Trochanteric fractures Published: July 2013 Reviewed: 2018 Reviwer: Rogier Simmermacher AO Trauma Basic Principles Course

Learning objectives Describe the (biological) difference between intra- and extracapsular proximal femoral fractures Describe the biomechanics of extracapsular fractures and the (resulting) choice of implant 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 cephalomedullary 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 objectives 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

Proximal femoral fractures differ… 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: 31A1, 31A2, 31A3 and variants BB: This is where differentiation between subtrochanteric and trochanteric fractures can be explained. 31A1.2 31A1.3 31A3.1 Pertrochanteric simple Pertrochanteric multifragmentary Intertrochanteric

What does the patient want? Treatment that enables the patient to return to, at least, pretrauma mobility as soon as possible

What does a doctor want for his/her patient ? Early full weight bearing Technically easy treatment

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

Type of bone healing preferred: Primary: No  means open, anatomical reduction Secondary: Given the biology, to be preferred

Implants available Replace the images?

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 Full weight bearing postoperatively is questionable So far, there is insufficient evidence concerning locking plates.

Choice of implant Replacement of (part of) the (essentially healthy) joint is not a first thought Muscles attached to the greater trochanter then have to be re- inserted = major functional loss 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 Replace the images? Therefore these two options are left

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

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

How to reduce the fracture Close reduction over fracture table: Reducible and stable Reducible by other means and unstable If no close reduction, then open reduction achieving anteromedial contact and fixation with the implant

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

Extramedullary implant Dynamic hip screw (DHS) Replace the images? DHS + trochanter stabilizing plate

Intramedullary implant

Extra - or intramedullary implant 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. 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):200–208. 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. 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):200–208.

Evidence  slight change Intramedullary vs extramedullary: …. tendency to better regain of mobility … with an intramedullary nail... (Parker [Injury. 2017;48:2762–2767]) …. supports the use of intramedullary nails for A3 fractures (Bretherton et al [J Orthop Trauma. 2016 Dec;30(12):642–646]) References: Audige 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. Bretherton CP, Parker MJ. Femoral Medialization, Fixation Failures, and Functional Outcome in Trochanteric Hip Fractures Treated With Either a Sliding Hip Screw or an Intramedullary Nail From Within a Randomized Trial. J Orthop Trauma. 2016 Dec;30(12):642–646. Nuber S, Schönweiss T, Rüter A. Stabilisierung von instabilen trochantären Mehrfragmentfrakturen. Vergleich zwischen PFN und DHS mit Trochanterabstützplatte [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. Parker MJ. Sliding hip screw versus intramedullary nail for trochanteric hip fractures; a randomised trial of 1000 patients with presentation of results related to fracture stability. Injury. 2017 Dec;48(12):2762–2767.

Take-home messages 31A1 (“stable”) fractures: Any sliding device 31A2 and 31A3 (“unstable”) fractures: Intramedullary device (Sliding hip screw with a lateral support device) 31A1 (“stable”) fractures might be treated with any sliding device. 31A2 and 31A3 (“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.