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Editorial

Pertrochanteric Hip Fractures: Time for Change

Russell, Thomas A MD; Sanders, Roy MD

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Journal of Orthopaedic Trauma: April 2011 - Volume 25 - Issue 4 - p 189-190
doi: 10.1097/BOT.0b013e3181f221c1
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Despite the fact that the treatment of hip fractures encompasses a vast amount of medical literature, over the past 50 years, there has been no real improvement with respect to function or even mortality. This has led to the somewhat nihilistic view by most surgeons, community members, and even patients that once an intertrochanteric fracture occurs, there is a progressive decline in both lifestyle and function for the patient. Recently, new methods and concepts are challenging the status quo and may lead to new models on which to base future research and clinical treatment.

In 1951, Ernest Pohl patented the “gliding hip screw,” which consisted of a cannulated screw (first developed by Godoy-Moreira in Brazil in 19381) attached to a lateral femoral plate with a barrel to accommodate the screw. In 1952, Schumpelick et al2 reported on good results with the Pohl device but noted that collapse after surgery resulted in a positive Trendelenberg sign. In 1956, Clawson3 developed the modern sliding hip screw with a strengthened side plate and a blunt tip screw to avoid hip penetration. During this time, Evans4 in his classic paper stressed the importance of obtaining and maintaining an anteromedial reduction of the femoral neck to achieve a better outcome. Sarmiento5 stated that “weight-bearing on the fractured extremity is safe only if the fracture…has been reduced so that there is an accurate fit of the fragments at the anteromedial cortex of the femur.” In 1980, Jensen6 again called attention to the effect of reduction in his classification system and noted that a stable anterior-medial cortex resulted in no secondary displacement, whereas a nonanatomic or unstable fracture resulted in a secondary displacement of 25% to 69% of cases. Despite this trend in recognizing reduction as critical to a good outcome and the importance of rotational stability, in 1963, Holt7 described a nonsliding large bolt-type hip device and specifically expressed the belief that rotational stability was not important in trochanteric fracture fixation. Based on this single study, there was a general trend in thought that rotation was not an important consideration in pertrochanteric hip fractures. This appears to have been the major error negatively affecting our treatment model for hip fractures.

The literature thereafter has focused on implant failure at the expense of functional recovery. In 1979, Kyle et al8 described 622 fractures with “good” results using a sliding screw device, a center head position, an anatomic reduction, prophylactic antibiotics, anticoagulation, and early ambulation. The authors noted that in unstable fractures, delaying ambulation did not prevent collapse and that this was an unsolved problem. They therefore classified a good result as normal range of motion, a permanent noticeable limp, occasional pain, and permanent cane dependence. This “good” outcome included a high percentage of their patients. This downgrading of the expectations of good results has contributed to the acceptance of our current results. In contradistinction to every other fracture, an analysis of malunion has not been included in most hip fracture outcomes research. The presumption has been that collapse is part and parcel of the treatment. Because of this implicit acceptance, most publications in the past 15 years have simply focused on the tip-apex distance as described by Baumgaertner9 without apparent regard for the anteromedial reduction before implant fixation.

Thankfully, in the past decade, the belief that rotational stability of pertrochanteric fractures is irrelevant has been challenged as a false concept and recognized as perhaps contributing to the patient's failure to regain preinjury function. Lustenberger et al10 noted that patients who had visible rotation of the proximal femoral component with a sliding hip screw had the highest complication rates in their series with cut out, varus angulation, and reoperation. Moroni et al11 documented that with sliding screw-type devices, there was a progressive collapse even in patients who healed. In 2004, Sommers et al12 using a mechanical model documented that rotation, when added to standard hip loading models, recreated clinical cut out. Ehmke et al13 using computer modeling reported that with walking, an average varus collapse of 8.5° and rotation up to 7° occurred when using sliding hip screw devices. Zlowodski et al14 recently noted that femoral neck shortening greater than 5 mm was correlated with a lower physical functioning and lower physical SF-36 scores. It is interesting to speculate that this shortening is applicable to trochanteric fractures as well.

Another factor related to failure of compression hip screws was the lateral wall fracture complication noted by Gotfried15 in 2004. This complication involves a late fracture avulsion of the great trochanter, which in turn leads to progressive collapse of the femoral neck region and abductor weakness. These principles were the basis for the Gottfried PCCP system described in the current article.16 Palm et al17 have documented and confirmed the importance of the lateral wall. They had a 22% reoperation rate after a lateral wall fracture. Furthermore, in their study, 74% of lateral wall fractures occurred during surgery using a single screw device. They concluded that an intertrochanteric fracture with a lateral wall fracture should not be treated with sliding hip screw devices. This is supported by the current article.

Based on the mechanical similarities, Russell18 classified modern implants into four types. Impaction Class devices consist of blade plate systems, the Jewett nail, Williams Y nail, and any device that has an impaction insertion technique. Dynamic compression devices consist of all conventional compression hip screws and variants such as the Medoff plate as well as Gamma nails, IMHS, and similar implants. Reconstruction class devices are best represented by the Russell-Taylor nail and similar implants consisting of two dynamic compression-type screws, which has some limitation on rotation as long as there is stable anterior cortical reduction. The latest devices, the Linear compression devices, negate translation and rotation altogether at the hip during insertion and are presently represented by the Gottfried PCCP system as well as the Intertan nail.19

These developments have led to a re-evaluation of how we approach hip fractures. The current article adds further support for previous articles using the Gottfried system documenting fewer malunions and collapse. The article by Ruecker et al19 using an integrated nail-type design also showed an improvement in functional scores and an absence of significant collapse with a specific design made to prevent rotation of the head neck fragment.

In conclusion, the current article in this issue of Journal of Orthopaedic Trauma supports a time for change in the status quo in the management of pertrochanteric hip fractures. Our new goal should be to create a stable fracture reduction and definitive fixation with devices and techniques that not only avoid varus collapse, but neck shortening, and lateral wall failures with shaft medialization. Surgical treatment must move away from the acceptance of malunions to improving the functional recovery of our patients by applying the same principles of stable fixation that we apply to all other fractures.

REFERENCES

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