INTERTROCHANTERIC FEMUR

FRACTURES
Michael Blankstein, MD, MSc, FRCSC
Assistant Professor
University of Vermont Medical Center

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Objectives
• Preoperative considerations
• Classification
• Stable vs. Unstable fractures
• Implant choice
• Intraoperative considerations
• Postoperative management

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Hip Fracture
• Transfer to
Hospital Patient’s Journey
• Investigations
Admission
• Pain control

•Consults
Medical •OR ASAP
Optimization •Discharge planning
•Anticoagulation reversal

OR •Anesthesia: Spinal vs. GA

Postop •GOAL: Immediate WBAT/early mobilization

management •Medical co-management

• Fracture liaison
Discharge • Osteoporosis Rx
• Falls prevention

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Standardized care pathway is key!
• NPO
• Medicine co-management
• Multimodal analgesia (avoid opioids)
• Delirium prevention
• Medication reconciliation
• Anticoagulation reversal
• Preoperative Thromboprophylaxis (Heparin/LMWH)
• DM – Glucose control

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• 42,230 patients with hip fractures
• Overall 30 day mortality 7%
• The risk of complications and 30-day mortality increased
when wait times >24 hrs

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 The Contentious Transthoracic Echocardiography
• 2014 ACC/AHA CPG’s on perioperative cardiovascular evaluation &
management of patients undergoing noncardiac surgery

• Routine evaluation of left ventricular function isn’t

recommended except for new or worsening heart failure

• Stress testing is only recommended if it will lead to intervention

that will change management

• Despite these guidelines, echocardiography, and pharmacological

stress testing are often part of the preoperative evaluation
• Can lead to a significant surgical delay

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• Compared hip fracture outcomes at 2 hospitals
• Same orthopedic and anesthesia departments
• At one hospital, 193 hip fracture patients admitted to an orthopedic-geriatric
comanagement service
• 121 patients at the other hospital continued to receive usual care
• Patients admitted for comanagement were older, had more comorbidities &
dementia, and less likely to dwell in the community
• Patients in the comanaged group were operated on sooner, had fewer
infections, fewer overall complications and shorter lengths of stay

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• “Hip fracture care that incorporates comanagement by a geriatrician
and orthopedic surgeon, standardized protocols, and a total quality
management approach leads to improved processes and clinical
outcomes”

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Is there a role for non operative treatment?

• Extremely limited!

Cannada LK, Mears SC, Quatman C. Clinical Faceoff: When Should Patients 65 Years of Age and Older Have
Surgery for Hip Fractures, and When is it a Bad Idea? Clin Orthop Relat Res. 2021 Jan 1;479(1):24-27
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• Retrospective review of hip fracture patients treated 2004 to 2012
• 231 study patients - 154 operative & 77 nonoperative patients
• 2:1 matched pairing for factors associated with increased mortality
• No significant differences among age, sex, fracture location, Charlson Comorbidity
Index, preinjury living location, dementia, & cardiac arrhythmia

• Nonoperatively treated hip fracture patients had an 84.4% 1-year mortality that
was significantly higher than a matched operative cohort

• Bleak overall prognosis for nonoperatively treated geriatric hip fractures

J Orthop Trauma 2019 Jul;33(7):346-350 Core Curriculum V5

What if the intertrochanteric fracture is occult and nondisplaced?

Methods: All nonoperatively treated femoral neck or intertrochanteric femur fractures (AO/OTA
31A and 31B) from 2003 to 2018 were identified. Patients >65 years with negative radiographs but
a hip fracture evident on MRI were included

Conclusion: Thirty-three percent (2/6, 33%) of femoral neck fractures displaced and required
surgery. The remainder of the cohort (13/15, 87%) healed without complication, including all of the
intertrochanteric fractures (9/9, 100%). The results may better inform treatment discussions for
geriatric patients with occult hip fractures diagnosed by MRI

Archives of Orthopaedic and Trauma Surgery. June 8 2020

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 AP Hip Traction
Radiographs View

AP Pelvis

Lateral

Personal x-rays Core Curriculum V5

Intertrochanteric fractures
• Extracapsular!
• Good healing potential

• Stable: will resist medial compressive loads once reduced

• Unstable: will collapse into varus or shaft will displace medially

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AO/OTA
Fracture and
Dislocation
Classification
Compendium
—2018

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STABLE

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Fracture stability
has significant
implication on UNSTABLE
surgical
management

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Surgical Goals
• Obtain neck-shaft axial alignment and correct translation
• Anatomic reduction of intermediate fragments is
unnecessary

• Surgeon should focus on:

• Getting Patient to OR ASAP
• Ideal Implant Selection
• Obtaining Good Reduction
• Proper Implant Application

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Closed reduction
maneuver for IT
fractures
- often successful

Traction, Internal Rotation, Adduction

*Image from Tornetta P, Ricci WM, eds. Rockwood and Green's Fractures in Adults, 9e.
Philadelphia, PA. Wolters Kluwer Health, Inc; 2019 Core Curriculum V5
Reduction Aids
• Traction (err on the side of valgus)
• Crutch when using fracture table (posterior sag)
• Ball spiked pusher
• Bone hook
• Clamps

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Implant Choices
• Dynamic/Compression/Sliding hip screw (SHS)
• Cephalomedullary nail (CMN) – short vs. long
• 95 degree blade plate (rarely used)

• SHS and CMNs allow for fixed angle controlled collapse (shortening at
fracture site)

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My Case – 82F, low energy fall

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Intraoperative Reduction

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Implant Application

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4 Weeks Post Op

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Trends demonstrate significant decline of SHS utilization with the usage of Nails on the rise

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• Surveys distributed to active AAOS members
• 37% response rate (3784)
• Despite the fact that sliding hip screw & cephalomedullary nail
fixation are associated with equivalent outcomes for most
intertrochanteric fractures, nail is the preferred construct
• Surgeons believe nails are easier, associated with improved
outcomes, or biomechanically superior to a sliding hip screw

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Advantages of Intramedullary Fixation over SHS
• Load-sharing device
• Intramedullary Buttress
• Nail resists excessive fracture collapse and medialization
• Nail more closely located to the axis of weight-bearing than SHS

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• 80 SHS and 87 CMN
• AO/OTA 31-A2 (unstable)
• No significant differences noted between intramedullary
and extramedullary fixation
• Intramedullary treatment had less femoral neck shortening
• While the use of the intramedullary devices led to better
radiographic outcomes, this did not translate to improved
functional outcomes

J Bone Joint Surg Am. 2015 Dec 2;97(23):1905-12

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A postoperative fracture of the lateral femoral wall is the main predictor for a reoperation following an
intertrochanteric fracture

Patients with fracture of the lateral femoral wall should not be treated with a sliding/compression hip-screw

J Bone Joint Surg Am. 2007 Mar;89(3):470-5 Core Curriculum V5

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 Standard versus reverse obliquity

Long cephalomedullary nails remain the preferred treatment

option for the treatment of 31-A3 intertrochanteric fractures,
demonstrating acceptable complication rates, low reoperation
rates, and high rates of healing

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• Multicenter National Prospective Cohort Study
• 2474 SHS, 158 SHS + Trochanteric Stabilization Plate
(TSP) and 598 CMNs

• TSP provides an intact lateral buttress for the SHS,

thereby reducing the risk of medial migration of the
shaft and subsequent failure
• For unstable proximal femur fractures, the authors
recommend the use of CMN or SHS + TSP
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Indications for cephalomedullary nailing –
unstable fractures!

• General consensus:
• Greater trochanter lateral wall fracture
• Significant Posteromedial comminution
• Reverse obliquity
• Subtrochanteric extension

Remember….SHS works very well when treating stable IT fractures!

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Orthoguidelines.org
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 nice.org.uk
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Long Nail
• Advantages: • Disadvantages:
• Protection of the entire • Increased cost
femoral shaft • Longer OR
• Ideal with diaphyseal • Inc Blood loss
fracture extension
• Free-hand distal
locking
• Possible mismatch
to bow to femur

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Short Nail

• Advantages: • Disadvantages:
• Easier to use • Older designs had a
• Targeted locking bolts high rate of
through the insertion periprosthetic femoral
jig shaft fractures
• Large diameter, rigid,
• Decreased operative stainless steel implants,
time and blood loss with large locking bolts
• Cheaper at the distal tip of the
nail (stress riser)

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Radius of curvature
• Modern nails have lower radius of curvature of 1-1.5 meters

Journal of Orthopaedics, 2014-06-01, Volume 11, Issue 2, 68-71 Core Curriculum V5

262 patients with OTA 31-A2 pertrochanteric fractures

125 treated with short CMNs and 137 treated with long CMNs

No significant differences in complications, readmissions, failures or death

JOT 2016;30:125-129 Core Curriculum V5

610 hip fractures: 171 short CMN and 439 Long CMN

Approximately ½ of nails in both groups were not distally locked

SIMN group showed a higher incidence of refracture than the LIMN

(not statistically significant)

Union rates were equivalent between groups and averaged over 97%

15 of the 16 refractures occurred in nails that were not distally locked

No differences in overall costs were seen between SIMNs and LIMNs

Distal locking seems to protect against femur fractures and may also
affect the refracture location when using LIMNs

JOT 2016;30:119-124 Core Curriculum V5

• 168 patients with intertrochanteric fractures
• Prospectively randomized to Short or Long Cephalomedullary Nail fixation

• Comparable functional outcomes

• No difference in peri-implant fracture or lag-screw cutout
• Short nails tolerated up to 3 cm of subtrochanteric extension

JOT 2019 Oct;33(10):480-486 Core Curriculum V5

Basicervical fractures strictly defined as 2-part fractures at the base of the femoral neck
and exit above the LT

Retrospective review of 11 patients with a basicervical fracture treated with a CMN

6 /11 had failure of the fixation. All 6 of these patients had an acceptable tip-apex
distance and alignment.

CMN may be inadequate fixation for this specific fracture pattern!

J Bone Joint Surg Am 2016 Jul 6;98(13):1097-102 Core Curriculum V5

Despite our best efforts…
Screw cut-out is still a problem!
• Up to 8-15% in some series
• Implant vs. technique vs.
bone problem?

• How can we best achieve

stable fixation of elderly
osteoporotic hip fractures?

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 TAP <25mm

Subchondral Bone

J Bone Joint Surg Am. 1995 Jul;77(7):1058-64 Core Curriculum V5

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• IM devices are susceptible to cut-out at TAD >25 mm
• Hence, surgeons should strive for a TAD <25 mm
when using IM devices, especially in the treatment of
comminuted intertrochanteric hip fractures to help
avoid lag screw cut-out

Int Orthop 2010 Jun;34(5):719-22 Core Curriculum V5

 Calcar referenced TAD

JOT 2012 Jul;26(7):414-21 Core Curriculum V5

JOT 2012 Jul;26(7):414-21 Core Curriculum V5
Retrospective review of 170 fractures treated with cephalomedullary nailing

Bone Joint J. 2014 Aug;96-B(8):1029-34 Core Curriculum V5

Disadvantages of the Lag Screw:

• Femoral head rotation during insertion

• Poor rotational control
• Requirement of bone removal prior to screw placement
• Loss of fixation with osteoporotic bone

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Can we get even better fixation?
• Newer implant designs or fixation techniques

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 Helical Blade Rationale
• Hypothesized to have better anchorage by compaction of
trabecular bone during blade insertion with rotational
control

• Does not require over-drilling, which effectively retains

cancellous bone

• Several biomechanical studies suggest that helical blades

may have higher cut-out resistance

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• 172 screws and 163 blades
• No difference in cut-out rates
• Both the screw and blade performed equally well
with both the sliding hip screws or IM nails
• TAD was most important factor in avoiding cut-out

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• Outcomes related to cut-out, other
complications and post-operative function were
similar between the blade and screw groups

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• Retrospective radiographic review of 362 patients
• Average age 83, mostly women
• Cephalomedullary nails with blade or single lag screw
• 22 cutouts 15% of helical blades and only 3.0% of
lag screws (P = 0.0001)
• Average TAD significantly greater for patients who
experienced cut-out both for blades and screws

JOT 2017 Jun;31(6):305-310 Core Curriculum V5

Retrospective Unique mode
review of 258
patients treated of failure
with helical blade Cut-through!

J Orthop Trauma 2016 Jun;30(6):e207-11 Core Curriculum V5

• Retrospective review
• Trochanteric Fixation Nail with either blade or screw
• There were no failures in the screw group compared with 10% failure
rate in the blade group (P = 0.02)
• Mode of failure - lateral migration of the femoral head with protrusion
of the helical blade
• Of the 126 total cases, there were 7 cases of failed fixation (5.6%) - all
helical blades

JOT 2018 Aug;32(8):397-402 Core Curriculum V5

Cement Augmentation
• Enhanced fixation via Cement bone
interdigitation
• Aims to resist cut-out
• Cement does not act as void filler
• Augmentation away from fracture
• Biomechanically superior
• Safety studies performed
Depuy Synthes
Permission to use image given

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• Contrast dye before cement use to rule out articular penetration

Injury 2011 Dec;42(12):1484-90 Core Curriculum V5

62 patients

F/U 15 months

Arch Orthop Trauma Surg 2014 Mar;134(3):343-9 Core Curriculum V5

• A prospective multicenter, randomized, patient-blinded trial
• Ambulatory patients >75 with a closed, unstable pertrochanteric fracture
• 105 patients randomized to PFNA Cement Augmentation and 118 to PFNA

• No patient in the PFNA Augmentation group had a reoperation due to mechanical failure
or implant migration compared to 6 patients in the PFNA group
• Augmentation of the PFNA blade did not improve patients’ walking ability
• Cement Augmentation might have the potential to prevent reoperations by
strengthening the osteosynthesis construct

Injury 2018 Aug;49(8):1436-1444 Core Curriculum V5

Dual Integrated Cephalocervical Lag Screws
• An intramedullary device using two integrated
cephalocervical screws
• allows linear controlled intraoperative compression with
improved rotational stability of the head–neck fragment

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Retrospective review of 413 patients

130 were treated with a single screw device

283 with an integrated dual screw device

The single screw group had significantly higher failure rate of 7.7% as
compared to the Dual screw group failure rate of 1.7% (P = 0.007)

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104 patients, mean age 81

Intertrochaneteric femur fractures fixed using a cephalomedullary

nail with either a single screw or integrated 2-screws

No difference in cut-out rates

JOT 2016 Sep;30(9):483-8 Core Curriculum V5

Post operative management
• WBAT is the main goal!
• PT and mobilize the patients ASAP
• Antibiotics for 24 hours
• DVT Prophylaxis

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Conclusions
• Fixing the hip...ASAP…is the best thing for the patient
• We should continue to work together -- Multidisciplinary
approach is key!
• Standardized perioperative care pathway
• Well executed surgery – Get it right the first time!
• Focus on return to function, activities of daily living
• Assessment and treatment of osteoporosis will mitigate the
risks of subsequent fractures
• Follow Clinical Practice guidelines

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Conclusions
• Cut-out after cephalomedullary nail or sliding hip screw is related to proper
surgical technique:
• Quality of reduction, Implant application

• SHS works well for simple stable intertrochanteric fractures

• When using CMN, distal locking screws may provide additional stability and
decrease risk of peri-implant fracture

• Short nails work as well as long nails

• Use long nails when when facing a subtrochantric extension

• Basicervical fractures should probably be treated with a SHS +/- antirotation screw
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Conclusions
• TAD <25mm should be respected regardless of the implant design
• “Deep center-center position”

• CalTAD with inferior screw placement might be more important when

using cephalomedullary nails

• The lag screws, dual integrated screws and blades perform well, but
most series continue to report screw cut-outs

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Conclusions
• The helical blade “cut-through” has raised concerns, especially with
TAD < 20mm

• Cement augmentation has been proven safe thus far and strengthens
the fixation construct, without documented cases of cut-out or AVN

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Video
• Sliding Hip Screw
• Intertrochanteric Fracture: Open Reduction Internal Fixation with
Dynamic Hip Screw
• Abiola Atanda, Daniel Bazylewicz, Kenneth A. Egol, Matthew Hamula

• https://otaonline.org/video-library/45036/procedures-and-
techniques/multimedia/16731365/intertrochanteric-fracture-open-
reduction-internal

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Video
• Long Cephallomedullary Nail by Paul Tornetta

• https://otaonline.org/video-library/45036/procedures-and-
techniques/multimedia/16776595/cephallomedullary-nail-for-
intertrochanteric

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