Intertrochanteric Fractures

Ovid: Rockwood And Green’s Fractures In Adults

Editors: Bucholz, Robert W.; Heckman, James D.; Court-Brown, Charles M.; Tornetta, Paul
Title: Rockwood And Green’s Fractures In Adults, 7th Edition
> Table of Contents > Section Four – Lower Extremity > 48 – Intertrochanteric Fractures

Intertrochanteric Fractures
Thomas A. Russell
Pertrochanteric fractures are those occurring in the
region extending from the extracapsular basilar neck region to the
region along the lesser trochanter before the development of the
medullary canal. Intertrochanteric and peritrochanteric are generic
terms for pertrochanteric fractures. Injury creates a spectrum of
fractures in this proximal metaphyseal region of bone, with damage to
the mechanically optimized placement of intersecting cancellous
compression and tensile lamellae networks and the weak cortical bone
with resulting displacement from the respective attachment of muscle
groups to the fracture fragments and an adjacent high mobility joint.
These structures are subject to multiplanar stresses after surgical
repair. This region of the femur shares many common biomechanical
properties with other short end-segment metaphyseal-diaphyseal
fractures with regard to the difficulty in obtaining stable fixation.
Although predominantly associated with low-energy older age patients,
high-energy trauma in young patients can result in similar patterns of
Pertrochanteric femoral fractures are of intense
interest globally. They are the most frequently operated fracture type,
have the highest postoperative fatality rate of surgically treated
fractures, and have become a serious health resource issue because of
the high cost of care required after injury. The reason for the high
cost of care is primarily related to the poor recovery of functional
independence after conventional fracture care in many patients.
Interestingly there has been no significant improvement in mortality or
functional recovery over the past 50 years of surgical treatment.
Paradoxically the last 50 years of acquiescence to the status quo of
hip fracture treatment are


to false assumptions that have been a hindrance to improvement in the
management of the hip fracture patient: (i) uncontrolled shortening and
varus collapse are acceptable in hip fractures but not other fractures;
(ii) reduction does not matter with sliding screw systems, as the
fracture will “collapse to stability” because rotation is not a problem
and placement of the head fixation takes precedence over fracture
reduction; (iii) union without implant failure overrides the
requirement of a stable anatomic reduction to the detriment of optimal
functional recovery; and (iv) the orthopaedic surgeon just fixes the
fracture, as opposed to treating the total musculoskeletal needs of the
patient. The reasons for these assumptions relate directly to the
historical evolution of hip fracture treatment and the arguments that
shaped our current understanding. A new paradigm regarding hip fracture
care and treatment is currently evolving, which hopefully will advance
our treatment goal back to optimal functional recovery and prevention
of future hip fractures.

In 1997 Gullberg et al. estimated that the future
incidence of hip fracture worldwide would double to 2.6 million by
2025, and 4.5 million by 2050.79 The
percentage increase will be greater in men (310%) than women (240%). In
1990 26% of all hip fractures occurred in Asia, whereas this figure
could rise to 37% in 2025 and 45% in 2050.143 Hagino et al. reported a lifetime risk of hip fracture for individuals at 50 years of age of 5.6% for men and 20.0% for women.82 Since 1986 in the Tottori Prefecture, Japan, the acceleration of hip fracture incidence continues for both genders.
There is hope that hip fracture risk has begun to
decline in certain areas of the world, but the reason is unknown. In
Denmark the incidence of hip fractures has declined about 20% from 1997
to 2006; Nonetheless, this decline cannot be explained by
antiosteoporotic medications, whose effect should only be an
approximate reduction of 1.3% in men and 3.7% in women.2
Epidemiologic studies among Olmsted County, Minnesota, residents in
1980 to 2006 revealed that the incidence of a first-ever hip fracture
declined by 1.37%/year for women and 0.06%/year for men. The cumulative
incidence of a second hip fracture after 10 years was 11% in women and
6% in men.
The focus of surgical research regarding internal
fixation in the late twentieth century was to minimize implant failure
and avoidance of cutout of the femoral head and neck fixation
components. Because many of these fractures are associated with
osteoporosis, the current paradigm shift regarding hip fracture care
relates to three main strategies: (i) Prevention by aggressive
screening and treatment of patients with high risk for fragility
fracture; (ii) standardization of hip fracture centers with aggressive
early intervention and protocols to avoid complications; and (iii)
optimization of fracture reduction and new designs of implant component
fixation in osteoporotic bone with conceptual design changes in
fixation stability and augmentation of the bone-implant interface.
Mechanisms of Injury
Low-energy falls from a standing height account for
approximately 90% of community hip fractures in patients more than 50
years of age, with a higher proportion of women. Higherenergy hip
fractures are relatively rare; they are more common in men less than 40
years of age and are usually referred to regional trauma centers for
treatment.100 Cummings et al.43
noted that neither age-related osteoporosis, nor the increasing
incidence of falls with age sufficiently explains the exponential
increase in the incidence of hip fracture with aging.43 Their hypothesis was that four conditions correlated for a fall to cause a hip fracture:
(a) the faller must be oriented to impact near the hip;
(b) protective responses must fail; (c) local soft tissues must absorb
less energy than necessary to prevent fracture; and (d) the residual
energy of the fall applied to the proximal femur must exceed its
This concept applies primarily to strategies to prevent
hip fractures. Fall with a rotational component is more common with
extracapsular hip fractures.98
Associated Injuries
In low-energy falls resulting in hip fractures,
associated injuries are most commonly distal radius and proximal
humerus fractures and minor head injuries that occur during the fall.
High-energy hip fractures are more commonly associated with ipsilateral
extremity trauma, head injury, and pelvic fractures. Associated
injuries or premorbid diseases may coexist with the fracture diagnosis.
Syncopal episodes resulting in a fall may bring attention to
cardiovasular and neurologic disease states. Primary neoplastic and
metastatic disease may reveal their presence with preceding hip
discomfort and subsequent fall resulting in fracture.
History and Physical Examination
Patients most commonly present with a history of pain
and inability to ambulate after a fall or other injury. The pain is
localized to the proximal thigh and is exacerbated by passive or active
attempts of hip flexion or rotation. Drug use, either illicit or
precribed pharmacologics, must be sought out as a confounding and
contributing factor. Nursing home and institutionalized patients must
be examined for the potential of neglect and abuse in the form of
previous fractures, and injuries in different states of repair and
The physical findings of a displaced hip fracture are
shortening of the extremity and deformity of rotation in the resting
position compared with the contralateral extremity. Pain with motion or
crepitance testing is not elicited unless there are no physical signs
of deformity and radiographic studies are negative for an obvious
fracture. Pain with axial load on the hip has a high correlation with
occult fracture. The auscultation Lippmann Test is quite sensitive for
the detection of occult fractures of the proximal femur or pelvis.132
By placement of a stethescope bell on the symphysis pubis and tapping
on the patella of both extremities, variations in sound conduction
through the pelvis and hip from the patella result when there is any
discontinuity. A decreased tone or pitch implies fracture within this
arc of bone.
Laboratory studies in addition to the standard workup
for surgery should include the following for all low-energy fractures
(osteopenic or fragility fractures): serum calcium, phosphate, and
alkaline phosphatase; a complete blood-cell count (CBC); 25
hydroxyvitamin D, thyroid-stimulating hormone (TSH); parathyroid
hormone (PTH intact); serum protein electrophoresis


(SPEP); and kidney-function tests, including blood urea nitrogen (BUN), creatinine, and glomerular filtration rate (GFR).45,206

A search for high-risk potentially preventable
complication includes: previous DVT/PE, anticoagulation medications,
immune deficiency disorders, malabsorption disease, angina or CVA
prodromal symptoms of atherosclerotic disease, and active infection
(pulmonary, genitourinary), which might result in sepsis
postoperatively. Protein-calorie malnutrition and vitamin D deficiency
are now recognized as serious risk factors for mortality and recovery.
Foster reports 70% mortality for patients with albumin less than 3
compared with a mortality rate of 18% in patents with albumin ≥3.61
Vitamin D deficiency is now viewed as an epidemic because of dietary
changes and lack of sunlight exposure; current recommendations are to
administer 50,000 IU of vitamin D immediately to all elderly patients
on admission with hip fracture.206
Imaging and Other Diagnostic Studies
Plain radiographs including an AP pelvis, AP, and cross
table lateral of the affected hip are usually recommended for diagnosis
and preoperative planning. Traction films are helpful is comminuted and
high-energy fractures in determining implant selection.117
Subtrochanteric extension requires full-length femoral AP and lateral
radiographs for implant length selection. If a long nail implant is a
consideration, then AP and lateral radiographs of the affected femur to
the knee are required, with special attention to femoral bow and
medullary canal diameter. Traction views with internal rotation may be
of benefit preoperatively as an aide in the selection of definitive
internal fixation.117
Computed tomography (CT) or magnetic resonance imaging
(MRI) scans are rarely required for displaced fractures but may be
useful in establishing the diagnosis in nonobvious fractures and
atypical fractures in high-energy trauma patients.181,209
The MRI does not necessarily require a full study, as the frontal
images are most often diagnostic. Nonetheless, complete studies usually
detect other diagnosis for hip pain in addition to occult fractures of
the proximal femur. MRI is preferred over the CT or the older
radionuclide scans because of a higher sensitivity and specificity for
a more rapid decision process.*
In actual practice, the best radiographic analysis of
hip fractures occurs in the operative suite with fluroscopic C-arm
views. This technology gives the surgeon an excellent modality for
fracture analysis in complex fractures and immediate feedback as to the
stability of the fracture after the initial reduction. In many
institutions this has led to elimination of preoperative lateral
radiographs. Unfortunately this practice may also result in a change in
the selected type of fixation with inherent stress on the operative
team and resource management.
Classifications for extracapsular fractures of the hip
occurring from the basicervical to the level of the subtrochanteric
regions have not been particularly helpful in clinical situations.
Nonetheless, increased sugical complexity and recovery are associated
with unstable fracture patterns. Unstable characteristics include
posteromedial large separate fragmentation, basicervical patterns,
reverse obliquity patterns, displaced greater trochanteric (lateral
wall fractures), and failure to reduce the fracture before internal
fixation. Stability after surgical treatment connotes anticipated union
without deformity or implant failure. The current controversy of
implant selection is largely focused on what amount of deformity and
fracture site motion is still compatible with a functional recovery to
the patient’s preinjury status.
There is no single classification system that has
achieved reliable reproducible validity. In 1822 Astley Cooper (London)
described the first (pre-radiographic) classification of hip fractures:
intracapsular and extracapsular fractures (with the main complication
of nonunion and avascular necrosis in the first and the second of coxa
In 1949 Boyd and Griffin described the first treatment
recommendation classification, predictive of the difficulty of
achieving, securing, and maintaining the reduction in four fracture
types: (i) Stable (two part); (ii) unstable with posteromedial
comminution; (iii) subtrochanteric extension into lateral shaft
extension of the fracture distally at or just below the lesser
trochanter (the term reverse obliquity was coined by Wright);220 and (iv) subtrochanteric with intertrochanteric extension with the fracture lying in at least two planes (Figure 48-1).
They were the first to report the use of lateral buttress plating of
the greater trochanter to avoid medialization of the shaft in type 3
fractures, the need for two-plane fixation for type 4 subtrochanteric
fractures with a coronal fracture line, and the possibility
ofiatrogenic conversion of type 1 and 2 fractures to type 3 during
implant preparation and insertion.
Boyd and Griffin classification: (i) stable (two-part), (ii) unstable
comminuted, (iii) unstable reverse obliquity, (iv)
intertrochanteric-subtrochanteric with two planes of fracture.

Also in 1949 M. Evans (Birmingham, England) reported on
a post-treatment classification with five types described. He compared
nonoperative treatment and fixed angle device surgical treatment. He
documented that 72% of his fractures could be fixed in a stable
configuration. Stability was not achieved in 28% of the fractures; 14%
as a result of the fracture pattern or comminution and 14% of which he
felt the reduction was never achieved (Figure 48-2).
This paper was primarily used to argue the value of internal fixation
over nonoperative treatment of hip fractures, which was controversial
in England in the 1940s and 1950s.
In 1979 and 1980, respectively, Kyle et al. and Jensen
et al. reported independently on a revision of the Evans classification
incorporating the lateral radiographic position of the posteromedial
fracture component and its relation to stability with sliding fixation
Kyle et al. showed an increased rate of deformity and collapse with
increasing instability classification. Jensen et al. related the
ability to reduce the fracture and secondary displacement risk with a
CHS-type device in their classification system.
Evans classification of trochanteric fractures. Type 1: Stable because
either undisplaced or displaced but anatomically reduced to stability
(intact medial cortex). Type 2: Unstable implies displaced and fixed in
an unreduced position, comminuted with destruction of the anteromedial
cortex, or reversed obliquity.
The OTA/AO classification is now the most quoted in
recent scientific articles and is a derivative of the Muller
classification (Figure 48-3). There is a higher
interobserver agreement with the AO/OTA classification than
Evans/Jensen, but neither meets the acceptable threshold for
reliability.64 The AO/OTA has nine
main types; however, correlation is best with only three categories;
also there is no lateral radiographic parameter with the AO/OTA
Generally 31A1 fractures are thought of as the most stable, 32A2
fractures are more unstable, and 31A3 fractures are the most unstable
with plate device


Unfortunatedly, the fifth digit of the classification has not been
found to be reliably identifiable in prospective evaluation.

In the OTA alphanumeric fracture classification, intertrochanteric hip
fractures comprise type 31A. These fractures are divided into three
groups, and each group is further divided into subgroups based on
obliquity of the fracture line and degree of comminution. Group 1
fractures are 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.
Group 2 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. Group 3 fractures are those in which the
fracture line extends across both the medial and lateral cortices. This
group includes the reverse obliquity pattern.
Gottfried and Kulkami et al. have developed the most
recent therapeutic-based classification, again derived from a
modification of the Evans and Jensen classification,120
primarily focusing on the stability of the lateral wall as a buttress
to minimize medialization and uncontrolled collapse after single screw
device fixation. Kyle has recently added another very unstable pattern
to his previous classification. In this variant, the fracture line
includes a separate femoral neck fracture; he concluded that this
variant should not be treated with a sliding hip screw device.121
Surgical and Applied Anatomy
The pertrochanteric region is quite variable in its
combination of cortical and cancellous bone structure. The
well-vascularized pertrochanteric region is dependent on the structural
integrity of a laminated cancellous bone arcade from the femoral head
and epiphyseal scar, around Ward’s triangle to the lesser trochanter,
where the solid nature of the structure changes to a tubular construct
with the origin of the femoral medullary canal; the strong plate of
bone posteriorly is named the calcar femorale (Figure 48-4).65
This is the region most affected with the posteromedial fracture
comminution leaving only the anteromedial cortex potentially stable.
The main structural attachments to the proximal femur
include the hip capsule and the musculotendinous junctions of the
gluteus medius and minimus (greater trochanter), iliopsoas (lesser
trochanter), pirifomis and short external rotators (posterior
trochanteric region from the greater trochanteric region to the lesser
trochanter), the oblique head of the rectus femoris (anterior capsule),
and the vastus lateralis (lateral femur distal to the greater
trochanter). The hip capsule is especially important in reduction of
pertrochanteric fractures and its continuity with the distal fragment
is the soft tissue attachment on which a stable reduction is possible (Figure 48-5).
With capsular disruption, the displacement of the
fracture fragments is dependent on the musculotendinous attachment to
the respective fragments. The greater trochanter is abducted and
externally rotated by the gluteus medius and short exteral rotators,
the shaft is displaced posteriorly and medially by the adductors and
hamstrings. This accounts for the usual shortening and coxa vara
deformity of displaced fractures. With aging the morphology of the hip
changes with thinning of the cortex and expansion of the diameter of
the bone (Figure 48-4C). The younger hip
fracture patients has a relatively narrow metaphysis and a high narrow
isthmus with a very thick cortex in the diaphysis. Further aging
results in a slight widening and thinning of a cortex of the
metaphysis, with bone loss and a decreased thickness of the diaphyseal
cortical bone stock and a widening of the isthmus. In the advanced age
group, there is a very wide vacuous metaphysis proximally with loss of
tension and compression trabeculae, a loss of the constriction of the
isthmus, and a very round expanded tubular-shaped femur with a thin
cortex Three types of morphologic anatomy were grouped together by Dorr
et al. in 1983 referencing the selection of cemented versus
non-cemented arthroplasty femoral components48 (Figure 48-6).
The same rationale applies to implant selection for hip fracture
patients. Type A femurs occur primarily in young patients and have a
narrow metaphysis, thick cortex, and high constricting isthmus.
Excessive bone removal is required for intramedullary devices, and
either a plate-type construct or smaller-diameter reconstruction nail
may be more bone conserving. Type B fracture morphology has a wider
metaphysis and larger medullary canal, but relatively good cortex and
isthmus constriction. Type C is the most problematic in geriatric
populations with hip fractures: a wide metaphysis, wide medullary
canal, and loss of isthmus constriction in association with loss of
cortical diaphyseal bone stock. There


a trend to prefer long intramedullary implants in these patients;
however, care must be taken that the straightened thin diaphyseal
cortex may be at risk of perforation distally by long devices in the
anterior supracondylar area.157

FIGURE 48-4 A. Posteromedial calcar shelf, which is usually damaged with unstable fracture patterns. B.
Ward crosssection of proximal femur. Best quality bone is within 10 to
30 mm of subarticular surface. Note tensile trabeculae between Ward’s
triangle and greater trochanter. C.
Changes in morphology of bone with age: adaptation to maintain whole
bone strength. Note expansion of geometry and thinning of cortical bone
with aging. (C adapted from Seeman E.
Pathogenesis of bone fragility in women and men. Lancet 2002;359:
1841-1850, and Seeman E. Periosteal bone formation—a neglected
determinant of bone strength. N Engl J Med 2003;349:320-323.)

FIGURE 48-5 A. Anterior hip capsule. Y-Ligament of Bigalow as structure for ligamentotaxis in closed reduction of stable Fractures. B. Posterior hip capsule. Note more-proximal position of capsule posteriorly and course of arteries to head.
The neurologic structures of interest are the femoral
nerve anteriorly and sciatic nerve posteriorly; however, they are
rarely encountered in surgical approaches for repair of pertrochanteric
fractures and are injured only rarely by penetrating trauma, usually by
displaced fracture fragments.49,112,140,152,179,212 Vascular injury affecting the femoral head is rarely involved in nonpenetrating injuries.192
Brodetti noted the rare possibility of injury to the vascularity of the
femoral head with femoral head fixation screws and nails with injection
studies, and found that the central and inferior locations were safe
zones.28 Avascular necrosis after
pertrochanteric fracture is extremely rare because of the relative
protected area of the medial circumflex artery with pertrochanteric
fractures, but may develop in 0.5% to 1% of pertrochanteric fractures
usually within 4 years of injury.13,69
Dorr classification of morphology of femur. Type A corresponds to a
small metaphysis, thick cortex, and high narrowed isthmus. Type B
corresponds to a wider metaphysis, thinner cortex, and a tapering but
wider isthmus. Type C corresponds to a wide metaphysis, thin cortex,
and a straight or varus curvature in the diaphysis with loss of isthmus
Common Surgical Approaches
Lateral Approach to the Proximal Femur
This approach has been relatively standardized over the
past 70 years for plate fixation. The patient is commonly operated on
with a fracture table and the leg and foot secured after closed
reduction. The entire proximal thigh from the iliac area to the distal
femur is prepared in the standard fashion. The incision length is based
on the length of the proposed plate-shaft component;


incision is started with reference from intraoperative C-arm
fluoroscopy views and is centered over the lesser trochanter. Commonly
the incision length is 5 to 10 cm in length. The iliotibial band is
incised and the proximal portion is extended sufficiently to develop
the area of the intertrochanteric line for palpation anteriorly. The
fascia of the vastus lateralis is incised near its attachment
posteriorly at the linea aspera. Leave sufficient fascia posteriorly (5
to 10 mm) for closure and to identify and obtain hemostasis of all
perforator arteriovenous structures. Reflect the vastus anteriorly,
exposing the lateral femoral shaft. There are no significant neurologic
or vascular structures at risk with this approach (Figure 48-7).

Intramedullary Approach
The incision for nail insertion is determined by the
intersection of a line from the anterior superior iliac spine directed
posteriorly and a line parallel to the long axis of the femur. Overlay
a 3.2 guidewire on the skin anteriorly and laterally and confirm
alignment with the proximal femur with C-arm. Incise the skin proximal
to the greater trochanter. Usually a 3- to 5-cm incision is adequate.
The fascia is incised, but the gluteus medius fibers are not
dissected, as this approach is designed to minimize soft tissue damage
around the proximal femur. A targeting guide and trocar system protects
the gluteus medius. Separate incisions for the femoral head fixation
are made through the short version of the lateral approach to the femur
(Figure 48-8).
Watson Jones Approach
This anterolateral approach to the hip is actually a
proximal expansion of the straight lateral approach previously
described. The muscular interval proximally is between the tensor
fasciae latae and the gluteus medius. The interval between these two
muscles is best begun distally and exposed proximally. Follow the
anterior border of the vastus lateralis proximally to reach the
anterior trochanteric ridge and hip capsule. The use of Schanz pins
drilled into the proximal femur is an aide in retraction for better
visualization and may be used for manipulation of the shaft. Further
capsulotomy and greater trochanteric osteotomy are rarely required for
pertrochanteric fracture management. The main vascular obstacle is the
ascending branch of the lateral femoral circumflex artery, which should
be isolated and ligated in the approach. Complete proximal dissection
of the gluteus medius and tensor fasciae latae interval to the iliac
crest is rarely necessary; the superior gluteal nerve to the tensor
fasciae latae is sacrificed with full proximal dissection; however,
this not clinically significant (Figure 48-9).
Lateral surgical approach to the hip. Slight curvature of proximal
extent of incision to allow palpation of the anterior cortex. Vastus
lateralis reflection distally as needed for length of plate.
Evolution of Treatment
The importance of understanding the evolution of
treatment concepts regarding pertrochanteric fractures is critical to
advancing treatment modalities. Those who are ignorant of the past are
condemned to repeat its mistakes.
Initial treatment in the 1800s in England focused on the
work of Pott and Cooper, who advocated supporting the thigh in a flexed
position. Early mobilization of the patient from bed rest to chair to
protective ambulation was the primary goal for survival of the patient.
They espoused “benign neglect of the


fracture” in an attempt to save life over limb.41 The other school was founded by Hugh Owen Thomas of Liverpool, who advocated immobilization and prolonged bed rest.20

Intramedullary approach. Incision is placed center to slightly
posterior to line of femoral shaft centered between the anterior
superior and inferior iliac spines anteriorly. Incision length is 2 to
4 cm.
Whitman in 1902 re-evaluated the role of neglect of this
type of fracture and advocated reduction and stabilization with
traction, abduction, and internal rotation, to better restore the
anatomy of the hip.217 This was
performed under general anesthesia; then the patient was placed in a
long leg hip spica cast to maintain the reduction. This basically moved
the treatment of hip fractures from a passive to an active role by the
FIGURE 48-9 Watson-Jones approach. Key interval between TFL and G. Medius to visualize anterior femoral neck and capsule.
Whitman reflected in 1938 on the evolution of hip fracture treatment from 1900.218
At the beginning of this century, fracture of the neck
of the femur was a therapeutic derelict. The futility of conventional
treatment, demonstrated by Sir Astley Cooper, had been accepted as a
finality and permanent disability as an inevitable sequence of the
injury. Neglect of the fracture in the alleged interest of the patient
entailed no responsibility, either moral or legal. Positive treatment,
by contrast, could appeal only to adventurous spirits, because the
correction of deformity might


up the sacrosanct impaction,” the only hope of union; whereas the
restraint of the plaster spica must endanger the life of the patient.
During the lapse of years, nonetheless, in spite of opposition and
inertia, the abduction treatment has come into general use, and
experience has disproved every assumption on which the negative
doctrine was based.

Whitman foresaw the replacement of nonoperative
treatment with operative treatment, with the success of the
Smith-Petersen nail as the next progression to restore the limb and
decrease mortality.
In the 1800s, Langebeck and others attempted internal
fixation of the hip from a transtrochanteric insertion, but problems
with material compatibility and the rigors of surgery resulted in the
failure of these techniques.127 William Lane, Albin Lambotte, and Ernest Hey-Groves were the pioneers, who developed the modern principles of osteosynthesis.93,124,125,126
The advent of radiology prompted a re-evaluation of hip fracture
treatment, and in 1911 the Section of Surgery of the British Medical
Association reviewed a series of patients with the use of a new
technique of radiographic imaging and concluded that operative
treatment should be performed early when necessary and that function
seemed to be correlated with absence of radiographic deformity.93
The real modern era of internal fixation of hip fractures began with
the report of the technique by Smith-Petersen in 1925 and his invention
of the triflange nail for hip fractures.197
The triflange design controlled rotational instability and was strong
enough for patient mobilization. It was used for both trochanteric and
femoral neck fractures. Brittain using a very low placement on the
lateral cortex of the femur treated pertrochanteric fractures with the
Smith-Petersen nail, presaging the later high angle type devices.27,108
Sven Johansson in Sweden developed the technique simultaneously with
Westcott in the United States of a radiographic controlled insertion of
the Smith-Petersen Nail without arthrotomy 1932.68,215 This was termed blind nailing,
and began the movement toward minimally invasive surgery. Johansson
also is credited with developing the first cannulated Smith-Petersen
nail. In 1934 King and Henderson independently reported the use of
K-wires for provisional fixation, as described by Lambotte for guidance
and proper placement of the Smith-Petersen nail.90,115
In the 1930s, Henry, Littman, Henderson, and others reported on the use of a lag screw type devices instead of nails.91,92,131
It was not until the late 1930s and early 1940s that plate attachment
to the femoral head fixation truly lay the groundwork for the movement
from nonoperative to surgical treatment for pertrochanteric fractures.
Lawson Thornton is credited with the first attachable side plate bolted
to a Smith-Petersen nail205 in 1937.
Within 10 years there was an explosion of new devices. The Jewett Nail,
which was a triflange nail welded to a plate for shaft fixation.107
Jewett was the first to advocate the open reduction of the “lesser
trochanter” (posteromedial fragment) with separate screws to increase
the stability of the fracture. Blount in conjunction with Moore in the
1940s actually coined the terminology and concept of blade plates.22,144 Neufeld in California and Capener in the United Kingdom developed the fixed-angle type nail plate in 1944.33,203
Trochanteric buttress plates were first reported by Boyd and Griffin in
1949 (they were invented by Richardson at the Campbell Clinic) for
preventing medialization with the Neufeld plate in unstable fractures.26 Boyd reported on refinements of the buttress technique in 1961, including screw fixation into the trochanter.25
The primary motivation of surgical implants in the 1930s
and 1940s was the belief that surgical fixation decreased mortality
from prolonged bed rest and eliminated the need for spica casts. Early
reports suggested that patients could be mobilized more rapidly and
with less hospitalization time. In 1949, Evans reported on the use of a
Neufeld nail type technique with open reduction compared with
nonoperative treatment for fractures and favored surgical repair on the
basis of four parameters that are still pertinent today: (i) Greater
pain relief and comfort of the patient; (ii) improved early patient
mobility; (iii) economy of bed control for nursing and hospital
efficiency; and (iv) lower mortality rate (18% compared with 33% for
nonoperative treatment).56
The mechanical analysis of hip fracture fixation began
in the 1940s with the realization of the magnitude of the hip forces by
Inman and the effect of compression on healing by Eggers.51,103 Smith developed mechanical cadaver testing to reproduce fractures and determine the forces required for their causation.196
In a review of implant failures, Taylor and Neufeld proposed the need
for implants with sufficient fatigue life and the importance of stable
reductions.203 In 1956 Martz presented the first load to failure testing for common hip implants of the day.138
In analyzing stresses on the human femur, Martz pointed out that on
average walking subjects the femoral head to forces in the vicinity of
400 lb because of momentum and leverages. He applied the engineering
rule of thumb, calling for a safety factor of two, arriving at a force
of 800 lb (3200 Newtons) as adequate resistance to load of a proximal
fixation system. Foster advocated higher angle nail-plates to minimize
the load on the implants base on geometric assumptions on loading.60 Cleveland argued that even with optimized designs some small percentage of implant failure would still occur.40
In 1963 Holt argued that implant failure was related to inadequate mechanical design.95
He was the first to theorize that the rotation was unlikely for
pertrochanteric fractures to justify his design of a round nail plate
(fixed angle design) eliminating flanges on the femoral head component
for rotational control in distinction to previous derivative plates
from Smith-Petersen’s original concept. He believed it unlikely that
the proximal fragment of an intertrochanteric fracture could rotate
after the fracture was reduced, the nail inserted, and the plate fixed
to the shaft because of engagement of bone fragments at the fracture
site. He did not detect any evidence of rotation in the follow-up of
the 100 fractures included in the using his design and technique. He
also was the first to advocate full weight-bearing after surgery when
the implant’s fatigue resistance was adequate for unrestricted loading.
Interestingly, he used bolted shaft fixation screws through the plate.
The invention of sliding compression with a cannulated
system of drilling and insertion was invented by Godoy-Moreira and is
the precursor of this class of implants in 1938.73
As with other devices, it was originally designed for femoral neck
fractures with the focus of minimizing implant failure. The author also
believed that the compression generated by the screw and side bolt
would prevent any rotation or flexion at the fracture site.
Schummpelick et al. described an implant designed by E. Pohl in Kiel,
Germany (the same man who designed for G. Küntscher) of a sliding
cannulated system with a side-plate in 1952.190 Interestingly they did report telescoping of the implant


with collapse of the fracture, leading to a Trendelenburg gait in some
patients. They also reported on the concept of early weight-bearing
with the sliding hip screw.

In 1955 to 1958 Pugh and Massie reported success with
the application of sliding with a nail plate device to minimize medial
penetration of the femoral head and early fatigue failure.139,178
Full weight-bearing was not advised for 4 to 6 months with these
devices. Interestingly Pugh attempted to classify the results on a
functional basis, but “because of the variations in age, as well as the
variation in the general physical status of these patients this was
deemed impractical. In the cases in which solid union occurred the
result was considered good or satisfactory.” The first commercially
available sliding compression hip screw in the United States was
introduced in 1956 in cooperation with K. Clawson of Seattle and
McKenzie of Scotland manufactured by Richards Manufacturing Company of
Memphis, Tennessee.38,39
Their modifications included a blunt-tipped cannulated screw design
coupled to a forged side plate of optional lengths and neck angles.
There was a keyed slot for enhanced rotational stability. The follow-up
series from Mullholland at Clawson’ institution (now Harborview Trauma
Center) in 1975 showed that functional status preoperatively correlated
with the postoperative recovery and mortality seemed to improve with
experience with the use of this device.151
The desire to increase stability of unstable fracture
patterns with proactive valgus oteotomies was popularized by Dimon and
Houston, Sarmiento, Harrington, and others in the 1960s to 1970s.47,87,187
Nonetheless, prospective studies and meta-analysis comparing the
results with sliding hip screws type designs showed no mortality or
functional improvement with osteotomies and a higher risk of blood loss.46,67,87,169
In 1979 to 1980 the issue of stability versus union with
sliding devices was focused by Kyle et al. and Jensen et al., both of
whom reported independently on a revision of the Evans classification
incorporating the lateral radiographic position of the posteromedial
fracture component and its relation to stability with sliding fixation
Kyle et al. showed an increased rate of deformity and collapse with
increasing instability classification. Nonetheless, they reported that
the use of a high-angle sliding nail technique with prophylactic
antibiotic, thromboembolism prophylaxis, and early mobilization was
acceptable for mortality and fixation failure. They did not advocate
the use of osteotomy. In their functional evaluation they considered
occasional pain, permanent limp, and use of a cane a good result.
Jensen et al. related the ability to reduce the fracture and secondary
displacement risk with a CHS type device in their classification
system. With anatomic reduction in both planes with a stable medial
cortex, no secondary displacement occurred. In nonanatomic and/or
unstable fractures they reported a 25% to 69% rate of secondary
displacement. In their statistical analysis, the correlation with
secondary displacement was not an unstable pattern but a lack of
reduction. Regarding the position of the tip of the device, Jensen et
al. advised placement over 10 mm from the articular surface and Kyle et al. within 10 mm to minimize cutout. The question that has persisted is how to address the secondary displacement problem.
In the 1980s to 1990s renewed interest in hip fracture
failures led to a new approach to fixation. In the plate field, Medoff
introduced the biaxial compression hip screw for unstable fractures,
which actually allowed axial compression along the shaft reminiscent of
an Egger’s plate concept in addition to dynamic compression at the
screw plate interface in the head.142
This biaxial compression concept was proved effective to minimize
implant failure in unstable fractures, but with increased shortening of
the leg.135,213
The re-emergence of the importance of rotational instability as a
problem in 2000 prompted Gottfried to develop the PCCP plate system,
which consisted of a side plate with two constrained partially threaded
lag type screws reminiscent of a reconstruction nail-type pattern that
optimized the rotational stability of the hip and minimized damage to
the greater trochanter (lateral wall of the femur).75
Preliminary reports suggest that patients may have a trend toward
earlier functional recovery with this type of device, although further
studies are needed. Locked and hybrid locking plates have been applied
recently for unstable fractures with only preliminary reports thus far.
Cephalomedullary implants are devices inserted with a
closed technique and fluoroscopic control with variable length femoral
geometry and enhanced proximal geometry to permit fixation with nails
or screws into the femoral head. They evolved from the Y-nail design of
G. Küntscher in 1940, described in the marrow nailing method in the
translation prepared by the U.S. naval forces, Germany technical
section in 1947, discovered in 2006.123
This was a nonlocking unreamed nail with an impaction-type nail
component for the femoral head driven through a perforation in the
centromedullary nail. The Zickel nail primarily developed for
subtrochanteric fractures was another impaction-type nail for the
femoral head, but with no distal locking capability. The TFN (Synthes,
Paoli, PA) is the most recent addition to this class of implant.
The Grosse-Kempf gamma nail and the Russell-Taylor
reconstruction nail were the start of two new classes of intramedullary
devices designed for the hip region; they coincided with the widespread
adoption and popularity of closed interlocking techniques in the 1980s
and 1990s. These devices made use of a compression screw inserted into
an intramedullary device instead of a nail for the femoral head
component. The gamma nail used an expanded head geometry of 17 to 18 mm
with a large single lag screw, and the reconstruction nail allowed a
smaller head geometry of 15 mm with two smaller lag screws for the head
component. Both devices have evolved over the past 20 years, with the
modern designs moving toward a 4- to 5-degree proximal bend with a
medial or tip trochanteric portal instead of a lateral trochanteric or
piriformis portal, respectively.
In 2004 the InterTAN class cephalomedullary nail
(Smith-Nephew, Memphis, TN) began clinical studies. It has a
trapezoidal cross-sectional geometry to protect the lateral wall of the
greater trochanter and a hybrid nail design similar to a hip prosthesis
stem for proximal nail stability in the shaft as well as linear
compression through an integrated screw construct in the femoral head,
resulting in much greater resistance to rotational instability and
Nonoperative Treatment
Nonoperative treatment should only be considered in
nonambulatory or chronic dementia patients with pain that is
controllable with analgesics and rest, terminal disease with less than
6 weeks of life expected, unresolvable medical comorbidites that
preclude surgical treatment, and active infectious diseases that
preclude insertion of a surgical implant. An exception to this
consideration are incomplete pertrochanteric fractures diagnosed by
MRI, which have been shown to heal with conservative


measures in selected patients.4,189
Nonoperative management must include attentive nursing care with
frequent positioning to avoid decubiti, attention to nutrition and
fluid homeostasis, and adequate analgesis/narcotic pain suppression.
Fracture callus formation at 3 weeks markedly decreases motion-related
pain, and by 6 weeks most patients can be lifted into a wheelchair or
reclining chair. Ambulatory capablility should not be anticipated after
nonoperative treatment. Meta-analysis of randomized trials does not
suggest major differences in outcome between conservative and operative
management programs for extracapsular femoral fractures, but operative
treatment appears to be associated with a reduced length of hospital
stay and improved rehabilitation.162
Opponents of nonoperative treatment even for nonambulatory patients
suggest that surgery is more effective for pain relief and does not
result in unacceptable increased mortality or complications.

If nonoperative care is selected because of an
excessively high risk of mortality form anesthesia and surgery, the
patient is nonambulatory and has minimal discomfort from the fracture,
or modern medical facilities are unavailable, then the strategy
previously discussed by Cooper20 of
rapid mobilization to chair and an upright chest position is
recommended. Mobilization is necessary to minimize decubitus,
pneumonia, and dementia. This form of treatment precludes any future
independent mobility.170
Operative Treatment
Once selected, surgical management should be performed
as soon as any correctable metabolic, hematologic, or organ system
instability has been rectified. Usually this is within the first 24 to
48 hours. The literature is inconclusive as to increased mortality
after this time, but patient suffering and hospital efficiencies demand
timely intervention. Holt et al. found that case mix variables (age,
gender, fracture type, prefracture residence, prefracture mobility, and
ASA scores) were the critical aspects of potential for mortality even
when corrected for time of fracture to treatment, admission time to
surgery, and grade of surgical and anesthetic staff undertaking the
procedure. Centers with experience and protocols for the rapid
diagnosis and treatment of hip fractures can effectively decrease the
hospitalization time and complication risks for these injuries.172,204 Interestingly, earlier surgery has not been found to be associated with a higher mortality or morbidity.113
Browne et al. found that surgeons with low volumes of experience (fewer
than seven cases per year) compared with high-volume hip fracture
surgeons (more than 15 cases per year) had higher rates of mortality
and complication, but that high- versus low-volume hospitals were
associated only with shorter hospital stay and lower nonfatal morbidity.30
TABLE 48-1 Classification of Plates



Failure Modes


Blade plates

Medial penetration

Nail plates


Dynamic compression

Sliding hip screw


Adjustable hip nails

Plate pull-off

Dynamic helical blades

Linear compression

Gotfried PCCP

Less risk of cutout?


Hybrid locking

Proximal femoral locking plates

Plate failure

Surgical implant options included plate and screw
constructs, either nail or screws for the head fixation, nail
constructs with either nail or screws, external fixation, and
arthroplasty. Generically these options can be grouped to designs with
common biomechanical behaviors, techniques, complications, and results.
The literature is exhaustive, with series of specific techniques and
implants designs and a fair number of meta-analyses and randomized
prospective studies.
Plate constructs may be grouped into four functional types:
  • Impaction class: Impacted nail-type plate devices (e.g., blade plates, fixed angle nail plate devices)
  • Dynamic compression class: Large single
    sliding screw or nail femoral head components with side plate
    attachments (e.g., standard sliding hip screws)
  • Linear compression class: Multiple head
    fixation components controlling rotation and translation but allow
    linear compression (e.g., Gotfried PCCP and the InterTAN CHS)
  • Hybrid locking class: Multiple fixation
    components with compression initially for fracture reduction followed
    by locking screws which prevent further axial compression; these types
    of fixation are the most stable (e.g., proximal femoral locking plates
    [Synthes, Paoli, PA, and Smith-Nephew, Memphis]) (Table 48-1).
Impaction or fixed angle plating today is more commonly
used for corrective osteotomies rather than as a primary treatment for
hip fractures. MacEachern reported on the difference of failure
mechanisms with medial penetration of the joint with the Jewett Nail
compared with the sliding hip screw.136
Attempts at modifying the results of nail plates with osteotomies fell
out of favor when comparisons were made with sliding hip screw devices
with anatomic reduction only giving equivalent results with less blood
loss and more rapid operative times.169
Chinoy et al.169 in a
1999 meta-analysis, compared accurately fixed nail plates with sliding
implants involving a total of 2855 patients. Results showed an
increased risk of cutout (13% vs. 4%), nonunion (2% vs. 0.5%), implant
breakage (14% vs. 0.7%), and reoperation (10% vs. 4%) for fixed nail
plates in comparison with the sliding implants. In addition, patients
treated with fixed nail plates had a higher mortality and the survivors
were more likely to have residual pain in the hip and


mobility. The continued use of fixed nail plates gave way in the 1980s
to the unequivocal superiority of the sliding hip screw due to these

Dynamic Compression Plating
From the 1980s to 2000, sliding compression hip screws
became the gold standard for hip fracture fixation, and many surgeons
still contend its usefulness in all fractures largely because of the
reports of Clawson, Mulholland, and meta-analysis studies by Parker et
al. from 2000 to now (Figure 48-10).164,167,168
In 1983 Rao evaluated 162 cases of unstable intertrochanteric fractures
treated by anatomic reduction and compression hip screw fixation. After
compression was applied, 90% of the fractures moved into medial
displacement position; 8% laterally displaced; and 2% maintained their
anatomic alignment. Loss of fixation with unacceptable varus angulation
of the fracture occurred in 4% of cases. One hundred ten patients were
bearing full weight an average of 3 weeks after operation. They stated
that the advantages of the sliding hip screw were that weight-bearing
could start early; the device was applicable to stable and unstable
intertrochanteric fractures with identical technique; and the fixation
maintained acceptable alignment.
Kyle et al. advocated 150-degree Massie telescoping
nails with a center-center head position within 10 mm of the
subchondral bone for all fractures, anatomic reduction, prophylactic
antibiotics, prophylactic anticoagulation, and early ambulation,
without osteotomy or interfragmentary fixation except as a
consideration for unstable components in Kyle type 4 in conjunction
with delayed ambulation (although they noted its ineffectiveness). In
classifying their outcome data, they considered a “good result” as
normal hip range of motion, a noticeable limp, occasional pain, and
routine use of a cane; and with this definition they achieved a 96%
good and excellent functional result.
The Medoff sliding plate (Medpac, Culver City, CA) design uses a biaxial sliding hip screw (Figure 48-11).
It has a standard lag screw/barrel component for compression along the
femoral neck. In place of the standard femoral side plate, it uses a
coupled pair of sliding components that enable the fracture to impact
parallel to the longitudinal axis of the femur. A locking set-screw may
be used to prevent independent sliding of the lag screw within the
plate barrel; if the locking set screw is applied, the plate can only
slide axially on the femoral shaft (uniaxial dynamization). If the
surgeon applies the implant without placement of the locking set screw,
sliding may occur along both the femoral neck and femoral shaft
(biaxial dynamization). For most intertrochanteric fractures, biaxial
dynamization is suggested.
FIGURE 48-10 Compression hip screw components: lag screw, blunt tip, side-plate of fixed angle and cortical shaft screws.
FIGURE 48-11 Medoff sliding plate.
Watson et al. compared the Medoff plate with a standard
sliding hip screw in a prospective randomized series of 160 stable and
unstable intertrochanteric fractures; follow-up averaged 9.5 months
(range, 6 to 26 months).213 Although
stable fracture patterns united without complication in both treatment
groups, there was a significantly higher failure rate with use of the
sliding hip screw for unstable fractures (14% vs. 3%). No differences
were observed between the two devices in terms of length of
hospitalization, return to prefracture ambulatory status, postoperative
living status, or need for postoperative analgesic medication.
Nonetheless, use of the Medoff plate for all fracture types was
associated with significantly greater blood loss and operating time.
Olsson et al. reported on a prospective randomized
series of intertrochanteric fractures stabilized using either a Medoff
plate or conventional sliding hip screw.153,154
In unstable fracture patterns, mean femoral shortening was
significantly greater with use of the Medoff plate (15 vs. 11 mm), but
the sliding hip screw was associated with more medialization of the
femoral shaft. All failures occurred in the sliding hip screw group.
Ekstrom et al. compared the proximal femoral nail (PFN,
Synthes) and the Medoff sliding plate (MSP) in patients with unstable
trochanteric or subtrochanteric fractures. They reported that the
ability to walk 15 meters at 6 weeks was significantly better in the
PFN group compared with the MSP group, with an odds ratio 2.2 (P
= 0.04, 95% confidence limit, 1.03 to 4.67). Reoperations were more
frequent in the PFN group (9%) compared with the MSP group (1%), but
there were no other significant differences.53
The current literature suggests that there is no
difference in mortality or functional recovery between compression hip
screws and intramedullary nails with single device fixation in the
femoral head. Interestingly the term malunion of a pertrochanteric fracture dropped out of usage after the 1970s and the emphasis was placed on implant failure.
Recently the sliding hip screw and similar devices have come


under scrutiny for its application to all fractures. Haidukewych et al.
noted a higher rate of failure with sliding hip screws for reverse
obliquity intertrochanteric fractures caused by excessive medialization.85 Gotfried noted the high failure rate with associated lateral wall fractures with compression hip screws.76
The effect of shortening of the limb and changes in abductor function
with collapse has always been in the background of the hip literature.

In a retrospective analysis of postoperative fracture
collapse in 142 patients with intertrochanteric hip fractures fixed
anatomically with sliding hip screws, Bendo et al. found collapse (as
defined by strict radiographic criteria relating the height of the
femoral head to the greater trochanter and Doppelt’s criteria) was seen
in 26 of the unstable fractures. Of the patients with moderate or
severe collapse, 93% had a poor functional result, whereas all the
patients with minimal collapse remained asymptomatic. Although
postoperative fracture impaction of hips fixed with sliding screws may
promote early healing, a high rate of union, and a low rate of hardware
failure, excessive collapse is a problem that must be addressed.18
Platzer et al. expressed concern about the amount of
shortening with compression hip screws in non-geriatric patients with
compression hip screw fixation.177
The concern that many surgeons share is the question of functional
impairment with excessive dynamic collapse. Zlowodzki et al. recently
quantified a lower SF-36 score with shortening more than 5 mm in
femoral neck fractures;224 it may be
that the transitional displacement during the first 6 weeks after
surgery with compression side plates may be an underlying problem with
recovery after surgery. Kamath et al. documented significantly more
collapse with compression hip screws in basicervical fractures compared
with reconstruction nail type constructs.109
When the lesser trochanter was intact, plate fixation was associated
with ten times more collapse than nail fixation (8.1 vs. 0.7 mm); and
with complete displacement of the lesser trochanter, the relative
shortening was twice as much for the plate group versus the nail group
(16.1 vs. 8.1 mm). Su et al. reported a greater tendency to collapse
and pain increase with basicervical fractures compared with
intertrochanteric fractures treated with compression hip screws (Figure 48-12).200
Pajarinen et al. reported less deformity with nail devices compared
with SHS and recommended over correction of the hip into valgus to
anticipate the varus collapse with SHS.160
Moroni et al. have explored the potential of augmenting
the stability of the compression hip screw with hydroxyapatite coating.
One hundred twenty patients with AO, A1, or A2 trochanteric fractures
were selected. Patients were divided into two groups and randomized to
receive a 135-degree four-hole dynamic hip screw fixed with either
standard lag and cortical AO/ASIF screws or HA-coated lag and cortical
AO/ASIF screws. Lag screw cutout occurred in four patients in with
conventional uncoated lag screws but no cutout occurred in the HA
group. The femoral neck shaft angle collapse from an average 134
degrees postoperatively to 127 degrees at 6 months in the standard CHS
group; but in the HA-coated group, the femoral neck shaft angle was 134
degrees postoperatively and 133 degrees at 6 months. The Harris hip
score was higher at 6 months in the coated group (60 vs. 71), although
the study was relatively small.146
Rotationally Stable Plating
Rotational stable plating differs from dynamic
compression plating by adding enhanced rotational stability with
multiple screw fixation in the femoral head. Because the screws are
coupled to the plate, the rotational stability is much better than an
accessory screw adjacent to standard single screw fixation (Figure 48-13).
The percutaneous compression plate by Gotfried (Orthofix, McKinney, TX)
has two smaller-diameter lag screw/barrel components, which stabilize
the femoral head and neck. This device was designed with a minimally
invasive surgical technique. The two lag screw components (9.3- and
7.0-mm diameter) provide enhanced rotational stability of the proximal
fracture.77 The device is available
only in 135-degree angles. It was reported initially by Gotfried in 98
fractures with good results and no collapse, head penetration, or
cutout. The InterTAN CHS (Smith-Nephew) consists of a 127- and
135-degree design with two integrated screws, with the option of locked
or standard shaft fixation.
FIGURE 48-12
Healing short CHS AP radiograph. Healing of 31A1 fracture with
shortening. Note accessory lag screw back out and compression screw
prominence in soft tissues.
In 2007 Peyser et al. found in their randomized trial
comparing dynamic hip screw and PCCP that the pain score and ability to
bear weight were significantly better in the PCCP group at 6 weeks
postoperatively. Radiographically there was a reduced amount of medial
displacement in the PCCP group (two patients, 4%) compared with the CHS
group (10 patients, 18.9%).176 In a
recent presentation of a randomized prospective group of dynamic hip
screw versus PCCP, Yang documented improvements in pain and ambulatory
ability with improved SF-36 scores in the PCCP group.222
Panesar161 performed
a meta-analysis review of comparative trials (1995 to 2006) comparing
the dynamic hip screw and the PCCP. There was a decreased trend in
overall mortality in the PCCP group [CI 0.84 (0.48 to 1.47)]. Similar
trends favoring the PCCP technique were seen with other outcomes. A
large randomized controlled trial was recommended. Other devices with
enhanced rotational stability, such as the InterTAN CHS


and the helical blade plate, are now being studied (Figures 48-14 and 48-15).

FIGURE 48-13 A. Percutaneous compression plate (PCCP). B.
InterTAN CHS device. Similar to CHS design but incorporates compression
mechanism in second inferior screw for enhanced rotational stability.
Hybrid Locking Plates
With the success of locking and hybrid locking plates
with unstable fractures of the distal femur, the same concepts are
being applied to the proximal femur. The devices offer maximal
stability with initial compression, and fixed angle stability from
locking screws.106 Initial results
are mixed because of early failure rate with original plate designs and
three screw limitations. Newer devices with enhanced fixation strength
may be helpful in complex intertrochanteric fractures with
subtrochanteric extension (Figure 48-16).
FIGURE 48-14
PCCP reduction and fixation. Note inferior placement of bottom screw
and protection of the greater trochanter by distal plate position.
Cephalomedullary Devices
Cephalomedullary devices are inserted through the
piriformis fossa, lateral greater trochanter, or medial greater
trochanter. The femoral head portion of the fixation construct consists
of one or more screw or blade devices interlocked with the nail
component of the construct. Cephalomedullary nails are most commonly
indicated in pertrochanteric and subtrochanteric fractures, and
although there is occasional overlap of these regions, the personality
of the fracture will be predominantly one of these major types. These
nails are designed to have either a pirforimis portal for insertion,
usually with the shaft component straight in the AP plane, or a
trochanteric portal, with the shaft component laterally angulated
proximally. Modern trochanteric designs have moved to a 4-degree
proximal bend positioned above the lesser trochanteric region, which
seem to function best.158
Cephalomedullary nail constructs have been similarly classified by Russell into four classes (Table 48-2),183 listed here in order of invention:
  • The impaction class or Y nail class originated with the Küntscher Y nail and current TFN Nail (Synthes) (Figure 48-17A).
  • The dynamic compression or gamma class
    pioneered by the Grosse and Kempf Gamma Nail (Stryker-Howmedica), which
    consists of a large head nail component (15.5 to 18 mm) with a single
    large lag screw (Figure 48-17B and 17E).
  • The reconstruction class developed by Russell and Taylor (Smith-Nephew) (Figure 48-17C), with a smaller head diameter (13 to 15 mm) and using two lag screws that are independent of each other.
  • The integrated class, consisting of a
    nail design cross-section with the stability of a arthroplasty hip stem
    and integrated two-screw construct with linear compression at the
    fracture site, developed by Russell and Sanders (Smith-Nephew) (Figure 48-17D).

FIGURE 48-15 InterTAN CHS case. A. Preoperative radiograph showing 31A2 fracture with greater trochanteric fracture lines and lesser trochanteric fracture. B. AP postoperative radiograph showing fixation. Stability of greater trochanter is maintained. C. Lateral postoperative radiograph.
Impaction Class (Y-Nail, TFN)
Davis et al. assessed outcomes and the etiology of
mechanical failure in a series of 230 intertrochanteric femoral
fractures internally fixed with either a sliding hip screw or a
Küntscher Y-nail.44 The cutout rate
for the Y-nail was 8.8% versus 12.6% for the sliding hip screw overall.
Cutout was related to the quality of the fracture reduction; age,
walking ability, and bone density had no significant influence on
cutout. Center-center placement of the head component correlated with
less cutout, and posterior placement increased cutout with both groups.
Y-nail cutout or medial penetration increased with articular placement
less than 10 mm from the tip of the nail (23% Y-nail, 11% CHS), whereas
Y-nail medial penetration decreased with tip placement greater than 10
mm (3% Y-nail vs. 18% CHS).44
The TFN (Synthes) device reintroduced an impaction nail
component for the femoral head of a helical blade design of 11 mm
inserted into a nail with a 17-mm proximal geometry. There are short
and long interlocking versions.66 In
a biomechanical study Sommers et al. showed better resistance to
rotation with the helical blade compared with single screw designs.198
The surgical technique precludes reaming of the femoral head, thus
saving bone stock and preventing instability of the fracture by a loose
nail. Gill et al.,72 comparing CHS
with TFN, revealed fewer blood transfusions with CHS and faster
operative time for the TFN group. Gardner et al. reported subtle
migration (approximately 2 mm) of the tip of the blade within the
femoral head in all fractures, but this did not preclude maintenance of
reduction and fracture healing. They noted that telescoping averaged 4
mm and did not affect stable fixation or fracture healing. All position
changes occurred within the first 6 weeks


postoperatively.66 Weil et al.214
reported medial penetration with the TFN analogous to the Y-nail type
penetrations described earlier. All eight clinical cases involved an
unstable intertrochanteric fracture pattern (AO/OTA 32A2).

FIGURE 48-16 Hybrid locking plate system (Smith-Nephew, Memphis, TN).
Dynamic Compression Class (Single Screw Head Component)
Since the introduction of the Gamma nail in the early
1980s, an exhaustive series of studies have guided its use and
modifications. Although initially a lateral trochanteric entry nail
with a 10-degree angle and a short nail, the design is now in its third
major revision with decreases to 15.5 mm in head geometry from 17 mm.
Angulation has decreased to 4 degrees for a tip trochanter entry site,
and its distal geometry has been tapered for less risk of
periprosthetic femur fractures (its main detraction in early studies).
The IMHS is a similar class nail with a sliding sleeve in the barrel to
promote dynamic compression (Figure 48-17E).
The clinical studies must be referenced to the different designs and
time periods for correct analysis. Adams et al. reported a prospective
randomized study comparing a sliding hip screw with an intramedullary
nail for treatment of intertrochanteric fractures.3
Two hundred and three patients were stabilized with a short gamma nail,
197 received a sliding hip screw. Patients were followed for 1 year.
Use of the gamma nail was associated with a nonsignificant higher risk
of postoperative complications and equivalent union and functional
TABLE 48-2 Classification of Nails



Failure Modes


Y-Nail, TFN

Medial penetration

Dynamic compression

Gamma, IMHS


Peri-implant failure with short designs

Two-screw dynamic compression



Linear compression integrated



In 1988 Hardy et al. reported the intramedullary
hip-screw device compared with the CHS was associated with
significantly less sliding of the lag-screw and subsequent shortening
of the limb in the region of the thigh. Patients whose fractures were
stabilized using the intramedullary hip screw experienced significantly
better mobility at 1 and 3 months follow-up. This difference was no
longer seen at 6 and 12 months, although patients who received the
intramedullary device enjoyed significantly better walking ability
outside the home at all time periods.
Currently Parker et al. report that there is no
consensus regarding the superiority of the dynamic compression nails or
plate type devices and that future studies with the same devices are
unneccesasry.168 There is also
evidence that the complications with nail devices are more frequent.
Despite this evidence, the trend for intramedullary fixation has
increased in the United States.7
Reconstruction Nail Class (Two Screw Head Components)
Reconstruction nails (Smith-Nephew) were initially
developed by Russell and Taylor in the early 1980s primarily for
complex subtrochanteric fractures and pathologic fractures. In 1991,
the Russell-Taylor reconstruction nail was first described for
intertrochanteric fractures in four cases.97
Different versions of this class have in common a smaller diameter head
(13 to 15 mm) with two lag screws of various diameters with long and
short interlocking versions. The original piriformis reconstruction
nail has been modified for medial trochanteric portal insertion, which
simplifies treatment for pertrochanteric fractures. Piriformis
reconstruction nails do no have optimal containment in the trochanter
because of their posterior placement in relation to the femoral head
and neck; they transfer essentially all the load to the head screws.
Trochanteric versions allow better containment of the nail in the
proximal femur and are optimally placed to minimize femoral neck
shortening (Figure 48-18).
Seif-Asaad reported good results in 40 patients using
the Variwall reconstruction nail for unstable intertrochanteric
fractures with 12 patients having subtrochanteric extension.191 Thirty-nine patients healed without deformity, shortening, or varus collapse.
Little et al., using the Holland nail in a comparative
series with CHS, demonstrated less blood loss and transfusion, no
cutout in the nail group, and all fractures united in the Holland


nail group.133
In a more complex group with both pathologic and multiple trauma cases,
Krastman et al. reported an 89% union rate with Holland nails in two
cases with screw penetration of the femoral head.118
The PFN (Synthes) was associated with a high implant failure rate and
the Z-effect of overpenetration of the cephalic screw proximally and
backing out of the inferior screw and has been discontinued in the
United States.10,31,59,194 The device brought attention to the differences in bone quality and effect of rotation with this type of fixation (Figure 48-19).199

FIGURE 48-17 A. Short trochanteric fixation nail (TFN). B. Short gamma 3 intramedullary nail. C. Short trochanteric antegrade nail (TAN). D. Short InterTAN cephalomedullary nail with integrated screw design and hybrid stem design. E. Short intramedullary hip screw (IMHS).
InterTAN Class (Integrated Nail and Screws with Linear Compression)
The InterTAN nail is a titanium alloy nail with a
proximal femoral cross-section similar to a press-fit arthroplasty stem
for shaft stability, an integrated screw mechanism that provides linear
compression of the fracture while moving the stem toward the medial
femoral cortex with compression and stress relieving the lateral wall.
It is a trapezoidal design proximally with a 16-mm diameter that tapers
like a hip stem with a 4-degree bend for medial trochanteric insertion.
It is available in 125- and 130-degree


long and short. The short version includes dynamic locking above a
split tapered tip design to minimize implant stress in the diaphysis.
Like the gamma and Y-nail class nails, it is indicated for older
patients with pertrochanteric fractures with Dorr B and C type
morphology (Figure 48-20).

FIGURE 48-18 A. 31A3 with subtrochanteric extension. B. Reduction and repair with long TriGen trochanteric reconstruction nail. C. Recon case lateral postoperative radiograph.
In 2009 Ruecker et al. reported results with the
InterTan femoral head for the treatment of intertrochanteric fractures
that uses two screws in an integrated mechanism, allowing linear
intraoperative compression and rotational stability of the head/neck
fragment.182 One hundred consecutive
patients with an intertrochanteric fracture were treated with the new
trochanteric antegrade nail (Smith-Nephew). The mean age of the
patients was 81.2 years. Thirty-seven patients died. The average
surgical time was 41 minutes (13 to 95 minutes). All fractures healed
within 16 weeks (range, 10 to 16 weeks). Forty-eight remaining cases
had detailed radiographic analysis at healing that revealed no loss of
reduction, no uncontrolled collapse of the neck, no nonunions, no
femoral shaft fractures, and no implant failures. Two cases in the
series were poorly reduced and settled into varus malalignment. No
varus malposition was seen in the remaining 46 fractures. The mean
prefracture Harris hip score was 75.1 ± 13.4, and at the time of
follow-up was 70.3 ± 14.5 (P = 0.003); 58%
of the patients recovered prefracture status. They concluded that the
InterTAN device appeared to be a reliable implant with stability
against rotation and resultant neck malunions (shortening) through
linear intraoperative compression of the head/neck segment to the
shaft. Further studies are in process for comparative analysis.
FIGURE 48-19
Demonstration of the “Z effect,” with one screw penetrating the hip
joint and the other screw backing out of the nail. (Courtesy of Enes
Kanlic MD, Texas Tech University Health Sciences Center, El Paso, TX.)
External Fixation
External fixation as a treatment for pertrochanteric
fractures was evaluated in the 1950s, but its use was unsuccessful
because of high rates of pin-tract infections, subsequent pin
loosening, instability, and failure.12,78,119
Renewed interest in this technique occurred recently with the new
fixation designs and the addition of hydroxyapatite coated pin
technology. The addition of the HA coated half-pins with the Orthofix
pertrochanteric fixator by Moroni et al. has resulted in equivalent if
not better results than compression hip screws in 31A1-A2 osteoporotic
fractures.148 There were no pin
tract infections and equivalent functional results by the Harris hip
score comparisons (approximately 62 for both groups). More interesting
is the lower rate of varus collapse of on average 2 degrees versus 6
degrees for the CHS group. The CHS group averaged 2 units of blood
replacement versus none for the external fixation group. Surprisingly,
the external fixation group reported equivalent or slightly less pain
than the CHS group (Figure 48-21).

FIGURE 48-20 A. 31A3 fracture with C-type morphology. B. Reduction and stabilization with InterTAN nail. Note alignment of nail paralleling the anterior cortex proximally. C. InterTAN case lateral postoperatively. D. Long nail selection due to wide diaphysis with loss of isthmus anatomy owing to aging and osteoporosis. E. Union without collapse or backing out of proximal fixation. F.
Note medialized nail position owing to integrated screw mechanism
inducing translation of nail to medial cortex, unloading lateral wall.
External fixation as reported by Moroni et al. may be
indicated in osteoporotic hip fractures in elderly patients, who may be
deemed at high risk for conventional open reduction and internal
fixation, or for those who cannot receive blood transfusions because of
personal conviction or religion. It may be superior to standard
compression hip screws in these patient groups.
Arthroplasty either hemiarthroplasty or total hip
arthroplasty, often with calcar replacement type components, is rarely
indicated in pertrochanteric fractures.211
Arthroplasty may be justified in neoplastic fractures, severe
osteoporotic disease, renal dialysis patients, and pre-existing
arthritis under consideration


hip replacement before the fracture occurred. Hemiarthroplasty, usually
cemented, has been reported to have a lower dislocation rate compared
with total hip arthroplasty. Haentjens et al. reported on 37 patients
more than 75 year old with unstable intertrochanteric or
subtrochanteric fractures from 1983 to 1986. Functional results were
rated as good to excellent in 75% of patients, but there was a
mortality rate of 36% and a dislocation rate of 44%.81
In a review of 29 THA and 5 HA patients with an average age of 80
years, Berend et al. reported 26/34 deaths within the study period of
12 years, with five patients requiring revision surgery for
dislocation. They did not believe their results supported the routine
use of arthroplasty in this elderly patient group.19

FIGURE 48-21 A. Preoperative radiograph showing a pertrochanteric fracture in an 83-year-old woman. B.
Immediate postoperative radiograph. (From Moroni A, Faldini C, Pegreffi
F, et al. Osteoporotic pertrochanteric fractures can be successfully
treated with external fixation. J Bone Joint Surg Am 2005;87:47.)
Conversely, between 1992 and 2005 Geiger et al.70
compared the mortality risk and complication rate after operative
treatment of pertrochanteric fractures with primary arthroplasty,
dynamic hip screw (DHS), or proximal femoral nail in this retrospective
study. Of these 283 patients, 132 were treated by primary arthroplasty,
109 with a DHS, and 42 with a PFN. Mortality was significantly
influenced by age, gender, and comorbidities, but not by fracture
classification. Primary hip arthroplasty did not bear a higher 1-year
mortality risk than osteosynthesis in a multiple regression analysis.
The main complication with DHS and PFN were cutting out of the hip
screw and nonunion, with a revision rate of 12.8%. With the
introduction of hemiarthroplasty instead of total hip arthroplasty, the
postoperative dislocation rate decreased from 12% to 0%. In a
randomized study, Kim et al. found a lower mortality and less blood
loss with a cephalomedullary nail compared with a cementless calcar
replacement arthroplasty with equivalent functional results.114
The general consensus is that arthroplasty is a better
salvage operation for failed internal fixation than a first-line choice
in the geriatric fracture patient; and there is no level-one evidence
to show any difference between compression hip screw and arthroplasty,
with the exception of a higher blood transfusion rate with arthroplasty.165
Medical Complications
A retrospective cohort multicenter study of patients 60
years or older found a rate of 1737 (19%) with postoperative medical
complications in 8930 patients.129
Interestingly, 81% of these patients had no medical complications after
hip fracture repair. Cardiac and pulmonary complications were most
frequent (8% and 4% of patients, respectively). Other complications
were gastrointestinal tract bleeding (2%), combined cardiopulmonary
complications (1%), venous thromboembolism (1%), and transient ischemic
attack or stroke (1%). Renal failure and septic shock were rare. After
the index complication, 416 patients had 587 additional complications.
Mortality was similar for serious cardiac or pulmonary complications
(30 day, 22% and 17%, respectively; 1 year, 36% and 44%, respectively)
and highest for patients with multiple complications (30 day, 29% to
38%; 1 year: 43% to 62%).129
Psychosocial Complications
Patients frequently have concerns regarding their
imminent mortality, especially if they have had loved ones’ who have
died from hip fractures in the past. They have questions regarding
their ability to walk again or be independent enough to return to their
own home. Most surgeons consider union of any type to be a successful
treatment, whereas from a patient’s perspective it is a return to the
previous level of functional activity and home environment that is
The fear of falling can be a devastating complication of
recovery, and this is best addressed by the patient’s ability to trust
in the injured extremities’ support.17,159
Patients with improved mobility early in the postoperative period
develop better functional abilities at the 3- and 6-month periods.201
Ziden et al. reported multidimensional and dramatic changes in
patients’ life situations, including existential thoughts and
reappraisal of the years of life that remained. The results indicate
that the fracture seemed not only to break the bone, but also to cause
social and existential cracks leading some patients to a positive
socially interactive lifestyle and others to a depressive, defeatist
mentality with withdrawal and a diminished zest for life.223
Thromboembolic Complications
Thromboembolic complications are a source of continuing
controversy about proper prophylactic management and postoperative
therapy, considering the added cost and medical surveillance required
and the concern for major hemorrhagic postoperative events.6,71,86,88
Complicating management in the hip fracture patient population is the
preoperative frequency of platelet inhibitors and anticoagulants for
unrelated medical problems. Recommendations from the American College
of Chest Physicians, American Academy of Orthopaedic Surgeons, and
governmental agencies are not in agreement as to the best strategy.
Options include pentasaccharides, low-molecular-weight heparins,
adjusted dose warfarin, mechanical compression, and aspirin.207,216 Prophylaxis has been recommended for 4 to 6 weeks postoperatively because of reports of late pulmonary embolism and DVT.
In a study by Fisher et al. the incidence of a venous
thromboembolic event in the no treatment group was 12%, and in the
mechanical compression group was 4%.58
In 1984 Alho reported a prospective study for the expenditure of
hospital resources and the incidence of clinical venous thromboembolism
under prophylaxis with heparin, aspirin, or warfarin. Thromboembolic
complications were more frequent (P < 0.02) and hospital


costs clearly higher in the low-dose heparin-treated patient group
compared with the aspirin and warfarin groups. There were no distinct
differences between aspirin- and warfarintreated patients either in
results or costs. Nonetheless, carefully monitored treatment with
warfarin with Thrombotest always less than 0.20 appeared to be the most
effective prophylaxis in patients with hip fractures. They use aspirin
as a general prophylaxis in orthopaedic patients, and warfarin in
patients with established risk of thromboembolic complications.5

TABLE 48-3 Pearls and Pitfalls of Treatment of Pertrochanteric Fractures

Key Point


Anteromedial cortex is key to reduction

Best defense against collapse/shortening

Bone quality and fracture pattern determines fixation

Don’t use a low stability device in a high instability risk fracture

Lateral wall continuity key functionality

Prevent damage, repair as necessary

Patient recovery

It’s not the time of operation but the quality of life the patient enjoys later

Who owns the bone?

Orthopaedic surgeons

Pitfalls of Plates Problem


Fracture unreduced

Release traction

Expose anterior fracture

Use Jocher or Cobb to disimpact

Check neck shaft angle, AP translation at fracture site, and rotation: not all reduce with IR

Fracture overdistracted

No soft tissue
attachment for taxis; proceed with open reduction and use K-wires and
Steinmann pins as joysticks with Weber for reduction compression

Fracture loss of reduction with plate

Incorrect angle selection for plate

Check center guidewire. Is it centered in head and neck or eccentric?

Pitfalls of Nails Problem


Loss of reduction with nail insertion

Fully seat nail, then push on proximal nail guide medially to reduce and adjust neck shaft angle

Provisionally fix fracture and reinsert nail

Screw position incorrect

If screw is in
valus or varus, the reduction was lost. Remove screw, correct varus
valgus with nail guide manipulation, redrill, and insert screw in new

Nail lies in posterior position of trochanter

Entry portal damage during reaming. Lift up on nail guide and redrill guidewire. May consider blocking screw technique

In 1993 Feldman et al. evaluated the efficacy of
thromboprophylaxis with aspirin, and dextran 40 was compared in a
prospective review of 530 geriatric hip fracture patients treated
surgically. All patients were also treated with early mobilization with
weight-bearing as tolerated and above-knee elastic stockings. The
incidence of DVT (0.5%) and PE (2.6%) in the aspirin group was
essentially the same as the incidence of DVT (0.3%) and PE (2.4%) in
the dextran group. Neither mortality nor infection rates were
different. They reported the average cost for aspirin at $1.79 per
patient. The safety, cost, and ease of administration of aspirin may
make its use more desirable in their opinion.57
Jeong et al. evaluated aspirin, dextran 40, and enoxaparin in conjunction with above-knee elastic stockings.105
With this protocol they reported a DVT rate of 0.5% to 1.7%, pulmonary
embolism 0% to 2.0%, fatal pulmonary embolism 0% to 0.5%, and no
difference with regard to the effectiveness of each pharmacologic
treatment. Wound hematoma complications were increased with enoxaparin
(3.8%) versus aspirin (2.4%) and Dextran 40 (1.6%).
Fondaparinux prophylaxis for 1 to 4 weeks was reported
as well tolerated, and compared with placebo, it significantly reduced
delayed venous thromboembolism events from 35% to 1.4%. Based on these
findings, a 4-week fondaparinux treatment may become the standard
thromboprophylaxis after hip fracture surgery.55
The effect of change in practice at one center from 1992
to 1997 reflected significant increases in pharmaceutical
thromboembolic prophylaxis (from 45% to 81%) and early mobilization
(from 56% to 70%). There were reduced levels of pneumonia,


infection, pressure sores, and fatal pulmonary embolism, but no change
was recorded in 3-month functional outcomes or mortality.62

Pulmonary embolism may be reduced by prophylactic
anticoagulation, but 17% of patients are at risk of hemorrhage, and
some surgeons advocate mechanical methods as a safer option in this
Nonunion of pertrochanteric fractures with previous
internal fixation is reported to affect 1% of older patients and is
usually treated with total hip replacement. In young patients it is
treated with osteotomy, bone grafting, and implant revision (Fig 48-31).
Vidyadhara et al. reported on using closing lateral wedge valgus
intertrochanteric osteotomy in addition to dynamic hip screw
osteosynthesis in the successful management of seven patients with
varus trochanteric nonunion. Average preoperative coxa vara of 94
degrees (range, 85 to 104 degrees) had improved to a femoral neck shaft
angle of 139 degrees (range, 134 to 145 degrees) on postoperative
radiographs. All fractures and osteotomies had healed. The Harris hip
score improved from 34 (range, 22 to 47) to 89 (range, 83 to 95) at an
average of 11 months follow-up (range, 7 to 13 months).210 Other reports have high success rates with osteotomy and ORIF (82% success).137,185
Hadikewych et al. reported a 95% union rate with a combination of
techniques, including blade plate, DHS, DCS, and Zickel devices. They
added autogenous iliac bone graft in 17 cases versus three allografts;
19/20 nonunions healed with this strategy. Talmo has reported success
with total hip arthroplasty, with a Harris hip score average of 86 at
30 months in 10 patients (Figure 48-32).83,84,202
FIGURE 48-31 A. Nonunion of a 31A3 fracture with CHS displaying maximal shortening with medialization of the distal shaft fragment. B. Distraction nonunion with TFN. Repair requires open reduction, grafting, and compression fixation. C. TFN distraction nonunion on lateral radiograph.
Implant Malfunction
Implant malfunction or failure is estimated to
approximate 5% of cases usually from a combination of implant fatigue
failure, shaft fixation failure with broken screws, femoral head medial
penetration, screw cutout, and disassembly of the device components.
With today’s stringent requirements for manufacturing and quality
control, manufacturing etiology for failure is extremely rare. Fatigue
failures associated with nonunion are most common.
Parker et al. analyzed by the radiographic
characteristics of 27 patients with a trochanteric fracture treated
with a sliding hip screw in which fixation failure occurred, and


with 74 patients having uneventful fracture union. Femoral
medialization was more common in specific fracture types, particularly
if there was comminution of the lateral femoral cortex at the site of
insertion of the lag screw. Femoral medialization was strongly
associated with fixation failure, with a sevenfold increase in the risk
of failure if medialization at more than one third occurred. This
author suggests that implants preventing femoral medialization in
specific types of trochanteric fracture merit further evaluation.163

FIGURE 48-32 A. Nonunion with locking plate. Note deformation of screws. B. Locking plate nonunion, lateral. C. Revision with open reduction, inductive grafting, and compression with InterTAN nail. D. InterTAN revision and union shown on lateral radiograph.
Loss of construct stability is one of the most frequent
complications manifested by collapse of the screw and varus migration
of the femoral head construct with final cutout failure in the worst
cases of screw and nail constructs. This occurs to a small degree in
all cases, as the sliding impaction was designed to minimize
catastrophic cutout, but frequently is compounded by lack of a stable
reduction. A center-center position of single screw devices minimizes
cutout as reported by many authors, but this is reduced to a
mathematical equation as the tip apex distance, as reported by
Baumgaertner16 (Figure 48-33).
A related problem to implant failure is the peri-implant fracture


that may occur around the lateral wall, the region of bone at the end
of a nail or side plate, or distally in the femur. These are problems
with tactics as the issue arises as to removal of the previous implant
or addition of further fixation. Gotfried and Palm et al. have
identified the seriousness of the lateral wall fracture, which
frequently occurs around a compression hip screw. These difficult
fractures require reattachment of the greater trochanter with buttress
plate techniques.80
Fractures distal to plates may be treated with retrograde nails with
removal of the inferior two to three screws of the sideplate to ensure
overlap of the fixation by the nail (Figure 48-34).
Periprosthetic fractures were more common with the first-generation
short trochanteric gamma nails, probably because of the large distal
diameter (up to 16 mm), larger proximal bend, and large distal locking
screws. Periprosthetic fracture rates as high as 17% have been
reported. With the newer design there has been a substantial drop in
periprosthetic femur fractures, but it remains a concern. Fractures
distal to short nails require revision to longer nails or locking
plates if the greater trochanter is also involved.

FIGURE 48-33
The tip-apex distance (TAD), expressed in millimeters, is the sum of
the distances from the tip of the lag screw to the apex of the femoral
head on both the AP and lateral radiographic views.
FIGURE 48-34 A. Peri-implant fracture of the femur below a CHS. Associated osteoarthritis of knee and osteoporosis in community ambulatory. B.
Treatment with retrograde locking nail overlapping sideplate by removal
of distal plate screws percutaneously. Blocking screws are used to
enhance construct stability and alignment. C. Lateral radiograph showing retrograde locking nail with blocking screws and overlap with plate.
Functional Recovery
Cooper et al. state that the consequences of hip
fractures relate to premature death, averaging 20% at 1 year, permanent
disability of 30%, inability to ambulate independently in 40%, and loss
of at least one activity of independent daily living (i.e., driving or
grocery shopping) in 80% of treated patients.42
In 1990 Larson et al. examined the functional 607
trochanteric fractures treated with a sliding-screw technique and
followed clinically and radiographically for at least 1 year. Of 351
patients admitted from their homes, 209 (60%) were discharged to their
homes after an average of 18 days in the hospital. During the first
year another 61 (17%) patients returned home after rehabilitation in a
geriatric ward. Of 446 patients walking without support or with one
cane before surgery, 360 (80%) had regained the same mobility after 1
year. The 1-year mortality rate was 18%, whereas the 10-year rate was
74%. Forty-five (7.4%) were reoperated, 17 because of technical
complications, three because of infection, and three because of
nonunion. The deep infection rate was nine of 339 (2.7%) before and two
of 268 (0.8%) after the introduction of antibiotic prophylaxis.128
Ekstrom et al. reported that even with stable two-part fractures, the 2-year mortality rate was 29%.52
The reoperation rate was 3%. At the final follow-up, 81% of the
patients reported no or only limited pain at the hip, 55% had regained


prefracture walking ability, and 66% had attained their prefracture level of ADL function.

In 2008 Rapp et al.180
evaluated the associated excess mortality with a large nursing home
population in Germany. The crude incidence rates of admission to a
nursing home were 50.8/1000 person-years in women and 32.7/1000
person-years in men. The incidence rates increased with increasing age
categories and were highest in the first months after admission to the
nursing home. Mortality in patients with a hip fracture was increased
(women: hazard rate ratio for the first 3 months after fracture, 1.7
and men the hazard ratio, 2.14) but excess mortality was limited to the
first months after injury.
The introduction of a comprehensive multidisciplinary
fast-track treatment and care program for hip fracture to optimize
patient care has been reported with components such as a switch from
systemic opiates to a local femoral nerve catheter block; an earlier
assessment by the anesthesiologist; and a moresystematic approach to
nutrition, fluid, and oxygen therapy, and urinary retention compared
with standard hospital care. In the intervention group, the rate of any
in-hospital postoperative complication was reduced from 33% to 20%
(odds ratio, 0.61, 95%; confidence interval; 0.4 to 0.9; P = 0.002). Rates of confusion (P = 0.02), pneumonia (P = 0.03), and urinary tract infection (P
= 0.001) were lower in the intervention group than the control group,
and length of stay was 15.8 days in the control group versus 9.7 days
in the intervention group. For community dwellers, 12-month mortality
was 23% in the control group. This study supports the concept of hip
fracture program to reduce the rate of in-hospital postoperative
complications and mortality. Randomized clinical trials are required to
validate and elucidate the elements of the program that have the
greatest effect on clinical outcomes and mortality.172
Infection occurs in 1% to 2% of postoperative patients
and is minimized by preoperative antibiotics, usually a cephalosporin
class drug. In immunocompromised and malnourished patients, standard
care involves isolation and sensitivity testing of the causative
bacteria and appropriate intravenous antibiotics in consultation with
an infectious disease specialist and standard débridement and
irrigation for wound care. If the implant is stable it should be
retained. A resection arthroplasty is rarely required.89
In 2008 Edwards et al. reported a 1.2% rate of deep wound infection and
1.1% superficial wound infection in a series of more than 3000 cases.
Fifty-seven of eighty infections (71.3%) were caused by Staphylococcus aureus
and 39 (48.8%) by MRSA (multiple organisms). No statistically
significant preoperative risk factors were detected. Length of stay,
cost of treatment, and predischarge mortality all significantly
increased with deep wound infection. The 1-year mortality in the total
series was 30%, and this increased to 50% in those who developed an
infection (P < 0.001). A deep infection
resulted in doubled operative costs, tripled investigation costs, and
quadrupled ward costs. MRSA infection increased costs, length of stay,
and predischarge mortality compared with non-MRSA infection.50
They recommended vigilance with a high index of suspicion for any signs
of wound inflammation or drainage. Oral antibiotics for 7 to 10 days
are suggested if the infection is superficial. Urgent formal surgical
débridement and irrigation are required for deep infection. Retain
stable implants. Antibiotic beads may be considered for defect
management. Wu et al. reviewed their experience with 23 pertrochanteric
osteomyelitis cases and presented a two-stage treatment protocol. They
used an external skeletal fixator or Buck’s traction after radical
débridement in the first stage and reconstruction in the second stage.
Only 12 of the 23 patients (52%) were successfully managed, and
infection recurred in four patients (17.4%) at final follow-up. The use
of external skeletal fixation was not recommended for managing
pertrochanteric osteomyelitis. Success using a two-stage protocol was
difficult to achieve.221
Vitamin D Deficiency
Vitamin D has been reported as an independent risk
factor for recovery. Because of the avoidance of sunlight for fear of
skin cancer and the lack of vitamin D in the modern diet, vitamin D
deficiency has re-emerged as a health epidemic.94
Vitamin D deficiency causes muscle weakness. Skeletal muscles have a
vitamin D receptor and may require vitamin D for maximum function.
Performance speed and proximal muscle strength were markedly improved
when 25-hydroxyvitamin D levels increased from 4 to 16 ng/mL and
continued to improve as the levels increased to more than 40 ng/mL.21
A meta-analysis of five randomized clinical trials (with a total of
1237 subjects) revealed that increased vitamin D intake reduced the
risk of falls by 22%, compared with only calcium or placebo. The same
meta-analysis examined the frequency of falls and suggested that 400 IU
of vitamin D3 per day was not effective in preventing falls, whereas 800 IU of vitamin D3 per day plus calcium reduced the risk of falls.21 In a randomized controlled trial conducted over a 5-month period, nursing home residents receiving 800 IU of vitamin D2 per day plus calcium had a 72% reduction in the risk of falls as compared with the placebo group.29
Mortality from hip fracture decreased with active
surgical treatment in the mid-twentieth century but has remained stable
at 25% to 30% since then. In 2009 Abrahamsen showed that patients
experiencing hip fracture after low-impact trauma are at considerable
excess risk for death compared with nonfracture community control
populations. Hip fracture is associated with excess mortality (over and
above mortality rates in nonfracture community control populations)
during the first year after fracture, with studies suggesting a range
of 8.4% to 36%. This initial risk for mortality after hip fracture was
at least double that for the age-matched control population, became
less pronounced with advancing age, was higher among men than women
regardless of age, was highest in the days and weeks after the index
fracture, and remained elevated for months and perhaps even years after
the index fracture. These observations show that patients are at
increased risk for premature death for many years after a
fragility-related hip fracture and highlight the need to identify those
patients who are candidates for interventions to reduce their risk.1
Holt has stratified the age groups as to risk of
mortality from the Scottish Hip Fracture Audit Database. Patients in
the 50-to 64-year group had significantly better outcome measures after
surgery for hip fracture in terms of survival and function. The
differences exist even after controlling for differences in patient
case-mix variables. Holt et al. developed a predictive formula


estimation of mortality at 30 and 120 days depending on age, ASA score,
gender, prefracture residence, prefracture mobility, and type of
fracture (Table 48-4).

TABLE 48-4 Predictive Mortality Variables

30 days
Odds ratio (95%
confidence interval)

P value


120 days
Odds ratio (95%
confidence interval)

P value


Explanatory variable and category

Age (yr)

< 0.001

< 0.001

50 to 59





60 to 69

1.78 (0.95 to 0.33)


1.98 (1.34 to 2.94)


70 to 79

3.46 (1.94 to 6.15)


3.46 (2.40 to 4.98)


80 to 89

5.68 (3.21 to 10.1)


5.94 (4.14 to 8.53)


≥ 90

7.11 (3.98 to 12.7)


7.95 (5.49 to 11.5)


ASA score

< 0.001

< 0.001

1 and 2






2.25 (1.88 to 2.69)


1.98 (1.77 to 2.21)


4 and 5

5.14 (4.18 to 6.31)


4.01 (3.48 to 4.62)



< 0.001

< 0.001







0.52 (0.46 to 0.60)


0.49 (0.45 to 0.54)


Prefracture residence

< 0.001

< 0.001

Own home





Ong-term care

1.69 (1.47 to 1.95)


2.06 (1.87 to 2.27)



1.69 (1.30 to 2.20)


2.24 (1.86 to 2.70)


Acute hospital ward

1.80 (1.43 to 2.26)


2.40 (2.04 to 2.83)



1.78 (0.97 to 3.27)


1.34 (0.84 to 2.13)

Prefracture mobility


< 0.001

No aids, unaccompanied





One aid, unaccompanied

0.98 (0.83 to 1.15)


1.07 (0.96 to 1.19)


Two aids/frame

1.07 (0.91 to 1.26)


1.15 (1.03 to 1.29)


Requires accompaniment

1.26 (1.04 to 1.51)


1.41 (1.24 to 1.61)


Unable to walk

1.47 (1.18 to 2.08)


1.62 (1.31 to 2.00)


Type of fracture

< 0.001

< 0.001







1.13 (1.00 to 1.27)


1.16 (1.06 to 1.26)



1.33 (0.96 to 1.82)


1.19 (0.95 to 1.50)



3.76 (2.72 to 5.19)


4.91 (3.77 to 6.39)


Regression constant



* B, logistic regression coefficient

ASA, American Society of Anesthesiologists.

From Holt
G, Smith R, Duncan K, et al. Early mortality after surgical reduction
of hip fractures in elderly: an analysis of data from the Scottish Hip
Fracture Audit. J Bone Joint Surg Br. 2008;90B:1360.

Mortality = 1/1 + e – (constant + B(ASA) + B(prefracture
residence) + B(age) + B(sex) + B(type of fracture) + B(prefracture
where e = 2.72 and the constant = -4.79 for 30-day mortality and -3.70 for 120-day mortality.
For example, the predicted 30-day mortality for a hip
fracture patient aged 90 or over; ASA = 3; from a care home, assuming
other base characteristics (male, intracapsular fracture, walked
without aids before fracture) = 1/1 + e – (-4.79 + 0.80 + 0.53 + 1.96)
= 18.2%. This formula applies to Intracapsular, extracapsular,
subtrochanteric and pathologic fractures. Mortality in those more than
90 years old averaged 50% at 120 days.96
In an autopsy study, 581 patients with fractures of the
proximal femur were identified. The principal causes of death after hip
fracture were bronchopneumonia, cardiac failure, myocardial infarction,
and pulmonary embolism. Surgical intervention within 24 hours of injury
significantly reduced death from bronchopneumonia and pulmonary
embolism. Early mobilization reduced death from bronchopneumonia.174
We have come from the era in which it was “to difficult
to analyze functional recovery” to one in which we analyze and maximize
functional recovery. It is interesting that the Harris Hip Score has
been well validated as a hip quality measure. Recently, several authors
have reported results with this measure. Moroni et al. reported Harris
Hip Scores of 60/100 for external fixation and standard compression hip
screws, with increases to 70/100 with HA coated compression hip screw
devices. Ruecker et al. reported average Harris hip scores in the
78/100 range for preoperative function, and recovery to 70/100 with an
integrated screw nail device.

Lorenz Böhler is credited with the strategy that with
injury the surgeon treatment should first preserve life, second save
the limb, and finally maximize functional recovery. There is a
dichotomy of opinion regarding a surgeon’s and a patient’s perspective
after a broken hip. Globally surgeons feel that most surgeries are
equivalent and that patients are expected to have a lower demand and
lower mortality after surgery, and frequently their focus is on the
time of the surgical procedure and union of any type rather than the
total care of the patient. We have now arrived in a new century in
which functional recovery in previously independent community
ambulators is expected if not demanded, and the satisfaction of a
united fracture from the mid-twentieth century with reduced mortality
is not enough.
The current re-evaluation of treatment methods for
pertrochanteric fractures relates to appreciation of the relative
instability of the fracture construct with a single cephalic component
with osteoporotic bone stock, unstable fracture reductions, or
combinations thereof. It is appreciated that even with optimal screw
purchase in the correct position of the femoral head, any rotational
stability will lead to progressive collapse and progressive incremental
instability until the fracture heals in a varus position, the femoral
head motion results in femoral neck erosion and collapse until the
sliding screw reaches maximal collapse with resultant implant failure,
or cutout occurs. This is certainly more common in severe osteoporotic
patients and those with unstable reductions or comminuted fractures.
Uncontrolled dynamization has come to be appreciated as a cause for
bony erosion and progressive continuing collapse. This frequently
results in excessive dynamization, which weakens the abductors and
shortens the extremity and makes it more likely the patient will have
diminished function. The Baby Boomer generation patient with a hip
fracture expects a functional result equivalent to their friends’
experience with a total hip replacement.
Rotational instability, which has essentially been
ignored since Holt’s concept in 1963, has resurfaced with biomechanical
and clinical validation of the importance of rotational stability. New
techniques and devices are required to overcome the status quo.
Another aspect of debate is the prevention of the first
fracture and the “next fracture.” Who can we save? Who can benefit from
prophylactic medications or even surgery? We know the major risk
factors for geriatric fractures, which include prior fragility
fracture, increased age, low bone mineral density, low body weight,
family history of osteoporotic fracture, glucocorticoid use, secondary
osteoporosis, liver and kidney disease, Crohn’s disease, rheumatoid
arthritis, hyperthyroid disease, antiepileptic medications, primary
hyperparathyroidism, and systemic inflammatory disease and smoking
tobacco products and now vitamin D.35,68
Boonen et al.24 have
documented the drugs alendronate and risedronate as effective in
decreasing the risk of hip fractures. The AOA “own the bone” initiative
notes that patients with a hip fracture have at least one treatable
secondary cause of osteoporosis, usually low vitamin D (osteomalacia).
Similarly, 40% of women and more than 60% of men with osteoporosis have
a secondary condition and a treatable cause of their low bone density.
They recommend that we should develop admission and discharge fracture
care checklists that include the following recommendations:
  • Prescribe calcium (1200 mg daily).
  • Prescribe vitamin D (minimum of 1000 IU
    daily). If the patient’s vitamin D level is low, consider prescribing
    50,000 IU weekly for 12 weeks.
  • Refer to physical medicine or physical therapy for fallprevention education.
  • Ask the family or friends to perform a home-safety check.206
Surgeons are technology aficionados and will always look
for better instruments and implants. Moroni et al. have been
instrumental in the progress of HA-coated implants and the bone
reaction to these coatings.146,147,148
These types of devices have garnered little acceptance in the United
States as of yet. The application of bone in-growth coatings will
parallel the addition of new studies and strategies to convince
surgeons of their removal potential. The use of alendronate to augment
the ingrowth of HA components is also under study for the osteoporotic
Cement augmentation with the use of PMMA or calcium
phosphate cements has been attractive since first described by Bartucci
et al. in 1985.15 The problem has
been the inability to demonstrate a functional improvement with the
increased stability hypothesized. In Bartucci’s experience patients
with PMMA had worse function at follow-up. The calcium phosphate
cements have also been tried but with the result in the most recent
meta-analysis primarily of decreased pain at the hip.9
It may be that the technique of application is incorrect. Recently the
trend has been to apply the cement in the femoral head and avoid the
fracture zone.8,37,54,74
As new techniques of delivery and cement composition are developed,
perhaps the addition of cements may prove more helpful in osteoporotic
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