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The management of intertrochanteric hip fractures
HIP FRACTURES
The management of intertrochanteric hip fractures
from such falls is 16 times higher to the energy required to fracture the proximal femur.5 However, only a small proportion of such incidences result in a fracture. This suggests that in addition to the poor bone stock, the loss of the body’s protective responses during the fall is crucial. Such responses include inadequate reflexes, loss of local shock absorbers like fat and muscle, as well as prolonged reaction times. The outcome of these fractures is daunting. Following such fracture, the documented mortality is approximately 10% at 30 days, reaching a significant 33% at one year.6 From the survivors, a steep drop in their quality of life is expected characterised by residual pain, loss of the previous functional status, and worsened physical health.7 The expansion of orthogeriatric services and fracture liaison service models for elderly patients can have a beneficial effect on subsequent mortality.8 Nevertheless, preventive measures and rigorous assessment at primary care level are of paramount importance together with the rigorous treatment of osteoporosis and investment in safety measures to reduce falls.
Ippokratis Pountos Peter V Giannoudis
Abstract The intertrochanteric proximal femoral fractures account for a significant amount of today’s orthopaedic surgeon’s workload and pose a challenge for the healthcare system around the globe. A timely surgical management that allows early mobilization is the key in the reduction of the high inherent mortality following these fractures. Several devices are currently available aiming to facilitate such an outcome. This article attempts to review the contemporary understanding of the available clinical evidence on the management options of intertrochanteric hip fractures.
Classification of intertrochanteric hip fractures Evans et al. pioneered the classification of the intertrochanteric hip fractures. In his classification he divided these fractures into stable and unstable configurations recognising the importance of the cortical continuity of the posteromedial wall.9 In the stable fractures, the posteromedial cortex had to remain intact or minimally displaced. The unstable fracture patterns were fractures with higher comminution of the posteromedial cortex. In this classification, Evans introduced a Type 2 unstable subset of fractures that consists of the transverse and the reverse oblique types. More recently, the Orthopaedic Trauma Association (OTA) developed an alphanumeric classification that incorporated the importance of the lateral cortex of the greater trochanter.10 (Figure 1) According to this classification; the fractures are divided into three main groups. The first group (31-A1) includes two part oblique pertrochanteric fractures extending from the greater trochanter to the medial cortex. The lateral cortex of the greater trochanter had to remain intact. Group 2 (31-A2) includes the pertrochanteric multifragmented fractures. This group consists of fractures with an intact lateral cortex of the greater trochanter but with fragmentation of the posteromedial wall. Group 3 (31-A3) includes fractures involving both the medial and lateral cortices. This group includes the reverse oblique fractures.
Keywords Cephalomedullary nail; hip fracture; intertrochanteric fracture; sliding hip screw
Introduction Hip fractures in the elderly represent a major challenge the healthcare systems around the globe have to face.1 Approximately 268 000 hip fractures were reported in the United States and 61 500 in the United Kingdom in 2013.1e4 The impact of these injuries is not limited to the surgical management but extends to all aspects of medical care ranging from the surgical and orthogeriatric medical input, to domains like rehabilitation, psychiatry and social work. Epidemiological trends indicate that their incidence will increase over the following decades, continuing to pose a threat to the health, mobility and independence of older adults.2,3 The intertrochanteric hip fractures represent a significant proportion of proximal femoral fractures ranging from 33% to 50%. The vast majority occur in the elderly population with a higher predominance in females suffering from osteoporosis. Patients who previously sustained an osteoporosis-related fracture are more likely to suffer an intertrochanteric proximal femoral fracture. An association exists between these fractures and the patients’ comorbidities, ambulatory and dependence levels. The mechanism of injury in the majority of the cases is a simple fall with a direct impact to the lateral upper thigh or buttock. Biomechanical data suggest that the energy generated
Management of intertrochanteric hip fractures Non-operative The conservative management of intertrochanteric fractures was the treatment of choice before the 1960s. It involved bed rest in traction for approximately 12 weeks followed by a lengthy rehabilitation program. Traction alone was not sufficient to maintain the position, therefore, a varus deformity and shortening of the affected limb was a common finding. The prolonged bed rest was also associated with numerous complications including pneumonia, urinary tract infections, thromboembolic events and joint contractures, resulting in high morbidity and mortality rates. An alternative non-operative approach with early
Ippokratis Pountos MB BSc MSc MD Hon Lecturer, Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, UK. Conflict of interest: No conflict of interest. Peter V. Giannoudis MD FRCS Professor, Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, UK. Conflict of interest: No conflict of interest.
ORTHOPAEDICS AND TRAUMA --:-
1
Ó 2016 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Pountos I, Giannoudis PV, The management of intertrochanteric hip fractures, Orthopaedics and Trauma (2016), http://dx.doi.org/10.1016/j.mporth.2016.03.004
HIP FRACTURES
Figure 1 The OTA classification.
practice.11 Young orthopaedic surgeons were the driving force for this change. A recent Cochrane systematic review highlighted that current literature can provide rather inconclusive results in terms of the clinical effectiveness of these implants.13 In the absence of robust evidence, the surgeons experience and training as well as the local availability of the implants seem to be the key factors in the selection process for the implants.
mobilisation ‘as pain allowed’ within days after the injury attempted to overcome some of these complications. This management plan did not attempt to safeguard the bony alignment and inherently accepted a variable degree of deformity. Today, the gold standard is operative management with metalwork fixation allowing early mobilization. However, in cases where the patient is unfit for anaesthesia and surgery, we believe that early mobilization with the acceptance of the resulted deformity is the treatment of choice.
The sliding hip screw: the currently available sliding hip screw, also known as compression hip screw or dynamic hip screw, is the result of years of evolution and development. Early implants were fixed-angle devices. It was soon realised that these devices had the disadvantage of implant cut-out and penetration of the joint in impacted fractures while non-union and metalwork failure occurred in cases of poor bony contact. The SHS has the advantage of the controlled fracture impaction through the telescoping lag screw within the barrel of an extramedullary side plate secured on the lateral femoral cortex with screws. An upregulation of fracture healing with reduced metalwork failure were apparent with the use of the SHS.30 A sound surgical technique with correct placement of the lag screw within the proximal femur is vital. Central and deep placement of the screw within the femoral head and neck on both
Surgical management The surgical options for the treatment of the intertrochanteric hip fractures included mainly the Sliding Hip Screw (SHS) and cephalomedullary nails. For the 31.A1 and 31.A2 fractures the SHS is the implant of choice. SHS have shown fewer complications and equal functional outcomes to the intramedullary devices.1,11,12 On the other hand, it is universally acknowledged that the 33.A3 are best treated with an intramedullary device.1 Over the last two decades, however, a dramatic change in the surgeon’s preference for the fixation device used for the treatment of intertrochanteric fractures has occurred. The intramedullary nail fixation rate increased from 3% in 1999 to 67% in 2006 despite the lack of evidence to support such a shift in our
ORTHOPAEDICS AND TRAUMA --:-
2
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Please cite this article in press as: Pountos I, Giannoudis PV, The management of intertrochanteric hip fractures, Orthopaedics and Trauma (2016), http://dx.doi.org/10.1016/j.mporth.2016.03.004
HIP FRACTURES
31.A3 fractures as well as in cases where protection of the femoral shaft is necessary, a long nail should be considered. The role of the distal locking screws is to bear the transferred axial loads, resisting fracture collapse and loss of femoral length. In addition they can provide rotational stability and increased overall stiffness to the device. In cases of fracture collapse or proximal instability, distal interlocking screws can prevent the painful toggling of the nail inside the medullary cavity or even the intra-articular migration of the nail inside the knee joint. On the other hand, distal locking screws add significantly to the operation time, increase the radiation exposure, can irritate the overlying soft tissues and act as a stress riser.1 Despite these potential advantages and disadvantages, the vast majority of cephalomedullary nails are currently locked. This current practise is based mainly on contradicting biomechanical experimental models as clinical evidence is rather limited.1,21,22 Ozkan et al. conducted retrospective case series study involving 24 patients with 31.A1 and 31.A2 fractures treated with unlocked nails. The authors found no significant complications concluding that such device is a successful and acceptable option.23 In conclusion, we believe that in the absence of substantial clinical evidence distal locking should be considered in all nails until future contradicting clinical studies support a shift in our current practice.
anteroposterior and lateral planes facilitates the best possible bony purchase and allow maximal sliding of the plate. Following observations that eccentric placed lag screws are likely to fail, Baumgaertner et al. developed the Tip-Apex distance (TAD) concept.14 The TAD can serve as a strong prognostic factor for screw cut-out.14 TAD is defined as the sum of the distance in millimetres, on anteroposterior and lateral radiographs, from the tip of the threaded lag screw to the apex of the femoral head, with appropriate correction for magnification. Some studies have suggested that values lower than 2 cm are ideal. On the other hand, a TAD greater than 2.5 cm is associated with increased risk for cutout. Some authors also advocate that a slight more caudal placement (central-inferior) of the screw in the anteroposterior plane can provide better support. Based on this concept, a modification of the TAD with the calcar referenced tip-apex distance (CalTAD) was introduced. Some authors suggest that values less than 20.98 mm are ideal.15 The same principles apply to the intramedullary devices for the ideal placement of the lag screw. One variation of the SHS is the Meddoff device, which allows biaxial compression.16 This implant is similar to the SHS, however, the standard femoral plate is replaced with paired sliding components also allowing for compression along the femoral axis. Therefore sliding can be allowed along the femoral neck and femoral shaft angles allowing biaxial dynamization. The available clinical evidence comparing the SHS with the Meddoff device is very limited. It was suggested that in unstable peritrochanteric fractures, a trend to a lower risk of fixation failure might exist, however, a higher blood loss and longer operation times should be expected.17
Proximal femoral locking compression plate: the proximal femoral locking compression plate (PF-LCP) is an alternative option to the SHS and the cephalomedullary nails. It is an anatomically contoured, low-contact, angularly stable construct developed specifically for fractures in the proximal femoral region. It carries multiple locking screw holes and their utilization could increase the mechanical strength of the construct. It has been suggested that PF-LCP fixation can be advantageous in complex proximal femoral fracture fixation including osteoporotic, complex multi-fragmented subtrochanteric fractures, and in cases where revision of the fixation is required. The utilization of the PF-LCP requires the adequate reduction of the bony fragments. Increased theatre time, exposure and blood loss have all been reported. To overcome these issues, a minimally invasive plate osteosynthesis technique can be used. Currently there is lack of robust evidence that PF-LCP can be advantageous in terms of clinical effectiveness in the acute setting; however, we believe that it should be considered as an implant of choice as a rescue option in revision surgery.
Intramedullary nails: since their first appearance in the 80s, the current fourth generation cephalomedullary nails are the result of advances in both clinical and biomechanical research. Intramedullary nailing for intertrochanteric fractures implies the anterograde insertion of a femoral nail with a wide slotted proximal part capable to allow a single or a couple lag screws or blades to be inserted across the femoral neck to the subchondral bone of the femoral head. These nails act as intramedullary splints designed to bare loads till the bone heals and is capable to cope biomechanically. These nails can be short, finishing at the level of the femoral isthmus or extend down to the whole shaft of the femur. Distally there is the option for interlocking screw insertions through the appropriate holes of the nail. Based on the aforementioned options, combinations between short or long and lock or unlocked nails can be used. As far as the length of intramedullary nail is concerned for relatively stable and multifragmented intertrochanteric fractures, there is paucity in the available literature to support the use of a long instead of a short nail. Long nails theoretically could provide a more stable construct, therefore, have fewer complications or re-fracture risk. Such conclusions however have not been reached from several comparative studies.1,18 No difference in terms of the overall clinical effectiveness and complication rates has been reported.18,19 However, longer operation and fluoroscopy times, as well as increased blood loss, were found.19,20 In terms of the 31.A3, only one retrospective study exists which reports similar failure rates with either nails.18 Overall, until proven otherwise in the future, both nail types are valid options in the treatments of stable and multifragmented fractures. In
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Complications of primary fixation Medical complications It is nowadays well recognised that a hip fracture carries a great degree of insult to the human body. Even in patients previously fit and well, the incidence of medical complications following a hip fracture is approximately 20%.6 This figure becomes significantly higher in patients with pre-existing medical problems.6 Cognitive and neurological alterations are common especially in the brief postoperative period. Acute kidney injury and anaemia in the perioperative period can be as high as 25% and 45% respectively, both requiring timely diagnosis and treatment.24,25 Cardiovascular complications including cardiac and thromboembolic events are estimated to occur in approximately 5% of the patients. Heart failure and myocardical ischaemia are
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HIP FRACTURES
with hydroxyapatite could in theory promote ingrowth and increase the extraction torque.29 The available clinical evidence on such approaches is rather limited and inconclusive.29 The surgical management choices for lag screw cut-out include the conversion to a prosthetic hip replacement or the revision of the osteosynthesis. Unipolar, bipolar or total hip replacements may all be acceptable options but are demanding and associated with high complication rates. The maintenance of the appropriate leg length and offset as well as the fixation of the greater trochanter can be challenging. A higher dislocation rate should be expected. Cement containment during the procedure can be problematic and cement extrusion in the acetabulum and femur can occur.28 Revision of the fixation with/without bone augmentation may be beneficial in younger patients. Conservative management should be also considered in high-risk patients.
the most common causes of in-patient mortality. Sepsis including hospital-acquired pneumonia and urinary tract infections affect a significant percentage of patients following a hip fracture fixation and has devastating outcome. It should be noted, that approximately half of the patients who develop a postoperative chest infection will die within 30 days after fixation.6 Surgical complications Lag screw cut-out: overall the surgical complications following an intertrochanteric hip fracture are low. Screw cut-out is the most common complication of both intramedullary and extramedullary fixation methods accounting for 85% of all fixation failures. The reported incidence varies between 1% and 6.3%. The incorrect eccentric placement of the lag screw is deemed to be the most common cause (Figure 2).26e28 Other causes for lag screw cut-out include poor bone stock, inadequate fracture reduction, excessive fracture collapse, and failure of the sliding capacity of the implant. Augmenting the hold of the lag screw with the use of cement or other injectable materials has been suggested. Biomechanical studies have shown an increased stiffness of the overall construct but the limited clinical evidence failed to depict a clear advantage.27 Concerns have been raised regarding the exothermic reaction that occurs which can lead to bone necrosis as well as the inhibition of the sliding potential of the implant. Resorbable augmentation materials have been also studied; once again the favourable biomechanical results could not match the clinical outcomes and the incidence of complications. On a different note, augmenting the hold of the lag screw by external coating
Non-union: non-union following the surgical fixation of a simple intertrochanteric hip fracture is uncommon. The incidence of non-union is higher in multi-fragmented unstable fractures or those where the operative management has been inadequate. Poor impaction and the presence of an osseous gap could jeopardize fracture union. Persistent pain, progressive loss of alignment and fracture of the metalwork, are all suggestive of failure of bony healing. Treatment options include the revision of the fixation accompanied by bone grafting and a valgus osteotomy, or the use of a prosthetic replacement. Other complications: several other complications have been reported in the literature but are less frequent. Deep sited
Figure 2 a, b Eccentric placement of the lag screw leading to screw cut-out postoperatively (c).
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HIP FRACTURES
infection can occur in approximately 1% of the patients.4 Such complication predisposes to a prolonged length of stay in the acute unit and subsequently to a more dependent destination after discharge. Avascular necrosis of the femoral head after peritrochanteric fractures, although rare, range from 0.3% to 1.16%.25,28 No relationship has been found between the fracture configuration or implant location with the development of osteonecrosis of the femoral head. The Z-effect is a complication occurring in proximal femoral nails where two proximal interlocking screws have been inserted. This phenomenon can occur during physiologic loading of the device and is characterised by the lateral migration of the inferior screw and the medial migration of the proximal screw. The actual incidence of this phenomenon is currently unclear as it is reported only when failure of the device occurs. Finally, various implant failures have been reported at case report level including lag screw breakage, plate-screw separation and screw fractures.
8 Hawley S, Javaid MK, Prieto-Alhambra D, et al. REFReSH study group. Clinical effectiveness of orthogeriatric and fracture liaison service models of care for hip fracture patients: population-based longitudinal study. Age Ageing 2016. Epub ahead of print. 9 Evans EM. The treatment of trochanteric fractures of the femur. J Bone Jt Surg Br 1949; 31B: 190e203. 10 Orthopaedic Trauma Association Committee for Coding and Classification. Fracture and dislocation compendium. J Orthop Trauma 1996; 10(suppl 1). veix, 1e154. 11 Anglen JO, Weinstein JN, American Board of Orthopaedic Surgery Research Committee. Nail or plate fixation of intertrochanteric hip fractures: changing pattern of practice. A review of the American Board of Orthopaedic Surgery Database. J Bone Jt Surg Am 2008; 90: 700e7. 12 Reindl R, Harvey EJ, Berry GK, Rahme E, Canadian Orthopaedic Trauma Society (COTS). Intramedullary versus extramedullary fixation for unstable intertrochanteric fractures: a prospective randomized controlled trial. J Bone Jt Surg Am 2015; 97: 1905e12. 13 Queally JM, Harris E, Handoll HH, Parker MJ. Intramedullary nails for extracapsular hip fractures in adults. Cochrane Database Syst Rev 2014. Issue 9. Art. No.: CD004961. 14 Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM. The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Jt Surg Am 1995; 77: 1058e64. 15 Tosounidis TH, Castillo R, Kanakaris NK, Giannoudis PV. Common complications in hip fracture surgery: tips/tricks and solutions to avoid them. Injury 2015; 46(suppl 5): S3e11. 16 Medoff RJ, Maes K. A new device for the fixation of unstable pertrochanteric fractures of the hip. J Bone Jt Surg Am 1991; 73: 1192e9. 17 Parker MJ, Das A. Extramedullary fixation implants and external fixators for extracapsular hip fractures in adults. Cochrane Database Syst Rev 2013. Issue 2. Art. No.: CD000339. 18 Kleweno C, Morgan J, Redshaw J, et al. Short versus long cephalomedullary nails for the treatment of intertrochanteric hip fractures in patients older than 65 years. J Orthop Trauma 2014; 28: 391e7. 19 Hou Z, Bowen TR, Irgit KS, et al. Treatment of pertrochanteric fractures (OTA 31-A1 and A2): long versus short cephalomedullary nailing. J Orthop Trauma 2013; 27: 318e24. 20 Boone C, Carlberg KN, Koueiter DM, et al. Short versus long intramedullary nails for treatment of intertrochanteric femur fractures (OTA 31-A1 and A2). J Orthop Trauma 2014; 28: e96e100. 21 Vopat BG, Kane PM, Mansuripur PK, et al. The effects of distal interlocking screws on torsional stability in three-part intertrochanteric hip fractures. Springerplus 2015; 4: 413. 22 Gallagher D, Adams B, El-Gendi H, et al. Is distal locking necessary? A biomechanical investigation of intramedullary nailing constructs for intertrochanteric fractures. J Orthop Trauma 2013; 27: 373e8. 23 Ozkan K, Unay K, Demircay C, Cakir M, Eceviz E. Distal unlocked proximal femoral intramedullary nailing for intertrochanteric femur fractures. Int Orthop 2009; 33: 1397e400. 24 Ulucay C, Eren Z, Kaspar EC, et al. Risk factors for acute kidney injury after hip fracture surgery in the elderly individuals. Geriatr Orthop Surg Rehabil 2012; 3: 150e6.
Summary Intertrochanteric hip fractures represent one of the most common fracture type encountered in orthopaedic clinical practice. The management of these fractures requires a prompt surgical fixation allowing early mobilization of the patient. Several implants have been developed and the surgeon today has many options for fracture fixation. It is generally acknowledged that the reverse oblique fracture types should be treated with long nails. The remaining of the intertrochanteric fracture types are treated based on the surgeon’s preference as available literature presents comparable results. Complications can occur and are most commonly related to the surgical technique. The surgeons experience and familiarity with the implants are probably the most important variables to avoid such complications. A REFERENCES 1 Kanakaris NK, Tosounidis TH, Giannoudis PV. Nailing intertrochanteric hip fractures: short versus long; locked versus nonlocked. J Orthop Trauma 2015; 29(suppl 4): S10e6. 2 Stevens JA, Rudd RA. The impact of decreasing U.S. hip fracture rates on future hip fracture estimates. Osteoporos Int 2013; 24: 2725e8. 3 Lamb JN, Panteli M, Pneumaticos SG, Giannoudis PV. Epidemiology of pertrochanteric fractures: our institutional experience. Eur J Trauma Emerg Surg 2014; 40: 225e32. 4 Theodorides AA, Pollard TC, Fishlock A, et al. Treatment of postoperative infections following proximal femoral fractures: our institutional experience. Injury 2011; 42(suppl 5): S28e34. 5 Pinilla TP, Boardman KC, Bouxsein ML, Myers ER, Hayes WC. Impact direction from a fall influences the failure load of the proximal femur as much as age-related bone loss. Calcif Tissue Int 1996; 58: 231e5. 6 Roche JJ, Wenn RT, Sahota O, Moran CG. Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: prospective observational cohort study. BMJ 2005; 331: 1374. 7 Hommel A, B a ath C. A national quality registers as a tool to audit items of the fundamentals of care to older patients with hip fractures. Int J Older People Nurs 2015. Epub ahead of print.
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Please cite this article in press as: Pountos I, Giannoudis PV, The management of intertrochanteric hip fractures, Orthopaedics and Trauma (2016), http://dx.doi.org/10.1016/j.mporth.2016.03.004
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€chter A. Complications following the treatment of 28 Hesse B, Ga trochanteric fractures with the gamma nail. Arch Orthop Trauma Surg 2004; 124: 692e8. 29 Moroni A, Faldini C, Pegreffi F, Giannini S. HA-coated screws decrease the incidence of fixation failure in osteoporotic trochanteric fractures. Clin Orthop Relat Res 2004; 425: 87e92. k M, Be hounek J. Complications of dynamic hip 30 Hrubina M, Skota screw treatment for proximal femoral fractures. Acta Chir Orthop Traumatol Cech 2010; 77: 395e401.
25 Carpintero P, Caeiro JR, Carpintero R, Morales A, Silva S, Mesa M. Complications of hip fractures: a review. World J Orthop 2014; 5: 402e11. 26 Li C, Xie B, Chen S, Lin G, Yang G, Zhang L. The effect of local bone density on mechanical failure after internal fixation of pertrochanteric fractures. Arch Orthop Trauma Surg 2016; 136: 223e32. 27 Bartucci EJ, Gonzalez MH, Cooperman DR, Freedberg HI, Barmada R, Laros GS. The effect of adjunctive methylmethacrylate on failures of fixation and function in patients with intertrochanteric fractures and osteoporosis. J Bone Jt Surg Am 1985; 67: 1094e107.
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Please cite this article in press as: Pountos I, Giannoudis PV, The management of intertrochanteric hip fractures, Orthopaedics and Trauma (2016), http://dx.doi.org/10.1016/j.mporth.2016.03.004
The management of intertrochanteric hip fractures
from such falls is 16 times higher to the energy required to fracture the proximal femur.5 However, only a small proportion of such incidences result in a fracture. This suggests that in addition to the poor bone stock, the loss of the body’s protective responses during the fall is crucial. Such responses include inadequate reflexes, loss of local shock absorbers like fat and muscle, as well as prolonged reaction times. The outcome of these fractures is daunting. Following such fracture, the documented mortality is approximately 10% at 30 days, reaching a significant 33% at one year.6 From the survivors, a steep drop in their quality of life is expected characterised by residual pain, loss of the previous functional status, and worsened physical health.7 The expansion of orthogeriatric services and fracture liaison service models for elderly patients can have a beneficial effect on subsequent mortality.8 Nevertheless, preventive measures and rigorous assessment at primary care level are of paramount importance together with the rigorous treatment of osteoporosis and investment in safety measures to reduce falls.
Ippokratis Pountos Peter V Giannoudis
Abstract The intertrochanteric proximal femoral fractures account for a significant amount of today’s orthopaedic surgeon’s workload and pose a challenge for the healthcare system around the globe. A timely surgical management that allows early mobilization is the key in the reduction of the high inherent mortality following these fractures. Several devices are currently available aiming to facilitate such an outcome. This article attempts to review the contemporary understanding of the available clinical evidence on the management options of intertrochanteric hip fractures.
Classification of intertrochanteric hip fractures Evans et al. pioneered the classification of the intertrochanteric hip fractures. In his classification he divided these fractures into stable and unstable configurations recognising the importance of the cortical continuity of the posteromedial wall.9 In the stable fractures, the posteromedial cortex had to remain intact or minimally displaced. The unstable fracture patterns were fractures with higher comminution of the posteromedial cortex. In this classification, Evans introduced a Type 2 unstable subset of fractures that consists of the transverse and the reverse oblique types. More recently, the Orthopaedic Trauma Association (OTA) developed an alphanumeric classification that incorporated the importance of the lateral cortex of the greater trochanter.10 (Figure 1) According to this classification; the fractures are divided into three main groups. The first group (31-A1) includes two part oblique pertrochanteric fractures extending from the greater trochanter to the medial cortex. The lateral cortex of the greater trochanter had to remain intact. Group 2 (31-A2) includes the pertrochanteric multifragmented fractures. This group consists of fractures with an intact lateral cortex of the greater trochanter but with fragmentation of the posteromedial wall. Group 3 (31-A3) includes fractures involving both the medial and lateral cortices. This group includes the reverse oblique fractures.
Keywords Cephalomedullary nail; hip fracture; intertrochanteric fracture; sliding hip screw
Introduction Hip fractures in the elderly represent a major challenge the healthcare systems around the globe have to face.1 Approximately 268 000 hip fractures were reported in the United States and 61 500 in the United Kingdom in 2013.1e4 The impact of these injuries is not limited to the surgical management but extends to all aspects of medical care ranging from the surgical and orthogeriatric medical input, to domains like rehabilitation, psychiatry and social work. Epidemiological trends indicate that their incidence will increase over the following decades, continuing to pose a threat to the health, mobility and independence of older adults.2,3 The intertrochanteric hip fractures represent a significant proportion of proximal femoral fractures ranging from 33% to 50%. The vast majority occur in the elderly population with a higher predominance in females suffering from osteoporosis. Patients who previously sustained an osteoporosis-related fracture are more likely to suffer an intertrochanteric proximal femoral fracture. An association exists between these fractures and the patients’ comorbidities, ambulatory and dependence levels. The mechanism of injury in the majority of the cases is a simple fall with a direct impact to the lateral upper thigh or buttock. Biomechanical data suggest that the energy generated
Management of intertrochanteric hip fractures Non-operative The conservative management of intertrochanteric fractures was the treatment of choice before the 1960s. It involved bed rest in traction for approximately 12 weeks followed by a lengthy rehabilitation program. Traction alone was not sufficient to maintain the position, therefore, a varus deformity and shortening of the affected limb was a common finding. The prolonged bed rest was also associated with numerous complications including pneumonia, urinary tract infections, thromboembolic events and joint contractures, resulting in high morbidity and mortality rates. An alternative non-operative approach with early
Ippokratis Pountos MB BSc MSc MD Hon Lecturer, Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, UK. Conflict of interest: No conflict of interest. Peter V. Giannoudis MD FRCS Professor, Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, UK. Conflict of interest: No conflict of interest.
ORTHOPAEDICS AND TRAUMA --:-
1
Ó 2016 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Pountos I, Giannoudis PV, The management of intertrochanteric hip fractures, Orthopaedics and Trauma (2016), http://dx.doi.org/10.1016/j.mporth.2016.03.004
HIP FRACTURES
Figure 1 The OTA classification.
practice.11 Young orthopaedic surgeons were the driving force for this change. A recent Cochrane systematic review highlighted that current literature can provide rather inconclusive results in terms of the clinical effectiveness of these implants.13 In the absence of robust evidence, the surgeons experience and training as well as the local availability of the implants seem to be the key factors in the selection process for the implants.
mobilisation ‘as pain allowed’ within days after the injury attempted to overcome some of these complications. This management plan did not attempt to safeguard the bony alignment and inherently accepted a variable degree of deformity. Today, the gold standard is operative management with metalwork fixation allowing early mobilization. However, in cases where the patient is unfit for anaesthesia and surgery, we believe that early mobilization with the acceptance of the resulted deformity is the treatment of choice.
The sliding hip screw: the currently available sliding hip screw, also known as compression hip screw or dynamic hip screw, is the result of years of evolution and development. Early implants were fixed-angle devices. It was soon realised that these devices had the disadvantage of implant cut-out and penetration of the joint in impacted fractures while non-union and metalwork failure occurred in cases of poor bony contact. The SHS has the advantage of the controlled fracture impaction through the telescoping lag screw within the barrel of an extramedullary side plate secured on the lateral femoral cortex with screws. An upregulation of fracture healing with reduced metalwork failure were apparent with the use of the SHS.30 A sound surgical technique with correct placement of the lag screw within the proximal femur is vital. Central and deep placement of the screw within the femoral head and neck on both
Surgical management The surgical options for the treatment of the intertrochanteric hip fractures included mainly the Sliding Hip Screw (SHS) and cephalomedullary nails. For the 31.A1 and 31.A2 fractures the SHS is the implant of choice. SHS have shown fewer complications and equal functional outcomes to the intramedullary devices.1,11,12 On the other hand, it is universally acknowledged that the 33.A3 are best treated with an intramedullary device.1 Over the last two decades, however, a dramatic change in the surgeon’s preference for the fixation device used for the treatment of intertrochanteric fractures has occurred. The intramedullary nail fixation rate increased from 3% in 1999 to 67% in 2006 despite the lack of evidence to support such a shift in our
ORTHOPAEDICS AND TRAUMA --:-
2
Ó 2016 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Pountos I, Giannoudis PV, The management of intertrochanteric hip fractures, Orthopaedics and Trauma (2016), http://dx.doi.org/10.1016/j.mporth.2016.03.004
HIP FRACTURES
31.A3 fractures as well as in cases where protection of the femoral shaft is necessary, a long nail should be considered. The role of the distal locking screws is to bear the transferred axial loads, resisting fracture collapse and loss of femoral length. In addition they can provide rotational stability and increased overall stiffness to the device. In cases of fracture collapse or proximal instability, distal interlocking screws can prevent the painful toggling of the nail inside the medullary cavity or even the intra-articular migration of the nail inside the knee joint. On the other hand, distal locking screws add significantly to the operation time, increase the radiation exposure, can irritate the overlying soft tissues and act as a stress riser.1 Despite these potential advantages and disadvantages, the vast majority of cephalomedullary nails are currently locked. This current practise is based mainly on contradicting biomechanical experimental models as clinical evidence is rather limited.1,21,22 Ozkan et al. conducted retrospective case series study involving 24 patients with 31.A1 and 31.A2 fractures treated with unlocked nails. The authors found no significant complications concluding that such device is a successful and acceptable option.23 In conclusion, we believe that in the absence of substantial clinical evidence distal locking should be considered in all nails until future contradicting clinical studies support a shift in our current practice.
anteroposterior and lateral planes facilitates the best possible bony purchase and allow maximal sliding of the plate. Following observations that eccentric placed lag screws are likely to fail, Baumgaertner et al. developed the Tip-Apex distance (TAD) concept.14 The TAD can serve as a strong prognostic factor for screw cut-out.14 TAD is defined as the sum of the distance in millimetres, on anteroposterior and lateral radiographs, from the tip of the threaded lag screw to the apex of the femoral head, with appropriate correction for magnification. Some studies have suggested that values lower than 2 cm are ideal. On the other hand, a TAD greater than 2.5 cm is associated with increased risk for cutout. Some authors also advocate that a slight more caudal placement (central-inferior) of the screw in the anteroposterior plane can provide better support. Based on this concept, a modification of the TAD with the calcar referenced tip-apex distance (CalTAD) was introduced. Some authors suggest that values less than 20.98 mm are ideal.15 The same principles apply to the intramedullary devices for the ideal placement of the lag screw. One variation of the SHS is the Meddoff device, which allows biaxial compression.16 This implant is similar to the SHS, however, the standard femoral plate is replaced with paired sliding components also allowing for compression along the femoral axis. Therefore sliding can be allowed along the femoral neck and femoral shaft angles allowing biaxial dynamization. The available clinical evidence comparing the SHS with the Meddoff device is very limited. It was suggested that in unstable peritrochanteric fractures, a trend to a lower risk of fixation failure might exist, however, a higher blood loss and longer operation times should be expected.17
Proximal femoral locking compression plate: the proximal femoral locking compression plate (PF-LCP) is an alternative option to the SHS and the cephalomedullary nails. It is an anatomically contoured, low-contact, angularly stable construct developed specifically for fractures in the proximal femoral region. It carries multiple locking screw holes and their utilization could increase the mechanical strength of the construct. It has been suggested that PF-LCP fixation can be advantageous in complex proximal femoral fracture fixation including osteoporotic, complex multi-fragmented subtrochanteric fractures, and in cases where revision of the fixation is required. The utilization of the PF-LCP requires the adequate reduction of the bony fragments. Increased theatre time, exposure and blood loss have all been reported. To overcome these issues, a minimally invasive plate osteosynthesis technique can be used. Currently there is lack of robust evidence that PF-LCP can be advantageous in terms of clinical effectiveness in the acute setting; however, we believe that it should be considered as an implant of choice as a rescue option in revision surgery.
Intramedullary nails: since their first appearance in the 80s, the current fourth generation cephalomedullary nails are the result of advances in both clinical and biomechanical research. Intramedullary nailing for intertrochanteric fractures implies the anterograde insertion of a femoral nail with a wide slotted proximal part capable to allow a single or a couple lag screws or blades to be inserted across the femoral neck to the subchondral bone of the femoral head. These nails act as intramedullary splints designed to bare loads till the bone heals and is capable to cope biomechanically. These nails can be short, finishing at the level of the femoral isthmus or extend down to the whole shaft of the femur. Distally there is the option for interlocking screw insertions through the appropriate holes of the nail. Based on the aforementioned options, combinations between short or long and lock or unlocked nails can be used. As far as the length of intramedullary nail is concerned for relatively stable and multifragmented intertrochanteric fractures, there is paucity in the available literature to support the use of a long instead of a short nail. Long nails theoretically could provide a more stable construct, therefore, have fewer complications or re-fracture risk. Such conclusions however have not been reached from several comparative studies.1,18 No difference in terms of the overall clinical effectiveness and complication rates has been reported.18,19 However, longer operation and fluoroscopy times, as well as increased blood loss, were found.19,20 In terms of the 31.A3, only one retrospective study exists which reports similar failure rates with either nails.18 Overall, until proven otherwise in the future, both nail types are valid options in the treatments of stable and multifragmented fractures. In
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Complications of primary fixation Medical complications It is nowadays well recognised that a hip fracture carries a great degree of insult to the human body. Even in patients previously fit and well, the incidence of medical complications following a hip fracture is approximately 20%.6 This figure becomes significantly higher in patients with pre-existing medical problems.6 Cognitive and neurological alterations are common especially in the brief postoperative period. Acute kidney injury and anaemia in the perioperative period can be as high as 25% and 45% respectively, both requiring timely diagnosis and treatment.24,25 Cardiovascular complications including cardiac and thromboembolic events are estimated to occur in approximately 5% of the patients. Heart failure and myocardical ischaemia are
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Please cite this article in press as: Pountos I, Giannoudis PV, The management of intertrochanteric hip fractures, Orthopaedics and Trauma (2016), http://dx.doi.org/10.1016/j.mporth.2016.03.004
HIP FRACTURES
with hydroxyapatite could in theory promote ingrowth and increase the extraction torque.29 The available clinical evidence on such approaches is rather limited and inconclusive.29 The surgical management choices for lag screw cut-out include the conversion to a prosthetic hip replacement or the revision of the osteosynthesis. Unipolar, bipolar or total hip replacements may all be acceptable options but are demanding and associated with high complication rates. The maintenance of the appropriate leg length and offset as well as the fixation of the greater trochanter can be challenging. A higher dislocation rate should be expected. Cement containment during the procedure can be problematic and cement extrusion in the acetabulum and femur can occur.28 Revision of the fixation with/without bone augmentation may be beneficial in younger patients. Conservative management should be also considered in high-risk patients.
the most common causes of in-patient mortality. Sepsis including hospital-acquired pneumonia and urinary tract infections affect a significant percentage of patients following a hip fracture fixation and has devastating outcome. It should be noted, that approximately half of the patients who develop a postoperative chest infection will die within 30 days after fixation.6 Surgical complications Lag screw cut-out: overall the surgical complications following an intertrochanteric hip fracture are low. Screw cut-out is the most common complication of both intramedullary and extramedullary fixation methods accounting for 85% of all fixation failures. The reported incidence varies between 1% and 6.3%. The incorrect eccentric placement of the lag screw is deemed to be the most common cause (Figure 2).26e28 Other causes for lag screw cut-out include poor bone stock, inadequate fracture reduction, excessive fracture collapse, and failure of the sliding capacity of the implant. Augmenting the hold of the lag screw with the use of cement or other injectable materials has been suggested. Biomechanical studies have shown an increased stiffness of the overall construct but the limited clinical evidence failed to depict a clear advantage.27 Concerns have been raised regarding the exothermic reaction that occurs which can lead to bone necrosis as well as the inhibition of the sliding potential of the implant. Resorbable augmentation materials have been also studied; once again the favourable biomechanical results could not match the clinical outcomes and the incidence of complications. On a different note, augmenting the hold of the lag screw by external coating
Non-union: non-union following the surgical fixation of a simple intertrochanteric hip fracture is uncommon. The incidence of non-union is higher in multi-fragmented unstable fractures or those where the operative management has been inadequate. Poor impaction and the presence of an osseous gap could jeopardize fracture union. Persistent pain, progressive loss of alignment and fracture of the metalwork, are all suggestive of failure of bony healing. Treatment options include the revision of the fixation accompanied by bone grafting and a valgus osteotomy, or the use of a prosthetic replacement. Other complications: several other complications have been reported in the literature but are less frequent. Deep sited
Figure 2 a, b Eccentric placement of the lag screw leading to screw cut-out postoperatively (c).
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HIP FRACTURES
infection can occur in approximately 1% of the patients.4 Such complication predisposes to a prolonged length of stay in the acute unit and subsequently to a more dependent destination after discharge. Avascular necrosis of the femoral head after peritrochanteric fractures, although rare, range from 0.3% to 1.16%.25,28 No relationship has been found between the fracture configuration or implant location with the development of osteonecrosis of the femoral head. The Z-effect is a complication occurring in proximal femoral nails where two proximal interlocking screws have been inserted. This phenomenon can occur during physiologic loading of the device and is characterised by the lateral migration of the inferior screw and the medial migration of the proximal screw. The actual incidence of this phenomenon is currently unclear as it is reported only when failure of the device occurs. Finally, various implant failures have been reported at case report level including lag screw breakage, plate-screw separation and screw fractures.
8 Hawley S, Javaid MK, Prieto-Alhambra D, et al. REFReSH study group. Clinical effectiveness of orthogeriatric and fracture liaison service models of care for hip fracture patients: population-based longitudinal study. Age Ageing 2016. Epub ahead of print. 9 Evans EM. The treatment of trochanteric fractures of the femur. J Bone Jt Surg Br 1949; 31B: 190e203. 10 Orthopaedic Trauma Association Committee for Coding and Classification. Fracture and dislocation compendium. J Orthop Trauma 1996; 10(suppl 1). veix, 1e154. 11 Anglen JO, Weinstein JN, American Board of Orthopaedic Surgery Research Committee. Nail or plate fixation of intertrochanteric hip fractures: changing pattern of practice. A review of the American Board of Orthopaedic Surgery Database. J Bone Jt Surg Am 2008; 90: 700e7. 12 Reindl R, Harvey EJ, Berry GK, Rahme E, Canadian Orthopaedic Trauma Society (COTS). Intramedullary versus extramedullary fixation for unstable intertrochanteric fractures: a prospective randomized controlled trial. J Bone Jt Surg Am 2015; 97: 1905e12. 13 Queally JM, Harris E, Handoll HH, Parker MJ. Intramedullary nails for extracapsular hip fractures in adults. Cochrane Database Syst Rev 2014. Issue 9. Art. No.: CD004961. 14 Baumgaertner MR, Curtin SL, Lindskog DM, Keggi JM. The value of the tip-apex distance in predicting failure of fixation of peritrochanteric fractures of the hip. J Bone Jt Surg Am 1995; 77: 1058e64. 15 Tosounidis TH, Castillo R, Kanakaris NK, Giannoudis PV. Common complications in hip fracture surgery: tips/tricks and solutions to avoid them. Injury 2015; 46(suppl 5): S3e11. 16 Medoff RJ, Maes K. A new device for the fixation of unstable pertrochanteric fractures of the hip. J Bone Jt Surg Am 1991; 73: 1192e9. 17 Parker MJ, Das A. Extramedullary fixation implants and external fixators for extracapsular hip fractures in adults. Cochrane Database Syst Rev 2013. Issue 2. Art. No.: CD000339. 18 Kleweno C, Morgan J, Redshaw J, et al. Short versus long cephalomedullary nails for the treatment of intertrochanteric hip fractures in patients older than 65 years. J Orthop Trauma 2014; 28: 391e7. 19 Hou Z, Bowen TR, Irgit KS, et al. Treatment of pertrochanteric fractures (OTA 31-A1 and A2): long versus short cephalomedullary nailing. J Orthop Trauma 2013; 27: 318e24. 20 Boone C, Carlberg KN, Koueiter DM, et al. Short versus long intramedullary nails for treatment of intertrochanteric femur fractures (OTA 31-A1 and A2). J Orthop Trauma 2014; 28: e96e100. 21 Vopat BG, Kane PM, Mansuripur PK, et al. The effects of distal interlocking screws on torsional stability in three-part intertrochanteric hip fractures. Springerplus 2015; 4: 413. 22 Gallagher D, Adams B, El-Gendi H, et al. Is distal locking necessary? A biomechanical investigation of intramedullary nailing constructs for intertrochanteric fractures. J Orthop Trauma 2013; 27: 373e8. 23 Ozkan K, Unay K, Demircay C, Cakir M, Eceviz E. Distal unlocked proximal femoral intramedullary nailing for intertrochanteric femur fractures. Int Orthop 2009; 33: 1397e400. 24 Ulucay C, Eren Z, Kaspar EC, et al. Risk factors for acute kidney injury after hip fracture surgery in the elderly individuals. Geriatr Orthop Surg Rehabil 2012; 3: 150e6.
Summary Intertrochanteric hip fractures represent one of the most common fracture type encountered in orthopaedic clinical practice. The management of these fractures requires a prompt surgical fixation allowing early mobilization of the patient. Several implants have been developed and the surgeon today has many options for fracture fixation. It is generally acknowledged that the reverse oblique fracture types should be treated with long nails. The remaining of the intertrochanteric fracture types are treated based on the surgeon’s preference as available literature presents comparable results. Complications can occur and are most commonly related to the surgical technique. The surgeons experience and familiarity with the implants are probably the most important variables to avoid such complications. A REFERENCES 1 Kanakaris NK, Tosounidis TH, Giannoudis PV. Nailing intertrochanteric hip fractures: short versus long; locked versus nonlocked. J Orthop Trauma 2015; 29(suppl 4): S10e6. 2 Stevens JA, Rudd RA. The impact of decreasing U.S. hip fracture rates on future hip fracture estimates. Osteoporos Int 2013; 24: 2725e8. 3 Lamb JN, Panteli M, Pneumaticos SG, Giannoudis PV. Epidemiology of pertrochanteric fractures: our institutional experience. Eur J Trauma Emerg Surg 2014; 40: 225e32. 4 Theodorides AA, Pollard TC, Fishlock A, et al. Treatment of postoperative infections following proximal femoral fractures: our institutional experience. Injury 2011; 42(suppl 5): S28e34. 5 Pinilla TP, Boardman KC, Bouxsein ML, Myers ER, Hayes WC. Impact direction from a fall influences the failure load of the proximal femur as much as age-related bone loss. Calcif Tissue Int 1996; 58: 231e5. 6 Roche JJ, Wenn RT, Sahota O, Moran CG. Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: prospective observational cohort study. BMJ 2005; 331: 1374. 7 Hommel A, B a ath C. A national quality registers as a tool to audit items of the fundamentals of care to older patients with hip fractures. Int J Older People Nurs 2015. Epub ahead of print.
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€chter A. Complications following the treatment of 28 Hesse B, Ga trochanteric fractures with the gamma nail. Arch Orthop Trauma Surg 2004; 124: 692e8. 29 Moroni A, Faldini C, Pegreffi F, Giannini S. HA-coated screws decrease the incidence of fixation failure in osteoporotic trochanteric fractures. Clin Orthop Relat Res 2004; 425: 87e92. k M, Be hounek J. Complications of dynamic hip 30 Hrubina M, Skota screw treatment for proximal femoral fractures. Acta Chir Orthop Traumatol Cech 2010; 77: 395e401.
25 Carpintero P, Caeiro JR, Carpintero R, Morales A, Silva S, Mesa M. Complications of hip fractures: a review. World J Orthop 2014; 5: 402e11. 26 Li C, Xie B, Chen S, Lin G, Yang G, Zhang L. The effect of local bone density on mechanical failure after internal fixation of pertrochanteric fractures. Arch Orthop Trauma Surg 2016; 136: 223e32. 27 Bartucci EJ, Gonzalez MH, Cooperman DR, Freedberg HI, Barmada R, Laros GS. The effect of adjunctive methylmethacrylate on failures of fixation and function in patients with intertrochanteric fractures and osteoporosis. J Bone Jt Surg Am 1985; 67: 1094e107.
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Please cite this article in press as: Pountos I, Giannoudis PV, The management of intertrochanteric hip fractures, Orthopaedics and Trauma (2016), http://dx.doi.org/10.1016/j.mporth.2016.03.004