Journal of Orthopaedic Trauma Publish Ahead of Print DOI: 10.1097/BOT.0000000000000369
Evaluation and Management of an Unstable Intertrochanteric Fracture of the Femur: A case report Harish Kempegowda, MS; Akhil Tawari, MS; Michael Suk, MD JD MPH FACS, Daniel S.
D
Horwitz, MD*
*Corresponding Author
PA 17822-2130, USA Tel: 570-271-6541 Fax: 570-271-5872
EP
Email Address: [email protected]
TE
Department of Orthopaedic Surgery, Geisinger Medical Center, 100 N. Academy Ave, Danville,
Conflict of Interest: Dr. Horwitz is a consultant and receives royalties from Biomet. Remaining authors declare no conflicts.
C C
No reproduced copyrighted materials are used within this manuscript.
Add Footnote under Reprints Information:
A
The views and opinions expressed in this case report are those of the authors and do not necessarily reflect the views of the editors of Journal of Orthopaedic Trauma or Biomet.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
1
Introduction:
2
Unstable intertrochanteric fractures (IT) are relatively common injuries among the geriatric
3
population.1,
4
integrity, intertrochanteric fractures with sub trochanteric extension and the reverse oblique
5
pattern are considered unstable.2,
6
hardware failure, non-union, malunion, limb length discrepancy and diminished abductor lever
7
strength.4 The increase in the incidence of complications has led to an extension of the
8
definition of instability to include lateral wall blow out, greater trochanteric fracture and
9
osteoporosis.4, 5 The preoperative identification of an unstable pattern is of utmost importance
As per the most commonly used Evans classification, loss of posteromedial 3
The complications following internal fixation include
TE
D
2
in reducing complications.
11
Many fixation methods have been described to treat intertrochanteric fractures, of which the
12
sliding hip screw and intramedullary devices (IMDs) have stood the test of time.
13
Biomechanical and clinical studies show a clear advantage of intramedullary devices over
14
sliding hip screws in fixation of unstable fracture patterns.6, 7 The evolution of nailing systems
15
began with the first generation gamma nail (Stryker, NJ) in the 1980s and has progressed to
16
current fourth generation nails.8, 9
17
Clinical scenario:
18
A 63-year-old female presented to the emergency room with 10/10 pain in her left hip
19
subsequent to fall at home. She had a known diagnosis of osteoporosis for which she was on
20
regular calcium, vitamin D supplements and once yearly bisphosphonates. She was non-
21
hypertensive, non-smoker and denied any other significant past medical or surgical illnesses. A
22
focused clinical examination revealed a left lower extremity in extreme external rotation,
24
C C
A
23
EP
10
shortening and generalized hip pain. Diagnostic assessment:
25
Plain radiographs anteroposterior view (AP) and cross table lateral view of the left hip,
26
traction-internal rotation view and a CT scan with 3D reconstruction were obtained. These
27
revealed a loss of posteromedial continuity, sub trochanteric extension, greater trochanteric
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
comminution and a fracture line extending up to the femoral neck, making this injury highly
29
unstable.(Fig.1A, 1B, 1C, 1D & 1E)
30
Treatment:
31
Considering the highly unstable nature of the fracture, the authors chose to proceed with long
32
intramedullary nailing. Closed reduction was attempted with longitudinal traction followed by
33
internal rotation but was unable to correct posterior sag and medialization of the femoral neck.
34
Based on this, the decision was made to perform an open reduction. 10 The posterior sag was
35
corrected using a posteriorly placed Cobb elevator and the medialization of the femoral neck was
36
corrected using a bone hook. The reduction thus obtained was maintained by using a coaxial
37
clamp (Fig. 2A). The intraoperative fluoroscopic images revealed an acceptable alignment of the
38
femoral head and neck with the shaft without any varus or medialization of femoral neck. An
39
incision was made proximal to the tip of the greater trochanter and an entry wire was placed 1
40
mm medial to the tip of greater trochanter to avoid damage to abductors and to promote valgus
41
reduction.11 The entry wire position was confirmed on AP and true lateral fluoroscopic views
42
and advanced into the medullary canal. After advancement of the wire, the position was
43
confirmed on AP and true lateral fluoroscopic views. The entry reamer was then used to gain
44
access to the medullary canal and the entry wire was removed. The reduction was maintained
45
with the reduction forceps throughout the procedure and a ball tipped guide wire was introduced
46
into the proximal femoral canal and advanced down the distal femur. Its position was confirmed
47
distally on AP and lateral views. The femoral canal was sequentially reamed up to 11 mm and a
48
9 mm x 360 mm nail was then placed over the guide wire and seated distally by hand. At this
49
point, central-central position of a compression screw guide wire in the femoral head was
50
obtained, screw length was determined, a step drill was used over the guide wire and an
52 53
TE
EP
C C
A
51
D
28
appropriate sized compression screw was placed. Due to concern for possible rotational instability the guide wire for a derotation screw was placed to provide provisional stability during compression screw advancement. The compression screw was rotationally locked with a
54
set screw device but was allowed to collapse. A ball-spiked pusher was placed laterally to
55
impact the fracture (Fig. 2B). At this point, traction was released and compression was achieved
56
which further increased rotational stability. The construct then underwent live fluoroscopic
57
evaluation on the lateral view and rotational stability was confirmed. Based on this it was felt
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
that the compression screw alone would provide adequate rotational stability and a derotation
59
screw was not required. Finally, a single distal interlock screw was placed. The intraoperative
60
images after the placement of the nail showed excellent neck shaft alignment, minimal fracture
61
gap and no significant medialization of femur neck (Fig. 3A, 3B).
62
Follow- up and outcomes:
63
Postoperatively the patient was made weight bearing as tolerated. Radiographs obtained at 6
64
weeks showed further impaction at the fracture site as anticipated. The patient was encouraged to
65
continue to mobilize and began outpatient physical therapy stressing aerobic conditioning, gait
66
training and balance exercises as the fracture showed excellent evidence of healing and well
67
positioned hardware. At one year post op, there was minimal limb length discrepancy without
68
any obvious deformity and radiographs showed overall excellent alignment with a well healed
69
fracture (Fig. 4A, 4B).
70
Discussion:
71
Intertrochanteric fractures are considered unstable when any of the following features are
72
present: posteromedial discontinuity, sub trochanteric extension, reverse oblique pattern,
73
greater trochanter comminution and lateral wall insufficiency. In addition, osteoporosis leads to
74
further instability.1, 2, 4, 5 Intertrochanteric fractures occur in metaphyseal regions, so healing is
75
rarely a major problem, but late complication including malunion, shortening of the limb, and
76
external rotation deformity can all significantly affect post-surgical ambulation.4
77
In this patient, the initial plain radiographs revealed a peritrochanteric fracture but the specifics
78
of the injury pattern were difficult to assess (Fig.1A, 1B). The addition of a traction view and
79
CT scan with 3D reconstruction were of great value in evaluating this injury (Fig. 1C, 1D). CT
81
TE
EP
C C
A
80
D
58
scan is not advisable in each case, but we recommend only if there is a complex fracture where specifics of injury pattern cannot be defined even on a traction view. Ideal preoperative
82
planning begins with classification and, as per the OTA classification, this case belongs to the
83
unstable intertrochanteric 31-A3.3 group.12 To address the complexity and instability in this
84
injury, a long cephalomedullary nail was chosen. A major key to success in this case was the
85
intraoperative reduction of the fracture as earlier described, and utilization of the dynamic
86
property of the implant which led to solid union. In this case further collapse at the fracture site
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
87
could be seen at 6 weeks, as was anticipated, and complete healing was evident at the end of
88
four months (Fig. 4A, 4B).
89
Historically, displacement osteotomies were considered as standard treatment for unstable IT
90
fractures, however later studies showed no advantage in comparison to anatomical fixation. 13,
91
14
92
screw was the implant of choice, but this is associated with significant soft tissue stripping and
93
only a 17% increase in the fixation strength.15 The greater trochanter constitutes the lever arm
94
of the abductor mechanism, so near anatomical fixation is necessary for normal hip function. In
95
this case, even though the greater trochanter appeared to be comminuted, it was felt that the
96
abductor mechanism was intact. If components of the greater trochanter are widely displaced,
97
we would advise open reduction and suture fixation of fragments to whatever implant is
98
chosen.
99
The cost effective analysis, biomechanical studies and clinical outcomes suggests IMDs are
100
better devices for unstable intertrochanteric fractures.16 The earlier generation nails were
101
associated with multiple problems including shaft fracture at the end of nail, screw cut out and
102
femoral neck fracture after hardware removal.8 The newer generation nails are associated with
103
significantly fewer complications; however, some issues such as femoral neck fracture after
104
implant removal continue to exist.
105
earlier mobilization and less limb shortening, both of which may enhance the patient’s general
106
well-being. 17
107
In conclusion, preoperative identification of the unstable fracture pattern with proper
108
radiological investigations, selection of the most suitable implant based on fracture pattern,
109
achieving and maintaining reduction during nail placement and early postoperative
D
TE
EP
The advantage of an intramedullary device also includes
C C
9
A
110
To restore the medial buttress, extra screws or circlage wire would be necessary if a sliding
mobilization will maximizes the patient’s recovery in an unstable intertrochanteric fracture.
REFERENCES
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
148 149 150 151 152
1. Koval KJ, Zuckerman JD. Intertrochanteric fractures. In: Bucholz RW, Heckman JD. Fractures in Adults. 5th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2001:1635– 1663. 2. Evans EM. The treatment of trochanteric fractures of the femur. J Bone Joint Surg Br. 1949 May; 31B:190-203.
D
3. Jensen JS. Classification of trochanteric fractures. Acta Orthop Scand. 1980; 51:803–810.
TE
4. Im GI, Shin YW, Song YJ. Potentially unstable intertrochanteric fractures. J Orthop Trauma. 2005 Jan; 19:5-9.
5. Weon-Yoo Kim, Chang-Hwan Han, Jin-Il Park, Jin-Young Kim, Failure of intertrochanteric fracture fixation with a dynamic hip screw in relation to pre-operative fracture stability and osteoporosis. International Orthopaedics December 2001; 25: 360-362.
EP
6. Curtis MJ, Jinnah RH, Wilson V, Cunningham BW. Proximal femoral fractures: a biomechanical study to compare intramedullary and extramedullary fixation.Injury. 1994; 25:99-104. 7. Al-yassari G, Langstaff RJ, Jones JW, Al-Lami M. The AO/ASIF proximal femoral nail (PFN) for the treatment of unstable trochanteric femoral fracture. Injury. 2002; 33:395-9.
C C
8. Albareda J, Laderiga A, Palanca D, Paniagua L, Seral F. Complications and technical problems with the gamma nail. Int Orthop. 1996; 20:47-50. 9. Xu Yaozeng, Geng Dechun, Yang Huilin, Zhu Guangming, Wang Xianbin. Comparative study of trochanteric fracture treated with the proximal femoral nail anti-rotation and the third generation of gamma nail Injury. 2010; 41:1234–1238. 10. Afsari A, Liporace F, Lindvall E, Infante A Jr, Sagi HC, Haidukewych GJ. Clamp-assisted reduction of high subtrochanteric fractures of the femur. J Bone Joint Surg Am. 2009; 91:1913-8.
A
111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147
11. Ostrum RF, Marcantonio A, Marburger R. A critical analysis of the eccentric starting point for trochanteric intramedullary femoral nailing. J Orthop Trauma. 2005; 19:681-6.
12. Marsh JL, Slongo TF, Agel J, Broderick JS, Creevey W, DeCoster TA, Prokuski L, Sirkin MS, Ziran B, Henley B, Audigé L. Fracture and dislocation classification compendium 2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma. 2007; 21(10 Suppl):S1-133.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
13. Dimon JH, Hughston JC. Unstable intertrochanteric fractures of the hip. J Bone Joint Surg Am. 1967; 49:440-50. 14. Desjardins AL. Roy A. Paimont G. et al. Unstable intertrochanteric fracture of the femur: A prospective randomized study comparing anatomical reduction and medial displacement osteotomy, J Bone Joint Surg Br. 1993; 75:445-447.
D
15. Apel DM, Patwardhan A, Pinzur MS, et al: Axial loading studies of unstable intertrochanteric fractures of the femur. Clin Orthop. 1989; 246:156-164.
TE
16. Swart E, Makhni EC, Macaulay W, Rosenwasser MP, Bozic KJ. Cost-effectiveness analysis of fixation options for intertrochanteric hip fractures. J Bone Joint Surg Am. 2014; 96:161220. 17. Gadegone, W. M., and Y. S. Salphale. "Proximal femoral nail–an analysis of 100 cases of proximal femoral fractures with an average follow up of 1 year." International Orthopaedics. 2007; 31.3: 403-408.
EP
153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173
LEGENDS
FIGURE 1. Anteroposterior (A), lateral (B), traction internal rotation(C) radiographic images
C C
and CT scan with 3D reconstruction (D & E) of left hip shows an intertrochanteric fracture femur with the comminution of greater trochanter, subtrochanteric extension and a separate anteromedial and posteromedial fragment. FIGURE 2. Note the correction of medialization of the femoral neck after the placement of a bone hook and the reduction was held with a coaxial clamp (A). The ball spiked pusher was
A
placed laterally to impact the fracture (B). FIGURE 3. Anteroposterior (A) and lateral (B) fluoroscopic images after the placement of nail shows an acceptable alignment, minimal fracture gap and insignificant medialization. FIGURE 4. 1 year postop radiographic images of anteroposterior (A), and lateral view (B) showing excellent alignment and well healed fracture.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
D TE EP C C A Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
D TE EP C C A Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
D TE EP C C A Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
D TE EP C C A Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
D TE EP C C A Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
D TE EP C C A Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
D TE EP C C A Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
D TE EP C C A Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
D TE EP C C A Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
D TE EP C C A Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
D TE EP C C A Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Evaluation and Management of an Unstable Intertrochanteric Fracture of the Femur: A case report Harish Kempegowda, MS; Akhil Tawari, MS; Michael Suk, MD JD MPH FACS, Daniel S.
D
Horwitz, MD*
*Corresponding Author
PA 17822-2130, USA Tel: 570-271-6541 Fax: 570-271-5872
EP
Email Address: [email protected]
TE
Department of Orthopaedic Surgery, Geisinger Medical Center, 100 N. Academy Ave, Danville,
Conflict of Interest: Dr. Horwitz is a consultant and receives royalties from Biomet. Remaining authors declare no conflicts.
C C
No reproduced copyrighted materials are used within this manuscript.
Add Footnote under Reprints Information:
A
The views and opinions expressed in this case report are those of the authors and do not necessarily reflect the views of the editors of Journal of Orthopaedic Trauma or Biomet.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
1
Introduction:
2
Unstable intertrochanteric fractures (IT) are relatively common injuries among the geriatric
3
population.1,
4
integrity, intertrochanteric fractures with sub trochanteric extension and the reverse oblique
5
pattern are considered unstable.2,
6
hardware failure, non-union, malunion, limb length discrepancy and diminished abductor lever
7
strength.4 The increase in the incidence of complications has led to an extension of the
8
definition of instability to include lateral wall blow out, greater trochanteric fracture and
9
osteoporosis.4, 5 The preoperative identification of an unstable pattern is of utmost importance
As per the most commonly used Evans classification, loss of posteromedial 3
The complications following internal fixation include
TE
D
2
in reducing complications.
11
Many fixation methods have been described to treat intertrochanteric fractures, of which the
12
sliding hip screw and intramedullary devices (IMDs) have stood the test of time.
13
Biomechanical and clinical studies show a clear advantage of intramedullary devices over
14
sliding hip screws in fixation of unstable fracture patterns.6, 7 The evolution of nailing systems
15
began with the first generation gamma nail (Stryker, NJ) in the 1980s and has progressed to
16
current fourth generation nails.8, 9
17
Clinical scenario:
18
A 63-year-old female presented to the emergency room with 10/10 pain in her left hip
19
subsequent to fall at home. She had a known diagnosis of osteoporosis for which she was on
20
regular calcium, vitamin D supplements and once yearly bisphosphonates. She was non-
21
hypertensive, non-smoker and denied any other significant past medical or surgical illnesses. A
22
focused clinical examination revealed a left lower extremity in extreme external rotation,
24
C C
A
23
EP
10
shortening and generalized hip pain. Diagnostic assessment:
25
Plain radiographs anteroposterior view (AP) and cross table lateral view of the left hip,
26
traction-internal rotation view and a CT scan with 3D reconstruction were obtained. These
27
revealed a loss of posteromedial continuity, sub trochanteric extension, greater trochanteric
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
comminution and a fracture line extending up to the femoral neck, making this injury highly
29
unstable.(Fig.1A, 1B, 1C, 1D & 1E)
30
Treatment:
31
Considering the highly unstable nature of the fracture, the authors chose to proceed with long
32
intramedullary nailing. Closed reduction was attempted with longitudinal traction followed by
33
internal rotation but was unable to correct posterior sag and medialization of the femoral neck.
34
Based on this, the decision was made to perform an open reduction. 10 The posterior sag was
35
corrected using a posteriorly placed Cobb elevator and the medialization of the femoral neck was
36
corrected using a bone hook. The reduction thus obtained was maintained by using a coaxial
37
clamp (Fig. 2A). The intraoperative fluoroscopic images revealed an acceptable alignment of the
38
femoral head and neck with the shaft without any varus or medialization of femoral neck. An
39
incision was made proximal to the tip of the greater trochanter and an entry wire was placed 1
40
mm medial to the tip of greater trochanter to avoid damage to abductors and to promote valgus
41
reduction.11 The entry wire position was confirmed on AP and true lateral fluoroscopic views
42
and advanced into the medullary canal. After advancement of the wire, the position was
43
confirmed on AP and true lateral fluoroscopic views. The entry reamer was then used to gain
44
access to the medullary canal and the entry wire was removed. The reduction was maintained
45
with the reduction forceps throughout the procedure and a ball tipped guide wire was introduced
46
into the proximal femoral canal and advanced down the distal femur. Its position was confirmed
47
distally on AP and lateral views. The femoral canal was sequentially reamed up to 11 mm and a
48
9 mm x 360 mm nail was then placed over the guide wire and seated distally by hand. At this
49
point, central-central position of a compression screw guide wire in the femoral head was
50
obtained, screw length was determined, a step drill was used over the guide wire and an
52 53
TE
EP
C C
A
51
D
28
appropriate sized compression screw was placed. Due to concern for possible rotational instability the guide wire for a derotation screw was placed to provide provisional stability during compression screw advancement. The compression screw was rotationally locked with a
54
set screw device but was allowed to collapse. A ball-spiked pusher was placed laterally to
55
impact the fracture (Fig. 2B). At this point, traction was released and compression was achieved
56
which further increased rotational stability. The construct then underwent live fluoroscopic
57
evaluation on the lateral view and rotational stability was confirmed. Based on this it was felt
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
that the compression screw alone would provide adequate rotational stability and a derotation
59
screw was not required. Finally, a single distal interlock screw was placed. The intraoperative
60
images after the placement of the nail showed excellent neck shaft alignment, minimal fracture
61
gap and no significant medialization of femur neck (Fig. 3A, 3B).
62
Follow- up and outcomes:
63
Postoperatively the patient was made weight bearing as tolerated. Radiographs obtained at 6
64
weeks showed further impaction at the fracture site as anticipated. The patient was encouraged to
65
continue to mobilize and began outpatient physical therapy stressing aerobic conditioning, gait
66
training and balance exercises as the fracture showed excellent evidence of healing and well
67
positioned hardware. At one year post op, there was minimal limb length discrepancy without
68
any obvious deformity and radiographs showed overall excellent alignment with a well healed
69
fracture (Fig. 4A, 4B).
70
Discussion:
71
Intertrochanteric fractures are considered unstable when any of the following features are
72
present: posteromedial discontinuity, sub trochanteric extension, reverse oblique pattern,
73
greater trochanter comminution and lateral wall insufficiency. In addition, osteoporosis leads to
74
further instability.1, 2, 4, 5 Intertrochanteric fractures occur in metaphyseal regions, so healing is
75
rarely a major problem, but late complication including malunion, shortening of the limb, and
76
external rotation deformity can all significantly affect post-surgical ambulation.4
77
In this patient, the initial plain radiographs revealed a peritrochanteric fracture but the specifics
78
of the injury pattern were difficult to assess (Fig.1A, 1B). The addition of a traction view and
79
CT scan with 3D reconstruction were of great value in evaluating this injury (Fig. 1C, 1D). CT
81
TE
EP
C C
A
80
D
58
scan is not advisable in each case, but we recommend only if there is a complex fracture where specifics of injury pattern cannot be defined even on a traction view. Ideal preoperative
82
planning begins with classification and, as per the OTA classification, this case belongs to the
83
unstable intertrochanteric 31-A3.3 group.12 To address the complexity and instability in this
84
injury, a long cephalomedullary nail was chosen. A major key to success in this case was the
85
intraoperative reduction of the fracture as earlier described, and utilization of the dynamic
86
property of the implant which led to solid union. In this case further collapse at the fracture site
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
87
could be seen at 6 weeks, as was anticipated, and complete healing was evident at the end of
88
four months (Fig. 4A, 4B).
89
Historically, displacement osteotomies were considered as standard treatment for unstable IT
90
fractures, however later studies showed no advantage in comparison to anatomical fixation. 13,
91
14
92
screw was the implant of choice, but this is associated with significant soft tissue stripping and
93
only a 17% increase in the fixation strength.15 The greater trochanter constitutes the lever arm
94
of the abductor mechanism, so near anatomical fixation is necessary for normal hip function. In
95
this case, even though the greater trochanter appeared to be comminuted, it was felt that the
96
abductor mechanism was intact. If components of the greater trochanter are widely displaced,
97
we would advise open reduction and suture fixation of fragments to whatever implant is
98
chosen.
99
The cost effective analysis, biomechanical studies and clinical outcomes suggests IMDs are
100
better devices for unstable intertrochanteric fractures.16 The earlier generation nails were
101
associated with multiple problems including shaft fracture at the end of nail, screw cut out and
102
femoral neck fracture after hardware removal.8 The newer generation nails are associated with
103
significantly fewer complications; however, some issues such as femoral neck fracture after
104
implant removal continue to exist.
105
earlier mobilization and less limb shortening, both of which may enhance the patient’s general
106
well-being. 17
107
In conclusion, preoperative identification of the unstable fracture pattern with proper
108
radiological investigations, selection of the most suitable implant based on fracture pattern,
109
achieving and maintaining reduction during nail placement and early postoperative
D
TE
EP
The advantage of an intramedullary device also includes
C C
9
A
110
To restore the medial buttress, extra screws or circlage wire would be necessary if a sliding
mobilization will maximizes the patient’s recovery in an unstable intertrochanteric fracture.
REFERENCES
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
148 149 150 151 152
1. Koval KJ, Zuckerman JD. Intertrochanteric fractures. In: Bucholz RW, Heckman JD. Fractures in Adults. 5th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2001:1635– 1663. 2. Evans EM. The treatment of trochanteric fractures of the femur. J Bone Joint Surg Br. 1949 May; 31B:190-203.
D
3. Jensen JS. Classification of trochanteric fractures. Acta Orthop Scand. 1980; 51:803–810.
TE
4. Im GI, Shin YW, Song YJ. Potentially unstable intertrochanteric fractures. J Orthop Trauma. 2005 Jan; 19:5-9.
5. Weon-Yoo Kim, Chang-Hwan Han, Jin-Il Park, Jin-Young Kim, Failure of intertrochanteric fracture fixation with a dynamic hip screw in relation to pre-operative fracture stability and osteoporosis. International Orthopaedics December 2001; 25: 360-362.
EP
6. Curtis MJ, Jinnah RH, Wilson V, Cunningham BW. Proximal femoral fractures: a biomechanical study to compare intramedullary and extramedullary fixation.Injury. 1994; 25:99-104. 7. Al-yassari G, Langstaff RJ, Jones JW, Al-Lami M. The AO/ASIF proximal femoral nail (PFN) for the treatment of unstable trochanteric femoral fracture. Injury. 2002; 33:395-9.
C C
8. Albareda J, Laderiga A, Palanca D, Paniagua L, Seral F. Complications and technical problems with the gamma nail. Int Orthop. 1996; 20:47-50. 9. Xu Yaozeng, Geng Dechun, Yang Huilin, Zhu Guangming, Wang Xianbin. Comparative study of trochanteric fracture treated with the proximal femoral nail anti-rotation and the third generation of gamma nail Injury. 2010; 41:1234–1238. 10. Afsari A, Liporace F, Lindvall E, Infante A Jr, Sagi HC, Haidukewych GJ. Clamp-assisted reduction of high subtrochanteric fractures of the femur. J Bone Joint Surg Am. 2009; 91:1913-8.
A
111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147
11. Ostrum RF, Marcantonio A, Marburger R. A critical analysis of the eccentric starting point for trochanteric intramedullary femoral nailing. J Orthop Trauma. 2005; 19:681-6.
12. Marsh JL, Slongo TF, Agel J, Broderick JS, Creevey W, DeCoster TA, Prokuski L, Sirkin MS, Ziran B, Henley B, Audigé L. Fracture and dislocation classification compendium 2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma. 2007; 21(10 Suppl):S1-133.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
13. Dimon JH, Hughston JC. Unstable intertrochanteric fractures of the hip. J Bone Joint Surg Am. 1967; 49:440-50. 14. Desjardins AL. Roy A. Paimont G. et al. Unstable intertrochanteric fracture of the femur: A prospective randomized study comparing anatomical reduction and medial displacement osteotomy, J Bone Joint Surg Br. 1993; 75:445-447.
D
15. Apel DM, Patwardhan A, Pinzur MS, et al: Axial loading studies of unstable intertrochanteric fractures of the femur. Clin Orthop. 1989; 246:156-164.
TE
16. Swart E, Makhni EC, Macaulay W, Rosenwasser MP, Bozic KJ. Cost-effectiveness analysis of fixation options for intertrochanteric hip fractures. J Bone Joint Surg Am. 2014; 96:161220. 17. Gadegone, W. M., and Y. S. Salphale. "Proximal femoral nail–an analysis of 100 cases of proximal femoral fractures with an average follow up of 1 year." International Orthopaedics. 2007; 31.3: 403-408.
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LEGENDS
FIGURE 1. Anteroposterior (A), lateral (B), traction internal rotation(C) radiographic images
C C
and CT scan with 3D reconstruction (D & E) of left hip shows an intertrochanteric fracture femur with the comminution of greater trochanter, subtrochanteric extension and a separate anteromedial and posteromedial fragment. FIGURE 2. Note the correction of medialization of the femoral neck after the placement of a bone hook and the reduction was held with a coaxial clamp (A). The ball spiked pusher was
A
placed laterally to impact the fracture (B). FIGURE 3. Anteroposterior (A) and lateral (B) fluoroscopic images after the placement of nail shows an acceptable alignment, minimal fracture gap and insignificant medialization. FIGURE 4. 1 year postop radiographic images of anteroposterior (A), and lateral view (B) showing excellent alignment and well healed fracture.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
D TE EP C C A Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
D TE EP C C A Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
D TE EP C C A Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
D TE EP C C A Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
D TE EP C C A Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
D TE EP C C A Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
D TE EP C C A Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
D TE EP C C A Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
D TE EP C C A Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
D TE EP C C A Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
D TE EP C C A Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
