INTRODUCTION
Trochanteric fracture of femur is a very common osteoporotic fracture encountered by orthopaedic trauma surgeons. Most of these patients are elderly and have many comorbidities.[1] Osteoporosis combined with fracture comminution and displacement poses serious challenge to the treating surgeon.[12] Early fixation and early mobilisation of the patient is of paramount importance and paves the pathway for a successful outcome.[123] Many factors contribute to decision making for success or failure in the management of trochanteric fractures.[3] In this article, we address key operative decisions pertaining to these factors with evidence from current literature.
FACTORS BEYOND SURGEON’S CONTROL
There are factors beyond surgeon’s control like osteoporosis, fracture comminution, posteromedial void, integrity of lateral wall. All or some of these can lead to difficult reduction, poor implant hold, varus and uncontrolled collapse and implant cut-out.
FACTORS UNDER SURGEON’S CONTROL
In spite of many factors, what surgeon can control are identification of stable from unstable fracture, proper reduction, right implant selection and proper fixation. Last but not least tackling osteoporosis and other medical co-morbidities with proper rehabilitation.
STABLE AND UNSTABLE FRACTURE; GENERAL CONSENSUS
There is no clear-cut clarity about stability of the intertrochanteric fractures.[4] However as per general agreement, stable fractures are usually 2-part fracture without fracture (small fracture, if at all present) of lesser trochanter (LT) and all others (e.g., 3 or more fragment, large posteromedial fragment, Lateral wall comminution – Gotfried, Subtrochanteric extension, Reverse oblique, Extension into neck etc.) are considered as unstable fracture.
STABLE AND UNSTABLE FRACTURE; AS PER AO CLASSIFICATION
Stability of IT fracture is difficult to assess without reduction. Several classification systems have been described to distinguish clearly between stable and unstable fractures but none found fully satisfactory.[5] Most of the surgeon follow AO/OTA Classification for stability of the trochanteric fracture.[6] It is a general consensus that the AO/OTA 31A1 to 31A2.1 subtypes are stable fracture and 31A2.2 to 31A3.3 subtypes are unstable. The unstable fractures are almost always associated with a loss of the medial buttress which, even if the head and shaft fragments are reduced relative to each other, will confer instability and the risk of varus collapse. While the 31A2.1 fracture also involves the medial buttress, the size of the fragment is sufficiently small that it is of little clinical consequence. The 31A3 subgroup exhibits loss of the lateral wall, including the reverse obliquity pattern, which render the fractures inherently unstable.
IMPORTANCE OF POSTEROMEDIAL FRAGMENT AND LATERAL WALL
Posteromedial Fragment is part of calcar and in the weight-bearing line hence very strong bone. Intact opposite cortex is important for plate to act as tension band otherwise there is chance of varus failure. Lateral wall is equally important as it acts as lateral buttress. Loss of lateral buttress leads to uncontrolled collapse and thickness of lateral wall is a reliable predictor for lateral wall fracture in post operative period.[7]
REDUCTION – WHAT IS DESIRABLE REDUCTION?
The aim is to achieve anatomical reduction which is not always possible so desirable reduction is to get good bone to bone cortical contact particularly anterior and medial cortical contact. For success of surgery, one must ensure the positive or Neutral reduction.[8] Negative and varus reductions are never acceptable. In spite of good desirable reduction, tackling shattered lateral wall and posteromedial defect are still a challenge. Trochanteric stabilisation plate, tension band wire, derotation screw, screw to fix the posteromedial fragment, bone graft and bone substitute are some remedies for such kind of unstable fracture.[910]
IMPLANT SELECTION – HOW TO DECIDE APPROPRIATE IMPLANT FOR FIXATION?
There is no argument about it that regardless of the fracture pattern, the aims of surgery are to restore the anatomy of the proximal femur, using a stable fixation device that would allow the patient to bear weight, with minimal soft tissue trauma and the least amount of physiological insult to the patient (14). In this context, selection of appropriate implant for stable fixation is very important.
Irrespective of various studies,[12345678910] there is consensus that all A1 and A2.1 can be treated with DHS, A2.2 and A2.3 with posteromedial defect and potentially thin lateral wall can be treated by DHS + TSP or Intramedullary device and all A3 fractures by Intramedullary device – long nail +/- Lateral wall reconstruction. Fracture extending into neck are better tackled by Arthroplasty rather than attempting osteosynthesis [Figure 1].
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Figure 1: Pre and post-operative radiograph of various types of IT Fracture operated by appropriate implant; Stable fracture treated with DHS [a], Type A2.2 and A2.3 with deficient lateral wall treated by DHS + TSP [b] or Intramedullary device [c] and A3 fractures by Intramedullary device – long nail +/- Lateral wall reconstruction [d]. Fracture extending into neck are better tackled by – Arthroplasty rather than attempting osteosynthesis [e]
GENERAL MEASURES – HOW IMPORTANT IS IT FOR FINAL OUTCOME?
As majority of intertrochanteric fracture occur in elderly and are associated with some or other kind of co-morbidities; timely, simultaneous and long-term management of such issues are very important of successful outcome. Good nutrition, Calcium and Vitamin D supplementation with proper management of Osteoporosis are key for success. DVT prophylaxis, proper rehabilitation and psychological support also needs to be taken care of.
CONCLUSION
In spite of many factors, what surgeon can control are identification of stable from unstable fracture, proper reduction, right implant selection and proper fixation. Last but not least tackling osteoporosis and other medical co-morbidities with proper rehabilitation.
Financial support and sponsorship
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Conflicts of interest
There are no conflicts of interest.
REFERENCES
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