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Trochanteric stabilizing plate has performance similar to IM devices
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Figure 1. The lateral surface of the trochanteric
stabilizing plate is shown.
Images: Baumgaertner MR
Earning “gold standard” status shortly after its introduction in the 1970s, the sliding hip screw and sideplate combination was the near unanimous choice to manage intertrochanteric hip fracture until intramedullary hip screw designs (e.g., Gamma [Stryker], IMHS [Smith&Nephew], etc.) became available after 1990. The newer devices provide a robust intramedullary buttress that has been demonstrated to more effectively resist excessive fracture collapse and promote earlier rehabilitation. Currently, most extracapsular proximal femur fractures are managed percutaneously or semipercutaneously with intramedullary implants. What has not received adequate attention is an adjunctive implant available for use with the sideplate that provides equivalent mechanical advantages as the current intramedullary devices (Figure 1).
The trochanteric stabilizing plate (TSP) is an add-on plate that extends proximally from the sideplate and provides a lateral buttress to the trochanteric segment. It prevents excessive implant collapse and gross medialization of the femoral shaft. This extramedullary extension provides a similar buttress to that provided by the proximal aspect of an intramedullary (IM) hip screw. The TSP is indicated for multiple fragment intertrochanteric fractures (AO/OTAtype 31A2) and so-called reverse oblique fractures (AO/OTA type 31A3) because of their particularly high failure rates when treated with a sliding hip screw and sideplate (Figures 2 and 3).
Figures 2 and 3. This displaced 31 A3 fracture was fixed with a sliding screw and sideplate and lateral buttressing with a trochanteric stabilizing plate.
Technical pearls
The surgical technique is identical to that of a sideplate in terms of fracture reduction, and lag screw location and insertion. It is important to note that trochanteric stabilizing plates are typically manufacturer specific, so your implant provider can give additional guidance.
Figure 4. The trochanteric stabilizing plate
is nested on the dynamic hip screw.
To use the TSP, the sideplate is initially fixed to the femur with only the second shaft screw. The exposure must be extended slightly proximally to allow the proximal aspect of the TSP rest on the lateral boarder of the trochanter, while the distal TSP lies directly on the sideplate itself. The remaining screws are used to fix the sideplate to the shaft capture and sandwich the TSP to the sideplate. There is an enlarged opening in the TSP immediately distal to the trochanter to allow the shaft of the sliding screw to retract out of the barrel of the sideplate during postoperative fracture settling and intrafragmentary compression (Figure 4).
Conclusion
Comparative studies have shown reduced fracture collapse when using the TSP compared to stand alone sideplate fixation, and similar performance to IM fixation. A large, randomized, prospective study by Matre and colleagues that compared IM fixation to sideplate fixation in which the TSP was used adjunctively in one-third of all side plates showed similar mechanical and clinical outcomes compared to IM devices.
Palm has shown that iatrogenic fracture of the lateral aspect of the trochanter where the barrel enters the bone occurs as often as 30% of cases when treating unstable 31A22 and 31A23 fractures (effectively turning an A2 fracture into an A3 pattern), and many of these required revision surgery. For all the above reasons, every hip fracture surgeon should be familiar with this simple “bailout” device and be certain it is available for immediate use when treating intertrochanteric fractures with a sliding hip screw and sideplate, and in cases in which fracture instability appears greater than initially diagnosed.
References:
Bong MR. Comparison of a sliding hip screw with a trochanteric lateral support plate to an intramedullary hip screw for fixation of unstable intertrochanteric hip fractures: A cadaver study. J Trauma. 2004;56(4):791-794.
Matre K. J Bone J Surg Am. 2013;doi: 10.2106/JBJS.K.01497.
Palm H. J Bone Joint Surg Am. 2007;doi: 10.2106/JBJS.F.00679.
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Disclosure: Baumgaertner has no relevant financial disclosures.