Several characteristics make lateral wall fracture a distinct entity: it is a complication caused by a surgical procedure, resulting in a deterioration in the pattern of the fracture. My study unequivocally showed that large diameter (barrel) drilling fractures the lateral wall, resulting in fracture collapse. This complication should be acknowledged and avoided. Preoperative 31-A2 fractures were converted to 31-A3 pertrochanteric fractures in which all trochanteric parts are broken.12
This extremely unstable fracture results in a severe and prolonged period of postoperative disability (Fig 1). If this complication is not recognized, all patients with healed 31-A2 fractures would be regarded as having optimal results, although some results clearly are suboptimal because patients had an exceptionally extended, painful healing process.
This study involved a relatively small number of patients, but uniform clinical and radiologic picture in all the patients provides valuable information and identifies a possible surgical complication that may occur in some unstable pertrochanteric fractures. After reduction has been achieved, it is important not to impair or jeopardize this delicate situation by the introduction of potentially damaging surgical tools or implants. If additional fractures occur after internal fixation of a pertrochanteric hip fracture, the prospects for the patient are worsened. Subtrochanteric fractures have been reported after intramedullary nailing.3,13,15 Fracture of the lateral wall as described in this study has similar consequences.
Traditionally, the medial and posteromedial fracture fragments have been considered to be the important elements in determining the severity of the intertrochanteric hip fracture.4 This is true, but only in assessing the extent of the bony damage. The trochanteric portion that is not broken, and is retained for fracture reconstruction, namely, the lateral wall, also is important. The lateral wall is the proximal extension of the femoral shaft. In an unstable three-part or four-part pertrochanteric hip fracture, the lateral wall is a fragile bony structure. It is this region that provides the best opportunity for osteosynthesis with the proximal part of the fracture complex (Figs 1, 2). It cannot be overemphasized that fracture of this delicate structure will convert a pertrochanteric fracture into a subtrochanteric fracture equivalent, which is a more severe problem, and therefore should be avoided.
An intact lateral wall plays a key role in the stabilization and fixation of unstable pertrochanteric hip fractures. By providing a lateral buttress for the proximal fragment, fracture impaction is facilitated, and followed by rotational and varus stability after fracture spike impaction occurs. If the lateral wall is broken, there is no lateral buttress for the proximal neck fragment and collapse will occur. Lateral wall fracture may occur during surgery5,10 or after surgery.10 Collapse has been reported to be a major contributor to postoperative morbidity because it is followed by a long period of disability2,14 (Fig 1). Because of the nature of this complication, it has been considered to be a distinct entity: the pantrochanteric fracture.5 The characteristics of this condition are: an intact lateral wall that is fractured at the drilling site of a compression hip screw/dynamic hip screw fixation device in an unstable pertrochanteric hip fracture. It is considered a complication of surgery; a lateral wall fracture is followed by collapse; a pertrochanteric fracture has deteriorated to a subtrochanteric fracture equivalent; these complications, occurring during or after surgery, result in a long period of disability.6
The pantrochanteric fracture may be responsible, in part, for the large number of patients who lose the ability to walk independently after surgery because of the long period of immobilization associated with it.1,2 No lateral wall damage or fracture collapse were reported with the use of percutaneous compression plating in patients with pertrochanteric hip fractures6,8 (Fig 3). This was attributed to the small diameter of the holes at the drilling site with percutaneous compression plating. In addition, incremental drilling from 7–9.3 mm, compared with the nonincremental drilling of 16 mm or as much as 32 mm drilling required for the screw barrel of the dynamic or compression hip screw, also were considered beneficial in minimizing trauma to the lateral wall.5,8
The results described in this retrospective study are important, and there clearly is a need for an additional prospective study to establish the precise relationship between dynamic hip screw/compression hip screw fixation of unstable pertrochanteric hip fractures, lateral wall damage, fracture collapse, and functional results.
Twenty-four patients with radiologic evidence of fracture collapse after unstable pertrochanteric fracture fixation with a compression hip screw/dynamic hip screw were evaluated retrospectively. In all patients, fracture of the lateral wall, which was intact preoperatively, was responsible for this complication. Therefore, maintaining the integrity of this structure should be a major objective in all surgical stabilization procedures for unstable pertrochanteric fractures.
I thank Dr. A. Goldberg for help in preparation of the manuscript and Donna Gotfried for technical assistance.
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