Per- and intertrochanteric fractures Published: July 2013 Rogier Simmermacher, NL AOT Basic Principles Course

Learning outcomes Describe the biomechanics of extracapsular fractures and the choice of implant Describe the difference between trochanteric and subtrochanteric fractures Explain the rationale of intra- as opposed to extramedullary fixation Describe the causes of failure concerning reduction and placement of implant Teaching points: Achievement of cephallo-medullary stability, reduction by distraction, importance of fluoroscopy. BB: Add to Classification slide(6) to clarify difference (CL2) BB: add complications to clarify failure (CL3)

Additional learning outcomes Understand the goal of treatment Understand that trochanteric fractures are extracapsular Understand the role of the lesser trochanter Understand that there is no real evidence

Trochanteric fractures Intracapsular Result determined by biology Osteonecrosis Nonunion Arthritis Extracapsular Result determined by mechanics Varus deformation Malunion Medialization

Trochanteric fractures—etiology Low-energy injury Usually elderly patients High-energy injury Usually younger patients

Trochanteric fractures BB: This is where differentiation between subtrochanteric and trochanteric fractures can be explained. 31 A.1 31 A.2 31 A.3

What does the patient want ? Treatment that enables the patient to return to normal as soon as possible

Treatment options Nonoperative: About 14 weeks bed rest Virtually impossible Secondary displacement obligatory Operative

Available implants

Choice of implant Rigid extramedullary fixation bears too high a risk for: Early failure (cut out) More postoperative hip pain Reduced postoperative mobility There is evidence that a rigid extramedullary fixation bears too high a risk for early failure (cut out), more postoperative hip pain, and reduced postoperative mobility.

Choice of implant Insufficient evidence concerning locking plates So far, there is insufficient evidence concerning locking plates.

Choice of implant Replacement of (part of) the joint is not a first thought In trochanteric fractures there is, by definition, no injury to the hip joint, therefore replacement of (part of) the joint is not a first thought

Operative treatment

How to make a choice? Read the fracture “Unstable” “Stable” After reduction “Unstable”

How to make a choice? In a “stable” fracture (31-A1) any (dynamic) device, extramedullary or intramedullary will serve well

How to choose in an unstable fracture? Varus deformation Rotation Medialization shaft

Extramedullary implant Dynamic hip screw (DHS) DHS + trochanter stabilizing plate

Intramedullary implant

Extramedullary versus intramedullary implants Extramedullary—(nearly) anatomical reconstruction Less strong implant Semi-open procedure Partial weight bearing Intramedullary—nonanatomical reconstruction Strong implant Semi-closed procedure Direct full weight bearing

Evidence Nail versus sliding hip screw—no difference Huang X, Leung F, Xiang Z, et al. Proximal femoral nail versus dynamic hip screw fixation for trochanteric fractures: a meta-analysis of randomized controlled trials. ScientificWorldJournal. 2013;2013:805805. doi: 10.1155/2013/805805. Epub 2013 Feb 19. Matre K, Vinje T, Havelin LI, et al. TRIGEN INTERTAN intramedullary nail versus sliding hip screw: a prospective, randomized multicenter study on pain, function, and complications in 684 patients with an intertrochanteric or subtrochanteric fracture and one year of follow-up. J Bone Joint Surg Am. 2013 Feb 6;95(3):200-8. doi: 10.2106/JBJS.K.01497. References: Huang X, Leung F, Xiang Z, et al. Proximal femoral nail versus dynamic hip screw fixation for trochanteric fractures: a meta-analysis of randomized controlled trials. ScientificWorldJournal. 2013;2013:805805. doi: 10.1155/2013/805805. Epub 2013 Feb 19. Matre K, Vinje T, Havelin LI, et al. TRIGEN INTERTAN intramedullary nail versus sliding hip screw: a prospective, randomized multicenter study on pain, function, and complications in 684 patients with an intertrochanteric or subtrochanteric fracture and one year of follow-up. J Bone Joint Surg Am. 2013 Feb 6;95(3):200-8. doi: 10.2106/JBJS.K.01497.

Evidence Proximal femoral nail versus DHS/TSP—no difference Audigé L, Hanson B, Swiontkowski MF. Implant-related complications in the treatment of unstable intertrochanteric fractures: meta-analysis of dynamic screw-plate versus dynamic screw-intramedullary nail devices. Int Orthop. 2003;27(4):197-203. Epub 2003 May 7. 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)]. Unfallchirurg. 2003 Jan;106(1):39-47. German. References: Audigé L, Hanson B, Swiontkowski MF. Implant-related complications in the treatment of unstable intertrochanteric fractures: meta-analysis of dynamic screw-plate versus dynamic screw-intramedullary nail devices. Int Orthop. 2003;27(4):197-203. Epub 2003 May 7. 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)]. Unfallchirurg. 2003 Jan;106(1):39-47. German.

Take-home messages 31-A1 (“stable”) fractures Any sliding device 31-A2 (“unstable“) fractures Intramedullary device Sliding hip screw with a lateral support device 31-A1 (“stable”) fractures might be treated with any sliding device. 31-A2 (“unstable“) fractures can be treated with either an intramedullary device, which permits immediate full weight bearing, or a sliding hip screw with a lateral support device.