To The Editor:
The article "Integrity of the Lateral Femoral Wall in
Intertrochanteric Hip Fractures: An Important Predictor of a
Reoperation," (2007;89:470-5), by Palm et al., is particularly important
because it confirms previous reports on the critical role played by the
lateral wall in the reconstruction of pertrochanteric hip
fractures1-3. While devices such as the dynamic hip screw and
sliding hip screw have been considered the gold standard in the treatment of
pertrochanteric hip fractures for fifty years, this type of iatrogenic
complication has been reported only recently1; thus, I would like
to offer some observations.
The lateral wall exists in conjunction with a pertrochanteric hip
fracture; it does not exist, as an anatomical structure, in a normal intact
femur. It is important to distinguish between those fractures where the
lateral wall does not exist preoperatively and those where it does exist
preoperatively and is fractured either intraoperatively or postoperatively.
The former have already been defined in the "Fracture and Dislocation
Compendium," where, in fact, the term lateral wall is not
used4. This classification system does distinguish types 31-A1 and
31-A2 fractures, which are defined as pertrochanteric fractures, from a type
31-A3, which is defined as an intertrochanteric fracture. It is unfortunate
that the authors do not use both terms. Rather, they use only the term
intertrochanteric fracture, which may lead to misunderstanding and
confusion. On the other hand, the iatrogenically fractured lateral wall,
occurring during or following a surgical procedure, converts a pertrochanteric
A1 or A2 fracture into an intertrochanteric A3 fracture and is certainly
different and deserves special attention. The clear distinction between the
two did not emerge from the paper.
Because of the nature of this complication, it has been considered to be a
distinct entity: the pantrochanteric fracture5.
Once a fracture of the lateral wall is recognized as an iatrogenic
complication, and the events leading to the fracture are understood, a
reevaluation of the situation is indicated. First, new definitions are
necessary. It is important to distinguish between fracture collapse, the
outcome of fracturing the lateral wall (an adverse postoperative event), and
controlled fracture impaction (a desirable postoperative event). This has
previously been defined together with other relevant definitions1
and could have been referred to by the authors.
Careful definition will not only contribute to better understanding of the
postoperative radiograph, and hence the patient's condition, but will also
facilitate decision-making in the postoperative rehabilitation period, e.g.,
the type of weight-bearing to be instituted.
In addition, when it is possible to attribute the collapse to certain
procedures and/or devices, this should enable us to set new surgical standards
designed specifically to avoid this kind of complication.