To The Editor:
With regard to 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., we first would like to
congratulate the authors for emphasizing that the integrity of the lateral
femoral wall is a predictor of success of open reduction and internal fixation
of intertrochanteric fractures. We would add that the lateral femoral wall
usually is intact preoperatively but becomes fractured intraoperatively.
This usually happens because, while surgeons aim to place the screw in the
center of the femoral head to obtain the optimum tip-apex distance, little
attention is paid to the entry point of the guidewire, which is frequently
placed either too anteriorly or too superiorly. When reaming is performed over
the guidewire, it leads to a large hole, producing a defect or a very thin
wall, which fractures while the lag screw is being put in. This eccentric
placement through the lateral wall is more common in the treatment of
comminuted fractures, in which anatomic reduction is seldom perfect and
attempts to place the guidewire in the center of the femoral head
inadvertently cause eccentric placement of the wire through the lateral
femoral wall.