Fractures in Adults

Ovid: Rockwood And Green's Fractures In Adults
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Editors: Bucholz, Robert W.; Heckman, James D.; Court-Brown, Charles M.; Tornetta, Paul Title: Rockwood And Green's Fractures In Adults, 7th Edition Copyright 2010 Lippincott Williams & Wilkins
> Table of Contents > Section Four - Lower Extremity > 48 - Intertrochanteric Fractures
48 Intertrochanteric Fractures
Thomas A. Russell
INTRODUCTION
Pertrochanteric fractures are those occurring in the region extending from the extracapsular basilar neck region to the region along the lesser trochanter before the development of the medullary canal. Intertrochanteric and peritrochanteric are generic terms for pertrochanteric fractures. Injury creates a spectrum of fractures in this proximal metaphyseal region of bone, with damage to the mechanically optimized placement of intersecting cancellous compression and tensile lamellae networks and the weak cortical bone with resulting displacement from the respective attachment of muscle groups to the fracture fragments and an adjacent high mobility joint. These structures are subject to multiplanar stresses after surgical repair. This region of the femur shares many common biomechanical properties with other short end-segment metaphyseal-diaphyseal fractures with regard to the difficulty in obtaining stable fixation. Although predominantly associated with low-energy older age patients, high-energy trauma in young patients can result in similar patterns of fracture. Pertrochanteric femoral fractures are of intense interest globally. They are the most frequently operated fracture type, have the highest postoperative fatality rate of surgically treated fractures, and have become a serious health resource issue because of the high cost of care required after injury. The reason for the high cost of care is primarily related to the poor recovery of functional independence after conventional fracture care in many patients. Interestingly there has been no significant improvement in mortality or functional recovery over the past 50 years of surgical treatment. Paradoxically the last 50 years of acquiescence to the status quo of hip fracture treatment are related to false assumptions that have been a hindrance to improvement in the management of the hip fracture patient: (i) P.1598 uncontrolled shortening and varus collapse are acceptable in hip fractures but not other fractures; (ii) reduction does not matter with sliding screw systems, as the fracture will collapse to stability because rotation is not a problem and placement of the head fixation takes precedence over fracture reduction; (iii) union without implant failure overrides the requirement of a stable anatomic reduction to the detriment of optimal functional recovery; and (iv) the orthopaedic surgeon just fixes the fracture, as opposed to treating the total musculoskeletal needs of the patient. The reasons for these assumptions relate directly to the historical evolution of hip fracture treatment and the arguments that shaped our current understanding. A new paradigm regarding hip fracture care and treatment is currently evolving, which hopefully will advance our treatment goal back to optimal functional recovery and prevention of future hip fractures. In 1997 Gullberg et al. estimated that the future incidence of hip fracture worldwide would double to 2.6 million by 2025, and 4.5 million by 2050.79 The percentage increase will be greater in men (310%) than women (240%). In 1990 26% of all hip fractures occurred in Asia, whereas this figure could rise to 37% in 2025 and 45% in 2050.143 Hagino et al. reported a lifetime risk of hip fracture for individuals at 50 years of age of 5.6% for men and 20.0% for women.82 Since 1986 in the Tottori Prefecture, Japan, the acceleration of hip fracture incidence continues for both genders. There is hope that hip fracture risk has begun to decline in certain areas of the world, but the reason is unknown. In Denmark the incidence of hip fractures has declined about 20% from 1997 to 2006; Nonetheless, this decline cannot be explained by antiosteoporotic medications, whose effect should only be an approximate reduction of 1.3% in men and 3.7% in women. 2 Epidemiologic studies among Olmsted County, Minnesota, residents in 1980 to 2006 revealed that the incidence of a first-ever hip fracture declined by 1.37%/year for women and 0.06%/year for men. The cumulative incidence of a second hip fracture after 10 years was 11% in women and 6% in men. The focus of surgical research regarding internal fixation in the late twentieth century was to minimize implant failure and avoidance of cutout of the femoral head and neck fixation components. Because many of these fractures are associated with osteoporosis, the current paradigm shift regarding hip fracture care relates to three main strategies: (i) Prevention by aggressive screening and treatment of patients with high risk for fragility fracture; (ii) standardization of hip fracture centers with aggressive early intervention and protocols to avoid complications; and (iii) optimization of fracture reduction and new designs of implant component fixation in osteoporotic bone with conceptual design changes in fixation stability and augmentation of the bone-implant interface.
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PRINCIPLES OF MANAGEMENT Mechanisms of Injury

Low-energy falls from a standing height account for approximately 90% of community hip fractures in patients more than 50 years of age, with a higher proportion of women. Higherenergy hip fractures are relatively rare; they are more common in men less than 40 years of age and are usually referred to regional trauma centers for treatment.100 Cummings et al.43 noted that neither age-related osteoporosis, nor the increasing incidence of falls with age sufficiently explains the exponential increase in the incidence of hip fracture with aging.43 Their hypothesis was that four conditions correlated for a fall to cause a hip fracture: (a) the faller must be oriented to impact near the hip; (b) protective responses must fail; (c) local soft tissues must absorb less energy than necessary to prevent fracture; and (d) the residual energy of the fall applied to the proximal femur must exceed its strength. This concept applies primarily to strategies to prevent hip fractures. Fall with a rotational component is more common with extracapsular hip fractures.98
Associated Injuries
In low-energy falls resulting in hip fractures, associated injuries are most commonly distal radius and proximal humerus fractures and minor head injuries that occur during the fall. High-energy hip fractures are more commonly associated with ipsilateral extremity trauma, head injury, and pelvic fractures. Associated injuries or premorbid diseases may coexist with the fracture diagnosis. Syncopal episodes resulting in a fall may bring attention to cardiovasular and neurologic disease states. Primary neoplastic and metastatic disease may reveal their presence with preceding hip discomfort and subsequent fall resulting in fracture.
History and Physical Examination

Patients most commonly present with a history of pain and inability to ambulate after a fall or other injury. The pain is localized to the proximal thigh and is exacerbated by passive or active attempts of hip flexion or rotation. Drug use, either illicit or precribed pharmacologics, must be sought out as a confounding and contributing factor. Nursing home and institutionalized patients must be examined for the potential of neglect and abuse in the form of previous fractures, and injuries in different states of repair and decubiti. The physical findings of a displaced hip fracture are shortening of the extremity and deformity of rotation in the resting position compared with the contralateral extremity. Pain with motion or crepitance testing is not elicited unless there are no physical signs of deformity and radiographic studies are negative for an obvious fracture. Pain with axial load on the hip has a high correlation with occult fracture. The auscultation Lippmann Test is quite sensitive for the detection of occult fractures of the proximal femur or pelvis.132 By placement of a stethescope bell on the symphysis pubis and tapping on the patella of both extremities, variations in sound conduction through the pelvis and hip from the patella result when there is any discontinuity. A decreased tone or pitch implies fracture within this arc of bone. Laboratory studies in addition to the standard workup for surgery should include the following for all low-energy fractures (osteopenic or fragility fractures): serum calcium, phosphate, and alkaline phosphatase; a complete blood-cell count (CBC); 25 hydroxyvitamin D, thyroid-stimulating hormone (TSH); parathyroid hormone (PTH intact); serum protein electrophoresis (SPEP); and kidney-function tests, including blood urea nitrogen (BUN), creatinine, and glomerular filtration rate (GFR). ,
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A search for high-risk potentially preventable complication includes: previous DVT/PE, anticoagulation medications, immune deficiency disorders, malabsorption disease, angina or CVA prodromal symptoms of atherosclerotic disease, and active infection (pulmonary, genitourinary), which might result in sepsis postoperatively. Protein-calorie malnutrition and vitamin D deficiency are now recognized as serious risk factors for mortality and recovery. Foster reports 70% mortality for patients with albumin less than 3 compared with a mortality rate of 18% in patents with albumin 3. 61 Vitamin D deficiency is now viewed as an epidemic because of dietary changes and lack of sunlight exposure; current recommendations are to administer 50,000 IU of vitamin D immediately to all elderly patients on admission with hip fracture.206
Imaging and Other Diagnostic Studies

Plain radiographs including an AP pelvis, AP, and cross table lateral of the affected hip are usually recommended for diagnosis and preoperative planning. Traction films are helpful is comminuted and high-energy fractures in determining
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implant selection.117 Subtrochanteric extension requires full-length femoral AP and lateral radiographs for implant length selection. If a long nail implant is a consideration, then AP and lateral radiographs of the affected femur to the knee are required, with special attention to femoral bow and medullary canal diameter. Traction views with internal rotation may be of benefit preoperatively as an aide in the selection of definitive internal fixation. 117 Computed tomography (CT) or magnetic resonance imaging (MRI) scans are rarely required for displaced fractures but may be useful in establishing the diagnosis in nonobvious fractures and atypical fractures in high-energy trauma patients.181, 209 The MRI does not necessarily require a full study, as the frontal images are most often diagnostic. Nonetheless, complete studies usually detect other diagnosis for hip pain in addition to occult fractures of the proximal femur. MRI is preferred over the CT or the older radionuclide scans because of a higher sensitivity and specificity for a more rapid decision process.* In actual practice, the best radiographic analysis of hip fractures occurs in the operative suite with fluroscopic C-arm views. This technology gives the surgeon an excellent modality for fracture analysis in complex fractures and immediate feedback as to the stability of the fracture after the initial reduction. In many institutions this has led to elimination of preoperative lateral radiographs. Unfortunately this practice may also result in a change in the selected type of fixation with inherent stress on the operative team and resource management.
DIAGNOSIS AND CLASSIFICATION

Classifications for extracapsular fractures of the hip occurring from the basicervical to the level of the subtrochanteric regions have not been particularly helpful in clinical situations. Nonetheless, increased sugical complexity and recovery are associated with unstable fracture patterns. Unstable characteristics include posteromedial large separate fragmentation, basicervical patterns, reverse obliquity patterns, displaced greater trochanteric (lateral wall fractures), and failure to reduce the fracture before internal fixation. Stability after surgical treatment connotes anticipated union without deformity or implant failure. The current controversy of implant selection is largely focused on what amount of deformity and fracture site motion is still compatible with a functional recovery to the patient's preinjury status. There is no single classification system that has achieved reliable reproducible validity. In 1822 Astley Cooper (London) described the first (pre-radiographic) classification of hip fractures: intracapsular and extracapsular fractures (with the main complication of nonunion and avascular necrosis in the first and the second of coxa vara). In 1949 Boyd and Griffin described the first treatment recommendation classification, predictive of the difficulty of achieving, securing, and maintaining the reduction in four fracture types: (i) Stable (two part); (ii) unstable with posteromedial comminution; (iii) subtrochanteric extension into lateral shaft extension of the fracture distally at or just below the lesser trochanter (the term reverse obliquity was coined by Wright); 220 and (iv) subtrochanteric with intertrochanteric extension with the fracture lying in at least two planes (Figure 48-1). They were the first to report the use of lateral buttress plating of the greater trochanter to avoid medialization of the shaft in type 3 fractures, the need for two-plane fixation for type 4 subtrochanteric fractures with a coronal fracture line, and the possibility ofiatrogenic conversion of type 1 and 2 fractures to type 3 during implant preparation and insertion.
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FIGURE 48-1 Boyd and Griffin classification: (i) stable (two-part), (ii) unstable comminuted, (iii) unstable reverse obliquity, (iv) intertrochanteric-subtrochanteric with two planes of fracture.
Also in 1949 M. Evans (Birmingham, England) reported on a post-treatment classification with five types described. He P.1600 compared nonoperative treatment and fixed angle device surgical treatment. He documented that 72% of his fractures could be fixed in a stable configuration. Stability was not achieved in 28% of the fractures; 14% as a result of the fracture pattern or comminution and 14% of which he felt the reduction was never achieved (Figure 48-2). This paper was primarily used to argue the value of internal fixation over nonoperative treatment of hip fractures, which was controversial in England in the 1940s and 1950s. In 1979 and 1980, respectively, Kyle et al. and Jensen et al. reported independently on a revision of the Evans classification incorporating the lateral radiographic position of the posteromedial fracture component and its relation to
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stability with sliding fixation systems.104, 122 Kyle et al. showed an increased rate of deformity and collapse with increasing instability classification. Jensen et al. related the ability to reduce the fracture and secondary displacement risk with a CHS-type device in their classification system.
FIGURE 48-2 Evans classification of trochanteric fractures. Type 1: Stable because either undisplaced or displaced but anatomically reduced to stability (intact medial cortex). Type 2: Unstable implies displaced and fixed in an unreduced position, comminuted with destruction of the anteromedial cortex, or reversed obliquity.
The OTA/AO classification is now the most quoted in recent scientific articles and is a derivative of the Muller classification (Figure 48-3). There is a higher interobserver agreement with the AO/OTA classification than Evans/Jensen, but neither meets the acceptable threshold for reliability.64 The AO/OTA has nine main types; however, correlation is best with only three categories; also there is no lateral radiographic parameter with the AO/OTA classification.156,175, 188 Generally 31A1 fractures are thought of as the most stable, 32A2 fractures are more unstable, and 31A3 fractures are the most unstable with plate device fixation. Unfortunatedly, the fifth digit of the classification has not been found to be reliably identifiable in prospective evaluation. P.1601
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FIGURE 48-3 In the OTA alphanumeric fracture classification, intertrochanteric hip fractures comprise type 31A. These fractures are divided into three groups, and each group is further divided into subgroups based on obliquity of the fracture line and degree of comminution. Group 1 fractures are simple (two-part) fractures, with the typical oblique fracture line extending from the greater trochanter to the medial cortex. The lateral cortex of the greater trochanter remains intact. Group 2 fractures are comminuted with a posteromedial fragment. The lateral cortex of the greater trochanter, however, remains intact. Fractures in this group are generally unstable, depending on the size of the medial fragment. Group 3 fractures are those in which the fracture line extends across both the medial and lateral cortices. This group includes the reverse obliquity pattern.
Gottfried and Kulkami et al. have developed the most recent therapeutic-based classification, again derived from a modification of the Evans and Jensen classification,120 primarily focusing on the stability of the lateral wall as a buttress to minimize medialization and uncontrolled collapse after single screw device fixation. Kyle has recently added another very unstable pattern to his previous classification. In this variant, the fracture line includes a separate femoral neck fracture; he concluded that this variant should not be treated with a sliding hip screw device.121
SURGICAL AND APPLIED ANATOMY AND COMMON SURGICAL APPROACHES Surgical and Applied Anatomy
The pertrochanteric region is quite variable in its combination of cortical and cancellous bone structure. The well-vascularized pertrochanteric region is dependent on the structural integrity of a laminated cancellous bone arcade from the femoral head and epiphyseal scar, around Ward's triangle to the lesser trochanter, where the solid nature of the structure changes to a tubular construct with the origin of the femoral medullary canal; the strong plate of bone posteriorly is named the calcar femorale (Figure 48-4).65 This is the region most affected with the posteromedial fracture comminution leaving only the anteromedial cortex potentially stable. The main structural attachments to the proximal femur include the hip capsule and the musculotendinous junctions of the gluteus medius and minimus (greater trochanter), iliopsoas (lesser trochanter), pirifomis and short external rotators (posterior trochanteric region from the greater trochanteric region to the lesser trochanter), the oblique head of the rectus femoris (anterior capsule), and the vastus lateralis (lateral femur distal to the greater trochanter). The hip capsule is especially important in reduction of pertrochanteric fractures and its continuity with the distal fragment is the soft tissue attachment on which a stable reduction is possible (Figure 48-5). With capsular disruption, the displacement of the fracture fragments is dependent on the musculotendinous attachment to the respective fragments. The greater trochanter is abducted and externally rotated by the gluteus medius and short exteral rotators, the shaft is displaced posteriorly and medially by the adductors and hamstrings. This accounts for the usual shortening and coxa vara deformity of displaced fractures. With aging the morphology of the hip changes with thinning of the cortex and expansion of the diameter of the bone (Figure 48-4C). The younger hip fracture patients has a relatively narrow metaphysis and a high narrow isthmus with a very thick cortex in the diaphysis. Further aging results in a slight widening and thinning of a cortex of the metaphysis, with bone loss and a decreased thickness of the diaphyseal cortical bone stock and a widening of the isthmus. In the advanced age group, there is a very wide vacuous metaphysis
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proximally with loss of tension and compression trabeculae, a loss of the constriction of the isthmus, and a very round expanded tubular-shaped femur with a thin cortex Three types of morphologic anatomy were grouped together by Dorr et al. in 1983 referencing the selection of cemented versus non-cemented arthroplasty femoral components48 (Figure 48-6). The same rationale applies to implant selection for hip fracture patients. Type A femurs occur primarily in young patients and have a narrow metaphysis, thick cortex, and high constricting isthmus. Excessive bone removal is required for intramedullary devices, and either a plate-type construct or smaller-diameter reconstruction nail may be more bone conserving. Type B fracture morphology has a wider metaphysis and larger medullary canal, but relatively good cortex and isthmus constriction. Type C is the most problematic in geriatric populations with hip fractures: a wide metaphysis, wide medullary canal, and loss of isthmus constriction in association with loss of cortical diaphyseal bone stock. There is a trend to prefer long intramedullary implants in these patients; however, care must be taken that the straightened thin P.1602 diaphyseal cortex may be at risk of perforation distally by long devices in the anterior supracondylar area.157
FIGURE 48-4 A. Posteromedial calcar shelf, which is usually damaged with unstable fracture patterns. B. Ward crosssection of proximal femur. Best quality bone is within 10 to 30 mm of subarticular surface. Note tensile
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trabeculae between Ward's triangle and greater trochanter. C. Changes in morphology of bone with age: adaptation to maintain whole bone strength. Note expansion of geometry and thinning of cortical bone with aging. ( C adapted from Seeman E. Pathogenesis of bone fragility in women and men. Lancet 2002;359: 1841-1850, and Seeman E. Periosteal bone formationa neglected determinant of bone strength. N Engl J Med 2003;349:320-323.)
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FIGURE 48-5 A. Anterior hip capsule. Y-Ligament of Bigalow as structure for ligamentotaxis in closed reduction of stable Fractures. B. Posterior hip capsule. Note more-proximal position of capsule posteriorly and course of arteries to head.
The neurologic structures of interest are the femoral nerve anteriorly and sciatic nerve posteriorly; however, they are rarely encountered in surgical approaches for repair of pertrochanteric fractures and are injured only rarely by penetrating trauma, usually by displaced fracture fragments.49, 112, 140,152,179,212 Vascular injury affecting the femoral head is rarely involved in nonpenetrating injuries.192 Brodetti noted the rare possibility of injury to the vascularity of the femoral head with femoral head fixation screws and nails with injection studies, and found that the central and inferior locations were safe zones. 28 Avascular necrosis after pertrochanteric fracture is extremely rare because of the relative protected area of the medial circumflex artery with pertrochanteric fractures, but may develop in 0.5% to 1% of pertrochanteric fractures usually within 4 years of injury.13, 69
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FIGURE 48-6 Dorr classification of morphology of femur. Type A corresponds to a small metaphysis, thick cortex, and high narrowed isthmus. Type B corresponds to a wider metaphysis, thinner cortex, and a tapering but wider isthmus. Type C corresponds to a wide metaphysis, thin cortex, and a straight or varus curvature in the diaphysis with loss of isthmus constriction.
Common Surgical Approaches

Lateral Approach to the Proximal Femur
This approach has been relatively standardized over the past 70 years for plate fixation. The patient is commonly operated on with a fracture table and the leg and foot secured after closed reduction. The entire proximal thigh from the iliac area to the distal femur is prepared in the standard fashion. The incision length is based on the length of the proposed plate-shaft component; the incision is started with reference from intraoperative C-arm fluoroscopy views and is centered over the lesser trochanter. Commonly the incision length is 5 to 10 cm in length. The iliotibial band is incised and the proximal portion is extended sufficiently to develop the area of the intertrochanteric line for palpation anteriorly. The fascia of the vastus lateralis is incised near its attachment posteriorly at the linea aspera. Leave sufficient fascia posteriorly (5 to 10 mm) for closure and to identify and obtain hemostasis of all perforator arteriovenous structures. Reflect the vastus anteriorly, exposing the lateral femoral shaft. There are no significant neurologic or vascular structures at risk with this approach (Figure 48-7). P.1604
Intramedullary Approach
The incision for nail insertion is determined by the intersection of a line from the anterior superior iliac spine directed posteriorly and a line parallel to the long axis of the femur. Overlay a 3.2 guidewire on the skin anteriorly and laterally and confirm alignment with the proximal femur with C-arm. Incise the skin proximal to the greater trochanter. Usually a 3- to 5-cm incision is adequate. The fascia is incised, but the gluteus medius fibers are not dissected, as this approach is designed to minimize soft tissue damage around the proximal femur. A targeting guide and trocar system protects the gluteus medius. Separate incisions for the femoral head fixation are made through the short version of the lateral approach to the femur (Figure 48-8).
Watson Jones Approach

This anterolateral approach to the hip is actually a proximal expansion of the straight lateral approach previously
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described. The muscular interval proximally is between the tensor fasciae latae and the gluteus medius. The interval between these two muscles is best begun distally and exposed proximally. Follow the anterior border of the vastus lateralis proximally to reach the anterior trochanteric ridge and hip capsule. The use of Schanz pins drilled into the proximal femur is an aide in retraction for better visualization and may be used for manipulation of the shaft. Further capsulotomy and greater trochanteric osteotomy are rarely required for pertrochanteric fracture management. The main vascular obstacle is the ascending branch of the lateral femoral circumflex artery, which should be isolated and ligated in the approach. Complete proximal dissection of the gluteus medius and tensor fasciae latae interval to the iliac crest is rarely necessary; the superior gluteal nerve to the tensor fasciae latae is sacrificed with full proximal dissection; however, this not clinically significant (Figure 48-9).
FIGURE 48-7 Lateral surgical approach to the hip. Slight curvature of proximal extent of incision to allow palpation of the anterior cortex. Vastus lateralis reflection distally as needed for length of plate.
CURRENT TREATMENT OPTIONS Evolution of Treatment

The importance of understanding the evolution of treatment concepts regarding pertrochanteric fractures is critical to advancing treatment modalities. Those who are ignorant of the past are condemned to repeat its mistakes. Initial treatment in the 1800s in England focused on the work of Pott and Cooper, who advocated supporting the thigh in a flexed position. Early mobilization of the patient from bed rest to chair to protective ambulation was the primary goal for survival of the patient. They espoused benign neglect of the fracture in an attempt to save life over limb.41 The other school was founded by Hugh Owen Thomas of Liverpool, who advocated immobilization and prolonged bed rest.
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FIGURE 48-8 Intramedullary approach. Incision is placed center to slightly posterior to line of femoral shaft centered between the anterior superior and inferior iliac spines anteriorly. Incision length is 2 to 4 cm.
Whitman in 1902 re-evaluated the role of neglect of this type of fracture and advocated reduction and stabilization with traction, abduction, and internal rotation, to better restore the anatomy of the hip. 217 This was performed under general anesthesia; then the patient was placed in a long leg hip spica cast to maintain the reduction. This basically moved the treatment of hip fractures from a passive to an active role by the surgeon.
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FIGURE 48-9 Watson-Jones approach. Key interval between TFL and G. Medius to visualize anterior femoral neck and capsule.
Whitman reflected in 1938 on the evolution of hip fracture treatment from 1900.218 At the beginning of this century, fracture of the neck of the femur was a therapeutic derelict. The futility of conventional treatment, demonstrated by Sir Astley Cooper, had been accepted as a finality and permanent disability as an inevitable sequence of the injury. Neglect of the fracture in the alleged interest of the patient entailed no responsibility, either moral or legal. Positive treatment, by contrast, could appeal only to adventurous spirits, because the correction of deformity might break up the sacrosanct impaction, the only hope of union; whereas the restraint of the plaster spica must endanger the life of the patient. During the lapse of years, nonetheless, in spite of opposition and inertia, the abduction treatment has come into general use, and experience has disproved every assumption on which the negative doctrine was based. P.1606
Whitman foresaw the replacement of nonoperative treatment with operative treatment, with the success of the SmithPetersen nail as the next progression to restore the limb and decrease mortality. In the 1800s, Langebeck and others attempted internal fixation of the hip from a transtrochanteric insertion, but problems with material compatibility and the rigors of surgery resulted in the failure of these techniques. 127 William Lane, Albin Lambotte, and Ernest Hey-Groves were the pioneers, who developed the modern principles of osteosynthesis.93, 124, 125, 126 The advent of radiology prompted a re-evaluation of hip fracture treatment, and in 1911 the Section of Surgery of the British Medical Association reviewed a series of patients with the use of a new technique of radiographic imaging and concluded that operative treatment should be performed early when necessary and that function seemed to be correlated with absence of radiographic deformity.93 The real modern era of internal fixation of hip fractures began with the report of the technique by Smith-Petersen in 1925 and his invention of the triflange nail for hip fractures. 197 The triflange design controlled rotational instability and was strong enough for patient mobilization. It was used for both trochanteric and femoral neck fractures. Brittain using a very low placement on the lateral cortex of the femur treated pertrochanteric fractures with the Smith-Petersen nail, presaging the later high angle type devices.27, 108 Sven Johansson in Sweden
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developed the technique simultaneously with Westcott in the United States of a radiographic controlled insertion of the Smith-Petersen Nail without arthrotomy 1932.68,215 This was termed blind nailing, and began the movement toward minimally invasive surgery. Johansson also is credited with developing the first cannulated Smith-Petersen nail. In 1934 King and Henderson independently reported the use of K-wires for provisional fixation, as described by Lambotte for guidance and proper placement of the Smith-Petersen nail.90, 115 In the 1930s, Henry, Littman, Henderson, and others reported on the use of a lag screw type devices instead of nails.91,92, 131 It was not until the late 1930s and early 1940s that plate attachment to the femoral head fixation truly lay the groundwork for the movement from nonoperative to surgical treatment for pertrochanteric fractures. Lawson Thornton is credited with the first attachable side plate bolted to a Smith-Petersen nail205 in 1937. Within 10 years there was an explosion of new devices. The Jewett Nail, which was a triflange nail welded to a plate for shaft fixation. 107 Jewett was the first to advocate the open reduction of the lesser trochanter (posteromedial fragment) with separate screws to increase the stability of the fracture. Blount in conjunction with Moore in the 1940s actually coined the terminology and concept of blade plates.22,144 Neufeld in California and Capener in the United Kingdom developed the fixed-angle type nail plate in 1944.33,203 Trochanteric buttress plates were first reported by Boyd and Griffin in 1949 (they were invented by Richardson at the Campbell Clinic) for preventing medialization with the Neufeld plate in unstable fractures. 26 Boyd reported on refinements of the buttress technique in 1961, including screw fixation into the trochanter.25 The primary motivation of surgical implants in the 1930s and 1940s was the belief that surgical fixation decreased mortality from prolonged bed rest and eliminated the need for spica casts. Early reports suggested that patients could be mobilized more rapidly and with less hospitalization time. In 1949, Evans reported on the use of a Neufeld nail type technique with open reduction compared with nonoperative treatment for fractures and favored surgical repair on the basis of four parameters that are still pertinent today: (i) Greater pain relief and comfort of the patient; (ii) improved early patient mobility; (iii) economy of bed control for nursing and hospital efficiency; and (iv) lower mortality rate (18% compared with 33% for nonoperative treatment).56 The mechanical analysis of hip fracture fixation began in the 1940s with the realization of the magnitude of the hip forces by Inman and the effect of compression on healing by Eggers.51,103 Smith developed mechanical cadaver testing to reproduce fractures and determine the forces required for their causation.196 In a review of implant failures, Taylor and Neufeld proposed the need for implants with sufficient fatigue life and the importance of stable reductions.203 In 1956 Martz presented the first load to failure testing for common hip implants of the day.138 In analyzing stresses on the human femur, Martz pointed out that on average walking subjects the femoral head to forces in the vicinity of 400 lb because of momentum and leverages. He applied the engineering rule of thumb, calling for a safety factor of two, arriving at a force of 800 lb (3200 Newtons) as adequate resistance to load of a proximal fixation system. Foster advocated higher angle nail-plates to minimize the load on the implants base on geometric assumptions on loading. 60 Cleveland argued that even with optimized designs some small percentage of implant failure would still occur.40 In 1963 Holt argued that implant failure was related to inadequate mechanical design.95 He was the first to theorize that the rotation was unlikely for pertrochanteric fractures to justify his design of a round nail plate (fixed angle design) eliminating flanges on the femoral head component for rotational control in distinction to previous derivative plates from Smith-Petersen's original concept. He believed it unlikely that the proximal fragment of an intertrochanteric fracture could rotate after the fracture was reduced, the nail inserted, and the plate fixed to the shaft because of engagement of bone fragments at the fracture site. He did not detect any evidence of rotation in the follow-up of the 100 fractures included in the using his design and technique. He also was the first to advocate full weight-bearing after surgery when the implant's fatigue resistance was adequate for unrestricted loading. Interestingly, he used bolted shaft fixation screws through the plate. The invention of sliding compression with a cannulated system of drilling and insertion was invented by Godoy-Moreira and is the precursor of this class of implants in 1938.73 As with other devices, it was originally designed for femoral neck fractures with the focus of minimizing implant failure. The author also believed that the compression generated by the screw and side bolt would prevent any rotation or flexion at the fracture site. Schummpelick et al. described an implant designed by E. Pohl in Kiel, Germany (the same man who designed for G. Kntscher) of a sliding cannulated system with a side-plate in 1952.190 Interestingly they did report telescoping of the implant with collapse of the fracture, leading to a Trendelenburg gait in some patients. They also reported on the concept of early P.1607 weight-bearing with the sliding hip screw. In 1955 to 1958 Pugh and Massie reported success with the application of sliding with a nail plate device to minimize medial penetration of the femoral head and early fatigue failure.139,178 Full weight-bearing was not advised for 4 to 6 months with these devices. Interestingly Pugh attempted to classify the results on a functional basis, but because of the variations in age, as well as the variation in the general physical status of these patients this was deemed impractical. In the cases in which solid union occurred the result was considered good or satisfactory. The first commercially available sliding compression hip screw in the United States was introduced in 1956 in cooperation with K. Clawson of Seattle and McKenzie
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of Scotland manufactured by Richards Manufacturing Company of Memphis, Tennessee.38,39 Their modifications included a blunt-tipped cannulated screw design coupled to a forged side plate of optional lengths and neck angles. There was a keyed slot for enhanced rotational stability. The follow-up series from Mullholland at Clawson' institution (now Harborview Trauma Center) in 1975 showed that functional status preoperatively correlated with the postoperative recovery and mortality seemed to improve with experience with the use of this device.151 The desire to increase stability of unstable fracture patterns with proactive valgus oteotomies was popularized by Dimon and Houston, Sarmiento, Harrington, and others in the 1960s to 1970s.47, 87,187 Nonetheless, prospective studies and meta-analysis comparing the results with sliding hip screws type designs showed no mortality or functional improvement with osteotomies and a higher risk of blood loss.46, 67,87,169 In 1979 to 1980 the issue of stability versus union with sliding devices was focused by Kyle et al. and Jensen et al., both of whom reported independently on a revision of the Evans classification incorporating the lateral radiographic position of the posteromedial fracture component and its relation to stability with sliding fixation systems.104, 122 Kyle et al. showed an increased rate of deformity and collapse with increasing instability classification. Nonetheless, they reported that the use of a high-angle sliding nail technique with prophylactic antibiotic, thromboembolism prophylaxis, and early mobilization was acceptable for mortality and fixation failure. They did not advocate the use of osteotomy. In their functional evaluation they considered occasional pain, permanent limp, and use of a cane a good result. Jensen et al. related the ability to reduce the fracture and secondary displacement risk with a CHS type device in their classification system. With anatomic reduction in both planes with a stable medial cortex, no secondary displacement occurred. In nonanatomic and/or unstable fractures they reported a 25% to 69% rate of secondary displacement. In their statistical analysis, the correlation with secondary displacement was not an unstable pattern but a lack of reduction. Regarding the position of the tip of the device, Jensen et al. advised placement over 10 mm from the articular surface and Kyle et al. within 10 mm to minimize cutout. The question that has persisted is how to address the secondary displacement problem. In the 1980s to 1990s renewed interest in hip fracture failures led to a new approach to fixation. In the plate field, Medoff introduced the biaxial compression hip screw for unstable fractures, which actually allowed axial compression along the shaft reminiscent of an Egger's plate concept in addition to dynamic compression at the screw plate interface in the head. 142 This biaxial compression concept was proved effective to minimize implant failure in unstable fractures, but with increased shortening of the leg.135,213 The re-emergence of the importance of rotational instability as a problem in 2000 prompted Gottfried to develop the PCCP plate system, which consisted of a side plate with two constrained partially threaded lag type screws reminiscent of a reconstruction nail-type pattern that optimized the rotational stability of the hip and minimized damage to the greater trochanter (lateral wall of the femur).75 Preliminary reports suggest that patients may have a trend toward earlier functional recovery with this type of device, although further studies are needed. Locked and hybrid locking plates have been applied recently for unstable fractures with only preliminary reports thus far. Cephalomedullary implants are devices inserted with a closed technique and fluoroscopic control with variable length femoral geometry and enhanced proximal geometry to permit fixation with nails or screws into the femoral head. They evolved from the Y-nail design of G. Kntscher in 1940, described in the marrow nailing method in the translation prepared by the U.S. naval forces, Germany technical section in 1947, discovered in 2006.123 This was a nonlocking unreamed nail with an impaction-type nail component for the femoral head driven through a perforation in the centromedullary nail. The Zickel nail primarily developed for subtrochanteric fractures was another impaction-type nail for the femoral head, but with no distal locking capability. The TFN (Synthes, Paoli, PA) is the most recent addition to this class of implant. The Grosse-Kempf gamma nail and the Russell-Taylor reconstruction nail were the start of two new classes of intramedullary devices designed for the hip region; they coincided with the widespread adoption and popularity of closed interlocking techniques in the 1980s and 1990s. These devices made use of a compression screw inserted into an intramedullary device instead of a nail for the femoral head component. The gamma nail used an expanded head geometry of 17 to 18 mm with a large single lag screw, and the reconstruction nail allowed a smaller head geometry of 15 mm with two smaller lag screws for the head component. Both devices have evolved over the past 20 years, with the modern designs moving toward a 4- to 5-degree proximal bend with a medial or tip trochanteric portal instead of a lateral trochanteric or piriformis portal, respectively. In 2004 the InterTAN class cephalomedullary nail (Smith-Nephew, Memphis, TN) began clinical studies. It has a trapezoidal cross-sectional geometry to protect the lateral wall of the greater trochanter and a hybrid nail design similar to a hip prosthesis stem for proximal nail stability in the shaft as well as linear compression through an integrated screw construct in the femoral head, resulting in much greater resistance to rotational instability and cutout.
Nonoperative Treatment
Nonoperative treatment should only be considered in nonambulatory or chronic dementia patients with pain that is controllable with analgesics and rest, terminal disease with less than 6 weeks of life expected, unresolvable medical comorbidites that preclude surgical treatment, and active infectious diseases that preclude insertion of a surgical implant.
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An exception to this consideration are incomplete pertrochanteric fractures diagnosed by MRI, which have been shown to heal with conservative measures in selected patients.4,189 Nonoperative management must include attentive nursing care with frequent positioning to avoid decubiti, attention to nutrition and fluid homeostasis, and adequate analgesis/narcotic pain suppression. Fracture callus formation at 3 weeks markedly decreases motion-related pain, and by 6 weeks most patients can be lifted into a wheelchair or reclining chair. Ambulatory capablility should not be anticipated after nonoperative treatment. Meta-analysis of randomized trials does not suggest major differences in outcome between conservative and operative management programs for extracapsular femoral fractures, but operative treatment appears to be associated with a reduced length of hospital stay and improved rehabilitation.162 Opponents of nonoperative treatment even for nonambulatory patients suggest that surgery is more effective for pain relief and does not result in unacceptable increased mortality or complications. If nonoperative care is selected because of an excessively high risk of mortality form anesthesia and surgery, the patient is nonambulatory and has minimal discomfort from the fracture, or modern medical facilities are unavailable, then the strategy previously discussed by Cooper20 of rapid mobilization to chair and an upright chest position is recommended. Mobilization is necessary to minimize decubitus, pneumonia, and dementia. This form of treatment precludes any future independent mobility.170 P.1608
Operative Treatment
Once selected, surgical management should be performed as soon as any correctable metabolic, hematologic, or organ system instability has been rectified. Usually this is within the first 24 to 48 hours. The literature is inconclusive as to increased mortality after this time, but patient suffering and hospital efficiencies demand timely intervention. Holt et al. found that case mix variables (age, gender, fracture type, prefracture residence, prefracture mobility, and ASA scores) were the critical aspects of potential for mortality even when corrected for time of fracture to treatment, admission time to surgery, and grade of surgical and anesthetic staff undertaking the procedure. Centers with experience and protocols for the rapid diagnosis and treatment of hip fractures can effectively decrease the hospitalization time and complication risks for these injuries. 172, 204 Interestingly, earlier surgery has not been found to be associated with a higher mortality or morbidity. 113 Browne et al. found that surgeons with low volumes of experience (fewer than seven cases per year) compared with high-volume hip fracture surgeons (more than 15 cases per year) had higher rates of mortality and complication, but that high- versus low-volume hospitals were associated only with shorter hospital stay and lower nonfatal morbidity. 30
TABLE 48-1 Classification of Plates
Class
Examples
Failure Modes
Impaction
Blade plates
Medial penetration
Nail plates
Breakage
Dynamic compression
Sliding hip screw
Cutout
Adjustable hip nails
Plate pull-off
Dynamic helical blades
Linear compression
Gotfried PCCP
Less risk of cutout?
InterTAN CHS
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Hybrid locking
Proximal femoral locking plates
Plate failure
Surgical implant options included plate and screw constructs, either nail or screws for the head fixation, nail constructs with either nail or screws, external fixation, and arthroplasty. Generically these options can be grouped to designs with common biomechanical behaviors, techniques, complications, and results. The literature is exhaustive, with series of specific techniques and implants designs and a fair number of meta-analyses and randomized prospective studies. Plate constructs may be grouped into four functional types: 1. Impaction class: Impacted nail-type plate devices (e.g., blade plates, fixed angle nail plate devices) 2. Dynamic compression class: Large single sliding screw or nail femoral head components with side plate attachments (e.g., standard sliding hip screws) 3. Linear compression class: Multiple head fixation components controlling rotation and translation but allow linear compression (e.g., Gotfried PCCP and the InterTAN CHS) 4. Hybrid locking class: Multiple fixation components with compression initially for fracture reduction followed by locking screws which prevent further axial compression; these types of fixation are the most stable (e.g., proximal femoral locking plates [Synthes, Paoli, PA, and Smith-Nephew, Memphis]) (Table 48-1). Impaction or fixed angle plating today is more commonly used for corrective osteotomies rather than as a primary treatment for hip fractures. MacEachern reported on the difference of failure mechanisms with medial penetration of the joint with the Jewett Nail compared with the sliding hip screw.136 Attempts at modifying the results of nail plates with osteotomies fell out of favor when comparisons were made with sliding hip screw devices with anatomic reduction only giving equivalent results with less blood loss and more rapid operative times.169 Chinoy et al.169 in a 1999 meta-analysis, compared accurately fixed nail plates with sliding implants involving a total of 2855 patients. Results showed an increased risk of cutout (13% vs. 4%), nonunion (2% vs. 0.5%), implant breakage (14% vs. 0.7%), and reoperation (10% vs. 4%) for fixed nail plates in comparison with the sliding implants. In addition, patients treated with fixed nail plates had a higher mortality and the survivors were more likely to have residual pain in the hip and impaired mobility. The continued use of fixed nail plates gave way in the 1980s to the unequivocal superiority of the sliding P.1609 hip screw due to these complications.36,166
Dynamic Compression Plating

From the 1980s to 2000, sliding compression hip screws became the gold standard for hip fracture fixation, and many surgeons still contend its usefulness in all fractures largely because of the reports of Clawson, Mulholland, and meta-analysis studies by Parker et al. from 2000 to now (Figure 48-10).164,167,168 In 1983 Rao evaluated 162 cases of unstable intertrochanteric fractures treated by anatomic reduction and compression hip screw fixation. After compression was applied, 90% of the fractures moved into medial displacement position; 8% laterally displaced; and 2% maintained their anatomic alignment. Loss of fixation with unacceptable varus angulation of the fracture occurred in 4% of cases. One hundred ten patients were bearing full weight an average of 3 weeks after operation. They stated that the advantages of the sliding hip screw were that weight-bearing could start early; the device was applicable to stable and unstable intertrochanteric fractures with identical technique; and the fixation maintained acceptable alignment. Kyle et al. advocated 150-degree Massie telescoping nails with a center-center head position within 10 mm of the subchondral bone for all fractures, anatomic reduction, prophylactic antibiotics, prophylactic anticoagulation, and early ambulation, without osteotomy or interfragmentary fixation except as a consideration for unstable components in Kyle type 4 in conjunction with delayed ambulation (although they noted its ineffectiveness). In classifying their outcome data, they considered a good result as normal hip range of motion, a noticeable limp, occasional pain, and routine use of a cane; and with this definition they achieved a 96% good and excellent functional result. The Medoff sliding plate (Medpac, Culver City, CA) design uses a biaxial sliding hip screw (Figure 48-11). It has a standard lag screw/barrel component for compression along the femoral neck. In place of the standard femoral side plate, it uses a coupled pair of sliding components that enable the fracture to impact parallel to the longitudinal axis of the femur. A locking set-screw may be used to prevent independent sliding of the lag screw within the plate barrel; if the locking set screw is applied, the plate can only slide axially on the femoral shaft (uniaxial dynamization). If the surgeon applies the implant without placement of the locking set screw, sliding may occur along both the femoral neck and femoral shaft (biaxial dynamization). For most intertrochanteric fractures, biaxial dynamization is suggested.
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FIGURE 48-10 Compression hip screw components: lag screw, blunt tip, side-plate of fixed angle and cortical shaft screws.
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FIGURE 48-11 Medoff sliding plate.
Watson et al. compared the Medoff plate with a standard sliding hip screw in a prospective randomized series of 160 stable and unstable intertrochanteric fractures; follow-up averaged 9.5 months (range, 6 to 26 months).213 Although stable fracture patterns united without complication in both treatment groups, there was a significantly higher failure rate with use of the sliding hip screw for unstable fractures (14% vs. 3%). No differences were observed between the two devices in terms of length of hospitalization, return to prefracture ambulatory status, postoperative living status, or need for postoperative analgesic medication. Nonetheless, use of the Medoff plate for all fracture types was associated with significantly greater blood loss and operating time. Olsson et al. reported on a prospective randomized series of intertrochanteric fractures stabilized using either a Medoff plate or conventional sliding hip screw.153, 154 In unstable fracture patterns, mean femoral shortening was significantly greater with use of the Medoff plate (15 vs. 11 mm), but the sliding hip screw was associated with more medialization of the femoral shaft. All failures occurred in the sliding hip screw group. Ekstrom et al. compared the proximal femoral nail (PFN, Synthes) and the Medoff sliding plate (MSP) in patients with unstable trochanteric or subtrochanteric fractures. They reported that the ability to walk 15 meters at 6 weeks was significantly better in the PFN group compared with the MSP group, with an odds ratio 2.2 (P = 0.04, 95% confidence limit, 1.03 to 4.67). Reoperations were more frequent in the PFN group (9%) compared with the MSP group (1%), but there were no other significant differences.53 The current literature suggests that there is no difference in mortality or functional recovery between compression hip screws and intramedullary nails with single device fixation in the femoral head. Interestingly the term malunion of a pertrochanteric fracture dropped out of usage after the 1970s and the emphasis was placed on implant failure. Recently the sliding hip screw and similar devices have come under scrutiny for its application to all fractures. Haidukewych et al. noted a higher rate of failure with sliding hip screws for reverse obliquity intertrochanteric fractures caused by excessive medialization.
85
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Gotfried noted the high failure rate
with associated lateral wall fractures with compression hip screws.76 The effect of shortening of the limb and changes in abductor function with collapse has always been in the background of the hip literature. In a retrospective analysis of postoperative fracture collapse in 142 patients with intertrochanteric hip fractures fixed anatomically with sliding hip screws, Bendo et al. found collapse (as defined by strict radiographic criteria relating the height of the femoral head to the greater trochanter and Doppelt's criteria) was seen in 26 of the unstable fractures. Of the patients with moderate or severe collapse, 93% had a poor functional result, whereas all the patients with minimal collapse remained asymptomatic. Although postoperative fracture impaction of hips fixed with sliding screws may promote early healing, a high rate of union, and a low rate of hardware failure, excessive collapse is a problem that must be
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addressed. 18 Platzer et al. expressed concern about the amount of shortening with compression hip screws in non-geriatric patients with compression hip screw fixation. 177 The concern that many surgeons share is the question of functional impairment with excessive dynamic collapse. Zlowodzki et al. recently quantified a lower SF-36 score with shortening more than 5 mm in femoral neck fractures;224 it may be that the transitional displacement during the first 6 weeks after surgery with compression side plates may be an underlying problem with recovery after surgery. Kamath et al. documented significantly more collapse with compression hip screws in basicervical fractures compared with reconstruction nail type constructs.109 When the lesser trochanter was intact, plate fixation was associated with ten times more collapse than nail fixation (8.1 vs. 0.7 mm); and with complete displacement of the lesser trochanter, the relative shortening was twice as much for the plate group versus the nail group (16.1 vs. 8.1 mm). Su et al. reported a greater tendency to collapse and pain increase with basicervical fractures compared with intertrochanteric fractures treated with compression hip screws (Figure 48-12).200 Pajarinen et al. reported less deformity with nail devices compared with SHS and recommended over correction of the hip into valgus to anticipate the varus collapse with SHS.160 Moroni et al. have explored the potential of augmenting the stability of the compression hip screw with hydroxyapatite coating. One hundred twenty patients with AO, A1, or A2 trochanteric fractures were selected. Patients were divided into two groups and randomized to receive a 135-degree four-hole dynamic hip screw fixed with either standard lag and cortical AO/ASIF screws or HA-coated lag and cortical AO/ASIF screws. Lag screw cutout occurred in four patients in with conventional uncoated lag screws but no cutout occurred in the HA group. The femoral neck shaft angle collapse from an average 134 degrees postoperatively to 127 degrees at 6 months in the standard CHS group; but in the HA-coated group, the femoral neck shaft angle was 134 degrees postoperatively and 133 degrees at 6 months. The Harris hip score was higher at 6 months in the coated group (60 vs. 71), although the study was relatively small.146
Rotationally Stable Plating

Rotational stable plating differs from dynamic compression plating by adding enhanced rotational stability with multiple screw fixation in the femoral head. Because the screws are coupled to the plate, the rotational stability is much better than an accessory screw adjacent to standard single screw fixation (Figure 48-13). The percutaneous compression plate by Gotfried (Orthofix, McKinney, TX) has two smaller-diameter lag screw/barrel components, which stabilize the femoral head and neck. This device was designed with a minimally invasive surgical technique. The two lag screw components (9.3and 7.0-mm diameter) provide enhanced rotational stability of the proximal fracture.77 The device is available only in 135-degree angles. It was reported initially by Gotfried in 98 fractures with good results and no collapse, head penetration, or cutout. The InterTAN CHS (Smith-Nephew) consists of a 127- and 135-degree design with two integrated screws, with the option of locked or standard shaft fixation.
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FIGURE 48-12 Healing short CHS AP radiograph. Healing of 31A1 fracture with shortening. Note accessory lag screw back out and compression screw prominence in soft tissues.
In 2007 Peyser et al. found in their randomized trial comparing dynamic hip screw and PCCP that the pain score and ability to bear weight were significantly better in the PCCP group at 6 weeks postoperatively. Radiographically there was a reduced amount of medial displacement in the PCCP group (two patients, 4%) compared with the CHS group (10 patients, 18.9%). 176 In a recent presentation of a randomized prospective group of dynamic hip screw versus PCCP, Yang documented improvements in pain and ambulatory ability with improved SF-36 scores in the PCCP group.222 Panesar161 performed a meta-analysis review of comparative trials (1995 to 2006) comparing the dynamic hip screw and the PCCP. There was a decreased trend in overall mortality in the PCCP group [CI 0.84 (0.48 to 1.47)]. Similar trends favoring
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the PCCP technique were seen with other outcomes. A large randomized controlled trial was recommended. Other devices with enhanced rotational stability, such as the InterTAN CHS and the helical blade plate, are now being studied (Figures 48-14 and 48-15). P.1611
FIGURE 48-13 A. Percutaneous compression plate (PCCP). B. InterTAN CHS device. Similar to CHS design but incorporates compression mechanism in second inferior screw for enhanced rotational stability.
Hybrid Locking Plates

With the success of locking and hybrid locking plates with unstable fractures of the distal femur, the same concepts are being applied to the proximal femur. The devices offer maximal stability with initial compression, and fixed angle stability from locking screws. 106 Initial results are mixed because of early failure rate with original plate designs and three screw limitations. Newer devices with enhanced fixation strength may be helpful in complex intertrochanteric fractures with subtrochanteric extension (Figure 48-16).
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FIGURE 48-14 PCCP reduction and fixation. Note inferior placement of bottom screw and protection of the greater trochanter by distal plate position.
Cephalomedullary Devices
Cephalomedullary devices are inserted through the piriformis fossa, lateral greater trochanter, or medial greater trochanter. The femoral head portion of the fixation construct consists of one or more screw or blade devices interlocked with the nail component of the construct. Cephalomedullary nails are most commonly indicated in pertrochanteric and subtrochanteric fractures, and although there is occasional overlap of these regions, the personality of the fracture will be predominantly one of these major types. These nails are designed to have either a pirforimis portal for insertion, usually with the shaft component straight in the AP plane, or a trochanteric portal, with the shaft component laterally angulated
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proximally. Modern trochanteric designs have moved to a 4-degree proximal bend positioned above the lesser trochanteric region, which seem to function best.158 Cephalomedullary nail constructs have been similarly classified by Russell into four classes (Table 48-2), 183 listed here in order of invention: 1. The impaction class or Y nail class originated with the Kntscher Y nail and current TFN Nail (Synthes) (Figure 48-17A). 2. The dynamic compression or gamma class pioneered by the Grosse and Kempf Gamma Nail (Stryker-Howmedica), which consists of a large head nail component (15.5 to 18 mm) with a single large lag screw (Figure 48-17B and 17E). 3. The reconstruction class developed by Russell and Taylor (Smith-Nephew) (Figure 48-17C), with a smaller head diameter (13 to 15 mm) and using two lag screws that are independent of each other. 4. The integrated class, consisting of a nail design cross-section with the stability of a arthroplasty hip stem and integrated two-screw construct with linear compression at the fracture site, developed by Russell and Sanders (SmithNephew) (Figure 48-17D). P.1612
FIGURE 48-15 InterTAN CHS case. A. Preoperative radiograph showing 31A2 fracture with greater trochanteric
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fracture lines and lesser trochanteric fracture. B. AP postoperative radiograph showing fixation. Stability of greater trochanter is maintained. C. Lateral postoperative radiograph.
Impaction Class (Y-Nail, TFN)

Davis et al. assessed outcomes and the etiology of mechanical failure in a series of 230 intertrochanteric femoral fractures internally fixed with either a sliding hip screw or a Kntscher Y-nail.44 The cutout rate for the Y-nail was 8.8% versus 12.6% for the sliding hip screw overall. Cutout was related to the quality of the fracture reduction; age, walking ability, and bone density had no significant influence on cutout. Center-center placement of the head component correlated with less cutout, and posterior placement increased cutout with both groups. Y-nail cutout or medial penetration increased with articular placement less than 10 mm from the tip of the nail (23% Y-nail, 11% CHS), whereas Y-nail medial penetration decreased with tip placement greater than 10 mm (3% Y-nail vs. 18% CHS).44 The TFN (Synthes) device reintroduced an impaction nail component for the femoral head of a helical blade design of 11 mm inserted into a nail with a 17-mm proximal geometry. There are short and long interlocking versions.66 In a biomechanical study Sommers et al. showed better resistance to rotation with the helical blade compared with single screw designs.198 The surgical technique precludes reaming of the femoral head, thus saving bone stock and preventing instability of the fracture by a loose nail. Gill et al.,72 comparing CHS with TFN, revealed fewer blood transfusions with CHS and faster operative time for the TFN group. Gardner et al. reported subtle migration (approximately 2 mm) of the tip of the blade within the femoral head in all fractures, but this did not preclude maintenance of reduction and fracture healing. They noted that telescoping averaged 4 mm and did not affect stable fixation or fracture healing. All position changes occurred within the first 6 weeks postoperatively.66 Weil et al.214 reported medial penetration with the TFN analogous to the Y-nail type penetrations described earlier. All eight clinical cases involved an unstable intertrochanteric fracture pattern (AO/OTA 32A2). P.1613
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FIGURE 48-16 Hybrid locking plate system (Smith-Nephew, Memphis, TN).
Dynamic Compression Class (Single Screw Head Component)

Since the introduction of the Gamma nail in the early 1980s, an exhaustive series of studies have guided its use and modifications. Although initially a lateral trochanteric entry nail with a 10-degree angle and a short nail, the design is now in its third major revision with decreases to 15.5 mm in head geometry from 17 mm. Angulation has decreased to 4 degrees for a tip trochanter entry site, and its distal geometry has been tapered for less risk of periprosthetic femur fractures (its main detraction in early studies). The IMHS is a similar class nail with a sliding sleeve in the barrel to promote dynamic compression (Figure 48-17E). The clinical studies must be referenced to the different designs and time periods for correct analysis. Adams et al. reported a prospective randomized study comparing a sliding hip screw with an intramedullary nail
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for treatment of intertrochanteric fractures.3 Two hundred and three patients were stabilized with a short gamma nail, 197 received a sliding hip screw. Patients were followed for 1 year. Use of the gamma nail was associated with a nonsignificant higher risk of postoperative complications and equivalent union and functional results.
TABLE 48-2 Classification of Nails
Class
Examples
Failure Modes
Impaction
Y-Nail, TFN
Medial penetration
Dynamic compression
Gamma, IMHS
Cutout
Peri-implant failure with short designs
Two-screw dynamic compression
Reconstruction
Z-effect
Linear compression integrated
InterTAN
Unknown
In 1988 Hardy et al. reported the intramedullary hip-screw device compared with the CHS was associated with significantly less sliding of the lag-screw and subsequent shortening of the limb in the region of the thigh. Patients whose fractures were stabilized using the intramedullary hip screw experienced significantly better mobility at 1 and 3 months follow-up. This difference was no longer seen at 6 and 12 months, although patients who received the intramedullary device enjoyed significantly better walking ability outside the home at all time periods. Currently Parker et al. report that there is no consensus regarding the superiority of the dynamic compression nails or plate type devices and that future studies with the same devices are unneccesasry.168 There is also evidence that the complications with nail devices are more frequent. Despite this evidence, the trend for intramedullary fixation has increased in the United States.7
Reconstruction Nail Class (Two Screw Head Components)

Reconstruction nails (Smith-Nephew) were initially developed by Russell and Taylor in the early 1980s primarily for complex subtrochanteric fractures and pathologic fractures. In 1991, the Russell-Taylor reconstruction nail was first described for intertrochanteric fractures in four cases. 97 Different versions of this class have in common a smaller diameter head (13 to 15 mm) with two lag screws of various diameters with long and short interlocking versions. The original piriformis reconstruction nail has been modified for medial trochanteric portal insertion, which simplifies treatment for pertrochanteric fractures. Piriformis reconstruction nails do no have optimal containment in the trochanter because of their posterior placement in relation to the femoral head and neck; they transfer essentially all the load to the head screws. Trochanteric versions allow better containment of the nail in the proximal femur and are optimally placed to minimize femoral neck shortening (Figure 48-18). Seif-Asaad reported good results in 40 patients using the Variwall reconstruction nail for unstable intertrochanteric fractures with 12 patients having subtrochanteric extension.191 Thirty-nine patients healed without deformity, shortening, or varus collapse. Little et al., using the Holland nail in a comparative series with CHS, demonstrated less blood loss and transfusion, no cutout in the nail group, and all fractures united in the Holland nail group. 133 In a more complex group with both pathologic and multiple trauma cases, Krastman et al. reported an 89% union rate with Holland nails in two cases with screw penetration of the femoral head. The PFN (Synthes) was associated with a high implant failure rate and the Z-effect of overpenetration of the cephalic screw proximally and backing out of the inferior screw and has been discontinued in the United States.10,31, 59,194 The device brought attention to the differences in bone quality and effect of rotation with this type of fixation (Figure 48-19).199
118
P.1614
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FIGURE 48-17 A. Short trochanteric fixation nail (TFN). B. Short gamma 3 intramedullary nail. C. Short trochanteric antegrade nail (TAN). D. Short InterTAN cephalomedullary nail with integrated screw design and hybrid stem design. E. Short intramedullary hip screw (IMHS).
InterTAN Class (Integrated Nail and Screws with Linear Compression)

The InterTAN nail is a titanium alloy nail with a proximal femoral cross-section similar to a press-fit arthroplasty stem for shaft stability, an integrated screw mechanism that provides linear compression of the fracture while moving the stem toward the medial femoral cortex with compression and stress relieving the lateral wall. It is a trapezoidal design proximally with a 16-mm diameter that tapers like a hip stem with a 4-degree bend for medial trochanteric insertion. It is available in 125- and 130-degree designs, long and short. The short version includes dynamic locking above a split tapered tip design to minimize implant stress in the diaphysis. Like the gamma and Y-nail class nails, it is indicated for older patients with pertrochanteric fractures with Dorr B and C type morphology (Figure 48-20). P.1615
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FIGURE 48-18 A. 31A3 with subtrochanteric extension. B. Reduction and repair with long TriGen trochanteric reconstruction nail. C. Recon case lateral postoperative radiograph.
In 2009 Ruecker et al. reported results with the InterTan femoral head for the treatment of intertrochanteric fractures that uses two screws in an integrated mechanism, allowing linear intraoperative compression and rotational stability of the head/neck fragment.182 One hundred consecutive patients with an intertrochanteric fracture were treated with the new trochanteric antegrade nail (Smith-Nephew). The mean age of the patients was 81.2 years. Thirty-seven patients died. The average surgical time was 41 minutes (13 to 95 minutes). All fractures healed within 16 weeks (range, 10 to 16 weeks). Forty-eight remaining cases had detailed radiographic analysis at healing that revealed no loss of reduction, no uncontrolled collapse of the neck, no nonunions, no femoral shaft fractures, and no implant failures. Two cases in the series were poorly reduced and settled into varus malalignment. No varus malposition was seen in the remaining 46 fractures. The mean prefracture Harris hip score was 75.1 13.4, and at the time of follow-up was 70.3 14.5 (P = 0.003); 58% of the patients recovered prefracture status. They concluded that the InterTAN device appeared to be a reliable implant with stability against rotation and resultant neck malunions (shortening) through linear intraoperative compression of the head/neck segment to the shaft. Further studies are in process for comparative analysis.
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FIGURE 48-19 Demonstration of the Z effect, with one screw penetrating the hip joint and the other screw backing out of the nail. (Courtesy of Enes Kanlic MD, Texas Tech University Health Sciences Center, El Paso, TX.)
External Fixation
External fixation as a treatment for pertrochanteric fractures was evaluated in the 1950s, but its use was unsuccessful because of high rates of pin-tract infections, subsequent pin loosening, instability, and failure.12,78, 119 Renewed interest in this technique occurred recently with the new fixation designs and the addition of hydroxyapatite coated pin technology. The addition of the HA coated half-pins with the Orthofix pertrochanteric fixator by Moroni et al. has resulted in equivalent if not better results than compression hip screws in 31A1-A2 osteoporotic fractures. 148 There were no pin tract infections and equivalent functional results by the Harris hip score comparisons (approximately 62 for both groups).
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More interesting is the lower rate of varus collapse of on average 2 degrees versus 6 degrees for the CHS group. The CHS group averaged 2 units of blood replacement versus none for the external fixation group. Surprisingly, the external fixation group reported equivalent or slightly less pain than the CHS group (Figure 48-21). P.1616
FIGURE 48-20 A. 31A3 fracture with C-type morphology. B. Reduction and stabilization with InterTAN nail. Note alignment of nail paralleling the anterior cortex proximally. C. InterTAN case lateral postoperatively. D. Long nail selection due to wide diaphysis with loss of isthmus anatomy owing to aging and osteoporosis. E. Union without collapse or backing out of proximal fixation. F. Note medialized nail position owing to integrated screw mechanism inducing translation of nail to medial cortex, unloading lateral wall.
External fixation as reported by Moroni et al. may be indicated in osteoporotic hip fractures in elderly patients, who may be deemed at high risk for conventional open reduction and internal fixation, or for those who cannot receive blood transfusions because of personal conviction or religion. It may be superior to standard compression hip screws in these patient groups.
Arthroplasty
Arthroplasty either hemiarthroplasty or total hip arthroplasty, often with calcar replacement type components, is rarely indicated in pertrochanteric fractures.211 Arthroplasty may be justified in neoplastic fractures, severe osteoporotic disease, renal dialysis patients, and pre-existing arthritis under consideration for hip replacement before the fracture occurred. Hemiarthroplasty, usually cemented, has been reported to have a lower P.1617 dislocation rate compared with total hip arthroplasty. Haentjens et al. reported on 37 patients more than 75 year old with unstable intertrochanteric or subtrochanteric fractures from 1983 to 1986. Functional results were rated as good to excellent in 75% of patients, but there was a mortality rate of 36% and a dislocation rate of 44%. 81 In a review of 29 THA
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and 5 HA patients with an average age of 80 years, Berend et al. reported 26/34 deaths within the study period of 12 years, with five patients requiring revision surgery for dislocation. They did not believe their results supported the routine use of arthroplasty in this elderly patient group.19
FIGURE 48-21 A. Preoperative radiograph showing a pertrochanteric fracture in an 83-year-old woman. B. Immediate postoperative radiograph. (From Moroni A, Faldini C, Pegreffi F, et al. Osteoporotic pertrochanteric fractures can be successfully treated with external fixation. J Bone Joint Surg Am 2005;87:47.)
Conversely, between 1992 and 2005 Geiger et al.70 compared the mortality risk and complication rate after operative treatment of pertrochanteric fractures with primary arthroplasty, dynamic hip screw (DHS), or proximal femoral nail in this retrospective study. Of these 283 patients, 132 were treated by primary arthroplasty, 109 with a DHS, and 42 with a PFN. Mortality was significantly influenced by age, gender, and comorbidities, but not by fracture classification. Primary hip arthroplasty did not bear a higher 1-year mortality risk than osteosynthesis in a multiple regression analysis. The main complication with DHS and PFN were cutting out of the hip screw and nonunion, with a revision rate of 12.8%. With the introduction of hemiarthroplasty instead of total hip arthroplasty, the postoperative dislocation rate decreased from 12% to 0%. In a randomized study, Kim et al. found a lower mortality and less blood loss with a cephalomedullary nail compared with a cementless calcar replacement arthroplasty with equivalent functional results.114 The general consensus is that arthroplasty is a better salvage operation for failed internal fixation than a first-line choice in the geriatric fracture patient; and there is no level-one evidence to show any difference between compression hip screw and arthroplasty, with the exception of a higher blood transfusion rate with arthroplasty. 165
AUTHORS' PREFERRED TREATMENT Preoperative Planning

Lambotte described the four components of surgical treatment of fractures at the turn of the twentieth century, and they are as applicable today as then.124,125 The first is exposure of the fracture, which today means visualization of the fracture deformity, and the safest approach to ensure reduction
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and placement of the implant in the correct position. The second is reduction of the fracture, which is critical to the stability and functional recovery of the patient. Inadequate reduction is the major preventable etiology for lost reduction and implant failure in pertrochanteric fractures. The third step is provisional fixation in an anatomically reduced position; this is frequently the most neglected step in hip fracture surgery. This involves the reduction of the fracture and then maintenance of the fracture with either provisional Kirschner pins and/or clamps to hold the fracture in position while the bone is prepared for the definitive implant. The last step is definitive fixation, which should maintain the reduced fracture in an acceptable anatomic and functionally correct position until fracture healing is complete. Definitive fixation selection is a process of elimination. The OTA/AO classification is a good starting point for determination of fracture treatment. Conceptually, the 31 A1 fracture can be treated with basically any of the previous implants if the bone quality and morphology are acceptable. The most common plan is the sliding hip screw system. Nevertheless, external fixation, intramedullary nail techniques, and linear compression type devices could be chosen for osteopenic individuals. External fixation might be used for patients who are too ill for conventional open reduction based on the suggestions from medical and anesthesia consultants. For 31A2 and A3, I prefer techniques with less potential for instability after fixation (Figure 48-22). I use the fracture morphology Dorr classification to optimize the size of the implant footprint for the bone stock available. For Dorr A type fractures, with small canals, a plate device or reconstruction class nail is chosen for bone conservation. For Dorr B type fractures, either a short nail or side plate is equally efficacious. For Dorr C type anatomy, a larger diameter cephalomedullary nail may offer advantages. My personal preference is to use a longer nail for A3 type fractures. The results with locking plates are relatively recent and most reports have primarily been descriptive in nature. The primary indication of these devices may be A3 type fractures with multifragmentary type patterns (31 A 3.3) and those with the extensive subtrochanteric extension. Trochanteric buttress plating is helpful for compression hip screws to minimize medialization of the shaft in unstable fractures or fixation of displaced trochanteric wall fractures.
FIGURE 48-22 Implant selection variables.
Intraoperative length measurements with the C-arm of the normal femur may be helpful in selecting the correct length nail in complex fractures (Figure 48-23). Determination of preoperative neck-shaft angle and medullary canal diameter is paramount to selection of the correct nail device, as different manufacturers have different neck shaft angle and diameter nails. Another important consideration is nail curvature for long nails. One and a half to two meter radius nails are applicable to most situations. It is important to note that multiple variables come into play in deciding on the treatment of hip fracture. As the entry portal and hip fracture nailing has moved from a piriformis or a lateral trochanteric portal to a medial trochanteric portal at the tip of the trochanter, the alignment of the curvature of the long nails is more compatible with the distal femoral anatomy. For the intermediate sizes of bone, either plate and screw devices or short intramedullary nails may be appropriate.
Positioning
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Intramedullary techniques for the proximal femur are best managed with a modern fracture table with image intensification (C-arm) capabilities. Although the lateral decubitus approach may be helpful for reverse obliquity patterns, the supine position is usually preferred because of the ease of setup and radiographic visualization in a familiar frame of reference. We prefer bilateral foot traction with knees in extension with the legs scissored. The operative leg is raised to approximately 20 to 30 degrees of flexion, and the nonoperative extremity is extended 20 to 30 degrees. The legs are pulled in line with the body to avoid varus positioning of the hip. The C-arm is brought in from the P.1619 opposite side with the base parallel to the operative extremity centered on the mid-femur such that the cepalad-caudad movement of the C-arm gives good visualization of the femoral head and shaft in AP and Lateral views. With this type of set up, the true AP of the hip is usually obtained with 10 to 20 degrees of rotation of the C-arm over the top, and the true lateral corresponds to approximately 15 to 30 degrees over the horizontal position (Figure 48-24).
FIGURE 48-23 Using contralateral extremity to measure nail selection for comminuted fracture. Nail package with anticipated nail length measured with intraoperative C-arm. Locate nail to lie at tip of greater trochanter to distal physeal scar. This length allows adequate length restoration.
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FIGURE 48-24 A. Conventional C-arm position will yield an oblique view. B. Correct C-arm position for flexion of the shaft. Make sure that C-arm axis is perpendicular to femoral axis. (continues)
P.1620
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FIGURE 48-24 (continued) C. Correct C-arm position for anteversion. Tilt C-arm over leg 10 to 15 degrees to get the maximum length of the femoral neck. D. Correct lateral C-arm to avoid excessive internal rotation. Obtain true lateral along neck anteversion without excessive internal rotation of leg.
Reduction of the Fracture

It is commonly assumed that internal rotation is the correct position for the hip fracture reduction but in studies by Bannister et al. and May et al., pertrochanteric fractures may have an equal chance of being reduced in neutral or external rotation and external rotation was required in 25% of cases.11,141 Excessive internal rotation can lead to posterior gapping, further destabilizing the fracture with a large posterior medial defect. The focus on the anatomic reduction is paramount to success and should be on the anterior medial cortex reduction. The author's preferred technique for
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the proximal femur involves a four-step technique: 1. After attachment to the foot positioner with the perineal post attached, correct posterior sag at the fracture with a posterior to anterior directed force and maintain. 2. Flex the leg through the foot holder 20 to 30 degrees from neutral for intertrochanteric personality fractures and 30 to 40 degrees for subtrochanteric personality fractures, maintaining the posterior to anterior reduction force at the hip. 3. Apply traction to restore length in line with the body. No varus. 4. Rotate the leg to align with the proximal fragment, 5 to 15 degrees of external rotation for most subtrochanteric fractures personalities and 0 to 10 degrees of internal rotation for pertrochanteric fracture personalities. One should not assume that any implant can substitute for a lack of reduction. In 1963 Sarmiento called attention to the key components of reduction of the pertrochanteric fracture: Weight-bearing on the fractured extremity is safe only if the fracture, whether simple or comminuted, has been reduced so that there is an accurate fit of the fragments at the anteromedial cortex of the femur. Absorption of the reduced medial cortex of the femur with loss of stability is unlikely because of the great thickness and strength of the medial cortex. Failure to obtain such reduction because of the degree of comminution or P.1621 technical difficulties precludes weight-bearing until bone union is complete. Anatomical reduction of the medial and anterior cortices is of great importance since the stability of the fracture and the efficiency of the nail depend on the reduction of this portion of the bone.186 The lack of adequate provisional fixation is the most common reason that obtained reductions are lost during fixation. Provisional fixation must be placed so that it will not interfere with the definitive fixation. Typically this can be achieved with 3.2 K-wires introduced away from the path of the definitive fixation. Alternatively, fixation can be achieved in long oblique fractures by K-wire fixation from the anterior longitudinal shaft region into the medial femoral neck. The key is to position these K-wires such that they do not interfere with the definitive preparation and fixation of the bone. Weber-type clamps with a wide jaw may be inserted in a limited open reduction in conjunction with a bone hook along the medial cortex or medial to the greater trochanter to achieve fracture reduction. If there is posterior displacement of the distal fragment, there are no soft tissue structures to leverage and a manual reduction of the shaft to an anterior position will be required. These displacements require a combination of traction, translation of the distal fragment, and some degree of rotational correction. Rotational reduction is best evaluated by intraoperative radiographic views.
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FIGURE 48-25 Stepoff deformity. A. Model of typical stepoff deformity showing overlap of anterior cortical surface. B. Lateral view showing overlap on lateral position. C. Reduction of the anterior cortex. Reduction of overlap with percutaneous pin with coach-lever maneuver. D. Reduction achieved.
Carr34 renewed Sarmiento's focus on the anteromedial cortex and described reduction techniques to facillitate the reduction. After a standard lateral approach is made to the hip, the anterior reduction is assessed by palpating the region of the intertrochanteric line anteriorly. Palpate for a stepoff, which identifies where the posteriorly displaced shaft overlaps the anteriorly displaced head and neck fragment (Figure 48-25A,B). First pull the shaft laterally to disimpact it from the head and neck fragment with a bone hook passed around the femoral shaft in a subperiosteal manner distal to the lesser trochanter. With the shaft displaced laterally, insert a narrow Jocher or key elevator between the head and neck shaft pieces, and lever the head and neck piece anteriorly, applying a posterior force to the shaft to align the two fragments (Figure 48-25C,D). Adjustment in length and rotation of the limb may be required at this time. Release the laterally directed traction on the shaft. Confirm the anterior reduction with C-arm views. At this point, P.1622 anteroposterior radiographic views of the hip reveal an anatomic neck shaft junction manifested as a hairline crack reduction. On the lateral view, the anterior cortex line is re-established. Secure the reduction with one or two 3.2-mm wires that are directed away from the area of intended lag screw placement. Be careful that the anterior reduction is not lost during insertion of the hip compression screw, which tends to rotate the head and neck fragment. Once all implants are positioned, the compression screw is used to compress the reduction after removal of the provisional wires.
Percutaneous and Limited Open Reduction Cephalomedullary Nail Technique

In closed nailing procedures, a combination of a percutaneous Schanz pin in the anterior distal shaft component in conjunction with a percutaneous ball spike pusher on the anterior proximal cortex can effect a reduction. A K-wire can then be introduced in a longitudinal direction from the anterior superior trochanter into the distal shaft fragment for provisional fixation. Ookuma and Fukuda reported that the anteromedial reduction can be obtained percutaneously with a 3.2-mm wire inserted
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in the same fashion as described by Carr in the open version. Furthermore, they developed a reduction classification that confimed stability with only 2 mm collapse with anteromedial reduction on the AP and lateral planes with two-part fractures treated with the gamma nail, but greater than or equal to 5 mm displacement with intramedullary malreduction of the proximal medial cortex into the distal medullary canal.155 Limited open reduction is indicated for more complex fracture patterns. The head and neck to shaft reduction can be obtained by manipulating the fracture in a manner similar to the side plate technique. A lateral approach at the site of the lag screw insertion can be made to allow placement of the bone hook or Weber clamps as needed. A small accessory incision anterior to the femur at the level of the femoral neck will allow insertion of the Jocher elevator or ball spike pusher.
Specific Operative Treatments: Definitive Fixation CHS Class Single Lag Screw and Side Plate: Dynamic Sliding Compression Hip Screw and Side Plate
The patient is positioned on the fracture table usually in the supine position with either a scissored leg traction setup or with the affected leg extended and the contralateral leg abducted and flexed out of the way of the C-arm. Slight flexion of the leg is usually helpful. Traction should not be too powerful, as it may disrupt any remaining soft tissue attachments and further destabilize the fracture. The reduction steps are carried out as described previously. A lateral incision is made after standard prep and drape centered from the Vastus lateralis ridge approximately 6 cm distally in line with the iliotibial band. Reflect the vastus lateralis near its origin on the posterolateral surface the femur with care to obtain control of any perforator vascular branches. The vastus is elevated anteriorly and Hohmann retractors are placed for exposure of the lateral shaft. After provisional fixation an anatomic reduction is secured with good reduction of the anterior medial cortex and the position for the plate is determined. A 3.2-mm K-wire is introduced over the anterior femoral shaft under image control centered in the femoral neck into the femoral head and tapped into the head. This will actually penetrate the capsule of the head and is safe if kept on the anterior surface of the bone. This gives the anteversion alignment of the proximal femur and also the relative neck shaft angle, as originally described by Tronzo.208 Next a 3.2-wire using an appropriate angle guide, usually 125 to 135 degrees, is introduced at the level of the lesser trochanter in line with the previous anteversion pin. In hard bone it is often helpful to predrill with a 4.5-mm drill bit direct the guidewire into the femoral head easier. The guidewire is then inserted centered on the AP and lateral views in the femoral neck. It is important that the wire should not be positioned too anteriorly or posteriorly from its entry portal and should be centered on the AP and the lateral x-rays into the femoral head. The wire should be advanced to within 5 to 10 mm of subchondral bone to meet the requirements of the tip apex distance, as described by Baumgaertner, of less than 25 mm. Next the length measurement is taken; usually at this point a triple reamer type device reams a path for the screw into the femoral head and also the expansion of the lateral cortex for the plate to the selected depth. Usually a screw will be selected that will be 5 mm less than the drill depth. If the bone is dense it should be tapped and provisional fixation should be applied to the fragment before tapping to ensure that there is no loss of rotation because of the torquing of the tap. Insert the lag screw with a cannulated attachment over the guidewire and seat the screw to within 5 to 10 mm of subchondral bone. The selected plate is usually of a 2- to 4-hole design; two holes for simple two-part stable fractures, and the larger length for more unstable patterns or osteoporotic bone. The plate is applied and inserted over the lag screws. If the plate does not oppose itself easily to the bone, the wrong angle may have been selected. Care should be taken not to force the reduction of the plate to the bone, as this may result in gapping of the medial cortex with induced instability. Attach the plate to the femoral shaft with a standard drill bit (3.2- or 3.5-mm, depending on the system) and a 4.5-mm cortical screw inserted in the proximal platehole. Care should be taken that the plate is aligned with the shaft of the femur to avoid offset or unicortical screws distally. Next release traction and impact the plate with an impactor. Most systems have compression screws that can be inserted through the plate into the large lag screw. Apply compression after traction is released. Excessive compression should be avoided, as it may disrupt the fixation of the head and render it unstable. Also, in anticipation of up to 5 mm of sliding, the screws should not be brought out so far that they actually protrude past the plate, as this may cause postoperative pain from the implant. Whether the compression screw device is left in place is up to the surgeon; there are no clear data as to removal or retention. The plate is then further secured with 4.5-mm screws with bicortical fixation (Fig. 48-26A-C). Hemostasis is confirmed and the wound is closed in layers in the standard fashion. Drains are not routinely used unless the patient is on anticoagulant therapy. Intraoperative confirmation of the reduction on the AP and lateral views and a radiographic record P.1623 obtained. The importance of provisional fixation during screw insertion was pointed out by Mohan et
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al. in 1993. Their study showed that malreduction occurred with tightening of the screw in left-sided patients with malreduction (Fig. 48-26D,E).
FIGURE 48-26 A. High-energy 31A fracture. B. Reduction and stabilization with CHS. Good position with good bone stock aids the stability of the fixation with CHS. C. Lateral postoperative radiograph. D. Malreduction with plate angle too high inducing medial opening of the fracture. E. Anterior translation of fracture with wrong angle plate.
Linear Compression Class: Gotfried PCCP (Orthofix)75

Routine scrubbing and draping was carried out after fracture reduction, using a standard fracture table and the posterior reduction device. Make a first stab incision of approximately 2 cm in the lateral trochanteric area, followed by introduction of the plate, connected to the introducer, which slides along the upper lateral femoral shaft. The anteroposterior and lateral positions of the plate are checked under an image intensifier and necessary corrections are made. Make the second stab incision approximately 2 cm. Introduce the percutaneous bone hook for reduction and clamping of the plate to the femur. Insert the main sleeve through the lower oblique hole in the plate. Insert the main guidewire into the femoral neck so that it is approximately 2 to 3 mm proximal to the calcar on the anteroposterior view and within the middle third of the femoral neck on the lateral view. The butterfly pin is then fixed for temporary fixation of the plate to the femur. The main guide and first sleeve are then replaced by the second sleeve and a 7.0-mm drill. A 7.0-mm hole is drilled. Next a final drilling of 9.3 mm is P.1624 performed for the screw barrel. The first neck screw is screwed through the plate and the femoral neck up to the subchondral bone, and the fracture is then compressed. Remove the main sleeve, insert the short shaft sleeve to drill, and fix the three shaft screws through the second incision.
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Remove the bone hook and butterfly pin after insertion of the first shaft screw. The second, proximal, neck screw is then placed in the same way as the first one. The introducer is disconnected and removed. The wound is irrigated and closed over a suction drain. Postoperatively, full weight-bearing is permitted after surgery with crutches or walker. Linear compression plating offers the potential to replace the original sliding compression hip screw, and many designs are now becoming available.
Common Technique for Cephalomedullary Nails: Minimally Invasive Nail Insertion Technique (Russell et al.)184
The rationale for the minimally invasive cephalomedullary surgical technique is based on three concepts of bone and soft tissue conservation and nail implantation that minimize the potential for malalignment: (i) Precision portal placement, (ii) trajectory control, and (iii) portal preservation. A precise starting point is the first criterion in assuring an accurate fracture reduction of proximal fractures, whether the entry portal is a modified trochanteric entry portal or a piriformis portal as defined by the selected nail geometry. The medial trochanteric portal has become the preferred portal for nail technqiues for hip fractures for both mechanical stability and minimal soft tissue damage to the gluteus medius.173 The proximal femur is filled with a solid cancellous bone architecture from the femoral head region until the level just below the lesser trochanter, where the medullary canal begins. Trajectory control is the development of a precise path for the nail through this solid cancellous bone, which will restore the proximal alignment in the anteriorposterior and medial-lateral planes. This correct trajectory parallels the anterior lateral cortex of the proximal femur and allows nail juxtaposition against a solid cortical structure. An incorrect trajectory will induce malalignment with nail insertion and result in an unstable juxtaposition against cancellous bone only, forcing the nail to migrate to the posterior cortex and resulting in a flexion deformity of the proximal fragment. Once the correct trajectory is established, the portal and the lateral wall of the trochanter must be protected from erosion and fragmentation by the subsequent instruments for fracture reduction and canal preparation. Typically with the patient in a supine position this erosion takes place in a posterolateral direction, further contributing to a flexed and varus position of the proximal fragment, with nail insertion occurring during reaming of the proximal femoral component. A stepwise approach to canal preparation simplifies the nail insertion technique.
Portal Acquisition
Insert the guidewire drill system with soft tissue protection to the region of the greater trochanter and insert a 3.2-cm guide wire approximately 5 to 10 mm into bone in the lateral aspect of the greater trochanter. This is a pivot pin about which a honeycomb-type targeter can be adjusted to precisely place the definitive guidewire pin at the tip of the greater trochanter. The definitive guidewire should be just medial to the tip of the greater trochanter on AP C-arm view and centerered in the femoral neck on the lateral C-arm view. The definitive guidewire should be inserted 10 to 15 mm into the trochanter and does not have to be in correct canal alignment because the definitve trajectory will be obtained in the next step (Figure 48-27A,B). Use a cannulated rigid reamer, preferably with modular end cutting capability (Channel Reamer, Smith-Nephew, Gamma3, Stryker), approximating the proximal nail geometry diameter and introduce it over the guidewire through the protective sleeve. Advance the rigid reamer or channel reamer directed toward a point projected in the center of the medullary canal just distal to the region of the lesser trochanter (Fig. 48-27C). Advance the reamer stepwise confirming maintenance of trajectory. After the reamer has been inserted approximately 20 mm, confirm the reamer's trajectory with a lateral C-arm view. The reamer should be directed along the anterior cortex of the proximal femur. Insert the reamer until it reaches the medullary canal just below the region of the lesser trochanter. Remove the inner reamer and maintain the outer reamer for protection of the proximal reamer during the next step. Insert a fracture reducer (TriGen, Smith-Nephew) or similar curved cannulated device through the retained channel reamer to the fracture site and thread it through the fracture site into the distal fragment intramedullary canal with manipulation in appropiate planes to align the fracture (Fig. 48-27E). Insert a long guidewire to the knee if a long nail is desired, confirming that the wire does not impinge on the anterior cortex distally. Preferably the guidewire should be inserted distally for long nails to the old physeal scar and centered on AP and lateral C-arm views (Fig. 48-27F). Remove the reducer, and maintain the guidewire position with an obturator proximally. Check the length with an appropriate ruler, allowing for fracture distraction and final nail position. Ream the diaphyseal region up to 1 mm over the desired nail size; ream up to 2 mm for excessive anterior bows. The proximal expansion of the nail should have already been reamed with the entry portal reamer, but always confirm diameters. Remove the channel reamer and insert the selected nail.
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Gamma Class Single Lag Screw Fixation: Dynamic Compression Cephalomedullary Nail Designs (e.g., Gamma [Stryker-Howmedica], IMHS [Smith-Nephew])
Minimally invasive entry portal acquisition, portal creation, and canal preparation are as previously described. With the correctly positioned guidewire and reduction obtained, proceed with nail insertion. Using the proximal alignment guide, insert the nail to a depth that will place the guidewire in a slightly inferior positon from the center-center position in the head and neck and confirm rotational alignment on the lateral radiograph (Fig. 48-28A-D). The gamma nail does not encourage the forceful insertion of the nail with a hammer, and this may cause difficulty with insertion and require additional proximal reaming to ensure sufficient depth insertion. Make a lateral incision on the thigh in line with the anteversion postion of the nail guide and insert the trocar to bone. Caution: During this step anteversion may be misaligned. Do not insert the drill for proximal screw fixation until both depth of insertion and anteversion are certain. Drill a wire to within 5 mm of subchondral bone, confirm fracture reduction, and measure length to lateral cortex. If compression is desired (usually 5 mm), ream for the screw and select a screw 5 mm shorter than measured. Insert the head fixation screw or nail to the desired depth and confirm on AP and lateral C-arm views. Insert the locking nut into the proximal nail canal and advance to the lag screw (Fig 48-28E,F).
P.1625
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FIGURE 48-27 A. AP guidewire options: tip of trochanter for most 4- to 5-degree angle nails or medial trochanter to minimize gluteus medius tendon damage and allow optimal compression with InterTAN nail. B. Lateral position should permit nail proximity to anterior cortex not posterior cortex and allow center position of head fixation. C. Medial trochanteric portal with reamer. D. Parallel anterior cortex with channel reamer for correct trajectory control. E. Reducer for subtrochanteric extension or segmental fractures. F. Use reducer to position distal guide wire centered on lateral radiograph to minimize risk of distal nail penetration.
P.1626
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FIGURE 48-28 A. Placement of the nail by hand down the medullary canal. B,C. Use of the sure-shot guide to help determine correct nail positioning to allow placement of the lag screw in the center of the femoral head and neck. D. Insertion of the lag screw through the intramedullary nail. E. Reverse obliquity 31A3 fracture. F. Anatomic reduction and optimal nail screw position.
Proceed with distal locking as desired with bicortical screw fixation preferably in a dynamic mode. One screw is sufficent for most pertrochanteric fractures that do not extend below the lesser trochanter. For distal extension, a long nail is preferable. Long nails require distal interlocking with a free-hand technique.
P.1627
Reconstruction Class Cephalomedullary Nails: Cephalomedullary Nail 2 Screw (Russell-Taylor Reconstruction Nail, TriGen TAN [Smith-Nephew])
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Prepare the entry portal, obtain fracture reduction, and prepare the canal with a minimialy invasive technique as described previously. For long trochanteric nails it is helpful to rotate the nail 90 degrees anteriorly during the first half of the nail insertion to minimize hoop stresses in the proximal femur; after partial insertion rotate the nail to the anticipated anteversion required for femoral head fixation (Fig. 48-29A,B). Insert the last 5 cm of the nail after releasing distraction sufficient for fracture apposition maintaining corrrect rotational alignment. Most commercial guides use reference marks to align with the femoral head on the lateral C-arm view. These same guides may be used for C-arm verification of correct depth of insertion to allow optimal femoral head fixation. Remove the long guide rod to proceed with interlocking. Proximal interlocking will depend on the type of implant selected; however, most designs recommend that the screw be placed as close to center-center as possible. If a secondary screw is included in the nail design, that is, reconstruction or InterTAN constructs, there is usually sufficient room for the second screw inferiorly, but exercise care in small patients. Correct anteversion alignment requires rotation of the C-arm to obtain a true lateral view of the hip. The nail guide and nail are superimposed and the handle rotated until equal amounts of femoral head are visualized anterior and posterior to the nail and guide. This position will center the guidewire on the head from the lateral reference point. Using the proximal guide, with the true AP view, insert the nail until the depth centers the guidewire on the AP view. Using the proximal targeting guide attached to the nail, insert the distal-most proximal guidewire along the femoral calcar within 5 mm of the inferior femoral neck centered on the lateral C-arm view to within 5 mm of subchondral bone (Fig 48-29C). Through the proximal targeting guide attached to the nail, insert the most proximal guide pin that will be close to the center postion of the femoral head parallel to the first guide pin and confirm its position with the C-arm. Remove the inferior guidewire, drill and ream for the selected lag screw for the system, and insert the inferior screw (Fig 48-29D,E). Next repeat the same steps for the proximal screw. Release traction before final tightening of the lag screws to allow fracture compression (Fig 48-29F). Proceed with distal interlocking with a free-hand image-guided technique.
External Fixation (Othofix Pertrochanteric External Fixator)147

This technique is recommended for patients at high risk with open procedures and is indicated in OTA/AO Class 31A1 to A2 fractures only (Figure 48-30). General recommendations of a stable reduction confirmed with intraoperative fluoroscopy under general or local anesthesia still apply. After standard skin preparation, prophylactic antibiotics, a 2.0-mm K-wire is introduced in the most cephalad portion of the femoral head and neck subtending an angle of 110 to 130 degrees and centered on the lateral radiograph. This wire serves as guidance and provisional stabilization during the femoral head fixation pin placement. A 4.8-mm drill guide and drill penetrate the lateral cortex through a percutaneous stab incision. Advance the drill appproximately 3 cm under image intensification control parallel to the path of the guidance K-wire previously placed. Insert the first HA (hydroxyappatite coating) 6-mm pin to within 10 mm of the articular surface and no more. Remove the drill guide and K-wire and attach the proximal fixator Clamp and insert the 6-mm trocar through the fixator body parallel to the proximal pin on the lateral view and slightly convergent on the AP view. Advance the drill guide through a second stab incision and advance the trocar to bone. Repeat the drilling and HA coated half-pin insertion for the second femoral head fixation. Clamp the proximal fixation 2 cm away from the skin and tighten the proximal pin cluster assembly. For shaft fixation, insert the 4.8-mm trocar and drill guide perpendicular to the shaft, below the level of the lesser trochanter. Through a stab incision, advance the trocar to bone and drill both cortices with a 4.8-mm drill. Insert the third HA coated pin confirming good screw purchase in the near and far cortices. Check rotation of the distal clamping array of the external fixator to ensure bicotical purchase of the fourth and final pin. Repeat the same half-pin preparation and screw insertion. Confirm fracture reduction, avoiding overdistraction and tighten all connections securely. Confirm that with flexion and extension of the hip there is no skin tension on the half-pins, and extend the incision about the pins as necessary. Apply dry dressings around the pin sites. Postoperative care is the same as for other types of internal fixation, with mobilization within 24 hours after surgery with walker or crutches and weight-bearing as tolerated. Pin sites are cleaned twice weekly with saline solution. External fixation is removed in the office without the need of anesthesia at 3 months postoperatively. Ambuation progresses as tolerated.
Postoperative Care
AP and lateral radiographs of the final construct should be obtained in the surgical suite before recovering the patient to assess the construct and ensure stability. If adjustments are necessary, these are best made while the patient is still under anesthesia. Radiographs should reveal the entire fracture region, including the entire implant construct. The patient is mobilized to a chair upright postion the day after the
P.1628
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operative procedure. Ambulation is performed with supervision with weight-bearing as tolerated with a walker or crutches with emphasis on heel-strike and upright balance exercises. Multiple trauma or patients with other complications may have delayed ambulation, but it should began as soon as possible to minimize secondary complications. Delay in getting the hip fracture patient out of bed is associated with poor function at 2 months and worsened 6-month survival.195 Studies also reveal decreased rates of pneumonia, urinary tract infection, and dementia with early mobilization.110 Besides accelerating recovery, the ability to ambulate postoperatively is prognostic for survival rates.101 Specific fracture service and rehabilitation protocols reduce 30-day mortality rate from 22% to 7%.171
FIGURE 48-29 A. 31A1 fracture in Dorr A bone. B. Trochanteric nails with a 5-degree proximal bend should be inserted with 90 degrees of internal rotation initially and then rotated externally at 50% insertion to
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minimize hoop stress at the insertion site. C. With recon technique the bottom guidewire should be inserted first and just above the inferior femoral neck. D. Inferior screw placed and drilling for proximal screw. E. Optimal lateral position of nail and screws. F. Final head fixation AP radiograph.
P.1629
FIGURE 48-30 Orthofix pertrochanteric fixation. A. Pin positions 1 and 2 are in cancellous bone; pin positions 3 and 4 engage cortical bone. B. The remaining pins are implanted, starting from pin position 2 (proximal) and ending with pin position 4 (distal), with use of the same surgical technique. (A from Moroni A, Faldini C, Pegreffi F, et al. Dynamic hip screw compared with external fixation for treatment of osteoporotic pertrochanteric fractures: a prospective, randomized study. J Bone Joint Surg Am 2005;87:755; B from
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Moroni A, Faldini C, Pegreffi F, et al. Osteoporotic pertrochanteric fractures can be successfully treated with external fixation. J Bone Joint Surg Am 2005;87:47.)
Weight-bearing is most important in these patients for optimal recovery and to assuage the fear of falling and lack of independence. Weight-bearing stability of the implant construct improves the functional ability of these patients.193 There must be sufficient stablity to allow aggressive physical therapy, especially in cognitvely impaired patients with hip fracture.150 Koval has reported that patients autoregulate their weight-bearing.116 Pain control postoperatively is also important for recovery. Patients with higher pain scores at rest had significantly longer hospital lengths of stay, and were more likely to have physical therapy sessions missed or shortened, less likely to be ambulating by postoperative day 3, took longer to ambulate past a bedside chair, and had significantly lower locomotion scores at 6 months.149 The issue here is adequate pain control and the importance of implant stability. If an implant is unstable in the first 6 weeks after surgery, pain and lack of mobility may affect long-term functional recovery. Protein and caloric nutrition, osteoportic therapy, including vitamin D supplementation, are important for sucessful recovery.32 Hip abductors exercises bilaterally in conjunction with proper balance and gait training are required. Resist the abandonment of crutches or walker until normal gait is restored. Patients must be counseled to report any increased swelling or respiratory distress as an emergency because of the high risk of thromboembolic disease. On discharge, prescribe vitamin D (minimum of 1000 IU daily); if the patient's vitamin D level is low, consider prescribing 50,000 IU weekly for 12 weeks. Fall prevention education and safe home checks should be explained to the patient's family or social support group. The patient is re-evaluated with exam and radiographs at 2 weeks and then monthly thereafter until fracture healing is documented and she or he has maximized amublatory capabilities, usually by 6 months after injury. The AOA has reccommended that orthopaedists include a plan to indentify secondary causes of osteoporosis, obtain bone density testing, and initiate osteoporois pharmacotherapy if appropriate. The FRAX calculator (http://www.shef.ac.uk/FRAX/) is a free service for patients not on osteoporosis treatment and is helpful for patient education and risk assessment.111 The AAOS, AOA, and Osteoporosis Foundation encourage the use of fragility fracture and osteoporosis for diagnosis in the discharge summary. Orthopaedic surgeons must treat the entire patient with the same diligence we prescribe a rehabilitation program after any sports injury, reconstructive surgery, or hand procedure.32
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Pearls and Pitfalls

See Table 48-3 for the pearls and pitfalls of pertrochanteric fracture treatment.
COMPLICATIONS Medical Complications

A retrospective cohort multicenter study of patients 60 years or older found a rate of 1737 (19%) with postoperative medical complications in 8930 patients.129 Interestingly, 81% of these patients had no medical complications after hip fracture repair. Cardiac and pulmonary complications were most frequent (8% and 4% of patients, respectively). Other complications were gastrointestinal tract bleeding (2%), combined cardiopulmonary complications (1%), venous thromboembolism (1%), and transient ischemic attack or stroke (1%). Renal failure and septic shock were rare. After the index complication, 416 patients had 587 additional complications. Mortality was similar for serious cardiac or pulmonary complications (30 day, 22% and 17%, respectively; 1 year, 36% and 44%, respectively) and highest for patients with multiple complications (30 day, 29% to 38%; 1 year: 43% to 62%).129
Psychosocial Complications
Patients frequently have concerns regarding their imminent mortality, especially if they have had loved ones' who have died from hip fractures in the past. They have questions regarding their ability to walk again or be independent enough to return to their own home. Most surgeons consider union of any type to be a successful treatment, whereas from a patient's perspective it is a return to the previous level of functional activity and home environment that is desired. The fear of falling can be a devastating complication of recovery, and this is best addressed by the patient's ability to trust in the injured extremities' support.17, 159 Patients with improved mobility early in the postoperative period develop better
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functional abilities at the 3- and 6-month periods.201 Ziden et al. reported multidimensional and dramatic changes in patients' life situations, including existential thoughts and reappraisal of the years of life that remained. The results indicate that the fracture seemed not only to break the bone, but also to cause social and existential cracks leading some patients to a positive socially interactive lifestyle and others to a depressive, defeatist mentality with withdrawal and a diminished zest for life.223
Thromboembolic Complications
Thromboembolic complications are a source of continuing controversy about proper prophylactic management and postoperative therapy, considering the added cost and medical surveillance required and the concern for major hemorrhagic postoperative events. 6,71, 86,88 Complicating management in the hip fracture patient population is the preoperative frequency of platelet inhibitors and anticoagulants for unrelated medical problems. Recommendations from the American College of Chest Physicians, American Academy of Orthopaedic Surgeons, and governmental agencies are not in agreement as to the best strategy. Options include pentasaccharides, low-molecular-weight heparins, adjusted dose warfarin, mechanical compression, and aspirin.207, 216 Prophylaxis has been recommended for 4 to 6 weeks postoperatively because of reports of late pulmonary embolism and DVT. In a study by Fisher et al. the incidence of a venous thromboembolic event in the no treatment group was 12%, and in the mechanical compression group was 4%.58 In 1984 Alho reported a prospective study for the expenditure of hospital resources and the incidence of clinical venous thromboembolism under prophylaxis with heparin, aspirin, or warfarin. Thromboembolic complications were more frequent (P < 0.02) and hospital costs clearly higher in the low-dose heparin-treated patient group compared with the aspirin and warfarin groups. There P.1631 were no distinct differences between aspirin- and warfarintreated patients either in results or costs. Nonetheless, carefully monitored treatment with warfarin with Thrombotest always less than 0.20 appeared to be the most effective prophylaxis in patients with hip fractures. They use aspirin as a general prophylaxis in orthopaedic patients, and warfarin in patients with established risk of thromboembolic complications. 5
TABLE 48-3 Pearls and Pitfalls of Treatment of Pertrochanteric Fractures
Pearls Key Point
Application
Anteromedial cortex is key to reduction
Best defense against collapse/shortening
Bone quality and fracture pattern determines fixation
Don't use a low stability device in a high instability risk fracture
Lateral wall continuity key functionality
Prevent damage, repair as necessary
Patient recovery
It's not the time of operation but the quality of life the patient enjoys later
Who owns the bone?
Orthopaedic surgeons
Pitfalls of Plates Problem
Solution
Fracture unreduced
Release traction
Expose anterior fracture
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Use Jocher or Cobb to disimpact
Check neck shaft angle, AP translation at fracture site, and rotation: not all reduce with IR
Fracture overdistracted
No soft tissue attachment for taxis; proceed with open reduction and use K-wires and Steinmann pins as joysticks with Weber for reduction compression
Fracture loss of reduction with plate
Incorrect angle selection for plate
Check center guidewire. Is it centered in head and neck or eccentric?
Pitfalls of Nails Problem
Solution
Loss of reduction with nail insertion
Fully seat nail, then push on proximal nail guide medially to reduce and adjust neck shaft angle
Provisionally fix fracture and reinsert nail
Screw position incorrect
If screw is in valus or varus, the reduction was lost. Remove screw, correct varus valgus with nail guide manipulation, redrill, and insert screw in new path
Nail lies in posterior position of trochanter
Entry portal damage during reaming. Lift up on nail guide and redrill guidewire. May consider blocking screw technique
In 1993 Feldman et al. evaluated the efficacy of thromboprophylaxis with aspirin, and dextran 40 was compared in a prospective review of 530 geriatric hip fracture patients treated surgically. All patients were also treated with early mobilization with weight-bearing as tolerated and above-knee elastic stockings. The incidence of DVT (0.5%) and PE (2.6%) in the aspirin group was essentially the same as the incidence of DVT (0.3%) and PE (2.4%) in the dextran group. Neither mortality nor infection rates were different. They reported the average cost for aspirin at $1.79 per patient. The safety, cost, and ease of administration of aspirin may make its use more desirable in their opinion.57 Jeong et al. evaluated aspirin, dextran 40, and enoxaparin in conjunction with above-knee elastic stockings.105 With this protocol they reported a DVT rate of 0.5% to 1.7%, pulmonary embolism 0% to 2.0%, fatal pulmonary embolism 0% to 0.5%, and no difference with regard to the effectiveness of each pharmacologic treatment. Wound hematoma complications were increased with enoxaparin (3.8%) versus aspirin (2.4%) and Dextran 40 (1.6%). Fondaparinux prophylaxis for 1 to 4 weeks was reported as well tolerated, and compared with placebo, it significantly reduced delayed venous thromboembolism events from 35% to 1.4%. Based on these findings, a 4-week fondaparinux treatment may become the standard thromboprophylaxis after hip fracture surgery.55 The effect of change in practice at one center from 1992 to 1997 reflected significant increases in pharmaceutical thromboembolic prophylaxis (from 45% to 81%) and early mobilization (from 56% to 70%). There were reduced levels of pneumonia, wound infection, pressure sores, and fatal pulmonary embolism, but no change was recorded in 3-month functional outcomes or mortality.62 Pulmonary embolism may be reduced by prophylactic anticoagulation, but 17% of patients are at risk of hemorrhage, and some surgeons advocate mechanical methods as a safer option in this population.174 P.1632
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Nonunion
Nonunion of pertrochanteric fractures with previous internal fixation is reported to affect 1% of older patients and is usually treated with total hip replacement. In young patients it is treated with osteotomy, bone grafting, and implant revision (Fig 48-31). Vidyadhara et al. reported on using closing lateral wedge valgus intertrochanteric osteotomy in addition to dynamic hip screw osteosynthesis in the successful management of seven patients with varus trochanteric nonunion. Average preoperative coxa vara of 94 degrees (range, 85 to 104 degrees) had improved to a femoral neck shaft angle of 139 degrees (range, 134 to 145 degrees) on postoperative radiographs. All fractures and osteotomies had healed. The Harris hip score improved from 34 (range, 22 to 47) to 89 (range, 83 to 95) at an average of 11 months follow-up (range, 7 to 13 months).210 Other reports have high success rates with osteotomy and ORIF (82% success).137, 185 Hadikewych et al. reported a 95% union rate with a combination of techniques, including blade plate, DHS, DCS, and Zickel devices. They added autogenous iliac bone graft in 17 cases versus three allografts; 19/20 nonunions healed with this strategy. Talmo has reported success with total hip arthroplasty, with a Harris hip score average of 86 at 30 months in 10 patients (Figure 48-32). 83,84,202
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FIGURE 48-31 A. Nonunion of a 31A3 fracture with CHS displaying maximal shortening with medialization of the distal shaft fragment. B. Distraction nonunion with TFN. Repair requires open reduction, grafting, and compression fixation. C. TFN distraction nonunion on lateral radiograph.
Implant Malfunction
Implant malfunction or failure is estimated to approximate 5% of cases usually from a combination of implant fatigue failure, shaft fixation failure with broken screws, femoral head medial penetration, screw cutout, and disassembly of the device components. With today's stringent requirements for manufacturing and quality control, manufacturing etiology for failure is extremely rare. Fatigue failures associated with nonunion are most common. Parker et al. analyzed by the radiographic characteristics of 27 patients with a trochanteric fracture treated with a sliding hip screw in which fixation failure occurred, and compared them with 74 patients having uneventful fracture union. Femoral medialization was more common in specific fracture P.1633 types, particularly if there was comminution of the lateral femoral cortex at the site of insertion of the lag screw. Femoral medialization was strongly associated with fixation failure, with a sevenfold increase in the risk of failure if medialization at more than one third occurred. This author suggests that implants preventing femoral medialization in specific types of trochanteric fracture merit further evaluation.163
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FIGURE 48-32 A. Nonunion with locking plate. Note deformation of screws. B. Locking plate nonunion, lateral. C. Revision with open reduction, inductive grafting, and compression with InterTAN nail. D. InterTAN revision and union shown on lateral radiograph.
Loss of construct stability is one of the most frequent complications manifested by collapse of the screw and varus migration of the femoral head construct with final cutout failure in the worst cases of screw and nail constructs. This occurs to a small degree in all cases, as the sliding impaction was designed to minimize catastrophic cutout, but frequently is compounded by lack of a stable reduction. A center-center position of single screw devices minimizes cutout as reported by many authors, but this is reduced to a mathematical equation as the tip apex distance, as reported by Baumgaertner16 (Figure 48-33). A related problem to implant failure is the peri-implant fracture
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that may occur around the lateral wall, the region of bone at the end of a nail or side plate, or distally in the femur. These are problems with tactics as the issue arises as to removal of the previous implant or addition of further fixation. Gotfried and Palm et al. have identified the seriousness of the lateral wall fracture, which frequently occurs around a compression hip screw. These difficult fractures require reattachment of the greater trochanter with buttress plate techniques.80 Fractures distal to plates may be treated with retrograde nails with removal of the inferior two to three screws of the sideplate to ensure overlap of the fixation by the nail (Figure 48-34). Periprosthetic fractures were more common with the first-generation short trochanteric gamma nails, probably because of the large distal diameter (up to 16 mm), larger proximal bend, and large distal locking screws. Periprosthetic fracture rates as high as 17% have been reported. With the newer design there has been a substantial drop in periprosthetic femur fractures, but it remains a concern. Fractures distal to short nails require revision to longer nails or locking plates if the greater trochanter is also involved.
FIGURE 48-33 The tip-apex distance (TAD), expressed in millimeters, is the sum of the distances from the tip of the lag screw to the apex of the femoral head on both the AP and lateral radiographic views.
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FIGURE 48-34 A. Peri-implant fracture of the femur below a CHS. Associated osteoarthritis of knee and osteoporosis in community ambulatory. B. Treatment with retrograde locking nail overlapping sideplate by removal of distal plate screws percutaneously. Blocking screws are used to enhance construct stability and alignment. C. Lateral radiograph showing retrograde locking nail with blocking screws and overlap with plate.
Functional Recovery
Cooper et al. state that the consequences of hip fractures relate to premature death, averaging 20% at 1 year, permanent disability of 30%, inability to ambulate independently in 40%, and loss of at least one activity of independent daily living (i.e., driving or grocery shopping) in 80% of treated patients.42 In 1990 Larson et al. examined the functional 607 trochanteric fractures treated with a sliding-screw technique and followed clinically and radiographically for at least 1 year. Of 351 patients admitted from their homes, 209 (60%) were discharged to their homes after an average of 18 days in the hospital. During the first year another 61 (17%) patients returned home after rehabilitation in a geriatric ward. Of 446 patients walking without support or with one cane before surgery, 360 (80%) had regained the same mobility after 1 year. The 1-year mortality rate was 18%, whereas the 10-year rate was 74%. Forty-five (7.4%) were reoperated, 17 because of technical complications, three because of infection, and three because of nonunion. The deep infection rate was nine of 339 (2.7%) before and two of 268 (0.8%) after the introduction of antibiotic prophylaxis. 128 Ekstrom et al. reported that even with stable two-part fractures, the 2-year mortality rate was 29%.52 The reoperation rate was 3%. At the final follow-up, 81% of the patients reported no or only limited pain at the hip, 55% had regained their prefracture walking ability, and 66% had attained their prefracture level of ADL function. In 2008 Rapp et al.180 evaluated the associated excess mortality with a large nursing home population in Germany. The crude incidence rates of admission to a nursing home were 50.8/1000 person-years in women and 32.7/1000 person-years in men. The incidence rates increased with increasing age categories and were highest in the first months after admission to the nursing home. Mortality in patients with a hip fracture was increased (women: hazard rate ratio for the first 3 months after fracture, 1.7 and men the hazard ratio, 2.14) but excess mortality was limited to the first months after injury. The introduction of a comprehensive multidisciplinary fast-track treatment and care program for hip fracture to optimize patient care has been reported with components such as a switch from systemic opiates to a local femoral nerve catheter block; an earlier assessment by the anesthesiologist; and a moresystematic approach to nutrition, fluid, and oxygen therapy, and urinary retention compared with standard hospital care. In the intervention group, the rate of any in-hospital postoperative complication was reduced from 33% to 20% (odds ratio, 0.61, 95%; confidence interval; 0.4 to 0.9; P = 0.002). Rates of confusion (P = 0.02), pneumonia (P = 0.03), and urinary tract infection (P = 0.001) were lower in the intervention group than the control group, and length of stay was 15.8 days in the control group versus 9.7 days in the intervention group. For community dwellers, 12-month mortality was 23% in the control group. This study supports the P.1635
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concept of hip fracture program to reduce the rate of in-hospital postoperative complications and mortality. Randomized clinical trials are required to validate and elucidate the elements of the program that have the greatest effect on clinical outcomes and mortality.172
Infection
Infection occurs in 1% to 2% of postoperative patients and is minimized by preoperative antibiotics, usually a cephalosporin class drug. In immunocompromised and malnourished patients, standard care involves isolation and sensitivity testing of the causative bacteria and appropriate intravenous antibiotics in consultation with an infectious disease specialist and standard dbridement and irrigation for wound care. If the implant is stable it should be retained. A resection arthroplasty is rarely required.89 In 2008 Edwards et al. reported a 1.2% rate of deep wound infection and 1.1% superficial wound infection in a series of more than 3000 cases. Fifty-seven of eighty infections (71.3%) were caused by Staphylococcus aureus and 39 (48.8%) by MRSA (multiple organisms). No statistically significant preoperative risk factors were detected. Length of stay, cost of treatment, and predischarge mortality all significantly increased with deep wound infection. The 1-year mortality in the total series was 30%, and this increased to 50% in those who developed an infection (P < 0.001). A deep infection resulted in doubled operative costs, tripled investigation costs, and quadrupled ward costs. MRSA infection increased costs, length of stay, and predischarge mortality compared with non-MRSA infection.50 They recommended vigilance with a high index of suspicion for any signs of wound inflammation or drainage. Oral antibiotics for 7 to 10 days are suggested if the infection is superficial. Urgent formal surgical dbridement and irrigation are required for deep infection. Retain stable implants. Antibiotic beads may be considered for defect management. Wu et al. reviewed their experience with 23 pertrochanteric osteomyelitis cases and presented a two-stage treatment protocol. They used an external skeletal fixator or Buck's traction after radical dbridement in the first stage and reconstruction in the second stage. Only 12 of the 23 patients (52%) were successfully managed, and infection recurred in four patients (17.4%) at final follow-up. The use of external skeletal fixation was not recommended for managing pertrochanteric osteomyelitis. Success using a two-stage protocol was difficult to achieve.221
Vitamin D Deficiency
Vitamin D has been reported as an independent risk factor for recovery. Because of the avoidance of sunlight for fear of skin cancer and the lack of vitamin D in the modern diet, vitamin D deficiency has re-emerged as a health epidemic.94 Vitamin D deficiency causes muscle weakness. Skeletal muscles have a vitamin D receptor and may require vitamin D for maximum function. Performance speed and proximal muscle strength were markedly improved when 25-hydroxyvitamin D levels increased from 4 to 16 ng/mL and continued to improve as the levels increased to more than 40 ng/mL.21 A meta-analysis of five randomized clinical trials (with a total of 1237 subjects) revealed that increased vitamin D intake reduced the risk of falls by 22%, compared with only calcium or placebo. The same meta-analysis examined the frequency of falls and suggested that 400 IU of vitamin D3 per day was not effective in preventing falls, whereas 800 IU of vitamin D3 per day plus calcium reduced the risk of falls.21 In a randomized controlled trial conducted over a 5-month period, nursing home residents receiving 800 IU of vitamin D2 per day plus calcium had a 72% reduction in the risk of falls as compared with the placebo group.29
Outcomes
Mortality from hip fracture decreased with active surgical treatment in the mid-twentieth century but has remained stable at 25% to 30% since then. In 2009 Abrahamsen showed that patients experiencing hip fracture after low-impact trauma are at considerable excess risk for death compared with nonfracture community control populations. Hip fracture is associated with excess mortality (over and above mortality rates in nonfracture community control populations) during the first year after fracture, with studies suggesting a range of 8.4% to 36%. This initial risk for mortality after hip fracture was at least double that for the age-matched control population, became less pronounced with advancing age, was higher among men than women regardless of age, was highest in the days and weeks after the index fracture, and remained elevated for months and perhaps even years after the index fracture. These observations show that patients are at increased risk for premature death for many years after a fragility-related hip fracture and highlight the need to identify those patients who are candidates for interventions to reduce their risk.1 Holt has stratified the age groups as to risk of mortality from the Scottish Hip Fracture Audit Database. Patients in the 50-to 64-year group had significantly better outcome measures after surgery for hip fracture in terms of survival and function. The differences exist even after controlling for differences in patient case-mix variables. Holt et al. developed a predictive formula for estimation of mortality at 30 and 120 days depending on age, ASA score, gender, prefracture residence, prefracture mobility, and type of fracture (Table 48-4). P.1636
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TABLE 48-4 Predictive Mortality Variables
30 days Odds ratio (95% confidence interval)
P value
B*
120 days Odds ratio (95% confidence interval)
P value
B*
Explanatory variable and category
Age (yr)
< 0.001
< 0.001
50 to 59
60 to 69
1.78 (0.95 to 0.33)
0.58
1.98 (1.34 to 2.94)
0.68
70 to 79
3.46 (1.94 to 6.15)
1.24
3.46 (2.40 to 4.98)
1.24
80 to 89
5.68 (3.21 to 10.1)
1.74
5.94 (4.14 to 8.53)
1.78
90
7.11 (3.98 to 12.7)
1.96
7.95 (5.49 to 11.5)
2.07
ASA score
< 0.001
< 0.001
1 and 2
2.25 (1.88 to 2.69)
0.80
1.98 (1.77 to 2.21)
0.67
4 and 5
5.14 (4.18 to 6.31)
1.62
4.01 (3.48 to 4.62)
1.37
Gender
< 0.001
< 0.001
Male
Female
0.52 (0.46 to 0.60)
-0.65
0.49 (0.45 to 0.54)
-0.70
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Prefracture residence
< 0.001
< 0.001
Own home
Ong-term care
1.69 (1.47 to 1.95)
0.53
2.06 (1.87 to 2.27)
0.72
Rehabilitation
1.69 (1.30 to 2.20)
0.53
2.24 (1.86 to 2.70)
0.81
Acute hospital ward
1.80 (1.43 to 2.26)
0.59
2.40 (2.04 to 2.83)
0.88
Other
1.78 (0.97 to 3.27)
0.58
1.34 (0.84 to 2.13)
Prefracture mobility
0.007
< 0.001
No aids, unaccompanied
One aid, unaccompanied
0.98 (0.83 to 1.15)
-0.02
1.07 (0.96 to 1.19)
0.06
Two aids/frame
1.07 (0.91 to 1.26)
0.07
1.15 (1.03 to 1.29)
0.14
Requires accompaniment
1.26 (1.04 to 1.51)
0.24
1.41 (1.24 to 1.61)
0.35
Unable to walk
1.47 (1.18 to 2.08)
0.45
1.62 (1.31 to 2.00)
0.48
Type of fracture
< 0.001
< 0.001
Intracapsular
Extracapsular
1.13 (1.00 to 1.27)
0.12
1.16 (1.06 to 1.26)
0.15
Subtrochanteric
1.33 (0.96 to 1.82)
0.28
1.19 (0.95 to 1.50)
0.18
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Pathological
3.76 (2.72 to 5.19)
1.32
4.91 (3.77 to 6.39)
1.60
Regression constant
-4.79
-3.70
B, logistic regression coefficient ASA, American Society of Anesthesiologists.
From Holt G, Smith R, Duncan K, et al. Early mortality after surgical reduction of hip fractures in elderly: an analysis of data from the Scottish Hip Fracture Audit. J Bone Joint Surg Br. 2008;90B:1360.
Mortality = 1/1 + e - (constant + B(ASA) + B(prefracture residence) + B(age) + B(sex) + B(type of fracture) + B(prefracture mobility) where e = 2.72 and the constant = -4.79 for 30-day mortality and -3.70 for 120-day mortality. For example, the predicted 30-day mortality for a hip fracture patient aged 90 or over; ASA = 3; from a care home, assuming other base characteristics (male, intracapsular fracture, walked without aids before fracture) = 1/1 + e - (-4.79 + 0.80 + 0.53 + 1.96) = 18.2%. This formula applies to Intracapsular, extracapsular, subtrochanteric and pathologic fractures. Mortality in those more than 90 years old averaged 50% at 120 days.96 In an autopsy study, 581 patients with fractures of the proximal femur were identified. The principal causes of death after hip fracture were bronchopneumonia, cardiac failure, myocardial infarction, and pulmonary embolism. Surgical intervention within 24 hours of injury significantly reduced death from bronchopneumonia and pulmonary embolism. Early mobilization reduced death from bronchopneumonia.174 We have come from the era in which it was to difficult to analyze functional recovery to one in which we analyze and maximize functional recovery. It is interesting that the Harris Hip Score has been well validated as a hip quality measure. Recently, several authors have reported results with this measure. Moroni et al. reported Harris Hip Scores of 60/100 for external fixation and standard compression hip screws, with increases to 70/100 with HA coated compression hip screw devices. Ruecker et al. reported average Harris hip scores in the 78/100 range for preoperative function, and recovery to 70/100 with an integrated screw nail device. P.1637
CONTROVERSIES AND FUTURE DIRECTIONS

Lorenz Bhler is credited with the strategy that with injury the surgeon treatment should first preserve life, second save the limb, and finally maximize functional recovery. There is a dichotomy of opinion regarding a surgeon's and a patient's perspective after a broken hip. Globally surgeons feel that most surgeries are equivalent and that patients are expected to have a lower demand and lower mortality after surgery, and frequently their focus is on the time of the surgical procedure and union of any type rather than the total care of the patient. We have now arrived in a new century in which functional recovery in previously independent community ambulators is expected if not demanded, and the satisfaction of a united fracture from the mid-twentieth century with reduced mortality is not enough. The current re-evaluation of treatment methods for pertrochanteric fractures relates to appreciation of the relative instability of the fracture construct with a single cephalic component with osteoporotic bone stock, unstable fracture reductions, or combinations thereof. It is appreciated that even with optimal screw purchase in the correct position of the femoral head, any rotational stability will lead to progressive collapse and progressive incremental instability until the fracture heals in a varus position, the femoral head motion results in femoral neck erosion and collapse until the sliding screw reaches maximal collapse with resultant implant failure, or cutout occurs. This is certainly more common in severe osteoporotic patients and those with unstable reductions or comminuted fractures. Uncontrolled dynamization has come to be appreciated as a cause for bony erosion and progressive continuing collapse. This frequently results in excessive dynamization, which weakens the abductors and shortens the extremity and makes it more likely the patient will have diminished function. The Baby Boomer generation patient with a hip fracture expects a functional result equivalent to their friends' experience with a total hip replacement. Rotational instability, which has essentially been ignored since Holt's concept in 1963, has resurfaced with biomechanical and clinical validation of the importance of rotational stability. New techniques and devices are required to overcome the
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status quo. Another aspect of debate is the prevention of the first fracture and the next fracture. Who can we save? Who can benefit from prophylactic medications or even surgery? We know the major risk factors for geriatric fractures, which include prior fragility fracture, increased age, low bone mineral density, low body weight, family history of osteoporotic fracture, glucocorticoid use, secondary osteoporosis, liver and kidney disease, Crohn's disease, rheumatoid arthritis, hyperthyroid disease, antiepileptic medications, primary hyperparathyroidism, and systemic inflammatory disease and smoking tobacco products and now vitamin D.35,68 Boonen et al.24 have documented the drugs alendronate and risedronate as effective in decreasing the risk of hip fractures. The AOA own the bone initiative notes that patients with a hip fracture have at least one treatable secondary cause of osteoporosis, usually low vitamin D (osteomalacia). Similarly, 40% of women and more than 60% of men with osteoporosis have a secondary condition and a treatable cause of their low bone density. They recommend that we should develop admission and discharge fracture care checklists that include the following recommendations: 1. Prescribe calcium (1200 mg daily). 2. Prescribe vitamin D (minimum of 1000 IU daily). If the patient's vitamin D level is low, consider prescribing 50,000 IU weekly for 12 weeks. 3. Refer to physical medicine or physical therapy for fallprevention education. 4. Ask the family or friends to perform a home-safety check.206 Surgeons are technology aficionados and will always look for better instruments and implants. Moroni et al. have been instrumental in the progress of HA-coated implants and the bone reaction to these coatings. 146, 147,148 These types of devices have garnered little acceptance in the United States as of yet. The application of bone in-growth coatings will parallel the addition of new studies and strategies to convince surgeons of their removal potential. The use of alendronate to augment the ingrowth of HA components is also under study for the osteoporotic patient. 145 Cement augmentation with the use of PMMA or calcium phosphate cements has been attractive since first described by Bartucci et al. in 1985.15 The problem has been the inability to demonstrate a functional improvement with the increased stability hypothesized. In Bartucci's experience patients with PMMA had worse function at follow-up. The calcium phosphate cements have also been tried but with the result in the most recent meta-analysis primarily of decreased pain at the hip.9 It may be that the technique of application is incorrect. Recently the trend has been to apply the cement in the femoral head and avoid the fracture zone. 8, 37,54,74 As new techniques of delivery and cement composition are developed, perhaps the addition of cements may prove more helpful in osteoporotic fractures.
REFERENCES
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Fractures in Adults

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Ovid: Rockwood And Green's Fractures In Adults

Ovid: Rockwood And Green's Fractures In Adults

PRINCIPLES OF MANAGEMENT Mechanisms of Injury

History and Physical Examination

Imaging and Other Diagnostic Studies

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DIAGNOSIS AND CLASSIFICATION

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Common Surgical Approaches

Watson Jones Approach

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CURRENT TREATMENT OPTIONS Evolution of Treatment

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TABLE 48-1 Classification of Plates

Sliding hip screw

Adjustable hip nails

Dynamic helical blades

Less risk of cutout?

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Proximal femoral locking plates

Dynamic Compression Plating

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FIGURE 48-11 Medoff sliding plate.

Gotfried noted the high failure rate

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Rotationally Stable Plating

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Hybrid Locking Plates

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Impaction Class (Y-Nail, TFN)

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FIGURE 48-16 Hybrid locking plate system (Smith-Nephew, Memphis, TN).

Dynamic Compression Class (Single Screw Head Component)

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TABLE 48-2 Classification of Nails

Peri-implant failure with short designs

Two-screw dynamic compression

Linear compression integrated

Reconstruction Nail Class (Two Screw Head Components)

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InterTAN Class (Integrated Nail and Screws with Linear Compression)

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AUTHORS' PREFERRED TREATMENT Preoperative Planning

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FIGURE 48-22 Implant selection variables.

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Ovid: Rockwood And Green's Fractures In Adults