Additional videos related to the subject of this chapter are available from the Medizinische Hochschule Hannover collection. The following video is included with this chapter and may be viewed at https://expertconsult.inkling.com :
- 55-1.
Treatment of a failed, infected osteosynthesis of a pertrochanteric fracture.
Pathology
Fractures of the hip have long been held as an injury, largely as a result of altered bone metabolism, that can significantly affect the life of a patient with regard to mortality and function. The recognition of the importance of physician and hospital care of elderly patients with intertrochanteric femur fracture is apparent, and the development of geriatric co-management programs has successfully improved patient care while decreasing cost. These fractures occur in both young patients with high-energy injuries and in patients with osteoporosis. The goals of successful treatment of these groups of patients are somewhat divergent but include the overall restoration of bony architecture, pain control, and eventual union. How this is achieved is often quite different for these patients, and as middle-age patients continue to evolve as more active patients, the demographic intersection of these two groups becomes more difficult to delineate and demands that the treating orthopaedist be well versed in all facets of care of the patient with an intertrochanteric femur fracture.
Goals of surgical treatment for any fracture include the maintenance of overall length and alignment and the restoration of bony contact to maximize the ability for mobilization and weight-bearing. Multiple factors are responsible for the reduction and fixation that a surgeon can achieve. Patient-directed factors include prefracture comorbidities, bone quality, other concurrent injuries, and social support. The surgeon-specific variables include fracture reduction, implant selection, and position of the implant within the bone. Many of these can be modulated more successfully now than ever before, and careful attention must be paid to each aspect of the care of a patient with this fracture.
The intertrochanteric region of the femur is defined as the region from the extracapsular femoral neck to the area just distal to the lesser trochanter. This chapter describes the evaluation and treatment of both high- and low-energy intertrochanteric hip fractures.
Incidence and Epidemiology
The incidence of hip fractures worldwide is estimated at 1.6 million. In 2010, there were 258,000 hospital admissions for hip fractures in people age 65 years and older according to the National Hospital Discharge Summary in the United States. This number decreased from 1996 to 2010, potentially because of the increased awareness and treatment of osteoporosis, but the incidence is still expected to rise by 12% from 2010 to 2030, therefore resulting in 289,000 annually. This does not account for patients younger than the age of 65 years, nor does it account accurately for the patients admitted with multiple injuries necessarily and certainly not the young high-energy intertrochanteric femur fracture patient.
It has been estimated that 75% of all hip fractures occur in women and that one-third of all women reaching age 90 years will have sustained a hip fracture. Intertrochanteric femur fractures occur in older patients than femoral neck fractures. These patients also have considerably poorer level of function preoperatively with more comorbidities. All of these factors are consistent with the fact that more complex comminuted fractures are being seen in much older patients. In 1984, Zain and colleagues reported the inverse relationship between advancing age and bone quantity and linked that to the direct relationship between bone quality and fracture severity. This is only compounded in 2013 by the multitude of medications and comorbidities that decrease bone quality, including hemodialysis and antiepileptic medications.
The cost of caring for patients with hip fractures is rising dramatically. Estimates are that in 2030, the United States will spend $12.9 billion on care of patients who fracture their hips. The care must not stop at the level of the initial operative care, however. Pike and colleagues recently demonstrated that the cost of subsequent fracture in a Medicare patient after a nonvertebral fragility fracture is estimated at $31,904 annually versus $19,377 for those who incur no further fractures. Intervention to keep these patients in the second group is critical both for their overall quality of life and for the improvement in health care quality.
Advancing the science of fall prevention remains a critical component of decreasing hip fractures. Low-energy falls continue to be associated with intertrochanteric fractures. These types increase with advancing age for many reasons. Declines in visual and auditory acuity, changes in environment, sedating and disorienting medications, and other musculoskeletal limitations all lead to falls. This is markedly increased by cognitive decline. It is estimated that in the United States 5.4 million people older than the age of 71 years have cognitive impairment without dementia. This combined with patients with dementia leads to an extremely large cohort of patients who are at increased risk of falling. Those with cognitive deficiency have a 60% increased risk of falling compared to their age-matched control participants. Cummings and Nevitt suggested that four factors must be met to cause a hip fracture: an impact mechanism that directs the force at the trochanter, a decline in protective measurements, decreased soft tissues about the hip, and diminished bone strength. These factors have not changed dramatically, and interventions aimed at fall prevention, including exercise interventions, home modifications, vitamin D supplementation, and home visits along with medical management of osteoporosis, are critical.
The higher energy fracture in the intertrochanteric region of the bone is an underappreciated, frequently extremely difficult fracture to treat. The mechanism is typically one that lends itself to extreme soft tissue disruption and often leads to a highly displaced fracture that might be a simple fracture pattern or an extremely complex one. Either of these along with any concomitant injuries can lead to individual problems, including attaining reduction and adequate fixation, preventing limb shortening, and achieving union. Historically, these fractures were always treated with plate osteosynthesis because this would be facilitated by open reduction techniques often required for reduction, which is in direct contrast to treatment modalities of osteoporotic fractures. This is not the only difference in these fracture patterns or the patients who present with them. These patterns require management of a multitude of other injuries usually and development of a surgical plan that appreciates the tenets of fracture fixation.
Anatomy of the Intertrochanteric Region
Bony Anatomy
The intertrochanteric region of the proximal femur is extracapsular. It is distal to the basicervical femoral neck and proximal to the subtrochanteric region. To adequately understand fixation of this region, the relationship of the femoral neck to the diaphysis must be understood because this is the connection between the two. The neck shaft angle of a normal adult ranges from 120 to 135 degrees. As patients grow older, this angle decreases. The transverse plane alignment of the femoral neck to the shaft is 10 to 15 degrees of anteversion relative to the femoral condyles. In 1838, the trabeculae of the femoral neck was first described as both compressive and tensile. The primary compressive trabeculae are found along the region of the bone known as the calcar, and this dense bone provides excellent support for the proximal femur when intact ( Fig. 55-1 ). The primary tensile trabeculae fan out across the proximal femur nearly perpendicular to the axis of the diaphysis toward the lateral cortex. The secondary compressive trabeculae cross these from the greater trochanter to the lesser trochanter and comprise the calcar. The lack of continuity along the medial aspect of the proximal femur at the junction of these compressive trabeculae has led to its inclusion of fractures in this region as unstable intertrochanteric femur fractures and might change the implant selection based on the degree of acceptable shortening for an individual patient.
Muscular and Neurovascular Anatomy
The complex muscular attachments of the proximal femur contribute not only to the dissipation of forces about the hip as a protective mechanism against impact but also result in significant displacement of unstable fracture patterns of the proximal femur. The typical deformity associated with intertrochanteric femur fractures is that of external rotation, abduction, and flexion of the proximal segment. The muscular forces about the hip create a foreshortening and an overall varus angulation of the proximal femur. As a patient loses continuity of his or her lower extremity to the proximal femur, the leg continues to externally rotate until the lateral aspect of the foot rests on the bed, preventing further external rotation. This leads to fracture stabilization and improved pain as a result of the paucity of motion. The external rotator muscles that insert on the proximal femur come from various origins, including the outer ilium and intrapelvic origin. These include the gluteus maximus, piriformis, superior and inferior gemelli, obturator externus and obturator internus, and quadratus femoris. Depending on the location of the fracture, these contribute to varying degrees of fracture displacement and the inability to attain a reduction.
The muscular attachments of the proximal femur include the abductors of the hip at the greater trochanter, the gluteus medius, the gluteus minimus, and the tensor fasciae latae. The medius and minimus attach to the greater trochanter directly, and the tensor fasciae latae originates from the outer table of the ileum anterior to the medius tubercle and inserts into the iliotibial band lateral to the trochanter. They abduct the proximal segment if the greater trochanter is intact or retract the greater trochanter if it is an independent fragment.
The hip joint adductors include adductor longus, adductor brevis, adductor magnus, gracilis, and pectineus. These originate on the ischial or pubic rami and insert on the proximal femoral diaphysis distal to the fracture zone except for the pectineus, which inserts on the pectineal line of the femur. The adductor moment accentuates the varus deformity of the proximal femur along with shortening and external rotation. Adductor contracture of the contralateral limb may prevent adequate positioning of the limb to allow for imaging of the proximal femur on the affected side.
Flexion of the proximal segment of the femur is facilitated by the iliopsoas, pectineus, sartorius, and rectus femoris. The primary contributor here is the iliopsoas, which inserts on the proximal femur at the lesser trochanter, a relatively posteromedial structure. This can contribute to flexion deformities of the intact proximal segment or aid in avulsion and destabilization of the posteromedial cortex.
Extension of the proximal femur is secondary to the hamstrings and gluteus maximus. This may lead to foreshortening of the limb and may rigidly hold the diaphysis posteriorly during fracture reduction. This can be particularly limiting with regard to high-energy fractures.
The capsuloligamentous anatomy of the proximal femur can significantly impact the ability to attain reduction of a proximal femur fracture. The iliofemoral, pubofemoral, and ischiofemoral ligaments blend with the capsule to provide strong connections from the acetabular margin to the base of the femoral neck. Disruption of these attachments is rare, but one may need to identify and reflect the insertions in a proximal intertrochanteric fracture.
The vascular supply of the proximal femur is contributed by the extensive muscular attachments of the proximal femoral metaphyseal bone in the intertrochanteric region. It is therefore uncommon to go onto nonunion. The profunda femoris runs in close proximity to the bone below the lesser trochanter and can be at risk for injury because of screw penetration.
The critical components of neurologic anatomy about the proximal femur include the sciatic nerve that exits the pelvis through the greater sciatic notch and passes anterior to the piriformis and posterior to the remaining short external rotators in the posterior thigh. The lateral femoral cutaneous nerve of the thigh is found in the sheath of the sartorius and is unlikely to be injured during surgery for an intertrochanteric femur fracture. The femoral nerve should also be well medial to the exposure.
Diagnosis
Radiographic Assessment
Radiographic evaluation of a proximal femur fracture should include both an adequate anterior-posterior (AP) image and a cross-table lateral projection of the hip. The goals of the radiographs are to allow for an adequate understanding of the proximal femoral anatomy bilaterally, so a low AP pelvis radiograph in addition to a dedicated AP of the affected hip is helpful. Ideally, the AP images are attained with the affected extremity internally rotated with gentle traction to most accurately neutralize the deforming forces and account for the anteversion of the unaffected hip ( Fig. 55-2 ). In addition, the entire femur should be imaged. Many of the affected patients may not be adequate historians to inform the surgical team of prior surgeries or potential for malignancy that might change a surgical plan. From a fracture anatomy standpoint, an adequate AP will demonstrate the fracture obliquity, the status of the greater trochanter, and any presence of femoral neck involvement, which is quite common in reverse obliquity type fractures. The lateral radiograph will help to identify any posterior fragmentation and often will help delineate the size of the posteromedial cortex associated with the lesser trochanter if unstable. This should be performed as a cross-table lateral as opposed to a frog leg lateral for patient comfort and for the most adequate image to allow for planning. An alternative that can help to delineate the anatomy of an intertrochanteric femur fracture is an obturator oblique radiograph. The success of this image in recreating the anatomy of the proximal femur is that it functions as an internal rotation view of an externally rotated femur.
Computed Tomography or Magnetic Resonance Imaging for Negative Radiographs
Since the mid 1980s, there has been intermittent literature regarding the diagnosis of a fracture of the proximal femur not demonstrated on plain radiographs. The widespread availability of magnetic resonance imaging (MRI) led to increased utilization to diagnose fracture in the 1990s, but with increasing availability of computed tomography (CT) scanning, this has become the modality of choice in many emergency departments. Recently, guidelines from the American College of Radiologists (ACR) were released when the ACR Appropriateness Criteria for the diagnosis of suspected hip fracture were published. Multiple studies have looked at both CT and MRI separately as diagnostic modalities but only since 2005 have they been compared head to head. In 2008, Cabarrus and colleagues looked at 129 patients with an average age of 65 years who underwent both CT and MRI for pelvic and proximal femoral insufficiency fractures. The sensitivity of MRI was 99%, and the sensitivity of CT was 69% overall. For proximal femur alone, MRI sensitivity was 90%, and CT sensitivity was 70%. The utility of bone scan has been challenged, and given the effectiveness of MRI, the role of this has been relegated to those who cannot undergo MRI. The overall sensitivity is akin to that of MRI, but a delay in patient care is evident, and it is less cost effective than MRI or CT. These data have led the current recommendations to be plain film radiography followed by MRI in patients older than the age of 50 years. In younger patients, there have been little data to support these studies because these patients typically have high-energy fractures in which CT scanning is probably more helpful for preoperative planning.
Classification of Intertrochanteric Femur Fractures
The ideal fracture classification system should be easy to apply and communicate, guide treatment, predict outcome, be reproducible among different observers, and be consistent with a generalized classification scheme for all skeletal injuries. Unfortunately, no such system yet exists for intertrochanteric fractures. In fact, the classification scheme continues to be expanded by multiple authors in an attempt to provide adequate descriptions of fractures that require different classification.
Evans Classification
In 1949, Evans published a classification system based on the general direction of the fracture line and the ability to obtain and maintain a reduction with closed manipulation and skeletal traction. He emphasized the importance of reestablishing posteromedial contact in achieving a stable reduction. The Evans classification was modified by Jensen and Michaelsen in 1975. Their version describes decreasing stability as the number of associated lesser and greater trochanteric fractures increases. Type IA (nondisplaced) and type IB (displaced) fractures are simple two-part fractures. Type I fractures were considered stable because they could be reduced into anatomic position (no fracture gap >4 mm in either plane) in 94% of patients and, after adequate fixation, were followed by loss of position in only 9% of patients ( Fig. 55-3 ). The type IIA fracture pattern is a three-part fracture with a separate greater trochanteric fragment. Jensen believed that these fractures tended to “sag” with reduction maneuvers, leaving the fracture malpositioned in the sagittal plane. Type IIB fractures are three-part fractures involving the lesser trochanter. Type IIB fractures could be anatomically reduced in only 21% of all patients, with displacement occurring in 61%. The problem primarily resulted from an inability to reduce and reestablish the medial cortical buttress ( Fig. 55-4 ). The type III pattern is a four-part fracture. Only 8% of these very comminuted fractures could be reduced, and displacement occurred later in 78%.
AO/OTA Classification
In The Comprehensive Classification of Fractures of the Long Bones, Müller and colleagues coded proximal hip fractures as part of an attempt to offer a uniform alphanumeric fracture classification that incorporates prognosis and suggests treatment for the entire skeleton. In this system, advocated by the Arbeitsgemeinschaft für Osteosynthesefragen/American Society for Internal Fixation (AO/ASIF) and adopted also by the Orthopaedic Trauma Association (OTA), type 31A fractures involve the trochanteric area of the proximal femur. These fractures are divided into three groups, and each group is further divided into three subgroups. Group 1 fractures are simple (two-part) fractures. The subgrouping defines the geometry of the fracture line. All group 1 fractures are inherently stable (i.e., they almost never displace after adequate reduction and internal fixation). Group 2 fractures are multifragmentary. The fracture line begins anywhere on the greater trochanter and extends medially in two or more places. This creates at least a third fracture fragment that can comminute the greater trochanter or isolate the lesser trochanter (or both). With the exception of a trivial lesser trochanteric fragment, fractures in this group are unstable. The subgrouping for group 2 fractures defines the number and geometry of the fragments. Group 3 fractures are by definition those with the lateral fracture line located beneath the vastus ridge of the greater trochanter, involving the shaft of the proximal femur; the subgroups describe fracture direction and comminution ( Fig. 55-5 ). Clearly identifying fractures with lateral cortical disruption in their own group is an advantage of this classification system because these fractures generally require different management strategies than fractures classified into the other groups. Although there has been shown to be only fair interobserver reliability at the subgroup level of the AO/OTA classification system even for experienced orthopaedic trauma surgeons, the reliability of this system at the group level is excellent. Additionally, despite its complexities, when compared with other classification systems (Evans, Kyle, and Boyd), the AO/OTA system has been shown to be more reliable among surgeons at both the group and subgroup levels. Its alphanumeric and standardized format make the system useful, particularly for research and documentation.
The reader should realize that the common bond among all the classification systems is the concept of stability. A stable fracture is one in which the posteromedial cortex is fractured in only one place and can, after anatomic reduction and fixation, withstand compressive loads without redisplacement ( Fig. 55-6 ). A fracture is considered unstable when, owing to a large posteromedial fragment, multiple fragments, or a reverse oblique fracture line, despite realignment and appropriate fixation, it remains incompetent, and the fracture tends to collapse on axial loading. This intuitive, simple, and reproducible description of stable versus unstable helps guide treatment and suggests prognosis. A majority of clinicians, and some respected researchers, prefer this binary description.
Although limitations in reliability and reproducibility of the historic classification systems have led to use of this binary fracture description system (stable vs. unstable), more recent data question the use of the posteromedial fracture fragment as the benchmark of fracture stability. It has been suggested that it is the integrity of the lateral trochanteric wall after the fracture reduction that ultimately determines fracture stability and patient prognosis. The lateral cortex provides a buttress to fracture impaction after fixation, leading to fracture stability and avoidance of excessive collapse. The importance of the lateral trochanteric wall was emphasized by the findings of Im and colleagues in their review of so-called stable, low-energy intertrochanteric fractures. In their series, all patients who went on to fracture collapse and loss of reduction were found to have a fracture of the lateral cortex after surgical fixation. They found lateral cortical fracture and patient age to be predictors of fracture collapse despite a stable fracture pattern with a single posteromedial cortical fracture line. In reality, it is likely a combination of the posteromedial and lateral trochanteric cortex that is important in fracture stability because modern fixation devices allow fracture impaction in both a lateral and an axial direction. The treating physician must recognize the potential for excessive fracture displacement with axial loading in both of these directions and adjust treatment accordingly.
Assessment of the Patient
With the advent of multidisciplinary care of the fragility fracture patient there have been sweeping advancements in medical management. Chapter 53 outlines the medical co-management guidelines that have been developed. An adequate history is often quite difficult to ascertain from the patient with many medical comorbidities. With this in mind, the best history is one taken from multiple sources that includes the patient, family members or caregivers, medical records, and primary care physicians. Critical to this understanding is the timing of the hip pain. Orthopaedic consultation is often attained after the diagnosis of hip fracture; therefore, a careful interrogation of the patient to assess for comorbid injuries is critical. The incidence of other fractures and other injuries, including intracranial hemorrhage, rib fracture, pulmonary contusion, and intraabdominal injuries, is unknown, and suspicion must be high given the relative small reserve that these patients often have. Young patients with high-energy fractures often have other injuries that need to be evaluated and treated by the general surgery trauma team. However, in elderly patients with low-energy fractures, assessment of prefracture ambulatory status, social situation, and resources are critical to minimizing hospitalization and the potential for medical complications.
Physical examination of a patient with an intertrochaneric femur fracture is classically described as a patient with a markedly externally rotated lower extremity. This is present for a patient with a displaced fracture, but in the occult fracture, the examination might be much less remarkable. Typically, however, motion of the affected extremity will elicit pain at the fracture site regardless of the displacement of the fracture. Some tests that should direct attention to the hip include a log roll in which the fully extended leg is internally and externally rotated on the hospital bed, which should reproduce pain in the acutely fractured patient. The lack of ability to straight leg raise and pain with heel strike also are indicative. Less subtle signs include gross crepitus with limb motion and tenderness to palpation locally over the greater trochanter.
Examination of the contralateral extremity is also critical. The presence of an amputation on either side, skin ulcerations, postpolio syndrome, previous surgery (total hip arthroplasty for example), contractures of adductors or hip flexors, or prior injuries can limit positioning during surgery. A preexisting limb length discrepancy might also be important to consider when treatment choices are selected because there will be expected loss of length that might be untenable to a patient with this problem.
Management
After the diagnosis of an intertrochanteric femur fracture has been made, the decision for nonoperative versus operative management must be made. The treatment goals for the patient should be early mobilization, pain control, restoration of limb alignment, and minimizing medical risks. In young patients with high-energy fractures, the timing to surgery is less critical than anatomic reconstruction for a patient. The decision-making pathway often coincides with the patient’s comorbid injuries. In patients of advanced age whose mechanism is low energy and probably related to osteoporosis, the timing to surgery is critical along with the medical co-management.
Historic comparisons of operative versus nonoperative care for elderly patients with displaced fractures have suggested an improved outcome with operative intervention. However, in selected patients, there can be adequate outcomes with nonoperative care. This form of treatment requires highly skilled nursing care to prevent decubiti, pneumonia, and thromboembolic events and to provide adequate pain control.
In the early 1970s, a revolution in the care of elderly patients with intertrochanteric femur fractures came about when the sliding hip screw construct was developed. The sliding screw device has gone through multiple developmental changes with the most current advances including the intramedullary device with a sliding screw. These developments and improvements in care for some fractures will be discussed. The evolution of these devices has proven to be a vast improvement over the fixed-length predecessors, which did not allow for postoperative compression at the fracture site. As a result, these devices would often fail before bony healing. Current devices can control bending and rotational forces during mobilization and therefore enhance bony contact and compression, encouraging bony union.
Nonoperative Management
There are numerous relative indications for nonoperative care of intertrochanteric femur fractures. These include patients who are nonambulators; patients who have advanced dementia, current sepsis, skin breakdown at the surgical site, or incomplete fractures; hospice patients; and minimally symptomatic patients. In 1977, Lyon and Nevins proposed that nonoperative care in patients who had little chance to ever walk again was the more humane and less expensive modality for treatment. This concept has continued to develop less among the orthopaedic surgical community and more within palliative care and hospice medicine. In a recent review of all Medicare beneficiaries in hospice care older than the age of 75 years who sustained a hip fracture, Leland and Teno found an overall improved survival in patients undergoing surgery. This study included 14,400 patients between 1999 and 2007. A total of 83.4% of these patients underwent surgery, and the median survival time from the time of hospitalization was 25.9 days for those patients treated nonoperatively and 117 days for those who underwent surgery. Although the study is observational, it does not preclude operative management for hospice patients. The orthopaedic surgeon must be an integral part of the decision making along with the palliative care and medical teams.
Nonoperative care falls into two basic categories. The first is one of benign neglect in which the patient is probably a prefracture nonambulator who needs pain control and the long-term outcome of the fracture is completely unrelated to the bony architecture and relies solely on pain control and prevention of medical complications. These patients should be treated on specialty mattresses by dedicated orthopaedic rehabilitation nurses who are capable of mobilization of a patient who is in pain until this improves and the patient is able to resume prefracture care. The second cohort consists of patients in whom surgery would be indicated for an improved bony outcome but is precluded by a contraindication. These patients might be treated in skeletal traction through the distal femur or proximal tibia at 15% of the patient body weight in balanced suspension. Aggressive physical therapy should be undertaken to maximize patient outcome.
Operative Management
The goals of management of intertrochanteric femur fractures are quite different for young and elderly patients. The overarching goal is the restoration of alignment of the major components of each fracture and internal fixation that allows for early mobilization and weight-bearing with adequate pain control.
High-Energy Fractures
The incidence of high-energy intertrochanteric femur fractures is unknown. The young patient typically has adequate bone stock but often has fractured the femoral neck or shaft, therefore influencing surgical approach. The goals of treatment include anatomic reconstruction and avoidance of excessive shortening that although well tolerated in an aged adult, can lead to long-term complications in a young patient. These fractures are commonly two-part fractures with minimal comminution that can be severely displaced with resultant soft tissue stripping. They may require open reduction with additional soft tissues stripping. Implant options include blade plate fixation, sliding hip screw and side plate, sliding hip screw intramedullary devices, proximal femoral locking plates, and reconstruction intramedullary nail fixation. Concerns over blood loss and increased operative time have been examined in the literature, but no head-to-head comparison of these fixation strategies has been performed.
Complications often encountered after fixation of a high-energy young intertrochanteric femur fracture include delayed union, nonunion, malunion, need for reoperation, and loss of range of motion. Utilization of provisional reduction aids and compression at the fracture can aid in avoidance of both early and late complications. The use of intramedullary fixation is favored over plate and screw fixation by many surgeons but can be more challenging if the goal is to avoid open reduction. In addition, the use of implants that are typically reserved for intertrochanteric femur fractures in elderly patients can be deleterious to young patients because they allow for significant dynamic compression that can result in loss of limb length. If the surgeon prefers such an implant, achieving significant bony contact at the time of the index surgery is critical to avoid excessive impaction at the fracture site with resultant limb foreshortening. In addition, comparison of rotation of the contralateral extremity can be quite difficult, and it can be helpful to have both extremities in the surgical field for direct comparison after provisional fixation is achieved.
Length can often be achieved through intraoperative distal femoral skeletal or manual traction. Anesthetic motor paralysis is critical in these often muscular patients.
Fragility Intertrochanteric Fractures
The preponderance of intertrochanteric femur fractures occur in adults older than the age of 60 years, and the primary age group that most orthopaedic surgeons will be involved with is older than the age of 75 years. Many features of the care of these patients are critical to outcome. The preceding chapter on medical co-management outlines many of the salient features of a co-management system.
Timing of Surgery
The relative urgency of surgical stabilization for these fractures has been debated extensively. In an often-cited retrospective study, Kenzora and colleagues noted an increased mortality rate at 1 year in patients surgically stabilized within 24 hours of admission. They recommended a thorough medical evaluation and optimizing of the patient’s condition over the initial 12 to 24 hours before proceeding with surgery. There has been general agreement that surgery should proceed within 48 hours unless there are strong medical contraindications. Zuckerman and colleagues reported that the 1-year mortality rate doubled when surgical repair did not occur in the first 2 days after admission in 367 prospectively evaluated community-dwelling cognitively intact ambulators who sustained a proximal femur fracture. Additionally, using a novel analytical tool to control for patient health biases, McGuire and colleagues found a 15% increase in mortality risk with a delay in surgery of more than 2 days. However, Moran and colleagues conducted an observational study of more than 2600 patients in Great Britain and found no difference in 30-day, 90-day, or 1-year mortality rate in patients deemed “fit for surgery” on admission with a delay in surgery of 1 day versus up to 4 days. They did find an increase in mortality rate at 90 days and 1 year with a greater than 4-day delay in surgery in this patient population. Furthermore, in patients deemed “unfit for surgery” on admission, there was no correlation between delay in surgery and mortality. There seems to be no advantage to rushing a geriatric hip fracture patient from the emergency department directly to the operating room (OR) without adequate medical evaluation, particularly late at night. Instead, adequate time should be spent optimizing intravascular volume and oxygen transport and correcting electrolyte imbalances and nontherapeutic drug levels. The patient should then proceed to skeletal reduction and stabilization by a well-prepared surgical and anesthetic team. The institution of prompt, appropriate medical and subsequent surgical management facilitates a quick recovery and reduces the risk of complications. While awaiting surgery, the patient is placed at bed rest with decubitus precautions. The affected lower extremity is carefully supported with pillows. Two randomized, prospective clinical trials showed no difference in pain level or complications between patients treated with or without skin traction.
With the increasing support for both geriatric fracture programs and medical co-management, the delay to surgical intervention should be dictated by correctable medical conditions. This might include a patient who requires reversal of anticoagulation or an acute cardiac, neurologic, or pulmonary event. A recent data analysis by Simunovic and colleagues looked at 16 observation studies in which 13,478 patients were available with complete medical records to critically evaluate the mortality rate. The data compiled confirmed a significant reduction in mortality, in-hospital pneumonia, and decubiti.
Surgical Intervention
A careful collaborative discussion with the anesthesiologists should be carried out. Options include neuraxial, regional, and general anesthetic. Historically, it was thought that neuraxial anesthesia could lead to decreased blood loss, decreased risk of venous thromboembolism, and decreased postoperative delirium. A recent Cochrane review highlighted these effects with a decreased short-term mortality rate and postoperative delirium favoring regional anesthetic. However, a retrospective review performed by Le-Wendling and colleagues demonstrated no difference in postoperative morbidity, rates of rehospitalization, inpatient mortality, or hospitalization costs over the course of 2 years at a level I trauma center comparing continuous spinal anesthetic with general anesthesia. The factors that were found to increase hospitalization costs included a delay in surgery over 72 hours and intensive care unit admission, both of which are often predicted by patient medical comorbidities. These are all considered within the ASA scoring of the patient, which has also been shown to predict the patient outcome in many studies. Some of the factors that need to be considered preoperatively include cardiac and pulmonary status, comorbid injuries, and anticoagulation status.
Patient Positioning
Multiple methods of patient positioning have been described. After the induction of an anesthetic of choice on the hospital bed, the patient can be transferred to a radiolucent table of the surgeon’s choice. Positioning of the patient on a fracture table has been advocated because it allows for quality biplanar fluoroscopy without having to manipulate a reduced and preliminarily fixed fracture. This also allows for adequate access to the proximal femur to allow for both reduction and internal fixation. The affected extremity is typically placed into either a traction boot apparatus or secured to a metatarsal bar. Either of these devices can be effective as long as the foot is held securely in dorsiflexion, thereby locking the transverse tarsal joint and allowing for both traction and rotation through the end of the extremity. A pneumatic compression apparatus should be applied to the affected extremity, and the ipsilateral upper extremity should be placed in a carefully padded sling across the chest to allow for access for intramedullary nail fixation or side plate fixation. If the affected extremity had a previous below-knee or above-knee amputation, a skeletal traction pin can be placed in the most distal extent of the extremity to allow for traction and rotation, but the appropriate positioning aids must be available to accomplish this.
The contralateral extremity is typically positioned in a well-leg holder where the extremity is externally rotated, flexed at both the hip and knee, and carefully placed into a device that supports the leg so that a cross-table lateral radiograph can be achieved. A pneumatic compression device should also be in place, and attention should be paid to the padding of all neurovascular structures. Particular attention should be paid to avoidance of pressure on the common peroneal nerve and to the avoidance of positioning an extremity in a potential position of danger if the patient has previously had a total hip arthroplasty on that side because this position might result in dislocation. In addition, be aware of long procedure times in this position, which can result in compartment syndrome of the well leg or pressure ulceration, and take appropriate precautions. As soon as all fluoroscopy has been attained while closure is commencing, it is recommended that an unscrubbed assistant remove the well leg from the hold and place it in full extension.
The perineal post is typically used as a restraint to allow for traction on the affected extremity. This should be well padded, and care should be taken to avoid long-term traction, which can result in paresthesias that can be long lasting. One of the difficulties that arises in this patient position is that the patient’s pelvis might rotate around the perineal post while traction is applied because there is no contralateral restraint. To avoid this and the potentially detrimental effects of a well-leg holder, many surgeons have turned to placing each extremity into well-padded traction boots and using a scissor position in which the unaffected extremity is extended at the hip below the level of the affected leg, which can allow for adequate biplanar fluoroscopy as well. This is, however, not an option on all fracture tables but should be considered for select patients.
Fluoroscopic Imaging
The position of the fluoroscope in the OR can vary depending on the preoperative plan for fixation. If a side plate and screw apparatus is selected, the monitor might be more convenient at the head of the bed because the surgeon will spend the majority of time facing the proximal end of the patient. If, however, an intramedullary device is used, it might be more convenient to have the monitor at the base of the bed to allow for ease in visualization while achieving preparation of the proximal femur. Other options include using systems that link with the overhead monitors that might be available and positioned freely. After patient positioning is complete, the radiographs should be scrutinized in multiple planes to allow for adequate imaging, particularly with respect to the lateral image in which the reduction can be accurately assessed along with the entire periphery of the femoral head.
Fracture Reduction
Of the five factors that affect the strength of a fixed fracture (bone quality, fracture pattern, fracture reduction, implant design, and implant placement), the first one that the surgeon can control is fracture reduction, and its importance cannot be overstated. Although the sliding hip screw allows for progressive impaction of fracture surfaces and closure of gaps between fragments that remained at surgery, it cannot convert a poor reduction to a good one. Best practice is to depend on the implant to support the reduction that is attained before application of definitive fixation constructs.
Stable Fractures.
In fracture patterns without posteromedial comminution (stable intertrochanteric fractures), anatomic fracture reduction restores the ability of the bone to transmit compressive loads across the medial cortex. Anatomic reduction of the fracture fragments can usually be achieved. Reduction simply requires adequate longitudinal traction to overcome shortening caused by unopposed muscle action and bleeding into the proximal thigh, mild abduction to correct any residual varus, and slight internal rotation to “screw home” the distal fragment. Because of the inherent stability of the fracture, any device that can hold the fragments aligned during healing should be successful. In fact, these fractures respond well to a variety of well-executed fixation techniques. MacEachern and Heyse-Moore did note that postoperative impaction occurred in approximately one fourth of injuries considered stable at the time of surgery. However, the small amount of impaction that may occur after adequate fixation of stable intertrochanteric fractures is rarely of consequence to the patient.
Unstable Fractures.
Although there is almost universal agreement that anatomic reduction is best for stable fractures, there have been numerous opinions regarding the preferred reduction for unstable fractures. Throughout the skeleton, comminuted metaphyseal bone is routinely treated with bridging techniques, and secondary bony healing is achieved. The difficulty at both the proximal humerus and the proximal femur is that fixation must often cross the primary fracture lines and simultaneously allow for a controlled healing environment. A considerable amount of clinical and some laboratory data exist to aid in decision making of how to achieve an adequate reduction, but some conflicting conclusions remain evident. Most investigators recommend attempted anatomic reduction of the unstable intertrochanteric fracture. In practice, because it is rare for the posteromedial lesser trochanter fragment and the lateral greater trochanter fragment to reduce spontaneously and open reduction and fixation of these fragments exact too much of a biologic cost to be beneficial, absolute anatomic reconstruction is rarely attempted. In fact, the likelihood of residual gaps greater than 4 mm between fragments after reduction was part of the basis for the Evans-Jensen classification into stable (type I), unstable (type II), and very unstable (type III) fractures. Instead, the goal is to reestablish an anatomic relationship between the head and neck fragment and the shaft fragment, both axially and translationally, in the AP and lateral planes. Fixation of these fragments with a fatigue-resistant sliding hip screw allows for a controlled impaction of the fracture surfaces without loss of axial or translational alignment as the fracture is loaded during the postoperative period. Clinical support for this method of reduction exists in various reports, such as those of Clawson, Kyle, and Rao and associates. Laboratory evidence, reported by Cheng and colleagues, indicates that anatomic reduction of a four-part fracture model prepared from cadaver bone consistently provided higher compression forces across the medial cortical bone area and lower tensile stresses on the sliding hip screw than did reduction by medial displacement osteotomy ( Fig. 55-7 ). This was true even if the posteromedial lesser trochanter fragment was discarded rather than reduced. Of the 162 unstable fractures treated by anatomic reduction and sliding screw fixation, only 2% retained the anatomic reduction; 90% were reported to have moved to a medial displacement position and 8% to a lateral displacement position. Nonetheless, the fractures healed, and at that time, the clinical results were considered successful. Little has changed with the goals of fixation for these fracture patterns except for minimizing the degree of postoperative displacement, which can often be achieved with intramedullary fixation.
Maintenance of the lateral trochanteric wall is important in facilitating controlled fracture impaction and maintenance of fracture alignment. In Gotfried’s small retrospective series, all patients with disrupted lateral trochanteric walls associated with very unstable (four-part) fractures after fracture reduction and fixation progressed to excessive fracture collapse and a poor clinical outcome. Palm and colleagues looked at the importance of the integrity of the lateral cortex of the femur and demonstrated it to be the most common factor leading to reoperation for intertrochanteric femur fractures. In their study, 3% of patients with an intact lateral wall required reoperation within 6 months compared with 22% of patients with a compromised lateral wall. This is typically an intraoperative complication, and techniques to deal with this when recognized are discussed later.
Valgus reduction with high-angled fixation (140 or 145 degrees) is a reasonable alternative to anatomic reduction in unstable fracture patterns ( Fig. 55-8 ). The valgus reduction of the fracture decreases the bending forces on the implant by decreasing the neck-shaft offset, and the more vertical orientation of the neck tends to offset some of the shortening expected with unstable fractures. Finally, positioning of the fragments into valgus reorients the fracture plane so that it is more perpendicular to the weight-bearing load vector and thus more favorably positioned for interfragmentary compression. Experimentally, a high-angled device has a greater tendency to slide because the barrel is more closely aligned to the direction of the joint reaction force than that of a 130-degree device during single leg stance. Good results have been reported with this technique. One in vitro study by Meislin and coworkers confirmed increased sliding for high-angled devices but noted that none of the expected benefits of increased loading of the medial cortex or reduction of implant strain occurred. These findings call into question the assumption that the high-angled implant is in itself advantageous. Clinically, a causal relationship between high-angled fixation and increased tendency to slide has not been shown. The complex and variable hip joint reaction forces and torsional strains that affect the fracture of a patient in the immediate postoperative period during log rolls, chair transfers, four-point gait, and so on may not relate well to laboratory models of static uniplanar axial loading. Although valgus reduction supported by high-angle fixation is an attractive alternative to anatomic reduction, there is reason to avoid a high-angled device in an anatomically aligned fracture. The high angle will not allow for the screw to be placed into the center of the femoral head because of the constraints of the positioning within the femoral neck. This places the tip of the lag screw into the superolateral femoral head, where it is at greatest risk for cut-out when the fracture collapse occurs.
Medial Displacement Osteotomy.
Before the development of fixation devices that allow fracture impaction, absolute stability of the fracture was required at the time of surgery. To achieve this goal in unstable fractures without posteromedial bony support, osteotomies were used to gain more rigid stability. The medial displacement osteotomy impacted the medial spike of the major proximal fragment into the medially displaced distal medullary canal. Alternatively, the valgus osteotomy of the proximal femur improved stability by orienting the fracture in a more transverse plane. Although quite useful when fixed-angle devices are used for fracture fixation, the anatomic realignment of the proximal femur may lead to shortening, valgus alignment, ipsilateral knee difficulties, and external rotation deformities of the limb. Multiple studies have compared the outcome of osteotomies with current fixation techniques and found no clinical benefit, increased surgical morbidity, and increased fixation failure with osteotomies. These techniques are more of historical value in acute fractures but may be useful in situations of fixation failure and nonunion.
Open Reduction.
The adequacy of a closed reduction should be measured by fracture displacement, neck-shaft angle, anteversion, and femoral shaft sag. When a closed reduction cannot adequately restore the anatomic alignment of the femur, percutaneous or open procedures should be undertaken. This requires a thorough understanding of the goals of open intervention. As discussed earlier, formal exposure of the greater or lesser trochanter is often not worth the biologic expense. However, there are many instances in which an open approach to an individual segment of bone might be helpful in the alignment of the proximal femur, thereby allowing for unimpeded placement of fixation.
After the closed reduction is complete, the proximal thigh spanning from a point 5 cm proximal to the intersection of the anterosuperior iliac spine and the lateral plane of the femur to the area distal to the knee joint line should be prepared using standard aseptic technique ( Fig. 55-9 ). Draping might consist of either a sterile transparent plastic curtain or via free draping techniques per the surgeon’s preference. Intraoperative blood salvage may be of some advantage if standard in the facility. The lateral approach to the proximal femur is performed through a directly lateral incision that is carried down through the subcutaneous tissue to the fascia of the thigh, which is incised in line with the skin incision. The vastus lateralis musculature is then retracted anteriorly to allow for elevation off of the intermuscular septum and hemostasis of the crossing vessels. The lateral aspect of the femoral diaphysis can be exposed distal to the origin on the vastus lateralis, which may then be incised depending on the fracture anatomy and if direct fracture visualization needs to be carried out. If any question remains as to the reduction, a gloved finger may be used to palpate the primary fracture lines.
