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

2. 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)

3. 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

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

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

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

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

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

9. Available implants

10. 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.

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

12. 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

13. Operative treatment

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

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

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

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

18. Intramedullary implant

19. 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

20. 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: doi: /2013/ 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 Feb 6;95(3): doi: /JBJS.K
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: doi: /2013/ 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 Feb 6;95(3): doi: /JBJS.K

21. 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): 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 Jan;106(1): 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): 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 Jan;106(1): German.

22. 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.