Techniques

Lambotte135 described the four components of surgical treatment of fractures at the turn of the 20th century and they are as applicable today as then (Table 50-5). The first is Exposure of the fracture which today means visualization of the fracture deformity and the safest approach to ensure reduction and placement of the implant in the correct position. The second is the Reduction of the fracture, which is critical to the stability, and functional recovery of the patient. Inadequate reduction is the major preventable etiology for lost reduction and construct failure in pertrochanteric fractures. The third step is Provisional Fixation in an anatomically reduced position; this is frequently the most neglected step in hip fracture surgery. This involves the reduction of the fracture and then maintenance of the fracture with either provisional Kirschner pins and/or clamps to hold the fracture in position while the bone is prepared for the definitive implant. The last step is Definitive Fixation that should maintain the reduced fracture in an acceptable anatomic and functionally correct position until fracture healing is complete. These steps are universal in application independent of device. 
Positioning Plating.
Move the patient to the fracture table after anesthesia is complete to minimize pain. A supine position with bilateral foot traction with knees in extension with the legs scissored is optimal. The operative leg is raised to approximately 20 to 30 degrees of flexion and the nonoperative extremity is extended 20 to 30 degrees. The legs are pulled in line with the body to avoid varus positioning of the hip. The C-arm is brought in from the opposite side with the base parallel to the operative extremity centered on the midfemur such that the cephalad—caudad movement of the C-arm gives complete visualization of the femoral head and shaft in AP and lateral views. With this type of setup, the true AP of the hip is usually obtained with 10 to 20 degrees of rotation of the C-arm over the top and the true lateral corresponds to approximately 15 to 30 degrees over the horizontal position (Fig. 50-9). 
Figure 50-9
 
A: Conventional C-arm position will yield an oblique view. B: Correct C-arm position for flexion of the shaft. Make sure that C-arm axis is perpendicular to femoral axis. C: Correct C-arm position for anteversion. Tilt C-arm over leg at 10 to 15 degrees to get the maximum length of the femoral neck. D: Correct lateral C-arm to avoid excessive internal rotation. Obtain true lateral along neck anteversion without excessive internal rotation of leg.
A: Conventional C-arm position will yield an oblique view. B: Correct C-arm position for flexion of the shaft. Make sure that C-arm axis is perpendicular to femoral axis. C: Correct C-arm position for anteversion. Tilt C-arm over leg at 10 to 15 degrees to get the maximum length of the femoral neck. D: Correct lateral C-arm to avoid excessive internal rotation. Obtain true lateral along neck anteversion without excessive internal rotation of leg.
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A: Conventional C-arm position will yield an oblique view. B: Correct C-arm position for flexion of the shaft. Make sure that C-arm axis is perpendicular to femoral axis. C: Correct C-arm position for anteversion. Tilt C-arm over leg at 10 to 15 degrees to get the maximum length of the femoral neck. D: Correct lateral C-arm to avoid excessive internal rotation. Obtain true lateral along neck anteversion without excessive internal rotation of leg.
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Figure 50-9
A: Conventional C-arm position will yield an oblique view. B: Correct C-arm position for flexion of the shaft. Make sure that C-arm axis is perpendicular to femoral axis. C: Correct C-arm position for anteversion. Tilt C-arm over leg at 10 to 15 degrees to get the maximum length of the femoral neck. D: Correct lateral C-arm to avoid excessive internal rotation. Obtain true lateral along neck anteversion without excessive internal rotation of leg.
A: Conventional C-arm position will yield an oblique view. B: Correct C-arm position for flexion of the shaft. Make sure that C-arm axis is perpendicular to femoral axis. C: Correct C-arm position for anteversion. Tilt C-arm over leg at 10 to 15 degrees to get the maximum length of the femoral neck. D: Correct lateral C-arm to avoid excessive internal rotation. Obtain true lateral along neck anteversion without excessive internal rotation of leg.
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A: Conventional C-arm position will yield an oblique view. B: Correct C-arm position for flexion of the shaft. Make sure that C-arm axis is perpendicular to femoral axis. C: Correct C-arm position for anteversion. Tilt C-arm over leg at 10 to 15 degrees to get the maximum length of the femoral neck. D: Correct lateral C-arm to avoid excessive internal rotation. Obtain true lateral along neck anteversion without excessive internal rotation of leg.
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Surgical Approach Plating.
The lateral approach to the proximal femur for plating has been relatively standardized over the past 70 years. The entire proximal thigh from the iliac crest to the knee is prepared in the standard fashion. The incision length is based on the length of the proposed plate–shaft component; the incision is started with reference from intraoperative C-arm fluoroscopy views and is centered over the lesser trochanter. Commonly the incision length is 5 to 10 cm in length. The iliotibial band is incised longitudinally and the proximal portion is extended sufficiently to develop the area of the intertrochanteric line for palpation anteriorly, usually just proximal to the origin of the vastus lateralis. The fascia of the vastus lateralis is incised near its attachment posteriorly at the linea aspera. Leave sufficient fascia posteriorly (5 to 10 mm) for closure and to identify and obtain hemostasis of perforating vessels. Reflect the vastus anteriorly exposing the lateral femoral shaft; detachment of the origin of the vastus may be required for fracture visualization and reduction. There are no significant neurologic or vascular structures at risk with this approach (Fig. 50-10). 
Figure 50-10
Lateral surgical approach to the hip.
 
Slight curvature of proximal extent of incision to allow palpation of the anterior cortex. Vastus lateralis reflection distally as needed for length of plate.
Slight curvature of proximal extent of incision to allow palpation of the anterior cortex. Vastus lateralis reflection distally as needed for length of plate.
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Figure 50-10
Lateral surgical approach to the hip.
Slight curvature of proximal extent of incision to allow palpation of the anterior cortex. Vastus lateralis reflection distally as needed for length of plate.
Slight curvature of proximal extent of incision to allow palpation of the anterior cortex. Vastus lateralis reflection distally as needed for length of plate.
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For more extensive dissection, the Watson-Jones anterolateral approach to the hip is a proximal expansion of the straight lateral approach previously described (Fig. 50-11). The muscular interval proximally is between the tensor fasciae latae and the gluteus medius. The interval between these to muscles is best begun distally and exposed proximally. Follow the anterior border of the vastus lateralis proximally to reach the anterior trochanteric ridge and hip capsule. The use of Schanz pins drilled into the proximal femur is an aid in retraction for better visualization and may be used for manipulation of the shaft (Fig. 50-12A, B). For pertrochanteric fracture management further capsulotomy and greater trochanteric osteotomy are rarely required. The main vascular obstacle is the ascending branch of the lateral femoral circumflex artery, which should be isolated and ligated in the approach. Complete proximal dissection of the gluteus medius and tensor fasciae latae interval to the iliac crest is rarely necessary; the superior gluteal nerve to the tensor fasciae latae will be sacrificed with full proximal dissection, however, this is not clinically significant. 
Figure 50-11
Watson-Jones approach.
 
Key interval between TFL and gluteus medius to visualize anterior femoral neck and capsule.
Key interval between TFL and gluteus medius to visualize anterior femoral neck and capsule.
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Figure 50-11
Watson-Jones approach.
Key interval between TFL and gluteus medius to visualize anterior femoral neck and capsule.
Key interval between TFL and gluteus medius to visualize anterior femoral neck and capsule.
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Figure 50-12
Step-off deformity.
 
A: Model of typical step-off deformity showing overlap of anterior cortical surface. B: Lateral view showing overlap on lateral position. C: Reduction of the anterior cortex. Reduction of overlap with percutaneous pin with coach-lever maneuver. D: Reduction achieved.
A: Model of typical step-off deformity showing overlap of anterior cortical surface. B: Lateral view showing overlap on lateral position. C: Reduction of the anterior cortex. Reduction of overlap with percutaneous pin with coach-lever maneuver. D: Reduction achieved.
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A: Model of typical step-off deformity showing overlap of anterior cortical surface. B: Lateral view showing overlap on lateral position. C: Reduction of the anterior cortex. Reduction of overlap with percutaneous pin with coach-lever maneuver. D: Reduction achieved.
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Figure 50-12
Step-off deformity.
A: Model of typical step-off deformity showing overlap of anterior cortical surface. B: Lateral view showing overlap on lateral position. C: Reduction of the anterior cortex. Reduction of overlap with percutaneous pin with coach-lever maneuver. D: Reduction achieved.
A: Model of typical step-off deformity showing overlap of anterior cortical surface. B: Lateral view showing overlap on lateral position. C: Reduction of the anterior cortex. Reduction of overlap with percutaneous pin with coach-lever maneuver. D: Reduction achieved.
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A: Model of typical step-off deformity showing overlap of anterior cortical surface. B: Lateral view showing overlap on lateral position. C: Reduction of the anterior cortex. Reduction of overlap with percutaneous pin with coach-lever maneuver. D: Reduction achieved.
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Surgical Technique Plating.
Anatomical reduction is often difficult or vascularly disadvantageous posteriorly, hence, emphasis should be focused on the anteromedial cortex reduction. One should not assume that any implant can substitute for a lack of reduction. Sarmiento in 1963 called attention to the key components of reduction of the pertrochanteric fracture, “Weight bearing on the fractured extremity is safe only if the fracture, whether simple or comminuted, has been reduced so that there is an accurate fit of the fragments at the anteromedial cortex of the femur. Absorption of the reduced medial cortex of the femur with loss of stability is unlikely because of the great thickness and strength of the anteromedial cortex. Failure to obtain such reduction because of the degree of comminution or technical difficulties precludes weight bearing until bone union is complete. Anatomical reduction of the medial and anterior cortices is of great importance since the stability of the fracture and the efficiency of the nail depend on the reduction of this portion of the bone” (Fig. 50-12A–D).195 
It is commonly assumed that internal rotation is the correct position for the hip fracture reduction but in a study by Bannister et al.12 and May and Chacha,151 pertrochanteric fractures have an equal chance of being reduced in internal or external rotation. Excessive internal rotation can lead to posterior gapping further destabilizing the fracture with a large posterior medial defect. Ramanoudjame et al.186 has recently reported a 40% malrotation rate of over 15 degrees of intertrochanteric fractures treated with compression hip screws or nails when examination of reduction was assessed by CT scan. 
My preferred technique for the proximal femur involves a four-step technique. 
  1.  
    After placement of the patient on the fracture table in the supine position, attach the foot into the traction boot, anchor the perineal post in the fracture table for counter-traction, then correct posterior sag at the fracture with a posterior to anterior directed force and maintain during following steps.
  2.  
    Flex the leg through the foot holder 20 to 30 degrees from neutral for intertrochanteric fractures and 30 to 40 degrees for subtrochanteric fractures, maintaining the posterior to anterior reduction force at the hip.
  3.  
    Apply traction to restore length in line with the body. Varus is not permitted. Traction should not be too powerful as it may disrupt any remaining soft tissue attachments and further destabilize the fracture.
  4.  
    Rotate the leg to align with the proximal fragment, 5 to 15 degrees of external rotation for most subtrochanteric fractures and 0 to 10 degrees of internal rotation for pertrochanteric fracture (Table 50-6).
 
Table 50-6
Closed Reduction Steps
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Table 50-6
Closed Reduction Steps
Attach foot to traction and lift up on femoral shaft, before traction is applied Reduces posterior sag, overcorrecting anterior wall
Flex extremity with knee in extension, 20–30-degree A1–2, 30–40-degree A3 Reduces posterior translation
Apply traction: No varus Ligamentotaxis if capsule still intact
Rotate leg to align with proximal fragment (10–15 IR vs. 10–20 ER) Often neglected step variability in anteversion in patients, some retroverted
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A lateral incision is made after standard skin preparation and drape centered from the vastus lateralis ridge approximately 6 cm distally in line with the iliotibial band. Reflect the vastus lateralis near its origin on the posterolateral surface of the femur with care to obtain control of any perforator vascular branches. The vastus is elevated anteriorly and Hohmann retractors placed for exposure of the lateral shaft. 
Carr41 renewed Sarmiento’s focus on the anteromedial cortex and described reduction techniques to facilitate the reduction. The reduction is assessed by palpation of the region of the intertrochanteric fracture line anteriorly. Palpate for a step-off, which identifies where the posteriorly displaced shaft is overlapped by the anteriorly displaced head and neck fragment. First pull the shaft laterally to disimpact it from the head and neck fragment with a bone hook passed around the femoral shaft in a subperiosteal manner distal to the lesser trochanter. With the shaft retracted laterally, insert a narrow Jocher or key elevator between the head/neck shaft pieces, and lever the head and neck fragment anteriorly, applying a force posterior to the shaft to align the two fragments (Fig. 50-12A–D). Adjustment in length and rotation of the limb may be required at this time. Release the laterally directed traction on the shaft. Confirm the anterior reduction with C-arm views. At this point, anteroposterior radiographic views of the hip should reveal an anatomic neck–shaft junction—manifested as a “hairline crack reduction.” On the lateral view, the anterior cortex line is re-established. Secure the reduction with one or two 3.2-mm wires that are directed away from the area of intended lag screw placement. Be careful that the anterior reduction is not lost during insertion of the hip compression screw, which tends to rotate the head and neck fragment. The lack of adequate provisional fixation is the most common reason that provisional reductions are lost during fixation. Provisional fixation must be placed so that it will not interfere with the definitive fixation. Typically this can be achieved with a 3.2-mm K-wire introduced away from the path of the definitive fixation. Alternatively, fixation can be achieved in long oblique fractures by K-wire fixation from the anterior longitudinal shaft region into the medial femoral neck (Fig. 50-13A, B). Weber-type clamps with a wide jaw may be inserted in a limited open reduction in conjunction with a bone hook along the medial cortex or medial to the greater trochanter to achieve fracture reduction. If there is posterior displacement of the distal fragment, there are no soft tissue structures to leverage and a manual reduction of the shaft to an anterior position will be required. These displacements require a combination of traction, translation of the distal fragment, and some degree of rotational correction. Rotational reduction is best evaluated by intraoperative radiographic views. 
Figure 50-13
 
A: Sliding hip screw technique. Provisional fixation lateral to medial proximal femoral neck region, AP view. B: Lateral view. Note parallel placement anterior to center–center guidewire. C: Insert lag screw to within 5- to 10-mm subchondral bone maintaining provisional antirotation pin in place. D: AP view 135-degree two-hole plate in proper alignment. E: Lateral view with correct trajectory of screw parallel to anterior neck. F: The tip-apex distance (TAD), expressed in millimeters, is the sum of the distances from the tip of the lag screw to the apex of the femoral head on both the AP and lateral radiographic views.
A: Sliding hip screw technique. Provisional fixation lateral to medial proximal femoral neck region, AP view. B: Lateral view. Note parallel placement anterior to center–center guidewire. C: Insert lag screw to within 5- to 10-mm subchondral bone maintaining provisional antirotation pin in place. D: AP view 135-degree two-hole plate in proper alignment. E: Lateral view with correct trajectory of screw parallel to anterior neck. F: The tip-apex distance (TAD), expressed in millimeters, is the sum of the distances from the tip of the lag screw to the apex of the femoral head on both the AP and lateral radiographic views.
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A: Sliding hip screw technique. Provisional fixation lateral to medial proximal femoral neck region, AP view. B: Lateral view. Note parallel placement anterior to center–center guidewire. C: Insert lag screw to within 5- to 10-mm subchondral bone maintaining provisional antirotation pin in place. D: AP view 135-degree two-hole plate in proper alignment. E: Lateral view with correct trajectory of screw parallel to anterior neck. F: The tip-apex distance (TAD), expressed in millimeters, is the sum of the distances from the tip of the lag screw to the apex of the femoral head on both the AP and lateral radiographic views.
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Figure 50-13
A: Sliding hip screw technique. Provisional fixation lateral to medial proximal femoral neck region, AP view. B: Lateral view. Note parallel placement anterior to center–center guidewire. C: Insert lag screw to within 5- to 10-mm subchondral bone maintaining provisional antirotation pin in place. D: AP view 135-degree two-hole plate in proper alignment. E: Lateral view with correct trajectory of screw parallel to anterior neck. F: The tip-apex distance (TAD), expressed in millimeters, is the sum of the distances from the tip of the lag screw to the apex of the femoral head on both the AP and lateral radiographic views.
A: Sliding hip screw technique. Provisional fixation lateral to medial proximal femoral neck region, AP view. B: Lateral view. Note parallel placement anterior to center–center guidewire. C: Insert lag screw to within 5- to 10-mm subchondral bone maintaining provisional antirotation pin in place. D: AP view 135-degree two-hole plate in proper alignment. E: Lateral view with correct trajectory of screw parallel to anterior neck. F: The tip-apex distance (TAD), expressed in millimeters, is the sum of the distances from the tip of the lag screw to the apex of the femoral head on both the AP and lateral radiographic views.
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A: Sliding hip screw technique. Provisional fixation lateral to medial proximal femoral neck region, AP view. B: Lateral view. Note parallel placement anterior to center–center guidewire. C: Insert lag screw to within 5- to 10-mm subchondral bone maintaining provisional antirotation pin in place. D: AP view 135-degree two-hole plate in proper alignment. E: Lateral view with correct trajectory of screw parallel to anterior neck. F: The tip-apex distance (TAD), expressed in millimeters, is the sum of the distances from the tip of the lag screw to the apex of the femoral head on both the AP and lateral radiographic views.
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After provisional fixation in an anatomic reduction is secured with good reduction of the anteromedial cortex, the position for the plate is determined. Care must be taken such that the plate is placed in line with the correct trajectory into the femoral head but also aligned with the shaft. The tendency is to place the plate anteriorly translated. Tronzo describe a technique for determining the correct anteversion and trajectory for the center–center guidewire of placing a 3.2-mm K-wire over the anterior femoral shaft under image control anterior to the femoral head and neck with the center of the femoral neck. This K-wire penetrates the capsule of the head and is safe if kept on the anterior surface of the bone. This gives the anteversion alignment of the proximal femur and also the relative neck–shaft angle.220 Next a 3.2-mm K-wire using an appropriate angle guide, usually 125 to 135 degrees, is introduced at the level of the lesser trochanter in line with the previous anteversion pin. In hard bone it is often helpful to predrill with a 4.5-mm drill bit to make guidance of the guidewire into the femoral head easier. The guidewire is then inserted centered on the AP and lateral views in the femoral neck. It is important that the wire should not be positioned too anteriorly or too posteriorly from its entry portal and should be centered on the AP and the lateral x-rays into the femoral head. The wire should be advanced to within 5 to 10 mm of subchondral bone to meet the requirements of the tip–apex distance (TAD) as described by Baumgaertner of less than 25 mm (Fig. 50-13F). Next the length measurement is taken and usually at this point a triple reamer-type device will be attached to drill into the head and neck fragment for the lag screw: In addition it opens the lateral femoral cortex to accept the barrel of the plate. This is reamed to the selected depth. Usually a screw will be selected that will be 5 mm less than the depth drilled. If the bone is dense it should be tapped and provisional fixation should be maintained in the head and neck fragment before tapping to ensure that there is no rotation due to the torque effect of the tap. The importance of provisional fixation during screw insertion was pointed out by Mohan et al. in 1993, with his study showing that malreduction occurred with tightening of the lag screw in left hip fractures. Once the lag screw has been selected, it is inserted with a cannulated attachment over the guidewire and seated to within 5 to 10 mm of subchondral bone. (Fig. 50-13C). The selected plate is usually of a two- to four-hole design; two holes for simple two-part stable fractures and four holes for more unstable patterns or osteoporotic bone. The plate is applied and inserted. If the plate does not oppose itself easily to the bone the wrong angle may have been selected and care should be taken not to force the reduction of the plate to the bone as this may result in a gapping of the medial cortex with loss of the reduction. After the plate is applied and clamped to the shaft, a lag screw is applied with a standard drill bit (3.2 or 3.5 mm depending on the system) and a 4.5-mm cortical screw is inserted into the proximal cortex position. Care should be made that the plate is aligned with the shaft of the femur to avoid offset or transcortical screws distally. Next the traction is released and the plate impacted with an impactor to ensure lateral plate contact with the shaft. Most systems have compression screws that can be inserted through the plate into the femoral head lag screw and after the traction is released, compression is applied. Excessive compression should be avoided as it may disrupt the fixation of the head and render the construct unstable. Also, in anticipation of up to 5 mm of sliding, the compression screw should not be left proud as this may cause pain from the implant postoperatively. Whether the compression screw device is left in place is up to the option of the surgeon and there is no clear evidence to support removal or retention. Disengagement of the lag screw from the barrel is a very rare complication but can occur. The plate is then further secured with 4.5-mm screws with bicortical fixation (Fig. 50-13D, E). 
Hemostasis is confirmed and the wound is closed in layers in the standard fashion. Drains are not routinely used unless the patient is on anticoagulant therapy. Intraoperative confirmation of the reduction on the AP and lateral views and a radiographic record obtained (Fig. 50-14A–E; Table 50-7). 
Figure 50-14
 
A: High-energy 31A fracture. B: Reduction and stabilization with CHS. Good position with good bone stock aids the stability of the fixation with CHS. C: Lateral postoperative radiograph. D: Malreduction with plate angle too high inducing medial opening of the fracture. E: Anterior translation of fracture with wrong angle plate.
A: High-energy 31A fracture. B: Reduction and stabilization with CHS. Good position with good bone stock aids the stability of the fixation with CHS. C: Lateral postoperative radiograph. D: Malreduction with plate angle too high inducing medial opening of the fracture. E: Anterior translation of fracture with wrong angle plate.
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Figure 50-14
A: High-energy 31A fracture. B: Reduction and stabilization with CHS. Good position with good bone stock aids the stability of the fixation with CHS. C: Lateral postoperative radiograph. D: Malreduction with plate angle too high inducing medial opening of the fracture. E: Anterior translation of fracture with wrong angle plate.
A: High-energy 31A fracture. B: Reduction and stabilization with CHS. Good position with good bone stock aids the stability of the fixation with CHS. C: Lateral postoperative radiograph. D: Malreduction with plate angle too high inducing medial opening of the fracture. E: Anterior translation of fracture with wrong angle plate.
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Table 50-7
ORIF Pertrochanteric Hip Fracture SHS: Surgical Steps
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Table 50-7
ORIF Pertrochanteric Hip Fracture SHS: Surgical Steps
Incise the lateral thigh from tip of trochanter to 8–10 cm distal
Incise the ITB and vastus lateralis fascia and elevate the muscle anteriorly, exposing subperiosteal. Palpate the anteromedial fracture defect.
Distract the fracture with traction longitudinally and correct the posterior sag of the shaft and reduce the anteromedial fracture region with lateral traction on the femoral neck and rotation of the shaft with Schanz pins, bone hooks, and elevators as necessary.
Provisionally fix with Weber clamp anteromedial to lateral, and insert 3.2-mm guidewire from anterior shaft into medial femoral neck transversely with bicortical purchase. Place the wire parallel to the anterior cortex on the lateral radiographic view so as not to interfere with lag screw placement and subsequent plate.
Insert center–center position guidewire in line with the femoral neck axis. Use Tronzo technique with extramedullary placed guidewire to discern trajectory Advance wire tip to within 5-mm subchondral bone. Measure for length of screw.
Ream over guidewire with triple reamer for desired depth of screw, maintaining provisional fixation with accessory wire and clamps to prevent rotational loss of reduction
Select screw 5 mm shorter than reamed length and insert by hand over guidewire
Attach selected plate over guidance driver and wire and rotate to align with shaft axis. Impact plate carefully to bone. Secure with bone forceps.
Remove guidewire and insert compression screw into lag screw.
Attach plate to shaft with bicortical screws.
Release traction and remove provisional fixation and compress fracture with screw under radiographic control. Confirm reduction and stability.
Close wound in layers in standard fashion.
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Postoperative Care.
Anteroposterior and lateral radiographs of the final construct should be obtained in the surgical suite to assess the construct and ensure stability. If there are adjustments to be made, these are best made while the patient is still under anesthesia. Radiographs should reveal the entire fracture region including the entire implant construct. Patients are mobilized to a chair upright position the day following the operative procedure. Ambulation with supervision with weight bearing as tolerated with a walker or crutches with emphasis on heel strike and not toe-touch gait and upright balance exercises. Multiple trauma or patients with other complications may have delayed ambulation but it should begin as soon as possible to minimize secondary complications. In patients with a hip fracture, delay in getting the patient out of bed is associated with poor function at 2 months and worsened 6-month survival.205 Studies also reveal decreased rates of pneumonia, urinary tract infection, and dementia with early mobilization.119 Besides accelerating recovery, the ability to ambulate postoperatively is prognostic of improved survival rates.112 Specific fracture service and rehabilitation protocols reduced 30-day mortality from 22% to 7% in one series.178 
Weight bearing is most important in these patients for optimal recovery and to minimize the fear of falling and lack of independence. Weight-bearing stability of the implant construct improves the functional ability of the patients.202 There must be sufficient stability to allow aggressive physical therapy especially in the cognitively impaired patient with hip fracture.160 Koval et al.125 has reported that patients will autoregulate their weight bearing. 
Pain control postoperatively is also important for recovery. Patients with higher pain scores at rest had significantly longer hospital lengths of stay, were more likely to have physical therapy sessions missed or shortened, were less likely to be ambulating by postoperative day 3, and had significantly lower locomotion scores at 6 months.158 If an implant is unstable in the first 6 weeks after surgery, pain and lack of mobility may affect long-term functional recovery. 
Protein and caloric nutrition, especially osteoporotic therapy with vitamin D supplementation, is important for successful recovery.38 Hip abductor exercises in conjunction with proper balance and gait training are required; resist the abandonment of crutches or walker until normal gait is restored. Patients must be counseled to report any increased swelling or respiratory distress as an emergency due to the high risk of thromboembolic disease. On discharge, vitamin D (minimum of 1,000 IU daily) is prescribed; if the patient’s vitamin D level is low, prescribing 50,000 IU weekly for 12 weeks is recommended. Fall prevention education and safe home checks should be explained to the patient’s family or social support group. Patients are reevaluated with examination and radiographs at 2 weeks and then monthly thereafter until fracture healing is documented and the patients have maximized ambulatory capabilities, usually by 6 months after injury. 
It is recommended that postoperatively, orthopedists include a plan to identify secondary causes of osteoporosis, obtain bone density testing, and initiate osteoporosis pharmacotherapy if appropriate. The FRAX calculator (http://www.shef.ac.uk/FRAX/) is a free service for patients not on osteoporosis treatment and is helpful for patient education and risk assessment.121 Bisphosphonate therapy should begin within 2 weeks after surgery. Orthopedic surgeons should treat the entire patients with the same diligence as after any sports injury, reconstructive surgery, or hand procedure. Another aspect is prevention: It is known that the major risk factors for geriatric fractures include prior fragility fracture, increased age, low bone mineral density, low body weight, family history of osteoporotic fracture, glucocorticoid use, secondary osteoporosis, liver and kidney disease, Crohn disease, rheumatoid arthritis, hyperthyroid disease, antiepileptic medications, primary hyperparathyroidism, systemic inflammatory disease, and smoking tobacco products.42,77 
Boonen et al29 have documented the drugs alendronate and risedronate as effective in decreasing the risk of hip fracture. Patients with a hip fracture typically have at least one treatable secondary cause of osteoporosis, usually low vitamin D (osteomalacia). Similarly, 40% of women and more than 60% of men with osteoporosis have a secondary condition and a treatable cause of their low bone density. Admission and discharge fracture care checklists should include the following recommendations. 
  1.  
    Prescribe calcium (1,200 mg daily)
  2.  
    Prescribe vitamin D (minimum of 1,000 IU daily; if the patient’s vitamin D level is low, consider prescribing 50,000 IU weekly for 12 weeks)
  3.  
    Refer to physical medicine or physical therapy for fall prevention education
  4.  
    Ask the family or friends to perform a home safety check218
Potential Pitfalls and Preventive Measures (Table 50-8)
Table 50-8
Pearls and Pitfalls of Treatment of Pertrochanteric Fractures
Pearls Key Point Application
Anteromedial cortex is key to reduction Best defense against collapse/shortening
Bone quality and fracture pattern determines fixation Do not use a low-stability device in a high-instability risk fracture
Lateral wall continuity key functionality Prevent damage, repair as necessary
Patient recovery It is not the time of operation but the quality of life the patient enjoys later
Who owns the bone? Orthopedic surgeons
Pitfalls of Plates
Problem
Solution
Fracture unreduced Release traction
Expose anterior fracture line
Use Jocher or Cobb to disimpact
Check neck–shaft angle, AP translation at fracture site, and rotation: Not all reduce with IR
Fracture overdistracted No soft tissue attachment for ligamentotaxis; proceed with open reduction and use K-wires and Steinmann pins as joysticks with Weber for reduction compression
Fracture loss of reduction with plate Incorrect angle selection for plate
Check center guidewire. Is it centered in head and neck or eccentric?
Pitfalls of Nails
Problem
Solution
Loss of reduction with nail insertion Fully seat nail, then push on proximal nail guide medially to reduce and adjust neck–shaft angle, insert provisional pin
Provisionally fix fracture and reinsert nail
Screw position incorrect If screw is in valgus or varus, the reduction was lost. Remove screw, correct varus/valgus with nail guide manipulation, redrill, and insert screw in new path
Nail lies in posterior position of trochanter Entry portal damage during reaming. Lift up on nail guide and redrill guidewire. May consider blocking screw technique
Impaction screw migration Place >10 mm from articular surface: Correct tip–apex distance (TAD)
Lag screw migration Place TAD <25 mm from articular surface (TAD center–center CHS)
(TAD center–inferior nail)
Fracture propagation Do not force the nail into the femur
Extract and overream if nail does not advance with reasonable (by hand) force
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Treatment-Specific Outcomes.
Approximately 25% of pertrochanteric fractures return to preinjury functional levels following fixation with an SHS. The best results with SHSs are in A1 fractures with an anatomic reduction. Bendo et al.20 performed a retrospective analysis of postoperative fracture collapse in 142 patients with intertrochanteric hip fractures fixed anatomically with SHSs and reported collapse in 26 of the unstable fractures. Of the patients with moderate or severe collapse, 93% had a poor functional result, whereas all the patients with minimal collapse remained asymptomatic. Although postoperative fracture impaction of hips fixed with SHSs may promote early healing, a high rate of union, and a low rate of hardware failure, excessive collapse is a problem that needs to be addressed (Fig. 50-15). 
Figure 50-15
Healing short CHS AP radiograph.
 
Healing of 31A1 fracture with shortening. Note accessory lag screw back out and compression screw prominence in soft tissues.
Healing of 31A1 fracture with shortening. Note accessory lag screw back out and compression screw prominence in soft tissues.
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Figure 50-15
Healing short CHS AP radiograph.
Healing of 31A1 fracture with shortening. Note accessory lag screw back out and compression screw prominence in soft tissues.
Healing of 31A1 fracture with shortening. Note accessory lag screw back out and compression screw prominence in soft tissues.
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Watson et al.227 compared the Medoff plate to a standard SHS in a prospective randomized series of 160 stable and unstable intertrochanteric fractures; follow-up averaged 9.5 months (range: 6 to 26 months). Although stable fracture patterns united without complication in both treatment groups, there was a significantly higher failure rate with use of the SHS for unstable fractures (14% vs. 3%). No differences were observed between the two devices in terms of length of hospitalization, return to prefracture ambulatory status, postoperative living status, or need for postoperative analgesic medication. For all fracture types, however, use of the Medoff plate was associated with significantly greater blood loss and operating time. 
Olsson et al.163,164 reported a prospective randomized series of intertrochanteric fractures stabilized with either a Medoff plate or conventional SHS. In unstable fracture patterns, mean femoral shortening was significantly greater with use of the Medoff plate (15 vs. 11 mm) but the SHS was associated with more medialization of the femoral shaft. All failures occurred in the SHS group. 
Platzer et al.184 have expressed concern as to the amount of shortening with the use of SHSs in nongeriatric patients: The question is of functional impairment with excessive dynamic collapse. Zlowodzki et al.242 have recently quantified a lower SF-36 score with shortening of more than 5 mm in femoral neck fractures; it may be that the transitional displacement during the first 6 weeks after surgery with SHSs may be an underlying problem with recovery after surgery. 
Gotfried noted the high failure rate with lateral wall fractures with SHSs with secondary collapse and medialization. He ascribed this to damage of the lateral wall following drilling for the barrel of the side plate.84 In a recent editorial, Gotfried estimated a 15% rate of this complication with SHSs. This is supported by reports from Bendo20, Palm,170 and Stappaerts209 in three independent studies. 
Ekstrom et al. compared the proximal femoral nail (PFN, Synthes) with the Medoff sliding plate (MSP) in patients with unstable trochanteric or subtrochanteric fractures. They reported that the ability to walk 15 minutes at 6 weeks postoperative was significantly better in the PFN group compared to the MSP group with an odds ratio of 2.2 (p = 0.04, 95% confidence limits 1.03 to 4.67). Reoperations were more frequent in the PFN group (9%) compared to the MSP group (1%) but there were no other significant differences.60 
The majority of randomized studies reporting on the SHS are in comparison to various nail designs. Older studies with old design nails are simply obsolete for review, so the current literature is evolving as to the continuing application of this device. Specific randomized clinical trials (RCTs) for new devices compared to the SHS will be discussed under their respective sections. 

Rotationally Stable Linear Compression Class

Rotational stable plating differs from SHS fixation by adding enhanced rotational stability with multiple screw fixation in the femoral head. Since the screws are coupled to the plate, the rotational stability is much better than an accessory screw adjacent to standard single screw fixation. The percutaneous compression plate by Gotfried (Orthofix, McKinney, TX) has two smaller-diameter lag screw/barrel components, which stabilize the femoral head and neck (Fig. 50-16A, B). This device was designed to be used with a minimally invasive surgical technique. The two lag screw components (9.3 and 7 mm diameters) provide enhanced rotational stability of the proximal fracture.85 The device is available only with a 135-degree angle. It was reported initially by Gotfried in 98 fractures with good results with no collapse, head penetration, or cutout. 
Figure 50-16
 
A: Percutaneous compression plate (PCCP) (Orthofix). B: PCCP reduction and fixation. Note inferior placement of bottom screw and protection of the greater trochanter by distal plate position.
A: Percutaneous compression plate (PCCP) (Orthofix). B: PCCP reduction and fixation. Note inferior placement of bottom screw and protection of the greater trochanter by distal plate position.
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Figure 50-16
A: Percutaneous compression plate (PCCP) (Orthofix). B: PCCP reduction and fixation. Note inferior placement of bottom screw and protection of the greater trochanter by distal plate position.
A: Percutaneous compression plate (PCCP) (Orthofix). B: PCCP reduction and fixation. Note inferior placement of bottom screw and protection of the greater trochanter by distal plate position.
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PCCP Technique PCCP (Orthofix).
After fracture reduction, using a standard fracture table and the posterior reduction device, routine scrubbing and draping was carried out.83 Make a 2-cm incision in the lateral trochanteric area, followed by introduction of the plate, connected to the introducer, which slides along the upper lateral femoral shaft. The anteroposterior and lateral positions of the plate are checked under an image intensifier and necessary corrections were made. Make the second incision of approximately 2 cm just distal to the lesser trochanter. Introduce the percutaneous bone hook for reduction and clamping of the plate to the femur. Insert the main sleeve through the lower oblique hole in the plate. Insert the main guidewire into the femoral neck so that it is approximately 2 or 3 mm proximal to the calcar on the anteroposterior view and within the middle third of the femoral neck on the lateral view. The butterfly pin is then fixed for temporary fixation of the plate to the femur. The main guide and first sleeve are then replaced by the second sleeve and a 7-mm drill guide. A 7-mm hole is drilled. Next a final drilling of 9.3 mm is performed for the screw barrel. The first neck screw is screwed through the plate and the femoral neck up to the subchondral bone and the fracture is then compressed. The main sleeve is then removed and the short shaft sleeve inserted to drill and fix the three shaft screws through the second incision. The bone hook is withdrawn and the butterfly pin removed after insertion of the first shaft screw. The second, proximal, and neck screws are then placed in the same way as the first one. The introducer is disconnected and removed. The wound is irrigated and closed over a suction drain. 
Treatment-Specific Outcomes.
Peyser et al. in 2007 found in their randomized trial comparing SHS fixation and the PCCP that the pain score and ability to bear weight were significantly better in the PCCP group at 6 weeks postoperatively. Radiographically, there was a reduced amount of medial displacement in the PCCP group (two patients, 4%) compared with the SHS group (10 patients, 18.9%).183 
In a meta-analysis, Panesar et al.171 reviewed a number of comparative trials (1995 to 2006) comparing the SHS and the PCCP. There was a decreased trend in overall mortality in the PCCP group (CI 0.84, [0.48 to 1.47]). Similar trends favoring the PCCP technique were seen with the other outcomes. Yang et al.237 in a randomized prospective study of SHS fixation versus PCCP, documented patients repaired with the PCCP had improvements in pain, ambulatory ability, with improved SF-36 scores. 
Langford et al. in 2011 in a prospective randomized study reported an overall lateral wall fracture incidence of 20% in the SHS group versus 1.4% in the PCCP group (p < 0.01).138 They concluded that an anatomic reduction, combined with a device (PCCP) that requires small-diameter drilling in the lateral trochanteric wall, essentially eliminates iatrogenic lateral trochanteric wall fractures. 
Linear compression plating designs offer the potential to replace the original sliding compression hip screw since they prevent rotational instability allowing controlled axial collapse in a linear fashion minimizing bone erosion from rotation of the adjacent fracture edges. 

Trochanteric Buttress Plating and Locked Plating

Trochanteric buttress plating in conjunction with an SHS has offered a solution to uncontrolled collapse and is especially helpful with reverse obliquity fractures as originally described by Boyd. Martre et al. reported equivalent results in reverse obliquity fractures repaired with trochanteric buttress/SHSs compared to the InterTAN linear compression intramedullary nail.66 Buttress plate fixation is not currently popular in North America because of the concern of increased implant irritation. Also, the report of Babst et al.10 showed telescoping averaging 9.5 mm even with buttress plating in three- and four-part fractures. Buttress plating was successful in preventing cephalad greater trochanteric migration. 
Following the success of locking and hybrid locking plates used for unstable fractures of the distal femur, similar concepts are being applied to the proximal femur.97 The devices offer maximal stability with initial compression, and then fixed-angle stability from locking screws (Fig. 50-17A–C). Initial results are mixed due to a high early failure rate with original plate designs and screw limitations; however modifications of these implants continue to evolve. Connelly and Archdeacon48 reported surgical tactics for A3 complex proximal femoral fractures, using proximal femoral locking plates in 10 cases of complex proximal femur fractures, and obtained an anatomic reduction in 70% with positioning in the lateral decubitus position. The primary indication for these plates is highly comminuted proximal femoral fractures with lateral wall displacement in addition to comminution of the posteromedial cortex extending distal to the lesser trochanter. 
Figure 50-17
 
A: Hybrid locking plate system (Smith & Nephew, Memphis, TN). B: Lateral position with leg extended and abduction to 0 to 10 degrees. C: Positioning lateral decubitus with knee slight flexion and foot slight external rotation.
A: Hybrid locking plate system (Smith & Nephew, Memphis, TN). B: Lateral position with leg extended and abduction to 0 to 10 degrees. C: Positioning lateral decubitus with knee slight flexion and foot slight external rotation.
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Figure 50-17
A: Hybrid locking plate system (Smith & Nephew, Memphis, TN). B: Lateral position with leg extended and abduction to 0 to 10 degrees. C: Positioning lateral decubitus with knee slight flexion and foot slight external rotation.
A: Hybrid locking plate system (Smith & Nephew, Memphis, TN). B: Lateral position with leg extended and abduction to 0 to 10 degrees. C: Positioning lateral decubitus with knee slight flexion and foot slight external rotation.
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Preoperative Planning.
CT scanning is helpful in preoperative planning of these fractures. 
Positioning Supine as in SHS or Lateral Option.
The lateral position is most helpful for pertrochanteric fractures involving displacement of the greater trochanter. It allows free manipulation of the distal fracture and then allows mobility of the fracture to aid reduction of the greater trochanter after the head/neck and shaft are provisionally assembled. 
Figure 50-18
Proximal femoral locked plate case.
 
A: High-energy pertrochanteric fracture. B: AP radiograph traction view. C: CT reconstruction showing lateral wall involvement. D: Surgical approach centered over greater trochanter. E: Watson-Jones approach with incision and retraction of vastus lateralis proximally. F: Schanz pins inserted for shaft manipulation, and reduction of anteromedial wall secured with four-hole semitubular plate. G: Position of four-hole plate in relation anteriorly to proximal femoral plate placement and reduction of posterior trochanter to anterior trochanter. H: Trochanteric reduction with Weber clamp and femoral proximal locking plate provisional fixation with inferior calcar alpha screw position. I: Trochanteric fixation screw. J: Final reduction and fixation AP. K: Lateral final fixation. L: Relationship of final proximal femoral locking plate and anteromedial wall reduction plate (after Connelly and Archdeacon).
A: High-energy pertrochanteric fracture. B: AP radiograph traction view. C: CT reconstruction showing lateral wall involvement. D: Surgical approach centered over greater trochanter. E: Watson-Jones approach with incision and retraction of vastus lateralis proximally. F: Schanz pins inserted for shaft manipulation, and reduction of anteromedial wall secured with four-hole semitubular plate. G: Position of four-hole plate in relation anteriorly to proximal femoral plate placement and reduction of posterior trochanter to anterior trochanter. H: Trochanteric reduction with Weber clamp and femoral proximal locking plate provisional fixation with inferior calcar alpha screw position. I: Trochanteric fixation screw. J: Final reduction and fixation AP. K: Lateral final fixation. L: Relationship of final proximal femoral locking plate and anteromedial wall reduction plate (after Connelly and Archdeacon).
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A: High-energy pertrochanteric fracture. B: AP radiograph traction view. C: CT reconstruction showing lateral wall involvement. D: Surgical approach centered over greater trochanter. E: Watson-Jones approach with incision and retraction of vastus lateralis proximally. F: Schanz pins inserted for shaft manipulation, and reduction of anteromedial wall secured with four-hole semitubular plate. G: Position of four-hole plate in relation anteriorly to proximal femoral plate placement and reduction of posterior trochanter to anterior trochanter. H: Trochanteric reduction with Weber clamp and femoral proximal locking plate provisional fixation with inferior calcar alpha screw position. I: Trochanteric fixation screw. J: Final reduction and fixation AP. K: Lateral final fixation. L: Relationship of final proximal femoral locking plate and anteromedial wall reduction plate (after Connelly and Archdeacon).
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A: High-energy pertrochanteric fracture. B: AP radiograph traction view. C: CT reconstruction showing lateral wall involvement. D: Surgical approach centered over greater trochanter. E: Watson-Jones approach with incision and retraction of vastus lateralis proximally. F: Schanz pins inserted for shaft manipulation, and reduction of anteromedial wall secured with four-hole semitubular plate. G: Position of four-hole plate in relation anteriorly to proximal femoral plate placement and reduction of posterior trochanter to anterior trochanter. H: Trochanteric reduction with Weber clamp and femoral proximal locking plate provisional fixation with inferior calcar alpha screw position. I: Trochanteric fixation screw. J: Final reduction and fixation AP. K: Lateral final fixation. L: Relationship of final proximal femoral locking plate and anteromedial wall reduction plate (after Connelly and Archdeacon).
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Figure 50-18
Proximal femoral locked plate case.
A: High-energy pertrochanteric fracture. B: AP radiograph traction view. C: CT reconstruction showing lateral wall involvement. D: Surgical approach centered over greater trochanter. E: Watson-Jones approach with incision and retraction of vastus lateralis proximally. F: Schanz pins inserted for shaft manipulation, and reduction of anteromedial wall secured with four-hole semitubular plate. G: Position of four-hole plate in relation anteriorly to proximal femoral plate placement and reduction of posterior trochanter to anterior trochanter. H: Trochanteric reduction with Weber clamp and femoral proximal locking plate provisional fixation with inferior calcar alpha screw position. I: Trochanteric fixation screw. J: Final reduction and fixation AP. K: Lateral final fixation. L: Relationship of final proximal femoral locking plate and anteromedial wall reduction plate (after Connelly and Archdeacon).
A: High-energy pertrochanteric fracture. B: AP radiograph traction view. C: CT reconstruction showing lateral wall involvement. D: Surgical approach centered over greater trochanter. E: Watson-Jones approach with incision and retraction of vastus lateralis proximally. F: Schanz pins inserted for shaft manipulation, and reduction of anteromedial wall secured with four-hole semitubular plate. G: Position of four-hole plate in relation anteriorly to proximal femoral plate placement and reduction of posterior trochanter to anterior trochanter. H: Trochanteric reduction with Weber clamp and femoral proximal locking plate provisional fixation with inferior calcar alpha screw position. I: Trochanteric fixation screw. J: Final reduction and fixation AP. K: Lateral final fixation. L: Relationship of final proximal femoral locking plate and anteromedial wall reduction plate (after Connelly and Archdeacon).
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A: High-energy pertrochanteric fracture. B: AP radiograph traction view. C: CT reconstruction showing lateral wall involvement. D: Surgical approach centered over greater trochanter. E: Watson-Jones approach with incision and retraction of vastus lateralis proximally. F: Schanz pins inserted for shaft manipulation, and reduction of anteromedial wall secured with four-hole semitubular plate. G: Position of four-hole plate in relation anteriorly to proximal femoral plate placement and reduction of posterior trochanter to anterior trochanter. H: Trochanteric reduction with Weber clamp and femoral proximal locking plate provisional fixation with inferior calcar alpha screw position. I: Trochanteric fixation screw. J: Final reduction and fixation AP. K: Lateral final fixation. L: Relationship of final proximal femoral locking plate and anteromedial wall reduction plate (after Connelly and Archdeacon).
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A: High-energy pertrochanteric fracture. B: AP radiograph traction view. C: CT reconstruction showing lateral wall involvement. D: Surgical approach centered over greater trochanter. E: Watson-Jones approach with incision and retraction of vastus lateralis proximally. F: Schanz pins inserted for shaft manipulation, and reduction of anteromedial wall secured with four-hole semitubular plate. G: Position of four-hole plate in relation anteriorly to proximal femoral plate placement and reduction of posterior trochanter to anterior trochanter. H: Trochanteric reduction with Weber clamp and femoral proximal locking plate provisional fixation with inferior calcar alpha screw position. I: Trochanteric fixation screw. J: Final reduction and fixation AP. K: Lateral final fixation. L: Relationship of final proximal femoral locking plate and anteromedial wall reduction plate (after Connelly and Archdeacon).
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Proximal Femoral Locking Plate Technique (as suggested by Connelly and Archdeacon) (Fig. 50-18A–L)
A Watson-Jones surgical approach is performed. The vastus lateralis is released proximally from its origin leaving a cuff of tissue proximally for reattachment after fracture fixation (Fig. 50-18D). For better visualization of the anterior capsule, a blunt Hohman retractor is placed anteriorly and levered against the medial proximal femoral neck. The anteromedial wall and fracture site are exposed for reduction and Schanz pins are inserted anteroposteriorly into the shaft distal to the fracture for manipulation of the shaft to affect the reduction. The distal fragment is reduced to the proximal fragment anteriorly and secured with clamps and a temporary four-hole semitubular plate. This maneuver simultaneously restores rotation and alignment of the fracture. The posterior displacement is further reduced and secured with clamps and provisional K-wires. The greater trochanteric fragment is reduced with slight abduction of the leg and secured with clamps and provisional K-wires. Provisionally align the selected length proximal femoral locking plate such that the head screws will be in the proper trajectory along the femoral neck axis. The plate is secured with compression lag screws into the inferior femoral neck and greater trochanter and placement confirmed with fluoroscopy. Fixation of the plate to the hip and shaft is completed with lag and finally locking screws. The initial lag screws are replaced with locking screws. After irrigation and hemostatsis is obtained, the wound is closed in layers in the standard fashion. 
Postoperative Care.
Postoperative care is the same as for SHS with the exception of a maximum 50-lb weight bearing with crutches for 12 weeks to avoid premature plate failure. Range of motion and leg lift exercises are permitted the same as for SHS rehabilitation. Increased weight bearing is permitted with radiographic new bone formation and clinical symptoms, usually at 8 to 10 weeks. 
Potential Pitfalls and Preventive Measures.
The fractures treated with these techniques are the most unstable fractures and has a higher rate of implant breakage, and screw back-out can be expected in noncompliant patients and in delayed union situations. A proactive approach including bone grafting or early revision is indicated if any signs of implant migration or bending is observed radiographically. 
Placement of the screws in a locking mode require a bone-on-bone cortical reduction of the anterior cortex; if this is not possible, or if large defects are present after reduction, autogenous bone grafting may be considered. 
Treatment-Specific Outcomes.
Zha et al.239 2011 reported a 95% union rate with a proximal femoral locking plate for intertrochanteric fractures. Zhou et al.240 in 2012 reported success with less invasive stabilization system (LISS, DePuy Synthes, West Chester, PA) distal femoral plate for primarily A2 fractures with medial comminution with high union and low-implant failure rates, however the patients were maintained nonweight bearing until union. Connelly and Archdeacon48 reported a detailed technique and results of 10 complex cases with only one implant failure at 12 months. 
Wirtz and Abbassi233 reported a 37% major complication rate in 19 patients with revision surgery due to implant failure and migration. Similarly, Streubel et al.211 reported a similar 37% failure rate with varus collapse and implant failure and reported that either medial cortical reduction or a “kickstand screw” prevented failure. These cases did not use accessory out-of-plane fixation as described by Connelly and Archdeacon. 

Cephalomedullary Interlocking Nails

Cephalomedullary devices may be inserted through the piriformis fossa, the lateral greater trochanter, or the medial greater trochanter based on their design. The femoral head portion of the fixation construct consists of one or more screw or blade devices interlocked with the nail component of the construct. Cephalomedullary nails are commonly indicated in pertrochanteric and subtrochanteric fractures and although there is occasional overlap of these regions, the personality of the fracture will be predominantly one of these major types. These nails are designed to have either a pirforimis portal for insertion, with the nail straight in the AP plane or a trochanteric portal with the nail laterally angulated proximally. Modern trochanteric designs have moved to a 4 to 6 degree proximal bend positioned above the lesser trochanteric region, to improve fit in the proximal femur.167 
Cephalomedullary nail constructs have been similarly classified by Russell into four classes (Table 50-3).190 In order of invention, (1) the impaction class or “Y” nail class originated with the Küntscher “Y” nail and currently represented by the trochanteric femoral nail (Titanium femoral nail [TFN], DePuy Synthes, West Chester, PA) (Fig. 50-19A), (2) the dynamic compression or gamma class pioneered by the Grosse and Kempf, gamma nail (Stryker, NJ) (Fig. 50-19B) that consists of a large diameter nail proximally (15.5 to 18 mm) with a single large lag screw into the head, (3) the reconstruction class developed by Russell and Taylor (Smith & Nephew, Memphis, TN) (Fig. 50-19C) with a smaller proximal nail diameter (13 to 15 mm) and two separate proximal lag screws. Newer designs incorporate constrained screws Targon PFN (Proximal femoral nail) (Braun, Bethlehem, PA) and trochanteric portal designs (Fig. 50-19D), and (4) the InterTAN class (Smith & Nephew, Memphis), comprising a medial trochanteric entry design with a trapezoidal proximal cross section (similar to a hip arthroplasty stem) and an integrated two-screw construct with linear compression at the fracture site, developed by Russell and Sanders (Fig. 50-19E). 
Figure 50-19
 
A: Impaction class: Short trochanteric fixation nail (TFN, Synthes, Paoli). B: Gamma class: Short gamma 3 cephalomedullary nail (Stryker, NJ). C: Reconstruction class: TriGen short trochanteric antegrade nail (TAN, Smith & Nephew, Memphis). D: Reconstruction class: Constrained Targon PFN (Braun, Bethlehem, PA). E: InterTAN class: Short InterTAN cephalomedullary nail with integrated screws and hybrid trapezoidal stem design (Smith & Nephew, Memphis).
A: Impaction class: Short trochanteric fixation nail (TFN, Synthes, Paoli). B: Gamma class: Short gamma 3 cephalomedullary nail (Stryker, NJ). C: Reconstruction class: TriGen short trochanteric antegrade nail (TAN, Smith & Nephew, Memphis). D: Reconstruction class: Constrained Targon PFN (Braun, Bethlehem, PA). E: InterTAN class: Short InterTAN cephalomedullary nail with integrated screws and hybrid trapezoidal stem design (Smith & Nephew, Memphis).
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A: Impaction class: Short trochanteric fixation nail (TFN, Synthes, Paoli). B: Gamma class: Short gamma 3 cephalomedullary nail (Stryker, NJ). C: Reconstruction class: TriGen short trochanteric antegrade nail (TAN, Smith & Nephew, Memphis). D: Reconstruction class: Constrained Targon PFN (Braun, Bethlehem, PA). E: InterTAN class: Short InterTAN cephalomedullary nail with integrated screws and hybrid trapezoidal stem design (Smith & Nephew, Memphis).
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Figure 50-19
A: Impaction class: Short trochanteric fixation nail (TFN, Synthes, Paoli). B: Gamma class: Short gamma 3 cephalomedullary nail (Stryker, NJ). C: Reconstruction class: TriGen short trochanteric antegrade nail (TAN, Smith & Nephew, Memphis). D: Reconstruction class: Constrained Targon PFN (Braun, Bethlehem, PA). E: InterTAN class: Short InterTAN cephalomedullary nail with integrated screws and hybrid trapezoidal stem design (Smith & Nephew, Memphis).
A: Impaction class: Short trochanteric fixation nail (TFN, Synthes, Paoli). B: Gamma class: Short gamma 3 cephalomedullary nail (Stryker, NJ). C: Reconstruction class: TriGen short trochanteric antegrade nail (TAN, Smith & Nephew, Memphis). D: Reconstruction class: Constrained Targon PFN (Braun, Bethlehem, PA). E: InterTAN class: Short InterTAN cephalomedullary nail with integrated screws and hybrid trapezoidal stem design (Smith & Nephew, Memphis).
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A: Impaction class: Short trochanteric fixation nail (TFN, Synthes, Paoli). B: Gamma class: Short gamma 3 cephalomedullary nail (Stryker, NJ). C: Reconstruction class: TriGen short trochanteric antegrade nail (TAN, Smith & Nephew, Memphis). D: Reconstruction class: Constrained Targon PFN (Braun, Bethlehem, PA). E: InterTAN class: Short InterTAN cephalomedullary nail with integrated screws and hybrid trapezoidal stem design (Smith & Nephew, Memphis).
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Preoperative Planning.
I use the fracture morphology Dorr classification to optimize the size of the implant footprint for the bone stock available (Fig. 50-6). For the Dorr “A” type fractures with small canals, a plate device or reconstruction class nail would be chosen for bone conservation. For the Dorr “B” type fractures either a short nail or side plate would be equally efficacious, and for the Dorr “C” type anatomy with a wide metaphysis and a “stove-pipe” large capacious medullary canal, a larger head cephalomedullary nail may offer advantages of fit and fill. My personal preference is to use a longer nail for the A3 type fractures. 
Intraoperative length measurements of the normal femur may be helpful in selecting the correct length nail in complex fractures (Fig. 50-20). Determination of preoperative neck–shaft angle and medullary canal diameter is important to select the correct nail device as different manufacturers have different neck–shaft angle and diameter nails. Another important consideration is nail curvature for long nails. Nails with a radius of curvature of 1.5 to 2 m are applicable to most situations. It is important to note that multiple variables come into play in deciding on the treatment of a hip fracture. As the entry portal has moved from a piriformis or a lateral trochanteric portal to a medial trochanteric portal at the tip of the trochanter the alignment of the curvature of the long nails is more compatible with the distal femoral anatomy. Anterior cortical perforation with long nails has been reported and can be avoided by proper nail entry, avoiding a posterior starting point, insertion of the guidewire to the distal epiphyseal scar, maintaining the guidewire in place centrally in the distal metaphysis until seating of the nail tip, and by use of 1.5-m radius nails. Excessive curvature of the femur has been described in Asian patients.166 For the intermediate sizes of bone (Dorr type B) either plate and screw devices or short intramedullary nails may be appropriate. 
Figure 50-20
Using contralateral extremity to measure nail selection for comminuted fracture.
 
Nail package with anticipated nail length measured with intraoperative C-arm. Locate nail to lie at tip of greater trochanter to distal physeal scar. This length allows adequate length restoration.
Nail package with anticipated nail length measured with intraoperative C-arm. Locate nail to lie at tip of greater trochanter to distal physeal scar. This length allows adequate length restoration.
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Figure 50-20
Using contralateral extremity to measure nail selection for comminuted fracture.
Nail package with anticipated nail length measured with intraoperative C-arm. Locate nail to lie at tip of greater trochanter to distal physeal scar. This length allows adequate length restoration.
Nail package with anticipated nail length measured with intraoperative C-arm. Locate nail to lie at tip of greater trochanter to distal physeal scar. This length allows adequate length restoration.
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Positioning.
Intramedullary techniques for the proximal femur are best managed with a modern fracture table with image intensification (C-arm) capabilities (Fig. 50-9A–D). Though the lateral decubitus approach may be helpful for reverse obliquity patterns, the supine position is usually preferred because of the ease of setup and radiographic visualization in a familiar frame of reference. Setup and positioning are the same as for ORIF with plate techniques. 
Surgical Approach.
The incision for nail insertion is determined by the intersection of a line from the anterior superior iliac spine directed posteriorly and a line parallel to the long axis of the femur. Overlay a 3.2 mm guidewire on the skin anteriorly and laterally and confirm alignment with the proximal femur using the image intensifier. Incise the skin proximally from the tip of the greater trochanter; usually a 3- to 5-cm incision is adequate. The fascia is incised but the gluteus medius fibers are not dissected, as this approach is designed to minimize soft tissue damage about the proximal femur. A nail system with a targeting guide and trocar system helps protect the gluteus medius. Separate incisions for the proximal fixation are made through small lateral incisions (Fig. 50-21). 
Figure 50-21
Intramedullary approach.
 
Incision is placed center to slightly posterior to line of femoral shaft centered between the anterior superior and inferior iliac spines anteriorly. Incision length is 3 to 5 cm.
Incision is placed center to slightly posterior to line of femoral shaft centered between the anterior superior and inferior iliac spines anteriorly. Incision length is 3 to 5 cm.
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Figure 50-21
Intramedullary approach.
Incision is placed center to slightly posterior to line of femoral shaft centered between the anterior superior and inferior iliac spines anteriorly. Incision length is 3 to 5 cm.
Incision is placed center to slightly posterior to line of femoral shaft centered between the anterior superior and inferior iliac spines anteriorly. Incision length is 3 to 5 cm.
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Common Surgical Technique for Cephalomedullary Nails.
Russell et al. have described the surgical approach for minimally invasive nail insertion191 based on three components of proximal femoral preparation: (1) precision portal placement, (2) trajectory control, and (3) portal preservation. A precise starting point is the first criterion in assuring an accurate fracture reduction of proximal fractures, whether the entry portal is a modified trochanteric entry portal or a piriformis portal. The medial trochanteric portal and trochanteric tip start points have become the preferred portal for nail techniques for hip fractures for reasons of both mechanical stability and minimal soft tissue damage to the gluteus medius.181 The proximal femur has a solid cancellous bone architecture from the femoral head region until the level just below the lesser trochanter, where the medullary canal begins. Trajectory control is the development of a precise path for the nail through this solid cancellous bone, which will restore the proximal alignment in the anterior–posterior and medial–lateral planes. This correct trajectory parallels the anterior cortex of the proximal femur and allows nail juxtaposition against a solid cortical structure. An incorrect trajectory will induce malalignment with nail insertion and result in an unstable juxtaposition against cancellous bone only, allowing the proximal portion of the nail to migrate to the posterior cortex and inducing a flexion deformity of the proximal fragment. Once the correct trajectory is established, the portal and the lateral wall of the trochanter must be protected from erosion and fragmentation by the subsequent reaming and canal preparation. Typically with the patient in a supine position this erosion takes place in a posterolateral direction, further contributing to a flexed and varus position of the proximal fragment with nail insertion. A stepwise approach to canal preparation will simplify the nail insertion technique. 
Portal Acquisition.
Insert the guidewire drill system with soft tissue protection to the region of the greater trochanter and insert a 3.2-mm guidewire approximately 5 to 10 mm into bone in the lateral aspect of the greater trochanter. This is a pivot pin about which a honeycomb-type targeter can be adjusted to precisely place the definitive guidewire pin just medial to the tip of the greater trochanter, and centered in the femoral neck on the lateral radiographic view. The definitive guidewire should be inserted 10 to 15 mm into the trochanter and does not have to be in correct canal alignment as the definitive trajectory will be obtained in the next step (Fig. 50-22A, B). 
Figure 50-22
 
A: AP guidewire options: Tip of trochanter for most 4- to 5-degree angle nails or medial trochanter to minimize gluteus medius tendon damage and allow optimal compression with InterTAN nail. B: Lateral position should permit nail proximity to anterior cortex not posterior cortex and allow center position of head fixation. C: Medial trochanteric portal with reamer. D: Parallel anterior cortex with channel reamer for correct trajectory control. E: Reducer for subtrochanteric extension or segmental fractures. F: Use reducer to position distal guidewire centered on lateral radiograph to minimize risk of distal nail penetration.
A: AP guidewire options: Tip of trochanter for most 4- to 5-degree angle nails or medial trochanter to minimize gluteus medius tendon damage and allow optimal compression with InterTAN nail. B: Lateral position should permit nail proximity to anterior cortex not posterior cortex and allow center position of head fixation. C: Medial trochanteric portal with reamer. D: Parallel anterior cortex with channel reamer for correct trajectory control. E: Reducer for subtrochanteric extension or segmental fractures. F: Use reducer to position distal guidewire centered on lateral radiograph to minimize risk of distal nail penetration.
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Figure 50-22
A: AP guidewire options: Tip of trochanter for most 4- to 5-degree angle nails or medial trochanter to minimize gluteus medius tendon damage and allow optimal compression with InterTAN nail. B: Lateral position should permit nail proximity to anterior cortex not posterior cortex and allow center position of head fixation. C: Medial trochanteric portal with reamer. D: Parallel anterior cortex with channel reamer for correct trajectory control. E: Reducer for subtrochanteric extension or segmental fractures. F: Use reducer to position distal guidewire centered on lateral radiograph to minimize risk of distal nail penetration.
A: AP guidewire options: Tip of trochanter for most 4- to 5-degree angle nails or medial trochanter to minimize gluteus medius tendon damage and allow optimal compression with InterTAN nail. B: Lateral position should permit nail proximity to anterior cortex not posterior cortex and allow center position of head fixation. C: Medial trochanteric portal with reamer. D: Parallel anterior cortex with channel reamer for correct trajectory control. E: Reducer for subtrochanteric extension or segmental fractures. F: Use reducer to position distal guidewire centered on lateral radiograph to minimize risk of distal nail penetration.
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Use a cannulated rigid reamer, preferably with modular end cutting capability, that approximates the proximal nail geometry diameter and introduce it over the guidewire through the protective sleeve. Advance the rigid reamer toward a point projected in the center of the medullary canal just distal to the region of the lesser trochanter (Fig. 50-22C, D). Advance the reamer stepwise confirming maintenance of trajectory. After the reamer has been inserted approximately 20 mm, confirm reamer trajectory with a lateral C-arm view. The reamer should be directed along the anterior cortex of the proximal femur. Insert the reamer until it reaches the medullary canal just below the region of the lesser trochanter. Remove the inner reamer and maintain the outer reamer for protection of the proximal reamer during the next step. Do not force the reamer through the greater trochanter as it will have two deleterious effects: (1) forcing the fracture line apart directing the proximal fragment into varus and (2) insufficient bone removal in the metaphysis for nail containment, thus forcing the fracture apart during nail insertion. Insert a reduction aid or similar curved cannulated device through the retained channel reamer to the fracture site and thread it through the fracture site into the distal fragment intramedullary canal with manipulation in appropriate planes to align the fracture (Fig. 50-22E). A combination of a percutaneous Schanz pin in the anterior distal shaft component in conjunction with a percutaneous ball spike pusher on the anterior proximal cortex can effect a reduction. A Kirschner wire can then be introduced in a longitudinal direction from the anterolateral trochanter into the medial cortex of the proximal fragment just above the lesser trochanteric region for provisional fixation. Ookuma and Fukuda reported that the anteromedial reduction can be obtained percutaneously with a 3.2-mm wire inserted in the same fashion as described by Carr. Furthermore, they developed a reduction classification which showed less fracture collapse with anteromedial reduction on the AP and lateral planes compared to intramedullary reduction of the proximal medial cortex into the distal medullary canal.165 
For more complex fracture patterns, limited open reduction is indicated. The head and neck to shaft reduction can be obtained by manipulating the fracture in a manner similar to the side plate technique. A lateral approach anterior to the site of the lag screw insertion can be made to allow placement of a bone hook or Weber clamp as needed. A small accessory incision anterior to the femur at the level of the femoral neck will allow insertion of the Jocher elevator or ball spike pusher (Fig. 50-23A–C). 
Figure 50-23
Reduction tactics for cephalomedullary nail technique.
 
A: Bone hook over anteromedial femur reducing the anteromedial cortex, bone elevator lifting up on posterior femur for alignment and correction of posterior sag, provisional pin from lateral femur into proximal femoral neck and trochanteric tip entry pin. B: AP radiographic view of technique. C: Lateral radiographic view of technique.
A: Bone hook over anteromedial femur reducing the anteromedial cortex, bone elevator lifting up on posterior femur for alignment and correction of posterior sag, provisional pin from lateral femur into proximal femoral neck and trochanteric tip entry pin. B: AP radiographic view of technique. C: Lateral radiographic view of technique.
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Figure 50-23
Reduction tactics for cephalomedullary nail technique.
A: Bone hook over anteromedial femur reducing the anteromedial cortex, bone elevator lifting up on posterior femur for alignment and correction of posterior sag, provisional pin from lateral femur into proximal femoral neck and trochanteric tip entry pin. B: AP radiographic view of technique. C: Lateral radiographic view of technique.
A: Bone hook over anteromedial femur reducing the anteromedial cortex, bone elevator lifting up on posterior femur for alignment and correction of posterior sag, provisional pin from lateral femur into proximal femoral neck and trochanteric tip entry pin. B: AP radiographic view of technique. C: Lateral radiographic view of technique.
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Insert a long guidewire to the knee if a long nail is desired, confirming that the wire does not impinge on the anterior cortex distally. Anterior cortical perforation can be a major problem in the elderly due to an increased bow of the femur. Preferably the guidewire should be inserted distally to the old physeal scar and centered on AP and (especially) the lateral C-arm views (Fig. 50-22F). Remove the reducer, and maintain the guidewire position with an obturator proximally. Length is measured with an appropriate ruler, allowing for fracture distraction and nail final position. Ream the diaphyseal region up to 1 mm over the desired nail size or for excessive anterior bows, ream up to 2 mm. The proximal expansion of the nail should have already been reamed with the entry portal reamer, but always confirm diameters. Remove the channel reamer maintaining the guidewire and insert the selected nail based on the nail design, taking care to maintain reduction during nail insertion with either provisional pins or clamps. Proximal and distal interlocking will vary based on the nail type. The selected nail is inserted over the 3-mm guidewire. Check anteversion alignment on the lateral radiograph and center the alignment guide inside the lateral screw holes in the nail with the femoral head bisected by the nail. Impact the nail into the canal and move to an AP position with the C-arm maintaining the anterversion position of the nail guide. As with SHS techniques a center–center or inferior-center position for two-screw designs, is optimal for the head component fixation. Specific techniques for the respective nail classes are as follows. 
Impaction Class.
The impaction class was first developed by Küntscher as the Y-nail in the 1940s. The trochanteric fixation nail (TFN, Synthes, Paoli) device reintroduced an impaction nail component for the femoral head in the form of a helical blade design of 11 mm inserted into a nail with a 17-mm proximal geometry; there are short and long interlocking versions.75 Sommers et al.208 in a biomechanical study showed better resistance to rotation with the helical blade compared to single-screw designs. The surgical technique does not require reaming of the femoral head thus saving bone stock and preventing instability of the fracture by a loose nail. 
TFN Technique.
The technique is the same as the preceding Common Cephalomedullary Nail technique with the following exceptions. In osteoporotic bone the lateral cortex only is drilled with the 11-mm reamer. Determine the cephalic nail length and insert the femoral head nail with gentle impaction. Do not use this technique for nonosteoporotic bone as it will cause distraction and loss of reduction. After final seating, lock the helical blade to the femoral nail component with rotation of the impaction connection. Distal locking is carried out for short nails with the attached proximal targeting arm and for long nails a free-hand technique is used. 
Potential Pitfalls and Preventive Measures.
The impaction technique is only recommended for osteoporotic fractures. In patients with normal bone density, impaction may lead to distraction of the fracture site or fragmentation of the head/neck. Exercise care not to penetrate the blade too deeply or central penetration of the blade can occur with femoral neck shortening. 
Treatment-Specific Outcomes.
Davis et al.53 assessed outcomes and the etiology of mechanical failure in a series of 230 intertrochanteric femoral fractures internally fixed with either an SHS or a Küntscher Y-nail. The cutout rate for the Y-nail was 8.8% versus 12.6% for the SHS overall. Cutout was related to the quality of the fracture reduction; age, walking ability, and bone density had no significant influence on cutout. Center–center placement of the head fixation device correlated with less cutout and posterior placement increased cutout in both groups. Y-nail cutout or medial penetration increased with articular placement <10 mm from tip of nail (23% Y-nail, 11% SHS) whereas Y-nail cutout decreased with tip placement >10 mm (3% Y-nail vs. 18% SHS).53 
Gill et al.80 compared SHS devices with TFN devices and revealed comparable clinical results but a faster operative time for the TFN group. Gardner et al. reported good results with the TFN, but noted that subtle migration (approximately 2 mm) of the tip of the blade within the femoral head occurred in all fractures. However, this did not preclude maintenance of reduction and fracture healing. They noted telescoping averaged 4 mm and did not affect stable fixation or fracture healing. All position changes occurred within the first 6 weeks postoperatively.75 Weil et al.228 reported medial penetration of the TFN in eight cases (all unstable intertrochanteric fracture patterns, AO/OTA 32A2) analogous to the Y-nail–type penetrations described earlier. 
Bienkowski et al.25 reported 71% of patients returned to preambulatory levels with the TFN compared to 33% of SHS patient, but the study was small. 
Paul et al.179 reported on the important effect of calcar anteromedial reduction of the hip, with compression through the TFN device. At union, mean collapse was 3.3 mm (SD = 2.41 mm) in the unstable fracture group versus 1.2 mm (SD = 0.81 mm) in the stable fracture group (p = 0.004). The stable group recovered 95% of the single limb stance versus 91% in the unstable group, at 1 year (p = 0.02). Return of single limb stance improved from 76% to 95% between 6 weeks and 6 months. No improvement in gait was seen after 6 months (p > 0.05). The average scores on the physical and mental components of 36-item short-form health survey (SF-36) and Harris Hip Scores were well maintained relative to population norms. The radiographic union rate was 100%. There was one (3%) screw cutout. This suggests the important benefit of anatomic anteromedial reduction and a stable internal fixation construct. 

Gamma Class Cephalomedullary Nail (Single Lag Screw Dynamic Compression Fixation) (Examples: Gamma–Stryker)

Since the introduction of the gamma nail in the early 1980s, an exhaustive series of studies have resulted in changes in technique and nail design. Though initially a lateral trochanteric entry nail with a 10-degree angle and a short nail, the design is now in its third major revision with a decrease in proximal nail diameter to 15.5 mm from 17 mm, a decrease in angulation to 4 degrees, and a recommendation for a trochanteric tip entry site. Due to a high incidence of distal fracture at the tip of the nail with the initial design, the distal geometry has subsequently been tapered to decrease this risk. 

Gamma Technique

Refer to the Common Cephalomedullary Nail Technique for general aspects of the procedure. At the point of nail insertion, use the proximal alignment guide, insert the nail to a depth that will place the guidewire for the compression screw in a slightly inferior position from the center–center position in the head and neck and confirm rotational alignment on the lateral radiograph (Fig. 50-24A–D). The surgical technique guide does not encourage the forceful insertion of the nail with a hammer: This may cause difficulty with insertion and require additional proximal reaming to ensure sufficient depth insertion. Make a lateral incision on the thigh in line with the anteversion position of the nail guide and insert the trocar to bone. During this step anteversion may be misaligned: Do not insert the drill for proximal screw fixation until both depth of nail insertion and anteversion are certain. Drill a guidewire to within 5 mm of subchondral bone, confirm fracture reduction, and measure the length to lateral cortex. If compression is desired (usually 5 mm), ream for the screw and select a screw 5 mm shorter than measured. Insert the head fixation screw or nail to the desired depth and confirm on AP and lateral C-arm views. Insert the locking nut into the proximal nail canal and advance and tighten to the lag screw to prevent migration or rotation of the femoral head fixation. 
Figure 50-24
Gamma class technique.
 
A: Placement of the nail by hand down the medullary canal. B, C: Use of the sure-shot guide to help determine correct nail positioning to allow placement of the lag screw in the center of the femoral head and neck. D: Insertion of the lag screw through the intramedullary nail. E: Reverse obliquity 31A3 fracture. F: Anatomic reduction and optimal nail screw position.
A: Placement of the nail by hand down the medullary canal. B, C: Use of the sure-shot guide to help determine correct nail positioning to allow placement of the lag screw in the center of the femoral head and neck. D: Insertion of the lag screw through the intramedullary nail. E: Reverse obliquity 31A3 fracture. F: Anatomic reduction and optimal nail screw position.
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Figure 50-24
Gamma class technique.
A: Placement of the nail by hand down the medullary canal. B, C: Use of the sure-shot guide to help determine correct nail positioning to allow placement of the lag screw in the center of the femoral head and neck. D: Insertion of the lag screw through the intramedullary nail. E: Reverse obliquity 31A3 fracture. F: Anatomic reduction and optimal nail screw position.
A: Placement of the nail by hand down the medullary canal. B, C: Use of the sure-shot guide to help determine correct nail positioning to allow placement of the lag screw in the center of the femoral head and neck. D: Insertion of the lag screw through the intramedullary nail. E: Reverse obliquity 31A3 fracture. F: Anatomic reduction and optimal nail screw position.
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Proceed with distal locking as desired with bicortical screw fixation, preferably in a dynamic mode. One distal locking screw and a short nail is sufficient for most pertrochanteric fractures which do not extend below the lesser trochanter. For distal extension below the lesser trochanter, a long nail is preferable. Long nails require distal interlocking with a free-hand technique (Fig. 50-24E, F). 
Treatment-Specific Outcomes.
Clinical studies on this topic must be considered in light of different designs and time periods for correct analysis. Adams et al.3 reported a prospective randomized study comparing an SHS to an intramedullary nail for treatment of intertrochanteric fractures. Two-hundred and three patients were stabilized with a short gamma nail whereas 197 received an SHS. Patients were followed for 1 year. Use of the gamma nail was associated with a nonsignificant higher risk of postoperative complications and equivalent union and functional results. 
Hardy et al.94 in 1988 reported the intramedullary hip screw device compared to the SHS was associated with significantly less sliding of the lag screw and subsequent shortening of the limb in the region of the thigh. Patients whose fractures were stabilized using the intramedullary hip screw experienced significantly better mobility at 1- and 3-month follow-up. This difference was no longer seen at 6 and 12 months, although patients who received the intramedullary device enjoyed significantly better walking ability outside the home at all time periods. 
Ahrengart et al.4 in an early study of gamma nailing showed less progressive deformity in nails versus compression hip screws. Most of the errors with the gamma nail were technical and results were equivalent with regard to union and reoperation. They suggested using the nail for more complex fractures and an SHS device for simple fractures. Bojan et al.28 reviewed the Strasbourg, France experience in 3,066 consecutive early-generation gamma nails for trochanteric fractures between 1990 and 2002 at the Centre de Traumatologie et de l’Orthopedie, the design center for the gamma nail. The results showed a low complication rate, with 137 (4.5%) intraoperative fracture-related complications. There were 189 (6.2%) complications detected postoperatively and during follow-up. Cutout of the lag screw from the femoral head was the most frequent mechanical complication (57 patients, 1.85%), whereas a femoral shaft fracture at the tip of the nail occurred in 19 patients (0.6%). However, follow-up was marginal: Only 1,980 patients had at least one follow-up visit documented. Utrilla et al.222 reported on the third-generation gamma nail with a 180 mm length, a medial–lateral proximal angle of 4 degrees, and a proximal diameter of 17 mm with distal diameter tapered to 11 mm. In this randomized prospective study, the new design and technique improvements resulted in equivalence in the perioperative complication rate, rate of fixation failure, and peri-implant fractures compared to an SHS device. The only functional difference was improved walking ability in unstable fractures with the gamma nail group. 
In a meta-analysis of studies comparing gamma nails to SHS devices the increased risk of femoral shaft fracture with gamma nails had been reduced, but that there were no convincing differences in outcome between the two groups.23,175 
In a 2010 study of 210 patients, Barton et al. refocused the nail/plate debate on AO/OTA 31A2 fractures by making the primary outcome measure reoperation. They advocated implant cost as the primary reason to prefer the SHS over the long gamma nail in light of no detectable improvement in mortality or functional outcome.14 Criteria for reoperation were screw cutout, implant failure, late fracture, and deep infection. The power analysis was based on published departmental data and a previous clinical audit reporting a 5% failure for the long gamma nail and 18% failure rate for the SHS. The reoperation rate for the long gamma nail was 3% and the compression hip screw 1.8% in the study. The authors noted that half the patients had reduced mental capacity and the results were from telephone interviews making underreporting of symptoms probable. 

Reconstruction Class (Dynamic Compression Two-Screw Head Fixation) Cephalomedullary Interlocking Nails

Reconstruction Nail Class (Two-Screw Head Components).
Reconstruction nails (Smith & Nephew, Memphis, TN) were initially developed by Russell and Taylor in 1984, and were designed primarily for complex subtrochanteric fractures and pathologic fractures. In 1991, the Russell–Taylor reconstruction nail was first described for the fixation of intertrochanteric fractures in four cases.107 Different versions of this device have in common a smaller diameter proximal nail portion (13 to 15 mm), two lag screws into the head and neck of various diameters, and long and short nail lengths. The original piriformis start point (straight) nails have been modified for medial or tip trochanteric portal insertion (such as the Holland nail, Variwall nail, TriGen nail, and Targon PF nail) which simplifies treatment for pertrochanteric fractures. Piriformis start point nails do not have optimal containment in the trochanter due to their posterior placement in relation to the femoral head and neck. This transfers essentially all the load to the head/neck lag screws. Trochanteric start point versions allow better containment of the nail in the proximal femur and are optimally placed to minimize femoral neck shortening (Fig. 50-25A–C). 
Figure 50-25
 
A: 31A3 with subtrochanteric extension. B: Reduction and repair with long TriGen trochanteric reconstruction nail. C: Recon case lateral postoperative radiograph.
A: 31A3 with subtrochanteric extension. B: Reduction and repair with long TriGen trochanteric reconstruction nail. C: Recon case lateral postoperative radiograph.
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Figure 50-25
A: 31A3 with subtrochanteric extension. B: Reduction and repair with long TriGen trochanteric reconstruction nail. C: Recon case lateral postoperative radiograph.
A: 31A3 with subtrochanteric extension. B: Reduction and repair with long TriGen trochanteric reconstruction nail. C: Recon case lateral postoperative radiograph.
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Reconstruction Nail Technique.
Refer to the common cephalomedullary nail technique to the point of nail insertion. For long trochanteric nails it is helpful to rotate the nail 90 degrees anteriorly during the first half of the nail insertion to minimize hoop stresses in the proximal femur; after partial insertion the nail is rotated to the anticipated anteversion required for femoral head fixation (Fig. 50-26A, B). Insert the last 5 cm of the nail after releasing distraction to allow fracture compression while maintaining correct rotational alignment. Most commercial guides use reference marks to align with the femoral head on the lateral C-arm view. These same guides may be used for C-arm verification of correct depth of insertion to allow optimal femoral head fixation. Remove the long guide rod to proceed with interlocking. 
Figure 50-26
 
A: 31A1 fracture in Dorr A bone. B: Trochanteric nails with a 5-degree proximal bend should be inserted with 90 degrees of internal rotation initially and then rotated externally at 50% insertion to minimize hoop stress at the insertion site. C: With Recon technique the bottom guidewire should be inserted first and just above the inferior femoral neck. D: Inferior screw placed and drilling for proximal screw. E: Optimal lateral position of nail and screws. F: Final head fixation AP radiograph.
A: 31A1 fracture in Dorr A bone. B: Trochanteric nails with a 5-degree proximal bend should be inserted with 90 degrees of internal rotation initially and then rotated externally at 50% insertion to minimize hoop stress at the insertion site. C: With Recon technique the bottom guidewire should be inserted first and just above the inferior femoral neck. D: Inferior screw placed and drilling for proximal screw. E: Optimal lateral position of nail and screws. F: Final head fixation AP radiograph.
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Figure 50-26
A: 31A1 fracture in Dorr A bone. B: Trochanteric nails with a 5-degree proximal bend should be inserted with 90 degrees of internal rotation initially and then rotated externally at 50% insertion to minimize hoop stress at the insertion site. C: With Recon technique the bottom guidewire should be inserted first and just above the inferior femoral neck. D: Inferior screw placed and drilling for proximal screw. E: Optimal lateral position of nail and screws. F: Final head fixation AP radiograph.
A: 31A1 fracture in Dorr A bone. B: Trochanteric nails with a 5-degree proximal bend should be inserted with 90 degrees of internal rotation initially and then rotated externally at 50% insertion to minimize hoop stress at the insertion site. C: With Recon technique the bottom guidewire should be inserted first and just above the inferior femoral neck. D: Inferior screw placed and drilling for proximal screw. E: Optimal lateral position of nail and screws. F: Final head fixation AP radiograph.
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Correct anteversion alignment requires rotation of the C-arm to obtain a true lateral view of the hip. The nail guide and nail are superimposed by rotating the handle until equal amounts of femoral head are visualized anterior and posterior to the nail and guide; this position will center the guidewire on the head from the lateral reference point. Using the proximal guide, with the true AP view, insert the nail until the depth centers the head/neck screw guidewire on the AP view. Using the proximal targeting guide attached to the nail, insert the distal most proximal guidewire along the femoral calcar within 5 mm of the inferior femoral neck (and centered on the lateral C-arm) view to within 5 mm of subchondral bone (Fig. 50-26C). Through the proximal targeting guide attached to the nail, insert the most proximal guide pin (which will be close to the center position of the femoral head) parallel to the first guide pin and confirm its position with C-arm. Remove the inferior guidewire and drill and ream for the selected lag screw for the system and insert the inferior screw (Fig. 50-26D). Next repeat the same steps for the proximal screw. Release traction before final tightening of the lag screws to allow fracture compression (Fig. 50-26E, F). Proceed with distal interlocking with a free-hand image-guided technique. 
Potential Pitfalls and Preventive Measures.
For unstable fracture patterns, constrained screw designs have been developed to avoid the potential instability of displacement of the inferior and superior screws (Fig. 50-27). Reconstruction nails should be used with caution in unstable proximal femoral fractures in which anteromedial cortical reduction cannot be achieved or if there is incompetence in the lateral wall. This will compromise the lateral stability for the femoral head lag screws. 
Figure 50-27
Demonstration of the “Z effect,” with one screw penetrating the hip joint and the other screw backing out of the nail.
 
(Courtesy of Enes Kanlic MD, Texas Tech University Health Sciences Center, El Paso, TX.)
(Courtesy of Enes Kanlic MD, Texas Tech University Health Sciences Center, El Paso, TX.)
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Figure 50-27
Demonstration of the “Z effect,” with one screw penetrating the hip joint and the other screw backing out of the nail.
(Courtesy of Enes Kanlic MD, Texas Tech University Health Sciences Center, El Paso, TX.)
(Courtesy of Enes Kanlic MD, Texas Tech University Health Sciences Center, El Paso, TX.)
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Treatment-Specific Outcomes.
Seif-Asaad et al.200 reported good results in 40 patients with unstable intertrochanteric fractures (12 patients having subtrochanteric extension) treated with a reconstruction nail. Thirty-nine patients healed without deformity or shortening or varus collapse. 
Little et al.,143 using a reconstruction nail in a comparative series with SHS devices, demonstrated less blood loss and transfusion, and no cutout in the nail group: All fractures united. In a more complex group with both pathologic and multiple trauma cases, Krastman et al.127 reported an 89% union rate with two cases of screw penetration of the femoral head, using a reconstruction nail. The PFN (Synthes, Paoli, PA) was associated with a high implant failure rate and the “Z-effect” (over penetration of the cephalic screw with backing out of the inferior screw) and has been largely discontinued.11,37,68,204 The device brought attention to the differences in bone quality and effect of rotation with this type of fixation.210 
Kamath et al.118 have documented significantly more collapse with SHS devices in basicervical fractures compared to reconstruction nail–type constructs. When the lesser trochanter was intact, plate fixation was associated with more collapse than nail fixation (8.1 vs. 0.7 mm). With complete displacement of the lesser trochanter, the relative shortening was twice as much for the SHS group versus the nail group (16.1 vs. 8.1 mm). Su et al.212 reported a greater tendency for collapse with increased pain in basicervical fractures compared to intertrochanteric fractures treated with SHS devices. Pajarinen et al.169 reported less deformity with nail devices compared to SHS and recommended over correction of the hip into valgus to anticipate the varus collapse with SHS. 
Parker et al.173 has recently reported improvement in mobility with a nail device, the Targon PF, over the SHS reinforcing Hardy’s original observations. In a prospective, randomized trial involving 598 patients with 600 trochanteric fractures of the hip, the patient’s mean age was 82 years (26 to 104). All surviving patients were reviewed at 1 year with functional outcome assessed by a research nurse blinded to the treatment used. There was no statistically significant difference between implants for wound healing complications or need for postoperative blood transfusion, and medical complications were similarly distributed in both groups. There was a tendency to fewer revisions of fixation or conversion to an arthroplasty in the nail group, although the difference was not statistically significant (nine vs. three cases, p = 0.14). The recovery of mobility was superior for those treated with the intramedullary nails (p = 0.01 at 1 year from injury). 

InterTAN Class Cephalomedullary Nail (TriGen InterTAN Nail, Smith & Nephew, Memphis, TN)

The InterTAN nail is a titanium alloy nail with a proximal femoral cross section similar to a press-fit arthroplasty stem for shaft stability, an integrated screw mechanism that provides linear compression of the fracture while moving the stem toward the medial femoral cortex: This relieves stress on the lateral wall. It is a trapezoidal design proximally with a 16-mm diameter that tapers like a hip stem with a 4-degree bend for medial trochanteric insertion. It is available in 125- and 130-degree designs, long and short. The short version includes dynamic locking above a split tapered tip design to minimize implant stress in the diaphysis. Like the gamma and Y-nail class nails, it is indicated for older patients with pertrochanteric fractures and Dorr B and C type morphology (Fig. 50-28A–F). 
Figure 50-28
 
A: 31A3 fracture with C-type morphology. B: Reduction and stabilization with InterTAN nail. Note alignment of nail paralleling the anterior cortex proximally. C: InterTAN case lateral postoperatively. D: Long nail selection due to wide diaphysis with loss of isthmus anatomy owing to aging and osteoporosis. E: Union without collapse or backing out of proximal fixation. F: Note medialized nail position owing to integrated screw mechanism inducing translation of nail to medial cortex, unloading lateral wall.
A: 31A3 fracture with C-type morphology. B: Reduction and stabilization with InterTAN nail. Note alignment of nail paralleling the anterior cortex proximally. C: InterTAN case lateral postoperatively. D: Long nail selection due to wide diaphysis with loss of isthmus anatomy owing to aging and osteoporosis. E: Union without collapse or backing out of proximal fixation. F: Note medialized nail position owing to integrated screw mechanism inducing translation of nail to medial cortex, unloading lateral wall.
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A: 31A3 fracture with C-type morphology. B: Reduction and stabilization with InterTAN nail. Note alignment of nail paralleling the anterior cortex proximally. C: InterTAN case lateral postoperatively. D: Long nail selection due to wide diaphysis with loss of isthmus anatomy owing to aging and osteoporosis. E: Union without collapse or backing out of proximal fixation. F: Note medialized nail position owing to integrated screw mechanism inducing translation of nail to medial cortex, unloading lateral wall.
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Figure 50-28
A: 31A3 fracture with C-type morphology. B: Reduction and stabilization with InterTAN nail. Note alignment of nail paralleling the anterior cortex proximally. C: InterTAN case lateral postoperatively. D: Long nail selection due to wide diaphysis with loss of isthmus anatomy owing to aging and osteoporosis. E: Union without collapse or backing out of proximal fixation. F: Note medialized nail position owing to integrated screw mechanism inducing translation of nail to medial cortex, unloading lateral wall.
A: 31A3 fracture with C-type morphology. B: Reduction and stabilization with InterTAN nail. Note alignment of nail paralleling the anterior cortex proximally. C: InterTAN case lateral postoperatively. D: Long nail selection due to wide diaphysis with loss of isthmus anatomy owing to aging and osteoporosis. E: Union without collapse or backing out of proximal fixation. F: Note medialized nail position owing to integrated screw mechanism inducing translation of nail to medial cortex, unloading lateral wall.
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A: 31A3 fracture with C-type morphology. B: Reduction and stabilization with InterTAN nail. Note alignment of nail paralleling the anterior cortex proximally. C: InterTAN case lateral postoperatively. D: Long nail selection due to wide diaphysis with loss of isthmus anatomy owing to aging and osteoporosis. E: Union without collapse or backing out of proximal fixation. F: Note medialized nail position owing to integrated screw mechanism inducing translation of nail to medial cortex, unloading lateral wall.
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InterTAN Technique

Refer to the common cephalomedullary nail technique to the point of nail insertion. Attach the external guide and correct for parallax error by rotating the C-arm axis until it is slightly tilted over the femur by approximately 10 degrees (Fig. 50-29). This should align the external guide shadow with the holes in the proximal nail. Impact the nail, maintaining anteversion, until the position of the superior screw is in the center–center position. Confirm that the anteromedial reduction of the femoral cortex is maintained. Insert the proximal drill housing through the guide and incise the skin and fascia and advance the guide. It does not have to touch bone. Using the drill sleeve, drill a 4-mm hole in the lateral cortex, then insert the 3.2-mm drill guide and advance the 3.2-mm guidewire through the proximal targeting guide and advance the wire in a center–center position of the femoral head to within 5 mm of subchondral bone. Make sure the guidewire is inserted slowly so it does not migrate cephalad (Fig. 50-29A). 
Figure 50-29
InterTAN technique.
 
A: Place 3.2-mm guidewire in center–center position of femoral head to within10 mm of subchondral bone B: Drill inferior cortical hole with short drill C: Drill into femoral head with long drill to 5 mm short of the guidewire. D: Insert the derotation bar into the femoral head. E: Measure the length of the desired lag screw and drill with the 10.5-mm cannulated drill over the first guidewire. F: Insert the desired lag screw within 5 to 10 mm of subchondral bone. G: Remove the derotation bar and insert the compression screw in the inferior hole, release traction on the leg, and compress the construct. Dissemble drivers and proceed with distal interlocking as desired. H: Lateral radiograph screw and nail position in proximal fragment and shaft, not nail juxtaposed to anterior cortex for stability.
A: Place 3.2-mm guidewire in center–center position of femoral head to within10 mm of subchondral bone B: Drill inferior cortical hole with short drill C: Drill into femoral head with long drill to 5 mm short of the guidewire. D: Insert the derotation bar into the femoral head. E: Measure the length of the desired lag screw and drill with the 10.5-mm cannulated drill over the first guidewire. F: Insert the desired lag screw within 5 to 10 mm of subchondral bone. G: Remove the derotation bar and insert the compression screw in the inferior hole, release traction on the leg, and compress the construct. Dissemble drivers and proceed with distal interlocking as desired. H: Lateral radiograph screw and nail position in proximal fragment and shaft, not nail juxtaposed to anterior cortex for stability.
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A: Place 3.2-mm guidewire in center–center position of femoral head to within10 mm of subchondral bone B: Drill inferior cortical hole with short drill C: Drill into femoral head with long drill to 5 mm short of the guidewire. D: Insert the derotation bar into the femoral head. E: Measure the length of the desired lag screw and drill with the 10.5-mm cannulated drill over the first guidewire. F: Insert the desired lag screw within 5 to 10 mm of subchondral bone. G: Remove the derotation bar and insert the compression screw in the inferior hole, release traction on the leg, and compress the construct. Dissemble drivers and proceed with distal interlocking as desired. H: Lateral radiograph screw and nail position in proximal fragment and shaft, not nail juxtaposed to anterior cortex for stability.
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Figure 50-29
InterTAN technique.
A: Place 3.2-mm guidewire in center–center position of femoral head to within10 mm of subchondral bone B: Drill inferior cortical hole with short drill C: Drill into femoral head with long drill to 5 mm short of the guidewire. D: Insert the derotation bar into the femoral head. E: Measure the length of the desired lag screw and drill with the 10.5-mm cannulated drill over the first guidewire. F: Insert the desired lag screw within 5 to 10 mm of subchondral bone. G: Remove the derotation bar and insert the compression screw in the inferior hole, release traction on the leg, and compress the construct. Dissemble drivers and proceed with distal interlocking as desired. H: Lateral radiograph screw and nail position in proximal fragment and shaft, not nail juxtaposed to anterior cortex for stability.
A: Place 3.2-mm guidewire in center–center position of femoral head to within10 mm of subchondral bone B: Drill inferior cortical hole with short drill C: Drill into femoral head with long drill to 5 mm short of the guidewire. D: Insert the derotation bar into the femoral head. E: Measure the length of the desired lag screw and drill with the 10.5-mm cannulated drill over the first guidewire. F: Insert the desired lag screw within 5 to 10 mm of subchondral bone. G: Remove the derotation bar and insert the compression screw in the inferior hole, release traction on the leg, and compress the construct. Dissemble drivers and proceed with distal interlocking as desired. H: Lateral radiograph screw and nail position in proximal fragment and shaft, not nail juxtaposed to anterior cortex for stability.
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A: Place 3.2-mm guidewire in center–center position of femoral head to within10 mm of subchondral bone B: Drill inferior cortical hole with short drill C: Drill into femoral head with long drill to 5 mm short of the guidewire. D: Insert the derotation bar into the femoral head. E: Measure the length of the desired lag screw and drill with the 10.5-mm cannulated drill over the first guidewire. F: Insert the desired lag screw within 5 to 10 mm of subchondral bone. G: Remove the derotation bar and insert the compression screw in the inferior hole, release traction on the leg, and compress the construct. Dissemble drivers and proceed with distal interlocking as desired. H: Lateral radiograph screw and nail position in proximal fragment and shaft, not nail juxtaposed to anterior cortex for stability.
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Drill the inferior hole location in the lateral cortex through the targeting guide with a step drill to clear away bone from the nail attachment site for the gear drive, then drill the inferior screw hole to within 5 mm of the center–center guidewire tip (Fig. 50-29B). Insert the derotation bar into the inferior hole to augment femoral head and neck stability and prevent rotation during large lag screw reaming (Fig. 50-29C). Confirm the length for the lag screw, subtracting 5 to 10 mm from the measure length for compression if desired. Overdrill the 3.2 mm wire with the 10.5-mm cannulated drill, and insert the selected large lag screw to within 5 to 10 mm of subchondral bone (Fig. 50-29D). 
Remove the derotation bar and insert the compression gear drive screw through the guide, release traction from the leg and start compression (Fig. 50-29E). Compression through the gear drive does not begin until the head of the gear drive screw contacts the nail. Visualization of compression can be confirmed on C-arm imaging and calibrations on the guide. Once satisfactory compression is achieved, disassemble the screwdrivers. Static locking of the screw assembly can be achieved with the integrated set screw within the nail (Fig. 50-29F–H). 

Distal Interlocking Technique

Short nails have distal locking capability in a static or dynamic mode. Dynamic locking is preferred by the author: This hole is targeted through the proximal nail guide and a single bicortical screw is usually sufficient. Long nails have distal locking capability with either static holes or combination of static and dynamic holes. For length stable proximal fractures, one bicortical screw is sufficient in a dynamic mode. Conversely for segmental fractures or extensive comminution two screws are preferred. Distal interlocking is performed with the same free-hand technique used in conventional femoral interlocking nail technique. 
Close the incision in the standard fashion. 
Treatment-Specific Outcomes.
Ruecker et al.189 reported results of this device in a prospective study of 100 consecutive intertrochanteric fractures. The mean age of the patients was 81.2 years. Thirty-seven patients died during follow-up. The average surgical time was 41 minutes (13 to 95 minutes). All fractures healed within 16 weeks (range: 10 to 16 weeks). Forty-eight cases had detailed radiographic analysis at healing that revealed no loss of reduction, no uncontrolled collapse of the neck, no nonunions, no femoral shaft fractures, and no implant failures. Two cases in the series were poorly reduced and settled into varus malalignment. There was no varus malposition seen in the remaining 46 fractures. The mean prefracture Harris Hip Score was (75.1 ± 13.4) and at the time of follow-up (70.3 ± 14.5, p = 0.003); 58% of the patients recovered their prefracture status. 
Wu et al.236 performed a radiographic analysis of 76 cases with A2 and A3 fractures with 1-year follow-up and documented an average change in neck-shaft angle of 3 degrees, lag screw shortening of 3.8 mm, and an average lag screw migration of 3.8 mm occurring within the first 8 weeks. Sakakibara et al.193 found similar minor degrees of collapse with the same device finding an average sliding of 2 mm with or without locking of the set screw.150 

External Fixation: Surgical Procedure

External fixation as a treatment for pertrochanteric fractures was evaluated in the 1950s but its use was unsuccessful due to high rates of pin tract infections, subsequent pin loosening, and instability and failure.13,86,129 Renewed interest in this technique occurred recently with new fixation designs and the addition of hydroxyapatite (HA)-coated pin technology. External fixation as reported by Moroni et al.155 may be indicated in osteoporotic hip fractures in elderly patients who may be deemed high-risk patients for conventional open reduction and internal fixation or for patients who cannot receive blood transfusions due to personal conviction or religion. This technique is recommended for patients at high risk for open procedures and is indicated in AO/OTA class 31A1-A2 fractures only (Fig. 50-30). 
Figure 50-30
 
A: Preoperative radiograph showing a pertrochanteric fracture in an 83-year-old woman. B: Immediate postoperative radiograph.
 
(From Moroni A, Faldini C, Pegreffi F, et al. Osteoporotic pertrochanteric fractures can be successfully treated with external fixation. J Bone Joint Surg Am. 2005;87:42–51.)
A: Preoperative radiograph showing a pertrochanteric fracture in an 83-year-old woman. B: Immediate postoperative radiograph.
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Figure 50-30
A: Preoperative radiograph showing a pertrochanteric fracture in an 83-year-old woman. B: Immediate postoperative radiograph.
(From Moroni A, Faldini C, Pegreffi F, et al. Osteoporotic pertrochanteric fractures can be successfully treated with external fixation. J Bone Joint Surg Am. 2005;87:42–51.)
A: Preoperative radiograph showing a pertrochanteric fracture in an 83-year-old woman. B: Immediate postoperative radiograph.
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External Fixation Technique

General recommendations include a stable fracture pattern with an accurate reduction confirmed with intraoperative fluoroscopy under general or local anesthesia.157 
After standard skin preparation and prophylactic antibiotics a 2-mm K-Wire is introduced in the most cephalad portion of the femoral head and neck subtending an angle of 110 to 130 degrees and centered on the lateral radiograph (Fig. 50-31A, B).This wire serves as guidance and provisional stabilization during the femoral head fixation pin placement. A 4.8-mm drill guide and drill penetrate the lateral cortex through a percutaneous stab incision. Advance the drill approximately 3 cm under image intensification control parallel to the path of the guidance K-wire previously placed. Insert the first (HA-coated) 6-mm pin to within 10 mm of the articular surface and no closer. Remove the drill guide and K-wire, attach the proximal fixator clamp, and insert the 6-mm trocar through the fixator body parallel to the proximal pin on the lateral view and slightly convergent on the AP view. Advance the drill guide through a second stab incision and advance the trocar to bone. Repeat the drilling and HA-coated half-pin insertion for the second femoral head fixation. Clamp the proximal fixation 2 cm away from the skin and tighten the proximal pin cluster assembly. For shaft fixation, insert the 4.8-mm trocar and drill guide perpendicular to the shaft, below the level of the lesser trochanter. Through a stab incision, advance the trocar to bone and drill both cortices with a 4.8-mm drill. Insert the third HA-coated pin confirming good screw purchase in the near and far cortices. Check rotation of the distal clamping array of the external fixator to ensure bicortical purchase of the fourth and final pin. Repeat the same half-pin preparation and screw insertion. Confirm fracture reduction, avoiding over distraction and tighten all connections securely. Confirm that with flexion and extension of the hip, there is no skin tension on the half-pins and extend the incision about the pins as necessary. Apply dry dressings around the pin sites. 
Figure 50-31
Orthofix pertrochanteric fixation.
 
A: Pin positions 1 and 2 are in cancellous bone; pin positions 3 and 4 engage cortical bone. B: The remaining pins are implanted, starting from pin position 2 (proximal) and ending with pin position 4 (distal), with use of the same surgical technique.
 
(Courtesy of Moroni A, Faldini C, Pegreffi F, et al. Dynamic hip screw compared with external fixation for treatment of osteoporotic pertrochanteric fractures: A prospective, randomized study. J Bone Joint Surg Am. 2005;87:753–759.)
A: Pin positions 1 and 2 are in cancellous bone; pin positions 3 and 4 engage cortical bone. B: The remaining pins are implanted, starting from pin position 2 (proximal) and ending with pin position 4 (distal), with use of the same surgical technique.
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Figure 50-31
Orthofix pertrochanteric fixation.
A: Pin positions 1 and 2 are in cancellous bone; pin positions 3 and 4 engage cortical bone. B: The remaining pins are implanted, starting from pin position 2 (proximal) and ending with pin position 4 (distal), with use of the same surgical technique.
(Courtesy of Moroni A, Faldini C, Pegreffi F, et al. Dynamic hip screw compared with external fixation for treatment of osteoporotic pertrochanteric fractures: A prospective, randomized study. J Bone Joint Surg Am. 2005;87:753–759.)
A: Pin positions 1 and 2 are in cancellous bone; pin positions 3 and 4 engage cortical bone. B: The remaining pins are implanted, starting from pin position 2 (proximal) and ending with pin position 4 (distal), with use of the same surgical technique.
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Postoperative Care.
Postoperative care is the same as for other types of internal fixation, with mobilization within 24 hours after surgery with walker or crutches and weight bearing as tolerated. Pin sites are cleaned twice weekly with saline solution. External fixation is removed in the office without the need of anesthesia at 3 months postoperatively following radiographic confirmation of union. Ambulation is progressed as tolerated. 
Potential Pitfalls and Preventive Measures.
Patients with skin problems and decubiti in the region of the external fixation pin sites are problematic, as with other fixation methods. The fixator should be checked regularly to make sure all components are tight; attentive pin site care and early treatment of pin site infections are essential. 
Treatment-Specific Outcomes.
In one study, the addition of the HA-coated half-pins to the pertrochanteric fixator had superior results with regard to loss of fixation and fracture collapse compared to standard SHS devices in A1-A2 osteoporotic fractures.157 There were no pin tract infections and equivalent functional results as measured by the Harris Hip Score (approximately 62 for both groups). More interesting is the lower rate of varus collapse (average 2 degrees vs. 6 degrees for the SHS group), although the clinical relevance of this is questionable. The SHS group averaged two units of blood replacement versus none for the external fixation group. Surprisingly, the external fixation group reported equivalent pain to the CHS group (Fig. 50-30A, B). 

Arthroplasty

Indications/Contraindications.
Hemiarthroplasty (HA) or total hip arthroplasty (THA), often with calcar replacement type components, is rarely indicated in pertrochanteric fractures.226 Arthroplasty may be justified in pathologic fractures, severe osteoporotic disease, renal dialysis patients, and preexisting arthritis under consideration for hip replacement before the fracture occurred. Hemiarthroplasty, usually cemented, has been reported to have a lower dislocation rate compared to THA. The general consensus is that arthroplasty has a role as a salvage operation for failed internal fixation, rather than a first-line choice in the geriatric fracture patient. However, there is no level one evidence to show any functional or outcome difference between SHS and arthroplasty in this setting. As anticipated, there may be a higher blood transfusion rate with arthroplasty.173 
Another possible indication would be the patient with preexisting arthritis of the hip who suffers high-energy trauma with a nonreconstructable fracture configuration. 
Outcomes.
Haentjens et al.88 reported on 37 patients over 75 years old with unstable intertrochanteric or subtrochanteric fractures treated with arthroplasty from 1983 to 1986; functional results were rated as good-to-excellent in 75% of patients, but a mortality rate of 36% and a dislocation rate of 44% is alarming. (Haentjens,88 1989) Berend et al. in a review of 29 THA and 5 HA with an average age of 80 years, reported 26 of 34 patients died within the study period of 12 years with 5 patients requiring revision surgery for dislocation. They did not believe their results supported routine use of arthroplasty in this elderly patient group.22 
Conversely, Geiger et al.79 compared the mortality risk and complication rate after operative treatment of pertrochanteric fractures with primary arthroplasty, SHS, or PFN between 1992 and 2005 in his retrospective study. Of these 283 patients, 132 were treated by primary arthroplasty, 109 with an SHS, and 42 with a nail. Mortality was significantly influenced by age, gender, and amount of comorbidities but not by fracture classification. Primary hip arthroplasty did not have a higher 1-year mortality risk than osteosynthesis in a multiple regression analysis. The main complication with SHS devices and nails were cutting out of the hip screw and nonunion with a revision rate of 12.8%. With the introduction of hemiarthroplasty instead of THA, the postoperative dislocation rate decreased from 12% to 0%. Kim et al.123 in a randomized study found a lower mortality and less blood loss with a cephalomedullary nail compared to a cementless calcar replacement arthroplasty with equivalent functional results. Mortazavi et al.159 found that THA for salvage of failed internal fixation for intertrochanteric fracture was challenging, but produced acceptable results. 

Implant Augmentation

The use of PMMA cement in conjunction with fracture fixation was initially advocated by Harrington95 who reported on the successful treatment of 42 elderly osteoporotic hip fractures by open packing of the curetted metaphyseal region of the fracture after fixation with doughy cement. Bartucci et al.17 reported on injecting liquid PMMA through a portal after internal fixation. Paradoxically, in Bartucci’s experience, the patients with injected PMMA had worse function at follow-up even though there were a lower number of failures of fixation. Tronzo221 in 1987, invented and reported early use of PMMA injected through a modified compression hip screw but a large clinical trial was never reported. 
Recently, the trend has been to apply the cement in the femoral head and avoid the fracture zone.9,43,82,92 Kammerlander et al.120 reported good results without cement complications with a new technique of injection into the perforated blade of the PFNA from which the fenestrated femoral head screw directed the cement around the superior portion of the screw. Approximately 4.2 cc of PMMA was used which effectively prevented cutout or implant migration in 59 patients. 
Moroni et al.156 have been instrumental in the progress of HA-coated implants and the bone reaction to these coatings. In a recent study, they selected 120 patients with AO type A1 or A2 trochanteric fractures. Patients were divided into two groups and randomized to receive a 135-degree four-hole dynamic hip screw fixed with either standard lag and cortical AO/ASIF screws or HA-coated lag and cortical AO/ASIF screws. Lag screw cutout occurred in four patients in the conventional uncoated lag screws but no cutouts occurred in the HA-coated group. The femoral neck–shaft angle collapsed from an average 134 degrees postoperatively to 127 degrees at 6 months in the standard CHS group, but in the HA-coated group, the femoral neck–shaft angle was 134 degrees postoperatively and 133 degrees at 6 months. The Harris Hip Score was higher in the HA-coated group at 6 months (60 vs. 71).156 The application of bone ingrowth coatings is a promising avenue of research in this area. The use of bisphosphonates to augment the ingrowth of HA components has also been reported for the osteoporotic patient.155 These devices have garnered little acceptance in North America at present. 

Management of Expected Adverse Outcomes and Unexpected Complications in Pertrochanteric Hip Fractures

Medical Complications in Pertrochanteric Hip Fractures

A retrospective multicenter cohort study of 8,930 hip fracture patients 60 years or older, found a rate of 1,737 (19%) with postoperative medical complications.140 Interestingly, 81% of patients had no medical complications after hip fracture repair. Cardiac and pulmonary complications were most frequent (8% and 4% of patients, respectively). Other complications were gastrointestinal tract bleeding (2%), combined cardiopulmonary complications (1%), venous thromboembolism (1%), and transient ischemic attack or stroke (1%). Renal failure and septic shock were rare. After the index complication, 416 patients had 587 additional complications. Mortality was similar for serious cardiac or pulmonary complications (30 day: 22% and 17%, respectively; 1 year: 36% and 44%, respectively) and highest for patients with multiple complications (30 day: 29% to 38%; 1 year: 43% to 62%).140 

Psychosocial Complications in Pertrochanteric Hip Fractures

From the patient’s perspective they frequently have concerns regarding their potential mortality, especially if they have had loved ones who have died from hip fractures in the past. They have questions regarding their ability to walk again or be independent enough to return to their own home. Most surgeons consider union of any type to be a successful treatment whereas from a patient’s perspective it is a return to the previous level of functional activity and home environment that is desired. 
The fear of falling can be a devastating complication regarding recovery and this is best addressed by restoring the patient’s ability to trust in the injured extremity.7,19,168 Patients who demonstrate early mobility develop better functional abilities at the 3- and 6-month periods.213 Zidén et al.241 reported multidimensional and dramatic changes in the patient’s life situation, including existential thoughts and reappraisal of the years of life that remained. The results indicate that the fracture seemed not only to break the bone but also to cause social and existential cracks leading some patients to a positive socially interactive lifestyle and others a depressive, defeatist mentality with withdrawal and a diminished zest for life. 

Thromboembolic Complications in Pertrochanteric Hip Fractures

Thromboembolic complications are a source of continuing controversy as to the proper prophylactic management and postoperative therapy. Added costs, the medical surveillance required, and the concern for major hemorrhagic events postoperatively are all considerations.92,98 Complicating the management is the frequent use preoperatively in the hip fracture patient population of platelet inhibitors and anticoagulants for unrelated medical problems. Recommendations from the American College of Chest Physicians, American Academy of Orthopaedic Surgeons and Governmental Agencies are not unanimous as to the best strategy. Options include the pentasaccharides, low–molecular-weight heparins, adjusted dose warfarin, mechanical compression, and aspirin.219,230 Prophylaxis has been recommended for 4 to 6 weeks postoperatively due to reports of late PE and DVT. 
In a study by Fisher et al.67 the incidence of a venous thromboembolic event in the no-treatment group was 12% and in the mechanical compression group, 4%. Alho et al.6 reported a prospective study examining the incidence of clinical venous thromboembolism during prophylaxis with either heparin, aspirin, or warfarin. Thromboembolic complications were more frequent (p < 0.02) and hospital costs clearly higher in the low-dose heparin-treated patient group compared with the aspirin and warfarin groups. There were no distinct differences between aspirin- and warfarin-treated patients either in results or in costs. However, carefully monitored treatment with warfarin with an INR always less than 2, appeared to be the most effective prophylaxis in patients with hip fractures. They recommended aspirin as general prophylaxis in orthopedic patients, and warfarin in patients with established risk of thromboembolic complications. 
Feldman et al.64 in 1993 compared the efficacy of thromboprophylaxis with aspirin versus dextran in a prospective review of 530 geriatric hip fracture patients treated surgically. All patients were also treated with early mobilization with weight bearing as tolerated and above-knee elastic stockings. The incidence of DVT (0.5%) and PE (2.6%) in the aspirin group was essentially the same as the incidence of DVT (0.3%) and PE (2.4%) in the dextran group. Neither mortality nor infection rates were different. They reported the average cost for aspirin at $1.79 per patient. The safety, cost, and ease of administration of aspirin made its use more desirable in their opinion. 
Jeong et al.115 evaluated aspirin, dextran, and enoxaparin in conjunction with above-knee elastic stockings. With this protocol, they reported a DVT rate of 0.5% to 1.7%, PE rate of 0% to 2%, fatal PE rate of 0% to 0.5%, and no difference with regard to the effectiveness of each pharmacologic treatment. Wound hematoma complications were increased with enoxaparin (3.8%) versus aspirin (2.4%) and dextran 40 (1.6%). 
Fondaparinux prophylaxis from 1 to 4 weeks was reported as well tolerated and, compared to placebo, significantly reduced delayed venous thrombotic events from 35% to 1.4%. Based on these findings, 4-week fondaparinux treatment may become the standard thromboprophylaxis after hip fracture surgery.62 
A multicenter study examined the change in practice from 1992 to 1997, and reflected significant increases in pharmaceutical thromboembolic prophylaxis (from 45% to 81%) and early mobilization (from 56% to 70%). There were reduced levels of pneumonia, wound infection, pressure sores, and fatal PE, but no change was recorded in 3-month functional outcomes or mortality.72 
PE may be reduced by prophylactic anticoagulation, but 17% of patients are at risk of a hemorrhagic complication, and therefore some surgeons are advocates of mechanical methods as a safer option in this population.182 

Nonunion in Pertrochanteric Hip Fractures

Nonunion of pertrochanteric fractures with previous internal fixation is reported to affect 1% of older patients and is usually treated with total hip replacement. In young patients, corrective osteotomy, bone grafting, and implant revision are preferred (Fig. 50-32A, B). Vidyadhara et al.225 used a closing lateral wedge valgus intertrochanteric osteotomy in addition to dynamic hip screw osteosynthesis in the successful management of seven patients with varus trochanteric nonunion. Average preoperative coxa vara of 94 degrees (range: 85 to 104 degrees) had improved to a femoral neck–shaft angle of 139 degrees (range: 134 to 145 degrees) on postoperative radiographs. All fractures and osteotomies healed. The Harris Hip Score had improved from 34 (range: 22 to 47) to 89 (range: 83 to 95) at an average of 11 months (range: 7 to 13 months) follow-up. Other reports have high success rates with osteotomy and ORIF (82% success).194,147 Haidukewych and Berry 90 reported a 95% union rate with a combination of techniques including, blade plate, DHS, DCS, and Zickel devices. He added autogenous iliac bone graft in 17 cases, while 3 had allograft; 19/20 nonunions healed with this strategy (Fig. 50-33A–D). Talmo and Bono 214 has reported success with revision to THA, with a Harris Hip Score average 86 at 30 months in 10 patients. 
Figure 50-32
 
A: Distraction nonunion with TFN. Repair requires open reduction, grafting, and compression fixation. B: TFN distraction nonunion on lateral radiograph.
A: Distraction nonunion with TFN. Repair requires open reduction, grafting, and compression fixation. B: TFN distraction nonunion on lateral radiograph.
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Figure 50-32
A: Distraction nonunion with TFN. Repair requires open reduction, grafting, and compression fixation. B: TFN distraction nonunion on lateral radiograph.
A: Distraction nonunion with TFN. Repair requires open reduction, grafting, and compression fixation. B: TFN distraction nonunion on lateral radiograph.
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Figure 50-33
 
A: Nonunion with locking plate. Note deformation of screws. B: Locking plate nonunion, lateral. C: Revision with open reduction, inductive grafting, and compression with InterTAN nail. D: InterTAN revision and union shown on lateral radiograph.
A: Nonunion with locking plate. Note deformation of screws. B: Locking plate nonunion, lateral. C: Revision with open reduction, inductive grafting, and compression with InterTAN nail. D: InterTAN revision and union shown on lateral radiograph.
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Figure 50-33
A: Nonunion with locking plate. Note deformation of screws. B: Locking plate nonunion, lateral. C: Revision with open reduction, inductive grafting, and compression with InterTAN nail. D: InterTAN revision and union shown on lateral radiograph.
A: Nonunion with locking plate. Note deformation of screws. B: Locking plate nonunion, lateral. C: Revision with open reduction, inductive grafting, and compression with InterTAN nail. D: InterTAN revision and union shown on lateral radiograph.
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Implant Malfunction in Pertrochanteric Hip Fractures

Implant malfunction or failure is estimated to occur in approximately 5% of cases, usually from implant fatigue failure, shaft fixation failure with broken screws, femoral head medial penetration, screw cutout, and disassembly of the device components. Combinations of failure mechanisms are common. With today’s stringent requirements for manufacturing and quality control, implant failure due to manufacturing defects are rare: Most implant failures are actually fatigue failures associated with fracture nonunion. 
Parker172 analyzed the radiographic characteristics of 27 patients with a trochanteric fracture treated with an SHS in which fixation failure occurred, and compared these with 74 cases with uneventful fracture union.172 Femoral medialization was more common in specific fracture types, particularly if there was comminution of the lateral femoral cortex at the site of insertion of the lag screw. Femoral medialization was strongly associated with fixation failure, with a seven-fold increase in the risk of failure if medialization of more than one-third of the shaft width occurred. These authors suggested that implants preventing femoral medialization in specific types of trochanteric fracture merit further evaluation. 
Im et al. reviewed 66 patients with 31A1 stable fractures treated with SHSs. Ten (15.1%) were noted to lose reduction while developing excessive medialization of the femoral shaft in the postoperative period. Of these patients, a fracture with displacement of the lateral cortex occurred in seven cases during the procedure and in three cases within 4 weeks after surgery. Whereas preoperative mobility scores were similar, a significant difference in mobility score was noted between patients who lost fracture stability after the operation versus those who did not.111 
Loss of construct stability is one of the most frequent complications manifested by collapse of the screw and varus migration of the femoral head construct with final cutout failure in the most severe cases. This occurs to a small degree in all cases, as the sliding impaction is designed to minimize catastrophic cutout. However, this may result in some loss of reduction of the head/neck fragment. A center–center position of the lag screw minimizes cutout: This was reduced to a mathematical equation, “the tip–apex distance” as reported by Baumgaertner.18 The TAD is the sum of the distance from the tip of the head fixation device to the apex of the femoral head. A summation of less than 25 mm of the distance on the AP and lateral radiographs is correlated with reduced cutout in a single head fixation device (Fig. 50-13F). 
A related problem is peri-implant fracture which may occur around the lateral wall, the region of bone at the end of a nail or side plate, or distally in the femur. Gotfried and Palm et al. have identified the significance of the lateral wall fracture, which frequently occurs about the insertion point of hip screw. These difficult fractures require reattachment of the greater trochanter with buttress plate techniques.87 Fractures distal to plates may be treated with retrograde nails with removal of the inferior two to three screws of the side plate to ensure overlap of the fixation by the nail (Fig. 50-34A–C). Periprosthetic fractures were more common with the first-generation short trochanteric gamma nails, likely due to the large distal diameter (up to 16 mm), larger proximal bend, and large distal locking screws. Periprosthetic fracture rates as high as 17% have been reported in this setting. With the newer design there has been a substantial drop in periprosthetic femur fractures, but it remains a concern. Norris et al. in a 2011 meta-analysis found that the improvements in implant designs has essentially made the periimplant fracture rate equivalent for short and long nails. However, there was a significantly lower fracture rate with static interlocking as opposed to dynamic locking and the same nail types still have a higher shaft fracture rate than other short cephalomedullary nails (1.7% vs. 0.7%).162 Fractures distal to short nails require revision to longer nails or locking plates if the greater trochanter is displaced. 
Figure 50-34
 
A: Periimplant fracture of the femur below a CHS with associated osteoarthritis of knee and osteoporosis in community ambulatory. B: Treatment with retrograde locking nail overlapping side plate by removal of distal plate screws percutaneously. Blocking screws are used to enhance construct stability and alignment. C: Lateral radiograph showing retrograde locking nail with blocking screws and overlap with plate.
A: Periimplant fracture of the femur below a CHS with associated osteoarthritis of knee and osteoporosis in community ambulatory. B: Treatment with retrograde locking nail overlapping side plate by removal of distal plate screws percutaneously. Blocking screws are used to enhance construct stability and alignment. C: Lateral radiograph showing retrograde locking nail with blocking screws and overlap with plate.
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Figure 50-34
A: Periimplant fracture of the femur below a CHS with associated osteoarthritis of knee and osteoporosis in community ambulatory. B: Treatment with retrograde locking nail overlapping side plate by removal of distal plate screws percutaneously. Blocking screws are used to enhance construct stability and alignment. C: Lateral radiograph showing retrograde locking nail with blocking screws and overlap with plate.
A: Periimplant fracture of the femur below a CHS with associated osteoarthritis of knee and osteoporosis in community ambulatory. B: Treatment with retrograde locking nail overlapping side plate by removal of distal plate screws percutaneously. Blocking screws are used to enhance construct stability and alignment. C: Lateral radiograph showing retrograde locking nail with blocking screws and overlap with plate.
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In considering revision surgery after failed internal fixation, the surgeon must assess the quality of the bone interface with the internal fixation, the defects created within the femoral head and neck by the previous implant, potential damage to the articular surface of the femoral head and acetabulum, and any shaft medialization. 
The restoration of mechanical alignment, rotation, length, head–neck angulation, offset, and trochanteric height are required for successful reconstruction. If these goals cannot be met, arthroplasty is the most reasonable salvage procedure. 

Infection in Pertrochanteric Hip Fractures

Infection occurs in 1% to 2% of cases. This risk is minimized by preoperative prophylactic antibiotics, usually a first-generation cephalosporin. If infection does occur, it can be life-threatening and standard care involves isolation and sensitivity testing of the causative bacteria and appropriate intravenous antibiotics. Consultation with an infectious disease specialist and debridement and irrigation of the wound may be required for cases that do not respond promptly to antibiotics. If the implant is stable it should be retained. Rarely a resection arthroplasty will be required.99 Edwards et al.58 reported a 1.2% rate of deep wound infection and 1.1% superficial wound infection in a series of over 3,000 cases. Most cases (57 of 80 infections or 71.3%) were due to Staphylococcus aureus and 39 cases (48.8%) were due to MRSA. No statistically significant preoperative risk factors were detected. Length of stay, cost of treatment, and predischarge mortality all significantly increased with deep wound infection. The 1-year mortality in the total series was 30%, and this increased to 50% in those who developed an infection (p < 0.001). A deep infection resulted in doubled operative costs, tripled investigation costs, and quadrupled ward costs. MRSA infection increased costs, length of stay, and predischarge mortality compared with non-MRSA infection.58 They recommended vigilance with a high index of suspicion for any wound inflammatory signs or drainage. If the infection is superficial, oral antibiotics for 7 to 10 days are suggested. If deep infection occurs, urgent formal surgical debridement and irrigation is required. Stable implants are retained. Antibiotic beads may be considered for defect management. Wu et al.235 reviewed their experience with 23 pertrochanteric osteomyelitis cases and presented a two-stage treatment protocol. They used an external skeletal fixator or Buck traction after radical debridement in the first stage and reconstruction in the second stage. Only 12 of the 23 cases (52%) were successfully managed and infection recurred in 4 (17.4%) cases at final follow-up. The use of external skeletal fixation was not recommended for managing pertrochanteric osteomyelitis. Success using a two-stage protocol was difficult to achieve. 

Vitamin D Deficiency in Pertrochanteric Hip Fractures

Vitamin D has been reported as an independent risk factor for recovery. Due to the avoidance of sunlight for fear of skin cancer and the lack of vitamin D in the modern diet, vitamin D deficiency has reemerged as a health problem.104 Vitamin D deficiency causes muscle weakness. Skeletal muscles have a vitamin D receptor and may require vitamin D for maximum function. Performance speed and proximal muscle strength were markedly improved when 25-hydroxyvitamin D levels increased from 4 to 16 ng/mm and continued to improve as the levels increased to more than 40 ng/mm.26 A meta-analysis of five randomized clinical trials (with a total of 1,237 subjects) revealed that increased vitamin D intake reduced the risk of falls by 22% as compared with only calcium or placebo. The same meta-analysis examined the frequency of falls and suggested that 400 IU of vitamin D3 per day was not effective in preventing falls, whereas 800 IU of vitamin D3 per day plus calcium reduced the risk of falls. In a randomized controlled trial conducted over a 5-month period, nursing home residents receiving 800 IU of vitamin D2 per day plus calcium had a 72% reduction in the risk of falls as compared with the placebo group.34 

Outcomes for Pertrochanteric Hip Fractures

Mortality from hip fracture decreased with active surgical treatment in the mid-20th century but has remained unchanged at 25% to 30% at 1-year post injury since then. Vestergaard et al.223 in a study of a Danish hip fracture registry reported an increase in mortality after hip fracture from 1981 to 2001, whereas nonhip fracture-matched controls showed a decrease in mortality. In a separate study, the increased mortality was shown to be the result of the fracture and its sequelae and not premorbid conditions.224 Abrahamsen in 2009 has shown that patients experiencing hip fracture after low-impact trauma are at considerable excess risk for death compared with nonfracture community control populations. Hip fracture is associated with excess mortality (over and above mortality rates in nonfracture community control populations) during the first year after fracture with studies suggesting a range of 8.4% to 36%. This initial risk for mortality following hip fracture was at least double that for the age-matched control population, became less pronounced with advancing age, was higher among men than women regardless of age, was highest in the days and weeks following the index fracture, and remained elevated for months and perhaps even years following the index fracture. These observations show that patients are at increased risk for premature death for many years after a fragility-related hip fracture and highlight the need to identify those patients who are candidates for interventions to reduce their risk.1 Holt has stratified the mortality risk for age groups from the Scottish Hip Fracture Audit Database.106 Patients in the 50- to 64-year group had significantly better outcome measures after surgery for hip fracture in terms of survival and function. These differences persisted even after controlling for differences in patient case-mix variables. They have developed a predictive formula for estimation of mortality at 30 and 120 days dependent on age, ASA score, gender, prefracture residence, prefracture mobility, and type of fracture. 
For example, the predicted 30-day mortality for a hip fracture patient aged 90 or over; ASA = 3; from a care home, assuming other base characteristics (male, intracapsular fracture, walked without aids before fracture) = 1/1 + e (–4.79 + 0.80 + 0.53 + 1.96) = 18.2% (Table 50-9). This formula applies to intracapsular, extracapsular, subtrochanteric, and pathologic fractures. Mortality in the ≥90-year-old averaged 50% at 120 days.106 
 
Table 50-9
Predictive Mortality Variables
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Table 50-9
Predictive Mortality Variables
30 Days Odds Ratio (95% Confidence Interval) P Value Ba 120 Days Odds Ratio (95% Confidence Interval) P Value Ba
Explanatory variable and category
Age (yrs) <0.001 <0.001
50–59 1
60–69 1.78 (0.95–0.33) 0.58 1.98 (1.34–2.94) 0.68
70–79 3.46 (l.94–6.15) 1.24 3.46 (2.40–4.98) 1.24
80–89 5.68 (3.21–10.l) 1.74 5.94 (4.14–8.53) 1.78
≥90 7.11 (3.98–12.7) 1.96 7.95 (5.49–11.5) 2.07
ASAb score <0.001 <0.001
1 and 2 1 0 1 0
3 2.25 (1.88–2.69) 0.80 1.98 (1.77–2.21) 0.67
4 and 5 5.14 (4.18–6.31) 1.62 4.01 (3.48–4.62) 1.37
Gender <0.001 <0.001
Male 1 0 1 0
Female 0.52 (0.46–0.60) –0.65 0.49 (0.45–0.54) −0.70
Prefracture residence <0.001 <0.001
Own home 1 0 1 0
Long-term care 1.69 (1.47–1.95) 0.53 2.06 (1.87–2.27) 0.72
Rehabilitation 1.69 (1.30–2.20) 0.53 2.24 (1.86–2.70) 0.81
Acute hospital ward 1.80 (1.43–2.26) 0.59 2.40 (2.04–2.83) 0.88
Other 1.78 (0.97–3.27) 0.58 1.34 (0.84–2.13)
Prefracture mobility 0.007 <0.001
No aids, unaccompanied 1 0 1 0
One aid, unaccompanied 0.98 (0.83–1.15) –0.02 1.07 (0.96–1.19) 0.06
Two aids/frame 1.07 (0.91–1.26) 0.07 1.15 (1.03–1.29) 0.14
Requires accompaniment 1.26 (1.04–1.51) 0.24 1.41 (1.24–1.61) 0.35
Unable to walk 1.47 (1.18–2.08) 0.45 1.62 (1.31–2.00) 0.48
Type of fracture <0.001 <0.001
Intracapsular 1 0 1 0
Extracapsular 1.13 (1.00–1.27) 0.12 1.16 (1.06–1.26) 0.15
Subtrochanteric 1.33 (0.96–1.82) 0.28 1.19 (0.95–1.50) 0.18
Pathologic 3.76 (2.72–5.19) 1.32 4.91 (3.77–6.39) 1.60
Regression constant −4.79 −3.70
 

Mortality = 1/1 + e (constant + B (ASA))+ B (prefracture residence) + B (age) + B (sex) + B (type of fracture) + B (prefracture mobility) where e = 2.72 and the constant = –4.79 for 30-day mortality and –3.70 for the 120-day mortality.

 

From Holt G, Smith R, Duncan K, et al. Early mortality after surgical reduction of hip fractures in elderly: An analysis of data from the Scottish Hip Fracture Audit. J Bone Joint Surg Br. 2008;90:1357–1363.

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Functional Recovery and Postoperative Pain in Pertrochanteric Hip Fractures

Cooper50 stated that the consequences of hip fractures relate to (1) premature death, averaging a 20% rate at 1 year, (2) permanent disability of up to 30%, (3) an inability to ambulate independently in 40% of patients, and (4) loss of at least one activity of independent daily living (i.e., driving or grocery shopping) in 80% of treated patients. 
Larson et al. reported on 607 pertrochanteric fractures treated with a sliding screw technique followed clinically and radiographically for at least 1 year in 1990. Of 351 patients admitted from their homes, 209 (60%) were discharged to their homes after an average of 18 days in the hospital. During the first year another 61 (17%) patients returned home after rehabilitation in a geriatric ward. Of 446 patients walking without support or with one cane before surgery, 360 (80%) had regained the same mobility after 1 year. The 1-year mortality rate was 18%, whereas the 10-year mortality rate was 74%. Forty-five (7.4%) were reoperated, seventeen because of technical complications, three because of infection, and three because of nonunion. The deep infection rate was 9 of 339 (2.7%) before and 2 of 268 (0.8%) after the introduction of antibiotic prophylaxis.139 
Ekström et al.61 reported that even with stable two-part fractures, the 2-year mortality rate was 29%. The reoperation rate was 3%. At the final follow-up, 81% of the patients reported no or only limited pain at the hip, 55% had regained their prefracture walking ability, and 66% their prefracture level of ADL function. 
Rapp et al.187 in 2008 evaluated the associated excess mortality in a large nursing home population in Germany. The crude incidence rates of admission to a nursing home were 50.8/1,000 person-years in women and 32.7/1,000 person-years in men. The mortality incidence rates increased with increasing age categories and were highest in the first months after admission to the nursing home. Mortality in patients with a hip fracture was increased (women: Hazard rate ratio for the first 3 months after fracture, 1.7; men: Hazard ratio 2.14) but excess mortality was limited to the first months after injury. 
Bentler et al.21 reported on Medicare data from the United States during 1993 to 2005 and showed poor results with conventional treatment. Mortality at 6 months and 1 year were 19% and 26% respectively, essentially unchanged for the past 50 years. Deterioration in motor activities was seen in 51%, self-reported health deterioration was seen in 39%, and instrumental activities of daily living deterioration in 51% of patients. This decline is three times larger than matched patients without a hip fracture. 
The introduction of a comprehensive multidisciplinary fast-track treatment and care program for patients with a hip fracture to optimize care has been reported. Components include a switch from systemic opiates to a local femoral nerve catheter block; earlier assessment by the anesthesiologist; and a more systematic approach to nutrition, fluid and oxygen therapy, and urinary retention prevention, and treatment compared to standard hospital care.180 
In the intervention group, the rate of any in-hospital postoperative complication was reduced from 33% to 20% (odds ratio = 0.61, 95% confidence interval = 0.4 to 0.9; p = .002). Rates of confusion (p = .02), pneumonia (p = .03), and urinary tract infection (p = .001) were lower in the intervention group than in the control group, and length of stay was 15.8 days in the control group, versus 9.7 days in the intervention group. For community dwellers, 12-month mortality was 23% in the control group. This study supports the concept of a hip fracture program to reduce the rate of in-hospital postoperative complications and mortality. Randomized clinical trials are required to validate and elucidate the elements of the program that have the greatest effect on clinical outcomes and mortality. 
Postsurgical pain has now been identified as a significant risk factor for functional recovery and dementia. Feldt and Oh related pain was significantly higher with movement than at rest after surgery at day 2 and day 5 postoperatively and this correlated with diminished functional improvement at 2 months.65 Foss et al.69 documented that cumulative pain levels were significantly different between different surgical procedures both for hip flexion and for walking: Highest pain levels were seen in patients who had either SHSs or intramedullary hip screws compared with patients treated with arthroplasty. There were significant negative correlations between ambulatory capacity (assessed by the cumulative ambulation score) with both hip flexion and walking. Postoperative pain levels after surgery for hip fracture are dependent on the surgical procedure, which should be taken into account in future studies of outcomes and functional evaluations and may be a guide to hip fracture implant stability. 
The importance of pain control after surgery was further documented in a prospective cohort study at four New York hospitals that enrolled 541 delirium-free patients with hip fractures: Eighty-seven of 541 patients (16%) became delirious.203 Among all subjects, risk factors for delirium were cognitive impairment (relative risk, or RR, 3.6; 95% confidence interval, or CI, 1.8 to 7.2), abnormal blood pressure (RR 2.3, 95% CI 1.2 to 4.7), and heart failure (RR 2.9, 95% CI 1.6 to 5.3). Patients who received less than 10 mg of parenteral morphine sulfate equivalents per day were more likely to develop delirium than patients who received more analgesia (RR 5.4, 95% CI 2.4 to 12.3). In cognitively intact patients, severe pain significantly increased the risk of delirium (RR 9, 95% CI 1.8 to 45.2). Cognitively intact patients with undertreated pain were nine times more likely to develop delirium than patients whose pain was adequately treated. Undertreated pain and inadequate analgesia appear to be risk factors for delirium in frail older adults. 
These studies show that patients with conventional internal fixation experience more pain for a longer period of time than patients treated with primary arthroplasty, and that the lack of pain control may increase delirium (precluding mobilization and rehabilitation). This could reflect the relative instability of single screw femoral head fixation, which has been the most common treatment during the past 50 years. There is also the future consideration of prophylactic surgical treatment of high-risk patients to avoid the second hip fracture or even the first fracture if treatment of sufficiently low risk and cost-effectiveness treatment could be developed. 

Author’s Preferred Treatment and Future Options in Pertrochanteric Hip Fractures

 
 

A number of problems exist when determining the best option for treatment for pertrochanteric hip fractures. The classification systems do not work well enough for preoperative planning, and the reduction criteria have not been well defined. With these limitations in mind, some suggestions can be made.

 

First, begin with the AO/OTA classification of 31A1, A2, A3. Next, categorize the morphology of the fracture into the Dorr A, B, C groupings. Next determine the preoperative functional independence class: (1) community ambulator-self sufficient, (2) household ambulator-partially reliant, or (3) functional nonambulator-dependent for ADL. Determine if the fracture is reducible and if the bone quality is sufficient for a stable bone implant fixation; if the patient is a functional nonambulator (class 3) and the fracture is severely osteoporotic or nonreconstructable, nonoperative treatment is recommended. If the patient is a functional class 1, 2 and the fracture is not reconstructable, arthroplasty is recommended. Next obtain adequate radiographs or a CT scan to ascertain the presence or absence of a lateral wall fracture (Fig. 50-35; Table 50-10).

 
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Figure 50-35
Implant selection variables.
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Table 50-10
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Table 50-10
Fracture Personality Considerations
Basilar femoral neck Maximum rotational stability required: High collapse rate CHS
Lesser trochanteric Larger the comminution, the higher the implant is loaded
Greater trochanter Displacement Large amount: Open reduction required
Small fragments: Nails acceptable
Shaft fracture Will behave like subtrochanteric or reverse obliquity fracture
Prevent shaft medialization: High implant loads with construct
Reverse obliquity A1 can be converted to A3 during surgery, may require changing implant preoperative plan
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Table 50-11 lists the order of preference for implant for the respective fracture pattern, morphology, and activity level.

 
Table 50-11
Morphology Combined with AO/OTA Classification for Implant Selection
Morphology AO/OTA Class 31A-1 AO/OTA Class 31A-2 AO/OTA Class 31A-3 Lateral Wall Failure Anteromedial Reduction Possible
Dorr Class A RSP
SDRSN
CHS
RSP
SDRSN
CHS
RSP
SDRSN
CHS + TBP
LPFP
SHS + TBP
Yes
Dorr Class B RSP
SDRSN
CHS
SCMN
SCMN
RSP
SDRSN
CHS
SCMN
SDRSN
CHS + TBP
LCMN
LPFP
CHS + TBP
Yes
Dorr Class C LDRSN
SCMN
RSP
CHS
LDRSN
SCMN
RSP
CHS
SCMN
LDRSN
CHS + TBP
LCMN
LDRSN
LPFP
Yes
Activity Class 1, 2 SDRSN
RSP
SCMN
SDRSN
LDRSN
LCMN
LDRSN
SDRSN
SHS + TBP
ORIF LPFP
Trochanteric Fixation
No
THA, HemiA
Cemented Femoral Component
Calcar Replacement
Activity Class 3 CHS
CHS
SCMN
SCMN
Ex-Fix
Non-Op Non-Op
Ex-fix
 

RSP, rotationally stable plate; SHS, sliding hip screw; TBP, trochanteric buttress plate; LPFP, locking proximal femoral plate with trochanteric buttress feature; SDRSN, small diameter rotationally stable cephalomedullary nail with multiple point fixation into femoral head (Nail Head D<15 mm); LDRSN, large diameter rotationally stable cephalomedullary nail with multiple point fixation into femoral head (Nail Head D>15mm); SCMN, single femoral head fixation cephalomedullary nail (Nail Head D>15 mm); cephalomedullary nails may be short or long versions; THA, total hip arthroplasty; HemiA, hemiarthroplasty; ex-fix, external fixation.

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Summary, Controversies, and Future Directions Related to Pertrochanteric Hip Fractures

Lorenz Böhler is credited with the strategy that with injury the surgeon treatment should first preserve life, secondly save the limb, and finally maximize functional recovery. There is a dichotomy of opinion regarding a surgeon’s perspective and a patient’s perspective after a broken hip. In the past, surgeons believed that most surgeries were equivalent and that the patients were expected to have a lower functional demand after surgery; so, frequently their focus was on the time required for the surgical procedure and acceptance of union of any type rather than the functional outcome of the patient. However, expectations have changed. The “Baby Boomer Generation” patient with a hip fracture expects a functional result equivalent to their friends’ experience with a total hip replacement. 
The current reevaluation of the treatment methods for pertrochanteric fractures relates to appreciation of the relative instability of the fracture construct with a single cephalic component due to osteoporotic bone stock, unstable fracture reductions, or combinations thereof.192 Even with optimal screw purchase in the correct position of the femoral head, any rotational instability can lead to progressive collapse and incremental instability. Thus, the fracture may heal in a varus position. Also, the femoral head motion results in femoral neck erosion and collapse until the sliding screw reaches maximal collapse with resultant implant failure or lateral wall failure. This is certainly more common in patients with severe osteoporosis and/or those with unstable reductions or comminuted fractures. Uncontrolled dynamic fixation has come to be appreciated as a cause for bony erosion and progressive continuing collapse, which weakens the abductors, shortens the extremities, and makes it more likely the patient will have diminished function. In the past 100 years we have progressed from nonoperative treatment, to rotationally stable simple nails (Smith-Petersen), then to rigid fixed-angle nail plating, then to dynamic sliding single nail or screw plates and nails, back to rigid locked plating and finally rotationally linear stable nails and plates. However, mortality following hip fracture in the elderly remains high and functional results disappointing. A refocus on the initial functional results and pain control in the early postoperative period may lead to new revelations as to the importance of the first few months on future outcomes after 1 year. Only continued innovative thinking will give us a solution to this vexing problem for our patients and the surgeons who treat these injuries. 

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