Background: Reoperations after intertrochanteric fractures are often
necessitated by fracture displacement following mobilization of the patient.
The biomechanical complexity of the fracture, the position of the implant, and
the patient's characteristics are known to influence postoperative outcome. We
investigated the importance of an intact lateral femoral wall as a factor in
postoperative fracture displacement after fixation with a sliding compression
Methods: Two hundred and fourteen consecutive patients with an
intertrochanteric fracture were treated with a 135° sliding compression
hip screw with a four-hole side-plate between 2002 and 2004. The fractures
were classified on preoperative radiographs according to the AO/OTA
classification system. The status of the greater and lesser trochanters, the
integrity of the lateral femoral wall, and the position of the implant were
assessed postoperatively. Reoperations due to technical failure were recorded
for six months postoperatively.
Results: Only 3% (five) of 168 patients with an intact lateral
femoral wall postoperatively underwent a reoperation within six months,
whereas 22% (ten) of forty-six patients with a fractured lateral femoral wall
were operated on again (p < 0.001). Multivariate logistic regression
analyses combining demographic and biomechanical parameters showed a
compromised lateral femoral wall to be a significant predictor of a
reoperation (p = 0.010). Seventy-four percent (thirty-four) of the forty-six
fractures of the lateral femoral wall occurred during the operative procedure
itself. A fracture of the lateral femoral wall occurred in only 3% (three) of
the 103 patients with an AO/OTA type-31-A1.1, A1.2, A1.3, or A2.1
intertrochanteric fracture compared with 31% (thirty-one) of the ninety-nine
with an AO/OTA type 31-A2.2 or A2.3 fracture (p < 0.001).
Conclusions: A postoperative fracture of the lateral femoral wall
was found to be the main predictor for a reoperation after an
intertrochanteric fracture. Consequently, we concluded that patients with
preoperative or intraoperative fracture of the lateral femoral wall are not
treated adequately with a sliding compression hip-screw device, and
intertrochanteric fractures should therefore be classified according to the
integrity of the lateral femoral wall, especially in randomized trials
comparing fracture implants.
Level of Evidence: Prognostic Level II. See Instructions
to Authors for a complete description of levels of evidence.