Blog Elements – Page 69 – Trauma International

Half Sized Blog Element (Single Author Style)

Half Sized Blog Element (Multi Author Style)

Management Options and Treatment Algorithm in Intertrochanteric Fractures

July 26, 2015/in July Sep | Volume 1 | Issue 1

Vol 1 | Issue 1 | July – Sep 2015 | page: 12-16 | Anoop C Dhamangaonkar [1] Author: Anoop C Dhamangaonkar [1]. [1]Lokmanya Tilak Municipal Medical College and Lokmanya Tilak Municipal General Hospital, Sion, Mumbai- 400022, India. Address of Correspondence Dr. Anoop C Dhamangaonkar 2/28,Madhavi Soc., Mogal Lane, Matunga (W), Mumbai-400016.India. Email: anoopd_7@yahoo.com Abstract Background: Intertrochanteric (IT) […]

Classifications of Intertrochanteric fractures and their Clinical Importance

July 25, 2015/in July Sep | Volume 1 | Issue 1

Vol 1 | Issue 1 | July – Sep 2015 | page: 7-11 | Dhiraj V Sonawane[1]. Author: Dhiraj V Sonawane[1]. [1] Grant Medical College and Sir JJ Group of Hospitals, Mumbai. India. Address of Correspondence Dr. Dhiraj V. Sonawane Asst. Prof. Grant Medical College and Sir JJ Group of Hospitals, Mumbai. Email: dvsortho@gmail.com Abstract Intertrochanteric fractures are […]

Management Options and Treatment Algorithm in Intertrochanteric Fractures

July 26, 2015/in July Sep | Volume 1 | Issue 1

Classifications of Intertrochanteric fractures and their Clinical Importance

July 25, 2015/in July Sep | Volume 1 | Issue 1

Full Sized Blog Element (Big Preview Pic)

Management Options and Treatment Algorithm in Intertrochanteric Fractures

July 26, 2015/in July Sep | Volume 1 | Issue 1

Vol 1 | Issue 1 | July – Sep 2015 | page: 12-16 | Anoop C Dhamangaonkar [1]

Author: Anoop C Dhamangaonkar [1].

[1]Lokmanya Tilak Municipal Medical College and Lokmanya Tilak Municipal General Hospital,
Sion, Mumbai- 400022, India.

Address of Correspondence
Dr. Anoop C Dhamangaonkar
2/28,Madhavi Soc., Mogal Lane, Matunga (W), Mumbai-400016.India.
Email: anoopd_7@yahoo.com

Abstract

Background: Intertrochanteric (IT) fractures are one of the most common lower limb fractures. There are many varied treatment options to treat the same. Also, our basic understanding of IT fractures is improving leading to evolution of newer concepts which in turn is leading to designing of newer implants. In this sea of newer treatment options, are all newer implants merely market driven? The new- age orthopaedic surgeon needs to be made aware of the newer concepts of IT fractures, implant designs and also a comprehensive literature support of the various treatment options available like concept of unstable IT farcture, the dynamic hip screw (DHS) system, Medoff’s plate, DHS with a trochanteric stabilization plate, 95 degree Dynamic Condylar Screw, first to third generations of gamma nails, proximal femoral nails (PFN), expandable PFN, InterTAN with integrated interlocking screws, proximal femoral locking plates and use of bipolar hemiarthroplasty. This article also aims to present a practical treatment algorithm for the treatment of IT fractures, but this may not be generalizable to all orthopaedic surgeons.
Keywords: Intertrochanteric; unstable; DHS; PFN; Gamma; hemiarthroplasty.

Introduction

Intertrochanteric (IT) fractures are disabling injuries that most commonly affect the elderly population and also in young. The incidence has increased significantly during recent years due to the advancing age of the world’s population. These fractures were managed by conservative methods before 1930s when the age of fixation began. Through this article we wish to present the gradual yet sudden transition in various treatment modalities.
Till the third decade of the twentieth century trochanteric fractures were treated conservatively. Conservative treatment regimes included, simple support with pillows or splinting to the opposite limb, Buck’s (skin) traction, Well-leg traction, plaster spica immobilization, Russell’s balanced traction and skeletal traction through the lower femur or upper tibia. Nonsurgical treatment of intertrochanteric hip fractures is not preferred but is usually reserved for patients with comorbidities who are not fit for anesthesia. Mortality after non-operative treatment is commonly due to cardiopulmonary complications, thromboembolism, and sepsis [1]. In 1989, Hornby et al compared the nonsurgical treatment with a dynamic hip screw (DHS) in 106 patients with intertrochanteric hip fracture [2]. There was no significant difference in complications, 6-month mortality, pain, leg swelling, or pressure sores. SHS group gave better anatomic reduction and a shorter hospital stay. Patients treated conservatively had greater loss of independence at 6-month follow-up. The authors recommended surgical treatment for medically stable patients. A 1981 prospective trial of 150 patients compared nonsurgical treatment (ie, skeletal traction with a tibial pin) with surgical treatment [3]. The authors concluded that excellent results with traction alone could be obtained provided a good nursing care was maintained with careful attention to bedside physical therapy, respiratory care, deep vein thrombosis prophylaxis, and prevention of ulcers. A 2003 retrospective study reviewed a population database to compare mortality rates in patients with severe comorbidities who were treated either nonsurgically or surgically for intertrochanteric hip fracture [4]. It concluded that the mortality rate was low in the conservatively treated patients provided the patients were mobilized early out of bed to chair. The evidence-based literature supports surgical fixation while also providing valuable information in regard to medically unstable patients who must be treated nonsurgically [2-4].

Operative treatment options
Era of Dynamic Hip Screw (DHS)
During the early 1950s when the use of Smith Peterson nail and Jewett nail-plate was very common, W. Schumpelick et al. revolutionized treatment of IT fractures by presenting the results of the sliding neck screw of the DHS in 1955 [5]. Here any force acting on the femoral head in the direction of the body axis will be diverted by the sliding neck screw into the direction of the axis of the screw, so that it strikes the fracture line approximately at a right angle and acts not as a shearing but as a compressing force stimulating callus formation. Here too varus collapse, shortening, superior cut-out occurred. But in non-union was rare.

What is an unstable intertrochanteric fracture?
Stable intertrochanteric fracture implies that the reduction is stable with a lesser tendency to collapse further post-operatively. Whereas the unstable IT fractures have a tendency to collapse much more post-operatively, especially in varus and retroversion. Fractures with a large posteromedial void, reverse oblique fracture configuration, IT fractures with subtrochanteric extension and IT fractures with a lateral wall fracture [6-10].
Modifications of DHS:
Two major modifications to the DHS are the Medoff’s plate and the DHS with a trochanteric stabilisation plate.
In 1991, Medoff et al used a new axial compression screw plate device for unstable intertrochanteric or proximal subtrochanteric fractures of the hip with no technical failures [11]. The device has an axial compression screw to allow compression along an axis parallel to the femoral shaft. As the fracture settles postoperatively, dynamic axial compression continues. In 1993, Babst et al. stated that the lateralisation of the greater trochanter could be prevented in all cases with a trochanteric buttress plate being added to the sliding screw-plate [12]. This also leads to a limitation of telescoping, with less shortening even with immediate full weight bearing. Leung F et al concluded that the DHS blade plate was an effective fixation option in elderly osteoporotic patients with intertrochanteric fracture femur where the conventional lag screw was replaced with a helical blade [13]. Here, the helical blade leads to better blade fixation in osteorotic bone by impaction of the cancellous bone while insertion rather than destroying bone while reaming for the DHS lag screw.

Other conventional options:
95 degree DCS or angle blade plate is often used to treat the reverse oblique intertrochanteric fractures as they biomechanically mimic the subtrochanteric fractures. Rosso R et al recommend that the DCS may be used to treat subtrochanteric fractures rather than intertrochanteric fractures [14].

Era of Intramedullary nails:
Gamma Nail:
This was one of the earliest intra-medullary (IM) imlants to be designed in 1988. The premise on which the IM implants were designed were:
1. To reduce the varus strain on the implant while weight bearing by reducing the force arm.
2. To provide a lateral buttress with an IM device to prevent the lateralization of the proximal fragment and control the collapse rather than relying on the integrity of the lateral wall.
Bridle et al in 1991, prospectively compared the dynamic hip screw and the gamma nail in100 intertrochanteric fractures in elderly patients [15]. They found no difference in the operating time, blood loss, wound complications, and stay in hospital or the patient’s mobility. But fractures of the femur in 4 cases were seen in the gamma nail group which required further revision surgery.
Leung KS et al in 1992conducted a randomized study in elderly patients comparing gamma nails and dynamic hip screws and concluded similar final outcome with both, but achieved less surgical trauma, less screening time, less blood loss and earlier rehabilitation with gamma nails [16].
Radford PJ et al prospectively compared the Dynamic hip screw and the Gamma nail for fixing 200 peritrochanteric femoral fractures in elderly patients [17]. There was less intraoperative blood loss and a lower rate of wound complications in the patients treated by the Gamma nail. They however had a high incidence of femoral shaft fractures which were related to the implant design. They did not recommend the use of the Gamma nail for these fractures. Curtis MJ in 1994 assessed the rigidity and strength of fixation provided by intramedullary and extramedullar devices for proximal femoral fractures [18]. Stable and unstable intertrochanteric fractures were studied after fixation with Gamma nail and DHS implants. There was no significant difference in the strength of fixation of stable and unstable intertrochanteric fractures between the Gamma nail and the hip screw, although the Gamma nail provided more rigid fixation. In 2001, Adams CI et al prospectively compared the IM nailing with a DHS and side plate in 400 patients [19]. Revision rates, femoral shaft fractures, and lag screw cutout were slightly higher in the IM nailing group but not statistically significant from the DHS cohort. There was no difference in the early or 1 –year functional outcomes. Ahrengart L et al randomized 426 intertrochanteric fractures to be fixed with either the Gamma nail or a compression hip screw [20]. The surgical time was not significantly different between the two groups. In the Gamma nail group, difficulty was encountered with the distal locking technique. The incidence of cephalic position of the compression screw within the femoral head, screw cutout, and intraoperative fracture were higher in the Gamma nail group. Walking ability was the same in both groups. The authors recommended compression hip screws for less comminuted fractures, reserving Gamma nails for comminuted patterns.
Utrilla AL et al compared the Gamma nail with a compression hip screw in 210 stable and unstable fractures and found no difference in total surgical time [21]. However, the Gamma nail group had a significantly lower postoperative transfusion requirement. Mortality, fracture healing, and intra- and postoperative complication rates were not significantly different between the two groups. In patients with unstable fracture patterns, postoperative ambulation was significantly improved in the Gamma nail group.

Newer Gamma nails:
The Preference to the use of Gamma nail for unstable IT fractures after early 2000 was primarily due to the introduction of second generation Gamma nail called the Trochanteric Gamma Nail (TGN) and the third generation Gamma nail called the Gamma3 Nail (G3). Better implant design led to decreased fracture shaft femur, which was the complication seen in early generation Gamma Nail [22].
The G3 proximal diameter is 15.5 mm, 1.5 mm smaller than TGN (17 mm). G3 design also allows distal dynamic locking screw. But the migration resistance in G3 is lesser than TGN. The main reason for this is the smaller diameter in the G3 lag screw measuring 10.5 mm rather than 12 mm in the TGN [22].
The latest edition to the G3 design is the Gamma3Rotational Control, with the addition of a spreading U-Clip over the cephalic screw which increases the surface area and also the resistance to failure [22].
Clinical studies report better results with G3. Varela-Egocheaga JR et al reported 2 cases of cutout and 1 screw protrusion in 40 patients (7.5%) in a series comparing G3 with an extramedullary device [23]. Andruszkow H et al reported that a TAD should not exceed 25mm and a valgus reduction reduces the chances of screw cut-out [24]. de Grave PW et al [25] reported 2 cases of mechanical failure in 61 patients treated with a Gamma3 nail, and Westacott D and Bould M [26] reported no case of mechanical failure in 36 unstable proximal femoral fractures treated with a long Gamma3 nail. Mingo-Robinet J et al stated that there was no relationship between cutout rate and TAD in TGN and G3 [22]. Though they concluded that Gamma3 Nail has higher cutout rates than TGN in unstable fractures.

Proximal Femoral Nail
In 1996, AO/ASIF developed the proximal femoral nail (PFN) as an intramedullary device for the treatment of unstable per, inter and subtrochanteric femoral fractures.
Pajarinen J et al compared the DHS with a proximal femoral nail (PFN) in 108 patients and the main outcome measure was recovery of ambulation [27]. The patients treated with IM devices had a significantly faster return to preoperative ambulation levels. Nuber S et al evaluated 129 patients with unstable intertrochanteric fractures treated with either a DHS or a PFN [28]. Revision rates were similar between the two groups. However, there was a significantly shorter surgical time, shorter hospital stay, earlier full weight bearing and lesser pain intensity at 6-months post-op in the PFN cohort. Zhang K et al stated in a meta-analysis of six studies including 669 intertrochanteric fractures that the PFN group had significantly less operative time, intraoperative blood loss and length of incision than the DHS group [29]. There was no significant difference in the postoperative infection rate, lag screw cut-out rate, or reoperation rate between the PFN and DHS groups. They concluded stating that PFN is a better implant than DHS.

Newer PFN designs
PFNA-II is the modified PFN design meant to match the Asian proximal femoral morphometry. Expandable PFN was designed to retain the mechanical characteristics of a large-diameter nail, to provide the good torsional stability between the femoral neck and shaft obtained by an expendable peg inserted in the femoral head (especially in cases of poor bone quality), and to avoid the need for interlocking screws. However its long term utility needs further literature support. Elis J et al concluded that the expandable PFN was at least as good as the 95 degree DCS after comparing the EPFN and the 95 degree DCS [30]. Jin YM et al concluded that expandable PFN are better implants than DHS and anatomic plates in treating intertrochanteric fractures [31].

InterTAN
This is a newer intra-medullary fixation device which uses proximal intergrated interlocking screws in a figure of eight position to attain compression of the intertrochanteric fracture site.
Wang Q et al compared the InterTAN and the DHS and concluded that InterTAN significantly reduces the operative time, intra-operative radiation exposure, intra-operative blood loss and postoperative complications [32]. The InterTAN can be used in elderly osteoporotic patients and in and unstable intertrochanteric fractures.
Jiang Y et al stated that a proper pre-operative imaging, reaming is essential before inserting the InterTAN [33]. But an open reduction and internal fixation with DHS be preferred in cases where the reduction is difficult.
Nüchtern JV et al concluded that the InterTAN with two integrated screws was able to withstand higher loads than the Gamma 3 nail [34].

Newer Proximal femoral Locking plates:
Many new designs of proximal femoral locking plates have been used to treat intertrochanteric fractures. But there is not enough literature evidence of they being better than IM implants. Haq RU et al concluded that PFN is a better implant than reverse-distal femoral locking plate for intertrochanteric fractures with a deficient lateral wall [35]. Zhong B et al stated that the proximal femoral locking plates were better for treating subtrochanteric fractures rather than intertrochanteric fractures [36].
Azboy I et al concluded that both proximal femoral locking plate and 95 degree angle blade plate gave equally good results in reverse oblique intertrochanteric fractures. However, angle blade plates were preferred as they were an economical option [37].
Dhamangaonkar AC et al compared the Proximal femoral locking plate with the DHS. They concluded that proximal femoral locking plates decreased the chances of limb shortening and medialisation of the shaft [38].
A recent study by Shen J et al concluded that these plates are an effective and safe method in the treatment of all types of intertrochanteric femoral fractures, but good fracture reduction and ideal positioning of the neck screw are prerequisites for the success of the device [39].

Hemiarthroplasty
Prosthetic hip replacement generally has not been considered a primary treatment option for intertrochanteric fractures. In this setting, prosthetic replacement for intertrochanteric fractures typically requires a more complex surgical procedure to reconstruct the calcar and trochanters with potentially higher morbidity. In the patient with preexisting symptomatic degenerative arthritis and in extremely comminuted osteoporotic intertrochanteric fractures, primary prosthetic replacement may be a better option [40].
Kim Y et al studied 143 hips in 139 octagenarians who underwent a cementless bipolar hemiarthroplasty for intertrochanteric fractures concluded that cementless bipolar hemiarthroplasty appears to be a suitable method for the treatment of intertrochanteric fracture in octogenarians [41]. And recommended that stable fixation of the posteromedial fragment is necessary to avoid stem subsidence. Emami M et al studied 60 patients with IT fractures, compared bipolar hemiarthroplasty and DHS fixation and concluded that in elderly patients with co-morbidities, bipolar hemiarthroplasty was more effective than DHS with better functional status, however there was no difference in pain severity between the two groups [42]. Cankaya D et al compared the functional outcome of cementless versus cemented hemiarthroplasty in 86 elderly patients and concluded that cementless hemiarthroplasty was better in terms of duration of surgery, amount of blood loss and perioperative mortality rates than in the cemented group [43]. But Shen J et al categorically stated after studying 124 patients above 70 years of age, that Internal fixation is preferred as it leads to a higher Harris scores, lesser pain, and better walking ability than those treated with hemiarthroplasty provided there is good and stable reduction, even when severe osteoporosis is present [44]. Tang P et al, after retrospectively studying 303 patients concluded that PFNA was superior to hemiarthroplasty according to the operative statistics, especially the anaesthesia, operation lasting time, blood loss, blood transfusion and the drainage, but there were no significant differences in functional outcome [45]. But the incidences of complications were higher in hemiarthroplasty group. Hemiarthroplasty may still find favor in cases with fracture comminution in elderly with severe osteoporosis or in cases with failed fixation of intertrochanteric fracture [46]. More definative evidence will be needed to stratify the patients who would be benefitted by hemiarthroplasty.

Treatment Algorithm
The American Academy of Orthopaedic Surgeons (AAOS) presented a Clinical Practice Guidelines (CPG) on the management of hip fractures after reviewing above16,000 abstracts and above 1700 full-text articles and came out with 25 evidence-based recommendations. We present here a summary of the same [47].
Apart from the operative decision, the recommendations do suggest important practices like avoiding delays to surgery, decreasing delirium, initiate postoperative physical therapy, nutritional, calcium and vitamin D supplementation and evaluation of osteoporosis.
The next important determinant affecting the operative plan, is the IT fracture configuration- whether stable or unstable. There is equal evidence for the use of either intramedullary implants or sliding hip screws in the treatment of stable intertrochanteric fractures. Though the newer generation orthopaedic surgeonsprefer the use of IM implants due to its percutaneous insertion, lesser operative time and blood loss. Though, the cost of implant, comfort and training of the surgeon determines the choice of implants.
There a strong recommendation to use the IM implants for the unstable IT fractures, especially the ones with a subtrochanteric extension and reverse oblique fracture configuration. There is however not enough literature to suggest use of short or long IM implants and further studies are required to determine the outcome of each.

Clinical Relevance

The most important determinant of treatment of IT fractures is whether the fracture is stable or unstable and advantages of the newer implant designs available to treat IT fractures. Stable fractures may be fixed with either intra-medullary or extra-medullary implants. The treatment of unstable IT fractures needs meticulous pre-operative planning, good intra-operative reduction and use of intra-medullary implants. The surgeon is free to use any design amongst the many intra-medullary implants as per the training and experience of the surgeon. There is as yet no consensus in literature regarding whether to use short or long IM nails. As far as possible fixation of IT fractures is to be attempted rather than a hemiarthroplasty.

References

1. Parker MJ, Handoll HH: Conservative versus operative treatment for extracapsular hip fractures. Cochrane Database Syst Rev 2000; 2: CD000337.
2. Hornby R, Evans JG, Vardon V: Operative or conservative treatment for trochanteric fractures of the femur: A randomized epidemiological trial in elderly patients. J Bone Joint Surg Br 1989; 71:619-623.
3. Bong SC, Lau HK, Leong JC, Fang D, Lau MT: The treatment of unstable intertrochanteric fractures of the hip: A prospective trial of 150 cases. Injury 1981; 13:139-146.
4. Jain R, Basinski A, Kreder HJ: Nonoperative treatment of hip fractures. Int Orthop 2003; 27:11-17.
5. Schumpelick W, Jantzen PM. A new principle in the operative treatment of trochanteric fractures of the femur. J. Bone Joint Surg. Am. 1955; 37; 693-698.
6. Aktselis I, Papadimas D, Fragkomichalos E, et al.. Intramedullary nailing of trochanteric fractures–operative technical tips. Injury. 2012;43:961–965.
7. Haidukewych GJ, Israel TA, Berry DJ. Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg Am. 2001;83-A:643–650.
8. Sims SH. Subtrochanteric femur fractures. Orthop Clin North Am. 2002;33:113–126
9. Gotfried Y. The lateral trochanteric wall: a key element in the reconstruction of unstable pertrochanteric hip fractures. Clin Orthop Relat Res. 2004;425:82–86.
10. Palm H, Jacobsen S, Sonne-Holm S, et al.; Hip Fracture Study Group. Integrity of the lateral femoral wall in intertrochanteric hip fractures: an important predictor of a reoperation. J Bone Joint Surg Am. 2007;89:470–475.
11. Medoff RJ, Maes K. A new device for the fixation of unstable pertrochanteric fractures of the hip. JBoneJoint Surg Am. 1991;73:1192-1199.
12. Babst R et al. The DHS (dynamic hip screw) buttress plate in the management of unstable proximal femoral fractures. Schweiz Med Wochenschr. 1993;123:566-568.
13. Leung F , Gudushauri P, Yuen G, Lau TW, Fang C, Chow SP. Dynamic hip screw blade fixation for intertrochanteric hip fractures. J Orthop Surg (Hong Kong). 2012;20:302-306.
14. Rosso R , Babst R, Marx A, Hess P, Heberer M, Regazzoni P. Proximal femoral fractures. Is there an indication for the condylar screw (DCS)?. Helv Chir Acta. 1992;58:679-82.
15. Bridle SH, Patel AD, Bircher M, Calvert PT . Fixation of intertrochanteric fractures of the femur. A randomised prospective comparison of the gamma nail and the dynamic hip screw. J Bone Joint Surg Br. 1991;73:330-334.
16. LeungKS , So WS, Shen WY, Hui PW. Gamma nails and dynamic hip screws for peritrochanteric fractures. A randomised prospective study in elderly patients. J Bone Joint Surg Br. 1992;74:345-351.
17. Radford PJ, Needoff M, Webb JK. A prospective prolonged comparison of the Dynamic hip screw and the Gamma locking nail. J Bone Joint Surg 1993; 75 : 789-793.
18. Curtis MJ, Jinnah RH, Wilson V. Proximal femoral fractures: A biomechanical study to compare intramedullary and extramedullar/ fixation. J Bone Joint Surg 1994; 25 :99-104.
19. Adams CI, Robinson CM, Court-Brown CM, McQueen MM: Prospective randomized controlled trial of an intramedullary nail versus dynamic screw and plate for intertrochanteric fractures of the femur. J Orthop Trauma 2001; 15:394-400.
20. Ahrengart L, Törnkvist H, Fornander P, et al.: A randomized study of the compression hip screw and Gamma nail in 426 fractures. Clin Orthop Relat Res 2002; 401:209-222.
21. Utrilla AL, Reig JS, Muñoz FM, Tufanisco CB: Trochanteric gamma nail and compression hip screw for trochanteric fractures: A randomized, prospective, comparative study in 210 elderly patients with a new design of the gamma nail. J Orthop Trauma 2005; 19:229-233.
22. Mingo-Robinet J, Torres-Torres M, Martínez-Cervell C, Alonso Del Olmo JA, Rivas Laso JA, Aguado-Hernández Het al. Comparative study of the second and third generation of gamma nail for trochanteric fractures: review of 218 cases. J Orthop Trauma. 2015;29:e85-90.
23. Varela-Egocheaga JR, Iglesias-Colao R, Suarez-Suarez MA, et al.. Minimally invasive osteosynthesis in stable trochanteric fractures: a comparative study between Gotfried percutaneous compression plate and Gamma3 intramedullary nail. Arch Orthop Trauma Surg. 2009;129:1401–1407.
24. Andruszkow H, Frink M, Frömke C, et al.. Tip apex distance, hip screw placement, and neck shaft angle as potential risk factors for cut-out failure of hip screws after surgical treatment of intertrochanteric fractures. Int Orthop. 2012;36:2347–2354.
25. de Grave PW, Tampere T, Byn P, et al.. Intramedullary fixation of intertrochanteric hip fractures: a comparison of two implant designs. A prospective randomised clinical trial. Acta Orthop Belg. 2012;78:192–198.
26. Westacott D, Bould M. Outcome in 36 elderly patients treated with the Gamma3 Long Nail for unstable proximal femoral fracture. Acta Orthop Belg. 2011;77:68–72.
27. Pajarinen J, Lindahl J, Michelsson O, Savolainen V, Hirvensalo E: Pertrochanteric femoral fractures treated with a dynamic hip screw or a proximal femoral nail: A randomised study comparing post-operative rehabilitation. J Bone Joint Surg Br 2005; 87:76-81.
28. Nuber S, Schönweiss T, Rüter A: Stabilisation of unstable trochanteric femoral fractures: Dynamic hip screw (DHS) with trochanteric stabilisation plate vs. proximal femur nail (PFN) [German]. Unfallchirurg 2003; 106:39-47.
29. Zhang K, Zhang S, Yang J, Dong W, Wang S, Cheng Y et al. Proximal femoral nail vs. dynamic hip screw in treatment of intertrochanteric fractures: a meta-analysis. Med Sci Monit. 2014;20:1628-33.
30. Elis J, Chechik O, Maman E, Steinberg EL. Expandable proximal femoral nails versus 95° dynamic condylar screw-plates for the treatment of reverse oblique intertrochanteric fractures. Injury. 2012;43:1313-1317.
31. Jin YM , Chen JP, Li XL, Huang YZ, Yang D. [Retrospective study of comparing the different internal fixation methods in treating intertrochanteric fracture of femur]. Zhongguo Gu Shang. 2008;21:329-332.
32. Wang Q , Yang X, He HZ, Dong LJ, Huang DG. Comparative study of InterTAN and Dynamic Hip Screw in treatment of femoral intertrochanteric injury and wound. Int J Clin Exp Med. 2014;7:5578-5582.
33. Jiang Y, Li J, Dib HH, Li YC.Implantation of INTERTAN™ nail in four patients with intertrochanteric fractures leading to single or comminute fractures: pitfalls and recommendations: a case series. J Med Case Rep. 2014;8:383.
34. Nüchtern JV, Ruecker AH, Sellenschloh K, Rupprecht M, Püschel K, Rueger JM et al. Malpositioning of the lag screws by 1- or 2-screw nailing systems for pertrochanteric femoral fractures: a biomechanical comparison of gamma 3 and intertan. J Orthop Trauma. 2014;28:276-282.
35. Haq RU , Manhas V, Pankaj A, Srivastava A, Dhammi IK, Jain AK. Proximal femoral nails compared with reverse distal femoral locking plates in intertrochanteric fractures with a compromised lateral wall; a randomised controlled trial. Int Orthop. 2014;38:1443-1449.
36. Zhong B , Zhang Y, Zhang C, Luo CF. A comparison of proximal femoral locking compression plates with dynamic hip screws in extracapsular femoral fractures. Orthop Traumatol Surg Res. 2014;100:663-668.
37. Azboy I, Demirtaş A, Gem M, Cakır IA, Tutak Y. A comparison of proximal femoral locking plate versus 95-degree angled blade plate in the treatment of reverse intertrochanteric fractures. Eklem Hastalik Cerrahisi. 2014;25:15-20.
38. Dhamangaonkar AC, Joshi D, Goregaonkar AB, Tawari AA. Proximal femoral locking plate versus dynamic hip screw for unstable intertrochanteric femoral fractures. J Orthop Surg (Hong Kong). 2013;21:317-322.
39. Shen J, Luo F, Sun D, Huang Q1, Xu J, Dong S et al. Mid-term results after treatment of intertrochanteric femoral fractures with percutaneous compression plate (PCCP). Injury. 2015;46:347-357.
40. Parker MJ, Handoll HH: Replacement arthroplasty versus internal fixation for extracapsular hip fractures. Cochrane Database Syst Rev 2000; :CD000086.
41. Kim Y, Moon JK, Hwang KT, Choi IY, Kim YH. Cementless bipolar hemiarthroplasty for unstable intertrochanteric fractures in octogenarians. Acta Orthop Traumatol Turc. 2014;48:424-430.
42. Emami M , Manafi A, Hashemi B, Nemati A, Safari S. Comparison of intertrochanteric fracture fixation with dynamic hip screw and bipolar hemiarthroplasty techniques. Arch Bone Jt Surg. 2013;1:14-17.
43. Cankaya D, Ozkurt B, Tabak AY. Cemented calcar replacement versus cementless hemiarthroplasty for unstable intertrochanteric femur fractures in the elderly. Ulus Travma Acil Cerrahi Derg. 2013;19:548-553.
44. Shen J, Wang DL, Chen GX, Yang HL, Li L, Wei MX et al. Bipolar hemiarthroplasty compared with internal fixation for unstable intertrochanteric fractures in elderly patients. J Orthop Sci. 2012;17:722-729.
45. Tang P, Hu F, Shen J, Zhang L, Zhang L. Proximal femoral nail antirotation versus hemiarthroplasty: a study for the treatment of intertrochanteric fractures. Injury. 2012;43:876-881.
46. Sancheti Kh, Sancheti P, Shyam A, Patil S, Dhariwal Q, Joshi R. Primary hemiarthroplasty for unstable osteoporotic intertrochanteric fractures in the elderly: A retrospective case series. Indian J Orthop. 2010 Oct;44(4):428-34
47. Roberts KC, Brox WT.From Evidence to Application: AAOS Clinical Practice Guideline on Management of Hip Fractures in the Elderly. J Orthop Trauma. 2015;29:119-120.

How to Cite this article: Dhamangaonkar AC. Management Options and Treatment Algorithm in Intertrochanteric Fractures. Trauma International July-Sep 2015;1(1):12-16.

(Abstract) (Full Text HTML) (Download PDF)

Classifications of Intertrochanteric fractures and their Clinical Importance

July 25, 2015/in July Sep | Volume 1 | Issue 1

Vol 1 | Issue 1 | July – Sep 2015 | page: 7-11 | Dhiraj V Sonawane[1].

Author: Dhiraj V Sonawane[1].

[1] Grant Medical College and Sir JJ Group of Hospitals, Mumbai. India.

Address of Correspondence
Dr. Dhiraj V. Sonawane
Asst. Prof. Grant Medical College and Sir JJ Group of Hospitals, Mumbai.
Email: dvsortho@gmail.com

Abstract

Intertrochanteric fractures are one of the most common fractures encountered by an orthopaedic Surgeon. Many attempts to classify these fractures are made and different scientific rationale are applied by various authors. Here we tried to provide an overview of both old and new classification of intertrochanteric fractures and also provide with the clinical significance of the same
Keywords: intertrochanteric fractures, hip fractures, classifications

Introduction

Intertrochanteric (IT) fractures are most common fractures seen in elderly osteoporotic, usually due to simple fall in the house. With increasing number of elderly patients its number is estimated to be double by 2040 [1]. Understanding important factors in management of IT fracture like stability, reduction, role of posteriomedial wall, lateral wall, will help in choosing implant for better outcome. Most classifications are based on these factors and help in selecting management protocols. Many classification systems have come from last 6 decades, but none of them are found to be unanimously acceptable worldwide. Few classifications have focussed on stability and anatomical pattern (Evans; Ramadier; Decoulx; & Lavarde) while others on maintaining reduction of various types (Jensen’s modification of Evan’s, Ender; Tronzo, AO).
An ideal classification should be simple, reproducible, easy to apply and should provide information on stability after reduction, secondary displacement, technique of fixation, postoperative mobilisation, outcome, and also data organisation for research. It should have good interrater and intrarater reliability and validity.
Classification Review:
Various classifications in Intertrochanteric fractures:
Evans Classification [2] (Fig 1):
In 1949, Evans published his classification on intertrochanteric (IT) fractures as follows:
Type I:
Stable:
-Undisplaced fractures.
-Displaced but after reduction overlap of the medial cortical buttress make the fracture stable.
Unstable:
-Displaced and the medial cortical buttress is not restored by reduction of fracture.
-Displaced and comminuted fractures in which the medial cortical buttress is not restored by reduction of the fracture.
Type II: Reverse obliquity fractures.

Clinical importance: This helped in better understanding of intertrochanteric fractures based on stability of fracture after close reduction and skeletal traction. According to Evans, posterior-medial cortex continuation is important for restoring stability of IT fractures. Based on this he classified IT fractures into Stable and Unstable fractures. Stable fractures have intact or minimally communited posteriomedial cortex, while Unstable fracture has greater communition of posteriomedial cortex. Unstable fractures after reduction can be converted to stable fracture if the posteriomedial cortex opposition can be achieved. Reverse oblique pattern was considered inheritably unstable fracture as distal femur has tendency to drift medially due adductor pull.

Jensen’s Modification of the Evans Classification [3] (Fig. 2):
Jansen (1975 ) later modified Evans classification into three groups.
Displaced or undisplaced stable 2-fragment fractures, Unstable 3-fragment fractures with greater or lesser trochanter fracture and 4-fragment fractures

Clinical Importance: the classification reduced the number of types from 6 to 5 by including the extremely rare fracture with a reversed oblique fracture line and large greater trochanter fragment into Type 3. Modification of the Evans system offers the best prediction of the possibility of obtaining reliable anatomical reduction and the risk of secondary fracture dislocation.
Kyle’s Classification [4] (Fig. 3):

Type I fractures consist of nondisplaced stable intertrochanteric fractures without comminution.
Type II fractures represent stable, minimally comminuted but displaced fractures; these are the fractures that, once reduced, allow a stable construct. Stable fractures are not a problem and hold up well with any type of fixation device.
Type III intertrochanteric fracture is a problem fracture and has a large posteromedial comminuted area.
Type IV fracture is uncommon and consists of an intertrochanteric fracture with a subtrochanteric component. This is the most difficult type of fracture to fix because of the great forces imposed by muscle forces and weight bearing on the subtrochanteric region of the femur.
Clinical Importance: Addition of new variant (type 4) extension of intertrochanteric fracture in neck.

AO/ Orthopaedic Trauma Association (OTA) Alphanumeric Classification [5] (1980-1987) (Fig. 4): Fig 4
In the Comprehensive Classification of Fractures of the Long Bones, Müller and colleagues coded proximal hip fractures to offer a uniform alphanumeric fracture classification. This system was advocated by the AO/ASIF, and later adopted by OTA in their Fracture Compendium.
According to AO/OTA alphanumeric classification intertrochanteric fractures (Type 31A) Bone = femur = 3,Segment = proximal = 1,Type = A1, A2, A3 A1: 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.
A2: 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
A3: fractures are those in which the fracture line extends across both the medial and lateral cortices; this group includes the reverse obliquity pattern or subtrochanteric extensions.
31-A Femur, proximal trochanteric
31-A1 Peritrochanteric simple
31-A1.1 Along intertrochanteric line
31-A1.2 Through greater trochanter
31-A1.3 Below lesser trochanter
31-A2 Peritrochanteric multifragmentary
31-A2.1 With one intermediate fragment
31-A2.2 With several intermediate fragments
31-A2.3 Extending more than 1 cm below lesser trochanter
31-A3 Intertrochanteric
31-A3.1 Simple oblique
31-A3.2 Simple transverse
31-A3.3 Multifragmentary.
Clinical importance: This helps in predicting prognosis and suggests treatment for the entire spectrum of IT fractures. Fractures A1.1 through A2.1 are commonly described as stable, and fractures A2.2 through A3.3 usually are unstable.
Generally, the Evans-Jensen type I fracture is represented by the 31-A1 group. Evans-Jensen type II fractures are in the 31-A2 group. The so-called reverse obliquity intertrochanteric fracture is in group 31-A3. It’s alphanumeric and standardized format make this system useful, particularly for research and documentation.

Boyd and Griffin Classification (1949) [6] (Fig. 5):
They were first to mention instability in both coronal and sagittal plane. This classification, included fractures from the extracapsular part of the neck to a point 5 cm distal to the lesser trochanter.
Type 1: Fractures that extend along the intertrochanteric line.
Type 2: Comminuted fractures with the main fracture line along the intertrochanteric line but with multiple secondary fracture lines (may be in coronal plane).
Type 3: Fractures that extend to or are distal to the lesser trochanter.
Type 4: Fractures of the trochanteric region and proximal shaft with fractures in at least two planes.

Clinical importance:
Type 1- Reduction usually is simple and is maintained with little difficulty. Results generally are satisfactory
Type 2- Reduction of these fractures is more difficult because the comminution can vary from slight to extreme
Type 3- these fractures usually are more difficult to reduce and result in more complications at operation and during convalescence.
Type 4- if open reduction and internal fixation are used, two-plane fixation is required because of the spiral, oblique, or butterfly fracture of the shaft.

Tronzo’s classification [7] (1973) (Fig. 6):

Tronzo incorporated Boyds and Griffin two plane instability in classification.
Type 1: Incomplete fractures
Type 2: Uncomminuted fractures, with or without displacement; both trochanters fractured
Type 3: Comminuted fractures, large lesser trochanter fragment; posterior wall exploded; neck beak impacted in shaft
Type 3 Variant: As above, plus greater trochanter fractured off and separated
Type 4: Posterior wall exploded, neck spike displaced outside shaft
Type 5: reverse obliquity fracture, with or without greater trochanter separation

Clinical importance:
This system is complex to use & not adequate to apply in clinical practice. It has poor reliability, though can be used for documentation of long-term results and comparison of treatment modality. Yet many surgeons prefer it for its simplicity and biomechanical rationale.

The Ramadier’s Classification[8](Fig. 7): Fig 7
A: Cervico-trochanteric fractures- with a fracture line at the base of the femoral neck
b: Simple pertrochanteric fractures- fracture line that runs parallel to the intertrochanteric line; frequently, the lesser trochanter is broken off
c: Complex pertrochanteric fractures have an additional fracture line that separates most of the greater trochanter from the femoral shaft; the lesser trochanter is often fractured
d: Pertrochanteric fractures with valgus displacement- fracture line that begins on the greater trochanter and finishes below the lesser trochante
e: Pertrochanteric fractures with an intertrochanteric fracture line
f: Trochantero-diaphyseal fractures- spiral line through the greater trochanter and into the proximal shaft often with 3rd fragment.
G: Subtrochanteric fractures- more or less horizontal fracture line that runs below the two trochanters

Decoulx and Lavarde’s classification [9](1969):Simple anatomical classification for descriptive purposes.
Cervico-trochanteric fractures
Pertrochanteric fractures
Intertrochanteric fractures
Subtrochanteric fractures
Subtrochantero-diaphyseal fractures
The Briot Classification Diaphyseo-Trochanteric Fractures [10] (1980) (Fig. 8):
A Evans’ reversed obliquity fracture
B “Basque roof” fractures
C Boyd’s “steeple” fracture
D Fractures with an additional fracture line ascending to the intertrochanteric line
E Fractures with additional fracture lines radiating through the greater trochanter
Briot’s posterior plate fractures
Note: Boundaries of posterior plate, Maximum extent of plate, Possible fracture lines
Clinical importance: Its simple and based on biomechanical concept. Briot’s found posterior wall fracture is important for sagittal instability and external rotation sometimes causing malunion in external rotation. Reduction can be done in these by internal rotation reducing the anterior gap while realign the posterior fractured wall.

Ender Classification(1970)[11] (Fig. 10):
Trochanteric eversion fractures
-1. Simple fractures
-2. Fractures with a posterior fragment
-3 Fractures with lateral and proximal displacement
3. trochanteric inversion fractures
-4. With a pointed proximal fragment spike
-5 .With a rounded proximal fragment beak
6. Intertrochanteric fractures
Subtrochanteric fractures
-7 and 7a Transverse or reversed obliquity fractures
-8 and 8a Spiral fractures
Clinical importance: This classification gives information on injury mechanism, which can be helpful to reduce fracture while performing closed nailing.

Dr G. S. Kulkarni et al Classification / Modified Jenson-Evan’s Classification[1] (Fig 11):
Dr G.S. Kulkarni et al [1] published his new classification in intertrochanteric fractures based on AO & Evan-Jansen classification. He added new varieties of intertrochanteric fractures described by Gotfried[12] and Kyle [4]. This classification is treatment oriented and will help in deciding the implant according to the fracture type.
Type IA- stable undisplaced.
Type IB- stable minimally displaced.
Type IC- stable minimally displaced with a small fragment of lesser trochanter.
Type IIA- unstable 3 piece fracture with large posteromedial fragment of lesser trochanter.
Type IIB- 4 piece fracture.
Type C- Shattered lateral wall.
Type IIIA- trochanteric fracture with extension into subtrochanter.
Type IIIB- reserve oblique.
Type IIIC- trochanteric fracture with extension into femoral neck area.

Clinical Importance: Classification helps in selecting treatment protocols as below.
Type I: This stable fractures can be managed by any fixation modality gives excellent results. DHS is implant of choice.
Type II: These unstable fractures are described as problem fractures can be managed with DHS with some modification or IMN.
Type III: This very unstable fracture with DHS gives poor results. In these type with lateral wall fracture use of DHS lead to excessive collapse, pain, restricted mobility in hip, sometime non union and failure. Intramedullary nails (IMN) are better choice as they prevents excessive collapse at fracture site, better restoration of anatomy and biomechanically stronger implants; Arthroplasty can also be done in select cases. Unusual fracture pattern like basi-cervical fractures extension can be fixed with additional derotation screw as these are also rotationally unstable. Reverse oblique pattern like fracture lateral wall are better fixed with IMN.
Conclusion:
Various classifications have been proposed over years described the fracture patterns, focusing on importance of posteriomedial and lateral wall for stability. Tronzo classification is found to be less reliable and not useful in clinical practice. AO/OTA and Dr G.S. Kulkarni et al modified classification has described in detail the preferred implant according to the fracture type. An AO/OTA group has good reliability but subgroup assessment has poor reliability; it is more useful in record keeping, deciding management and research. Kulkarni et al classification is found to be more simple & easy to apply in practice, record keeping and research. There is still no consensus on the best classification but with new biomechanical informations coming through, the classification systems would continue to evolve.

References

1. GS Kulkarni, Rajiv Limaye, Milind Kulkarni, Sunil Kulkarni. Current Concept review: Intertrochanteric fractures. Indian Journal of Orthopaedics.2006;40:16-23.
2. Evans, E. M. () The treatment of trochanteric fractures of the femur. J. Bone Jt Surg. 1949;31-B: 190-203.
3. Jensen J. S. Classification of trochanteric fractures. Actaorthop. Scand. 1980; 51:803-810.
4. Kyle R. F., Gustilo R. B. And Premer R. F. Analysis of six hundred and twenty-two intertrochantenc hip fractures. J. Bone joint(Am). 1979;61: 216-21.
5. M.E. Muller, S. Nazarian, P. Koch, J. Schatzker The comprehensive classification of fractures of long bones Springer, Berlin. 1990.
6. Boyd HB, Griffin LL. Classification and treatment of trochanteric fractures. Arch Surg. 1949; 58:853.
7. Tronzo RG. Symposium on fractures of the hip. Special considerations in management. Orthop Clin North Am. 1974; 5(3): 571–583.
8. M. Bombart, J.O. Ramadier Trochanteric fractures Rev Chir Orthop, 52 (1966), 353–374.
9. Decoulx P, Lavarde G. Fractures of the trochanteric region. A statistical study of 2,612 cases. J Chir (Paris). 1969; 98(1):75-100.
10. Briot B. Fractures per-trochantériennes: anatomie pathologique et classification. Cahiers d’Enseignement de la SOFCOT Expansions Sci Franc.1980;12: 69-76.
11. J. Ender Per- und subtrochantere Oberschenkelbrüche. Hefte Unfallheilk;1970:106, 2–11.
12. Gotfried Y. The lateral trochanteric wall. Clin Orthop. 2004; 425:.82-86.

How to Cite this article: Sonawane DV. Classifications of Intertrochanteric fractures and their Clinical Importance. Trauma International July-Sep 2015;1(1):7-11

Half Sized Blog Element (Single Author Style)

Half Sized Blog Element (Multi Author Style)

Management Options and Treatment Algorithm in Intertrochanteric Fractures

Classifications of Intertrochanteric fractures and their Clinical Importance

Management Options and Treatment Algorithm in Intertrochanteric Fractures

Classifications of Intertrochanteric fractures and their Clinical Importance

Full Sized Blog Element (Big Preview Pic)

Management Options and Treatment Algorithm in Intertrochanteric Fractures

Author: Anoop C Dhamangaonkar [1].

Abstract

Introduction

Clinical Relevance

References

(Abstract) (Full Text HTML) (Download PDF)

Classifications of Intertrochanteric fractures and their Clinical Importance

Author: Dhiraj V Sonawane[1].

Abstract

Introduction

References

(Abstract) (Full Text HTML) (Download PDF)

Contact

Important Links

LICENSE