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Integrity of the Lateral Femoral Wall in Intertrochanteric Hip Fractures: An Important Predictor of a Reoperation
Henrik Palm, MD1; Steffen Jacobsen, MD1; Stig Sonne-Holm, MD, DMSc1; Peter Gebuhr, MD1
1 Bjelkes Allé 9A, I, DK-2200 Copenhagen, Denmark. E-mail address for H. Palm: hpalm@dadlnet.dk. E-mail address for S. Jacobsen: sjac@dadlnet.dk. E-mail address for S. Sonne-Holm: s.sonne-holm@dadl.dk. E-mail address for P. Gebuhr: peter.gebuhr@hh.hosp.dk
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Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants of less than $10,000 from the IMK-Foundation. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
Investigation performed at the Department of Orthopaedic Surgery, Copenhagen University Hospital of Hvidovre, Hvidovre, Denmark

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2007 Mar 01;89(3):470-475. doi: 10.2106/JBJS.F.00679
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Abstract

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 hip screw.

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.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Henrik Palm, M.D.
    Posted on January 13, 2008
    Dr. Palm et al. respond to Dr. Deshpande
    NULL

    We appreciate the interest by Dr. Deshpande in our recent article(1). However, we do not agree that “the DHS functions best if the femoral neck anteversion is neutralised to zero degrees in anatomically reduced comminuted intertrochanteric fractures.”

    Our article recommends that the DHS should not be used in comminuted fractures, but only in the more stable trochanteric fractures (AO/OTA type 31-A1 and A2.1). These fractures should be anatomically reduced on the traction table with the anteversion reduced by correct rotation of the foot. And - very important - with the sagging position reduced by posterior support from the Posterior Reduction Device (PORD).

    The key point is a correct entry point of the guide wire, both in the anterior-posterior view as mentioned in our response to Dr. Garg(2), - and in the lateral view. If the entry point is placed too anterior, the DHS will travel from the central lateral shaft/entry point through the centre of the neck and into the posteromedial portion of the femoral head, thus facilitating its cut-out posteriorly. However, the solution for this, is a slightly more posterior entry point; not to compromixe the anatomically correct anteversion of the femur.

    References:

    1. Palm H, Jacobsen S, Sonne-Holm S, Gebuhr P, and the Hip Fracture Study Group. Integrity of the lateral femoral wall in intertrochanteric hip fractures: an important predictor of a reoperation. J Bone Joint Surg Am. 2007;89:470-475.

    2. Palm H, Jacobsen S, Sonne-Holm S, Gebuhr P. and the Hip Fracture Study Group. Integrity of the lateral femoral wall in intertrochanteric hip fractures: an important predictor of a reoperation. J Bone Joint Surg Am. 2007;89:470-475. [Letter to The Editor] J Bone Joint Surg Am. epub 29 Mar 2007. http://www.ejbjs.org/cgi/eletters/89/3/470.

    Milind M. Deshpande
    Posted on November 27, 2007
    Importance of DHS Placement in Treating Intertrochanteric Fractures
    Vivekanand Hospital, Hubli, Karnataka, INDIA

    To The Editor:

    The DHS functions best if the femoral neck anteversion is neutralised to zero degrees in anatomically reduced comminuted intertrochanteric fractures. With neutral anteversion of the neck, the DHS can be introduced from the centre of the lateral wall/shaft into the centre of the neck and head in the lateral view. If anteversion is not introduced into the reduction,the DHS will travel from the central lateral shaft/entry point to the posteromedial portion of the femoral head, thus facilitating its cut-out posteriorly.

    The disadvantage of this technique (which has accepatable clinical consequences) is a loss of external hip rotation equal to the degree of anteversion.

    The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated .

    Henrik Palm, M.D.
    Posted on May 10, 2007
    Dr. Palm et al. respond to Dr. Gotfried
    Department of Orthopaedic Surgery, Copenhagen University Hospital of Hvidovre, Hvidovre, Denmark

    We appreciate the interest by Dr. Gotfried in our recent article(1) and are delighed that he finds our study to be particularly important. In a large number of patients our study does, in fact, confirm previous reports of the importance of the integrity of the lateral femoral wall, including that it is most often an iatrogenic complication.

    Dr. Gotfried raises good questions regarding the nomenclature used in the article. The general nomenclature in these fractures is quite confusing. As the terms trochanteric, pertrochanteric, pantrochanteris and intertrochanteric etc. are often mixed up, we also find it highly relevant to achieve international consensus on this matter. In our article, we simply used the term intertrochanteric for all type 31A fractures, in part because we found that Dr. Gotfried also previously did this(2), although not in a later article referred to in our article(3). We now agree that using the terms pertrochanteric for the 31-A1 and 31-A2 fractures and intertrochanteric only for the 31-A3 fractures would have been more precise. On the other hand, we still find that we enable the reader to distinguish between the fracture types by using the AO/OTA classification numbers including the very important subtypes in text and tables and by showing an illustrating diagram.

    We agree that new definitions of biomechanical complications are necessary, and that the knowledge of the lateral femoral wall being an iatrogenic complication could contribute to a better understanding of the treatment of these fractures. We currently treat 31-A1 and 31A2.1 fractures with a sliding hip screw fixed to a lateral plate, and the 31A3 with a sliding hip screw fixed to an intramedullary nail.

    As a third of the 31A2.2 and 31A2.3 fractures in our study where converted in to 31A3 fractures, we now also treat these fractures using the sliding hip screw fixed to an intramedullary nail. In the future, perhaps other systems designed specifically to avoid a per-operative fracture of the lateral femoral wall(2) might prove to be superior to treat these specific fracture subgroups. To date, it has not been feasible to categorize fractures into all the AO/OTA subgroups as this demands very large groups of patients.

    Reference:

    1. Palm H, Jacobsen S, Sonne-Holm S, Gebuhr P, and the Hip Fracture Study Group. Integrity of the lateral femoral wall in intertrochanteric hip fractures: an important predictor of a reoperation. J Bone Joint Surg Am. 2007;89:470-475.

    2. Gotfried Y. Percutaneous compression plating of intertrochanteric hip fractures Orthop Trauma 2000;14:490-495.

    3. Gotfried Y. The lateral trochanteric wall:a key element in the reconstruction of unstable pertrochanteric hip fractures. Clin. Orthop Relat Res. 2004;425:82-6.

    Yechiel Gotfried, M.D., MS
    Posted on April 21, 2007
    The Trochanteric "Lateral Wall"
    Bnai Zion Medical Center, Haifa, ISRAEL

    To The Editor:

    The article “Integrity of the Lateral Femoral Wall in Intertrochanteric Hip Fractures: An Important Predictor of Reoperation”(1) is particularly important because it confirms previous reports on the critical role played by the lateral wall in the reconstruction of pertrochanteric hip fractures(2,3,4). While sliding hip screws such as the DHS (Dynamic Hip Screw) and the SHS (Sliding Hip Screw) have been considered the gold standard in the treatment of pertrochanteric hip fractures for 50 years, this type of iatrogenic complication has been reported only recently(2); 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 pre-operatively, and those where it does exist preoperatively and is fractured either intra or post operatively. The former, have already been defined in the “Fracture and Dislocation Compendium” where, in fact, the term” Lateral Wall” is not used(5). This classification does distinguish the 31-A1 and 31-A2 being defined as pertrochanteric fractures from a 31-A3 defined as intertrochanteric fracture. It is unfortunate that the authors are not using both terms. They are rather using only the term intertrochanteric fracture which may lead to misunderstanding and confusion. On the other hand, the iatrogenic fractured lateral wall,occuring 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 fracture(6).

    Once fracture of the lateral wall is recognized as an iatrogenic complication, and the events leading to fracture are understood, a re-evaluation 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 post-operative event) and controlled fracture impaction (a desirable post-operative event). This has previously been defined together with other relevant definitions(2) and could have been referred to by the authors.

    Careful definition will not only contribute to better understanding of the post-operative x-ray and hence patient's condition, but will also facilitate decision-making in the post-operative rehabilitation period e.g. the type of weight bearing to be instituted.

    In addition, where 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.

    The authors did not receive any outside funding or grants in support of their research for or preparation of this work. One or more of the authors, or a member of his or her immediate family, received, in any one year, payments or other benefits in excess of $10,000 or a commitment or agreement to provide such benefits from a commercial entity (Orthofix, Inc.). No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

    References:

    1. Palm H, Jacobsen S, Sonne-Holm S, Gebuhr P, on behalf of the Hip Fracture Study Group. Integrity of the lateral femoral wall in intertrochanteric hip fractures: an important predictor of a reoperation. J Bone Joint Surg Am. 2007;89:470-475.

    2. Gotfried Y. Percutaneous compression plating of intertrochanteric hip fractures Orthop Trauma 2000;14:490-495.

    3. Gotfried Y. The lateral trochanteric wall:a key element in the reconstruction of unstable pertrochanteric hip fractures. Clin. Orthop Relat Res. 2004;425:82-6.

    4. Im GI, Shin YW, Song YJ. Potentially unstable intertrochanteric fractures. J Orthop Trauma. 2005;19:5-9.

    5. Fracture and dislocation compendium.Orthopaedic Trauma Association Committee for Coding and Classification Orthop Trauma. 1996;10 Suppl: v-ix, 1-154.

    6. Gotfried Y. Pantrochanteric hip fracture: An entity. J Bone Joint Surg Br (Suppl III) 2000;82:235.

    Henrik Palm, M.D.
    Posted on March 29, 2007
    Dr. Palm et al. respond to Dr. Kong
    Department of Orthopaedic Surgery, Copenhagen University Hospital of Hvidovre, Hvidovre, Denmark

    We appreciate the interest by Dr. Kong in our recent article(1) and are pleased that he agrees that the presence of a lateral femoral wall fracture is associated with problems in fracture healing in intertrochanteric fractures. He raises good questions regarding the postoperative sliding of fragments in the figure and the optimum rotation of the injured leg while operating. He also suggests a trochanteric osteotomy for achieving a more stable fixation in unstable intertrochanteric fractures.

    We agree that in the figure the dynamic hip screw has slid laterally and superior in the femoral head. (Not anterior after re-checking the un- published lateral radiographs). Nevertheless, we continue to believe that the main movement is the medialization of the shaft and lateralization of not only the trochanteric fragment but the femoral head and neck fragments as well.

    Displacement of fragments in an intertrochanteric fracture could be due to external rotation of the shaft in relation to the femoral head and neck fragment, and theoretically a posteromedial defect could cause a higher risk. As the screw and plate connection are both stable in angle and rotation this displacement would loosen the screw in the head with a risk of migration and subsequently a risk of cut out. We routinely fix all intertrochanteric fractures with the injured leg in neutral position on the traction table during surgery and use the Posterior Reduction Device (PORD) to reduce both the sagging position and an eventual posterior defect before fixation.

    A posteromedial defect could also, in our opinion, cause difficulty in fracture reduction and theoretically also in displacement, but if we interpret the posteromedial defect as a fractured lesser trochanter, our paper shows that this is, however, not a significant predictor of a re- operation. We are aware that trochanteric osteotomy has been used previously, but have so far not found it necessary to employ this technique when treating stable intertrochanteric fractures (AO/OTA type 31-A1 to A2.1) with a dynamic hip screw fixed to a side plate, or treating unstable intertrochanteric fractures (A2.2 to A3) with a sliding hip screw fixed to an intramedullary nail. We hope to be able to prove this in future studies.

    Reference:

    1. Palm H, Jacobsen S, Sonne-Holm S, Gebuhr P, and the Hip Fracture Study Group. Integrity of the lateral femoral wall in intertrochanteric hip fractures: an important predictor of a reoperation. J Bone Joint Surg Am. 2007;89:470-475.

    Henrik Palm, M.D.
    Posted on March 29, 2007
    Dr. Palm et al. respond to Dr. Garg et al.
    Department of Orthopaedic Surgery, Copenhagen University Hospital of Hvidovre, Hvidovre, Denmark

    We appreciate the interest by Dr. Garg in our recent article(1) and are pleased that he agrees that lateral femoral wall fractures usually occur intraoperatively. We agree with his contention that a suboptimal entry point of the guide wire may contribute to the risk of lateral wall fracture,

    Our recent experience suggests that a reason for fracturing the lateral femoral wall could be an entry point that is too superior, despite using the protractor. We agree that this probably occurs more often if a perfect anatomic reduction is not achieved.

    When trying to obtain the minimum “tip apex distance” the plate-screw angle may become too acute. Therefore when tightening the cortical screws, the fixed angle plate pressures the proximal part of the lateral femoral wall outwards with a high risk of fracturing it through the most vulnerable position, the hole made for the dynamic hip screw.

    As shown in our paper(1) this risk is significantly higher in the more complex intertrochanteric fractures (AO/OTA type 31-A2.2 and A2.3). We therefore now treat these fractures - and the A3 fractures - with a sliding hip screw fixed to an intramedullary nail, in which the nail-screw angle is fixed through the guide system. As mentioned in the paper, it is most likely that the nail itself also stops the telescoping displacement of the fracture by directly blocking the lateralization of the head-neck fragment.

    The simple intertrochanteric fractures (A1 to A2.1) should, however, still be treated with the sliding hip screw fixed to a side-plate, as the risks of re-operation due to the above mentioned reasons presumably are smaller than the risk of a shaft fracture when using the intramedullary nail.

    Reference:

    1. Palm H, Jacobsen S, Sonne-Holm S, Gebuhr P, and the Hip Fracture Study Group. Integrity of the lateral femoral wall in intertrochanteric hip fractures: an important predictor of a reoperation. J Bone Joint Surg Am. 2007;89:470-475.

    Bhavuk Garg
    Posted on March 12, 2007
    Is intraoperative lateral femoral wall fracture preventable?
    All India Institute of Medical Sciences, New Delhi, INDIA

    To The Editor:

    We would like to congratulate the authors for emphasizing that lateral femoral wall integrity is a predictor of success when performing ORIF for intertrochanteric fractures. We would add that the lateral femoral wall is usually intact preoperatively but is fractured intraoperatively.

    This usually happens because while surgeons aim to place the screw in the centre of the femoral head to obtain the optimum 'tip apex distance', little attention is paid at the entry point of the guide wire, which is frequently placed either too anteriorly or superiorly. When reaming is performed over the guide wire, it leads to a large hole, producing a defect or a very thin wall, which fractures while putting in the lag screw. This eccentic placement through the lateral wall is more common in comminuted fractures where anatomic reduction is seldom perfect and attempts to place the guide wire in the centre of femoral head inadvertantly causes eccentric placement of the wire through the lateral femoral wall.

    The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

    K C Kong
    Posted on March 01, 2007
    Integrity of the Lateral Femoral Wall in Intertrochanteric Hip Fractures
    King George Hospital, Ilford, UK IG3 8YB

    To The Editor:

    I read with great interest the article Palm et al.(1). I agree with the authors that the presence of a lateral wall fracture is associated with problems in fracture healing(2). However, the authors' explanation that a fracture of the lateral wall results in the trochanteric, femoral head and neck fragments sliding laterally and the shaft sliding medially is not represented by the figure. While the shaft has slid medially overall, it is the dynamic hip screw device which has slid laterally, superiorly and probably anteriorly too. Sarmiento(3) and Hartog et al.(4) suggested that a trochanteric osteotomy would allow a more stable fixation for unstable intertrochanteric fractures by allowing good cortical contact medially.

    In failed fixation of this type of fracture it is the persistence of the posteromedial defect that allows the fracture to collapse resulting in cut out by the hip screw which exits laterally, superiorly and anteriorly usually. The description by Sarmiento(3) and Hartog et al.(4) allows substantial reduction of the posteromedial defect.

    Another way this occurs is by external rotation of the shaft fragment and varus collapse of the head and neck fragment. In the figure in this paper, one can observe progressive external rotation of the femoral shaft which implies that reduction was achieved on the fracture table by internal rotation of the leg.

    There is disagreement regarding the optimal amount of external rotation of the injured leg on the traction table when fixing intertrochanteric fractures. For unstable intertrochanteric fractures I tend to fix the injured leg in some degree of external rotation on the traction table to reduce the posteromedial defect before fixation with a dynamic hip screw. Can the authors adivise us about which position they tend to place the leg in on the traction table during surgery?

    In reverse obliquity fractures where there is a lateral wall fracture, the failure mechanism is predominantly medialisation of the shaft fragment. The lateral wall fracture thus changes the behaviour of an unstable intertrochanteric fracture to that of a reverse obliquity type. It is quite likely that an intramedullary hip screw device would prevent the medialisation of the shaft(5) and possibly block excessive collapse in intertrochanteric fractures with a large posteriomedial defect, minimising screw cut out as the head, neck and shaft fragments collapse into the defect.

    The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated .

    References:

    1. Palm H, Jacobsen S, Sonne-Holm S, Gebuhr P, on behalf of the Hip Fracture Study Group. Integrity of the lateral femoral wall in intertrochanteric hip fractures: an important predictor of a reoperation. J Bone Joint Surg Am. 2007;89:470-475.

    2. Gotfried Y. The lateral trochanteric wall: a key element in the reconstruction of unstable pertrochanteric hip fractures. Clin Orthop Relat Res.2004;425:82-6

    3. Sarmiento A and Williams EM. The Unstable Intertrochanteric Fracture: Treatment with a Valgus Osteotomy and I-Beam Nail-Plate: A Preliminary report of one hundred cases. J. Bone Joint Surg. Am. 1970;52: 1309 - 1318.

    4. Hartog BD, Bartal E, and Cooke F .Treatment of the unstable intertrochanteric fracture. Effect of the placement of the screw, its angle of insertion, and osteotomy. J. Bone Joint Surg. Am. 1991; 73:726 - 733.

    5. Sadowski C, Lübbeke A, Saudan M, Riand N, Stern R, Hoffmeyer P. Treatment of reverse oblique and transverse intertrochanteric fractures with use of an intramedullary nail or a 95 degrees screw-plate: a prospective, randomized study. J Bone Joint Surg Am. 2002; 84:372-81.

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