A recent article in the Journal of Bone and Joint Surgery found a “dramatic change in surgeon preference” from plate fixation to intramedullary (IM) nail fixation for the treatment of intertrochanteric fractures. What method do you use to treat intertrochanteric fractures and why?

Richard F. Kyle, MD
Hennepin County Medical Center
I use a hip screw for all routine intertrochanteric fractures with an intact lateral buttress (Fig. 1). The world literature on the treatment of intertrochanteric fractures supports the use of IM nail fixation in subtrochanteric-intertrochanteric fractures but does not show any advantage of IM fixation over hip screw fixation in standard intertrochanteric fractures with an intact lateral buttress. Randomized prospective studies for routine intertrochan­teric fractures with an intact lateral buttress show no difference in operating time, complication rate, blood loss, hospital stay, time to ambulation, or patient satisfaction.

Many reasons could account for the recent shift toward the use of IM fixation. With the advent of closed nailing and interlocking rods, the use of IM fixation has expanded in our training institutions. Techniques and devices for IM fixation have improved markedly, and more surgeons are comfortable with these techniques.

The fact that reimbursement for IM fixation of hip fractures is greater than for fixation with a sliding hip screw may have some effect on the usage of this technique. IM fixation has not, however, improved outcomes in patients with stable intertrochan­teric fractures.

Surgeon preference, skill, and comfort in performing a technique may have some impact on the increased use of intramedullary devices. The key to success is the sur­geon’s skill in using any fixation device.

The clear advantage for the IM device is in intertrochanteric fractures with subtrochanteric extension. Several randomized prospective studies have shown that an IM nail is superior to a hip screw in situations where the fracture extends into the subtrochanteric region (Fig. 2). Even in this fracture, however, a right-angle plate device may be successfully used by the surgeon who is not familiar with IM fixation (Fig. 3).

The surgeon must also be aware of the impact of treatment on revision and conversion to total hip arthroplasty if the hip fracture fixation fails. In my experience, revising failed hip screw fixation is easier than revision when an IM nail was used. Driving a 16 mm drill through the abductor muscle attachment to the trochanter does some damage, as described in anatomic cadaver studies, but no clinical correlations have been published to date.

The regional variation in the use of hip screws versus IM fixation may be related to champions of the technique who are in the area and to training institutions that teach the technique.

Although an intertrochanteric fracture with an intact lateral buttress can be fixed equally well with a sliding hip screw or with an intramedullary rod, I prefer a hip screw because of lower cost and the possibility of reduced damage to the abductor musculature. The cost of IM fixation devices is substantially greater than that of a standard hip screw.

Intertrochanteric fractures with subtrochanteric extension should be fixed with IM fixation unless the surgeon is not familiar with the technique, and then a right-angle type device with indirect reduction can be used.

Thomas A. Russell, MD
Campbell Clinic-University of Tennessee
Whether it is a revolution or a paradigm shift, this generation of orthopaedic surgeons has realized that we need to improve clinical results for hip fractures. According to current statistics, only 25 percent of hip fracture patients return to previous functional levels, and mortality rates exceed 25 percent using the current single screw nail or plate designs in treatment.

The current therapy debate is based on the premise that a change in implant designs might offer improved results. Reports have shown higher than expected rates of implant failure and reoperation when compression hip screw devices are used in reverse-type intertrochanteric fractures. Other studies indicate an improvement in the early function and definitive malunion rate with the use of IM nails rather than plate devices for peritrochanteric fractures. The Cochrane Database meta-analysis reports for the past 6 years, however, show no difference in mortality and final functional outcome between nails and plate devices with single screw fixation into the femoral head. The issue has become the stability of the femoral head fixation.

More surgeons may be choosing IM techniques as the result of the following three convergent events:

• This generation of surgeons has the highest level of expertise with IM techniques in history and expects better results with nails as weight-bearing implants in general.
• More importantly, fundamental flaws in the concept of single screw femoral head fixation have been recognized. The biomechanical reevaluation of single screw fixation for the peritrochanteric fracture has revealed rotational instability as a problem. In many cases, a single screw-type design is inadequate because it permits rotational instability, varus cut-out, and bone erosion in the femoral head.
• Finally, the potential for deficiency fracture of the lateral wall or greater trochanter is also an issue. These intraoperative fractures have a higher complication rate with compression hip screw techniques. This potential compli­cation is driving surgeons to consider IM devices or plate devices with trochanteric stabilization.

For me, the issue is not nail versus plate but fracture reduction and stability of the construct. My personal preference is for a long IM device with a stable IM interface and integrated screws for fixation of the femoral head placed after an accurate reduction of the fracture.

New nail and plate designs are designed to improve the stability of the fixation over a single screw design device. Plate fixation of proximal femoral fractures will always have a place in the surgeon’s armamentarium, but plate techniques and designs will more resemble IM techniques, to preserve soft tissue and provide multiplanar fixation of the proximal femur, probably using hybrid locking plate techniques.

Implant fixation in osteoporotic bone with surface texturing and coatings and/or a combination of calcium phosphate cements with metal implants will soon be com­monplace in hip fracture fixation.

Conceptually, I believe the goal should be to replicate the functional recovery in our peritrochanteric fracture patients that we expect with total hip arthroplasty in patients with comparable baseline prefracture independence levels.

Andrew N. Pollak, MD
University of Maryland School of Medicine
Most intertrochanteric hip fractures occur in elderly patients and in association with falls. Most are simple, uncomplicated fracture patterns, which I prefer to treat with a sliding hip screw and side plate device.

I believe restoration of proximal femoral stability and alignment facilitates rehabilitation and limits long-term disability associated with these injuries. I further believe that restoration of proximal femoral alignment is facilitated by utilizing plate and screw fixation for these injuries. IM nail fixation of these injuries is technically demanding, particularly if the goal is to restore anatomic alignment.

Failure to restore anatomic alignment leads to shortening and varus, which impair abductor functioning. This leads to gait disturbances, pain, and decreased mobility. Regardless of whether proximal femoral alignment is restored, healing very predictably results.

The challenge with IM nail fixation of these fractures is that the starting portal is precariously close to the fracture site. As a result, the reamers typically fall into the fracture site as opposed to creating a new channel for the nail at the tip of the greater trochanter. When the nail is finally placed, the medial fragment displaces medially, leading to shortening and varus. This is easily avoided by using a plate and screw device.

The literature suggests that the major difference between nails and plates is an increased complication rate with nail fixation. Those increased complications are typically substantial and include secondary fracture and need for reoperation. In the context of very good reported results with plate and screw fixation, I do not believe that nail fixation can be justified routinely for treatment of stable intertrochanteric fracture patterns.

Unstable intertrochanteric fracture patterns are a different story. The results of treatment of these injuries are not as good as with stable fractures, and complications such as nonunion, failure of fixation, and malunion are more frequent with plate and screw fixation. Furthermore, level II and level III evidence suggest that results after treatment of these injuries can be improved with IM nail fixation. These unstable fracture patterns include reverse obliquity intertrochanteric fractures, fractures with posterior and medial comminution, and fractures with extension into the femoral neck or subtrochanteric region. Just as with stable intertrochanteric fracture patterns, nailing is technically demanding for these injuries; however, the disadvantage of those technical demands is, in my hands, smaller than the disadvantage of the increased failure rate with plate and screw fixation.

I think that orthopaedic surgeons who intend to treat a broad spectrum of intertrochanteric hip fractures need to be technically capable of performing both the sliding hip screw and plate procedure and the IM nail fixation procedure well.

Richard M. Kyle, MD, receives royalties from DePuy, A Johnson & Johnson Company; Encore Medical; Smith & Nephew; and Zimmer. Thomas A. Russell, MD, receives royalties from Smith & Nephew. Andrew N. Pollak, MD, receives no royalties.

References:

1. Hardy D, Descamps P, Krallis P, et al. Use of an intramedullary hip-screw compared with a compression hip-screw with a plate for intertrochanteric femoral fractures. A prospective, randomized study of one hundred patients. J Bone Joint Surg 1998;80A:618 – 630.
2. Sommers MB, Roth, C, Hall H, et al. A laboratory model to evaluate cutout resistance of implants for pertrochanteric fracture fixation. J Ortho Trauma 2004;18:36:361-368.
3. Haidukewych, GJ, Israel TA, Berry DJ, Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg 2001; 83A:643
4. Gottfried Y, Lateral wall fractures, CORR 2004:425:82-86
5. Palm, Jacobsen sonne-Holm and Gebuhr for Hip Fracture Study Group Denmark Integrity of the Lateral Femoral Wall in Intertrochanteric Hip Fractures: An Important Predictor of a Reoperation, J Bone Joint Surg 2007;89A:470-475