We appreciate the interest by Dr. Garg et al. in our recent article and are
pleased that they agree that lateral femoral wall fractures usually occur
intraoperatively. We concur with their contention that a suboptimal entry
point of the guidewire may contribute to the risk of lateral wall
fracture.
Our recent experience suggests that a reason for fracturing of the lateral
aspect of the femoral wall could be an entry point that is too superior,
despite the use of the protractor. We agree that this probably occurs more
often if a perfect anatomic reduction is not achieved.
When the surgeon tries to obtain the minimum tip-apex distance, the
plate-screw angle may become too acute. Therefore, when the cortical screws
are tightened, the fixed-angle plate pressures the proximal part of the
lateral femoral wall outward, with a high risk of fracturing it through its
most vulnerable area, the hole made for the dynamic hip screw.
As shown in our paper, this risk is significantly higher in the treatment
of more complex intertrochanteric fractures (AO/OTA types 31-A2.2 and A2.3).
We therefore now treat these fractures—and 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 risk of a
reoperation due to the above-mentioned reasons presumably is smaller than the
risk of a shaft fracture when the intramedullary nail is used.