August 01, 2003

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Innovations in the Management of Hip Fractures

ABSTRACT

Robert D. Teasdall, MD [photo] --Robert D. Teasdall, MD
Hip fractures include fractures of the head, neck, intertrochanteric, and subtrochanteric regions. Head fractures commonly accompany dislocations. Neck fractures and intertrochanteric fractures occur with greatest frequency in elderly patients with a low bone mineral density and are produced by low-energy mechanisms. Subtrochanteric fractures occur in a predominantly strong cortical osseous region that is exposed to large compressive stresses. Implants used to address these fractures must accommodate significant loads while the fractures consolidate. Complications secondary to hip fractures produce significant morbidity and include infection, nonunion, malunion, decubitus ulcers, fat emboli, deep venous thrombosis, pulmonary embolus, pneumonia, myocardial infarction, stroke, and death.

Subtrochanteric fractures are defined as injuries with epicenters that are located at or within the region (5 cm) below the lesser trochanter and comprise 15% of hip fractures. They are roughly distributed into three groups: elderly patients (>65 years) with low-energy mechanism, young patients (< 65 years) with high-energy mechanism, and patients with metastatic disease producing a pathologic fracture.

Mechanism

Subtrochanteric fractures are produced in an area of the femur with thick cortical bone that is normally subjected to high mechanical stress. Weight-bearing stresses of >0.5 ton per square inch apply to the subtrochanteric femoral bone of a 200-lb man.¹ Due to these high stresses, a fixation device for a fracture in this region must be strong and gain sufficient purchase in the “near” and “far” fragments to negate relative motion in the most sufficient and timely area of fracture to permit consolidation of the fracture.

An intramedullary device has advantages as a “load-sharing implant” over a plate by allowing a patient to bear weight. A plate device is a “load-bearing device.” Weight bearing must be protected in this region of high stress, otherwise the fatigue life of the implant or its anchorage to the bone is exceeded/dislodged.

Implant selection is determined by the fracture pattern. For the reasons outlined above, a third-generation intramedullary nail is the preferred implant for a type 1 fracture. For Russell-Taylor type 2 fractures, where the piriformis fossa is fractured, a 95° blade plate or 95° condylar screw-plate device is used. Because these fractures are sometimes produced by high-energy mechanisms, internal bleeding and associated injuries are not uncommon and should be treated. Blood loss contributes to hemorrhagic shock in these patients. Usually the fracture is managed operatively. In circumstances in which this is not possible or when operative management must be delayed, skeletal traction via a distal femoral pin with flexion, external rotation, and abduction can be used.

Frequent (every few days) radio-graphs and appropriate balanced traction adjustments are performed until the patient is ready for surgery or until the fracture is “sticky” (usually 4-6 weeks). At this point, the patient is placed in a hip spica cast until the fracture is healed (12-16 weeks).

A useful classification for subtrochanteric fractures is that of Russell-Taylor.^2,3 A type 1 fracture does not involve the piriformis fossa, whereas a type 2 fracture does (Figure 1).

Figure 1: Russell-Taylor type 1 fractures have a proximal fragment consisting of the head, neck, and upper portion of the greater trochanter in continuity (A). The piriformis fossa is intact (B). Russell-Taylor type 2 fractures have a fracture extension to the piriformis fossa (C). The upper portion of the greater trochanter and the head/neck segments are separate fragments (D).

Treatment

Type 1 fractures are best managed with an interlocking (third-generation) intramedullary nail with a retrograde proximal lock. A type 2 subtrochanteric fracture can be managed with a 95° blade plate, a 95° condylar screw-plate device, or a cephalomedullary (gamma type) nail.

Many surgeons put the patient in the supine position and use a fracture table to permit traction and C-arm visualization. Typically the proximal fragment is flexed due to the action of the iliopsoas, and a percutaneously placed Schanz pin or pointed trocar on the distal end of the proximal fragment can be used to extend the fragment to the reduced position. For Russell-Taylor type 1 fractures, nailing is accomplished via an incision cephalad to the greater trochanter in line with the shaft of the bone in the usual manner.

For Russell-Taylor type 2 fractures, many surgeons position the patient supine on a radiolucent table with the leg free. The lateral aspect of the proximal femur from the greater trochanter to below the fracture zone is exposed (it is usually preferable to minimize the surgical exposure of the fracture zone, allowing preservation of soft-tissue attachment and blood supply to bone fragments), a reduction effected and provisionally secured (eg, pointed bone holding forceps or a femoral distractor). A 95° device is then applied with appropriate placement of seating chisel-cannula for drilling the head and neck segment.⁴ Cancellous bone grafting of the fracture zone is seldom used with type 1 fractures that are nailed (some would argue that intramedullary reaming serves this purpose). Bone grafting is used selectively in fractures that are managed with plate devices.

Postoperative Care

Postoperative management is dictated by the fracture type and the stability of the internal fixation construct. For stable type 1 fractures with simple fracture patterns treated with a locking intramedullary nail, weight bearing as tolerated is permissible. For unstable patterns addressed with a 95° blade plate device, protected, partial, or weight or leg ambulation is appropriate with progression of weight bearing contingent on roentgenographic evidence of healing and patient comfort.

Prognosis

Unlike intracapsular femoral neck fractures, extracapsular basocervical fractures and intertrochanteric fractures are of minimal risk for nonunion or avascular necrosis of the femoral head.⁵ For elderly patients who are most likely to sustain the fracture, mortality and morbidity due to general debility or associated general conditions are significant.

Complications

Delayed union and nonunion are more of a problem for subtrochanteric fractures where the bone surface area is small and cortical as opposed to the intertrochanteric fracture where the bony surface areas are larger and the bone is cancellous (more vascular). When an intramedullary nail has been used, exchange to a larger nail (diameter >2 mm) with reaming is the usual treatment. For fractures managed with plate devices, removal of the device and cancellous bone grafting with placement of a new device with compression or conversion at that point to condylocephotic or third-generation interlocking nail with reaming of the medullary canal can be effective (the latter, if the portion of the fracture that involved the piriformis fossa has healed).

Malunion is usually a varus and/or flexed malposition and presents with an accompanying delayed union or nonunion. Correction may require an osteotomy/open osteoclasis of the fracture and fixation with either a cephalomedullary nail or a 95° device. The specific operative approach is best achieved by following a careful preoperative plan.⁶

Intertrochanteric Fractures

Incidence and Mechanism

Intertrochanteric fractures affect 150,000 patients each year in the United States and usually result from a fall in elderly patients. As is the case in patients with femoral neck fractures, comorbid conditions such as arrhythmias, electrolyte imbalance, and disorientation may be causal and may contribute to postoperative morbidity. Careful and complete evaluation is crucial. In young patients (<50 years), these injuries are often produced by high-energy mechanisms.

Diagnosis and Classification

Diagnosis is made from anteroposterior (AP) and lateral radiographs. Fractures are classified as either stable or unstable. Stable fractures are simple two-part fractures, where the fracture line runs from lateral and cephalad to medial and caudad. Fractures with posteromedial comminution, reverse obliquity, or subtrochanteric extension are unstable. Using the AO/OTA system, 31A1 fractures are stable fractures and 31A2 or 31A3 fractures are unstable (Figure 2).

Figure 2: 31A1 fractures are two-part fractures with the fracture line directed from cepholateral to caudomedial on the AP radiograph (A). 31A2 fractures are multifragmentary, but inferior fragment consists of the shaft and outer portion of the greater trochanter in continuity (B). 31A3 fractures have inferior fracture fragments that consist of the shaft with a fracture between the shaft and the outer portion of the greater trochanter. Reverse obliquity fracture patterns are included in this group (C).

Treatment

Intertrochanteric fractures are customarily treated by closed reduction and internal fixation. The internal fixation most commonly used is a sliding hip screw and side plate. The reduction is usually obtained on a fracture table, entails longitudinal traction and internal rotation of the distal fragment, and is verified on two views taken with the image intensifier fluoroscope prior to the commencement of surgery.

The surgical approach for a sliding hip screw is via an incision on the upper lateral thigh, carried through the fascia lata. The vastus lateralis is incised in the line of the femur on its posterior aspect to minimize denervation of this muscle. During osteosynthesis with a sliding hip screw, placing the guidepin for the lag screw is the most important step of the operation. Placing the pin at the center-center (center of the femoral neck on the lateral view) position is crucial. This can be facilitated by prior placement of a guidepin along the anterior aspect of the femoral neck with superimposition over the midaxial line of the femoral neck when seen on the AP view.

The pin is adjusted so it has an appropriate angle to the shaft, usually 135°. This pin can then be used as a guide to the placement of the “center-center” pin, which is drilled parallel and posterior to the first. The position of the pin determines the position of the tip of the lag screw, which is an important variable in the stability of the bone-implant composite.^7,8

Unstable intertrochanteric fractures (intertrochanteric/subtrochanteric or reverse obliquity fractures, AO/OTA 31A2 and 31A3 types) can be managed with a 95° condylar screw device. Alternatively, an intramedullary trochanteric nail with proximal retrograde interlocking lag screw (a cephalomedullary or gamma nail type device) can be used, although early reports have cited a higher likelihood of complications with this technique.⁹ Prosthetic replacement has been reported in management of these fractures with reasonable results.¹⁰

Postoperative Care

Postoperative gait training with partial weight bearing is appropriate for stable fractures managed with a sliding hip screw. This results in compression of the fracture line and enhances the frictional resistance to torsion and shear.

The trochanteric region presents rich vascular cancellous bone with little likelihood for delayed healing. For unstable variety intertrochanteric fractures, weight bearing is individualized and depends on the “personality” of the fracture, its inherent stability and stabilizing construct. Compliance with any postoperative regimen is largely contingent on the cognition and memory of the patient, which is not always a given in this patient population. Recent work by Koval et al¹¹ showed through foot forceplate data that patients who have good cognition have an automatic protective weight bearing if allowed to weight bear to toleration/comfort. Koval et al¹² demonstrated that a regimen that called for unrestricted weight bearing had a low revision surgery rate of 2.9% and concluded that the regimen speeded rehabilitation without added risk or disrupting the fixation.

Prognosis

Generally, the prognosis for this injury is contingent on the general condition of the patient, the quality of the reduction, the extent of osteoporosis, and the suitability of the fixation construct. A recent study has shown that for locomotion, transfers, and self care, only 33%-37% of patients returned to their previous level of function by 6 months, and only 24% were independent in locomotion at 6 months.¹³

Figure 3: Garden I fractures are incomplete fractures (A). Garden II fractures are complete fractures, but nondisplaced (B). Garden III fractures are partially displaced (some apposition remains) (C). Garden IV fractures are completely displaced (no remaining fracture surface apposition) (D).

Femoral Neck Fractures

Femoral neck fractures may be intracapsular or extracapsular. Extracapsular fractures are biomechanically and biologically similar to intertrochanteric fractures. Intracapsular fractures are either subcapital or transcervical in location. Displaced intracapsular fractures are prone to nonunion, malunion, and/or avascular necrosis.

Incidence and Mechanism

The majority (>95%) of patients who sustain intracapsular fractures are >50 years of age. Most intracapsular fractures occur among women; osteoporosis is a frequently associated and predisposing factor. Low-energy mechanisms such as falls are common. Comorbid conditions, including cardiac arrhythmia, transient ischemic attacks, and balance problems are commonly associated with intracapsular fractures, and these conditions should be ruled out (or identified and medically optimized), especially if the fall is unexplained. In younger patients with normal bone mineral density, a high-energy mechanism such as a motor vehicle accident is frequently the cause, and associated injuries such as ipsilateral femoral shaft fractures are reported in 20% of patients.¹⁴

Classification

Intracapsular femoral neck fractures are classified into four groups according to Garden¹⁵ (Figure 3). Garden I fractures are incomplete fractures or valgus impacted fractures; Garden II fractures are complete fractures but not displaced; Garden III fractures are complete fractures but incompletely displaced (partial apposition); and Garden IV fractures are complete fractures with complete displacement (no apposition).

Treatment

Treatment options include internal fixation or arthroplasty. Nonoperative management is associated with higher mortality and morbidity than operative management. For older patients with low bone mineral density, hemiarthroplasty is a reasonable option. For patients with pre-existing hip arthritis, total hip replacement (THR) may be an appropriate option.^16,17 Although there is some controversy regarding the relative benefits of osteosynthesis versus arthroplasty, it appears that arthroplasty may benefit active elderly patients with a normal mental function and high functional demands.¹⁸

For younger patients, anatomic reduction and internal fixation are indicated. Incomplete or nondisplaced (Garden I and II) intracapsular femoral neck fractures are managed with internal fixation, usually with three or four parallel interfragmentary cannulated screws.¹⁹

Displaced fractures are managed with open (or closed) anatomic reduction and internal fixation usually with three or four parallel interfragmentary cannulated screws. If attempted closed reduction is not anatomic, then an open reduction is indicated. If an anatomic closed reduction is accomplished, then there is rationale for performing a capsulotomy for evacuating any associated intracapsular hematoma. Theoretically, this alleviates pressure that may disrupt the blood flow of the femoral head^20-24 and reduces the incidence of avascular necrosis.

Total hip replacement is indicated in elderly patients with significant
pre-existing hip arthritis. The preferred surgical approach for arthroplasty is either an anterior, direct lateral,²⁵ or modified posterior approach,^26,27 to minimize the likelihood of a dislocation. Alternatively, an osteosynthesis with retention of the femoral head fares well among elderly patients who are in good health and mental status.²⁸ Progressive arthritis may be managed by elective THR at a later date.

Prognosis

Comorbid conditions are prevalent among patients who sustain a femoral neck fracture and mortality is contingent on the extent and severity of these comorbidities.²⁹ The likelihood for uncomplicated fracture healing is contingent on the extent of the displacement, the quality of the reduction, the stability of the fixation construct, and bone quality. Failure of internal fixation in patients with poor bone mineral density has been reported in 9%-27% of patients.³⁰ Appropriately managed Garden III and IV femoral neck fractures have a higher likelihood than Garden I and II fractures for avascular necrosis and nonunion.³¹

Management using arthroplasty is associated with dislocation and infection rates of 4.7% and 2.9%, respectively.³² Thrombosis, a potential life- threatening complicating factor for all patients with this injury, occurs after osteosynthesis or endoprosthetic replacement surgery.^33-35

In elderly patients, this risk applies despite current thromboprophylaxis regimens. A recent prospective trial of 644 hip fracture patients whose thromboprophylaxis consisted of compression stockings and subcutaneous low-molecular-weight heparin showed a proximal deep vein thrombosis (DVT) of 6.1% by Duplex Doppler ultrasonography.³⁶ These patients have experienced an incidence of 2%-4% pulmonary emboli and 3%-4% DVT.³⁰

Complications

Nonunion of a femoral neck fracture is often accompanied by a varus malposition. Varus malposition changes the mechanics of the fracture line. In young patients with good bone, varus malposition may be addressed by a valgus osteotomy at the trochanteric level,³⁷ which establishes compression at the fracture and minimizes shear. Older patients are managed by excising the head fragment and arthroplasty.³⁸ Avascular necrosis may be managed by vascularized bone graft, endoprosthetic, or total joint replacement.

Figure 4: Type I fractures are at or below the fovea (A); type II fractures are above the fovea (B). Type III fractures are either type I or type II fractures in combination with a femoral neck fracture (C). Type IV fractures are either type I or type II fractures in combination with an acetabular fracture (D).

Femoral Head Fractures

Incidence and Mechanism

Generally, femoral head fractures are infrequent injuries. Between 1975 and 1993, Stockenhuber et al³⁹ reported that only nine of 231 (3.9%) operatively treated hip injury patients sustained a femoral head fracture. Although these fractures can occur due to direct trauma, notably by gunshot, most occur as shearing or avulsion injuries at the time of hip dislocation or subluxation.⁴⁰ If the femur is loaded axially with a force vector similar to that which produces dislocation, then the acetabular wall and corresponding portion of the femoral head are loaded, a shearing force is produced where the femoral head abuts the rim of the acetabulum, and a fracture is created. Additionally, the ligamentum attachment teres of the fovea of the femoral head may play a role in this mechanism.

Classification

Fractures of the femoral head are classified by Pipkin⁴¹ into four groups (Figure 4). Type I fractures occur below the fovea and are not associated with a femoral neck or acetabular fracture. Type II fractures occur at or above the fovea, and are not associated with a femoral neck or acetabular fracture. Type III is associated with a femoral neck fracture and type IV is associated with an acetabular fracture.

Treatment

For Pipkin type I fractures, simple excision of the fragment(s) is an appropriate option if small or comminuted fragments make open reduction and internal fixation difficult and anatomic restoration of the femoral head unlikely. Pipkin type II fractures are managed with open reduction and internal fixation. Typically located anteriorly on the femoral head, these fractures are best treated using an anterior approach.⁴² Reduction and fixation are facilitated by use of cannulated screws situated below the surface of the articular cartilage (to avoid causing cartilage wear with joint motion or with headless compression screws).

Pipkin type III fractures are rare and occur in young patients with good bone. Anatomic reduction and internal fixation are indicated. Open reduction and internal fixation of the femoral head may be performed through an anterior approach. The head and fracture fragment may need to be manipulated with K-wires placed provisionally, which serve as joysticks and permit fragment manipulation to the reduced position.

Definitive fixation is obtained with cannulated screws inserted over a guidepin placed for stable fixation. Placement of the cannulated screw with the entire screw placed below the line of the articular cartilage provides a definitive fixation. By extending the capsulotomy inferiorly, the femoral neck can be reduced under direct vision.

Temporary fixation can be obtained by placing a guidepin from the lateral aspect of the proximal femur, as one would customarily do for an isolated femoral neck fracture. Sequential placement of parallel cannulated screws provides definitive fixation. In the authors’ experience, the Pipkin type III injury that occurs in elderly patients is an indication for hemiarthroplasty after fragment excision.

Pipkin type IV fractures are most commonly anterior femoral head fragments associated with posterior wall fracture. Treatment of this injury pattern is facilitated by an anterior incision to address the femoral head fracture and a separate Kocher-Langenbach incision to address the posterior wall fracture.^43,44

Complications Secondary to Hip Fracture

Occasionally, a patient presents with symptoms of hip fracture and normal radiographs. Magnetic resonance imaging is useful in this setting.⁸

Thromboprophylaxis

In patients with proximal femoral fractures who are unprotected, DVT ranges from 40% to 83%, and the incidence of pulmonary embolus from 4% to 38%.

The most recent American College of Chest Physicians (ACCP) guidelines⁴⁵ (2001) recommend thromboprophylaxis with low-molecular-weight heparins or adjusted-dose warfarin and, as an alternative option, low-dose unfractionated heparin after hip fracture surgery. Since the publication of the 2001 ACCP thromboprophylaxis guidelines, the new antithrombotic agent fondaparinux was approved for prevention of venous thromboembolism after surgery for hip fracture in the United States. In a randomized prospective study of DVT after surgery for hip fractures, patients receiving fondaparinux had a significantly lower rate of DVT than patients receiving enoxaparin. Because fondaparinux is the only agent currently approved in the United States for thromboprophylaxis after surgery for hip fracture, it is an appropriate agent for thromboprophylaxis in patients undergoing surgery for hip fracture.

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Authors

From the Department of Orthopedic Surgery, Wake Forest University School of Medicine, Winston-Salem, NC.