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Plates and hip screws recommended for displaced intertrochanteric fractures
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KOLOA, Hawaii — Using dynamic hip screws and intramedullary nails may be the best treatment for some displaced intertrochanteric fractures, according to a level 1 trauma surgeon.
“Is there a place for the hip screw anymore?” Richard F. Kyle, MD, asked the attendees of Orthopedics Today Hawaii 2011, here. “Certainly when we started out with intertrochanteric fractures, they represented 50% of the treatments for hip fractures.”
However, at that time, the device had a rigid design which did not transfer the load, leading to failure. “The name of the game in treating hip fractures is vascularity and reduction,” Kyle said.
The most problematic of intertrochanteric fractures is the subtrochanteric, which accounts for approximately 15% of femoral neck fractures, according to Kyle. About 50% of femoral neck fractures are stable, with the remainder unstable with a large posterior-medial fragment of subtrochanteric component.
 Richard F. Kyle |
Subtrochanteric fractures can be tremendously unstable. “You can recognize them under your AP X-ray, or even a lateral X-ray will show that the whole posterior wall may be gone,” Kyle, a past president of the American Academy of Orthopaedic Surgeons, said.
Screws
To avoid problems with sliding screws, Kyle recommended engaging the screw deep in the barrel to avoid the creation of tremendous forces at the tip of the screw-barrel interface.
The most important aspect of screw placement is getting the screw in the center of the head. “If you leave it in the superior aspect of the head, you get a 34% failure rate, according to a study by Mike Baumgartner,” Kyle said. “The bull’s eye position, 3 mm to 5 mm from the subchondral bone, is absolutely essential. If you look at the femoral head … the best bone is right in the middle, whether it is osteoporotic or not. You want to penetrate deep into that head. If you go eccentric way posterior or way inferior, you are not really going deep into the head.”
The fracture sags posteriorly, so you want to make sure that you lift up on the distal fragment, he added.
Nails
In the past, surgeons used angled nails for the subtrochanteric and intertrochanteric fractures. “We used a lot of secondary fixation and we messed around with the biology — bad idea,” Kyle said.
“One of the most important works in the literature on this is a very small series of subtrochanteric fractures by Jeff Mast. He had 24 open reductions, 17% delayed or nonunion, 22 indirect reductions,” he said. “Don’t mess around with the human biology.”
The real workhorse for these fractures is the second-generation intramedullary rod. “It uses the same principles — you have to go through that piece of metal to get your guidewire in the center of the head if you over-ream a little bit so you can rotate it a bit so you don’t have to back it out,” he said.
Another important aspect of this surgery is the setup. “Before I scrub and drape a patient, I make sure that through the C-arm I can see a good lateral, and I can see a good AP. It is absolutely essential because once the blood starts flowing, it is hard to figure this out.”
Screws vs. nails
Meta-analyses comparing screws and nails have shown that for a stable intertrochanteric fracture, there is no difference between a dynamic hip screw and a nail.
“However, subtrochanteric fractures that are extremely comminuted are different, but there also is a big difference in costs [an almost four-fold increase for the nails],” he said.
“Is there a place for hip screws? I think so in terms of cost and that they work really well in unstable situations. But if you have a subtrochanteric component with a lot of comminution, and the shaft won’t medialize, you might want to use a buttress plate if you have to. If you are not that familiar with rodding, the plate still works well to give an indirect reduction.” – by Lee Beadling
Reference:
- Kyle RF. Intertrochanteric fractures: Nail. Presented at Orthopedics Today Hawaii 2011. Jan. 16-19. Koloa, Hawaii.
Disclosure: Kyle receives royalties from Zimmer.
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