Intertrochanteric Fractures

 

IT 4 partHip Pin and Plate APHip Intertrochanteri Fracture IMN

 

Definition

 

Fracture which extends between the trochanters of the proximal femur

 

Extra capsular / well vascularized

 

Epidemiology

 

50% of hip fractures

- elderly

- osteoporotic

- female

 

Signs

 

Leg

- shortened

- externally rotated

- groin pain with leg movement

 

Evans Classification 

 

Two main types

- Type 1 Intertrochanteric

- Type 2 Reverse Oblique

 

Type 1 Intertrochanteric

 

Hip Intertrochanteric Fracture Type 3

2 part undisplaced                             

 

2 part displaced2 part displaced

2 part displaced

 

3 part fracture GT3 part GT

3 part without posterolateral support (GT fracture)

Hip Intertrochanteric fracture Type 43 part

3 part without posteromedial support (LT fracture)

 

Four Part Inter trochanteric fracture4 part IT

4 part without posterolateral or posteromedial support

 

Type II Reverse Oblique Type

 

Inherently unstable - tendency of femoral shaft fragment to shift medially

 

Reverse oblique 1Reverse oblique 2

Reverse oblique fractures

 

Stability

 

Depends on medial cortical reduction

 

Unstable (AO 31.A2 + 31.A3)

- intact lateral wall

- posteromedial cortical fracture

- reverse oblique

- subtrochanteric extension

 

Isolated GT Fracture

 

Isolated Greater Trochanter Fracture

 

Management

 

Non operative

 

Indications

 

Unfit for surgery

- high risk of DVT / PE

- pressure ulcers

- pain with nursing

 

Operative

 

Goal

 

Obtain stable fixation

Early mobilisation

 

Timing

 

Welford et al Bone Joint J 2021

- systematic review of 46 studies and 500,000 hip fractures

- surgery < 24 hours reduces mortality

 

Leer-Salveson et al Bone Joint J 2019

- Norwegian registry of 80,000 hip fractures

- no change in mortality (3 day, 1 year) if surgery < 48 hours

 

Workup

 

Griffiths et al Anaesthesia 2021

- PDF for guidelines for the management of hip fractures

 

Issues

- consent

- do not resuscitate

- preoperative hemoglobin

- anti-platelet / anticoagulation

- GA versus spinal

 

Options

 

Hip Pin and Plate APHip Intertrochanteri Fracture IMNHemi

 

Sliding hip screw/dynamic hip screw

Cephalomdeullary nail

 - Short / long

 - one screw / two screws / blade

Fixed angle plate

Arthroplasty

- Calcar replacing prosthesis

 

Results

 

DHS versus nail

 

Depends on stability

Requires intact lateral wall for DHS (or GT plate)

- post-operative fracture of lateral wall turns stable intertroch into unstable

 

Granhaug et al, BJJ 2022

- Norwegian hip registry review of 17341 patients

- DHS vs nail for unstable intertrochs (A1/2/3)

- Nails have lower re-operation, and lower mortality rate

 

Raj et al J Orthop 2023

- meta-analysis of 22 studies and 3000 patients including all types of extracapsular proximal femur fractures

- DHS v cephalomedullary nail

- no difference in mortality / reoperation / failure fixation / complications

- IMN had shorter operative times and reduced blood loss

- Did no delineate between fracture patterns

 

Single versus dual screws

 

Hip Intertrochanteri Fracture IMNDual screw nail

 

Yang et al J Orthop Surg Res 2023

- systematic review of single versus dual screw cephalomedullary nail

- 23 studies and 3500 surgeries

- dual screw reduced risk of failure and reoperation

 

Nail with helical blade vs screw

 

Kim et al, J Orthop Trauma 2021

- systematic review of 2331 femoral nails

- TFNA neck screw vs helical blade

- helical blade more likely to fail compared to screw (OR 5.33)

- non-union rate same

 

Long vs short nail

 

Cinque et al, Arch Orthop Trauma Surg. 2022

- meta-analysis of 3208 intertrochs

- long vs short nail

- short nails had less blood loss, and operative time

- no difference in re-operation, failure, or transfusion rates

 

ORIF versus hemiarthroplasty

 

Hongku et al Orthop Traumatol Surg Res 2022

- systematic review of 7 RCTs and 500 patients

- higher operative failure with DHS / PFN compared with hemiarthroplasty

- higher long term hip scores with PFN

 

Dynamic hip screw

 

Hip Pin and Plate APPin and plate lateral

 

Mechanism

 

Plate is a lateral tension band whilst the sliding screw allows controlled fracture impaction

 

Technique

 

Synthes technique guide PDF

 

Youtube step by step sawbone guide

 

Set up

- traction table with anatomic reduction

- traction, adduction, internal rotation

 

Lateral approach to femur

- elevate vastus lateralis and control bleeding from perforators

 

Guide wire

- centred in femoral head in 2 planes 

- tip-apex distance < 25 mm

 

Tip - apex distance

- from tip of screw to apex femoral head

- accumulative on AP and lateral

- > 25 mm, increases cut out

 

Measure angle

- wire in centre of neck / centre of head

- usually 130o prosthesis

 

Ream to within 5 mm of end of wire

- tap

- insert screw / tip apex distance < 25 mm

- attach plate

 

Options for improving stability

 

a.  Valgus Osteotomy for unstable Fractures

 

Theory

- reduces shear force

- increases compression

- stronger construct

 

Technique

- 135° plate placed in at 120°

- valgises proximal fragment and medializes shaft

- +/- lateral wedge removed / sarmiento valgus osteotomy

 

b.  Trochanteric stabilization plate

 

Theory

- buttresses the GT and prevents lateral displacement

 

Cephalomedullary nail / Proximal femoral nail

 

Hip Intertrochanteri Fracture IMNHip Intertrochanteric IMN Lateral

 

Mechanical advantages

- load sharing rather than load bearing

- decreases lever arm

- supports medial cortex

 

Surgical advantages

- smaller incision / minimally invasive

- reduced blood loss

- shorter surgical times

 

Indications

- reverse oblique

- unstable fracture / loss of lateral buttress / loss posteromedial support

- subtrochanteric extension

 

Technique

 

Vumedi surgical technique cephalomedullary nail

 

Stryker gamma nail technique animations

 

Smith&Nephew Intertan youtube animation

 

Hemiarthroplasty / Total hip replacement

 

Hemi for ITIT Hemi

 

Indications

- severe comminution

- salvage of failure of previous fixation

 

Technical

- may need calcar replacement

- may need greater trochanter fixation

 

Complications

 

Malreduction

Screw cut out

Malunion

Non union

Infection

Periprosthetic fracture

 

Malreduction

 

Malreduction nailMalreduction plate

 

Screw Cut

 

Cut out 1Cut out 2Cut out 3

 

Causes

- malreduction

- poor screw position / high tip apex distance

- poor bone quality

 

Baumgartner et al, JBJS 1995

- Retrospective review of 198 intertrochs treated DHS

- none < 25mm cutout. > 25mm strong predictor of cut-out

 

Options

- revised to 95o DCS

- hemiarthroplasty / THA

 

THA Issues

 

THR post pin and plateCalcar replacing

 

A. Femoral component

- cement will come out screw holes

- Option 1:  leave screws in laterally, and strip medially to insert small screws

- Option 2:  use uncemented stem

 

B.  Length of femoral stem

- should bypass distal screw hole by 2 cortical diameters

 

C.  Calcar

- normal stem usually sufficient if LT healed back on

- otherwise may calcar replacing

 

D. Greater trochanter

- may need plate / cables to reduce

 

Failed intertrochFailed IT

 

Failed intertrochRevision intertroch

 

Malunion

 

Excessive lateral sliding / shaft medialisation

 

Cause

- collapse with insufficent lateral buttress

- reverse obliquity fracture

 

Intertrochanteric Fracture Barrel ImpingementMalunion

 

Management

 

1.  Fracture united

- remove screw

 

2.  Fracture non union

- revise fixation in young patient

- hemiarthroplasty / THA

 

Non Union

 

Uncommon

 

Presentation

- pain

- hardware failure

- exclude infection

 

NOF Intertrochanteric Non unionNOF Intertrochanteric Nonunion CT

 

Options

 

A. Closing lateral wedge valgising osteotomy + graft - younger patients

B.  Revision fixation  - 95 degree DCS Plate / IM nail

C.  THA

 

Recon Nail Cut outRecon Nail Cutout LateralRecon Nail Cutout Salvage

 

Periprosthetic fracture

 

Peripros 1Peripros 2