3.1 Clinical evaluation

Precise preoperative patient assessment with a detailed review of the medical history is essential. Clinical examination should assess blood loss, evaluate the vascular, muscular, and neurological status of the extremity, and identify soft-tissue injuries or any infections (eg, chest infection). The preoperative evaluation should be done in a comanaged system together with a physician with experience in geriatrics and perioperative medical care, and is described in detail in chapter 2.4 Elements of an orthogeriatric comanaged program.

3.2 Imaging

5.1 Operative versus nonoperative management

Given the high tensile forces acting on the trochanteric area of the proximal femur [8] and the overall complication rates with bed rest and immobility, treatment should almost always be operative. Nonoperative management is associated with higher mortality and serious functional loss [9]. For these reasons operative fracture fixation is generally recommended in almost all geriatric patients, including bedridden patients, to facilitate nursing care, positioning, and pain relief.

5.2 Intramedullary versus extramedullary device

Extramedullary and intramedullary (IM) fixation devices are available for hip fracture fixation. Correct identification of the fracture pattern should influence the choice of implant as recommended by the American Academy of Orthopaedic Surgeons and should be based on a cost-effective implant selection.

There is limited evidence for superiority of either implant based upon randomized trials, and the discussions remain controversial. Recent studies reported that the dynamic hip screw (DHS) was tolerated better by young patients with stable fractures while IM devices such as the proximal femoral nail antirotation (PFNA) had better outcomes with osteoporotic patients, weak bone mass, and reverse oblique fractures [10]. Furthermore, IM fixation can be minimally invasive, which appears to benefit older trauma patients.

A study investigating markers of muscle damage (serum creatine phosphokinase) associated with the surgical approach revealed that intertrochanteric fractures stabilized by a DHS experienced greater soft-tissue injury when compared to patients whose fracture was stabilized by a nail [11].

More studies have compared outcome parameters of intra-versus extramedullary fixation:

• 
  

  Reduced blood loss and costs were observed in a comparative analysis from France in patients being treated with a DHS [12].

  
  
• 
  

  Operative time appears to be longer in the DHS group, the surgical incision needs to be bigger and convalescence to early full weight bearing (FWB) was achieved at a later stage in patients being treated with a DHS [13].

  
  
• 
  

  A relevant disadvantage of extramedullary fixation with a DHS appears to be the higher risk of femoral neck shortening. However, radiographic findings which favor IM fixation did not correlate with improved functional outcomes as shown in a comparative study [14].

  
  
• 
  

  The additional use of a trochanteric stabilizing plate and a tension band wire with the DHS may be required when the greater trochanter is affected. However, additional implant stabilization of the greater trochanter can be bulky.

  
  
• 
  

  It has been proposed to use a sliding hip screw in stable fractures with intact lesser trochanter and lateral wall of the greater trochanter and to prefer intramedullary systems in all other cases.

Intramedullary nailing seems to be less invasive than DHS placement. In a randomized study of 186 fractures treated by gamma nail or dynamic hip screw, gamma nails were implanted with significantly shorter operation times, smaller incisions, and less intraoperative blood loss. The gamma nail group had a shorter convalescence and earlier FWB, but there was no significant difference in mortality at 6 months, postoperative mobility, or hip function at review [13].

5.3 Blade versus screw

Biomechanically, a helical blade improves rotational stability of the construct [15] by compacting the bone around the implant and provides additional purchase in less dense bone [16] (see topic 7.2 in this chapter).

5.4 Fixation versus joint replacement

The mainstay of treatment of pertrochanteric fractures is internal fixation [17]. Yet, optimal treatment of unstable trochanteric fractures is controversial due to the variation of available implants and no clear evidence-based guidelines. Potential complications associated with osteosynthesis of proximal femoral fractures include cut-out of the screw or blade (see topic 7.1 in this chapter), loss of reduction, and nonunion.

An investigation of 91 patients treated with a cemented hemiarthroplasty for an unstable pertrochanteric fracture described an operative revision rate of 3.3% and a 30-day mortality of 5.5%. The authors concluded that hemiarthroplasty was a safe treatment strategy for unstable trochanteric fractures in older adults and allows early FWB [18]. A recent age-, gender-, and fracture type-matched case-controlled study conducted by Fichman et al [19] revealed a major complication rate of 3.4% in fracture patients treated with arthroplasty, significantly lower than the complication rate of 20.7% reported with cephalomedullary nailing. In this study, no significant difference was noted between the groups with regard to blood loss, operative time, hospitalization time, discharge destination to rehabilitation, or clinical outcome [19].

Acute prosthetic replacement may be considered but has not yielded broader acceptance and is generally more reserved for revision surgeries [20].

In severe ipsilateral arthritis of the hip, avascular necrosis of the femoral head ( Case 1: Fig 3.10-1 ), and in selected unstable pertrochanteric fractures, arthroplasty may be a reasonable option for primary treatment.

5.5 Augmented fixation versus nonaugmented fixation

Polymethylmethacrylate (PMMA) has been used successfully to augment different implants in fixation of osteoporotic fractures [22, 23]. Treatment of trochanteric fractures with a dynamic hip screw and additional PMMA augmentation or an absorbable bone cement based on calcium phosphate has produced faster pain relief and improved fracture healing compared to controls [23]. Augmentation of the head-neck element (blade) following IM PFNA fixation increases the implant-bone interface and therefore strengthens fixation [22, 24]. Cyclic loading of osteoporotic trochanteric fractures treated with a cement-augmented PFNA is notable for significantly more cycles to failure compared to specimens treated with a noncemented PFNA [25], but comparative clinical studies are rare.

Biomechanical findings related to the standardized augmentation of the PFNA:

1. 
   

   Better anchorage of the blade in osteoporotic bone is the main advantage [26].

   
   
2. 
   

   The use of small amounts of PMMA, ie, 1–2 mL, significantly improves load cycles to cut-out of the PFNA blade [27].

   
   
3. 
   

   Cement positioning at the tip and the cranial side of the blade was found to be most favorable [28].

   
   
4. 
   

   Temperatures higher than 45° C were not measured in the bone cement interface region outside of the cement [29] if up to 6 mL of PMMA cement was used and therefore this procedure is not associated with thermal bone necrosis.

Major advantages of implant augmentation with PMMA are:

• 
  

  Increased bone-implant interface—implants fail in metaphyseal fractures at the interface with surrounding bony structures, ie, trabeculae. Trabeculae are rarefied and thinned in osteoporotic bone with broken interconnections. Augmentation increases the implant-bone contact by increasing the contact surface area.

  
  
• 
  

  Procedural safety—in a prospective study of 64 patients with trochanteric fractures treated with a PMMA-augmented DHS, no complications such as an avascular necrosis of the femoral head were reported [30]. Another study on augmentation use with the PFNA showed no complications related to the cement especially the exothermic reaction while hardening is not exceeding temperatures above 42° C [31].

  
  
• 
  

  Procedural flexibility—cement is applied through small perforations of the fixation device once it has been inserted. The decision on whether or not to augment can be made only at the end of the operative procedure.

Clinically, there is no contraindication to perform augmentation with reduction and fixation of the fracture, so the decision to use additional augmentation can be taken at the end of the operative procedure.

The use of augmentation is an individual decision. The following factors may suggest a benefit from augmentation:

• 
  

  Risk of cut-out or device instability due to poor bone quality

  
  
• 
  

  Additional injuries of the upper extremities

  
  
• 
  

  Less than optimal implant placement, mostly combined with malreduction (tip-apex distance [TAD])

  
  
• 
  

  Exchange of blade

  
  
• 
  

  Pathological fractures

  
  
• 
  

  Haptics of helical blade insertion suggesting little resistance and osteoporotic bone conditions

6.1 Preoperative treatment

• 
  

  A preoperative femoral nerve block is helpful to reduce pain before, during, and after the procedure; the risk of complications such as nerve palsy, bleeding, or infection is rare but should be considered [32].

  
  
• 
  

  Additionally, routine acetaminophen and intermittent opioids are recommended for perioperative analgesia throughout the typical hospital course [33] (see also chapter 2.4 Elements of an orthogeriatric comanaged program).

Skin traction of the affected femur may also be considered preoperatively, ie, if surgical delay is unavoidable and traction is necessary, although this may not be well tolerated by frail older adults or those with cognitive impairment.

6.2 Intraoperative imaging

It is of utmost importance to use standardized x-ray planes intraoperatively and to achieve an optimal anatomical reduction before inserting the nail. In particular, a true lateral view, where the femoral shaft is in one line with the head-neck-fragment, is the only projection to accurately assess the implant position. With excessive anterior bowing of the femur, insertion of a long screw or nail device may be impossible without perforating the anterior cortex of the femoral shaft or causing a fracture [34]. In such a case, a shorter nail or a long bent nail may be used.

6.3 Reduction

Reduction is an important step prior to nail insertion and should be oriented towards the opposite side. Closed reduction is performed on a traction table with 10° of adduction and rotation of the foot, if needed. Malrotation of the affected leg must be excluded. The patella should point directly upwards.

If acceptable reduction cannot be achieved with closed reduction, minimally invasive procedures are performed prior to nail insertion. The most commonly used reduction aids for fracture reduction are retractors, bone hooks, collinear clamps, blocking screws, Schanz screws, or the femoral distractor [35].