Current concepts offered for managing geriatric intertrochanteric hip fractures

Standard sliding hip screws, percutaneous plates with two neck screws, or IM devices: Surgeons have many options.

More than 352,000 new hip fractures occur every year in the United States and that number is projected to grow to more than 650,000 annually by 2050. Even with proper treatment, the mortality rate within the first year after fracture treatment for patients over 50 is 25%.

With an aging population, an even larger proportion of our resources will be dedicated to treating these hip fractures in the coming years. Preventing complications is of utmost importance to help these frail patients get back to a functional level.

This Virtual Round Table discussion considers current concepts in the treatment of intertrochanteric hip fractures in an effort to focus attention on problem fracture types and different trends in fixation methods.

Elton Strauss, MD, FACS
Joshua R. Langford, MD
Co-moderators

Round Table Participants Co-moderators Elton Strauss, MD, FACS, Orthopedics Today Editorial Board Member Associate Professor Chief of Orthopaedic Trauma and Adult Reconstruction The Mount Sinai Medical Center New York, NY Joshua R. Langford, MD, Chief Resident Department of Orthopaedic Surgery The Mount Sinai Medical Center New York, NY Michael R. Baumgaertner, MD, FACS, Professor Department of Orthopaedics and Rehabilitation Yale University School of Medicine New Haven, CT George J. Haidukewych, MD, Orthopaedic Trauma and Adult Reconstruction Florida Orthopaedic Institute, Tampa General Hospital University of South Florida Tampa, FL Wolfgang Klein, MD, Director Department of Trauma, Orthopaedic and Hand Surgery Klinikum Wolfsburg Affiliate of University of Goettingen Wolfsburg, Germany Kenneth J. Koval, MD, Professor Dartmouth HItchcock Medical Center Lebanon, NH

Elton Strauss, MD, FACS, and Joshua R. Langford, MD: What is your current treatment for AO/OTA 31A1 (stable intertrochanteric) and 31A2 (unstable intertrochanteric) hip fractures, and what is your rationale for employing this treatment method?

Kenneth J. Koval, MD: AO/OTA Type 31A1 is a stable intertrochanteric fracture associated with an intact posteromedial cortex. Type 31A2 is an unstable fracture pattern characterized by comminution of the posteromedial cortex.

The sliding hip screw has been the implant of choice for stabilizing both stable and unstable intertrochanteric fractures. However, recently there has been dissatisfaction with the resultant deformity associated with use of this type of device to stabilize unstable fracture patterns. Excessive sliding of the lag screw within the plate barrel results in limb shortening and medialization of the distal fragment, and has been reported to result in poorer outcomes. Use of an intramedullary (IM)-type device limits the amount of screw sliding and limb shortening and deformity that can occur compared to a sliding hip screw. The fracture can settle only until the proximal fragment abuts against the nail.

I currently reserve using a sliding hip screw for stable intertrochanteric hip fractures and an IM hip screw for unstable fracture patterns (including reverse obliquity patterns and intertrochanteric fractures with subtrochanteric extension).

With stable fracture patterns, minimal fracture settling should occur, resulting in minor limb shortening and medialization of the distal fragment. In unstable fracture patterns, I prefer to use an IM-type hip screw device because it prevents excessive fracture collapse and therefore deformity.

Michael R. Baumgaertner, MD, FACS: With few exceptions, I have employed closed reduction and IM hip screw fixation for these geriatric fractures for more than 15 years. Although there are no good data to suggest that A1 fractures do better with IM fixation than a sliding screw and plate — and since the translational reduction is usually straightforward — they are excellent cases for the residents to learn the nuances of percutaneous cephalomedullary IM fixation.

The A2 fractures have done better in at least one clean, randomized and prospective study (Utrilla et al, 2005), and although our numbers did not prove it, that was the impression we got from the clinical trial we completed more than 10 years ago. A properly executed, percutaneous stabilization of this fracture offers the patient a documented faster return to function and less fracture collapse. I think these advantages support the use of this device for these fractures and justify the increased cost of the implant.

I use a sideplate for a base-of-the-neck fracture, where nail insertion can displace the fracture. A small open reduction with a clamp and antirotation pin prior to screw and sideplate assures the most stable reduction.

George J. Haidukewych, MD: My preferred treatment varies by fracture pattern. Rather than abide by a “one-implant-fits-all” approach, I try to identify the problem fracture patterns, that is, those that are more unstable. Some examples of such unstable patterns include fractures with reverse obliquity, those with subtrochanteric extension, and those with a large posteromedial fragment (not just the lesser trochanter). These fracture patterns benefit biomechanically from intramedullary implants.

I treat routine, standard obliquity intertrochanteric fractures with a sliding hip screw device for many reasons. First and foremost, the sliding hip screw is still the gold standard for these fractures. It is relatively inexpensive, and if it is implanted accurately in a well-reduced fracture with the appropriate fracture pattern, the failure rate is almost zero and weight-bearing can commence immediately, as tolerated.

Image 1: Percutaneous compression plate with two head screws, used for rotational control. Images: Klein W.

In such stable patterns, there is no data to suggest that IM implants provide any clinical benefit. The position of the lag screw in the femoral head has a bigger impact on failure rates than whether it is connected to a sideplate or an IM device. Also, the abductors are not affected by sliding hip screw insertion. Therefore, simple problems get simple, cost-effective solutions (sliding hip screws), while more unstable patterns are treated with more complex, more expensive implants (cephalomedullary nails).

Wolfgang Klein, MD: In our unit, 31A1 and 31A2 fractures are treated routinely with a percutaneous compression plate [PCCP, Orthofix]. The rationale is: It is a rotationally stable implant with two angular stable neck screws (Image 1), which provide better stability than monoaxial systems (i.e. standard sliding hip screws). This is especially true in unstable fractures. Swiontkowski et al in 1987 published that the sliding hip screw has little, if any, rotational stability. This stability refers to rotation between the proximal fragment and the neck screw, not between the neck screw and the plate, and is a prerequisite for loosening and cut out.

The PCCP can be applied minimally invasively and several investigators have shown a decreased need for blood transfusions in comparison to the standard sliding hip screw (Brandt and colleagues, Kosygan and colleagues).

The construct of two angular stable neck screws that can slide for controlled impaction within the sleeves prevents lateral protrusion and thereby avoids pain and discomfort when lying on the side. The angular stable construct ensures absolute parallelism of the neck screws, which is important for controlled impaction. This is important because even slightly converging or diverging screws can have a jamming effect. Also the Z-effect is avoided by the special design. The PCCP allows smaller diameter screws and hereby can prevent iatrogenic weakening of the lateral wall.

Strauss and Langford: How does the integrity of the lateral trochanteric wall influence your implant selection? As suggested recently in a paper by Palm et al., should we change how we classify these fractures and select our implants based on preoperative “at risk” patterns which may proceed to intraoperative lateral wall fractures?

Baumgaertner: Unlike the hip screw and sideplate, the proximal aspect of the IM nail buttresses the proximal fragment and prevents excessive lateral collapse. Therefore, the integrity of the lateral wall (the lateral cortex of the proximal femur distal to the vastus ridge) is not necessary when using an IM device.

The article by Palm shows convincingly that a sideplate does not adequately stabilize a trochanteric fracture with lateral wall involvement, and more importantly that the very insertion of the device caused the fracture in the majority of cases. In their study, the complication was more common in the more unstable A2 patterns compared to the two-part fractures and those with a small lesser trochanter fracture, and lead to an eight-fold increase in reoperations. I believe this information further supports the use of IM fixation for the “typical” unstable A2 patterns. It also suggests that surgeons who elect plate fixation for A2 fractures should have a contingency plan to deal with an intraoperative lateral wall fracture.

Koval: In the article, Palm and colleagues reported on 214 patients who sustained an intertrochanteric fracture and were treated with a 135· sliding hip screw. They found that fracture of the lateral femoral wall was the main predictor for revision surgery and concluded that patients with preoperative or intraoperative fracture of the lateral femoral wall should not be treated with a sliding hip screw device.

I agree with the findings of this study. The status of the lateral wall on the preoperative radiograph should be a factor in determining the type of internal fixation device used for fracture stabilization.

The importance of the lateral wall has previously been described by Gotfried in a series of 24 patients with documented postoperative fracture collapse. He felt that an intact lateral wall provides a buttress for the proximal fragment and confers rotational and varus stability after fracture impaction has occurred.

If the lateral wall is broken, as may occur during drilling the large diameter hole in the lateral femoral cortex to insert a sliding hip screw, severe fracture sliding (collapse) can occur. He proposed for unstable intertrochanteric fractures, the traditional description of the posteromedial fracture component as the most important prognostic factor should be revised to include the structural description of the lateral wall.

Haidukewych: If the lateral wall is fractured, then, by definition, the fracture is of reverse obliquity or a transtrochanteric pattern, and falls into the unstable category. The proximal fragment is free to lateralize along the axis of the sliding hip screw. These fractures benefit from intramedullary fixation. There is a mechanical block that the body of the nail provides, hopefully resisting excessive lateralization of the proximal fragment.

I worry about fractures where the lateral wall is intact, yet very thin and osteopenic. With preparation of the hole for the lag screw (regardless of a nail or a plating strategy), one can iatrogenically convert the fracture into an unstable pattern, via fracture at the base of the lateral wall.

The size of the hole in the lateral wall depends on the size of the lag screw you wish to insert into the femoral head, so a trade off exists. Femoral head fixation is paramount, so a certain-sized screw is necessary. Whether you make one larger hole or two smaller ones probably doesn’t matter, it will still substantively weaken the lateral wall.

I have renewed interest in the concept of a “prosthetic lateral wall,” where one can reinforce the lateral wall using a sliding hip screw with a trochanteric extension (blocking plate). Previous data have demonstrated the efficacy of these devices; however, soft tissue irritation was a concern because the trochanteric extensions were bulky and ridiculously shaped. I suspect that we will see a new generation of sliding hip screws in the near future that will probably incorporate locking technology, limited collapse, and lower profile trochanteric stabilization to essentially make a metal lateral wall to address all the issues mentioned. Also, I suspect that the concept of jig-targeted submuscular plating will spread to the hip as well to minimize the need to elevate the vastus lateralis. Then we would have a muscle-sparing method of treating the vast majority of intertrochanteric fractures, even those with thin or compromised lateral walls.

Klein: The integrity of the lateral wall is one of the most important factors in the outcome of these fractures. A fracture of the lateral wall means an avulsion of the greater trochanter, proximal migration and insufficient gluteus medius muscle function, a problem that cannot be solved by the use of an IM implant. Erli et al have shown that a positive Trendelenburg sign (ie, gluteus medius insufficiency) is the strongest predictor for a poor outcome in fractures of the proximal femur.

Gotfried and Gun have shown that lateral wall fractures, either intraoperatively or postoperatively, have a significant influence on secondary dislocation/collapse and poor function (Images 2 and 3).

In our view, we should avoid any critical additional damage to the lateral wall caused by the surgical procedure by using implants with smaller neck screws. Gérard et al has shown that the danger of a greater trochanter avulsion fracture increases with the diameter of the lateral wall hole for the neck component of any implant.

We believe it is difficult to define “at-risk fracture” in view of a possible lateral wall fracture. We therefore suggest and practice the routine use of the PCCP also for A1 fractures in order to minimize the risk of iatrogenic complications.

Image 2: A 31A2 fracture treated with a dynamic hip screw (DHS). The first postop xray shows intact lateral wall.

Image 3: Same patient days later in postop period. A fracture of the lateral wall has propagated, leading to uncontrolled collapse with shortening and medialization of the femur.

Strauss and Langford: When treating these fractures with an IM implant, when do you use a long vs. short implant? Is there a time when no distal locking is appropriate?

Haidukewych: Because I only treat unstable patterns with IM nails, I only use long nails. Also, the bone is pathologic (osteopenic), which is probably why you met the patient in the first place. A key principle of managing fractures in osteopenic bone is to protect the length of the bone with your implant.

The need for locking is dictated by the axial and rotational stability of the fracture. I like to avoid locking screws in the subtrochanteric region of the femur — another reason to routinely go long. However, if a surgeon chooses to lock a short nail, I recommend an implant that allows a small-diameter locking screw.

It is important, regardless of the surgeon’s nail length preference, to make sure that traction is released and that no fracture distraction exists prior to locking the construct.

I recommend dynamic locking to further decrease tensile stresses on the lateral nail barrel hole caused by unsupported load, as seen in a locked-distracted construct. We have all seen broken nails, and usually the fracture was distracted and locked in that position. Also, a varus malreduction typically exists, further increasing the loads on the lateral nail lag screw hole, which is the most vulnerable point on nails.

It is important to be aware of the femoral bow, which often increases with age. I tend to stop the nail a bit short in the distal femur, perhaps several centimeters short of where I would sink a femoral nail for a diaphyseal fracture. It is also wise to know the radius of curvature of the nail you select, as this varies widely by manufacturer. I believe nails with a radius of around 2 meters seem right for the overwhelming majority of patients.

Koval: I usually select a full length nail to: minimize the risk of periprosthetic fracture secondary to a stress-riser-effect at the tip of the nail and locking bolt insertion sites; and to protect the entire femur against possible later fractures in the vulnerable elderly population, to subsequent falls.

I rarely use a locking bolt to distally lock the nail. The full-length nail provides rotational stability to the fracture construct. Furthermore, both biomechanical and clinical studies have questioned the need for routine interlocking of both stable and even unstable fractures. At the end of surgery, I rotate the leg under fluoroscopy. If the fracture moves as a unit, I do not place any distal locks. I do place a distal-locking bolt if the fracture segments move independently in subtrochanteric fractures and in intertrochanteric fractures with subtrochanteric extension.

Klein: We do not treat the A1 and A2 fractures with an intramedullary implant. In these fractures, the nail very often has to be introduced through the proximal fracture line. When introducing the nail, lateralization of the shaft fragment and an enlargement of the fracture gap often results.

Only A3 fractures receive intramedullary implants, because they represent a different biomechanical entity in which the main problem is the medialization of the shaft against the proximal fragment. In A3 fractures without subtrochanteric extension, we use a short implant, the Gamma Nail [Stryker Ltd]. In those with fracture extension down the shaft, we use a long version.

We routinely perform a distal interlocking in all of these cases. However, Werner et al provided evidence in 2005 in a poster at the German Society for Trauma Surgery that when using a short nail in cases of secure fixation of the neck screw in the lateral femoral cortex, distal interlocking may not be necessary. This, however, to our knowledge needs further evaluation.

Baumgaertner: I use a short intramedullary nail when fixing A1 and A2 fractures, and I generally employ a longer nail for the A3 fracture patterns, especially if there is significant subtrochanteric extension. Although long nails do prevent the midshaft fractures that were associated with first-generation short nails, they are not without problems. Most of the longer nails have a tendency to impinge and can frankly extrude through the supracondylar anterior cortex. In Robinson’s study of long gamma nails, the researchers noted impingement in 7% of patients, and a fracture at the distal tip occurred in 2%.

I prefer the short nail, because the current more-anatomic and smaller designs, combined with an improved surgical technique have made shaft fracture distal to short nails is a rare complication. Most A1 and A2 fractures were not distally interlocked in our study. Our protocol for these fractures patterns has always been to insert the nail and compression screw, then release traction, gently impact the fracture, and then rotationally stress the construct under fluoroscopic control. If it was stable, no interlock was used.

Because today’s smaller, more anatomic implants tend to get less than three-point fixation within the canal, and with the new awareness of the frequency and danger of iatrogenic lateral wall fractures, which transform a rotationally stable A2 fracture into a rotationally unstable fracture, I now interlock more fractures. Since most new nail designs have an option for a “dynamic” distal interlocking, we can achieve rotational stability but still allow for some fracture impaction.

For more information:

• Michael R Baumgaertner, MD, can be reached at Yale University School of Medicine, 800 Howard Ave., PO Box 208071, New Haven, CT 06519; 203-737-5667; e-mail: Michael.baumgaertner@yale.edu.
• George J. Haidukewych, MD, can be reached at Florida Orthopaedic Institute 13020 N. Telecom Parkway, Temple Terrace, FL 33637; 813-978-9700; e-mail: docgjh@aol.com. He indicated that he receives royalties from DePuy Trauma.
• Wolfgang Klein, MD, can be reached at Klinikum Wolfsburg, Department for Trauma, Orthopedic and Hand Surgery, Sauerbruchstrasse 7, D 38440, Wolfsburg, Germany; 49-5361-801240; e-mail: wkleindr@aol.com. He indicated that research funding for the trauma department of his institution was received from Orthofix SRL.
• Kenneth J. Koval, MD, can be reached at Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756; 603-650-7959; kjkmd@yahoo.com. He is a paid consultant to Stryker Trauma and Biomet Trauma.
• Joshua R. Langford, MD, can be reached at Mt. Sinai School of Medicine, Dept. of Orthopaedics, Box 1188 5 E. 98 St., New York, NY 10029; 212-987-2454; e-mail: Joshua.Langford@mssm.edu. He indicated he has no financial disclosures to any products or companies mentioned in the article.
• Elton Strauss, MD, FRCS, can be reached at 5 E. 98th St., Box 1188, New York, NY 10029; 212-241-1648; e-mail: bonesdoc@optonline.net. He indicated he has no financial disclosures to any products or companies mentioned in the article.

References:

• Brandt SE, Lefever S, Janzing HM, et al. Percutaneous pressure plating (PCCP) versus the dynamic hip screw for pertrochanteric hip fractures, preliminary results. Injury. 2002;33(5):413-418.
• Erli HJ, Klever P, Paar O. Bipolar hemiarthroplasty for treatment of femoral neck fractures in geriatric patients — surgical technique and outcome. Surg Technol Int. 2002;10:221-225.
• Gérard D, Degreif J, Runkel M. [Experimental studies in weakening the stability of the trochanter major by lateral fenestration] 1: Unfallchirurgie. 1993;19(4):208-213.
• Gotfried Y. The lateral trochanteric wall: a key element in the reconstruction of unstable pertrochanteric hip fractures. Clin Orthop Relat Res. 2004;(425):82-86.
• Gun GI, Shin YW, Song YJ. Potentially unstable intertrochanteric fractures. J Orthop Trauma. 2005;19:5-9.
• Kosygan KP, Mohan R, Newman RJ. The Gotfried percutaneous compression plate compared with the conventional classic hip screw for the fixation of intertrochanteric fractures of the hip. J Bone Joint Surg Br. 2002;84(1):19-22.
• Palm H, Jacobsen S, Sonne-Holm S, et al. Integrity of the lateral femoral wall in intertrochanteric hip fractures: an important predictor of a reoperation.. J Bone Joint Surg Am. 2007;89(3):470-475.
• Robinson CM, Houshian S, Khan LA. Trochanteric-entry long cephalomedullary nailing of subtrochanteric fractures caused by low-energy trauma. 1: J Bone Joint Surg Am. 2005;87(10):2217-2226.
• Swiontkowski MF, Harrington RM, Keller TS, Van Patten PK. Torsion and bending analysis of internal fixation techniques for femoral neck fractures: the role of implant design and bone density. J Orthop Res. 1987;5(3):433-444.
• Utrilla AL, Reig JS, Muñoz FM, Tufanisco CB. Trochanteric gamma nail and compression hip screw for trochanteric fractures: a randomized, prospective, comparative study in 210 elderly patients with a new design of the gamma nail. J Orthop Trauma. 2005;19(4):229-233.